and The Risk of Dying
Malaria, Flux and Unclassified (con’t)
The diagnosis of malaria is difficult. It may resemble flu, gastroenteritis or acute respiratory infection in the early stages. As fever becomes symptomatic, it may be confused with relapsing fever, yellow fever, typhoid fever, tuberculosis, dengue or a whole host of other viral infections. 41
Malaria must have presented a very perplexing picture to colonial physicians. Unclassified epidemics described by Rush in “An Account of the Bilious Remitting Fever as it appeared in Philadelphia in the Summer and Autumn of the year 1780” from Medical Inquiries and Observations 42 probably encompasses mild yellow fever, dysentery, malaria, typhus or break-bone fever. The fever appeared in July and August, but in a mild form, and on August 19, the fever became epidemic. “This fever generally came on with rigor”… in some persons a slight sore throat… and in others, hoarseness. It was accompanied by giddiness in the head, faintness, and apoplexy, and more severely by coma, convulsions and delirium. There were pains in the head, back and limbs, and sometimes the eyeballs. The flesh of every part of the body was sore to the touch, sometimes believed to be rheumatism, but more generally it was called “break-bone fever.” Symptoms of nausea and vomiting, and in severe cases, dysentery accompanied the fever. Remissions occurred in the morning and sometimes in the evening. On the third or fourth day a rash might appear. If the fever did not break on day four, it might go on twenty days or more, exhibiting signs of typhus gravior and hemorrhage from the mouth and bowels. When hemorrhage occurred, death usually followed. Fever was succeeded by jaundice. When the weather cooled to sixty degrees in October, the fever declined as well.
Rush’s treatment consisted of the following: Induce to vomit with emetics, rest, increase fluid intake, blisters, purges and opium, bark, but no bloodletting.
Elizabeth Drinker described an illness in her family in early September of 1783 that consisted of chills and fever, disordered bowels, sick stomach, bone pain, vomiting, sweats, and headache. Cinchona bark, bleeding, and blistering were used to treat the illness that doctors called “the fall fever, of which many in the city are ill – some of nervous and some of putrid fevers – though they don’t say it is a very sickly season or not a very mortal one.” 43 During an earlier account in September of 1768 as Drinker describes the ‘regular intermitting fever’ typical of malaria in daughters Nancy and Sally, she noted that Sally had “double tourchen.” Because fever occurs every third day, the disease was called tertian malaria; in double tertian, the fever occurs every day. 44
Elizabeth Drinker recorded that Sally Drinker, age seventeen, was stricken with the flux on July 6, 1778. She became “very ill, with vomiting and flux, above 30 stools today.” Dr. Redman visited, but it was not until August 3, 1778, that Sally was sufficiently recovered to eat breakfast downstairs. 45
Typhoid fever is an infectious febrile disease with a mortality of twelve percent in the pre-antibiotic era. In view of the primitive sanitary conditions it is remarkable that epidemic typhoid did not strike colonial urban areas with greater frequency. Philadelphia’s polluted wells, open markets, and lack of sewage disposal provided multiple opportunities for introduction of salmonella typhii into the gastrointestinal tract. Symptoms of typhoid are similar to many other fevers and it may have passed unnoticed as a usual autumnal or bilious fever. Kelley reported 273 deaths in 1754 attributable to typhoid. 46 One or more of the bilious plagues referred to by Packard as unclassified may have been typhoid.
Palatine fever, gaol fever, hospital fever, camp fever, and ship fever are all names applied to typhus, an acute febrile disease transmitted to man by body lice. The Palatine fever or ship fever was named for the disease German immigrants suffered during their passage to and arrival at Philadelphia. 47
Untreated severe typhus may be fatal in nine to eighteen days but the milder cases may pass unnoticed. Incubation varies from between six to fifteen days. The onset is characterized by sudden fever, headache, and prostration, mild at first progressing to profound. Nausea, vomiting, stupor, and mental lethargy may be present. A pink rash appears on the upper trunk about the fourth to seventh day and spreads over the rest of the body, sparing the face; later the lesions darken. 48
Complications in untreated cases are common and include bronchopneumonia, hemorrhagic rash, and delirium. Mortality may approach sixty percent, but may be as low as ten percent. 49 Treatments in the absence of antibiotics included delousing and fluid therapy.
Typhoid and measles bear some resemblance to typhus, and it is probable that some mixing of the diagnoses by early medical practitioners did occur. Since Pennsylvania had few jails, no militia and few hospitals (only Blockley, Pennsylvania and Bush Hill hospitals) during the period 1699 to 1799, typhus probably had little impact after immigration.
Known by a host of other names, including quinsy, bladders of the windpipe, throat distemper, and putrid sore throat, diphtheria was recognized as a plague among the children. It was more often reported among the New England colonies than the middle or southern, but two epidemics appear to have struck Philadelphia in 1746 and 1763. 50
Samuel Bard, a Philadelphian by birth, was one of the more important early American physicians who, in 1771, wrote a description of diphtheria entitled “An Enquiry into the Nature, Cause and Cure of the Angina Suffocative, &c.” On days one through five, he wrote, children exhibited a prodrome including slightly watery, inflamed eyes, bloated and livid countenance and a few red eruptions on the face. There was an uneasy sensation in the throat without hoarseness or pain and the tonsils appeared swollen and inflamed with a few white specks on them, which increased to cover them. A slight fever accompanied the early symptoms. In the next phase, on days two to three, there was a gradual increase in breathing difficulty and with it came prostration. A dry cough accompanied by changes in tone of voice followed. Constant fever became evident, higher at night, as the disease progressed to coma, facial swelling, profuse sweating and increased breathing difficulty, until death occurred on the fourth or fifth day from apparent suffocation. 51 Benjamin Rush noted that Philadelphia’s 1763 epidemic of malignant sore throat was fatal to many children. Elizabeth Drinker reported on the death of her son Charles from what appears to have been diphtheria.
[O]ur dear little one after diligent nursing had out grown most of his weakness and promised fair to be a fine Boy, became much oppressed with phlegm, insomuch that Doctor Redman’s opinion was that unless we could promote some evacuation he could not live, he ordered what he thought might prove a gentle vomit, agitated him much, but did not work, and in little more than 20 minuts fro ye time he took it, he expired aged 2 years 7 months and one day – about a week before he was fat, fresh and hearty – he cut a tooth a day before he dyed…thus was I suddenly deprived of my dear little Companion over whom, I had almost constantly watched, from the time of his birth, and his late thriving state seemed to promise a [reward] to all my pains – he died the 17 March, fourth day. 52
Risk of Dying
Since the first official national census did not occur until 1790, population numbers for Philadelphia prior to that date are imprecise. Thus, consensus on population numbers for colonial Philadelphia is a work in progress. 53,54,55,56,57 Using population estimates and number of deaths from the city of Philadelphia cited from Klepp’s table 58 entitled “Components of Growth – Philadelphia 1690-1859” and facsimile documents 59, approximate percent mortality can be calculated for each year from 1699 to 1799. (Table 1) In the forty-nine years in which there is written evidence of an epidemic, percent mortality averaged 4.28 percent with a high of 15 percent and a low of 2.3 percent. In the remaining fifty-one years during which no written evidence of epidemic disease was discovered, percent mortality averaged 3.48 percent with a high of 8.7 percent and a low of 2.2 percent. During three of these years (1709, 1729 and 1751) the mortality exceeded 6 percent.
Comparison of average mortality percentages for all known epidemic years (4.28 percent) and non-epidemic years (3.48 percent) reveals a difference of 0.8 percent for the 1699-1799 century. The possibility that an individual might die from an epidemic disease was on average only slightly more than the risk of dying from all causes. The slight difference in mortality during epidemic years would indicate that the true power of disease is in the illness and debility that it causes. Morbidity, a much more difficult aspect to illustrate numerically, is probably the more important measure of epidemic disease.
During the eighteenth century (1699-1799), Philadelphians experienced sixty-six epidemics (thirteen smallpox, six measles, nine respiratory illnesses, eleven scarlet fever, thirteen yellow fever, one flux, two typhoid, three typhus, two diphtheria and six unclassified) in forty-nine years. Presumably, they were relatively healthy as conditions permitted during the remaining fifty-one years of the century. Certain diseases such as malaria and dysentery may have been endemic because of location and/or lack of sanitation. While it appears that physicians held a general belief that only one epidemic disease was operative in the city at any one time 60,61,62, it is likely that combination epidemics existed but were unrecognized because of the prevailing medical mindset.
The author, Suzanne M. Shultz is Director of Library Services Philip A. Hoover, M.D. Library York Hospital.
- G. Thomas Strickland, Hunter’s Tropical Medicine. 8th ed. (Philadelphia: W.B. Saunders, 2000), Chap 92. Terrie E. Taylor and G., Thomas Strickland, “Malaria,” p. 629.
- Rush, Medical Inquiries, vol 2, p. 233-235.
- Drinker, The Diary, p. 415
- Drinker, The Diary, p. 145
- Drinker, The Diary, p. 315, 319.
- Joseph J. Kelley, Pennsylvania, The Colonial Years 1681-1776. (Garden City: Doubleday and Company, 1980), p. 317.
- Farley Grubb, “Morbidity and mortality on the North Atlantic passage: eighteenth-century German immigration,” Journal of Interdisciplinary History 17(Winter 1987): 565-585.
- Strickland, Hunter’s Tropical Medicine., chap 66, James G. Olson, “Typhus: general principles,” p. 430-431.
- Strickland, Hunter’s Tropical Medicine, p. 432.
- Duffy, Epidemics, p. 115, 123, 127.
- Samuel Bard, “An Enquiry into the Nature, Cause, and Cure of the Angina Suffocative, &c.” in Ralph Major, Classic Descriptions of Disease (Springfield: C.C. Thomas, 1932), p. 107-111.
- Drinker, The Diary, p. 420
- John K. Alexander, “The Philadelphia numbers game: An analysis of Philadelphia’s eighteenth-century population,” Pennsylvania Magazine of History and Biography 108 (1974): 314-324.
- Gary B. Nash and Billy G. Smith, “The population of eighteenth-century Philadelphia,” Pennsylvania Magazine of History and Biography 109 (July 1975): 362-368.
- Billy G. Smith, “Death and life in a colonial immigrant city: A demographic analysis of Philadelphia,” Journal of Economic History 37 (Dec 1977): 863-889.
- Susan E. Klepp,. “Demography in early Philadelphia, 1690-1860,” Proceedings of the American Philosophical Society 133 (June 1989): 85-111.
- Sharon V. Salinger and Charles Wetherell, “A note on the population of pre-revolutionary Philadelphia,” Pennsylvania Magazine of History and Biography 109 (1985): 369-386.
- Susan E. Klepp, “Demography,” p.103-106.
- Susan E.Klepp, The Swift Progress of Population: A Documentary and Bibliographic Study of Philadelphia’s Growth 1642-1859 (Philadelphia: American Philosophical Society, 1991)
- Charles Caldwell, “An address to the Philadelphia Medical Society on the analogies between yellow fever and true plague,” Medical Repository 2 (1800): 400-408.
- Rush, Medical Inquiries, vol. 3, p. 77
- Powell, Bring Out Your Dead, p. 9