AN ESSAY ON COLONIAL FEVER; WITH OBSERVATIONS ON DIARRHŒA AND DYSENTERY (As at present prevailing in Otago).

Otago Witness, Issue 653, 4 June 1864, Page 20

AN ESSAY ON COLONIAL FEVER; WITH OBSERVATIONS ON DIARRHŒA AND DYSENTERY (As at present prevailing in Otago).

Ifr James Bewmitt Cltjttksbuck, M.D. (No. vm.) DYSENTERY, continued.

Mercury, its use. — Since the late Mr -Abernethy promulgated the doctrine that iisorder of the digestive apparatus was the indirect source of many other diseases, no class of medicines has been so indiscriminately used in affections of the alimentary •anal as the various preparations of mercury. In relation to the treatment of iysentery, it will be useful to inquire the cause which has led to the employment of this measure. Some, especially those who lave practised in tropical climates, have entertained the idea, that hepatic disease (vulgarly, "liver disease"} is invariably combined with dysenteric affection — the former being not infrequently viewed as the cause of the latter ; hence, the alleged coexistence of the two has given apparent sanction to the use of this mineral. So far as my observation has extended, I have met with pure dysentery independent of a morbid condition of the above viscus. It has been imagined, likewise, that as biliary natter can rarely be traced in dysenteric evacuations, the liver must be in a state of inactivity, sluggishness, torpor as it is technically styled, and that this gland required a stimulant of some kind. The blue jwfl, consequently, very readily suggested itself as a suitable means of attaining this object. or four grains of this compound have been therefore usually given at night, but with what precke effect it is uot easily determined ; bo minute a quantity of mercury would seem to be nearly, if not wholly, inert ; and if so, its administration in so dangerous and sometimes speedily fatal disease, is attended with disadvantages which need not be pointed out. The treatment of this affection by mercury alone has, according to the testimony of many practitioners, whose veracity we ! ljave no right to question, 4 frequently) proved successful. Yet, a reliance upon j this, or that remedy exclusively, has, I imagine, been a fertile means of abusing, and of disusing, several of the most important ones. A practitioner, for instance, may have been induced to put implicit confidence in blood-letting, as a means of cure : not upon actual trial of such agent, but simply from the high enconiums which lave been passed upon it by some of the most distinguished writers — other powerful auxiliary remedies having been but •uperficially alluded to, or used. It is kardly necessary to remark that, should the measure on which he has relied disappoint his expectations, in nineteen cases «ut of twenty he will most probably be induced to consign the lancet to its case, or ' the mercury to the shelves of the chemist. It is to the combination of means, properly applied, that a successful issue can be fairly anticipated in the majority of <*ur formidable diseases. The order, however, in which each is used is a matter of the greatest importance— one active agent does not necessarily supersede the use of another'; both are valuable, or otherwise, according as either be primarily or secondarily employed. Blood-letting, for example, is a remedy of inferior note after mercury lias been persisted in ; the continuous introduction of this mineral into the system causes a state somewhat allied in its nature to inflammation, and from this fact alone, experience induces the belief that the lancet is less effectual in its application in acute cases, inasmuch as a constitutional ! toturbance, independently of a ltcal affec- 1 tiori, has to be overcome. In adult subjects, in whom this disease did' not sensibly appear to have decreased, I have sometimes, after the operation of Wood-letting, found small doses of calomel of great advantage — one grain, conjoined with three grains pulv. ipec c. being given tvety second hour until its absorption leeiune evident, as, a peculiar odour of the breath, a coppery taste in the mouth, swelling and redness of the gums, pain and achingof the joints, flushingof the cheeks, &c. When one or more of such signs has appeared, the disease has frequently gradually declined, and the evacuated xaatter has presented a more healthy, fteculent character. The circumstance of bile being detected in the dejections is no proof that mercury, ©n ita exhibition, exerta a particular specific effect on the liver more than on any other •rgan of the body ; when such an appearance is noticed, on the administration of »ercurial preparations in various diseases, as in that which is vulgarly denominated "dyspepsia" (which, by the way, is only a name expressive of a symptom, having so reference, either directly or indirectly, to any pathological or physiological coniition from Which indigestion could be supposed to originate), the inference'drawn is, that the seat of mischief is the liver, and hence the " mercurial treatment ;" vhereas, all parts of the system are' more tr leta (susceptible and under the 'influence

of such remedy. I have not found the exclusive use of mercury for the relief of dysenteric disease of that advantage which some have apparently derived from it, having rarely succeeded in controlling the acute form by 6uch means, unaided by previous venesection, either general or local ; and, in mild cases, I am not sure whether the artificial disease created by its use has not increased the real one, a<*, also, interfered with its natural tendency to decline early. The administration of small, repeated doses of mercury appears, as before stated, on all occasions to have the power of inducing disease (how, or in what manner this ia accomplished is veiled in obscurity), consequently, the finest discrimination is required in the use of so active an agent in , the milder forms of the disease under con- j sideration, whose peculiarities differ so widely from most others. Calomel, in repeated doses, sometimes produces an ! action of the intestinal tube, mouth, and adjacent parts, so specific as to lead to inflammation, this succeeded by ulceration, and even death, although administered , with the greatest circumspection ; or, net uncommonly, the irritative fever consequent thereon protracts the cure, inducing \ a doubt, too, whether such constitutional disturbance were the consequences of the I primary affection or its remedy. Even the most sceptical will admit this. It i 3 evident a patient's safety may be endangered by administering this most powerful agent j in a speculative manner, through which the vires natures mcdi catrices may be inadequate to effect a healthy change. Two cases, highly confirmatory of the opinion, that extreme caution should be exercised in the use of mercury, came under my observation several years ago : and however painfully I view the practice I adopted, the cause of science is more effectually aided by the relation of such unfavorable cases than by the recital of a dozen successful cures. The following is a brief outline of facts as they occurred : — A child, five years of age, had been suffering from dysenteric purging four days previously to my visit ; the symptoms were slight in degree, very little uneasiness complained of, the dejections, by no means frequent, small in quantity, and very slightly tinged with blood, the tongue white but moist, the pulse 110 and steady, the child's appetite comparatively so good that medical attendance was hardly deemed requisite by .the parents. The disease continuing una- 1 bated for three days under a mild treatment, (small doses of. chalk and magnesia, mucilaginous drinks, the use of animal food interdicted, being all that I judged requisite), and the efficacy of mercury having been urged upon my. notice j in such cases, I resolved upon giving the mildest preparation — one grain and a half of the hyd. c. creta., were ther«fore ad- j ministered every four hours during the J two ensuing days without apparent change. , On the morning of the third day, sudden hectic flushes were observed on each cheek, and great restlessness prevailed; still, no impression appeared to have been made on the disease, nor did its features vary in a very marked degree ; the mercury was discontinued. Towards the evening, violent secondary fever ensued, followed by swelling of the submaxillary glands and tonsils, with a copious secretion of saliva, the mucous membrane of the mouth and fauces being in a highly inflammatory (aphthous) condition. These symptoms were shortly followed by impeded deglutition, loss of natural articulation, the child at intervals moaning piteously, as if in pain, and drawing its knees towards the abdomen, slight pressnreover which produced increased suffering ; the dejections were now very frequent, foetid, and sanguineous. Coor air was admitted, four leeches to the abdomen, a table-spoonful of 01. ricin., which with great difficulty was swallowed, and an enema administered composed of 20 drops tinct. opii in half a pint of gruel. The patient gradually got worse, extensive inflammation of the salivary glands ensued, the saliva flowing copiously, the breath having a strong mercurial fetor; the tongue protruded out of the mouth, and the features collapsed. In the middle of the night the little sufferer was in its place of rest. The other case so closely resembled the one just described that it would be useless to relate it— however, my belief is, both patients were destroyed by the mercurial plan I unfortunately adopted, not from the effects of the disease under which they originally labored. It is to be regretted no inspection of the bodies was permitted. The impression left on my mind by those fatal terminations is too vivid to be readily effaced, and I have recorded these as involving an important practical lesson : — The powers of the constitution were gradually undermined in proportion to the influence excited by the agent employed, and under these circumstances no re-action ensued, Nature herself being inadequate to the task of reparation. The proportion of mercury that was exhibited was exceedingly small, not exceeding six grains in the 48, hours, yet the sequel shewed how insidiously these minute

doses were paving the way towards a fatal termination. These cases prove that the remedy we are now considering is, at times, attended by very uncertain effects, especially in the acute diseases o/very young children ; and it unfortunately happens that we can seldom succeed in controlling the action of this mineral even in the adult subject ; salivation, ulceration, and other evils, will frequently arise in opposition to the best directed efforts to prevent their occurrence ; and no one in the present •day, it is presumed, would purposely induce ptyalism in order to cure disease, specific or otherwise. Notwithstanding what has been said respecting the employment of mercury in the active stage of dysenteric purging, as occurring in children, there can be no doubt when the disease has been protracted to a period of weeks, or months, very decided benefit has frequently accrued both to young, but especially to adult subjects, by the occasional and cautious use of very minute doses of this medicine. If, to such treatment, suitable depletion have been previously employed, together with the use of such means as excite cutaneous exhalation, a formidable malady may occasionally be made to yield ; whilst, on the other hand, the exhibition of the mo3t powerful astringents — amongst which catechu probably holds the highest rank, — opium, &c, these whilst they may occasionally relieve particular sypmtoms, make no radical impression on the disease itself. The experiments of that distinguished physiologist, Majendie, have tended to establish an important fact, and which might be usefully kept in view when trusting the cure of this affection to the influence of mercury. He has satisfactorily demonstrated that the absorbent vessels are greatly influenced, or rather increased in point of activity when the sanguiferous system has been moderately reduced, as by blood-letting ; whenever, therefore, jt is deemed advisable to inftoduce any of the mercurial preparations speedily, a surer raean9 of accomplishing this object cannot be found than that of unloading the vessels, to a judicious extent (other circumstances favoring such an evacuation) by the method so frequently alluded to in the preceding pages.

If, during the course of inflammatory action, alteration of structure have taken place, it will be unreasonable to anticipate a permanent cure, by a combination of any measures. Thus, again, is shown ■ the obvious necessity of endeavoring to remove or eradicate all traces of inflammation in the first or earlier stage of dysentery ; no passive mode of treatment, however judiciously directed, caa subse- j quently cause such a change in the animal economy as to be productive of new and healthy structure out of disorganised matter^ which latter is often found to exist in the chronic stage. Dr. Wilson Phillip, in his " Treatise on the Influence of Minute Doses of Mercury," entertains an opinion opposed to that which I have hazarded. "It is not surprising' 1 observes this eminent physician, "that a medicine, which so powerfully influences the secreting organs in general, should influence the secreting power of this organ, j the liver, but independently of this power, it has a specific operation on the liver ; a power not merely of exciting its function but of correcting the various derangements of that function in a way which it does not possess with respect to any other organ, and which no other medicine possesses with respect to the liver, and that even to such a degree as not only to restore a healthy state of the bile in various deviations of this fluid, but often to correct the most formidable change of structure in the organ which secretes #." Every one must feel sensible of the observations emanating i from such a source, yet, with the greatest deference, some objections require to be j surmounted to render the above doctrine conclusive. Opportunities are afforded of appreciating the effects of mercurial preparations without ascribing to the liver the means by, or through which, parts remotely situated from this organ, are often restored to,a healthy state ; examples are furnished in that specific form of inflammation caused by the absorption of venereal virus ; in mesentric, cutaneous, and also in some other affections. It could hardly be imagined that mercury, on getting into the stomach, travels only so far as the " halfway-house," the liver, expending its sole influence in its substance. The " removal of the most formidable change of structure" occurring in this glandular body, by a mercurial plan of treatment, can only he presumed; as, during I life, we have no direct means of discovering many of those morbid conditions which are so frequently supposed to exist, viz , induration of the liver, tubereulated condition of the liver, schirrhous liver, &c. Such conditions being conjectural, it is impossible to appreciate the effects produced by mercury, or any class of agents, under such circumstances. Mere swelling of the organ is no criterion of its disorganisation or change of structure ; thiseffect may continue for an indefinite period, and disappear on the subsidence of its cause — inflammation. According to Dr Baillie

(vide his " Morbid Anatomy ")» the fluid secreted by the liver is found to vary in different subjects; and he considers this to be an event of so conmon an occurrence as to question the propriety of using remedies for the sole purpose of correcting any of its impurities, if the bile be occasionally vitiated in quality, the diseased organ concerned in its production must first be influenced by medical- treatment in order to restore the secretion to its natural state. A case of pure fever shews the changes which are usually induced ia the various secreted fluids ; but as these changes are usually considered in the light of effects, not causes, of the febrile commotion, attempts to correct them are seldom made.

The therapeutic action of remedies is not to be estimated from the obscure and unmeaning names with which they are invested ; the bewildering phrases — antibilious, antiseptic, nervous, hydragogue, carminative medicines, cum multis aliis, are retained in medical nomenclatures, hut without apparent gain to science ; and were a twentieth part of the drugs enumerated in our pharmacopoeias expunged, simplicity in prescription would at least more generally obtain. The judicious remarks of Dr W. Phillip, on the use of very small doses of mercury (especially in combination with general blood-letting), fully apply to that form of dysentery so Harassing to a patient on returning from India — the chronic as we term it. This gentleman states that a length of time may elapse ere perceptible amelioration takes place on the exhibition of very minute doses ; but that this circumstance should not induce a larger administration than an eighth-part of a grain twice daily, for a period of a week or so, resuming it at intervals, according to circumstances. By such a method of proceeding, a gradual absorption of the mercury takes place, salivation is ia a great measure guarded against, and a steady impression excited in the system generally, during which the disease is sometimes disposed to decline. Some years since, — and even now the custom is not obsolete, — it was the fashion to give scruple doses of calomel in this disease, but it is difficult to understand the rationale of such practice. As a purgative, it is too drastic and irritating to the surface of a membrane already in a state of preternatural excitement, and prone to ulceration; and we can hardly imagine so large a dose is given with a. view of " improving the secretions." In concluding the treatment of this affection, it is scarcely necessary to observe that all sources of irritation are to be avoided. Solid animal food is to be withheld during the progress of the complaint ; the most simple and easily digested, administered very sparingly on the approach of convalescence ; — trifling errors in diet frequently reproducing the disease. A few deplorable, and, apparently, hopeless cases of dysentery, as well as diarrhoea, which occurred some years ago in Melbourne in young children, terminated favorably, and within a very short period, by a removal to the sea-side (Brighton and Williams Town) ; and lam induced to think the issue of many cases might be more favorable, if, instead of endeavoring (sometimes fruitlessly) to effect cures solely bymedicinal agents, patients were sent, within a day or two of the attack, to some suitable locality near Duuedin, where the advantages of a bracing sea-air were obtainable; a chalky soil and elevated land would also be desirable elements. An infirmary must, unquestionably, 'sooner or later, be erected by the citizens outside this town ; the fact is too patent (to use the words in the leading article of the "Daily Times" of the 9th ultimo), " pools of stagnant fseculent matter still poison the atmosphere in every direction." That the prevailing fever is traceable, amongst other causes, to the offensive effluvium generated in the manner pointed out, does not admit of doubt. The " manufacture of fever is as simple a process as the manufacture of bread." A contaminated atmosphere, therefore— bad drainage — added to another evil of scarcely less magnitude, the small ill-ventilated sleeping apartments in which frequently three or more persons are huddled together to consume the' vital air (oxygen), with no outlet for the contaminated air expired, — are of a nature to lend strength to the supposition that, should any pestilential malady burst forth, there i 3 no public or private institution in Dunedin strictly available, as regards locality, for the reception of a class of patients who, at a moment's warning;, perhaps, may need shelter within the walls of such an establishment.

(To be concluded in our next.)

A Judge in India is reported to hare addressed a person convicted before him, prior to passing sentence :—" Prisoner at the bar, Providence has given you a good degree of health and strength, instead of which you go about the country stealing ducks."

A Crooked Company. — A Hibernian sergeant was drilling an. awkward squad of volunteers, and spite of all his efforts, failed to bring them into a straight line. At last, out of all patience, h« cried out, "Oh! what a bent hwj just com* out lads, and look at youreelyee."

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