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cess of putrifaction, which may be going on in the tissues, fluids, and excreta of his body. Typhus (sometimes not inappropriately called putrid fever), greatly varies in its gravity and durations, and symtomatology. It is a rare disease outside of crowded cities, filthy prisons, and badly policed military encampments. Like the epidemic cause of influenza,
MALARIA, besides inpressing the general system in its own puculiar manner, may under the influence of the secondary causes and contingencies already alluded to, be the prime factor in the development of local congestions, irritations and inflammations, that so much vary the expressions of periodical fevers and increase their duration and gravity, not only before their paroxysms have been broken up by anti-periodics, but also afterwards.
The grave local inflammatory abnormities incident to malarial fevers, and sequel thereof, have given origin to the now fashionable, pathological heresy, that has uttered the dogma, that there is a specific fever entitled to be called
TYPHO-MALARIAL. Whenever in matters of science any individual or individuals assume to announce a theory, a principle or a fact, unsupported by evidence, it matters not how exalted in position and reputation they may be, they are guilty of dogmatizing, which in medicine, is most fruitful of error in theory, and promotive of routinism in practice.
Recognizing inflammation (of greater or less gravity and extent) of the mucous lining of the body as the chief factor of the continuation of fevers provoked primarily by sporadic causes, by the morbific agent of influenza, and by malaria, in the absence of a better nomenclature (if we must generically denominate them fevers) I prefer to use the adjective catarrhal to specify them. For the noun catarrh, signifying inflammation of the mucous membrane, the adjective catarrhal prefixed to the word fever, is more nearly indicative of the true pathology of the numerous cases of symptomatic fever we are all frequently called upon to treat.
The prolongation and fatality of idiopathic fevers are mainly due to disturbance of function, malnutrition and lesion of mucous membranes. Reflected disturbances and the extensive (almost universal) synergical relationships of the mucous membranes with other parts of the organism, afford a rational theoretical explanation of this fact. It is proper therefore, whenever in clinical charge of a patient in a febrile condition, that the practitioner shall carefully investigate the condition of the mucous membranes of all parts of the body. Not only should he endeavor to ascertain the location of abnormities, but also, if possible, their character and extent. For in every case of fever, it matters not to what cause it may owe its origin, some part or parts of the mucous membranes are in an abnormal state.
The custom, of immemorial usage, of examining the tongue, palate and fauces of a patient at almost every visit, owes its value, as an aid to diagnosis, to the hints, thus obtained of the state of the mucous membrane there and elsewhere situated. Yet how often is its examination regarded as mere form of clinical conventionalism !
Unless a practioner shall give laborious, intelligent attention to the the mintute diagnosis of each and every one of his cases exhibiting the febrile state, his notion in regard to the fevers he treats, will ever be vague and undefined, and his practice unsatisfactory. If content to merely nominate a disease, and indifferent to its etiology and true pathology, he is destined to play the role of routinist; and, if a conscientious and humane man, to experience at the bedside of his dying patients that bitterness of regret that follows mortifying defeats and disappointments, the wages of ignorance and neglect of duty.
of fevers whether continued, paroxysmal, exanthematous, traumatic or toxic, involves in its full extent the whole field of pathology and therapeusis. Volumes, almost numberless, have been written and will yet be written without exhausting the subject. Nineteen-twentieths of the time spent at the bedside by the general practitioner, is occupied in diagnosticating and treating fevers. Upon their successful treatment in all their forms and types, mainly depends the respectability and usefulness of our profession. More victims are slain by fevers than by all other diseases.
Only a brief outline of my views upon this branch of the subject will be attempted here. They will, however, be presented from the standpoint of experience.
Called to a patient with febrile symptoms, my inquiries are first directed to the age, sex, habits, (moral and physical) occupation and mode of living of the patient, to the family and individual nosological history, and the history of the particular attack under which he is laboring. The next effort is to ascertain whether it is a toxic, traumatic, malarial or specific fever. The temperature, the state of the general circulation, and nervous abnormities are then carefully noted. The locality where the patient is or has recently been residing, and the character of the epidemics prevailing there, are thoughtfully considered ; because those epidemics aid in the determination of the character of the fever, if not of toxic or traumatic origin.
Whether the fever be idiopathic or symptomatic, careful investigation must be had of the nature, extent and situation of local departures from the healthy state, and the influence of these local abnormities as original or secondary causes of unrest, reflected irritations, pain, thirst, anorexia, etc. On the first visit to a patient laboring under fever, it is important to weigh well his recuperative energy, the probable duration of his disease, (even if a favorable termination is probable) as well as the nature, extent and situation of the local abnormities. Without a condsideration of these, the practitioner is liable to err in two extremes, viz: his treatment may be too active and heroic, or two conservative and expectant. A knowledge of pathology and symptomatology is then invaluable, both to the patient and practitioner. For upon it depends the life of the former and the reputation of the latter.
Just here the temptation is irresistible to remark that owing to the great activity of the drug trade, the millions of money invested in it and the great profits that often accrue therefrom and the advertising capital it commands, it is too much the fashion of writers upon medicine (owing no doubt, to the daily pressure upon them to try new remedies) to devote more space to the discussion of their value, than to the discussion of the pathological phenomena of their cases, a proper knowledge of whose causes is of more value to suffering humanity than all the drugs of the shops. For in the treatment of diseases, if the practitioner is familiar with the pathology of his cases, and is able to diagnosticate them with minuteness, experience teaches him that only a few medicines judiciously chosen and skillfully prescribed, are needed in the treatment of fevers.
Some of these it may be proper now to enumerate. Mercurials, anodynes, arterial and nervous sedatives, diaphoretics, diuretics, purgatives, diluents, demulcents, counter-irritants and emetics may be indicated in the treatment of fevers. It would be well for every young practitioner at the outset of his career to resovle to study the modus operandi of one or two of each class, and by persistent practice with these, learn to use them skillfully. The numerous medicines of every class are well calculated to daze him. If he tries to use any large number of them before acquiring skill in the use of a few, he will find his judgment constantly wavering, as to their relative merits.
The materia medica are to the physician what the contents of his chest of tools are to the joiner. That chest may be well filled, but the daily use of its contents is confined to very few tools.
When a workman, young or old, proposes to put a straight edge upon a board (whether he is enlightened enough to be aware of it or not), he practically recognizes the principle that the rays of light proceed in straight lines. But one joiner, in fitting his work, will use his drawingknife more than he does his plane, while another will use his plane more than his drawing-knife; yet both may put together a first-rate job.
So physicians and surgeons, guided by principles, may use different articles of the materia medica, and operate in different methods, yet have equally favorable results.
This digression, in preface of what follows, rationally accounts for the equally favorable results of treatment reached by skilled practitioners, though using different drugs. The indications for treatment being understood and recognized, they use different articles of the classes of medicines needed to fill those indications.
Therefore, in the brief outline of my preferences for certain drugs in the treatment of fevers, it is not intended, directly or by implication, to condemn the practice of those who prefer other drugs, of equal potency for good, when prescribed by them.
OF THE MERCURIALS. When a mercurial is needed I prefer, both as a purgative and antiplastic, calomel. Long study of its effects and modus operandi, and its almost uniform purity, as found in the shops, are the grounds of this preference. It is in a more convenient form for the pocket-book or saddle-bags of the general practitioner, who has often to dispense medicine at the bedside of his patients, than blue mass. In the form of saccharated calomel (in the proportion of two grains of hard white sugar thoroughly triturated with one grain of calomel), we have an excellent and unchanging preparation, which answers all the purposes of blue mass. In this form I have been accustomed to its use from my earliest pupilage in medicine. Of this mixture I have often seen four grains, put upon the tongue and swallowed with the saliva alone, produce as prompt effect as a purgative as ten grains of blue mass. Its purgative effect is rendered more certain if the patient abstains from drinking water, or any other fluid, fifteen or twenty minutes after it is placed upon the tongue.
As in all fevers of the sthenic type, there is a call for antiplastics. Mercury has been found the most valuable of our remedial resources, when judiciously used.
The condition popularly termed biliousness is, in many cases, a misnomer. That condition is oftener owing to deficient or vicious secretions by the mucous membranes, than to inactivity of the liver; and the purgative and anti-plastic effects of the mercurial medicines is due more to their arousing of the secretions of those membranes and the consequent relief of their distended capillaries, and the purging their surfaces of the vitiated secretions and excretions in contact with them, than to stimulation of the biliary secretions, which is also generally aroused by their use.
The habitual use of small and frequently repeated doses of ice water by residents in tropical climates, is a well-known preventive of this socalled biliousness. It prevents capillary engorgements of the mucous membrane of the stomach. The cooling and soothing effect of the juices of the lemon and orange is generally taken advantage of by the residents of Southern Georgia and Florida, as a preventive as well as a cure of so-called biliousness.
In deciding to use or not to use a mercurial for its anti-plastic effect, care must be taken to note the probable condition of each patient's blood—whether its plasticity is above or below the normal standard, plethoric or anæmia or scorbutic, or poisoned by agents visible or invisible, that tend to destroy its nutritive power.
Under the guidance of an improved pathology and a better understanding of their modus operandi, practitioners are acquiring more skill in the prescription of mercurials; and fewer abuses of them are seen at the present day than were to be met with during the last generation. During a clinical experience of thirty-six years, in the use of mercurial medicines, it has never been my misfortune to cause any patient's teeth to drop out from excessive ptyalism, or to otherwise inflict by their use any permanent injury to the organism of those I have treated. It has ever been my rule never to push mercurial preparations beyond that point when there can be discovered a white line upon the edges of the gums, or a faint odor of the breath characteristic of mercurialization. Pushed further, in any case, I have never seen any better results follow;