Article by Dr. W. N. Hiron

Part One

Medical Times and Gazette

This article was published in the Medical Times and Gazette in two parts. The first part appeared in the edition published on the 29th July 1871, pages 124-126.

YELLOW FEVER IN THE RIVER PLATE

by WM. NATHANIEL HIRON L.R.C.P. Lond.,

M.R.C.S. Eng., L.S.A.L;

Admitted to practice in Monte Video; ex-Surgeon-Major Argentine Army
on the Medical Staff of the Popular Health Commission
during the Epidemic


The city of Buenos Ayres has been visited, during the latter part of January, February, March, April and May of 1871 with a most severe epidemic of yellow fever. The same disease appeared during the latter part of 1870 in the city of Asuncion - capital of the Republic of Paraguay - where it raged with a certain violence. Cases of the same disease were observed in this city during the preceding summer, 1869-70, supposed to have been imported from Rio Janeiro. The town of Corrientes, capital of the province of the same name in the Argentine Confederation, and on the line of direct communication between Buenos Ayres and Asuncion, was most severely visited by the plague at the commencement of the previous year. A few cases (less than a dozen) of this disease occurred in Buenos Ayres in the autumn (April) of 1870, during the time this disease was raging in Rio Janeiro, and were believed to have been imported thence; but the affection did not spread outside the hotel in which the cases occurred.

On the appearance of the disease in Buenos Ayres, a Medical man of Monte Video published in the journals of that city a statement expressing his belief that the affection was not the specific yellow fever, but a bilious remittent fever. Arriving in Buenos Ayres about this period, and desiring to assure myself about the real nature of the fever, I went daily to the lazaretto, and there saw all the symptoms described as essential to the fever, and was able to ascertain the frequent accession of urinary suppression and the common presence of albumen in the urine. About this time, also, a Medical man, who had been very assiduous in attending the sick, himself sickened and died of the fever. This seems to prove the contagion.

The population of Buenos Ayres numbers some 180,000. It is generally believed that at least 100,000 very wisely fled the city, and of those who remained. probably three-fourths sickened and one-fourth died. Various and very varied computations have been made of the extent of the fatality of the epidemic. The official returns appear to have been most loosely kept, and only give between 13,000 and 14,000 as the extent of the mortality; my own impression is that about 20,000 (under, rather than over, this amount) have perished. I hope to be able to send you amended official statistics, which we are promised anon.

Of some seventy Medical men who remained at the post of duty, fifteen have died, and probably half sickened. In the town of Corrientes, five died out of seven, and two apothecaries of three that were there when the epidemic commenced.

I believe yellow fever existed in Barcelona in the autumn of 1869; I am not sure if it may not have been later. There is some talk about an importation of the disease thence. I cannot find confirmation of this idea, and think with all the yellow fever we have had near us a cause close at home may be accepted. You must understand, it is very difficult to ascertain facts of this kind in this country. There is not the least doubt, howver, that quarantine, although imposed, have been simply farcical during all the time the disease was raging in Asuncion, and even at Corrientes, in the same Republic. It is said that two employés of the steamer Provndor, which ran between this port - Corrientes - and Asuncion, came ashore suffering from the fever; also that a patient escaped from the quarantine lazaretto, and brought the disease to the city. Possibly, more may be made public on this matter; if so, I will inform you. For a considerable period before the outbreak of the epidemic an exceptional season prevailed: the preceding winter, spring, and early part of summer had been exceptionally dry, the summer hot. This condition had prevailed throughout these parts.

Buenos Ayres is a city without drainage, in which the population occupies a small area in proportion to its number; the streets are narrow, and, rents being very high, it is natural for many people to live in one house. The most complete disregard for all hygienic rules exists, and the débris from the slaughter of the cattle has been hitherto discharged into an almost stagnant inlet of the river in most unpleasant proximity to the city. The odour from this source has been, with a favourable wind, almost insupportable, even in the centre of the city. The method of making streets has been to fill up with offal before macadamising. Such filthy water-closets I have never met with anywhere although one gets to a certain extent prepared by what one encounters on the Continent in Europe.

The city of Monte Video at first imposed a stupid quarantine of three days duration; after a time it was increased to twelve days, then to twenty days, and finally the port was closed entirely. In the town of Rosario a quarantine of fifteen days was imposed from the first. After a time, the port here also was closed. Both Monte Video and Rosario have saved themselves from the plague. The disease springing up in one parish, was for a long time confined to that parish; and in the early period, although cases passed from this parish to others, they did not seem to originate the disease in the parishes whither they went; and this happened throughout the epidemic in the country districts where cases have been imported from the city, and have been fatal, but have not called forth the disease in others. However, in time, the disease spread throughout the city. Immediately after the Carnival, the disease doubled in amount, and was probably truly attributed to the intermixture of the people during that season; for this reason, the festivities of Holy Week were very properly dispensed with.

The influence of meteorological conditions was remarkable: - Cold increased greatly the number of deaths, but seemed to be followed by a smaller number of new cases; heat augmented the number of new cases; and rain combined with heat appeared to favour most the progress of the epidemic. An arrest seemed to be put to the disease by several days of extreme cold, followed by very heavy rains, even although the temperature which followed was again higher, though not so high as previous to the week of climatic crisis.

The temperature is very variable here; the thermometric ranges are great, even in a period of twelve hours; rain falls rarely, but in considerable quantity within a short period. Thus generally three or four hours in midday may be quite hot, and yet the remaining part of the day cold, and the night exceedingly so; it seemed as though a continuously low temperature was necessary to affect sensibly the plague.

It seems that fevers of varied type (probably malarious) exist here, but to a limited extent; and that yellow fever has not yet found a habitat. It was here in 1858, and again last year; but last year it appeared to extinguish itself in the place where it broke out in the autumn, and the first cases this year were in quite a different, and sufficiently distant, part of the city.

The greatest sufferers by the plague have been the Italians, who are the poorest part of the population, and live in the worst hygienic conditions, and, besides, are the most ignorant and least disposed to apply for Medical assistance. These are the occupants of the "Convent Moa" a term which may be literally rendered "fever dens". You will readily understand that the number of Medical men should have been insufficient to cope with this colossal plague; national prejudices also impeded that beneficient united action which should have been cultivated at all cost.

The importance of early treatment was clearly apparent; the proportion of mortality increased terribly with every day of unassisted fever. The fatal symptom was urinary suppression - but very, very few recovered after this symptom set in. I estimate that the natural mortality of the disease, unassisted, was not more than 40 per cent. of the attacked; Medical treatment reduced it about 20 per cent., and in the decline of the epidemic it was probably less.

Statements about diminution of ozone in the atmosphere, and of electrical aberrations, were made, but they were entirely unsupported by acceptable evidence. It was the opinion of the Professor of Chemistry in the University (who unfortunately himself succumbed to the disease), from some partial experiments, that the amount of ozone was not diminished.

The towns on the line of infection are Monte Video, Buenos Ayres, Parana, Corrientes, and Asuncion. The disease existed in Asuncion in the summer, in Corrientes during summer and the early part of the autumn, in Buenos Ayres during the latter half of summer and autumn. The summer throughout was hot and dry; during this Asuncion and Corrientes suffered. The temperature in Buenos Ayres during the epidemic was very variable, and there were several very heavy rainfalls, but also a few light rainfalls with general moisture, and, when the epidemic fell, a more maintained low temperature. Although exposed, then, to similar climactic conditions, Parana, Rosario and Monte Video were not infected. They, however, took alarm, and exercised rigid quarantines.

Males suffered in much greater proportion than females. The mortality amongst children was small. Plethoric habits were bad subjects, and lymphatics seemed to have a better chance.

We hope that the cold of winter will be sufficiently maintained to prevent, as hitherto, the fever taking up its abode here. Everything prompts such hope. The streets of the most infected quarters were sprinkled with tar, at the recomendation of the lamented Professor of Chemistry in the University.

The disease generally began with some sensation of cold, giddiness, and (usually) nausea; occasionally vomiting. Then follows intense headache and pain in the back; often too, with general pain, high fever, very injected eyes, and rapid pulse. The urine, at first, highly charged with colouring-matter and lithates. The tongue was generally lightly coated, sometimes heavily so. The bowels constipated. Any early vomit was of ingested substances. A yellow colouring of the conjunctives was generally early apparent. In the second stage great adynamia prevailed, with a remarkably slow pulse (often not more than 40 per minute). Jaundice proceeded. Bleedings from nose and mouth, occasionally from the bowels; still more rarely with the urine, and very rarely from the vagina, with petechia (???). Sometimes eochymosis in the cellular tissue, and generally in the conjunctive. Vomits of decomposed blood, often very copious. Hiccough occasionally. Generally albumen in the urine, and suppression of this secretion in many cases, but rarely, indeed, relieved, and of all but certain fatal augury. In this stage the urine highly charged with bile. Some patients died within sixty hours, overwhelmed by the disease; the majority about the fourth or fifth day. Some cases put on typhoid symptoms, and lasted twenty, thirty, even fourty days; generally, but most invariably, recovering. With some frequency, parotid abscess.

The fever, as a fever, was of continuous type, but aspects of periodicity frequently presented themselves to me, on which I have formed my opinion, and based my treatment. A high range of temperature was rapidly attained, and maintained, with the exception of differences of fractions of a degree between the night and morning temperatures, the night returns being slightly higher than those of the preceding morning; the decline was quite gradual. These statements are based on a few observations taken in the lazaretto. I was not working there, or would have tried to have furnished more complete accounts. Seeing about sixty patients daily in different quarters of the city, it was impossible that I could undertake this investigation.

The autopsies, of which I saw a number in the lazaretto, disclosed inflamatory injection, and eochymosis of the coats of the stomach and the intestines, generally extending as far as the ascending colon. Very frequently one found coffee-grounds liquid in the stomach, and green-paint stuff in the intestines. The liver presented notable appearances. The first stage (seen in those who died early) seemed to be one of active congestion, followed speedily, as it were, by a stuffing (pardon the expression) of the organs with bile, and giving it the rhubarb aspect. The gall-bladder generally only contained some bile, amd was never distended, but rather somewhat empty: once the connective tissue surrounding it was infiltrated with eochymosed blood. The kidneys were almost invariably dyed with biliary colouring-matter, and, in anuric cases, congested in the cortical part, to all appearances, with an eochymosed look in the pyramidical portions, and true eochymosis about the calyces and pelvis. The spleen occasionally seemed a little swollen and immoderately firm, but it`s changes were almost nil. The cavities of the heart showed the biliary staining in their lining membranes, particularly about the valves; generally a very dark and fluid condition of the blood; some-times post-mortem or intermediate clots, always with the biliary colour. The lungs generally natural; once with apparently passive sanguinary infiltration un one lower lobe. The brain and spinal cord, negative appearances; once much fluid in the ventricles and subarachnoid space (the subject had died in uremic convulsions); but in other - even anuric - cases, negative appearances.

Cases seemed to terminate thus: A few, early in the disease, comme foudroyés, yet with exalted temperature but senseless; the majority, with convulsions just before death - generally anurics, yet many anurics seemed to die in syncope; and several by syncope generally having this concentrated pulse of small number. Quite a few seem to me to present, since their attack, the anæmia and malaise usual in paludal cases, and some of the cases of the typhoid form had the dysentery one so commonly meets with in those cases. The greater number recovered perfectly.

All kinds of ideas upon the nature of the fever and its treatment were emitted in the newspapers. At first, all seemed determined to refuse the diagnosis of the native Faculty, and sustained it was not true yellow fever. However, I have explained to you that the fact of an importation having occurred appeared highly probable. Then we had cases which gave colour to the idea that it was contagious; and, to stop all doubt, came albumenuria and suppression of urine. Now the journalists are at the statistics; the natives uphold the official 13,000, and the foreigners assert that double the number have died. Also in treatment, we have vomitives lauded and vomitives condemned; and the same of purgatives, mercury, quinine, etc; of homæopathy, hydropathy, and "Let me alone, please," etc.

I have spoken to you of the periodic aspect one could not fail to remark in many cases of the disease; I have told you that the generally continuous type of the fever, its infection or contagion, and the urinary symptoms proved to us that we had to deal with the disease described as "specific yellow fever;" certainly, though hourly, one could recognise in the disease the same nervous expressions one is so conversant with in the experience of tropical fever - let it be shore fever, or marsh fever, or heat fever. Where is the difference; what is the difference; is there a difference in these fevers? And if there is a difference, is it a difference of nature or of form? And does malaria exist, or does ot not exist? And if they exist, are they necessarily local and not portable, intransmissible from place to place? And is a pernicious fever - let it be an intermittent, a remittent or continued fever - simply the expression of the result of weather changes on the frame, or caused by some agent that is disengaged from the soil under certain local and meteorological conditions? And are malaria the products of topographical or geological conditions, and are they caused by organic or inorganic decomposition? How imperfect is one's knowledge when one cannot prove one's science; one should be scientific to be a sure Physician.

We had one plausible theory from an Italian chemist: bilious remittent, the product of vegetable decomposition, yellow fever, the same plus animal composition, both produced by a neglect of sanitary laws, coupled with atmospheric aberrations, and generally local in their nature and effects.

If I find, then, that antiperiodic treatment is efficacious against "specific" yellow fever, do I utter an heresy in saying that this fever must not be expelled from the family - the common family- of which it bears the impress, and to which it stands in the closest and most intimate relation? Yellow fever, certainly, necessitates a most vigilant and active treatment, but the basis of that treatment is quinine in antiperiodic doses. Shall we deny that a miasma, the malaria, may not under certain conditions, climatological and local, become contagious or infectious (as contagious and as infectious as may be expressed by its existence in the sick man as an infection-centre, and around him, by his presence, for a limited distance), and be portable from point to point; being intensified and producing an intense disease, so intense that you shall get but a glimpse of its real nature, but that glimpse shall suffice to the initiated to recognise an old acquaintance, and to counsel the adoption of the same means of repelling him as have sufficed to control other of his brethren.

We are told that yellow fever is a disease of the West, and does not exist in the East; yet, was it not anciently called "mal de Siam"? Has any Medical man seen the two diseases, each in its native home? What is this malarious yellow fever one reads of? - is it never infectious? - for truly the contagiousness of specific yellow fever is more an infectiousness than anything else; and the urinary symptoms are not satisfactorily sufficient as a basis of distinction - this symptom is merely a question of degree. Quinine will not cure yellow fever alone but neither will it cure a severe bilious remittent alone.

(To be continued,)


The next part of the article appeared in the following edition.
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