YEEEOW FEVER 
R Brief Sketch of Its Natural and Clinical Hist cry, 
Together with Some Practical Suggestions 
Relating to the Sanitary Control of 
Yellow Fever Outbreaks, 
A Paper Read Before the Indiana State Medical Society May, 1889, 
BY S. H. COLLINS, M. D., 
OF 
LAWRENCEBURG, INDIANA, 
Formerly Secretary Board of Health, Memphis, Term.; Ex-Inspector National Board 
of Health, Memphis Tenn., New Orleans, La., and late Quarantine Officer, Ship Island, 
Oulf of Mexico. 
WM. B. B(J K P* IKD, PKINTKK, IN Dl A N A POLIM. Yellow Fever* 
SAMUEL II. COLLINS, M. D., LAWRENCEBURG, INI) 
It seems that it will be not inappropriate, in view of the 
outbreaks of last summer and fall, at several points in the 
South, of this disease, to eall your attention through this pa- 
per, to a few of its salient features, as regards symptoms, treat- 
ment and prophylaxis, especially as the mildness of our winter 
throughout the States has been such that there exists among 
many of those best qualified to judge, a grave apprehension 
of outbreaks at various points, and they early in the seasou. 
Yellow fever, deriving its name from a symptom, not always 
markedly present, and occurring in a late stage of the disease, 
is a disease of special type, infections, perhaps somewhat con- 
tagious, consisting of one febrile paroxysm. Originating in 
tropical America, it has been known in medical literature as 
having prevailed more or less extensively since the latter part 
of the fifteenth century in tropical, sub-tropical and insular 
America; along the Atlantic sea coast, and occasionally ascend- 
ing the valleys of the Mississippi, Red and Ohio rivers. It has 
occurred as far north as Portland, Me., upon the sea coast, and 
inland in the valley of the Ohio, to Gallipolis, Ohio. While 
pre-eminently a disease of the low lands, it has repeatedly 
raged at elevations varying from 3 to 14,000 feet above the sea. 
Once established in a territory where conditions favor, it will 
spread through rural as well as urban 
this is not generally believed to be the it is undoubt- 
edly true that its spread is specially favored in crowded com- 
munities, particularly among persons born in colder latitudes. 
Its spread seems dependent upon an average daily temperature 2 
of not less than 65° F. Warm, damp weather is conducive to 
the rapid propagation and spread of the disease. Storms oc- 
curring during an epidemic, especially those accompanied hy 
lightning, by clearing the atmosphere, lessen the number of 
new cases for several days; but such storms always exert an 
unfavorable influence upon those already sick. The ravages 
of yellow fever are checked by the advent of cold weather, but 
only checked, the disease lying dormant under the influence 
of cold, not killed, repeated and severe freezes have proved 
inadequate to render sterile the virus of this disease. Of this 
fact the w.iter has had ample proof. Heat, on the other hand 
will, and does effectually destroy the vitality of the poison, and 
whether this heat be applied dry or moist matters not. 
The white races are most susceptible to the poison of yellow 
fever; sex is not a factor, nor occupation. The disease is rare 
in children under five. Whites, born in regions beyond the 
northern range of this disease, are more liable, when exposed, 
to be attacked than those southern born. The negro is less 
susceptible to the action of the poison of yellow fever, than 
the white; this immunity being weakened, in proportion to the 
amount of white blood, in the mixed race. The old theory 
that negroes could not have yellow fever, is now known to 
be untrue; they have it and die of it. One attack ordinarily 
affords immunity from the disease for life, unless perhaps in 
the cases of persons moving to colder latitudes, there residing 
for several years and then returning to an infected district. 
Still the writer has seen a second attack of yellow fever, occur- 
ring within sixteen months of the first, both attacks being char- 
acterized by unusually severe symptoms, the patient dying in 
the second attack. On the other hand, there are individuals 
who have been constantly exposed to the disease and who never 
have been attacked. The anatomical features as seen after death 
from yellow fever are quite constant. The body is often bloated, 
the conjunctiva, skin of the face and neck, and sometimes of 
the upper extremities is of a yellow hue, varying from a light 
lemon-color to an orange-bronze. The belly, back and lower 
extremities are mottled with dark, purplish-brown spots and 
patches. Putrification sets in immediately with death, and in 
some cases I have noted such changes before death. Rigor 3 
mortis may or may not be present. The autopsy shows, almost 
always, fatty degeneration of the heart, the cavities filled with 
dark clots. Lungs congested, sometimes showing traces of 
localized hemorrhages. The mucous lining of the stomach is 
always more or less congested and softened; often there are spots 
of erosion. This organ generally contains a considerable quan- 
tity of dark, grumous matter. The intestines are softened and 
dark, distended with gas, and often contain large quantities of 
transuded blood of a tarry color and consistency. The liver is 
firm and yellow, and filled with fat. I have never failed to find 
the spleen enlarged, but as the subjects of my autopsies had 
been residents of intensely malarial districts, malarial poison- 
ing may have been somewhat of a factor in these enlargements. 
The kidneys are infiltrated with fat. The bladder, as a rule, 
will be found to be empty. 
The disease is ushered in, after a period of incubation of 
from one to thirty days, by symptoms varying from a 
feeling of slight malaise, chilly sensations, pain in the head, 
back and limbs, to pronounced rigors, intense, bursting head- 
ache, pain in the back and limbs of excruciating severity. The 
attack being, as a rule, sudden. The eyes are suffused, the 
face is flushed. There may now follow a chill of light grade, or 
so deep as to numb the sufferer to temporary unconsciousness, 
and cause the skin to have a shriveled look. This stage of chill 
may be absent. The stage of invasion is hardly established 
before the thermometer shows a rise of body heat. This rise 
is rapid. The mercury ranges from 101 to 114 degrees F. The 
highest thermometric reading of any case, coming under my 
observation, was 109 degrees. Though this is a disease of but 
one febrile paroxysm, the type of fever may vary; it may be 
simply continuous and having reached its maximum, decline rap- 
idly; it may be remittent in character, each succeeding wave of 
heat mounting higher until the crisis is reached thence, grad- 
ually downward; or the type may be intermittent; this last vari- 
ety I believe to be rare, as I have never seen it but a very few 
times in many hundreds of cases of the other types. This 
stage of invasion, chill and febrile excitement, lasts from forty- 
eight to seventy-two hours. The pulse is remarkably slow in 
proportion to the grade of fever. The skin has a pungent feel 4 
to the hand. The borders of the eyelids are red and raw-look- 
ing. The eyes are bright, but expressionless. The odor of 
the patient, once smelled, will never be forgotten. The con- 
junctivae show slight tinges of yellow. The bowels and kidneys 
are inactive. There may or may not be muttering delirum. 
Usually the patient is mentally clear in this stage of the fever. 
There is nothing characteristic about the tongue. The urine 
always contains albumen. The fever subsides rapidly. The skin 
is moist, sometimes clammy. The second stage is on. The 
pains have subsided. The pulse is soft, weak, quick. The face, 
neck and arms are now distinctly yellow. The kidney action 
still scanty. There is now either a rapid and marked improve- 
ment within twenty-four hours or hiccough sets in, the stomach 
becomes irritable and ejects without nausea or much effort; at 
first a glairy mucous which soon changes to the characteristic, 
grumous discharge, the black vomit; this stage lasts from five 
to thirty-six hours, and unless the vomiting is checked and 
the inactive kidney roused, the sufferer dies from heart failure, 
or in uremic coma or convulsions. Should convalescence set 
in, recovery is rapid; though great caution should be exercised 
to guard against relapses which are almost invariably fatal; in- 
discretions in diet, over-exertion, the untimely bath, have many 
times carried off a patient who was nicely on the way to re- 
covery. Of the cause of yellow fever we know nothing de- 
finitely. Researches now begun, may throw light upon this 
question. Undoubtedly of germ origin; later investigators are 
coming to the opinion that the seat of attack is the stomach 
and intestinal tract. Of treatment I have little to say. Many 
remedies have been given, but one after another they have been 
discarded. Quinia is useless, 1 think worse than useless. The 
best treatment is what is known in the far South as the Creole, 
which consists in unloading the stomach, if necessary, at the 
onset of the attack, by some mild emetic, preferably warm mus- 
tard water. If the case is seen early a brisk purge of calomel 
followed by castor oil may be given, but this procedure is only 
advisable at the onset of the disease. A hot mustard foot-bath 
should be used and the patient lightly enveloped in wool 
blankets, put to bed in a well ventilated room free of draughts. 
If there is much back pain or gastric irritability, applications 
of mustard are useful. 5 
Mild perspiration may be induced by drinks of warm orange- 
leaf tea, or hot lemonade. For reduction of temperature, fre- 
quent and careful spongings with tepid water are most effectual. 
Opiates should be used with the greatest caution, in fact my 
experience is that opium in any form is dangerous. If there 
is too little action of the kidneys, mild diuretics may be used, 
but on account of the irritable condition of the stomach great 
care should govern their use. For the vomiting, applications 
of mustard, and cold, over the epigastric region. Internally, 
pellets of ice, oxalte of cerium, etc. I have seen very happy 
results in obstinate and copious vomiting from Mur. tinct. ferri, 
in teaspoonful doses. In view of the probable germ origin of 
the disease; the treatment lately suggested by Dr. Geo. Stern- 
berg, U. S. A., of minute doses of Hydrarg-Bi-chlorid, repeated 
hourly; should be given a full trial. In the stage of recovery, 
rest of mind and body, and the greatest caution with regard to 
diet, is all that is necessary. I now come to that part of my 
subject which deals with the proper disposition of the dead, 
the disinfection of infected houses and household goods, and 
the isolation and care of the sick. First, the public, through 
the medical profession, should be taught if possible the folly of 
the unreasoning shows of terror, which are so often brought to 
our notice. Too often do the members of our profession add 
fuel to this fire of terror, by their personal exertions to flee 
the plague. Honesty in dealing with the public with regard to 
suspicious cases, in districts liable to yellow fever, and prompt 
reporting of each and every case would do much in stripping 
off some of the unnecessary terror attached to the announce- 
ment of yellow fever in a town or city. Once known to be in 
any given community, a quiet and orderly retreat is right and 
proper. Those able, and not protected by a previous attack, 
should go away from and out of the infected district. Those 
not able to leave, and not protected, should be moved at public 
expense to camps of detention and observation. The sick 
should be taken to fever camps, properly selected with regard 
to elevation, drainage and water supply. Such camps should 
be strictly guarded, absolute non-intercourse between a fever 
camp and the outside should be enforced. When in camps of 
detention and observation, cases appear,as they generally do, 6 
such cases should be quickly and quietly moved to the fever 
camps. In both varieties of camps, the lodgings should be tents. 
Where cases occur in detention camps, and such cases have been 
removed, all others at the time living in the newly infected 
tent should be removed to the outskirts of the observation 
camp and lodged in tents by themselves for observation; the 
lately infected tent and its bedding should be burned. Should 
no cases develop within thirty days, those under observa- 
tion may be allowed to return into eamp. There should be no 
passing between a camp of detention and an infected town. 
All supplies for both varieties of camps should be brought to 
some designated point at least a half mile outside the picket 
line and there left to be taken into camp one hour later by 
camp messengers. In a town where the disease has made its 
appearance, after the removal of all occupants, infected 
houses should be thoroughly disinfected so far as their walls 
and wood-work are concerned, by fumigation with burning 
sulphur for 12 hours, each room being as tightly closed as 
possible. The house should then be open to free ventila- 
tion for 48 hours. All bedding, carpets and wearing apparel 
should be included in this process of fumigation; the clothes 
worn by a patient dead of yellow fever should be destroyed by 
fire, as should his bedding, if much soiled ; otherwise it should, 
after fumigation, be thoroughly boiled. Cellars, out-buildings, 
damp places about the premises should be thickly strewn with 
slacked lime. No re-occupation of a house so disinfected should 
be allowed until after the disease has been stamped out of the 
town. The bodies of those dead of fever should be stripped of 
all clothing, enveloped in a sheet or shroud wet in a saturated 
solution of sulph. of zinc, and immediately buried in graves 
or trenches not less than six feet in depth, the bodies being 
covered with slacked lime, before refilling the grave. 
During the existence of yellow fever in any town, although 
its remaining inhabitants are supposed to not be liable to at- 
tack, all public gatherings or public burials should be absolutely 
prohibited. Now, gentlemen of the society, I am aware that 
I have told you nothing new. I have presented no theories, but 
have called your attention, in plain language, to this subject, 
because, before the summer is over, we may have it brought 7 
to our attention in a more forcible manner. Because it is a 
subject with which the great majority of the members of this 
society have no practical experience. Because if yellow fever 
should be introduced into our State at a sufficiently early date, 
during the summer its ravages would be of untold damage ; 
and if I have slightly refreshed your memories, or outlined a 
method of treatment (the best now known), with some easily 
applicable rules for the governance of health authorities with 
regard to the proper sanitary management of fever outbreaks, 
I shall have accomplished what I had hoped to do. I have not 
drawn my information from books. What I have to day given 
you is the result of a large practical, personal experience, hav- 
ing been through three epidemics of yellow fever, having had 
the disease, and from having seen hundreds of cases, as physi- 
cian and sanitary officer.