THE AMERICAN 
MEDICAL MONTHLY. 
MAY, 1 8 5 8. 
ESSAYS, MONOGRAPHS, AND CASES. 
The Yellow Fever at Port au Prince. By G.Van Arcken, M.D. 
Yellow Fever is a disease whose occurrence is limited to certain 
districts and to certain times of the year; a long-continued tempera- 
ture of from 75° to 90° F. favors its appearance and increases its rav- 
ages. In cold and temperate climates it appears generally towards 
the end of summer, and is suddenly cut short upon the setting in of 
cold. In the tropics its usual time is at the commencement of the dry 
season. It is hardly ever met with north of 42°, either because the 
heat of the summer is not intense enough, and does not continue a 
sufficient length of time, or because there are other concomitant causes 
necessary for its production that are not present. 
Yellow Fever presents itself by preference in large cities and ports, 
and at all places where a large number of human beings are congre- 
gated into a small space. It occurs per.odically at most places; still, 
there are some where its ravages never cease, and are only influenced 
by the presence or absence of the human material. 
Tne worst of these latter places is no doubt Port au Prince, in 
Hayti, which has of late acquired the not very enviable reputation of 
the grace-yard of the whites;" and it is to the bellow lever at that 
place that these remarks in particular apply. 322 
THE YELLOW FEVER 
[MAY, 
The different epidemics of yellow fever, such as we have them upon 
the strength of the testimony of medical witnesses, appear to have 
been marked by individual symptoms of a very different character. 
The effluvia and miasmata generated amongst the houses of a large 
mass of people, together with the heat of a tropical climate, may 
have given them either a bilious or a typhoid character, and a scorbu- 
tic tendency may also have considerably modified their character and 
severity. 
Owing to the different constitutions, the method of living, and the 
peculiar susceptibility of some persons, yellow fever may assume all 
grades of violence, from a slight indisposition to the most fatal form. An 
attack of yellow fever is sometimes preceded by the usual febrile symp- 
toms, but more frequently it comes on without any warning whatever. 
There is generally some chilliness at the beginning, and the duration 
and violence of this is often a sure indication of the character of the 
disease, and of the remedies that must be employed; the case being a 
slight one and easily managed if the chilliness has amounted to a rigor. 
In some cases there is no chilliness at all, and these should, however 
slight they appear, always be viewed with suspicion. Among the most 
constant symptoms are, a deep-seated and severe pain in the supra- 
orbital jegion, and a weakness in the back and limbs, amounting some- 
times to a sort of spasmodic pain. 
When febrile action has fairly set in, the skin is found to be hot and 
dry, the respiration hurried, the face flushed, and the eyes red and 
watery. The tongue is mostly covered with a thick white fur, and 
the throat occasionally sore. 
In the majority of slight cases there is more or less vomiting from 
the beginning, the ejected matter being of a decidedly bilious charac- 
ter, although the later vomitings sometimes have the appearance of 
boiled barley water. But in fatal cases the gastric symptoms are not 
fully developed until about forty-eight hours afterwards, when fre- 
quently the black vomit all of a sudden makes its appearance. 
Patients complain sometimes, from the beginning, about a feeling 
of weight and oppression in the epigastrium. When examined, that 
region is found to be very sensitive upon the slightest pressure. Ina 
generality of these cases, the stomach rejects everything that is swal- 
lowed. At this time the bowels are mostly very costive, and when at 
last discharges are obtained, they are of an unhealthy character, and 
very offensive. The mind of the patient is usually very much disturb- 
ed; he is apprehensive and restless, and his countenance is strongly 
marked with these feelings. Delirium is not an uncommon symptom; 1858.] 
AT PORT AU PRINCE. 
323 
it amounts sometimes to maniacal violence, but it soon gives way to 
a deep coma. 
These symptoms, indicative of the first stage, continue mostly from 
two to four days, and then a great apparent amelioration is experi- 
enced. The pulse becomes nearly natural, the respiration calm, and 
the pains in the head, back, and limbs disappear almost entirely. At 
this stage of the disease, it is not uncommon to find the patient sitting 
up in bed, and perfectly confident of recovery; but, unfortunately, this 
is only a temporary calm; the fever still continues internally with un- 
abated violence, and the partial subsidence of its outward symptoms 
only shows the inability of the system to struggle any longer against 
its powerful enemy. 
To distinguish this stage from a genuine convalescence, it is only 
necessary to make slight pressure over the epigastrium, when great 
tenderness will be discovered, and very often a hard lump, of the 
size of a goose egg, may be felt there, distinctly pulsating, although 
these pulsations cannot be attributed to pressure of the stomach upon 
the abdominal aorta, the pulsations not being synchronous with the 
contractions of the heart. The redness of the eye has now changed 
to a yellow or orange color. A pale violet or bluish color sometimes 
shows itself on the forehead and cheeks, extending in some cases over 
the whole body. It is owing to a stagnation of the blood in the ca- 
pillaries. The pulse is lower than in health; it falls to fifty pulsations 
per minute, and sometimes less. These symptoms continue for about 
twenty-four hours; but in fatal cases they make place in a few hours 
for a quite different class of phenomena, to wit: extreme debility and 
prostration. 
The pulse now becomes frequent and irregular, forming distinctly 
marked intermissions. The tongue is dry and brown, and its edges 
red; and on the teeth and gums appears a deposit peculiar to typhoid 
diseases-I mean the formation of sordes. 
The stomach is now exceedingly tender; everything swallowed is 
thrown up again, and with it a matter consisting of black flakes and 
particles, floating in a colorless or slightly yellow liquid, which ulti- 
mately becomes opaque and black. 
The heart and large vessels, especially the carotids, are beating vio- 
lently, the already mentioned epigastric pulsation increases, and still 
at the wrist the pulse is almost imperceptible. 
The urine becomes very scanty now, often entirely suppressed; 
htemorrhage takes place from the mucous membranes, and blood is 
not unfrequently vomited up, and discharged by stool. 324 
THE YELLOW FEVER 
[May, 
The extreme restlessness of the first or febrile stage has now given 
way to a gloomy indifference. The pulse gradually ceases, hiccough 
sets in, the skin becomes cold and clammy, the body exhales an offen- 
sive odor, and death takes place quietly or amidst convulsions. 
In slight cases, after the febrile symptoms have passed off, a gradual 
improvement in the state of the stomach, a general perspiration, or the 
discharge of a dark brown urine, show that the vital energies are not 
yet exhausted. After this convalescence takes place, either with ty- 
phoid symptoms, or more frequently without them. 
This is the ordinary course of the fever; but, as I have stated be- 
fore, it is liable to great diversity. The febrile action of the first stage 
may be inflammatory, with a strong and full pulse, or typhoid and as- 
thenic; in which case the pulse is, from the beginning, very feeble and 
frequent. In this latter case the general prostration is such as to war- 
rant the assumption that the patient has received his death blow at 
the beginning. 
The most prominent symptoms of this malignant state are: a gen- 
eral weakness, with a sense of stupefaction in the head; pain in the 
back and inferior extremities; a very feeble pulse at the wrist, while 
the carotids beat violently; a pale and purplish face, and a counte- 
nance expressive either of gloomy indifference, or of intense horror 
and agony. 
Sometimes the patient has been suddenly struck down in the midst 
of apparent health, with symptoms of overwhelming precordial op- 
pression. When examined, his pulse is found to be very weak, or en- 
tirely absent. In such cases the tongue may be clear, and the pulse 
almost natural; still the great restlessness of the patient gives cause 
for alarm, which is soon confirmed by black vomit, convulsions, and 
death. 
The expression of the countenance in this disease is peculiar, and 
by carefully observing it the practitioner may often see clearly depicted 
in it, what a sulky or cross patient does not want to acknowledge. 
From the beginning of the fever the white of the eye is reddened, and 
appears as if bloodshot. The forehead and cheeks have at the same 
time an unnatural red color, which is found in no other disease so 
striking'y as in this. The color, as also the redness of the eye, grad- 
ually gives way to a deep yellow or orange. 
The black vomit, the most striking symptom of this disease, mostly 
makes its appearance on the third or fourth day, although it is by no 
means a universal symptom ; for plenty of cases prove fatal without 
its occurrence. It was formerly thought to be black bile ; but at 1858.] 
AT PORT AU PRINCE. 
325 
present the most generally admitted opinion is, that it is blood thrown 
out to relieve the congested and inflamed vessels, and which has been 
altered by the acid of the stomach. 
Still, the blood must undergo some changes in making its exit from 
the capillaries; for were it simply blood altered by the action of acid, 
it should return to the state of natural blood upon the exhibition of 
magnesia, instead of remaining unaltered. Black vomit separates, 
upon standing, into two parts-an insoluble black matter, like coffee 
grounds, which subsides, and a clear liquid ; the first is the altered 
coagulable matter of the blood-the liquid, the serum. 
According to some authors, animalculse of the genus Acarus have 
been discovered by means of the microscope in the black vomit very 
recently ejected ; the same has been said of the vomitings and evacu- 
ations in cases of Asiatic cholera. It remains yet to be seen whether 
this will assist in clearing up the obscure nature of the yellow fever. 
There is, however, no doubt that the black vomit is essentially disin- 
tegrated blood. 
Great diversity of opinion exists as to whether the cause of yellow 
fever is a peculiar and specific one. It has also been said that the 
nature of bilious and yellow fever is essentially the same, and that the 
latter is only an aggravated form of the former. But the authors of 
those statements undoubtedly have never seen the yellow fever at 
Port au Prince, or they would have been convinced that bilious 
fever, typhus, and yellow fever may exist at the same time, aye in 
the same hour, and still there be to the experienced physician not the 
least trouble in drawing an exact line of demarcation between them. 
The predominance of the gastro-bilious symptoms in slight cases, 
and of those of malignant typhus in the fatal ones, has suggested to 
me the idea that yellow fever might be a combination grown out of 
gastro-bilious fevers on one side and a malignant typhus on the other, 
and that according as the one or the other is predominant the char- 
acter of the disease changes. 
Another question of some importance is, whether yellow fever is 
to be considered contagious or not. With regard to this I have only 
to state, that during the time that I have practised in the West In- 
dies and on the Spanish Main, I have never seen anything which 
could convince me of the contagious nature of yellow fever, and 
I would just as soon admit intermittent fever to be contagious. 
The diagnosis of yellow fever is not attended with many difficulties. 
In the beginning, the redness of the eye, the white-coated tongue, to- 
gether with the pains in the back and limbs, and the bluish color of 326 
THE YELLOW FEVER 
[May, 
the forehead and cheeks, afford plenty of cause to suspect the true 
nature of the disease, and the black vomit soon comes and dissipates 
any doubt that may have remained. 
The prognosis is more difficult, and it requires some experience to 
distinguish between slight and fatal cases, especially in the beginning. 
Among the most unfavorable symptoms are excruciating pains in 
the back, limbs and forehead, great feebleness of the pulse, sometimes 
an entire absence, a bronze color of the face, bloodshot eyes, together 
with extreme restlessness, epigastric tenderness, black vomit, and sup- 
pression of the urine. 
The favorable symptoms are, first, the absence of any of the above 
mentioned ; then a prolonged continuance of the primary fever, which 
subsides only gradually, and under the effect of a general diaphoresis, 
the passing dark brown urine, salivation, a gradual clearing of the 
tongue, and a diminution of thirst, and epigastric tenderness. 
Much has been said about the treatment of this most malignant 
disease, and books have been written to prove the good effects of this 
or that medicine, which may not have proved by far as effective in all 
hands, as was at first anticipated. Bleeding has had its partizans, 
and the employment of emetics and strong purges also ; I have 
never liked either. 
As 1 make especial reference to the yellow fever at Port au Prince, 
I shall abstain from all speculations on this subject, and limit myself 
to giving a description of the method of treatment which has proved 
most successful in my hands at that place. 
Port au Prince is the capital of the negro Empire of Hayti, of which 
at present a certain Soulouque calls himself the Emperor and autocrat. 
Only colored people are allowed to settle on the island, and only in 
the seaports an exception is made in favor of a few foreigners, most 
of whom are merchants. But these, having been for a long time resi- 
dents on the island, have consequently already become acclimated; 
the only subjects, then, who arc exposed to an attack of fever, are the 
crews of foreign vessels, of which there arrive yearly about three hun- 
dred at Port au Prince. My position as physician to the American 
Consulate made it my duty to attend to them. It will thus be seen 
that all my patients were strong and able-bodied men, mostly from 
twenty to thirty-five years of age, about half of them being Ameri- 
cans, and the other half from the different commercial nations of 
Europe. 
When called to a patient, my first care is to decide, whether it is a 
case of an inflammatory, or of a typhoid character. 1858.] 
AT PORT AU PRINCE. 
327 
The inflammatory cases may generally be known by the full and 
strong pulse, which seldom runs above one hundred to one hundred 
and five per minute ; the tongue is covered with a white or slight yel- 
low fur, the taste in the mouth is very foul, with an occasional feeling 
of soreness in the throat. There is usually some pain in the head, and 
also a peculiar giddiness, together with a weakness in the back and 
limbs. 
The typhoid or asthenic cases are characterized by a very frequent 
and feeble pulse, which sometimes makes regular intermissions from* 
the outset. The tongue is either natural or covered with a white fur. 
The patient complains of intense pains all over his body, and his head 
feels, as some have told me, like an empty paper box. The eyes are 
very much bloodshot, and in the whole countenance there is depicted 
an intense feeling of horror and agony. In these cases the bowels are 
generally obstinately costive from the beginning, and the stomach 
very tender. 
As soon as I make a case out to be of the inflammatory kind, I ad- 
minister thirty grains of calomel, which I place dry upon the tongue, 
and allow only a few spoonfuls of water to swallow it. To obtain 
a mercurial action being my object, I give then every two hours 
from one to two grains of calomel, which I continue for two days. 
In cases of yellow fever it is a most difficult thing to obtain a mercu- 
rial action, the process of absorption having entirely ceased; I generally 
continue the mercury for about forty-eight hours, and then stop, hav- 
ing found it entirely useless to continue any longer. Salivation, if it 
takes place, will do so within thirty-six hours, and there is no danger 
at all of discontinuing it, as soon as it occurs. To allay the frequent 
desire for cold drinks, I let the patient take small quantities of grate- 
ful acid drinks, such as tamarind water, or cream of tartar lemonade. 
If the bowels have been costive, I also prescribe several purgative 
clysters, composed of castor oil, common salt, and tepid water. 
On the next day, the patient having had several stools, feels him- 
self considerably relieved, and now I make a careful examination 
of the epigastric and right hypochondriac region, and if upon 
pressure there I find the least tenderness, or anything like a pulsa- 
tion, I immediately order a dozen leeches to be put around the 
anus. After this a tepid bath is given, and then a large emollient 
poultice applied to the stomach. 
With this the patient passes the second day well, and on the next 
morning ten grains each of calomel and quinine are again given. 
On the morning of the fourth day I usually give again ten grains of 328 
THE YELLOW FEVER 
[Mat, 
quinine, but this time combined with one grain of powdered opium, part- 
ly to procuresleep, but more especially for the purpose of bringing about 
a general diaphoresis, which is theu kept up by small dosts of liquid 
acetate of ammonia. On the next day the patient is allowed a cup 
of weak soup, and also to sit up for a few hours. After this, all the 
medicine I give is an occasional dose of citrate of magnesia, to keep 
the bowels loose ; and at the end of eight or ten days the patient is 
well enough to go to work again. 
. But matters do not always progress so favorably. Frequently on 
the third day I find the epigastrium very tender, and the patient 
evinces a tendency to vomit. Upon this I apply from six to ten wet 
cups to the seat of pain, and wait then a few hours to see the effect 
If the tenderness diminishes, I go on with the already given method; 
but if it increases, I immediately put two large blisters to the inside 
of the thighs. Blisters have at such a critical moment often worked 
like a charm, calming the tenderness of the stomach, breaking up the 
fever, and restoring the interrupted equilibrium between peripheral and 
abdominal nervous sensibility. 
But to be productive of such good, they must be applied in time, 
and before the black vomit sets in ; if this has once taken place, they 
hardly ever do any good, and always torment and exasperate the pa- 
tient very much. 
Should the blisters not produce the desired effect, and the disease 
proceed to black vomit, then I follow the treatment hereafter to be 
specified. 
Cases of a typhoid character are easily distinguished, and, as a 
n atter of course, require a method of treatment altogether different. 
The nervous system being from the beginning evidently broken down, 
it requires a powerful remedy, acting at once as a sedative and tonic, 
to assist the system in rallying from under the first blow of the disease. 
This medicine we have in the sulphate of quinine. But to be produc- 
tive of good it must be given immediately, and in very large doses. 
If the stomach is still quiet, I give immediately about thirty grains in 
about half a dozen spoonfuls of coffee, without either sugar or milk. 
If given in this vehicle, I have found it to sit better on the stomach 
than in any other. But should the state of the stomach not admit of 
any medicine being given internally, then I dissolve sixty grains of 
quinine in one ounce of sulphuric ether, with the addition of two 
drachms of liquor ammonia, and have this rubbed in under the arm- 
pits and over the whole abdomen about three times during the day. 
If the bowels be costive, the already mentioned purgative enema 
should also be administered. 1858.] 
AT PORT AU PRINCE. 
329 
On the following day the patient frequently feels himself better; if 
formerly not successful, quinine will now mostly stay on the stomach; 
but whether it does or not, the external application of it should by 
no means be forgotten, but repeated in about half the strength of the 
day before. 
During this day the symptoms of epigastric tenderness return fre- 
quently more intense than ever; they should be immediately combatted 
by leeches to the anus and (no cupping in these cases) hot fomenta- 
tions to the seat of pain, putting them on as warm as the patient can 
bear them, changing them at least every fifteen minutes. 
Should this not have the desired effect, then blisters must be resorted 
to, under whose action either an abundant discharge of dark brown 
urine takes place, or a slight diaphoresis appears, which has then to 
be encouraged by opiates, etc. Still, in a great many cases all these 
remedies prove in vain, and the so much dreaded black vomit makes 
at length its appearance. 
To combat this, I have ransacked all the known and recommended 
remedies, and given them all a trial; but, from gum kino to acetate 
of lead and nitrate of silver, none has succeeded in my hands. Thrown 
back upon my own resourses, I resolved to try the corrosive sublimate, 
and I am happy to say that seven people, who had the black vomit, 
recovered under the effect of this remedy. 
To employ it, I proceed in the following way: Six grains of bi- 
chloride of mercury are dissolved in two ounces of pure water, with 
the addition of twelve drops of muriatic acid. A small teaspoonful, 
(one of those manufactured out of horn or ivory for the use of children,) 
and which may contain about a drachm and a half, is my usual dose. 
I commence with making the patient drink about half a cnpful of 
tepid water, with a little common salt in it; this has the effect of caus- 
ing him to vomit immediately, and thereby cleaning the stomach effectu- 
ally; I then make him open his mouth and-let the mentioned solution 
run down drop by drop in his throat. 
It generally causes a slight burning sensation in the stomach, for 
which I always have an emollient poultice ready, which soon relieves 
it; and directly after this has been effected, I order a purgative clyster 
to be administered, for the purpose of assisting in checking the vomiting. 
This same process has to be repeated, according to the urgency of 
the symptoms, every two or three hours. 
If it proves effectual, it will do so after three or four doses have 
been taken; in such cases the vomitings assume first a brown mahog- 
any color, which gradually goes over to a greenish opaque, until they 
cease altogether and the matter is passed off by the bowels. YELLOW FEVER AT PORT AU PRINCE. 
[May, 
330 
The black vomit, if it does not yield to remedies, continues from 
two to four days, after which it spontaneously ceases. 
Then commences the last or true typhoid state of the fever, which 
in most cases is followed soon by convulsions and death. But in some 
cases the disease has run its course so quickly, that the system is not 
yet entirely broken down. 
The patient is mostly found to lay in a half-inclined position. He 
complains of no pain, except in the forehead; but says, to use a sailor's 
expression, that he is as weak as a new-born baby. 
A nutritious diet should now be ordered, together with wine and 
water and other stimulants, according to the degree of prostration. 
In some cases the carbonate of ammonia in an emulsion of gum arabic 
is sufficient, while in others egg punch and brandy, together with tinc- 
ture of musk, must be resorted to. 
The oil of turpentine, so much lauded by some practitioners as an 
alterative to the mucous membrane of the stomach, may now be 
employed. 
Sulphate of quinine in small doses may now be administered with 
very good effect, and the whole must be conducted upon the principles 
laid down for the treatment of the latter stage of malignant typhus 
fever. 
The wandering pains that are now frequently felt all through the 
body are generally relieved by slight frictions with some aromatic 
spirits, which, to make it feel more comfortable, may be slightly warmed. 
Frictions, besides, produce very good effects all through the course 
of yellow fever. 
At this stage patients may remain in pretty much the same con- 
dition for fifteen or twenty days; still it should be recollected that 
every additional day brings also additional hope. 
The greatest care is now necessary to guard the patient against im- 
prudence in diet^ it should be kept strongly impressed upon the mind 
of the nurses that he needs a generous and nutritious diet; but crude 
things, for which sailors have always a strong liking, should be scru- 
pulously avoided, for a single mistake of this kind is sufficient to bring 
on a sudden and fatal relapse, followed in a few hours by convulsions 
and death. 
I have sometimes been called to patients, when, after the most care- 
ful examination, I could not decide as to whether it was an inflamma- 
tory or asthenic case, the distinguishing symptoms being equally strong 
on either side. Experience has taught me to regard these cases as of a 
most fatal malignancy. Quinine should be immediately given in large 1858.] 
MARSHALL HALL'S READY METHOD. 
331 
doses, and the case treated on the most active principles possible; for 
the black vomit sometimes makes its appearance only twenty-four 
hours after the patient is taken sick. 
With regard to the prevention of yellow fever at Port au Prince, a 
great deal might be done by keeping the city and harbor clean; but 
to clean them effectually at present, would be a job worse than the one 
Hercules had in cleaning the cow stables of King Augean. 
Cleanliness may mitigate the violence of the fever; but some will 
undoubtedly be always present. 
A great deal may also be done by paying attention to the selection 
of sailors for a trip to Port au Prince; none should be taken under 
twenty-eight or thirty years of age. These resist the fever the best, 
and, if taken sick, have a fair chance of recovering. 
All the nationalities are alike subject to the fever; still the Ameri- 
cans have a better chance of recovery than any other, and the worst 
cases are found among the Germans, Swedish, Danes, and Irish. 
The French, Spanish, Italians, and Belgians hold about the middle 
rank. 
The fever appears to have a particular liking for cabin boys; out of 
twenty that are taken sick, hardly one recovers. 
During my stay at Port au Prince I attended two hundred and 
forty-three cases of yellow fever. 
Of these, forty-eight had the black vomit, of which number only 
seven recovered. Eleven more died without having the black vomit, 
making the number of deaths in the whole number of two hundred 
and forty-three, just fifty-two. 
Of the fifty-two that died, only fourteen were Americans, and of 
the seven that recovered after having the black vomit, five were 
Americans. But as among the whole number of patients more than 
half were born Americans, the chances in their favor are very great, 
as may be seen from the above stated facts. As another singular fact, 
I must state that the only cabin boy which I brought over the fever 
was an American.