BLAJE ON THE YELLOW FRYE& OF DEXERA.314.. *
Da. Emmn is a medical in of George Town, Britis/x
Guiano, who has resided. n the colony for many years. lie had ample means of observing the yellow fever during its prevalent's. between 1837 and 1842, and felt the disease in his own person :- from 1842 the public hospitals have been under his charge; so that he has had full opportunity of studying not only the yellow fever but the other diseases prevalent in Demerara. Of these oppore 'entities he has taken advantage to. write a memoir on the yet- low fever as it fell under his observation: in his absence from England it has been edited by his friend Dr. Davy, who has alact added a commentary in the form of foot-notes ; and into this com- mentary Dr. Davy has poured the results of his own experience of' Tropical fevers, and of the various opinions on the subject that have officiolly come before him as Inspector-Genera/ of Army Hospitals. He has also occasionally corrected and frequently en,- forced the views of Dr. Blair.
The account of the yellow fever is a, very close and exhaustive. production; entering upon the natural circumstances and hygienie conditions that may be supposed to have produced the disease, as well as its history, statistics, symptoms, and treatment, and the atmospherie, phenomena by which the epidemio was accompanied.. The various topics of the memoir are separately considered, so that the reader's attention is not diverted by having several things pressed upon him at wee; and as the topics follow in appro-
. te order, a very thorough survey of the whole subject is attained. e book opens with a, full, plain, and even graphic account of the locality and appearanee of George Town, such as only a. personal( knowledge could give. This is followed by a description of the commencement of the fever and its early stages, equally bearing marks of the results of experience : indeed, this living spirit accompanies the whole account of the disease, while the views of ita nature and. treatment have that certainty which arises from practical knowledge over mere theory. In voiding the reader to any certain conclusion, however, the book has no superiority over those books which have preceded it on. the subject of malignant epidemic disease.
"Al that we know is, nothing can be known."
"Every sinquirer" says Dr. Davy, "who has given close attention, to epidemre diseases—from Hippocrates to Sydenharte and fens Sydeaham to oar contemporanes—has been forced into the ac- knowledgment of a hidden cause, a something known only by Ito (JOU, impalpable, invisible, distinct from the causes of ordinary diseases—according to Hippocrates, a something divine--accordas to Sydenham, a something emanating from the bowels of the earth."' Dr. Blair's volume, however, strengthens an opinion we have car several occasions advanced, fluit the essence of this "something" is probably uniform, the varieties arising from clithate, eircumstancesk and constitution • or if there is an exception—if there is a specific poison, always producing specific, results—it is probably in the case of the plage.e. The Niger fever, though possessing general elm, racteristies, exhibited considerable diversity of symptoms, which seem traceable. only to diversity of age, constitution, and the like. The yellow fever exhibits the same peculiarities,-'-'a broad uni- form character, with great diversity of subordinate features ac- cording to place and circumstances. Something similar aceom- e Some Account of the last Yellow Fever Epidemic of British Guiana. By Daniel Blair, M.D., Surgeon-General of British Guiana. Edited by Sohn Davy, 3LD., Inspector-General of Army Hospitals, &c. &c. Published by Long- man and Co. panies cholera ; and it is proper to remark upon the strong generic analogies between that pestilence and the yellow fever, in the vomiting, the unclouded faculties to the very last, and the undiminished muscular strength. Fearful as these complaints are in their result, their external accompaniments do not seem so ter- rible as exaggerated description, the use of such terms as "yellow" and "black vomit," and possibly concomitants either of dirt, pre- vions ill habit of body, or complication of other disorders, have in- duced the idea of. The plague alone appears to hold preemi, nence in this respect; though we have lately had no account of this disease at once graphic and sober. This remark, however, is limited to external terrors. The relentless, treatment-defying clia- racter, and the unnatural phtenomena of such diseases, are terrible enough to medical science. One remarkable feature of the yellow fever as witnessed by Dr. Blair was a preternatural condition of the pulse in its later stages.
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"The pulse was rarely very quick during any period of the disease. It was highest in the first stage, and gradually declined in frequency.. Before death it generally became quicker and smaller ; and, where much fluid ejec- tions occurred, it became extinct at the wrist many hours before death. During convalescence, the pulse was uniformly slow where no complication existed. The pulse was quickest in the cerebral variety,. In some cases, when the disease determined to the intestines, the pulse became startlingly, slow, even on the second day of disease : thus in Mr. Mackae's case it was 48 ; he re• covered. In case 2,895 of Seaman's Hospital, the pulse on the sixth day of fever was 24. The insidious nature of some of the attacks, (when the seat of the malady was the intestinal, urinary, or pulmonary apparatus,) the perfect ease of the patient, the external air of good health, and the solemnity of the pulse in such cases, frequently inspired the practitioner with a kind of awe and horror of the new, treacherous, and remorseless malady,
• "In some cases of our late yellow fever, it seemed as if the poison acted directly and at once as a sedative on theleart; and in some cases there seemed a sudden and temporary excitability of it., which must have been fa- Vourable to the production of fatal local congestions."
Contrary to the usual notion of Tropical disease, the yellow fever as exhibited in Demerara was longer in doing its work and for a while more yielding to medicine, than cholera as witnessed in our temperate climate. When taken in an early stage, it appeared to give way to copious doses of calomel and quinine; and if prudence and removal to another air accompanied the convalescence, the disease was finally subdued. But the patient did not appear to be so secure against further attack when he emerged from the first and second stages of the disease, as when he had gone through the third stage. If any imprudence followed convalescence, or the patient remained exposed to the same conditions as those under which the disease was developed, it would reappear and steadily, pursue its course. Even when it seemed to yield to medicine, it would rally again and again with deadly pertinacity. There was the same flattering slowness even when the fever ran its natural course ; forming a strong contrast to the rapid progress of cholera. The first stage of the yellow fever lasted longer than cholera alto- gether. "These symptoms continue steady during two or three days, the bilious ejections, however, becoming greenish by the end of that time. The fever then subsides; the skin becomes cool and pleasant; the tongue shows a dis- position to clean, and there is less fieriness of tip and edge; thirst abates, find there is some appetite for food. The patient's anxiety and morbid fear of death, which may have been very great, subside, and both he and the bystanders are-, satisfied of his convalescence. By and by the eye, which has lost its glistening appearance, assumes a condition of chronic vascularity, of a dull orange red. The flushed countenance has given way to a sottish ap- pearance and greasy dirty complexion. If the eyelid be turned down, a yet- I lowish suffusion is perceived on the sclerotica ; the forehead has a dusky ap- pearance, which extends also to the angles of the mouth, and over the neck and chest. Pressure of the hand over the chest or abdomen winnow leave pale finger-marks, indicating languor in the capillary, circulation. Some food which the patient has been permitted to eat lies heavy on the stomach and is rejected. The stomach again becomes irritable and clear mucous acid fluid is thrown off in considerable quantities. If this last symptom continues with severity for a few hours, specks may be noticed in the fluid, as if a pinch of snuff had been scattered in it; or a tenacious dark clayey deposit will be found in the bottom of the basin. The gastric irritation may now again subside ; and the fur will clean off the tongue, and the fiery edge and tip disappear, leaving a preternaturally clean or raw surface • or an attempt at fur may show itself, as if a coat of milk-and-water had been brushed over the tongue. "The yellow or purple suffusion of surface is now more marked ; in gene- ral, local uneasiness is chiefly referred to the fauces, or to the course of the esophagus, or ensiform cartilage ; but the patient feels tolerably well, and hungry. lithe finger be now drawn briskly: across and against the pectoral muscle, a wheal will follow the pressure, rising up and subsiding with a ver- micular motion. After a time an indication of loss of vital cohesion shows itself, probably by epistaxis or ecchymosis ; and, in consequence of some un- easiness, the patient turns himself in bed, and an involuntary gush of black vomit is spurted over the bed and furniture. Bloody oozings take place from the mouth ears, or anus; the scrotum becomes excoriated ; the blistered surfaces become raw and claret-coloured. The skin is damp and cold, though the patient complains of heat ; the fingers are shrivelled ; an unpleasant odour emanates from the breath and body. Black vomit continues to be ejected. The pulse loges strength, till at last it ceases to be felt at the wrist; and the patient dies with intelligence nee unclouded, and his muscular strength but little impaired, telling you e is getting quite well, or, as a poor dying Irish sailor expressed himself, iligant this morning.'" The sickness of the first stage is attended by all the distress that usually accompanies that disturbance ; but the celebrated "black !omit" is less felt by the patient. "The expulsive efforts of the stomach are of a very different kind in the first and third stages of the yellow fever. There is violent retching, strain- ing, suffusion of face and spasm of recti muscles, at first; but when black vomit is established all these cease, and the stomach seems to act alone. Then the patient will speak to you, lean his head over the bed, .eject his mouthful or basinful of black vomit, and resume his conversation with scarcely any interruption. Sometimes it comes up as if in rumination, and it others it is ejected in a spout to a considerable distance. In both latter cases, however, it seems perfectly involuntary,. The vomiting in the last stage is generally provoked by swallowing anything either fluid or solid, but I have seen it induced by the erect position, and the act of falling Weep. The white ropy acid fluid, which is frequently ejected at the close of the second stage in considerable quantities and with much relief to the symp- toms, is generally attended with considerable retching. This is the fluid which during our epidemic was called premonitory' or precursory ' fluid, or 'white vomit.' "The first effect of black vomit seems to be of the most sautary kind, particularly on the tongue. Indeed, when with sudden improvement of the tongue and other symptoms there exists dirty or other discolouration of the surlace, and at the age of the disease when black vomit might be expected, then succusaion will sometimes detect the presence of the effused fluid before vomiting occurs. The scanty clay and snuff-like black vomit generally at- tends or follows the white vomit' of the second stage or mitior form of the &Rase.
"Black vomit' is rarely black ; it is generally of a dark brown or umber. Its appearance is sometimes thin, like bog water—sometimes thick, like molasses.
"Black vomit, although a very unfavourable symptom, and more so than yellow skin, being as 75.68 to 46.23, is still not necessarily fatal. Out of the 366 eases of it, 277 only- died, giving the centesimal mortality .just stated, viz. 75-68."
The uselessness of the medical art has been a subject for the wits of all ages : "when your time has come," you must go; if not, the doctor does not hasten your departure, though he may shake your constitution. The experiment of various treatments and. no-treat- ment was tried at some Continental hospital, with little difference in the ultimate results. Dr. Blair, withoi4 seeming to mean it, points to the same conclusion : after a certain number were dead, the rest were pretty safe.
"It is difficult to discover what percentage of mortality occurred in purely untreated cases. From the first, however, it did not require much nicety of observation to find out that the number of deaths among a given number of eases, as well as a given number of cases among a certain number of susceptible persons subjected to similar exposure, had determinate laws. The early appreciation of this fact was of great service to the reputation of the medical practitioner at a time when the treatment was -nearly totally inefficient. I find among my earliest notes of the epidemic a remark on what I call the complement of mortality, and one or two instances of an application of the knowledge of it. The bark Glasgow (Milrae master) was attended by Dr. F., who was exceedingly unfortunate with the cases on board of this Clyde vessel. Seven or eight of the crew had died, and the rest, including the master, were so disheartened that it was determined to change the practitioner, and I was requested to take charge. Having no de- sire thus to supersede Dr. F., I declined, and explained to the shipmaster that it was highly probable that henceforth there would be no more deaths on board, as the complement of mortality was already full. The result was as predicted. In the same note I find it stated, of course on mere general observation, The mortality generally ceased below eight in the Bristol, Liverpool, London, and Clyde vessels, and below four in the Belfast vessels.' This was during the first half of the epidemic. Perhaps the mortality of the Babel temporary Seaman's Hospital might be taken as the mortality of untreated cases ; for from the total disorder and want of supervision in that establishment, and the inadequacy of the sick-nurse attendants, it is likely the disease was in no way beneficially affected by the treatment prescribed.'
We could extend this notice by many interesting facts respecting yellow fever, and many curious incidental pictures of George Town and its habits ; but we have sufficiently indicated the nature of the work,—whieh may be pronounced a full, painstaking, and valuable contribution to medical knowledge.
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