CHAPTER X.

TREATMENT.

To combat the visceral lesions; to oppose the return of the paroxysms; to prevent the occurrence of relapses;-such is the triple base upon which rests the treatment of periodical fever.-MAILLOT.

ARTICLE I.

BILIOUS REMITTENT FEVER.

SEC. I.-Preliminary. The treatment of the common form of bilious remittent fever is pretty well settled; and although the varieties in the character of the disease, in different seasons and localities, render necessary certain modifications in the treatment, the essential principles of this remain the same.

SEC. II.-Bloodletting. General bleeding is not commonly resorted to in the treatment of this disease. There can be no doubt, however, that in robust and plethoric habits, and where there exists no contraindication, either in the circumstances of the individual case, or in the prevailing character and constitution of the disease, early and moderate general bleeding is of much utility. Early in the disease, under these circumstances, where the headache is violent, the skin dry and hot, and the pulse full and bounding, the symptoms will be moderated by this remedy; but in the absence of these or analogous special indications, it would seem to be safer to abstain from general bleeding. Lind cautions against bleeding in hot climates. He says great harm has been done by English practitioners, who follow the example of Sydenham. Sir Gilbert Blane recommends bleeding in athletic habits, with high excitement, violent pains, or delirium: but he adds these words: "Although the cases requiring bloodletting are more frequent in this sort of fever than in typhus, yet great caution and nice discernment are necessary with regard to it, in all cases, in a hot climate. Bloodletting, un

seasonably and injudiciously employed, either endangers life, or has a very remarkable effect in protracting recovery, by the insurmountable weakness it induces."1

Topical bleeding, by cups or leeches, is of very great service, and of very general application. There are, probably, but few cases in which it may not be beneficially applied. This means is especially valuable for the removal or diminution of the epigastric pain, tenderness, and distress. In ordinary practice, cups will usually be made use of; and they should be applied across the epigastrium and the hypochondria, and repeated according to the urgency of the symptoms and the strength of the patient until their object is accomplished. The best time for their application is during the febrile exacerbation, when the skin is warm and dry; and the earlier in the disease the better. "As regards the stage of the disorder," Dr. Stewardson says, "I should say that it was not worthy of much consideration in determining upon the propriety of local depletion in cases of an ordinary remittent, where considerable epigastric or hypochondriac tenderness coincided with more or less acceleration of pulse, and heat of skin. For although here, as in the more severe disease of hot climates, early depletion, i. e., from the first to the fourth day, is highly desirable, in order to shorten its course and diminish the force of the local determinations, yet the same danger does not exist as in the latter, in reference to depletion at a much later period; unless, of course, where the symptoms of prostration clearly forbid it. I would not hesitate, then, to abstract a few ounces of blood under the circumstances mentioned, even at a late period of the disorder, since it is certainly a point of paramount importance, in the treatment of remittent, to prevent, as far as practicable, the production of those chronic alterations of the spleen and liver, which, when once firmly rooted, so generally prove fatal after lengthened suffering."

Strong determination of blood to the head, indicated by headache, heat, throbbing, and in some instances delirium, requires the application of scarified cups to the temples and back of the neck.

SEC. III.—Purgatives. The use of purgatives in the treatment of bilious remittent fever is almost universal. In the United States they are nearly always given at the commencement of the disease, and repeated occasionally, during its subsequent course. Different

1 Diseases of Seamen, p. 389.

2 Am. Journ. Med. Sci., April, 1842.

combinations of cathartic substances are adopted by different practitioners; but nearly all of them make use of some mercurial preparations-either calomel, or blue pill. One of these substances is preferred on account of the peculiar action which they are believed to exert upon the liver; and for their efficacy in restoring and correcting arrested or depraved secretions. Whatever may be the precise mode of action of the mercury, experience seems to have demonstrated its usefulness as a purgative in this form of disease. From five to ten grains of calomel may be combined with ten or fifteen grains of jalap, or with fifteen or twenty grains of rhubarb, to constitute a single purgative dose; this may be repeated, if necessary, or it may be followed by an ounce of castor oil. Instead of the calomel, ten or fifteen grains of blue pill may be made use of.

Excessive purgation should be avoided. This evil, owing to the disastrous influences of a false and preposterous pathological theory, has been pretty extensively prevalent throughout many portions of our Southern and Western States. Happily for science and humanity, like the bastard philosophy whose legitimate offspring it was, it has nearly run its race, and had its day, and is fast disappearing from the practice of our art. It is quite enough, as a general rule, that two or three consistent stools should be procured during each twenty-four hours, for the active period of the disease, and one or two, later. If there is intestinal irritation, still greater caution is necessary; and the milder laxatives should always be preferred.

SEC. IV. Cinchona. The periodical element in the pathology of this disease is to be met and neutralized by the great antiperiodic remedy-cinchona and its preparations. There is no substitute for these. They are universally relied upon for this purpose. In all countries, and at all periods, since the discovery of the properties of this incomparable and invaluable substance, amidst all the conflicting dogmas of different medical doctrines, Peruvian bark has never failed to sustain its reputation, and to answer the expectations that have rested upon it. Amidst the manifold uncertainties of medical science, and the perpetual contingencies of medical art; amidst the disheartening scientific infidelity which has lately been taking possession of the medical mind, shaking to its deep foundations the firm old faith in the potency of drugs, and threatening to overturn and demolish it altogether-it is gratifying and consolatory to feel and to know, that here at least we stand upon solid

ground, that here we may hold-that there is at least one great and important therapeutical relationship definitively and positively ascertained and established, defying alike the open assaults of quackery from without, and the treacherous machinations of indolent scepticism from within.

The sulphate of quinine is altogether the best of the preparations of the bark, and it is now almost universally and exclusively used. There is a good deal of difference in the mode and circumstances of its administration, by different practitioners-a difference that is probably rendered necessary by modifications in the character of the disease itself. As a general rule, in the treatment of the common form of bilious remittent fever, practitioners desire to diminish the intensity of the local congestions and irritations, by depletion and purgatives; to lessen the general febrile excitement, and thus to develop the periodical element in the disease, by rendering the remissions more distinct, before resorting to the use of the quinine. Two or three grains an hour are then usually given during the period of remission. Some physicians prefer very much larger doses-fifteen or twenty grains, for instance-given at once, and repeated, if necessary. Other observers attach less importance to the preparation of the system, by bloodletting, cathartics, &c., for the quinine, and resort immediately, and without much regard to the stage of the disease, to its use. There seems to be good ground for believing, as I have just intimated, that these differences may have arisen from differences in the character of the disease. It appears probable, for instance, that in the more northern and temperate latitudes, it is more necessary to prepare the way for the use of quinine, by the preliminary remedies before mentioned, than it is in the more southern and warmer latitudes. In these latitudes, the disease may sometimes assume a graver character than it wears in the former, verging towards its congestive co-gener, and requiring somewhat the same treatment that is necessary in the latter.

SEC. V.-Diaphoretics; Refrigerants, &c. Remedies of this class are generally made use of, especially during the height of the febrile paroxysm. Small doses of ipecac., nitrate of potash, and spirit of mindererus, are amongst the articles most frequently selected the choice depending upon the circumstances of the case, or the opinions of the practitioner. Cold drinks, acidulated or not,

effervescing draughts, and so on, according to the taste of the patient, should be freely administered.

ARTICLE II.

CONGESTIVE FEVER.

Although the general indications in the management of the congestive variety of periodical fever may be nearly the same as in that of the bilious remittent form, very important modifications are necessary in the details of the treatment and in the application of remedies. In no other disease, of so grave a character, does so much depend upon the prompt, efficient, and judicious interference of art; under no other circumstances, of ordinary acute disease, is the life of the patient placed so absolutely in the hands of his physician. A blow struck at the right time, in the right place, and in the right direction, will very often save the life that would otherwise have been lost. And the action of the physician in the treatment of this terrible form of disease is crowded into the briefest space of time; the issues of life and death hang upon a single hour; the morbid processes must be immediately arrested, or modified, or they will inflict irreparable and fatal injury upon the organs in which they are situated.

In laying down rules for the treatment of congestive fever, I shall rely mostly upon the observation and experience of the physicians of our Southern and Western States. They have long been extensively familiar with the disease in all its phases, and in its gravest form; they have studied carefully and attentively its therapeutical relationships; they have been, for the most part, sufficiently free from the influence of preconceived opinions and doctrinal theories, to look steadily at Nature and to follow its teachings, and I regard their authority upon this subject as high at least as any in the world. There are, as might naturally enough be expected, some differences amongst them; but, so far as the most important and fundamental principles of treatment are concerned, they are very well agreed.

I shall first speak of the means that are usually resorted to during the cold fit a condition which appertains to all the varieties of the disease-in what is commonly called the congestive chill-in order to bring about reaction. External heat and stimulants, and internal stimuli, are generally relied upon for this purpose. Hot