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GEN. III.

SPEC. II.

6 E. malig

nus flavus.

Yellow fever.

Alterant and depleting methods.

free use of opium to keep the bark on the stomach as well as to allay pain and procure rest: to which were occasionally added wine and brandy in considerable abundance, three bottles of the latter having sometimes been given to a patient in less than twenty-four hours, and the same proportion continued for several days*: while recourse was only had to the lancet where there was obvious proof of very violent local affection.

The times, however, have since changed, and by far the more popular plan of late years has consisted in active, profuse, and repeated venesections, large and quickly renewed doses of calomel, cold affusion, gestation in pure air, and, as advised by some, the bolder exercise and rapid motion of a cart, spring-waggon, or any other carriage +. It was in this manner that Dr. Rush, regarding the inflammatory impetus as the sole cause of danger, boldly resolved to lay prostrate if possible the morbid Hercules at its birth, by bleeding, according to the state of the pulse, two or three times a-day during the first two days, and by following up the same plan as long as a single germ of an inflammatory diathesis should Rush's continue manifest. "I paid no regard", says he, "to practice as to bleeding; the dissolved state of the blood, when it appeared on the first or second day of the disorder, but repeated the bleedings afterwards, in every case, when the pulse continued to indicate it. It was common to see sizy blood succeed that which was dissolved. The dissolved appearance of the blood I supposed to be the effect of a certain action of the blood-vessels upon it. The presence of petecchia did not deter me from repeating bloodletting where the pulse retained its fulness or tension." And he affirms, that both petecchia and vibices disappeared in various cases after bleeding. This plan he often pursued through the fifth and even the seventh day, in the course of which period, from a hundred to a

* M'Cabe in Edin. Med. and Sur. Journ. Oct. 1819.

+ Hist. and Cure of Fever, by R. Jackson, M.D. Part 1. Chap. XI. pp. 267-270.

hundred and twenty ounces of blood were frequently GEN. III. taken away by six or eight applications of the lancet.

SPEC. II.
B E. malig-

Yellow

His purgative plan was not less alert. Ten grains of nus flavus. calomel and fifteen of jalap, was the force with which he fever. opened his remedial attack, and which he repeated every as to purgsix hours, till the aivine canal was effectually evacuated. ing; This mode of treatment, he tells us, he was led to by accident; and with it he became as successful as he had highly sucbeen unsuccessful under the tamer and more established method.

cessful.

Employed

with dif

ferent views.

Sudden and

decisive de

Under this plan of treatment, the venesection and the calomel were employed on a principle of depletion alone, aud of diminishing a real or supposed increased action; and the former on the principle of a gradual depletion, Gradual Dr. Rush rarely venturing to withdraw more than six- depletion. teen ounces of blood at a time, though the venesection was as closely repeated as the patient's strength was conceived equal to. Both these remedies have, however, still more lately been employed on different grounds, and under a different mode of management. Blood, instead of being taken away gradually and successively, has by many, and especially by Dr. Jackson, who seems to have introduced the practice, been drawn off, on the accession of the disease, to thirty or forty ounces at once, with a view of making a decisive impression upon the system; the same bold use of the lancet being repeated within three hours, if such impression be not effected: after which "such powers are recommended as stimulate to a train of action, congenial to the action of health" *: and calomel, instead of being employed as a purgative, Calomel as has been enlisted as a powerful alterant and deobstruent, and persevered in to salivation, by doses of from five to five and twenty or thirty grains every third or fourth hour, according to circumstances, till this point is obtained; which, however, is not regarded as important in itself, but as showing that the system is sufficiently under its influence. Dr. Chisholm seems fairly entitled to the

* Hist, and Cure of Fever, B. 11. Ch. x1. pp. 267-293.

pletion.

a deob-
struent

rather than
a purgative.

Salivation a supposed sign of its succeeding.

SPEC. II. B E. malignus flavus.

Yellow fever.

GEN. III. honour of having first tried and recommended mercury with this intention*. "It ought", says he, "to be a general rule of practice to consider all remittent fevers within the tropics as symptomatic of local congestion, and inflammation. It is a rule, the observation of which can never be injurious-almost always positively beneficial-and the neglect of which is always productive of harm. Under this view, the judicious practitioner will consider the tendency to congestion, as the object of his main attention, and direct his efforts to prevent it. Upon the whole, then, the treatment is reduced to one sentence-bleeding to the extent necessary, plentiful alvine evacuation, MERCURIAL PTYALISM, and cold affusion;" and he adds, in another part of the same volume," Let it never be forgotten that at whatever period of the disease salivation is excited, whether the supposed signs of putrefaction have appeared or not, the accession of it is the certain signal of cessation of disease, and of returning health.”‡

How far such discre

pancies capable of

reconcilia

tion.

This general plan of Dr. Chisholm has in the present day become highly, and perhaps chiefly popular ; and is powerfully recommended from personal experience of its advantage by Dr. James Johnson §, Dr. Burnett ||, Dr. Boyd ¶, Dr. Denmark **, and a long list of valuable authorities, who have practised in the one or the other of the Indies; all of whom, however, combine the use of calomel with copious bleeding; the former being regarded as the 'sine qua non', or the sheet-anchor', by some of them: and the latter being designated by the same terms, by others.

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On a cursory glance, these diversified modes of treatment appear in many respects, to be directly hostile to each other, and to establish an utter absence of any one therapeutic principle common to the whole; but a

Hist. and Cure of Fever, B. 11. Ch. x1. pp. 267–293.

On the Climate and Diseases of Tropical Countries, pp. 46, 47.
Id. p. 215. § Influence of Tropical Climates, &c., pp. 50, 51, et passim.
On the Bilious Remittent Fever of the Mediterranean.

De Febre Minorcæ, &c., 1817.

** Medico-Chir. Trans. Vol. VI.

closer attention to the subject will show us, that there is not necessarily any opprobrium medicorum in the discrepancy, except what results from becoming so exclusively the champion of any one of these respective modes of treatment as to bend every case to its own limits, and thus convert it into a bed of Procrustes: for there seems abundant reason for believing that, in different situations, or under different circumstances, each of these plans has proved equally judicious and successful; since we have seen that the disease under different incidents and coadjuvants has exhibited every variety of violence, and inclined to almost every variety of febrile type. Where there is not much impetuosity in the onset, no great derangement or prognostic of inflammatory congestion in the larger viscera, where the remissions are regular, and the epidemy is pretty uniform in its character, large and repeated bleedings, as a general rule, must prove mischievous. They will not shorten the career of the disease, but they will convert the remittent into a continued fever and we shall in the latter stage of its course stand woefully in need of that strength which we shall have squandered away at first, if we have commenced with profuse venesection.

:

GEN. III.

SPEC. II. 6 E. malignus flavus.

Yellow

fever.

Where copious venepurging must be mis

section and

chievous.

illustrated.

This is more especially the case where the disease Further makes its attack slowly and insidiously, assuming in some degree a typhous guise, as in the Guzzerat form described by Mr. Gibson of the Bombay Medical Department in which he tells us that the debility is so great and instantaneous, as well as the tendency to putridity, that bleeding is never to be hazarded, except occasionally, to the robust new-comer; and in which, even spontaneous hemorrhages, instead of proving critical, have always seemed to hasten death, and indeed, without a single exception, in his experience, to prove fatal. And it was probably from a survey composed largely of cases of this kind, though in the West Indies, that Dr. Hunter, in a tone still more generally proscriptive, and

Edin. Med. and Surg. Journ. Vol. xi.

This view sometimes

carried to an extreme.

SPEC. II.

B E. malignus flavus. Yellow fever.

GEN. III. which will meet with few defenders at present, thought himself justified in affirming respecting venesection that even "in such cases as seemed most to require it-for example, where the patient was young, strong, of a full habit, and lately arrived from Europe--when the pulse was quick and full, the face flushed, with great heat and head-ache—and all these at the beginning of the feverbleeding did no good."

Pinkard's

account of his own

attack.

Where both

Dr. Pinkard, in his "Notes on the West Indies ", has given a very interesting description of his own sufferings under this disease, and of the remedial process to which he had recourse. His attack commenced in the more common manner, slowly and insidiously, and demanded eight or nine days to reach its acme. His head, stomach, and at last his bowels, were severely affected, especially the first; but his intellect continued sound; and, though the symptoms were vehement, there seems to have been little tendency to that violent visceral inflammation which in the stage of debility is so apt to produce gangrene; and consequently he had no black vomit. He lost twelve or fourteen ounces of blood at the commencement of the disease, and took a strong dose of calomel, which considerably relieved the pain in his head and eyes, and diminished the restlessness; but the thirst, heat, and dryness of the skin were still intense; and his weakness became extreme. Affusions of cold water, old hock, opium, and bark, were made use of in profusion, and each seemed to afford great relief. Yet on the subsidence of the fever, he represents his feebleness as most deplorable, and such as it appeared impossible to recover from. Here a freer use of the lancet could have been of no avail, and, had not the author most judiciously forbade its further employment, in all probability he would never have been the historian of his own case+.

On the contrary, if the disease make its incursion with be beneficial, great impetuosity; if the pulse be full and strong, or

means must

and ought to

be employ

ed.

On the Diseases of Jamaica, p. 118. 3d Edit.

+ Vol. I. Letter xi. p. 134.

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