MEDICAL CLINIC; REPORTS OF MEDICAL CASES J BY G. ANDRAL, \J* PROFESSOR OF THE FACULTY OF MEDICINE OF PARIS, MEMBER OF THE BOTAL Jl ACADEMY OF MEDICINE, ETC., ETC. \ ffiorrtienseo' arrtr SranslateH, | WITH OBSERVATIONS EXTRACTED FROM THE WRITINGS OF THE ^^5 MOST DISTINGUISHED MEDICAL AUTHORS: ^. BY .V\ D. SPILLAN, M.D. ^ FELLOW OF THE KING AND Q.UEEn's COLLEGE OF PHYSICIANS IN IBELAND, MEMBER \3* OF THE ASSOCIATION OF THE FELLOWS AND LICENTIATES ^X OF THE COLLEGE OF PHYSICIANS, ^ ^ AND FORMERLY PHYSICIAN TO THE DUBLIN GENERAL DISPENSARY. '4 CONTAINING DISEASES OF THE ENCEPHALON, ^_ V WITH EXTRACTS FROM '^ OLLIVIER'S WORK ON DISEASES OF THE SPINAL CORD AND ITS & ^ MEMBANES. H PHILADELPHIA: HASWELL, BARRINGTON, AND HASWELL, 293 MARKET STREET. 1838. U'V ON THE MEDICAL PROPERTIES THE NATURAL ORDER RANUNCULACEiE; AND MORE PARTICULARLY ON THE USES OF SABADILLA SEEDS, DELPHINIUM STAPHISAGRIA, AND ACONITUM NAPELLUS, AND THEIR ALCALOIDS, VERATRIA, SABADILLINE, DELPHINIA, AND ACONITINE. BY A. TURNBULL, M.D PHILADELPHIA: HASWELL, BARRINGTON, AND HASWELL 1S38. & PREFACE. The greater part of the contents of the following pages has been already laid before the profession, and the object the author has in view at present, is to give a connected account of the new medical properties, which he conceives to reside in many of the plants belonging to the natural order Ranunculacece, and more particularly as they are found in Sabadilla seeds, in the seeds of the Delphinium Staphisagria, and in the root of several species of the genus Aconitum. The properties alluded to, are those possessed by preparations of the plants above mentioned, when ad- ministered internally, of exciting sensations of heat and tingling on the surface of the body, and of producing similar effects locally when rubbed upon the skin, without, in most instances, giving rise to irritation of the vascular system; and when exhibited in either way in certain painful diseases, as Neuralgia, Rheumatism, and Gout, of alleviating or removing the pain, apparently by exerting a peculiar effect upon the nervous system, unattended by any narcotic influence. These effects are more certain and exist in a higher degree of energy in the active principles obtained from the plants, and on this account the author has bestowed more attention on them, and, in most cases, would give them the preference as medicinal agents. He has also dwelt more fully upon the effects produced by them when ap- plied to the surface, than when exhibited internally, because experience has shown, that by the former method, a quan- 4 PREFACE. tity sufficient to remove disease may be introduced into the system, whilst at the same time, in topical affections the remedy may in this manner be applied over the seat of the disease; but when the affection is more general in its character, the internal use, or both methods combined, will be found most advantageous. The author would caution the profession against expect- ing too much from the employment of these remedies. In some cases they have given only a temporary relief, whilst in others they have had no effect: but generally speaking he has found them of much more advantage in the treat- ment of a very distressing class of affections, than any means hitherto discovered, and on this account he would recom- mend their use. Russell Square, June 1st, 1835. CONTENTS. PAGE Introduction............-t 7 CHAPTER I. Medicinal Properties of Sabadilla Seeds.........9 Preparation of Veratria..............10 Internal Administration of Veratria and its Salts......11 External Application of Veratria...........15 in Affections of the Heart........17 in Neuralgic Affections.........27 in Rheumatism............37 in Gout..............42 in Dropsy and Paralysis.........44 Properties of the Constituents of the Veratria of Commerce, viz : Veratrine, Veratrin, Sabadilline, Mono-hydrate of Sabadilline . 47 CHAPTER II. Medicinal Employment of Delphinium Staphisagria, and its Active Principle Delphinia..............48 Preparation of Delphinia............. . 49 Internal Administration of Delphinia and its Salts......50 External Application of Delphinia...........50 6 CONTENTS. CHAPTER III. PAGE Medicinal Employment of the Genus Aconitum, and its Active Principle Aconitine..............53 Processes for preparing Aconitine...........55 External Application of Aconitine...........56 of Ammoniated Extract of Aconite.......59 Severe Case of Neuralgia of the Finger, cured by Preparations of Aconite..................gO St. Thomas's Hospital Report............66 Appendix—Cases communicated to the Author.......69 ON THE MEDICAL PROPERTIES OF THE NATURAL ORDER RANUNCULACESE; AND OF THE ALCALOIDS, VERATRIA, SABADILLINE, DELPHINIA, AND ACONITINE. Of the three plants, whose medicinal properties it is intended to give an account of in the following pages, two, the Delphinium Staphisagria and the Aconitum Napellus, belong to the extensive family ranunculacese; and with regard to the third, the plant which yields the Sabadilla seeds, little appears to be known, by which its precise character and situation in botanical arrangements can be determined. It has been supposed to belong to the class Colchicacese, but. as in some of its medicinal properties it is much more allied to the ranunculacese, it is intended, for the sake of con- venience, to speak of it as belonging to this latter class, until our knowledge of it becomes more definite. The natural family ranunculacese, as a whole, exhibits consider* able uniformity ; but nevertheless, some discrepancy occurs when its parts are more minutely examined. Many of the individuals are acrid and caustic in the highest degree, whilst others are aromatic, as the Nigella Saliva, which in consequence of its taste is some- times used as a pepper. In some again, the properties they possess are owing to an active principle which can be separated by che- mical processes ; whilst in others, as for instance, in almost the whole tribe of ranunculuses, these are destroyed by drying and boiling, or even by simple infusion in water, whilst they are aug- mented by acids, honey, sugar, wine, alcohol, &c* The acrid Cle- matis Vitalba is used as an article of food after being boiled, by the country people in the north of Italy, and the Ranunculus aquaticus is sometimes given to cattle after being deprived of its acrimony by drying. The general properties of the family may be * Decandolle Essai sur les Proprietes Medicales des Plantes. 8 TURNBULL ON RANUNCULACESE. thus stated ; Acrid and vesicatory, e. g. many of the ranunculuses, Clematis recta, Knowltonia Vesicatoria, &c, which are used as blisters. Acrid, stimulant, cathartic, emetic, e. g. the roots of dif- ferent species of Hellebore, Delphinium Staphisagria, &c. Bit- ter, tonic, antispasmodic, e. g. Zanthoriza apufolia, Hydrastis Canadensis, Pseonia officinalis. Along with the acrid prin- ciple there exists a powerful narcotic property in the Aconites ; some of the acrid plants, as the Ranunculus Glacialis, are sudorofic, and others are diuretic and vermifuge. In addition to these, there is another class of properties, which exists in the Delphinium Staphisagria, some species of the Aconites, and in the Sabadilla seeds, and in a more marked degree in the alca- loids prepared from these plants ; namely, the Delphinia, Aconi- tine, and Veratria ; and there can be little doubt, that further inves- tigation into the medicinal action of the ranunculacese, will in- crease the number of the individual plants which possess such properties. When preparations of the species above mentioned, or their alca- loids, are exhibited internally in small and repeated doses, they give rise to peculiar effects on the nervous system, but more particularly upon the nerves of sensation. These consist of heat, and tingling on the surface of the skin, beginning generally in the extremities, and extending themselves towards the trunk and head, and some- times ending in perspiration ; and in rheumatic and other painful affections, these sensations are attended by marked relief to the patient. The same effects are produced, but more locally, when the active principles and other preparations of the plants are applied by friction over the seat of the disease ; heat and tingling are like- wise induced ; at first only in the part where the friction has been made, but afterwards extending itself over the skin. In affections which are topical in their nature, these peculiar feelings are also attended by great diminution in the severity of the symptoms, and often by a removal of them after every other means have failed. It would be an interesting question, to determine in what manner such effects are produced : but as yet nothing has been made out, that is calculated to throw light upon the subject. All that can be said, is, that they are matters of observation, and it is quite sufficient for the purpose of the practitioner that they are so, for it is upon such evidence that a great part of our practice is founded. It is to this latter class of properties, then, that it is the author's wish to direct the attention of the profession ; and in doing so he may be allowed to express his conviction, that if the directions and illus- trations to be given, be sufficiently explicit to enable the profession to employ the remedies he recommends, the results will be satis- factory. USES OF SABADILLA SEEDS. 9 CHAPTER I. Medicinal Properties of Sabadilla Seeds. Considerable difference of opinion exists, as to the precise plant which yields the Sabadilla seeds. Some authors are of opin- ion that they are the produce of different species of Veratrum ; the V. Sabadilla, V. Ovbilia, and V. Officinale—others, of the Vellozia Squamata ; and lately the plant has been considered as a species of Xerophyllum, the X. Sabadilla. It is a native of Mex- ico ; it has been placed amongst the Colchicacese, but in some of its properties it appears more nearly allied to the Ranunculacese ; very little that is certain, however, is known regarding its history. The seeds are dark-coloured, rugous and slightly curved, and are contained in a light brown capsule about half an inch in length. They are without smell, but have an acrid burning taste. When given to animals in sufficient quantities to produce poisoning, their effects are marked by great irritation in all the mucous membranes, particularly in the intestinal canal, in the mucous membrane of which they excite inflammation by whatever manner the poisonous matter may have been introduced ; and along with this effect, great disturbance of the nervous system comes on before death. They have been used medicinally in the form of powder, ointment, and infusion for destroying pediculi, and internally for removing taenia, and for the cure of hydrophobia.* I have employed two preparations ; the tincture and extract, made from Sabadilla seeds, with considerable advantage in some cases. The tincture made use of is a saturated one, prepared by digesting for ten days a quantity of the seeds, freed from their capsules and bruised, in as much strong alcohol as will cover them. It forms a useful rubefacient in chronic rheumatism and paralytic cases, and has a tendency to bring out a slight eruption on the skin after it has been rubbed for some days. It produces, in a very marked degree, a tingling sensation, similar to that caused by Veratria ; and friction with it ought always to be continued until this effect is brought about at each application. When rubbed over the heart, this tincture has in some instances the effect of reducing the frequency and force of the pulse, in a marked degree, and has often appeared useful in cases of nervous palpitation. The extract is prepared by evaporating the saturated tincture made as above directed, with a very gentle heat, to a proper consistence. When given internally in small doses, it has nearly the same effects * Hardy's Travels in Mexico. January, 1838.—-S 2 10 TURNBULL ON RANUNCULACE.E. as Veratria, and may be employed with advantage in painful rhea- matic and neuralgic affections. One sixth part of a grain, made into a pill, and given three or four times a day, appears to be the proper dose, and it should be continued,and gradually increased in quantity according to circumstances. This preparation alsoinduces sensations of heat and tingling on the surface of the skin, and sometimes acts as a diuretic. Preparation of Veratria. Veratria, the active principle of the Sabadilla seeds, was discover- ed by MM. Pelletier and Caventou, in the year 1819,* and about the same time in Germany by Meissner and Van Mons. In their subsequent investigations, the two first-named chemists detected the presence of a similar principle in the bulb of the Colchicum Aulu?n- nale, and in the root of the Veratrum Album : the substance obtained from the colchicum, however, has since been discovered by MM. Geiger and Hesse, to differ from Veratria in several important particulars, to be afterwards noticed, and they have in consequence considered it as a new principle under the name of Colchicine^ The true nature of the alcaloid extracted from the white hellebore, is still unknown ; so that the Veratria of commerce may be consi- dered as being obtained entirely from the Sabadilla seeds. Until very lately, Veratria, as obtained according to the processes employed by its discoverers, was considered to be a simple body; but from the recent investigations of M. Couerbe, it. appears to consist of four distinct substances, to which he has given the names Veratrine, Veratrin, Sabadilline, and Mono-hydrate of Sabadilline; and these are obtained separately in the following manner :—A concentrated tincture, made by digesting Sabadilla seeds with boiling alcohol, is slowly evaporated to the consistence of an extract, which is next dissolved in water acidulated with sulphuric acid, and the solution filtered, after being heated to the boiling temperature. The liquor obtained, holds dissolved in it the four substances above-mentioned, along with a quantity of colouring matter. By the addition of potass, they are all precipitated, and the precipate is to be re-dissolved in alcohol, and the tincture thus obtained is evaporated to the consis- tence of an extract, and this again dissolved in acidulated water, as before. The addition of potass to this solution, throws down a light-coloured precipitate, which, when dried, is nearly white, and constitutes the Veratria of commerce. As thus obtained, it is acrid, alcaline, and forms incrystallizable salts with acids. This substance, however, is still in an impure state, and is again to be dissolved in water acidulated with sulphuric acid. To this solution nitric acid is to be added, so as to throw down an abundant dark-coloured precipitate. The liquid is next poured cautiously off, and a solution of potass or ammonia is added, drop by drop, as long * Journal de Physique, 1819. f Journal de Pharmacie, 1834- PREPARATION OF VERATRIA. 11 as any precipitate is formed. The precipitate is next to be washed with cold water, and dissolved in alcohol, and the tincture evaporated to the consistence of an extract. By treating this extract with boiling water, the Sabadilline and Mono-hydrate of Sabadilline are taken up, and the other two prin- ciples left undissolved. The solution, on cooling, deposits the Sa- badilline in crystals, and the Mono-hydrate is obtained by slowly evaporating the remaining liquid in vacuo. The portion of the extract left undissolved by the water, is next treated with ether, which takes up the pure Veratrine, and leaves the Veratrin. The Veratria of commerce is then a very complicated substance; but as it is the only form which has yet been introduced into medi- cine, the remarks which are to follow are applicable, at least so far as we yet know, to it alone. It is prepared in the form of a fine subtile powder, varying in colour from light brown to nearly white ; it is very sparingly soluble in water, but sufficiently so to communi- cate a sensibly acrid taste to the fluid. It is very soluble in alcohol and ether. It is insoluble in alcalis, but combines readily with acids, and forms incrystallizable salts. It restores the blue colour of litmus paper, reddened by acid. When heated, it melts, and has the ap- pearance of wax ; and on cooling, presents a mass of a brownish transparent appearance. It is destitute of smell, but when brought in contact with the mu- cous membrane of the nose, it occasions violent sneezing ; when applied to the conjunctiva, it excites considerable irritation, and causes an abundant flow of tears. Its taste is extremely acrid, but destitute of bitterness. According to the experiments of MM. Magendie and Andral, Veratria acts on animals as a powerful irritant, occasioning rapid in- flammation in the lining membranes of the cavities into which it is in- troduced ; ending in tetanus and death.* There is some discrepancy, however, betwixt its effects upon the intestinal canal, as observed by M. Magendie, and those that have come under the author's ob- servation, and which shall now be noticed. Internal Administration of Veratria and its Salts. The acknowledged value of colchicum autumnale in the treat- ment of a variety of diseases, appears to have given rise to consi- derable expectations that the discovery of the active principle of the plant would be of great advantage to medicine ; and accordingly we find, that no sooner had MM. Pelletier and Caventou succeed- ed in obtaining Veratria, than a number of experiments were in- stituted, with a view to determine its action upon the animal econo- mv. These were principally conducted by MM. Andral and Ma- gendie, and agreed in proving it to be possessed of most energetic properties, and similar, though in a more exalted degree, to those * Magendie, Journal de Physiologie, torn. 1.—Formulaire. 12 Tl RNBULL ON RANUNCULACEiE. ascribed to white hellebore, sabadilla seeds, and colchicum, by Scha- bel,0rfila, Sir Everard Home, and other observers. Unfortunately, however, these properties appeared to be of such a nature as almost to preclude the possibility of Veratria ever being employed in me- dicine. From M. Andral's experiments on animals, it was proved that when applied directly to any of the tissues, it produced rapid inflammation of the part ; and that when introduced in small doses into the system, either through the medium of the veins or intes- tines, it occasioned violent vomiting and purging ; and in larger doses, tetanus and death. M. Magendie administered it internally in the human subject, and found that,in the dose of a quarter of a grain,it acted powerfully upon the intestines, and produced very copious dejections ; and he recom- mends its employment on this account, as a convenient remedy in cases requiring a speedy action upon the bowels, particularly in old men, in whom he states his having used it with much advantage ; he also advises its substitution for the preparations of colchicum, in the treatment of those diseases in which they had been employed. Such, however, was the dread inspired by the observed properties of the new alcaloid, that few practitioners ventured upon a trial of it ; and much surprise was expressed that, with these before his eyes, M. Magendie should have ventured upon such a dangerous recommendation. Veratria has hitherto been little employed internally in this country ; but where it has been used, the effects produced have been nearly similar to those already recorded by practitioners on the Continent ; and agree with them in proving it to be possessed of great activity as a purgative and emetic : so much so, indeed, that its administration appears to have been very generally abandoned, as being fraught with greater danger, from this circumstance, than could have been counterbalanced by any good effect that might have arisen from it. This was also the author's opinion at the time his work on Veratria was published ; and as the impressions he had received from the writings of others had to a certain extent been confirmed by his own experience, he considered it his duty to lay them before the public. Since then, however, he has employed pure Veratria internally to a considerable extent, in consequence of having observed that its salts produced none of those effects which had been ascribed to it, and in very few cases out of a great many in which it has been employed, even when given to the extent of four or six grains in twenty-four hours, has it produced the slightest purgative effect : it has often occasioned a degree of nausea, but this may easily be obviated by taking care that too large a dose be not given at one time. To what are we to ascribe this great discrepancy in the operation of so powerful a substance ? It may arise from one of two causes, or perhaps from both. Veratria, when first used, appears to have been obtained in part from the colchicum autumnale, and on this account differed in some material points from the alcaloid, as it is INTERNAL ADMINISTRATION OF VERATRIA, ETC. now prepared from the seeds of the Veratrurn Sabadilla : so much so, that it has been described as a new principle by MM. Geiger and Hesse, under the name of Colchicine — one of the most prominent properties of which, according to those gentlemen, is to produce violent purging and then vomiting. Two counter-experiments are related by them : in one of which a small dose of Colchicine was given to a cat: at the end of an hour it was violently purged ; vomiting next came on, and then death ; and upon examination, it was found that violent inflamma- tion had taken place in the stomach and intestinal canal, with san- guineous infiltration throughout their whole extent. The second experiment was made upon a younger cat, and a smaller dose of Veratria was administered : the animal died very speedily, but neither vomiting nor purging are mentioned as having been pro- duced : and upon examination, it was observed that the superior part of the oesophagus was the only portion of the alimentary tract where inflammation had taken place ; and it was remarked that this part had escaped injury in the animal which had been poisoned by the Colchicine.* These facts might of themselves be sufficient to account for the great difference in the observed action of Veratria above alluded to ; but it ought also to be kept in mind, that it is very probable the alcaloid, from the large quantity which has been lately brought into the market, may now be made in a state of greater purity, from that dexterity in its manufacture which prac- tice alone ean give. Whichever explanation of the circumstance may be adopted, it certainly appears that pure Veratria, or any of its salts, may be substituted for preparations of colchicum, not only with perfect safety, but with considerable advantage, provided an ordinary degree of caution be observed in its exhibition. The best form of administering it is that of pill; and the follow- ing prescription is the one I generally make use of:— R—Veratriae . . . . . . . . gr. ii. Pulv. Rad. Glycyrrh.......gr. xii. Ext. Hyoscyam . . . . . . . gr. vi. M. fiat mass, in pilul. aequal. duodecim. divid. quarum sumat unam ter in die. For the two last ingredients it will sometimes be found advan- tageous to substitute a few grains of compound rhubarb pill, espe- cially when there is a tendency to costiveness. This prescription I have found very useful in the treatment of painful spasmodic affec- tions, rheumatism, gout, &c. It has also been used in diarrhoea with considerable effect; and in this disease one pill ought to be given after each stool, until the relaxed state be removed. After a few doses have been taken, the patient generally experiences a sensation of warmth in the stomach, which extends over the abdomen, chest, and upper and lower extremities : this is succeeded by a feeling of tingling in various parts of the body, and frequently a degree of perspiration is induced. Veratria has been combined with several acids ; but the only * Jour, de Pharmacie, Mars 1834. 2* 14 TURNBULL ON RANUNCULACESE. products as yet obtained that are fit for administration, are the sul- .phate, tartrate, and acetate. According to Professor Turner, and M. Courbe, they are crvs- tallizable, when prepared (vom pure Veratria ; hut the difficulty in obtaining them in this state must, for some time at least, render it necessary to make use of the more common and more easily pre- pared form. In this condition they have, when solid, very much the appearance of resins ; they are friable, and can be reduced to a fine powder, which is of a brownish aspect. They are all very acrid when applied to the tongue, and leave a sensation of heat and tingling in the part of the mucous membrane with which they may have been brought in contact. When given in the doses to be presently mentioned, like Vera- tria itself, they in general give rise to the following effects : a sen- sation of warmth in the stomach, which gradually extends itself over the abdomen and lower part of the chest: after the dose has been repeated once or twice, the same feeling is experienced in the lower extremities, and particularly in the feet ; the upper extremities and head become also affected in the same manner : and if the medicines be pushed further, a sensation of tingling, exactly similar to that caused by frictions with Veratria ointment manifests itself in vari- ous parts of the body, and sometimes over the whole surface of the skin ; this is generally accompanied by considerable perspira- tion, and some feeling of oppression, and all these effects are aug- mented by heat, or by the use of warm diluents. To this succeeds a sensation of coldness ; and should their administration be still continued, the stomach becomes affected, and a degree of nausea takes place, followed by vomiting. In a few instances only have they acted as diuretics, and in still fewer as purgatives. No narcotic effect has been observed to arise from their use. in their action upon disease, the salts of Veratria, when given internally, are possessed of powers very similar to those exercised by the base when rubbed upon the skin. The particular diseases in which they appear to be of most service, are tic douloureux, gout, and rheumatism, especially in the two first named. In the treat- ment of these, any of the salts may be employed : but the tartrate is upon the whole to be preferred, as it is less liable than the others to give rise to irritation of the stomach ; either of them, however, may be had recourse to with safety. The best method for exhibiting them is the form of pill, made according to the following prescrip- tion : R—Tart. Veratriae.......gr. ii. Pulv. Rad. Glycyrrhiz. gr. xii. Mucilag. Acaciae.....q. s. Misce optime et divide in pilulas eequales duodecim, quarum sumat unam tertia quaque hora. The dose of the tartrate ordered above is sufficient to begin with, and it may be augmented, until the quantity given amounts to a grain and a half, or two grains in the course of the day : beyond EXTERNAL APPLICATION OF VERATRIA. 15 which it will not be necessary to push the medicine, as its peculiar effects in general show themselves before that quantity is used. Should the sulphate or acetate be preferred, the doses administered ought to be rather less, as these act more readily upon the stomach than the tartrate. M. Magendie has suggested the form of solution for the employment of the sulphate, but it is a very objectionable one, both on account of its taste, and from the disagreeable sensations left by it in the mouth and pharynx, which often are of such a na- ture as to occasion nausea and vomiting. In any case in which it may be desired to make use of the salts of Veratria, the plan that appears the best to be followed, is to adminis- ter a pill every three hours, until the sensation of heat and tingling manifests itself, and when this takes place, some alleviation of the pain will in general be observed ; but should this not be the case, the treatment ought to be persevered in, until it has had a fair trial, the dose being at the same time augmented accordingly as the pa- tient can bear it. In some instances, it has not been found necessary to continue the pills above a few days, whilst in others, a week or two has been required to produce their full effects ; and in almost every case, it has been requisite to regulate the bowels, by means of gentle aperients, to obviate the constipation which often comes on during their use. When the disease occurs in regular paroxysms, the pills ought to be resumed an hour or two before the expected time of attack. External Application of Veratria. Veratria may be applied externally, either in solution, in alcohol, or made into an ointment with hog's lard : the latter form is the one which has been most generally employed ; but where unctuous applications are objected to, an embrocation made by dissolving from ten to twenty or more grains of Veratria, in an ounce of boiling alcohol, if applied in the same manner as the ointment, will prove equally efficacious.* The ointment may be made with similar proportions of the alcaloid to an ounce of lard, and of this, a piece, the size of a large nut, may be rubbed with the hand from five to fifteen minutes, night and morning, as nearly as possible, over the seat of the disease, until relief from the urgent symptoms be expe- rienced ; care being taken to observe that the skin over which the friction is to be made, be free from injury, otherwise considerable irritation of the part will ensue : and for reasons already given, the person who applies either form, must be careful not to insert even the smallest quantity under the eyelids. M. Magendie appears to have been the first person who suggest- ed the external application of Veratria in rheumatism, gout, and anasarca ; but his proposition does not seem to have been complied * In cases where the skin is irritable, the proportions of Veratria employed, must be smaller than those now given. 16 TURNBULL ON RANUNCULACESE. with, neither does he himself appear to have been fully aware of its importance in a medicinal point of view ; and indeed, the weakness of the preparations recommended by him, even had they been made use of, must have prevented the striking effects produced upon cer- tain diseases by the Veratria, when more freely employed, from coming under his observation. • The skin over which the ointment has been rubbed, in general shows no mark of irritation, even after the friction has been conti- nued for some length of time: sometimes an evanescent blush per- vades the surface, and in rare instances a quantity of eruption has appeared upon the part, but these bear only a small proportion to the cases in which no such effects are produced. When a small quantity of the ointment is rubbed in, the patient generally experien- ces a considerable degree of warmth and tingling in the part, and until this takes place, the peculiar effects of the medicine never mani- fest themselves; the circumstance, therefore, is one worthy of atten- tion, and may serve as a criterion whereby to estimate the extent to which the friction may be carried without producing inconvenience, and also to judge of the degree of purity of the Veratria employed ; for when, as is sometimes found to.be the case, the medicine is mixed with impurities, these sensations are not produced, and its action is by no means either so certain or powerful as when it is free from adulteration. This last observation appears necessary to prevent the practitioner from laying a charge of failure against it in cases where the impure Veratria may have been made use of in compounding the prescription.* After the ointment has been applied a sufficient length of time to put the constitution completely under its influence, the feeling of heat and tingling extends itself from the place where the friction may have been made, over the whole surface of the body, and pro- duces sensations similar to those which have been already described as arising from the internal use of Veratria and its salts. The sensibility of the parts over which the application has been made, is increased so as to render them peculiarly susceptible of the presence of certain stimuli, particularly electricity or galvanism ; these agents have in some instances been applied along with the Veratria ointment, but have given rise to sensations so acute as to render their further employment almost insupportable, and that without the slightest perceptible alteration of the surface. Such are a few of the more remarkable effects resulting from the application of the Veratria to an entire surface, and in the great ma- jority of cases these will be found sufficient for every purpose which * Pure Veratria is entirely soluble in alcohol, and burns without leaving any residuum ; but, perhaps the simplest and best test is to dissolve four grains in a drachm of alcohol, and to rub a small quantity of this solution on the wrist or forehead ; when the Veratria is good, the heat and tingling manifest themselves after the friction has been continued for two or three minutes, and the length of time required to produce this effect affords a tolerably correct estimate of the effi- cacy of the medicine. EXTERNAL APPLICATION OF VERATRIA, ETC. 17 they are intended to serve : in some affections, however, in which the symptoms are more severe, or which are seated in parts only thinly covered by integuments, the attempt has been made to apply it directly to a part denuded of the cuticle, but although the effects upon the disease were much greater than when the surface remained unbroken, yet the extreme irritation which followed the practice rendered its repetition impossible. External Application of Veratria in Affections of the Heart. When any of the preparations of Sabadilla or Veratria are adminis- tered in repeated small doses by the mouth ; besides exerting their peculiar effects upon the nerves of sensation already mentioned, they act also upon the circulating system. In many instances the force and frequency of the pulse are remarkably diminished by them, and the circulation is rendered more regular; whilst in others, a contrary effect is produced. This appears to be the result of the influence exerted by the medicine on the nervous system, for it takes place chiefly in those whose nerves are easily excitable ; in some cases, also, in which organic disease of the heart has been present, the internal exhibition of one or other of the preparations has afforded the patient considerable relief, but apparently, not so much byacting upon the nervous system, as upon the kidneys, and thus removing some effusion existing in the chest, and which was the immediate cause of the aggravated symptoms. Precisely the same effects are produced, when Veratria ointment, or the tincture of Sabadilla, are rubbed over the region of the heart, though perhaps not in so great a degree. This latter method, however, of employing Veratria, is upon the whole the preferable one, as in many cases the stomach might be incommoded by the internal use of it, and in addition to its action on the heart, there is also another exerted, when it is applied to the skin, namely, the tingling, which of itself appears to have a beneficial effect, especially in nervous cases, probably by acting as a counterstimulant, whilst the quantity absorbed during the friction is sufficient to produce its other effects on the system. From the observations which I have made on the action of Veratria in affections of the heart, I have been led to conclude, that there are some cases in which the symptoms may be removed by its use, though of a class that might have been considered as indica- ting confirmed organic disease; amongst the fallowing, will be found instances of this kind, and others could have been given; these have occurred in patients in whom a gouty or rheumatic diathesis has been present, and this fact may perhaps afford some explanation of the effects of the remedy. There are, then, three states of disease, in which the ointment may be tried: namely, simple nervous palpitation; in the same affection occurring in gouty subjects; and as a diuretic in cases of organic disease, though of course in instances of this kind any 18 TURNBULL ON RANUNCULACESE. relief which it may give, can at best be only temporary; it has, nevertheless, given relief, and if it should do no good it will at least do no mischief. The application best adapted for this class of affections, consists of fifteen or twenty grains of Veratria, made into an ointment with an ounce of lard, and of this a piece the size of a nut, should be rubbed over the region of the heart for five minutes every night, and it may be continued according to the effect produced. CASE I. A lady, fifty-five years of age, was attacked seven years ago with what her medical attendants considered to be an inflammatory affection of the lungs, and for which she was profusely bled, and otherwise actively treated. The violent symptoms were by these means removed ; but there still remained a degree of weakness and affection of the chest, sufficient to confine her almost constantly to her room for nine months afterwards. Since that time, she has recovered considerably, but has been under the necessity of remain- ing in an apartment, kept at an equable temperature, during the winter; and with the prospect of being obliged to continue the same regimen for the remainder of her life. Throughout the whole seven years she has had constant cough, attended with scanty mucous expectoration: a difficulty of breath- ing so great, as to prevent her sleeping at night, or even remaining in the recumbent posture for any length of time without bringing on distressing fits of coughing: respiration very much hurried, and the lips of a purplish hue: pulse so small, rapid, and irregular, as to render it difficult to ascertain the number of its beats. Over the region of the heart, and over a great part of the anterior surface of the thorax, there was a very perceptible undulatory motion, al- together different from ordinary pulsation; and the ear, applied to the chest over the same region, distinguished the heart's action to be extended, indistinct, and undefined in character. Along the whole length of the left arm, from the shoulder to the points of the fingers, she eomplained of pain and a feeling of numbness, which rendered the extremity almost useless: this symptom had lasted about four years. There was no very marked derangement in the digestive organs. The bowels were regular, the appetite pretty good; but there existed a slight degree of flatulence, not however ^o great as to occasion much inconvenience, and there was nothing very particular in the appearance of the tongue. The patient had previously been under almost every variety of treatment, but without receiving any benefit. Upon the supposi- tion that there might be some accumulation in the bowels sufficient to aggravate the symptoms, she was directed to use aperient medi- cine for a few days, but without producing any alleviation. She was then put under the influence of small and repeated doses of the EXTERNAL APPLICATION OF VERATRIA, ETC. 19 tartrate of antimony, and along with this treatment, frictions with croton oil were applied over the chest and down the left arm, until a pretty free eruption was brought out. Under this plan the patient, for the first time from the commencement of her illness, experienced decided relief; and it should certainly have been persevered in until a fair trial had been given to it, had not such a degree of debility supervened, as to give rise to considerable doubt whether or not it could be continued with safety; the cough and difficulty of breathing had very much diminished in severity, but the pain in the arm remained unabated, and at the end of ten days she would not consent to the further employment of the remedies, and they were in consequence given up. Before the time at which this patient came under treatment, the very striking effects which the Veratria, when applied externally, exercises upon the pulse, in removing irregularities and intermissions, and in diminishing its frequency, had presented themselves to observation; and although it was not anticipated that very great benefit could arise from its use in a case so apparently hopeless, it nevertheless appeared probable that, at least, a temporary relief from the violence of the symptoms might be procured, if the medi- cine only acted upon the circulation, without inducing such a degree of general debility as had resulted from the means previously had recourse to. A piece, as large as a nut, of an ointment composed of fifteen grains of Veratria and an ounce of hog's lard, was ac- cordingly directed to be rubbed twice a-day over the chest and along the affected arm five minutes each time, and the result very far exceeded the expectations formed. The first application re- lieved the chest symptoms considerably. The cough and breath- lessness, to a certain extent, subsided, and the pulse and action of the heart were greatly improved: the most decidedly beneficial effects however were produced upon the extremity; the pain and numbness had not altogether disappeared, but these symptoms were so much alleviated,as to induce the patient to state that, comparatively speaking, she had recovered the entire use of her arm. From this time the ointment was directed to be used every evening for about ten days, and then only occasionally, as it might be found ne- cessary. In about a fortnight from the first application of the Veratria, the patient was able to leave her room and walk up and down stairs with facility; and the general improvement of her health was such, that she ventured into the open air, but in consequence of incautious exposure, the symptoms returned two or three times, though by no means with the same severity as before; and when such an occur- rence took place, one or two rubbings with the ointment afforded complete relief. She is now in comparative health; her general appearance is good, the pain and numbness of the arm have entirely disappeared, the circulation is much more regular than it has been for a great length of time, the cough and difficulty of respiration are almost gone, and she can now remain in the recumbent position, 20 TURNBULL ON RANUNCULACEsE. and enjoy a good night's rest; and the last time I saw her, she had walked about four miles without any inconvenience. CASE II. Mr. B., aged thirty-six, of sedentary habits, and by profession a banker's clerk, was seized about ten years ago, without any apparent cause, with palpitation on the left side of the thorax, which was followed by pain and a sensation of tightness and anxiety over the legion of the heart; his pulse became irregular and intermittent; his breathing, however, has not been to any great degree disturbed, and he has been able to take free exercise, and with some benefit. During the course of his illness he has had no cough, but has had occasional sighing. The digestive functions have been considerably impaired, the appetite bad, the bowels disordered, and an almost constant tendency to flatulence has been present. The. nervous system has also been for some time under much derangement, marked by tremors in the hands, irritability of temper, disturbance of the mental powers, particularly of the memory, which has suffered a good deal in its integrity ; for some time past he has experienced a disinclination for exertion, and has gone through his business more as a matter of duty than of pleasure. His sleep has been disturbed and unrefresh- ing; and he has laboured under great depression of spirits, from the belief that his complaint, from the number of remedies he had tried without advantage, was incurable. Under these circumstances, and considering from the account he had given, that to attempt a cure by the means usually employed in such cases, would only be a waste of time, and also in consequence of the success which had attended the previous trials made with the Veratria, it was determined at once to employ it in his case; and with this view he was directed to take a little opening medicine, a practice always necessary to be pursued during the time the Veratria is in use; and an ointment of the same strength as that applied in the preceding case, was ordered to be rubbed on, night and morning, over the region of the heart. As the patient lived at some distance he did not present himself again until the end of a week, when he returned to announce that he was quite well. The palpitation and nervous symptoms had entirely vanished, and he was then in the enjoyment of the best health and spirits. I have seen him once since that time, and he has not had the slightest return of his com- plaint CASE III. Mrs. L., a lady thirty-six years of age, and of a spare habit of body, residing in Bristol, has been suffering for five years from palpitation of the heart, attended by considerable difficulty of breath- EXTERNAL APPLICATION OF VERATRIA, ETC. 21 ing. She dates the commencement of her disease from a severe inflammatory affection of the chest, occasioned by cold caught during her confinement. To relieve the chest symptoms, bleeding and other antiphlogistic measures were had recourse to; but the palpitation continued to such a degree, as to render her incapable of taking any exercise without materially aggravating her symptoms. She has had many exacerbations arising from slight causes, and yet so severe as to render venesection necessary to alleviate the violent throbbing in the left side of the thorax. Her eyes are suffused, her memory impaired, and she has a considerable degree of nervous irritability. Her breathing is difficult, accompanied by slight cough and a sense of partial suffocation, along with pain across the region of the heart and down the left arm, and these feelings are materially increased by walking or any other exertion. Her pulse is irregular and quick; bowels costive; feet generally cold ; and her sleep interrupted by the palpitation. While labouring under these symptoms she was put under the influence of small doses of tartrate of antimony and blue pill; and at the same time an embrocation of croton oil was ordered to be rubbed over the chest and down the affected arm, until a free erup- tion was produced. So long as the patient continued this plan of treatment, and remained quiet, she experienced great relief; but the palpitation returned nearly as violent as ever, upon slight exertion, and she now began to complain of a degree of debility which she had not before been subject to. Under these circumstances, she was ordered to have an ointment prepared with twenty grains of Veratria to an ounce of lard, rubbed in the usual quantity over the region of the heart for five minutes night and morning; and owing to the severity of the pain in the arm, frictions with the croton oil were ordered to be made along it, until a raw surface was obtained, and over this the Veratria ointment was applied. On the night after the first application the symptoms were very much diminished in intensity, but the Veratria had occasioned a degree of heat and tingling in the arm, so great as to prevent her sleeping; the pain, however, never afterwards returned. In three or four days she began to take exercise without inconvenience; from this time she gradually improved, and at the end of three weeks left town, and returned home quite well. CASE IV. Mr. J., a clergyman, fifty years of age, has been affected with severe palpitation for the last seven years, accompanied by quickness and irregularity of the pulse, difficulty of breathing, loss of voice, cough, expectoration, and a distressing sense of anxiety ; has some- times been seized in the pulpit with giddiness, succeeded by throb- bing in the neck and confusion of intellect, and these symptoms have occasionally gone on to such an extent as to oblige him to de- Januart, 1S38.—C 3 22 TURNBULL ON RANUNCULACESE. sist from his duties for two or three months at a time : his bowels are regular, and his digestion generally good. He was ordered to take small doses of tartar emetic, and to have a blister applied over the chest; and this treatment was pursued with considerable advantage for the time, but when it was remitted he soon returned to the same state as before. As this seemed a fair case upon which to make trial of the Veratria, it was ordered to be rubbed on in the manner already described. By making use of the frictions once every night he became gradually better, and at the end of a week considered himself quite well ; he was advised, how- ever, to continue the ointment for a little longer, and then to leave it off by degrees : this was accordingly done about a year and a half ago, and he has remained ever since in excellent health, free from his old complaints, and able for the discharge of the functions of his office. CASE V. Mr. W., aged fifty-eight, has been affected for seventeen years with palpitation, which, during the last seven of that period has been attended by great difficulty of breathing, occurring in paroxysms, and coming on especially whilst taking exercise on foot. The dysp- noea at these times has been so severe, and has been accompanied by such extreme pain across the chest, as to compel him to lay hold on the nearest object for support. The pain, during the fit, extends down the left arm ; and is of such intensity, that in the words of the patient, " no language can describe it.'' For these and other symptoms he has, during the last ten years, applied to all sources for relief, and almost every possible remedy has been tried without procuring for him any ease. At the time he came under treatment, he had, besides the symptoms mentioned, a purple blush upon his face, and more particularly over his nose and lips ; his voice was weak and quivering. Upon applying the ear over the region of the heart, a tremulous, confused, irregular pul- sation was heard : the pulse was irregular and very intermittent : the left side of the chest appeared much larger than the right, and the ribs over the cardiac region seemed pushed out as if to afford a larger space for the heart's action. There was considerable disten- sion of the abdomen, along with a very evident degree of enlarge- ment on the right side, immediately under the margins of the ribs; his bowels had been for some time in a very torpid state, and re- quired active medicines to operate upon them ; the lower extremi- ties were a little swrollen, and the urine deficient in quantity. His sleep was unrefreshing,and often disturbed by fits of coughing, which generally ended in great exhaustion. As it was evident, that in a case of such severity and duration, little more could be done than merely to relieve the sufferings of the patient, by endeavouring to mitigate the symptoms as much as possible, the treatment followed was addressed to that end. A course EXTERNAL APPLICATION OF VERATRIA, ETC. 23 of medicine was prescribed, consisting of purgatives combined with antacids, for the purpose of clearing out the bowels and removing the distension of the abdomen. These means were employed alone, for about a week, and then, with the addition of a little squill to the pills previously ordered, it was persevered in for a fortnight longer; at the end of which time he felt considerably better. The swelling in the legs had diminished, the digestion was improved,.and, alto°-e- gether, he was in a more favourable state pf health than before. During the previous treatment of this case, counter-irritation, by means of blisters, issues, tartar emetic ointment, &c, had been freely employed, and with so little effect, further than bringing about a temporary alleviation, that the patient would, on no account, consent to their repetition now, and he was therefore recommended to make use of the Veratria ointment, but certainly without any great expec- tations of its producing a beneficial effect. An ointment of the usual proportions was ordered to be rubbed, for five minutes, night and morning, over the region of the heart ; and, in the course of three days, the feeling of pain and constriction across the chest had disappeared. As the pain in the left arm still remained, he was ordered to use frictions with the ointment to it also, and almost, immediate relief from that symptom followed the application. In the course of a fortnight from the time the Veratria was had recourse to, the most decidedly beneficial effects had been produced upon the disease : the pulse and action of the heart had become much more regular and natural, the difficulty of breathing had very much diminished, the complexion was completely changed, and exhibited signs of an unimpeded circulation: and this improve- ment went on gradually, under the occasional use of the ointment, along with a little medicine to act upon the bowels, so that, in about six weeks he could walk about, and go up and down stairs without inconvenience. As this case was one in which a cure could not be expected, the patient was left to himself with directions to rub the ointment whenever a return of pain or uneasiness rendered its employment necessary. This, he accordingly does, and by its means, is enabled to pursue his avocations with ease and comfort. Before taking leave of this case it is proper to state, that it was one of those in which the Veratria exerted its peculiar diuretic effects ; for, during the first week it was used, no less than six pints of urine a day were evacuated by the patient. CASE VI. Mrs. C, a lady betwixt fifty and sixty years of age, has been ill about nine years. During the first three she suffered from dyspepsia and irregularity of the bowels, and, for six years, she has been affec- ted with almost constant palpitation and difficulty of breathing ; which symptoms she describes as having been on the increase, until at last she was obliged to confine herself to one floor of the house, 24 TURNBULL ON RANUNCULACEsE. from inability to ascend or descend the stairs, and to refrain from walking, under the impression that the exertion might prove fatal. She has violent pulsation over the region of the heart, along with an irregular and intermittent pulse, and complains, at times, of severe pain across the chest, and stretching down the left arm : her lips arc of a purplish colour ; her eyes dull ; her countenance sallow ; and she labours under considerable nervous irritability, accompanied by impairment of the memory ! she has a degree of fulness in the right side, under the margin of the ribs, and her feet are generally cold, and a little swollen. For these symptoms she had previously been treated by bleeding, blistering, purgatives, and indeed, every thing possible appeared to have been done, without procuring any abate- ment of the disease. From the disordered state in which the digestive organs evident- ly were, she was put under a plan of treatment similar to the one pursued in the preceding case, for about three weeks, but no diminu- tion of the symptoms took place; and then the Veratria ointment of the usual strength, was ordered to be rubbed over the left side of the chest, and down the arm, every night. The first application afforded great relief to the palpitation and difficulty of breathing, and the pain in the arm was also considerably alleviated. In the course of a few days all the symptoms were nearly gone; the oint- ment was, however, directed to be applied occasionally, for about a month : and at the end of that time, the patient could walk with ease, three miles at a time, and returned home quite well, and has had no return of the disease since. CASE VII. The following case is given for the purpose of showing the effect which the Veratria has upon the circulation, in a disease attended by symptoms of great development of the heart's action, occasioned by simple hypertrophy of the walls of fthe left ventricle. Every one must have remarked the difficulty which there exists of modera- ting the pulsation of the heart and arteries, in this disease, and that, in consequence, it is no easy matter to procure even a temporary relief from the distressing sensations experienced by those who are affected by it. The cases of this kind, in which the ointment has been resorted to, are not sufficiently numerous to warrant the as- sertion, that decidedly beneficial effects will result from its applica- tion in every instance; but it will, nevertheless, be allowed, that the subject is worthy of attention, from the fact of its having al- ready proved successful in doing so. Mrs. S., a lady about sixty years of age, has, during the last five years, suffered much from violent beating of the heart, attended by strong pulsation in the neck, throbbing and giddiness in the head, and a continued whizzing noise in the left ear, along with feelings of anxiety, and considerable nervous irritability. INTERNAL APPLICATION OF VERATRIA, ETC. 25 The action of the heart is strong, constant, and concentrated in a .pace over the situation of the apex, and communicates a powerful impulse to any thing placed on it; the pulse is very full, throbbing, and, incompressible; the carotid arteries beat violently, and the patient complains much of the noise in her ear, and of giddiness- she has also confusion of ideas, and a feeling of heat and fulness in trie head. She has considerable anxiety, and her sleep is interrupted by palpitation. There is some pain in the region of the heart • and all these symptoms are materially augmented by exertion ; but'this from the sensation of lassitude which she almost constantly labours under, cannot be made to any great extent. The bowels are generally costive, and require the employment ol active purgatives, which are the only medicines capable of re- moving the uneasy feelings of the patient, to any degree; the digestive functions are very active, and the appetite preternaturallyVeat She complains neither of difficulty of breathing, cough, nor pain in the arm. In the previous treatment of this case nothing had been found useful, and as it did not appear that any bad consequence could ar-se from the external application of the Veratria, it was ordered to be rubbed over the region of the heart, in the usual manner, after purgatives had been administered, for a few days to regulate the bowels. ' After the first or second friction with the ointment, all the symptoms were materially diminished in intensity; the palpitation had greatly subsided ; the pulse had become much softer and weaker; the anxiety, the pulsation in the head, the feeling of giddiness, the confusion of intellect, and the sensation of whizzing in the ear had all disappeared, and the general health and appearance of the pa'tient were much improved ; but still some of the symptoms remained, not, however, to such a degree as to occasion inconvenience, and she is now in a comfortable state, and able to follow her household em- ployments ; though exertion, to any great extent, cannot be used without aggravating her complaints. From the manifest benefit experienced from the Veratria ointment, she uses it herself when- ever, from any cause, an increase in the symptoms takes place, and with the effect of procuring immediate relief. CASE VIII. A gentleman, aged about sixty, of a weak constitution, of seden- tary habits, and given to mental occupations, has laboured, for seven years, under slight palpitation, accompanied by feelings of anxiety and general languor, coming on at intervals, and increased by exer- tion ; his pulse is feeble, rapid, and intermitting; palpitation over the lower part of the left side, not excessive, but attended with a painful sensation in the region of the heart, which is so augmented by walking, especially against the wind, as to compel him to stop and support himself on the nearest object. Respiration generallv 3* 26 TURNBULL ON RANUNCULACESE. unimpeded, except under these circumstances. The circulation in this patient is peculiarly languid, the face pallid, and the surface of the body cold. The nervous system is easily excitable, and he finds that continued exertion of mind very much aggravates all his symptoms. Appetite good, digestion easy, but occasonially ac- companied by flatulence; bowels rather costive. In the previous treatment of this case the same measures were employed as in those already related, but without the least effect. He was ordered to take a little opening medicine for a week, and then to apply the Veratria ointment over the region of the heart as usual. On the night after the first friction had been used, the patient got no rest in bed from the excessive nervous irritation which it had given rise to; his feelings of anxiety, and palpitation were so much augmented, that he would on no account repeat the application: these symptoms continued unabated for two days, at the end of which however the disease began to decline, and went on afterwards to do so until every vestige of it had disappeared, although no curative means whatever had been employed after the first application of the Veratria; and he still continues well. CASE IX. A lady, about sixty years of age, was seized with a fit of fainting about sixteen years ago, in which she continued for an hour and a half, and ever since that occurrence she has been affected with pal- pitation of the heart, accompanied by frequent returns of the syn- cope. She now complains of palpitation, and difficulty of respiration, along with deep sighing, occasioned by a sensation of constriction, which she describes as extending over the chest, but unattended by cough ; and the angles of the mouth are slightly bluish in appearance. The action of the heart is violent and irregular, and she complains of oppression and weight over the lower part of the left side of the thorax. The pulse is intermittent and irregular, and does not at all times correspond with the intensity of the heart's pulsations. She complains of occasional shooting pains in the arm, reaching to the points of the fingers; she is sometimes nervous, and low-spirited, and at intervals nearly free from all those symptoms; but not for any length of time, for they return again from very slight causes. The appetite in this patient is at all times pretty good, but the digestion is not performed with a corresponding degree of facility, which renders a careful selection of the articles of diet, as well as attention to their quantity, necessary; and notwithstanding that these precautions are attended to, there is considerable flatulence and pain in the stomach during the process. The bowels are habitually costive, and require the employment of active purgatives from time to time, to keep them easy; and the lower extremities are generally cold. Almost every form of treatment that could be devised, had in EXTERNAL APPLICATION OF VERATRIA, ETC. 27 this case^been resorted to, during the long continuance of the disease; but the palpitations and faintings never ceased, although trie general health by great care had been preserved tolerably good. 10 relieve the disordered state of the stomach and bowels, the patient was now directed to take opening medicine, combined with antacids, along with small doses of blue pill, for a week; and by these means the dyspeptic symptoms were, to a certain extent, removed, but the affection of the heart still remained nearly as violent as ever. The Veratria ointment was then prescribed of the usual strength, and ordered to be rubbed every night over the left side of the thorax. She did not return till the end of a week from this time, and from her own account, as well as from examination, she then appeared very much better. During the interval the palpitation and syncope had been much relieved, and indeed the latter had not returned. The feeling of tightness and oppression was quite gone; the pulse was materially improved in character, but still rather irregular. She was directed to persevere in the application of the ointment; her health and appearance became gradually amended, and at the end of a month from the time at which the Veratria was had recourse to, she was quite well. External Application of Veratria in Neuralgic Affections. In no class of diseases have the beneficial effects of the Veratria ointment been more strikingly manifested than in that which it is now proposed to bring under consideration ; for in none are the symptoms productive of more distress to the patients, and by no other means can the same degree of relief be afforded in so short a period. The external application of the Veratria has been made use of in neuralgic affections situated in every part of the body ; it is, how- ever, in tic-douloureux that the most remarkable and speedy change is effected in the state of the patient, for sometimes during the continuance of the first friction the paroxysm is brought to a termination, and does not again return ; and if this be not the case, the following interval is at least of greater length than any that may have previously occurred, and the next accession of pain is less severe, and more easily removed. The principal considerations to be attended to in the employ- ment of Veratria in tic-douloureux are connected with the part of the face, and the extent of surface, in the which the pain is situated, and the length of time the patient has laboured under the disease. With regard to the first of these, it has been found that in cases where the affection is not confined to one particular point, but has extended itself along the ramifications of the nerve in which it has its seat, the symptoms may be removed much more speedily, and by means of an ointment containing a smaller quantity of the Vera- tria than when the contrary is the case ; and this probably arises from the circumstance of their intensity in such instances being 28 TURNBULL ON RANUNCULACEsE. much less, and from the surface under which the disease is actually situated being greater than where one spot only is affected, thereby affording an opportunity of making the application over a number of affected points at the same time. In cases, too, of long duration, there is more difficulty experi- enced in performing a complete cure, than in those of a more recent date ; but this does not appear to arise from the ointment having less power in removing the existing paroxysm in these instances than in others, for it almost always affords immediate relief, but from the habit of recurrence at stated intervals which its previous long continuance seems to have impressed upon the disease : even this, however, may be broken through by a little perseverance ; and a recovery be effected, if not. as quickly, at least as certainly, as in less obstinate cases. For those forms of the disease which have been characterised as occupying the branches of the affected nerve, an ointment, made with twenty grains of Veratria to an ounce of lard, must be rubbed during the paroxysm, over the whole seat of the pain for fifteen or twenty minutes, or what is better, until the heat and tingling caused by the friction have been so great as to produce an impression on the feelings of the patient equal to that arising from the disease itself;* and when such an effect has been brought about, the fric- tion may be discontinued for a short time, to allow the irritation occasioned by it to subside, so as to enable the patient to form a judgment of the relative intensity of the pain now, compared with what it was before the ointment was had recourse to. In many instances the paroxysm will be found to have been cut short; but if any degree of uneasiness remain, the part must be again rubbed with the ointment until the peculiar sensations arising from its use again show themselves, and this second application will, in general, be succeeded by a remission of the pain. Should an instance, however, occur of such obstinacy as to resist this repetition, the patient should still persevere, until the paroxysm be subdued. In the great majority of cases to which this form of treatment has been applied, the removal of the paroxysm has been readily effect- ed ; and those in which a continuance of the friction, in the manner now recommended, is found necessary, are almost without excep- tion cases in which the affection has been confined to one point. For the purpose of obtaining the full effect of the Veratria as soon as possible in such instances, it has been used in the proportion of forty grains to an ounce of lard, and this may be done either from the very beginning of the treatment, or the quantity of the alcaloid may be augmented by five grains in each prescription until it attain to that amount. The former method is upon the whole to be pre- ferred, because by it an immediate check is put upon the paroxysm in severe cases, without the necessity of continuing for a length of time the employment of weaker applications. * Tt is of the greatest importance to attend to this caution, as the ointment has, no effect whatever in removing the disease unless these sensations are induced. EXTERNAL APPLICATION OF VERATRIA, ETC. 29 It may not be out of place to repeat here the caution already given, against allowing even the most minute quantity of the Veratria to come into contact with the conjunctiva, an accident which may easily happen during the application of the ointment in affections situated in the face ; as such a circumstance, although it may not be fol- lowed by danger, is nevertheless productive of so much irritation as to make it an object to guard against its occurrence. The general instructions which have now been given regarding the plan to be pursued in the treatment of tic-douloureux, are equally applicable to cases of neuralgia, situated in other parts of the body. These last, however, are not so difficult of removal ; and do not, so far as has been hitherto observed, require the ointment made use of to contain more than twenty grains to an ounce of lard. There is a form of this affection occurring in the loins, and extending down the thighs of women during the men- strual period, in which the application of the Veratria is found of great service, as affording an easy and expeditious means of re- moving it. CASE I. A lady, fifty-five years of age, has been affected for the last thirty-six years with tic-douloureux in the cheek, and in the fore- head above the eyebrow on the left side. From the commence- ment of the disease, she has had a paroxysm generally once a week, and at no time does she remember the interval to have been greater than fourteen days. Her sufferings during the continuance of the attack have been extreme, and have compelled her to confine her- self to bed until its termination, and it has never lasted a shorter time than two days. In the intervals, however, she has been per- fectly free from pain, and her general health has all along been tolerably good. It appeared from the history of the case given by the patient, that throughout the long course the disease had already run, almost every kind of medical treatment had been put in practice without giving rise to any permanently good resultj; and in consequence of this cir- cumstance, and as the symptoms appeared to admit of nothing*but slight alleviation, if even that could be procured, she was ordered to keep the bowels open by the use of an aperient pill, and at the com- mencement of every paroxysm to take a small dose of acetate of morphia, and to repeat it every hour until the pain abated. She persevered in these means for two months, and experienced con- siderable relief ; but although the violence of the symptoms was moderated, neither any diminution of the length of the attack, nor anv change in the duration of the interval, could be observed. Under these circumstances, and as the general health of the pa- tient was beginning to suffer from the employment of the morphia, it was ordered to be discontinued ; and she was directed to take small doses of strychnia, for the purpose of removing, if possible, a 30 TURNBULL ON RANUNCULACEsE. paralytic affection of the levator muscle of the upper eyelid, and of the left side of the face, which had come on during the previous ex- istence of the disease. This course was persevered in, until the convulsive twitchings, brought on by the medicine, became as strong as the patient could bear them, but without producing any effect upon the paralysis. Her health was now much weaker, but her sufferings continued unabated ; and as it became a duty to call into use any means which might afford even the slightest prospeet of relieving the violence of the pain, she was directed, after the manner already stated, to rub over the forehead and on the side of the face, a por- tion of ointment, made with twenty grains of Veratria to an ounce of lard, till every uneasy sensation was gone. In about fifteen minutes this effect was produced ; but the paroxysm again made its appearance within two hours, and by a renewal of the friction for a few minutes it was again extinguished, instead of continuing two days, as usual. To this there succeeded an interval of perfect ease for ten days, when the attack again returned, but not by any means so violently as before. On this occasion the same plan was pursued as in the preceding paroxysm, and the relief afforded was still more marked, for the pain was entirely removed by the first application. From this time the patient had only one or two very slight accessions, but these were at once cut short by the use of the ointment for a few minutes, and the disease entirely left her. Not the least remarkable circumstance in this case was the change which took place upon the paralysis, for immediately after the first friction had been made use of, it was observed to have diminished considerably ; and by the time the patient was cured of the tic- douloureux, it had disappeared, and has not since in any degree returned. CASE II. Mr. C, aged forty, has laboured for sixteen years under tic-dou- loureux over the right side of the face and forehead, but particularly along the lower jaw as far as the mesial line, where it terminated ; and when the paroxysms were severe, the pain also extended itself to the same side of the tongue. During the whole course of the disease, this patient has hardly ever been free from pain ; and when an interval of ease did take place, his sufferings were renewed by the slightest causes, and more especially by mastication, which seldom failed to bring on an accession : his general health and appe- tite have been good, so much so, that he has frequently brought on an attack by inattention to proper rules for regulating his diet and regimen. In the previous management of this case, under the supposition that the pain might depend upon decayed teeth, the patient had had several extracted without affording any relief. He was then EXTERNAL APPLICATION OF VERATRIA, ETC. 31 bled, generally and locally ; blisters and embrocations were repeat- edly employed, but still no abatement in the severity of the symp- toms took place. Along with these means he had also used large doses of carbonate of iron, arsenic, mercury, opium, morphia, sul- phate of quinine, nux vomica, &c, without effect ; and when he came under treatment, he had been taking prussic acid in a quantity sufficient to affect the nervous system, and with as little success as from the measures which had before been resorted to. As it appeared, from the history of the case, that the patient had been in the habit of indulging his appetite for food and drink to a considerable degree, and as his digestive organs appeared somewhat deranged, he was directed to take small doses of blue pill with Epsom salts ; and along with these means the Veratria ointment was prescibed, of the same strength as in the preceding instance ; and from the fact of there being no distinct interval observable betwixt the paroxysms, he was directed to rub it over the seat of the pain twice a day, and to renew the friction at any other time should the attack come on. In the course of four or five days he returned very much improved in every way. His general health appeared better ; the disease had been greatly relieved, for instead of being almost always pre- sent, as had been the case for so long a time, it had been broken up into distinct accessions, and these were attended with comparatively little pain : he was therefore directed to discontinue the regular application of the ointment, and to employ it only when threatened with a renewal of the paroxysm : soon after this, he gave up the use of the internal medicines which had been prescribed for him, and he went on gradually improving under the influence of the Veratria alone ; the intervals became longer, and the fits less and less painful, until at the end of four weeks from the time he came under treatment, he returned home perfectly free from pain, and I believe has been so ever since. CASE III. A lady, forty-eight years of age, has been affected with severe tic-douloureux, situated in the middle of the left side of the face, for a period of twenty-two years. She has made use of every possible medicine, particularly of carbonate of iron, which she had taken for three months in very large doses, but without experienc- ing any benefit. The paroxysms are irregular in their duration, but never shorter than twelve hours, and they return generally at the end of three days, sometimes at the end of a week, but seldom longer ; and during the interval she is not altogether free from pain. A short time before this patient came under treatment she had an attack of paralysis ; from which, however, she had recovered, with the exception of a slight palsied appearance of the countenance. There were no very marked symptoms of derangement in the diges- 32 TURNBULL ON RANUNCULACEsE. five organs, but it was thought advisable to put her under a course of medicine for a few days, similar to that made use of in the last case ; and the Veratria ointment, of the same strength, was ordered to be rubbed on in the usual manner when the next paroxysm occurred. This was accordingly done ; and after the friction had been continued for a quarter of an hour, the pain ceased entirely, and never came on afterwards in the shape of a regular attack. During five weeks from this date, the disease appeared occasion- ally in the form of slight twinges of pain in the part previously affected, but these were at once removed by rubbing on a little of the ointment, and at length completely disappeared. CASE IV. A lady, about thirty-five years of age, has suffered most severely and almost without intermission for the last eighteen months, from tic-douloureux in the cheek and side of the forehead. She has, during all that time, been put under the effects of nearly every variety of medical treatment that could be suggested, without pro- ducing any effect whatever upon the disease ; and the only remedy which has in any degree alleviated her sufferings is galvanism, but this also has failed in producing any permanent benefit. This patient appeared to enjoy very good health : so that, with- out any other treatment being put in practice, it was determined upon at once to try the effects of the Veratria ointment. She was therefore ordered to rub over the affected part in the usual manner an ointment made with twenty grains of Veratria to an ounce of lard, which she accordingly did, and in ten minutes from the com- mencement of the friction, every vestige of the pain had disappeared, and it has never since returned. CASE V. A lady, twenty-five years of age, has been for the last seven years affected with severe tic-douloureux, confined to one point, exactly in the situation of the supra orbitary foramen of the right side. The paroxysms have varied in duration, from sixteen hours to two days ; and intervals, extending from ten days to three weeks, but never longer, have intervened between the attacks of pain, and these, when short, have generally been followed by a recurrence of the symptoms in two or three days. In this, as in the preceding cases, almost every means of cure appeared to have been already had recourse to, but, as usual, with- out procuring any permanent alleviation of the sufferings of the patient, except that small doses of acetate of morphia administered during the paroxysm, sometimes caused an immediate cessation ; but it was attended with this inconvenience, that if it did not pro- EXTERNAL APPLICATION OF VERATRIA, ETC. 33 duce the desired effect, all the symptoms were immediately aggra- vated to a great degree. The digestive functions in this patient appeared to be considera- bly impaired, her circulation languid, and her extremities cold, especially during the attack. On these accounts she was put under a course of laxatives, combined with blue pill, for about a week, which was the means of removing these symptoms, but without producing any change on the disease itself. As it appeared that carbonate of iron was almost the only medicine which she had not previously made use of, it was prescribed in pretty large doses, and persevered in until it evidently appeared to exercise no effect what- ever upon the symptoms ; it was then given up, and about six weeks afterwards the Veratria was applied. At the commencement of one of the accessions, she rubbed over the eyebrow and forehead of the affected side, part of an ointment made with twenty grains of the Veratria to an ounce of lard ; and after the friction had been continued in the usual manner for about twenty minutes, the paroxysm was cut short. During the interval she was directed to apply, in the same way, an ointment made with morphia and hog's lard, in the same proportions as the pther, twice a day, in order to prevent a return of the attack, but without pro- ducing the intended effect, for it again made its appearance in ten days. With the view of making a decided impression at once upon the disease, an ounce of ointment containing forty grains of Veratria was ordered to be employed as before, whenever a new accession of the pain took place ; and in a few minutes after its first application, there followed a great increase of the symptoms, which continued for about two hours, and then subsided, leaving no trace of the affec- tion behind, neither has any renewal of it taken place.* CASE VI. A lady, aged twenty-six years, who has been subject to occasional attacks of hysteria since her fifteenth year, has also since that period suffered from tic-douleureux, situated in the left eyebrow and extend- in