regular exacerbations, and, unless arrested by medical aid or some
effort of nature, running its course, in a progressive manner, either to
a happy or fatal termination; whereas the yellow fever is almost
invariably a continued fever, presenting obscure and irregular, or even
_no_ remissions. On the fourth day, it generally presents so perfect a
remission, as to cause the patient, in many cases, to imagine himself
perfectly free from disease, and induce him to get up, and even
sometimes to walk out. This remission, which sometimes amounts to an
intermission, so far as an experience of upwards of forty years can
authorize me to decide, is never found to attend in bilious fever, in
which, if there be any remission, and recurrence of the unpleasant
symptoms, the former is always a real convalescence, and the latter an
accidental relapse.
2nd. The red colour of the eye, to which I have alluded above as
occurring in the early stage of the yellow fever, and its peculiar
yellow tinge in the after part of the disease, are different from the
redness and yellowness of the same organ in bilious fever; in the first
stage of which the eye presents a more fiery redness, and in the
subsequent period, a more saffron yellowness.
3d. The colour of the skin in the two diseases presents also some
difference, being more constantly noticed in yellow fever, and
disappearing much more rapidly than in bilious fever. In yellow fever,
moreover, it assumes, most commonly, a yellowish-brown or even mahogany
tinge; whereas in bilious fever, when it occurs, it does not differ from
the ordinary jaundice colour, of a lighter or deeper shade.
4th. These fevers may likewise be distinguished by an attention to the
state of the intellectual faculties, and of the muscular strength; these
remaining often unimpaired to the last in yellow fever, whereas, in a
very large majority of cases of bilious fever, the mind becomes soon
involved in the disorder of the system, and the greatest muscular
debility prevails, even from the very onset of the attack.
5th. The matter vomited might of itself serve to distinguish the two
diseases. Independently of the difference we shall notice when speaking
of the black vomit, we may mention that patients complain, even
sometimes from the commencement of the attack, of the acidity of the
vomited matter; whereas in bilious fever, the mouth is bitter, and the
matter ejected of the same taste.
6th. As a further mark of difference, we may state, that, in yellow
fever, the tongue, except at the tip, the skin, and the pulse are
sometimes little altered; whereas in bilious fever they are usually
pretty much so.
7th. In respect to the duration of the two diseases, we may state as a
general rule, that yellow fever runs its course to death or
convalescence, in a much shorter time than bilious fever. Nor is the
promptness of recovery from yellow fever less different from the
slowness of convalescence, noticed in most cases of bilious fever.
8th. The suppression of urine is a frequent attendant on the last stage
of yellow fever, and is seldom noticed in bilious fever.
9th. I have never witnessed a second attack of yellow fever in the same
individual; whilst on the contrary, so far as I have seen, there is no
limitation to the number of times a person may be affected with the
other form of fever.
_Prognosis._--As regards the prognosis in yellow fever, I shall merely
state, that I generally found, an early evacuation from the alimentary
canal, and a disposition to diaphoresis during the first twenty-four or
thirty-six hours, and its continuance during the course of the disease,
to be favourable omens. When the disease continued beyond the 7th, 9th,
or 11th day, greater hopes might be entertained. It was likewise found,
that the mortality was much smaller among patients, who remained free
from apprehensions as to the nature and termination of the disease. To
this cause, more than any other, do I refer my greater success among
Quakers; who, being generally surrounded and comforted by their friends,
retained more than any other class of people, the necessary tranquillity
of mind.
Among the unfavourable signs may be mentioned, a discoloration of the
skin before the fourth day. This symptom was, indeed, almost always a
fatal one. Obstinate vomiting and costiveness, haemorrhages from
different parts of the body, unattended with an abatement of the
symptoms, and vomiting of black matter, were very unfavourable; whilst a
suppression of urine, agreeably to my experience, was always a fatal
sign.
_Black Vomit._--In a preceding part of these observations, in alluding
to the black vomit, I took occasion to express my views respecting its
nature,--stating that I regard it as consisting of mucous flakes, mixed
with a large proportion of altered blood. That such is the true nature
of this substance, on which so much has been said and written, I have
had sufficient reason to be convinced. The opinion that it consists of
altered bile, I deem totally untenable, for the following reasons: The
matter is occasionally voided in large quantities, in cases in which the
liver is not at all affected, and in which, after death, the gall
bladder is discovered to be more or less filled with _natural_ bile.
Independently, of this, it may be stated, that the appearance of the two
substances is very dissimilar;--the black bile vomited in bilious fever
being of a homogeneous nature, and of a black or deep green colour;
whilst the matter of the black vomit is, in a large majority of cases, a
compound of a mucous, flaky substance, and a sanguineous matter, bearing
some resemblance to the grounds of coffee, and, for the most part, of a
brown tinge. When mixed with water, the two substances produce very
different effects,--the bile mixing with and imparting a greenish tinge
to it without difficulty, whilst the grounds of the other, float on the
surface of the water, without mixing with and colouring it, in the same
manner as bran, deprived of all its mucilage, or rather like mahogany
saw-dust. This I consider as one of the best modes of distinguishing
these two substances,--serving at the same time to establish a
difference between the fevers, I was in the habit of observing in the
West Indies, and the yellow fever of this country. Nor are these the
only reasons for rejecting the supposition of the black vomit of yellow
fever being of a bilious nature; for I have known this substance (and I
suppose other practitioners have observed the same fact) occasionally to
exude from surfaces, from which, in all probability, bile is excluded. I
allude particularly to the skin and verous membranes. Thus it has often
happened, that the application of a blister, especially in the advanced
stage of the disease, has been followed by a copious exudation of a
fluid, resembling, in all respects, the matter ejected from the stomach;
an occurrence which was strikingly exemplified in a case, which fell
under my immediate observation during the last visitation of the disease
in this city, in 1820. During the same epidemic, I had occasion to
attend a Mrs. H. about 70 years of age, who presented a curious example
of the exudation of a similar substance from the peritoneum. She had not
been exposed to the causes of the yellow fever, and indeed presented
none of its ordinary pathognomonic signs. She was attacked very early in
the morning with violent colic, attended with fever, great tenderness of
the abdomen, and high colour of the face. She was bled at 10 o'clock; at
11 vomited a large quantity of coffee ground matter, and died in about
12 or 15 hours from the commencement of the attack. The next morning her
body was examined in the presence of several highly respectable and
experienced physicians, who all coincided in the opinion, that the
matter vomited and which continued to be discharged from the nose, was
identical with that discharged in yellow fever. The stomach as well as
the intestines were found to contain a large quantity of a similar
substance. The cavity of the peritoneum being likewise found filled with
a large portion of it, we at first suspected the existence of an opening
in the intestines, by which an effusion had taken place. After a careful
and minute examination, however, no such opening was discovered. Our
attention was now directed to the condition of the peritoneum itself,
which was highly inflamed. It was, moreover, found, that the substance
in question exuded from its surface,--the membrane, in many places,
especially the portion of it which covers the liver, being coated so
thickly with the grounds, that they could readily be scraped off with
the back of a scalpel.
These cases show conclusively, that the matter of the black vomit,
occurring in yellow fever, should not be regarded as altered bile; and
that the supposition of its consisting of a secretion of the mucous
membrane of the stomach, does not rest on a much more solid foundation.
For bile can hardly be admitted to exude from the skin and serous
membranes, and we cannot suppose, that fluids, similar in every respect,
can be secreted from two surfaces, so very distinct in their
organization, and in the nature of their ordinary products, as those of
the mucous and serous membranes.
From these facts I am led to regard the black vomit as a true
haemorrhage, resulting from a state of previous irritation of the surface
which furnishes it. That inflammation may be cause of it, we have a
sufficient proof in the fact, that a similar fluid is occasionally
vomited in cases of puerperal fever, when the irritation progresses from
the serous to the mucous membrane of the intestines; as well as in cases
of inflammation from blows on the stomach, and the action of poisons. A
case of this kind, arising from a kick of a horse, was attended by
myself and two respectable physicians in consultation, a few years ago;
and another case arising from a large dose of carbonate of potassa,
swallowed by mistake, occurred in my practice not long since. But as it
would occupy too much time to give them here in detail, I pass them by
without further notice.
That the matter of the black vomit is the product of a haemorrhage, I
have thought may also be inferred from the fact, often noticed by myself
and others, of large portions of coagulated blood being found in the
intestines; the surface having the appearance of the common black
matter, whilst on cutting into them, the centre is found to consist of a
red solid coagulum. I have also sometimes noticed, that the duodenum
contained the coffee ground matter, and the intestines, coagulated
blood. In such cases, in order to adopt the opinion of secretion, we
must believe, that the same vessels, occupied in the secretory process,
afforded, at the same time, passage to a portion of common blood; for we
can hardly admit, that the mucous follicles are the organs secreting the
black matter. Besides, is this not a mere dispute about words; and is it
proved that what are called sanguineous secretions are not the result of
the same action, which gives rise to haemorrhagic exudations? and is
there any other difference between the haemorrhage of yellow fever, and
of ordinary cases of hematemesis, than that arising from a difference in
the _quality_ of the blood?
Nor do I find much difficulty in believing, that the colour of the skin,
which is more frequently brown than yellow, as well as the petechiae, &c.
are the effects of the stagnation of blood, altered by the capillaries
of the surface, in the same manner as that exuding from the mucous
surfaces. I believe that this opinion, suggested by some European
writers, is supported by the fact, that this fluid exudes from the
orifices made by the bites of leeches and the incisions of scarified
cups; as well as from the raw surface occasioned by blisters; and that
the vibices contain a serous fluid mixed with blood.
_Analogy to Plague._--On comparing the symptoms of the yellow fever of
this country with those of plague, as detailed so minutely and, I
believe, accurately by authors, and especially by the physicians who
accompanied Bonaparte to Egypt, I have been led to regard these diseases
as bearing a closer analogy to each other than has hitherto been
admitted. I do not pretend to assert that they are the same disease, but
only that they are so nearly allied, as on some occasion, to lead even
an experienced observer into an error of diagnosis. The great difference
between them consists in the frequency of the affection of the lymphatic
glands in the plague, and its comparative rareness in yellow fever; and
in the greater predominance of gastric symptoms in the latter.
Nevertheless, I have had, on many occasions, during our different
epidemics, opportunities of noticing buboes, situated in the same parts
as those mentioned by writers on the plague, running the same course,
and curable by the same means. Carbuncles are frequently seen in both
diseases, though not so frequently in yellow fever as in the plague.
Both diseases present what are called the walking cases. Patients in
both, though more frequently in yellow fever, retain their muscular
strength as well as their intellectual faculties. So far as we are
informed, the mortality in both is pretty nearly the same, and the
treatment similar.
_Contagion of Yellow Fever._--The question of the contagion or
non-contagion of yellow fever has so long occupied the attention of the
profession and been discussed so extensively, that I deem it unnecessary
to devote much space to it here. Nevertheless, as I have had frequent
opportunities of noticing the disease under all circumstances; in all
parts of the city, and in the country; among the wealthy and the poor, I
may without much impropriety offer, in a few words, the result of my
observations and reflections on this head. I must unhesitatingly
declare, that, establishing my opinion on what I have seen, I am led to
the conviction, that the yellow fever is not a contagious disease; that
it never has been carried hither in the way mentioned by contagionists;
and that it has invariably proved an infectious disease, using this word
to express a malady arising from a local source of contamination, other
than a living body. It is plain, that this view of the subject does not
exclude the possibility of a vessel carrying the disease to this or any
other port; but, in that case, the vessel itself or its cargo, must be
the source of infection, and not the individuals on board. And this may
take place, when the port from whence the vessel sailed is free from the
disease. That such has been the case, there cannot be any doubt; and
that the idea, predicated on it, of the contagiousness of the fever is
erroneous, I have not the least hesitation in believing.
How else than on the principle of infection, and not of contagion, can
we explain the attack of individuals frequenting those parts of the
city, where the disease had originated, and which (all the inhabitants
having been removed to some distant situation) had been barricaded? How
could we, in any other way, account for the exemption from the fever of
individuals, who, out of the infected district, nursed, touched, and
even slept with their diseased relatives and friends; and not always in
clean and well ventilated apartments and parts of the city; but, in very
many instances, in the filthiest hovels, and alleys, and among the
lowest classes of society. Striking and unanswerable facts of the sort
have frequently presented themselves to my observation, during our
various epidemics. Children have sucked their parents, affected with the
fever, and, in one case which fell under my notice, the child continued
attached to the breast after its mother's death; and in all such
instances with impunity. I have constantly reprobated the practice of
burning the clothes and bedding of the dead, and have never found any
bad results to occur to those who followed my advice. From a
consideration of all these facts, I must once more express it as my
decided opinion, that the yellow fever, so far as I have had an
opportunity of observing it, is not a contagious disease.
_Treatment._--Whatever opinion we may entertain respecting the specific
nature of yellow fever, I was early convinced that this disease was not
to be treated by specific remedies, and that our curative indications
should be formed on an attentive consideration of the condition of the
system in general, and of particular organs, as pointed out by the
symptoms during life and the morbid lesions after death.
In a former part of these remarks, I suggested the opinion, that the
yellow fever is a gastro-duodenic inflammation, (perhaps of a specific
kind,) and that it required a mode of treatment appropriate to this
morbid state; but proportioned to the strength of the patient, to the
violence of the attack, and to the power of re-action. In general,
however, I have not found active depletion by the lancet, as easily
borne in this, as in bilious and other fevers;--the disease assuming
more rapidly, under this plan, a state of prostration or adynamia. Nor
can this appear surprising, since the same circumstance of a disease
being of an inflammatory nature, but, under a peculiar condition of the
system, contraindicating ample depletion, is a subject of frequent
notice during certain epidemics; for example, of scarlatina, pneumonia,
&c. With the exception of those cases, therefore, occurring in very
robust and plethoric constitutions, and accompanied with much pain in
the head, high febrile excitement, and hard pulse, either large or
small, I have seldom resorted freely to the lancet. When, however, these
symptoms presented themselves, especially the hardness of the pulse, I
have not been sparing of blood-letting, and have sometimes repeated it
several times with the most decided success. But even under these
circumstances, I have seldom found that _large_ bleedings were as
beneficial as small and repeated ones;--the system not reacting always
as energetically as could have been desired, and symptoms of prostration
occurring with much more rapidity. I do not recollect to have bled with
advantage, patients presenting a large, full, but _compressible_ pulse,
owing to the want of reaction; although the other symptoms might seem to
indicate the propriety of the practice. The effect of bleeding on the
vomiting was very different in this, from what I mentioned it to have
been in the bilious fevers of the West Indies; owing probably to the
circumstance, that, when, in yellow fever, the irritation of the stomach
became sufficiently violent to give rise to this symptom, the state of
the system was very often such as to contraindicate the use of the
lancet.
The application of scarified and dry cups to the epigastrium and head,
when there existed pain in these regions, was often resorted to, and
afforded much relief. And I very much regret, that, during our
epidemics, it was out of my power to make use of leeches to the former
part, as so warmly recommended, at the present day, by the French and
Spanish physicians; as I am inclined to the opinion, from the view I
have adopted respecting the pathology of the disease, that, used early
and in large numbers, they would prove very serviceable.
In conjunction with general and local bleeding, fomentations were had
recourse to in almost every case, and applied to the epigastrium in the
form of poultices, or flannels wrung out of warm emollient decoctions.
In order to excite perspiration and to determine action to the surface,
a tepid bath was occasionally prescribed, and in some cases afforded
considerable relief; but as it was an inconvenient remedy, pediluvia,
and hot bricks on which water, or water mixed with vinegar was poured,
were substituted. In cases, however, in which much arterial action
existed, these last means were not prescribed, until the pulse had been
brought down by the lancet, and other remedies presently to be
mentioned.
On the subject of emetics, I shall not enlarge; as I can safely assert,
that I very seldom saw a patient recover from yellow fever, to whom
tartarized antimony, or any other active remedy of the same class, had
been administered. Of the impropriety and danger of this practice in the
present disease, I was early convinced from a careful analysis of the
symptoms, indicating an acute irritation of the stomach and upper
portion of the small intestines, and from the circumstance, that, of the
first family in which I was called to prescribe, five members, to whom
emetics had been administered, had already fallen victims to the fever,
under the care of a very respectable physician, and that three
succeeding ones, who were treated agreeably to my view of the pathology
of the disease, recovered. From these facts and reflections, I was
induced to watch the effects of these remedies in subsequent cases, in
my own practice, and in the practice of other physicians, and was soon
led, from this extended experience, to abandon totally the use of tartar
emetic in the treatment of this malady. Ipecacuanha in emetic doses was
also tried by me; but although, thus administered, it did not occasion
the bad effects resulting from the exhibition of the preceding article,
yet it was often productive of harm, and never of benefit. These
remarks, however, apply more particularly to the use of tartar emetic
during the state of excitement of the fever, and not to that of collapse
which sometimes precede it, and in which it is recommended by some
physicians of the southern states. In this condition of the system, I
have never resorted to it, and, I must confess, could not easily be
persuaded to do so; suspecting that even in such cases, the digestive
organs are already too far implicated, to justify the use of so powerful
and acrid a remedy.
It would seem that the bad effects of emetics, and more particularly of
tartarized antimony, resulted, not only from their irritating qualities,
but also from the efforts of vomiting, during which the stomach is
compressed by the abdominal muscles, and made to contract very forcibly.
To this opinion I am naturally led from the circumstance, that
purgatives, whose action is certainly primarily irritating, are very
advantageously employed in yellow fever. It is not my intention to
attempt here an explanation of this seeming contradiction. Leaving to
others the accomplishment of this difficult task, I shall content myself
with stating, that during the whole course of my long practice, I have
seldom seen a patient die of this disease, whose bowels had been well
evacuated, and in whom perspiration had been excited within the first
twenty-four hours after the attack. I exhibited purgatives in almost
every instance _every day_, until copious evacuations had been procured,
and I generally found, that the mild purges were of greater service than
those of a severe and irritating nature. Senna, acidulated with lemon
juice or tamarinds, answered sometimes remarkably well, when the stomach
could retain it. Castor oil, manna, salts, magnesia, were frequently
employed by me with advantage; and although I did not make an extensive
use of calomel in this disease, yet I prescribed it to children, and to
adults, who, owing to great irritability of the stomach, could not
retain other purgative medicines. When I resorted to it, I generally did
so in doses sufficient to ensure a purgative effect, and never with a
view of exciting ptyalism. In doing this, I was not guided, however, by
any fear of the effects of a salivation, since I was well aware that a
ptyalism occurring in malignant diseases is often a favourable crisis;
but by a knowledge of the great difficulty experienced in producing it,
and from the observation, that in cases in which it was obtained, much
valuable time had been lost, and the patient might have recovered
without.
To promote the operation of the above remedies, purgative enemata were
resorted to, in the early stage of the fever; and were followed by the
frequent use of injections, composed of emollient decoctions, from which
the patient derived considerable relief and comfort.
As counter-irritants, blisters and sinapisms were used, and often with
great advantage. They were found of much value when applied to the
epigastric region, for the purpose of arresting the vomiting. Sinapisms
were in general preferred to blisters, as being more prompt in their
effects and more easily renewed. Blisters were sometimes applied to the
extremities in the different stages of the disease; but so far as I can
judge, from my experience, not with much real benefit.