USA > Tennessee > Shelby County > Memphis > A history of the yellow fever : the yellow fever epidemic of 1878, in Memphis, Tenn., embracing a complete list of the dead, the names of the doctors and nurses employed, names of all who contributed money or means, and the names and history of the Howards, together with other data, and lists of the dead elsewhere > Part 6
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A HISTORY OF THE YELLOW FEVER.
with some; neither can I attach much importance to the internal adminis- tration of diuretics or diaphoreties, which have been thought eliminative, in consequence of their nauseating effects on the stomach. If we can not re- move the cause of diseased action, we should attempt to annul it or coun- teract its effects. The cause of yellow fever, now recognized to be a peculiar zymotic poison, acting as a destructive ferment, depresses and perverts the vital and functional forces, gives rise to great excitement of the circulation and torpor of the glandular and secretory organs. The intense eremacausis of the tissues, and high combustion acting through the blood, may produce, in a short time, destructive changes in the most important organs of the body. . The indications for treatment are obvious, and are to remove all offending matter from the primce vic and rouse the emunctories to action, and are best fulfilled by the administration of mercurials and salines, and promoting their action by warm diluents; at the same time that we attempt to reduce the temperature by sponging the upper extremities with ice-cold water, and assist in equalizing the circulation by revulsives to the surface of the abdomen, and hot stimulating pediluvia. These are, I believe, the best means of disgorging the glandular apparatus and equalizing the circu- lation preparatory to the use of agents which tend directly to counteract the destructive fermentation which is going on in the blood. All spoliative and depressing medication should now cease, though the action of the skin and kidneys should be promoted without disturbing the stomach; for upon the proper performance of their functions will depend the progress of the case and the impending lesion of the heart. Here judgment comes into play; and upon a recognition of the true pathological conditions of each individual case, and a knowledge of the therapeutical properties of the remedial agents adapted for its relief, will depend the result; always provided that the patient can be placed in a position suitable to his condition, and have all the agree- able surroundings which are required. Bland and nutritious liquid food should be regularly given to shcathe the lining of the stomach, and neu- tralize or dilute the gastric juice; but warm drinks for other purposes are to be discontinued. Crushed ice, or ice-water, may be used for their refrig- erant effect only; but the urgent thirst, which necessarily ensues from the elimination of the watery elements of the blood by the induced catharsis, must be allayed by cool, pure water, or refrigerant, agreeable beverages, mixed with good wine; otherwise, iuspissated blood will engorge the kidneys, and the case will be materially injured. The practitioner will always have to regard the idiosyncrasy of his patient, and be governed by the peculiari- ties of each case. After sufficient catharsis has been induced, wine, and even the stronger alcoholic stimulants, are more efficient than any other class of medicines. They will be found, in manageable cases of yellow fever, almost a sine qua non, preventing, eten paribus, the supervention of the de- structive changes which might otherwise occur, thus making a simple, mild case, which, if allowed to run its course expectantly, or attempted to he jugulated heroically, would become a "full-fledged" one, either to drag its slow course along, or terminate fatally. After congestions or other compli-
50
A HISTORY OF THE YELLOW FEVER.
cations have occurred, it is too late to expect a specific action from the preparations of alcohol; but still, either with or without quinine and citric acid, its supporting action is required to stimulate the heart and equalize the circulation ; and in malarial complications, its combination with quinine is the best for the exhibition of this salt. For irritable stomach, when the tongue is red and dry, and the thirst urgent, ice will not succeed so well as ice-cream or sherbet, or evol vinous drinks delicately prepared to zuit the taste of the patient. Stimulating embrocations, sinapisms, or blisters over the epigastrium. in connection with the above treatment, have given relief to the most dis- tressing symptoms. The hydrate of chloral and bromide of potassium. or the salts of morphia and camphor-water, are of questionable utility in this disease. If no complications arise, no drugs are to be given ; the patient should be made comfortable by a proper regulation of diet and hygiene; and if there be no contra-indications, vinous, fermented, or distilled liquors, in quantities and combinations to suit the condition of the patient, should be allowed. The use of alcohol in the treatment of pyzemia, and its property of lowering the tem- perature in pyrexia. bas, of late, attracted much attention; and the medical reader is competent to form an opinion on the subject .* I will briefly sum up, from the results of my own researches and those of others, the theory of the modus operandi of this agent, and would most respectfully call the atten- tion of the profession to its action in yellow fever. In a state of health, alco- hol does increase the animal heat, especially when the system is depressed by cold; when there is diminished capillary circulation and reduced temperature. by virtue of its combustible nature; and it resolves congestion of the lungs in incipient pneumonia by arousing the nervous forces and equalizing the circu- lation. In a state of fever it diminishes the temperature at the same time that it sustains the action of the heart ; and this is explicable from the fact. that while rapidly oxidized itself, it prevents the oxidization of the tissues ; therefore, by arresting the frightful combustion which obtains in yellow fever, it diminishes the temperature; and by arousing the latent vital energies, it equalizes the eirculation and relieves engorgements or congestions. Another explanation is, that it aets within the animal economy as it does without, by preventing or arresting the putrefactive or fermentative process, each of which is attended by heat. It may yet be proved to be the best antidote to all zymotic poisons, as well as to the bites of venomous animals. When the temperature of the blood is too much increased, as it is in yellow fever, its saccharine elements can not be converted into alcohol (as I contend does take place in a state of health); but the acetous fermentation is induced in- stead, similar to what always occurs when the mash -- prepared for the in- duction of the alcoholic fermentation -- is subjected to a too great degree of heat. Under the conditions present in a marked case of yellow fever, we can readily conceive how, in a short time, the whole mass of the blood may be- come acetified, and so changed that the emunctories cease to act at all, and
# Dr. Austin Flint, Jr., of New York, has recently declared himself in favor of alcohol as a specific in cases of fever.
51
A HISTORY OF THE YELLOW FEVER.
the functions of the economy are in abeyance, in consequence of the circula- tion of a fluid other than that which nature bas designed for the maintenance of their action. The kidneys becoming as impermeable and useless as a foreign body, the abnormal death fluid seeks the great work-shop of the sys- tem, and oozes through its parietes, to be known to the observer as lluck vonit. The moral treatment is by no means unimportant in yellow fever. Fear being the most potent agent for evil, the patient should not be alarmed by being made acquainted with the nature of his case; neither should those nearest him be better informed, unless absolute necessity arises. The medical attendant should never betray doubt or anxiety as to the result; a confident look, kind words, and a manifestation of a friendly interest in behalf of the patient, encouraging him to hope for a successful issue, will do more good than medication. None but congenial, cheerful, and discreet persons should be allowed access to the sick-room; the exclusion of all disagreeable or de- pressing influences should be enforced, and the patient should be relieved of all personal cares of whatever nature, and feel himself perfectly secure in the hands of those to whom his physician has intrusted the management of his case."
Dr. R. W. Mitchell, recently appointed a member of the National Board of Health, who, as Medical Director of the Howard Association of Memphis, in 1878, enjoyed unusual opportunities for obtaining a thorough knowledge of the effects of yellow fever upon the human system, and of the value of almost all the known remedies, and who enjoyed the confidence of every physician who served under him as well as that of the public at large, by request furnishes the following as his method of treatinent, which, it may be remarked, was very successful: "The natural history of yellow fever suggests the plan of treatment which observation and experience have proven to be the best. Being a self-limited disease, and one of very short duration. what could possibly be the aim of rational treatment beyond warding off complications and sustaining nature? To fulfill this indication, I have sought always to enforce absolute rest of mind and body during the entire course of the disease, to the full establishment of convalescence; to protect my patients from all perturbing and deleterious influences, such as might arise from the conversa- tion of injudicious friends, or from changes of temperature; to watch the bodily secretions, and insure as perfectly as possible the performance of the various fune- tions. The first objects requiring attention in a case of yellow fever, are the bringing about of reaction after the chill, and free evacuation of the bowels. The first is quite easily attained by means of the hot mustard foot-bath, and moderate covering with blankets. The second is, in most instances, best accomplished by a dose of castor-oil. Sometimes, when the attack is ushered in with nausea and a coated tongue, a few grains of calomel. followed in six hours by oil, or one of the saline aperients, is better practice. Having attended to these matters, I now lay medicine aside, unless the pains in the head aud back are violent or delirium is present. To relieve these symptoms I preter to make use of a combination of bromide potassium and tincture gelsemium- 15 grains of the first, and as many drops of the second-every two hours during the first day of the fever. Gentle perspiration, not free sweating, should
52
A HISTORY OF THE YELLOW FEVER.
be maintained for 15 or 18 hours by the foot-bath, suitable covering, and warm sage or orange-leaf tea. As a rule, no food of any kind should be adminis- tered during the continnance of the fever, unless the patient is very feeble, or the fever is disposed to run over three days. Under such circumstances, milk and lime-water, or rice-water, in small quantities, should be given at short intervals. Pellets of ice may be given to all patients in the beginning, and to the close. Having discontinued those remedies calculated to keep up perspira- tion, the closest attention should be given to the bodily temperature. If the clinical thermometer shows that this temperature is not above 102º, I instruct the nurse to sponge the entire body, under cover, every few hours with com- mon whisky. If, however, the temperature goes above this figure, and reaches 104° or 105°, the whisky must be freely applied every hour, and as cold as ice can make it. To be effectual, each sponging should be continued for 20 or 30 minutes. A faithful nurse, who does not mind hard work, will in a few hours bring the temperature down two or three degrees. Patients thus treated, long for a return of the time for sponging, and will often beg for it: it relieves pain, soothes the troubled nervous system, and induces sleep. It also insures proper action of the kidneys, and serves to ward off that state of things in the stomach which gives rise to black vomit. The essence of treatment, then, in yellow fever, is to be found in keeping the digestive organs at perfect rest, by giving them nothing to do; in keeping the temperature of the body as near the normal as possible; and in warding off congestion of the liver and kidneys by making appeals to the skin. Should suppression of urine arise in a patient with high temperature, the best means of relief is the application of poultices of ice and salt over the loins. This application is made for 15 or 20 minutes, then removed and reapplied in half an hour. For the relief of suppression of urine in one whose temperature is nearly normal, I know nothing of much value. Allusion has been made to the good effect of cold sponging in keeping off' black vomit. In addition to this, mustard plasters or blisters over the pit of the stomach may be required; but to do good they must be applied early. The nausea and vomiting with which attacks of yellow fever are ushered in. are not usually serious, and no special medication is required for their relief. When the fever subsides, we begin to repair the shattered strength of the patient by the administration, at short intervals, of a teaspoonful of milk and lime-water. After awhile, chicken-water or beef-tea may be substituted for this. Thirst may now be allaved by water in small quantities, and by the German seltzer-water. Should the temperature fall below the normal, and the pulse drop down to 50 or less, a little brandy may be added to the nourish- ment; but as a rule it is very seldom that stimulants can be used advanta- geonsly or safely with temperate subjects. Mach harm has been done, and many lives destroyed, by the administration of champagne and whisky during the stage of calm which follows the sub-idence of the fever. We go on, then, adding little by little to the nourishment, but not allowing solid food until nearly a week of convalescence has been reached. During all this time con- finement to the horizontal position is rigidly enforced. When the blood has been renewed by food, and the strength in a measure re-tored, the patient is
53
A HISTORY OF THE YELLOW FEVER.
allowed to leave his bed. The reactionary fever, which in many cases follows the stage of calm, is usually very moderate, and requires no treatment but sponging. In very many cases malarial fever appears about the fourth or fifth day of convalescence : it comes in the evening, very insidiously, and the patient complains of having had a restless night. This is repeated for two or three days, and the patient dies. I saw many such cases during the past summer, and also observed that these attacks yielded to quinine if given promptly. Late in the season, I found it an advantage, in cases in which there seemed to be a malarial element, to commence the treatment of the disease by the administration of one or two ten-grain doses of quinine. Some patients seem stricken with death at the very outset of their attack, and for these no treat- ment is of any avail. In a large majority of the cases recovery ensues if the plan of treatment here described be scrupulously followed."
Dr. G. B. Thornton, who, like Dr. Mitchell, had the fullest public experi- ence during the yellow fever epidemics which scourged. Memphis in 1867 and 1873, was, as in the latter year, in charge of the City Hospital in 1878. A victim of the fever twice, he writes as one should who adds to knowledge acquired by an extended practice, that of a personal nature. He gives the following, by request, as his method of treatment: "Believing that yellow fever is a specific disease, a blood poisoning caused by a peculiar miasm against which medical prophylaxis has proven inefficient, and that active heroic medication to arrest it, when once established, is not only useless but positively injurious, the successful treatment has to be by such medication and management as will alleviate suffering and assist nature to throw off or eliminate this poison from the system. There is a fixed course the disease must run, or, in other words, an evolution which must follow as a consequence of this blood toxemia. Therefore, assuming that the treatment must be essen- tially of this auxiliary character. it becomes an important question to do nothing that will interfere with the efforts of nature to eliminate this poison. While the disease can not be cut short or aborted, as an ordinary malarial fever, it can be modified and rendered more tolerant to the patient by judicious medication and nursing. Ordinarily I commence my treatment by a mercurial cathartic, followed, if necessary, in sis or eight hours, by castor-oil. After . the bowels are once thoroughly moved cathartics are no longer indicated during the course of the disease. Quinine, if admissible at all, should be administered early in the attack, in the cold stage which precedes the fever. In anticipation of the fever it is thought, and I will not assert to the contrary, that given at this time in a positive dose, say ten grains, the fever is modified. and the temperature kept down. After the febrile stage is once established, my experience and observation is, quinine is positively injurious. It doe- no good towards eliminating this poison, and only complicates the case by aggra- vating the gastric and cephalic disturbance. After a warm foot-bath, the patient should be placed between blankets, and blankets enough used as cover, as not to oppress but keep the skin gently acting without exhausting perspira- tion. Woolen blankets are the best covers for yellow fever patients; they ab- sorb perspiration without causing the inconvenience that these fluids would on
A HISTORY OF THE YELLOW FEVER.
cotton goods; they also allow the exhalations of the body to escape through their meshes without injury. Bedding should not be changed until convalescence is well established. Such medication should be used as will promote and keep up the action of the kidneys and this mild perspiration. To alleviate thirst, drinks possessing some diuretic property should be given in such quantities and at such intervals as not to offend the stomach. When equally agreeable to the patient, and not contra-indicated by any symptom that may exist, I prefer warm drinks, or, at least, of the temperature of ordinary cistern water, to either ice or iced water. The latter produces a decided unpleasant feeling in the stomach, amounting in some instances to a pain (at least that was my experi- euce), and has no advantage over the former in allaying thirst. Rinsing the mouth with cold water, contributes very much towards alleviating this symp- tom. To relieve muscular soreness and promote gentle perspiration, and some- times induce sleep, sponging the body and limbs with warm or tepid water, or water medicated with vinegar, ammonia, alcohol, or whisky. This should be done without exposing the patient to the air, or subjecting him to physical exertion. Unless it is properly done it had best not be attempted. Mental and physical quietude is an es ential feature in the treatment, and every thing shoukl be done to preserve this that does not interfere with the course of the disease. Opiates, as a rule, should be prohibited. There are some instances in which a cautious use of them is not only admissible, but demanded; but, like quinine, they can not be used indiscriminately : the judgment and dis- cretion of the practitioner can alone decide when to use either. When good does not follow their use, harm certainly does. Opiates are likely to be fol- lowed by irritability of stomach and arrested action of the kidneys: to pre- serve the integrity of these organs is an important and may be an essential feature. In the secondary fever, as a rule, where there is no complication, no medication is required. A judicious administration of diet then takes the place of medication. This should be of a fluid character, given in such quantities and at such intervals as the stomach will appropriate without causing unpleas- ant symptoms. Approaching convalescence should be watched as closely as the first stage of the disease. Stimulants of some character are necessary in the majority of cases, and no arbitrary preference can or should be for a par- ticular 'stimulant. Brandy or whisky are, as a rule, my preference, though in some cases one of the wines act better; and with some, as convalescence progresses, the malt liquors are preferred and aet best. Special symptoms. as they arise during the course of the disease, such as diarrhoea, irritable stomach. black vomit, hemorrhage from any outlet, suppression of urine, and delirium. of course demand specific medication to combat. To guard against or meet an indication which may arise from a preexisting infirmity, the general principles of practice are applicable, guarding against any therapeutic remedy that may be contra-indicated by the main disease."
Dr. R. B. Null, surgeon in charge of Camp Joe Williams,* who was so fort-
* Sitnated seven miles from Memphis, on the line of the Mississippi and Tennessee Railroad.
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A HISTORY OF THE YELLOW FEVER.
unate, notwithstanding the exposures his patients were necessarily subjected to, not to have even one case of relapse, furnished, by request, the following as his method of practice : "To deal in the various theories advanced by men who have spent years of devotional industry in the attempt to explain the nature of the insidious matris morbi of yellow fever, is beyond the intention of this paper; the objeet is to prove that whatsoever has been administered to the sick as a curative agent, based either on scientific principles or empyrical notions, have all alike been barren of fruit. The sanitarian and scientist, assisted by the charity and generosity of the educated masses, have failed to check its fearful ravages, even under favorable meteorological conditions. The inhabitants of Camp Joe Williams were composed in the main of citizens of what was then known as the "intected district" (Poplar, Washington, Adams, etc.), who were removed by a detailed police force, under the vigilant supervision of the Citizens' Relief Committee, to the camp. On their arrival, every article of clothing or bedding which favored the propagation of the dis- ease, was, by order of the surgeon in charge, consumed by fire. Of course, among so many hundred people, cases were soon developed, and most of them run that fatal course which is so characteristic of the dis- ease. The remarkable and favorable feature of Camp Williams was that the disease did not spread among the inhabitants, nor did those who visited the camp from the surrounding country contract the disease. Those who visited the city soon died, or were quite ill for a time, while he or she who feared the place of death steered clear. Parties from the infected district joined those from the non-infected, living in common, occupying at night a small A tent-the former die, the latter escape. Every case which happened substantiated these facts. The details of several cases may not be out of place. The first case that happened was Mr. E., a painter ; the disease run the usual fatal course, and on the fourth day he died. He was cared for assiduously by two friends, a lady and gentleman. Neither of these took the disease. Mrs. D. arrived at camp from the infected portion of the city. She took the fever a few days after her arrival. She and her husband occupied a small, close tent, during her illness. even sleeping together in the same bed. She recovered; he escaped the fever entirely. Another striking illustration of the non-contagious character of the disease is the following: Mrs. S., aged 40, the mother of four children, developed a case of fever. She was ordered to the hospital, her chil- dren to be cared for some distance from the hospital, in tents. One day these children took advantage of a favorable opportunity, stole away to the hospital, in which their mother lay sick of the fever, and in which several had died. Dur- ing my evening visit to the mother, I found them gathered around her bed. My first intention was to have them immediately removed to their isolated quarters. But the children wept and entreated that they might be permitted to remain with their mother, while she argued that she could not survive, and begged that I would let them remain with her. The mother recovered; nonc of the children were attacked. In the wards of the male hospital were employed eight male nurses, five of whom, after nursing for three or four weeks among fifteen or twenty patients in all stages of the fever, thinking themselves proof against
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A HISTORY OF THE YELLOW FEVER.
the disease, determined to go to the city and there offer their services, because of the higher price paid nurses by the Howard Association. I advised them fully as to the dangers of the city, nevertheless they went and remained there several days. The sick were all bountifully supplied with nurses from a dis- tance; they were therefore unable to obtain positions, and consequently re- turned to camp. Four of these men died of the fever in the hospital in which they had nursed, the other was found dead between the city and the camp, a short distance from the latter-the result, I believe, of debauchery and fever. The three nurses who did not visit the city, but remained in the hospital dur- ing the epidemic (seventy-two days), nursed and buried their confederates, but were not attacked themselves. Every physician, except Dr. T. O. Summers, of Nashville, who was officially connected with the camp, and who visited the city, either died or had the fever, while I, who left the city early and never visited the infected district before I left for camp, escaped the disease. During the fatal illness of the late Dr. Sample, of Austin, Miss., I remained in the tent with him the whole time-four or five days; I was convalescing from a severe attack of bilious fever, but entirely escaped the fatal disease. From observations of Camp Joe Williams, I am driven to the conclusion that yellow fever, under favorable meteorological conditions, intense heat and humidity- particularly the former-finds a nidus or pabulum in the exhalations which emanate from the excreta of human beings."
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