Yellow Fever.

This dread disease has been known by numerous names at dif­
ferent times, and in different parts of the world; yet in the United
States, which has acquired an unfortunately intimate acquaintance
with the disease in the last two decades, the name, " yellow fever,"
is universally employed. It is a little remarkable that this name,
derived from the yellowish tint of the skin during the disease, is by
no means always applicable, since this tint is sometimes absent.

Yellow fever is a perfectly typical malarial disease. It occurs
in certain limited districts where the following combination of cir­
cumstances prevail: First, continuous high temperature, about eighty
degrees for one or two months; second, excessive moisture in the
atmosphere; third, vicinity to the ocean or to a large river empty­
ing into it; fourth, vegetable matter in a state of decomposition.
This latter feature may be furnished by the offal of the cities, or by
the upturning of the soil of the country. Yet many quarters of the
globe, presenting just this combination of conditions, are never vis­
ited by yellow fever. Yellow fever prevails only during certain of
the warmer months, and occurs as an epidemic at intervals of a few
years; it is then evidently due to a miasfri, as to the nature of
which we have, as yet, no positive information, though from anal­
ogy we may be reasonably certain that this miasm, like that of cer­
tain other diseases, is à microscopic vegetable organism.
All the places which have ever been visited by yellow fever,
within the history of medicine, are situated upon or near the Atlan­
tic sea coast. The disease has never been known to visit the Pa­
cific coast of either Asia or America; nor has it ever been seen in the
interior towns of any continent, which were not situated upon large
rivers emptying into the sea. It occurs as an epidemic most frequently
upon those parts of the western coast of Africa and the eastern
coast of America, situated south of the thirtieth parallel of north
latitude. The Guinea coast is almost constantly devastated by the
disease; the West Indies, Central America, and the border of the
Gulf of Mexico, are rarely entirely free from it. The most destruc­
tive epidemics of yellow fever have occurred in New Orleans,
where it appears almost every year; in Shreveport, Louisiana, and
in Memphis, Tennessee, in 1873, and again in Memphis in 1878.
Symptoms.-The onset of yellow fever is generally very
abrupt, though in the majority of cases it may be preceded for a
few days by a general indisposition, languor, wandering pains and
occasional shiverings. The attack itself is ushered in by a chill of
moderate violence, after which follows fever. Both the intensity
and duration of this fever vary considerably; in many cases the
heat of the skin seems but little raised, and the fever appears quite
out of proportion to the severity of the general symptoms. Dur­
ing this fever thirst is extreme, the tongue is heavily coated, though
perhaps moist; there is usually nausea and vomiting with great pain
in the stomach on the second day and thereafter ; there is also ex­
treme pain in the head, especially over the eyes; pain in the small
of the back, radiating down the thighs, and wandering pains in
various parts of the body. This pain in the small of the back is so
usual and so intense as to remind one of small­pox. The eyes are
reddened and watery-a very constant mark of the disease. The
bowels are usually constipated; there is commonly delirium in severe
cases.

This fever with the accompanying symptoms continues for sev­
eral hours, or even two or three days, at the end of which time there
is a decided abatement in the severity of the symptoms, like the
remission of remittent fever. All the symptoms subside, though
there still remains considerable fever; this condition has been called
" the state of calm. " During this remission the yellowness of the
skin becomes quite marked. In mild cases the severity of the
symptoms may not recur; the patient improves slowly but surely,
and ultimately recovers. In the majority of cases, however, there
occurs the dreaded " state of collapse. " During this period there
is extreme prostration of the nervous system, and the greatest
debility of the muscles; the pulse is rapid, irregular, almost imper­
ceptible; the skin intensely yellow or bronze; the tongue brown and
parched; delirium, convulsions or unconsciousness mark the impair-
ment of the mental functions. But the most characteristic feature
- from which indeed the disease has obtained one of its numerous
names - occurs during this stage of collapse, the black vomit. In
the great majority of fatal cases, and in some of those which ulti­
mately recover, the black vomit occurs. This matter consists merely
of blood which has escaped into the stomach and has been changed
from red to black by the action of the stomach juices. The matter
ejected from the stomach is a thin reddish brown or blackish liquid
with a sediment resembling coffee grounds; if the quantity of blood
which has escaped into the stomach be very great, the vomit is
usually red, because the blood has undergone but little change.
The influence of the stomach juices in turning the blood black may
be readily imitated outside of the body by adding a little acid, such
as strong vinegar, to fresh blood.

This black vomit rarely occurs until the first stage of the
disease is passed, and is most frequent during the period of collapse
which succeeds. The discharges from the bowels also frequently
present this same black appearance, resembling tar, due to the
presence of blood in the intestine ; sometimes red blood but little
altered is also evacuated from the bowels. It is during this stage
that the yellowness of the skin, from which the disease derives its
usual name, is especially marked ; the mucous membrane of the
eye also exhibits this color, giving to the countenance a peculiar
appearance. This yellowness is due to certain constituents of the
bile, and occurs in the severer cases with especial frequency; in
fact, it is somewhat rare in the cases that recover ; in these latter it
persists until the patient is almost well.

Blood may escape from other portions of the body also than
the stomach and intestines ; it frequently appears in the urine,
causing the latter to assume a dark brown or smoky appearance.
Blood may also issue from the mouth, nostrils, female genitals,
sometimes even from the eyes, ears, and around the finger nails.
A remarkable feature of the disease is the apparent lightness of the
attack in cases which, nevertheless, prove suddenly fatal. Some­
times patients are not compelled to take to the bed, may even keep
about their usual employments, until a few hours before the fatal
result. Thus, one man shaved himself on the day of his death ;
another, a soldier, continued on duty until the black vomit occurred ;
still another wrote a letter a quarter of an hour before he died.
Perhaps these cases should be considered as examples of the delirium
which not infrequently constitutes a feature of the disease.
The appearance of the face, too, is said by all observers to be
quite characteristic. There is a deep red flush on the countenance,
while the eyes are described as particularly brilliant, fiery, and
glassy. The duration of this second stage is variable, according to
the severity of the case ; it may terminate in death in a few hours,
or lead to convalescence in one or two days. Then follows the
period of exhaustion, during which the majority of deaths occur.
The duration of the disease is said to vary from three to nine days,
averaging less than a week. A certain degree of immunity against
subsequent attacks is said to be conferred by one attack of yellow
fever ; yet it is well known that the same individual frequently suf­
fers from it two or more times.

It seems clearly established that yellow fever is not commu­
nicated by contagion from one individual to another, in which
particular it resembles the malarial fevers generally. It is a familiar
fact, for instance, that the ordinary intermittent fever, or " ague,"
while attacking most individuals living within certain districts, is not
communicated by a sufferer from it to other persons. This fact has
been proven by numerous personal tests. Medical men have sub­
mitted themselves to direct inoculation from yellow fever patients ;
have slept in beds in yellow fever hospitals, in which patients had
just died with the disease. While, however, the disease is not
spread by personal contagion, it is transferred by the atmosphere,
presumably, because the virus of the disease is composed of material
particles, which are swept abroad by currents of air. Much study
has been devoted to ascertaining the conditions under which the
disease becomes epidemic, as well as the agencies by which it is
spread from one center of infection to another. The extensive and
long-continued observations made in the southern part of our own
land during the last forty years have furnished the following facts
with regard to the origin and spread of the disease :

I. The yellow fever poison is usually diffused over very limited
districts ; it freq'uently happens that the area in which it appears is
but the fraction of a square mile. Beyond these limits no cases of
the disease appear spontaneously, and patients suffering from it when
removed out of this area do not communicate the disease to others
with whom they may come in contact.

2.     The disease appears simultaneously at several points within
such an infected district; there is an apparently spontaneous
origin ; that is, the first cases have not been exposed to contagion.

3.     In the infected districts, scattered or sporadic cases occur
almost every year, though they do not result in general extension
of the disease ; yet, at intervals of years, epidemics arise in these
same localities. This is true, for instance, of New Orleans, which
has experienced several severe epidemics in the last thirty years ;
yet scarcely a summer passes in which numerous cases do not occur
along the wharves and in the shipping in the river.

4.     The germs of the disease, while apparently not communi­
cated by the clothing or the bedding of the patient, seem, never­
theless, capable of maintaining their infectious activity in a section
of the infected atmosphere - so to speak, be transported ; thus
it is well established that the disease is transferred by ships, and
several local epidemics in seaports on the Gulf of Mexico have been
traced directly to the landing of vessels from the West Indies. Yet
even in these instances, if the port thus infected be not habitually
the home of yellow fever, the disease will spread but a short dis­
tance from the ship. It has been, also, abundantly established that
such infected ships can be thoroughly disinfected, by cleansing and
airing them.

5.     It is evident that there is only a limited field for attempts
to prevent the spread of yellow fever. For a large section of the
country quarantine regulations are wholly unnecessary. The entire
population of Memphis, for instance, might have been transported
to Chicago without inducing a solitary case among the citizens of
that place, for the atmospheric conditions and the temperature in
Chicago are such as to render the development of the disease
impossible. On the other hand, quarantine regulations are utterly
impotent to prevent the appearance of the disease in New Orleans,
or similar localities where the disorder is generated. It is only in
one class of localities that quarantine can hope to accomplish much
- namely, in those places where the fever has been in previous
years spontaneously produced, but has not as yet made its appear­
ance during the season in question. Such quarantine should be
rigorously enforced as to vessels, but can derive no advantage from
the detention of individuals.

6.     It has been repeatedly demonstrated that the liability to
an epidemic of yellow fever can be much diminished by sanitary
regulations. Thus the rigid military rule of General Butler h New
Orleans, in 1862, prevented the usual extensive occurrence of the
fever that year. It seems probable, too, that the strict police regu­
lations in the same city, in 1873, prevented a disastrous epidemic
similar to that which was at the same time prevailing at Shreveport
and in Memphis.

Treatment.-Up to the present time no treatment ha^ been
devised by which the duration of an attack of yellow fever can be
shortened or its course changed with certainty. There is, indeed,
no course of treatment the results of which have commended them­
selves to medical men as worthy of general adoption. There is, of
course, a vast number of remedies for which especial value in the
treatment of this disease is claimed ; but the very length of the
list is ample proof that no one of them is reliable. The only
rational course is, in every case, to meet, so far as possible, the
symptoms as they arise, and not to adopt any set of rules for treat­
ing the disease in general.

It is a fortunate fact that a considerable majority of cases tend
to recover spontaneously ; yellow fever, like the other infectious
diseases, is self-limited ; and if the patient survive for a certain
time, there is a strong probability that he will recover. Such is,
indeed, the history of many cases. Then, on the other hand, there
are instances which are inevitably fatal, the patient often dying in
a few hours after the attack begins. The suggestions for treatment
to be given here will, therefore, be indications for meeting the dif­
ferent symptoms according to the severity of the case.

In the milder cases no active measures are required for treat­
ment. The patient must be kept quiet. His diet must be light and
nutritious. And especial care should be directed to ventilation.
During the height of the fever the usual remedies employed during
febrile conditions may be used, such as cold applications to the
head, frequent sponging of the skin with lukewarm water, cold and
effervescing drinks, laxatives in case of constipation. Dr. Stone, of
New Orleans, \\*ho has had much experience in the treatment of this
disease, recommends " foot baths under the bed clothes and spong­
ing the body with tepid water. " Dr. Flint says that many cases of
mild yellow fever in New Orleans are managed by Creole nurses
without medical aid. This is doubtless true of the scattered cases,
but scarcely during epidemics. Furthermore, some of the cases
which at first appear mild may develop malignant features subse­
quently. It is therefore desirable to observe and meet carefully
every symptom of the disease. It is therefore of extreme import­
ance that the patient should in every case take to his bed at the first
indications of the disease. Both body and mind should be rested
as completely as possible, and the most careful attention be bestowed
even upon the slightest details.

In the more malignant cases the same general measures are
indicated; that is, extreme care as to all the hygienic surroundings of
the case. It is not advisable to follow the plan so much in vogue,
that the measures shall be the more heroic according as the severity
of the disease increases. It is doubtless possible to do much harm
by the use of powerful medicine; this is particularly true of purga­
tives, since the intestinal canal is in a very debilitated condition.
There is, perhaps, one indication for the use of sharp purgatives,
namely, unconsciousness or stupor on the part of the patient. By
causing the blood to flow to the alimentary canal we may succeed in
reviving the congestion of the brain, upon which the unconscious­
ness depends. During the hot stage the remedies usually employed
in other fevers may be used to advantage; such are sponging of the
skin, the use of ice in the mouth, etc. If the patient be extremely
restless and vigilant, opium will be found useful. Ten to fifteen
drops of laudanum may be given, and repeated in three hours, if
necessary.

The extreme danger comes usually during the stage of ex­
haustion. During this stage nothing may be left undone which can
sustain and invigorate the patient. These measures consist, of
course, first in the application of friction to the skin, which may be
vigorously rubbed with brandy or other alcoholic fluid. The use
of hot bottles or hot flat-irons to the feet and spine may im­
part strength, while the application of mustard plasters to the
stomach and abdomen may be efficient in relieving the black vomit
and discharge of blood from the bowels. In many of these
cases of collapse advantage is asserted from the application of
leeches to the back of the neck; but the great reliance must
be, and is generally admitted to be, the internal use of alco­
holic stimulants. If there be one fact established in the treat­
ment of this disease, it is that lives have been saved by the
use of whisky and brandy in quantities that would, under other
circumstances, seem excessive. So far, therefore, as treatment
can be recommended in these cases of malignant yellow fever,
it may be summarized as follows: During the hot stage sponging
of the body, or hot baths ; the use of ice, cold drinks or effervescing
waters internally. During the collapse, stimulation by friction of
the surface, application of hot bottles around the patient, and the:
use of whisky or brandy.

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