SECTION. II.
Symptoms of the Yellow Fever, as described by various authors.—Comparison between them and those of the Plague, with an inquiry into the Causes.—History of the Distemper as it has appeared in various parts of the United States since the year 1793.—A discussion of the question Whether the Yellow Fever is Contagious or not.
OFall those who have attempted to give an account of this fatal disease, none appear to have exceeded Dr. Moseley, either in his accuracy in enumeration, or perspicuity in description, of the symptoms. According to him the yellow fever is a species of thekausosof Hippocrates, Aretœus and Galen; that is, thefebris ardensorcausus, aggravated by climate, incidental only to the gross, inflammatory and plethoric at any season of the year, totally different from the remitting bilious fever to which all habits of body are subject in hot climates, particularly after rains, and in the fall of the year. The causus, seldom seen in the temperate climates of Europe, never appears there with the violent symptoms which attend it in hot climates. “Whether in the latitudes (says he) so mild as those of Spain, Greece, Italy and the Archipelagan islands, the causus has ever been attended with black vomiting, as in the West-Indies, I cannot tell. Lommius mentions the vomiting of blood, and voiding black liquid stools and black urine. Critical and symptomatical yellowness of the skin in the causus are enumerated by Hippocrates among its symptoms, and Lommius mentions the danger of that appearance before the seventh day. The affinity of the symptoms, progress and termination of a causus in Europe to those of the yellow fever in the West-Indies, excepting the black vomiting, leaves no room to doubt that the difference of climate constitutes all the difference that is found between them.”
For these reasons Dr. Moseley adopts the name ofendemial causus; and he takes notice that many difficultieshave arisen to young practitioners, and to strangers in the West-Indies, from the various names improperly given to it from its ultimate and not from its primary symptoms. Some call it aburningbilious fever; Warren, aputridbilious fever; but, though they have disputed about their terms, Dr. Moseley thinks that neither of them have proved whether bile be the cause or the effect of the disease. To call it the black vomit or the yellow fever, he thinks also improper, as a stranger would not know the disease until some of these symptoms appear; both of which are generally fatal, and neither of them constant.
The West-India causus he says is no more putrid than the small-pox, or any other acute disease; which may, after it has passed its inflammatory state, change to putrefaction, and end in death with an extraordinary dissolution of the fluids. The disease is in truth an inflammatory one in the highest degree possible; accompanied with such symptoms in a greater extent as attend all inflammatory fevers, and most strikingly the reverse of any disease that is putrid, or of one exacerbation. It obeys no season of the year, and attacks such people, and under such circumstances, as are seldom the objects of putrid diseases, viz. all who are of an inflammatory diathesis, and do not perspire freely.
This distemper attacks sailors in the West-Indies more than any other set of men, even of new comers. For this the Dr. assigns as a reason, that they eat, drink, and sleep, so much at sea, use no exercise, and are always of gross habit of body. To this he adds the heat and dampness of harbours, generally in the neighbourhood of marshes, and their exposure to land winds at night; the labour they endure on board vessels in port, and the carelessness and excesses frequently committed by these people after long voyages.
When a stranger newly arrived feels a sudden loss of strength, with a continual desire of changing his position without finding rest in any, we may expert a causus. If he has exposed himself to any of the causes just mentioned, the probable consequences would be, that on themorrow he would feel an heaviness, lassitude, oppression and loss of appetite.147Next day, or perhaps within twelve hours from the first indisposition, the violence of the disease commences with faintness, generally giddiness of the head, with a small degree of chillness and horror, but never any rigor. These symptoms are succeeded by a high fever, great heat, and strong beatings of the arteries, particularly those of the temples and carotids; flushings of the face, gasping for cool air; tongue white tinged with yellow, after the retchings have commenced; excessive thirst; redness, heaviness, and sensations of burning in the eyes; heaviness and darting pains in the head, small of the back, and often down the thighs; the pulse generally full and strong, but sometimes quick, low, and vacillating; the skin hot and dry, though sometimes it has a partial and momentary moisture. There is a sickness of stomach from the beginning; retchings succeed immediately after any liquid is swallowed, which bring up bilious matter. There is an anxiety with stricture, soreness, and intense heat about the præcordia; great restlessness, heavy respiration, sighing, urine deep coloured and in small quantity.
Thus the fever goes on during its first stage, which constitutes the inflammatory period, and continues from twenty-four to sixty hours. The second, which our author calls themetaptosis, is comparatively mild, and is an intermediate state between the inflammatory and gangrenous stages. In this there is an abatement of many of the former symptoms, and a kind of deceitful tranquillity, accompanied, however, with a perturbation, if the patient should happen to sleep. There now appears a yellow tinge in the eyes, neck and breast; the heat subsides, sometimes accompanied with chillness, but never with that kind of rigor, which, when it happens, terminates the disease by sweat, or by copious bilious evacuations, upwards or downwards. The retchings increase and become porraceous: the pulse flags, but is sometimes high,and sometimes soft; the skin moist and clammy; urine of a dark saffron colour, and in small quantity; the tongue in some cases is dry, hard, and discoloured, in others furred and moist; the head is confused, sometimes with delirium, with a glossiness of the eyes. This stage of the disease continues sometimes only for a few hours, at others from twelve to forty-eight, seldom longer, and too frequently the disease hurries on rapidly from the first to the third stage, which is the gangrenous or fatal state. Now the pulse sinks, intermits, and becomes unequal, sometimes very quick; the vomiting becomes frequent with great straining and noise. The matter discharged is now in greater quantity, appearing like the grounds of coffee, or of a slate colour, and the stomach can retain nothing: the breathing is difficult, the tongue black, the sweats cold and clammy, the eyes yellow and sunk; there is a yellowness round the mouth and temples, and soon after over the whole body. The deepening of the yellow colour, with an aggravation of the other symptoms, is a forerunner of death. There is a deep respiration, subsultus tendinum, a convulsive kind of sighing; the urine is quite black, and sometimes totally suppressed. There is a death-like coldness of the hands, feet and legs, while the heat still remains about the stomach; the patient is delirious, and struggles to get up in bed; he trembles, his speech falters; blood oozes from the mouth and nostrils, sometimes from the corners of the eyes and ears; a black bloody cruor is discharged both by vomit and stool: livid spots appear on different parts of the body, particularly the præcordia; hiccup, muttering, coma, and death, follow in quick succession.
The affecting case of capt. Mawhood, who died on the fourth day of the disease, at Port-Royal in Jamaica, in the year 1780, exhibits a dreadful picture of this disease in its last stage. “When I entered the room, (says Dr. Moseley) he was vomiting a black, bloody cruor, and he was bleeding at the nose. A bloody ichor was oozing from the corners of his eyes, and from his mouth and gums. His face was besmeared with blood, andwith the dullness of his eyes it presented a most distressing contrast to his natural visage. His abdomen was swelled and inflated most prodigiously. His body was all over of a deep yellow, interspersed with livid spots. His hands and feet were of a livid hue. Every part of him was cold, excepting about his heart. He had a deep, strong hiccup, but neither delirium nor coma; and was, at my first seeing him, as I thought, in his perfect senses. He looked at the changed appearance of his skin, and expressed, though he could not speak, by his sad countenance, that he knew life was soon to yield up her citadel, now abandoning the rest of his body. Exhausted with vomiting, he was at last suffocated with the blood he was endeavouring to bring up, and expired.”
The symptoms just now enumerated generally take place in those who die from the third to the seventh day of the disease. But in this, as in other fevers, the symptoms vary considerably according to the constitution of the patient, and habit of the body. In some it begins neither with chillness, faintness, nor flushings of the face. Sometimes the pulse is much depressed and not quick; and in sultry weather, and damp situations, where the inflammatory state has been only of a few hours duration, themetaptosishas been so rapid, that the black vomiting and the mortified state have unexpectedly appeared, and have ended the patient in 24, 36 or 48 hours. But our author says that he never saw or heard of an instance of what Lind says, that the black vomit may attack a man when newly arrived, without any previous complaint; or of that mentioned by the same author, viz. “an uneasy itching sensation, commonly in the legs; and upon pulling down the stockings, streams of thin-dissolved blood followed, and a ghastly yellow colour quickly diffused itself all over the body.”
In some cases the disease is much more mild. There are instances where it has been protracted to the eighth, ninth or tenth day; and others where it has never passed from the inflammatory stage; but being checked, though not extinguished, it has been lengthened out, andat last converted into a remittent of great duration, most difficult of cure, and tedious of recovery.
According to our author, the stomach seems to bear the principal burden of the disease, and accordingly, after death, appears to have been principally affected. Great heat is perceived near the præcordia during all the stages of the disease, and pain and uneasiness are complained of when those parts are pressed with the hand. After death, livid spots appear over the whole body, particularly about the præcordia. On dissection, the stomach, in some part or other, is generally found mortified, especially if the black vomiting has continued long, and the livid spots have appeared before death. Frequently the upper part of the duodenum is in a gangrenous state, and always bears the marks of inflammation, lest the disease have been of ever so short a duration.
Though both liver and gall-bladder must be very much affected in this disease, yet Dr. Moseley is of opinion that nothing can be depended upon from an inspection of them after death. Some symptoms there are in common with inflammations of the liver, but none of those which distinguish it from other diseases. It never terminates in suppuration of the liver as the hepatitis sometimes does, though it is frequently carried off by an enormous secretion of bile. “Dissections (says the Doctor) have never discovered any certain and uniform appearance in the liver of those who have died of this disease. In hot climates a sound state of the liver is never to be expected after death, whether the disease has been acute or chronical. Of the latter class of diseases it is almost always either the seat, or the origin.”
Dr. Lining, in a letter to Dr. Whytt at Edinburgh, published in the Physical and Literary Essays, defines the disease, to be “that fever, which continues two or three days, and terminates without any critical discharge by sweat, urine, stool, &c. leaving the patient excessively weak, with a small pulse, easily depressible by very little motion, or by an erect posture; andwhichis soon succeeded by an icteritious (jaundice)colour in the white of the eyes and the skin; vomiting, hæmorrhages, &c. and those without being accompanied with any degree of a febrile pulse and heat.”
In the four times in which he mentions it to have been epidemic at Charleston, our author says, that none of the years (excepting 1739, the summer and autumn of which had been remarkably rainy) were either warmer or more rainy (and some of them less so) than the summers and autumns were in several other years in which there was not one instance of any one being seized with it. The subjects were whites of both sexes, especially strangers lately arrived from cold climates, Indians, Mistees, Mulattoes of all ages, excepting young children, and of those only such as had formerly escaped the infection. Negroes were not liable to it.
Those affected with the fever, for a day or two previous to the attack generally complained of head-ach, pain in the loins and extremities, but principally in the knees and legs, debility and lassitude; but some were taken ill suddenly without any warning. The symptoms were, shivering; frequent, full, hard and strong pulse; though sometimes small and hard, and in others soft and small; but towards the end of the fever it became smaller, harder, and less frequent. Sometimes there was a remarkable throbbing in the hypochondria and carotids, the former causing in some a tremulous motion of the whole abdomen. The heat was about 102 of Fahrenheit, and nearly equal over the whole body; some had frequent returns of chilliness without any diminution of temperature of the body. “In a few there happened so great a remission of the heat for some hours, when at the same time the pulse was soft and less frequent, and the skin moist, that one from these circumstances might reasonably have hoped that the fever would only prove a remittent or intermittent. About the end of the second day the heat began to abate.” Here Dr. Moseley takes notice that when the fever abates, some, who have mistaken thebilious remittentfor thecausus, speak of remissions which do not happen in this fever. “This circumstance of the endemial causus (says he) I believe, has never been mentioned before.”
Dr. Lining goes on to inform us, that the skin was rarely dry in this disease, there being generally a propensity to sweat. “On the first day the sweating was commonly profuse and general, on the second it was more moderate; but on both those, there happened frequent and short remissions of the sweatings, at which times the febrile heat increased, and the patient became more uneasy. On the third day the disposition to sweat was so much abated that the skin was generally dry; only the forehead and backs of the hands continued moist.” A great despondency and prostration of strength took place from the first attack. On the first day they generally dozed much, but were afterwards very watchful. On the second day the pains in the head, loins, &c. of which they had complained before the attack, and which were sometimes very acute in the forehead, generally went off. Many on the first day were a little delirious, but afterwards not until the recess of the fever.
The blood had no inflammatory crust; in warm weather it was florid like arterial blood, and continued in one soft homogeneous like mass, without any separation of the serum after it was cold. When there was any separation, the crassamentum was of too loose a texture.
This disease was not attended with any remarkable thirst; but, on the third day, as the fever began to lessen, or rather, says the Doctor, as the fulness of the pulse, heat and disposition to sweat, began to abate, a nausea, vomiting, or frequent reachings to vomit, came on especially after the exhibition of either medicines or food. A very few had a vomiting, either bilious or phlegmatic, on the first day. The whole febrile state was attended with an obstinate costiveness.
These were the principal symptoms with which the febrile state was attended, and which generally went off on the third day, or in seventy-two hours from the first attack, without any salutary crisis, and was soon succeeded by the secondstadium, as our author calls it; a state, though without a fever, much more terrible than the former. The symptoms now were,
1. The pulse, though hard and small, became less frequent; very little more so than in health. Soon after it became much slower, and very soft; this softness remaining while any pulse could be felt. In many it gradually subsided, till it became scarce perceptible; neither could it be supported by any of the ordinary means used for that purpose. After this the yellow suffusion, the vomiting, delirium, restlessness, &c. increased to a great degree. Sometimes the pulse would recover its strength, but only for a short time.
2. The heat did not exceed the natural, and was still farther diminished as the pulse sunk; the skin became cold, and the face, breast and extremities acquired something of a livid colour. There was no great thirst, though the sick had a great inclination for strong liquors.
3. The vomiting or reaching to vomit increased, and in some were so constant, that neither medicines nor aliment of any kind could be retained. Some vomited blood, others only what was last exhibited, mixed with phlegm, while others had what is called theblack vomit. But this, though its general appearance is black, appears not to be entirely so, but owes its colour to a great number of black flakey substances. These are by our author supposed to be the bile mixed with the mucus of the stomach, or adhering to it. He founds his opinion upon observations from dissection, where the mucus of the stomach was always found abraded, and the bile in its cystis black, and sometimes very viscid. This change in the state of the bile he has always observed in such as died of this disease, and likewise that the blood was very fluid, and the vessels of the viscera much distended. In one case he found the bile of the consistence of turpentine, and carbuncles or gangrenous specks on the stomach.
The reaching to vomit continued a longer or shorter time, according to the state of the pulse; an increase of fulness of the pulse being attended with an abatement of the reaching, and the contrary.
In this state the patients were extremely unquiet, even their sleep being frequently attended with dejection of spirits and debility. This last symptom was so excessivethat if the patient was only raised up in bed, or sometimes if the head was only raised from the pillow, while a little drink was given, the pulse sunk immediately, and became sometimes so small, that it could scarce be felt: they became cold, the skin became clammy, the delirium increased, their lips and skin, especially about the neck, face and extremities, as well as the nails, acquired a livid colour. The restlessness and tossing were so great, that it was sometimes scarce possible to keep the sick in bed, though, even in this state, they made no particular complaint, and if asked how they did, the reply was,Very well.
A yellowness in the eyes became now very observable, and this was soon diffused all over the body; but in some, this colour did not appear until a little before death, when it spread surprisingly quick, especially about the breast and neck. Along with this were a number of small spots of a scarlet, purple or livid colour. These appeared principally about the neck and breast.
Some were obstinately costive, others the contrary, with large, liquid and black stools, but others were relieved by moderate stools, even though black. In some they resembled tar, in smoothness, tenacity, colour and consistence.
In this disease there was such a putrid dissolution of the blood that hæmorrhages took place from almost all parts of the body. In women the menstrua flowed, sometimes in great quantity, even at irregular periods. Blood flowed also from the eyes, nose, mouth and ears, and from those parts where blisters had been laid on. “Nay, (says our author) in the year 1739 or 1745, there were one or two instances of an hæmorrhage from the skin, without any apparent puncture, or any loss of the scarf-skin.” The urine was pale while the patient was not yellow, but a deep saffron colour when the yellowness had come on. Sometimes it was turbid, at others bloody, and the quantity of blood was always in proportion to the state of the pulse; diminishing as the pulse became more full, and increasing as it became weaker.
In the third stage, which always terminated in death, the pulse was exceedingly small and unequal, though soft; the extremities were cold, clammy and livid; the face and lips in some flushed, in others they were of a livid colour; the livid specks increased so fast, that in some the whole breast and neck appeared livid; the heart palpitated strongly; the heat about the præcordia was greatly increased, respiration became difficult, with frequent sighing; the patient became anxious and extremely restless, the sweat flowed from the face, neck and breast, blood from the mouth or nose or ears, and in some from all together; the deglutition became difficult, hiccup and subsultus tendinum came on, the patient picked the bed-clothes, was comatous or constantly delirious. In this terrible state some continued eight, ten or twelve hours before they died, even after they had been so long speechless, and without any perceptible pulsation of the arteries and wrists; whereas in all other acute diseases, death follows immediately after the pulse in the wrists ceases. When the disease was very acute, violent convulsions seized the unhappy patient, and quickly brought this stadium to its fatal end. After death the livid blotches increased fast, especially about the face, neck and breast, and the putrefaction began very early, or rather increased very quickly. In hot weather, and when the symptoms at first were very violent, there was little difference to be observed between the stadia, the whole tragedy being completed in less than forty-eight hours.
On this disease in general Dr. Lining remarks, that the infection was increased by warm, and lessened by cold, weather. In hot days the violence of the symptoms were augmented to such a degree as sometimes to become fatal to those who, in moderate weather, seemed to be in no danger; while, on the other hand, in cold days, some who had been in great danger were apparently saved from the jaws of death. The disease was also more fatal to those who lay in small chambers without a proper ventilation, to such as were of an athletic and full habit, to strangers, natives of a cold climate, and to such as were most afraid of it, as well as to thosewho had previously overheated themselves by exercise in the sun, or by excessive drinking of strong liquors. It proved also most certainly fatal to valetudinarians, or to such as had been previously weakened by any disease.
Dr. Lind observes that “a yellow colour of the skin is observed not only in common agues, but likewise in other fevers; sometimes denoting, as in contagious fevers, their malignant nature, at other times, as in some West Indian fevers, an universal dissolution of the blood and humours; and frequently this symptom accompanies gentle discharges of the bile, and a diseased liver.” In speaking of the disease in the West Indies, he mentions some fevers, which he derives from stagnated air, “of such a malignant nature, that the people after being there a few days are suddenly seized with violent vomitings, head-achs, deliriums, &c. and in two or three days more the whole body putrefies, and the dissolved mass of blood issues from every pore. . . . On considering the yellow fever particularly he is of opinion that the remarkable dissolution of the blood, together with the tendency to putrefaction in the whole body, the black vomit, and other characteristic symptoms, are often accidental though fatal appearances in fevers of the West Indies. They proceed, according to him, in such as are newly arrived, sometimes from a gross habit of body, excessive drinking of spiritous liquors, and from being afterwards overheated in the sun; but the intense heat and unhealthfulness of the air does much more frequently produce all those symptoms. This fever was once supposed to have been first carried into the West Indies by a ship from Siam:an opinion truly chimerical; as similar diseases have made their appearance, not only in the East Indies, but in some of the southern parts of Europe, during a season when the air was intensely hot and unwholesome. This happened in the months of September and October 1764, when excessive heat and want of rain for some months gave rise to violent epidemic bilious diseases, resembling those of the West Indies, in the city of Cadiz in Spain, of which anhundred persons often died in a day. At this time the winds blew mostly from the south, and after sunset there fell an unusual and very heavy dew. The disease began with alternate heats and chills, nausea, pains of the head, back, and loins, and at the pit of the stomach, These symptoms were often followed, in less than 24 hours, with violent reachings, and a vomiting of green and yellow bile, the smell of which was very offensive. Some threw up an humour as black as ink, and died soon after, in violent convulsions and in a cold sweat. The pulse was sometimes sunk, sometimes quick, but often varying. After the first day, the surface of the body was generally either cold, or dry and parched. The head-ach and stupor often ended in a furious delirium, which quickly proved fatal. The dead bodies having been examined by order of the court of Madrid, the stomach, mesentery and intestines were found covered with gangrenous spots. The orifice of the stomach appeared to have been greatly affected, the spots upon it being ulcerated. The liver and lungs were both of a putrid colour and texture.
“The stomach contained a quantity of an atrabilious liquor, which, when poured on the ground, produced a sensible effervescence; but, when mixed with spirit of vitriol, a violent ebullition ensued. The dead bodies turned so quickly putrid, that at the end of six hours their stench was intolerable, and in some of them worms were already found lodged in the stomach. His Majesty’s ship the Tweed being at that time in Cadiz bay, several of her men were taken ill when on shore, but, by being carried on board, all of them recovered. Neither did the black vomit or any other deadly symptom of that fever make its appearance in any of the ships. The dread of this distemper forced many people of fashion to retire into the country, where they remained in perfect safety.”
Dr. Lind further remarks, that in the yellow fever it is a bad sign if the skin is very dry and rough; “and the longer it continues in this state, the greater is the danger,as such patients seldom recover, though the pulse may give hopes, and the other symptoms also be fluttering; for many have a good pulse in this fever a little before death.” He also quotes Dr. Bruce, an eminent physician of Barbadoes, whose account of the disease is to the same purpose. He says it may come on at any season of the year, but that the symptoms are most severe when there is great heat joined with moisture. The blood, even in the beginning of the disease, is of a florid red colour, and as it were rarefied; the crassamentum scarcely cohering; the serum of a clay-coloured yellow. It sometimes finishes its course in 24 hours.
The account given by Dr. Hillary corresponds also very much with that already given. The subjects of the disease are the same with those already mentioned. He has seen it at all seasons of the year, but it is worst in a hot season, especially if it was preceded by moist and warm weather. “Blood, taken even at the beginning of the disease, is often of an exceeding florid red colour, much rarefied and thin, and without the least appearance of fiziness; and the crassamentum, when it has stood till it is cold, will scarce cohere, but fluctuates; the serum is very yellow. . . . On the second or third day the blood is much more dissolved, the serum more yellow, and the crassamentum loose, scarcely cohering, but undulates like sizy water when shaken, and sometimes has dark, blackish spots on its surface, showing a strong gangrenescent diathesis. . . . In the latter stage of this fever the blood is so attenuated and dissolved, that we frequently see it flowing not only out of the nose and mouth, but from the eyes, and even through the very pores of the skin; also great quantities of black, half-baked, half-mortified blood is frequently voided, both by vomiting and stool, with great quantities of yellow and blackish putrid bile, by the same ways; and the urine, which was before of a high icteritious colour, is now almost black, and is frequently mixed with a quantity of half-dissolved blood. . . . Soon after death the body appearsmuch fuller of livid, large, blackish, mortified spots, particularly about the præcordia and hypocondres, especially the right; which parts seem to be, even from the first seizure, the principal seat of this terrible disease. And upon opening the bodies of those who die of it, we generally find the gall-bladder and biliary ducts filled with a putrid blackish bile, and the liver and stomach, and adjoining parts, full of blackish and mortified spots, and sometimes gangrenes, in those, as also in several other parts of the body. And the whole corpse soon putrefies after death, and can be kept but a few hours above ground.”
Dr. Jackson, in describing the yellow fever of Jamaica, acknowledges the difficulty of characterising the disease, even though he is of opinion that it “possesses some characteristics of its own, different from those of any other.” In a note at the end of his work, he observes the impropriety of calling it theyellowfever; because that yellowness sometimes does not appear at all; and in no one case does it ordinarily show itself till the latter stages. “I know also (says he) that most of the practitioners of Jamaica consider it only as an aggravated species of the remittent, the common endemic of hot climates. It appeared to me, I must confess, in a different light. . . . It may not, however, be improper here to take notice of the opinion of Dr. Moseley, who has endeavoured to persuade us that it is no other than thekausos, or ardent fever, of the ancients. But the yellow fever of the West Indies is, by Dr. Moseley’s own confession, in some measure peculiar to strangers newly arrived in tropical climates. Thekausos, we are informed, made its appearance in the islands of the Archipelago, and on the coasts of the contiguous continents, indiscriminately among men and women, natives and foreigners: in fact it has not, as far as I can perceive, any claim to be considered as a distinct disease. If I rightly understand Hippocrates, or the description of the still more accurate Aretæus,kausosin reality is only an accidental condition of thecommon endemic of the country, where the force of the fever is chiefly exerted upon the stomach and alimentary canal. In this manner it appears frequently in Jamaica, and in the southern provinces of America. In the hot months of summer, it appears occasionally in every climate; and is not necessarily accompanied with, nor does it depend upon, a general inflammatory diathesis of the system for its existence.”
The Doctor divides this disease into three species: 1. Where “signs of putrefaction are evident at a very early stage, which is generally rapid in its course, and which casually terminates in black vomiting. Yellowness seldom or never fails to make its appearance in the present instance; and perhaps it is the only one which, strictly speaking, can be called the yellow fever. 2. A form of fever which has either no remissions, or remissions which are scarcely perceptible; in which signs of nervous affection are more obvious than symptoms of putrescency; and in which yellowness and black vomiting are rare occurrences. 3. Another form, in which regular paroxysms and remissions cannot be traced, but in which there are marks of violent irritation, and appearances of inflammatory diathesis in the earlier stage, which give way, after a short continuance, to signs of debility and putrescency, to which yellowness frequently succeeds, or even sometimes the so much dreaded vomiting of matter of a dark colour. The disease in these three forms appears to be in reality one and the same. The difference of the symptoms probably arises from very trivial or very accidental causes. It is in some measure peculiar to strangers from colder regions soon after their arrival in the West Indies, and may generally be distinguished from the common endemic of the country, not only by a total want of paroxysms and remissions, but likewise by a certain expression of the eye and countenance, with something unusually disagreeable in the feelings, of which words convey only an imperfect idea.”
The symptoms enumerated by Dr. Jackson are in general the same with those already taken notice of.He mentions likewise a degree of confusion frequently joined withgrimness, difficult to be described in words, but which a person acquainted with the appearances of the disease immediately recognises as one of its distinguishing marks. In the second stage he says, that no sweat or moisture was now observable on any part of the body: the state of the skin impressed the idea as if it were not pervious to any degree of perspiration, and heat gradually forsook the surface and extremities: the tongue became moist, and at the same time frequently clean about the edges: the gums became redder, more spongy, and showed a greater disposition to bleed: vomiting was troublesome: the matter thrown up was ropy, in large quantity, and abounding with villous or mucous flakes of a darker colour. The circulation in the extreme vessels became gradually more languid; the natural heat retired from the surface of the body, which was now dry and impervious; the pulse returned nearly to its ordinary state, or became slow, full and regular; the yellowness increased fast, so that the whole body was frequently yellow as an orange, or of as deep a colour as the skin of an American savage: anxiety was inexpressible; vomiting was irrestrainable, and the vomiting of a matter like the grounds of coffee at last made its appearance. This matter was often as black as soot, where the progress of the disease had been rapid; while it was not only less intensely black, but often tinged with green, where the disease had been more slow and gradual. The number of villous or mucous flakes, in the matter discharged by vomit, increased as the disease advanced, and with them were joined streaks of blood, which seemed principally to come from the throat and gums. As the disease advanced, the vomiting became more frequent, but was seldom accompanied with any violent retching. Quantities of liquor were discharged, so enormous that it was often difficult to imagine whence they came; after which the patient enjoyed some respite, till a similar collection was made. As soon as the matter discharged by vomit acquired this dark and sooty colour, the belly generally became loose, the stools being black, smooth, and notunlike tar or molasses; the tongue became clean, the gums putrid; hæmorrhages, or ratheroozings of blood, were sometimes observed in different parts of the body, while livid blotches made their appearance on the belly and insides of the thighs. The pulse, which during the latter stages of the distemper could scarcely be distinguished from that of a person in health, became at last irregular, quick, or intermitting; soon after which coma or convulsions closed the scene. Sometimes the yellowness succeeded the black vomiting. In these the vomiting began unexpectedly, or without much previous affection of the stomach: the colour was commonly intensely black; the patient turned yellow almost in an instant, and died in a very short time. When any one recovered from this deplorable situation, of which there were some few instances, the termination was not by any regular crisis. The black vomiting ceased, sometimes apparently in consequence of treatment, sometimes evidently of its own accord: but a vomiting of a ropy, glutinous matter continued for a great length of time, together with an extreme irritability of the stomach, and a very peculiar state of the skin; which sometimes did not recover its natural smoothness and unctuosity for several weeks.
The disposition to faint, so common in the yellow fever, is supposed by Dr. Jackson to arise from a kind of torpor in the nervous system, rather than the usual causes of fainting. For this opinion he assigns as a reason, that “the patient was often able to stand upright for some time, and even to walk to a considerable distance; and, when at last overcome, was observed to fall down in a torpid, rather than a fainting, state.”
In dissections our author observed that the omentum and all its appendages were in a dry and parched state, and of an uncommon dark grey colour. But, along with this dark grey colour, and want of unctuosity and moisture, usually met with in the abdomen, the stomach and intestines had a dirty yellow appearance, were highly putrefied, and much distended with wind. The liver and spleen were generally enlarged in size; the formerof a deeper yellow than any of the other abdominal viscera; while the texture of the spleen was often less firm than natural. The bile was usually black and thick, like tar or molasses; the blood-vessels of the liver bearing marks of uncommon distension. A quantity of black fluid, similar to that ejected by vomit, was found in the stomach, which fluid our author says positively derived its blackness from the bile, the flakes observed to float in it being parts of the villous coat of the stomach abraded. He denies that the black colour of the matter vomited is owing to blood, as many authors have supposed. He says that the passage of the bile might be easily traced from the gall-duct into the pylorus.
This being in the Doctor’s opinion the only true kind of yellow fever, we shall not follow him through the description of the other two species, but proceed to consider that remarkable and excessively fatal distemper which appeared in the year 1793, first in the West India islands, and then on the American continent. Dr. Chisholm, who has described the distemper very particularly, derives it from the coast of Africa, and gives the following account of its origin on the authority of a Mr. J. Paiba, “one of the adventurers in the Boullam scheme; and who, despairing of success, left the coast of Africa in a vessel called theHankey. This vessel sailed from England in April 1792 with stores and adventurers for the intended colony at Boullam. The people were all in good health: that part of the coast of Africa on which they touched is remarkable for its healthiness; only it is destitute of water except what can be procured by digging temporary wells on the beach, and which is brackish, and consequently unwholesome. The ferocity of the negroes who inhabit that part of the continent prevented them from being accommodated on shore, so that they found themselves obliged to remain on board the Hankey for nine months. As the rainy season came on almost immediately after their arrival on the African coast, they attempted to shelter themselves by raising the sides of the vessel several feet, and covering it with a woodenroof.” Thus were upwards of two hundred persons, among whom were many women and children, confined in such a manner as must be supposed capable of producing fevers of a bad kind, if they could be produced by such causes. Accordingly a malignant fever did break out; the vessel was not ventilated, nor were the bed-clothes, &c. of the sick destroyed; from whence Dr. Chisholm concludes that the infection remained on board the vessel. The Doctor then proceeds to give the following account of the vessel after her departure from Boullam:148“Capt. Coxe, finding the water at Boullam unwholesome, proceeded with his ship to Bissao, where there is a Portuguese settlement, for a supply. The ship was navigated by about twelve seamen, most of whom had not experienced sickness, and had probably been procured from Sierra Leone: at any rate they were then taken on board for the first time. Of these, before the return of the Hankey to Boullam, nine died; and the remainder, with the captain, were reduced to a deplorable state. The time for which the Hankey was chartered being expired, Mr. Paiba, with his family, intended to return to England in her; but as no seamen could be procured they put to sea, having on board the captain, sick, and only the mate, Mr. Paiba and two seamen to navigate the ship. With much difficulty they arrived at St. Jago, where they fortunately found the Charon and Scorpion ships of war. Capt. Dodd of the former, humanely rendered them every service in his power, and on leaving them put two men of each ship on board the Hankey. With this aid they proceeded to the West Indies; a voyage to England being impracticable in their wretched state. On the third day after leaving St. Jago, the men they procured from the ships of war were seized with the fever, which had carried off three fourths of those on board the Hankey at Boullam; and, having no assistance, two of the four died: the remaining two were put onboard here in the most wretched state possible. Capt. Dodd, on his arrival at Barbadoes from the coast of Africa, was ordered to convoy the homeward-bound fleet of merchantmen. In the execution of his orders he came to Grenada on the 27th of May, and, hearing of the mischief which the Hankey had been the cause of, mentioned that several of the Charon’s and Scorpion’s people were sent on board the Hankey at St. Jago, to repair her rigging, &c. that from this circumstance, and the communication which his barge’s crew had with that ship, the pestilence was brought on board both ships; and that of the Charon’s crew thirty died, and of the Scorpion’s, about fifteen. The Hankey arrived at the port of St. George’s (in Grenada) on the 19th of February, in the most distressed situation, and for a few days lay in the bay, but was afterwards brought into the careenage. From this period are we to date the commencement of a disease before, I believe, unknown in this country, and certainly unequalled in its destructive nature.”
This account of the introduction of the fever (which however is by Dr. Chisholm accounted very different from the yellow fever above described) is so clear and distinct, that, at first reading, it commands our belief. It hath not, however, met with universal approbation; and even thefacts, for which both parties appeal to Mr. Paiba and capt. Dodd, vary from one another in a surprising manner. Dr. Trotter, in his Medicina Nautica, p. 328, gives the following account: “Dr. Chisholm tells us, that the ships of war on the African station, having sent men to assist the Hankey, after numbers had perished from the fever, received the infection by means of this communication, and that in the Charon thirty died, and fifteen in the Scorpion. Capt. Dodd, who at that time had his broad pendant in the Charon, now commands the Atlas of 98 guns in the fleet; Mr. Smithers, the surgeon, is at present in the Formidable, a second rate, also in the fleet;from themI have copied the following narrative of their transactions with the Hankey:
“When the squadron under commodore Dodd came to St. Jago in 1793, the Hankey lay there in great distress for want of hands; having buried above one hundred persons, men, women and children, from the time she had been at Bulam.The fever was now overcome: Mr. Smithers saw two men that had lately recovered. He left a quantity of bark. The Charon and Scorpion sent two men each to assist in navigating her to the West Indies. The Hankey at this port was cleaned, washed with vinegar, and fumigated.No fever appeared in either of the men of war, in consequence of this communication; they arrived at Grenada in perfect health, but did not go into the same part of the island to which the Hankey went. The Charon, at this harbour received some seamen from the merchant ships then taking in cargoes for England; she had afterwardsfourteencases of yellow fever, of which one died; but it is remarkable that the Scorpion did not bury a single man during the whole voyage.149It is probable from these facts, that the Hankeydid notimport the infection that produced the Grenada fever; for,after the disease was worn out, she had a passage to make to the West indies of many hundred leagues. It is also doubtful how the effects left in the Hankey could produce the fever, for thebedding was thrown away, and what clothing remained had been aired, and probably had scarcely been in contact with the body after being sick.”
The discordance between this and the foregoing account is abundantly evident. Dr. Chisholm’s account of the bedding, &c. is also very different. “Our lieutenant governor, Ninian Home, esq. some time after the disease became epidemic, informed me, that, in consequence of the information he had received of the clothes, &c. of the victims of the fever at Boullam being still on board the Hankey, he ordered Capt. Coxe to be brought before him and some gentlemen of the council. He then acknowledged, thatall the effectsof those who had died were then on board hisship, and said that hewould notdestroy them, unless he was indemnified for the loss he might sustain, should the heirs of the deceased call on him for those effects. Every argument was used to induce him to destroy the articles, but the only one which influences a man of this description,indemnification; and he of course carried the seminium of the disease to England.” It was this consideration which induced the governor to write to the secretary of state, and in consequence of his representation the vessel was obliged to perform quarantine in England, a circumstance which Dr. Trotter mentions without approbation.
Thus far the matter offactseems to be very much obscured; and the more we investigate, the more we are involved in darkness. In the Medical Repository, vol. i, p. 484, we find the following severe censure passed upon Dr. Chisholm by the late Dr. Smith of New York: “It belongs to another part of this paper to assign the probable motives of Dr. Chisholm for maintaining that the fever was imported into Grenada: certain it is that he avowed a different opinion to Mr. Paiba, to whom he freely declared, that he could by no means trace the disease to theHankey; and that he believed it to be of local origin, owing to the unhealthy condition of the careenage, and the particular prevailing winds: and, to confirm this notion, he informed Mr. Paiba that a similar disease, from the same cause, though in a less degree, had existed in St. George’s some years before.”
This was plainly giving Dr. Chisholmthe lie; which, whatever might have been the consequence between the two parties, absolutely supersedes, to any impartial and unconcerned person, the evidence ofboth, at least as far as regards the origin of this disease. It is not, however, to be supposed that Dr. Chisholm would pass such a censure unnoticed. He did accordingly reply in a letter to Dr. Smith, who had sent him a copy of the Repository, with a letter inviting him to defend what he had said. Dr. Smith died before this letter reached him, but the principal part has appeared in the Medical Repository,vol. ii, p. 285. In this Dr. Chisholm retracts what he had said concerning the mortality on board the Charon and Scorpion ships of war. “I have lately received (says he) from a gentleman of the navy here, a log-book of the Charon, kept by one of her officers during the voyage in question. In this I find, that no sickness took place in either of these ships in consequence of this interview. A log-book is unquestionable evidence, and I therefore admit it.” As to the more serious part of the charge, viz. that Dr. Chisholm had wilfully misrepresented matters, the Doctor replies, that the narrative published by him was in general such as he had from Mr. Paiba; not indeed in manuscript, as Dr. Smith stated his to have been, but in conversation; and that this conversation took place expressly with a view to elucidate the cause of the fever, which he (Dr. Chisholm) could not account for by any reasoning from local causes, but heard it very generally ascribed to infection from the Hankey. Mr. Paiba was introduced to Dr. Chisholm at the request of the latter by the Hon. Samuel Mitchillnow(the letter is dated Sept. 6th 1768 probably 1798) the senior member of the council of Grenada. “Mr. Mitchill (says the Doctor) brought Mr. Paiba to my house, and was present during the greatest part of the time the conversation continued. I found Mr. Paiba very willing to give me every information in his power relative to the state of the Bulama or Boulam colony, and of the ship Hankey; but I found him strongly disinclined to fall in with the universally received opinion, that that ship introduced the disease. The particulars I have given, are those Mr. Paiba related to me in this conversation; and, in order to be correct, I immediately, after Mr. Paiba left me, committed them to paper. Mr. Paiba promised to favour me with a written account; and in order to direct that gentleman’s attention to the points I considered as of most importance, I drew up a set of queries, and Mr. Mitchill charged himself with the delivery of it. A copy of these I have now in my possession, and a slight attention will exhibit my viewin framing them, and show the doubts respecting the nature of the epidemic which suggested them. Although I repeatedly, through Mr. Mitchill and Mr. Palmer, the gentlemen with whom Mr. Paiba resided in the country, renewed my request to have this promise fulfilled, Mr. Paiba left the Island without gratifying it. If no other strong proof existed of something peculiar in the fever which at that time prevailed, the circumstance of my formally applying to Mr. Paiba for information relative to the state of the Hankey, and of taking the trouble to obtain an interview with him, presents an evidence as conclusive as can well be required by reasonable men. But the belief of the infection of the Hankey wasuniversal, nor was it by any means confined to those whose interest might have been affected by the prosperity of an infant colony on the coast of Africa.”
Another charge against Dr. Chisholm is, that he falsifies the date of the Hankey’s arrival at Grenada; and which in Dr. Smith’s paper is brought forward in the following words: “In p. 91 the Doctor remarks, that, ‘in the short space of time from the beginning of March to the end of May, 200 of about 500 sailors, who manned the ships in the regular trade, died of this fever.’ By this it appears that the fever in question broke out as early as the beginning of March. The disingenuousness of this author is particularly evident from this quotation, if the period of the commencement of the disease be correctly assigned: and that it is so is probable from the difficulty of concealing the fact; as there must have been thousands of witnesses to the progress of the fever. When therefore it was thought proper to fix the odium of introducing the disease upon the Hankey (a project of which Dr. Chisholm seems originally to have had no idea) it became necessary for him to fix an earlier date to her arrival. Now, that the Hankey did not arrive till towards the latter end of March, is verified by the concurring testimony of Mr. and Mrs. Paiba, and of Mr. Bell, of this city (New York) who happened tobe in Grenada about that time, and was personally acquainted with Mr. and Mrs. Paiba in that island.”
In answer to this Dr. Chisholm repeats his declaration that the Hankey arrived at Grenada on the 18th ofFebruary, and not on the 19th of March, as Dr. Smith (supposed on the authority of Mr. Paiba) had stated. In proof of this he produces an incontestible evidence, viz. an extract from the St. George’s Gazette in Grenada, of date 19th of February, which begins thus: “By the ship Hankey of London, arrived hereyesterdayfrom the island of Boulam on the coast of Africa, we are informed,” &c. The remainder of the extract contains an account of the excessive mortality on board the ships; which, as it may perhaps be exaggerated, it is needless to transcribe.
The next thing of consequence is the destruction of the bed-clothes and effects of the deceased; of which Dr. Smith says, “Before the Hankey put to sea, all the bedding of the sick was thrown overboard or destroyed; the ship was washed from stem to stern, both above and below, with salt water; and the purification was completed by fumigating her with tar, pitch and gun-powder. In this clean condition they bade farewel to Bulama on the 22d of November, 1792; but, in attempting to pass through the channel near to the entrance into the open sea, in a dark and foggy night, they got aground on a sand-bank, upon the north side of the island of Formosa or Warang, belonging to the Bijugas, who are represented as cannibals. The extreme terror excited by this accident was not calculated to improve the health of the people on board the Hankey; so that, when it became necessary to take measures for their security and deliverance, only four men were found in a condition to do duty, and all of these had intermittents. With them, however, and his lady, Mr. Paiba set off, in an open boat, for Bissao, to obtain assistance from the Portuguese settlement. Thither he arrived, rowing through rains and fogs, in a leaky boat, after being outtwo nights and a day; and having obtained such help as he could, returned to the Hankey, got her off, and carried her to Bissao. On the passage thereeightpersons died who belonged to this ship. At Bissao they refitted, and the Hankeywas a second time purified as completely as she had been before leaving Bulama.”
In answer to all this Dr. Chisholmagain declares, “that the bedding and effects of the deceasedwere preservedon board the Hankey, and constituted the seminium of the infection. Capt. William Liddle, of the ship General Mathew, saw them on board; and it was in consequence of that gentleman’s representation that the lieutenant governor, Mr. Home, entered into a strict investigation of the matter; the general result of which I have given; and the authenticity of it may be depended on. Capt. Liddle is now resident in London, and Mr. Byles, the governor’s secretary, is now resident commissary at Grenada; and these gentlemen will readily testify to the truth of my statement. The destructive articles I have mentionedwere not thrown overboardtill the Hankey arrived in Grenville Bay, when they were destroyed at the request of Mr. Prendfoot, the gentleman who chartered the ship for England.”
Dr. Chisholm is likewise charged with having mis-stated the case of a Capt. Remington, said to be the first who suffered by the fever in Grenada. The words in Dr. Chisholm’s Essay are, “A Capt. Remington, an intimate acquaintance of Capt. Coxe’s, was the first person who visited the Hankey after her arrival in St. George’s bay. This person went on board of her in the evening after she anchored, and remained three days; at the end of which time he left St. George’s, and proceeded in a drogher (a coasting vessel) to Grenville bay, where his ship, the Adventure lay. He was seized with the malignant pestilential fever on the passage; and the violence of the symptoms increased so rapidly, as, on the third day, to put an end to his existence.” In opposition to this Dr. Smith gives the following statement from Mr. Paiba: “He (Capt. Remington) hadbeen all day and all night coming from Grenville bay, and had been wet through. He slept on board in his clothes; and went in an open boatthe next dayback to his ship: enough to kill any one in that climate.” Dr. Chisholm replies “that the above statement is not correct, nor founded on fact; Dr. Chisholm’s evidence for what he said was founded on the information of captains of vessels, who knew all the circumstances of his visit to the Hankey; and of Dr. Stewart, an eminent practitioner, who attended him at Grenville bay, when he landed there. Lastly, that the idea of his having returned to Grenville bay in an open boat, is absurd; nothing of the kind having been ever attempted.”
From this tedious account it is plain that the evidence relative to the importation of the fever into Grenada by the Hankey is quite contradictory, and subversive of itself, because we are unable to judge between the two disputants. A further consideration of it would lead us entirely from the subject of this treatise, into an endless dispute about which of the two parties had spoken the truth. Setting aside thereforethe wholeof the evidence on both sides as insufficient, we shall now proceed to give an account of the symptoms of the distemper as described by Dr. Chisholm, and to which description there has never been any objection made.
In the most violent kind of this fever, according to our author, “the patient, without any previous complaint, suddenly becomes giddy; he loses his eye-sight; every thing seems to move round him with inconceivable velocity; he falls down almost insensible, and in that state remains near half an hour, or upwards. During this paroxysm the body feels cold, and is over-spread with cold sweat, which issues from every pore in astonishing abundance. On his recovery the cold goes off, and is instantly succeeded by intense heat, and quick, small, hard pulse; the head achs dreadfully, particularly the fore part; generally accompanied with pain in the right side and at the præcordia. The last, however, has never been acute, and may rather be calledoppression than pain. The eyes are much inflamed, watery, protruded, and wildly rolling; the face much flushed; much heat is felt at the pit of the stomach, and that organ seems to be considerably affected by the frequent retching and vomiting which then come on. The patient soon after complains of intolerable pains in the small of his back and in the calves of his legs; but the latter appears to be most violent. During twelve, eighteen, twenty-four or thirty-six hours, these symptoms continue increasing, except the quickness and hardness of the pulse, which does not change materially during that time; and are then succeeded by general coldness, cold sweat, a greater or less degree of coma and delirium, or a state very much resembling intoxication. Life in this state is lengthened out to sixty or ninety hours from the first attack. A short interval of reason then takes place; the patient considers himself better, and is, for a moment, flattered with the prospect of recovery: but a fit as sudden and unexpected as the first comes on, during which he foams at the mouth, rolls his eyes dreadfully, and throws out and pulls back his extremities in quick succession. In general the patient expires in this fit; but some have recovered from it, and continued rational for a few hours longer, when a second fit has carried them off.”
This, without much deviation, was the general progress of the worst kind of the fever. In some, however, a comatose disposition showed itself from the very first; in others the disease began with short convulsive fits in frequent succession, followed by constant delirium and cold clammy sweat, without any intervening heat. In a few cases the first symptoms were coldness and shivering, as in other fevers.
The distinguishing symptoms were the uncommonly sudden attack, the remarkably acute pain in the loins and calves of the legs, the watery, inflamed and rolling eye, flushing of the face, tendency to coma, the pain generally confined to the forehead, and the peculiar cast of the delirium, during which the looks and actions of the patientvery much resembled those of a person intoxicated. It was never furious in any other way than by making efforts to get out of bed; and these in a few instances rose so high that the patients got up, dressed themselves, and walked out a considerable way before they could be overpowered. “The strength during the delirium is to appearance surprisingly great, for it is frequently necessary to use the united efforts of two or three men to keep the patient in bed. This is, however, no more than a spasmodic affection of the muscles; for in reality the powers of the sick in this disease are reduced to the extreme of debility, as is seen in the convalescent state.”
The most unequivocal characteristic of this disease, however, according to our author, is the appearance of a kind of petechiæ, but which look rather like red or livid patches than what is commonly understood by that word. They werealwaysthe forerunners of death. In a few very violent cases the body was almost of a livid or black colour, but they were generally seated on the neck, shoulders and breast.Vibicesalso, like those in the plague, described p.258, sometimes made their appearance, and were also a fatal presage.
Hæmorrhage occurred much more frequent and profuse in this than in any other acute distemper our author had met with. “In several instances, the immensity of blood discharged has evidently been the more immediate cause of death. The robust, plethoric and gross habits have been the most subject to it. It has taken place from the nostrils, mouth, anus, and urethra; sometimes from the canthi (corners) of the eyes; but never, I believe, from the ears or pores of the skin. The most profuse discharge has been from the nostrils and anus, and has frequently, amounted to three or four pounds at a time; the stools having been on those occasions entirely composed of pure blood. Towards the close of life, the blood thus discharged has appeared granulous, or like ichor, with a sediment of a black gritty substance, and has been so extremely offensive as to oblige all the attendants to keep at a considerabledistance till the hæmorrhage ceased. Hæmorrhage, however, has never been critical, nor has it in any instance permanently relieved the head-ach or pain in the breast or side. . . . Nearly about the period that these profuse discharges came on, a rawness was felt on the whole of the interior surface of the nose, and on several parts of it little ulcers formed; on others, small eschars, which were remarkably itchy, but on being touched, or an attempt made to detach them from the membrane of the nose, were very painful, and bled. These disappeared in proportion to the patient’s recovery; and I have reason to suspect, that, when the issue of the disease was fatal, these little eschars became gangrenous.”
In this distemper there was always a tendency to coma after the first two days; and after the third, it certainly came on. On examining the heads of two who died convulsed after having been comatose for some time, a great quantity of serum was found in the brain; and, on narrowly inspecting the eyes of those who were afterwards seized with coma, the pupil was found manifestly dilated.
A remarkable symptom unnoticed in any other fever is taken notice of by our author; viz. an affection of the testicles. “About the end of the second day the patient began to complain of a violent pain in these parts, accompanied with a contraction of the spermatic cord, and a drawing up of the testicles towards the abdominal ring. On examination they appear very much lessened in size, are drawn up considerably towards the abdomen, and the scrotum appears at the same time remarkably flaccid and empty. The surface of the scrotum becomes soon after very painful, and an excoriation takes place, chiefly at the most descending part, from which a considerable quantity of very offensive purulent matter issues: at the same time a similar discharge from the urethra takes place, which ceases with the disease when the event is favourable, or becomes ichorous and bloody, and insufferably fœtid when death is the consequence. In cases which terminatefavourably, the whole of the scrotum, in a few days, is covered with a crust of hardened pus, which in the convalescent state, comes away very easily by means of a warm bath. The thickness of this coat may be about the fourth of a line; and, when separated, it much resembles moistened parchment. In fatal cases, this affection of the scrotum always terminates in gangrene a few hours before death.”
Another remarkable symptom is the change of voice to a shrill, soft and low sound when compared with the natural tone, at the same time that the syllables are more distinguished, and the words are strangely lengthened out in a drawling and whining manner. This change of voice affords a pretty certain prognostic; every alteration towards the natural tone being an almost certain sign of a favourable change, and the contrary if the voice becomes farther removed from it.
The pains felt in this fever were in a great measure peculiar to it, and seem to have been of a spasmodic nature. In the head the pain shot from the forehead, to which it was confined, invariably towards the bottom of the orbits, where it was generally exquisite. Sometimes it extended to the temples, where there was always a throbbing; but in no case did it extend to the back part, or over the whole head. This pain extended also to the balls of the eyes, which were protruded, and seemed ready to start from their orbits, with an inflammation externally, and a sensation of pain internally, rendering the admission of light intolerable. In the legs the pain had its seat at the top of the great tendon, immediately below the calf, and in the point where it was seated a gnawing sensation was felt, occasioning exquisite torture, with an involuntary contraction of the limb; so that, on the whole, our author concludes that this pain much resembles the cramp, differing only in being more permanent.
With regard to the pulse, our author observes, that in this disease “it never intermits. Even at the approach of death it has not intermitted, but has generally been remarkably tremulous, and so slow as tobeat no more than thirty times in a minute. On the whole, it has not been found quicker than 130, or slower than 30, in a minute.” In violent cases the pulse was hard, quick and small, but sometimes full; and when it was so it was a good sign. It was however subject to excessive variations; and it frequently happened, “especially in the robust, that, after the first stage, flushing and chillness have often alternated in less than a minute; and that, although the skin felt considerably warm, the pulse has been no more than 52; but that, even when the low state came on, in which there was always a disagreeable coldness of the surface, it has been as quick, and nearly as full, as during the preceding febrile stage, although unaccompanied with thirst, or any other evident symptom of the existence of fever.”
In the state of delirium, Dr. Chisholm observes, that, whatever was the subject of the patient’s raving thoughts, he was always strongly under the impression of fear; and a word from the physician always reduced him to implicit obedience, however restless he might have been before. During this state he complained of no pain, even from blisters, nor was he sensible of the operation of laxative medicines. On being asked about his situation, he always answered that he was very well, and sensible of no pain, as in the yellow fever already described. It is observable, however, that the yellow colour, so remarkable in the former, seldom took place in the Boulam fever; but indeed this symptom, as has formerly been noticed, is by no means a characteristic either of the one disease or the other; but Dr. Chisholm observes “that in some protracted cases on shore, and in some among the sailors, which might have been a combination of the pestilential and yellow fevers, this symptom appeared about the 5th, 7th or 9th day.”
Besides the petechiæ and vibices, already mentioned, Dr. Chisholm takes notice of two other sorts of eruptions, which appeared about the lips: the one was such as frequently appears at the termination of the common remittents, and was favourable; the other resemblingspots made by the fine black pencil of a painter, all round the mouth, but especially the upper lip, and certainly affording a fatal prognostic.
This disease was attended with a suppression of urine, a violent pain above the os pubis, a scalding in the urethra, a sense of fulness, without any visible swelling, a contraction and distortion of the penis; the urine generally of a deep red, sometimes brownish, green, very often bloody, and in a few cases much inclining to black, and of an oily consistence. Its smell was generally very offensive. All the excretions were exceedingly offensive, but the fæces most remarkably so towards the latter end of the disease; for in the beginning they had no remarkable fœtor. The sick were almost universally costive, which our author supposes to have arisen from a suspension of tone in the intestinal canal; for by exciting action in the fibres a large evacuation generally ensued. The colour of the fæces varied from yellow, or a yellowish white, to black; and from a considerable degree of thickness, to the exact appearance of coffee-grounds. The matter discharged by vomit also varied from porraceous to black, and resembling coffee badly boiled.
In this disease, as in the plague described by Thucydides, most other diseases degenerated into it, or partook of its nature. Dysenteries suddenly stopped, and were immediately succeeded by the symptoms of pestilential fever. A remarkable instance of this is given in twenty-seven recruits, who had been seized with dysentery, in consequence of being exposed to rain, receiving the infection in the hospital to which they were carried. The medicines exhibited with a view to cure the dysentery seemed to be attended with surprising effect; but in a short time symptoms of pestilential fever came on, even in a few hours after those of dysentery had disappeared. In like manner catarrhal complaints soon changed their nature. Convalescents from other diseases, such as laboured under chronical complaints, particularly rheumatism and inflammation of the liver, were particularly subject to it. “The puerperal fever became malignant,and of course fatal; and even among pregnant negro women, who might otherwise have had it in the usual mild degree peculiar to that description of people, many were reduced to a very dangerous situation by it. In short, every disease in which the patient was liable to infection, sooner or later assumed the appearance, and acquired the danger, of the pestilential fever.”
This fever was said to be propagated from Grenada to others of the West India islands, and to the United States, where in the same year, 1793, it raged with great violence in Philadelphia. Without entering into any inquiry at present concerning the truth of this report, or the origin of the fever itself, let us see whether from the symptoms enumerated by Dr. Rush, who hath written a very lengthy dissertation upon the disease, it was the same with the Boulam fever already described. According to him the fever in 1793 was frequently preceded by “costiveness, a dull pain in the right side, defect of appetite, flatulence, perverted taste, heat in the stomach, giddiness or pain in the head, a dull, watery, brilliant, yellow or red eye, dim and imperfect vision, hoarseness, or slight sore throat, low spirits, or unusual vivacity, a moisture on the hands, a disposition to sweat at nights, or after moderate exercise, or a sudden suppression of night sweats. . . . On entering a sick room the physician was first struck by thecountenanceof the patient. It was as much unlike that which is exhibited in the common bilious fever, as the face of a wild animal is unlike that of a domestic one. The eyes were sad, watery, and so inflamed in some cases as to resemble two balls of fire. Sometimes they had a most brilliant or ferocious appearance. The face was suffused with blood, or of a dusky colour, and the whole countenance was dusky and clouded. After the 10th of September, when the determination of blood to the brain became universal, there was a preternatural dilation of the pupil. Sighing attended in almost every case. The skin was dry, and frequently of its natural temperature. . . . The pulse at the beginning of the attack was sometimes full, tense andquick, but frequently weak; sometimes so low that it could not be perceived without pressing the wrists; and sometimes it had no preternatural quickness. In many it intermitted after the fourth or fifth, and sometimes after the fourteenth stroke. In some it was extremely slow; even as low as thirty strokes in a minute. The pulse was alsotenseandchorded. The slow intermitting pulse was observed more frequently in children than adults, and supposed to proceed from a collection of water in the brain. Impressed with this idea, I requested Mr. Coxe, one of my pupils, to assist me in examining the state of the eye. For two days we discovered no change in it; but on the third day after we began to inspect the eyes, we both perceived a preternatural dilatation of the pupils in different patients; and we seldom afterwards saw an eye in which it was wanting. In Dr. Say it was attended with squinting, a symptom which marks a high degree of a morbid affection of the brain. Had this slowness or intermission of the pulse occurred only after signs of inflammation or congestion had appeared in the brain, I should have supposed that it had been derived wholly from that cause; but I well recollect having felt it several days before I could discover the least change in the pupil of the eye. I am forced therefore to call in the operation of another cause, to assist in accounting for this state of the pulse, and this I take to be a spasmodic affection, accompanied with preternatural dilatation or contraction of the heart. Lieutaud mentions this species of pulse in several places, as occurring with an undue enlargement of this muscle. Dr. Ferriar describes a case, in which a low, irregular, intermitting and hardly perceptible pulse attended a morbid dilatation of the heart. . . . After the 10th of September this undescribable orsulkypulse became less observable, and, in proportion as the weather cooled, it disappeared. It was gradually succeeded by a pulse full, tense, quick, and as frequent as in pleurisy or rheumatism. It differed, however, from a pleuritic or rheumatic pulse, in imparting avery different sensation to the fingers. No two strokes seemed to be exactly alike. Its action was of a hobbling nature. . . . It was an alarming symptom. . . . The pulse most frequently lessened in its fulness, and became gradually weak, frequent and imperceptible before death; but I met with several cases in which it was full, active, and even tense, in the last hours of life.