UNITED STATES OF AMERICA WASHINGTON, D. C. B19574 DUE TWO WEEKS FROM LAST DATE ftp* 4 lasg 1ft—71341-1 \ . AN ESSAY. ^ ON YELLOW FEVER. COMPRISING THE HTSTORY OF THAT DISEASE, AS IT APPEARED IN THE ISLAND OF ANTIGUA Ik theveaks 1835,1839, & 1842. WITH AN APPENDIX CONTINUING THE HISTORY TO 18 55. By THOMAS NICHOLSON, M. D. (Read before the Epidemiological Society of London, July 4, 1853, and published in the Association Medical Journal for Sept 1853.J vt ' 0^, J ANTIGUA : REPRINTED BY W. MERCER, 1856. WCK 1256 AN ESSAY. The subject of the following eisay is that peculiar form of fever, which, under the different names of Yellow Fever, Vomi- to Negro, Vomito Prieto, and Bulam Fever, has been known to the English and Spanish colonistbon both sides of the At- lantic for nearly a century, occurring at distant and uncertain intervals, and producing great mortality, especially amongst Europeans who have resided but a short time in these parts. Ithas been described by nosologists under the termsof Typhus Icterodes, Cullen ; Synochus Icterodes, Young ; Epanetus Malignus Flavus, Good; and more recently by Dr (oplana, from its pathological characters, Hsemagastrie Pestilence. The term Hcemalytic Epidemic of the Atlantic shores would, in my opinion, express more accurately the peculiar features ot the disease ; but I am unwilling to make any addiiions to its no- menclature, which, after all, is of little importance. I had been thirteen years in Antigua, before 1 had an op- portunity of witnessing a single case of this disease, although severe and fatal cases of Bilious Remittent were met with in malarious localities every year, and in some seasons prevail- ed as an epidemic over the whole Wand ; as, for instance, in the year 1823, a short account of which, by my friend Dr. Musgrave, will be found in the twenty eighth volume of the Edinburgh Medical and Surgical Journal for 1827. Yet, al- though the mortality from this epidemic was very great, in no instance did black vomit occur ; and, from the informa- tion I could collect on the subject, I have every reason to believe that vomito prieto was not known amongst civilians in that colony, from 1816 till 1835. I exclude, of course the cases of the Pyramus, and two other men-of-war, which arrived at English Harbour with yellow fever in 1821 and 1822. 4 Being taught in my early years, by the writings of Ban- croft, Fergusson, and others, and by the oral instructions of the medical gentlemen under whom I served in the West In- dies, to regard yellow fever as a more severe grade only of the endemic fever, I was often puzzled to account for the absence of this peculiar symptom in all the cases I had seen; and I was sometimes inclined to hazard an opinion that, after all, Chisholtn might be right. Subsequent experience has con- vinced me that yellow fever differs as much from bilious re- mittent, as the epidemic or Asiatic cholera differs from spo- radic or English cholera; but I never met with any circum- stance that could prove its propagation by contagion. The following history will show that it broke out in St. John's in 1835. at a time when our harbour was almost destitute of shipping, and when, consequently, we had no intercourse with the neighbouring islands ; and, although convalescents were frequently carried into the couutry for change of air, the disease was not propagated in the rural districts. On the 12th August, 1835, the island of Antigua was visit- ed by a severe hurricane, which did great damage to the buildings in town and country, but more so to the vessels in tbp harbour of St. John's, most of which were driven on shore and destroyed, or so much disabled as to be unfit for sea. A person inexperienced in these tropical tornadoes, can scarcely form an adequate idea of the fury with which the wind raged for a few hours. The Barometer fell in the course of one hour and twenty minutes 1*5 inch, a rapidity of descent which, as far as I can learn, has not been equalled in any former hurricane on record. The centre of this whirlwind moved at a steady rate in a westerly direction, being felt some hours later at each island in that course ; and, strange to say, it was scarcely felt at all forty miles to the south of Antigua. Be- fore the occurrence of the hurricane, the inhabitants were tolerably healthy, at least they were free from any acute or febrile diseases ; but the weather was dry and sultry, and dyspeptic complaints were more than usually prevalent. The excitement, however, occasioned by the hurricane, and the vigorous exertions required to repair its effects, dispelled these anomalous complaints, and for 6ome weeks subse- quent to the gale, the number on the sick list was small. 5 Ine state of the weither was not similarly ameliorated by the atmospheric commotion. The heat was greater ; the wind variable, and mor^ westerly fhan usual ; and there were fre- quent showers of rain. The sea, which rose in the gale above its usual level, aided by the wind, had deposited a great quantity of marine organic matters and vegetable rubbish about the wharves and precincts of the town bounded by the harbour ; and it was remarked by the inhabitants in that quarter, that the smell arising from tbe sea, particularly at night, was peeuliarlv offensive. On the 20th September. 1 was called to a case of fever in a young Irishman, who resided in a houseon one of the wharves, which had sufferpd greatly in the gale, and was then under- going repair. I? proved rather nn obstinate case ; the head- ache, gastric irritability, and rachialgia, being very severe; but it terminated favourably. When, each successive day, one or two other cases were added to my list, I began to suspect that we were about to have a visitation of some epidemic ; and it is recorded in my note-book at that time as epideinic gas- tric fever. It is worthy of remark, tbat it broke out in the same locality, and much in the same way, as the "Dandy Fever", that peculiar arthritic exanthem, which I have de- scribed in vol. xxxi of the Edinburgh Medical and Surgical Journal fox 1829, p. 115. I was attacked myself on the 7th October ; and during my confinement, which was only three days, the more malignant characters of the disease were developed. But it was not till the 10th October that we had a case of black vomit, when the true nature of the epidemic was discovered. It may be necessary to mention, however, that none of the medical gen- tlemen engaged in practice in St. John's at that time, had ever seen a case of yellow fever, otherwise the discovery might have been made earlier. The epidemic continued to increase till the first week of November ; after which it gradually declined, and by the end of December had nearly disappeared. The last death occur. red on the 24th of that mouth, in the wife of a Moravian mis- sionary, who arrived in the island from England on the 9 th, and was attacked on the 15th. During that period, I had attended two hundred and twenty cases ; of whom seventy- 6 five were Europeans, sixty-five white Creoles, and eighty coloured persons. Of the Europeans, twelve died ; of whom ten had not been in the island twelve months. None of tha Creoles or native whites died ; but two of the mixed race sunk under peculiar circumstances. In June 1839, yellow fever again made its appearance, at- tacking only those young men who had come to the island during the interval. This epidemic was of a more open or in- flammatory type than the former, and copious venesection was practised with much success. In September 1842, another invasion of the disease took place, and continued till the middle ,of iNovember, duriug which time I attended forty-three cases, viz ; twenty-two Lu- ropeans, twenty white Creoles, and one of the mixed race. The Europeans had only been a few years in the colony, and of these eight died; the Creoles were chiefly children, of whom three died. On all these occasions, it is remarkable that the epidemic was confined to the town of St. John's ; andaltnough our practice extends over twenty-eight estates, on each oi which several white persons resided, who were unprotected by a for- mer attack, none oi these took the disease. SYMPTOMS. In private practice, the physician has few opportunities of witnessing the premonitory symptoms of fever, except in his own person ; and therefore I will only describe what 1 my- self experienced. I got up in the morning with an unusual feeling of la**>irude, and with some uneasiness in the head, and pain in the back aud limbs, I had no sense of chilliness, nor was the temperature of the sui^ce increased ; but 1 had much thirst, and the swallowing of liquids was immediately followed by nausea and copious perspiration. The pulse was weak and variable, and much accelerated by the slightest ex- ertion. Notwithstanding these symptoms, I continued to dis- charge my professional duties till 10 p. m , when the pains in the head and back became almost intolerable, the vomiting incessant, and the febrile excitement, fully developed. The paroxysm continued for thirty six hours, when it left me in a state of extreme exhaustion, with a furred tongue, which last- . ed for several days, and a yellow hue in the skin and con- junctiva. Such was the mild form in which the epidemic manifested itself in natives and persons who had been long resident in the West Indies ; but in others it assumed a highly malig- nant character, producing a rapid dissolution of the blood, which exuded into the mucous canals, and sometimes even through the pores of the skin ; and it frequently terminated in death by asthenia or coma, on the third, fifth, or seventh day. Three varieties of this malignant type were observable. The first I shall term the ardent ; the second, the adynamic ; the third, the congestive ox apyretic. i. The ardent form was ushered in with the usual symp- toms of a febrile attack—slight rigors, or only a coldness of the extremities, headache with suffusion of the eyes, general lassitude, and pain in the back. In a few hours, these symp- toms were followed by a hot burning skin, great throbbing of the carotid and temporal arteries, intense headache and rachi- algia,pulse from 90 to 120, full and strong, incessant thirst, and vomiting of fluid which often exceeded in quantity what was swallowed. The bowels were obstinately constipated, the urine high coloured, and sometimes entirely suppressed. The discharges from the bowels produced by medicine, generally resembled ditch water, being free from all appearance of bile. The blood drawn at the first visit presented no unusual char- acter. About the second day, the patient complained much of flatulency in the stomach, occasioning frequent efforts to expel it, which Dr. Dewees of Philadelphia has very graphi- cally described as a vomiting of wind. There was also a sense of stricture about the cardiac orifice. On the third day, the skin had assumed a lemon colour, which w&3 first per- ceptible in the conjunctiva and upper parts of the neck ; the heat had subsided, but the pulse had increased in frequency ; hiccough was urgent. The matters vomited were mixed with dark flakes, sometimes resembling snuff, sometimes the dregs of port wine. Soon after this, two or three pints of a black fluid, like soot an! water, were ejected with great force, and death closed the scene. In some cases, the vomiting would cease suddenly, either spontaneously or on the exhibition of 8 an opiate, and violent delirium or coma would supervene. Case i. D. G i aged 21, engiueer, lately arrived from Eng- land, Oct. 23, 1835, awoke with a sense of fatigue and pain in his back, which he ascribed to a long walk he had taken the evening before. At noon he was fouud in a high state of fever, with intense pain over the orbits, red watery eyes, pulse 100, full and strong. He was bled to thirty ounces, and pills of calomel, compound extract of colocynth, and jalap, were ordered. The bleeding relieved the headache, reduced the pulse to 90, and occasioned a copious diaphoresis. At 4 p. m , headache and febrile heat had returned ; and vomiting was urgent. The abstraction of eight ounces of blood was again followed by relief of all the symptoms. The pills were repeated every second hour, with effervescing draughts of the tartrate of soda. 8 r. m. The fever was less violent ; the bow?ls had not been moved. The hair was cut ; and cold affusion applied to the head as often as the heat returned. The medicines were continued. 24th. Headache and vomiting were still urgent; the medi- rine had acted but slightly. Five grains of calomel were giv- en every two hours, with solution of sulphate of maguesm in the intervals. A sinapism was applied to the epigastrium. The cold douche was continued. 25th. The medicines had acted slightly ; and heat had abat- ((. There was frequent emission of gas ; a yellow tinge of the skin ; scanty urine. A blister was applied to the epigas- trium ; the calomel was continued, and two grains of cam- phor, every two hours. 2'6\h. He was much easier ; had had dark tar-like stools. :27tli. He was reported to have passed a quiel night; but I found him at 6 a. m. sinking; the skin cold and pulse scarce- ly perceptible. Wine and other stimulants were prescribed ; but he died at 10 a. m., immediately after ejecting a wash- hand basinful of the black vomit. Post Mortem Examination at 3 p. m. The external sur- face was of a yellow colour, spotted with purple patches. Abdomen. The viscera appealed healthy externally. Liver cf a natural size ; yellow colour. The gall-bladder contain- ed a small quantity of dark green viscid bile. The stomach contained a pint of black fluid : internal surface highly con- 9 gested, from cardiac orifice to H inch from pylorus. Small intestines full of black inky fluid, which was warm, and in a state of fermentation. Peyer's glands were very conspicuous. colon stained of a dark livid colour, intsrspersed with red patches. Kidneys healthy. There was half a pint of urine in the bladder. Case 11. Mr S. A. aged 25.1 was called at 11 p. m. on the 8tb October, 1342, to visit this young man, a native of Scot- land, who had been but a short time in the island. 1 was in- formed that he had been complaining of great lassitude all day, with pain in the back and limbs. I found him labour- ing under intense rachialgia and incessant jactitation, with much headache and coldness of the lower extremities. Eis feet were immersed in hot witer, and in that position he was blooded to the extent of thirty ounces with great relief of all the symptoms. His pulse which before the bleeding was 120 and very small, became fuller and less frequent. His skin became moist, and the temperature rue re equable. He wa* ordered to take large doses of calomol, colocy-ah, and jaiap. every two hours till bis bowels were emptied. On the morning of the 9th, Dr. Musgrave found him complaining of a return of headache, with an increase cf heat, and he thought it advisable to abstract about eight ounces more blcod from him. The purgative pills were continued, with the addition of a mixture of the compound powder of jalap, but his bowels were slow in responding. In the course of Monday, the 10th, his stomach became very irritable, and hs brought up much larger quantities of fluid than appeared to be icgested. The prescription was a blister to the stomach, five grains of calo- mel every two hours, with effervescing draughts. On the morning of the 11th, he was found much cooler, and quinine wis tried : but the irritability of the stomach prevented a con, tinuance of it. Black vomit and hiccough succeeded ; and he died at six o'clock in the evening. Case hi. Mr. F. P., aged 21, an Englishman, about two years in the island, was attacked 1st November, 1842, with giddiness, and pain in the head and back. When visited, the febrile excitement was fully developed. He was bled in ♦he erect position till approaching syncope, when profuse per- spiration broke out; the heat was subdued and all the symp^ 10 toms relieved. The bowels were freely opened with calomel, colocynth, and jalap. He took ten grains of nitr?, with a few drops of spirit, scth. niiros, in a glass of water every two hour*. On the 3rd, he was in a state of complete apyrexia. Two grains of sulphate of quinine were given every second hour, during the day, and on the 6th he was struck off my list as perfectly cured. Case iv. Ivlrs. P. wife of the preceding, aged 20, a native of the island, but who had been some years in England for education, was attacked November 7th with all the symptoms of the prevailing epidemic, being five months advanced in prpgnancy. She was blooded to the extent of twenty-four ounces, and treated in every respect like herhusband ; and on the 12th she was convalescent. Case v. Mr. W. B., Englishman, aged 35, about three months in the island, was attacked 7th November 1842, with the usual symptoms of the ardent form of yellow fever then prevailing. He was bled to the extent of forty ounces ; was purged with calomel, colocynth, and jalap, and afterwards took effervescing draughts of tartrate of soda with nitre. On the 10th he was convalescent. He took quinine for three days, after which I took my leave. ii. The adynam:c form was usually met with in females and persons of a lax fibre and deficient animal vigour. It was ushered in by slight rigors, giddiness, and pain in the back, frequent sighing, and sense of oppression at the pree- cordia. The reaction which followed was slight, unattend- ed with pungent heat of the skin, or strong arterial action ; the pulse was small and compressible. This stage did not last more than forty-eight hours, and was followed by the stage of collapse, great prostration of strength, cold clam- my sweats, feeble pulse, hiccup, vomiting of a dark gru- mous fluid, yellow colour of the conjunctiva, and auridhue of the face. Haemorrhage from the nose, mouth, anus, and vagina, followed, under which the patient sunk in a fit of syncope or asthenia. In others the sensorium was early af- fected, there was a total suppression of all the secretions; the patient lay tossing about in a state of wild delirium, totally disregarding exposure of her person. Haemorrhage took place from all the passages; the sheets were stained with blood; her 11 hnnds were bloody, and her eyes yellow the arms, legs and back spotted with vibices, the fairest of creation became an object of pity and abhorrence : in SUch cases death was hail- ed with joy by all her attendants. Case vi. Mrs. W. aged 31, native of Scotland, about three years in the island, was attacked at 5 a. m., on the 10th Oc- tober, 1842. with shivering, and great pain in the back, which were soon followed by symptoms of fever of a mild character, the pulse was quick and feeble, and the skin warm, but rather moist. The fever continued during tbat and the following day without any urgent symptom, except a distressing pain in the back. On the 12th, she was fonnd free from fever, and a solution of sulphate of quinine was prescribad. But at 3 p. m., she was suddenly seized with v6miting, and brought up a pint of black fluid ; after which her pulse began to fail, and symptoms of collapse occurred. At 5 P. m , she had an epileptic fit; diffusible stimulants were administered liberal- ly ; but she remained for several days in a state of extreme exhaustion. On the ISth, hiccup was added to the other bad symptoms. On the 14th, the abdomen was tympanitic, when twenty drops of oleum terebinth were given every two hours with good effect. Next day the bowels became relax- ed. The discharges consisted of bloody serux : these were restrained by tincture of opium and carbonate of ammonia, and she gradually recovered. Case vii. Mrs. W., aged 28, a native of England, from which she had arrived only a few months. This lady's hus- band was a physician, holding an official situation in the colo- ny, but was not engaged in practice. His mother-in-law died of fever on the 15th October, 1842; never having been con- sidered by him in danger till fatal coma occurred This un- expected event occasioned much grief to Mrs. W, and she was preparing to accept the invitation of a friend to spend some time in the country, when I was sent for, on the 25th Oc- tober. I found her seated on a chair dressed in mourning, and the carriage p.t the door ready for the journey. She complain- ed of giddiness, pains in the back, and a total prostration of strength. Her husband was urging her to proceed, protest- ing that she was suffering only from grief and want of sleep. Her pulse was quick ; and there was increased heat aboiitthe 12 head and trunk ; although her skin was generally moist. I gent her to bed, and called a consultation of her medical friends iu two hours ; when I hoped reaction would have taken place, and as she was of a plethoric habit, though phlegmatic teni- perameut, the propriety of bloodletting might be a question of intricacy. At our visit, fever was mere fully developed ; but the state of the pulse did not admit of venesection. Purga- tives, into which calomel entered largely, were prescribed, to be repeated at short intervals. Next day there was no dis- tinct change. The following day, the febrile symptoms were increased, with much cerebral excitement and constant jacti- tation. The head was shaven; and the calomel with cam- phor, given evety two hours. But the symptoms became gradually worse. The delirium was violent, and she was with difficulty retained in the bed. The secretion of urine was suppressed; haemorrhage took place from the nose, mouth, and vagina ; the skin was yellow, and the arms, legs, and de- pending parts were marked with livid spots. She died on the fifth day. Her husband was attacked with the disease under the congestive form on the 27th, and died on the seventh day. in. TKh congestive form is characterised by the total ab- sence of febrile heat. The patient has a stupid, drunken ap- pearance, willscarcely admit that he is ill, or complains only of slight pain in the back and limbs. He staggers in his gait, or lies in a soporose state. Deafness ensues, and afterwards low muttering delirium. The pulse is at first slov and in- termitting ; it becomes quicker in the progress of the disease, but seldom exceeds 100. The stools are unnatural, without any admixture of bile ; the urine is scanty, aud is ultimate- ly suppressed. The skin is of a yellow mottled hue. Hic- cup occurs early, with black vomiting, and hsemorrhags from the mouth and nose, and the case usually terminates by con- vulsions or coma. Case vhi. Mr. F., a native of the United States, aged 38, about a week after his arrival in Antigua, in November 1833, was attacked with slight headache, and pain in the limbs, which he said he would scarcely have noticed but for the pre- valence of yellow fever in St. John's: His pulse was slow and intermitting. His medical attendant treated him with 13 active doses of ralomel ; but the bowels were scarcely moved, Bnd the discharges were desmute of bile. On the third day he became tinged with a yellow f-uffuHon. On the fourth I 6 w him ; his pulse was then 96; he had hiccup ; haemorr- hage hum the gnms; and vomiting of a brownish fluid with dark coloured flocculi. lhe urinary secretion was suppress. td. Being a stranger aud a man of family, the mereh-nt to whom he was consigued, requested that we would make known to him our opini n, if we thought him in danger. This was dune in us considerate terms as possible by his medical attendant; when he replied verv angrily, that he begged leave to dihVr f'otn us, he was not ill, and we had quite mistaken his i-cmplaint. Next morning he was found incoherent sit- ting up in bed and with a fixed melancholy gaze and corru- gau-.i hiow : blood was issuing from the pores of the right chei k. lie took no notice of us as we entered his room, but continued icpea ing the letters of the alphabet slowly. He died in lhe evtiiing after several convulsions. lJissRcrio>. On opening the abdomen, the stomach was obs. t \ etl much distended, and presenting on its external as- pect aeveial dark spois like incipient gangrene ; but on lay- ing n open, this was found to be occasioned by the abrasion ot the mucous coat in several places, and the preseuce of a black ink) fluid, like soot and water. The mucous mem- brane o. the upper half of the duodenum was also abraded. The rest of the intestines were sound. The liver was pale ; the gali bladder was distended with dark green bile. The lining membrane of the heart was highly injected and stud- ded with patches of extravasated blood in several places. The sigmoid valves exhibited the same appearance. ax atomic al characters. The yellow coloui of the surface of the body was always more distinctly visible after death ; and on the depending parts it was mixed with purple patches. All the appearances in- dicated a defective crasis of the blood : it remained fluid after death. The capillaries of the serous membrane were in a state of hyperEemia, but there was seldom any exudation of liquor sanguinis perceptible. The mucous membrane of the upper half of the alimentary canal was generally softened, 14 and the epithelium detached from the stonwh and duodenum. The muciparous glands were found enlarged only in one ca.-«. The stomach contained always more or le*s blood, whw-h was changed into a black colour, and frequently mixed wi»h gas. The liver was usually of a pale bloodless colour, and the spVen presented no unusual appearance. The gull bin ! 'or was sometimes tinged with black bile, in othf*r cases it was nearly empty. The thoracic viscera exhibited onlv such ap- pearances of congestion, as were referrible to the fluid stn*<> of the blood, and *h,j mule of death. In one case, the blond in the right ventricle had a frothy appearance, having been evidently mixed with gas during life, DIAGNOSIS. The only diseases with which yellow fever can be con • founded are bilious remittent, and the malignant forms of intermittent fever, and as many medical m^n, f >r whose opinion I entertain the highest respect, consider all thes^ fe* vers as the offspring of the same tetrestrial miasmata, modi- fied only by the constitution of the individual, and other un- known agents, it is necessary that T should relate moro ful- ly the circumstances which have induced me to form a differ- ent opinion. ]\jy experience is derived entirely from a resi„ dence of twenty-five years in Antigua, where intermittent and remittent fevers are endemic, and met with every year, chief- ly from September to March, and where yellow fever has on- ly occurred three times during that period. The endemic fe- vers prevail chiefly in the country districts, and the inhabit- ants of St. John's are seldom attacked with them. Whereas, the epidemic yellow fever was confined to the city and to the garrison at the Ridge, and at English harbour. It is difficult to account for the comparative exemption from remittent fe- ver which is enjoyed by the European youths who are employ- ed in the mercantile profession in town, whilst those who su- perintend agricultural operations in the country, never escape. Antigua is of a rough circular figure, being 20 miles long and 54 in circumference, containing 108 square mile3, equi- valent to 69,277 acres ; two-thirds of which are under culti- vation. There are few springs in the island, and no streams that deserve the name of rivers ,• but it is much indented with 15 creeks and bays, whose oozy waters maintain th* growth of impenetrable thickets of the different species of mangrove, and are the fertile sources of malaria. In a geological point of view, the island comprises thipe distinct formations of the tertiary class, of which the most su- perficial beds occupy the northern and eastern divisv> is. These consist of a calcareous marl, and coarse sandstone, in- terspersed with masses of a tolerably compact shell limestone. On the surface are found a great variety of marine exuviae, analogous to those which at present inhabit the surrounding seas, as astrea, meandrinse, tubipora,etc. The surface of this district is exceedingly broken and undulated, consistino; of a serirs of round-backed hills of no great elevation, eo\e«ed wirh a light arid soil. The sides of tha hills and intervening valleys are highly cultivated, and produce a rapid growth' when duly favoured with rain. 'lhe mountainous district, forming the southern and west- ern divisions, is composed of rocks of the newest h\>*z trap for- mations, as wacke, porphyry, trap breccia, ampygdnloid, and some spherical masses of basaltic green-stone. So-ne of these mountains rise with eouical summits to the height of 800 to 1,000 feet; others, of the same elevation, are more rounded and leas precipitous, affording a good soil for the sugar-cane even on the tops. They are intersected by beautifully roman- tic valleys ; and the abrupt sides of the mountains are cloth- ed with the verdant foliage of a great variety of herbs, and trees, and twining shrubs. The intermediate district is occupied by a series of argilla- ceous strata of varied characters, which dip at a considerable Hngle to the north and north-east, and extend across tbp is- land from Willoughby Bay on the south-east to St. John's in the north west. The northern limit of this district is formed by a zone of low land, which at no very distant period, appears to have been submerged, and even now, after heavy rains, ig readily converted into a marsh. 1c rises with a gentle jljfrli- vity towards the south and south-west, where it presents a precipitous escarpment, and is divided from the trap forma- tion by a ravine, in which are pools of stagnant water, and a sluggish stream which runs towards the west, through a beautifully luxuriant plain. 16 Although this district, and the mangrove creeks with which the island is ii,denied, pr seiit the only unequivocal sources of raludal emanations ; yet all parts of the island are at cer- tain seasons affected by malaria—the dry, calcareous soil of the north, equally with the humid valleys of the south Mow is this u» be explained ? Two things are always pit&ent when ievcr prevails in these districts—a hot sun duiin- the day, ami circumstances favourable to the radiation of heat from the earth, and the deposition of dew at night. The febrific poison, whatever it may be, appeals to be de- posited «nh the dew, even at a distance from its source ; and all who are subjected to its influence, as it rises again at the approach of the sun, are as much affected as if they had iu- haUd it at the fountain-head. This is the only way in which 1 ntii explain the greater prevalence of fever in country dis- tiit Ls than in St John's ; it being well known that more dew is deposited in the open country than in cities, where houses conceal a portion of the sky. A soil covered with vegetation Js als » more favourable to the production of dew, than the trodden streets of a town. At these seasons, the mean dew point is about 70°; but, in the cloudless moonlight nights, the thermometer falls sometimes to 66°, producing an unpleasant sensation of cold, of which the inhabitants of northern latitudes, who enjoy a temperature some degrees lower than this, can scarcely form an idea* The injurious effects of dew have been long known to the vulgar ; and I think it has been unjustly r verlooked by the late Dr. William Feigusson, in his interesting paper on " Marsh Poi>on." * Dr. Chisholm in his manual of 1 iopical Diseases mentions this peculi- arity of temperature in Antigua, bat in my opinion he hts overlooked thi true cause He says, ■' Antiuua, being altogether argillaceous, is distin- guished by a peculiarity in the temperature of its atmosphere ; it is a de- gree of cold no: observed in any of the other islands, but which has, on the human body, all the influence of marsh exhalation, although no swamps are in the neighbourhood of St. John's where this singular cold is chiefly felt, a! terrain has continued to fall for a few hours—On these occasions Fah- renheit's thermometer falls to 62°"—page 2. Now I have never observed the tlvrmometer below 64°—and it was always in the driest seasons and in eV.udlcss moonlight nights, and generally in the month of February not after rain, when this unusually low temperature occurred. Antigua is" one of the driest of the West India islands, anjd to this circumstance and the lo v dew point I attribute the descent o£ the thermometer where terrestrial radiation is great. Professor Fleming on the "Temperature of the Sea- sons" observes ;—" When the air is yery dry, or where the dew-point is 17 So much for the extrinsic cause of endemic fevers. Let us next inquire whether these fevers may be so far modified by constitutional peculiarities in the Eurcpean, as to assume the continued or malignant form of yellow fever. Since the year 1837, a considerable number of English labourers have been imported into Antigua, which has afforded me an opportuni- ty of seeing this question put to the test of exp< liment ; and, an hough ih«y have all suffered more oriels Iromtue/fecre au poys, uotone case oi olatk vomit has come to my knowledge. lu »jay 1843, i«enty-six English tradesmen were imported, by a weuiihy mercantile firm, for lhe purpose of rebuilding thi'Se works which were destroyed by the earthquake on the 8th oi FeniUiiy ot that year They were lodged in the coun- try, in a house sumtienilv iouiny, and in every respect com- modious, but in a locality much exposed la malaria. Their employer, considering the heat of the sun the only thing like- ly to be prejudicial to the health of these unacclimated stran- gers, allowed them to retiie to their house for tnree hours at noon ; but they entered on their woik befoie sunrise in the morning. They were all attacked in a short time with re- mittent fever, of the most aggravated type, attended with a deep yellow colour of the surface, delirium, etc; yet they all recovered without haemorrh ige from the mucous passages, black vomit, or any symptoms indicative of that dyscrasia of the blood peculiar to yellow fever.* Again, in 1845, about thirty mechanics were imported, to rebuild oik cathedral, which was destroyed by the same visi- tation. They were located in St. John's, where they remain- ed upwrds of two years ; and not one of them was attacked With fever —another proof of the greater prevalence of the en* ▼fry low the descent of the evening branch of the curve will be prolong- ed, in the absence of the counteracting curve which has been referred to - (viz. the caloric given out when vupouris converted into dew j) and in con, Bequence the cold of the night may be great. But when the air is humid or in ordinary language nearly saturated with moisture, and the dew-point consequently hiuh, then the sinking of the evening temperature is prevent- ed from exceeding in any considerable dearee that point at which lhe ex- isting vapoiar must be converted into water.'"—pige 22. • One old man died afterwards in the Colonial Infirmary, of the sequela Of the fever ; and 1 have heard that some of the others died of dropsical symp- toms on the passage to England, no doubt from organic diseases of the abdo« minal viscera produced by the feVer. 18 demic in the country than in town, and also that ing from atmospheric changes. The suffusion of the eyes, pain in the head and back, closely resemcle the precursory s)mptoms of influenza, it is only in the progress of the disease, when the torpid state of the se< cretorv glands, the rhlorotic hue of the skin, and hsemorr- hage from the mucous surfaces, reveal the nature of the epi- demic. Whether the morbid state of the blood, which forms the pathognostic symptom of this fever, is the immediate ef- fect of its contamination with a poisonous principle from mth. out, or merely the consequence of defective elimination of ef- fete matter generated within the body, is a question that has not yet been determined. Probably this change in the vital fluid is attributable to both causes. It is very evident that the first link in the concatenation of morbid phenomena is congestion of the capilliaries of the brain, spinal chord, and abdominal viscera ; and the great beuefit derived from blood letting at the commencement of the attack, so a* to remove this state of congestion, would seem t" prove that it is the chief proximate cause of the disease. On the other hand, the fereat susceptibility of Europeans, who have never had the disease, and the immunity of those who have once had it, and of those whose blood has been modified by a long residence in a warm climate, look like the operations of a morbid poison on certain substances, which may exist in the blood of one individual, and not in another. The yellow colour which attends bilious remittent is gen- erally, if not always, produced by excessive secretion of bile, and the reabsorption of some of it into the blood: notwith- standing, a large quantity is duly excreted, as shown by the 19 colour of the stools, which varies from a deep yellow to a dark green. Some doubts have been entertained recently whether excretions from the b nvels of a green colour are due to bile ; but of this no practitioner in the West Indies can possibly have anv doubt. Louis, in h;s observatioMS on the yellow fpver of Gibraltar has laid much str^s «>n a peculiar coln-ir of the liver, as ^ dl- aonsiir character. N-'hing very remarkable to thanked eye was observe., in An'iign once in his lifetime. This was in great measure conoboiated bv the epidemics that fell under my uotice ; not one of .hose persons who suffered in the first epidemic was attacked in the subsequent visitations. TREATMENT. When the epidemic began in 1835, it was treated on.the general principle pursued in the treatment of feveis within the tropics. At the tirst visit, if the symptoms were sufficient- ly urgent, and particularly if the patient was a European, in whom the tone of the v.ry ''isch*rg3 from the bow- els was pioduced ; the action of the kidneys was stimulated by small doses oi nitre, frequently repealed ; and the head and chest were assiduously sponged with cold water. When these measures failed to relieve the febrile symptoms, and to rouse the hver n. increased secretion, five grains of calomel Were given ev*rV t«n bonis Vomiting was arrested by the application „f rubefacient of capsicum or mustard, or some- times „f a blister to the epi. astrium, aided with saline effer- vesccnts, or a draught of magnesia, tincture of opium, and mint water. so The following case, however, created a strong prejudice against blood-letting, and the mercurial treatment was chief- ly c>nfided to after that. Calomel was given in some cases to the extent of 250 grs.. without any sensiblp cfT ct on the system ; and i' could generally be detected a' the bottom of the vessel containing the watery stools, in tin to;m of black oxide. Casp tx. Mrs B. a native of England, aged 35,was attack- ed, on October 4th, 1835, with symptoms of fie prevailing fever, tier husband, in his \ooih, had been some lime in an apothecary's shop, and slid retained a love for the pio e>>ion, which he displayed occasionally by the practice of tnit.oi sur» gical operations, stub as bleeding au-1 extraction o. teeth, for the benefit of his friends. On ihe evening of the 4th, he made vaiioiis ineffectual attempts to draw b.ood tiom Airs ii ; and on the oih 1 was sent for. i lound her labouring under symp- toms ot a mild attack of the fever, and vt uesectiou might have been considered unnecessary ; but to please htr husband, and at the same time, perhaps, not a liti le influenced by a desire of convincing him inat he was not an expeit suigt-ou, 1 ab- stiacted about sixtt.cn ounces of blood at a full stream. '4. his dopletiou appeared to be well borne, and the headache aud otn^r ft hnle symptoms were much lulitved. She had al- ready taken purgative medicine, and a mild febrifuge was all that wa» considered necessary. Her husband was attacked the following day, and i mysdt ou the 7th, having left Mrs. B. appaiently convalescent. On the morniiig ottheyih.she was so well, that she got up, and went into the adioiniu" bedroom wncie Mi. ii was lyiug. She sal mr some time on his bed, eudeavouimg io commit him wuli leligious conver- sation, and expressing her gratitude that she tiaU s> far re- coveied as to be «.bl« u, atteud to him. On returning to her chamber, she discovered that *he h,d a discharge which she took for the caumenia. Soon afterwards, she was attacked with syncope. messengers weie tent in vveiy direction for medical men, and thiee n. re veij soon at her benside ; but the vital spark had fled. Two of these medical men were Strongly opposed to Hie use of the lancet in fever, ami it waS very currently reported that Mrs. B. had fallen a victim to this rash practice ; and the effect ou the public mind was such £1 that to. propose such a measure afterwards was met withhor-. ror both by the patient and his friends. The lancet was not used in any of the cases that died sub- sequently, except that of D. G., already described, page 8. In the epidemic of 1839, when the ardent form prevailed, and also in 1842, blood-letting was had recourse to at the commencement of the attack, with great benefit, and, in some pases, to a very large extent. Our assistant, Dr. C, lost about 60 ounces of blood, and my son not much less ; and, iu a few days, they were both convalescent. However, it is only within the first twelve hours from the commencement of the hot stage, that this bold. treatment is admissible. If the congestion iu the capillary system is not removed by the early and decided use of ihe lan- cet, the biood soon becomes, so disorganised, and the tone of the extreme vessels so destroyed, that the loss of even, a few ounces cannot be borne with safety. Case x. Mr. C, aged 23, a native of England, had been about six weeks iu the island, when he was attacked with symptoms of yellow fever, op the 8th October, 1842. He had been confined to his bed, and under treatment for a sprained aukle, for some days previously, so that the first nyelye hours of the lever were overlooked. On the morning of the 9th he was bled ; but a tendency to syncope occurred before eight ounces ot blood had flowed. His pulse was never above 90. Ou the 10th, he had black vomit, and the stage of collapse commenced. His skin was yellow and mottled with hvid spots. Wine and porter were given liberally, and for a nine he appeared to be recovering his strength ; but on the even- ing oi the 11th, the wound in his aim burst out bleeding, which was not observed till his pulse was nearly extinguish- ed. He died at midnight. In the asthenic form, blood-letting was of course never thought of; and in the congestive, 1 never had the courage to make the trial. In the latter momeuts, diffusible stimulants, rubefacients, and blisters, were the remedies used ; but they were generally as ineffectual as if they had been applied to a dead body. During convalescence, quinine was always administered, 22 to the extent of six or eight grains of the disulphate daily ; and the dietetic regimen required the utmost attention. APPENDIX. Tha foregoing essay was written in the early part of 1849. and presented to the Faculty of Medicine in the University of Glasgow, as a graduation thesis. On my return to Anti- gua in November of that year, I found that yellow fever was prevailing amongst the European troops to a roofet fatal ex- tent ; the surgeon and many of the men of the 64th Regiment having fallen victims. On this occasion, it was remarkable that the civilians, unconnected with the garrison, were entire- ly exempt from the epidemic. Indeed, the poisonous atmos- phere appeared to be confined within very small limits, being confined to the Ridge, the chief military station, situated on the south-east part of the island, on a hill of 800 or 900 feet elevation, bounded by the sea on the east and south, and over- looking English Harbour and the Dockyard on the west. The northern boundary is occupied by an extensive tract of uncultivated land, covered with thickets of brushwood. Af- ter a time, the troops were removed, and placed under tents at Monk's Hill, an old military post about four mileS to the westward of the Ridge, and about the same elevation. It presents an abrupt precipice to the south, which shows it to be composed chiefly of trap breccia and conglomerate; cap- ped by a stratified rock of a beautiful sea-green colour, con- taining crystals 6f atigite and other minerals* Here the dis. ease gradually abated ; but it was some weeks before the poi- son imbibed at the Ridge was entirely eliminated from the Bystem, as cases occurred among the men daily for some time after their removal. One officer, who was on a visit to a gen- tleman in the neighbourhood of St. John's fell under our care. He was hied by my son at the very onset of the attack, and treated with active mercurial purgatives and saliue refriger- ants and diuretics. On tbe third day he was convalescent, and taking quinine ; the only symptom of disease remaining being a remarkably slow pulse. Another officer, a youn<* * This rock was mistaken by Dr. Chisholm many years ago for an ore of copper, and formed the basis of his theory of fish poison —Edin. Mtd. and &u/y. Journal, vol. iv, p. 393. S3 Irishman of gigantic stature and robust frame, was seize" whilst on dutv at Monk's Hill. Having witnessed the spee- dy recovery of his comrade, he was most anxious to come to town to he placed under our care At length the colonel yield- ed to his wishes, and he was conveyed in a four-wheeled car- riage, accompanied by an assistant surgeon. When I saw him, it was too late for general bleeding ; but his intense headache, ferret-like eyes, and bounding pulse, in- duced me to have him cupped on the nape of the neck. This produced apparent relief ,* but the case was attended from the first with an obstinate diarrhoea, which resisted the use of calomel and opium, acetate of lead, and similar remedies. Nevertheless, he survived the critical days on which death Usually occurs, and we began to entertain hopes that he might struggle through it, when suddenly he was attacked with de- lirium, the stools assumed the colour and appearance of black vomit, and he died on the ninth day. A melancholy case occurred in the family of an engineer officer, who was about to return to England in the next steam- er. He fled to St. -.John's with his wife and daughter a young lady in (he full blo^m of health and beauty. A day or two af- ter her arrival in the city, this young lady was attacked with the disease, and died on the fifth day. Five artillerymen were removed to the barrack in St. John's on the 30th November. Next day two of them sickened i and the following day the three others. They were under the care of my friend Dr. Furlonge, who has published an account of them in the Lancet for.1850.~One died on the fifth, and another on the seventh day ; the rest recovered. I have heard much (Wing the la°t three years of the suc- cessful treatment of yellow fever in Demeraiaby large doses of quinine and calomel ; twenty four grains nf the former and twenty grains of the latter being the usual dose. This prac- tice is so contrary to what I consider the rational treatment °f ardent fevers, that I could not in my conscience adopt it in such cases. I might venture to try it in the congestive form of the disease ; and perhaps that is the type most prevalent in the swampy colouies of Guiana. Dr. Blair has had ample Opportunities recently of testing the efficacy of this empirical treatment; and the profession may u justly claim from him a report of his extended experience, li i» to be hoped, also, that he will publish the result of ano- ther experiment he has been making, with the view of pro- tecting individuals from the disease by administering bella- donna as a prophylactic. Yellow fever broke out in Antigua on the 15th of May, 1853 * in the person of a delicate female, a native of Scotland, who had been only eighteen months or two years in the is- land. This case was reported to me by an express from my son, when 1 was at St. Kitt's, whither 1 bar gone for change of air, having suffered for some months from a severe attack of acute rheumatism. No other case occurred fpr several days $ but when 1 arrived, on June 3rd, I learnt that my son had two other cases on his list ; one, a young Scotchman, who resided not many yards from the house in which the firs-i case occurred ; the other, an army surgeon, living in another part of the citv. Both these proved fatal on the fifth diy, with, black vomit. Cases were now added daily to the list till the end of July, our last case having proved fatal on the 3]st of that month. The following table contains an abstract of all the cases which I attended myself, or with my son, exclusive of those I saw in consultation with other medical men : — Itace Recovered. Died. Total Europeans. . ■ .Adults ...... 23........' 9......32 White Creoles-Adults...... 3........0...... 3 „ Children...... 6........2...... 8 Mixed race... .Adults ...... 0........0...... 0 Children .... 5........ 1 ...... 6 American................ 1.......0...... 1 Portuguese................ 2.,...... 1 ...... 3 40, 13 53 The type of this epidemic, in all cases that came under my observation, was certainly that of the ardent form. I did not meet with a single case of the apyretic or congestite type, such as I have witnessed in former epidemics. The patient wts most frequently seized in the morning. No decided rigor May is usually tho healthiest month in the year. 25 was observed, but he awoke with a feeling of having slept heavily, as if from a narcotic. This was immediately follow- ed by intense headache and pain iu the back ; the vessels of the conjunctiva became injected and red ; the force and ve- locity of the pulse great; and the heat of the surface pungent. At this period, the tongue presented no unusual appearance. About the third day, the febrile heat subsided ; the cheeks, which had been of a florid red colour, assumed a darker hue ; the lips were red, and the gums spongy and very vascular; the hands and nails became livid, and, when pressed upon, it was long before the blood returned to the cutaneous vessels. By-and bye, a yellow tinge was perceptible on the conjunc- tiva, and on each side of the nose, which spread gradually over the neck and chest. Haemorrhage from the nose ant1 mouth uow took place ; flatulency was very distressing ; an( the vomiting, which was distressing from the first, now be came more urgent, and, in the fatal cases, the matter ejected was mixed with dark flakes, like the lees of port wine, which gradually became blacker and more copious till death closed the scene. In those cases which terminated favourably the discharges from the bowels were copious, and of the darkest sap-green ; and the urine was abundant, and of a good co- lour. In fatal cases, the motions had not the slightest tinge of green or yellow ; and they exhaled an offensive odour like putrid albumen. In those cases, the urine was frequently suppressed and symptoms of uraemia were more or less ap- parent. None of the cases in my own practice presented unequivo- cal marks of petechia) ; but a military officer, under the care of Dr. Fmlonge, was spotted like a leopard from head to foot: even the mucous membrane of the mouth exhibited the same symptoms of extravasation. Death occurred most frequently on the fifth day ; one died on the fourth day, two on the sixth, and one on the seventh day. In those cases in which the urinary secretion was not suspended, death took place by asthenia ,• the patient retain- ing his intellect till the last. When uraemia existed, convul- sions and coma preceded death. • From a variety of causes, no post mortem examinations were made. *6 Treatment. When I artived, I found the lancet had not been used in any case ; but purgatives, and five grain doses of quinine, frequently repeated; with the usual auxiliaries, Were chiefly confided in. The quinine so administered ap- peared to me decidedly injurious, and it was abaudon?d. In simple cases, where there was no symptom of local con- gestion or inflammation, purgatives of calomel, colocynth, and ja!ap, saline refrigerants, and effervescing draughts, formed the chief medicinal treatment. In more severe casss, five grains of calomel were interposed every two hours. The cold douche was always most agreeable to the patient, and was constant- ly had recourse to in the first stage. When the headache continued beyond the second day, blisters Were applied to the neck or forehead with good effect. In all cases in which at my first visit there were symptoms of cerebral or hepatic]congeStion, or when the force of the cir- culation was so great as to threaten destruction to the capil- lary system, 1 had recourse to blood-letting ; and, if we may judge of the propriety of the operation by the rules laid down by Dr Marshall Hall, we must decide in its favour, although it did not always cure the disease. The loss of blood was well borne in every case. In one patient only was syncope induced, after the loss of twenty-fottr ounces, and he rapidly recovered. In all the other cases a much larger quantity of blood was drawn, whilst the patient was in the sitting pos- ture, and syncope did not occur. The effect produced was vomiting, copious perspiration, bleaching of the eyes, and re« lief of the headachs. When permanent reduction of the pulse followed these effects, the case invariably did well; but when the velocity of the pulse continued, the case proved a bad one, and, in my opinion, would have resisted every kind of treat- ment. To prove that blood-letting did not do harm, I would men- tion that it was had recourse to only in the worst cases, and yet not one of these died before the fifth day, whilst two of them lived till the sixth, and one till the seventh day. Of twelve cases in which the lancet was used, six recovered, and six died. In no case was the operation repeated ; and it is a question whether the advocates of this practice would not have deemed it right to repeat the operation at a short inter- 27 val, when the pulse continued quick. But the prejudice whi.-h has been excited by modern writers against large detractions of blood in fevers deterred me. Having lost in succession four cases in which blood-letting was performed, eith?r by myself or in my prm-mre, with all the immediate effects which follow a succps«ful operation, I considered that I was then bound conscien'iously to try the empirical or abortive treatment, with largp doses of quinine and calomel, as recommended by Dr Blair of Demerara. Tba first case that occurred for this trial was that of a young Scotchman, who had recently come to the island. The e~- cond dose produced great congestion of the bruin, and a stu- por from which he could scarcely be roused, and he died on the fourth day. Nevertheless, our next case was treated in the same way, with twenty grains of calomel and twenty-'* ur grains of quinine. Great drowsiness was the immediate re- sult, and we were deterred from continuing the practice, v.'o resumed our former mode of treatment, and the patient reco- vered. ^ It is unnecessary to enter upon the treatment that w,s pur- sued after haemorrhages and black vomit occurred ; for i have no confidence then in any medicinal astringent, or in any- thing hut the most diligent exhibition of diffusible stimulants-. Patients have sometimes recovered after all hope was aban- doned. This was the case with two seamen, who were land- ed lure from a ship bound from St. Thomas to Barbadoes. They were in the last stage of the disease, with haemorrhages from the nose, mouth, and anus, and black vomit, when ad- mitted into the Infirmary. Sulphate of alum with quinine, tannic acid, and acetate of lead, were successively prescribed ', but I discovered that they took nothing freely except theis wine. NOTE TO PAGE 24, LINE 5. These remarks with regard to the abortive treatment with quinine -were written in January 18*3 ; since then Dr. Blair has fully respoiule-l »o the call and has published in the January and Anril numbers of the Lutish andForeign Medico Chirurgical Review an elaborate report on the !a?t epi- demic in Guiana ; in which he has availed himself of the most recent im- provements in chemical and physical science in investigating. a.id describ- ing the phenomena of the disease ; and has arrived at the following hypo- thetical conclusion.-" The efficient cause of the disease kno-n rs yellow fevr la an nerial poison, probably organic, which requires a certain tern- 28 perature for its generation and existence, and affects special localities and persons. This poison attaches itself to the mucous surfaces of the human body. One of the primary effects of such contact, when the quantity is ade- quate, is to rouse the system into febrile reaction, and to excite through the stomach and intestines an effort to expel the noxious agent. There is rea- son to believe that this expulsory effort is sometimes successful unassisted, but is materially aided by the action of certain medicinal substances. In the event of the expulsory effort being unsuccessful, the effect of ttiis poison is to act destructively on the epithelial structures of the body by inducing a specific irritation in the basement membrane, by which, and by allied con- secutive lesions, the arterial and capillary tissues are impaired, the viscera become congested, the blood thereby contaminated by suppressed secre- tions, and fatal haemorrhage! eusue.' NLM041426948