HISTORY OF THE YELLOW FEVER.
HISTORY.
THE Yellow Fever is known by a variety of names. By the French it has been denominated La Maladie de Siam, from a country of that name in the East-Indies, where it is supposed to have had its origin, and from thence to have been conveyed to distant parts of the world. Sometimes they call it La fiévre matelotte, from its attacking seafaring people and foreigners more readily than the natives of the country in which it prevails. The Spaniards have given it the name of vomito préto, or the black vomit, which is one of its most malignant and characteristic symptoms. Some have called it [Page 8]the malignant fever—others the putrid bilious, and bilious remitting fever, &c. This disease first appeared in this city about the year 1740; and, as I am informed by Doctor JOHN BARD, who was at that time a practitioner, it manifested the same malignant symptoms which characterised the late mortal epidemic.—In some of the southern states it has been known to prevail at a much earlier period.* In 1791 it appeared again in New-York, and has been described in a dissertation published by Doctor ADDOMS.
THE epidemic I am now about to describe, and which has universally received the name of yellow fever, first appeared about the middle of July, and continued until the weather became cold. The season, during its prevalence, was very hot and moist. It raged with most violence in those parts of the town adjacent to the eastern shore, where the air is less pure, and the ground lower than in any other part of the city; which, consequently, must, in some degree, serve as a reservoir for the filth of the upper parts of [Page 9]the city. It attacked persons of all ages, adults more frequently than children, and males than females—foreigners more than the natives, or such of our inhabitants as had lived in warm climates.* Frenchmen and [Page 10]blacks who had lately arrived from the West-Indies, were rarely the subjects of this disease, as they appeared to have been inured, and thence rendered insensible to the operation of its cause; but their exemption is, no doubt, more particularly to the ascribed to their temperate mode of life, and especially their freer use of vegetables; for it is certain, that those who most indulge in the [Page 11]use of animal food and spirituous drinks were most susceptible of the disease.
THE symptoms which marked the yellow fever in its first stage were, a general langour and heaviness—depression of the spirits, sometimes approaching to stupor—disinclination to motion—a sense of cold, and shivering—acute pain in the head, especially above the eyes—pains in the back, and frequently extending down the extremities— the skin was hot, dry, and much flushed, not unlike the scarlet blush of an erysipelatous inflammation—the eyes were suffused with water, and the vessels of the tunica adnata much distended with blood: so constant were these last symptoms, that they may, in a certain degree, be considered as characteristic of the disease. The pulse was, for the most part, frequent, full, and hard—respiration was proportionably quickened, attended with much anxiety, stricture, soreness, and frequently intense heat about the precordia—the tongue was foul, the appetite depraved, with nausea, vomiting, and not unfrequently pain about the region of [Page 12]the stomach: these were among the first symptoms of the disease. The bowels were constipated, unless the patient laboured under a diarrhoea at the commencement of the fever —the urine, in this stage of the disease, appeared, for the most part, as in the first stage of the fevers in general, viz. high-coloured, and small in quantity; in the last stage, when the fever had continued for some days with violence, and the general mass of fluids became changed, this excretion manifested the same alterations, becoming sometimes turbid, and at others yellow, as if tinged with bile.—Such are the symptoms which generally appeared at the commencement of the disease, constituting what I would call the inflammatory stage, but differing from any inflammatory disease, inasmuch as in the former there was no particular part of the body which appeared to be exclusively the seat of inflammation. Where the disease terminated favourably, there was, for the most part, an evident abatement of the above symptoms in forty-eight hours; and in the course of five days the patients were generally [Page 13]freed from fever, but were left greatly debilitated by the violent operation of the poison producing the disease, and the evacuations which became necessary for the removal of the fever: even in those instances where blood-letting, the most debilitating of all evacuations, was not employed, the patient was so reduced as to require all the resources, both of nature and of art, for his support. This stage of the disease was rather marked by symptoms of debility, yet accompanied with great irritability, so much so, that the least imprudence in diet, clothing, bodily exertion, or indulgence in conversation and company, would frequently induce a return of fever. But where this abatement of the disease did not take place within the first three days, a very different and more malignant train of symptoms appeared, partaking more of the symptoms of the last stage of putrid fever, as described by HUXHAM and CULLEN.
IN the last stage of the disease, the pulses sunk, became more frequent, irregular, and sometimes intermittent: the person would [Page 14]lie continually on the back, with the knees drawn up, and the body sinking toward the bottom or foot of the bed; the breathing became proportionably more difficult; and the crust which had formed on the tongue became of a black colour, which change also took place on the lips and teeth; the yellowness became more general over the body, attended with cold clammy sweats; the vomiting now became more frequent and copious; in some instances patients have vomited incessantly, and in astonishing quantities; and what was brought up resembled the grounds of coffee: this, for the most part, was considered as a fatal symptom: there were, however, several instances of recovery after this had taken place to a considerable degree.* It is worthy of remark, [Page 15]that when the vomited liquor acquired this black colour, a diarrhoea sometimes followed, in which there was a discharge of a similar sort of black matter, but more resembling tar or molasses. The florid colour now left the eyes, and they became yellow and sunk. The functions of the brain and nervous system were also very much deranged: the patient was attacked with delirium, attended with subsultus tendinum, and sometimes a perfect stupor, with a convulsive kind of sighing. The speech began to faulter and tremble. The patient appeared very uneasy, and shewed a disposition to leave the bed. Sometimes [Page 16]a deceitful tranquillity appeared, and by some was supposed to be a favourable symptom; but the patient, upon getting asleep, was much agitated. The stools and urine became black, very offensive, and discharged involuntarily: in some instances there was an entire suppression of urine: the extremities became cold, but the heat still continued about the stomach: blood was discharged from the mouth, nose, ears, and eyes, and from those parts of the skin where blisters had been applied. Sometimes blood was effused in the cellular membrane, appearing in the form of mortification—petechiae appeared about the neck and breast— vibices, or livid spots, came out upon the body, particularly upon the abdomen—the perspiration became very foetid—the eyes shone like glass—hiccough and muttering came on, and were followed by death.
Doctor RUSH, in his history of the yellow fever as it prevailed in Philadelphia, has taken notice of buboes and carbuncles as among its symptoms. I do not now a single instance where these symptoms have occurred in this disease in New-York. In [Page 17]the West-Indies these symptoms are not uncommon, as would appear from the following extract of the before-mentioned letter, which I have introduced, as it serves to establish the similarity of the yellow fever to the plague.—"We have had a return of the yellow fever during the months of July, August, and September, much more violent than I ever recollect seeing. The rainy season set in very late, and the weather proved, during these three months, remarkably warm and sultry. The disease commenced early in July, and was not only contagious, but attended with pestilential symptoms. Buboes appeared in several patients, who, however, recovered; and I have seen several instances of the anthrax and pestilential carbuncle. One patient evidently sunk from a carbuncle on his elbow, the haemorrhage from which could scarcely be suppressed by pledgits dipt in diluted vitriolic acid; and two others also appeared upon the foot and ankle of the same patient. I am at present attending a medical gentleman who has above fifty carbuncles upon his body. The [Page 18]discharge has reduced him, but he is recovering. The appearance was first a red unequal erysipelatous appearance upon the skin; in the centre appeared an elevated spot, which gradually changed to black, burst, and discharged a blackish bloody ichor, and left behind it a deep pit. Upon other parts a white pustule appeared, which, after bursting, discharged pus and bloody serum, and pitted in the same manner. The back, loins, and upper part of the thighs were principally affected."
PREDISPOSING CAUSE.
PREDISPOSITION is that state of the body not of itself capable of producing the disease, but rendering the body more susceptible of the exciting cause. In order to produce yellow fever, it is necessary that the body should be in such a state as to receive the action of the exciting cause. This state appears to be a peculiar irritability in the [Page 19]system, by whatever means induced. Upon no other principle can we explain the reason why the contagion does not affect every person within its atmosphere, and why the attendants of the sick are not always attacked. The causes which produce predisposition in the body, for the most part, are,
1st. Fear, which possesses great power in debilitating the body, and hence rendering it more irritable. Upon this principle we may account for the good effects of the different preventives which many were in the habit of using; such as the wearing a small quantity of camphor, vinegar, &c. constantly about the body, inspiring them with a certain degree of courage. The use of tobacco was supposed to have a good effect in counteracting the disease, probably from its possessing more stimulus than the matter of contagion.
2d. Heat. especially exposure to the direct rays of the sun, was a common cause, as it assisted the stimulus of contagion in bringing on indirect debility. Fire also rendered the contagion more active. To prove [Page 20]this we notice, that a great majority of those that were infected were such as, from the nature of their occupations, were much exposed to the heat of the sun and fire.
3d. Fatigue, whether induced upon the mind or body, and from whatever source.
4th. Grief. Persons who attended friends or relatives in this disease were not unfrequently seized during their attendance.
5th. Excess in venery, and other evacuations, such as bleeding and purging, aided by fear, which caused some persons to adopt these means in order to prevent the operation of contagion.
6th. Cold; accordingly such as had been previously much heated, upon getting themselves wet, drinking largely of cold water, or exposing themselves to a stream of cool air, were readily attacked with the disease.
7th. Intemperance in eating or drinking: taking either too large or small quantity of improper food; or a scantity allowance of common diet.
EXCITING CAUSE.
DISEASE is brought on by the action of the exciting cause, after the body is rendered capable of receiving the contagion by the action of the predisposing cause. The yellow fever being a contagious disease, it must undoubtedly depend upon the action of a poison either generated or introduced into the body. This matter, or poison, is generally acknowledged to be exhaled from animal and vegetable substances in a state of putrefaction: but, as there is a great contrariety of opinion upon this subject, I shall purposely pass it over, referring the reader to the works of LAVOISIER and others.— There are also many different opinions as to the mode in which this contagion acts upon the body in producing the disease. Some have supposed that it enters the system by the stomach—some that it enters by the lungs—and others, that the body receives [Page 22]it by the pores of the skin. All these opinions have their advocates; but by whichever passage it is communicated to the system, whether by the stomach, the lungs, or the pores of the skin, it is certain, that, in common with the matter of small-pox, measles, lues venerea, the venom of the rattle-snake, &c. it produces a violent irritation throughout the whole system. Its first operation I consider to be upon the nervous system: hence the violent pains of the head, back, and extremities of the body—hence the sickness of stomach and vomiting— hence the sensation of cold and constriction upon the secreting and excreting vessels. Such an irritation upon the nervous system, with an interruption to the secretions and excretions, are necessarily followed with a quickened circulation. The irritating matter of itself is sufficient to produce this effect; but the suppression of perspiration, the confined state of the bowels, and especially the retention of bile of an uncommonly acrid quality, must also unquestionably have a share in adding to this irritation and increased action.
CURE.
HAVING stated the symptoms and causes of the disease, we are next to consider the indications of cure, which appear to be,
First, To prevent the further operation of the poison producing the disease.
Secondly, to procure a solution of the inflammatory stage of the fever.
Thirdly, To counteract the putrescent state of the body, as described in the second stage of the disease. And,
Lastly, to restore the tone of the system when the preceding indications are accomplished.
First, To prevent the further operation of the poison producing the disease. To this end it is necessary that the patient be removed from the atmosphere in which he took the disease, and placed in a situation where he may enjoy a pure, free air: all articles capable of conveying the contagion should [Page 24]be immediately removed from the body, such as clothing, &c. in place of which there should be clean dry clothing, bedding, &c.
Secondly, To procure a solution of the inflammatory stage of the fever. It is necessary to moderate the increased action of the system, and to remove, as far as possible, every other source of irritation. To evacuate immediately the poison from the body, when one introduced, is as impossible as to eradicate the matter of small-pox, measles, or any other disease produced by specific contagion. In the treatment of yellow fever, as in that of the small-pox, if the analogy be a just one, t [...]sness of the physician appears to be, to moderate the action of the poison producing the disease, and, at the same time, to remove every circumstance which can aggravate its operation upon the body. With a view to diminish the increased action of the system, evacuations of different kinds were employed. Some practitioners had recourse to blood-letting, followed by purging and sweating; and others trusted [Page 25]entirely to the two latter. With respect to blood-letting, my observation has been, that the promiscuous use of the lancet was very injurious and unsuccessful. In the New-York hospital it was frequently employed, but in the majority of cases the disease terminated fatally; yet, in some few instances, where the constitution was uncommonly plethoric, and the determination to the head more violent than usual, I have observed good effects follow the loss of a moderate quantity of blood. But, generally speaking, blood-letting was attended with pernicious consequences. The same has been confirmed by the observations of several of our most respectable practitioners. The more common and successful practice was,
1. To procure a free evacuation from the bowels. The purgative medicines which were employed were many and various. By some, calomel and jalap were prescribed, and, in the beginning of the disease, with good effect. Others administered a mixture of rhubarb and magnesia with cinnamon or mint-water. This also answered well in [Page 26]many cases, where the stomach was irritable, and rejected the former medicines. But the medicine which was the most successful, and acquired the greatest reputation, was the Glauber's salts, given in warm diluting drinks. The dose was generally from one to two ounces, dissolved in a pint of gruel made of Indian meal, and given in divided doses until it operated freely; the patient at the same time drinking freely of gruel or chicken water, to promote its operation. Salts, exhibited in this form, for the most part sat well on the stomach: they were expeditious in their operation, and, in many instances, possessed the additional advantage of relaxing the skin and inducing perspiration, especially where the patient drank largely during their operation. But when the stomach was so much irritated as immediately to reject every thing taken into it, recourse was then had to glysters, composed of vinegar and water, quickened by the addition of a small quantity of molasses: these scarcely ever failed to produce the intended effect.
[Page 27]2. Having procured copious and free evacuations from the bowels, the next object appeared to be to relax the surface of the body, and induce free perspiration. In some instances this salutary discharge came on immediately after the bowels had been emptied, and was readily continued by taking plentifully of warm drinks; but, for the most part the febrile symptoms continued violent, the skin remained hot and dry, the pains still distressing, and it became necessary to have recourse to more active means to induce sweating. For this purpose many sudorific medicines were employed. Some practitioners used emetics, and others small doses of James's powders, and the different preparations of antimony. Vomiting, in this disease, I have generally observed to be of dangerous tendency. It may, perhaps, not be amiss, when the disease first discovers itself, and is attended with much sickness and vomiting, to empty the stomach freely, by means of an infusion of chamomile flowers: but the exhibition of emetics I consider to be highly dangerous and improper. I [Page 28]believe I have seen some cases in which the death of the patients could be ascribed to no other cause than the incessant vomiting brought on by an emetic given in the commencement of the disease. But the most certain and successful means were, to wash the whole surface of the body with cold vinegar and water, and immediately after covering the patient with blankets—to administer such medicines as possess the effect of bringing on sweating: of these the spiritus mindereri and saline draughts of RIVERIUS succeeded well, more especially if the warm drinks were continued, such as the infusion of snake-root, gruel, toast water, tamarind water, lemonade, &c. These were much aided by applying to the feet of the patient a warm brick, steeped in vinegar and covered in a flannel cloth wet with vinegar or spirits: the steam, thus emitted and diffused through the bed, had a wonderful effect in softening the skin and exciting sweat, especially where the cold washing had been previously employed.—Some practitioners have preferred the practice of plunging the patient [Page 29]several times in a cold bath, and violently dashing the body with cold water. But simply washing the patient with cloths dipped in cold vinegar and water, was found much preferable to immersion, both because it more effectually diminished the heat of the system, and was less fatiguing to the patient. Experiments have proved, that repeatedly wiping and washing with water, in the ordinary way in which the operation is performed, diminishes the heat seven or eight degrees more than simple immersion, or dashing it over the body with pails.
THE practice of cold bathing in fevers of this type is not a new one, but was very commonly employed at Breslaw, in Silesia;* and of late years has been very successfully applied in the West-Indies,† as well as in different parts of Europe, where diseases of this type prevail.
PROFESSOR GREGORY, of Edinburgh, and Doctor CURRIE, an eminent physician [Page 30]at Liverpool, have also prescribed it with great advantage in the low typhus fevers of those cities. But its great success in the New-York hospital, as employed by Doctor SAMUEL BARD, and in the private practice of my brother, have fully convinced me of the propriety of its use. It is also proper to remark, that where the physician was not called to the patient in the first stage of the disease, and putrid symptoms had appeared, and the patient had become much debilitated, the cold bath was injurious; and from the abuse of cold bathing, by employing it in the last stage of the disease, it has fallen into disrepute with some practitioners. But as the abuse of a thing is no argument against its use, I repeat my observation, that in the first or inflammatory stage of the disease, it was one of the most useful remedies that was employed. When the cold bath had been thus made use of, and immediately after followed by the spiritus mindereri or saline mixture, with plentiful dilution, it rarely failed to produce sweating in the course of fifteen minutes; and when once [Page 31]induced, it was easily continued by the repetition of the sudorific medicines and drinks, until a solution of the fever was obtained. In some instances where the patient refused his drink and medicines, or, from the carelessness of the nurses, they had not been supplied as frequently as was proper, and the perspiration had been suppressed, it became necessary to repeat the cold bathing, which seldom failed to procure a return of the sweating. By the continuance of this discharge an abatement of all the symptoms took place: it appeared to operate as a specific in the disease; the pulse in a short time became moderate; the heat of the skin diminished; the pain in the head and back, before so distressing, was also relieved; the sickness of stomach and vomiting were removed; and, in the course of two or three days from the attack, the patient had little else to contend with but mere debility.
Thirdly, In those cases where the physician was not called in the early stage of the disease, where the bowels were not freely emptied, and perspiration had remained suppressed, [Page 32]with a continuance of the fever, a more distressing train of symptoms appeared, as described in the second stage of the disease, and required a different mode of practice: few patients, however, recovered from this stage of the disease.
WHERE the stomach was much disturbed with sickness and vomiting, which was one of the most dangerous symptoms, the saline draught was exhibited in the effervescing state; and, in some instances, yeast was employed with advantage, followed with nourishing antiseptic drinks, as milk-punch, lemonade, porter diluted with water, &c. Snake-root-tea, where it sat well upon the stomach, appeared to possess most advantages in this stage of the disease, inasmuch as it procured a free determination to the surface of the body, independent of its antiseptic properties; but where the stomach rejected every thing, recourse was had to blisters, applied immediately over the region of the stomach, and, in some instances, with the most happy effects. Spirituous fomentations, applied to the lower extremities, [Page 33]especially where they were followed with perspiration, in many instances gave relief to the stomach, and rendered it more retentive.
WHERE the bowels were in a costive state, purgative medicines were given to the patient; at the same time injections were employed, composed of vinegar and water, with the addition of molasses and repeated every hour until they produced the desired effect.
WHEN the functions of the brain and nervous system were much disturbed, as indicated by delirium, subsultus tendinum, restlessness, &c. sinapisms, composed of rye-meal, vinegar, and mustard, applied to the soles of the feet, blisters to the ankles, to the inside of the thighs, and to the head, in some few instances procured relief.—In this stage of the disease some practitioners had recourse to bark, wine, and the tonic treatment in general; but the plan I have observed to be attended with most success in addition to the medicines and treatment related above, was to support the patient's [Page 34]strength, by the mildest nourishment, and such as was the least stimulating to the system, viz. soups, composed of a great proportion of vegetables, sago, milk punch, with a small quantity of spirits or brandy, merely sufficient to render it grateful to the stomach. In addition to this mode of treatment, great attention was paid to the removal of every external source of irritation, by frequent changes of linen and bedding, by frequently wiping the body with cloths dipped in spirits or vinegar, removing every offensive matter from the room, and by correcting the atmosphere around him, by the explosion of gun-powder, sprinkling vinegar over his bed, and through the room, and procuring a free circulation of fresh air.
Fourthly, Having, by the means above enumerated, procured an entire solution of the fever, it remains to restore the strength of the system. In the stage of the disease alluded to under the last indication, while a degree of fever remained, an active tonic or stimulating plan of treatment was found injurious; but, when a perfect solution of the [Page 35]disease was obtained, and the patient laboured under mere debility of body, this mode of treatment was not only admissible, but, in many instances, the patient's strength was so completely exhausted, that the most restorative medicines and diet became necessary. In this state of body recourse was had to the bark, serpentaria, the different bitters, mineral acids, and the usual medicines prescribed with this intention, viz. wine, porter, milk-punch, &c. The diet employed with most advantage consisted chiefly of vegetables: sago, tapioca, indian and oat-meal gruel, rendered palatable by the addition of wine, were, for the most part, grateful to the patients—were sufficily nourishing, and, being of a more antiseptic quality, were found less hazardous than the use of animal food. When animal food was employed, it was in the form of soups, with a large proportion of vegetables, or calves-feet jelly, with the addition of wine: in this form it became less exceptionable. But solid animal food was very commonly injurious, retarding the recovery of the patient, [Page 36]and in many instances producing a return of the disease; it was therefore very generally prohibited during the convalescent state of the patient.
THE drinks employed with most benefit, and which were found most grateful to the sick, were wine and water, milk-punch, porter, &c. Such was the disease, and such the mode of treatment, as far as has come within my knowledge.