Treatment.—Whatever opinion we may entertain respecting the specific nature of yellow fever, I was early convinced that this disease was not to be treated by specific remedies, and that our curative indications should be formed on an attentive consideration of the condition of the system in general, and of particular organs, as pointed out by the symptoms during life and the morbid lesions after death.
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.