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tissue which many operators, and Farquar Curtis (Medical News, June 24, 1899) but lately stated to take place for days or weeks even in aseptic wounds though primary union be not disturbed (this occurs frequently in strumectomy, less so in operation on the mamma and after herniotomy); or those that follow shock either immediately or aíter a preceding subnormal temperature; or those that depend on the absorption of urine during nephrectomy, or of bile, or of thyreoid secretion; or those which happen during abstinence from water, or after venesections. In both conditions metabolism is increased with the result of furnishing the water which is wanting. Exacerbations of temperature after transfusion are also, in my opinion, the result of rapid decomposition and forced elimination or superfluous or rather unused material. The body temperature is raised during the absence of oxygen; metabolism is excessive and rapid when oxygen is wanting, as for instance in pneumonia where the artificial supply of oxygen can be made to relieve both metabolism and respiration. The same increase of body temperature takes place during muscular overexertion—the term muscular fever has often been given to this condition. It is easily explained when we consider that even under normal conditions metabolism is induced by disintegrating enzymes first in the circulating, afterwards only in the tissue-albumin, and in the carbohydrates when not quite firmly organized, and that this process takes place mostly during and in consequence of the contraction of the muscles. The inference on general hygiene need not be pointed out; except in this that without muscular exercise there can be no healthy body-economy. Most characteristic for the non-microbic elevation of temperature, however, are the fevers that follow catheterization, or those that attend the passing of gallstones, or the sudden transition from heat to cold on the cutaneous surface. In all of these cases we have to deal with a reflex irritation of the vasomoter centre and with contraction of the cutaneous bloodvessels. In these cases there may be and probably is some increased production of heat, but the main source of the fever should be sought for in the diminution of surface loss. This is normally brought about by conduction through the normal tissues, that is, by radiation, and the evaporation of water. These are stopped when the innumerable sweat follicles cannot act and be relieved under the influence of heavy or impermeable clothing or covering, or of excessive atmospheric humidity, and can be restored by the dilatation of cutaneous bloodvessels through artificial means. Diaphoretics are here indicated, and are aptly supported by derivants, i. e., diuretics and laxatives. Before our minds were both enlightened and clouded by such bacteriologists as claimed the earth for exclusive microbic etiology, and by their followers who are still nothing unless in the fashion, there were, though with less accurate knowledge it is true, great physicians with good observing powers. They treated such fevers on the above-mentioned s. c. metasyncritical methods, a name dating from Galen
So do we though some of us do not admit it. The disadvantage of the method was only in this, that while the difference between nonmicrobic and microbic fevers was not substantiated, the same method was applied to all of them. Thus it happened that infectious fever cases were smothered under heavy downs, drowned in hot teas, and exhausted by intestinal draining.
The reduction of increased temperatures has been attempted in different ways. A direct action against the source of fever was attempted with very indifferent results, by administering antiseptics, that was when antiseptics and antipyresis were considered identical—an assumption which is not demonstrable as yet. A second method consisted in the use of remedies which were meant to paralyze the organs of circulation; but digitalis, veratrum, etc., require very large, indeed too large doses, to have that immediate effect. The third method, which is more effective, is directed upon the locality of the production of heat, viz., either the cells of the tissues, or upon the heat regulating centres in the brain and medulla. Quinin seems to act on the cells, most of the other antipyretics appear to reduce the temperature of the body by the increase of heat elimination, through hyperæmia and perspiration.
Thus the general indications of anti-febriles are various. They may be given for the purpose of killing or paralysing microbes, or of annihilating the effect of their toxins; of reducing the action of the temperature centre and the increased metabolism, and thereby preventing excessive inanition and exhaustion; and of increasing the surface loss of temperature with the effect not of reducing metabolism but of relieving somnolence and other cerebral dangers, thereby adding to the comfort of the patient, diminishing the period of actual danger, and thus reducing mortality, At the same time the danger of diminishing the alkalescence of the blood is averted and the degeneration of the tissues precluded. The latter end is perhaps best attained by the use of mineral acids.
Can we kill microbes in the blood or the tissues? Perhaps. We may do so by antiseptics given in doses sufficient to kill the patient, if that patient be a child, so much the worse for him. Is it necessary to kill them, or is it sufficient to paralyse them? The latter is a possibility since Prodden succeeded in so doing by administering largely diluted carbolic acid.
Whether protracted dosing with bichloride of mercury has some such effect as I so fondly hoped that I still practice it in many forms of infectious fevers, remains to be seen. The effects of toxins may surely be counteracted by antiseptics in the accessible cavities, the occasioral objections of bacteriologists to intestinal disinfection notwithstanding.
Moreover, that diluted antiseptics, even when but temporarily employed, have a beneficial effect, is visibly proved by the effects of wound irrigation. Zimmerman's experiments made under Kocher's direction which proved that, have always been sustained by what every operator knows. Though antiseptic irrigations may irritate a wound and cause a secretion, still they cause no suppuration; and the vital energy of the cells is not injured by them; and finally wounds may and will heal though they be not entirely free of microbes.
Of late some soluble silver salts have been proclaimed as the sheet anchor of antisepsis in many forms of septic fevers.
B. Crede's first publication* on "Silver and Silver Salts as Antiseptics” appeared in 1896. That pamphlet was followed by many journal articles since, also by a paper read by him during the meeting of the Moscow International Medical Congress in 1897. His experience with them extends over many thousand cases and has often been renewed and extolled by observers of all countries. His followers are sometmes more enthusiastic than he is himself though his own convictions approach sometimes the fervor of fanaticism. Credé first tried the lactate of silver (in the trade called actol), and the citrate of silver (itrol), which are non-poisonous and efficient antiseptics, but require too large dilutions for subcutaneous injections and cannot be employed in strong solutions on account of their forming insoluble combinations with the albumin of the tissues.
*Compare Klinisch-Therapeutische Wochenschrift, 1898, Nos. 14 and 15.
So he applied to chemists who produced for him metallic silver in fluid form changing in the body into the antiseptic salts. This "colloidal silver" is almost entirely soluble in water and albuminous fluids, and apparently hinders the development of and destroys certain pathogenic germs, viz., staphylo and streptococci, to such an extent as to very often effect a rapid and absolutely surprising cure in recent cases, and also in chronic ones, such as slow sepsis and furunculosis, where secondary changes of vital organs, such as abscesses, or gangrene, have not occurred.
The first form of the drug recommended by Credé was an ointment which goes by his name containing fifteen per cent. of metallic silver, three grammes of which are a dose for an adult, one gramme for a child. It takes twenty or thirty minutes to be fairly well rubbed into the skin. In average cases a single inunction, in severe cases several, in chronic cases from five to twenty inunctions were required to cause a decided improvement in the symptoms.
The internal administration of colloidal silver is resorted to mainly where there is a contraindication to inunctions. Credé orders pills of 0.01 with 0.1 of milk sugar, with glycerine and water, two of which are taken two to three times daily. Improvement is said to be immediate. Chronic cases, for instance tuberculosis, require one pill twice a day. No argyriasis was observed after many months.
For subcutaneous use a solution in 200 parts of water was employed for fungous and tuberculosis processes in which it is customary to make iodoform glycerin injections. The dose is from one-half to two grammes every week or two. Externally it may be used in a solution of one in 5,000 to 10,000; solutions of one in 2,000 are said to prevent the growth of staphylo and streptococci in the culture tube.
The internal administration of colloidal silver meets with difficulty when the stomach is acid. In that case the drug is decomposed. This does not occur with egg albumin, which is prepared by bottling the white of an egg with equal parts of glycerin. The prescription is one to four parts of colloidal silver, 200 to 800 parts of distilled water, egg albumin one to four; a tea or a tablespoonful three times daily with a glass of water. Sugar may be added. Rectal and intravenous administration has also been resorted to.
This is the preparation which is claimed to relieve or to cure phlegmon, lymphangiectasis and lymphadenitis, phlegmonous angina, foetid bronchitis, peritonitis, furunculosis, erysipelas, puerperal fever, gonorrhoeal and articular rheumatism, tuberculosis, scarlatina, diphtheria, typhoid, gonorrhoea, etc. At all events this is the class of cases in which that soluble and noninjurious antiseptic is expected to be serviceable, and there are many reports that appear to prove the justifiability of its claims, at least to a certain extent. The careful practitioner who has seen many rockets to rise like stars and to descend like sticks, will do well (to judge from what I have seen myself), to try the colloidal silver for what it may be worth. We have all been looking for a soluble antiseptic which would kill cocci and toxins without harming the tissues. In this drug we are promised such a material. We are not bound to accept the dicta of enthusiasts bent upon writing an article that will carry their names through the ephemeral literature of a brief half year. On the other hand we need not condemn like Conrad Brunner and Carl Meyer, who in a big book lately proved to their satisfaction that the claims of Credé were not at all sustained by the facts. That happened this way. Credé expressed the hope that bacilli would be as amenable to the action of his silver preparations, as cocci, and was once led away to say that all microbes were killed by colloidal silver in five minutes." Our clever authors found that lactate of silver (not the colloidal) one in 1,000 could not kill anthrax in three days, and the citrate did not destroy staphylo coccus aureus in sixty minutes. They need not have disproved what was not claimed. My own experience is limited to a few cases of phlebitis, puerperal fever, and pyæmia. I am sufficiently impressed by it to make further experiments, not relying on colloidal silver alone, but supporting it with aid of stimulating and supporting treatment, and that of the knife in appropriate cases.
The temperature centres may certainly be influenced; they may as I intimated be paralyzed even by large doses of digitalis and veratrum, and by excessive doses of phenol preparations. But the temperature is not only regulated by the centre but also in the periphery. The effect of quinine as I said before is local in the cells and remains evident even after the section of the spinal cord, while the phenols appear to act both on the centre and on the surface. The latter which regulates the loss of temperature,