the moment of attack. If pregnancy exists or delivery has just
occurred, it is, under most circumstances, extremely unfavorable.
Fatigue, anxiety, despair, or grief, all render prognosis more gloomy.
The march of temperature is also important in determining fatal
results.
The following statistics show the influence of temperature in relation
to mortality from yellow fever:
|First| |Second| |Third| |Fourth| |Fifth|
| day.|Died.| day. |Died.| day.|Died.| day. |Died.| day.|Died.
-----+-----+-----+------+-----+-----+-----+------+-----+-----+-----
106° | ... | ... | 3 | 2 | 1 | 1 | 2 | 2 | ... | ...
105° | 9 | 3 | 5 | 4 | 2 | 5 | 2 | 2 | 2 | 2
104° | 18 | 10 | 23 | 13 | 8 | 3 | 2 | 2 | 3 | 2
103° | 14 | 4 | 11 | 8 | 2 | 2 | 3 | 1 | 2 | ...
-----+-----+-----+------+-----+-----+-----+------+-----+-----+-----
It will be seen from this table that the danger line of temperature in
yellow fever descends as the case progresses.
It may again be stated that yellow fever, like scarlet fever, exhibits
such striking contrasts in its mortality-rate that it is hardly
possible to assert any average standard. It is true that in this
disease, as in all others, statistical accumulations tend to correct
their own errors in exact proportion to the magnitude of the
collections.
In 1878 some 36,000 cases occurred in Louisiana, of which number not
less than 6000 were fatal, a percentage of 16.66. The results of
private practice in New Orleans are exhibited in the following
statistics: Four of the principal practitioners in the city treated in
private practice 975 patients--909 white and 66 colored. Of the
former, 92, or 10.11 per cent., died; of the colored only 2 died. The
cases and deaths among the whites, classified by age, were as follows:
AGE. | Cases. | Deaths. | Per Cent.
---------------------------+---------+----------|----------
Under 5 years of age | 206 | 26 | 12.67
From 5 to 10 years of age | 233 | 20 | 8.61
" 10 to 20 " " " | 183 | 9 | 4.9
" 20 to 40 " " " | 232 | 39 | 16.7
" 40 to 60 " " " | 47 | 6 | 12.7
" 60 to 80 " " " | 4 | 2 | 50
---------------------------+---------+----------+----------
The physicians above quoted lived in different parts of the city. All
of them extended their visits and professional services to the sick to
the {648} very limits of physical endurance, and consequently included
in the above lists some patients who were not able to procure the
comforts and attention necessary to the sick. Some cases also were
included to which the physician was only brought that he might sign
the death-certificate and so avoid the coroner's inquest. After making
allowance for increase of mortality on these scores, I think it safe
to assert that the best results obtained in private practice varied
from 7 to 10 per cent. of mortality-rate.
DIAGNOSIS.--While there is no one symptom pathognomonic of yellow
fever in every stage of the disease, its differential diagnosis is
nearly always possible. The morbid action of its special poison
produces phenomena sufficiently characteristic to prove its presence.
The sudden attack, the slight cold stage, the frontal and lumbar pain,
and the capillary congestion are important diagnostic symptoms.
Even in mild attacks this capillary blood-stasis is usually sufficient
to alter the patient's countenance to such a degree as to attract
attention. A great many different adjectives are used in description
of the countenances of yellow-fever patients. While no one among them
is constantly applicable, the presence of a changed facial expression
should enlist the physician's attention and incite investigation. If
this altered countenance be associated with watery or glistening
injected eyes, the probability of yellow fever is increased.
The slow pulse which coexists with elevated temperature is a point of
much diagnostic value. But it must be remembered that this symptom is
not peculiar to yellow fever. I have noted this lack of correlation of
pulse and temperature in several cases of dengue. It is also not
infrequently found in ordinary cases of jaundice. The slow pulse of
yellow fever must be attributable to the special action of the poison
upon the nervous system. The heart's action may be slowed by
influences exerted directly or through the retrograde effects of the
delay of blood-currents in the capillary distribution.
Albuminous urine is a symptom of much diagnostic importance.
A tendency to hemorrhage may be safely stated to exist in all cases of
yellow fever. In the mildest cases hemorrhage may not actually take
place unless the patients be non-gravid females within the ovulating
limits of life. These patients seldom pass through yellow-fever
attacks without sanguineous vaginal discharges. But even in the
mildest cases yellow fever establishes the hemorrhagic diathesis to an
extent sufficient to render the occurrence of hemorrhage an imminent
event. This fact is shown first, by the congested and tumid gums, from
which blood can be readily pressed, and also by the still more
important circumstance that medical or hygienic mismanagement is so
quickly and certainly followed by black vomit or by hemorrhages from
other parts of the system. Capillary congestion is undoubtedly an
important factor in the production of hemorrhages in yellow fever,
since we cannot otherwise account for the liability to hemorrhage
which is so general in this disease.
The yellow color of the skin and eyes during life, and of the tissues
and serum of the cadaver, is probably due to the coincident influence
of two causes: first, to the coloring matter of the red corpuscles
diffused in the serum of the blood; second, to an accumulation of
secondary blood-poisons. The occurrence of the yellow color and its
intensity bear a {649} direct relation to the sluggishness of
capillary circulation during the paroxysm. It appears likely,
therefore, that the yellowness is principally ascribable to coloring
principles derived from dissolution of the blood, to which capillary
obstruction would so strongly predispose this fluid.
Schmidt has made a very careful résumé of the pathological changes
found after death from yellow fever. The most important and uniform of
these affected the nervous system, liver, and kidneys. They consisted
for the most part of hyperæmic conditions, not infrequently attended
by points of extravasation and of degenerative changes. The latter are
principally found in the liver, and bear some relation to the duration
of the case, and it may be also to the degree and persistence of the
pyrexia. When the liver is the seat of fatty degeneration, it is
yellowish in color in whole or in parts. It is then sometimes spoken
of as the café au lait or the box-wood liver.
In cases which run a very rapid course these changes are not observed,
but only those which indicate congestion are found, and often
hemorrhagic puncta. In these instances the depending portions of the
body have dark or livid ecchymoses.
TREATMENT.--There are two propositions to which due attention should
be given before formulating rules for the treatment of yellow fever.
The first of these is, that yellow fever is strictly a self-limited
disease, and therefore is insusceptible of jugulation. Both clauses of
this proposition are indisputably true. Cases have been observed in
which mitigation of symptoms and abridgment in duration appeared to
follow spontaneous diarrhoea. Such events must be extremely uncommon,
since in my large experience I know of but one such instance supported
by good testimony.
Efforts to abort the disease by purgatives, bleedings, cold baths,
quinia, etc. have all signally failed. Among the possibilities of the
future is the discovery that some drug or combination of drugs is
capable of meeting yellow-fever poison in the field of the circulation
and antagonizing it sufficiently to rescue the victim from its fatal
toxic effects.
The second proposition is, that the formative stages of the
disease--that is, the early hours of the paroxysm--afford the most
precious moments for instituting such medication as may be considered
proper. This proposition applies no doubt to a number of other acute
affections, but in no one among them all is it so important to be
regarded as in yellow fever. The primary effects of the poison are so
boldly outlined that it appears highly probable that the damage it
exerts upon the economy is chiefly inflicted during the paroxysm. This
affords an additional reason why efforts at medication should be
principally restricted to the paroxysm and to the earliest periods of
that stage.
It is probable that during an attack of yellow fever the patient's
hold upon life is more or less secure in direct ratio to the number of
functions which retain their physiological integrity fairly well. The
suggestion of such a fact should exclude all scholastic or routine
rules of treatment.
In simple forms of yellow fever the first desideratum of the
practitioner is to become acquainted with the patient's condition at
the moment of attack. If this has occurred after eating indigestible
food or after a hearty meal of any description, the stomach should be
emptied. Ipecacuanha may be given in warm water or chamomile infusion
until this result {650} has been accomplished. After emesis, provided
this should have been considered necessary or as a first step of
treatment under other circumstances, a purgative is usually given. The
benefits of purgation are, in my opinion, limited to the act of
ridding the bowels of any fecal accumulations present. For this
purpose those purgatives which combine a due degree of efficiency with
inoffensiveness in operation have appeared to me to be the best.
Castor oil is at the head of this class. An ounce may be given to an
adult in some acceptable vehicle. This may be followed by an enema of
tepid water when required. Salines are more agreeable to the palate,
but far too unmanageable in their cathartic effects to be adopted
generally.
Some very good practitioners believe that a mercurial purge at the
onset of the attack impresses the subsequent career of the case in
some favorable manner. I do not share in this opinion, but I do select
calomel as the preliminary purgative in cases where much gastric
irritability attends the early periods of the attack. I exhibit it
also in those cases in which previous indisposition had occasioned
coating of the tongue, or in which other conditions of systemic
derangement existed for which calomel is usually prescribed.
In many cases it is desirable to avoid the disgust at taking a
purgative or the perturbation it may occasion by its action. Enemas of
tepid infusion of linseed or of milk and water may be substituted,
with the addition of castor oil when necessary.
In the early hours of the attack warm pediluvia are always grateful
and proper. They are to be given by placing a basin of warm water near
the foot of the bed, beneath the covering of a light blanket or sheet,
and allowing the patient's feet to remain immersed for ten or fifteen
minutes. If the feet are cold, mustard should be added. During the
foot-bath the patient usually falls into a perspiration which is
sometimes profuse and general.
Perspiration is a desirable event during the paroxysm, although it is
not, like the sweatings of the malarial fevers, critical, in the sense
of being accompanied by a marked decline in temperature. The idea that
sweating is beneficial is so strongly and generally prevalent as to
give countenance to the erroneous practice of resting the cure of the
disease upon its production and maintenance. I have seen valuable
lives sacrificed by obstinate persistence in measures to promote
diaphoresis, more especially in the later hours of the paroxysm or in
the succeeding or calm stage. It is quite sufficient to encourage the
perspiration by the pediluvia and by a moderate allowance of cool,
palatable drinks. Much value is attached by non-professional persons
to a warm infusion of orange-leaves or some other warm and grateful
beverage. When agreeable to patients I permit them in moderate
amounts, but do not regard them as especially valuable.
Jaborandi has been used in yellow fever. Strong hopes were quite
naturally based upon the action of this drug in exciting excretory
functions, especially diaphoresis, but the observations of my friend
Dr. Thomas Layton and of others show that it possesses no special
value, while it frequently increases the vomiting and has to be
discontinued.
After the bowels have been relieved of fecal accumulations it is good
practice to exhibit a scruple of quinia in solution with ten to thirty
{651} drops of tincture of opium, by rectal injection. Infusion of
linseed or mucilage of elm-bark or gum-arabic are the best vehicles.
The combined action of the quinia and opium mitigates the patient's
headache and lumbar pains. But the influence of these drugs is not
limited to their effect on the nerves of sensation. In quite a
proportion of cases reaction is not so prompt or complete as usual; or
reaction may be quite pronounced, and still the surface may alternate
between a dry and a perspiring state. These oscillations of function
of the organic nerves are also often corrected by this prescription.
In the great majority of simple cases no other medication than this is
requisite or proper, for no medication is proper in yellow fever
unless it is requisite.
When the neuralgias are excessively violent, opium may be again
administered, preferably by enema, and in combination with bromide of
potassium or chloral hydrate. But the effects of opium in limiting
excretory function must always be borne in mind and carefully avoided.
External applications are very efficacious in relieving the
neuralgias. In the southern part of this country the "eau sedative" of
Raspail is greatly used. This is a mixture of ammonia, camphor, and
common salt in solution, and may be prepared extemporaneously. The
applications may be made hot or cold, but if used cold they must be
continuously kept up. It is therefore better to use them warm if
sufficiently effective. Stimulating embrocations of turpentine or
mustard, or dry or wet cups, are sometimes resorted to for relief of
pain.
Excessive temperature demands attention and antagonistic treatment in
direct measure with its persistence, its degree, and its occurrence in
advanced periods of an attack.
In the epidemic of 1867, I used gelsemium as an antipyretic in fifty
cases or more, but the results were so unsatisfactory that I have
quite abandoned its exhibition. I have given quinia as an antipyretic,
but never in doses of more than a scruple. In these doses it has
failed to accomplish the desired result in the great majority of the
cases. Perhaps its antipyretic effects are limited to those cases in
which malaria is a known or an unknown complication.
I have exhibited small doses of digitalis with apparent benefit, but
aconite and veratrum viride I have long since discarded. The physician
cannot afford to sacrifice gastric quietude and competency of function
to the use of remedies whose value as antipyretics is, to say the
most, quite doubtful.
Cold has for a long period of time been brought into use as an
antipyretic in yellow fever. Its positive value and instantaneous
action should be constantly borne in mind, and in the hyperpyrexia of
yellow fever it constitutes by far the most reliable remedy, though
its mode of application must be carefully adapted to the degree of
fever present and to the susceptibilities of the patient. Cold drinks
in limited quantities, but frequently repeated; cold spongings of the
surface, or the use of the cold pack, especially in very high degrees
of body heat; large injections of cold water per rectum, which may be
passed off and repeated once in two to four hours,--form safe and
effective modes of treatment.
Hemorrhages are a constant source of anxiety in yellow fever. It is
very true that persons do not often die from actual loss of blood. I
do not know that I have ever witnessed such an event except when the
{652} blood was poured out from a recently-emptied uterus. But the
chances of recovery are lessened, because the hemorrhagic state
indicates a degree of spoliation of both the fluids and solids of the
system incompatible with maintenance of life. When this condition of
constitution is once established, the stomach rarely escapes, and in a
majority of instances it is the first, and sometimes the only,
bleeding surface. The treatment should be directed, first, to the
great indication of correcting the hemorrhagic diathesis; secondly, to
quiet gastric irritability, in order that vomiting shall not cause
rupture of capillaries. To meet the first indication I regard
nutrition and stimulants as the most important measures of treatment.
The mode of administration will be specially referred to under the
head of alimentation.
Hæmostatic remedies, given as specific treatment, generally fail in
accomplishing the purpose for which they are administered. It has
always appeared to me that those therapeutic agents which are capable
of controlling hemorrhage where yellow fever is not present are
completely neutralized by the effects of its toxic agent upon the
vaso-motor nerves. Consequently, while ergot, turpentine, gallic acid,
and other like remedies may be resorted to, too much hope should not
be entertained as to their good effects.
Some excellent practitioners rely greatly on preparations of iron. The
tincture of the chloride is undoubtedly the best. This may be given in
water or upon shaved ice in doses of five or ten drops every half
hour. To allay the gastric irritability pellets of ice should be
swallowed. Effervescing drinks may be given with benefit.
I have often used with good results the following prescription:
Rx. Sodii Bicarb. gr. xx;
Morphiæ Sulph. gr. ss.
Aquæ Lauro-Cerasi,
Aquæ Menth. Pip. _aa._ fl. drachm iv. M.
S. Teaspoonful after every act of emesis.
Occasionally I have given the following prescription:
Rx. Creasoti gtt. viij;
Tinct. Opii Deodorat. gtt. xl.
Aquæ Menth. Pip.,
Muc. Acaciæ _aa._ fl. drachm iv. M.
S. Teaspoonful after every act of emesis in iced Seltzer or
Apollinaris water, or in champagne.
Sometimes a few drops of chloroform in a spoonful of iced mucilage of
acacia act favorably.
In cases which appear utterly hopeless the physician, acting
desperately, is sometimes able to save life by treatment which could
scarcely be safely recommended. I once administered a fourth of a
grain of morphia to a child of seven years, who, after a sleep of ten
hours, ceased to throw up black vomit and recovered.
External applications to the epigastrium usually afford some relief to
nausea at any stage of yellow fever. Mustard or aromatic cataplasms
may at all times be used with hopes of favorable effects. Towels wrung
from cold water are very efficacious. Sometimes a drachm or two of
chloroform dashed over them increases their anti-emetic action.
Suppression of urine is generally a symptom of fatal import. {653}
Attempts may be made to establish the secretion by dry or wet cups in
the lumbar region, by warm applications around the loins, or by
mustard cataplasms or blisters. If the condition of the patient's
stomach is such as to permit this practice, copious diluent drinks and
diuretics should be given. Lemonade holding bitartrate of potassium in
solution is generally the most acceptable, and probably the most
efficient. Some physicians think they oftener obtain good results from
small and frequently repeated doses of turpentine. I can bear
testimony to the good results which sometimes follow large rectal
injections of warm or cold water, the latter being preferable when
there is high fever.
In certain cases of yellow fever reaction from the cold stage is
feeble and imperfect, or perhaps may not occur at all. This departure
from type is very fatal. The patients are stupid, sometimes
semi-comatose and incoherent, from the earliest hours of the attack.
The face is listless, drunken, or idiotic in expression. The color of
the skin is dark olive and almost livid. The print of a hand on the
chest is very slowly effaced. Sometimes the surface is covered with a
peculiarly unctuous perspiration. The pulse is feeble and
compressible; the temperature seldom more than one or two degrees
above the normal standard. Albuminous urine is found during the first
day. Death, attended by convulsive rigors, generally closes the scene
within seventy-two hours from the moment of seizure.
Hot mustard-baths should be resorted to. Blood may be drawn by cups or
leeches from the back of the neck or temples, and this may be followed
by the application of a blister. Morphia and atropia may be exhibited
subcutaneously in small doses, to be repeated as often as proper.
Quinia may be administered per rectum or by the hypodermic method.
Lastly, pilocarpine may be thrown into the tissues in sufficient doses
to procure its vigorous physiological action.
Almost in precise symptomatic contrast with these cases of failure in
reaction is another form of attack, in which violent disturbances of
nerve-function occurs; such cases often being characterized as
congestive in type. The most typical of these attacks are among
children or adolescents. If attended by noticeable chill, it is
ordinarily slight. Reaction is quick and excessively violent. The face
is flushed, the eyes injected, and convulsions with delirium are
liable to occur as early symptoms. I have watched with much interest
the alternate flushings and pallor of the countenance occurring in
these cases, such as are often observed in basilar meningitis.
The treatment in this type of attacks should include chloroform by
inhalation in sufficient amount to control convulsions. Chloral
hydrate may be administered by enema, or morphia hypodermically.
Cathartic doses of calomel often exert a beneficial effect. Leeches or
cups, to be followed by cold applications or by blisters, may be
applied about the head or neck. But cupping and leeching should only
be resorted to in the treatment of grave symptoms, since obstinate
hemorrhage is liable to occur from any and every point from which the
cuticle has been removed.
Yellow fever is often masked during the paroxysm by some pre-existing
disease. Malarial fevers, the febrile states of pulmonary consumption
or of the recently-delivered female, may all mask the early clinical
{654} phenomena to such a degree that the most experienced and
vigilant practitioners are sometimes astonished to find black vomit,
suppression of urine, and all those symptoms which mark the last
stages of the disease, suddenly developed.
Walking cases should be classed in the same category as masked forms.
In these instances the early symptoms are so slight as to be
overlooked or neglected by their subjects. They continue to prosecute
their usual pursuits until, by sheer exhaustion, they are driven to
beds from which they seldom arise.
The hygienic and dietetic management of yellow-fever patients is
extremely important, and the strictest attention must be paid to the
condition and discipline of the sick chamber. In this disease those
occurrences and circumstances which in other affections would be
reckoned as unimportant and trivial become matters of serious
magnitude.
The physician, by a composed and cheerful demeanor, often decides
which end of the balance shall go down. But an intelligent,
experienced, and faithful nurse is equally as important as the
excellent physician.
The patient should be confined in strictly recumbent positions, and
all drinks and foods must be given through tubes or from pap-cups. It
frequently occurs that patients are unable to void the bladder in such
positions. In these cases the catheter should be used, rather than
suffer any violation of the rule which demands a maintenance of
unbroken decubitus.