The same failure which has followed the use of quinine, of arsenic, and of salicin and the salicylates has attended the effort to prevent the relapse by berberine, benzoate of soda, tincture of eucalyptus, and other reputed antiperiodics.
Digitalis, veratrum viride, and aconite were used by us quite freely as antipyretics. The first two of these were often suspended on account of the irritability of the stomach, and no valuable results followed their use when well tolerated. Aconite in small doses, frequently repeated, as one drop every two hours, seemed to aid in allaying nausea and to exert some slight influence upon the fever. In cases where there was a distinct tendency to heart-failure, digitalis was given freely with advantage.
Cold baths were not used to reduce the temperature in any of the cases under our observation. They have been employed in other epidemics, but, as far as we know, with no other effect than to cause merely temporary lowering of temperature, without any decided relief to the other symptoms and without any apparent influence upon the course of the disease. Frequent spongings with cool water and the application of ice to the head gave only slight and temporary relief.
Simple febrifuge remedies, such as effervescing draught or spirit of nitrous ether with solution of acetate of ammonium, were well received by the stomach, and appeared to promote perspiration and the more free secretion of urine.
Finding all our efforts to control the pyrexia so unsuccessful, recourse was had in a large proportion of our cases to the hyposulphite of soda, given, dissolved in two ounces of water, in doses of twenty grains every two or three hours. In two cases it seemed to increase nausea, and at times it caused some purging, but otherwise it was well borne by the stomach, and, indeed, frequently appeared to aid in controlling vomiting. The records show that this drug was given in only two or three of the fatal cases, so that although the patients who took it regularly presented every grade of severity of the disease, they did well uniformly. It is certain, however, that the hyposulphite of soda exerted no specific effect upon the disease; it did not reduce temperature, it did not prevent or modify the relapses nor relieve the severe pains; it may have promoted more free and healthy secretions, and, by tending to prevent vomiting, may have aided in maintaining nutrition; but, on the whole, it may fairly be doubted whether this remedy merits any more extended trial.
One chief reason of the failure of antipyretics in relapsing fever is to be found in the existence of widespread irritative lesions of the glandular and mucous tissues, which combine with the specific blood-changes in causing and maintaining the high temperature. It is not surprising, therefore, that the remedies which afford the greatest relief in this disease are opiates and sedatives to the gastro-intestinal mucous membrane. Opium, or morphia, must indeed be regarded as the basis of the rational treatment of relapsing fever. It is called for by the insomnia, the severe headache and the pains in various parts of the body, the nausea and vomiting, and the pyrexia. It does not appear to have been as prominent a feature in the treatment of other epidemics as we found it necessary to make it in Philadelphia. Parry42 used it very freely, chiefly in the form of opium, by the mouth, and found a singular tolerance exhibited by his patients, several of whom took as large a dose as three grains every two hours during the afternoon and night without producing any sleep or even any contraction of the pupils. This resistance to the action of opium was observed chiefly in the early part of the epidemic, and we may add that it was exhibited chiefly when opium was given by the mouth. When morphia was used hypodermically we found that one-fourth of a grain, given at intervals of six to twelve hours, afforded very great relief to the pains, aided and relieved vomiting, and often induced quiet, refreshing sleep. Its use was not contraindicated by jaundice, by cough or pulmonary congestion, or by moderate contraction of the pupils. It was frequently given so as to maintain decided drowsiness throughout the pyrexia. When the pains persisted during the intermission the morphia was continued in smaller doses or at longer intervals. It occasionally happened that when patients were thus kept continuously under opium influence no relapse occurred; but here, as in regard to the action of quinine, it may safely be asserted either that what was regarded as the initial paroxysm was in reality the relapse, or else that the absence of a relapse was a mere irregularity, and in no way to be attributed to the action of the opium. On the other hand, in cases presenting a tendency to the typhoid state, with a disposition to stupor, or where the urine was scanty and albuminous, no opiate was administered.
42 Loc. cit.
We have already stated that in our cases quinine in acid solution was frequently ordered, and it answered very well to add to each dose of this a suitable amount of morphia.
Atropia, in the dose of gr. 1/60 to gr. 1/40, was usually associated with the hypodermic injections of morphia. This was done particularly in cases where the pains were very severe, when the pupils were disposed to be contracted, or when there was continued profuse sweating. In addition to this, atropia was continued without morphia during the intermission in a few cases. The patients proved susceptible to its influence, and dryness of the mouth with dilatation of the pupils was readily produced by gr. 1/60 every six hours. In one case gr. 1/40 every four hours for two days caused delirium, with the usual symptoms of belladonna action, all of which passed away quickly after withdrawal of the drug. But in none of these cases was the relapse influenced in the least.
Other remedies may be used for the relief of the insomnia, which is always one of the most distressing symptoms. Chloral and bromide of potassium have been found serviceable in various epidemics, and some observers have preferred them to opium for the relief of headache and insomnia. They did not prove reliable in the Philadelphia epidemic of 1869-70. Bromide of potassium, even in large doses, produced scarcely any effect, and, while in a few cases chloral in doses of gr. xx. gave positive relief, in the majority of instances 40 grains failed to cause sleep or relieve suffering. It must not be forgotten also that, as there is a special tendency to cardiac failure in this affection, the action of chloral must be closely watched.