Chapter III: Part 3

The precursors, or premonitory signs of this fever were, costiveness, a dull pain in the right side, defect of appetite, flatulency, perverted taste, heat in the stomach, giddiness, or pain in the head, a dull, watery, brilliant, yellow, or red eye, dim and imperfect vision, a hoarseness, or slight sore throat, low spirits, or unusual vivacity, a moisture on the hands, a disposition to sweat at nights, or after moderate exercise, or a sudden suppression of night sweats. The dull eye, and the lowness of spirits, appeared to be the effects of such an excess in the stimulus of the miasmata as to induce depression, while the brilliant eye, and the unusual vivacity, seemed to have been produced by a less quantity of the miasmata acting as a cordial upon the system. More or less of these symptoms frequently continued for two or three days before the patients were confined to their beds, and in some people they continued during the whole time of its prevalence in the city, without producing the disease. I wish these symptoms to be remembered by the reader. They will form the corner stone of a system which I hope will either eradicate the disease altogether, or render it as safe as an intermitting fever, or as the small-pox when it is received by inoculation.

Frequent as these precursors of the fever were, they were not universal. Many went to bed in good health, and awoke in the night with a chilly fit. Many rose in the morning after regular and natural sleep, and were seized at their work, or after a walk, with a sudden and unexpected attack of the fever. In most of these cases the disease came on with a chilly fit, which afforded by its violence or duration a tolerable presage of the issue of the disease.

Upon entering a sick room where a patient was confined by this fever, the first thing that struck the eye of a physician was the countenance. It was as much unlike that which is exhibited in the common bilious fever, as the face of a wild, is unlike the face of a mild domestic animal. The eyes were sad, watery, and so inflamed, in some cases, as to resemble two balls of fire. Sometimes they had a most brilliant or ferocious appearance. The face was suffused with blood, or of a dusky colour, and the whole countenance was downcast and clouded. After the 10th of September, when a determination of blood to the brain became universal, there was a preternatural dilatation of the pupil. Sighing attended in almost every case. The skin was dry, and frequently of its natural temperature. These were the principal symptoms which discovered themselves to the eye and hand of a physician. The answers to the first questions proposed upon visiting a patient, were calculated to produce a belief in the mind of a physician, that the disease under which the patient laboured was not the prevailing malignant epidemic. I did not for many weeks meet with a dozen patients, who acknowledged that they had any other indisposition than a common cold, or a slight remitting or intermitting fever. I was particularly struck with this self-deception in many persons, who had nursed relations that had died with the yellow fever, and who had been exposed to it in neighbourhoods where it had prevailed for days and even weeks with great mortality. I shall hereafter trace a part of this disposition in the sick to deceive themselves to the influence of certain publications, which appeared soon after the disease became epidemic in the city.

In the further history of this fever, I shall describe its symptoms as they appeared,

I. In the sanguiferous system.

II. In the liver, lungs, and brain.

III. In the alimentary canal; in which I include the stomach as well as the bowels.

IV. In the secretions and excretions.

V. In the nervous system.

VI. In the senses and appetites.

VII. In the lymphatic and glandular system.

VIII. Upon the skin.

IX. In the blood.

After having finished this detail, I shall mention some general characters of the disease, and afterwards subdivide it into classes, according to its degrees and duration.

I. The _blood-vessels_ were affected more or less in every case of this fever. I have elsewhere said, that a fever is occasioned by a convulsion in the arterial system[16]. When the epidemic, which we are now considering, came on with a full, tense, and quick pulse, this convulsion was very perceptible; but it frequently came on with a weak pulse, often without any preternatural frequency or quickness, and sometimes so low as not to be perceived without pressing the artery at the wrists. In many cases the pulse intermitted after the fourth, in some after the fifth, and in others after the fourteenth stroke. These intermissions occurred in several persons who were infected, but who were not confined by the fever. They likewise continued in several of my patients for many days after their recovery. This was the case in particular in Mrs. Clymer, Mrs. Palmer's son William, and in a son of Mr. William Compton. In some, there was a preternatural slowness of the pulse. It beat 44 strokes in a minute in Mr. B. W. Morris, 48 in Mr. Thomas Wharton, jun. and 64 in Mr. William Sansom, at a time when they were in the most imminent danger. Dr. Physick informed me, that in one of his patients the pulse was reduced in frequency to 30 strokes in a minute. All these different states of the pulse have been taken notice of by authors who have described pestilential fevers[17]. They have been improperly ascribed to the absence of fever: I would rather suppose that they are occasioned by the stimulus of the remote cause acting upon the arteries with too much force to admit of their being excited into quick and convulsive motions. The remedy which removed it (to be mentioned hereafter) will render this explanation of its cause still more probable. Milton describes a darkness from an excess of light. In like manner we observe, in this small, intermitting, and slow pulse, a deficiency of strength from an excess of force applied to it. In nearly every case of it which came under my notice, it was likewise tense or chorded. This species of pulse occurred chiefly in the month of August, and in the first ten days in September. I had met with it formerly in a sporadic case of yellow fever. It was new to all my pupils. One of them, Mr. Washington, gave it the name of the "undescribable pulse." It aided in determining the character of this fever before the common bilious remittent disappeared in the city. For a while, I ascribed this peculiarity in the pulse, more especially its _slowness_, to an affection of the brain only, and suspected that it was produced by what I have taken the liberty elsewhere to call the _phrenicula_, or inflammatory state of the internal dropsy of the brain, and which I have remarked to be an occasional symptom and consequence of remitting fever. I was the more disposed to adopt this opinion, from perceiving this slow, chorded, and intermitting pulse more frequently in children than in adults. Impressed with this idea, I requested Mr. Coxe, one of my pupils, to assist me in examining the state of the eyes. For two days we discovered no change in them, but on the third day after we began to inspect them, we both perceived a preternatural dilatation of the pupils, in different patients; and we seldom afterwards saw an eye in which it was absent. In Dr. Say it was attended by a squinting, a symptom which marks a high degree of a morbid affection of the brain. Had this slowness or intermission in the pulse occurred only after signs of inflammation or congestion had appeared in the brain, I should have supposed that it had been derived wholly from that cause; but I well recollect having felt it several days before I could discover the least change in the pupil of the eye. I am forced therefore to call in the operation of another cause, to assist in accounting for this state of the pulse, and this I take to be a spasmodic affection, accompanied with preternatural dilatation or contraction of the heart. Lieutaud mentions this species of pulse in several places, as occurring with an undue enlargement of that muscle[18]. Dr. Ferriar describes a case, in which a low, irregular, intermitting, and hardly perceptible pulse attended a morbid dilatation of the heart[19]. In a letter I received from Mr. Hugh Ferguson, then a student of medicine in the college of Edinburgh, written from Dublin, during the time of a visit to his father, and dated September 30th, 1793, I find a fact which throws additional light upon this subject. "A case (says my young correspondent) where a remarkable intermission of pulse was observed, occurred in this city last year. A gentleman of the medical profession, middle aged, of a delicate habit of body, and who had formerly suffered phthisical attacks, was attacked with the acute rheumatism. Some days after he was taken ill, he complained of uncommon fulness, and a very peculiar kind of sensation about the præcordia, which it was judged proper to relieve by copious blood-letting. This being done, the uneasiness went off. It returned, however, three or four times, and was as often relieved by bleeding. During each of his fits (if I may call them so), the patient experienced an almost total remission of his pains in his limbs; but they returned with equal or greater violence after blood-letting. During the fit there was an intermission of the pulse (the first time) of no less than thirteen strokes. It was when beating full, strong, and slow. The third intermission was of nine strokes. The gentleman soon recovered, and has enjoyed good health for ten months past. The opinion of some of his physicians was, that the heart was affected, as a muscle, by the rheumatism, and alternated with the limbs."

[16] Outlines of a Theory of Fever.

[17] Vergasca, Sorbait, and Boate in Haller's Bibliotheca Medicinæ,
vol. iii. also by Dr. Stubbs in the Philosophical Transactions,
and Riverius in his treatise de febre pestilenti.

[18] Historia Anatomica Medica, vol ii. obs. 405, 418, 423, 510.

[19] Medical Histories and Reflections, p. 150.

I am the more inclined to believe the peculiarity in the pulse which has been mentioned in the yellow fever, arose in part from a spasmodic affection of the heart, from the frequency of an uncommon palpitation of this muscle, which I discovered in this disease, more especially in old people. The disposition, likewise, to syncope and sighing, which so often occurred, can be explained upon no other principle than inflammation, spasm, dilatation, or congestion in the heart. After the 10th of September this undescribable or _sulky_ pulse (for by the latter epithet I sometimes called it) became less observable, and, in proportion as the weather became cool, it totally disappeared. It was gradually succeeded by a pulse full, tense, quick, and as frequent as in pleurisy or rheumatism. It differed, however, from a pleuritic or rheumatic pulse, in imparting a very different sensation to the fingers. No two strokes seemed to be exactly alike. Its action was of a hobbling nature. It was at this time so familiar to me that I think I could have distinguished the disease by it without seeing the patient. It was remarkable that this pulse attended the yellow fever even when it appeared in the mild form of an intermittent, and in those cases where the patients were able to walk about or go abroad. It was nearly as _tense_ in the remissions and intermissions of the fever as it was in the exacerbations. It was an alarming symptom, and when the only remedy which was effectual to remove it was neglected, such a change in the system was induced as frequently brought on death in a few days.

This change of the pulse, from extreme lowness to fulness and activity, appeared to be owing to the diminution of the heat of the weather, which, by its stimulus, added to that of the remote cause, had induced those symptoms of depression of the pulse which have been mentioned.

The pulse most frequently lessened in its fulness, and became gradually weak, frequent, and imperceptible before death, but I met with several cases in which it was full, active, and even tense in the last hours of life.

_Hæmorrhages_ belong to the symptoms of this fever as they appeared in the sanguiferous system. They occurred in the beginning of the disease, chiefly from the nose and uterus. Sometimes but a few drops of blood distilled from the nose. The menses were unusual in their quantity when they appeared at their stated periods, but they often came on a week or two before the usual time of their appearance. I saw one case of a hæmorrhage from the lungs on the first day of the fever, which was supposed to be a common hæmoptysis. As the disease advanced the discharges of blood became more universal. They occurred from the gums, ears, stomach, bowels, and urinary passages. Drops of blood issued from the inner canthus of the left eye of Mr. Josiah Coates. Dr. Woodhouse attended a lady who bled from the holes in her ears which had been made by ear-rings. Many bled from the orifices which had been made by bleeding, several days after they appeared to have been healed, and some from wounds which had been made in veins in unsuccessful attempts to draw blood. These last hæmorrhages were very troublesome, and in some cases precipitated death.

II. I come now to mention the symptoms of this fever as they appeared in the _liver_, the _lungs_, and the _brain_. From the histories which I had read of this disease, I was early led to examine the state of the _liver_, but I was surprised to find so few marks of hepatic affection. I met with but two cases in which the patient could lie only on the right side. Many complained of a dull pain in the region of the liver, but very few complained, in the beginning of the disease, of that soreness to the touch, about the pit of the stomach, which is taken notice of by authors, and which was universal in the yellow fever in 1762. In proportion as the cool weather advanced, a preternatural determination of the blood took place chiefly to the lungs and brain. Many were affected with pneumonic symptoms, and some appeared to die of sudden effusions of blood or serum in the lungs. It was an unexpected effusion of this kind which put an end to the life of Mrs. Keppele after she had exhibited hopeful signs of a recovery.

I saw one person who recovered from an affection of the lungs, by means of a copious expectoration of yellow phlegm and mucus. But the _brain_ was principally affected with morbid congestion in this disease. It was indicated by the suffusion of blood in the face, by the redness of the eyes, by a dilatation of the pupils, by the pain in the head, by the hæmorrhages from the nose and ears, by the sickness or vomiting, and by an almost universal costive state of the bowels. I wish to impress the reader with these facts, for they formed one of the strongest indications for the use of the remedies which I adopted for the cure of this disease. It is difficult to determine the exact state of these viscera in every case of bilious and yellow fever. Inflammation certainly takes place in some cases, and internal hæmorrhages in others; but I believe the most frequent affection of these viscera consists in a certain morbid accumulation of blood in them, which has been happily called, by Dr. Clark, an _engorgement_ or choaking of the blood-vessels. I believe further, with Dr. Clark[20] and Dr. Balfour[21], that death in most cases in bilious fevers is the effect of these morbid congestions, and wholly unconnected with an exhausted state of the system, or a supposed putrefaction in the fluids. It is true, the dissections of Dr. Physick and Dr. Cathrall (to be mentioned hereafter) discovered no morbid appearances in any of the viscera which have been mentioned, but it should be remembered, that these dissections were made early in the disease. Dr. Annan attended the dissection of a brain of a patient who died at Bush-hill some days afterwards, and observed the blood-vessels to be unusually turgid. In those cases where congestion only takes place, it is as easy to conceive that all morbid appearances in the brain may cease after death, as that the suffusion of blood in the face should disappear after the retreat of the blood from the extremities of the vessels, in the last moments of life. It is no new thing for morbid excitement of the brain to leave either slender, or no marks of disease after death. This, I have said, is often the case where it exceeds that degree of action which produces an effusion of red blood into serous vessels, or what is called inflammation[22]. Dr. Quin has given a dissection of the brain of a child that died with all the symptoms of hydrocephalus internus, and yet nothing was discovered in the brain but a slight turgescence of its blood-vessels. Dr. Girdlestone says, no injury appeared in the brains of those persons who died of the symptomatic apoplexy, which occurred in a spasmodic disease which he describes in the East-Indies; and Mr. Clark informs us, that the brain was in a natural state in every case of death from puerperile fever, notwithstanding it seemed to be affected in many cases soon after the attack of that disease[23].

[20] Vol. i. p. 168.

[21] Treatise on the Intestinal Remitting Fever, p. 125.

[22] Outlines of a theory of fever.

[23] Essay on the Epidemic Disease of Lying-in Women, of the years 1787
and 1788, p. 34.

I wish it to be remembered here, that the yellow fever, like all other diseases, is influenced by climate and season. The determination of the fluids is seldom the same in different years, and I am sure it varied with the weather in the disease which I am now describing. Dr. Jackson speaks of the head being most affected in the West-India fevers in _dry_ situations. Dr. Hillary says, that there was an unusual determination of the blood towards the brain, after a _hot_ and _dry_ season, in the fevers of Barbadoes in the year 1753; and Dr. Ferriar, in his account of an epidemic jail fever in Manchester, in 1789, 1790, informs us, that as soon as frost set in, a delirium became a more frequent symptom of that disease, than it had been in more temperate weather.

III. The _stomach_ and _bowels_ were affected in many ways in this fever. The disease seldom appeared without nausea or vomiting. In some cases, they both occurred for several days or a week before they were accompanied by any fever. Sometimes a pain, known by the name of gastrodynia, ushered in the disease. The stomach was so extremely irritable as to reject drinks of every kind. Sometimes green or yellow bile was rejected on the first day of the disease by vomiting; but I much oftener saw it continue for two days without discharging any thing from the stomach, but the drinks which were taken by the patient. If the fever in any case came on without vomiting, or if it had been checked by remedies that were ineffectual to remove it altogether, it generally appeared, or returned, on the 4th or 5th day of the disease. I dreaded this symptom on those days, for although it was not always the forerunner of death, yet it generally rendered the recovery more difficult and tedious. In some cases the vomiting was more or less constant from the beginning to the end of the disease, whether it terminated in life or death.

The vomiting which came on about the 4th or 5th day, was accompanied with a burning pain in the region of the stomach. It produced great anxiety, and tossing of the body from one part of the bed to another. In some cases, this painful burning occurred before any vomiting had taken place. Drinks were now rejected from the stomach so suddenly, as often to be discharged over the hand that lifted them to the head of the patient. The contents of the stomach (to be mentioned hereafter) were sometimes thrown up with a convulsive motion, that propelled them in a stream to a great distance, and in some cases all over the clothes of the by-standers.

Flatulency was an almost universal symptom, in every stage of this disease. It was very distressing in many cases. It occurred chiefly in the stomach.

The _bowels_ were generally costive, and in some patients as obstinately so as in the dry gripes. In some cases there was all the pain and distress of a bilious colic, and in others, the tenesmus, and mucous and bloody discharges of a true dysentery. A diarrh[oe]a introduced the disease in a few persons, but it was chiefly in those who had been previously indisposed with weak bowels. A painful tension of the abdomen took place in many, accompanied in some instances by a dull, and in others by an acute pain in the lower part of the belly.

IV. I come now to describe the state of the _secretions_ and _excretions_ as they appeared in different stages of this fever.

In some cases there was a constipation of the liver, if I may be allowed that expression, or a total obstruction of secretion and excretion of bile, but more frequently a preternatural secretion and excretion of it took place. It was discharged, in most cases, from the stomach and bowels in large quantities, and of very different qualities and colours.

1. On the first and second days of the disease many patients puked from half a pint to nearly a quart of green or yellow bile. Four cases came under my notice in which black bile was discharged on the _first_ day. Three of these patients recovered.

2. There was frequently, on the 4th or 5th day, a discharge of matter from the stomach, resembling coffee impregnated with its grounds. This was always an alarming symptom. I believed it at first to be a modification of vitiated bile, but subsequent dissections by Dr. Physick have taught me that it was the result of the first stage of those morbid actions in the stomach, which afterwards produce the black vomit. Many recovered who discharged this coffee-coloured matter.

3. Towards the close of this disease, there was a discharge of matter of a deep or pale black colour, from the stomach. Flakey substances frequently floated in the bason or chamber-pot upon the surface of this matter. It was what is called the _black vomit_. It was formerly supposed to be vitiated bile, but it has been proved by Dr. Stewart, and afterwards by Dr. Physick, to be the effect of disease in the stomach.

4. There was frequently discharged from the stomach in the close of the disease, a large quantity of grumous blood, which exhibited a dark colour on its outside, resembling that of some of the matters which have been described, and which I believe was frequently mistaken for what is commonly known by the name of the _black vomit_. Several of my patients did me the honour to say, I had cured them after that symptom of approaching dissolution had made its appearance; but I am inclined to believe, dark-coloured blood only, or the coffee-coloured matter, was mistaken for the matters which constitute the fatal black vomiting. I except here the black discharge before-mentioned, which took place in three cases on the first day of the disease. This I have no doubt was bile, but it had not acquired its greatest acrimony, and it was discharged before mortification, or even inflammation could have taken place in the stomach. Several persons died without a black vomiting of any kind.

Along with all the discharges from the stomach which have been described, there was occasionally a large worm, and frequently large quantities of mucus and tough phlegm.

The colour, quality, and quantity of the _fæces_ depended very much upon the treatment of the disease. Where active purges had been given, the stools were copious, f[oe]tid, and of a black or dark colour. Where they were spontaneous, or excited by weak purges, they had a more natural appearance. In both cases they were sometimes of a green, and sometimes of an olive colour. Their smell was more or less f[oe]tid, according to the time in which they had been detained in the bowels. I visited a lady who had passed several days without a stool, and who had been treated with tonic remedies. I gave her a purge, which in a few hours procured a discharge of fæces so extremely f[oe]tid, that they produced fainting in an old woman who attended her. The acrimony of the fæces was such as to excoriate the rectum, and sometimes to produce an extensive inflammation all around its external termination. The quantity of the stools produced by a single purge was in many cases very great. They could be accounted for only by calling in the constant and rapid formation of them, by preternatural effusions of bile into the bowels.

I attended one person, and heard of two others, in whom the stools were as white as in the jaundice. I suspected, in these cases, the liver to be so constipated or paralyzed by the disease, as to be unable to secrete or excrete bile to colour the fæces. Large round worms were frequently discharged with the stools.

The _urine_ was in some cases plentiful, and of a high colour. It was at times clear, and at other times turbid. About the 4th or 5th day, it sometimes assumed a dark colour, and resembled strong coffee. This colour continued, in one instance, for several days after the patient recovered. In some, the discharge was accompanied by a burning pain, resembling that which takes place in a gonorrh[oe]a. I met with one case in which this burning came on only in the evening, with the exacerbation of the fever, and went off with its remission in the morning.

A total deficiency of the urine took place in many people for a day or two, without pain. Dr. Sydenham takes notice of the same symptom in the highly inflammatory small-pox[24]. It generally accompanied or portended great danger. I heard of one case in which there was a _suppression_ of urine, which could not be relieved without the use a the catheter.

[24] Wallis's edition, vol. i. p. 197.

A young man was attended by Mr. Fisher, one of my pupils, who discharged several quarts of limpid urine just before he died.

Dr. Arthaud informs us, in the history of a dissection of a person who died of the yellow fever, that the urine after death imparted a green colour to the tincture of radishes[25].

[25] Rosier's Journal for January, 1790, vol. xxxvi. p. 380.

Many people were relieved by copious _sweats_ on the first day of the disease. They were in some instances spontaneous, and in others they were excited by diluting drinks, or by strong purges. These sweats were often of a yellow colour, and sometimes had an offensive smell. They were in some cases cold, and attended at the same time with a full pulse. In general, the skin was dry in the beginning, as well as in the subsequent stages of the disease. I saw but few instances of its terminating like common fevers, by sweat after the third day. I wish this fact to be remembered by the reader, for it laid part of the foundation of my method of treating this fever.

There was in some cases a preternatural secretion and excretion of _mucus_ from the glands of the throat. It was discharged by an almost constant hawking and spitting. All who had this symptom recovered.

The _tongue_ was in every case moist, and of a white colour, on the first and second days of the fever. As the disease advanced, it assumed a red colour, and a smooth shining appearance. It was not quite dry in this state. Towards the close of the fever, a dry black streak appeared in its middle, which gradually extended to every part of it. Few recovered after this appearance on the tongue took place.

V. In the _nervous system_ the symptoms of the fever were different, according as it affected the brain, the muscles, the nerves, or the mind. The sudden and violent action of the miasmata induced apoplexy in several people. In some, it brought on syncope, and in others, convulsions in every part of the body. The apoplectic cases generally proved fatal, for they fell chiefly upon hard drinkers. Persons affected by syncope, or convulsions, sometimes fell down in the streets. Two cases of this kind happened near my house. One of them came under my notice. He was supposed by the by-standers to be drunk, but his countenance and convulsive motions soon convinced me that this was not the case.

A coma was observed in some people, or an obstinate wakefulness in every stage of the disease. The latter symptom most frequently attended the convalescence. Many were affected with immobility, or numbness in their limbs.

These symptoms were constant, or temporary, according to the nature of the remedies which were made use of to remove them. They extended to all the limbs, in some cases, and only to a part of them in others. In some, a violent cramp, both in the arms and legs, attended the first attack of the fever. I met with one case in which there was a difficulty of swallowing, from a spasmodic affection of the throat, such as occurs in the locked jaw.

A hiccup attended the last stage of this disease, but I think less frequently than the last stage of the common bilious fever. I saw but five cases of recovery where this symptom took place.

There was, in some instances, a deficiency of sensibility, but, in others, a degree of it extending to every part of the body, which rendered the application of common rum to the skin, and even the least motion of the limbs painful.

I was surprised to observe the last stage of this fever to exhibit so few of the symptoms of the common typhus or chronic fever. Tremors of the limbs and twitchings of the tendons were uncommon. They occurred only in those cases in which there was a predisposition to nervous diseases, and chiefly in the convalescent state of the disease.

While the muscles and nerves in many cases exhibited so many marks of preternatural weakness, in some they appeared to be affected with preternatural excitement. Hence patients in the close of the disease often rose from their beds, walked across their rooms, or came down stairs, with as much ease as if they had been in perfect health. I lost a patient in whom this state of morbid strength occurred to such a degree, that he stood up before his glass and shaved himself, on the day on which he died.

The mind suffered with the morbid states of the brain and nerves. A delirium was a common symptom. It alternated in some cases with the exacerbations and remissions of the fever. In some, it continued without a remission, until a few hours before death. Many, however, passed through the whole course of the disease without the least derangement in their ideas, even where there were evident signs of a morbid congestion in the brain. Some were seized with maniacal symptoms. In these there was an _apparent_ absence of fever. Such was the degree of this mania in one man, that he stripped off his shirt, left his bed, and ran through the streets, with no other covering than a napkin on his head, at 8 o'clock at night, to the great terror of all who met him. The symptoms of mania occurred most frequently towards the close of the disease, and sometimes continued for many days and weeks, after all other febrile symptoms had disappeared.

The temper was much affected in this fever. There were few in whom it did not produce great depression of spirits. This was the case in many, in whom pious habits had subdued the fear of death. In some the temper became very irritable. Two cases of this kind came under my notice, in persons who, in good health, were distinguished for uncommon sweetness of disposition and manners.

I observed in several persons the operations of the understanding to be unimpaired, throughout the whole course of the fever, who retained no remembrance of any thing that passed in their sickness. My pupil, Mr. Fisher, furnished a remarkable example of this correctness of understanding, with a suspension of memory. He neither said nor did any thing, during his illness, that indicated the least derangement of mind, and yet he recollected nothing that passed in his room, except my visits to him. His memory awakened upon my taking him by the hand, on the morning of the 6th day of his disease, and congratulating him upon his escape from the grave.

In some, there was a weakness, or total defect of memory, for several weeks after their recovery. Dr. Woodhouse informed me that he had met with a woman, who, after she had recovered, could not recollect her own name.

Perhaps it would be proper to rank that self-deception with respect to the nature and danger of the disease, which was so universal, among the instances of derangement of mind.

The pain which attended the disease was different, according to the different states of the system. In those cases in which it sunk under the violence of the disease, there was little or no pain. In proportion as the system was relieved from this oppression, it recovered its sensibility. The pain in the head was acute and distressing. It affected the eye-balls in a peculiar manner. A pain extended, in some cases, from the back of the head down the neck. The ears were affected, in several persons, with a painful sensation, which they compared to a string drawing their two ears together through the brain. The sides, and the regions of the stomach, liver, and bowels, were all, in different people, the seats of either dull or acute pains. The stomach, towards the close of the disease, was affected with a burning or spasmodic pain of the most distressing nature. It produced, in some cases, great anguish of body and mind. In others it produced cries and shrieks, which were often heard on the opposite side of the streets to where the patients lay. The back suffered very much in this disease. The stoutest men complained, and even groaned under it. An acute pain extended, in some cases, from the back to one or both thighs. The arms and legs sympathized with every other part of the body. One of my patients, upon whose limbs the disease fell with its principal force, said that his legs felt as if they had been scraped with a sharp instrument. The sympathy of friends with the distresses of the sick extended to a small part of their misery, when it did not include their sufferings from pain. One of the dearest friends I ever lost by death declared, in the height of her illness, that "no one knew the pains of a yellow fever, but those who felt them."

VI. The _senses_ and _appetites_ exhibited several marks of the universal ravages of this fever upon the body. A deafness attended in many cases, but it was not often, as in the nervous fever, a favourable symptom. A dimness of sight was very common in the beginning of the disease. Many were affected with temporary blindness. In some there was a loss of sight in consequence of gutta serena, or a total destruction of the substance of the eye. There was in many persons a soreness to the touch which extended all over the body. I have often observed this symptom to be the forerunner of a favourable issue of a nervous fever, but it was less frequently the case in this disease.

The _thirst_ was moderate or absent in some cases, but it occurred in the greatest number of persons whom I saw in this fever. Sometimes it was very intense. One of my patients, who suffered by an excessive draught of cold water, declared, just before he died, that "he could drink up the Delaware." It was always an alarming symptom when this thirst came on in this extravagant degree in the last stage of the disease. In the beginning of the fever it generally abated upon the appearance of a moist skin. Water was preferred to all other drinks.

The _appetite_ for food was impaired in this, as in all other fevers, but it returned much sooner than is common after the patient began to recover. Coffee was relished in the remissions of the fever, in every stage of the disease. So keen was the appetite for solid, and more especially for animal food, after the solution of the fever, that many suffered from eating aliment that was improper from its quality or quantity. There was a general disrelish for wine, but malt liquors were frequently grateful to the taste.

Many people retained a relish for tobacco much longer after they were attacked by this fever, and acquired a relish for it much sooner after they began to recover, than are common in any other febrile disease. I met with one case in which a man, who was so ill as to require two bleedings, continued to chew tobacco through every stage of his fever.

The convalescence from this disease was marked, in some instances, by a sudden revival of the venereal appetite. Several weddings took place in the city between persons who had recovered from the fever. Twelve took place among the convalescents in the hospital at Bush-hill. I wish I could add that the passion of the sexes for each other, among those subjects of public charity, was always gratified only in a lawful way. Delicacy forbids a detail of the scenes of debauchery which were practised near the hospital, in some of the tents which had been appropriated for the reception of convalescents. It was not peculiar to this fever to produce this morbid excitability of the venereal appetite. It was produced in a much higher degree by the plague which raged in Messina in the year 1743.

VII. The _lymphatic_ and _glandular system_ did not escape without some signs of this disease. I met with three cases of swellings in the inguinal, two in the parotid, and one in the cervical glands: all these patients recovered without a suppuration of their swellings. They were extremely painful in one case in which no redness or inflammation appeared. In the others there was considerable inflammation and but little pain.

In one of the cases of inguinal buboes, the whole force of the disease seemed to be collected into the lymphatic system. The patient walked about, and had no fever nor pain in any part of his body, except in his groin. In another case which came under my care, a swelling and pain extended from the groin along the spermatic cord into one of the testicles. These glandular swellings were not peculiar to this epidemic. They occurred in the yellow fever of Jamaica, as described by Dr. Williams, and always with a happy issue of the disease[26]. A similar concentration of the contagion of the plague in the lymphatic glands is taken notice of by Dr. Patrick Russel.

[26] Essay on the Bilious or Yellow Fever, p. 35.

VIII. The _skin_ exhibited many marks of this fever. It was preternaturally warm in some cases, but it was often preternaturally cool. In some there was a distressing coldness in the limbs for two or three days. The yellow colour from which this fever has derived its name, was not universal. It seldom appeared where purges had been given in sufficient doses. The yellowness rarely appeared before the third, and generally about the fifth or seventh day of the fever. Its early appearance always denoted great danger. It sometimes appeared first on the neck and breast, instead of the eyes. In one of my patients it discovered itself first behind one of his ears, and on the crown of his head, which had been bald for several years. The remissions and exacerbations of the fever seemed to have an influence upon this colour, for it appeared and disappeared altogether, or with fainter or deeper shades of yellow, two or three times in the course of the disease. The eyes seldom escaped a yellow tinge; and yet I saw a number of cases in which the disease appeared with uncommon malignity and danger, without the presence of this symptom.

There was a clay-coloured appearance in the face, in some cases, which was very different from the yellow colour which has been described. It occurred in the last stage of the fever, and in no instance did I see a recovery after it.

There were eruptions of various kinds on the skin, each of which I shall briefly describe.

1. I met with two cases of an eruption on the skin, resembling that which occurs in the scarlet fever. Dr. Hume says, pimples often appear on the pit of the stomach, in the yellow fever of Jamaica. I examined the external region of the stomach in many of my patients, without discovering them.

2. I met with one case in which there was an eruption of watery blisters, which, after bursting, ended in deep, black sores.

3. There was an eruption about the mouth in many people, which ended in scabs, similar to those which take place in the common bilious fever. They always afforded a prospect of a favourable issue of the disease.

4. Many persons had eruptions which resembled moscheto bites. They were red and circumscribed. They appeared chiefly on the arms, but they sometimes extended to the breast. Like the yellow colour of the skin, they appeared and disappeared two or three times in the course of the disease.

5. Petechiæ were common in the latter stage of the fever. They sometimes came on in large, and at other times in small red blotches; but they soon acquired a dark colour. In most cases they were the harbingers of death.

6. Several cases of carbuncles, such as occur in the plague, came under my notice. They were large and hard swellings on the limbs, with a black apex, which, upon being opened, discharged a thin, dark-coloured, bloody matter. From one of these malignant sores a hæmorrhage took place, which precipitated the death of the amiable widow of Dr. John Morris.

7. A large and painful anthrax on the back succeeded a favourable issue 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.