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].
[14] Outlines of a Theory of Fever.
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.
[15] Treatise on the Fevers of Jamaica, p. 298.
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."
[16] Outlines of a Theory of Fever.
[17] Vergasca, Sorbait, and Boate in Haller's Bibliotheca Medicinæ,
vol. iii. also by Dr. Stubbs in the Philosophical Transactions,
and Riverius in his treatise de febre pestilenti.
[18] Historia Anatomica Medica, vol ii. obs. 405, 418, 423, 510.
[19] Medical Histories and Reflections, p. 150.
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.