Inspirations of Cold Air in Fevers.-According to clinical experience, cold air inspirations have a positive value in febrile affections. Patients breathing cold air (adults and children) have a better digestion and sleep better than those in heated rooms. The phenomena of bronchial catarrh decrease to a marked degree under the influence of cold air inspirations, and the general course of

disease appears to be favorably influenced.

Antipyresis by drinking large quantities of cold water, in connection with cool water enteroclysis and keeping open the windows of the room day and night, has given excellent results in cases of typhus and typhoid fever. Both these methods of antipyresis increase the quantity of urine and diminish its specific gravity, especially the drinking of water. Thus the internal organs, which have the highest temperature during fever, are cooled, and the tissues are permeated and cleaned by the water and freed of ptomaines.

STIMULATION

When the physician suspects or recognizes circulatory failure, he resorts to methods of stimulation, as with alcohol, drugs, or enteroclysis and baths. When circulatory failure is due to shock or loss of blood (when an individual bleeds into his own blood vessels from vasomotor paralysis), the surgeon relies more upon hypodermoclysis and venous infusion than upon drugs. In the so called weak heart in acute infectious fevers, we have no clear conception of the exact nature of the circulatory failure, and at the bedside we are generally unable to determine whether heart weakness or vasomotor paralysis or both are present, and hence the choice of stimulants in a critical and grave case is not an easy matter. Laboratory experiments on animals poisoned with toxines have demonstrated that circulatory embarrassment, heretofore attributed to cardiac weakness, is due mainly to vasomotor paralysis, particularly in the early stages, whereas the late circulatory failure, in diphtheria for instance, appears to be due to cardiac weakness. In medical practice, and particularly

among children, drug stimulation and reflex nerve stimulation by means of cool water are almost exclusively relied upon.

A moderate rise of pulse and temperature appears to be the indication for the administration of the various heart drugs in use at the present. time. It is questionable whether early stimulation or promiscuous stimulation is in the interest of the patient. Unfortunately the indications for stimulation are by no means clearly understood, and no doubt in many instances we credit happy results to some particular drug or method when the inherent reserve power of the heart alone is responsible for the recovery of the patient. In view of the many disappointments and failures which

we encounter in our attempts to keep the circulation going, there arises this very important question: Is stimulation by means of enteroclysis, hypodermoclysis, and venous infusion as effective and as safe in sepsis as in surgical shock, and in what class of cases may we employ them? The problem will be solved by clinicians at the bed-side.

In June, 1903, at a meeting of the American Paediatric Society in Boston, the writer reported some observations bearing on this question from his hospital experience in cases of pneumonic, typhoid, diphtheritic, and puerperal sepsis, of which the following is a résumé.

From the study of the effects of saline infusion in shock and haemorrhage,

it would appear that this procedure and also hypodermoclysis1 may be relied upon to promptly and safely stimulate in circulatory failure. And it is safe to continue with the saline until the pulse is of good quality. From a study of the septic cases treated by saline infusion it would appear that in order to remain on safe ground, it should be used for septic cases in which there has been a decided loss of fluids, as in cholera or typhoid diarrhoea. In cases of sepsis without loss of fluids, with an imperceptible pulse and rapid respiration in conjunction with a rapidly thumping and undilated heart, an infusion or hypodermoclysis may be warranted, but under no circumstances should these methods be employed in a routine way.

Enteroclysis. Enteroclysis, or flushing of the colon with a saline at 110°, is an absolutely safe method of combating circulatory failure in septic conditions. It stimulates kidney secretion and promotes the elimination of poisons. It induces intestinal absorption of water when the body craves it, has a certain effect in reducing temperature, and is indicated as a routine treatment in all septic conditions even if the kidney is not involved. In severe anæmias the writer has found that enteroclysis is followed by an actual improvement of the constitution of the blood independently of the administration of drugs, such as iron or arsenic.

Enteroclysis is performed by means of a long flexible tube and a fountain syringe, or by means of a double current flexible tube (Kemp's method). A tablespoonful of salt is dissolved in two quarts of water at 100° to 110°, and by elevating or lowering the fountain syringe the water is made to flow slowly into the bowel. In order to be effective, this must be kept up from thirty to sixty minutes and carried out by a trained nurse or by the physician himself. Enteroclysis should be universally adopted as a therapeutic measure of great value, and it may be used in connection with drugs, baths, etc.

The advantage of enteroclysis over venous infusion in sepsis lies in its safety. When the heart muscle is weakened by the septic and febrile process, it is dangerous to suddenly increase the blood pressure, and there is also danger of carrying thrombi to other parts. The absorption of fluids from the intestine can only be slow and gradual, and not more can be absorbed than the organism craves.

In general practice enteroclysis is readily possible, and hypodermoclysis or infusion demands a sterile manipulation which is often difficult to obtain. Enteroclysis should be our routine method in typhoid, smallpox, scarlet fever, measles, diphtheria, cholera infantum, eclampsia, and anæmia.

Drug Stimulation

We often administer drugs for the purpose of stimulation, such as alcohol, camphor, strychnine, nitroglycerine, digitalis, and ammonia, and also in connection with the cool douche or cold pack, with a view of effecting a reflex nerve stimulation.

Alcohol. The conclusion seems to be that, while alcohol cannot build up the body, it does serve as fuel to the body, and at the same time it is

'The subcutaneous injection of a decinormal salt solution, 3vj of sterilized salt to one gallon of sterilized water at 100° to 120° F.

capable to a certain degree of stimulating respiration. It is therefore of value in febrile disease and often aids to prolong life.

May be administered in twenty-four hours.

Children take from five drops to a teaspoonful of whiskey in water at a time. Mild stimulants, such as coffee, black tea, and hot beef tea, may be given in connection with or instead of alcohol. Adults may require much larger quantities.

Other drugs used are ether (spir. æther. comp.), gtts. 2 to 20 on sugar; ammonia (spir. ammon. arom.), gtts. 5 to 15 in sugar water; camphor, powder, or oil; digitalis powder, infusion, tincture, fluid extract; strychnine; nitroglycerine; caffeine.

Strychnine, gr. 6-3; nitroglycerine, gr. - every three hours; caffeine and sodium benzoate, gr. iij every three hours; camphor in oil (1-15) is a powerful stimulant and expectorant. Five to ten drops may be injected subcutaneously every three hours.

When the stomach is not rebellious we obtain satisfactory results from

Camphor,

Digitalis pulv., aa,

Acid benzoic,

.gr. j to iij.

q. 4. h. in sweetmeats or sweet chocolate.

Timely and judicious stimulation is important in the management of disease conditions. Overstimulation is to be avoided, particularly overstimulation by drugs. The reserve power of the heart in children is almost always to be relied upon except in malignant sepsis, and time and again drugs have received the undeserved credit of having sustained the patient in critical times.

Stimulation, alcoholic or non-alcoholic, is contraindicated when the pulse is full and strong, and it may be injurious in such conditions. However, when the pulse becomes weak and compressible, and long before it becomes intermittent, stimulation is necessary.

Apparatus for Infusion and Hypodermoclysis. A good infusion apparatus should possess the following qualities: It should be cleanly, convenient, easily kept in order, and capable of being immersed in warm water in order to maintain the temperature of the contained infusion fluid as equable as possible. The temperature of the infusion fluid as it reaches the cannula should be known. Finally, the apparatus should be adapted for use in intracellular infusion. In the apparatus herewith figured the bottle is graduated in ounces. Through the rubber cork, which is secured by a simple clamp and screw device, two lengths of glass tubing are placed (A, B), the one reaching to the bottom of the bottle, the other terminating just within the bottle; in the course of the latter a bulb is blown in which a

GENERAL SYMPTOMATIC MANAGEMENT

73

mass of cotton or lamb's wool is placed as an air filter. To the glass tube a rubber bulb is attached. To the long tube a length of rubber tubing is connected, and to the farther extremity is attached a piece of glass tubing in the interior of which a ther

mometer is placed. Finally, a conveniently curved metal cannula is connected with the latter by a short piece of rubber tubing.

The manner of emptying the apparatus is as follows: The bottle is filled with decinormal saline solution of the proper temperature. Hot water is added to that in the basin from time to time, as required to maintain the temperature within the bottle. The infusion fluid is forced from the bottle by slow and steady strokes of the bulb, air being driven above the surface of the water, passing through the filter on its way to the bottle. As much or as little. pressure as may be desired may be made in this way, this being graduated according to requirements.

FIG. 26.-APPARATUS FOR VENOUS INFUSION. (Dr. Fowler.)

GENERAL SYMPTOMATIC MANAGEMENT

DYSPEPTIC SYMPTOMS AND THIRST

Coated Tongue, Nausea, Vomiting, Diarrhoea and Belching of Gas.In acute and chronic illness digestion is always impaired and dyspeptic symptoms are complained of. After the bowels have been emptied with an enema or laxative drug, feeding the patient should not be pushed much beyond the limits of a natural desire for food. A few drops of dilute hydrochloric acid and frequent small quantities of cooled aerated water or iced black or peppermint tea will usually overcome nausea and vomiting, particularly if the patient remains quiet in bed. In the presence of a coated tongue and foul stomach, it may be wise to get the patient to swallow a pint of warm water and to encourage emesis, and thus empty the stomach. In cases of obstinate vomiting, drop doses of tincture of iodine in sweetened peppermint water may be given every hour, and ice may be applied to the lower part of the spine. The vomiting and diarrhoea of acute gastroenteritis in adults generally subside after a few doses of the following medicine:

R Morphin. sulphat.,..

Tinct. valerianæ athereæ,

gr. 1;
3ij.

Signa: 5 to 30 drops in cooled carbonated water or on cracked ice every hour until relieved.