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Towards an Understanding of Yellow Fever

There is no cure for yellow fever, a deadly disease that ravaged the United States since the nation was founded. Although Carlos Finlay presented his theory that the disease was transmitted through mosquitoes in 1881, it was not until the experiments of Walter Reed and his team in 1900 that public health officials acted on those findings.

Nineteenth century letters are filled with terrible stories of families and cities ravaged by the disease. Equally frightening are the official medical dispatches of the time that demonstrate how desperate and confused physicians tried multiple treatments for yellow fever, all to no avail.

Treatments Administered for Yellow Fever, 1848
An 1848 report by doctor J.C. Nott on the epidemic in Mobile begins with a mild description, but the list of treatments described seems left over from the Middle Ages.

From The Charleston Medical Journal and Review, Vol. 3: 1, Charleston, S.C., January, 1848.


Messrs. Editors:

You ask me for a sketch of the epidemic of Yellow Fever, which has just taken leave of Mobile. If you will accept a hurried sketch you are welcome to it -- I shall not attempt a perfect picture, but will only touch on those points which caught my eye en passant.

So wide spread, so mild in type, and so manageable has been the yellow fever of 1847, that it should properly be called an ephemeral epidemic. During the months of August, September and October, we had probably 7 or 800 cases of yellow fever of all grades, and the books of the sexton, which can be fully relied on showed but 68 deaths from this disease to the 1st of November. When we turn our eyes to the melancholy picture presented by our sister city, New Orleans, where nearly 3000 persons have died of the same disease; when too, we remember the havoc so often committed by it in the West Indies, and more especially in Spain, where instances are recorded of nearly a third of the entire population of a city being swept off by a single epidemic, such results might well excite a doubt as to the identity of these various epidemics. The diseases however are the same, and our ephemeral epidemics, which alone would scarcely be worthy of record, belong as much to the natural history of fever, and possess as much interest as the most deadly pestilence.


So much importance has been attached to weather by writers, that it may be well to say a few words on this head. It would be needless to fatigue you with details, and I will remark in general terms, that appreciable changes in our summer weather, have about as little to do with yellow fever as they have with small pox or measles. Long observation has brought the physicians of Mobile to this conclusion, and the following extract from my note book, will add confirmation to past observations; dated 1st August, 1847. " The summer up to this time has been the most temperate and rainy I have seen in twelve years, the thermometer has in my office but once reached 89 degrees F. -- it rained half the days in June, and twenty-five days in July, often in torrents -- nearly 14 inches of rain fell in the latter month, and yet in the midst of these incessant rains the yellow fever commenced. The first subject was Captain Smith, of the ship Emblem, who had arrived 9 days previous to his attack, direct from New York -- he left his vessel 30 miles below the city, came to the Mansion House, and there remained until attacked. He was attacked on 18th July, and did not die until the 4th Aug. An Irishman died with black vomit on Dauphin, near Cedar street on the 2d August."


Treatment. -- On this head I shall say but little, as our epidemic has been so mild that la medecine expectante, except in a small proportion of cases, night have been safely relied on.

Ample experience and the frequent and friendly interchange of ideas has brought our older practitioners in Mobile to great uniformity in the treatment of yellow fever, and I believe the disease is not better treated anywhere. Our treatment is not only modified to suit different epidemics, but individual cases in each year. The leading remedies about which doctors dispute are bleeding, purging, quinine, mercury and stimulants.

Bleeding. -- Our rule is to be guided in the use of the lancet by the symptoms of each case, and not by the name of the disease -- when the pulse is above par we cut it down; when it is at par or below it we hold off; where there are local determinations we use cups. In every epidemic I have seen, the lancet has been the exception and not the rule, and we have all been led to this conclusion by much practical experience, though we bleed more in some years than in others. Even Dr. [Benjamin] Rush, who sang so loudly the praises of the lancet in '93 [1793], was compelled in after years to moderate his tone; and any one who relies upon the lancet as a universal or even general remedy in the yellow fever of our country, has studied to little purpose the long history of those diseases produced by morbid poisons -- as yellow fever, cholera, scarlet fever, small pox, &c. These diseases, unlike the phlegmasiae, have a course to run, are really cases of strength husbanded, the general result in severe epidemics can never be satisfactory.

Purgatives. -- Many writers tell us that the bowels are much constipated and difficult to operate on in yellow fever; but instances of this kind are exceedingly rare in Mobile -- there is not one case in twenty in which ten grains of calomel and a dose of oil will not evacuate the bowels thoroughly; and after the first stage almost any light aperient will act; and even a Seidlitz powder or dose of magnesia will often produce numerous watery stools, which require to be checked by opium. We therefore use calomel or blue mass, followed by mild purgatives, as oil, rhubarb, some simple pill, &c. The hydorogogues we discard -- even Epsom salts, so often recommended, certainly is not a proper remedy for our disease. Independent of any specific effect we use mercury as a purgative, because it is the least irritating and least apt to produce watery discharges. You see, then, by the manner we use bleeding and purgatives, that we are bearing in mind, with fear and trembling, the approaching collapse, or "that bugbear, debility," of which one of our good friends speaks in a late journal.

Quinine. -- This remedy has met with no favor amongst us, except in a few intermittent cases which are seen in every epidemic; and even here it is a very uncertain remedy. In the uncomplicated cases of one paroxysm, I believe, to say the least of it, it is utterly useless. I understand it has been used in New Orleans the last season with immense success, but some how or other about 3000 persons have died there with yellow fever, and I have no doubt it has injured as many as it has benefited. Experience is often fallacious, and there is nothing more easy, as Mirabeau says, than to deceive ourselves. A new and infallible remedy was discovered in every town the cholera visited. The fact that the profession are all quarrelling about the efficacy of quinine proves it cannot have much. Where a well known remedy produces a decided benefit the profession soon unite on it -- no one doubts the value of quinine in intermittent, neuralgias, and some other affections.

Stimulants. -- We are all agreed in Mobile on this point -- whenever the pulse begins to flag we begin to stimulate, and nothing seems to hit a Mobile stomach like a mint julap -- whether it be or not because we like this charming beverage so much in health I cannot say, but certain it is the brandy julap is the thing for the collapse stage. Sometimes Champagne, sometimes porter, do well; but how any one can recommend carbonate of ammonia I cannot divine -- I have never seen it agree. There is nothing gained by forcing stimulants on the stomach, but when they are kindly borne they may be taken freely.

Mercury. -- One of the grand disputes, even in Mobile, is as to the true value of the specific virtues of this remedy, though we all use it to some extent. Of its advantages as a purgative, from its mildness and efficiency, I have no question; as to its great specific virtues, j'en doute. Baron Louis, whose deep research and whose ability in sifting medical evidence cannot be questioned, says, "The discovery of a remedy must be left to time and chance, and to the acuteness of the observer, for experiences has sufficiently proved that no dependence is to be placed on mercurial preparations of any sort." Now, the Baron has here perhaps gone too far, as I believe that in a certain class of cases calomel or blue mass are often used with decided advantage. Where there is a coated tongue, or watery stools, and the stomach bears them well, they may be used as alternatives with decided benefit, in small and often repeated doses; but where the tongue is clear, particularly where it nauseates, mercury in any shape I regard as worse than useless. It is a fundamental point in this disease to keep the stomach quiet, and no remedy which violates this rule can do good. I have repeatedly seen patients who had been kept nauseated by calomel, commence improving as soon as it was withheld.

Marine Hospital Report, 1898 Treatment and Managment of Train Tracks
In 1898 the United States Marine Hospital Service issued a report on yellow fever. In Section B, Surgeon R.D. Murray speculates that yellow fever is a disease of the duodenum, before cataloguing treatments for the disease. The general sense of impotence in his descriptions is palpable, as the methods he describe constantly remind doctors not to let patients know how sick they are and what they are suffering from.

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 no 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 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, as well as bed side experience, have shown me that the death-dealing 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 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 to the spinal column the duodenum lies. If the stools could be all and carefully examined sometimes 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 common in this 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 deathbed. I have given immune certificates to persons who never went to bed.

In ordinary, the patient should like the medical attendant. If the physician is distrusted, he should be called off or feign illness, 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 to-morrow, with its reward or revenges. Several people are living now because, in their desire to take vengeance on me for what they thought was my 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 or 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 curds 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 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 Bright's disease sufferer; of a morphiomaniac's recovery, and last summer gave a diabetic doctor such a 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 most honest, most trivial, and cheapest to treat of all diseases that kill." It is "honest" because it comes with definite signs and leaves no trace, always insuring the afflicted on that he is hereafter immune; it kills, if at all, in a few days and is merciful in the killing, as the doomed 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 miserable 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 treat" 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 cost very little.

TREATMENT OF YELLOW FEVER.

When called to a man (most of my work has been with men) who has had a chill some time during the previous night, has a pulse of 100 to 112, with temperature of 101.5 degrees to 103 degrees, 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 the yellow fever.

Give three or four compound cathartic pills at once and 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 enough of it and are in your vest pocket. Every yellow fever doctor should carry first doses of compound cathartic pills, compound acetanilide tablets, and such other pocket remedies 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," but do not say so. Keep back information about the actual temperature all the way through, but tell them about the height of the fever. No patient should ever hear that his fever went about 102 degrees until after he gets well. (I saved a doctor once by hiding his thermometer and using my French scale, which he could not translate.)

Give as soon as convenient, or, if fever is above 102 degrees, at once, any coal-tar derivative in 7 1/2 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. I 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 or dumped into a tub of water; dispose of the wet sheets 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 to skin, so much the better for prevention of skin shock. Quilts and counterpanes are objectionable because of the nasty odors they retain.

fever-primarysource-trains.jpg
Arrival of boat from Cuba at train stop | Library of Congress

Another section of the Marine Hospital Service Report of 1898 prescribes methods of preventing the spread of yellow fever through the management of railway lines. As can be seen, many of the recommendations -- using cane seats rather than upholstery -- are based on the assumption that the disease can infect and be transmitted through inanimate objects like bedding.

Inspection Service by P.A. Surg. G.B. Young

PREAMBLE.

In conducting a system of train inspection for the purpose of preventing the spread of disease and of facilitation intercourse and trade as far as is consistent with safety, it is most important to always keep in mind that the limitation of the spread of the disease should be paramount to every other consideration, the facilitating of traffic being of only secondary importance.

I lay stress upon this because my own experience has taught me that it is often difficult to maintain the proper point of view in the face of the senseless and vexatious oppositions of local origin that often upset one's carefully considered plans. One is apt to become absorbed in the task of opening lines, moving trains, and the like unless careful to remember that such things, while unquestionably of great importance for the public good, are not the most important part of the work.

RELATIVE IMPORTANCE OF QUARANTINE AND TRAFFIC.

I do not mean to belittle the importance of opening up traffic, however, for the suffering and loss that accompany the interruption of trade and travel during the presence of yellow fever, and the resulting local quarantines, are among the most dreadful consequences of the scourge.

Next to preventing the actual spread of the disease the most important thing to do is to strive to minimize the distress that the fear of its coming brings to all within the threatened territory.

In conducting a system of train inspection, then, our first duty is to facilitate in all proper ways the escape from infected places into noninfectible territory of those who desire to go; second, to supervise the movement from place to place in infectible, but clean territory, of those whose necessities compel them to travel; and, finally, to do what we can toward keeping open the channels of trade.

Let us consider the principles that should govern our action in securing each of these several ends, and then take up, somewhat in detail, the methods to be followed in maintaining these principles.

Under the first head, then, the rule can be laid down that all persons can be permitted to leave for noninfectible territory if a reasonable certainty can be secured that they will not return into infectible territory before the expiration of ten days from the last possible exposure to infection, which, however, may be and often is a very different thing form ten days since their departure from an infected place; but that this movement must be so conducted that no danger results to the territory through which they pass en route.

ALL PERSONS MUST GIVE SANITARY HISTORY OF THEMSELVES.

Under the second head the fundamental principle is that only those should be permitted to travel who can give a good sanitary history; and that while en route they shall be preserved from contact with any infected or suspected person, place, or thing.

Given the observance of these principles as to both persons and things and the opening of the channels of trade would seem to follow as a natural corollary, but on account of the peculiar conditions which arise under local quarantines it does not naturally do so.

For the proper opening of trade it is necessary, first to secure the confidence of the various local authorities and, second, to maintain sanitary control of the transfer and junction points, the "strategic points" in our sanitary campaign.

FORMULATION OF DETAILED RULES AND DESIGNATIONS FOR CLASSES OF PERSONS AND THINGS.

An attempt will now be made to formulate somewhat detailed rules of the conduct of a system of train-inspection service.

For the purpose of brevity the name "suspects" will be applied to persons from infected territory and that of "passengers" to those from uninfected territory.

Where mail, freight, or express cars are referred to they will be called "cars," passenger cars being spoken as of "coaches."

"Train crews" will refer to all persons employed on the train in any capacity, except that in some instances, to be noted at the time, the Pullman conductor and porter are treated as belonging to a slightly different class.

PASSENGER TRAFFIC FROM OR THROUGH INFECTED TERRITORY.

CLASS OF COACHES PREFERRED.

Whenever possible, the coaches used in conveying passengers from or through infected territory should be of the kind equipped with cane seats. These are much less apt to become infected and are much easier to clean. No matting should be allowed in the central aisle and, as far as possible, all curtains and hangings should be prohibited.

WHERE TO DISINFECT COACHES.

Wherever possible, coaches used for carrying suspects should be disinfected at the ends of their runs, i.e., in clean territory.

This disinfection can be done by the employees of the road, but should be under the supervision of a sanitary inspector, who should be informed by wire on the departure of each train from the infected place of the numbers of the suspect coaches, and after disinfection the coaches should be placarded with the date of disinfection and the signature of the inspector.

TRAIN SHOULD NOT STOP IN THE INFECTED TOWN.

The train should not stop at the infected place, but should pick up the refugee coaches at some point outside the town, even if only a few hundred yards, and the necessary couplings and setting of switches must be done by employees other than the train crew.

ARRANGE WITH HEADS OF RAILROADS AT FIRST.

Arrangements must be made with all the roads in the territory to furnish transportation for all officers and inspectors, and to issue orders to all employees that the train inspectors are in absolute control of all sanitary matters on the trains and that their orders must be obeyed to the letter.

Provided one goes to the head officers to make arrangements he will find it a pretty general rule that the larger the corporation the more intelligent will be its cooperation in his work.

A clear understanding must be promptly reached with the express companies and with the superintendent of the Railway Mail Service and with the Pullman Company as to just what you want them to do. In all such cases treat only with the man at the top; it will save some trouble and a great deal of time.

TIME IS OF PRICELESS VALUE AT BEGINNING.

Time is of priceless value at the beginning. If it is a question of losing time or having misunderstandings with local authorities and railroads, act first and straighten things out afterwards; it is surprising how much you can do without any real authority if you insist on having your own way.

A competent steward should be in charge of the central office, and, if the territory is a large one, a stenographer and typewriter.

Yellow Fever: Its Epidemiology, Prevention, and Control, Lecture, 1914
In 1914, Dr. Henry Rose Carter gave a series of lectures on yellow fever at the United States Public Health Service School, an institution that grew out of the Marine Hospital Service. While acting as the chief quarantine officer of the Marine Hospital Service in Havana, Carter discussed theories of yellow fever with Walter Reed. In his first lecture on March 26, Carter makes immediately clear and unequivocally the method of infection that his colleague had proven: yellow fever is transmitted by mosquitoes.


I am directed to tell you something about yellow fever. In the time allotted it is impossible to cover the subject unless so superficially as to be useless to you. I am therefore going to take only one aspect of this disease, the one of most importance and of most interest to you.

You are, or ought to be, sanitarians, and it is the sanitary aspect of yellow fever only that I will present you. I will not discuss the disease, as it concerns the practitioner. I am also going to assume a considerable knowledge of yellow fever in this class, because you have it. I am not going over a lot of facts well known about it, not because they are unimportant, but because you know them, and it would be a waste of time.

As preliminary to the sanitation of any disease we must know its epidemiology, and to know this satisfactorily a knowledge of the method of its conveyance is necessary. Yellow Fever, as you know, is one of the host-borne diseases. The history of the discovery and the demonstration of this by the Army board of which Maj. Reed was chairman are known to you. The subject is extremely interesting, but I have not time to go into it. The findings of the board were, briefly: Yellow fever is contacted by man from the bite of a mosquito, itself infected by having previously bitten a man sick with that disease, and is only thus contracted. The first part is a direct statement of observed facts, the latter a deduction (and a negative one) from the facts; both are not only universally admitted but abundantly proven, which is by no means the same thing. Upon this doctrine all sanitary measures for the control of yellow fever rest.

There are evidently three factors considered in the creed we have mentioned above-the sick man, the mosquito, the well man. There is also implied the infective microorganism of which as yet we know but little.

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