_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.
Instead of sending to one hospital only, the sick coming from garrison
and from government ships, several military hospitals ought to be
established. Every barrack should have its infirmary, with medical
service, and the sick should not have to cross the city to obtain
treatment. There is no disease which develops contagious miasm more
suddenly than yellow fever. A large accumulation of sick in the same
place, is a certain source of disease and contagion.
On board of vessels, a good hygienic system would greatly diminish the
number of the sick. In ordinary times, government vessels should not
have full crews. The men will then have a sufficient quantity of air to
breathe. They should not be drilled in the fierce heat of the sun, or in
rain, and they should be required to go to the surgeon, for the least
pain in the head.
We have observed, that the incubation of yellow fever, is from ten to
twelve days. It will be prudent then, in the heated term, not to remain
in port more than six days. English vessels have the habit of not
remaining more than three days, but they cruise in the vicinity, or go
to Jamaica, so that they are always exposed. The best plan would be to
leave the waters of the Gulf, which is the true centre of infection.
When, despite every precaution, there are sick men on board, and their
condition inspires apprehension, they should be put ashore at once, the
vessel whitewashed, and sail set for other latitudes to the north.
Commercial are not under the same conditions as government vessels. On
the former all is sacrificed to speculation. The crew is lodged as
closely as possible, and ten or twelve men are often seen in a space,
where four men can scarcely lie down. The government should require the
lodgment of the crew to be on deck, so as to allow free circulation of
air. Their food should be wholesome, and well chosen, and instead of
giving the crew fresh meat every day, it is better to continue giving
them salt meat which is more wholesome, and more nourishing. Let us add,
that the meat of the country, bought by merchantmen, is not of first
quality.
There are some captains, who, to shun the invasion of the disease,
engage blacks to load and unload their vessels, and during this time,
leave their crews inactive. This plan is of no avail. The crew is
generally composed of strong men, habituated to bodily exercise, which
facilitates transpiration. They require, therefore, moderate labor.
The water of the country is bad, and it would be good to add to it a
little brandy or rum. This drink is better than wine, or beer, which are
adulterated and often give colic.
Prophylactic remedies have been much recommended. In latter times,
chlorine on board ships was extolled, and has fallen into disuse, like
others I have tried without satisfaction. I have seen a captain, who,
convinced of possessing the universal panacea, neglected his sailors,
and they became gravely sick. Prophylactics can not have any action on a
disease which is in the air. Hygienic precautions and cleanliness, are
worth more than these pretended preventives.
_Inoculation._—At one time, it was attempted at Havana to prevent yellow
fever by inoculation of the poison of a snake, supposed to be the
_crotalus horridus_. A German adventurer assumed the respectable name of
Humboldt to sustain his theory. This man had observed that the Indian
prisoners, lead from Mexico to Vera Cruz, exhibited, when they were
bitten by a viper, symptoms analogous to those of yellow fever. He then
made some experiments with the inoculation of this substance at Vera
Cruz, and at New Orleans. He came afterwards to Havana, and obtained
from General Concha, then Governor of the Island, permission to make
some trials at the military hospital. He proceeded in this wise: He
made, said he (no one saw it), the snake bite the liver of an animal,
and kept it to putrefaction. He inoculated with this substance, and gave
at the same time, internally, a syrup composed of _mikiana-guaco_ and
rhubarb, with the addition of iodide of potassium and gutta-gamba.
The symptoms appeared in the following order: at the moment of
inoculation, the subject was taken with a transient vertigo, at other
times, with a nervous trembling, which lasted a longer time. Seven hours
after, the pulse was modified in a permanent manner, more frequent or
slower, stronger or weaker. Eleven hours after, he had febrile heat. At
the end of fourteen hours, he had headache, inappetence, thirst; sixteen
hours after, the face red, the conjunctiva injected. From the outset,
the gums were swollen and the patient suffered from colic. Eighteen
hours after, the gums were painful, and their borders became red, with
pains in the salivary glands, and in the nerves of the face and teeth.
Nineteen hours after, pain in the lower jaw, in the direction of the
submaxillary nerve. At the twentieth hour, bad taste in the mouth,
coryza, and œdema of the face; at the expiration of twenty-two hours, a
sensation of contraction of the throat, without visible change. At the
twenty-third hour, jaundice; at the twenty-fourth, gingival hemorrhage;
at the twenty-eighth, conjunctiva injected, chills; at the twenty-ninth,
tonsillary angina; at the thirtieth, pains in the loins; at the
thirty-eighth, pain in the joints; at the seventy-second, swelling of
the lower lip. During convalescence, prurience of the skin, with
cutaneous eruptions. These symptoms are far from being those of yellow
fever. They belong in part to those produced by the mixture of guaco and
iodide of potassium, and in part to those, which putrifying substances
produce, when they are absorbed.
M. Humboldt would not yield to the desire of the Commission, to try
solely the inoculation and the syrup of guaco. The conclusions of the
report were absolutely unfavorable to the experimentalist. The epidemic
of yellow fever continuing its course, the proportion of mortality was
the same among the inoculated, as among other subjects, and if the
statistical tables, presented by M. Humboldt, disagree with the
conclusions of the Commission, it is because he had among the
inoculated, not only a great number of acclimated persons, but of
individuals who had already had the disease. These ideas of inoculation,
inspiring a false security, might produce the saddest results. I think,
however, that this interesting question might deserve to be studied
anew.
I here terminate my effort. I have proposed to make yellow fever known,
as I have observed it at Havana for some twenty years. The reflections,
which I have presented on the nature and the causes of this terrible
disease, the details into which I have entered, in order that all that
relates to its symptoms, its progress, and its treatment, may be clearly
estimated, make this work a monograph, the utility and opportuneness of
which, will, I hope, be appreciated by those medical men, who are called
to practice in tropical regions.
* * * * *
_The Elastic Bandage in the Treatment of Aneurisms._—It seems likely
that Esmarch’s bandage will add very greatly to our means of treating
aneurism. Dr. Weir has collected twenty-one cases of iliofemoral,
femoral, and popliteal aneurisms, mostly the latter, treated in this
way. Twelve of these were successful, while the others failed, owing
chiefly to the fact that obstruction to the arterial current was not
kept up after the removal of the elastic bandage. Upon this point Dr.
Weir lays great stress, and states that in it is the gist of the
treatment.
In connection with the study of this matter, the question of how
long a limb can be kept desanguinated is of importance. In the lower
animals the time is six or eight hours. In man the time is longer
than has been heretofore supposed. Ischæmia has been enforced for
four, five, and in one case fourteen hours without injury. During
the compression it is important to remember that the arterial
tension elsewhere is increased.
Autopsies have made it probable that coägulation begins in the tumor
and extends up several inches into the artery. The arterial clot
then becomes organized into fibrous tissue, and for this
organization a healthy state of the wall is necessary. Aneurisms
with large mouths are perhaps more easily cured by Esmarch’s
bandage.
As the result of a study of the cases collected, including his own,
Dr. Weir recommends a plan of treatment like the following: the limb
should be bandaged up to the tumor and above it, but not over it.
The patient should stand erect before the upper bandage is put on.
Tubing should be applied in the usual manner. The elastic
compression may be kept on for two hours, followed by the
application of a tourniquet for two hours. If pulsation is still
apparent, the elastic and mechanical compression should be repeated
until pulsation has ceased. After consolidation of the tumor is
secured it is well to moderate current above the tumor for twelve or
twenty-four hours by a bag containing seven or ten pounds of
shot.—_Amer. Jour. Med. Sciences_, Jan., 1879.