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.
[27] Outlines of a Theory of Fever.
[28] See Wallis's edition of Sydenham, vol. i. p. 165. vol. ii. p. 52,
94, 98, 350; De Haen's Ratio Medendi, vol. ii. p. 162. vol. iv. p.
172; Gaubii Pathologia, sect. 498; and Dr. Seybert's inaugural
dissertation, entitled "An Attempt to Disprove the Doctrine of
Putrefaction of the Blood in Living Animals," published in
Philadelphia in 1793.
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]."
[29] Wallis's edition, vol. i. p. 344.
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].
[30] De Febre Pestilenti, vol. xi. p. 93.
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.
[31] Diseases of Minorca, p. 185.
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 diarrh[oe]a, 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]."
[32] Dr. Hodge's Account of the Plague in London, p. 26.
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].
[33] Sed hoc observatu dignum fuit, omnes alios morbos acutos, durante
peste siluisse, et omnes morbos acutos e pestis genere suisse.
Nosologia Methodica, vol. i. p. 416.
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]."
[34] Vol. i. p. 340.
[35] Vol. i. p. 352.
[36] Vol. ii. p. 164. See also p. 1, 109, 122, 204, 212, 233, 274, 355,
358-9, and 436.
[37] De Aere et Morb. Epidem. p. 33, 34.
[38] Page 285.
[39] De Febre Pestilenti, vol. ii. p. 95.
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]."
[40] Vol. i.
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
diarrh[oe]a, 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].
[41] Page 28.
[42] Page 132.
[43] Observations on the Diseases in Long Voyages to the East-Indies,
vol. i. p. 13, 14, 48, 151. vol. ii. p. 99, 318, and 320.
[44] Lib. ii. cap. v.
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.
[45] Hunter on the Venereal Disease, introduction, p. 3.
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.