Part 3

The action of calomel and of sulphate of quinine has led some medical men to employ these remedies, united in the same formula. I have never understood the effect expected from this, and my experience has not proved the result satisfactory. When one is fortunate enough to have determined an intermission, frictions of sulphate of quinine produce a good effect. Calomel is not indicated, when the disease following its course, the alterations of the coat of the stomach become more observable, the epigastric pain more violent. In this case recourse may be had to the treatment heretofore recommended.

We have seen already, that there are three kinds of black vomit—that formed by bile, that formed by decomposed blood, and finally, that which is a mixture of these substances. The most numerous cases of cure are those, in which the black substance is formed by bile, and in these bicarbonate of soda and nux vomica will ordinarily triumph. But if the black vomit is formed from decomposed blood, there is no treatment which can result in positive action.

When cerebral symptoms predominate, with delirium, restlessness, etc., recourse should be had to blisters, to compresses upon the forehead of cold water and of brandy with belladonna, and to the administration internally of calomel alone, or combined with opium. This combination is valuable—it calms the cerebral excitement. When the delirium is violent, it is dissipated or quieted by an infusion of valerian.

Hiccough may be arrested by compressing with the fingers the phrenic nerve on the level of the os hyoid. In other instances, it yields to the application of cold water on the stomach to opium, to belladonna in small doses, to ice swallowed in small pieces.

When hemorrhages occur, the most appropriate remedies are acids, astringents, and iron. Local, such as buccal hemorrhages, yield to lotions of diluted sulphuric acid every half hour, or to gargles of borax. The best means of resisting epistaxis is by application of ice to the forehead; at the same time, by acid injections into the nostrils. Plugging of the anterior openings of the nostrils would be insufficient, because the hemorrhage is passive, and comes from the whole surface of the nasal mucous membrane. For anal hemorrhages, acid injections, the application of cold to the abdomen, and tannin given internally, are prescribed.

General hemorrhage, that is to say decomposition of the blood, is combatted with tannin or perchloride of iron administered every two hours, with lotions of vinegar or of wine of cinchona, applied over the whole body.

Hematuria is combatted with weak sulphuric lemonade.

It is during the period of hemorrhages, that the parotids become swollen—a frequent indication of amelioration of the general condition. When pain or swelling appears, I apply tincture of iodine three times a day externally, _loco dolenti_. During the epidemic of 1862, I had twenty-nine cases of inflammation of one parotid, and seven of both parotids, and lost but one patient. I attribute this success to iodine. When suppuration does not invade the whole gland, premature incisions must be avoided. They would produce the serious inconvenience of retarding the cure, of making the patient suffer uselessly, and of occasioning hemorrhages difficult to arrest.

The tumors which show themselves on different parts of the body ought to be treated with topical tonics. Compresses soaked in wine of cinchona, facilitate resolution. It is not necessary to open these tumors; this would expose them to hemorrhage.

During the first period, slightly acidulated drinks are prescribed, warmed to promote diaphoresis; in the second, the patient takes cool beverages; in the third, tonics are preferable.

During the whole course of the disease, absolute diet is essential. There must be no indulgence on this point. Often a little broth, given before the period of remission, is enough to bring on indigestion, then reäction, and finally death. In the second period, there is sometimes a sensation of false hunger, which deceives the patient; but the least compliance on the part of the physician might be fatal.

To be more exact, we now proceed to examine singly each one of the recognized therapeutic remedies against yellow fever:

_Bleeding._—I consider general bleeding injurious, except with individuals of apoplectic temperament, presenting symptoms of inflammatory fever. I repeat that cupping is preferable to leeches. I have already so insisted on this mode of application, that it is useless to allude to it again. I will say only, that it is necessary to employ the spring scarificator, and never the lancet or bistoury.

_Pediluvia._—Foot-baths are perfectly associated with cuppings, to diminish local congestions. They ought to be given in the manner following: The patient lying on the back, draws his thighs upon the stomach, the legs upon the thighs. In this position the feet and legs are placed in a vessel filled with warm water, the temperature of which is gradually increased, until it becomes unendurable. The bath ought to last from fifteen to twenty minutes. Its effect will be increased by the addition of powdered mustard. When taken from the water, the feet should be carefully dried, and mustard plasters applied to the thighs and allowed to remain as long as the patient can bear them, when they will be removed, and placed on the calves of the legs.

_Emetics._—Emesis is one of the most important remedies in the first, but becomes injurious in the second period. Black vomit often comes soon after the administration of an ill-judged emetic. The principle indication are these—the tongue humid, saburral, charged with whitish mucous deposits, nausea, disposition to vomit, bad taste in the mouth, the temperament bilious, constitution lymphatic, atmosphere damp, etc. Administered under these circumstances in the first period of the invasion, the emetic is a heroic remedy. I prescribe thirty grains of ipecac, dissolved in six ounces of distilled water, taken in one draught. Nausea soon occurs, and as soon as the patient begins to vomit, the effect of the medicine is assisted by drinks of warm water. The food contents of the stomach are first ejected, then bile. The drinks of warm water should be continued, until the liquid ejected is as clear as the water that is swallowed. After the vomiting, the patient takes one or two cups of tilia. Ordinarily, the congestive symptoms of the brain increase, by reason of these efforts, but after a short repose and a little sleep, the skin becomes covered with sweat, and on awaking, the pain in the head is sensibly diminished.

I prefer ipecac to tartar emetic, because the action of the former is more gentle and more constant, and because tartar emetic irritates the mucous membrane of the stomach. After ipecac, the patient remains calm, whilst after tartar emetic, the nausea continues, and is very often followed by diarrhœa. I insist strongly on patiently awaiting the effect of the ipecac before giving warm water, because prematurely swallowed, this embarrasses instead of promoting the effect of the medicine.

Let us, however, observe, that ipecac, if useful when clearly indicated, may produce deplorable consequences, if administered despite counter-indications. In my experience, it is counter-indicated, whenever the period of invasion is passed, and even during the period of invasion, when the patient has not been attacked immediately after a meal, when the disease has not commenced with chills, when the individual is plethoric and is subject to cerebral congestions, or when he complains of pains in the stomach, even when fasting.

The first twenty-four hours of the invasion passed, the emetic can have fatal effects. At this period, indeed, the stomach and abdominal organs suffer in a manner more direct, and the efforts of vomiting increasing, these local congestions may determine a condition as much more difficult to encounter, as the period of the disease is advanced. How often have I seen black vomit appear after an emetic improperly given! I have seen under the same circumstances epistaxis which could not be arrested, and such irritability of the stomach, that it could not bear anything.

_Purgatives._—Purgatives are of as great importance as emetics in the treatment of yellow fever.

After the administration of the emetic and a repose of twelve to twenty-four hours, the purgative may be used to induce action by the intestines. It slightly excites the secretion of mucus, and facilitates the circulation and the passing of bile by the stools. Drastics should be absolutely excluded, their too violent action producing injurious irritation. Among the purgatives I recommend, above all, castor oil alone, or associated with oil of sweet almonds. When judged proper to be administered alone, two ounces at least should be given at once. When mixed with oil of sweet almonds, three ounces of the first, and two ounces of the second, adding some drops of lemon juice, unless it is preferred to give the patient a slice of lemon, after the potion, to prevent vomiting.

The action of castor oil is a little slow, but it should be assisted with injections of olive oil and warm water.

If the patient has an antipathy to castor oil, sulphate of magnesia is administered, in a dose of one ounce in a half tumbler of fresh water, with the addition of six grains of nitrate of potash. The mixture of these two remedies produces secretion of intestinal mucus, acts upon the kidneys, augments the secretion of urine, and at the same time excites diaphoresis.

This mixture ought to be given in small doses, every half hour, as the stomach will bear it better. Given in this way it is sometimes vomited in part, so that there should be no attempt to give the remainder. If its action is delayed, it should be assisted with injections slightly purgative, warm sea water, or sulphate of magnesia, mixed with olive oil. During the action of the purgatives, especially of sulphate of magnesia, the patient may drink as much fresh water as he wishes.

Obstinate constipation, indicating a congestive state of the brain, will be combatted with Seidlitz water. The different purgatives generally bring on a calm, and marked relief.

Other purgative substances are employed, among which I would cite rhubarb and Seidlitz powder, or Seidlitz water. They are particularly indicated in the jaundice of the second, and in the commencement of the third period.

The counter-indications of purgatives are colliquative diarrhœa, the third period of the disease, hemorrhages, especially those of the anus. Feeble and lymphatic temperaments do not endure them well. They should be given to women and children with caution, and in small doses frequently repeated.

_Calomel._—We have spoken of calomel, the action of which, so different according to the dose, is here formally indicated, either as a purgative, or as an alterative, or as a derivative. We have seen, that emetics were counter-indicated with persons too robust and disposed to cerebral congestion. It is in these cases, that calomel should be employed, at least, when there are no symptoms of local irritation or inflammation of the stomach. But if the tongue is loaded, humid, large and saburral, without redness of its borders, if the region of the liver is painful, the indication for calomel is more precise.

For a purgative dose there will be given every half hour from three to six grains, until the patient has taken eighteen. If, after having obtained the purgative action, it is necessary to continue the medicine for a certain time in smaller doses, as a derivative, it is given in doses of two grains every hour, until the characteristic greenish stools are obtained.

Calomel is still applicable, when constipation persists, despite the employment of sulphate of magnesia. Administered then, every hour, in grain doses up to twelve, it works marvellous effects. I have seen convulsive symptoms disappear after the administration of this remedy. One of its inconveniences is ptyalism, but this is obviated with the aid of Seidlitz powder. Very often when it has been given after the emetic and sulphate of magnesia, calomel is sufficient to produce a remission, when there has been none.

_Sudorifics._—When the remedies, of which we have spoken heretofore, do not bring on a remission of the symptoms, it is well to look to sudorifics, which, facilitating the peripheric circulation, produce a general relaxation, and with this an abatement of the pulse. Among the sudorifics, I commonly select Dover’s powder, and the liquid acetate of ammonia or spirit of mindererus.

The latter administered in doses of twenty drops, in four ounces of flower of elder, acts as an antiseptic and sudorific. It is indicated, when the skin is dry, with the sharp heat so common in yellow fever of the continued acute type, without remission. I have often seen individuals stubborn to sweat, despite the purgative, transpire abundantly after some doses of this medicine.

Dover’s powder suits, when the patient has dry skin, is restless, and turns over in his bed uttering deep sighs. I give for the dose, every two hours, from three to four grains in two or three spoonfuls of infusion of tilia, warm or hot. After the second or third dose, the patient becomes more calm, sleeps, and wakes covered with sweat. The effect of sudorifics will always be assisted by a mustard foot-bath.

Some medical men have considered the transpiration so useful, that they have made it the basis of their treatment. In the outset, they prescribe a steam bath. I have tried this but without advantageous results.

When transpiration is determined, the pulse remains full and strong, diuretics are indicated, and among these powder of digitalis associated with nitre.

_Sulphate of Quinine._—Sulphate of quinine is one of the most powerful and most useful remedies in the treatment of this disease; but it must be well indicated, well administered, and in a suitable dose. What are the indications of sulphate of quinine in yellow fever? There must be at least remission, if there is not complete intermission of the fever. Its application is then excluded from the continued type. When the fever has yielded, by the use of the medicines of which we have spoken, or when, with sweat or moisture of the skin, the pulse has sensibly lowered, the employment of quinine is always good. Its effect will be shown, for the strongest reason, in the intermittent type. In this last case, it acts with the same precision and the same success, as in simple intermittent fever.

As sulphate of quinine has a prompt and durable action, the mucous membrane of the stomach ought to be in the best possible condition for absorption. It must, therefore, be empty. An emetic and a purgative, at least the latter, should precede the administration of sulphate of quinine. I know that there are medical men, who administer quinine in the height of the fever, regardless of the state of the stomach and of the mucous membrane. If they have found this treatment beneficial, it is by chance; for it is illogical, and its effects are commonly deplorable.

As for the dose in which sulphate of quinine ought to be prescribed, it depends on the age, sex, and temperament of the patients. For adults and men, the average is twenty grains in a single dose, in about three ounces of black coffee, without sugar. If it is feared, that the irritated stomach cannot bear so strong a dose, it should be dissolved in a few ounces of distilled water with a sufficient quantity of sulphuric acid, and given every hour by the large spoonful. If the stomach cannot bear this, give an injection of a double dose, with the precaution, not to inject more than one ounce of liquid at once, every hour. The action of the medicine will be assisted by friction of quinine ointment along the vertebral column, on the articulations of the wrist, knees, and under the arm-pits, etc.

Some enthusiasts consider sulphate of quinine, as a preventive, and direct it to be taken in a perfect state of health, or administer it in the outset of the fever. I have tried this without having felicitated myself. I will say as much of the association of calomel with sulphate of quinine. This combination should be rejected.

I have nothing to add to what I have already said as to blisters.

_Bicarbonate of Soda—Nux Vomica._—When the patient complains of nausea, disposition to vomit, of eructations warm and acid, that he feels in the throat and liver a burning sensation, bicarbonate of soda is the remedy indicated. I give it in doses of one gramme in six ounces of distilled water, taken by the spoonful every hour.

I have stated before, how and under what circumstances nux vomica ought to be given. The effect of these two last remedies is often much more sure, if their action is assisted by cold fomentations upon the abdomen, perhaps with cold water alone, or with camphorated alcohol and belladonna.

_Belladonna—Camphor._—Compresses of camphorated alcohol and belladonna, placed upon the epigastric region, diminish the beating of the cœliac trunk, the epigastric pain, and the vomiting. Laid at the bottom of the abdomen, they quiet the colic pains and facilitate the passage of urine. Camphor alternated with belladonna, finds its use internally, in combatting hiccough, and camphor alone is especially useful in the typhoid period of the disease.

_Tannin._—Tannin diminishes the excitement of the stomach. I recommend its employment, where nitric acid reveals the commencement of albuminous deposit in the urine. Its use must be suspended, if the albumen persists or increases. Tannin is administered every hour, in grain doses in a spoonful of water. When the twelfth grain has been given, and it works no favorable change, it is replaced by arsenic.

_Arsenic._—Towards the end of the second period, when the vomiting cannot be arrested, when the patient has continual nausea, when the vomit contains bile or mucosities filled with blackish or sanguinolent streaks, in a word when the characteristic signs of pronounced yellow fever are developed, there is no better remedy than arsenic. It is given as arsenious acid dissolved in water, and prepared in the following manner: Boil for an hour a grain of arsenious acid in a porcelain cup, containing a half pint of distilled water; then replace the evaporated liquid with an equal volume of boiling water, let it cool, and give this solution by the teaspoonful every half hour, until the nausea and vomiting cease. The administration of this remedy is continued for two days, at longer intervals, that is every hour, then every two hours, finally every four hours. Prescribed under fitting circumstances, arsenic often brings unhoped for amelioration.

There are some medicines, whose action, though certain, is inexplicable. Such is arsenic, the influence of which must be accepted as a fact, without considering theories more or less satisfactory. I should add, that arsenic often determines a deceptive hunger, to which there should be no concession, because at this period of the disease, the lightest broth might cause fatal indigestion.

I have tried every possible remedy for black vomit, and there is not one, which has constantly given the same result. I have had extraordinary success with agents, which at other times produced no effect; and I affirm, that there is no therapeutic agent, which can always be employed with entire confidence. Black vomit is the symptom of alteration, more or less profound, of the bile and of the blood. If it is alteration of the bile, presenting solely the black color of jet, hope remains; but when the vomited matter is of the color and consistency of coffee grounds, the patient is irretrievably lost. This truth rests on an experience of forty years.

It is not surprising then, that under a great number of circumstances, the most heroic agents are absolutely ineffective.

_Iron._—It is not necessary to give iron in too large doses. The two best ferruginous preparations are iron reduced by hydrogen, and the muriatic tincture of perchloride of iron. Small doses, often repeated, are much more easily absorbed than large doses. A quarter of a grain of powder of iron every hour, or a drop of perchloride of iron in three ounces of water, taken by the spoonful, every hour, is all that the stomach can bear; more is rejected by the stool or by vomiting. The reconstructive action of this remedy will be assisted by cold lemonades, and by ice in small quantities. Cold vinegar lotions over the whole body, frictions, enveloping the patient in sheets wet with cool vinegared water, compresses of cold vinegared water on the abdomen, changed as soon as they become warm, are adjuncts, which should not be neglected, and which will always be found good.

_Ice._—Ice is one of the agents greatly abused, especially in the first and second period. It is an excellent tonic; but I am not well assured of its employment in the third period.

_Drinks._—During the first period, the diet drinks ought to be warm or hot, to facilitate the diaphoresis so necessary at this time. But in the second and third period, there is used only cool water, slightly acidulated, and sweetened _ad gratam saporem_. In the great majority of cases the patient prefers simple water.

_Regimen._—Absolute diet is demanded, rigorously, while the fever lasts. But when the febrile symptoms have disappeared entirely, and at the same time local congestions dissipated, a little thin broth may be allowed.

A certain sensation of hunger is felt, especially towards the end of the first period; but the desire of the patient must be resisted, although the pulse maybe less frequent and less full. Often at the first touch, the pulse seems regular, but the attentive physician will find something abnormal, and he will soon be assured, that the improvement is more apparent than real.

_Convalescence._—The greatest care should be given to convalescents, because relapse is often fatal. The nourishment ought to be select and the patient should not be exposed to the sun or to the influence of the moon. When the disease does not go beyond the first period, convalescence is much shorter, if there is no leading organ assailed; but if it reaches the second and third period, especially that of hemorrhages and profound alterations of the blood, convalescence is long and painful, and often leaves its traces during the whole life.

When restoration is complete, wine of cinchona, wine of iron, cold baths, and sea baths are prescribed. In cases of swollen parotids, convalescence is prolonged during many months.

Is it possible to prevent a disease, which makes such ravages? Its entire destruction seems to me an unrealizable utopia, because we have seen, that one of the causes of its existence is in the atmosphere: but it is certainly possible to diminish its effects, and to avoid it, when it exists. A well observed hygiene would give the best results, and the government, which would attach its name to this undertaking, would deserve well of mankind.

Besides the causes of the disease, described in the commencement of this memoir, there is one important cause, in the collection of persons living together under the same roof, especially in barracks. These establishments are designed to shelter, day and night, strangers, who expose themselves without precaution to sun and to damp, and who drink, and eat, as if they had nothing to fear. These barracks ought to be built on elevated places, far from the city, and from the seashore, and especially, be well ventilated. The surgeon of the regiment, should have a roll-call three times a day, and, on his responsibility, put in the infirmary, and on diet, any one, who complains of the least headache.