Yellow Fever in Ceara, Brazil, by [Lewis W. Hackett], [December, 1922?]

    COPY

    YELLOW FEVER IN CEARA, BRAZIL

    In the year 1851 yellow fever became rooted in Fortaleza, capital of
Ceara. This was two years after the disease had first entered Brazil by the port
of Bahia. An American brig sailing from New Orleans had carried the disease to
this country where it has ever since been maintaining a foothold. In the first
year of the disease in Fortaleza 8,000 of the 15,000 inhabitants were attacked.
Since that time there has never been a serious epidemic of the disease in Forta-
leza probably because the small port does not permit of much intercourse with
the world at large. The mortality records of Fortaleza since 1914 up to the
1st of November of this year are as follows:

    

Year	No. of Deaths
1914	8
1915	4
1916	11
1917	0
1918	1
1919	0
1920	0
1921	1
1922	3

    Clinical records of the last four fatalities as well as one suspected
case which recovered are presented below. It should be borne in mind that much
of the data was secured from the attending physicians who had kept no written
records of the cases.

    Case I. Claude Ashmare - Age 50, American Engineer - Heavy Drinker.

    In May 1921 he became sick suffering daily with chills, high fever and
frontal headache. After three days there was a short interval with few symptoms
followed by a recrudesence. When first seen by a doctor on the 4th day the pulse
was above 100 and temperature 39.5° C. Abdomen a little tympanitic with slight
generalized tenderness. Liver one finger below costal border, hard to palpation.
Spleen not palpable.

    5th day. Temperature 38.5° C. Patient felt better.

    6th day. " 38° C.

    - 2 -

    8th day. Temperature rose above 38° C. A bloody extravesation found at the
point where a serum was injected. Delirium set in during the night.
10th day. Jaundice, great prostration. Temperature 37° + . Pulse number not
recorded but was weak. Lungs - bases congested.

    11th day. Condition worse. Completely jaundiced. Slight cough with dark
bloody sputum. Blood examination negative for malaria: Very weak agglutination
for paratyphoid B. Urine bloody. Died in the afternoon. Consultation with 2
colleagues. Diagnosis, clinical yellow fever.

    Autopsy.

    Liver enlarged, yellow. Spleen appeared normal. Stomach wall showed
dilated arterioles. Lungs - bases greatly congested. Attending physician in
view of clinical history and autopsy reported death from yellow fever.

    Material was taken for microscopic examination. Culture of spleen was
positive to plague. Because of doubt, all the viscera were sent to the Oswaldo
Cruz Institute in Rio and examined by Dr. Crowell who reported that lesion s
characteristic of yellow fever were not found but those of chronic malaria were
reported. This report caused a great surprise to the clinicians of Fortaleza.

    -3-

    CASE 2 - JAMES DAY, AMERICAN

    No clinical is extent. The following telegrams from
the Secretary of the Recife Department of Health are pertinent
however.

    1) I advise you that yesterday James Day, age 37, died
in this city. He came from Fortaleze and disembarked here on the
18 February 1922; already sick - Dr. Bentes Carvalho.

    2) In regard the previous telegram I sent you, I advise
you that James Day died on February 22, 1922 of yellow fever -
Dr. Bentes Carvalho.

    -4-

    CASE 3 - MRS. CHAGNON, FRENCH

    July 24, 1922 called her physician who furnished this cli-
nical record:

    Temperature oscillating between 38° & 39° C. Vomiting and
epigastric pain. Symptoms improved and on fourth day judged patient
to be convalescing; fifth day symptoms all returned and death follow-
ed at once. Generalized jaundice became apparent immediately after
death.

    The attending physician diagnosed the case Yellow Fever
which was substantiated by the gross pathological examination.
Cultural and microscopic diagnosis was plague.

    About the same time, the brother of Mrs. Chagnon also fell
ill of an identical disease but much milder; microscopic examination
of the sputum, urine, feces, etc. revealed the bacillus of Yersin.

    -5-

    CASE 4.

    MASTERSON - AMERICAN - RESIDENT IN BRAZIL 4 MONTHS.

    1st day. First day of illness, September 21, 1922, showed temperature
39.5°C. Conjunctiva congested, lumbar pains and headache.
Liver not tender but enlarged. Tongue coated.

    2nd day. Temperature 38.3° C. symptoms more severe.

    3rd day. Temperature 37.3° C. Conjunctiva less congested. Lumbar pains
more severe. Urine showed large quantity of albumin.

    4th day. Temperature 37° C. Slight conjunctival jaundice. General condition
better.
The jaundice gradually became more intense involving skin.

    8th day. Temperature 36.5° C. to 37° C. Pulse 60 to 62.

    9th day. Albumin began to disappear as well as the jaundice.
By the twelfth day the patient was entirely free of symptoms.
Diagnosis of attending physician was Suspected Yellow Fever.

    -6-
No.

    CASE No. 5.

    LEE GREENLEAF, Age 25, American. He arrived in Fortaleza October
6, 1922. Visited the Masterson's house on several occasions before
falling ill October 13th.

    2nd. day.: - Seen by a physician - Temp. 39 c. Pulse 102, Headache
and generalized pains. Prostrated and indifferent to his surroundings.
Liver normal. Conjuntiva congested; lachrymation; tongue coated.

    3rd. day: - Symptoms less severe, Temp. 39, Pulse 84.

    4th. day: - Generalized pains continue. Headache intense, epigastric
tenderness, slight, conjunctive icterus. Urine diminished & contained
considerable albumin. Tep. 38 Pulse 62.

    5th. day: - Fetid breath. Complete anuria. Conjunctival-icterus more
intense. Much pain on pressure over stomach and liver. Nasal hemorrhage.

    6th. day: - Delirium set in. Expelled blood from nose and mouth
repeatedly. Removed by catheter, 30 cc. of urine.

    7th. day: - In the early morning patient had an abundant hemorrhage
and expired immediately thereafter.

    AUTOPSY: - Skin - generalized icterus. Blood oozing from mouth and
nose. Lividity of the dependant parts.

    Conjunctiva intensely yellow.

    Lungs - right - anthrocosis and small hemorrhagic infarcts.
left - upper lobe anthracosis and hemorrhagic infarcts.

    Pleural cavities - 80 to 100 cc. sero sanguinous liquid in
each side.

    Pericardium - 50 c.c. of a clear egg yellow liquid.

    Heart - More or less normal.

    Intestines - intensely yellow.

    - 7 -

    Liver - slightly enlarged - straw yellow color with
greenish anterior edge. Cut surface showed nutmeg appearance.

    Stomach - Contained 350 c.c. of a black bloody
liquid. Hemorrhagic areas visible internally or externally.

    Kidney - Slightly yellow otherwise appeared normal.

    Intestines - Hemorrhagic areas.

    Spleen - Appeared normal.

    Bladder - Contained about 80 c.c. urine. Walls appeared
normal.

    The report of the microscopic examination of viscera
has not yet been received.

    DIAGNOSIS: From clinical and gross pathological findings;
Yellow Fever. Case was considered to be typical.