Noguchi reports success in prophylaxis by the injection of 2 cc. of a killed culture of Leptospira icteroides. Immunity is not conferred until after the tenth day. He notes that among 3607 persons vaccinated in Salvador there were no cases of yellow fever while among the unvaccinated 181 cases occurred. Killed cultures of Leptospira icteroides were first used for protective inoculation in 1918 when 427 vaccinations were carried out.
Treatment.—At the onset one should give calomel in small doses, repeated every twenty minutes, until about 2 grains are taken, as 8 doses of ¼ grain calomel with soda. Magnesium citrate or sodium phosphate should follow the calomel. Some prefer castor oil in large doses (2 ounces). This treatment should not be repeated, it is only indicated at the onset of the disease, so that if the case is not seen until after the second day the laxative or purgative measures should be withheld.
During the first three days of the disease no nourishment whatever should be given. The patient should be allowed an abundance of fluid, of which the best is Vichy, of which may be given a couple of ounces every twenty minutes or so, iced or just cool, as the patient prefers. Water, to which 30 grains of bicarbonate of soda to the pint has been added, makes a good substitute. It is of vital importance to put the patient to bed and keep him quiet. When vomiting is severe cracked ice or iced champagne may be of value. Alkaline enemata are indicated when the patient cannot retain the Vichy. There would seem to be an acidosis in yellow fever.
A mustard foot bath is best given in bed, the feet and legs of the prone patient being immersed in a foot tub half full of warm water into which a pound of freshly ground mustard has been stirred. Every few minutes there should be added a quart of very hot water so that the bath may be very hot—just short of burning the feet. The blankets are kept over the patient and the foot tub, so that we also give a vapor bath which causes free sweating. This treatment relieves the headache and backache. This foot bath can be repeated 2 or 3 times in the first twenty-four hours. After the bath, the sweating patient must be thoroughly dried. Cold spongings are important means of keeping down fever. For anuria use dry cups to the loins or hot fomentations. Strychnine may be indicated in the asthenic stage and camphor in oil hypodermically for extreme cardiac weakness. The Sternberg treatment is 150 grains of sodium bicarbonate and ⅓ grain of bichloride of mercury in a quart of water. The dose is 1½ ounces every hour.
Any exertion causing a rise in blood pressure may be fatal. It is possible that the stimulation of the circulation incident to the taking of food may explain the dangers of allowing food to a patient. As before stated no food should be given for the first two or three days. Then commence with albumin water and thin barley gruel. Later on wine jelly and easily digestible broths. Even when convalescence sets in we should be very careful as to diet.
Noguchi has produced an immune serum to his spirochaete by injecting horses. He has records of 170 cases of yellow fever treated with this serum with a mortality of 13.6%, while untreated cases gave a death rate of 52%. He notes that the serum must be given before the third day of the disease to be of any value—best results in the first day. He believes also that though salvarsan and neosalvarsan have some leptospiricidal action they are both too damaging to the kidney to supplant serum in treatment.
CHAPTER VI
INFECTIOUS JAUNDICE
Definition and Synonyms
Definition.—Infectious jaundice is a spirochaete infection, caused by Leptospira icterohaemorrhagiae. This spirochaete is a common parasite of rats in various parts of the world and man possibly receives his infection from this source. There is a sudden onset with rather high fever, headache and vomiting. The jaundice appears about the third or fourth day when the urine shows albumin and bile. Haemorrhages, especially epistaxis, are common and the liver rather than the spleen shows enlargement. A polymorphonuclear increase is a feature.