By CHARLES BELOT.
(_Concluded from page 165_).
It is at the moment even, of this remission, that sulphate of quinine
must be administered in a dose of thirty-six grains taken at once in a
half cup of black coffee without sugar. When the intermission is
complete, its action is marvellous, the disease is immediately
moderated; but if there is no remission, it is necessary to be prudent,
for sulphate of quinine, because of its powerful action, can do much
harm, if it is not indicated. When the disease commences with chills,
followed by abundant sweats after the emetic and purgative, there is
assurance, that there will be another remission, and then the sulphate
of quinine is preëminently the remedy. But when there are no chills in
the commencement of the disease, when the prominent symptoms are heat
and dryness of the skin, and the fever continues, the exacerbation will
not be long delayed, and no propitious moment can be found to administer
the anti-periodic.
In cases where sulphate of quinine cannot be employed, calomel is an
excellent remedy, especially when in the absence of remission, the
tongue shows itself humid, loaded, white, large, the gums engorged, the
stools difficult, or when there is bilious diarrhœa. Under these
circumstances, calomel taken in purgative doses every half hour, until
the characteristic stools of this remedy appear. Very often, after the
administration of calomel, remission of the fever and of the congestive
symptoms takes place; the skin becomes moist, and sulphate of quinine,
the effect of which will be more sure in proportion to the distinctness
of the remission, may then be appropriately used. Its effect is assisted
by oil and by emollient injections. If there was no chill in the
commencement, aconite and tincture of digitalis will be pressed. These
are ordinarily sufficient to bring the patient into full convalescence.
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.