The febrile symptoms, which abate during the process of maturation, are apt to return during desiccation; and when the skin begins to desquamate, they then constitute what is called secondary fever. The skin which had suffered so much, occasionally exhibits at this time an erysipelatous blush, accompanied by an inflammation of the subjacent cellular tissue, and the formation of troublesome boils, or infiltration of serum, especially where there is much laxity of structure, as in the eyelids, cheeks, lips, &c. The cutaneous system, during and immediately after the removal of its cuticle, and much of its rete mucosum, is of course very sensible, as well to the impression of clothes as to atmospherical extremes, and particularly cold. This is with many a critical time. It not unfrequently happened that persons, who had passed through the different stages of the disease, and were advancing rapidly to convalescence, were suddenly seized with an affection of the chest, pleurisy, bronchitis or pneumonia, and speedily carried off by the violence of the inflammation. The skin, exquisitely sensible in its denuded state to atmospherical vicissitudes, transmits with great promptness the morbid impression to the lungs, already prone to take on disease, in consequence of the active part they are compelled to play during the eruptive fever.
The anomalous varieties, if we can admit any standard form of the disease, were numerous. Those which most fixed our attention were the confluent, the roseate, the tuberculous, and the erysipelatous.
The confluent was ushered in by symptoms of greater febrile disorder than the regular distinct variety: the throat was sorer; eyes more suffused and watery, and more intolerant of light; gastric and pulmonic uneasiness, and oppression more aggravated. In place of the papulae being separate, or merely in clusters, they are so crowded, that on the progress of the eruption the vesicles first and then the pustules are contiguous at their bases, and often run into each other, forming at times, a large irregular bag filled with pus, and technically called blebs, or else exhibiting over a considerable space of skin the appearance of imperfect vesication. The vesicles and pustules are, in such cases, flattened, and with indented centres, which latter display at times a dark point or spot, while the edges are of a livid red. This is the appearance of the limbs and trunk. The cheeks and forehead during the process of maturation present a continuous puffy elevation of a pearly white colour. The eyes are nearly closed by the swelling of the lids, and the thick copious secretion from the borders and the conjunctiva; the lips are tumid and the angles of the mouth ulcerated. In fact the human face divine, deprived of all lineaments and expression, is now a foul, misshapen mass. Associated with this state are swelled throat, rendering deglutition very painful—salivation, cough—occasional vomiting, delirium, sometimes phrenitical, sometimes evidencing itself in low mutterings and jactation.
The roseate variety of small-pox might, without creating much confusion, be ranked with the confluent, which it closely resembles in its second stage. The first is characterized by the rose or pink colour of the face, which is covered with a copious eruption of papulae, some with dry points, while from others, the bases of which are small and hard, arise minute vesicles of a pearly colour, which soon dry away. The inflammation, however, still continues, but spreads under the cuticle, which is raised in large patches of a white colour, but not vesicular, or distinctly pustular, or containing fluid: they approximate and produce the continuous puffy elevation already described. On the trunk and extremities, the eruption is either of confluent patches or of pustules dry and flat, with indented centres, the intermediate skin being of a deep red or crimson colour.
The constitutional disorder runs high in these cases,—delirium and great gastric distress being very common symptoms. The tongue, especially at its border, is frequently the seat of eruption, which may be compared to the vesicular stage on the skin, with the summits cut off. The lining membrane of the mouth and fauces and pharynx, are, we presume, similarly affected, judging from the soreness of these parts, and the thick muco-purulent matter sometimes mixed with blood, which is spit out or brought up by screatus. The subjects most liable to the roseate eruption, were the intemperate and debauched of the sanguine temperament.
The tuberculous variety of small-pox was most frequent among the negroes. The eruption at first consisted of broad papulae, which were converted into hard, rough, and knotted prominences, tuberculous at base and flattened in the centre. This was not unaptly called by some the seal skin eruption. Sore throat, causing the greatest difficulty in deglutition, and delirium were the almost invariable concomitants of this variety. Occasionally the patient was in a state of stupor and disinclination to motion—at other times wakeful and restless, and requiring coercive means to confine him to his bed. In many instances, the muscular strength was retained to within a few hours of death. The fatal termination in these three varieties, confluent, roseate, and tuberculous, was in the second period of the disease, that is, in the one corresponding with the completion of maturation, and the absorption and drying away of the pus in the simple distinct form of small pox. After some experience, we were enabled, from the appearance of the eruption at the outset, to presage the event, which in the above described kinds, was almost universally fatal.
The erysipelatous variety was more an adventitious conversion of the primary form of the disease, by hospital air and delicacy of the cutaneous tissue induced by prior irregularities of life, than a distinct kind to be met with in general practice. It was most commonly presented to us in persons who had a very copious eruption, interesting to a great degree the whole cutaneous surface, and in whom the process of maturation was complete, and the cuticle began to lose its adhesion to the subjacent tissue. In some cases, even after desquamation was almost completed, and the skin nearly dry and smooth, erysipelatous inflammation would supervene, and seem to be repeated on the pulmonary and gastric surfaces, producing great trouble in respiration and derangement in the digestive functions, accelerated pulse, and other symptoms of fever.
We could readily pourtray other nicer shades of the natural small-pox, but the originals might not perhaps be so readily recognized by succeeding observers, or their nature well understood by our readers. Our object being to convey practical knowledge, we pass on to a notice of the subjects, most liable to suffer from exposure to the variolous poison.
The African race would seem to be peculiarly obnoxious to the small-pox: the actual number of people of colour brought to the hospital being greater than the whites, and the proportionate mortality much more considerable; being as four deaths to six cases of disease in the former, and two deaths to four cases of disease in the latter. As regards sex, the proportion of deaths among the males was three-fifths, among the females two-fifths, of the entire number under treatment in the hospital. In both, the violence of the disease, and the number of anomalous symptoms and complications, depended greatly on their prior dissolute life. Drunkards among the men, and prostitutes among the women, rarely escaped death. The former had the roseate eruption, and the latter the confluent, on which dark spots as if gangrenous were a frequent appearance. Menorrhagia, at any time in the course of the disease, was a bad augury.
The better to elucidate the nature of this dire malady, we shall now give from our records some cases of fatal termination, and add an account of the appearances on post mortem examination of these same subjects.
CASES.—I. Wilhelmina Smith, white, aged nineteen years, of irregular habits, has a well defined circular scar, with smaller pits in it, on the left arm; but has no recollection of having been vaccinated, nor does she remember ever having heard her parents, who are now dead, speak of it.
She was taken sick on Thursday night, the 11th of March, 1824, and in the morning had vomiting and pains in the back. On the 13th in the afternoon, the eruption first appeared.
15th. Admitted and visited. Eruption on face slightly prominent, is red, tuberculous and rough—small and scattered on the arms, like flea bites. Legs nearly clear: they have many cicatrices, especially on the shin and outer part. There is at present an ulcer above the inner ancle. Tongue yellow, and furred in centre, white at borders. Pulse small and threaded.
16th. Eruption rising vesicular from face and limbs; no fever; tongue greenish and loaded; coughs much.
17th. Eruption fine, dry, flat, and partly indented in centre on the face, which burns much; skin red and inflamed; on limbs same appearance, but eruption less copious; pulse small, threaded, and frequent; tongue furred and yellow in centre; complains of pain in deglutition; cough.
18th. Eruption on face dry, flat, white and small in size, and copious; rather more elevated on limbs and neck; tongue dry and furred; pulse frequent and threaded; throat sore.
19th. Eruption same as yesterday; pulse scarcely to be felt; skin cool; coughs with an appearance of choking.
Dead at midnight. She retained her muscular strength and ability to sit up to the last.
Examination in the afternoon of March 21.—On removing the sternum and anterior portion of the ribs, the anterior mediastinum was found filled with a frothy adipo-mucous collection of a yellowish colour. The lungs on both sides adherent to the thorax, and the left lobes to each other. A sanguineo-serous effusion on both sides, probably a quart on the right, the lungs of which were changed in texture, and shrunk. The pericardium contained a large quantity of the same kind of fluid, which was found in the cavity of the thorax. The heart was highly injected. On removing the lungs and the trachea, and larynx, the lining membrane of the two last showed a brownish-red, coated with mucus, and deeply injected. Same appearances in a more marked degree in the bifurcations of the trachea.
The oesophagus next examined, was found of a natural appearance, except near the stomach, where it was injected and assumed a red hue, contrasting with the whiteness of its upper part. The mucous membrane of the stomach near the cardiac orifice was in some parts of a roseate hue, in others a brownish-red; while in others it was ash-coloured, and dotted with red and yellow points. Towards the pyloric orifice, less disease. The stomach contained nothing but dark green bile and mucus. The duodenum was also highly injected. Lower down, the small intestines were in places lined with a dark red and brown, and the mesentery highly injected in the portions corresponding to these spots. Intestines much inflated, and omentum dark and injected. The uterus was not examined. The ovaria were large, white and soft; in the left was a small sac of dark blood, which readily burst on pressure.
The liver was very large, of a soft texture and white colour; gall-bladder full of dark green bile, which had in part transuded through its coats.
On looking at the trachea after it was washed, it exhibited in places whitish elevated spots, having all the appearance of an eruption.
II. Ann Collins, white, aged 18 years, unprotected, became sick on Tuesday evening, March 23, 1824, and was taken to the Alms House, as one having the measles, on Wednesday. On Thursday evening, some eruption was visible; on Saturday evening, March 27, admitted.
28th. Visited. Face covered with a red, flat, dry eruption, particularly on the cheeks; small and vesicular on the chin and around the mouth. On the arms, it has the appearance of measles; on the hands, it is of a deep scarlet, with central vesicular elevations; on the legs is slight; tongue loaded and yellow, except at the borders, which are clean; pulse natural; complains much of pain in the back and sickness of stomach.
30th. Eruption covering the face, vesicular on a deep red ground with some tumefaction; rising vesicular on the limbs with scarlet bases. Tongue smooth and shining anteriorly, and with vesicles on it. Throat sore. Salivation. Pulse small and feeble. Has had menorrhagia since her admission into the hospital.
31st. The menorrhagia continues. Had last night epistaxis. Pulse small and slow. Tongue furred and red. Eruption confluent with indented and dark centres. Surface white and dry. Skin between, red and inflamed. Very slight eruption on legs, and none on feet.
April 1. Menorrhagia continues. Pulse small and labouring. Respiration laborious and hurried. Face swelled. Surface smooth, with white spots to represent the pustules. On breast and arms the eruption is in confluent patches which are nearly continuous—some pustules flat and indented, others smooth, with appearance of radii, and some more elevated forming blebs. Skin of the feet cold, and blue in spots; no elevated eruption on lower extremities. Tongue furred and yellowish. Throat sore. Eruption very copious on body, generally with blebs.
Vespere; pulse hardly perceptible. Anxiety and distress great. Dead at 10, P. M.
Examination April 2nd, in the afternoon.—On opening the thorax, the lungs and heart were found of the natural appearance and size. The larynx and trachea being divided, exhibited all the way down to the lungs an injected surface with whitish irregular spots, having nearly the same appearance as the flat smooth eruption on the face: in parts it was more evidently pointed, and showed, by the aid of the microscope, a pustular appearance. In the lungs, the inner surface was still darker. The root of the tongue was covered with large and rather hard papillae, with open summits. The oesophagus was smooth and white. The stomach near the cardia injected, and of a brownish-red in spots: the remaining portion white, presenting no diseased appearance. The spleen was very large and covered with copious miliary points. The omentum, to appearance gangrened, was dark, and altered in texture. The peritoneum, especially in the pelvis, was injected and inflamed, being of a semi-opaque dark colour. The uterus, small and firm, contained some bloody mucus in its cavity.
III. Joseph Foster, white, aged 22 years, unprotected, became sick on Monday evening 8th of March. The eruption began to show itself on Wednesday morning, 10th.
12th. Admitted and visited. Face covered with a red, dry, tubercular eruption, with some few yellow pustules. Same on arms, but no pustular appearance; partly tuberculous, partly vesicular. More sparse and scattered on breast and legs: none on feet. Slight cough. Tongue white, clammy, and loaded in middle—red at borders. Pulse rather frequent.
14th. Face covered with a pustulo-vesicular eruption, with whitish summits, red and inflamed bases. Skin between, of same colour. Eruption dry and hard; very red, copious on limbs; less so on trunk. Tongue moist and less loaded. Pulse regular.
15th. No fever. Face of a deep red colour; eruption rising from it rather flat, irregular in figure and white at summits. Eyes inflamed. On limbs the eruption is red at base, vesicular in body and summit: on trunk in clusters. Tongue yellowish and rather furred. No complaint made; rests easy; sleeps well.
16th. No fever: tongue moist and a little loaded. Pustules nearly white. Some yellow, and beginning to dry on summits. Skin between still of a deep red. Eruption filling on limbs and trunk.
17th. Pulse strong and frequent; skin hot; tongue moist and loaded. Pustules scabbing on face. Not yet entirely filled on limbs, where they are in clusters with inflamed bases.
18th. Pustules full and matured on limbs. Running into each other in places. Tongue dry, brown, and furred in centre, yellow and loaded at sides. Pulse quick and frequent. Lies easy.
19th. Blebs formed on arms; pustules running into each other, beginning to shrink; matter oozing out. Tongue covered with a dark crust. Pulse quick and frequent. Erysipelas of eyelids and ophthalmia. Throat sore.
20th. Blebs larger and more numerous on hands and arms; purulent matter oozing out from some of the pustules. Face nearly scabbed over. Some small white pustules formed on the eyelids. Pulse frequent and vibrating. Tongue as yesterday. Gums tender.
21st. Pulse weaker. Desquamation going on; pustules shrunk and drying on limbs. Tongue as yesterday.
22nd. Matter much absorbed on limbs, leaving a shrunk cuticle. Face covered with a brown and yellow scab and scurf. Tongue black and furred; clear at apex.
23d. Some erysipelatous inflammation of the skin; pustules all nearly disappeared from arms, trunk and thighs; some few, white and soft remain scattered over breast. Pulse frequent. Tongue black and incrusted.
24th. Was brought into town from Bush Hill.
30th. Desquamation nearly complete. Low frequent pulse. Respiration slow and laboured. Tongue incrusted.
April 2nd. Dead at 10, A. M.
Calomel had been freely given to this man in the earlier stage of his disease: and during the last week, spts. terebinth. and nutritive farinaceous food.
Examination.—The pericardium, of a greenish colour and its capillaries finely injected, was full of yellow serum. The lining membrane of the larynx and trachea was of a greenish-yellow colour throughout, and in the spaces between the cartilages ulcerated and disorganized in several spots. Beneath the membrane was a venous injection. About the bifurcation it was injected; and in the ramifications of the trachea were seen several inflamed, and in places abraded and disorganized spots. A chocolate coloured liquor with a sediment filled the bronchiae and the larger tracheal subdivisions.
The oesophagus was sound. The stomach showed clusters of bright red and brownish-red spots, in stellated and other regular figures extending along the smaller curvature. The duodenum, at its commencement and in its course, presented similar clusters. The rest of the intestine was healthy. The brain was to appearance in a natural state.
IV. Peter Johnson, black man, aged 38 years, unprotected, was taken sick on Monday, 29th March, in Sandy Hook. Eruption of small-pox appeared April 3d, Saturday morning. Admitted same day.
4th. Eruption copious on face; papular and of irregular figure. Eyes suffused and red. On arms, same appearance as on face, but less tuberculous. On breast and body, eruption small and pointed; beginning to show on legs. Throat sore. Tongue yellow and loaded at sides; red in centre. Pulse full, equal, and rather frequent. Cough.
5th. Much anxiety and moaning. Eruption rough and tuberculous on face. On arms, it is in parts papillary and pointed, and in parts flat with indented centres. Pulse slow and equal.
6th. Eruption hard and tuberculous on face and arms; small and pointed on breast. Pulse slow; throat less sore; mind wandering. Is sitting up in bed, dressed. Tongue moist and yellow.
7th. Delirious through the preceding night; is now dozing. Eruption same as yesterday. Not so thick on legs, but hard and tuberculous.
8th. Tongue black and incrusted. Throat very sore. Eruption hard and flat. Pulse active.
9th. In a comatose state. Pulse slow. Skin cool.
10th. In the same condition. Drawn down in the bed, the thighs flexed on the abdomen, and lies on his side.
11th. Dead at six A. M.
Examination.—The upper surface of the tongue of a brownish yellow, full of holes and rough. At the posterior part, in place of the larger papillae, were ulcers and cavities. The posterior nares and pharynx were covered with holes, formed by ulceration, and of a brownish hue, adjoining injected and apparent pustular parts. Tonsils ulcerated, and their investing membrane mostly destroyed. The oesophagus immediately below the glottis, smooth and sound. Yellowish matter flowing from the glottis. On opening the larynx, it was found half filled with a viscid light olive-coloured fluid; on removing which, the whole lining membrane, down to the bifurcation of the trachea, was found covered with clusters of ulcerated pustules of a yellow colour, with the intervening spaces of a brownish-red, highly injected, and destitute of its natural smooth, shining appearance. The internal surface of the glottis and epiglottis was in a similar but less marked state as the larynx and trachea. The pustular surface extends to the minute ramifications of the bronchiae, and their cells beyond were highly injected.
On opening the abdomen, the omentum was found dark and shrunk. Stomach contracted. Intestines distended, shining, and very vascular, with capillary injection when viewed externally. The peritoneal covering of the stomach showed a similarly injected appearance.
The stomach being opened, displayed at its upper curvature, spaces studded with spots of a deep red or purple; apparently effusions surrounded by a vascular net-work. Same appearance towards the pyloric orifice, and in places on the duodenum, which, together with the jejunum, particularly the latter, is of a dark leaden colour, and injected.
The diaphragm on its upper surface, highly injected, as was also the pleura lining the thorax. The pericardium healthy.
The brain was not, unfortunately, examined.
V. Jacob Fry, black man, aged 30 years, unprotected, was taken sick on Sunday, 11th April, 1824. Eruption appeared on Thursday, April 15th.
16th. Admitted and visited. Eruption copious and papular on face; smooth and flat, with dark centres, on trunk and arms. Tongue loaded. Cough. Tenderness of epigastrium on pressure. Throat sore. Pulse small and threaded. Eyes muddy.
18th. Eruption flat and rough; diffused over face. On breast red and flat; on limbs in clusters, shrunk, and hollow in centre. Pulse small.
19th. Tongue moist. Pulse small and frequent. Throat much swelled. Restless, and somewhat delirious.
20th. In a comatose state; but is roused to attention by calling him.
21st. Dead at five P. M.
Examination. April 22nd.—On opening the thorax, the lungs were seen to appearance healthy. Both adhered to the pleura costalis. The pleura lining the diaphragm, and also the pericardium, were finely injected. Fauces inflamed, injected, and ulcerated. From the tonsils oozed out pus.
The larynx contains a light olive coloured fluid, muco-serous, which likewise covered the trachea and bronchiae. The lining membrane throughout was rough, and exhibited a net-work of a brownish-red colour, finely injected.
The oesophagus about half way down, has its lining membrane removed for one-third its length, showing miliary points on its muscular coat. The stomach on its outer surface, and near its upper end, showed a black spot, like effusion of black blood, under the peritoneal coat. On examining the oesophagus near the cardia, it was found of a dark colour in lines. From the cardia, half over the inner surface of the stomach, radiates inflamed membrane of a deep red colour, and corroded at the place corresponding to the dark spot above mentioned. Red spots near the pyloric orifice. Intestines not diseased. Liver adherent by its right lobe to the ribs; this lobe was of a greenish leaden colour. No alteration of its structure. Brain injected in its arachnoid coat. Ventricles contained some serum. Tela choroides dark and gorged.
VI. William Lawrence, aged 18 years, unprotected, became sick on Saturday, April 17th. On Sunday taken to the Alms House, and on Wednesday, 21st was transferred to the Hospital.
21st. Eruption fine and papillary on face; red and scarcely raised on arms. None on legs. Has cough since yesterday. Pulse slow and regular. Tongue brown, and incrusted in centre. Moist on sides.
22nd. Eruption confluent and red. Papulo-vesicular on face and arms. Flat, dry, and copious all over the trunk. Scattered and small on legs and feet. Pulse small and regular. Tongue loaded and brown in middle. Eyes sparkling. Is delirious and very restless.
23rd. Eruption very copious all over the body, rising vesicular from red margin. Pulse small and slow. Tongue loaded, furred, and yellow. Head and back easier. Has slept well. Face deeply suffused with red.
24th. Cough. Eruption flat, indented centres, dark in places. It is now coming out on legs. Pulse small and firm. Skin cool. Much uneasiness and hurried breathing.
25th. Dead at seven A. M.
This man had been bled twice before his admission, and once again on the 22nd. Cold affusions had been freely used.
Examination, on the 26th April.—Pericardium sound, but contained much sanguinolent serum. Pleura sound. Lining membrane of pharynx partly destroyed. No ulceration. Tonsils give out pus on pressure.
Oesophagus of a dark red, and partly lost its inner membrane. Larynx and trachea injected; but the membrane lining them is entire, without pustules or ulceration. Some frothy effusion in bronchiae.
Liver healthy. Spleen large. Omentum sound, and of a natural white colour, traversed by some large veins. Stomach externally of a brown-red colour; and when opened, presents, spread out from the cardiac orifice, dark brown-red streaks; and towards the pyloric orifice and upper side, an extensive surface shaded over with vermillion and darker spots. Near the duodenum, the surface is white. Intestines slightly injected. Bladder dotted all over with bright red spots on its inner surface, which is covered with a fine capillary reticulated structure.
VII. An infant, white, unprotected, aged three weeks, child of Clarissa Clarke, who had been inoculated twenty-one years ago. Taken sick on Sunday, 2nd May. Eruption appeared Thursday, 6th. Admitted 9th.
10th. Eruption copious, and in confluent patches, with red bases, and flat vesicular summits. Has also aphthae.
13th. Eruption confluent, in large white patches on face. Throat very sore.
15th. Dead at eight A. M.
Examination.—The stomach of a light colour, perfectly healthy. Folds and plaits of mucous membrane strongly marked. Mucous surface of trachea nearly healthy.
VIII. Infant, female, of a woman who died in the Alms House of varioloid disease, shortly after giving birth to this child. It is three weeks old; was admitted Sunday, 25th April, second day of the eruption. Dead on Thursday, 29th. The skin became livid after death..
Examination.—Pharynx inflamed, and the eruption on it extending all the way down the oesophagus, to near the cardiac orifice; the lining membrane being also in part destroyed. Stomach of a fine clear red, and beautifully injected to the minutest capillaries all over the mucous surface. Intestines, both large and small, red and injected.
The larynx has some eruption on its lining membrane. The trachea and bronchiae nearly healthy; there being no eruption or secretion on their surface.
Doctor DARRACH was present at the majority of the above detailed examinations, and kindly officiated at some of them. This gentleman, well known for his zeal in the study of comparative and morbid anatomy, made many interesting microscopical examinations of the various kinds of variolous pustules, and the corresponding changes in the cutaneous tissue, the results of which, we hope, he will make public.
Having thus freely described what we saw, we wish it were in our power to lay down next, for the benefit of those who come after us, a satisfactory method of treating small-pox. The hospital returns are not of such an encouraging nature as to make our self-love predominate over observation and experience, and lead us to inferences which might seem to sanction the utility of this or that medicine, or curative plan. We had to deal, it is true, with the worst portion of the community; persons of constitutions exhausted or perverted by excess of sensual indulgences, or by poverty, or both conjoined. In private and even dispensary practice, where the subjects were of a better physical and moral nature, we often saw the disease subside, and health return, after less attention to administer medical aid, or to supply other wants, than was exhibited at the hospital. We are, notwithstanding, sanguine enough to anticipate useful results from our attentive study of the symptoms of the disease, in connexion with that of the post mortem examinations, and to consider ourselves as in possession of lights to guide us with more certainty than before. Let us see how far a cautious analysis will tend to dispel old errors, and establish useful truths.
The gastric distress, and the associated uneasiness and pain in the head, back, and limbs, with evening exacerbations of fever, for the three days preceding the eruption, evince conclusively a disease to which the skin is a stranger, except by its usual sympathies of heat and coldness, moisture and dryness. The appearance of the tongue, the loss of appetite, thirst, nausea, and occasionally vomiting, are testimonies to the impeded function of the stomach in this first period, or that of precursory fever: and if to this we add the soreness of the fauces and pharynx, producing impeded deglutition, we cannot refuse our assent to the belief that the mucous surface, on which the preparatory process of digestion takes place, is mainly affected. The next leading symptom is the appearance of the eruption on the skin. The character of the disease is now fixed, and the physician feels himself compelled to respect the cutaneous inflammation, throughout its entire course, naturally enough regarding it as the disease itself, rather than the last link in the chain of morbid actions. To support the circulatory system at such a degree as shall enable the skin to secrete this new matter of small-pox, is nearly as much as he proposes to himself. But here arises a question of great practical moment. To what extent, if any, is the eruption a natural or necessary sequence of the previous symptoms or condition of the system. Perhaps in the existing state of medical science, we hardly dare reply positively to this question. This much we know, that there is no correspondence in general between the intensity of the precursory fever, and the copiousness of the after eruption. We are, moreover, well apprized of the fact of very many, who had been protected in earlier life by inoculation or vaccination, being seized with all the symptoms of the precursory fever of the small-pox, and remaining seriously indisposed for a few days, yet with very little eruption in some cases, and without any in others.
Next we may inquire, what control, salutary or otherwise, we can exercise over the skin in reference to its eruption, by adopting certain methods in medicine and hygeine, during the period of invasion or of precursory fever. To foster the germ of the poison, as yet only affecting the inner surfaces, into efflorescence on the outer or cutaneous one, by hot air, warm and heavy clothes, and cordial drinks, is a practice, which, though at one time advocated on what was thought very sufficient theory, is now abandoned as at war with experience. Of these means, clothing acts primarily on the skin, and we will suppose heat to do the same: the cordial drinks must however affect this organ by stimulating and irritating the gastric and intestinal surface. Against all stimulation of this surface we are then bound, from knowledge and theory, to object.
The cooling regimen as it is called, was substituted for the 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.)
 This was first at Bush Hill, and subsequently at the Sugar House, near the Alms House.
 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.
 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.
 Of these 165 were by yellow fever.
 The deaths from inflammation of the different viscera, were as reported in this year, 290, and from infantile flux and cholera morbus, 177.
 Same proportion of inflammations as last year, viz. 339.
 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:
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, 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.
I seldom derived much advantage from the use of tonics and stimuli in yellow fever; except when the powers of life seemed to fail, and petechiae, vibices, haemorrhages, and other signs of malignancy had occurred. In general, under such circumstances, the Peruvian bark, either alone or combined with serpentaria, was administered in preference to any other remedy of the same class. In cases, however, unattended with reaction, tonics and diffusible stimuli internally, and revulsives of all sorts externally, were had recourse to from the commencement of the attack, and sometimes with the desired effect of arousing the powers of the system. Opium was never found beneficial, on account of its tendency to aggravate or produce coma, as well as from its effect in suppressing intestinal evacuations.
Whilst making use of the above remedies, the plentiful exhibition of diluent drinks was not neglected,—care being taken, however, not to load unduly the stomach, and to select such drinks as would suit the taste of the patient. In almost every case, acids did not answer so well as the bland mucilaginous infusions. The drinks were almost universally allowed cold, except when there existed a tendency to perspiration; under which circumstances they were administered slightly warm and a little aromatic.
During the course of the yellow fever, some of the symptoms demanded particular attention. Influenced by the idea of prostration and dissolution, many practitioners, and myself for some time among the rest, resorted to the bark and other tonics for the purpose of arresting the black vomit, and of correcting that condition of the organs, which gave rise to this effusion; but after many unsuccessful trials, I was led to abandon this practice and to resort to other means. Of all the remedies employed to attain this effect, calcined magnesia mixed in a thick solution of gum arabic seemed to me to answer best; for whilst it succeeded, in many cases, in arresting the vomiting, it tended to keep the bowels open. Together with this, revulsive remedies were applied to the skin, and sometimes succeeded very well,—a sufficient proof, I think, that this haemorrhage is the effect of an increased action of the mucous membrane of the digestive tube, and not of a passive condition of the capillaries of the parts. For the purpose of controlling the great irritability of the stomach, and arresting the vomiting occurring in the early stage of the disease, besides the usual remedies used in such cases, I found advantage in the use of small and frequently repeated injections with a solution of salts, an infusion of senna, or the like substances. Such a practice, however, did not seem to succeed so well in the latter stage of the disease.
With the intention of promoting the secretion of urine, in cases in which it was suppressed, all the diuretics, as well as every external stimuli, were in vain employed;—this symptom, as I have already mentioned, being, in all instances which fell under my immediate observation, the forerunner of death.
ARTICLE V.—Remarks on the Prophylactic Treatment of Cholera Infantum. By JOSEPH PARRISH, M. D., one of the Surgeons to the Pennsylvania Hospital.
The great mortality of cholera infantum renders it one of the most interesting diseases, which come under the notice of the physician. Its ravages among the infant population of our large cities, are too well known, and too strongly felt, to require any comment. No disease contributes so largely to swell our bills of mortality during its prevalence; and were it not restricted to the summer season, it would prove a greater scourge to the community than consumption itself.
This mortality is owing less to our ignorance of the nature of the complaint, and the proper mode of treatment, than to the continued operation of the causes by which it is produced. I have often compared our endeavours to cure cholera infantum, while these causes remain, to an attempt to relieve inflammation in a part, while a thorn is sticking in the flesh. We may resort to bleeding and leeching; we may restrict our patient to the lowest diet, and the most perfect rest; we may employ all those remedies, which are ordinarily best calculated to reduce inflammation: but so long as the thorn continues in the wound, our efforts will be fruitless. Thus it is with cholera. We may obviate the more violent symptoms; we may procure temporary relief; we may even flatter ourselves that a cure has been effected: but the original causes have not lost their power; an increased susceptibility to their operation remains; relapse upon relapse is experienced; and at last the little sufferer, worn out by the successive attacks, sinks beyond the reach of medicine, and expires. Unhappily, the nature of the causes is such, that, in very many instances, their removal is exceedingly difficult, if not altogether impossible; and, under such circumstances, the patient who has once been severely affected, seldom recovers in the end. Hence it becomes of the greatest importance to prevent the occurrence of the disease; and attention to the prophylactic treatment is no less essential than the adoption of curative measures. It is with the view of calling the attention of the profession to this subject, that I have been induced to offer the following observations.
It is obvious, that, in the preventive treatment, two objects demand attention; first, to remove, as far as possible, the causes of the disease; and secondly, where their entire removal is not attainable, to fortify the system against their influence. On each of these, I shall offer a few observations.
I. Excessive and continued heat is, perhaps, the most fruitful source of cholera. Thus we find, that the disease makes its first appearance in the commencement of the hot weather, increases and becomes more fatal with the rise of the thermometer, and declines with the return of cool weather in autumn. During its continuance, it may be observed to vary with every permanent change of temperature. A few very hot days in succession, in the 6th month, are sufficient to call it into action; and during the height of its prevalence, a spell of cold weather will diminish, if not suppress it. In the summer of 1806, which was remarkably cool and pleasant, there was very little of the disease; and generally in moderate summers, it is much less prevalent than in those of a contrary character.
I believe that it is by a direct operation on the system, and not by the generation of miasmata, that heat proves so deleterious to the infant. In the country, where miasmata are most abundant, there is comparatively little cholera; for the heat of the sun is there moderated by the free circulation of the air; and the debilitating operation of the high temperature of the day is counteracted by the refreshing coolness of the morning and evening. It is in the close air of cities, that the complaint flourishes with greatest vigour; and the most confined situations are the most favourable to its production. Let any one take a walk, in a summer's morning, through the thickly built lanes and alleys of Philadelphia. He will be struck with the appearance of the children, reclining their heads, as if exhausted, upon the breast of their mothers, with a pale and languid countenance, a cool and clammy skin, a shrunk neck, and other signs of debility, arising from their confinement, during the night, to close and hot apartments. It will readily be believed, that such places are the very hot beds of cholera.
Heat, therefore, connected with confined air, being among the most frequent causes of the complaint, it is necessary, as far as possible, to counteract them. Should a strong predisposition to cholera be suspected, the best plan will be to send the child into the country during the summer. Both as a preventive and a remedy, country air is decidedly the most effectual, to which we can resort. But in most instances, it would be exceedingly inconvenient, sometimes impossible for mothers to leave their homes and occupations in the city; and, under such circumstances, it becomes necessary to substitute measures, which may produce, as nearly as possible, the same effects. To keep the child cool, and expose him to the fresh air, are the ends to be obtained. For this purpose, he should be carried frequently into the open squares, or beyond the suburbs of the city. I am in the habit of recommending to parents, whose circumstances will not allow of a removal from the city during the summer season, to make frequent excursions across the Delaware, and into the neighbouring woods of New Jersey. The refreshing effects of the air on the river are truly surprising. The brightened eye and animated countenance of the infant, give speedy proof of their favourable influence; and when labouring under the disease, even in its lowest stage, the little patient will often exhibit immediate signs of amendment.
In the prevention of cholera, much may also be expected from a proper attention to the lodging of children. Many parents have a great dread of the night air; and exclude it from their chambers, as sedulously as if it were infected with poison. But, in guarding their children from taking cold, they expose them to a much greater danger. Observe their mode of treatment. The doors and windows are carefully closed; the child is placed in a feather bed, with his parents on each side, and almost smothered with the bed-clothes. Perhaps other children are lodged in the same apartment; and thus the delicate system of the infant is exposed to the debilitating influence of great heat and stagnant air, combined with the effluvia, which, in such a situation, must be abundantly generated. Simply to enter such a room in the morning, is almost sufficient to sicken a healthy individual; how much more injurious must be its effects upon the lodgers themselves. Examine in the morning a child, who has passed the night thus confined. You will find him limber as a rag, exhausted by perspiration, wholly destitute of animation, without appetite, and on the very verge of cholera. I should recommend an entirely different plan of management. Instead of a feather bed, the child should be placed on a hard mattress, or on blankets folded and laid upon the floor. The covering should be light, but comfortable. The doors and windows should be open; so that fresh air, that pabulum vitae, without which health cannot be sustained, may be freely admitted. Thus treated, instead of the feeble and sickly appearance before mentioned, he will present a lively countenance, with all that activity of motion, and enjoyment of existence, which are natural to his age, and afford the surest criterion of vigorous health. Experience has fully convinced me of the great importance of attention to the lodging of children, as a prophylactic measure; and this renders me desirous of impressing upon the profession generally, the truth of my own convictions on the subject.
With the same design of obviating the injurious effects of a high temperature upon the infantile system, I advise frequent ablutions with cool water, and its free employment as a beverage. Infants, unable to make their wants known, often suffer exceedingly from the inability of their attendants to understand them. During the heat of summer, the increased evaporation from their surface is necessarily productive of increased thirst, which, if unsatisfied, renders them uneasy and restless. To quiet them, the breast or bottle is offered. Aliment is thus given, where drink only was required; and the stomach, overloaded and oppressed, is apt to become irritable, and is thus brought into a condition most favourable to the occurrence of cholera. By attention to the peculiar language of infants, expressed not by words, but by signs, I have often been able to detect their wants; and, in many instances, have afforded the most decided relief, by simply giving them a little cool water for drink. From the dread which some individuals have for cool air and cold water, it would seem that they were considered rather as destructive poisons than as absolute necessaries. I have no fear of either, when judiciously employed; and as prophylactics in cholera, I do not think their place can be supplied.
But heat is not the only cause of this complaint. Dentition is well known both to predispose the system to its attack, and, after it has occurred, to increase its violence, and diminish the chances of recovery. In the employment, therefore, of preventive measures, it is highly necessary to attend to the state of the gums, and to remove or counteract this source of irritation. If at all swelled or painful, they should be lanced freely, and the operation should be repeated as often as their inflammatory condition may demand. In severe cases, much good may be expected from the application of blisters behind the ears. The irritation thus receives an external direction, and the stomach and bowels are in less danger of an attack. I was led to this practice, by observing that the eruption, which, during dentition, is apt to make its appearance behind the ears, often proves a most salutary effort of nature; and that, while it continues, the infant generally enjoys an exemption from those dangerous disorders, incident to this critical period of life. To imitate nature as closely as possible, the discharge from the blistered surface should be maintained for some time by stimulating dressings. I have witnessed the most beneficial effects from the practice, and can strongly recommend it to the attention of the profession.