Chapter IV: Part 4

I think I observed the fever to terminate on the third day more frequently in August, and during the first ten days in September, than it did after the weather became cool. In this it resembled the common bilious remittents of our city, also the simple tertians described by Dr. Cleghorn[31]. The danger seemed to be in proportion to the tendency of the disease to a speedy crisis, hence more died in August in proportion to the number who were affected than in September or October, when the disease was left to itself. But, however strange after this remark it may appear, the disease yielded to the remedies which finally subdued it more speedily and certainly upon its first appearance in the city, than it did two or three weeks afterwards.

[31] Diseases of Minorca, p. 185.

The disease continued for fifteen, twenty, and even thirty days in some people. Its duration was much influenced by the weather, and by the use or neglect of certain remedies (to be mentioned hereafter) in the first stage of the disease.

It has been common with authors to divide the symptoms of this fever into three different stages. The order I have pursued in the history of those symptoms will render this division unnecessary. It will I hope be more useful to divide the patients affected with the disease into three classes.

The _first_ includes those in whom the stimulus of the miasmata produced coma, languor, sighing, a disposition to syncope, and a weak or slow pulse.

The _second_ includes those in whom the miasmata acted with less force, producing great pain in the head, and other parts of the body; delirium, vomiting, heat, thirst, and a quick, tense, or full pulse, with obvious remissions or intermissions of the fever.

The _third_ class includes all those persons in whom the miasmata acted so feebly as not to confine them to their beds or houses. This class of persons affected by the yellow fever was very numerous. Many of them recovered without medical aid, or by the use of domestic prescriptions; many of them recovered in consequence of a spontaneous diarrh[oe]a, or plentiful sweats; many were saved by moderate bleeding and purging; while some died, who conceived their complaints to be occasioned by a common cold, and neglected to take proper care of themselves, or to use the necessary means for their recovery. It is not peculiar to the yellow fever to produce this feeble operation upon the system, It has been observed in the southern states of America, that in those seasons in which the common bilious fever is epidemic "no body is quite well," and that what are called in those states "inward fevers" are universal. The small-pox, even in the natural way, does not always confine the patient; and thousands pass through the plague without being confined to their beds or houses. Dr. Hodges prescribed for this class of patients in his parlour in London, in the year 1665, and Dr. Patrick Russel did the same from a chamber window fifteen feet above the level of the street at Aleppo. Notwithstanding the mild form the plague put on in these cases, it often proved fatal according to Dr. Russel. I have introduced these facts chiefly with a view of preparing the reader to reject the opinion that we had two species of fever in the city at the same time; and to show that the yellow fever appears in a more simple form than with "strongly marked" characters; or, in other words, with a yellow skin and a black vomiting.

It was remarkable that this fever always found out the weak part of every constitution it attacked. The head, the lungs, the stomach, the bowels, and the limbs, suffered more or less, according as they were more or less debilitated by previous inflammatory or nervous diseases, or by a mixture of both, as in the gout.

I have before remarked, that the influenza, the scarlatina, and a mild bilious remittent, prevailed in the city, before the yellow fever made its appearance. In the course of a few weeks they all disappeared, or appeared with symptoms of the yellow fever; so that, after the first week of September, it was the solitary epidemic of the city.

The only case like influenza which I saw after the 5th of September, was in a girl of 14 years of age, on the 13th of the month. It came on with a sneezing and cough. I was called to her on the third day of her disease. The instant I felt her pulse, I pronounced her disease to be the yellow fever. Her father was offended with this opinion, although he lived in a highly infected neighbourhood, and objected to the remedies I prescribed for her. In a few days she died. In the course of ten days, her father and sister were infected, and both died, I was informed, with the usual symptoms of the yellow fever.

It has been an axiom in medicine, time immemorial, that no two fevers of unequal force can exist long together in the same place. As this axiom seems to have been forgotten by many of the physicians of Philadelphia, and as the ignorance or neglect of it led to that contrariety of opinion and practice, which unhappily took place in the treatment of the disease, I hope I shall be excused by those physicians to whom this fact is as familiar as the most simple law of nature, if I fill a few pages with proofs of it, from practical writers.

Thucydides long ago remarked, that the plague chased all other diseases from Athens, or obliged them to change their nature, by assuming some of its symptoms.

Dr. Sydenham makes the same remark upon the plague in London, in 1665. Dr. Hodges, in his account of the same plague, says, that "at the rise of the plague all other distempers went into it, but that, at its declension, it degenerated into others, as inflammations, head-ach, quinsies, dysenteries, small-pox, measles, fevers, and hectics, wherein the plague yet predominated[32]."

[32] Dr. Hodge's Account of the Plague in London, p. 26.

During the prevalence of the plague in Grand Cairo, no sporadic disease of any kind makes its appearance. The same observation is made by Sauvage, in his account of the plague at Alais, in the province of Languedoc[33].

[33] Sed hoc observatu dignum fuit, omnes alios morbos acutos, durante
peste siluisse, et omnes morbos acutos e pestis genere suisse.
Nosologia Methodica, vol. i. p. 416.

The small-pox, though a disease of less force than the plague, has often chased it from Constantinople, probably from its being in a declining state. But this exclusive prevalence of a single epidemic is not confined to the plague and small-pox. Dr. Sydenham's writings are full of proofs of the dominion of febrile diseases over each other. Hence, after treating upon a symptomatic pleurisy which sometimes accompanied a slow fever, in the year 1675, and which had probably been injudiciously treated by some of those physicians who prescribe for the name of a disease, he delivers the following aphorism: "Whoever, in the cure of fevers, hath not always in view the constitution of the year, inasmuch as it tends to produce some particular epidemic disease, and likewise to reduce all the cotemporary diseases to its own form and likeness, proceeds in an uncertain and fallacious way[34]." It appears further, from the writings of this excellent physician, that where the monarchy of a single disease was not immediately acknowledged, by a sudden retreat of all cotemporary diseases, they were forced to do homage to it, by wearing its livery. It would be easy to multiply proofs of this assertion, from the numerous histories of epidemics which are to be found in his works. I shall mention only one or two of them. A continual fever, accompanied by a dry skin, had prevailed for some time in the city of London. During the continuance of this fever, the regular small-pox made its appearance. It is peculiar to the small-pox, when of a distinct nature, to be attended by irregular sweats before the eruption of the pock. The continual fever now put on a new symptom. It was attended by sweats in its first stage, exactly like those which attended the eruptive fever of the small-pox[35]. This despotism of a powerful epidemic extended itself to the most trifling indispositions. It even blended itself, Dr. Sydenham tells us, with the commotions excited in the system by the suppression of the lochia, as well as with the common puerperile fever[36]. Dr. Morton has left testimonies behind him, in different parts of his works, which establish, in the most ample manner, the truth of Dr. Sydenham's observations. Dr. Huxham describes the small-pox as blending some of its symptoms with those of a slow fever, at Plymouth, in the year 1729[37]. Dr. Cleghorn mentions a constitution of the air at Minorca, so highly inflammatory, "that not only tertian fevers, but even a common hurt or bruise required more plentiful evacuations than ordinary[38]." Riverius informs us, in his history of a pestilential fever that prevailed in France, that "it united itself with phrenitis, angina, pleurisy, peripneumony, hepatitis, dysentery, and many other diseases[39]."

[34] Vol. i. p. 340.

[35] Vol. i. p. 352.

[36] Vol. ii. p. 164. See also p. 1, 109, 122, 204, 212, 233, 274, 355,
358-9, and 436.

[37] De Aere et Morb. Epidem. p. 33, 34.

[38] Page 285.

[39] De Febre Pestilenti, vol. ii. p. 95.

The bilious remitting fever which prevailed in Philadelphia, in 1780, chased away every other febrile disease; and the scarlatina anginosa which prevailed in our city, in 1783 and 1784, furnished a striking proof of the influence of epidemics over each other. In the account which I published of this disease, in the year 1789, there are the following remarks. "The intermitting fever which made its appearance in August was not lost during the month of September. It continued to prevail, but with several peculiar symptoms. In many persons it was accompanied by an eruption on the skin, and a swelling of the hands and feet. In some it was attended with sore throat, and pains behind the ears. Indeed such was the prevalence of the contagion which produced the scarlatina anginosa, that many hundred people complained of sore throats, without any other symptom of indisposition. The slightest exciting cause, and particularly cold, seldom failed of producing the disease[40]."

[40] Vol. i.

I shall mention only one more authority in favour of the influence of a single epidemic upon diseases. It is taken from Mr. Clark's essay on the epidemic disease of lying-in women, of the years 1787 and 1788. "There does not appear to be any thing in a parturient state which can prevent women from being affected by the general causes of disease at that time; and should they become ill, their complaints will probably partake of the nature of the reigning epidemic[41]." I have said that the fever sometimes put on the symptoms of dysentery, pleurisy, rheumatism, colic, palsy, and even of the locked jaw. That these were not original diseases, but symptomatic affections only of the reigning epidemic, will appear from other histories of bilious fevers. Dr. Balfour tells us, in his account of the intestinal remitting fever of Bengal[42], that it often appeared with symptoms of dysentery, rheumatism, and pleurisy. Dr. Cleghorn and Dr. Lind mention many cases of the bilious fever appearing in the form of a dysentery. Dr. Clark ascribes the dysentery, the diarrh[oe]a, the colic, and even the palsy, to the same cause which produced the bilious fever in the East-Indies[43]; and Dr. Hunter, in his treatise upon the diseases of Jamaica, mentions the locked jaw as one of its occasional symptoms. Even the different grades of this fever, from the mildest intermittent to the most acute continual fever, have been distinctly traced by Lancissi to the same marsh exhalation[44].

[41] Page 28.

[42] Page 132.

[43] Observations on the Diseases in Long Voyages to the East-Indies,
vol. i. p. 13, 14, 48, 151. vol. ii. p. 99, 318, and 320.

[44] Lib. ii. cap. v.

However irrefragably these numerous facts and authorities establish the assertion of the prevalence of but one powerful epidemic at a time, the proposition will receive fresh support, from attending to the effects of two impressions of unequal force made upon the system at the same time: only one of them is felt; hence the gout is said to cure all other diseases. By its superior pain it destroys sensations of a less painful nature. The small-pox and measles have sometimes existed together in the body; but this has, I believe, seldom occurred, where one of them has not been the predominating disease[45]. In this respect, this combination of epidemics only conforms to the general law which has been mentioned.

[45] Hunter on the Venereal Disease, introduction, p. 3.

I beg pardon for the length of this digression. I did not introduce it to expose the mistakes of those physicians, who found as many diseases in our city as the yellow fever had symptoms, but to vindicate myself from the charge of innovation, in having uniformly and unequivocally asserted, after the first week in September, that the yellow fever was the only febrile disease which prevailed in the city.

Science has much to deplore from the multiplication of diseases. It is as repugnant to truth in medicine, as polytheism is to truth in religion. The physician who considers every different affection of the different systems in the body, or every affection of different parts of the same system, as distinct diseases, when they arise from one cause, resembles the Indian or African savage, who considers water, dew, ice, frost, and snow, as distinct essences; while the physician who considers the morbid affections of every part of the body (however diversified they may be in their form or degrees) as derived from one cause, resembles the philosopher who considers dew, ice, frost, and snow, as different modifications of water, and as derived simply from the absence of heat.

Humanity has likewise much to deplore from this paganism in medicine. The sword will probably be sheathed for ever, as an instrument of death, before physicians will cease to add to the mortality of mankind, by prescribing for the names of diseases.

The facts I have delivered upon this subject will admit of a very important application to the cure, not only of the yellow fever, but of all other acute and dangerous epidemics. I shall hereafter assign a final cause for the law of epidemics which has been mentioned, which will discover a union of the goodness of the Supreme Being with one of the greatest calamities of human life.

All ages were affected by this fever, but persons between fourteen and forty years of age were most subject to it. Many old people had it, but it was not so fatal to them as to robust persons in middle life. It affected children of all ages. I met with a violent case of the disease, in a child of four months, and a moderate case of it, in a child of but ten weeks old. The latter had a deep yellow skin. Both these children recovered.

The proportion of children who suffered by this fever may be conceived from a single fact. Seventy-five persons were buried in the grave-yard of the Swedish church in the months of August, September, and October, twenty-four of whom were children. They were buried chiefly in September and October; months in which children generally enjoy good health in our city.

Men were more subject to the disease than women. Pregnancy seemed to expose women to it.

The refugees from the French West-Indies universally escaped it. This was not the case with the natives of France, who had been settled in the city.

It is nothing new for epidemics to affect persons of one nation, and to pass by persons of other nations, in the same city or country. At Nimeguen, in the year 1736, Deigner informs us, that the French people (two old men excepted), and the Jews, escaped a dysentery which was universal among persons of all other nations. Ramazini tells us, that the Jews at Modena escaped a tertian fever which affected nearly all the other inhabitants of the town. Shenkius says, that the Dutch and Italians escaped a plague, which prevailed for two years in one of the towns of Switzerland; and Dr. Bell, in an inaugural dissertation, published at Edinburgh, in 1779, remarks, that the jail fever, which attacked the soldiers of the duke of Buccleugh's regiment, spared the French prisoners who were guarded by them. It is difficult to account for these facts. However numerous their causes may be, a difference in diet, which is as much a distinguishing mark of nations as dress or manners, will probably be found to be one of them.

From the accounts of the yellow fever which had been published by many writers, I was led to believe that the negroes in our city would escape it. In consequence of this belief, I published the following extract in the American Daily Advertiser, from Dr. Lining's history of the yellow fever, as it had four times appeared in Charleston, in South-Carolina.

"There is something very singular (says the doctor) in the constitution of the negroes, which renders them not liable to this fever; for though many of them were as much exposed as the nurses to the infection, yet I never knew of one instance of this fever among them, though they are equally subject with the white people to the bilious fever[46]."

[46] Essays and Observations, Physical and Literary, vol. xi. page 409.

A day or two after this publication the following letter from the mayor of the city, to Mr. Claypoole, the printer of the Mail, appeared in his paper.

"SIR,

"It is with peculiar satisfaction that I communicate to the public, through your paper, that the AFRICAN SOCIETY, touched with the distresses which arise from the present dangerous disorder, have voluntarily undertaken to furnish nurses to attend the afflicted; and that, by applying to ABSALOM JONES and WILLIAM GRAY, both members of that society, they may be supplied. MATTH. CLARKSON, _September 6th, 1793._ _Mayor_."

It was not long after these worthy Africans undertook the execution of their humane offer of services to the sick before I was convinced I had been mistaken. They took the disease in common with the white people, and many of them died with it. I think I observed the greatest number of them to sicken after the mornings and evenings became cool. A large number of them were my patients. The disease was lighter in them than in white people. I met with no case of hæmorrhage in a black patient.

The tobacconists and persons who used tobacco did not escape the disease. I observed snuff-takers to be more devoted to their boxes than usual, during the prevalence of the fever.

I have remarked, formerly, that servant maids suffered much by the disease. They were the only patients I lost in several large families. I ascribe their deaths to the following causes:

_1st._ To the great and unusual debility induced upon their systems by labour in attending their masters and mistresses, or their children. Debility, according to its degrees and duration, seems to have had the same effect upon the mortality of this fever that it has upon the mortality of an inflammation of the lungs. When it is moderate and of short duration it predisposes only to a common pneumony, but when it is violent and protracted, in its degrees and duration, it predisposes to a pulmonary consumption.

_2dly._ To their receiving large quantities of impure air into their bodies, and in a most concentrated state, by being obliged to perform the most menial offices for the sick, and by washing, as well as removing foul linen, and the like.

_3dly._ To their being left more alone in confined or distant rooms, and thereby suffering from depression of spirits, or the want of a punctual supply of food and medicines.

There did not appear to be any advantage from smelling vinegar, tar, camphor, or volatile salts, in preventing the disease. Bark and wine were equally ineffectual for that purpose. I was called to many hundred people who were infected after using one or more of them. Nor did the white washing of walls secure families from the disease. I am disposed to believe garlic was the only substance that was in any degree useful in preventing it. I met with several persons who chewed it constantly, and who were much exposed to the miasmata, without being infected. All other substances seemed to do harm by begetting a false confidence in the mind, to the exclusion of more rational preservatives. I have suspected further, that such of them as were of a volatile nature helped to spread the disease by affording a vehicle for miasmata through the air.

There was great mortality in all those families who lived in wooden houses. Whether this arose from the small size of these houses, or from the want of cleanliness of the people who occupied them, or from the miasmata becoming more accumulated, by adhering to the wood, I am unable to determine. Perhaps it was the effect of the co-operation of all three of those causes.

I have said, formerly, that intemperance in drinking predisposed to the disease; but there were several instances of persons having escaped it who were constantly under the influence of strong drink. The stimulus of ardent spirits probably predominated over the stimulus of the miasmata, and thus excited an artificial fever which defended the system from that which was epidemic.

I heard of some sea-faring people who lived on board their vessels who escaped the disease. The smell of the tar was supposed to have preserved them; but, from its being ineffectual in other cases, I am disposed to ascribe their escape to the infected air of the city being destroyed by a mixture with the water of the Delaware.

Many people who were infected in the city were attacked by the disease in the country, but they did not propagate it, even to persons who slept in the same room with them.

Dr. Lind informs us that many persons escaped the yellow fever which prevailed in Pensacola in the year 1765, by retiring to the ships which lay in the harbour, and that when the disease had been taken, the pure air of the water changed it into an intermitting fever[47]. The same changes have frequently been produced in malignant fevers, by sending patients infected with them from the foul air of a city, into the pure air of the country.

[47] Diseases of Warm Climates, p. 169.

Persons confined in the house of employment, in the hospital, and in the jail, escaped the fever. The airy and remote situation of those buildings was probably the chief means of their preservation. Perhaps they derived additional security from their simple diet, their exemption from hard labour, and from being constantly sheltered from heat and cold.

Several families, who shut up their front and back doors and windows, and avoided going out of their houses except to procure provisions, escaped the disease.

I have taken some pains to ascertain, whether any class of tradesmen escaped the fever, or whether there was any species of labour which protected from it. The result of my inquiries is as follows: Three butchers only, out of nearly one hundred who remained in the city, died with the disease. Many of them attended the markets every day. Two painters, who worked at their business during the whole time of the prevalence of the fever, and in exposed situations, escaped it. Out of forty scavengers who were employed in collecting and carrying away the dirt of the streets, only one was affected by the fever and died. Very few grave-diggers, compared with the number who were employed in that business, were infected; and it is well known, that scarcely an instance was heard of persons taking the disease, who were constantly employed in digging cellars. The fact is not new that grave-diggers escape malignant fevers. It is taken notice of by Dr. Clark.

It was said by some physicians in the public papers, that the neighbourhood of the grave-yards was more infected than other parts of the city. The reverse of this assertion was true in several cases, owing probably to the miasmata being diluted and weakened by its mixture with the air of the grave-yards: for this air was pure, compared with that which stagnated in the streets.

It was said further, that the disease was propagated by the inhabitants assembling on Sundays for public worship; and, as a proof of this assertion, it was reported, that the deaths were more numerous on Sundays than on other days; occasioned by the infection received on one Sunday producing death on the succeeding first day of the week. The register of the deaths shows that this was not the case. I am disposed to believe that fewer people sickened on Sundays, than on any other day of the week; owing to the general rest from labour, which I have before said was one of the exciting causes of the disease. From some facts to be mentioned presently, it will appear probable, that places of public worship, in consequence of their size, as well as of their being shut up during the greatest part of the week, were the freest from miasmata of any houses in the city. It is agreeable to discover in this, as well as in all other cases of public and private duty, that the means of health and moral happiness are in no one instance opposed to each other.

The disease, which was at first confined to Water-street, soon spread through the whole city. After the 15th of September, the atmosphere of every street in the city was charged with miasmata; and there were few citizens in apparent good health, who did not exhibit one or more of the following marks of their presence in their bodies.

1. A yellowness in the eyes, and a sallow colour upon their skin.

2. A preternatural quickness in the pulse. I found but two exceptions to this remark, out of a great number of persons whose pulses I examined. In one of them it discovered several preternatural intermissions in the course of a minute. This quickness of pulse occurred in the negroes, as well as in the white people. I met with it in a woman who had had the yellow fever in 1762. In two women, and in one man above 70, the pulse beat upwards of 90 strokes in a minute. This preternatural state of the pulse during the prevalence of a pestilential fever, in persons in health, is taken notice of by Riverius[48].

[48] "Pulsus sanorum pulsibus similes admodum, periculosi."--_De Febre Pestilenti, p. 114._

3. Frequent and copious discharges by the skin of yellow sweats. In some persons these sweats sometimes had an offensive smell, resembling that of the washings of a gun.

4. A scanty discharge of high coloured or turbid urine.

5. A deficiency of appetite, or a greater degree of it than was natural.

6. Costiveness.

7. Wakefulness.

8. Head-ach.

9. A preternatural dilatation of the pupils. This was universal. I was much struck in observing the pupil in one of the eyes of a young man who called upon me for advice, to be of an oblong figure. Whether it was natural, or the effect of the miasmata acting on his brain, I could not determine.

It will be thought less strange that the miasmata should produce these changes in the systems of persons who resided constantly in the city, when I add, that many country people who spent but a few hours in the streets in the day, in attending the markets, were infected by the disease, and sickened and died after they returned home; and that others, whom business compelled to spend a day or two in the city during the prevalence of the fever, but who escaped an attack of it, declared that they were indisposed, during the whole time, with languor or head-ach.

I was led to observe and record the above effects of the miasmata upon persons in apparent good health, by a fact I met with in Dr. Mitchell's history of the yellow fever in Virginia, in the year 1741. In that fever, 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 miasmata, who discovered no other symptom of the disease.

A woman whom I had formerly cured of a mania, who lived in an infected neighbourhood, had a fresh attack of that disease, accompanied by an unusual menstrual flux. I ascribed both these complaints to the action of the miasmata upon her system.

The smell emitted from a patient, in a clean room, was like that of the small-pox, but in most cases of a less disagreeable nature. Putrid smells in sick rooms were the effects of the excretions, or of some other filthy matters. In small rooms, crowded in some instances with four or five sick people, there was an effluvia that produced giddiness, sickness at stomach, a weakness of the limbs, faintness, and in some cases a diarrh[oe]a. I met with a f[oe]tid breath in one patient, which was not the effect of that medicine which sometimes produces it.

The state of the atmosphere, during the whole month of September, and the first two weeks in October, favoured the accumulation of the miasmata in the city.

The register of the weather shows how little the air was agitated by winds during the above time. In vain were changes in the moon expected to alter the state of the air. The light of the morning mocked the hopes that were raised by a cloudy sky in the evening. The sun ceased to be viewed with pleasure. Hundreds sickened every day beneath the influence of his rays: and even where they did not excite the disease, they produced a languor in the body unknown to the oldest inhabitant of the city, at the same season of the year.

A meteor was seen at two o'clock in the morning, on or about the twelfth of September. It fell between Third-street and the hospital, nearly in a line with Pine-street. Moschetoes (the usual attendants of a sickly autumn) were uncommonly numerous. Here and there a dead cat added to the impurity of the air of the streets. It was supposed those animals perished with hunger in the city, in consequence of so many houses being deserted by the inhabitants who had fled into the country, but the observations of subsequent years made it more probable they were destroyed by the same morbid state of the atmosphere which produced the reigning epidemic.

It appears further, from the register of the weather, that there was no rain between the 25th of August and the 15th of October, except a few drops, hardly enough to lay the dust of the streets, on the 9th of September, and the 12th of October. In consequence of this drought, the springs and wells failed in many parts of the country. The dust in some places extended two feet below the surface of the ground. The pastures were deficient, or burnt up. There was a scarcity of autumnal fruits in the neighbourhood of the city. But while vegetation drooped or died from the want of moisture in some places, it revived with preternatural vigour from unusual heat in others. Cherry-trees blossomed, and apple, pear, and plum-trees bore young fruit in several gardens in Trenton, thirty miles from Philadelphia, in the month of October.

However inoffensive uniform heat, when agitated by gentle breezes, may be, there is, I believe, no record of a dry, warm, and stagnating air, having existed for any length of time without producing diseases. Hippocrates, in describing a pestilential fever, says the year in which it prevailed was without a breeze of wind[49]. The same state of the atmosphere, for six weeks, is mentioned in many of the histories of the plague which prevailed in London, in 1665[50]. Even the sea air itself becomes unwholesome by stagnating; hence Dr. Clark informs us, that sailors become sickly after long calms in East-India voyages[51]. Sir John Pringle delivers the following aphorism from a number of similar observations upon this subject: "When the heats come on soon, and continue throughout autumn, not moderated by winds or rains, the season proves sickly, distempers appear early, and are dangerous[52]."

[49] "Sine aura, usque annus fuit."--_Epid. 3._

[50] Letter from Sir John Bernard to Dr. Floyer, p. 233.

[51] Vol. i. p. 5.

[52] Diseases of the Army, p. 5. of the 7th London edition.

Who can review this account of the universal diffusion of the miasmata which produced this disease, its universal effects upon persons apparently in good health, and its accumulation and concentration, in consequence of the calmness of the air, and believe that it was possible for a febrile disease to exist at that time in our city that was not derived from that source?

The West-India writers upon the yellow fever have said that it is seldom taken twice, except by persons who have spent some years in Europe or America in the interval between its first and second attack. I directed my inquiries to this question, and I now proceed to mention the result of them. I met with five persons, during the prevalence of the disease, who had had it formerly, two of them in the year 1741, and three in 1762, who escaped it in 1793, although they were all more or less exposed to the infection. One of them felt a constant pain in her head while the disease was in her family. Four of them were aged, and of course less liable to be acted upon by the miasmata than persons in early or middle life. Mr. Thomas Shields furnished an unequivocal proof that the disease could be taken after an interval of many years. He had it in the year 1762, and narrowly escaped from a violent attack of it this year. Cases of reinfection were very common during the prevalence of this fever. They occurred most frequently where the first attack had been light. But they succeeded attacks that were severe in Dr. Griffitts, Dr. Mease, my pupil Mr. Coxe, and several others, whose cases came under my notice.

I have before remarked that the miasmata sometimes excited a fever as soon as they were taken into the body, but that they often lay there from one to sixteen days before they produced the disease. How long they existed in the body after a recovery from the fever I could not tell, for persons who recovered were, in most cases, exposed to their action from external sources. The preternatural dilatation of the pupils was a certain mark of the continuance of some portion of them in the system. In one person who was attacked with the fever on the night of the 9th of October, the pupils did not contract to their natural dimensions until the 7th of November.

Having described the effects of the miasmata upon the body, I proceed now to mention the changes induced upon it by death.

Let us first take a view of it as it appeared soon after death. Some new light may perhaps be thrown upon the proximate cause of the disease by this mode of examining the body.

My information upon this subject was derived from the attendants upon the sick, and from the two African citizens who were employed in burying the dead, viz. Richard Allen and Absalom Jones. The coincidence of the information received from different persons satisfied me that all that I shall here relate is both accurate and just.

A deep yellow colour appeared in many cases within a few minutes after death. In some the skin became purple, and in others black. I heard of one case in which the body was yellow above, and black below its middle. In some the skin was as pale as it is in persons who die of common fevers. A placid countenance was observed in many, resembling that which occurs in an easy and healthful sleep.

Some were stiff within one hour after death. Others were not so for six hours afterwards. This sudden stiffness after death, Dr. Valli informs us, occurred in persons who died of the plague in Smyrna, in the year 1784[53].

[53] Experiments on Animal Electricity, p. 90.

Some grew cold soon after death, while others retained a considerable degree of heat for six hours, more especially on their backs.

A stream of tears appeared on the cheeks of a young woman, which seemed to have flowed after her death.

Some putrified in a short time after their dissolution, but others had no smell for twelve, eighteen, and twenty hours afterwards. This absence of smell occurred in those cases in which evacuations had been used without success in the treatment of the disease.

Many discharged large quantities of black matter from the bowels, and others blood from the nose, mouth, and bowels after death. The frequency of these discharges gave rise to the practice of pitching the joints of the coffins which were used to bury the dead.

The morbid appearances of the internal parts of the body, as they appear by dissection after death from the yellow fever, are different in different countries, and in the same countries in different years. I consider them all as effects only of a stimulus acting upon the whole system, and determined more or less by accidental circumstances to particular viscera. Perhaps the stimulus of the miasmata determines the fluids more violently in most cases to the liver, stomach, and bowels, and thereby disposes them more than other parts to inflammation and mortification, and to similar effusions and eruptions with those which take place on the skin. There can be no doubt of the miasmata acting upon the liver, and thereby altering the qualities of the bile. I transcribe, with great pleasure, the following account of the state of the bile in a female slave of forty years of age, from Dr. Mitchell's History of the Yellow Fever, as it prevailed in Virginia, in the years 1737 and 1741, inasmuch as it was part of that clue which led me to adopt one of the remedies on which much of the success of my practice depended.

"The gall bladder (says the doctor) appeared outwardly of a deep yellow, but within was full of a black ropy coagulated atrabilis, which sort of substance obstructed the pori biliarii, and ductus choledochus. This atrabilis was hardly fluid, but upon opening the gall bladder, it retained its form and shape, without being evacuated, being of the consistence of a thin extract, and, within, glutinous and ropy, like soap when boiling. This black matter seemed so much unlike bile, that I doubted if there were any bile in the gall bladder. It more resembled bruised or mortified blood, evacuated from the mortified parts of the liver, surrounding it, although it would stain a knife or probe thrust into it of a yellow colour, which, with its ropy consistence, seemed more peculiar to a bilious humour."

The same appearance of the bile was discovered in several other subjects dissected by Dr. Mitchell.

The liver, in the above-mentioned slave, was turgid and plump on its outside, but on its concave surface, two thirds of it were of a deep black colour, and round the gall bladder it seemed to be mortified and corrupted.

The duodenum was lined on its inside, near the gall bladder, with a viscid ropy bile, like that which has been described. Its villous coat was lined with a thick fur or slime, which, when scraped or pealed off, the other vascular and muscular coats of the gut appeared red and inflamed.

The omentum was so much wasted, that nothing but its blood-vessels could be perceived.

The stomach was inflamed, both on its outside and inside. It contained a quantity of bile of the same consistence, but of a blacker colour than that which was found in the gall bladder. Its villous coat, like that of the duodenum, was covered with fuzzy and slimy matter. It moreover appeared to be distended or swelled. This peculiarity in the inner coat of the stomach was universal in all the bodies that were opened, of persons who died of this disease.

The lungs, instead of being collapsed, were inflated as in inspiration. They were all over full of black or livid spots. On these spots were to be seen small vesicles or blisters, like those of an erysipelas or gangrene, containing a yellow humour.

The blood-vessels in general seemed empty of blood, even the vena cava and its branches; but the vena portarum was full and distended as usual. The blood seemed _collected_ in the _viscera_; for upon cutting the lungs or sound liver or spleen, they bled freely.

The brain was not opened in this body, but it was not affected in three others whose brains were examined.

Dr. Mackittrick, in his inaugural dissertation, published at Edinburgh in the year 1766, "De Febre Indiæ Occidentalis, Maligna Flava," or upon the yellow fever of the West-Indies, says, that in some of the patients who died of it, he found the liver sphacelated, the gall bladder full of black bile, and the veins turgid with black fluid blood. In others he found the liver no ways enlarged, and its "texture only vitiated." The stomach, the duodenum, and ilium, were remarkably inflamed in all cases. The pericardium contained a viscid yellow serum, and in a larger quantity than common. The urinary bladder was a little inflamed. The lungs were sound.

Dr. Hume, in describing the yellow fever of Jamaica, informs us, that in several dead bodies which he opened, he found the liver enlarged and turgid with bile, and of a pale yellow colour. In some he found the stomach and duodenum inflamed. In one case he discovered black spots in the stomach, of the size of a crown piece. To this account he adds, "that he had seen some subjects opened, on whose stomachs _no marks of inflammation_ could be discovered; and yet these had excessive vomiting."

Dr. Lind has furnished us with an account of the state of the body after death, in his short history of the yellow fever, which prevailed at Cadiz, in the year 1764. "The stomach (he says), mesentery, and intestines, were covered with gangrenous spots; there were ulcers on the orifice of the stomach, and the liver and lungs were of a putrid colour and texture[54]."

[54] Diseases of Warm Climates, p. 125.

To these accounts of the morbid appearances of the body after death from the yellow fever I shall only add the account of several dissections, which was given to the public in Mr. Brown's Gazette, during the prevalence of this epidemic, by Dr. Physick and Dr. Cathrall.

"Being well assured of the great importance of dissections of morbid bodies in the investigation of the nature of diseases, we have thought it of consequence that some of those dead of the present prevailing malignant fever should be examined; and, without enlarging on our observations, it appears at present sufficient to state the following facts.

"1st. That the brain in all its parts has been found in a natural condition.

"2d. That the viscera of the thorax are perfectly sound. The blood, however, in the heart and veins is fluid, similar, in its consistence, to the blood of persons who have been hanged, or destroyed by electricity.

"3d. That the stomach, and beginning of the duodenum, are the parts that appear 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 exactly 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 in the gall-bladder was quite of its natural colour, though very viscid.

"In another person, who died on the 8th day of the disease, several spots of extravasation were discovered between the membranes, particularly about the smaller end of the stomach, the inflammation of which had considerably abated. Pus was seen in the beginning of the duodenum, and the villous membrane at this part was thickened.

"In two other persons, who died at a more advanced period of the disease, the stomach appeared spotted in many places with extravasations, and the inflammation disappeared. It contained, as did also the intestines, a black liquor, which had been vomited and purged before death. This black liquor appears clearly to be an altered secretion from the liver; for a fluid in all respects of the same qualities was found in the gall bladder. This liquor was so acrid, that it induced considerable inflammation and swelling on the operator's hands, which remained some days. The villous membrane of the intestines, in these last two bodies, was found inflamed in several places.

"The liver was of its natural appearance, excepting in one of the last persons, on the surface of which a very few distended veins were seen: all the other abdominal viscera were of a healthy appearance.

"The external surface of the stomach, as well as of the intestines, was quite free from inflammation; the veins being distended with blood, which appeared through the transparent peritonium, gave them a dark colour.

"The stomach of those who died early in the disease was always contracted; but in those who died at a more advanced period of it, where extravasations appeared, it was distended with air. "P. S. PHYSICK, "J. CATHRALL."

I have before remarked, that these dissections were made early in the disease, and that Dr. Annan attended a dissection of a body at Bush-hill, some time afterwards, in which an unusual turgescence appeared in the vessels of the brain.

Thus far have I delivered the history of the yellow fever, as it affected the human body with sickness and death. I shall now mention a few of those circumstances of public and private distress which attended it. I have before remarked, that the first reports of the existence of this fever were treated with neglect or contempt. A strange apathy pervaded all classes of people. While I bore my share of reproach for "terrifying our citizens with imaginary danger," I answered it by lamenting "that they were not terrified enough." The publication from the college of physicians soon dissipated this indifference and incredulity. Fear or terror now sat upon every countenance. The disease appeared in many parts of the town, remote from the spot where it originated; although, for a while, in every instance, it was easily traced to it. This set the city in motion. The streets and roads leading from the city were crowded with families flying in every direction for safety to the country. Business began to languish. Water-street, between Market and Race-streets, became a desert. The poor were the first victims of the fever. From the sudden interruption of business they suffered for a while from poverty as well as from disease. A large and airy house at Bush-hill, about a mile from the city, was opened for their reception. This house, after it became the charge of a committee appointed by the citizens on the 14th of September, was regulated and governed with the order and cleanliness of an old and established hospital. An American and French physician had the exclusive medical care of it after the 22d of September.

The disease, after the second week in September, spared no rank of citizens. Whole families were confined by it. There was a deficiency of nurses for the sick, and many of those who were employed were unqualified for their business. There was likewise a great deficiency of physicians, from the desertion of some, and the sickness and death of others. At one time there were but three physicians who were able to do business out of their houses, and at this time there were probably not less than 6000 persons ill with the fever.

During the first three or four weeks of the prevalence of the disease I seldom went into a house the first time, without meeting the parents or children of the sick in tears. Many wept aloud in my entry, or parlour, who came to ask for advice for their relations. Grief after a while descended below weeping, and I was much struck in observing that many persons submitted to the loss of relations and friends without shedding a tear, or manifesting any other of the common signs of grief.

A cheerful countenance was scarcely to be seen in the city for six weeks. I recollect once, in entering the house of a poor man, to have met a child of two years old that smiled in my face. I was strangely affected with this sight (so discordant to my feelings and the state of the city) before I recollected the age and ignorance of the child. I was confined the next day by an attack of the fever, and was sorry to hear, upon my recovery, that the father and mother of this little creature died a few days after my last visit to them.

The streets every where discovered marks of the distress that pervaded the city. More than one half the houses were shut up, although not more than one third of the inhabitants had fled into the country. In walking for many hundred yards, few persons were met, except such as were in quest of a physician, a nurse, a bleeder, or the men who buried the dead. The hearse alone kept up the remembrance of the noise of carriages or carts in the streets. Funeral processions were laid aside. A black man, leading or driving a horse, with a corpse on a pair of chair wheels, with now and then half a dozen relations or friends following at a distance from it, met the eye in most of the streets of the city, at every hour of the day, while the noise of the same wheels passing slowly over the pavements, kept alive anguish and fear in the sick and well, every hour of the night[55].

[55] In the Life of Thomas Story, a celebrated preacher among the
friends, there is an account of the distress of the city, in its
infant state, from the prevalence of the yellow fever, in the
autumn of 1699, nearly like that which has been described. I shall
insert the account in his own words. "Great was the fear that fell
on all flesh. I saw no lofty or airy countenance, nor heard any
vain jesting to move men to laughter. Every face gathered
paleness, and many hearts were humbled, and countenances fallen
and sunk, as such that waited every moment to be summoned to the
bar, and numbered to the grave." The same author adds, that six,
seven, and sometimes eight, died of this fever in a day, for
several weeks. His fellow-traveller, and companion in the
ministry, Roger Gill, discovered upon this occasion an
extraordinary degree of christian philanthropy. He publicly
offered himself, in one of the meetings of the society, as a
sacrifice for the people, and prayed that "God would please to
accept of his life for them, that a stop might be put to the
contagion." He died of the fever a few days afterwards.

But a more serious source of the distress of the city arose from the dissentions of the physicians, about the nature and treatment of the fever. It was considered by some as a modification of the influenza, and by others as the jail fever. Its various grades and symptoms were considered as so many different diseases, all originating from different causes. There was the same contrariety in the practice of the physicians that there was in their principles. The newspapers conveyed accounts of both to the public, every day. The minds of the citizens were distracted by them, and hundreds suffered and died from the delays which were produced by an erroneous opinion of a plurality of diseases in the city, or by indecision in the choice, or a want of confidence in the remedies of their physician.