Along with all the discharges from the stomach which have been described, there was occasionally a large worm, and frequently large quantities of mucus and tough phlegm.
The colour, quality, and quantity of thefæcesdepended very much upon the treatment of the disease.Where active purges had been given, the stools were copious, fœtid, and of a black or dark colour. Where they were spontaneous, or excited by weak purges, they had a more natural appearance. In both cases they were sometimes of a green, and sometimes of an olive colour. Their smell was more or less fœtid, according to the time in which they had been detained in the bowels. I visited a lady who had passed several days without a stool, and who had been treated with tonic remedies. I gave her a purge, which in a few hours procured a discharge of fæces so extremely fœtid, that they produced fainting in an old woman who attended her. The acrimony of the fæces was such as to excoriate the rectum, and sometimes to produce an extensive inflammation all around its external termination. The quantity of the stools produced by a single purge was in many cases very great. They could be accounted for only by calling in the constant and rapid formation of them, by preternatural effusions of bile into the bowels.
I attended one person, and heard of two others, in whom the stools were as white as in the jaundice. I suspected, in these cases, the liver to be so constipated or paralyzed by the disease, as to be unable to secrete or excrete bile to colour thefæces. Large round worms were frequently discharged with the stools.
Theurinewas in some cases plentiful, and of a high colour. It was at times clear, and at other times turbid. About the 4th or 5th day, it sometimes assumed a dark colour, and resembled strong coffee. This colour continued, in one instance, for several days after the patient recovered. In some, the discharge was accompanied by a burning pain, resembling that which takes place in a gonorrhœa. I met with one case in which this burning came on only in the evening, with the exacerbation of the fever, and went off with its remission in the morning.
A total deficiency of the urine took place in many people for a day or two, without pain. Dr. Sydenham takes notice of the same symptom in the highly inflammatory small-pox[24]. It generally accompanied or portended great danger. I heard of one case in which there was asuppressionof urine, which could not be relieved without the use a the catheter.
A young man was attended by Mr. Fisher, one of my pupils, who discharged several quarts of limpid urine just before he died.
Dr. Arthaud informs us, in the history of a dissection of a person who died of the yellow fever, that the urine after death imparted a green colour to the tincture of radishes[25].
Many people were relieved by copioussweatson the first day of the disease. They were in some instances spontaneous, and in others they were excited by diluting drinks, or by strong purges. These sweats were often of a yellow colour, and sometimes had an offensive smell. They were in some cases cold, and attended at the same time with a full pulse. In general, the skin was dry in the beginning, as well as in the subsequent stages of the disease. I saw but few instances of its terminating like common fevers, by sweat after the third day. I wish this fact to be remembered by the reader, for it laid part of the foundation of my method of treating this fever.
There was in some cases a preternatural secretion and excretion ofmucusfrom the glands ofthe throat. It was discharged by an almost constant hawking and spitting. All who had this symptom recovered.
Thetonguewas in every case moist, and of a white colour, on the first and second days of the fever. As the disease advanced, it assumed a red colour, and a smooth shining appearance. It was not quite dry in this state. Towards the close of the fever, a dry black streak appeared in its middle, which gradually extended to every part of it. Few recovered after this appearance on the tongue took place.
V. In thenervous systemthe symptoms of the fever were different, according as it affected the brain, the muscles, the nerves, or the mind. The sudden and violent action of the miasmata induced apoplexy in several people. In some, it brought on syncope, and in others, convulsions in every part of the body. The apoplectic cases generally proved fatal, for they fell chiefly upon hard drinkers. Persons affected by syncope, or convulsions, sometimes fell down in the streets. Two cases of this kind happened near my house. One of them came under my notice. He was supposed by the by-standers to be drunk, but his countenance and convulsivemotions soon convinced me that this was not the case.
A coma was observed in some people, or an obstinate wakefulness in every stage of the disease. The latter symptom most frequently attended the convalescence. Many were affected with immobility, or numbness in their limbs.
These symptoms were constant, or temporary, according to the nature of the remedies which were made use of to remove them. They extended to all the limbs, in some cases, and only to a part of them in others. In some, a violent cramp, both in the arms and legs, attended the first attack of the fever. I met with one case in which there was a difficulty of swallowing, from a spasmodic affection of the throat, such as occurs in the locked jaw.
A hiccup attended the last stage of this disease, but I think less frequently than the last stage of the common bilious fever. I saw but five cases of recovery where this symptom took place.
There was, in some instances, a deficiency of sensibility, but, in others, a degree of it extending to every part of the body, which rendered the applicationof common rum to the skin, and even the least motion of the limbs painful.
I was surprised to observe the last stage of this fever to exhibit so few of the symptoms of the common typhus or chronic fever. Tremors of the limbs and twitchings of the tendons were uncommon. They occurred only in those cases in which there was a predisposition to nervous diseases, and chiefly in the convalescent state of the disease.
While the muscles and nerves in many cases exhibited so many marks of preternatural weakness, in some they appeared to be affected with preternatural excitement. Hence patients in the close of the disease often rose from their beds, walked across their rooms, or came down stairs, with as much ease as if they had been in perfect health. I lost a patient in whom this state of morbid strength occurred to such a degree, that he stood up before his glass and shaved himself, on the day on which he died.
The mind suffered with the morbid states of the brain and nerves. A delirium was a common symptom. It alternated in some cases with the exacerbations and remissions of the fever. Insome, it continued without a remission, until a few hours before death. Many, however, passed through the whole course of the disease without the least derangement in their ideas, even where there were evident signs of a morbid congestion in the brain. Some were seized with maniacal symptoms. In these there was anapparentabsence of fever. Such was the degree of this mania in one man, that he stripped off his shirt, left his bed, and ran through the streets, with no other covering than a napkin on his head, at 8 o'clock at night, to the great terror of all who met him. The symptoms of mania occurred most frequently towards the close of the disease, and sometimes continued for many days and weeks, after all other febrile symptoms had disappeared.
The temper was much affected in this fever. There were few in whom it did not produce great depression of spirits. This was the case in many, in whom pious habits had subdued the fear of death. In some the temper became very irritable. Two cases of this kind came under my notice, in persons who, in good health, were distinguished for uncommon sweetness of disposition and manners.
I observed in several persons the operations of the understanding to be unimpaired, throughout the whole course of the fever, who retained no remembrance of any thing that passed in their sickness. My pupil, Mr. Fisher, furnished a remarkable example of this correctness of understanding, with a suspension of memory. He neither said nor did any thing, during his illness, that indicated the least derangement of mind, and yet he recollected nothing that passed in his room, except my visits to him. His memory awakened upon my taking him by the hand, on the morning of the 6th day of his disease, and congratulating him upon his escape from the grave.
In some, there was a weakness, or total defect of memory, for several weeks after their recovery. Dr. Woodhouse informed me that he had met with a woman, who, after she had recovered, could not recollect her own name.
Perhaps it would be proper to rank that self-deception with respect to the nature and danger of the disease, which was so universal, among the instances of derangement of mind.
The pain which attended the disease was different, according to the different states of the system.In those cases in which it sunk under the violence of the disease, there was little or no pain. In proportion as the system was relieved from this oppression, it recovered its sensibility. The pain in the head was acute and distressing. It affected the eye-balls in a peculiar manner. A pain extended, in some cases, from the back of the head down the neck. The ears were affected, in several persons, with a painful sensation, which they compared to a string drawing their two ears together through the brain. The sides, and the regions of the stomach, liver, and bowels, were all, in different people, the seats of either dull or acute pains. The stomach, towards the close of the disease, was affected with a burning or spasmodic pain of the most distressing nature. It produced, in some cases, great anguish of body and mind. In others it produced cries and shrieks, which were often heard on the opposite side of the streets to where the patients lay. The back suffered very much in this disease. The stoutest men complained, and even groaned under it. An acute pain extended, in some cases, from the back to one or both thighs. The arms and legs sympathized with every other part of the body. One of my patients, upon whose limbs the disease fell with its principal force, said that his legs felt as if they had been scraped with a sharp instrument. The sympathy of friends withthe distresses of the sick extended to a small part of their misery, when it did not include their sufferings from pain. One of the dearest friends I ever lost by death declared, in the height of her illness, that “no one knew the pains of a yellow fever, but those who felt them.”
VI. Thesensesandappetitesexhibited several marks of the universal ravages of this fever upon the body. A deafness attended in many cases, but it was not often, as in the nervous fever, a favourable symptom. A dimness of sight was very common in the beginning of the disease. Many were affected with temporary blindness. In some there was a loss of sight in consequence of gutta serena, or a total destruction of the substance of the eye. There was in many persons a soreness to the touch which extended all over the body. I have often observed this symptom to be the forerunner of a favourable issue of a nervous fever, but it was less frequently the case in this disease.
Thethirstwas moderate or absent in some cases, but it occurred in the greatest number of persons whom I saw in this fever. Sometimes it was very intense. One of my patients, who suffered by an excessive draught of cold water, declared, just before he died, that “he could drinkup the Delaware.” It was always an alarming symptom when this thirst came on in this extravagant degree in the last stage of the disease. In the beginning of the fever it generally abated upon the appearance of a moist skin. Water was preferred to all other drinks.
Theappetitefor food was impaired in this, as in all other fevers, but it returned much sooner than is common after the patient began to recover. Coffee was relished in the remissions of the fever, in every stage of the disease. So keen was the appetite for solid, and more especially for animal food, after the solution of the fever, that many suffered from eating aliment that was improper from its quality or quantity. There was a general disrelish for wine, but malt liquors were frequently grateful to the taste.
Many people retained a relish for tobacco much longer after they were attacked by this fever, and acquired a relish for it much sooner after they began to recover, than are common in any other febrile disease. I met with one case in which a man, who was so ill as to require two bleedings, continued to chew tobacco through every stage of his fever.
The convalescence from this disease was marked, in some instances, by a sudden revival of the venereal appetite. Several weddings took place in the city between persons who had recovered from the fever. Twelve took place among the convalescents in the hospital at Bush-hill. I wish I could add that the passion of the sexes for each other, among those subjects of public charity, was always gratified only in a lawful way. Delicacy forbids a detail of the scenes of debauchery which were practised near the hospital, in some of the tents which had been appropriated for the reception of convalescents. It was not peculiar to this fever to produce this morbid excitability of the venereal appetite. It was produced in a much higher degree by the plague which raged in Messina in the year 1743.
VII. Thelymphaticandglandular systemdid not escape without some signs of this disease. I met with three cases of swellings in the inguinal, two in the parotid, and one in the cervical glands: all these patients recovered without a suppuration of their swellings. They were extremely painful in one case in which no redness or inflammation appeared. In the others there was considerable inflammation and but little pain.
In one of the cases of inguinal buboes, the whole force of the disease seemed to be collected into the lymphatic system. The patient walked about, and had no fever nor pain in any part of his body, except in his groin. In another case which came under my care, a swelling and pain extended from the groin along the spermatic cord into one of the testicles. These glandular swellings were not peculiar to this epidemic. They occurred in the yellow fever of Jamaica, as described by Dr. Williams, and always with a happy issue of the disease[26]. A similar concentration of the contagion of the plague in the lymphatic glands is taken notice of by Dr. Patrick Russel.
VIII. Theskinexhibited many marks of this fever. It was preternaturally warm in some cases, but it was often preternaturally cool. In some there was a distressing coldness in the limbs for two or three days. The yellow colour from which this fever has derived its name, was not universal. It seldom appeared where purges had been given in sufficient doses. The yellowness rarely appeared before the third, and generally about the fifth or seventh day of the fever. Its early appearance always denoted great danger. It sometimes appearedfirst on the neck and breast, instead of the eyes. In one of my patients it discovered itself first behind one of his ears, and on the crown of his head, which had been bald for several years. The remissions and exacerbations of the fever seemed to have an influence upon this colour, for it appeared and disappeared altogether, or with fainter or deeper shades of yellow, two or three times in the course of the disease. The eyes seldom escaped a yellow tinge; and yet I saw a number of cases in which the disease appeared with uncommon malignity and danger, without the presence of this symptom.
There was a clay-coloured appearance in the face, in some cases, which was very different from the yellow colour which has been described. It occurred in the last stage of the fever, and in no instance did I see a recovery after it.
There were eruptions of various kinds on the skin, each of which I shall briefly describe.
1. I met with two cases of an eruption on the skin, resembling that which occurs in the scarlet fever. Dr. Hume says, pimples often appear on the pit of the stomach, in the yellow fever of Jamaica. I examined the external region of the stomachin many of my patients, without discovering them.
2. I met with one case in which there was an eruption of watery blisters, which, after bursting, ended in deep, black sores.
3. There was an eruption about the mouth in many people, which ended in scabs, similar to those which take place in the common bilious fever. They always afforded a prospect of a favourable issue of the disease.
4. Many persons had eruptions which resembled moscheto bites. They were red and circumscribed. They appeared chiefly on the arms, but they sometimes extended to the breast. Like the yellow colour of the skin, they appeared and disappeared two or three times in the course of the disease.
5. Petechiæ were common in the latter stage of the fever. They sometimes came on in large, and at other times in small red blotches; but they soon acquired a dark colour. In most cases they were the harbingers of death.
6. Several cases of carbuncles, such as occur in the plague, came under my notice. They were large and hard swellings on the limbs, with a black apex, which, upon being opened, discharged a thin, dark-coloured, bloody matter. From one of these malignant sores a hæmorrhage took place, which precipitated the death of the amiable widow of Dr. John Morris.
7. A large and painful anthrax on the back succeeded a favourable issue of the fever in the Rev. Dr. Blackwell.
8. I met with a woman who showed me the marks of a number of small boils on her face and neck, which accompanied her fever.
Notwithstanding this disposition to cutaneous eruptions in this disease, it was remarkable that blisters were much less disposed to mortify than in the common nervous fever. I met with only one case in which a deep-seated ulcer followed the application of blisters to the legs. Such was the insensibility of the skin in some people, that blisters made no impression upon it.
IX. Thebloodin this fever has been supposed to undergo a change from a healthy to a putrid state,and many of its symptoms which have been described, particularly the hæmorrhages and eruptions on the skin, have been ascribed to this supposed putrefaction of the blood. It would be easy to multiply arguments, in addition to those mentioned in another place[27], to prove that no such thing as putrefaction can take place in the blood, and that the symptoms which have been supposed to prove its existence are all effects of a sudden, violent, and rapid inflammatory action or pressure upon the blood-vessels, and hence the external and internal hæmorrhages. The petechiæ on the surface of the skin depend upon the same cause. They are nothing but effusions of serum or red blood, from a rupture or preternatural dilatation of the capillary vessels[28]. The smell emitted from persons affected by this disease was far from being of a putrid nature; and if this had been the case, it would not have proved the existence of putrefaction in the blood, for a putrid smell is often discharged from the lungs, and from the pores in sweat, which iswholly unconnected with a putrid, or perhaps any other morbid state of the blood. There are plants which discharge an odour which conveys to the nose a sensation like that of putrefaction; and yet these plants exist, at the same time, in a state of the most healthy vegetation: nor does the early putrid smell of a body which perishes with this fever prove a putrid change to have taken place in the blood before death. All animals which die suddenly, and without loss of blood, are disposed to a speedy putrefaction. This has long been remarked in animals that have been killed after a chase, or by lightning. The poisonous air calledsamiel, which is described by Chardin, produces, when it destroys life, instant putrefaction. The bodies of men who die of violent passions, or after strong convulsions, or even after great muscular exertion, putrify in a few hours after death. The healthy state of the body depends upon a certain state of arrangement in the fluids. A derangement of these fluids is the natural consequence of the violent and rapid motions, or of the undue pressure upon the solids, which have been mentioned. It occurs in cases of death which are induced by the excessive force of stimulus, whether it be from miasmata, or the volatile vitriolic acid which is supposed to constitute the destructive samiel wind, or from violent commotions excited in the body byexternal or internal causes. The practice among fishermen, in some countries, of breaking the heads of their fish as soon as they are taken out of the water, in order to retard their putrefaction, proves the truth of the explanation I have given of its cause, soon after death. The sudden extinction of life in the fish prevents those convulsive or violent motions, which induce suddendisorganizationin their bodies. It was observed that putrefaction took place most speedily after death from the yellow fever, where the commotions of the system were not relieved by evacuations. In those cases where purges and bleeding had been used, putrefaction did not take place sooner after death than is common in any other febrile disease, under equal circumstances of heat and air.
Thus have I described the symptoms of this fever. From the history I have given, it appears that it counterfeited nearly all the acute and chronic forms of disease to which the human body is subject. An epitome, both of its symptoms and its theory, is happily delivered by Dr. Sydenham, in the following words. After describing the epidemic cough, pleurisy, and peripneumony of 1675, he adds, “But in other epidemics, the symptoms are so slight from the disturbance raised in the blood by the morbific particles contained in themass, that nature being in a manneroppressed, is rendered unable to produceregularsymptoms that are suitable to the disease; and almost all the phenomena that happen areirregular, by reason of the entiresubversionof the animal economy; in which case the fever is oftendepressed, which, of its own nature, would be very high. Sometimes also fewer signs of a fever appear than the nature of the disease requires, from a translation of the malignant cause, either to the nervous system, or to some other parts of the body, or to some of the juices not contained in the blood; whilst the morbific matter is yet turgid[29].”
The disease ended in death in various ways. In some it was sudden; in others it came on by gradual approaches. In some the last hours of life were marked with great pain, and strong convulsions; but in many more, death seemed to insinuate itself into the system, with all the gentleness of natural sleep. Mr. Powell expired with a smile on his countenance. Dr. Griffitts informed me that Dr. Johnson exhibited the same symptom in the last hours of his life. This placid appearance of the countenance, in the act of dying, was not new to me. It frequently occurs in diseases whichaffect the brain and nerves. I lost a patient, in the year 1791, with the gout, who not only smiled, but laughed, a few minutes before he expired.
I proceed now to mention some peculiarities of the fever, which could not be brought in under any of the foregoing heads.
In every case of this disease which came under my notice, there were evident remissions, or intermissions of the fever, or of such symptoms as were substituted for fever. I have long considered, with Mr. Senac, atertianas the only original type of all fevers. The bilious yellow fever indicated its descent from this parent disease. I met with many cases of regular tertians, in which the patients were so well on the intermediate days as to go abroad. It appeared in this form in Mr. Van Berkel, the minister of the United Netherlands. Nor was this mild form of the fever devoid of danger. Many died who neglected it, or who took the common remedies for intermittents to cure it. It generally ended in a remittent before it destroyed the patient. The tertian type discovered itself in some people after the more violent symptoms of the fever had been subdued, and continued in them for several weeks. It changed from a tertian to a quartan type in Mr. Thomas Willing, nearly amonth after his recovery from the more acute and inflammatory symptoms of the disease.
It is nothing new for a malignant fever to appear in the form of a tertian. It is frequently the garb of the plague. Riverius describes a tertian fever which proved fatal on the third day, which was evidently derived from the same exhalation which produced a continual malignant fever[30].
The remissions were more evident in this, than in the common bilious fever. They generally occurred in the forenoon. It was my misfortune to be deprived, by the great number of my patients, of that command of time which was necessary to watch the exacerbations of this fever under all their various changes, as to time, force, and duration. From all the observations that were suggested by visits, at hours that were seldom left to my choice, I was led to conclude, that the fever exhibited in different people all that variety of forms which has been described by Dr. Cleghorn, in his account of the tertian fever of Minorca. A violent exacerbation on even days was evidently attended with more danger than on odd days. The same thing was observed by Dr. Mitchell in the yellow fever of Virginia,in the year 1741. “If (says he) the exacerbations were on equal days, they generally died in the third paroxysm, or the sixth day; but if on unequal days, they recovered on the seventh.”
The deaths which occurred on the 3d, 5th, and 7th days, appeared frequently to be the effects of the commotions or depression, produced in the system on the 2d, 4th, and 6th days.
The remission on the third day was frequently such as to beget a belief that the disease had run its course, and that all danger was over. A violent attack of the fever on the 4th day removed this deception, and, if a relaxation had taken place in the use of proper remedies on the 3d day, death frequently occurred on the 5th or the 7th.
The termination of this fever in life and death was much more frequent on the 3d, 5th, 7th, 9th, and 11th days, than is common in the mild remitting fever. Where death occurred on the even days, it seemed to be the effect of a violent paroxysm of the fever, or of great vigour of constitution, or of the force of medicines which protracted some of the motions of life beyond the close of the odd days which have been mentioned.
I think I observed the fever to terminate on the third day more frequently in August, and during the first ten days in September, than it did after the weather became cool. In this it resembled the common bilious remittents of our city, also the simple tertians described by Dr. Cleghorn[31]. The danger seemed to be in proportion to the tendency of the disease to a speedy crisis, hence more died in August in proportion to the number who were affected than in September or October, when the disease was left to itself. But, however strange after this remark it may appear, the disease yielded to the remedies which finally subdued it more speedily and certainly upon its first appearance in the city, than it did two or three weeks afterwards.
The disease continued for fifteen, twenty, and even thirty days in some people. Its duration was much influenced by the weather, and by the use or neglect of certain remedies (to be mentioned hereafter) in the first stage of the disease.
It has been common with authors to divide the symptoms of this fever into three different stages. The order I have pursued in the history of those symptoms will render this division unnecessary.It will I hope be more useful to divide the patients affected with the disease into three classes.
Thefirstincludes those in whom the stimulus of the miasmata produced coma, languor, sighing, a disposition to syncope, and a weak or slow pulse.
Thesecondincludes those in whom the miasmata acted with less force, producing great pain in the head, and other parts of the body; delirium, vomiting, heat, thirst, and a quick, tense, or full pulse, with obvious remissions or intermissions of the fever.
Thethirdclass includes all those persons in whom the miasmata acted so feebly as not to confine them to their beds or houses. This class of persons affected by the yellow fever was very numerous. Many of them recovered without medical aid, or by the use of domestic prescriptions; many of them recovered in consequence of a spontaneous diarrhœa, or plentiful sweats; many were saved by moderate bleeding and purging; while some died, who conceived their complaints to be occasioned by a common cold, and neglected to take proper care of themselves, or to use the necessary means for their recovery. It is not peculiar to the yellow fever to produce this feeble operation uponthe system, It has been observed in the southern states of America, that in those seasons in which the common bilious fever is epidemic “no body is quite well,” and that what are called in those states “inward fevers” are universal. The small-pox, even in the natural way, does not always confine the patient; and thousands pass through the plague without being confined to their beds or houses. Dr. Hodges prescribed for this class of patients in his parlour in London, in the year 1665, and Dr. Patrick Russel did the same from a chamber window fifteen feet above the level of the street at Aleppo. Notwithstanding the mild form the plague put on in these cases, it often proved fatal according to Dr. Russel. I have introduced these facts chiefly with a view of preparing the reader to reject the opinion that we had two species of fever in the city at the same time; and to show that the yellow fever appears in a more simple form than with “strongly marked” characters; or, in other words, with a yellow skin and a black vomiting.
It was remarkable that this fever always found out the weak part of every constitution it attacked. The head, the lungs, the stomach, the bowels, and the limbs, suffered more or less, according as they were more or less debilitated by previousinflammatory or nervous diseases, or by a mixture of both, as in the gout.
I have before remarked, that the influenza, the scarlatina, and a mild bilious remittent, prevailed in the city, before the yellow fever made its appearance. In the course of a few weeks they all disappeared, or appeared with symptoms of the yellow fever; so that, after the first week of September, it was the solitary epidemic of the city.
The only case like influenza which I saw after the 5th of September, was in a girl of 14 years of age, on the 13th of the month. It came on with a sneezing and cough. I was called to her on the third day of her disease. The instant I felt her pulse, I pronounced her disease to be the yellow fever. Her father was offended with this opinion, although he lived in a highly infected neighbourhood, and objected to the remedies I prescribed for her. In a few days she died. In the course of ten days, her father and sister were infected, and both died, I was informed, with the usual symptoms of the yellow fever.
It has been an axiom in medicine, time immemorial, that no two fevers of unequal force can exist long together in the same place. As thisaxiom seems to have been forgotten by many of the physicians of Philadelphia, and as the ignorance or neglect of it led to that contrariety of opinion and practice, which unhappily took place in the treatment of the disease, I hope I shall be excused by those physicians to whom this fact is as familiar as the most simple law of nature, if I fill a few pages with proofs of it, from practical writers.
Thucydides long ago remarked, that the plague chased all other diseases from Athens, or obliged them to change their nature, by assuming some of its symptoms.
Dr. Sydenham makes the same remark upon the plague in London, in 1665. Dr. Hodges, in his account of the same plague, says, that “at the rise of the plague all other distempers went into it, but that, at its declension, it degenerated into others, as inflammations, head-ach, quinsies, dysenteries, small-pox, measles, fevers, and hectics, wherein the plague yet predominated[32].”
During the prevalence of the plague in Grand Cairo, no sporadic disease of any kind makes its appearance. The same observation is made bySauvage, in his account of the plague at Alais, in the province of Languedoc[33].
The small-pox, though a disease of less force than the plague, has often chased it from Constantinople, probably from its being in a declining state. But this exclusive prevalence of a single epidemic is not confined to the plague and small-pox. Dr. Sydenham's writings are full of proofs of the dominion of febrile diseases over each other. Hence, after treating upon a symptomatic pleurisy which sometimes accompanied a slow fever, in the year 1675, and which had probably been injudiciously treated by some of those physicians who prescribe for the name of a disease, he delivers the following aphorism: “Whoever, in the cure of fevers, hath not always in view the constitution of the year, inasmuch as it tends to produce some particular epidemic disease, and likewise to reduce all the cotemporary diseases to its own form and likeness, proceeds in an uncertain and fallacious way[34].” It appears further, from the writings of this excellent physician, that where the monarchy of a single disease was not immediately acknowledged,by a sudden retreat of all cotemporary diseases, they were forced to do homage to it, by wearing its livery. It would be easy to multiply proofs of this assertion, from the numerous histories of epidemics which are to be found in his works. I shall mention only one or two of them. A continual fever, accompanied by a dry skin, had prevailed for some time in the city of London. During the continuance of this fever, the regular small-pox made its appearance. It is peculiar to the small-pox, when of a distinct nature, to be attended by irregular sweats before the eruption of the pock. The continual fever now put on a new symptom. It was attended by sweats in its first stage, exactly like those which attended the eruptive fever of the small-pox[35]. This despotism of a powerful epidemic extended itself to the most trifling indispositions. It even blended itself, Dr. Sydenham tells us, with the commotions excited in the system by the suppression of the lochia, as well as with the common puerperile fever[36]. Dr. Morton has left testimonies behind him, in different parts of his works, which establish, in the most ample manner, the truth of Dr. Sydenham's observations.Dr. Huxham describes the small-pox as blending some of its symptoms with those of a slow fever, at Plymouth, in the year 1729[37]. Dr. Cleghorn mentions a constitution of the air at Minorca, so highly inflammatory, “that not only tertian fevers, but even a common hurt or bruise required more plentiful evacuations than ordinary[38].” Riverius informs us, in his history of a pestilential fever that prevailed in France, that “it united itself with phrenitis, angina, pleurisy, peripneumony, hepatitis, dysentery, and many other diseases[39].”
The bilious remitting fever which prevailed in Philadelphia, in 1780, chased away every other febrile disease; and the scarlatina anginosa which prevailed in our city, in 1783 and 1784, furnished a striking proof of the influence of epidemics over each other. In the account which I published of this disease, in the year 1789, there are the following remarks. “The intermitting fever which made its appearance in August was not lost during the month of September. It continued to prevail, but with several peculiar symptoms. In many persons it was accompanied by an eruptionon the skin, and a swelling of the hands and feet. In some it was attended with sore throat, and pains behind the ears. Indeed such was the prevalence of the contagion which produced the scarlatina anginosa, that many hundred people complained of sore throats, without any other symptom of indisposition. The slightest exciting cause, and particularly cold, seldom failed of producing the disease[40].”
I shall mention only one more authority in favour of the influence of a single epidemic upon diseases. It is taken from Mr. Clark's essay on the epidemic disease of lying-in women, of the years 1787 and 1788. “There does not appear to be any thing in a parturient state which can prevent women from being affected by the general causes of disease at that time; and should they become ill, their complaints will probably partake of the nature of the reigning epidemic[41].” I have said that the fever sometimes put on the symptoms of dysentery, pleurisy, rheumatism, colic, palsy, and even of the locked jaw. That these were not original diseases, but symptomatic affections onlyof the reigning epidemic, will appear from other histories of bilious fevers. Dr. Balfour tells us, in his account of the intestinal remitting fever of Bengal[42], that it often appeared with symptoms of dysentery, rheumatism, and pleurisy. Dr. Cleghorn and Dr. Lind mention many cases of the bilious fever appearing in the form of a dysentery. Dr. Clark ascribes the dysentery, the diarrhœa, the colic, and even the palsy, to the same cause which produced the bilious fever in the East-Indies[43]; and Dr. Hunter, in his treatise upon the diseases of Jamaica, mentions the locked jaw as one of its occasional symptoms. Even the different grades of this fever, from the mildest intermittent to the most acute continual fever, have been distinctly traced by Lancissi to the same marsh exhalation[44].
However irrefragably these numerous facts and authorities establish the assertion of the prevalence of but one powerful epidemic at a time, the proposition will receive fresh support, from attending to the effects of two impressions of unequal force madeupon the system at the same time: only one of them is felt; hence the gout is said to cure all other diseases. By its superior pain it destroys sensations of a less painful nature. The small-pox and measles have sometimes existed together in the body; but this has, I believe, seldom occurred, where one of them has not been the predominating disease[45]. In this respect, this combination of epidemics only conforms to the general law which has been mentioned.
I beg pardon for the length of this digression. I did not introduce it to expose the mistakes of those physicians, who found as many diseases in our city as the yellow fever had symptoms, but to vindicate myself from the charge of innovation, in having uniformly and unequivocally asserted, after the first week in September, that the yellow fever was the only febrile disease which prevailed in the city.
Science has much to deplore from the multiplication of diseases. It is as repugnant to truth in medicine, as polytheism is to truth in religion. The physician who considers every different affection of the different systems in the body, or everyaffection of different parts of the same system, as distinct diseases, when they arise from one cause, resembles the Indian or African savage, who considers water, dew, ice, frost, and snow, as distinct essences; while the physician who considers the morbid affections of every part of the body (however diversified they may be in their form or degrees) as derived from one cause, resembles the philosopher who considers dew, ice, frost, and snow, as different modifications of water, and as derived simply from the absence of heat.
Humanity has likewise much to deplore from this paganism in medicine. The sword will probably be sheathed for ever, as an instrument of death, before physicians will cease to add to the mortality of mankind, by prescribing for the names of diseases.
The facts I have delivered upon this subject will admit of a very important application to the cure, not only of the yellow fever, but of all other acute and dangerous epidemics. I shall hereafter assign a final cause for the law of epidemics which has been mentioned, which will discover a union of the goodness of the Supreme Being with one of the greatest calamities of human life.
All ages were affected by this fever, but persons between fourteen and forty years of age were most subject to it. Many old people had it, but it was not so fatal to them as to robust persons in middle life. It affected children of all ages. I met with a violent case of the disease, in a child of four months, and a moderate case of it, in a child of but ten weeks old. The latter had a deep yellow skin. Both these children recovered.
The proportion of children who suffered by this fever may be conceived from a single fact. Seventy-five persons were buried in the grave-yard of the Swedish church in the months of August, September, and October, twenty-four of whom were children. They were buried chiefly in September and October; months in which children generally enjoy good health in our city.
Men were more subject to the disease than women. Pregnancy seemed to expose women to it.
The refugees from the French West-Indies universally escaped it. This was not the case with the natives of France, who had been settled in the city.
It is nothing new for epidemics to affect persons of one nation, and to pass by persons of other nations, in the same city or country. At Nimeguen, in the year 1736, Deigner informs us, that the French people (two old men excepted), and the Jews, escaped a dysentery which was universal among persons of all other nations. Ramazini tells us, that the Jews at Modena escaped a tertian fever which affected nearly all the other inhabitants of the town. Shenkius says, that the Dutch and Italians escaped a plague, which prevailed for two years in one of the towns of Switzerland; and Dr. Bell, in an inaugural dissertation, published at Edinburgh, in 1779, remarks, that the jail fever, which attacked the soldiers of the duke of Buccleugh's regiment, spared the French prisoners who were guarded by them. It is difficult to account for these facts. However numerous their causes may be, a difference in diet, which is as much a distinguishing mark of nations as dress or manners, will probably be found to be one of them.
From the accounts of the yellow fever which had been published by many writers, I was led to believe that the negroes in our city would escape it. In consequence of this belief, I published the following extract in the American Daily Advertiser, from Dr. Lining's history of the yellow fever, as ithad four times appeared in Charleston, in South-Carolina.
“There is something very singular (says the doctor) in the constitution of the negroes, which renders them not liable to this fever; for though many of them were as much exposed as the nurses to the infection, yet I never knew of one instance of this fever among them, though they are equally subject with the white people to the bilious fever[46].”
A day or two after this publication the following letter from the mayor of the city, to Mr. Claypoole, the printer of the Mail, appeared in his paper.
“Sir,
“It is with peculiar satisfaction that I communicate to the public, through your paper, that theAfrican Society, touched with the distresses which arise from the present dangerous disorder, have voluntarily undertaken to furnish nurses to attend the afflicted; and that, by applying toAbsalom JonesandWilliam Gray, both members of that society, they may be supplied.
MATTH. CLARKSON,
September 6th, 1793.Mayor.”
It was not long after these worthy Africans undertook the execution of their humane offer of services to the sick before I was convinced I had been mistaken. They took the disease in common with the white people, and many of them died with it. I think I observed the greatest number of them to sicken after the mornings and evenings became cool. A large number of them were my patients. The disease was lighter in them than in white people. I met with no case of hæmorrhage in a black patient.
The tobacconists and persons who used tobacco did not escape the disease. I observed snuff-takers to be more devoted to their boxes than usual, during the prevalence of the fever.
I have remarked, formerly, that servant maids suffered much by the disease. They were the only patients I lost in several large families. I ascribe their deaths to the following causes:
1st.To the great and unusual debility induced upon their systems by labour in attending their masters and mistresses, or their children. Debility, according to its degrees and duration, seems to have had the same effect upon the mortality of this fever that it has upon the mortality of an inflammation of the lungs. When it is moderate and of short duration it predisposes only to a common pneumony, but when it is violent and protracted, in its degrees and duration, it predisposes to a pulmonary consumption.
2dly.To their receiving large quantities of impure air into their bodies, and in a most concentrated state, by being obliged to perform the most menial offices for the sick, and by washing, as well as removing foul linen, and the like.
3dly.To their being left more alone in confined or distant rooms, and thereby suffering from depression of spirits, or the want of a punctual supply of food and medicines.
There did not appear to be any advantage from smelling vinegar, tar, camphor, or volatile salts, in preventing the disease. Bark and wine were equally ineffectual for that purpose. I was called to many hundred people who were infected afterusing one or more of them. Nor did the white washing of walls secure families from the disease. I am disposed to believe garlic was the only substance that was in any degree useful in preventing it. I met with several persons who chewed it constantly, and who were much exposed to the miasmata, without being infected. All other substances seemed to do harm by begetting a false confidence in the mind, to the exclusion of more rational preservatives. I have suspected further, that such of them as were of a volatile nature helped to spread the disease by affording a vehicle for miasmata through the air.
There was great mortality in all those families who lived in wooden houses. Whether this arose from the small size of these houses, or from the want of cleanliness of the people who occupied them, or from the miasmata becoming more accumulated, by adhering to the wood, I am unable to determine. Perhaps it was the effect of the co-operation of all three of those causes.
I have said, formerly, that intemperance in drinking predisposed to the disease; but there were several instances of persons having escaped it who were constantly under the influence of strong drink. The stimulus of ardent spirits probablypredominated over the stimulus of the miasmata, and thus excited an artificial fever which defended the system from that which was epidemic.
I heard of some sea-faring people who lived on board their vessels who escaped the disease. The smell of the tar was supposed to have preserved them; but, from its being ineffectual in other cases, I am disposed to ascribe their escape to the infected air of the city being destroyed by a mixture with the water of the Delaware.
Many people who were infected in the city were attacked by the disease in the country, but they did not propagate it, even to persons who slept in the same room with them.
Dr. Lind informs us that many persons escaped the yellow fever which prevailed in Pensacola in the year 1765, by retiring to the ships which lay in the harbour, and that when the disease had been taken, the pure air of the water changed it into an intermitting fever[47]. The same changes have frequently been produced in malignant fevers, by sending patients infected with them from the foul air of a city, into the pure air of the country.
Persons confined in the house of employment, in the hospital, and in the jail, escaped the fever. The airy and remote situation of those buildings was probably the chief means of their preservation. Perhaps they derived additional security from their simple diet, their exemption from hard labour, and from being constantly sheltered from heat and cold.
Several families, who shut up their front and back doors and windows, and avoided going out of their houses except to procure provisions, escaped the disease.
I have taken some pains to ascertain, whether any class of tradesmen escaped the fever, or whether there was any species of labour which protected from it. The result of my inquiries is as follows: Three butchers only, out of nearly one hundred who remained in the city, died with the disease. Many of them attended the markets every day. Two painters, who worked at their business during the whole time of the prevalence of the fever, and in exposed situations, escaped it. Out of forty scavengers who were employed in collecting and carrying away the dirt of the streets, only one was affected by the fever and died. Very few grave-diggers, compared with the number whowere employed in that business, were infected; and it is well known, that scarcely an instance was heard of persons taking the disease, who were constantly employed in digging cellars. The fact is not new that grave-diggers escape malignant fevers. It is taken notice of by Dr. Clark.
It was said by some physicians in the public papers, that the neighbourhood of the grave-yards was more infected than other parts of the city. The reverse of this assertion was true in several cases, owing probably to the miasmata being diluted and weakened by its mixture with the air of the grave-yards: for this air was pure, compared with that which stagnated in the streets.
It was said further, that the disease was propagated by the inhabitants assembling on Sundays for public worship; and, as a proof of this assertion, it was reported, that the deaths were more numerous on Sundays than on other days; occasioned by the infection received on one Sunday producing death on the succeeding first day of the week. The register of the deaths shows that this was not the case. I am disposed to believe that fewer people sickened on Sundays, than on any other day of the week; owing to the general rest from labour, which I have before said was one ofthe exciting causes of the disease. From some facts to be mentioned presently, it will appear probable, that places of public worship, in consequence of their size, as well as of their being shut up during the greatest part of the week, were the freest from miasmata of any houses in the city. It is agreeable to discover in this, as well as in all other cases of public and private duty, that the means of health and moral happiness are in no one instance opposed to each other.
The disease, which was at first confined to Water-street, soon spread through the whole city. After the 15th of September, the atmosphere of every street in the city was charged with miasmata; and there were few citizens in apparent good health, who did not exhibit one or more of the following marks of their presence in their bodies.
1. A yellowness in the eyes, and a sallow colour upon their skin.
2. A preternatural quickness in the pulse. I found but two exceptions to this remark, out of a great number of persons whose pulses I examined. In one of them it discovered several preternatural intermissions in the course of a minute. This quickness of pulse occurred in the negroes, aswell as in the white people. I met with it in a woman who had had the yellow fever in 1762. In two women, and in one man above 70, the pulse beat upwards of 90 strokes in a minute. This preternatural state of the pulse during the prevalence of a pestilential fever, in persons in health, is taken notice of by Riverius[48].
3. Frequent and copious discharges by the skin of yellow sweats. In some persons these sweats sometimes had an offensive smell, resembling that of the washings of a gun.
4. A scanty discharge of high coloured or turbid urine.
5. A deficiency of appetite, or a greater degree of it than was natural.
6. Costiveness.
7. Wakefulness.
8. Head-ach.
9. A preternatural dilatation of the pupils. This was universal. I was much struck in observing the pupil in one of the eyes of a young man who called upon me for advice, to be of an oblong figure. Whether it was natural, or the effect of the miasmata acting on his brain, I could not determine.
It will be thought less strange that the miasmata should produce these changes in the systems of persons who resided constantly in the city, when I add, that many country people who spent but a few hours in the streets in the day, in attending the markets, were infected by the disease, and sickened and died after they returned home; and that others, whom business compelled to spend a day or two in the city during the prevalence of the fever, but who escaped an attack of it, declared that they were indisposed, during the whole time, with languor or head-ach.
I was led to observe and record the above effects of the miasmata upon persons in apparent good health, by a fact I met with in Dr. Mitchell's history of the yellow fever in Virginia, in the year 1741. In that fever, blood drawn from a vein was always dissolved. The same state of the blood was observed in many persons who had been exposedto the miasmata, who discovered no other symptom of the disease.
A woman whom I had formerly cured of a mania, who lived in an infected neighbourhood, had a fresh attack of that disease, accompanied by an unusual menstrual flux. I ascribed both these complaints to the action of the miasmata upon her system.
The smell emitted from a patient, in a clean room, was like that of the small-pox, but in most cases of a less disagreeable nature. Putrid smells in sick rooms were the effects of the excretions, or of some other filthy matters. In small rooms, crowded in some instances with four or five sick people, there was an effluvia that produced giddiness, sickness at stomach, a weakness of the limbs, faintness, and in some cases a diarrhœa. I met with a fœtid breath in one patient, which was not the effect of that medicine which sometimes produces it.
The state of the atmosphere, during the whole month of September, and the first two weeks in October, favoured the accumulation of the miasmata in the city.
The register of the weather shows how little the air was agitated by winds during the above time. In vain were changes in the moon expected to alter the state of the air. The light of the morning mocked the hopes that were raised by a cloudy sky in the evening. The sun ceased to be viewed with pleasure. Hundreds sickened every day beneath the influence of his rays: and even where they did not excite the disease, they produced a languor in the body unknown to the oldest inhabitant of the city, at the same season of the year.
A meteor was seen at two o'clock in the morning, on or about the twelfth of September. It fell between Third-street and the hospital, nearly in a line with Pine-street. Moschetoes (the usual attendants of a sickly autumn) were uncommonly numerous. Here and there a dead cat added to the impurity of the air of the streets. It was supposed those animals perished with hunger in the city, in consequence of so many houses being deserted by the inhabitants who had fled into the country, but the observations of subsequent years made it more probable they were destroyed by the same morbid state of the atmosphere which produced the reigning epidemic.
It appears further, from the register of the weather, that there was no rain between the 25th of August and the 15th of October, except a few drops, hardly enough to lay the dust of the streets, on the 9th of September, and the 12th of October. In consequence of this drought, the springs and wells failed in many parts of the country. The dust in some places extended two feet below the surface of the ground. The pastures were deficient, or burnt up. There was a scarcity of autumnal fruits in the neighbourhood of the city. But while vegetation drooped or died from the want of moisture in some places, it revived with preternatural vigour from unusual heat in others. Cherry-trees blossomed, and apple, pear, and plum-trees bore young fruit in several gardens in Trenton, thirty miles from Philadelphia, in the month of October.
However inoffensive uniform heat, when agitated by gentle breezes, may be, there is, I believe, no record of a dry, warm, and stagnating air, having existed for any length of time without producing diseases. Hippocrates, in describing a pestilential fever, says the year in which it prevailed was without a breeze of wind[49]. The same state of the atmosphere,for six weeks, is mentioned in many of the histories of the plague which prevailed in London, in 1665[50]. Even the sea air itself becomes unwholesome by stagnating; hence Dr. Clark informs us, that sailors become sickly after long calms in East-India voyages[51]. Sir John Pringle delivers the following aphorism from a number of similar observations upon this subject: “When the heats come on soon, and continue throughout autumn, not moderated by winds or rains, the season proves sickly, distempers appear early, and are dangerous[52].”
Who can review this account of the universal diffusion of the miasmata which produced this disease, its universal effects upon persons apparently in good health, and its accumulation and concentration, in consequence of the calmness of the air, and believe that it was possible for a febrile disease to exist at that time in our city that was not derived from that source?
The West-India writers upon the yellow fever have said that it is seldom taken twice, except bypersons who have spent some years in Europe or America in the interval between its first and second attack. I directed my inquiries to this question, and I now proceed to mention the result of them. I met with five persons, during the prevalence of the disease, who had had it formerly, two of them in the year 1741, and three in 1762, who escaped it in 1793, although they were all more or less exposed to the infection. One of them felt a constant pain in her head while the disease was in her family. Four of them were aged, and of course less liable to be acted upon by the miasmata than persons in early or middle life. Mr. Thomas Shields furnished an unequivocal proof that the disease could be taken after an interval of many years. He had it in the year 1762, and narrowly escaped from a violent attack of it this year. Cases of reinfection were very common during the prevalence of this fever. They occurred most frequently where the first attack had been light. But they succeeded attacks that were severe in Dr. Griffitts, Dr. Mease, my pupil Mr. Coxe, and several others, whose cases came under my notice.
I have before remarked that the miasmata sometimes excited a fever as soon as they were taken into the body, but that they often lay there from one to sixteen days before they produced the disease.How long they existed in the body after a recovery from the fever I could not tell, for persons who recovered were, in most cases, exposed to their action from external sources. The preternatural dilatation of the pupils was a certain mark of the continuance of some portion of them in the system. In one person who was attacked with the fever on the night of the 9th of October, the pupils did not contract to their natural dimensions until the 7th of November.
Having described the effects of the miasmata upon the body, I proceed now to mention the changes induced upon it by death.
Let us first take a view of it as it appeared soon after death. Some new light may perhaps be thrown upon the proximate cause of the disease by this mode of examining the body.
My information upon this subject was derived from the attendants upon the sick, and from the two African citizens who were employed in burying the dead, viz. Richard Allen and Absalom Jones. The coincidence of the information received from different persons satisfied me that all that I shall here relate is both accurate and just.
A deep yellow colour appeared in many cases within a few minutes after death. In some the skin became purple, and in others black. I heard of one case in which the body was yellow above, and black below its middle. In some the skin was as pale as it is in persons who die of common fevers. A placid countenance was observed in many, resembling that which occurs in an easy and healthful sleep.
Some were stiff within one hour after death. Others were not so for six hours afterwards. This sudden stiffness after death, Dr. Valli informs us, occurred in persons who died of the plague in Smyrna, in the year 1784[53].
Some grew cold soon after death, while others retained a considerable degree of heat for six hours, more especially on their backs.
A stream of tears appeared on the cheeks of a young woman, which seemed to have flowed after her death.
Some putrified in a short time after their dissolution, but others had no smell for twelve, eighteen,and twenty hours afterwards. This absence of smell occurred in those cases in which evacuations had been used without success in the treatment of the disease.
Many discharged large quantities of black matter from the bowels, and others blood from the nose, mouth, and bowels after death. The frequency of these discharges gave rise to the practice of pitching the joints of the coffins which were used to bury the dead.
The morbid appearances of the internal parts of the body, as they appear by dissection after death from the yellow fever, are different in different countries, and in the same countries in different years. I consider them all as effects only of a stimulus acting upon the whole system, and determined more or less by accidental circumstances to particular viscera. Perhaps the stimulus of the miasmata determines the fluids more violently in most cases to the liver, stomach, and bowels, and thereby disposes them more than other parts to inflammation and mortification, and to similar effusions and eruptions with those which take place on the skin. There can be no doubt of the miasmata acting upon the liver, and thereby altering the qualities of the bile. I transcribe, with great pleasure,the following account of the state of the bile in a female slave of forty years of age, from Dr. Mitchell's History of the Yellow Fever, as it prevailed in Virginia, in the years 1737 and 1741, inasmuch as it was part of that clue which led me to adopt one of the remedies on which much of the success of my practice depended.
“The gall bladder (says the doctor) appeared outwardly of a deep yellow, but within was full of a black ropy coagulated atrabilis, which sort of substance obstructed the pori biliarii, and ductus choledochus. This atrabilis was hardly fluid, but upon opening the gall bladder, it retained its form and shape, without being evacuated, being of the consistence of a thin extract, and, within, glutinous and ropy, like soap when boiling. This black matter seemed so much unlike bile, that I doubted if there were any bile in the gall bladder. It more resembled bruised or mortified blood, evacuated from the mortified parts of the liver, surrounding it, although it would stain a knife or probe thrust into it of a yellow colour, which, with its ropy consistence, seemed more peculiar to a bilious humour.”
The same appearance of the bile was discovered in several other subjects dissected by Dr. Mitchell.