BLxiCK VOMIT OF YELLOW 
FEVER. 
BY 
JOSEPH JONES, M.D., 
Profess.)]' of Chemistry and Clinical Medicine in the Medical Department of the University of 
Louisiana : Visiting Physician of Charity Hospital, New Orleans, La. 
HE PRINTED FROM 
Dr. Brou-n-Set/uard’s Archives of Scientific antl Practical Medicine. 
No. 5, 1873. 
new York: 
G. P . PUTN A M’S SONS, 
Twenty-third St. and Fourth Ave. 
1873. BLACK VOMIT OF YELLOW FEVER. 
IV. 
BLACK VOMIT OF YELLOW FEVER. 
BY 
JOSEPH JONES, M.D., 
PPOFESSOR OF CHEMISTRY AND CLINICAL MEDICINE IN THE MEDICAL DEPARTMENT OF THE UNI 
VERSITY OF LOUISIANA ; VISITING PHYSICIAN OF CHARITY HOSPITAL, NEW ORLEANS, LA. 
The following observations upon the black vomit of yellow fever, 
are the results of labors commenced in 1856, and pursued in various 
portions of the Southern States up to the present time. 
During the active stages of yellow fever profound changes take 
place in the organs and tissues, and especially in the kidneys, heart, 
and liver; and oil and granular albuminoid and fibroid matters 
transude through the capillaries and fill up the cells and excretory 
ducts, and arrest the functions of these organs. 
The liver of yellow fever does not present the soft, friable con- 
dition characteristic of true fatty degeneration. The jaundice 
resulting from the suppression of the excretory function of the liver, 
or from the reabsorption of the bile, would appear to be due to the 
same causes which induce the suppression of urine, viz., to the de- 
posits of oil and granular albuminous or fibrinous matter in the ex- 
cretory structures of the kidneys and liver. 
The heart in yellow fever appears to be as fully permeated with 
oil as the liver; in the latter organ, however, a large amount of oil 
is enclosed within the liver-cells. 
Yellow fever is not only attended with what may be called “ acute 
fatty degeneration,” but also with such profound alterations of the 
fibrinous element of the blood, as to permit the transudation of the 
altered fibrin and albumen into the excretory tubes. 
The ejection of altered blood (black vomit) from the mucous 
membrane of the stomach, during the period of calm or depression, 
although not absolutely characteristic of yellow fever—as it may occur 
in other diseases—is still of such frequent occurrence in yellow fever 
as to demand the most careful consideration, both as to its nature 
and origin. 
The character of the matters vomited, during the progress of yellow 
fever, varies in different stages of the disease, and with the char- 428 
JOSEPH JONES. 
acter, relative mildness and severity, and the progress of the changes 
in the blood and organs. 
Whilst yellow fever is characterized, in common with several other 
diseased states, by an irritation of the gastric mucous membrane, the 
peculiar nature of the vomited matters does not rest entirely upon 
the congestion and irritation of the mucous membrane of the stomach, 
but is influenced, to a greater or less extent, by the changes of the 
blood, liver, kidneys, and nervous system. 
The vomiting in yellow fever may also be regarded as, to a certain 
extent, salutary, and as an effort for the elimination of certain excre- 
mentitious materials from the blood. In some cases, the first effect 
of the black vomit may seem to be salutary : the tongue improves in 
appearance, the febrile heat abates, and if it were not for other pro- 
found changes in the blood, liver and kidneys, lying back, as it were, 
of this almost universally fatal symptom, beneficial results of the 
most important character might flow from the relief afforded by the 
removal of a certain amount of excrementitious matter from the 
blood, as urea and ammonia. 
The first ejections of the stomach of a yellow-fever patient con- 
sist, most generally, of the ordinary secretions and contents of the 
stomach ; then follow vomiting of a mucoid fluid, frequently, at first, 
tinged with bile, the reaction of which varies in different cases, being 
alkaline in some and acid in others. 
After the first vomiting, the stomach may remain tolerably quiet 
until the subsidence of the fever, on the third or fourth day, when, 
without any premonitory symptoms of nausea, the stomach, on any 
trifling provocation, may eject a quantity of clear, pale, almost lim- 
pid, and slightly acid, opalescent fluid. At this period the disease 
may terminate, or make no further progress, as if this elimination 
was similar to the perspiration of intermittent fever, the whole ail- 
ment vanishing at this stage. 
If the vomiting continues, and passes on to black vomit, it becomes 
first streaked with dark flocculi of altered blood ; the reaction, in many 
cases, changes from the acid to the alkaline; and careful chemical 
examinations have convinced me that this change in the reaction of 
the black vomit was due to the elimination, by the gastric mucous mem- 
brane, of urea, by its conversion into ammonia. 
The acid reaction of the yellow-fever vomit is due, not to the 
presence of any peculiar acid, but to several; as the phoric (existing 
in t ie foim of acid phosphates), lactic, acetic and hydrochloric acids. 
The degree of the acidity will also vary with the character of the fluids 
and solids taken into the stomach: thus, if much sugar be taken, 
the vomited matters will be much more strongly acid, and the pres- BLACK VOMIT OF YELLOW FEVER. 
429 
ence of this substance will also determine, to a great extent, the 
presence and development of certain fungi, as the yeast-plant. 
The rapid generation of torulae, as well as the effervescence of the 
black vomit, is, in certain cases, referable chiefly to the presence of 
sugar in the aliment, and in the tea and coffee drank. 
The specific gravity of black vomit, as determined by weighing 
with the specific-gravity bottle, varies from near the standard of dis- 
tilled water to that of blood. 
It is now fully admitted that black vomit is not entirely confined 
to yellow fever, and that it is chiefly the secretion of- the mucous 
membrane of the stomach, and the matters introduced from without, 
as food, mingled with the blood, which oozes into this viscus, from 
the mucous surface of the stomach, denuded of epithelium and 
intensely congested 
But, in most cases, black vomit is something more. It is, to a 
certain extent, an excrementitious product, containing urea and car- 
bonate of ammonia. 
The kidneys are more or less affected in every case of yellow fever. 
When these organs act continuously and freely, the blood is purified 
of bile and urea, and black vomit more rarely occurs than in those 
cases in which their functions are arrested, and the mucous membrane 
of the stomach assumes the excretory function. 
1 st. To the direct irritation and structural alteration of the gastric 
mucous membrane, by the poison of yellow fever. This poison, most 
probably, is received into the blood and acts in this manner, or 
through this medium, upon the gastric mucous membrane, for we find 
contemporaneous changes taking place in the heart, liver and kidneys; 
and these changes would most probably succeed to the gastric irrita- 
tion, if the poison was received in food or drink, primarily, by the 
stomach. 
Black vomit is due to several causes :— 
2d. To the structural alterations of the blood, and especially to 
the marked diminution of the fibrous elements, which, as I have 
shown by chemical analysis of the blood of yellow fever, sinks 
to a lower figure than in any other known disease. It is well known 
that the diminution of the fibrine of the blood, below a certain stand- 
ard of health, so deranges the capillary circulation, as to lead to 
congestion, alteration of nutrition, and secretion and passive hemor- 
rhages. The hemorrhages and effusions of scurvy can only be 
referred with reason to the changes of the blood, and especially to the 
diminution of fibrine. 
3d. To suppression of the action of the kidneys and the retention 
in the blood of urea and other excrementitious products, and the JOSEPH JONES. 
elimination of urea and carbonate of ammonia, and ammonia, by the 
gastro intestinal mucous membrane. 
4th. To the direct irritant action of the ammonia, and excremen- 
titious materials, eliminated vicariously, upon the mucous membrane 
of the stomach and intestines. 
Bernard and Frerichs long since explained by experiments what 
we observe in these cases of yellow fever, attended with urinary 
suppression. 
Thus the former experimenter found that a dog, which had a 
fistulous opening in the stomach, passed daily Avith his urine about 
93 grains of urea and uric acid, and yet during the succeeding twenty- 
four hours, after the removal of the kidneys, the blood drawn from 
the animal exhibited only a mere trace of these constituents, but urea 
in abundance was detected in the gastric juice, withdrawn through 
the fistula; and after remaining for some time in the stomach and 
intestine, the urea changed into ammoniacal salts ; and the gastric 
juice was secreted continuously, and not, as in the normal condition, 
only after a meal. 
Not only was the manner of formation and chemical constitution 
of the secretion of gastric juice altered by this vicarious excretion 
of the main constituents of the urine, but the mucous membrane was 
structurally altered and became disqualified, not only for the per- 
formance of this elimination, but also for the elaboration of its 
normal secretion. 
In yellow fever the suppression of the action of the kidneys 
follows immediately after, or may even commence in the midst of a 
devastating fever, attended with rapid alteration and chemical change 
of the elements of the blood, and the formation of large amounts 
of urea and other excrementitious matters, and the work suddenly 
thrown upon the already weakened and altered stomach is far 
greater than when the kidneys cease their action suddenly from 
mechanical injuries, or from sudden congestion, caused by cold, in 
health. 
Bidder and Schmidt have shown that the digestive powers of the 
gastric juice are weakened, if it be mixed with any considerable quantity 
of saliva, in consequence, as they suppose, of the neutralization of the 
free acid by the alkali of the saliva ; and they also found that the 
addition of bile to the normal gastric juice entirely suspended its 
digestive property, although the mixture still exhibited an acid 
reaction. 
Bernard, Bidder and Schmidt found that gastric juice, secreted 
with urea, sooner or later not only became alkaline, but also lost its 
power of converting albumen and albuminous matters into assimilable BLACK VOMIT OF YELLOW FEVER. 
431 
forms; and Lehmann also found that the digestive power of the 
gastric juice was much impaired by the addition of alkaline salts, or 
by saturating the fluid with peptones or other organic substances, 
either nitrogenous or non-nitrogenous. 
In yellow fever, when there is an impairment or suppression of the 
function of the kidneys, we not only have a combination of these 
various causes, producing derangement of the gastric juice, but we 
also have the destruction of the fibrine of the blood, inducing passive 
hemorrhages from the congested and altered gastric mucous mem- 
branes, and at the same time such an elevation of temperature as is 
most favorable to the rapid decomposition of the contents of the 
enfeebled stomach and intestines. 
5th. To the irritant and nauseating effects of the bile retained in 
the blood. 
The bile retained in the blood without doubt produces its charac- 
teristic effects upon the nerves supplying the stomach, inducing 
nausea and vomiting. 
6th. To the degeneration of the excretory and secretory cells of 
the gastro-intestinal mucous membrane, attended with or characterized 
by the deposit of granular, fibrous or albuminous matter, and oil- 
globules in the secretory cells, and in the walls of the smaller blood- 
vessels and capillaries. 
7th. To the capillary congestion of the gastro-intestinal mucous 
membrane, similar in all respects to the intense capillary congestion 
which characterizes all the organs and tissues in this fever. 
The chief causes of black vomit therefore are :—the direct irrita- 
tion of the gastric mucous membrane ; intense capillary congestion, 
in consequence of the morbific action of the poison of yellow fever 
and its products upon the vaso-motor system of nerves; suppression 
of the functions of the liver and kidneys, and the retention in the 
blood of bile and urea, and the elimination of urea from the gastric 
mucous membrane, as such, in the state of ammonia and carbonate of 
ammonia ; and the direct irritant and solvent effects of ammonia and 
carbonate of ammonia upon the gastro-intestinal mucous membrane, 
and the effects of the urea, ammonia, and other constituents of the 
metamorphosis of the tissues upon the blood; the alterations of this 
fluid by the changes excited by the yellow-fever poison, and the de- 
struction and alteration of the fibrous elements. 
When careful sections of the kidneys were made with Valentin’s 
knife, and examined under the microscope, the Malpighian corpuscles 
and tubuli uriniferi were filled with oil-globules and granular nitro- 
genized matter, which appeared to be the result of the changes and 
modifications of the albumen and fibrine of the blood. JOSEPH JONES. 
The excretory cells of the kidneys also contained o 11-globules and 
granular matter. 
The poison of yellow fever appears to act in an analogous manner 
to the agents producing small-pox, or the poison of certain reptiles, 
which alter the constitution of the blood, and lead to the formation 
of altered albuminous and fibrous products from the blood, and which, 
in the case of yellow fever, transude into the hepatic ducts and uri- 
nary tubes, and thus cause suppression of the urinary and biliary 
secretions. 
When in any case of yellow fever the function of the kidneys is 
arrested, a fatal result necessarily ensues, not only from the retention 
of the urinary constituents, but also from the retention of the bile. 
As long as the kidneys perform their normal function, the retained 
bile will be continuously eliminated; but as soon as these organs cease 
to act, the bile, as well as the urinary excretion, is retained in the blood, 
and certain nervous disturbances are induced, as dulness of the 
intellect, uraemic convulsions, and, in some cases, violent agitation 
of the muscles, resembling tetanic spasms. 
Black vomit, therefore, is an effect or result of preceding actions or 
changes, and is not a cause; it is an error, therefore, to search, 
either by chemical means or by the microscope, for the cause of the 
disease in one of its products. 
Black vomit, from its great amount in some cases, may be possibly 
a cause of death ; but it is in all cases only secondary to the preced- 
ing changes in the liver, kidneys and blood, and in some cases at 
least in which it is the result of an effort on the part of the organism 
to eliminate certain materials from the blood, it may, to a certain 
extent, be even salutary. ARCHIVES 
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