CURRENT LITERATURE.
In a paper read before the Medical Society of the State of New York, (Medical Record, March 5th), Dr. Jacobi reviews in a very careful manner the remedial effects of chlorate of potash, and calls attention also to what he considers the dangers of large dosages so commonly employed by physicians and patients.
Sir James Y. Simpson, introduced chlorate of potash on the theoretical ground of its employment in chemistry to develop oxygen, to supply oxygen to the blood on the part of the fœtus in cases of placentitis.
Many years ago, Isambert and Honie, found chlorate of potash eliminated without any change, and in large quantities, even as much as 95 or 99 per cent. of the amount administered, in the various secretions of the body; that is in the urine, the saliva, the tears, the perspiration, the bile, and now and then even in the milk; no oxygen was developed at all. The theory of Simpson was long ago given up, because it was found out that the same redness was produced in the blood by other alkalies.
Its principle value consists in its effect upon catarrhal and follicular stomatitis; further, in mercurial stomatitis, the former being a frequent and the latter a rare disease in infancy and childhood.
“In regard to [the employment of chlorate of potash] diphtheria, I can give [my position] in a few words. It is this: that chlorate of potassa is a valuable remedy in diphtheria, but that it is nottheremedy for diphtheria. There are very few cases of diphtheria which do not exhibit larger surfaces of either pharyngitis or stomatitis than of diphtheritic exudation.”
There are also a number of cases of stomatitis and pharyngitis, during every epidemic of diphtheria, which must be referred to the epidemic, perhaps as introductory stages, but which still do not show the characteristic symptoms of the disease. * * * *
The dose of chlorate of potassa for a child two or three years old should not be larger than half a drachm in twenty-four hours. A baby of one year or less should not take more than one scruple aday. The dose for an adult should not be more than a drachm and one-half, or at most two drachms, in the course of twenty-four hours.
The general effect might be obtained by the use of occasional larger doses; but it is best not to strain the eliminating powers of the system. The local effect cannot be obtained with occasional doses, but only by doses so frequently repeated that the remedy is in almost constant contact with the diseased surface. Thus the dose, to produce the local effect should be very small and frequently administered. It is better that the daily quantity of twenty grains should be given in fifty or sixty doses than in eight or ten: that is, the solution should be weak, and a drachm or a half-drachm of such solution can be given every hour or every half hour, or every fifteen or twenty minutes, care being taken that no water is given soon after the remedy has been administered for obvious reasons. He referred to these facts with so much emphasis because of late an attempt has been made to introduce chlorate of potassa as the main remedy in bad cases of diphtheria—and, what is worst, in large doses.
As early as 1860, Dr. Jacobi advised strongly against the use of large doses of chlorate of potassa. * * * * The treatment is dangerous and because of the largeness of the dose of the chlorate given.
After reviewing the opinions of several writers who have extolled chlorate of potassa in large doses, and having pointed out the real solution of so many having succumbed to nephritis or similar symptoms, he concludes:
“The practical point I wish to make is this, that chlorate of potassa is by no means an indifferent remedy; that it can prove and has proved dangerous and fatal in a number of instances, producing one of the most dangerous diseases—acute nephritis. We are not very careful in regard to doses of alkalies in general, but in regard to the chlorate we ought to be very particular. The more so as the drug, from its well-known either authentic or alleged effects, has arisen or descended into the ranks of popular medicines. Chlorate of potassa or soda is used perhaps more than any other drug I am aware of. Its doses in domestic administration are not weighed but estimated; it is not bought by the drachm or ounce; but the ten ortwenty cents worth. It is given indiscriminately to young and old, for days or even weeks, for the public are more given totaking holdof a remedy than toheed warnings, and the profession are no better in many respects. Besides, it has appeared to me, acute nephritis is a much more frequent occurrence now than it was twenty years ago. Chronic nephritis is certainly met with much oftener than formerly, and I know that many a death certificate ought to bear the inscription of nephritis instead of meningitis, convulsions or acute pulmonary œdema. Why is that? Partly, assuredly, because for twenty years past diphtheria has given rise to numerous cases of nephritis; partly however, I am afraid, because of the recklessness with which chlorate of potassa has become a popular remedy. Having often met medical men unaware of the possible dangers connected with the indiscriminate use of chlorate of potassa or soda, I thought this Society would excuse my bringing up this subject. It may appear trifling, but you who deal with individual lives, which often are lost or recovered by trifles, will understand that I was anxious to impress the dangers of an important and popular drug on my colleagues, and through them on the public.”
The importance of the study of urology has of late been more fully realized by Medical practitioners, and M. Demange in his thesis (Thése de Paris, 1878) has undertaken to give a full account of the progress of this branch of medical science, being also fortunate enough to be able to enrich it by several new or very little known observations on azoturia. The latter seem the most interesting part of his thesis; we give them here briefly. The normal quantity of urea which must be contained in the urine in the space of twenty-four hours is from nineteen to fourteen grammes. If more or less is excreted, this is caused either by some local or general affection. Some years ago, Bouchard, in studying the causes of loss of flesh in patients suffering from diabetes insipidus, discovered that a large number among them lost an enormous quantity ofurea. Having thoroughly examined their symptoms he thought himself fully justified in describing azoturia as a special disease, having peculiar clinical symptoms. The affection begins with a sensation of ravenous hunger, polydipsia or profuse sweating. The thirst is excessive, and the urine passed is generally in proportion with the quantity of drink swallowed by the patient. Its density is from 1000 to 1002. In order to be able to calculate justly the amount of urea lost in twenty-four hours, all the urine passed in twenty-four hours, all the urine passed in this time must be kept and mixed. In some cases it has reached the amount of eighty-seven grammes, a most enormous quantity, which proves that nutrition is very much impaired. Senator Kien and M. Bouchard have shown that what is called extractive matter is eliminated, corresponding to urea in such cases, and that chlorates and phosphates are ejected in a similar proportion. We must, therefore, not be astonished if the patients present general symptoms which are analogous to those of diabetic patients, with the exception of the visual troubles of the latter. Both the crystalline lens and the retina remain intact, and the sight is only influenced by the anæmic state of the brain, which is caused by the dyscrasia, and which in certain cases produces a torpor of the intellect verging on imbecility. As in cases of diabetes mellitus and albuminuria, sometimes the quantity of urea decreases, and even falls below the normal amount.
In order to be able to make an exact diagnosis, it is necessary to examine carefully, both the urea and the other excreta, for several days consecutively. As a rule, persons attacked by simple polyuria, or who are suffering from interstitial nephritis, beginning with polyuria, do not present the symptoms which we have enumerated.
Disturbances of the nervous symptom and alcoholism claim the first place in the etiology of this affection, and indicate the treatment which has to be adopted. It consists in administering drugs to calm the nervous erethism (opium and valerian), and to put a stop to the excessive and progressive impoverishment of the tissues (arsenic, a suitable diet, etc.) Valerian has proved specially successful in different cases, even effecting a complete cure. Besides these cases of azoturia, combined with polydipsia, Bouchard thoughtthat there was another form of the same disease, in which there was no abnormal excretion of urine, although the latter contained an excessive amount of urea. However, as his observations in that respect are far from being satisfactory, and as these are evidently cases of cachexia, the etiology of which is very obscure, it will be wiser to leave them alone for the present. The author then goes on to consider the much-debated question on the varying amount of urea in glycosuria. In some patients suffering from the latter affection, as much urea is eliminated as the general amount in azoturic patients. It is true, however, that there may be something more than a simple coincidence between these two affections, and several authors have tried to link them together. Lécorché, who admits the hepatic theory of the formation of urea, thinks that this is only the double result of hyper-activity of the functions of the liver. Bouchard, on the contrary, considers it as a true complication of the existing affection, where troubles of nutrition are added to those resulting from insufficient respiratory combustion. According to him, the difference between melitæmia and azotæmia consists in the first resulting from the accumulation of a product of secretion, while the second results from the accumulation of a product of secretion. Azoturia is, therefore, as we said, only a complication, an accessory element which must, however, be considered as being a most important prognostic symptom. According to the same author the abundance of sugar in diabetes is owing more to a want of combustion than an exaggerated production of this substance in the organisms. If this be the case, how can we explain the coincidence of an abnormally low temperature with the production of an exaggerated quantity of urea, such as has been observed in every case without exception? This is the weak point of M. Bouchard’s theory, and it would perhaps be better to refrain from giving a decided opinion on the subject until it has been more thoroughly studied. In short, whenever there is an excessive excretion of urea we may consider it as a symptom of incipient cachexia, followed by loss of flesh. The most important question, however, for the medical practitioner is the following: are these two affections to be considered as belonging to two different groups, but having been developed incidentally at the same time in the same patient; or are they connected through a link which is still unknown to us, thereby forming one affection or disease? If these questionscould be solved, there might be some hope of discovering some rational mode of treatment, so as to prevent albuminuria from setting in, in which case all is lost. In another chapter we find the calculation of the amount of urea excreted in several chronic diseases, such as obesity, syphilis and athrepsy. Here it is easy to make a mistake, and still more so to err in trying to interpret the results obtained, because here the nourishment taken by the patient plays an important part, which is easily overlooked, e. g., in fleshy persons. Azoturia may be produced either by excess of food, or by abstaining from farinaceous food. The only way of ascertaining if the combustive functions are really exaggerated in a patient would be to compare the amount of chlorates contained in the secretions with the weight of the patient. Since Brouardel published his paper, on what he termed the uropoietic functions of the liver, several experiments have been made to ascertain the amount of urea excreted in diseases of this organ. The results have been very contradictory, but it is certain that large quantities of urea have been found in the urine of patients whose liver was completely degenerated.—London Medical Record.
Observations “were undertaken” by H. Fillman, of Leipzig, “in order, if possible to obtain further and more accurate information upon some contested points regarding erysipelas.” The experimenter has addressed himself here, especially to the answering of the four following questions:
I. Is it possible to convey erysipelas by inoculation from a diseased to a healthy individual? In other words, do those fluids obtained from the tissues of an erysipelatous part and employed for inoculation (e. g., lymph, blood, the contents of bullæ, pus, etc.,) exercise a specific,i. e., contagious action on healthy individuals when inoculated, or do they not?
II. What is the action of carbolic acid upon those erysipelatous animal fluids which produced the same disease on being inoculatedinto healthy individuals, and therefore in all probability contained the erysipelas poison?
III. In what way is it possible (apart from direct conveyance) to produce erysipelas in healthy animals by the application of different morbid matters?
IV. What do we learn from the results of anatomical and experimental investigation regarding the presence and significance of bacteria? What relation have they to erysipelas?
It would be difficult for four more interesting or important questions for the practical and scientific surgeon than these. But in proportion to their importance are the difficulties which surround them. These, however, are grappled with by the author courageously, patiently, and honestly, and the result is at all events a series of experiments of extreme interest, whatever be the conclusion, we may feel disposed to draw from them. Indeed, the writer himself seems to have set out upon his investigation purely with the desire to learn whatever is to be learned on the points stated, by careful and patient anatomical research, and without being wedded to any particular theory in regard to them, or desiring to force any conclusion.
Recognizing the great importance of the subject, and the efforts that have been made by others in the same direction to throw light upon it, notably by William, Ponfick, Orth, Bellien, Zuelzer, and Lukomsky, he has recognized many points in which these observers have failed, and has endeavored, in following out somewhat similar lines of research, to avoid their, and other, errors.
To the danger of one great source of possible error the author seems specially alive, the introduction of other matters into the system of the animal operated on than the mere morbid fluid inoculated, and this he has endeavored to guard against by the most scrupulous cleanliness in obtaining, preparing and introducing such fluids into the bodies of animals.
In touching upon the first question his first case is to define as clearly as possible what are the clinical features which characterize erysipelas in the human subject. He then details in all his experiments, and, from the kind of success of five out of twenty-five inoculations he believes there can be no doubt “that erysipelas is inoculable in rare cases; that fluids from an erysipelatous part, displaya specific contagious action.” In three cases he inoculated animals from the human subject successfully with erysipelas, and in two cases animals were infected from other animals. He believes, too, that one human subject might be inoculated from another.
In regard to the second question propounded, four experiments were made with erysipelatous inoculation material, which had been potent in other cases, but here a portion of 2–4 per cent. solution of carbolic acid was added. In none of these cases was there any appearance of either local or general symptoms of any disease.
In answer to question III, all the author’s results were negative. In no case was erysipelas produced by even the most putrid inoculations, when they were not taken from an erysipelatous part. In several cases, however, the animals died of distinct septicæmia.
The observations on the last point which are related in detail, point to the conclusion that bacteria are present in some cases of erysipelas and absent in others, so that we may infer that the advance of the disease does not depend upon their presence.—London Medical Record.
A contribution to the etiology, pathology, and therapeutics of cholera infantum,[4]by Dr. T. Clarke, Miller, opens fairly and clearly a theme which will be uppermost in the thoughts of physicians in the approaching hot weather.
The writer begins by pointing out how differently the nameCholera Infantumhas been applied, including every phase of choleraic diseases. But, “Classification of these diseases to be practical, must of necessity be rather coarse in order to adopt itself to the grain of the great mass—the rank and file—who in the main observe well, though not so systematically as we could wish. The great office-workers do not contribute largely to our mortality statistics, but we will derive great comfort as we proceed, in findingthat the figures of these common men are stupendously significant—that the bullet and bayonet are in the aggregate little less important than the epaulette and the gold lace.” He supposed that in the large majority of cases reported as cholera infantum that the choleraic feature was present at some time during the illness, though very likely not at or very near the time of death. For these reasons he considers that the statistics presented are not materially impaired.
“The onset of cholera infantum is characterized by copious watery evacuations from the bowels, often attended by nausea and free vomiting. Attending upon this or even sometimes preceding it, or rapidly succeeding upon it, is the extreme muscular prostration and great depression of the respiratory functions; there is generally more or less griping pain and restlessness, and a rapid appearance of all the symptoms of collapse, coldness of the surface and tongue, feeble rapid pulse, and partial or total loss of voice. Cholera infantum proper, lasts but a few hours—hardly a few days—when it ends in recovery, death, or inflammatory disease of some portion of the intestinal tract; in the latter case the choleraic disease is rapidly rekindled by conditions similar to those which brought about the first attack.
“The condition under which cholera infantum appears, and theonlycondition essential to its development, is continued high temperature day and night—a mean thermometer above 75°, with small daily range. This high and slightly varying temperature continued from six to ten days, will invariably, in our climate, bring cholera infantum (together with the bowel trouble symptomatically more or less distinct, but pathologically akin to cholera infantum), and the longer this condition of things continues the more numerous and the more intractable the cases become. This is as true in the country as in the city, though we are led to think, as we read the books, that this is a disease of the city especially. Deaths are registered, to be sure, and the books are made in the cities, but if the conditions above mentioned exist in the country, the disease appears there—of course, not a great many cases, for the susceptible bodies furnished by a single block in the city would outnumber those of two or three square miles in the country—yet I am glad to admit that theconditionsfor obvious reasons are not so likely to be presentin the country; the contrast, in point of green grass, shade, cool water, and moving air, is no less marked than is the percentage of mortality, and it isno moremarked.
“Few, if any, recoveries take place until the temperature falls; this fall is usually attended by rain; but this does not seem to be essential, the fall of temperature alone being sufficient to bring about a better state of things. When the temperature falls, cases improve and new cases cease to appear. Sewer emanations do not seem to have anything directly to do with the production of disease, except so far as they tend to impair the general health, and thus diminish the power of the system to resist any disease producing influence, and sewer poisons are no less abundant and deadly at other times than they are when cholera infantum cases are most numerous, and this is the time of year above others when the sewers are abundantly ‘flushed.’”
Filth he does not consider is any more abundant in the summer, and the disease declines with the increase of the very rains that favor increased decomposition. He does not attach much importance to unripe fruits as a causative element. “For whoever saw a youngster who would not exchange all his earthly possessions for a green apple, and whoever saw a child in good health injured by an unripe apple or by any quantity not altogether unreasonable?” And then the sufferers from cholera infantum are all under two years, and hence have not arrived at the green-fruit eating stage of their existence.
Nine tables are constructed, showing the weekly mortality from cholera infantum in Philadelphia, New York, Boston, Baltimore, Cincinnati and Chicago, and also as far as possible the record of thermometric range. An analysis of the table bears out the author’s views as regards the causative influence of continued high temperature.
He thinks there are some points of striking resemblance between this disease and sunstroke, so much as to suggest a pathological relationship. 1st. The same conditions seem to be sufficient for and essential to the development of each. 2. They come and go together. 3. The development is gradual and the recovery is slow in each, showing a profound impression made on the living-power of the patient. 4. The explosive character of the attack under thecumulative effects of continued high temperature with the sudden severe or fatal prostration consequent.
“Wash your children well withcold watertwice a day, andoftenerin the hot season,” is the direction of the New York Board of Health, and Dr. Miller thinks if this one prescription were carried out, cholera infantum cases could be well nigh eliminated from the mortality reports. He thinks it worth while to inculcate among our patrons that however important it may be to take special care in feeling, this will not be sufficient alone, to carry the infant safely through the high temperature of July and August; and we would try to have the people study to keep the little onescool, and the means recommended is cool-bathing or cool-sponging. Medicines are not of much use if the surroundings are cool.
The subject selected by the Medical Society at the last meeting in Goldsborough, wasSpondylitis. They were fortunate in selecting Dr. M. Whitehead as the essayist. It seems to us it would be more agreeable to the essayist, to allow him to select his own theme, and provided he announced it in advance of the meeting, it would answer the same purpose.
The annual oration will be delivered by Dr. W. W. Lane, of Wilmington, upon a subject not announced.
The Society expects from these gentlemen rare entertainment and instruction.
In our quotation from theNation’sBerlin letter on “The Discovery of the Soul,” the printers made the mistake of not ending the paragraph with quotation marks, and our northern neighbors who copied it from the Journal entire without acknowledgement, have incorporated Sambo’s philosophy in a way that we considered original with ourselves. It would be news to theNation’scorrespondent that he is versed in the mysteries of the philosophy involved in the “folk lore” of our Southern negroes.