Chapter 8

In a former part of these remarks, I suggested the opinion, that the yellow fever is a gastro-duodenic inflammation, (perhaps of a specific kind,) and that it required a mode of treatment appropriate to this morbid state; but proportioned to the strength of the patient, to the violence of the attack, and to the power of re-action. In general, however, I have not found active depletion by the lancet, as easily borne in this, as in bilious and other fevers;--the disease assuming more rapidly, under this plan, a state of prostration or adynamia. Nor can this appear surprising, since the same circumstance of a disease being of an inflammatory nature, but, under a peculiar condition of the system, contraindicating ample depletion, is a subject of frequent notice during certain epidemics; for example, of scarlatina, pneumonia, &c. With the exception of those cases, therefore, occurring in very robust and plethoric constitutions, and accompanied with much pain in the head, high febrile excitement, and hard pulse, either large or small, I have seldom resorted freely to the lancet. When, however, these symptoms presented themselves, especially the hardness of the pulse, I have not been sparing of blood-letting, and have sometimes repeated it several times with the most decided success. But even under these circumstances, I have seldom found that _large_ bleedings were as beneficial as small and repeated ones;--the system not reacting always as energetically as could have been desired, and symptoms of prostration occurring with much more rapidity. I do not recollect to have bled with advantage, patients presenting a large, full, but _compressible_ pulse, owing to the want of reaction; although the other symptoms might seem to indicate the propriety of the practice. The effect of bleeding on the vomiting was very different in this, from what I mentioned it to have been in the bilious fevers of the West Indies; owing probably to the circumstance, that, when, in yellow fever, the irritation of the stomach became sufficiently violent to give rise to this symptom, the state of the system was very often such as to contraindicate the use of the lancet.

The application of scarified and dry cups to the epigastrium and head, when there existed pain in these regions, was often resorted to, and afforded much relief. And I very much regret, that, during our epidemics, it was out of my power to make use of leeches to the former part, as so warmly recommended, at the present day, by the French and Spanish physicians; as I am inclined to the opinion, from the view I have adopted respecting the pathology of the disease, that, used early and in large numbers, they would prove very serviceable.

In conjunction with general and local bleeding, fomentations were had recourse to in almost every case, and applied to the epigastrium in the form of poultices, or flannels wrung out of warm emollient decoctions. In order to excite perspiration and to determine action to the surface, a tepid bath was occasionally prescribed, and in some cases afforded considerable relief; but as it was an inconvenient remedy, pediluvia, and hot bricks on which water, or water mixed with vinegar was poured, were substituted. In cases, however, in which much arterial action existed, these last means were not prescribed, until the pulse had been brought down by the lancet, and other remedies presently to be mentioned.

On the subject of emetics, I shall not enlarge; as I can safely assert, that I very seldom saw a patient recover from yellow fever, to whom tartarized antimony, or any other active remedy of the same class, had been administered. Of the impropriety and danger of this practice in the present disease, I was early convinced from a careful analysis of the symptoms, indicating an acute irritation of the stomach and upper portion of the small intestines, and from the circumstance, that, of the first family in which I was called to prescribe, five members, to whom emetics had been administered, had already fallen victims to the fever, under the care of a very respectable physician, and that three succeeding ones, who were treated agreeably to my view of the pathology of the disease, recovered. From these facts and reflections, I was induced to watch the effects of these remedies in subsequent cases, in my own practice, and in the practice of other physicians, and was soon led, from this extended experience, to abandon totally the use of tartar emetic in the treatment of this malady. Ipecacuanha in emetic doses was also tried by me; but although, thus administered, it did not occasion the bad effects resulting from the exhibition of the preceding article, yet it was often productive of harm, and never of benefit. These remarks, however, apply more particularly to the use of tartar emetic during the state of excitement of the fever, and not to that of collapse which sometimes precede it, and in which it is recommended by some physicians of the southern states. In this condition of the system, I have never resorted to it, and, I must confess, could not easily be persuaded to do so; suspecting that even in such cases, the digestive organs are already too far implicated, to justify the use of so powerful and acrid a remedy.

It would seem that the bad effects of emetics, and more particularly of tartarized antimony, resulted, not only from their irritating qualities, but also from the efforts of vomiting, during which the stomach is compressed by the abdominal muscles, and made to contract very forcibly. To this opinion I am naturally led from the circumstance, that purgatives, whose action is certainly primarily irritating, are very advantageously employed in yellow fever. It is not my intention to attempt here an explanation of this seeming contradiction. Leaving to others the accomplishment of this difficult task, I shall content myself with stating, that during the whole course of my long practice, I have seldom seen a patient die of this disease, whose bowels had been well evacuated, and in whom perspiration had been excited within the first twenty-four hours after the attack. I exhibited purgatives in almost every instance _every day_, until copious evacuations had been procured, and I generally found, that the mild purges were of greater service than those of a severe and irritating nature. Senna, acidulated with lemon juice or tamarinds, answered sometimes remarkably well, when the stomach could retain it. Castor oil, manna, salts, magnesia, were frequently employed by me with advantage; and although I did not make an extensive use of calomel in this disease, yet I prescribed it to children, and to adults, who, owing to great irritability of the stomach, could not retain other purgative medicines. When I resorted to it, I generally did so in doses sufficient to ensure a purgative effect, and never with a view of exciting ptyalism. In doing this, I was not guided, however, by any fear of the effects of a salivation, since I was well aware that a ptyalism occurring in malignant diseases is often a favourable crisis; but by a knowledge of the great difficulty experienced in producing it, and from the observation, that in cases in which it was obtained, much valuable time had been lost, and the patient might have recovered without.

To promote the operation of the above remedies, purgative enemata were resorted to, in the early stage of the fever; and were followed by the frequent use of injections, composed of emollient decoctions, from which the patient derived considerable relief and comfort.

As counter-irritants, blisters and sinapisms were used, and often with great advantage. They were found of much value when applied to the epigastric region, for the purpose of arresting the vomiting. Sinapisms were in general preferred to blisters, as being more prompt in their effects and more easily renewed. Blisters were sometimes applied to the extremities in the different stages of the disease; but so far as I can judge, from my experience, not with much real benefit.

I seldom derived much advantage from the use of tonics and stimuli in yellow fever; except when the powers of life seemed to fail, and petechiæ, vibices, hæmorrhages, and other signs of malignancy had occurred. In general, under such circumstances, the Peruvian bark, either alone or combined with serpentaria, was administered in preference to any other remedy of the same class. In cases, however, unattended with reaction, tonics and diffusible stimuli internally, and revulsives of all sorts externally, were had recourse to from the commencement of the attack, and sometimes with the desired effect of arousing the powers of the system. _Opium_ was never found beneficial, on account of its tendency to aggravate or produce coma, as well as from its effect in suppressing intestinal evacuations.

Whilst making use of the above remedies, the plentiful exhibition of diluent drinks was not neglected,--care being taken, however, not to load unduly the stomach, and to select such drinks as would suit the taste of the patient. In almost every case, acids did not answer so well as the bland mucilaginous infusions. The drinks were almost universally allowed cold, except when there existed a tendency to perspiration; under which circumstances they were administered slightly warm and a little aromatic.

During the course of the yellow fever, some of the symptoms demanded particular attention. Influenced by the idea of prostration and dissolution, many practitioners, and myself for some time among the rest, resorted to the bark and other tonics for the purpose of arresting the black vomit, and of correcting that condition of the organs, which gave rise to this effusion; but after many unsuccessful trials, I was led to abandon this practice and to resort to other means. Of all the remedies employed to attain this effect, calcined magnesia mixed in a thick solution of gum arabic seemed to me to answer best; for whilst it succeeded, in many cases, in arresting the vomiting, it tended to keep the bowels open. Together with this, revulsive remedies were applied to the skin, and sometimes succeeded very well,--a sufficient proof, I think, that this hæmorrhage is the effect of an increased action of the mucous membrane of the digestive tube, and not of a passive condition of the capillaries of the parts. For the purpose of controlling the great irritability of the stomach, and arresting the vomiting occurring in the early stage of the disease, besides the usual remedies used in such cases, I found advantage in the use of small and frequently repeated injections with a solution of salts, an infusion of senna, or the like substances. Such a practice, however, did not seem to succeed so well in the latter stage of the disease.

With the intention of promoting the secretion of urine, in cases in which it was suppressed, all the diuretics, as well as every external stimuli, were in vain employed;--this symptom, as I have already mentioned, being, in all instances which fell under my immediate observation, the forerunner of death.

ARTICLE V.--_Remarks on the Prophylactic Treatment of Cholera Infantum._ By JOSEPH PARRISH, M. D., one of the Surgeons to the Pennsylvania Hospital.

The great mortality of cholera infantum renders it one of the most interesting diseases, which come under the notice of the physician. Its ravages among the infant population of our large cities, are too well known, and too strongly felt, to require any comment. No disease contributes so largely to swell our bills of mortality during its prevalence; and were it not restricted to the summer season, it would prove a greater scourge to the community than consumption itself.

This mortality is owing less to our ignorance of the nature of the complaint, and the proper mode of treatment, than to the continued operation of the causes by which it is produced. I have often compared our endeavours to cure cholera infantum, while these causes remain, to an attempt to relieve inflammation in a part, while a thorn is sticking in the flesh. We may resort to bleeding and leeching; we may restrict our patient to the lowest diet, and the most perfect rest; we may employ all those remedies, which are ordinarily best calculated to reduce inflammation: but so long as the thorn continues in the wound, our efforts will be fruitless. Thus it is with cholera. We may obviate the more violent symptoms; we may procure temporary relief; we may even flatter ourselves that a cure has been effected: but the original causes have not lost their power; an increased susceptibility to their operation remains; relapse upon relapse is experienced; and at last the little sufferer, worn out by the successive attacks, sinks beyond the reach of medicine, and expires. Unhappily, the nature of the causes is such, that, in very many instances, their removal is exceedingly difficult, if not altogether impossible; and, under such circumstances, the patient who has once been severely affected, seldom recovers in the end. Hence it becomes of the greatest importance to prevent the occurrence of the disease; and attention to the prophylactic treatment is no less essential than the adoption of curative measures. It is with the view of calling the attention of the profession to this subject, that I have been induced to offer the following observations.

It is obvious, that, in the preventive treatment, two objects demand attention; first, to remove, as far as possible, the causes of the disease; and secondly, where their entire removal is not attainable, to fortify the system against their influence. On each of these, I shall offer a few observations.

I. Excessive and continued heat is, perhaps, the most fruitful source of cholera. Thus we find, that the disease makes its first appearance in the commencement of the hot weather, increases and becomes more fatal with the rise of the thermometer, and declines with the return of cool weather in autumn. During its continuance, it may be observed to vary with every permanent change of temperature. A few very hot days in succession, in the 6th month, are sufficient to call it into action; and during the height of its prevalence, a spell of cold weather will diminish, if not suppress it. In the summer of 1806, which was remarkably cool and pleasant, there was very little of the disease; and generally in moderate summers, it is much less prevalent than in those of a contrary character.

I believe that it is by a direct operation on the system, and not by the generation of miasmata, that heat proves so deleterious to the infant. In the country, where miasmata are most abundant, there is comparatively little cholera; for the heat of the sun is there moderated by the free circulation of the air; and the debilitating operation of the high temperature of the day is counteracted by the refreshing coolness of the morning and evening. It is in the close air of cities, that the complaint flourishes with greatest vigour; and the most confined situations are the most favourable to its production. Let any one take a walk, in a summer's morning, through the thickly built lanes and alleys of Philadelphia. He will be struck with the appearance of the children, reclining their heads, as if exhausted, upon the breast of their mothers, with a pale and languid countenance, a cool and clammy skin, a shrunk neck, and other signs of debility, arising from their confinement, during the night, to close and hot apartments. It will readily be believed, that such places are the very hot beds of cholera.

Heat, therefore, connected with confined air, being among the most frequent causes of the complaint, it is necessary, as far as possible, to counteract them. Should a strong predisposition to cholera be suspected, the best plan will be to send the child into the country during the summer. Both as a preventive and a remedy, country air is decidedly the most effectual, to which we can resort. But in most instances, it would be exceedingly inconvenient, sometimes impossible for mothers to leave their homes and occupations in the city; and, under such circumstances, it becomes necessary to substitute measures, which may produce, as nearly as possible, the same effects. To keep the child cool, and expose him to the fresh air, are the ends to be obtained. For this purpose, he should be carried frequently into the open squares, or beyond the suburbs of the city. I am in the habit of recommending to parents, whose circumstances will not allow of a removal from the city during the summer season, to make frequent excursions across the Delaware, and into the neighbouring woods of New Jersey. The refreshing effects of the air on the river are truly surprising. The brightened eye and animated countenance of the infant, give speedy proof of their favourable influence; and when labouring under the disease, even in its lowest stage, the little patient will often exhibit immediate signs of amendment.

In the prevention of cholera, much may also be expected from a proper attention to the lodging of children. Many parents have a great dread of the night air; and exclude it from their chambers, as sedulously as if it were infected with poison. But, in guarding their children from taking cold, they expose them to a much greater danger. Observe their mode of treatment. The doors and windows are carefully closed; the child is placed in a feather bed, with his parents on each side, and almost smothered with the bed-clothes. Perhaps other children are lodged in the same apartment; and thus the delicate system of the infant is exposed to the debilitating influence of great heat and stagnant air, combined with the effluvia, which, in such a situation, must be abundantly generated. Simply to enter such a room in the morning, is almost sufficient to sicken a healthy individual; how much more injurious must be its effects upon the lodgers themselves. Examine in the morning a child, who has passed the night thus confined. You will find him limber as a rag, exhausted by perspiration, wholly destitute of animation, without appetite, and on the very verge of cholera. I should recommend an entirely different plan of management. Instead of a feather bed, the child should be placed on a hard mattress, or on blankets folded and laid upon the floor. The covering should be light, but comfortable. The doors and windows should be open; so that fresh air, that _pabulum vitæ_, without which health cannot be sustained, may be freely admitted. Thus treated, instead of the feeble and sickly appearance before mentioned, he will present a lively countenance, with all that activity of motion, and enjoyment of existence, which are natural to his age, and afford the surest criterion of vigorous health. Experience has fully convinced me of the great importance of attention to the lodging of children, as a prophylactic measure; and this renders me desirous of impressing upon the profession generally, the truth of my own convictions on the subject.

With the same design of obviating the injurious effects of a high temperature upon the infantile system, I advise frequent ablutions with cool water, and its free employment as a beverage. Infants, unable to make their wants known, often suffer exceedingly from the inability of their attendants to understand them. During the heat of summer, the increased evaporation from their surface is necessarily productive of increased thirst, which, if unsatisfied, renders them uneasy and restless. To quiet them, the breast or bottle is offered. Aliment is thus given, where drink only was required; and the stomach, overloaded and oppressed, is apt to become irritable, and is thus brought into a condition most favourable to the occurrence of cholera. By attention to the peculiar language of infants, expressed not by words, but by signs, I have often been able to detect their wants; and, in many instances, have afforded the most decided relief, by simply giving them a little cool water for drink. From the dread which some individuals have for cool air and cold water, it would seem that they were considered rather as destructive poisons than as absolute necessaries. I have no fear of either, when judiciously employed; and as prophylactics in cholera, I do not think their place can be supplied.

But heat is not the only cause of this complaint. Dentition is well known both to predispose the system to its attack, and, after it has occurred, to increase its violence, and diminish the chances of recovery. In the employment, therefore, of preventive measures, it is highly necessary to attend to the state of the gums, and to remove or counteract this source of irritation. If at all swelled or painful, they should be lanced freely, and the operation should be repeated as often as their inflammatory condition may demand. In severe cases, much good may be expected from the application of blisters behind the ears. The irritation thus receives an external direction, and the stomach and bowels are in less danger of an attack. I was led to this practice, by observing that the eruption, which, during dentition, is apt to make its appearance behind the ears, often proves a most salutary effort of nature; and that, while it continues, the infant generally enjoys an exemption from those dangerous disorders, incident to this critical period of life. To imitate nature as closely as possible, the discharge from the blistered surface should be maintained for some time by stimulating dressings. I have witnessed the most beneficial effects from the practice, and can strongly recommend it to the attention of the profession.

II. At the same time that we endeavour to remove or diminish the causes of cholera, we should not neglect to put the system of the child in such a condition, as may enable it most effectually to resist their operation. As cholera is a disease of irritation, originating generally in a debilitated state of the alimentary canal, I believe this end may be most easily attained, by preserving the natural tone of the digestive organs. For this purpose, all flatulent and indigestible food should be carefully avoided. During the first year, the mother's milk is, in general, the most appropriate nutriment. When the stomach of the infant is very delicate, the diet of the mother should be strictly regulated; and, in all cases, it would be adviseable for her to avoid articles of a flatulent nature. While the child is still at the breast, if a predisposition to cholera be suspected, I would recommend the occasional use of nutritious animal juices. The sucking of small pieces of salt meat, as ham or dried beef for example, will sometimes be found productive of advantage. After weaning, animal food should always enter into the diet of the child. Many parents, fearing to render their children gross and unhealthy, restrict them altogether to vegetable aliments; and thus, by weakening the powers of digestion, prepare the way for that very result which they are most anxious to avoid.