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

by Unknown

Constipation is an occasional symptom, but it rarely calls for active interference. When it is present so early in the course of the disease that the diagnosis is still uncertain, and has continued for several days, it is best to prescribe a small dose of castor oil; a dessertspoonful is generally sufficient. The late Dr. Gerhard was in the habit of giving a tablespoonful of sweet oil in this condition. The inordinate action which frequently follows the administration of these mild purgatives will often dispel all uncertainty as to the nature of the disease we have to do with. When it occurs in a more advanced stage of the disease it is best met by the administration of enemata, which may contain, if there is much tympanites present, a small quantity of oil of turpentine. Under all circumstances it will be well to remember the advice given by Baglivi two centuries ago, to avoid the use of active cathartics in this disease.¹⁰⁷

¹⁰⁷ "Fuge purgantia tanquam postem," Opera Omnia Medico-Practica et Anatomica, Georgii Baglivi, 1788.

The headache which is sometimes a distressing symptom in the beginning of the disease is usually relieved by the application to the head of cloths constantly wet with ice-water or by that of a bladder filled with ice and lard. If it is very severe and does not yield to these remedies, a few leeches applied to the temples often have a very happy effect in moderating the pain. Murchison recommends that the cold affusion should be administered by simply placing the patient's head over a basin at the edge of the bed and pouring water on it from a height of two or three feet. He also says that warm fomentations are to be preferred to cold in aged and infirm persons of feeble circulation. Sleeplessness will often disappear under the use of remedies presented for the relief of the headache and other nervous symptoms. It is occasionally so persistent as to call for special treatment. If it occur early in the disease, it will generally be sufficient to prescribe at bedtime ten grains each of potassium bromide and chloral, repeated once or twice during the night. Later in the disease this combination ceases to produce any effect, besides which chloral cannot be administered with safety after the action of the heart becomes feeble. It is therefore necessary to have recourse to opium in some form or other. There are, it is true, theoretical objections to its use in typhoid fever, such as its interference with digestion and its tendency to lock up the secretions; but these will hardly weigh in the balance against the fact that the patient will die of exhaustion if the insomnia is allowed to continue, and that under certain circumstances opium is the only drug which will procure the needed sleep. The form in which it is given is not a matter of much importance. I prefer the deodorized tincture, twenty or thirty drops, repeated if necessary in an hour or two, but I have seen good results from the solid opium and from the hypodermic injection of morphia. When the insomnia is attended by much tremor and muttering delirium, camphor may be added to the opium, and given throughout the day as well as in the evening. Violent delirium is sometimes also relieved by administration of opium and alcoholic stimulants, and by the application of cold to the head. It is also much lessened by the cold-water treatment. When the delirium is so violent that restraint is necessary, it is better that this should be mechanical than that it should be left wholly in the hands of ignorant and untrained nurses. A folded sheet passed over the chest of the patient and fastened to the sides of the bed is frequently all that is needed. Stupor requires very much the same kind of treatment as that suitable for the other forms of nervous derangement. If it is extreme, counter-irritants should be applied to the nape of the neck and cold to the head. The late Dr. Wood was in the habit of shaving the hair and applying a blister to the scalp of a patient in this condition, and I have seen good in more than one instance result from this treatment. The urine should also be examined, and if the quantity be insufficient diuretics should be given. If it contain albumen or blood, counter-irritants and even cut cups should be applied to the loins. It is also important, if the patient be in this condition, that the physician should not rest satisfied with the nurse's assurance that the urine is passed freely, but should from time to time examine the supra-pubic region himself. It is not infrequently found under these circumstances that there is really retention, and that the wetting of the bed upon which the nurse has based her assurances is really the consequence of the dribbling of urine from an over-distended bladder. I have known of serious results, such as cystitis, paralysis of the bladder, having followed the neglect of this very simple precaution. Convulsions when they occur are to be treated by the application of cold to the head and counter-irritants to other parts of the body.

Epistaxis is rarely so severe as not to yield to the use of simple remedies, such as the application of ice to the forehead or back of the neck, or of styptics locally. In a few cases, however, it is profuse, and it will then be necessary to have recourse to hypodermic injections of ergotin, as in the case of hemorrhage from the intestines, or to plug the nostrils.

TREATMENT OF COMPLICATIONS.—Hypostatic congestion of the lungs, as it is usually the consequence of feeble action of the heart, is best treated by frequently changing the position of the patient, and by remedies calculated to increase the power of the organ, such as alcoholic stimulants, ammonium carbonate, oil of turpentine, and digitalis. Recent German authors, however, regard digitalis as a dangerous remedy when the heart has undergone the granular degeneration peculiar to fevers. It had, therefore, better not be given if the congestion occurs late in the disease. I have myself always found advantage from the application of turpentine stupes to the chest, and occasionally from the application of dry cups. Pneumonia when it occurs as a complication does not render necessary a material modification of the above treatment. It may sometimes be well, if it occur early in a robust subject, to take blood locally, but it can rarely be justifiable to do so by venesection.

Bed-sores may generally be prevented by frequently changing the position of the patient, by scrupulous attention to cleanliness, and by bathing prominent parts of his body with whiskey and alum. These parts should also be protected from pressure by the judicious arrangement of pillows and cushions. When redness or abrasions appear the part should be covered with soap plaster smoothly spread upon kid. This application may be continued even after the formation of sloughs. As soon, however, as these show a tendency to suppurate poultices should be applied, and the resulting ulcer treated as if occurring under other circumstances.

Thrombosis of the femoral vein is best treated by elevating the affected leg and enveloping it with flannel cloths saturated with hot vinegar and water. Thrombosis of other veins is to be treated on the same general principles. When an artery becomes obliterated, whether from embolism or thrombosis, the part which it supplies should be surrounded with cotton wool and every effort made to favor the establishment of the collateral circulation. If sphacelus occurs, it should be treated on general surgical principles.

TREATMENT OF CONVALESCENCE.—The importance of a strict adherence to a liquid diet in the early part of the convalescence of typhoid fever has already been alluded to. The ulcers in the intestines often remain unhealed for some time after the subsidence of the fever, and errors in diet may therefore readily cause recrudescences of fever, if not true relapses. These recrudescences are sometimes produced by very slight causes. I have seen them follow undue mental exercise or worry, or sitting up too early or too long. It is therefore important to guard our patients at this stage of the disease from undue fatigue or excitement of any kind. Medicines calculated to build up the strength and to improve the nutrition are clearly indicated at this time. If the diarrhoea should persist, nitrate or oxide of silver, sulphate of copper, and subnitrate of bismuth in appropriate doses, given with a little opium, will all be found to be useful remedies. When, on the contrary, constipation exists, it is still necessary to avoid the use of drastic cathartics; indeed, even mild laxatives should be given by the mouth only after enemata have failed to produce a movement of the bowel.

SPECIFIC TREATMENT.—The search for a specific remedy in typhoid fever is not new. It is as old as the theory that the disease is generated by a specific cause. The hypothesis that this is an alkaline poison led many years ago to the use of the mineral acids, and it was only after experience had shown that they were without power to cut the disease short, or even to control many of its symptoms, that they ceased in a measure to be prescribed. Calomel also, which was occasionally resorted to formerly for its antiphlogistic effects upon the intestinal lesions, has been lately recommended in Germany in the treatment of typhoid fever on account of its supposed antidotal properties. Seven and a half grains of the drug, and in some cases a much larger dose, are given four times daily on alternate days as soon as the nature of the disease is fully recognized. It is claimed for this treatment that when it is begun early the rate of mortality and the duration of the disease are much less under it than under any other. Its advocates admit, however, that the latter is not always the case—a variety in the action of the medicine which is attributed to a difference in the way in which the poison of the disease has been taken into the body. Salivation is rarely produced by the calomel. The diarrhoea, which is at first increased by it, subsequently diminishes, and the administration of each dose is followed by a decided although temporary reduction of temperature.

A diminution in the rate of mortality is also said to have been obtained by the administration of iodine in typhoid fever, although the results of its use are on the whole less favorable than those of calomel. Liebermeister recommends that three or four drops of a solution of one part of iodine, two parts of iodide of potassium, and ten parts of water should be given every two hours in a glass of water.