ON THE VALUE OP ANTIFEBRIN AND QUININE IN TYPHOID FEVER.

By Surgeon G. h.

Civil Surgeon, Bignor.

There has been a great deal written of late about Typhoid Fever and its probable origin and capricious behaviour in casea which occur

out in this country. Bad hygienic conditions, domestic insanitary

arrangements, and the habits of the people who contract it have been accountable for the curi- ous course it takes. But climate and malarial fever have also a large share in the production of such cases, whose temperature takes such erratic courses, and is so very different to the cases one has seen in Europe.

Again, it strikes one also that the difference iu treatment of typhoid cases also may account

.June, 1889.] FINK ON" ANTIFEBRIN AND QUININE IN. TYPHOID. 173

lor the great variability in the temperature charts out in India.

In Europe the treatment on the water bed seems to be in great favour, at least I found it to be so while in charge of a medical ward under Dr. Frederick Roberts, of University College Hospital, London, where almost every case was treated in this manner and with a great measure of success. The hydropathic treatment of

typhoid does not seem to meet with the favour which it deserves out in India, and if in a climate such as England, physicians deal with

their cases on this plan which has also found

favour in the German schools, surely in a

country where the heat is greater and the variations and alternations of temperature great- er, the water treatment ought to be carried out more largely.

There are, of course, reasons for the water

treatment not finding favour, and the one which is strongest, I believe, is 011 account of the

difficulty of procuring water-beds of India

rubber, and, when obtained, the beds are either found to leak badly or they soon begin to de- teriorate through the heat and crack and give rise to much inconvenience. Water beds of India rubber if properly stored and kept always in a cool place with a certain degree of moisture by half filling with water, and replenishing this

water, say ouce or twice a week, ought not to

crack and become useless. A good substitute, however, for the India rubber water bed is a

series of mussuks of sufficiently large size sewn side by side and filled with sufficient water to

make them springy without being uncomfort- ably swollen out and bulky to cause your patient to roll out of bed. The wet pack, too, has its advantages and disadvantages in hyper- 'pyrexial conditions, and although much advocat- ed by medical men in this country, is not receiv- ed without a murmur by the friends of the

patient, who consider-the treatment somewhat

heroic, because they have not witnessed the

advantages, and being novel and having con-

servative ideas on the subject, they rather ad-

here to the usual and ordinary measures for

reducing temperature by the fan, tepid spong- ing with vinegar added, quinine, etc. ;

The point I; should like to -elucidate with

regard to typhoid or enteric fever iu India is the temperature of the patient and why it

is, it does not present that picture on the che- mical chart which cases of typhoid described -by European authors do ?

Malaria, undoubtedly, plays some powerful part in this matter, and if the temperature be regularly taken every hour it will be found to be periodical in its rise, that is, some cases are mixed up with Quotidian Tertian, Quartan and other mixed forms of malarial fever, and it is

important to study the temperature therefore and mark its periodicity in the rise, or .its re-

mittent character. 1 have seen cases where the temperature has risen periodically on a

certain day at a certain hour, and it will also be observed that in a district where Tertian

ague prevails, if a case of typhoid be watched, the temperature tj\kes the type of a Tertian charac- ter. So again in a place where Quartan ague prevails, it will be of a Quartan nature in its

course; but always very obstinate to treatment. Hence the value of keeping a correct chart and a strict vigilance over the temperature of your

patient, so that the medicine (quinine by prefer- ence) may be given at the right time to overtake the fever in its onward march, and to exhaust the poison from the system and lower the tempera- ture, which is a great pull, for there is such terrible waste of tissue in heightened fever of

long standing and obstinacy. Careful nursing is undoubtedly the great stand by in all cases of illness, and more especially in typhoid fever, and it is always necessary to have a nurse who will act in concert with the physician, for there are nurses and nurses, and very often those very clever nurses will not do as they are told by the doctor, and see no harm in administering a five grain dose of quinine when fifteen or

twenty grains are ordered, or who will persist in administering it at 12 o'clock when ordered at 2 o'clock. Nursing is half the battle in all cases of a protracted nature, if the nurse under- stand her. duty, and has been in attendance on

typhoid cases, which of itself is a separate study. We have,heard much of late of the relative

value of various drugs in reducing the tempera- ture, and antefebrin has its place among the list; It has. a most rapid effect on most cases, bringing the temperature down most markedly within very short space of time ; nay, I may say in a few minutes in some patients who re-

spond very readily to this drug, whilst in others it takes a. longer time, it also produces... powerful diaphoresis, and the clothes and bed clothes are

simply sodden with perspiration. At such a time one has to guard against your patient taking a chill, and if he has been having a

-punkah Or a thermantidote or khus-khus, every care should be exercised in changing his linen ? t

D O

for dry ones, but first stopping the punkah, otherwise there are dangers from a sudden check to sweating. Antipyrin has a similar action to the above drug, and is in favour with some. It

has been observed, however, that these drugs, although reducers of temperature, are not highly persistent in keeping it down, for very often

the temperature rises suddenly to a high degree, leaving the patieut far more exhausted alter the free sweating he has just undergone. I have found : quinine a very useful adjunct to anti-

febrin, after the latter drug has caused a reduc- tion in the temperature. And to obtain the real value of the quinine, it must be given in

24

174 THE INDIAN MEDICAL GAZETTE. [Juke, 1889.

large doses, of xv, xx or even xxx grains, for it then keeps down the temperature and soon there is a reduction to normal, after which, stop the antipyrin or autifebrin altogether, and give your patient quinine a couple of hours before

you expect the periodical rise. Having then subdued the fever to a much lower degree, you lessen the dose of your quinine gradually until your patient is fever-free and then after continu- ing it for another three or four days in still

lesser quantity, you give perhaps a grain or two twice or thrice a day.

I do not wish to lay down any dogmatic line of treatment of typhoid ; but from the cases

which I have had uuder my care, and one just recently of a severe type when I took over

charge of it, I have noticed a periodicity in the rise of temperature, and in its behaviour similar to heightened forms of malaria, and powerfully affected by quinine, which is our great sheet- anchor for malarial fever. I have noticed also that cases which have been treated before I took

charge of them, have presented most erratic charts; but the above plan of treatment has

made them assume more of the typhoid type we see in Europe. The water plan of treatment has the great

advantage of keeping the fever down, and thus

enhancing the value of the quinine treatment

without that fearful drain produced by antifeb-

rin, which is powerful sudorific. The rest of the treatment of the cases I have

had, have been'chiefly the dietary, and atten-

tion to symptoms as they appear, and which

must be promptly and energetically treated to save your patient the double drain on his

system.