7. When suddenly and totally discontinued during the course of the illness, serious, and in some cases fatal, effects ensued.
8. In no case was a habit of drinking known to be induced, and very rarely was any chronic disease seen to arise out of the acute attack."
The subjoined abridged remarks of Dr. Murchi-son, although having special reference to Typhus and Typhoid Fevers, offer some valuable suggestions for the use of stimulants in the advanced stages of Fevers of all descriptions.
2. They are rarely required during the first five or six days, but most cases require them more or less during the second week. As a rule, they may be commenced about the seventh or eighth day.
* Clin. Lect. on certain Acute Diseases, Lond. 1860. P. Blakiston, M.D., Clinical Observations on the Heart and Thoracic Aorta. 1865, p. 27. On Fevers, &c., p. 269, et seq.
4. Extreme softness and compressibility of pulse, especially if irregular, intermittent, or imperceptible, are greater indications for stimulants than mere rapidity. An abnormally slow pulse (e.g., 40 to 60) is occasionally a stronger indication for stimulants than a quick pulse. If the pulse becomes quicker and the face flushes under their use, they are contra-indicated; if the pulse is made slower, they may be expected to do good.
5. The state of the heart affords valuable information: if the cardiac impulse is good, stimulants are not required; but when the impulse is weak, and when the first sound is impaired or absent, a liberal allowance is demanded. In all cases of doubt the heart should be examined with the hand and stethoscope.
6. Other indications for the use of stimulants are - a, a tendency to syncope, when the patient is raised into the semi-erect posture; b, the eruption becoming darker and more copious; c, profuse perspirations, with no attendant improvement in general symptoms; d, coldness of the extremities; e, the marked presence of the typhoid state, i.e., low delirium, tremor, subsultus, &c.; f, a dry brown tongue: if the tongue becomes clean and moist at the edges, it is a sign that the Alcohol is doing good; g, the presence of complications, as PyAemia, Erysipelas, Bronchitis, Pneumonia, Bed-sores, Gangrene, &c.; h, persons of intemperate habits, or of advanced years: here they are required earlier and in larger quantities.
7. Scanty urine of low specific gravity, containing little urea or much albumen, and complete suppression of urine, are in themselves indications against a large amount of spirits.
8. As a rule, they are contra-indicated if there be severe darting or throbbing headache, or acute noisy delirium, especially when these symptoms co-exist, with great heat and dryness of skin and suffusion of the eyes, and with little or no improvement of the cardiac and radial pulse. When stimulants are thought to be required under such circumstances, they should be given in the intervals between the paroxysms of delirium.
9. The propriety of giving stimulants in delirium depends upon the state of the pulse: if the patient becomes more restless and delirious under their use, they do harm; if he becomes more tranquil, they do good.
Port, sherry, Madeira, brandy, gin, and whiskey are the forms in which Alcohol is best given; but when a weaker stimulus is wanted, claret and Burgundy answer well. Malt liquors are best adapted for convalescence. Spirits should be given diluted; iced soda water is the best vehicle; but when great prostration exists, hot brandy or whiskey punch is the best stimulant. They should be given in divided doses, frequently repeated. In urgent cases, a dose may be given every hour, and, as a rule, a larger quantity will be required during the night and towards morning than in the day-time, for it is usually in the early morning that the vital powers are at the lowest ebb. Many patients are undoubtedly lost from negligence of their attendants at this time. It is impossible beforehand to decide upon the quantity required. Begin with 4 oz. of wine in twenty-four hours, and watch its effects. It will be rarely necessary to give more than 8 oz. of brandy daily at any period of the fever. Occasionally this may be exceeded. It is astonishing how much some persons, of previously temperate lives, can take with advantage. In urgent cases they should be persisted in as long as the patient is able to swallow: apparently hopeless cases have been known to recover under frequent enemas of beef-tea and brandy. When the symptoms improve, the quantity should be reduced, and smaller doses ordered at longer intervals. In most cases of great prostration, it is as well to combine other stimulants - Ether, &c. - with the wine and spirits.
3219. In the treatment of the Exanthemata, the lighter French wines, which contain less alcohol than Madeira, Port, or Sherry, as Bordeaux, mixed with water, make a most agreeable and refreshing beverage. It supports strength and induces sleep. In the treatment of Scarlatina, Claret was first proposed by Dr. A. T. Thompson, and has of late years been extensively prescribed. It is an excellent adjunct to Carbonate of Ammonia, Quinine, and the Mineral Acids. In Diphtheria, Dr. Ranking* insists strongly on the necessity of wine in large quantities, believing that medicine is secondary to a vigorous support of general power by stimulants.
3220. In Apoplexy, when the state of the patient approximates more or less nearly to a state of syncope, the pulse being weak, the aspect pinched and bloodless, and the skin cool, blood-letting is inadmissible, and the treatment the most likely to prove successful is the cautious application of warmth to the surface, and the cautious administration of diffusible stimulants, particularly the preparations of Ammonia; gr. v. of the Sesquicarbonate, or 3ss. of Sp. Ammon. Arom., may be given in Camphor Julep. Stand by, till the first stunning effect of the internal shock passes off, and carefully watch meanwhile for symptoms of reaction. (Dr. Watson.)
3221. In certain forms of Asthenic Paralysis, the cautious and moderate use of diffusible as well as topical stimulants is productive of benefit. In Local Paralysis, where one or more sets of muscles are affected, without organic lesion of the nervous centres, the stimulus of Electricity or Galvanism proves of the highest service. Abercrombie considers that stimulants are more useful, if the general system, at the time of their administration, be kept in a very low state, by spare living and occasional evacuants.
* On Diphtheria, 1859.
Lectures, vol. i. p. 535.
3223. In Asphyxia from Submersion, Cold, 85c, it is to stimulants, cautiously employed, that we look for hope of success. "Warmth (from 90° to 100°) by baths or dry cloths or heated bricks, friction, electricity, the application of stimulant vapours to the nostrils, and of largely diluted diffusible stimuli, as Brandy, internally, form the basis of all other treatment. Artificial respiration is an important part of the treatment to be adopted at the same time.
3224. In Cholera, stimulants were formerly considered an indispensable and invariable resource; but of their real value many doubts are, at the present day, justly entertained. It appears certain that the indiscriminate use of stimulants, especially the more diffusible ones, as Brandy, if given in large quantities, and in a concentrated form, so far from being beneficial, is actually injurious. There are few points in medicine which require more care and discrimination than the selection of the proper cases and the proper periods for administering stimulants in Cholera. No rule can be laid down on the subject, as almost every case differs so widely from the preceding one; certain it is, that they should not be given in the excessive quantities formerly advised; that they should be given largely diluted; that they should not be trusted to alone; and that in some instances, at least, they appear to exercise a prejudicial influence. Champagne, Ammonia, and Turpentine are, perhaps, the best stimulants which can be employed.
3225. In Passive Diarrhoea attended with Debility, in the advanced stages of Phthisis, in Chlorosis, in some forms of Atonic Dyspepsia, in Convalescence from Acute Diseases, and in other states of Debility, Dr. Aran* speaks highly of the advantages to be derived from the employment of wine in the form of enema. In Chlorosis, its effects were most marked. The wine should be diluted with water, and care taken to prevent a loaded state of the bowels. Dr. Williams relates a severe case of Post-partum HAemorrhage, in which Port wine enemata exercised the best effects, saving, apparently, the life of the patient. He employed it in fiv. doses with xx. of Tinct. Opii. Three enemata were found sufficient. In the Vomiting of Pregnancy, sparkling Moselle is productive of the best effects, allaying vomiting, and enabling the patient to retain and digest food.
* Bull. de Therap., Jan. 15 and 30,1855.
Brit. Med. Journ., Sept. 4, 1858.