THE TREATMENT OF YELLOW FEVER. An address before the physicians of New Orleans, by request BY JOSEPH HOLT, M. D., OF NEW ORLEANS, LA. In the course of my remarks on the treatment of yellow fever, I mention to you now that, for clearer illustration, I may use mixed metaphor, and, if so, you will know that it is intentional, and no apology necessary. This subject is one that may be briefly epitomized or hugely extended. It may be condensed into a very small brochure or expanded voluminously, according to literary proclivity. One may I have much to say in little, or little in much. As for myself, I can better respond to your wish by repeating, while fresh in mind, and with some enlargement, my reply to a young physician a few evenings since, who propounded these questions: "Doctor, please tell me, do you give quinine in yellow fever? and what do you consider the best treatment of the disease?" My esteemed young friend, you are just entering the gateway of experience, and I hope you may find wisdom without paying overdear for its possession. As to quinine in yellow fever, I ask why, what has suggested it? "Well, Dr. Osler advises it." Yes, my dear boy, and he further tells us that neither emetics nor purgatives are now employed, and when hemorrhage sets in, to use perchloride of iron, all of which is enough to make a New Orleans physician collapse in fatal syncope. Let Dr. Osler pursue this course in Baltimore, where they have inhabitants, perhaps, overcrowded and to spare, but to advise it as permissible in New Orleans, he merely declares to us that he has passed his forty mark by many decades, and for the sake of his yellow fever We send patients should have been chloroformed long ago. him a counter recommendation in the Kibby cot and ice water affusion. They will surely settle the business for Baltimore. No sir! After your initial and preparatory measures give no drug, and least of all, a nauseous one, when you know that the stomach already is moving on in dreadful haste in the direction of a supreme crisis, a disorganizing and hemorrhagic congestion, whose terminal may be black vomit and speedy death. Why do you speak of quinine, knowing that you are dealing with a poison possessed of the putrefactive virulence, invoking a like universal sepsis, a liquifying spoliation of the blood and hemorrhages, with rapid tissue changes and softening of the fatty degenerative series, such as characterize also the venom of the fer-de-lance, and both alike touching the life of all the blood corruptibly? Did it ever flash into your mind, young gentleman, the close geographical kinship between yellow fever and the family crotalidæ, represented in the fer-de-lance, the moccasin, and the rattlesnake? Of course it is coincident, but is more than merely coincident. I call it a geographically localized creative tendency; as witness, China: all things yellow, and one pervasive, absolutely unique odor, and numerous, even more, striking evidences of such like qualitative kinships in nature, geographically limited. As to what we shall give in yellow fever, let me cover a wide field in a few words. But let me say to you right here, that your duty is in behalf of your patient first, and to the protection of your people second, and not to the furtherance of pharmacological inquiry. In responding to this dual duty, you must have the backing of your own strong integrity; of a courageous manhood; and conduct yourself so clearly in your high office that you may command unquestioning confidence in the face of any trial. Quail not under a covert threat. Far better to forfeit your life in a glorious martyrdom for truth, than to have your people cry out in their distress, like Job, rising in his affliction, "But ye are forgers of lies, ye are all physicians of no value." Concerning treatment, I tell you now that every known energy and substance, excepting, to date, the X-ray and radium, have. been ransacked in the quest of a specific; and in that particular we are to-day where we were one hundred years ago. In assuming the care of a case of yellow fever, the physician must have clearly defined a mental picture of the four stages of the disease, shading one into the other, in progressive unfolding; recognizing and interpreting each in the succession of symptoms. To do this makes the skilled diagnostician, and without it there is no such thing as a masterful, a safe and judicious treatment. Right here lies the difference between the trustworthy yellow fever physician, and the wholly unreliable physician, because not skilled in this bedside interpretation: so the whole question rests finally on this power. From observation, I will boldly say that, the most dangerous allies of yellow fever, excepting, of course, first and always, the man who chooses not to recognize the first cases when he sees them glaringly, and suppresses information of the first sparks of pestilence, from motives of cowardice, or his own little rascally preferment - next to him, but far less criminal is the charlatan and blatant ignoramus, with diploma or not; close behind is the educated physician, long in practice outside the yellow fever zone, simply because he brings his accumulated experience to bear in confident assurance in the one, lone, absolutely unique malady, the most mysterious on the planet. With a big heart and a generous, helping hand, a complete and sacrificial offering of self, he plunges into the treatment of an infection that holds its destructive sway in the unseen world of matter, in its operation, the analogue of the rattlesnake among things visible. Named by its nature, it should be called Noli me tangere, and no such dignified, warning name, misapplied to a chronic ulcer. In every variegated diamond, in the triangular, squarejawed head and sullen eye, you see in the rattler written all over by the hand of nature, Noli me tangere, and so in the outward signs and inward working of yellow fever. "Provoke me, if you dare! I hold this patient, and in me is the issue of life and death: hands off." In the symptomatic movement through its stages we note the chill, speedily followed by a fever of variable intensity and duration, let us say from twenty-four to seventy-two hours, declining abruptly or gradually into a listless stage of intermission or of marked remission. This is the treacherous vortex calm following the storm of primary assault of the true poison itself. This calm may be final in death or convalescence; but usually on the third, fourth, or fifth day comes the secondary storm, from a new direction, and due to septic and other toxic consequences, and the enormous obstruction accumulation of tissue debris. The successful elimination of these secondary toxins introduces the last stage, convalescence; its failure means death. Simply recognizing the composite detail of this picture: the gathering storm, the approaching crisis in destructive congestions and probable hemorrhages; the universal degenerative changes; oftentimes localized inflammations; and always the obstructive tissue wreckage, this picture before your eyes, the treatment of the disease suggests itself. First, last, and all the time, your defensive cry is, Elimination! That one word, and gentle ministration in hygienic care, covers, with rare exception, the whole field of your ability; "for whatsoever is more than these cometh of evil." A firm self-control, and a strict interpretation of symptomatic evidence, is your panoply in the fight. To have a strong or reasonable hope of success, the treatment must begin early; certainly within the first twenty hours. Later than that, the precious time is forfeited. Your initial step is elimination without irritation. According to age, physique, and urgency, from five to fifteen grains of calomel, but no bicarbonate of soda, given preferably in a teaspoonful of fine ice. Four hours later, a full dose of an active, but mild purgative, such as the stomach is most likely to bear: no pills. The old-time infusion of senna, manna, and salts, or a full dose of castor oil, made as agreeable as possible, or an active saline water. This may be supplemented by a large enema if not unduly exciting to the patient. Where the stomach is gorged with a recent meal or things hard of digestion, empty quickly with an emetic, first thing. When the stomach has been cleared and the bowels freely relieved of their entire contents. you have reached your limit of vigorous medication; and like Paul in the tempestuous Euroclydon: "When the ship was caught and could not bear up into the wind, we let her drive." Go on favoring elimination, and your safe friend is water, cool or cold, plain so, or any modification, as a light lemonade, Apollinaris, Vichy, the light, pure fruit juice additions, or Buffalo Lithia ad libitum. For high fever, a large bowl of warm water and free wet toweling of the body; but never ice or anything cold applied externally. The guarded icebag to the hemorrhagic stomach is the only exception. To further aid in control of high fever, small one or two grain doses of phenacetin or acetanilid, or such like according to preference, may be given and repeated in two hours if required. Invoke only the gentle effect. Everything gentle and non-irritant in all that you do. Comfort is itself a powerful remedy. The calm stage calls for absolute rest. A little Ducros' Elixir, with ice or water, if acceptable, or panopepton and water if preferred. The use of a small, soft catheter is sometimes imperative; watch for retention. In the fourth, fifth, or sixth day we reach a danger line in the resumption of nourishment. The state of the stomach and its ability to bear must be our guide. Until the red-edged and pointed tongue and the oral mucous membrane and gums have paled from their appearance of acute erythema, you must proceed with exceeding caution in nourishing your patient; a little haste in premature feeding, giving too much or too rich, or any kind of solid, may readily irritate and rush an otherwise wellprogressing case into gastric hemorrhage and into uncontrollable recurrent fever, or the tornado from another quadrant, let me rather say. For such hemorrhage, actual or threatened, I give ice freely, sometimes with an eighth or twelfth of a grain of cocaine hydrochlorate. Here I use ice as a poultice over the stomach, carefully guarding against excessive refrigeration by one, two, or three thicknesses of flannel or towel between icebag and skin. Iced champagne is sometimes grateful, but often soon tired of; Ducros' Elixir is generally liked better, panopepton or sometimes a little weak, very fine brandy. As the evidences of acute inflammatory action subside, begin with three or four teaspoonfuls of iced milk with one fourth of lime water, or milk and Vichy half and half. Repeat in an hour |