Peter Brown, and totally suppressed in John Madge for two days. I
ascribed this defect of natural action in the kidneys to an _engorgement_
in their blood-vessels, similar to that which takes place in the lungs
and brain in this fever. I had for some time entertained this idea of a
morbid affection of the kidneys, but I have lately been confirmed in it
by the account which Dr. Chisholm gives of the state of one of the
kidneys, in a man whom he lost with the Beullam fever, at Grenada. "The
right kidney (says the doctor) was mortified, although, during his
illness, no symptom of inflammation of that organ was perceived[108]." It
would seem as if the want of action in the kidneys, and a defect in
their functions were not necessarily attended with pain. I recollect to
have met with several cases in 1793, in which there was a total absence
of pain in a suppression of urine of several days continuance. The same
observation is made by Dr. Chisholm, in his account of the Beullam fever
of Grenada[109]. From this fact it seems probable, that pain is not the
effect of any determinate state of animal fibres, but requires the
concurrence of morbid or preternatural excitement to produce it. I met
with but one case of strangury in this fever. It terminated favourably in
a few days. I have never seen death, in a single instance, in a fever
from any cause, where a strangury attended, and I have seldom seen a
fatal issue to a fever, where this symptom was accidentally produced by a
blister. From this fact there would seem to be a connection between a
morbid excitement in the neck of the bladder, and the safety of more
vital parts of the body. The idea of this connection was first suggested
to me, above thirty years ago, by the late Dr. James Leiper, of Maryland,
who informed me that he had sometimes cured the most dangerous cases of
pleurisy, after the usual remedies had failed, by exciting a strangury,
by means of the tincture of Spanish flies mixed with camphorated spirit
of wine.
[108] Essay on the Malignant Pestilential Fever introduced into the
West-Indies from Beullam, p. 137.
[109] Page 224.
The tongue was always moist in the beginning of the fever, but it was
generally of a darker colour than last year. When the disease was left to
itself, or treated with bark and wine, the tongue became of a fiery red
colour, or dry and furrowed, as in the typhus fever.
_Sweats_ were more common in the remissions of this fever, than they were
in the year 1793, but they seldom terminated the disease. During the
course of the sweats, I observed a deadly coldness over the whole body to
continue in several instances, but without any danger or inconvenience to
the patient. In two of the worst cases I attended, there were remissions,
but no sweats until the day on which the fever terminated. In several of
my patients, the fever wore away without the least moisture on the skin.
The _milk_, in one case, was of a greenish colour, such as sometimes
appears in the serum of the blood. In another female patient who gave
suck, there was no diminution in the quantity of her milk during the
whole time of her fever, nor did her infant suffer the least injury from
sucking her breasts.
I observed tears to flow from the eye of a young woman in this fever, at
a time when her mind seemed free from distress of every kind.
V. I proceed next to mention the symptoms of this fever in the nervous
system.
Delirium was less common than last year. I was much struck in observing
John Madge, who had retained his reason while he was so ill as to require
three bleedings a day, to become delirious as soon as he began to
recover, at which time his pulse rose from between 60 and 70, to 96
strokes in a minute. I saw one case of extreme danger, in which a
hysterical laughing and weeping alternately attended.
I have before mentioned the frequency of mania as a symptom of this
disease. An obstinate wakefulness attended the convalescence from this
fever in Peter Brown, John Madge, and Mr. Cole.
Fainting was more common in this fever than in the fever of 1793. It
ushered in the disease in one of my patients, and it occurred in several
instances after bleeding, where the quantity of blood drawn was very
moderate.
Several people complained of giddiness in the first attack of the fever,
before they were confined to their beds. Sighing was less common, but a
hiccup was more so, than in the year before.
John Madge had an immobility in his limbs bordering upon palsy. A
weakness in the wrists in one case succeeded a violent attack of the
fever.
Peter Brown complained of a most acute pain in the muscles of one of his
legs. It afterwards became so much inflamed as to require external
applications to prevent the inflammation terminating in an abscess. Mrs.
Mitchell complained of severe cramps in her legs.
The sensations of pain in this fever were often expressed in extravagant
language. The pain in the head, in a particular manner, was compared to
repeated strokes of a hammer upon the brain, and in two cases, in which
this pain was accompanied by great heat, it was compared to the boiling
of a pot.
The more the pains were confined to the bones and back, the less danger
was to be apprehended from the disease. I saw no case of death from the
yellow fever in 1793, where the patient complained much of pain in the
back. It is easy to conceive how this external determination of morbid
action should preserve more vital parts. The bilious fever of 1780 was a
harmless disease, only because it spent its whole force chiefly upon the
limbs. This was so generally the case, that it acquired, from the pains
in the bones which accompanied it, the name of the "break bone fever."
Hippocrates has remarked that pains which descend, in a fever, are more
favourable than those which ascend[110]. This is probably true, but I did
not observe any such peculiarity in the translation of pain in this
fever. The following fact from Dr. Grainger will add weight to the above
observations. He observed the pains in a malignant fever which were
diffused through the whole head, though excruciating, were much less
dangerous than when they were confined to the temples or forehead[111].
[110] Epidemics, book ii. sect. 2.
[111] Historia Febris Anomalæ Batavæ Annorum 1746, 1747, 1748, cap. i.
I saw two cases in which a locked jaw attended. In one of them it
occurred only during one paroxysm of the fever. In both it yielded in
half an hour to blood-letting. I met with one case in which there was
universal tetanus. I should have suspected this to have been the primary
disease, had not two persons been infected in the same house with the
yellow fever.
The countenance sometimes put on a ghastly appearance in the height of a
paroxysm of the fever. The face of a lady, admired when in health for
uncommon beauty, was so much distorted by the commotions of her whole
system, in a fit of the fever, as to be viewed with horror by all her
friends.
VI. The senses and appetites were affected in this fever in the following
manner.
A total blindness occurred in two persons during the exacerbation of the
fever, and ceased during its remissions. A great intolerance of light
occurred in several cases. It was most observable in John Madge during
his convalescence.
A soreness in the sense of touch was so exquisite in Mrs. Kapper, about
the crisis of her fever, that the pressure of a piece of fine muslin upon
her skin gave her pain.
Peter Brown, with great heat in his skin, and a quick pulse, had no
thirst, but a most intense degree of thirst was very common in this
fever. It produced the same extravagance of expression that I formerly
said was produced by pain. One of my patients, Mr. Cole, said he "could
drink up the ocean." I did not observe thirst to be connected with any
peculiar state of the pulse.
George Eyre and Henry Clymer had an unusual degree of appetite, just
before the usual time of the return of a paroxysm of fever.
A young man complained to me of being afflicted with nocturnal emissions
of seed during his convalescence. This symptom is not a new one in
malignant fevers. Hippocrates takes notice of it[112]. I met with one
instance of it among the sporadic cases of yellow fever which occurred in
1795. It sometimes occurs, according to Lomius, in the commotions of the
whole system which take place in epilepsy.
[112] Epidemics, book IV.
VII. The disease made an impression upon the lymphatic system. Four of my
patients had glandular swellings: two of them were in the groin; a third
was in the parotid; and the fourth was in the maxillary glands. Two of
these swellings suppurated.
VIII. The yellowness of the skin, which sometimes attends this fever, was
more universal, but more faint than in the year 1793. It was, in many
cases, composed of such a mixture of colours, as to resemble polished
mahogany. But, in a few cases, the yellowness was of a deep orange
colour. The former went off with the fever, but the latter often
continued for several weeks after the patients recovered. In some
instances a red colour predominated to such a degree in the face, as to
produce an appearance of inflammation.
In Mrs. Vogles a yellowness appeared in her eyes during the paroxysm of
her fever, and went off in its remissions.
In James Lefferty the yellowness affected every part of his body, except
his hands, which were as pale as in a common fever.
Peter Brown tinged his sheets of a yellow colour, by night sweats, many
weeks after his recovery.
There was an exudation from the soles of the feet of Richard Wells's
maid, which tinged a towel of a yellow colour.
In my Account of the Yellow Fever of 1793, I ascribed the yellow colour
of the skin wholly to a mixture of bile with the blood. I believe that
this is the cause of it, in those cases where the colour is deep, and
endures for several weeks beyond the crisis of the fever; but where it is
transitory, and, above all, where it is local, or appears only for a few
hours, during the paroxysm of the fever, it appears probable that it is
connected with the mode of aggregation of the blood, and that it is
produced wholly by some peculiar action in the blood-vessels. A similar
colour takes place from the bite of certain animals, and from contusions
of the skin, in neither of which cases has a suspicion been entertained
of an absorption or mixture of bile with the blood.
A troublesome itching, with an eruption of red blotches on the skin,
attended on the first day of the attack of the fever, in Mrs. Gardiner.
A roughness of the skin, and a disposition in it to peel off, appeared
about the crisis of the fever, in Miss Sally Eyre.
That species of eruption, which I have elsewhere compared to moscheto
bites, appeared in Mrs. Sellers.
John Ray, a day labourer, to whom I was called in the last stage of the
fever, had petechiæ on his breast the day before he died.
That burning heat on the skin, called by the ancients "calor mordens,"
and from which this fever, in some countries, has derived the name of
_causus_, was more common this year than last. It was sometimes local,
and sometimes general. I perceived it in an exquisite degree in the
cheeks only of Miss Sally Eyre, and over the whole body of John Ray. It
had no connection with the rapidity or force of the circulation of the
blood in the latter instance, for it was most intense at a time when he
had no pulse.
It is remarkable that the heat of the skin has no connection with the
state of the pulse. This fact did not escape Dr. Chisholm. He says he
found the skin to be warm while the pulse was at 52, and that it was
sometimes disagreeably cold when the pulse was as quick as in ordinary
fever[113].
[113] Page 117.
IX. I have in another place rejected putrefaction from the blood as the
cause or effect of this fever. I shall mention the changes which were
induced in its appearances when I come to treat of the method of cure.
Having described the symptoms of this fever as they appeared in different
parts of the body, I shall now add a few observations upon its type or
general character.
I shall begin this part of the history of the fever by remarking, that we
had but one reigning disease in town during the autumn and winter; that
this was a bilious remitting, or intermitting, and sometimes a yellow
fever; and that all the fevers from other remote causes than putrid
exhalation, partook more or less of the symptoms of the prevailing
epidemic. As well might we distinguish the rain which falls in gentle
showers in Great-Britain, from that which is poured in torrents from the
clouds in the West-Indies, by different names and qualities, as impose
specific names and characters upon the different states of bilious fever.
The forms in which this fever appeared were as follow.
1. A tertian fever. Several persons died of the third fit of tertians,
who were so well as to go abroad on the intermediate day of the fever. It
is no new thing for malignant fevers to put on the form of a tertian.
Hippocrates long ago remarked, that intermittents sometimes degenerate
into malignant acute diseases; and hence he advises physicians to be on
their guard upon the 5th, 7th, 9th, and even on the 14th day of such
fevers[114].
[114] De Morb. Popular. lib. VII.
2. It appeared most frequently in the form of a remittent. The
exacerbations occurred most commonly in the evening. In some there were
exacerbations in the morning as well as in the evening. But I met with
several patients who appeared to be better and worse half a dozen times
in a day. In each of these cases, there were evident remissions and
exacerbations of the fever.
It assumed, in several instances, the symptoms of a colic and cholera
morbus. In one case the fever, after the colic was cured, ended in a
regular intermittent. In another, the colic was accompanied by a
hæmorrhage from the nose. I distinguished this bilious colic from that
which is excited by lighter causes, by its always coming on with more or
less of a chilliness[115]. The symptoms of colic and cholera morbus
occurred most frequently in June and July.
[115] See Sydenham, vol. I. p. 212.
4. It appeared in the form of a dysentery in a boy of William Corfield,
and in a man whom my pupil, Mr. Alexander, visited in the neighbourhood
of Harrowgate.
5. It appeared, in one case, in the form of an apoplexy.
6. It disguised itself in the form of madness.
7. During the month of November, and in all the winter months, it was
accompanied with pains in the sides and breast, constituting what
nosologists call the "pleuritis biliosa."
8. The puerperile fever was accompanied, during the summer and autumn,
with more violent symptoms than usual. Dr. Physick informed me, that two
women, to whom he was called soon after their delivery, died of uterine
hæmorrhages; and that he had with difficulty recovered two other lying-in
women, who were afflicted with that symptom of a malignant diathesis in
the blood-vessels.
9. Even dropsies partook more or less of the inflammatory and bilious
character of this fever.
10. It blended itself with the scarlatina. The blood, in this disease,
and in the puerperile fever, had exactly the same appearance that it had
in the yellow fever. A yellowness in the eyes accompanied the latter
disease in one case that came under my notice.
A slight shivering ushered in the fever in several instances. But the
worst cases I saw came on without a chilly fit, or the least sense of
coldness in any part of the body.
Such was the predominance of the intermitting, remitting, and bilious
fever, that the measles, the small-pox, and even the gout itself, partook
more or less of its character. There were several instances in which the
measles, and one in which the gout appeared with quotidian exacerbations;
and two in which madness appeared regularly in the form of a tertian.
I mentioned formerly that this fever sometimes went off with a sweat,
when it appeared in a tertian form. This was always the case with the
second grade of the fever, but never with the first degree of it, before
the third or fourth paroxysm; nor did a sweat occur on the fifth or
seventh day, except after the use of depleting remedies. This peculiarity
in the fever of this year was so fixed, that it gave occasion for my
comparing it, in my intercourse with my patients, to a lion on the first
seven days, and to a lamb during the remaining part of its duration.
The fever differed from the fever of the preceding year in an important
particular. I saw or heard of no case which terminated in death on the
first or third day. In every case, the fever came on fraught with
paroxysms. The moderate degrees of it were of so chronic a nature as to
continue for several weeks, when left to themselves. I wish this
peculiarity in the epidemic which I am now describing to be remembered;
for it will serve hereafter to explain the reason why a treatment
apparently different should be alike successful, in different seasons and
in different countries.
The crisis of the fever occurred on uneven days more frequently than in
the fever of the year 1793.
I remarked formerly[116] that remissions were more common in the yellow
fever than in the common bilious fever. The same observation applies to
critical days. They were observable in almost every case in which the
disease was not strangled in its birth. Dr. Chisholm describes the same
peculiarity in the Beullam fever. "I have not met with any disease (says
the doctor) in which the periods were more accurately ascertained[117]."
[116] Account of the Yellow Fever of 1793.
[117] Page 141.
In addition to the instances formerly enumerated[118], of the
predominance of powerful epidemics over other diseases, I shall add two
more, which I have lately met with in the course of my reading.
[118] Account of the Yellow Fever in 1793.
Dr. Chisholm, in describing the pestilential fever introduced into the
West-Indies from Beullam, has the following remarks. "Most other diseases
degenerated into, or partook very much of this. Dysenteries suddenly
stopped, and were immediately succeeded by the symptoms of the
pestilential fever. Catarrhal complaints, simple at first, soon changed
their nature; convalescents from other diseases were very subject to
this, but it generally proved mild. Those labouring at the same time
under chronic complaints, particularly rheumatism and hepatitis, were
very subject to it. The puerperile fever became malignant, and of course
fatal; and even pregnant negro women, who otherwise might have had it in
the usual mild degree peculiar to that description of people, were
reduced to a very dangerous situation by it. In short, every disease in
which the patient was liable to infection, sooner or later assumed the
appearance, and acquired the danger of the pestilential fever[119]."
[119] Page 129, 130.
Dr. Desportes ascribes the same universal empire to the yellow fever
which prevailed in St. Domingo, in the summer of 1733. "The fever of Siam
(says the doctor) conveyed an infinite number of men to the grave, in a
short time; but I saw but one woman who was attacked by it." "The
violence of this disease was such, that it subjected all other diseases,
and reigned alone. This is the character of all contagious and
pestilential diseases. Sydenham, and before him Diemerbroek, have
remarked this of the plague[120]."
[120] Page 40, 41. See also p. 111, 230, 231. vol. I.
In Baltimore, the small-pox in the natural way was attended with unusual
malignity and mortality, occasioned by its being combined with the
reigning yellow fever.
It has been urged as an objection to the influence of powerful epidemics
chasing away, or blending with fevers of inferior force, that the measles
sometimes supplant the small-pox, and mild intermittents take the place
of fevers of great malignity. This fact did not escape the microscopic
eye of Dr. Sydenham, nor is it difficult to explain the cause of it. It
is well known that epidemics, like simple fevers, are most violent at
their first appearance, and that they gradually lose their force as they
disappear; now it is in their evanescent and feeble state, that they are
jostled out of their order of danger or force, and yield to the youthful
strength of epidemics, more feeble under equal circumstances of age than
themselves. It would seem, from this fact, that an inflammatory
constitution of the air, and powerful epidemics, both in their aggregate
and individual forms, possessed a common character. They all invade with
the fury of a savage, and retire with the gentleness of a civilized foe.
It is agreeable to discover from these facts and observations, that
epidemic diseases, however irregular they appear at first sight, are all
subject to certain laws, and partake of the order and harmony of the
universe.
The action of the miasmata upon the body, when, from the absence of an
exciting cause, they did not produce fever, was the same as I have
elsewhere described. The sensations which I experienced, in entering a
small room where a person was confined with this fever, were so exactly
the same with those I felt the year before, that I think I could have
distinguished the presence of the disease without the assistance of my
eyes, or without asking a single question. After sitting a few minutes in
a sick room, I became languid and fainty. Weakness and chilliness
followed every visit I paid to a gentleman at Mr. Oellers's hotel, which
continued for half an hour. A burning in my stomach, great heaviness, and
a slight inflammation in my eyes, with a constant discharge of a watery
humour from them for two days, succeeded the first visit I paid to Mrs.
Sellers. These symptoms came on in less than ten minutes after I left her
room. They were probably excited thus early, and in the degree which I
have mentioned, by my having received her breath in my face by inspecting
her tonsils, which were ulcerated on the first attack of the fever. I
formerly supposed these changes in my body were proofs of the contagious
nature of the yellow fever, but I shall hereafter explain them upon other
principles.
I recollect having more than once perceived a smell which had been
familiar to me during the prevalence of the yellow fever in 1793. It
resembled the smell of liver of sulphur. I suspected for a while that it
arose from the exhalations of the gutters of the city. But an accident
taught me that it was produced by the perspiration of my body. Upon
rubbing my hands, this odour was increased so as to become not only more
perceptible to myself, but in the most sensible degree to my pupil, Mr.
Otto. From this fact, I was convinced that I was strongly impregnated
with miasmata, and I was led by it to live chiefly upon vegetables, to
drink no wine, and to avoid, with double care, all the usual exciting
causes of fever.
There was another mark by which I distinguished the presence of the seeds
of this fever in my system, and that was, wine imparted a burning
sensation to my tongue and throat, such as is felt after it has been
taken in excess, or in the beginning of a fever. Several persons, who
were exposed to the miasmata, informed me that wine, even in the smallest
quantity, affected them exactly in the same manner.
I attended four persons in this fever who had had it the year before.
It remains now that I mention the origin of this fever. This was very
evident. It was produced by the exhalations from the gutters, and the
stagnating ponds of water in the neighbourhood of the city. Where there
was most exhalation, there were most persons affected by the fever. Hence
the poor people, who generally live in the neighbourhood of the ponds in
the suburbs, were the greatest sufferers by it. Four persons had the
fever in Spruce, between Fourth and Fifth-streets, in which part of the
city the smell from the gutters was extremely offensive every evening. In
Water-street, between Market and Walnut-streets, many persons had the
fever: now the filth of that confined part of the city is well known to
every citizen.