alexipharmic, in so far as regards light clothing and cool air. Can
emetics and purgatives be viewed as a part of this regimen, and exert as
such a salutary influence over the second period of the disease, or that
when the eruptive effort takes place? Admitting they are but local
stimulants, can they as such be with advantage applied to a surface, as
that of the stomach and intestines, already highly irritable, and which,
as the disease advances, becomes inflamed? If our object be in this
first period to diminish the violence of the second or eruptive one, we
doubt whether our expectations will be at all met by any kind of
stimulant to parts, which so promptly transfer their irritation to the
cetaceous surface. Whatever may be thought of these suggestions; whether
they are to be regarded as well-founded, or merely speculative, must be
a subject of future investigation; since we are as yet compelled to deny
that experience can be adduced in favour of the practice of vomiting and
purging to the first period of variolous disease.
On the same line with the remedies just mentioned, have been placed
bleeding, general and local, though as we apprehend, very erroneously.
There is not in bleeding as in purging, conflicting and alternating
effects of debility from evacuation, and irritation, primary and
sympathetic, from local stimulation; but a direct diminution of morbid
action, more tranquil movements of the heart and capillary system, that
is of the circulatory apparatus, and of the membranes, mucous, serous
and cutaneous, &c. Bleeding, unlike most other remedial agents, produces
a direct calmness and ease in the animal economy: it does not like them
substitute one disturbance for another, or make the great appear the
lesser evil. The experienced physician well knows the value of this
remedy, in the first period or invasion of the phlegmasiae, and of some
fevers called general. He is fully aware, that if he cannot produce by
it a decided impression on the malady in the commencement, he is but too
often afterwards a prey to doubts and anxieties, wishing to relieve, but
unknowing what to attempt. Conceding, however, the power of venesection,
in the forming stage of the disease, now under review, so that we by
this remedy may control the series of morbid actions in the second
period, and diminish the extent of the eruption; it may yet be seriously
asked, whether we can with safety and propriety prevent or destroy the
succession of changes to which the skin is subjected, from the first
papulae on to desiccation. On this point, we believe, has turned the
practice of the profession at all times, whether in the ages of
humoralism, or in the reign of solidism. In addition to the reasons
already assigned, which would lead us to doubt the necessity of the
eruption being left uncontrolled, or even suffered to run its course, we
may appeal to the practice of inoculation, which as effectually
saturated the system, and indisposed to subsequent attacks, as if the
skin had formed a continuous pustular surface; and yet this benefit was
often gained by the trifling tax of a few days' fever, and half a dozen
of pustules. Where the fever runs high and the respiration is much
affected, in the first period of measles, and before there is the
slightest appearance of eruption, we conceive it often so be our duty to
bleed freely, without reference to the subsequent disease of the skin,
or any nicety of calculation about this latter going through its regular
stages. Indeed, we have usually reason to congratulate ourselves for
having, by this means, rendered the subsequent disease milder and more
tractable. That affection of the urethra termed gonorrhoea, the
product of contagion, will, if left to itself, go through its several
stages; and, if rest and regimen be enjoined, will often leave the
subject healthy as before. But we can, notwithstanding, cut it short
with perfect impunity, by suitable remedies, and thereby prevent
numerous unpleasant symptoms and effects, which are often present when
the disease is left to nature. Syphilis has its several stages, each
marked by characteristic symptoms; but the skilful treatment of the
first stage prevents, how beneficially we all know, the appearance of
the others. We must then in small-pox, as well as in other diseases,
beware how we confound a common and even natural, with a necessary and
unavoidable succession of symptoms and periods.
The precursory fever in small-pox is seldom marked by the same common
inflammatory symptoms as that in measles; and does not seem, by its
actual violence, to urge the physician to deplete with freedom, if he
only have regard to the existing condition, rather than to the impending
danger and complication. The diversity in the two diseases consists not
so much in the greater intensity of the latter, as in the more decided
gastro-enteritic derangement in the former. Experience has not yet
sanctioned the benefit of copious bleeding from the arm, in incipient
disease, or irritation verging to inflammation of the intestinal
surface, as in small-pox; while its efficacy is admitted in measles. But
conceding its doubtful character, local bleeding, as by cupping, and
leeching on the abdomen, might be serviceably employed in the form of
disease now under consideration; as we know it to have been in other
febrile affections, where the same parts were diseased. Topical
depletion does unquestionably exercise the best effect on membranous
inflammation. In addition to cool air, we may with some confidence have
applied at this time to the skin, cool, if not cold, affusions; while
cold or cool drinks, and these of mucilaginous kind, would constitute
the principal ingestae and medicines. Our own experience was little
favourable to the efficacy of cold water, applied to the surface during
the eruptive stage; and we apprehend, that, if decided benefit can grow
out of its use, it must be during the first or precursory fever, before
the formation of vesicles has commenced, when every thing is to be
attempted to sooth irritation, and prevent febrile reaction.
The first period over, the eruption on the skin now appears, and
constitutes a leading and exceedingly important symptom of the disease.
This eruption, like many others the product of gastric derangement,
acts for a time as a counter-irritant, and as such affords temporary
relief to the internal organs; but when continued, as in the farther
progress of the disease, it, in common with all irritants on the skin,
returns with interest to the digestive tube, the irritation which it
first received from this latter.
We must not lose sight of the state of the lining membrane of the lungs
during this time. It cannot be said so much to sympathize with the skin,
as to be affected by continuous disease; since the eruption on the
mucous membrane of the larynx, trachea, and its ramifications, undergoes
nearly the same changes, in the same time with that on the cutaneous
surface. The danger and violence of a disease in which the three
surfaces, cutaneous, pulmonary, and gastric, are all organically
affected at the same time, must be very apparent. Even though there be
no eruption on the internal coat of the stomach, its appearance after
death, of high vascularity and sanguineous injection, corresponding
precisely in appearance with the circles found in the lungs, of which
the pustules were the centres, justifies this belief of its being
organically affected. Each of the three above mentioned surfaces is in
degree ancillary to the others, and each may, on occasions, partially
supply their functions; but in this period of variolous disease, our
hopes of such vicarious action must be very faint indeed, and hence the
hazard attending any application to any one of them.
Are we from these appearances to pronounce the eruption a phlegmasia of
the skin and lungs, associated with a previous one of the stomach, and
recommend the free use of venesection? Life may occasionally be
prolonged, or at times saved by this means; but the disease will not be
thereby materially arrested in its course, or modified in its
appearance. We shall find that the inflammation of the membranes,
consisting as most of them do of cellular tissue and minute capillary
vessels, is often not susceptible of being checked by general depletion,
carried even so far as to almost empty the larger arteries, and arrest
the heart's motion.
Still more will this inflammation persist, if it have gone to the extent
of forming new parts, whether phlegmons or pustules. The intensity of
the inflammation may be somewhat moderated, but it cannot be conquered
now as at the commencement, or during the first period, or that of
invasion. We cannot, from our own experience, speak favourably of the
remedy in the second, or eruptive stage. It did not answer our
expectations, though employed in subjects apparently the best
constituted to derive the good effects proposed from it. We must at the
same time grant, that it was complicated with other remedies. Of topical
bleeding, we are unable to speak, not having seen it tried. In this
period of the disease, it must be of very difficult execution. Still
less reason have we to boast of the good effects of purging. Though the
skin may for a while be relieved by the watery secretions from the
intestinal canal; yet the irritation of the latter, consequent on
purging, is soon communicated to the cutaneous surface with the effect
of aggravating the eruption. To the class of stimuli or stimulating
diaphoretics, the same objections apply with increased force. As on the
one hand, in cases of high fever, seeming to call for great depletion,
the surfaces are often not relieved by general bleeding, but retain
their own vitality; so on the other, in cases of apparent prostration,
and feebleness of circulation, they often retain all their morbid
activity, and will of course be materially injured by stimulation,
either of hot air to the skin, or heating drinks to the gastric and
intestinal surface. Of the various diaphoretics employed, we had reason
to be least dissatisfied with the combination of opium and ipecacuanha
in small doses. In some few cases, tartrate of antimony and cream of
tartar, dissolved in rice or barley water, and the solution used as a
drink, seemed to be beneficial. Several grains of the former were thus
taken in the 24 hours, without its producing vomiting or purging. But in
very many other instances of the disease, this medicine had no
ameliorating effects. Calomel alone, or in combination with opium, was
given, and in a few cases caused _ptyalism_. We did not lose persons
thus affected, but we cannot speak with any confidence of the propriety
of the treatment.
The application of cold water to the skin, was tried by us on the
strength of its alleged good effects in this disease, but in no case had
we reason to be satisfied with it. The state of the cutaneous surface,
during the vesicular and pustular stages, is such as to prevent its
transmitting the usual impressions to the interior. Cold may deaden it,
and hasten the disorganization of its tissue, but cannot arrest and
suspend morbid capillary action here, as in ordinary fevers, or diseases
with great local determination, as to the head, &c. If useful at all,
it will, we apprehend, be in the forming stage of the disease, before
the skin is altered by the eruptive effort. The same objections do not
hold against the internal use of cool or cold liquids. We have in this
instance to be regulated by the usual precautions, as in all febrile
disease where the gastric system is the greatest sufferer. More benefit
will follow the sustained use of cool, than the occasional
administration of very cold draughts; since in the former case the
morbid action of the mucous surface may be restrained in due bounds,
without the risk and danger of reaction, and increase of heat and
thirst, which are apt to ensue from the latter. The same principle will
guide us in the temperature of the air to be inhaled by the lungs.
The secondary diseases, erysipelas, catarrh, and pneumonia, occurring on
the decline or subsidence of the variolous disease, would, we may now
presume from the phenomena in life, and the autopsic examinations, bear
and require a treatment, nearly similar to that used in these diseases
arising under other circumstances. Perhaps leeching and cupping ought to
be substituted, in such emergencies, for bleeding from the arm.
The extension unavoidably given to this first branch of our subject,
requires that we should defer the history of the modified small-pox, or
varioloid disease, to the next quarter, when it shall appear in the
corresponding number of this Journal.
EXPLANATION OF THE PLATE.
Figures 1, 2, 3, represent various appearances of the lining membrane of
the stomach.
Fig. 4, is a portion of the oesophagus; but the red bands ought to run
vertically, and not horizontally, as in the plate.
Fig. 13, is another appearance of the stomach.
Fig. 12, indicates the eruption having gone on to ulceration in the
pharynx.
Fig. 6, displays the appearance of the lining membrane of the trachea,
on the 6th day of the eruption, as in the case of Ann Collins.
Fig. 5, is intended to represent the same part in an advanced stage of
the disease, as in the case of Joseph Foster.
Resembling this is the case of Peter Johnson, as far as regards the
ulceration and dark colour of the intermediate surface; but differing in
the disorganization of the membrane being less.
Figs. 7, 8, 9, 10, and 11, represent the progress of the eruption, in a
female, from its incipient to its maturated state. The same section of
skin is represented from the 1st to the 5th day of the eruptive stage,
on which day the patient died. On the 2nd day, (fig. 8,) the vesicles
began to exhibit a central lividness, which was augmented on the
subsequent days. The patient had been some years before successfully
vaccinated. She was delivered of a child on the 1st day of the eruptive
stage. The minutes of this case have been mislaid; but the post mortem
appearances were indicative of high action, if not inflammation, of the
uterus and its appendages. The infant of this woman, forming Case VIII.
died of small-pox three weeks afterwards, on the sixth day of the
eruption.
This plate, together with some others yet unpublished, are from the
accurate pencil of Mr. now Dr. HARRINGTON, of this city.
(TO BE CONTINUED.)
FOOTNOTES:
[11] This was first at Bush Hill, and subsequently at the Sugar House,
near the Alms House.
[12] The largest proportion of these deaths was in the six months from
the 1st of November, 1823, to 1st of May, 1824, being in that period
about four hundred.
[13] Kept by Reuben Haines, at Germantown, seven miles from the city.
The thermometrical mean is that from daily observations made by this
gentleman at sunrise and at 2 P. M.
[14] Of these 165 were by yellow fever.
[15] The deaths from inflammation of the different viscera, were as
reported in this year, 290, and from infantile flux and cholera morbus,
177.
[16] Same proportion of inflammations as last year, viz. 339.
[17] Should it be hereafter necessary, we can illustrate other varieties
of the disease by drawings which were taken at the same time with those,
of which coloured engravings are now furnished.
ARTICLE IV.--_Remarks on the Pathology and Treatment of Yellow Fever._
Arranged from the Notes of Dr. J. A. MONGES, of Philadelphia.
I arrived at St. Domingo in the year 1785, and from that period to the
time of my departure from thence, I had very ample opportunities of
observing and treating the diseases of that island, both in the country
and at the Cape. During the whole time of my residence there, the
ordinary febrile diseases of hot climates were of very frequent
occurrence, especially among the new comers, and those not acclimated;
but the real yellow fever, or vomito negro, never prevailed. So that
when I reached this city in 1793, I never had had an opportunity of
observing this disease.
As introductory to the subject more particularly before us, I shall
offer a few remarks on the nature and treatment of the fever, which
prevailed in that island. It was usually of the remittent type, of a
bilious nature, and rather violent in its character; presenting very
often symptoms of a typhoid, or malignant condition of the system. In
almost every case, it was attended with great gastric irritability and
pain; and, in very many instances, accompanied with vomiting of dark
green, and even of black bilious matter,--determination to the brain
producing delirium, coma, &c. &c. In general, this fever differed but
little from the bilious fevers of this country; except, perhaps, in its
greater severity, and in a larger quantity of bile commonly evacuated.
The treatment of this disease, at the time of my arrival, was generally
attended with some difficulty, owing to the great prejudice prevailing
against the use of the lancet; not only among the mass of the
population, but even among the old physicians of the island. Experience,
however, having taught me, that venesection was essentially necessary in
fevers of the same sort, which I had noticed in other places, I resorted
to it, notwithstanding the existing opinion; and am now convinced, that
by its means I saved many patients. Nor was I the only one to adopt this
mode of practice; as it was commonly resorted to by all _new_
physicians, who were soon found to be more successful than the older
practitioners. To arrest the violent vomiting, already alluded to, it
was of the highest utility, and, in many instances, the only remedy that
could be depended upon. Emetics were very commonly used, and sometimes
with great benefit; but, in many instances, they were contraindicated by
the pain and irritation of the stomach.
Cooling and saline purgatives were advantageously employed, as well as
the saline mixture, and nitre and camphor in small and repeated doses, a
very favourite practice in the place. In a more advanced period, and
when the fever assumed a typhoid type, blisters, bark, and serpentaria
were resorted to.
I arrived in Philadelphia on the 20th of August, 1793, and on the 22nd
of the same month, began to see patients. The epidemic was then at its
height, and such was the demand for physicians, and the prevalence of
the idea, that, as I came from the West Indies, I must be familiar with
the yellow fever, that I soon became very extensively employed. Such,
indeed, was soon the extent of my engagements, that I was compelled for
a time to refuse my attendance on many patients, and to limit my visits
from Race to Dock streets, and from the water to Third street.
From the first time I had an opportunity of seeing the yellow fever, I
perceived that there existed but a very distant, if any, analogy between
it and the fevers I had been in the habit of treating in the West
Indies. And this opinion I have ever since entertained, in opposition to
the statement of many respectable authorities; but in conjunction with
some highly respectable physicians and friends, who, like myself, had
had an opportunity of treating both diseases. The points of difference
between these fevers will be noticed in a subsequent part of these
observations. But although entertaining this sentiment, I very early
came to the conclusion, that the yellow fever was the effect of a
gastro-duodenic inflammation, somewhat modified by some unknown
cause,--requiring the usual remedies for such a complaint, proportioned
only to the strength of the patient, and the force of reaction in the
system; and all my subsequent experience has only served to confirm me
in this belief. Differing from many physicians respecting its bilious
character, I have been led to believe, that the liver is very seldom
implicated in the disease;--the secretion of bile, in the majority of
cases, being very little, if at all altered. This may very readily be
discovered by an attentive examination of the symptoms of the disease,
as well as by the appearances noticed on dissection; the lining membrane
of the stomach and duodenum presenting in almost every case, marks of
inflammation, and giving passage to a large quantity of black matter,
which I have always been led to regard as altered blood, mixed with
mucus. The liver, on the contrary, so rarely showed marks of disease,
that when it did, it was natural to regard its alteration as secondary.
Such being my opinion respecting the pathology of yellow fever, I cannot
view otherwise than as secondary to the gastric affection, all the
morbid conditions of other organs, indicated during life by their
peculiar symptoms, and revealed on dissection by the ordinary marks of
inflammation; such as affections of the lungs, kidneys, &c. This view of
the subject will cease to be regarded as merely hypothetical, when it is
recollected, that these symptoms and morbid appearances are occasionally
not found; whilst the symptoms referrible to the gastric and duodenic
irritation, being the true characteristics of the disease, are always
present. Indeed, what would authorize us to regard any subject as
affected with yellow fever, who would not present the pain in the
stomach, the redness of the tip of the tongue, the thirst, irritability
of the stomach, and vomiting either of simple mucus, or black matter?
And, on the other hand, how many have died with these symptoms, who were
not affected with all the others we have noticed, and, on dissection,
have shown no mark of disease, except in the digestive apparatus?
Finally, can pain in the head, affections of the kidneys, vomiting of
bile, &c. constitute yellow fever, without the concurrence of some of
the gastric symptoms we have enumerated?
With respect to the characteristic features of yellow fever, and the
different signs, by which it may be distinguished from bilious fever, I
must be very brief; as a great deal having been written on the subject,
any long details in this place would occasion undue repetition of what
is already known to the profession. A few words, however, may not be
improper. Every one who has had frequent opportunities of seeing the
yellow fever, must have noticed, among its most habitual signs, a
peculiar inflamed glassy appearance of the eye, easily recognised, but
difficult to describe. It is one, however, on which I should be willing
to place considerable reliance, in establishing my diagnosis of this
disease; as I do not recollect to have noticed it in any other form of
febrile affection. Together with this, there is, in the majority of
cases, an intense supra-orbitar pain, apparently unconnected with great
disordered action of the brain, as the intellectual functions are
generally unimpaired. These two signs, together with pain in the loins,
and, in more advanced periods, the peculiar appearance of the skin, the
vomiting of the coffee grounds matter, the intermission on the 4th day,
the retention of muscular strength, and suppression of urine, are the
only signs by which the yellow fever, so far as I am prepared to say,
may be recognised. In regard to the supposed identity of this fever with
the bilious, a great deal has been written; but I must confess, that I
feel inclined to doubt the correctness of this opinion, for the
following reasons: