to all appearances healthy, although sometimes it is greatly inspissated. The weight of evidence is, however, quite the other way. Louis says: "It is fair to presume on account of the anæmic state of the liver, in individuals dying of the yellow fever of Gibraltar, that the secretion of bile was not abundant in the course of that disease. Very little of it was found in the stomach and small intestines of the subjects whom we have opened; and in the same cases, the gall-bladder contained less bile than is found in the victims of other acute diseases; and especially less than in those who have died of typhoid fever, where the bile is abundant, of a pale color, and of little consistence-characters the opposite of those found in the cases we are now studying, in all of which, with two apparent exceptions, the bile was thick, scanty, and of a dark green color." Dr. Arnold says: "In all cases that I have ever examined, with the exception of viscid bile in the gall-bladder, in vain did I ever look for the slightest trace of bile in the dead body. The same is true of the excretions during life. Perhaps there may be bile in the very beginning of the attack, before a physician is called; but in every case that has ever come under my notice, that has terminated in black vomit, the absence of bile from the excretions has been the distinctive characteristic of the disease."3 Dr. Nott, of Mobile, found the gall-bladder in fifteen of sixteen cases containing bile, varying in quantity from half an ounce to four ounces; of a pale green, olive, or black color, and its consistence ranging from that of water to that of tar. He adds: "The secretion of bile in this disease is almost invariably suppressed early; in severe cases, it is rarely vomited after the second day; and I believe I have never seen it after the third day, when they were fatal, except in one or two very protracted cases."4 Dr. Cooke, in his account of the yellow fever of Opelousas, speaks particularly of this arrest of the biliary secretion. Of all the phenomena of the disease, he considers this the most constant and characteristic. Mr. John McColme, in the letter already quoted, says: "The bile in the gall-bladder was of a deeper color, much thicker and more viscous than common; small in quantity, never exceeding an ounce; oftener from half an ounce to six drachms." Dr. Robert Jackson says: "The contents of the gall-bladder are changed, in

IN. O. Med. and Surg. Journ., vol. ii. p. 138.

Louis on Yellow Fever, p. 140.

Ibid., April, 1845.

115

almost every case of the concentrated yellow fever, into a thick black fluid, resembling tar or molasses." Dr. Devèze found the gall-bladder generally empty, but sometimes containing a small quantity of bile. In a few instances, the gall-bladder contains other fluids, or blood.

SEC. V.-Spleen; Mesenteric Glands; Urinary Organs. No one of these organs is the seat of any frequent or important alterations. Louis and Trousseau found the spleen somewhat softened in eight cases; but in half the subjects, it was entirely natural. [The spleen Dr. Bache found enlarged and softend in two cases only out of ten. The kidneys are reported by the same author to have had a natural appearance in four of thirteen examined, they were pale yellow in four, congested in three, and enlarged in one. Regarding the kidneys, Dr. Blair makes the following statements: "In cases which have terminated fatally after protracted illness, or apparent convalescence, the bloody condition of the kidneys has passed away, and the cortex is hypertrophied and of a dull ochrey color. But I have never been able to detect oil-globules in the kidney. The congestion of the kidneys during life seems to have been attended by no irritation; it is signalized only by albuminosity of the urine. The pain so often complained of in the loins is lumbar, and in many of the best marked cases, careful pressure failed to detect tenderness of the kidneys:" and again, " occasionally I have noticed the kidneys in an almost apoplectic state, and yet their function was scarcely interrupted; and on the other hand I have been disappointed in the amount of congestion in instances of entire suppression." He intimates that these points demand further investigation.]

ARTICLE IV.

MISCELLANEOUS LESIONS.

SEC. I.-Exterior of the Body; Muscles. In most subjects, the surface of the body is generally yellow. In three of the cases examined by Louis and Trousseau, this color was not present; and when the yellowness was not well marked, it was more so on the trunk, and about the head, than on the limbs; and in some subjects, it

1 Jackson on Febrile Diseases, vol. i. p. 79.

2 Traité de la Fièvre Jaune. Par Jean Devèze, p. 66.

was very slight over the whole extent of the limbs. Cadaverous muscular rigidity is generally strongly marked; and the muscles preserve their healthy firmness, color, and cohesion. [In Dr. Bache's fourteen cases the yellow color of the skin, varying in shade, was observed in all. Bloody discoloration of the dependent parts was noticed in thirteen, in the remaining one not looked for; rigor mortis in nine, not examined for in the others; yellowness of the conjunctiva in six, not looked for in the other eight.

"Inflammatory diseases," says Dr. Blair, "seem congenial to the action of the yellow fever poison, and during the progress of the disease we have frequently found them supervening as epiphenomena."]

ARTICLE V.

GENERAL REMARKS.

SEC. I.-Relation between Symptoms and Lesions. It is quite clear, I think, that the febrile symptoms-the chills, the heat of the surface, the accelerated pulse, and so on-cannot with any propriety be attributed to local inflammations, in any part of the body. In the first place, these inflammations, so far as we can ascertain from the lesions found after death, are sometimes absent; and, in the second place, we have good reasons for believing that the inflammations usually occur after the subsidence, or at least, after the partial subsidence of the febrile symptoms. Louis says the commencing coldness of the lower extremities usually coincides with the appearance of the black vomit, and probably depends upon this gastric hemorrhage.

There is no evidence of any special connection between the state of the tongue and that of the stomach. There can be no reasonable doubt, perhaps, that the vomiting in the latter stage, and near the close of the disease, is more or less dependent upon the lesions of the gastric mucous membrane, which have been described; but we shall be carrying our interpretation further than our facts will justify us in doing, if we attribute the vomiting, and the other gastric and epigastric symptoms, always and invariably, to the inflammation of this membrane. The grounds of this qualification are found in the fact already stated that, in a certain proportion of cases, attended like the rest by vomiting, the mucous membrane of the stomach presents no traces of previous inflammation. If it is alleged here, as it has been, that inflammation had existed, but that its results

had disappeared with death; our reply is, that the allegation is wholly gratuitous; and that we have no right, in the absence of positive facts, to indulge in assertions which are necessarily more or less conjectural. In relation to the particular question before us, it is, at least in the actual condition of our knowledge, more philosophical to refer the vomiting, as we have referred the production. of the matter itself of black vomit, partly at least, to some anterior and more specific morbid condition, the precise nature of which is yet wholly unknown. Similar remarks may be made in regard to the loss of appetite, the thirst, the epigastric distress, and the general restlessness, so common towards the close of fatal cases. None of the symptoms can be referred, with entire constancy or uniformity, to the appreciable lesions of the organs making up the pathological anatomy of the disease.

According to Louis, the colicky pains of the abdomen, which are present in a certain number of cases, often coincide in their appearance with the discharges of black matter from the bowels; so that they are probably occasioned by the presence of this matter. The yellow color and anæmic condition of the liver do not reveal themselves by any characteristic symptoms during life. It is reasonable, however, to attribute the absence of bile from the gastro-intestinal discharges to the morbid condition of the liver.

I am not aware that the suppression of urine, which is occasionally met with, has been found connected with any appreciable alteration of the kidneys. [The discovery of albuminuria, as a common attendant on yellow fever, will, however, stimulate new inquiries on this point, and call in the aid of the microscope.]

The headache which so constantly attends the early period of yellow fever, as well as the other local pains, must be regarded as purely nervous phenomena, in no way dependent upon any appreciable alteration of the cerebral, or the cerebro-spinal apparatus; and the same thing is true of the delirium and coma which are occasionally present towards the close of the disease. These latter symptoms are as common in cases where the brain is free from any alteration as they are in cases where the lesions are found. For similar reasons, none of these symptoms can be referred directly to the inflammation of the stomach, or to any other of the local lesions.

It is very natural that we should refer the yellowness of the skin. to the morbid condition of the liver, and perhaps this explanation of the phenomenon is more rational than any other. It is quite

clear that, in most cases, and it may be in all, there is, early in the disease, a suspension of the functions of the liver, and it is a very reasonable conclusion that the two phenomena are connected. It is well to remember, however, that the yellowness of the surface is frequently preceded by a more or less intense sanguineous congestion of the skin, and that the discoloration may depend upon some modification in the condition of the blood, or the action of the cutaneous capillaries, or both, quite independent of the state of the liver. The tendency to hemorrhage depends also, probably, upon the altered state of the blood.

The hemorrhagic spots and masses in the tissue of the lungs do not often indicate their presence by any symptom during life-a fact that furnishes us with another lesson, if any such were needed, of the danger of trusting, in any degree, to what we call analogies, or à priori probabilities, however reasonable and plausible these may seem to be.

There is no proof that the character of the pulse is dependent upon any appreciable morbid alteration of the heart.

SEC. II. Causes of Death. The present seems to me as appropriate a place as any for a few remarks upon the causes of death. Keeping myself, as I have always endeavored to do in these interpretations, strictly within the authority of well ascertained phenomena, what I have to say must necessarily be rather approximative and conjectural than positive in its character. Considering the rapidity with which the changes in the liver and in the mucous membrane of the stomach take place, it is not unreasonable to suppose that, in a certain number of cases, these changes, together with the hemorrhagic effusion, play a very important part in the destruction of the patient's life; they may, perhaps, of themselves, be considered as adequate causes of this result. The relative agency and importance of each of these phenomena it would be an idle labor to attempt to ascertain. There are many cases, however, especially such as are attended with but slight lesions or with no appreciable lesions of the stomach, in which it seems to me more philosophical to look elsewhere for the causes of death; and in which, if our knowledge was sufficiently accurate and extensive, they would probably be found in the altered state of the blood, and in other immediate and remote effects of the unknown etiological poison of yellow fever upon the different tissues of the body. The analogies of many other diseases, especially such as are of a