An essay on the epidemics of the winters of 1813 and 1814 : in Talbot & Queen-Anne's counties in the state of Maryland

Dedication

TO NOAH WEBSTER, Esq.

Author of a "Brief History of Epidemical and Pestilential Diseases, 1 " Sfc. Sfc.

Sir,

Preface

It may be considered rather an unhappy circumstance attendant on the science of medicine, that its practice should be commenced, and continued under impressions of the correctness of certain theoretic principles, more especially so, if the physician should be so presumptuous as to suppose, his doctrines are capable of standing the test of experience. The mind thus predisposed is prepared to make facts bend to theory, instead of founding theory on facts. In other words, under such preconceived notions, the judgment is too liable to be perverted by false reasoning from incorrect principles. Correct practice will ever depend on a great variety of circumstances, but on nothing more than a knowledge of the " constitution" of the atmosphere, which unfortunately can never be sufficiently understood, until it has discovered its morbid effects on the human body in the production of disease. Hence to establish a system of medical practice upon the experience of a course of years, might before the expiration of another year, be attended with very fatal issue.

The occurrence of an epidemic disease in this town and county (Talbot, Maryland,) in the winter and spring of 1813, has proved beyond all controversy, that established systems of practice, which had apparently stood the test of time immemorial, have been dangerous in the hands of the unwary, and that being at constant variance with epidemics, they may become a double scourge at such a period. Folly and wickedness have destroyed thousands of human beings, but system and empericism have done more ; they have multiplied the instruments of

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death, and destruction ten fold. Whether the following essay will have any tendency to correct some of the errors, which are incident to human weakness, in the preservation of life, the author will not be so vain as even to express a hope, much less an opinion, being too sensible of his own imperfections, and liability to err ; but thus much he will venture to proclaim to the world, that the epidemic of 1813, has freed his mind from the shackles of system. Having made the attempt to prevent or lessen the evils, to which he believes every quarter of this globe may become liable, he has some consolation, that, perhaps, he may be the humble means, of putting the practitioner of medicine on his guard against the hasty use of remedies, which though they have frequently done much good, they may under a change of circumstances, even when the symptoms of a disease are apparently the same, do much harm. He trusts, it will not be deemed presumptuous to use the language of the great Sydenham, when he says, " though the same variety does " not happen in all distempers, yet I hope to make it plainly " appear in the following sheets, that there are several, which, " notwithstanding their being treated of by authors under the " same name, without any distinction of kind, are extremely " different," as to their cause, and the effects of that cause on the human body.

THE

EPIDEMIC OF 1813,

In Talbot and Queen Anne's County, in the State of Maryland.

BEING fully persuaded, that it is altogether impossible for a

physician, who undertakes to write the history of a disease of

any kind, but more especially that of an epidemical disease, to

be instructive and useful, unless he candidly relate the errors,

as well as the correctness of his judgment in its treatment,

I shall commence the account of the epidemic of 1813, by

Betting down a few of the first cases, with a faithful account of

their treatment.

It is generally admitted, that the whole of the Eastern-shore

of Maryland, of which Talbot, and Queen Anne's counties make

a part, is sickly, being addicted every autumn to intermittent

and remittent fevers ; but it was a fact beyond all contradiction,

bat the autumnal months of 1812, were uncommonly healthy.

During all November, and the greater part of December, there

was scarcely any thing like disease in Talbot ! This great bane

to human happiness seemed to be hushed to rest. The whole

district of country appeared to feel a state of security, and

tranquillity, so much so, that if there had not been a few

chronic cases of disease ; it would have been forgotten, that

physicians were necessary appendages to society ! It was in

our attendance on one. of these distressing cases, about the 20th

of December, that Dr. Tristram Thomas, and myself fell into

conversation on the subject of the unusual healthiness of the

preceding season, and particularly that of the present and last month, when we were both of one opinion, that we had never known a more healthy time.

On the 24th of December 1812, 1 was called to visit Hannah Martin about 27 years old, late in the evening, eight miles from Easton, in a southerly direction, who being the mistress of a large family, after more than usual exercise on the preceding day had gone to bed early, and was taken about 12 o'clock at night with a violent ague, which was succeeded as was believed by as violent a fever with all the common symptoms of pleurisy. A neighbouring physician was called in before day, who considered the case a plain one, and bled her largely, to the quantity of more than a pint. When I saw her after night, she was comotose ; her face flushed ; skin dry and hot ;* tongue moist, and to appearance as well as in perfect health ; pulse feeble, complained when roused, of nothing except a violent pain in the head ; but upon being interrogated, and desired to make a full inspiration, she said, she felt a pain about the sternum, and some stricture across the thorax, as well as a degree of heaviness and fullness there. At first view there was an appearance of something singular in this case, though I confess I did not from habit, take time to consider it as any thing new, or extraordinary. I commenced the treatment upon the symptoms, but never thought of deviating from the usual mode in such cases. As the pulse was such as not to indicate the use of the lancet, and other symptoms did not seem to call for it, it was not used at all ; but nauseating doses of vir. antimon. &c. &c. were used freely. Blisters were not spared ; and as it seemed to be soon indicated, a decoction of bark with serpentan. virg. was administered liberally, together with a sparing use of wine and toddy. The chamber contrary to my desire, was kept warm, which, I have not the least doubt, was a most fortunate circumstance, as may appear before long. Her bowels were moved with difficulty throughout the whole course of her illness, another lucky circumstance. She never expectorated freely, and yet she recovered unexpectedly, though slowly.

* The feet were not attended to.

On the 25th, I visited William Brown, a black -smith in Easton, of very intemperate habits, about 30 years old. He had been ill a day or two. His pulse was full, but neither very hard, nor frequent ; his face was much flushed, and he complained greatly of his head, and of nothing else until interrogated, as in the case of Hannah Martin, when he said, he had a pain in his side, &c. He was rather comotose, but rambled in his sleep. His expectoration was inconsiderable, and had nothing unusual in its appearance. Under a consideration of all these symptoms, I did not hesitate long about taking away blood from the arm, but contrary to expectation, before I had drawn off half the quantity at first intended, the pulse sunk, and I found myself under the necessity of stopping short of eight ounces. Though I saw him two and three times daily, I did not venture on bleeding him the next day, but thought myself justified from the symptoms, to venture on a second bleeding on the 27th, but with the same result. In the evening of this same day, he was very delirious ; stole out of the house, and wandered on the commons some time before he could be found. On the 28th I bled him again, which he bore much better. On the 30th he was bled, but never with those pleasing effects, which I have so often experienced in former years, and on former occasions. He was blistered on his sides, back and head, and went through the usual routine of antimonials, &c. which are so common in cases of pneumonia in ordinary seasons. But after depleting to some extent, and finding my patient sinking, I reflected on the stimulating habits of the man and did not hesitate long, before I saw the necessity of altering my course, and of supporting sinking nature by a free use of diffusible stimulus, which, perhaps, were the principle means of rescuing him from the jaws of death, though it might have contributed to have confirmed him in old and bad habits.

On the 29th I was called on to visit John Burgess, 54 years of age, intemperate, and much addicted to the gout, living three miles from Easton in an easterly direction. He had been bled in the morning by a young physician rather freely ; perhaps, in a high fever, but when I saw him, his pulse was hardly perceptible. Himself and his wife thought he had been taken the night before with the cholic, but that could not have been so ; for from their own statement, he was taken with an ague some time in the night, and had been chilly, and cold from that time. I thought it advisable to do nothing more than give him forty or fifty drops of laudanum, and direct hot bricks to be applied to his feet, and something warm to his stomach, where he complained of some pain ; and left him not to see him again, unless sent for. I understood he was visited the next day, or day after by some other physician, but too late to arrest the hand of death. The 7th of January 1813, 1 was called on by one of his neighbours to visit Thomas Custallo, eight miles from Easton, directly north, but found him dead. [ understood be had been sick only three or four days, with a pleurisy, and that he had been bled more than once. No doubt, this was a case of the epidemic.

On the 14th, I saw a small boy, son of the late John Burgess. His face was much flushed, his fever was high, and he complained very much of his head ; and a little of his side when desired to make a full inspiration. I bled him, and gave hint some antimonial medicine, and though the pulse sunk, while the blood was flowing, he soon recovered without any further medical aid.

On the 15th, I visited John Higgins in Easton. He was taken the night before, with an ague succeeded by a fever, pain in his head, side, and all the ordinary symptoms of pleurisy, and yet he repeatedly expressed an opinion, that though he had been addicted to the pleurisy almost every winter or spring, yet his feelings were different from any thing which he had experienced before. I did not bleed him immediately, but determined to wait for the bleeding point, and then was disappointed as to the happy result, for his pulse evidently sunk before I had taken as much blood, as the occasion seemed to require. For two successive days I bled him, and went on with nauseating doses, blisters and anodynes at bed-time, not thinking venee sectio indicated again, before the 20th, when he expressed relief, before the arm was untied. On the 7th day from the first attack, he complained of a pain in his ankle, which was succeeded by severe inflammation, when all the symptoms of pleurisy gradually went off, and his whole attention was directed to his ankle. The inflammation terminated in resolution.

On the 16th, Robert Huzza came across the street from his house about 10 o'clock at night, requesting me to see his wife. She had been taken the night before with symptoms, which were beginning to be familiar to several families, though not as

yet alarming. Mr. was called in because he could bleed,

and give calomel and jalop. She was bled in the morning and took calomel and jalop, which operated violently. She ceased to exist long before the beginning of another day.

About this time the alarm began to spread, not more on account of the death of Robert Huzza's wife, than from several other sudden deaths in Easton, and its vicinity. Bleeders were called in as soon as a patient was taken ill; more particularly as the disease assumed scarcely any other type, than that of pleurisy ; and as the lancet had been proved on former occasion and seasons, it was expected it would retain its virtues, but alas ! all things are uncertain in this world, and nothing more precarious than a remedy, which is administered without caution, and without judgment. This is proved unfortunately on ordinary occasions, but the history of epidemics ought to be a lesson to physicians, who ought to use the lancet with fear and trembling, whenever the seasons usher in a disease of any type whatever. Though this epidemic fever had been stalking along in formidable disguise, it had until now been productive of but few deaths, and I can assert without a fear of contradiction, that the numbers would have been much fewer, if the lancet had not been " wielded by chance," and not by the steady hand of judgment. When I wis called to a patient about this time, I was too often mortified to find, that any judgment, which I had acquired from experience, was rendered useless by an indiscriminate use of the lancet, or a dose of calomel and jalop, which continued to be the first and last resort, notwithstanding deaths were multiplied every day.

and few recovered, who were attacked violently. I will candidly confess, that though I was staggered in my unbounded confidence in the lancet, yet like all others wedded to system, I continued to use it in almost every case, which seemed to indicate it, but with caution, and due reflection, aiming like Dr. Rush to hit " the bleeding point" both as to time, and quantity. Like others I plunged along through all January, and a great part of Febuary, before I could be induced to consider this unrelenting disease as an epidemic sui generis, differing in its origin, and effects on the human system from every other disease, which had appeared before in this part of the country, but not unlike a disease, which had recently made its appearance in several of the New England states, exciting alarms, and proving in too many instances malignant and mortal.

When this Epidemic commenced its career in December 1812, it was in the type of Pneumonia, and continued so with very little variation, (if my observation was correct, and I am confirmed in it by the testimony of the most experienced physicians in Easton) through all January, down to the 20th of Febuary, when for the first time, and in the first case in that neck of land, I was called to visit William Blake, over Miles River Ferry, who had been taken the night before with an ague, succeeded by a fever, and sore-throat. It was then snowing, and blowing most dreadfully, which with the risk of crossing the ferry deterred me from visiting him until the next day, when I fonnd him in a smart fever, and labouring under all the other common symptoms of synanche tonsillaris. I was told, he had got a neighbour to bleed him the preceding evening, and thought himself relieved by it. I repeated the same remedy, and directed a dose of salts to be given in divided doses, promising to see him the next day, when I was mortified and disappointed to find him much worse ! His tongue was now so much swelled as to be protruded out of his mouth. Yet I did not despair of affording him speedy relief having seen several such cases, as I conceived, happily terminated by topical bleeding. In this hewever, I was greatly disappointed. Upon examining the part affected under the tongue, I could see none of those numerous veins, which had been so visible, and so readily opened on former occasions. They were entirely obsuned by an effusion of serum under the sneiderion membrane.

Yet I was confident of relieving him, if, perchance, I could divide a vein, and therefore boldly plunged the lancet in, and through the membrane, and serum, but to little purpose, as scarcely any blood flowed from the several punctures ! The pulse being full, though not hard, and topical bleeding having failed, I ventured on taking blood from the arm, omitting none of the usual remedies at the same time, which I thought could relieve him except a blister ot his throat, which was improperly, though I have not the least doubt in vain, reserved for the next day, but alas ! I had the mortification of seeing him no more. There is not the least question with me, that the "effusion of serum,'''' which was so visible in his mouth, had in a very short space of time extended to his lungs, and thus suddenly, in all probability, closed the avenues of life ! This was an instructive case, which raised reflections, and considerations, which heretofore had not been pressed upon my mind. I began to view the subject of the "prevailing complaint" with new light under whatever shape it might appear, and to reflect, that there was something new, and extraordinary in the several cases whicli had come under my notice, as well those, which had terminated in recovery, as those, which had been fatal in their issue. The lungs had most generally been the seat of the disease, and " effusion" had invariably been its termination. From hence I concluded, there was something in the air, or something deficient in its qualities, which had been and still was the cause of the disease, and that that cause was singular in its effects, or at least they were such as had not, except in a few sporadic cases ever came under my notice before. In truth, that, though I had succeeded in most cases, (where there had not been any interference of others,) merely by close attention to the symptoms : nevertheless I had heretofore incorrect ideas of the nature, and treatment of the disease ; and that, though it had assumed the leading and characteristic symptoms of the various types of pneumonia, which had, as I conceived, been familiar to me for nearly thirty years ; yet I had been mistaken in the exact, and correct mode of treating the epidemic under this type. The observations I had made upon the cold stage of the fever more especially as to its duration, had begun early to give a new direction to my reflections, and to cause the necessity of adopting the method of cure to the nature of symptoms, which has been a constant rule in my practice from its earliest date, as may be perceived in the treatment of those cases, which had ushered in this extraordinary epidemic at a time, when the most knowing had not expected any thing beyond the usual routine of annual complaints.

Though the symptoms of the epidemic have been in a great measure delineated in the history of the several preceding cases, which, as was just observed, had ushered in the disease j it will nevertheless for the sake of order be necessary to give as accurate a description of it as possible, and to endeavour to distinguish it from other diseases, notwithstanding it was accustomed to assume the form of all other diseases to which the human body has been subjected, which is nothing more than saying that every " type of disease partook of the nature of the epidemic," because the remote cause of all was the same. But inasmuch as it cannot be expected under these circumstances, that any disease to which we are liable can be described ; it will be deemed proper to select the type of disease, which was the most common, and at the same time the most fatal : therefore I shall content myself with describing the epidemical pneumonia, considering all others of minor consideration, except synanche.

It does not appear from any observations, which I was capable of making, that there were any premonitory signs, or symptoms, which indicated an approaching attack of this disease. Patients were seized at all times of the day, but more generally, as in ordinary pleurisy, sleeping in bed, while the least insensible to external stimuli, and in a state of the most fatal security ! As in all other fevers it commenced with an a?ue, seldom violent, but of protracted duration ; and though the patient might soon cease complaining of sensations of cold, the external surface of the body had in the most dangerous cases a cold feel, and in almost all while the other parts might be warm to the touch, and the face flushed, the extremities, more especially the feet, would have an icy feel, if some warm applications had not been made to them. Indeed in the most advanced stage, it would most generally seem as if the patient was insensible to the cold, complaining at the same time of great internal heat. If he were asked, if bis feet were cold, the answer, nine times out of ten, would be in the negative. If hot applications were made to the feet and removed, they would soon become cold again. In fact it was difficult to determine, whether the cold stage in the most violent cases, was even completely succeeded by the hot stage, until symptoms of recovery were actually apparent.

The face was flushed from the very beginning, though most other parts of the body were cold ; and the bead in every type of the disease, was most violently complained of, if the patient complained of any thing, insomuch so, that the epidemic very early in the season, got the name of the "head complaint ;" for though he might have a pain in the side, it was rarely he complained of it, unless interrogated concerning it.

If a coUgh and common cold, had not been hanging upon him before the formation of the disease, it was sure to come on very shortly afterwards, when he would sometimes complain of pain in the thorax, though very seldom, unless questioned on the occasion, and requested to make a full inspiration.

The respiration was, generally speaking, free and easy, from the commencement of attack, unless, as was too often the case, the economy of nature was disturbed by some improper interference, which might, and did in many instances bring on an "effusion of serum'''' in the lungs, before a determination could be made to the skin, when it became quick and laborious, and a sure presage of a fatal termination.

Expectoration of mucus from the lungs was among the first symptoms of their affection, and was rarely copious, except when it was bloody, which was an unfavourable sign, though not a fatal one, as in the case of quick resinration.

The pulse was frequently full, even when the cold had not been completely succeeded by the hot stage, and was sometimes feeble, when the external surface was rather warm. It could never be said to be hard, and very seldom quick. Very frequently, if other symptoms were not attended to, it might be said to be a healthy one from the feel. In fact, when the epidemic began to be better understood, it ceased with me to be a sure guide in the treatment of topical affections of the lungs, and every other type of disease ; though it had been almost unerring in its indications in hundreds and thousands of cases before this period : For when it would seem to indicate in some cases, from its fulness, the loss of 24 oz. of blood, it would begin to intermit before three ounces were taken away, and not unfrequently cease to beat before five were abstracted.

The blood never flowed freely, and was invariably of a dark livid colour, and yet had very much the appearance of pleuritic blood in former times, which had been considered as a test of violent " inflammation.'''' I have known it stand for hours, without separating into crassamentun and serum, fully demonstrating to my view of the subject, that it had not acquired in its passage through the lungs, a sufficient proportion of that vital principle from the atmosphere, which could make it active and properly vital.

The skin in some violent cases would be cold, but in others scorching hot, while the feet and hands, as has been before observed, would be cold. At other times, it would feel soft and cool, while the patient would complain of great internal heat. It would feel warm, while covered by bed clothes, but upon the least exposure, it would become cool ; and put on the appearance of goose flesh, when the surrounding atmosphere was rather of moderate temperature.

The stomach was rarely disordered at any stage of the disease, but on some occasions, and in some instances, it became extremely irritable when considerable quantities of bile, and tough mucus were ejected, which I never have considered as an indication of any thing unpromising, though it might sometimes have proved troublesome.

The bowels were disposed in most cases to remain quiescent, unless disturbed by improper treatment ; from whence as much mischief might, and too often did arise as from bleeding. The one could be instantly restrained, the other was generally beyond controul.

The urine was in almost every case free, and often copious, but could not be considered as in ordinary pleurisy, a favourable sign. In fact there was neither sign, nor symptom, from whence any thing favourable could not be prognosticated except a warm moisture of the whole body, which was seldom excited by nature, but very readily by art at the earliest commencement of the disease, but with great difficulty afterwards.

In whatever type of disease this epidemic fever might have appeared, I think, I can assert without a fear of contradiction, that the above description might be applied to it, with the exception nevertheless of the symptoms peculiar to affections of the lungs, and adding at the same time, those which are peculiar to the several parts or organs of the body, when disordered ; so that it may be said of this epidemic, what Sydenham has said of the epidemics of his day, viz. that " all other diseases, partook of the nature of the epidemics," for this plain and obvious reason, they all proceeded from the same

REMOTE CAUSE.

But this great man seems to think an " investigation of remote causes" of no importance, and little short of a " loss of labour," inasmuch as " they are undiscoverable."

Before we proceed, it may be of consequence to describe the extent of country, which this epidemic occupied, and know, whether there was not an invisible power, which seemed to say, " thus far shalt thou go, and no farther, " when the reflecting and candid reader, will have an opportunity of judging for himself, and of determining, after he has heard the whole matter, whether there may be any use in tracing causes, and the effects of those causes on the human body. Certainly at this sera of philosophical enquiry, when a disease is prevailing, and it is obviously the effects of a peculiar cause, while those effects are of a very extraordinary and singular nature, it cannot be deemed presumptuous, nor unphilosophical to attempt an investigation of that cause ; more especially when it is considered, that too many are in the constant habit of referring the cause of all epidemical diseases to contagion, which at one dash cuts up all further enquiry, to the no small injury of medical science, and the cause of humanity.

While the epidemic of 1813 has been seen springing up insidiously in every direction of my small circle of practice, it was at the same moment bursting forth throughout all Talbot and Queen Anne's Counties, scarcely touching on the banks of Choptank on the Dorchester side, doing no injury beyond the village of Cambridge, in a manner altogether desultory. Perhaps, it did not reach the opposite banks of the Tuckahoe, which divides Caroline from Talbot county; then skirting along in zigzag direction the whole line, which separates the first named county from Queen Anne's, it probably stretched across to the head of Chester river, which is known to have cut it off from Kent county, and from the Western shore by the Chesapeake bay. These were the limits of this mortal epidemic ; and I defy contradiction, while the mourning relatives of its numerous victims live in this devoted district, for beyond them there is scarcely one, who can be found to say, as here, I have lost a father, mother, brother, sister, son, daughter, or some one or more relatives.

That the remote cause of this epidemic was in the atmosphere, there can be no question ; but why it should commence, and rage in the small section of country, and not spread into those parts contiguous to it, where the same causes apparently existed, so far as they could depend upon heat, cold, moisture, and every other sensible quality of the air, is a phenomenon both singular and extraordinary, and not very readily accounted for ; more especially in this quarter of the country, where epidemic fevers in the autumnal seasons, are as familiar as the seasons, which revolve around ! These can he traced to certain sources, such as putrid effluvia, and marsh miasmata, but not so with this epidemic, which unexpectedly and insidiously commenced in the month of December from no visible source, and progressed with accumulated malignity throughout the remaining winter months, and all the spring months with very little if any abatement; and at a time, as has been just observed, when our neighbours were enjoying more than usual health ; a circumstance truly astonishing, and a phenomenon, which seems to bid defiance to investigation ; nevertheless the research is a laudable and useful one, and such as I conceive ought to be attempted.