Part 105

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.

Prognosis is seriously influenced by the condition of the patient at 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.