Chapter 7

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:

1st. Bilious fever is almost always a remittent fever, presenting 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, hæmorrhages 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 hæmorrhage, 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 hæmorrhage, 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 hæmorrhagic exudations? and is there any other difference between the hæmorrhage 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 petechiæ, &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.