Rubert W. (Rubert William) Boyce.

Yellow fever and its prevention : a manual for medical students and practitioners online

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vomiting diminished ; jaundice deeper ; pulse 78 ; bile in

20th April. — Temperature ioi-2°-i02°; conjunctivae deep
yellow, also whole body.

21 st April. — Temperature ioi°-io2° ; vomiting almost ceased ;
feels better.

2^rd April. — Temperature 97°-98°.

2^th April. — Temperature 98°-99°.

2^th April. — Temperature gy°-gg° ; taking solid food, but
jaundice still very deep.

27/^ April. — Temperature 98°-99-4°.

2Stk April. — Sailed for England, but jaundice still marked.

Comments. — No albuminuria or suppression of urine developed.

Comment. — The kidneys in this case do not appear, there-
fore, to have been affected. The jaundice increased, and the
slowing of the pulse is no doubt associated with this symptom.
The fly spots in the vomit indicate the very early commence-
ment of congestion of the stomach ; they did not, however,
deepen and pass into black vomit.

Case II.— Mr R. C.

27th April. — Taken suddenly ill ; temperature 104 ; frontal
headache ; vomiting.

28//Z April. — Examined by Dr Ralph ; temperature ioi-8°-
102-8°. Conjunctivae congested; photophobia; tongue furred;
pulse 80 ; headache became severe and persistent ; vomited ;
urine scanty; no albumin ; tinge of jaundice.

29//Z April. — Temperature 101 ; headache persists; intra-
muscular injection of 9 gr. of quinine given without effect ;
vomiting troublesome and showed the black specks ; urine
contained a trace of albumin ; pulse now 78 ; restless.

30th April. — Patient was able in the morning to attend to a
little business and to sign his name to a letter. Very little
urine was, however, passed during the day. At 10.30 A.M. had
a convulsion, sank, and died. The "jaundice, which had been
present from the beginning, became much more marked after
death, the body being a dark brown colour."

Comment. — In this case the kidneys appear to have been
early severely affected; the headache and vomiting were more


severe and persistent. It is therefore a more severe case than
the previous one. It was the case which caused the medical
officer, Dr Ralph, to consider that he was dealing with yellow
fever. Quinine, it will be noted, had no effect.

Note. — In previous years Mr R. C. had lived at a consider-
able distance from the native town. Immediately prior, however,
to his fatal illness he had lived in the native town, and no doubt
became whilst there infected with yellow fever.

Case III. — Mr W., white man.

8tk May. — Taken suddenly ill in the early morning ; tem-
perature 105 ; severe headache ; some vomiting. At 8 A.M.
seen by Dr Ralph. He showed the following symptoms :
intense headache ; face very flushed ; eyes injected ; tongue
furred ; great prostration ; there was no albuminuria.

gth May— Fair night; slight vomiting; two intramuscular
injections of 9 gr. each of quinine given without any
marked effect, temperature being 103 ; urine very scanty and

lOtk May. — Temperature varied from 98-4° to ioo-8° ; in the
evening pulse 72 ; troublesome hiccough now set in with vomit-
ing ; the vomit contained black specks ; muscular twitchings
appeared and the jaundice deepened markedly ; sclerae deep
yellow ; convulsions increased in frequency, and at 1 1 P.M.
patient vomited a large quantity of black vomit.

Comment. — This case is more severe than the preceding one ;
the kidney is markedly affected, the jaundice was intense, and
the pulse became slow, showing, no doubt, profound change in
the liver ; the gastric symptoms became more intense, ending in
black vomit on the third day.

Note. — Mr W. had visited the bungalow occupied by Case II.,
but so had another gentleman, who did not get it. There was
the other possibility that Mr W. contracted the infection at the
warehouse, close to which there was a native house.

CASE IV. — Rev. H. B., white man, missionary, living in
commercial town.

gth May. — Patient seen by Dr Ralph, and complained of
headache ; lassitude ; temperature normal, but in the afternoon
it rose to 103 ; pulse 90 ; eyes congested.


loth May. — Constipation ; intense headache ; jaundice
appeared ; intramuscular injection of quinine.

i \th May. — Injection of quinine was repeated, but without
effect on temperature ; pulse now 80 ; albumin appeared for the
first time ; jaundice deepened ; towards end of day patient
became restless and delirious.

12th May. — Temperature 103 , pulse 80; black specks
present in the vomit; urine more albuminous.

\^th May. — Symptoms progressed, and at midnight black
vomit ejected by the pump-like action of the stomach, there
being no effort. At 4 A.M. the following morning, 14th May,
patient died.

Comment. — This case is like the preceding one. The kidneys,
liver, and stomach appear, however, to have been more severely

Post-mortem made twelve hours after death. — Body well
nourished ; surface stained pale yellow, with well-marked
petechiae about the neck and shoulder ; rigor mortis still
present ; body slightly warm ; conjunctivae stained a deep
saffron colour. Heart and Lungs. — Beyond staining of valves
nothing abnormal. Liver. — Slightly enlarged ; pale yellow on
section ; but was more congested than some of the other cases ;
considerable fatty degeneration was present. Kidneys. — Showed
haemorrhages under capsule, which stripped readily, but these
were more marked at bases of pyramids ; no haemorrhage into
pelvis. Spleen. — A little swollen ; no marked microscopic
change. Stomach. — Contained black fluid, with marked conges-
tion of the mucous membrane. Lntestines. — Lower part of small
intestine contained black, tarry matter ; small haemorrhages
could be seen under the peritoneum.

Case V. — Mr W. R., white man, living in commercial town,
close to the market.

gth May. — Dr Ralph called in and found patient complaining
of headache; pains in the limbs; temperature 104 ; pulse 84 ;
later, face flushed ; eyes injected ; edges of tongue red.

10th May. — Passed fair night ; temperature varied from
102 to 105 at 6 P.M. ; pulse 72 ; no albuminuria ; was given two
intramuscular injections of quinine, which had no effect.


nth May. — Vomited during the night; black specks in the
vomit; temperature I04°-I05°; delirium marked; tried to
get out of bed (shouting) ; albumin appeared for the first

\2th May. — Temperature 105 ; heart failing; albuminuria
more marked ; then suppression of urine for eighteen hours
before death ; the delirium was marked throughout the night ;
constant black vomit was present ; marked convulsions took
place five hours before death.

Comment. — A severe case like the two preceding ones ;
kidneys and stomach more profoundly affected.

CASE VI. — Adam, a native black man; post-mortem 14th
May 1910; said to have died the previous night, 13th May;
tall muscular man; rigor mortis passing off; conjunctivae deep
yellow ; some " black vomit " on table escaped from mouth.
Heart. — Beyond slight dilatation was healthy ; valves deeply
stained. Lungs. — Old adhesions over right base and about
upper portion of lower lobe ; congested at bases, but crepitant.
Liver. — A little enlarged ; almost lemon colour on section ;
tissue appeared to be softer than normal ; I think fatty
degeneration was present. Spleen. — Enlarged ; capsule thick-
ened ; tough on section. Kidneys. — Showed small haemorrhages
in the cortex ; not very marked under capsule, which stripped
readily. Stomach. — Contained " black vomit." Lntestines. —
Lower part for a short distance contained black, tarry mucous
matter. All tissues deeply stained, including cartilages and

CASE VII. — Kroo-boy, of the Gold Coast Machinery and
Trading Co. Brought to the mortuary dead on 16th May
1910. Post-mortem made about twelve hours after death.
Body well nourished, muscular ; conjunctivae stained deep
yellow colour. All tissues were of a saffron tint.

Heart. — Valves showed the general staining, otherwise
normal. Lungs. — Old adhesions on both sides, but crepitant
throughout. Liver. — Slightly large on section, of a pale yellow
colour, very suggestive of fatty degeneration. Kidneys. —
Showed haemorrhages in the cortex, chiefly at base of


pyramids. Spleen. — Enlarged, capsule very thick and tough,
adherent to abdominal wall. No marked change beyond
toughness on section. Stomach. — Contained small quantity
of dark, almost black fluid, with marked congestion of mucous
membrane. Intestines. — In lower part contained black tarry
matter. There were small red patches under the peritoneum,
which appeared to be haemorrhages. Congestion of mucous
membrane not so marked as in the stomach.

CASE VIII. — Mr B., living in commercial town, in an
inferior class hotel, was under the care of Dr Hayford, but
owing to the necessary evacuation of that part of Secondee at
night, he slept in the Colonial Hospital (part of which has been
turned into a dormitory) on the 17th inst. Dr Ralph first saw
him on the morning of 18th May, when he had a high tempera-
ture, but would persist in going into the town. He returned
at 2 p.m. obviously very ill, and was at once admitted into the
hospital. Temperature 103-8° ; flushed face ; marked injection
of the eyes, which were very bright and watery ; tongue furred,
red tip; pulse 90, full and hard ; temperature ioi° at 8 P.M.

igtfz May. — Urine passed during the night contained
albumin. Conjunctivae jaundiced. Was very restless and did
not sleep much. Temperature 6 A.M., 101 ; 6 P.M., 101 . Pulse
much softer, not so full, 70. There was some nausea, and he
vomited a lot of milk, but no sign of " coffee grounds." Was
restless and talkative all day, gradually getting more jaundiced.
Constantly trying to get out of bed.

20th May. — Urine contained more albumin. Temperature
6 AM. 102 , 6 P.M. 103° ; pulse better, 70. He was very rest-
less and excited all day, but slept fairly well at intervals.

2 1st May. — Very restless and delirious all night. Vomited
at intervals, the " black specks " in vomit much more pronounced.
Urine almost solid with albumin. Very small quantity, about
5 oz., passed during the night. Temperature 6 A.M., 103° ; 6 P.M.,
half an hour after death, 104°. He was very delirious and
excited all day, tearing up mosquito net and blankets. At
the end vomited large quantity of " black vomit." Jaundice
gradually got deeper all day, and before death there were
petechias about the neck and upper part of trunk. He had


slight convulsion at the end. No urine was passed for twenty-
four hours.

Comment. — This case shows very well the increase of the
gastric, hepatic, and renal symptoms.

Post-mortem made on 23rd May, about twelve hours after
death. Body deep yellow with petechiae about the neck and
upper part of trunk ; conjunctivae deep saffron colour, body not
well nourished, thin and spare. Heart. — Valves healthy, stained
colour. Lungs. — Normal. Liver. — Slightly enlarged. On
section pale yellow, seemed tougher than normal. I consider
fatty degeneration was present. Kidneys. — Haemorrhages into
cortex very small, but present chiefly at the base of pyramids ;
capsule stripped readily. Spleen. — Enlarged, soft. Stomach. —
Contained " black vomit," marked congestion of mucous mem-
brane. Intestines. — Small quantity of black, tarry matter.

Case IX. — Rev. A. T. R. B. came from Accra on 12th
May and stayed at the Mission House.

20th May. — Patient was brought to the hospital at 5 P.M.,
semi-conscious, in a hammock, and was at once admitted ;
temperature 103 . There was no complaint of headache, only
general feeling of weakness and discomfort. Given phenacetin
5 gr., to be repeated in half an hour if not sweating, with hot
lime drinks. This started a profuse sweat, and temperature fell
to 10 1. ° When seen late in the evening he expressed himself
as being better; no albuminuria ; pulse full and hard, 80.

2\st May. — Temperature 6 A.M., 101 ; 6 P.M., 103-2°. Was
given intramuscular injections of quinine, bihydrochloride 9 gr., at
intervals of twelve hours, which produced no effect on the tempera-
ture ; faint trace of albumin in urine ; bowels confined, slight
jaundice. Was quite cheerful and comfortable during the day,
but complained that light hurt his eyes ; pulse not so hard, 76.
During the night began to complain of headache and was a
little deaf. More albumin in urine, which was very acid, 102-2°.

22nd May. — Temperature 6 A.M., 102° ; 6 P.M., 104-4°. Late in
the afternoon mental symptoms developed. Incoherency and
forgetfulness, but was able to write letters. Bowels open three
times; stools paler; passed only 12 oz. of urine and very
little with the stools.


2^rd May. — Temperature 6 A.M., 102 ; pulse 72, .weaker.
Slept fairly well. Bowels open during the night but very little
urine passed. There was a little vomiting of blackish fluid.
Jaundice was very much more pronounced, the conjunctivae
being of a deep yellow colour. In spite of stimulants his heart
gradually failed, and he died at 10.30 A.M.

Case X. — Native, post-mortem examination held 23rd May.
Wife of a clerk living at Essikadu. Post-mortem held about
sixteen hours after death. Well-nourished healthy woman ;
considerable enlargement lower part of abdomen ; conjunctivae
deep yellow colour.

Lungs and Heart. — Normal, all tissues stained deep yellow.
Liver. — Slightly large ; yellow colour on section ; very blood-
less ; looked like fatty degeneration. Stomach. — Contained
small quantity of black fluid ; mucous membrane congested.
Small intestines. — Lower part contained blackish mucous
material for a considerable length. Spleen. — A little enlarged,
otherwise normal on section. Was perhaps a little tough.
Uterus very considerably enlarged ; definite haemorrhages in
both ovaries ; Fallopian tubes very much swollen and enlarged ;
fimbriated extremities much congested. The patient had had
a miscarriage (22nd May) previous to death the same day.

Case XL — Mr A. H. H., assistant commissioner of police,
arrived in Secondee from Accra on 14th May. His duties
consisted of superintending the evacuation of the declared
infected area each evening at 5 P.M. This also necessitated a
later visit to see that there were no Europeans sleeping in the

22nd May. — Early on the morning he was awakened by
severe frontal headache, pain in the eyes, and photophobia ;
temperature 103 . He was seen by Dr Purkis about 6.30
A.M. On admission to the hospital his temperature was 103-4° ;
pulse full and hard ; no albumin in urine.

2-$rd May. — Temperature in the morning and afternoon was
103° ; pulse 90 full. Still had persistent headache ; was very
restless all night, but dosed at intervals. Intramuscular
injection of quinine bihydrochloride, 9 gr., was given at 10


A.M. and repeated at 9 P.M., but had no effect on temperature.
Stools were light clay-coloured. Had slight nausea but no
actual vomiting ; slight jaundice.

24M May. — Was slightly delirious during the night but
slept at intervals; vomited after a cup of tea at 6 A.M. This
contained small " black specks " in the mucus and tea ;
temperature 6 A.M., 103 . Passed no urine during the night,
but a specimen obtained late on the 23rd contained albumin ;
temperature 6 P.M., 102-6° ; jaundice much more pronounced.

2^th May. — Vomited black grumous fluid ; no urine passed
during the night ; bowels open, stools loose, light clay colour.
Heart failed rapidly and he died at 7 A.M. There was no con-
vulsions before death.

Case XII. — Mr R. D., white man, agent, living in com-
mercial town.

igtk May. — Was taken ill suddenly. He vomited and had
a high temperature 105 , first seen on the morning of 20th
May. He then had a temperature of 102 . Tongue furred,
face very flushed, eyes injected. He took 10 gr. of quinine in
solution, and 10 gr. that night when his temperature was ioo-6°,
but without effect.

21st May. — Removed to hospital. On admission his
temperature was 101 ; pulse full and hard; skin moist;
intense headache, otherwise little complaint of illness ;
temperature 6 P.M., 101 . Was given an intramuscular in-
jection of quinine, 9 gr., which produced absolutely no effect
on the temperature. No albumin in urine, which was acid.

22nd May. — Temperature 6 A.M., ioi-2°;6 P.M., 102 . Seemed
more comfortable. Bowels open, motions normal in colour.
Stated he had passed a good night. Took plenty of nourish-
ment. The jaundice which had been but slight began to
become deeper. Conjunctivae very injected, and measles-like
rash appeared on the face, upper part of trunk, and back of
hands. Bowels open twice, was passing but little urine, only
12 oz. in twelve hours; no albuminuria; pulse much the
same as yesterday. Liver was slightly enlarged and tender,
but the patient is very stout ; spleen not palpable.

2$rd May. — Slept at intervals during the night. Tempera-


ture 6 A.M., 102-4° ; 6 P.M., 102° ; pulse not so good, given brandy
and champagne as required ; jaundice much more pronounced ;
conjunctivae now deep saffron colour. The eyes look swollen
and watery. Albumin in urine ; more lethargic ; not so inclined
to talk but had tried to smoke. There was a little nausea and
vomiting at intervals during the day; no "black specks" in
vomit which was of a reddish colour like the dregs of beef tea.

2^\.th May. — Temperature 6 A.M., 102 ; 6 P.M., 103-4°. Had
passed a fair night. Bowels open, is not passing much urine ;
jaundice very deep ; measles-like rash fading ; tongue fairly
clean ; skin moist ; pulse soft — 70. Is taking nourishment well
with small quantities of stimulant. There was a little vomiting
which had changed its character, being now marked with " black
specks " more mucous than before ; urine highly albuminous.

2^th May. — Seemed fairly well; temperature 6 A.M., ioi°;
6 P.M., ioi°. Much more lethargic in the early part of the day;
later became restless ; said he could not stay in bed ; kept on
getting up and sitting on the side of his bed. No complaint of
severe headache, only a dull ache ; passing very little urine in
the twenty-four hours ; in consequence saline injections were
ordered to be repeated every four hours.

26th May. — Slept a good deal last night ; continues to take
nourishment well; temperature 6 A.M., 99-4°; 6 P.M.,- 98-8° ;
urine very albuminous ; vomiting not frequent, chocolate-
coloured ; pulse 80, fairly full and soft. The pulse began to
fail a little about midnight. During the greater part of this day
he was lying apparently asleep, bathed in a profuse sweat.
Measles-like rash quite gone, but petechias appeared for the first
time about the neck and trunk, also on the hands ; jaundice
very deep ; hiccough very troublesome.

27th May. — Some twitching about the angle of the mouth
and hands first noticed ; temperature 98-8°. Was semi-
conscious till the afternoon, when the muscular twitchings
became much more marked ; pulse failing ; no urine since 5 A.M.
Rectal saline injections were kept up. He died quite quietly
at 10.45 P - M - There was considerable haemorrhage from the
mouth after death.

The post-mortem examination was held eleven hours after
death. The face and neck deeply cyanosed ; petechias about the


upper part of trunk and on the hands, rigor mortis well marked ;
body slightly warm, the whole of the abdomen and extremities
of a saffron tint ; conjunctivae deep yellow.

Heart. — Valves stained deep yellow, otherwise normal. There
was early evidence of fatty degeneration of the muscle ; consider-
able amount of fat on exterior. Lungs. — Bases congested but
the whole of both lungs crepitant Stomach contained black
grumous fluid. There was evidence of haemorrhage from the
mucous membrane which was deeply congested. Intestines
contained similar haemorrhagic matter, with marked congestion
chiefly in the lower part of small intestines. Bladder appeared
to be healthy and contained about 8 oz. of bilious urine. Spleen
slightly enlarged and congested. Kidneys. — Cortex thin with
haemorrhages around base of pyramids and under capsule which
stripped readily. Pancreas. — Beyond the deep staining, which
was a marked feature of the whole of the abdominal viscera, no
obvious change. Liver. — There was slight enlargement more
marked in the left lobe than the right. On section it was of a
deep yellow colour, and had rather the appearance of a " nut-
meg." There were well-marked haemorrhages in the tissues,
covering the gall bladder, but not marked on mucous membrane.
The gall bladder contained about \\ oz. of deep green gall.
The whole of the abdominal and thoracic viscera appeared to
assume a deeper tint of yellow on exposure to the air. The
blood was also of a darker colour than normal.

List of Doubtful Cases previous to the Outbreak of Fatal Cases ;
taken from the Secondee Case Book.

J. C. E. Hepatitis. Date 17/9/04.

Symptoms — Temperature 101 ; pain in epigastrium; coated
tongue ; jaundice recovered. W. S. W.

Comment — Suspicious case (Boyce).

T. B. W. Remittent Fever. Date 20/9/04.

Admitted with temperature 105-2°; headache; tongue
coated ; recovered. W. S. W.


F. G. Remittent Fever.

Admitted into Colonial Hospital ; temperature 103-6°, with
marked bilious symptoms ; recovered.

W. H. D. Hepatitis. Admitted 17/ 11/04.
Temperature ioo° ; usual symptoms hepatitis ; recovered.

C. H. C. Insolation and Fever. Date 14/11/04.
Admitted with intense headache ; nausea ; vomiting ;
temperature 104 . Very suspicious case of yellow fever

J. B. Hepatic Congestion and Fever. Admitted 23/1/05.

Temperature 104° ; symptoms — congestion of the liver and
other bilious symptoms ; temperature ioo°-ioi°, lasted ten
days ; recovered.

W. H. Date 14/2/05.

Symptoms of intermittent fever and gastric catarrh, with
marked gastric disturbance ; eight days' duration ; recovered.

A. T. N., District Commissioner, set. twenty-eight. Admitted


Diagnosis — Remittent fever germinated fatally.

G. F. S. Diagnosis — Remittent Fever. Admitted 26/2/95.

Temperature 103 ; vomiting ; fever characterised by gastric
and bilious symptoms ; recovered in ten days.

F. G. M. Diagnosis — Enteritis.
Temperature 103-4° 5 vomiting six days.

H. H. H. Intermittent Fever; recovered. Date 21/3/05.
Temperature 103° ; nausea ; vomiting and gastric disturb-
ance ; recovery ; quinine did not affect the temperature.

G. F. S. Gastric Catarrh and Fever. Date 17/3/05.
Admitted suffering from vomiting; continuous fever and
prostration ; invalided.


T. H. F. Hsemoglobinuric Fever ; recovered. Admitted


Temperature 103 ; weakness ; urine and alb. looks like
that of blackwater ; skin very yellow ; much bilious vomit-
ing ; temperature 104 ; vomiting continued ; recovery.

H. C. R., Mines Accountant. Blackwater Fever. Date


Admitted to hospital with well-marked symptoms of black-
water ; urine alb. ; skin yellow ; vomiting same afternoon ;
temperature 104-2°; recovery.

H. H. Intermittent Fever.

Admitted vomiting and great irritability of stomach ;

E. D. M'F. Bilious Remittent Fever. Admitted 26/8/05.

Temperature 102-6°; jaundiced; headache; nausea; tem-
perature rose to 104-6°.

A. W. H. Diagnosis not given. Death. Admitted 5/1/07.

6th January 1907. — Vomiting commenced; black vomit on
the 7th ; eyes intensely congested and jaundiced ; skin yellow,
with purple patches of discoloration ; temperature 103° ;
delirium ; coma ; epistaxis.

Post-mortem. — Skin yellow ; conjunctivae yellow ; lungs con-
gested ; liver fatty ; kidneys congested ; trace alb. in urine ;
intestines contained same material as the vomit. Undoubted
case of yellow fever; temperature 102°, with a pulse of 96

Mr K. Dysentery and Blackwater Fever. Admitted 1 3/1/04.

Symptoms. — Vomiting; epistaxis; blood in stool; black-
water ; skin jaundiced ; pulse 96 ; epistaxis ; recovery.

John (Convict Prisoner). Cirrhosis of Liver. Date 26/4/07.

Symptoms. — Jaundice ; bleeding from gums ; eyes irritating ;
coma ; death.



Online LibraryRubert W. (Rubert William) BoyceYellow fever and its prevention : a manual for medical students and practitioners → online text (page 16 of 30)