189 1847] Its resemblance to other Intertropical Fevers. mospheric heat; by exposure to the sun; by the night airs or dews, and the influence of cold following such exposures or excessive exertion or high ranges of temperature; by intemperance and errors of diet or of regimen; by excesses in vinous or spirituous liquors." P. 984. With regard to the mild form of the true Yellow Fever, all that requires to be said respecting it is that, however slight and unalarming the symptoms may be, the disease is declared by our author to be essentially and invariably infectious; so much so that, in his opinion, the most fatal and malignant infection may originate from a case of the least possible severity. He acknowledges, indeed, that in this mild form it cannot be distinguished but with very great difficulty from the common bilious or bilio-gastric fever; so nearly do their symptoms resemble each other. This difficulty, too, must be not a little enhanced by the circumstance, admitted by Dr. C., that the latter may acquire, under peculiar circumstances, infectious properties. "The influence of infection in producing it," says he, "has been doubted; but the experience of Drs. Denmark and Boyd, in ships and hospitals in the Mediterranean, has demonstrated its occasional origin in the cause-or, at least, the power infection evinces in producing a severe modification of it." Before taking leave of the two kinds of fever described above-viz. the Bilio-gastric and the mild form of Yellow-fever-we must not omit to state that there is quite as close an analogy or alliance between the Remittent fever of warm climates and these, as there is between the two kinds themselves. This alliance is rendered the more conspicuous from the fact admitted by our author, that the bilio-gastric fever not only arises from the same causes as the remittent, but also not unfrequently lapses into the periodic type. Compare the following description of the first form or degree of the latter with those already given: Mild Remittent.-"The stage of invasion is similar to that already described; it being attended by coldness of the surface, and frequently by shivering. The coldness is soon superseded by heat, by febrile flushes, or by alternations of heat and cold, by nausea, and occasionally by vomiting, which soon develop the stage of excitement. With it, the pains of the head, back, and limbs become remarkably aggravated; the mouth is clammy and dry; the tongue white or loaded; the surface very hot and parched; the face flushed; the features tumid; and the pain of the head attended by a feeling of distension and throbbing, often passing into delirium. The pulse, which, at the invasion, was small, irregular, and weak, is now full, large, strong, and frequent; thirst is urgent; the bowels constipated; and the urine scanty and high-coloured. There is always more or less tenderness at the epigastrium, with nausea, and often with vomiting. These symptoms generally continue from about ten or twelve to eighteen hours, when perspiration breaks out; the pulse falls in frequency and strength; the irritability of the stomach subsides; delirium disappears; and the skin becomes cooler: but there is merely a remission or abatement, but no intermission of the febrile symptoms. The remission usually continues from three to nine or ten hours, when an exacerbation occurs, sometimes preceded by chills or shiverings, at other times not, and the severer symptoms are renewed. Thus the disease proceeds with alternate remissions and exacerbations, the former generally taking place in the morning, until the seventh day, or the ninth, eleventh, or fourteenth day, or much later, in temperate countries, when a copious perspiration generally puts a termination to its progress." Vol. I., p. 947. Having thus shown how nearly the milder form of the true pestilential fever of the West Indies and of the African coast resembles, in its outward features at least, the common endemic fevers, remittent as well as continued, of these countries, we shall now advance a step farther in our comparative investigation of their histories, and this we shall do according to the same plan we have followed above. Yellow Fever." The more severe and more frequent form appears more suddenly (than the mild form already described-Rev.) and the symptoms are much more violent. The attack is ushered in by shivering and rigors. The pain in the orbits and forehead is excruciating; severe pain is also complained of in the loins and calves of the legs; the face is flushed; the eyes are glassy, suffused, or apparently inflamed; the pulse is rapid; the skin burning hot and dry; and the tongue is loaded, but moist, with little thirst. A few hours afterwards, uneasiness of stomach, with nausea and vomiting, supervenes; followed by severe pain and tenderness at the epigastrium, with a sense of rawness, heat, or inflammation in the fauces and down the œsophagus; great anxiety, restlessness, and watching, with a desire of sleep. The bowels are constipated, the evacuations scanty and deficient in bile: the urine dark-coloured and small in quantity. "If the disease be judiciously treated, these symptoms often become ameliorated on the second or third day; the patient falling into a sleep, from which he awakes refreshed, with a perspiring or moist skin, and nearly free from all the symptoms. Debility only remains, the recovery from which is generally rapid. In many cases, however, either a partial amelioration only occurs, or the more complete subsidence of the symptoms is of short duration; the patient in a few hours beginning to be troubled with flatus in the stomach, and distressing hiccough. Not unfrequently the patient is suddenly and unexpectedly seized with faintness, sickness, and painful retchings, followed by vomiting, at first of whatever had been taken into the stomach, but soon afterwards of a The Ardent or Seasoning Fever.*"The attack is usually sudden. Giddiness, faintness, and general uneasiness, sometimes, however, precede it for ten or twelve hours. There is, occasionally, a slight and brief chilliness at the commencement, especially in the less violent cases, rapidly followed by a sense of universal heat; by flushed face, frontal headache, and vertigo; by inflamed, heavy eyes, and great sensibility to light and sound; by pain in the occiput, neck, back, and limbs; and by a strong, full, hard, and accelerated pulse. A sense of heat, oppression, pain, or anxiety, is felt at the præcordia, sometimes with a dry cough, and pain in the side; respiration is quick, laborious, suspirous, or anxious; the tongue is white, excited, and its edges red; the fauces are arid, thirst urgent, and skin hot and dry; the urine is scanty, the bowels costive; and there is generally nausea, but seldom vomiting until some time after the attack. If the disease be not mitigated by treatment, the patient becomes extremely restless; the headache is rending and intense; vascular action is excessive; and the heat very great. Vomiting now supervenes, and follows the ingestion of whatever is taken to allay the urgency of thirst. The matters thrown off are generally tinged with bile; and a bilious yellow suffusion of the skin is frequently observed. Bilious vomiting and purging occasionally occur with the yellowness of the surface, and, in the slighter cases, become a favourable crisis. There is often great drowsiness, but no refreshing sleep. These symptoms of excessive excitement proceed with various degrees of violence, and occupy a period of from twenty-four to sixty hours, but most commonly from twenty-four to This is the Endemial Causus of Moseley, the Inflammatory Endemic of Dickenson, and the Endemic Yellow Fever of some writers. 1847] Its Resemblance to other Intertropical Fevers. brownish fluid, resembling dirty water, mixed with a dark-coloured flaky matter, which floats upon its surface; and at last, by a matter resembling coffeegrounds or thin pitch. At this time, also, a great change takes place in the countenance, which assumes a putrid, dingy, and bloated appearance, which is most remarkable in those of a florid or sanguine complexion. A light yellow or lemon tinge appears under the eyes and ears, and soon spreads down the neck to the chest, and over the whole body. The vessels of the conjunctiva appear relaxed, and distended with blood. The vomitings continue, and the quantity of fluid ejected much exceeds that which has been drunk. They often return without being excited by ingesta; or even suddenly or unexpectedly, and when the patient has just before considered himself relieved from them." "The third form of attack also commences with shivering or rigors, and is an aggravation of the symptoms of the second from the beginning. In this form, the face is more flushed, and the burning heat of skin is greater than in the preceding. The sickness of stomach, hiccough, and black-vomiting appear much earlier. The bowels are obstinately constipated, and resist strong purgatives; the motions being watery, of a dirty colour, and rarely feculent or bilious. Violent delirium often occurs early in the attack, and hæmorrhages frequently take place at an early period from the nose, mouth, eyes, ears, and even from all the outlets of mucous canals. The tongue is often clean, moist, livid, or red, and raw-like, or covered with dissolved blood. The action of the kidneys is suppressed, either little or no urine being secreted. The countenance changes to a livid and yellowish hue, with yellowness of the skin. In the most severe of these attacks the patients may be carried off on the second, but generally on the third day, sometimes in convulsions." P. 139. The blood is always more or less changed-most remarkably after the calm occurring on the third day. Even at the commencement and during reaction, it does not coagulate, or does so 191 forty-eight hours. During this period, blood taken from a vein is remarkably florid, warm, and fluid. The fibrin coagulates firmly, but the crassamentum is without crust, and is rarely cupped. "The excitement having reached its acme, is quickly followed by exhaustion, This is indicated by a subsidence of the most urgent symptoms: the pain and heat are lessened; the skin becomes damp or clammy; and the patient has a sense of cold or slight chilliness. This delusive remission is a state of great danger in some cases, it passes into rapid sinking-into a speedily fatal collapse." "Discolouration of the skin generally takes place in this stage; appearing in yellow, yellowish brown, and livid patches. It never occurs in the period of excitement, for it is quite dissimilar from the bilious yellowness occasionally observed in that period. It is commonly attended by passive hæmorrhage from the nose, gums, eyes, ears, &c., and by black and grumous vomiting. The change of colour, and hæmorrhage, proceed from exhaustion of the vital influence in the extreme vessels, and from the changes induced in the mass of blood. The matters thrown off the stomach consist at first of ingesta and serous fluid, often coloured by bile. In a more advanced stage they are ropy, mixed with numerous small shreds, flocculi, or films, which soon acquire a dark brown, purple, or black colour; but do not, at first, communicate much of the same tint to the fluid containing them. Afterwards, the matters vomited are more intimately mixed; and, from dark-coloured blood which has been effused into the stomach, vitiated bile, and other morbid secretions, assume a dark or coffee-grounds appearance. At the same time, dark-coloured matter, resembling tar mixed with black blood, is freely discharged from the bowels." "The blood at this period is black, thin, and dissolved, its fibrin seems diminished, and it does not separate into crassamentum or serum; or if it does, the former consists of a thin dark jelly, with the black colouring matter precipitated towards the bottom of the vessel." Vol. I., p. 977. imperfectly and loosely, and is deficient in fibrine. It afterwards becomes still more loose and defective as to crasis, and ultimately very dark, partially dissolved, and grumous; and apparently insufficient in quantity, in many cases, to distend the veins." Vol. III., p. 141. Dr. Copland remarks that the Ardent or Seasoning Fever," after the inflammatory excitement is subdued by copious depletions, sometimes assumes a remittent character."* He also expressly says that, "it is not liable to recur." "A first attack," he adds, "prevents a second, if the individual continue in the climate which caused it; but, if he return to a cold country, and reside there until the energy of his system is restored, he becomes liable, upon his return to the hot climate, to a second attack, although less so than before, and in a milder form." He afterwards qualifies this statement by saying that a second attack is rare even in persons who may have returned to a temperate climate and then gone back to their tropical residence; the seasoning fever, under these circumstances, being much more frequently of a remittent than of a continued type. The Seasoning Fever, we are also told, "will not prevent those diseases which proceed from marsh exhalations; but, if the person who has been seasoned by it, be seized with fever from this cause, the periodic type will be assumed." Lastly, Dr. C. does "not believe that this-the climate or seasoning-fever— will exempt from the pestilential yellow-fever, although it may lessen the susceptibility to it, when the individual has not intermediately changed the climate. Instances are numerous of seasoned persons-of those who have suffered from this, the climate or severe inflammatory, fever-afterwards being seized with endemic or remittent fever, or with the pestilential disease (genuine yellow fever)." This form of fever" is the disease which most frequently attacks new comers into the West Indies, more especially sailors and soldiers. * * * * * * * It was also very prevalent during the last war among the British troops and sailors in the Mediterranean, and was described by Burnett, Irvine, Boyle, Brunton, and others; but it generally assumed a milder form than in the West Indies." Dr. C. does not allude to this fever ever exhibiting infectious properties, unless perhaps the fact implied in the following remark :-" If animal or vegetable miasms concur with them (the usually exciting causes, viz. a very high temperature, often conjoined with rich, nutritious and heating food, stimulating drinks and suppressed perspiration), the fever will present adynamic or malignant characters in proportion to the activity of either of these agents." Here, before proceeding further, a good opportunity occurs of alluding to the nature and cause of the "black vomit" and black discharges from the bowels, that constitute so remarkable a character of certain fevers in hot climates. The following excellent remarks on the subject are introduced by our author at the close of his description of the Climate or Seasoning fever. of "Mr. Martin, speaking of the ardent fever of Bengal, says-" The type this fever is usually continued, but sometimes remittent."-Influence of Tropical Climates, 6th Edition. 1847] Nature and Source of the Black Vomit. 193 "The source of the black matter passed from the stomach and bowels in the last stage of this and of other severe fevers of warm countries, has been variously stated. Some consider the black colour to proceed from the exudation of dark blood, which, in mixing with the secretions of the stomach, liver, and bowels, imparts to them a still darker tint. Some ascribe it chiefly to the bile, and secretions from the digestive mucous follicles, which are often both very dark and thick, in the last stage of the more malignant kinds of intertropical fevers; and others believe it to arise both ways. There is no doubt that all the secretions poured into the digestive canal are more or less diseased, particularly in the latter stages: but it is as clear, that the black colour mainly depends upon the state of the blood; and that all the matter ejected upwards and downwards, presenting this appearance, does not consist of altered secretions merely, a great part of it probably being an exudation of blood from the mucous surface. I believe, also, that these matters vary very remarkably in the ardent climate fever, in the more malignant forms of marsh or endemic fevers, and in the pestilential yellow fever -the diseases thus characterised. Dr. Jackson remarks that the secretions from the digestive mucous surface are ropy and clear during the early periods, and are brown or black in the latter-sometimes black as soot; and that the sooty or ink-like colour is chiefly observed where the head and stomach are simultaneously attacked. When we consider that the blood becomes darker than natural, as well as otherwise changed, early in the period of exhaustion, and that the liver and mucous follicles of the digestive canal, with the kidneys, are the principal organs of depuration, or channels by which the elements producing these changes are eliminated from the circulation, we need not be surprised at the secretions, which these elements go to form, and which these organs excrete, presenting somewhat similar characters. It must however be admitted, that the share which the secretions perform in producing this phenomenon, or that which the exudation of blood has in giving rise to it, will vary much in different varieties or cases of intertropical fevers.-The rapidity with which a dissolution of the tissues takes place after death, in the severe forms of climate fever, deserves notice, as marking the rapidity of vital exhaustion, and as resulting from the changes of the blood; these changes commencing with the stage of exhaustion, and advancing_until this fluid is no longer capable of influencing the nervous system, and of preserving the irritability of contractile parts-or until it poisons, instead of exciting, the sensitive and moving tissues." Vol. I., p. 980. We may here observe that it is scarcely, if at all, possible to perceive any distinction between the ardent or climate fever mentioned above, and the inflammatory and the bilio-inflammatory forms of remittent fever, as described by our author. Every symptom, that occurs in the one, is met with in the others, and in exactly the same progression. They are seen under the same circumstances, in the same regions, and are most frequent in the same class of persons, viz. in Europeans recently arrived in hot climates. The only (apparently) recognisable distinction between them is, that the one is spoken of as a continued, whereas the other is described as a remittent, fever. But then this distinction will not always hold, according to our author's own admission. We have already seen that the ardent fever sometimes puts on a remittent type; and now we find that the inflammatory and the bilio-inflammatory forms of remittent fever, are apt at times to become continued. For example, of the former we read that, "if the disease be neglected at the beginning, the remissions disappear, the skin becomes dry and caustic, or moist and clammy; the pulse small and irregular; the tongue black and crusted; and the vomiting, pain at the epigastrium, &c., more constant. In the most severe and unfavourable NEW SERIES, NO. XI.-VI. |