Part 106

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.