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"The desired effect was obtained immediately, and remained for some hours; I could expose myself to the sun without fits of sneezing and the other disagreeable symptoms coming on. It was sufficient to repeat the treatment three times a day, even under the most unfavourable circumstances, in order to keep myself quite free. There were then no such vibrios in the secretion. If I only go out in the evening, it suffices to inject the quinine once a day, just before going. After continuing this treatment for some days the symptoms disappear completely, but if I leave off they return till towards the end of June.
"My first experiments with quinine date from the summer of 1867; this year (1868) I began at once as soon as the first traces of the illness appeared, and I have thus been able to stop its development completely.
"I have hesitated as yet in publishing the matter, because I have found no other patient 2 on whom I could try the experiment. There is, it seems to me, no doubt, considering the extraordinary regularity in the recurrence and course of the illness, that quinine had here a most quick and decided effect. And this again makes my hypothesis very probable, that the vibrios, even if being no specific form but a very frequent one, are at least the cause of the rapid increase of the symptoms in warm air, as heat excites them to lively action.
I should be very glad if the above lines would induce medical men in England-the haunt of hay fever-to test the observation of Helmholtz. To most patients the application with the pipette may be too difficult or impossible; I have therefore already suggested the use of Weber's very simple but effective nose-douche. Also it will be advisable to apply the solution of quinine tepid. It can, further, not be repeated often enough that quinine is frequently adulterated, especially with cinchonia, the action of which is much less to be depended upon.
1 There is no foundation for the objection that syringing the nose could not cure the asthma which accompanies hay fever; for this asthma is only the reflex effect arising from the irritation of the nose.-B.
2 Helmholtz, now Professor of Physics at the University of Berlin, is, although M.D., no medical practitioner.-B.
Dr. Frickhöfer, of Schwalbach, has communicated to me a second case in which hay fever was cured by local application of quinine (cf. Virchow's Archiv , vol. 51, p. 176). Professor Busch, of Bonn, authorises me to say that he succeeded in two cases of "catarrhus æstivus" by the same method; a third patient was obliged to abstain from the use of quinine, as it produced an unbearable irritation of the sensible nerves of the nose. In the autumn of 1872 Helmholtz told me that his hay fever was quite cured, and that in the meantime two other patients had, by his advice, tried this method, and with the
Untersuchungen über den fieberhaften Process und seine Behandlung. Von Dr. H. SENATOR, Docent an der Universität in Berlin. 8vo. pp. 208; 1873. Berlin: Hirschwald. London: Williams and Norgate.
THESE researches upon the febrile condition and its treatment are of great intrinsic value; and they come very opportunely at the present moment, as they afford us a good excuse for reviewing the general state of our knowledge regarding the nature and treatment of pyrexia. We doubt whether the general profession is sufficiently alive to the interesting position in which these questions now stand, and we propose to attempt some elucidation of the principal points at issue.
Fever, or pyrexia, as a general state linked to many different conditions of the bodily organs, is once again assuming the importance of which it seemed to be temporarily deprived by the striking progress of knowledge respecting local morbid changes which was effected during the first half of the present century. A marked elevation of the bodily temperature, persisting, though with diurnal fluctuations, through many days or weeks, is acknowledged as a phenomenon which has an importance of its own, whatever may be the condition of particular organs with which it may happen to be connected in any individual case. Of this fact pathologists have for some years past become increasingly convinced; but undoubtedly the most decisive impulse to medical opinion has been given by two events. The first of these is the discovery, due to Parkes more than to any other observer, of the very general tendency, ir acute diseases with considerable and persistent elevation of temperature, to a production and elimination of urea which obviously depended on something quite different to the normal vital processes of tissue-exchange. The full significance of this fact was but tardily appreciated, owing to the slowness with which the modern doctrines of nutrition have been accepted by the profession. A febrile excretion of 600, 800, or 1,000 grains daily of urea was far from assuming its true importance in the
eyes of pathologists so long as they clung to the belief that the urea-discharge of health was the outcome mainly of destruction of muscular tissue in the ordinary vital work. The second great impulse to recent changes in fever doctrines has been caused by the remarkable facts brought to light by the results of coldwater treatment of pyrexia so happily revived during the last thirteen years. It is singular that the essay of Brand "On Hydrotherapy of Typhus (typhoid)" was published in 1861, and the invaluable work of Parkes "On the Urine" in 1862. Those two years are memorable landmarks in the progress of febrile pathology: from them we date an entirely new kind of advancement towards the solution of the mysteries of pyrexia. The work now before us is in every respect a worthy continuation of the important investigations of which Parkes and Brand may be said to have been the respective originators.
We shall deal, first, with the more striking and simple part of modern fever doctrine and fever treatment, viz., the effects (as they are now understood) of superheating of the blood, and the treatment which is directed to the simple physical removal of the superabundant caloric which is working a direct mischief in the organism and may even prove fatal by its own unaided influence. It is not necessary to recall to our readers many facts which have been repeatedly stated in the pages of this journal. It will be remembered that a constantly accumulating testimony has shown that when the blood remains for more than a very limited period at a temperature much beyond the normal, certain lesions of the tissues are uniformly induced. If the mean daily temperature, for instance, be as much as 103° Fahr. for ten, fifteen, or twenty days together, that fact of itself determines a number of functional affections of the most serious kind, and contributes, probably, in an important degree to fatty and other degenerative changes of the organs. On the part of the nervous centres the evil influence is confessed by the occurrence of delirium, coma, paralysis, sometimes going on rapidly to extinction of life; on the part of the muscular tissues there is an increased wasting and feebleness, and where this extensively affects the heart or the respiratory muscles, life may be cut short by the sudden failure of one or other of those organs.
Concerning the treatment of this condition of danger from mere excess of heat, there is no longer any difference of opinion, except as to the question of degree, between those who have really investigated the subject. The mass of the profession (including some of its nominal leaders) is, indeed, as yet far enough from putting in practice the treatment which is indisputably the best, even in the cases where it can be shown to be not merely the best method but actually the only one which
offers the slightest chance of a favourable issue. But among the real leaders of medical thought and experience it has been settled beyond the possibility of question (as the paper of Professor Behier in our February number clearly shows), that there is only one way of dealing with excessive bodily heat which is itself dangerous to life, viz., the abstraction of caloric from the surface of the body by cold baths or other simple physical methods. After the striking services which this method has been shown by Dr. Wilson Fox to render, even in the apparently desperate circumstances of extreme rheumatic hyperpyrexia, there can be no longer any doubt upon this point. At the same time it may be worth while to consider an indication pointed out by Senator, whether we accept or reject his particular way of fulfilling it. Senator belongs to that school which regards the diminution of temperature by the cold bath not merely as a simple physical phenomenon, but as produced in part by a stimulation of the superficial nerves. So important does he consider this latter action to be, that he proposes to supplement it by an additional method. Before the bath, he applies very large mustard poultices, fastened on so firmly that they can be retained while the patient is in the water; his obvious intention being to produce a reflex dilatation of the vessels of the skin, and thus an increased discharge of heat from the surface.
Whether this view will ultimately prove to be just we cannot say; but we cannot help feeling with Professor Behier, that Senator's proposal savours of impractical refinement. For the higher ranges of febrile heat, it certainly appears to us that the purely physical abstraction of heat is the one sufficing remedy, and that attention is prejudicially distracted when it is turned to other methods.
Although it is no longer disputed that, when present in any great excess, heat is by far the most dangerous element of the febrile process, it is otherwise with those medium and lower ranges of temperature which would still be universally called febrile. If for example we take the very common case of a severe typhoid fever, with temperature in the third week fluctuating between 103° and 105°, morning and evening, in what relation are we to suppose that the febrile heat and the degenerative changes which we should probably find in the muscles, the liver, &c., if the patient died, stand to each other? Pathologists are far from accepting en bloc the doctrine of Liebermeister, which would ascribe these degenerations almost exclusively to the influence of the heat itself. As Senator himself points out, supporting himself by numerous quotations from authors, there is no such agreement between the intensity and duration of fever and the amount of anatomical change as would support