^ / • :*< ' . > • \ *.'*&: ■s 4£ r* ^ _.^J /< Surgeon General's Office A. j?%^7 j\ '4., XX; ,iJL,, '4. ' <£%, & J, \<«o— AN ACCOUNT t^t^Jkc, ***** INFLAMMATORY BILIOUS FEVER, WHICH PREVAILED IN THE SUMMER AND FALL OF 1804, COUNTY OF LOUDOUN, VIRGINIA. BY JOHN ESTEN COOKE, A. M. OF VIRGINIA; HONORARY MEMBER OF THE PHILADELPHIA MEDICAL SOCIETY; \ND MEMBER OF THE AMERICAN WHIG SOCIETY OF NASSAU HALL. /t+tdz. PHILADELPHIA: PRINTED FOR THE AUTHOR BY THOMAS T. STILES, NO. 10, CYPRESS-ALLEY. 1805. > AN INAUGURAL ESSAY, FOR THE DEGREE OF DOCTOR OF MEDICINE, Submitted TO THE EXAMINATION OF THE REV. J. ANDREWS, D.D. PROVOST, PRO. TEM THE TRUSTEES, AND MEDICAL PROFESSORS OF THE UNIVERSITY OF PENNSYLVANIA, ON THE FIFTH DAY OF JUNE, ONE THOUSAND EfOHT HUNDRED AND FIVE. TO THOMAS SIM, M. B.- OF LOUDOUN, VIRGINIA. This essay is inscribed as a tribute of respecl for his medical talents, and of gratitude for the care with which he endeavoured to inculcate just principles of medical science, on the mind of his obliged friend, and pupil, JOHN E. COOKE. TO JOHN ESTEN, M. D. OF THE ISLAND OF BERMUDAS. Permit me thus publicly, to express the high opinion I entertain of that worth which renders you so dear to your friends j of those ta- lents unfortunately rendered unprofitable to your fellow citizens by the unremitting violence of one of those diseases, which still remain monuments of the imperfection of the science of medicine. Your affectionate Nephew, JOHN ESTEN COOKE. AN ACCOUNT INFLAMMATORY BILIOUS FEVER, &£. Were I to consult my own inclination, I should not, at so early a period of life, publish my sentiments on any subject. Having as it were but just entered the threshold of science, I feel the want of experience and a more mature judge- ment, properly to digest the principles I have been taught in this University. It is therefore with great diffidence and even reluctance, that in this instance I yield obedience to its laws....the more so, as there is not in the long catalogue of diseases which afflict the human race, one, on which volumes have not been written; one, on which I could hope to offer any thing new. It is not therefore with such an expectation, that I have 2 10 chosen bilious fever for the subject of my inau- gural dissertation; for on no one have splendid talents been more successfully employed. But having in the summer and autumn of 1804 as- sisted my friend, Doctor Sim of Leesburg, in his extensive practice ; and having carefully marked the rise and progress of the bilious fever, which spread terror and desolation through the popu- lous county of Loudoun, I hope a communica- tion of my observations will not be unacceptable. More especially, as so violent a grade of this dis- ease has hitherto seldom visited the interior of our country, and perhaps in no instance, so heal- thy and hilly a country as Loudoun j the inha- bitants of the low range of mountains extending through it, which is thickly settled and well cul- tivated, having suffered more by the fever, than the cultivators of the rich low grounds on the banks of the Potowmac. It may not be improper to premise a few remarks on the weather, and the diseases which preceded the fever. The spring was cold and wet; vegetation was more backward than usual. The blossoms of the peach tree began to open on the 17th of April; of the cherry, sassafras, and dogwood trees, 11 on the 22nd and 23rd; and of the apple tree on the 28th of April. The month of May was cooler than usual; there were fourteen days of rain; the wind gene- rally from the westward. The people were for the most part healthy; diseases were not of a very inflammatory grade, but few cases requiring the use of the lancet. Early in the month, the Potowmac overflowed its banks, covering many hundred acres of grain. June was also cooler than usual ; there were twenty days of westerly winds, and twenty days of rain, which greatly damaged the growing wheat and corn. The low lands on the Potow- mac were again flooded, whole fields of grain be- ing entirely covered. Diseases were rather more inflammatory than in May. Two cases of teta- nus occurred ; one terminated fatally, the other in health. A few days in the beginning of July were ex- tremely sultry; the harvest people suffered great- ly; but in general the weather was not warm- er than usual. There were ten days of rain; on the 31st a severe storm from the northwest of rain and hail of a very large size. Diseases now became more inflammatory, very few cases 12 of intermittents occurring. About the 20th of this month, the fatal fever commenced its de- structive career. August was very warm, many days extreme- ly so ; the wind was mostly from the east; there were nine days of rain. The fever became general; whole families were seized....the labours of the field were in a great measure suspended....it be- came the indispensible duty of those in health, to visit and assist their sick and distressed neigh- bours. September was pleasant, dry, and clear; the wind was westerly twenty-four days ; there were four days of rain. There was a white frost on the 20th of this month; on the 26th a more severe one, which killed the more tender vegetables. Until this period, the epidemic raged with the greatest violence; the new cases were from twen- ty to five and twenty daily, sometimes twice that number. But the frost increasing in severity, they were reduced in the first week of October to three and four a day. This change in the wea- ther, which so suddenly checked the prevalence of the disease, proved very injurious to the sick and convalescent. The symptoms became more inflammatory; determinations to the brain and 13 lungs were more frequent, requiring the free use of the lancet. Notwithstanding the early frosts, a cherry tree in the town of Leesburg was in full bloom early in October. It may probably be expected, that I should in the first place give some account of the origin of this fever. I should be happy were I able to give a satisfactory one. Had it made its first appear- ance on the banks of the Potowmac, I might pro- bably be induced to trace its origin to marsh mi- asmata, and the putrid exhalations arising from the rich sediment and vegetable matter left by the overflowing waters of the river in May and June, generally supposed by the best writers in Europe and America, to be the remote cause of bilious fever. But it is known that the fever made as early an appearance among the inhabi- tants of the mountainous parts of the country, where it would be difficult to find either marshes, low grounds, or putrid exhalations, as it did on the banks of thePotowmac; and raged there with rather greater violence and mortality. A gentle- man, who cultivates an island in the Potowmac, kept his negroes in tolerable health during the summer, by giving them, on the first appearance 14 of indisposition, a solution of Glauber's salts, and tartar emetic; whereas in higher situations co- pious and repeated bleedings were generally ne- cessary. Bilious fevers have generally been ob- served to prevail most, after hot and dry seasons; but the fever which carried off so many of the inhabitants of Loudoun, followed the wettest summer ever known by the oldest persons in the county. Even during the prevalence of the epi- demic, we had seasonable rains. We cannot therefore trace its origin to a hot and dry season. On this subject Doctor Rush has offered an opi- nion well deserving attention. He supposes, in one of the volumes of his printed works, that un- der such circumstances as those I have mentioned, the fever is owing to temporary putrefaction pro- duced on the high grounds by the unusual quan- tity of water that has fallen; or else, to the marsh miasmata from the low grounds being arrested by the summits of. the hills, as is every day the case with vapours. This opinion is confirmed by many facts, to be met with in the writers of the East and West Indies. The tops of some of the mountains in those parts of the world, are found to be very unhealthy; and it is obvious to com- mon observation that they are generally covered 15 with mists, which arise from the vallies below. I have also frequently heard it mentioned as a sin- gular circumstance, that families who lived im- mediately adjoining a marsh were healthy; while others on the surrounding eminences were often affected by disease. In the month of July, the prevailing com- plaint was a remittent biHous fever. About the 20th of the month, the symptoms became more violent and inflammatory; the head-ach and pains in the loins and limbs were more severe; the patient complained of great oppression of the breast and sickness of the stomach....great quan- tities of bile were thrown up....the countenance was flushed....the eyes inflamed....the pulse was generally full and hard. The patient was often delirious during the paroxysm. If these symp- toms were not speedily relieved by copious bleed- ing, and powerful evacuants, death soon closed the scene. But generally the disease came on with more moderation. The patient felt weary, complained of a dull head-ach, of slight pains in his loins and limbs, of loss of appetite; chills and fever soon succeeded. Timely medical aid frequently check- ed these symptoms, and prevented a more severe 16 attack. The fever would go off, and apparently an intermission take place. Sometimes the patient would walk out the next day, and endeavour to attend to his business. The chill and fever on the second day were often slight. This apparent intermission led many persons into a fatal error. It induced them to believe the disease to be noth- ing more than the common ague and fever, which could be cured by large doses of bark. But du- ring this remission, as it really was, there was a considerable tenseness of the pulse, which was in- creased by the bark. If the patient persisted in the use of this medicine, the fever became highly inflammatory and fatal in several instances. On the third day, the chill and fever attended with all the distressing symptoms, returned with in- creased violence, and on the following day would again be more moderate* In a few instances the disease continued in this way for a considerable time, without any symptoms alarming to the pa- tient. But even in these moderate attacks, the fever if neglected, or improperly treated, increas- ed rapidly to the great hazard of th$ patient's life. The habit of the body was generally costive; sometimes extremely so, and attended with severe 17 colic. In this situation a boy took 60 grs. of jalap and 30grs. of calomel in the course of twelve hours, before he was relieved ; larger doses were some- times necessary. The discharges from the bowels were extremely fetid and bilious, and often of a very dark colour. Those from the stomach were mostly bilious. The oppression of the praxordia, and con- stant nausea and retching, proved fatal to an old lady: her fever was moderate. Many complained of a soreness of the sto- mach ; the slightest touch was painful. Some were afflicted by malignant ulcers in their groin and other parts of the body, which proved fatal in three instances. Sometimes the sores made by blisters became gangrenous, and extremely diffi- cult to heal. In one instance a mortification came on after such an application to the back, and the patient died. She applied the plaister without medical advice. Children were often seized with convulsions. They were generally relieved by bleeding, eva- cuants, and the warm bath. Several were afflicted with the hooping-cough, accompanied by all the violent symptoms of the bilious fever; to some of these it proved fatal. There were two cases 3 18 of croup, both attended with bilious stools, and other symptoms of the prevailing fever....two lovely girls, sisters, were taken nearly at the same time ; and both fell victims to the combined at- tack of these two dreadful diseases. The treatment of this fever was in general conformable to the most improved practice of the present day. When it came on with great nau- sea, &c. a mercurial emetic of lOgrs. of calomel, and 1 1-2 or 2grs. of tartar emetic, was given first, in preference to a cathartic, and even before bleed- ing. But in general, from twelve to twenty ounces of blood were first taken from the patient, according to the fulness and hardness of the pulse, and the violence of the fever ; and some- times more. Then either a mercurial emetic, or a full dose of jalap and calomel, 20grs. and lOgrs. was directed. The bleeding, and one or two pur- gatives were often sufficient to check the fever, and restore the patient to health. But it was too often necessary to bleed freely a second, a third, a fourth, and even a fifth time, before the pulse could be reduced, and the fever subdued. If the first dose of medicine did not act on the bowels in a few hours, its operation was as- sisted by small doses of jalap and calomel, 6grs. of 19 the former with 2grs. of the latter, given every two hours ; and when the desired effect was pro- duced, a constant discharge was kept up by the same means, as long as the evacuations continued fetid and bilious, and until the symptoms of fever abated. But the pulse was not always full and hard. In some cases the physician, from its state, would almost doubt the propriety of drawing blood, if a knowledge of the nature of the epidemic and experience had not taught him not to trust to ap- pearances ; that the pulse, although it appeared weak and depressed, wOuld rise after the use of the lancet. The want of this knowledge too fre- quently restrained its use to the destruction of the patient. The use of all animal food and spirituous liquors was forbidden, and a proper vegetable diet recommended. The usual remedies to excite perspiration, to abate the burning heat, to relieve the deadly sickness of the stomach, &c. were often prescrib- ed; but they seldom or never afforded relief be- fore the stomach and bowels were cleansed. During the continuance of the inflammatory stage, blisters were very injurious. So violent 20 was every kind of inflammation, that ptyalism was a dangerous expedient. It was seldom tried except in the commencement of the epidemic, and in desperate cases. The fever under this treatment generally abated, and a complete intermission ensued; when the columbo and bark were useful. But experi- ence taught the necessity of caution in adminis- tering the bark. It proved injurious to many in the early part of their convalescence. A lady was distressed by great sickness and puking of bile from the first attack of the fever, and during the course of it with a burning heat in her stomach, and intense thirst. She was bled copiously and repeatedly ; the jalap and calomel were given at first in full doses, and afterwards in small doses every two hours, which occasioned a severe ptya- lism. But the sickness and puking still conti- nued. The discharges from the stomach were at one time nearly as dark as coffee grounds. After a long and painful illness she began to mend. As she was extremely reduced, it was thought the bark would be serviceable. It was tried in vari- ous ways; in no one was it useful for a conside- rable time. It irritated the stomach, and induced sickness and fever. 21 I experienced its injurious effects myself. After great fatigue and exposure to the night air, I had a severe chill; an intense head-ach and high fever soon came on. It was treated in the usual way....after some days an apparent intermission took place. Anxious to attend to business, I was induced to take a dose of bark. Although it re- mained but a few minutes on the stomach, it oc- casioned extreme sickness and shuddering, which were immediately followed by a severe chill and fever. Another dose was tried the next morning, and the morning after. At each time it produ- ced excessive sickness, and brought on the chill and fever four hours sooner than usual. After an interval of several days, during which the par- oxysms became gradually milder and the pulse quite soft, recourse was again had to bark in wine, with the happiest effects. In this stage of the fe- ver, blistering was often very useful. This epidemic, which carried off so many in the bloom of life, was very much under the con- trol of medicine. Very few of the great num- bers who were taken, fell victims to its violence, when medical aid was obtained in due time; but this was often impossible. The physician after riding the whole day, would find on his return 22 in the evening, his shop crowded with people waiting for him. Their entreaties for assistance, a sense of duty and humanity, would compel him again to mount his horse, and ride until midnight, and often all night. These exertions were repeated day after day, until worn down with fatigue he could no longer make them. Many of course were lost for want of medical aid. But, though greatly under the control of medicine, unfortunately it was not entirely so. Vain were the earliest and the most strenuous exertions, to save the lives of some miserable victims to the ungovernable rage of the disease. A stout man in the prime of life, was copiously bled soon after the attack; and five times after- wards. He took large doses of jalap and calomel, and other medicines; yet his fever continued high, and his pulse full until within a few hours of his death. For some days before this event, he was afflicted with a most painful, burning heat in his stomach, an intense thirst, a distressing sensation of choking, and a rising of acrid matter in his throat, which occasioned a continual spitting. His misery was greatly increased, by an almost constant hickup. When the operation of medi- cine required him to be raised, he frequently faint- 23 ed. A blister was applied to his stomach, with- out relieving him. The day before his death, the sore assumed an unfavourable appearance, being covered with livid streaks and spots. On the morning of the day on which he died, he thought himself better. The painful symptoms were great- ly abated. He was soon after alarmed at the dark colour of some matter like coffee grounds, which he threw up; but as he continued easier than he had been, the alarm soon went off. About three o'clock, p. m. his mind was somewhat deranged; but he knew his friends and attendants, talked freely to them, and said he was much relieved. But this was no more than the deceitful calm, which often precedes dissolution. On being raised an hour after he fainted, and died before mid- night. Mr. Amos Thompson, a respectable clergy- man, who spent much of his time in visiting and assisting the sick, had, during the early part of the illness of the patient whose case has been just related, devoted great part of his nights and days in attendance on him. Feeling much indisposed he returned home. Soon after, he was suddenly taken ill, and fell from his chair. Medical aid could not save him; he died within twenty-four hours. 24 Fifty ounces of blood were taken from him, in the course of the forenoon; his pulse becoming strong- er by the loss. . His sudden death was not attri- buted to any contagion received during his at- tendance on the sick. The fever was not believed to be contagious. Although the unconquerable violence of the disease too often deprived the patient of his life, more frequently this was occasioned by his own folly and imprudence. It frequently happened, that on being bled freely, and taking a few cathar- tics, he found himself relieved from the urgent symptoms of the disease. But too early an atten- tion to business, or the too eager indulgence of a keen appetite, invited a return of the fever, with such force as to baffle every attempt to save him. From these and other causes, relapses were remarkably frequent. In some cases, eruptions appeared about the mouth and other parts of the head; they were frequently symptoms of a fa- vourable termination. In these details, I have perhaps been rather tedious. My object being to convey a clear idea of the fever which prevailed in the county of Loudoun, and of the manner in which it was treated, I have confined myself pretty closely to 25 a plain history of it, without advancing opinions' of my own, or quoting those of others. I have not thought it necessary to swell this essay with enquiries, whether the burning fever of Hippo- crates, Aretaeus, and others, and the bilious fever of the present day be the same ; or whether the fever, which afflicted the inhabitants of Loudoun, resembles the yellow fever of the West Indies, and the sea ports of our own country. I have avoided these fashionable digressions* When stating the great advantage experienced from early and copious bleeding in this fever, and the necessity of repeat- ing the operation, according to the state of the pulse and violence of the symptoms, I did not think it necessary to cite the authority of Prin- gle, Mosely, and many other physicians to justify the practice; to shew that it facilitates the action of calomel on the bowels, promotes perspiration, relieves the oppression of the breast, and often the sickness of the stomach. It is well known, that when the present mode of treating bilious fever was first recommended by our much res- pected professor to his suffering fellow citizens* it was warmly opposed by many very respectable physicians, as novel and dangerous; and that there was a general prejudice against it. To remove 4 2G these prejudices; to prove the mode recommend- ed to be neither novel nor dangerous, but to have been advised by many celebrated physicians, it was necessary to quote authors, ancient and mo- dern. But this necessity no longer exists ; hap- pily these prejudices are removed. Experience has convinced us that this mode of treating bilious fever, when attended with inflammatory symp- toms, has saved the lives of thousands of our fel- low citizens. At this period therefore to quote authorities to justify it, would be as unnecessary as to demonstrate a self evident proposition. As the effects of this disease on the different parts of the human system, so nearly resemble the effects of the fever, that has of late years been so destructive in many parts of America; and as these have been so accurately recorded by an emi- nent physician, I have declined particularly enu- merating them. But they may in a great mea- sure be collected from the history I have given. It may not be improper to observe, that the epidemic, which was so highly inflammatory in many parts of Loudoun, extended itself to seve- ral of thp neighbouring counties, Fairfax, Prince William, and Fauquier, and beyond the Blue ridge ; but generally under a milder form. Par- 27 ticularly beyond the Blue ridge, the lancet was seldom necessary. Emetics, cathartics, and dia- phoretics were generally found sufficient to mo- derate the symptoms; when a liberal use of bark, wine, and opium completed the cure. Blistering was an advantageous practice. I will close with the observation, that hap- pily the fever was not found to be contagious. There were none of those distressing scenes which disgrace human nature; the sick were in no in- stance deserted. Where whole families were af- fected, as was too often the case, their neighbours without apprehension of danger visited them, and rendered them every assistance in their power. This duty was so faithfully performed, that the labours of the field were partially suspended, to the great detriment of these benevolent people. THE END. •*