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RECORD OF MEDICAL SCIENCE.
Ship Fever at the Bellevue Hospital. To the Editor of the New York Journal of Medicine:
Dear Sir:-In compliance with your request, I send you the en: closed brief statement of my observations and experience at Bellevue Hospital, during the late prevalence of Ship Fever, in the midst of which I was appointed to the charge of the establishment, in May last.
Your readers are doubtless informed of the immense influx of pauper immigration into the port of New York, especially from Ireland, during the present year. Their impoverished condition by reason of the famine at home, had superinduced a morbid predisposition, which only needed an exciting cause to develope those functional disturbances, which characterize fever. Their circumstances on ship-board, being crowded together between decks, to an extent little short of that said to be resorted to in slavers ; short of provisions, and even oi water; without the possibility of cleanliness or ventilation; presented a combination of morbid agencies which could scarcely fail to generate not merely fever, but pestilential fever, in some malignani form. Amid such accumulated filth and wretchedness, it is not at all wonderful that such frightful reports of disease and deathe should herald almost every arrival; nor could it reasonably be expected otherwise, than that our hospitals and almshouses should be crowded with the sufferers, borne thither on landing, either already sick, or so deeply infected as to render escape from an attack of fever scarcely possible.
Such has accordingly been the fact, and to an extent which may be estimated from the following statistical items prepared from the best data found in the hospital.
From the 1st of January, 1847, to May 25th, this hospital was under the charge of my predecessor in office, who admitted during this period 769 cases, many of them direct froin ship-board. Of these, as appears by the record, 306 were discharged cured -- 154 died, and 309 remained in the hospital under treatment, a large portion of whom were nearly moribund, when I assumed the charge as resident physician.
At that time, May 26th, 1847, there were over 800 patients in the house, 309 were suffering with ship-fever. Cases of the latter de. scription were then admitted at the rate of 60 to 80 per day, so that within a week or two, notwithstanding deaths and discharges, the number had increased to 1147 in the hospital, over 600 or whom were ill with the ship-fever.
With this large number, being so much beyond the capacity of the hospital buildings to accommodate, and alike beyond the available resources of the establishment, to furnish immediate supplies, very great suffering, and appalling mortality were unavoidable, until other and more extended facilities could be provided. The crowded state of the wards, which could not be adequately ventilated or even cleansed, had already resulted in developing an endemic atmosphere, for only in confined and impure air is this fever ever infectious. The proof that it had become so, was seen in the fact that a majority of the medical assistants had already sickened, and one of them had died. Many of the nurses were sick and some of them dead. Moreover, the adjacent alms-house building, with a population of 1500, began
, to give proof of having become infected, no less than 17 cases of the identical form of fever having occurred within 48 hours, some of which were rapidly fatal.
Under these appalling circumstances, 80 tents were pitched upon the adjacent green, and were immediately filled with the patients from crowded wards, which thus admitted of being whitewashed, cleansed and ventilated. A number of shanties in the yard were soon filled in like manner and for the same purpose. By these and the like ex. temporaneous devices, ample room was provided for the increasing number of patients, and a thorough purification of the apartments was attained. And here, as in other cases, it was soon demonstrated, that the patients who were removed into the open air immediately improved, and a very large portion of them soon recovered. The new cases were very generally placed in the tents, and my records show that over 200 cases were discharged cured from the tents, no one of whom had entered the walls of the hospital.
But to return to the statistics of the hospital. It appeared by the books that from May 25th to August 3d, 1847, there were admitted into the hospital 917 cases of ship-fever, which, added to those reinaining in the house, makes the aggregate of cases treated within that period amount to 1226 during about ten weeks.
By a table, prepared August 3d, the following results are furnished, viz. : Discharged cured, .
129 Remaining under treatment,
Whole number as above,
1226 From these respective data, the whole number of cases of ship. fever admitted into this hospital since Jan. Ist, 1847, has been 1995, of whom 347 have died, which latter number gives the aggregate mortality, down to Aug. 3d, the date to which the calculations have been made. It gives an appalling aspect to the fever, but furnishes no just criterion of the necessary fatality of the disease, nor of its want of amenability to judicious treatment; as appears from the fact that a very large proportion of the cases were brought in suffering under the profound coma which characterizes late periods of the disease, and still worse, very many were moribund when they reached
the hospital. No less than 17 died during one week, within four hours after admission, while four, during the same week, were dead before !hey could be carried to their beds. The folly and inhumanity of sending dying persons in a heavy carriage over the rough pave. ments, to so distant a hospital, must be painfully obvious, extinguishing, as it often does, the spark of life which remains, and which else might possibly be revivified.
The following extracts from the weekly reports since May 26th, 1847, though they include deaths from all diseases, may aid in arriving at the comparative mortality, hefore and after the cleansing and venti. lation of the hospital, and the removal of hundreds of the sick for treatment into the open air; a measure resorted to in this instance from necessity, but found highly salutary and useful, especially in the management of ship-fever.
No. of patients.
Deaths. 1st week,
39 5th 66
981 6th "
38 7th 66
937 8th 06
31 9th 66
25 During this period, the cases of ship-fever numbered about one half of all the diseases in the house; and differing but little from this ratio in the proportion of deaths, showing that the mortality, of late, is not greater than that resulting from other diseases. Since Aug. 3d, the cases of fever have been diminishing rapidly, and the whole mortality of the hospital has not exceeded 18 weekly. At present, Aug. 23, there are not more than 50 cases of the fever in the establishment, the most of these having been landed at Quebec, whence they have found their way to this city, and these less malignant and dangerous than those we have heretofore treated.
This subsidence of the fever, so that the discharges now exceed the admissions, has reduced the aggregate of patients below 700, so that the tents have now been emplied, and I find ample room for all in the wards of the hospital; while the comfortable state of these wards, and the encouraging condition of the sick, are sources of no small gratification.
In respect to the peculiar nature and specific character of this fever, the late period at which the patients generally reached the hospital, has precluded very accurate observations. Occasional opportunities, however, have occurred for watching its inception and progress in the persons who sickened on our premises. Many of these came hither from on ship-board apparently in healih, but really in a state of morbid predisposition, though latent, which soon after developed itself in an attack of the fever, as well characterized as were the cases which had fully developed the disease on board of the saine ships. While others occurred among the assistant physicians, orderlies and nurses in the hospital, which were as well marked by pathognomic signs throughout their whole course; nor could they be discriminated in their symptoms, stages, or duration, from those direct from the ships. In the latter examples it is evident that the malady originated from the pestilential atinosphere generated within our walls, which was sufficiently potent at one time to become both the remote and the exciting cause, the same identical agency being sufficient to produce the predisposition, and afterwards develope the fever.
Nor is there the slightest foundation for the suspicion of any spe. cific contagion in the case, as is seen in the fact that no new instances of the fever have occurred in the premises, since the cleansing, purification, and ventilation of the establishment has been effected; so that the rationale of the infection which was undoubtedly endemic here, and had become epidemic in the vicinity, must be obvious; and is precisely the same as that existing on ship-board in the instances of sickness and death which have become so lamentably notorious. The want of pure air, of wholesome food, and of pure water, are privations which by a physical necessity generate disease. In a crowd. ed hospital, as well as in a crowded ship, filthy apartments, ill-ventilated wards, and the contined air resulting from such untoward circumstances, have from time immemorial been known to be such violations of hygenic laws, as will develope pestilential fever. All who inhale such an atmosphere for any length of time become sick, ani each sufferer by the morbid exhalations from his skin and lungs, contributes to augment the infection, and increase the sources of danger to himself and others. Still worse, if amid such a crowd there be, as is 100 often the case, a neglect of personal cleanliness, and a fail. ure to remove the morbid excretions, which, if allowed to remain, vastly add to the intensity of the atmospheric poison. Such are the precise circumstances under which, in certain latitudes and given temperatures, ship-fever, jail-fever, and hospital-fever have been generated and perpetuated. Such a pestilence may be manufactured to order; and may be arrested with equal facility by obeying the laws of hygeine, instead of violating shem. So much for the contagiousness of the ship-fever. As to the figment of contingent contagion,” it is only contingent nonsense.
Those who have imagined that in this much dreaded "ship-fever," there has been any distinctive or specific character constituting it a new disease, or in any sense sui generis, must have had very limited opportunities for observing it. Nor is there anything in its pathology or treatment contradistinguishing it from the family of congestive fevers, of which it is a familiar variety, modified, however, by differ. ent causes, but alıvays characterized by the same type. Indeed, this identical fever has been annually observed to greater or less extent on board ships, in our hospitals and in other crowded apartments of our city, inhabited by a degraded population; and it has often appeared in jails, prisons, etc., in various sections of our country.
The symploms, course and type of the ship-fever here, have been
identical with those of that form of malignant disease denominated “ Typhus Petechialis," modified in different examples by age, sex, temperament, habits of living, etc., but all bearing the impress of the same cause, proving :heir absolute identity in nature, though differing in degree. Always congestive, often inflammatory, and very fre. quently both the one and the other, constituting the mixed fever of modern writers.
In the example which came under our observation sufficiently early to allow of recording and discriminating its premonitions and development, there was found very great uniformity. The earliest and most prominent symptoms of an attack, have been sudden loss of strength, soon followed by a sense of overwhelming debility, while as yet there was no appreciable functional disturbance. A disinclination for food and an inability to sleep supervened, often with great rapidity. The tongue and eyes usually presented the first distinct morbid appearances, the former becoming coated and the latter red and watery, while no manifest febrile symptoms, properly so called, were discoverable. At this period a slight chilliness was often complained of, though not always cognizable. A full chill did occasionally occur, but it was but very seldom. Nausea was very often present, and in a few rare cases vomiting, with or without diarrhæa, seemed to designate the development of the fever. The skin remained dry, and slightly elevated in temperature, while the pulse indicated the presence of indirect debility, though differing in frequency very little from the natural standard for several days, when it usually became accelerated somewhat, and in bad cases soon fell below 70 in the minute.
The most constant characteristics of this fever were great apathy, and apparent indifference to life ; sudden and continued deafness; a mental torpor which could not be roused to sensibility, and the absence of all pain, or at least of all complaining, except of weakness, which was universally present throughout the whole course of the disease. Petechiæ, though not invariably present, were very generally so, occasionally over the entire body, but more frequently upon the neck, chest, and abdomen, in which situations they usually were most visible and most numerous. In general, these appeared about the seventh day, but often earlier, sometimes on the third day; and I have seen them in great numbers as late as the seventeenth day of the disease, with and without sudamina, especially over the abdomen. The tongue presented very variable appearances, sometimes continuing white and thickly coated throughout, more frequently, however, becoming dry, brown, and even black, with occasional sordes, but the latter very rare, even in fatal cases. Delirium was very generally present after the seventh day, followed after a few days by coma, stertorous breathing, and subsultus tendinum, but these latter symptoms were not frequent.
In most of the cases, prior to the occurrence of delirium, a diarrhæa to greater or less extent was present, which was difficult to control by the usual remedies, when the excretions were biliary in their