solutions have not been rewarded by such results as to establish in
any degree their special efficacy.
In all ordinary cases the expectant treatment recommended by Zuelzer
is abundantly to be commended. The inflamed tissue is to be dusted
with finely-powdered starch, and protected by a layer of soft
cotton-wool which exercises a moderate degree of pressure upon it.
Antiseptically, the highest ends are thus reached.
The diet of the patient should consist of animal broths, soups, milk,
and eggs, with a view to the reparation of the waste incidental to the
febrile process. Stimulants are to be freely used in all asthenic
conditions. In convalescence the warm water and soap bath is to be
employed, followed by dusting of the surface with starch powder or by
inunction with vaseline.
{640}
YELLOW FEVER.
BY S. M. BEMISS, M.D.
Yellow fever is a specific, infectious, and communicable disease of
one febrile paroxysm.
This definition includes some of the most prominent characteristics of
the disease. The malady, however, derives its name from a symptom not
mentioned in the definition. The yellow color of the skin and
scleroticæ which appears in advanced stages of grave cases of yellow
fever, and which becomes especially marked in the cadaver, has ruled
its nomenclature. Whatever objections may be urged against the term
"yellow fever" as being founded upon a symptom of the disease not
always present, it is too strongly fixed in both medical literature
and popular usage to justify efforts to change it.
Neither is it liable to beget confusion as long as it is understood
that it is to be restricted in its application to a specific fever
induced by a specific poison, and that as an incident of its morbid
process it produces yellow coloration of the surface so frequently as
to suggest the prefix yellow to its title.
ETIOLOGY AND SYMPTOMATOLOGY.--In this day of almost general belief in
the theory which holds that each specific disease has its own specific
poison or morbific germ, it is scarcely expedient to occupy much space
in discussing the propriety of classing yellow fever among the
specific maladies.
Whether we rest the decision of this question upon the uniformity of
those circumstances and conditions which originate and develop
epidemics of yellow fever, or upon the sameness of its symptomatic
phenomena wherever observed, we find very nearly as substantial claims
to a specific individualization of the disease as any one of the
eruptive fevers possesses. Not only are its morbid phenomena so
characteristic that even non-professional observers designate it by
such epithets as Bronze John, Yellow Jack, Vomito Prieto, etc., but it
is inconvertible with other specific affections. This inconvertibility
of yellow fever with other diseases is absolute, and affords
irrefrangible evidence of the specificity of that germ or poisonous
principle which produces it.
The study of yellow-fever poison after the objective method has
hitherto been unproductive of definite results. When such experienced
and truthful observers as Sternberg, Woodward, and Schmidt, working
with the most approved microscopes, have failed to identify any
organism or object peculiar to the products from the bodies of
yellow-fever subjects or to the circumfusa of the sick, this
declaration is sufficiently supported.
{641} But when we turn to a subjective method of investigating that
toxic agent which causes yellow fever, it is found to possess
sufficiently well-marked characteristics to justify practically
valuable conclusions. Some of these characteristics or modes of
behavior merit notice.
1st. The human system is a field of reproduction and multiplication of
yellow-fever poison. This is sufficiently established by two facts:
(_a_) A person in the incubative stage of yellow-fever intoxication
may be divested of all fomites and yet originate other cases after a
developed attack.
(_b_) The infection is intensified by aggregation of the sick.
These propositions are indisputably true.
2d. The poison or infection undergoes some change after leaving the
human system. This appears to be susceptible of proof, because
communication of the disease from person to person is not a common
event. When this does apparently occur, there is often very strong
reason for a belief that the contagion was resident in some fomites
connected with the patient's bed or clothing.
3d. There are no sustained observations which prove that yellow-fever
poison is ever created de novo.
The autochthonous birthplace of the poison is unknown. The suggestion
of Niebuhr, that yellow fever may have been one of the causes of death
during the plagues of Athens, can not be authoritatively denied. It
may have been called into existence at the moment when all things else
were created which were to perpetuate each its kind.
4th. Some of those conditions and circumstances which favor or retard
the development or maturation of yellow-fever poison outside the human
body are quite well understood. Warm, damp weather is most prominent
among those climatic conditions which are favorable to the growth of
yellow-fever epidemics.
5th. A freezing temperature ordinarily destroys the contagium of
yellow fever. A high degree of artificial heat produces a similar
result. It is highly probable that certain chemical agents would also
effect its destruction if brought in contact with it.
6th. If yellow-fever fomites are hermetically enclosed in situations
protected from cold or other agents which are destructive to their
infection, its vitality may be preserved for an undetermined length of
time, and its toxic qualities again made manifest when unacclimated
persons are exposed to it.
7th. Yellow-fever poison possesses ponderability. This characteristic
is so distinctly marked that it has been frequently termed a
"low-lying poison."
8th. It is incapable of being air-borne through any great distance, at
least without being deprived of its toxic effects.
9th. It is transportable in fomites through great distances, either on
sea or land, and as often as its toxic effects are manifested after
these portations they are so uniform as to be promptly recognizable.
A great number of different materials in common use may act as
fomites, such as loose wool, cotton, or hair, or textile fabrics of
various descriptions.
The following facts, which illustrate how yellow-fever infection may
be conveyed in the most unsuspecting and innocent manner, are well
{642} authenticated. There can be no ground for accusation of error
except in the hypothesis that the infection was encountered
simultaneously in some unexplained manner. The facts are furnished by
Dr. Shannon of Ocean Springs, Mississippi: "On the 14th of October,
1883, Maj. J. B. B. died of yellow fever in Ocean Springs, Miss. I
moved the family at once to the healthy locality where you saw Miss
B., not allowing them to take any article from the room where the
husband and father had died. The children applied to me for a lock of
their father's hair, which I refused, but the oldest daughter, now
dead, prevailed upon the nurse to give it her. She placed it in an old
envelope that had been torn open at the end and carefully folded the
torn end down, thus practically sealing it, and laid it away among
other old letters. On Sunday, the 4th of November, at 12.30 P.M., she
brought this envelope out upon the open gallery, and opened it for the
first time to examine the lock of hair and show it to her aunt, Miss
S., who was visiting her, and upon inhaling the concentrated poison
confined in the envelope and emanating from the hair, exclaimed, 'Oh,
what a peculiar smell!' She then handed the envelope to her aunt, Miss
S., who, unconscious of danger, also inhaled the 'messenger of death'
with a similar exclamation, when Mrs. B., who was standing near,
reached out her hand for the envelope, but was prevented from getting
it by the entreaties of a fretful child to be taken up in her arms.
This gave time for sufficient reflection, and she admonished the young
ladies of the possible danger. The envelope was then carefully folded,
and with its fatal contents replaced in the drawer where it had been
since the 14th of October. This drawer had been almost daily opened.
On the following Saturday night, Nov. 10th, at 9 P.M., Miss S. was
taken sick with a chill, and Miss B. at about 2 A.M., some five hours
later, the period of incubation being less than seven days in both
cases. No other person handled the fatal envelope or in any way came
in contact with it, and there is, after the most careful inquiry, no
suspicion of any other source of infection in these two cases. Miss S.
died on Oct. 14th, Miss B. on Oct. 16th."
10th. These qualities of yellow-fever infection, and especially its
faculty of reproduction (which only organisms possess), furnish almost
conclusive evidence that yellow fever is a germ disease produced by a
specific contagium vivum.
Many facts are patent which sustain the generally accepted opinion
that yellow-fever poison gains admission to the system through the
medium of atmospheric air. On the other hand, I know of no
observations which prove that the disease is ever communicated by food
or drinks, or through any other vehicle than atmospheric air.
In respect to atmospheric infection by yellow fever, localizations of
aërial impregnation are often observable, not common in other
air-infecting diseases. A certain district of a large and populous
city may become the seat of a sweeping and fatal epidemic, and yet no
case occur outside of this area of prevalence. It is customary to
speak of these points of epidemic prevalence as infected localities.
If unprotected persons visit such infected places, even for a short
period of time, they are liable to attacks of yellow fever, although
they may take neither food nor drink within the limits of infection
and bring no fomites away with them. Under these circumstances
atmospheric impregnation is conclusive.
{643} But it is difficult to determine how this infection of a
locality has been produced in the first place, and how, in the second
place, it is maintained sometimes for periods of from one to three
months, with so little apparent diminution or change in the liability
to communicate yellow fever to unprotected visitors within the limits
of infection.
It seems highly probable that yellow-fever poison, after its exit from
the human body, attaches itself to various solid surfaces in proximity
to the sick, where, under suitable climatic conditions, it undergoes
more or less speedy processes of maturation in toxic qualities. The
poison thus matured is capable of being preserved with but little
change for the periods indicated above, and is communicable through
the atmosphere for short distances. It is also capable, by virtue of
some unexplained process or quality, of spontaneously extending its
area of infection. But this is at all times slow, and is readily
interrupted by streams of water, high walls, or even by much-travelled
thoroughfares.
There are no instances in which the water-supply of cities has been
shown to have distributed yellow fever.
The periods of time which may intervene between exposure to
yellow-fever poison and attacks of the disease are extremely variable.
The shortest period of incubation which has come under my observation
was about twenty hours. In three cases in which I was able to fix the
hours of first exposure with precision attacks followed in 72 hours,
83 hours, and 101 hours, respectively. Of 55 unacclimated physicians
who exposed themselves at Memphis during the epidemic of 1878, 54
suffered attacks of yellow fever. In these cases the periods of
incubation varied from one to twenty-five days, the average duration
being ten days. These physicians all remained steadfastly at their
posts of duty; consequently, the attack which occurred on the
twenty-fifth day was postponed for that length of time during constant
exposure in a locality most intensely infected.
It must be true that many cases of individual resistance to the
effects of yellow-fever infection depend upon states of the system or
idiosyncrasies which diminish liability to the action of the poison.
In other words, their personal receptivity to it is lessened by
certain constitutional states.
That this position is correctly taken is proved by the fact that many
circumstances which violently disturb the system determine attacks in
persons who may have for a long time enjoyed immunity from them.
Anxiety, grief, fright, fatigue, or exposure to sudden wettings or
cold may precipitate attacks, either by disturbing vital processes by
which the system is ridding itself of the poison--so far, at least, as
to prevent an accumulation great enough to occasion attacks--or by
lowering powers of resistance through enfeeblement of nerve-force.
But it can be affirmed in regard to yellow-fever poison that it is not
more capricious or eccentric in its behavior as an infection than that
of scarlet fever. Each of these diseases may appear in a large family
of unprotected persons with a degree of violence which results in
death in every instance, and suddenly cease, leaving a greater or less
number of the household without attacks, though equally exposed with
those who have died.
One attack of yellow fever confers immunity from the disease during
after life. A person who has suffered an attack is said to be
acclimated {644} or protected. Neither of these terms should be
applied to those who have not suffered attacks, however long they may
have withstood exposure during epidemics. It often occurs that persons
who have escaped attacks through many years of renewed exposure at
last succumb to the disease. On the other hand, I know of three
well-authenticated instances of immunity in a sweeping epidemic of
persons whose mothers had suffered attacks during the gestations which
respectively resulted in their births.
While negroes are susceptible to yellow-fever infection, attacks are
far less fatal than among whites.
SYMPTOMS IN MILD OR SIMPLE CASES.--Yellow fever is usually sudden in
its onset. Persons are liable to be seized while pursuing their
ordinary avocations, or, as often occurs, the attack may begin during
the night. The initial symptoms are chilliness or cold sensations,
seldom amounting to a decided rigor. Reaction is usually prompt and
decided, the temperature reaching within a few hours 102° to 105° F.
Yellow fever is not a disease in which it is very common to observe
excessive body heat.
As the fever is established, the countenance becomes flushed and the
eyes injected and glistening. Frontal headache and lumbar pain are
experienced very early in the attack, and are liable to become more
intense during the progress of the fever. Muscular neuralgias,
especially in the lower extremities, are not uncommon.
During the early period of the attack the tongue is indifferent as a
symptom. It is generally moist and free from any coating. In cases
attended by much furring of the tongue careful investigation is pretty
sure to disclose the fact that it has been brought about by some
pre-existing state of disease.
The bowels are generally inactive, though naturally impressible to
cathartic drugs. The stomach is querulous from the inception of the
attack to its conclusion. Vomiting may not occur spontaneously, but it
is easily provoked by repletion of the stomach with any description of
ingesta or by harsh or disgusting medicines. The acts of emesis are
sudden and short in duration. Bile is a very uncommon constituent of
the matters ejected. Whether vomiting has occurred or not, patients
nearly always express repugnance to the weight of the physician's hand
over the epigastrium. In the very mildest cases it seems to excite
gastric distress and a tendency to emesis. The stomach and bowels are
liable to distension by flatus, sometimes to the extent of producing
colicky pains. Gaseous eructations are common.
During and shortly succeeding the cold stage the urine may be somewhat
increased in amount, but after the fever is established both the
quantity and the specific gravity are notably lessened. Albumen seldom
appears in the urine during the first twenty-four hours of an attack.
In very mild cases it is altogether absent throughout.
Delirium is not unusual during the fever. Among children attacks are
often ushered in by convulsions. In such cases delirium may be
persistent and alarming in violence.
The pulse in the early stage of yellow fever is slower in proportion
to the temperature than in most other acute diseases. This is more
especially true in respect to mild cases. Another characteristic
feature of the pulse in {645} yellow fever is that it declines in
frequency before the fever has reached its maximum. In the mildest
forms of the disease the temperature will attain its highest record
within twelve hours. It then rapidly defervesces, never to return
again. But in some cases of a moderately mild form the body heat does
not reach its acme of intensity until the second day, occasionally not
until the third or fourth day. In these cases also the pulse is apt to
decline in frequency before the fever has culminated. There are
therefore no fixed laws which govern the duration of the hot stage of
yellow fever. Those which relate to the pulse are more uniform.
The following clinical reports of two cases support this statement.
The detailed account of the symptoms establishing their diagnosis as
mild cases of yellow fever is omitted.
Susie W----, white, aged seventeen years, was admitted to Charity
Hospital on August 28, 1878. First observation, nine hours after the
beginning of the attack, pulse 100, temperature 104.6°. Morning of
29th, pulse 94, temperature 102.8°; evening, pulse 80, temperature
101.5°. Sanguineous discharge from vagina began on 29th; patient
supposed it to be her proper period. Aug. 30th, pulse 80, temperature
99.2°; convalescent and dismissed from further observations. In this
case the urine presented a trace of albumen early on the second day,
but as the menses appeared shortly after the urine was obtained, the
presence of albumen may be in that manner accounted for.
Bessie L----, white, age twenty-seven years, admitted to Charity
Hospital on August 28, 1878. First observation, twelve hours after
beginning of attack, pulse 100, temperature 100.6°. 29th, pulse 76,
temperature 102.3°. 30th, pulse 64, temperature 101.5°. Sanguineous
discharge from vagina began on 30th and continued until Sept. 4th;
this was two weeks before the patient's regular period. The urine
showed traces of albumen at date of admission. Discharged, cured, Aug.
31st.
It may also be stated of the pulse of yellow fever that it is easily
compressible and often gaseous in character.
Perspiration is probably an incident in the natural clinical history
of a case of yellow fever. It occurs spontaneously if the patient's
surface is protected from those influences which conflict with its
appearance. It is not critical in any sense of the word, and may
coexist with high temperature.
Yellow fever is considered to have two clinical stages. The first is
the paroxysm. This is made to include the cold stage and succeeding
fever. The cold stage is often almost or quite inappreciable, and when
this is not the fact it is in simple cases a very unimportant event.
It is therefore quite convenient to include it with the fever under
the term paroxysm. The paroxysm of a simple case is terminated by a
subsidence of the fever to nearly or quite a normal temperature.
Sometimes the temperature falls below the normal standard.
The neuralgias and subjective sufferings are greatly mitigated or
cease altogether. Thirst and restlessness are relieved, and the
patient sees before him a delicious, but too often treacherous, mirage
of restoration to perfect health. This is termed the stage of calm,
perhaps because it often precedes a tempest of fatal symptoms.
In mild cases convalescence begins at the termination of the paroxysm,
and may proceed without interruption until complete re-establishment
of {646} health has been accomplished. But in the very mildest cases
the process of recovery is easily interrupted.
In these simple forms the tendency to hemorrhage first manifests
itself in the calm stage. The gums become red, tumid, and spongy, the
tongue pointed and red at the tip. Epistaxis is liable to occur. The
eyes and skin may be slightly yellow, and the urine may show traces of
albumen. However mild the other symptoms may appear, the tendency to
hemorrhage, to albuminous urine, and to jaundice in the calm stage
bears a direct relation in frequency of occurrence and in degree to
the blood-stasis, or sluggish capillary circulation, of the first
stage.
The foregoing is a recital of the clinical phenomena of typical and
simple forms of yellow fever. The departures from type have been
divided by different writers into a variety of forms. The most
important of these will be referred to in connection with suggestions
as to treatment.
PROGNOSIS.--Prognosis is variable in different epidemics, this
observation being understood to apply to the same localities. Some of
those circumstances which affect epidemic force, so as to increase the
mortality-rate, are appreciable. If an epidemic invades a population
after an interval of exemption sufficiently long to allow a large
number of unprotected persons to have accumulated in its midst, the
crowding of the sick will increase the death-rate. We may naturally
assume that this is attributable, first, to sheer multiplication of
the infection; second, to lack of proper attention to the sick, and to
fright, grief, exhaustion, etc.
_Tabulated Abstract of Practice in Yellow-Fever Epidemic of 1878, New
Orleans Charity Hospital._
---------+---------+-----------+-----------+---------+-----------+-----
AGES. | July. | August. | September.| October.| Total. |
---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------
| N | N | N | N | N | N | N | N | N | N | P
| o | o | o | o | o | o | o | o | o | o | e
| . | . | . | . | . | . | . | . | . | . | r
| | | | | | | | | | |
| t | f | t | f | t | f | t | f | t | f | c
| r | a | r | a | r | a | r | a | r | a | e
| e | t | e | t | e | t | e | t | e | t | n
| a | a | a | a | a | a | a | a | a | a | t
| t | l | t | l | t | l | t | l | t | l | .
| e | . | e | . | e | . | e | . | e | . |
White. | d | | d | | d | | d | | d | |
| . | | . | | . | | . | | . | |
---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------
Under 5 | .. | .. | 7 | 3 | 3 | 1 | .. | .. | 10 | 4 | 40.0
5 to 10 | .. | .. | 2 | 1 | 1 | 1 | .. | .. | 3 | 2 | 66.66
10 to 20 | 8 | 3 | 26 | 7 | 25 | 6 | 7 | .. | 66 | 16 | 24.2
20 to 40 | 18 | 9 | 246 | 141 | 175 | 91 | 61 | 24 | 500 | 265 | 53.0
40 to 60 | 9 | 6 | 75 | 45 | 83 | 45 | 18 | 10 | 185 | 106 | 57.3
60 to 80 | 2 | 2 | 7 | 6 | 5 | 1 | 1 | 1 | 15 | 10 | 66.66
---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------
Total. | 37 | 20 | 363 | 203 | 292 | 145 | 87 | 35 | 779 | 403 | 51.7
---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------
Black. | | | | | | | | | | |
---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------
10 to 20 | .. | .. | 2 | ... | 5 | ... | 1 | .. | 8 | ... | ...
20 to 40 | .. | .. | 11 | 3 | 8 | 1 | 5 | 1 | 24 | 5 | 20.8
40 to 60 | .. | .. | 2 | 1 | 1 | 1 | 3 | 1 | 6 | 3 | 50.0
---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------
Total. | .. | .. | 15 | 4 | 14 | 2 | 9 | 2 | 38 | 8 | 21.0
---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------
Grand total. | 817 | 411 | 50.3
-----------------------------------------------------+-----+-----+------
{647} Prognosis is especially bad in hospital practice. The foregoing
statistics of cases admitted to the Charity Hospital of New Orleans
during the greater part of the epidemic of 1878 illustrate the usual
results of hospital practice.
Many of these patients were conveyed to the hospital in extreme
conditions; occasionally they were moribund on admission. It is
hazardous to the life of a yellow-fever patient to transfer him over
the rough streets of a city, often for two or three miles, unless this
is done in the very earliest hours of the attack.