Chapter XXII: Section I: History of the Yellow Fever (3)

“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 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 of 1762. In proportion as the cool weather advanced, a preternatural determination of the blood took place to the brain and lungs. Many were affected with pneumonic symptoms, and some appeared to die of sudden effusions of blood or serum in the lungs.... The disease seldom appeared without nausea or vomiting. In some cases they both occured for several days, or a week, before any fever took place. This was more frequently the case where the disease _was taken by exhalation from the putrid coffee, than by contagion_. 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 disorder; but I much oftener saw it continue for two days without discharging any thing from the stomach, but the drinks which the patient had taken. 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 disorder. I dreaded this symptom on those days; for, though 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 disorder, 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 occured before any vomiting took place. Drinks were now rejected so suddenly as often to be discharged over the hand that lifted them to the head of the patient. The contents of the stomach were sometimes thrown up with a convulsive motion which propelled them in a stream to a great distance, and in some cases all over the clothes of the by-standers.... On the first and second days many puked from half a pint to nearly a quart of yellow or green bile. In four (three of whom recovered) the bile, even at this time, was black. On the 4th or 5th day a matter resembling coffee-grounds was discharged.... Many recovered in whom this symptom appeared. Towards the close of the disease there was a discharge of a deep or pale-coloured black matter, with flakey substances frequently swimming on the top of it.”

A quantity of grumous blood, dark coloured on the outside, was frequently discharged by vomit towards the end of the disease; and, along with all the discharges from the stomach, there was occasionally a large worm, and frequently large quantities of mucus and tough phlegm. Our author supposes the black blood and coffee-coloured matter to be different from that which constitutes the true _black vomit_. This last he supposes to arise in some cases from matter formed in consequence of a mortification of the stomach.

The bowels were generally costive, sometimes with extreme pain, tenesmus, and mucous and bloody discharges. Sometimes the disease came on with diarrhœa, principally in those who had weak bowels. Sometimes there was a tension of the abdomen, with pain in the lower part of it. Flatulency, chiefly in the stomach, was almost universal in the disorder throughout all its stages.

The colour and consistence of the fæces was various according to the mode of treatment the patient had undergone. Where they were spontaneous, or brought away only by gentle purgatives, their appearance was natural; but when the patient was strongly purged, they were dark-coloured, fœtid, and in large quantity. The colour was sometimes green, sometimes olive. Their fœtor was proportioned to the time they had been detained in the bowels. In one case, where tonics had been used, and the patient had no stool for several days, a purge produced such an excessively fœtid discharge, that the smell produced fainting in an old woman who attended. Their acrimony was so great that the rectum was excoriated, and an extensive inflammation sometimes produced round its extremity. In some cases the stools were as white as in the jaundice. Large round worms were frequently discharged with them.

The urine in this disease was sometimes plentiful and high-coloured, sometimes clear, and sometimes turbid; sometimes discharged with a burning pain, as in a gonorrhœa; sometimes it was suppressed; and in one case the patient voided several quarts of limpid urine just before he died.

Many were relieved on the first day by sweats, sometimes spontaneous, and sometimes produced by diluting drinks, or strong purges; sometimes of a yellow colour, and offensive smell. Sometimes they were cold, though the pulse was full at the same time. In general, however, the skin was dry, and there were but few instances of the disease terminating by sweat after the third day. In some there was a great discharge of mucus from the throat, occasioning an almost constant hawking and spitting; and those always recovered.

In this fever, as in that of Boullam, and in the true plague, people sometimes fell down suddenly in apoplexy, syncope or universal convulsions. Some had numbness and immobility of their limbs. Some had a coma (a continual sleepiness) or an obstinate wakefulness; the latter chiefly attended a state of convalescence. In some the distemper began with a violent cramp in the legs or arms. The last stage was attended with a strong hiccup, which was a very dangerous symptom, as indeed it is in all fevers. In some cases there was a deficiency of sensibility, in others too much, so that the mere motion of the limbs was attended with pain.

In this, as in the Boullam fever, the patient often manifested a considerable degree of strength, even without any delirium. One of Dr. Rush’s patients stood up before a looking-glass, and shaved himself, the day on which he died. A delirium, however, was common, alternating in some cases with the _exacerbations and remissions_ of the fever, but in some continuing without intermission to a few hours before death. Some had maniacal symptoms, without any appearance of fever; but in many the understanding was not impaired throughout the whole course of the disease.

In this disease the pains in almost every part of the body were very distressing. In those cases, however, “where the system sunk under the violent impression of the contagion, there was little or no pain.” In other cases the patients were distressed with pains in their head, particularly affecting the eyeballs. Sometimes it extended from the back down the neck. A pain was felt in the ears, as if they were drawn together by strings. The sides, stomach, liver and bowels were all affected. A burning pain in the stomach was sometimes so excessive that the patient shrieked out violently. The back was often the seat of violent pain, which sometimes extended from the back to the thighs; and the arms and legs were sometimes affected in such a manner that one patient said his limbs felt as if scraped with a sharp instrument.

The thirst was generally moderate, but sometimes otherwise; and, when excessive thirst came on in the last stage of the disorder, it was a dangerous symptom. Water was preferred to all other drinks. The appetite for food returned much sooner in this than in other fevers, and was excessively keen. Coffee was relished in the remissions, in every stage of the disorder. Wine was disliked, but malt-liquors were agreeable. In some cases the recovery was attended with a great propensity to venery, as in the true plague, but in an inferior degree.

In some cases the disease was attended with buboes and glandular swellings. “I met with three cases (says our author) of swellings in the inguinal, two in the parotid, and one in the cervical glands: all these patients recovered without any 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.

“Several cases of carbuncles, such as occur in the plague, came under my notice. They were large, 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 an hæmorrhage took place, which precipitated the death of an amiable lady. A large and painful anthrax on the back succeeded a favourable issue of the fever in another patient. 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 the disposition to cutaneous eruptions in this disorder, it was remarkable that blisters were much less disposed to mortify than in the common nervous fever. Such was the insensibility of the skin in some people, that blisters made no impression upon it.... In every case of this disorder which came under my notice, there were evident remissions or intermissions of the fever, or such symptoms as were substituted for fever.”

The yellow colour rarely appeared before the third day, and generally about the fifth or seventh day. The eyes were not always affected with this colour. Sometimes it appeared first on the neck and breast; and in one case it appeared behind the ears and on the crown of the head, which had been bald for some years. It varied in the deepness of the tint, and sometimes disappeared altogether; but, though some cases of great malignity and danger appeared without any yellowness, it was always a dangerous symptom when it appeared early. The cause of this yellowness is by our author supposed to be an absorption and mixture of the bile with the blood.

After death the body appeared of a deep yellow colour, sometimes a few minutes after death; sometimes it was purple or black; and in one case yellow above, and black below, the middle. In some it was pale, as in common diseases, and many died with a placid countenance as in natural sleep. In some the body grew cold soon after death, in others not till six hours afterwards, and in like manner stiffness occurred sometimes in one hour, in others not till six. Where evacuations had been procured, symptoms of putrescence were longer in making their appearance than in those who had used no medicines for that purpose. Many discharged large quantities of black matter from the bowels, others, of blood from the nose, mouth and bowels.

“The morbid appearances of the internal parts of the body (says the Doctor) as they appear by dissection after death, from the yellow fever, are different in different countries and in different years.” Dr. Mitchill, in his history of the yellow fever in Virginia, in 1737 and 1741, informs us, that, in a female slave of forty, the gall-bladder was outwardly of a deep yellow, but within, full of a black, ropy, coagulated _atrabilis_ (black bile) obstructing the biliary ducts. It was so thick, that it retained its figure when the gall-bladder was opened. It more resembled bruised and mortified blood than bile, though it would stain a knife or probe of a yellow colour. Two thirds of the liver on its concave surface were of a deep black colour, and round the gall-bladder it seemed to be mortified and corrupted. A viscid bile, like that just described, was found in the duodenum near the gall-bladder. The villous coat being taken off, the other parts were found red and inflamed. The whole was lined with a thick fur or slime. The omentum was so much wasted, that nothing but its blood-vessels could be perceived. The stomach appeared to be distended or swelled, lined like the duodenum, containing a quantity of bile even blacker than that in the bladder. It was inflamed both on the outside and inside. The lungs were inflated and all full of black or livid spots; and on these spots were small blisters like those of an erysipelas or gangrene, containing a yellow humour. The blood-vessels in general were empty; only the vena portarum seemed full and distended as usual. On cutting the sound part of the liver, the lungs or the spleen, blood issued freely.

Dr. Mackittrick found the liver sphacelated, the gall-bladder full of black bile, and the veins tinged with a black _fluid_ blood. In all cases the stomach, duodenum and ilium were remarkably inflamed. The pericardium contained a viscid yellow serum, and in larger quantity than usual. The urinary bladder a little inflamed; the lungs sound.

Dr. Hume, of Jamaica, found the liver enlarged and turgid with bile, and of a pale yellow colour; the stomach and duodenum sometimes inflamed; and, in one case, the former had black spots of the size of a crown-piece. He had seen some bodies in which there was no appearance of inflammation of the stomach, though the patients had been afflicted with excessive vomiting.

Dr. Lind’s account is given on p. 394.

Drs. Physic and Carthrall, of Philadelphia, found the brain in a natural state; the viscera of the thorax perfectly sound; the blood in the heart and veins fluid, similar in its consistence to the blood of persons who have been hanged, or destroyed by electricity. “The stomach and beginning of the duodenum are the parts that are most diseased. In two persons, who died of the disease on the 5th day, the villous membrane of the stomach, especially about its smaller end, was found highly inflamed; and this inflammation extended through the pylorus into the duodenum some way. The inflammation here was extremely similar to that induced in the stomach by acrid poisons, as by arsenic, which we have once had an opportunity of seeing in a person destroyed by it. The bile was of its natural colour, but very viscid.”

In others the stomach was spotted with extravasated blood; and it contained, as well as the intestines, a black liquor like that which had been vomited and purged before death. The gentlemen were of opinion that this must have been a secretion from the liver, as a fluid of the same kind was found in the gall-bladder, of such an acrid nature that it inflamed the operator’s hands, and the inflammation lasted some days. The liver was of its natural appearance, or nearly so. These dissections were made early in the season; and at that time Dr. Rush is of opinion that the disease was not attended with any congestion in the brain, though it was so afterwards; and accordingly we are informed that Dr. Annan attended a dissection at Bush-hill, in which the vessels of the brain were remarkably turgid. Dr. Rush, however, is likewise of opinion, that the morbid appearances in the brain may cease after death, as well as the suffusion of blood in the face disappears 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 affections of the brain to leave either slender or no marks of disease after death. Dr. Quin has given a dissection of a child that died with all the symptoms of hydrocephalus internus, and yet nothing was distinguished in the brain but a slight turgescence of the blood-vessels. Dr. Girdlestone says, that 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 puerperal fever, notwithstanding it seemed to be affected in many cases soon after the attack of the disorder.”

With regard to the state of the blood in this distemper, Dr. Rush says, that when drawn from a vein, it was, “1. In the greatest number of cases, dense, and of a scarlet colour, without any separation into crassamentum and serum. 2. In many cases it did separate into crassamentum and yellow serum. 3. In a few cases the serum was of a natural colour. 4. There were many cases in which the blood was as sizy as in pneumony and rheumatism. 5. In some instances the blood was covered with a blue pellicle of sizy lymph, while the part which lay in the bottom of the bowl was dissolved. In two cases the lymph was mixed with green streaks. 6. It was in a few instances of a dark colour, and as fluid as _molasses_. Both this and the 5th kind of blood occurred chiefly where bleeding had been omitted altogether, or used too sparingly, in the beginning of the disorder. 7. In some patients the blood in the course of the disease exhibited nearly all the appearances which have been mentioned. They were varied by the time in which the blood was drawn, and by the nature and force of the remedies which had been used in the disorder.”

From this account of the different appearances of the blood, it appears to have varied at the very first attack from an healthy state, and to have gradually deviated from that state more and more, as the disease advanced. Dr. Rush says,[150] from Dr. Mitchill’s History of the Yellow Fever in Virginia, in 1741, that “blood drawn from a vein was always dissolved. The same state of the blood was observed in many persons who had been exposed to the contagion, who discovered no other symptom of the disease.” In p. 70 Dr. Rush gives his own opinion in the following words: “I shall say, hereafter, that the blood was seldom dissolved in this fever;” and p. 73, speaking particularly of the blood, he enters into an argumentation against the putrescency of that fluid. “It” (the blood) says he, “has been supposed to undergo a change from a healthy to a putrid state; and many of the 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 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 on the same cause. They are nothing but effusions of serum or red blood, from a rupture or preternatural dilatation of the capillary vessels. The smell emitted from persons affected with 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 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 chace, 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, putrefy 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 every case of death from indirect debility, whether it be induced by the excessive stimulus of contagion, by the volatile vitriolic acid which is supposed to constitute the destructive _samiel_ wind,[151] or by 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 remarkable 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 it was much slower. There is a fact mentioned by Dr. Ferriar, from Dr. Hamilton, late professor of anatomy at Glasgow, which may seem at first to militate against the facts I have mentioned. He says that he had observed that bodies which were brought into the dissecting room that had petechiæ on them were longer in putrefying than any others. The fevers of which the poor (the common subjects of dissection) die, are generally of the low nervous kind. Great _direct_ debility is the characteristic of those fevers. The petechiæ which occur in them appear in the last stage of this direct debility. They are the effect, not of too much impetus in the blood, as in the yellow fever, but of a defect or total absence of it in the last hours of life. The slow progress of the body to putrefaction after death, in the instances mentioned by Dr. Hamilton, seems to depend upon the same cause as that to which I have ascribed it in those cases of death from the yellow fever in which evacuations had been used, viz. direct debility. In the former cases this slowness of putrefaction is induced by nature, in the latter by art. The effects of debility from both causes are, notwithstanding, the same.”

[150] Account of the Bilious Remitting Fever, &c. p. 106.

[151] See p. 126, n. where an account is given of the samiel, and
another hypothesis concerning its nature.

From this long detail, in which the author’s meaning seems rather involved in obscurity, we may gather that in the fever of 1793 the blood had no determinate appearance, but that, according to the action of the vascular system, it was sizy or otherwise. This position, which in my opinion is the meaning of the passage just now quoted, is not supported by any facts. It is mentioned indeed that the blood in some was sizy, in others quite fluid, but as the cases in which it was so are not particularly related, we do not know whether the action of the vessels was stronger in those where the blood was fluid than where it was not. Certain it is, that the blood may be made fluid by certain substances mixed with it, without any action of the vessels at all. The poison of the ticunas, as well as all other animal poisons, renders the blood fluid, yet this will kill instantaneously when injected into a vein, before the vessels have time to act in such a manner as could be supposed to change the texture of any of the fluids.[152] Or if this still will not satisfy, we are assured that the poison of serpents, as well as many other substances, which are not poisons, when mixed with the blood taken out of the body, will prevent it from coagulating. Granting, therefore, what hath not been proved, that the greater the action of the vessels, the more fluid the blood will be, yet we cannot know whether this fluidity be occasioned by the action of the vessels, or the action of the vessels by the tendency to fluidity in the blood. But it matters not which of the two is cause or effect: the question is, Whether in the yellow fever does the ultimate effort of the disease tend to produce any alteration in the texture of the blood to fluidity, or otherwise? This can be known only from considering the symptoms which take place in the last stage of the disorder, and from dissections. Now, from the concurrent testimonies of all the writers quoted in this treatise, it appears that towards the end of the disease there is such a tendency to dissolution, that the whole body seems ready to fall down into a putrid mass; or at least into what is commonly called so, whether with strict propriety of language or not, signifies little. In short, the difference between the plague and yellow fever seems to be entirely of the same kind with that taken notice of in this treatise, p. p. 269, 270, where the bile of a person dying of a malignant fever was injected into the veins of a dog. Here the blood was very fluid. In capt. Mawhood’s case (p. 385) the blood flowed from his nose, eyes and gums, besides what he discharged by vomit. Dr. Lining (p. 389) attests a similar tendency to dissolution in the blood in a most remarkable manner. See also Dr. Lind’s opinion to the same purpose, p. 393, Dr. Hillary’s, p. 395, Dr. Jackson’s account, p. 399, Dr. Chisholm’s, p. 411; and lastly, Dr. Rush’s own testimony concerning the hæmorrhages from all parts, lately quoted.

[152] See p. 221–223.

As we have formerly seen, that in the plague there was no such tendency to dissolution, but rather to coagulation, in the blood, it was thence concluded that the immediate cause of the symptoms of plague is a tendency in the blood to throw out the latent heat it contains, by which means the parts on which these discharges fall, are burnt up to a kind of cinder. In the yellow fever the reverse takes place. The blood has a tendency to absorb heat, and if it does so it must of course become thinner, for this is the nature of all fluids, and indeed it is abundantly manifest that fluidity in all cases is an effect of the absorption of heat.[153] In consequence of this absorption, the body towards the latter end feels cold, the heat seems to retire from the extremities towards the vital parts, and the vessels contracting and losing their power by reason of the abstraction of sensible heat, the pulse ceases entirely some time before death. Dr. Huxham takes notice of this excessive coldness in the limbs taking place in a lady who died of a malignant fever, and likewise that an intolerable stench issued from her body for some time before her death, though kept clean with all possible care. As the plague therefore is the highest of all inflammatory diseases, so the yellow fever seems to be the highest of the malignant class.

[153] See p. 150.

It may be objected, however, that as hæmorrhages, petechiæ, black vomiting, and convulsions, sometimes take place in the plague, we cannot from the existence of similar symptoms in the yellow fever, conclude that they are different diseases. But, with regard to the first, it must be observed, that an hæmorrhage may ensue from a rupture of vessels as well as from an oozing of blood in consequence of an acrimonious thinness of blood. It is indeed to be questioned, except in cases where blood is discharged by the pores of the skin, whether any hæmorrhage takes place but by a rupture of vessels. In an healthy subject, hæmorrhages very frequently take place from the nose where the blood is of a very proper consistence; and Dr. Russel says that he had occasion to see hæmorrhages from the nose and uterus only; that in the advanced stages of the disease though the blood was paler and of a _thinner_ consistence, the hæmorrhage was seldom profuse. It was, however, of very bad omen; most of the cases in which it appeared having terminated fatally.

That towards the end of this disease the blood should begin to absorb the heat which it had before thrown out, is not wonderful. A tendency to dissolution very probably does in all cases take place in a greater or lesser degree; but we have not any reason to suppose that in the true plague hæmorrhages ever are as frequent, violent, or attended with such an apparent tendency to putrefaction, as in the yellow fever, and consequently we must suppose that there is some _specific_ difference between the state of the blood in the one disease and in the other.

Convulsions, though very frequent in the yellow fever, yet, according to Dr. Russel, were very rare attendants on the access of the pestilential fever. Even hiccup was seldom observed, and sneezing not once. However, he says that convulsive motions of the limbs were frequently observed in the course of the disease; but this is far from what Dr. Chisholm says of the Boullam fever, where the patient expired in a violent convulsive fit; or what Dr. Rush says of the fever of 1793, in which the patient sometimes fell down in universal convulsions. In short, the absence, or much less frequency, of nervous symptoms in the plague, seems to constitute another _specific_ difference between the two.

With regard to black vomiting, it is neither peculiar to the plague nor yellow fever. Dr. Miller[154] has shown that it may be occasioned by almost any kind of acrid poison taken into the stomach. In proof of this he quotes from Sauvages the case of a man who died in consequence of taking a drachm of white arsenic instead of cream of tartar, in whose stomach was found, on dissection, a black liquor which deposited a sediment like powdered charcoal. The villous coat of the stomach was likewise abraded. For other cases of the same kind he refers to Wepfer de cicuta aquatica, Morgagni, &c. Another case of poison by arsenic occurred in New-York hospital, in which the patient had a black vomiting. In another case in which corrosive mercury was swallowed by mistake, the patient, after being to appearance in a fair way of recovery, began to vomit a dark-coloured matter, and died in a day or two. The agaricus clypeatus, a kind of poisonous mushroom, brought on bilious stools, locked jaw, vomiting, delirium, oppression of the breast, sighing, anxiety, great prostration of strength, yellowness on some parts of the skin, and death on the sixth day. On dissection the stomach was found to be inflamed, the duodenum distended with flatus, and the gall-bladder full of green and black bile.

[154] Med. Repository, vol. ii, p. 412.

But the principal distinctions between the plague and yellow fever seem to be the eruptive nature of the former, and the propensity in the latter to attack strangers newly arrived from colder climates; also in being more easily checked by cold than the plague. It has already been remarked from Dr. Russel, that of _two thousand seven hundred_ patients, whose cases he noted, every one had buboes. These, however, were not all the cases he saw; for he mentions some that had no eruptions; but from this it is impossible to avoid drawing the conclusion, that eruptions are the true characteristics of the plague. Of these two thousand seven hundred, eighteen hundred and forty-one had buboes in one or both groins; five hundred and sixty-nine had them in the arm-pit; two hundred and thirty-one had parotids; four hundred and ninety, carbuncles; and seventy-four, spurious buboes. Now, in all the number of cases of fever which Dr. Rush attended in 1793, he had only two with buboes, and one parotid; and as to the carbuncles they do not answer the description of those in the former part of this work.[155] It is impossible therefore that any more clear line of distinction can be drawn between the plague and yellow fever. The following table, however, exhibiting at one view the symptoms of the plague, the yellow fever, fever of Boullam, and fever of 1793, will perhaps set this matter in a still clearer light.

[155] See p. 257.

From a mere inspection of the detail of symptoms in this table, the difference between the several distempers is obvious. It is evident that none of them can with any kind of propriety be called higher and lower degrees of the rest. The plague is _essentially_ different from the other three, which seem indeed to be nearly allied; the Boullam fever being only attended with more violent and malignant symptoms. We ought now to enter into a particular inquiry concerning the origin and nature of these fevers; but, as a knowledge of this is in some measure dependent on the question, whether or not they are contagious, we shall in the first place present the reader with the following extract from a French treatise, in which the question seems to be handled in an agreeable and judicious manner, and then make another attempt, by an investigation of matter of fact, to determine whether the disease has ever been excited by imported contagion or not:

“A very important question is--whether this disease is contagious. The greater part of the American physicians are of opinion that it is, and are persuaded that it is brought from the West Indies, by the ships which arrive here in the beginning of every summer. It is even from that opinion, and on their vigorous representations, that quarantines have been established, which every vessel from the West Indies is obliged to perform during 10 and sometimes 20 days at Fort Mifflin, several miles distance from Philadelphia. This formality, so troublesome to navigation, was observed this year (1798) with more severity than ever it was; but without answering any good purpose for the vessels; for very few ships’ companies appeared taken with the _yellow_ or _putrid fever_. Nevertheless the epidemic, whatever name it assumes, raged this year in Philadelphia with more fury than even in 1793. Besides, if the quarantine was a sure preservative, if almost all the ships’ crews coming from the West Indies brought the _yellow fever_ with them, why should not CHARLESTON, NORFOLK, ALEXANDRIA, BALTIMORE, BOSTON and SALEM, where no quarantines are performed, be affected with the contagion, as well as New York and Philadelphia? The American physicians are so convinced that the _yellow fever_ is contagious, that they scrupulously prohibit persons in health from all communications with those diseased; they order frequent _waterings_ in the streets and about the houses where the fever has manifested itself, and aromatic fumigations. They even order the clothes of those who have fallen by it to be burned, as is practised with respect to those who die with the plague. It must be confessed that their precautions, in this respect, have in some sort been justified, on seeing all the individuals of one family successively taken with it, and often at the same time, their neighbours, and so on, to a number of people who might be authorised to attribute their misfortunes only to their vicinage with the first victims.

_Characters and most remarkable Symptoms_

OF THE

Plague, Yellow Fever, Fever of Boullam, and of Philadelphia in 1793.

(_In this table the mark Do. refers to the column immediately preceding._)

_General Characters._

FEVER OF FEVER OF
PLAGUE. YELLOW FEVER. BOULLAM. PHILADELPHIA
IN 1793.

Known and Not known to Supposed by Various opinions
described exist before the Dr. Chisholm concerning it.
by ancient last century. to be a kind
historians. of new disease
originating in
foul vessels on
the coast of
Africa in 1793.

Attacks Attacks Do. Attacks more
indiscriminately principally generally than
people of all those who change the common yellow
nations. their climates, fever.
especially from
cold to hot.

Not brought on Brought on Do. Do.
by intemperance. not only by
At least Dr. P. intemperance, but
Russel never saw by slight errors
an instance. in regimen.

Sometimes seems Attacks the Attacks the As in the yellow
to spare the robust much intemperate and fever.
weakly and more violently robust.
delicate, and to than those of
attack the robust. a contrary
description.

People sometimes Not observed. Those attacked by Patient sometimes
struck dead as the disease fall falls down in
by a stroke down giddy and apoplexy, syncope
of lightning. almost insensible or universal
Sometimes fall with a profuse convulsions.
down suddenly, cold sweat.
but revive,
and by proper
management regain
their health in a
short time.

Death sometimes Death sometimes Do. Do.
takes place within
without any fever twenty-four
or complaint; hours, but
preceded only not without
by momentary some previous
sickness, by complaints.
eruptions of
purple spots, or
the breaking out
of hard eschars
in different
parts of the body.

Irregular No remission, Do. Remissions and
remissions and but a cessation exacerbations.
exacerbations. of one set of
symptoms to make
way for another.

Venereal appetite Not observed. Do. Venereal appetite
monstrously increased but
increased on less than in the
recovery. plague.

_Symptoms of the Disease in various parts of the Body, or over the whole System._

FEVER OF FEVER OF
PLAGUE. YELLOW FEVER. BOULLAM. PHILADELPHIA
IN 1793.

Infection Not commonly Do. Do.
sometimes begins observed.
with apparent
intoxication.

Sometimes is felt Not observed. Infection felt at Do.
like an electric the commencement
stroke. of the disease,
occasioning a
nausea and rigor.

Fainting very Do. Do. Do.
frequent.

Convulsions rare Not commonly Convulsions Tremors of the
at the beginning. observed. sometimes very limbs uncommon.
Convulsive violent: the
motions of patient often
the limbs not expiring in a
unfrequent fit.
throughout the
disease.

Hiccup uncommon. Hiccup extremely Do. Do.
common.

Sudden loss of Do. Excessive A surprising
strength. strength during degree of
the delirium. strength
sometimes only a
few hours before
death.

Delirium at times. Do. Do. Sometimes Do.
constant.

Loss of speech, Not observed. Do. Do.
faltering and
trembling of the
tongue.

Coma very general. Do. Do. Do.

Muddiness of the Grimness of Eyes inflamed, Eyes watery,
eyes, scarce to countenance. Eyes watery, rolling inflamed, or like
be described. red and heavy. and protruded. balls of fire.
Countenance wild
and ferocious.

A solitary A deep yellow The yellow colour Yellow colour
instance of the colour all over scarcely metvery frequent.
patient becoming the body so with.
green all over. common that the
disease has one
of its names from
it.

Eruptions of Never observed. A kind of small The carbuncles
the nature eschars in the do not answer to
of eschars, nose. Small any description
sometimes black spots on of those in the
small, and the upper lip, plague.
called tokens, but neither
pepper-corns, &c. resembling
sometimes larger, the tokens or
and called carbuncles in
carbuncles, on the plague.
many different Carbuncles
parts of the body. mentioned, but
not described.

Buboes in the Very rarely Sometimes A very few
inguinal, observed. observed, but
instances.
axillary and only in fatal
parotid glands cases.
exceedingly
common.

Pulse extremely Pulse sometimes Pulse Pulse disappeared
variable; indistinguishable disappearing on as in the plague
disappearing from that of a pressure. Did not and Boullam
entirely on healthy person, intermit even at fever; otherwise
pressure; often even a short time the approach of as in the yellow
intermitting. before death. death. fever.
Otherwise of
all possible
varieties.
Sometimes
entirely gone a
considerable time
before death.

Excessive Not observed. Do. Do.
uneasiness at the In the last
heart. One person stage the heart
died with violent palpitates
palpitation. strongly.

Violent pain at Universal in the Very frequently Disease sometimes
the pit of the yellow fever of observed. began with a pain
stomach, which 1762. in the stomach.
could not bear A burning pain
the touch. frequently
accompanied the
vomiting.

Hæmorrhages not Hæmorrhages Do. Do.
very common, and excessively
only from the common from every
nose and uterus. part of the body.

Vomiting of Vomiting of Do. Do.
yellow, green and matters of the
black matter. same kind;
also of matter
resembling coffee
grounds with
flaky substances
floating in it.

Stools less Stools Do. Immense Stools extremely
fœtid than in a excessively quantities of fœtid when
common tertian. fœtid, and in excessively fœtid strong evacuants
Dark coloured great quantity. blood discharged. had been used,
blood sometimes otherwise the
discharged. fœtor was less.

Sweats of various Not observed. Not observed. Yellow and fœtid
colours, and sweats.
fœtid.

Sweat the natural No natural Do. Seldom terminated
crisis of the crisis. by sweat after
distemper. the third day.

_Appearances on Dissection._

FEVER OF FEVER OF
PLAGUE. YELLOW FEVER. BOULLAM. PHILADELPHIA
IN 1793.

Bile of a black Bile of a black Intestines Bile very viscid.
and greenish colour, and very mortified.
colour; turning viscid. Congestion of
quite black by Effusions of blood in the
the addition Stomach affected blood and serum brain.
of spirit of by gangrenous in the brain.
nitre; a lasting spots called Blood in a fluid
grass green by carbuncles by Dr. Liver sometimes state. Stomach
adding spirit Lining. shrunk up into and intestines
of vitriol; and half its natural inflamed.
of a yellow by Blood very fluid, size.
the addition of and the vessels Liver sometimes
alkalies. of the viscera of its natural
much distended. appearance.
Heart of an
extraordinary Duodenum and
bigness; in seven other parts of
cases stuffed the intestines
with thick, black mortified.
blood; in one,
filled with a Worms from
large polypus; putrefaction
in another the found in the
contents not stomach in six
mentioned. hours.

Lungs in five Omentum and its
cases either appendages of a
purple, livid, dark grey colour,
or covered with and uncommonly
spots of these dry.
colours.
Liver and spleen
Liver greatly enlarged.
enlarged, with
mortified spots
in five cases.
Stuffed also with
thick blood.

Mortifications
in the brain,
intestines, &c.

Abscesses in
two cases; one
in the muscular
integuments of
the thorax, the
other in the
aorta.

Fever of 1798.

_Doctors_ RAND _and_ WARREN’s _Dissections_.

CASE I. Patient died CASE II. Death on the CASE III. Death on
on the 6th day. Lungs 12th day. Patient the fourth day. Lungs
filled with dark had been delirious inflamed on the fore
blood. Air vessels since the 6th. Blood part, and exceedingly
not distended. Large vessels of the brain stuffed with blood
extravasation of greatly distended. in the back parts.
firmly coagulated An effusion of serum Liver inflamed, and
blood in the thorax. between the dura of a very dense
Fluid blood in the and pia mater. A consistence. Gall
pericardium. Coronary band of coagulated bladder entirely
veins extremely lymph producing an obliterated; its coats
distended. Liver adhesion between the forming a confused
inflamed on both two coverings of the membranous substance
sides, and indurated brain, under the by coalescence with
as if boiled. Gall sagittal suture. Lungs the neighbouring
bladder contracted, adhered firmly to parts. Stomach covered
and containing only the pleura, and had in the inside with the
about a quarter of an several indurations black vomit. Colon and
ounce of a substance of the size of a part of the omentum
resembling pitch. pigeon’s egg. Left inflamed.
The secretion of lobe extremely
bile had apparently diseased, and in a * * * *
ceased for some time. state of suppuration.
Stomach and intestines Liver much enlarged In the two cases where
inflamed, and their and inflamed, the the gall bladder had
veins distended. inside of the great been diseased, and
Omentum thickened lobe near the gall the liver did not
and dark coloured bladder appearing as perform its functions,
from the swelling of if contused. Stomach the patients became
its vessels. Spleen covered on the inside yellow; but not in the
enlarged but without with the matter of other, where the bile
inflammation. the black vomit, was in due quantity.
though the patient In the second case the
had no evacuation of patient had previously
that kind. Duodenum had a pulmonary
and small intestines complaint.
much inflamed. Gall
bladder full of bile,
and ducts pervious.
Bladder contracted to
the size of a pullet’s
egg, with a quantity
of blood effused in
it.

“Nevertheless, if this distemper was as contagious as certain physicians pretend, why should they not be the first to be taken with it; they who see, examine and touch many patients every day? Why should not those who nurse them day and night, who continually breathe those putrid miasmata; why should not those who attend the hospitals, those who daily carry 30 or 40 coffins to the grave, be taken with it? We do not hear, however, that the physicians, surgeons, nurses and sextons have enlarged the funeral list more than any other class of citizens. Some doubtless have fallen, and perhaps they owed their death to their frequent communications with the sick; but would the epidemic have spared them in any other condition, more than a number of unfortunate people who are neither physicians nor nurses?

“Another particular not less remarkable is, that the _yellow fever_ seems hitherto to have spared the Frenchmen who have resided in the West India colonies, the greatest part of whom have nevertheless staid in New York and Philadelphia during the _yellow fever_, and have lived in the midst of the contagious air which proves so fatal to the Americans. The result of all this is, that, notwithstanding four years’ experience, notwithstanding the public and private researches and discussions which took place between the physicians and philosophers of the American continent, there is still much uncertainty on the nature of the distemper which so rapidly depopulates New York and Philadelphia. Every opinion, every system, presents palpable contradictions, and is liable to objections which it is difficult, not to say impossible, to answer in a satisfactory manner. If the disease be contagious, why are not the physicians, the nurses, the servants of the hospitals, taken sooner than persons who have no sort of communication with the sick?

“If it be not contagious, how happens it that the natives of every age and sex, many of which, the women and children especially, live in a pretty sober manner, and seldom drink any of those liquors so liable to inflame the blood, are taken with it, and fall, in spite of all the efforts of medicine? How happens it that the Europeans and Frenchmen who have never been in the colonies are attacked like the Americans, whilst the planters in the West Indies are spared?

“On the other hand, if, as the French physicians pretend, this is nothing else than the malignant putrid fever, often prevalent in Hispaniola, how happens it that those medicines and that mode of treatment which were so frequently successful in the colonies have no sort of success when administered to Americans, and seldom with Europeans? Why is this fever attended, in its very first stage, with vomitings of blood, bile, black spots, _purples_ and other alarming symptoms, which they frequently have at Hispaniola? How comes it that the West India planters, who, while they resided in the colonies, had frequent attacks of putrid and often inflammatory fevers, enjoy the most blooming health ever since they have been on the American continent? And why are they not taken with those putrid and inflammatory fevers, at a time when those who have given them an asylum are the daily victims of it? Finally, if we must attribute the epidemic to no other cause than the immoderate heat of the summer, which is really greater here for two or three months than at Hispaniola, where a land and sea breeze tempers its violence, why does it not stop its ravages when the heat moderates? We have observed in the epidemics of New York and Philadelphia, that they were less destructive in the burning dog-days than in the months of September and October, when the mornings, evenings and nights begin to be cool, and even cold enough to allow people to go clothed as warmly as in winter.

“We have now a recent and striking example that it is not heat only which causes the epidemics; since there were only, in the month of September, three or four days of great heat. The rest were very cool. It may even be said that from the 22d it was cold, especially on the 28th and 29th, when a violent north wind obliged many people to have a fire. The number of deaths never were, however, so numerous as they have been since the 20th of September. The funeral list, which in July and August amounted to 40 per day, reached on the 20th of September to 78, the 22d, 68, the 23d, 71, the 24th, 63, the 25th, 80, the 26th, 77, the 27th, 96, the 28th, 106, the 29th, 76, and from the 29th at twelve o’clock, to the 1st of October, same hour, the number was 170; a number as prodigious as it is frightful: we could not therefore even flatter ourselves that the severest frosts of the end of October would dispel the epidemic, did not experience afford us that comforting hope.

“What then is the physical cause of this scourge, which all human prudence and science are unable to avert? The ministers of religion will not fail to ascribe it to celestial wrath, and to advise prayers, fast and charity to appease it. Those pious practices cannot assuredly do harm; but the philosophical observer, who does not conceive that Philadelphia and New York should have excited the Heavenly wrath more than those of other cities of the continent, will seek for more natural causes, and will examine whether they should not be attributed to some local and peculiar vice of those two unfortunate cities, and perhaps to the temperament, the diet, the mode of life, of their inhabitants. Respecting this, we do not find, in the _localities_ of New York and Philadelphia sufficient reasons, nor in the constitutions or mode of life of their inhabitants sufficient variations, to mark them as the victims of the _yellow fever_, while the inhabitants [of other places] are free from it.

“I am however inclined to think that New York and Philadelphia, more than any other cities, contain causes of corruption or putridity, occasioned by their size and the extent of their commerce, which, added to the high mode of life of the Americans, may be the source of the calamity which now affects them.

“In effect, we observe that in these two cities the epidemic has constantly manifested itself in those parts which are not only the most commercial, but also where the _common_ sinks of the city meet; where the houses, inhabited by the poorer class of people, being smaller, and more crowded together; where the stores contain most provisions liable to fermentation and putridity; where the shipping crowded in the _wharfs_ render the water stagnant; where immense quantities of dirt and litter are brought from every quarter for the purpose of filling up new wharves and other places designed to be taken from the sea, to enlarge lands to build upon; finally, where the water used to drink does not reach the pumps of the lower part of the city until it has filtrated through the burying-grounds and privy-houses of the upper parts, most of which have no walls, and are never emptied.

“Let us add to all those causes of infection the dead dogs, cats, pigs, and rats, which are thrown into the common sinks and docks, the rotten fish, and the privies, which in several houses, especially at New York, are nothing but _tubs_, which are emptied weekly on the sea shore, and we shall have less reason to wonder at the putrid exhalations which issue on the eastern part of New York, and at Philadelphia on that part contiguous to the Delaware, and which are capable of infecting the whole atmosphere, and to impair the health of those who live in it. If the people who dwell in those parts are not scrupulously sober, if they frequently indulge in the use of spiritous liquors, if they feed on such food as is generally known to be unhealthy, is it to be wondered that, with such a mode of life, their blood should be more disposed to inflammation and to be dissolved and corrupted, in the midst of an air already corrupted and loaded with destructive miasmata?