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The mistake made by the board of experts of New Orleans, when they failed to recognize the existence of yellow fever at Ocean Springs, was due to the finding of the plasmodium in at least two of the cases.
DENGUE AND YELLOW FEVER.
The prevalence of a widespread, mild, epidemic fever during the present outbreak of yellow fever has been undoubtedly a source of doubts and difficulties in connection with the diagnosis.
Many of these cases were found to exist in houses where cases of yellow fever were present at the time, and I must confess that it was impossible to discover in them any of the characteristic symptoms of yellow fever. Many of these cases had a distinct eruption and must be looked upon as cases of dengue. This fact may bring forward new problems as to the relations between these two diseases. From our present point of view, we can only state that yellow fever appears to spread more easily when there is an epidemic of dengue prevailing. All evidence goes to show that a previous attack of dengue does not protect against yellow fever, and we must look upon the former as an entirely distinct disease.
IMPORTANCE OF DIAGNOSIS OF FIRST CASE.
I can not insist too much upon the importance of the diagnosis of the first case of yellow fever in a locality. Undoubtedly the cause of the epi. demic of yellow fever is to be found in the introduction into a community of cases that are not suspected to be yellow fever. This probably occurs most frequently in connection with individuals of the colored race. The disease in them is usually very mild, and their movements from place to place are less likely to attract the attention of the health authorities. I bave no hesitation in saying that if the first case of yellow fever introduced into a city were always recognized, the spreading of the disease would be invariably prevented.
I will conclude this report by inviting your attention to the fact that the movements of the yellow fever expert have been frequently interfered with by the fears of the communities that he might convey the disease from place to place. In moving from one locality to another I took all the necessary precautions and felt absolutely sure that I could not be a source of infection. I was immune and traveled with very little baggage, which I frequently changed. Yellow fever has never been carried from one locality to another in this manner.
This fear of the communities was in part genuine and due to ignorance, but was also in part a pretended fear of those who knew better. I have finally to state that I have received every attention and assistance from the local health authorities in all the cities that I have visited.
TREATMENT OF YELLOW FEVER,
By Surg. R. D. MURRAY.
I have seen yellow fever in twenty-one summers (including 1870) and in every month except February. The elimination of yellow fever from our nomenclature will follow when there is a proper conception of the influence of clothing, bedding, and unclean bedrooms as transmitters. The disease is air borne for some distance; the infection is stronger at times and places than at others; whether it is intensity or quantity I do not know; it may be diluted, and is transmitted by clothing, bedding, and related articles. Hair from the dead has transmitted it; corn sacks, blankets, and old newspapers have carried it; mountains of filth will not produce it; they may give it a new nidus or garden from which it goes out “seeking whom it may devour.” The cleanest town in the South may have a severe prevalence if the people insist on disobeying the advice of the health officials. In 1875, as a result of several post-mortems and an attack Certain ideas
as to path gy. of the disease, I came to the conclusion that yellow fever was an inflammation of the duodenum, primarily, and wanted to call it epidemic duodenitis. Many post-mortem examinations have since convinced me that the primary lesion is in the duodenum, and I insist that the mildest cases have a lesion in the organ referred to that can be demonstrated, if due care is taken. The same after death examinations, as well as bed side experience, have shown me that the deathdealing process was not the “inflammation” that I was taught thirty years ago to understand as inflammation, i.e., there is no proliferation of cells or tissue and no new growth. There is a primary involvement of the duodenum and Duodenal ori.
gin the symptoms of the disease follow generally in regular order. The mildest cases have a tender duodenum (if you know how to press) and a little back ache; note how close
Stools to be er. to the spinal column the duodenum lies. If the stools could amined.
be all and carefully examined sometime a mass of white mucus with a black or brownish middle will be found. Maybe there will be a stool of black mucus once only. It is fair to say that there is always a clay or bismuth stool with the mucus clot stained with black. The "bloody sweat” from the duodenum, and in bad cases from upper intestines and stomach, starts in the duodenum.
Sometimes the symptoms come in such quick succession that we think the attack is necessarily fatal. Many times in such cases we have no chance to ask the patient how matters fared with him twenty-four or thirty-six hours before, when he was sick, but would not admit the fact. Walking cases are as common in tbis as in the other bed diseases. I have known a man, suffering with headache for three days on duty, to vomit black on the stairs on the way to his deathbel. I have given immune certificates to
persons who never went to bed. Choice of a In ordivary, the patient should like the medical attend. physician.
ant. If the physician is distrusted, he should be called off or feign ilhess, so that a favored one can be called in. Consultations over the patient are injurious. I would have the doctor do his share in keeping up courage, hope, and life-purpose in his patient; to minimize the aches, distress, and fears, and to carry his patient's mind away from the
now with its dreads to tomorrow, with its reward or rePsychological venges. Several people are living now because, in their effects.
desire to take vengeance on me for what they thought was iny indifference, they forgot themselves and their conditions.
NOT EVERY CASE NEEDS TREATMENT.
It is fair to say that of one hundred cases seventy-five need only to be let alone by the extra-attentive nurse or friend and heroic physician. They will get well under any plan of treatment and under miserable local conditions; notably so with infants, who, if they die, are generally sacrificed by cards or some acrid medication.
These seventy-five are cases" and should be recorded, but only for sake of good records and to establish their immunity. They should receive only what occasion demands and be watched for untoward incidents.
Of the twenty-five some will need formal attention and careful procedure; others will die in spite of all reasonable aid. Some vicious habit or chronic disease will add to the trouble, and in some cases uncontrollable fear will insure a fatal result.
My oldest patient to get well was 109 years of age; the
eases and habits
youngest was 52 hours old when she threw up black vomit. One of my children had black vomiting five days after she was born. I know of the recovery of a chronic Chronic dis. Bright's disease sufferer; of a morphiomaniac's recovery, as factors. and last summer gave a diabetic doctor such cheerful council that he had a severe attack without fatal result, and has been in better health since than before. I cite these cases to show the triviality of the disease if " taken right and in time.” I have often said “ Yellow fever is the Yellow fover a most honest, most trivial, and cheapest to treat of all dis. eases that kill.” It is “honest” because it comes with definite signs and leaves no trace, always insuring the afflicted one that he is hereafter immune; it kills, if at all, in a few days, and is merciful in the killing, as the dooined one is usually conscious to the last and does not linger as a consumptive or one afflicted with cancer; “trivial” because 50 per cent of those who suffer with it are scarcely aware of serious illness, and have no sequels to make them iniserable the remainder of their lives; also, because it rarely takes off children, and they, by reason of the attack, gain the privilege of living in its habitat; “cheapest to Cheapness of
m treatment. reat” because it is so; the delicacies, liquors, etc., sometimes provided are generally consumed by the disbursers and attendants and are not fairly chargeable to the sick; the medicine actually needed costs very little.
TREATMENT OF YELLOW FEVER.
When called to a man (most of my work has been with Initial signs men) who has had a chill some time during the previous prompt treat. night, has a pulse of 100 to 112, with temperature of 101.50 to 103°, headache (cutting across the forehead), backache running down into the thighs, sore muscles, skin hot if you hold your hand on it a while (hands and wrist not hot to gentle touch), anorexia, white tongue (may be a yellow center far back—the red edges and red diamond on tip will not show at once), suffused eyes, and notably or faintly purpled cheek bones with semipuffed upper lip, the hundred chances are you have a case of yellow fever.*
* Yellow fever usually begins at night when the person is in bed and in a relaxed condition; malarial fever usually attacks when the person is at work. Regardless of books, I reasoned this point out as a diagnostic fact over twenty years ago, and am flatterod that others discovered it too. Night watchmen have sickened in daytime. A restless early morning in bed with little desire for breakfast is a frequent history; everything eaten as breakfast does harm in such cases. Dengne pains are worst in joints-yellow fever soreness is between the joints. As malaria coincidents there is no rule for differentiation excepting perhaps the attack in bed or at work.
Initial purge Give three or four compound cathartic pills at once and necessary
as soon as possible give a hot foot bath (an all-over bath is better, but is not always possible), with or without mustard and salt. Mustard at this time is really a nonessential, but sometimes the patient thinks it is the proper thing; so with the table salt. As to the cathartic: calomel at first is too slow and usually must be sent for, the pills contain enongh
of it and are in your vest pocket. Every yellow fever docCarry, purga- tor should carry first doses of compound cathartic pills, tives in your pocket. compound acetanilide tablets, and such other pocket reme.
dies as may be needed on emergency. A parade of a small medicine chest is not advised. Do not begin to make a reputation for wonderful medical skill now. Dwell on the dengue symptoms and the signs of malaria, and without
great formality convince the patient that it is not yellow," Don't let the but do not say so. Keep back information about the patient know he is very ill. actual temperature all the way through, but tell them about
the height of the fever. No patient should ever hear that his fever went above 1020 until after he gets well. (I saved a doctor once by hiding his thermometer and using my
French scale, which he could not translate.) Coal-tar deriv. Give as soon as convenient, or, if fever is above 1020, at atives.
once, any coal-tar derivative in 77-grain doses, with some bicarbonate of soda and caffeine. The antikamnia compound is a good one. If powders or tablets are objectionable to the patient, give antipyrine. I nearly always use acetanilide with soda and caffeine. Have no objection to any, except that I like cheapness and simplicity. After the bath and a good sweating, under blankets, for from four to six hours, rub dry and cover with two blankets.
(The clothing should have been hung outside of the house Disposal of or dumped into a tub of water; dispose of the wet sheets changed cloth ing.
and blankets in like manner. When washed they are ready for use again; this hint in regard to prevention of infection.)
If a person likes blankets next the skin, so much the better for prevention of skin shock. Quilts and counterpanes are objectionable because of the pasty odors they retain.
Repeat the coal tar derivative every three to six hours if fever keeps above 102°; give for effect and not pro forma.
Have the face and hands wiped frequently, give orange-leaf Drinks. tea, Apollinaris water, lemon-grass tea, hot lemonade, gin
ger ale, small sips of ice water, and other drinks ad libitum, but not ad nauseam. Always start with the quantity you are willing the patient should have, and let him drain the cup; this particularly in the case of water. Try to supply