A system of practical medicine. By American authors. Vol. 1

by Unknown

In cases in which only a gentle stimulus is required wine in the form of wine-whey will often be found to meet the indication fully. Generally, however, it will be necessary to have recourse to whiskey or brandy. The choice between these may usually be left to the patient's fancy; brandy is, however, to be preferred in cases in which diarrhoea is a prominent symptom. These stimulants should be given in small quantities frequently repeated. In many cases a dessertspoonful every two or three hours, either diluted with water or, when the stomach is irritable, with carbonic acid water or given in the form of milk punch, will be sufficient. In others a tablespoonful every two hours, or even at shorter intervals, will be required, but it will rarely be necessary to exceed eight ounces a day for more than a few days at a time.

Although the physician will not often be called upon at the present day to encounter and combat the prejudice so common formerly against the free administration of water in the febrile condition, he will frequently find nurses and others not sufficiently alive to the importance of supplying it when the patient, having fallen into the typhoid state, ceases to ask for it. The high temperature which is generally present in this condition, and the rapid combustion of tissue which it causes, make a full supply of liquid an urgent necessity which it is dangerous to disregard. Water is the best of all diuretics, and it is important in this disease, as indeed it is in many others, that the functions of the kidneys should be kept active, so that the products of the combustion of the tissues may be eliminated with their secretion. Care, however, should of course be taken, as pointed out by Da Costa,⁹⁸ that water is not given in such quantity that the desire for and capability of digesting food is destroyed by it.

⁹⁸ Preface to Wilson's Treatise on the Continued Fevers.

In the few cases which begin abruptly with symptoms simulating those of a so-called bilious attack the practitioner will usually content himself with the administration of medicines calculated to allay the irritability of the stomach and bowels. For this purpose I have found the bicarbonate of potassa in solution, to which lemon-juice is added at the moment it is taken, so as to produce an extemporaneous effervescing draught, often an admirable remedy. In other cases I have used with advantage small doses of calomel or blue mass, followed, if necessary, by a gentle saline purge. When the symptoms have occurred soon after a hearty meal, or when there is evidence that the stomach is overloaded, it will occasionally be necessary to have recourse to an emetic. Usually, the indications for treatment at the beginning of an attack are much less definite, and even in the class of cases just referred to they become so after the subsidence of the gastro-intestinal symptoms. Indeed, the treatment in the larger number of cases must be purely symptomatic until the nature of the disease has fully declared itself. The presence of fever will suggest the use of the neutral mixture, effervescing draught, or spirit of Mindererus, combined, if there is decided tendency to evening exacerbations, with sulphate of quinia in full doses. If there is much diarrhoea, Hope's camphor mixture or opium in some other form may be given; if delirium is a prominent symptom, ice or cloths wrung out of cold water should be kept constantly applied to the head.

But even after all doubt in regard to the diagnosis has been dispelled and the existence of typhoid fever has been recognized, the treatment most in favor with physicians is in large measure symptomatic in character. It is true that various specific treatments, to which fuller reference will be made hereafter, have been lately proposed, but the results obtained by them up to the present time where they have been fairly tested are not so favorable as to induce the body of the profession to adopt them to the exclusion of all other methods. It is certain that no remedy or plan of treatment has yet been discovered which has the power of cutting the disease short, although this power has been claimed at different times for several. Thus, at one time quinia in very large doses was believed to possess it, at another venesection, and at another cold baths. But experience has shown that these and other perturbating remedies often do harm, and there is good reason to believe that the apparent good which has followed their use in a comparatively small number of instances may be better explained by supposing that an error of diagnosis has been made than by attributing to them the power of arresting the progress of the disease. Medicines are, however, by no means useless in the treatment of typhoid fever. There is no question that the disease is not only generally conducted to a favorable issue, but that its duration is often materially shortened, by their judicious use. It is evident, however, that the treatment must vary with the severity of the attack. In a few cases it is scarcely necessary to interfere with the course of the disease by the administration of medicines. In others, on the contrary, it is necessary to act promptly and energetically in order to save life.

When called upon to treat typhoid fever, if the case is a mild one with no bad symptoms, such as excessive diarrhoea, delirium, tremors, and the like, and especially if the temperature does not rise higher than 102° F., I am accustomed, after giving minute directions as to the diet and general care of the patient, to prescribe from two to three grains of sulphate of quinia four times daily. No great power in reducing the temperature of the body can, of course, be claimed for these doses, but experience has shown that the impression which they make is useful, and they do not interfere with the administration of the drug in larger quantities should this become necessary. Their action, too, is tonic, and, as they rarely produce cinchonism, the objection often made to the use of larger doses does not apply to them. I am also in the habit of adding to each dose of quinia from ten to fifteen drops of one of the mineral acids. These acids were originally prescribed in typhoid fever under the impression that they neutralized the cause of the disease, which was supposed to be an alkaline poison. Although the results of recent research, which tend to show that the cause of the disease is an organized germ, give no support to this theory, they continue to be used by a large number of physicians of experience. I do not know that any satisfactory explanation of their action in typhoid fever has ever been given. They are certainly tonics, and are therefore indicated, if not in the beginning of the disease, as soon as the strength begins to fail. If, as the disease progresses, the tongue becomes dry and fissured, and if there is much tympany, it will be well to give, in addition to the quinia, ten drops of the oil of turpentine in mucilage every two hours. This was a favorite remedy of the late George B. Wood, the distinguished professor of the Theory and Practice of Medicine in the University of Pennsylvania, who attributed the improvement in the symptoms which generally follows its use to a direct influence of this medicine upon the ulcers in the intestines. Although inclined to believe that the correct explanation of this improvement is its stimulating action upon the circulation and secretions, I fully agree with him in regard to its usefulness in many cases. Under its use I have often seen the dry, fissured, and shrivelled tongue grow moist and throw off its coating much earlier than in all probability it would otherwise have done.

No other than this simple treatment is required in a large number of cases, but even in mild cases symptoms occasionally arise which render necessary some modification of it. It will, however, be more convenient to postpone the discussion of this part of the treatment of typhoid fever until after the treatment of the more serious forms of the disease has been considered.

When typhoid fever assumes a severe type, the success of the physician in the management of the disease will depend largely upon the readiness with which he detects indications for treatment and the promptness with which he meets them. Usually, one of the first symptoms to demand attention is the high temperature. This is not only an early symptom in many bad cases, but may continue throughout the attack; or it may suddenly supervene in cases in which the fever has previously been moderate in degree, and when excessive may be the direct or indirect cause of death. The reduction of the temperature is therefore an indication the importance of which cannot well be overestimated. Fortunately, there are several methods by which this end may be accomplished. It will, however, be necessary for our purpose to consider only two of them in detail: 1, the cold-water treatment; 2, sulphate of quinia in full doses.

The cold-water treatment is not new, since it was practised in the form of cold effusion in the treatment of fevers as long ago as 1787 by Currie of Liverpool, who may be said to have introduced it, and who asserted that it had the power not merely of moderating the symptoms of these diseases, but also, in many cases, of cutting them short. It enjoyed at first a high degree of popularity, which lasted for from twenty to thirty years, but finally fell into disuse, probably in consequence of the exaggerated character of the claims which were made for it by its advocates. Although resorted to from time to time in various parts of the world, the merit of having brought it again into notice seems to be due to Brand of Stettin, who published a work on The Hydrotherapy of Typhoid Fever in 1861. Still more recently, the recorded observations of Bartels, Jürgensen, Ziemssen, and Liebermeister in Germany, and of Wilson Fox and others in England, have so far restored the treatment to professional favor that there are few physicians either in this country or abroad who do not occasionally have recourse to it.

The cold-water treatment may be applied in several different ways: 1, the cold bath; 2, the graduated bath; 3, cold affusions; 4, the cold pack; 5, cold sponging; 6, cold compresses; and 7, frictions with ice. They all act in the same manner, and depend for their efficacy upon their power of abstracting heat from the body, and are useful just in proportion as they do this. There is no reason for believing that they have the power to modify the conditions upon which the production of heat depends, but there is, on the other hand, no doubt that under their use distressing and dangerous symptoms, such as coma, stupor, subsultus, and the like, are often much relieved. They probably act, therefore, by diminishing the metamorphosis of the tissues, and the consequent loading of the blood with excrementitious products which the hyperpyrexia has a tendency to promote.