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1847] Serres on Treatment of Typhoid Fever. 549 the opportunity of stating that he suspected the so-called pseudo-membranes of the mucous membranes were nothing but portions of detached epithelium. M. Velpeau, while believing this may sometimes be the case, considered that it was not so in the present disease. Diphtheric inflammation is not confined to the mucous membranes, for it may affect any region of the skin ; and, on its removal, this structure be found sound beneath.
Although we certainly have never expressly examined the eye for the detection of the false membrane in question, we feel somewhat sceptical as to its usually forming a characteristic of this disease. It may, perhaps, do so sometimes in the impure atmosphere of the Paris Foundling Hospital, but it could scarcely have escaped detection in private practice were it a common occurrence. We have frequently seen the discharge assume an almost membranous tenacity. In respect to treament, it seems to us that free syringing the eye with cold water would accomplish all the objects derivable from irrigation; but we would not like to employ this as any other than a subsidiary means. The hourly use of injections of sulphate of zinc or nitrate of silver generally rapidly subdue the disease, although the assistance of a leech may occasionally, but very rarely, be required also, if the inflammation, as denoted by the tumefaction of the lid, is excessive.- Rev.]
ON THE TREATMENT OF TYPHOID, OR ENTERO-MESENTERIC, FEVER BY
THE BLACK SULPHURET OF MERCURY. By M. SERRES.
M. Serres has recently read some papers upon this subject before the Academie des Sciences, and as they have excited much attention in Paris, a notice of some of the principal points dwelt upon by him may prove acceptable to our readers.
He believes that the symptoms, progress, and anatomical lesions of this disease all show that it belongs to the exanthematous fevers, and this fact constitutes the basis of the proposed treatment. The histories of measles, scarlatina, erysipelas, but especially of variola and vaccinia, prove that the amount of fever is proportionate to the amount of eruption; if this is discrete the fever is slight; if it is confluent the fever is intense; "it becomes confluent also by the change which takes place in the composition of the blood, and the phenomena of re-action which are developed throughout the system.” As long ago as 1812, the author, together with M. Petit, endeavoured to demonstrate a like dependence of typhoid fever upon the amount of entero-mesenteric changes which were developed; and 35 years additional opportunities of investigating the subject at La Pitié and the School of Anatomy, where bodies are brought from all the hospitals of Paris, have conferred upon the proposition all the certitude attainable in medicine.
“ If, as now stated, every eruptive fever is compounded of two distinct elements : of the eruption, which is the dominating element, and of the fever which is the dominated element, the therapeutical course is traced out in this disease by this subordination of the phenomena. Reasoning indicates this, and medical experience has demonstrated it. In the remarkably faithful picture drawn by Sydenham of the progress and generation of symptoms in the small-pox (the passages are quoted, but they are or ought to be familiar to our readers), we recognize that of the typhoid fever which was furnished by M. Petit and ourselves. If, in fact, in the comparison of the two diseases, we form an abstraction of the eruption or fundamental portion of each, we find a perfect resemblance in the phenomena of the consecutive fever constituting them—the same infection of the blood—the same permanence in the source of the infection—the same saturation of the system with a deleterious principle. The bases of their therapeutics should partake of and reflect this uniformity. But, for the bases of therapeutics to assume such conformity they must be able to extend to the foundation of these two diseases. And here is the difficulty. With respect to small-pox the etiology has never been contested. All agree that, beyond the affection of the skin, there is a general affection, having its vehicle in the mass of the blood. It is not the same with the etiology which is here given of typhoid or entero-mesenteric fever. Eminent observers, and whose consummate experience might well serve as a guide in medicine, have entertained an opposite opinion. They have seen in the disease only an enteritis, or an inflammation of the intestine, different degrees of which might explain the general and local symptoms by which it reveals itself.”
“ The treatment I propose consists in the administration of the black sulphuret of mercury in the form of pills, and the inunction of the abdominal parietes by means of the mercurial ointment every morning. Four grains of the black sulphuret are formed into a pill with tragacanth and syrup; and from four to six of such are given every second day. The treatment may be continued for six or eight days, provided no stomatitis occurs. If the mucous membrane of the mouth becomes inflamed the frictions are to be suspended and the sulphuret diminished or discontinued, applying alum gargles or slices of lemon to the gums.
“ Although every one recognises that the gravity of the disease is dependent upon the amount of the intestinal eruption, no one has hitherto tried to treat this topically. Purgatives in general fulfil the first indication of treating the general poisoning of the system; but it is the mercurial purgative which alone exerts a special topical action on the intestinal patches. We cannot give proofs of this direct action; but from the effect which mercurials exert on analogical diseases, we are enabled to make an a posteriori induction upon the subject. We know that the application of mercury procures the abortion of variolous pustules. Mercurial frictions dissipate an erysipelas springing from internal causes-as they do the rose-coloured lenticular patches which appear on the abdomen in typhoid. The diarrhea and distension of the abdomen in typhoid are certainly due to the irritation which the intestinal eruption determines upon the mucous membrane of the intestines ; and both these symptoms are relieved under the use of the black sulphuret (although ordinary purgatives fail to relieve them), proving that this exerts a topical action upon the intestinal eruption, preventing or arresting its development. But it likewise exerts a more generally beneficial effect upon the organism, seeming as if it reached the cause of the disease itself ;—the fever becomes less, the pulse diminishes in number, and the delirium abates—and this in so decided a manner as to be obviously the result of the medicine. By this method we do not abridge the duration of the fever. It continues, as under other treatment, for 3 or 4 weeks : but generally, when seen early, it is conducted through its course without any accident arising."
“ Although the lenticular and rose-coloured spots on the abdomen, which constitute so characteristic a symptom of typhoid fever, differ essentially from the variolous pustule, yet the septic nature of the two diseases, the concomitant changes in the state of the blood, led me to the study of the action of mercury on these petechiæ. In the year 1845, this petechial eruption was remarkably abundant in most of these patients; but, under the application of the mercurial ointment, they disappeared very rapidly-the accompanying meteorism simultaneously diminishing. This double result led me to conclude not only that the mercury operated beneficially upon the petechiæ, but also upon the intestinal eruption, which constituted the foundation of the fever. If this last conclusion were correct, it was reasonable to suppose that, could the mercury be brought into direct action on the intestine, its effect would be still more prompt and efficacious; and, after an attentive examination of several pharmaceutical preparations of this metal, the black sulphuret seemed the best adapted to fulfil the desired indication."
Some particulars of a few of the cases which have fallen under M. Serres' notice are furnished, and he draws the following conclusions :-1. The fever and
The Medical Profession in Paris.
cephalalgia have been evidently influenced by the second or third day of the medicine. 2. The pulse has fallen below the inean, and even become remarkably slow. 3. No adynamic or ataxic accidents occurred; and, when adynamia appeared at the commencement of the disease, it was soon removed. 4. The quantity of ethiops employed to procure these results has not exceeded 50 grains, and several times but 30 have been administered. 5. Only a slight stomatitis, of which the patients hardly complained, was produced. 6. Convalescence was fairly established from the 8th to the 15th day, return to health always having been accomplished without relapse. 7. The patients left the hospital entirely cured in between 30 and 50 days; although they were encouraged to stay in as long as possible for the purpose of observing any relapse if such occurred. -Gazette Medicale, Nos. 33 and 34.
[That the consentaneous employment of the black sulphuret of mercury and mercurial inunctions have proved highly useful in typhoid fever, the statements of so intelligent an observer as M. Serres sufficiently prove; but that such effect has resulted from the ectrotic effect this substance has exerted upon the diseased follicles of the intestinal canal is the purest conjecture. Even in the analogical case of small-pox, so much dwelt upon in the memoir, mercury exerts no specific action in producing the abortion of the pustules, the same end being attainable less conveniently by the use of caustic and more conveniently by the application of blisters. Still, with any of these aids, the progress and result of the disease is capable of very slight modification, though, for the prevention of disfigurement of the face, they become valuable subsidiary means. We are not told whether the sulphuret acts as an active purgative. If so, its utility may to some extent be explained, as many of the French practitioners have derived great benefit from this class of medicines, mercurial and otherwise, now the belief in the disease being essentially an enteritis has nearly passed away.--Rev.]
THE MEDICAL PROFESSION IN PARIS.
According to M. Domangés Medical Almanack, the number of practitioners in
-1617 To these may be added, Pharmaciens
-2442 In estimating the amount of practice which falls to the lot of these 1617 qualified medical men (at Paris as elsewhere, charlatans and unlicensed persons abound likewise), we find the official statements in 1846 give us a population (including, however, hospitals, colleges, and garrison) of 1,053,897 souls. In 1845, of 32,905 births, 5,678 occurred in the hospitals, that is more than a sixth part did not fall into the hands of the practitioners and midwives, these last taking the lion's share of the remainder. In the same year, 25,156 deaths took place, of which 15,888 took place at their own houses, the rest dying in hospitals, &c. In 1845 there were 1598 practitioners, and dividing the deaths among these, we find about 10 must fall to the lot of each. In the hospitals, the proportion of deaths to patients is about one-eighth ; but, if in the easier classes of society, we call it a fifteenth, each practitioner would then, upon an average, have an annual practice among 150 patients, or 12 per month. We may leave to others to calculate the mean number of visits these may require, and the product of such, at charges of 5, 3, 2 francs, or even less—to say nothing of bad debts. This, if patients were equally divided; but there are some few of great repute who receive their £4000., others whom the hardness of the times leaves only £2000; and so on, from step to step, to those who, yet better provided for than the mass of their brethren, with great difficulty attain £200. at the end of the year. Lower, and much lower still, there are practitioners who make as little as £60. £50. or £40. per annum; and how many are there in the first year of their practice do not take £20.
And yet the evil is on the increase : the number of practitioners is constantly augmenting. In 1845 there were but 1430 doctors : 50 died and 62 left; but this vacuum of 112 was not only filled up, but replaced by 124. In 1845 there were 168 officiers de santé, 175 in 1847 : so that the total addition of practitioners in only two years amounted to 19. In 1845 there were 450 midwives, in 1847 there are 480; while the accouchements at home in 1845 only amounted to 27,227. Take from these the gratuitous confinements provided by the charitable societies, and those conducted by the practitioner, and there certainly cannot remain a mean of 50 patients per annum for each midwife. The majority then cannot live by their profession. What then do they live by? That would be worth while inquiring into ! L'Union Medicale, No. 102.
[The writer goes on to recommend the limitation of the number of the practitioners to the wants of the population; forgetting apparently that every occupation and profession is in like manner overburdened and could put forth equal claims to repression, if these were not perfectly inadmissible in the present state of society, which is to be governed by moral and prudential restriction, and not by the exclusivism of a worn-out period. The medical profession has, however, the remedy in its own hands in a great measure, by means of which it may right itself, and yet benefit the public, namely, the increasing the period of study and the amount of requisite qualifications. Certainly the pecuniary position of the medical body in Paris, if the above representation be correct
, is far worse than that of our own capital : since, for our own two million souls, we have but 2,413 qualified practitioners, while for their 1 million, they have 1617. Then again, the midwives with us are a most insignificant class, employed only by the poorest of the population as a matter of necessity; while too many of our own practitioners add to their strictly professional receipts the profits of tradesmen by vending drugs, perfumery, and even quack medicines ! For our parts we prefer the honorable poverty of our neighbours to this lucrative but degrading practice among ourselves. -Rev.]
OBSERVATIONS ON THE MATERIA MEDICA.
1. On Alkaline Medicines. By M. Mialhe.-M. Trousseau has recently recalled attention to the fact that, when these are taken in too great a quantity, they increase the fluidity of the blood and deprive it of colour, and lead to cachexia, pallor, and general infiltration, passive hæmorrhage, and an irreparable wasting-giving rise to far greater and more irremediable evils than the disease they are employed to combat, and causing just as much mischief as the abuse of iodine, mereury, or the preparations of iron. I propose here to indicate some of the circumstances under which alkalis may give rise to these ill consequences, and those of a contrary, character, under which perseveringly used, they may re-establish the derangel equilibrium of the economy.
First, we may observe that the administration of alkalis in excess does not give rise to so much mischief as does a similar abuse of acids. In the state of health
the three principal fluids of the body, the chyle, the lymph, and the blood, are alkaline, and the amount of alkaline base they contain is incomparably greater than the amount of acids contained in other fluids. It is then in an alkaline medium
Mialhe on Alkaline Medicines.
that the animal organic mutations are operated, while in plants it is always in a neuter or acid medium that the phenomena of nutrition take place. The alkalis fulfil a far more important function in the economy than that of mere exciters and fluidifiers, presiding as they do over the decomposition and assimilation of the hydro-carbonaceous substances of the amylaceous or cellular families.
But however the blood and other liquids may be physiologically a little more or a little less alkaline, it does not follow that they may be inconsiderately administered. They stand at the head of the agents which exert on the serum the most marked fluidifying action. All the alkalis affect our economy in an identical manner. They produce on the organ of taste an impression sui generis, designated as alkaline or urinary. M. Chevreul showed this to be always due to the same substance, ammonia, which is set free by the decomposing effect exerted by the alkaline base on the hydrochlorate of ammonia contained in the buccal fluids. Experience has shewn that, the same chemical fact prevails in respect to the bicarbonates and carbonates, and all the other fluids of the living body. Hence, wherever we introduce any alkaline substance into the economy, a certain quantity of ammonia is set free. This explains why the ingestion of a certain quantity of bi-carb. soda dissipates the symptoms of drunkenness—the ammonia disengaged restores to the albuminous elements of the blood that fluidity which the coagulating action of alcohol had partially deprived them of.
Under what circumstances is the employment of alkalis efficacious or dangerous ? Clinical observation shows us that the daily taking of a drachm or a drachm and a half of bicarbonate of soda, or its equivalent of any other alkali, so far from being generally injurious is frequently advantageous. Many persons can take far larger doses with impunity, while much smaller ones have, in some cases, induced serious accidents. All substances which produce an acid predomiDance in the blood allow of a large quantity of alkalis being taken. Thus, the inactive inhabitants of towns, in whom there is hardly any acid secretion from the skin, especially in Winter, will bear large doses of alkalis. It is the same with those who live upon an almost exclusively meat diet, inasmuch as the albuminised elements containing sulphur and phosphorus, these two elements produce, by their interstitial combustion, phosphoric and sulphuric acids in marked proportions. This explains why the urine of the carnivora is normally acid, that of the herbivora always alkaline. On the other hand, whatever favours the predominance of alkalis in the vital humours forbids their employment. Thus the laborious inhabitants of the country, in consequence of their abundant acid sweats, can ill bear the ingestion of alkalis. So with persons who adopt an exclusively vegetable regimen, the blood is normally rich in carbonate of potass, by means of the transformation which the salts of potass in combination with the organic acids have undergone. Lastly, there are certain pathological conditions which lead us to vary the amount of alkalis given. Who does not know that in gout, gravel, and especially diabetes, immense quantities of these may be given ? and who is not aware that certain Summer and Autumn putrid affections will not tolerate them?
Clinical observation has long shown that the various alkalis may replace each other in practice. This is the case with carbonate of lime and of magnesia : as also with the compounds of soda and potass. It has been erroneously stated that, soda is more favourable to the animal constitution than potass. Analysis of the animal liquids shows that the potass compounds are equally prevalent with the soda, and as regards the herbivora, far more so. But, although we can in general by the aid of any alkaline preparation induce an identical medical result, we believe it is better to give the preference (as mere antacids) to those alkaline compounds which present the advantage of having always an uniform chemical composition, and of producing little or no therapeutical effect; and in these respects the hydrated calcined magnesia and the bicarbonate of soda seem to hold the first rank.-L'Union Medicale, Nos. 1 and 4.