Part 6

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 phlegmasiæ, 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 papulæ 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 ingestæ and medicines. Our own experience was little favourable to the efficacy of cold water, applied to the surface during the eruptive stage; and we apprehend, that, if decided benefit can grow out of its use, it must be during the first or precursory fever, before the formation of vesicles has commenced, when every thing is to be attempted to sooth irritation, and prevent febrile reaction.

The first period over, the eruption on the skin now appears, and constitutes a leading and exceedingly important symptom of the disease. This eruption, like many others the product of gastric derangement, acts for a time as a counter-irritant, and as such affords temporary relief to the internal organs; but when continued, as in the farther progress of the disease, it, in common with all irritants on the skin, returns with interest to the digestive tube, the irritation which it first received from this latter.

We must not lose sight of the state of the lining membrane of the lungs during this time. It cannot be said so much to sympathize with the skin, as to be affected by continuous disease; since the eruption on the mucous membrane of the larynx, trachea, and its ramifications, undergoes nearly the same changes, in the same time with that on the cutaneous surface. The danger and violence of a disease in which the three surfaces, cutaneous, pulmonary, and gastric, are all organically affected at the same time, must be very apparent. Even though there be no eruption on the internal coat of the stomach, its appearance after death, of high vascularity and sanguineous injection, corresponding precisely in appearance with the circles found in the lungs, of which the pustules were the centres, justifies this belief of its being organically affected. Each of the three above mentioned surfaces is in degree ancillary to the others, and each may, on occasions, partially supply their functions; but in this period of variolous disease, our hopes of such vicarious action must be very faint indeed, and hence the hazard attending any application to any one of them.

Are we from these appearances to pronounce the eruption a phlegmasia of the skin and lungs, associated with a previous one of the stomach, and recommend the free use of venesection? Life may occasionally be prolonged, or at times saved by this means; but the disease will not be thereby materially arrested in its course, or modified in its appearance. We shall find that the inflammation of the membranes, consisting as most of them do of cellular tissue and minute capillary vessels, is often not susceptible of being checked by general depletion, carried even so far as to almost empty the larger arteries, and arrest the heart's motion.

Still more will this inflammation persist, if it have gone to the extent of forming new parts, whether phlegmons or pustules. The intensity of the inflammation may be somewhat moderated, but it cannot be conquered now as at the commencement, or during the first period, or that of invasion. We cannot, from our own experience, speak favourably of the remedy in the second, or eruptive stage. It did not answer our expectations, though employed in subjects apparently the best constituted to derive the good effects proposed from it. We must at the same time grant, that it was complicated with other remedies. Of topical bleeding, we are unable to speak, not having seen it tried. In this period of the disease, it must be of very difficult execution. Still less reason have we to boast of the good effects of purging. Though the skin may for a while be relieved by the watery secretions from the intestinal canal; yet the irritation of the latter, consequent on purging, is soon communicated to the cutaneous surface with the effect of aggravating the eruption. To the class of stimuli or stimulating diaphoretics, the same objections apply with increased force. As on the one hand, in cases of high fever, seeming to call for great depletion, the surfaces are often not relieved by general bleeding, but retain their own vitality; so on the other, in cases of apparent prostration, and feebleness of circulation, they often retain all their morbid activity, and will of course be materially injured by stimulation, either of hot air to the skin, or heating drinks to the gastric and intestinal surface. Of the various diaphoretics employed, we had reason to be least dissatisfied with the combination of opium and ipecacuanha in small doses. In some few cases, tartrate of antimony and cream of tartar, dissolved in rice or barley water, and the solution used as a drink, seemed to be beneficial. Several grains of the former were thus taken in the 24 hours, without its producing vomiting or purging. But in very many other instances of the disease, this medicine had no ameliorating effects. Calomel alone, or in combination with opium, was given, and in a few cases caused _ptyalism_. We did not lose persons thus affected, but we cannot speak with any confidence of the propriety of the treatment.

The application of cold water to the skin, was tried by us on the strength of its alleged good effects in this disease, but in no case had we reason to be satisfied with it. The state of the cutaneous surface, during the vesicular and pustular stages, is such as to prevent its transmitting the usual impressions to the interior. Cold may deaden it, and hasten the disorganization of its tissue, but cannot arrest and suspend morbid capillary action here, as in ordinary fevers, or diseases with great local determination, as to the head, &c. If useful at all, it will, we apprehend, be in the forming stage of the disease, before the skin is altered by the eruptive effort. The same objections do not hold against the internal use of cool or cold liquids. We have in this instance to be regulated by the usual precautions, as in all febrile disease where the gastric system is the greatest sufferer. More benefit will follow the sustained use of cool, than the occasional administration of very cold draughts; since in the former case the morbid action of the mucous surface may be restrained in due bounds, without the risk and danger of reaction, and increase of heat and thirst, which are apt to ensue from the latter. The same principle will guide us in the temperature of the air to be inhaled by the lungs.

The secondary diseases, erysipelas, catarrh, and pneumonia, occurring on the decline or subsidence of the variolous disease, would, we may now presume from the phenomena in life, and the autopsic examinations, bear and require a treatment, nearly similar to that used in these diseases arising under other circumstances. Perhaps leeching and cupping ought to be substituted, in such emergencies, for bleeding from the arm.

The extension unavoidably given to this first branch of our subject, requires that we should defer the history of the modified small-pox, or varioloid disease, to the next quarter, when it shall appear in the corresponding number of this Journal.

EXPLANATION OF THE PLATE.

Figures 1, 2, 3, represent various appearances of the lining membrane of the stomach.

Fig. 4, is a portion of the oesophagus; but the red bands ought to run vertically, and not horizontally, as in the plate.

Fig. 13, is another appearance of the stomach.

Fig. 12, indicates the eruption having gone on to ulceration in the pharynx.

Fig. 6, displays the appearance of the lining membrane of the trachea, on the 6th day of the eruption, as in the case of Ann Collins.

Fig. 5, is intended to represent the same part in an advanced stage of the disease, as in the case of Joseph Foster.

Resembling this is the case of Peter Johnson, as far as regards the ulceration and dark colour of the intermediate surface; but differing in the disorganization of the membrane being less.

Figs. 7, 8, 9, 10, and 11, represent the progress of the eruption, in a female, from its incipient to its maturated state. The same section of skin is represented from the 1st to the 5th day of the eruptive stage, on which day the patient died. On the 2nd day, (fig. 8,) the vesicles began to exhibit a central lividness, which was augmented on the subsequent days. The patient had been some years before successfully vaccinated. She was delivered of a child on the 1st day of the eruptive stage. The minutes of this case have been mislaid; but the post mortem appearances were indicative of high action, if not inflammation, of the uterus and its appendages. The infant of this woman, forming Case VIII. died of small-pox three weeks afterwards, on the sixth day of the eruption.

This plate, together with some others yet unpublished, are from the accurate pencil of Mr. now Dr. HARRINGTON, of this city.

(TO BE CONTINUED.)

FOOTNOTES:

[11] This was first at Bush Hill, and subsequently at the Sugar House, near the Alms House.

[12] The largest proportion of these deaths was in the six months from the 1st of November, 1823, to 1st of May, 1824, being in that period about four hundred.

[13] Kept by Reuben Haines, at Germantown, seven miles from the city. The thermometrical mean is that from daily observations made by this gentleman at sunrise and at 2 P. M.

[14] Of these 165 were by yellow fever.

[15] The deaths from inflammation of the different viscera, were as reported in this year, 290, and from infantile flux and cholera morbus, 177.

[16] Same proportion of inflammations as last year, viz. 339.

[17] Should it be hereafter necessary, we can illustrate other varieties of the disease by drawings which were taken at the same time with those, of which coloured engravings are now furnished.

ARTICLE IV.--_Remarks on the Pathology and Treatment of Yellow Fever._ Arranged from the Notes of Dr. J. A. MONGES, of Philadelphia.

I arrived at St. Domingo in the year 1785, and from that period to the time of my departure from thence, I had very ample opportunities of observing and treating the diseases of that island, both in the country and at the Cape. During the whole time of my residence there, the ordinary febrile diseases of hot climates were of very frequent occurrence, especially among the new comers, and those not acclimated; but the real yellow fever, or vomito negro, never prevailed. So that when I reached this city in 1793, I never had had an opportunity of observing this disease.

As introductory to the subject more particularly before us, I shall offer a few remarks on the nature and treatment of the fever, which prevailed in that island. It was usually of the remittent type, of a bilious nature, and rather violent in its character; presenting very often symptoms of a typhoid, or malignant condition of the system. In almost every case, it was attended with great gastric irritability and pain; and, in very many instances, accompanied with vomiting of dark green, and even of black bilious matter,--determination to the brain producing delirium, coma, &c. &c. In general, this fever differed but little from the bilious fevers of this country; except, perhaps, in its greater severity, and in a larger quantity of bile commonly evacuated. The treatment of this disease, at the time of my arrival, was generally attended with some difficulty, owing to the great prejudice prevailing against the use of the lancet; not only among the mass of the population, but even among the old physicians of the island. Experience, however, having taught me, that venesection was essentially necessary in fevers of the same sort, which I had noticed in other places, I resorted to it, notwithstanding the existing opinion; and am now convinced, that by its means I saved many patients. Nor was I the only one to adopt this mode of practice; as it was commonly resorted to by all _new_ physicians, who were soon found to be more successful than the older practitioners. To arrest the violent vomiting, already alluded to, it was of the highest utility, and, in many instances, the only remedy that could be depended upon. Emetics were very commonly used, and sometimes with great benefit; but, in many instances, they were contraindicated by the pain and irritation of the stomach.

Cooling and saline purgatives were advantageously employed, as well as the saline mixture, and nitre and camphor in small and repeated doses, a very favourite practice in the place. In a more advanced period, and when the fever assumed a typhoid type, blisters, bark, and serpentaria were resorted to.

I arrived in Philadelphia on the 20th of August, 1793, and on the 22nd of the same month, began to see patients. The epidemic was then at its height, and such was the demand for physicians, and the prevalence of the idea, that, as I came from the West Indies, I must be familiar with the yellow fever, that I soon became very extensively employed. Such, indeed, was soon the extent of my engagements, that I was compelled for a time to refuse my attendance on many patients, and to limit my visits from Race to Dock streets, and from the water to Third street.

From the first time I had an opportunity of seeing the yellow fever, I perceived that there existed but a very distant, if any, analogy between it and the fevers I had been in the habit of treating in the West Indies. And this opinion I have ever since entertained, in opposition to the statement of many respectable authorities; but in conjunction with some highly respectable physicians and friends, who, like myself, had had an opportunity of treating both diseases. The points of difference between these fevers will be noticed in a subsequent part of these observations. But although entertaining this sentiment, I very early came to the conclusion, that the yellow fever was the effect of a gastro-duodenic inflammation, somewhat modified by some unknown cause,--requiring the usual remedies for such a complaint, proportioned only to the strength of the patient, and the force of reaction in the system; and all my subsequent experience has only served to confirm me in this belief. Differing from many physicians respecting its bilious character, I have been led to believe, that the liver is very seldom implicated in the disease;--the secretion of bile, in the majority of cases, being very little, if at all altered. This may very readily be discovered by an attentive examination of the symptoms of the disease, as well as by the appearances noticed on dissection; the lining membrane of the stomach and duodenum presenting in almost every case, marks of inflammation, and giving passage to a large quantity of black matter, which I have always been led to regard as altered blood, mixed with mucus. The liver, on the contrary, so rarely showed marks of disease, that when it did, it was natural to regard its alteration as secondary.