Sidebilder
PDF
ePub

of volume, and was precisely what we usually observe to follow the administration of tonics. But the cases of yellow fever, noticed by Professor H., in which the sulphate was given at the onset of the fever, presented a widely different state of the system; and although, after a general or local bleeding had induced a remission, the sulphate cut short the fever most astonishingly, I do not regard the facts as developing a sedative, but rather an anti-periodic agency. “ The breaking up of the whole condition upon which the morbid actions depend,” (the language employed by this writer), is an effect so like the usual action of the sulphate of quinine, as an anti-periodic, that I can refer it to no other power. It is true, the concentration of the poison in yellow fever, changes the intensity of the phenomena, or exalts it, so as to disguise, to a certain extent, the ordinary operation of this heroic medicine.

As a specimen of the practice in these cases, we quote from a report of Dr. Mackie. "A stout young man, aged 28, was seized with yellow fever, at 1 P.M. At 6 P. M. of the same day, he was under treatment. Ten cups were applied to the epigastrium, thirty grains of the sulphate of quinine were directed to be taken by the mouth, immediately after the cupping, and forty grains to be given by injection.” Says Dr. Harrison, "He was cupped before I saw him, but had not taken the sulphate. His pulse was 120, full and strong; he had great heat of skin, great pains in the head, back and lower extremities, tongue a little furred, eyes heavy and a little injected, great restlessness on account of the pains. I saw him next morning, between 6 and 7 o'clock. He was perfectly free of pain ; pulse 84, skin cool, and every vestige of disease gone. From prudential reasons, he was kept in the hospital four or five days longer, but there was no return of disease.”

This and similar cases give some reason for assigning to the sulphate a sedative action; but I feel more confident by far, that the secret of arrest of the fever is to be found in the anti-periodic agency.

I cannot but think that Surgeon McCormick, of the U.S. army, is in error, in asserting, that excitants are never given when the system is highly excited, and that, therefore, the sulphate of quinine, given by him in that condition of the system, must necessarily have acted as a seda. tive. The premises are not so, and of course the inference cannot be sustained. Opium is conceded to be an excitant, in doses of one to three grains, and has thus teen given, a long time, in the hot stage of intermittents, and is now employed by very respectable physicians, in inflammatory diseases. I do not say, positively, that the sulphate may not act as a sedative; but I am satisfied, that the argument of Surgeon McC., as employed in the New Orleans Medical Journal, does not settle the question. I have never exhibited the remedy in the same range of inflammatory diseases, it may be, with that gentleman, and therefore cannot decide the point. If he has not been mistaken, there would seem to be ground for conceding the sedative quality contended for. A perusal of the essay, however, will discover an acknowledgment of the need of the lancet, in some cases, as the first means, immediately after which the sulphate was employed in 30 or 40-grain doses. Now, the lancet is, unquestionably, a powerful sedative; but why resort to it at all, if the sulphate possess the very same power, to such an omnipotent degree, as is claimed for it? The region where the practice was carried out was

highly malarious; and we incline to the belief, that the lancet induced just so much of remission, in the given cases, as secured more effectu. ally the complete anti-periodic action of the sulphate. We do not doubt the correctness of the practice, and differ only as to the explanation.

In reference to the question, yet mooted by some, of large doses of the sulphate of quinine, it is due to truth, as developed by an immense amount of experience, to declare emphatically, that it is not only a safe remedy, but decidedly more often successful than when administered, as originally, in very small doses. Let it be borne in mind, however, that the force of the medicine, when properly given in very large doses, is spent on the morbid action to be subdued, in the absence of which, the same dose would, most probably, be injurious.

I may add, in reference to intermittents and remittents, that their prompt arrest, by the liberal use of the sulphate of quinine, is rarely, if ever, followed by dropsy; an event often seen, when those diseases were treated with feeble doses of bark and snake-root.

III.-Practical Reinarks on the Epidemic of Yellow Fever which pre.

vailed at Opelousas in the years 1837, '39, and '42. By T. A.

COOKE, M.D. Having read many interesting essays in the Medical and Surgical Journal on the subject of Yellow Fever, I have thought that some ac. count of the epidemics of that disease, which prevailed in the town of Opelousas in the years of 1837, '39, and '42, might not be destitute of interest to those, at least, who seek to explore its many mysterious phe. nomena.

But before entering on the subject, permit me to congratulate my country confrères particularly, on the establishment of your journal in the city of New Orleans. Of its merits, the very important matter which it has been the medium of conveying abroad, affords a flattering proof; and of its success, none who are acquainted with the zeal, energy, and talents of its proprietors can for a moment doubt. Its establish. ment constitutes an era in the medical profession, in the South; and affords an opportunity to the profession of the city, of liquidating those just claims which they owe to the physicians of the country. Many able contributions have already been made to the pages of your journal, -articles which afford satisfactory proof that only an opportunity, with fit incentives to exertion, is wanting, to elicit from the resident phy: sicians of the city, whether native or foreign, evidences of acquirement and capacity, commensurate with the vast requirements which so great a city, presenting, as it does, diseases more violent and varied than any other in the world, exacts from the votaries of the medical profession. Enjoying, as they do, the advantages of union, of a constant intercom. munication of ideas, and of hospital or clinical studies, it not only becomes them, as guardians of the honor of the profession, to watch over it and promote its purity, by discouraging that fatal charlatanry too prevalent over the land, but also, by continued investigation and experiments, to

scatter over the land the results of their labors, and the fruits of their experience.

The many interesting communications from the country, highly cre. ditable to their authors, afford a flattering promise of what may in future be expected; and surely there is no want of subjects which merit the attention of physicians, in the complaints of an endemic and epidemic nature to which the country is subject. It is in the South, particularly, that we witness the immense influence of local causes in modifying the character -- the form, and treatment of disease. No one is ignorant of the fact, that there is a diversity in the effects of the same remedy in different years, in the fevers of the country: it is confessed, that yellow fever assumes different forms, and that the effect of remedies is modified thereby in different years. When we read, in the histories of yellow fever, and in the description of particular epidemics, opposite modes of treatment recommended, (at least, so to be considered, according to the general explanations of the modus operandi of medicines),- remedies by some extolled as the safest, if not indispensable, and condemned by others as either uncertain or dangerous, we must conclude that such diversity of results arises from the modifications of the fever in the dif. ferent circumstances under which it has been observed; and if such be the truth, another conclusion is established, which is, that in every epi. demic, the first duty of the physician is to modify his treatment according to the form of the disease, – to adapt his remedies to what is called the type of the fever. In a subsequent part of this paper, this important subject may, perhaps, be more particularly developed.

I proceed now, in an irregular manner, to make some remarks on some of the facts or phenomena of yellow fever, and to consider some of the remedies generally regarded as the most important in the treatment of the affection ; and I wish it particularly understood, that these re. marks will relate exclusively to three epidemics of a formidable charac. ter which it was my fortune to witness in the town of Opelousas, in the years '37, '39, and '42. Any comments which I may be led to make, will have reference to these epidemics, being suggested by the facts which were witnessed. The symptoms of the fever on the three occa. sions alluded to were much the same. I am of opinion, that all three presented very nearly the same form or type. In 1837 and 1839, the attack came on suddenly, rarely with premonitory symptoms, and, in a large majority of cases, between the hours of midnight and daybreak As regards severity, no difference was observable, as a general rule, between the cases commencing at night or during the hours of the day.

As regards duration, the fevers of '37 and '39 were the same. The cases which formed an exception to those of confirmed convalescence, or of a fatal termination before the completion of the fifth day, were few. But the disease of '42 was frequently protracted to twice the duration of the two previous fevers, and presented, in some cases, pictures of human suffering, and of the most appalling symptoms which ever fell within the observation of physicians.

The first fact which appears to me worthy of mention, and which no one will deny, is, that in all cases drastic medicines were fatal. Too many instances, unfortunately, of fatal results, occurring in individuals both old and young, of both robust and feeble constitution, attributable

clearly to drastic purgatives which had been taken by the patients them. selves, may be cited. The general effect of the operation of such medi. cines was a great reduction of the fever, so far, at least, as a full and strong pulse, and hot skin, are evidences of fever; but, at the same time that the pulse diminished in force it increased in frequency, and was accompanied by a cool skin, with clammy and offensive perspiration; the tongue would become redder, more pointed, and in some cases would clean off; the stomach, the seat of great irritation and nausea, accompanied with belching of gas; very frequently there ensued an impossi. bility of discharging by stool, in consequence of that singular and myg. terious state of the colon sometimes observed in yellow fever, which con. sists in its contracting on itself, in some cases to the extent of obliterat. ing its cavity, and thus rendering the passage of matter through it utterly impossible ; and then comes on, at an early period after this purging, a coldness of the end of the nose, fingers and toes; an indescribable sensa. tion of fullness in the epigastric region, with constant nausea, would continue to increase until about the fourth or fifth day, when black vomit would ensue, and death soon close the scene. Notwithstanding the ex. cessive purging which such medicines never failed to produce, and which sometimes resulted from the administration of a single dose of oil, that sinking-in of the abdomen, seen frequently in our autumnal fevers, was never witnessed, the bowels always feeling full and doughy to the touch.

The fact alluded to, viz., the fatal effects of drastic purgatives, is so constantly seen, as not to admit of an exception in confirmation of its truth; and it appears to me, of itself, sufficient to show, that between yellow and bilious fevers there exists no affinity or relationship whatso. ever; and yet, by more than one writer, the one is regarded but as a higher grade of the other.

All who are conversant with autumnal bilious fevers in the South know the fact, that drastic purgatives are commonly resorted to, and that speedy cures frequently result from the perturbating effects of such reme. dies. In some regions of our country, the famous preparation of Le Roy, remarkable for its violence of action, supersedes all other medicines in the treatment of our common fevers. Emetics also, condemned in yel. low fever, are liberally employed, by experienced physicians, in many forms of our bilious fevers.

These facts go to show, that the cause of the one fever is different from that of the other; that the lesions of tissue are different, and that the organs are differently affected by the causes in these different affections.

I now proceed to notice a circumstance, which, though it may be said to have been universal in the epidemics of Opelousas, has not been observed generally, and never to a similar extent, elsewhere, that I am aware of — I mean, an arrest of the secretion of bile. Of all the facts or symptoms of yellow fever, this appeared the most fixed--the only never-failing one. In the only two dissections which were made (and it is to be regretted that the great projudices in the country render autopsies almost impossible), no bile was found in the intestines; and in the gall bladder, only thick mucous, tinged with bile, was found; and it was also universally observed, that simultaneously with a favorable change in the disease, there was a return of the biliary secretion, shown

by the presence of bile in the evacuations. As far as I have conversed with the physicians of this place, the fact stated has been confirmed, with one exception, in which there was a vomiting of matter mixed with bile during the rigor or at the onset of the attack. I have never seen bilious_ vomiting in cases of yellow fever, from the beginning to their termina. tion. So constant was this condition of the liver on the epidemics of Opelousas, that some of my medical friends, as well as myself, considered it pathognomonic of the fever, and would hardly have been disposed to give its name to any case which presented a free secretion of bile : we regarded it, in fact, as an essential element in the nature of the fever. I am well aware, that, in many accounts of particular epidemics of yel. low fever, as well as in professed treatises on the subject, copious secre. tions of bile has been cited as a common, if not a constant condition, nor do I wish to be considered as denying its frequency; I desire only to specify a fact as appertaining to the epidemics of Opelousas.

The secretion of bile was a certain sign of returning health. In the fatal cases, it never re-appeared : hence, the most painful anxiety was experienced until the presence of bile in the evacuations showed the restoration of the hepatic function.

No account has ever been published of the epidemics of Opelousas. During the wide-prevailing maladies of the years 1837 and 1839, the physicians were too incessantly occupied with their cases, even to allow them to take notes; and I presume this circumstance must have pre. vented several of my esteemed colleagues from presenting for publica. tion an account of the disease. For my part, relying, as I do, upon some disjointed memoranda taken shortly after each epidemic, aided by a memory too vividly impressed, not to be faithfully retentive of the leading facts of the disease, I offer no apology for the absence of all system or method in the previous or following pages.

Each of the epidemics was preceded by a fatal case of yellow fever in individuals who had contracted the disease in New Orleans.

In a population, white and black, of about 1400, there occurred, in 1837, about 250 cases; and in 1839, the disease spared none who remained in town, except only those who had previously had it: amongst these, embracing very many who, two years before, had been attacked, and also others, who had, a great many years ago, contracted the disease in different parts of the world, there was not a single case of it. It attacked white and black-old and young. Its duration was from four to seven days. The exceptions, to a favorable or unfavorable change about the fifth day, rapidly progressing towards health or death, were very few. Black vomit, in nearly every case, was thrown up before death; and there was no recovery after its appearance. In one in. stance, though none had been discharged before death, the stomach and small intestines, on a post-mortem examination, were found full of it, and in many instances it flowed after death, from the mouth and nose, though none had been ejected before. In one instance, I observed passive hæmorrhages from the mouth, anus, nose and eyes, flowing in immense quantities, and which nothing appeared capable of arresting. Such hæmorrhages were common towards the end of the disease, and, though not a fatal, was considered a very unfavorable symptom. The disease sometimes commenced with a chill or rigor, during which, goma

« ForrigeFortsett »