Popular Science Monthly/Volume 13/October 1878/Yellow Fever
By ROGER S. TRACY, M. D.
AN attack of yellow fever is generally quite sudden, though in some cases there are slight premonitory symptoms, such as loss of appetite, general uneasiness, headache, or costiveness. It is commonly ushered in by chilliness, alternating with flushes of heat, or the person may be overcome with languor and extreme debility, while at his usual occupation. These feelings are soon followed by fever, and the bodily temperature rises rapidly, often reaching 1022° Fahr. in a few hours, the normal temperature being 98.4°. The fever is accompanied by headache, generally located immediately over the eyes, or shooting through from temple to temple, and often very severe. But the headache is frequently trivial in comparison with the frightful pains in the loins, which make the patient writhe in agony. The pulse is generally full, strong, and rapid, beating from ninety to a hundred and twenty times a minute. The skin is hot and dry, the face flushed, the eyes bloodshot, brilliant, and watery, and the tongue covered with a creamy white fur, but with red, clean tip and edges. There is usually some uneasiness of the stomach from the first, and in from twelve to twenty-four hours this develops into nausea and a persistent sensitiveness, which will not allow anything to be retained. The pit of the stomach is very tender on pressure, and vomiting is almost incessant. With all this there is intense thirst, and iced drinks are exceedingly grateful to the patient. The bowels are at first generally costive, and sometimes obstinately so, but, as the disease progresses, they become loose. The patient is usually very much debilitated, but is uneasy and tosses about in bed, and occasionally will try to rise and walk about the room. In most cases there is some confusion of intellect, not amounting to delirium, and the face expresses the greatest anxiety and distress. The fever continues for two or three days, being most severe in the evening, the temperature often reaching 104° or 105°, and, according to La Roche, in malignant cases, even 110°. Then the fever subsides, never to return, and the temperature within twelve hours may become nearly normal. The other symptoms mostly disappear, and the organs resume their natural functions. At this time, i. e., on the third or fourth day, the yellow discoloration of the skin appears upon the face and thence extends over the body. If the attack is mild, recovery is now rapid. In the vast majority of cases, however, this lull in the symptoms is deceitful, and lasts only from a few hours to a day, when the gravest stage of the disease sets in. The pulse soon becomes small and thready, beating only thirty or forty to the minute, and the heart often works vigorously after the pulse can no longer be felt at the wrist. The nausea and vomiting return and become constant, the respiration is often embarrassed, the tongue becomes dry and brown, the skin is cool and dry, there is often a distressing hiccough, and the thirst is insatiable. The mind is often clear, but singularly apathetic, or there may be delirium or stupor. The disorganization of the blood and the tissues has now gone so far that the small vessels of the mucous membranes no longer retain their contents, and blood oozes into the stomach. This produces intense nausea, and the blood is vomited up, changed in color by the acids with which it is mingled. This forms the dreadful "black-vomit," and varies in hue from brown to almost jet black, generally appearing like coffee-grounds floating in a thin, watery fluid. The urine, which becomes scanty early in the disease, may now be entirely suppressed, or, if excreted at all, is black and bloody. The discoloration of the skin increases, until the body is of a dusky brown, livid or mahogany color, and there are frequent hæmorrhages from the mouth, nose, eyes, or even under the skin, forming livid spots and blotches. The body now exhales a cadaverous odor, the tendons of the wrist twitch convulsively, hiccough is constant, the features are pinched and ghastly, cold sweats come on, and the patient passes away in convulsions or coma, though occasionally he retains his intellectual faculties unimpaired to the last.
Patients may recover in either of the three stages above described. A favorable termination is indicated by a gradual amelioration of all the symptoms, or sometimes by profuse perspiration, sudden cessation of nausea, rapid return of the pulse to its natural fullness and strength, or other marked event, which seems to indicate a crisis in the disease.
The symptoms of yellow fever vary exceedingly at different times, in different localities, and in different persons. Sometimes a person is smitten with the disease as with apoplexy, falls into a profound collapse, and dies in a few hours. Others walk about the room, or even out in the street, and insist that they are perfectly well; or, if they acknowledge that anything is the matter with them, complain merely of weariness or debility. They often betray no symptom of the disease to the casual observer; but the physician will see an expression of dullness or listlessness in the face, and a wateriness of the eye, and will find the pulse feeble or even absent. The patient may even be talking, smoking, or reading, when black-vomit comes on, and he is speedily a corpse. To a non-professional person the exceeding variability of the symptoms cannot, perhaps, be better shown than by quoting a line or two from the work of La Loche, of 1,400 pages, on "Yellow Fever:" "The skin is hot, dry, harsh, and pungent, or it may be dry, unctuous, or perspiring, flabby, and cold. . . . The pulse becomes rapid, irregular, and depressed; or, more generally, it is natural in frequency, or even slower than in health." And this, of the post-mortem appearances, is a gem in its way: "The liver is usually of a light-yellow, nankeen, fresh-butter, straw, coffee-and-milk, gum-yellow, buff, gamboge, light-orange, or pistachio color; or it may be dark-yellow, brown, red, purple, bluish, slate, chocolate, or livid." Even the characteristic symptoms of yellow skin and black-vomit may occur in other diseases, and they may both be absent in yellow fever. These differences in the disease are largely due, in all probability, to individual idiosyncrasies, and to the simultaneous presence of other morbid processes. Thus, the present terrible epidemic at the South, from all we can learn, seems to be decidedly modified by the malarial atmosphere of that region, and presents so many of the features of the pernicious malarial fevers that some physicians (whether competent or not I do not know) decline to report their cases as yellow fever.
The disease lasts from three to nine days, and in severe cases recovery is apt to be very slow. Relapses are not common. The black-vomit, indicating, as it does, a profound disorganization of the blood, is, in most cases, a fatal sign. Alvarenga states that, in the epidemic of 1857, at Lisbon, out of one hundred and seventy-eight cases of black vomit, forty recovered, but this is an isolated experience, and in this country, at least, such recoveries are rare. The mortality varies between five and seventy-five per cent, of those attacked.
The disease develops in from one to fourteen days after exposure. Those most liable to it are strangers or recent comers. Old residents enjoy a certain immunity, excepting in severe epidemics, and, even if they are attacked, the disease is generally mild. Women and children, old persons, and those of delicate constitutions, are visually less liable to it than robust, healthy men. This year the children are said to have suffered most. The negro natives are generally exempt, though it has been noticed that negroes who have left the South for the North, and have returned during an epidemic, do not possess this immunity. In the present epidemic, even the negroes seem to succumb in great numbers. It is a singular fact that persons exposed to offensive effluvia when working at their trade, as tanners, butchers, soap-boilers, and scavengers, are almost exempt from the disease, while those whose trade exposes them to great variations of temperature, as bakers and cooks, are extremely prone to it. Like small-pox, it may occur more than once in the same person, but, as a rule, those who have had it once are never attacked again.
All methods of treatment agree in the principal points. The bowels must be cleared at the start, and the patient kept perfectly quiet. The temperature is kept down by applications of cold water, and ice is applied to the head if symptoms of congestion of the brain appear. The excessive thirst is relieved by swallowing lumps of ice, and the nausea controlled to some extent by iced lemonade or champagne. In the West Indies, lemon-juice plays an important part in the treatment, and the old negro nurses rub it over the surface of the body. When the appetite revives, great caution has to be exercised, as a premature return to solid food may result fatally.
The first fully recorded outbreak of the disease was in the West Indies in 1647, and since then it has recurred at irregular intervals, and has gradually extended its range. Epidemics have occurred as far north as Quebec and as far south as Montevideo, as far west as Mexico and as far east as Algiers. It is endemic in the West Indies, Venezuela, New Granada, and Mexico, on the easterly coast of the United States as far north as Charleston, South Carolina, and on the northerly coast of Africa. To become epidemic, it requires a mean temperature of at least 72°, and Griesinger holds that the temperature must be as high as 80° for a considerable time before it can acquire a foothold, though West Indian physicians have seen the temperature fall suddenly just before an outbreak. If the temperature falls during an epidemic its severity abates, and at 32° it disappears entirely. It rarely occurs inland, but follows water-courses and lines of ocean-travel, and so usually appears in commercial cities, and begins its march at the wharves. It is uncommon in elevated regions, and 2,500 feet is commonly regarded as its altitudinal limit, but it has been known to occur at Newcastle, Jamaica, at a height of 4,000 feet, and if the belief be true that ancient Mexico was visited by it under the name of matlazahuatl, then it has been epidemic at a height of between 7,000 and 8,000 feet above the sea.
There has been no severe epidemic of this disease in New York since 1822, but it breaks out on our Gulf and South Atlantic coasts at intervals, with no appearance of periodicity. It first appeared in New Orleans in 1796, and has often been epidemic there since. The most fatal epidemic was that of 1853, when the deaths were variously stated at from 8,000 to 10,000, or about eight times as many as have occurred there during the present summer, though the population was only half as large. It is the common impression that New Orleans was saved from the disease during its occupation by Federal troops in 1862-'65, because the city was put in such excellent sanitary condition; but Dr. Nott calls attention to the fact that there are often periods of exemption from the disease in all places visited by it, and that in New Orleans in 1859 there were only 91 deaths from yellow fever, in 1860 only fifteen, and in 1861 not a single one; while in 1863 Dr. Harris says there were nearly 100 cases of the disease, with two officially recorded deaths, and in 1864 more than 200, with 57 deaths.
Yellow fever occupies a singular position between the contagious and non-contagious diseases. The poison is not, like that of small-pox, directly communicable from a sick person to a well one; but, although the emanations of the sick are connected with the spread of the disease, they seem to require an appropriate nidus in which to germinate and develop. This nidus must be warm and moist, and there the germs, whatever they are, lie and grow, or, in some way develop until they are able to migrate. The germs are portable, and may be conveyed in baggage or merchandise (fomites) for hundreds or thousands of miles. If not so conveyed, its progress is very slow. In 1822 in New York, when it gained a foothold in Rector Street, it appeared to travel about forty feet a day until killed by the frost. It often leaves a house or a block intact, going around it and attacking those beyond, with no assignable reason. A thin board partition seems to have stopped it on Governor's Island in 1856, and an instance is related where it attacked the sailors in all the berths on one side of a ship before crossing to the other. Such apparent vagaries are, in the present state of our knowledge, inexplicable.