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].
[20] Vol. i. p. 168.
[21] Treatise on the Intestinal Remitting Fever, p. 125.
[22] Outlines of a theory of fever.
[23] Essay on the Epidemic Disease of Lying-in Women, of the years 1787
and 1788, p. 34.
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 diarrh[oe]a 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, f[oe]tid, 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 f[oe]tid, 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 f[oe]tid, 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 gonorrh[oe]a. 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.
[24] Wallis's edition, vol. i. p. 197.
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].
[25] Rosier's Journal for January, 1790, vol. xxxvi. p. 380.
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.
[26] Essay on the Bilious or Yellow Fever, p. 35.
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.