Gambar halaman
PDF
ePub

cation of foods into plastic and calorifacient was considered a convenient one, though open to grave objections; these are forcibly put by Lewes in the work above referred to. Yet nitrogenous articles are especially histogenetic, and fats and other ternary bodies are especially calorifacient, experiments by Flint, Jr., Pavy, and others having shown that the heat value of sugars, oils, etc., is greater than that of albumen. Experiments of Binz, recorded in the Practitioner, have proved that nearly all of the alcohol ingested is consumed in the system, and that its products are CO, and H,0. By virtue of such decomposition, as much heat must be evolved as if the same quantity of alcohol were burned in a spirit lamp.

As to the seat of these combustions, the probabilities are all in favor of the view that they take place at the foyer of organic combustion generally, namely, the inmost recesses of the tissues, and under the excitation of nutritive or socalled vital force. We know that the chemico-vital processes on which heat depends are enhanced by food as well as by moderate quantities of alcohol, and there is reason to believe that in the destructive processes taking place in the tissues combustible food elements and alcohol participate; whether the latter retards the waste of the tissues, as some have taught, is known only inferentially.

It would be reasonable to expect that processes which in the recesses of the tissues give rise to normal heat should, when exaggerated, produce fever. There

may be a more than ordinary loss of heat from the cutaneous surface by radiation and evaporation, and yet thermogenesis may be excessive, and may destroy life by its baneful effect on the tissues.

Theories of Fever. - The hypothesis of calorific nerves and nervous centres (supported by Bernard) was discussed, and shown to be destitute of proof; that of a primitive perturbation of the vaso-motor system was found to be equally wanting in solid foundation. In fevers the nervous symptoms are not constant, and when they occur they are secondary to the nutritive disorders. The abnormal heat is not due to simple paralysis of the sympathetic, for division of the sympathetic does not produce fever. The evidence all points to a pyretogenous cause at work in the blood, and, by its irritating effects on the tissues, exaggerating all calorifacient chemico-vital processes. In short, the humoral theory is the best. The materies morbi of fevers in general is unknown. The germ theory lacks inductive proof, and certainly cannot apply to sympathetic fever (from wounds or surgical operations, etc.), or to ephemeral or catarrhal fever. The hypothesis of a ferment in the blood, exciting and giving preponderance to disassimilation, is more probable; this ferment may be a chemical poison from the atmosphere, or it may be a morbid product of the system itself.

The effects of heat on the animal economy were next described, and allusion was made to experiments on birds, hares, dogs, etc., exposed to an elevated temperature. High heat is a veritable toxic agent. The animal is thrown into a high fever, and death takes place when the febrile heat reaches 116° F. in birds, 110° in mammals. A fixed degree of temperature 4° or 5° above the normal soon kills. Thermogenesis is heightened by the stimulus of external heat, conducted by the blood from the periphery to the tissues and central organs; circulation and respiration are quickened. The animal dies agitated, panting, convulsed, with loud outeries. Sectio cadareris shows the heart's action ceased, and the blood in the veins very dark; muscular rigidity speedily supervenes. The muscular system especially suffers from excess of heat, the muscles of organic life most of all. Heat is a paralyzer of the beart. This organ is most speedily and profoundly affected, but the voluntary muscles undergo serious lesions. High heat coagulates the muscular syntonine, and thus destroys the physiological function of the muscle. Long pyrexias induce fatty degenerations of almost all the tissues; the heart, the liver, the kidneys, the spleen, etc., undergo softenings, the nutrition and constitution of the ana. tomical elements under the toxic influence of heat having been profoundly altered.

1 I still cling (with dullness that is characteristic) to this expression of opinion, after a careful perusal of the able paper of Dr. Becker, in the Journal for May 15th. As an effort of the scientific imagination (supported, I confess, by striking analogies) Dr. B.'s the

I ory leaves nothing to be desired.

Interesting experiments of Claude Bernard (section of the nerves of an ex. tremity) have shown that the toxic effects of heat are exercised directly on the anatomical elements, and not through the intervention of the nervous system.' Fever being an exaggeration of the disassimilating processes of nutrition, the assimilating processes are lessened or suspended; hence the loss of appetite and arrest of digestion, etc. The tissue waste reveals itself in the bigh-colored urine, which has urea and uric acid in abnormal proportion.

In all febrile maladies the thermic cycle presents three periods or stages, an initial or ascending period called "augment," a stationary period called “ fastigium,” a terminal period called “ issue.” [The typical forms of these stages were described by the help of graphic representations which were er. hibited to the meeting, the essayist remarking that no general work on practice had treated fevers, from the point of view of march of temperature, so scientifically and satisfactorily as that of Jaccoud. He continued :]

Enough has been said to indicate what a fruitful field for observation and study the febrile cycle affords, and how indispensable for accurate diagnosis and prognosis is the clinical thermometer. We see, moreover, how absurd must be the notion that this orderly series of morbid changes can be much affected by small doses of sweet spirits of nitre, muriatic acid, and mindererus, and how infinitely more foolish the notion that the thermic oscillations can be in any way influenced by attenuated doses of rarefied moonshine, in the form of third dilutions of aconite and belladonna.

We are becoming more and more convinced that there is an orderly se quence of events in fevers as in all other phenomena of nature, that there is law and not disorder even in disease, and that human skill and knowledge are impotent materially to modify the course of febrile diseases. There will be occasions when your frail bark will be tossed on angry billows, when by adroit maneuvres you may avoid rocks and quicksands ; there will be other occasions when the utmost you can do is to determine your bearings, your latitude and longitude, powerless even to guide the craft amid the raging storm.

1 Loc. cit., Leçon 18. 2 The work by this author, Pathologie Interne, deserves translation.

“Nature with equal mind

Sees all her sons at play ;
Sees man control the wind,

The wind sweep man away ;
Allows the proudly riding and the foundered bark.”

The treatment of fevers comprises the following principles : (1.) Eliminate the cause. (2.) Support the strength. (3.) Meet dangerous complications as they may arise. (4.) Rescue the organism from the baneful effects of the fever heat.

(1.) The first indication, to neutralize or remove the materies morbi, cannot be efficiently met, because we do not know what the materies morbi is. It may be an altered condition of the blood from cold or heat, or constitutional cachexia, or from retained excreta, the pyretogenous element acting as a ferment, poisoning the whole mass of the blood, and exciting to inordinate activity the organic combustions; it may be a living germ from the vegetal world, or a degraded form of bioplasm.

We are wholly in the dark on this subject, and therefore cannot intelligently combat the materies morbi. We are certainly not warranted, on the basis of positive knowledge, in dosing our fever patients with antiseptics and antizymotics with the intent to neutralize in the blood or destroy the fever ferment or fever germ. I cannot except the traditional chlorate of potash and euchlorine, permanganate of potash and salicylic acid, carbolic acid and sulpho-carbolate of sodium, sulphurous acid and bisulphite of sodium, or even, in this connection, quinine and alcohol. Till we have positive knowledge, a judicious

, and respectful skepticism is our highest wisdom. Nevertheless, while we may not aim our shaft at an imaginary foe, we do well to keep the emunctories open, as there is reason to believe that through the ordinary channels of excretion the fever poison passes out of the system. It is certain that return to health is coincident with return to normal activity of the organs of secretion and excretion. Hence the continued use of the customary sweet spirits of nitre finds justification ; the vinum ipecacuanhae in diaphoretic or expectorant doses ; the acetate, citrate, and bicarbonate of potassa, and other mild diuretics ; and the occasional laxative of senna, rhubarb, castor oil, or buckthorn when the bowels are confined.

My own limited experience does not lead me to repose much faith in aco nite or other nerve sedatives as febrifuges. It is very improbable that the morbid heat production is at all influenced by these drugs, or that they are in any marked degree antipyretic. (2.) The second indication, to support the vital forces, includes all food and stimulants, as well as the hypnotics and anodynes which you give to procure sleep and relieve pain and restlessness. Doubtless an important advance in rational therapeutics has been made since bleeding and depressants in the treatment of fevers were abandoned, since Todd taught us to use alcoholic stimulants more freely and Graves fed fevers. And yet just here caution and judgment are needed. I am convinced that many cases of continued fever do better without a drop of wine and only a moderate supply of liquid aliments. Others do better with a little wine or whisky every two, three, or four hours, and an abundance of pure milk. Sometimes it is advantageous to begin the stimulant treatment early, as where Clinical expe

the tendency to death is markedly by asthenia. We must combat the fever heat by our cold baths and quinine at the same time that we stimulate with alcohol. Restlessness, wakefulness, and delirium must be controlled by camphor and Dover's powder, or better still with chloral, or the bromides with hy. drobromic acid. (3.) The third indication, to meet complications as they may arise, comprehends all those measures, medical and surgical, necessary to arrest hæmorrhages, check diarrhæa, stay the progress of ulcerations, etc., attention to which is necessary to save the life of the patient. (4.) The fourth indica. tion, which we can happily do much to fulfill, is to restrain as far as possible morbid heat production, or save the tissues from its toxic effects.

[The writer here gave the degrees of fever heat which are fatal and those which are considered dangerous, citing Dr. Clifford Allbut, in Braithwaite, Part LXIX., page 24.]

Can anything be done to lessen heat production ? Quinine in large doses is, I believe, the only safe antipyretic which even temporarily lessens organic combustions. Salicylic acid is of limited avd doubtful utility. rience has determined that quinine is a veritable antipyretic, and therefore, in a sense, specific in all fevers.

A few years ago we should have shuddered at the suggestion of giving to a child three years of age, laboring under a fever heat of 105° F., five grains of quinine every hour, with the view of bringing down the fever; now we find by experience that such doses produce no immediate bad effects, and that we can obtain a fall of several degrees by a few doses. Much larger doses may be given to adults, generally with gratifying results. Any cinchonism that ensues is of transient duration. The quivine in dose of a couple of grammes is often conjoined with the cold bath, with more marked antipyretic effect.

It is not claimed that the antipyretic cuts short the febrile processes; the most that the advocates of this treatment claim is that by virtue of its antifermentative action on the blood or its tovic effect on the tissues, or by virtue of being a germicide, quinine restrains excessive waste, promotes assimilation, checks the riotous production of bioplasm, and thus rescues the tissues, and especially the heart, from the destructive effects of high heat. If it acts as an antiseptic or germicide, it is certainly not very successful in its work, as it does not cut short the fever. To do good its use must be persevered in, and it must be given boldly. Whenever the temperature reaches 104° F. the quinine treatment must be commenced, and it must be given in repeated large doses at short intervals till the temperature falls to nearly the normal figure. (Ten grains an hour to an adult will bring down the fever heat after a few doses to nearly the normal.)

The next antipyretic to be mentioned, and probably the first in importance, is cold, applied in the form of cold baths, sponge baths, wrappings of ice-cold water, or ice-bags.

Twenty years ago it would have been considered madness to take a child, in the first stage of scarlet fever, manifesting delirium or stupor from febrile calorification and the force of the virus, immerse it in cold water, and keep it there for several minutes, pouring (it may be) cold water on the head of the child till rigor supervened, the thermometer indicating the point at which the child should be removed from the bath. Now this is done with seeming im

reason.

punity, and is countenanced by good clinicians as legitimate practice. Some of us country physicians think that in desperate cases we have saved life by these means. In ordinary practice cold baths are inconvenient, and our patients are shy of this mode of treatment; cold sponging is much resorted to as a substitute. The patient is stripped of his clothing and laid on a rubber cloth; he is rapidly sponged from head to foot with ice-cold vinegar and water till the temperature falls from 104° or 105° to pearly 100° F.; then he is wrapped in a dry flannel blanket, and returned to his bed. The cold sponging is repeated whenever the thermometer indicates 104° F.

As to the results of the antipyretic treatment, after an experience of nine or ten years, we cannot speak very confidently. The immediate effects are generally very salutary, but the fever runs on ; repeated baths somewhat exhaust the patient, and our large doses of quinine may do lasting harm. Certainly hospital statistics do not speak very encouragingly for the antipyretic treatment of fevers.” But clinical statistics are notoriously unreliable. It is to such statistics that homeopaths appeal, and we know with how little

The antipyretic system seems to be theoretically sound, and we have probably yet to learn how it may be most safely and efficiently managed. We must feel our way along, proving all things and holding fast that which is good; we must persevere, hopeful; follow the best lights; where certainty is impossible be content to remain in doubt; indulge no vain dreams; obey the dictates of common sense.

I
I say,

Fear not ! Life still
Leaves human effort scope;
But since life teems with ill,

Nurse no extravagant hope. Because thou must not dream, thou needst not then despair!” In discussing the essay, Dr. Towle, of Haverhill, said that he had little faith in the antipyretic treatment. He was shy of extreme measures. Dr. Lovejoy thought that quinine and cold baths simply combated symptoms, the disease was not arrested ; and said that if he were to put a child laboring under scarlet fever into a cold bath, and the child were to die, he should expect to be blamed for causing the child's death. Dr. William Cogswell narrated instances that had come under his observation where large antipyretic doses of quinine seemed to do good. — Dr. Huse, of Georgetown, had treated scarlet fever with tepid baths, the water being gradually cooled down to 60° F., with benefit. This treatment was repeated every day for a week. - Dr. Stackpole gave very little medicine in fevers, and believed in simple treatment; we have to work so much in the dark that we should be cautious and expectant. He

1 “If administered in heroic doses it frequently overdoes the work required of it; it produces a cinchonism which adds to the burdens of the already struggling system, whilst it increases the derangement of the nervous centres and intensifies the disturbance of the di. gestive function.” (Dr. Edward Warren in Medical Record, vol. xi., page 46.) See also Peters in the Medical Record, vol. xv., page 511. “ Professor Lindwurm cautions against ts use in large doses in weak heart.“ Professor Binz shows that large doses may produce death by paralyzing the heart.” Niemeyer abandoned large doses. Woods and Bartholow speak of its irritant action on the alimentary canal.

2 See Medical Record, November 9, 1878, page 366, for statistics which show that in Bellevue Hospital the antipyretic treatment has not been proven to be of certain therapeutic value. According to the Medical Record, vol. xv., p. 510, the mortality of several of the continental hospitals has greatly increased under this treatment.

a

[ocr errors]
« SebelumnyaLanjutkan »