CONTENTS OF VOLUME III.
| page | |
| Outlines of a theory of fever | [1] |
| An account of the bilious yellow fever, as it appeared in Philadelphia in 1793 | [67] |
| An account of the bilious yellow fever, as it appeared in Philadelphia in 1794 | [355] |
| An account of sporadic cases of bilious yellow fever, as they appeared in Philadelphia in 1795 and 1796 | [435] |
OUTLINES
OF A
THEORY OF FEVER.
As many of the diseases which are the subjects of these volumes belong to the class of fevers, the following remarks upon their theory are intended to render the principles and language I have adopted, in the history of their causes, symptoms, and cure, intelligible to the reader.
I am aware that this theory will suffer by being published in a detached state from the general view of the proximate cause of disease which I have taught in my lectures upon pathology, as well as from its being deprived of that support which it would receive from being accompanied with an account of the remedies for fever, and the times and manner of exhibiting them, all of which would have served to illustrate and establish the facts and reasonings which are to follow upon this difficult and interesting inquiry.
I shall not attempt to give a definition of fever. It appears in so many different forms, that a just view of it can only be given in a minute detail of all its symptoms and states.
In order to render the theory, which I am about to deliver, more simple and intelligible, it will be necessary to premise a few general propositions.
I. Fevers of all kinds are preceded by general debility. This debility is natural or accidental. The former is the effect of the sanguineous temperament, and exists at all times in many constitutions. The latter is induced,
1. By such preternatural or unusual stimuli, as, after first elevating the excitement of the system above its healthy grade, and thereby wasting a part of its strength, or what Dr. Brown calls excitability, and Darwin sensorial power, afterwards reduces it down to that state which I shall call debility of action. Or,
2. It is induced by such an abstraction of natural stimuli as to reduce the system below its healthy grade of excitement, and thereby to induce what Dr. Brown calls direct debility, but what I shall call debility from abstraction. This general debility is the same, whether brought on by the former or the latter causes. When induced by the latter, the system becomes more excitable than when induced by the former causes, and hence an attack of fever is more frequently invited by it, than by that state of debility which succeeds the application of an undue portion of stimulating powers. To this there is an exception, and that is, when the remote causes of fever act with so much force and rapidity as suddenly to depress the system, without an intermediate elevation of it, and before sufficient time is given to expend any part of its strength or excitability, or to produce the debility of action. The system in this state, is exactly similar to that which arises from a sudden reduction of its healthy excitement, by the abstraction of stimuli. This debility from abstraction, moreover, is upon a footing with the debility from action, when it is of a chronic nature. They both alike expend so much of the quality or substance of excitability, as to leave the system in a state in which irritants are seldom able to excite the commotions of fever, and when they do, it is of a feeble nature, and hence we observe persons who have been long exposed to debilitating causes of both kinds, often escape fevers, while those who are recently debilitated, are affected by them, under the same circumstances of exposure to those causes.
That fevers are preceded by general debility I infer from their causes, all of which act by reducing the excitement of the system, by the abstraction of stimuli, or by their excessive or unusual application. The causes which operate in the former way are,
1. Cold. This is universally acknowledged to be a predisposing cause of fever. That it debilitates, I infer, 1. From the languor which is observed in the inhabitants of cold countries, and from the weakness which is felt in labour or exercise in cold weather. 2. From the effects of experiments, which prove, that cold air and cold water lessen the force and frequency of the pulse.
2. The debilitating passions of fear, grief, and despair.
3. All excessive evacuations, whether by the bowels, blood-vessels, pores, or urinary passages.
4. Famine, or the abstraction of the usual quantity of nourishing food.
The causes which predispose to fever by the excessive or unusual application of stimuli are,
1. Heat. Hence the greater frequency of fevers in warm climates, and in warm weather.
2. Intemperance in eating and drinking.
3. Unusual labour or exercise.
4. Violent emotions, and stimulating passions of the mind.
5. Certain causes which act by over-stretching a part, or the whole of the body, such as lifting heavy weights, external violence acting mechanically in wounding, bruising, or compressing particular parts, extraneous substances acting by their bulk or gravity, burning, and the like[1]. The influence of debility in predisposing to fevers is further evident from their attacking so often in the night, a time when the system is more weak than at any other, in the four and twenty hours.
II. Debility being thus formed in the system, by the causes which have been enumerated, a sudden accumulation of excitability takes place, whereby a predisposition is created to fever. The French writers have lately called this predisposition “vibratility,” by which they mean a liableness in it to be thrown into vibrations or motions, from pre-existing debility. It is not always necessary that a fever should follow this state of predisposition. Many people pass days and weeks under it, without being attacked by a fever, by carefully or accidentally avoiding the application of additional stimuli or irritants to their bodies: but the space between this state of predisposition, when it is recent, and a fever, is a very small one; for, independently of additional stimuli, the common impressions which support life sometimes become irritants, and readily add another link to the chain of causes which induce fever, and that is,
III. Depression of the whole system, or what Dr. Brown calls indirect debility. It manifests itself in weakness of the limbs, inability to stand or walk without pain, or a sense of fatigue, a dry, cool, or cold skin, chilliness, a shrinking of the hands and face, and a weak or quick pulse. These symptoms characterize what I have called in my lectures the forming state of fever. It is not necessary that a paroxysm of fever should follow this depressed state of the system, any more than the debility that has been described. Many people, by rest, or by means of gentle remedies, prevent its formation; but where these are neglected, and the action of stimuli, whether morbid or natural, are continued,
IV. Re-action is induced, and in this re-action, according to its greater or less force and extent, consist the different degrees of fever. It is of an irregular or a convulsive nature. In common cases, it is seated primarily in the blood-vessels, and particularly in the arteries. These pervade every part of the body. They terminate upon its whole surface, in which I include the lungs and alimentary canal, as well as the skin. They are the outposts of the system, in consequence of which they are most exposed to cold, heat, intemperance, and all the other external and internal, remote and exciting causes of fever, and are first roused into resistance by them.
Let it not be thought, from these allusions, that I admit Dr. Cullen's supposed vires naturæ medicatrices to have the least agency in this re-action of the blood-vessels. I believe it to be altogether the effect of their elastic and muscular texture, and that it is as simply mechanical as motion from impressions upon other kinds of matter.
That the blood-vessels possess muscular fibres, and that their irritability or disposition to motion depends upon them, has been demonstrated by Dr. Vasschuer and Mr. John Hunter, by many experiments. It has since been proved by Spallanzani, in an attempt to refute it. Even Dr. Haller, who denies the muscularity and irritability of the blood-vessels, implies an assent to them in the following words: “There are nerves which descend for a long way together through the surface of the artery, and at last vanish in the cellular substance of the vessel, of which we have a specimen in the external and internal carotids, and in the arch of the aorta; and from these do not the arteries seem to derive a muscular and convulsive force very different from that of their simple elasticity? Does not it show itself plainly in fevers, faintings, palsies, consumptions, and passions of the mind[2]?”
The re-action or morbid excitement of the arteries discovers itself in preternatural force, or frequency in their pulsations. In ordinary fever, it is equally diffused throughout the whole sanguiferous system, for the heart and arteries are so intimately connected, that, like the bells of the Jewish high-priest, when one of them is touched, they all vibrate in unison with each other. To this remark there are some exceptions.
1. The arteries are sometimes affected with great morbid excitement, while the natural functions of the heart are unimpaired. This occurs in those states of fever in which patients are able to sit up, and even to walk about, as in pulmonary consumption, and in hectic fever from all its causes.
2. The heart and pulmonary artery are sometimes affected with great morbid excitement, while the pulsations of the arteries on the wrists are perfectly natural.
3. The morbid excitement of the arteries is sometimes greater on one side of the body than on the other. This is obvious in the difference in the number and force of the pulsations in the different arms, and in the different and opposite appearances of the blood drawn from their veins, under equal circumstances.
4. The arteries in the head, lungs, and abdominal viscera are sometimes excited in a high degree, while the arteries in the extremities exhibit marks of a feeble morbid action. Fevers attended with these and other deviations from their common phenomena, have been called by Dr. Alibert, altaxiques. They occur most frequently in malignant fevers.
While morbid excitement thus pervades generally or partially the sanguiferous system, depression and debility are increased in the alimentary canal, and in the nervous and muscular systems. In the stomach, bowels, and muscles, this debility is occasioned by their excitement being abstracted, and translated to the blood-vessels.
I shall now endeavour to illustrate the propositions which have been delivered, by taking notice of the manner in which fevers are produced by some of its most obvious and common causes.
Has the body been debilitated by exposure to the cold air? its excitability is thereby increased, and heat acts upon it with an accumulated force: hence the frequency of catarrhs, pleurisies, and other inflammatory fevers in the spring, after a cold winter; and of bilious remittents in the autumn, when warm days succeed to cold and damp nights. These diseases are seldom felt for the first time in the open air, but generally after the body has been exposed to cold, and afterwards to the heat of a warm room or a warm bed. Mild intermittents have frequently been observed to acquire an inflammatory type in the Pennsylvania hospital, in the months of November and December, from the heat of the stove rooms acting upon bodies previously debilitated and rendered excitable by cold and disease.
Has there been an abstraction of heat by a sudden shifting of the wind from the south-west to the north-west or north-east points of the compass, or by a cold night succeeding to a warm day? a fever is thereby frequently excited. These sources of fever occur every autumn in Philadelphia. The miasmata which exist in the body at that time in a harmless state, are excited into action, in a manner to be mentioned presently, by the debility from cold, aided in the latter case by the inaction of sleep, suddenly induced upon the system.
Again: has the body been suddenly debilitated by labour or exercise? its excitement is thereby diminished, but its excitability is increased in such a manner that a full meal, or an intemperate glass of wine, if taken immediately after the fatigue is induced upon the body, excites a fever: hence the frequency of fevers in persons upon their return from hunting, surveying, long rides, or from a camp life.
But how shall we account for the production of fever from the measles and small-pox, which attack so uniformly, and without predisposing debility from any of its causes which have been enumerated? I answer, that the contagions of those diseases seldom act so as to produce fever, until the system is first depressed. This is obvious from their being preceded by languor, and all the other symptoms formerly mentioned, which constitute the forming state of fever. The miasmata which induce the plague and yellow fever, when they are not preceded by the usual debilitating and predisposing causes, generally induce the same depression of the system, previously to their exciting fever. Even wounds, and other local irritants seldom induce fever before they have first produced the symptoms of depression formerly mentioned. I shall presently mention the exceptions to this mode of producing fever from contagious miasmata and local injuries, and show that they do not militate against the truth of the general proposition that has been delivered.
It may serve still further to throw light upon this part of our subject to take notice of the difference between the action of stimuli upon the body predisposed by debility and excitability to fever, and their action upon it when there is no such predisposition to fever.
In health there is a constant and just proportion between the degrees of excitement and excitability, and the force of stimuli. But this is not the case in a predisposition to a fever. The ratio between the action of stimuli and excitement, and excitability is destroyed; and hence the former act upon the latter with a force which produces irregular action, or a convulsion in the arterial system. When the body is debilitated, and its excitability increased, either by fear, darkness, or silence, a sudden noise occasions a short convulsion. We awake, in like manner, in a light convulsion, from the sudden opening of a door, or from the sprinkling of a few drops of water in the face, after the excitability of the system has been accumulated by a night's sleep. In a word, it seems to be a law of the system, that stimulus, in an over-proportion to excitability, either produces convulsion, or goes so far beyond it, as to destroy motion altogether in death.
V. There is but one exciting cause of fever, and that is stimulus. Heat, alternating with cold[3], marsh and human miasmata, contagions and poisons of all kinds, intemperance, passions of the mind, bruises, burns, and the like, all act by a stimulating power only, in producing fever. This proposition is of great application, inasmuch as it cuts the sinews of the division of diseases from their remote causes. Thus it establishes the sameness of a pleurisy, whether it be excited by heat succeeding cold, or by the contagions of the small-pox and measles, or by the miasmata of the yellow fever.
To this proposition there is a seeming objection. Cold, sleep, immoderate evacuations, and the debilitating passions of grief and fear (all of which abstract excitement) appear to induce fever without the interposition of a stimulus. In all these cases, the sudden abstraction of excitement destroys the equilibrium of the system, by which means the blood is diverted from its natural channels, and by acting with preternatural force in its new directions, becomes an irritant to the blood-vessels, and thus a stimulating and exciting cause of fever. When it is induced by cold alone, it is probable so much of the perspirable matter may be retained as to co-operate, by its irritating qualities, in exciting the fever.
VI. There is but one fever. However different the predisposing, remote, or exciting causes of fever may be, whether debility from abstraction or action, whether heat or cold succeeding to each other, whether marsh or human miasmata, whether intemperance, a fright, or a fall, still I repeat, there can be but one fever. I found this proposition upon all the supposed variety of fevers having but one proximate cause. Thus fire is a unit, whether it be produced by friction, percussion, electricity, fermentation, or by a piece of wood or coal in a state of inflammation.
VII. All ordinary fever being seated in the blood-vessels, it follows, of course, that all those local affections we call pleurisy, angina, phrenitis, internal dropsy of the brain, pulmonary consumption, and inflammation of the liver, stomach, bowels, and limbs, are symptoms only of an original and primary disease in the sanguiferous system. The truth of this proposition is obvious from the above local affections succeeding primary fever, and from their alternating so frequently with each other. I except from this remark those cases of primary affections of the viscera which are produced by local injuries, and which, after a while, bring the whole sanguiferous system into sympathy. These cases are uncommon, amounting, probably, to not more than one in a hundred of all the cases of local affection which occur in general fever.
In my 4th proposition I have called the action of the arteries irregular in fever, to distinguish it from that excess of action which takes place after violent exercise, and from that quickness which accompanies fear or any other directly debilitating cause. The action of the arteries here is regular, and, when felt in the pulse, affords a very different sensation from that jerking which we feel in the pulse of a patient labouring under a fever.
This irregular action is, in other words, a convulsion in the sanguiferous, but more obviously, in the arterial system.
That this is the case I infer from the strict analogy between symptoms of fever, and convulsions in the nervous system. I shall briefly mention the particulars in which this analogy takes place.
1. Are convulsions in the nervous system preceded by debility? So is the convulsion of the blood-vessels in fever.
2. Does debility induced on the whole, or on a part only, of the nervous system, predispose to general convulsions, as in tetanus? So we observe debility, whether it be induced on the whole or on a part of the arterial system, predisposes to general fever. This is obvious in the fever which ensues alike from cold applied to every part of the body, or from a stream of cold air falling upon the neck, or from the wetting of the feet.
3. Do tremors precede convulsions in the nervous system? So they do the convulsion of the blood-vessels in fever.
4. Is a coldness in the extremities a precursor of convulsions in the nervous system? So it is of fever.
5. Do convulsions in the nervous system impart a jerking sensation to the fingers? So does the convulsion of fever in the arteries, when felt at the wrists.
6. Are convulsions in the nervous system attended with alternate action and remission? So is the convulsion of fever.
7. Do convulsions in the nervous system return at regular and irregular periods? So does fever.
8. Do convulsions in the nervous system, under certain circumstances, affect the functions of the brain? So do certain states of fever.
9. Are there certain convulsions in the nervous system which affect the limbs, without affecting the functions of the brain, such as tetanus, and chorea sancti viti? So there are certain fevers, particularly the common hectic, which seldom produces delirium, or even head-ach, and frequently does not confine a patient to his bed.
10. Are there local convulsions in the nervous system, as in the hands, feet, neck, and eye-lids? So there are local fevers. Intermittents often appear in the autumn with periodical heat and pains in the eyes, ears, jaws, and back.
11. Are there certain grades in the convulsions of the nervous system, as appears in the hydrophobia, tetanus, epilepsy, hysteria, and hypochondriasis? So there are grades in fevers, as in the plague, yellow fever, small-pox, rheumatism, and common remitting and intermitting fevers.
12. Are nervous convulsions most apt to occur in infancy? So are fevers.
13. Are persons once affected with nervous convulsions frequently subject to them through life? So are persons once affected with fever. The intermitting fever often returns with successive springs or autumns, and, in spite of the bark, sometimes continues for many years in all climates and seasons.
14. Is the strength of the nervous system increased by convulsions? This is so evident that it often requires four or five persons to confine a delicate woman to her bed in a convulsive fit. In like manner the strength of the arterial system is increased in a fever. This strength is great in proportion to the weakness of every other part of the body.
15. Do we observe certain nervous convulsions to affect some parts of the nervous system more than others, or, in other words, do we observe preternatural strength or excitement to exist in one part of the nervous system, while other parts of the same system exhibit marks of preternatural weakness or defect of excitement? We observe the same thing in the blood-vessels in a fever. The pulse at the wrist is often tense, while the force of the heart is very much diminished. A delirium often occurs in a fever from excess of excitement in the blood-vessels of the brain, while the pulse at the wrist exhibits every mark of preternatural weakness.
16. Is there a rigidity of the muscles in certain nervous diseases, as in catalepsy? Something like this solstice in convulsion occurs in that state of fever in which the pulse beats but sixty, or fewer strokes in a minute.
17. Do convulsions go off gradually from the nervous system, as in tetanus, and chorea sancti viti? So they do from the arterial blood-vessels in certain states of fever.
18. Do convulsions go off suddenly in any cases from the nervous system? The convulsion in the blood-vessels goes off in the same manner by a sweat, or by a hæmorrhage, frequently in the course of a night, and sometimes in a single hour.
19. Does palsy in some instances succeed to convulsions in the nervous system? Something like a palsy occurs in fevers of great inflammatory action in the arteries. They are often inactive in the wrists, and in other parts of the body, from the immense pressure of the remote cause of the fever upon them.
From the facts and analogies which have been mentioned, I have been led to conclude that the common forms of fever are occasioned simply by irregular action, or convulsion in the blood-vessels.
The history of the phenomena of fever, as delivered in the foregoing pages, resolves itself into a chain, consisting of the five following links.
1. Debility from action, or the abstraction of stimuli. When this debility is induced by action, it is sometimes preceded by elevated excitement in the blood-vessels, from the first impressions of stimuli upon them.
2. An increase of their excitability.
3. Stimulating powers applied to them.
4. Depression. And,
5. Irregular action or convulsion.
The whole of the links of this chain are perceptible only when the fever comes on in a gradual manner. But I wish the reader to remember, that the same remote cause is often debilitating, stimulating, and depressing, and that, in certain fevers, the remote cause sometimes excites convulsions in the blood-vessels without being preceded by preternatural debility and excitability, and with but little or no depression of the system. This has often been observed in persons who have been suddenly exposed to those marsh and human miasmata which produce malignant fevers. It sometimes takes place likewise in fevers induced by local injuries. The blood-vessels in these cases are, as it were, taken by storm, instead of regular approaches.
I might digress here, and show that all diseases, whether they be seated in the arteries, muscles, nerves, brain, or alimentary canal, are all preceded by debility; and that their essence consists in irregular action, or in the absence of the natural order of motion, produced or invited by predisposing debility. I might further show, that all the moral, as well as physical evil of the world consists in predisposing weakness, and in subsequent derangement of action or motion; but these collateral subjects are foreign to our present inquiry.
Let us now proceed to examine how far the theory which has been delivered accords with the phenomena of fever.
I shall divide these phenomena into two kinds.
I. Such as are transient, and more or less common to all fevers. These I shall call symptoms of fever.
II. Such as, being more permanent and fixed, have given rise to certain specific names. These I shall call states of fever.
I shall endeavour to explain and describe each of them in the order in which they have been mentioned.
I. Lassitude is the effect of the depression of the whole system, which precedes fever.
The same cause, when it acts upon the extremities of the blood-vessels, produces coldness and chills. This is obvious to any person, under the first impression of the miasmata which bring on fevers, also under the influence of fatigue, and debilitating passions of the mind. The absence of chills indicates the sensibility of the external parts of the body to be suspended or destroyed, as well as their irritability; hence when death occurs in the fit of an intermittent, there is no chill. A chilly fit, for the same reason, seldom occurs in the most malignant cases of fever. It is sometimes excited by blood-letting, only because it weakens those fevers to such a degree, as to carry the blood-vessels back to the grade of depression. Coldness and chills are likewise removed by blood-letting, only because it enables the arteries to re-act in such a manner as to overcome the depression that induced it. It has been remarked, that the chilly fit, in common fevers, seldom appears in its full force until the patient approaches a fire, or lies down on a warm bed; for in these situations sensibility is restored by the stimulus of the heat acting upon the extremities of the blood-vessels. The first impressions of the rays of the sun, in like manner, often produce coldness and chills in the torpid bodies of old and weakly people.
Tremors are the natural consequence of the abstraction of that support which the muscles receive from the fulness and tension of the blood-vessels. It is from this retreat of the blood towards the viscera, that the capillary arteries lose their fulness and tension; hence they contract like other soft tubes that are emptied of their contents. This contraction has been called a spasm, and has improperly been supposed to be the proximate cause of fever. From the explanation that has been given of its cause, it appears, like the coldness and chills, to be nothing but an accidental concomitant, or effect of a paroxysm of fever.
The local pains in the head, breast, and bones in fever, appear to be the effects of the irregular determination of the blood to those parts, and to morbid action being thereby induced in them.
The want of appetite and costiveness are the consequences of a defect of secretion of the gastric juice, and the abstraction of excitement or natural action from the stomach and bowels.
The inability to rise out of bed, and to walk, is the effect of the abstraction of excitement from the muscles of the lower limbs.
The dry skin or partial sweats appear to depend upon diminished or partial action in the vessels which terminate on the surface of the body.
The high-coloured and pale urine are occasioned by an excess or a deficiency of excitement in the secretory vessels of the kidneys.
The suppression of the urine seems to arise from what Dr. Clark calls an engorgement, or choaking of the vessels of the kidneys. It occurs most frequently in malignant fevers.
Thirst is probably the effect of a preternatural excitement of the vessels of the fauces. It is by no means a uniform symptom of fever. We sometimes observe it, in the highest degree, in the last stage of diseases, induced by the retreat of the last remains of excitement from every part of the body, to the throat.
The white tongue is produced by a change in the secretion which takes place in that organ. Its yellow colour is the effect of bile; its dryness is occasioned by an obstruction of secretion, or by the want of action in the absorbents; and its dark and black colour, by a tendency to mortification.
It will be difficult to account for the variety in the degrees and locality of heat in the body in a fever, until we know more of the cause of animal heat. From whatever cause it be derived, its excess and deficiency, as well as all its intermediate degrees, are intimately connected with more or less excitement in the arterial system. It is not necessary that this excitement should exist only in the large blood-vessels. It will be sufficient for the purpose of creating great heat, if it occur only in the cutaneous vessels; hence we find a hot skin in some cases of malignant fever in which there is an absence of pulse.
Eruptions seem to depend upon effusions of serum, lymph, or red blood upon the skin, with or without inflammation, in the cutaneous vessels.
I decline taking notice in this place of the symptoms which are produced by the debility from action and abstraction, and by the depression of the system. They appear not only in the temperature of the body, but in all the different symptoms of fever. It is of importance to know when they originate from the former, and when from the latter causes, as they sometimes require very different and opposite remedies to remove them.
It remains only to explain the cause why excess in the force or frequency of the action of the blood-vessels should succeed debility in a part, or in the whole of the body, and be connected for days and weeks with depression and preternatural debility in the nerves, brain, muscles, and alimentary canal. I shall attempt the explanation of this phenomenon by directing the attention of the reader to the operations of nature in other parts of her works.
1. A calm may be considered as a state of debility in the atmosphere. It predisposes to a current of air. But is this current proportioned to the loss of the equilibrium of the air? By no means. It is excessive in its force, and tends thereby to destroy the works both of nature and art.
2. The passions are given to man on purpose to aid the slow and uncertain operations of reason. But is their action always proportioned to the causes which excite them? An acute pneumony, brought on by the trifling injury done to the system by the fatigue and heat of an evening spent in a dancing assembly, is but a faint representation of the immense disproportion between a trifling affront, and that excess of passion which seeks for gratification in poison, assassination, or a duel. The same disproportion appears between cause and effect in public bodies. A hasty word, of no mischievous influence, has often produced convulsions, and even revolutions, in states and empires.
If we return to the human body we shall find in it many other instances of the disproportion between stimulus and action, besides that which takes place in the excitement of fever.
3. A single castor oil nut, although rejected by the stomach upon its first effort in vomiting, has, in one instance that came within my knowledge, produced a vomiting that continued nearly four and twenty hours. Here the duration of action was far beyond all kind of proportion to the cause which excited it.
4. A grain of sand, after being washed from the eye, is often followed by such an inflammation or excess in the action of the vessels of the eye, as to require bleeding, purging, and blistering to remove it.
Could we comprehend every part of the sublime and ineffable system of the divine government, I am sure we should discover nothing in it but what tended ultimately to order. But the natural, moral, and political world exhibit every where marks of disorder, and the instruments of this disorder, are the operations of nature. Her influence is most obvious in the production of diseases, and in her hurtful or ineffectual efforts to remove them[4]. In again glancing at this subject I wish it to be remembered that those operations were not originally the means of injuring or seducing man, and that I believe a time will come when the exact relation, between cause and effect, or, in other words, the dominion of order shall be restored over every action of his body and mind, and health and happiness again be the result of every movement of nature.
From the view I have given of the state of the blood-vessels in fever, the reader will perceive the difference between my opinions and Dr. Brown's upon this subject. The doctor supposes a fever to consist in debility. I do not admit debility to be a disease, but place it wholly in morbid excitement, invited and fixed by previous debility. He makes a fever to consist in a change only of a natural action of the blood-vessels. I maintain that it consists in a preternatural and convulsive action of the blood-vessels. Lastly, Dr. Brown supposes excitement and excitability to be equally diffused over the whole body, but in unhealthy proportions to each other. My theory places fever in excitement and excitability unequally diffused, manifesting themselves, at the same time, in morbid actions, depression, and debility from abstraction, in different parts of the body. No new excitement from without is infused into the system by the irritants which excite a fever. They only destroy its equal and natural distribution; for while the arteries are in a plus, the muscles, stomach, and bowels are in a minus state of excitement, and the business of medicine is to equalize it in the cure of fever, that is, to abstract its excess from the blood-vessels, and to restore it to the other parts of the body.
II. I come now to apply the theory which I have delivered to the explanation and description of the different phenomena or states of fever.
I have said in my sixth proposition that there is but one fever. Of course I do not admit of its artificial division into genera and species. A disease which so frequently changes its form and place, should never have been designated, like plants and animals, by unchangeable characters. The oak tree and the lion possess exactly the same properties which they did nearly 6000 years ago. But who can say the same thing of any one disease? The pulmonary consumption is sometimes transformed into head-ach, rheumatism, diarrhœa, and mania, in the course of two or three months, or the same number of weeks. The bilious fever often appears in the same person in the form of colic, dysentery, inflammation of the liver, lungs, and brain, in the course of five or six days. The hypochondriasis and the hysteria seldom fail to exchange their symptoms twice in the four and twenty hours. Again: the oak tree has not united with any of the trees of the forest, nor has the lion imparted his specific qualities to any other animal. But who can apply similar remarks to any one disease? Phrenitis, gastritis, enteritis, nephritis, and rheumatism all appear at the same time in the gout and yellow fever. Many observations of the same kind might be made, to show the disposition of nearly all other diseases to anastomose with each other. To describe them therefore by any fixed or specific characters is as impracticable as to measure the dimensions of a cloud on a windy day, or to fix the component parts of water by weighing it in a hydrostatic balance. Much mischief has been done by nosological arrangements of diseases. They erect imaginary boundaries between things which are of a homogeneous nature. They degrade the human understanding, by substituting simple perceptions to its more dignified operations in judgment and reasoning. They gratify indolence in a physician, by fixing his attention upon the name of a disease, and thereby leading him to neglect the varying state of the system. They moreover lay a foundation for disputes among physicians, by diverting their attention from the simple, predisposing, and proximate, to the numerous, remote, and exciting causes of diseases, or to their more numerous and complicated effects. The whole materia medica is infected with the baneful consequences of the nomenclature of diseases, for every article in it is pointed only against their names, and hence the origin of the numerous contradictions among authors who describe the virtues and doses of the same medicines. By the rejection of the artificial arrangement of diseases, a revolution must follow in medicine. Observation and judgment will take the place of reading and memory, and prescriptions will be conformed to existing circumstances. The road to knowledge in medicine by this means will likewise be shortened; so that a young man will be able to qualify himself to practise physic at as much less expence of time and labour than formerly, as a child would learn to read and write by the help of the Roman alphabet, instead of Chinese characters.
In thus rejecting the nosologies of the schools, I do not wish to see them banished from the libraries of physicians. When consulted as histories of the effects of diseases only, they may still be useful. I use the term diseases, in conformity to custom, for, properly speaking, disease is much a unit as fever. It consists simply of morbid action or excitement in some part of the body. Its different seats and degrees should no more be multiplied into different diseases, than the numerous and different effects of heat and light upon our globe should be multiplied into a plurality of suns.
The advocates for Dr. Cullen's system of medicine will not, I hope, be offended by these observations. His immense stock of reputation will enable him to sustain the loss of his nosology without being impoverished by it. In my attempts to introduce a new arrangement of fevers, I shall only give a new direction to his efforts to improve the healing art.
Were it compatible with the subject of the present inquiry, it would be easy to show, that the same difficulties and evils are to be expected from Dr. Darwin's division of diseases, as they affect the organs of sensation and motion, and as they are said to be exclusively related by association and volition, that have been deprecated from their divisions and subdivisions by the nosologists. Diseases, like vices, with a few exceptions, are necessarily undisciplined and irregular. Even the genius of Dr. Darwin has not been able to compel them to move within lines.
I return from this digression to remark that morbid action in the blood-vessels, whether it consist in preternatural force and frequency, or preternatural force without frequency, or frequency without force, constitutes fever. Excess in the force and frequency in the pulsations of the arteries have been considered as the characteristic marks of what is called inflammatory fever. There are, however, symptoms which indicate a much greater excess of irritating impressions upon the blood-vessels. These are preternatural slowness, intermissions, and depression in the pulse, such as occur in certain malignant fevers.
But there is a grade of fever, which transcends in force that which produces inflammation. It occurs frequently in hydrophobia, dysentery, colic, and, baron Humboldt lately informed me, upon the authority of Dr. Comoto, of Vera Cruz, in the yellow fever of that city, when it proves fatal in a few hours after it attacks. In vain have physicians sought to discover, by dissections, the cause of fever in those cases, when followed by death, in the parts of the body in which it was supposed, from pain and other symptoms, to be principally seated. Those parts have frequently exhibited no marks of inflammation, nor of the least deviation from a healthy state. I have ascribed this apparent absence of disease to the serous vessels being too highly excited, and thereby too much contracted, to admit the entrance of red blood into them. I wish these remarks to be remembered by the student of medicine. They have delivered me from the influence of several errors in pathology; and they are capable, if properly extended and applied, of leading to many important deductions in the practice of physic.
I shall now briefly mention the usual effects of fever, or morbid excitement in the blood-vessels, when not removed by medicine. They are,
1. Inflammation. It is produced by an effusion of red particles of blood into serous vessels, constituting what Dr. Boerhaave calls error loci. It is the second grade of fever, and, in fevers of great violence, does not take place until morbid excitement has continued for some time, or has been reduced by bleeding.
2. Secretion, or an effusion from rupture, of the serum of the blood, constituting dropsies.
3. Secretion of lymph or fibrin, forming a membrane which adheres to certain surfaces in the body.
4. Secretion of pus, also of sloughs.
5. An effusion by rupture, or a congestion of all the component parts of the blood.
6. Gangrene from the death of the blood-vessels.
7. Rupture of blood-vessels, producing hæmorrhage.
8. Redness, phlegmon, pustules, and petechiæ on the skin, and tubercles in the lungs, and on the liver and bowels.
9. Schirrus.
10. Calcareous and other earthy matters. Both these take place only in the feeble and often imperceptible grades of morbid action in the blood-vessels.
11. Death. This arises from the following causes.
1. Sudden destruction of the excitability of the blood-vessels.
2. A disorganization of parts immediately necessary to life.
3. A change in the fluids, so as to render them destructive to what are called the vital organs.
4. Debility, from the exhausted or suspended state of the excitability of the blood-vessels.
All these effects of fever are different according to its grade. Dr. Blane says fevers are rarely inflammatory in the West-Indies; that is, they pass rapidly from simple morbid excitement to congestion, hæmorrhage, gangrene, and death. This remark is confirmed by Dr. Dalzelle, who says the pneumony in the negroes, in the French West-India islands, rarely appears in any other form than that of the notha, from the arteries in the lungs being too much stimulated to produce common inflammation; but such is the force of morbid excitement in hot climates, that it sometimes passes suddenly over all its intermediate effects, and discovers itself only in death. This appears to have taken place in the cases at Vera Cruz, mentioned by baron Humboldt.
All the different states of fever may be divided,
I. Into such as affect the whole arterial system; but with no, or very little local disease.
II. Into such as affect the whole arterial system, and are accompanied at the same time with evident local disease.
III. Into such as appear to pass by the arterial system, and to fix themselves upon other parts of the body. I shall call these states of fever misplaced.
I. To the first class of the states of fever belong,
1. The malignant. It constitutes the highest grade of morbid diathesis. It is known by attacking frequently without a chilly fit, by coma, a depressed, slow, or intermitting pulse, and sometimes by the absence of pain, and with a natural temperature or coldness of the skin. It occurs in the plague, in the yellow fever, in the gout, in the small-pox and measles, in the hydrophobia, and after taking opium and other stimulating substances. Dr. Quier has described a pleurisy in Jamaica, in which some of those malignant symptoms took place. They are the effect of such a degree of impression as to prostrate the arterial system, and to produce a defect of action from an excess of force. Such is this excess of force, in some instances, in this state of fever, that it induces general convulsions, tetanus, and palsy, and sometimes extinguishes life in a few hours, by means of apoplexy or syncope. From its being accompanied with these symptoms, it has received the name of adynamique by Dr. Alibert. The less violent degrees of stimulus in this state of fever produce palsy in the blood-vessels. It probably begins in the veins, and extends gradually to the arteries. It seems further to begin in the extremities of the arteries, and to extend by degrees to their origin in the heart. This is evident in the total absence of pulse which sometimes takes place in malignant fevers, four and twenty, and even eight and forty hours before death. But there are cases in which this palsy affects both the veins and arteries at the same time. It is probably from this simultaneous affection of the blood-vessels, that the arteries are found to be nearly full of blood after death from malignant fevers. The depressed, and intermitting pulse which occurs in the beginning of these fevers perhaps depends upon a tendency to palsy in the arteries, independently of an affection of the heart or brain.
This prostrate state of fever more frequently when left to itself terminates in petechiæ, buboes, carbuncles, abscesses, and mortifications, according as serum, lymph, or red blood is effused in the viscera or external parts of the body. These morbid appearances have been ascribed to putrefaction, and the fever has received, from its supposed presence, the name of putrid. The existence of putrefaction in the blood in a fever is rendered improbable,
1. By Dr. Seybert's experiments[5], which prove that it does not take place in the blood in a living state. It occurs in the excretions of bile, fæces, and urine, but in this case it does not act as a ferment, but a stimulus only upon the living body.
2. By similar appearances, with those which have been ascribed to putrefaction, having been produced by lightning, by violent emotions of the mind, by extreme pain, and by every thing else which induces sudden and universal disorganization in the fluids and solids of the body. The following facts clearly prove that the symptoms which have been supposed to designate a putrid fever, are wholly the effect of mechanical action in the blood-vessels, and are unconnected with the introduction of a putrid ferment in the blood.
Hippocrates relates the case of a certain Antiphillus, in whom a putrid bilious fever (as he calls it) was brought on by the application of a caustic to a wound[6].
An acute pain in the eye, Dr. Physick informed me, produced the symptoms of what is called a putrid fever, which terminated in death in five days, in St. George's hospital, in the year 1789.
Dr. Baynard relates, upon the authority of a colonel Bampfield, that a stag, which he had chased for some time, stopped at a brook of water in order to drink. Soon afterwards it fell and expired. The colonel cut its throat, and was surprised to perceive the blood which issued from it had a putrid and offensive smell[7].
Dr. Desportes takes notice that a fish, which he calls a sucker, affected the system nearly in the same manner as the miasmata of the yellow fever. A distressing vomiting, a coldness of the extremities, and an absence of pulse, were some of the symptoms produced by it, and an inflammation and mortification of the stomach and bowels, were discovered after death to be the effects of its violent operation.
Even opium, in large doses, sometimes produces by its powerful stimulus the same symptoms which are produced by the stimulus of marsh miasmata. These symptoms are a slow pulse, coma, a vomiting, cold sweats, a sallow colour of the face, and a suppression of the discharges by the urinary passages and bowels.
Error is often perpetuated by words. A belief in the putrefaction of the blood has done great mischief in medicine. The evil is kept up, under the influence of new theories, by the epithet putrid, which is still applied to fever in all our medical books. For which reason I shall reject it altogether hereafter, and substitute in its room.
2. The gangrenous state of fever; for what appear to some physicians to be signs of putrefaction, are nothing but the issue of a violent inflammation left in the hands of nature, or accelerated by stimulating medicines. Thus the sun, when viewed at mid-day, appears to the naked eye, from the excess of its splendour, to be a mass of darkness, instead of an orb of light.
The same explanation of what are called putrid symptoms in fever, is very happily delivered by Mr. Hunter in the following words: “It is to be observed (says this acute physiologist) that when the attack upon these organs, which are principally connected with life, proves fatal, that the effects of the inflammation upon the constitution run through all the stages with more rapidity than when it happens in other parts; so that at its very beginning, it has the same effect upon the constitution which is only produced by the second stage of inflammation in other parts[8].”
3. The synocha, or the common inflammatory state of fever, attacks suddenly with chills, and is succeeded by a quick, frequent, and tense pulse, great heat, thirst, and pains in the bones, joints, breast, or sides. These symptoms sometimes occur in the plague, the jail and yellow fever, and the small-pox; but they are the more common characteristics of pleurisy, gout, and rheumatism. They now and then occur in the influenza, the measles, and the puerperile fever.
4. The synochus state of fever is known by a full, quick, and round pulse without tension. The autumnal bilious fever and colic, also the gout, often appear in this form.
5. There is a state of fever in which the pulse is small, but tense and quick. The patient, in this state of fever, is seldom confined to his bed. We observe it sometimes in the chronic rheumatism, and in pulmonary consumption. The inflammatory state of this grade of fever is proved from the inefficacy of the volatile tincture of guaiacum and other stimulants to remove it, and from its yielding so suddenly to blood-letting. I have called it the synochula state of fever.
6. There is a state of fever inclining more to the synocha, than what is called the typhus, or low chronic state of fever. I have called it the synochoid state of fever.
7. The typhus state of fever is generally preceded by all those circumstances which debilitate the system, both by the action and abstraction of stimuli. It is known by a weak and frequent pulse, a disposition to sleep, a torpor of the alimentary canal, tremors of the hands, a dry tongue, and, in some instances, by a diarrhœa. These symptoms occur most frequently in what is called the jail, the ship, and the hospital fever. I heard of it in a few cases in the yellow fever of 1793, and all writers take notice of cases of the plague, which run on into a slow fever that continues 30 or 40 days. I have seen it succeed the common bilious fever, pleurisy, and influenza. It has been confounded with the malignant state of fever, or what is called the typhus gravior; but it differs widely from it in being accompanied by a feeble excitement in the blood-vessels, from a feeble stimulus, and by the usual signs of debility from abstraction in every other part of the body.
From the accession of new stimuli, or an increase in the force of former ones, this typhus state of fever sometimes assumes, on the 11th, 14th, and even 20th days, the symptoms of the synocha state of fever. It will be useful to remember this remark, not only because it establishes the unity of fever, but because it will justify the use of a remedy, seldom prescribed after the disease has acquired that name which associates it with stimulating medicines.
The common name of this state of fever, is the nervous fever. This name is improper; for it invades the nervous system by pain, delirium, and convulsions much less than several other states of fever. To prevent the absurd and often fatal association of ideas upon the treatment of this state of fever, I have called it, from its duration, the low chronic state of fever. I have adopted the term low, from Dr. Butter's account of the remitting fever of children, in order to distinguish it from states of fever to be mentioned hereafter, in which the patient is not confined to his bed. This new name of the typhus or nervous fever establishes its analogy with several other diseases. We have the acute and the chronic rheumatism; the acute and chronic pneumony, commonly called the pleurisy and pulmonary consumption; the acute and chronic inflammation of the brain, known unfortunately by the unrelated names of phrenitis, madness, and internal dropsy of the brain. Why should we hesitate, in like manner, in admitting acute and chronic fever, in all those cases where no local inflammation attends?
8. The typhoid state of fever is composed of the synocha and low chronic states of fever. It is the slow nervous fever of Dr. Butter. The excitement of the blood-vessels is somewhat greater than in the low chronic state of fever. Perhaps the muscular fibres of the blood-vessels, in this state of fever, are affected by different degrees of stimulus and excitement. Supposing a pulse to consist of eight cords, I think I have frequently felt more or less of them tense or relaxed, according as the fever partook more or less of the synocha, or low chronic states of fever. This state of fever occurs most frequently in what are called the hectic and puerperal fevers, and in the scarlatina.
9. The hectic state of fever differs from all the other states of fever, by the want of regularity in its paroxysms, in which chills, fevers, and sweats are included; and by the brain, nerves, muscles, and alimentary canal being but little impaired in their functions by it. It appears to be an exclusive disease of the blood-vessels. It occurs in the pulmonary consumption, in some cases of lues, of scrophula, and of the gout, and after most of the states of fever which have been described. The force of the pulse is various, being occasionally synochoid, typhoid, and typhus.
10. Intermissions, or the intermitting and remitting states of fever, are common to all the states of fever which have been mentioned. But they occur most distinctly and universally in those which partake of the bilious diathesis. They have been ascribed to the reproduction of bile, to the recurrence of debility, and to the influence of the heavenly bodies upon the system. None of these hypotheses has explained the recurrence of fever, where the bile has not been in fault, where debility is uniform, and where the paroxysms of fever do not accord with the revolutions of any part of the solar system. I have endeavoured to account for the recurrence of the paroxysm of fever, in common with all other periodical diseases, by means of a natural or adventitious association of motions. Dr. Percival has glanced at this law of animal matter; and Dr. Darwin has explained by it, in the most ingenious manner, many natural and morbid actions in the human body.
11. There is a state of fever in which the morbid action of the blood-vessels is so feeble as scarcely to be perceptible. Like the hectic state of fever, it seldom affects the brain, nerves, muscles, or alimentary canal. It is known in the southern states of America by the name of inward fevers. The English physicians formerly described it by the name of febricula.
These eleven states of fever may be considered as primary in their nature. All the states which remain to be enumerated belong to some one of them, or they are compounds of two, three, or more of them. Even these primary states of fever seldom appear in the simple form in which they have been described. They often blend their symptoms; and sometimes all the states appear at different times in the course of a fever. This departure from a uniformity in the character of fevers must be sought for in the changes of the weather, in the casual application of fresh irritants, or in the operation of the remedies which have been employed to cure them.
To the first class of the states of fever belong the sweating, the fainting, the burning, and the cold and chilly states of fever.
12. The sweating state of fever occurs in the plague, in the yellow fever, in the small-pox, the pleurisy, the rheumatism, and in the hectic and intermitting states of fever. Profuse sweats appeared every other day in the autumnal fever of 1795 in Philadelphia, without any other symptom of an intermittent. The English sweating sickness was nothing but a symptom of the plague. The sweats in all these cases are the effects of morbid and excessive action, concentrated in the capillary vessels.
13. The fainting state of fever accompanies the plague, the yellow fever, the small-pox, and some states of pleurisy. It is the effect of great depression; hence it occurs most frequently in the beginning of those states of fever.
14. The burning state of fever has given rise to what has been called a species of fever. It is the causus of authors. Dr. Mosely, who rejects the epithet of yellow, when applied to the bilious fever, because it is only one of its accidental symptoms, very improperly distinguishes the same fever by another symptom, viz. the burning heat of the skin, and which is not more universal than the yellowness which attends it.
15. The cold and chilly state of fever differs from a common chilly fit, by continuing four or five days, and to such a degree, that the patient frequently cannot bear his arms out of the bed. The coldness is most obstinate in the hands and feet. A coolness only of the skin attends in some cases, which is frequently mistaken for an absence of fever.
Having mentioned those states of fever which affect the arterial system without any, or with but little local disease, I proceed next to enumerate those states of fever which belong to the
II. Class of the order that was mentioned, in which there are local affections combined with general fever. They are,
16. The intestinal state of fever. I have been anticipated in giving this epithet to fever, by Dr. Balfour[9]. It includes the cholera morbus, diarrhœa, dysentery, and colic. The remitting bilious fever appears, in all the above forms, in the summer months. They all belong to the febris introversa of Dr. Sydenham. The jail fever appears likewise frequently in the form of diarrhœa and dysentery. The dysentery is the offspring of marsh and human miasmata, but it is often induced in a weak state of the bowels, by other exciting causes. The colic occasionally occurs with states of fever to be mentioned hereafter.
17. The pulmonary state of fever includes the true and bastard pneumony in their acute forms; also catarrh from cold and influenza, and the chronic form of pneumony in what is called pulmonary consumption.
18. The eruptive state of fever includes the small-pox, measles, erysipelas, miliary fever, chicken-pox, and pemphigus.
19. The anginose state of fever includes all those affections of the throat which are known by the names of cynanche inflammatoria, tonsillaris, parotidea, maligna, scarlatina, and trachealis. The cynanche trachealis is a febrile disease. The membrane which produces suffocation and death in the wind-pipe is the effect of inflammation. It is said to be formed, like other membranes which succeed inflammation, from the coagulable lymph of the blood.
20. The rheumatic state of fever is confined chiefly to the labouring part of mankind. The topical affection is seated most commonly in the joints and muscles, which, from being exercised more than other parts of the body, become more debilitated, and are, in consequence thereof, excited into morbid and inflammatory action.
21. The arthritic or gouty state of fever differs from the rheumatic, in affecting, with the joints and muscles, all the nervous and lymphatic systems, the viscera, and the skin. Its predisposing, exciting, and proximate causes are the same as the rheumatic and other states of fever. It bears the same ratio to rheumatism, which the yellow fever bears to the common bilious fever. It is a fever of more force than rheumatism.
22. The cephalic, in which are included the phrenitic, lethargic, apoplectic, paralytic, hydrocephalic, and maniacal states of fever. That madness is originally a state of fever, I infer, 1. From its causes, many of which are the same as those which induce all the other states of fever. 2. From its symptoms, particularly a full, tense, quick, and sometimes a slow pulse. 3. From the inflammatory appearances of the blood which has been drawn to relieve it. And, 4. From the phenomena exhibited by dissection in the brains of maniacs, being the same as are exhibited by other inflamed viscera after death. These are, effusions of water or blood, abscesses, and schirrus. The hardness in the brains of maniacs, taken notice of by several authors, is nothing but a schirrus (sui generis), induced by the neglect of sufficient evacuations in this state of fever. The reader will perceive by these observations, that I reject madness from its supposed primary seat in the mind or nerves. It is as much an original disease of the blood-vessels, as any other state of fever. It is to phrenitis, what pulmonary consumption is to pneumony. The derangement in the operations of the mind is the effect only of a chronic inflammation of the brain, existing without an abstraction of muscular excitement.
23. The nephritic state of fever is often induced by calculi, but it frequently occurs in the gout, small-pox, and malignant states of fever. There is such an engorgement, or choaking of the vessels of the kidneys, that the secretion of the urine is sometimes totally obstructed, so that the bladder yields no water to the catheter. It is generally accompanied with a full or tense pulse, great pain, sickness, or vomiting, high coloured urine, and a pain along the thigh and leg, with occasionally a retraction of one of the testicles. It exists sometimes without any pain. Of this I met with several instances in the yellow fever of 1793. I include diabetes in this state of fever.
24. The hydropic state of fever, in which are included collections of water, in the lungs, cavity of the thorax, cavity of the abdomen, ovaria, scrotum, testicles, and lower extremities, and usually preceded, and generally accompanied with morbid action in the blood-vessels. That dropsy is a state of fever, I have endeavoured to prove in another place[10]. Nineteen dropsies out of twenty appear to be original arterial diseases, and the water, which has been supposed to be their cause, is as much the effect of preternatural and morbid action in the blood-vessels, as pus, gangrene, and schirrus are of previous inflammation. This has been demonstrated, by the late Dr. Cooper, in a man who died of an ascites in the Pennsylvania hospital. Pus and blood, as well as water, were found in the cavity of the abdomen. It is no objection to this theory of dropsy, that we sometimes find water in the cavities of the body after death, without any marks of inflammation in the contiguous blood-vessels. We often find pus, both in the living and dead body, under the same circumstances, where we are sure it was not preceded by any of the obvious marks of inflammation.
25. The hæmorrhagic state of fever, in which are included discharges of blood from the nose, lungs, stomach, liver, bowels, kidneys and bladder, hæmorrhoidal vessels, uterus, and skin. Hæmorrhages have been divided into active and passive. It would be more proper to divide them, like other states of general fever, into hæmorrhages of strong and feeble morbid action. There is seldom an issue of blood from a vessel in which there does not exist preternatural or accumulated excitement. We observe this hæmorrhagic state of fever most frequently in malignant fevers, in pulmonary consumption, in pregnancy, and in that period of life in which the menses cease to be regular.
26. The amenorrhagic state of fever occurs more frequently than is suspected by physicians. A full and quick pulse, head-ach, thirst, and preternatural heat often accompany a chronic obstruction of the menses. The inefficacy, and even hurtful effects, of what are called emenagogue medicines, in this state of the system, without previous depletion, show the propriety of introducing it among the different states of fever.
I have designedly omitted to take notice of other states of general fever accompanied with local disease, because they are most frequently combined with some one or more of those which have been mentioned. They may all be seen in Dr. Cullen's Synopsis, with their supposed respective generic characters, under the class of pyrexiæ, and the order of fevers. We come now in the
III. And last place, to mention the misplaced states of fever. The term is not a new one in medicine. The gout is said to be misplaced, when it passes from the feet to the viscera. The periodical pains in the head, eyes, ears, jaws, hips, and back, which occur in the sickly autumnal months, and which impart no fulness, force, nor frequency to the pulse, are all misplaced fevers. There are, besides these, many other local morbid affections, which are less suspected of belonging to febrile diseases. The nature of these states of fever may easily be understood, by recollecting one of the laws of sensation, that is, that certain impressions, which excite neither sensation nor motion in the part of the body to which they are applied, excite both in another part. Thus worms, which are not felt in the stomach or bowels, often produce a troublesome sensation in the throat, and a stone, which is attended with no pain in the bladder, produces a troublesome itching in the glans penis. In like manner, the irritants which produce fever in ordinary cases pass through the blood-vessels, and convey their usual morbid effects into a remote part of the body which has been prepared to receive them by previous debility. That this is the case, I infer further, from fevers being called back from their misplaced or suffocated situations, by creating an artificial debility in the arteries by the abstraction of blood. This is often done in muscular convulsions, and in several diseases of the brain.
Under this class of fevers are included
27. The chronic hepatic state of fever. The causes, symptoms, and remedies of the liver disease of the East-Indies, as mentioned by Dr. Girdlestone, all prove that it is nothing but a bilious fever translated from the blood-vessels, and absorbed, or suffocated, as it were, in the liver. This view of the chronic hepatitis is important, inasmuch as it leads to the liberal use of all the remedies which cure bilious fever. Gall stones and contusions now and then produce a hepatitis, but under no other circumstances do I believe it ever exists, but as a symptom of general or latent fever.
28. The hæmorrhoids are frequently a local disease, but they are sometimes accompanied with pain, giddiness, chills, and an active pulse. When these symptoms occur, it should be considered as a hæmorrhoidal state of fever.
29. The opthalmia, when it occurs, as it frequently does in sickly seasons, with a quick and tense pulse, and pains diffused over the whole head, may properly be called an opthalmic state of fever.
30. The tooth-ach, and
31. Ear-ach, when they arise from colds, and are attended with great heat, a quick and tense pulse, and pains in the head, are odontalgic and otalgic states of fever.
32. The apthæ, from the pain and fever which attend them, are justly entitled to the name of the apthous state of fever.
33. The symptoms of scrophula, as described by Dr. Hardy, in his treatise on the glandular disease of Barbadoes, clearly prove it to be a misplaced state of fever.
34. The scurvy has lately been proved by Dr. Claiborne, in his inaugural dissertation, published in the year 1797, to arise from so many of the causes, and to possess so many of the symptoms, of the low chronic and petechial states of fever, that I see no impropriety in considering it as a state of fever.
35. The convulsive or spasmodic state of fever. Convulsions, it is well known, often usher in fevers, more especially in children. But the connection between spasmodic affections and fever, in adults, has been less attended to by physicians. The same causes which produced general fever and hepatitis in the East-Indies, in some soldiers, produced locked jaw in others. Several of the symptoms of this disease, as described by Dr. Girdlestone, such as coldness on the surface of the body, cold sweats on the hands and feet, intense thirst, a white tongue, incessant vomitings, and carbuncles, all belong to the malignant state of fever[11]. By means of blood-letting, and the other remedies for the violent state of bilious fever, I have seen the convulsions in this disease translated from the muscles to the blood-vessels, where they immediately produced all the common symptoms of fever.
36. The hysterical and hypochondriacal states of fever. The former is known by a rising in the throat, which is for the most part erroneously ascribed to worms, by pale urine, and by a disposition to shed tears, or to laugh upon trifling occasions. The latter discovers itself by false opinions of the nature and danger of the disease under which the patient labours. Both these states of the nervous system occur frequently in the gout and in the malignant state of fever. It is common to say, in such cases, that patients have a complication of diseases; but this is not true, for the hysterical and hypochondriacal symptoms are nothing but the effects of one remote cause, concentrating its force chiefly upon the nerves and muscles.
37. The cutaneous state of fever. Dr. Sydenham calls a dysentery a “febris introversa.” Eruptions of the skin are often nothing but the reverse of this introverted fever. They are a fever translated to the skin; hence we find them most common in those countries and seasons in which fevers are epidemic. The prickly heat, the rash, and the essere of authors, are all states of misplaced fever. “Agues, fevers, and even pleurisies (says Mr. Townsend, in his Journey through Spain[12]), are said often to terminate in scabies, and this frequently gives place to them, returning, however, when the fever ceases. In adults it takes possession of the hands and arms, with the legs and thighs, covering them with a filthy crust.” Small boils are common among the children in Philadelphia, at the time the cholera infantum makes its appearance. These children always escape the summer epidemic. The elephantiasis described by Dr. Hillary, in his account of the diseases of Barbadoes, is evidently a translation of an intermittent to one of the limbs. It is remarkable, that the leprosy and malignant fevers of all kinds have appeared and declined together in the same ages and countries. But further, petechiæ sometimes appear on the skin without fever. Cases of this kind, with and without hæmorrhages, are taken notice of by Riverius[13], Dr. Duncan, and many other practical writers. They are cotemporary or subsequent to fevers of a malignant complexion. They occur likewise in the scurvy. From some of the predisposing, remote, and exciting causes of this disease, and from its symptoms and remedies, I have suspected it, like the petechiæ mentioned by Riverius, to be originally a fever generated by human miasmata, in a misplaced state. The hæmorrhages which sometimes accompany the scurvy, certainly arise from a morbid state of the blood-vessels. The heat and quick pulse of fever are probably absent, only because the preternatural excitement of the whole sanguiferous system is confined to those extreme or cutaneous vessels which pour forth blood. In like manner the fever of the small-pox deserts the blood-vessels, as soon as a new action begins on the skin. Or perhaps the excitability of the larger blood-vessels may be so far exhausted by the long or forcible impression of the remote and predisposing causes of the scurvy, as to be incapable of undergoing the convulsive action of general fever.
With this I close my inquiry into the cause of fever. It is imperfect from its brevity, as well as from other causes. I commit it to my pupils to be corrected and improved.
“We think our fathers fools, so wise we grow.
Our wiser sons, I hope, will think us so.”
Footnotes:
[1] Cullen's First Lines.
[2] First Lines, sect. 32 of the chapter on arteries.
[3] Perhaps there is no greater enemy to the life of man than cold. Dr. Sydenham ascribes nearly all fevers to it, particularly to leaving off winter clothes too soon, and to exposing the body to cold after it has been heated. These sources of fever, he adds, destroy more than the plague, sword, or famine.—Wallis's edition, vol. I. p. 357.
[4] See the Comparative View of the Diseases of the Indians and of Civilized Nations. Vol. I.
[5] Inaugural dissertation, entitled, “An Attempt to disprove the Putrefaction of the Blood in Living Animals.”
[6] Epidemics, book iv.
[7] Treatise on the Cold Bath.
[8] Treatise on Inflammation. chap. I. 8.
[9] Account of the Intestinal Remitting Fever of Bengal.
[10] On Dropsies, vol. II.
[11] Essay on the Spasmodic Affections in India, p. 53, 54, 55.
[12] Vol. II. Dublin edition, p. 262.
[13] Praxis Medica, lib. xviii. cap. i.
AN ACCOUNT
OF THE
Bilious Remitting Yellow Fever,
AS IT
APPEARED IN PHILADELPHIA,
IN THE YEAR 1793.
Before I proceed to deliver the history of this fever, it will be proper to give a short account of the diseases which preceded it.
The state of the weather during the first seven months of the year, and during the time in which the fever prevailed in the city, as recorded by Mr. Rittenhouse, will be inserted immediately after the history of the disease.
The mumps, which made their appearance in December, 1792, continued to prevail during the month of January, 1793. Besides this disease there were many cases of catarrh in the city, brought on chiefly by the inhabitants exposing themselves for several hours on the damp ground, in viewing the aërial voyage of Mr. Blanchard, on the 9th day of the month.
The weather, which had been moderate in December and January, became cold in February. The mumps continued to prevail during this month with symptoms so inflammatory as to require, in some cases, two bleedings. Many people complained this month of pains and swellings in the jaws. A few had the scarlatina anginosa.
The mumps, pains in the jaws, and scarlatina continued throughout the month of March. I was called to two cases of pleurisy in this month, which terminated in a temporary mania. One of them was in a woman of ninety years of age, who recovered. The blood drawn in the other case (a gentleman from Maryland) was dissolved. The continuance of a tense pulse induced me, notwithstanding, to repeat the bleeding. The blood was now sizy. A third bleeding was prescribed, and my patient recovered. Several cases of obstinate erysipelas succeeded inoculation in children during this and the next month, one of which proved fatal.
Blossoms were universal on the fruit-trees, in the gardens of Philadelphia, on the first day of April. The scarlatina anginosa continued to be the reigning epidemic in this month.
There were several warm days in May, but the city was in general healthy. The birds appeared two weeks sooner this spring than usual.
The register of the weather shows, that there were many warm days in June. The scarlatina continued to maintain its empire during this month.
The weather was uniformly warm in July. The scarlatina continued during the beginning of this month, with symptoms of great violence. A son of James Sharswood, aged seven years, had, with the common symptoms of this disease, great pains and swellings in his limbs, accompanied with a tense pulse. I attempted in vain to relieve him by vomits and purges. On the 10th day of the month, I ordered six ounces of blood to be drawn from his arm, which I observed afterwards to be very sizy. The next day he was nearly well. Between the 22d and the 24th days of the month, there died three persons, whose respective ages were 80, 92, and 96½. The weather at this time was extremely warm. I have elsewhere taken notice of the fatal influence of extreme heat, as well as cold, upon human life in old people. A few bilious remitting fevers appeared towards the close of this month. One of them under my care ended in a typhus or chronic fever, from which the patient was recovered with great difficulty. It was the son of Dr. Hutchins, of the island of Barbadoes.
The weather, for the first two or three weeks in August, was temperate and pleasant. The cholera morbus and remitting fevers were now common. The latter, were attended with some inflammatory action in the pulse, and a determination to the breast. Several dysenteries appeared at this time, both in the city and in its neighbourhood. During the latter part of July, and the beginning of this month, a number of the distressed inhabitants of St. Domingo, who had escaped the desolation of fire and sword, arrived in the city. Soon after their arrival, the influenza made its appearance, and spread rapidly among our citizens. The scarlatina still kept up a feeble existence among children. The above diseases were universal, but they were not attended with much mortality. They prevailed in different parts of the city, and each seemed to appear occasionally to be the ruling epidemic. The weather continued to be warm and dry. There was a heavy rain on the 25th of the month, which was remembered by the citizens of Philadelphia, as the last that fell for many weeks afterwards.
There was something in the heat and drought of the summer months which was uncommon, in their influence upon the human body. Labourers every where gave out (to use the country phrase) in harvest, and frequently too when the mercury in Fahrenheit's thermometer was under 84°. It was ascribed by the country people to the calmness of the weather, which left the sweat produced by heat and labour to dry slowly upon the body.
The crops of grain and grass were impaired by the drought. The summer fruits were as plentiful as usual, particularly the melons, which were of an excellent quality. The influence of the weather upon the autumnal fruits, and upon vegetation in general, shall be mentioned hereafter.
I now enter upon a detail of some solitary cases of the epidemic, which soon afterwards spread distress through our city, and terror throughout the United States.
On the 5th of August, I was requested by Dr. Hodge to visit his child. I found it ill with a fever of the bilious kind, which terminated (with a yellow skin) in death on the 7th of the same month.
On the 6th of August, I was called to Mrs. Bradford, the wife of Mr. Thomas Bradford. She had all the symptoms of a bilious remittent, but they were so acute as to require two bleedings, and several successive doses of physic. The last purge she took was a dose of calomel, which operated plentifully. For several days after her recovery, her eyes and face were of a yellow colour.
On the same day, I was called to the son of Mrs. M'Nair, who had been seized violently with all the usual symptoms of a bilious fever. I purged him plentifully with salts and cremor tartar, and took ten or twelve ounces of blood from his arm. His symptoms appeared to yield to these remedies; but on the 10th of the month a hæmorrhage from the nose came on, and on the morning of the 12th he died.
On the 7th of this month I was called to visit Richard Palmer, a son of Mrs. Palmer, in Chesnut-street. He had been indisposed for several days with a sick stomach, and vomiting after eating. He now complained of a fever and head-ach. I gave him the usual remedies for the bilious fever, and he recovered in a few days. On the 15th day of the same month I was sent for to visit his brother William, who was seized with all the symptoms of the same disease. On the 5th day his head-ach became extremely acute, and his pulse fell to sixty strokes in a minute. I suspected congestion to have taken place in his brain, and ordered him to lose eight ounces of blood. His pulse became more frequent, and less tense after bleeding, and he recovered in a day or two afterwards.
On the 14th day of this month I was sent for to visit Mrs. Leaming, the wife of Mr. Thomas Leaming. I suspected at first that she had the influenza, but in a day or two her fever put on bilious symptoms. She was affected with an uncommon disposition to faint. Her pulse was languid, but tense. I took a few ounces of blood from her, and purged her with salts and calomel. I afterwards gave her a small dose of laudanum which disagreed with her. In my note book I find I have recorded that “she was worse for it.” I was led to make this remark by its being so very uncommon for a person, who had been properly bled and purged, to take laudanum in a common bilious fever without being benefited by it. She recovered, however, slowly, and was yellow for many days afterwards.
On the morning of the 18th of this month I was requested to visit Peter Aston, in Vine-street, in consultation with Dr. Say. I found him on the third day of a most acute bilious fever. His eyes were inflamed, and his face flushed with a deep red colour. His pulse seemed to forbid evacuations. We prescribed the strongest cordials, but to no purpose. We found him, at 6 o'clock in the evening, sitting upon the side of his bed, perfectly sensible, but without a pulse, with cold clammy hands, and his face of a yellowish colour. He died a few hours after we left him.
None of the cases which I have mentioned excited the least apprehension of the existence of a malignant or yellow fever in our city; for I had frequently seen sporadic cases in which the common bilious fever of Philadelphia had put on symptoms of great malignity, and terminated fatally in a few days, and now and then with a yellow colour on the skin, before or immediately after death.
On the 19th of this month I was requested to visit the wife of Mr. Peter Le Maigre, in Water-street, between Arch and Race-streets, in consultation with Dr. Foulke and Dr. Hodge. I found her in the last stage of a highly bilious fever. She vomited constantly, and complained of great heat and burning in her stomach. The most powerful cordials and tonics were prescribed, but to no purpose. She died on the evening of the next day.
Upon coming out of Mrs. Le Maigre's room I remarked to Dr. Foulke and Dr. Hodge, that I had seen an unusual number of bilious fevers, accompanied with symptoms of uncommon malignity, and that I suspected all was not right in our city. Dr. Hodge immediately replied, that a fever of a most malignant kind had carried off four or five persons within sight of Mr. Le Maigre's door, and that one of them had died in twelve hours after the attack of the disease. This information satisfied me that my apprehensions were well founded. The origin of this fever was discovered to me at the same time, from the account which Dr. Foulke gave me of a quantity of damaged coffee which had been thrown upon Mr. Ball's wharf, and in the adjoining dock, on the 24th of July, nearly in a line with Mr. Le Maigre's house, and which had putrefied there to the great annoyance of the whole neighbourhood.
After this consultation I was soon able to trace all the cases of fever which I have mentioned to this source. Dr. Hodge lived a few doors above Mr. Le Maigre's, where his child had been exposed to the exhalation from the coffee for several days. Mrs. Bradford had spent an afternoon in a house directly opposite to the wharf and dock on which the putrid coffee had emitted its noxious effluvia, a few days before her sickness, and had been much incommoded by it. Her sister, Mrs. Leaming, had visited her during her illness at her house, which was about two hundred yards from the infected wharf. Young Mr. M'Nair and Mrs. Palmer's two sons had spent whole days in a compting house near where the coffee was exposed, and each of them had complained of having been made sick by its offensive smell, and Mr. Aston had frequently been in Water-street near the source of the exhalation.
This discovery of the malignity, extent, and origin of a fever which I knew to be attended with great danger and mortality, gave me great pain. I did not hesitate to name it the bilious remitting yellow fever. I had once seen it epidemic in Philadelphia, in the year 1762. Its symptoms were among the first impressions which diseases made upon my mind. I had recorded some of these symptoms, as well as its mortality. I shall here introduce a short account of it, from a note book which I kept during my apprenticeship.
“In the year 1762, in the months of August, September, October, November, and December, the bilious yellow fever prevailed in Philadelphia, after a very hot summer, and spread like a plague, carrying off daily, for some time, upwards of twenty persons.
“The patients were generally seized with rigours, which were succeeded with a violent fever, and pains in the head and back. The pulse was full, and sometimes irregular. The eyes were inflamed, and had a yellowish cast, and a vomiting almost always attended.
“The 3d, 5th, and 7th days were mostly critical, and the disease generally terminated on one of them, in life or death.
“An eruption on the 3d or 7th day over the body proved salutary.
“An excessive heat and burning about the region of the liver, with cold extremities, portended death to be at hand.”
I have taken notice, in my note book, of the principal remedy which was prescribed in this fever by my preceptor in medicine, but this shall be mentioned hereafter.
Upon my leaving Mrs Le Maigre's, I expressed my distress at what I had discovered, to several of my fellow-citizens. The report of a malignant and mortal fever being in town spread in every direction, but it did not gain universal credit. Some of those physicians who had not seen patients in it denied that any such fever existed, and asserted (though its mortality was not denied) that it was nothing but the common annual remittent of the city. Many of the citizens joined the physicians in endeavoring to discredit the account I had given of this fever, and for a while it was treated with ridicule or contempt. Indignation in some instances was excited against me, and one of my friends, whom I advised in this early stage of the disease to leave the city, has since told me that for that advice “he had hated me.”
My lot in having thus disturbed the repose of the public mind, upon the subject of general health, was not a singular one. There are many instances upon record, of physicians who have rendered themselves unpopular, and even odious to their fellow-citizens, by giving the first notice of the existence of malignant and mortal diseases. A physician, who asserted that the plague was in Messina, in the year 1743, excited so much rage in the minds of his fellow-citizens against him, as to render it necessary for him to save his life by retreating to one of the churches of that city.
In spite, however, of all opposition, the report of the existence of a malignant fever in the city gained so much ground, that the governor of the state directed Dr. Hutchinson, the inspector of sickly vessels, to inquire into the truth of it, and into the nature of the disease.
In consequence of this order, the doctor wrote letters to several of the physicians in the city, requesting information relative to the fever. To his letter to me, dated the 24th of August, I replied on the same day, and mentioned not only the existence of a malignant fever, but the streets it occupied, and my belief of its being derived from a quantity of coffee which had putrified on a wharf near Arch-street. This, and other information collected by the doctor, was communicated to the health officer, in a letter dated the 27th of August, in which he mentioned the parts of the city where the disease prevailed, and the number of persons who had died of it, supposed by him to be about 40, but which subsequent inquiries proved to be more than 150. He mentioned further, in addition to the damaged coffee, some putrid hides, and other putrid animal and vegetable substances, as the supposed cause of the fever, and concluded by saying, as he had not heard of any foreigners or sailors being infected, nor of its being found in any lodging-houses, that “it was not an imported disease.”
In the mean while the disease continued to spread, and with a degree of mortality that had never been known from common fevers.
On the 25th of the month, the college of physicians was summoned by their president to meet, in order to consult about the best methods of checking the progress of the fever in the city. After some consideration upon the nature of the disease, a committee was appointed to draw up some directions for those purposes; and the next day the following were presented to the college, and adopted unanimously by them. They were afterwards published in most of the newspapers.
Philadelphia, August 26th, 1793.
The college of physicians having taking into consideration the malignant and contagious fever that now prevails in this city, have agreed to recommend to their fellow-citizens the following means of preventing its progress.
1st. That all unnecessary intercourse should be avoided with such persons as are infected by it.
2d. To place a mark upon the door or window of such houses as have any infected persons in it.
3d. To place the persons infected in the centre of large and airy rooms, in beds without curtains, and to pay the strictest regard to cleanliness, by frequently changing their body and bed linen, also by removing, as speedily as possible, all offensive matters from their rooms.
4th. To provide a large and airy hospital, in the neighbourhood of the city, for the reception of such poor persons as cannot be accommodated with the above advantages in private houses.
5th. To put a stop to the tolling of the bells.
6th. To bury such persons as die of this fever in carriages, and in as private a manner as possible.
7th. To keep the streets and wharves of the city as clean as possible. As the contagion of the disease may be taken into the body, and pass out of it without producing the fever, unless it be rendered active by some occasional cause, the following means should be attended to, to prevent the contagion being excited into action in the body.
8th. To avoid all fatigue of body and mind.
9th. To avoid standing or sitting in the sun; also in a current of air, or in the evening air.
10th. To accommodate the dress to the weather, and to exceed rather in warm, than in cool clothing.
11th. To avoid intemperance, but to use fermented liquors, such as wine, beer, and cyder, in moderation.
The college conceive fires to be very ineffectual, if not dangerous means of checking the progress of this fever. They have reason to place more dependence upon the burning of gunpowder. The benefits of vinegar and camphor are confined chiefly to infected rooms, and they cannot be used too frequently upon handkerchiefs, or in smelling-bottles, by persons whose duty calls to visit or attend the sick.
Signed by order of the college,
WILLIAM SHIPPEN, jun.
Vice president.
SAMUEL P. GRIFFITTS,
Secretary.
From a conviction that the disease originated in the putrid exhalations from the damaged coffee, I published in the American Daily Advertiser, of August 29th, a short address to the citizens of Philadelphia, with a view of directing the public attention to the spot where the coffee lay, and thereby of checking the progress of the fever as far as it was continued by the original cause.
This address had no other effect than to produce fresh clamours against the author; for the citizens, as well as most of the physicians of Philadelphia, had adopted a traditional opinion that the yellow fever could exist among us only by importation from the West-Indies.
In consequence, however, of a letter from Dr. Foulke to the mayor of the city, in which he had decided, in a positive manner, in favour of the generation of the fever from the putrid coffee, the mayor gave orders for the removal of the coffee, and the cleaning of the wharf and dock. It was said that measures were taken for this purpose; but Dr. Foulke, who visited the place where the coffee lay, repeatedly assured me, that they were so far from being effectual, that an offensive smell was exhaled from it many days afterwards.
I shall pass over, for the present, the facts and arguments on which I ground my assertion of the generation of this fever in our city. They will come in more properly in the close of the history of the disease.
The seeds of the fever, when received into the body, were generally excited into action in a few days. I met with several cases in which they acted so as to produce a fever on the same day in which they were received into the system, and I heard of two cases in which they excited sickness, fainting, and fever within one hour after the persons were exposed to them. I met with no instance in which there was a longer interval than sixteen days between their being received into the body and the production of the disease.
This poison acted differently in different constitutions, according to previous habits, to the degrees of predisposing debility, or to the quantity and concentration of the miasmata which had been received into the body.
In some constitutions, the miasmata were at once a remote, a predisposing, and an exciting cause of the disease; hence some persons were affected by them, who had not departed in any instance from their ordinary habits of living, as to diet, dress, and exercise. But it was more frequently brought on by those causes acting in succession to each other.
I shall here refer the reader to the principles laid down in the outlines of the theory of fever, for an account of the manner in which the system was predisposed to this disease, by the debility induced by the reduction of its excitement, by action and abstraction, and by subsequent depression. Where a predisposition was thus produced, the fever was excited by the following causes, acting directly or indirectly upon the system. Where this predisposition did not exist, the exciting causes produced both the predisposition and the disease. They were,
1. Great labour, or exercises of body or mind, in walking, riding, watching, or the like. It was labour which excited the disease so universally among the lower class of people. A long walk often induced it. Few escaped it after a day, or even a few hours spent in gunning. A hard trotting horse brought it on two of my patients. Perhaps riding on horseback, and in the sun, was the exciting cause of the disease in most of the citizens and strangers who were affected by it in their flight from the city. A fall excited it in a girl, and a stroke upon the head excited it in a young man who came under my care. Many people were seized with the disease in consequence of their exertions on the night of the 7th of September, in extinguishing the fire which consumed Mr. Dobson's printing-office, and even the less violent exercise of working the fire engines, for the purpose of laying the dust in the streets, added frequently to the number of the sick.
2. Heat, from every cause, but more especially the heat of the sun, was a very common exciting cause of the disease. The register of the weather during the latter end of August, the whole of September, and the first two weeks in October will show how much the heat of the sun must have contributed to excite the disease, more especially among labouring people. The heat of common fires likewise became a frequent cause of the activity of the miasmata where they had been received into the body; hence the greater mortality of the disease among bakers, blacksmiths, and hatters than among any other class of people.
3. Intemperance in eating or drinking. A plentiful meal, and a few extra glasses of wine seldom failed of exciting the fever. But where the body was strongly impregnated with the seeds of the disease, even the smallest deviation from the customary stimulus of diet, in respect to quality or quantity, roused them into action. A supper of twelve oysters in one, and of but three in another, of my patients produced the disease. Half an ounce of meat excited it in a lady who had lived, by my advice, for two weeks upon milk and vegetables, and even a supper of sallad, dressed after the French fashion, excited it in one of Dr. Mease's patients.
4. Fear. In many people the disease was excited by a sudden paroxysm of fear; but I saw some remarkable instances where timid people escaped the disease, although they were constantly exposed to it. Perhaps a moderate degree of fear served to counteract the excessive stimulus of the miasmata, and thereby to preserve the body in a state of healthy equilibrium. I am certain that fear did no harm after the disease was formed, in those cases where great morbid excess of action had taken place. It was an early discovery of this fact which led me not to conceal from my patients the true name of this fever, when I was called to them on the day of their being attacked by it. The fear co-operated with some of my remedies (to be mentioned hereafter) in reducing the morbid excitement of the arterial system.
5. Grief. It was remarkable that the disease was not excited in many cases in the attendants upon the sick, while there was a hope of their recovery. The grief which followed the extinction of hope, by death, frequently produced it within a day or two afterwards, and that not in one person only, but often in most of the near relations of the deceased. But the disease was also produced by a change in the state of the mind directly opposite to that which has been mentioned. Many persons that attended patients who recovered, were seized with the disease a day or two after they were relieved from the toils and anxiety of nursing. The collapse of the mind from the abstraction of the stimulus of hope and desire, by their ample gratification, probably produced that debility, and loss of the equilibrium in the system, which favoured the activity of the miasmata in the manner formerly mentioned[14].
The effects of both the states of mind which have been described, have been happily illustrated by two facts which are recorded by Dr. Jackson[15]. He tells us, that the garrisons of Savannah and York-Town were both healthy during the siege of those towns, but that the former became sickly as soon as the French and American armies retreated, from before it, and the latter, immediately after its capitulation.
6. Cold. Its action, in exciting the disease, depended upon the diminution of the necessary and natural heat of the body, and thereby so far destroying the equilibrium of the system, as to enable the miasmata to produce excessive or convulsive motions in the blood-vessels. The night air, even in the warm month of September, was often so cool as to excite the disease, where the dress and bed-clothes were not accommodated to it. It was excited in one case by a person's only wetting his feet, in the month of October, and neglecting afterwards to change his shoes and stockings. Every change in the weather, that was short of producing frost, evidently increased the number of sick people. This was obvious after the 18th and 19th of September, when the mercury fell to 44° and 45°. The hopes of the city received a severe disappointment upon this occasion, for I well recollect there was a general expectation that this change in the weather would have checked the disease. The same increase of the number of sick was observed to follow the cool weather which succeeded the 6th and 7th of October, on which days the mercury fell to 43° and 46°.
It was observed that those persons who were habitually exposed to the cool air, were less liable to the disease than others. I ascribe it to the habitual impression of the cool night air upon the bodies of the city watchmen, that but four or five of them, out of twenty-five, were affected by the disease.
After the body had been heated by violent exercise, a breeze of cool air sometimes excited the disease in those cases where there had been no change in the temperature of the weather.
7. Sleep. A great proportion of all who were affected by this fever, were attacked in the night. Sleep induced what I have called debility from abstraction, and thereby disposed the miasmata which floated in the blood, to act with such force upon the system as to destroy its equilibrium, and thus to excite a fever. The influence of sleep as a predisposing, and exciting cause was often assisted by the want of bed-clothes, suited to the midnight or morning coolness of the air.
8. Immoderate evacuations. The efficacy of moderate purging and bleeding in preventing the disease, led some people to use those remedies in an excess, which both predisposed to the disease, and excited it. The morbid effects of these evacuations, were much aided by fear, for it was this passion which perverted the judgment in such a manner, as to lead to the excessive use of remedies, which, to be effectual, should only be used in moderate quantities.
The disease appeared with different symptoms, and in different degrees, in different people. They both varied likewise with the weather. In describing the disease, I shall take notice of the changes in the symptoms, which were produced by changes in the temperature of the air.
The precursors, or premonitory signs of this fever were, costiveness, a dull pain in the right side, defect of appetite, flatulency, perverted taste, heat in the stomach, giddiness, or pain in the head, a dull, watery, brilliant, yellow, or red eye, dim and imperfect vision, a 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. The dull eye, and the lowness of spirits, appeared to be the effects of such an excess in the stimulus of the miasmata as to induce depression, while the brilliant eye, and the unusual vivacity, seemed to have been produced by a less quantity of the miasmata acting as a cordial upon the system. More or less of these symptoms frequently continued for two or three days before the patients were confined to their beds, and in some people they continued during the whole time of its prevalence in the city, without producing the disease. I wish these symptoms to be remembered by the reader. They will form the corner stone of a system which I hope will either eradicate the disease altogether, or render it as safe as an intermitting fever, or as the small-pox when it is received by inoculation.
Frequent as these precursors of the fever were, they were not universal. Many went to bed in good health, and awoke in the night with a chilly fit. Many rose in the morning after regular and natural sleep, and were seized at their work, or after a walk, with a sudden and unexpected attack of the fever. In most of these cases the disease came on with a chilly fit, which afforded by its violence or duration a tolerable presage of the issue of the disease.
Upon entering a sick room where a patient was confined by this fever, the first thing that struck the eye of a physician was the countenance. It was as much unlike that which is exhibited in the common bilious fever, as the face of a wild, is unlike the face of a mild domestic animal. 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 downcast and clouded. After the 10th of September, when a determination of blood to the brain became universal, there was a preternatural dilatation of the pupil. Sighing attended in almost every case. The skin was dry, and frequently of its natural temperature. These were the principal symptoms which discovered themselves to the eye and hand of a physician. The answers to the first questions proposed upon visiting a patient, were calculated to produce a belief in the mind of a physician, that the disease under which the patient laboured was not the prevailing malignant epidemic. I did not for many weeks meet with a dozen patients, who acknowledged that they had any other indisposition than a common cold, or a slight remitting or intermitting fever. I was particularly struck with this self-deception in many persons, who had nursed relations that had died with the yellow fever, and who had been exposed to it in neighbourhoods where it had prevailed for days and even weeks with great mortality. I shall hereafter trace a part of this disposition in the sick to deceive themselves to the influence of certain publications, which appeared soon after the disease became epidemic in the city.
In the further history of this fever, I shall describe its symptoms as they appeared,
I. In the sanguiferous system.
II. In the liver, lungs, and brain.
III. In the alimentary canal; in which I include the stomach as well as the bowels.
IV. In the secretions and excretions.
V. In the nervous system.
VI. In the senses and appetites.
VII. In the lymphatic and glandular system.
VIII. Upon the skin.
IX. In the blood.
After having finished this detail, I shall mention some general characters of the disease, and afterwards subdivide it into classes, according to its degrees and duration.
I. The blood-vessels were affected more or less in every case of this fever. I have elsewhere said, that a fever is occasioned by a convulsion in the arterial system[16]. When the epidemic, which we are now considering, came on with a full, tense, and quick pulse, this convulsion was very perceptible; but it frequently came on with a weak pulse, often without any preternatural frequency or quickness, and sometimes so low as not to be perceived without pressing the artery at the wrists. In many cases the pulse intermitted after the fourth, in some after the fifth, and in others after the fourteenth stroke. These intermissions occurred in several persons who were infected, but who were not confined by the fever. They likewise continued in several of my patients for many days after their recovery. This was the case in particular in Mrs. Clymer, Mrs. Palmer's son William, and in a son of Mr. William Compton. In some, there was a preternatural slowness of the pulse. It beat 44 strokes in a minute in Mr. B. W. Morris, 48 in Mr. Thomas Wharton, jun. and 64 in Mr. William Sansom, at a time when they were in the most imminent danger. Dr. Physick informed me, that in one of his patients the pulse was reduced in frequency to 30 strokes in a minute. All these different states of the pulse have been taken notice of by authors who have described pestilential fevers[17]. They have been improperly ascribed to the absence of fever: I would rather suppose that they are occasioned by the stimulus of the remote cause acting upon the arteries with too much force to admit of their being excited into quick and convulsive motions. The remedy which removed it (to be mentioned hereafter) will render this explanation of its cause still more probable. Milton describes a darkness from an excess of light. In like manner we observe, in this small, intermitting, and slow pulse, a deficiency of strength from an excess of force applied to it. In nearly every case of it which came under my notice, it was likewise tense or chorded. This species of pulse occurred chiefly in the month of August, and in the first ten days in September. I had met with it formerly in a sporadic case of yellow fever. It was new to all my pupils. One of them, Mr. Washington, gave it the name of the “undescribable pulse.” It aided in determining the character of this fever before the common bilious remittent disappeared in the city. For a while, I ascribed this peculiarity in the pulse, more especially its slowness, to an affection of the brain only, and suspected that it was produced by what I have taken the liberty elsewhere to call the phrenicula, or inflammatory state of the internal dropsy of the brain, and which I have remarked to be an occasional symptom and consequence of remitting fever. I was the more disposed to adopt this opinion, from perceiving this slow, chorded, and intermitting pulse more frequently in children than in adults. Impressed with this idea, I requested Mr. Coxe, one of my pupils, to assist me in examining the state of the eyes. For two days we discovered no change in them, but on the third day after we began to inspect them, we both perceived a preternatural dilatation of the pupils, in different patients; and we seldom afterwards saw an eye in which it was absent. In Dr. Say it was attended by a squinting, a symptom which marks a high degree of a morbid affection of the brain. Had this slowness or intermission in 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 that muscle[18]. Dr. Ferriar describes a case, in which a low, irregular, intermitting, and hardly perceptible pulse attended a morbid dilatation of the heart[19]. In a letter I received from Mr. Hugh Ferguson, then a student of medicine in the college of Edinburgh, written from Dublin, during the time of a visit to his father, and dated September 30th, 1793, I find a fact which throws additional light upon this subject. “A case (says my young correspondent) where a remarkable intermission of pulse was observed, occurred in this city last year. A gentleman of the medical profession, middle aged, of a delicate habit of body, and who had formerly suffered phthisical attacks, was attacked with the acute rheumatism. Some days after he was taken ill, he complained of uncommon fulness, and a very peculiar kind of sensation about the præcordia, which it was judged proper to relieve by copious blood-letting. This being done, the uneasiness went off. It returned, however, three or four times, and was as often relieved by bleeding. During each of his fits (if I may call them so), the patient experienced an almost total remission of his pains in his limbs; but they returned with equal or greater violence after blood-letting. During the fit there was an intermission of the pulse (the first time) of no less than thirteen strokes. It was when beating full, strong, and slow. The third intermission was of nine strokes. The gentleman soon recovered, and has enjoyed good health for ten months past. The opinion of some of his physicians was, that the heart was affected, as a muscle, by the rheumatism, and alternated with the limbs.”
I am the more inclined to believe the peculiarity in the pulse which has been mentioned in the yellow fever, arose in part from a spasmodic affection of the heart, from the frequency of an uncommon palpitation of this muscle, which I discovered in this disease, more especially in old people. The disposition, likewise, to syncope and sighing, which so often occurred, can be explained upon no other principle than inflammation, spasm, dilatation, or congestion in the heart. After the 10th of September this undescribable or sulky pulse (for by the latter epithet I sometimes called it) became less observable, and, in proportion as the weather became cool, it totally 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 a very different sensation to the fingers. No two strokes seemed to be exactly alike. Its action was of a hobbling nature. It was at this time so familiar to me that I think I could have distinguished the disease by it without seeing the patient. It was remarkable that this pulse attended the yellow fever even when it appeared in the mild form of an intermittent, and in those cases where the patients were able to walk about or go abroad. It was nearly as tense in the remissions and intermissions of the fever as it was in the exacerbations. It was an alarming symptom, and when the only remedy which was effectual to remove it was neglected, such a change in the system was induced as frequently brought on death in a few days.
This change of the pulse, from extreme lowness to fulness and activity, appeared to be owing to the diminution of the heat of the weather, which, by its stimulus, added to that of the remote cause, had induced those symptoms of depression of the pulse which have been mentioned.
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.
Hæmorrhages belong to the symptoms of this fever as they appeared in the sanguiferous system. They occurred in the beginning of the disease, chiefly from the nose and uterus. Sometimes but a few drops of blood distilled from the nose. The menses were unusual in their quantity when they appeared at their stated periods, but they often came on a week or two before the usual time of their appearance. I saw one case of a hæmorrhage from the lungs on the first day of the fever, which was supposed to be a common hæmoptysis. As the disease advanced the discharges of blood became more universal. They occurred from the gums, ears, stomach, bowels, and urinary passages. Drops of blood issued from the inner canthus of the left eye of Mr. Josiah Coates. Dr. Woodhouse attended a lady who bled from the holes in her ears which had been made by ear-rings. Many bled from the orifices which had been made by bleeding, several days after they appeared to have been healed, and some from wounds which had been made in veins in unsuccessful attempts to draw blood. These last hæmorrhages were very troublesome, and in some cases precipitated death.
II. I come now to mention the symptoms of this fever as they appeared in the liver, the lungs, and the brain. From the histories which I had read of this disease, I was early led to examine the state of the liver, but I was surprised to find so few marks of hepatic affection. I met with but two cases in which the patient could lie only on the right side. Many complained of a dull pain in the region of the liver, but very few complained, in the beginning of the disease, of that soreness to the touch, about the pit of the stomach, which is taken notice of by authors, and which was universal in the yellow fever in 1762. In proportion as the cool weather advanced, a preternatural determination of the blood took place chiefly to the lungs and brain. Many were affected with pneumonic symptoms, and some appeared to die of sudden effusions of blood or serum in the lungs. It was an unexpected effusion of this kind which put an end to the life of Mrs. Keppele after she had exhibited hopeful signs of a recovery.
I saw one person who recovered from an affection of the lungs, by means of a copious expectoration of yellow phlegm and mucus. But the brain was principally affected with morbid congestion in this disease. It was indicated by the suffusion of blood in the face, by the redness of the eyes, by a dilatation of the pupils, by the pain in the head, by the hæmorrhages from the nose and ears, by the sickness or vomiting, and by an almost universal costive state of the bowels. I wish to impress the reader with these facts, for they formed one of the strongest indications for the use of the remedies which I adopted for the cure of this disease. It is difficult to determine the exact state of these viscera in every case of bilious and yellow fever. Inflammation certainly takes place in some cases, and internal hæmorrhages in others; but I believe the most frequent affection of these viscera consists in a certain morbid accumulation of blood in them, which has been happily called, by Dr. Clark, an engorgement or choaking of the blood-vessels. I believe further, with Dr. Clark[20] and Dr. Balfour[21], that death in most cases in bilious fevers is the effect of these morbid congestions, and wholly unconnected with an exhausted state of the system, or a supposed putrefaction in the fluids. It is true, the dissections of Dr. Physick and Dr. Cathrall (to be mentioned hereafter) discovered no morbid appearances in any of the viscera which have been mentioned, but it should be remembered, that these dissections were made early in the disease. Dr. Annan attended the dissection of a brain of a patient who died at Bush-hill some days afterwards, and observed the blood-vessels to be unusually turgid. In those cases where congestion only takes place, it is as easy to conceive that all morbid appearances in the brain may cease after death, as that the suffusion of blood in the face should disappear after the retreat of the blood from the extremities of the vessels, in the last moments of life. It is no new thing for morbid excitement of the brain to leave either slender, or no marks of disease after death. This, I have said, is often the case where it exceeds that degree of action which produces an effusion of red blood into serous vessels, or what is called inflammation[22]. Dr. Quin has given a dissection of the brain of a child that died with all the symptoms of hydrocephalus internus, and yet nothing was discovered in the brain but a slight turgescence of its blood-vessels. Dr. Girdlestone says, no injury appeared in the brains of those persons who died of the symptomatic apoplexy, which occurred in a spasmodic disease which he describes in the East-Indies; and Mr. Clark informs us, that the brain was in a natural state in every case of death from puerperile fever, notwithstanding it seemed to be affected in many cases soon after the attack of that disease[23].
I wish it to be remembered here, that the yellow fever, like all other diseases, is influenced by climate and season. The determination of the fluids is seldom the same in different years, and I am sure it varied with the weather in the disease which I am now describing. Dr. Jackson speaks of the head being most affected in the West-India fevers in dry situations. Dr. Hillary says, that there was an unusual determination of the blood towards the brain, after a hot and dry season, in the fevers of Barbadoes in the year 1753; and Dr. Ferriar, in his account of an epidemic jail fever in Manchester, in 1789, 1790, informs us, that as soon as frost set in, a delirium became a more frequent symptom of that disease, than it had been in more temperate weather.
III. The stomach and bowels were affected in many ways in this fever. The disease seldom appeared without nausea or vomiting. In some cases, they both occurred for several days or a week before they were accompanied by any fever. Sometimes a pain, known by the name of gastrodynia, ushered in the disease. The stomach was so extremely irritable as to reject drinks of every kind. Sometimes green or yellow bile was rejected on the first day of the disease by vomiting; but I much oftener saw it continue for two days without discharging any thing from the stomach, but the drinks which were taken by the patient. If the fever in any case came on without vomiting, or if it had been checked by remedies that were ineffectual to remove it altogether, it generally appeared, or returned, on the 4th or 5th day of the disease. I dreaded this symptom on those days, for although it was not always the forerunner of death, yet it generally rendered the recovery more difficult and tedious. In some cases the vomiting was more or less constant from the beginning to the end of the disease, whether it terminated in life or death.
The vomiting which came on about the 4th or 5th day, was accompanied with a burning pain in the region of the stomach. It produced great anxiety, and tossing of the body from one part of the bed to another. In some cases, this painful burning occurred before any vomiting had taken place. Drinks were now rejected from the stomach so suddenly, as often to be discharged over the hand that lifted them to the head of the patient. The contents of the stomach (to be mentioned hereafter) were sometimes thrown up with a convulsive motion, that propelled them in a stream to a great distance, and in some cases all over the clothes of the by-standers.
Flatulency was an almost universal symptom, in every stage of this disease. It was very distressing in many cases. It occurred chiefly in the stomach.
The bowels were generally costive, and in some patients as obstinately so as in the dry gripes. In some cases there was all the pain and distress of a bilious colic, and in others, the tenesmus, and mucous and bloody discharges of a true dysentery. A diarrhœa introduced the disease in a few persons, but it was chiefly in those who had been previously indisposed with weak bowels. A painful tension of the abdomen took place in many, accompanied in some instances by a dull, and in others by an acute pain in the lower part of the belly.
IV. I come now to describe the state of the secretions and excretions as they appeared in different stages of this fever.
In some cases there was a constipation of the liver, if I may be allowed that expression, or a total obstruction of secretion and excretion of bile, but more frequently a preternatural secretion and excretion of it took place. It was discharged, in most cases, from the stomach and bowels in large quantities, and of very different qualities and colours.
1. On the first and second days of the disease many patients puked from half a pint to nearly a quart of green or yellow bile. Four cases came under my notice in which black bile was discharged on the first day. Three of these patients recovered.
2. There was frequently, on the 4th or 5th day, a discharge of matter from the stomach, resembling coffee impregnated with its grounds. This was always an alarming symptom. I believed it at first to be a modification of vitiated bile, but subsequent dissections by Dr. Physick have taught me that it was the result of the first stage of those morbid actions in the stomach, which afterwards produce the black vomit. Many recovered who discharged this coffee-coloured matter.
3. Towards the close of this disease, there was a discharge of matter of a deep or pale black colour, from the stomach. Flakey substances frequently floated in the bason or chamber-pot upon the surface of this matter. It was what is called the black vomit. It was formerly supposed to be vitiated bile, but it has been proved by Dr. Stewart, and afterwards by Dr. Physick, to be the effect of disease in the stomach.
4. There was frequently discharged from the stomach in the close of the disease, a large quantity of grumous blood, which exhibited a dark colour on its outside, resembling that of some of the matters which have been described, and which I believe was frequently mistaken for what is commonly known by the name of the black vomit. Several of my patients did me the honour to say, I had cured them after that symptom of approaching dissolution had made its appearance; but I am inclined to believe, dark-coloured blood only, or the coffee-coloured matter, was mistaken for the matters which constitute the fatal black vomiting. I except here the black discharge before-mentioned, which took place in three cases on the first day of the disease. This I have no doubt was bile, but it had not acquired its greatest acrimony, and it was discharged before mortification, or even inflammation could have taken place in the stomach. Several persons died without a black vomiting of any kind.
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 the fæces depended 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 the fæces. Large round worms were frequently discharged with the stools.
The urine was 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 a suppression of 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 copious sweats on 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 of mucus from the glands of the throat. It was discharged by an almost constant hawking and spitting. All who had this symptom recovered.
The tongue was 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 the nervous system the 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 convulsive motions 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 application of 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. In some, 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 an apparent absence 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 with the 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. The senses and appetites exhibited 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.
The thirst was 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 drink up 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.
The appetite for 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. The lymphatic and glandular system did 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. The skin exhibited 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 appeared first 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 stomach in 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. The blood in 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 is wholly 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 called samiel, 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 by external 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 sudden disorganization in 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 the mass, that nature being in a manner oppressed, is rendered unable to produce regular symptoms that are suitable to the disease; and almost all the phenomena that happen are irregular, by reason of the entire subversion of the animal economy; in which case the fever is often depressed, 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 which affect 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, a tertian as 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 a month 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.
The first includes those in whom the stimulus of the miasmata produced coma, languor, sighing, a disposition to syncope, and a weak or slow pulse.
The second includes 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.
The third class 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 upon the 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 previous inflammatory 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 this axiom 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 by Sauvage, 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 eruption on 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 only of 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 made upon 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 every affection 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 it had 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 the African 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 to Absalom Jones and William 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 after using 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 probably predominated 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 who were 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 of the 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, as well 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 exposed to 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 by persons 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.
The liver, in the above-mentioned slave, was turgid and plump on its outside, but on its concave surface, two thirds of it were of a deep black colour, and round the gall bladder it seemed to be mortified and corrupted.
The duodenum was lined on its inside, near the gall bladder, with a viscid ropy bile, like that which has been described. Its villous coat was lined with a thick fur or slime, which, when scraped or pealed off, the other vascular and muscular coats of the gut appeared red and inflamed.
The omentum was so much wasted, that nothing but its blood-vessels could be perceived.
The stomach was inflamed, both on its outside and inside. It contained a quantity of bile of the same consistence, but of a blacker colour than that which was found in the gall bladder. Its villous coat, like that of the duodenum, was covered with fuzzy and slimy matter. It moreover appeared to be distended or swelled. This peculiarity in the inner coat of the stomach was universal in all the bodies that were opened, of persons who died of this disease.
The lungs, instead of being collapsed, were inflated as in inspiration. They were all over full of black or livid spots. On these spots were to be seen small vesicles or blisters, like those of an erysipelas or gangrene, containing a yellow humour.
The blood-vessels in general seemed empty of blood, even the vena cava and its branches; but the vena portarum was full and distended as usual. The blood seemed collected in the viscera; for upon cutting the lungs or sound liver or spleen, they bled freely.
The brain was not opened in this body, but it was not affected in three others whose brains were examined.
Dr. Mackittrick, in his inaugural dissertation, published at Edinburgh in the year 1766, “De Febre Indiæ Occidentalis, Maligna Flava,” or upon the yellow fever of the West-Indies, says, that in some of the patients who died of it, he found the liver sphacelated, the gall bladder full of black bile, and the veins turgid with black fluid blood. In others he found the liver no ways enlarged, and its “texture only vitiated.” The stomach, the duodenum, and ilium, were remarkably inflamed in all cases. The pericardium contained a viscid yellow serum, and in a larger quantity than common. The urinary bladder was a little inflamed. The lungs were sound.
Dr. Hume, in describing the yellow fever of Jamaica, informs us, that in several dead bodies which he opened, he found the liver enlarged and turgid with bile, and of a pale yellow colour. In some he found the stomach and duodenum inflamed. In one case he discovered black spots in the stomach, of the size of a crown piece. To this account he adds, “that he had seen some subjects opened, on whose stomachs no marks of inflammation could be discovered; and yet these had excessive vomiting.”
Dr. Lind has furnished us with an account of the state of the body after death, in his short history of the yellow fever, which prevailed at Cadiz, in the year 1764. “The stomach (he says), mesentery, and intestines, were covered with gangrenous spots; there were ulcers on the orifice of the stomach, and the liver and lungs were of a putrid colour and texture[54].”
To these accounts of the morbid appearances of the body after death from the yellow fever I shall only add the account of several dissections, which was given to the public in Mr. Brown's Gazette, during the prevalence of this epidemic, by Dr. Physick and Dr. Cathrall.
“Being well assured of the great importance of dissections of morbid bodies in the investigation of the nature of diseases, we have thought it of consequence that some of those dead of the present prevailing malignant fever should be examined; and, without enlarging on our observations, it appears at present sufficient to state the following facts.
“1st. That the brain in all its parts has been found in a natural condition.
“2d. That the viscera of the thorax are perfectly sound. The blood, however, in the heart and veins is fluid, similar, in its consistence, to the blood of persons who have been hanged, or destroyed by electricity.
“3d. That the stomach, and beginning of the duodenum, are the parts that appear most diseased. In two persons who died of the disease on the 5th day, the villous membrane of the stomach, especially about its smaller end, was found highly inflamed; and this inflammation extended through the pylorus into the duodenum, some way. The inflammation here was exactly similar to that induced in the stomach by acrid poisons, as by arsenic, which we have once had an opportunity of seeing in a person destroyed by it.
“The bile in the gall-bladder was quite of its natural colour, though very viscid.
“In another person, who died on the 8th day of the disease, several spots of extravasation were discovered between the membranes, particularly about the smaller end of the stomach, the inflammation of which had considerably abated. Pus was seen in the beginning of the duodenum, and the villous membrane at this part was thickened.
“In two other persons, who died at a more advanced period of the disease, the stomach appeared spotted in many places with extravasations, and the inflammation disappeared. It contained, as did also the intestines, a black liquor, which had been vomited and purged before death. This black liquor appears clearly to be an altered secretion from the liver; for a fluid in all respects of the same qualities was found in the gall bladder. This liquor was so acrid, that it induced considerable inflammation and swelling on the operator's hands, which remained some days. The villous membrane of the intestines, in these last two bodies, was found inflamed in several places.
“The liver was of its natural appearance, excepting in one of the last persons, on the surface of which a very few distended veins were seen: all the other abdominal viscera were of a healthy appearance.
“The external surface of the stomach, as well as of the intestines, was quite free from inflammation; the veins being distended with blood, which appeared through the transparent peritonium, gave them a dark colour.
“The stomach of those who died early in the disease was always contracted; but in those who died at a more advanced period of it, where extravasations appeared, it was distended with air.
“P. S. PHYSICK,
“J. CATHRALL.”
I have before remarked, that these dissections were made early in the disease, and that Dr. Annan attended a dissection of a body at Bush-hill, some time afterwards, in which an unusual turgescence appeared in the vessels of the brain.
Thus far have I delivered the history of the yellow fever, as it affected the human body with sickness and death. I shall now mention a few of those circumstances of public and private distress which attended it. I have before remarked, that the first reports of the existence of this fever were treated with neglect or contempt. A strange apathy pervaded all classes of people. While I bore my share of reproach for “terrifying our citizens with imaginary danger,” I answered it by lamenting “that they were not terrified enough.” The publication from the college of physicians soon dissipated this indifference and incredulity. Fear or terror now sat upon every countenance. The disease appeared in many parts of the town, remote from the spot where it originated; although, for a while, in every instance, it was easily traced to it. This set the city in motion. The streets and roads leading from the city were crowded with families flying in every direction for safety to the country. Business began to languish. Water-street, between Market and Race-streets, became a desert. The poor were the first victims of the fever. From the sudden interruption of business they suffered for a while from poverty as well as from disease. A large and airy house at Bush-hill, about a mile from the city, was opened for their reception. This house, after it became the charge of a committee appointed by the citizens on the 14th of September, was regulated and governed with the order and cleanliness of an old and established hospital. An American and French physician had the exclusive medical care of it after the 22d of September.
The disease, after the second week in September, spared no rank of citizens. Whole families were confined by it. There was a deficiency of nurses for the sick, and many of those who were employed were unqualified for their business. There was likewise a great deficiency of physicians, from the desertion of some, and the sickness and death of others. At one time there were but three physicians who were able to do business out of their houses, and at this time there were probably not less than 6000 persons ill with the fever.
During the first three or four weeks of the prevalence of the disease I seldom went into a house the first time, without meeting the parents or children of the sick in tears. Many wept aloud in my entry, or parlour, who came to ask for advice for their relations. Grief after a while descended below weeping, and I was much struck in observing that many persons submitted to the loss of relations and friends without shedding a tear, or manifesting any other of the common signs of grief.
A cheerful countenance was scarcely to be seen in the city for six weeks. I recollect once, in entering the house of a poor man, to have met a child of two years old that smiled in my face. I was strangely affected with this sight (so discordant to my feelings and the state of the city) before I recollected the age and ignorance of the child. I was confined the next day by an attack of the fever, and was sorry to hear, upon my recovery, that the father and mother of this little creature died a few days after my last visit to them.
The streets every where discovered marks of the distress that pervaded the city. More than one half the houses were shut up, although not more than one third of the inhabitants had fled into the country. In walking for many hundred yards, few persons were met, except such as were in quest of a physician, a nurse, a bleeder, or the men who buried the dead. The hearse alone kept up the remembrance of the noise of carriages or carts in the streets. Funeral processions were laid aside. A black man, leading or driving a horse, with a corpse on a pair of chair wheels, with now and then half a dozen relations or friends following at a distance from it, met the eye in most of the streets of the city, at every hour of the day, while the noise of the same wheels passing slowly over the pavements, kept alive anguish and fear in the sick and well, every hour of the night[55].
But a more serious source of the distress of the city arose from the dissentions of the physicians, about the nature and treatment of the fever. It was considered by some as a modification of the influenza, and by others as the jail fever. Its various grades and symptoms were considered as so many different diseases, all originating from different causes. There was the same contrariety in the practice of the physicians that there was in their principles. The newspapers conveyed accounts of both to the public, every day. The minds of the citizens were distracted by them, and hundreds suffered and died from the delays which were produced by an erroneous opinion of a plurality of diseases in the city, or by indecision in the choice, or a want of confidence in the remedies of their physician.
The science of medicine is related to every thing, and the philosopher as well as the christian will be gratified by knowing the effects of a great and mortal epidemic upon the morals of a people. It was some alleviation of the distress produced by it, to observe its influence upon the obligations of morality and religion. It was remarked during this time, by many people, that the name of the Supreme Being was seldom profaned, either in the streets, or in the intercourse of the citizens with each other. But two robberies, and those of a trifling nature, occurred in nearly two months, although many hundred houses were exposed to plunder, every hour of the day and night. Many of the religious societies met two or three times a week, and some of them every evening, to implore the interposition of Heaven to save the city from desolation. Humanity and charity kept pace with devotion. The public have already seen accounts of their benevolent exercises in other publications. It was my lot to witness the uncommon activity of those virtues upon a smaller scale. I saw little to blame, but much to admire and praise in persons of different professions, both sexes, and of all colours. It would be foreign to the design of this work to draw from the obscurity which they sought, the many acts of humanity and charity, of fortitude, patience, and perseverance, which came under my notice. They will be made public and applauded elsewhere.
But the virtues which were excited by our calamity were not confined to the city of Philadelphia. The United States wept for the distresses of their capital. In several of the states, and in many cities and villages, days of humiliation and prayer were set apart to supplicate the Father of Mercies in behalf of our afflicted city. Nor was this all. From nearly every state in the union the most liberal contributions of money, provisions, and fuel were poured in for the relief and support of such as had been reduced to want by the suspension of business, as well as by sickness and the death of friends.
The number of deaths between the 1st of August and the 9th of November amounted to four thousand and forty-four. I shall here insert a register of the number which occurred on each day, beginning on the 1st of August, and ending on the 9th of November. By comparing it with the register of the weather it will show the influence of the latter on the disease. Several of the deaths in August were from other acute diseases, and a few in the succeeding months were from such as were of a chronic nature.
| died. | ||
| August | 1 | 9 |
| 2 | 8 | |
| 3 | 9 | |
| 4 | 10 | |
| 5 | 10 | |
| 6 | 3 | |
| 7 | 12 | |
| 8 | 5 | |
| 9 | 11 | |
| 10 | 6 | |
| 11 | 7 | |
| 12 | 5 | |
| 13 | 11 | |
| 14 | 4 | |
| 15 | 9 | |
| 16 | 7 | |
| 17 | 6 | |
| 18 | 5 | |
| 19 | 9 | |
| 20 | 7 | |
| 21 | 8 | |
| 22 | 13 | |
| 23 | 10 | |
| 24 | 17 | |
| 25 | 12 | |
| 26 | 17 | |
| 27 | 12 | |
| 28 | 22 | |
| 29 | 24 | |
| 30 | 20 | |
| 31 | 17 | |
| September | 1 | 17 |
| 2 | 18 | |
| 3 | 11 | |
| 4 | 23 | |
| 5 | 20 | |
| 6 | 24 | |
| 7 | 18 | |
| 8 | 42 | |
| 9 | 32 | |
| 10 | 29 | |
| 11 | 23 | |
| 12 | 33 | |
| 13 | 37 | |
| 14 | 48 | |
| 15 | 56 | |
| 16 | 67 | |
| 17 | 81 | |
| 18 | 68 | |
| 19 | 61 | |
| 20 | 67 | |
| 21 | 57 | |
| 22 | 76 | |
| 23 | 68 | |
| 24 | 96 | |
| 25 | 87 | |
| 26 | 52 | |
| 27 | 60 | |
| 28 | 51 | |
| 29 | 57 | |
| 30 | 63 | |
| October | 1 | 74 |
| 2 | 66 | |
| 3 | 78 | |
| 4 | 58 | |
| 5 | 71 | |
| 6 | 76 | |
| 7 | 82 | |
| 8 | 90 | |
| 9 | 102 | |
| 10 | 93 | |
| 11 | 119 | |
| 12 | 111 | |
| 13 | 104 | |
| 14 | 81 | |
| 15 | 80 | |
| 16 | 70 | |
| 17 | 80 | |
| 18 | 59 | |
| 19 | 65 | |
| 20 | 55 | |
| 21 | 59 | |
| 22 | 82 | |
| 23 | 54 | |
| 24 | 38 | |
| 25 | 35 | |
| 26 | 23 | |
| 27 | 13 | |
| 28 | 24 | |
| 29 | 17 | |
| 30 | 16 | |
| 31 | 21 | |
| November | 1 | 13 |
| 2 | 21 | |
| 3 | 15 | |
| 4 | 15 | |
| 5 | 14 | |
| 6 | 11 | |
| 7 | 15 | |
| 8 | 8 | |
| 9 | 6 | |
| Total[56] | 3881 | |
From this table it appears that the principal mortality was in the second week of October. A general expectation had obtained, that cold weather was as fatal to this fever as heavy rains. The usual time for its arrival had come, but the weather was still not only moderate, but warm. In this awful situation, the stoutest hearts began to fail. Hope sickened, and despair succeeded distress in almost every countenance. On the fifteenth of October, it pleased God to alter the state of the air. The clouds at last dropped health in showers of rain, which continued during the whole day, and which were succeeded for several nights afterwards by cold and frost. The effects of this change in the weather appeared first in the sudden diminution of the sick, for the deaths continued for a week afterwards to be numerous, but they were of persons who had been confined before, or on the day in which the change had taken place in the weather.
The appearance of this rain was like a dove with an olive branch in its mouth to the whole city. Public notice was given of its beneficial effects, in a letter subscribed by the mayor of Philadelphia, who acted as president of the committee, to the mayor of New-York. I shall insert the whole of this letter. It contains, besides the above information, a record of the liberality of that city to the distressed inhabitants of Philadelphia.
“Sir,
“I am favoured with your letter of the 12th instant, which I have communicated to the committee for the relief of the poor and afflicted of this city.
“It is with peculiar satisfaction that I execute their request, by making, in their name, on behalf of our suffering fellow-citizens, the most grateful acknowledgements for the seasonable benevolence of the common council of the city of New-York. Their sympathy is balm to our wounds.
“We acknowledge the Divine interposition, whereby the hearts of so many around us have been touched with our distress, and have united in our relief.
“May the Almighty Disposer of all events be graciously pleased to protect your citizens from the dreadful calamity with which we are now visited; whilst we humbly kiss the rod, and improve by the dispensation.
“The part, sir, which you personally take in our afflictions, and which you have so pathetically expressed in your letter, excites in the breasts of the committee the warmest sensations of fraternal affection.
“The refreshing rain which fell the day before yesterday, though light, and the cool weather which hath succeeded, appear to have given a check to the prevalence of the disorder: of this we have satisfactory proofs, as well in the decrease of the funerals, as in the applications for removal to the hospital.
“I have, at your request, this day drawn upon you, at sight, in favour of the president and directors of the Bank of North America, for the sum of five thousand dollars, the benevolent donations of the common council of the city of New-York.
“With sentiments of the greatest esteem and regard,
“I am, sir,
“Your most obedient humble servant,
“MATTH. CLARKSON.
“Philadelphia, Oct. 17, 1793.
“Richard Varick, mayor
of the city of New-York.”
It is no new thing for bilious fevers, of every description, to be checked or subdued by wet and cold weather.
The yellow fever which raged in Philadelphia in 1699, and which is taken notice of by Thomas Story in his journal, ceased about the latter end of October, or the beginning of November. Of this there are satisfactory proofs, in the register of the interments in the friends' burying-ground, and in a letter, dated November 9th, old style, 1699, from Isaac Norris to one of his correspondents, which his grandson, Mr. Joseph P. Norris, politely put into my hands, with several others, which mention the disease, and all written in that memorable year in Philadelphia. The letter says, “It has pleased God to put a stop to our sore visitation, and town and country are now generally healthy.” The same disease was checked by wet and cold weather in the year 1741. Of this there is a proof in a letter from Dr. Franklin to one of his brothers, who stopped at Burlington, on his way from Boston to Philadelphia, on account of the fever, until he was assured by the doctor, that a thunder gust, which had cooled the air, had rendered it safe for him to come into the city[57]. Mr. Lynford Lardner, in a letter to one of his English friends, dated September 24, 1747, old style, after mentioning the prevalence of the fever in the city, says, “the weather is now much cooler, and those under the disorder revive. The symptoms are less violent, and the fever gradually abates.”
I have in vain attempted to procure an account of the time of the commencement of cold weather in the autumn of 1762. In the short history of the fever of that year, which I have inserted from my note book, I have said that it continued to prevail in the months of November and December. The register of the interments in the friends' burying-ground in those months confirms that account. They were nearly as numerous in November and December as in September and October, viz. in September 22, in October 27, in November 19, and in December 26.
The bilious remitting fever of 1780 yielded to cool weather, accompanied by rain and an easterly wind[58].
Sir John Pringle will furnish ample satisfaction to such of my readers as wish for more proofs of the efficacy of heavy rains, and cold weather, in checking the progress and violence of autumnal remitting fevers[59].
From the 15th of October the disease not only declined, but assumed more obvious inflammatory symptoms. It was, as in the beginning, more necessarily fatal where left to itself, but it yielded more certainly to art than it did a few weeks before. The duration of it was now more tedious than in the warmer weather.
There were a few cases of yellow fever in November and December, after the citizens who had retired to the country returned to the city.
I heard of but three persons who returned to the city being infected with the disease; so completely was its cause destroyed in the course of a few weeks.
In consequence of a proclamation by the governor, and a recommendation by the clergy of Philadelphia, the 12th of December was observed as a day of thanksgiving throughout the state, for the extinction of the disease in the city.
It was easy to distinguish, in walking the streets, the persons who had returned from the country to the city, from those who had remained in it during the prevalence of the fever. The former appeared ruddy and healthy, while the latter appeared of a pale or sallow colour.
It afforded a subject of equal surprise and joy to behold the suddenness with which the city recovered its former habits of business. In the course of six weeks after the disease had ceased, nothing but fresh graves, and the black dresses of many of the citizens, afforded a public trace of the distress which had so lately prevailed in the city.
The month of November, and all the winter months which followed the autumnal epidemic, were in general healthy. A catarrh affected a number of people in November. I suspected it to be the influenza which had revived from a dormant state, and which had not spent itself, when it yielded to the predominance of the yellow fever. This opinion derives some support from a curious fact related by the late Mr. Hunter of the revival of the small-pox in a patient, in whom it had been suspended for some time by the measles[60]. The few fevers which prevailed in the winter were highly inflammatory. The small-pox in the natural way was in several instances confluent; and in one or two fatal. I was prepared to expect this inflammatory diathesis in the fevers of the winter; for I had been taught by Dr. Sydenham, that the diseases which follow a great and mortal epidemic partake more or less of its general character. But the diseases of the winter had a peculiarity still more extraordinary; and that was, many of them had several of the symptoms of the yellow fever, particularly a puking of bile, dark-coloured stools, and a yellow eye. Mr. Samuel D. Alexander, a student of medicine from South-Carolina, who was seized with a pneumony about Christmas, had, with a yellow eye, a dilated pupil and a hard pulse, which beat only fifty strokes in a minute. His blood was such as I had frequently observed in the yellow fever. Dr. Griffitts informed me that he attended a patient on the 9th of January, in a pneumony, who had a universal yellowness on his skin. I met with a case of pneumony on the 20th of the same month, in which I observed the same degrees of redness in the eyes that were common in the yellow fever. My pupil, Mr. Coxe, lost blood in an inflammatory fever, on the 18th of February, which was dissolved. Mr. Innes, the brewer, had a deep yellow colour in his eyes, on the fourth day of a pneumony, on the 27th of the same month; and Mr. Magnus Miller had the same symptom of a similar disease on the 16th of March. None of these bilious and anomalous symptoms of the inflammatory fevers of the winter and spring surprised me. I had been early taught, by Dr. Sydenham, that the epidemics of autumn often insinuate some of their symptoms into the winter diseases which follow them. Dr. Cleghorn informs us, that “the pleurisies which succeeded the autumnal tertians in Minorca, were accompanied by a vomiting and purging of green or yellow bilious matters[61].”
It belongs to powerful epidemics to be followed by similar diseases after they disappear, as well as to run into others at their first appearance. In the former case it is occasioned by a peculiar state of the body, created by the epidemic constitution of the air, not having been changed by the weather which succeeded it.
The weather in March resembled that of May; while the weather in April resembled that of March in common years. A rash prevailed in many families, in April, accompanied in a few cases by a sore throat. It was attended with an itching, a redness of the eyes, and a slight fever in a few instances. The small-pox by inoculation in this month was more mortal than in former years. However unimportant these facts may appear at this time, future observations may perhaps connect them with a similar constitution of the air which produced the previous autumnal epidemic.
The appearance of bilious symptoms in the diseases of the winter, excited apprehensions in several instances of the revival of the yellow fever. The alarms, though false, served to produce vigilance and industry in the corporation, in airing and purifying such houses and articles of furniture as belonged to the poor; and which had been neglected in the autumn, after the ceasing of the disease.
The modes of purifying houses, beds, and clothes were various. Fumigations of nitre and aromatic substances were used by some people. Burying infected articles of furniture under ground, and baking them in ovens, were used by others. Some destroyed all their beds and clothing that had been infected, or threw them into the Delaware. Many white-washed their walls, and painted the wood-work of their house. I did not conceive the seeds of the disease required all, or any of those means to destroy it. I believed cold and water to be sufficient for that purpose. I therefore advised keeping the windows of infected rooms open night and day, for a few days; to have the floors and walls of houses well washed; and to expose beds and such articles of household furniture as might be injured by washing, upon the bare earth for a week or two, taking care to turn them every day. I used no other methods of destroying the accumulated miasmata in my house and furniture, and experience showed that they were sufficient.
It is possible a portion of the excretions of the sick may be retained in clothes or beds, so as to afford an exhalation that may in the course of a succeeding summer and autumn, or from accidental warmth at any time, create a solitary case of fever, but it cannot render it epidemic. A trunk full of clothes, the property of Mr. James Bingham, who died of the yellow fever in one of the West-India islands about 50 years ago, was opened, some months after they were received by his friends, by a young man who lived in his brother's family. This young man took the disease, and died; but without infecting any of the family; nor did the disease spread afterwards in the city. The father of Mr. Joseph Paschall was infected with the yellow fever of 1741, by the smell of a foul bed in passing through Norris's Alley, in the latter end of December, after the disease had left the city. He died on the 25th of the month, but without reviving the fever in the city, or even infecting his family.
The matter which produced the fever in both these cases, had nothing specific in it. It acted in the same manner that the exhalation from any other putrid matters would have done in a highly concentrated state.
In a letter from Dr. Senter of Newport, dated January 7th, 1794, I find the following fact, which I shall communicate in his own words. It is introduced to support the principle, that the yellow fever does not spread by contagion. “This place (says the doctor) has traded formerly very much to the West-India islands, and more or less of our people have died there every season, when the disease prevails in those parts. Clothes of these unfortunate people have been repeatedly brought home to their friends, without any accident happening to them.”
I feel with my reader the fatigue of this long detail of facts, and equal impatience with him to proceed to the history of the treatment of the fever; but I must beg leave to detain him a little longer from that part of the work, while I resume the subject of the origin of the fever. It is an interesting question, as it involves in it the means of preventing the return of the disease, and thereby of saving the lives of thousands of our citizens.
Soon after the fever left the city, the governor of the state addressed a letter to the college of physicians, requesting to know their opinion of its origin; if imported, from what place, at what time, and in what manner. The design of this inquiry was to procure such information as was proper to lay before the legislature, in order to improve the laws for preventing the importation or generation of infectious diseases, or to enact new ones, if necessary for that purpose. To the governor's letter the college of physicians sent the following answer:
”Sir,
”It has not been from a want of respect to yourself, nor from inattention to the subject, that your letter of the 30th ult. was not sooner answered; but the importance of the questions proposed has made it necessary for us to devote a considerable portion of time and attention to the subject, in order to arrive at a safe and just conclusion.
”No instance has ever occurred of the disease called the yellow fever having been generated in this city, or in any other parts of the United States, as far as we know; but there have been frequent instances of its having been imported, not only into this, but into other parts of North-America, and prevailing there for a certain period of time; and from the rise, progress, and nature of the malignant fever, which began to prevail here about the beginning of last August, and extended itself gradually over a great part of the city, we are of opinion that this disease was imported into Philadelphia, by some of the vessels which arrived in the port after the middle of July. This opinion we are further confirmed in by various accounts we have received from unquestionable authorities.
”Signed, by order of the college of physicians,
”JOHN REDMAN, President.
”November 26th, 1793.
”To the governor of Pennsylvania.”
Dr. Redman, the president of the college, Dr. Foulke, and Dr. Leib, dissented from the report contained in this letter. I have been necessarily led to continue it in the present edition of this work, not only because all the other members of that body still retain their belief of the importation of the fever, but as a reason for republishing the facts and arguments in support of its domestic origin.
I have asserted, in the introduction to the history of this fever, that I believed it to have been generated in our city; I shall now deliver my reasons for that belief.
1. The yellow fever in the West-Indies, and in all other countries where it is endemic, is the offspring of vegetable putrefaction. Heat, exercise, and intemperance in drinking (says Dr. Lind) dispose to this fever in hot climates, but they do not produce it without the concurrence of a remote cause. This remote cause exists at all times, in some spots of the islands, but in other parts even of the same islands, where there are no marsh exhalations, the disease is unknown. I shall not waste a moment in inquiring into the truth of Dr. Warren's account of the origin of this fever. It is fully refuted by Dr. Hillary, and it is treated as chimerical by Dr. Lind. They have very limited ideas of the history of this fever who suppose it to be peculiar to the East or West-Indies. It was admitted to have been generated in Cadiz after a hot and dry summer in 1764, and in Pensacola in 1765[62]. The tertian fever of Minorca, when it attacked Englishmen, put on the usual symptoms of the yellow fever[63]. In short, this disease appears, according to Dr. Lind, in all the southern parts of Europe, after hot and dry weather[64].
2. The same causes (under like circumstances) must always produce the same effects. There is nothing in the air of the West-Indies, above other hot countries, which disposes it to produce a yellow fever. Similar degrees of heat, acting upon dead and moist vegetable matters, are capable of producing it, together with all its various modifications, in every part of the world. In support of this opinion, I shall transcribe part of a letter from Dr. Miller, formerly of the Delaware state, and now of New-York.
“Dover, Nov. 5, 1793.
“Dear Sir,
“Since the middle of last July we have had a bilious colic epidemic in this neighbourhood, which exhibits phænomena very singular in this climate; and, so far as I am informed, unprecedented in the medical records, or popular traditions of this country. To avoid unnecessary details it will suffice at present to observe, that the disease, on this occasion, has assumed, not only all the essential characters, but likewise all the violence, obstinacy, and malignity described by the East and West-Indian practitioners. If any difference can be observed it seems here to manifest higher degrees of stubbornness and malignity than we usually meet in the histories of tropical writers. In the course of the disease, not only extreme constipation, frequent vomiting, and the most excruciating pains of the bowels and limbs, harass the unhappy patient; but to these succeed paralysis, convulsions, [**amp]c. and almost always uncommon muscular debility, oppression of the præcordia, [**amp]c. are the consequence of a severe attack. Bile discharged in enormous quantities constantly assumes the most corrupted and acrimonious appearances, commonly æruginous in a very high degree, and sometimes quite atrabilious.
“The inference I mean to draw from the phænomena of this disease, as it appears in this neighbourhood, and which I presume will also apply to your epidemic, is this, that from the uncommon protraction and intenseness of our summer and autumnal heats, but principally from the unusual drought, we have had, since the middle of July, a near approach to a tropical season, and that of consequence we ought not to be surprised if tropical diseases, even of the most malignant nature, are engendered amongst us.”
To the above information it may be added, that the dysentery which prevailed during the autumn of 1793, in several of the villages of Pennsylvania, was attended with a malignity and mortality unknown before in any part of the state. I need not pause to remark that this dysentery arose from putrid exhalation, and that it is, like the bilious colic, only a modification of bilious fever.
But further, a malignant fever, resembling that which was epidemic in our city, prevailed during the autumn in many parts of the United States, viz. at Lynn in Massachusetts, at Weatherfield and Coventry in Connecticut, at New-Galloway in the state of New-York, on Walkill and on Pensocken creeks in New-Jersey, at Harrisburgh and Hummelstown in Pennsylvania, in Caroline county in Maryland, on the south branch of the Potowmac in Hardie county, also in Lynchburgh and in Alexandria in Virginia, and in several counties in North-Carolina. In none of these places was there a suspicion of the disease being imported from abroad, or conveyed by an intercourse with the city of Philadelphia.
It is no objection to the inference which follows from these facts, that the common remitting fever was not known during the above period in the neighbourhood of this city, and in many other parts of the state, where it had usually appeared in the autumnal months. There is a certain combination of moisture with heat, which is essential to the production of the remote cause of a bilious fever. Where the heat is so intense, or of such long duration, as wholly to dissipate moisture, or when the rains are so great as totally to overflow the marshy ground, or to wash away putrid masses of matter, no fever can be produced.
Dr. Dazilles, in his treatise upon the diseases of the negroes in the West-Indies, informs us, that the rainy season is the most healthy at Cayenne, owing to the neighbouring morasses being deeply overflowed; whereas, at St. Domingo, a dry season is most productive of diseases, owing to its favouring those degrees of moisture which produce morbid exhalations. These facts will explain the reason why, in certain seasons, places which are naturally healthy in our country become sickly, while those places which are naturally sickly escape the prevailing epidemic. Previously to the dissipation of the moisture from the putrid masses of vegetable matters in our streets, and in the neighbourhood of the city, there were (as several practitioners can testify) many cases of mild remittents, but they all disappeared about the first week in September.
It is worthy of notice, that the yellow fever prevailed in Virginia in the year 1741, and in Charleston, in South-Carolina, in the year 1699, in both which years it prevailed in Philadelphia. Its prevalence in Charleston is taken notice of in a letter, dated November 18th, O. S. 1699, from Isaac Norris to one of his correspondents. The letter says, that “150 persons had died in Charleston in a few days,” that “the survivors fled into the country,” and that “the town was thinned to a very few people.” Is it not probable, from the prevalence of this fever twice in two places in the same years, that it was produced (as in 1793) by a general constitution of air, co-operating with miasmata, which favoured its generation in different parts of the continent? But again, such was the state of the air in the summer of 1793, that it predisposed other animals to diseases, besides the human species. In some parts of New-Jersey, a disease prevailed with great mortality among the horses, and in Virginia among the cows, during the autumn. The urine in both was yellow.—Large abscesses appeared in different parts of the body in the latter animals, which, when opened, discharged a yellow serous fluid. From the colour of these discharges, and of the urine, the disease got the name of the yellow water.
3. I have before remarked, that a quantity of damaged coffee was exposed at a time (July the 24th) and in a situation (on a wharf and in a dock) which favoured its putrefaction and exhalation. Its smell was highly putrid and offensive, insomuch that the inhabitants of the houses in Water and Front-streets, who were near it, were obliged, in the hottest weather, to exclude it by shutting their doors and windows. Even persons, who only walked along those streets, complained of an intolerable fœtor, which, upon inquiring, was constantly traced to the putrid coffee. It should not surprise us, that this seed, so inoffensive in its natural state, should produce, after its putrefaction, a violent fever. The records of medicine (to be mentioned hereafter) furnish instances of similar fevers being produced, by the putrefaction of many other vegetable substances.
4. The rapid progress of the fever from Water-street, and the courses through which it travelled into other parts of the city, afford a strong evidence that it was at first propagated by exhalation from the putrid coffee. It was observed that it passed first through those alleys and streets which were in the course of the winds that blew across the dock and wharf, where the coffee had been thrown in a state of putrefaction.
5. Many persons who had worked, or even visited, in the neighbourhood of the exhalation from the coffee, early in the month of August, were indisposed afterwards with sickness, puking, and yellow sweats, long before the air of Water-street was so much impregnated with the exhalation, as to produce such effects; and several patients, whom I attended in the yellow fever, declared to me, or to their friends, that their indispositions began exactly at the time they inhaled the offensive effluvia of the coffee.
6. The first cases of the yellow fever have been clearly traced to the sailors of the vessel who were first exposed to the effluvia of the coffee. Their sickness commenced with the day on which the coffee began to emit its putrid smell. The disease spread with the increase of the poisonous exhalation. A journeyman of Mr. Peter Brown's, who worked near the corner of Race and Water-streets, caught the disease on the 27th of July. Elizabeth Hill, the wife of a fisherman, was infected by only sailing near the pestilential wharf, about the 1st of August, and died at Kensington on the 14th of the same month. Many other names might be mentioned of persons who sickened during the last week in July or the first week in August, who ascribed their illnesses to the smell of the coffee.
7. It has been remarked that this fever did not spread in the country, when carried there by persons who were infected, and who afterwards died with it. During four times in which it prevailed in Charleston, in no one instance, according to Dr. Lining, was it propagated in any other part of the state.
8. In the histories of the disease which have been preserved in this country, it has six times appeared about the first or middle of August, and declined or ceased about the middle of October: viz. in 1732, 1739, 1745, and 1748 in Charleston, in 1791 in New-York, and in 1793 in Philadelphia. This frequent occurrence of the yellow fever at the usual period of our common bilious remittents, cannot be ascribed to accidental coincidence, but must be resolved, in most cases, into the combination of more active miasmata with the predisposition of a tropical season. In speaking of a tropical season, I include that kind of weather in which rains and heats are alternated with each other, as well as that which is uniformly warm.
9. Several circumstances attended this epidemic, which do not occur in the West-India yellow fever. It affected children as well as adults, in common with our annual bilious fevers. In the West-Indies, Dr. Hume tells us, it never attacked any person under puberty. It had, moreover, many peculiar symptoms (as I have already shown) which are not to be met with in any of the histories of the West India yellow fever.
10. Why should it surprise us to see a yellow fever generated amongst us? It is only a higher grade of a fever which prevails every year in our city, from vegetable putrefaction. It conforms, in the difference of its degrees of violence and danger, to season as well as climate, and in this respect it is upon a footing with the small-pox, the measles, the sore-throat, and several other diseases. There are few years pass, in which a plethoric habit, and more active but limited miasmata, do not produce sporadic cases of true yellow fever in Philadelphia. It is very common in South and North-Carolina and in Virginia, and there are facts which prove, that not only strangers, but native individuals, and, in one instance, a whole family, have been carried off by it in the state of Maryland. It proved fatal to one hundred persons in the city of New-York in the year of 1791, where it was evidently generated by putrid exhalation. The yellow colour of the skin has unfortunately too often been considered as the characteristic mark of this fever, otherwise many other instances of its prevalence might be discovered, I have no doubt, in every part of the United States. I wish, with Dr. Mosely, the term yellow could be abolished from the titles of this fever, for this colour is not only frequently absent, but sometimes occurs in the mildest bilious remittents. Dr. Haller, in his pathology, describes an epidemic of this kind in Switzerland, in which this colour generally attended, and I have once seen it almost universal in a common bilious fever, which prevailed in the American army, in the year 1776.
I cannot help taking notice, in this place, of an omission in the answer to the governor's letter, by the college of physicians. The governor requested to know whether it was imported; if it were, from what place, at what time, and in what manner. In the answer of the college of physicians to the governor's letter no notice was taken of any of those questions. In vain did Dr. Foulke call upon the college to be more definite in their answer to them. They had faithfully sought for the information required, but to no purpose. The character of their departed brother, Dr. Hutchinson, for capacity and vigilance in his office, as inspector of sickly vessels, was urged without effect as an argument against the probability of the disease being imported. Public report had derived it from several different islands; had chased it from ship to ship, and from shore to shore; and finally conveyed it at different times into the city, alternately by dead and living bodies; and from these tales, all of which, when investigated, were proved to be without foundation, the college of physicians composed their letter. It would seem, from this conduct of the college, as if medical superstition had changed its names, and that, in accounting for the origin of pestilential fevers, celestial, planetary, and demoniacal influence had only yielded to the term importation.
Let not the reader reject the opinion I have delivered because it is opposed by so great a majority of the physicians of Philadelphia. A single physician supported an opinion of the existence of the plague at Messina, in the year 1743, in opposition to all the physicians (33 in number) of that city. They denied the disease in question to exist, because it was not accompanied by glandular swellings. Time showed that they were all mistaken, and the plague, which might probably have been checked, at its first appearance, by their united efforts, was, by means of their ignorance, introduced with great mortality into every part of the city. This disposition of physicians to limit the symptoms of several other diseases, cannot be sufficiently lamented. The frequent absence of a yellow colour, in this epidemic, led to mistakes which cost the city of Philadelphia several hundred lives.
The letter of the college of physicians has served to confirm me in an opinion, that the plagues which occasionally desolated most of the countries of Europe, in former centuries, and which were always said to be of foreign extraction, were of domestic origin. Between the years 1006 and 1680, the plague was epidemic fifty-two times all over Europe. It prevailed fourteen times in the 14th century. The state of Europe, in this long period, is well known. Idleness, a deficiency of vegetable aliment, a camp life, from the frequency of wars, famine, an uncultivated and marshy soil, small cabins, and the want of cleanliness in dress, diet, and furniture, all concurred to generate pestilential diseases. The plagues which prevailed in London, every year from 1593 to 1611, and from 1636 to 1649, I believe were generated in that city. The diminution of plagues in Europe, more especially in London, appears to have been produced by the great change in the diet and manners of the people; also by the more commodious and airy forms of the houses of the poor, among whom the plague always makes its first appearance. It is true, these plagues were said by authors to have been imported, either directly or indirectly, from the Levant; but the proofs of such importation were as vague and deficient as they were of the West-India origin of our epidemic. The pestilential fevers which have been mentioned, have been described by authors by the generic name of the plague, but they appear to have originated from putrid vegetable exhalations, and to have resembled, in most of their symptoms, the West-India and North-American yellow fever.
I shall resume this interesting subject in another place, in which I shall mention a number of additional facts, not only in support of the domestic origin of the bilious yellow fever, but of its not spreading by contagion, and of course of its being impossible to import it. I shall at the same time enumerate all its different sources, and point out the means of destroying or removing them, and thus of exterminating the disease from our country.
With these observations I conclude the history of the epidemic fever of the year 1793. A few of its symptoms, which have been omitted in this history, will be included in the method of cure, for they were discovered or produced by the remedies which were given for that purpose.
☞ The following page begins an account of the states of the thermometer and weather, from the 1st of January to the 1st of August, and of the states of the barometer, thermometer, winds, and weather, from the 1st of August to the 9th of November, 1793. The times of observation, for the first three months are at 7 in the morning, and 2 in the afternoon; for the next five months they are at 6 in the morning, and 3 in the afternoon. From the 1st of October to the 9th of November, they are as in the first three months.
| JULY, 1793. | ||||||||||||
| Barom. | Ther. | Winds. | Weather. | |||||||||
| Days. | 6 A. M. | 3 P. M. | 6 A. M. | 3 P. M. | 6 A. M. | 3 P. M. | ||||||
| 1 | 30 | 0 | 29 | 8 | 77 | 88 | W | W | fair. | |||
| 2 | 29 | 8 | 29 | 7 | 77 | 81 | W | fair, showers. | ||||
| 3 | 29 | 9 | 30 | 0 | 74 | 80 | E | E | cloudy. | |||
| 4 | 30 | 1 | 30 | 0 | 70 | 83 | E | SW | cloudy, fair, rain. | |||
| 5 | 30 | 0 | 29 | 9 | 76 | 90 | NW | SW | fair, ditto. | |||
| 6 | 29 | 9 | 30 | 0 | 78 | 91 | SW | SW | cloudy, thunder. | |||
| 7 | 29 | 9 | 30 | 0 | 73 | 88 | NE | NW | fair, clouds. | |||
| 8 | 30 | 1 | 30 | 1 | 72 | 85 | E | E | cloudy, fair. | |||
| 9 | 30 | 0 | 29 | 8 | 73 | 81 | S | SW | cloudy, ditto. | |||
| 10 | 30 | 0 | 30 | 0 | 70 | 84 | W | NW | fair, ditto. | |||
| 11 | 30 | 0 | 30 | 0 | 74 | 88 | NW | NW | fair, clouds. | |||
| 12 | 30 | 1 | 30 | 2 | 70 | 84 | N | N | fair, ditto. | |||
| 13 | 30 | 1 | 30 | 0 | 68 | 83 | NW | NW | fair, ditto. | |||
| 14 | 30 | 0 | 30 | 0 | 65 | 80 | N | Calm | fair, hazy. | |||
| 15 | 30 | 0 | 29 | 9 | 66 | 75 | SW | SW | cloudy, ditto. | |||
| 16 | 29 | 8 | 29 | 7 | 70 | 83 | W | W | rain, fair. | |||
| 17 | 29 | 8 | 29 | 9 | 68 | 81 | NW | NW | fair, ditto. | |||
| 18 | 30 | 0 | 30 | 0 | 66 | 86 | W | SW | fair, ditto. | |||
| 19 | 29 | 9 | 29 | 9 | 75 | 85 | SW | W | fair, cloudy, rain. | |||
| 20 | 30 | 0 | 30 | 0 | 72 | 87 | W | NW | fair, ditto, shower. | |||
| 21 | 30 | 1 | 30 | 1 | 70 | 86 | NW | NW | fair, ditto. | |||
| 22 | 30 | 0 | 30 | 0 | 72 | 87 | SW | SW | fair, ditto. | |||
| 23 | 30 | 0 | 30 | 0 | 73 | 91 | SW | SW | fair, cloudy. | |||
| 24 | 29 | 9 | 29 | 9 | 75 | 89 | Calm | W | cloudy, fair. | |||
| 25 | 30 | 1 | 30 | 1 | 71 | 83 | NW | NNW | fair, ditto. | |||
| 26 | 30 | 2 | 30 | 2 | 63 | 82 | N | NE | fair, ditto. | |||
| 27 | 30 | 2 | 30 | 1 | 64 | 81 | S calm | S | fair, cloudy. | |||
| 28 | 30 | 1 | 30 | 0 | 72 | 85 | Calm | NNE | cloudy, fair. | |||
| 29 | 30 | 1 | 30 | 1 | 74 | 85 | SSE | NE | cloudy, ditto, rain. | |||
| 30 | 30 | 1 | 30 | 0 | 73 | 86 | S | SW | cloudy, fair. | |||
| 31 | 29 | 9 | 29 | 8 | 76 | 80 | SSW | SW | cloudy, rain, fair. | |||
| AUGUST, 1793. | ||||||||||||||
| Barom. | Ther. | Winds. | Weather. | |||||||||||
| Days. | 6 A. M. | 3 P. M. | 6 A. M. | 3 P. M. | 6 A. M. | 3 P. M. | 6 A. M. | 3 P. M. | ||||||
| 1 | 29 | 95 | 30 | 0 | 65 | 77 | WNW | NW | cloudy, | fair, | ||||
| 2 | 30 | 1 | 30 | 1 | 63 | 81 | NW | SW | fair, | fair, | ||||
| 3 | 30 | 6 | 29 | 95 | 62 | 82 | N | NNE | fair, | fair, | ||||
| 4 | 29 | 97 | 30 | 0 | 65 | 87 | S | SW | fair, | fair, | ||||
| 5 | 30 | 5 | 30 | 1 | 73 | 90 | SSW | SW | fair, | fair, | ||||
| 6 | 30 | 2 | 30 | 0 | 77 | 87 | SW | W | cloudy, | fair, | ||||
| 7 | 30 | 12 | 30 | 1 | 68 | 83 | NW | W | fair, | fair, | ||||
| 8 | 30 | 1 | 29 | 95 | 69 | 86 | SSE | SSE | fair, | rain, | ||||
| 9 | 29 | 8 | 29 | 75 | 75 | 85 | SSW | SW | cloudy, | fair, | ||||
| 10 | 29 | 9 | 29 | 9 | 67 | 82 | W | SW | fair, | fair, | ||||
| 11 | 30 | 0 | 30 | 0 | 70 | 84 | SW | WSW | cloudy, | cloudy, | ||||
| 12 | 30 | 0 | 30 | 0 | 70 | 87 | W | W | fair, | fair, | ||||
| 13 | 30 | 5 | 30 | 0 | 71 | 89 | SW | W | fair, | fair, | ||||
| 14 | 30 | 0 | 29 | 95 | 75 | 82 | SW | SW | fair, | rain, | ||||
| 15 | 30 | 0 | 30 | 1 | 72 | 75 | NNE | NE | fair, | cloudy, | ||||
| 16 | 30 | 1 | 30 | 1 | 70 | 83 | NNE | NE | fair, | fair, | ||||
| 17 | 30 | 1 | 30 | 0 | 71 | 86 | SW | SW | fair, | fair, | ||||
| 18 | 30 | 1 | 30 | 1 | 73 | 89 | calm | SW | fair, | fair, | ||||
| 19 | 30 | 1 | 30 | 0 | 72 | 82 | N | N | fair, | cloudy, | ||||
| 20 | 30 | 1 | 30 | 12 | 69 | 82 | NNE | NNE | fair, | fair, | ||||
| 21 | 30 | 15 | 30 | 25 | 62 | 83 | N | NNE | fair, | fair, | ||||
| 22 | 30 | 3 | 30 | 35 | 63 | 86 | NE | SE | fair, | fair, | ||||
| 23 | 30 | 25 | 30 | 15 | 63 | 85 | calm | S | fair, | fair, | ||||
| 24 | 30 | 1 | 30 | 1 | 73 | 81 | calm | calm | cloudy, | rain, | ||||
| 25 | 30 | 1 | 30 | 1 | 71 | 66 | NE | NE | rain, | gr. rain, | ||||
| 26 | 30 | 15 | 30 | 2 | 59 | 69 | NE | NE | cloudy, | cloudy, | ||||
| 27 | 30 | 2 | 30 | 2 | 65 | 73 | NE | NE | cloudy, | cloudy, | ||||
| 28 | 30 | 2 | 30 | 15 | 67 | 80 | S | calm | cloudy, | clearin. | ||||
| 29 | 30 | 16 | 30 | 15 | 72 | 86 | calm | SW | cloudy, | fair, | ||||
| 30 | 30 | 1 | 30 | 1 | 74 | 87 | calm | SW | fair, | fair, | ||||
| 31 | 30 | 0 | 30 | 0 | 74 | 84 | SW | NW | rain, | fair, | ||||
| SEPTEMBER, 1793. | ||||||||||||||
| Barom. | Ther. | Winds. | Weather. | |||||||||||
| Days. | 6 A. M. | 3 P. M. | 6 A. M. | 3 P. M. | 6 A. M. | 3 P. M. | 6 A. M. | 3 P. M. | ||||||
| 1 | 30 | 0 | 29 | 30 | 71 | 86 | calm | SW | fog, | fair, | ||||
| 2 | 29 | 75 | 29 | 8 | 73 | 86 | SW | SW | fair, | fair, | ||||
| 3 | 30 | 0 | 60 | NW | N | fair, | fair, | |||||||
| 4 | 30 | 15 | 30 | 15 | 55 | 75 | W | W | fair, | fair, | ||||
| 5 | 30 | 15 | 30 | 1 | 62 | 80 | SE | S | fair, | cloudy, | ||||
| 6 | 29 | 97 | 29 | 95 | 70 | 89 | WSW | W | fair, | cloudy, | ||||
| 7 | 30 | 0 | 30 | 0 | 65 | 77 | WNW | NW | fair, | fair, | ||||
| 8 | 30 | 1 | 30 | 1 | 64 | 70 | calm | calm | cloudy, | cloudy, | ||||
| 9 | 30 | 0 | 30 | 0 | 66 | 80 | SE | NW | rain, | fair, | ||||
| 10 | 30 | 0 | 30 | 0 | 64 | 72 | N | NNE | fair, | cloudy, | ||||
| 11 | 30 | 1 | 30 | 0 | 62 | 72 | NNE | N | cloudy, | fair, | ||||
| 12 | 29 | 96 | 29 | 9 | 58 | 76 | NW | NNW | fair, | fair, | ||||
| 13 | 29 | 95 | 30 | 0 | 57 | 72 | NW | N | fair, | fair, | ||||
| 14 | 30 | 0 | 30 | 5 | 58 | 79 | NW | NW | fair, | fair, | ||||
| 15 | 30 | 0 | 29 | 97 | 65 | 80 | N | S | fair, | fair, | ||||
| 16 | 29 | 9 | 29 | 70 | 84 | S | SW | cloudy, | fair, | |||||
| 17 | 29 | 8 | 29 | 85 | 66 | 67 | N | N | cloudy, | cloudy, | ||||
| 19 | 30 | 4 | 30 | 35 | 45 | 70 | calm | SW | fair, | fair, | ||||
| 20 | 30 | 3 | 30 | 15 | 54 | 69 | calm | SE | hazy, | hazy, | ||||
| 21 | 30 | 0 | 29 | 0 | 59 | 78 | calm | cloudy, | fair, | |||||
| 22 | 30 | 0 | 30 | 0 | 63 | 83 | calm | cloudy, | fair, | |||||
| 23 | 30 | 1 | 30 | 1 | 62 | 80 | calm | SE | cloudy, | cloudy, | ||||
| 24 | 30 | 2 | 30 | 2 | 65 | 70 | NE | ENE | cloudy, | fair, | ||||
| 25 | 30 | 15 | 30 | 0 | 61 | 68 | NE | NE | cloudy, | cloudy, | ||||
| 26 | 29 | 8 | 29 | 7 | 58 | 79 | N | N | cloudy, | fair, | ||||
| 27 | 29 | 7 | 64 | NW | NW | cloudy, | fair, | |||||||
| 28 | 30 | 5 | 30 | 15 | 54 | 73 | NW | NW | fair, | fair, | ||||
| 29 | 30 | 3 | 30 | 3 | 56 | 74 | NE | ENE | cloudy, | fair, | ||||
| 30 | 30 | 35 | 30 | 3 | 57 | 75 | calm | SW | foggy, | fair, | ||||
| OCTOBER, 1793. | ||||||||||||||
| Barom. | Ther. | Winds. | Weather. | |||||||||||
| Days. | 7 A. M. | 2 P. M. | 7 A. M. | 2 P. M. | 7 A. M. | 2 P. M. | 7 A. M. | 2 P. M. | ||||||
| 1 | 30 | 15 | 30 | 5 | 64 | 80 | SW | SW | cloudy, | fair, | ||||
| 2 | 29 | 9 | 30 | 5 | 70 | 72 | W | NNW | cloudy, | fair, | ||||
| 3 | 30 | 2 | 30 | 15 | 50 | 72 | W | SW | fair, | fair, | ||||
| 4 | 29 | 75 | 29 | 7 | 50 | 72 | SW | W | cloudy, | cloudy, | ||||
| 5 | 30 | 0 | 30 | 1 | 58 | 66 | N | N | fair, | fair, | ||||
| 6 | 30 | 3 | 30 | 3 | 43 | 66 | NE | W | fair, | fair, | ||||
| 7 | 30 | 45 | 46 | calm | fair, | |||||||||
| 8 | 30 | 6 | 30 | 6 | 53 | 68 | N | N | fair, | fair, | ||||
| 9 | 30 | 5 | 30 | 4 | 53 | 70 | NW | NW | fair, | fair, | ||||
| 10 | 30 | 2 | 30 | 2 | 49 | 74 | E | NW | fair, | fair, | ||||
| 11 | 30 | 0 | 29 | 85 | 51 | 74 | W | W | fair, | fair, | ||||
| 12 | 29 | 6 | 29 | 55 | 58 | 64 | SW | NW | rain, | rain, | ||||
| 13 | 29 | 85 | 29 | 9 | 49 | 69 | NW | NW | fair, | fair, | ||||
| 14 | 30 | 5 | 30 | 0 | 52 | 76 | SW | SW | calm, | fair, | ||||
| 15 | 29 | 75 | 29 | 8 | 56 | 54 | SW | N | fair, | rain, | ||||
| 16 | 30 | 0 | 30 | 0 | 37 | 53 | NNW | N | fair, | fair, | ||||
| 17 | 30 | 1 | 30 | 1 | 37 | 60 | NE | NE | fair, | fair, | ||||
| 18 | 30 | 1 | 30 | 1 | 41 | 62 | NW | NW | fair, | fair, | ||||
| 19 | 30 | 0 | 29 | 9 | 51 | 66 | N | N | cloudy, | fair, | ||||
| 20 | 30 | 0 | 30 | 0 | 44 | 54 | NW | N | fair, | fair, | ||||
| 21 | 30 | 0 | 30 | 2 | 49 | 59 | N | NW | fair, | fair, | ||||
| 22 | 29 | 6 | 29 | 5 | 51 | 65 | NW | NW | fair, | fair, | ||||
| 23 | 29 | 8 | 29 | 8 | 47 | 60 | W | W | fair, | fair, | ||||
| 24 | 30 | 3 | 30 | 4 | 36 | 59 | W | NW | fair, | fair, | ||||
| 25 | 30 | 4 | 30 | 3 | 46 | 71 | S | S | cloudy, | do. h-w. | ||||
| 26 | 30 | 2 | 30 | 2 | 60 | 72 | calm | SW | cloudy, | cloudy, | ||||
| 27 | 30 | 3 | 30 | 3 | 44 | 44 | NNE | NNE | cloudy, | cloudy, | ||||
| 28 | 30 | 2 | 30 | 1 | 34 | 37 | N | N | cloudy, | cloudy, | ||||
| 29 | 29 | 85 | 29 | 85 | 28 | 44 | NNW | NW | fair, | fair, | ||||
| 30 | 30 | 1 | 30 | 1 | 28 | 49 | calm | SW | hazy, | hazy, | ||||
| 31 | 30 | 15 | 30 | 2 | 42 | 45 | calm | NNE | cloudy, | rain, | ||||
| NOVEMBER, 1793. | ||||||||||||||
| Barom. | Ther. | Winds. | Weather. | |||||||||||
| Days. | 7 A. M. | 2 P. M. | 7 A. M. | 2 P. M. | 7 A. M. | 2 P. M. | 7 A. M. | 2 P. M. | ||||||
| 1 | 30 | 1 | 30 | 1 | 40 | 41 | NNE | NE | rain, | cloudy, | ||||
| 2 | 30 | 3 | 30 | 25 | 32 | 49 | NNE | NE | fair, | fair, | ||||
| 3 | 30 | 1 | 30 | 0 | 43 | 56 | calm | SW | cloudy, | cloudy, | ||||
| 4 | 29 | 8 | 29 | 9 | 55 | 67 | SW | SW | cloudy, | fair, | ||||
| 5 | 30 | 15 | 30 | 1 | 50 | 64 | NE | NE | rain, | rain, | ||||
| 6 | 29 | 8 | 29 | 65 | 63 | 67 | S | S | cloudy, | cloudy, | ||||
| 7 | 29 | 8 | 29 | 8 | 44 | 64 | calm | SW | fair, | fair, | ||||
| 8 | 29 | 8 | 29 | 85 | 43 | 56 | SSW | SW | fair, | fair, | ||||
| 9 | 29 | 9 | 29 | 95 | 42 | 65 | SW | SW | fair, | fair, | ||||