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LECTURES
THEORY AND PRACTICE
PHYSIC.
BY WILLIAM STOKES, M.D.,
LECTURER AT THE MEDICAL SCHOOL, PARK STREET, DUBLIN; PHYSICIAN TO
THE MEATH HOSPITAL, ETC., ETC.
AND
BY JOHN BE
LL,
M.D.,
LECTURER ON MATERIA MEDICA AND THERAPEUTICS ; FELLOW OF THE COLLEGE
OF PHYSICIANS OF PHILADELPHIA;
CORRESPONDING SECRETARY OF THE PHILADELPHIA MEDICAL COLLEGE;
MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, AND OF THE GEORGOFILI
SOCIETY OF FLORENCE, ETC., ETC.
SECOND EDITION
IN TWO VOLUMES.
VOL. I.
Pfulafoelphfa:
ED. BARRINGTON & GEO. D. HASWELL.
NEW YORK —J. Sc H.G. LANGLEY: CHARLESTON, S. C.-WM. H. BERRETT.
RICHMOND, VA. — SMITH, DRINKER, AND MORRIS.
LOUISVILLE, KY.- J AMES MAXWELL, JR.
1842.
•*rV*
\
[Entered, according to act of Congress, in the year 1842, by Barrington and
Haswell, in the clerk's office of the district court for the eastern district of Penn-
sylvania.]
WB
5WZ.
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PREFACE
TO THE SECOND EDITION.
It was not without some misgivings that I undertook, two years
ago, tcvedit the Lectures of Doctor Stokes,— fearing that my addi-
tions might not enhance the value of this gentleman's labours, and
knowing that adequate scope was not allowed me for separate
efforts. The rapid ^ale of a large edition of our joint work has,
however, reassured me on these points, while it has imparted fresh
desire to contribute a fuller share on my part than was required of
me on the former occasion. In order to preserve a harmony, in
one respect at least, between theJBritish and American portions of
the present edition, I have continued the lecture style throughout.
By the large additions which it has received, the work is now
made to assume the character of a System of Medicine more than
heretofore; at least, the circle of the most important and violent
diseases, those which constitute the chief outlet to human life, is in
a great measure complete. It consists at present of the following
classes of diseases: — I. The Digestive System; II. The Biliary Ap-
paratus ; III. The Spleen and Pancreas; IV. The Urinary Appa-
ratus ; V. The Respiratory Apparatus ; VI. The Heart; VII. The
Nervous System ; VIII. Fevers. Of these classes, the third, fourth,
fifth, and sixth, are contributed for the first time, and constitute
large and material improvements in the present edition. To the
first class, or the Diseases of the Digestive System, my additions,
both on the score of number and detail, have been considerable.
It may, perhaps, be alleged, that to one of these, Epidemic Cholera, I
have allowed disproportionate space; but,if the extent of its range—
diffusion over the whole earth, its mortality — equal to the destruc-
tion of millions in a few years, the suddenness of its invasion, and the
rapidity of its progress, leaving often little time for study or counsel,
be considered ; and if, also, we bear in mind the fact, that, numerous
as have been the separate publications on this dread malady, there is
no one to which we can refer for anything like a complete history
of its pathology and medical treatment, or of the hygienic con-
siderations of cause and prophylaxis, it will, I hope, be conceded
that the task which I have attempted, however imperfectly exe-
cuted, was becoming the requirements of the case. The disease
may again appear among us, and it will be, of course, desirable
IV PREFACE.
that the practitioner called upon, in the emergency, should b P^
prised of his true position, as regards the benefit which ma>
expected from any remedy or particular plan of treatment.
not encouraged by the success of his predecessors, it will be "is
duty not to repeat their vain trials, and not to expose himselt to
their failures by the same mistakes and deficiencies.
In preparing the lectures on the Diseases of the Respiratory
System, I have incorporated much valuable matter derived from the
work of Dr. Stokes on the Diagnosis and Treatment of Diseases of
the Chest, besides that which appears in a lecture form, as directly
from him, but, also, taken from the work just mentioned. On this
last point, an explanation, if not apology, is due to Dr. Stokes, — not
for any change of his language or train of argument; for the text,
with the exception of a few words, has not been altered, but for my
arranging in quasi lectures some of the matter which he published in
a volume, without his having previously presented it in this shape.
The only difference, however, between the originally printed matter
and that which I have introduced formally as from Dr. Stokes, is in
its receiving the division and headings of lectures. Perhaps less
objection will be found with this innovation, as there was not even a
division into chapters in the work on Diagnosis and Treatment of
the Diseases of the Chest.
The class of Fevers has not been treated so much in extenso as
precedent would have warranted; but by withholding common-
place literature, and the mystical disquisitions of the past age,
without, however, yielding too much to the arithmetical affectation
of the present, and by steadily bearing in mind the wants and ex-
pectations of the American practitioner for information respecting
the fevers of the United States and analogous climates, rather than
those of European hospitals, camps, and jails, less disappointment
will, it is hoped, be felt at my abbreviations on this head. I have
curtailed "to some extent my former lectures on Congestive Fever,
but have still retained those distinctive features which imparted to
them that interest in the minds of the physicians of the South and
West, which I was sanguine enough to anticipate when I first took
up the subject. Let me, in conclusion, exhort them to send back to
us in the city, in return for our issues, full and carefully prepared his-
tories of their fevers; for a complete elucidation of the nature and
treatment of which they must not look to the hospital statistics nor
collegiate teaching of Europe, without the aid which it is in their
power so amply to supply.
JOHN BELL.
CONTENTS OF VOL. I.
LECTURE I.
General Observations................page 13
LECTURE II.
DISEASES OF THE DIGESTIVE SYSTEM.
General remarks on local diseases — Fixed rules for the guidance of students—
Great importance of diagnosis — Existence of pure fever rare — Doctrine of
the Humoralists and of the Brownists — Pathology of the digestive system . 25
LECTURE III.
DR. BELL.
Diseases of the Mouth and Pharynx. — Connexion in structure and function
between them and diseases of the stomach and bowels — Stomatitis — its
different species—Simple erythematic stomatitis — Its nature, causes, and
treatment—Follicular or aphthous stomatitis — Its varieties, complications
pathology, analogous to follicular gastritis and enteritis — Connexion with
dyspepsy in adults, and in children with cholera and diarrhoea —Remedies,
general and local — Importance of hygienic measures — Ulcerous stomatitis —
Pultaceous stomatitis, or muguet — Its pathology—Treatment. . . . 35
LECTURE IV.
DR. BELL.
Pseudo-membranous Stomatitis. - Its amplications with viWaHisea^-
insidious anoroach — Pathology— sometimes prevails epidemica Jy — Treat-
insidious approacn r gj diffestive system and degree of local excite-
men , modified by *£^ * ™^& properly applying mineral acids and
ment — Local aPP'"*™11* ~"1 _ Iodin/topically and interna ly _ Warm
^l^^SZ^S^As a'rfsult'of Stherimds of stomal, and as
fseparate disease- Different opinions as to its violence and danger-Two
♦acres of gangrene of the mouth —Its pathology—common origin in the gums
Treatment, general and local — Emetics, tonics, and the warm bath and
T- tions — Iodine — Topical remedies — numerous — The chief one is sul-
fate of copper;...................45
v yOU !•--l
2
CONTENTS.
LECTURE V.
DR. BELL.
Glossitis — Its varieties and causes —Symptoms — Termination — D*^="°S'Si
Treatment — Importance of scarifications — Symptomatic or Becon""*y
sitis — Treatment modified by the nature of the primary disease. — r ak
-Primary-Supposed contagion of-Terminations-Metastasis to otner
organs —Treatment—Secondary or symptomatic parotitis— mat cause y
mercury, —its treatment. - Diseases of Dentition-Predisposition to nu-
merous diseases in early infancy — Causes besides dentition— ine SUk- P
bility of the organs of the child, and peculiar exposure to external agenw
Sympathies of the dental apparatus — Direct and remote — Treatment aunng
dentition — hygienic and medicinal — The measures chiefly demanded . p. oo
LECTURE VI.
DR. BELL.
Diseases of the Throat.—Their various origins and complications. Retro-
pharyngeal phlegmon—Difficulty of diagnosis, and danger of this inflammation
—Cases.—Angina simplex—Its causes, symptoms, and treatment—Sometimes
associated with typhoid fever.—Chronic angina—Inflammation sometimes lo-
cated in the uvula, sometimes in the palate—Treatment of the same.—Tonsil-
litis—Most common in young subjects—Symptoms, duration, treatment—
Importance of bloodletting—Purging—Gargles.—Chronic Tonsillitis—In-
convenience and even danger in this disease—An indirect cause of spinal cur-
vature—Treatment, local and general; by caustics and inunction and internal
remedies—Diseased follicles of the tonsils—Morbid secretion,—how distin-
guished from tuberculous matter—Morbid states of hearing and deafness
caused by enlarged tonsils, and diseased mucous membrane of the throat—
Voice and speech modified from similar cause—Change of voice after extirpa-
tion of tonsils ....................71
LECTURE VII.
DR. BELL.
Angina Membranacea—The simple and the malignant varieties—Malignant
angina, or diphtheritis—Earlier notices of it—Causes—Connexion witlTscar-
latina—Persons most liable—Epidemical and endemical, and sometimes spo-
radic—Symptoms—Diagnosis—Its anatomical characters—Membranous exu-
dation—Is sometimes ulcerous and gangrenous—Prognosis—\oe, temperament,
particular exposure and lodging modify result. — Treatment—Bloodletting
sometimes admissible—Emetics—Revulsives— Stimulants—Calomel—Blisters
under what indications required-Topical treatment—Stress kid on it in ma-
hgnant angina-Chief articles employed-Summary of treatment in some of
the worst cases marked by suddenness of invasion and prostration of the powers
LECTURE VIII.
Pathology and treatment of diseases of the digestive svstem n;m^„ «. c c
gastritis- Pathology of this disease imperfectly uSj by^e fnS?
Gastritisandenteritisjiotalwaysfound in connection-Phenomena character^™
acute gastritis - Symptoms and sympathetic relations — Diagnosis — Gastr "A
simulating other diseases .,,...... ° # 'on
CONTENTS.
3
LECTURE IX.
Gastritis—No one symptom decidedly indicative of the particular condition ot
any organ—Sympathetic irritation liable to terminate in organic disease—
Sympathetic relations as connected with the viscera of the thorax—Treatment
of simple acute gastritis—Antiphlogistic remedies—Purgative medicines inju-
rious—Enemas and injections—Use of ice beneficial—Effervescing medicine
hurtful..................... p. Ill
LECTURE X.
Pathology and Treatment of Gastritis—Application of blisters—Emetics can
be seldom used in acute gastritis—Haematemesis and delirium tremens com-
plicated with gastritis—Treatment of these affections—Dyspepsia, or chronic
gastritis—Hypochondriasis.—Termination of chronic gastritis .... 120
LECTURE XI.
Treatment of Chronic Gastritis.—Frequent excitementof the vascular system
necessary to the performance of the functions of the stomach — Local bleeding
— Regimen — Counter-irritation over the stomach — Treatment of Broussais
— Use of. vegetable tonics — Oxide of bismuth — Acetate of morphia . 129
Friction with croton oil — Attention to diet during convalescence — Organic dis-
ease of the stomach — Principles of treatment — Diet and attention to the
bowels—Duodenitis — Inflammation of the jejunum.......137
LECTURE XII.
DR. BELL.
Dyspepsia.—Temperaments and constitutions most liable to the disease—Habits
of life inducing it—Concomitant diseases—of brain, liver, skin, lungs, and
kidney—These are sometimes causes, sometimes effects of dyspepsia—A complex
disease, sometimes caused by, sometimes causing spinal irritation—Modifica-
tion of treatment required—Andral's case and reflexions—Dr. Chapman's
notice of chief causes—Tobacco, its injurious tendency and effects—High ex-
citement of brain in England and United States.—Dyspepsia with Morbid
Gastric Secretion—Pyrosis or Waler-Brash—Its causes and treatment.—
Cardialgia,—its mixed nature and treatment—Mercury—Ipecacuanha—Sul-
phuret of potassa—Gunpowder..............142
LECTURE XIII.
DR. BELL.
C astrodynia, or Gastralgia—Its symptoms—Diagnosis—Causes—Treatment—
Hyienic means the first to be attended to—Alleviation of pain—Caution respect-
incrstimulants—Draughts of hot water—Blending of gastritis and gastralgia—
Hydrocyanic acid—colchicum—emetic tartar in small doses—oil of turpentine
—subnitrate 0f bismuth—oxide of zinc—subcarbonate of iron—carbonated
chalvbeate waters—nitrate of silver.—Periodical gastrodynia requires sul-
nhate of quinia—Danger of alcoholic stimulants—Superiority of water as a
drink__Attention to the lower bowels—The kind of food proper—Regulation
of the cutaneous functions—Mental habits to be studied—Change of scene
and travel.....................154
4
CONTENTS.
LECTURE XIV.
DR. BELL.
Gastro-duodenal Dyspepsia—Relations of the duodenum—Varieties of duo-
denal disease—the acute and the chronic or atonic—General characters—
Particular symptoms—direct and sympathetic—Causes—common in the United
States—Necessity of a better pathology of diseases called bilious and hepatic
—Treatment—depletion if the acute disease be present—Counter-irritation—
Emetic tartar—castor oil—nitrate of potassa—mercury—taraxacum—mineral
acids—In the atonic variety,—purging—suitable food—exercise—laxatives,
tonics, and alteratives. — Follicular duodenal dyspepsia — Its symptoms,
progress, and treatment. — Strumous dyspepsia—Its course, complications,
and treatment—General directions............p» 164
LECTURE XV.
Ileitis, — complication and nature of—Dothinenteritis — Ulceration of the
mucous membrane — Symptoms and diagnosis of ileitis. — Diseases of the
small intestines — Symptoms of ileitis — Occurrence of diarrhoea with fever
symptomatic of this form of inflammation — Frequency and symptoms of the
disease in children. — Tabes mesenterica, — treatment of.....178
LECTURE XVI.
Treatment of ileitis— Advantage of leeching— Stimuli sometimes beneficial —
Infantile remittent fever— Inflammation of the mucous membrane — Enteritis
with diarrhoea — Effects of opium in inflammation of serous and mucous mem-
branes — Pathology and treatment of diarrhoea and dysentery — Perforation of
the intestine — Diseases of the large intestine.........190
LECTURE XVII.
Diseases of the Large Intestines—Treatment of diarrhoea—Apyrexial period of
diarrhoea—Danger in suddenly arresting the discharge—Purging in phthisis—
Dysentery—Epidemic dysentery.............199
LECTURE XVIII.
Sporadic Dysentery—Nature of this disease—Treatment; mercurial, stimulating,
antiphlogistic—Recommendation of Dr. Elliottson—Success of Dr. O'Beirne in
the use of tobacco injections—Tympanites, or meteorism—Windy colic, reme-
dies for the cure of.........,........20S
LECTURE XIX.
DR. BELL.
Dysentery.—The anatomical lesions in dysentery,—same in all parts of the
world—Dr. Cheyne's experience in Dublin ; Mr. Twining's in Calcutta • Dr.
CornuePs in the West Indies.—Stomach, small intestines, and liver, sometimes
inflamed concurrently with the colon.—Causes of dysentery__crude ingesta__
atmospherical vicissitudes—damp and impure air—particular seasons and cli-
mates,—Malaria not a cause—The disease not contagious—Duration__Termina-
tions—Prognosis—Treatment—venesection— leeching—mercurials__ipecacu-
anha—diaphoretics.—Rectal inflammation—its treatment.—Hepatic Flux__
its symptoms and treatment...............216
CONTENTS.
5
LECTURE XX
DR. BELL.
Enterorrhcea—Includes both diarrhoea mucosa and d. serosa.—Gastrorrhcea.—
Pathology of enterorrhcea—Two varieties of the disease—Acute and chronic
stages—Connexion between dentition and development of the intestinal mucous
follicles—Treatment of enterorrhcea based upon subduing intestinal irritation—
diet, and sudorifics and opiates, sometimes astringents—In lymphatic subjects
and in epidemic visitations, emetics and purgatives proper.—Importance of diet
for the cure of diarrhoea in all its forms—Kind of diet most beneficial—Ente-
rorrhcea with Membranous Formations—Pellicular exudation on intestines
of very young children—Associated sometimes with stomatitis—Later in life
with dysentery—Probably the result of morbid follicular secretion, with or
without inflammation—May appear and recur frequently,—sometimes without
much general disorder—in duodenal dyspepsia—Causes and seat not known—
Treatment.................... p. 235
LECTURE XXI.
DR. BELL.
Colonic Dyspepsia__The colon—its extent, situation, and functions.—Atonic
colonic dyspepsia—Constipation—its general character, symptoms, causes, and
various terminations—Spinal irritation connected with dyspepsia—Treatment
of the colonic disease—Importance of a suitable diet.—Inflammatory colonic
dyspepsia—Connexion with chronic colitis—Causes and treatment.—Irritable
colonic dyspepsia—Enteralgia—Peculiar temperament of persons suffering
from this disease—Treatment; to be simple and mild.—Follicular colonic dys~
pepsia—its analogy to follicular duodenal dyspepsia—Treatment . . . 244
LECTURE XXII.
DR. BELL.
Diseases of the Cecum.—Peculiarities of position, structure, and function of
the caecum—Its liability to be disordered—Symptoms of fecal accumulations in
it—Treatment—Importance of enemata—Best means of employing them—
Suspicion of hernia being present—Liniments and friction—Attention to diet.—
Inflammation of the Caecum—Its varieties.—Stercoral Ccecitis—Symptoms
and treatment.—Acute Ccecitis.—Inflammation of the peri-ccecal tissue.—
Perforative ulceration of the csecum and of the appendix vermiformis—Causes—.
Symptoms—Prognosis—Treatment.—Chronic inflammation of the ccecum—
Us causes, complications, and cure.............259
LECTURE XXIII.
DR. BELL.
Diseases of the Rectum.— The structure and sympathies of the rectum—
Chief diseases of the rectum, viz., hemorrhoids, ulceration, stricture, and
cancer.—Danger from neglect of proper knowledge of rectal diseases.—He-
morrhoids—Definition—Disease, both hemorrhage and tumours—Varieties of
hemorrhoids or piles—The anatomical characters of the three principal ones,—
varicose, erectile, and cystic or spongy (mariscse)—Hemorrhoidal Flux or
Discharges—Their sources—Quantity and colour of blood discharged.—Mu-
cous or Sero-Mucous hemorrhoidal discharge—Causes—Constipation and
drastic purgatives overrated as causes of hemorrhoids—Consequences and
Complications of hemorrhoids..............273
1*
6
CONTENTS.
LECTURE XXIV.
DR. BELL.
Treatment of Hemorrhoids.—Relief afforded by hemorrhagic discharge.—Dis-
advantage of this natural method.—Measures, medicinal and hygienic, required
in a first attack of hemorrhoids.—Treatment of the fixed disease.—Difference
between stopping and curing a disease.—Attention to the general system, and to
the removal of plethora and visceral disease.—Sometimes active measures—
v.s., leeching, calomel, &c, required—To vary the treatment according to pre-
ceding or accompanying disease.—Chronic variety—Balsams, turpentine, and
cubebs, useful.—Periodical hemorrhoids—treatment of—Precautions to avoid
an attack of the disease.—Hemorrhoids with anemia.—Extirpation of tumours
practised sometimes with advantage—Danger—Constitutional measures more
prudent.—Necessity of preparing the system for the operation of removal—Re-
stricted regimen afterwards—External and topical applications—washes, oint-
ments, injections, pads to cause pressure.—Remarkable case by M. Guyot.—
Reasons for enlarging on the subject of hemorrhoids.— Ulceration of the rec-
tum—Two varieties—treatment of.—Prolapsus of the rectum—its peculiarities
and treatment.—Stricture of the rectum—Mistakes and malpractice respecting
this disease.—Spasmodic stricture—Fissures—Carcinoma of the rectum—
Treatment, palliative.—Neuralgia—Preternatural pouches or sacs.—Blenor-
rhagia—Pruritus Ani...............* p.. 284
LECTURE XXV.
DR. BELL.
Colic — Its chief divisions—Community of causes, and of many symptoms and
other pathological features of these varieties—Inference to guide us in the
treatment.—Simple Colic—Its seat, and diagnostic symptoms—Varieties of
simple colic—Treatment—Preliminary inquiries to be made—Remedies accord-
ing to the cause of colic—from cold, indigestible matters, or stercoraceous accu-
mulations — Carminatives— Enemata—Purgatives—Venesection—Cupping—
Liniments of narcotic substances—Oil of turpentine—Croton oil.—Infantile
Colic—Two varieties of—the stercoraceous and that from indigestible matters—
Modifications of treatment in consequence—Importance of attention to the diet
and health of the mother—Danger from habit of giving opium to children—
Periodical infantile colic................ 309
LECTURE XXVL
DR. BELL.
Bilious Colic—Time of its attacks—Causes and Symptoms—Anatomical lesions__
Treatment—Venesection—Opiates—-The warm bath or fomentations__Purga-
tives—Enemata—Means of acting on the bowels—Calomel__Caution against
too early excitement of any kind—Recourse at times again to bloodletting__
Dover's powder—Blisters—Practice by others—Sydenham's directions__Eme-
tics sometimes used.—Dry Bellyache—Analogous to bilious colic__Does
not arise from lead—Common formerly in the West Indies and "in America__
Description by Hillary—Paralysis of limbs—Metastasis.—Colic of Madrid
Closely resembles the preceding—Causes of—Symptoms—Anatomical lesions—'.
Devonshire colic—Causes.— Vegetable colic, similar to the preceding__Treat-
ment of this kind of colic, including the preceding varieties.....gig
CONTENTS.
7
LECTURE XXVII.
DR. BELL.
Ileus — Affinity between ileus and colic — Symptoms of ileus — Causes —
Anatomical characters— Volvulus, or intussusception,—Invagination of
intestine.—How formed ; its varieties and termination — Diagnosis of intus-
susception — Treatment. — Preliminary inquiry into the existence of hernia —
Localization of intus-susception—For this last, bloodletting, opium and tartar
emetic, and enemata— Venesection generally called for in ileus — Blisters —
Turpentine epithem — Dry cupping — Purgatives — Stimulants in last stage —
Other remedies — cold—tobacco injection—Other narcotics externally and
internally — Injections of linseed oil — Crude mercury in quantity. — Opera-
tion of gastrotomy— its doubtful propriety and dangerous consequences, p. 330
LECTURE XXVIII.
Painters' Colic—Effect of metallic poisons on the nervous system— Symptoms
of painters' colic — Pathology of neuroses — Action of lead on the system —
Abdominal and cerebral symptoms—Species of painters' colic — Dr. Thomson's
researches on lead — Effects of, in animals — Effects of, on the generative
system...................... 341
LECTURE XXIX.
Pathology of painters'colic—Researches on the state of the nervous and digestive
systems—Treatment—Use of narcotics, purgatives, tobacco, &c, &c.—Treat-
ment of paralysis from lead—Efficacy of strychnia and brucia—Colic from
copper—Poisonous effects of mercury—Remarkable case—Affection of the
respiratory muscles..................352
LECTURE XXX.
DR. BELL.
Cholera Morbus — Definition — Sydenham's description — Divisions of cho-
lera.—Sporadic or Common Cholera—Symptoms—Not a very fatal disease—
Proportion of cases and deaths in the British troops in different regions—
Greater proportionate mortality in northern than in southern latitudes—Often
exceptions tot his.—Causes—Mutations of temperature from heat to cold, and
errors in regimen—Seat of the disease—Not often depending on inflammation.—
Diagnosis.— Treatment — Diluents—External irritation—Emetics—Opium—
Venesection occasionally—Calomel—Calomel and opium—Laxatives—Oc-
currence of gastro-enteritis,—its appropriate treatment—venesection or leech-
ing—laxatives, diluents, mild diaphoretics, and the warm bath.—Conva-
lescence from cholera—Its treatment............363
LECTURE XXXL
DR. BELL.
Epidemic Cholera.—A counterpart to the pestilences of olden times—The
great pestilence in the fourteenth century—Less mortality with advanced
civilization.—First appearance of the epidemic cholera in India—Its progress
in that country and in Eastern and Western Asia and the islands—in Russia;
Poland ; Hungary; Austria—Its appearance in England, Scotland, and Ireland;
United States; Mexico; Havana; Southern Europe; Algiers—Order of suc-
cession of the attacks of cholera—No regular rate of progress or rule of trans-
mission— Quarantine restrictions useless—Singular limitations of its range by
the smallest change of locality.—Causes. The special cause unknown—Pre-
8
CONTENTS.
disposing and modifying causes, in weather and season; low situations; poverty,
destitution, and vice of the inhabitants; bad food; watery fruits and vegetables;
intoxicating drinks; sudden debility of the nervous system; fear; great and
unusual exposure to atmospherical extremes and changes—Atmosphere and
other phenomena anterior to and contemporaneous with cholera—Attacks of
the disease mainly in the summer-half of the year—Prevalent winds—Sickness
and mortality among animals coincident with cholera in different countries-
Cholera not transmissible by contagion..........p« 371
LECTURE XXXII.
DR. BELL.
Symptoms—To be described under the head of diarrhceal stage, or cholerine; con-
firmed cholera, collapse and reaction—Importance ofattention to the first,or diar-
rhceal stage—Time of attack of.—Confirmed cholera—Disorder of the stomach
and bowels; of the circulation; animal heat—Vomiting and purging vary in
extent—Collapse without evacuations—Mind undisturbed—Symptoms of dis-
ordered innervation—Spasms and cramps—Symptoms of collapse, or blue
stage—Sinking of the circulation the most constant and alarming symptom of
cholera—Thirst, and sense of heat in the stomach—Respiration, how affected—
Symptoms connected with the blood and circulation—Sameness of cholera in
all parts of the world — Stage of reaction, or consecutive fever — Analogy
between cholera ana" pernicious or malignant intermittents — Torti cited—
The lecturer's case of comatose intermittent — Urea in the blood, an al-
leged cause of the consecutive fever.—Prognosis—Common and individual
signs—Modification by age, sex, occupation, and race—Promptness of recovery
—Congestions with slower convalescence—Immediate causes of death—Re-
moter causes, in the constitution and habits of the individual—Misleading signs
in the consecutive fever.—Post mortem appearances—The adventitious but
common—Automatic muscular movement—Increase of temperature.—Organic
alterations—venous congestions—whitish and albuminous fluid in the intestines
—congestion of the lungs,—of the kidneys—Appearances after reaction . 387
LECTURE XXXIII.
DR. BELL.
Post Mortem Appearances in subjects dead of cholera—The occasional yet com-
mon ones mentioned in the last lecture—Peculiar and distinctive ones—Change
in the blood—emptiness and contraction of the bladder—whitish fluid in the
intestines—exudation on intestinal mucous surface—development and other
changes in the follicular glands—psorenterie—Dr. Horner's observations—a ve-
sicular eruption on the entire surface of the digestive tube—exfoliation of epider-
mic and venous lining of the tube—Great number of the gastro-intestinal mucous
follicles—Changes in the fluids,—m the blood,—in the secretions from the
bowels—Special pathology of cholera—Analogy to poisoning—Two orders of
functions affected—Experiments by injection of poisons into the veins__Dr Na-
mias's experiments with cholera blood—Organs and tissues simultaneously af-
fected—respiratory, digestive mucous, and cutaneous—Mortality from cholera—
In India—Russia—Poland—Hungary—France—Great Britain and Ireland-
Berlin—Naples—Geneva—Leghorn—Sunderland—Glasgow—Quebec — Mon-
treal—New York—Philadelphia—Cincinnati— Law of Recoveries and Mor-
tality in cholera................ .,-,
LECTURE XXXIV.
DR. BELL.
Treatment of Cholera.—Study previously of its mortality, and comparison with
that in other diseases—Almost certainty of death, unless medicine be given—
CONTENTS.
9
The sedative class of remedies most useful in cholera—Evidences of increased
innervation—Increased glandular secretion—Indications of cure—Treatment
of the Diarrhceal Stage.—Necessity of prompt attention to the first symptoms
of irregular digestion—Mild purgatives, sometimes an emetic; laudanum; dilu-
ents; rest; moderate warmth—Case—Selection of purgatives—Treatment of
Marked Cholera.—An emetic—Bloodletting—Sedative or contra-stimulant
remedies—Calomel; its primary and sedative effect; is to be given in large
doses, sometimes alone, often with a full dose of laudanum—Opium . p. 424
LECTURE XXXV.
DR. BELL.
Treatment of Cholera (Continued).—Drinks; warm; cold; ice—Stimulating
drinks injurious—Tartar emetic as a sedative; its successful use—Ipecacuanha
with similar intention—Magnesia—External medication—Warm, tepid, and
cold baths, all sedative — Stimulants externally; blisters; cauterising skin;
dry heat; continued frictions of the skin—Internal Stimulants; the milder
kind preferable; tonics; sub-acetate of lead and sub-nitrate of bismuth are seda-
tives—More active stimulants; ammonia, capsicum, camphorated ether—Treat-
ment of the stage of Collapse—Difficulty—Stimulants and sedatives often
alike fail—External remedies; friction, ammoniacal liniment; friction with ice;
the cold dash—Sudden collapse treated sometimes by venesection—Arteriotomy
useless and cruel—Cups to the abdomen—Astringent injections—Stimulant in-
jections—Astringents—Special stimulants; oil of turpentine and capsicum—Ice
grateful and serviceable—Cold water treatment—Dr. Shute's views in directing
it—Tobacco enemata................. 441
LECTURE XXXVI.
DR. BELL.
Treatment of Cholera (Concluded).—The saline treatment—General experi-
ence not in its favour—Saline injections into the veins—Delicacy and difficulty
of the operation—Treatment of the Stage of Reaction.—This and the diar-
rhceal stage less common in India—Convalescence.—Prophylaxis. — Chief
means are temperance, cleanliness, and equable temperature of the body—
Importance of early attention to the very first symptoms of the disease—Con-
nexion between cholera and other diseases—Influenza—Influenza and cholera
in 1780 and 1781—Both have pursued a similar course, including divergencies
from the main line—Prevalence of bowel affections in cholera seasons—In-
creased mortality at this time from other diseases—Scarlet fever with cho-
lera....................... 453
LECTURE XXXVII.
DR. BELL.
Cholera Infantum.—Is endemial in the United States—Scarcely noticed by the
English and French writers—Dr. Cheyne's atrophia ablactatorum resembles
it.—Symptoms—Ushered in generally by diarrhoea—state of the circulation—
skin—discharges from the bowels—thirst—nervous symptoms—state of the
brain—expression of the countenance.—Prognosis.—Causes—High heat of
summer—Irritation of teething—Errors of regimen—Predisposition—Anatomi-
cal lesions — chiefly disease of the mucous follicles of the intestines—softening
of the gastro-intestinal mucous membrane—Billard's case—Entero-mesenteric
fever of Serres and Petit,—dothinenteritis of Bretonneau.....465
10
CONTENTS.
LECTURE XXXVIII.
DR. BELL.
Cholera Infantum (Continued).—Farther dissections exhibiting inflammation of
the small intestines and follicles—Dr. Horner's opinion of the nature of cho-
lera infantum—M. Billard's view of the cause of follicular development applied
to the pathology of infantile cholera.—Resemblance between this disease and
epidemic cholera—Hepatic pathology of cholera infantum not sustained by
autopsic examinations—Mode in which heat causes hepatic derangement-
Contents of intestinal canal.—Treatment—Indications to guide us—To re-
duce excessive sensibility and to remove irritations—Modification depending on
temperament and constitution—Treatment of first stage—Demulcents, chalk
mixtures,—an opiate, if the teeth irritate—Calomel in minute doses—Oil ^of
turpentine—Cold affusions and cold water injections—Sugar of lead . p. 477
LECTURE XXXIX.
DR. BELL.
Cholera Infantum (Concluded).—Caution not to irritate the stomach by needless
repetition of either food or medicine—Danger of relapse during hot weather—
Remedies for the diarrhoea after vomiting has ceased—Nitrate of silver—alu-
mina—Dr. Diirr's cases, illustrative of German practice—Astringents,—of
secondary value—Treatment when the disease remits—Renovation by fresh
air—Treatment in the state of collapse with diseased brain—Proper food
for the patient—Drinks,—great importance of selecting them and regulating
their use—Removal of irritation from teething—Paramount importance of
pure air, day and night—Bathing—Continued watchfulness on the part of the
mother to withhold all irritating ingesta—Preservation of equable tempera-
ture of the skin—Prophylaxis,—cool air, cool bathing, cool drinks, and proper
food at stated intervals.................437
LECTURE XL.
Gastritis, with delirium tremens—Varieties of intestinal worms—Organization and
origin of—Occurrence in the foetuses of various animals—Formation—Patho-
logy of—Perforation of the intestines by—Worms in tumours and abscesses, 496
LECTURE XLI.
Symptoms of intestinal worms—Sympathetic irritations—Affections of the nervous
and respiratory systems—Various diseases mistaken for worms—Exciting causes
of worms—Farinaceous and milk diet—Verminous fever—Treatment of worms
—Specific and mechanical purgatives; calomel, turpentine, &c, &c—Reme-
dies for each species of worms— Preventive measures.......506
SUPPLEMENT TO LECTURE XLI.
DR. BELL.
Double indication in the treatment of worms—Iron with purgatives—with calo-
mel followed by purgatives-Bark of pomegranate root-Spigelia Marilandica
—Chenopodium anthelmintica—Pride of China—Common salt — Treatment nf
a«c«r»rf«-Purgatives occasionally—Injections,—chiefly of turpentine, aloes
&c.-Mixed treatment of worms,—by bitter, saline, and sulphurous waters 514
CONTENTS. 11
LECTURE XLII.
DISEASES OF THE BILIARY APPARATUS.
Pathology of Jaundice—Its coexistence with a flow of bile—Case of aneurism
of the hepatic artery—The disease, independent of mechanical obstruction—Co-
louring of the various parts—Effects on the milk, and humours of the eye—Jaun-
dice with preservation of health—Icterus infantum.......p. 517
LECTURE XLIII.
Jaundice from gastro-duodenitis—Researches of Broussais and Marsh on—Jaun-
dice without hepatic inflammation—Nervous symptoms—Treatment—Yellow
fever—its occurrence in this country—Predominance of gastric irritation in
warm climates—Typhus icterodes—Jaundice from biliary calculi—Different
situations in which biliary calculi may be found........526
LECTURE XLIV.
Diagnosis of jaundice from biliary calculi — Proof of the passage of the calculus —
Indications of treatment — Rupture of the gall-bladder after the use of
emetics — Spasmodic jaundice — Treatment of spasmodic jaundice — Dis-
charges of fatty matter — Researches of Drs. Bright and Elliotson — Connec-
tion with malignant disease examined — Source of fatty matter . . . 536
LECTURE XLV.
Acute and Chronic Hepatitis—Pathological differences—Effect of climate—
General and local symptoms — Character of fever— Pain of shoulder— Use of
pleximeter — Complication with jaundice — Resolution — Abscess— Various
openings of the latter—Cicatrization............545
LECTURE XLVI.
Diagnosis of the rupture of hepatic abscess—Pulmonary openings—Case of double
opening—Puncture of the gall-bladder—Gangrene of the liver—Its connection
with hepatic apoplexy—Diagnosis of distended gall-bladder—Its causes—inflam-
mation of the parietes over the liver—Sympathy of the integuments . . 555
LECTURE XLVII.
Aneurism of the hepatic artery—Distention of the liver with bile—Treatment of
hepatitis—Employment of mercury—Symptoms of suppuration—Dr. Graves's
operation for giving exit to matter in hepatic abscess—Rupture into the perito-
neum—Chronic hepatitis—Complication with disease of the heart—Embryonary
state of the liver...........-........565
LECTURE XLVIII.
Treatment of chronic hepatitis—Neuralgia of the liver succeeding hepatitis—
Connection of hepatic with gastro-intestinal disease—Modes of transmission of
disease from the mucous surface of the liver—Phlebitis of the vena porta—Ob-
struction of this vein—Case of pulmonary, hepatic, and intestinal fistula?—Hepa-
tic neuralgia.................., . 5~.">
12
CONTENTS.
LECTURE XLIX.
DR. BELL.
DISEASES OF THE PANCREAS AND SPLEEN. — CHLOROSIS.
Pancreas—Its pathological states not well appreciated—Symptoms of inflam-
mation of the pancreas—Few positively diagnostic ones—Post mortem ap-
pearances of the organ—Its morbid secretions—Connection of these with
pyrosis—Diagnosis.— Treatment. Moderately depleting remedies, with opiates
and narcotics, and counter-irritants.—Diseases of the Spleen. Connexion
between the spleen and the liver, and stomach, and bowels—Community of #
affection with these organs in paludal fevers—Organic lesions of the spleen
and their sympathetic disturbances—Exploration of the spleen—its situation
and size.—Splenitis. Obscurity of its symptoms—Enlargement—characters
of the tumour—Structural changes.—Chronic Splenitis. Symptoms equi-
vocal—Terminations of inflamed spleen—suppuration—softening—congestion—
Sympathetic disorders from splenitis............586
LECTURE L.
DR. BELL.
Treatment of Diseases of the Spleen.—Remedies for acute splenitis the same
as for other phlegmasia? — Mercury in general inadmissible—Avoidance of
extreme views and practice — Sedative narcotics useful—Free purging in
enlargements of the spleen, or chronic splenitis; to be followed or alternated
with chalybeates—Mr. Twining's plan of treatment—Spleen mixture—Addi-
tion of sulphate of quinia—Venesection and cupping, or leeching, occasionally
directed before the use of chalybeates—Salutary crisis by hemorrhages—Native
(Bengalese)?remedies for diseased spleen; chiefly aloes and iron, with occa-
sionally castor oil — Acupuncture — Enlarged spleen with intermittent and
remittent fevers, requires sulphate of quinia—Great utility of this medicine—
Iron in other varieties of tumid spleen—Connexion between spleen cachexia
and chlorosis, scurvy, and anemia.—Chlorosis—Its real nature—Depending
on impoverished blood—Changes in the blood atthis time—Causes—Symptoms—
Means of renovation—Iron, the chief medicinal agent—Hygienic restoratives—
Hemorrhages do not always contraindicate the use of iron.....596
LECTURES
OS TBS
THEORY AND PRACTICE OF PHYSIC.
LECTURE I.
GENERAL OBSERVATIONS.
Gentlemen : — You may have often heard that the approaches
to science are rugged and uninteresting, and some of you have
perhaps experienced the truth of the remark. Hence the custom
of delivering an introductory lecture, in order to lay before the
young mind, when first entering on each path of knowledge, the
objects, the results, the attained good, and the hoped-for glory of
the pursuit. These are to be displayed with clearness and with
truth, yet it is obvious that much of the effect of such a lecture
must depend on the nature of the subject and the judgment of the
speaker; and it is well when the exalted nature of the one is
attainable by the capabilities of the other. Such a lecturer, then,
should be an earnest lesson on the objects, the pleasures, and the
advantages of that science, of which the course is destined to treat;
its history, its true mode of study, its interest, actual state, and
future prospects, may all form legitimate subjects, and when thus
rightly viewed, an introductory lecture, so far from being a mere
ornamental appendage, may become a most important part of the
course.
With these views let us approach our subject, the theory and
practice of medicine. Let us contemplate that study and that
profession, which, venerable by all antiquity, yet in itself is " ever
new." Even in its infancy, when the world was in darkness, was
medicine a glorious science when compared with its cotemporaries;
and its first professors were ennobled and exalted by its influence.
As their mantles descended through a long line of illustrious suc-
cessors, we see medicine progressively expanding, and even when
vol. i.—2
14
GENERAL OBSERVATIONS.
the night of barbarism hung gloomily over the earth, we see its
genius triumphing over the surrounding darkness, and shining in
the east as a beacon to the shipwrecked mind of man: and I trust
that I shall be able to prove to you, that, in our own time, when
the human mind has made such astonishing advances, medicine has
kept pace with her sister sciences, and it is a gratifying reflection
to think, that, among the most distinguished promoters of the col-
lateral sciences, physicians have ever held a commanding rank,
thus proving themselves foremost in knowledge, as they have ever
been in philanthropy, in private and public charity, and in all good
will to man.
It is scarcely necessary to allude to the title of this course of
lectures, further than to remark, that, however different they may
be in name, it is yet impossible to draw the line of distinction
between the theory and the practice of medicine. If medicine
were merely the knowledge of a number of empirical remedies for
particular symptoms, given without our inquiring into their mode
of action, or any acquaintance with the dependence of one func-
tion, or one viscus, on another, of any knowledge, in short, of
physiology in the healthy or diseased state, then we might have a
practice of medicine independent of what is called its theory. But
medicine now holds a higher place, and much of its improvement
is traceable to our advances in physiological and pathological
science. Thus to treat, or teach, the treatment of a disease, we
must know the healthy function of the organ, or organs, the history
of development, the influence of other organic systems, the changes
produced by disease, and, as far as possible, the action of all
external or internal agents on the viscera. But this is the theory
of medicine.
For example, let us suppose that we are called either to treat or
to teach the treatment of a case of enlarged liver. Let me here
remark, that in selecting this case I do not wish you to suppose
that I am one of what might be called the hepatic school of medi-
cine, in which the existence of almost every organ, except the
liver, seems to be forgotten, and of which the creed seems to be,
that there is but one viscus, the liver one source of disease, biliary
derangement, and one cure, mercury; a creed which, though not
enforced and defended by the sword, has lost perhaps as much of
human life as others whose history is written in letters of blood.*
But no one can doubt the importance of the organ, and I have
taken it to illustrate the connection between the theory and the
practice of medicine.
* [I wish it could be said that we in the United States are not
amenable to this censure. But, alas ! the spoonful doses of calomel,
and pills with calomel for their basis by the dozens, are, or have
been, prescriptions which have cast a stigma on too many American
practitioners, who see but one disease, — that of the liver. — B.]
TWOFOLD OBJECTS OF MEDICINE.
13
You detect an enlarged liver; you are called to cure the dis-
ease : —
1st. You must be aware of the healthy state of the organ, and
of its healthy functions, as shown by the volume, sensibility, influ-
ence on digestion, and the healthy state of the secretion. You must
know all these, as it is by the departure from these conditions that
you recognise this disease at all. — But this is the theory of medicine.
2dly. You must know the history of its development, because
there is a period of life when the natural state of the liver is in a
greatly enlarged condition, and this may continue even to adult
life, and produce an enlarged liver, not the result of disease but
the arrest of development, and the question will arise as to whether
the case before you is an example of this, or of recent and actual
disease. The whole treatment turns on this.— Yet this is the theory
of medicine.
3dly. You must know the influence of other organic systems.
An enlarged liver may be produced mechanically by obstructions
in the lungs or in the heart; it may be produced from the sympa-
thetic irritation of a duodenitis, or be the result of original disease
in its own structure. All these circumstances must be known and
taken into account. If it be merely obstruction in the venae cavae
hepaticae the ordinary treatment will not answer ; if there be duo-
denitis we must modify our treatment, and so on. We must know
these things; we must know how to recognise these diseases before
we can prescribe or practise successfully. All this is that part of
the theory of medicine called pathology, or the physiology of the
diseased body.
4thly. You must know the effects of disease on the liver itself.
Some of these are removable by art, others are totally incurable.
You must know these in order to determine on the probability of
their existence.
5thly, and lastly. You must know the influence of remedial
agents on the liver and the adjacent organs. You must be fami-
liar with the effects of stimulation of the mucous surfaces of the
stomach and duodenum. Then, indeed, and not till then, will you
be qualified to treat the case with judgment and success. The
same remarks, I need scarcely add, will be found applicable to the
diseases of each viscus in the body.
The objects of medicine, gentlemen, are twofold ; first to cure
disease, no matter where sealed or how produced ; and secondly,
to relieve bodily suffering in cases where a cure is impossible. Its
great end is to prolong life, and to diminish the bodily evils which
result from the infirmities of our nature and other circumstances.
Some of you may ask, where then is the distinction between medi-
cine and surgery ? In truth, there is no distinction in reality, and
there should be none in theory. The human constitution is one; —
there is no division of it into a medical and surgical domain; the
same laws and the same principles of treatment apply to the cure
of a fractured bone and the cicatrization of an internal ulcer.
16
GENERAL OBSERVATIONS.
Unlike the corporations of medicine and surgery, the supposed
purely medical and purely surgical parts of the body live in excel-
lent harmony. Here, then, there is no division, no jealousy, no
separation of interests.
I am by no means prepared to deny that advantages may arise
from a practitioner devoting himself to this or that branch of his
profession; but if he seeks for eminence, he will first educate
himself generally. Let him attain extended views of pathological
medicine ; let him make himself master of the actual state of the
science, and then he will find that there is not a single fact or law
with which he has become acquainted that will not have its bear-
ing on his particular pursuit. It is in the education of medical
men that the ruinous effects of the division of the professions of
medicine and surgery are most perceived : and I feel convinced
that, of the two, the surgical student is the greater sufferer, be-
cause his views of pathology are injured. All the great laws in
pathology are drawn from the consideration of visceral disease ; yet
the attention of the surgical student is diverted from this, and
directed to what, I will say, can never elevate him in the ranks of
science. He is taught anatomy, and what is called surgical disease,
but he is kept ignorant, by this wretched system, of the great part
of his profession, until he comes to practise, when, if he has a mind
fitted for observation, he will find, that for one dislocation there
will be hundreds of visceral diseases; and he will discover what
was concealed from him during his pupilage, that many, many
more die of what are called medical than surgical diseases.
During the late war, more men in the British navy died of fever
than of all other causes—including the sword. But, I rejoice to
say, in Dublin the exclusive system of education is fast wearing
way, and one of the many excellences of our national school of
medicine is the instruction in general pathology. There are few
schools of medicine where now a more enlarged and liberal spirit
of education exists.
In the study of your profession, gentlemen, let me warn you not
to allow yourselves to be misled by the idea that surgery and me-
dicine are different in their nature. The mere surgeon, or the mere
physician, only knows half of his profession. Reckless of human
life, he may practise the healing art as a trade, but he never can
know it as a science. But, as there are infinitely more cases of
what are termed medical than surgical disease, it is plain, that the
surgeon, ignorant of medicine, will far exceed the physician igno-
rant of surgery, in the extent of his malpractice. I have fong
observed the ruinous system which has been pursued by teachers,
as connected with this subject. The pupil was taught to consider]
that if he was a skilful anatomist, if he understood the routine
surgery of an hospital, and had carefully studied certain works on
surgery, and some obsolete books of pathology, he was thereby
prepared, in the language of the schools, to go forth to teach and
practise the art and mystery of medicine in general. Now, all this
A GENERAL AND LIBERAL SYSTEM.
17
was wrong. You may be profound anatomists and be bad surgeons,
and worse physicians ; you may have by heart the writings of Pott
and Dessault, of Hunter and Thompson, and be totally incapable of
treating a simple or complicated fever, or a case of visceral disease.
But it is not necessary to say more. Society demands that the
old system of a division in education should be abolished ; and ere
long, I even trust to see a fusion of the profession, when much of
the present evils must cease, when medical men shall have a
common centre, from which they shall receive a common impulse;
when their efforts shall be solely directed to the increase of medical
science, and the political and moral exaltation of their profession;
and last, yet not least, when the ingenuous pupil shall not be led
astray; when we shall not be told by one teacher to despise this,
and by another to neglect that part of his profession ; but, having
the whole of the noble science of medicine thrown open to him, his
mind unwarped by prejudice, unfettered by fear, shall be permitted
to take that right view of his pursuit, that alone can lead him, and
assuredly will lead him, to the honours and success which truth
bestows on all its votaries.
1 have said, that the exclusive system of education had singularly
diminished in Dublin. Indeed, our national school has earned great
reputation for general pathology ; and, from a long and cordial
intercourse with the class of Dublin, I will affirm, that there are
few places where we can see such zeal, talent, and thirst for know-
ledge among the students. As an Irishman, addressing my own
countrymen, let me congratulate you on the fame the Dublin
School of Medicine and Surgery has now acquired, and is every
day acquiring; and when the strength of Irish talent, aided by the
proper working of our unrivalled institutions, is brought into play,
may we not anticipate a still more glorious result ? This reflection
has often cheered me, that within the last few years there has been
a greater stimulus infused into the science and literature of this
country. Amid the ungenial influences of political excitement, and
the animosities of party, how gladly should we contemplate the
advance of what will prove an honour to our national character,
and an advantage to mankind. It is like the growth of the coral
into rocks and fertile islands, though surrounded by the strife and
waste of waters. Our scientific societies have multiplied; our
periodical literature, the want of which furnished so fruitful a theme
for cavil, has been extended so as to afford a wholesome and vigor-
ous supply in the varied departments of literature and science ; and
our monthly and quarterly publications are taking their proper
place among the ranks of British journals. When we turn to
works of a more permanent kind, we also see cause for satisfaction.
Many most important works in anatomy, surgical pathology,
physiological medicine, and widwifery, have lately issued from the
Irish press : and the Irish contributions to the Cyclopaedia of Prac-
tical Medicine are allowed on all hands to give to that work no
mean portion of its value.
18
GENERAL OBSERVATIONS.
There are few more wholesome exercises for the mind, few so
necessary and so useful as the comparison of the actual state of
any science with its advance and character at a former period;
and it is in this, most chiefly, that the value of what is called the
history of medicine consists. We study it then, not as a matter of
antiquarian research, of learned curiosity, but as the picture of the
human mind, now on the right path, now misled by error, yet still
struggling onward ; as the record of a dear-bought experience, and
a beacon to warn us of the rocks and shoals that beset its future
progress unto truth. To analyse the actual state of medical science,
to show you all that has been done within a little time, to display
all old pretensions to the character of a true and thrice noble science,
would far exhaust my capabilities and your patience. Let it suffice
to contemplate the improvement considered generally, and the
means by which that improvement has been attained.
It is an error too generally received, that medicine owes all its
advances to the researches of modern times. Far be it from me to
undervalue these, but I believe that the opinion I have alluded to
is wrong, and is perhaps kept alive by our own vanity; for by a
specious deception we often take to ourselves the honours and dis-
tinctions of the time we live in. The truth is, that medicine, like
many other of the sister sciences, has been long steadily advancing,
and the flippant every day remarks that the inductive system (that
is, the observation of facts and the embodying of those conclusions
that legitimately flow from them) has only been introduced into
medicine in our time; and that our predecessors in medicine put
theory first and fact second in their medical philosophy, are " as
false as dicers' oaths.' Have the authors and teachers who are so
fond of decrying the medicine of a former day, at a time when they
are (perhaps innocently) making use of its facts and observations
— have they read the writings of the father of medicine? Have
they studied that " aureum opus," so well called from its lustre, its
purity, and its surpassing value? Was Avicenna a mere theorist?
Did Morgagni observe no facts, nor truly record them, even at the
expense of his medical reputation? Is there no induction in Bag-
livi. Was Haller unacquainted with the method of experiment and
induction ? Or is the discoverer of the circulation of the blood, the
good, the great, the injured, but the immortal Harvey, forgotten?
Where do they place Boerhaave ? and shall the name of Sydenham
go down with his ashes to oblivion?
The true state of the case is, that medicine, in its present ad-
vanced state, only represents the improvement in other branches of
human knowledge, all of which are so intimately linked together,
that, although their extremes be far removed, there is a point where
all are reciprocally cause and effect; so that if we take any one of
them, it is easy to show its intimate bearings with, and importance
to, all the rest. We have been long advancing in medicine; and
though I admit most fully the vast strides which have been made,
still I must here declare'my firm conviction, that the study of the
older authors is too much neglected, and that in them you will find
MODERN SYSTEM OF INVESTIGATION.
19
a treasury of knowledge, much of which you may think to be the
production of modern times.
If the writings of the ancient authors only contained a small
portion of the information with which they abound, it would be a
sufficient stimulus to their study; to reflect that it is in them, in
the medical writings of the ancients, that the germs of the induc-
tive philosophy are first to be found. It is, then, in the old regions
of medicine that we find the fountains of that mighty river, which,
for two thousand years, has fertilized the earth, and made man its
lord. Had the progress of man not been retarded by the ignorance
which is the child and servant of barbaric despotism, an earlier
Newton might have enlightened the earth, an earlier Laplace have
measured the heavens, or a Cuvier declared the glories of a past
and present creation. The mind of man would have burst its chains,
and ages ago have formed that holy alliance with knowledge and
her first-born, liberty, which now is its safeguard and its glory. I
repeat it, in the writings of Hippocrates you will find the principles
of the inductive philosophy. A physician showed Bacon the road
to immortality.
We find that there is in the mind of man a tendency to reverse
the true mode of reasoning, and to seek for a principle before it has
observed facts, and this was the cause of the retardation of medicine,
as well as of all other sciences. Hence the various schools, from
Pythagoras to Cullen or Brown, in our day. But a slow, though
sure, revolution was long going forward ; and I believe that Cullen
and Brown were even behind the actual state of medicine in their
time. Physicians turned disgusted from the war of words and
doubt, to seek in tangible objects the certainty which these only
can produce ; in a word, they began to follow the Baconian system
more generally. They reverted to the instructions of Hippocrates,
and from that period our modern improvement may date. They
turned their attention to the examination of those changes which
disease produces on the human body, and connected these with
the symptoms observed during life. And what has been the result
of this?
1st. The accumulation of an enormous number of facts, relative
to the changes of organs produced by disease.
2d. The connection of a vast number of these changes with
particular symptoms, and hence the advance in diagnosis.
3d. The establishment of the true value of symptomatology, and
the verification of that all-important fact, that opposite states and
organs may produce similar symptoms.
4th. The knowledge of the vast class of latent diseases; in other
words, diseases which exist without influencing the phenomena of
animal life, or, in some cases, the phenomena of both animal and
organic life. Diseases, either without symptoms at all, or only
with such as previously were not supposed capable of leading to
their detection. You know that the phenomena of life are divided
into two classes, viz., those of organic or vegetable life, such as
so
GENERAL OBSERVATIONS.
nutrition, circulation, absorption, respiration, secretion. While
those of animal life, or the life of relation (so called from its being
the source of our connection with surrounding bodies), are the
senses, the phenomena of mind, and muscular motion. The one
life seems more under the influence of the ganglionic, and the other
under that of the cerebro-spinal system of nerves.
As some of the junior part of the class may not have accurate
ideas as to the meaning of symptoms, I may state that disease is
recognised by signs and symptoms.
By signs, we mean those mechanical alterations, produced by
disease, in the conditions of parts, which are recognisable to the
external senses of touch, sight, and hearing; changes in appearance,
volume, shape, resistance, peculiarities of feel, and the production
of sounds. We may make a diagnosis by signs alone. Take, for
example, a case of tympanitis. The abdomen is prominent,
enlarged, circular, elastic, and sounding like a drum when struck.
Thus we learn that the belly is distended by air.
Now, symptoms are totally different; they consist in certain
changes produced in functions; and these functional changes are to
be considered in a threefold manner ; —
1st. Changes in the functions of the part itself.
2d. Changes in the phenomena of organic life.
3d. Changes in the phenomena of animal life.
Let us take, for example, a case of inflammation of the stomach.
We have, first, changes in its own functions — morbid sensibility,
vomiting, thirst, anorexia. In the next place, we have changes in
the functions of organic life — fever, from the action on the circu-
lating system; hurried respiration, and cough, and hiccup, from
the action on the respiratory system ; jaundice, from its action on
the biliary system ; suppression of the secretion of the skin,
kidneys, &c. All these, you observe, are lesions of the functions
of organic life.
But we may have other symptoms; prostration, headache, deli-
rium, convulsions; these are lesions of the life of relation, or
animal life.
Now, in many cases, we have to combine these sources of
knowledge to form a correct diagnosis. Take, for example, a case
of hepatitis.
The patient has had pains in the hepatic region, fever, jaundice,
hurried breathing, tenderness. After some time he has a tumour ;
the side dilated ; the hypochondrium dull on percussion. Well, the
signs point out an enlargement of the liver ; the symptoms, that the
cause of that enlargement was an acute hepatitis.
In general, we may state, that signs only declare the actually
existing mechanical condition, while symptoms, either present or
past, point out the cause of the change, whatever it may be. Both
must be studied together; but you will learn more from symptoms
without signs, than from signs without symptoms. But to return
to the results of the improved method of investigation.
BENEFITS FROM PATHOLOGICAL ANATOMY. gl
Great light was thrown on fever in general; and it is, I believe,
quite true, that all the advances which we have made in the know-
ledge of fever, are due to the prosecution of pathological anatomy.
Almost all of what we may call our general knowledge of fever, is
due to Hippocrates; but anatomy has revealed its effects, its com-
plications ; and the all-important fact that the cause of its fatality
is often local inflammation. This knowledge, however, is not so
new as is taught by some modern systematists. Galen De Affect.
Intern, c. xli.) taught, that in continual fevers bleeding and cold
drinks were the powerful remedies. Sydenham declares, that the
ignorance of the inflammations in malignant fevers has been more
fatal to the human race than the invention of gunpowder. Baglivi,
that malignant fevers often depend on a visceral inflammation,
and Van Swielen knew the frequency of intestinal ulcerations in
typhus.
Among the direct results of pathological anatomy, it is shown
that disease is seldom confined to one organ, or even one system,
and thus it has utterly shaken the nosological system of Cullen
and his predecessors, which, you know, consisted in classifying
disease by symptoms, which were supposed to point out a certain
and single disease. For example, the nosologists class phthisis as
an affection of the lung; but pathological anatomy has shown, that
in many cases it is the result of a disease invading many organs
and systems, and that the pulmonary disease is but a link in the
chain of morbid actions. Pathological anatomy, also, has demon-
strated the inflammatory nature of a vast number of diseases, and
has thus given us a key to treatment, to prevention, and to pallia-
tion, when the disease is incurable.
The last grand result of pathological anatomy is the discovery
that a vast number of affections, supposed to be merely lesions of
function, are more or less connected also with alteration of struc-
ture. Thus many of the dyspepsias of the nosologists are proved
to be examples of gastritis, or of other organic diseases; cases of
asthma turn out to be chronic inflammation with emphysema; the
palpitations may depend on organic disease which has sprung from
a carditis, and so on. I need not now dilate on the vast importance
of such facts to practical medicine.
But let us now come to an all-important inquiry. Is patholo-
gical anatomy to be considered as the basis of medicine? or is it,
even when combined with clinical observations, the foundation of
all medical knowledge ? This inquiry, you will at once perceive,
involves the question as to whether Hippocrates and his followers
have done anything for the science, or whether medicine is wholly
new, an infant, and consequently a weak and imperfect science.
Are we to despise the works of the ancients, to be ignorant of them,
and to allow medicine to be in its infancy? In fact, if we review
the history of medicine from the Hippocratic era to the absurdities
of Hahnemann, we find that there have been two orders of men,
one constituting what we may term the school founders, who made
22
GENERAL OBSERVATIONS.
a theory, and sought to square facts to meet that theory; these
have only brought disgrace on medicine. The other class consists
of the Hippocratic observers; that is, of men who sought for facts,
who collected and pondered on these facts, in other words, who
were Baconian philosophers. It is the labour of these that has
really advanced medicine. Asclepiades, who lived in the first
century of the Christian era, declared that the medicine of Hippo-
crates was a cold meditation of death. The celebrated Thessalus,
who lived under Nero, in writing to the emperor, makes use of the
following words: —
" I have founded a new sect, which is the only true one. I
have been forced to this, because none of the physicians who have
preceded me have discovered anything useful, either for the pre-
servation of health, or for the cure of diseases, and because Hippo-
crates himself has put forward many dangerous maxims."
And what was this new doctrine ? That nature in each case
pointed out to the patient what was the most fit for him, and that
hence he should be diligently supplied with everything that he
fancied.
We have next Paracelsus. He commenced his course of lectures
at Basle, in the year 1526, by publicly burning the writings of
Galen and Avicenna, and assured his auditors that a single hair of
his head contained more knowledge than Hippocrates and his suc-
cessors. He taught the cabalistic medicine, the intimate connec-
tion between the planets and the viscera: he was a vitalist, but
embodied his vitalism under the shape of a demon, who resided
within the system, and which he called Archaeus. Diagnosis was
to repose on the examinations of the stars, and not on symptoms.
He invented the doctrine of tartar, which is the cause of all dis-
eases of accumulation, obstruction, and concretion ; " and I call it
tartar," says he, " because it contains the oil, the spirit, and the
salt, which burn the patient as hell does."
Hahnemann, the founder of the homoeopathic doctrine, may be
quoted next as an example of these school founders; and he, like
his predecessors, expresses himself with all that arrogance, which
ignorance, when it pretends to learning, invariably assumes. Speak-
ing of the Hippocratic medicine, he says —
" Since this art only consists in a gross imitation of a danger-
ous and insufficient process, it must be admitted that the true medi-
cine was not discovered until by me. It is the infallible oracle of
the art of curing; it is the sole mode of really curing disease, be-
cause it reposes on an eternal and infallible law of nature."
And what is this mode and doctrine ? We have it in four pro-
positions, and it is hard to say which of them is most revolting to
common sense. We are told that it is absurd to seek for the cause
of symptoms in order to remove them; that we must cure diseases
by the exhibition of substances which would otherwise produce
them; that the dose is to be inconceivably small; and that there
are three original diseases from which spring all the maladies
HIPPOCRATIC OBSERVATION.
23
which afflict mankind — syphilis, sycosis, and the itch. These are
the fruitful causes of all diseases, — epidemic, sporadic, idiopathic,
and symptomatic. Like his predecessor in quackery and deceit,
he, too, has his syphilis, sycosis, and itch, the oil, the spirit, and the
salt, which burn the patient as hell does. Like Paracelsus, too,
he maintains the curability of diseases, and is a disciple of animal
magnetism.
Let us next see how Broussais announced his doctrine to an
admiring world.
" After so many vacillations in its march, medicine at length
follows the only path which can conduct it to truth — the observa~
tion of the relations of man, with external modifications and the
relations of the organs of man, one to the other." This is the
physiological method, because it cannot be followed without study-
ing life.
I am more anxious to draw your attention to this doctrine, as
Broussais may be considered as the source of the anatomical
school, which, of late, was so completely the fashion — if I may
use such a term; and it is a striking instance of the danger that
attends the idea of our having made a discovery, to see a man like
Broussais, than whom few have really added so much to medicine,
falling into the same fault of arrogance and contempt towards his
predecessors.
At this moment, the medical world, particularly on the continent,
is divided into two great sects. One may be called that of the
pathologico-anatomists, the other the Hippocratists. The first
declares that diseases are primitively local in all cases; that the
symptoms—say in a case of fever— are only the results of sympa-
thetic irritation from some local disease, which is to be attacked with
vigour; that pathological anatomy is to be the foundation of all
practice; that there is nothing approaching to a specific in medicine ;
and that nature makes little or no attempt to cure. Their favourite
maxim is that saying of Bichat's — " What is observation, if we are
ignorant of the seat of disease ?"
This is the sentiment of an anatomist, but not of a physician:
and we must regret that it once escaped the author of the " Re-
searches on Life and Death," a book of such interest and such
beauty, as to captivate even the non-medical reader, and make the
very name of Bichat be hallowed in our memory. Many are the
diseases of which we know not the seat: yet in which observation
— Hippocratic observation—is of the greatest utility.
We know not the seat of fever, let the followers of Broussais say
what they may to the contrary ; yet is observation of symptoms of
no avail in fever? Are the effects of contagion, the history and
nature of epidemics, the termination by crisis, the results of treat-
ment, of symptoms as connected with prognosis — is the observa-
tion of these useless or unnecessary ? Sydenham knew not the seat
of variola; yet he declared the true principles of its treatment.
There are very many diseases on which pathological anatomy
24
GENERAL OBSERVATIONS.
throws but a negative light — if I may use such a term — particu-
larly affections of the fluids, and the neuroses.
So much for the doctrine of the anatomical school. I beg ot you
not to misunderstand me as undervaluing pathological anatomy; 1
only wish to show you its true value. I believe there could hardly
be adduced a single fact in pathological anatomy that has not.its
distinct bearing on practical medicine. And it is true that the dis-
eases whose treatment is best understood are those whose patholo-
gical nature are best known. Even in fever, the actual nature of
which has not been revealed, great advantage has been derived
from anatomical researches ; for all the advance in our knowledge
of this Protean disease consists in ascertaining the number, nature,
and seat, of the local inflammations which accompany or rise in the
course, and complicate the disease.
Let us, lastly, revert to the opinion of the Hippocratists. They
admit that vast advantage has arisen from pathological anatomy ;
but they see that its light is limited within certain bounds. They
believethat great advantage is to be derived from the careful study
of symptoms, even in cases whose pathological nature is not re-
vealed by the knife. They believe that there are many diseases
whose local origin cannot be demonstrated; for instance,fever.
They deny that pathological anatomy is always to be our guide;
but admit a rational empiricism, and the use of remedies which
may*be called specifics; and, lastly,they hold that nature, in many
cases, makes an attempt to cure; and that the physician, in the
words of Hippocrates, is to be the minister and interpreter of
nature, rather than her master.
Let us, then, combine the precepts of the founder of medicine
with the lights of modern science. — Let us take observation, and
that observation rendered fruitful by study, for our guide; and let
the observation equally embrace the phenomena of the living as
well as the dead. Let us be Hippocratists in the dissecting room
as well as at the bedside. By comparing the practice of these two
schools, we get more accurate ideas as to their doctrine. The
anatomists, holding that all diseases are local, direct their whole
attention to the discovery of the lesion, and its connection with
symptoms. This, with their doctrine that almost all diseases are
inflammatory, leads them to a strict general and local antiphlogistic
treatment. Fever is to them symptomatic, and the supposed source
is to be vigorously attacked in the commencement. Diathesis, the
nature of the epidemic, and the powers of nature to effect a cure,
are comparatively neglected. They inhibit purgatives for fear of
increasing the local inflammation, and lose many patients for want
of a timely support of the powers of life.
They deny specificism in diseases as well as in medicine, and are
sorely puzzled to explain the extraordinary powers of bark, and
mercury, and sulphur, and iodine. They despise the experience of
the past.
The true Hippocratist, on the other hand, believing that we have
REMARKS ON LOCAL DISEASES.
25
not yet arrived at the knowledge of the local origin of all diseases,
and particularly fevers, grounds his practice accordingly. He
draws his experience from the recorded knowledge of the past, and
his own unbiassed observation. When he recognises a local in-
flammation, he meets it with judgment, taking into account the
habits, diathesis, epidemic, constitution, and tendency to crisis. He
trusts much to nature, and watches her operations, particularly in
fever. He is not afraid of moderate evacuations ; the phantom of
a local inflammation does not always haunt him; and even where
he recognises its existence, that does not prevent him from using
a stimulating and supporting treatment, if the general state of the
patient requires-it. He treats particular diseases by particular
remedies, the utility of which has been proved by experience —
such as syphilis, scrofula, intermittent fever, and so on. He uses
the expectant medicine, which is not inactive treatment, but founded
on the observations of the powers of nature — " JVatura morborum
medicatrix;" but he never loses the opportunity of doing good,
when such presents itself, remembering the first aphorism of his
great master: —
" Occasio praeceps."
I have great hopes for medicine, for I see men's minds turning
to the true path ; and I trust that all whom I now address will deem"
themselves as labourers in the great work. Think what a noble
science you profess ! the only one relating to earth-born things,
which, while it ennobles the mind of man, yet softens and expands
his heart; whose source is all science, whose end is good to man.
Above all things follow truth ; nature can never deceive — see that
you be her faithful interpreter. The great evil is, that there has as
yet been adopted no means by which the experience of the past can
be brought fully to bear on the actual teaching and practice of
medicine. Too often has the physician to create his own instru-
ments. But when all the scattered facts of medicine are collected,
whether they be the observations on the living or the dead body,
as old as history, or as young as to-day: when these votive tablets
are hung up in the temple of truth, and their facts verified, com-
pared, and classified, then, and not till then, will you see medicine
in all her glory.
LECTURE II.
General remarks on local diseases — Fixed rules for the guidance of students -
Great importance of diagnosis — Existence of pure fever rare — Doctrine of
the Humoralists and of the Brownists — Pathology of the digestive system.
I commence the course by entering at once on the subject of
particular diseases. I am aware that the common practice is to
occupy the early part of a course on the theory and practice of
medicine with preliminary discussions on general pathological
vol. i.—3
26
REMARKS ON LOCAL DISEASES.
subjects. To this I have strong objections. Every man who as-
sumes to himself the office of teacher, no matter what the fact may
be, should presume that his auditors are ignorant of the subject he
is about to teach; if he does not, he must be unjust to his class.
Some of the class must be ignorant of the information he wishes to
convey, and he should take it for granted that all are so. To
commence with the consideration of general disease would argue
that the whole class was acquainted with the subject in all its
bearings, and capable of understanding its principles without any
previous illustration. I think this is beginning at the wrong end.
My plan is first to teach the facts, and then the general principles
and conclusions to which these facts lead. It is of the deepest im-
portance in the study of medicine to be able to form a collection of
laws or fixed principles. In your professional career, nothing will
give you so much satisfaction as having in your minds a number
of established facts and fixed rules to bear on every case which
comes under your cognizance. We commonly hear of the uncer-
tainty of medicine and the instability of its practice; it is said to
have as many phases as the moon, and as many changes as the
tide; but, after all, I think this expression is more general among
those who know little than among those who know much. Those
who have successfully laboured in treasuring up a store of deep
and extensive knowledge are firmly convinced, that, though some
cases are involved in doubt and obscurity, the general certainty of
medicine is at present increased far beyond what it was in former
times. No man, except one in full and extensive practice, earned
by industry and capacity, can be aware of the vast improvements
of modern'practical medicine, and of the number of lives which are
saved by the judicious treatment which the rapidly progressive
improvement of medical science has introduced. Medicine is much
more certain now than it was in past times. There are two reasons
for this; one of which is, that at the present period diagnosis, the
guide and master-key to sound treatment, is more certain. Here,
gentlemen, is a great source of certainty in the practice of medicine.
You will find, in the course of a few years, that the old saying of
" doctors differ," will become less frequently applicable, because, as
the education and acquirements of' medical men become more ex-
tended, diagnosis will be reduced to fixed rules, and difference of
opinion will be very seldom observed. A vast number of local
diseases, formerly wrapt in obscurity, are now detected with the
most unerring certainty, and this certainty of diagnosis must bear
on fixed principles of treatment and similarity of practice. Another
vast source of increased certainty is the fact, now extensively
established, that the element of a great number of diseases is the
same. This is an important law, because the deduction from it is,
that the principles of treatment are the same in these cases. The
principles of treatmerft in a case of hydrocephalus and in a case of
vomiting from gastritis may be, and often are, completely identical,
because, in many cases, both are reducible to a common action. In
FEVER WITH VISCERAL DISEASE.
27
the one case we have to deal with inflammatory action in the
stomach, in the other we have to treat an inflammation of the
membranes of the brain. The principle in both cases is to deplete
the suffering organ, and to diminish or remove everything that
keeps up irritation. Pathological anatomy, too, has effected a vast
deal for medicine by the improvements in diagnosis which it has
introduced, and by reducing to one class a vast number of affections
formerly supposed to be unanalogous and distinct.
Before I commence entering on the consideration of the patho-
logy and treatment of diseases of the digestive system, it is neces-
sary that I should mention another peculiarity of the mode of
teaching the theory and practice of medicine adopted in this school.
The ordinary way of lecturing medicine in the schools is this : the
teacher begins by going over, at great length, the whole subject of
fevers, and then proceeds to the consideration of the signs, symp-
toms, and treatment of local diseases. We reverse this mode
here; we begin by teaching the pathology and treatment of local
diseases, or affections of particular organs; and having studied
these with care and attention, we then proceed to the consideration
of fevers. In point of fact, we are thoroughly impressed with the
truth of this splendid conclusion in medicine, that local diseases
may be considered, as it were, the alphabet of fevers, and that to
have a distinct and accurate conception of the whole subject of
fever, it is essentially necessary that we should be acquainted with
all kinds of local disease. To commence with a class which the
teacher presumes, or should presume, to be ignorant of the pheno-
mena of local diseases, unacquainted with the rules on which their
diagnosis depends, and unacquainted with the principles which
should regulate their treatment—to begin with such a class by
entering at once on the subject of fever, would, in my opinion, be
extremely wrong. You will read in books and hear teachers speak
of bilious fevers, of nervous fevers, of catarrhal fevers, of gastric
fevers, and of simple fevers. These expressions are founded on the
fact of the complication or noncomplication of fever with local dis-
ease in various parts of the system. If simple fever was the rule,
and its complication the exception, then, indeed, there would be
some reason for pursuing the ordinary track of medical instruc-
tion, and we might commence by teaching the subject of fever,
independent of local inflammation. But the truth is, that fever, in
the simple form, is the exception, and its complication the rule, and
that to have a correct idea of fever, in the general acceptation of
the term, we must previously possess an intimate knowledge of the
affections of particular organs. The progress of medicine has
established, by the most unquestionable evidence, that simple fever
is a matter of extremely rare occurrence ; so rare, in fact, that you
might pass through the practice of a fever hospital for years without
meeting with a single case which you could say was, through its
whole course, a case of pure, essential fever. Sooner or later its
character is changed, and the complication with visceral disease
28
REMARKS ON LOCAL DISEASES.
comes on ; you may take this with you as a well-proved fact.
You will have, at some period, a complication with local disease
in the head, or local disease in the chest, or in the belly, or in the
circulating system, or perhaps all the great viscera in the body
will be simultaneously affected. My experience on this point, after
having attended the fever wards of the Meath Hospital many years,
is this, that among all the cases which were admitted under such
circumstances, there were very few indeed in which I could not say
that the patient had something more than fever. Many were
admitted who presented no indication of disease in the head, chest,
or digestive tube; all that could be said of them, at the period of
their admission, was, that they had fever; but my experience of
them is, that, in a vast majority, there was, during their progress,
unequivocal evidence of the supervention of visceral disease. I do
not go as far as the disciples of Broussais have gone, nor do I
mean to say that all fevers are symptomatic; all I assert is, that,
at some period, most fevers are complicated with local disease. I
admit that there is a vast number of symptomatic fevers, but I
believe there are two which are essentially simple, typhus and
intermittent. The progress of medicine has shown that these may
exist in the simple form, and that their complications may be
secondary; this I believe to be the fact, but the almost invariable
liability to complication is a point of the highest importance. We
scarcely ever see typhus accompanied by symptoms of local dis-
ease ; and, with respect to intermittent, in ninety-nine cases out of a
hundred, visceral disease of the head, or chest, or belly, may, and
will, supervene.
Another great fact bearing on this subject, and which patholo-
gical anatomy has established beyond the possibility of a doubt, is,
that in the great majority of cases having a fatal termination, death
is caused by disease of some particular organ or organs. The old
notion of the cause of death was, that the patient died of debility
or exhaustion. In cholera, in tetanus, in hydrophobia, we cannot,
to be sure, demonstrate any appreciable lesion of structure, and
we may say, if we like, that the patient died of debility ; but this
does not hold good in cases of fever, for on dissection you will
generally find disease sufficient to account for death, even though
there had been no fever at all. From these circumstances it fol-
lows that, in the management of fevers, the attention of the physi-
cian must be directed to the local affections, or, at all events, that
to understand fever well, and to treat it successfully, he must be
acquainted with the nature and treatment of every form of visceral
disease. It will be sufficient for me to call your attention to this
fact, that there is not a single acute local disease which may not
occur during the progress of a fever. This is a broad and general
proposition. If you look to the nervous system you will find in
patients who have died of fever, traces of lesion'in almost every
part of it, inflammation or congestion in the cerebrum, in the cere-
bellum, and in the spinal cord. If you go to the respiratory system
FEVER WITH VISCERAL DISEASE.
29
you will see all kinds of shades and varieties of inflammatory
action, thickening and ulceration of the bronchial membrane, hepa-
tisation, congestion, and destruction of the parenchymatous tissue,
effusions of lymph, serum, or pus, into the pleural cavities. As
you proceed in your examination you will discover new lesions ;
you may see the whole lung filled with lately formed tubercular
matter; you will meet with the destructive ravages of phthisis.
You will find the pulmonary tissue converted into a dark and fetid
mass by gangrene. You may see carditis, hypertrophy, inflamma-
tion of the external or internal coverings of the heart, inflamma-
tion of the lining membrane of the arteries, phlebitis (a common
occurrence in typhus fever); and passing on to the lymphatic sys-
tem, you will often find evident traces of inflammation in its glands
and vessels, an occurrence which I shall be able to demonstrate to
you when treating on the subject of gastric fever. If we go to the
digestive system we find that disease has here taken a wider
range; congestions and ulcerations of the stomach and intestines,
morbid states of the liver, congestion and inflammation of the spleen
or kidneys, evidence the fatal extent of local inflammation. I
think I might safely challenge any one to point out any one single
organ which may not become diseased during the progress of a
typhus fever. I do not wish you to suppose that typhus is a symp-
tomatic affection. I think we may define it, in general terms, as a
diseased state of the whole system, in which various local diseases
arise, modify the character of the original complaint, give it an addi-
tional intensity, and are generally the cause of death. Go round
the wards of an hospital during the prevalence of an epidemic fever,
examine every patient in succession, and bring this principle to the
test. You will see one labouring under the morbid excitement of
high delirium ; his face injected, his eyes sparkling, his carotids
throbbing with intensity. Come next day, and you will find him in
a state of profound coma, perfectly insensible to everything around
him : — two or three days afterwards he is dead. You follow his
body to the dissecting room, and open his brain; unequivocal
marks of excessive congestion, inflammation of the substance of the
brain, or of its membranes, sufficiently indicate the cause of the
fatal termination. Here is a case of inflammation of the brain.
You find another with cold skin, his face of a dirty hue, faintly
tinged with red, his breathing quick and hurried, and the spitting-
vessel by his bedside filled with adhesive mucus tinged with blood;
you percuss his chest, and find dulness over the whole surface of
one lung; you apply the stethoscope, and discover intense bron-
chitis, hepatization, or suppurative pneumonia. Farther on you
see another in a state of deep prostration, with a sunken counte-
nance, constant hiccup, and low delirium. Take down his bed-
clothes, and you find his belly swelled, tympanitic, and tender on
pressure ; then his tongue, lips, and gums, are parched and encrusted
with dusky sordes ; his thirst is insatiable; he vomits, and has an
emaciating diarrhoea. After death you find traces of an extensive
3*
30
DISEASES OF THE DIGESTIVE SYSTEM.
and fatal gastro-enteritis; in others you will find exemplified the
very climax of inflammation, and all the three great cavities are
simultaneously affected.
But these, you will say, are cases in which the complications
are evident, and where an ordinary knowledge of the phenomena
of local disease will be quite a sufficient guide. Well, here is
another case. You will meet with instances of fever without any
apparent local symptoms, where the patient lies in what you would
consider a quiet state, and free from danger: nothing seems to be
the matter with him, except that he is very weak ; he perhaps does
not sleep at night, and his tongue is a little foul; he complains, in
fact, of nothing but weakness and some thirst, and you think his
fever is going on very well. Some morning or other, on coming
to the hospital, you are astonished to see the change which has
been wrought in him since the day before; his countenance is
altered, his pulse can hardly be felt, and life is fast ebbing away.
You ask the nurse about him, and she tells you that, during the
night he suddenly complained of violent pain in his belly. On
examining him, you find distinct evidence of intense peritonitis,
and, after death, dissection reveals the existence of a perforating
ulcer of the intestines, of which there was apparently no sign
during life, except fever and the unexpected occurrence of peri-
tonitis. The frequency of the complication of local disease with
fever, its insidious latency, and the fact, that death, in the majority
of fever cases, is caused by visceral inflammations, all clearly point
out the necessity of being intimately acquainted with every modi-
fication of local disease before you proceed to the study of fevers.
Diseases of the Digestive System. — I commence with the
digestive system. I am anxious to do this for several reasons,
but for none more than this — that, to the improvements made in
the pathology of the digestive system we owe much of the rapid
advancement of modern practical medicine. Before our time the
pathology of the digestive system was very little known, and
if not quite a terra incognita in medicine, there existed respect-
ing it a great deal of misconception. The schools were deeply
tinctured with the doctrines of the Humoralists and the Brown-
ists; and this had the effect of giving rise to irrational theories
and false notions of the true state of the system in disease. The
humoral pathologists, who sought for disease in an alteration
of the fluids alone, neglected the study of visceral lesions; and
when they turned their attention to the digestive system, they only
considered it, its secretions, and not its actual condition, or the
state of its sympathies. The liver, with them, was an or^an of the
highest importance, and the secretion of bile claimed a vast share
of their attention. To it they gave a paramount influence, and to
an alteration in its quantity and quality they attributed most of the
changes which occur, not only in the digestive tube, but also in
the whole system; and hence the great object of their practice was
to attempt to restore its healthy condition, convinced that if this
were once accomplished everything would go on favourably.
NEGLECT OF MORBDD ANATOMY. 31
From this, too, arose the purgative plan of treatment in various
forms of intestinal disease, a plan too often rashly pursued, even
where there was unequivocal proof of inflammation in the diges-
tive tube.* Their sole purpose was to evacuate sordes, to produce
a flow of healthy bile, and to eliminate depraved secretions; and
they did this without possessing any knowledge of local inflamma-
tion, or of the effects of disease of the digestive system on other
organs. The followers of Brown, on the other hand, only admitted
disease of the digestive system in a state of intense, manifest vio-
lence, as, for instance, ileus or violent enteritis; but in the great
majority of cases, they did not recognise intestinal inflammations,
because their prominent symptom was prostration, or, to use their
own terms, an asthenic condition of the whole system. They saw
nothing but prostration; they prescribed for nothing but debility;
they gave wine instead of iced water; ordered bark instead of local
depletion. They exasperated the disease by stimulants ; and then,
thinking they had not gone far enough, they heightened the stimu-
lant and doubled the debility.
Another cause of the low state of pathology in former times was
the general neglect of dissection. The fact is, that in fever there
were no post mortem examinations made, until very lately. Mor-
gagni, who did so much for pathological anatomy on almost every
other subject, did little for fever, because he was afraid to dissect
the bodies of persons who had died of a contagious disease. This
was the idea which prevailed among the older pathologists; and
hence this source of knowledge was avoided, and for many succes-
sive centuries the state of the viscera in fever was a matter of specu-
lation, doubt, and uncertainty. Even at the present day it is only
done by the ardent pathologist, who cares not about filth and stench,
and who had rather encounter the miasm of contagion than remain
in the mists of error. Nothing is more common, I regret to say,
even at the present time, than this: — A person says he has dis-
sected cases of fever, and when asked whether he had examined
the intestinal canal, he says that the intestines appeared healthy,
but he did not make any particular inspection of them ; he only
opened the belly, and, finding no trace of inflammation in the peri-
toneum, he went no farther. Now, nothing can be more useless
than such an examination. If we compare the information afforded
by an inspection of the serous membranes of the three great cavities,
we shall find that the least is given by an examination of that of
the abdomen. .Disease of the substance of the brain is rare with-
out affections of its investing membrane; disease of the substance of
the lung is exceedingly rare without the occurrence of disease of
the pleura; but you may have most extensive and fatal disease of
the intestinal canal, without the slightest lesion of the peritoneum.
In this point, therefore, it differs from the pleura, and from the
* [Our medical brethren of the south and west, will see, if not
reproof, at least a salutary hint, in these remarks of the lecturer.—B.]
32
DISEASES OF THE DIGESTIVE SYSTEM.
arachnoid membrane. The fact of the rarity of disease of the peri-
toneum in cases of disease affecting the parts beneath, was noticed
by Dr. Graves and myself, in our report of the Meath Hospital, and
also by Mr. Annesley, in his account of the diseases of India. You
will see cases of hepatic abscess, which present a distinct tumour
externally, and where you can detect a perceptible fluctuation;
and yet, if you examine these cases, after death, you may not find
any adhesions of the peritoneum, even in the situation of the ab-
scess. You will find the mucous and muscular coats of the colon
extensively destroyed, you will see the stomach all but perforated,
you will meet with cases where the whole ileum is one extensive
sheet of ulcerations, with no disease in the adjacent peritoneum.
In entering on the consideration of diseases of the digestive
system, we shall begin first with the mucous expansion of the sto-
mach and intestines, and then proceed to the affections of the solid
viscera connected with thenru The mucous surface of the stomach
and intestines is of enormous extent and extraordinary sensibility,
possessed of innumerable and powerful sympathies; its influence
is felt by almost every organ in the body, formed for receiving and
elaborating everything destined for nutrition; its conditions, both
in health and disease, are entitled to the deepest and most attentive
consideration. To facilitate the study of its affections, and for the
sake of some practical arrangement, we shall divide its diseases
into five classes, beginning with the oesophagus, or that portion of
the digestive tube which is above the diaphragm, and then pro-
ceeding to the stomach, duodenum, ileum, colon, and rectum. But,
in order to give you a clear idea of diseases of the intestinal canal,
I shall commence with diseases of the stomach; because, if you
consider the whole range of animal life, you will find that its func-
tions are the most important, the stomach constituting, as it were,
the source and fountain of life, which is nutrition, and giving by
its existence a character to all the upper classes of animals. No
organ possesses such remarkable sympathies as the stomach, whe-
ther we look upon them as sympathies, of organic or of animal life,
none possesses such remarkable power and influence in modifying
the condition of every part of the system. But, putting aside phy-
siological reasons, let us come to practical matters. The success of
almost every form of medical treatment, all the advantages to be
derived from the administration of internal medicine, depend upon
the stomach ; in fact, in whatever point of view we consider it, we
must look upon a knowledge of the state of the stomach as the great
key to sound and successful practice.
It is a most useful reflection to consider the extraordinary fre-
quency of disease in some portion of the digestive tube. It is now
admitted by every person possessed of experience in the causes of
mortality, that more human beings die with acute or chronic dis-
eases of the digestive tube than with diseases of any other part of
the system. This has been established by numerous investigations
and is admitted by the best pathologists; and, indeed, I Think it
LOCAL AND REMOTE PHENOMENA.
33
can be easily accounted for, when we call to mind how many per-
sons die of some form of fever or other, when we look to the ravages
of remittent and yellow fever, to the hundreds of thousands who
annually perish by the various classes of fevers. Now, in almost
every one of these cases, disease of the digestive system forms one
of the most prominent pathological characters. Recollect, besides,
all that die of dysentery, whether sporadic or simple, and here is
inflammation of the colon ; see, too, how many die with diarrhoea—
here,too, there is intestinal disease; remember how many die of the
malignant intermittent of the West Indies, in which unequivocal
proofs of disease of the stomach and intestines have been found.
Observe what a close connection there is between tabes mesente-
rica and inflammation of the mucous membrane and surface of the
intestines ; think what a vast number of persons fall victims to the
harassing effects of constipation and dyspepsia; and recollect that
there is a host of diseases in which the train of morbid phenomena
commences in the digestive system, and then exhibits itself by
functional alteration or organic disease of other parts.
We recognise the presence of disease in the digestive tube, first,
by the local phenomena and the lesion of the digestive function,
and next by the sympathetic relations of other parts, by the sym-
pathies of the respiratory system, of the circulation of the skin, and
of the nervous system. I shall enumerate the local phenomena
and functional lesions : vomiting, anorexia, thirst, jaundice, pain,
tenderness on pressure, tympanitis, changes in the character and
quality of the discharges, constipation. Here are a set of functional
lesions and local phenomena; let us now consider the sympathetic
relations ; these are fever, heat of skin, suppression of the cutane-
ous secretion, suppression of the secretion of urine, morbid states
of the tongue and pulse, pains in the chest and cough, hurried
breathing, and palpitations of the heart. In the next place, we may
have prostration of strength, delirium, coma, convulsions, tetanic
spasms, and other symptoms of functional disease of the brain ;
these are all sympathies of relation. Now, in the first place, I
have to remark, that there is a great deal of variety in the combi-
nation of these symptoms. On what does this depend 1 on a variety
of circumstances ; sometimes on the intensity or extent of the in-
flammation : sometimes on the situation of the disease: sometimes
on the complication of the affection; sometimes on the various
modes and degrees of susceptibility of the individual. All these
causes tend to produce a great variety in the disease, and an exten-
sive modification of the sympathetic relations. For instance, in
some cases inflammation of the stomach and intestines is so slight
that the patient is not prevented from going about and pursuing
his ordinary avocations; in others, on the contrary, the patients
are struck down at once by the violence of the disease, and are
carried off by the fever which accompanies it before the inflamma-
tion is completely developed. It varies also according to situation;
there is a difference between gastritis and dysentery: in the former
34 DISEASES OF THE DIGESTIVE SYSTEM.
we have an inactive state of the Jtreat intestine, and consequent
constipation; in the latter, the colon is thrown into violent action,
and there are frequent dejections. Disease of the duodenum is
attended with a very remarkable peculiarity, being very frequently
complicated with jaundice; here is a modification produced by
situation. Again, inflammation of the ileum is attended with a
very curious peculiarity, namely, the absence of pain. The patient
states, that he feels unwell, he has obscure symptoms of intestinal
disease, but it is neither dysentery nor gastritis; you investigate
it with care, and find that the ileum is in a state of inflammation.
Yet the patient does not complain of any pain; and this is another
peculiarity depending on situation.*
But in considering the differences which depend upon intensity,
extent, and situation of disease of the intestinal canal, we must not
omit those which depend upon tissue. If disease be confined to
the mucous membrane of the intestines alone, we may have an
extremely diffused and extensive inflammation, sufficient to destroy
life, without any pain being complained of by the patient; it is a
painless though fatal disease. Recollect this, — extensive and fatal
inflammation without pain. In former times the ideas of pain and
inflammation were inseparable. Thanks to the light which patho-
logy has shed upon modern medical science, we are now acquainted
with this seeming anomaly, and can conceive the existence of ex-
tensive disease of mucous surfaces unaccompanied by pain. But
let the inflammation seize on the muscular tissue, the character of
the disease is instantly changed, and the pain is dreadful. Here
is a case in which difference of tissue is to be taken into consider-
ation.f
The phenomena and sympathetic relations of intestinal disease
may vary also according to its complication, and here we come to
investigate one of the most beautiful laws of the human economy,
namely, that the more complicated a disease is, the more latent will
be any local lesion. This is a point that should never be forgotten.
For instance, enteritis by itself is much more easily recognised
than when complicated with pneumonia, or with irritation of the
brain, and gastritis is but too often completely masked by being
* [The physiological explanation consists in the fact of the ner-
vous supply to the ileum, coming from the sympathetic; a fact of
importance, which should be borne in mind in making our prognosis
of typhoid fever. The absence of pain might induce belief that
there was no organic lesion. — B.]
| [The position is, perhaps, rather too broadly laid down in the
text. The sensations of the patient will depend very much on the
portion of intestine affected; whether duodenum, for example, or
jejunum, and whether even the upper or the lower part of the ileum.
The first and last portions of the intestinal canal receive branches
of the cerebro-spinal nerves, — the middle is supplied almost entirely
by the sympathetic. — B.]
DISEASES OF THE MOUTH AND PHARYNX. 35
combined with irritation of the bronchial mucous membrane.
Lastly, we have the varieties which depend on different degrees of
susceptibility. In one person we may have only slight cerebral
irritation, in another high excitement, in a third delirium and ex-
traordinary convulsions. The variety, then, in the modifications
of diseases, and the combination of sympathies, is very great, and
is referable to the extent and the intensity of the inflammation,
difference of situation, complication of disease, difference of tissue,
and different degrees of susceptibility.
LECTURE III.
DR. BELL.
Diseases of the Mouth and Pharynx. — Connexion in structure and function
between them and diseases of the stomach and bowels — Stomatitis — ita
different 6pecies—Simple erythematic stomatitis —Its nature, causes and
treatment—Follicular or aphthous stomatitis—Its varieties, complications;
pathology, analogous to follicular gastritis and enteritis — Connexion with
dyspepsy in adults, and in children with cholera and diarrhoea—Remedies,
general and local —Importance of hygienic measures — Ulcerous stomatitis —
Pultaceous stomatitis, or muguet—Its pathology—Treatment.
Doctor Stokes passes directly from a general view of the patho-
logy of the digestive system to a consideration of gastritis, its
pathology and treatment. But before taking up this subject, it
will be well to describe to you some of the chief morbid alterations
in the upper portion of the alimentary canal, or the buccal and
pharyngeal regions. This proceeding is in conformity with an
affinity between these regions and the stomach, which is manifested
both by a continuity and general resemblance of tissue, (the mu-
cous,) and by a resemblance and sympathy between them in their
morbid states. In fact, just as we look at the tongue for an index to
the state of the stomach, so may we expect to see often in the diseases
of the mucous membrane of the mouth and pharynx a reflexion of
those of the gastric mucous membrane. I do not by any means
assert, that there is uniformity in this respect; but that there is so
frequent a connexion between the inflammation and irritation of the
stomach and the upper cavities already mentioned, that we shall be
not a little remiss in our diagnosis, and needlessly conjectural in our
prognosis, of the diseases of the digestive system, if we do not, with
a knowledge of the frequency of this connexion, institute a careful
inquiry into the state of both regions, even when our attention is
invoked solely for one of them. In practice, we shall be much more
successful by taking this enlarged view, than if we restrict ourselves
to an investigation of either alone, and fail to see more than a
mere local disease in the morbid alterations of the mucous mem-
brane of the mouth; or are aware that a chronic affection of the
36
DISEASES OF THE DIGESTIVE SYSTEM.
stomach assumes a much more serious, not to say alarming aspect*
when accompanied with some degree of pharyngitis, and still more
with aphthae and ulcers of the mouth and palate.
Stomatitis.—The morbid states of the buccal mucous membrane
have been va riously designated, not only in reference to t heir varieties,
but to each of these separately. They have engaged the attention
of medical men more when they appear in the infantile subject than
in the adult; on account of their greater frequency of occurrence
in the former than in the latter. The general and popular term for
designating the sore mouth of infants is thrush ; the technical one
aphtha. Of late years a new title is given to the whole class of
diseases of the mucous membrane of the mouth, which, as far as
its radicle is concerned, is perfectly appropriate, but as in all cases
implying inflammation is not so accurate. The title is Stomatitis,
from o-tofAo., mouth; and this is the generic name which is now
adopted by the French and some English and American writers
for diseases of the lining membrane of the mouth. The specific
titles are more or less numerous with different authors. Those of
M. Andral (Cours de Pathologie Interne) seem to me to designate
with sufficient distinctness the several morbid states of this region,
and I shall therefore adopt them, with the addition of the ulcerous
species. They are—1. Simple Stomatitis; 2. Aphthous (Follicu-
lar) Stomatitis; 3. Ulcerous Stomatitis ; 4. Pultaceous Stomatitis ;
5. Pseudo-membranous, or Pellicular; and 6. Gangrenous Stomatitis.
1. Simple or Erythematic Stomatitis. — This species is common,
but in a mild degree, in newly-born children, who are predisposed to
it by the congested state of the mucous membrane of the mouth at
birth. It is usually marked by redness, heat, and some degree of
dryness of the mouth and tongue. Sometimes, as M. Billard de-
scribes it, the inflammation is confined to one part of the buccal
surface, at others it covers the whole and spreads to the lips, which
tumefy, excoriate, crack, and frequently become the seat of herpes
labialis. Often it accompanies inflammation of the stomach or
bowels, but rarely causes fever in very young infants, whereas
this is a common addition in children from seven to nine years of awe.
The functions of the mouth, or those in which it participates, such
as mastication, deglutition, and speech, are performed with difficultv
and pain; and sometimes there is a copious ptyalism. The dura-
tion of the disease is from three to eight days; and the termination
is commonly by resolution. This description is applicable to in-
fantile stomatitis, but when the erythematic variety occurs, as it
every now and then does, in adults, associated with dyspepsia, and
is aggravated by the use of tobacco, and particularly smoking
this poisonous weed, the prognosis is not by any means so clear.
Nor must we expect, even in children, always to find this kind of
inflammation of the mouth retain its simple erythematic character*
for, sometimes, it is followed by ulcerations and even gangrene;
and it is not uncommon, says M. Andral, for us to see after this dis-
ease an induration of the sub-mucous tissue of the mouth.
FOLLICULAR OR APHTHOUS STOMATITIS. 37
Causes. —Of the causes of simple stomatitis, dentition is the first
and most common one; others are enumerated, such as very hot
drinks taken into the mouth : acrid, caustic, and poisonous substances
of various kinds; contusions, operations on the teeth, and the accu-
mulation of tartar. Sometimes, as already intimated, it is sympto-
matic of inflammation of the digestive canal.
Treatment. — The cure of simple stomatitis is generally trusted
to mild means, such as simplicity of regimen, mucilaginous drinks,
consisting of gum water, or a decoction of slippery-elm or sassafras
pith, alone, or mixed with milk. If the inflammation run higher,
and fever be present, a few leeches should be applied at the base of
the jaw, or even to the gums themselves, provided the child be not
of a scorbutic habit, or badly nourished and with little habitual ac-
tivity of capillary circulation. In this latter case, counter-irritation
by moderately stimulating liniments is to be practised on the skin
of the base of the jaw and mouth, extending back to the angles of
the former. Saline or slightly acidulated gargles will be of ser-
vice, and in nearly all cases of any intensity the bowels should be
excited to increased exonerationbycastor oil,magnesia and rhubarb,
or, with reserve adapted to the temperament of the child, a small
dose or two of calomel. This medicine will be most serviceable in
the sanguine or nervoso-sanguine; but much less so, if allowable
at all, in the decidedly lymphatic with much sluggishness of the
functions generally. The warm bath is a useful adjunct to the
treatment in this as it is in most of the diseases of children, and in
many cases it will, with a little change of air, and a simple, and
even reduced milk diet, suffice for the cure.
2. Follicular or Aphthous Stomatitis — Aphtha — Thrush. — This
is the most common kiud of sore mouth in children; and it is that
which is a frequent accompaniment of chronic diseases of the gastro-
intestinal mucous surface in subjects of all ages, as of gastritis,
gastro-enteritis, cholera infantum, and dysentery ; also of typhous
fever, and diseases of the lungs, and particularly of pulmonary
phthisis in its third stage.
Three varieties are described of aphthous stomatitis, viz.— 1.
papular; 2, vesicular; 3, pustular. These are often met with
constituting successive stages rather than separate varieties of the
disease. Whatever may be the form under which it exhibits itself,
it more especially attacks the parts in which the epithelium is the
most apparent. It usually appears first in the angles of the lips, and
then on the tongue and the lining membrane of the lips and cheeks,
and on the velum palati, in the form of little papular, vesicular, or
pustular white specks, which some writers have denominated ulcers;
but this term is not applicable until the specks burst, — a termination
which usually occurs between the second and third day.
The eruption may be either discreet or confluent. The former
is happily the most common ; but sometimes the other, or con-
fluent variety, is met with, and it may prevail epidemically. It is
no uncommon thing to meet with, in persona, and particularly
vol. 1.—4
3S
DISEASES OF THE DIGESTIVE SYSTEM.
children, who have long suffered from bowel disease, an increase
in the number and size of the specks, which run together and com-
pose a thin white crust, that at length lines the whole inside of the
mouth, from the lips even to the oesophagus. In this stage there is
fever, headache, and often vomiting and other disorder of gastric
function. But when this kind of sore mouth, or thrush, is a pri-
mary disease, there is not, says Underwood, (Treatise on the
Diseases of Children,) in nine out of ten cases, the least fever,
though the mouth is often so much heated as to excoriate the nip-
ples of the nurse, and so tender that the child is often observed to
suck with reluctance and caution.
It is a popular opinion that the eruption and ulceration of thrush
are continued down the oesophagus, and thence into the stomach,
and along the entire course of the intestinal canal, showing itself in
a redness about the anus. No doubt there is often coincident and
sometimes preceding disease of the stomach and other parts of the
digestive tube in stomatitis; but the continuity as above described
seldom exists. Nothing is more common than this redness and
erythematic inflammation about the anus in diseases of the diges-
tive system of children; and it is worthy of remark, that certain
poisons will spend their whole force, as far as this system is im-
plicated, on the stomach, pharynx, and rectum, leaving the inter-
mediate regions intact, or but slightly affected.
The duration of this disease in its milder or simpler forms will vary
from three or four days to as many weeks; sometimes returning at
different intervals. Underwood states, that he has seen this so very
often the case, that when he found a child to have the complaint
very slightly, and that it did not increase after two or three days,
he ventured to pronounce it likely to continue a long time, but that
it will be of no consequence.
Pathology. — It would be an erroneous notion respecting aph-
thae, if we regarded them as an ulcerative termination of com-
mon inflammation. Callisen has described them as small tumours,
from a change of the muciparous glands. Billard,with more pro-
bability, considers them to be a morbid development of these bodies,
or follicles of the mouth, sometimes in a state of simple tumefaction,
at other times in a state of ulceration. " The muciparous follicles of
the mucous membrane of the mouth are invisible in their ordinary
state, and remain hidden in the thickness of the membrane, and
compensate by their infinite number for the smallness of their size;
but when they begin to inflame and tumefy, they appear on the
internal surface of the lips and cheeks, on the pillars of the velum
and the palatine arch, on the inferior surface and lateral parts of
the base of the tongue, under the form of small white points, some-
times exhibiting a coloured spot in their centre, slightly prominent,
and often surrounded by a slight inflammatory circle. These fol-
licles are either isolated, and few in number, or multiplied and spread
over every part of the mouth. Sometimes they may be felt with
the finger, when they are not sufficiently distinct to be seen. They
FOLLICULAR OR APHTHOUS STOMATITIS.
3ft
often do not stop at the mouth, but spread to the oesophagus, sto-
mach, and intestinal tube." (Billard — Treatise on the Diseases of
Infants, Dr. Stewart's Translation.)—The follicular points enlarge,
preserving still their primitive circular form; and from their central
aperture there soon issues a white matter, which, being squeezed
by the surrounding epithelium, itself soon beginning to ulcerate,
there is an exudation of white puriform matter over all the parts.
Numerous aphthae and their proximity soon allow of the spread-
ing of the excreted curdy matter so as to form a continuous coat of
greater or less thickness, as already mentioned. In this state the
aphthous is often confounded with the pultaceous stomatitis, or
muguet, hereafter to be described ; but they may be distinguished
by inspection of the inflamed follicles, and a solution of continuity,
which is not met with in the latter disease. This is most common
within the month ; aphthae during dentition.
Aphthae do not always exhibit the same characters in different
spots. Sometimes, when the follicles are about to ulcerate, the
edges of the ulcers, instead of being covered with a slight curdy ex-
cretion, exhale a small quantity of blood, which concretes under
the form of a slight brown scab, mistaken, says Billard, by some
authors, for a gangrenous eschar.
The causes of follicular or aphthous stomatitis are predisposing
and exciting; and of these the first is the most important and the
l&asl controllable, because consisting in an excess of the white
tissues, or a predominance of the lymphatic temperament. This
may be greatly increased by bad or defective food and im-
pure air, under the influence of slight causes, such as indigestion,
common bowel complaint, or changes in the milk or other food.
As evincive of predisposition in certain subjects over others,
the practitioner must doubtless be able, from his own observa-
tion, to confirm the remarks of Underwood, that " the thrush is
sometimes found to seize every infant in certain families, in what-
ever way the children may be managed." Illustrating the effect
of dietetic regimen, is the additional observation of this experienced
physician, though inelegant writer, that want of a proper attention
to the state of the alimentary canal will bring on the disease, as
" where the mother happening to be ill, the whole attention of the
family has been thereby engaged; or where one infant has been
put to nurse, while all the rest of the children have been carefully
brought up at home."
Aphthous stomatitis is mainly induced and kept up by disordered
digestion and impeded nutrition; and hence its common occur-
rence in those children who are brought up by the hand, and espe-
cially in those who, in addition to the deprivation of their mother's
or nurse's milk, are cooped up together in hospitals, and deprived of
fresh air, and illy attended to in the means for preserving a clean
and fresh state of the skin. " The fact is, the thrush is a disease of
debility, and therefore, attacks very young and very old subjects,
especially if otherwise weakened," Whoever has watched the
40
DISEASES OF THE DIGESTIVE SYSTEM.
progress of protracted cases of cholera infantum, and seen the
spread and severity of aphthae, increasing as the disease advanced,
and the little patient become weaker and more emaciated, will con-
firm the accuracy of this remark.
Reference has been before made to some of the symptoms ac-
companying aphthae. Those most marked are produced by the
morbid state of digestion, such as eructations of an acid smell,
sometimes vomiting and irregular action of the bowels; heat of
skin and fever; but you have been already told that this last
is by no means a common complication of simple or discreet
aphthae. On this point, however, we must remember that the ex-
citement of the heart and bloodvessel system is relatively low in
subjects of a lymphatic temperament, and hence we are not to lay
stress on this as the only measure of inflammation or febrile action
in them. If we were to judge from the cries, wakefulness and
restlessness of children affected with aphthae, we should infer that
they experience pain. When the disease extends to the pharynx
and produces a swelling of the glands and inflammation of the
trachea, which is among its alleged effects, the cry of the child is
sensibly altered, and it manifests pain, but more by a harsh or hissing
cry than by its tears. (Gardien, Traite Complet d'Accouchemens.)
Treatment. — We cannot judiciously apply our remedies in aph-
thous stomatitis, without a due knowledge and consideration of its
precursory and concomitant disorders. Thus, if it exists with den-
tition, and there be much tumefaction and redness of the gums,
with irritative fever at the same time, the treatment will be directed
to the relief of this morbid state, and nearly all the medicines used
for the aphthae will be of a topical kind, and these the most simple,
such as a linctus made of mucilage of gum arabic and syrup, with
a little acetic acid ; or if the heat and irritation of the mucous mem-
brane be considerable, a weak solution of sugar of lead may be
lightly applied to the parts by means of a fine brush or a piece of
lint tied to the end of a small, rounded stick. The sub-lingual, or
the sub-maxillary glands, taking on secondary disease by the irri-
tation transmitted from the mucous membrane of the mouth, may
require the application to them of a few leeches, followed by a
poultice and camphorated spirituous lotions so applied as to pro-
duce evaporation.
Patches of aphthae or scattered ones in the regions already men-
tioned, without apparent complication of pain or fever, may be
treated by, at first, mild mucilaginous linctus applied cold, and the
administration of adoseof castoroil,or rhubarb and magnesia,to pro-
cure a moderate but yet tolerably complete evacuation of the bowels.
The disease still persisting, recourse will be had to a somewhat sti-
mulating substance, such as borax, or alum ; the former in a linctus
with sugar and mucilage, or with honey and water; the latter dis-
solved in sweetened barley water, in the proportion of ten grains to
the ounce. The preparation of borax which I prefer myself, after
frequent trials of its efficacy, is a solution with sugar in water and
FOLLICULAR OR APHTHOUS STOMATITIS. 41
alcohol; to which sometimes a little laudanum is added, as follows :
B. Sodae sub-borat. 9i.; Aquae fluvialis, f 5ij; Alcohol, f^ss; Sacchar.
albi, 3ij. M. ft. Solutio. As there is great difference in the com-
mon, as well as the morbid, sensibility of the parts, the quantity of
borax will be increased or diminished accordingly. If it be thought
advisable to circumscribe more accurately, and to retain the sub-
stance longer on the part to which it is applied than can be done
by a simple solution, gum arabic may be mixed in adequate quan-
tity. But of the preparations which combine power with mildness,
I know none equal to a solution of chloride of soda, as it is sold in
the shops, and diluted with water, and to be applied as a gargle, in the
proportion of one drachm to an ounce. In place of this, the chloride
of lime in solution may be used. The fetor is removed, and the
sores cleansed and excited to heal by these chlorides. I need not
enlarge on the use of other topical remedies in this disease, as I
shall have occasion to recur to this kind of medication, when treating
of pultaceous and pseudo-membranous stomatites.
But, whenever we are called to a case of aphthous stomatitis which
has lasted more than a few days in a child of very lymphatic tem-
perament, and whose regimen has-been faulty, we must regard all
local remedies, indeed all treatment purely medicinal, as- of secon-
dary importance; and direct our measures to a change in the food,
the air, and the applicata, both as regards clothing and bathing. If a
child has been weaned, we ought to restore it to the breast; or, if
this cannot be done, to give it nutriment nearly analogous to that
derived from the maternal bosom. Sometimes, indeed, we are
compelled to prescribe the substitute in preference to the original
supply, as. where the mother is pregnant, and her milk evidently
disagrees with, and disorders the child. Cow's, milk, fresh, and
with a little farinaceous matter, as ground rice, pounded crackers,
arrow root, or barley flour, mixed with it, and sweetened, is the
best succedaneum for the mother's milk, and will, when given at
proper intervals, in quantity not too great at a time, nourish, and
correct, at the same time controul, previous looseness and concomi-
tant disturbance of the bowels. Fresh air is to be admitted to the
little patient in the room, if circumstances prevent its being taken
out; but the latter course is still better, and will alone exert a bene-
ficially controling power over the disease. Frequent changes of
body-clothes, which must be of a suitable warmth, but not oppres-
sive by their weight and thickness,—and the daily, or twice daily,
use of the warm bath, at from 90° to 94° F., according to the
temperature of the skin and activity of circulation, will greatly
contribute to the cure. During the time in which the appropriate
regimen is employed attention is to be paid to the state of the
bowels. Sometimes they will be acted on by castor oil, or rhubarb
and magnesia ; sometimes with chalk mixture, and at other times
again with minute or fractional doses of calomel, mixed with gum-
arabic, or still farther reduced in strength by mixture with chalk.
For the most part vou will discover complications of visceral
4*
42
DISEASES OF THE DIGESTIVE SYSTEM.
disorder with aphtha? of sufficient moment to prompt you to the
remedies just indicated; and it is on this account that 1 en-
large the more on the treatment of the disease of which aphthae
are but a part, perhaps only a symptom, as in gastritis, or in gastro-
enteritis of children, constituting what is generally called cholera
infantum, or it may be to analogous irritation in the digestive tube,
kept up by teething. u
If I insist on the paramount importance of regimen in aphthous
stomatitis, and dwell on the wants of nutrition, as indicated by the
causes, and precursory as well as associated phenomena, I would wish
to be understood as recommending renovation, but not that kind of
excitement procured by stimulating remedies; and hence the pre-
ference I give of regiminal over medicinal means. I would now,
in harmony with this view of the nature of the disease, add that,
after the therapeutic treatment, which I have stated to you, has been
tried, and the febricula which may have been present removed,
or so much abated as to excite no uneasiness in your mind, you
may then administer with advantage a mild tonic. Of this class,
a simple watery cold infusion of chamomile flower, or of wild-
cherry tree bark, or if the skin be cold and circulation feeble,
sulphate of quinia, are to be preferred. Stress has been laid by
some on preparations of iron, and I have myself used the muriated
tincture with advantage in that feebleness of frame, in which pros-
tration and derangement of digestion and aphthae were the predo-
minant disorders.
3. Ulcerous Stomatitis. — This may be readily confounded with
the former kind, but it differs in its not being restricted to the folli-
cles. The ulcers occupy indifferently every part of the buccal
cavity, viz., the frenum of the tongue, its base, the internal surface
of the cheeks, and the palatine arch.
Under this head we may properly introduce mercurial stomatitis,
the existence of which is not always announced nor accompanied by
the characteristic mercurial fetor. I have seen ulcers of the
mouth and gums following the use of calomel in large doses in
young children, at a time when they who administered them
thought that the medicine produced no effect.
The treatment of ulcerous stomatitis requires nothing of a spe-
cific character, — at any rate different from that of follicular stoma-
titis. The same attention should be given, as in this latter disease, to
the state of the general health, and the means recommended for
renovating the digestion and quickening nutrition, concurrently with
topical applications, used in the one, as were thought advisable in
the other.
Pustular Stomatitis is a name given by M. Billard to the inflam-
mation developed during the course of small-pox, and is analogous
to the circumscribed pustular ulceration of the skin,and identical pre-
cisely with that variolous ulceration which attacks all parts of the mu-
cous surface (pharyngeal and tracheo-bronchial) that are reached by
the atmospheric air. Nor do the aphthae which accompany scarlet
PULTACEOUS STOMATITIS.
43
fever or measles, require any specific notice in this place, consti-
tuting as they do a part of these formidable diseases, and to be no-
ticed with the other symptoms and the treatment hereafter.
4. Pultaceous or Curdy Stomatitis, or Stomatitis with altered Secre-
tion—Muguet—White Thrush. — This species has a greater affinity
to the first described one, or the erythematic, than any other. It is
peculiarly a disease which attacks, in preference, infants soon after
birth, and those still at the breast. " It is characterized by a con-
cretion of mucus on the surface of inflamed mucous membrane,
whether this be an epithelium or not. This concretion may be ob-
served in the mouth, oesophagus, stomach, and small or large intes-
tines" (Billard).
Pultaceous stomatitis begins with small specks on the surface of
the inflamed membrane ; they are seen on the inside of the lips and
at the tip of the tongue. Gradually they are increased, enlarge, and
unite together as irregular, thin laminae, which sometimes remain
separate, then exfoliate, and are replaced by others in successive se-
ries. Sometimes, on the other hand, they become thicker and more
diffused, so as to run into one another and form a continuous mem-
brane, which lines the cavity of the mouth and covers the surface
of the tongue, extending even over the pharynx and oesophagus, and*
as M. Billard asserts, continued into the stomach and the whole
intestinal canal. In the first or simpler form the disease is called
discreet, in the latter confluent.
Pathology. — Pultaceous stomatitis consists in an inflammation of
the buccal mucous membrane, which soon produces a morbid secre-
tion of mucus, of a white or curd-like appearance, that afterwards
concretes, and covers a surface of more or less extent. This pelli-
cular or curdy production takes the place of the mucus which
moistens and lubricates the mouth. Concretion in laminar shape,
external to the epithelium and unaccompanied by ulceration, and
its repeated removal and reproduction until the inflammation is ex-
hausted, distinguish this kind of stomatitis, the true muguet of French
writers, from the aphthous or ulcerous species.
The causes of this disease, as laid down by M. Billard, are, " the
first period of infancy — bad nutrition — the assemblage of a great
number of children in the same place — debility — inflammation of
the buccal membrane,— and lastly, the disposition which the mucous
membrane exhibits in young children to be covered, when they are
inflamed, with thick, curdy, and membraniform concretions."
" As to general symptoms, they scarcely exist in very young in-
fants ; fever is hardly ever manifested. I counted," says M- Billard,
"the pulse and the beatings of the heart in forty children, aged from
one to twenty days, affected with it, and found fifty, sixty, sixty-
five, eighty, and in one instance one hundred pulsations in a minute
With the exception of the last case, the number of pulsations did
not differ from the natural state of the pulse." M. Billard, you
ought to be apprised, does not believe that there is greater frequency
of pulse in infants than in adults; but in this opinion he is not sus-
44
DISEASES OF THE DIGESTIVE SYSTEM.
tained bv the experimental observations of other physicians. The
skin is u'sually hot and drv. When the membraniform concretions
spread to the tonsils, and cover the pillars of the velum palati,
the cry is husky. Sometimes, and the fact merits your attention,
pultaceous stomatitis is complicated with other phlegmasiae. In
fifty cases, fatal either from the disease or its complications, there
was disease of the digestive apparatus in thirty-two.
Season is said not to exert .any marked modifying influence
in causing muguet. It prevailed, according to M. Billard, with
almost equal intensity, and at all times, at the Hospice des Enfans
Trouves (Foundling Hospital). But the statement which he gives
is not in unison with this assertion. In the quarter ending in March,
1826, out of two hundred and ninety patients, there were thirty-four
cases of this disease. In the quarter ending in June, out of two
hundred and thirty-five patients, there were thirty-five cases; in
the three months ending in September, out of two hundred and
thirteen sick, there were one hundred and one cases; and forty-eight
cases in the quarter ending in December among one hundred and
eighty-nine patients. Thus we see that the actual numbers in each
quarter were respectively, 34, 35, 101 and 48, showing nearly three
times as many in the third or summer quarter, as in the winter
and spring, and more than twice as many as in the autumn. The
proportion of the sick with muguet to other diseases in the
Hospital, were as 1 to 8| in the winter; 1 to not quite 7 in the
spring; 1 to a little more than 2 in the summer, and 1 to not quite
4 in the autumn.
The contagiousness of this kind of stomatitis, believed by many,
is denied by M. Billard, who refers to, while confirming, the expe-
rience of M. Baron. This gentleman has often seen children drink
from the cup used by those who have been affected without their
contracting the disease.
Treatment. — The remedies for this kind of sore mouth are
nearly the same as those recommended in other kinds of stomatitis.
In simple or discreet muguet, it will be sufficient to cleanse the mouth
with a little piece of sponge, or of lint, tied to the end of a quill, after
dipping it either in a simple mucilage, or in one slightly quickened
with vegetable acid ; and to alter somewhat the intestinal secretions
by a mild laxative. But in confluent or diffused pultaceous sto-
matitis, or muguet, we should apply fomentations or cataplasms to
the neck, and cooling saline gargles to the mouth, and purge with
a small dose of calomel, followed by castor oil and magnesia. The
farther treatment will be regulated by the state of the stomach, ac-
cession of fever, and the appearance of the mouth. Minute doses of
the alkalies, — carbonates of potassa and of soda, in solution with
ipecacuanha wine; or ipecacuanha and chalk, the warm bath, and
mildly astringent or stimulating washes or linctus to the mouth and
fauces, will be brought into requisition, in the more violent cases of
the kind of stomatitis now under notice. Of gargles, my prefer-
ence is still in favour of fluid chloride of soda, to which, on occa-
PSEUDO-MEMBRANOUS STOMATITIS.
45
sions, in this, as well as in aphthous stomatitis, may be added tinc-
ture of myrrh, as in the following prescription:—R. Liq. chlorid.
sodae, Tinct. myrrhae, aa f gss.; Aquse fluvialis, f^vi.; Aquae Ro-
sar. f |i. M. This gargle to be applied at intervals, as may be
deemed necessary.
LECTURE IV.
DR. BELL.
Pseudo-membranous Stomatitis. — Its complications with visceral disease —
insidious approach — Pathology — sometimes prevails epidemically — Treat-
ment, modified by the state of the digestive system and degree of local excite-
ment— Local applications — Means of properly applying mineral acids and
lunar caustic — Sulphate of copper — Iodine, topically and internally — Warm
bath — Gangrenous stomatitis — As a result of other kinds of stomatitis, and as a
separate disease—Different opinions as to its violence and danger — Two
stages of gangrene of the mouth — Its Pathology—common origin in the gums
— Treatment, general and local — Emetics, tonics, and the warm bath and
frictions — Iodine — Topical remedies — numerous — The chief one is sul-
phate of copper.
Iwr continuing my observatious on the different kinds of sore mouth,
with inflammation, I shall in this lecture speak of the one which is
characterized by a membranous or pellicular secretion, somewhat re-
sembling that in croup, and identical with that which lines the fauces
and pharynx in certain varieties of angina. After this, your attention
will be directed to the gangrenous sore mouth, the most violent and
unmanageable of all the species of stomatitis. Let me again im-
press on your minds the necessity of constantly being aware of the
dependence of the local disease on the state of the general system,
and especially on interrupted and perverted nutrition; and the im-
possibility of removing the former unless the latter be corrected,
and the permanent stimulants of pure air, wholesome food, and some
exercise, be brought into operation on the frame of the little suf-
ferer.
5. Pseudo-Membranous Stomatitis — Buccal Diphtheritis. —
This is the most dangerous of all the stomatites. It occurs not only
alone but in connexion with inflammation and a similar exudation
on the pharynx, tonsils, or soft palate of children. Its seat is com-
monly on the gums, angles of the lips, and on their inner surface, and
the lining of the cheeks, or the tip and sides of the tongue. It is more
usually seen on one side only : at first appearing as small patches of
a grayish-white, irregularly rounded, it afterwards extends by the
running of these together, and their becoming gray, dark, and
livid : they appear depressed, owing to the projection on their mar-
gin of the surrounding mucous membrane. Laminae of the false
membrane are, after awhile, detached to be replaced by others. At
this epoch of the disease, the membranous formation extends over
46
DISEASES OF THE DIGESTIVE SYSTEM.
a part of the tongue, the gums, and the internal surface of the cheeks.
During some days it is nearly stationary, after which there is a
change, either by resolution or gangrene. In the first contingency
the patches at their centres, or their borders, begin to be absorbed,
and there only remains a simple whitish streak, which gradually
disappears, leaving no trace of disease. But when gangrene super-
venes, we see some points on which absorption takes place, whilst
the rest of the tissue is completely mortified.
This kind of stomatitis is complicated at times with bronchitis,
pneumonia, or inflammation of the digestive canal. Regarded as a
pellicular inflammation, or one attended with exudation, for such is
the etymological signification of diphtherite, this disease is not com-
mon, but occasionally, as Drs. Evanson and Maunsell observes (A
Practical Treatise on the Management and Diseases of Children),
" we have seen and removed from the velum or back of the pharynx
a thick pellicle of lymph; the mucous membrane beneath being in-
flamed, but free from ulcer or slough. On the contrary, we have
found from the first the inflamed surface beneath converted wholly
into an ash-coloured slough or studded with patches of such."
Happily this form of diphtherite is not so common as might be sup-
posed from the remarks of some writers who apply this term to any
spreading ulceration at the back part of the throat. It is always
dangerous, and often the more so from the insidiousness of its ap-
proach, and its having made extensive progress without any unea-
siness in the throat, pain in swallowing, or other symptom to
indicate the real nature of the disease. Sloughing in gangrene
may be the result of any of the morbid conditions of the mouth or
fauces of which we have spoken ; but it is most liable to occur in
affections of the tonsils, soft palate, or back of the throat; perhaps
more particularly when attended by false membranes.
" When inflammation of the tonsils or pharynx is very intense, ac-
companied by false membranes, or occurring during scarlatina or
any livid-coloured eruption, we may apprehend gangrene, parti-
cularly if the child be very delicate, badly nourished, or exposed to
contagion, (as when gangrenous sore throat prevails,) or if gan-
grene of other parts of the body be present. We judge of the ap-
proach of gangrene by the local appearances and general symptoms,
as when much or sudden prostration attends, or is induced by a
disproportionate degree of depletion; while the colour of the in-
flamed part changes from a lively red to pale, or appears from the
first of a livid or dusky red hue." (Op. citat.) When the isthmus
of the fauces is affected the appearance of the parts betrays this
state, accompanied by a sense of suffocation, and difficulty of de-
glutition ; which last becomes impossible, if the gangrene has ex-
tended to the oesophagus; and when it has passed into the air tubes,
there is a remarkable alteration in the cry or voice, which becomes
hoarse or inaudible, with a peculiar cough, or wheezing respiration.
Symptoms. — In the .beginning of this disease, increased heat of
the mouth is felt and complained of, and also pain, aggravated by
PSEUDO-MEMBRANOUS STOMATITIS. 47
the contact of any foreign body. The breath is fetid, and the sub-
maxillary glands are engorged and painful. After a while the lips
and gums are tumid and bleed, and a sanious saliva flows copiously
from the half open mouth; the breath becomes more and more of-
fensive, the face red and swelled, and the fever more or less intense;
there are, also, headache, restlessness and vigilance. Gradually,
when absorption has begun, these symptoms abate, and the con-
valescence sets in.
Causes.— Membranous stomatitis attacks persons of all ages,
but more frequently children than adults. It is most apt to occur
in cold and damp weather, and where attention has not been paid
to cleanliness and ventilation, as where a number of children are
crowded together in hospital wards, or small and close rooms.
Sometimes this kind of stomatitis prevails epidemically, but it does
not appear to be contagious. It has been known to follow mercu-
rial ptyalism, and it has been observed in fevers called by some
continental writers mucous, and at the termination of certain
chronic maladies.
Treatment. — The remedial measures to which we have re-
course in pseudo-membranous stomatitis are nearly the same with
those in aphthous stomatitis. The same prompt attention is
required to remove the external and other causes by which nutri-
tion is deteriorated, viz., impure air, bad and insufficient food, and
personal filth ; and to substitute in their stead wholesome and appro-
priate aliment, pure air, bathing, and clean and frequently changed
body linen. The condition of the digestive system must be ame-
liorated, it cannot all at once be relieved of disease, by mild laxatives,
with the first dose of which we may combine a grain or two of calo-
mel ; and afterwards simple bitters, or a weak solution of sulphate of
quinia. Concurrently with these means we attempt an abatement of
the local malady, by leeches beneath the chin or under the jaw, if
the glands be sympathetically swollen and inflamed. But, if good
is expected from even local depletion, it must be in the first stage
of the disease, and ere the system becomes prostrated, as if under
the influence of a poison. In a more advanced stage, when the
skin is cold and the circulation feeble, we may place considerable
reliance on the effects of oil of turpentine, given at first in a dose
of 3i- with castor oil 3ij. to ^ss., according to the age of the child,
and afterwards alone in a dose of 3ss. three times in the twenty-four
hours, mixed wiih sugar and gum, — or, in extreme cases, with
carbonate of ammonia. At this time a stimulating liniment, with
turpentine oil as its basis, will be usefully applied, by rubbing, and
by means of a piece of flannel dipped in the same to the throat and
lower jaw.
More stress is laid upon early recourse to local applications, and
especially to those of a stimulant nature to the mouth, in this, than
in the other kinds of stomatitis; and above all, if the subject of it
has been exposed to the deleterious influences so prevalent in hos-
pitals and crowded and illy ventilated rooms. In the selection of
48
DISEASES OF THE DIGESTIVE SYSTEM.
these it is most prudent to begin with the milder ones, such as
vinegar and water, fluid chloride of soda and water, tincture of
myrrh, or a solution of borax, or even of common salt, which last
is a very good detergent ; and afterwards, if the excitement is feeble
or rapidly diminishing, we use those of a more potential character.
Foremost in the good opinion of many, are the mineral acids, and
of these the preferred one is the hydrochloric or muriatic acid.
It may be used either as a common detersive gargle, sufficiently
diluted or mixed with honey, in the proportion of one drachm of the
acid to an ounce of the vehicle, or used as an escharotic undiluted, in
which case it may be applied by a glass capillary tube, which,
when immersed in the acid, takes up two or three drops, and after-
wards put on the diseased surface, allows of their escape. In the
common method of applying the acid with a sponge or dossil of
lint tied to a quill, or a small rod of ivory or other stick, the acid is
apt to be diffused over a greater surface than was originally
intended. At all times, without great care, the teeth may suffer
from this acid. On this account, as well as owing to its compara-
tively less stimulating nature, and a belief that the mode of action
which it induces, approaches nearer to the healthy one of the
mucous tissue, lunar caustic is preferred by some judicious practi-
tioners. It is recommended in solution — from a scruple to half a
drachm, to the ounce of water — as a gargle or rather collutory.
Preferably, however, to this, is rubbing quickly and lightly the
diseased surface with a pencil of lunar caustic. There is one great
advantage attending this latter method, — that it must be done by
the physician himself, and hence that it will be properly done:
whereas gargles left to be used by the mother or nurse are seldom
applied as they ought to be, either through ignorance and timidity,
or a false tenderness and fear of hurting the child. In discreet
aphthae it is also employed in substance; but pains are taken to
touch each separate aphtha, in place of rubbing it over the whole
diseased surface as is done in diphtheritis, and also in confluent
aphthae, particularly when the back part of the throat is the seat of
either of these diseases.
A still more favourite remedy with several who have written on
this subject, and also tested its efficacy, is. sulphate of copper, in solu-
tion or as a linctus, in which ten grains, or even twenty and thirty, of
this salt are added to an ounce of water or of honey; or this salt
alone may be employed in many obstinate cases. Testimony in
favour of this practice is borne by Drs. Maunsell and Evanson, in
the following terms: " From no other application have we derived
equal benefit in the treatment of aphthae, muguet, cancrum oris,
ulcerated sore throat, &c, &c. According to its strength, the
solution of copper acts as a stimulant or escharotic, while its astrin-
gent power is of a higher order. Hence its applicability to a great
variety of cases; while it is remarkable that under its use the sur-
rounding inflammation is lessened, as well as the ulceration im-
proved."
PSEUDO-MEMBRANOUS STOMATITIS.
49
Powdered alum, blown into the back part of the throat, has been
recommended by Bretonneau, when diphtheritis has extended that
far:—" When sloughing has actually taken place, the most decided
escharotics may be required to destroy the sloughing parts, and
arrest the progress of the disease. For this purpose the muriate,
or butter of antimony, is perhaps the most effectual and manageable
of the escharotics, as its action does not extend beyond the part to
which it is applied, nor is its use attended by inflammation of the
surrounding parts."
There is yet another article of considerable activity, not hitherto
mentioned by writers in this disease, but one in which I am dis-
posed to put no little confidence. I refer now to iodine, and par-
ticularly to the tincture and the compound solution of the iodide of
potassium, — the first prepared by dissolving two scruples of iodine
in an ounce of rectified spirit; the latter by dissolving a drachm of
iodine with two drachms of iodide of potassium (hydriodate of
potassa) in one ounce of water. With either of these the diseased
surface may be painted over with a brush dipped in it; repeat-
ing the application after the lapse of twelve hours,—in less urgent
cases in twenty-four hours. The tincture or the compound solution
may be reduced in strength by dilution, — of the first with rectified
spirit, and of the second with water, — in cases in which the pelli-
cular exudation is not very thick, or the vitality of the mucous mem-
brane is yet active, or where the stronger preparation has been
found to be too severe. The advantages of the iodine used in this
way are, that the morbid exudation is absorbed; sloughs, if they
have taken place, are thrown off, and healthy granulations formed.
At the same time that we use the iodine topically, we should,
with no small reliance in its therapeutical virtues, direct its adminis-
tration internally. With this view we give a simple solution of the
iodide of potassium in a watery infusion of a bitter, at intervals of
from four to six hours. The dose of the iodide will be from a
sixth of a grain to half a grain, for young children. Its effects will,
of course, be carefully watched, and if it prove irritating to the
stomach, or cause any oppression of breathing, or restlessness and
vigilance, for all these are occasional and unwelcome effects of
this medicine, we must either suspend its employment or greatly
reduce the dose.
Carbonate of ammonia in full doses, of from five to ten grains, is
also highly spoken of in this disease.
Reference has been already made to bathing as a preliminary or
incipient part of the treatment of this disease, in order to cleanse
the skin of impurities, and to restore, in a measure at least, its func-
tion, suspended by accumulation of perspirable matter and want of
common ablution, as is the case under circumstances already
explained. In the progress of the disease the warm bath ought to
constitute a part of the regular treatment, and be used twice a-day,
for about ten minutes at a time. In extreme cases and stages of
the disease, stimulating pediluvia should be frequently had recourse
vol. i.—5
50
DISEASES OF THE DIGESTIVE SYSTEM.
to, as answering all the purposes of counter-irritation, without the
annoyance and troublesome sores, even of a gangrenous nature,
which sometimes ensue on the application of blisters and even
sinapisms to the extremities of subjects in whom capillary circula-
tion is feeble, and the tissues prone to disorganization, owing to
their lax temperament and imperfect and depraved nutrition.
6. Gangrenous Stomatitis. — This kind of stomatitis corresponds
more nearly with gangrenous aphthae than with gangrene of the
mouth (cancrum oris), or gangrenous erosion of the cheek; names,
these two last, given to a formidable and generally fatal disease.
Gangrenous stomatitis may be the consequence or termination of
any of the kinds of sore mouth already mentioned, and it is fre-
quently spoken of and described in this light; as, for example, by
Andral (Cours de Pathologie Interne). Aphthae are liable to de-
generate into deep chancrous and eating ulcers, which soon be-
come sphacelated in subjects whose vital energy from defective
nutrition is feeble. The supervention of this state in common
aphthae, or other kinds of stomatitis, requires a change of treatment,
and a suspension of the liberal use of stimulating and caustic appli-
cations which may have been used before. Emollients, such as
mucilaginous and slightly warm fluids, are to be applied to the
parts; and not until gangrene is fairly begun ought we to attempt
to aid them to throw off the now foreign and dead matter by
stimulating substances, already mentioned.
The other and more important, and unfortunately still less ma-
nageable variety of gangrenous sore mouth, is that which spends
much of its force on the cheek, and hence one of its names, gan-
grenous erosion of the cheek. It is also peculiar in being preceded
by very slight inflammation; indeed the chief and almost the sole
evidence of this morbid state of the capillaries of the part is cedema
and congestion, which soon yields to disorganization of the tissue.
In this respect it is analogous to anthrax or carbuncle. Antece-
dently, however, to these changes in the substance of the cheek,
are others in the mucous tissue lining this part, and also in the
gums, which are designated under the title of cancrum oris —
canker of the mouth.
Owing to the different degrees of intensity of this last mentioned
disease depending on* the difference in constitution and circum-
stances of the patients, writers are not at all agreed in their opinion
of its violence and danger. " The common canker," Underwood
tells us, " is rarely troublesome to cure." It sometimes, he con-
tinues, makes its appearance in the month ; at others, about the
time of teething; and frequently at the age of six or seven years,
when children are shedding their first teeth, and the second are
making their way through the gums, which are covered with little
foul sores, extending sometimes to the inside of the lips and cheeks.
The worst variety of this disease which he saw was during the
second period of dentition, when a child has been shedding a num-
ber of teeth together, leaving the rotten stumps behind, which have
GANGRENOUS STOMATITIS.
51
been neglected to be drawn out. The whole gums will then be-
come spongy, or dissolve into foul spreading ulcers; and small
apertures will be formed, communicating from one part to another,
accompanied with an oozing of a fetid and some purulent discharge.
Gangrene of the Mouth. — Very different from this is the gan-
grene of the mouth, properly so called, in which, with M. Baron, we
recognise two well-marked stages of the disease: — 1. An oedema-
tous circumscribed swelling, characterized by a shining, and, as it
were, oily appearance of the skin, and by a central body of more or
less hardness, in which there is sometimes an obscure red spot,
either on the internal or external surface of the buccal parietes.
In this first stage in young infants we do not meet with fever, or
any symptom of reaction. 2. This central part presents an eschar
which usually forms from within; the mucous membrane becomes
disorganized, the bones are laid bare, all the soft parts, even to the
periosteum, mortify and separate in shreds, at the same time that
the mucous or bloody matter, mixed with the remains of the gums
or sides of the mouth, flows out, exhaling an infectious odour. (M.
Billard, op. cit.)
Pathology.—Dr. B. H. Coates (N. Amer. Med. and Surg. Journ.,
Vol. II.), in a valuable paper on the "Gangrenous Sore Mouth
of Children," says, coincidently with M. Billard, that its access
was frequently preceded by no marks of visible disease, or at least
none that attracted attention. The little subjects were, apparently,
in merely a drooping or enfeebled state. Those met with in the
Doctor's clinic, at the Asylum for Children below the city, in a low
and unhealthy situation, were generally of feeble and anemic habit,
that which is one of the chief, if not the chief predisposing cause of
the disease. Sometimes the ulceration followed a common remit-
tent or intermittent fever; insomuch that, at one time, whenever a
child was brought to the asylum it was expected, as a matter of
course, that its mouth would become sore. Dr. Hall (Edinb. Med.
and Surg. Journ., Vol. XV.) states that, in all the cases which have
come to his knowledge, this affection had been preceded by fever,
acute disorder of the digestive organs, typhus, inflammation of the
lungs, variola, rubeola, or scarlatina. In illustration of the effects
of debilitating causes, may be mentioned the great proportion, at
times, of children congregated in an asylum who are attacked with
this disease. Thus, out of 240 at one time in the institution, Dr.
Coates tells us that 70 were more or less affected with the ulcera-
tion in question.
The ulceration may begin in many parts of the mouth, but Dr.
Coates tells us that, in by far the greatest number of cases, it
commences immediately at the edges of the gums in contact with
the necks of the teeth, and most generally of the two incisors. The
spread of the disease is, he thinks, uniformly from the gums to the
cheek. When gangrene is formed, a fever of irritation is generally
developed. It is aggravated by loss of rest, want of nourishment,
and probably by putrid matter finding its way to the stomach. To
this latter cause, Dr. C. refers a diarrhoea which almost uniformly
52
DISEASES OF THE DIGESTIVE SYSTEM.
comes on towards the close. We must not, however, forget the
probability of a morbid state of the intestinal mucous follicles and
membrane being coincident with that of the same tissue in the
mouth, as has been already adverted to when speaking of follicular
stomatitis.
Dr. Cuming (Dublin Hospital Reports, Vol. IV.), in his " Obser-
vations on an Affection of the Mouth in Children," as it occurred in
the Dublin Institution for the Diseases of Children, says, that, in
most instances, the ulceration, commencing in the gums, extends by
continuity of surface to the lips and cheek, but sometimes it com-
mences in the lining membrane of the lips or cheek, and extends
from thence to the gums. This disease is most liable to attack
during the period of the first dentition. It is, however, he adds,
frequently met with in children between three and seven years of
age. The greater number of cases under Dr. Coates's*observation
occurred between two and five years of age, but some as late as
eight or ten. Dr. Cuming has frequently seen it when the child
had only six or eight teeth ; and he constantly observed, that when
it occurs thus early it is always the upper gum that is first and
principally attacked. This he conceives to be the mildest and most
manageable form of the disease. The most formidable variety, in
his experience, is that which occurs in children between twenty
months and seven years of age.
Thickness and hardness have always occurred in the other
situations, besides the cheek, where this gangrene has approached
the external cellular masses of the face. After reaching this stage
a black spot is frequently seen on the outer surface of the swelling.
This spreads rapidly, and has always, in Dr. Coates's experience,
been the immediate harbinger of death. I have seen the skin of
the cheek and chin all black, or of a brownish hue, hard like tanned
leather, in a fatal case of this kind of gangrene shortly before
death.
Billard directs attention to the coexistence of the affections of the
teeth, the congestions of the gums, and the oedematous swelling of
the face on the diseased side; and he adds, this agreement esta-
blishes the existence of some connexion between the diseases of the
gums and of the teeth, and gangrene of the mouth ; and he expresses
his belief, that this lattertdisease may follow swelling and disorgani-
zation of the gums. If it should occur in a child in whom the
second dentition had commenced, the consequences would be very
serious, and might result in the loss of the teeth for the remainder
of life.
Treatment.—Before prescribing, we ought to be aware that the
prognosis in gangrene of the mouth is unfavourable, as we might
suppose from the class of subjects who are chiefly affected, and the
gravity of the disease itself, as well as of its complications. If fully
apprised, as we ought to be, of the antecedents of this disease, inter-
mittent or remittent fever, or bowel disease, we must address our-
selves earnestly and early to all the means adapted to alter this
morbid condition ; and whilst doing so, to modify at once the func
GANGRENOUS STOMATITIS.
53
tions of nutrition. With this view, a mild emetic of ipecacuanha
will often be of service, followed at once by tonics, and among
these the sulphate of quinia, infusion of calumba or of quassia, are
to be preferred. Alternating with the quinia, and administered
conjointly with the simple bitter, should be minute doses of
iodine in its state of iodide of potassium, at intervals of four
to six hours. Carbonate of ammonia is also to be used.
Warm salt water bath, twice or thrice daily for a few minutes
each time, followed by assiduous frictions, will contribute to the
restorative effects of the preceding treatment. On purgatives we
must not lay stress after an evacuation of the bowels has been
obtained by castor oil with oil of turpentine, in the proportions
already indicated. Mercury finds advocates in this form of gan-
grene as well as in aphthous stomatitis, but we cannot rely on its
local action to the exclusion of the interference by its impression
on the general system with nutrition. The same remark applies, with
still more force, to arsenic, which is directly adverse to nutrition, and
on all occasions like that now under consideration, we cannot afford
an hour for vitality to retrograde, as would be the case by the dimi-
nished activity of nutritive life. Some may object, that iodine also
attacks nutrition; but it is only in large doses that it acts in this
way, and it does not produce that morbid impression on the nutri-
tive centre, the digestive system, that arsenic does, and even mer-
cury also not unfrequently. In small or moderate doses iodine
quickens digestion and nutritive absorption, and increases, instead
of diminishing, the bulk of the tissues and of the frame generally.
Much and not unmerited stress is laid upon the local treatment
in gangrenous sore mouth; but if we hope for more than tempo-
rary relief from this means, it must be when fully aided and sus-
tained by the general remedies just indicated.
Dr. Stewart (Practical Treatise on the Diseases of Children)
very properly advises, in the forming stage of infiltration, the appli-
cation o[ stimulating frictions to excite the absorbent vessels. Lini-
ment of hartshorne may be used for this purpose, or a solution of
muriate of ammonia, applied to the cheek by means of pledgets
saturated with the solution. The disease being farther advanced,
various substances, of a more or less stimulant and escharotic na-
ture, are recommended ; such as lunar caustic, butter of anti-
mony, the chlorides, as already mentioned in the treatment of other
kinds of stomatitis; also caustic potassa, and the actual cautery,
the last a favourite remedy with some of the French practitioners.
In the use of these powerful agents we ought, however, to be regu-
lated by the extent of action of the tissues around the gangrened
spot: if they be inflamed, and indicate a readiness to separate
themselves from the mortified matter, we ought not to be too pro-
digal of astringents and stimulants, or escharotics; but rather use
mild applications, such as the carrot or yeast poultice, or the
slightly stimulating wash of a solution of common salt, or powdered
borax, on the part.
5*
54
DISEASES OF THE DIGESTIVE SYSTEM.
There is one remedy which latterly unites more suffrages in its
favour than any other, as a local stimulant and detergent, in gan-
grenous sore mouth : it is sulphate of copper, the eulogy on which,
by Dr. Evanson and Maunsell, in the worst and aphthous forms
of sore mouth, I have already placed before you. 1 shall now add
the unequivocally expressed testimony of Dr. Coates, who* is also
joined in opinion by some recent French writers, probably as a re-
sult, in a measure, of his experience, which was recorded some
fifteen years ago (JV. A. Med. and Surg. Jour., 1826). Dr. Coates's
formula is as follows: —
R. Sulph. cupn, 3'j>
Pulv. cinchona?, ^ss.
Aquae, ^ v. M.
"To be applied twice a-day, very carefully, to the full extent of the
ulcerations and excoriations. The cinchona here is not absolutely
necessary, but operates by retaining the sulphate longer in contact
with the edges of the gums." Sulphate of zinc, in solution with
tincture of myrrh, was useful; also, a simple solution of this salt,
3i. to an ounce of water. Extraction of the diseased teeth, or of
the teeth of the diseased gums, early, is an important part of the
cure. For the reasons already assigned;we might, with some con-
fidence, use topically the compound solution of iodine, as a suitable
stimulant to the parts.
There is yet a kind of sore mouth which, as far as our present
knowledge extends, is seen only in women during lactation, and
hence I shall call it
Stomatitis JVutricum. — The first notice of this disease which
has met my eye is in a short communication from Dr. Backus, of
Rochester, New York (American Journal of the Medical Sciences,
Jan. 1841). But a more detailed description had been previously
given by Dr. E. Hale (1830) in the Medical Communications of the
Massachusetts Medical Society, Vol. V., also Am. Journ. April.
J 842. ^ '
The disease commonly begins with a hard pimple upon the edge of
the tongue, generally at a little distance from the tip, which is very red
and extremely painful. After a fewreturns, and not unfrequently after
a first attack of this nature, the central spot ulcerates. The ulcer
is deep, with hard elevated edges surrounded by an inflamed circle,
and is still exquisitely painful. The location of these ulcers is gener-
ally the same as in the stomatites of children, viz., on the tono-ue and
inside of the cheeks, but rarely, if ever, upon the gums or the° palate.
Ine inflammation, however, extends to the fauces, and, as we have
seen in the case of muguet or pellicular stomatitis, is continued
on tne oesophagus, stomach, and intestines, and is then accompa-
nied with diarrhcea. The ulcerations increase in depth, though
their exten of surface is not great. Dr. Hale has seen a consider-
able loss of substance in the edge of the tongue, which was onlv
Tnd une^^Tt When ^ "^ healed' leavi»g the pa^aggeS
and uneven. The accession of the disease is represented by I)r
STOMATITIS NUTRICUM.
55
Backus to be very sudden ; " in three hours time after seeing your
patient in health, you may find her with a scalded tongue and fauces,
and unable to co'nverse or to take food." The appetite is good
throughout the whole course of the disease, but the pain from taking
food is so great that nothing but the mildest liquids can be borne.
Although the patient becomes greatly emaciated, and her strength
wastes rapidly, the secretion of milk is little if at all diminished,
and the child continues vigorous and healthy.
The subjects of this disease are, as before stated, women during
the period of lactation. Sometimes, indeed, Dr. Hale has seen it
during pregnancy; but never in the first pregnancy, nor in a sub-
sequent one, unless the woman had previously suffered from it while
nursing; and even when it appeared at this time it readily yielded
to remedies without any considerable constitutional irritation. Dr.
Backus also admits that it sometimes appears during the latter-
months of pregnancy. Its attacks are not confined to any parti-
cular constitution or temperament; but are made at times on the
most robust who have always enjoyed good health. Dr. Backus
is inclined, however, to believe " that females of a leucophlegmatic
temperament and of dyspeptic habits, with habitually slow bowels,
are perhaps more liable to its attacks than others." A woman
who has once had this disease is always liable to a recurrence of
it in every subsequent period of nursing.
The prognosis is generally favourable, if too long a period be not
allowed to pass after symptoms of debility and exhaustion have
been manifested: and it is chiefly where there is a predisposition to
phthisis pulmonalis that such appearances should excite solicitude,
lest the constitution should be fatally undermined. Of course, under
these circumstances we must be more urgent in our recommenda-
tion that the mother or nurse should wean the child, or hand it
over to another and healthier person.
Treatment. — This last measure is the most certain and speedy
means of cure of this kind of stomatitis, and in some instances it
is indispensable. The symptoms which require that the nursing
should be suspended, are the violence of the diarrhoea and general
exhaustion, more than the increased soreness of the mouth.
As the stomach is sometimes disordered, an emetic of ipecacuanha
will be of service. But this, although an occasionally useful pre-
liminary to other parts of the treatment,isnotindispensably necessary.
Dr. Hale rests the cure chiefly on tonics, such as the lime-water in-
fusion of bark, given in the dose of a wine-glassful two or three
limes a day. Carbonic acid, as in bottled beer and porter, and the
effervescing salts, was found to be serviceable. When a laxative
is proper, it is best given with some effervescing mixture, as, for
example, powdered rhubarb mixed in water with the bicarbonate
of potassa, to which'a little lemon-juice or vinegar is added at the
moment of taking it. When the porter has stimulated too much,
and the effervescing salts were agreeable to the patient, Dr. Hale
gave a fermented solution of tartaric acid and sugar, as follows :
56
DISEASES OF THE DIGESTIVE SYSTEM.
An ounce of tartaric acid is put into about three gallons of water,
with white sugar in quantity to please the taste: to this add two or
three spoonfuls of good yeast, and stir it well when first mixed, ana
again after two or three hours; at which time, if necessary, add
more yeast: let it stand quietly in a cool cellar about twenty-four
hours; then draw it off and carefully bottle it. Sulphate of quinia
is well adapted to some cases, and more particularly to those in
which the debility is considerable. All stimulating tonics are inju-
rious, and tinctures of all kinds are inadmissible. Dr. H. found
it necessary to direct a discontinuance in the use of wine, a pro-
hibition which ought to be the rule with mothers while nursing their
children; and the use of wine or of any fermented liquors the ex-
ception during this same period.
Coincident with this view of the treatment of sore mouth of
nurses is that of Dr. Backus, who places his chief reliance in cha-
lybeates, combined with rhubarb and aloes, as in the following pre-
scription :— B. Carb. ferri, grs. lxv.; Pulv. rhei et Gum aloes, aa
grs. xv. M. ft. mass, in pil 50 dividend. " Two of these pills should
be taken twice or three times a day, or often enough to keep the
bowels very open."
Little value is attached to local remedies by Dr. Hale. When
they are had recourse to, some of those heretofore mentioned, such
as the chlorides, or a weak solution of the nitrate of silver, may be
used.
LECTURE V.
DR. BELL.
Glossitis — Its varieties and causes —Symptoms — Termination — Diagnosis —
Treatment — Importance of scarifications — Symptomatic or secondary glos-
sitis — Treatment modified by the nature of the primary disease. — Parotitis
— Primary—Supposed contagion of—Terminations—Metastasis to other
organs — Treatment — Secondary or symptomatic parotitis— That caused by
mercury, — its treatment. — Diseases of Dentition — Predisposition to nu-
merous diseases in early infancy — Causes besides dentition — The suscepti-
bility of the organs of the child, and peculiar exposure to external agents —
Sympathies of the dental apparatus — Direct and remote — Treatment during
dentition — hygienic and medicinal — The measures chiefly demanded.
In the description of the various species of stomatitis in the last
two lectures, you have learned that the tongue is frequently affect-
ed, and, indeed, that the disease sometimes first manifests itself by
aphthous or pellicular inflammation of its mucous membrane. But,
in addition to these affections, which it has in common with other
parts of the mouth, the tongue every now and then becomes the
sole seat of inflammation. This morbid state of the organ is termed
glossitis, from y\u«T«r, the Greek name of this gland. There are two varieties of
this disease, primary or idiopathic ; or, as called by some, specific,
and the other accidental or secondary and symptomatic. To the
first only the English term mumps is applicable. It is most apt to
attack young persons, especially those of the male sex, just before
the approach to puberty: but it seldom appears after the age of
25 or 30 years. It rarely attacks the same person more than once
in his life; and on this account, as well as its sometimes appearing
about the same time, or in quick succession in several persons, it is
commonly alleged to be contagious. As yet no morbific matter of
a peculiar nature, and capable of causing the disease in another and
healthy person, has been secreted by, or at least has been detected
on a patient with parotitis. There are also abundance of cases
in which no trace of contagion could be ascertained, but which
originated from exposure to cold or analogous causes. Sometimes
it has prevailed epidemically.
Parotitis is ushered in, generally, by the symptoms common
to inflammation, such as rigors, lassitude, acceleration of pulse,
and hot and dry skin. To this succeeds a feeling of uneasiness,
and then shooting pain in the parotid gland, some swelling under
the ear and impediment in mastication. More commonly, the
swelling is on both sides, and increases to the third or fourth day,
accompanied with hard and frequent pulse, thirst, headache, loss of
appetite, and at times a great heaviness. When the inflammation, or
at least tumefaction, is participated in by the sub-maxillary glands,
velum palati, tonsils and pharynx, deglutition becomes excessively
painful, and for a period impossible. In other cases, again, the
swelling is more oedematous than inflammatory, and the constitu-
tional symptoms are very slight.
The most usual termination of mumps is by resolution, which
occurs in most subjects on the fourth or fifth day from the begin-
ning of the swelling. The accompanying, or as some might regard
it, critical evacuation, is by sweat over the region of the gland
and adjoining portion of the neck and head, and sometimes over
the whole body. Suppuration is a termination of rare occurrence
in primary parotitis; when it does occur, it is announced by the
vol. i.—6
62
DISEASES OF THE DIGESTIVE SYSTEM.
customary symptoms, — prominence of the swelling at a particular
point, and softness and fluctuation, with a bluish hue and sluggish
circulation of the skin above the tumour.
More generally, however, as I have just said, resolution takes place,
and there is a prompt diminution and almost disappearance of the
swelling. But, at the same time, another and remote organ, the
testicle in males and the mamma or external parts of generation
in females, becomes, by metastasis, the seat of inflammation. When
the disease is confined to one parotid, the testicle or mamma of
the same side is affected. Sometimes the disease is retransferred
from the genital organ to the gland, a change which may be fol-
lowed by a second metastasis from this latter to the former.
Treatment. — The remedial means, in general, are quite simple
in parotitis. A saline laxative, reduced regimen for a few days, and
an avoidance of dampness and cold, will suffice in most cases. If
the fever should, however, be high, and the pain and difficulty of
deglutition considerable, a small bleeding from the arm, or a few
leeches over the gland, followed by a cathartic of calomel and
jalap, and antimonials, will meet the requirements of the case.
Metastasis to the testicle will be treated by cooling applications to
this part, and a suspensory bandage if the patient should be up and
move about; and also by a stimulating liniment rubbed over the
parotid gland, or a sinapism of mustard applied to this part, with a
view of restoring the inflammation to its original seat. Fever
accompanying the metastasis will be obviated by the same reme-
dies as are adapted to the original disease.
Secondary or Symptomatic Parotitis requires little else than
topical remedies, such as cataplasms in the first stage, and deter-
gent washes if suppuration is declared, — other than the treatment
adapted to the particular disease in which the parotitis manifests
itself. Inflammation and abscess of the parotid are occasionally
met with in fevers, such as typhus and plague, and in the eruptive
ones, as in scarlatina and measles. I have seen the gland entirely
exposed by the breaking of an abscess and loss of the teguments, in
the case of a child with scarlatina. My little patient recovered not-
withstanding, and the opening gradually closed without much dis-
figuration. The chief dressing was of lint and solution of chloride
of lime.
A variety of parotitis once quite common, in connection with
similar inflammation of the other salivary glands, from the exces-
sive use of mercury, is now, happily, of rare occurrence. The sali-
vation in these cases, which was merely a symptom or an effect of
the morbid excitement of the salivary glands, was spoken of as the
disease, against which the remedies were chiefly directed. But if
we fix our attention on the parts really diseased, viz., the buccal
mucous membrane, and the glands connected with it bv their
excretory ducts, we shall have little difficulty in devising a treat-
ment adapted to the exigency. Fever if high, and accompanied by
parotitis, stomatitis, and even sometimes glossitis, will be removed by
DISEASES OF DENTITION. 63
venesection or leeches over the parotid and sub-maxillary glands,
to be followed by fomentations to these parts; or, if the state of the
patient, owing to the nature of the antecedent disease for which the
mercury had been given, forbid, the detraction of blood, we have
recourse to purging by saline medicines, and to potassio-tartrate
of antimony, at first conjoined with nitre or, in dilution, with pur-
gative salts, and afterwards with opium. The extremes of cold or of
heat should be avoided, and the feelings of the patient be the guide
as to the amount of clothing, fire in the room, &c: but the ad-
mission of cool air, so as not to blow on the patient, will be ser-
viceable. The warm bath daily is one of the best means of keeping
up a moderate action of the skin, by which the cure will be greatly
accelerated. Of the various gargles recommended on these occa-
sions, the milder or mucilaginous are the best in the acute stage, and
afterwards an infusion of green tea, or a weak solution of sugar of
lead. The last is apt to cause a temporary discoloration of the
teeth. If there be mercurial ulceration of the mouth, hydrochloric
acid, or the nitrate of silver may be employed in the manner re-
commended in a preceding lecture.
In the treatment of a case of mercurial salivation, we cannot
propose to ourselves, nor promise our patient, that it will be ar-
rested at once by any kind of treatment. On the contrary, like all
kinds of poisoning, of which this is one, time is required both for an
elimination of the deleterious agent from the system and for a
subsidence of the morbid phenomena, such as depraved secretions,
and perverted innervation to which it has given rise.
Diseases or Dentition. — There must, almost of necessity, be
some vagueness in the ideas associated with the expression Dis-
eases of Dentition. They are often confounded with the diseases
of the period of dentition, and particularly of that which elapses
from six months after birth to the appearance of the deciduous
teeth. This is the period of the greatest mortality, as it is that in
which the probability of life is less than in the years immediately
succeeding it. Dentition is one of the contributing causes; but it
is only one, and even though it were the chief, there would remain
many diseases, the origin of which must be traced to other sources.
The excessive activity of the organs of nutrition, and impressi-
bility of the nervous system in early infancy, and the excitement, so
apt to become morbid in consequence of the change of food from
that of the mother's breast to various articles of a more stimulating
and heterogenous nature, throw the system of the young being open,
in a peculiar degree, to irritation of any kind, and d, fortiori to that
from teething. If, to these we add the extremes of heat and cold,
to which, from the ignorance of parents and the carelessness of
nurses, infants are so much exposed, we can have some idea of
the strain upon the tender organization and naturally great suscep-
tibility of the child during the period of first dentition.
You need hardly be told of the great vascular pnd nervous
supply to the dental apparatus, and of the excitement of both the
64
DISEASES OF THE DIGESTIVE SYSTEM.
nerves and bloodvessels during the growth of the teeth. The
direct sympathies, by means of the great and important sensitive
nerves of the fifth pair, between the dental arches and all the senses,
and the readiness with which febrile reaction must occur under
the excitement of these parts during their nutritive erethism, are
inferences which, irrespective of positive experience, might almost
be drawn h priori from a survey of the anatomical relations
between the teeth and adjoining organs of the face and head. The
indirect and reflex sympathies by which, through the irritation of
the brain consequent upon morbid excitement of the dental appa-
ratus, remote organs suffer, is also explicable though not so imme-
diately obvious. In this way the stomach and digestive apparatus
generally, the respiratory and secretory organs, including under
this latter the skin, are so often affected during painful and laborious
digestion. It maybe made a question, whether the functions of
these organs are deranged in consequence of the primary excite-
ment transmitted by the dental apparatus, or are predisposed to be
morbidly excited by other and common agents, such as cold and
moisture giving rise to catarrh, bronchitis and pneumonia, great
heat to gastric and intestinal diseases, wrong food to similar affec-
tions, and diseases of the skin, &c. On a review of all the premises,
we should lean to the latter of these two opinions, while we cannot
deny that at times dentition seems to be the direct exciting cause,
since the disease is developed without any notable or sometimes
any obvious or appreciable change in the qualities of the ingesta
or sensible states of the atmosphere.
Your physiology will have taught the obedience of the muscular
to the nervous system, and that any undue excitement of the latter
is immediately followed by violent and irregular action, spasmodic
or convulsive, of the former. Now, with an irritation of large
branches of the fifth nerve continued for many months, acting on a
susceptible brain, we cannot be surprised that at any moment of this
period a slight exacerbation of the irritation should cause a reflex
action on the muscles, manifested by convulsions. Not seldom,
during this period, the cerebral irritation and its reflexion on the
muscles are the consequence of morbid impressions transmitted
from an excitable stomach or intestine, and caused by food irrita-
ting either by its indigestibility or its excess.
With this view of the subject we cannot either be ignorant of
the nature of the morbid phenomena as they present themselves
during dentition, or negligent of the appropriate means of relief.
Topical irritation is manifested by increased heat and swelling
of the gums, and its extension to the salivary glands causing an
increased flow of saliva, one of the most common and generally
accredited symptoms of teething. There are great differences
among children as to the time when this process begins, as well as
the ease with which it is accomplished. Dr. Ashburne (Med. Gaz.
1833-4) gives the following table, as exhibiting the average order
of the appearance of the teeth of the first dentition: —■
DISEASES OF DENTITION.
65
Periods. Teeth.
Seventh month from birth
Eighth " " "
Ninth " " "
About ninth or tenth
" twelfth or fourteenth .
u seventeenth eighteenth, ) TwQ canine
nineteenth or twentieth j rr
Twenty-third to thirtieth . . Four last molars.
Two central lower incisors.
Two central upper incisors.
Two lateral lower incisors.
Two lateral upper incisors.
Four first molars.
There are many examples of children born with some of their
teeth cut; and some of those who had not any till they were twenty
months old: Duges (Diet, de Med. and de Chir. Prat.) states
his having seen a young person who did not cut them until she had
reached the eleventh year of her age; and Smellie cites a case
in which they were not even visible until the twenty-first year.
The child experiences a troublesome itching of the gums prior
to the eruption of the teeth, which prompts to rubbing them with
its own, and to willingly submit to this being done by others'
fingers, or by hard bodies, such as coral, &c. Morbid heat of the
gums and mouth alse makes the application of cold bodies to
them, or mouthfuls of cold water, grateful to the child. The irrita-
tion at this time is often transmitted to the nose, and by the Eu-
stachian tube to the ear, causing symptoms of coryza and pain in
the ear, and a frequent turning and tossing of the head, and also to
the eyes, as manifested by their watering. Starting in the sleep,
and occasional twitches of the muscles of the face or contraction
of the hands, are not uncommon during this period. Alternations of
drowsiness and morbid vigilance succeed each other. Sympa-
thetic disorder of the digestive canal is indicated by occasional
ejection of the contents of the stomach, and sour and bilious dis-
charges from the bowels. The skin is often hot and the pulse fre-
quent, constituting a state of things approaching to the febrile,-^-
the more evident if the heat and redness of the gums be increased
and salivation suspended. The urinary secretion is very irregular;
more commonly less, sometimes more copious than natural. There
is often a circumscribed redness of the cheeks, and blotches or
papular erythemas on this part of the face, and on the thighs,
hips, &c, and eruptions on the scalp. "A symptom less common
than any of the foregoing, and appearing in certain habits, is,"
as Underwood apprises us, " a swelling of the tops of the feet and
hands : it is seldom, however, of much importance, and goes away
upon the appearance of the teeth." Where this symptom persists
with aggravation, dentition is slow and painful; and there is a
greater call for purgative medicines to remove the frequently ac-
companying costiveness. Another occasional effect of, or at least
associated disease with dentition, is laryngismus stridulus, or spasm
of the glottis, on which I shall have occasion to address you more
fully hereafter. Bronchitis is at times developed apparently under
6*
66
DISEASES OF THE DIGESTIVE SYSTEM.
the direct excitation of teething; but more frequently the bronchia
and pulmonary mucous membrane acquire a morbid irritability
from this cause, which renders them peculiarly sensible to atmo-
spheric changes.
Lancing the Gums. — The treatment of the diseases of dentition
must of course be modified by the organ or the apparatus which
suffers most and the degree of morbid excitement. As in the case
of all symptomatic fever of irritation, we attempt a removal, or if
this is impossible, a mitigation of the force of the local and exciting
cause. On the present occasion, we direct our attention first to the
gums, and if we find them redder than natural, swelled, and painful
or spongy, we can have little hesitation in lancing them, either with
the shoulders of a common lancet or with a gum lancet. In per-
forming the operation we cut down direct on the tooth, and do
not stop until we feel the edge of the instrument grating on it:
nor can we be content with one incision, but must make another
intersecting the first, at an angle more or less approaching a
right one. In cutting down on the tooth, the incision should be not
entirely on the summit of the gum, but also somewhat on the ante-
rior face of this latter, — very much as the swelling points and the
tooth is seen to protrude, when it does rise from the gum. The
fears entertained by some that, if the tooth does not soon appear
after scarifications of the gum, the cicatrix will be an additional
obstacle to its progress outwards, are groundless; for this, like all
newly formed parts, is more readily absorbed than the original
structure. Ulcerations of the gum, spoken of as a sequence of
lancing it, are thought by experienced writers, such as Underwood
and Hamilton, to be more frequent in cases in which this operation
had never been performed, than in those in which recourse has
been had to it.
There are cases in which, even though the gums be not swelled
or protruded by the tooth, it will be advisable to cut down on this
latter. The resistance to the passage of the tooth, as where denti-
tion is backward, may be greater from a hard and not inflamed,
than from a prominent and inflamed gum, and there may be greater
necessity for removing this resistance, and renewing the irritation
by pressure, which the confined tooth produces in the subjacent
nerve. Hence, when we are called to a child from eight months
to twenty months old, and are required to prescribe for the relief of
some violent disorder, such as vomiting and purging, orhi^h fever,
or great restlessness, spasms, and general convulsions, it will be
prudent, on inspection of the mouth, to lance the elevated gum
when this presents; or if it does not, to make our incisions in that
part corresponding with or covering the expected tooth or teeth.
Even if we have not thought it necessary to begin the treatment in
this way, it will be highly advisable to have recourse to it, if we
find that the disease for which our assistance was invited does not
yield soon to the common and generally recognised appropriate
remedies. Not unfrequently, no other treatment is required for
DISEASES OF DENTITION.
67
convulsions of violent and frequent recurrence before we are called,
than free lancing of the gums and a warm bath.
The persistence of heat, and flushing of the face and preter-
natural excitement about the head in dentition, will justify, in addi-
tion to scarifying the gums, the application of a few leeches under
the angles of "the lower jaw or behind the ear, and the administra-
tion of laxative medicines, and cooling drinks and a restricted regi-
men ; and also warm pediluvia. Convulsions when violent, and
recurring after the gums are lanced, will require venesection, the
warm bath and opium. This last, after we are assured that the
stomach and bowels are cleared of any indigestible or other irritating
matter in them, is essentially required for preventing the return of
convulsions, by allaying the exquisitely morbid irritability in some
children of a nervoso-lymphatic temperament, when vascular and
local determination to any important organ are not evident. With
the same view tonics, such as the sulphate of quinia and the simple
bitters, are useful; they should be given early in the day,— and the
warm bath or a mild opiate, such as a portion of Dover's powder, in
the evening.
Diseases of the stomach and bowels, manifested by vomiting and
purging, and depraved secretions, will be met by the treatment
adapted to them in other cases. But both in these, and in the
affections of the thoracic viscera during the period of dentition,
we must not expect a reduction of the morbid excitement by the
same direct and frank treatment as we would in subjects more
advanced in life, and in whom the nervous system is not so con-
tinually excited. The predominance of nervous symptoms, or
rather the greater share which the nervous has than the vascular
in the diseases of dentition, require of us to address our remedies
more to the first than the second. In our hygienic as well as
therapeutical treatment, we must constantly bear this fact in mind;
and accordingly we shall avoid exposing the child either to extreme
cold or high heat, both of which are inimical to the nervous sys-
tem ; and endeavour to give it tone by tepid bathing and fresh air.
In its dietetic regimen, care must be taken not to confound nutri-
tive with diffusible stimulants. The former are tonic; the latter,
whilst they excite fever, also tend to provoke and keep up nervous
disturbances of various kinds.
Among the most troublesome diseases of dentition are, eruptions
on the face and scalp, sores of the ears, &c. These are really less
alarming than other internal diseases, but they often excite more soli-
citude on the part of the mother,— by the disfiguration of features
which they cause to her little favourite, — mixed with anxiety and
impatience to have them removed. Now, if it be ever required of
us to avoid the charge of nimia medicina, or an impertinent inter-
ference with nature at the risk of the patient's life, it is in these
cutaneous affections of children. Not that we are forbidden to use
remedies on the occasion; but these must be directed to an improve-
ment of the digestive and nutritive systems by general treatment,
68
DISEASES OF THE DIGESTIVE SYSTEM.
rather than any specific one, to carry off the eruption or dry up
sores. I shall not pretend to particularise the different eruptions
which harass infants during dentition, but proceed to the more
important part of my subject, an indication of the best measures to
be pursued for their treatment. If we bear in mind the fact, that
the remote irritation which keeps up those diseases of the skin being
that of dentition, must last for a considerable period, we shall be
less tempted to urge the use of heroical or violent remedies; but
rather content ourselves with moderating its intensity, and calling
off the secondary irritation of the skin by derivation to the bowels
and increasing the natural secretions, than have recourse to repel-
lent remedies of any description.
The warm or tepid bath, according to the degree of excitement
and the powers of reaction in the little patient, with mucilaginous
applications to the skin, occasionally laxatives to maintain a regular
state of the bowels, the use of small doses of calomel with chalk,
and the chalk mixture or chalk powder, alternating with small doses
of bitters and iron, will constitute the outline of the therapeutical
treatment. The hygienic will consist in taking the patient out in
the fresh air, giving it good cow's milk diluted with water, and in
which some farinaceous powder has been mixed, in addition to, or
in place of the breast of the mother, according to the period of
lactation. But if the child be puny, and without suffering from
fever or phlogosis, and its teething slow and painful, in addition
to the cutaneous disorder, we may every now and then with advan-
tage direct a somewhat more nutritive and varied diet,— such as
animal jellies and broths, and counter-irritation to the skin on parts
remote from that which is the seat of the eruption.
In the preceding remarks you will see that no attempt is made
to lay down a specific plan of treatment for children during the
period of dentition. This must vary with the constitution of the
child and the particular disease, as well as the stage of disease
under which it may be suffering. Your intercourse will often be
with those who are overfed, and in whom a plethoric state is in-
duced by this means, which throws them open to inflammation of
the brain and convulsions, or to gastric and intestinal disorder, and
troublesome pustular eruptions. The mother will sometimes boast
of the quantity of milk, in addition to that furnished from her own
breast, which her child takes daily, as if the measure of capacity for
liquid aliment were in fact the measure of strength. It will be
difficult to persuade her, in advance, that she is doing wrong to her
offspring; and even when disease, such as bowel complaint, comes on,
she will be prone to give broths in addition to milk, and condiments to
flour in order to strengthen the digestion of the little sufferer, whose
bowels she supposes to be disordered because they are weak. All
that is necessary often in such a case, is a reduction to a third of
the original quantity of food, and an increase of exercise, or of airing
at least, in order to restore health and obviate many impending and
alarming maladies, r 5
DISEASES OF DENTITION.
69
Dr. John Clarke, in his Commentaries on the Diseases of Children,
is disposed to attribute most of the diseases of dentition to over-
feeding and consequent plethora, and to improper kinds of food
which produce irritation. To these he adds another cause, too
often overlooked by experienced medical men in their attendance
on sick children, butt which is undoubtedly one of a serious nature.
It is keeping the head too warm. I have had frequent occasion,
as indeed almost every observing practitioner must have had, to
notice the sores and eruptions on the scalp and behind the ears kept
up by the unnatural and unreasonable and cruel fashion of wear-
ing caps, and these often worked and embroidered so as to render
them still more rough and irritating to the tender heads of infants.
There are few instances of more expressive natural language, than
that of the little being in its desire to tear off its cap under the
annoyance of itching, heat, and other irritation caused by this
covering, or in its pleasure when freed for a while from this incum-
brance. I have found it, in some cases, impossible to cure sores
and scalding of the ears so long as a cap was worn ; but in a
few days after it was laid aside the disease was almost entirely
well, without there having been scarcely anything applied, to quicken
the curative process.
Contrasted with the practice of keeping the head too warm by
giving it a covering in the house which it does not require, since,
independently of its natural covering of hair, the abundant supply
of blood to this region and its great vascularity insure a con-
tinued evolution of animal heat, is that of leaving the limbs, and
particularly the lower ones, without adequate protection by cloth-
ing. Vitality in this part is relatively feeble, and extrinsic aid
is required by friction, bathing, and warm covering for the feet
and legs, the latter of which are so commonly exposed when the
child is in the nurse's or mother's arms. After the little being is
old enough to run about, the circulation is rendered more active in
the lower limbs, and there is then less call for the precautions just
stated, which are indispensably necessary before this time. Of one
elementary principle of physiology there is very general ignorance
among the community, and oversight by too many physicians. I
refer now to the established fact, that animal heat requires for its
evolution a certain degree of energy of function of the nervous as
well as the vascular systems, and that one of the best means of ex-
citation of these two systems for such evolution is external heat and
retention of animal heat itself by warm clothing. In the young of
all animals there is less activity of calorification than in older and
adult ones; and hence the necessity of additional means of pro-
tecting the former from the depressing influence of external cold,
and of fostering by external aids the generation of animal heat.
The young of birds are covered in a close nest by their mother's
body and wings until they have acquired their own natural cover-
ing and protection, down and feathers, against atmospheric ex-
tremes, and especially that of cold and moisture. Provision is
70
DISEASES OF THE DIGESTIVE SYSTEM.
made by the parent for imparting some of its own warmth to its
young, in the case of the young of the mammalia which are not
born with a hairy covering adequate to their wants in this parti-
cular. It is only in the young of our own species that instinct does
not meet the exigency of the case, and false reasoning fails to supply
the omission. During the night the child is covered in excess with
body and other clothes, in a warm and often close and illy-ventilated
room : during the day it is imperfectly clad, — its legs and arms, and
breast and shoulders, are bare, and exposed part of the time to cross
currents of air. Catarrhs, croup, bronchitis and pneumonia are
common effects of this unequal and inconsistent exposure, which is as
adverse to plain and well-ascertained physiological principles as it
is to medical experience. Children require more external covering,
more warmth than adults: they have less energy of calorification
and less ability to take sustained and irregular muscular exercise by
which the nervous and vascular systems are excited and animal
heat is evolved. Even when acute disease is not produced by this
exposure of some of the most sensitive parts of the body to cold
and moisture, there is a deterioration of the functions of nutritive
life, and impediment to regular and easy dentition, with additional
probability, if not the direct occurrence, of scrofulous tumours, and
even of tubercles.
The plain hygienic precept for avoiding many of the evils which
I have just sketched, is, to protect the child by suitable clothing, and
with this view to cover all parts of the skin which in after life are
kept covered. The breast and shoulders and arms ought to be
clothed, as they are among the most susceptible parts of the body
to atmospherical vicissitudes and extremes. The common and
hacknied but ill-founded excuse of a wish to harden the child, is
not applicable to the practice of leaving naked and exposed these
portions of the body ; for, it is not meant that they should remain
so after the child leaves the nursery, nor ever be so subsequently in
any period of after life; at any rate in the male sex. In the texture
of the garments we shall be guided by the season: as to fashion,
they ought to be always loose.
It may perhaps be said that these considerations and details be-
long to the nursery, and are beneath the consideration of a Professor
of the Theory and Practice of Physic. But a little reflexion will
soon convince you, without any argument from me, that the theory
of medicine involves, in fact imperatively requires, a study of all the
probable causes of disease, and of the circumstances which give
them additional activity, or in any way modify them. As the high-
est and noblest aim of ethical philosophy is premonition and pre-
vention, so in medical philosophy it is both more humane and
more intellectual to devise means to guard against disease, than to
display skill, learning and research in trials to cure, uncertain as we
must be of a successful result, and knowing often that our best
devised efforts, in some cases, will almost certainly fail.
DISEASES OF THE THROAT.
71
LECTURE VI.
DR. BELL.
Diseases of the Throat.—Their various origins and complications.—Retro-
pharyngeal phlegmon. Difficulty of diagnosis, and danger of this inflammation
—Cases.—Angina simplex—Its causes, symptoms, and treatment. Sometimes
associated with typhoid fever.—Chronic angina.—Inflammation sometimes lo-
cated in the uvula, sometimes in the palate—Treatment of the same.—Tonsil-
litis—Most common in young subjects—Symptoms, duration, treatment—
Importance of bloodletting—Purging—Gargles.—Chronic Tonsillitis—In-
convenience and even danger in this disease—An indirect cause of spinal cur-
vature—Treatment, local and general; by caustics and inunction and internal
remedies—Diseased follicles of the tonsils—Morbid secretion,—how distin-
guished from tuberculous matter.—Morbid states of hearing and deafness
caused by enlarged tonsils, and diseased mucous membrane of the throat.—
Voice and speech modified from similar cause—Change of voice after extirpa-
tion of tonsils.
Continuing my notice of the diseases of the mouth and throat, I
shall next direct your attention to those which consist in an inflam-
mation of the mucous membrane lining the palate and pharynx and
covering the tonsils. To these the generic designation of" angina
or strangulation has been applied, from angere, to suffocate or
strangle, or rather from the radical term *y%», I strangle ; this being
regarded as the sensation or symptom of the greatest moment and
danger. Cynanche is also a generic term for the same class of
affections: it having the same root, with the prefix cy, the real
meaning of which we may, with Dr. Good, regard as doubtful, and
hardly justifying at any rate the common explanation of its being
from Kvm, a dog, under the idea either that dogs suffered much from
this kind of disease, or that the noise they occasionally made when
thus afflicted suggested the recollection of that made by the human
subject when suffering under throat affections. The name used by
Hippocrates of paristhimia, or throat affection, morbus faucium, is
sufficiently plain and general; and its equivalent has been given by
the older writers in our own language, under the title of quinsy, or
rather squinsy or squianancy. The French corresponding term is
esquinancie. I would apologise for thus occupying your attention
with philology in place of medical description and narrative, were
I not desirous of showing you that there is no real meaning con-
cealed under these terms of learned sound, and that critical refine-
ments of language are no substitute for pathological and therapeu-
tical knowledge. Of late years more precise ideas are conveyed
of the seat of affections of the throat, by referring them to their ana-
tomical seat; and hence, although some writers still retain the
generic title of angina or cynanche, the specific and true designa-
tion is that of palatitis, tonsillitis, pharyngitis ; and for affections of
the air-passages, glottitis, laryngitis, tracheitis, and bronchitis.
72
DISEASES OF THE DIGESTIVE SYSTEM.
It may readily be supposed, however, from a very slight inspec-
tion of the mucous membrane, continuous as it is from the mouth
to the esophagus, and analogous as the several portions of it are in
this space, both in texture and organic function, that its morbid state is
seldom restricted entirely to any one of these portions, although the
subjacent muscular and other tissues perform somewhat different
offices. On this account it is occasionally convenient to use a term
which shall serve to designate the inflammatory condition of the
mucous membrane of the palate, isthmus of the fauces, tonsils, and
pharynx, even although its use be arbitrary, and its acquired mean-
ing different from its original and radical one. Angina and an-
ginose, therefore, to a certain extent, hold their places in the medical
descriptions of the present day, but in a very subordinate relation
to that which they once had. A physician is not now afraid of
being thought illiterate, even though he should talk in English of
diseases of the throat, instead of using Greek terms : but then it will
be expected that he shall be able to show, when occasion requires,
the anatomical seat and characters of these several diseases.
Throat affections differ not only in the seat and extent of mu-
cous surface inflamed, but also in their intensity, origin, and com«
plications with other organic diseases. Often slight and of small
moment, they are also often violent and alarming: sometimes very
painful without corresponding danger; and, again, with little com-
plaint on the part of the patient, they prove suddenly fatal. They
are either acute or chronic, primary or symptomatic ; but whenever
they appear in the latter relation, they complicate the disease and
add to its danger. Thus, in scarlatina, small-pox and measles,
angina, particularly in the two first of these diseases, is of common
occurrence; and we measure often their danger by its persistence
and violence. It is met with in some of the worst forms of acute
gastritis, and when established in chronic gastritis makes us less
confident of a cure, — at any rate, of a speedy one. The same
remark applies to certain forms of enteric disease. Sometimes
angina accompanies fatal affections of the heart, and it is the only
symptom of any note which arrests the attention of the physician
when it appears some hours before sudden and unlooked-for death.
Common and pellicular or membranous inflammation, and ulcera-
tion of the fauces and pharynx, are frequently associated with, and
aggravate not a little, disease of the air-passages, and particularly
of the larynx and trachea. This complication is most generally met
with in an epidemic form. It is very obvious, therefore, from these
considerations, that our prognosis in diseases of the throat should
generally be guarded, and especially so if we cannot detect after a
careful inspection adequate correspondence between the local in-
flammation or other organic change, and the impediment of func-
tion of the part, and remote or sympathetic disturbance.
Retro-Pharyngeal Phlegmon. — In some cases of an obscure
nature, an abscess forms in the sub-mucous cellular tissue of the
posterior pharynx, which, by pressing on the glottis, produces
RETRO-PHARYNGEAL PHLEGMON.
73
great distress, and in some instances has caused death, without
the physician being able to form a correct diagnosis of the dis-
ease. On this point I would refer to Porter on the Pathology
of the Larynx and Trachea. An interesting case of this de-
scription was quite recently related by Dr. Caspar Morris, and
is recorded in the first Quarterly Summary of the College of
Physicians of Philadelphia, 1842. The patient, a female near her
term of utero-gestation, was seized with a severe chill, slight cough,
and much greater difficulty of swallowing than could be attributed
to the apparent condition of the throat, which was examined with
great care, the tongue being depressed and the mouth well open.
She could not lie down from a dread of strangulation. On the
third day from the attack, she drank with tolerable ease, but was
unable to swallow liquids or to lie down: she was unable to raise
the natural tones of her voice; the uvula was slightly swollen, and
there was some small deposits of lymph upon it. There was little
cough. On the fourth day there was entire aphonia, slight cough,
and utter inability to swallow. "Gargles were applied with a
syringe, and always with some relief; and frequently she was able
to swallow small portions immediately after their use." Dr. Mor-
ris " examined the fauces and neck at each visit, but without being
able to ascertain any cause for the urgency of the symptoms."
About 11 o'clock in the evening the labour commenced. In the
intervals between the pain she spoke freely with her natural tones
of voice. Under the care of Dr. Hodge she was delivered on the
following (Thursday) morning at 7 a.m., being the fifth of her ano-
malous disease. A few hours afterwards she was able to sit up
so as to allow of a weak solution of sulphate of copper to be in-
jected into her throat, " which she threw again from her mouth,
but could not swallow. Her voice was hoarse, but there was but
little cough, and no difficulty of respiration." At 11 o'clock on
Friday morning she expired; having been visited frequently from
the preceding afternoon up to this time by Drs. Hodge and Meigs
in conjunction with Dr. Morris. The treatment consisted in free
bloodletting on the second and third days of the disease, and leech-
ing the throat a few hours after the first venesection; and in the
administration of morphia, and towards the last of stimulating and
nutritious enemata. I shall give the conclusion of this narrative in
Dr. Morris's own words.
" The interesting points in this case are the intensity of the
arterial excitement, the dysphagia and aphonia, without a corre-
spondingdifticulty of respiration, or sufficient swelling and inflamma-
tion in those parts of the throat within sight and commonly affect-
ed, to account for these symptoms. It was not laryngitis, nor
bronchitis, nor pharyngitis, nor tonsillitis. The examination of the
body revealed the whole mystery. Upon opening the trachea and
larynx, the traces of inflammation were so slight as hardly to be
recognised; and we were disposed at one time to seek the causes
of death in the brain, or some other organ. It was, however,
vol. i.—7
74
DISEASES OF THE DIGESTIVE SYSTEM.
determined to remove entirely the pharynx, together with the base
of the tongue, in order to look at them carefully from behind ; in
doing this an abscess was opened, situated between the esophagus
and the vertebra, containing about half an ounce of purulent mat-
ter, and so immediately behind the glottis as to account most satis-
factorily for the difficulty of swallowing, and dread of strangulation
expressed by the patient, from the time the disease first assumed a
serious character. There were also minute depositions of pus
between the arytenoid and cricoid cartilages, showing the cause of
difficulty of speaking." p. 17.
Dr. Ballot, physician to the Hospital of Gien, reports (Archiv.
Gen. de Med., Oct. 1841,) a case analogous to that of Dr. Morris,
the chief feature of which I have just detailed to you. The sub-
ject was forty years of age, in robust health but for the deterioration
•caused by excess in drinking: he was in his calling much exposed
to atmospherical vicissitudes. He had suffered for some days from
an affection of the throat when he entered the Hospital of Gien on
the 27th of September, 1837. Dr. Ballot found, on examination of
the patient, that there was redness and dryness of the pharynx, but
without any appreciable swelling of any part of the throat which
was visible: the pulse was full, and beat 100 in a minute: there
was some difficulty in deglutition and respiration; the latter of
which was somewhat hissing, especially during inspiration: the
voice was muffled. The patient complained of a feeling of uneasi-
ness in the larynx, as if there was something which interfered with
freedom of swallowing and breathing, particularly when he inspired.
Dr. B., in carrying his finger far down into the pharynx, detected in
a line with the upper part of the larynx a resisting yet elastic
tumour, which seemed to be lost in the borders of the glottis, and
which sensibly obstructed the opening of this latter. From time to
time there was short, dry, and wheezing cough. Though a man of
courage and energy, he is sad and restless; his face is pale, and
expressive of anxiety.
Sept. 27th. Morning. — The treatment was begun by venesection
to the amount of sixteen ounces (500 grammes) in the morning. No
relief following this evacuation, the same quantity of blood was
taken away in the evening; and a mucilaginous gargle, veal waterfor
sole food, and mustard pediluvia prescribed. On the following day,
thirty leeches were applied to the sides and front of the neck ; pedi-
luvia in the evening, and a large blister to the nucha. On the 29th the
respiration was very laborious, and the patient sometimes had fits
of suffocation. Deglutition was not more affected than on his
entrance into the hospital; an emetico-cathartic potion was given,
which caused abundant evacuations both upwards and downwards.
A new exploration of the^harynx did not indicate any change in the
supposed laryngeal tumour.—*30th. Twenty leeches on the°front of
the neck; purgative draught; mustard pediluvia. On the four follow-
ing days large doses of emetic tartar were given, and this seemed
lo prevent the increase of the symptoms, and to prolong the inter-
RETRO-PHARYNGEAL PHLEGMOX.
75
vals between the fits of suffocation, during which the inspiration
was always made with extreme difficulty, — incompletely, and with
an evident hissing sound: but this slight amelioration was temporary
only, and on the 6th and 7th of October, Dr. Ballot applied a large
moxa on each side of the larynx. Notwithstanding these mea-
sures, the entire closing of the glottis was more and more imminent,
and suffocation being threatened, the operation of laryngotomy was
resolved on after consultation with a colleague, who examined the
state of the pharynx and larynx, and agreed with Dr. Ballot in
opinion respecting the affection of this latter organ.
There was this peculiarity attending the operation, that, although
the crico-thyroidean membrane was largely opened, the breathing
was imperfectly restored ; and it was only until the canula was
introduced, through which the air passed freely, that he felt himself
better. Unfortunately it was difficult to prevent frequent displace-
ments of the instrument; and notwithstanding the care taken by
Dr. B., and his injunctions to be watchful, it was partially displaced
during the night, and the patient expired from suffocation.
Twenty-four hours after death, a post mortem examination was
made. On opening the larynx in front, through its entire length,
the mucous membrane and the cartilages were observed to be per-
fectly healthy, and there was no oedema of the rimee glottidis; but
the opening itself was almost completely closed by a fluctuating
tumour, of the size of a hazel-nut, which projected at the upper part.
This tumour extended downwards to the cricoidean cartilage, and
encroached on the cavity of the larynx: it was a continuation
of a collection of white and well-concocted pus, in contact with the
anterior face of the vertebral column and on the posterior coat of
the esophagus: thence the purulent fluid had diffused itself along
the sides of the larynx, so that, on the left side, it was only separated
by a few lines from the upper angle of the incision made in the
middle of the crico-thyroidean space. Here is found an explana-
tion of the projection met with by the finger, on introducing it into
the pharynx, and which was attributed to the swelling of the bor-
ders of the glottis, and also of the difficulty of the air passing through
the opening made in the crico-thyroidean membrane, as well as of
the continual tendency of the canula to slip out from the opening.
Dr. Ballot was prevented by special engagements from completing
in detail the post mortem examination, but he ascertained the state
of the lungs, and that the posterior part exhibited a hypostatic con-
gestion, and was emphysematic over almost its entire surface.
The above case, as Dr. Ballot remarks, although not really oede-
matous laryngitis, serves to confirm the accuracy of the advice
given by Bayle, to have recourse early to procuring artificial respi-
ration in this disease. Even if we commit an error in diagnosis
similar to that which Dr. B. made, the operation may still be most
serviceable to the patient: only in place of having recourse to laryn-
gotomy, as recommended by Bayle, a preference ought to be given
to tracheotomy.
76
DISEASES OF THE DIGESTIVE SYSTEM.
The editors of the Archives refer to analogous cases recorded by
different writers. In some, the purulent collections are formed
behind the deep cervical aponeuroses, and spreading more towards
the thorax, offer but little impediment to deglutition and respiration.
An instance of this kind is given by M. Meandre-Dassit. (The-
ses de Montpelier, 1836, No. 78.) In other cases, the tumour being
more superficial, or in the cellular tissue, between the vertebral
column of the pharynx and the esophagus, may acquire so great a
size as to induce suffocation. Many examples of this nature, under
the name of retro-pharyngeal or retro-esophageal abscess, have been
furnished, such as that by M. Prion, recorded in the Bulletins de
VAcademie de Me'de'cine, 1830, and Archiv., lre Series, T. XXII.,
p. 413, Mars, 1830. In this case, puncture of the abscess gave
issue to half a pint of pus of good quality; a second opening was
followed by the discharge of the same quantity, of the colour of
wine lees, and the patient was cured in a short time.
Dr. Ballot's case was analogous to those in which the chief seat
of the abscess was between the vertebral column and the upper
part of the esophagus; but in consequence of sinuses formed in the
sides of the latter, and of their prolongation towards the trachea
and upper portion of the larynx, it bears some resemblance to the
abscesses mentioned by Desault (CEuvres Chirurgicales, par X.
Bichat, 2e partie, 1798, p. 256). M. Vernois records a case simi-
lar to that which has been detailed, in its nature and fatal termina-
tion, although the progress was slower (Traite de la Phthisie
Laryngee, par Trousseau and Belloc, p. 73). Dr. Carmichael has
likewise published a case of the same kind (Edinb. Med. Trans.
1820). A woman was seized with pain in the throat, dysphagia
and dyspnoea, threatening suffocation. Tracheotomy was performed,
but it did not prevent a fatal issue. The abscess was opposite to
the seventh cervical vertebra, compressed the oesophagus and
upper part of the trachea, and opened by a narrow orifice near the
summit of the larynx.
In the case reported by Dr. Ballot, the editors of the Archives,
whose bibliographical notices I have just been repeating, think that
if it had been possible to discover the real cause of the disease, and
that tracheotomy had been practised in place of laryngotomy, the
success would probably have been more durable and complete.
Our diagnosis is the more difficult in cases of dysphagia and
aphonia, as these affections are sometimes the results of a tempo-
rarily depraved condition of the nervous system, and pass off without
leaving any organic trace; although at the time they were not a
little alarming.
I have thought it right to prepare you by these views and cases
for appreciating better the details under the head of each separate
disease of the throat; to which I now proceed to direct vour atten-
tion. J
Angina Simplex vel Diffusa, called also guttural angina. Some
writers speak of this disease under the name of Pharyngitis, but
ANGINA SIMPLEX.
77
in giving to this latter a more extensive meaning than would be
inferred from it anatomically. All agree in speaking of it as a
simple inflammation of the mucous membrane of the throat, com-
monly interesting that which covers the isthmus faucium, the velum
palati, uvula and tonsils, and to a certain extent the pharynx; or the
disease may be almost exclusively seated in the latter, and only a
slight redness and irritation manifested in the other parts. Of itself,
simple and diffused angina has little gravity. The symptoms are
dryness of the throat, with frequent and painful attempts to swallow;
the inflamed membrane of the throat is at first red, dry, shining, and
tumid, except at the uvula, which is relaxed, and resting on the basis
of the tongue stimulates to continual efforts to swallow and some-
times to vomit, and excites cough. After a while, the dryness of the
membrane is succeeded by a secretion, more or less abundant, of
stringy mucus. The membrane covering the tonsils is coated with
a grayish layer. If the inflammation extends into the nasal cavities
along the Schneiderian membrane, the voice is affected, becomes
nasal, and there is sneezing; and a sensation of heat and dryness
of the part, followed, as in the case of the mucous membrane of
the throat, by an increased secretion, which gives relief to these
unpleasant feelings. As breathing through the nose is not easy at
this time, the patient sleeps with his mouth open, and in consequence,
when he awakes, the throat is dry by the evaporation of the
mucus, and the first efforts on awaking to clear it by hawking and
spitting are troublesome and rather painful. Cough with hoarseness
may be associated symptoms, when the inflammation spreads to the
glottis and larynx.
Causes.—This kind of angina is most common in spring or in an
open and damp winter, and it,is most frequently excited by sudden
exposure to changes of temperature, and particularly from heat to
cold, and more by partial application of the cause, as when a person
is much heated, and afterwards sits in a current of cool air from a
window, or door, or crevice, than if he were blown on in all direc-
tions. Alcoholic drinks, very hot or very cold liquids, caustics,
irritating vapours, are also exciting causes. Sometimes it comes
on without any obvious cause; but this is more especially the case
when it prevails, as it does at times, epidemically. The subjects
most readily affected with this kind of angina are the'youthful and
those of a sanguineo-lymphatic temperament.
The symptoms have been already described. It may be well
to know in addition, that simple angina is not so readily recog-
nisable in young children, whose mucous membrane lining the throat
is habitually of that degree of redness which would simulate the
colour of inflammation. It is, therefore, with subjects of this class, the
more necessary to inquire carefully whether there is fever, any
difficulty in deglutition or a regurgitation of food, and alteration of
the voice; and also, whether the redness, in place of being general,
is not in patches or circumscribed.
The termination of simple angina is, for the most part, in resolu-
7'
78
DISEASES OF THE DIGESTIVE SYSTEM.
tion; although sometimes suppuration takes place in the uvula or
arch of the palate. When an abscess forms in the uvula it is
known by the increased size, while abscess of the velum is easily
distinguished by the difference in the size and shape of the two
halves, the one being depressed and convex, the other raised and
of a concave or semilunar form. The presence of matter will also
often be indicated by the sensation communicated on the application
of the finger, as if pressing on a soft or fluctuating substance. Com-
monly the abscess is left to break of itself; but if it should be trouble-
some by its size and duration, so as to offer much impediment to
deglutition, it ought to be opened by a bistoury with a sharp point
and dull or covered edges.
Our prognosis in simple or diffused angina is favourable; but as the
disease is sometimes symptomatic of scarlatina, our opinion must be
expressed with more caution if this latter disease be prevalent at
the time; for of its results we cannot commonly speak with confi-
dence, varying as it does in its character from season to season. If
the inflammation be restricted to the pharynx, remembering the
possibility of suppuration taking place, and the risk of pressure on
the glottis and its consequences, we should be also careful not to
speak lightly of the disease, nor hazard a favourable prognosis
without some qualifying considerations.
Treatment. — In the milder and common cases of angina, rest
in a medium temperature, abstinence from exciting food, and re-
striction to and the use of demulcents and mucilaginous drinks,
with a laxative, such as a Seidlitz powder, and warm pediluvia, will
generally suffice for a cure. But if there be fever, much soreness
of the throat and pain in swallowing, and the habit full and ple-
thoric or sanguine, a more decided impression must be made on the
system by venesection followed by purgatives; or if the constitution
illy bears general bloodletting, leeches may be applied beneath the
angles of the jaw, and afterwards fomentations or cataplasms to the
throat; and the disease persisting,the part is then to be rubbed with
stimulating liniments. I think that I have seen marked bene-
ficial effects result, both in this and other forms of angina, from the
leeches being applied on the back part of the neck, or below and
behind the mastoid processes towards the occipital protuberances.
Failing to procure leeches, cups to this last mentioned region and
on the nucha will form a very good substitute. An abatement of
the more urgent symptoms having been procured by these means, we
may trust the treatment for the remaining period, until resolution
is completely effected, to mild antimonials and salines; and for
the relief of the local irritation, to the inhalation of the vapour of
warm water and vinegar, which is less fatiguing to the throat, and
answers the indications better than gargles.
In some years more than others we meet with diffused angina
associated with a fever of a low kind,— hot skin, frequent and soft
or readily compressible pulse, loaded and white tongue, gastric
uneasiness, and some thirst and headache. The chief noticeable
TONSILLITIS.
79
symptoms are those of the affection of the throat, although I think
we must regard this as rather a part or an effect of the derange-
ment of the system generally, than as the main disease. Under
these circumstances an emetic is often serviceable, both by its re-
lieving the stomach and abating the irritation of the throat. Stimu-
lating liniments externally, and gargles, such as of the chlorides
and of capsicum, are also to be had recourse to. These appli-
cations are the more called for if the bright redness of the mu-
cous membrane at the onset of the disease is soon succeeded by
grey or ash-coloured spots. The bowels will be acted on by some
of the stimulating purgatives, — calomel and jalap, senna and salts,
and the compound colocynth pill. Mild diaphoresis induced by
the acetate of ammonia, Dover's powder and the warm bath, will
in these cases be entitled to confidence, after suitable evacuations
of the bowels. Akin to these remedies are counter-irritants to the
lower extremities, sinapisms, stimulating pediluvia, &c. Seldom is
bloodletting called for — most generally indeed it will be injurious
in the variety of angina now under notice, or that which is com-
monly called typhoid.
Sometimes the diffuse or simple angina becomes chronic: its
chief features are a puffiness, owing to some slight sub-mucous
infiltration and a relaxation of tissue, alternating with dryness of
the parts. In these cases moderate action of the bowels by the
blue mass, and rhubarb and magnesia, or infusion of senna, and
gargles of solution of sulphate of copper, or of alum, or tannin,
will suffice. If it still persist after this treatment, the iodide of
potassium in solution, and touching the parts with the nitrate of
silver, will be used with success.
Without any difference in the cause or in the nature of the
disease, the force of the inflammation is spent at times on the soft
palate, or velum palati, or on the uvula, which parts become exces-
sively enlarged. I have had a case in which the uvula was the
size of one's little finger, and hard and rigid ; but although the
symptoms were severe, the disease was quite amenable to venesec-
tion and purgatives. The uvula was slow in returning to its
natural size. Neither palatitis nor uvulitis requires a peculiar treat-
ment, or one differing from that of simple inflammatory angina.
The relaxation and elongation of the uvula after frequent returns
of catarrhal inflammation may become so troublesome, by irritating
the epiglottis and exciting cough, as to require strong astringents
and stimulating gargles to be used, or even excision of a part of it
with a scissors or other instrument. That which I prefer is the
one introduced by Dr. J. K. Mitchell.
Tonsillitis; or Amygdalitis — Angina or Cynanche Tonsilla-
ris.— To this variety of angina the popular term of quinsy is
more especially applicable. Often the inflammation in angina
affects at the same time the tonsils, commonly on the surface, but
sometimes, also, in their substance, as manifested by some enlarge-
so
DISEASES OF THE DIGESTIVE SYSTEM.
ment of these bodies. The remark just made respecting palatihs and
inflamed uvula, is applicable to this moderate degree of tonsillitis.
The case is one of simple angina, and is to be treated as such. But
it frequently happens, also, that the tonsils are the chief seat of
inflammation and of swelling, to such a degree as to render deglu-
tition excessively painful, and for a while impossible ; — the fluid
being either rejected by the mouth, or returned by the way of the
posterior nares through the nose.
Tonsillitis is one of the most common inflammations to be
met with in northern and middle latitudes, in which the vicissitudes
of weather, particularly in the spring and autumn, are so frequent.
Sometimes it recurs periodically, and it is known, also, to prevail
epidemically, and especially after the prevalence of measles or of
scarlet fever. Its most usual-cause is transition from heat to cold
and moisture when the body has been previously heated. It often
appears in women just about the time of the menstrual flux, if they
have been suddenly chilled, or even after immersion of the hands in
cold water. It may appear under the operation of the other
causes, already enumerated, of simple angina. But it must be
acknowledged that sometimes this disease shows itself without
obvious cause.
Tonsillitis affects all ages and both sexes, but it has been said to
more frequently attack children and women. This popular belief
is not, however, sustained by the observations of MM. Louis and
Rufz, who found that, of sixty-four cases of tonsillitis, thirty-nine
were met with in men and twenty-five in women. It would also
seem to be the result of inquiries, instituted with the view of deter^
mining the question, that the disease is more common among boys
than girls in boarding schools. Do not these results coincide
with the experience of most physicians, deduced from their own
practice 1 The inflammation is seldom confined to one tonsil. Out
of forty-eight cases, both tonsils were affected in forty-one;
Symptoms.—Tonsillitis may come on without precursory symp-
toms or prodromi, and manifest itself by a sensation as if there was
some extraneous substance in the throat, and by a difficulty of swallow-
ing. More commonly it is preceded by the characteristic symptoms of
all inflammations ; such as chills, headache, thirst, loss of appetite,
and febrile reaction. After a period of variable duration this state
is succeeded by pain in the throat, and a continual but often inef-
fectual desire to swallow. Deglutition is painful and difficult;
the efforts to hawk and spit are frequent, and alternate with a
hoarse and guttural cough ; the mucus expelled is clear and stringy ;
the voice is muffled or entirely extinct. If the swelling of the tonsils
be great, so that they nearly meet, respiration is impeded, and, on
occasions, to an alarming degree.
On inspecting the throat, a duty never to be omitted in anv
disease, however slight, of this region, by depressing the lower ja\v,
and keeping the tongue down with the handle of a spoon, or a paper
folder or spatula, we see the enlarged and inflamed tonsils, and
TONSILLITIS.
81
their investing membrane of a deep red or scarlet colour and dry,
or presenting whitish concretions, or an exudation of lymph. The
uvula and palate are commonly more or less affected at the same
time, and the former particularly is inflamed and elongated, and
thus largely contributes to the frequent efforts at swallowing and
desire to cough. Inflammation extending to the Eustachian tube,
the hearing is affected, and sometimes even temporary deafness
is the result: there is also complaint of earache.
With the local are associated, also, general symptoms of more or
less intensity, such as headache, flushed face, tumid and glistening
eyes, thirst, nausea, morbid heat of the skin and other concomitants
of the febrile state. The bowels are constipated ; and the urine, of
a high colour, is not discharged without some feeling of heat or
scalding.
The duration of tonsillitis is from six to eight days: its termina-
tion is for the most part by resolution ; but it is far from uncommon
for it to be in suppuration. We infer that this latter has taken place
when, without diminution of the swelling, the pain is considerably
abated, and yet the difficulty of swallowing and of respiration are
as great as ever. Inspection at this time shows that the abscess
is pointing, or by a ready yielding to pressure manifests fluctua-
tion. The bursting of the abscess is sometimes brought about
by efforts of retching, or in coughing, and sometimes it takes
place when the patient is asleep. The pus is generally of a
fetid odour, and at times fetor is the announcement of the burst-
ing of the abscess. It is not often that both tonsils suppurate.
There are instances of the opening for the discharge of the
matter being external in place of into the throat. This is an un-
usual termination of tonsillitis ; but I have had a case of the kind in
the person of a beautiful girl, whose neck was much scarred by
the cicatrix of the sore, which was slow in healing, and assumed
for some time a scrofulous appearance. I did not see the patient
until the tumour had attained considerable size externally, and the
fluctuation was so manifest as to leave no choice but to give issue
to the pus by a lancet.
Treatment.—Without some strong contraindication depending
on the temperament and shattered constitution of the patient, or the
exhaustion caused by prior disease, we may safely begin the treat-
ment of tonsillitis by venesection. The earlier we have recourse to
this remedy after the disease is fairly established, the greater the
probability of its terminating in resolution. Sydenham used (in
quinsy) to " bleed plentifully in the arm, and presently after in the
veins under the tongue." I pass over his mention of the gargle and
liniment which he directed, in order to repeat what he says again
about bloodletting and purging. " I bleed again in the arm the
next morning," he says," unless the fever and difficulty of swallowing
be in some measure abated, in which case I give a gentle purge,
much experience having taught me that this is highly necessary
and useful after bleeding." Nor does he even yet put aside the
82
DISEASES OF THE DIGESTIVE SYSTEM.
lancet; for he proceeds : " If this fever and other symptoms are like
to be violent even after purging, which yet seldom happens, they
are to be quieted by repeated bleeding, and applying a large and
strong blister to the back." Here, in a few words, we find the rule
of treatment of tonsillitis laid down, which has been generally fol-
lowed since the time of Sydenham by British and American practi-
tioners. Sir John Pringle was content to adopt the practice of his
distinguished countrymen in the treatment of quinsy, as it appeared
in the British army in Flanders. He tells us—"Its tendency
to bring on suffocation requires speedy and large bleedings,
purging, and blistering." He added another, and still a popular
remedy, viz: the application of a strip of flannel moistened with
volatile liniment to the throat, renewed every four or five hours.
I have found that, notwithstanding recourse has been had to one
or even two bleedings from the arm, the inflammation will some-
times persist, and with so much accompanying distress in deglutition
and breathing as to require farther and active treatment. Under
such circumstances, I do not hesitate to direct a considerable num-
ber of leeches, say from twenty to thirty on each side, to be applied
under the angle of each jaw on a spot corresponding externally
with the tonsils inside. In the course of a few hours after the ap-
plication the greatest relief is obtained ; either resolution takes
place, or the suppurative process is accelerated, and the abscess
breaks. Pringle was no stranger to the value of leeches in this dis-
ease, as he informs us that, at times, he has applied seven or eight
leeches under the fauces; and he adds,in confirmation of the prac-
tice of Sydenham, " when the patient has been brought low by the
loss of much blood from the arm, I have opened one of the veins
under the tongue, and taken away two or three spoonfuls." Small
as the quantity of blood here mentioned may seem, and few the
leeches applied, a moderate acquaintance with the phenomena of
disease shows us that a slight hemorrhagic effort, as in a very small
discharge of blood from the nose, or from hemorrhoidal tumours,
will sometimes be followed by an abatement, if not removal, of
symptoms indicating violent disease of the brain or some other
vital organs. By leeches in the vicinity of a diseased part we
may sometimes simulate a critical hemorrhage, and procure speedy
and complete relief far beyond that which would follow on the loss
of a much larger quantity of blood from the arm. This remark,
as far as it is meant to recommend leeching to your favour, is ap-
plicable chiefly, in the disease before us, to tonsillitis with little ac-
companying fever, or to that stage in which this state of the system
has been materially diminished by venesection. In well-marked ton-
sillitis, attacking the young and robust, and associated with fever and
a full and active pulse, we cannot hesitate, however, at least in the
beginning of the disease, to give a preference to the lancet over
leeches. Sometimes it will be desirable to apply the latter to a
remote organ, as to the vulva or anus, in cases of tonsillitis succeed-
ing suppressed menses or hemorrhoids.
TONSILLITIS.
S3
Purging ought to follow bloodletting as pointed out by Syden-
ham. In the extent to which the former is to be carried, as well
as in the selection of purgatives, we must be influenced by the tem-
perament and functional habits of the patient. If he be of a lym-
phatic temperament and bowels habitually slow, we should purge
freely with calomel and jalap, compound powder of jalap, infusion
of senna and salts, &c. If, on the other hand, he be of a sanguine,
or sanguineo-nervous temperament, and liable to, or suffering at the
time from chronic gastro-enteritis, we shall be content with a com-
mon laxative of rhubarb and magnesia, or of castor oil, and occa-
sionally an enema to relieve the bowels. After bloodletting in this
class of persons, febrile and inflammatory action is kept down by
emetic tartar with neutral mixture, and Dover's powder. In all
cases, after the abstraction of blood, warm, or even hot and stimu-
lating pediluvia are to be employed. This measure is the more
necessary after leeching the throat, in order to prevent an addi-
tional afflux of blood to this region; an inconvenience which some-
times occurs after the operation of leeching.
In cases in which local bloodletting is indicated, and leeches
cannot be procured, the method practised by Pringle might be had
recourse to with advantage: or, preferably still, cups applied to
the back of the neck and behind the ear. Blisters to the throat, as
sometimes used by Pringle, and still a favourite remedy with some,
I hardly ever employ.
The local treatment of tonsillitis is for the most part simple: the
inhalation of the vapour of hot water, warm water held in the
mouth for gargling is too painful, and fomentation or cataplasms
to the throat externally after V.S., and leeches, being the chief
means in the acute state. When the disease persists in a sub-acute
form, or when acute supervenes on chronic inflammation of the
tonsils, and deglutition is impeded, and respiration also interfered
with, it becomes sometimes necessary to scarify freely these bodies.
This is done with a sharp-pointed bistoury, covered with muslin up
to within an inch of its point; or what is safer in less experienced
hands, a bistoury concealed in a sheath or a canula, from which
the former is protruded when it rests on the tonsils. The point or
the edge will be used according as we intend either to puncture the
abscess, or scarify by incisions the inflamed tonsil. If the swelling
be accompanied with infiltration, and the redness not intense,
touching the tonsils with nitrate of silver will occasionally stimu-
late the parts to a more vigorous absorbent action, and cause a
diminution, if not removal, of the enlargements. Should more active
applications than simple vapour or warm water be thought desi-
rable, as the disease advances and the inflammation abates, and
when there is a secretion of tough viscid mucus, causing constant
efforts by hawking and spitting for its expulsion, a solution of ace-
tate of ammonia or acetous acid may be added to the water; to
the hot for the purpose of inhaling the vapour from the mixture, and
to the warm, but of less strength, to be held in the mouth as a quasi
84 DISEASES OF THE DIGESTIVE SYSTEM.
gargle. The free secretion and discharge of mucus may itself
become a means of diminishing the inflammation ; and hence some
stimulating solutions applied to the mucous membrane of the throat
will be of service to aid the elimination of the viscid phlegm, and
favour its farther secretion. But we cannot promise ourselves
much, or indeed any benefit from gargles in the common fashion
of using them by the patient himself. The solution, of what-
ever nature it may be, as of chloride of soda, or of acetate of
ammonia, alcohol and water, or even astringents, such as of alum,
or the compound infusion of roses acidulated with diluted sul-
phuric acid, to be usefully applied must be directed on the parts by
the aid of a syringe. This method, which some may regard as
a refinement of late date, is especially recommended by Pringle,
who tells us that he found " little benefit from common gargles," or
rather, it should be said, from the common method of using gar-
gles. His " composition is thirteen ounces of barley water (or
sage tea), with two ounces of mel rosum, and one ounce of
vinegar." Sometimes he added a spoonful of mustard for a greater
stimulus. In all cases, whether of simple quinsy, or of angina
maligna hereafter to be described, Sir John directed five or six
syringefuls to be injected, one after another, as far into the throat
as the patient can bear,-and the operation to be repeated three
times a day.
Chronic Tonsillitis — Enlarged or Hypertrophied Tonsil. — In
saying that enlargement of the tonsils is characteristic of or equi-
valent to chronic disease of these organs, we but indicate one of
the most common symptoms: but with this may be associated
morbid secretion or disease of the follicles, or morbid growth of
the cellular tissue, or inflammatory engorgement kept up by vas-
cular injection. Although hypertrophy of the tonsils is commonly
the effect of frequent attacks of acute inflammation, it is sometimes
congenital, or readily induced by slight catarrhal irritation, and
maintained without apparently adequate cause. This is more espe-
cially true in reference to children and other young persons of a
strumous or scrofulous habit.
But although originating from slight causes, and in its course
productive of little pain or distress, this early enlargement of the
tonsils cannot be regarded with indifference, nor treated with
neglect. It is a frequent sustaining cause of a troublesome cough in
children of the habit already specified ; and with some of them be-
comes indirectly the origin of spinal curvature posteriorly. The
continued cough tends to draw up the shoulders, and throw the head
forwards, and to cause a strain upon the walls of the thorax which
extends to the spine. The little patient becomes round-shouldered,
stoops, and after a while exhibits posterior curvature of the upper
dorsal vertebras. Hence, so soon as we discover enlarged tonsils
in a delicate child of a lymphatic temperament, it becomes our
duty to use all appropriate means,not only to remove this local affec-
tion, but to build up by wholesome food, pure air, and moderate
CHRONIC TONSILLITIS.
85
exercise, the osseous system and locomotive apparatus generally,
whilst attending also to the state of the digestive system as an im-
portant step towards the attainment of our object. Iodine has been
recommended under such circumstances, and I have myself derived
considerable advantage from prescribing it. Adapted as it is to
correcting the predisposition to scrofula, of which we see so many
evidences in the enlarged cervical glands, tumid lips, and other
characteristics, we shall be the more encouraged to employ it for
the removal of hypertrophied tonsils. This medicine is to be admin-
istered in the form of iodide of potassium, both by inunction of the
neck at the part corresponding externally with the tonsils, and
also in solution internally. Chalybeate preparations are indicated
on such occasions; but more than all, must we lay stress on light
yet nutritive food, much, but not fatiguing, play and exercise in the
open air, and the tepid salt bath, with frictions in the length of the
spine. A similar treatment is applicable to older and adult subjects
with chronically enlarged tonsils. To such persons we can give, in
addition and with more freedom, narcotics; sometimes combined
with purgatives, sometimes with tonics, and at times, but after
mature deliberation and with great caution, blue mass or calomel.
The tonsils may also be cauterised with nitrate of silver, butter of
antimony, &c.
All proper medicinal agents, general and topical, having been
applied, but without success, we invoke the aid of surgery for the
removal of enlarged and hypertrophied tonsils. This is done either
by the ligature or by excision. The latter is now the mode gener-
ally preferred. Various instruments have been devised, or modified
after the discoveries of others, for this purpose. That which I
prefer myself for use, is the one devised or improved by Dr. Fahen-
stock. But as there is a very natural aversion to submitting to an
operation for the removal of the tonsils, which really has quite a
formidable appearance, although in general it is comparatively
easy and safe, a physician is only justifiable in urging it on the
patient whose health is materially injured, if not life endangered,
by these morbidly enlarged glands. There are some persons in whom
the tonsils are so hypertrophied as almost to meet together, and to
render deglutition difficult, and breathing through the mouth during
sleep laborious. With them a slight additional enlargement, as may
readily happen from catching cold, will bring on the worst features
of acute tonsillitis, and extreme suffering if not imminent danger.
After some abatement of the phlogisis an operation is both proper and
imperatively required. There are cases, on the other hand, and par-
ticularly in children whose tonsils remain enlarged after scarlatina or
even acute tonsillitis, in which, finally, and without any treatment,
these glands recover their normal size. A knowledge of this fact,
which I have had occasion to note within the circle of my own
practice, as well as to be apprised of analogous ones by other
physicians, will very properly induce us to pause before we recom-
mend excision unless the call be urgent; and this can hardly be
vol. i.—8
S6
DISEASES OF THE DIGESIIVE SYSTEM.
considered such, unless both tonsils are much enlarged and tend to
a close approximation. In many cases, the removal of one, even
where both are diseased, will serve to render the patient com-
fortable.
It has been already intimated that, associated with hypertrophy
of the tonsils, there may exist a morbid state of their follicles.
This is manifested by depraved secretions, as of a fatty or seba-
ceous matter, or concretions consisting either of indurated mucus or
of saline substances, such as phosphate of lime. The mucous con-
cretions are susceptible of a change to such a degree as to become
putrid and give rise to an insupportable fetor of the mouth, consti-
tuting one of the causes of "bad breath." The true concretions
sometimes distend the tonsils, and dilate the opening of the lacunae
to such a degree that they may be seen by the naked eye, if the
mouth be opened and the tongue depressed, and even touched with
a probe. Persons who are thus troubled, sometimes spit them
out, after they have fallen into the mouth or the pharynx. M.
Blandin (Dictionnaire de Mtdecine et de Chirurgie Pratique)
states, that he frequently extracted concretions of this nature from
the tonsils of a young man affected in this way. The operation,
when necessary, is readily performed by means of a long and delicate
forceps. The annoyance may be so great, from the number and
size of these morbid formations, as to make it desirable to remove
their cause by the extirpation of the tonsils.
There are persons, otherwise in good health, from the follicles of
whose tonsils and pharynx are secreted fatty masses, which have
a general resemblance in colour and consistence to the granules of
phthisical expectoration. "From these latter, however, they may
be at once distinguished by heating the substance on paper; if the
secretion be derived from the follicles of the pharynx or tonsils, it
is sebaceous, and leaves a greasy stain on the paper, which is not
the case with pulmonary or tubercular granules." (Tweedie —
Cyclop. Pract. Med.)
Impeded Hearing.—A morbid state of the mucous membrane of
the throat and enlarged tonsils are not unfrequent causes of impeded
hearing, and even deafness. Mr. Yearsley (On Deafness from
Morbid Conditions of the Mucous Membranes of the Stomach, Throat,
and Ear, the Effect of Cold, Scarlatina, Measles, &c.) points out the
various circumstances under which these morbid causes are oper-
ative. One of the most striking causes of deafness, and fortunately
one most easily remedied, is that in which, after catarrhal inflamma-
tion of the Eustachian tubes, the tubes and middle ear are gorged
with thickened mucus, which often remains fixed the whole life-time,
unless accidentally displaced by a sudden respiratory action, as
sneezing, or during the effort of vomiting. The most rational way of
cleansingout the obstructed cavities would seem to be the injection of
tepid water through an Eustachian catheter, as performed by Wathen.
The same end is obtained, and much more agreeably to the patient,
CHRONIC TONSILLITIS.
87
by the injection of compressed air, after the manner of Deleau. Mr.
Yearsley adopts the latter, and finds that a few operations, or even
one, will break down the agglutinated mucus, and admit air to the
tympanum, so as to reproduce the hearing in a most remarkable
manner.
Morbid growth of the tonsils is a more frequent cause of deaf-
ness, in Mr. Yearsley's experience, than has ever yet been supposed.
Simple inspection is not enough to apprise us of the degree of pro-
jection of the tonsils, as they are often hidden by the anterior pillar
of the palatine arches and the soft palate. Were the parts examined,
as they ought to be, by the -finger, the enlarged tonsil would not
unfrequently be detected, growing upwards and encroaching on the
mouths of the Eustachian passages.
The enlargement, on the other hand, which is productive of
thickened speech, strikes the eye immediately on the mouth being
opened, and extends downwards in a direction opposite to that
which is calculated to produce deafness. If the upper margin of
the morbid growth be visible, thick speech only is the result;
but if the growth ascend so as to interfere with the movements of
the uvula and soft palate, then we may have, associated with the
thickened speech, nasal speech. The enlarged tonsil which inter-
feres with swallowing is that which projects into the pharynx,
almost or entirely meeting its fellow; and each is generally attached
to its site by a narrow base.
In those cases, continues Mr. Yearsley, where the enlarged glands
have an extended base, reaching from the vicinity of the Eusta-
chian tubes to the bottom of the pharynx, we may look for defective
speech, hearing, and breathing, altogether associated, more parti-
cularly if the uvula enters into the diseased condition of the parts.
With such a state of the throat, on getting up in the morning the
sensations are most disagreeable. The vitiated mucus collected
during the night, and adhering to the throat, produces nausea, or
even vomiting for some time, till the tenacious phlegm can be ex-
pelled by hawking or coughing. A person thus affected does not
often feel himself fitted for the duties of the day until an hour or
two after rising.
Of the persons most liable to tumefied states of the throat, children
of a strumous diathesis rank foremost. Enlargement of the tonsils
may often be inferred to exist from the presence of glandular swell-
ings of the neck.
Frequently, when the tonsillary growths are not so large as to
interfere materially with the freedom of the Eustachian tubes, their
diseased state excites a morbid secretion of mucus, both in the tube
and tympanum, which of necessity obstructs the hearing. In this
state catheterism and the air-douche will effect a^temporary resto-
ration, but as the cause of the disease remains untouched, the deaf-
ness is speedily reestablished.
In old age, when absorption is much more active than the depo-
sition of new matter, enlarged tonsils invariably disappear. Mr.
S8
DISEASES OF THE DIGESTIVE SYSTEM.
Yrearsley has never seen a case where the enlargement remained
after the fiftieth year ; but, unfortunately, the removal of the morbid
growth, as age advances, does nothing towards a restoration of
hearing, when this sense has been impaired by the long existence
of the evil.
As it does not come within the scope of my design at this time
to treat formally of deafness, I will just remark incidentally,
that, where this disease is connected with a morbid state of the
mucous membrane of the throat, manifested by thickening and
perverted secretions in the throat, nose, and ear, we may advan-
tageously recommend a few leeches, once or twice a week, either
behind the ears, or within the nostril to the side of the septum
narium, followed by moxa, blister, or emetic-tartar applied behind
the ear or along the inner margin of the lower jaw, and catheterism
with the air-douche. If this diseased state of the auditory function
and of the throat be complicated with depraved digestion and
nutrition, excellent effects are obtained from the iodide of potassium
(hydriodate of potassa) given in small doses, as of one or two grains
largely diluted. No medicine, within the knowledge of Mr. Yrearsley,
has an equally beneficial effect on the ear with this. In such high
praise I willingly concur, from having been repeatedly witness of
the good effects of the iodide under such circumstances.
While on the subject of morbidly enlarged tonsils, and adverting
to the means of relief occasionally had recourse to by their excision,
it is proper that I should prepare you for finding sometimes a change
of voice in your patient after this operation. The fact is one of some
interest, and has been lately introduced to the notice of the College
of Physicians, of this city, by Dr. Isaac Parrish (Quarterly Summary
of the Transactions, &c). The modification of the voice is of
a peculiar kind, — a hissing or whistling sound.
LECTURE VII.
dr. bell.
Angina Membranacea—The simple and the malignant varieties.—Malignant
angina, or diphtheritis—Earlier notices of it—Causes—Connexion with scar-
latina— Persons most liable—Epidemical and endemical, and sometimes spo-
radic—Symptoms—Diagnosis—Its anatomical characters.—Membranous exu-
dation—Is sometimes ulcerous and gangrenous—Prognosis—Age, temperament,
particular exposure and lodging modify result — Treatment.— Bloodletting
sometimes admissible—Emetics—Revulsives—Stimulants—Calomel__Blisters,
under what indications required—Topical treatment—Stress laid on it in ma-
lignant angina—Chief articles employed.—Summary of treatment in some of
the worst cases marked by suddenness of invasion and prostration of the powers
In addition to the common inflammation of the mucous membrane
of the throat, the chief varieties of which, as far as they may be
ANGINA MEMBRANACEA SIMPLEX.
89
supposed to depend on the parts specially affected, I have described
in my last lecture, there is inflammation of a particular, perhaps
we might venture to say, specific kind. Its distinctive anatomical
trait is membranous or pellicular exudation, sometimes preceded
and-accompanied by mild constitutional disease, at other times and
more frequently with symptoms of violence and danger, which the
result does not by any means belie. I shall speak of these two
varieties under separate heads, and first of —
Angina vel Pharyngitis Membranacea Simplex — Simple or
Benignant Membranous Angina. — This has been called, also, acute
membranous angina, but not, as I think, with propriety; for the
next and formidable variety is also acute; eminently so, indeed, if
we allow this word to designate a disease which sets in with great
violence, at least with great perturbation of function, and runs its
course with rapidity to often a fatal termination.
Simple membranous angina begins, like the diffused variety, with
some uneasiness in deglutition, increased redness of the mucous
membrane of the pharynx and palate, and swelling of the tonsils.
A membranous exudation, at first in patches, and afterwards con-
tinuously diffused, soon appears, and the difficulty of swallowing is
increased, but the pain not in a corresponding degree. The pre-
ceding and accompanying symptoms are those of common guttural
or anginose inflammation: the pulse is moderately full, but without
much frequency, and the skin is warm.
In some instances, as first more distinctly pointed out by M.
Guersent, the exudation appears in the form of portions of lymph
on the inner surface of the throat, of a grey or yellowish-white
colour, of a soft consistence, easily detached and seized by any
hard body, and easily renewed. They readily extend to the eso-
phagus, but never to the larynx. To this variety the term angina
pultacea or caseiformis has been given by M. Guersent. But we
do not see in the difference of the form of morbid secretion or of
exudation any adequate cause for regarding this as a distinct variety,
requiring a separate name.
The treatment of simple membranous angina is not different
from that of the diffused angina without membrane. If the subject
is robust and of sanguine temperament, we bleed at once without
hesitation; or if there be no contraindication in weakness of habit
or from special exposures, and the symptoms of febrile excitement are
considerable, wo also have recourse to the lancet. Purging, the
cooling regimen, and mild antimonials with warm pediluvia, will
generally complete the cure. Local depletion by leeches or cups
in the manner already indicated may be sometimes necessary after
venesection; sometimes also in place of this operation. Calomel
in moderate doses, repeated at short intervals, exerts a good effect
on this as, I shall have occasion to tell you, it does on the other
variety of malignant angina.
Angina Membranacea Maligna. — Cynanche vol Angina Ma-
ligna, Putrid, or Ulcerated, or Gangrenous Sore Throat—Diph-
S*
90
DISEASES OF THE DIGESTIVE SYSTEM.
therite ou Angine Gangreneuse of French writers—Secondary
Croup.
In giving the above titles to the disease of which I am about to
speak, I do not by any means affirm that they are synonymous, or
that the symptoms are identical; but merely that there are traits
enough in common to justify us, for the present, in speaking of
them together. Although the term diphtheritis be of recent intro-
duction into medical literature, the diseased states which it is
intended to designate are not by any means of such modern date.
Few epidemic anginas, especially those called malignant, either
separate, or, as was most commonly the case, combined with a
cutaneous febrile eruption, have proved fatal, without numerous
instances having occurred of the complication of a diseased state of
the mucous membrane of the fauces and pharynx, conjoined with that
of the larynx and trachea.
In the novelty of nomenclature and refinements of morbid ana-
tomy, there is some danger of our forgetting that the disease in
question is one which has been fully described by several Eng-
lish as well as continental writers, anterior to the present century.
There is no malady which at times has committed more ravages
and been less amenable to medicine than malignant angina, or
putrid sore throat. The accounts of the disease are numerous, and
have been detailed with accuracy in nearly all particulars, and the
treatment laid down as ably in the generation preceding our own,
as we can lay claim to for our own day, — except in two important
points. The first, as respects description, — in our having learned
that the diseased mucous membrane is neither ulcerated nor gan-
grened in the cases generally met with, even when of a fatal kind:
the second, as respects treatment, is in the greater stress laid on
topical applications to the throat itself. Huxham, about the middle
of the last century (1751), Quarin, of Vienna, and Fothergill in the
last quarter of the century (1781 and 1784), have severally left us
full histories of this disease. Nor has it been overlooked by the
venerated and practical Heberden in his " Commentaries." I say
nothing of Cullen, Y\ne\,(JVosographiePhilosophique, T. II. p. 248-58)
and other systematic writers up to the present time, a reference to
whose productions is so easy.
Causes. — The close connexion between angina or cynanche
maligna and scarlatina has been generally noticed. Heberden
remarks on this point: " it seems highly probable that they are both
names of the same distemper, with some little variety in a few of
the symptoms; and this opinion is confirmed by our finding that
they are both epidemical at the same time. Even in the same
family, where a number of children have been ill either together, or
immediately after one another, some have had the distinguishing
symptoms of the scarlet fever, and others of the malignant sore
throat." Cullen believes them to be specifically different; but he
admits their affinity, and that there may be scarlatina anginosa
resembling cynanche maligna sine eruplione, just as on the other
hand we see scarlatina sine cynanche, or without an affection of the
ANGINA MEMBRANACEA MALIGNA.
91
throat. That angina depends upon a specific contagion identical with
thatofscarletfever is a common belief. By somethisopinion has been
modified, into affirming an analogous but not identical cause ; and
they tell us of the eruption which accompanies malignant angina,
and which makes its appearance sometimes on the first, and at
other times not until the fourth day of the disease of the throat. It
generally shows itself first about the neck and breast, sometimes
with itching of the skin, more frequently without this symptom.
The eruption, often attended with some degree of swelling, gradu-
ally spreads over the trunk and extremities. As in the case of
scarlatina it comes out in stains which, when nearly inspected,
appear to be composed of small prominent papulae, with the inter-
stices of a natural colour. Their prominence may be distinguished
by the eye, but more readily by the touch. It rarely happens, how-
ever, that the eruption is uniformly diffused in severe cases of
malignant membranous angina; but it more generally comes out in
blotches or small points scattered over the trunk and extremities,
which are of a dark purplish or livid hue, and terminate in a very
scanty desquamation.
The class of persons most liable to this disease, children and
young persons, would seem to favour the idea of its analogy to
scarlatina ; but, on the other hand, we cannot overlook the fact of its
being both endemial, as in parts of France, (Touraine and Picardy,)
and epidemical, and of its prevailing chiefly in most situations in
the spring months, — as well as in hospitals and workhouses ; and
in these places it is confined to young children, the first cases oc-
curring in the most crowded wards. Under these last circum-
stances it spreads with frightful rapidity. When adults are attacked,
it is often after being exposed to the operation of similar causes,
viz., a close, impure atmosphere, the effects of which were increased
by accidental wetting of the body or feet, and mental anxiety and
depression. Whether sporadic or epidemical, or obeying the in-
fluence of seasons, we shall generally find angina maligna to have
resulted from causes which attack " the springs of life," — prostrate
the nervous system, deteriorate, if not poison, the fluids, and pervert
all the secretions. Now, while we know that contagion is emi-
nently calculated to produce these effects, we cannot deny that
other agents will produce analogous ones, and of these the most
potent is impure and noxious air.
Under epidemical and complicated influences, or if there be unity
of cause it is as yet beyond our ken, angina maligna is not by any
means confined to children or those of tender age. I have seen
adults and old persons in large numbers sink under it, with more
or less of the complications hereafter to be described. At such
times angina will be found to be the precursor, sometimes the asso-
ciate of epidemic catarrh or of measles, as well as of scarlatina
proper. In some of the worst cases of small-pox which I have had
under treatment, the fatal complication was evidently that of mem-
branous angina, in which this exudation extended to the larynx
92
DISEASES OF THE DIGESTIVE SYSTEM.
and trachea, and in this way destroyed the patient, at a time when
he was apparently out of danger from the eruptive fever.
As respects the immediate cause of the membranous exudation,
M. Roche (Dictionn. de Med. el de Chir. Prat., Art. Angine) is in-
clined to believe that it is colourless fibrin thrown out by a hemor-
rhagic inflammation on the mucous membrane, the engorgement of
which, with dark blood in patches, visible when the membrane is
detached, is cited as farther evidences to the same point.
Symptoms. — Angina maligna, diphtheritis, (from *, skin,)
as it was first called by M. Bretonneau, of Tours, or the secondary
croup of Dr. Stokes, commences with stiffness in the muscles of the
neck, pain in the throat, difficulty of swallowing, and general febrile
symptoms. Inspection of the fauces shows us that the tonsils are
swelled and reddened, and have upon their surface patches of
thick, opaque, whitish concretions, which at this period of the dis-
ease are easily detached from the mucous membrane. If allowed
to go unchecked, the inflammation and the membranous exudation
spread by continuity to the adjacent parts, the soft palate and pha-
rynx ; the glands at the angle of the jaw begin to swell, and
deglutition becomes more difficult, the face is puffed, and the eyes
glistening and watery. If the concretion be detached from the
membrane beneath, the redness greatly augments on the denuded
parts, and another and thicker concretion is soon formed, which
adheres to the mucous surface with more tenacity than before.
Frequently it happens, that some days after the commencement of
the attack the disease becomes milder, is less disposed to spread,
and even ceases altogether without reaching the air-passages,
in which case there is very little reason to fear the consequences.
In most instances, however, at the end of four or five days laryngeal
symptoms begin to display themselves, such as a hoarse cough,
alteration of the sound of the voice, and dyspnoea. From this time
the patient has every appearance of suffering from severe croup,
with the addition of an almost complete inability to swallow ; the
breathing becomes quite laborious and sonorous, the voice is soon
extinct, the countenance livid, and pulse small and intermitting;
paroxysms of suffocation take place, till, in one more severe than the
rest, death closes the scene.
The pseudo-membranous concretion is detached and renewed
several times. Sometimes the disease is terminated by resolution
and the false membrane is absorbed. Commonly the last formed
becomes softer, and is expelled in fragments mixed with sanguino-
lent mucus. The extension of the inflammation to the nasal fossae is
followed by a discharge from the nostrils of a serous, yellowish,
bloody, and very fetid matter. The anginose affection often engages
exclusive notice, to an oversight of the broncho-pneumonia which is
sometimes associated with it, even when the laryngeal symptoms
are not very intense, and which destroys the patient, even when he is
thought to be out of danger.
The duration of diphtheritis is various.- In some instances it has
ANGINA MEMBRANACEA MALIGNA. 93
caused death in the course of a few hours: generally when the
angina is complicated with laryngitis the patient sinks under the
disease from the third to the seventh day. If the inflammation is
restricted to the pharynx and fauces, it may last for two or three
weeks. It is rarely chronic, although M. Roche says that he has
seen a case of eight months duration in a female, and M. Girouard
relates one of a membranous inflammation of the tongue and fauces
which lasted two years. In both these cases the false membrane
was from time to time detached, and replaced by a fresh one.
Diagnosis. — The chief anatomical character of diphtheritis is
the false membrane, or lymphatic exudation, which gives a name to
the disease: it is either continuous or in patches, occupying some-
times the nasal fossae, the velum palati, tonsils, pharynx, esopha-
gus, larynx, trachea, and even the divisions of the bronchi. M.
Guersent has seen it extend into the frontal sinus, and M. Breton-
neau once on the concha of the ear. Sometimes, the exudation is
found in the stomach, with an interruption of continuity, however, on
the esophagus. Often, if not in a majority of cases, its range is more
circumscribed, covering only the pharynx and tonsils; sometimes
extending to the epiglottis and rima-glottidis, but without passing this
latter. It is commonly adherent to the velum palati, the tonsils and
the pharynx, whilst on the other hand it is, for the most part, loose,
or hanging in shreds in the trachea. In thickness it varies from that
of a leaf of paper toa line. Contrary to what was generally imagined,
before a careful inspection of the parts in late years, the subjacent
mucous membrane is neither ulcerated nor gangrenous. The nu-
merous patches with which it is studded, and the central depressions
on these, and the dark-red colour of the mucous membrane, together
with the extreme fetor of the breath, gave rise at one time to a
belief that these organic changes were the consequence of gangrene,
and hence one of the names of the disease, gangrenous sore throat.
But there was error in all this — the pseudo-membrane is the result
of either inflammation or of hemorrhage which does not even end
in gangrene.
Diphtheritis is occasionally sporadic, but much more frequently
epidemic. It attacks individuals of all ages; displaying, however,
a marked preference for children of either sex from the age of four
or five to the time of puberty. According to Mr. Bretonneau it is
decidedly contagious, and especially when combined with scarla-
tina, which is one of its most frequent complications. We must
regard as diphtheritis the epidemic croups which are on record.
The epidemic which prevailed during the winter months in succes-
sive years, from 1813 to 1816, in so many parts of the United
States, presented numerous examples of diphtheritis, in which the
pneumonia and bronchitis were sometimes apparent, but in other
cases they were completely masked by the anginose symptoms.
Then, however, although but a student, I remember very distinctly
that adults and those advanced in life were the greatest sufferers
and most numerous victims : in some of the oldest persons the an-
94
DISEASES OF THE DIGESTIVE SYSTEM.
ginose symptoms were most predominant. But whilst admitting
this complication, it is a refinement beyond the facts, it seems to me,
to believe that all epidemic anginas are really diphtherites in the
sense laid down by M. Bretonneau, viz., the extension of the mem-
branous formation to the air-passages. Still less tenable is the
position, that croup and diphtherites are one and the same disease,
as affirmed by the French pathologist just named.
In admitting that angina membranacea maligna, or diphtheritis, is
the same disease with cynanche maligna or angina, and that the
identity of scarlatina simplex with scarlatina anginosa and scar-
latina or angina maligna, and the sore throat without efflorescence
on the skin, are merely varieties of the same disease, as affirmed
by Dr. Tweedie, we cannot see a common origin nor symptoms
identical in all. That angina maligna appears at times without
specific contagion, we can hardly doubt — certainly diphtheritis
does ; and, as regards the complication of membranous inflamma-
tion of the throat and air-passages, which is thought to distinguish
diphtheritis, although this is met with also in many cases of malig-
nant membranous angina, it is not in all. In scarlatina anginosa,
we are told expressly by Rayer, that although the exudations of
lymph often extend to the lateral parts of the pharynx and occa-
sionally as far as the esophagus, they are never observed after
death in the larynx or trachea. This coincides with the experience
of Dr. Tweedie, who has not seen in the dissections of scarlatina
with anginose inflammation which he has made, an instance of
membranous exudation extending to the larynx.
In diphtheritis there is no ulceration nor gangrene; the removal
of the membrane leaves the parts beneath entire, with some of the
mucous lacunse larger and more open than usual. In scarlatina
or angina maligna, on the other hand, cases occur in which, on the
clear testimony of Huxham, Fothergill, and Heberden, there are
deep ulcerations, the consequence of gangrenous eschars, which
cannot be confounded with any crust or coat formed and spread in
the mucous membrane itself. Sometimes the uvula and portions of
the palate are entirely destroyed in this way-
The tendency to affections of the larynx and trachea by the
spreading of the inflammation from the pharynx was pointed out
and known long before MM. Bretonneau and Guersent indicated
the fact. Dr. Johnstone had many years ago (17G9) proposed, on
this account, to divide the disease into the cynanche maligna ton-
sillaris and cynanche maligna trachealis. But that which the
British writers, and I might add the name of Heberden to the list,
regarded as occasional, the French pathologists insisted on being
a constant and diagnostic feature of the disease. Opposed to this
extreme view is the recent testimony of MM. Rillet and Barthez,
(ArcHv. Gen. de Med., Dec. 1841,) who give a case of membra-
nous angina with gangrenous ulcerations of the pharynx, in which
the nasal passages were lined by a pseudo-membrane. They
present also cases in which a difused gangrene occupied the velum
ANGINA MEMBRANACEA MALIGNA.
95
palati, the half arches, the tonsils, and the pharynx. You may
expect, therefore, after what I have laid before you, to meet with
simple membranous pharyngitis or angina, alone, and also with
malignant membranous angina or malignant angina ; this latter
sometimes restricted to the throat, sometimes extending into the
larynx or trachea — often without ulceration, sometimes with ulcer-
ation and gangrene. In epidemic angina or diphtheritis it is com-
mon to find the face and the glands of the neck swelled. In spo-
radic diphtheritis, as in the case recorded by M. Marie, (Archives
Gen., Mars, 1841,) there was no swelling of these parts, but the
whole throat and air-passages, from the nasal cavities to the bronchia
inclusive, were lined with a false membrane.
Prognosis.—Stress has been laid, by some, on the appearance
and fluctuations of the eruption as guiding us in our augury of the
kind of termination of malignant angina; but in this there are no
certain rules. Thus, while it is said that a florid colour, uniform
diffusion, and large desquamation, give us a good prognosis, we learn,
at the same time, that the eruption may be full and high-coloured
and yet death ensue, as in cases related by Huxham, in which the
patients were covered with "the most fiery rash" he ever saw, and
yet they died in this disease " of a phrensy." So, also, Heberden
observes, that where this redness was the most florid, the patients
have not seemed at all the better, nor have they been apparently
hurt where it has faded and disappeared. Increase of anxiety,
coma, difficult respiration, with impaired tone of voice or aphonia,
and an aversion to take any food or drink, are unfavourable signs.
Hemorrhage from the intestines, nose, mouth, or ears, is of bad
augury; so also is exhausting diarrhoea, and the excretion from
the mouth of mucus mixed with blood and sanies.
A general moisture of the skin about the time of desquamation ;
a copious sediment in the urine ; the pulse preserving its fulness and
becoming slower; the breathing clearer and less hurried; the
fauces and pharynx losing lividness of colour, which they may
have previously acquired; increased ease of deglutition; saliva
rather than bloody mucus flowing from the mouth ; abatement of
the swelling of the parotid and cervicalglands,are encouraging signs,
and may allow us to utter a favourable prognosis. We are not, it
will be readily understood, to expect to see all or a majority of these
signs at once. The presence of any two or three will give us
hope.
" The younger the patients are the greater is their danger,"
is a remark of Heberden, the correctness of which is generally
proved by the issue of the case. But there are many exceptions
to the opinion advanced with some confidence by Fothergill and
others, that not only are adults less subject to the disease, but it
seldom proves fatal to them. In the winter epidemic of 1814-15,
to which I have already referred, the proportion of adults attacked
was greater than of children, and the deaths among the former
were unhappily very numerous. A lymphatic temperament and
96
DISEASES OF THE DIGESTIVE SYSTEM.
previously sickly habit are unfavourable. We shall have less hope
of a happy result if the patient is in a close and crowded room, and
have suffered from penury and destitution, before the coming on of
the disease. The prognosis will be more encouraging towards the
decline than at the beginning of epidemic angina.
Termination. — The mortality from this disease, in all its visita-
tions and under all modes of treatment, is excessive. To the affec-
tion of the throat and air-passages is superadded a malignant form
of fever, either of which is sufficient to destroy life. The disease
generally reaches its height at the sixth or seventh day. In fatal
cases it has terminated in two or three days. In favourable ones
it will remain to fourteen days, although the imminent danger is
over in half the time.
Treatment. — If we carry in our minds the antecedent and ac-
companying circumstances by which diphtheritis is modified, we
shall begin the treatment with less hesitancy, certainly with less
chance of serious error than they have done who, under the influ-
ence of an exclusive pathology, insisted either on its being a disease
of pure asthenia, with a rapid tendency to gangrene, or on its being
a phlegmasia. In those persons of a feeble frame and exhausted
constitution, who have been badly fed and lodged, the prostration
is great and the reaction slight. On the other hand, the strong,
plethoric, and sanguine, exhibit, with great severity of the local
symptoms, a frequent, full, and resisting pulse, and a general and
almost acrid heat of the skin. In some, the angina is associated
mainly with symptoms of gastric disorder: in others, the membra-
nous exudation extends, in the manner already described, into the
air-passages, and the chief complications will be laryngitis, or
broncho-pneumonia. Now it is very obvious that the same treat-
ment cannot be applicable to all these varieties, and that while
venesection may be imperatively required in cases of the latter, it
would be eminently prejudicial, if not fatal, in the former; and so,
also, local and general stimulants which might be clearly indicated
in one kind, would be worse than useless in the other. In the same
epidemic to which I have already referred, and in which, from
the necessity of the time I was allowed to act a part as well as
entertain an opinion, I well remember the opposite views and prac-
tice adopted by physicians. Some, who saw the anginose cha-
racter predominate, and the accompanying cold skin, feeble pulse,
and general prostration, would not admit the safety of any other
remedies than of emetics, stimulating gargles, blisters to the neck,
and diffusible stimulants. Others, witnesses to distinct pneumonia
and less-marked angina, shaped their practice accordingly, and
bled their patients. Some, again, who met with a predominance
of gastric disorder and hepatic derangement, relied on calomel and
purgatives.
In premising that bloodletting is less called for in malignant,
plastic, or membranous angina, than in other inflammations of the
pharynx, tonsils, and larynx, we ought not, however, to exclude it
ANGINA MEMBRANACEA MALIGNA.
97
entirely from our list of remedies. The plethoric and the sanguine,
or the cases in which pneumonia is complicated with the angina,
will be benefited often by venesection. M. Roche, among others,
gives cases of the benefit of this practice, and I have tried it myself
with advantage. In more doubtful circumstances, but in which the
pulse has still .some fulness and resistance, and in which there is
evidence of great determination to the throat, marked by redness
and swelling, leeches may be applied under the angle of the jaw,
and on each side, and in front of the neck, or cups to the nucha
and under the mastoid processes. Even the cautious and skeptical
Heberden says on this point: " Yet, in some few persons, whose
strength seemed able to bear it, and whose heat and headache, and
manner of living, seemed to require it, I have known blood taken
away once, and even twice, in the beginning of the distemper, with
safety, and perhaps with advantage." Here, as in acute laryngitis,
we should have a definite object in view7 in detracting blood, viz.,
to produce a decided impression on the diseased membrane ; failing
to do this, we only aggravate the disease by encouraging a morbid
reaction. Hence, if the first leeching or cupping do not produce
the effect proposed, the operation should be repeated after a brief
period.
In the cases, on the other hand, in which the patient has but
little vital energy, owing to his having been badly nourished or
exhausted by prior diseases, as phthisis, for example, or in which
there is little or no augmentation of action of the pulse ; but on the
contrary a cold skin, but slight pain of the throat, and the voice
nearly extinct, bloodletting, either general or local, is clearly con-
traindicated, and could hardly fail to be prejudicial. In this state
of disease, revulsives of various kinds are serviceable; among
which emetics are entitled to a trial first, provided the stomach be
not inflamed. A combination of ipecacuanha and of the infusion of
polygala senega would be preferred here to the tartar emetic, the
use of which, is applicable to the cases distinguished by vascular
excitement and calling for previous detraction of blood. In croupal
complications the emetic practice is still more requisite. Carrying
out the revulsive treatment, we prescribe calomel, conjoined with
jalap or scammony or colocynth, in such doses as shall purge freely.
Medicines of this class are entitled to a preference over salines,
which exhaust by copious watery evacuations without exciting to
active secretion the intestinal mucous follicles and the liver. With
a view of carrying out consistently the course begun, we should
endeavour to stimulate the lower extremities by warm pediluvia,
sinapisms and liniments, and to excite the cutaneous function
generally by the warm bath, and by the warm infusion of polygala
or eupatorium. Calomel has been extolled as admirably adapted to
bring about a removal of the membranous exudation in secondary,
as it is believed by so many to do in primary croup. Its adminis-
tration with this view will not be incompatible with the employment
of the remedies just named. It should follow purging, and be con-
vol. i.—9
&s
DISEASES OF THE DIGESTIVE SYSTEM.
joined with the external revulsives already named, as well as with
those to be next specified: the dose may be a grain every hour or
two, with a very minute fraction of opium if the bowels are loose,
or of ipecacuanha. Among these vesication has always been a
favourite. Like certain other remedies, however, it has retained
its vogue from very opposite causes. Some prescribe a blister in
angina, because it has been prescribed by others; some, because
they have seen positive good result from its application ; and others,
because they do not know what else to advise. It would argue
prejudice, on my part, were I to tell merely of the frequent suffering
without any corresponding adequate relief which I have seen to be
caused by blisters applied in the common fashion on the anterior
part of the neck under the chin: and yet my earlier reminiscences
of this kind are much more distinct than those of any decided good
from the practice. On the nucha, or over the trachea just above
the sternum, is a preferable spot for the application of a blister;
and if counter-irritation be still thought advisable near the affected
part, an ammoniacal or turpentine liniment may be rubbed on th^e
neck, from the angle of the jaw downwards and forwards over the
larynx.
But, whilst a trial is made of some, or all, of these remedies in suc-
cession, we ought to be aware of the importance, from the first, of
making applications to the diseased mucous membrane of the
fauces, tonsils, and pharynx, — not, because as M. Bretonneau
would persuade us, this is the main and almost sole plan of treatment,
but because it is of no little moment for preventing the farther
spread of the plastic exudation, and thus far saving the larynx, and
air-passages generally, from dangerous participation in the disease.
The chief topical remedies are hydrochloric acid, nitrate of silver, and
alum. Of these, the two latter are to be preferred. The safest and
easiest of application is the alum, blown on the part by means of a
tube, with gauze applied on the end next the throat, or reduced to
a paste by mixture with water and honey, and applied to the dis-
eased surface by means of a small brush, or the handle of a tea-
spoon. It, as well as sulphate of copper, may be inhaled through
a tube, one end of which is carried back to the fauces or pharynx.
The nitrate of silver may be used in the same way, or that which
will be found to be more expedient and complete, is to fasten a
piece of the caustic, properly secured to a quill, and run it rapidly
over the mucous surface ; the mouth being kept open by means of
a spoon pressed on the tongue. Gargles have always been largely
used in diphtheritis, as well as the simpler forms of angina. The
popular one, composed of vinegar, salt, and capsicum, is often well
adapted to the disease in question. The chlorides of soda and of
lime, of late years, have been a good deal used, and with results
which warrant a ready repetition of the practice. Creosote has,
also, its eulogists at the present time. As a preventive measure
of the farther spread of diseases of the throat, we can only
anticipate benefit from topical means in the membranous variety.
ANGINA MEMBRANACEA MALIGNA. 99
In the ulcerous and gangrenous they are of less efficacy: when
used they should be introduced by means of a syringe.
Before I conclude the outline of the treatment of angina maligna,
I must impress on your minds the necessity of making your prac-
tice quadrate with the pathological view which supposes in some
cases a deterioration of the system, a poisoning, as it were, by which
the blood and fluids are depraved, and the nervous system depressed
and almost prostrated. The affection of the throat is but secondary
to, and merely symptomatic of, the violence of the general disease,
just as black vomit is of the worst forms of yellow fever, and the
blue stage of fatal cholera. The sufferers have been exposed to
depressing passions, loss of sleep, a close and almost pestiferous
atmosphere, as in crowded court rooms, jails, and certain places
misnamed asylums and hospitals: — their food has been scanty, or
of bad quality ; and, in fine, the functions of digestion, respiration,
and circulation, and innervation so interfered with, that neither good
chyle is formed, nor is the blood changed in the lungs: this fluid now
circulates in a more than usually carbonated condition, deterio-
rating and almost poisoning the organs. When the patient com-
plains of his throat, and his friends are solicitous about him, and
the physician is sent for, the mischief has been done. What are
the resources of art on this occasion 1 The routine of prac-
tice will little avail against the weakened heart, the feeble and
frequent pulse, the illy elaborated blood, the poisoned nervous sys-
tem and brain, with depraved and impeded sensation and intellect,
muttering delirium, &c. We may give an emetic to empty the
stomach, and really, under the olden faith of evacuating it of sordes,
at least of matter, which only interferes with vitality, and can no
longer be converted into a homogeneous and nutritive chymous
mass, and chylous fluid. But how alter the diseased blood, unless
by inducing the patient to inhale the freshest and purest air,— and
perhaps by a free use of saline drinks. The skin may be changed
from its now morbid state of dryness, burning and acrid heat, or
in regions unnaturally cold, by the prolonged use of the warm
bath, and preferably, if it can be got ready, the vapour, followed
by frictions or sponging with dilute hydrochloric, or nitric acid, or
of solution of one of the chlorides. The nervous system already
depressed, or rather stunned, requires no sedatives, and has not
strength enough to bear much stimulus. It may be appealed to by
remedies applied to the skin, such as those just mentioned, and by
stimulating pediluvia, frictions of stimulating liniment on the spine;
to the stomach by substances readily soluble and absorbed, pos-
sessed of some stimulant property, without causing much excite-
ment, such as by acetate of ammonia in solution, carbonate of ammo-
nia, turpentine with spirits of nitre, and small doses of the fluid chlo-
ride of soda. In the intervals between these you will give minute
portionsof calomel, and if the mind be very disquieted and restless
or there be muttering delirium, small doses of Dover's powder* its
effect on the skin, to be aided by light and pleasant drinks__of such
100
DISEASES OF THE DIGESTIVE SYSTEM.
a temperature as the patient himself may crave. If penury
and want, deficiency of food, or impeded nutrition from other dis-
eases, have preceded and contributed to bring on this form of an-
ginose fever or plague, and the skin be cold, and capillary excite-
ment less than natural, wine whey will come in most timely in
conjunction with carbonate of ammonia. We must, however, care-
fully watch its effects, so that they shall not transcend the line of
proper excitement, for if they do, and hence the disadvantage of
diffusible stimulants of the alcoholic class, the nervous system is
enfeebled, and digestion and hematosis are more or less impeded,
whilst the vitality of the membranes dependent so much on that of
the capillaries, suffers in an especial manner. In those cases where
there is an urgent call for increase of tone, the sulphate of quinia
should be given early, in small and repeated doses.
If the skin be of an acrid heat, and the pulse excessively frequent,
but without fulness or force, we may abate the morbid excitement
of the heart by small and repeated doses of digitalis, and indirectly
by sponging the surface with tepid, or even cool water, to which a
little mineral acid or common salt has been previously added. By
this means we determine to the kidneys, and procure discharges,
more or less meriting the name of critical. The bowels should be
acted on by enemata, at first laxative, afterwards saline, and, as the
strength sinks, terebinthinates.
During all this time we are not to forget the throat; but whilst
making suitable applications to it, we must ever remember that this is
but a secondary part of the treatment. Of the various substances
to be used, the chlorides will be entitled to the preference in the
variety of disease now under notice.
LECTURE VIII.
Pathology and treatment of diseases of the digestive system — Different forms of
gastritis— Pathology of this disease imperfectly understood by the ancients-
Gastritis and enteritisuot always found in connection—Phenomena characterising
acute gastritis — Symptoms and sympathetic relations — Diagnosis — Gastritis
simulating other diseases.
Gastritis. —The consideration of the pathology and treatment of
diseases of the digestive system will occupy our attention to-day.
I shall commence with the study of gastritis, and to this subject I
would entreat your undivided attention ; not that I have anything
very new to communicate, but because I believe that many of the
statements, which are connected with this disease, will be found to
rest on the basis of fact and truth, many of them will be found useful
in your future practice, and this subject, I fear, is not sufficiently
considered in schools of medicine of this and the sister countries.
The older authors describe gastritis as occurring under two dif-
PATHOLOGY OF GASTRITIS.
101
ferent forms, one of which they termed phlegmonous, and the other
erysipelatous. The advanced students know the meaning of these
terms, and that they are admitted as significant of different modifi-
cations of the inflammatory process, but to those who are not ad-
vanced I shall state that it is very difficult to give an accurate idea
of these terms, so far as they are applicable to cases of internal
disease. But we may attempt a general definition by saying, that
phlegmonous inflammation occurs in a good constitution, and under
favourable circumstances, that it is an inflammation of a bold and
distinct character, requiring and admitting of depletion, and, like
that on the external parts, terminating in healthy suppuration, or
adhesion. Erysipelatous inflammation is (described to be) a disease
of a different kind, occurring in bad and debilitated constitutions,
and under such circumstances that the same treatment, employed
in the phlegmonous form, is more or less inadmissible ; and when
stimulants are necessary, if not in the commencement, at least at a
very early period of the disease. It is quite impossible to found any
system of pathology on this division into phlegmonous and erysipe-
latous; we are, however, sometimes obliged to make use of it for
want of a better. The terms themselves are highly calculated to
mislead. Healthy inflammation, which is all but a contradiction in
terms, may occur in a debilitated constitution, and erysipelatous in
a strong one. The latter of these, too, is particularly erroneous,
as we now know that erysipelas may occur under opposite cir-
cumstances. In the one case, requiring the lancet and leeches, and
purgation ; in the other, demanding a stimulant and tonic treatment,
In speaking of gastritis I do not intend to adopt this division, be-
cause it would be likely to embarrass you, and, in truth, it is un-
necessary, as there is no difference in the (principles of) treatment,
whatever may be the form of this inflammation. The proper way
to consider gastritis is to look upon it as a disease, presenting, on
the one hand, symptoms of extreme violence and urgent danger ;
on the other, feebly shadowed out by the phenomena of ordinary
and slight indigestion. Between these there are many shades and
numberless gradations. The phlegmonous gastritis of the old
authors implied a violent and extensive inflammation, in which all
the coats of the stomach were implicated ; but, in treating of the
subject of gastritis in these lectures, I shall only allude to inflam-
mation of the mucous membrane and glandular apparatus of the
stomach. The other tissues are sometimes engaged, but the
mucous membrane, constituting the most important of these tissues,
and forming an exquisitely delicate vasculo-nervous expansion, is,
in the great majority of cases, the principal seat of inflammation,
and to this I would direct your particular attention.
The true pathology of gastritis was but very imperfectly under-
stood by the ancients. They knew enteritis and gastritis as intense
inflammations of the coats of the stomach and intestinal canal,
accompanied by violent pain and fever, but they had no conception
of their various shades and modifications. For a knowledge of the
9* °
102
DISEASES OF THE DIGESTIVE SYSTEM.
true nature of gastritis, and of its numerous varieties, we are in-
debted to modern pathology, and it is the boast of pathological
anatomy to say, that in this instance its labours have shed a broad
and vivid light on a class of diseases previously involved in deep
obscuritv.
It has been stated, that it is impossible to separate the symptoms
of gastritis from those which characterise enteritis, and the reason
given for this is, that the two affections frequently coexist. This
is a proposition of vast importance. It is said, that in cases where
you have gastritis, the chances are that there is more or less of
enteritis; but according to this doctrine, if a man has gastritis the
probability is that he has inflammation of some other portion of the
intestinal canal. Broussais, in the 138th proposition, makes the
following observations: "Inflammation of the stomach, or, as it is
called, gastritis, is never found except in conjunction with disease
of the small intestine. It is better, therefore, to give it the name of
gastro-enteritis; and even in those cases, in which we have enteri-
tis, we have gastritis as the irritative." Now if this proposition is
true, it is one of very great importance, and entitled to a large
share of our attention, in studying the phenomena and treatment
of inflammation affecting the digestive tube. Pathology, however,
has proved that these inflammations are not always found in con-
nection. Andral gives many cases, in which disease existed sepa-
rately in one or other portion of the intestinal canal; when it was
found in the stomach and not in the duodenum or ileum, and when
it was found in the ileum, but not in the duodenum or stomach. I
myself have seen many examples of gastritis without disease of any
other part of the digestive tube, and disease of various parts of the
digestive tube without the coexistence of gastric inflammation.
But I believe the proposition is generally true, particularly in
cases of fever, in which you have secondary inflammation of the
digestive tube during the course of the disease. When inflamma-
tion attacks the intestinal mucous surface during the progress of
a fever, you will, in most cases, have these two diseases com-
bined ; the patient generally presenting symptoms of gastritis, and,
at the same time, symptoms of enteritis affecting the lower third of
the ileum.*
Symptoms. — Let us now proceed to investigate the phenomena
which characterise acute gastritis. Here I must remark, that, as
an idiopathic disease, acute gastritis is extremely rare. This is a
very curious circumstance. When we compare the stomach with
other viscera, we shall find that one of the most remarkable differ-
ences between it and other organs is, that it is much less liable to
be attacked by violent inflammation, as an idiopathic affection.
This is an interesting fact, So rare, indeed, is the violent form of
gastritis, that our knowledge of the symptoms which indicate intense
* [A state of things this very common in our remittent fevers, as
well bilious as those which soon assume a typhoid character. — B.]
SYMPTOMS OF ACUTE GASTRITIS.
103
gastric inflammation is principally drawn from the study of cases
of acute gastritis caused by swallowing corrosive poisons. We
very seldom meet with an inflammation of the stomach, presenting
those decided characters so frequently witnessed in similar affec-
tions of other organs. We may attempt to explain this fact, by
considering what the functions of the stomach are, and by recol-
lecting that it is the organ of the body, whose functions require that
it should be most frequently in a state of great vascular excitement.
Every one is aware that the vascularity of the stomach is amazingly
increased during the act of digestion ; but it is to be remembered
that this is a physiological and not a pathological condition. If the
stomach were as liable to inflammation as other organs, it could
no longer carry on its functions with safety; every meal would
prove a stimulus sufficient to excite inflammation — every digestion
would be followed by gastritis. Nature has provided against such
accidents.
Let us take a brief review of the symptoms of acute gastritis: —
Intolerable thirst, desire for cold and acidulated drinks, constant
nausea and vomiting, pain and burning sensation of heat about the
stomach, and fever — these are the symptoms of a violent gastritis.
It has been stated, that in gastritis the fever is at first inflammatory
and afterwards typhoid. If authors mean by this, that the patient
rapidly falls into a low typhoid state, the observation is true.
There is no form of inflammation, except that which accompanies
severe peritonitis, in which the typhoid state comes on so rapidly.
Inflammations of the digestive tube differ, in general, from similar
affections of other organs, chiefly in this — prostration rapidly
supersedes excitement. A patient labouring under inflammation of
the brain will exhibit, for a long time, decided symptoms of high
excitement, and of what has been termed the phlogistic diathesis;
acute pneumonia and inflammatory affections of other parts will go
on for days, without prostration, and require the use of the lancet;
but gastritis is a disease in which the inflammatory symptoms, as
they are called, last but for a very short time. In violent cases the
irritation of the stomach is excessive, and everything is rejected.
I have seen cold water thrown up almost immediately ; I have seen
effervescing draughts rejected the moment they were swallowed,
and make the patient evidently worse. The epigastric region and
the left hypochondrium are exquisitely tender on pressure, and the
tenderness differs from that of peritonitis in this, that it is almost
always localized. The patient screams with agony when you
touch the epigastrium, but will bear pressure freely on the lower
part of the abdomen.
Now, with respect to the sympathetic relations of gastritis, I have
to remark that they are very numerous. First, as to respiration__
it is extremely quick and hurried ; the heart, also, is violently ex-
cited ; and hence gastritis has sometimes been mistaken for pneu-
monia and pericarditis. Sometimes we have bronchitic cou^h ; the
patient is restless, gets no sleep, and is extremely uneasy ; his 'skin
104 DISEASES OF THE DIGESTIVE SYSTEM.
is hot, his bowels confined, his pulse rapid and small. In the second
stage, he is beginning to sink, his features become contracted, his
skin cold and pale, his extremities sunk below the natural tempera-
ture; he now bears pressure; the vomiting is changed for regur-
gitation of everything he swallows: low delirium supervenes, and
he dies.
It is of the greatest importance to attend to the sympathetic rela-
tions of gastritis, for this reason, that in many cases the local
symptoms are all but wanting, and the disease is only to be known
by its sympathetic relations. Before I enter on this subject tehall
make one or two remarks on some symptoms which have not been
attended to by many practitioners. One of these is an incapability
of swallowing, sometimes so great that all ingesta, whether fluid
or solid, are rejected. This will sometimes arise from spasmodic
stricture of the esophagus or cardiac orifice of the stomach; and,
as there has been no other cause revealed, by dissection, in several
cases in which this symptom was present, we must admit this as
one of the causes of the dysphagia, which, on some occasions,
attends gastritis. This symptom is most commonly accompanied
by tightness and oppression about the praecordia. The patient,
feeling a load or weight, as he expresses it, in this situation, thinks
it would be relieved by vomiting, and begs his medical attendant to
give him an emetic, which is sometimes administered, and pro-
duces very bad effects. There is only one case in which an emetic
can be given in gastritis, and that is, where indigestible or irri-
tating substances in the stomach give rise to irritation, and when
we cannot expect a favourable termination until we effect their
removal.
There is another most disagreeable and distressing symptom,
generally occurring in cases in which there is inflammation about
the cardiac orifice of the stomach — I mean hiccup. Hiccup is a
most harassing symptom ; it does not allow the patient a moment's
rest; in his brief and uneasy slumbers he is conscious of it, and is
constantly awakened by it. Now, this is also one of the results of
gastritis, with inflammation about the cardiac orifice. I say this,
because I have seen it in many cases, in which there was distinct
evidence of inflammation about the cardiac orifice of the stomach ;
and, in three instances, I have verified it by dissection. I do not
mean to say that every case of hiccup is indicative of disease of the
cardiac orifice, but I believe it is a very frequent accompaniment.
The case of a celebrated professor of languages was a remarkable
example. A short time previous to fuVdealh, he came from Liver-
pool in one of the steam-packets. He was always subject to sea-
sickness ; but on this occasion'he was extremely ill, and vomited
during the entire passage or sea-voyage. He complained of his
stomach for sometime, and then got hiccup, which resisted every
kind of treatment, and continued without any abatement up to the
time of his death. On opening the stomach, this organ was found
in a state of intense inflammation, particularly about the cardiac
STATE OF THE TONGUE IN GASTRITIS.
105
orifice. You can see the stomach (of which a very good prepara-
tion has been made by Dr. Houston) in the museum of the College
of Surgeons. There was another very remarkable case in the
Meath Hospital. A patient was admitted who had laboured under
acute pneumonia, for which he was treated with tartar emetic, and
the symptoms rapidly declined, but vomiting and hiccup came on,
and the latter symptom continued until death. We opened the
body eighteen hours after his demise, and found the lung quite
healthy; but the stomach, and the cardiac orifice in particular,
were, as in the case I have just mentioned, in a state of intense
inflammation. When hiccup is the result of inflammation of the
cardiac orifice, you will also frequently observe that the patient
complains of pain in the lower part of the chest, along the course
of the diaphragm. These are some of the relations of gastritis,
their connection with which is proved by their being relieved by
draughts of cold water, leeching, and every other means calculated
to remove inflammation of the stomach.
We come now to consider the state of the tongue. A vast deal
of error and misconception prevails among British practitioners on
this subject. Nothing is more common, than from the condition of
the tongue to form an opinion as to the state of the alimentary canal.
For instance, whether it is in a state of inflammation, whether there
are sordes present or not, and whether it requires this or that medicine.
All this is behind the actual state of medicine, and it is melancholy
to think what a vast quantity of mischief is done by those practitioners
who take the tongue as the index of an inflammatory or non-inflam-
matory condition of the intestinal canal. The schools of Abernethy
and Broussais are wrong in stating that the tongue will point out
the state of the digestive tube. The connection between the state
of the tongue and that of the stomach has been lately made the
subject of extensive clinical investigation by M. Andral: listen to
his sentiments on this point. From the experience of a vast number
of cases, he declares " that there is no constant relation between the
state of the tongue and that of the stomach." In the next place he
states,"that there is no modification of the one corresponding with
any special modification of the other." " Thirdly, the stomach may
be found in a certain state after death, with various conditions of
the tongue during life." " Fourthly, we may have a diseased sto-
mach with a healthful condition of the tongue, and diseased ap-
pearance of the tongue with a healthful state of the stomach."
These are facts of the greatest importance. Let us now refer to
Louis. In giving an account of the gastritis which accompanies
fever, he states that in many of the worst cases the appearance of
the tongue was natural; in fact, that there was not the slightest re-
lation between the tongue and the stomach. It is fair, however, to
observe here, that both these pathologists drew their information
only from cases of gastritis, occurring in fever. But it has also
been frequently observed, that even in idiopathic cases there is a
want of correspondence between the condition of the tongue and
106 DISEASES OF THE DIGESTIVE SYSTEM.
stomach, and we have seen several instances of this in the Meath
Hospital. I believe we should be wrong in taking the tongue alone
as our guide in the treatment of intestinal derangement, whether
existing in the stomach or any other portion of the tube; and this I
state as the conclusion which I have drawn from myown experience,
in gastric and enteric inflammation. Yet how many will you see
taking the tongue as the unerring index of various conditions of the
digestive tube ? hundreds and thousands. It is unquestionably true,
that in certain cases of gastritis, particular morbid appearances, as
redness, dryness, pointing, and a tremulous state of the tongue, are
observed, but what I wish to impress on you is, that it is necessary
that these phenomena should coincide with other symptoms. I do not
wish you to believe, that the inspection of the tongue, or the know-
ledge derived from its appearance, is useless, particularly in cases
of fever: the state of the tongue is never to be overlooked, but you
should understand on what principle it is to be examined. You
should examine the tongue not so much as a guide to the know-
ledge of local disease, but as an index of the condition of the general
system. For instance, if, during the course of a fever, the appear-
ance of this organ changes and becomes more favourable, it is a
sign that the whole disease has taken a favourable turn, and vice
versa. This is the proper way to look at the tongue in fever, not
as reflecting any particular state of the intestinal canal, but as being
indicative of some modification of the whole economy.*
* [I know well a person, who, for twenty-five years, never had
an entirely clean tongue; and who for years used to awake every
morning with his tongue dry, furred, and yellow, or often brown,
and sometimes giving out a little blood mixed with the first sa-
liva. In fact, the tongue of this individual often resembled that of
a patient in the advanced stage of typhoid fever; and yet he has
been seldom laid up by sickness. His digestion was regular,
but slow and laborious; and was particularly troublesome in the
colon, in its being attended with flatulence, and alternate diarrhoea
and constipation. His renal secretion was habitually disordered
by the presence of uric acid. He was a moderate eater, and ab-
stinent generally from all kinds of intoxicating liquors. He found
that the appearance of his tongue and the dryness of his mouth,
together with epigastric heat and tenderness, was increased much
more evidently by late hours of even quiet study, than by indulgence
in suppers, or the occasional excesses of the table. Of late years,
his brain and nervous system have been less continually excited,
and he now awakes in the morning with a moister and less morbid
tongue; although his dyspepsic symptoms are nearly as before.
But whilst thus adducing evidence in supportof theopinion advanced
in the text, I ought to add, that any unusual article of food, salted
or smoked meat, pastry, or an apple at dinner, will cause disturbed
sleep and a drier tongue the next morning in this individual. A
circumstance worthy of notice, in his case, is, that, when he
SYMPTOMS IN GASTRITIS FROM OTHER SYSTEMS. 1Q7
Symptoms derived from the Respiratory and Nervous Systems. —
Let us now consider the sympathetic relations of the nervous and
respiratory systems in gastritis. This is a very curious and inter-
esting point in the study of gastric disease. I may mention here,
that these relations are subject to considerable variety, and differ
according to the peculiar predisposition of the individual. If a
person of nervous habits gets gastritis, he will be very liable to have
sympathetic affections of some part of the nervous system ; but if he
is a person with unsound lungs, the irritation will be transferred to
the respiratory apparatus. Can we define these irritations? I
believe the best definition we can give of them is, that they are
affections of some organ, which are the result of sympathy; and
that they are at first functional, but afterwards become organic.
A person of nervous habit, labouring under gastritis, will frequent-
ly have his head sympathetically affected ; he will complain of head-
ache, more or less intense; toss about and get no sleep; still he has
no actual disease of the brain. But let the cerebral irritation go on,
let the pain and uneasiness and watchfulness continue, and he will
finally get arachnitis. So, too, with respect to the lung; the patient
has hurried breathing and cough, without any of the stethoscopic
signs of pulmonary disease ; but if these symptoms continue for any
length of time, or if the irritation be severe, he will get pneumonia
or bronchitis. Observe the importance of this law with reference
to treatment, because it shows you that you cannot always expect
to remove sympathetic affections by attacking the original source of
disease; for if functional derangement, produced by sympathetic
irritation, has gone so far as to become organic, you must direct
your attention to parts which have been secondarily engaged, as well
as to those which are primarily affected. Every one is aware of
the effects of particular states of the stomach on the brain, and of
the influence which the brain exercises over the stomach. Most
individuals know, that by grief or strong mental emotion the appe-
tite is completely removed ; and that after a surfeit, or from taking
bad and indigestible food, a person will get sick headache. If this
happens every day under ordinary circumstances, and where the
original affection is so slight that it does not interfere with the
usual avocations of the patient, you can readily conceive how intense
the sympathetic irritations may be in a case of violent gastritis.
The headache is frequently intense, the patient is extremely restless,
there is considerable intolerance of light, delirium, tetanic spasms,
and other symptoms characteristic of inflammation of the brain.
There are numerous cases on record in which these symptoms were
particularly noticed, and it was supposed that the brain was in a
happened to awake in the night, or at two, or three, or four o'clock
in the morning, his tongue was moist, and his mouth without any
feeling of dryness or discomfort: but after the last sleep, and at the
common hour of rising, the tongue and mouth would be dry and
parched, and otherwise changed, as above described___B.]
108
DISEASES OF THE DIGESTIVE SYSTEM.
state of inflammation, but on dissection there was no disease found
except in the mucous membrane of ihe stomach. There are many
cases, too, in which medical men, not aware of the extent of these
relations, looked upon the disease as a pure cerebral affection, and
directed their whole attention to the brain. They certainly suc-
ceeded in modifying the apparent disease, but as they took no steps
to remove its cause, the patients generally sunk from an unsuspected
gastritis. There is one important law with respect to inflammation
of the stomach, which perhaps may be fairly applied to all inflam-
matory affections of the digestive tube. When inflammation of the
stomach or any other portion of the intestinal canal has continued
for some time, and when the disease has attained a certain degree
of violence, the local symptoms may subside, and the gastritis or
enteritis will be represented by disease of some other organ, by
symptoms of an affection of the brain or its investments, or by
symptoms of disease of the lining membrane or parenchymatous
tissue of the lung. I shall endeavour to explain this. Here is a
case taken from the Clinique Medicate of Andral.
" A middle aged man, four days before his entrance into the hos-
pital, was seized with bilious vomiting, epigastric pain, and fever.
(Here is a certain case of gastritis.) In about twenty-four hours
after the invasion of these symptoms, he first perceived a difficulty
in depressing the lower jaw, and a violent trismus was established,
which continued for the two following days; at the end of this time
he entered the hospital in the following state: — Trismus,the head
drawn backwards and forcibly retained in this position by the
muscles which are inserted into the occipital region; rigidity of all
the extremities; abdomen hard as a board; intellect perfect. Not-
withstanding the trismus, the patient could articulate with sufficient
distinctness to give the above account of his case. From the time
when the first tetanic symptoms appeared the vomiting and epigastric
pain ceased. He died on the evening of his admission. On dis-
section no appreciable alteration of structure was found in the brain
or spinal marrow; the meninges of the brain were very slightly
vascular, but those of the spinal marrow pale. The whole surface
of the stomach presented an intense red colour, which was at first
concealed by a thick layer of mucosities. The remainder of the
digestive tube was perfectly healthy, and the thoracic organs were
natural." This may be called a case of tetanus ; and it is a curious
fact, that when the tetanic spasms came on, the vomiting and other
symptoms of gastritis subsided. Now this is what I wish to direct
your attention to. A man dies with symptoms of an affection of
the brain, the head is opened after death, there is no trace of cere-
bral disease found,but the whole surfaceofthe stomach is discovered
to be in a state of intense inflammation. That the stomach was
inflamed is proved by the vomiting and epigastric pain which ex-
isted during life, as well as by the vascularity which was revealed
by dissection; and there can be no doubt that this condition was
the result of an intense inflammation, as there was no other cause
to produce it.
GASTRITIS FROM SYMPATHETIC IRRITATION.
109
Last year, a patient was admitted into the Meath Hospital, la-
bouring under violent maniacal excitement, his eyes bloodshot, ana
his aspect ferocious. He had thirst, a dry fissured tongue, a quicK,
weak pulse, and constipated bowels. There was no epigastric ten-
derness, no vomiting, in fact none of the prominent symptoms ot
gastritis complained of. On the third day the belly was slightly
tender and tympanitic. The cerebral symptoms increased so as
to require the use of the strait waistcoat, and continued with violence
until a short time before death, which occurred on the eighth day.
On dissection there was no appearance of inflammation iound
in the brain or its membranes, but there was a vast extent of disease
in the digestive tube. The splenic extremity of the stomach pre-
sented several patches of vascularity, and its mucous coat was
softened ; the lower half of the ileum, the caecum, and part of the
ascending colon, were in a state of intense inflammation, and dotted
all over with numberless ulcerations.
You observe of what importance the knowledge of these facts
will be to you in practice, and how much it should become the
object of your study, since you will thereby be able to make the
diagnosis of gastritis from the sympathetic relations, though the
usual symptoms are more or less absent. Even in cases of this
kind, in which the symptoms have subsided on the appearance of
these sympathetic irritations, the judicious practitioner will not be
diverted from directing his attention to the source of the original
mischief; nor will he, because the local symptoms have disappeared,
conclude that the disease has therefore been removed from the sto-
mach. Many examples of this apparent transition of disease are
to be seen in cases of children, in which an inflammation of the
upper part of the digestive tube frequently similates hydrocephalus,
and where the headache, delirium, and intolerance of light, are com-
pletely removed by the application of leeches to the epigastrium.
I have seen this occur many times, and would entreat your particular
attention to it. I believe many children are lost from the want of
correct notions on this subject on the part of their medical attend-
ants.* The phenomena present in such cases are certainly those
* [Unless we are fully acquainted with the precursory symptoms
and the admitted cause, as external injury, sun-stroke, &c, of cere-
bral affections, whether manifested by delirious ravings, and jacti-
tation or by convulsions, either in children or in adults, we shall
find the gastric to be the safer pathology, and we ought to pre-
scribe accordingly. Among other cases which might be related, I
remember, very distinctly, that of a child between three and four
years old, whom I found with flushed face, eyes shining and in-
jected, and somewhat incoherent and raving, with occasional
spasms, short of of convulsions. The mother of the patient thought
it had been eating stramonium seeds. I believed, on inquiry, that
it had made too free with cherries, and, accordingly, gave it an
emetic, which made it throw up a goodly number of this fruit, and
vol. i.—10
U0 DISEASES OF THE DIGESTIVE SYSTEM.
which characterise hydrocephalus; but you should always inves-
tigate them with care, and ascertain whether the disease has com-
menced with symptoms of inflammation of the mucous membrane
of the stomach, or bowels; and if you find that it has originated in
this way, and that the cerebral symptoms have not gone too far,
direct your treatment in the first place to the digestive tube.
It is extraordinary how rapidly all the symptoms of apparent
cerebral disease subside under this plan of treatment. I must
mention here to you a very remarkable case of enteritis, which
simulated local disease of the substance of the brain. A girl
who had received an injury was admitted into the Meath Hos-
pital ; she was treated with purgative medicines, and was " dis-
charged cured!" In a few days afterwards she was readmit-
ted with pain in the head, and violent spasmodic contractions
of the forearm, by ivhich the fingers were bent so forcibly that
the nails were driven into the hand. There was no thirst, vomit-
ing, or abdominal tenderness. She died a few days after her
admission ; and on dissection the brain was found perfectly healthy,
the viscera of the thorax were in the normal state, the stomach
presented nothing remarkable, but the ileum was almost one sheet
of deep and recent ulcers. The result of this case is important,
also, in another point of view. You know that spasmodic contrac-
tions of the upper extremity are believed by certain pathologists to
point out an inflammatory softening of the optic thalamus, and its
prolongations. Here we had the symptom, at all events, without
the corresponding lesion.
I shall reserve the subject of sympathetic irritations of the respi-
ratory system until my next lecture, when I expect to be able to
finish the pathology and treatment of gastritis.
brought, in consequence, speedy and complete relief. The symp-
toms, a little before, would have justified bleeding, cold applications
to the head, &c.
A case which occurred under my observations, when I was yet
a student of medicine in Virginia, made a permanent impression
on my mind. A child, about two years old, had eaten of some
fruit, the kind I do not remember, which caused violent convulsions,
followed by coma and strabismus, in which state it remained for
three days. At last, to the wonderment both of its physician, who
barely hoped, and of the attending crones, who had been sighing
and croaking death around its cradle, it revived, and ultimately re-
covered its health.
In other cases, although the offending substance may have been
ejected from the stomach, this organ soon after becomes inflamed,
and the cerebral symptoms return with violence. Then must we
have recourse to leeches to the epigastrium, and other means of
removing the gastritis, and, in so doing, we shall find that there is
a subsidence of the disorder of the brain. — B.]
PATHOLOGY OF GASTRITIS-
111
LECTURE IX.
Gastritis—No one symptom decidedly indicative of the particular condition of
any organ—Sympathetic irritation liable to terminate in organic disease—
Sympathetic relations as connected with the viscera of the thorax—Treatment
of simple acute gastritis—Antiphlogistic remedies—Purgative medicines inju-
rious—Euemas and injections—Use of ice beneficial—Effervescing medicine
hurtful.
You recollect that at our last meeting I endeavoured to lay before
you some of the general facts connected with the pathology of
gastritis, and showed you that the statement made by Broussais,
that inflammation of the mucous membrane of the stomach is
always accompanied by a similar affection of some part of the
intestines, has not been confirmed by the investigations of more
recent observers; but, on the contrary, that their experience goes
to disprove, in various instances, the validity of this assertion.
But, when I say that this statement has been disproved, it is only
as taken in the general and extended sense. The fact of their fre-
quent coexistence has been proved; the statement that they are
always associated has been found incorrect. Another thing con-
nected with this, which has been also established by repeated ob-
servation, is, that the cases in which they are commonly combined
are those in which a secondary affection of the mucous surface of
the digestive tube comes on during the course of a fever; so that,
if in fever a gastritis supervenes, you will commonly have ente-
ritis ; or if the fever be complicated with enteric inflammation, the
mucous surface of the stomach will partake in the diseased action.
I have described some of the more prominent symptoms of gas-
tritis, and directed your attention not only to the ordinary symp-
toms, as mentioned in books, but also to others which have either
been passed over, or slightly noticed, by authors; as, for instance,
dysphagia, oppression and sense of constriction about the prse-
cordia, globus, pains relieved by cold and acid drinks, &c, and
that obstinate hiccup, which, in cases where there is reason to
suspect gastritis, marks inflammation of the cardiac orifice of the
stomach. I stated that hiccup alone does not prove the existence
of inflammation of the cardiac orifice of the stomach, unless where
symptoms, indicative of gastric inflammation, prevail at the same
time. I laid before you the actual state of the case with respect to
the value and certainty of diagnosis, as derived from an inspection
of the tongue ; and showed you that no reliance can be placed on
it, since it has been proved that we have the most opposite condi-
tions of the digestive tubes, accompanied by a similar condition of
the tongue; and that there is no peculiar modification of the one,
corresponding exactly and constantly with any peculiar modifica-
tion of the other. The conclusion to be deduced from these facts
is, that in the treatment of inflammatory affections of the digestive
H2 DISEASES OF THE DIGESTIVE SYSTEM.
tube, we are not authorized, and would frequently err, in taking
the tongue alone as our guide in practice; and you may lay down
this as a rule, and an important one; — if we look through the
whole range of the history of medicine, we shall scarcely be able
to point out any symptom which, taken singly, is decidedly indica-
tive of any one particular condition of an organ. You will find
that this proposition is not only extensive in its scope and relations,
but also of extreme value in its application. You will commonly
hear persons saying, that is such a disease, for this symptom is pre-
sent, and that is such a disease, for such a symptom is extremely
well marked. But there is no single symptom which points out,
with certainty, any peculiar condition; and to arrive at a just and
well-grounded diagnosis, you must always take the whole group of
existing phenomena, connect the lights which they collectively
throw upon the case, and then make a cautious decision. It may
be objected to this that there are particular signs; as, for instance,
the stethoscopic, which point out distinctly particular states of
organs. It is said that gargouillement is decidedly indicative of
a phthisical cavity, that cegophony points out a particular stage of
pleuritic effusion, and that metallic tinkling is an unequivocal proof
of pneumothorax. This, however, is not the fact; even in these
cases you are not authorized to depend on any sign or symptom
taken alone. If you ground your decision on any individual sign,
you will very often fail in arriving at the truth.
I showed you that the sympathetic irritation of gastritis varied
according to the peculiar character of the disease, and the habit
and degree of susceptibility of the patient; that, generally speak-
ing, the more intense the disease is, the more numerous are its
irritations; but that, in all cases, they are considerably modified
by predisposition (I use this term for want of a better), the sympa-
thetic irritation being reflected on the lungs in cases where these
organs are naturally unsound, and on the brain, where the patients
have a tendency to disease of that organ. I endeavoured, also, to
impress on you the fact, that these irritations are at first functional;
but when long continued, or marked by extreme severity, they are
very apt to terminate in organic disease. I illustrated this point
by several examples; I shall give a few more of this kind before I
enter on the treatment of gastritis.
If a patient labouring under acute gastritis has a bad cough, if
respiration be very much hurried, and the distress of the chest
great, and that these symptoms are overlooked or neglected, vou
will find that the cough, which was at first only a result of func-
tional disease, will at last point out an organic affection of the lung.
Again; let a patient, labouring under gastritis, have severe head-
ache, restlessness, and irritation; suffer these symptoms to go on
and increase in violence, and the great probability is, that they will
terminate in arachnitis. The obvious deduction from these facts
is, that when a sympathetic irritation has existed for some time in
a state of considerable intensity, it is verv probable that there is
THORACIC COMPLICATIONS WITH GASTRITIS. H3
more or less of organic derangement produced, and we are not to
expect to be able to remove it by merely attacking the original seat
of the disease.
The last great rule which I endeavoured to impress upon you
was, that where these sympathetic irritations, these affections of
the nervous, respiratory, and circulating systems, were extremely
well marked, the ordinary local symptoms were more or less want-
ing, but that this does not by any means imply the subsidence of
the original disease. This is a most important law in pathology.
Sympathetic Thoracic Irritations. — In my last lecture, I entered
into a detail of the sympathetic irritations connected with the brain
and other parts of the nervous system ; to-day we shall consider the
sympathetic relations, as connected with the viscera of the thorax.
If you look to the cases of acute gastritis, mentioned in works on
toxicology, you will find that in cases of gastritis, produced by
swallowing corrosive poisons, the patient has often frequent hard
cough, the breathing is at first hurried, then becomes protracted
and laborious, and that death is generally ushered in by tracheal
rattle. The same symptoms are observed in cases of acute idio-
pathic gastritis; hurried breathing, extraordinary hard and almost
laryngeal cough, sometimes occurring in paroxysms, sometimes
constant. For the first few days it is, generally speaking, dry; as
it progresses, there is more or less expectoration. At first, it is the
result of sympathy; there is as yet no organic affection of the
respiratory system, and the disease is purely functional; still it is
of importance, and entitled to your particular attention, because, in
consequence of the apparent identity of the symptoms, it is often
mistaken for disease of the substance of the lung, or its mucous
lining. The existence of a gastritis is frequently overlooked ; the
ordinary symptoms of pain in the region of the stomach, tenderness
on pressure, and thirst, are overlooked, and the sympathetic rela-
tions alone are attended to. Observe what mischief may result
from this error. The treatment of acute affections of the lining
membrane, or parenchymatous tissue of the lung, is very different
from the treatment of a gastritis. In the one case bleeding is neces-
sary ; in the other, its efficacy may be doubtful, or the practice
even dangerous. In one, tartar emetic is one of the best and most
expeditious means of effecting a cure ; in the other, the use of anti-
monials has the worst effect. It will strike you that in such cases
percussion and the stethoscope are of inestimable value* You are
called to attend a patient in fever, you find he has cough, hurried
breathing, and perhaps pain in the chest; from a consideration of
the history of the case, and the primary symptoms, you have reason
to think the case is one of gastritis, and you wish to know whether
the symptoms be purely sympathetic, or caused by organic disease
of the lung. In sach a case, a person without the knowledge of the
stethoscope is completely helpless, and unable to decide the point.
This, I assure you, is a very common case, and should be a strong
inducement to the study of the stethoscope.. What advantage does
114
DISEASES OF THE DIGES'l IVE SYSTEM.
a knowledge of the stethoscope give 1 It leads to the formation of
an accurate diagnosis ; it points out either that there is no disease
in the lung, or if there be, that it is not sufficient to account for the
symptom,°and therefore that you should look for its cause in some
other situation. You find a person with laboured and rapid breath-
ing, perhaps fifty or sixty in a minute; you are struck with the
apparent lesion of the respiratory system, but on percussing the
chest, and using the stethoscope, you find the respiration perfectly
clear, or perhaps a slight bronchitis, insufficient to account for such
violent symptoms. Where such phenomena are observed, you will
often find that they are connected with a gastritis, particularly
where there is fever, and the local signs of a gastric inflammation.
I can tell you, from a most extensive experience, that in such cases
you can inform the patient's friends, that the most sudden and
decided relief will be experienced from the use of iced water, and
the application of leeches to the epigastrium. You can have hardly
an idea of the rapidity with which all the symptoms of pulmonary
irritation are removed by this practice. Cases of this extraordinary
sympathetic irritation are very common in children, but you will
also frequently meet with them in adults.
Diagnosis of Gastritis and Pneumonia. — I have been called to
decide the question, whether a disease was pneumonia or gastritis,
where there was a difference of opinion between two practitioners.
Now, it is very easy to come to a proper decision in such cases.
There is one point which you should always hold in view, and that
is, the length of time the symptoms have lasted. If symptoms of
pulmonary disease have been going on for four or five days, and,
at the end of that time, you find that there is no perceptible organic
disease of the lung, you may be certain that it is gastric irritation ;
because if it were organic disease of the lung, it would have shown
itself before that time, and could be detected by percussion or by
the stethoscope. We have had many cases of these sympathetic
irritations of the lungs in the Meath Hospital, which recovered
under the treatment for gastritis ; and where the patients, by some
excess or error in diet, brought on the pulmonary symptoms again,
they were removed a second time by putting them on a low diet.
Before I quit this subject, I wish to make one remark, by way of
caution. When you have discovered the existence of those sympa-
thetic irritations, you should not be thrown off your guard, and
consider them only as functional affections. You should examine
the next day and the day after, for you may find that in a very
short space of time actual disease of the lung has taken place.
You should be, therefore, watchful, and never omit making a daily
examination ; for if the sympathetic irritation be severe, it is very
apt to run into actual organic disease.
We now come to speak of the treatment of simple acute gastritis.
Here there are fhree principal indications. One of these is to
remove inflammation as speedily as possible. You cannot, as
under other circumstances, leave this disease to nature ; the organ
TREATMENT OF GASTRITIS.
115
affected is one of the utmost importance to life; and if you do not
cut it short at once, a typhoid state comes on, to which the ordinary
and efficient means of antiphlogistic treatment are inapplicable.
The first indication, then, is to cut short the inflammation as
speedily as possible. The next thing is to prevent the introduction
of anything into the stomach which will excite the physiological
action of that viscus. You are aware, that while the stomach is
engaged in the process of digestion, its vascularity is very much
increased, and that this, which in health is merely a physiological
condition, is unaccompanied by any kind of danger. But in a state
of disease it proves a source of violent excitement, and superadds
very much to the existing inflammation. You must, therefore, be
extremely cautious with respect to what enters your patient's
stomach, and carefully remove everything capable of adding to the
excitement which always attends gastritis. The third indication
in the treatment is to modify and remove the sympathetic or
secondary irritations.
Treatment of Gastritis. — Now I shall suppose that we have to
treat a case of simple acute gastritis, not produced by the swallow-
ing of corrosive poison, or indigestible food. Here we have a
patient labouring under violent inflammation of one of the most
important organs in the body; and the question is, are you to adopt
the ordinary and usual mode of stopping inflammation by opening
a vein in the arm 1 I must here state, that we are very much in
want of a series of well-established facts to guide our practice on
this point, and to inform us how far general bleeding is useful in
acute inflammation of the stomach. At the present period, the
question is by no means settled, and the practice is uncertain. I
believe, however, that when we are called in at an early period of
the disease, where the patient is young and robust, the stomach
previously healthy, the fever high, and the pain great, we may
have recourse to general bleeding with advantage; bearing this in
mind, however, that you are not to expect to cut short the inflam-
mation by the use of the lancet. Inflammations of the mucous
membrane of the stomach and bowels, and perhaps of the lungs,
are not to be overcome at once by the lancet; the only cases in
which you can expect to cut short an inflammatory attack, are
those in which the parenchymatous tissue of an organ, or its serous
membrane, is affected. This is a general and important law.
You will often be able to cut short a hepatitis or pneumonia by a
single bleeding, but you will not by the same means be able to
repress a bronchitis or an inflammation of the mucous membrane
of the intestines. If you bleed in gastritis, bleed at an early period ;
not too largely, or with the expectation of cutting short the inflam-
mation, but in order to prepare your patient for the grand agent in
effecting a cure — local bleeding. This is the principle on which
you are to employ the lancet.
In the treatment of gastritis there is nothing more useful, nothing
116
DISEASES OF THE DIGESTIVE SYSTEM.
more decidedly efficacious, than the free and repeated application
of leeches, whether the case be idiopathic, or produced by the
swallowing of a corrosive poison. In this treatment of acute gas-
tritis, you will frequently see, perhaps, the most striking instances
of the rapid and decided utility of medical treatment; you will
see the vomiting subside almost immediately, the epigastric pain
and tenderness disappear, the cough and headache relieved, the fever
subside, and the tongue change, after the application of leeches.
To remove these symptoms, the best and most effectual means are
leeches; and these must be applied again and again, according to
the duration and obstinacy of the symptoms. Here I wish to make
one remark of importance. From an opinion, very prevalent in
former times, that pain and inflammation were inseparable, the older
practitioners thought that when the pain ceased the inflammation
also ceased; and hence many of our predecessors, and I fear some
of our cotemporaries, never think of reapplying leeches, no matter
what the existing symptoms may be, if pain has been relieved by
the first application. Nothing is more erroneous than this
practice. It frequently happens that the pain and epigastric
tenderness are removed by the first application of leeches, but the
breathing is still quick, the fever high, and the thirst ardent. So
long as these symptoms remain, the inflammation of the stomach
is still going on. The mere subsidence of pain or tenderness of
the epigastrium should never prevent us from resorting to the
application of leeches. In leeching the belly for inflammation of
the stomach or bowels, it is a common practice to apply a poultice
over the leech-bites, with the view of getting away as much blood
as possible. I am not inclined to approve of this practice. The
weight of a poultice is frequently troublesome, and the heat
produced by it disagreeable ; the patients desire cold, and for
this purpose they will often throw off their bed-clothes, feeling a
degree of relief from exposing the epigastrium to a stream of cool
air. Some practitioners have applied pounded ice over the
stomach with good effects, and we see it frequently applied to the
head with the same results in cases of encephalitis. Again: the
application of poultices causes an oozing hemorrhage, the amount
of which it is impossible to calculate, which is often hard to be
arrested, and which, in debilitated persons and children, has the
effect of lessening the powers of life without removing the original
disease. It is much better to leech again and again than to do
this. Where there is not much epigastric tenderness, you may
apply a cupping-glass over the leech-bites with advantage, as you
can get away as much blood as you choose, and the tendency to
after-hemorrhage from the leech-bites is diminished by the applica-
tion of the cupping-glass. In very young subjects, the tendency
to obstinate hemorrhage from leech-bites is so great, that many
practitioners are afraid to use leeches, and I believe some children
have been sacrificed to this fear. The best mode of managing
ATTENTION TO THE BOWELS IN GASTRITIS. 117
this is, if the leech-bites cannot be stopped by the ordinary means
(and in very young children they seldom can), to stop them at once
by the application of caustic. Do not lose time in trying to arrest
the flow of blood with flour, or lint, or sticking-plaster; wipe the
blood off the bite with a piece of soft dry lint, plunge into it a piece
of lunar caustic, scraped to a point, give it a turn or two, and the
whole thing is settled; and you can generally go away with the
agreeable consciousness of having prevented all further danger,
and without being uneasy lest your patient should bleed to death in
your absence.
Management of the Bowels. —With respect to the management
of the bowels in acute gastritis, a few observations will suffice.
You will always have to obviate the effects of constipation ; both in
the acute and chronic forms of the disease there is always more or
less constipation ; in fact, the same condition of the bowels is gene-
rally observed in both. Now, if you attempt to relieve this consti-
pation in acute gastritis, by administering purgatives, you will most
certainly do a vast deal of mischief. Nothing can exceed the irri-
tability of the stomach in such cases; the mildest purgatives are
instantly rejected, even cold water, or effervescing draughts are
often not retained, and a single pill or powder is frequently thrown
up the moment it is swallowed.* Under such circumstances, it is
plain that the administration of purgative medicine is totally out of
the question. Even though the stomach should retain the purgative,
you purchase its operation at too dear a price ; for it invariably
proves a source of violent exacerbation, kindling fresh inflammation
in an organ already too much excited. In this state of things, the
best thing you can employ to remove constipation is a purgative
enema, repeating it according to the urgency or necessity of the case.
Where there is no inflammation in the lower part of the intestinal
canal, you may employ injections of a strong and stimulating nature,
with the view not merely of opening the bowels, but also of exer-
cising a powerful revulsive action. I shall mention' here an inter-
esting fact, proving that stimulant injections have a decided revulsive
effect; and that their influence extends not only to other portions
of the intestinal tube, but also to distant parts of the system. In
South America, where, from the heat of the climate, and the preva-
lence of bilious affections, sick headache is a very common and
distressing symptom, a common mode of cure is to throw up the
rectum an extraordinary enema, composed of fresh capsicum and
other aromatic stimulants. The irritation which this produces
* [I have, in some cases, after venesection and leeching, given
calomel with advantage in gastritis : — its action on the duodenum,
liver, and large intestine, renders it decidedly revulsive. I prefer
it alone, to its union with opium, under the*se circumstances. I can
.speak favourably, also, of a laudanum enema in gastritis after san-
guineous depletion. — B.]
118
DISEASES OF THE DIGESTIVE SYSTEM.
acts as a very efficacious and speedy revulsive, causing the almost
immediate removal of the cerebral symptoms.
In those cases of gastritis, where not only purgatives, but even
the mildest substances, are rejected, the plain common-sense rule
is to give nothing. Where cold water is borne by the stomach, it
may be taken in small quantities, as often as the patient requires
it. Solid ice, too, may be given with decided benefit. There is a
mistake which prevails with respect to the employment of ice in
gastritis, which I wish to correct. Some persons object to its
use, and reason in this way : — Persons who have taken a quantity
of cold water, or ice, when heated by exercise, have been frequently
attacked with gastritis and fever, and consequently the use of these
substances must be attended with danger in case of gastric inflam-
mation. This, however, is false reasoning; you need not be afraid
to order your patient ice, ad libitum; depend upon it, there is no
danger in employing either ice or cold water in gastritis. There
is nothing so grateful to the patient as ice. Let a quantity of it be
broken into small pieces, about the size of a walnut; let your
patient take one of these pieces, and, having held it in his mouth
for a few moments to soften down its angles, let him swallow it
whole. The effect produced by this on the inflamed surface of
the stomach is exceedingly grateful, and the patient has scarcely
swallowed one portion when he calls for another with avidity. It
will be no harm if I should here mention to you a secret worth
knowing. There are few things so good for that miserable sick-
ness of the stomach, which some of you may have felt after a
night's jollification with a set of pleasant fellows, as a glass of ice;
Byron's hock and soda-water are nothing to it.
After the first violent symptoms of the disease have been sub-
dued, I believe the very best thing which can be given is cold
chicken-broth.* The point which we are always to keep in view
is, to remove inflammation from the stomach, and this should regu-
late the use of everything taken into the stomach. I believe we
might derive much advantage from anodyne injections in gastritis.
I cannot say that I have ever employed them in such cases; but
if I were to reason from their utility in other forms of abdominal
inflammation, I should be induced to look upon them as entitled to
some consideration. There is another point to which I will briefly
advert. In the treatment of acute gastritis, there is nothing more
commonly used than effervescing draughts ; yet I have frequently
seen them produce distinct irritation of the stomach. In cases
where gastric irritability is excessive, I would not advise you to
give effervescing draughts, or if you do, watch their immediate
effect; see how the first one has agreed with the stomach before
you venture to give any more. Patients labouring under this dis-
* [There are cases of'gastritis in which even this simple animal
food is inadmissible thus early in the disease, and before conva-
lescence has set in. — B.I
AFTER-TREATMENT OF GASTRITIS.
119
ease should be kept extremely quiet, as frequently a slight motion
brings back the vomiting. Everything which is swallowed should
be in small quantity; a large quantity of any substance frequently
causes a return of the vomiting, by distending and irritating the
stomach. One of the best things you can give, and the best way
of giving it, is iced lemonade, giving a tablespoonful from lime to
time. The extremities, which are generally cold in cases of intes-
tinal disease, should be swathed in warm flannel.
I shall mention here a rule which should be carefully observed
in the after-treatment. A patient has recovered from the violent
symptoms of the disease ; the fever, thirst, pain, epigastric tender-
ness, and sympathetic affections, have subsided; but he still is con-
fined to bed, and in a state of great debility. Some patients, under
these circumstances, have been unfortunately lost by allowing
them to sit up in bed, or on the night-chair. The nurse will some-
times, through ignorance, suffer a patient, thus enfeebled, to risk
his life by sitting up in bed; sometimes, during the course of the
night, she is overcome by sleep; the patient has a call to empty
his bowels; and not wishing to disturb her, attempts to get up, and
is found, in some time afterwards, sitting on the night-chair quite
dead. This is an unfortunate termination for the physician as well
as the patient. A German author, Hoffmann, has written a treatise
on the danger of the erect position after acute diseases; and in the
course of the work, which is a very interesting one, he cites
numerous instances of its bad effects. Not very long since, a
patient was lost in the Meath Hospital, by the nurse allowing him
to sit up after a severe attack of enteritis. Such, also, was the
melancholy cause of death in the case of the late Mr. Hewson,
one of my best and earliest friends. He got a severe attack, which
was subdued with difficulty, and his convalescence was doubtful
and protracted. One night, in the absence of his attendant, he got
up for the purpose of emptying his bowels, and was found, some
time afterwards, on the night-chair, nearly dead. He was imme-
diately brought back to bed, and the necessary means employed
to relieve him, but without much benefit, for he never recovered
the effect produced on his debilitated frame.*
* [Not only in cases of great prostration from hemorrhage, cho-
lera, &c, but in the advanced stage of all diseases of an acute
character, the patient should be prevented from rising or even sitting
up in bed. A bed-pan slipped under him will be the substitute for
a close-stool; nor should any foolish prejudice—a thing not un-
common with persons who have heretofore enjoyed good health,—
prevent its use. — B.]
120
DISEASES OF THE DIGESTIVE SYSTEM.
LECTURE X.
Pathology and Treatment of Gastritis—Application of blisters—Emetics can
be seldom used in acute gastritis—Hagmatemesis and delirium tremens com-
plicated with gastritis—Treatment of these affections—Dyspepsia, or chronic
gastritis—Hypochondriasis—Termination of chronic gastritis.
There is one point connected with the treatment of gastritis
which I have not yet touched upon — the use of blisters ; and as
this is the first time I have spoken of them, I shall make a few re-
marks on their general application.
It is a great error to think that blistering is a matter of course in
inflammatory diseases, or that the proper period for their applica-
tion should not be carefully marked. It is a common idea, that if
a blister does no good it will do no harm; that it is probable some
benefit may result from its employment, and that you may try it
at all events. I need not tell you that all this is wrong, and that
we must be guided by exact principles in this as well as in every
other part of practical medicine. I am afraid there is a great deal
of loose reasoning and empirical practice connected with this sub-
ject, even at the present day. Here is the general rule by which
you should be invariably guided. No matter what kind of disease
you have to deal with, if it be inflammatory, blistering in the early
stage of it is decidedly improper. I might amplify this rule, and
say, that if the disease be inflammatory and in its early stage, or if,
under such circumstances, the symptoms require the general or
local abstraction of blood, blisters cannot be used with propriety.
The truth is, that many persons take a very limited view of this
subject; they look upon blisters as merely revulsive agents, which,
by their action on the surface, have the property of diminishing
visceral inflammation. This I am willing to allow is true to a
certain extent,but there is abundant evidence to prove, that blisters
have sometimes a direct stimulant effect on the suffering organ.
That this occasionally occurs has been established by many facts
in medicine; and I have not the slightest doubt that the applica-
tion of a blister over an organ in a state of high inflammatory ex-
citement will certainly be productive of injurious consequences.*
* [Not only in primary gastritis, but, also, in gastritis as a com-
plication with fever, some practitioners, either from not fully re-
cognising the nature of the disease, or not appreciating the opera-
tion of blisters, are in the habit of applying them forthwith, so soon
as the patient complains of heat and pain or tenderness in the epi-
gastrium. This is bad practice in a double sense ; bad in itself, as
tending to aggravate the disease; and bad indirectly, by preventing
the application of leeches, and of ice or cloths immersed in cold
water. We cannot afford to give away the epigastric surface in
this manner, in the first stage of either gastritis, gastro-enteritis, or
APPLICATION OF BLISTERS IN GASTRITIS. 121
But if you apply them at the period when stimulation is admissible
and useful, (and there will always be such a period in every inflam-
mation,) you then act on just principles, and will generally have
the satisfaction of finding your practice successful. The greatest
empiricism is sometimes practised in the application of blisters to
the head in acute inflammation of the brain. You will see, in Mr.
Porter's admirable work on the Pathology of the Larynx, how
strongly he is opposed to the early use of blisters in acute laryn-
gitis. Dr. Cheyne, also, may, among many others, be quoted in
support of this doctrine.
If there is one system more than another likely to be injured by >
early blistering, it is the digestive. Broussais says that blisters
should not be applied in any of the stages of acute gastro-enteritis,
and that in the early stage their application is the very height of
malpractice. I do not go so far as to say that they should not be
applied in any period of the disease, for when the skin is cool, the
pulse lessened, and the local inflammation so far reduced as not to
require the abstraction of any more blood, I think you may employ
them with very considerable advantage. I shall again return to
the subject of blisters; and will for the present merely remark,
that blistering is almost always mismanaged, in consequence of
persons who apply them being ignorant of their stimulating effects
on organs. They generally allow them to remain on too long, and
the consequence of this is often violent excitement of the organ
over which they are applied, great constitutional irritation, stran-
gury, and bad sores. The best mode of using them is to direct the
person who prepares the blister to cover it with a piece of silver-
paper before it is applied, and having put it on with the paper
next the skin, to let it remain until a decided sense of smarting is
produced, when it sho.uld be immediately removed. By adopting
this plan, you will save yourself and your patient a great deal of
inconvenience; you will have no strangury, stimulation of the
whole economy, or excessive local irritation, and the inflamed
surface will heal kindly. The mode (too often practised) of apply-
ing a blister sprinkled all over with an additional quantity of pow-
dered cantharides, and leaving it on for twelve, twenty-four, or
even thirty-six hours, particularly in the case of females, is nothing
better than horse doctoring. During a seven years' experience in
the hospital at Tours, Bretonneau, by attending to this principle,
never had a case followed by these troublesome symptoms, and yet
he never failed in producing the necessary degree of counter-irrita-
tion. The active principle of cantharides, being soluble in oil, ex-
udes through the silver-paper in sufficient quantity to produce the
necessary effect on the skin, without exposing the patient to the
of fevers generally. The judicious practitioner will regard a blister
as among the remedies to be the last employed in most of the acute
diseases. See Article Epispaslics in Practical Dictionary of Ma-
teria Medica, by John Bell, M.D. 1841.
VOL. I.—11
122 DISEASES OF THE DIGESTTVE SYSTEM.
risk of having too much irritation excited by the direct application
of the blistering plaster to the cutaneous surface.*
With respect to emetics, I need not tell you that they can be very
seldom used in acute gastritis, and that all your efforts should be
directed to obviate and remove vomiting. But are we to interdict
their use altogether? There are some few cases where we are
compelled to use them ; as, for instance, in cases of acute gastritis
caused by swallowing corrosive poison, or by the irritation of indi-
gestible food remaining in the stomach. The first step to be taken
in a case of corrosive poisoning, is to evacuate the stomach. In the
same way, when you are called to treat a case of gastritis produced
by indigestible aliment, you must commence by giving an emetic.
But even here the emetic is admissible only in the early period;
and you should never trust to its operation for removing the gas-
tritis altogether, unaided by other therapeutic means; nor are you
to conclude that because you have produced vomiting you have
succeeded in curing the disease. The same principles apply to the
use of purgatives in enteritis as to emetics in gastric inflammation;
we should never have recourse to them except where inflammation
is kindled and kept up by the presence "of irritating matter.
Hematemesis and Delirium Tremens.—There are two cases in
which certain affections are complicated with an acute gastritis ;
and as these complications are not sufficiently known, and have
been scarcely noticed by systematic writers on gastritis, I am
anxious to draw your particular attention to them. One of these
is hematemesis, the other that disease which has been termed
delirium tremens. There are cases of vomiting of blood, which
are little more than acute gastritis, in which there is a copious
secretion of blood from the mucous surface of the stomach. Vomit-
ing of blood may arise from various causes. It may be vicarious,
as in the case of females, where the menstrual flux is suppressed;
it may be accidental, as from the rupture of a bloodvessel; or it
may be caused by mechanical obstruction to the circulation, either
in the liver, spleen, heart, or lungs. But there is a species of gas-
tritis, in which there is a copious vomiting of blood ; or there is
an hematemesis, of which the cause is gastric irritation. How
are you to recognise this form of the disease?—The patient is
vomiting blood ; but then he has fever, hot skin, and excited pulse.
Again, you will see some peculiar modification of the tongue ; you
will find ardent thirst and longing for cold drinks; you will ob-
serve fulness and tenderness of the epigastrium; you may have
severe local pain; finally, you will have all these symptoms occur-
* [Mr. Trousseau has recently recommended an ethereal extract of
cantharides, which is obtained from the action of sulphuric ether on
the powder of cantharides. Portions of blotting paper of various
sizes are imbibed with this extract and form so many blisters.
Blistered surfaces may be kept running by applying to "them the
extract of cantharides mixed with yellow wax, in the proportion of
the former of one-tenth to one-twentieth. — B.]
COMPLICATIONS WITH GASTRITIS.
123
ring in a person who, previously to the attack, exhibited nothing
capable of accounting for the hematemesis. Here, then, we have
an hemorrhagic gastritis, very little known, and too often impro-
perly treated. The ordinary practice, in such cases, is to give
astringents. Astringents are very good and useful where they are
clearly indicated; but there are many forms of disease where their
routine employment is productive of a great deal of mischief; and
I believe lives are sometimes lost by looking upon this affection as
a simple hematemesis, and by practitioners contenting themselves
with the use of astringents. But where you have the symptoms of
this form of gastric irritation present, where, in addition to the
vomiting of blood, you have fever, and thirst, and hot skin, and
pain, and epigastric tenderness, you may be sure that it is a gastritis,
and that the best treatment is leeches, iced water, and the other
means recommended in the treatment of gastric inflammation. It
may happen that, under this treatment, the vomiting of blood will
not entirely subside; but the pain, the thirst, the fever, and epigas-
tric tenderness will subside, and then you can with propriety give
astringents. The best thing you can do in the commencement is
to leech freely, give iced lemonade, and cold water; prohibit every-
thing purgative, stimulant, or astringent; and then, when you have
reduced inflammation, if the hematemesis continues, have recourse
to astringents.
A few words now with respect to the other complication—delirium
tremens. You have all seen cases of delirium tremens, but you
are not, perhaps, aware that it arises under two opposite classes of
causes. In some cases, a patient who is in the habit of taking
wine or spirituous liquor every day in considerable quantities, meets
with an accident or gets an attack of fever. He is confined to bed,
put on an antiphlogistic diet, and in place of wine or whiskey-
punch gets whey and barley-water. An attack of delirium tremens
comes on, and symptoms of high cerebral excitement appear.
Another person, not in the habit of frequent intoxication, takes to
what is called a fit of drinking, and is attacked with delirium
tremens. In the first case the delirium arises from a want of the
customary stimulus, in the second from excess. In each the cause
of the disease is different; and, consequently, with this view of the
subject, it would be a manifest departure from sound practice to
treat both cases in the same way. Yet, I believe, this error is
frequently committed, even by persons whose authority is high in
the medical world, and is part of a system not yet exploded — the
system of prescribing for names and not for things. The patient is
treated for a disease which has been called delirium tremens, the
present symptoms are only attended to, and the cause and origin of
the affection are overlooked. What are the true principles of
treatment? — In the first variety, where the delirium is produced
by a want of the customary stimulus, there is no doubt that patients
have been cured by the administration of the usual stimulants, by
giving them wine, brandy, and opium. Indeed, this seems to be
124
DISEASES OF THE DIGESTIVE SYSTEM.
the best mode of treating this form of the disease. But is it proper
or admissible in the second variety, where the delirium is caused by
an occasional excess in the use of ardent spirits ? — Certainly not.
Yet what do we find to be the ordinary practice in hospitals when
a patient is admitted under such circumstances ? — A man, who has
been attacked by delirium tremens after a violent debauch, is
ordered a quantity of porter, wine, brandy, and opium ; and the
worse he gets, the more is the quantity of stimulants increased.
Now this practice seems to me as ridiculous as the old principle of
treating a case of hydrophobia with a hair of the dog that bit. Let
us consider what the state of the case is:—A large quantity of
stimulant liquors have been taken into the stomach, the mucous
surface of that organ is in a state of intense irritation, the brain
and nervous system are in a highly excited condition from the
absorption of alcohol, or in consequence of the excessive sympa-
thetic stimulation to which they have been subjected. Are we to
continue this stimulation? — I think not. What would be the
obvious and natural result ? — Increased gastric irritation, encepha-
litis, or inflammation of the membranes of the brain. The super-
vention of inflammatory disease of the brain in delirium tremens is
not understood by many practitioners, and they go on administering
stimulant after stimulant, totally unconscious that they are bringing
on decided cerebral disease. I have witnessed the dissections of
a great many persons who died of delirium tremens, and one of
the most common results of the dissection was, the discovery of
unequivocal marks of inflammation in the brain and stomach.
Broussais considers all such cases as merely examples of gastritis,
and ridicules British practitioners for inventing a " new disease;"
but in this he is certainly wrong, for there have been several cases
in which no distinct marks of gastric inflammation could be dis-
covered. In all cases, however, where the delirium supervenes on
an excessive debauch, there.is more or less of gastritis ; and though
it may occasionally happen, that a patient under such circumstances
may recover under the stimulant treatment, yet I am convinced
that the physician will very frequently do harm by adopting it.
This complication of delirium tremens with gastritis is also ex-
ceedingly curious in another point of view, as it illustrates how
completely the local symptoms are placed in abeyance, and as it
were lost during the prevalence of strong sympathetic irritation.
The patient's belly will not be tender; the tongue may not be red;
the symptoms present may be indicative of a mere cerebral affec-
tion, and yet intense gastric inflammation may be going on all the
time, and all the appearance of cerebral disease be quickly removed
by treatment calculated to subdue a gastritis. Is this all theory?
No; for we have practised on this principle with the most extra-
ordinary success in the Meath Hospital. We have seen cases of
violent outrageous delirium subside under the application of leeches
to the epigastrium, and iced water, without a single drop of lauda-
num. I beg of you, if you meet with any cases of delirium tremens
CHRONIC GASTRITIS.
125
under such circumstances, to make trial of this mode of treatment,
and record its effects, for it is important that they should be more
extensively known. I have seen the whole train of morbid pheno-
mena, the delirium, the sleeplessness,the excessive nervous agitation,
all vanish under the application of leeches to the epigastrium. In
some cases where after the sleeplessness and delirium were removed
by this practice, and the tremors alone remained, we have again
applied leeches to the epigastrium, and succeeded in removing the
tremors also. On the other hand, where a stimulant plan of treat-
ment was employed, and the patients died, we have most com-
monly found inflammation in two places, in the stomach, or in the
brain or its membrane. The rule, then, is this — in a case of de-
lirium tremens from the want of a customary stimulus, use the
stimulant and opiate treatment; but when it comes on after an oc-
casional violent debauch, such remedies must be extremely im-
proper. Adopt here everything calculated to remove gastric
irritation. We have facts to show that most decided advantage
may arise from the application of leeches, even where the symptoms
of gastritis are absent.*
Chronic Gastritis.—We come now to consider chronic gastritis,
an extremely interesting disease, whether we look upon it with refer-
ence to its importance, its frequency, or its Protean character. It
is commonly called dyspepsia, and this term, loose and unlimited in
its acceptation, often proves a stumbling-block to the student in
medicine. Dyspepsia, you know, means difficult digestion, a cir-
cumstance which may depend on many causes, but perhaps on none
more frequently than upon chronic gastritis. In the great majority
of dyspeptic cases the exciting cause has been over-stimulation of
the stomach, either from the constant excess in strong highly-sea-
soned meats, or indulging in the use of exciting liquors. Persons
who feed grossly, and drink deeply, are generally the subjects of dys-
pepsia ; by constantly stimulating the. stomach they produce an
inflammatory condition of that organ. Long-continued functional
lesion will eventually produce more or less organic disease; and
you will find that in most cases of old dyspepsia there is more or
less gastritis. But let us go farther, and inquire whether those
views are borne out by the ordinary treatment of dyspeptic cases.
When you open a book on the practice of physic, and turn to the
article dyspepsia, one of the first things which strikes you is the
* [In my own practice, I have met repeatedly with gastritis in
women brought on by the secret use of mixed liquors, cordials, &c.
In one of these cases the attack was exceedingly severe, requiring the
most energetic means for relief. As too often happens, I was kept,
at the time, in entire ignorance of its cause. Those vile compounds,
true poisons, sold and drunk by the common people, and in greater
proportion by females, under the name of cordials, are, to my
knowledge, frequently causes of gastritis, both acute and chro-
nic—B.j
11*
126
DISEASES OF THE DIGESTIVE SYSTEM.
vast number of cures for indigestion. The more incurable a disease
is, and the less we know of its treatment, the more numerous is
the list of remedies, and the more empirical is its treatment. Now
the circumstance of having a great variety of " cures" for a disease,
is a strong proof, either that there is no real remedy for it, or that
its nature is very little understood. A patient afflicted with dys-
pepsia will generally run through a variety of treatment, he will
be ordered bark by one practitioner, mercury by another, purga-
tives by a third ; in fact, he will be subjected to every form of treat-
ment. Now all this is proof positive that the disease is not suffi-
ciently understood. What does pathology teach in such cases ? In
almost every instance where patients have died with symptoms of
dyspepsia, pathological anatomy proves the stomach to be in a state
of demonstrable disease. It appears, therefore, that, whether we
look to the uncertainty and vacillations of treatment, or the results
of anatomical examination, the case is still the same; and that,
where dyspepsia has been of considerable duration, the chance is
that there is more or less of organic disease, and that, if we pre-
scribe for dyspepsia, neglecting this, we are very likely to do mis-
chief. I do not wish you to believe that every case of dyspepsia
is a case of gastritis. This opinion has brought disgrace on the
school of Broussais. His disciples went too far; for whether the
gastric derangement depended on nervous irritation, of anaemia, or
disease of the liver, or mental emotion, they prescribed leeches and
water-diet, and thus very often brought on the disease they sought
to cure. We may have functional disease, independent of structural
lesion, in the stomach, as well as in any other organ ; it is no un-
usual circumstance, and the practical physician meets with it every
day. A great deal of confusion, however, arises from the similarity
of the symptoms. I remember an accomplished friend of mine
getting into disgrace with one of the members of a board of exa-
miners on this subject. He was asked to tell the difference between
the symptoms of chronic gastritis and dyspepsia, and in reply stated
that he could not. For this he was nearly rejected ; but, I believe,
on a candid review of the circumstances, you will agree with me,
that he knew more of the matter than the learned professor. In
ninety-nine cases out of a hundred of chronic gastritis there is no
fever, scarcely any thirst, often no fixed local pain, and this leads
persons away from any idea of the existence of an inflammatory
condition of the stomach. What are the symptoms of a chronic
gastritis? pain of occasional occurrence, flatulence, acidity, swell-
ing of the stomach, fetid eructations, sensation of heat and weight
about the epigastrium, and perhaps vomiting. Well, these are also
the symptoms of dyspepsia, whether it be accompanied by inflam-
mation or not. How, then, when called to a case of this kind, are
you to determine the point? I must mention to you here, that it
is often hard to do this with certainty. There are two circum-
stances, however, which you should always bear in mind, as they
will afford you considerable assistance in coming to a correct dia-
ACUTE AND CHRONIC GASTRITIS.
127
gnosis; first, the length of time which the disease has lasted;
secondly, the result of the treatment which has been employed.
You will find, that where the disease is a chronic gastritis, that it
has been of some duration, that it has come on in an insidious
manner, and that it has been exasperated by the ordinary treat-
ment for dyspepsia. Many persons think, that if you give a patient
medicine, without regulating his diet or issuing a prohibition against
full meals, that you can cure him, and that, as he has no fever, and
can go about his usual business, there is no necessity for antiphlogis-
tic regimen. But as the disease goes on, he complains of pain in the
stomach during the process of digestion, feels uneasy after dinner,
there is an unpleasant degree of fulness about the epigastrium, he
also experiences a variety of disagreeable symptoms, sometimes
being annoyed with pain in the chest, sometimes he says he feels
it in the region of the heart, and sometimes about the cartilages of
the eighth and ninth ribs. These symptoms subside after the
process of digestion is completed, but during its continuance they
harass the patient. Very often relief is obtained by vomiting, and
hence some persons are in the habit of throwing up their food for
the purpose of relieving themselves, and consequently can have no
benefit by it.* In some cases digestion goes on until the food
seems to reach a particular point, and then an acute feeling of pain
is experienced. In these cases the gastritis is generally circum-
scribed, and is likely to terminate in circumscribed ulceration.
Various fluids are rejected from the stomach during the course of
a gastritis: sometimes acid, sometimes alkaline, sometimes insipid
and sweet, sometimes bitter and bilious. There is generally a
degree of fulness about the stomach, and the epigastrium is tender
on pressure, but no decided tumour, either of the pylorus, liver, or
spleen, although the epigastrium presented that appearance of ful-
ness and tension termed by the French " renitence." The bowels,
too, are constipated, and this is a matter worthy of your attention,
for it sometimes unfortunately happens that the practitioner, mis-
taking the gastritis for simple constipation, goes on prescribing
purgative after purgative, until the patient gets incurable disease of
the stomach. I know a case of a lady who gets one stool a week
by taking eight drops of croton oil. Some years ago she was in the
enjoyment of excellent health ; her bowels happened to get confined,
and she was treated by a systematic practitioner with continued
purgatives: her bowels are now completely torpid, except when they
are subjected to this unnatural stimulus. There are thousands of
persons treated in this way, because practitioners look to conse-
quences and not to causes.
One great difference between Acute and Chronic Gastritis. — There
is one remarkable difference between acute and chronic gastritis,
* [I have been told by a person who was in the habit of familiar
intercourse with Lord Byron, in Italy, that this was a common
practice of the noble poet. — B.]
123 DISEASES OF THE DIGESTIVE SYSTEM.
which deserves your attentive consideration, as it exemplifies a law
applicable to all viscera under similar circumstances, and this is,
that the sympathetic irritations are not so frequent or so distinct in
chronic inflammation as in the acute form, and hence, in a case of
chronic gastritis we almost never have fever, and the affections of
the nervous respiratory or circulating systems are by no means so
well marked. I may even go on to actual disorganization of the
stomach, and yet the patient will not complain of any particular
symptom during its whole progress, which you could set down as
depending exclusively on the sympathetic irritation of gastritis.
Some of these cases, called dyspeptic phthisis, by Dr. W. Philip,
are most probably examples of the sympathetic irritation of the
lungs from chronic gastritis. Another case, respecting which
much error prevails, is what has been called hypochondriasis.
Persons labouring under these affections are condemned to run the
gauntlet of every mode of treatment; sometimes (and fortunately
for themselves) they are sent to travel, sometimes they are treated
with musk and antispasmodics, then with the mineral acids, then
with purgatives and mercurials, and lastly, with bark, nitrate of
silver, and stimulants. They go about like spectres from one
practitioner to another, trying remedy after remedy, alternately
sanguine with hope or saddened by disappointment, until at last
they die, and, to the astonishment of all the doctors, the only disease
found, on dissection, is inflammation and thickening of the mucous
surface of the stomach. A condition which, under these circum-
stances, it was difficult to say whether it was the original disease,
or produced by "fair trials " of a number of powerful agents.
Hypochondriasis is not always gastritis; but it is now found that,
in many cases, it commences and terminates with disease in the
upper portion of the digestive tube and the assisting viscera. This
you must always bear in mind.
Chronic gastritis terminates in various ways. Sometimes the
inflammation is limited to a particular spot of the stomach, and here
we frequently discover circumscribed ulcerations. In very bad
cases these ulcers go on perforating the various coats of the stomach,
until at last the contents of that organ escape into the serous cavity
of the abdomen, and the patient rapidly sinks under a fatal perito-
nitis. It does not follow, however, that, in all cases of perforation,
the contents of the stomach get into the peritoneum, causing death.
Very often adhesions are formed, and the base of the ulcer is the
serous covering of some other portion of the digestive system, or a
false passage may be formed into the colon. One of the most
common terminations of a chronic gastritis is, that the inflammation
extends to other viscera ; the patient gets disease of the liver,
spleen, peritoneum, or lungs, and sinks under a complication of
disorders. It was somewhat in this way that Napoleon died. He
laboured for a considerable time under chronic disease of the
stomach, which seems to have been overlooked by his medical at-
tendants, and this terminated in the extension of disease to various
other organs.
TREATMENT OF CHRONIC GASTRITIS.
129
LECTURE XL
Treatment of Chronic Gastritis. — Frequent excitement of the vascular system
necessary to the performance of the functions of the stomach — Local bleeding
— Regimen — Counter-irritation over the stomach — Treatment of Broussais
— Use of vegetable tonics — Oxide of bismuth — Acetate of morphia.
I shall begin to-day with the treatment of chronic gastritis, and I
beg of you to bear in mind what I mentioned at my last lecture,
that this disease, in its true and pathological meaning, is not suffi-
ciently recognised. In general,it gets some wrong name or other;
and as many practitioners are in the habit of prescribing for names,
it generally meets with wrong treatment. It is called everything
but what it is, and its remedies are as numerous and as various as
its appellations. By some, it is called dyspepsia, and is treated
with bitters, astringents, and stimulants; by others, it is termed
constipation, and treated with purgatives ; the school of Abernethy
look upon it as an affection of the liver, and prescribe blue pill and
black draught; others give it the name of hypochondriasis, and
exhaust the whole catalogue of nervous and anti-dyspeptic medi-
cines in attempting its removal; in fact, it is called everything
but what it is, and the result is an unsteady and mischievous
empiricism.
You will recollect a fact, to which I alluded in my last lecture,
that the physiological condition of the stomach requires that it
should be subject to frequent excitements of its vascular tissue, and
that this increased vascularity being the consequence of a natural
process, digestion is, generally speaking, exempt from any kind of
danger. If the brain or lungs were to experience an equal increase
of vascularity, sensibility, and excitement, the consequence would
be dangerous, or perhaps fatal, and we should have pulmonary
and cerebral diseases produced. But though the stomach enjoys
such a remarkable exemption from the liability to acute inflamma-
tion, under circumstances of repeated vascular excitement, yet the
slow, insidious, chronic gastritis, is an exceedingly common affec-
tion. I feel convinced that many persons die of it, or of the exten-
sive class of fatal diseases which it frequently induces. But I
rejoice to say, that we have good reason to hope that the progres-
sive amelioration of medical science will materially diminish the
amount of human suffering from this cause. As physiological
medicine advances, the number of those who die of unrecognised
chronic visceral disease will be less and less, because diagnosis will
become more extended and certain, and practice more simple and
successful.
The first thing you should do, when called to treat a case of dys-
J 30 DISEASES OF THE DIGESTIVE SYSTEM.
pepsia, is to ascertain whether it be a purely nervous disease, or a
chronic gastritis. The majority of practitioners give themselves
no trouble about this matter, not recognising the fact, that of the
number of dyspeptic persons who seek for medical advice, a con-
siderable proportion are really labouring under a chronic gastritis,
and forgetting, that, in consequence of long-continued functional
injury, what was at first but a mere nervous derangement may
afterwards become complicated with organic disease. You must
also bear in mind, that the stomach is perhaps placed under more
unfavourable circumstances for bringing about a cure than any
other organ, because the life of the individual demands that the
stomach, though in a state of inflammation, should still continue to
perform its functions. In treating diseases of other organs, you will
have the advantage of a comparative state of rest; but, in a case
of the stomach, if you wish to preserve life, you cannot prohibit
nutriment, and, consequently, you must run the risk of keeping up
these periodic vascularities which its condition requires, which,
though harmless in health, become a source of evil when the sto-
mach is diseased. The obvious deduction from this is, that the
cure of chronic gastritis depends as much upon regimen as upon
medical treatment, and particularly where the symptoms have
arisen from long-continued excitement, as in the case of persons
who live highly. Here the treatment chiefly depends on regulating
the diet, and if your patient has sense enough to live sparingly for
a few weeks or months, you may be able to effect a cure without
other treatment. The great error is, that most practitioners at-
tempt to cure the disease by specifics, and when these fail, they
then go to the symptomatic treatment, prescribing sometimes for
acidity, sometimes for nausea, sometimes for flatulence, sometimes
for constipation, or "the liver," or debility.
You should be careful in the examination of such cases, and
should try to ascertain whether these symptoms may not depend
upon inflammation of the stomach; for as long as the patient is in
this state, the less you have recourse to symptomatic or specific
treatment the better. It is hard to mention one single medicine
which, in this state, will not prove stimulant, and if the stomach be
unfit for stimulants, it must be unfit for the generality of medicines.
There are numbers of cases of persons labouring under chronic
gastritis, which have been cured by strict regulation of diet, and
by a voiding every article of food requiring strong digestive powers.
We find that articles of diet vary very much in this respect; some
are digested with ease, some with pain. We might express this
otherwise, by saying, that some require very little excitement of
the stomach, and others very great vascular excitement. Patients,
in this irritable state of stomach, can scarcely bear any kind of
ingesta ; and when you consider the great vascularity, thickening
of the mucous membrane, and tendency to organic disease, you
will be induced to think that everything entering the stomach
TREATMENT OF CHRONIC GASTRITIS.
131
should be of the mildest kind, and not requiring any powerful de-
termination of blood to that organ.*
If you continually prescribe for symptoms, neglecting or over-
looking the real nature of the disease, giving arsenic to excite the
system, and iron to remove anaemia, and bitter tonics to improve
the appetite, and alkaline remedies for acidity, and carminatives to
expel flatus, you will do no good; you may chance to give relief
to-day, and find your patient worse to-morrow ; and at last he will
die, and you may be disgraced. On opening the stomach, after
death, you are astonished to find extensive ulceration, or, perhaps,
cancerous disease. Very often, in such cases, practitioners say
that it is cancerous disease, and that no good can be done. But
the thing is to be able to know, when you are called to a case,
whether it is a case of mere nervous dyspepsia, or chronic inflam-
mation of the stomach. Some of the best pathologists think that
most of the cancerous affections of the stomach are, in the begin-
ning, only chronic inflammations of that organ.
I believe we have not yet in this country adopted the plan of
moderate application of leeches to the epigastrium in cases of
chronic gastritis. I have seen, in many cases, great benefit result
from the repeated application of a small number of leeches to the
epigastrium, at intervals of two or three days. Here is a point
which you will find very useful in practice. You will meet with
cases which have lasted for a long time; cases where there is
strong evidence of organic disease, and which have resisted the
ordinary dyspeptic treatment. You will be called frequently to
* [This course, so conformable with reason and experience, and
so readily understood by the attentive inquirer, is, however, the
most difficult to be carried out in practice. Our patients will take
evry kind of nauseating drug without much grimace; they will
consent to be blistered and cauterised and punished, after every
medical fashion: but so soon as we wish to substitute a regulated
and restricted diet for this polypharmacy, they all at once discover
innumerable difficulties in the way. We then become cruel, starv-
ing doctors ; without good bowels of our own, it is believed, and of
course without compassion for the bowels of others! In fact, a
doctor will be much more likely to preserve his reputation in a
family, whilst, bringing on chronic, perhaps incurable, gastritis, by
the needless administration daily of arsenic, than whilst he is suc-
cessfully attempting the cure of a case of this disease by a very
restricted diet. It will be found with this, after all, as with many
other prejudices of the people, that they are but the reflexion or
echo of former opinions and now exploded hypotheses of the pro-
fession. If physicians, generally, would cease, indolently perhaps
oftener than ignorantly, to administer to the whims of their dys-
peptic patients, the latter seeing a general concert of opinion among
medical men, would be less reluctant to follow out literally the
advice of their immediate professional advisers. — B.]
132
DISEASES OF THE DIGESTIVE SYSTEM.
treat these three different cases: — where the disease has been of
long duration ; where there is distinct evidence of organic disease ;
and where the disease has resisted the ordinary dyspeptic treat-
ment. Here is a case of a patient labouring under what is called
indigestion, and which has resisted the stimulant, and tonic, and
purgative treatment. Here is one fact. In the next place, the
disease is chronic, and the probability is that there is inflammation,
and consequently that there is chronic gastritis. Now if, in such
a case, you omit all medicine by the mouth, apply leeches to the
epigastrium, keep the bowels open by injections, and regulate the
diet, you will often do a vast deal of good. I have seen, under this
treatment, the tongue clean, the pain and tenderness of the epigas-
trium subside, the acidity, thirst, nausea, and flatulence, removed,
the power of digestion restored, and all the symptoms for which
alkalies, and acids, and tonics, and purgatives, were prescribed,
vanish under treatment calculated to remove chronic inflammation
of the stomach.
What is next in importance to regulated regimen and local
bleeding 1 A careful attention to the bowels, which in chronic gas-
tritis are generally constipated, and this has a tendency to keep
up disease in the upper part of the digestive tube. Is this to be
obviated by introducing purgative medicine into the stomach]
No. If you introduce strong purgative medicine by the mouth,
you will do a great deal of mischief You must open the bowels
by enemata, or, if you give medicine by the mouth, by the mildest
laxatives in a state of great dilution. A little castor-oil, given
every third or fourth day, or a little rhubarb, with some of the neu-
tral salts, will answer in most cases.* The diet, too, can be
managed, so as to have a gently laxative effect.f The use of
injections is, however, wtiat I principally rely on. I have seen
many cases of gastritis cured by the total omission of all medicine
by the mouth, by giving up every article of food which disagreed
with the stomach, and by the use of warm water enemata. I have
seen this treatment relieve and cure persons whose sufferings had
lasted for years previous to its employment, and who had been
considered by many practitioners to labour under organic disease
of an incurable nature. It is important that you should bear this
in mind. The old purgative and mercurial treatment of gastritis,
I am happy to say, is rapidly declining; and British practitioners
* [Salts are often singularly unfriendly to the stomach of a dys-
peptic. Rhubarb and soap pill, or rhubarb and carbonated mag-
nesia with a little cinnamon or ginger well mixed, are prefer-
able.— B.] v
f [And for this purpose bran or rye bread, rye mush and milk
for breakfast and spinach for dinner, are among the best articles.
Butter-milk in season, and melasses and water for occasional drink,
will tend to the same end. —B.]
TREATMENT OF CHRONIC GASTRITIS. • 133
are now convinced that they cannot cure every form of dyspepsia
by the old mode of treatment. I do not deny that many diseases
of the digestive tube may be benefited by the mild use of mercury
and laxatives, but I think I have every reasonable and scientific
practitioner with me in condemning the unscientific routine prac-
tice, which was followed by those who took the writings of Aber-
nethy and Hamilton for their guide. I do not say that, where
cases of gastric inflammation, treated after the plan of Mr. Aber-
nethy, have proved fatal, the medicines have destroyed life; I
merely assert that the patients died of inflammation, over which
these medicines had no control; and the error lay in mistaking and
overlooking the actual disease, as much as in its maltreatment.
You will find some practitioners (they are becoming fewer in
number every day), who seem to have but two ideas, the one a
purgative, the other a potful of feces ; but the connecting link — the
gastro-enteric mucous membrane — that vast expansion, so com-
plicated, so delicate, so important, seems to be totally forgotten.
But practitioners are now beginning to see that purgatives are not
to be employed empirically; that they should be administered in
many cases with great caution, and with a due attention to the actual
condition of the alimentary canal, and that they have been a source
of great abuse in the medical practice of these countries.
Next to leeching, and a proper regulation of the bowels, is the
employment of gentle and long-continued counter-irritation over
the stomach. This may be effected by the repeated application of
small blisters, or by the use of tartar emetic ointment. I have
been in the habit of impressing upon the class, that the tartar
emetic ointment used in these countries is too strong, the conse-
quence of which is an eruption of large pustules, which are exces-
sively painful, and often accompanied with such disturbance of the
constitution as amounts to symptomatic fever. In fact, tartar
emetic ointment of the ordinary strength produces so much irrita-
tion, that few patients will submit to it long The form which I
recommend you to employ is the following : — Take seven drachms
of prepared lard, and, instead of a drachm of tartar emetic, which
is the usual quantity, take half a drachm, directing, in your pre-
scription (this is a point of importance), that it be reduced to an im-
palpable powder ; and you may add to it, what will increase its
action, one drachm of mercurial ointment. This produces a crop
of small pustules, which give but little pain, and are easily borne ;
and the counter-irritation may be kept up in this way for a con-
siderable time, by stopping, for a few days, until the eruption fades
away, and then renewing the friction. I have often seen the utility
of this remedy exemplified in cases of chronic gastritis, where the
symptoms of gastric irritation, which had subsided under the em-
ployment of friction with tartar emetic ointment, returned when
it was left off, and again vanished when it was resumed. The
case of the celebrated anatomist, Beclard, furnishes a very remark-
able proof of the value of a well-regulated diet and repeated
vol. i.—12
134 DISEASES OF THE DIGESTIVE SYSTEM.
counter-irritation in the treatment of this disease. While he was
engaged in the ardent prosecution of his professional studies he got
an affection of the stomach, which he considered to be a chronic
gastritis, and immediately put himself under a strict regimen, using,
at the same time, repeated counter-irritation. He kept up the
counter-irritant plan for a considerable length of time, for he
found that, when he discontinued it, the gastric symptoms had a
tendency to return. In this way he got completely rid of the dis-
ease. Several years afterwards he died of an attack of erysipelas;
and, on opening his stomach, the cicatrix of an old ulcer was
discovered in the vicinity of the pylorus, which was exactly the
spot to which he had referred his pain during the continuance of
his gastric affection.*
There is, perhaps, no science in which the motto, "medio tutissi-
mus ibis," is of more extensive application than in medicine. Some
physicians on the continent, particularly the disciples of Broussais,
having repeatedly witnessed the advantages of strict regimen and
local depletion in chronic gastritis, have pushed this practice too
far. They seemed to forget that the system requires support and
nutrition, which can be effected only through the agency of the
stomach; they saw the evils which result from the use of stimu-
lating food in cases of chronic gastritis ; and, looking to these alone,
they ran into the opposite extreme, the consequence of which was,
that they kept their patients so long upon low diet that they
actually produced the very symptoms which they wished to
remove, * The patients became dyspeptic from real debility of the
stomach and the whole frame. You remember a general law of
pathology to which I have alluded on a former occasion, and
which I shall again mention, as it illustrates this point, namely,
that opposite states of the economy may be accompanied by the
same symptoms. Thus we observe, that palpitation may depend
on two different causes—on a sthenic or asthenic condition — on
the presence of too much or loo little blood in the heart. Now, it
frequently happened that patients, labouring under chronic gas-
tritis, and who had been treated for a long time after the strict plan
adopted by the Broussaists, finding themselves not at all improved,
went to other physicians who had different views, and were rapidly
cured, by being put upon a full nutritious diet. In this way numer-
ous cases, which water-diet and depletion had only aggravated,
were relieved, and the consequence was, that a mass of facts was
brought forward and published, not long since, by a French author,
against the antiphlogistic treatment of dyspepsia and chronic gas-
tritis. It must be stated, however, that the cases which he pub-
lished were chiefly those in which the depleting system had been
carried to excess, and that they cannot, therefore, be received as
* [For additional means of producing counter-irritation, see my
lecture on chronic rheumatism.—B.J
TREATMENT OF CHRONIC GASTRITIS. 135
proofs of the value of a stimulating diet in the treatment of chronic
inflammation of the stomach. Bear this in mind; the sooner you
can put your patient on a nutritious diet the better will it be for
him. It would be absurd to keep a patient for many months, as the
Broussaists have done, on slops and gum-water. It will be neces-
sary for you to feel your way and improve the diet gradually.
Commence by giving a small quantity o( mild nutritious food ; if
your patient bears it well, you can go on; if the gastric symptoms
return, you can easily stop. If a small portion df the milder species
of food rest quietly on the stomach, you may increase it the next
day, or the day after, and thus you proceed to more solid and
nutritious aliment, until the tone of your patient's stomach regains
the standard of health. Never lose sight of this fact, that you may
have a case of dyspepsia depending on a chronic gastritis, in which,
though you remove the inflammation by a strict antiphlogistic treat-
ment, you may not by this remove the dyspepsia; and if you con-
tinue to leech, and blister, and starve your patient, after the inflam-
matory state be removed, you will do great injury. Such a patient,
falling into the hands of another practitioner who treated him on a
different system, might be relieved, and his case quoted against you
and your treatment, though this, at the commencement, was judi-
cious and proper.
With respect to internal remedies, the school of Broussais think
that there is nothing required but cold water and gum. This is
going too far. In a former lecture, I have drawn your attention to
the fact, that in the treatment of acute inflammation there is a
point where antiphlogistics should cease, and where tonics and
stimulants are the most efficient means of cure. Of this fact, the
disciples of Broussais appear to be ignorant, and they consequently
declare against every remedy for chronic gastritis except leeches
and cold water. Now, is this right? I think not. We find that,
in all cases of gastric inflammation, a change in medication seems
to be useful at some period of the disease, that is a change from
antiplogistics to tonics and stimulants, and I believe that in cases
of chronic gastritis these remedies may be used with very great
advantage, having, of course, premised depletion and counter-irri-
tants. I believe, too, that most of the remedies, which we see every
day unsuccessfully employed, would have acted beneficially, if the
preparatory treatment, which I have mentioned, had been adopted.
Among the best remedies of this kind is the oxide of bismuth; I
have seen more benefit from the use of this than of any other
medicine, after the treatment already alluded to. Generally speak-
ing, the list of internal remedies for chronic gastritis is very small,
but after the use of antiphlogistics, you may prescribe the vegetable
tonics and oxide of bismuth with advantage. The most decidedly
valuable remedy, however, in the after stage of a chronic gastritis,
is the acetate of morphia, which, I am convinced, has a very
powerful effect in allaying chronic irritation of the stomach. Dr.
Bardsley, of Manchester, in one of his published works, entitled
136
DISEASES OF THE DIGESTIVE SYSTEM.
" Hospital Facts and Observations," adduces many cases of gastric
irritation which were completely relieved by the use of this remedy,
and I am perfectly satisfied of the truth of his statements. It may
be said that Dr. Bardsley's cases were only instances of dyspepsia.
But as his cases were extremely numerous, some of them of long
standing, and the symptoms very severe, the great probability is,
that some of them at least must have been cases of chronic gas-
tritis. I know very few books, the perusal of which I would more
strongly recommend to you than Dr. Bardsley's accurate and
instructive work. The great besetting sin of medical writers is,
that their statements of successful practice are grounded on a very
limited number of cases, or that, in publishing the result of their
practical investigations, they only give their successful cases, and
leave out those in which the treatment recommended has been
found inefficacious. Yet this is a circumstance which should
never be neglected. If a man declares that he has discovered a
cure for gastritis, or dyspepsia, and brings forwards one hundred
cases in which the remedy has done good, the statement is still
unsatisfactory and insufficient, because there may be one thousand
cases in which it has totally failed. Unless he comes forward and
gives both his successful and unsuccessful cases, of what value are
his statements ? Dr. Bardsley, with the candour and good sense
which always characterize the philosophic inquirer, gives the
result of all his cases, forms them into tables, and then leaves his
readers to judge for themselves. From an inspection of these
tables, you will be convinced of the efficacy of acetate of morphia
in the treatment of chronic gastritis. I have been in the habit of
using it with the most gratifying results after leeching, regulating
the diet, and paying proper attention to the state of the bowels.
There are some forms of the disease in which it is more useful
than others. The particular form, in which it proves more service-
able, is where there is a copious secretion of acid from the stomach
(that form in which all kinds of alkalies have been exhibited),
where severe pain and constant acidity are the prominent symp-
toms. Here I have seen the acetate of morphia act exceedingly
well. You may begin with one-twelfth of a grain, made into a
pill with crumb of bread, or conserve of roses, twice a day; the
next day you may order it to be taken three times, and you may
go on in this way until you make the patient take from half a
grain to a grain and a half in the twenty-four hours. I shall here
mention the circumstances of a case, which I do not mean to bring
forward as an instance of cure, but as an illustration of the extra-
ordinary power which acetate of morphia possesses in relieving
gastric irritation. A gentleman of strong mind and highly culti-
vated intellectual powers, which he kept in constant exercise, got
a severe chronic gastritis; his appetite completely declined; he
had frequent vomiting of sour matter; fetid eructations ; and such
violent pain in the stomach, that he used, when the attack came
on, to throw himself on the ground, and roll about in a state of
TREATMENT OF CHRONIC GASTRITIS. 137
indescribable agony. He applied to various practitioners, had
several consultations on his case, and the opinion of the most
eminent medical men was, that he had incurable cancerous disease
of the stomach. These symptoms continued for several years, but
for the last two or three years they were quite intolerable. He
had repeated cold sweats, vomited everything he took, even cold
water, was reduced to a skeleton, and led a life of complete torture.
Under such circumstances he tried for the first time, by my advice,
the acetate of morphia. He tried it first in doses of one-tenth of a
grain three times a day, and experienced the most unexpected
relief. On the third day all his bad symptoms were gone. He
had no pain, no vomiting, no sweats ; his spirits were raised to the
highest state of exhilaration, and he thought himself perfectly
cured. He went out in the greatest joy, visited all his friends, and
told them that he had at last got rid of his tormenting malady. In
the evening he joined a supper party, indulged very freely, and
next morning had a violent hematemesis, to which he had been
for some time subject. All his old symptoms again made their ap-
pearance. He again had recourse to the acetate of morphia, and
again immediately experienced relief, but the vomiting of blood
again returned, so that he discontinued the remedy. This gentle-
man is now in the enjoyment of good health. He regulated his diet,
left off all medicine by the mouth, used warm water injections, and
thus recovered from his supposed cancer.
I do not bring this case forward as an instance of the curative
effect of acetate of morphia, but as an instance of its powerful
effect in allaying gastric irritation. I could adduce other cases in
proof of its value in the treatment of the after stage of chronic
gastritis, and particularly of that form in which pain and acidity
are the prominent symptoms; but I perceive my time has nearly
expired.
Friction with croton oil — Attention to diet during convalescence — Organic dis-
ease of the stomach —Principles of treatment— Diet and attention to the
bowels— Duodenitis —Inflammation of the jejunum.
In speaking of the employment of counter-irritation in cases of
chronic gastritis, I forgot to mention the use of friction with croton
oil which has been found beneficial in many cases of chronic
inflammation. It has been extensively used by many practitioners
in the treatment of chronic affections of the joints, and in various
forms of pulmonary disease ; and I have employed it myself in
some cases of chronic gastritis with benefit. I cannot say that the
cases "m which I have used it presented all the symptoms o'f chronic
gastritis, but they were certainly cases of chronic gastrodvnia, with
severe local pain, nausea, and loss of appetite. It is an'excellent
counter-irritant, and gives verv little pain. The mode in which I
employ it is this — take a few drops of croton oil, five or six, for
instance, drop them on the epigastrium, and rub them in with a
1^*
L38
DISEASES OF THE DIGESTIVE SYSTEM.
piece of lint or bladder, interposed between your finger and the
skin, and the next day you have an eruption of small papulae,
which you can increase at will. There is one interesting circum-
stance connected with the use of croton oil frictions, which you
should be made acquainted with. The liability to produce counter-
irritation, seems to depend upon the absorption or non-absorption
of the croton oil; if it be absorbed it will purge, but if it be not it
will produce counter-irritation. In cases of this kind, therefore,
where it produces the necessary degree of irritation in the skin, the
chances are, that it will not act disagreeably by bringing on ca-
tharsis. I have only seen one case where there were both the
eruption and catharsis. This was a gentleman who had lately
suffered from dysentery in warm climates.
I may also mention, that, in convalescence from an attack of
chronic gastritis, you must pay great attention to diet for a long
time, because there is no affection of any organ in the body, in
which an error in diet so rapidly induces a return of the original
symptoms, as in diseases of the stomach, while each return of the
disease renders the attack more dangerous and unmanageable, until
at last disorganization takes place.
This leads me to speak of organic disease of the stomach. On
this subject I shall be very brief; the best mode of communicating
information will be to exhibit these preparations; you will derive
more instruction from their inspection than from any lecture I
could deliver. (Dr. Stokes here exhibited a number of beautiful
preparations from the Park street museum, illustrative of various
organic lesions of the stomach.) Here is a case, which some pa-
thologists would call cancer, others chronic gastritis. I may
remark here, that pathologists are divided as to what is the cause
of cancer of the stomach, but the best informed are of opinion that
in those cases of gastric disorganization which are called cancer
or scirrhus, all that can be demonstrated by the knife is referable
to the results of chronic inflammation. This is a different propo-
sition from saying that chronic inflammation alone will produce
cancer. As yet we know little of cancer; dissection of cancerous
organs gives but scanty information; but this seems certain that,
in particular conditions of the economy, an inflammation of the
stomach will end in cancerous disease. Here is an excellent pre-
paration of the stomach of a person who died of cancer of that
organ. For several years before his death he had a jaundiced
look, an emaciated appearance, frequent vomiting, and severe pain
towards the termination of the digestive process, a circumstance
which denotes disease of the pylorus. He also had hematemesis.
You see the inner surface in the vicinity of the pylorus presents
ulcerations of the mucous membrane and thickening of the sub-
mucous cellular tissue. The pylorus itself does not appear to be
at all contracted, but the parts around it are in a state of extraordi-
nary disease. Look at the preparation again, and say what could
bitters, or acids, or alkalies, or tonics, have effected 'in a case of
ORGANIC DISEASE OF THE STOMACH. 139
such extensive disease. Here is a stomach in a state of long con-
tinued chronic inflammation, and exhibiting lesions, which some
would designate as cancer of that organ. Now, though I do not
know the treatment which this patient underwent, I would venture
to say that he took plenty of the usual anti-dyspeptic medicines.
Yet, in a vast number of cases, where enormous quantities of these
remedies are taken daily, the stomach is in as bad a state as that
preparation exhibits, and I feel the more strongly convinced of this,
because I am aware that many persons die after having gone
through the whole routine of anti-dyspeptic practice, and, when
they are opened after death, incurable disease of the stomach is
discovered. Here is an example of vast cancerous disease of the
stomach ; here is a very interesting specimen of chronic gastritis,
chiefly representing a most remarkable and circumscribed ulcer at
the termination of the stomach. Here you see is the ulcer, with
raised, thickened, and introverted edges. Now, in all probability,
this ulceration was exceedingly chronic, for you perceive nature
has been at work with it, and has made some attempts at repara-
tion. It is in such a case as this that patients generally refer their
pain to a particular part of the stomach: digestion goes on without
any pain until the food reaches a certain point, when acute pain
is felt, and this continues until it is relieved by vomiting. The
occurrenceof this symptom, after an attack of acute gastritis, would
lead you to suspect the formation of one or more ulcers, and the
persistence of this localized pain should induce you to persevere in
employing every means in your power calculated to remove the
disease. The preparation which I now exhibit is interesting, as it
shows the effect of corrosive poison on the stomach. The patient,
to whom this stomach belonged, died in consequence of swallowing
a quantity of sulphuric acid ; here you see the consequences — the
mucous membrane is black and disorganized, exhibiting this ragged
appearance. In some cases of malignant fever we have found
the stomach presenting somewhat similar appearances; and the
same state of the stomach is described by some writers as occur-
ring in cases of intertropical fever. Here is a preparation which
you should inspect; chronic gastritis with a large ulcerated patch
in the centre of the stomach. Here is another example of extensive
cancerous disease.
A very few words will suffice for the state of the science on the
subject of cancer of the stomach. It is very hard, nay, even almost
impossible, to draw a line of distinction between the symptoms of
cancer of the stomach and chronic gastritis, and I believe it is ad-
mitted on all hands that the same causes give rise to both. Long
continued irritation will, in one case, produce cancer of the sto-
mach, in another, chronic gastritis. Again, it is admitted by many,
that what is called cancerous ulceration of the stomach has no
appreciable difference from ulceration in various other organs ; and
hence some other persons have gone so far as to say that there is
no such thing as cancer of the stomach (separately considered);
140 DISEASES OF THE DIGESTIVE SYSTEM.
and that all the cases adduced of it are nothing more than so many
forms of chronic gastritis. In the present state of medicine, we
are not, indeed, possessed of any data which would enable us to
come to a final determination on this question. It is certainly im-
possible to determine this point; but if there be anything peculiar
in cancerous matter, similar to tubercular or melanotic matter,
there is no reason why, under the influence of inflammation, it
should not be developed in the stomach as well as in any other
part of the body. But whatever views we entertain on this subject,
we must confess that, in the majority of cases, there is a chronic
gastritis, and that the principles of treatment which would alleviate
the patient's sufferings and prolong life, are those which are calcu-
lated to prevent the occurrence of gastric inflammation. The more
you approximate the treatment of cancer to that of chronic gastritis,
the greater comfort will you afford your patient, and the more will
you prolong his existence.
The most celebrated case on record of this affection is that of the
Emperor Napoleon. He died with extensive ulceration of the sto-
mach, which, of course, was called *' cancerous," and there were
also distinct traces of disease of the liver, the mucous coat of the
intestines, and the lungs. His disease was believed by himself to
have originated in the stomach, and to this opinion he adhered,
notwithstanding the results of some solemn consultations, at one of
which his affection was declared to be an " obstruction of the liver,"
with a " scorbutic dyscrasy." At another it was pronounced to
be a " chronic hepatitis," and a course of mercury recommended!
When we reflect on this, and read in the account by Gaubert,
(which you will see in the Examen des Doctrines Medicates,) the
regimen which was used, and the list of stimulating medicaments
employed, you will not wonder at the words of this great man,
when he was pressed to take more drugs, to swallow the universal
nostrum, mercury, to which he had the greatest aversion. " Your
disgusting preparations are good for nothing. Medicine is a col-
lection of blind prescriptions, which destroy the poor, sometimes
succeed with the rich, but whose whole results are more injurious
than useful to humanity." But he got mercury, notwithstanding,
mercury for his " digestive organs ;" to " excite the liver ;" to " re-
move its obstruction," and mercury to create bile, and purgatives
to remove it; and tonics, and antacids, and stimulants; and he
died in torture, and his body was opened, and the stomach was
found " cancerous."
I should not omit mentioning to you, that in those cases of
chronic gastritis which run on to an incurable stage, the best
treatment consists in a careful regulation of diet, in keeping the
bowels open by enemata, or the very mildest laxatives, and in
avoiding everything capable of producing excitement. You will-
also derive advantage from the employment of gentle counter-
irritation, and from the internal use of narcotics, which in such
cases appear to have a more beneficial effect than any other class
DUODENITIS.
141
of remedies. With the exception of these, I do not know any
other kind of medicine you can safely employ? and I believe that,
in the majority of cases, you will find that the patients have taken
already too much medicine. Anxious for relief, and urged on by
the hope of obtaining some remedy capable of relieving their suf-
ferings, they have recourse to every grade of quacks, are persuaded
to swallow every kind of drug, and are subjected to every form of
harassing and mischievous treatment. The diet which you pre-
scribe for such patients should be sparing but nutritive; give the
stomach as little to do as will be consistent with the support of life
and strength; and you may take it as a general rule in the treat-
ment of all chronic affections of the digestive tube, whether cancer
of the stomach, scirrhus of the pylorus, or stricture of the intestines,
that there are two great principles of general application — preserv-
ing a gently open slate of the bowels, and allaying inflammatory
excitement.
Duodenitis. — Let us now proceed to the remaining parts of the
digestive tube, of which the next in order is the duodenum. I shall
not dwell much to-day on the subject of duodenitis; as I shall revert
to its consideration when speaking of jaundice, because inflamma-
tion of the duodenum is a common cause of jaundice, perhaps the
most common, if we take the whole of its cases together. You are
not to suppose that I wish to inculcate the doctrine that jaundice is
a necessary complication in duodenitis, but it has been proved that
there is an extraordinarily frequent coincidence between both, and
that jaundice very often seems independent of any mechanical
cause, such as an obstruction of the biliary ducts. So far from this,
that, in some cases, particularly those which are produced by, or
accompany, a duodenitis, we have intense universal jaundice at the
same time that the bile is flowing freely into the digestive tube.
The researches of the immortal Bichat gave the first hint which
directed the attention of practitioners to the circumstance, that, in
many cases where jaundice had existed during life, there was no
obstruction or disease in the liver or biliary ducts, but that in such
cases there was always more or less inflammation in the part of
the digestive tube into.which the bile was immediately discharged;
and this led ultimately to the discovery of the connection which
exists between inflammation of the duodenum and jaundice. In
treating of the sympathies which depend upon continuity of surface,
Bichat refers to the connection which exists between the surfaces
of mucous membranes and the ducts which open on them, and en-
deavours to show that the natural mode of excitement in all secre-
ting glands is a stimulus applied to the surface on which their
ducts open. As examples of this, he instances the effect which
food and other substances, applied to the mucous membrane of the
mouth, have in stimulating the salivary glands; the effect which
stimulants applied to the conjunctiva, or nose, have on the lachry-
mal gland, and many others. Hence Broussais concludes that,
when the mucous surface of the duodenum is thrown into a state
142
DISEASES OF THE DIGESTIVE SYSTEM.
of excitement, we may have a consequent affection of the liver,
for the duodenum bears the same relation to the liver as the mouth
does to the parotid glands. That this is frequently the case, I think,
is very probable. It is now established, that the cause of the yellow-
ness in what has been called yellow fever, is disease of the upper
part of the digestive tube, in which the duodenum is always in-
volved; and that the fever itself (the typhus icterodes of the no-
sologists) has been found to be greatly connected with inflammation
of the stomach and duodenum. During the epidemic of 1827, we
had in the Meath Hospital a great many cases which bore a
striking resemblance to the yellow fever of warm countries, and
particularly in this, that they were accompanied by intense jaundice,
and inflammation of the upper part of the digestive tube. You
will see in the works of Rush and Lawrence, two of the best
American writers on yellow fever, that, of the numerous bodies
they examined, there were scarcely any in which the jaundice
was found in connection with liver disease, but that in all cases
there was intense inflammation of the digestive surface. I shall
return to this subject when I come to speak of liver disease.
With respect to the jejunum, I may state that we know very
little of the symptoms which characterize inflammation of this
part of the intestinal canal; and it is a curious pathological fact,
that this portion of the tube is, of all others, the least liable to in-
flammation.
In point of fact, we have no means of ascertaining what are the
prominent symptoms of inflammation of the jejunum, because, in
almost every case in which jejunitis has been discovered, there has
been also extensive disease of the rest of the small intestine. We
have cases of simple gastritis; there have been also cases of dis-
tinct disease of the duodenum. We may have disease in the lower
third of the ileum, accompanied by an affection of any other part
of the tube. The same thing may occur in the case of the caecum,
colon, or rectum, but it seldom or never occurs so far as the
jejunum is concerned.
LECTURE XII.
DR. BELL.
Dyspepsia.—Temperaments and Constitutions most liable to the disease__Habits
of life inducing it—Concomitant diseases—of brain, liver, skin, lungs, and
kidney—These are sometimes causes, sometimes effects of dyspepsia__A complex
disease, sometimes caused by, sometimes causing spinal irritation__Modifica-
tion of treatment required—Andral's case and reflexions—Dr. Chapman's
notice of chief causes—Tobacco, its injurious tendency and effects__Hio-h ex-
citement of brain in England and United States.—Dyspepsia with Morbid
Gastric Secretion—Pyrosis or Water-Brash—Its causes and treatment.—
Cardialgia,—its mixed nature and treatment—Mercury—Ioecacuanha—Sul-
phuret of potassa—Gunpowder.
Doctor Stokes has pointed out, with his usual judgment, the fre-
quent dependence of dyspepsia on chronic gastritis; but, in making
CAUSES AND CONCOMITANTS OF DYSPEPSIA. 143
this latter the subject of his lecture, he has not had scope for ex-
hibiting the various functional disturbances that give rise to and
keep up a state of the stomach which is not inflammatory, but
which entails on its possessor all the horrors of dyspepsia or indi-
gestion. I shall endeavour, in this and the two following lectures, to
point out the chief causes and concomitants of this disease, or series
of disorders, and the remedies best adapted to the particular classes
of cases.
Causes and Concomitants. —Dyspepsia, that kind of functional
derangement which interferes with the conversion of aliment into
chyle, is found in all temperaments, but more in the sanguineo-
nervous and the nervoso-bilious than in others. The purely lym-
phatic and the nervoso-lymphatic are less frequently sufferers, and
when attacked their cases are more readily cured than those of the
other temperaments just indicated. In some the stomach suffers
by irregular innervation,— its nervous system at times over-excited,
and at others wanting its appropriate nervous stimulus, — as we
see in nervous and hysterical persons of either sex, for hysteria in
all its essential phenomena is far from being confined to females.
Persons of this class, particularly if they are of a rheumatic dia-
thesis, often suffer from a sudden transference of irritation to the
stomach, with pains and cramp. So, also, we can readily believe
that there is, at times, an original deficiency in the secretion of
gastric juice, just as there is of cutaneous or renal secretion : and
that, although the stomach is fully competent to digest, in limited
quantity, any kind of food, yet it suffers if more is introduced in
it. This state of things, we have reason to believe, exists where
the digestion is very slow, but without pain, eructation, heat, thirst,
or distress of any kind during the entire period from ingestion to
defecation.
Of the acquired predispositions, that induced by sedentary life in
a constrained posture, with the mind intent on some exclusive sub-
ject, and its possessor inhaling a close or impure air, merits the
first notice. Of the exciting causes which operate directly on the
stomach, the continued use of alcoholic liquors is entitled to con-
spicuous mention. Dr. Beaumont has shown, in his experimental
observations on Alexis Martin, that all these drinks irritate the
gastric mucous membrane and pervert the secretion of gastric
juice. The same remark applies to spices and condiments, and
in degree to coffee and tea. Of course, therefore, whatever may
have been the habits of the patient anterior to disease, he is bound
to desist from all these articles when he is actually suffering under
it — provided he is honestly intent on getting cured. Impure air,
which I have mentioned as a predisposing, is also frequently a
powerfully exciting cause of dyspepsia ; so much so, indeed, that I
should dread its secondary effects on the stomach more than its
primary ones on the lungs, even though the latter were also weak
and predisposed to disease. Late hours, deprecated for the invalid
by physicians and writers of hygiene, are chiefly hurtful, if he
144
DISEASES OF THE DIGESTIVE SYSTEM.
be exposed, as in a crowded company, or even in his own room
or study, to close, impure and imperfectly renewed air. Imperfect
atonement for this kind of exposure is made by those who pass the
night in a close and badly ventilated chamber.
Among the concomitants, which are sometimes causes and some-
times effects of the disorder of the stomach constituting dyspepsia,
may be enumerated derangements in the functions of the brain,
skin, lungs, uterus, and kidneys.
Continual excitement of the brain in the mere exercise of intel-
lect, and, still more, in the conflict of passions, exerts a prejudicial
influence over the stomach, and is a too common, though not yet
sufficiently recognised cause of dyspepsia. Nor is the evil con-
fined to those whose aspirations are for this world's wealth and
honours alone. An over-heated imagination, extreme direction of
the feelings to the subject of religion, intentness on doctrinal dis-
quisitions, devotion to an excessive routine of external observances
and the acerbity of sect, in place of the active discharge of per-
sonal and social duties under religious guidance, induce a morbid
state of the nervous system, which is often felt in irregular and
painful digestion. Persons, under these influences, are too prone to
forget that, in their eagerness to do what they believe to be ac-
ceptable to the Deity, by carrying out the various observances of
form, they act in direct opposition to the natural laws which are
also his, and a conformity with which is a necessary condition for
their enjoying health. They act, often, as if they believed that an
exception to these laws would be made in their favour; and that
meetings, night after night, during which they respired over and
over again the same close air, and transitions from these, in which
the heat was excessive within doors, to the outer air, and often amidst
the greatest inclemencies of weather, would not be productive of the
customary bad effects on the bodily frame, because their mental
was in such zealous exercise. If worship were penitential, instead
of the offerings of gratitude and entreaty for protection and aid, we
might admit that people are consistent in subjecting themselves
to present suffering and future disease by this voluntary privation
of air, and by over-excitement and subsequent languor and lassitude
of the body generally, and of the nervous system in particular.
Derangement of the hepatic function is a cause of dyspepsia, but
not nearly to the extent that it has credit for. I would' say that the
cause, when present, is adequate, but that it does not really exist in
a majority of those cases in which its presence is assumed. He-
patic disease is often, as I will show you hereafter, supposed to be
present when the real derangement is duodenal dyspepsia. The
circumstances of atmospheric exposure and of irregular living, in-
cluding errors both of physical and moral hygiene which bring on
hepatitis, are also well calculated to give origin to dyspepsia.
Great and manifold are the gastric disorders of all kinds, from
simple heartburn up to chronic gastritis,—which are produced
by impeded functions of the skin, by which I do not mean merely
CAUSES AND CONCOMITANTS OF DYSPEPSIA. 145
suppressed perspiration, but that low degree of vitality kept up by
continual exposure to cold and moisture and unclean things, without
adequate clothing and even common ablution. There is not a viscus
that does not suffer in every imaginable degree by this means, and
the stomach more, if we except perhaps the lungs, than any other. In
maritime exposures, and particularly if easterly winds are prevalent,
people are greatly troubled with dyspepsia, which assumes a variety
of shapes, and becomes so aggravated as to simulate scurvy itself.
Under such circumstances the morbid impression is first and chiefly
made on the skin.
The influence of the lungs in the process of digestion will be
generally understood by reference to their function of hematosis,
any impediment to which, by causing imperfectly elaborated blood
to circulate and reach the stomach, must modify injuriously its
vitality, and prevent the requisite secretion of gastric juice. In
another way, also, or by sympathy, the direct deleterious impression
of impure air on the mucous membrane of the lungs is transmitted
to the analogous membrane of the stomach,—both organs being
supplied by the same nerve, the par vagum—and both, also, having
other intercommunication by means of the ganglia and plexus of the
sympathetic. It is in these two ways that want of ventilation is so
injurious to the gastric function, and is so frequent a cause of
dyspepsia.
In the suspended or perverted function of the uterine system, as
in amenorrhoea and menorrhagia, and even in the plenitude of its
exercise, as in pregnancy, we have frequent occasion to note the
injury done thereby to the stomach, which is at these times singu-
larly, even for it, capricious and irregular in its appetites and powers.
Derangement of the uterine functions is truly a concomitant of
dyspepsia ; being at one time an obvious cause, at another an
equally evident effect of this latter disease. Nor is it by any means
easy always to declare the order of causation.
Impeded or perverted function of the kidneys is, we know, of late
years, a more common cause of disordered digestion than was at one
time dreamed of. The fact that it was a frequent effect of gastric
disorder we were tolerably familiar with, but it was reserved for the
more careful observations of modern pathology, aided by chemis-
try, to show that chronic disease of the kidneys, as in their state
of albuminous secretion, injures permanently the function of the
stomach. The sympathetic irritation transmitted by the kidneys, in
a state of acute inflammation, to the stomach, was noted by every tyro
in pathology,—I was going to say, by every reader of nosology.
A very slight knowledge of physiology, or observation of morbid
phenomena, prepares us to find all the organs already enumerated,
which cause, by their morbid state, dyspepsia, becoming themselves
functionally disturbed, and even undergoing lesion of tissue in con-
sequence of protracted gastric disease. Of gastric origin are the
depression, gloom, and terrors of the hypochondriac; as likewise
the irascibility and violent passionate excitement in other cases,__
vol. i.—13
146
DISEASES OF THE DIGESTIVE SYSTEM.
all manifesting a morbid state of the cerebral functions. Continued
irritation of the stomach and duodenum is a frequent cause of he-
patic derangement, which singularly aggravates the primary
disease. What a tribe of cutaneous disorders, to say nothing
of the perversion of the functions of secretion and absorption, and
the modification of sensibility of the skin, result from chronic disease
of the stomach in dyspepsia. So, likewise, we meet with a host of
disorders of the lungs, from simple hurried breathing after a full meal
up to confirmed phthisis pulmonalis, the consequences of gastric de-
rangements. When tubercles follow prolonged dyspepsia, as in
some cases they undoubtedly do, we must attribute this effect to the
imperfectly elaborated blood and interruption to nutrition, rather
than to a direct sympathetic irritation of the lungs with the stomach.
Continuing our illustrations,—we are able to point out the readiness
and frequency of uterine derangement after gastric disorder, and to
show how entirely obedient, in many cases, the uterus is to impres-
sions, at first morbid and afterwards therapeutical, made on the
stomach.
In all these cases the stomach, whether transmitting morbid im-
pressions to, or receiving them from other organs, may be in a state
of chronic phlogosis,or it may manifest functional disturbance without
organic lesion. Hence, although attention to the concomitants of
dyspepsia is of paramount importance, both in investigating this
disease and in aiding us to devise a proper treatment for its re-
moval, it alone will not indicate the actual condition of the stomach.
Nor will the remedies be always essentially Or materially different,
according as the dyspepsia is primary or the result of reflex irri-
tation on the stomach from some other organ. We may have, for
instance, dyspepsia connected with chronic gastritis from errors of
regimen directly affecting the stomach, or a similar morbid con-
dition from mental causes, an over-excitement of the brain indi-
rectly affecting the stomach. From the operation of the same
causes, direct and indirect dyspepsia may result, without any in-
flammation or equivalent morbid change of gastric mucous tissue.
In thus directing your attention to this large circle of morbid
associations with dyspepsia, and of its possible numerous causes,
my aim is to show the necessity of a careful inquiry into all the
antecedents of the disease which may have given rise to it, and
all the concomitants by which it may be supported. Dyspepsia is
a complex disease, the chief and most annoying feature of which is
generally, but not always, gastric distress and disturbance. The
stomach is often the centre for the radiation of irritations to nu-
merous other organs, whose functions are troubled in various ways;
but it is, also, often that centre to which converge irritations from
these same organs. At one time you will see it, by its transmitted
irritation, forcing the spinal marrow and its motor nerves into a
state of morbid excitement, evinced by irregular contractions and
spasmodic movements of some part of the muscular system; at
another, into indirect debility from prior excitement, and then
MODIFICATION OF TREATMENT IN DYSPEPSIA. 147
there is inability to move, — partial paralysis, in fact, in some of the
limbs. And again the stomach is itself the recipient of spinal
irritation, and it is tormented with pain and spasms, which disappear
with the removal of the primary disease.
The successful treatment of a disease, or one might say congeries
of diseases, such as dyspepsia is, must obviously be rational rather
than empirical: it must be also hygienic as well as therapeutical,
and often partake more of the former than the latter. He who
bases his treatment on the belief that dyspepsia is uniformly the
effect of chronic gastritis, is not more in error than he who con-
tends that the stomach in such cases is never inflamed, but that
its derangements of function depend on debility and imperfect or
irregular secretion of gastric juice. The duty of every physician,
who feels his responsibility as he ought, is, to ascertain, by a careful
observation of all the symptoms, whether the stomach of a dyspeptic
patient be in a state of chronic inflammation, or whether the disease
depends on transmitted irritation from other sources, but yet with-
out causing any organic lesion. If inflammation be present, then
will he refer to the excellent remarks in the two preceding lectures
by Dr. Stokes. In illustration of the other condition of things —
severe and even fatal dyspepsia without inflammation — you will
thank me for repeating the following case from Andral's Clinique
Medicale, as translated by Dr. Spillan, p. 871.
"A woman, thirty-eight years of age, entered the Pitie in the
month of April, 1831. She stated that since the last seven or eight
months she entirely lost her appetite; every time she took food she
felt an insupportable weight in Ihe epigastrium, and occasionally
rather an acute pain. From time to time she vomited some whitish
mucus. Strong pressure on the epigastrium produced no painful
sensation in this region. The remainder of the abdomen was soft
and free from pain; the patient was habitually constipated; tongue
natural; no disturbance of any other organ; the patient was very
much emaciated and very feeble. She mentioned that she had
begun to lose her appetite and her powers of digestion after having
been subjected to severe mental distress.
" We considered this woman as labouring under chronic gastritis,
and in consequence of the perfectly natural appearance of the tongue
we apprehended the existence of a cancerous degeneration of the
submucous cellular tissue. We prescribed milk diet, and esta-
blished a seton over the epigastrium. The woman wasted away
gradually, and eventually died without presenting any new symptoms.
Towards the latter period of her life she even refused to take milk,
and admitted nothing else into her stomach except a few spoonsful
of gum-water.
" Post mortem. The brain, lungs, heart, and abdominal viscera
were all found in a perfectly healthy state, as also the trisplanchnic
and pneumogastric nerves."
The reflexions on this case by M. Andral himself are so pertinent,
and at the same time corroborative of the strain of my own re-
marks, that I shall repeat them to you.
14S
DISEASES OF THE DIGESTIVE SYSTEM.
" Thus, in this case, anatomy was entirely unable to reveal to us
the cause of the symptoms and of death. This stomach, so very
much disturbed in its functions, was perfectly healthy in its texture.
" It was not therefore of chronic gastritis that this patient died;
for gastritis leaves behind it traces of its existence. Was there in
this case neurosis of the stomach, or atony of this organ? Who
could prove it? We know so little by what force chymifaction is
accomplished, that we cannot appreciate all the causes which pre-
vent its going on.
" On the other hand, the sympathetic connections between the
stomach and the other organs are so numerous, that the disturbance
of one of these organs must necessarily modify the functions of the
stomach, without this modification being necessarily an inflamma-
tion, or even simple irritation. May it not be in this respect the
same with the gastric mucous membrane as with the skin? And
in the course of most chronic diseases the cutaneous covering is
often found considerably modified in its several secretions, without
its being in the slightest degree inflamed or irritated; why, under
such circumstances, might not the functions of the mucous mem-
brane of the stomach be also more or less seriously altered 1 In a
word, by virtue of this wonderful law of synergy, of which the
animal economy presents us with such continual examples, it seems
that the functions of the stomach, in which the act of assimilation
commences, must tend to become suspended, for this sole reason,
that other organs of nutritive life (small intestine, lungs, liver, etc.)
have themselves ceased to fulfil their functions. Of what use in
fact would it be that chyme should* be formed, if the further changes
of the aliment could not be produced, if it could become neither
chyle, nor blood, nor an integral part of the tissues of the indi-
vidual? Professor Berard, of Montpellier, seems to have expressed
this idea with as much strength as accuracy, when he said that
the system digested by means of the stomach."
I have, in the remarks already made, anticipated much of what
would be regarded as belonging to the etiology of dyspepsia. The
causes more directly operating on the stomach, are errors in diet.
On this point, I shall borrow the expressive language of Dr. Chap-
man, who has given us an admirable paper on dyspepsia in the
Amer. Journ. of Med. Sciences, vol. xxv and xxvi. " The causes of
this affection are such as act directly in the stomach, or indirectly
through the intervention of other portions of the system. Of the
first, among the most operative, are indulgences in eatin^ and
drinking, so as preternaturally to stimulate or distend the stomach
— or the use of unwholesome or imperfectly cooked articles, or an
undue limitation of diet, as is practised to reduce obesity, or to sub-
due protracted diseases. The most opposite modes of living the
full or stimulating, or the penurious and abstemious in extremes,
are alike productive of indigestion."
*' The most pernicious articles in excess, are acid, vinous, malt,
or spirituous drinks, especially in the shape of punch, or stron°- green
tea, or coffee —exclusive vegetable matter, if it be crude or flatu-
CAUSES OF DYSPEPSIA.
149
lent — or gross animal food, whether fresh or salted, or smoked --
many of the condiments, and nearly all tne things included in the
term dessert.
"Taking, habitually, drugs, conduces to the same end, as the
frequent repetition of emetics or purgatives, or opiates, or other
narcotics. Tampering, however, with any medicine or medicines,
so much the practice with some people of valetudinary dispositions,
is very detrimental. Every ache or discomfort, real or imaginary,
must be relieved by a recurrence to some supposed remedy, till,
finally, the powers of the stomach are worn out, and derangements,
either functional or structural, take place."
On the detrimental effects of that vile weed, tobacco, which the
members of all the professions, the clergy among the foremost,
consume, as it were, in rivalry, the Professor holds the following
language: —
" The most common of the causes of disease, in certain parts of
our country, is the enormous consumption of tobacco in its several
forms. Certain I am, at least, that a large proportion of the cases
of it, which come to me, are thus produced. It is usually very
obstinate, and sometimes of a truly melancholy character. Easy
as it were to cite numerous instances to this purport, I must be
content with a limitation.
" By a member of congress from the west, in the meridian of
life, I was some time since consulted, who told me that he laboured
under the greatest physical and moral infirmity, which he was
utterly unable to explain, and that, from having been one of the
most healthy and fearless of men, he had become, to use his own
phrase,' Sick all over, and as timid as a girl.' He could not pre-
sent even a petition to Congress, much less say a word concerning
it, though he had long been a practising lawyer, and served much
in legislative bodies.
" By any ordinary noise he was startled, or thrown into tremu-
lousness, and was afraid to be alone at night. His appetite and
digestion were gone — he had painful sensations at the pit of the
stomach, and unrelenting constipated bowels.
"During the narrative of his sufferings his aspect was ghastly,
approaching the haggard wildness of mental distemperature. On
inquiry I found that his consumption of tobacco was almost incre-
dible, by chewing, snuffing, and smoking. Being satisfied that all
his misery ai ose from this poisonous weed, its use was discontinued,
and in a few weeks he entirely recovered."
Dr. Chapman relates other cases in which symptoms of delirium
tremens were induced by the use of this poison.
Even when it is not an exciting cause, it very often becomes a
predisposing one ; and the stomach and nervous system, deteriorated
by tobacco, are readily excited into open disease by some other
cause which, but for this morbid predisposition, would be either
relatively innocuous, or produce merely temporary disorder. Vain
will be our hopes of permanent cure, or even of marked amendment,
13*
150
DISEASES OF THE DIGESTIVE SYSTEM.
of dyspepsia, so long as the patient wilfully persists in the use of
tobacco.
Of external causes, compression of the chest and abdomen by
corsets is not an unfrequent one among females. Dr. Chapman
says that he is " habitually consulted for dyspepsia and its associate
affections assignable to this fantastic usage."
I have already adverted to the influence of the brain, through
the intense and exaggerated manifestations of its faculties, includ-
ing intellect, senthnents, and propensities, in the production of dys-
pepsia. With some slight modifications, the picture drawn by
Dr. Dick (On the Organs of Digestion : Philadelphia edition) of the
combination of the causes as operative in England, will apply to
the state of things in the United States.
" All the moral concurrents which are fitted to excite human
passion are rife in our country. A free government; unbounded
license to social and individual enterprise; an unrestricted press,
permitting zealots of all sorts to stimulate prejudice, political and
religious ; a daily press ministering, with systematic art, fuel to feed
the flame of parties; vast wealth in juxta-position with dire po-
verty; all the feverish anxieties and terrible reverses incident to
commercial adventures and negotiations, conducted on a scale
greater than elsewhere through the earth; perpetual monetary
fluctuations; an overpopulated country; wherein well educated
and respectable youth of both sexes cannot in many cases make
bread by honourable means, but are almost literally reduced to the
dreadful alternative to beg or die of want; high civilization and
refined education, by which the intellectual faculties are apt to be
cultivated at the expense of the physical, and the moral affections
to be quickened into a false sensibility, rather than fortified and
purified ; great religious and political fears and dissensions. Such
is the heated moral atmosphere in which the people of this country
live: and who can wonder that digestion, the earliest of all the
actions of the body to be affected by moral causes, should be, in
such circumstances, strongly predisposed and prepared for derange-
ment, on the appearance of exciting causes ?"
I regret to be obliged to say, that the remark which immediately
follows this passage is so strictly applicable to the United States,
which must divide with England the disgrace of neglect of such
paramount questions as those of mental and physical recreation, since
they are part of the grand problem of education, both in its physical
as well as intellectual and moral aspects.
" I have to add," continues Dr. Dick, " that there is in no civil-
ized country in the world in which the art and duty of mental and
physical recreation are less understood and less cultivated than in
this; and that, at the same time, there is none in which attention
to that art can be with less impunity dispensed with."
Dyspepsia with Morbid Gastric Secretions. — Noticing, first,
the forms of dyspepsia depending on morbid states of the stomach
itself, and passing over gastritis as already adequately commented
TREATMENT OF PYROSIS.
151
on by Dr. Stokes, we meet with the variety which consists in a
disease of the mucous follicles of the stomach, and hence it might
be called follicular dyspepsia. It is that form designated by the
term Pyrosis, or water-brash, — the leading symptom of which is
the discharge from the mouth, by eructation, of a tenacious, ropy
mucus, possessing sometimes acrid properties, preceded by a burn-
ing heat at the epigastrium. It is common and sometimes endemic
in the northern countries of Europe, and from time to time presents
itself among our dyspeptics at home. The persons most liable to
it are those°under middle age; it seldom appears before puberty,
and very rarely in advanced life. Females are more frequently
affected with it than males; and of the former, the single more than
the married, although it sometimes occurs during pregnancy. The
combination of cold and moisture with a poor diet, may be regarded
as a more common cause than any other. Extraordinary mental
emotions are, also, an occasional cause. I shall not detail the
symptoms which have been so well described by Cullen, and since
his time by every writer on Practical Medicine.
Treatment. — The treatment of pyrosis will consist of the occa-
sional administration of an emetic of ipecacuanha, to expel the
mucus which often remains for a length of time in the stomach,
and is the cause of irritation during all this period ; and also to
modify somewhat the secretion of the gastric mucous follicles.
Partly with the same intentions, and also to remove an occasional
accompaniment, costiveness, a laxative compound of blue mass
and rhubarb will be advisable, alternating with aloes and some
aromatic bitter. Astringents have had their eulogists, but, we
must believe, on speculative grounds, and under a belief that ex-
cessive discharge was the chief symptom to be combated. We
shall gain little, however, unless we remount to the original cause, —
a morbid state of the mucous follicles of the stomach, or, as some
would persuade, of the pancreas, the secretion from which, say they,
constitutes the matter discharged from the stomach. Opium has
been found useful, alone and in combination with soap or rhubarb
and extract of gentian. Linnaeus, who saw much of pyrosis,
recommended nux vomica in doses of ten grains three times a-day.
Granting the value of this remedy, it will be safer to prescribe it, in
the beginning, in much smaller doses. Strychnia, as an article of
uniform strength and easily measured, to the minutest dose, would
seem to be still preferable to the nux vomica. The success attending
the use of the sub or tris-nitrate of bismuth in gastrodynia, prompted
to trials of this medicine in pyrosis, and with results quite encou-
raging. Dr. Bardsley, of Manchester, (Medical Reports of Hospital
Practice,) believes it to exert a local and specific action upon the
organs of digestion, restoring the stomach to a state of vigour and
consequent healthy secretion, essential to the removal of the symp-
toms of acidity, spasm, and pain. Acetate of lead and spirits of
turpentine are also recommended on occasions. Baillie, who was
skeptical of the curative power of any medicine in this disease, tells
152
DISEASES OF THE DIGESTIVE SYSTEM.
us that a dracbm of compound tincture of benzoin, rendered misci-
ble, with mucilage, was found by him to be the most efficacious.
If we look for a radical change in the secretory apparatus of the
stomach, we must procure it by means of a regulated diet and
attention to the function of the skin. With this view acescent
vegetables, common fruits, much or imperfectly prepared fari-
naceous matter, fermented drinks, tea and coffee, condiments, and
smoked meat or fish, are to be abstained from, and in their stead a
small portion of plainly dressed animal food, with stale bread or
biscuit and milk, or milk and water and bread, sago, or arrow-root.
Cardialgia. — Akin to pyrosis is anorexia humoralis or pitui-
tosa of the nosologists, follicular gastric dyspepsia of some late
writers. The greater regularity of discharge of a viscid fluid in
the morning, and the addition of cramp and a sensation of gnawing
complained of in anorexia, are not, I think, grounds for any specific
difference between this and pyrosis, nor between either of these
again and cardialgia. The differences are more in the tempera-
ment and constitution of the persons affected, than in any organic
change or peculiarity of functional disturbance of the stomach.
They all exhibit the characteristic in common of pain with more
or less heat, and the secretion and discharge of a morbid mucus,
sometimes insipid, at other times acid and acrid. They belong
to the Diacrises of Gendrin (Traite" Philosophique de Medicine
Pratique, T. II.), and are regarded by Good, with all his fondness
for nosological refinement, as kindred disorders, the treatment of
which need not be studied separately. The painful sensation at the
cardiac orifice, as of heat and scalding, and which has given the
popular name of heartburn to cardialgia,\s often more an evidence
of the morbid sensibility of this region of the stomach than of any
peculiarly acrid qualities in the fluid secreted. Sometimes it is
manifestly acid, at other times neutral. The origin of this fluid is
not accurately determined; since by some it is regarded as a pecu-
liar morbid secretion ; by others the result of chemical change of
healthy secretion in the stomach, and by a third party, again, as a
depraved state of the gastric juice itself. We can hardly doubt
that cardialgia, marked as it is by morbid sensibility and morbid
secretion, may depend on different states, or at least degrees of
vascular and nervous irritation of the mucous membrane and
mucous follicles of the stomach. In one case there is merely a
morbid condition of the nerves of organic life, and accompanying
morbid secretjon, with but little exaltation of the nerves of animal
life or of sensation. In another these latter are greatly excited,
and the pain is considerable; while in a third, again, associated
with disorder both of secretion and sensation, we meet with capillary
excitement and incipient phlogosis.
Treatment. — Obviously must our treatment vary with the vary-
ing condition of the stomach in these cases. Simple nervous car-
dialgia— some pain and acid eructation and vomiting, without
increased heat of skin or activity of pulse, will require opiates and
TREATMENT OF CARDIALGIA.
153
other narcotics, or preferably quinia and iron and bitter tonics, in
alternation with carbonate of ammonia and other antacids. If,
on the other hand, the fluid be acrid, and evidences of morbid
irritation be present, so far from discountenancing the use of her-
baceous vegetables and an acidulous diet, which were prohibited
in the first variety, these may be even recommended with good
effect. In morbid capillary excitement of the gastric mucous mem-
brane, manifested by a red tongue, tenderness of the epigastrium, dry
skin, and an ever-craving thirst, leeches below the ensiform carti-
lage ought to precede other treatment. Inability to procure these,
or prejudices against them, will authorise the substitution of a suc-
cession of small blisters in their place. After this, if the disease is
not cured, we have recourse to other general means adapted to the
presumed state of the organ and its mucous secretors.
Mercury is generally prohibited in dyspepsia, but on a very im-
perfect pathology of this disease. No doubt that, in strumous
habits and in nervous temperaments and subjects, in whom the skin
is cold, and there is little or no vascular excitement, — the tongue
moist and clean or simply loaded, and the urine secreted in its
customary abundance,—mercurial preparations are seldom called
for, indeed ought to be withheld. But in more mixed cases of
excitement with morbid secretion, dry, and occasionally hot skin,
and imperfect renal discharges, small doses of the blue mass, or of
this with ipecacuanha, or mercury with chalk, will exert a very
beneficial effect. In making this remark, let me add, however, a
caution against continuing this medicine, or giving it in such doses
as will affect the constitution.
Ipecacuanha, made popular by Daubenton, has since his time been
much used by practitioners in the treatment of dyspepsia, when cha-
racterized by morbid sensibility and depraved gastric secretions. The
French practitioner just mentioned,gave the medicine in small doses,
or from a quarter of a grain to two grains early in the morning
fasting. Dr. Thomson was accustomed to divide a full dose of
ipecacuanha into several equal parts, which he directed to be taken
in the course of twenty-four hours. This article is sometimes con-
veniently combined with an aperient, sometimes with an alkali.
Both these indications may be fulfilled by its union with rhubarb
and soap, as in the following prescription: —
R. Pulv. Ipecac, gr. xii.
Pulv. Rhei,
Sapon. aa. 2ss.
M. ft. mass, in pil. xviii. dividend.
Give a pill morning, noon, and night. Where nausea is easily
excited, we ought to give in combination with it a little subcar-
bonate of ammonia, aromatic powder, cayenne pepper, or sulphate
of quinia. With this last, joined to ipecacuanha, I have had
frequent cause to be pleased, in the treatment of the forms of dys-
pepsia now under notice. The prevalence of acidity will call for
154 DISEASES OF THE DIGESTIVE SYSTEM.
lime-water, and if the system be in an atonic state, subcarbonate of
ammonia or aqua ammonia with the ipecacuanha.
The sulphuret of potassa is another remedy which has enjoyed
the credit of exhibiting a specific operation on the diseased mucous
follicles. It is given alone, when not contraindicated by too great
gastric sensibility, in doses of from a few grains to half a drachm,
or it is combined with subcarbonate of ammonia, bitter extracts,
aromatics, carminatives, or with rhubarb, aloes, pil. galban. comp.
I have at different times, in cases of dyspepsia with amenorrhoea,
derived very good effects from the combination of sulphuret of
potassa and sulphat of potassa with aloes, in such doses as to act on
the bowels. Sulphurous waters have been found to be efficient
remedies in the varieties of the disease now under notice,
For heartburn with eructations, gunpowder has been recommend-
ed by Dr. Dick (On the Digestive Organs, p. 128, Phil. Edit;) in very
decided terms. " Its effects are to heal the putrescent eructations
characteristic of this form ; to allay the sensation of heartburn ; to
restore the secretions along the whole intestinal canal, as is proved
by the production of healthy, easy, soluble, bulky stools. I am not
certain that I know one laxative that is a safer, surer, and more
gentle restorer of irregular and morbid intestinal action, than the
substance I now introduce to your notice. Its good effects, more-
over, are not confined to the intestinal tract. It restores, simulta-
neously, the action of the bowels, that of the skin, kidneys, and lungs.
During its employment, an occasional dose of castor oil or of
magnesia may be interposed." The gunpowder should be of a fine
quality, and ought to be taken dry, or in some glutinous vehicle, as
melasses, jelly, or a solution of gum.
LECTURE XIII.
DR. BELL.
Gastrodynia, or Gastralgia—Its symptoms—Diagnosis—Causes—Treatment-
Hygienic means the first to be attended to—Alleviation of pain—Caution respect-
ing stimulants—Draughts of hot water—Blending of gastritis and gastralgia—
Hydrocyanic acid—colchicum—emetic tartar in small doses—oil of turpentine
—subnitrate of bismuth—oxide of zinc—subcarbonate of iron—carbonated
chalybeate waters—nitrate of silver.—Periodical gastrodynia requires sul-
phate of quinia—Danger of alcoholic stimulants—Superiority of water as a
drink—Attention to the lower bowels—The kind of food proper—Regulation
of the cutaneous functions—Mental habits to be studied—Change of scene
and travel.
Allied to cardialgia by some of its symptoms, but best charac-
terised by excessive morbid sensibility of the stomach, and often
concomitant spasm or cramp, is gastrodynia, or gastralgia, the
irritable gastric dyspepsia of Dr. Todd (Cyclopsedia of Practical
Medicine), and the morbid sensibility of the stomach of Dr. Johnson.
In the same case we may have a succession of morbid states
GASTRODYNIA.
155
indicated first by the symptoms of pyrosis, then those of cardialgia,
and, finally, of gastrodynia. This last is sometimes a termination,
also, of common inflammatory dyspepsia.
Gastrodynia is marked not only by a pain in the stomach but by
the varieties of this pain, which is at one time acute and gnawing,
at another obtuse, and again burning, as in cardialgia. It may be
brought on and sometimes alleviated by eating. It is relieved, but
not uniformly, by pressure. On occasions, the morbid sensation con-
sists of coldness, or of itching, tickling, or formication. Its accom-
paniments are often yawning, anxiety, feeling of fulness and tension,
and pulsation at the epigastrium. Its usual time of paroxysmal ac-
cession is early in the morning, or any time after midnight. The
slightest causes, — physical or moral, — an unpleasant dream, unex-
pected news, the impression of cold, a simple change of posture,
will suffice to bring it on, or to aggravate it when present. Ab-
normal sensations, often of an exquisitely painful nature, are com-
plained of in other organs, sometimes coincident with, but more
commonly replacing, the gastralgia; such are pain of the head,
alternations of heat and cold on the cutaneous surface, horripilation,
frequent palpitation, distention of the abdomen, feeling of suffocation,
being strangled, &c. Spasmodic pain in the uterus, bladder, or
urethra, or neuralgic pain in some part of the body, in the uterus,
testicles, or rectum ; frequently a fit of hysteria, sometimes even
symptoms of hysteria in men supervene. Or the patients may feel
restless and unquiet, or be seized with a fit of depression, or of un-
governable impatience or anxiety. These symptoms generally termi-
nate with digestion, but may be renewed by taking the mildest food.
They are usually accompanied with coldness of the extremities; and
early in the attack a discharge of pale limpid urine takes place.
The appetite is capricious, often voracious, sometimes wanting,
or craving unaccustomed articles. The tongue is pale and moist,
at times covered with a mucous coat and larger than natural.
Although underactive irritation it may be dry, yet no thirst is com-
plained of. There is, in fact, a deficiency of saliva, but the patient
is endeavouring to get rid of a white frothy secretion which covers
the tongue and lips. At times the tongue is furred as if, to use the
comparison of Dr. Todd, a fine white gauze were thrown over it:
"sometimes it is covered with a thin, milky-white fur, as if the
patient had just been drinking milk, and sometimes it is besmeared
with a thin frothy mucus." In a majority of cases the bowels are
obstinately constipated.
So exquisite, after a while, is the sensibility of the stomach, that
not only does it receive the impression from the ingesta when swal-
lowed, and in their mutation into chyme, and the passage of this into
the duodenum, but, also, as a Parisian lady suffering under the
disease told Pinel, it feels pain, pleasure, and all the moral affec-
tions. A disobliging look struck her sensibly, as it were, on the
stomach, — " I think even by the stomach," was her expression.
Diagnosis.—Gastralgia, or gastro-enteralgia, has often been con-
156
DISEASES OF TFIE DIGESTIVE SYSTEM.
founded with gastritis and gastro-enteritis. Sometimes the two
diseases attack at the same time, and then it is not easy to un-
ravel the complications. In a majority of cases, however, the
symptoms are sufficiently contrasted to enable us to establish a
correct diagnosis. Thus, the natural or pale and moist tongue in
gastro-enteralgia contrasts with the red and furred appearance of
this organ in gastritis. In the latter the appetite is deficient or
wanting entirely, and there is an aversion both to stimulating food
and drinks, which are often sought for with avidity by the gas-
tralgic patient. When vomiting occurs in gastro-enteralgia it
is of glairy mucus and simple fluids, — in gastritis it is of ali-
mentary substances. There is no thirst, the skin is soft and satiny,
and of a natural temperature, the pulse natural or slow, fever, if
it appear at all, is intermittent and with morning paroxysms in
gastro-enteralgia. In gastro-enteritis, on the contrary, the thirst
is troublesome, the skin is dry and harsh and often hot, the pulse is
frequent and the fever continued, or if it exacerbates, it is in the
evening. The physiognomy is little changed, and the fulness of
habit not materially reduced in gastro-enteralgia, whereas the fea-
tures have a parched appearance, and the complexion is muddy,
and there is often great emaciation in gastro-enteritis. The dispo-
sition, often singularly altered, the patient becoming fitful and
irascible, in gastralgia, is little affected in gastritis. The diagnosis
in the former is obscure, and the prognosis favourable ; in the latter
the diagnosis is easy, and the prognosis is of an unfavourable
nature. Between gastralgia and pneumonia in anemic habits it is
not easy at first to distinguish, when the pains in the former dart,
as they sometimes do, through the chest and impede respiration,
and are accompanied with cough.
Causes. — Various are the causes of gastralgia. Among those
depending on errors in the use of ingesta the most conspicuous is
poor and indigestible food, as restriction to potatoes, from which
cause the Irish peasantry are often afflicted with this disease and
pyrosis, and to oatmeal, which produces similar effects on the
Scotch. The poor in large cities are frequent sufferers in this
way, — and certainly in their case the chief cause is stint quan-
tity and unwholesome quality even of the food which they do par-
take of. Long fasts come in as a powerfully contributing cause
with those persons already enfeebled, even when their scanty nutri-
ment was taken regularly. Sudden transitions from high to low
living, and even refinement in restricting one's-self in the choice of
food, are recognised causes. Certain ingesta, as green tea and
coffee, drastic purgatives, interruption in the use of narcotics, as of
opium and tobacco, also bring on this disease. Small, however, is the
temporary discomfort from ceasing to use these narcotics, compared
to the manifold ailments and distresses which follow in their train,
in certain temperaments, such as the irritable or nervous, who are
so open at any time to an attack of the disease. In such persons,
moral causes, as anxiety, jealousy, morbid indulgence of senti-
TREATMENT OF GASTRALGIA.
157
ment, &c, are apt to induce gastralgia, which reacts with fearful
force on the temperament and morbid frame of mind, aggravating
all their ills, and investing common events with the most malign
features. Exhausting discharges, as by hemorrhage or venesec-
tion, predispose the stomach to be perniciously affected by cer-
tain articles, which, although of difficult digestion, would hardly
have displayed those morbid effects but for the predisposition thus
induced. Transmitted irritation from other organs, of which I
spoke in the beginning of this lecture as causes of dyspepsia, some-
times brings on gastralgia of considerable intensity. Such are
dysmenorrhea, leucorrhoea, pregnancy, hysteria, inflamed kidney,
strictured urethra, irritable testicles, and other painful local com-
plaints.
Treatment. — A knowledge of the causes of gastralgia, or gastro-
dynia, will suggest much that is necessary and useful towards its
cure. Errors in regimen must be corrected, by the substitution of
nutritive for poor food ; of that easy of digestion, for the crude and
the gross: abstinence from noxious beverages is to be enjoined;
and the entire mode of living altered or brought back to the stand-
ard sanctioned by general experience, as deduced from sound phy-
siology and hygiene. Under these heads are included a due control
of and direction to the feelings, healthy occupation of mind as well
as of body, and an avoidance, of course, of all excesses and extremes,
whether of mere sensual indulgence, or of privation from a mis-
taken sense of duty. The hygienic means of cure, instead of being
regarded as secondary or incidental, ought to have the precedence
over the pharmaceutical, which, although they may alleviate and
soothe, and procure intervals of repose, are incompetent, alone, to
remove the disease.
The period at which gastralgia often makes its attack, early in
the morning, and when the stomach is empty of alimentary matter,
would naturally suggest the administration of food, as a means of
temporary relief at least; and, in fact, a few morsels of common
food —a biscuit, a crust of bread, or small piece of meat, ade-
quately masticated, has sufficed to relieve. Anything which
stimulates the stomach, as an aromatic or spice, in substance or
infusion, or a bitter tincture, will, on occasions, have the same
effect. Vomiting, although it merely expels some mucus, wil
give a lull to the symptoms. A draught of hot water, camphor
mixture, water of ammonia, I have found, each, on occasions,
to answer this purpose. Alone, or in combination with some one
of the articles already mentioned except emetics, opium and its
preparations are most and deservedly relied on to remove the more
intense pain and often accompanying cramp in severe gastralgia.
The first and most urgent call, during the paroxysm, is an allevi-
ation or removal of pain; and this is proposed to be brought about
generally by stimulants, antispasmodics, and opiates or narcotics.
But even at the very outset, and during the imminency of distress,
we ought, if possible, to take early note of all the circumstances, —
vol. I.—14
158 DISEASES OF THE DIGESTIVE SYSTEM.
concomitants and complications, — which modify the character of
the disease. If gastralgia be, as it sometimes is, a sequel, or one of
the accompaniments, of dysmenorrhea, in a full and plethoric
habit, stimulants of all kinds ought to be withheld; first, because
they generally fail to even alleviate the pain; and, secondly,because
they increase -subsequent distress, light up fever, and endanger
phlogosis both of stomach and uterus. More is gained, in such
cases, by repeated draughts of hot water, or by emptying the stomach
by draughts of warm water, or of salt and water, and by pediluvia,
and an opium pill.
Sometimes, there is a blending of gastralgia and gastritis, in which
case we must endeavour to reduce the disease to its simplest or
nervous element, by removal of the phlogosis. A few leeches to
the epigastrium, a laxative by the mouth, or a purgative enema,—
simple mucilaginous drink and an opiate will greatly contribute to
this end, which will be farther expedited by the warm bath. In
these mixed cases some remedies are applicable to meet both
indications, viz., to abate neuropathia and capillary excitement.
Hydrocyanic acid, colchicum, and minute doses of emetic tartar,
are of this class; and they have the additional advantage of pro-
ducing an impression beyond the period of the paroxysm, and
protracting that of its return. Of hydrocyanic acid I know little
from personal experience, but the good opinion of its efficacy in
gastrodynia, originally expressed by Dr. Elliottson, has been con-
firmed by too many persons since to allow me to doubt it. Dr. A. T.
Thomson has recommended it as an adjunct to tonics, in those
forms of dyspeptic irritability of stomach which are accompanied
with heat and soreness of the tongue. The great difficulty of pre-
serving this acid of a suitable and equal strength, the danger
from differences in recognised formulae, and the uncertainty of
therapeutical effect under the most careful administration, are draw-
backs which we cannot overlook when this medicine is the subject
of our deliberations. Hydrocyanic acid, prepared according to
the processes directed in the last United States Pharmacopoeia (1842),
contains two per cent, of pure anhydrous acid. With the good
effects of colchicum, in the shape of vinous tincture of the seeds, in
doses of twenty or thirty drops every two hours, or of half a drachm
twice or thrice a day, mixed with some aromatic water, I am more
familiar. The same may be said of emetic tartar, and particularly
when combined with minute quantities of opium ; an addition, this
last, which enhances, in the circumstances now before us, the vir-
tues of the colchicum. In enteralgia, I know of no remedy equal to
the colchicum, when united to magnesia, or alternating with one of
the alkalies. In gastralgia, if there be heartburn or cardialgia, these
last mentioned remedies may be advantageously conjoined with the
wine of colchicum seeds.
In cases in which the disease has been of long duration, and the
patient exhausted by its violence, I have found the oil of turpentine,
in drachm doses every hour or two, mixed with simple mucilage,
TREATMENT OF GASTRALGIA.
159r
give earlier and more complete relief than any one article with
which I am acquainted. If constipation be present, a larger dose, or
from two drachms to half an ounce, joined to half an ounce of castor
oil, may be given with the double view of relieving the gastric pain
and emptying the bowels. A long interval of ease will sometimes
follow this single dose.
For permanent effect various mineral preparations are prescribed
in gastralgia. Of these, subnitrate or trisnitrate of bismuth, oxide
of zinc, subcarbonate of iron, nitrate of silver, and arsenical
solution, have been the most extensively employed. If the former
be prescribed, it should be at first in a dose of four or five grains,
gradually increased to twenty grains. Some French writers speak
of prescribing it familiarly in quantities of eighteen, thirty, and even
seventy grains in the course of a day. (Trousseau and Pidoux,
Traite de Therapeutique et de Matilre Medicale, T. II., p. 776.)
The observations of Odier of Geneva, on the subnitrate of bismuth
in pains and cramps of the stomach, recorded in 1786, (Journal de
MMtcine,) seem to have been quite forgotten,, if we may form an
opinion from the emphatic reference to writers of our own time on this
subject. Our obligations are, however, due to M. Bretonneau for a
more precise and definite description of the circumstances under which
this remedy can be used with the greatest advantage. The subni-
trate of bismuth is more particularly adapted, as we learn from the
French writers, to laborious digestion, accompanied with nidorous
eructations and tendency to diarrhoea. When the eructations are
acid or the flatus inodorous, the medicine almost always fails. It is
indicated in chronic vomiting, without fever, which follows acute
gastritis, indigestion, or the effect of an irritating medicine, and in the
gastralgia complicated with this state. But, on the other hand, if
gastralgia be accompanied by habitual constipation, and there is no
vomiting, or only of a glairy, insipid, or acid mucus, and complica-
tion of chlorosis, or facial neuralgia, or rheumatism, or of leucor-
rhoea and hemorrhoids, or any other flux, except diarrhoea, the sub-
nitrate is of small service.
In the vomiting to which children are subject, during dentition,
and which so often precedes softening of the mucous membrane of
the stomach, and, also, to that which is caused by overfeeding and
accompanies the muguet (stomatitis with altered secretion), this
medicine displays its curative agency in a very satisfactory
manner.
Chalybeates are best, if not exclusively, adapted to gastralgia
in persons of an anemic habit, and especially in females of a lax and
delicate frame suffering from amenorrhcea and leucorrhcea. The
ammoniated iron and the vinum ferri have been recommended on
these occasions. Preferable to both is the subcarbonate (precipi-
tated carbonate), in conjunction with aromatic powder, or a little
ginger alone. It has been found that the carbonated chalybeate
waters are often successful when no officinal preparation of iron
can be borne; and hence a visit to Ballston, or Bedford Springs, and
160
DISEASES OF THE DIGESTIVE SYSTEM.
drinking the chalybeate waters there, will give the patient a double
chance of restoration; first, by the journey and its concomitants,
change of air and scene, and change of thoughts and feelings; and,
secondly, by the medicinal effects of the waters themselves.
Nitrate of silver has of late years been tried, in cases of morbid
sensibility of the stomach, by Dr. James Johnson, (Morbid Sensibi-
lity of the Stomach and Bowels,) and is well spoken of by Auten-
reith, Rueff, and others, in this disease. For Rueffs practice,
see Amer. Journ. of Med. Science, May, 1837. By this latter
it has been given, not only in gastrodynia, but in cases of ner-
vous vomiting and other derangements of the digestive organs
so common in young infants, and, also, as a palliative in cancer and
scirrhus of the stomach. The dose of the nitrate is a sixth of a
grain,gradually increased to three or four grains three times a day,
given in the form of pills made of bread-crumb. Objection has
been made to this latter, on account of the chloride of sodium which
it contains; but the decomposition by this agent, considering its
extremely minute quantity, must be inconsiderable, if it takes place at
all. Some mild vegetable powder with mucilage may be preferable
to the bread. We must enjoin on the patient theprecaution nottotake
common salt or salted food, either immediately before or immediate-
ly after swallowing these pills. The dose of the nitrate has been
carried as far as fifteen grains by Dr. Powell. I may have occa-
sion, when treating of epilepsy and the remedial value of nitrate of
silver in this disease, to speak of the discoloration of the skin of a
blue or slaty hue caused by persistence for a length of time in the
use of the remedy. Dr. Johnson, on this point, however, asserts
that there is no instance on record where the complexion has been
affected by the medicine, when restricted to three months adminis-
tration. It will be more prudent to desist for a while from its use
after a month.
Gastrodynia, assuming a distinctly periodical character, or oc-
curring endemically as it sometimes d"oes, and at the same time with
periodical fever, will be advantageously treated with sulphate of
quinia and a little opium,—or if the bowels are torpid and the
secretions unhealthy, blue mass and a little aloes should be com-
bined with the former. When the neuralgia of the stomach alter-
nates with facia] or temporal neuralgia, and the system is weakened
by their duration, or by other causes, sulphate of quinia in tolerably
full doses, as of five grains, exerts a very good effect. Indeed there
would seem to be no adequate substitute for this medicine in such
cases, although I know that arsenic will be at once suggested by
more than one practitioner.
Most stimulants, and especially alcoholic ones, we ought to regard
with great mistrust in gastralgia. That thev will often give speedy,
though temporary relief, is undoubted ; but the habit of using them,
begun in this way, is so often prejudicial in other respects, and so
apt to lead to downright intemperance, as well as ultimate aggra-
vation of the disease, or at any rate a conversion of gastralgif into
TREATMENT OF GASTRALGIA. 161
gastritis, that, in no case, ought the physician to allow discretionary
privilege to his patient to have recourse to them without advice
specifically given, and never to direct their continuance beyond
the urgency which seemed to call for them at the time of suf-
fering. How many have acquired habits of drunkenness, how
many of the habitual use of opium or laudanum, owing to the care-
less advice of their physician to take a little tincture of bark or some
aromatic tincture, or a glass of brandy and water, or a few drops of
laudanum, whenever they felt the approach of gastrodynia, or other
form of neuralgia, or of erratic gout. Medical ethics require a
supervision on this point, so as to quicken the sensibilities of physi-
cians to their responsibility for the habits of their patients after con-
valescence from disease; for these habits are often the result of
formal advice, or casual suggestion, offered by medical men at this
time.
There is no other drink than water for habitual, that is daily, use,
which can be taken with any permanent advantage. Drunk quite
hot it will often relieve the violence of the paroxysm ; and if, in com-
mon, its coldness should offend the stomach of a gastralgic patient, it
is easy to correct this by having it boiled, and a piece of toast in-
fused in it, or the rawness removed by placing that which is to be
drunk in warm water for a few minutes. I speak now, of the
daily drink, both that at meals and at other times. When toast
and water is directed, the toast should be slowly made, be quite
brown and dry, and only allowed, in warm weather particularly,
to remain for an hour in the water previously ; after which time this
latter should be strained, or carefully poured into another vessel.
The state of the lower bowels always demands our attention in
gastrodynia. Generally torpid, they require to have their action
quickened in some way or other. This is best performed by mild
means, — such as simple enemata, where the stomach is very irri-
table, and in common by a combination of rhubarb and magnesia,
with ginger in powder, or of aloes, blue mass and soap, hyoscyamus
with aloes and soap, in pill. A tumblerful of hot water, with a tea-
spoonful of carbonated magnesia, and a few drops of aqua ammo-
nia mixed in it, taken at the time, will often answer a good purpose.
Sometimes a little rhubarb and magnesia with a simple bitter, such
as gentian or columba, will be found beneficial, by its effects both
on the stomach and the colon. But here, again, hygienic means
are the only ones on which we can rely for permanently removing
constipation. Something will be gleaned from the patient's own
experience, something suggested by the physician, in the selection
of suitable ingesta. Stale wheat bread, that is, bread baked on the
day preceding that in which it is eaten, or bran crackers, ought in
all cases to be preferred to fresh, and especially warm bread, than
which there is no article more injurious to the dyspeptic, and above
all to the gastrodynic stomach. In some cases' corn bread agrees
better with the stomach than wheat. If butter be added to fresh
or hot bread, or to hot toast, and eaten as part, and sometimes the
14*
162 DISEASES OF THE DIGESTIVE SYSTEM.
chief part, of a repast, no medical skill is equal to devising means
of cure of the disease in question. The same difficulty will be inter-
posed by the use of green tea and coffee. Nor can chocolate, with
its oily ingredients, be received as a substitute for these beverages.
On the subject of food generally, it is not easy to specify the
articles which will be found to be adapted to every case of gastro-
dynia, as there are notable differences in gastric sensibility as well
as digestive capability among persons affected with this disease.
Milk, often beneficial, is at times positively noxious. Occasionally,
boiling it, or diluting it with hot water, or the admixture of a little
rice or arrow-root, or even wheat flour when it is boiling, will ren-
der it more digestible for adults, as it is found to be, by these means,
for children. If milk be used, it ought to be for breakfast or early
dinner; but not in the evening. Cures have been brought about by
restricting the patients to a very small quantity of this nutriment,
as one or two tablespoonfuls of skimmed milk at a time. Dr. Barlow
of Bath reached the same good result, by confining his patient to
a diet consisting wholly of fresh-made, uncompressed curd, of which
she took only one tablespoonful at a time, repeating it as often as
she found it advisable. Dr. Johnson has found gruel in some cases
to be equally successful.
In simple gastrodynia and where the inflammatory element if it
had existed is removed, a small portion of some plainly dressed
meat with a vegetable addition, is admissible at dinner. From
the latter, however, I would exclude potatoes, which I have seen
so often to bring on and keep up gastric pain and spasm both in
children and in adults. Spinach, though h priori it would not seem
to be adapted to dyspepsia, is often very serviceable, by keeping
up a regular state of the bowels, without, at the same time, offend-
ing the stomach, as the brassica or cabbage tribe so commonly do.
Lettuce, with a little good vinegar and salt, is not unfrequently both
grateful and wholesome to the patient affected with gastrodynia;
the addition of oil and of mustard, and still more of egg, renders
it of more doubtful value, if it does not make it positively detri-
mental. Rice will be found less liable to produce acescency than
any other article of vegetable food; and hence, in cardialgia as
well as in gastrodynia, it is entitled to a preference.
Fruits must be eaten with reserve by the dyspeptic, and particu-
larly by him who suffers from gastrodynia. Those most apt to derange
the stomach, are the melon, the plum, the apple, and the strawberry.
The apple, in its simple state, without having been subjected to any
culinary process, is a frequent source of pain and spasm of the sto-
mach, and of disorder to other parts of the digestive canal. I have
found, on different occasions, that nearly complete exemption was
procured from annoying and oft-recurring gastrodynia by an
abandonment of the use of potatoes and of apples. Preserved fruits
are generally oppressive, and pastries of all kinds are inadmis-
sible.
But, however precise and correct we may be in the selection of
TREATMENT OF GASTRALGIA.
163.
suitable articles of aliment, little will avail if their quantity or bulk
be not considered at the same time. The stomach will be fully as
much, in many instances more, injured in its digestive functions by
undue distention than by physiological excitement of its mucous
surface. Hence, not only solids but even the simplest fluids must
be taken in moderate quantity at a time.
Attention to the cutaneous function, necessary in all the forms
of dyspepsia, is peculiarly so in that now under consideration. In
order to do justice to this part of the treatment it would be neces-
sary not only to direct suitable clothing, including flannel next the
skin and a flannel roller round the abdomen, but, also, a removal
from damp lodgings and locality, and the enjoyment of a dry and
pure air. The daily use of the tepid bath, and, during the paroxysms,
of the warm, will aid not a little towards this object.
Coincident with*a reform in the diet of the patient with gastro-
dynia must be that in his mental habits, if, as may be inferred from
the announcement of causes already specified, these are in any
way irregular or extravagant. And here the physician must
invoke the aid of ethics, and be not unmindful of the benefit to his
patient of proper religious convictions, which impart that sobriety
of thought and feeling so necessary to preserve the nervous
system, and through it the digestive, in their healthy condition.
One knows not which is most injurious to health — passionate
outbreaks at irregular intervals, or that continued under-toned
and sometimes silent fretting ^nd discontent at any and everything
which thwarts the humour of the hour, or interferes with any pre-
conceived scheme of doctrine or practice. The first is declared
to be wrong, — the latter is too often practised by those whose pro-
fessions would imply very different conduct. Punishment awaits
both kinds of wrong; and in no way more obviously than in keep-
ing up dyspepsia with hypochondriasis in its train, and sometimes
giving rise to mental aberration.
As operating both on the body through the mind, and on the
mind through the body, travel and change of scene are curative
means, which ought if possible to be enlisted for the removal of
dyspepsia, both of the atonic kind and of that marked by morbid se-
cretion, as well as by gastrodynia. In the acute form of dyspepsia,
depending on inflammation of the stomach, and accompanied with
fever and thirst, travelling, or active exercise of any description, is
injurious, and has often, together with the use of chalybeate and
stimulating mineral waters, exasperated the malady, and brought
these very admirable curative agents into disrepute in other va-
rieties of the disease in which, their good effects cannot be con^
tested.
164
DISEASES OF THE DIGESTIVE SYSTEM.
LECTURE XIV.
DR. BELL.
Gastro-duodenal Dyspepsia—Relations of the duodenum—Varieties of duo-
denal disease—the acute and the chronic or atonic—General characters—
Particular symptoms—direct and sympathetic—Causes—common in the United
States—Necessity of a better pathology of diseases called bilious and hepatic
—Treatment—depletion if the acute disease be present—Counter-irritation—
Emetic tartar—castor oil—nitrate of potassa—mercury—taraxacum—mineral
acids—In the atonic variety,—purging—suitable food—exercise—laxatives—
tonics, and alteratives. — Follicular duodenal dyspepsia — Its symptoms,
progress, and treatment. — Strumous dyspepsia—Its course, complications,
and treatment—General directions.
Gastro-Duodenal Dyspepsia.— The important changes to which
the chyme is subjected in the duodenum by its admixture with the
secreted fluid of this portion of the intestinal canal and the bile and
pancreatic juices, are known to every pathological student. Sup-
plied with nerves of animal life, or branches of the par vagum,
the duodenum has, in consequence, sensibility analogous to that
of the stomach, whilst by the nerves of organic life it resem-
bles the rest of the small intestines, whose sympathies with other
organs are less active and acute than either those of the stomach
above or the large intestines below. The duodenum, receiving the
matters passed from the stomach, is dependent very much on
the integrity of function of this latter for the due performance
of its own; and hence the difficulty of distinguishing between
simple gastric dyspepsia and duodenal dyspepsia, or even of indi-
cating that form of disease which is gastro-duodenal. The duode-
num is subject to the same series of irritations as the stomach; but
it does not of course betray them with the same readiness and
diffuseness: its mucous membrane maybe inflamed, its follicles
excited to morbid secretion and inflammation, and its nervous fila-
ments, and even their ganglia, take on that algos which will throw
them into a state analogous to gastralgia. But although the symp-
toms coming directly from this- intestine are fewer and less evident,
it makes its disorder known through other organs, and especially
the liver and the chyliferous apparatus. Transmitting by continu-
ity of surface, and, to a certain extent, of tissue, its excitement along
the ductus choledochus, disorder of the duodenum is participated
in by the liver, whose secretion is hurried or impeded in conse-
quence. The absorption of the fluid part of the chyme, soon to
become chyle, is modified also by the state of the duodenum, — and
hence hematosis is affected, and the secretions, depending as they
do so much on the blood, are in consequence apt to be vitiated or
altered.
Symptoms. — Guided by these premises we can tell with tolerable
accuracy that the stomach is no longer the seat, at any rate the
exclusive seat, of dyspepsia when the patient manifests the following
FEATURES OF DUODENAL DYSPEPSIA.
163
symptoms. I am the more desirous of placing them before you in
distinct relief, because you will see in them the picture of what our
practitioners in the country are so fond of calling liver disease.
His pain or uneasiness, distention, and oppression, are not so acute,
nor are they referred to the same region, as when the stomach is
disordered, A longer time elapses than in the latter case, com-
monly two to four hours after taking food, before complaint is
made or uneasiness experienced. The appetite is generally little
impaired; sometimes, on the contrary, it is keen, and even raven-
ous : the urine is sedimentous, feces more or less unnatural in
appearance.
I shall not divide duodenal dyspepsia into varieties, such as atonic,
inflammatory, irritable, follicular, and strumous, in the manner of
Dr. A. T. Todd, in his excellent article (Indigestion), written for the
Cyclopaedia of Practical Medicine; but, whilst availing of his labours,
I shall proceed to designate the chief features by which you can
yourselves judge of the degree of duodenal disease, and shape your
measures accordingly. Duodenal disease will manifest itself gener-
ally by a sense of weight and uneasiness, sometimes of pain in the
right hypochondrium, extending sometimes to the back, frequently
between the spine and the right scapula, or under the right scapula,
or it is accompanied with a dull pain at the top of the shoulder, and
numbness extending down the right arm, to the elbow, wrist, and
little finger, — more rarely with pain of the right hip, extending
down the right leg. The uneasy feeling in the right hypochondrium
sometimes extends round the right side to the spine, like half a zone,
giving the feeling as if the right side were begirt and compressed
by a sickle. I have had quite recently a patient who described his
sensation as if he were begirt with something round the body in the
line just described. Often the cause of the pain may be traced with
anatomical accuracy in the course of the duodenum downwards and
backwards in the direction of the right kidney. Examination of
the right hypochondrium, more particularly when the patient is in
an erect posture, will exhibit a fulness more or less perceptible
through the whole hypochondrium, most evident when compared
with the left: a circumscribed puffiness even is perceptible on the
site of the duodenum, more particularly just before the cartilage of
the eighth rib, in which situation it is observed that pressure is dis-
agreeable, sometimes occasioning a sense of oppression and dys-
pnoea. This puffiness will readily disappear under the operation
of a brisk purge, bat to return again, and become so obvious as to
be observed through the clothes, more especially in females. At
times, there is a soreness, or a sense of fulness below the pit of the
stomach in the situation of the arch of the colon, but deeper seated.
On other occasions, again, a sensation of fulness is felt at the lower
bowels, leading to ineffectual efforts to relieve them ; and not rarely,
there is spasmodic stricture of the rectum. These affections occur
in paroxysms, as if connected with the stage as well as state of
digestion ; for the symptoms are more or less mitigated by full eva*
166
DISEASES OF THE DIGESTIVE SYSTEM.
cuations from the bowels, and relief is even experienced as soon as
the upper portion of the bowels is put in motion, and often long before
an evacuation. The tongue, in the more acute form of duodenal
dyspepsia, is more or less furred, and of a glossy red colour at the
point and margin; in the atonic or chronic varieties this organ is
large, broad, soft and flaccid, covered with a yellowish-white
mucous fur towards the root; but moist, slimy, and of a dull red
colour towards the point and margin, presenting, in general, a
flabby and sodden appearance. There is no particular thirst: the
appetite is often voracious. Although nausea is not a common
symptom, yet, in the acute stage, when this is felt and vomiting comes
on some hours after eating, we may suspect that these symptoms
are those of duodenal dyspepsia. The bowels are costive, more rarely
alternating with occasional diarrhoea ; and the evacuated matters, in
the former case, are hard, dry, and adust, of a dark brown or dull
olive or greenish-black colour. If the discharges be loose, they are
generally of too light a colour, and devoid of their natural smell; or
sometimes nearly tape-like, or of a faint yellow colour, floating
upon the water. In some cases the discharges are dark and
pitchy, and fetid. In the interval between the periods of digestion,
the pain and uneasy feeling of the right hypochondrium are con-
siderably less sensible, seldom amounting to more than a sense of
heat, gnawing,'or sinking towards the epigastric region, with a
frequent desire to take food, which often corresponds with a sense
of heat, smarting, or blistering at the tip of the tongue, and with
watering of the mouth.
Among the sympathetic affections of diseased state of the duode-
num, are a general, painful, confused headache,increased by stopping
or by holding the breath, or a dull pain in the back part of the head,
which feels lightly bound, or painful pulsation of the head excited
by the least effort of attention: vertigo is also a very common
symptom. The senses are impaired, and the intellect enfeebled,
and even the whole mind is so disordered that mania is the final
result.
Irritation of the larynx, producing a short, dry cough, and im-
perfect expectoration, a sense of constriction and laborious breath-
ing, even to simulate spasmodic asthma, and the supervention of
phthisis pulmonalis, are recorded among the effects of duodenal
disease. Not less sensible are painful affections of the heart from
this cause. Various pains in the joints, of a rheumatic character,
are also noticed to follow in its train. Early struck with the con-
nexion between these pains and abdominal disease, my first essay,
being that for introduction into the Philadelphia Medical Society,
was on what I then termed ' Hepatic Rheumatism.' At that time
I attributed, as is still too much the case, to the liver, that which
was due to gastro-duodenitis of a sub-acute and chronic nature.
Disorders of the skin, sueh as herpes zoster, acne induratum, urti-
caria, lichen, psoriasis, and pityriasis, fyc, are external indications
at times of disease of the duodenum.
CAUSES OF DUODENAL DYSPEPSIA.
167
The pulse, in the acute form of duodenal dyspepsia, is either
quicker than natural or easily accelerated; and it exhibits the
quality of hardness or tension. In other cases it is but slightly
altered from that of health. The temperature of the body is unequally
distributed and variable; sometimes there is fever,or feverish heat—
sometimes chilliness ; hands and feet cold in the day, but the palms
and soles become hot after meals or in the night, when there is a
tendency to partial heavy sweats, especially towards morning.
Among the sympathetic irritations may be mentioned those at
either extremity of the digestive tube. Relaxation of the uvula,
and ulceration of the fauces at the upper: prurigo-podicis, hemor-
rhoids, and spasmodic stricture of the anus or rectum at the lower
extremity.
But, as Dr. Todd justly observes, whatever maybe the particular
sympathetic affections resulting from the disorder of the duodenum,
there is one general and constant, which belongs and giT"?s cha-
racter to them all, — hypochondriasis, despondency, and dejection
of spirits, the mind constantly intent upon and occupied with the
bodily feelings.
Causes. — The most frequent cause of gastro-duodenal dyspepsia
is an inability in the stomach to bring about the requisite changes
in the ingesta, so as to convert them into a properly elaborated and
homogeneous chyme. A consequence of this is the passage into
the duodenum of crude and necessarily irritating substances, which
stimulate unduly its mucous membrane, and throw it into a state of
erethism, which is transmitted to the liver, and disturbs its func-
tion. Sometimes, even healthy aliment, from its being taken in too
great quantities by hearty eaters, or from its being imperfectly
masticated, is too much for the stomach to manage; and although
it may at first be refused a passage by the pylorus, yet after
a while it fatigues this sense, and finds entrance into the duo-
denum.
Enchelosis, or the mutual action and reaction of chyme, bile, pan-
creatic, and intestinal juices, which results in chylosis, cannot,
under these circumstances, be regularly performed. The duode-
num irritated, passes on its offensive contents into the next portion of
the intestine, and there ensues more or less disturbance along the
whole tract, and diarrhoea. Or if it retain, as it is apt to do after
a while, by a diminution of its contractility from over-excitement,
the imperfect chyme and bile, it transmits its disturbance more per-
manently to the liver and other organs, and presents continued
obstacles to complete chylosis. The bile is interrupted in its excre-
tion by the duct, and there ensues more or less discoloration of
skin and approach to jaundice in consequence, — as will be ex-
plained hereafter by Dr. Stokes in his lectures on jaundice. But
excessive chymosis, or the pouring into the duodenum a dispropor-
tionate quantity of even the healthiest chyme quicker than the pro-
cess of enchelosis can go on, will be followed by identical effects
with those just sketched. " This is the reason," says Dr. Todd,
168 DISEASES OF THE DIGESTIVE SYSTEM.
" that children are proportionately more subject to duodenal dys-
pepsia than adults; for, having in general a good appetite and
powerful gastric digestion, they are wont to eat at all hours and
seasons, taking a second meal before the first is digested, so that
the duodenum becomes distended with chyme, which it cannot
transmit, interrupts the discharge of bile, and accumulation takes
place." Any cause which abridges the peristaltic action of the
small intestines, prevents the transmission of the chyme downwards,
and leads to accumulation in the duodenum, to distension, and to all
the consequences of duodenal dyspepsia. The accumulation of feces
in the colon, which, in some constitutions, induces, by sympathy,
atonic gastric dyspepsia, also, by its pressure upon the duodenum,
mechanically interrupts its free action, and prevents it from dis-
charging its contents. Certain postures, by which the body is
habitually bent, produce the same consequences; and hence the
frequency of the kind of dyspepsia now under notice in shoemakers,
tailors, engravers, and also in clerks and literary persons, who lean
much over their desk or table. Women, also, in their sedentary
occupations, as when engaged with their needle, suffer in the same
way; still more prejudicial is the pressure from corsets or tight-
lacing.
The duodenum may, of course, be affected by the common causes
of diseases of the stomach and of other organs, — such as suppressed
perspiration, exposure to cold, particularly in dry weather : its irri-
tation may also be a sequel of catarrh, and a frequent consequence
of the retrocession of eruptions of the skin.
In placing before you this picture of gastro-duodenal, and more
particularly of duodenal dyspepsia, I will not vouch for the entire
accuracy of all its details, but I introduce it here because I believe
it to be a representation of the series of disorders which commonly
pass for hepatic in the United States generally; and because an
amended pathology will lead to a more rational treatment, if in no
other particular than in preventing the prodigal, and I must add,
empirical, and often cruel administration of mercury. In our
country, more than in any other, are the people exposed to the
causes of duodenal dyspepsia: they are great eaters, and fast and
frequent eaters of the most substantial and often stimulating and
various aliment, and they use, at the same time, the strongest drinks,
(Bell on Regimen and Longevity, p. 95,) which, although not ad-
verted to before among the causes of the form of dyspepsia now
under notice, must be regarded as exerting a powerful agency in
its production. At first disturbing chymosis, by chemically modify-
ing the gastric juice, and then irritating the mucous follicles, they
cannot fail, when they pass the pylorus, to exert analogous bad
effects on the duodenum, and interrupt, by their action on the bile
and intestinal mucus, the process of enchelosis. Alternating often
with the operation of this cause, and employed with a view to
correct its effects, but really aggravating them as far as regards
irritation of the duodenum, is the frequent use of mercurial and
TREATMENT OF DUODENAL DYSPEPSIA. jgg
drastic purgatives. We commonly find those addicted to alco-
holic potations manifest some, and often many, of the charac-
teristic symptoms of duodenal dyspepsia. The sallow complexion,
muddy conjunctiva, and furred tongue, with occasional stitch or
dull pain in the side, are more frequently symptoms of this disease
than of hepatitis.
Treatment.— In approaching a case of duodenal dyspepsia,
with a view to institute the proper curative indications, the first
object is to determine whether it be of a phlogistic nature, or not;
as on this point the preliminary treatment will turn. If, therefore,
the pulse be tense, and frequent or full, the pain in the right hypo-
chondrium severe, there be much heat and dryness of the mouth,
and fur and redness of the tongue, venesection is to be practised,
as a means of present and considerable relief, and as preparing the
affected region and the system generally for the beneficial operation
of other remedies. " When the symptoms indicate a state of ple-
thora of the abdominal circulation, such as a full or varicose state
of the veins of the lower extremities, swelling of the feet, pain in
the loins, more especially in the sacrum, indicative of a hemor-
rhoidal disposition, dark coloured or sedimentous urine, a large
tongue seemingly swollen with blood, and eruptions of the skin, the
congestion is more speedily subdued, and with less exposure to the
constitution, by very small bloodlettings repeated at intervals of a
fortnight, than by any other method." In cases in which there are
few symptoms of general morbid activity of circulation, or of abdo-
minal plethora, but still those of duodenal excitement, cups to
the right hypochondrium, or leeches over this region or tender part
of the epigastrium, will answer a good purpose ; their repetition to
depend on the persistence of the symptoms which first indicated
their use. When hemorrhoids are present, leeches to these tumours,
or to the verge of the anus, will often afford, by derivation, great
relief to the upper bowel. Succeeding these means is counter-
irritation by common warm plasters, or those of emetic tartar, or
blisters, and in extreme cases setons in the direction of the false
ribs. Contributing to the process of reduction of excitement are
minute doses of emetic tartar, continued for a period of several days,
and after suspension, its use to be again renewed. Vegetable acids,
colchicum, and hydrocyanic acid, are also of value; the two last
particularly, in a morbidly sensible or irritable state of the upper por-
tion of the alimentary canal. Dr. Todd speaks highly of the sooth-
ing, and almost sedative, effects of castor oil administered in small
doses in this disease. The medicine should be given in doses of a
drachm, repeated once in the twenty-four hours; in the evening, if
" its soothing and antiphlogistic effect upon the mucous membrane,"
in the morning, if its aperient action, is desired. " In obstinate
chronic cases of this disease, we have known a small teaspoonful of
castor oil taken every night at bed-time, as long as the stomach
could easily bear it, a remedy attended with the most signal suc-
cess." The effects of castor oil will vary with the condition of
vol. i.—IS
170
DISEASES OF THE DIGESTIVE SYSTEM.
the mucous membrane; producing nausea and vomiting in atonic
dyspepsia, griping in the irritable variety, and soothing in vascular
excitement of the membrane. It may be here, as in so many other
cases, allowably combined with a mild carminative water, or given
in emulsion, or with a little liquor potassae. Dr. Todd attaches
considerable value to the nitrate of potassa, for its power of abating
vascular excitement of the mucous membranes: it may be given in
doses of from five to ten grains, three times a day, in an ounce of
water, to which may be added a small quantity of mucilage of
gum-arabic. Our common antimonial powder, in which the pro-
portion of emetic tartar need not, however, exceed the twelfth of a
grain, and the nitre ten grains, will answer a very good purpose.
If there be pain, or irritability, or restlessness, narcotics, such as
the tincture or extracts of hyosciamus, or of lettuce or conium, will
be had recourse to; and a dry skin will be met by minute doses of
ipecacuanha powder,or wine, or evenof Dover's powder. Conjoined
with these remedies, and adding not a little to their good effects,
will be the warm bath, either early in the morning or at noon — that
is to say, when the stomach is empty, — an indispensable condition
for the salutary use of a bath of any description. To be more ex-
plicit, I ought to say, that a bath should never be taken after a full
meal, although some cases of inertia and sluggish circulation,
or of nervous debility, may require that the fast shall have been
broken by some simple food, in small quantity, an hour or two before
the bath.
Mercurials, to which our American practitioners have recourse
at once in this form of the disease, or " bilious disorder or hepatic
derangements," as they generally term it, had better be withheld
until morbid excitement, both local and general, has been abated
if not entirely removed. Then the blue mass, given at bed-time in
doses of from three to five grains, will, I know, exert a very calm-
ing, and indeed it might be truly termed anodyne effect. A still
milder preparation is the hydrargyrum cum cretd; or, if a combina-
tion be required which shall act both on the diseased mucous mem-
brane and on the skin at the same time, the blue mass and ipecacu-
anha, in the proportion of three grains of the first and half a grain
of the second, in pill, two or three times a-day, will be found to
answer our expectation very happily. Taraxacum, as auxiliary to
mercury, and in the opinion of some a substitute for it, displays,
every now and then, a very sensible effect in soothing the mucous
membranes. The extract may be given in infusion of hop, chamo-
mile, or orange-peel, or the compound decoction of sarsaparilla, and
to nervous patients in a camphor mixture, to which may be added,
according to the intention, a small quantity of nitrate of potassa, or
of sulphate of potassa, or compound decoction of aloes. The fol-
lowing is a good formula for its administration: —
R. Extract Taraxaci, 3ij.
Potassag Nitratis, Jss.
Spiritus ^Eth. Nitrici, f3i.
Infus. Cort. Aurant. f§vi.
M. Dose, a tablespoonful, two or three times a-day.
TREATMENT OF DUODENAL DYSPEPSIA.
171
As useful aids towards a cure, we may occasionally have recourse
to nitric, nitro-muriatic acids, and the solution of chlorine. Inter-
nally they may be used in decoction of liquorice, or compound de-
coction or syrup of sarsaparilla.
In fulfilment of the second indication, or to render the function of
digestion easy of performance, attention must be paid— 1, to the diet
of the invalid ; 2d, to the preserving an open state of the bowels ; and
3, to the assisting the digestive function by mild tonics and adequate
air and exercise. These indications are as important in the atonic
duodenal dyspepsia as in the acute form, and the directions for one
are applicable to the other. It will be proper before giving these to
indicate some modifications of treatment required in the duodenal
dyspepsia, in which there is little or no excitement, either in the
abdominal circulation or in the.system at large.
In this atonic form it will be proper, in the first place, to unload
the duodenum, or to relieve it of the irritating pressure of an over-
loaded colon. Early observation induced me to concur in the
opinion that senna is the medicine which deserves the preference
for emptying the duodenum. In bilious colic, and in febrile affec-
tions of considerable violence, I have not succeeded in procuring
permanent relief for the patient until this intestine was unloaded, by
means of senna with some adjunct, such as salts or cream of tartar,
of feces of a dark and pitch-like appearance and consistence. I
had long ago adverted to this fact, as well as to the occurrence
of duodenal dyspepsia,in my Inaugural Dissertation (On- the Liver:
Its Influence over the Animal Economy in Health and Disease, 1817).
The following extract will show that the views now placed before
you were very early adopted by me: I had just been speaking of
dyspepsia. " We are in these cases too hasty in assigning the
stomach as the sole seat of the disease. It is highly probable that
many of the morbid changes, productive of much distress, take
place in the duodenum or second stomach (as it is properly termed
by some), where the process of digestion is completed, and where
the alimentary mass is mixed with the pancreatic and biliary fluids.
" If these are deficient or depraved, the chyme will undergo a
kind of decomposition, evinced by the spasm and flatus which will
be felt in many cases extending under the seventh or eighth rib,
passing deep and stretching towards the right hypochondrium, and
which is often the more distressing from the manner in which this
intestine is braced down by the mesocolon." p. 33.
The griping effects of senna may be obviated by adding to the
infusion some carminative water, or some bitter, such as the Vir-
ginia snake-root, which I frequently prescribe in this conjunc-
tion. A few drops of liquor potasscv, or spiritus ammonia aro-
maticus, added to each dose of the senna infusion, are deemed to be
still stronger correctives. Rhubarb comes next to senna, and it
may be given in substance combined with sulphate of potassa or
tartarised soda.
To procure regular alvine discharges, after the bowels have been
172
DISEASES OF THE DIGESTIVE SYSTEM.
unloaded by purgatives, in order to meet the special exigency of
overfulness and accumulation, an enema of tepid water, morning
and evening, or, this failing, the addition of aperients, the best of
which is aloes, will be had recourse to. The compound galbanum
pill, to which rhubarb has been added, is well adapted to a torpid
state of the bowels. But we must bear in mind, and unceasingly
impress on the patient, the fact, that permanent relief, and the
establishing of a healthy habit, can only be procured by hygienic
means — a proper selection of articles for food, reference being
had both to their digestibility and their bulk, — regular and some-
what active exercise in the open air, and riding on horseback
is the best, simple water for drink, with occasionally some slight
bitter or aromatic infusion.
The diet in the acute or inflammatory form of dyspepsia should
be of a mild vegetable nature; farinaceous articles constituting the
basis, and garden vegetables added according to the taste and di-
gestive habit of the patient. In some cases a restriction wholly to
a fluid diet is necessary : but in common gastric, and in chronic
or atonic duodenal dyspepsia, a small portion of plainly dressed
animal food, with stale bread or biscuit, or well boiled rice, is
both proper and beneficial. To render any kind of solid food di-
gestible it must be well and slowly masticated, so as to insure not only
its comminution, but its mixture with the saliva. One of the first
duties of the dyspeptic, and that of which he is too often oblivious,
will be, therefore, slow eating. If he can do this with cheerfulness,
and in pleasant company and conversation, so much the better.
Follicular Duodenal Dyspepsia is described, in its general cha-
racter by Dr. Todd, to be marked by symptoms of painful or diffi-
cult digestion, felt chiefly a considerable time after taking food,
most frequently observed in phlegmatic habits; occasional alvine
discharges of mucus in various morbid states ; acute attacks of
gastrodynia or jaundice sometimes intervening. The appetite is
deficient in this form of duodenal dyspepsia, even to loathing.
" There is no remarkable loss of flesh, but the appearance of the
skin is much altered, the complexion becomes bloated, loses its
colour, is dull and cloudy, sometimes swarthy, frequently clammy,
greasy, or waxy, as if covered with a thin film of melted wax; or
the skin is sallow and somewhat jaundiced ; it feels generally cold,
moist, and clammy, the hands and feet particularly so. The lips
and gums are generally pale; the tongue is moist, pale, and flabby,
covered with a pearly-white mucous coating, but seldom much
loaded; sometimes there is a thick, shaggy, cottony fur. The
mucous coating of the tongue often has the appearance of a false
membrane, which, falling off in pieces, leaves patches quite clean,
sometimes red and morbidly tender. The bowels are almost al-
ways constipated, but diarrhoea is sometimes though rarely ob-
served." The characteristic feature of the evacuation is consider-
able quantities of mucus, which are discharged in various morbid
FOLLICULAR DUODENAL DYSPEPSIA. 173
states and forms; sometimes it resembles transparent jelly, or is
glairy like the white of an egg ; sometimes it assumes the solid
form, appearing in concrete masses varying in size and figure, fre-
quently resembling small bits of tallow, wax, or bits of the blanched
kernels of walnuts ; sometimes, again, shreds, apparently parts of a
membrane, and even perfect tubes of considerable extent, are passed.
These discharges of mucus appear to take place periodically, and as
it were critically, being in general preceded by considerable aggra-
vation of the symptoms; and the recovery is attended with eva-
cuations of quantities of mucous or glutinous substances.
"In these attacks the patient is sometimes suddenly affected with
acute spasmodic pain in the right hypochondrium, darting through
to the back, frequently accompanied with vomiting or a hard dry
cough, by either of which the pain is greatly exasperated. Often
there is sudden and excessive pain towards the epigastrium, re-
turning with vomiting or violent paroxysms. These pains are
occasionally rather relieved by pressure; but the parts are frequently
so sensitive, that the slightest touch cannot be borne; and,even dur-
ing the intervals of the pain, the patient complains of great tender-
ness and soreness in these parts. The tongue, already coated with
a white fur, becomes dry, the pulse accelerated, the stools white,
the urine turbid, and of a dark red colour like blood. As the pain
remits, the patient is bathed in a profuse perspiration. After a day,
sometimes longer, the skin becomes jaundiced, and on examining
the evacuations, instead of gallstones, as he expected, the physi-
cian finds copious flakes of mucus in various forms, which are
passed with considerable relief to the patient. This mucus, some-
times fluid and approaching to pus in appearance, has, in connec-
tion with the foregoing symptoms, frequently imposed the disease
upon attendants for the rupture of an abscess of the liver; but the
same symptom and the same discharge occasionally occur without
jaundice or any symptom of hepatic obstruction." The pulse is,
except during the attack, always weaker than natural, generally
slow and small, more rarely frequent and small, or wiry and flut-
tering.
It is with regret that I find myself obliged to curtail the admira-
ble description of this disease by Dr. Todd, who very properly
remarks, that the secondary affections sometimes cause both
patient and physician to overlook its seat. Among these are a
remarkably altered state of the temper and feelings, mani-
fested in a great variety of ways, from languor and apathy to
great irritability and moroseness. The organs of respiration and
of circulation are greatly troubled; and the nervous system so
much affected as to be seized with chorea or even paralysis. Asso-
ciated with the intestinal disease, for we cannot pretend to restrict
it to the duodenum alone, are rheumatic gout and rheumatic pa-
ralysis; and among the disorders of the skin, erysipelas, erythema,
acne, and impetigo. " The unfavourable progress of the disease
15*
174 DISEASES OF THE DIGESTIVE SYSTEM.
leads to a state of general cachexy, cachexia piluitosa, which
sometimes terminates in anasarca."
Pathology. — The seat of this disease is implied in its title. Al-
though noticed and described by Marcard and Stoll, admitted to
be a cause of death by Theden and Hoffman, and its anatomical
features detailed by Bonnet, Morgagni, and others, it is to Kampf,
a Dutch physician, that we are indebted for a description ex pro-
fesso of this disease, under the title of infarctus. The mucous
glands of Peyer and the follicles of Brunner are often unusually
developed, frequently they contain a whitish concrete matter, more
or less friable, bearing a due resemblance to the caseous or larda-
ceous matter of tubercles; at other times a great number of small,
white bodies are found disseminated over the surface of the intes-
tines, corresponding to the grub or emphragma sebaceum of the
skin; for they are nothing more than the follicles filled with con-
crete mucus. ~ From these bodies is secreted a thin, greyish mucus,
which sometimes collects in astonishing quantities in particular
parts of the intestinal canal; or, spreading itself in every direction,
forms a thick mucous coat over a considerable part of the surface
of the intestine, which, on first view, might be easily mistaken for
the mucous membrane itself in a white and healthy state. Occa-
sionally the mucus is of a brown colour and tenacious, or a con-
crete matter, either spread in the form of a membrane, or forming
solid masses. These secretions would at first seem to be, and
perhaps at times are, the product of inflammation, but often they
acknowledge no such origin. They resemble the pultaceous and
pseudo-membranous stomatitis, which I have described in preceding
lectures, in their nature and mixed character; and still more the
exudation which overspreads often the mucous coat of the intes-
tines in malignant cholera. In the disease before us, the disordered
state of the follicles occurs in two ways ; first, in which the secre-
tion is suppressed or retained ; and second, in which it is excessive
or overflows. It is easy to conjecture how the mucous membrane,
according as it is*denuded of its appropriate mucus, or sheathed and
coated by it, will either acquire morbid sensibility and give rise to
most painful affeotions of the intestinal canal, and by sympathy
rouse other organs into action ; or excite disorders of another
kind by the mechanical causes of irritation furnished in its morbid
secretion.
The subjects of follicular duodenal, or rather enteric dyspepsia,
are most frequently females and children, in whom the mucous fol-
licles are most developed. It prevails most in cold, humid seasons
and climates; and therefore, prepared by the influence of winter, it
often declares itself in early spring and on the return of cold in
autumn. " Sedentary employment, or confined and impure air, with
neglect of personal cleanliness, are the circumstances most powerful
in producing it; to which may be added unwholesome food. When
the predisposing causes have been in operation, it is generally ex-
cited at once by colds, errors of diet, drastic purgatives, fatigue,
STRUMOUS DYSPEPSIA.
175
watching, anxiety, alarm, and bodily accidents. Constipation of
the bowels, while it is a consequence, is, also, one of the exciting
causes of this disease."
Treatment.— We begin the cure of follicular enteric dyspepsia
by the administration of certain purgatives which exert a more
particular effect on the mucous follicles, such as senna, rhubarb,
scammony and aloes; and of other agents, such as chloride of
sodium, alkalies, iodine, mercurials, chalybeates, colchicum, an.d
ipecacuanha. There being no signs of intestinal irritation present,
we may give rhubarb with sulphate of potassa, or the compound
powder of scammony, or the infusion of senna ; this last sometimes
being combined with compound infusion of gentian, and receiving
ten to twenty drops of liquor potassce, repeated so as to produce four
or more stools in the twenty-four hours. Small doses of mercurials
are no bad preparatives for the administration of purgatives. Iodine
in the shape of iodide of potassium will, also, in conjunction with
sulphuret of potassa, exert a good effect in altering the morbid state
of the follicles. Chalybeates are also recommended, and in this
disease, instead of rendering the feces darker, restore them to their
natural colour. The mineral acids or chalybeates ought to follow,
or occasionally alternate with, the employment of purgatives.
Among the corrective and restorative means, bathing will stand
high on the list; the kind of bath, shower or immersion, and its
temperature depending on the constitution and habits, in this respect,
of the patient. The tepid, or warm salt water bath will, generally,
however, be entitled to the preference.
As might be inferred from a knowledge of their effects in other
forms of dyspepsia, and in glandular obstructions generally, mine-
ral waters have been found to display virtues in this variety superior
to all other remedies. The sulphurous class are especially to be
relied on; and of these our own country furnishes abundant oppor-
tunities for the invalid to avail of their virtues.
Strumous Dyspepsia, as defined by Dr. Todd, is that form of
dyspepsia which belongs to the scrofulous constitution; and the
features of which are more distinctly marked than might be in-
ferred from the want of any good portrait which has yet been made
of it. Whatever may be the temperaments in which scrofula pre-
sents itself, and it is met with in all of them, this form of dyspepsia
will there be found. Of late years it has been described by Mal-
fatti of Vienna, under the name of latent scrofula; by Dr. Ayre,
under that of chronic marasmus ; and most faithfully by Sir James
Clark, under the term tubercular cachexy : it has also been sketched
by Dr. Marshall Hall, under the title of disorder of the general
health in tuberculous affections. It has not, however, Dr. Todd
thinks, been connected by any of these physicians with a special
disorder of the chylopoietic viscera.
I cannot repeat the very lucid and detailed, yet not overcharged,
description of this disease by Dr. Todd, but must content myself
with a brief summary; premising, that I can vouch for the accuracy
176
DISEASES OF THE DIGESTIVE SYSTEM.
of all his details, from the disturbance of digestion during the first
dentition, to the formation of scrofulous deposits, some years after-
wards. The complexion loses its colour, the skin its tone, the
flesh is soft and flabby, the abdomen tumid; uneasiness soon follows
exercise or play; the temper is fretful or capricious; the intellect
exceedingly precocious, or unusually dull. The sleep is seldom calm
or composed. Costiveness and diarrhoea alternate, although the for-
mer is the prevalent derangement. As the child grows, sore throat
with tonsillitis is a common complaint, together with a frequent
tickling cough, and itching and picking of the nose and lips. The
hands and feet are usually cold and clammy, or,on the least cold, turn
of a dark, livid, purple colour, and the child is extremely subject to
chilblains, even sometimes in summer. Diseases of the skin and
eyelids, and abscesses of the cellular tissue, still farther complicate
the disorder and increase the sufferings of the patient.
I have seen the nutritive functions so entirely perverted by a
continuance of these disorders, that spinal irritation resulted, and
all the symptoms of pulmonary tubercles manifested.
In adult life the disease is modified in various ways — although
the same general character is obvious. The appetite is good, some-
times voracious, and eating does not produce a feeling of repletion
and content. The bowels are torpid ; sometimes, but more rarely,
loose; the urine generally deposits a whitish sediment, sometimes
mucus. The pulse, always weak, is small, and accelerated by the
least emotion or exercise, although generally it is slow and weak.
The sleep is seldom natural; there is listlessness and drowsiness by
day, and the patient is commonly timid, nervous, torpid, or hypo-
chondriacal. The lymphatic glands of the neck and groin, and the
thyroid gland, are large and swollen, but not painful. In women,
leucorrhcea, painful or deficient menstruation; in men, a disposi-
tion to hemorrhoids is observed ; but the usual progress of the dis-
ease is to tabes mesenterica or phthisis pulmonalis.
Pathology. — In a constitution in winch the solids are lax, the
general circulation feeble, and the tone of the system low, it is
obvious that any part much and habitually stimulated will become
the centre and seat of afflux and congestion. Now, this is precisely
what takes place in the case of children of a strumous habit; the
wants of nutrition are unceasing, but the aliment is not assimilated
as it ought to be. The natural excitement is not diffused through
the different apparatus of organic life, as it is in health ; but is re-
stricted to the first or digestive, and the continued irritation of the
gastro-enteric mucous membrane causes a congestion which inter-
feres with a due circulation of the system of the vena portarum,
and produces a plethora in its roots and branches. The liver thus
disturbed in its structure, is equally so in function, and contri-
butes to the deterioration of the system, by preventing chylosis and
healthy hematosis. Consequent on this disturbance and irritation,
arise a host of sympathetic derangements in other and remote
organs, — the brain, nerves, muscles, &c. Not dissimilar to these are
TREATMENT OF STRUMOUS DYSPEPSIA.
177
the views expressed by Dr. Ayre in the following extract: " Diseased
mesenteric glands occur in children from acrid condition of
the duodenal contents; the liver, pancreas, and duodenal glands
become diseased from congestion, and irritation will be propagated
to the brain,giving rise to hydrocephalus,spasms, convulsions, vomit-
ing, contortions of the countenance, affections of the sight, violent
headaches, faltering voice, chorea, palsy."
Treatment. — It is seldom necessary to begin the treatment by
bloodletting in order to relieve the congestive state of the liver;
but when there are evidences, in a dry and red tongue, and fulness
of the right hypochondrium, of febrile excitement, the application of
a few leeches will afford speedy relief and prevent the necessity of
administering active agents internally. In general, a light or sim-
ple diet, even when abstinence is not enjoined, and nitrate of
potassa in small doses, with free dilution preceding and accompa-
nying laxatives, will constitute the requisite antiphlogistic treatment.
The hydrargyrum cum creld, and a small quantity of ipecacuanha,
or ipecacuanha and chalk, are good formulas, to follow after these
medicines. Small doses of castor oil, a little electuary of senna,
are useful adjuncts to the mercurial preparation, to which may
succeed a course of taraxacum, or sarsaparilla, or both united. It
is in this form of dyspepsia, more than any other, that we may
look for the alterative and recuperative effects of the iodide of
potassium, or of the iodide of iron, or of the former alternating with
the subcarbonate or the muriated tincture of iron. I have tried
both modes of practice with satisfactory results. Saline chalybeate
water is a still preferable mode of using the iron, and allows of its
continued use for a longer period than when procured from the
shop. Dr. Todd recommends a combination of iron and iodine, as
follows: —
R. Tinct. Ferri Chloridi,
Tinct. lodini, aa f 3'J-
Aquae Pura?, f ^ss. M.
Dose, ten to thirty drops three times a day, in common syrup, or simple bitter
infusion.
Bathing must be put in requisition, aided by frictions and mode-
rate, but by no means fatiguing, exercise, in order to give tone to
the skin, and by directing the blood to this organ, as well as to the
muscles, make them diverticula for the congested liver and portal
system generally.
The food should be small in bulk, but of adequately nutritive sub-
stances. Milk will not often agree without dilution. Farinaceous
food—stale bread, biscuits, rice, arrow-root with cream at the
morning repast, and a small portion of animal flesh af dinner,
are best adapted to the patients suffering under this form of dys-
pepsia.
I shall reserve for another occasion the remarks which might
find place now on that other troublesome form or common accom-
178
DISEASES OF THE DIGESTIVE SYSTEM.
paniment of dyspepsia called colonic, in which the large intestine
is the chief seat of irritation and the cause of disorder of the diges-
tive function.
In concluding, I cannot give you better parting counsel for your
guidance, than by repeating the expressive language of Dr. Chap-
man, in the discourses already quoted.
"But what will all I have said accomplish, unless the remote and
exciting causes of the disease be carefully avoided. Let it, there-
fore, be imperatively inculcated on a patient, that he is altogether
to renounce those habits and pursuits, which, directly or indirectly,
may have contributed to the production or maintenance of his
case. If he be intemperate, he is to become sober: if he uses
tobacco, opium, or any other baneful article, he is to relinquish it :
if he be luxurious, he must institute a reform in his way of living:
if he be indolent, he should be awakened to enterprise: if he be
studious, he is to abandon the midnight lamp : if he be afflicted, we
must soothe his misfortunes by holding out to him the promises of
hope, and the gilded prospects of the future.
" These cases are often very troublesome and trying to the
patience of a practitioner, from the great predominance of hypo-
chondriaism. Exceedingly querulous, from the very nature of the
disease, the dyspeptic is eternally complaining of the most prepos-
terous feelings, and is apt, after a time, to exhaust our benevolence
and sympathy. But this is wrong. Whatever may be the extra-
vagance of his conceits, they arise from the intimate dependence
of our moral nature on our physical constitution — and being the
result of diseased action, become legitimate objects of medical care.
Treat him, therefore, kindly, and even with tenderness. Encourage
him to the last with the expectation of cure — and never, on this or
any other occasion, should the patient be consigned to the horrors
of despair."
" Sunt verba et voces, quibus hunc lenire dolorem
Possis et niagnam morbi deponere partem."—Hor.
" The power of words, and soothing sounds appease
The raging pain, and lessen the disease."— Francis.
LECTURE XV.
Ileitis, — complication and nature of—Dothinenteritis — Ulceration of the
mucous membrane —Symptoms and diagnosis of ileitis___Diseases of the
small intestines — Symptoms of ileitis —Occurrence of diarrhoea with fever
symptomatic of this form of inflammation — Frequency and symptoms of the
disease in children. — Tabes mesenterica, — treatment of.
Ileitis. — Inflammation of the ileum is a most important affection,
for two reasons; first, in consequence of its extraordinary frequency,
and, in the next place, of its insidious latency, the disea'se generally
requiring a considerable degree of tact and experience on the part
NATURE OF ILEITIS.
179
of the practitioner to make out its diagnosis with certainty. In
fever, it is the most frequent of all forms of intestinal inflammation;
and hence Broussais, finding inflammation of the ileum of such
constant occurrence in fever, concluded that fever was only symp-
tomatic of intestinal inflammation. Further researches have shown
that he was mistaken, and that the inflammation of the digestive
tube is, in many cases, secondary; but it is still a circumstance of
almost constant occurrence, and in many cases of fever is the cause
of death. Now, the portions of the intestinal tube most commonly
affected in fever are the stomach and lower part of the ileum ;
and the frequent occurrence of this in fever is very remarkable.
There are few cases of typhus without it. In some cases of typhus
you will, on examination after death, be astonished to find exten-
sive disease of the intestinal canal, which, during life, had not
attracted any particular notice, and this you will most commonly
find in the lower part of the ileum. So common is it, that Louis
says that ileitis is the grand anatomical feature of typhus fever ;*
that is, had he been obliged to pitch on the lesion of some particu-
lar organ as giving a character to typhus, he would say that it was
ileitis. There are other diseases, too, in which inflammation of
the ileum forms the principal complication. In the diseases of
children, which go by the names of worm fever, remittent fever,
and bilious fever, I believe that ileitis is generally the first affection,
and that the fevers are only symptomatic of it. It constantly
occurs at some period or other of tabes mesenterica; and I believe
that in many cases it precedes the affection of the mesenteric
glands. It is exceedingly common in phthisis. In every case of
phthisis, where diarrhoea has lasted for some time, the probability
is, that there is ulceration in the caecum, colon, and lower part of
the ileum.
Now, what is the nature of this ileitis 1 This preparation, (hand-
ing one for inspection,) which I beg of you to hand round, will
furnish a very good illustration of the disease. Here is a portion
of the intestine exhibiting various distinct ulcerations of different
sizes, occupying the situation of the mucous glands. I do not mean
to say that the character of the disease consists in this distinct
ulceration; it is an essential disease of the mucous membrane; and
of its glands, which exists in great numbers on the surface of the
lower third of the ileum, and are called solitary and aggregate.
These glands frequently take on the inflammatory condition, be-
come softened, run into ulceration, and produce extraordinary
sympathetic irritation of the whole system. There has been lately
a great deal of discussion with respect to the question — Whether
disease begins in the glands or in the mucous membrane, and
whether we can separate disease of the glands from disease of the
mucous membrane. This has been carried to a great extent; and
* [We must rather say of typhoid fever. Farther particulars, re-
specting the connection between this fever and intestinal lesions,
will be given, by me, in a subsequent lecture. — B.]
180 DISEASES OF THE DIGESTIVE SYSTEM.
a change has been attempted to be made in the name of the disease,
it being entitled dothinenteritis by those who say that the inflam-
mation commences in the glands. But this, I think, is a mere
refinement, and is carrying the thing too far. It is next to impos-
sible for the glands to be affected without involving the mucous
membrane, or for the mucous membrane to be affected without an
extension of the disease to the glands. We sometimes, however,
see the mucous membrane diseased without the glands being ap-
parently engaged ; but I think the glands are never engaged without
the coexistence of disease in the mucous membrane. In this
preparation you see the mucous membrane is just giving way ; and
here is an actual slough, where the mucous and submucous tunics
have yielded to the inflammation. In the lower portion of the
ileum we meet with an infinite variety in" the size and number of
the ulcerations : in some they are very close and numerous, in others
there are only two or three detached ones ; in some, the whole
circle of the intestine is destroyed ; and the ulcer is nearly as broad
as the palm of your hand. It is interesting to consider, with
respect to the pathology of the respiratory and digestive systems,
how it comes that ulceration of the mucous membrane is so much
more common in the digestive apparatus than in the respiratory.
For one ulceration of the bronchial mucous membrane from acute
disease, you will have one hundred of the gastro-intestinal. For
this peculiarity we cannot clearly account; but there seems to be
more development in the digestive than in the respiratory system,
and that this over-development produces a tendency to diseases.
This, perhaps, is an approximation to an explanation of the facts:
and to this may be added, that the mucous membrane of the intes-
tines is exposed to the influence of a much greater variety of agents.
It is difficult to give an accurate idea of the symptoms of ileitis, as
we can only arrive at a knowledge of it by negative evidence, or,
as the French term it, " par voie d'exclusion."
In a case of gastritis and of inflammation in the upper part of
the digestive tube, the most prominent symptoms are thirst and
vomiting. In this affection, too, there is thirst, but it is by no
means so urgent as in the former cases, and there is generally no
vomiting. In a case of acute gastritis there is always a desire for
cold drinks. In this disease there is also a desire for fluids, but
the patient prefers them warm. Here you perceive two symp-
toms connected with the predominance of disease in the upper part
of the digestive tube are absent — vomiting and the desire for cold
drinks.
Now, you are aware that, in a case of inflammation of the colon
and rectum, the most prominent symptoms are diarrhoea, tenesmus,
and the passing of a quantity of morbid secretions. These symp-
toms, in a case of ileitis, are either wanting, or they are so slight
as to excite very little notice. If, then, in a case of intestinal dis-
ease, we abstract the characteristic symptoms of disease in the
upper and lower part of the digestive tube from the phenomena of
the existing disease; if we find that it presents symptoms which do
DIAGNOSIS OF DLEITIS.
181
not properly belong to either the stomach, duodenum, colon, or
rectum ; we conclude that it must depend on a lesion of the re-
maining part of the canal, and we are in this way led to the dia-
gnosis of ileitis. Let us enumerate the symptoms of an ileitis. In
the first place, thirst, without a preference for cold drinks; in the
next absence of vomiting ; again, in the early period of the disease,
there is generally a tympanitic state of the belly, and the patient
seldom complains of pain, even in fatal cases. This is a point of
extreme importance. There is, however, most commonly a degree
of tenderness over the ileum, which you will be able to detect by
an accurate examination, and this tenderness presents a remarkable
difference from the tenderness of gastritis, both in degree and situa-
tion. It is very seldom so exquisite as in a case of gastritis, the
patient can bear a considerable degree of pressure, and the tender-
ness, in place of being towards the epigastrium, is situated between
the umbilicus and the crest of the ileum on the right side; here
pressure excites pain. The tongue in this affection is generally of
a dirty white, pointed, and red along the edges and tip; the pulse
is quick and small, and the face is contracted. As to the nature of
the discharges from the bowels they are exceedingly various; there
has been as yet no diagnosis founded on their appearance, and in
some fatal cases they have been observed to retain an almost per-
fectly healthy appearance throughout. What would the gentlemen
who draw their diagnosis from the chamber-pots say in such cases?
I have seen perfectly natural stools in cases which immediately after
have terminated fatally, and where, on examination after death,
there was a vast extent of ulceration in the ileum. In addition to
the symptoms just recited, the patient most commonly has fever,
and this presents itself under various forms, frequently assuming the
type of a simple continued fever; hence, in a great many cases, the
patient is merely supposed to labour under simple continued fever,
and the existence of extensive inflammation of the ileum is entirely
overlooked. In other instances, there is more or less prostration,
which increases with the progress of the disease, and the fever
frequently receives the appellation of typhoid. Under these cir-
cumstances, the patient often gets bark and wine, every means is
taken to support his strength and remove the typhoid condition of
the system, the inflammation of the intestine is exasperated by
neglect and maltreatment, the patient dies, and, on dissection, the
ileum presents an enormous sheet of ulcerations.
In cases of this kind, where the diagnosis depends as much on
negative as on positive circumstances, it is of importance to have a
direct sign by which we may be able to ascertain, with some degree
of certainty, the existence of a suspected enteric inflammation, and
I think I have discovered one, which I believe has not been as yet
noticed ; this is increased pulsation of the abdominal vessels. In
many cases of acute inflammation of the brain, the increased pul-
sation of the carotids has been frequently remarked, and every one
sees, that, under such circumstances, there is an undue excitement
vol. i.—16
132
DISEASES OF THE DIGESTIVE SYSTEM.
of these vessels, or, in other words, that there is a want of propor-
tion between the action of the carotids and the arteries of the
extremities. If your finger be attacked by paronychia the same
phenomenon is observed, the artery leading to the inflamed finger
beats much stronger than the artery of the corresponding one on
the opposite side. From these circumstances I was led to conclude,
that, in cases of acute inflammation of the digestive tube, there
would be increased pulsation of the abdominal aorta; and on fol-
lowing up the investigation by examining several persons who had
distinct and well marked intestinal inflammation, I found that my
conclusions were well-grounded. In such cases, I found not only a
remarkable throbbing of the abdominal aorta, but I also discovered
that this throbbing was prolonged to the femoral arteries, and that,
on the other hand, there was little or no corresponding excitement
in the arteries of the upper extremities.
You remember I mentioned to you that most of our knowledge
of the inflammatory affections of the small intestines refers to the
ileum, and that, in point of fact, we know little or nothing of disease
of the jejunum. This, however, is not of much importance ; of all
the parts of the digestive tube, the jejunum is the least liable to disease,
and is seldom or never engaged without the coexistence of disease
in the ileum or duodenum. You recollect I drew your attention
strongly to the extreme frequency of inflammation in the lower third
of the ileum, and the importance which it derives from this as well
as from its insidious latency. I showed that it was one of the
most common secondary lesions in typhus fever, and a frequent
cause of death. This cannot be impressed too much upon your
minds—it is a point of pathology on which the best informed
medical men are agreed. It may, also, and very often does, occur
as a pure idiopathic affection, without being preceded or superin-
duced by that morbid state of the whole economy to which we give
the name of fever. I said it was extremely common in children ;
that here it was in many instances mistaken for worms, or bilious, or
remittent fever; that it constantly occurred during the progress of
tabes mesenterica, and often appeared to have the initiative. It
alluded to the discussion which has arisen as to the question
whether disease begins in the glands or mucous membrane, and
stated that such discussions are useless, as it is impossible to sepa-
rate the two affections in diagnosis or treatment, and practical
medicine gains nothing by the distinction.
With respect to the symptoms of ileitis, I observed that they were
those of a general affection of the digestive tube, the phenomena
which indicate irritation at its upper and lower part being absent.
That if you abstract from symptoms of a general affection of the
intestinal canal, the vomiting and desire for cold drinks which
characterize inflammation of the upper part, and the diarrhoea and
tenesmus which denote disease of the lower part, you will have the
diagnostic marks of an ileitis. At our last meeting I showed you
some preparations illustrative of this disease; I intended to have
SYMPTOMS OF ILEITIS.
183
exhibited others of the same kind to-day, but regret that I cannot
lay my hands on them at present. Allow me to rehearse the
symptoms of ileitis once more. Thirst, without desire for cold
drinks; absence of vomiting, and of the characteristic symptoms of
inflammation of the colon and rectum ; early tympanitis, generally
on the second day of the disease; absence of pain, but existence of
tenderness on pressure between the umbilicus and the crest of the
ileum ; pointed tongue, of a dirty white on the upper surface, and
red at the sides and tip; contracted features; quick, small pulse;
fever, and, what I forgot to mention in my last lecture, scanty high-
coloured urine, a very constant symptom, so much so that I have
known this disease mistaken for an affection of the kidney, and the
patient treated accordingly. I must add, that the patient died, that
the kidney was found perfectly healthy, the ileum in a,state of
violent inflammation, and the suppression of urine to be referred to
this cause alone.
I drew your attention at my last lecture to the increased pulsa-
tion of the abdominal aorta and its immediate branches, and stated
that I looked upon this as a direct sign of abdominal inflammation.
I do not mean to say that every case of increased action of the
great abdominal arteries is significant of ileitis or intestinal inflam-
mation. We see unusual pulsation of the abdominal aorta in
hysterical females, and see it subside under the use of antispas-
modics; we see it in painter's colic ; we see it in cases of extreme
emaciation; we see it in disease of the aorta, or some of its first
large branches. What I wish to draw your attention to, is this:
where we have this symptom in addition to other signs of inflam-
mation of the digestive tube, it is of considerable value as a dia-
gnostic.
You may remember I stated that ileitis, from being generally
attended by fever of the continued type, has been frequently supposed
to be simple continued fever, and that this was one of the conse-
quences which resulted from the latency of the disease. Petit was
the first who described this disease rightly. He described it under
the name of entero-mesenteric fever, that is to say, fever depending
on disease of the mesenteric glands and small intestines. The fol-
lowing in an outline of his description : " The attacks come on with
debility, irregular fever, quick, small pulse, sunken countenance,
perhaps some diarrhoea, a lustrous expression of the eye." I may
remark here that the occurrence of diarrhoea without any evident
affection of the great intestine, and accompanied by fever, is almost
always a sign of ileitis. It too often happens that practitioners, as
I before remarked, prescribe for names. In cases of pulmonary
disease, if the patient has fever, with copious expectoration, they
say he is labouring under an attack of bronchitis; but in case of
intestinal inflammation, accompanied by increased secretion, it is
different; they merely say he has diarrhoea, and prescribe for it
without connecting it with its proper cause. The general rule is,
184
DISEASES OF THE DIGESTIVE SYSTEM.
that when you have diarrhoea with fever, there is inflammation of
the digestive tube.
In inflammation of the ileum the patient generally lies on his
back, and avoids motion as much as he possibly can, his skin is
dry and harsh; he is feverish; he has thirst, but little desire for
cold drinks; he scarcely ever vomits; his alvine dejections are
sometimes thin and purgative, sometimes figured and natural.
But there is one circumstance which is of considerable importance
in pointing out the amount of disease, even in cases where patients
have considerable diarrhoea, and this is, that the diarrhoea is not
sufficient to account for the extraordinary prostration. There must
be some cause for the great reduction of vital power besides the
mere diarrhoea, and I must state to you that there are few diseases
which bring on such rapid prostration as inflammation of this por-
tion of the digestive tube. In the advanced stage of this disease
the patients have cold skin, subsullus tendinum, petechias, involun-
tary discharge of urine and feces, low delirium, coma, gangrenous
ulcerations of the back, sinking of the powers of life, effusions into
the head and chest, in fact all the symptoms which characterize
the last stage of typhus. Generally speaking, the disease is more
or less prolonged, and the patients die of exhaustion, but in some
cases the approach of death is more sudden and formidable. Some
of the ulcers pass deeply into the substance of the intestine, perfo-
rate all its coats in succession, the contents of the intestine escape
into the peritoneum, and the patient is carried off by a rapid
peritonitis.
Inflammation of the ileum is very frequently met with in chil-
dren, and it is most important that you should be aware of the ex-
treme frequency, as well as the symptoms, of this disease, in those
little creatures. There is one fact in pathology which seems not
to be generally acted on — that there is a class of diseases which
are intra-uterine, and with which a child may be born. There are
a great many cases of this kind on record, but still, I must confess,
there is a great scope for investigation, and that our knowledge
on this subject is imperfect. I believe that any one who has the
opportunity of dissecting a great number of still-born children, or
of those who die immediately after birth, would, by examining the
state of the different cavities, and publishing the results of his
examinations, earn for himself very great reputation. It is a well
known fact that children may be born with hydrocephalus, with
tubercles in the lungs, with acute inflammation of the stomach;
nay, more, children have been known to be born with chronic gas-
tritis, and with old ulcerations in the ileum and colon. When
children happen to be born with gastro-enteric disease, they are
puny and weak; the fact of this occurrence is generally overlooked,
the case is considered to be one of general debility, and hence most
of those children are lost in consequence of their medical attendants
being ignorant of the real nature of the disease. It is a very
FREQUENCY OF ILEITIS IN CHILDREN.
1S5
curious fact, too, that where enteric disease occurs in very young
children, it is frequently met with without any accompanying fever,
and this is a point of great importance. Here is a fact not gene-
rally known. A new-born infant has vomiting, swelled belly, con-
tracted features, but at the same time he has cold skin and feeble
pulse; he has no distinct symptoms of fever, and a puny and feeble
state of constitution appears to be the prominent symptom. He
dies, and on opening the body you find distinct traces of enteric
inflammation. The younger the child is, the less will be the chance
of fever occurring as a sign of enteric inflammation. It seldom
happens that this take place after dentition, but before it is very
common.
Now, what are the circumstances which would enable us to re-
cognise this disease in children who have passed the period of first
dentition? If you find the child vomiting, thirsty, with swelled
belly, hot skin, a tendency to diarrhoea, and an erythematous red-
ness about the anus, you may be sure that there is disease of the
digestive system; if the child is restless, and you perceive that the
symptoms of irritation of the head are coming on, you will be more
certain, and in such cases pathology will inform you that the dis-
ease is chiefly in the ileum. In the advanced stage the diarrhoea is
lessened, but the belly continues tympanitic, the child exhibits
traces of long suffering, and the circumstance of the teeth not
being developed gives it the appearance of premature old age,
which cannot be mistaken by an experienced eye, and is a sign of
long continued and extensive intestinal disease. In some cases the
child gets a common attack of diarrhoea ; this is neglected, but
after going on for two or three days, symptoms of fever begin to
appear. Here we arrive at a practical rule. Where a child has
diarrhoea, and, after labouring under this for a few days, gets an
attack of fever, you may be almost sure that it is a case of enteritis,
and that you will be acting wisely in treating it as such. In the
opinion of many well-informed practitioners, that form of fever
which has been called infantile remittent, is only an example of this
disease, in proof of this fact, Dr. Marsh, my friend and predecessor
in this school, in his paper on jaundice, makes some excellent re-
marks on this subject. " There is yet one form of disease of very
frequent occurrence, the seat of which is in the stomach and small
intestines. That to which I allude, is the infantile remittent fever,
or, as it is vulgarly termed, the worm fever of children. Its charac-
teristic symptoms, if closely analysed, will be found all of them to
point to the mucous surface as the original seat of morbid action."
— Dublin Hospital Reports, vol. iii.
It would be well for medicine, if the valuable information con-
veyed in Dr. Marsh's paper was more universally diffused. I feel
convinced that many children fall victims to malpractice under
circumstances of this kind. A child gets symptoms of diarrhoea,
has irregular or bad appetite, and swelled belly. The disease is
called worm fever ; he gets a dose of calomel and jalap, and per-
16* '
186
DISEASES OF THE DIGESTIVE SYSTEM.
haps, passes some worms; for, when we come to speak of worms,
we shall find that disease of the mucous surface is intimately con-
nected with worms, and, in the opinion «f one practitioner, worms
may be the result of enteric inflammation. Well, some worms are
passed; the purgative is again used; the child may not pass any
more, or he may pass one or two in a week, to encourage the
practice. But all the symptoms of intestinal inflammation, the
diarrhoea, the tympanitis, the thirst, the fever, are supposed to
depend upon the presence of more worms, and these are to be
evacuated by purgative medicine; and thus the affair goes on,
until the child falls into tabes mesenterica, or gets sympathetic in-
flammation of the brain, and dies of hydrocephalus. I regret to
add, that in many cases of this kind the head alone is opened; a
little fluid is discovered in the ventricles of the brain, the doctor's
diagnosis of the head is found to be correct, and all parties are
satisfied. In cases of this kind, the early application of leeches to
the belly, the regulation of diet, keeping the bowels gently open by
enemata and mild counter-irritation, would have saved the patient.
This is not mere theory; it is but a statement of facts, supported
by the experience of practical men.
Tabes Mesenterica.—Iwishto say a few words here with respect
to tabes mesenterica. In a course of lectures like the present, it would
be impossible to examine, in detail, the different forms of this disease ;
it will be as much as I can do to draw your attention to the general
principles of its pathology and treatment. The, term, tabes mesente-
rica, is employed to designate that species of consumption which
depends upon disease of the mesenteric glands. The common idea
formerly entertained with respect to this affection, and, I believe, still
to a great extent, is, that the disease first commences in the mucous
glands, and from these extends to the lymphatic ganglia of the
mesentery, which, in their turn, become enlarged, thickened, and
less pervious, so that a sufficient share of nutriment cannot be
absorbed, the consequence of-which is, that the patient dies of
atrophy and exhaustion. With such views of the case, the prin-
ciples of treatment consisted in employing a class of medicines
called deobstruent, the operation of which was supposed to be
efficacious in removing this obstruction, this deposition in the sub-
stance of the mesenteric glands, and the enlargement by which it
was accompanied. This was, and this, I am sorry to say, is the
idea still entertained by many. What is the actual state of the
science with respect to this disease 1 It is found that the glands
are certainly changed in their structure, and that they are mani-
festly enlarged ; but this is only a link in the chain of phenomena,
for it has been proved that in the majority of cases the disease is
ushered in by enteritis, and that the swelling of the glands is the
result of disease, propagated along the course oj the lymphatics
from the mucous surface of the intestines to the mesenteric ganglia.
This preparation, which I shall send round, will give you an idea
TABES MESENTERICA.
187
of the actual state of the disease. Here is one of the glands which
has been cut through; it exhibits the cheesy texture commonly
observed in this disease, but you can perceive there are a number
of lines running towards each of the glands ; there are the engorged
lymphatics, which, you see, correspond with ulcers on the mucous
surface of the small intestine. That this is the true pathology of
the disease will appear from the following circumstances: — First,
it has been proved that the glands of the mesentery commonly
become inflamed, enlarge, and suppurate, in cases of inflammation
of the mucous membrane of the intestinal canal in the adult. A
patient gets enteric, inflammation and dies ; on dissection, we find
distinct marks of disease in the intestines, and, in addition to this,
we find the glands evidently diseased. Here is one fact. In the
next place, it has been proved that, in a great many cases of tabes
mesenterica, if you retrace the history of the disease, if you go
back to its first and earliest phenomena, you will find that it began
with the symptoms of what has been termed remittent fever, or that
the patient had enteritis or diarrhoea, which afterwards became
chronic, and that then the symptoms of tabes mesenterica began to
appear. In the third place, you will find that, in a vast number of
cases, where a fatal termination has occurred, if you pursue your
dissection, and slit up the whole of the ileum, you will discover
numerous old ulcerations of the mucous membrane, and find that the
lymphatics which correspond with these ulcerations are in a state
of manifest disease. Lastly, it has been observed that the best
treatment for tabes mesenterica is that which is calculated to remove
enteric inflammation, and that the old treatment, founded on the
principle of removing obstruction, by the use of alkalies, absorbents,
and solvents, is erroneous and false in the majority of cases. So
that we have proof of the origin of this disease in intestinal inflam-
mation, drawn from the occurrence of analogous affections in the
adult, from the phenomena of the disease in its early stage, from
morbid anatomy, and from treatment. I think there can be no
doubt that, in most instances, it commences by intestinal inflamma-
tion. Of course a predisposition to disease of the glandular system
will favour the occurrence. But is there no case in which the dis-
ease has commenced in the glands, and where the mucous mem-
brane of the digestive tube is secondarily engaged? My answer
to this question is, in a few cases we cannot prove that the disease
commenced in the mucous membrane, and there is no reason why
the glands of the mesenterica should not be liable to primary tuber-
culous or scrofulous deposition as well as those of any other part
of the body; but in a vast number of instances, the enlargement of
the mesenteric glands is secondary, and resembles the inflammation
of the inguinal glands which results from chancre on the penis. I
would advise you to consult the Commentaries or Pathological
Propositions by Broussais. On this subject, also, Dr. Mackintosh's
Practice of Physic.
There is one thing more connected with this disease, which is of
188
DISEASES OF THE DIGESTIVE SYSTEM.
considerable importance, and to which I shall briefly draw your
attention, and this is, that this inflammation of the glands of Peyer
and Brunner, this dothinenteritis, as it has been called, is a very
common cause of slow convalescence in fever. You will meet
with cases of fever, which will go on to the 17th or 21st day, and
then something like a crisis takes place ; you expect that from this
time forward the patient will get progressively better; but in the
course of a few days you will be surprised to find no amendment,
and that he is not gaining strength; you feel his pulse, and find it
quick and small; his attendant informs you that he is restless at
night; and when you ask him how he feels, he says he has no
particular complaint, but that he is very weak, gets no sleep at
night, and has no appetite. Under these circumstances you are
anxious to find out what his disease is ; you inquire into the state
of the heart, lungs, and brain ; you find no evidence of disease in
any of these organs; you run over in your mind the symptoms
present, the feverishness, quick pulse, want of appetite, restless-
ness, and finding some degree of abdominal tenderness and tym-
panitic swelling, you arrive at the conclusion that the return of
health and strength is impeded and delayed by the existence of a
dothinenteritis. The first person who discovered this fact was
Dr. Cheyne. " In these cases," says he, " the distress of the patient
often bore no proportion to the danger he was in; the former was
very little, while the latter was extreme. The disease would pro-
ceed without violent symptoms; nay, a patient would seem to be
recovering, although without any critical discharge; he would
call for full or middle diet, and for days take his food regularly.
The only circumstance in his situation which demanded attention
was, that he regained neither flesh nor strength, and he expressed
no desire to leave his bed. Then, his pulse again became quick
and his tongue dry; and he would complain of dull pain and un-
easiness in his belly, attended with soreness on pressure, and a
degree of fulness in the upper part of the abdomen. Then came
on a loose state of the bowels, and great weakness. Probably at
the next visit the patient was lying on his back, with a pale sunken
countenance, and a very quick pulse; his mind without energy.
Then his stools (mucous) passed from him in bed, and the urine
also. Perhaps a hiccup came on; next his breathing became fre-
quent, in which case death was at no great distance." In all these
cases the mucous membrane and glands were found in a state of
decided disease.
Now, what was the nature of this disease ? It came on as a
secondary affection during the course of fever, became more marked
and intense, and finally destroyed the patient. I have seen very
many cases of this disease. I give you this as a general rule : —
when, after the apparent termination of a fever, your patient con-
valesces very slowly and imperfectly; when you find that he is
becoming weak, that his pulse is quick, his belly tympanitic, his
thirst still present, and all this without evidence of disease in the
TREATMENT OF TABES MESENTERICA.
189
respiratory, circulating, or nervous system, you may suspect inflam-
mation of the mucous glands of the digestive tube, which may ter-
minate in deep ulcerations; and you will not be surprised if your
patient should be carried off by rapid peritonitis, occasioned by an
ulceration of all the coats of the intestine. I have witnessed many
instances of the truth of this statement.
It has been objected to the doctrine, that infantile remittent fever
and tabes mesenterica depend on inflammation of the mucous
membrane of the digestive tube, because it has been found that
purgatives are sometimes useful in the treatment of the disease ;
and those who bring forward this objection ask, " if purgatives
give relief, how can it be intestinal inflammation 1" Now, what
are the real facts of the case? These cases, which have been
relieved by purgatives, are cases in which purgative medicine has
been given in the early stage, and has been productive of benefit;
or, in other words, where the disease is only just commencing, and
where its cause is proved to be the presence of irritating matter in
the bowels. A physician is called to a case of this kind; he gives
a purgative ; a quantity of offending matter is evacuated, and the
child gets better. You should act in the very same way, and have
recourse to purgatives whenever you have reason to suspect the
existence of irritating or indigestible matter in the bowels. You
are to employ purgatives on the same principle as every one em-
ploys emetics in cases where corrosive poison has been swallowed;
but no one is inclined to think that he will be able to cure the dis-
ease by the continued use of emetics. But, unfortunately,.persons
do not attend to the actual state of the digestive tube; they go on
prescribing purgative after purgative, until the irritation, which was
originally produced only by indigestible matter, becomes exacer-
bated, and terminates in ulceration of the intestinal mucous surface,
accompanied by all the symptoms of tabes mesenterica.
The treatment of this affection is both simple and easy, particu-
larly when the patient applies to you at an early period. In the
case of children, one of the first things you have to determine is,
whether you shall have recourse to the employment of purgatives
or not. If you happen to be called in at an early period, or if the
patient has taken no purgatives, and there is reason to suspect a
loaded state of the bowels, you will be right in employing some
mild laxative. You cannot commence your treatment better than
by prescribing some mild opening medicine, particularly when you
discover that the patient has been taking indigestible, improper food.
This plan I think both reasonable and useful. You will frequently
meet with cases in which all the bad symptoms will disappear after
the use of a few laxatives. Here is a point on which the followers
of Broussais erred. They declared that the exhibition of a single
laxative would be to endanger the patient's life; and that the only
treatment which could be relied upon consisted in the use of leeches,
low diet, and cold water. But I think there is as much reason in
giving a laxative to remove indigestible matter from the bowels in
190 DISEASES OF THE DIGESTIVE SYSTEM.
a case of this kind, as there would be in giving an emetic in a case
of gastritis produced by the presence of indigestible matter or cor-
rosive poison in the stomach. But if, after having evacuated the
bowels, the symptoms of intestinal irritation should continue, you
are not to persist in the use of purgatives; change your hand, and
attack the symptoms of intestinal inflammation, which have now
decidedly commenced.
We should occupy ourselves, gentlemen, at our next lecture, in
considering the treatment of this disease in the adult as well as
children, and then go on to the disease of the large intestines.
LECTURE XVI.
Treatment of ileitis— Advantage of leeching— Stimuli sometimes beneficial —
Infantile remittent fever— Inflammation of the mucous membrane — Enteritis
with diarrhoea — Effects of opium in inflammation of serous and mucous mem-
branes— Pathology and treatment of diarrhcea and dysentery — Perforation of
the intestine — Diseases of the large intestine.
We shall be occupied to-day in considering the treatment of in-
flammation of the mucous membrane of the small intestine. You
may recollect that in my last lecture I spoke of the employment of
laxatives in this disease, and mentioned that we are to employ
laxative's in enteritis, on the same principle as emetics are used in
cases where corrosive poison has been taken into the stomach. We
are not to expect to be able to cure the disease by the use of laxa-
tives, nor are we to have recourse to them in every case ; we employ
these remedies where we have decided evidence of the existence of
offending matter in the bowels. We may meet with a case in the
early stage, under such circumstances that the removal of the irri-
tating matter by judicious purgation may completely relieve the
patient, and this, I believe, is the foundation on which the super-
struction of the British purgative practice in ileitis and tabes
mesenterica was raised. It was concluded that a laxative treat-
ment, which had on many occasions succeeded in removing the first
symptoms of the disease, would necessarily cure it in all stages and
cases. This, I need not tell you, is wrong. Whenever you give
purgatives or laxatives in enteritis, bear this in mind, that the effect
which you have to produce is to be brought about at the least pos-
sible risk. If you can unload the bowels with a little castor oil or
rhubarb, or some mild neutral salt, it is much better than to have
recourse to calomel or scammony, or colocynth. As a general
rule, drastic purgatives must be avoided in inflammation of the
mucous membrane of the intestines. The school of Broussais
committed an error, on the one hand, by never admitting the use
of laxatives, and British practitioners have been wrong, on the other
hand, by giving too much purgative medicine. The error of the
Treatment of ileitis.
191
latter arose from looking always upon purgatives as antiphlogistics,
which they are certainly, so far as they contribute to relieve in-
flammation by causing an increased secretion from the intestinal
mucous surface. But this increase of secretion can be produced
only by stimulating the organ to which they are applied; and
hence, before they can become general antiphlogistics, they must of
necessity be local stimulants. Further; if in a case of inflammation
of the digestive tube you prescribe a purgative, and it fails in causing
an increase of secretion, it will add considerably to the existing
inflammation. It is, however, of very great importance that there
should be no accumulation of offending matter in the bowels; and
hence, when you find a degree of fulness in the belly, and the de-
jections scanty, you should always give a laxative and follow it up
by the administration of a narcotic. By using enemata, you can do
a great deal of good, and this without any injury to the digestive
tube; and I think they may be always employed with benefit in
disease affecting the ileum. Recollect, gentlemen, what I wish to
impress upon you respecting this part of the treatment is, that laxatives
are to be employed in ileitis as one of the means of cure; but you
are not to expect that a cure by the use of these alone will always
be a matter of constant occurrence. It is true that many cases,
presenting symptoms of enteritis, have, in the beginning, yielded to
laxatives; but it is true, also, that horrible mischief has been done
by their continued or indiscriminate employment.
A few observations now with respect to bleeding. There is in
simple inflammation of the mucous membrane of the intestines this
peculiarity —it very seldom happens that it is necessary to use the
lancet. The whole class of intestinal inflammations is so generally
accompanied, even in the early period, with marked prostration and
a typhoid condition of the whole system, that general bleeding is
very seldom employed. But when the disease is recent, the con-
stitution vigorous, the patient young, the skin intensely hot, and the
pain violent, (a combination of circumstances which is not of very
common occurrence,) you may employ the lancet with safety and
with great advantage to your patient. But what I wish to impress
upon you is this — you must not expect to cut short an attack of en-
teric inflammation by general bleeding. Over inflammations of mu-
cous membranes in general, but particularly of the intestinal mucous
surface, the lancet has comparatively but little direct power; it is in
the inflammatory affections of parenchymatous tissues and serous
membranes, that we generally observe the most brilliant and decided
effects of venesection. Neither can you, as in parenchymatous in-
flammation, bleed a second and a third time with benefit. In cases
of inflammation affecting the mucous membrane of the intestinal
canal, you are to look upon venesection as a preparatory step to
leeching. Where the pain is violent, the fever high, the attack
recent, and the constitution strong, you will do well to bleed; but
only bleed once, and then apply leeches in abundance over this
suffering organ. There is nothing of more importance, nothing of
such decided value, as bleeding by leeches in inflammation of the
192 DISEASES OF THE DIGESTIVE SYSTEM.
mucous membrane of the intestinal canal, and here we arrive at a
fact, the explanation of which is involved in much obscurity. A
patient is attacked with inflammation of the mucous membrane and
glands of the digestive tube, twelve or twenty leeches are applied to
the integuments of the abdomen, and their application is followed
by extraordinary relief. This is a very curious fact when we con-
sider that between the place where we apply the leeches and the
tissue which is affected, there intervene skin, cellular membrane,
superficial fascia, cellular membrane again, deep-seated fascia,
muscular substance, cellular membrane again, two layers of peri-
toneum, and muscular substance enveloped in cellular tissue. Yet,
notwithstanding this extraordinary succession of tissues, it is an
undeniable fact, that the application of a dozen leeches to the sur-
face of the belly will frequently cut short an intestinal inflammation,
or materially diminish its intensity. Here is a fact, the explanation
of which is extremely difficult; and I tell you candidly, I cannot
explain it. The school of Broussais attempt to explain it as follows.
They state that it is a constant law of the economy, that there is a
strong sympathy between the internal parts and their respective
integuments, but they do not say why this sympathy should exist.
We frequently, however, observe facts confirmatory of this law;
you are aware that it often happens, that, in cases of deep-seated
muscular phlegmon, mentioned by Mr. Crampton.in abscess of the
liver, and in empyema, we have a swelling of the integuments,
showing the existence of a sympathy between the integuments and
the internal organs.
In treating a case of inflammation of the small intestine, I think you
may generally commence with the application of twelve or eighteen
leeches over the ileo-coecal region.* The ordinary result of this
application is, that the pain and tympanites are reduced, and the
thirst diminished; but the patient still has fever, and you are to bear
in mind that the mere subsidence of pain does not imply the re-
moval of the disease. We may modify the character of an ileitis
very considerably by a single application of leeches, but we are not
on that account to expect that we shall be able to remove the dis-
ease entirely. In general it is necessary to apply them two or three
times, lessening the number at each succeeding application, and
taking care that they are applied in the proper place, that is, mid-
way between the umbilicus and the crest of the ileum. Many
* [Twice, or even three times, this number of our common
American leech may be applied in such a case. If leeches are not
at hand, we should not be backward in having recourse to the
lancet. I have employed venesection largely and repeatedly in
the case of a person who was neither young nor robust, but in
which there was much pain and an active pulse ; and with this
good effect, in addition to his recovery, that, whereas he used, pre-
viously, at not long intervals, to have frequent attacks of ileitis, he
has not had, subsequently, a return of the disease for a period of
seventeen years past. —B.]
TREATMENT OF ILEITIS.
193
practitioners are afraid of employing leeches in the advanced stage
of this affection, in consequence of the great debility which cha-
racterizes the advanced stage of this, as well as inflammation of
every other part of the digestive tube. But though I am quite of
opinion that the school of Broussais is wrong in using them at any
period, still I think they may be employed even where the disease
is advanced, particularly if they have not been used before, and I
have frequently seen leeches applied with advantage as late as the
twelfth day. I have employed them myself in the Meath Hospital
as late as the ninth and tenth days with decided benefit. Many
physicians on the continent are in the habit of treating inflamma-
tion of the digestive system by the application of leeches to the
anus, and this is said to have a very good effect, and the number
of leeches required is smaller. In disease of the great intestine
accompanied by diarrhoea, tenesmus, and tormina, I think this is
an excellent mode, but when the disease is in the upper part of the
tube, I prefer applying them to the belly over the situation of the
inflamed organ.
Now with respect to internal medicines. In this disease every-
thing that is administered should be given with the view of remov-
ing irritation, and for this purpose I know no better preparation
than a combination of ipecacuanha and opium, as in Dover's
powder. The exhibition of the compound powder of ipecacuanha
is attended with decided advantage. You are all aware of the long
established use of ipecacuanha and opium in diseases of the intes-
tinal canal, and I think there can be no doubt that they possess
considerable utility. With this I generally combine some mild
mercurial; the best you can employ is the hydrarg. cum cretd.
Give two or three grains of each every second or third hour, as
the case may be, and you may continue this for several days.
Where there is no diarrhoea, and the bowels have a tendency to
be constipated, it will be necessary to order, every second or third
day, a mild laxative, a little manna, or rhubarb, or some castor
oil; you should insist on the daily use of enemata, and if they
answer the purpose sufficiently I would advise you to be sparing
of the use of laxatives by the mouth. In addition to these reme-
dies, I am in the habit of giving a considerable quantity of gum
arabic, which appears to have an extraordinary efficacy in dis-
ease of the small intestine. I look upon it as peculiarly valuable
in diseases of children. The ordinary mode of prescribing it
is to give a certain quantity of gum water. If this is insufficient,
you should order half an ounce or an ounce of the gum to be dis-
solved in a pint or quart of water, which the patient is to use during
the day. After the use of the hydrarg. c. cretd and Dover's powder,
this has a decided value in the treatment of ileitis.*
* [I ha ve given with advantage, in ileitis, the blue mass in small doses,
say three grains three times a day; and have found warm fomenta-
tions by stupes and cataplasms on the iliac region serviceable. — B.]
vol. i.—17
194
DISEASES OF THE DIGESTIVE SYSTEM.
In this way by leeching, mild laxatives, prescribing mercury
with chalk, and compound powder of ipecacuanha with gum water,
your patient begins to improve. The tenderness of the epigastrium
disappears, the tongue begins to clean, the fever diminishes, the
thirst goes off, and appetite returns. This is the favourable termi-
nation. When the patient is of a weak and delicate habit, it is of
great importance to pay particular attention to supporting the
strength, even from an early period of the disease. In such a case,
after the first week, the physician who neglects the proper means
of supporting his patient's strength does wrong, and it has justly
been remarked, that a practitioner will be right in supporting the
general strength, at the same time that he is employing local anti-
phlogistics. It is in steering clear between these two opposite
dangers that the judicious practitioner is seen; he does not allow
his patient to die of inanition, while at the same time he takes
care to remove local inflammation. I have seen several experi-
enced physicians prescribe leeches to the abdomen on the same day
that they ordered the patient to have chicken-broth, and even a
little wine. There is nothing improper in this; an inexperienced
practitioner, who has his eye merely on the local inflammation, is
apt to fall into the error of overlooking the constitutional debility,
and allowing it to steal upon him. He finds very little difference
between the appearance of his patient this day and the next, and
thinks the slight increase of debility undeserving of any attention.
At last his patient begins to sink visibly, he gets alarmed and has
recourse to stimulants, but it is now too late. Besides, there are
several articles of diet which support strength, without increasing
inflammation ; as, for instance, chicken-broth, sago, arrow-root,
strained rice, &c. These do no harm, and they prevent the patient
from falling into a dangerous typhoid condition. Let us look at
this in another point of view. Suppose you are called to a child
who is said to have had an attack of worms, or bilious derange-
ment, or that his bowels' were costive, and purgatives were given,
that the discharges were found to be bad and more purgatives
were administered ; or suppose you are called to a child of a weak
scrofulous habit, who had been taking large quantities of purgative
medicine, for what has been termed derangement of the bowels, and
you find the little sufferer with pale, shrunken face, a black circle
round his eyes, cold extremities, rapid faltering pulse, great thirst,
and evident symptoms of increased cerebral excitement; the little
arms and hands are cold as death, but the belly burning, tympanitic,
and very sensible to pressure, and when you compare the radial
artery with the femoral, as it turns over the pubis, you will have
some conception of the excited condition of the abdominal vessels;
and in addition to this train of morbid phenomena, you find there
is suppression of urine. Are you to attack these symptoms with
antiphlogistic means 1 No; the first thing you are to do, is to
prevent any further mischief, by totally inhibiting every kind of
purgative medicine. You are next to consider carefully what the
TREATMENT OF ILEITIS.
195
best line of treatment to be pursued is, for here you are under
circumstances of difficulty, and have a great many prejudices to
contend with. What I find generally to be most successful is this.
I begin by taking proper steps to support the strength, ordering the
patient to take chicken-broth, arrow-root, or jelly ; the extremities
are to be wrapped up in warmed flannel; and if the patient is sink-
ing, and has his mouth and teeth crusted with dark sordes, a little
wine, watching its effects. If it produces sleep, if the pulse comes
down under its use, and the fever is not increased, it will do a great
deal of good, and you can gradually increase the quantity. Always
bear in mind that there is a certain period in all inflammations, in
which stimulants prove to be antiphlogistics, a circumstance which
has been overlooked by the school of Broussais. So far with re-
spect to constitutional treatment; but what will you do with local
disease? The application of blisters is of decided use, nay, I have
seen a few leeches very effective. Apply a blister to the abdomen,
and dress it with mercurial ointment, at the same time you may
employ frictions with mercurial ointment; you will also swathe
the belly with flannel, so as to keep up a comfortable temperature.
In this way you will be able to do a great deal of good. You will
also prescribe hydrarg. c. cretd, with Dover's powder; and if the
bowels are confined, emollient injections. By steadily pursuing this
plan of treatment, you will often rescue from imminent danger a
case which would prove fatal under the purgative plan, and you
will add greatly to your own reputation.
There is one form of this disease in which diarrhoea is a promi-
nent symptom, where the purging is from the very commencement.
On this form I am anxious that you should have clear ideas. In
cases of this kind there is a copious discharge of fluid matter from
the bowels. In the majority of cases you may lay down this law,
that where there is a decided irritation of any secreting organ, in-
creased discharges from the surface of that organ give more or less
relief. Suppose two cases of hepatitis; in the one we have no
secretion of bile, in the other the secretion is copioas ; the latter is
certainly most favourable. Again, suppose two cases of bronchitis;
in one there is copious expectoration, in the other it is extremely
scanty; now every medical man knows that the former is more
easily managed. The increased secretion of any organ in the early
stage is to be looked upon as a relief to the inflammation. The
practical inference to be deduced from this is, that we should be
cautious in adopting any means of arresting this discharge, as it is
one of the modes which nature employs in relieving the irritation of
a suffering organ. Well, then, suppose you have a case of enteritis,
and that on the first or second day diarrhoea sets in, what does the
routine and systematic physician do? He gives chalk mixture and
opium with tincture of kino and catechu, and what is the conse-
quence I The belly becomes tympanitic; the pain is increased,
and even peritonitis may supervene; — this is one result of the
increase of inflammation; or the breathing becomes difficult, and
196
DISEASES OF THE DIGESTIVE SYSTEM.
the patient gets bronchitis or pneumonia. Diarrhoea occurring in
the early period of this disease is not to be interfered with, except
when it gets to such a height as to threaten the patient's life; and
where it increases his sufferings by the frequency of the discharges.
In the first week or fortnight, when there are only three or four
discharges, or even five in the twenty-four hours, I believe it is
better not to interfere by prescribing direct astringents ; but in the
advanced period, when the powers of life are low, or the discharges
very copious, then the physician comes to the assistance of nature
with just reason, and in such cases you should always interfere.
The best mode of managing diarrhoea of this kind is to employ
small, frequently repeated doses of Dover's powder, with anodyne
injections. And here I may mention briefly, to such of you as
have not seen them used, the best way of employing them. As
these injections are used on a different principle from the common,
the latter being intended to empty the great intestine and be dis-
charged, the former to be retained, we are constantly to make the
basis of our anodyne injection in such a manner, that it will not
prove stimulant from its bulk, or from any irritating substance it
may contain. Mucilage of starch, new milk, or linseed decoction
may be used as the basis, and the quantity taken for one injection
should never exceed three ounces. To this, for an adult, you add
from fifteen to thirty drops of tincture of opium, for it is a curious
fact connected with this subject, that opium given by the rectum
has frequently been observed to exercise a much more powerful
effect on the system than when an equal or even smaller quantity
has been taken by the mouth. The rule then is, that when you
first make trial of the remedy in this manner, feel your way cau-
tiously, and if you find that your patient bears ten or fifteen drops,
you can increase the quantity on repeating the enema. An emi-
nent practitioner of this city thinks the narcotic effect of opium by
the rectum much better marked than by the mouth, and I believe
this to be true in many instances. I believe the administration of
opium in this way requires a good deal of caution. I recollect the
case of a man who had been for a considerable length of time in
the habit of using laudanum in large quantities, and was, in fact, a
regular opium eater. During an attack of illness he got an injec-
tion containing sixty drops of laudanum; this produced, in a very
short time, symptoms of decided narcotism, from which the patient
never recovered; in fact, he died with every appearance of being
poisoned by opium.
There is another fact with respect to this disease which I would
have you to bear in mind, that, under certain circumstances, inflam-
mation of the small intestine will produce a remarkable tolerance
of opium. This applies not only to the advanced stage of enteritis,
but also to many other forms of disease. Some time since I made
a series of clinical experiments with the view of ascertaining the
power which opium possesses in relieving inflammation, and the
result has been, that in many cases where the powers of life are so
TREATMENT OF ILEITIS. 197
low that we cannot have recourse to the lancet, or any kind of
depletory measures, opium alone furnishes us with a powerful
means of subduing inflammatory action. When we come to treat
of peritonitis, I shall have occasion to speak of the good effects of
very large doses of opium, particularly in that form of disease
which results from intestinal perforation. My first trials of this
remedy were in affections of serous membranes, and to this I was
led by some interesting clinical experiments made by Dr. Graves.
I next tried it in diseases of mucous membranes, where antiphlo-
gistics were inadmissible, and here, as in the former cases, I had
many proofs of its great efficacy. I shall state the particulars of a
very remarkable case. A young gentleman, a pupil of mine, and
a member of the class at Park street, of an irritable habit, was
attacked with intense inflammation of the mucous membrane of the
intestines. He had a high degree of fever, and his thirst was so
insatiable that for two days he never ceased calling for drink. His
pulse was weak but rapid ; his tongue red and pointed ; respira-
tion very much hurried ; but the stethoscopic signs of disease of the
lung were absent. His belly was exceedingly tender on pressure ;
and he had another remarkable symptom — constant smacking of
the lips. The case, as you may perceive, was one of severe gastro-
enteritis, and it was treated in the ordinary mode, by leeches, cold
water, &c, but the disease showed great obstinacy, and at the end
of a month the patient was evidently in a state of imminent danger.
At this period a curious revulsion took place: the chest became
engaged, and the patient got bronchitis. For this he was blis-
tered, and took the decoct, polygalae with large doses of carbonate
of ammonia, under the use of which he recovered. The bronchitis
disappeared, but was almost immediately replaced by symptoms of
intense gastro-enteric inflammation, thirst, quick pulse, tympanitis,
low delirium, and subsultus tendinum. In the course of two or
three days diarrhoea come on, becoming more profuse as it ad-
vanced. The first day he had four discharges, the next eight, and
thus it went on increasing until there was a constant discharge of
thin fluid matter from the anus. The patient was quite run down, and
on three different occasions his friends thought him dead. Having
made an unsuccessful trial'of various stimulants and astringents, I
determined to try what might be expected from large doses of
opium. The patient was dying, and it was necessary to do some-
thing instantly which would be likely to arrest the diarrhoea. I
ordered a grain of opium to be given every hour; on the first day
he took twelve grains with apparent benefit, the next day he took
six, the same quantity on the third day, and on the fourth the diar-
rhoea had so much diminished, and the young gentleman was so
much better, that I thought it might be safely omitted. From this
period my patient recovered rapidly. I would not bring forward
this case in proof of the efficacy of opium if there were not many
others of a similar kind; and I have no doubt that this was a cure
17*
198 DISEASES OF THE DIGESTIVE SYSTEM.
effected by the use of opium in large doses. In the treatment of
this disease by opium, there is one simple rule, by observing which
you will be able to avoid all difficulties, and at the same time have
a criterion to judge of the value of the opiate treatment. If the
remedy produces the ordinary narcotic effects of such large doses
on the system, it will not do much good. You begin, therefore,
cautiously ; and if, after the first or second dose, you find that de-
cided narcotism is produced, or at least more than you would
think the quantity given could have brought on, give it up — it will
be dangerous. But if he bears one, two, or three grains, or if, after
having taken six or eight grains in the twenty-four hours, he
appears to be improving, you may then persevere in the adminis-
tration of opium, and it will be attended with decided advantage.
We have next to proceed to the consideration of the pathology
and treatment of diarrhoea and dysentery; I shall, however, first
exhibit a few preparations illustrative of the diseases of the small
intestine. Here is a preparation of the affection called tabes me-
senterica. You see here various masses of those cheesy glands
which are generally supposed to be the result of original scrofulous
deposition; but if you look among the folds of the intestine, you
will see a vast number of engorged lymphatics running up directly
to those glands, and you will perceive that these lymphatics corre-
spond at their commencement with ulcerative disease of the intes-
tinal mucous surface and glands. Here is an interesting preparation,
exhibiting three distinct ulcers. In one of these you see the bright
vascularity and turgescence of the areola, and the ulcerative pro-
cess which has just begun in the centre. Close to this is another
large ulcer, which has destroyed the texture of the gut down to its
serous covering, through which you perceive the light is shining.
The last is an example of perforating ulcer; all the coats of the
intestine have been destroyed, and on turning the preparation you
see evident marks of peritoneal inflammation. This preparation
also exhibits one of the modes in which an ulcerative perforation of
the intestine may terminate. Sometimes, at the very moment the
ulcerative process has succeeded in destroying the last coat of the
intestine, inflammation of the serous membrane in the immediate
vicinity takes place, a quantity of lymph is poured out, and if the
matter be not in great quantity, and the hole not too large, the
opening is closed up by the effused lymph, and a stop is put to
further mischief. Again, by the effusion of lymph the ulcerated
portion of the intestine may form an adhesion to another sound
portion, the effused lymph does not permit the passage of the con-
tents of the intestine in the peritoneum, but does not prevent them
from getting into the sound portion by a continuance of the ulcera-
tive process, and in this way we have another termination, in the
formation of a false passage. Here is a good example of disease
of the csecum, here is an example of disease of the colon, and here
is another with a vast number of ulcerations. Here is an interest-
ing specimen of disease of the large intestine. The patient to
DISEASES OF THE LARGE INTESTINES.
199
whom it belonged died of phthisis; — look at it and you will see
what extensive ravages have been made by the ulcerative process.
We come now to take up the subject of disease of the large
intestine, which, as I find my time nearly past, I must reserve until
our next meeting. I shall then speak of dysentery and diarrhoea,
and shall draw your attention to some new and curious facts respect-
ing the discharge of fatty matter from the bowels. In the last
number of the Medico-Chirurgical Transactions, three separate
papers have appeared on this subject from Dr. Elliottson, Dr. Bright,
and Mr. Lloyd. Dr. Bright has brought forward several interesting
facts tending to show that discharges of fatty matter may be
found to be indicative of certain forms of disease of the digestive
tube and the neighbouring glands.
LECTURE XVII.
Diseases op the Large Intestines—Treatment of diarrhoea—Apyrexial period of
diarrhoea—Danger in suddenly arresting the discharge—Purging in Phthisis—
Dysentery—Epidemic dysentery.
To-day we proceed to the consideration of the nature and treat-
ment of some of the diseases of the large intestine. You will see,
in the various systematic treatises on the practice of physic, sepa-
rate descriptions of the affections of this portion of the digestive
tube; you will find diarrhoea in one chapter and dysentery in
another; and you will observe, that a great deal of ingenuity has
been expended in forming nosological differences between these
affections. I fear that much of what has been written respecting
them is rather calculated to puzzle and mislead than to inform the
student. Viewed anatomically, there is no essential difference.
You may for every practical purpose place them in the same class,
and consider them as the result of the same morbid condition of
the same part, namely, an inflammation of the lower portion of the
digestive tube. Some persons may quarrel with the term inflam-
mation— call it, then, irritation, if you please; but the truth is,
that it is a disease of the lower portion of the intestine ; the results
of which are increased sensibility and altered secretion; and this
description, I think, will fairly apply to one as well as the other.
If a man has purging, with fever and pain, it is called dysentery ;
if he has purging, without pain, and without any manifest febrile
excitement, we call it diarrhoea. But, in cases where persons have
died, after having laboured under diarrhoea for a length of time, we
generally find, on dissection, lesions of the mucous membrane of
the intestinal canal, sufficient to account for death. There are
some cases, indeed, in which the mucous surface takes on a gleety
discharge, similar to that which follows gonorrhoea, and under
200 DISEASES OF THE DIGESTIVE SYSTEM.
such circumstances you will not be able to discover any distinct
anatomical evidences of disease. These, however, are compara-
tively rare, and bear little or no proportion to those cases which
present distinct traces of organic lesion.
Diarrhoea.—On the subjects of diarrhoea and dysentery I shall be
very brief,asourtime isshort,andeverythingrelating tothe pathology
and treatmentof these affections may be expressed in a very few words.
First, then, as to diarrhoea, which is the frequent passing of stools
of a more or less watery consistence, and which may, and gene-
rally does, occur without fever. This affection may be considered
to arise under three different circumstances; but, in point of fact,
every form of the disease may be referred to a single cause, as
there is no essential difference in the actual nature of the circum-
stances by which they are produced. A patient, for instance, takes
a quantity of indigestible food, this produces irritation in the gastro-
intestinal mucous surface, and diarrhoea is the consequence. Another
is exposed to cold, or gets wet feet, the mucous membrane of the
bowels becomes more or less inflamed, and this terminates in diar-
rhoea. Again, a patient, labouring under hectic, has profuse perspi-
rations, these go off and are replaced by frequent fluid discharges
from the bowels — here, also, the result is called diarrhoea. All
these forms are, however, referable to the same cause—irritation
of the mucous lining of the digestive tube.
A man commits an excess at table, eats something that he cannot
digest, and gets diarrhoea. If you happen to be called to such a
case at an early period, your course is very plain and easy; there
is every chance that the affected organ has received (as yet) no
material injury, and is attempting to relieve itself by increased
secretion. The indication here is to get rid of the source of irrita-
tion as soon as possible, and this is best done by prescribing a laxa-
tive, to remove the offending matter, and then following it up with
an opiate. The simple rule is to relieve the intestine, and prevent
the liability to inflammation. A mild laxative, followed by opiates
and demulcents, keeping the patient on a low regimen for a few
days, and in a warm temperature; this is sufficient for the manage-
ment of the first form of diarrhoea. In point of fact, the principal
thing which the practitioner has to do, is to watch his patient,
and take care not to permit the inflammatory action to become
developed. It is in such cases as these that the expectant medi-
cine is of value. What you are to direct your attention to, is
the state of the intestinal surface. If a patient gets an attack of
pain, if his belly becomes tender on pressure, if he is more or less
feverish, you may be sure there has been some mischief done*. If,
on the contrary, the diarrhoea yields to the exhibition of a mild
laxative and light diet; if the pulse be soft, and thg belly not tender,
you have no reason to fear. But if the purging becames more dis-
tressing, if the pain is severe, the abdominal tenderness evident, the
thirst and restlessness continue unabated, it is a sign that the irri-
tation has produced something more than mere increased, secretion,
TREATMENT OF DIARRHOZA.
20L
and that actual disease of the mucous tissue is setting in. We
have now a true inflammatory diarrhoea, which may be looked.
upon altogether as an enteritis of that kind in which there is a
copious secretion from the surface of the intestine. You observe
this leads us at once to the principles of treatment. Here we have
fever, pain, frequent morbid stools, thirst, and abdominal tender-
ness. Well, then, what are you to do? In a case where these
symptoms are so severe as to excite alarm, at once begin with
applying leeches. Where there is merely evidence of intestinal
irritation, caused by indigestible food, give a laxative, and follow
it up with an opiate; where, in addition to the ordinary symptoms,
you have fever, pain, and tenderness, never omit the application ot
leeches. Many a time have I seen cases of this kind, in which
chalk mixture and astringents not only failed but even caused
additional suffering, speedily and completely relieved by the appli-
cation of a few leeches. In using leeches, too, we are not like the
practitioners who trust to astringents, playing at the game ot
double or quits ; nor do we stop the purging by exchanging it lor
something else equally bad, or even worse, — for a peritonitis or a
bronchitis, for instance ; by removing its cause we not only check
the diarrhcea, but we obviate any tendency to a metastasis oj inflam-
mation to other tissues, and our mode of cure has at once the merit oj
being successful and safe.
A patient who has had an attack of diarrhoea should have his
belly swathed with flannel; this should never be neglected. He
will also experience a great deal of benefit from the use of the hip
bath and occasional opiates. Give, also, a combination of rhubarb
and Dover's powder, and you will find that it will do him a great
deal of good. This is the remedy which Roederer and Wag'er
found to be of extraordinary advantage in the mucous fever, with
diarrhoea, which ravaged parts of Germany in the last century.
Give two or three grains of each every second or third hour, and
increase or diminish each of the ingredients according to circum-
stances, increasing the Dover's powder where the indication is to
remove pain and irritation, and increasing the rhubarb where you
wish to produce a laxative effect. This combination forms a
remedy of decided value in enteric inflammations; it has been
much used in such cases by Dr. Cheyne, and I have repeatedly
employed it in the Meath Hospital with marked advantage. Yon
are also to bear in mind, that though the principle of treatment in
this disease is to remove its cause and put a stop to the purging,
still you are in no case authorized to give it a sudden check, by
astringents, in the early period. I gave the reasons for this at my
last lecture, and showed that it was based upon a general law of
the economv. If an organ in a state of inflammation pours out
an increased quantity of secretion, it is the mode in which nature
attempts to give relief; and if you suddenly arrest this secretion,
the probability is, that you will excite more inflammation in that
organ or cause a metastasis to other parts. This is particularly
202
DISEASES OF THE DIGESTIVE SYSTEM.
the case if inflammatory fever exists. You must also attend to
your patient's diet. Your object here is to support him on such a
diet as will require but little digestive power, and will not produce
large collections of fecal matter in the bowels. Jellies, arrow-root,
chicken-])roth, and mild farinaceous food, are the only things that
can be used with safety, until the intestinal irritation has subsided.
By pursuing this plan of treatment with steadiness and decision,
you generally succeed in cutting short the disease.
Chronic Diarrhoea.—In some cases, the diarrhoea will run on to the
chronic state, just like the gleet which follows gonorrhoea ; and this
is to be looked upon as the apyrexial period, in which antiphlogistic
remedies are no longeradmissible,and where you may employ stimu-
lants and astringents with effect. The best way to manage this form
of the disease, is to make your patient use warm clothing, an even
temperature, and mild nutritious diet; to prescribe the vegetable and
astringent tonics, the hip bath, and the occasional use of mild laxa-
tives, followed by an opiate. In this way, after some time, the dis-
ease generally goes off, and the patient recovers his strength. But it
may happen that this gleety discharge will continue unabated ; it
is running the patient down, and he wants some decided remedy to
check it. Now, the remedies which appear to have the greatest
power in stopping this discharge, are the metallic astringents, and
the turpentines and balsams, combined with some of the prepara-
tions of opium. It is a curipus and interesting matter to consider
how these remedies act. They are a class of medicines which
exercise an extraordinary influence over discharges from mucous
surfaces, in a way we do not understand, but the effect is to arrest
these discharges. In a case of ophthalmia, accompanied by copious
secretion from the conjunctiva, or in a case of chronic gonorrhoea,
we know there is nothing more beneficial than metallic astringents
and balsams; and we are also aware of the great value which tur-
pentine and balsam copaiva possesses in checking the increased
expectoration of a chronic bronchitis. In diarrhoea, also, they
have the same power; they check inordinate secretions, and
remove the morbid condition of the mucous membrane on which
it depends, by some effect produced on the surface of that mem-
brane; but in what manner this is accomplished we know not. In
severe cases of this gleety discharge, one of the most certain
remedies we can employ is acetate of lead. You will seldom have
occasion to use this or any of the other remedies alluded to, in the
case of a healthy person, because the disease will seldom pass into
this second or gleety stage; but if it should, and that it is running
down the patient, it behoves you to check it as soon as possible,
consistent with safety. Give, then, the acetate of lead in free and
repeated doses, and it is singular to remark what quantities of it
patients under such circumstances will bear without any bad con-
sequence ensuing. Hitherto many persons have been afraid to
employ it in large quantities, from fear of producing painters'
colic; but at present it is known that this disease is to be attributed
TREATMENT OF DIARRHOZA.
203
to the absorption of the carbonate of lead in almost every instance,
and that the acetate is comparatively harmless. On this point I
can mention one interesting fact, namely, that I have been in the
habit of using it constantly, and in considerable doses, for the last
six years, and I cannot bring to my recollection one single instance
of colic produced by it. One patient, in particular, who was under
my care, took it in very considerable doses for six weeks, without
any apparent injury. The only cases in which I have seen the
acetate of lead act as a poison, were those in which it had been
used as an external application. Whether it be that this remedy is
more pernicious when employed after the endermic mode, or
whether, when applied to the skin, it attracts carbonic acid from
the air, and is converted into a carbonate, I do not know; but of
this I am certain, that where bad effects have followed the employ-
ment of the acetate of lead, they have been brought on by its
external use. I generally use this remedy in the form of pill, pre-
scribing two grains of the acetate of lead and a quarter of a grain
of opium, three times a day. With the same intention you may
employ the turpentines and balsams, which have a powerful effect
in checking mucous discharges. Dr. Pemberton, in his work on
Abdominal Diseases, speaks very highly of the efficacy of balsam
copaiva ;* and I have seen many cases where turpentine has had a
great efficacy in arresting chronic diarrhoea. You will see, in the
works of materia medica, some other remedies which you can
employ with benefit in such cases, but I may mention one which is
not generally known — the alkali of the nux vomica. Strychnine
was first used in checking mucous discharges by a German phy-
sician, and afterwards by Dr. Graves in this city. The cases in
which it proves most successful, are those in which there is a mere
gleety discharge, a copious secretion from the mucous surface,
without any inflammatory action whatever, or if there be, where it
is so low as not to produce the least feverish excitement or pain.
Cases of this kind, in which strychnine has been eminently success-
ful, have been published by Dr. Graves. Among others, is that of
a gentleman, who had sudden calls, so that he often had not time
to reach the close-stool. He passed a quantity of thin, jelly-like
substance, and then experienced a transient relief until another
attack came on. This case was cured by the use of strychnine,
one-twelfth of a grain, three times a day, made into pills with
crumb of bread or aromatic confection.
I may mention here, that, in treating gleety diarrhoea in this way,
one thing should be always borne in mind — it is always dangerous
to check any copious secretion suddenly, and the danger consists
in the liability to metastasis or new inflammation. Never forget
* [Dr. La Roche, of Philadelphia, has recorded his successful
experience of the efficacy of the balsam in this disease. See Eclectic
Journal of Medicine, vol. ii., p. 409-19. — B.J
204 DISEASES OF THE DIGESTIVE SYSTEM.
this. What generally happens is, that the patient's belly begins to
swell, and you have ascites rapidly formed. Now, I have never
seen a case do well in which this kind of ascites came on after the
sudden checking of a diarrhoea; the patients all died. Another
consequence is the rapid supervention of pulmonic inflammation,
and here the disease is almost as bad as in the bowels. You will
ask how this unfavourable termination may be avoided. The best
mode is, while you are arresting the discharge from the bowels, to
promote a determination to the surface. While you are using
opiates, and stimulants, and astringents, employ general warm
bathing, or the hip bath, dress the patient in flannel, and use mild
diaphoretics every night. You will also do right in blistering the
belly occasionally. In this way you will succeed in curing the
worst cases of this chronic flux, without exposing your patient to
the risk of new inflammation, or translation of disease to other
organs.*
Colliquative Diarrhoea.—One of the most common forms of diar-
hcea is the purging which occursincases of phthisis; a physician will
be called to treat this as often asanyother,and it is of importance that
you should have correct ideas with respect to its pathology and treat-
ment. The ordinary opinion is, that this kind of diarrhoea is one of
the results of hectic fever, and many practitioners, in treating the purg-
ing of consumptive patients, overlook the actual condition of the in-
testine, and only take into consideration the state of the whole constitu-
tion, of the hectic state of which the diarrhoea is looked upon as one of
the symptoms. The consequence of this is, that they do not proceed
on the same principles in the treatment of this as of other similar
affections of the intestinal canal. Now, I would impress upon you,
that you should always consider the diarrhoea of phthisis as de-
pending, in almost every instance, on enteric inflammation. There
is no fact in medicine better established than this. Persons think it
is the hectic which produces the purgation, but I believe the con-
verse of this proposition is often much nearer the truth, and that
the constant diarrhoea often produces and keeps up the hectic. If
you examine the digestive tube of a patient who has died with
symptoms of phthisical diarrhoea, you will commonly find extensive
ulcerations in the colon, caecum, and ileum. In some cases of con-
sumption, where the purging has been very severe, the amount of
disease will often be found to be quite extraordinary: I have often
seen the whole of the lower part of the tube one sheet of extensive
* [In such a state of things as that recorded in the text I have
repeatedly and with the best effect prescribed the blue pill alone if
there be heat and dry tongue, and with opium if the skin is cold
and tongue moist. This will be found to be a safer practice than
the administration of astringents. If the stomach is not oppressed
by the balsam copaiva,it may be given in the morning, and the blue
pill at night.—B.]
TREATMENT OF DIARRHffiA.
' 205
ulceration. I find I have not brought up any specimens of the
effects of phthisical diarrhoea from the museum, but will exhibit
them at our next meeting. The preparations before us are those
which are illustrative of dysentery, but they will convey to you a
good idea of the state of the great intestine in the diarrhoea of con-
sumption, for the effects are nearly the same. Observe now, the
importance of this fact, and recollect that in treating every case of
consumption, with diarrhoea, you will have constantly to bear in
mind this enteric complication. Recollect, also, that one of the
best means of stopping it, when all other remedies have failed, is a
blister applied over the abdomen. If the purging depended on
hectic, this would not be the case. I could bring forward several
cases in which everything had been tried without success, when a
blister was applied to the belly, and from the time it rose the patients
ceased to be troubled with diarrhoea, and continued so up to the
period of death. I do not mean that you should in these cases pro-
ceed to attack the enteritis with the same vigour as you would a
similar disease in the healthy subject. Generally speaking, I be-
lieve this form of enteritis to be incurable ; but it is of importance
that you should be aware of this enteric complication in phthisis,
and when you are called in to treat such a case, you should care-
fully avoid prescribing anything calculated to add to the existing
irritation.*
Before I quit this subject, I wish to make one remark by the way
of caution. It not unfrequently happens that a person, labouring
under chronic diarrhoea, comes to consult a medical practitioner,
and tells him that he has been suffering from this complaint for
months, that he has eight or nine discharges by stool in the day,
and that he has been under the care of five or six doctors in suc-
cession, without any benefit. Well, you are determined to have
your trial, too, and you commence operations by putting him on
full doses of acetate of lead. After a week or a fortnight, he comes
back and tells you he is not a bit the better. You then try turpen-
* [I have found, very generally, this form of diarrhoea to be more
controlled by change of regimen than by active medicinal means.
The discharges, from having been copious and frequent, and irri-
tating and exhausting, will be reduced to two or three in the twenty-
four hours, by the substitution of bland farinaceous food for that of
a more stimulating character, — such as meats, animal broths, &c.
The patient himself, however craving his appetite may be for strong
food, soon sees his advantage in at least temporary abstinence, and
that his strength is rather improved than otherwise, under the use
of what he contemptuously called slops —- rice or barley water, and
rice or arrow-root boiled into a jelly, and flavoured with a little spice
and sugar. Of the medicines which I have employed in these
cases I prefer the simplest,— small doses of carbonate of magnesia
with a fourth or half a grain of ipecacuanha, and a drink of muci-
lage of gum arabic. — B.]
vol. i.—18
506
DISEASES OF THE DIGESTIVE SYSTEM.
tine or balsam copaiva — no use. Nitrate of silver — the same
result. The man gets tired of you in turn, and perhaps goes to a
surgeon to ask his advice. The surgeon examines the rectum
carefully, and finds, at a short distance from the anus, an ulcer,
which he immediately touches with a strong solution of the nitrate
of silver. The ulcer begins to heal, the irritation of the gut ceases,
and the diarrhoea goes off. The surgeon is extolled to the skies,
and the doctors disgraced for ever in the opinion of the patient.
Now this is not an uncommon case. I have seen several instances
of it, and I must tell you I was once mistaken in this way myself.
These ulcers are situated close to the verge of the anus ; they occur
chiefly in persons of broken-down constitution, and those who have
taken a great deal of mercury. They produce irritation in the
colon, tenesmus, griping, frequent discharges by stool, and, most
commonly during the straining, a little blood is passed. During
the course of last summer, I treated a soldier for this affection,
who had been discharged from the East India Company's service
(as was stated in his discharge) for incurable dysentery. I ex-
amined the rectum, and finding some ulcers close to the anus, had
them touched with the nitrate of silver. Under this treatment a
rapid amendment took place, and in the space of three weeks the
man was discharged, quite cured. Now, are you to make this
examination in every case? I believe you will act rightly in
doing so in every case of chronic diarrhoea in the male, but the
examination is absolutely necessary in all cases under the following
circumstances : first, when the diarrhoea has been of long standing;
secondly, when it has resisted a great variety of treatment; thirdly,
when it has been combined with tenesmus and a desire of sitting
on the night-chair after a stool has been passed, showing irritability
of the lower part of the great intestine; and, lastly, when the
patient's health does not appear to be so much affected as it natu-
rally should be, where there was long-continued disease of a large
portion of the great intestine. A patient will come to consult you,
who will inform you that he has had eight or ten alvine evacua-
tions every day for the last six months, and yet he eats heartily and
looks quite well. Under these circumstances, the cause of the
diarrhoea will generally be found to be ulceration of limited extent
low down the tube, and capable of being quickly and effectually
removed by a strong solution of the nitrate of silver. I shall
recapitulate all the circumstances under which an examination is
indispensable; where the symptoms have been persistent, have
resisted a variety of treatment, are accompanied by tenesmus, and
where the injury done to the general health is not in proportion to
the duration of the disease. I may mention here, that a medical
friend of mine has communicated to me the particulars of another
case of this form of diarrhoea in a soldier who was invalided on
this account, and who experienced sudden and permanent relief
from the application of nitrate of silver to some ulcerated spots
which were discovered near the termination of the rectum.
DYSENTERY.
207
We come now to the subject of dysentery. I shall draw your
attention briefly to the general principles of the pathology and treat-
ment of this affection; but I do not intend to enter upon the con-
sideration of its general history, which you will find sufficiently
detailed in books. The first principle I have to enforce on this
subject—and you may take it as an observation based on the
soundest pathology — is this, that dysentery is inflammation of the
large intestine. In some cases it is complicated with fever, and in
others with disease in the upper portion of the digestive tube; and
I believe that those cases which are termed epidemic dysentery, are
those in which this disease is combined with typhus fever, or with
an extensive affection of the small intestines — where there is ileitis
as well as colitis. I shall not take up your time with discussions
respecting epidemic dysenteries, or those of warm climates ; it will
be sufficient, for the present, to allude to that form of disease which
is observed in this country.
I have told you that dysentery is an inflammatory affection of the
great intestine, and all the symptoms during life, as well as the
phenomena revealed by dissection, tend to confirm this view of the
subject. We often have fever, because the constitution sympathizes
with the inflammation of an important organ: we have excessive
pain and irritation of the intestine, in consequence of its muscular
fibres being involved in the inflammation ; and we have discharges
of morbid, purulent, and bloody secretion. You will now please
to inspect this preparation, and hand it round. See the effects of
dysentery — the extensive inflammation, ulceration, and sloughing
of the mucous membrane. Here is another preparation ; you per-
ceive the whole surface of the colon is covered with coagulable
lymph, which, in some cases, forms a chief part of the dejections.
Here is a preparation which exhibits extensive sloughing of the
mucous membrane ; its tissue, you see, is quite abraded and
destroyed. Here is a preparation of chronic dysentery, which pre-
sents a very curious appearance; the mucous membrane is finely
mamillated, as it were, and it is stated1 on the label that the process
of cicatrisation was going on. If you compare it with the others,
you will find a remarkable difference. Here is another specimen
of dysenteric destruction.
Here, then, is a disease in which we have violent inflammation
of the mucous membrane and submucous cellular tissue, and, in
severe cases, I believe, of all the coats of the great intestine, except
the serous. Let us rehearse its symptoms briefly. Fever of an
inflammatory or typhoid character, great pain and excessive irrita-
bility of the great intestine, morbid discharges of purulent, bloody,
and lymphy matter, twisting pains called tormina, and frequently the
absence of fecal matter in the dejections.
At my next lecture I hope I shall bo able to finish this subject,
and I shall then bring before you some remarks on constipation
and collections of air in the great intestine; two points upon which
much light has been lately thrown.
208
DISEASES OF THE DIGESTIVE SYSTEM.
LECTURE XVIII.
Sporadic Dysentery—Nature ofthis disease—Treatment; mercurial, stimulating-,
antiphlogistic—Recommendation of Dr. Elliottson—Success of Dr. O'Beirne in
the use of tobacco injections—Tympanites, or meteorism—Windy colic, reme-
dies for the cure of.
I drew your attention briefly, in my last lecture, to the subject of
dysentery ; I stated that its anatomical character is now known to
be inflammation of the great intestine, and gave it as my opinion,
that, in many cases of the epidemic, disease of the large intestine
occurs under one of two conditions, either as secondary to typhus
fever, or with an extension of the inflammatory process into the
small intestine. These circumstances should, I think, be always
taken into consideration in cases of epidemic dysentery ; but the
ordinary sporadic dysentery of this country, which we have now
to consider, is, generally speaking, an inflammation of the large
intestine. The old doctrine on this subject was, that dysentery
was the result of an irritation caused by the presence of scybala
in the colon; and the indication was to attempt their removal by
purgatives. You will find this opinion put forward in many of the
older authors, and that the plan of treatment which they recom-
mend is in perfect accordance with their notions of the disease. It
is a very curious fact, however, that in this country these hard
fecal masses, or scybala, are very seldom met with in cases of
dysentery. During the epidemic of dysentery, which occurred in
Ireland in 1818, a series of clinical investigations was made on an
extensive scale by Dr. Cheyne, who at that period had charge of
the Hardwicke Hospital; and he states, that on a strict examina-
tion of the discharges in a vast number of cases, no scybala could
be discovered; and in the sporadic cases, which we receive from
time to time into the Meath Hospital, I have never found that the
patients passed them. It is a great error to think that dysentery
depends on the presence of scybala ; the notion is now shown to
be founded on a false pathology, and the treatment which it incul-
cates decidedly bad. You will be convinced of the latter when
you recollect that the disease is inflammation of the great intestine,
that its effect is to throw the muscular fibres of the gut into violent
and painful contractions, and that the existing mischief must be
therefore greatly increased by the exhibition of strong purgatives.
For a knowledge of the true and scientific treatment of this disease,
we are indebted to the light which modern pathology has shed upon
practical medicine. We now employ purgatives with extreme
caution, we use general or local bleeding, according to the urgency
of the case ; and we treat the disease as an inflammatory affection
of the lower intestine demanding active depletion. All writers are
unanimous in recommending the employment of the lancet, in cases
of acute inflammation; and acute dysentery in one of those cases in
which general bleeding seems to have the best effect. Dr, Cheyne
SPORADIC DYSENTERY. go 9
states, that in this disease the most decided relief result from the
use of the lancet. He says that in several cases in which there
were excessive pain and tormina, and in which nothing was passed
for several days but mucus and blood, as soon as venesection had
been performed, the patients became comparatively easy, and
passed large quantities of feculent matter. He also found that the
blood drawn was buffed and cupped ; and states that his experience
led him to conclude that this disease was best treated by the lancet.
Dr. Mackintosh, who has had great experience in dysentery, says,
that laxatives will act with the best effects when bloodletting has
been premised. In fact, the utility of general bleeding in dysentery
is established beyond any possibility of doubt; and those who
object to the use of the lancet object to it on theoretical and not
on practical grounds. As a proof of this, you will see a great
many cases in which decided relief is obtained by a natural he-
morrhage from the bowels; and this I think ought to be sufficient
to overcome the doubts of those who are skeptical as to the value
of general bleeding in acute dysentery.
Next to bleeding, the best thing you can have recourse to is the
free application of leeches, a practice not sufficiently appreciated or
followed in this country. I would advise you to apply leeches
freely along the course of the colon; and if the tenesmus be con-
stant and distressing, round the anus also. The case in which the
application of leeches round the anus is attended with the greatest
relief, is that in which the tormina and tenesmus are excessive, and
in which a quantity of blood is found blinded with each discharge.
After you have applied the leeches, I would strongly recommend
you to direct your patient to sit in a hip bath for some time, and
you will find that he will experience great relief, because the bath
will act as a fomentation, and promote the flow of blood from the
leech-bites. I have often seen the application of a dozen leeches
round the anus, followed by the hip bath, attended with the most
rapid and signal advantage in dysentery.
Many persons are in the habit of giving small doses of some
mild saline laxative in this affection; of this practice I cannot
speak much from experience, and I think more benefit will be
derived from the free use of demulcents, gum-water, whey, barley-
water, and linseed tea.* But the internal remedies on which we
chiefly rely in the treatment of dysentery, are mercury and opium.
Blue pill and Dover's powder are an excellent combination, so are
calomel and opium, and you may give either of these remedies
alternately with a mild laxative, whenever you are led to suspect
an accumulation of fecal matter in the bowels. In very bad cases
* [Saline purgatives, so far from giving relief in some cases, are
decidedly irritating; they cause serous discharges, but not proper
defecation. Alone I have found them of no benefit; following
calomel, they answer a better purpose. — B.J
18*
m
210 DISEASES OF THE DIGESTIVE SYSTEM.
it will be necessary to continue the mercury until the mouth is
affected; but in the sporadic dysentery of this country you will
very seldom be under the necessity of bringing on actual sali-
vation.
Permit me here, gentlemen, to make a few observations on
mercurial action. In treating a case of dysentery, it does not, in
the first place, follow as a matter of course that you will cure your
patient by subjecting him to the full influence of mercury. You
are not to expect that salivation will be always attended with suc-
cess. There is another point which should never be forgotten,
although it is one which I believe has not been sufficiently consi-
dered. It is a common idea with respect to the administration of
mercury in cases of local inflammation, that if you produce saliva-
tion you do a great deal towards accomplishing a cure, and this
is true in most cases. Many persons are of opinion that it is the
ptyalism which carries off the disease, and hence it is that we so
often see the principal share of a practitioner's attention directed to
produce salivation at all hazards. This is the history of the
medical treatment ordinarily pursued in warm climates, where
such vast quantities of calomel are given. Here the. idea seems to
be, that the disease is to be subdued by salivation alone, and
accordingly the practitioner " throws in" mercury, an expression
evidently arising from the enormous quantities given. There are
many cases on record in which eight hundred and even one thou-
sand grains have been given for the cure of a single local inflam-
mation. But it is remarkable, that in several cases in which vast
doses have been given, no ptyalism has been produced, and thus
it frequently happens, that the practitioner goes on increasing the
quantity, lest he should have failed in consequence of not having
given enough. All this practice is wrong and founded on false
notions; and I think that when you come to practice yourselves,
you will be inclined to adopt the opinion, that, in cases in which
mercury has been employed in the treatment of local inflammation,
salivation is to be looked upon more as the result of the relief of the
inflammation to a certain degree than as its primary cause. For
instance, suppose you are called to treat a case of acute enteritis or
hepatitis; you give ten grains of calomel two or three times a
day, and find that day after day passes without any appearance
of salivation. Another practitioner is called in, who bleeds the
patient, and this is almost immediately followed by the appearance
of salivation and relief. My friend, Staff-Surgeon Marshall, who
is intimately conversant with the diseases of India, has informed
me that he has never known a case in which abscess actually
formed in the substance of the liver, in which salivation could be
produced; and that when the patient became salivated, he believed
it to be a proof that there was no inflammation of an intense cha-
racter, or that no abscess had formed. The greater the intensity
of the disease, the less was the chance of salivation occurring, so
that the salivation in certain cases appears to be the result of the
TREATMENT OF SPORADIC DYSENTERY.
211
same influence which produces a relief of inflammation, and not
the cause of that relief. When, therefore, you have given mer-
cury in free and repeated doses for twenty-four or forty-eight
hours, and find no sign of salivation appearing, you should be
cautious how you proceed, because in such cases the inflammation
may be of that intense character which will not permit the mouth
to be affected. Under such circumstances, the use of mercury, if
rashly persevered in, will only aggravate the disease. In many
cases of intense pneumonia, you will find that the patient will not
be salivated until an advanced period, when, in consequence of the
subsidence of intense irritation, the mercury is, as it were, allowed
to produce its effect on the salivary glands. You may also fre-
quently observe instances of intervals between the salivation, in
which, during the course of an inflammation, the patient's mouth
becomes affected by mercury ; but if he gets fresh symptoms of the
original affection the salivation disappears, and returns only when
the new attack has been overcome by appropriate treatment. I
think that, under these circumstances, we are authorized in consi-
dering salivation as the effect of a certain degree of reduction of
inflammation, and not as its cause. You will see the importance
of these observations when you reflect in how many cases of local
inflammation practitioners are in the habit of trusting to calomel
alone; not being aware of the fact, that inflammation of an intense
character has a powerful tendency to prevent it from acting on the
salivary glands. Be assured of this, that if, in any acute visceral
inflammation, after you have performed the usual depletions, you
find an unusual resistance to the action of mercury, you may, on
that account, form a more unfavourable prognosis.
There is one point in the treatment of dysentery which it is
necessary you should be acquainted with. Sometimes the symp-
toms steal on gradually, and the patient appears to be in a condi-
tion not at all dangerous, when, all at once, the disease explodes
with violence, and exhibits an extraordinary intensity; the fever
is ardent, the tormina excruciating, the tenesmus constant and
harassing, the dejections frequent and blended with lymph and
blood. Such an array of threatening symptoms must be met with
a corresponding activity. In such a case as this I would bleed,
leech, use the hip bath, and give free doses of calomel and opium;
and if you were to ask me to which of the internal remedies used I
should attribute the most decided alleviating influence, I should say
to the opium. Dr. Cheyne says, " after the lancet, the best remedy
I know of is opium." He says further: if another epidemic, similar
to that which he witnessed, occurred, he would have no hesitation
in giving opium, in four-grain doses, in such cases.
There was a very curious circumstance connected with the his-
tory of the epidemic dysentery of 1818-19. At one time the deaths
happened to be extremely numerous, and everything which the
experience or ingenuity of Dr. Cheyne could suggest failed in
arresting the disease, in many cases. An English physician, who
212 DISEASES OF THE DIGESTIVE SYSTEM.
happened to be in Dublin at that period, and was in the habit of
visiting the hospital, proposed the administration of large doses of
cream of tartar, stating that he had tried it on several occasions
under similar circumstances, and was convinced of its value. As
the cases were not succeeding which had been treated after any of
the ordinary modes, Dr. Cheyne consented to the exhibition of the
cream of tartar, and allowed the physician to prescribe and ad-
minister it himself. Accordingly, he proceeded to give it in doses
of half an ounce every fourth hour. Its first effect, generally, was
to produce violent distress, and to aggravate all the symptoms, but,
after three or four doses, bilious and feculent stools came away, and
the patient experienced the most extraordinary relief. Many cases
which had been considered desperate improved and recovered, and
Dr. Cheyne expresses his conviction that many persons were saved
by this practice, who would have been lost under the ordinary
modes of treatment. One of the old German authors has also
alluded to this singular efficacy of cream of tartar in the treatment
of dysentery; and from the result of Dr. Cheyne's experiments,
there can be no doubt that it is entitled to a high rank among the
remedies usually employed. In case you should prescribe castor
oil as a laxative, it will be necessary to combine it with mucilage
of gum arabic and a few drops of laudanum ; given alone it will be
likely to prove too irritating, particularly during the acute stage.
In the advanced stage much benefit will be derived from a combi-
nation of castor oil, with tincture of opium and a small quantity of
oil of turpentine. This is not at variance with the pathology of the
disease, for there is a period in this as well as in every other form
of inflammation, when stimulants may be used with benefit.
Such is the treatment of the ordinary forms of acute dysentery,
but it may happen that you may be called to a case in which you
cannot employ these decided measures; and here I shall mention,
that in all local inflammations it is of the utmost importance that
you should act with judgment and decision in the commencement.
Every hour is precious; a single day is worth much; and if two
or three days are allowed to pass, and the treatment is inactive or
indecisive, the patient too often sinks into the chronic stage, or dies.
Whenever you happen to be called to treat a case of acute local
inflammation, attempt to cut it short as soon as possible: it is
much easier to cure an inflammatory attack in its commencement
than to save the patient from the effects of it in the advanced stage.
Now if you should be called to a case of dysentery of some stand-
ing, and on your arrival find the patient lying on his back, his
skin of a pale dirty hue, his eyes sunk and without lustre, his
extremities cool, and bedewed with a clammy sweat, his pulse
small, rapid, and feeble; his thirst ardent ; his pains and tormina
incessant; and constantly passing from his bowels a quantity of
fluid matter, blended with depraved mucus, lymph, and blood, with
great irritation about the anus ; and if these symptoms have lasted
for some days, you may be sure there is extensive ulceration of the
TYMPANITES.
213
lining membrane of the large intestine. How are you to act under
such circumstances? The patient will not bear bleeding, nor per-
haps the application of a small number of leeches. Here your sole
object must be to support your patient's strength ; you must give
wine, (if the skin be cool,) strong chicken broth, beef tea, jellies, &c.;
you must wrap your patient in flannel, and have recourse imme-
diately to anodyne and astringent injections, and you should blister
the abdomen, taking care to remove the blister at a proper time,
and not leave it on so long as may add to the existing irritation.
You may also prescribe the acetate of lead, or the sulphate of zinc
with tincture of opium. I have seen several cases of this kind in
the Meath Hospital, in which the administration of the sulphate of
zinc was attended with good effects. The best mode of using it is
to dissolve ten or twelve grains of the sulphate of zinc in six or
eight ounces of cinnamon water, with a proportion of laudanum,
and direct this quantity to be taken during the twenty-four hours.
Dr. Elliottson recommends the sulphate of copper, and you can
employ it in combination with opium. In this way, by supporting
your patient's strength, keeping him warm, paying attention to the
state of his bowels, using counter-irritation, and prescribing astrin-
gents combined with opiates, (taking care not to check the discharge
too suddenly,) you will often succeed, even in very bad cases.
Before I quit this subject I may observe, that Dr. O'Beirne has
succeeded in some cases, and in others has given great relief by the
use of tobacco injections. You can understand this when you
reflect that tobacco acts powerfully on the general system, and pro-
duces effects somewhat analogous to bleeding. Like general bleed-
ing it brings on faintness, vomiting, cold skin, perspirations, and
feeble pulse. It is also a powerful antispasmodic, and Dr. O'Beirne
states, that its employment has been attended with the best effects
in several very bad cases. I have not tried this remedy myself,.
but I think it well worthy of atrial in the acute stage of dysentery,
when there is room for an antiphlogistic treatment. In the ad-
vanced stages, of course, it is inadmissible.
We come now to consider the affection of the digestive tube,
which merits a separate consideration, and this is Tympanites, or, as
it is sometimes termed, meteorism. I shall not enter upon the ge-
neral pathology of aeriform effusions into the abdomen ; we are not
acquainted with that peculiar condition of parts which produces
them, but it is now established that we may have effusions of air,.
not only into the digestive tube, but also into every part of the
body. The term tympanites is limited to effusion of air into the
digestive tube, in all parts of which we may find it. We detect it
in the stomach under two circumstances ; first, as a recent and
transient affection, as when it comes on after swallowing indigesti-
ble matter; secondly, in a more permanent form, as when it depends
upon hysteria, hypochondriasis, or chronic gastritis. It may be
also frequently seen in very young children, when there is fever-
214
DISEASES OF THE DIGESTIVE SYSTEM.
ishness with irritation of the digestive system. I recollect a very
remarkable case of this kind, in which the distension was so great,
and the pressure on the diaphragm so considerable, as to cause
displacement of the heart upwards : — this, I believe, has not been
mentioned among the causes of displacement of the heart. The
symptoms of this affection are sufficiently obvious; — a sense of
uneasiness and distension at the region of the stomach ; when the
effusion is in excess, a distinct tumour can be felt, and the sound
on percussion, over the stomach, is like that of a drum. It often
happens, also, that when the patient is shaken, a distinct sound of
fluctuation is heard, a circumstance which more than once has led
to a suspicion of the existence of pneumothorax, or empyema.
There are also cases on record, in which the distension was so great
as to cause rupture of the stomach, and effusion of its contents into
the cavity of the peritoneum, causing intense inflammation and
rapid death.
The effusion of air into the intestinal tube is extremely common
in cases of acute enteric inflammation and gastro-enteritis, after the
disease has lasted for a few days; and, as this is a matter of consi-
derable interest, I wish to make a few remarks upon it. It is of
importance that you should bear in mind that this is one of the
results of enteric inflammation, because many persons are in the
habit of looking upon it, not as a mere symptom of another affection,
but as a peculiar form of disease, forgetting that it may occur with,
as well as without, inflammation. In consequence of this limited
and imperfect view of the subject, they are in the habit of prescribing
turpentine as a specific remedy for tympanites. Now, I can say
that I have seen the most dreadful effects from the administration
of turpentine in the tympanites of acute enteric inflammation. The
immediate effect is to produce a rapid diminution of the tympanitic
swelling ; but this is purchased at too dear a rate; for you will find
next day that there will be a violent exacerbation of the existing
symptoms, and the tympanites becomes worse than before. You
should never, therefore, interfere in this way with the tympanites of
acute enteric inflammation, nor should you alter your practice on
this account in the slightest degree, except where the tympanites is
so great as to interfere with the due performance of the function of
respiration; but, in the advanced stage, after the twelfth or sixteen
day, when the fever has abated and the tongue is moist, I have
frequently seen great advantage result from the use of turpentine.
But as long as the condition of your patient admits of antiphlogistic
treatment, be assured that the administration of turpentine is hazard-
ous. When the patient is in a low state, when you can no longer
have recourse to bleeding or leeching, when the tympanites is con-
nected with an asthenic condition of the intestinal mucous membrane,
then, and not till then, should you venture on the employment of
turpentine. I shall return to this subject when we come to speak
of hysteria.
I may mention here, that the occurrence of flatus in the intestines
TREATMENT OF TYMPANITES.
215
sometimes gives rise to dreadful sufferings in that affection, which
has been termed Windy Colic. A person in the enjoyment of good
health happens to take at his dinner or supper a quantity of indi-
gestible food, he goes to bed without feeling any particular incon-
venience, but about the middle of the night he awakes with an
attack of pain and tormina, which extend from the hypochondria
to the umbilicus. This subsides for a short time, and then returns
with violence, and the patient often finds that it is relieved by pres-
sure. In a short time the pains get worse, and the abdomen begins
to swell, sometimes at one point, sometimes at another, as if the air
was confined and pent up in particular situations. The patient
begins to suffer indescribable anguish, he has great anxiety, extreme
prostration of strength, his face is pale, his extremities cold, a cold
sweat breaks out all over the body, and he sits bent forwards, with
his hands pressed on his stomach to relieve the paroxysms of pain
which come on with increasing rapidity. In some cases there is
distressing hiccup, in some a large quantity of aqueous urine is
passed, in some there are loud borborygmi, and the intestines may
become so enormously distended as to fall rapidly into a state of
gangrene. Hippocrates has given a description of one of the forms
of this disease, which terminates by the passage of air upwards
and downwards, by which the patient obtains relief; this he calls
dry cholera. This windy colic is an exceedingly violent disease:
one of the first cases of which I witnessed, presented such an array
of alarming symptoms, that I thought every moment the patient
would expire. It is, however, a disease which is generally easily
managed if taken in time. One of the first things to be done is to
apply heat to the abdomen by anodyne stupes, or warm flannel.
Flannels wrung out of a decoction of poppyheads, as hot as can be
borne, will do a great deal of service, and in some cases will give
complete relief, when assisted by the use of carminative draughts.
But of all the remedies which i" have seen, the most efficacious is
an injection with tincture of asafostida, turpentine, and opium.
This is generally followed by speedy relief, the pulse becomes more
natural, the belly soft, and the excruciating agony is relieved. This
is the mode of treatment in which I have the greatest confidence.
After the acute symptoms are removed, it will be proper to exhibit
a laxative, for the purpose of removing the exciting cause of the
disease —indigestible matter; unless you get rid of this, your pa-
tient is liable to a return of the attack, and even to an inflammation
of the tube itself. Be not, therefore, satisfied with merely relieving
your patient; watch him carefully, and, by a proper treatment,
obviate a recurrence of the symptoms, and prevent any tendency to
inflammation. [For further details on this point see a subsequent
ecture. — B.]
216
DISEASES OF THE DIGESTIVE SYSTEM.
LECTURE XIX.
DR. BELL.
Dysentery.—The anatomical lesions in dysentery,—same in all parts of the
world—Dr. Cheyne's experience in Dublin; Mr. Twining's in Calcutta; Dr.
Cornuel's in the West Indies.—Stomach, small intestines, and liver, sometimes
inflamed concurrently with the colon.—Causes of dysentery—crude ingesta—
atmospherical vicissitudes—damp and impure air—particular seasons and cli-
mates,—Malaria not a cause—The disease not contagious—Duration—Termina-
tions—Prognosis—Treatment—venesection— leeching—mercurials — ipecacu-
anha—diaphoretics.—Rectal inflammation—its treatment.—Hepatic Flux—
its symptoms and treatment.
Before dismissing the subject of dysentery, it may not be thought
amiss for me to fill up, to a certain extent, the outlines of the disease
so ably sketched by Dr. Stokes in the preceding lecture.
The anatomical character, of dysentery consisting of lesions
of the great intestine, is placed beyond doubt by dissections made
in different and remote quarters of the earth, and on people of dif-
ferent races. The testimony furnished by Dr. Cheyne in Dublin,
and by Dr. Twining in Bengal, taken in conjunction with our
own observations here in the United States, and Dr. Cornuel's
in the West Indies, would alone suffice for producing entire
conviction on this point. Dr. Cheyne has given us an ample
account of dysentery as it appeared, in the latter end of 1818, in
Dublin and some other parts of Ireland; his own personal expe-
rience being the result of observations made at the Whitmore Hos-
pital, in the Irish capital. The anatomical lesions in this dysen-
tery have been divided by Dr. Cheyne into two classes: in one the
coats of the intestine were not thickened; in the other they were.
In the former, the mucous membrane of the colon was increased in
vascularity, without abrasion or ulceration ; or it was covered with
coagulable lymph, or simply abraded, and its epidermoid coat re-
moved. Sometimes the mucous membrane was ulcerated; the
portions of membrane intervening being of a natural appearance.
Lastly, the mucous membrane was partly ulcerated, and partly
covered with coagulable lymph. In the second class, or that in
which the mucous membrane was thickened, there was found, in
one case, simple abrasion, in another ulcerations; the portions be-
tween the ulcers being of a natural appearance; sometimes the
mucous membrane was rugous and ulcerated; sometimes ulcer-
ated and filamentous, hanging in shreds as if sphacelated; or at
another time partly ulcerated, partly removed, exposing the mus-
cular coat. In many of the preparations, the mucous membrane,
when not eroded or ulcerated, was covered with an exudation of
coagulable lymph.
Numerous large holes in the rectum and lower part of the colon,
regularly round and vascular, with elevated edges, at first supposed
to be ulcers, were found, on more careful inspection, to be the ducts
ANATOMICAL LESIONS IN DYSENTERY.
217
of mucous glands enlarged, and in the advanced stages, either
ulcerated or connected with a cyst formed of the lining membrane
of the duct, which secreted a gelatinous matter, whereof these cavi-
ties were often full.
The stomach, small intestines, and liver, were implicated to a con-
siderable degree in some of the fatal cases recorded by Dr. Cheyne.
The continued inflammation, of increasing intensity, in the order
of descent, from the small to the large intestines, is thus described:
" The mucous membrane of the stomach and small intestines
sometimes presented an inflamed appearance, which in general be-
came more remarkable as we approached to the great intestines;
then ulceration began to show itself; at first superficial, afterwards
laying bare the muscular fibres of the intestines; the ulcerations
became larger, more numerous, and deep as the rectum was ap-
proached ; but it was remarked that the last three or four inches
of the rectum were sometimes pretty sound. The peritoneum was
found less diseased than might have been expected." In a ma-
jority of dissections the liver was apparently sound, but in a good
many instances remarkably otherwise; in two cases there were ab-
scesses formed in its substance, and in a considerable number of
bodies it was in a state of great sanguineous congestion.
The peculiarly advantageous position of Dr. Cheyne, by which
he was enabled to note with all minuteness every symptom and
every morbid appearance, entitles his observations to more than
common respect; and I dwell, on this account, the more on the
anatomical details respecting dysentery with which he has favoured
the profession. (Dublin Hospital Reports, Vol. III.) Dr. Stokes was
well aware of the value of his countryman's merits on this point,
and has quoted him accordingly.
Of a similar purport with the results of the post mortem examina-
tions made in the fatal cases of dysentery in Dublin, are those
recorded by Mr. Twining in Calcutta. (Clinical Illustrations of the
More Important Diseases of Bengal, &c.)
On dissection of those dead of dysentery we find, says Mr.
Twining, the following appearances : —
1. Inflammation, ulceration, and, at times, sloughing or mortifi-
cation of the inner coats of the intestines; principally affecting the
caecum, colon, and rectum.
2. Morbid vascularity of the mesocolon, mesentery, and omen-
tum ; adhesions of the omentum to the parts adjacent, and of con-
tiguous portions of intestine to each other.
3. Glands of the mesentery and mesocolon often enlarged, some-
times inflamed, and more rarely suppurating,— the corresponding
portion of intestine usually contains a deep and large ulcer.
4. The omentum is occasionally adhering to these diseased
glands, forming a band that may strangulate a portion of intestine
and cause death.
5. The ulcerations within the great intestine are generally most
vol. i.—19
218 DISEASES OF THE DIGESTIVE SYSTEM.
numerous and most extensive at the cascum and first portion of the
colon: the valvula ileo-colica has in some cases been found quite
destroyed by ulceration, and the lower end of the ilium has formed
an intussusception into the caecum; and, becoming there strangu-
lated, has caused death.
6. The right portion of the omentum is frequently found adher-
ing to the caecum, and this morbid attachment gives rise to symptoms
that are liable to be mistaken for hepatic abscesses. When these
adhesions exist, we find that irritation or distention of caecum, or
pressure over that part, produces pain at the transverse portion of
the colon, which is drawn downwards by this attachment to the
part most diseased, — the patient cannot stand erect, nor extend
the body as he lies down, without feeling pain, which is referred to
the region of the liver; the same pain is excited by raising the right
arm above the head; there is occasionally cough, and sometimes
a pain in the right shoulder, rendering the diagnosis very difficult.
7. In a few instances the size of the intestine is increased by
thickening of its coats, so that when a transverse section is made,
the canal of the colon stands up like a thick leathern tube; the in-
terior of the intestine being covered, to a great extent, with numer-
ous large, ragged ulcers, in the intervals of which the mucous
membrane is partly destroyed and partly hanging in shreds.
In several of these cases there is a thick layer of coagulable
lymph deposited under the peritoneal coat of the intestine, and be-
neath the gut, extending a considerable distance along the iliacus
muscle ; in some instances an unusual quantity of fat has been found
at this part.
In other cases the whole of the great intestines are contracted
in diameter, resembling a cord ; and numerous small superficial
ulcers are observed in their interior. The patients have been much
emaciated, with flat, retracted belly, and dry skin ; the tongue of a
slate colour, glossy, and morbidly clear, as if skinned ; the stools an
opaque, dirty brown water.
8. Sometimes we find, in the whole course of the colon, not
above eight or ten large deep ulcerations, with sloughing, thick,
abrupt, raised edges, surrounded by a thickened base, into which
sinuses and undermining cavities are seen to penetrate.
Patients have been seen to die with not more than six or eight
of these spots of disease in the colon. These persons had flushed
face, restlessness, and continued symptoms of fever, which were
not easily subdued by remedies.
The patients with this sort of disease were generally recent arri-
vals from Europe, of light complexion, and not in affluent circum-
stances.
9. In those who die of dysentery, the last three or four inches of
ilium, adjoining the caecum, are generally affected with superficial
ulcerations and roughness. With this exception, we rarely meet
any disease of the small intestines in the post mortem examination
of dysenteric cases; unless we look to the dysenteric termination
CAUSES OF DYSENTERY.
219
of protracted fevers, in which ulceration of the small intestines
frequently exists ; and it may be deemed one cause of the tardy and
imperfect convalescence after fever.
In the West Indies, the colon exhibits the same peculiarities as in
the East Indies and in Europe. Dr. Cornuel tells us, in reference
to this point, in the former region, that from the ileo-ccecal valve
to the rectum, the whole mucous membrane of the colon often pre-
sented " one vast ulcer, of a cherry-red or reddish-black, which
looks like the advanced stage of osteo-sarcoma." He also adds,
that the intestine is contracted and greatly thickened, being in
some parts almost an inch in thickness, and sometimes cartilaginous,
and that the inflammation, although extensive and grave towards
the ileo-coecal valve, is nevertheless of greatest intensity towards
the sigmoid flexure.
The mucous follicles are commonly diseased, being either en-
larged and transparent, or else enlarged, hard, and opaque. Some-
times they have been observed, both in the dysentery of London
and of Jamaica, to assume the appearance of hard pustules or tu-
bercles. The mucous membrane of the colon would seem, there-
fore, to be liable to two kinds of inflammation; the first, the
spreading or continuous, which is always acute at the beginning,
but may become chronic, causing either thickening, roughening,
or ulceration. The second, though affecting the colic mucous
membrane generally, is, however, principally seated in the muci-
parous follicles, which are raised and altered in the manner already
described, and is for the most part chronic. (Craigie's Practice oj
Physic.) I would refer, also, to Dr. Geddings's paper on Follicular
Gastro-Enteritis, in the Baltimore Med. and Surg. Journal, Vol. I.
Causes. — Both Cheyne and Twining's observations point to
the occurrence of inflammation of the small intestines, and particu-
larly in the lower portion of these, or towards the ileo-coecal
valve — a morbid condition which is so common in typhoid fever.
In the dysentery of Ireland, Dr. O'Brien found the liver diseased
in one-half of the dissections, the spleen in one-fourth, the small
intestines in two-thirds, and the colon and rectum in all. May
we not believe these anatomical lesions, when they occur in dys-
entery, to be modifying causes of the phenomena of this disease, as
when we find low fever associated with dysentery, and sometimes
preceding its appearance? Complications of this nature are more
apt to occur in endemic dysentery under the operation of local
causes — as of cold, dampness, and moisture after high heat, the
impure air of camps, prisons, or hospitals. Of a like operation are
scanty or damaged food, and the depressing passions. In epidemic
dysentery we must look more to atmospherical vicissitudes and ex-
tremes than to errors of regimen for the cause, — although, even
here, the latter are not without their effect.
In illustration of the influence of ingesta, either improper in itself
or by excess causing dysentery, I may adduce the instance of the
Prussianarmy which invaded France,in 1792,and had advanced into
220
DISEASES OF THE DIGESTIVE SYSTEM.
Champagne, having been decimated by a dysentery caused by
eating unripe grapes; and that of the French troops who traversed
Provence, on their way to Algiers, suffering in like manner from
excessive use of oranges and other fruits of that region. Dysen-
tery prevailed for a period of thirty years in Cork, at particular
seasons, and most especially in years of scarcity, and when the
common articles of food have proved of bad quality. The effect
of weather is shown in the fact of its having prevailed with most
severity in the autumnal season and during the continuance of wet
weather. A diet of salted meat has been productive of dysentery
at many posts in different parts of the world, among the English
troops, and likewise in the navy. (Elements of Medicine, by Dr. Ro-
bert Williams, Vol. II.)
A change from old barracks, in low, damp situations, to new ones
well aired and ventilated, and on a drier position, has been attended
with almost a complete cessation of the disease. Even under the
adverse circumstance of unhealthy situation, the substitution of good
spring water for that of the impure water of the river Lee, which
passes through Cork, has sufficed to exempt the soldiers in barracks
from dysentery, to which previously they had been very subject.
Dr. Perston, in describing the disease among the troops at Limerick,
mentions, as among the most probable causes, the intense prevail-
ing heat of the days and the cold and profuse dews of the nights,
at the time it first showed itself; but he makes the qualifying addi-
tion, " together with some unknown peculiarity of the atmosphere."
Noxious exhalations from accumulated filth in the narrow streets,
and the effluvia from the banks of the Shannon, may also, he thinks,
have contributed to produce the disease. As regards persona]
habits, he attributes much to the liberal use of pernicious spirituous
liquors; for those addicted to irregularities were observed to be the
principal sufferers, though in several instances this could not be
imputed. Dr. Cornuel says that, in the foremost place of individual
causes, we must place drunkenness and an intemperate indulgence
in spirits. Indeed, at Basse Terre (Gaudaloupe) there is no con-
stitution so strong that it can escape dysentery without the practice
of temperance. Every regiment arriving at Basse Terre loses, in
the first year, three-fourths of those addicted to drinking, and the
remaining fourth dies at no distant period afterwards. (Memoire
sur la Dysenterie, 6rc.)
Mere morbid impression on the skin, by which its functions are im-
peded, will bring on the disease; as, in the instance of the French sol-
diers, who, at the battle of Dettingen, were exposed during a whole
night to heavy rains, and were, in consequence, seized with dysentery.
Another body of troops, encamped at a little distance, who were
not thus exposed, escaped the disease. Sir John Pringle relates,
that the English troops suffered at the same time from the like
cause.
Although dysentery has prevailed in every season, yet it has been
met with much more frequently in the summer than in the winter
CAUSES OF DYSENTERY.
221
half of the year. Dr. Ozanam has collected the history of fifty
epidemic dysenteries which occurred in Europe, from which we
learn that, of this number, thirty-six occurred in summer, twelve in
autumn, one in winter, and one in spring. Mr. Annesley relates,
that there were 13,900 persons attacked with dysentery in Bengal
from 1820 to 1825; and that of this number two thousand four
hundred were attacked in the cold season, four thousand five hun-
dred in the hot and dry season, and seven thousand in the hot and
moist season. In the United States army it has been observed,
that the ratio of the disease in the third quarter of the year is more
than threefold that in the first, and more than twice as high as
that in the fourth quarter. (Dr. Forry—The Climate of the United
States, p. 298.)
The attempt to trace a community of malarious origin of dysentery
with intermittent fever, has not been successful: — they are rife often
at different seasons, and under different circumstances of locality.
In our own country, both sporadic and epidemic dysentery are most
frequent during the intense heats of summer, and in situations in
which intermittent fever is either not seen, or is comparatively
rare. That there is sometimes alternation of the two diseases in
the same person, is no more than is noted in the case of remittent
fever and dysentery, and of typhous fever and this disease. In early
autumn, says Dr. Cheyne, several cases of cholera [morbus] degene-
rated into dysentery, and in the spring following symptoms of
dysentery accompanied the measles. Very often, he tells us, dys-
entery arose during convalescence from fever, in which case,
he several times ascertained that the preceding fever was not
attended with any unusual gastric or enteric irritation* In other
cases he suggests, that, when the symptoms of bilious or gastrie
fever were exchanged for those of dysentery, probably an extension
took place of the irritation from the mucous membrane of the
stomach and small intestines to that of the large intestines; a sup-
position rendered probable by some of the dissections made both by
Dr. Cheyne himself and by Mr. Twining, in which the stomach,
and still more the small intestines, were found to be inflamed.
A contagious origin has been attributed to dysentery by writers
and practitioners of great repute; but, as it seems to me, without
adequate foundation. The same mistake pervades the reasoning
in this as in so many other diseases, viz., in confounding community
of cause, by which a number of persons are affected in a certain order
of succession, modified by constitutionand degree of exposure, with
transmission of a morbid poison from one of these persons to another.
By the same logic, intermittent fever, and even catarrh, might be
shown to be contagious; as it could be proved, that one member of a
family was seized with the disease while nursing another suffering
under the same malady. The most plausible argument in favour of the
contagiousness of dysentery is made when this disease is associated
with fevers of a typhoid character, and sometimes with typhus itself;
but in such cases,dysentery,like bronchitis,is a superadded disease, a
19*
222
DISEASES OF THE DIGESTIVE SYSTEM.
complication of the original malady, and, in this view, does not come
within the scope of investigation into the etiology of either the real
sporadic or epidemic dysentery.
Doctor Cheyne, who expresses his belief in the contagion of dysen-
tery under particular circumstances, or, at least, that the contagion
of fever may at one time produce fever, at another dysentery, re-
lates an experiment which was meant to prove the adverse side of
the question. It was a dirty, but not a conclusive one. " In the
years 1797, 1798, and 1799, the dysentery prevailed in the Caith-
ness legion of fencibles to some extent. The surgeon, anxious to
determine the question as to its infectious [contagious T] nature,
caused the same glyster-pipe to be used, without cleansing, for
those labouring under dysentery, and those who were free from
that disease; the latter, notwithstanding, were not infected, from
which he concluded that the dysentery of Cork is not infectious."
Duration, Termination, and Prognosis. — It is difficult to assign
a duration to dysentery. It may disappear in twenty-four hours,
or it may last fifteen to twenty days. Commonly the period is from
four to eight days. If the disease does not end in health, it will in
some other disease, or in death. Dysentery is productive of several
forms of dropsy, — ascites and anasarca in particular; and it is
worthy of remark, that a swelling occurred in several of the pa-
tients, both male and females, resembling the phlegmasia dolens in
all respects, but in its connection with parturition. (Cheyne, op. cit.)
Sometimes there was a translation of disease to the lungs, with
great dyspnoea, which was in one or two instances removed by
venesection and a blister to the sternum. The continued irritation
and straining at stool may lead to very unpleasant consequences,—
frequently to dysuria and procidentia ani. The deaths, says Dr.
Cheyne, which took place in the first stage of dysentery, were owing
to fever, or to some other fatal disease which concurred. When
owing to fever, a peculiar state of the mucous membrane of the
stomach and intestines was noted. It was found of a deep red or
purple colour, rather thickened, soft, and pulpy ; and exhibited
uneven, rough, and granulated spots, surcharged with blood; and
others of a deep red colour, depending on bloodvessels ramifying
in an arborescent form. The stomach contained a viscid mucus,
firmly adhering to its coats, and mixed with an opaque yellow, or
whitish matter; the contents of the large intestines were fluid, and
of a yellowish-green colour. Dysentery frequently, and in warm
climates, is attended by disease (congestion) of the liver and spleen.
One of the most fatal complications with dysentery in the East
Indies is, according to Mr. Twining, disease of the spleen. Sir
James Macgrigor examined twenty bodies that had died of dys-
entery in the East Indies, and found the liver diseased in sixteen of
them.
Death sometimes occurred unexpectedly, from the escape of the
contents of the intestines into the cavity of the peritoneum, in con-
sequence of a portion of that coat being destroyed by ulceration.
PROGNOSIS OF DYSENTERY.
223
When the disease continued without relief for twelve or fourteen
days, a degree of emaciation usually became observable; much
more rapid in some than in others, and which was always an
alarming symptom; if, added to emaciation, a patient in the
second or third week of dysentery acquired a haggard look,
had a quick pulse, and an abdomen intolerant of pressure, we
had, says Dr. Cheyne, little hope of his recovery. At one period,
continues this author, when the disorder was fatal, our expectations
of recovery were confined to those cases which had not existed
long, and in which the patient was not emaciated at the time re-
ferred to. A majority of the patients died who had been ill more
than six or seven days, and of those who were emaciated scarcely
one recovered.
The prognosis must vary with the intensity of the disease and
the concurrent circumstances under which we meet with it. Spo-
radic is less alarming than epidemic dysentery, and in this latter
our augury will be unfavourable according to the persistence and
violence of the fever, as when this is of a typhoid or remittent cha-
racter, and occurs in low and damp situations, and in badly venti-
lated lodgings, and among men crowded together, as in ships, camps,
prisons, and hospitals. Chronic dysentery may last for weeks,
months, and even years. If a person has acute dysentery in the
latter part of the summer, the disease is sometimes greatly miti-
gated, but not entirely cured, by appropriate treatment; and it
assumes the chronic form, which often persists during the whole
winter, and is only removed on the approach of warm weather
in spring or early summer.
It would be a point of no little interest, to be able to determine when
ulceration in the colon begins, as not only influencing us in our pro-
gnosis, but, also, to a considerable degree, in our therapeutical treat-
ment. That this lesion is curable we are well assured, from the fact
having been repeatedly noticed, that in persons who had been ex-
amined after death from another disease long subsequent to the attack
of dysentery, smooth spots, cicatrices, were met with taking the place
of the ulcers which had healed. The second stage of dysentery is
said to commence when pus appears in the stools, but there are cases
in which the disease pursues a chronic course, and terminates fatally
without any such appearance. Discharge of pus does not neces-
sarily imply ulceration; for, as we learn from Dr. Cornuel, he has
examined cases in which no ulceration has been found, and yet
pus in large quantities was occasionally contained in the colon.
In some mild cases the pus passed is small in quantity; but more
commonly it amounts to several ounces in the twenty-four hours, and
may be voided with or without blood, shreds of lymph, lumps of a
sebaceous substance, with fecal matter. Portions of mucous mem-
brane, varying from a few inches to a few lines, are often passed
in the dysentery of the West Indies, according to Dr. Cornuel, and
in a gangrenous state, during the second stage of the disease.
Extreme emaciation is noticed by this last mentioned writer as
224
DISEASES OF THE DIGESTIVE SYSTEM.
presenting in the last stage of dysentery, and as a sign of bad
augury. So also is a burning sensation or constriction of the throat,
which hinders the patient from speaking; the buccal membrane
also inflames, the mouth becomes aphthous, and sometimes even the
cheek is ulcerated.
The prognosis depends much on the country in which dysentery
occurs. In general it is unfavourable in the acute stage in hot
climates, in the proportion of one to twenty or twenty-five,
at least when the patient (a soldier) can command the com-
forts of a hospital. On actual service, however, the chances
of recovery are often much diminished ; while the chronic form
shares the probabilities of one death in every four or five cases, in
whatever country the patient may be seized. In the dysentery
which reigned in Edinburgh in 1828, Dr. Christison considers the
mortality in eighty cases to have been one in four. In the military
hospitals at Namur in 1831, out of one hundred and seven cases
treated, twenty-six died, or nearly one in four. In the Peninsular
war, the change in the same person from intermittent fever to dys-
entery was sometimes common. If both diseases attacked the same
patient at the same time, the dysenteric symptoms were aggravated.
When dysentery was combined with typhus, the patient seldom
survived. (Williams, op.cit., vol. ii., p. 562.)
Treatment.— In the first stage of the milder cases of dysentery, the
simpler means pointed out by Dr. Stokes, as applicable to diarrhoea
(p. 200), will suffice. Symptoms of inflammation of the intestine
will indicate venesection and leeches. In the sporadic dysentery
as I have met with it in Philadelphia, and, in earlier life, quite fre-
quently in the lower part of the valley of the Shenandoah in Vir-
ginia, the lancet cannot, with safety, in many cases, and with advan-
tage on the score of speedy abatement of fever and pain, be dis-
pensed with. But in epidemic and camp dysentery, I use this
term to indicate locality rather than any specific or well-marked
difference of disease, we do not, by any means, speak with the
same confidence of this remedy. At the most, its cautious use only
at the outset of the disease is allowed by Cullen, Annesley, Ballin-
gall, Macgrigor, Cornuel, Latham, McCarthy, &c. But yet we
must not forget the practice of free bleeding by Pringle, Munro, and
other army surgeons, Twining, &c. When associated with ileitis,
as in typhoid fever, or with regular typhus, we cannot, after the
very outset of dysentery, promise ourselves much benefit from the
use of the lancet. But even in cases of this kind of complication,
and where he had reason to believe that ulceration existed in the
intestine, Dr. Cheyne repeated venesection, and with great tem-
porary relief; and when followed by blisters, mild aperients and
anodynes, the relief was permanent.
In all cases, even in the advanced stage, in which there is much
tenderness or pain confined to one region, we may promise our-
selves excellent effects from the application of leeches; and, if need
be, afterwards of a blister; the vesicated surface to be frequently
TREATMENT OF DYSENTERY.
225
dressed by cataplasms of flaxseed or bread and milk, so as to keep
up, not only counter-irritation, but a kind of revulsive secretion.
As regards the use of mercury in dysentery, I shall repeat the
opinions which I expressed on a former occasion.
It is mere empiricism to look to salivation, either as a necessary
proof that enough of mercury has been administered, or as an in-
dispensable means of curing the disease. Salivation is an occa-
sional result to be deprecated and avoided rather than sought for.
After venesection and leeching, or where the inflammation is less
intense, after leeching alone, I give calomel, in a dose of from ten
to twenty grains, at once, or in a dose of five grains, repeated two
or three times at an interval of three hours, until the lower bowels
are relieved by a discharge of retained scybala and fecal matter
mixed with bile and mucus. If the medicine fails to operate freely
in this way in from twelve to sixteen hours, we should administer
some of the milder purgatives, such as rhubarb and magnesia,
salts and magnesia, compound powder of jalap, or castor oil. If
there be much nausea and distress of stomach, we may be content
to aid the operation of the calomel by enemata. Again and again
I have seen the most complete relief from all the troublesome symp-
toms of dysentery — tenesmus, mucous and bloody discharges
from the rectum, fever, and the indescribable painful sensations
which follow irritation of the large intestine — after one or two
copious evacuations, procured by calomel. Sometimes this relief
is but temporary; and the pain, and straining at stool, fever,
and foul and even dried tongue, harsh and hot skin of the ab-
domen, and coldness of the extremities, show that the disease
persists in its course. Leeches over the region of the colon, and,
notably, corresponding with its arch, or to the anus, will again be
advisable here; and calomel in smaller doses, say one to two grains
every three hours mixed with a little gum arabic, will be useful,
by acting on the mucous surface and muciparous glands of the
intestines, restoring their healthy secretion, and that also of bile
which is suspended, or it is retained in the small intestines,
and does not enter the colon. If calomel fail to answer our
expectations in this way, we ought not blindly to persevere in
its use, with a view of inducing salivation. On the contrary,
we ought to desist from its administration, and abstain from ac-
tive medication for a while; content to direct demulcent drinks
and mucilaginous enemata, warm pediluvium, perhaps a few
leeches, and if fever persist, minute doses of tartar-emetic com-
bined with opium. I prefer giving calomel alone, in the earlier
stage of dysentery, to its combination with ipecacuanha, or with
ipecacuanha and opium, from a belief that the former of these two
medicines rather interferes with than aids the salutary action of the
calomel; and that it is directed under the influence, very much, of the
old pathology of dysentery, in which the disease was regarded as
one of weakness, caused and marked by excessive morbid discharge
from the bowels, which ipecacuanha had the power of checking.
226
DISEASES OF THE DIGESTIVE SYSTEM.
I do not think that we are prepared to speak in positive terms of
the real effects, either direct or remote, of the combination of
opium and ipecacuanha with calomel in the early or inflammatory
stage of dysentery; and, until we have definite notions of the
operation of a compound, we had better content ourselves with
the articles singly of which it consists, when they have, each of
them, admitted power. In succession or alternation, we can gener-
ally procure all the salutary results derived from the adminis-
tration of several medicines at once. Thus, after calomel has ex-
erted its effects in the manner already mentioned, if there is still
diarrhoea with little or no tenesmus or tormina, ipecacuanha
with chalk or carbonate of magnesia will advantageously come
into play. At this time, also, as the skin is commonly found to
be dry, and there is restlessness and general irritation preventing
sleep, opium will answer a good end. Taking it as a basis, we can
add ipecacuanha to it, as in Dover's powder ; or, substitute for the
neutral salt in this latter, chalk or carbonated magnesia. We may
at the outset, of at least so soon as we think it advisable to give
calomel in dysentery, combine a little opium with it; with a
view of making it. rest more tranquilly on the stomach, and of dimi-
nishing its sickening effects in its passage through the small
intestines : but to the frequent routine use of calomel and opium,
from the beginning, in dysentery, lam opposed, for the reason, in
addition to that already given, that opium is generally prejudicial
in the beginning of the disease, and thus interferes with in place of
aiding the operation of the calomel. The best preparation for the
latter is venesection and leeches: the best adjuvants diluent and
demulcent drinks, simple enemata, and fomentations. Camphor
water, mint water, or mint or peppermint teas, may, on occasions,
be used at the same time, with the effect of temporarily allaying and
soothing pain, until more complete and permanent relief is obtained
by the calomel; but the appropriate drinks for common and con-
tinued use through the course of the disease, are rice, barley or gum
water, and occasionally a little well-boiled, thin gruel.
You will see that, whilst 1 deprecate the empirical practice of
giving mercury in dysentery, with a view to its sialagogue opera-
tion, I am not backward in using it with other views, and to pro-
duce other effects: these are, first, in conjunction with laxatives, to
unload the bowels of scybala when they are present, or of mucus
and remains of ingesta, which are so many causes of irritation ;
and, secondly, to produce a soothing effect on the mucous folli-
cles and membrane generally, and through the duodenum on the
liver and its secretory apparatus. Need I adduce the names of
practical men, who have recorded their experience against the
curative value of mercurial ptyalism in dysentery? " I have met,"
says Mr. Twining, " with a vast number of cases in which it had
been used so as to produce salivation, without curing the dysentery."
So, likewise, Dr. Cheyne tells us expressly, " that mercury, when it
produced salivation, even in the earlier stages of the disease, was
TREATMENT OF DYSENTERY.
227
in many instances unequal to the cure, was established beyond a
doubt. In the ulcerative stage, and in cases in which emaciation
had taken place, and in cases in which the tongue was florid and
glazed, the mercurial treatment was injurious." Mr. Annesley, (Dis-
eases of India,) while he agrees with Dr. Johnson in recommending
calomel in scruple doses in the acute stage, differs from him pointedly
in opinion as to its value as a sialagogue, and warns us against
carrying the remedy so far as to affect the mouth, " for, in that
case, it generally depresses the powers of life too rapidly ;" and he
adds, "after the acute symptoms are removed, the calomel, in the
manner now recommended, should be either altogether discontinued,
or given only occasionally, when its operation may be assisted by
mild oleaginous aperients."
Believing it. myself to be an agent which lowers the powers
of life, and that its constitutional operation is that of a seda-
tive, I use mercury, and particularly blue mass, in the remains
of irritation of the intestinal mucous membrane in the subacute
and chronic dysentery, on the same principle as that by which I am
led to its employment in larger doses in the first or acute stage.
In this latter its sedative action is often not equal, without the
aid of venesection or topical bloodletting and laxatives, to relieve
the intestinal inflammation and to reduce the general febrile excite-
ment. Dr. Ballingall, although opposed to mercury in the acute
stage of dysentery, is a warm eulogist of this medicine in the
chronic form of the disease, in which, he alleges, we may place im-
plicit confidence in it. This is an extravagant opinion, as all
extreme opinions in the practice of medicine are: but it must not
drive us to an opposite extreme, and induce us to withhold, in suita-
bly prepared cases, in any stage of the disease, mercurials, either
alone, in alternation with other remedies, or combined with them,
in the manner already indicated.
The fact is, that colitis is often so associated with other lesions,
as of the small intestines, or of the liver or the spleen; or, using
nosological language, dysentery is so often complicated with inter-
mittent, or remittent or typhous fever, that neither one remedy
nor one plan of treatment is adequate to the cure of the disease,
as it presents itself in different climates and seasons, or in differ-
ent localities and even persons.
Dr. Harlan, in his Medical and Physical Researches, p. 567,
adduces his favourable experience with sugar of lead in dysentery,
as it prevailed in Philadelphia in 1820. In an acute and very
severe case, with great tormina and tenesmus, and a discharge of
a considerable quantity of blood, Dr. H. prescribed, within the first
twenty-four hours, the following: —
R. Sacchar. Saturn, gr. xviii.
Pulv. Opii, gr. vi.
M. ft. pulv. vi. One to be taken three times daily.
By the use of this medicine alone, the patient was perfectly cured
228
DISEASES OF THE DIGESTIVE SYSTEM.
in three days. The tenesmus, tormina, and bloody discharges
were promptly relieved, and the cure was permanent. In some
instances, the sugar of lead was given alone, or combined only
with small doses of opium; to which latter, without this observation,
might otherwise be attributed the cure of the disease.
Dr. Zollickoffer has succeeded in giving entire relief, in many
cases of dysentery, after venesection and laxatives, by Prussian
blue (ferracyanuret of iron), in doses of four grains mixed with a
little sugar and water every four hours. From seven to eight doses
have sufficed for a cure.
A cold and dry skin, diarrhoea in place of tenesmus and tormina,
or the occasional recurrence only of these; pulse frequent, but with-
out force; a tongue which has lost its redness and is less loaded,
will indicate the propriety of the administration of Dover's powder,
with warm herb teas, the warm bath or warm pediluvia, or stimu-
lating liniments to the abdomen. As regards the use of turpentine,
I refer you to Dr. Stokes's lecture. A combination of opium or
laudanum in camphor mixture, with mucilage of gum arabic, and
the addition of a few drops of nitrous or nitric acid, known for
some time as Hope's Mixture, is a favourite prescription with some
practitioners. I have often employed it, but without anything like
the uniformity of pleasant results which its more sanguine friends
claim for it.
In the autumnal dysentery, and that which prevails in low lands
at the same time with intermittent fever, there is not the same
urgency for the use of the lancet as in the variety already described.
Leeches to the abdomen, or even a few cups where the former are
not readily obtained, will take the place of the lancet. Recourse also
will be had more freely to sulphate of quinia, and greater stress laid
on counter-irritation by blisters and tartar-emetic ointment; not so
much with a view of acting on the colon as for the relief of the
liver and spleen, engorgements and chronic inflammation of which
are not unfrequent accompaniments of the disease. The use of calo-
mel will be of shorter duration, and will be followed by the earlier
administration of ipecacuanha and opium, than in the more acute
and inflammatory dysentery of summer. The variety under con-
sideration most commonly ends in chronic diarrhoea, which taxes
the ingenuity of the practitioner in the selection of various astrin-
gent medicines. Without denying the utility of these, I can speak
with more confidence of the advantages to be obtained from the use
of the blue mass in doses of two or three grains night and morning,
and mucilaginous drinks—the food to consist of rice well boiled,
arrow root,&c, with the addition, if they do not prove too oppressive
to the stomach, of milk and cream. I learned, now many years ago,
when in China, the practice of using the blue pill in this stage of
dysentery from Mr. Pearson, the estimable surgeon of the English
Factory at Canton, and have had continued reason to be pleased
with the remedy ever since. In simple profluvia, after the subsi-
dence of inflammatory irritation, as well as in hemorrhage from the
TREATMENT OF DYSENTERY.
229
bowels, and menorrhagia of a chronic kind, I have employed tannin,
. in doses of three to five grains twice or thrice a day, according to
the exigency of the case. Extract of Krameria, sugar of lead with
opium, and alum, have been used in this stage of disease with good
effect.
Although the anatomical lesion characteristic of dysentery, on
which the chief symptoms and progress of the disease depend, is
inflammation and ulceration of the mucous follicles and intermediate
membrane of the colon and rectum, and occasionally of the lower
part of the ileum, there have been fatal cases in which no organic
change of this nature was obvious. At times, and not unfrequently,
especially at the commencement of dysentery, the gastric symp-
toms predominate; a modification set forth in a strong light, with
his accustomed ability, by Dr. Chapman. Under such circum-
stances, our attention should be at first mainly directed to the sto-
mach, and suitable means had recourse to in order to allay its
irritation. With this view, leeches over the epigastrium, laxative
enemata, cooling and demulcent drinks, will be a proper prelude to
ulterior treatment, which in this case will be singularly simplified
and easier. Frequent nausea and retching, or a bitter taste in the
mouth, and the known presence of indigestible matters in the
stomach and upper bowels, would seem to indicate the propriety of
administering an emetic; and, accordingly, vomiting has been often
had recourse to as a remedy in dysentery. That it is sometimes
useful in the beginning of the disease I know well from repeated
experience; but the same cannot be said of it in a more advanced
stage, when the tongue is dry and furred and the abdomen hot and
tender, and other symptoms point out phlogosis of the intestine. The
emetic to which preference is commonly given is ipecacuanha, but,
as I cannot help thinking, on speculative grounds. Thus, it was
supposed to have the double action of an emetic and an astringent,
and as such thought to be peculiarly adapted to dysentery. But
admitting this double property, which, by the way, is not proved, it
does not by any means follow that the first stage of sporadic
dysentery is the time for its salutary manifestation. Whether we
have regard to the inflammatory state of the large intestine, or to
the febrile disturbances in consequence, preference ought to be
given to a remedy which has a direct and well-marked effect in
reducing if not removing these phenomena; and this remedy is
tartar emetic. There is every indication for this latter, and none
for the astringency of the ipecacuanha. Some persons would cut
short all reasonings as to its modus operandi, and claim now for
ipecacuanha the same credit which it enjoyed when introduced
into general practice by the first Helvetius, viz., the power of
exerting a direct and specific action on the diseased organs.
Without formally announcing a proposition of this nature, the late
Mr. Twining of Calcutta seems to have acted on the idea involved
in it, by recommending large doses of ipecacuanha in dysentery,
without its exciting vomiting. Having cleansed out the bowels by a
vol. i.—20
230 DISEASES OF THE DIGESTIVE SYSTEM.
dose of castor oil, he gave six grains of ipecacuanha, with four
grains of extract of gentian, and five grains of blue mass in three
pills, which were repeated every night at bed-time, and at day-
light in the morning a small dose of compound powder of jalap.
A cessation of all the distressing symptoms ensued ; and it was
sufficient to continue six grains of ipecacuanha, with four grains of
gentian every night, and to give a very small dose of compound
powder of jalap, or a moderate dose of oil every morning for four or
five days more. Mr. Twining says, that ipecacuanha thus combined
seldom produces vomiting, and that he has often given twelve grains
of this article with eight grains of extract of gentian in four pills with-
out any effect of this kind ; and half this quantity to a young per-
son, thirteen years of age, without causing nausea. The power of
the gentian to control the emetic effects of the ipecacuanha seems
to be evident from the fact, that three grains of the latter of the
same parcel and bottle, given alone, repeatedly vomited. Accord-
ing to Mr. T. the first effect of ipecacuanha, in ordinary cases
of acute dysentery, is for the most part a slightly increased
intestinal secretion, the evacuations becoming more copious and
feculent — pain and tenesmus are abated, while the quantity of
blood and slime immediately decrease, and soon disappear alto-
gether. It will be seen, at once, that this practice is not by any
means conclusive of the operation and effects of ipecacuanha, so
much as of the prescriptions of Mr. Twining, into the composi-
tion of which it is true this latter medicine enters in large propor-
tion.
We can repose the more confidence in the accuracy of Mr.
Twining's description of the results of what some would term
the ipecacuanha practice, from the fact that he was not by any
means exclusive in his views, nor wedded to one particular
remedy. Thus, he most strenuously urges the necessity of a free
use of the lancet, and repeated bleeding by leeches in all recent
cases of dysentery, where there is either pyrexia, morbid sensibility
of the belly on pressure, evacuation of blood with the stools, or
tenesmus. But when repeated bleedings have accomplished all that
can be wished from them, ipecacuanha, with the medicines above
stated, will be found of infinite service in soothing irritability and
restoring a healthy state of the bowels. " I need not say," con-
tinues Mr. T., " that tepid baths, fomentations, and poultices, over
leech-bites while they are still bleeding, are useful. Where the free
use of calomel has been chiefly relied on and employed to salivate,
in some instances a purging and tenesmus have still continued, and
in these the combination of ipecacuanha and gentian has then been
employed with the most happy results. Opiates have generally
appeared injurious in dysentery, except when given with calomel,
so as to cause that medicine to be retained in the first portion of
the intestines, while it may act on the secretions of the duodenum
and liver."
In modification of the above views, as far as respects the ipeca-
TREATMENT OF DYSENTERY.
231
cuanha practice, Mr. Martin's views (Official Report of the Climate
and Topography of Calcutta) will find appropriately a place here.
In the dysentery of Bengal, bloodletting, general and local, as
first practically urged by Dr. James Johnson, takes the lead, and
has done so for many years. "But," observes M. Martin," as in most
cases of this formidable disease, as it appears within the tropics, the
diseased state of the large intestines is essentially mixed up with
general abdominal complications, other and important means fol-
low the bloodletting ; and of the first are those which act power-
fully on all the secreting organs, internal and external — such
as calomel in full doses with antimony, or with ipecacuanha, fol-
lowed by laxatives, warm baths, enemas, and other adjuvantia. I
believe this to be the general course here, and I have seldom seen
calomel carried the length of salivation; neither do I consider this
degree of effect necessary to the cure."
Mr. Martin and Dr. Whitelaw Ainslie, after many years expe-
rience in Indian dysentery, both among the natives and Europeans,
place the greatest confidence in the remedial powers of ipecacuanha,
in the simple uncomplicated forms of the disease, as an exclusive
remedy, that is, after bleeding and moderate purging. But both
they and Dr. Macnab, an East India physician of much expe-
rience, have been quite disappointed in their trials of the ipecacu-
anha with gentian and blue pill practice, so highly extolled by Mr.
Twining.
I draw the more freely on the descriptions of writers on tropical
diseases, for the benefit of the practitioners of the southern portions
of the United States, who may be expected to regard them as au-
thority of more weight than writers at home, residents in the
northern states.
A partiality for large doses of ipecacuanha in dysentery was
manifested long before Mr. Twining's time. Reference to a com-
munication by Mr. Balmain, in the fourth volume of the Memoirs
of the Medical Society of London, will show us that this gentleman
gave repeatedly two drachms at a dose, with the addition, however,
of sixty drops of laudanum. In many cases, he tells us, that a dose
or two was sufficient to remove every dangerous symptom. The
ipecacuanha answered the purpose best when given in the form of
pills; and, adds the narrator, " if the patient kept still and lay on his
back, with the head and chest tolerably elevated, nausea seldom or
never followed it; and oftentimes it happened that he had not a stool
the succeeding day, although previously the gripings were violent,
and the discharges of blood frequent and in large quantities."
Chloride of lime has been found highly serviceable in dysentery
by Dr. Read of Dublin, who employed the medicine also with ex-
cellent effects in the epidemic fever of Ireland, with which dysen-
tery was often associated. His prescription was
R. Chlorid. Calcis. gr. x.
Tinct. Colorab. lij.
Aquaj Purae, giv. M.
Half an ounce to be taken every hour.
232
DISEASES OF THE DIGESTIVE SYSTEM.
Dr. Read also administered the chloride as an enema, ten grains
being added to the common enema. Simaruba bark has been
highly spoken of, especially in conjunction with opium, by Dr.
O'Brien, in epidemic dysentery.
M. Trousseau has employed at the Necker Hospital nitrate of
silver, in enema, both in the acute and chronic stage of the disease ;
and with great success. He premises an emetic of ipecacuanha,
and then gives an enema composed of five grains of the nitrate in
twenty ounces of water. A single enema often sufficed, but in gene-
ral the treatment was continued for four or five days. Where the
disease was supposed to extend to or be connected with lesions of
the ileum, M. Trousseau directed the medicine to be used by the
mouth, instead of per anum, in the dose of half a grain. To a
child, age not stated, with chronic diarrhoea, one-fifth of a grain
was given by the mouth, or a grain in enema.
I ought not to conclude these remarks on the treatment of dysen-
tery without specific allusion to the use of opium in large doses,
from an early day, in this disease. Broussais, Cheyne, Christison,
and other names of high authority, are adduced in its favour. Dr.
Cheyne's opinion has been given already by Dr. Stokes. Dr. Chris-
tison, in the treatment of the cases of epidemic dysentery which
came under his charge about eleven years ago in the Edinburgh
Infirmary, found opium to give the greatest relief, after the stage
in which feculent matter was discharged and had ceased, and the
evacuations had become muco-sanguinolent, or sero-sanguinolent.
At this time he commonly directed the application of leeches to be
immediately followed by doses of pure opium, of such magnitude
and frequency as were found necessary to check the unremitting
diarrhoea and tormina; and sometimes the desired effect was not
procured until the patient was pretty strongly affected by the
narcotic action of the drug. In urgent cases, twenty or twenty-
four grains in the twenty-four hours were sometimes necessary
from the very beginning; in the slighter cases, four or six grains
were sufficient. " When an impression was once made on the dis-
charges, it was maintained by doses of two or three grains repeated
according to circumstances, and frequently the exhibition of opium
by the mouth was conjoined with its employment in the form of
suppository." But it would appear from the sequence of Dr.
Christison's narrative, that the opium was more palliative than de-
cidedly curative in its operation, for he speaks of the blood reap-
pearing abundantly in the stools, " if the opium was intermitted on
account of its causing too complete constipation." And again:
" After the hemorrhage was permanently checked, the frequent, thin,
feculent stools continued many days, sometimes many weeks, indi-
cating, it is to be presumed, the existence of ulceration, which con-
sequently must have taken place at a very early period of the
disease." It is worthy of remark, that the medicine which Dr.
Christison found to be most useful in allaying irritable stomach,
and in correcting and checking the thin discharges mixed with
TREATMENT OF DYSENTERY.
233
some blood in the subacute form of dysentery, was the acetate of
lead.
In autumnal dysentery, in that alternating with rheumatism, or
in which the symptoms indicate a predominance of neuralgia oyer
phlogosis, in cases of cold skin and feeble action, and in the begin-
ning of more acute cases before reaction, and when the skin and
extremities are still cold, opium in a full dose of two or three grains,
with warm drinks, may be given with advantage. But if the in-
flammatory action has been fully developed in the mucous follicles
and membrane, this medicine will poorly meet our wishes, by
merely deadening sensibility, and simply suspending for a while the
morbid processes, which, if not more completely checked, will end
in ulceration and gangrene. Dr. Miner of Connecticut, who is an
advocate for the opium practice, lays great stress on the benefits
of its union with capsicum. His prescription is, a pill consisting
of one grain of capsicum and opium each, every two hours — but
for how long a period he does not state. Of the utility, and ex-
ceeding comfort, by the removal of tormina and tenesmus, from the
use of opium by enema, there can be no doubt: even this mode
of administration is not adapted to every stage of dysentery, but
rather to the second, in which there is an abatement of fever and
inflammation, and in which it becomes necessary to procure, if
possible, tranquillity and sleep for the patient during even a few
hours. The chances of retention of the enema will be, of course,
in proportion to the smallness of the quantity and the mildness of
the vehicle — warm mucilage, or even simple water.
There are cases in which the disease is confined almost entirely
to the rectum, which is inflamed and discharges blood and some
mucus, and is thrown into a spasm at each effort of defecation.
Here, although there is often much sympathetic distress—headache,
fever, full pulse, with thirst and restlessness— the remedies required
are merely topical, viz., leeches to the anus, emollient and narcotic
enemata, and afterwards a weak solution of the acetate of lead, and,
still later, of sulphate of zinc. After the subsidence of the rectal
inflammation the bowels may be acted on by a dose of calomel,
followed by castor oil mixture, which will discharge scybala and
bile, and give the patient entire ease.
Hepatic Flux.—The disease which has obtained this name is a
chronic variety of tropical dysentery to which Europeans who have
resided some time in India are liable. I shall take the summary
description of it by Dr. Craigie (Practice of Physic). Like the
common dysentery it commences with an ordinary attack of diar-
rhoea, and is afterwards characterized by frequent and severe fits
of griping, like colic pains, near the navel, each of which is suc-
ceeded by a call to stool. The discharges are, from the first, always
unnatural in colour, varying from the darkest inky hue to the dif-
ferent and alternating shades of green and yellow. The stools,
which exhibit a frothy appearance, are voided with copious dis-
charges of wind, and with a sense of scalding about the anus.
234 DISEASES OF THE DIGESTIVE SYSTEM.
Each evacuation is followed by relief, — but the gripings, with the
sense of air moving in the bowels, are soon succeeded by a call to
stool with the same powerful sensations.
The tongue is covered with a yellow mucous coat, and often
furred; appetite lost; thirst great. The pulse is quickened, and
the skin parched and hot. When these symptoms have existed for
some days, the stools become of a whitish colour, are mixed with
portions of half digested aliment, and are passed with painful
straining. In this state the disease is termed, by the soldiers, the
White Flux. The griping pains continue, sometimes with perma-
nent oppression at the epigastric region, or even hysteric strangu-
lation. Squeamishness and loathing of food, with hiccup and bilious
vomiting, are very distressing; thirst is extremely urgent; weak-
ness and lassitude increase as the flesh is lost; the pulse continues
quick; and the skin often communicates a greasy sensation to the
touch.
Under these symptoms, modified by peculiarity of constitution,
season, and local situation, the patient may labour for weeks or
months, while the flux injures the constitution irreparably, and
wastes the strength by its long duration. Yet it generally does not,
of itself, prove fatal, but may either terminate in recovery by gra-
dually and spontaneously exhausting itself; or an abscess of the
liver, or ulceration and mortification of the colon, either of which
may be fatal.
The treatment of hepatic flux is comparatively simple ; it consists
of mercurials, mild purgatives, and diaphoretics. The blue mass is
to be given in a pill of from three to five grains, three times a dav,
followed by and alternating with castor oil and infusion of senna ;
or aloes and calomel combined may be given to operate on the
bowels. The addition of hyosciamus or of taraxacum to the calomel
or the blue mass will be an improvement. When the skin is hot
and dry, the warm bath, with Dover's powder, in a dose of five to
ten grains, morning and night, or of tartar emetic and opium, will
be very serviceable.
Change of air and the exercise taken to procure it have been
decidedly curative in dysentery, after the first or acute stage has
subsided ; but the patient still suffering from, and greatly exhausted
by, the chronic disease. More particularly is this change required
in cases of dysentery in tropical climates. Desgenettes, physician-
in-chief to the army in Egypt, relates, that four hundred soldiers
who had been reduced to a stale of extreme emaciation by chronic
dysentery, were embarked from Alexandria for France; and that,
with the exception of nineteen who sank under the disease within
a few days after their leaving port, they were all entirely conva-
lescent on their arrival at Malta. Desgenettes attributes these
good effects to the movements of the vessel, by which nausea and
vomiting were produced, and the peristaltic action of the intestinal
canal inverted ; in connexion with the change of air and approach
to a cooler climate.
ENTERORRHCEA.
235
In admitting unripe fruits to be a cause of dysentery, we cannot
at the same time deny the fact that the ripe kind, and especially
grapes, have often displayed marked curative effects in dysentery,
particularly when it is associated with fever.
LECTURE XX.
DR. BELL.
Enterorrhcea—Includes both diarrhoea mucosa and d. serosa.—Gastrorrheea.—
Pathology of enterorrhoea—Two varieties of the disease—Acute and chronic
stages—Connexion between dentition and development of the intestinal mucous
follicles—Treatment of enterorrhcea based upon subduing intestinal irritation—■
diet, and sudorifics and opiates, sometimes astringents—In lymphatic subjects
and in epidemic visitations, emetics and purgatives proper.—Importance of diet
for the cure of diarrhoea in all its forms—Kind of diet most beneficial—Ente-
rorrhcea with Membranous Formations—Pellicular exudation on intestines
of very young- children—Associated sometimes with stomatitis—Later in life
with dysentery—Probably the result of morbid follicular secretion, with or
without inflammation—May appear and recur frequently,—sometimes without
much general disorder—in duodenal dyspepsia—Causes and seat not known—
Treatment.
Enterorrhcea (from «vT«gov, intestine, and §«*> I flow), on which I now
propose to make some observations, will include diarrhoea mucosa
and diarrhoea serosa of systematic writers. The former term is
much more distinctive than this latter: the prefix of Si*, through
conveys no definite meaning, and is just as applicable to excessive
discharges* from the stomach, bladder, vagina, and uterus, and even
from the skin, as it is to those from the intestines. A wrong direc-
tion is also given by the word diarrhoea to our pathological inves-
tigation, which it makes to turn upon the mere amount and quality
of the flow, or matters discharged, rather than on the condition of the
organ or organic system on which the discharge mainly depends.
Enterorrhoea consists of a morbid change of secretory function of
the intestinal mucous membrane, by which there is an excess of
mucus, or of muco-serous fluid, discharged from the bowels. I did
not designate by its appropriate title of gastrorrheea an analogous
morbid state of the gastric mucous membrane, but contented
myself, in a former Lecture (XII), with directing your attention to
this derangement under the head of Dyspepsia with Gastric Morbid
Secretions^(p. 150-2). We may readily suppose, that, in some
cases, this morbid condition of the mucous membrane prevails,
both in the stomach and intestines, constituting a true gastro-ente-
rarrhaa; but as I am not in possession of any diagnostic characters
of this form of the disease, I shall pass on to the more immediate
subject of the first part of this lecture, or to enterorrhoea proper.
As regards the pathology of this disease — its causes, symptoms,
and theltructural alterations, we find that it originates from ex-
posures similar to those which often bring on dyspepsia and dys-
entery. It resembles in some particulars the chronic state of this
236
DISEASES OF THE DIGESTIVE SYSTEM.
latter disease ; but differs from it in the organic lesion not being in-
flammation of the mucous membrane, but irritation of this tissue, and
irritability of its follicles. In low situations, and exposed to a damp
and cold atmosphere, and in seasons and climates in which this kind
of constitution of the air prevails, we often find mucous fluxes, some-
times endemic, and at others even epidemic. Indigestible food, or
bulky aliment in which mucilage is too abundant, are also causes par-
ticularly active in persons of a lymphatic temperament, and of a
scrofulous diathesis. So also are bad water, intoxicating drinks,
and particularly fresh or sour beer. Strong mental emotions of a
depressing or anxious kind will sometimes bring on this flux.
There are two varieties of enterorrhcea; the first not distinguished
by the passage of much fluids — the second characterised by copious
discharges. In the first variety the abdomen is full and tumid ; there
is rumbling of the bowels, increased by pressure on the abdominal
parietes, under which pain is also created. The stools are few and
irregular; and there is sometimes alternation of diarrhoea and con-
stipation. The tongue is not abnormal, and the general symptoms
are not very clear. The second variety has, for its distinguishing
symptom, a copious discharge, consisting of serum, (albumen dis-
solved in water,) or of mucus in excess, and sometimes of both ; or
they may be mixed with a notable quantity of bile. On occasions,
as where gastro-enterorrhoea has been epidemic, and complicated
with or gave rise to fever, death has resulted, and an opportunity
has been afforded for examining the mucous membrane. Roederer
and Wagler, who were among the first to direct attention to the
morbid state of the muciparous glands of the gastro-intestinal cavity
in fevers, tell us (Traite de la Maladie Muqueuse, &c, French
translation, p. 61), that not only were the stomach and intestines,
but particularly the small intestines, coated with a thick, viscous
and tenacious mucus, which was detached with difficulty; but
beneath this were seen numerous follicles, filled with mucus and
jutting out from the membranes. Often, on examination, the intes-
tinal mucous membrane is not altered either in colour or consist-
ence ; and instead of being red, it is, on the contrary, pale, as if
the secretion resulted from an anemia of the membrane.
Enterorrhoea is most frequently met with in children; in whom,
also, it displays itself under two forms, the acute and the chronic.
When chiefly serous, it has been cahed watery gripes, the diarrhoea
serosa of Sauvages and Good. By Cullen it is properly included
under the other variety, or diarrhoea mucosa. Acute enterorrhcea
may come on suddenly without appreciable cause ; it may follow
a sudden check to perspiration, as when the body, after having been
bathed in sweat, is exposed to a cold and damp air. One of the
consequences of such exposure is, we know, disease of some por-
tion of the serous system, causing pleurisy or peritonitis. Another
effect may be the disease now under consideration, and a flux of
the mucous membrane of the digestive passages. In supposing
this cause and order of sequence, it does not follow that the morbid
TREATMENT OF ENTERORRHOEA.
237
secretion should be the result of inflammation. The mucous mem-
brane may, as M. Andral supposes, perspire profusely as the skin
does. Sometimes the disappearance of effusion in a serous cavity
is followed by a serous flux from the intestine, of a fluid closely
resembling that effused. Moral causes have been mentioned be-
fore as adequate to bring on the flux. The only precursor at times
of copious evacuations in enterorrhoea is a rumbling noise in the
bowels. In the adult the pulse is remarkably small: in young
children the flux is apt to bring on, or be speedily followed by, coma
or convulsions.
Let me, in connexion with the pathology of enterorrhoea in infan-
tile subjects, point out the interesting fact of the greater growth and
development of the mucous follicles of the digestive canal at the
period of dentition. (Billard, op. cit.) Now, although we cannot
call this state a pathological one, yet neither can we deny, on the
other hand, that the rapid evolution and augmented size of the
glands will greatly predispose them to the common causes of dis-
ease, and especially improper ingesta or suppressed perspira-
tion. But while we refuse to admit inflammation as a cause of in-
creased follicular secretion, we must not, mistaking effect for cause,
predicate of the exhaustion to which the flux gives rise that it is a
disease of debility, and as such to be treated by stimulants and
more exciting food. Enterorrhcea is the more serious in proportion
as it is complicated with encephalitis, or aphthous or follicular sto-
matitis, as is often observed during the period of dentition. Before
dismissing the pathology of this disease, I must caution you against
the sweeping inference from what has been said, that the intestinal
follicles do not take on inflammation in children similar to that which
is met with in adults. On the contrary, these glands undergo two
kinds of change, the result of phlogosis, in their being either simply
red and tumefied, or disorganized, forming ulcers. But I shall not
enlarge on this point now, as it will more properly come under
notice when I speak of cholera infantum. The duration of ente-
rorrhoea varies ; it commonly lasts but a few days.
A neglect of enterorrhoea in its acute stage will be followed by
its passing into the chronic: the secreted mucus becomes an irritant
of itself, and forces the bowels to increased peristaltic action, and
diarrhoea, with more or less interruption, is the consequence.
Treatment.— The indications of cure are to allay the irritation
of the mucous membrane, and then to remove the debility which
sometimes remains after such irritation. With this view, supposing
that all the proper feces have been removed, either by the natural
efforts, or by purgatives administered for the purpose, we direct a
plain and simple diet; avoiding, on the one hand, food of too excit-
ing a quality, and on the other that which would fatigue by its
bulk, without containing adequately nutrimental matter. At first,
restriction to barley or rice water, and arrow-root, for food, and
even these in small quantities, will suffice of themselves, if the skin
be kept warm, to end the attack in a day or two. In every variety
233
DISEASES OF THE DIGESTIVE SYSTEM.
of enterorrhoea, and the principle may be extended to all diseases
of the gastro-intestinal canal, our success in curing will be very
much proportioned to the control which we have acquired over
the skin, by restoring and maintaining the activity of its functions.
This remark has peculiar fitness,if the disease, now under considera-
tion, have proceeded from obstructed perspiration, or cold and
moisture retarding and reducing the cutaneous capillary circula-
tion. In addition to confinement to bed in a warm room, we then
give mild saline diaphoretics and opiates, or small doses, three or
four grains, at intervals, of Dover's powder. More violent cases,
manifested by much soreness of the abdomen on pressure, and very
frequent discharges, will require fomentations to this region, of flan-
nel bags wrung out of hot water and vinegar, and of warm water
injections, mucilaginous drinks, and aqua ammonia acetatis, with a
few drops of laudanum, and rigid adherence to the simplest diet.
The disease persisting, with much coldness of the skin, and tormina,
and perhaps tenesmus, it will be proper to direct starch mucilage,
two ounces, and ten or twenty drops of laudanum, as an enema,
for an adult, and Dover's powder mixed with chalk, at intervals.
Although, in a great majority of cases, the detraction of blood is not
admissible, yet sometimes symptoms may manifest a combination
of enteritis with enterorrhoea, or at least such a state of some por-
tion of the mucous membrane as to require the application of a few
leeches and entire restriction to mucilaginous and diluent drinks,
and the administration of an opiate clyster. More benefit will be
procured by applying the leeches, in number about fifteen or twenty,
to the anus, than to any portion of the abdominal surface; or if
here, let us select one or other iliac region.
If we are adequately impressed with the true pathology of serous
and mucous diarrhoea, or of enterorrhcea, and fix our attention on the
mucous membrane as the seat of the disease, and its sympathies
with other organs, and particularly the skin, we shall rely more on
rest, external warmth, and simple regimen, or rather restriction to
demulcent drinks in small quantity, than on any decided mode of
treatment, either by purgatives, or by opiates or astringents. If we
must prescribe in the simpler cases, we should give chalk mixture,
or ipecacuanha, in small doses, with a few grains of magnesia,
repeated at intervals. But after the disease has lasted some days,
and the skin is cold, pulse small, and exhaustion considerable, we
then reach the second part of the indication of cure, and prescribe
astringents, of which kino with chalk, or alum with some aromatic
powder, will be entitled first to a preference. If a child be the
patient, we "watch carefully whether the cerebral symptoms are
aggravated or abated by this treatment,— whether we have ar-
rested a derivation from the brain, or checked a discharge that
caused exhaustion, which itself gave rise to the comatose symptoms.
It is in subjects of this nature that a blister to produce rubefaction,
or a sinapism might be applied to the abdomen, or on the inside of
the thighs.
TREATMENT OF ENTERORRHCEA. 239
Dr. Graves (Clinical Lectures, with additions by Dr. Gerhard)
recommends strong'y in chronic diarrhoea, especially as it occurs
in delicate and nervous females, the persesquinitrate of iron. It is
the form used with such advantage by Dr. Christison. Dr. Graves
succeeded with this medicine in curing two cases which had re-
sisted all the efforts of medical skill, the one for seven months, the
other for two years. The disease to which this medicine is appli-
cable is not inflammatory, but rather a congestion of the digestive
mucous membrane, of a passive nature, re;embling the scrofulous.
The persesquinitrate if kept longer than a week is apt to spoil, and
hence the prescription should be renewed every day or two.
In the variety of sero-mucous enterorrhoea which is met with in
lymphatic habits, or sometimes in certain epidemic forms of the
disease, the mucus secreted becomes itself a source of irritation,
and measures must be taken for its expulsion, and for giving better
tone to the mucous membrane. Both an emetic of ipecacuanha and
a purge of calomel and rhubarb are indicated here; or afer a few
grains of calomel alone, a small dose of castor oil with half a
drachm to a drachm of oil of turpentine. In cases of this nature
balsam copaiba often exerts a very happy effect, relieving and
curing the intestinal as it does pulmonary and vesical catarrh. I
have given it even to children thus affected w-iih evident advantage.
In this variety of enterorrhcea the treatment recommended by Dr.
Stokes for gleety diarrhoea, p. 203, is applicable. The warm bath,
aided, or if it cannot be continued, replaced by assiduous friction
of the skin, especially along the spine and over the abdomen, will
come in aid of completion of the cure. But of these means, the
bath will have rather an injurious effect, than otherwise, unless the
skin be carefully and continually covered with flannel, either of
wool or cotton, and the feet protected by similar clothing and thick-
soled boots or shoes. The approach of summer, or removal to a
warmer climate, exerts a salutary effect in simple sero-mucous
intestinal flux, by calling the skin into greater and more sustained
functional activity, on the same principle that a change to a colder
climate will sometimes cure hepatic flux by relieving the liver of
the continued transmitted excitement from the skin kept up by
tropical heat.
If I have been at all successful in giving a proper direction to
your inquiries into gastro-intestinal disease, and especially if you
have studied in a proper sense the lectures of Dr. Stokes relating
to them, you must be aware, by this time, that in all the profluvia
of the digestive canal, whether they be morbid secretions from the
stomach, and occasional eructation and vomiting of these, or from
the intestines, with purging and other morbid phenomena, your task
will consist in ascertaining the precise extent and degree of irrita-
tion and other organic change of the mucous membrane, much
more than in a measure of the nature and quantity of the fecal and
other matters discharged. Symptoms you are bound to study, but
these should be of organic change, not those depending on or made
240 DISEASES OF THE DIGESTTVE SYSTEM.
by accidental products. The cause is generally intrinsic in the
membrane, not extrinsic, or the matters in apposition with it or con-
tained in its cavity. That these may and do prove sources of
irritation and disease I do not deny, nor that there are indications
for emptying the stomach of irritating ingesta by emetics, and the
bowels of similar ingesta and of irritating bile and mucus; but it is
not the less clear that, for the most part, the contained matters in
the digestive canal become irritant according to the irritability or
phlogosis of the mucous membrane itself; and consequently, that the
chief indication, after all, is that for allaying organic irritation,
rather than for evacuating irritating matters.
Among the various remedies and modes of treatment for diar-
rhoea, both acute and chronic, diet must ever rank, as it generally
has hitherto ranked, among the chief curative means; itself pre-
ceding and giving effect to all others, and often proving an all suf-
ficient substitute for them. Alone it frequently cures completely;
if it be rejected as an auxiliary, we have no certainty and but a
remote probability of other and more strictly medicinal agents
being either immediately or permanently beneficial. It is true, one
who insists on a strict diet soon gets the reputation of being a
starving doctor, but this is a small inconvenience compared with
the great and permanent service rendered to one's patients. A
little firmness in carrying out a dietetical system has often been the
means, in my hands, of not only saving life, but of recovering
health and strength, and freshness of feeling and hope, those things, in
fact, which make life desirable, in cases of persons worn down by
indigestion and diarrhoea, who had gone the round of medicine and
of many doctors, but who had not been impressed with the im-
portance of diet for the cure of their disease. There is no unusual
skill required by the physician on such occasions as these. Pos-
sessed of the correct pathology of the disease, all that he need do is
to be honestly firm in carrying out his convictions; neither diverted
therefrom by the ill nature of patients, nor the ridicule nor imper-
tinent interference of their so-called friends — that is, of the gossips
and busy-bodies who infest the house of a sick person, and who
derive, or think they derive, a little factitious importance from
placing their own ignorant impulses in opposition to the carefully
elaborated results of long study, diversified observation, matured
reflexion, and possession of the recorded experience of the great
masters of the art for the last twenty centuries.
That I may not seem to be either extravagant or exclusive in
the kind of diet which I habitually direct, and would therefore
recommend for your approval, in diarrhoea, I cheerfully adopt the
very language of two able writers on the subject — Mr. Crampton
and Dr. Forbes (Art. Diarrhoea, in Cyclopaedia of Pract. Med.), in
prescribing the kind which in their opinion is best adapted to the
various disorders coming under this head: —
" The following may be stated as the order in which the articles
of diet will be found more proper in such cases: barley water,
ENTERORRHCEA WITH MEMBRANOUS FORMATIONS. 241
arrow root made with water, sago, tapioca, rice gruel, oatmeal
gruel carefully strained, light broths with some of the preceding
ingredients. In some cases, more especially of the chronic kind,
a drier diet is found more suitable— the liquid food appearing to keep
up the diarrhoea ; but in all cases the ingesta must be of the mildest
quality. Rice is one of the most valuable articles of diet in such
cases. It should be well boiled, and merely moistened with a little
broth. While it is extremely mild and unirritating, rice scarcely
leaves any remains to be transmitted along the intestines; and this
is the reason why it is generally regarded as astringent. As soon
as in can be borne, a small proportion of the lightest animal food may
be taken with the rice. Tender chicken [eaten without the skin] is
the best to begin with ; then white game boiled ; then sweet mutton.
The meet of young animals, as lamb and veal, should be avoided.
Beef is too stimulant, and fish is bad on account of the large quan-
tity of excrementitious matter it leaves in the bowels. Animal
jellies are generally allowable in the cases where meat is found to
agree; but they often are more irritating to the bowels than the
muscular flesh of animals." I would modify this opinion respecting
animal jellies by saying that they are oppressive rather than stimu-
lating to the stomach, which digests them slowly and imperfectly
when it is in a state of atony, or weakened by long disease. A some-
what more compound animal food is required, such as the addition
of osmazome to jelly, as it is found in chicken. Beef, especially
when imperfectly masticated,— as it is by half the people who eat it,
is a bad article of diet, both for the dyspeptic as well as the invalid
with weak bowels : but I find that, when boiled with rice into a thick
broth, from which the fat is carefully skimmed, it gives nutriment
both palatable and congenial with the digestive canal throughout.
Even to children in the advanced stage of diarrhoea, when animal
food is required, it is particularly serviceable.
Enterorrhosa with Membranous Formations. — I prefer using
this title for the disease of which I am about to speak, to adopting
that of Pseudo-Membranous Enteritis, as given by M. Roche, or of
Fibrinous Diarrhoea by Dr. Symonds. Dr. Good calls it diarrhoea
Tubularis. My designation does not imply a positive cause, such
as inflammation, which, in fact, is not a necessary or precursor of
the morbid formations in question: it expresses, however, their
origin, viz., from the intestine, and the most usual if not universal
preceding and accompanying phenomena, viz., enterorrhcea.
In saying that membranous formations on the mucous surface of
the intestinal canal are not necessarily, nor in a majority of cases,
preceded by inflammation, I had better, at the same time, direct
your attention to the observations made by M. Billard (Op. cit,
p. 273) on the appearance presented by the intestinal canal of a child
shortly after birth. "When all the liquid parts of the intestinal tube
are removed, there remains," says M. B., " a layer of thick mucus,
adhering to the intestinal surface of the canal, forming on it a kind
of plastering. This layer may be raised with the nail, under the
vol. i.—21
242
DISEASES OF THE DIGESTIVE SYSTEM.
form of a pellicle, resembling, to a superficial observer, portions of the
mucous membrane itself." This secretion, whatever may be its use,
remains but a short time, " and detaches itself, without the assist-
ance of any purgative, by a kind of natural exfoliation," in very thin
lamellae, which, being rolled together, form the small, white flocculi
so frequently met with in the stools of young children.
Somewhat later in infantile life, and when a child is attacked
with stomatitis with morbid secretion and pseudo-membranous
formation, the mucous deposit and membranous exudation some-
times extend into the stomach; and on occasions into the small
intestines. In the large intestine, both in the child and adult,
membranous formation on the mucous or villous coat is common
enough, particularly in dysentery. In whatever part of the diges-
tive canal, from the mouth to "the rectum, this morbid formation
occurs, it is most probably in the same way, viz., secreted matter
from the mucous follicles, which spreads over the surface and be-
comes concreted into membrane. Sometimes this is the result of
simple follicular irritation, sometimes of inflammation of the glands
and intervening mucous membrane. Dr. O'Brien describes this false
membrane as occurring, in dysentery, both in the large and small
intestines, but as being mostfrequent and remarkable in the colon and
rectum. In some cases he found it exhibited in patches, but in others
the mucous membrane was covered by a uniform layer of white lymph.
Similar observations have been made by other writers on dysentery.
M. Roche (Diction, de Med. et de Chir. Prat., Art. Colite) tells us,
that he has seen patients, and, what is somewhat remarkable,
they were always females, affected with obstinate diarrhoea for
months and years, pass daily, during the disease, a large quantity of
these false membranes. He adds, that the cases of colitis (chronic)
in which these discharges occur are not, in consequence, more
alarming than others. Elsewhere (Art. Enterite) M. Roche re-
marks, that pseudo-membranous enteritis is much more common in
a chronic than in its acute form; and that a number of persons dis-
charge them in different degrees of size, resistance, and figure.
Some are but slightly incommoded in consequence; only they are
troubled, from time to time, with colic, and then they pass more than
common of these false membranes. They eat with appetite, and
digest well so long as they adhere to their customary diet; but on
the slightest deviation their colic returns, and the glairy discharges
are increased. Some, on the other hand, evince symptoms of
chronic enteritis; they suffer habitually from dull colicky pains, a
feeling of heat and often of burning in a circumscribed point of the
abdomen. They go to stool frequently in the course of the day, and
pass each time amorphous pieces of false membrane. The expul-
sion of these pseudo-membranes is often accompanied with a sensa-
tion of burning at the rectum, so pungent that the patient dreads
the time for evacuating the bowels. These persons have but little
appetite, digest badly; their tongue is almost always loaded with a
whitish or yellowish coat; but without any redness at its side or
ENTERORRHCEA WITH MEMBRANOUS FORMATIONS.
243
point: the skin preserves almost always its natural heat; the pulse
is rarely accelerated, and there is little or no thirst. Occasionally,
in wet seasons, or owing to errors in regimen, and more com-
monly perhaps to moral causes, the skin is hotter, the pulse more
frequent than natural, at the same time that the local irritation
is increased. After two or three days the disorder returns in its
customary degree; although sometimes these exacerbations are
prolonged beyond this period.
In a former Lecture (XIV), when describing, after Dr. Todd, the
symptoms of follicular duodenal dyspepsia, p. 172-3,1 mentioned the
quantities of mucus discharged in various morbid states and forms—
sometimes like " shreds, apparently part of a membrane, and
even perfect tubes of considerable extent are passed." These dis-
charges of mucus appear to take place periodically, and as it were
critically, being in general preceded by considerable aggravation
of the symptoms ; and the recovery is attended with evacuations of
quantities of mucous or glutinous substances. The course and
termination of these forms of the disease, which I call enterorrhoea
with membranous formations, do not justify the prognosis given by
Andral, in speaking of chronic enteritis, who says that the presence
of pus and of false membranes mixed with the alvine discharges
indicates great danger. Not only do they take place in the chronic
forms of enteritis described by Drs. Todd and Roche, but also are
quite common in dysentery ; and in all these circumstances the
augury from their appearance, though sometimes, is not necessarily
or commonly sinister. The frequent occurrence of the disorder in
females would remind us, even if anatomical inspection did not
suggest the fact, of the resemblance of these pseudo-membranes to
the decidua, or to the membrane discharged in dysmenorrhoea. I
have seen it alternate with this last mentioned disorder. Its analogy
to the lymphatic exudation in croup is mentioned by more than one
writer.
Neither the precise causes nor the special seat of membranous
exudation with enterorrhcea is known to us. Its duration for years
forbids our referring it to any particular cause ; and as to its seat,
we can only say that it is sometimes in the small and perhaps
oftener in the large intestines.
In the treatment of this disease we must be guided by the con-
stitution of the individual who is its subject, and the nature and
extent of the general sympathies. At first, recourse may be had
advantageously to local depletion by leeches to the tender part of
the abdomen, if there be such, or to the neighbourhood of the anus,
followed by fomentations, the warm bath, and laxative enemata.
Having thus removed any enteritic complication, and placed the
intestinal mucous surface in the best state to be acted on by altera-
tives of a penetrating and active kind, we endeavour by these
means to alter the secreting function of the muciparous glands.
This indication will be met by the administration of calomel, where
the membranous shreds are still being passed, followed by castor
244 DISEASES OF THE DIGESTIVE SYSTEM.
oil and oil of turpentine ; or where febrile irritation is present, the
blue mass with ipecacuanha, or hydrargy. c. cretd, alternating with
balsam of copaiba. The iodide of potassium with syrup and
decoction of sarsaparilla furnishes us with a safe and efficacious
means of correcting the morbid secretions in this as it does in so
many other forms of disease. In a lymphatic temperament and
weakened state of the digestive organs, mild mercurials should soon
be followed by preparations of iron and pure vegetable bitters.
LECTURE XXI.
DR. BELL.
Colonic Dyspepsia.— The colon—its extent, situation, and functions.—Atonic
colonic dyspepsia—Constipation—its general character, symptoms, causes, and
various terminations—Spinal irritation connected with dyspepsia—Treatment
of the colonic disease—Importance of a suitable diet.—Inflammatory colonic
dyspepsia—Connexion with chronic colitis—Causes and treatment.—Irritable
colonic dyspepsia—Enteralgia—Peculiar temperament of persons suffering
from this disease—Treatment; to be simple and mild.—Follicular colonic dys-
pepsia—its analogy to follicular duodenal dyspepsia—Treatment.
Following, properly enough, an account of acute and chronic
inflammation of the large intestine accompanied with discharges of
varying character and quantity, will be a notice of that functional
enlargement which is entitled to the epithet of colonic dyspepsia.
Often secondary and a consequence of disorder of the small intes-
tine and of the liver, colonic derangement is not seldom so far
primary as to precede in its manifestations functional disturbances
of other parts of the alimentary canal, and to singularly aggravate
and complicate these latter. Small progress shall we make in our
diagnosis of the diseases of the abdominal viscera without an accu-
rate knowledge not only of the structure, but of the situation, extent,
and connexions of each viscus and tissue of the digestive canal with
other viscera and tissues. Neglect of attention to the anatomical
relations and the locality of organs, has often made physicians
confound disease of the colon with* that of the stomach, as well as
of the liver, xand at times, also, of the kidneys. The course and
distribution of the colon, contiguous at its transverse portion to
the stomach, and running in part under the liver and behind on the
kidneys, will show the cause of these mistakes. So, on the other
hand, its disorder, as in colic, is often the direct effect of phlogosis
or irritation'of one of these organs; and hence, in addition to the
variety of gastric origin, we have hepatic or cystic, and nephritic
colic. The colon, with its immense mucous surface, its extended
muscular coat, and its appropriate and double supply of nerves,
spinal and organic, and a circulation modified by the vital activity
of the parts just mentioned, may naturally be expected to undergo
vicissitudes of function from causes affecting the system at large,
such as plethora, excess or defect of innervation, and suspended
COLONIC DYSPEPSIA, 245
perspiration, as well as from those acting more particularly on itself,
viz., local plethora or congestion, irritation of the spinal nerves distri-
buted to it, and above all, the varying quantity and quality of its contents,
or the fecal matter, the residue of digestion, which it is destined for a
while to retain and discharge. Although this office appears to be
ignoble, it is not by any means unimportant; nor analogous to that
of a mere recipient of substances sent into it from the intestines
above. It has its secretory and absorbent functions, by both of
which the residue of digestion is subjected to important changes,
very different from those merely physical or chemical, — changes
necessary for conversion of this residue into matter properly fecal
or excrementitial. Regarded in connexion with the part performed
by the caecum, we cannot be ignorant of the fact, that the functional
phenomena of the large intestine are too diversified, and their mor-
bid sympathies too impressive, to allow of our passing them by in the
cursory, not to say slighting manner, which is commonly practised.
Of late times, acute disease of the colon, colitis, and its sequelae,
enterorrhcea or diarrhoea, have been properly elucidated by the aid of
morbid anatomy, and their treatment placed in consequence upon a
better basis: but we are still wanting in that precision of detail respect-
ing the more chronic and less violent deviations from health of this in-
testine, which bear the same relation to colitisiha\ gastric and gastro-
duodenal dyspepsia do to gastritis and gastro-enteritis. I will not
promise you to supply the omission, but will at least put you in the
track of rational inquiry, and furnish you with some aids to further
investigations.
Colonic Dyspepsia. — I begin with a notice of certain morbid
phenomena which require, I think, that we should class them under
this head. If a better title for them shall occur to any of you here-
after than that which I use after Dr. Todd, I am not at all tenacious
on this subject, and shall very readily adopt it. There are three
portions of the colon in which its disorders are more apt to occur, or
at any rate to be manifested by pain and other symptoms than else-
where: there are, 1, at its beginning, or caecal portion in the right
iliac region; 2, its transverse arch, contiguous to the stomach and
liver in the epigastric region ; and 3, its sigmoid flexure in the left
iliac region. In all derangements of function of the colon, and in its
acute diseases or phlegmasiae, these regions should be carefully
examined by touch and palpation; the posture of the patient, the
while, being changed from a recumbent to a stooping, and after-
wards, if his strength allows, to an erect posture.
Constipation.—Colonic dyspepsia is divided by Dr. Todd (Cyclop.
Pract. Med.) into the atonic, the inflammatory, the irritable, and the
follicular. A few observations on each of these kinds, deduced
mainly from the source just indicated, will place the subject suffi-
ciently before you, to prevent false diagnosis, and to guide to the
most judicious treatment. I may state, by the way, that Dr. Todd
himself professes to have drawn a considerable part of his descrip-
tion from the accurate portrait of Dr. M. Hall. Much of the subse-
<„>!*
246 DISEASES OF THE DIGESTIVE SYSTEM.
quent details are descriptive of effects commonly attributed to con-
stipation, and the treatment is that required for the latter; and hence
I shall be saved the necessity of repetition, or of recurring to the
subject of constipation as a separate disease, requiring separate and
special notice.
The general character of atonic colonic dyspepsia is habitual
constipation of the bowels, but with no great alteration of the alvine
evacuations, pain or uneasiness in some part of the colon, variable
in degree, situation, and constancy: often stridulous noise in the
abdomen. A not unusual mistake in forming an opinion of this
disease is to suppose that it consists in costiveness, which is, in fact,
but one of its symptoms, and indeed a troublesome effect of colonic
weakness. This form is not confined exclusively to either sex; it is
most common in young females, and in delicate boys or young
men. Months, even years, may elapse after the first coming on
of costiveness, or scanty, even though daily, evacuations before this
and concomitant ailments, such as impaired appetite, lassitude,
aching of the whole body, or distressing pain in the loins and lower
extremities attract serious notice. " There is frequent headache,
great nervousness or susceptibility of impression, a tendency to
perspiration on the least surprise or exertion, fluttering, faintishness,
timidity, discomposure by the least hurry or agitation; sometimes
tremor and vertigo." Among the most marked changes in the
physiognomy of the patient, and these do not occur at first, are a
dark or sallow discoloration, going on to a greenish-black, of the
lower eyelid ; a pale, sometimes chlorotic, complexion; and a sen-
sibly greater paleness of the upper lip than any other part of the
face.
The pain of the colon, for a while shifting from one side and from
one part to another, becomes by degrees more fixed in one of the
iliac regions, frequently in the right, in the course of the ascending
colon, accompanied by spasms returning in paroxysms, and not
rarely by vomiting and great irritability of the stomach (the colica
stercorea of some authors). This is every now and then the pre-
cursor of stercoraceous and phlegmonous tumours, of which I shall
speak under the head of Cescitis and Tuphlo-Enteritis. A common
situation of the pain is in the left side just under the false ribs, and
very often in the left iliac region in the course of the sigmoid flexure
of the colon; in which case there is a frequent desire to go to
stool, accompanied with distressing tenesmus. " Frequent though
ineffectual efforts are made to obtain a stool for several days, and
at length a number of small, hardened, and slimy lumps, or scybala,
either separately or connected together, similar to sheep's dung,
more rarely of a flattened or tape-like form, will be voided, some-
times preceded and sometimes succeeded by liquid and sanious
stools of various colours, of a frothy consistence, and always ex-
tremely offensive. This is the tenesmus a scybalis of some authors,
and the dysentery of others, of which inflammation and ulceration
of the mucous membrane, and occasionally stricture of the lower
CHARACTERS OF ATONIC COLONIC DYSPEPSIA. 347
part of the colon, are the remote consequences." Sometimes there
is pain and soreness at the hypogastric region and a slight pain on
urinating. There may be felt a distinct hardness in some part of
the colon, particularly on the left side, depending on accumulated
and indurated feces. I have had occasion to watch this disease for
many years, and have found that the pain was at first, for a year or
more, in the sigmoid flexure of the colon and afterwards in the
transverse portion. In the latter there is more of an uneasy sensa-
tion than of positive pain, which is only experienced when pressure
on the part is made.
One of the most annoying and common attendants on this dis-
order is a disagreeable noise, which has been compared to the
croaking of a frog, heard in the bowels, and proceeding more espe-
cially from the left side. " This noise is very much under the in-
fluence of respiration, and also any state of excitement. For the
most part, especially on inspiration, it is similar to the croaking of
a frog; but on expiration it is somewhat less so, conveying the
idea of the sound issuing, as it were, from water: often before it
ceases it is like the plaintive sound of a dying animal." A curious
sensation is conveyed to the hand applied on the left umbilical region,
between the navel and the spine of the ilium, during inspiration, as
if some liquid was forcibly dashed or squirted against the perito-
neum. On expiration this is less perceptible. Sometimes this ver-
beration will be felt between the navel and spleen. There is no
limited duration of this noise, which, however, seldom lasts more
than twenty minutes, and returns at irregular intervals. It is most
marked in an erect posture, and will disappear so soon as the re-
cumbent posture is taken. Induced by the first few mouthfuls eaten,
it soon abates as the meal advances, and after some intermissions
entirely ceases. It has seemed to me to be most frequent and
troublesome in the case of female patients when they were tightly
laced; and I have procured from them an admission of this fact, in
their own cases. The artificial pressure of corsets was not so great
as to diminish much the diameter of the colon, while yet it destroyed
the tone of t+ie abdominal muscles, and prevented the elastic com-
pression on the intestine which they habitually exert.
The assimilating functions manifest disorder by an impaired
appetite, but frequently without any symptoms of gastric or duodenal
dyspepsia, sometimes irritable stomach and ejection of food soon
after taking it, accompanied with pain or uneasiness or tightness
across the stomach. Sometimes there is faintness with a sense of
craving for food. The tongue is loaded or furred, and of a white
or yellow colour; frequently loaded, swollen and oedematous, and
marked by pressure against the contiguous teeth ; and at times so
large in proportion to the mouth, that from compression it is found
more or less divided with sulci or folded into plaits. Foulness of
the teeth and mouth, a vitiated taste and viscid saliva, are often
accompanied with a tainted and fetid and almost stercoraceous
breath ; but this last is by no means a uniform symptom. I have
248
DISEASES OF THE DIGESTIVE SYSTEM.
seen long and tedious cases of the disease, in which the breath was
almost uniformly fresh and pure, unless on occasion of gastric dis-
order or common indigestion, — although the tongue and mouth,
especially in the morning, were as just represented. The bowels
are, at first, always constipated, afterwards constipation and diar-
rhoea occasionally alternate; but in the advanced stage the latter
becomes permanent. The appearance of the feces is various,—
being at first indurated and scanty, afterwards fluid, dark coloured,
scanty and fetid, often accompanied with mucus and even blood ;
sometimes, as already remarked, their discharge is attended with
tenesmus, bloody stools, and pain in the right iliac region; an occur-
rence very common in young females. In the beginning of the
disorder the urine is high coloured and apt to be loaded, depositing
a whitish sediment, and presenting a supernatant iridescent pellicle ;
afterwards it lets fall a mucous deposit, sometimes of a lateritious
tinge. I have seen this followed by large deposition of uric acid,
which in some cases, in which there is a complication of irritable
and atonic colonic dyspepsia, attends every exacerbation. The
urine will frequently become limpid, but a slight exasperation of the
malady soon restores the deposit. The pulse is often nearly natural;
sometimes it is quick, or easily accelerated ; but usually soft and
weak, and becoming somewhat more frequent with the progressof the
complaint. The skin is in general cool, rather moist and clammy,
particularly the hands and feet, which are apt to be obstinately
cold; the fingers are rather livid, and the nails assume a lilac hue.
Allusion has been made to the patient's complaining of head-
ache, nervousness, and vertigo, and sensations of weakness and
aching after slight exertion. "The headache, which is severe on
rising from bed in the morning, insomuch as sometimes to excite
vomiting, will continue unabated for an hour or two, and is often
proportionate to the degree and length of time which the patient
has slept." Nervous tremor supervenes on the least excitement or
surprise, and is manifested in a quivering of the lip or dimpling of
the chin in speaking, or under the least agitation by tremor on
holding out the hand or carrying a cup of tea to the mcuth. Some-
times there is oppression, heavy sleep, or considerable stupor or
obtuseness of intellect during the day, and during the night great
wakefulness and restlessness, disturbed sleep, dreams, and incubus.
The following description of an attack of the disease will be
acknowledged to be faithful both by the patient who has expe-
rienced it, and, what is more to our present purpose, by the physi-
cian who has ever been called on to advise for such a case. I
transcribe it the more cheerfully, because, although the attacks are
common enough, their real nature and cause are often overlooked;
and at one time bloodletting, at another opium, or again some anti-
spasmodic is had recourse to, when the real means of relief would
consist in relieving an overloaded colon and preventing a recur-
rence of its torpor.
" The patient is liable to violent and sudden attacks, generally
CHARACTERS OF ATONIC COLONIC DYSPEPSIA. 249
induced by some improper article of diet or a more than usually
loaded state of the large intestines, such as sickness, vertigo, faint-
lshness with cold perspirations, paleness of the countenance, and,
coldness of the extremities. These attacks are sometimes accom-
panied with spasmodic or convulsive paroxysms, frequently assum-
ing the form of hysteria, more rarely of epilepsy, and occasionally
temporary delirium, loss of memory, or absence of mind. Some-
times the attacks consist of spasmodic or anomalous pains about
the heart or side, or in various parts of the abdomen; in fluttering,
irregular action, violent palpitation of the heart with syncope; in
local pains more or less severe, occasionally so severe as to re-
semble tic douloureux, of longer or shorter duration, and in various
forms and situations; in some instances resembling the passages
of gallstones, in others inflammation of the pleura, of the liver,
spleen, kidneys, and intestines or peritoneum, and affections of the
bladder. Sometimes there is an extraordinary loss of muscular
power, especially of the lower extremities, which are so enfeebled
as to appear affected with paralysis."
In scrofulous constitutions, curvature of the spine has been
noticed to be not a rare complication and consequence of atonic
colonic dyspepsia. It is gradual in its approach; but after a longer
or shorter time, the spine gives way at the third or fourth lumbar
vertebra, either by projecting anteriorly or to the left side. " In
consequence of the curvature of the spine on the left side, the right
hip has the appearance of being enlarged, by reason of the hollow-
ness between the ilium and the vertebral column being increased,
whilst the left hypogastric region is more swollen than the right."
Dr. Todd controverts the opinion of Dr. Bradley, who supposes
that the disease of the spine is the primary affection, of which the
stridulous sound and other derangements are only the conse-
quences. I would add that, in general, organic spinal disease, and
that, less understood still, spinal irritation, are more commonly, by
far, part of a series of reflex actions, the first of which was in a
disease of some viscus, the second its transmission to the spine or
spinal marrow, and a third the reflexion of this last on the affected
viscus and adjoining organs.
I must here supply, in part at least, an omission in my lecture
on dyspepsia, among the causes and associated phenomena of
what I stated was spinal irritation. But I forgot, when detailing
the treatment of dyspepsia, to direct your attention to the fact of
gastrodynia, or at least of violent muscular pain of the intercostal
and abdominal muscles associated with that of the stomach, being
not unfrequently controlled and removed by applications to the spot
on, and more commonly one side of, the vertebrae, where tenderness
was felt on pressure. A few leeches to this spot, or a small blister
kept running for a few days, or where the abdominal pain is less
urgent an irritating liniment rubbed in, will often give wonderfully
prompt and even occasionally entire relief of all the distressing
symptoms.
250 DISEASES OF THE DIGESTIVE SYSTEM.
The predisposing causes of atonic colonic dyspepsia are a
certain period of life, between ten and thirty years of age; perhaps
also a natural conformation of body, and still more a change of
habits from childhood to adolescence in the offspring of the rich
and the luxurious, by which, from wrong notions of what is due to
graceful carriage and to the requirements of education, they are
deprived of suitable exercise. With the children of the poor, from
different motives, similar restrictions are imposed, as in the factories
and workshops; in which, in addition to constrained posture, a close
and impure air exerts a constant and deleterious operation. Another,
and a quite common and influential cause, is false modesty or shame,
by which young persons are prevented from obeying the calls of
nature for exoneration of the bowels, when absent from home, or
travelling, or in any way exposed to more than customary observa-
tion. Serious diseases of the bladder are not unfrequently brought
on in this way.
The immediate cause, or that which, erroneously enough, in the
fashion of the writings of the present day, is called the pathology of
the disease, is an atonic state of the colon, and, as a consequence,
although we have reason to believe sometimes a cause, also, ex-
cessive accumulation of feces in its cavity. This condition of parts
is capable of affecting the upper portion of the digestive tube, both by
continuity and sympathy, and by pressure on the abdominal aorta
and some of its important branches interfering with secretion, and
deranging in both ways the nervous system.
The colon may suffer by mere sluggishness, owing to a want of
proper stimulus in the matters passed down to it from the upper
bowels — a want chiefly depending on deficient or depraved secre-
tion of bile. Its contents are by this means, however accumu-
lated, become hardened, and irritate the surface of the intestine,
causing tenderness on pressure, a feeling of hardness in the part,
and all the symptoms of colonic disorder already described. Per-
sons thus circumstanced, if they are exposed to high heat, alter-
nating with cold and moisture, or under strong and contending
emotions, and commit some error in regimen, are liable to a variety
of dysentery, in which rectal heat, irritation, and straining, are
among the most troublesome symptoms. Possessed of a knowledge
of the antecedent state and habits of the patient, we prescribe with
confidence, in this kind of dysentery, a mercurial purge, aided by oil
and enemata, with the effect of causing a free evacuation of the large
intestines and almost entire removal of the disease. It is generally
in such cases that scybala are seen, and that their discharge gives
manifest relief.
But this is in anticipation of the treatment of atonic colonic
dyspepsia, the indications for which, as laid down by Dr. Todd, are,
1, to remove any accumulation of feces by having the bowels full
and satisfactorily evacuated ; 2, to facilitate and promote the regular
performance of the function of the colon ; and 3, to correct the
morbid condition of this intestine.
TREATMENT OF ATONIC COLONIC DYSPEPSIA. 251
For fulfilling the first indication we cannot, at times, well dispense
with purgatives, unless the patient shall manifest determination
and perseverance in the use of particular ingesta, and of other
hygienic means calculated to prevent and obviate constipation.
Rhubarb with sulphate of potassa; sulphur with cream of tartar;
solutions of sulphates of magnesia and potassa with sulphuret of
potassa; pills of rhubarb, aloes, and blue mass, alternating with the
infusion of senna, ought to be preferred to other purgatives. In
pursuance of the second indication we must insist on the superior
power of a due regulation of the ingesta, more than on any kind
of medication; or if an exception be made, it will be in favour of
enemata of tepid or warm water, in which, if the constipation is ob-
stinate and of long duration, a small quantity of soap may be occa
sionally mixed, or of common salt dissolved. When, of necessity,
recourse must be had to aperients, these should be of the milder class,
or so combined with articles from other classes that their operation
will be adequate, but without irritation and consequent probability
of inertia of the colon in consequence of previous undue excitement.
If there be febrile symptoms present, or heat and tenderness in any
part of the abdomen, or the temperament of the patient be san-
guineo-bilious, we may give with advantage tartar emetic in combi-
nation with purgatives; as, for example, a teaspoonful of Epsom
salts, dissolved in half a pint of water, and thirty drops of antimonial
wine, at bedtime, or the following prescription: —
R. Extract. Colocynth, compos.,
Extract. Hyosciam. aa. 3ss.
Antimon. Potassio-Tartrat. gr. i.
Syrup, q. s. M.
Ut. ft. mass, in pil xvi. dividend. Sum. aeger ii. vel iii. pro dosi.
The extract of hyosciamus is a useful adjuvant, and in this case
corrigent, also, to purgative medicines. With aloes, or gamboge
and blue mass, it makes a convenient combination in the present
case. In prescribing this or any other preparation of mercury for
occasional and repeated use, care must be taken to ascertain the sus-
ceptibilities of the patient to this medicine, both as regards its direct
action on the bowels and its remote, but more serious one, by bring-
ing on salivation. Whether we direct enemata or aperients for
opening the bowels, we must be aware, and press the fact on the
minds of our patients, that these are means of temporary benefit
only, and can never be continued long, certainly habitually, without
injury, and final aggravation of the disease.
The better and more constant means of cure will consist very much
in suitable diet, which implies that it should be mild and nutritious,
taken in moderate quantities and not at long intervals, or not less
than three meals in the course of the day. It should consist of mild
animal food, boiled, roasted, or stewed, such as mutton, chicken, game,
the tender loin of beef: the last mentioned meat is not as digestible as
mutton. Sometimes a moderate quantity of salt meat, as of bacon,
with an abundance of vegetable food, agrees very well with the patient:
252
DISEASES OF THE DIGESTIVE SYSTEM.
at other times it invariably produces disorder of digestion, and more
especially in the large intestine. Next in importance, if not itself of
paramount consideration, is slow and adequate mastication. Few
articles of food are easily digested if this rule be neglected; few
will prove very troublesome if it be carefully attended to, so that the
alimentary substance shall be reduced to the greatest degree of com-
minution and well mixed with saliva, in order to form a soft, homoge-
neous mass. In the selection of vegetables, the experience, and some-
times the idiosyncrasy, of thepatient, mustregulateouradvice. Mealy
potatoes mashed answer well for some, to others they are irritating
in any shape, and more, it has seemed to me, certainly in my own
personal experience, to the colon than the stomach and duodenum.
The bread should be always stale, or at least of the baking of the
day before that on which it is eaten. The pan-loaf, as it is commonly
called, into the composition of which a small portion of corn-meal
enters, is palatable, and preserves the requisite softness longer
than the loaf of wheat alone. Of the various vegetables for table
use, I know of no one at all comparable to spinach, in its laxative
property, without causing acidity or flatulence. Milk without large
dilution, or unless in the state of butter-milk or whey, seldom agrees in
colonic dyspepsia. When the stomach is not disordered by their use,
stewed fruits, such as prunes and apples, or those with a predomi-
nance of sugar, such as figs, and rye mush and the like, will be found
to contribute to preserve a soluble state of the bowels. The same
modified advice will apply to the use of melasses, or drink of melasses
and water, and cream of tartar whey.
For the removal of the atonic state of the colon and constipation
from this cause, in obedience to the third indication, the union of a
bitter, as the extract of gentian or of quassia, with a purgative,
' should be directed. The same good effects may be expected to
follow a combination of a mineral tonic with a purgative, to which
a warm gum, as myrrh, or an antispasmodic like assafoetida, can
be added, as in the following: —
R. Pulv. Aloes,
G. Myrrhs, aa. Jss.
Ferri Sulphat. 9i. M.
Syrup, q. s.; ut. ft. mass, in pil. xx. dividend. Take two or three before breakfast.
R. Extract. Gentianae,
Pulv. Assafoetida, aa. %i.
---- Aloes, Jss. M.
Adde syrup, q. s.; ut. ft. mass, in pil. xl. dividend. Take two or three twice daily.
Or the compound aloes pill, made of aloes, extract of gentian, with
a little oil of caraway, in doses of from five to ten grains, answers
very well to open the bowels. Two five-grain pills, taken two
hours before dinner, or about noon, will evacuate the bowels some-
times in the evening, sometimes on the following morning. Sul-
phate of quinia with aloes in pill, or with the pills of aloes and
myrrh, exerts frequently the best effects in constipation, or in a
INFLAMMATORY COLONIC DYSPEPSIA.
253
torpid state of the colon and of the system generally. Solution of
iodide of potassium and compound syrup of sarsaparilla are excel-
lent alteratives in the disease now before us, both by their action
on the mucous secretions and on the liver. I have obtained very
satisfactory results from their use. The combination of salines and
chalybeates, or of sulphur and salines, as at certain mineral springs,
if continued for some months, has procured entire exemption from
the disease during a considerable period.
Among the hygienic means of" giving tone to the colon are
moderate exercise, in which alternate flexion and extension, a
gentle commotion, as in some agreeable sport, or riding on horse-
back, are imparted to the body. To the same purport are travelling
and change of air and scene, assiduous friction with kneading of
the abdomen, and sponging this region and the spine with cool or
tepid salt water. A hot, and, at times, cold douche on the abdo-
men, is found to be quite successful in Italy and some other parts
of the continent. Violent and prolonged exercise are injurious.
Inflammatory Colonic Dyspepsia. — The general character of
this variety of disorder of the colon is pain in some part of the in-
testine, prevailing in one particular point, felt always, more before
an evacuation of the bowels, seldom increased on pressure; stools
generally liquid, rarely formed, not always more frequent than
natural. " The patient," continues Dr. Todd, " is always remark-
ably lowered, irritated or made otherwise uncomfortable by the
action of purgative medicine, and even by the spontaneous action of
the bowels, which is always followed by more or less feeling of ex-
haustion; he feels always most strong and most comfortable when
his bowels are confined." The pains are accompanied with a
somewhat tense and accelerated pulse; there is some degree of
thirst, but little heat of surface. The evacuations vary in con-
sistence and colour ; more commonly they are liquid or pultaceous;
sometimes almost white, or yellow and frothy, less frequently
green or black; sometimes a tenacious puriform matter streaked
with blood. Generally more frequent than natural; they are often
not so, an evacuation occurring but once in a day, or in two days.
" The stools are frequently discharged with considerable force; but
occasionally there is tenesmus without any excrementitious dis-
charge. The appetite is seldom much impaired. The complexion
is pale or whitish, sometimes of a remarkably greenish paleness,
and the body emits more or less of a cadaverous smell.
" The unfavourable progress of the disease is to hectic fever
accompanied with oedema of the lower limbs and face, dejected
features, and gradual exhaustion."
Very analogous to the disease just described is that which
M. Roche designates as a variety of chronic colitis. It is not
accompanied with diarrhoea if the patient's diet be simple; but
looseness follows the use of stimulating meats and wine. The
patient feels in some part of the large intestine, commonly in
vol. i.—22
254 DISEASES OF THE DIGESTIVE SYSTEM.
the caecum, a dull, sometimes a sharp pain, intermittent or irregu-
lar, and which often comes on suddenly, and disappears, after
a variable duration, in like manner. So long as it lasts the
patient is sad and gloomy, feels a weariness in his limbs, all of
Which will disappear with the cessation of the pain. Rarely is this
last felt in the horizontal posture, except on pressure and in thin
persons only, for in those of a full habit the strongest pressure will
not give rise to it. It is often calmed by taking food, and by de-
mulcent and narcotic enemata. It is more especially manifested
four or five hours after a meal, and also after a long fatiguing
walk, or by jolting on horseback or in a carriage; sometimes it
is induced by sudden flexion of the body, or throwing it back-
wards. Grief, crosses, and anger, will bring it on. It may last a
long time without materially interfering with nutrition, provided
the patient lead a regular life; but at last, sooner or later, if it
be not attended to, emaciation will show itself, and sometimes a
tumour becomes visible in the painful region. Stricture of the in-
testine, cancerous conversion, and finally ascites, are often the con-
sequences of this phlegmasia when it is neglected. When it has its
seat in the caecum, it often happens that the inflammation is ex-
tended to the surrounding cellular tissue, and gives rise to those
abscesses, of which I shall soon speak, in connexion with accumu-
lations in the caecum, and inflammation of this intestine.
The causes of this variety of colonic dyspepsia are all those
which can excite chronic colitis, and more particularly continu-
ance of the atonic variety, and the use of drastic purgatives, often
resorted to for its cure; also, the irritation of worms, and that of the
violent remedies sometimes empirically used for their expulsion.
Atmospheric changes, by interfering with the regular functions of
the skin, seem, also, to be determining causes. The morbid condi-
tion of the colon is analogous to that in colitis; sometimes the
inflammation is limited in extent, frequently terminates in ulcera-
tion, occasionally in thickening or induration.
The treatment is tolerably well pointed out by the symptoms
and recognised state of the colonic mucous membrane. It will con-
sist in leeches or cups to the affected part, followed by fomenta-
tions, flannel rollers round the trunk, and covering of course the
abdomen; frictions; counter-irritation by croton oil or tartar
emetic. These last I have found to be of considerable benefit when
the pain was fixed in one part, as in the right iliac region. The
food should be plain, light, and easy of digestion; neither troubling
by acescency nor by stimulation. Farinaceous articles with a
small quantity .of milk, if it agrees with the patient, and after a
while light animal broth, made quite thick by the quantity of rice
boiled with it, should be used. Tea, when it does not annoy by
causing flatulency, is to be preferred to coffee, which is so apt to
excite the alimentary canal, and particularly the large intestine.
Rest of body, and sometimes a recumbent posture, for a length of
time, are requisite as a means of relief. Exasperated as the com-
IRRITABLE COLONIC DYSPEPSIA.
255
plaint is by purging, we must abstain from all medicines which
produce this effect, and confine ourselves to the direction of ene-
mata of warm water to relieve the bowels of their contents in case
of constipation. The warm bath, and some of the narcotic extracts,
either by the mouth or as an enema, will prove to be soothing and
useful remedies. Opium, as inducing a constipated habit of bowels,
will of course be withheld, except in cases of extreme and con-
tinued pain, when we shall use it as we would do in the like exigency
in other diseases, in which it is not abated or removed by blood-
letting.
Irritable Colonic Dyspepsia. — Enleralgia. — The general cha-
racter of this variety, still following Dr. Todd in his description, is
intestinal digestion accompanied with pain, uneasiness in some part
of the abdomen, seldom fixed to one spot, but changing its situation
and intermitting. This disease is most frequently met with in persons
of a nervous and irritable temperament, whose morbid irritability
would seem to be frequently concentrated in the intestines, and to give
rise to hypochondriasis, with its minute attention to one's own feelings
and extravagant opinions of their importance and meaning. There
is a complaint of pain or twisting at the umbilicus, or in the course
of the colon, seldom augmented, generally relieved by pressure;
frequently a sensation of sinking or dragging of the bowels, giving
the notion of the intestines falling out; "some patients experience
this uneasy feeling to such a degree that they are obliged to con-
fine themselves to the recumbent posture. Sometimes, instead of
pain, the patient feels in the intestines an indescribable uneasiness
or peculiar sensation similar to those which are perceived in the
stomach in irritable gastric dyspepsia; occasionally the pain and
preternatural sensation exist together, frequently they alternate with
each other."
Flatulence, with borborygmi, colic, and other spasms, harass the
patient, in conjunction with, at times, ptyalism and copious dis-
charges of limpid urine. In some subjects there is such an aggra-
vation of the symptoms as to make the disorder in men resemble
hysteria: and I have seen all the characteristic symptoms of this
last disease, including the globus hystericus, in men, during a pa-
roxysm of this flatulentia convulsiva. It has been arrested, as we
learn from Dr. Todd, by the application of cold to the testicles.
Would not the same good effects be still more certainly procured,
and with less risk of subsequent disorder, by cold applied to the
nucha, between the mastoid processes, and over the occipital region?
The uneasy feelings are exasperated during intestinal digestion,
which is ordinarily difficult and laborious. I have watched the
phenomena of this disease, and have noted that it is not uncommon
for a person thus afflicted to eat his meal with relish, experience
no inconvenience during the period of gastric and duodenal diges-
tion, feel pretty comfortable during the afternoon and evening and
only be apprised in the course of the night, or early in the morning,
that ha has indigestion. This will be manifested by some pain in
256
DISEASES OF THE DIGESTIVE SYSTEM.
the lower bowels, sometimes a looseness if he has eaten any unusual
article at the dinner of the preceding day, and, as the morning ad-
vances, flatulence, flying pains, and the other symptoms already
enumerated. The irritation thus felt on the passage of the chymous
residue from the ileum into the caecum and colon, and producing
the diarrhoea, with sometimes a deep feeling of sickness and pros-
tration, early in the morning, is continued during the passage of the
fecal matters through the great intestine. The change in the state
of the tongue, mentioned in a note of mine to Lecture VIII., p. 106-7,
in the morning, may have arisen from the incipient irritation of the
colon at this time.
Motion and travel, which often suspend and relieve the intestinal
pain and uneasiness, sometimes, on the contrary, aggravate it.
Unsettled and stormy weather is often an exciting cause. If, to the
enumeration of symptoms, we add the singular fickleness of pur-
pose and conduct of the patient in all that regards his medical treat-
ment— flying from one physician to another, using all remedies in
quick succession, without giving any one of them, or indeed any
mode of treatment, a fair trial — we shall have a pretty accurate
idea of the features of the disease, and be better able to ascertain
its nature.
The temperament of the individual suffering under this form of
colonic dyspepsia is nervous and excitable, and at once predisposes
him to be readily affected by stimulants of any kind. Now, as there
is no class in which excesses in quantity and quality, and irregu-
larity of period of application, are so apt to be committed as in the
use of ingesta, we are prepared to find a person thus constituted
suffer from indigestion. The variety of the disease will be deter-
mined very much by his kind of life, his habitual posture, and the
particular circumstances which operate on one part of the diges-
tive canal more than another. But we shall fall short, it seems to me,
of a knowledge of its correct pathology, if we suppose merely a mor-
bid irritability of the nervous system at large, without taking into
account some particular portion — such as of the dorso-lumbar
region of the spinal marrow and its nerves — in explanation of the
pain and violent spasmodic movements of the intestine. Still more
connected with the causation of other phenomena manifesting de-
rangement in the organic functions, and including anomalous feelings
and distress not explicable by any language, is perverted func-
tion of the organic or ganglionic nerves. An attempt to locate the
disease in the muscular coat of the intestine, is mistaking an effect
for cause, — a symptom for the disease. There is an entire and
morbid change in the impressibility and transmitting or motive
power of a portion of the cerebro-spinal axes, and also of that of the
sympathetic or nerves of organic life, by which the large intestine is
supplied. To correct these, constitutes a more important indication
for the cure of irritable colonic dyspepsia than the regulation of
the quantity of fecal contents in the'intestines, and the precise de-
gree of irritability of its muscular coat. One of the means of con-
TREATMENT OF IRRITABLE COLONIC DYSPEPSIA.
trolling and modifying the nervous apparatus more particularly dis-
ordered, may, it is true, be in regulating, if possible, the kind and
amount of stimulus habitually acting on it; but this is not all.
Treatment.—The remarks which I have just made directly bear
on the selection of our curative methods in this disease. This
obviously now, it seems to me, is resolved into two heads; first, that
which tendsto withhold all morbidstimulants,and diminishesthe force
of hygienic ones; and secondly, that which modifies by diminishing
the morbid susceptibility of both the special and general nervous ap-
paratus, by giving them tone to resist being too strongly impressed by
common transient exciting agents. We can neither stimulate noV
deplete with advantage. Both high living and low diet are equally,
though in different ways, injurious. The food should be bland and yet
nutritious. In its selection we may perhaps glean useful suggestions,
by learning the kind habitually used by the patient in earlier life,
and before the habits ofluxuriousorpromiscuouseatingwere formed,
which were contemporaneous with, perhaps partly causative of, his
disease. Among the articles which would most readily present
themselves to our mind is milk; and if adapted to his powers of
digestion, the patient ought to restrict himself mainly to it, in con-
junction with light farinaceous food — well raised" but not fresh
wheat bread, rice and rice flour, fine hominy or grits. After
a while, or where milk does not agree, a limited portion of animal
food, and in its selection the experience of the patient will be the
best guide, is to be directed. Fluids ought to be taken in small
quantity, and the diet generally must not be bulky, so as to fatigue
by distention, nor much mixed, so as to irritate by the evolution of
new products in the intestinal canal opposed to its vital and assimi-
lating action.
Content to keep the bowels open by simple enemata or the mildest
aperients, we must refrain from giving active and especially drastic
purgatives. A beneficial impression will be made on the organic
nervous system by narcotics, such as hyosciamus, belladonna, conium,
alone, or combined with preparations of iron and zinc, alternating
with, or to be replaced by narcotics and the pure bitters, as gentian
and quassia, and preferably, I think, to them all, sulphate of quinia.
Extract of hyosciamus and the last named salt, equal parts of each
made into four-grain pills, one taken night and morning, will be
found to display often a pleasant controlling influence on the dis-
ease, by removing pain and spasm, and abating flatulence, while a
regular state of the bowels is preserved at the same time. Nux
vomica and its active principle strychnia, may be expected to exert
a good influence in this, as in some other morbid conditions, in
which pain and enfeebled or irregular muscular action constitute
the chief characters.
Among the agencies which act on both the nervous system of
animal and on that of organic life are exercise on horseback,
sailing, and e\en long voyages; and,as much as,can be, a succession
82*
258 DISEASES OF THE DIGESTIVE SYSTEM.
of pleasing objects in which the patient takes a lively interest. If
this kind of change cannot be procured, we must insist on an aban-
donment of those habits, which are known to be so often a positive
cause of this disease, as of so many other diseases of the digestive
system, — viz., eating in excess or at unusual hours, alcoholic pota-
tions of any kind, the use of tobacco in any form, late hours, con-
strained and particularly a bent posture, confinement in close and
badly ventilated rooms, neglect of the state of the skin, either by
withholding warm clothes, or refusing to preserve its farther activity
by bathing and frictions.
Follicular Colonic Dyspepsia.—This disease, which occurs in per-
sons of sedentary habits, and especially young females, who are gene-
rally subject to costiveness and accumulation of feces in the large
intestines, has a similar origin, in the morbid states of the follicles,
to that already explained under the head of follicular duodenal dys-
pepsia. It often supervenes on the atonic variety, and is marked by
acute attacks of pain or spasm, frequently amounting to regular parox-
ysmsof colic. Frequently some violent affection of the nervous system
is brought on, and children in particular are seized in consequence with
convulsions, followed by chorea and sometimes paralysis of the bowels.
Young women are attacked with hysteric and various disorders of
the nervous and muscular systems, including catalepsy itself; and
of the heart and circulation generally. Uterine derangements are
a common sequence. " Generally the patient becomes pale and
delicate looking, but sometimes preserves a natural appearance or
even good looks; the skin is cool, moist, and clammy, particularly
the extremities; the lips and gums are pale, and the tongue is in-
variably large, moist, and covered with a thin, clammy coating;
frequently it is swollen and oedematous, divided laterally or trans-
versely by deep cuts or fissures, and retaining the impressions of
the teeth." The bowels, when relieved of their constipation, which
is often obstinate and for a while intractable to the most active
medicines, discharge matters varying in colour, consistence, and
smell, — being sometimes of a chalky-white and inodorous, at others
fetid and dark, and occasionally mixed with membranous shreds.
There is nothing distinctive in the appearance or quantity of the
urine. The pulse is almost always weak, small, soft, and generally
slow ; and there seems to be a defect of capillary circulation.
The pathology of this disease need not be detailed here, as it would
be little else than a repetition of that of follicular duodenal dyspepsia,
on which I have already adequately enlarged (Lect. XIV., p. 174),
as far at least as regards the condition of the mucous follicles and
their morbid secretion. The most common causes of follicular
colonic dyspepsia are the habitual costiveness of sedentary persons,
repeated irritation of the alimentary canal by crude and indigestible
articles of food, and the ill-judged use of purgative medicines. But
as these are causes of other forms of dyspepsia, and may be present
without inducing enteric follicular disease at all, we must believe
that there is a predisposition of a scrofulous nature in persons
DISEASES OF THE CiECCM.
259
thus affected, who are, I may add, generally of a lymphatic tem-
perament.
The treatment will consist of the use of means to evacuate the
bowels, to alter the morbid state of the follicles, and to give the re-
quisite tone to these organs and the colonic mucous membrane gene-
rally. With this view we give castor oil and oil of turpentine,
calomel and rhubarb, croton oil, compound powder of scammony,
in order to relieve the colon of its accumulated feces. After this
we shall endeavour both to preserve a soluble state of the bowels
and modify follicular secretion, by blue mass and rhubarb, hydrarg,
cum. cretd — rhubarb with ipecacuanha, balsam copaiba, cubebs
with bicarbonate of soda, and iodide of potassium, in conjunction
with some saline and a chalybeate. The tone of the bowels will be
maintained by vegetable bitters, with occasionally narcotics and
sulphurous and chalybeate waters.
LECTURE XXII.
DR. BELL.
Diseases of the Caecum.—Peculiarities of position, structure, and function of
the ceecum—Its liability to be disordered—Symptoms of fecal accumulations in
it—Treatment—Importance of enemata—Best means of employing them—
Suspicion of hernia being1 present—Liniments and friction—Attention to diet.—
Inflammation of the Cjecvm—Its varieties.—Stercoral Ccecitis—Symptoms
and treatment.—Acute Cacilis.—Injlammation of the peri-cacal tissue.—
Perforative ulceration of the caecum and of the appendix vermiformis—Causes-
Symptoms—Prognosis—Treatment.—Chronic inflammation of the cacum—
Its causes, complications, and cure.
The diseases of the caecum, of which I am now about to speak, are
not of common occurrence; and on this account their diagnosis re-
quires to be laid down with some distinctness, in order that they may
receivea suitable treatment. They areapt to be mistakenby the inex-
perienced for other affections, and measures are attempted for their
relief which are inadequate or mischievous. We cannot, however,
duly appreciate the circumstances of the liability of the caecum to
disease without a knowledge of its anatomical character and rela-
tions as well as its functions. An extensive pouch at the termina-
tion of the small intestines, it receives the chymous residue from
these latter, including, of course, any crude and indigestible sub-
stances which had escaped gastro-enteric digestion: itself liberally
supplied with large mucous follicles, which secrete an acid, albumi-
nous, and solvent juice, it subjects all these matters to a second
digestion, likened by some physiologists to that of the stomach. A
more complete remora of its contents is procured by its mode of
connexion with the colon, by which these have to ascend against
gravity before they find entrance into the latter. In the caecum, the
intestinal contents first acquire their fecal odour, w hich is attributed
260
DISEASES OF THE DIGESTIVE SYSTEM.
to a volatile oily substance secreted by their follicles; and on this
occasion is generated, together with an acid, hydrosulphuretted hy-
drogen gas. We can now readily understand how, if the upper
and°chief digestive organs fail to effect complete chymosis, either by
their being disordered, or forced to yield a passage to crude and
indigestible food, if the secretions of"the liver, pancreas, and upper
(small) intestines be of a depraved or irritating nature, the caecum
should be heavily tasked by accumulations and remora, disordered
in its function, and, finally, taking on inflammation be disorganised
in its structure.
Weakened energies of the digestive system will of course be
largely participated in by the caecum, which manifests its disorder
by flatus and colicky pains in the iliac region, sometimes ileus itself,
and alternate constipation and diarrhoea. To this state it is brought,
in young, irritable, or nervous persons, by the use of much acid and
unripe fruit, neglect of the bowels, and tight lacing, or belts round
the upper part of the abdomen; and, in fine, by several other of
the common causes of dysentery; some of the most distressing
symptoms of which are occasionally connected with accumulations
in the caecum, and inflammation of this part. Several instances
are recorded by the older writers where the stones of fruit, biliary
and intestinal concretions, and hardened fecal matters, lodged in the
caecum, have occasioned severe colic, and even fatal ileus. Most
of these are referred to by Dr. Copland, in his Dictionary of Prac-
tical Medicine (Art. Ccecum), who has himself contributed not a
little, by his own cases and observations, towards fixing the atten-
tion 'and enlarging the knowledge of his professional brethren on
this subject. "°When the distention by accumulated matter is great,
it may, from rising high in the abdomen and pressing upon the
nerves, vessels, and ducts in its vicinity, occasion numbness and
oedema in the right lower extremity, retraction of the testicle, and
derangement of the urinary secretion ; and thus be mistaken for
disease of the kidney." Dr. Copland observes, also, that besides
various indigestible substances which may be lodged for a length of
time in the caecum, producing more or less disease, " large balls of
worms, both lumbrici and ascarides, collect in the viscus, and occa-
sion much local irritation, or even inflammation, of its inner sur-
face, and constitutional disturbance."
The symptoms occasioned by fecal accumulations in the caecum,
and by its distention, enlargement, and irritation, are local, symp-
tomatic, and constitutional The local symptoms are, more or less
fulness, hardness, or distention, in the right iliac region ; sometimes
in examination carefully with the point of the fingers, the abdomi-
nal muscles being relaxed, a doughy hardness is felt. " When the
bowels are constipated, and interruption of the passage of matters
through the caecum occurs, the paroxysms of pain are very acute,
and sometimes attended with vomiting and all the symptoms of the
most severe colic, and even those of ileus." Some of the sympto-
matic disorders have been already mentioned, viz., numbness of the
ENEMATA IN CJECAL ACCUMULATIONS. 261
right thigh ; oedema of the right foot and ankle ; sometimes retrac-
tion of the testicle, or frequent calls to empty the bladder; to which
may be added, hemorrhoids, uneasiness in the right iliac region,
often extending to the right hypochondrium; various dyspeptic
symptoms and irregularity of the bowels, — constipation alternat-
ing with diarrhoea, and scanty, offensive, and mucous stools, and
severe tormina, even to retching, when the mucous surface and
follicles of the organs are irritated. Dr. Copland, whose descrip-
tion I still follow, adds, that he has seen several cases of varicose
veins of the leg, or indolent ulcers, and a case of disease of the
bones of the feet, the occurrence of which was evidently connected
with great distentions and accumulations in the caecum. The con-
stitutional symptoms are very analogous to those of atonic colonic
dyspepsia detailed in my last lecture, to which I refer you.
The indications of treatment of caecal accumulations and the ac-
companying costiveness are the same as those already recom-
mended for torpid colon, under the head of atonic dyspepsia of
that intestine. But greater liability to disorder of the stomach and
inverted action of this viscus and of the small intestines, in the dis-
ease now under notice, requires of us more reserve in the adminis-
tration of active purgatives, especially those of the resinous or
drastic kind. Calomel in a full dose, as from fifteen to twenty
trains, will be found to answer belter than these ; it will, it is true,
be very apt to cause some nausea, and even vomiting, when it has
reached the ileo-caecal valve, and has entered the caecum; but, in
return, it will bring awav much indurated feces; and often by its
action on the liver and mucous follicles of the intestines, stimulate
these to a free secretion, which, going down with it, will excite the
caecum and colon to farther peristaltic action and discharge of their
contents. Pain, flatus, or spasm, being present, will indicate the
propriety of adding opium, hyosciamus, or belladonna, to the
calomel, or, subsequently, to aloes, in order to insure a complete,
yet not painful or irritating evacuation of the bowels.
Enemata. — Difficulties interposed to prevent the administration
of medicines by the mouth or to their full operation after their being
swallowed, we must have recourse to enemata, among the best ot
which is castor oil and oil of turpentine,^-one to two ounces
of the former, and half an ounce to an ounce of the latter, mixed
with a pint of gruel or thin flaxseed mucilage. W hen worms are
suspected to be present in addition to other morb.d matters, we
may use aloes, and the alkaline solutions, assafoetida, camphor, lime-
water, &c, in union with the injections, all of which, to be efficient,
should be large, and introduced by a suitable instrument well up in
the intestine. The simpler enema of salt and water, in such quantity
as to distend the colon, will often, by repetition alone, suffice to pro-
cure free evacuations.
Both caecal and colonic accumulation, the latter occurring par-
ticularly at the sigmoid flexure, and certain cases of colic, as well
as the obstruction from hernia, require the persevering use of ene-
262
DISEASES OF THE DIGESTIVE SYSTEM.
mata, in order that the bowels may be relieved of their fecal con-
tents. Not unfrequently, a passage to the injected fluid is refused
in consequence of a spasm at the sigmoid flexure of the colon, and
by the same cause the feces are prevented from passing down-
wards. In such cases it will be useful, and indeed necessary, to
adapt a flexible tube of sufficient length to the pipe of an injecting
syringe, and to carry the former up the rectum and beyond the
spasmodically strictured part of the colon, and then to introduce
through this tube the contents of the syringe. A speedy discharge,
both of flatus and feces, after the withdrawal of the instrument, in-
dicates, and, at times, loudly proclaims, the effect of the remedy
and the cure of the disease, or at least the removal of the obstruc-
tion by which it was either caused, or to a great extent kept up.
Dr. O'Bierne, who was among the first to adopt this practice, has
certainly most contributed, by the cases which his experience fur-
nish him, to show its usefulness. Sometimes a good purpose will
be answered by introducing an apparatus in the manner just
directed, or even a common syringe with a moderately long nozzle
or terminal tube, empty, but with the piston pushed up. After the
instrument is properly introduced, let the piston be drawn down :
the patient will soon complain of a feeling of dragging and sinking;
some air, and even particles of feces, will enter the syringe, and
afterwards there will be a copious discharge of scybala and other
fecal matter. A still simpler plan is to introduce an elastic tube,
alone, well up the intestine, and past, if possible, the strictured por-
tion. Mr. Maunder relates a case in his own practice (Lancet,
February 1, 1842), of scrotal hernia, of three days duration, irredu-
cible by taxis, in which all the alarming and painful symptoms
were removed by this means. He introduced the tube of a stomach-
pump twenty-six inches up the intestine, " and after the expiration
of about ten minutes air escaped in small quantities from its mouth ;
the scrotal tumour gradually diminished, and the poor fellow was
soon released from suffering; the sickness ceased, pain was dimi-
nished, and the dragging sensation completely relieved." Two
drops of croton oil with sugar, divided into three doses, one taken
every three hours, and followed up by a little saline mixture, acted
powerfully on the bowels, and completed the cure.
I cannot at any time more appropriately than the present, when
constipation is the subject of remark, insist on the necessity, in all
cases in which stools cannot be procured, and there is at the same
time nausea, retching, or vomiting, dragging at the epigastrium,
and symptoms of colic, of instituting careful inquiries, and making
yourselves minute examination, in order to ascertain whether the
disease is not in reality hernia, either at the crural or abdominal
ring. In some old persons, and particularly women who have
borne many children, and whose abdominal parietes is much relaxed
and yielding, it is not easy, at first, to distinguish distention and
accumulations in the caecum, by which it is protruded forwards and
downwards, from inguinal hernia.
STERCORAL INFLAMMATION OF THE CJECUM. 263
Among the means resorted to for enabling the caecum to recover
its tone and acquire power for the expulsion of its contents, are
liniments assiduously rubbed, with moderate pressure, over the
abdomen, and particularly in the region from the umbilicus to
the tuberosity of the ilium, and thence downwards to Poupart's
ligament.
After we have succeeded in apparently removing whatever
obstructions may have existed — the caecal region being soft and
natural, and the motions of the bowels free, — the next object is to
prevent the recurrence of the disorder by imparting the requisite
strength to the digestive organs, and to «the large intestine in par-
ticular. As the indication here is identical with that for the treat-
ment of atonic colonic dyspepsia in a similar stage of the disease,
I must refer to the directions given on the occasion in my last lec-
ture. The liniments may be continued at this time, or occasionally
in their place a warm plaster worn over the region of the abdomen
already specified. Attention to the diet and to procuring regular
alvineevacuationsare of the sameimportance here as in the derange-
ments of function of the colon before described.
Stercoral Inflammation of the Ceecitm.— So far we have spoken of
impediment of function of this organ as dependent on accumulations
of feces or concretions in it; for the relief of which we have recourse
tp the same measures as for common, yet obstinate, constipation.
But a persistence of this disorder without material abatement in-
duces another and more complicated state of things, which gives
rise to phlogosis of the gut. Stercoral inflammation of the caecum
is the occasional consequence of the protracted detention of the
fecal matter in the cells of the caecum, until a process, at first of
irritation, and afterwards of inflammation, is excited, and then all the
symptoms of enteritis or of strangulated hernia are evinced. As
obstinate constipation is perhaps the only symptom that is present
for a great length of time, the physician may have no grounds to
suspect any local mischief until swelling or pain is felt in the right
groin. At this time, the abdomen, says Professor Albers, is usually
tense, hard, and prominent, especially at the right flank. If we at-
tentively examine this part, we shall generally find that it is the seat
of a large swelling, which can be displaced more easily from one
side to another than from above downwards. At first, light frictions
over this part will probably cause the swelling to disperse ; not so,
when the malady is farther advanced. Pressure on the part usually
causes a certain degree of uneasiness, but rarely any acute pain.
In the left iliac region the descending colon may often be found
filled with indurated feces. A sense of pain and numbness is not
unfrequently felt along the line of the iliacus internus muscle, from
the groin downwards along the inner side of the thigh ; this feeling
usually becomes more and more distressing as the complaint ad-
vances. A dull sound is elicited by percussion on the right iliac
region.
The various symptoms which attend this disorder may exist for
264
DISEASES OF THE DIGESTIVE SYSTExM.
several days before they come to a crisis. Professor Albers has
observed in some cases that the most conspicuous symptom for a
great length of time is a most troublesome itching of the surface.
If a diarrhoea should take place either spontaneously or from the
use of purgative medicines, the symptoms are, in common, relieved
rapidly and effectually. It is truly astonishing to see what quanti-
ties of fecal matter have been discharged before entire relief is
obtained.
Our prognosis in this complaint is for the most part favourable.
There are cases, however, in which the feces are lodged perma-
nently in the caecum, and consequently upon this state will be an
inflammatory and perhaps suppurative action in its walls or in the
adjacent cellular tissue. But even should the abscess burst out-
wardly, feculent matter is not always mixed with the purulent dis-
charge, as the gut may never have been perforated, or the aperture
may have been so small that it has subsequently closed up. Such
cases not unfrequently terminate well; the suppuration gradually
diminishing, and the abscess at length healing up. In a few rare
instances the inflammation has terminated in gangrene. Finally,
though rarely, the life of the patient has been much prolonged
by the yielding of the bowel, and the formation of an artificial anus
in the right groin.
The following case will illustrate some of the foregoing re-
marks: —
" Case.—A man, seventy-two years of age, died last year (1839) in
the Salpetriere at Paris, after protracted suffering from intestinal dis-
turbances. The interior part of the sigmoid flexure was much
contracted ; and the consequence of this lesion had been that an
immense quantity of feces, in large hard lumps, was accumulated in
the transverse portion of the colon, which might actually be felt
through the thin parietes of the abdomen; the liquid parts seemed
to have been, as it were, filtered through them, and hence during
life the patient had supposed that he had a diarrhoea. He died sud-
denly and without experiencing much pain. On dissection, a large
ulceration was found in the caecum, and a cancerous contraction
of the sigmoid flexure.
"In another case — which terminated favourably — where the
rectum was obstructed by an encephaloid tumour, the feces had
accumulated in large hard balls in the sigmoid flexure and descend-
ing portion of the colon. The caecum and rest of the colon were
distended with gas. This state had continued for upwards of a
twelvemonth, when suddenly the abdominal parietes became the
seat of sharp pain, which were most severe in the right groin. Bv
the use of purgative medicines, an immense quantity of the large
fecal balls was discharged, and the patient was speedily relieved."
The period of duration, of the stage of stercoral inflammation of
the caecum, will modify its treatment. When there is simply accu-
mulation and retention of feces, indicated by protracted costive-
ness and some fulness in the right iliac region, we can have recourse
TREATMENT OF CJECIT1S.
265
to all those means which are in common use for the relief of con-
stipation. Calomel and jalap in full doses,a calomel pill often grains,
followed by the compound powder of jalap, the compound extract
of colocynth, or an infusion of senna with salts, or castor oil and
spirits of turpentine, may, severally, be prescribed with advantage.
Tartar emetic, in nauseating or relaxing doses, to be succeeded by
active enemata, will sometimes procure free fecal discharges. Cro-
ton oil, if the stomach revolt at medicine in bulk, or if the other
prescriptions prove unavailing, is a resource in reserve.
But if, to the symptoms of stercoral accumulation, be added dif-
fused tenderness of the abdomen, vomiting, and protrusion of the
intestine in the groin, we should have recourse to the same reme-
dies which are directed in strangulated hernia. Of these, venesec-
tion or leeching, according to the constitutional vigour or evidences
of general febrile excitement, tartar emetic, as a sedative and re-
laxant, and enemata, will constitute the first part of the treatment.
Relief being obtained, we may then give some tolerably active pur-
gatives, selecting those which are least irritating to the mucous
coat. Calomel, therefore, and castor oil, or castor oil and turpen-
tine, will have the preference over the resinous and drastic medi-
cines of this class. Where the muscular coat is partially paralysed
by inflammation, or the diameter of the intestine diminished by
external tumour, or other causes, it will be desirable to produce a
relaxation of the whole intestine, and at the same time diminish the
inflammation. Hence we have recourse to free leeching in the neigh-
bourhood of the tumefied part, tartar emetic by the mouth and per
anum, and finally, if need be, enemata of tobacco,as used for hernia,
and as successfully employed by Dr. O'Bierne in dysentery. We must
not forget the means of at least partial relief afforded by the elastic
tube introduced some way up the gut, as already recommended.
In all cases in which an enema is to be administered, the pipe pro-
jecting from the barrel ought to be longer than it is ; or the defect
in this particular may be supplied by the affixing to it an elastic tube,
which, especially in cases of obstinate constipation and colic, or
where stricture of the rectum exists or is suspected, should be car-
ried high up in the intestine ; as far, at least, as the sigmoid flexure
of the colon. Knowing the immense quantity of accumulated fedes
which have sometimes been retained in and distended the caecum
and colon, we ought not to desist from a continuation of our mea-
sures for their entire evacuation, even after the fecal discharges
have been copious. We may remit, for a day or two, the adminis-
tration of purgatives after ease has been procured by large discharges
of scybala and feces ; and then resume the use of this class of medi-
cines, varying the kind so as at one time to give saline, at another
resinous, then again oleaginous. The increased activity and milder
operation of certain purgatives are obtained by the addition of a
bitter, as sulphate of quinia, gentian, &c.
Frequent and regular friction, and gentle kneading of the abdomi-
nal parietes; the tepid bath at first, and afterwards the cool shower
vol. i.—23
266
DISEASES OF THE DIGESTIVE SYSTEM.
bath or douches along the spine, and moderate exercise in the open
air, will be among the measures of restoration, in addition to those
already recommended, for the convalescent from this disease.
Until of late years inflammation of the caecum and its ap-
pendix, as a separate disease, has engaged but little attention. Dr.
Burne, and Dr. Albers of Bonn, are our chief guides on the
subject—the former in an article on the Inflammation and Per-
forative Ulceration of the Ccecum and of the Appendix Vermi-
formis Cceci in the Medico-Chirurgical Transactions, — the latter
on Inflammations of the Ccecum.* To these, for reference, I may
add Dupuytren (Lecons Orales), Ferral on Phlegmonous Tu-
mours in the Right Iliac Region (Edinb. Med. and Surg. Journ.
vol. xxxvi.), American Cyclopedia of Practical Medicine, &c. (Art.
Abdomen — Abscess of, by Dr. Hays), and M. Grisolles — Histoire
des Tumeurs Phlegmoneuses des Fosses lliaques (Arch. Gen., 1839).
Acute Inflammation of the Ccecum begins in the mucous membrane
during the progress of dysentery and enteritis ; but sometimes it
arises idiopathically and unconnected with any other complaint.
In the latter set of cases, the inflammation is usually rapid and in-
tense. Its symptoms are, at first, tenderness on pressure and some
colic disorder, but then the peritoneal coat is also affected; there
is a burning, pungent pain, in the right iliac fossa, aggravated by
pressure and by intestinal evacuations, and frequently extending
more or less along the line of the transverse colon. A sensation of
burning heat at the anus every time that the bowels act is a com-
mon attendant symptom.
Usually there is a distressing diarrhoea present, which, in general,
diminishes the pain in the iliac fossa. The stools are thin, often
loaded with mucus, and not unfrequently bloody. As the disease
abates, the mucosities become whiter and of a thicker consistence,
not unlike those which are often expectorated in bronchitis. The
mucous secretion has frequently been mistaken for and described as
purulent; and hence a common error, that in this affection the
stools are often mixed with matter. The extension of inflammation
from the mucous to the muscular and peritoneal coats of the great
intestine constitutes the phlegmonous dysentery of authors.
With respect to the pain which accompanies inflammation of the
caecum, it deserves notice that this usually extends down the sur-
face of the right limb, more especially when the patient walks, or
turns his body round in bed. Hence it is apt to be considered as
of rheumatic origin ; and as the muscles covering the inflamed
bowel generally sympathize with it, there may be a degree of rheu-
matic suffering blended with that arising from the enteric disease.
In some cases retraction of the right testicle has been noticed ; and
in others symptoms of irritated kidney appear.
The duration of inflammation of the caecum has never, to Pro-
fessor Albers' knowledge, extended longer than seven days.
* An analysis of this last is contained in the Medico-Chirurgical Review for
April, 1840, and from it I draw on this occasion.
DIAGNOSIS OF CJECITIS.
267
Inflammation of the cellular tissue round the ccscum or peri-ccecal
tissue—perforative ulceration of the ccecum and of the appendix
vermiformis. The cellular inflammation commences suddenly after
exposure to cold, irregularity of diet, or taking a draught of cold
liquid when the body is heated and perspiring. The pain which
attends it is felt at first sometimes near the umbilicus, and at other
times in the iliac region. When it begins round the navel, the pa-
tient usually complains of slight cutting pains, which do not differ
much from ordinary colic : when in the iliac region it is much more
intense. Wherever situated it gradually diffuses itself, so that the
entire surface of the abdomen soon becomes exceedingly tender, as
is the case in genuine peritonitis. Sometimes the pain extends
round to the loins and back, and then the cases may be mistaken
for nephritis or psoitis. But at length it is concentrated chiefly in
the iliac fossa. When this takes place the disease is fully developed,
and suppuration is probably near at hand. The pain is aggravated
by any movement of the body, or by the accumulation of flatulence
in the bowels, &c. When the pain has lasted for some time there
is always considerable tension, swelling and hardness in the right
iliac region, stretching from thence in all directions, but chiefly
downwards in the direction of Poupart's ligament. These pheno-
mena are more circumscribed than in peritoneal inflammation;
although it must be admitted that the two cases are not easily
distinguishable. The following is an example of the difficulty of
diagnosis: —
A child, eight years of age, was suddenly seized, after a chill,
with considerable fever attended with severe abdominal pain, which
was seated at first in the epigastrium, and gradually extended itself
to the right iliac region, and finally over the whole abdomen. There
had been diarrhoea ; but this was replaced by constipation and
troublesome vomiting. The case was considered as one of genuine
peritonitis, and treated with bloodlettings, local and general, fomen-
tations, mercury internally and externally, &c. The patient died
on the ninth day after the attack. Dissection showed the whole
extent of the peritoneum, intestinal as well as abdominal, to be per-
fectly sound, with the exception of one spot about the size of a
dollar over the caecum, where it was evidently inflamed, and exhi-
bited a few flocculi of coagulable lymph. On examining more
minutely the parts at this region, a fluctuation was perceptible; and,
on making an incision there, a large cupful of purulent matter flowed
out. The cellular tissue surrounding the caecum behind was found
to be greatly destroyed by suppuration, and the pus had made its
way between the abdominal muscles forwards to the iliac region.
These muscles were quite dissected, as it were, from the subjacent
peritoneum ; the caecum also was much softened in texture, so that
it was easily torn across; and its mucous surface was of an almost
livid colour: no perforation, however, had taken place. All the
other abdominal viscera were sound.
It will be observed that in the case now related there was at
26g DISEASES OF THE DIGESTIVE SYSTEM.
first diarrhoea, which was followed by obstinate constipation.
Inch is the iisud occurrence whenever the cellular substance
around the caecum becomes inflamed. The constipation here is
partly owing, we may suppose, to the loss of contractility in he
muscular coat of the intestine by inflammation, and partly to he
mechanical pressure of the swelling on the caecum, and on the
colon also and small bowels. In addition to the symptoms already
enumerated, there is usually pain and a sense of numbness down
and about the hip-joint. These symptoms may be owing to the
psoas and iliacus internus muscles being peculiarly affected. 1 he
excretion of urine is also in many cases more or less disturbed.
It is probable that the right kidnev sympathises from the very begin-
ning of the disease, and that the swelling in the latter stage may
press upon the ureter.
It may be readily supposed that there is generally more or less
feverish irritation present. The progress of the disease is often
very obscure and slow; the symptoms being at first inconsidera-
ble, but becoming on a sudden violent and most alarming. The
prognosis is in general favourable; since, out of sixteen cases col-
lected by M. Meniere, only one proved fatal. The duration of the
disease may be said to vary from two or three weeks to several
months, or even to upwards of a year.— Termination. It is, we
are told, not rare for the inflammation of the cellular substance
round the caecum to terminate favourably by resolution, but cer-
tainly in the majority of cases suppuration is induced. The pus
usually finds its way into the cavity of the gut, either directly, or
by bursting into the appendix vermiformis. In some of the cases
published by Dupuytren, the purulent matter had infiltrated itself
as high as the kidneys, and so low in the pelvis as to collect
between the rectum and bladder. When suppuratidn takes place
there is a sudden change in all the symptoms; the severe pain and
the obstinately confined state of the bowels being generally followed
by a complete remission of suffering and by a greater or less degree
of diarrhoea; so that the patient, and his medical attendant, also, if
he be not on his guard, are apt to suppose that a favourable crisis
has taken place. Too often, however, this is but a delusive calm;
the strength of the patient becomes weaker and weaker, the stools
are found to be mixed with purulent matter, and the system at length
gives way. The history of the following case affords a good illus-
tration of the usual progress of the disease :—
" Case. — A man, twenty-nine years of age, who had been pre-
viously in perfect health, was seized, during the summer of 1833,
when the influenza was prevailing, with smart abdominal pains,
which returned at periodic intervals, but were not attended with
fever or any gastric disturbance; diarrhoea however was present.
By the use of cupping the pains abated, but they became more per-
manent and more fixed in the right iliac region; and at the same
time a constipated state of the bowels ensued. For five days the
patient was able to attend to his affairs; and then he was seized
PROGRESS OF CECITIS.
269
with feverish chills followed by flushes of heat. The pain became
much more severe, and occasional vomitings supervened ; at the
same time the groin was somewhat swollen and very tender on
pressure, and the urine was thick and very red. Purulent matter
was observed to be mixed with the alvine dejections ; all the symp-
toms became suddenly very alarming, the extremities being cold
and the pulse scarcely perceptible ; and the patient died in a state
of coma.
" On dissection, a large collection of pus was found behind the
caecum, stretching up to the right kidney, and down to the pelvis;
the appendix vermiformis was hard and thickened. In the caecum,
at about an inch from the appendix, there was a perforation with
irregular edges, through which the matter had escaped into its
cavity ; the right kidney was softened and very red ; and the
iliacus internus muscle was partly destroyed by ulcerative absorp-
tion.
" In a few rare cases, the pus makes its way not only into the gut,
but also outwardly through the abdominal parietes; thus an anus
contra naturam is established. Occasionally the outward opening
alone takes place. When this is the case, the symptoms are gene-
rally very severe for ten or twelve days, and then suddenly they
subside, when the abscess bursts. Under all circumstances the dis-
ease must always be considered as a very dangerous one; the
colliquative exhaustion that is induced by the protracted suppura-
tion proving in most cases fatal.
" With respect to the age, at which peri-ccecal suppurations are
most frequent, perhaps it is that of youth."
M. Meniere (Archiv. Gen. de Med., t. xvii., p. 213) supposes
that adults and the male sex are most liable to this disease. Dupuy-
tren tells us that disorders of the digestive tube caused by certain
trades have a great tendency to produce this diffused inflammation
and subsequent abscess. He specifies house-painters, colour-grinders,
and copper-turners, as more peculiarly liable.
Dr. Burne remarks: The peculiarity in the organisation of the
caecum, which bears upon the present subject, is the absence of a
peritoneal tunic at its posterior part, where it is fixed and attached
by adipose cellular tissue to the iliac fascia, so that in the event of
a perforative ulceration in this direction an abscess would form
behind and without the peritoneum upon the iliac fascia, and direct
its course to the lumbar region at the outer edge of the quadratus
lumborum muscle. Dr. Burne, in premising that the caecum by
its conformation is peculiarly exposed to the lodgement of undigested
substances, thinks that the greater number of cases of inflammation
of this intestine are to be ascribed to the prolonged irritation of
bodies so lodged, and that such inflammations are, therefore, pro-
perly symptomatic; a conclusion borne out, moreover, by the man-
ner of the attack, which is characterised by a development of the
local preceding that of the general symptoms, and by the absence
of the chills and rigors which usher in idiopathic inflammation.
270
DISEASES OF THE DIGESTIVE SYSTEM.
That the inflammation of the caecum may be idiopathic, and arise
from the ordinary exciting causes, cold and vicissitudes of the
weather, there can be no doubt; but these instances are rare, in
comparison with those which may be fairly attributed to the irri-
tation of crude substances which have reached the caecum and
lodged in its pouch.
The termination of the symptomatic inflammation of the caecum
is usually by resolution ; the symptoms yielding at the end of five
or six days, and subsiding altogether soon afterwards; except in
patients of an inflammatory or gouty diathesis, in whom inflam-
mation once excited will continue in a subacute or chronic form,
and require several weeks for its removal, notwithstanding the
original exciting cause shall have passed away.
The termination by perforative ulceration and abscess of the
caecum is rare: but this organic lesion of the appendix is more apt
to occur, and is next in frequency to the inflammation of the
caecum.
The varieties of the disease are — 1. Inflammation, acute or sub-
acute, of the caecum, terminating quickly or slowly in resolution,
or lingering on and leading to permanent organic impairment.
2. Perforative ulceration of the caecum from within and abscess
behind the peritoneum, pointing externally in the corresponding
lumbar or inguinal region, or in both. 3. Inflammation of the
appendix spreading over the peritoneum. 4. Perforative ulcer-
ation of the appendix with consequent universal peritonitis ending
rapidly in death, or with circumscribed peritonitis and abscess
within the peritoneum, sometimes ending in death in the course of
ten days, or, life being preserved, it bursts eventually into the
caecum and discharges itself by the rectum, or directs its course
to the surface of the body and pointing in the right lumbar or in-
guinal region.
As regards the tumour which occurs in the right iliac fossa, Dr.
Burne assigns the following as its causes :— 1. Collection of fecal
matter in the caecum. 2. The presence of any crude undigested
substance, of worms, concretions, or other foreign bodies. 3. In-
flammation of the caecum resulting from the irritation of the above.
4. Chronic disease of the caecum. 5. Abscess from perforative
ulceration either of the caecum or of the appendix.
The perforative ulceration of the appendix may be suspected by
the more or less sudden development of the local si^ns, which are
always severe, by their being fixed in the right iliac°fossa, and not
preceded by bowel complaints or ill health; by the supervention of
vomiting and constipation, the constipation yielding readily to me-
dicine ; yet, having yielded, no amendment following; by the great
tension of the ileo-inguinal region, there being always a circum-
scribed peritonitis and abscess within the peritoneum ; by the sym-
pathetic tenderness of the whole abdomen ; and subsequently, by
the occurrence of a diarrhoea, and a discharge of pus by the rectum,
followed by subsidence of the tumour and amelioration of all the
TREATMENT OF CiECITIS.
271
symptoms, or by the pointing of the abscess in the form of an em-
physematous tumour in the lumbar-inguinal or ileo-inguinal regions.
The peritonitis excited at the moment of the perforations of the
ap'pendix will not unfrequently spread rapidly and universally over
the peritoneum, and destroy life in from twelve to twenty-four
hours.
The diagnosis in the two varieties of the disease will be the less
doubtful by our remembering that the perforation of the caecum is
generally preceded for weeks or months by bowel complaints, in-
dicating ulceration of the mucous membrane; while the perforation
of the appendix is not preceded by such bowel complaints.
The statistical information afforded by the cases collected by
Dr. Burne is presented as follows :— Termination : 13 recovered ;
8 died. Character: 19 acute; 2 chronic. Varieties: 11 were in-
flammation of the caecum — all recovered : 2 were chronic disease
of the caecum—both died: 1 was ulcerative perforation of the
caecum from within, with abscess externally — recovered: 1 was
inflammation of the appendix, with circumscribed peritonitis —
died : 6 were ulcerative inflammation of the appendix — 5 died, 1
recovered. Of the five fatal cases of perforative ulceration of the
appendix, one died of diffuse peritonitis in about sixty hours; one
of peritonitis and circumscribed abscess in the peritoneum in nine
days; one of circumscribed peritonitis and abscess in the perito-
neum in twelve days; one of circumscribed abscess in the perito-
neum in four weeks; and one of abscess in the peritoneum, point-
ing in the right ileo-lumbar region, in eleven days. The one which
recovered was a circumscribed abscess in the peritoneum bursting
into the caecum.
The ages were, two under ten years of age; seven between ten
and twenty; three between twenty and thirty; six between thirty
and fifty ; three between fifty and seventy. Sex: sixteen were
males ; five were females. Occupation : six were gentlemen ; one
was a coachman ; one a farmer; five were boys having no par-
ticular occupation; three were destitute; five were females having
no particular occupation. Season: In the autumn and beginning
of winter more frequently.
The treatment of caecitis may be pretty well inferred from the
description of the disease. It will be nearly the same as that of
ileitis, and consist of—1, leeches or cups over the iliac fossa and
behind, between the ridge of the os innominatum and the lower rib,
and anterior to the psoas muscles, followed by fomentation and poul-
tices;— 2, a blister, which is to be kept freely discharging, and if
the symptoms persist, the surface to be dressed with mercurial
ointment;—3, antimonials to act on the bloodvessel system, by
reducing action ; and afterwards a mild purgative, in order to
insure a discharge from the caecum of any retained fecal or im-
perfectly digested or other irritating matters. Active purging
should not be produced by any medicine given by the mouth; but
enemata may be frequently administered, partly with- a view of
272
DISEASES OF THE DIGESTIVE SYSTEM.
revulsion, and partly of gently soliciting the passage downwards of
the matters in the ileum, caecum, and upper part of the colon, the
delay of which would prove irritating. Small doses of calomel at
intervals will contribute to this end, and be otherwise useful. Sali-
vation has been followed by a cure. Local as inflammation of the
caecum is, we ought, nevertheless, in cases in which the pain is
fixed and violent and extends over the abdomen, in a young and
well constituted subject, not to rely entirely on topical detractions
of blood, but must have recourse to venesection, and allow the
blood to flow from the arm until approaching syncope. Turpen-
tine embrocations applied over the abdomen, and retained as long
as it can be borne by the patient, is a remedy of great power.
Leeches to the anus will sometimes be of service, the more so if
there have been preexisting irritation of this part by hemorrhoids.
" If notwithstanding these measures the peri-caecal tumour in-
creases and is converted into a vast abscess, M. Donne advises,
that no endeavour should be made to draw it to a head and to open
it externally ; but that the surgeon should wait patiently the dis-
charge of the purulent matter by the intestine.- Where this termi-
nation does not take place, and where there is a disposition in the
abscess to open externally, the matter should be let out by incision,
before the skin heals; and by proper dressings, and especially a
suitable position, the abscess entirely evacuated and its cavity ob-
literated. As the most dependent part of the tumour is towards the
posterior part of the body, it has been recommended for the patient
to be on his face. When the disease becomes complicated with
peritonitis, the remedies for this latter affection are to be employed."
(Am. Cyclop., &c. Art. cited.)
Chronic Inflammation of the Ccecum.—This form of caecal disease
is less common as an effect of prior acute inflammation than as pri-
mary and of slow and insidious approach, and as being long confined
to the mucous surface and follicles of the intestine. It often, as Dr.
Copland justly remarks, advances imperceptibly, until serious or-
ganic changes have takenplacein the coatsof the caecum,the general
health, although more or less affected, not being so far injured as to
alarm the patient. Occasionally on this state may supervene a sub-
acute or an acute attack, which mayterminatein peritonitis, or in sup-
puration, or in gangrene. " Chronic inflammation is the most com-
mon organic state of disease by which the caecum is affected."
The causes of this form of disease are, some of them, common to
both sexes, others peculiar to females, who are the most frequent
sufferers from it. Among the first may be enumerated the use of
unripe or acerb fruits, sedentary occupation, deficient, or occasion-
ally too violent exercise on foot or horseback; the depressing
passions; previous disorder of the digestive organs, particularly
costiveness, and habitually or occasionally deferring the earlier inti-
mations to evacuate the bowels; suppression of accustomed dis-
charges, such as hemorrhoids; the pressure of an illy-constructed
bandage or truss, or blows on the part. The causes to which
DISEASES OF THE RECTUM.
273
females are exposed are contingent on their uterine functions and
child-bearing, and to their modes of dress. It often occurs among
them previously to menstruation, or soon after the climacteric
epoch. The symptoms of chronic caecitis are those common to
disordered digestion, such as flatus, occasional colic, irregular alvine
discharges, loaded tongue with red borders, muco-purulent dis-
charges ; and some more distinctive and peculiar, such as the in-
clination of the patient to lie on the right side, pain or uneasiness
in the right iliac region on turning to the left side, which is increased
by keeping this position; pain on pressure over the caecal region,
and a deep-seated fulness and hardness here.*
The treatment of chronic caecitis differs but in the degree to
which we carry the use of remedies from that of acute inflamma-
tion of the caecum. " When," says Dr. Copland, " the disease has
gone on to thickening of the coats of the intestine, as indicated by
obscure hardness and tumour, uneasiness, &c, in the iliac region,
particularly if it be attended with ulceration, as may be inferred
from the presence of small quantities of blood or pus mixed in fluid,
or but little consistent, muco-feculent, and offensive stools, amend-
ment is procured with great difficulty under the most favourable
circumstances; but it should not be despaired of, although it may
be long in appearing." The treatment suggested by this author is
enemata, laxative electuaries, blue pill, hydrarg. cum. cretd, ipe-
cacuanha, hyosciamus, and camphor, liniments, and repeated blis-
tering, and subsequently the deobstruent plaster. In addition to
these, I would recommend mercurial alternating with iodine inunc-
tion of the right iliac region, the internal use of iodine, and syrup
of sarsaparilla.
LECTURE XXIII.
DR. BELL.
Diseases of the Rectum. — The structure and sympathies of the rectum—
Chief diseases of the rectum, viz., hemorrhoids, ulceration, stricture, and
cancer.—Danger from neglect of proper knowledge of rectal diseases.—He-
morrhoids—Definition—Disease, both hemorrhage and tumours—Varieties of
hemorrhoids or piles—The anatomical characters of'the three principal ones,—
varicose, erectile, and cystic or spongy (mariscse)—Hemorrhoidal Flux or
Discharges—Their sources—Quantity and colour of blood discharged.—Mu-
cous or Sero-Mucous hemorrhoidal discharge—Causes—Constipation and
drastic purgatives overrated as causes of hemorrhoids—Consequences and
Complications of hemorrhoids.
The diseases of the rectum merit more consideration than they
generally receive; or, I ought rather to say, that the morbid altera-
tions of this part of the intestine are not studied with the care and
attention to which their importance entitles them ; and it is only
after they have made a progress which is at once alarming and
* In the sixth volume of Dr. Chapman's Medical and Physical Journal, Dr.
Beezeley gives an account of a case of Schirrous Tumour of the Ccecum.
274
DISEASES OF THE DIGESTIVE SYSTEM.
dangerous, and places them often beyond the reach of the art, that
the physician and surgeon are appealed to for their removal. 1 he
rectum is not a mere continuation and termination of the colon.
Its mucous coat is more vascular, and its muscular coat thicker,
and it receives a more abundant mucous supply than this latter.
Its sympathies are. both organic and animal, — for the reception
and transmission of impressions either healthy or morbid. Its
susceptibility to irritating purgatives and acrid poisons is mani-
fested in the fact, that often the effects of these are felt more by
the rectum than by any other part of the digestive canal, after the
stomach and perhaps the duodenum ; and hence it is that the chief
traces of phlogosis, or analogous structural alterations of mucous
tissue caused by the ingestion of poisons, are found in the stomach
and rectum. It is a curious fact, says Christison (Treatise on
Poisons, p. 318), that the rectum is much inflamed, though the colon,
and more particularly the small intestines, arfe not in cases of poi-
soning with arsenic. A common appearance in lingering cases is
excoriation or ulceration of the anus, and, in some, it is said
that even gangrene has been produced. Often, under the operation
of drastic purgatives, persons complain of heat and burning at the
lower part of the gut and anus, which, they are told, proceed from
the irritation caused by bile. Sometimes the explanation may be
valid ; but more generally these sensations are the effect of the me-
dicines acting on a susceptible portion of the intestinal canal.
Whenever sensations in this portion of intestine more than those
of mere distention, and especially when heat and some pain, how-
ever slight, are felt by a person during fecal exoneration, we must
suppose that the digestion is not healthy ; and, in fact, it will be
found on inquiry that the rectum is participating in a morbid state
of the stomach. By its contiguity as well as anatomical relations
through bloodvessels and nerves, and in degree also muscles, with
the genital organs and bladder, it both receives irritation from and
transmits it to these parts. Supplied as its lower portion is with spi-
nal nerves, it readily transmits its impressions by one set, and its
muscular coat and levator ani are stimulated in consequence by
another or motor set to contraction. This is part of the series of
nervous actions which takes place in health for the evacuation
of the rectum and sigmoid portion of the colon. The entire series
includes the call upon the abdominal muscles and diaphragm and
their contraction to aid the expulsive movement. When the trans-
mission of impression by the rectum is too quick and too frequent,
in a morbidly sensitive state of its mucous surface, there is corre-
sponding quickness and frequency of motor action, and violent and
irregular contraction of its muscular coat and of the levator ani
muscle, and tenesmus or straining and expulsive efforts with pain are
produced. If, on the other hand, the rectal sensibility be less
than natural, the circle of sensitive and motor actions is tardily
performed, feces accumulate to some extent, and are retained here ;
or, in common language, the person is said to be costive. The
circulation of blood in the rectum is liable to irregularity chiefly
DISEASES OF THE RECTUM.
275
by retardation. This is owing first to the straight veins, which are
also without valves, and to their being subjected to irregular and,
in cases of constipation, undue and prolonged pressure by the fecal
accumulation distending the rectum. In addition to these local
causes, there are the remote ones operating through other parts
of the vena porta, remora of the blood in which may be caused by
obstruction of the circulation in the upper portion of the intestinal
canal, and still more in the liver. Undue fulness and congestion
of the vessels of the rectum may also proceed from the double
cause of impediment in the capillary tissue of the rectum itself, or
in the trunks of the vena porta, of which the upper hemorrhoidal
veins are, it will be remembered, branches. Nor is the lower he-
morrhoidal plexus which terminates in the hypogastric vein exempt
from retardation, on the return of its blood, by the same causes;
since the lower hemorrhoidal veins composing it anastomose_with the
upper ones. Among the mechanical causes more or less interfering
with the regular circulation of the rectum, and especially with the
return of blood by the veins, are distention of the bladder and en-
largement of a gravid uterus. The very circumstance of lax
cellulo-adipose tissue surrounding the rectum, and particularly
abundant at its lower part, which prevents the retarded and irre-
gular circulation from being at first painful or leading to rupture,
gives facility for distention to a great extent, and for establishing
congestion and stases of blood, which, if by any cause converted
into inflammation, are more troublesome and difficult to cure than
phlogosis and its concomitants when they come on in other regions
in a more frank and violent manner.
The chief diseases of the rectum are, hemorrhoids, ulceration,
stricture, and cancer: complete fistula is, to a certain extent, a
rectal disease, as it depends on a solution of continuity in the coats
of the intestine; but it is more commonly regarded as an adven-
titious one, local, and calling for surgical rather than medical aid.
It happens, unfortunately enough, with reference to all the diseases
of the rectum, that their constitutional origin and connexions are
either regarded as of little moment or entirely overlooked ; and,
if we except partial remedies to soothe present irritation and pain,
the patient does not think of asking for regular professional assist-
ance until the distress from morbid growth or obstruction is so
great as to leave apparently no option. The surgeon is sent for,
and the knife or ligature is put in requisition; the local obstacle is
remedied, the parts heal, the patient is rendered comfortable,
thinks himself quite well, is prodigal of expressions of gratitude to
the operator, who was allowed to have his own way; but he more
than hints dissatisfaction at his physician, whose reasoning on the
complicated nature of his rectal disease he could not or would not
understand, and whose directions for hygienic, still more than
medical treatment, he thought were too rigid, and adverse to pre-
sent sensual enjoyment. But, after a while, uneasy sensations of
fulness and oppression are felt in some other organ ; sometimes in
276
DISEASES OF THE DIGESTIVE SYSTEM.
the liver, at other times in the lungs, or more frequently, and,
worse than all, in the brain, and without speedy relief be afforded
disease of an alarming kind, apoplexy or palsy, supervenes, and death
will close the new series of disorders which have taken the place
of the rectal ones, the removal of which was so gratifying to the
patient at the time, and a cause of so much eulogy by him of his
surgical attendant. Equally unfortunate effects have followed the
use of various empirical remedies for the cure of diseases of the
rectum, which were applied in ignorance of their pathology, and
with a view to the removal merely of a local disorder.
Hemorrhoids, the first disease of which I shall speak, and to
which, the preceding remarks are more particularly applicable, is
derived from «<«*. blood, and 5*°c,a flux ; the last derived from g«», I
flow. The derivation is little different, in the radicles not at all,
from that of hemorrhage ; and, in fact, by some of the ancient and
older writers since, the two were used as synonymous : but yet we
have the authority of Hippocrates himself in favour of a more re-
stricted designation by the term hemorrhoids, viz., that of dilata-
tion of the veins of the extremity of the rectum, accompanied with
a flow of blood ; and the vessels of the part have consequently been
called the hemorrhoidal vessels. The definition of hemorrhoids as
given by Dr. Copland (Diet. Pract. Med.) is as follows : Pain,
tension, weight, heat, or other uneasy sensation, referred to the
rectum and anus, accompanied or followed by tumours in these
parts, or by a flow of blood from them when the patient is at
stool; recurring after intervals, and sometimes periodically.
By hemorrhoids or piles we now understand not merely dis-
charge of blood from the rectal vessels, but also, in . addition,
tumours, either external or internal to the intestine ; and even these
tumours without discharge of blood at all. When the tumours are
accompanied or preceded by sanguineous discharge, the disease is
called bleeding piles; and when they are not thus accompanied,
blind piles ; so, also, according as they are inside the anus or on its
margin, they are called internal or external. A more definite and
technical nomenclature has been attempted by calling the bleeding
tumours hemorrhois, and the blind mariscce. When blood is dis-
charged without tumours being present, or at least without their
being external or readily ascertained, the hemorrhage in this case
is not directly distinguishable from entero-hemorrhage higher up
the canal. By a careful inspection, however, we shall be able
to feel a tumour or tumours inside, an inch or two above the
anus, or the dilated vessels and thickening of the mucous coat of the
rectum. In hemorrhoidal discharge, the blood generally escapes
either mixed with the feces or in jets,Squirted out, as it were, just
before and oftener just after the passage of the feces by the action
of the levator ani and straining of the abdominal muscles and
diaphragm. In entero-hemorrhage, even from the colon, the blood
is passed per anum in a continuous flow, without rectal irritation,
and of a dark colour, unmixed often with any fecal matter: it may
ANATOMICAL CHARACTERS OF HEMORRHOIDS. 277
escape without any effort at defecation. For the most part, intes-
tinal hemorrhage higher up than the rectum is the result of
metastasis from some other important organ, or it is a symptom
of dangerous visceral disease, and frequently appears in the ad-
vanced stage of certain low fevers.
Anatomical characters. — Common as is the disease before us
and well appreciated as are its general phenomena, its anato-
mical characters have not been ascertained with that entire
accuracy which might be expected. Of late years an approxi-
mation has been made, by zealous and pains-taking patholo-
gists, towards this desirable end ; and I shall, therefore, draw
from their labours the materials for the following sketch. The
rectum itself is found, on dissection of those who have had for
a length of time hemorrhoids, to exhibit enlargement of its veins,
and hypertrophy of its sub-mucous tissues. The veins are seen
through and directly under the mucous membrane, taking a course
parallel to each other for seven or eight inches; their trunks
being, as noted by Dr. Colles, as large as crow-quills. Morgagni
mentions a case in which they had almost acquired the diameter
of a thumb, in the entire length of the rectum and adjoining portion
of the colon.
The hemorrhoidal tumours themselves, piles, are organised in
different ways, constituting them into so many varieties. The first
organic change is simple dilatation of the capillary tissue, and more
particularly of the venous part, which may be followed by hemor-
rhage, or remain for a longer or shorter period without any evacu-
ation of their contained blood. After the paroxysm has passed off,
these vessels recover their customary size and tone, and exhibit no
traces of vascular engorgement or change. This slighter devia-
tion from health must be of frequent occurrence in most persons,
especially when there is derangement of the lower bowels: but the
prolonged operation of particular causes and increasing predisposi-
tion by age, give the congestion a fixed character; the veins become
more and more distended, and, at length, varicose, and form small
tumours, in clusters, which are chiefly internal, but project more or
less beyond the anus. M. Begin (Diet, de Med. and de Chir. Prat.)
has sometimes seen the lower part of the rectum as if completely
interwoven with a venous network, forming a thick vascular ring,
gorged with blood ; the incision of which would give rise to danger-
ous hemorrhages. These are the varicose hemorrhoidal tumours:
they are internal, and only after straining efforts at stool are they
protruded externally. Another and more common variety is the
erectile, consisting of an areolar structure, soft, spongy, and full of
blood, but which are shrunken when there is no excitement or irri-
tating cause producing an afflux to them. Numerous capillaries
ramify through these tumours in such a manner that if, after cut-
ting into them, we were, as Chaussier has pointed out, to throw
a coloured fluid into the arterial branch, we should see it issue
from all points of their surface by innumerable minute orifices. A
vol. i.—24
278
DISEASES OF THE DIGESTIVE SYSTEM.
somewhat remarkable example of this kind is furnished by Sir James
Earle in the case of a young lady in whom the tumour was about
nine inches, and altogether "like a piece of sponge, bleeding from
every pore. It was, however, of a healthy appearance, soft and
compressible. Varicose piles are very prone to hemorrhage. In
their colour they vary, says Dr. Gross (Pathological Anatomy,
p. 285, vol. ii.), from a light red to a deep purple, and they often ac-
quire the magnitude oi" a common almond. Sometimes these bodies
are supplied by vessels of some size, as in the case mentioned by Dr.
Colles, in which, after death resulting from another cause, he had
an opportunity of making an examination. On slitting up the rec-
tum, he saw " three bloodvessels, each as large as a crow-quill,
running for some way down the intestine, and then dividing into a
number of branches; these vessels ramified very profusely, and each
seemed, by interweaving of its branches, to form one of these
tumours. The trunks and branches were covered only by the lining
membrane of the intestine." (Dublin Hospit. Rep., vol. v., p. 152.)
A third variety of hemorrhoidal tumour is the encysted or spongy,
and, technically, marisca, appearing in the shape of a fleshy tuber-
cle. It is formed between the mucous and muscular coats, by the
interweaving of distended capillaries and cellular tissue, and con-
tains a centre or cyst filled with blood which had escaped from
some of the ruptured capillaries. At first, this effusion disappears
after the subsidence of the hemorrhoidal paroxysm ; but by repeated
congestion the sac remains more or less permanently distended,
and gives issue to an oozing of blood, constituting a hemorrhoidal
discharge. This kind of tumour projects often far into the rectum, is
somewhat solid or spongy, and when divided presents a compact
or porous and bloody surface. When the tumour is external it is
paler and more elastic, is infiltrated by serum, and is sooner pro-
duced and disappears more readily than when it is internal. A
modification of marisca is formed by a small fold of mucous mem-
brane, which, with its sub-mucous tissue, has been forced through
the anus by the effort of defecation or other strain; and, being pinched
by the contraction of the sphincter,is prevented from returning within
the bowel; or the thin skin connecting the internal mucous and exter-
nal cutaneous membrane, which is naturally puckered, but by slight
causes becomes irritated, has its cellular tissue enlarged, and under-
goes other changes similar to those just described. Liable, by friction
and accidental qndue pressure, to inflammation, thesetumours become
thickened and indurated, and the mucous membrane by continual
exposure is transformed into skin. By long irritation from friction
and want of cleanliness, they often increase to a large size, and
assume, from the pressure of the nates, a flattened oblong form,
with a thick, rounded, irregular, edge. Their opposing surfaces
become abraded and ulcerated ; and fissures and rhagades are pro-
duced, from which a thin purulent discharge takes place. These
tumours are often exceedingly painful, but do not bleed. Some-
times, small abscesses form in them, attended with a discharge of
HEMORRHOIDAL FLUX OR DISCHARGES. 279
purulent matter from the anus, and more pain and irritation of this
part than usual.
Hemorrhoidal Flux or Discharges. — Dr. Copland enumerates
the various sources of hemorrhoidal discharges (Diet, ut supra) to
be— 1st. From congestion of the vessels of the part, followed by
exhalation or exudation from the internal surface of the rectum.
2d. From irritation of this bowel, followed by vascular determina-
tion and sanguineous exhalation. 3d. From the surface of the
hemorrhoidal tumours, especially those belonging to the second
and third varieties; and, 4th. From the rupture of varicose or
enlarged vessels. We may well doubt the fact of hemorrhage
from the surface of the tumours themselves; they bleed, owing
to compression and rupture of some of their own or immediately
contiguous vessels. When the discharge is a continuous stream
we may generally suppose it to come from the ruptured varicose
hemorrhoidal vein. I have already adverted to the perpendicular
course which the hemorrhoidal veins take from the anus up the
rectum, and to their being unprovided, for the most part, with
valves; and hence you must be well prepared to understand why
blood will escape in a full stream, and sometimes to a great and
alarming extent, in hemorrhage, from a rupture of one of these
veins when varicose or dilated.
The quantity of blood discharged during a hemorrhoidal parox-
ysm, at the different times when the patient goes to stool, will
vary with the kind of tumour, or according as it comes from the
latter or a ruptured vessel. It may not exceed a drachm or two, or it
may amount, at one time, to several pounds. It ought to be known,
that a person may lose several ounces of pure blood in the act of
defecation, without, at times, his being made conscious of the loss
by pain or uneasiness, either previous or subsequent to the dis-
charge. Sometimes, in place of feces, blood is passed at intervals
of a week, a month, or longer, to the amount of half a pint. In fact,
there is often no correspondence between the size and number of
the hemorrhoidal tumours, or the irritation to which they give rise,
and the quantity of blood discharged. In many cases, the blood
flows for a short time only, and is not again seen until the next
attack. But, in others, it is observed repeatedly when the bowels
are acted upon, or the discharge is renewed when the feces are
expelled, for several days.
The colour of the blood is generally red, as coming from the
arterial capillaries, and it either covers or follows the fecal evacua-
tion ; but when it is consequent upon venous congestion or dilata-
tion, it is of a darker hue, and follows, or is partially mixed with
the feces.
A colourless hemorrhoidal discharge — mucous or serous hemor-
rhoids of some writers — sometimes takes place after, and as a
consequence of sanguineous discharge, or it may be associated
with the hemorrhoidal tumours of the third variety, or marisca.
The discharge varies much as to quantity and appearance. When
2S0
DISEASES OF THE DIGESTIVE SYSTEM.
watery, serous, or mucous, it usually exudes slightly from the anus;
when more albuminous and abundant, it is commonly passed at
stool. These varieties of colourless discharge, which may be
called anal leucorrhoea or blenorrhagia, are most frequent when
there is little or no hemorrhage, and when the disease is associated
with ascarides, or with pregnancy, and even leucorrhoea.
Causes. — Of the predisposing causes, hereditary constitution,
age, and excessive alimentation, are the chief ones. A predomi-
nance of the venous system, as in persons of a bilious and nervoso-
sanguine temperament and of a plethoric habit of body, like any
other peculiarity of an organic system, is transmissible from parent
to child, and by such means the tendency to hemorrhoids is inhe-
rited. In this way, alone, can we explain the appearance of the
disease in children, and in all the individuals of some families, al-
though of different constitutions, and differently exposed to the
common exciting causes. Hemorrhoids is most common in mature
age, when the abdominal viscera are in a state of the greatest
functional activity and of the fullest organic development. More
especially is the vascular system full and almost turgid at this
time; and hence any undue excitement of one part of it will
endanger afflux and congestion, which finds temporary relief in
hemorrhage. Excessive alimentation, by which I mean the use of
nutritive ingesta beyond the actual wants of the animal economy,
is a common predisposing cause of hemorrhoids. When the
system cannot relieve itself of the superabundant nutritive mate-
rials elaborated into blood, by the common depiiratories, as of
urine, sweat, and the pulmonary and intestinal secretions and ex-
cretions, the bloodvessels become necessarily loaded, and in a
more particular manner is the system of the vena portae slow and
sluggish, and its circulation liable at this time to be gorged
throughout all its ramifications. Animal food and fermented
liquors, and especially malt liquors, contribute more than other
substances to produce both the general and abdominal plethora
which predisposes to the disease in question. Their bad effects
will be not a little increased by indolence, sedentary habits, undue
time in bed, and irregular hours in general; all of which may be
regarded as additional predisposing causes to this, as they are to
another and more fatal hemorrhage, viz., apoplexy.
The influence of climate in the production of hemorrhoids is not
well ascertained. At first we might suppose that the disease
would be more common in hot climates; but the difference in
atmospherical heat in the latter is made up by the artificial in-door
heat in colder climates, which is often excessive, and also unequal,
and hence more apt to induce congestions in the system of the vena
portae. Partwl congestion and remora of the hemorrhoidal vessels
are also more readily brought on among the inhabitants of cooler cli-
mates by their warm clothing, indulging in warmer seats, cushions,
&c and preserving more the erect position, and being less attentive
to topical ablutions, than among the people of more genial regions,
HEMORRHOIDAL FLUX OR DISCHARGES. 331
who spend so much of their time in the open air, are loosely and
lightly clad, and for the sake of luxurious enjoyment have frequent
recourse to the bath and other fashions of personal ablution. Seasons
exert a modifying influence over hemorrhoids: those in which the
alternations of temperature are most abrupt and frequent, and the
circulation correspondingly affected, such as spring and autumn,
would seem to be the most unfavourable in this respect; but I have
seen the high heat of summer obviously induce large hemorrhoidal
discharges, when the bowels were constipated, more than a similar
condition of the latter would have effected with the body exposed
to a different temperature.
Some of the causes already mentioned as predisposing, viz., the
sitting posture, and above all, when this is retained for many hours
in succession or habitually on warm and soft cushions, full or rich
food, condiments, spices, and highly-seasoned dishes and intoxicating
beverages, are, at times, exciting causes. The same remark ap-
plies to inordinate excitement of the sexual organs, habitual con-
stipation, straight and tight corsets, and the use of irritating injec-
tions.
Hemorrhoids is liable to occur from any cause which prevents the
free return of blood by the hemorrhoidal veins, — as constipation, the
lodgement of hardened feces in the rectum or lower part of the colon,
and repeated efforts at evacuation; torpor, congestion, or structural
alterations of the liver, and obstructed circulation in any part of the
portal system, as from a gravid uterus pressing on the mesenteric
veins, diseased ovarium, and disease of the prostate or sphincter
ani. Among the exciting causes, we rank all agents by which the
rectum is irritated, as drastic purgatives, among which aloes is
more particularly supposed to offend in this way, worms, articles
used as emmenagogues; also the local influence of cold or of
warmth, the first operating by reactive or indirect, the latter by
direct excitement, — as sitting on the ground, or on stone seats or
damp cushions, and the habit of standing with the back to the fire,
or our more American fashion of being seated before it and the feet
raised and resting on the mantel-piece. Violent mental emotions,
either exciting or depressing, induce hemorrhoids, probably by the
pernicious influence which they exert over the liver and portal
system generally.
Great stress is always laid, by writers on this subject, on consti-
pation, as the chief cause of hemorrhoids; and there are undoubtedly
many cases which seem fully to justify the ascription. But I can-
not help thinking that its importance is overrated. Constipation
and hemorrhoidal predisposition are concomitants in persons of the
same temperament, and in whom similar causes are in operation
in the production of both. Hepatic obstructions and retardation ot
the portal circulation, by interfering with the secretion of bile, and
measurably also with intestinal secretions, prevent due stimulation
of the intestinal mucous surface, and in this way cause constipation.
Similar obstruction and retardation, and deficient intestinal secre-
24*
282
DISEASES OF THE DIGESTIVE SYSTEM.
tions, bygiving rise to congestion in the rectal vessels, will cause also
hemorrhoids. Constipation may indeed prove to be an occasionally
exciting cause; but of itself would have comparatively little effect
in "inducing hemorrhoids, without the predisposition developed under
the circumstances just mentioned. I believe that inquiry into the
history of the cases of hemorrhoids will fail to show their occurrence
and that of constipation as always coincident, even in the indivi-
duals suffering from the disease. In persons of a sluggish or lym-
phatic temperament, costiveness is common enough, but without
the accompaniment of hemorrhoids. In those of a sanguineo-
nervous temperament, on the other hand, in whom hemorrhoids
is quite common, constipation is not of corresponding frequency,
nor is the conjunction of the two a matter of general observa-
tion. I have frequently seen hemorrhoidal discharges to come on
with a loose state of the bowels; indeed I know that they appear
in some cases almost uniformly after looser and more frequent
fecal discharges than common; and that in these same cases
their appearance is relatively rare during a rather constipated
condition of bowels. The fact would seem to be, that the mo-
limen hemorrhoidale, congestion of the rectal vessels, determined
by the general causes already mentioned, requires often slight irri-
tation of the rectal mucous surface to give rise to sanguineous
discharge. Constipation bears about the same relation to hemor-
rhoids, as a cause, that picking or pinching violently the nose does
to epistaxis. It is one which ought certainly to be withheld, but
it can hardly be regarded of that paramount importance with
which most writers seem disposed to invest it, except as a trouble-
some accompaniment and an effect of imperfect and depraved
digestion.
Analogous reasoning may be brought to bear on the question of
purgatives inducing a predisposition to hemorrhoids, and proving,
also, an exciting cause of the disease. The chronically dyspeptic,
the hypochondriac and the melancholic, who suffer from costive-
ness and slow digestion, are habitually prone to the use of drastic
purgatives; and no doubt often aggravate their maladies, and
superinduce gastro-intestinal irritation if not inflammation by this
practice. But whilst we admit, that hemorrhoids is occasionally
one of the bad consequences of this hypercatharsis, we cannot be
blind to the fact, that the disease or series of disorders which pro-
voked to the use of purgatives, was precisely that which also
predisposed to hemorrhoids. Of the purgatives which are more
especially accused of bringing on this disease, aloes stands fore-
most, but, as I conceive, without adequate proof. It is the favourite
medicine, or basis, at least, of purgative preparations most in vogue
with the constipated, and hence has a larger share than other medi-
cines of the class in irritating the bowels. It has, indeed, we know, a
decided action on the pelvic viscera, and may be supposed to stimu-
late the hemorrhoidal vessels: but the proofs are not manifest that
its use is so much more mischievous than other purgative medicines,
CONSEQUENCES OF HEMORRHOIDS.
283
even of a milder kind. In persons whose pelvic circulation is con-
gested and the mucous surfaces irritable, any purgative stimulant
will suffice to bring on hemorrhoidal discharge. I am prevented,
in the case of some of my patients, from prescribing castor oil, on
account of their so generally having had an attack of piles when
they used it in former times ; nor is my experience peculiar in this
respect. Epsom and Glauber salts, I know, also, have repeatedly
brought on hemorrhoidal discharge, and in some cases for the
first time. In persons with irritable intestines, and especially
rectum, calcined magnesia has commonly the same effect. The
inference from all these facts is, that any stimulus to which the
digestive canal is unaccustomed, whether it be crude ingesta, the
remains of chyme not fully elaborated, or medicines, is peculiarly
liable to irritate the lower bowels, and of these the rectum most.
If at this time there be molimen hemorrhoid ale, blood will be
discharged under the irritation of the agents just mentioned; if
there be no disorder in the circulation, the patient will complain
of some heat and tormina, and have increased muco-fecal dejec-
tions.
The consequences and complications of hemorrhoids are both
local and constitutional; and merit notice, both as aiding us in our
diagnosis and giving to us a proper appreciation of the means of
cure and of their relative safety. Inflammation is a no uncommon
effect of piles; or ought we not to say, that the irritation by which
the afflux to the vessels, causing congestion, and to particular spots
of the mucous and cellular tissue of the rectum, causing tumour,
being continued, ends in inflammation if not prevented by hemor-
rhagic discharge. Mucous or sero-mucous secretion is not unusual
at this time. When the phlogosis is severe, it implicates not
merely the mucous membrane and subjacent cellular tissue, but
also, in a slighter degree, the prostate gland and neck of the blad-
der, occasioning much pain in the perineum, sacrum, &c, with
dysuria or even strangury. In females the uterus may become
sympathetically irritated in this way. Constipation is induced or
kept up by the tumefaction of the rectum and spasmodic constric-
tion of the sphincter; and straining and tenesmus are the consequence.
Not unfrequently the inflamed tumours, protruded by the expulsive
action of the intestine, become inflamed and very painful, and are
even sometimes strangulated, and slough. The general system
sympathises with the local irritation, and a variety of abnormal
sensations and even functional disorders, particularly of the diges-
tive system, are the consequence, — constituting, at the same time,
so many symptoms of hemorrhoids. Among these heaviness and
a feeling of fulness of the head are quite common. " In those who
have hemorrhoids from or associated with habitual constipation,
there will be weight and heat and a sense of fulness about the rec-
tum very constantly, an obscure tenesmus, frequent micturition from
sympathetic irritation of the bladder, and leucorrhoea from a simi-
lar irritation of the vagina and uterus; all of which are tempora-
284
DISEASES OF THE DIGESTIVE SYSTEM.
rilv alleviated by the discharge of blood, but are never entirely re-
moved, the cause remaining»-Dr. Burne (Cyclop. Pract. Med.,
SZ1t3heehst' of troublesome complications, and in degree conse-
quences of hemorrhoids, or of the irritation of parts to which they give
rise, are fissures or rhagades of the anus, ulceration or abscess fre-
quently passing into fistula, tenesmus, or spasmodic contraction of
the sphincter, frequently with protrusion of the mucous coat of the
rectum. Sometimes the protruded mucous membrane is girt so
tightly by the spasmodically contracted sphincter as to threaten
strangulation, and give rise to symptoms, such as tumid abdomen,
colics, borborygmi, nausea, and even vomiting, nearly similar to
those from strangulated hernia. A reverse state may obtain, and
after fissures the rectum becomes tumid and relaxed, allowing o
the ready escape of blood without defecation, and also the partial
escape of fecal matter, which is insinuated into the sides of the fis-
sures, or lodged in little sacs remaining after the hemorrhoidal
paroxysm, and forming stercoral abscess, or even stercoral fistula.
LECTURE XXIV.
DR. BELL.
Treatment of Hemorrhoids.—Relief afforded by hemorrhagic discharge.—Dis-
advantage of this natural method.-Measures, medicinal and hygienic, required
in a first attack of hemorrhoids.—Treatment of the fixed disease—Difference
between stopping and curing a disease—Attention to the general system, ana to
the removal of plethora and visceral disease—Sometimes active measures—
v s , leeching calomel, &c, required—To vary the treatment according to pre-
ceding or accompanying disease—Chronic variety—Balsams, turpentine, and
cubebs, useful.—Periodical hemorrhoids—treatment of—Precautions to avoid
an attack of the disease.—Hemorrhoids with anemia.—Extirpation of tumours
practised sometimes with advantage—Danger—Constitutional measures more
prudent.—Necessity of preparing the system for the operation of removal—Re-
stricted regimen afterwards—External and topical applications—washes, oint-
ments, injections, pads to cause pressure.—Remarkable case by M. Guyot—
Reasons for enlarging on the subject of hemorrhoids.— Ulceration of the rec-
tum—Two varieties—treatment of.—Prolapsus of the rectum—its peculiarities
and treatment.—Stricture of the rectum—Mistakes and malpractice respecting
this disease.—Spasmodic stricture—Fissures—Carcinoma of the rectum-
Treatment, palliative.—Neuralgia—Preternatural pouches or sacs.—Blenor-
rhagia—Pruritus Ani.
Treatment.__If we bear in mind the pathology of hemorrhoids,
and especially of the causes by which the disease is induced, and
of the symptoms preceding the hemorrhagic discharge, we cannot
fail to see in it a mode of relief, both to the general plethora which
had existed before a first attack, and to the abdominal plethora
with which hemorrhoids at all times is associated. The discharge
of blood relieves the congestion of the liver, bowels, and indeed
sometimes of the whole pelvic viscera, as epistaxis does that of the
brain, and hemoptysis that of the lungs. Nature does here that
which art, under similar circumstances, accomplishes by venesec-
TREATMENT OP HEMORRHOIDS. 285
tion, or leeching, or cupping; with the advantage in favour of the
former, that the bleeding was of imminent necessity and forced by
the state of the bloodvessels of the organ ; but with the drawback,
also, of a compulsory repetition of the discharge whenever the
organ becomes turgid and congested, without reference to the state
or wants of the general system. While, therefore, we may hail
with satisfaction the appearance of a hemorrhage which, like that
in hemorrhoids, not only relieves the organ more immediately
oppressed by congestion, and sometimes inflammation, but also a
more vital organ, as the brain, lungs, or liver, it does not follow that
we should desire this kind of evacuation to become habitual, sure,
as we are, that, like all frequently repeated or periodical sanguineous
emissions, it will either exhaust and bring on anemia, or keep up
the very plethora which it first manifestly relieved. If the hemor-
rhoidal discharge have occurred for the first time, under the opera-
tion of occasional causes, and be followed by removal of the local
congestion and inflammation, and of the general febrile excitement,
the physician has little to counsel on the score of immediate action.
His advice will be of a negative kind; viz., to avoid the admitted
causes, whether they be of a general or a local nature, and to
adopt a rather cooling regimen. But if the rectal irritation be
still considerable, and accompanied by a sense of weight, heat,
and pain in the sacral and lumbar regions, headache, and a quick
and somewhat resisting pulse, the better plan will be to carry
out the treatment as we would for inflammation of any other
organ. Not caring to leave to nature farther sanguineous evacua-
tions, we take the treatment in our own hands and draw blood
from the arm. By this means we reduce both general and local
excitement, and at the same time relieve the rectum by a kind
of derivation. Next, we prescribe remedies akin to venesection,
such as antimonials, cooling and acid drinks; and, if the symp-
toms of fulness in the portal system indicate it, we give calomel,
not simply as a purge, but as a means of relieving the congestion
of the intestinal mucous membrane, and perhaps, also, of the liver,
by procuring a free secretion from its muciparous glands, and, by
continuous sympathy, of bile also. The compound powder of jalap,
castor oil, or rhubarb and magnesia, may severally answer in a
mild case to open the bowels, or in a more severe one as a
sequence to calomel. Washes of cold water to the anus, sacrum,
and perineum, will be found refreshing and useful after purging;
and if there be not much obstruction by hemorrhoidal tumours at
the anus, or directly within the sphincter, cold water enemata may
be used with benefit. In some cases, from peculiarity of constitu-
tion, cold is illy borne, and tepid water may be substituted for cold,
both for enema and ablution. A recumbent or somewhat reclining
posture is to be enjoined on hair sofas or hair mattresses, with
just clothing enough to prevent a feeling of chilliness. The diet
should be quite simple; chiefly of well-dressed vegetables, ripe or
gtewed fruits, and all these, as well as the drinks, taken cold or
286
DISEASES OF THE DIGESTIVE SYSTEM.
nearlv so. By these means, due attention being paid to preserve a
soluble state of the bowels, without, however, much purging, the
local congestion and general excitement will be reduced and gradu-
ally disappear, and with them the disease. The more permanent
sta'te of plethora and other morbid predisposing causes can then be
abated at leisure by a regulated regimen and the occasional yet cau-
tious use of laxative and cooling medicines, and other remedies to
be hereafter mentioned. To many, perhaps to most persons, these
directions may seem to be needlessly particular and minute for a
disease which few think of anv great moment, and fewer still
care to be rid of on such conditions. But their professional
advisers ought to impress on their minds the fact, that, although
the hemorrhoidal flux is a means of relief of excessive fulness of
the general system, at any rate of the portal circulation, and at
the moment prevents much more alarming and even fatal disease,
yet that it is an evidence of an unhealthy state of the body,and, unless
this latter be removed, the flux may itself become a diseased habit,
which cannot be cut short without great danger. Make persons
who are attacked for the first time with hemorrhoids aware of the
real nature of the disease, of its causes, its probable complications
and effects, and of its augmentation until life becomes intolerable;
and then the risk of their being drawn, in despair, to submit to violent
and harsh measures for the removal of the local malady, at the
cost of suffering in some other more vital organ, perhaps of loss
of life itself. By placing the question before them in all its bearings,
strengthening, it may be, our advice by reference to the known suf-
ferings of their progenitors, or some other members of their families,
we may succeed in inducing them to submit to the requisite reme-
dies and restrictions for the present cure of the disease, before it
becomes habitual and in every way more complicated and difficult
of management.
Commonly, however, medical opinion and assistance are not
invoked for ihe cure or even relief of hemorrhoids until, by frequent
repetition, the disease has become aggravated by the amount of the
discharge, or the size and painful nature of the tumours. The
very idea of the hemorrhage being a salutary effort of nature for
the removal or abatement of a disease of a more vital or serious
kind than this one set up in its place, makes many slow to ask
for professional assistance; and they either allow the discharge to
take its course, and the tumours, if not too painful, to remain un-
touched ; or they are content to try some nostrum or domestic pre-
scription, or the favourite remedy of a friend, which he knows to be
efficacious because he has tried it for the last twenty years. We
have then, we will suppose, an established case of hemorrhoids ; one,
in fact, of some duration. What course shall we counsel? Much
will depend on a correct view of the subject, or the idea we attach
to the cure of a disease. Many confound the cure of a disease
with arresting the course of some of its leading or pathognomonic
symptoms: but the difference is great, in fact of vast importance, to
TREATMENT OF HEMORRHOIDS.
287
the welfare of the patient. Thus, we may break the concatenation of
morbid actions which constitutes intermittent fever, by preventing the
return of the paroxysm; but if, in so doing, we lea-ve or create gas-
tritis, as may be done by the administration of arsenic, the term cure
would be misapplied in such a case. So, also, if we have to do with
headache, associated with gastric disorder, although we may possibly,
by certain palliatives, relieve or for a time remove the former, yet if
the stomach be still disordered or its derangements increased by our
remedies, such as opium and narcotics, it would be mockery to say
that we had cured the disease. Now, in the case of hemorrhoids,
there is a series of disordered functional actions which have been
controlled, and at the same time partially relieved, by a hemorrhage,
from the vessels of the rectum, of more or less abundance, and fre-
quency or regularity of recurrence. Sometimes this hemorrhage
ends in a mucous secretion ; sometimes it is replaced by this latter.
There are, also, commonly associated with the hemorrhage, and,
remaining in the intervals between its recurrence, tumours of a
varicose or cellulo-vascular texture, which after a while acquire
something of the structure, as they assume the office, of secreting
glands.
If now the question be repeated — What course shall we counsel 1
The reply is — To cure the disease, but not to stop it; to carry off or
abate the general plethora; to diminish and remove the local con-
gestion, and so to alter the habit of the diseased parts that, divested
of the pabulum of blood for distending the rectal vessels and for
nourishing the tumours, and no longer by local excitement inviting
blood into their tissues, the merely local disease, the hemorrhoids,
will cease and gradually disappear with the removal of the causes
that gave origin and nutrition to them. The modification of treat-
ment will depend on the other morbid states and tendencies of the
patient, such as of gout, rheumatism, apoplexy, plethora or hepatitis,
and the degree of inflammation accompanying the hemorrhoids, and,
also, on the irritability of the intestinal canal, and particularly of the
lower bowels. During the violence of the hemorrhoidal paroxysm,
if the tumours be large and painful and the rectal irritation great,
with fever accompanying, we shall more promptly and efficaciously
relieve by venesection to an adequate extent — twelve to twenty
ounces — than by any other means. In a case of the disease, in a
female, before parturition, but which a few days after delivery
became greatly exasperated, and the tumour of which was very
voluminous, producing exquisite pain and great constitutional dis-
turbance, I drew twenty ounces of blood from the arm, directed
cooling washes to the tumours, had the bowels opened by calo-
mel, followed by castor oil, and in fine carried out the antiphlogistic
practice which I have already indicated as that adapted to a first at-
tack of hemorrhoids. The disease was entirely removed in this case,
Without any interruption being given to the lochiae or to the flow of
milk, nor was any inconvenience felt by my patient. I attended her in
two subsequent labours,but she wasnot,ineitherof them, troubled with
288
DISEASES OF THE DIGESTIVE SYSTEM.
hemorrhoids. Where the constitution is feeble or contraindications
exist to venesection,-leeches are recommended to be applied to the
tumours; but when this operation is required, it ought to be practised
in the vicinity of the tumours, by which they and the congested
mucous membrane will still be adequately relieved, without making
them the direct centre of painful afflux, causing serous effusion,
and keeping up enlargement for a while as great as that before
the application of the leeches. As a substitute for these latter, or
where a great aversion exists on the part of the patient to their being
applied, cups to the sacrum and adjoining portions of the pelvic
surface will often give early relief. They may advantageously,
in all cases in which we have any doubts about the efficacy of
venesection, be substituted for this latter ; and in some very severe
cases, in young and inflammatory subjects, they may still be re-
quired in addition to it. Laxatives, which, given at first, would
either have failed to operate, or would have increased the irrita-
tion of the rectum, will now, after bloodletting, exert a beneficial
effect. Calomel has been already mentioned as useful in rectal
hemorrhage ; it ought, also, to be the preferred medicine in rectal
irritation with painful hemorrhoidal tumours, accompanied by con-
stipation. Combined with rhubarb, or followed by castor oil,
rhubarb and magnesia, or infusion of senna with salts, it procures
the required evacuations and relieves the congested vessels by in-
creasing the intestinal secretions. A similar action may be kept up
in the sub-acute or chronic form of the disease by means of blue
mass with hyosciamus, and rhubarb or aloes. After the subsidence
of the acute form of the disease, which is characterised either by
hemorrhage or by painful tumours, or by both, we shall have
recourse to various medicines which are believed to be more espe-
cially useful in certain diseases that were replaced or reached
a critical termination by hemorrhoids. Thus, in a gouty habit,
we direct colchicum and magnesia, or the alkalies with bitters;
and in chronic hepatitis, the blue mass with extract of taraxacum,
and small doses of salines; in rheumatism, opium with tartar
emetic, and iodine with salines; in chronic cutaneous diseases,
laxatives, sulphur, sulphurous waters, iodine and sarsaparilla. In
all these diseases complicated with hemorrhoids, medicines which
act on the kidneys, such as nitrate of potassa, iodide of potassium,
colchicum and digitalis, &c, may be expected to manifest excellent
effects without irritating the digestive mucous surface as purgatives
would do. If the requisite facilities are at hand, the warm bath
may be used at the same time with considerable benefit, as one of
the means to equalise circulation and excitement, and to relieve the
disease by revulsion to the skin. If the hemorrhoidal tumours have
appeared in a case in which the constitution has not been injured
by former disease, such as gout, rheumatism, hepatic or cutaneous
diseases, or incipient phthisis, we may have recourse, after the gene-
ral treatment already recommended in the paroxysm, to coolinff
washes,-as cold water, solutions of sugarof lead and of sui?
TREATMENT OF HEMORRHOIDS.
259
phate of zinc respectively. In the more doubtful and mixed cases
it will be safer to trust to frequent ablutions of the parts with tepid
water.
The treatment of hemorrhoids conducted on these principles
will be found properly curative and safe: it is that to which we
would have recourse in other cases of hemorrhage with inflamma-
tory action, and is, of course, calculated to reduce or remove the
visceral disease from which danger might be apprehended by the
mere stoppage or suppression of the hemorrhoidal flux and repelling
of the tumours.
Guided by the same pathology, we shall know how to direct the
treatment in the more mixed and indeed more common forms of
hemorrhoidal attacks — occasionally discharges of blood with few
or no tumours, and these of small size, or tumours commonly indo-
lent but occasionally becoming painful; mucous or sanguineo-
mucous discharges, and irregularity of bowels, constipation being
the prevalent but not uniform derangement. Laxatives, with which
blue mass may often be combined, will be here more freely adminis-
tered than during the earlier period and acute form of the disease;
and, conjointly with their administration, the hygienic means for
obviating constipation, already mentioned in treating of colonic
dyspepsia, should be sedulously used. They are, fortunately, of such
a nature, — vegetables and fruits,—as that, while they meet the
present indication, they also contribute best to remove the plethora
and inflammatory condition whichgave predispositiontohemorrhoids.
Succeeding and alternating with laxatives we give terebinthinates
and balsams, and particularly the oil of turpentine and the balsam of
copaiba, and also cubebs, in doses respectively of from half a drachm
to a drachm of each, in an appropriate vehicle, two or three times
a day. For the turpentine a few spoonfuls of common gruel will
suffice. These are well adapted to constitutions shattered by other
diseases, such as gout or rheumatism, or exhausted by the conti-
nuance of the hemorrhoidal flux and the irritation of the hemor-
rhoidal tumours. They have been found to procure not only pre-
sent relief, but sometimes exemption for a length of time from the
disease ; and from their diffused action on the mucous membranes
generally, and also on the kidneys through the circulation, they are
salutary derivatives, of whose therapeutical operation in this case
we can have little or no apprehension. Their employment con-
stitutes still part of the curative treatment, and harmonises with
the views which I advocate in this lecture; — that we must aim at
the removal of the morbid condition of the viscus or viscera, and of
general or abdominal plethora, of which hemorrhoids is but a part
and an effect.
Even after hemorrhoids has been, as it were, established and be-
come a part of the series of functional movements of the system, or
returns habitually at stated intervals, and in so doing has replaced
violent headache and old cough, a gastro-enteritis or duodenal hepa-
titis, and might lay claim to be a salutary process, we need not be
vol. i.—25
290
DISEASES OF THE DIGESTIVE SYSTEM.
deterred from its removal if we act on the principles of true patho-
logy, as enforced in preceding remarks. It is safer, assuredly, to
place the patient beyond the contingency of fresh metastatic
change, by which, from accidental causes, or his own impatience
quickening empiricism into action, the hemorrhoids may disap-
pear and the original disease be brought on with complications and
renewed violence. We do this by the general and constitutional
treatment already laid down ; and advance, thereby, a step farther
than the existing dogma sanctions; so that, instead of a person
having the lighter and less dangerous of two diseases, he may pro-
cure exemption from both.
In the treatment of periodical hemorrhoids we must be governed
by the same principles with those that guide us in periodical diseases
generally, viz., 1, to abate the violence of the paroxysm and excessive
determination to the suffering viscus; and,2, so to change the state
of the system during the interval as to prevent the recurrence of the
paroxysm. We are less called on to practise venesection or analo-
gous depletion in this than in the irregular variety; although in
both we shall be greatly influenced in our practice by the habit of
the patient, and the more or less exhaustion caused by prior attacks
of the disease. One great means of preventing an accumulation of
blood in the rectal vessels, and of the general plethora by which
this is supported and foundation laid for a hemorrhage, will be to
keep up a regular and frequent secretory action from the whole
intestinal canal by laxatives, and a revulsive action to the skin and
muscles by the tepid bath and moderate exercise. The supply of
food, even of a bland kind, ought not to exceed the actual wants
of the economy. If the nutritive system have suffered, or a morbid
irritability induced by the length of the disease, or that of which
it takes the place, tonics come into requisition; and of these the
sulphate of quinia, as an antiperiodic, is every way entitled, between
the paroxysms, to the preference. In addition to the general bath,
or, whether it is used or not, ablution, with cool fresh water, of the
anus, perineum, and sacrum, every morning after rising, and of
sponging the part after a stool in the day, provided the body is not
perspiring, will be found one of the most efficacious as it is the
simplest and most readily attainable means of prevention. With
some few exceptions the practice ought to be enjoined in all hemor-
rhoidal subjects. Auxiliary to it is the use of a cold water enema,
which, if sufficient to evacuate the bowels at the same time that it
reduces excitement of the rectal mucous membrane and hemorrhoi-
dal vessels, fulfils a desirable twofold indication. I have not recom-
mended this remedy in an acute attack of hemorrhoids; for, although
in some cases of excessive hemorrhage it may be necessary, yet in
general the irritation, first by the introduction of the end of a
syringe or clyster-pipe, and secondly, by the distention of the
rectum by the fluid introduced, more than counterbalance the good
derived from it. Still more forcibly does this difficulty apply when
purgative enemata are administered; since, both by their ingredi-
TREATMENT OF HEMORRHOIDS. 291
ents and their bulk, they must necessarily irritate the rectum not a
little. The same objection does not apply to the use of a supposi-
tory of opium or hyosciamus, or belladonna, when the pain is great
during the efforts at stool.
Continuing the directions for treatment during the interval between
the attacks of periodical hemorrhoids, and in the main they are
applicable to that which elapses between the common or irregular
variety of the disease, we should enjoin on the patient to avoid
breathing hot air, being in hot rooms, seated on soft cushions, or
wearing clothes which press upon the anal and perineal regions, or
ligatures of any kind, which must, more or less, interfere with an
equable circulation and distribution of blood. Internal stimulants,
such as spices, condiments, and alcoholic drinks, are likewise to be
carefully eschewed; and that other more difficultly abstained from,
and, if possible, more pernicious excitement than intoxicating drinks,
the indulgence in strong emotions and contending passions.
So far I have treated of hemorrhoids as the effect of plethora
and morbid excitement, and in their progress associated with these
states of the system. But it is not always thus. The sanguineous
discharge, though not to any great extent, proves, by frequent
repetition, enfeebling and exhausting, arid brings on a state of
anemia. We are in some cases apprised by these effects on the
general health of the loss of blood, for sometimes there is no pre-
ceding pain or dulness, or tumour, even to indicate the mischief to
the patient himself; or from false modesty, in the case of a female,
the physician is not made acquainted with the existence of the
disease. Symptoms analogous to those of chlorosis are manifested
under these circumstances. " The patient looses flesh, and acquires
a remarkable paleness of complexion, which is afterwards exchanged
for a peculiar dingy-yellow hue, like that of imperfectly bleached
wax. The lips no longer possess their vermilion colour, but re-
semble those of a dead body; the tongue, too, has a blanched
appearance, very characteristic of the state induced by excessive
or continued depletion. These symptoms are attended with great
listlessness, or want of energy, both of body and mind, disturbed
sleep, irritability of temper, quick pulse, and headache, which is
generally increased by rising up more than by lying down. Palpi-
tation and pain in the region of the heart, and difficulty of breath-
ing, are also frequently induced by slight exertion or agitation of
any kind." Mr. Syme, from whose work on Diseases of the Rectum
I have taken this description of the effect of bleeding piles of long
standing, then proceeds to show, in opposition to the popular,
and still, as I conceive, well-grounded opinion, of the danger of
checking a habitual discharge like that of hemorrhoids, that the
disease may be stopped in cases with entire safety, " even when of
the longest standing and greatest extent." He gives the case of
a lady who had suffered for upwards of thirty years from hemor-
rhoids, which went on increasing, " until at length the bleeding,
which for seven or eight years had been very profuse, so affected
2.92
DISEASES OF THE DIGESTIVE SYSTEM.
the general health as to excite the serious alarm of her friends.
She exhibited, in an extreme degree, the peculiar aspect and other
symptoms of exhaustion caused by a continued drain of blood. But
very soon after the removal of the hemorrhoidal tumours, which
were large and numerous, so as to encircle the aperture of the
gut, she regained her strength, together with a healthy look ; and
though three years have now elapsed since the operation was pert
formed, she has not suffered any unpleasant symptoms from the
sudden suppression of her complaint."
Mr. Syme points out an error in diagnosis which is every now and
then committed,— by mistaking the disordered function of an im-
portant organ for the cause of hemorrhoids, when in fact it is the
effect. He adduces, in illustration of this advice, the case of a person
who was supposed to labour under disease of the heart, and whose
" waxy look, bloodless lips, and defective energy, together with
irregular action of the heart, certainly afforded considerable ground
for this opinion ; but Dr. Alexander discovered that there was an
internal hemorrhoid, which bled profusely every time the patient
went to stool, and I removed it," says Mr. Syme," with the effect
of quickly restoring him to health." In cases in which anemia of
this decided character is induced by the persistence of hemorrhoids,
we may suppose that the sanguineous discharge, like that in other
hemorrhages, particularly those called passive, in which the general
system is greatly enfeebled, may be properly enough stopped. But
when hemorrhoids have followed other diseases, and alternate with
and when coining on relieve them, then we have not the same
freedom in arresting the rectal disease by local means. It will be
safer to institute a general treatment, as we would in other hemor-
rhages of any great duration: and to give tonics, particularly the
chalybeates, at the same time that we guard against sudden ple-
thora, even in this case, and relieve the congested vessels of the
rectum by the regular use of laxatives, into the preparation of
which blue mass will enter. It is under such circumstances turpen-
tine and balsam copaiba have been successful. Counter-irritants
to the inside of the legs are also proper. In this way we may
succeed in imparting the requisite tone to the system, and at the
same time abate or carry off the local congestion, including the
hemorrhoidal tumours, without the risk which follows extirpation of
these latter, and of thus closing up entirely the sanguineous outlet.
But there is still greater risk in removing by a surgical operation
those hemorrhoidal tumours which do not bleed, nor are associated
with hemorrhage, but which discharge mucus or sero-mucus,
and which, in fact, have taken on regular secreting action, and
become, in a great measure, additional and supplementary organs.
They resemble old ulcers, or an issue in broken-down constitutions',
the drying up of which is perilous to the individual, to whose sys-
tem they have served so long as a kind of drain. Their removal
by surgical means, without prior preparation of the system, and
well enjoined rules of living, precautions to obviate local plethora
TREATMENT OF EXTERNAL HEMORRHOIDS. 293
or determination by the proper revulsives, and particularly laxa-
tives and the warm bath and pediluvia, cannot but be reprobated
as empirical and hazardous, tampering with the patient's health
and endangering his life. Where alarming consequences, such as
apoplectic seizure, asthma, incipient phthisis, convulsions, are threat-
ened after the removal of hemorrhoidal tumours, and the entire
drying up of hemorrhoidal flux, attempts have been made, with
more or less success, to establish an analogous congestion and
discharge, as by leeches to the anus, followed by irritating injec-
tions of turpentine, or rubbing tartar emetic ointment on the verge
of the anus and the lower margin of the rectum ; a blister to
the sacrum, to be kept running by some stimulating ointment; the
administration of aloes and calomel by the mouth, and the like.
The danger, after surgical operations for the removal of hemor-
rhoidal tumours of the kind just mentioned, will be greatly abated
by careful attention to regimen, and particularly to a diet as little
stimulating as possible consistent with the actual wants of nutri-
tion. Mere abstinence from animal food will not always meet the
requirements of such a case; it will be necessary to be restricted
even in the quantity of farinaceous food, which, as in the instance
of bread in abundance, when taken with milk, will induce in some
persons a morbidly full and plethoric habit, — particularly adverse
to the object proposed in instituting the regimenal course.
I have not pretended to lay down methodically the treatment
of external hemorrhoids, and more particularly of tumours, believ-
ing that if the means already indicated be adopted this will be of
relatively small moment. At the same time I must add, that ex-
ternal applications of an astringent or repelling kind, which, when
used alone, are either inefficient or injurious, may prove an aux-
iliary to the constitutional treatment worth attending to. In the
inflammatory stage of hemorrhoids in young subjects of a sanguine
temperament, after suitable depletion and the course which I have
mentioned, the applications will be of simple cold or tepid water,
and solutions of acetate of lead or sulphate of zinc. In the subse-
quent attacks, it is customary to apply either cooling washes of
this nature, or astringents, decoctions, or ointments, into which
galls enter and of which tannin is the active principle. It is very
important, as I think I have already recommended, that the anus
should be washed with cold water after each fecal evacuation; or
with yellow soap and water, as recommended by Mr. Mayo, before
the piles be returned, if they are internal. A more complete asper-
sion of the parts would be procured by injecting into the rectum
some cold or tepid water, with, on occasions, a few grains of sul-
phate of zinc dissolved in it, immediately after each defecation.
Advantage has occasionally been derived from pressure exerted on
external hemorrhoidal tumours, and those which are permanently
protruded, by means of a conical pad or piece of ivory, made to
slide along a bandage or handkerchief, passed between the nates,
and fastened to a cincture or belt worn round the loins, in the form
25*
29-1
DISEASES OF THE DIGESTIVE SYSTEM.
of a T bandage. " The pad may be provided with a concentric
wire spring, the more internal coils of which rise in a conical
form." Dr. Copland (op. cit.), who suggests this practice, describes,
also, a means of combining the internal with the external method
of imparting pressure, when the tumours are internal and protrude
at stool, dragging the mucous coat with them, or when they consist
chiefly of varicose veins. The instrument is that introduced by
Mr. Mackenzie ; being a metallic bougie, of an oval form with a
short slender neck, and a conical base to press upon the anus ex-
ternally : after being carefully introduced into the rectum, it may
be attached to the bandage and worn occasionally. It must be
obvious, however, that, unless the pressure be equally and uniformly
applied, it will heat and irritate the parts, and not only fail to
answer the purpose, but may aggravate the disease ; and hence the
necessity of making a suitable instrument, and neatly and accu-
rately adapting it to the parts. I know not how far back the
recommendation of pressure for the piles goes in English sur-
gery ; but, although mentioned in the first French Encyclopasdia
of Diderot and D'Alembert, it seems to have been forgotten by the
modern French surgeons, until it was introduced anew by M.
Guyot. The case that suggested its use to this gentleman, as he
details it in the Archives Ge'ne'rales, December, 1836, is of a very
interesting nature. The subject of the disease had been plagued
with internal soft piles for twenty-five or thirty years, which had
grown as large as a turkey-egg. At first they only escaped ex-
ternally by efforts at defecation; but they finally so dilated the
sphincter ani that they fell out while the patient was walking and
even when standing. He was forced, when in this position, to sup-
port or to push back the tumours with his hand. Every now and
then, after fatigue or a spontaneous fluxionary movement, the tu-
mours, to the number of ten or twelve, formed a lobulated ring,
the surface of which became red, inflamed, and exquisitely painful,
until relief was afforded by a copious hemorrhage. The patient
applied to his friend, the celebrated Delpech of Montpelier, for
relief; but the latter dissuaded him from submitting to an opera-
tion, either by excision or by ligature, and told him that compres-
sion by a suppository, such as the bougie internally, would only
irritate the surface of the tumour, and might bring on a cancerous
condition of the part. Dupuytren and other celebrated surgeons
of Paris gave him the same advice. He had mentioned to his
friend, M. Guyot, that in the midst of his greatest sufferings, when-
ever he could support his anus, either by his hand or in being
seated, he felt considerable relief; and, also, that after having
passed several days in a carriage on a journey, he could, to his
great astonishment, walk more freely than before, and without the
tumours coming down for some time. Acting on this information,
M. Guyot prepared a T bandage of leather; the posterior band
from the back becoming wider as it approached the os coccyx, so
as to serve for a support to a cushion of soft leather well padded,
ULCERATION OF THE RECTUM.
295
which occupied the space between the coccyx, scrotum, and the
two tuberosities of the ischium; and at the scrotum divided into
two slips, which, coming up by the groins, were attached to the
circular bandage round the trunk above the haunches. In the
middle of the cushion he sewed a hard ball, of the form of a hen s-
egg cut in two, lengthways, and so -fixed that the projecting or
central part should correspond with the end he applied to the anus.
M. Guyot, after having retained the hemorrhoidal tumours, applied
this bandage, and had the satisfaction of discovering that his patient
found no inconvenience whatever from it, but was able, at once, to
walk with perfect ease and comfort, and ever after was exempt
from hemorrhoids.
Among the minor but far from unimportant precautions dur-
ing a hemorrhoidal paroxysm, is for the patient to preserve the
recumbent or horizontal posture, and as much as possible during
defecation also, in order to diminish the chance of protrusion of
the tumours. It will be desirable to resist the second call in
the morning to go to stool, as this is often merely owing to the irri-
tation of the congested rectal mucous surface, or from blood in
small quantity which had escaped from the hemorrhoidal vessels
into the rectum, if this feeling be yielded to, expulsive efforts of
some force are made; and not only will the hemorrhoidal tumours,
if there be any, be protruded, but there will be discharge of blood
and eversion of the lower part of the gut, and often without any
or very slight expulsion of feces,
I have enlarged the more on the subject of hemorrhoids, because,
1, it is a common, and a troublesome, and a nasty disease; 2, it is
associated with many other important diseases; and its cure on this
account is not unattended with danger; and 3, the principles in-
volved in its pathology and treatment are analogous to those which
must guide us to correct views of hemorrhage in general,, and of
diseases maintained or induced by plethora.
Ulceration of the Rectum is chiefly confined to the mucous mem-
brane of the intestine. It is a common sequela of inflammation, as
in dysentery, and as such has already been spoken of when this dis-
ease was under consideration. In some cases the ulceration is pure-
ly local, and restricted to the rectum, which is kept in a state of
constant irritation, manifested by tenesmus, frequent discharges,
purulent or mucous, at other times feces with mucus and pus, and
sometimes a tinge of blood : at first there may be some fever, but
afterwards the pulse is not affected, and the skin is colder than
natural, thirst not great, and appetite as usual. This is a complaint
common enough to young children, in whom it will last for weeks
and even months, gradually disappearing, sometimes without any,
at least adequate, treatment. On occasions, we find within the
rectum, at a short distance above the anus, an ulcer, unconnected
with any other disease. The patient complains, says Mr. Colles
(op. cit., p. 156), that he observes his linen stained with a purulent
discharge, which often flows when he is not at stool; " on examina,-
096 DISEASES OF THE DIGESTIVE SYSTEM.
tion this will prove different from healthy pus, frequently contain-
ing an admixture of thin bloody fluid ; at times the quantity of dis-
charge is much lessened, and then the sufferings of the patient are
aggravated; but on the flowing off of a larger quantity he experi-
ences great relief; he suffers sharp pain on going to stool, and this
continues for an hour or two. On examination, the finger soon dis-
covers the seat of the disease, which at first feels rather raised and
rather rough, but by pressing the finger firmly on this spot the
point sinks into a small hollow cup of an ulcer, the edges of which
are found in some degree hardened. We may obtain a satisfactory
view of the ulcer by passing upon the finger a blunt polished
gorget, the cavity of which is to look towards the seat of the dis-
ease ; then, by everting the anus as much as we can, we shall
obtain a full view of the ulcer, by the light reflected from the gor-
get." A speculum will be found more convenient for procuring
the requisite exposure of the ulcer.
The treatment of ulceration of the rectum will consist in the
administration of mild laxatives and enemata, alternating with the
balsams and terebinthinates; the latter of which may be adminis-
tered occasionally by injection. Topically, in this way, we use solu-
tions of sulphate of zinc or of copper, and, what is perhaps preferable
to either, of nitrate of silver. The single ulcer described by Mr.
Colles will be touched, if we can reach it, with nitrate of silver or
sulphate of copper, or some stimulating ointment, as of chloride of
lime, red precipitate, &c, applied to the part, and retained for a
while by a dossil of lint. Spasmodic irritation of the sphincter,
which sometimes accompanies the ulceration, will be soothed by
belladonna ointment, or lotion of the liquor of the sub-acetate of
lead. In more intractable cases the remedy is in the domain of
surgery, and is thus described by Mr. Colles: —" To introduce into
the rectum a convex-edged scalpel, and make an incision through
the entire length of the ulcer, continuing it through the sphincter,
and dividing the verge of the anus ; as soon as this wound has got
into a state of suppuration, we should dress it and the ulcer with
some stimulating ointment, introduced on a dossil of lint. The cure
goes on without interruption, although it is rather tedious and slow
of healing. I need hardly add, that the final cicatrisation will be
promoted by the occasional application of nitrate of silver."
Prolapsus of the Rectum, or, as it is less accurately called, pro-
lapsus ani, is commonly believed to be more within the domain of
surgery than of medicine : but its prevention and treatment in most
cases depend on measures under the control of the physician, who
will generally be able, with suitable care, to prevent the extreme
measure of an operation. The disease consists in the descent of
the upper portion of the intestine, which becomes invaginated in
the lower part and protrudes beyond the anus. " It has been main-
tained by some, that the lower part of the rectum alone was con-
cerned in the formation of prolapsus, the protrusion of this appa-
rently fixed portion being accounted for by the relaxation of its
TREATMENT OF PROLAPSUS OF THE RECTUM. 297
coats. But this explanation does not agree with the anatomical
structure, the phenomena observed during reduction of the pro-
truded bowel within the sphincter, or the appearances which have
presented themselves in cases that terminated fatally." (Syme,
op. cit.) The disease is chiefly confined to children and old per-
sons. In the former the expulsive efforts to evacuate the bowels
are often violent, owing to the frequent sources of intestinal irrita-
tion, at the same time that, owing to the lesser curvature of the
sacrum and deficient resistance of the os coccygis and of the
attachments of the rectum to adjoining parts, there is less- resist-
ance offered by the intestine to these inordinate strainings. Fits
of crying cause also a violent contraction of the diaphragm and
abdominal muscles, and bring on, sometimes, prolapsus. In old
persons, with weakness of innervation there is corresponding
weakness of the muscular system, and one manifestation of this is
deficient energy of the sphincter ani, often connected with similar
feebleness of the pelvic viscera and lower extremities. At first the
prolapsed intestine is like a simple soft ring external to the anus,
but after frequent expulsions and aggravation of the disease it
assumes the appearance of a globular mass, several inches long,
of a red colour: by pressure of the sphincter, and impeded cir-
culation in consequence, it becomes of a deeper and almost livid
hue. When the patient has been long subject to prolapsus, the
lining membrane of the rectum to the extent of an inch or two is
rendered insensible, changes its appearance from exposure and
contact with external substances, and approaches in structure to
the common skin.
The treatment resolves itself into the means required for re-
placing the intestine, and those to which we should have recourse
for preventing a return of the complaint. For the successful per-
formance of the first, the posture of the patient is an important
consideration. He should be laid horizontally on his side or back,
with his pelvis raised, and the limbs bent on the pelvis, so as to
remove the weight of the abdominal viscera and relax the muscles
of the abdomen, which might otherwise oppose the descent of the
gut. The physician or surgeon " then grasps the tumour in his
hand, having previously lubricated its surface with oil, and gently
but steadily compressing its neck, while at the same time he urges
in the body of the swelling, gradually pushes the protruded parts
within the sphincter." It has seemed to me that more equable
pressure is exerted on the prolapsed intestine, by the interven-
tion of a soft and oiled napkin or even rag between the tumour
and the fingers which push it gently upwards and a little back-
wards; or, the two thumbs may be so applied to the end and a
little on each side that, by a moderate pressure upwards, and bein»
slightly inclined also to one another, the intestine will glide up-
wards and come within the sphincter. " There commonly remains,
however, some laxity of the integuments about and within the
canal; and, in order to insure that the last portions of the mucous
298
DISEASES OF THE DIGESTIVE SYSTEM.
membrane are returned within the orifice of the internal sphincter,
it is advisable to apply the thumbs or the two indices to the sides of
the anus, so as to press the skin inward, and then, by introducing
a well-oiled finger within the rectum, we may remove any folds or
irregularities that might otherwise keep the cellular tissue on the
stretch, or prove a source of irritation to the rectum. When the
tumour is very large, it cannot be returned by so simple a pro-
ceeding, and it becomes necessary to roll the prolapsed membrane
towards the orifice of the intestine in the middle of the tumour by
means of the fingers; thus gradually reducing the swelling by
returning, first, the portions last discharged. In extreme cases this
is often a task of great difficulty; and the inexperienced operator
should bear in mind the fact, that the membrane may be returned
within itself without entering the canal; or, in other words, that
the part of the tube which escapes last may be folded within the
portion which should line the lower part of the rectum without
pressing the sphincter ; and may thus increase the difficulty of
reduction, while the surgeon thinks that he is gaining ground.
The efforts at reduction should never be forcible or rough ; and
while the fingers are employed in involving the tube, it is often
proper to keep up a moderate general pressure on the tumour
with the palms of" the hands." (Dr. Reynell Coates, Am. Cyclo-
pedia of Med. and Surg., Art. Anus.) In quoting from this article
I must add, that I know not where else to refer you for so full,
able, and practical a description of the diseases of the anus and its
vicinity, viz., neuralgia, spasm, atony, wounds, prolapsus, inflam-
mation, Menorrhagia, organic stricture, tumours and ulcers, fissures,
preternatural pouches, abscess, and fistula.
Where the intestine has been long protruded and is much
swelled, it may be necessary to reduce its volume by leeches ap-
plied round the anus and cold applications to the tumour itself;
immediately after which attempts at reduction in the manner al-
ready indicated should be made.
The prevention of prolapsus will consist in an avoidance of the
exciting cause, and chiefly, in children, of intestinal irritation, in-
cluding that from ascarides : the bowels should be kept in a regular
state, alike exempt from constipation and purging. Astringent
washes and injections, in cases of great relaxation of the parts un-
accompanied by inflammation or fever, are sometimes serviceable;
but their use demands judgment. Mechanical supports, of the same
nature with those already recommended for hemorrhoidal tumours,
may be had recourse to, particularly when adults and old persons
are the sufferers. It is in this class of subjects with prolapsus of
the rectum, accompanied by relaxation of the sphincter and skin
round the anus, that the operations recommended and practised by
Dupuytren and Hey are found useful. By the removal of a few
folds of pendulous skin at the margin of the anus, the sphincter is
enabled to contract more completely, and a greater consolidation
of the tissues is procured, so that adequate resistance will be offered
STRICTURE OF THE RECTUM.
299
to the descent of the rectum, or the escape of fragments of feces or
portions of mucus through the anus, and one great source of irri-
tation is thereby removed. " The scissors, curved to one side,
prove," says Mr. Syme, " most convenient for effecting this ex-
cision, and should be directed from the circumference towards the
centre of the aperture. The folds of skin should be held tense by a
hook or forceps, and be removed from the distance of about an
inch and a half quite up to the mucous membrane, a small part of
which should be included in the incision."
Alteration, by injection and thickening, of the mucous membrane
of the rectum, and its descent and protrusion in adults, constitute
properly a variety of hemorrhoids, rather than a case of pro-
lapsus; and demand a different mode of treatment from this latter.
Hence, instead of astringents or any mechanical means of support,
we should endeavour to amend the morbid state of the mucous mem-
brane of the rectum by local depletion, mild laxatives, enemata of
tepid water, and occasionally mercurial alteratives with hyoscia-
mus. If condylomata, or hard, white piles, prove a cause of irrita-
tion and straining, they should be removed.
Means should be taken, among the preventive measures of rectal
prolapsus, for the patient to avoid straining at stool; and with this
view, besides repeated injunctions to this effect, it will be proper
to require him to sit upon a chair so high as to prevent his feet from
reaching the ground, which will keep the trunk erect and moderate
the efforts at expulsion. Care should be taken, also, to prevent him
from being too long or too frequently at stool.
Stricture of the Rectum is, happily, not so common a disease as
bougie doctors and shallow surgeons persuade themselves, or try
to persuade their patients, is the case. There are two causes of
obstruction, besides real stricture, to introducing the finger or a
bougie up the rectum, which might impose on those who are igno-
rant of the anatomy of the intestine, but which, in fact, belong to its
healthy structure. The first of these is the lacunas, and folds or
valves, so well pointed out by Mr. Houston, (Dublin Hosp. Rep.,
vol. v.,) and the second, the angle made by the rectum within
about a distance varying from two to four inches of the anus,
and where, from following the curvature of the sacrum, it makes
a sudden turn outward to its termination.
As some inveterate bougie introducers, doubtless in ignorance,
adduce these natural obstructions to the passage of the finger or
bougie as really strictures, I will just repeat as much of Mr. Hous-
ton's description of the healthy folds of the rectum as will be neces-
sary to guard you against error yourselves or imposition on the
part of others. " The valves exist equally in the young and in the
aged, in the male and in the female; but in different individuals
there will be found some varieties as to their number and posi-
tion. Three is the average number, though sometimes four, and
sometimes two are present in a marked degree. The position of
the largest and most regular valve is about three inches from the
300
DISEASES OF THE DIGESTIVE SYSTEM.
anus, opposite to the base of the bladder. The fold of next most
frequent existence is placed at the upper end of the rectum. The
third in order occupies a position about midway between these;
and the fourth, or that more rarely present, is attached to the side
of the gut, about one inch above the anus." The form of the
valves is semilunar; in breadth, they are from half to three-quar-
ters of an inch, extending from one-third to one-half the circum-
ference of the gut; their structure is a duplicature of the mucous
membrane with some intermediate cellular tissue and a few mus-
cular fibres. The relative position of the valves is such, that the
one situated opposite to the base of the bladder most commonly
projects from the anterior wall of the gut; the valve next above
from the left; and the uppermost from the right wall. Confirma-
tory of this description, Mr. Colles, (op. cit. Rep., vol. v., p. 141-2,)
points out the fact, that in some patients who are free from all
symptoms of morbid condition of the rectum, the finger in ano can-
not discover any canal in the gut, the entire of its calibre above the
sphincter being filled up with soft folds of the lining membrane.
As respects the angle and consequent obstruction, in some cases
greater than in others, at the junction of the colon and rectum,
Mr. Colles does not think that the term stricture is ever applicable
to it.
If to these natural or anatomical obstacles to the ready in-
troduction of the finger into the rectum be added the spasmodic
constriction of the gut in irritable states of the intestine, when
attempts at exploration are made, you will be the less surprised,
though not the less pained, at the narratives of so much needless
suffering inflicted on patients labouring under constipation or
hemorrhoids and sometimes irritation of the neck of the bladder,
by their being subjected to the bougie practice. Mr. Colles, in the
work already mentioned, p. 147 — Mr. Syme (op. cit, Am. Edit.,
p. 35) — Dr. Burne (On Habitual Constipation, Am. Edit., p. 103)
give other examples of this pernicious meddling, which is severely
commented on by all intelligent surgeons.
Stricture is commonly the consequence of inflammation, but it is
sometimes spasmodic or functional, and felt only when the patient
is in a particular posture or straining. Dr. Bushe (A Treatise on
Malformations, Injuries and Diseases of the Rectum) tells us that
he has examined four cases of stricture of the rectum after death
which had not caused any disease in the surrounding parts. " In
one, the lesion seemed to be confined to the muscular tunic and
cellular tissue; in another, to the cellular tissue alone; and in two,
to the mucous coat and cellular tissue. The alteration of structure
seemed to depend upon the deposition of lymph, which gave to the
parts more or less hardness. The extent of the stricture varied
from one-quarter to one inch, occupying the entire circumference
of the gut, but in two cases, while in one it scarcely passed half
around it." Any long continued irritation at the extremity of the
intestine, with straining to evacuate its contents, injury by the pas-
TREATMENT OF STRICTURE OF THE RECTUM. 301
sage or lodgement of indurated feces or foreign bodies, as fruit-
stones, seeds, bones, &c.; injury during parturition, as well as by
common inflammation in any way produced, will be occasional
causes of strictured rectum.
Stricture of the rectum makes its approach slowly and insidi-
ously ; difficulty in discharging the bowels being a common,
though not a fixed symptom, until the disease is established. In its
advanced stage, a diagnostic symptom is the frequent squirting
out of thin feculent matters, containing no solid matters, or only
very small ones, and mixed with blood or mucus, accompanied by
a sensation of cutting or burning in the rectum. "In addition to
this," continues Mr. Syme, " the abdomen is distended partly by
retention of its feculent contents, partly by tympanitic swelling
caused by derangement of the bowels. Pain also is felt in the
sacrum, extending down the limbs; and abscesses frequently
form in the vicinity, so as to lay the foundation for fistula in ano."
The disease is more frequent in females than in males. Extreme
emaciation and hectic irritation are induced by the prolonged con-
tinuance of the disease, which, after attaining a certain height, seems
to remain stationary.
The treatment of stricture of the rectum is divided into two
parts,— the general and topical: the first, by medicines ; the second,
by surgical means, and of these the chief is a bougie; sometimes,
though rarely, the knife or bistoury to cut the stricture. These two
parts ought to be carried on simultaneously, but with a leaning in
favour of constitutional treatment, by which the bowels are to be kept
regular, and impactions of feces in the colon prevented; the digestive
function in general improved; and absorption made active by a
regulated and somewhat reduced regimen and appropriate altera-
tives; blue mass with hyosciamus; cicuta; salines to procure
semiliquid discharges; iodine with sarsaparilla ; arsenical solution,
but with great reserve, and watching its effects on the stomach.
If not positively contraindicated by the feebleness of the patient,
evacuation and derivation may be usefully practised by the appli-
cation of a few leeches, from time to time, to the anus ; or cups to
the lower part of the sacrum, and afterwards permanent counter-
irritation kept up by a small blister, tartar emetic ointment, or cro-
ton oil.
The bougie, by effecting pressure, excites the absorbents to a
removal of the effusion and morbid deposit in the cellular tissue: but
if it is retained too long, or too often repeated, or of too great diame-
ter, there will be danger of passing the point of absorbent excite-
ment, and of irritating the parts so as to produce fresh deposit.
Experience now happily proves that, instead of the bougie being
required to be introduced daily and to remain in for hours, suffi-
cient excitement is caused by the instrument being used every third
or fourth day, and withdrawn in a few minutes after being passed
through the stricture. Mr. Liston (Practical Surgery, p. 437, Am.
Edit.) thinks, that the bougie is more conveniently retained, when
vol. 1.—26
302 DISEASES OF THE DIGESTIVE SYSTEM.
it is of such a form and length as to be received entirely within
the sphincter." Stricture often takes place at the upper margin of
the internal sphincter, and its treatment is identical with that higher
up the rectum. Rectum bougies are constructed of various mate-
rials ; the best is gum-elastic. The physician or surgeon, having
satisfied himself by the introduction of his finger into the rectum
of the seat of the stricture, passes a bougie, lubricated with oil or
lard, up to the obstruction, and endeavours, but without violence, to
carry it past this. Failing to do so, he tries a smaller bougie, until
he gets one to pass through the contracted part, and almost imme-
diately after withdraws it. The patient is to be on his side lying
in bed ; the bladder should be emptied and the rectum cleaned out
previously. Mr. Colles (op. cit.) does not believe that a perfect
cure of organic stricture of the rectum has been effected by any
plan of treatment hitherto employed.
Spasmodic Stricture of the Rectum, or, more appropriately, we
ought to call it, spasmodic stricture of the anus, is usually accom-
panied with much pain, and fissures and ulcerations between the
folds of the anus. The bowels are evacuated with difficulty and.
pain; which latter does not come on until after a stool,and is very
severe for an hour or two; sitting is uncomfortable, unless the body
rests on one hip, so as to protect the anus from pressure; there is
an unpleasant sensation of fulness in the perinaeum, with heat in the
urethra, frequent desire to make water, or other symptoms of irri-
table bladder. The anus, continues Mr. Syme, instead of pre-
senting its ordinary conical appearance, looks flat when examined,
and hardly presents any trace of the orifice, owing to the inor-
dinate contraction of the external sphincter muscle. " If the finger
be introduced, which is not accomplished without great pain and
difficulty, every attempt to examine the gut causing excessive dis-
tress, not only at the time, but for hours afterwards, it feels much
more strongly compressed than usual. And when the nates are
held aside, so as to bring the lining membrane of the anus Into
view, one or more ulcerated fissures are occasionally observed
between its folds." This morbid state is often associated with
hemorrhoids, and not unfrequently results from constipation. The
pains, as Copland very truly tells us, sometimes extend down to
the feet and ankles, and even occasionally assume a neuralgic cha-
racter in these or other parts of the lower extremities; or give rise
to spasm in various parts, especially in nervous and hysterical
females. Whatever tends to irritate the rectum, increases the
patient's sufferings. Thus, introducing the finger, or foreign bodies
of any kind, within the anus; forcibly expelling indurated matters
from the bowels; using stimulating articles of food or drink, and
remaining long in a sitting posture, are observed to be hurtful.
The treatment is here both medical and surgical. If the first be
patiently and perseveringly carried out, the latter may often be
dispensed with. With this view the bowels should be kept open
by laxatives and emollient enemata. Montegre advises the as-
SPASMODIC STRICTURE OF THE RECTUM. 303
cending douche or the application in a stream,'with some force, of
cold water against the anus, and cold water injections. (Des He-
morroides ou Traite" Analytique, Sec.) In order to render the
evacuation more easy, the injection should be thrown up when the
patient feels an inclination to go to stool. Careful ablution of the
affected parts is to be practised ; and washes of the liquor plumbi
diacetatis, (Goulard's extract,) alternating with ointment of the
extract of hyosciamus, or of belladonna or stramonium, directed to
be applied to the anus; or a suppository of one of these narcotic
preparations, or of opium, may be occasionally introduced into the
rectum, with the effect generally of giving relief. Dr. Copland,
when advising these remedies, properly enjoins caution in the ad-
ministration of narcotic injections, which are often rapidly absorbed
from the colon and rectum; he has known half a grain of bella-
donna in one case and thirty drops of laudanum in another pro-
duce the most serious effects. The same objections do not apply
to their use in ointment, pomade, or suppository. In additionto
these means we have recourse to that rational alterative treatment
recommended in case of organic stricture of the rectum, and
which, if continued for a suitable period in the present disease, will
carry it off, as it would ulceration with chaps and neuralgic
pains in other parts of the body.
Fissures of the anus are not always associated with spasmodic
stricture, nor stricture of any kind, although they are frequent
accompaniments of iL By Boyer they were regarded as an effect
and complication of anal structure. Of late years a very import-
ant addition to our Armamsenarium Medicaminumin the treatment
of this disease, is the introduction of rhatany (Krameria). Its use
was suggested to M. Bretonneau on apparently sound physiological
principles. Constipation he regarded as thechief cause of the fissures,
and of course as the great obstacle to their cure. Now, constipation
is often productive of a dilatation of the rectum above the sphincter,
in which the feces accumulate, and the more so the weaker and less
resisting the rectal coats; so that, when, at last, the patient goes to
stool, and tries to relieve himself of the enormous accumulation, he
suffers pains little short of those of childbearing,—in fact, more than
some women experience in this act. It occurred, therefore, to M.
Bretonneau, that in order to overcome obstinate constipation, whether
it is accompanied by fissures or not, it is necessary to restore
tone to the dilated and weakened intestine. Practising on this view,
he directed, in a case of constipation with fissure, an enema made
of the extract of rhatany root with water, and the addition of a
little alcoholic tincture of the same medicine. Success crowned
his expectations; and the like results followed this treatment in
other cases. Even in cases of fissure in which constipation was
not present, the use of the rhatany was successful. The facts in
the latter category are as clearly established as the others; but do
not rest on the same physiological basis: nor can we suppose that
the hypothesis which pointed originally to the practice is tenable.
304
DISEASES OF THE DIGESTIVE SYSTEM.
Since then, several French surgeons and physicians have been equally
successful in the use of rhatany for the cure of fissures'; and I feel
myself justified in recommending this medicine strongly to your
attention in this troublesome and hitherto often unmanageable
malady. The mode of employing it is thus described by MM.
Trousseau and Pidoux (Traite de Therap. et de Mat. Med.,t. i.,
p. 119). The patient is to take every morning a mild mucilagi-
nous or oleaginous enema, so as to empty the lower intestine; half
an hour after this has been returned the following enema is given;
water, five or six ounces; extract of rhatany, a drachm and a quarter
to three drachms ; alcohol, half a fluid drachm. The patient will try
to retain this injection, and then take another of the same kind in
the evening. When the pains have entirely ceased, he need take
only one injection daily; and when there is reason to believe that
the cure is complete, one every other day for a fortnight. Equal
success in the hands of Drs. Johnson and Biddle, (Med. Exam., 1841,)
have attended the use of the rhatany in this country. Another
remedy of an analogous nature, and of recent introduction into
practice, the Monesia, has likewise been found to be an excellent
curative agent for fissures, when employed in the form of enema,
or of pomade to the fissures themselves.
With all these resources of a medical nature, which I have stated
to you, at our command, there will be less necessity for having
recourse to the use of the knife, as recommended by Boyer and
other surgeons, in order to cut through the sphincter, or even a part,
together with the lining membrane of the anus and subjacent cellu-
lar tissue, as directed by Mr. Syme. There is, however, a variety
of contraction of the anus, depending on the slow inflammation and
condensation of the cellular tissue round the anus, with fissure,
which may be the consequence sometimes of the excision of hemor-
rhoidal tumours; and which requires the use of the bougie, and
occasionally the cutting through the indurated ring. Caustic applied
to the fissure is recommended here, as it has been in the other
variety, or the spasmodic stricture, already spoken of.
Fistula in Ano is apt to follow stricture of the rectum, by abscess
forming at the side of the contraction, opening into the bowel above,
and occasionally it makes its way to the external surface also. I
refer to fistula just now, in order to enjoin caution in attempting
its radical cure in cases of incipient phthisis and recent insanity,
or where its appearance has evidently alleviated any serious vis-
ceral disease.
Carcinoma of the Rectum, like all carcinomatous affections, is a
harassing, painful, and seldom curable disease. It may consist
either of the schirrous tissue or encephaloid matter. Its chief seat
is the subcellular tissue of the bowel, which, being converted into
tumours of various size, project either externally into the muscular
tissue, or internally into the canal; and in the latter case are opposed
to the progress of the matters in the intestine. The muscular coat
is seldom implicated, except by distention and separation of its fibres;
CARCINOMA OF THE RECTUM.
305
sometimes into so many lobuli, as it were, by the morbid cellular
ramifications. It may, however, be atrophied by the increased
thickness and pressure of the cellular tissue, and even disappear by
absorption. The mucous membrane is sometimes intact in the
midst of the cancerous tumour; sometimes it exhibits the charac-
ters of a chronic inflammation, and after a while, by being ulcerated,
allows the cancerous structure to be seen through it: at other times,
the cancer begins with the mucous membrane, which,in consequence,
becomes covered with vegetations. Whatever may be the seat of
carcinoma,its termination is always in ulceration; and by gradual
extension inwardly it may, when higher up in the intestinal canal, per-
forate the peritoneum, or outwardly, and cause a fistulous opening
into the intestine. Occasionally the arteries are destroyed, and
hemorrhage follows : the nerves remain entire in the midst of the
morbid alteration of other parts. (Andral—Cours de Pathologie In-
terne.)
The causes of this disease are predisposing and exciting, or occa-
sional. The first is the most powerful, and depends on a particular
modification of the tissues, which we can neither explain nor,
when present, appreciate. Of the latter kind of causes, it is usual
to cite neglected or ill-treated hemorrhoids, any strong irritation, in
fact, of the intestine, prolapsus recti, &c.
The symptoms of carcinoma of the rectum, are pain in different
regions, morbid secretions, and sometimes hemorrhage. The seat
and degree of pain vary greatly: there is often only an itching or
peculiar sensation like that produced by worms, but after a time
this is converted into a true pain, which in some persons is only
felt when they are erect or long seated. It may be more or less
diffused; and it is common to find patients cease to complain of pains
in the rectum, and refer them to the hips, sacrum, and thighs.
The pain is aggravated by walking, standing, and defecation, and
especially after constipation. The secretion from the rectum is
sometimes white, sometimes reddish, and in some cases there is
real hemorrhage. As the disease advances, the fecal evacua-
tions become less and less frequent. Occasionally they resemble
fragments of vermicelli, and seem to have been spun out; in other
cases they are flat and ribbon-like, and have mixed with them glairy,
sanious, purulent, and sanguinolent matters. Sometimes the feces
find exit through fistulous orifices made by the cancerous ulcera-
tion, and they have been known to come from the vagina and
adjoining parts. A gradual and alarming wasting of flesh and
strength, and loss of all functional energy, now take place; and
this result is accelerated if some important organ, such as the
bladder, or the uterus, becomes implicated in the disease.
If the cancer is very low in the rectum it may be seen exter-
nally ; and if higher up in the intestine it may be felt by the finger,
by which we discover, at one time, a circular ring surrounding the
rectum, at another, abridged mucous membrane and agglomerated
projections.
2G*
306
DISEASES OF THE DIGESTIVE SYSTEM.
The treatment of this horrible disease is merely palliative, unless
the cancer be near the termination of the rectum so as to allow of
its excision; but even after the operation there will be great danger
of a return of the disease. The pain will be soothed by simple
enemata of tepid water, so as to keep the feces soft, and at the
same time to allay rectal irritation. This will be still better accom-
plished by suppositories or enemata of opium, and if there be stric-
ture, by the introduction of the extracts of belladonna or of stramo-
nium, in a fluid form, through a canula, or a projecting terminal
tube of a syringe carried past the obstruction. Bougies have been
used, but with very equivocal benefit. By the mouth, narcotics may
be administered conjoined with minute doses of corrosive sublimate
or arsenical solution. Washes of chloride of lime or of soda will
temporarily abate the cancerous ulceration and remove offensive
odours. Iodine, topically applied and administered internally, merits
a trial. The hip-bath is a soothing remedy. Recumbent posture
and a light yet nourishing diet are to be enjoined.
Sometimes bad ulcers and vegetations at the margin of the anus
have been confounded with cancer. Their cure may be brought
about by mercurials internally, and suitably stimulant applications,
among the best of which are nitrate of silver and sulphate of cop-
per externally.
Neuralgia of the rectum will occur as part of a similar disease
affecting other regions,— either remote, as the face, or contiguous
organs, as the neck of the bladder and the uterus. Of its associa-
tion with spasmodic stricture of the rectum and anus, and fissures,
I have already spoken. Where it is unattended by any organic
change, we must be content to treat it as we would neuralgia in
other parts; and to find, also, our success to be, as in the latter case,
very unequal. Sulphate of quinia, iron, opium, arsenic by the
mouth, and belladonna topically applied, have all been used, and
all have at times failed to relieve the sufferings of the patient. Some
have been benefited by dilatation of the anus by bougies; others
have derived no benefit from the remedy. There are certain gene-
ral rules, however, for our guidance "in all cases of neuralgia,
which are, of course, applicable to the present variety; viz., to
restore the digestive organs to a healthy state; to make a mild
and abiding impression on the system by vegetable and mineral
tonics — sulphate of quinia representing the first, and some pre-
paration of iron the second — associated with opium or sulphate of
morphia; a few leeches to the affected part, and vesication and
counter-irritation in its vicinity or of some one of the vertebra?: in
this case it might be at the junction of the last lumbar one with the
sacrum. Endermic medication, by the application of morphia and
belladonna to a denuded skin, might also be practised with advan-
tage; and likewise douches of warm or hot water from some
height along the whole course of the spine. Incision, carried
through the sphincter, was found, by Dr. Bushe, to give, in one case,
entire relief from pain and all the other troublesome symptoms.
PRETERNATURAL POUCHES, ETC., OF THE ANUS. 307
If we have reason to believe that the neuralgia of the intestine is
secondary to that of the bladder or uterus, or is dependent on dis-
ease of either of these organs, we shall of course address our reme-
dies to them primarily.
Preternatural Pouches or Cavities of the Anus deserve to be
noticed in this place, in connexion particularly with neuralgia of
the same part. The morbid condition of tissues constituting this
disease, was first clearly pointed out by Dr. Physick. The symp-
toms are thus described by Dr. Reynell Coates, in the article to
which I have before referred. " The patient makes little or per-
haps no complaint in the interval between the stools, but more
frequently he suffers a continued uneasiness about the anus, which
varies in character in different individuals. Some state that the
sensation is indescribable, but very uncomfortable; others compare
it to the crawling of an insect within the canal; whilst others
suffer an intolerable itching, sometimes sufficiently severe to produce
insomnolence and extreme distress. It is apt to be most severe at
night. One patient described the uneasiness to feel like the pressure
of a ton weight upon the anus. Pain is rarely felt except after a
stool, nor is it then present at every evacuation; several days may
pass over and several discharges may take place without material
exacerbation of the symptoms; yet at the next stool the pain may
be excruciating. The exacerbation does not precede the evacua-
tion, as it generally does in inflammatory affections of the anus; but
commonly follows after an interval of a few minutes; it is most
severe at its first attack, and gradually subsides and disappears in
a few hours. Dr. Physick has never observed it to be complicated
with spasm of the sphincter, as is the fissure of the anus. (See § 11.)
When the finger is introduced into the anus, it perceives no well-
defined tumour, and seldom any other marks of disease." p. 124,
op. cit. Dr. Physick used to explore the lower part of the canal by
means of a probe, with about half an inch of its extremity doubled
back upon itself so as to form a kind of hook. " If the uneasiness
and other symptoms are really occasioned by the presence of these
cavities, a little patience and perseverance in causing the probe to
advance and retreat along the canal, so as to bring the point to bear
successively on various parts of its circumference, will render their
existence and character sufficiently obvious. The reverted point
passes through a small orifice, and enters a cavity or hollow space,
of greater or less dimensions, situated immediately within or beneath
the integument; and it is sometimes so low as to become promi-
nent under the external skin around the margin of the anus. The
pouch is so exquisitely sensitive, that the presence of the instrument
gives acute suffering; and so much of its parietes as is formed
by the lining membrane of the canal is diaphanous, permitting the
silver to shine distinctly through."
" The mode of operating, devised by Dr. Physick, for the relief of
the complaint (one which has proved successful in every instance),
consists in drawing down the membranous covering of the cavity
308
DISEASES OF THE DIGESTIVE SYSTEM.
by means of a bent probe, and then removing the whole of this
portion, or as much of it as possible, by the scissors, taking care to
include the orifice by which the probe enters in the part excised.
The opposite surface is thus laid completely open to the anal canal."
Attention to the state of the bowels is requisite as in other cases of
rectal irritation.
I have the more willingly introduced a description of this disease
and the minor surgery by which it is cured, from my knowledge
of the real sufferings of the patients who are afflicted with it, and
of the shade which for a while rests on the tact and diagnostic
skill of the medical attendant who does not appreciate the real
cause of the distress. With a very little attention to the case, and
the commonest dexterity in the use of an instrument, a practitioner
in any section of the country is competent to the treatment of the pre-
ternatural pouches or cavities of the anus; and hence, he need not
send his patient to be placed under the care of city surgeons or
other professional celebrities.
Blenorrhagia, or mucous and muco-purulent discharges from the
anus sometimes are met with as resulting from the application of
gonorrhoeal matter to the anus, and on occasions without any spe-
cific cause. In the former case the inflammation runs high, and
demands recourse to vigorous antiphlogistic measures, and cooling
washes to the part. After this, the balsams, or the confectio piperis
nigri (Ward's paste), will be prescribed with salutary effect,—
followed by or alternating with injections of acetate of lead, sul-
phate of zinc, or nitrate of silver, in solution. Common mucous
discharge, although a frequent attendant on piles, is not necessarily
so, as it may be occasioned by ascarides or other irritating cause.
The expulsion of these worms when they are present will be the
first step; and should the discharge continue or arise from common
irritation of the mucous glands, the balsams and local applications,
as just advised in the other variety of the disease, will then come
advantageously into use. If, again, this discharge be the direct
sequence of inflammation of the anus, appropriate measures must
be taken for the removal of this morbid state before we attempt to
employ any remedy simply for the blenorrhagia.
Pruritus Ani.-^Itching of the anus proceeds from various causes:
in children and young persons it is induced by ascarides; in older
subjects by erythematic and pruriginous eruption, secretions from
the glands of the anus, and a deranged state of the intestines.
According to our knowledge of the cause will be the remedies which
we prescribe. Ascarides will be removed by aloetic and turpen-
tine enemata, and by calomel followed by castor oil and turpentine.
If costiveness and a depraved state of the bowels prevail, these are
to be corrected by appropriate treatment. The most troublesome
variety of pruritus ani is that dependent on cutaneous eruption,
either centred here, or alternating with a similar disease on other
parts of the surface. The treatment ought to be rational in all
cases — due attention being paid to placing the digestive functions
COLIC. 309
in order, regulating the diet of the patient by substituting one of
vegetable and milk for animal food; or, if this latter is still allowa-
ble, to discard spices and condiments, and all made dishes and
stimulating drinks, among which, in the present case, we must in-
clude coffee. The local remedies will be tepid ablution and emol-
lient fomentations. After these measures, which will often of them-
selves suffice for a removal of the disease, we may, if it still persist,
have recourse to the various alteratives,—mercurial, antimonial,
saline, sulphurous, or iodinic,—in alternation or combination; and
also occasionally drinks of vegetable dococtions, which experience
has ascertained to be serviceable in the eruption affecting other
parts of the cutaneous surface. At this period of the treatment
some astringent and stimulating applications may be of service;
such as infusion of oak-bark or of nut-galls, creosote, and an oint-
ment or a solution of nitrate of silver: a good purpose will be
answered by running a pencil of nitrate of silver lightly over the
affected skin.
LECTURE XXV.
DR. BELL.
Colic — Its chief divisions—Community of causes, and of many symptoms and
other pathological features of these varieties—Inference to guide us in the
treatment.—Simple Colic—Its seat, and diagnostic symptoms—Varieties of
simple colic—Treatment—Preliminary inquiries to be made—Remedies accord-
ing to the cause of colic—from cold, indigestible matters, or stercoraceous accu-
mulations—Carminatives—Enemata—Purgatives —Venesection — Cupping—
Liniments of narcotic substances—Oil of turpentine—Croton oil.—Infantile
Colic—Two varieties of—the stercoraceous and that from indigestible matters-
Modifications of treatment in consequence—Importance of attention to the diet
and health of the mother—Danger from habit of giving opium to children—
Periodical infantile colic.
In making colic the subject of the present lecture, I wish, in ad-
vance, to apprise you, that under this head I place simple or
common colic, including the nervous^ flatulent, and stercorace-
ous; bilious colic; colic of Madrid, or dry bellyache; ileus, and
painters' colic, or colica pictonum. As Dr. Stokes has treated of
the last, it remains for me to say something of the other kinds of
colic. They all have this much in common,—that there is great
exaltation of intestinal sensibility, with violent and unequal contrac-
tion and dilatation of portions of the intestinal canal, — pent up
flatus,and its occasional explosive discharge; constipation, and the
occasional occurrence of inflammation. Indigestible matters, or
other irritants to the digestive canal, combined with sudden chill
and suppression of perspiration, will suffice to bring on cases of
all the kinds of colic, even a return of the colica pictonum, or lead
colic, although this last must be traced to the deleterious operation
of lead in the first instance. By habituating yourselves to this gene-
310 DISEASES OF THE DIGESTIVE SYSTEM.
ral picture and community of symptoms and causes, you will the
more readily appreciate the propriety of a general sameness of
treatment, without, however, determinately avoiding some special-
ties called for by certain peculiarities of the case, — as in lead
colic. That which we ought to guard against is, making some of
the traits of the disease pass for the entire picture, and some of
the remedies frequently employed const'4ute the whole of the cura-
tive treatment. Thus, in common flatulent colic, we give often,
and with advantage, carminatives, and fear little from inflammation;
but there are cases in which the phlogosis is going on insidiously
without any other premonition than this flatulency: and of course
carminatives being exciters are injurious. In bilious colic, the
discharge of bile and emptying the intestines will often suffice for
the relief of the patient; but perilous will be our mistake, if we
always rely on vomiting or purging, or even make them the chief
end of our therapeutical measures. In lead colic itself, in which
the nervous system is poisoned, we must not rely on antidotes or
means purely directed to neutralise the poison, to the exclusion of
remedies adapted to common inflammation. Spasm, or unequal and
violent contraction and dilatation of the muscular coat of the intes-
tines, in which, in most of the kinds of colic, the voluntary muscles
also participate, generally requires at once opium in full doses to
allay the morbid excitement of the nerves on which the irregular
muscular action depends.. But this will only be a step towards a
cure, if crude matters remain in the stomach or compacted feces
in the great intestine, or morbid secretions and chymous residue
choke up the duodenum, or inflammation has seized some portion
of the intestinal canal.
Simple Colic— The origin of the word colic, from kuxov, implies
the belief entertained by the ancient writers of the seat of the dis-
ease. At the present time we give a much more extended or
rather diversified location to colic; but I should still be inclined so
far to respect the opinion of antiquity, as to believe that colic of all
kinds is, at one stage or another of its duration, marked by the
evolution and irregular escape of flatus, and that this chiefly comes
from the colon. I know that air is extricated in the process of
digestion in all parts of the digestive canal, and that every now
and then such evolution taking place in the stomach is a source of
much disturbance and pain before it is expelled. But, extrication
of gas, the product of secretion, I regard as one of the diagnostic
symptoms of colic, most evident in the simple kind, but met with, more
or less, in all; nor can I believe it to be merely the air commonly
present in the gastro-intestinal cavity, and retained by more or less
weakness and distention of the muscular coat in parts of the cavitv.
With some writers pain and the morbid state of the nerves supply-
ing the intestines on which it depends, are regarded as the chief
characteristics of colic, and hence they designate it as an enteralgia.
But this, it seems to me, is quite too restricted a view, as is that
other which would make it consist in a lesion of contractility. To
SIMPLE COLIC.
311
a certain extent both these errors are committed by M. Andral in
his Internal Pathology (op. cit.), where, under the head of Order I,
Neuroses of the Digestive Tube characterised by a Lesion of Con-
tractility, he introduces the second species, or that in the intestines,
and its genera as equivalent to so many colics, including, in the
fourth genus, ileus itself: and under Order II, or Neuroses marked
by a Lesion of Sensibility, he places, after gastralgia and various
enteralgias, including the saturnine or colica pictonum, colic from
copper, the colic of Madrid, vegetable colic, and nervous colic.
Were I to define colic, I should say, that it is a disease of some
portion of the gastro-intestinal canal, in which there is morbid
sensibility and contractility with morbid secretion, commonly that
of air; and manifested by acute pain, rolling and twisting, alternating
with flatulent distention and spasmodic contractions of the bowels,
and often of the abdominal muscles; with sometimes vomiting, and
almost always constipation. The locomotive muscles are some-
times contracted«painfuHy and irregularly at the same time. In sim-
ple colic, the chief but not the sole derangement is nervous, the result
of morbid excitement of some part of this system by any gross irri-
tant, viz., food in the stomach, and sometimes in the small intestine;
in which last the hepatic and pancreatic secretions are now and
then additional irritants; and feces and remains of ingesta unchanged
in the colon. An unaccustomed stimulus will sometimes alone
bring on colic in a healthy person, as when it follows the taking of
unripe fruit, crude vegetables, and certain meats: but when the
disease recurs frequently and after slight exciting causes, we must
suppose that a predisposition is induced, as by cold and wet feet, or
obstructed perspiration, deteriorated state of the digestive organs
by the use of ardent spirits, wines, or mixed acescent liquors; in
females by the period of menstruation, &c.
I have said that the chief but not the sole derangement in simple
colic is that of some part of the nervous system; but, as already
intimated, I consider the disease to be something more than mere
enteralgia. You will see a patient with the latter disease suffering
often acutely, but without spasm and the extrication or escape -of
flatus, which occur in colic. Not only then is there a lesion in the
nerves of sensation and motion, but likewise of secretion, in this latter
disease. Still, the predominance of the nervous element, and the
absence generally of inflammation in colic, are evinced in the cir-
cumstance of pressure being not only tolerated but almost instinc-
tively sought for by the patient; and this is a peculiarity which
distinguishes this disease, as indeed it also does enteralgia, from
gastro-enteritis and enteritis. Another diagnostic sign is the little
change in the pulse, as regards frequency; whereas in enteritis it is
greatly accelerated.
The varieties of common colic laid down by some writers, — viz.,
the nervous, the flatulent, and the spasmodic, are neither useful nor
instructive; for every colic is nervous, and flatulent, and spasmodic,
if these terms are intended to apply to the systems —the intestinal,
312
DISEASES OF THE DIGESTIVE SYSTEM.
nervous, and muscular — which are affected, or to the symptoms.
But if by nervous we mean to designate the temperament, as well
as some of the exciting causes, and the symptoms in remote organs
manifesting disorder of innervation, less objection can be found to
the use of the word. In females, and in persons leading a studious
or sedentary life, and whose temperament is nervous or irritable,
and habit of bowels costive, a slight error in regimen, exposure to
cold, and often very strong mental emotion, will bring on an attack
of colic; in which, besides pain, spasm, borborygmi, and escape of
flatus upwards or downwards, and sometimes both ways, there is
a pale and anxious expression of the face, cold sweat, and a sinking
and loss of strength almost to fainting away.
Colic has been subdivided into numerous varieties, according to its
presumed obvious and material exciting cause; and in this way we
read of the colica cibaria, c. conslipata, c. constrictiva, of Good, and
colique vegetale of Chomel and other French writers. A knowledge
of the immediate cause will be useful to us in treating the disease,
but will hardly justify our swelling the nosological catalogue, in
consequence, by new names. Of the propriety of the term bilious
colic I shall soon take occasion to speak.
Treatment.—When called to a case of colic our diagnosis should
be as complete as possible. First, we are to ascertain whether it
is merely symptomatic of disease of some other organ than the
gastro-intestinal canal; sometimes inflamed kidney, distended blad-
der, irritated or impregnated uterus, or congested liver, will give
rise to colic. Second, we are to inquire, particularly if there is
vomiting and intense and continued pain, and the constipation has
been of long duration, into the previous history of the patient, or
whether he has had hernia; and failing to be satisfied on this
head, we should make the requisite examination at the abdominal
ring, and in the inguinal and umbilical regions. Thirdly, we are
to learn whether any offending substance of an alimentary or other
nature has been swallowed for some hours preceding the attack.
Fourthly, what cause, either in exposure to cold and moisture, use
of alcoholic and acid drinks, menstrual period, or depressing pas-
sions, may have predisposed to an attack of the disease. Finally,
we ought, by careful observation of all the symptoms and palpation
of the abdomen, to try and determine the particular part of the in-
testinal canal which suffers most, and in which there is an obstruc-
tion by feces or other matter impacted in the intestine.
In slighter cases of colic, some aromatic water, as of mint, pep-
permint, ginger, cinnamon, dill, &c, a few drops, of essential oil of
these and kindred plants on sugar, forming an aeleo-saccharum,
or an essence made by solution of the oils in alcohol, will often
suffice to give relief, by discharging flatus and equalizing the action
of the muscular coat of the intestine. Persistent pain and spasm
with a cold skin will require from twenty to thirty and even sixty
drops of laudanum, with a little sugar and water, or combined with
some aromatic. In nervous and hysterical subjects, infusion of
STERCORACEOUS COLIC.
313
valerian, mixture of assafoetida, oil of turpentine, and some of the
balsams, are indicated. Enemata of a similar nature are sometimes
called for, where the distress through flatus in the lower bowels is
considerable, especially if constipation have preceded the attack.
The effect of all these substances will be increased by warm bodies,
as of hot bricks, bottles filled with hot water, &c, applied to the
feet and legs, warm flannel to the abdomen, or, preferably to all
of these, immersion in a warm bath to the very limit of a hot one,
or at 98° Fahrenheit, for half an hour.
Colic from indigestible or indigested food, and accompanied
with pain at the stomach and nausea or slight inclination to vomit,
will be benefited by evacuating this viscus of its contents. The
patient should be encouraged to drink freely of tepid water, or
salt and water; or ten to fifteen grains of ipecacuanha may
be administered in a little water. I very early in my medical
noviciate learned a lesson touching the value of an emetic in
colica cibaria, as Dr. Good would call it. The case was of a stout
butcher, to whom, in the absence of my preceptor, I was required
to administer relief. I gave him essence of peppermint, and mint
tea, and hartshorn and laudanum, in succession, but without any
notable mitigation of his disease, until, happily, owing either to the
irritation from the admixture of my medicines, or to that> from the
offending food which he had eaten a few hours before for dinner, he
vomited up the latter. The consequence of this evacuation was
immediate and entire relief. In colic from excessive repletion, or
from substances not readily changed in the stomach, but which
irritate the nerves of the mucous coat of the whole digestive canal
in their passage downwards, after pain in the upper bowels and
efforts to vomit, there succeed colic in the large intestine, and purging,
by which the offending cause is more or less completely carried
away and the disease removed. It will generally be prudent,
however, after an attack of this nature, to administer a laxative,
such as castor oil, with some carminative, or rhubarb and magnesia
with a few grains of ginger; its operation to be aided by diluents —
barley or rice water, or gruel and the like. When the stomach
is irritable or the taste very fastidious, a calomel pill of ten grains,
followed by magnesia or a Seidlitz powder, or cold infusion of
senna, will be preferred to the castor oil or rhubarb.
Stercoraceous Colic.— In other cases, the sustaining, if not actually
exciting, cause of colic is in the colon, and consists of hardened feces,
or sometimes of intestinal concretions. We have at this time a col-
lection of symptoms, some of which are indicative of a paroxysm of
atonic colonic dyspepsia, others manifesting a state of things very ana-
logous to stercoral inflammation of the caecum,—described informer
lectures (pp. 24(5, 265). In some tolerably thin subjects we can assure
ourselves of the direct cause of this malady by feeling the indurated
matter in the colon, particularly at its arch and in each iliac region,
through the abdominal integuments. In this variety of colic there is
less distention of the bowels and irregular puffiness in any part of the
vol. i.—21
314
DISEASES OF THE DIGESTIVE SYSTEM.
abdomen; and the pain, which is referrible to the colon and between
the iliac region and the umbilicus, is more fixed than in the flatulent
colic. More complaint is made of pain in one of the kidneys and
of the scanty discharge of urine, which is high coloured and some-
times quite offensive. The stomach is irritable at intervals, and
occasionally vomiting of green matter is met with; the pulse is not
increased in frequency, sometimes it is slower than natural, but at
the same time rather full, and often quite hard and resisting; the
tongue is white and moist.
The indication of cure in this variety of colic is— 1, to procure
the evacuation of the impacted feces ; and, 2, to prevent their undue
accumulation. But the means are not as simple nor as easy of
operation as this announcement might seem to imply. Often we
have to combat more than mere atony or enfeebled contractility of
the intestinal muscles, — one evidence of which, Dr. Abercrombie
thinks, is the undue dilatation of some part or parts of the canal.
Were this all, we need only to give purgatives, with a view to
stimulate the bowels to increased contraction in order to enable
them to expel their contents; but there is not unfrequently asso-
ciated with the constipation and distention from flatus a spasmodic
contraction of parts of the canal, which requires other remedies.
Of these the chief ones are bloodletting, more generally from the
arm, sometimes by cups or leeches to the iliac or other region of
the abdomen, and opium.
If the stomach tolerates the medicine we may properly begin the
treatment of stercoraceous colic with the administration of castor
oil, given with some aromatic water, and its operation to be quick-
ened and aided by common purgative enemata, such as infusion of
salts and senna, or castor oil mixed with gruel and melasses.
Much flatus and distention being present, an assafoetida mixture, or,
in less quantity, the tincture, will be added advantageously to the
purgative enema. An active combination for this purpose is castor
oil, ^ii.; oil of turpentine §ss.; gruel or flaxseed mucilage, one pint;
tincture of assafoetida, two drachms; or mixture of this medicine,
^i. Sometimes, after the rectum is evacuated, we are unsuccess-
ful in procuring the farther discharge of feces, owing to a spasmodic
stricture at the lower part of the colon or at its sigmoid flexure,
by which the passage downwards of wind and feces, and upwards
from the rectum of enemata, are alike prevented. In such a case
it will be necessary to have recourse to the expedients already
mentioned, when I spoke of enemata in caecal accumulations (Lect.
XXII., p. 242) and of the treatment of CEecitis (p. 265), particularly
in reference to the introduction of an elastic tube beyond the con-
stricted part of the colon, in order to allow of the escape of pent-
up gas, as well as of the introduction of enemata from a syringe
attached to the tube. A measure of this kind is still more called
for if the obstruction and colic be caused by strangulated intestine,
as in hernia. You will find in the lecture to which I have just
directed your attention, one passage that requires some explana-
STERCORACEOUS COLIC.
315
tions and qualifying remarks. It is that in which, after recom-
mending leeching of the part, tartar emetic by the mouth and
per anum, I add, " and finally, if need be, enemata of tobacco, as
used for hernia, and as successfully employed by Dr. O'Bierne in
dysentery." The question of the propriety of employing tobacco
in this disease is too important to be dismissed thus brief. In
favour of the practice we have, it is true, the opinion of very judi-
cious practitioners; but, on the other hand, the proofs of its alarm-
ing and, every now and then, fatal effects, are too clearly on record
to allow of our regarding it in the light of other means of treatment
— as one to be employed or withheld at pleasure. In all the forms
and stages of ileus, which is but a higher grade of colic, Dr. Aber-
crombie speaks of the tobacco-injection as the remedy which,
as far as his observation extends, is of most general utility. He
adds, immediately after; it should be given, at first, with much
caution, — perhaps not more than fifteen grains, infused for ten
minutes in six ounces of boiling water; after the interval of an
hour, if no effect has been produced, it may be repeated in the
quantity of twenty grains, and so on, until such effects are pro-
duced, in slight giddiness and muscular relaxation, as show that
its peculiar action is taking place upon the system. It may then be
repeated, at intervals of one or two hours, a great many times, if
the case do not speedily yield; and, with the precautions now men-
tioned, I have never seen any unpleasant effect from a free use of
this powerful remedy." Even the cautious and sceptical Heberden
speaks without drawback of the curative powers of the injection of
tobacco smoke and tobacco infusion in ileus; but, on the other hand,
both in surgical and medical practice, we have many cases on record
in which speedy death was the result of the administration of this
powerful medicine as an enema. I shall recur to this point when
the subject of ileus is before us.
Resuming my sketch of the treatment of stercoraceous colic, I
have to direct your attention to a state of things of very probable,
I may say common, occurrence, not adequately dwelt on by writers
or practitioners. It is the gradual coming on of the constipation
and morbid state of the intestinal canal, of which this is often a
symptom merely, or one of the effects; and the strong probability of
inflammation, not very acute, indeed, but still quite decided, having
been established before the patient was laid up in bed and had sent for
the doctor. The more immediate and pressing uneasiness with the
sick man himself is costiveness, with its concomitants, heat and
fulness of the part, and some flatulence; and to its removal he directs
his self or domestic prescriptions. These being found ineffectual,
the physician is sent for, who, not seldom, too readily adopts the
erroneous pathology, and with it the purgative practice of his
patient; and persists in administering purges, one after another,
or in combination, and enemata of the same nature. Mere spas-
modic colic with fecal accumulations will every now and then
be removed by these means; but if, as I have just intimated,
316
DISEASES OF THE DIGESTIVE SYSTEM.
there be inflammation, we ought to lose no time, after the initial and
probationary steps of giving some purgative medicine by the mouth
and per anum have been tried without effect, to draw blood from
the arm, even though the pulse be not frequent and the pain of
the abdomen be inconsiderable. After venesection, calomel, in
a dose of ten grains with one grain of opium or four or five of
hyosciamus extract, may be given, and the patient made to take
a table-spoonful, every half hour, of a solution of one ounce of
sulphate of magnesia in four ounces of water. The passage of flatus
downwards and per anum indicate that the bowels are about to
yield and to discharge the matters accumulated in them, and at the
same time the propriety of giving an enema, either simple or pur-
gative. But if, in twelve hours after venesection, the bowels are not
moved ; if the pain and restlessness return, or the stomach is
nauseated, or bilious and other matters are ejected from it; and, also,
if the pulse is hard, even though of its common frequency, and there
is thirst, we must not hesitate to draw blood again from the arm;
or, at any rate, to apply cups to the lumbar region of each side, or
leeches over the abdomen — around the umbilicus, and in the course
of the great arch of the colon and the iliac regions. Making now
the discharge of feces an affair of secondary moment, we con-
tinue to keep up the relaxation which was began by the bleeding,
and which alone will sometimes be followed by a stool. For this
purpose we direct tartar emetic with opium in small and frequently
repeated doses,orhydrocyanic acid; calomel with hyosciamus every
hour; fomentations to the abdomen, and warm water enema;—in
fine, all the measures which have been already pointed out for the
cure of caecitis, including even liniments of belladonna rubbed on
the abdomen, and a suppository of this medicine. Relaxation of the
bowels induced in this way will be evidenced by easy fecal evacu-
ations, and may be received at the same time as evidence of the
abatement, perhaps removal, of the disease, and not, as before, of
one of its symptoms. If purgatives are still required, we can, with
safety, have recourse to castor oil and oil of turpentine, in the
proportion of an ounce of the first and half an ounce of the second,
mixed with gruel or with some mucilage, and flavoured with oil of
cinnamon or peppermint. Occasionally one drop to two drops of
croton oil, mixed with crumb of bread in the form of pills, or with
syrup of gum arabic, will answer, in cases of very sluggish bowels
in lymphatic temperaments, or where we have no apprehensions
about inflammation. If the state of the stomach prohibits the ad-
ministration by the mouth of purgatives, they may be introduced into
the rectum, as heretofore advised. It should be borne in mind, that,
after the colon has been once unloaded of its accumulated contents,
subsequent motions of the bowels are best procured bv mild or
laxative medicines and compounds, in which sulphur merits a lead-
ing place.
Infantile colic is sometimes of the stercoraceous variety; but more
frequently it depends on morbid secretions from the liver and bowels,
INFANTILE COLIC.
317
and on imperfect change which the food undergoes from its want
of adaptation to the digestive sensibility. Of the first kind is the
colic of new-born infants, or when the viscid meconium adheres to
the colon, and is not evacuated. Castor oil warmed, and in doses of
half a drachm to a drachm, and in more obstinate cases of retention
with the addition of five dropsof oil of turpentine, will generally suffice
to give relief in a case of this nature. Doctor Dewees (On the Phy-
sical and Medical Treatment of Children) details a case of disease,
which, by the way, wasnot colic, caused by retention of the meconium,
and in which the common laxatives, castor oil and magnesia, failed
to operate. He succeeded at last by the administration of a grain
of the carbonate of soda, dissolved in a teaspoonful of lukewarm
water, every fifteen minutes, until ten grains were taken. Another
modification of stercoraceous colic is met with in infants who are
habitually constipated, and whose appetite and growth are both vigor-
ous. Purgatives, as is soon discovered, are not the remedy in this case.
We must be content to palliate until, with time and some natural
change in the functions, the bad habit is changed. Laxative enemata
of the simple kind, or occasionally a little castor oil, or syrup of rhu-
barb, or manna dissolved in its food, as sweetening, if the child uses
spoon-victuals, will generally suffice. A suppository of soap is oc-
casionally useful. I have sometimes given from a quarter to half
a grain or a grain of calomel with a little magnesia ; but of course
not frequently, still less habitually, in every case. This prescrip-
tion is called for when colic proceeds from deficient secretion of
bile, as in jaundice. In this disease, as it attacks new-born infants,
I have had occasion to be much pleased with the oil of turpen-
tine, in doses of from ten to twenty drops, with a teaspoonful of cas-
tor or sweet oil, repeated at an interval of twenty-four or forty-eight
hours. It is, also, one of the best medicines for infantile colic with
constipation. Simple syrup, with a little of some essential oil,
answers well at times, as follows: — Simple syrup, one pint; oil of
rue, 8 to 10 drops. Mix. Dose, one to two teaspoonfuls.
In the other, and still more common, colic of children, depending
on indigestion, our attention must be first directed to the health of the
mother. In her, bad digestion or other derangement of health, kept
up sometimes by gross and improper food, drinking tea and coffee
to excess and malt liquors; sometimes by want of air and exercise,
and late hours; and again, by indulgence in strong emotions, or by
any cause which irritates the nervous system, must we seek an
explanation of the depraved nature of her milk, and, consequently,
of colic and other forms of indigestion of the infant. Dr. De-
wees (op. cit.) relates a case of serious and alarming disease of a
child, beginning with colic and running on to vomiting and diar-
rhoea with great emaciation, which was produced by the altered
quality of its mother's milk, owing to severe and protracted
toothache. To the child itself suffering from colic, a few grains
of carbonate of magnesia, with some simple carminative, — mint, or
peppermint water,or camphor mixture,or a grain of subcarbonate of
27*
318
DISEASES OF THE DIGESTIVE SYSTEM.
potassa, or two or three drops of liquor potassae in a similar fluid, with
sugar, — will often give relief, without interfering with the peristaltic
action of the bowels, or impairing the digestive energy, as all cor-
dials and mixtures into whichopium enters are so apt to do. Calamus
aromaticus, in powder, with chalk or magnesia, answers a similar
intention. In some extreme cases of suffering, a drop or two of
laudanum will give the desired relief; but never ought the physi-
cian to prescribe it regularly, or to allow of its regular use in the
nursery. He can hardly be too emphatic in his cautions against the
dangers of the practice of habitual laudanum or opium-taking in
child or adult.
In some cases infantile colic recurs so regularly at particular
times in twenty-four hours as to force attention to periodicity,
and to suggest its being treated accordingly. I have, in cases
of this nature, given the sulphate of quinia in a dose of twelfth to
an eighth of a grain in solution, with the effect of greatly miti-
gating the violence of the attack, and sometimes of warding it off
entirely. One may, however, reasonably suspect, that this periodi-
cal colic is sometimes owing to the recurrence of an external ex-
citing cause, as in the quality of the mother's milk at a particular
time in the twenty-four hours, rather than to an internal organic con-
dition of the nervous system,which generally gives rise to periodicity.
In confirmation of this, I may state one of my boarding-school re-
miniscences. A boy, whose digestive organs werenever very strong,
used to have regularly every Monday afternoon an attack of colic ;
not very severe, it is true, but quite troublesome and well marked in
all its symptoms. The cause of this weekly return of disease was
almost forced on his attention, after a while, by its uniformly follow-
ing a dinner on cold beef, which was the regular dish of meat for
Monday. Many a dyspeptic, who thinks that his sufferings are en-
tailed on him, of necessity, for life, would discover, by a little retro-
spection of his diet during the preceding twenty-four hours, that
these are avoidable ; and that if he were to omit some article of
the cold-beef class, he would escape his special ailment.
Before dismissing the treatment of infantile colic, let me enjoin
attention to the feet of the child being carefully covered with warm
socks and shoes, which ought occasionally in the day to be taken
off, and the feet well rubbed by the warm hands of its mother or nurse
before the fire, or over a flue of hot air. The early use of a tepid
salt water bath, to be followed by careful friction over the abdo-
men and the lower limbs, will prove to be a useful preventive of
colic, as well as corroborant of the system generally.
BILIOUS COLIC.
319
LECTURE XXVI.
DR. BELL.
Bilious Colic—Time of its attacks—Causes and Symptoms—Anatomical lesions—
Treatment—Venesection—Opiates — The warm bath or fomentations—Purga-
tives—Enemata—Means of acting on the bowels—Calomel—Caution against
too early excitement of any kind—Recourse at times again to bloodletting—
Dover's powder—Blisters—Practice by others—Sydenham's directions—Eme-
tics sometimes used.—Dry Bellyache—Analogous to bilious colic—Does
not arise from lead—Common formerly in the Wesfr Indies and in America—
Description by Hillary—Paralysis of limbs-^Metastasis.—Colic of Madrid,
Closely resembles the preceding—Causes of—Symptoms—Anatomical lesions—
Devonshire colic—Causes.— Vegetable colic, similar to the preceding—Treat-
ment of this kind of colic, including the preceding varieties.
Bilious Colic. — The extension which I have given to my re-
marks on the subject of common colic and its varieties, by enabling
me to notice some of the chief points of the pathology and of the
therapeutical treatment of colic in general, will free me from the
necessity of any elaborate account of bilious colic, the dangerous
character of which entitles it, however, to a careful study. First,
as respects the name which, although certainly not a proper patho-
logical one, we can hardly see any harm now in retaining, pro-
vided we no longer believe that the disease proceeds either from
a deficiency or redundancy of bile. Our scruples on this point will
be abated, if not overcome, by knowing that the title of bilious colic
has the sanction of Sydenham, whose outlines of its treatment are
those which, in the main, have proved to be the most accurately
drawn.
Bilious colic, as far as my own observations extend, is a dis-
ease much more frequently met with in the country than in cities:
at least I saw more cases of it when a student in Virginia than I
have since met with either in private or public (Dispensary) prac-
tice in Philadelphia. Bilious colic makes its attacks in the great
heats of summer, and is a precursor, on the score of time, as it is
sometimes more immediately in the same person, of bilious fever.
Some are more predisposed to the disease, so as to be much more
readily affected than others by its occasional or exciting causes : —
These are excess in the quantity, and error in the quality of the
food ; free potations of spirituous or acescent liquors ; cold drinks,
as of ice water or milk, especially if the stomach has been weak-
ened by indulgence in the use of strong liquors ; hard labour, or
excessive exercise of any kind in a hot sun, and subsequent expo-
sure to the cool damp air of night, either by sleeping in the open
air or under open windows indoors. A little difference, hardly
appreciable, in the constitution of two individuals, and perhaps in
the quality of the articles eaten at supper, will cause in the one
bilious colic, in the other cholera morbus.
Bilious colic is sometimes preceded by indigestion and slight
320 DISEASES OF THE DIGESTIVE SYSTEM.
febrile action: but, often, it comes on suddenly in the night or at an
early hour in the morning without other premonition than a slight
chill. The symptoms are — irritability of the stomach, and occa-
sionally vomiting of bilious matter; pain in different parts of the
intestinal canal and distention by flatus; cramp of the abdominal
muscles, which is soon participated in by the muscles of the limbs,
especially the lower ones; coldness of the surface, particularly of
the hands and feet. After a short time, the skin of the abdomen is
hot, the face is flushed, and there is some throbbing of the temporal
arteries; the pulse, at first small or not materially changed, is now
frequent, hard, and voluminous; the tongue is loaded and of a
yellowish colour. In a short time, together with the expression of
anxiety and suffering displayed in the face, the complexion is altered
from its natural colour to a dingy-yellow hue, — partially relieved,
in the stage of febrile reaction, by a blush on the cheeks. The
bowels are almost universally in a constipated state, — a symptom
this, diagnostic^of the disease from cholera morbus. Sometimes the
vomiting is carried so far as to constitute the iliac passion. Numb-
ness and tremors of the upper extremities are occasional symp-
toms.
The anatomical lesions manifested in the bodies of those who
have sunk under bilious colic are, chiefly, inflammation and inflam-
matory congestion of various parts of the small intestine, particu-
larly of the duodenum and the ileum, and similar though less marked
alterations in the stomach, and morbid accumulation of blood in the
liver. If we connect these appearances with the symptoms sketched
above, we can have no hesitation in regarding bilious colic as a
true gastro-enteritis, with the occasional complication of hepatic
disorder.
Treatment. — The treatment of bilious colic with which I became
early familiar is the best adapted, if we except the too free use of
purgatives,,to the chief exigencies of most cases of the disease. It
consists in venesection from sixteen to twenty-four ounces, the
administration of sixty to a hundred drops of laudanum, or three
or four grains of opium, if the stomach was irritable, immersion
in the warm bath, or, in its stead, fomentations over the abdo-
men of cloths squeezed out of hot vinegar and water, and sina-
pisms to the legs and arms. Relief commonly procured by these
means is rendered more abiding by large stimulating enemata, as
of an infusion of senna with salts, castor oil with turpentine and
assafoetida, repeated until the bowels are freely evacuated, and at
any rate until fecal matter ceases to be discharged. The recur-
rence of pain will be met by simple enemata of warm water, or by
those of fluid in small bulk with which thirty to forty drops of
laudanum have been mixed.
Having by this active treatment procured a respite from suffer-
ing, and a remission, in part, of the disease, the next point to be
determined is how far and by what means the bowels should be
acted on with a view to their complete evacuation. In the same
TREATMENT OF BILIOUS COLIC. 321
school in which I was initiated into the early treatment of bilious
colic I was taught the advantages of a full dose, say twelve to
fifteen grains, of calomel at this time, — either alone, or if the sto-
mach was still irritable, combined with two or three grains of
opium. More commonly this prescription was made with a view to
its administration preceding nearly all other remedies by the mouth;
and in place of the laudanum or opium, as before recommend-
ed, I now prefer the simple course,— viz., to obtain a cessation
of all the symptoms by the treatment which I have laid down, and
then to give a calomel pill in the dose just indicated. In prescribing
this medicine at this time and in this dose, I bear in mind, and indeed
participate, in the strong dislike which the Broussais school enter-
tain to drastic or irritating purges in gastro-enteritis. But I do not
think that in my practice I am inconsistent with my theory. I
believe calomel to be, when judiciously timed in its administration,
one of the best remedies we have against phlegmasia of the digestive
canal: at the same time it must be acknowledged that I am more
persuaded of the fact than ready with an adequate explanation.
The calomel now given, in its passage downwards, exerts a kindly
operation on the duodenum and the ileum, and by its impression on the
former being transmitted to the liver it acts on this latter organ, which
is, in consequence, relieved from its temporary congestion, and se-
cretes bile. The large intestine, obedient to the double stimulation
of the bile brought to it from above and of the calomel, now dis-
charges freely its contents, together with those which have been
passed down from the small intestines; and entire relief, manifested
often in a tranquil sleep, is, soon after, enjoyed by the patient. It
may be that the calomel is slow in its operation, or that, although
it is the first and often the best medicine to tranquilize an irritable
stomach, it now, just at the time of its passage through the ileo-
cecal valve, causes sympathetic nausea and sickness. In either
case we give moderately stimulating enemata — often tepid water
with some common salt dissolved in it will answer — and repeated
until there be free evacuations. In desiring free evacuations in
colic in all its varieties, I am not influenced merely by the consider-
ation of removing irritating matter from the bowels, and diminishing
excitement by the discharges from the mucous surface, but also by
that of being assured that the regular peristaltic action is reesta-
blished in the entire course of the digestive canal.
At this juncture, when the violence of the attack has subsided,
the practitioner must be on the alert, in order to ascertain, very
positively, whether his patient is now clear of disease, and only
requires rest and simple farinaceous diet for his restoration, or that
he sees before him merly a state of remission. If the latter, he will
expect to find the pulse somewhat hard, or slightly corded and fre-
quent, and the abdomen still tender; not that diffused tenderness
which any muscular part will evince after violent exertion, normal-
or spasmodic, but circumscribed in some portion, as the iliac region,
or round the umbilicus. The tongue at the same time is dry and
322 DISEASES OF THE DIGESTIVE SYSTEM.
furred, and the thirst considerable. This is a critical period in the
disease. If recourse be had now to drastic purgatives, or, from
mistaken notions about debility, to tonics, the inflammation of the
intestine will be aggravated, the distress of the stomach increased,
and the disease terminate rapidly and fatally. Equally to be dreaded
is the ingestion of animal broths or stimulating drinks, sometimes
allowed under the idea that the first remission is the actual begin-
ning of convalescence. Should there be doubt about the real state
of the digestive canal, the safer plan will be to abstain for a day
or two from active medication, and certainly from animal food or
diffusible stimuli, under which head I include vinous and distilled
liquors, until the characteristic symptoms, oneway or another, are
more fully developed. But if the symptoms, as indicated at the
beginning of these remarks, are present, we should have recourse
to the use of leeches, or, if there be not too great tenderness of
abdomen, to cups applied on the iliac regions. Circumstances pre-
venting recourse to either of these means of local abstraction of
blood, we ought to endeavour to attain our end by venesection in
small quantities, viz., six ounces at a time ; watching the effect, and
repeating in twelve hours the operation, if the pain and tenderness
of a portion of the abdomen corresponding with the intestines beneath
seem to call for the measure. During this time we should abstain
from irritating the bowels, either by active purging or by strong
enemata. Tepid water thrown up the rectum will answer every
purpose in procuring regular evacuations. Antimonials with opium,
or Dover's powder, given at intervals of two or three hours through-
out the twenty-four, contribute to remove the inflammation and
to abate febrile action. Revulsion, by blisters over the abdomen or
to the lower limbs, and warm pediluvia, may next be used with
advantage.
Having sketched the course of treatment in bilious colic which
my own experience induces me to believe correct, I will add some
particulars of the practice of others in the disease. If I refer first
to that of Sydenham, it is that I may express the obligation which
I, in common with all others whose mode of treating the disease
resembles that just described, owe to this great man's precepts on
this head. He began with freely bleeding from the arm, and in
three or four hours administered an opiate. The next day he di-
rected some lenient purgative, and ordered it to be repeated a second
time, at a day's interval, and sometimes a third time, " according
as the remains of the humour seemed to be more or less in quan-
tity." This phraseology of the humour, at the present time, seems
to us to be misplaced. Is that of'depraved secretions' very differ-
ent, or more philosophical ? In case the stomach were oppressed
" with a surfeit of fruit, or with any other kind of aliment of difficult
digestion," his first prescription was free dilution, followed by
vomiting, after which he gave an opiate, and on the following day
opened a vein and purged, as just described. Some exceptions will
be taken to his advice, in a more violent form of the disease, to give
TREATMENT OF BILIOUS COLIC.
323
strong purgatives when the milder do not operate. This error is,
however, redeemed by his subsequent remark; that where, either
through the weakness of the stomach or from the vomiting purgative
pills cannot be retained, he prescribes an opiate and in a few hours
after a purgative. But because a purge always increases the pain in
this and most other diseases where opiates are indicated, at least
when the operation isover,the patient sometimes finding relief whilst
it works, Sydenham generally gave an opiate immediately after
the operation of the purgative, and ordered it to be repeated daily,
morning and evening, on the intermediate days between those in
which purgatives were administered. When the affair of purging
is over, he endeavoured "to check the violent motion of the humours,
which is all that now remains to be done," by exhibiting an opiate
every morning and evening. Sometimes, when the case demands
it, omitting both bleeding and purging, he recommends the cure to
be begun with opiates; as where the patient had been subjected,
by reason of some preceding illness, to large evacuations, or was in
a state of indirect debility from the excessive use of wine or any
spirituous liquor.
A tendency to recurrence of bilious colic, which, by the way, is
quite common, is, according to Sydenham, destroyed by the patient
using much exercise on horseback — a remedy which he extols as
very successful in most chronic diseases.
Emetics have been freely employed by different practitioners since
Sydenham's time, and, as may be inferred from the accounts on the
subject, with benefit. The stomach is evacuated, by an emetic, of
irritating ingesta, which, despite the retching and vomiting that are
often part of the disease, would otherwise remain for some time the
source of continued distress; the liver is made to discharge more
freely its bile, which finds its exit not only upwards by the stomach,
but passes downwards, and may be supposed to contribute to a
relief of the lower bowels, by either purging itself off, or rendering
the enemata easier in their operation. But, in addition to these
commonly cited advantages alleged to follow the administration of
an emetic, there is another and more important one yet which
would incline me to this remedy: it is the general relaxation of the
capillary system and diminution of vascular excitement. In order
to procure this result, a selection should be made of that article the
action of which is not limited to the stomach, but which is diffused
through both the bloodvessel and nervous systems. I refer, of
course, to the tartar emetic. Administered in solution, in moderate
doses, at short intervals, at the outset of the disease, and preceding
all other remedies, where the phlogosis and excitement are not
thought to be sufficiently great to require the lancet, this medicine
not only procures the desired evacuations, and acts as a revulsive
by this means, but also, if its use be continued in small doses at
longer intervals, it displays its customary counterstimulant or seda-
tive power. In colica pictonum, which bears so close a resem-
blance to the disease in question, I have given the tartar emetic in
this way with unequivocally good effect. If the spasm of the ab-
324
DISEASES OF THE DIGESTIVE SYSTEM.
dominal muscles and limbs should continue after the vomiting in-
duced by the emetic, although in general we shall find it abated by
this remedy, we may then add to the antimonial preparation small
doses of opium, and continue the combination until the spasm is
removed, and the skin becomes soft and moist and the pulse has
lost its hardness and frequency. The bowels during this time should
be acted on by enemata, the operation of which will be easier after
the relaxation caused by the antimony. But if free fecal evacua-
tions cannot be procured in this way, and if after the operation of
the emetic the stomach is still irritable, we then direct calomel in
pill, or mixed with a little gum arabic in powder, and wait or
quicken its action in the manner already described — by laxatives
and enemata.
I have said nothing respecting the effervescing draughts and the
prescriptions in common use for sick stomach, because they are for
the most part either inefficient or injurious. This organ is best
tranquilized by rest from all kinds of stimuli — and by the use of the
simpler bland or demulcent drinks in very small quantities at a
time; by revulsion, by means of leeches to the epigastrium; after-
wards of stimulating liniments or sinapisms to the same part and also
to the extremities, and of enemata to evacuate the large intestines;
and by opium, administered sometimes by the mouth, sometimes by
the rectum.
Costiveness, on occasions, continues in bilious colic in despite of
the means hitherto recommended for its removal. Much can, I
know, be done to prevent this morbid state by the judicious selec-
tion and persistent use of enemata, one of the chief conditions
for their efficacious operation being the large quantity of the fluid
and the frequency of repetition. By some, tartar emetic in solution
has been recommended: others lay stress on the relief procured
by the administration of calomel in doses of one or two grains re-
peated every two hours, and after the lapse of a day, sometimes
two days, to follow up this course with the use of laxatives, if the
stomach will allow of their ingestion. I have seen this last treat-
ment successful, although at the cost, sometimes, of salivation.
Relapses will readily occur unless proper care be exercised by
the convalescent to protect his skin, and particularly his feet,
against dampness and cold; to avoid all indigestible or doubtful
food, particularly of an evening; and to keep his bowels regular.
If the disease should have made its attack in the latter part of the
summer, or the individual is exposed, subsequently, in his vocation
to a damp atmorphere or raw weather, he will find his advantage
in the use of sulphate of quinia combined with aloes, in pills, in
such a manner that three to five grains of the former and three of
the latter may be taken every morning before breakfast.
The disease designated variously as dry bellyache, Madrid
colic, the colic of Poitou, Devonshire colic, and vegetable colic, is
analogous to our bilious colic. For a long time attributed to the
action of lead, to the acid wines, or cider, or the spirits drank by
DRY BELLYACHE.
325
the inhabitants, or to milk used in too great abundance, and other
errors of regimen, it is now admitted generally to be induced by
great atmospherical vicissitudes, the operation of which is favoured
by improper food, and probably some causes of an endemial na-
ture, which cannot be well appreciated. Hillary (Observations on
the Changes of Air and the concomitant Epidemical Diseases in the
Island of Barbadoes, &c. With Notes, by Benjamin Rush, M.D.)
speaks of the class of persons most subject to dry bellyache, and
especially those who live in America and the West Indies, in which
countries it seems to be endemial. At times it assumed an obvi-
ously inflammatory type (p. 34), being, as Dr. Rush tells us in a
note, complicated with bilious colic. It was, as we learn from the
last mentioned distinguished writer in another note (p. 134), "a
common disease in Philadelphia between the years 1760 and 1770.
Its rare occurrence [now] has been ascribed to the disuse of punch,
and of late and heavy suppers; to the general use of flannel next the
skin, and to the abolition of porches, which afforded a temptation
to our citizens to expose themselves for several hours, in a state of
inactivity, to the damp evening air." The causes of dry bellyache
implied in this sentence, are precisely those which I have described
as giving rise to bilious colic. But in the absence generally of
inflammation and fever, in the frequently protracted duration of
the former disease, and the liability, when it does not end fatally,
to cause paralysis of the limbs, we find differences between it and
bilious colic. " This state of costiveness, pain, and misery," say
Hillary, "has continued for twenty or thirty days, and sometimes
longer; for I remember a case which being thus treated in a wrong
manner, the patient continued, with some small intervals of being
something easier,in this painful condition for six months,or more, and
then recovered by a different method of treatment in one week's time."
The following is a well-drawn picture of the progress of the disease,
and especially that part which portrays the transmission of irrita-
tion from the viscera to the spinal marrow, and its subsequent
irradiation to the limbs, followed by deficient innervation and palsy.
The passage would be particularly pleasing to Dr. Marshall Hall,
as illustrative of his doctrine of reflex-function of a portion of the
nervous system. "When the sick fall into the hands of those who
treat them in this wrong manner, the pain continues to be very
violent, and at times almost intolerable, and that for a long time; and
then the patient's breath commonly acquires a strong, fetid, sterco-
raceous smell like excrement, from a long retention of feces, and an
absorption of the putrid effluvia from them into the lacteals, by the
strong convulsive contractions of the guts; and when the pain in
the bowels has continued long, and at last begins to abate, a pain
in the shoulder-joints and adjoining muscles comes on, with an
unusual sensation and tingling along the spinal marrow; which
soon afterwards extends itself from thence to the nerves of the arms
and legs, and they become weak, and their weakness increases till
those extreme parts become paralytic, with a total loss of motion,
vol. i.—28
326
DISEASES OF THE DIGESTIVE SYSTEM.
though a benumbed sensation often remains.'' The author next
adverts to the occasional metastasis from the bowels to the brain,
producing stupor and delirium, which are succeeded by strong
convulsions terminating often in death; also, to the sudden transfer
from the limbs, which were paralytic, to the bowels or head.
The colic of Madrid (entripado, constipado) closely resembles,
in all essential particulars, if it is not entirely identical with, the
colic, or dry bellyache of the West Indies. Our knowledge of it
has been rendered much more precise, of late times, by the writings
of several French medical men, whose residence in Spain with the
armies gave them ample opportunities of observation. That the
disease does not depend on causes purely local, nor on acid wines,
nor on water running through leaden pipes, in Madrid, is proved by
the fact of its being common in other parts of Spain, as in Galicia
to the north, and Valencia in the south-east. The cause most
operative is said to be the sudden mutations of temperature, which
are more frequently met with in the table-land of the Castilles than
elsewhere. To great heat by day succeeds coldness of the night;
and even a transition from the sun to the shade produces often a
feeling of excessive coldness. The scanty clothing of the labouring
classes and the poor, and their often imperfect protection from the
night air during sleep, give greater effect to these atmospherical
' enormities.' Baron Larrey supposes the Madrid colic to proceed
from this cause and acid drinks, and designates it by the title of rheu-
matic bilious colic.
M. Marquand, during eight months tour of duty at the hospital of
St. Jamesof Compostella, in which there were never less,at one time,
than forty to fifty men attacked with this disease, had ample op-
portunities to study it. He was, moreover, himself a sufferer from
an attack ; and hence was well qualified to describe its symptoms
and course. At first there were dull but transient pains through-
out the whole course of the colon, but more particularly at its trans-
verse portion. In other respects the functions were very little affected :
but after a time there followed uneasiness ; wantof appetite ; difficult
defecation, but not constipation ; frequent passages in the day, but in
small quantity, and accompanied with a discharge of flatus. The
patient suffers less in bed than when up. At the expiration of two
or three days more, there is no longer any desire to evacuate the
bowels, nor any flatulency; but the gastric symptoms which,
hitherto, had not been manifested, now appeared in full force. We
next notice pain in the epigastric region; the face pale, and with
a sad expression ; pulse small, slow, and contracted, but yet regular;
urine in small quantity, though natural; skin dry, yet not hot. The
patient is often seated, leaning forward, with his arms clasped on his
abdomen, which he compresses. If he is in bed, his lower extremi-
ties are flexed on his trunk. Hiccup and vomiting now supervene;
and afterwards there is rejection of the fluid drank, mixed with glairy
and yellow bilious matters in small quantity. No sleep, no rest,
no suitable posture is allowed to the unhappy patient. If these sy mp-
COLIC OF MADRID.
327
toms continue, the abdomen more frequently becomes flat; pain is
begun to be felt commonly in the right hypochondrium, sometimes
in the umbilicus, but without any diminution of the epigastric dis-
tress. The sclerotica becomes yellow, and after a while the whole
body. The disease is aggravated; and death sometimes termi-
nates the series of sufferings above described. It is sometimes pre-
ceded by marasmus, sometimes by partial palsy. This disease
often has sudden remissions, promising complete convalescence.
In addition to these symptoms Dr. Pascal notes ischuria or
dysuria, and paralysis of both the upper and lower limbs. This
writer (Recherch. Anat. Pathol, sur la Colique dite de Madrid) gives,
as the result of six autopsic examinations of persons dead of the
colic, his opinion, that the disease has its seat in the ganglionic
nervous system, which is in a state of either acute or chronic in-
flammation. In five of the subjects examined he found the thoracic
and abdominal ganglia more or less enlarged in size, and of a red
colour, studded in the middle with yellowish spots, and some of the
ganglia were even of a cartilaginous hardness. M. TJ. Coste (Mem.
sur la Colique de Madrid) is opposed to this opinion ; and believes
that the disease is caused by an inflammatory irritation of the mus-
cular coat of the intestines, particularly of the colon. In this sketch
of the Madrid colic I have followed MM. Chomel and Blache in
the Diet, de Medicine, fyc, 2me edition.
The Devonshire colic and that of Poitou need not be described,
exhibiting as they do phenomena identical with those just detailed.
In connection with the etiology of this disease, the remarks of Dr.
Chisholm are worthy of notice (.# Manual of the Climate and Dis-
eases of the Tropical Countries, fyc). The colica pictonum, or
dry bellyache, constitutes, he tells us, one of the most remarkable
proofs of intemperance being a principal cause of disease within
the tropics. He refers to a work by Dr. Philip Fermin, (Traite des
Maladies d, Surinam,) who says, that neither tongue nor pen can
describe the horrors of this disease, called by the natives Beillac,
or the work of the devil. The common causes, according to Dr.
Fermin, are, excessive debauch, the immoderate use of strong
drinks, and passing the night abroad in a climate like that of Suri-
nam, in which the nocturnal coolness produces a strong impression
because following a day of excessive heat. Dr. Chisholm relates,
that five and thirty years before the time of his writing (in 1822)
when he first settled in the West Indies, colica pictonum was very
common, and often most afflictive and fatal. "At that time, ex-
cessive abuse of wine, spirits, and malt liquors, was generally prac-
tised by all ranks of society; but more especially among the lower
whites spirits were the principal drink, because easily procured__
either raw or slightly diluted." Since then a reform in the mode of
living has been followed by a diminution in the frequency of appear-
ance of dry bellyache, until at the present time it is quite a rare
disease. " Alternation of heat and cold, doubtless, may have contri-
buted ; but that the poison of lead had any share in its production
328
DISEASES OF THE DIGESTIVE SYSTEM.
within the tropics at least, there is no just ground for believing." In
Devonshire, continues Dr. Chisholm, where the disease may be said
to be endemic, no lead is employed in the cider-presses or cisterns ;
and yet there is every reason to be assured that it is the excessive
abuse of this liquor, and the peculiar harshness and acidity of it,
which may be considered as the principal cause of its prevalence
in that country. The operation of this cause was thus explained
to him on the spot. " In the summer and autumn, when the husband-
men are laboriously employed in the hay and corn-harvest, the
common practice of these men is to drink cider to the extent of
their ability to buy, or rather, as it is allowed without limitation in
hay-harvest, to the extent of the capacity of their stomachs to con-
tain it. The labour at this season produces an intolerable heat in
their persons. Now the great cold of the cider, together with its
harshness and acidity, acting against the heat produced by labour,
give rise to a spasmodic state of the bowels, which, acquiring its
acme in twenty-four hours, or even less time, in very many in-
stances terminated in death. These labourers are so very incon-
siderate, that to allay the excessive heat and thirst occasioned by
their work and the great heat of the season, they often drink to the ex-
tent of six or eight quarts of cider in the day; and not unfrequently,
such is their avidity and the uncomfortable state of their feelings,
fill their stomach at one draught. In neither Devonshire nor
Gloucestershire is lead used in lining the cistern which receives the
liquor from the press." Huxham had long ago attributed the De-
vonshire colic to the abuse of cider and apples, as Cotys did the
colic of Poitou to white wine.
Vegetable colic is one of the titles which I stated to you has been
bestowed on the disease of which I am now treating. It is a com-
prehensive one; and, although probably not significative of the
cause, it is less misleading than some others which would imply a
saturnine origin. It is essentially the colic of Madrid, that of
Poitou, and of Devonshire, and of the West Indies. At French
Guiana this disease prevails ; but it cannot be attributed, in the opi-
nion of M. Segoud, who spent some time at Cayenne, to acerb fruits,
nor to the quality of the wines which are drunk, for the former are
rare and little eaten, and of the latter Bordeaux is the only kind
used. It is then to atmospherical vicissitudes that we must refer
the cause of this colic. Thierry and Lepecq de la Cloture held
similar opinions.
Treatment of Dry Bellyache, Colic of Madrid,or Vegetable Colic.—
There is a tolerable unanimity of opinion respecting the suitable
practice in this disease, whether it appears in the West Indies, and
is designated by the name of dry bellyache ; in Spain, by that of
the colic of Madrid ; in England, as Devonshire colic ; in France,
as that of Poitou or vegetable colic. The indications are, to calm
irritation and spasm by opiates, and to remove feculent obstructions
and restore the secretions by purgatives. With the first view opium
is administered, in doses of a grain every three or four hours, until
TREATMENT OF DRY BELLYACHE, ETC. 329
relief is obtained; or an equivalent quantity of laudanum with a little
mucilage is thrown into the rectum, and repeated, until the same
effect is procured. In full plethoric habits, in those of a sanguine
temperament, or when the diseases of the season wear an inflam-
matory type, venesection, or scarifying cups, over the loins and on
each side of the spine, will aid, not a little, in the solution of the
spasm, and increase the susceptibility to the impression of the medi-
cines to be afterwards given, — whether these be opiates or pur-
gatives. Sometimes the relief is so considerable after bloodletting
that opium may be dispensed with, and we proceed at once to purge
as we would do in case we had given opium first. Here, as in
bilious colic, a full dose of calomel will operate more kindly on the
bowels, and allay the irritability of the stomach better than any
others of the class of purgatives, — certainly better than any of the
drastic variety. It will either follow opium or be combined with
it. Dr. Musgrave, a writer of authority on the West India colic,
or dry bellyache, recommends, after the first and larger dose of
calomel of fifteen grains, smaller ones of five grains combined with
a common cathartic. His intention is to evacuate the bowels and
to affect the system with mercury. The Spanish physicians are
partial to castor oil in the Madrid colic; and it may generally be
had recourse to at the very outset, combined with laudanum
and some aromatic water and sugar; or after calomel, and
in a very torpid state of the alimentary canal: when these fail to
operate we should give it with oil of turpentine, as so pointedly
recommended in other varieties of the disease, both by the mouth
and per anum. Of the purgative clysters, one of the simplest
or common salt, an ounce, in a pint of water, is also one of the best.
Calomel and rhubarb was. the favourite purge of Dr. John Hunter
(Observations on the Diseases of the Army in Jamaica, &c). He
remarks, sensibly enough, on the subject of perseverance in the use
of purgatives; "that whatever purgative was employed, regard
was not had to the common dose, which would not have been strong
enough ; but it was repeated from time to time, either till it dis-
agreed with the stomach, or till it operated." For the removal of
pain, which is abated by the warm bath and fomentations, Dr.
Hunter, in common with many other practitioners, recommends a
large blister applied to that part of the abdomen where the pain is
greatest; " it was further of great use in promoting the operation
of the purgative; for, in general, it was observed, that soon after the
pain became easier free evacuations followed."
It was long ago a practice among the French physicians to give
an antimonial emetic in the dry bellyache, as it still is in the
Madrid or vegetable colic at the present time. An emetic is at
times an efficient remedy; it evacuates the stomach of irritating
matters, which were not sufficiently ejected by previous efforts to
vomit; it allays internal spasm, and by urging the bile into the in-
testine from the ductus choledochus, it favours the evacuation of
28*
330
DISEASES OF THE DIGESTIVE SYSTEM.
the bowels; at any rate predisposes them to be more readily acted
on by purgatives.
A "soluble state of the bowels and freedom from spasm will be
maintained by mild laxatives conjoined with the simple bitters,
extract of gentian and the like, or sulphate of quinia. A preventive
measure of paramount consideration is to wear flannel next the
skin, and to secure as much as possible an equable temperature for
this organ. This advice is applicable to all the varieties of colic.
Paralysis is the most troublesome, and, at the same time, quite a
common sequence of the kind of colic now under consideration.
Acting on the hint furnished by Hillary in the description of the
order in which parts are affected before the limbs are seized with
paralysis, and enlightened by a better physiology than heretofore,
we should use, after suitable purging, irritants to the spine and its
vicinity, such as croton oil, tartar emetic ointment, or the excite-
ment of the warm douche or spout-bath — preferably to applying
these means to the limbs themselves. This last practice has been
followed by a metastasis to the bowels and renewal of all the urgent.
symptoms. At times, if the habit be full, or decided symptoms of
irritation be manifested at particular spots between the vertebras,
a few leeches, or cups to draw blood from these parts, will properly
precede the employment of the other local means. As an agent of
power over the muscular system, strychnia might be used with
benefit in this stage of vegetable or West India colic, as it is in
the similar one of painters' colic.
LECTURE XXVII.
DR. BELL.
Ileus — Affinity between ileus and colic — Symptoms of ileus — Causes —
Anatomical characters— Volvulus, or intussusception,—Invagination of
intestine. How formed ; its varieties and termination — Diagnosis of intus-
susception — Treatment. — Preliminary inquiry into the existence of hernia —
Localization of intus-susception — For this last, bloodletting-, opium and tartar
emetic, and enemata— Venesection generally called for in ileus — Blisters —
Turpentine epithem — Dry cupping — Purgatives — Stimulants in last stage —
Other remedies — cold—tobacco injection—Other narcotics externally and
internally — Injections of linseed oil — Crude mercury in quantity. — Opera-
tion of gastrotomy — its doubtful propriety and dangerous consequences.
To a certain extent embarrassed by the nosological divisions of
colic, and the ideas still entertained by some of there being several
kinds of the disease, I have not been as free as I could wish to present
the whole subject in a condensed shape. Early, however, in my lec-
ture before the last, I warned you not to look for any broad line of
distinction between these alleged different kinds, but really only varie-
ties of one disease, differing not so much in the organ or organs impli-
cated^ in the extent of the affection. I told you that colic, beginning
SYMPTOMS OF ILEUS.
331
as nervous or flatulent, might soon become inflammatory; and you
will have seen that, between stercoraceous colic and bilious colic
the traits are hardly differential, any more than between bilious
colic and vegetable colic. There is a general community of causes
of them all. In all, the stomach is irritable; often ejects yellow
or bilious matter; there is pain, spasm, flatus, and constipation.
Fever and inflammation, more manifest in bilious colic, are not
always wanting in stercoraceous and vegetable colic, or dry belly-
ache ; and venesection, so commonly necessary in the former, cannot
always be dispensed with in the latter. Opium and purgatives are
the chief remedies in vegetable colic; they will often suffice for
the cure of stercoraceous colic, and may be mainly relied on in
some cases of bilious colic. I shall now advance a step farther,
and give you a description of the most aggravated form of colic
disease, the highest grade of the series of morbid phenomena the
beginning of which was manifested in nervous or flatulent colic.
This close affinity is distinctly affirmed by Dr. Abercrombie ; and I
cannot better introduce the present subject to you, than by using
the words of this eminent physician and pathologist in his account
of ileus.
Symptoms. — " Colic and ileus are different degrees of the same
affection, and the name, therefore, may apply to both. The symp-
toms, in the early stages, are pain of the bowels, chiefly twisting,
with great severity round the umbilicus, obstinate costiveness, and
generally vomiting, but without fever, and commonly at first with-
out tenderness; the pain, on the contrary, being rather relieved by
pressure. As the disease advances, and if no relief be obtained,
the abdomen becomes tense, tender, and tympanitic; the vomiting
very often becomes stercoraceous, with severe tormina, intense
suffering, and rapid failure of strength. In this manner, the disease
may be fatal without inflammation, or, at an advanced period, it may
pass into inflammation, and be fatal by extensive gangrene." (Pa-
thological and Practical Researches on Diseases of the Stomach
and Intestinal Canal and Liver.) In many instances ileus super-
venes on some one of the varieties of colic already described; and
hence, in addition to other considerations, the propriety of a general
and enlarged view of the entire pathology of colic, and consequent
vigilance in observing a transition from the slight to the more
serious and severe. But, seldom it is true, ileus is suddenly usher-
ed in with the most violent pains in the abdomen, and vomiting ;
the patient tossing about in the utmost agony, and the other symp-
toms supervening, and the disease terminating fatally. Syden-
ham's notice of ileus, or the iliac passion, as it has been often termed,
is very short. " In this disorder the peristaltic motion of the bowels
is inverted; cathartics and glysters soon become emetic, and the
excrements are vomited up." His description of bilious colic is,
however, applicable, in its chief features, to ileus; and Pringle com-
plains of his having transferred that of the latter to the former.
The true iliac passion, in which there is a total inversion of the
332
DISEASES OF THE DIGESTIVE SYSTEM.
peristaltic motion, is a rare disease: the author just mentioned
never saw but one case, and that terminated fatally.
The appearance of the tongue varies in different cases and
stages of the complaint; but often it deviates little from the healthy
state. Pain or local disease is not referrible, at the beginning, to
any particular region of the abdomen ; sometimes it is felt in the
ileo-csecal region; sometimes in the sigmoid flexure, or in the
transverse colon: in others, again, about the umbilicus, or low in
the pubic region.
I shall not repeat the enumeration of the organic changes in the
intestine observed in fatal cases, which Dr. Copland has given in
his Dictionary; to which I refer you for these and many other
particulars of the disease. Dr. Abercrombie has recorded cases
of fatal ileus, in which the intestines were found distended without
inflammation: others, in which there was gangrene without exu-
dation and also with exudation. He next adduces cases in which
there had been " previous disease, of such a nature that it seemed
to act by deranging the muscular power without mechanical ob-
struction ;" and afterwards ileus, with mechanical obstruction or
other organic changes in the structure of the parts ; one example
of which was presented in a remarkable stricture of the arch of
the colon. Tympanites is sometimes associated with ileus, and is
always of bad augury.
The causes of ileus are very various ; generally they are the
same as those of colic and enteritis, with the addition of others
depending on mechanical obstruction. Pringle thinks that children
and those who are delicate are, perhaps, more liable to it than men
in the vigour of life. It is, I think, more frequently met with in
cholera infantum than in any other one disease induced by causes
not acting primarily by obstructing the bowels. Pringle mentions
two cases in which it preceded a fit of the gout.
Anatomical Characters. — The observations of Dr. Abercrombie
and others leave no doubt that there is a remarkable variety in the
morbid appearances in those cases which are usually included
under the term ileus: sometimes it is simple distention without any
change of structure, and at other times extensive inflammation and
gangrene. Obstruction, which is a not unfrequent cause, is, in
other cases, not to be found. " It would, therefore, appear probable,"
says Dr. Abercrombie, " that, in the cases which assume the cha-
racters of ileus, there is great diversity in the primary state of the
affected parts; that, in some, it consists of simple loss of muscular
power, though it may pass into inflammation at an advanced
period; while, in others, it is at an early period connected with
inflammation as a part of the primary disease." When,, in ileus,
we find gangrene uncombined with any other morbid appearance,
we are, perhaps, Dr. A. thinks, warranted to conjecture that the
muscular coat has been the principal seat of the inflammation.
As respects the precise part of the intestine diseased in ileus, —
the morbidly distended, or the contracted,. — Dr. Abercrombie
ANATOMICAL CHARACTERS OF ILEUS. 333
thinks it most probable that " the distended part is the real
seat of the disease, and that the contracted part is not contracted
by spasm, but is merely'collapsed, because it is empty, — its mus-
cular action being unimpaired." Still repeating the language of
Dr. Copland on this head,—spasmodic constriction evidently exists;
for, independently of the occasional detection after death of a more
contracted state of a part of the bowel than can be considered na-
tural, we cannot explain various phenomena connected with colic
and volvulus without its aid. Besides, continues Dr. C, its existence
is supported by analogical evidence; for it is a principle in the human
economv, that all membranous, and, a fortiori, all muscular canals,
contract spasmodically or inordinately upon irritation of their inter-
nal surfaces.
Volvulus or ileus from intus-susception,muGrg7na//o7iq/Me intestine,
is not unfrequently met with in post mortem examinations. At one
time great and undue importance was attached to this change,
which was supposed to explain and be a cause of the fatal ter-
mination of the disease. More careful observation, however,
shows, not only that intestinal invagination is often unconnected
with inflammation, but that it is an accidental and not necessarily
fatal consequence of preexisting disease; and even if it takes place
some time before death it does not present that obstruction to the
passage downwards of the contents of the bowels and of medicines
which was thought formerly to be one of its inevitable effects.
The readiness with which invaginations are removed by the re-
storation of the intestine to its normal situation, in the dead body,
and the frequency with which they are seen after deaths from
acute gastro-enteritis, render it probable that these displacements
have occurred and been removed by a natural retraction of the
intestine, in those who have recovered from ileus and other dis-
eases in which strong intestinal commotion has been experienced.
The ileum and jejunum are the portions of intestine most frequently
implicated by invagination, which may take place from above
downwards, or in a contrary direction; that is to say, sometimes it
is the upper portion of the intestine which descends or falls into the
lower and dilated portion; and at other times the upper is the
recipient or hood, as it were, of the lower portion. The first va-
riety, however, is the most common ; but it is not unusual to meet
with both it and the second in the same subject; and even, sometimes,
to see a particular part of the intestine, more dilated than the rest,
receive a portion from above and another from below, so that the
two varietiesof invagination, in different directions, meet at the same
point. In the extent of intus-susception there is great latitude ; in
some cases it is only a few lines, in others as many inches. The
whole ileum, and even a part of the jejunum, has been found con-
tained in the caecum and ascending colon ; and we are told of a
case in which the caecum and the first part of the colon, filled by
the small intestine, themselves occupied the lower part of the colon
and rectum.
334
DISEASES OF THE DIGESTIVE SYSTEM.
In regular invaginations, the mucous membrane of the dilated or
containing portion is in contact with similar membrane of the
narrower or contained portion above : so, likewise, between the two
portions on the other, or peritoneal side, the serous surface is also in
contact with its like. The invagination exhibits, therefore, three
thicknesses of the intestinal parietes, viz., the central or entering
'portion, the external or containing and the intermediate one, con-
tinuous from the first to the second. If we open with a bistoury
the external portion, we see in its cavity a sort of cone or nipple,
of more or less length, free in all directions, and exhibiting on its
surface valvules conniventes, while at its summit or projecting ter-
mination there is an opening which gives passage to intestinal
matters: the disposition of parts is, in fine, precisely like that
which is seen in prolapsus of the intestine through the opening in
artificial anus. I have thought that this description of invaginated
intestine, the accuracy of which is easily tested by observation on
the body after a case of death from ileus, and for which I am in-
debted to M. Begin (Diet, de Med. et de Chir. Prat.), would not
be without interest and instruction, by serving to correct common
misconceptions as to the real nature and the effects of this dis-
placement.
The occasional causes of intus-susception are worms, inflam-
matory action of some one of the intestinal surfaces, and as a
consequence of dysentery and chronic diarrhoea, particularly the
dysentery of warm climates, in the dissection after death from
which Mr. Annesley has frequently found it. Dr. Copland has met
with it " not unfrequently" in fatal cases of the brain or its mem-
branes in children. One of the most common causes of invagina-
tion of the intestine is, as the same author justly remarks, the
inappropriate use of drastic purgatives. In all the cases of inva-
gination observed after death from dysentery that Dr. Copland has
perused, purgatives had been unsparingly and unnecessarily exhi-
bited. He cites a case which occurred to M. J. Cloquet, wherein
a female died of enteritis occasioned by a polypous excrescence
arising from the mucous surface, and which, having been pushed
onwards by the peristaltic action of the intestine, dragged the part
to which it was attached along with it. Among the occasional
causes may be likewise mentioned costiveness, which acts by pro-
ducing local irritation followed by dilatation.
The termination of volvulus or invagination is by a restoration
of the displaced intestine to its normal state, and removal of the
disease; in death without inflammation, or, finally, in death with,
and we may Relieve on account of, inflammation, and that com-
monly of the peritoneal coat. It is of this last mode of termination
that I shall speak. I mentioned, when describing the changes in
the relation of the portions of the intestine which constitute invagina-
tion, that two parts of the surface of the serous membrane are in
apposition on one side, as two parts of mucous surface are in
similar contiguity on the other side. Now, as long as there is no
VOLVULUS OR INTUS-SUSCEPTION.
335
change on these surfaces by inflammation, they are capable of
gliding readily on each other; and the subsidence of morbid dilata-
tion in the containing part of the intestine, and equalised muscular
power in its coats, will enable the displaced part to resume its
natural position. But if the serous membrane is the seat of in-
flammation and throws out coagulable lymph, this will, after a
while, become a bond of union between the two surfaces, and they
will adhere permanently, or at least so long that the function of the
intestine is perverted, and peritonitis destroys the patient.- The
readiness with which a morbid change of this nature is brought
about, is much greater when the intestine is invaginated by the
protruded or containing portion coming from below. The contents
of the intestinal canal, on arriving at the invaginated portion, are
suddenly arrested in their passage downwards by the base of the
projecting cone of invaginated intestine, accumulate at the angle
made by the turn of the mucous membrane upwards, and, by com-
pressing the base and sides of the cone, contribute not a little
almost to obliterate the opening at its summit, which was at the best
small, and which was the only passage for the transmission of the
matters from the upper portion of the intestine. Thus there is
established an obstruction equivalent almost to strangulation of the
intestine, and the life of the patient is in imminent danger. Should
the invagination be slight, the pressure of the contents of the intes-
tine from above against the base of the invaginated cone may help
to remove it, and things take their natural course.
If, on the other hand, the invaginated portion be from above and
project downwards into the cavity of the intestine, the danger is
much less. The descending contents, it is true, on reaching the
invaginated portion, come to a narrower canal than natural, and
are somewhat retarded in their course; but they pass through an
opening which corresponds with the base of the cone, and escape
from its projecting, though narrow mouth, with much more facility
than they could have found entrance into it, if it had projected
upwards or had been the end of an invagination from below upwards.
Even if the parts become adherent, the duplicated, or rather tripli-
cate walls of the canal at the invaginated section, become merged
into one, which gradually dilates more and more, and offers slight
resistance to the passage of the intestinal contents.
Even in the worst or upward form of invagination, already de-
scribed, unexpected relief by a natural process has been procured.
The internal part of the invagination, or the protruded section of
the intestine on which the contents of the upper portion of the diges-
tive tube are continually pressing, becomes gangrened and sepa-
rates, but not until adhesions are ready to be formed at the outer
base of the invaginated fold, which preserve the continuity of the
entire tube. The internal or protruded portion, being now detached
in all its circumference, is carried downwards to the rectum, and
expelled with fecal matters at stool. Occurrences of this nature,
extraordinary as they may at first seem, have been proved to take
336
DISEASES OF THE DIGESTIVE SYSTEM.
place, by the fact of portions of intestine, some lines in length, and
whose structure was accurately ascertained by dissection, having
been found, after their expulsion per anum. (Begin, op. cit.)
In framing the diagnosis of intus-susception, it has been asked;
whether it is possible to distinguish ileus owing to or connected
with this state, from colic or ileus arising from other pathological
states ? Dr. Copland thinks, that in some instances symptoms
may present themselves which will enable the observing practitioner
to infer the existence of invagination. These are,—sudden invasion
of the symptoms of severe colic or ileus after a violent straining at
stool; and, subsequently, the constant desire to go to stool, attempts
at evacuation being accompanied with violent tormina and tenes-
mus, and either unattended by evacuation or followed by the dis-
charge of a little bloody mucus, and these by symptoms of enteritis.
" In some instances, also, the sudden occurrence of an elongated
tumour, in addition to these symptoms and before abdominal dis-
tention comes on, will further guide the opinion; particularly if the
invagination be extensive, and seated in the caecum or course of the
colon. Much, however, will depend on the precision and tact with
which an examination of the abdomen is made. In all such cases
the rectum should be examined by the finger; and the extent to
which enemata may be thrown up observed as an additional means
of information ; for, whenever the intus-susception is in the colon,
as much fluid cannot be thrown up as in health. Hiccup, and a
small, irregular pulse, characterise the advanceddisease,and indicate
the existence of inflammatory action in the invaginated bowel."
Treatment.—Our curative measures are the same in ileus as in the
other kinds of colic, viz., bloodletting, purgatives, enemata, opium,
the warm bath, fomentations, blisters, and other external irritants.
Let me premise, however, to any specification of the relative value
and order of administering these remedies, a caution already given
when treating of common colic, viz., to examine carefully and
minutely the various regions of the abdomen, particularly the two
iliac and the umbilical, in order to ascertain whether or not the
patient is suffering from hernia. Nor must we be satisfied with
one examination, nor have our suspicions allayed by not finding a
tumour prominent externally, or felt with the fingers pressing on
the part, for sometimes a very minute portion only of the intestine
is strangulated, and yet ileus may exist and death ensue. On this
occasion we must be guided to a certain extent in our diagnosis by
the symptoms already laid down as indicative of the locality of the
invaginated intestine. Thus, if the patient suffers from violent
attacks of tormina, occurring in paroxysms, like the strong impulse
downwards from the action of a drastic purgative, — the action
proceeding to a certain point, — then stopping and becoming in-
verted, followed by vomiting; and this point referred to is in
either of the inguinal regions or at the umbilicus, we may suspect
that the intestine is protruded, out of place, and strangulated. A
correct diagnosis will not a little influence us in the kind of treat-
TREATMENT OF ILEUS.
337
ment we are to pursue. If there be invagination or hernia, we shall,
of course, refrain from active, certainly drastic purgatives, and
begin with venesection —followed by opium and tartar emetic; and
having emptied the lower bowels by a common purgative enema,
administer laudanum per anum. Belladonna ointment or tincture
rubbed over the region where the invagination or strangulation is
believed to exist, has been productive of good effects. The warm
bath is a useful auxiliary to these means; but to be serviceable it
ought to be used for an hour or more at a time.
In common, knowing the tendency of ileus to end in inflamma-
tion, we ought not to be backward in having early recourse to the
lancet. There is reason, also, to believe, as Dr. Abercrombie has
pointed out, " that there is a modification of the disease depending
on inflammation of the muscular coat, and therefore not exhibiting
the characteristics of enteritis, but simply of ileus, though in a very
violent and rapidly fatal form." On this ground we ought to bleed ;
and it must have been noticed by every practitioner, as quite re-
cently I have had occasion to observe in a case under my care,
that the relief is often immediate, a call to stool being made almost
as soon as the arm is tied up. Pringle (op. cit.) recommends
bleeding largely and often as long as the violence of the symptoms
remained, or whilst the strength permitted. " If after the first
bleeding the patient was not sensibly better, in a few hours the vein
was opened a second time, and immediately after a blister (as
large as the palm of the hand with the fingers) was applied over
that part of the belly which was most affected." More than once
the author tells us, that he has known the patient to be relieved in
his bowels as he felt the burning of his skin, and at the same time
have stools by a purge or clyster which had been given before
without effect; and hence he concludes, that the blister acts more
as an antispasmodic than an evacuant. To the same practice is
Dr. Abercrombie led ; and indeed it is that which most observing
practitioners must have found efficacious under similar circum-
stances with those now described. If time and opportunity favour,
I premise a. pack of Jeeches over the affected spot, and after the
blood from them has ceased to run, to apply, the symptoms still
seeming to require it, a blister. A better application even than
the blister, especially after leeching, is a hot spirit of turpentine
fomentation placed over the whole abdomen, as strongly recom-
mended by Dr. Copland. Dry cupping on both the loins and abdo-
men has the authority of CelSus, and, still more, subsequent expe-
rience in its favour. Quarin states, that in an extreme case, all other
means having failed, he had recourse to dry cupping with porcelain
bowls. Relief soon followed, and the bowels were copiously eva-
cuated, their action having been assisted by enemata of infusion of
chamomile flowers, and the potassio-tartrate of soda.
In general, active purging is not required in ileus; and it may,
especially in cases of obstruction from displaced intestine, be
positively mischievous. But where the stomach is irritable, and
vol. i.—29
338
DISEASES OF THE DIGESTIVE SYSTEM.
the patient vomits from time to time, calomel, from ten to twenty
grains, in the form of a pill, with, if the pain be violent, a grain of
opium, or ten grains of camphor, will serve both to allay the sickness
of the stomach, abate the morbid muscular action of the intestine,
and bring on evacuations per anum. Hyosciamus or belladonna
may be advantageously united to calomel, if it is thought advisable
to repeat its use, at intervals, in smaller doses. When the patient feels
that the medicine has traversed his bowels, and there is a passage of
wind downwards and a desire to go to stool, free evacuations may
be procured by administering, at this juncture, turpentine enemata
with castor oil, as already recommended for constipation in caecal
accumulation and in stercoraceous colic. Even taken by the mouth,
the oil of turpentine is, I think, a good succedaneum to the calomel,
and in its direct effect on the bowels contributes to equalise the
action of the muscular coat, and thus to remove some of the most
pressing morbid symptoms. This remedy is still more highly prized
in the advanced or sinking stage of the disease, in which there is
constant and feculent vomiting. I have found that, in some cases,
after the most active and approved purgatives, — calomel and aloes,
or calomel and rhubarb, compound powder of jalap, &c, have failed
to operate, that the infusion of senna and salts has had this effect very
entirely. Even Epsom salt alone, taken in small and oft-repeated
doses in a considerable quantity of fluid, answers the purpose when
many other articles of more power disappoint me. Croton oil in
a full dose has procured a passage and given a salutary turn to the
disease in some cases apparently desperate. In the advanced stage,
stimulants with purgatives, as tincture or wine of aloes, compound
tincture of senna, and the like, alternating with ammonia and
essence of peppermint or aniseed, and the stimulating embrocation
before mentioned, serve wonderfully to revive the strength and
sinking powers of life, and to give a salutary turn to the disease.
Among the remedies of undoubted power, but which are attended
with more risk than the ones already mentioned in ileus, I may
mention cold and the tobacco injection. Physicians in Germany,
France, and Great Britain, have attested to the decidedly remedial
effects of cold, particularly when applied to the abdomen, in the early
stage of the disease. Some have had cold water dashed over the
lower extremities and abdomen of the patient while he was kept in
a standing posture ; but the preferable method is to apply it to the
abdomen itself. Dr. Brandes of Copenhagen states, that he has
employed iced drinks, and cloths wetted with iced water, to the
abdomen in ten cases with success; but that, in some instances, the
practice requires to be persevered in for a length of time, and to
be assisted by antispasmodic and laxative enemata, and by opiates,
with stimulants and tonics taken internally. (Copland, op. cit.) If
the conviction of the physician is decidedly strong in favour of the
use of cold in ileus, he ought to have recourse to it early, or at least
after trial has been made of bloodletting and opium, and before the
tone and power of reaction in the system have undergone any
notable abatement.
TREATMENT OF ILEUS.
339
The remark just made respecting cold will apply to the use
of tobacco. If a purgative will not pass, and purgative ene-
mata are ineffectual, and bloodletting and opium have been em-
ployed without success, it will then become a question for the
physician to decide, whether he proposes to use tobacco in the
case. If he has confidence in its powers, and believes that it can
be administered in such a dose as not to be deleterious, he will resort
to its use at once, before the powers of life are prostrated by the
disease. He will not be unmindful, on this occasion, of the cases of
death from tobacco enemata witnessed by Desault, Ansiaux, Ugard,
Sir Astley Cooper, Sir Charles Bell, and Dr. Copland. In the
case recorded by this last-named writer, an injection, made by
infusing half a drachm of tobacco in a pint of water for fifteen
minutes, was followed by death in three minutes after its adminis-
tration. In most of the fatal cases, however, a large quantity of
tobacco, or an ounce to an ounce and a half, was used to prepare
the infusion. On the other hand, he will derive encouragement from
the authority and practice of Sydenham, Heberden, Abercrombie,
and others; the two first of whom recommend the smoke of tobacco,
which is milder in its operation, and if we could, by an appropriate
apparatus, secure its ready and complete administration, would be
generally, if not always, entitled to a preference. Heberden, indeed,
tells us: — "Where the proper instrument for giving the smoke
cannot be had, then an infusion of tobacco may be used, made of
twelve ounces of boiling water, poured upon half a quarter of an
ounce (one drachm). This infusion has been borne without occa-
sioning vomiting or sickness, but has seemed to affect the head more
than the smoke." Dr. Abercrombie's high opinion of tobacco in-
jection, and his cautious mode of administering this medicine, have
been placed before you in a preceding lecture (p. 315), and I need not
repeat them in this place.
Respecting the use of the cataplasms of tobacco leaves on the
abdomen, recommended by some writers in this arid some other
diseases, I have nothing to say in commendation. There is much
uncertainty in the operation of tobacco applied in this way: some-
times it has no effect, at other times all the depressing and alarm-
ing effects of the drug ensue. Other medicines of the class Sola-
nacece might be employed with a view to produce similar results
to those of tobacco, and with less danger. Within these few years
past we have seen, in the Medical Journals, accounts of cases of
incarcerated hernia, and all the symptoms of strangulation, as also
retention of urine and spasmodic contraction of the uterus, relieved
by the use of belladonna. It was applied in the form of ointment
rubbed on the hernial tumour. I have already suggested its use in
this way in severe colic; and take this opportunity of recommend-
ing it in the disease before us, and especially in case of volvulus,
rubbed on the skin of the abdomen corresponding with the inva-
ginated intestine beneath. The belladonna might also be used as a
suppository. In the stramonium which is so readily procured, we
have an analogous remedy of the same class, and which may be
340
DISEASES OF THE DIGESTIVE SYSTEM.
used both in the form of ointment to the affected region, and
internally of pill by the mouth, and suppository per anum.
Among the simple remedies to which recourse has been had, and
occasionally with success, may be noticed, injections of warm water
in a full and continued stream, carried up into the colon; inflation of
the intestines by air; large injections of linseed oil — from two to
four pints. Dr" Musgrave, who speaks well of the use of this last,
directs that it be steadily and slowly thrown up, regurgitation
being prevented by pressing the guard of the pipe against the anus.
He found it to be remarkably successful, even after feculent vomit-
ing had come on, and the usual means had failed. He recom-
mends, in such cases, the patient to be placed on the right side,
with the pelvis elevated above the rest of the body; the premature
return of the injection being prevented by firmly pressing a ball of
linen against the anus. This clyster is to be repeated every three
or four hours until relief is obtained ; and, when much exhaustion
is present, with the addition of laudanum.
The ingestion of crude mercury to the extent of one or two
pounds, particularly where invagination is suspected, has been long
an occasional remedy in ileus ; and there are not wanting cases of
success attending its use. Dr. Copland has seen a female, aged
between thirty and forty, relieved from this state of disease by the
ingestion of two pounds of common shot. This writer very pro-
perly recommends that bloodletting, the warm bath, and enemata,
should generally precede the administration of lead or quicksilver.
The last resource, but one of more than doubtful propriety, con-
sists in exposing the invaginated portion of bowel, by making an
incision through the parietes of the abdomen, and then freeing it, or
allowing it to free itself, of the displacement. Dangerous as this
operation must necessarily be, it has, however, been performed, and
not always unsuccessfully and with fatal results. Nuck is referred
to by Dr. Copland as recorder of a case in which it was success-
ful. Dr. Fuschius, also, (Hufeland's Journal, for February, 1826,)
gives a case in which, after an exhibition of the diagnostic symp-
toms already recorded, he performed an operation over the place
to which the patient referred the sensation of obstruction, and
where an obscure oblong tumour, in the situation of the ascending
colon, was detected. An invagination of the colon was removed,
and the patient perfectly recovered. (Copland, op. cit.)
On the other hand, we must be aware that a tumour, well de-
fined and obviously the seat of pain and distress, may be of chronic
growth, and embrace the teguments adjoining the intestine, as at
the caecum ; and, of course, that it cannot be benefited by an
operation. In a case of this nature, marked by constipation, fecal
vomiting, hiccup, &c, gastrotomy was performed by M. Monod, one
of the surgeons of the Hospital Cochin, at Paris. After exposing a
portion of intestine, which proved to be the colon, the surgeon
replaced it, and, inserting his finger into the wound, drew down
gently a loop of the small intestine, which was red and tumefied,
and into which he took a fancy, for reasons not explained, to,
PAINTERS' COLIC.
341
make an opening with scissors to the extent of about an inch and
a half. A quantity of fecal matter flowed out, and the patient ac-
knowledged that she experienced great relief. — But on such terms !
A ligature was applied through the mesentery of the divided intes-
tine, and retained at the edge of the wound by means of strips of
adhesive plasters, light dressings were applied, and the patient put
to bed. On the following day the loop of intestine was found to
have retracted inwards; but it was easily found, and was then
fixed more securely than before, by means of two sutures. The
patient became rapidly worse, and she died on the following day.
Examination of the body showed that, while the surgeon had
inflicted an injury on the small intestine which was of itself suffi-
cient cause of death, he had not reached the real seat of obstruc-
tion, nor, had he reached it, could he have removed it. On
opening the abdominal cavity, some sero-purulent fluid flowed out;
the convolutions of the intestines in the pelvis were coated with
semiconcrete pus, and were redder than the other portions of the
canal. The intestine which had been opened in the operation
proved to be the ileum, eight or more inches above the caput coli;
a very trifling adhesion had taken place at the seat of the artificial
anus. On examining the intestinal canal, for the purpose of disco-
vering where the obstruction had been seated, it was found to be at
the point of junction of the caecum with the ascending colon ; the
contraction of the tube was so considerable, that the point of the
little finger could scarcely be passed through it. The caecum rested
posteriorly on an indurated mass of scirrhous-like formation; but
the mucous coat of the gut was not injured. The other portion of
the intestinal canal exhibited no marks of disease, with the excep-
tion of patches, here and there, of redness. (Archiv. G&n., 1838.)
The duration of the disease, which was manifested by swelling in
the ileo-caecal region, constipation succeeding diarrhoea, and vomit-
ing, at first bilious, and afterwards stercoraceous, ought to have
deterred the surgeon from operating. Three months nearly had
elapsed from the time of the first symptoms appearing to that of the
operation.
LECTURE XXVIII.
Painters' Colic—Effect of metallic poisons on.the nervous system— Symptoms
of painters' colic — Pathology of neuroses — Action of lead on the system —
Abdominal and cerebral symptoms—Species of painters' colic — Dr. Thomson's
researches on lead — Effects of, in animals — Effects of, on the generative
system.
A great deal of our time has been already occupied with the dis-
eases of the digestive system—in fact, much more than I originally
intended; the only apology I have to make for this, is the deep
and paramount importance of the subject.
29*
342
DISEASES OF THE DIGESTIVE SYSTEM.
The disease next to be considered is called painters'colic, from
the circumstance of house-painters being extremely liable to it from
comino- into frequent contact with the poison of lead. Its synonyms
are numerous, dry colic, saturnine colic, rachialgia metallica, De-
vonshire colic, &c, &c.
Painters' colic is an example of the effects of a metallic poison
on the nervous system. There are certain metals which produce
a powerful effect on the system, not by means of their corrosive
properties, or by any direct action on the surface to which they are
applied, but by a peculiar impression made upon the nervous
system. Thus we find that mercury, under certain circumstances,
will give rise to a very singular nervous disease; arsenic may be
introduced into the system in such a way as to produce symptoms
of nervous lesion ; copper exercises a similar morbid influence,
and the effects of lead are universally known. I do not mean to
say that all these metals produce similar effects on the economy,
for this is not the case ; but there is one point of agreement between
them, that all may produce symptoms which are called nervous or
neurotic, and the diseases thus produced are classed among the
neuroses. What is the meaning of this term neurosis? A lesion
of nervous function, more or less complete, occurring independ-
ently of any demonstrable organic change. A neurosis, then, is
an alteration in the functions of the nerves of organic and animal
life, the nature of which alteration we cannot understand, neither
can it be demonstrated by the knife, nor by any examination of the
state of the nervous tissue. In other words, a person will die with
the symptoms of a neurosis; and when you come to examine the
body, you will be unable to detect, in the minute ramifications of
the nerves, the trunks, or the nervous centres, any appreciable lesion.
Diseases of this description have been divided into two classes —
active and passive neuroses. Active neuroses signify an increase
or exaltation in the nervous function ; passive neuroses are those in
which there is a diminution of nervous energy; in both, there is an
absence of perceptible organic change. Take, for instance, an
example from the nerves of animal life: a case of convulsions,
independent of organic disease, is an example of the active neurosis ;
a case of paralysis, under similar circumstances, is an example of
the passive. In the former, there is an exaltation of the nervous
function, which is reflected upon the muscular system ; in the
latter, there is a diminution, producing a partial or total loss of the
power of motion. It has been asserted, by eminent physiologists,
that passive neurosis can only exist in the organs of the life of
relation, because the functions of the ganglionic system, which
presides over organic life, cease only at the death of the individual.
But there may be such a thing as semi-paralysis of the organs to
which the ganglionic nerves are distributed ; and hence we may
have passive neuroses of the system of organic as well as of animal
life. VVe get a good idea of these neurotic affections, by taking
some of the most remarkable instances of this kind. Hydrophobia
is a remarkable instance of excessive lesion of the nervous function,
PAINTERS' COLIC.
343
without any known organic change; so is tetanus, and so are some
forms of apoplexy, convulsions, and mania. Here we have violent
irritations of the nervous system, in which there is no perceptible
organic change; and where the only information we derive from
pathological anatomy is of a negative character, telling us what
these diseases are not, and leaving thus, as to their actual nature, as
much in the dark as ever. We find by dissection that hydrophobia,
and tetanus, and hysteria, and convulsions, and apoplexy, are not
caused by inflammation of the brain or spinal marrow, and that is
all. Hydrophobia, tetanus, convulsions, and hysteria, are instances
of active neurosis; paralysis and apoplexy, without any known
cerebral disease, are looked upon as examples of the passive kind,
because they present either a diminution or abolition of the nervous
function.
In the present state of medical science, we must admit this
division of the affections of the nervous system into diseases with
and without perceptible organic lesion. I grant that it is very diffi-
cult, when we come to consider alterations in the functions of parts,
to conceive how such changes could be effected without molecular
alterations, or that the brain could be deranged in its functions,
without some change of this kind. We are, however, compelled to
consider such functional alterations of the nerves as changes with
which we are unable to connect any process of hardening, or soft-
ening, or anemia, or congestion, or, in fact, any known pathological
condition. Rostan is of opinion that all diseases are organic ; that
is to say, that they are produced by some molecular change, and
this, he says, should be the basis of medicine. Unfortunately for
medicine, it has been given so many bases, that it sometimes knows
not what leg to stand on.
But to return to our subject. Painters' colic is an example of
a neurosis, that is to say, it is a lesion of the nervous function, un-
connected with any known pathological alteration. It presents,
commonly, two periods — the first exhibiting the phenomena of ac-
tive, the second of passive, neurosis ; or,in other words, the signs of
exaltation of the nervous function precede those of depression. In
the majority of cases, we find the first stage of this affection charac-
terised by violent spasm, pain, and convulsions, symptoms indicative
of active nervous lesion ; whereas, in the second stage we have
paralysis, the diagnostic mark of the passive kind. This is the
order in which the phenomena of painters' colic are generally met
with, but in some cases the first stage is either very imperfectly
shadowed out, or even entirely wanting ; the paralysis comes on in
an insidious manner, and without being ushered in by any symp-
toms of exaltation of the nervous function.
In this country, the most common victims to this disease are
painters, who are much in the habit of working in white lead, and
when you are connected with the management of any public
medical institution (as I hope you will all be), you will often have
to treat cases of this description. In Dublin, and all large cities, it
is an exceedingly common affection, and the patients are for the
344
DISEASES OF THE DIGESTIVE SYSTEM.
most part house-painters. Next to these, the persons who are most
subject to it are plumbers, and those who are employed in the melt-
ing of lead.
When the poisonous particles of lead enter the system in a highly
volatilized state, its morbid effects are more certain and extensive.
Every house-painter will tell you that the kind of work which is
most* likely to produce a deleterious effect, is painting " the dead
white" or, as it has been termed, statuary white. In doing this,
they use white lead combined with a large proportion of the oil of
turpentine, and, in order to produce the intended effect, they are in
the habit of excluding the air as much as possible. By means of
the turpentine and the warm temperature of a close room, the lead
is volatilized, and, in this state, appears to have an extraordinary
power of impregnating the system. Some of the very worst cases
of painters' colic are produced in this way. Painting in the open
air, even where the same preparation is employed, is comparatively
harmless. A poor fellow, who was for a considerable time under
my care, assured me that he had escaped for twenty years, and was
convinced that he would have enjoyed a much longer immunity, had
he not been put to work at the statuary while in a close room.
With respect to plumbers, it is now ascertained that this disease
is of comparatively rare occurrence,among them; and the reason
of this is, that they generally work in the open air, or in well ven-
tilated apartments, and have now but little to do with the actual
manufacture of lead. The kind of lead which they generally use,
sheet and pipe lead, is furnished from the manufactories, and their
occupation principally consists in the moulding and soldering of it.
We very seldom now see a plumber labouring under colic.
Painters' colic may be observed under a great variety of forms ;
but, for the convenience of studying the disease, we may divide
these varieties into four classes. In the first, we have the pheno-
mena of simple colic, without any obvious or marked symptoms of
bilious, gastric, or cerebral derangement. In the second variety,
the disease assumes a more decided character ; the colic is compli-
cated with symptoms of fever of a gastric character, the pain in
the belly is more acute, the constipation more obstinate; there is
pain and difficulty in going to stool, nausea and vomiting, with oc-
casional headache, dyspnoea, and sense of constriction about the
prascordia; the belly is hard and retracted, and there is often pain
in passing urine. In the third variety we have a more formidable
array of symptoms. The functions of the brain and spinal marrow
are deranged ; there are wandering pains in the extremities ; and
the patient has frequent attacks of violent convulsions, resembling
those of epilepsy. He also labours under the abdominal symptoms,
but in this stage they are not so well marked, or so distinct, as in
the former; the lesions of the functions of the cerebro-spinal system
begin now to exhibit a greater degree of preponderance, and claim
me principal share of the attention of a symptomatolo"ist. In the
iourth variety there is paralysis, without being preceded by the
ordinary symptoms of abdominal or cerebral derangement. A
SYMPTOMS OF PAINTERS' COLIC.
345
medical friend of mine met with a case of this kind not long since.
He was called to visit a child who had lost the use of his limbs.
He went, and found the child lying in bed perfectly quiet and easy,
his intellect sound, and his spirits good, but labouring under com-
plete paralysis of all his limbs. He inquired minutely into the
history of the case, and made a most scrutinizing examination, but,
from all he could see or learn, there was not the slightest ground to
suspect disease of the brain or spinal cord. There had never been
any symptoms of colic. He was puzzled with the case, and tried
one thing after another without benefit. At length he found out
that the child's father was a painter by trade, and this led him to
suspect that the symptoms might have some connection with the
poison of lead. He inquired ; and was told by the mother that a
quantity of white lead had latterly been kept in the room, and that
it was impossible to keep the child from it. He instantly had the
paint removed, a free current of air admitted into the room, and by
the use of purgatives, assisted by stimulating frictions, the child
recovered.
Symptoms. — The following is the order of symptoms generally
observed in this disease.* First, we have the precursory, denoted
* [Prior to the development of more decided forms of dis-
ease, there are effects produced on the system by lead, constitut-
ing what may be called "a saturnine diathesis." The prin-
cipal marks by which this state may be recognised are, according
to JV1. Tanquerel, who, in his Traite des Maladies de Plomb
ou Saturnines, has entered largely into the subject, are a pecu-
liar bluish or bluish-gray tinge of the gums, which sometimes ex-
tends over the mucous membrane of the mouth generally, the
teeth at the same time becoming discoloured and affected with caries;
a sweetish, styptic, astringent taste in the mouth, with a peculiar
fetor of the breath, sallowness of the skin, and a dull yellow tinge of
the conjunctivae ; general emaciation, and a small, soft,compressi-
ble pulse, and, in some rare cases, a considerable reduction in the
number of its beats: of these symptoms, the discoloration of the
gums and teeth is the most frequent and the most characteristic.
It appears to be owing to the deposition of a very minute film of
sulphuret of lead on the mucous surface and on the enamel of the
teeth, the former becoming of a bluish slate-gray colour, as before
mentioned ; the latter of a brown colour, which is deepest at the
neck of the tooth, or the part in immediate contact with the gum.
The importance of a knowledge of and attention to these premoni-
tory symptoms is shown by a statement of M- Tanquerel, from
which it appears that, of 1217 cases of this affection coming under
notice, 1195 had been previously affected with one or more of the
symptoms specified, a timely attention to which, on the part of the
person himself, with temporary cessation from work, has in many
instances been successful in averting the threatened attack.—
(British and Foreign Medical Review, Oct. 1840.)—B.]
346
DISEASES OF THE DIGESTIVE SYSTEM.
by pain and sensation of weight about the epigastrium ; a weak, small
pulse ; general languor and weakness of the muscular system ; want
of appetite; cold, clammy skin; a tremulous and coated tongue.
At this period there is sometimes diarrhoea. Then comes some ex-
citing cause, exposure to cold or wet, excess in eating or drinking,
and The disease sets in with more or less intensity. The patient is
attacked with dreadful pain in the belly, which differs from the
pain of inflammation in this, that, so far from being increased by
pressure, it is in most cases relieved. In fact, so decided is the
relief produced in this way, that there is a case on record in which
the patient used to get the greatest ease by making one of his
fellow-workmen stand upon his belly. This relief from pressure
is very generally observed in colicky affections. Indeed, so general
is it, that you will hear it frequently stated, that all cases of colic
are relieved by pressure. This, however, is not invariably true;
for I have seen cases where the patients could not bear pressure,
and where it required a careful examination to distinguish the
symptoms from those of inflammation. The pain is of a twisting
kind, and felt about the umbilicus; and, in connection with this,
there is scanty urine, with more or less pain in passing it, obstinate
constipation, and a tense, hard, retracted state of the belly, from the
violent contraction of its muscles. The upper,portion of the belly
is sometimes more retracted than the lower, and the pulsations of
the abdominal aorta are unusually distinct. The pains remits, and
then becomes exacerbated, and the patient's countenance is expres-
sive of acute suffering. - In that form of the disease where there is
a complication of gastric or bilious symptoms, the patient has a
semi-jaundiced look, a hot moist skin, quick pulse, foul tongue,
vomiting, hiccup, thirst, and epigastric tenderness.*
* \Lead rheumatism or lead neuralgia is a common effect of the
poison. It may generally be regarded as spasms or cramp-pains
of the lead colic affecting the muscles of the limbs instead of those
of the abdomen, and is most commonly a mere extension of that
disease, although occasionally observed separate. According to
M. Tanquerel, this, which he calls arthralgia, is, with the exception
of colic, the most frequent result of lead poisoning. The pain, which
is the chief symptom, occupies most commonly the lower extremi-
ties, then the upper extremities, the loins, the parietes of the chest,
the back, and the head.
Arthralgia is, with the exception of colic, the most frequent result
of lead poisoning. The liability of workers in lead to contract this
affection is, as a general observation, in direct proportion to their lia-
bility to suffer from colic, with, however, one remarkable exception,
viz., in the case of the manufacturers of red lead the flexor muscles
are more frequently the seat of pain than the extensors, the affected
muscles being, in either case, strongly and spasmodically contracted,
and their powers of motion greatly impeded : an exacerbation of
pain often occurs during the night; but there is neither preternatural
SYMPTOMS OF PAINTERS' COLIC.
347
In the third form, the chief force of the poison seems to be directed
against the brain and spinal chord. There is vertigo, headache,
stupor, and sometimes delirium ; the patient has fits resembling
those of epilepsy, but of longer duration, and violent convulsions,
which sometimes continue with unabated intensity for twelve, or
even twenty-four hours. You will see those unfortunate creatures
rolling and twisting in every form, sometimes doubled forwards,
sometimes in a state of perfect opisthotonos, sometimes moving
their limbs with the convulsive action of an epileptic, and foaming
at the mouth. In addition to this, it is stated, in the descriptions of
this disease, that the patient loses his sight, and becomes amaurotic ;
this I can confirm, for I have seen it more than once. It is a
curious fact, too, that this blindness may come on before the other
cerebral symptoms are developed. I recollect a case in which one
of the first symptoms was blindness. The patient happened one
evening to be indulging himself in whiskey-punch, and was in a
fair way of getting comfortably drunk, when, unfortunately, he
found that all of a sudden he could neither see single nor double.
He groped about in a very disconsolate state for his glass, but not
finding it, and finding, at the same time, that he had lost his sight,
he came to the hospital next morning, and shortly after his admis-
sion, had a violent attack of convulsion. In cases of this kind, I
have generally found the pupils contracted. The patients toss
about in bed, and are frequently found lying with their heads turned
towards the foot of the bed. In some cases, the breathing has been
stertorous for a length of time, and the head fixed, but the fingers
and hands were flexible. I have seen cases in which the coma
disappeared, and was followed by perfect blindness, lasting for two
or three days, and then yielding to treatment.
These symptoms, striking and extraordinary as they are, do not
seem to depend on the same state of the brain as cases of other dis-
eases which are accompanied by sanguineous determination to that
organ. Trie reason I make this assertion is, that many of the most
violent nervous symptoms, including profound coma, subside under
the use of a stimulant treatment. 1 think we may look upon these
symptoms as similar to what are termed the symptoms of the
nervous apoplexy of the ancients. A case of this kind, which
occurred in the Meath Hospital, is deserving of notice, from the
singular effect produced by treatment. The patient was in a state
of profound coma, but the head was cool, and the arteries had no
inordinate pulsation. If this was a case which presented the other
redness, heat, or swelling of the parts, and the circulation is stated to
be, for the most part, undisturbed. Yet we are also told, that in
forty-five of the cases of simple arthralgia, that is, upwards of one-
fourth of the number of cases of this description, the pulse was found
to be hard, slow, vibrating, and, in seventeen of them, irregular.
p. 510. — (Brit, and For. Med. Rev.) —B.J
34S
DISEASES OF THE DIGESTIVE SYSTEM.
symptoms of apoplexy, I would have prescribed bleeding, leeches,
and cold applications. But I reasoned thus — Here is a case in
which there is no evidence of the existence of inflammatory action.
Opium has been found to relieve the abdominal symptoms of the
disease — may it not also relieve the cerebral ? I ordered the pa-
tient to have a free dose of laudanum in camphor mixture. In a few
hours he awoke, sat up in his bed, and next morning we found the
symptoms of coma had completely disappeared. In two other
cases of a similar kind, I have given opium and carbonate of am-
monia with the most favourable result.
Dr. Clutterbuck mentions a peculiar symptom of this disease — a
kind of gouty inflammation attacking the great toe, and followed
by relief. I have not seen this. He states that the first joint of the
great toe becomes red, hot, painful, and swollen, and that this re-
mits by day and returns again at night. I have never seen this, nor
have I ever seen those hard tubercles on the tendons in various parts
of the body, which some authors have described.
After these symptoms, we come to a new class, namely, the pas-
sive, characterised by paralysis of the muscles of animal life.* It
is remarkable that this paralysis seems to be principally a paralysis
of motion, and that the power of sensation is seldom or never
* [Ancesthesia from Lead. — Twenty-three cases of ansssthesia
were noticed by M. Tanquerel, in four of which the disease was
deep-seated, in seven the loss of sensation was confined to the skin,
and in twelve the eye was affected. In the eleven cases of deep-
seated and superficial anassthesia, three times there was paralysis
of the corresponding muscles, four times the paralysis of motion
and of sensation occupied different parts, and four times the loss
of sensation was unaccompanied by loss of motion; in one case
only did amaurosis and anaesthesia of the skin exist together. The
lesion of sensation is always partial or of limited extent, sometimes
confined to certain parts of the abdomen, of the chest or neck,
sometimes occupying the limbs; it may be complete or varyino- in
degree, frequently shifting its place, or differing in extent; when
deep-seated it is less mobile than when confined to the skin.
Usually it makes its attack suddenly, and rapidly attains its fullest
extent, though occasionally it is preceded by a slight numbness.—
(Bell's Practical Dictionary of Materia Medica, from Brit, and For.
Med. Rev.)
It might have been stated, in connection with paralysis from lead,
that it is altogether a different affection from what is* termed mer-
curial paralysis. M. Tanquerel remarks, that in upwards of fifty
cases of mercurial tremors observed in the hospital La Charite in
no one instance was paralysis seen to supervene, and his researches
among the workmen generally employed in the manipulation of
this metal and other metallic substances, lead to the conclusion that
lead is the only mineral capable of producing paralysis properly so
SYMPTOMS OF PAINTERS' COLIC.
349
impaired. Generally speaking, the upper are more subject to
paralysis than the lower extremities, and the right than the left
arm. The latter circumstance is explained bv assuming that the
direct influence of the poison is more applied to the right arm.
The paralysis of the arm is also frequently partial; the extensors
lose their power, but the flexors do not in so great a degree. You
will see a patient with his arm hanging by his side as if it were
dead, but if you give him anything to hold he can grasp it firmly.
I have known painters continuing to work with a semi-paralysed
arm. There is also an atrophied condition of the affected part;
and this sometimes comes on with such rapidity, that, in the space
of a week or ten days, the affected limb will be scarcely half as
bulky as the corresponding one. We cannot account for this re-
markable emaciation on the principle of loss of motion alone, for
the short space of time in which it occurs, in manv instances, is
opposed to our entertaining such an opinion, and we must look for
some other explanation. On this point science affords us no satis-
factory information.
This disease, notwithstanding all its terrible array of symptoms,
is very seldom fatal. Hence the uncertainty which long prevailed
as to its pathological nature. In the great majority of cases, where
a dissection was made, the patients died of some other disease,
which either occurred during its course, or had preceded it. All
that appears to be established at present is, that there is no known
organic change of the nervous system connected with this disease ;
that it occurs in all its forms without the coexistence of organic
lesion, and that its exciting cause is the poison of lead.
It was formerly supposed that all the preparations of lead,
whether applied externally, or used internally, were capable of
producing colic ; but this doctrine is at present considered very
questionable. It was thought that metallic lead, and all its salts,
were capable of causing the disease; but the morbid influence of
this metal is now restricted by the best chemists and pathologists
chiefly to its carbonate. This opinion, I believe, was first put for-
ward by Dr. A. T. Thomson, the author of the London Dispensa-
tory, in an interesting paper published by him in the tenth volume
of the Medico-Chirurgical Transactions. The object of this paper
is to prove that, of all the preparations of lead employed in phar-
maceutical and other purposes, the carbonate is that which is
chiefly poisonous, and that the acetate and sub-acetate are compara-
tively harmless.
You have all, I am convinced, heard of cases of colic produced
by the external use of the acetate of lead, and you will see some
cases in proof of this opinion in Darwin's Zoonomia, and other
writings. There is a case on record of a woman, who, having
poulticed her ankle with this preparation, for the cure of a sprain,
got colic and fell into a state of marasmus. I knew of a deplorable
case of burn affecting the abdominal integuments, which was treated
vol. i.—30
350
DISEASES OF THE DIGESTIVE SYSTEM.
with a solution of the acetate of lead. After using it for a fortnight
or more, symptoms of colic came on, which not being recognised,
the lead wash was continued, and the woman died in great agony.
Dr. Thomson explains all this in a very satisfactory way. He
shows that the solution of acetate of lead, when exposed to the air,
attracts a quantity of carbonic acid, and is thus converted into a
carbonate; of this I have very little doubt, for you will find that,
by exposing a solution of the acetate of lead to the full influence of
the air, the carbonate will gradually be deposited in the shape of a
white powder. In the same way we can understand why it is that a
solution of the acetate of lead, added to fermenting poultices, may
be converted into a carbonate by the carbonic acid which is evolved.
It is also a fact, that the acetate can be used internally for a long
time without producing anything like deleterious effects. I have
given it for weeks together in full doses, without its having been
ever followed by colic, or any symptoms characteristic of the ab-
sorption of a poisonous matter. There are cases on record where
as much as six drams of this salt have been taken internally with-
out producing any sensible morbid effect. As far as my experience
goes, all those cases, in which the medical use of the acetate of lead
has been attended with disagreeable symptoms, were cases in which
it had been used as an external application. There were two cases
in the Meath Hospital in which this medicine was used externally,
in which colic, and other indications of poisonous absorption, took
place, but not a single one in which its internal employment had
been injurious. An excellent practical rule is laid down by Dr.
Thomson, that, where you wish to employ the acetate of lead inter-
nally, you should take care to combine it with diluted acetic acid.
Of the two combinations of lead with acetic acid, the sub-acetate is
most liable to be decomposed and converted into a carbonate, so
that, if you prevent this by mixing with the sub-acetate, or acetate,
a certain quantity of distilled vinegar, there will be little or no
chance of unpleasant symptoms being produced, even where the
medicine is given in very considerable doses. We are, therefore,
I think, justified in concluding that it is the carbonate of lead which
is productive of poisonous effects; and that where bad symptoms
have resulted from the use of the acetate, it was in consequence of
its being converted into a carbonate. I must, however, remark,
that it has not been sufficiently proved, as yet, that the use of the
acetate is perfectly safe.
It is an interesting fact, that many of the lower classes of animals
are subject to this disease. Burserius was one of the first authors
who directed the attention of medical men to this singular occur-
rence. I have got from my father an abstract of some observations
made by him on this subject, during a visit to the lead hills in
Scotland. He found that, in the pastures among these hills, and in
their immediate vicinity, cows, horses, sheep, dogs, and even poul-
try, were subject to colic from lead. The svmptoms, also, in these
SYMPTOMS OF PAINTERS' COLIC.
351
animals were observed by him to bear a very close analogy to those
of the human subject. Thus, for instance, in cows there was obsti-
nate constipation with suppression of urine; the poor animals seemed
to suffer from violent twisting pain in the belly, and sometimes were
thrown into a state of furious excitement, running wildly across the
country. He learned, also, that during that period it was calcu-
lated that at least one-tenth of the cows in this nation had died of
the effects of the poisonous absorption of lead. One of the most
ordinary precursory symptoms, was the animal becoming what is
called hide-bound ; this was followed by obstinate costiveness, and
there was much apparent suffering, with panting, starting, and
slavering from the mouth. Where the cerebral symptoms were
most prominent, the signs of abdominal irritation were by no means
distinct; and this, as I have remarked, is the case in the human
subject. In some, who had the head affected, and ran wildly
through the country, the secretion of milk was stopped; and this
accords, too, with the effect of lead on the human female. Another
remarkable circumstance is, that animals living in the vicinity of
these lead hills have exceedingly difficult labours. Sheep are sub-
ject to epileptic convulsions and paralysis ; dogs have the head
principally affected, they run across the country slavering at the
mouth, as if in a state of hydrophobia, but they do not bite, and are
in all respects perfectly harmless. In barn-door fowl, the genera-
tive function was injured, and the hens reared or brought there
ceased to lay eggs.
There is one fact, mentioned in these observations, which tends
to confirm the opinion of Dr. A. T. Thomson, that the poisonous
effects of lead are produced chiefly by the carbonate. A distance
of very few miles from the valley renders animals quite free from
any liability to the disease; but if they should happen to stray into
the immediate neighbourhood, and particularly into a portion of low
ground, flooded during the winter months by a river which runs
along the valley from the mines, and which, in all probability, leaves
behind an efflorescence of the carbonate of lead, they are very liable
to be affected with colic. It is said, also, that the poison is pro-
duced by the volatilization of lead in the smelting houses, the vapours
of which are carried down the valley and through the neighbouring
parts. Be this as it may, the Gaelic name of the valley signifies the
poisonous vale; and as it is very probable that this name had been
given in consequence of the deleterious qualities of the place long
before the establishment of lead works, it tends strongly to favour
the opinion that it is the water which contains the poison.
The mode of cure employed by the shepherds in this place, is to
give strong purgative injections, and to remove the cattle from the
influence of the poison, by sending them to new and healthy pas-
tures. In this way they frequently recover ; and if we look to the
cause of the disease, its symptoms, or mode of cure, we shall ob-
serve a striking analogy between it and the colic from lead in the
human subject. I shall conclude this subject at my next lecture.
352
DISEASES OF THE DIGESTIVE SYSTEM.
LECTURE XXIX.
Pathology of painters'colic—Researches on the state of the nervous and digestive
systems—Treatment—Use of narcotics, purgatives, tobacco, &c, &c—Treat-
ment of paralysis from lead—Efficacy of strychnia and brucia—Colic from
copper—Poisonous effects of mercury—Remarkable case—Affection of the
respiratory muscles.
We were occupied at our last lecture in considering the symptoms
of painters' colic. I mentioned that it occurs under a variety of
forms; that the symptoms are to be attributed to a lesion of nervous
function independent of any known organic change; and that the
same disease may be seen in animals which have been exposed to
the poison of lead. There are some other facts connected with this
disease which should not be passed over, and which I am anxious
to lay before you previously to entering upon the treatment.
You will recollect that I introduced the subject by stating that
painters' colic belonged to the class neuroses, and that I endea-
voured to show that this implied a lesion of function of any part of
viscus of the body, frequently characterised by the most decided
departure from the natural condition, and yet unaccompanied by
perceptible organic change.1 I said, also, that it was hard to sup-
pose the existence of great functional alteration, without any mole-
cular change; but that, in the present state of science, we are
compelled, for the want of a better term, to call these affections
neuroses, in contradistinction to diseases in which there is organic
lesion visible. To illustrate this point, take an example from two
different cases. In one case of what is called dyspepsia, we have
inflammatory, or, at least, sub-inflammatory derangement of the
stomach : here the disease is traceable to organic change; in another
we have symptoms of nearly the same character, and yet there is
no organic lesion. Painters' colic comes under the latter head ;
we observe symptoms of excessive functional lesion, but dissection
does not exhibit any organic change. Pathological anatomy tells
us what it is not, and we arrive merely at a negative knowledge of
its nature. We have decided proofs of extraordinary lesions of the
nervous system, and yet, when we come to the post mortem exa-
mination, we cannot find any visible change to account for these
striking phenomense.
The old pathologists maintained that spasm of the intestines was
the principal cause of the disease, and attributed the symptoms to
their contraction. This opinion appears to have some foundation,
when we consider the violent symptoms of colic which accom-
pany this affection. Dubois de'Rochfort has mentioned, that in
such cases he has found intus-susception of the intestines. De
ilaen says that contractions of the colon are very common ; and
PATHOLOGY OF PAINTERS' COLIC.
353
several authors make the same assertion. The results of more
modern observation, however, are against these opinions. I have
told you already, that in consequence of this disease seldom or
never proving fatal, there is a degree of doubt attached to its pa-
thology; but it is an interesting fact, that where death from other
causes has occurred during the existence of painters' colic, the
digestive tube has been found either in its healthy state, or with a
few detached spots of vascularity, without any decided inflamma-
tory character, and totally insufficient to account for the symptoms.
This, which is all that pathological anatomy reveals, may be con-
sidered as purely accidental, and only of occasional occurrence, so
that we are compelled to look upon the disease as one in which
there is great lesion of function without any organic alteration.
In the hospital of La Charite", at Paris, a vast number of cases of
painters' colic have been treated. In the space of eight years five
hundred cases of this description have been admitted; out of these,
five died while labouring under the disease; and the following is
an abstract of the appearances observed in dissection. In the first
case, there was rupture of an aneurism of the abdominal aorta, and
the patient sank from loss of blood. On examination, the digestive
tube was found in the natural and healthy condition — there was
neither vascularity nor contraction. The subject of ihe second
case died of apoplexy. The whole intestinal canal was found
healthy, and, contrary to the doctrines of the school of Broussais,
there was neither congestion nor vascularity. In the third case,
the patient had fits of an epileptic character, in one of which he
expired. The colon exhibited a slight degree of redness, but quite
insufficient to explain the symptoms during life. In the fourth, the
cause of death was the same, and, on dissection, the tube was found
healthy. Another patient, after recovering from the symptoms of
painters' colic, got a sudden attack of asphyxia and died. His body
was examined, but there was no trace of disease in the colon or
any other part of the intestinal canal. Here we have five cases in
which there was either no disease at all in the digestive tube, or,
if there was any, the amount was quite insufficient to account for
the symptoms. Louis, in a memoir which he has published, on
sudden and unexpected deaths, gives a case of this disease where
death occurred suddenly on the eighth day. The intestines were
found to be in a healthy condition. Martinet gives two cases of
persons who died of the cerebral symptoms while labouring under
this disease; here, also, the tube was in the normal state. Thus
we have eight cases with dissections detailed by various authors,
all men of high professional celebrity, having no theo'ry to support,
and all agreeing in the statement that there is little or no apprecia-
ble lesion of the digestive tube; that in the majority of cases it is
in a state of health; that no contraction exists; and that such
morbid appearances as have been found must be looked on as
accidental.
There is one interesting circumstance in these cases which
30*
351
DISEASES OF THE DIGESTIVE SYSTEM.
deserves to be noticed. With the exception of the first and fifth
cases, all the patients presented that form of the disease in wnicli
the functions of the brain are decidedly injured. Here it seems
probable that the cause of death was excessive irritation ot the
nervous system. Now, in the observations I made on the cases
which were treated at the Meath Hospital, you will recollect I
stated that where the cerebral symptoms were predominant the
abdominal were more or less indistinct and latent, and that the
cause of indistinctness, or even total absence, of these might be
owing to the force of the disease being thrown upon the brain and
spinal cord. Such was the case in the instances above recited, and
such we have also seen to be the result in the case of those animals
of an inferior order that have been exposed to the poison of lead.
How far the predominance of cerebral excitement may explain the
want of appearances of disease in the digestive tube may be a sub-
ject of consideration.
What is the state of science with respect to the brain and spinal
marrow 1 Allow me here to call to your recollection the symp-
toms of functional derangement of the nervous centres, the coma, the
violent convulsions, the amaurosis, the deafness, the delirium, the
paralysis. All these are violent symptoms, and you would natu-
rally expect to find them connected with some sensible alteration,
some congestion, or inflammation, or ramollissement. But nothing
of this kind can be discovered. In all the cases where death
occurred under such circumstances, at La Charlie, with the excep-
tion of some slight appearances of cerebral lesion in the second,
there was no perceptible disease in the brain or spinal cord. The
membranes and substance of the brain presented their normal con-
dition ; there was little or no fluid in the ventricles ; the spinal cord
was healthy and natural in consistence and colour, and there was
no effusion into its sheath. All these circumstances led to the
conclusion that painters' colic is essentially a neurosis. Observe,
too, how interesting it is to connect the circumstance of the absence
of organic change with the singular fact which I mentioned in my
last lecture, that the comatose symptoms of this affection may be
treated with stimulants and opiates. Where we have coma with
congestion of the brain, opium has the effect of increasing the
symptoms ; here it was found to have a contrary effect. So that
our experience and the results of pathological anatomy, as far as
they go, appear to square exactly. We see, then, that painters'
colic is not inflammation of the intestines, or of the brain, or of the
spinal cord, and this information, though of a negative character,
possesses considerable value in a practical point of view. I do not
know any cases of what have been termed neuroses, in which the
bearings of pathological research on practice are so extensive and
so satisfactory.
Treatment. — It is a fortunate circumstance that this disease is sel-
domfatal,and itissome consolationtothink that, althoughthepatient's
sufferings are dreadful and often protracted, there is little danger of
TREATMENT OF PAINTERS' COLIC. 355
life, and that the complaint is almost always amenable to judicious
treatment.* I have been for some years in the habit of treating it in
a routine way, and can speak from experience of its success — of
course this treatment is to be modified by circumstances. Suppose
a patient applied to you with violent pain about the navel, a hard
and retracted state of the abdomen, obstinate costiveness, and the
other symptoms which characterise an attack of painters' colic ;
the first thing I would advise you to do is to prescribe a full opiate.
Many persons would object to this, and say that there is constipa-
tion enough already, and that opening the bowels would be much
more likely to give relief. But opium does not here add to the
constipation : indeed, so far from doing this, it sometimes acts as a
laxative. At all events, it is a remedy which is perfectly unobjec-
tionable. Give, then, in the first place, a full opiate; it will have
the effect of relieving the patient's sufferings, and will enable you
to gain time for the employment of other means. The next thing
is to place the patient in a hip bath, and keep him in it as long as
possible. Do not neglect this, for I know of nothing that gives
more decided relief. I have often seen cases where the patient was
quite easy while he remained in the bath, but experienced a return
of the pain as soon as he left it. If you have no means of procur-
ing a bath in this way, the next best thing is to have recourse to
emollient stupes containing some narcotic, after the manner first
introduced by my colleague, Dr. Graves. One of the best of this
kind is the tobacco stupe; if you cannot get this, you may employ
poppyheads for the same purpose. The tobacco stupe is much
better than the tobacco injection, because its effect can be more
easily regulated, but in violent cases I am in the habit of combining
both, employing the stupe during the paroxysms of pain, and throw-
ing up a tobacco enema every four or six hours, until a decided
impression has been made on the symptoms. In the success which
has attended my distinguished friend Dr. O'Beirne's treatment of
tetanus by the use of tobacco we seen an analogous effect. In this
way you wiil succeed in giving relief; you should also prescribe a
brisk cathartic ; and this you may do without any fear of injuring
the patient, or exciting intestinal inflammation. The insensibility of
the intestines to the stimulus of even powerful purgatives is a curi-
ous feature in this disease, and bears strongly against the idea of
its being connected with any inflammatory condition of the tube.
In the Hospital La Charite the treatment is routine; it consists of
* [Out of the entire number of cases of lead colic, 4809 observed
and recorded by M. Tanquerel a*nd others, 111, or 1 in 43,terminated
fatally. It would be more correct to say, that the deaths here were
from lead poisoning, as, with one exception, the fatal result is said
to be either owing to cerebral affection, to paralysis of the respira-
tory muscles, or to some accidental complication with disease
foreign to those originating from lead. — B.]
356
DISEASES OF THE DIGESTIVE SYSTEM.
an emeto-purgative [and narcotic] plan, which is continued day
after day until the symptoms yield. The purgatives we employ in
the Meath Hospital are croton oil, combined with castor oil and
mucilage, or given in the form of pill. When the bowels have been
freely acted on, the case generally goes on well. After the bowels
have been opened, we continue the employment of the hip bath, the
narcotic stupes, and anodyne injections, taking care at the same time
to persevere in the use of purgatives.
Andral makes a good remark on this point: — " Here (says he)
are cases in which, from some peculiar alteration in the state of
innervation, the mucous surface of the bowels is rendered less sen-
sible than in its ordinary condition, and can bear freely the stimulus
of powerful purgatives. Maynot this condition also occur in other
states of the economy 1 We are, therefore, led to conclude that
purgatives are not, in all cases, direct stimulants.
Painters' colic has been treated in Paris by bleeding and leech-
ing; but this has not been found so successful as the ordinary pur-
gative plan. I have never seen a case in which general bleeding
seemed to be called for except one, and this was a most violent
case,- which had resisted the ordinary means of treatment forty-
eight hours. I recommended bleeding from its well known anti-
spasmodic power; a quantity of blood was taken, and soon after
the purgatives began to act, and the patient got relief. With respect
to leeches, I have employed them only in those cases which are
accompanied with symptoms of fever and gastric irritation; where
there is quick pulse, hot skin, foul tongue, thirst, vomiting, and
epigastric tenderness. In such cases I have applied leeches, but my
experience of them is, that the relief afforded is by no means so
great, or so decided, as in cases of intestinal inflammation, and it is
a mode of treatment which I do not by any means rely upon for
removing the disease.*
* [In the cases of painters' colic which have fallen under my
notice and care, I have found but little benefit from other means,
unless the lancet had been freely used. In one of the two last cases
which I treated in this way, with the addition of cups on the abdo-
men, calomel, and castor oil and turpentine, with opiates occasion-
ally, there has been no return of the disease for nearly nine years,
although the person has been regularly engaged in his trade ever
since.
Alum is one of the most approved, in fact is the most entitled to
our confidence, of any one single remedy, in the treatment of lead
colic. In its favour we have the experience of practitioners in
Germany, France, and Great Britain. Its administration long
constituted the treatment of lead colic by M. Kapeler, at the Hospital
Saint Antoine in Paris. M. Montanceix assures us that, in doses
of three or four drachms daily, the potassio-sulphate of alumen
cures, invariably, lead colic, however violent it may be, in less
TREATMENT OF PAINTERS' COLIC.
357
After the violent symptoms have been subdued, the next thing
you have to consider is, whether there is any paralytic affection,
and how this is to be treated. If the disease be severe or of consi-
than six to seven days, and commonly also without relapse occur-
ring. M. Gendrin tells us, that fifty-eight patients attacked with
the disease, some of whom had been subjected unsuccessfully to
other modes of treatment, were cured without a single exception
and inconvenience to the digestive organs. In a dose of a drachm
and a half to two drachms, the alum arrested the farther march of
the disease in twenty-four cases, in a period of from ten to fifteen
hours; and in six the persons were not obliged to suspend their
work. But, he adds, that when the dose exceeds two and a half or
three drachms in twenty-four hours, disagreeable effects ensue.
The next, and the last lauded remedy for lead colic, is sulphuric
acid, to the use of which M. Gendrin was led by his investigations
into the modus operandi of alum,* and a suspicion that its activity
was owing to the excess of sulphuric acid in this salt. He asserts
that he has now treated three hundred cases of lead colic with sul-
phuric lemonade, — made by adding a drachm to a drachm and a
half of the acid to three or four pints of water. Commonly he
carries the dose of the acid as far as two scruples, diluted in a pint
and a half to two pints of water, suitably sweetened — taking care
that this drink shall not be kept in vessels of metal. Unfortunately,
however, for science and for medical ethics also, the accuracy of
M. Gendrin's results has been not only denied by M. Tanquerel, but
denied in terms anything but courteous or civil. This latter gen-
tleman asserts, that the trials made with the sulphuric acid in the
Charlie were utter failures, and that the physicians, MM. Andral,
Dalmas, and Sandras, were obliged, for conscience sake, to desist
from its use, and have recourse to the purgative plan. The dispute
between M. Gendrin and M. Tanquerel was, I find, still continued
in the French medical journals in the last year.
The alkaline sulphurets have been recommended in the treatment
of lead colic, under an idea that the oxide of the metal would com-
bine with the sulphur and form a sulphuret, — a substance insoluble
and inert in the digestive tube. But practice has not sanctioned
the theory.
Mercury has beeri given by different physicians for lead colic,
with a view to procure its sialagogue effects; but salivation will
not unlikely predispose more readily to palsy, and we are not, be-
sides, reduced to the strait, in this case, of curing one kind of poison-
ing by exciting another. But in some of the more unmanageable
forms of the disease, attended with great irritability of stomach,
lead itself, in the shape of sugar of lead, has been given by Dr.
Harlan and others in this disease. Dr. H. combined the salt of
lead with calomel and opium, as follows :—R. Cal. ppt., gr. v.; Pulv.
opii, gr. ij.; Pulv. sacch. sat., gr. iij. M. ft. pulv.: to be repeated
35S DISEASES OF THE DIGESTIVE SYSTEM.
derable duration, you may look for paralysis of one or both of the
upper extremities with a good deal of certainty. This part ot the
subiect, I believe, more properly belongs to the consideration of
nervous affections, but, as I have gone so far into the treatment of
painters' colic, I may as well give the whole together. 1 he para-
lysis which follows this disease is different from that which is the
result of apoplexy; it is a neurosis of the passive kind, and to be
treated as such. The patient, some time after the occurrence ot the
usual symptoms of colic from lead, begins to complain of weakness
in his arm, he feels some difficulty in extending his fingers or
raising his hand to his head, and then the symptoms become more
marked. The arm and forearm become rapidly atrophied, the
paralysis principally affects the extensors, while the flexors retain a
considerable share of power, the fingers are bent, and the arm hangs
by the side. Here the first thing you should do is to adopt the
treatment recommended by Dr. Pemberton in his work on Abdomi-
nal Diseases, namely, to apply a splint to the inside of the forearm
and hand, so as to counteract the preponderating influence of the
flexors. Apply a splint to the forearm, wrap it up in flannel, and
make the patient keep it supported by a sling. In this way you
establish a kind of balance between the antagonist muscles, and
place the extensors under favourable circumstances for bringing
about a cure. If the patient has both arms affected, which is
sometimes the case, change the splint from one arm to the other
every second day, and continue this alteration until the cure is
completed.
You will next have recourse to the use of strychnia, one of the
best remedies we possess in cases where the paralysis does not de-
pend upon organic diseases of the brain. This is a remedy which
is given with good effects even in cases of paralysis from apoplexy,
ivhere there is reason to suppose that absorption of the clot has taken
place. In cases of apoplexy it can be employed only after some
time, and where depletive measures have been sedulously put in
force, but in a paralysis of this description you may begin with it
at once. Commence with the exhibition of one-twelfth of a grain
of strychnia two or three times a day, and go on increasing the
dose gradually, until a grain, or even a grain and a half, is taken
in the twenty-four hours. To insure the exact division of this
powerful drug, you should direct a grain of it to be dissolved in a
few drops of alcohol, and then made into pills'of an equal size with
crumb of bread or conserve of roses. In this way you will succeed
every two hours until relief is obtained, — which, he tells us, is
usually the case after two or three powders have been taken. But,
in this prescription, we cannot say what is due to the opium, and
what to the sugar of lead, or the calomel. The same difficulty
occurs in his prescription of sugar of lead with opium as an ene-
ma. —B.]
TREATMENT OF PAINTERS' COLIC.
359
in bringing back the lost power of the muscles of the forearm and
restoring its nutritive functions. I may mention here, that the
atrophy of the paralysed limb, which occurs in this disease, cannot
be accounted for by supposing that it is produced by want of exer-
cise ; the emaciation is so rapid (sometimes taking place in ten days
or a fortnight) that we can only attribute it to some unknown lesion
of innervation.
If the use of strychnia be followed by severe muscular twitches,
pain in the head, or convulsions, you must omit it for some time,
and then, when these effects have completely subsided, it may be
resumed if necessary. You should also bear in mind that this
remedy is one of those medicines which have been termed accumu-
lative, that is to say, a patient may be taking it for a considerable
time, without any perceptible symptom, and then its effects explode
suddenly, the quantity which has been accumulating in the system
manifesting itself at once by symptoms of great intensity. Here
you omit it immediately, and with a view of relieving the existing
symptoms, prescribe a draught, composed of camphor mixture,
ammonia, and opium. This has generally the effect of calming
the nervous excitement, and you will seldom have any more trouble
on this account. En passant, I would advise you, whenever you
employ strychnia in private practice, to inform your patient of the
occurrence of such symptoms, and tell him that there is no cause
for alarm. Instead of strychnia, some of the continental practi-
tioners are in the habit of prescribing brucia, and it is stated with
considerable advantage. I have tried it in two or three cases'with-
out much apparent benefit, and I am inclined to think that it is
decidedly inferior to strychnia. In France, however, it has been
very largely employed, and has the reputation of being a remedy
of considerable value in the treatment of paralysis. It has one
advantage at least over strychnia, it can be much more easily divided
and regulated, so far as respects the quantity given, as it is a much
weaker preparation than strychnia, one grain of which is equivalent
to six grains of brucia.
In addition to these measures, I have seen much benefit result
from the application of blisters and frictions, with stimulating lini-
ments to the spine. It is also of importance to remove the clothes
in which the patients have worked; they are frequently charged
saturated with lead, and have a considerable tendency to keep up
the disease.* I have often seen an attack of painters' colic reap-
* [This precaution is a very proper one. To it should be added
that of a regular and careful ablution of the hands and face, and
arms, if they have been exposed, and a careful combing of the head
and cleaning of the nails, before every meal, and also a daily
washing of the feet. The night clothes ought always to be differ-
ent from those worn during the day. By these means, and temperate
living, which implies abstinence from all intoxicating drinks, paint-
360
DISEASES OF THE DIGESTIVE SYSTEM.
pear so shortly after leaving hospital, and without any evident ex-
posure, that I could only attribute it to the circumstance of their
garments being saturated with lead.
3 In the foregoing plan of treatment there is nothing new; it is, in
fact, a routine practice, but is one that is borne out by the results
of pathology, and which, from long experience, I can strongly re-
commend. I may also remind you that the plan of treatment fol-
lowed in the hospital of La ChariU, which has more cases of this
disease than any similar institution in Paris, is completely routine.
Other metals'besides lead, as, for instance, copper, produce effects
somewhat analogous. Copper is said to produce salivation, colic,
and vomiting. Brass-founders are liable to these symptoms, as also
other persons employed in the manufacture of copper. I have not
seen the disease, but it is said to be analogous to lead poisoning, so
far as colic is concerned; in other respects the symptoms differ.
The convulsions are not so violent, nor is the paralysis or coma so
frequent; there is often considerable fever, thirst, difficulty of respi-
ration, prsecordial anxiety, diarrhoea, and prostration of strength,
so that it comes much nearer to ordinary intestinal inflammation
with fever than painters' colic. Yet it is a curious fact, that not-
withstanding all its array of symptoms so closely bordering on in-
flammation, it has been found in Paris, where several cases of this
disease have been seen, that it is amenable to the same treatment
as painters' colic, and that, under the use of purgatives, the fever,
thirst, diarrhoea, and tenesmus subside.
Mercury, under certain circumstances, will produce a most ex-
traordinary affection, on which I shall here make a few observations.
The disease is not of very frequent occurrence, but it is of import-
ance in practice to be able to recognise and treat it properly. It
is a proposition well known to almost every one, that many bad
effects have resulted from the abuse of mercury ; and I need not tell
you how many persons are injured by the empirical employment
of this potent drug on all occasions and in all constitutions. It is a
common opinion that mercury acts principally on the capillary and
absorbent systems, but there can be no doubt'that it also acts upon
the nerves, and that in a very remarkable manner. I have seen cases
where the constant use of calomel has produced a marked derange-
ment of the nervous system, manifested by great irritability, tremo°rs,
hysterical excitement, and hypochondriasis. You will see in the
various works on Toxicology an account of the effects produced
ers and glaziers may escape for a term of years, if not for life, from
an attack of painters' colic.
As respects the general therapeutic course required in this dis-
ease, I have not found it to differ materially from that which I
nave followed in bilious colic, with the treatment of which the
reader is already acquainted. —B.]
TREATMENT OF PAINTERS' COLIC.
361
by mercury on persons employed in quicksilver mines, and on
tradesmen, such as looking-glass manufacturers and others, who
come in contact with mercury. I shall read for you the notes of a
remarkable case of this kind, which was some time back under
treatment in the Meath Hospital. It may be called a form of the
paralysis agitans from the effects of mercury. Similar cases have
been described.
A man, aged forty-six, was admitted into one of our medical
wards in October, 1833. He stated that, from the time he was
eight years of age, he had been employed in a looking-glass manu-
factory, and that his occupation principally consisted in what is
technically termed the silvering of mirrors. In this process the
operator's right hand is repeatedly immersed in a vessel filled with
mercury, while the left fixes a sheet of tinfoil, on which the metal
is rubbed. Artizans while thus engaged are in the habit of using a
muffle, which covers the mouth and nostrils. This the patient said
he had never used, because he found that those who were in the
habit of wearing it did not enjoy better health. For thirty years
he continued to enjoy tolerable health, with the exception of some
bleeding from the gums, with shooting pains and a sense of formi-
cation in various parts of the body, accompanied by a slight loss
of power in the hands, which came on at various times, and was
generally relieved by the use of ardent spirits. He had been fre-
quently salivated, and when admitted had lost nearly all his teeth.
The mode in which he lost them was this: gum-boils formed close
to the roots of the teeth, which soon after dropped out, and in this
way the local inflammation subsided. About three years ago, he
had an attack similar to that for which he had been admitted ; he
went into the hospital and was put under an active antiphlogistic
treatment with relief. From that time up to the period of his ad-
mission, he had enjoyed tolerable health, except that the sight of the
right eye was considerably impaired, and that his memory was
slightly affected. He forgot the names of persons and places, and
was frequently at a loss in endeavouring to recollect the persons to
whom he had lent his tools. On being brought into the hospital he
presented an extraordinary specimen of human suffering, and I was
at first unable to give his complaint a name, the case being the first
of the kind I had seen. It exhibited the phenomena of a violent
spasmodic affection; it was different from tetanus, or hydrophobia,
or hysteria, but it bore some faint analogy to chorea. The head,
arms, and fingers, particularly on the left side, presented a succession
of quick, convulsive, jerking motions. The angles of the mouth
were retracted, the eyebrows twitching, the head constantly thrown
back, but the agitation scarcely raised the arms. The nostrils
were spasmodically dilated. The sterno-mastoid, trapezius, scaleni,
diaphragm, and the abdominal muscles, were similarly affected.
Their contractions were short, rapid, and painful. From the con-
stant hiccup with which the spasms of the diaphragm were at-
tended, and the jerking motions of the tongue, his speech was in-
vol. i.—31
362
DISEASES OF THE DIGESTIVE SYSTEM.
terrupted and indistinct. He was occasionally free from spasms
altogether, but whenever he transmitted volition to any part of the
muscular system, it became instantly affected. When he endea-
voured to raise his foot from the ground, it quivered and fell quite
powerless and useless. Whenever he attempted to carry a vessel
to his lips he generally overshot the mark, carrying the vessel
towards his ear, nose, or forehead, and spilling its contents over his
face or neck, so that it was a common saying among the patients
in the wards, that he did not know the way to his mouth. But if
the vessel was applied to his lips by another person he could swal-
low easily. A sudden blast of cold air, the application of a cold
hand to the skin, or the abrupt entrance of any person into the
wards, brought on an attack of spasms. The muscles of the left
hand and of the left side were affected much more than those of
the right. The mental powers were not impaired, the patient was
intelligent, and seemed anxious to communicate the particulars of
his case. During the whole course of the disease he retained a full
power over the urinary discharge and defecation. There was
some slight tenderness on pressure over the fourth and fifth dorsal
vertebras, but the rest of the spine exhibited no increase of sensi-
bility. His skin was cool and dry, his pulse quick, weak, and
small, his bowels inclined to be costive, but easily moved by laxa-
tives. Here we see a marked difference between this affection and
painters' colic.
The treatment adopted in this case was very simple. Leeches
were applied to the tender part of the spine, the patient was placed
in a warm bath, and got some laxative medicine, followed by an
opiate. He was also ordered to have a large flannel shirt, and to
be placed in a warm, comfortable bed. He passed the night
tolerably well, and next day appeared to be much improved. I
shall not continue the daily reports of this case, but shall merely
mention, that after a few days a great improvement took place.
The spasms of the left side continued, though much less severe.
Those of the purely voluntary muscles on the right ceased, while
the spasms continued in the respiratory muscles on this side. We
found that all the muscles of the face which have been called re-
spiratory by Sir C. Bell, the platysma, scaleni, pectoral, and inter-
costal muscles, and the diaphragm, were thrown into violent spasms,
while the purely voluntary muscles remained in a state of perfect
quiescence. I am not aware that this circumstance has been ob-
served in any other case. As far as it goes, it tends to corroborate
the views of Sir C. Bell. In the treatment of this case we employed
narcotic frictions, particularly those composed of the extract of
belladonna, to the spine, with considerable benefit. The patient
was cured by very simple means, and at little expense to his con-
stitution.
DEFINITION OF CHOLERA MORBUS. 3^3
LECTURE XXX.
DR. BELL.
Cholera. Morbus — Definition — Sydenham's description — Divisions of cho-
lera.—Sporadic or Common Cholera—Symptoms—Not a very fatal disease—
Proportion of cases and deaths in the British troops in different regions—
Greater proportionate mortality in northern than in southern latitudes—Often
exceptions to this.—Causes. Mutations of temperature from heat to cold, and
errors in regimen—Seat of the disease—Not often depending on inflammation.—
Diagnosis.— Treatment. Diluents—External irritation—Emetics—Opium—
Venesection occasionally—Calomel—Calomel and opium—Laxatives—Oc-
currence of gastro-enteritis,—its appropriate treatment—venesection or leech-
ing—laxatives, diluents, mild diaphoretics, and the warm bath.—Conva-
lescence from cholera—Its treatment.
Cholera Morbus, the name of the disease which will form the
subject of the present lecture, is a barbarous compound of Greek
and Latin, as bad as if in our own vernacular language we should
say cholera disease. The term cholera itself has been in use since
the days of Hippocrates ; but, respecting its origin, subsequent
medical writers differ. Celsus derives itfrom*ox», bile, and/>«*>, I flow;
which is, literally, bile-flux. Trallianus, again, supposesit to be derived
from ;to***, intestine, and ft* ; or intestinal flux. With our present
knowledge of the subject we may wish that this last explanation
had always been the popular one ; as it would have saved much erro-
neous speculation and practice, which have resulted from the pre-
dominant idea of the disease originating from an excess and acri-
mony of the bile.
A brief definition of cholera as, until late years, it presented itself
in the adult subject, is — griping pains followed by vomiting and
purging, very rarely with flatulent eructations and dejections, and
always with spasms of the extremities, particularly the inferior, and
anxiety. To these should be added coldness of the skin, and often
a cold sweat. The nervous and spasmodic character of the disease
was dwelt on by Cullen, and its affinity to fevers pointed out by
Pinel. I shall not occupy your time with repeating the descrip-
tions of cholera by the ancient writers, but come down at once to
him, among the moderns, who has treated the subject with the
greatest clearness and practical acumen,—I refer now to Syden-
ham. He tells us, that " it comes almost as constantly at the close
of summer, and towards the beginning of autumn, as swallows in
the beginning of spring, and cuckoos towards midsummer;" thus
declaring its epidemical visitations, and the state of weather which
gives rise to it. He distinguishes cholera appearing under the
predisposing operation of atmospherical causes from the occasional
variety caused by a surfeit, " which happens at any time of the year,
which, with respect to its symptoms, resembles the cholera morbus,
and yields to the same treatment, and yet it is of a different kind."
Sydenham notices a dry cholera, which he admits he saw but
once, and which certainly is not, in the absence of retching and
364
DISEASES OF THE DIGESTIVE SYSTEM.
stools, and in its alleged causes, "flatus passing upwards and
downwards," entitled to be regarded as cholera at all. The only
useful divisions of the disease are into — 1, Sporadic Cholera;
2, Epidemic Cholera; and 3, Cholera of Children, or Cholera In-
fantum. I shall speak of these in succession, and in the order of
their enumeration.
Sporadic, or common cholera, sometimes is preceded by symp-
toms of indigestion — eructations, oppression at the epigastrium,
colic, and distressing nausea. At other times the attack is sudden
—purging followed almost immediately by vomiting — and the pro-
gress of the disease is short. The matters first discharged from
the stomach are aliment mixed with fluids, if the attack has come
on shortly after a meal. Soon, however, bilious fluid constitutes
the almost entire discharge; which is unaccompanied with pain,
and allows of intervals of some repose. The discharges by stool,
after the first or feculent ones, are analogous to those by the
mouth. After the lapse of a few hours these symptoms are aggra-
vated ; the cardialgia is insupportable, the violent movements of
ejection of the stomach and bowels, and the forced contractions
of the abdominal muscles, are accompanied by much pain and
anxiety; the matters passed by vomiting and stool are also
changed ; they are now brown, or blackish, eruginous or porraceous,
and diffuse a fetid odour ; sometimes they are acid, and occa-
sionally sanguinolent. But although the discharges generally are
thus dark, they are not always so, particularly in warm climates,
Celsus and others have noted their white appearance. The patient
is tormented with excessive thirst; all his functions are perverted ;
the breathing is quick and panting; the voice hoarse; the pulse
small, frequent, contracted, irregular, and extinguished by pressure.
The tongue is dry; the urine scanty. The face, which at first
was somewhat suffused, assumes a frightful paleness; it is bathed
with a cold sweat, particularly evident on the upper part of the
trunk; sinking and fainting away are common, and there is an
extreme prostration of both physical and mental energy. Not-
withstanding this extreme weakness, the muscles still contract, but it
is in jerks, or with an almost tetanic rigidity; the arms and legs
are motionless some minutes, until a new pain throws them into a
new posture. The patients always complain of very painful
cramps. It is difficult for them to take any drinks at this time;
the contractions of the stomach reach the esophagus; all is
thrown back by the efforts to vomit and the hiccup; and the intro-
duction of enemata is prevented by the emission of gas from the
intestines.
Death is not by any means a common result of cholera,even in hot
climates, unless it assume an epidemic form. In the island of Jamaica
the aggregate strength of the troops duringtwentyyears,ending 1836,
was 51,517, of which number, in this period, there were 12,282
cases of diseases of the stomach and bowels; and of these, but 216
of cholera morbus, of which the deaths were only three in number.
CAUSES OF SPORADIC CHOLERA.
365
Among all the troops, in both the Windward and Leeward
Islands, the aggregate number of whom, for twenty years, (1817
to 1836, inclusive,) was 86,661, the number of cases of cholera
morbus during this period was 1173; of which only 24 resulted
fatally, or a little over 1 death in 49 attacks. The proportion in
Jamaica was but 1 in 72. A better idea of favourable result in
this disease will be obtained by comparing it with remittent fever
in the same island, among the same force, and for the same lime:
the proportion of deaths in this latter was rather more than 1 to 9
attacks. In Gibraltar, the cases of cholera morbus during eighteen
years, was 1230, of which the deaths were but 7, or 1 in 175.7, in
an aggregate strength of 60,269. In Malta, during the same period,
in an aggregate force of 60,269 men, the number of cases of
cholera morbus was 454, and the deaths 5, or about 1 in 91. On
the western coast of Africa, however, the proportions are different;
for, of 9 cases of cholera morbus, in an aggregate strength of 1843
men, the deaths were 2, or 1 in 4i cases of admission to hospital
treatment. At the Cape of Good Hope, the number of deaths to
cases of cholera morbus was 2 in 68, or 1 to 34. In Nova Scotia,
in an aggregate strength of 46,442 men, in a period of twenty years,
there were 427 cases of cholera morbus, of which the deaths were
4, or 1 in 106.7. For the preceding returns I am indebted to the
Statistical Reports on the Sickness, Mortality, and Invaliding, among
the Troops at the different Foreign Stations of the British Empire,
by Major Tulloch. If we compare Gibraltar with Nova Scotia,
we find that the proportion of cases of cholera morbus in the troops,
was, in the former place, 1 in 59, and in the latter, 1 in 108, omit-
ting decimal proportions, but that the proportion of mortality to the
number of cases of the disease was greater in Nova Scotia than in
Gibraltar. In the United States, there are more cholera and colic
among the troops in the northern than in the middle and southern
division; the annual ratio of cases per 1000 is 145 in the former,
and 131 in the latter. In the northern division only 2 deaths in
3221 cases are reported ; and in the middle and southern, 7 in 3882
(Dr. Forry — The Cli?nate of the United States and its Epidemic
Influences). Hillary, speaking from his observation on the inhabi-
tants of Barbadoes, thinks that cholera morbus is a lighter disease
there than at home, in England.
Causes. — The preceding details are introduced to show the
comparative infrequency of cholera morbus, and the small propor-
tion in which it is fatal. I ought to have stated, however, in order
to make the comparison more complete, that, in the Windward
Islands, where the proportionate mortality for cholera morbus was
greatest, or 1 in 49, the proportion of deaths from acute dysentery,
during the same period and among the same number of soldiers,
was 1 in 23, and from chronic dysentery 1 in 5. These details
are useful in another point of view, by enabling us to dispute both
the propriety of regarding the disease as the effect of excess or of
acrimony of bile, and the divisions into bilious,flatulent, and spas-
31*
3«6
DISEASES OF THE DIGESTIVE SYSTEM.
modic, as attempted by some writers. There is not a proportion
in the relative frequency of cases of disease, certainly not in mor-
tality, so much greater in southern than in northern regions, to justify
a belief in its hepatic origin. The mortality on the coast of Africa
from cholera morbus is analogous to that from fevers in that
region, but not to that from hepatic derangements. The differences
in the amount of bile discharged and in the greater or less preva-
lence of spasm are fortuitous, and will vary at different times in the
same individual. I speak now of merely one of the elements of
climate, atmospherical heat, which is believed to be an exciter of
the hepatic secretion. But if we extend the range of inquiry, after
noting the causes of sporadic cholera morbus, we soon discover
that these are more common at particular seasons and in particular
localities, and that in such a degree as to render the disease ende-
mic. It has been thus that it appears from time to time in the East
Indies, and other tropical regions. Epidemically, or as the occur-
ring from a combination of causes produced or measured by parti-
cular seasons, it is not uncommon in northern Europe and America,
as described by Sydenham and others.
But however common cholera may present itself sporadically
or frequent, and aggravated by epidemical influences, we recognise
a general sameness of causative impressions. These are exposure
of the body, after it has been much heated and over-fatigued, to a
cool and damp air, by which congestion is induced in the system
of the vena portae; the use of indigestible and irritating food, which
acts as a morbid exciter to the already irritable gastro-intestinal
mucous membrane; and drinking spirituous and newly fermented
liquors, which serve still further to irritate this latter.
Seat of the Disease. —The first effects of this irritation are the
increased secretion from the gastro-intestinal glands, and by con-
tinuous sympathy from the liver; but the prevailing tendency to
congestion soon locks up the supply from this last viscus, and the
bile, poured for a short time, is now arrested, and the disease con-
tinues to manifest its violence, not owing to excess, nor, it may
be said, to deficiency of bile; but certainly this last mentioned
fluid is after a while deficient; and one of the evidences of an
amelioration of the disease and return to health, is the restora-
tion of its secretion. Truly has Dr. Johnson said, "that in no
disease has a symptom passed for a cure with more currency or
less doubt than in cholera morbus." (On Diseases of Tropical
Climates.) You will find many instructive views pleasantly ex-
pressed, both in this and other diseases of intertropical regions, in
the work just referred to. I stated to you, in my remarks on
bilious colic, that a slight modification in the state of the system
of a person attacked with it, would have subjected him to cholera
morbus, so much is there of sameness in the causes. Bilious colic
is distinguished, it is true, in one essential particular ; viz., in the
absence of all purging; and in the comparatively small proportion
of fluids discharged by vomiting; but in both there are gastro-
intestinal irritation and congestion, and in both a transfer of this to
CAUSES OF SPORADIC CHOLERA.
367
the spinal marrow and its subsequent irradiation on the voluntary
muscles, and cramps and other spasms are the consequence. The
analogy is still more evident between the two diseases in a patho-
logical point of view, when we observe the symptoms in some cases
of cholera morbus in which the vomiting and purging and spasms
have ceased. The patient feels at this time some uneasiness in the
epigastrium and other parts of the abdomen, which is increased on
pressure. The pulse is frequent and resisting, the tongue dry and
furred, or red and glazed ; the thirst is great, appetite wanting;
some nausea and constipation, When the bowels are moved the
discharges are usually of a dark brown appearance. These symp-
toms, so closely resembling those occurring in bilious colic after a
subsidence of the disease, as I pointed out to you at the time (p. 321),
indicate gastro-enteritis, and demand no little watchfulness from the
medical attendant.
But it would be a grave error to assume that this state of oc-
casional occurrence represents cholera, as we commonly meet
with it. Irritation we undoubtedly have, and its concomitant in
all the mucous surfaces,increased secretion, followed, if this go on
long, by congestion; but inflammation of the gastro-intestinal tissues
is far from being proved; on the contrary, we must admit its
absence in the greater number of cases of common cholera. Au-
topsic examinations of the bodies of those who have died of the
disease are far from proving it to be a modification of gastritis or of
gastro-enteritis; and the occasional presence of certain spots of
discoloration and injection, sometimes in one part or other of the
stomach or of the small intestine, sometimes on the liver, may be re-
garded as acasual associationoreffect,rather than the materialcause
of cholera. These lesions have been found more generally after
the appearance and duration of symptoms described as character-
ising the second but not common stage. Where death has come on
rapidly, no organic change was seen. Nor can we derive more aid
from morbid anatomy in any attempt to give a hepatic pathology to
cholera, by enabling us to point out congested and otherwise morbid
conditions of the liver. These are, indeed, met with, but not with a
uniformity or a frequency that can allow of our regarding them
either as causes or necessary accompaniments even of the disease.
We shall not, it seems to me, be in error, if we admit, as the direct
exciting cause of the phenomena of cholera, an irritation of the
digestive mucous membrane, beginning chiefly in the duodenum,
and extending in one direction to the stomach, small intestines
and their continuation, and in another direction, along the common
duetto the gall-bladder and liver; with, as a common sequence
of mucous irritation, increased and irregular contraction of the
muscular coats of the gastro-intestinal canal, and determination and
accumulation of blood in its tissues.
Cholera sometimes ushers in another disease, or may lapse into
one, such as fever of some kind, or dysentery. Cleghorn speaks
of its assuming a tertian type; and Martin relates a case of
368
DISEASES OF THE DIGESTIVE SYSTEM.
intermittent cholera. Dr. Chapman mentions it as one of the
forms of yellow fever, and that he met with many instances of
it during the prevalence of pernicious intermittents among us.
(Lecture on Cholera Morbus, Am. Jour, of Med. Sciences, vol. vii.
p. 297.)
To arrive at a correct diagnosis of cholera morbus, we have to
distinguish it from epidemic cholera and from poisoning by acrid
substances. Between a severe case of the first and a common
attack of the second it is not easy to determine, unless in the cir-
cumstances of accompanying atmospherical constitution and epi-
demical extension of disease. The more precise characters of the
epidemic kind will be given in a subsequent lecture, when it will be
formally the subject of inquiry. Common cholera is not readily
distinguishable from certain kinds of poisoning. The more rapid
termination of the latter, in fatal cases, has been alleged by Dr.
Christison, (On Poisons,) to be a characteristic feature, but erro-
neously. Diarrhoea, common to both diseases, generally occurs
almost simultaneously with vomiting, or somewhat precedes it in
cholera, whereas it comes on after the vomiting where poisons have
been swallowed. A common, but far from universal difference, is in
the sanguinolent fluid being mixed with the ejected matters in the
latter case, and its absence in the former; but sometimes this feature
is distinctly observable in cholera. The chief diagnostic sign, how-
ever, is the sense of heat, acridity, or burning in the throat, and along
the oesophagus to the stomach, which is so much complained of in
poisoning, and precedes the vomiting. In cholera a similar sensa-
tion is far from being so uniform ; and when it does show itself, it is
often confined to the stomach, and follows ihe vomiting. The dia-
gnosis between cholera and colic, ileus, diarrhoea, and dysentery,
is easy, and need not be repeated here.
Treatment. — That which is generally regarded as the first in-
dication in the treatment of cholera morbus, is to encourage the
evacuation of the morbid secretions, and to diminish their acrimony.
In order to effect this, free dilution is recommended, by the inges-
tion of simple drinks, such as herb teas, rice arid barley water, and,
as Sydenham prescribed, weak chicken broth or chicken water.
But I believe that a more important indication to propose to our-
selves is a removal of the irritation of the gastro-intestinal mucous
membrane, and the accompanying congestion, on which the morbid
discharges are dependent. Hence, our remedies should be ad-
dressed to the organs rather than to their secreted products ; the
quantity and acrimony of Which latter will seldom be detrimental
if the sensibility of digestive surfaces be brought to a healthy stand-
ard. Even, to accomplish this end, diluents and demulcents are not
without their value; and of all, there is not probably anv one better
than water, cold or tepid, or warm or hot, according" to the in-
stinctive craving of the patient, and his gastric sensibility at the
time. The ingestion of tepid or moderately warm water will at
first increase the vomiting; and might, if long continued, keep up
TREATMENT OF SPORADIC CHOLERA.
369
the nausea ; but, after a while, the stomach is more composed, and
the feelings generally of the patient tranquillized. Cleghorn tells
us, that the Spanish physicians found nothing more beneficial in the
worst cases of cholera than drinking of cold water. The thirstbeing
great, and the patient still clamorous for drink, water may again be
administered — cold, if the inward heat be great and depression not
alarming, — hot, if an opposite state of things exists. In any
case, the quantity of fluid of any kind taken into the stomach, and
indeed in all circumstances, after the first draughts of tepid water,
should be small. Repeated doses of water, as hot as can be drunk
without scalding the mouth, will often be readily retained by the
stomach, and act as an anodyne to this organ, and diffuse moderate
excitement through the system at large, and in a most beneficial
manner to the skin. Favouring this latter operation, and at the
same time contributing to the relief of the congestion of the chylo-
poietic viscera, will be warm applications, by dry heat, to the ex-
tremities, fomentations to the abdomen, or the warm bath, if it can
be used without fatigue to the patient, or requiring him to change his
recumbent posture. Conjoined with this means of procuring cuta-
neous excitement will be friction with the hand, or soft flannel, or
a flesh-brush, steadily but not roughly applied along the limbs and
spine. More potent applications are sinapisms, ammoniated lini-
ments, &c.^ to the extremities and over the epigastric region.
Before detailing the farther treatment in this disease, I must
speak of the course advocated and pursued in the first stage, dif-
ferent from that which I have just described. It is to administer
an emetic, with the intention of exciting the stomach not only to
an entire discharge of its contents, but also both it and the small in-
testine and liver to a healthier secretion. Hazardous as this prac-
tice would at first seem, it is not only sustained by plausible argu-
ment, but, still more, by successful results. I well remember my
feelings of repugnance when 1 first heard it formally announced
and advocated by Dr. Chapman, in the first course of his admirable
lectures on the practice of medicine; and my private (written) cri-
ticisms on the occasion. I was at the time little aware that, in
fifteen years from that time, I should be found among those who
placed no little reliance on the emetic practice in the more formi-
dable and dreaded variety of cholera. Hillary, antecedently, had
recommended ipecacuanha in the cholera morbus, in the Island of
Barbadoes, and particularly among children. When we design to
administer a remedy of this nature, ipecacuanha should be pre-
ferred ; and, as it is desirable to produce a deeper impression on the
stomach than simple expulsive contraction of its muscular coat,
we had better give the medicine, mixed with water, in a dose of
two or three grains, to be repeated at intervals of half an hour
until the dark and morbid matters are all discharged, and the
healthier secretion of mucus, mixed with some bile from the liver,
is visible. By the operation of an emetic, reaction is brought about
more speedily and entirely; and the skin, before cold and clammy,
now becomes warm, and moistened with a natural sweat. There
370
DISEASES OF THE DIGESTIVE SYSTEM.
is a greater probability, also, of the purging being abated and
checked by an emetic, than if the evacuation of the stomach is left
to natural irritation. .
Relief having been procured from vomiting and purging by these
means, either the simpler ones first recommended or the emetic
just described, the patient often falls into a slumber; and in milder
cases the disease requires little else than a mild purgative infu-
sion of rhubarb or of senna to insure convalescence. But if the
original symptoms remain or return after a slight remission, re-
course must be had to opium in some form. In a solid stale, or by
pill, it is most apt to be retained by the stomach; in its liquid, or
in the shape of laudanum, is that best adapted for use as an enema,
with a small quantity of warm water or of gruel, or flaxseed tea.
At this juncture, the question may well present itself, as it would do
in bilious colic, viz., whether we require the aid of the lancet.
The answer will depend not only on the existing symptoms, — the
violence of the spasms, the intestinal heat and oppression com-
plained of, obvious determination to some important viscus, and
the resistance of the pulse,— but also on the antecedent circum-
stances, such as gastro-intestinal irritation, chronic phlogosis of
some organ, or a course of life well calculated to bring on gastro-
enteritis. If this state of things present itself, we ought to bleed, —
as a measure of wise prudence, if not of imperative necessity. By
so doing we shall probably relieve the congestion of the portal
system, remove any existing gastro-enteritis and the oppression
from accumulation in the great vessels and right side of the heart,
and favour healthy reaction, besides predisposing the system to be
more promptly and beneficially impressed by opium. I say nothing
of the various received remedies of the class of aromatics and
spices which are supposed to be efficient in checking vomiting.
They are in severe cases of little avail, and in milder cases hardly
called for. Their preparation and administration are often indi-
rectly injurious, by diverting attention from more important mea-
sures. This remark does not apply to camphor mixture, a few
drops of tincture of camphor on sugar, or oil of turpentine, also, in
small doses with sugar. Opium, and these remedies, and the
simpler external irritants failing to check vomiting, or the oppres-
sion being great from the beginning, and no adequate reaction
manifesting itself, a blister must be applied to the epigastrium.
In a large number of cases we shall be content to evacuate the
stomach by diluents or a mild emetic, then tranquillise it by opium,
and afterwards endeavour to carry off still retained excretions in
the intestines, and to restore the proper secretions of these parts.
If we can procure a remedy which, whilst it is congenial with the
irritated stomach, shall also meet the indications just mentioned,
we shall of course give it the preference. In calomel we have an
agent of this nature ; and ten or twelve grains of it, in pill, adminis-
tered attheoutset, will suffice to soothe the stomach, check vomiting,
and acton the liver, and determine downwards the still retained mat-
ters in the digestive canal, and finally procure their expulsion. It
EPIDEMIC CHOLERA.
371
will be well, in general, in order to secure the first sedative operation
of the calomel, to give opium, from half a grain to a grain, in com-
bination with this latter. Failure of the first dose, or its incomplete
effects, will justify a repetition of the calomel, either alone or with
opium, as the symptoms, particularly the persistence of the spasms,
may seem to require. Bile once seen in the stools, or their being
coloured green with calomel, will indicate that an adequate effect
has been produced by this medicine; and the propriety, if more abun-
dant evacuations are required, of giving a laxative of rhubarb and
magnesia with ginger,— or castor oil with cinnamon water. Should
the stomach remain irritable, we must be content with prescribing a
few grains of blue pill, once or twice a day, or hydrarg. cum
cretd, and enemata to open the bowels.
Mention has been made already of a state of things of occasional
occurrence in cholera morbus, resembling gastro-enteritis. This
is more liable to be met with after a sudden stop has been put to
the vomiting and purging by the premature use of opium and
astringents: but it may come on without any such cause. In either
case, it requires venesection, or, if there be much epigastric tender-
ness and a red and dry tongue, leeches to the affected part of the
abdomen, — then laxatives, simple enemata, diluent drinks, and the
milder saline diaphoretics, such as citrate or acetate of potassa
with minute doses of tartar emetic dissolved in it, warm pediluvia,
or the warm bath.
The languor and debility, often extreme, left after an attack of
cholera, require great care, by an avoidance of the former causes
of the disease, the use of a simple yet nutritious diet, simple bitters
with some aromatic addition; and, if these do not suffice, sulphate of
quinia, from three to five grains daily, for a few days.
LECTURE XXXI.
DR. BELL.
Epidemic Cholera.—A counterpart to the pestilences of olden times—The
great pestilence in the fourteenth century—Less mortality with advanced
civilization.—First appearance of the epidemic cholera in India—Its progress
in that country and in Eastern and Western Asia and the islands—in Russia;
Poland; Hungary; Austria—Its appearance in England, Scotland, and Ireland;
United States; Mexico; Havana; Southern Europe; Algiers—Order of suc-
cession of the attacks of cholera—No regular rate of progress or rule of trans-
mission— Quarantine restrictions useless—Singular limitations of its range by
the smallest change of locality.—Causes. The special cause unknown—Pre-
disposing and modifying causes, in weather and season; low situations; poverty,
destitution, and vice of the inhabitants; bad food; watery fruits and vegetables,
intoxicating drinks; sudden debility of the nervous system; fear; great and
unusual exposure to atmospherical extremes and changes—Atmosphere and
other phenomena anterior to and contemporaneous with cholera—Attacks of
the disease mainly in the summer-half of the year—Prevalent winds—Sickness
and mortality among animals coincident with cholera in different countries—
Cholera not transmissible by contagion.
It was reserved for our own time to present a counterpart of those
372
DISEASES OF THE DIGESTIVE SYSTEM.
dreadful pestilences which devastated the world in the latter period
of the Roman empire, and afterwards in the middle or barbarous
ages of Christendom. Many a reader of history must have felt his
amazement at the extent a"nd violence of those visitations abate
by a not ill-founded doubt of the accuracy of the narrator, whose
ignorance, ministered to by his love of the marvellous, might have
led him into exaggerations. But the appearance and spread of the
epidemic cholera over all parts of the civilized world, or wherever
men were largely congregated into thickly settled communities,
and the frightful mortality which everywhere followed in its train,
brought too convincing proofs to the mind of the most skeptical
that historians, in describing the pestilences in the reign of the
Antonines and of Justinian, and later in the period which elapsed
between the years 1345 and 1350, had not drawn the materials of
their narratives either from their own fancy or the stores of fiction.
But, while thus reminded in such fearful characters of the times
of imperfect civilization, or, what is sometimes worse, methodised
barbarism, and although seemingly, for a time, we were reduced
to a level with the people of the barbarous ages, we shall soon
discover, after a proper comparison, that our arts and sciences,
and the social influences of our religion and institutions, have ex-
erted a conservative power for the benefit of the many, which
in former times was imperfectly secured to the few. Let me
detain you for a few moments in setting forth some data for a
comparison of this nature. I shall draw them from a small work
which, on the spur of the occasion, I prepared in 1832, in conjunc-
tion with my friend, Dr. Condie, at the time of the prevalence of the
cholera in this city. It is entitled " All the Material Facts in the
History of Epidemic Cholera: Being a Report of the College of
Physicians of Philadelphia to the Board of Health: and a Full
Account of the Causes, Post Mortem Appearances, and Treatment of
the Disease. Second Edition."
The great pestilence in the fourteenth century just adverted to,
like the cholera in our own time, is represented to have begun in the
east (China).—It appeared in Egypt, Syria, Greece, and Turkey, in
1346; in Italy, and Sicily, in 1347; in France, and the southern parts
of Spain, and in England, in 1348; in Ireland, Holland,and Scotland,
in 1349; and in Germany, Hungary, and the north of Europe, in
1350. In this period a comet was visible — also meteors of various
kinds; the seasons were irregular — myriads of insects were seen
— domestic animals sickened and died — and fish were found dead
in immense numbers. So deadly was the onset of this plague, that
at least half, some say two-thirds, of the human race, were de-
stroyed by it. It was most fatal in cities, but in no place died less
than a third of the inhabitants. In many cities, nine out of ten of
the people perished, and many places were wholly depopulated.
In London, we are told that 50,000 dead bodies were buried in one
grave-yard. In Norwich, about the same number perished. In
Venice, there died 100,000. In Lubec, 90,000. In Florence, the
same number. In the East, is has been said, with what degree of
EPIDEMIC CHOLERA.
373
accuracy we cannot vouch, that twenty millions perished in one
year. In Spain, the disease raged three years, and carried off two-
thirds of the people.
In England, and probably in other countries, cattle were neglected
and ran at large over the land. The grain perished in the fields
for want of reapers; and after the malady ceased, multitudes of
houses and buildings of all kinds were seen mouldering to ruin.
Although in the preceding year there had been abundance of pro-
visions, yet the neglect of agriculture during the general distress
produced a famine. Such was the loss of labourers, that the few
survivors afterwards demanded exorbitant wages, and the Parlia-
ment of England was obliged to interfere, and limit their wages,
and even compel them to labour. See 23 Edward III., a.d. 1350.
The disease reached the high northern latitudes; it broke out in
Iceland, and was so fatal that the island is supposed never to have
recovered its population. It was there called the sorte diod, or
black death. (See Hecker on the Black Death.)
The pestilence was remarkably fatal to the monks and regular
clergy of all descriptions. At Avignon, where the disease first ap-
peared in France, 66 of the Carmelites had died before the citizens
were apprised of the fact; and when it was discovered, a report
circulated that the brethren had killed one another.
It is an important fact in the history of this epidemic, adverse to
a belief in its contagion, viz., that the disease first appeared in a
city not commercial, nor a sea-port; and in a monastery which
was probably crowded with idle and not over-cleanly monks.
Our motives for introducing here the narrative of the awful
plagues in the reign of Justinian, and in the first part of the four-
teenth century, are to show our readers that mankind have suffered
more on former occasions from the visitations of disease, than, of
late years, from the dreaded scourge of cholera; and also, that
they may be made aware of the ameliorating influence of civiliza-
tion— implying improved minds, and knowledge, and a greater
amount of means for promoting personal comfort and protection
against morbid causes. Dreadful as the mortality from cholera
has been, we cannot but see that it is mainly restricted to a par-
ticular class, whose situation and habits reduce them to a level
with a large majority of the people of the middle or barbarous
ages, and expose them to the same calamities in seasons of epi-
demical disease. When a pestilential malady, call it what you
will, yellow fever, cholera, &c, now appears in a city, but a small
portion of the inhabitants are victims to the disease. In former
ages, analogous diseases passing under the common appellation of
plague, would nearly depopulate a city. We have already men-
tioned the loss of 90,000 citizens of Florence, nearly a third of the
entire population, by the plague of 1347. In 1359, on a similar
visitation, the mortality was estimated at 100,000; whereas the
deaths from the cholera in Moscow, with a population of 350,000,
in 1830, were short of 5000. St. Petersburgh also, with nearly an
vol. i.—32
374
DISEASES OF THE DIGESTIVE SYSTEM.
equal population, encountered the like loss. Vienna, containing
300,000 inhabitants, lost not 4000. Even in Paris, where the
mortality was excessive, amounting to upwards of 18,000, if we
consider the population of that city, 800,000 inhabitants, we cannot
but be sensible of the increased advantages which the people of the
civilized world at this time enjoy, of either warding off pestilence
entirely, or of greatly mitigating the violence of its attacks.
London, with a population of 1,500,000, lost but 5000, and in all
Great Britain the deaths were somewhat more than 20,000. In
Philadelphia, with a population of 160,000 souls, the loss by cholera
was under 1000. In the East, the mortality from the cholera has
been excessive, but this fact serves to confirm our proposition —
since we know that the mass of the people in that quarter of the
globe are in the same half barbarous state now in which they were
five and even ten centuries ago.
Without fear of being taxed with plagiarism I shall borrow with
equal freedom from the Report of the College of Physicians in 1832,
which I drew up in the name of the Committee on the occasion.
First, I shall speak of its reputed origin and geographical range : —-
Most of the historians of cholera describe it as first showing it-
self in Jessore, a town 62 miles N.E. of Calcutta, about the middle
of the month of August, 1817. But it is known that its appearance
in this last mentioned city was nearly contemporaneous, nay, some
say anterior, to its breaking out in Jessore. It is distinctly affirmed
in the Bengal Medical Reports, that the disease appeared in the
Nuddeah and Mymensing districts in May, 1817, raged exten-
sively in June, and in July reached Dacca. Before the end of No-
vember, few towns or villages in an area of several thousand miles
escaped" an attack. Across the whole extent of the Gangetic
Delta, and especially in the tracts bordering the Hoogly and Jel-
linghy rivers, the mass of the population was sensibly diminished
by the pestilence. It is needless to describe minutely in this place
the ravages of the cholera in the various towns and districts of
Hindostan. These were, in one direction, along the Ganges and
its tributary streams. Delhi, the ancient capital of that country, on
the western bank of the Jumna, was attacked in July, 1818. The
disease appeared in Bombay, on the western coast, in August, and
in Madras, on the eastern coast of the peninsula, in October, 1818.
In Trincomalee, in the Island of Ceylon, it was first noticed in De-
cember of the same year. Since 1817, Calcutta has been a regular
sufferer from cholera every season. The same remark will apply
to Bombay, and, with the exception of two years, to Madras.
In 1820, we find the cholera to have shown itself in Cochin
China, Tonquin, arid the Phillipine Islands, and at the conclusion of
the year it was in Canton, and the southern part of China Proper.
Pekin, the capital, was assailed in successive years, and in Chinese
Tartary, cholera appeared at two different times, with a consider-
able period intervening. In the Island of Java, it broke out in
April, 1821, and in the Molucca Islands, and in Canton for the
EPIDEMIC CHOLERA.
375
second time, in 1823. In July, 1821, it showed itself at Muscat on
the southern end of the Persian Gulf, and in the same year at Bas-
sorah and Bagdad. Persia has been subjected to its ravages five
different times from 1821 to 1830. In 1822, the disease was
raging in Mesopotamia and Syria, having appeared as far west
as Tripoli, on the shore of the Mediterranean Sea, and in the year
1824, at Tiberias, in Judea, on the same coast.
In September, 1823, the disease showed itself in Astracan, a
large and populous town at the mouth of the Volga, on the northern
shore of the Caspian Sea. But it soon subsided here, and did not
break out again in any part of the Russian Empire until the close
of the year 1829, when the town of Orenberg was attacked. On
the last of July, 1830, it again appeared in Astracan, in which city
and province the mortality was this time excessive. Near the close
of September, of the same year, it was announced as prevailing in
Moscow, and in June, 1831, in St. Petersburgh and Archangel.
Riga and Dantzic had begun to suffer from the pestilence in May
of the same year. Its presence was discovered among the
wounded and prisoners, Who had been conducted to Praga, a
suburb of Warsaw, but separated from that city by the Vistula.
On the same day it appeared in the Polish army, after the battle of
Inganie. Hungary was the theatre of its operations in August of
the same year (1831). Constantinople was its theatre in July; and
part of Greece in November. In Berlin and Prussia it appeared in
August, in Vienna in September, and in Hamburgh in October, of
that year. It reappeared in Berlin, Prague, and Dantzic, in 1837.
The first place attacked in England, by the cholera, was Sun-
derland, a sea-port town in the county of Durham. The disease
had appeared there as early as August, 1831, but did not engage
general attention or excite alarm, until the latter part of the year.
It then manifested itself in Newcastle-upon-Tyne, and many other
contiguous places in the north of England ; and in Haddington, Edin-
burgh, Glasgow, and other towns in Scotland, from January to Au-
gust, 1832. It showed itself in London in February of this year, 1832;
and again, in a more limited degree, in 1833 and 1834; and attacked
a few individuals in 1837. In the spring of 1S32 it was in Dublin,
Belfast, Cork, and other places in Ireland. In the early part of April,
its presence was announced in Paris, and since then it has appeared
not only in the small towns around that capital, but in many other
places in France. In June, 1832, it was ravaging Montreal and
Quebec. In July, New York; and in August, Philadelphia, Balti-
more, and Washington ; Cincinnati and New Orleans were assailed
in October. Boston suffered slightly, in this year, also. Richmond
had its turn in the following year.
The different military posts of the United States were assailed in
succession, during the years 1832, 1833,1834, and 1836. Mexico
was ravaged by it in the summer of 1832, and Havana was a
sufferer in the spring of 1833. In 1834 cholera renewed its attacks
in New York and Philadelphia, but, especially in the latter city,
with mitigated violence; Charleston, S. C., was visited in 1836.
376
DISEASES OF THE DIGESTIVE SYSTEM.
The disease broke out in Portugal in 1833 ; its first appearance
was at Oporto ; but it did not show itself in Lisbon until the follow-
ing year. In 1835, when the cholera had ceased its ravages in the
south of France, it showed itself in Piedmont, Genoa, and Florence,
and in September, 1836, at Naples; while Rome was not a suf-
ferer until August, 1837: Malta also suffered about the same time.
In the kingdom of Naples, all the machinery of quarantine, aided
by the military cordons and the greatest vigilance of the govern-
ment and its officers, was insufficient to prevent the breaking out of
the disease in the capital, and equally unavailing were all the
measures of separation and seclusion of the first attacked, to pre-
vent its diffusion. Spain paid the tax of fright and death in 1833;
Gibraltar, in 1834. Algiers and Bona were attacked in 1837.
A few observations will naturally follow, on the Order of Succes-
sion in which different Countries and Districts have suffered from
Cholera. These will serve to remove the impression which the
account of its progress from east to west, apparently along the
great highways of trade and social intercourse, might produce in
favour of the disease having been extended by contagion. The
cholera, during the year 1817, that in which it first appeared in
many different parts of Bengal, was mainly restricted to this pro-
vince. It ceased to prevail anywhere on the approach of winter
of that year. Up to this time the most southerly point along the
coast, stretching to the south and west, which was attacked, was
Cuttack, and that to the north and east, (taking Calcutta as the
centre,) was Silhet.
In the following year, 1818, the order of succession was remark-
ably regular — a month's interval for every degree of latitude.
Ganjam, which is in 19° and some miles north latitude, was attacked
on the 20th March; and Madras, in north latitude, 13°, October
8th. This was the rate during the dry season, and when there was
no interference with the constant commercial intercourse which
prevails on the Coromandel Coast. From Madras south, the order
of succession was in an accelerated degree. It is worthy of re-
mark here, that for two months, beginning on the 10th of October,
the port of Madras is annually closed, and in consequence of the
prevailing winds, and of the surf, which during this period breaks
upon the whole of that open coast, every vessel is forced to leave
it, and the small vessels are drawn high and dry on land. Yet still,
as just remarked, the places to the south were assailed by the dis-
ease even in more rapid succession than those to the north of this
city.
Not very dissimilar was the order of succession in which places
in the interior of the peninsula were attacked — so that the disease
appeared nearly simultaneously at the sea-port of Madras, and in
places on parallel latitudes, in the interior. At Masulipatam, a
town on the Coromandel Coast, and situated near the mouth of the
Kristnah river, the disease showed itself on the 10th of July, 1818;
SMatnJ>UJnderpoor' on one of the head branches of this river, in a
W.JN.W. direction, and distant some hundred miles, it appeared
EPIDEMIC CHOLERA.
377
on the 14th of the same month, while intervening places were
affected at a later period. Bellary, in the centre of the peninsula,
in latitude 15°, was attacked on the 8th September. Nellore, on
the eastern, coast was first a sufferer, on the 20th of the same
month — so that we cannot conceive of any direct progression of
the disease, orof any substantive cause of its passing from the coast to
the interior, nor from the interior to the coast. The long interval
also between the appearance of the disease at Cuttack by the last
of September, 1817, and at Ganjam, on the 20th of March, 1818,
forbids our supposing the transmission of any known substantive
cause of the disease "from one of these places to the other—both
being situated on the coast, and within a moderate distance of each
other. Aska, near Ganjam, in the interior, and on the main route
south-west from Cuttack, was not visited by the disease till the 23d
April, 1818.
In China, we find that the disease one season attacked places in
succession in a south-easterly direction from Tartary to Pekin, and
at another time assailed them in a north-west course from Canton
to Pekin. Persia was attacked in different years by cholera, and
the order of succession and direction not regular. From Bassorah
on the head of the Persian Gulf, through Mesopotamia to Aleppo,
and along the coast of Syria to Damascus, the direction was north-
west— but the attacks were not in any very marked order — the
period between its being in Basorrahandin Damascus wasfour years.
A caravan would traverse the same space in nearly as many months.
Egypt, contiguous to Syria, and holding regular intercourse with it
both by sea and land, did not suffer from cholera until eight years
after its appearance in Antioch and Tripoli, a Syrian sea-port, and
nine after its attacking Aleppo.
During the month of May, 1831, the Cholera broke out in Mecca
and other places in Arabia, and in the month of August in Cairo
and Alexandria, in Egypt. The disease was in Astracan, at the
mouth of the Volga, on the Caspian Sea, in September, 1823. No
places to the north and west were sufferers from the disease either
on this or the following years, until the month of July, 1830, when
it reappeared in Astracan. From this time, until the beginning of
winter, a great portion of Russia in Europe was attacked with cho-
lera ; but in following a given line, from Astracan, along the banks
of the Volga, in a north-west course, we cannot find any regular
order of succession of attacks of towns and villages. Thus, Astra-
can, at the mouth of the river, was, as we have seen, the seat of
the pestilence in July, 1830. Saratov, higher up, and Novgorod,
some hundred miles still farther up the stream, suffered in August of
the same year, while Samara, situated between them on the Volga,
had no cholera all October. Asof, at the mouth of the Don, was
attacked in October, whilst the region of country to the north and
west, and on as far as Moscow, suffered from the disease in Sep-
tember. Kiow, on the Dnieper, felt its ravages in October, 1830,
whilst Brody, on the southwest, had not the disease until May, 1831.
378
DISEASES OF THE DIGESTIVE SYSTEM.
On the Baltic, we meet with similar irregularities. In Riga, the
disease prevailed in May; in Mitteau, to the south, in June ; in Lie-
bau, more southerly, in May; and in Polangen, still farther south
along the same line of coast, in June. If, again, we take a city on
the extreme eastern boundary, as Orenberg, for example, we dis-
cover that the disease prevailed there in September, 182y, and a
year elapsed before places on the great roads, to the west or
interior of the empire, were affected. Archangel and St. Peters-
burgh, the first on the White Sea, the second on the Gulf of Fin-
land, were both the seats of the disease in the same month (June),
1831, while Valogda, directly in the line of water or commercial
communication, was a sufferer in September of the year before, or
1830.
Thecholera appeared in Warsawin April, 1831; inDantzicin May;
in Pest, (Hungary,) on the Danube, in July; in Vienna, higher up the
river, in September of the same year. In Berlin, it broke out in the
last of August, 1831; whilst Thorn, more to the east, and holding direc t
intercourse with Warsaw and Dantzic, escaped. In Hamburg it ap-
peared inOctober. Whatever line we may assume, we cannot observe
any regular order of succession in which the different cities were
attacked — either along rivers, or on the great high roads between
capital cities. In Russia, Prussia, and Austria, where the greatest
efforts were made to set limits to the disease by sanitary cordons,
and the most rigid system of quarantine, the periods between the
attacks of cities and districts were not any longer than in India,
where the most unrestrained intercourse by sea, and along the
rivers and roads, was allowed. Any line by which we should pre-
tend to mark the places attacked by the cholera, must be very
irregular—sometimes approaching a town or village, and then
passing around it — to return after the lapse of weeks or ev6n
months. Sometimes the disease would nearly depopulate small vil-
lages near a principal station, before it made its appearance there.
It is worthy of remark, that, at the very time when the western part
of Russia and Poland, and parts of Germany, were suffering from
the cholera, it raged with great violence in Arabia and Egypt.
Perhaps we could not cite a stronger example of the difficulty of
explaining, by any known law of transmission or order of succes-
sion, an attack of cholera, than its sudden appearance in the heart
of Paris — the first city in France to suffer from the pestilence.
Equally sudden and unexpected was the bound, as it were, of the
disease from Montreal to the city of New York.
The annals of cholera prove, that when it made its appearance in
a camp or a city, far from extending to every habitation, it was
almost invariably confined to particular portions of even the most
populous places. Sometimes in an army, for instance, one or two
regiments encamped together, or separated by other corps, were
the only sufferers in an attack of the disease; one division in one
street only of a town had the disease existing in it — nay, its pre-
sence has been known to be limited to one side of a market-place.
EPIDEMIC CHOLERA.
379
Removing a camp a few miles has frequently put an entire and im-
mediate stop to the occurrence of new cases ; and when the disease
prevailed destructively in a village, the natives often got rid of it
by deserting their houses for a time, though, in so doing, they neces-
sarily exposed themselves to many discomforts, which would com-
monly be considered as exciting causes of disease.
It has been said, that the course in which the cholera has suc-
cessively appeared, has been westwardly. This is an error, if we
have regard to the chronological order in which it has made its
attacks, or assume any place as a point or beginning from which
the disease may have been supposed to diverge. Thus, in the year
1823, we find the cholera to have shown itself as many degrees
eastward of Calcutta — viz., the islands of Banda and Timor — as
it had done westward, or on the shores of Syria and Judea. Nor
has the line of its progress been either north-west or north-east.
"Assuming the cause of cholera to be poison in the air, its mode
of progression is singular. Originating in India, it spread east and
west, till, having reached China, its extreme eastern point, the
stream suddenly wheeled round to the west, and pursuing its course
through Tartary it joined in the attack on Europe. On the con-
trary, the western branch having reached England, [and Ireland,]
the extreme point of western Europe, the stream has suddenly
retrograded to the east through France, Spain and Italy, to Malta,
where it seemed to have become evanescent. In pursuing its
westward course, it appears to have been developed in two dif-
ferent manners, probably according to the nature of the country,
sometimes forming one or more centres, from which disease has
radiated in every direction; and again running in lines of no great
breadth, the country on either side being healthy." (Dr. R. Williams'
Elements of Medicine, vol. ii., p. 606.)
The same writer from whom I have just quoted relates some of
the peculiarities of cholera progress, as follows: — "Although the
great streams of cholera have, on the whole, steadily advanced,
they have not proceeded at an equal pace, the rate of progression
varying greatly in different countries. In the year 1817, the
cholera had overrun in India, in three months, a space westward of
not less than four hundred miles, while to the south it had pene-
trated no farther than Ganjam, only eighty-eight miles from Cal-
cutta, in six months. In the next six months, however, it had
extended in a southerly direction from that point over more than
four-fifths of the Peninsular. It reached Pekin in about the same
time that it attacked Muscat, the former being twice the distance
of the latter. In Europe its progress was equally capricious. It
travelled from the Caspian to Vologda and Pskou, within one hun-
dred miles of the Baltic, at a rate which would have infected all
Europe in three months, while it did not reach Riga, only one
hundred and eighty miles distant from the latter town, until eight
months after. Its rate, however, appears to have been most
retarded in its retrograde movements, for it took six years after
380
DISEASES OF THE DIGESTIVE SYSTEM.
London was infected to reach Rome. In a word, it took only one
year to span the base of the Peninsular of India, while it occupied
twenty years to compass the globe."
Causes. — The cause by the operation of which the common
and appreciable causes of disease give rise to cholera is unknown
to us. That it is in the atmosphere we have every reason to
believe; but in what state or how combined, we cannot hitherto
ascertain. The most probable supposition is, that it is a peculiar
poison. It is, however, encouraging for 41s to know, as we
now positively do, from all which has transpired in the history
of the disease, that the concealed general or aerial cause is compa-
ratively harmless, unless effect is given to it by subjection to evi-
dent modifying agencies.
Preceding and accompanying the appearance of the cholera in
a country or city, there have been deviations from the usual state of
the weather and season— unwonted vicissitudes or extremes, with,
often, changes in the electrical state of the atmosphere. These
would not probably be of themselves adequate to the production of
cholera but for the additional predisposing cause of unfavourable
localities. The chief home and seat of cholera is in low, damp
situations — on the banks of rivers, or near pools and ponds of
water,— or which are encumbered with vegetable remains, and
filth of any kind. Those parts of cities thus situated and circum-
stanced, have always suffered most, and sometimes have been the ex-
clusive seats of the disease. In all the chief cities of Hindostan, as
in Calcutta, Madras, Bombay, Seringapatam, &c, &c.; of Russia,
as in Moscow, St. Petersburgh, Astracan; of Germany, as in
Vienna, Breslau, Berlin, Hamburg; of France, as in Paris and
other places; of Great Britain and Ireland, as in London, Sun-
derland, Newcastle, Gateshead, Musselburgh, Dublin, Cork, &c,
this fact has been placed beyond doubt.
In Montreal, Quebec, and other places along the St. Lawrence
in our Atlantic cities, and in those on the Ohio and the Mississippi,
similar testimony has been afforded. Additional intensity is given
to unfavourable locality by narrow streets and numerous small and
ill-ventilated houses, crowded with inhabitants. Low, underground
lodgings increase greatly the risk of their inmates having the disease,
and the danger of its terminating in death.
Experiencehasalso fully shown,that, in regard tothemannerof liv-
ing, the intemperate, the devotedly sensual in anyway, they who are
unclean in their persons, and who are deprived of a suitable supplv
of wholesome aliment, are peculiarly liable to the disease, and to
perish under its attack. The drunkard has everywhere been
singled out as a victim of the disease, on its first appearance in a
place. Women of the dissolute and abandoned class were among
the foremost sufferers from cholera in India, as elsewhere.
" When Moscow was attacked, the mortality was severe onlv
among those persons living in low, damp habitations, whose diet
was poor, and whose conduct was irregular and debauched. The
CAUSES OF EPIDEMIC CHOLERA.
381
same fact was also observed at St. Petersburgh; for, in ninety-nine
cases out of a hundred, the victims, according to Dr. Gill, were the
drunkard, the dissipated, and the poorly fed; and it may be stated
as a general principle, that the ravages of the disease have been
confined nearly to the same class of persons throughout the whole
of Prussia and Germany."—(Dr. Williams, op. ci/.) This remark
may be extended to nearly every place where the cholera com-
mitted its greatest ravages. The most notable exception is in the
case of its attack on Lexington, Ky.
Food of a bad quality, irritating the stomach and bowels, has
often proved an exciting cause of the cholera. In India, the crops
of rice fell short and were damaged, and the inhabitants, whose
chief reliance for nutriment was on this grain, suffered dreadfully
from the disease. Similar deficiencies and badness of quality of
the wheat in Russia and Poland, were attended with the like re-
sults. Wherever watery fruits and vegetables were largely used
and relied on as food, such as cucumbers, melons, cabbages, &c,
the disease committed great ravages. Meats, which, though nutri-
tive, task excessively the digestive powers of the stomach, are to
be avoided, such as fat pork, smoked beef, lobsters, clams, and
crabs.
Among intoxicating drinks, distilled liquors are especially perni-
cious. At all times improper for a habitual beverage, they are little
short of poison when thus used in seasons of epidemic cholera*
Water, under all circumstances the best drink for mankind, may
be given of such temperatures, and so prepared by boiling, as
to be adapted to every stomach, and to prove both safer arid more
healthful than any liquid whatever prepared by art.
Any sudden or considerable debility of the nervous system is to
be greatly dreaded, as of itself laying the body open to an attack of
cholera. On this account, anxiety, fear, and the depressing pas-
sions in general, should not be allowed an abiding place in our
minds. Many have been destroyed by fear alone — but on the
same ground as that on which a tranquil mind is recommended to
be preserved, an equable state of the senses and functions generally
should be maintained, by regular hours of sleep, regularity of
meals, and the accustomed daily exercise.
Long exposure to the sun, and great fatigue, have been found ta
be powerfully contributing causes of cholera. If circumstances re-
quire imperiously such an exposure, additional circumspection is to
be exercised, in the manner of living, in other respects, and an
especial avoidance of the night air and dews, or of getting wet with
rain.
As a contribution of facts, but not as an attempt to assign
causes, 1 shall repeat here some of the notices, which I collected,
on Atmospheric and other Phenomena anterior to and contempora-
neous with the prevalence of the Disease. — Many of the British
physicians and surgeons in India describe frequent and great de-
viations from the usual order of the seasons before and during the
3S2
DISEASES OF THE DIGESTIVE SYSTEM.
existence of cholera ; and they speak of unusually violent thunder-
storms, " violent squalls," and storms of wind and rain. Earth-
quakes were also felt in various parts of Hindostan, At the time
when the grand army under the Marquis of Hastings suffered so
dreadfully from the disease, the thermometer ranged from 90 to 100°
— the heat was moist and suffocating, and the atmosphere a dead
calm.
The origin of the disease at Calcutta has been attributed to the
extreme heats and drought of the season, followed by heavy
rains, and the use of unwholesome food, viz., bad fish and ouze, or
new rice. In the Island of Java the weather, when the cholera
broke out (April), was represented as unusually dry and hot.
At Bombay the fall of rain was unusually great in August, 1818,
in the latter part of which month the disease broke out. The
same remark was made of the weather at Madras. It was' ob-
served that the different attacks of the epidemic in General Smith's
force at [Seroor, and other places, were always accompanied by a
cloudy, overcast state of the sky, sudden showers, composed of
large drops of rain, resembling those of a thunder-storm, and a thick,
"heavy" state of the air, giving it a whitish appearance; and
whenever the weather cleared up, the disease disappeared. The
person (an intelligent officer) who makes the above remarks, also
observed that the disease was invariably preceded and accompanied
by a large black cloud hanging over the place ; and added, that
this had been universally remarked, and that the appearance had
even received the name of the cholera cloud.
Similar notices abound of the connexion between the disturbed
state of the weather and the appearance of the disease in various
parts of India. It was also a subject of very general remark, that
the prevalence of southerly and easterly winds, seemed to give
vigour and force to the disease, while after a change to the north
and west, and a dry and pure atmosphere, it almost uniformly
subsided. However aggravated the disease was in the summer
months, or rather from spring to the beginning of winter, it was
most generally quiescent in this latter season, in India.
It would seem, however, that, of all the atmospherical phenomena,
which have been alleged to accompany the disease, none are uni-
versally present, except those which indicate a diminution in the
density of the air, and a tendency to rain and storms. In other
words, the atmosphere, during the prevalence of the disease, is in a
rarefied state; and exhibits a great tendency to part with its mois-
ture, forming thick clouds, heavy rain, or haziness; and to become
agitated by storms. It has been further said, but not generally
confirmed, that the meteorological occurrences which have been
observed to accompany the disease, are either produced by, or at-
tended with, a diminution of the quantity of free electric fluid in the
atmosphere.
The influence of season on the appearance and virulence of the
disease in Persia and Turkey is thought to be as evident as in India:
CAUSES OF EPIDEMIC CHOLERA. 383
for we learn that, during the three years in which it prevailed in
succession at various places from the shores of the Persian Gulf to
the Mediterranean, in one direction, and to the borders of Russia
in Europe, in the other, it prevailed only in summer.
In the United States the irruptions of cholera were, without ex-
ception, I believe, in the summer half or climate of the year.
^ The weather, before the breaking out of the cholera in Mecca
(in 1831), was remarkable for the excessive heat—the thermometer
being steadily as high as 102° F., and afterwards heavy rains, with
the wind from the south and south-east.
Before the appearance of the disease in Suez, a very hot south
wind prevailed.
At Cairo, during the first period of the disease, the wind was
from the north-east, and the heat, during the day, suffocating.
At Nishni Novogorod in Russia, there suddenly succeeded to a
warm and dry state of the atmosphere, in the month of August,
1830, a continuance of cold and wet. At this time the cholera be-
gan. Prevailing winds south-east.
The cholera appeared in Riga at the commencement of uncom-
monly hot and sultry weather.
In Poland, the cholera increased as the weather in March and
April became cooler and more damp. With warmth and dryness
of the air the disease rapidly abated. When, however, in August
and September the days became very hot, and the nights cold, it
again raged to an alarming extent.
The prevalence of the disease at Moscow is stated to have been
in proportion to the humidity of the atmosphere.
At Vienna the cholera broke out on the 13th of September, after
a hurricane and much cold rain.
At Dantzic so irregular and unfavourable to health had been the
weather of the spring, that pestilential diseases were expected as a
consequence.
Prior to the appearance of the epidemic and during its continu-
ance at Gibraltar, easterly winds were uncommonly prevalent.
During May and June preceding the cholera period in July and
August there were frequent thunder-storms accompanied with
heavy showers.
But although the attacks of cholera were, in a large majority, at
the period of the year between spring and fall, they were not con-
fined to this time. Thus, it appeared at Edinburgh in January, at
London, in February, at Paris in March.
The prevalent winds, in most places in which the cholera com-
mitted its ravages, have been easterly, from N.E. to S.E. These
winds, be it remembered, have almost invariably preceded and ac-
companied some of the worst pestilences and various fevers — such
as plagues, yellow fever, and violent bilious and intermittent fevers.
Among the phenomena worthy of record connected with the his-
tory of cholera, is the sickness and mortality of animals antece-
dent to and at the time of the ravages of the disease, in many parts
384
DISEASES OF THE DIGESTIVE SYSTEM.
of the world, where it prevailed. The general character of the
disease in them was of a choleiform nature.
Is cholera contagious ? The scope of my preceding remarks will
have shown my disbelief in the contagiousness of cholera. My
opinion in this matter is coincident with a majority of those who
have seen and written on the disease, although I am aware that
a contrary one is held by physicians of acumen and authority.
Among these, Dr. Graves is entitled to more conspicuous mention.
Into the whole argument I cannot of course enter at this time,
nor even reproduce all the facts, which I presented in the Report
of the College of Physicians before referred to. I must content
myself with a mere announcement of the, as it seems to me, promi-
nent objections against the creed of contagion: The simultaneous
outbreak of cholera in different parts of Bengal, as noticed by the
British physicians: a similar peculiarity marked its appearance in
most of the cities which it attacked. The utter inefficiency of all
quarantine regulations, as instanced in the Island of Bourbon, As-
tracan, Orenberg, St. Petersburgh, Breslau, Berlin, Hamburgh,
Vienna, Sunderland, Cairo, Alexandria, Naples, &c, &c, to say
nothing of attempts of a similar nature here at home, as absurd
as they were abortive. The sudden cessation and speedy dis-
appearance of the disease among men, by a slight change of
encampment. A corps encamped on low ground, in very rainy
weather, was severely visited ; of thirteen sepoys taken ill, six died.
After a few days they moved to a higher spot, and only one more
case occurs, which appears on the march to the new ground. Dur-
ing an attack of the epidemic, in April, 1823, by the sixty-eighth
regiment in quarters, at the suggestion of the surgeon, the wing of
the corps in which the disease prevailed the most was encamped
on a piece of high ground in the neighbourhood, and, he reports,
that not a case occurred in that camp. As illustrative of the in-
fluence of locality, but as adverse to contagion, the following facts
are of interest. In the three grounds of encampment of the centre
division of the British army, in the year 1818, the soil was low and
moist, the water foul, stagnant, and of a brackish quality, and
everywhere not more than two or three feet from the surface of
the earth, and the vicinity abounded in animal and vegetable putre-
fied matter ; whereas, at Erich, where the army regained its health,
the situation was large and salubrious, and the water clear and
pure, from a running stream. The disease, though prevailing so
fatally in the camp, did not appear in Allahabad for four months
afterwards, and yet the intercourse between this town and the
camp was very great. Even some corps of the division, stationed
at a little distance, escaped, though a diseased party arrived among
them from the main body. The crew of a ship from England were
seized with the disease immediately on her coming to anchor in
Bombay harbour, before there was any communication with the
shore. The rate of transmission of the disease in the order of
time, is not explicable by the doctrine of personal communica-
CAUSE OF EPIDEMIC CHOLERA.
385
tion. Cholera appeared at Orenberg in September, 1829, and
yet a year elapsed before places on the great roads to the
west or interior of the empire were affected. In Russia, Prussia,
and Austria, where the greatest efforts were made to set limits to
the disease by sanitary cordons, and the most rigid system of qua-
rantine, the periods between the attacks of cities and districts were
not any longer than in India, where the most unrestrained inter-
course by sea and along the rivers and roads was allowed. The
instances of the incommunicableness of cholera by persons and
goods are innumerable. Let a few among these suffice. The per-
sons composing the family of the Persian prince quitted the city
of Tabriz after the violence of the disease had already begun to
abate. They, however, carried the cholera along with them, and
continued to be attacked, from four to six a day, for about ten
days; but not a single person in the village through which they
passed, or where they slept, took the disease. During the preva-
lence of the cholera in Moscow, about forty thousand persons
quitted that city, of whom a large number never performed quaran-
tine ; and yet no case is on record of the disease having been trans-
ferred from Moscow to other places. (See Report, Sf-c.) The ge-
neral immunity of the physicians and nurses, and other attendants
on those sick with cholera, both in hospitals and in private prac-
tice, is utterly irreconcilable with a belief in the contagiousness of
the disease. Even regarded as an epidemic, the general exemption
of all these persons is surprising. Their consciousness of the dis-
charge of a high and noble duty, their intentness in watching the dis-
ease and studying its phenomena, together with their freedom from
fear, will go far to explain the escape of medical men from an
epidemic disease, but not from a contagious one. Eight hundred and
sixty patients with other diseases were in the hospital of Ordinka at
Moscow, during the time in which five hundred and eighty persons
were sick with cholera in the hospital, which consisted of three
stories, communicating by stairs placed within the hospital wards.
Not one of the former class of patients became affected with the
disease, although they had the same attendants as the cholera sick.
Of these attendants, a hundred and twenty-three in number, many
of whom were employed in washing the clothes of both classes of
patients, two only were affected with cholera, a man and a woman,
both of whom were disposed to the disease for very irregular con-
duct, for which they had been censured. Unlike contagious dis-
eases, under circumstances of free intercourse, cholera was not
spread generally in agricultural districts, except, as in parts of
India, and in some instances in the southern and western region of
the United States, where there were obvious peculiarities of an
endemic character, which would give additional power to any
epidemic visitation. Cholera was chiefly confined to towns, and
generally to particular parts of towns, — a restriction, whereno qua-
rantine is in force, not to be expected of a contagious disease. In
1837, when cholera appeared in the seaman's hospital, Dreadnought,
vol. i.—33
386
DISEASES OF THE DIGESTIVE SYSTEM.
in the Thames, none of the nurses or medical officers were at-
tacked ; nor did a case occur in any other vessel in the Thames,
although, during the prevalence of the disease, patients were dis-
charged almost daily from the Dreadnought, who immediately
entered other vessels. The persons attacked with cholera were
admitted into the Dreadnought for other complaints. Bearing on
the present argument is the fact, that while cholera existed in this
isolated manner in the Dreadnought, and when other parts of Lon-
don were free from it, some cases occurred in the Marylebone
Infirmary, situated in a part of the metropolis the most remote from,
and maintaining the least intercourse with, Greenwich, where the
Dreadnought was stationed.
In the United States, the great weight of medical evidence and
opinion is adverse to a belief in the contagion of cholera. The
almost general immunity from attack of medical and other attend-
ants on the sick, and the peculiarities of the circumstances of the
appearance and diffusion of the disease, and, indeed, nearly all the
facts already mentioned, have been repeated in this country, showing
that the disease was not communicated nor communicable from
person to person.
The shortness of the duration of epidemic cholera in a place, the
suddenness and rapid diffusion of the disease beyond what could
occur from personal intercourse, and its entire disappearance, are
facts adverse to a belief that it is contagious. To the same pur-
port is the disorder of the digestive organs among the inhabitants,
preceding its regular attack, and anterior also to any imputed im-
portation or intercourse of any kind with the sick in other parts.
Although cholera in the period of its attacks as well as in their
intensity, has been not a little modified by the seasons and atmo-
spherical vicissitudes, yet there are facts enough to show that it
has appeared in all seasons and states of weather ; unless we were
to assert that in cities, where alone it has rhadeits attacks in winter,
there is a combination of circumstances ever present, which keep
up a state of air in many of their close and illy-ventilated courts
and houses analogous to that of an unhealthy autumnal season.
On the ground of the difficulty of explaining the cause of cholera,
from any particular condition or combination of states of the at-
mosphere, a telluric origin has been supposed, and by some be-
lieved, to be the true one ; " for if we suppose it [the poison of cho-
lera] to be generated below the crust of the earth, and consequently
beyond the influence of the atmosphere, it is easy to understand why
its course is entirely independent of the seasons." (Williams.) By
some, again, it has been alleged that the poison, if not the electrical
or magnetic fluids themselves, must be extricated by their agency.
Dr. Holland (Medical Notes and Reflections) has suggested an-
other cause, viz., the generation of insect swarms, which, in their
migration, gave the course of cholera. He adduces many plausible
facts and analogies in favour of this opinion, in the paper entitled,
" On the Hypothesis of Insect Life as a Cause of Disease?" In
SYMPTOMS OF EPIDEMIC CHOLERA.
387
all our reasonings on this subject, the author lays it down, as the
first obvious and assured condition; " that the cause of the disease
must be a material poison; definite in its nature, and specific in its
effects." He then speaks of a wandering cause of the disease, a
migrating malaria, possessing the power of reproducing itself, and
depending, as he supposes, on animal origin and reproduction. " In
many respects, indeed, the erratic and ambiguous course of cho-
lera is well represented by the flight, settlement, and propagation
of the insect swarms which inflict blight upon vegetable life."
" The reappearance of the disease in the same locality at uncertain
intervals, but generally during the latter part of the year, is another
fact bearing on the same hypothesis." It is explained in " the con-
tingency of fresh swarms arising, or of the development of ova de-
posited in these places during the preceding incursions of the dis-
ease, and called more or less numerously into life by increased
temperature or other causes." But I cannot pretend to give you
the entire argument of Dr. Holland, which is very plausible, and
obviates more objections than any other. Were we to admit it, we
must also receive, in a qualified sense, the infectious nature of the
disease, and " that man, the peculiar recipient of this cause of dis-
ease, is also the principal agent in its diffusion."
LECTURE XXXII.
DR. BELL.
Symptoms—To be described under the head of diarrhceal stage, or cholerine; con-
firmed cholera, collapse and reaction—Importance of attention to the first, or diar-
rhceal stage—Time of attack of.—Confirmed cholera—Disorder of the stomach
and bowels; of the circulation; animal heat—Vomiting and purging vary in
extent—Collapse without evacuations—Mind undisturbed—Symptoms of dis-
ordered innervation—Spasms and cramps—Symptoms of collapse, or blue
stage—Sinking of the circulation the most constant and alarming symptom of
cholera—Thirst, and sense of heat in the stomach—Respiration, how affected—
Symptoms connected with the blood and circulation—Sameness of cholera in
all parts of the world — Stage of reaction, or consecutive fever — Analogy
between cholera and pernicious or malignant intermittents — Torti cited—
The lecturer's case of comatose intermittent — Urea in the blood, an al-
leged cause of the consecutive fever.—Prognosis—Common and individual
signs—Modification by age, sex, occupation, and race—Promptness of recovery
—Congestions with slower convalescence—Immediate causes of death—Re-
moter causes, in the constitution and habits of the individual—Misleading signs
in the consecutive fever.
Symptoms. — I shall speak of these under the heads of the several
stages of the disease, viz. : — 1. The Diarrhceal, or Cholerine___
2. Confirmed Cholera.—3. Collapse.—4. Reaction or Consecutive
Fever.
Cholerine.— On an early attention to the premonitory symptoms,
or to this first or forming stage of the disease, will greatly depend the
favourable issue of the case, and of course the life of the patient.
He complains of lassitude; has, frequently, partial uneasiness in the
region of the stomach; but this not to such a degree as to alarm
388
DISEASES OF THE DIGESTIVE SYSTEM.
him. He has frequent evacuations from the bowels—from two to
a dozen times a day—not attended with much griping. His coun-
tenance is sharp and dark. He knows not of this symptom, and it
is only recognisable to the eye of experience. Occasional nausea
may oppress him: but this is not a very common occurrence.
These symptoms may continue, varying in severity, from one to
ten days, before the second stage of the disorder supervenes. The
evacuations at the first are generally of a dark brown or blackish
hue, and not unfrequently bilious. As the looseness continues, they
gradually become less and less of a natural appearance, until they
assume the consistence and aspect of dirty water. Some headache,
cramp of the fingers, toes, and abdomen, and almost always slight
giddiness and ringing of the ears, accompany these symptoms.
Sometimes an intervening two or three days of costiveness super-
venes, which is followed again by the diarrhoea, and in a few hours
collapse may come on, and in general nausea and vomiting. On the
prompt appreciation of the nature of this diarrhoea, and timely appli-
cation to a physician, will greatly depend the issue of the cure. Dr.
Kirk says that it was found, from regular records of upwards of
4000 patients, to prevail in all. The same fact has been generally
noticed in an immense majority of those who have suffered from
cholera in theCanadas and in New York, Philadelphia, and other
parts of the United States.
Symptoms of Confirmed Cholera. — From among the numerous
minute and graphic accounts which have been published of the
phenomena by which the epidemic cholera is accompanied, from
its invasion until its termination, it is somewhat difficult to make a
selection ; but, as my desire is rather to present a general summary
of the symptoms, than a detailed account of every trifling deviation
from the ordinary course of the disease, I shall follow very closely
the excellent description presented to us by Mr. Scott in the Madras
Report.
The attack of cholera generally takes place in the night, or to-
ivards morning. The patient becomes sick at the stomach, vomits,
and his bowels are at the same time evacuated. This evacua-
tion is of a nature peculiar to the disease — the entire intestinal
tube seems to be at once emptied of its fecal or solid contents, and an
indescribable but most subduing feeling of exhaustion, sinking, and
emptiness is produced. Faintness supervenes,the skin becomes cold,
and there is frequently giddiness, and ringing in the ears. The
powers of locomotion are generally soon arrested; spasmodic con-
tractions or twitchings of the muscles of the fingers and toes are
felt; and these affections gradually extend along the limbs to the
trunk of the body; they partake both of the clonic and tonic spasm,
but the clonic form chiefly prevails. In other words, they consist
more generally of permanent contraction than of convulsive move-
ments of the muscular fibres. The pulse, from the first, is small, weak,
and accelerated, and, after a certain interval, but especially on the
accession of spasms or of severe vomiting, it sinks suddenly, so as to
SYMPTOMS OF EPIDEMIC CHOLERA.
389
be speedily lost in all the external parts. At this time, however
there is strong pulsation of the cEeliac trunk, and often of the abdo
minal aorta. The skin, which at first is suffused with a deep or
almost bronzed flush, soon falls below the natural temperature, and
becomes colder and colder, and pale; it is very rarely dry ; generally
covered with a profuse cold sweat, or with a clammy moisture.
During the progress of these symptoms the stomach and bowels
are very variously affected. After the first discharges by vomiting
and purging, however severe these symptoms may be, the matter
evacuated is always watery; and in a great proportion of cases
it is colourless, often homogeneous, and without fecal fetor, but giv-
ing out a peculiar odour, which is imparted by all the secretions,
and which, once experienced, is afterwards readily recognised. In
some it is turbid, resembling muddy water ; in others it is of a yel-
lowish or greenish hue. A very common appearance is that which
has been emphatically called the " congee stools," or like rice water,
an appearance produced by numerous mucous flakes floating in the
colourless, watery, or serous part of the evacuation. The discharges
from the stomach and those from the bowels do not appear to differ,
excepting in the former being mixed with portions of the food which
may have been eaten. Neither the vomiting nor the purging is a
symptom of long continuance; they are either obviated by art, or
the body becomes unable to perform the violent actions; and they,
together with the spasms, disappear a considerable time before death.
If blood be drawn, it is always dark, or almost black, ropy, and
generally flows slowly and with difficulty. Towards the close of the
attack, jactation, or restlessness, comes on, with evident internal
anxiety and distress ; and death takes place, often in ten or twelve,
generally within eighteen or twenty hours from the commencement
of the attack.
Cholera, however, like other diseases, has presented considerable
variety in its symptoms; thus, it may, on one occasion, be dis-
tinguished throughout by the absence of vomiting and by the pre-
valence of purging; on another, by the excess of vomiting; and,
though more rarely, by the absence of purging. Spasm may be
generally present in one instance ; in another, it may not be dis-
tinguishable. A frequent variety, the worst of all, is that which is
marked by a very slight commotion in the system — in which there
is no vomiting, hardly any purging, perhaps one or two loose stools;
no perceptible spasm, no pain of any kind: a mortal coldness, with
arrest of circulation, comes on from the beginning, and the patient
dies without a struggle.
Vomiting is sometimes, as already remarked, entirely absent, or,
if it has been present, soon ceases from an atonic state of the
stomach, under which that organ receives and retains whatever may
be poured into it, as if it were really a dead substance. Purging
is a more constant symptom than vomiting, and in a large majority
of cases it is the first in the order of occurrence; but being a less
striking deviation from a state of health than vomiting, which ir>
33*
390
DISEASES OF THE DIGESTIVE SYSTEM.
stantly arrests the attention, it has usually been spoken of as occur-
ring subsequently to the latter. Purging has been very rarely
absent altogether — its absence appears, indeed, to denote a peculiar
degree of malignancy in the attack. There is seldom much griping
or tenesmus, although the calls to stool are very sudden and irre-
sistible. They also sometimes take place simultaneously with
vomiting, spasm, and a suspension of the pulsation at the wrist; as
if all these symptoms originated at the instant from one common
cause. In advanced stages of the disease purging generally ceases,
but in many cases a discharge of watery fluid takes place on every
change of posture. The matters evacuated after the first emptying
of the bowels have been occasionally observed to be greenish or
yellowish, turbid, of a frothy appearance, like yeast, and sometimes
bloody ; but by far the most common appearance is that of pure
serum, so thin and colourless as not to leave a stain on the patient's
linen. The next in order of frequency is the congee-like fluid ; the
mucus is at times so thoroughly mixed, however, with the serum,
as to give the whole the appearance of milk. The quantity of the
clear watery fluid, which is sometimes discharged, is very great,
and were it uniformly so, it might afford us an easy solution of the
debility, thirst, thickness of blood, and other symptorfls; but it is
unquestionable, that the most fatal and rapid cases are by no means
those which are distinguished by excessive discharges. Death, on
the contrary, has ensued in innumerable instances after one or two
watery stools, without the development of any other symptom
affecting the natural functions. Collapse has even come on before
any evacuation by stool had taken place.
The undisturbed state of the mind in this disease has been the
subject of general remark : instances are not wanting of patients
being able to walk, and to perform many of their usual avocations,
even after the circulation has been so much arrested, that the pulse
has not been discerned at the wrist. The cases here alluded to are
those chiefly in which the disease has begun by an insidious watery
purging: and many lives have beenlost in consequence of the patients,
under these fallacious appearances, not having early taken the alarm,
and applied for medical aid. In othercases again,the animal functions
appear to have been early impaired, and the prostration of strength
to have preceded most of the symptoms. The voice, in general,
partakes of the debility prevailing in the other functions; it is usually
noticed as being feeble, often almost inaudible. Deafness has also
been remarked, in some instances, to have been completely esta-
blished. Coma does occasionally occur, especially towards the
termination of the case, when it is fatal: but delirium has seldom
or never been observed, unless as a sequela of cholera.
Spasm has been held to be so essential a feature of the epidemic
cholera, as to confer on it a specific name, Spasmodic Cholera: in so
far, however, as relates to the muscles of voluntary motion, and it is
that description of spasm only to whic h we now refer, no symptom is
more frequently wanting. Spasms of the muscles chiefly accompany
those cases in which there is a sensible and violent commotion of the
SYMPTOMS OF EPIDEMIC CHOLERA.
391
system — hence they are more frequently found in cases where
Europeans are the subjects of the disease, than when it attacks the
natives of India, and in robust patients more frequently than in the
weakly. In the low and most dangerous form of cholera, whether
in European or Indian, spasm is generally wanting, or is present in
a very slight degree. The muscles most commonly affected are
those of the toes and feet, and of the calves of the legs: next to
these, the corresponding muscles of the superior extremities, then
those of the thighs and arms — and lastly, those of the trunk;
producing various distressing sensations to the patient.
Stage of Collapse, or Blue or Cold Stage. — In the description of
confirmed cholera, which I have just placed before you, no attempt
has been made to separate it into two stages, and in fact the
transition is sometimes so gradual from vomiting and purging with
spasms, to a sinking of the circulation, cessation of pulse at the wrist,
shrinking of the outer teguments, and blueness or lividness of skin,
that we cannot positively define the line between the two. The more
obvious features of the stage of collapse maybe, however, summed up
as follows : — The skin assumes a blue or livid hue ; the whole sur-
face appears collapsed, the lips become blue, the nails present a similar
tint, and the skin of the feet and hands becomes much corrugated,
and exhibits a sodden appearance; in this state the skin is insensi-
ble, even to the action of chemical agents; yet the patient gener-
ally complains of oppressive heat on the surface, and wishes to
throw off the bed-clothes; the eyes sink in their orbits and are sur-
rounded with a livid circle; the cornea becomes flaccid, the con-
junctiva frequently suffused with blood ; the features of the face
collapse, and the whole countenance assumes a cadaverous aspect,
strikingly characteristic of the disease. There is almost always
urgent thirst, and desire for cold drink, although the mouth be not
usually parched. The tongue is moist, whitish, and cold; a dis-
tressing sense of pain and of burning heat at the epigastrium is
common; little or no urine, bile, or saliva, is secreted, nor are
tears shed; the voice becomes feeble, hollow, and unnatural; the
respiration is oppressed, and generally slow, and the breath of
the patient deficient in heat. The pulse, from being very feeble,
is now extinct at the wrist, and is felt with difficulty at the larger
arteries. The spasms are sometimes so violent that the whole
body is drawn, as it" were, into a ball. In other cases no corr-
plaint of this nature is made.
The duration of this stage varies from a few minutes to tweke,
twenty-four, or forty-eight hours, and even to three days. Of all
the symptoms of cholera, none is so invariably present, nor in-
deed so truly essential and destructive, as the immediate sinking
of the circulation. The period at which a marked diminution
of vascular action takes place, is somewhat various—'the pulse
sometimes keeps up tolerably for several hours, though very
rarely ; it more generally becomes small and accelerated at an
early stage, and on the accession of spasm or vomiting, suddenly
392
DISEASES OF THE DIGESTIVE SYSTEM.
ceases to be distinguishable in the extremities. The length of time
during which a patient will sometimes live in a pulseless state is
extraordinary.
The reduction of temperature at this time is great. A thermo-
meter placed on the skin indicates 84° F., or even only 79° or 72°.
The blood itself is of reduced temperature : a thermometer intro-
duced into the cephalic vein has fallen to 88°, 84°, and even to 82° F.
Thirst and sense of heat, or burning in the region of the stomach,
are generally connected together, and form very prominent and
constant symptoms of cholera ; yet not only in individual cases, but
even in epidemic visitations, these symptoms have often been alto-
gether wanting. Even when they are present, in the highest
degree, the mouth is not parched, nor the tongue often dry; on the
contrary, there seems in general no want of moisture in these parts.
The sense of thirst seems to subdue all other feelings — cold water
is constantly craved and eagerly swallowed.
The state of the skin is cold, generally clammy, and often co-
vered with profuse cold sweats: nevertheless, varieties occur in
this, as in other symptoms of cholera— the skin is sometimes ob-
served to be dry, though cold: and sometimes of a natural, and
even in some rare cases of preternatural warmth. An increase of
temperature has been repeatedly observed to take place just before
death ; but the development of heat appears to be confined then to
the trunk and head; and, in almost all cases, this partial develop-
ment of heat is found to be a fatal symptom : it is entirely uncon-
nected with any restoration of the energy of the bloodvessels, or
any improvement in the function of respiration. Often, at a very
. early stage of cholera, leeches cannot draw blood from the skin;
when the sweat is thin, it is usually poured out in large quantities
from the whole surface of the body, but when thick or clammy, it
is more partial, and generally confined to the trunk and head. The
action of the vapour and hot baths seems unquestionably to increase
the exudation or secretion from the skin : and the application of dry
heat, as the natural temperature of the skin augments, appears to
restrain these discharges. The perspiration or moisture is often
\ free from odour; at other times it has a fetid, sour, or curdy smell,
\which has been said to be peculiarly disagreeable, and to " hang
about the nostrils" of the bystander.
\ In some cases, patches of eruption like urticaria, and still more
o\ten resembling roseola, or, again, minute miliary vesicles, were
observed; the appearance of those eruptions was general!v a good
augury.
That remarkable shrinking of the features of the face, which has
acquired the emphatic term of the " true cholera countenance," ap-
pears in every case not quickly cut short by medicine. This ex-
pression of countenance, which conveys so truly that of death itself,
cannot be mistaken, and by an attentive observer it will be per-
ceived that a similar shrinking takes place throughout the limbs and
all the projecting parts of the body.
Respiration is not usually interrupted in the early stages of cho-
SYMPTOMS OF EPIDEMIC CHOLERA.
393
lera. In many cases terminating in death, respiration has gone on
in its mechanical part with little or no interruption, excepting that
it becomes more and more slow. Numerous cases, on the other
hand, are noticed, occurring especially in Europeans, where the
interruption of respiration was most distressing, and could only be
compared to the most violent attacks of asthma. Modifications in
this respect must occur according as pneumonia is present, for
this latter complication was far from being uncommon. Although
the breath is stated, in many reports, to have been deficient in heat,
it is not clear that this is a general symptom, nor is it understood that
this coldness is more particularly observed in cases of difficult and
laborious respiration, than in those where the function seemed to be
at least mechanically performed without interruption. Dr. Davy
ascertained that less than the usual proportion of caloric was deve-
loped at this time.
No symptoms of cholera are so uniform in their appearance and
progress as those connected with the blood and its circulation. It
is established by undoubted evidence, that the blood of patients
attacked with cholera is of an unnaturally dark colour and thick
consistence. These changes in the circulation of the blood are like-
wise observed to be in direct ratio with the duration of the
disease, and, in general, only well manifested after the gastro-intes-
tinal discharge have set in.
In a great majority of the reports of the physicians in India it is
stated unequivocally, that after a certain quantity of dark and thick
blood has been abstracted, it is usual for its colour to become
lighter, and its consistency less thick, and for the circulation to
revive — such appearances always affording ground for a propor-
tionably favourable opinion as to the termination of the case. In
many instances, however, no such changes have been observed to
accompany the operation of bleeding, and yet the result of the case
was favourable. The blood is generally found to be less changed
in appearance in those cases of cholera which have been ushered
in with symptoms of excitement, than where the collapsed state of
the system has occurred at an early period. The blood has been
occasionally found, on dissection, to be of a dark colour in the left
as in the right side of the heart — affording reason for believing
that in the whole arterial system it was equally changed. The
temporal artery having been frequently opened, the blood was found
to be dark and thick like the blood of the veins. It is the laboured
respiration, and almost stoppage of the circulation, and darkness of
the blood, that have procured for the disease the name of Cholera
Asphyxia. But as this, if at all, is only applicable at a particular
stage, and that generally the fatal one, or that of collapse, the
epithet cannot serve to designate epidemic cholera.
In the natives of India, in whom respiration is pretty generally
free, until the very last stage, the colour and consistence of the
blood in the instances in which venesection was performed, has
been very uniformly found to be dark, whether excessive discharges
prevailed or not. In the majority of cases, the secretion of urine
394
DISEASES OF THE DIGESTIVE SYSTEM.
is diminished — and in violent cases it is entirely suspended
throughout the attack. . .
The general symptoms of cholera, as it presented itself in the
different districts of India, correspond precisely with those observed
in the disease during its prevalence in Russia, Poland, the rest of
Europe, the Canadas, United States, &c, &c. This is proved by
the history of the disease which is contained in the circular dis-
tributed by the Austrian Government, and the elaborate epitome of
its svmptoms, transmitted by Dr. Keir, of Moscow, to the British
Government, and in the accounts received from Montreal and
Quebec, as well as our own published ones, in this country. It
is needless to dwell on this topic, with a view of establishing
the identity of the symptoms of the epidemic cholera which
prevailed in Europe and America, with those observed by the
English practitioners in the cholera of the East Indies. All the
Russian and German reports agree, that in the generality of cases
there were the same excessive evacuations, upwards and down-
wards, of a watery turbid fluid, the same collapse of the skin,
coldness of the surface, sinking of the pulse, failure of the strength,
lividity of the face, shrinking of the features, spasms of the muscles,
sense of pain at pressure on the region of the splanchnic plexus of
nerves, entireness of the mental faculties, and blackness and inspis-
sation of the venous blood; that in Europe, as in India, some in-
stances occurred of rapid death, with collapse and spasms, and
without vomiting or purging; that in other instances chronic irri-
tation of the bowels continued for a long time after the violence of
the disease was broken ; and that sometimes symptoms of cerebral
congestion supervened on the violent constitutional disorder which
accompanied the intestinal symptoms, and quickly terminated in
coma and death, when not counteracted by an appropriate treat-
ment.
Stage of Reaction or Consecutive Fever of Cholera. — The men-
tion of this stage,as coming next in orderin those who survive the col-
lapse, suggests the very natural, and, as I think, correct idea, that con-
firmed cholera is but a stage of fever corresponding with the cold one
of intermittents. The forming stage of cholera is marked generally
by diarrhoea and some other disturbances of function. The stage
of reaction corresponds with the febrile reaction after the chill of
intermittent fevers, or still more, after the stupor, coma, &c, of
pernicious or malignant intermittents, as they have been termed.
In both cases, the collapse and asphyxia of cholera, and the chill and
coma of intermittent fever, will kill — in both,escape from these may
be followed by fever and phlegmasia, which will often destroy the
patient.
Mr. Searle, a judicious writer, who witnessed the disease both
in India and Poland, observes that " cholera was generally based
upon, or succeeded by, fever of a bilious inflammatory type — in
Europe, of a low remittent or typhoidal character. In Europe, the
choleric symptoms were less marked than in India, and the suc-
ceeding fever evinced less of simple reaction.
SYMPTOMS OF EPIDEMIC CHOLERA.
395
" I have said remittent, though the first few days I have gener-
ally found it to be intermittent; coming on daily at about the same
hour, preceded by coldness of the extremities, quivering of the lip,
and depression of the circulation: but from the excitement of
inflammation, which but too frequently becomes developed in the
organs previously congested, the intermissions become imperfect,
and, in consequence, it assumes a remittent, and from the conjoint
debility, a typhoidal form."
One of the best descriptions of the stage of reaction which I
have seen, is that given by Messrs. Haslewood and Mordey, in their
" History and Medical Treatment of Cholera, as it appeared in
Sunderland, in 1831." " The fatal termination of the cold blue
stage of cholera," say those gentlemen, '' occurs often without a
struggle, or preceded only by a few short convulsive heavings of
the chest: but in other instances a slight appearance of reaction,
indicated by some throbbing of the carotids and warmth of the
chest, is succeeded by sleep, from which the patient can only be
roused for a moment: perfect coma succeeds; and the patient sur-
vives, perhaps, for a few hours. From the large doses of opium
administered in some of the cases, we were at first disposed to at-
tribute this state to narcotism ; but we were subsequently convinced
that it was by no means confined to such cases, and was rather to
be attributed to the general tendency of the febrile stage of cho-
lera to produce cerebral congestion.
" The comatose state is sometimes preceded by a sudden attack
of furious delirium ; the patient throwing off the bed-clothes, at-
tempting to get up, striking every one within his reach, and raving
wildly, the muscular strength exhibited is considerable; but the
struggle is short, and soon succeeded by total insensibility.
When the spasms, the vomiting, and the purging, have ceased ;
when the pulse begins to return at the wrist, and the breathing
becomes unembarrassed, and a genial warmth diffuses itself gradu-
ally and equably over the surface, the patient falls into a tranquil
sleep, which continues some hours, accompanied with gentle per-
spiration : he awakes refreshed, declares himself' quite well,' asks
for something to eat, and is ready to be up and away. It is at this
period the medical attendant is most likely to be thrown off his
guard. Very limited experience, however, will convince him that
there is yet a period of the disease calling for unremitting attention
and decisive treatment. An almost invariable symptom at this
period is a considerable suffusion of the eye; the cornea looks dull;
vessels containing red blood are visible on the surface of the scle-
rotic, and are most numerous at the lower part of the eye.* The
appearance differs from that of inflammation ; the vessels are large
* "The following case occurred in the practice of Dr. Odgen :—December 12,
John Parkin, aged 1, attacked with malignant cholera in a severe form : during
the cold stage the eyes had a dry and shrunk appearance, and the lower half
of each cornea became opaque. The child recovered. In the febrile stage, an
onyx was formed in each cornea, where the opacity had been previously ob-
ereved. For about three weeks the child was in a state of incoherence."
396
DISEASES OF THE DIGESTIVE SYSTEM.
and numerous, but terminate abruptly, rarely forming the vascular
network observed in ophthalmia; the redness is dusky, and the
affection unattended with pain. At the same time there is often
some degree of stupor ; and if the patient moves the head suddenly,
he complains of a dull, deep-seated pain. The tongue is coated
with white fur, and rather dry; or becomes red, glistening and
chapped. The secretions are not restored ; or, if restored, present
unhealthy appearances; that of urine has continued suppressed for
four or five days. When this has been the case, its restoration is
attended with uneasiness in the bladder, and the attempt to void
urine gives great pain, — arising, probably, from the accumulated
sensibility of the mucous membrane, so long devoid of its natural
stimulus. The discharges from the bowels become highly offen-
sive, and contain an abundance of vitiated bile, and of the glutinous
matter (sometimes in large masses) which gives the flocculent ap-
pearances to the earlier evacuations.
"The patient is, in fact, labouring under a fever, bearing a con-
siderable resemblance to the ordinary fever of this country, — as-
suming, in mild cases, a remittent or intermittent type, but always
accompanied with a strong tendency to local congestions, especially
of the brain: but where strong predisposition existed, or, in other
words, when some organ was, from natural or accidental causes,
peculiarly weakened, manifesting itself in it.
" The first approaches of coma are often so insidious as to escape
observation ; but the pulse continuing quick, with fetid watery dis-
charges, and, above all, the continued suppression or insufficient
secretion of urine, will convince the observer that all is not right;
drowsiness gradually increases, and his sleep is attended with
stertor; he may still be roused, and will swallow what is offered
him, but quickly falls back into the same slate. If the eye is exa-
mined, the suffusion is found to have increased, the pupil is dilated,
and almost or quite insensible to light ; and this phenomenon is
sometimes confined to one eye. Complete coma succeeds."
Urea, which has been found largely in the blood of cholera
patients, is regarded by Dr. Roupell, who first noticed the fact, as
the cause of secondary fever.
No other disease serves as an exclusion of cholera. It attacked
in Paris the patients at Si. Louis Hospital, heretofore labouring under
itch, and the insane at the Salpetri&ie and Bicetre. It was not un-
common among the phthisical, and has supervened on the treatment
of inflammations.
Analogy of Cholera to Malignant Intermittents and other Fevers.
The views which I hold of cholera being properly a stage of cho-
lera fever, are further corroborated in the following extracts from
two letters published by Dr. Negri, an intelligent Italian physician,
residing in London. They go to show the great resemblance,
if not identity, between the malignant cholera and the pernicious
fevers, described by Torti, more than 120 years ago.
" Speaking of the character of those fevers, Torti says,«the per-
nicious intermittent, more especially that wearing the tertian form,
YMPTOMS OF EPIDEMIC CHOLERA.
397
kills about the beginning of the paroxysm, when it is accompanied
with violent bilious vomiting and purging of bilious humours, equally
vicious both in quality and quantity, being sometimes clear, at
others coloured, and occasionally of inspissated greenish bile; to
which vomiting and purging are added, hiccup, a hoarse, sonorous
voice, hollowness of the eyes, pain of stomach, small sweat upon the
forehead, weak pulse, and cold or livid extremities : in one word,
all the symptoms which usually mark cholera morbus ; from which,
however, this, as it were, choleric affection, is to be distinguished;
since it is a mere symptom of the fever, the period of which it fol-
lows, as a shadow does a body.'' "
Torti describes a "febris perniciosa cholerica," in which the
patient becomes nearly exhausted, " universally chilled, lies supine,
with a pulse almost abolished, sunken eyes, and difficult breathing."
Dr. Negri also quotes from Mercatus, physician to the King of Spain,
who describes a pernicious tertian, presenting the same symptoms
as cholera, and frequently lapsing into a pernicious fever. The fol-
lowing passage from Morion, quoted by Dr. Negri, is also to the
point.
" Among the innumerable symptoms attending these fevers there
is none which may not rise to a great height, endangering the life
of the patient, so that typhus fever (marked in its stages, of cold, heat,
and sweating) supervenes, rendering it impossible to be distinguished
by the urine, temperature, pulse, or indeed any other means ; but,
concealed under the appearance of cold, vomiting, diarrhoea, cho-
lera morbus, colic, or other disease, not unfrequently misleading
the physician."
Torti, as well as Morton, exhibited bark as early as possible, and
in large quantities ; and this practice is recommended by Dr. Negri,
from experience of its good effects in the paludal fevers of Italy.
Dr. Negri comes to the conclusion " that the malignant cholera of
our days belongs to the same class of diseases which was seen by
Mercatus in Spain, Torti in Italy, and Morton in England." He
suggests the administration of bark in large doses and early in the
disease.
The following case from Torti presents (says Dr. James Johnson)
a complete picture of the Sunderland cholera : —
" When I reached the patient, he had been several hours labouring
under the disease. I found him universally cold as marble, with the
pulse altogether, if I may so say, absent, breathing laboriously,
and having a leaden-coloured countenance. There was some tor-
por, but no confusion of intellect, (he never mentioned delirium,)
and his urine was secreted in a small quantity. I prescribed the
bark in large doses. A gentle heat soon pervaded his entire frame ;
the pulse gradually returned; the respiration became natural; the
face lost its leaden hue; the urine was secreted in its ordinary
quantity, and in three days he was quite recovered.
I have myself met with a still more marked case of complete
vol. i.—34
398
DISEASES OF THE DIGESTIVE SYSTEM.
collapse, which represented the paroxysms of intermittent fever.
It was of a tertian type, and came on twice. There was complete
insensibility, and with a pulse barely perceptible— coma, in fact. I
had the patient leeched over the abdomen in the first attack, and
cupped in the same region, and on the temples in the second one.
Sulphate of quinia prevented the return of a third paroxysm, and
the man soon got weH. He had suffered antecedently from a long,
harassing, and dangerous attack of bilious remittent fever. Dr.
Jackson.of the University of Pennsylvania, in describing the stage of
collapse in cholera (Personal Observations and Experience of Epi-
demic or Malignant Cholera in the City of Philadelphia—Am. Jour.
Med. Science, vols. xi. & xii.), represents it as "analogous to the
last periods of particular cases of malignant fevers, and to the algid
form of intermittents. I can recall, he continues, many instances
of malignant yellow fever, and of the malignant typhus which for-
merly prevailed as an epidemic in our Alms-house, presenting
symptoms approaching very closely to those characteristic of the
period of cholera. So strongly was I struck with this resemblance,
when I, for the first time, saw this disease, on entering the cholera
shed in Montreal, that I exclaimed to my associates — this is the
typhus of our Irish emigrants in the Alms-house. In yellow fever
I have repeatedly witnessed the patient in possession of his senses,
pulseless, the entire surface cold, and bathed in cold perspiration;
the hands and feet shrivelled and sodden; the stomach highly irri-
table; vomiting frequent, and dejections copious. The discharges
are, however, entirely different. In cholera, the serous and watery
fluids are effused and discharged ; in yellow fever it is the colouring
matter and the globules of the blood, forming the black vomit and
melsenic stools. The result is the same—prostration and exhaustion
of the circulating forces, absence of pulse, and failure of the vital
functions, attended with nearly similar symptoms."
Prognosis. — I shall first speak of the probabilities of recovery, or
of death, depending on circumstances anterior to the morbid condi-
tion of the organs and derangement of function pending the disease:
and, afterwards, of signs derived from these, as constituting the
prognosis.
The anterior circumstances belong to the history of the patient,
and may be regarded as so many predisposing causes of the disease,
and modifying ones, also, of its progress and termination. They
may properly be considered under the heads of age, sex, employ-
ment, race.
Age. — The various periods of life give rise to differences in the
susceptibility to cholera. Children were less frequently attacked
than adults ; and the proportion of deaths to cases was I believe
less. In the British army, the deaths from this disease have been
nearly in the ratio of the age of the party. The following table,
formed from Major Tulloch's statistical reports, will distinctly
prove this to be the case : —
PROGNOSIS OF EPIDEMIC CHOLERA. 399
Mortality in the household Mortality of troops in Ca-
Age. troops from cholera per nada from cholera per Gibraltar.
1000 mean strength. 1000 mean strength.
under 18 years .0 .0 .0
from 18 to 25 2.3 15.5 47
25 — 33 2.5 25.— 41
33 — 40 4.— 36 54
40 — 50 4.9 70.4 60
In civil life, although the calculation is less to be relied on, the
mortality has in almost every country increased with advance of
age. The deaths from cholera in Paris were estimated at 18,402
or 23,42 per 1000. Of this number it was remarked that the mor-
tality was least from six years to twenty, greater from thirty to
forty, and greatest in old age. In Philadelphia according to Dr.
Jackson, the rate was as follows (op. cit.): —
Age. Deaths. Ratio to population. Age. Deaths. Ratio to population.
under J year between 1 & 2 years 2— 5 — 5 — 10 — 10 — 15 — 15 — 20 — 20 — 30 — 30 — 40 — 4 4 30 39 19 22 179 228 1 in 604 1 — 503 1—912 1—919 1 — 188 1— 96 1— "81 1— 60 between 40 & 50 50 — 60 60 — 70 70 — 80 80 — 90 90—100 100 — 110 159 100 71 47 5 1 1 999 1 in 46 1— 28 1 — 102 1 —212 1— 36
In Cincinnati, as we learn from Dr Drake, the proportion of chil-
dren among the whites, who fell victims to the disease, was 22 to
472, or something less than a twenty-second part.
Advanced age is not only unfavourable to recovery, but predis-
poses to the disease. " By a recent regulation, the ages of all sailors
who enter the port of London are registered at the custom-house.
We have obtained permission to examine these registers, and have
found that, of 5000 sailors, taken consecutively, 961, or considerably
less than 1 in 5, had arrived at the age of 40. But the pre-
disposing influence of advanced age is rendered more manifest by
taking, in the two classes, ages still greater. Of the cholera pa-
tients, 22 in 160, or more than 1 in 8, were of the age of 50 or
upwards; while of the sailors registered at the custom-house, 289
400
DISEASES OF THE DIGESTIVE SYSTEM.
in 5000, or less than 1 in 17, were of this age; so that the
proportion of cholera patients of the age of fifty or upwards is
mor- than double what it would have been were all ages equally
liable to this disease. The influence of age on mortality is even
more clearly shown. The mortality was least in patients between
the ages of fifteen and thirty; and in these the number of deaths
was less than that of recoveries; it was greatest in patients above
the age of fifty: of the 22 who had arrived at this age, only two
recovered; the age of each of these two was fifty-three: of 13
whose ages exceeded fifty-three, not one recovered." (Dr. Budd,
Lib. Pract. Med.) .
Sex.—The sex probably has an influence in predisposing to cholera,
though this fact cannot be considered as quite determined, since the
proportion has greatly varied in different countries. In Calcutta,
Mr. Jameson states, that it appears from the returns that, of the
native inhabitants attacked by cholera, the males were to the fe-
males as four to one. In Bombay, the reverse appears to have
been the case; the deaths of the women being to those of the men
as two hundred and fifty-four to one hundred and seventy-two. In
other parts of India, also, the results were equally opposed. Mr.
Corbyn, however, affirms distinctly that men were generally more
susceptible than women.' In Canada, the soldiers' wives were ob-
served to suffer nearly in an equal proportion with their husbands;
and this was the case at Gibraltar among the civil inhabitants.
Age. Estimated numbers of the civil inhabitants of Gib-raltar. Number attacked by cholera. Died.
Severe. Slight.
Men . . . Women . Children . 6000 5000 6000 193 216 58 345 267 95 104 107 41
In Paris, up to the 20th of July, 1832, of 12,259 persons attacked
with cholera, 6,243 were men, and 6,106 women. The number of
children affected is said to have been few, but the proportion of
deaths great. Up to this period only 693 had fallen under seven
years of age; and of these, some were not more than four months old.
At first the mortality was much greater among women than men
in England ; but the entire results do not manifest such a dispropor-
tion. In Philadelphia the proportion was, according to Dr. Jack-
son (op. cit.), as follows : —
Males.
539 ...
.70 . .
Under 20 years of age
Females.
370
48
The difference is not in sex, but in the kind of occupation and
the exposure of the women.
PROGNOSIS OF EPIDEMIC CHOLERA
401
Occupation.— The loss by cholera in one detachment of five
companies of United States troops, on the way from Fort Monroe
(Chesapeake Bay) to Chicago, was equal to one out of every three
men. It was at Fort Dearborn, situated on the south-west shore
of Lake Michigan, that the disease displayed its most fatal effects
among the troops. According to the report of Assistant-Surgeon
S. G. J. De Camp, 200 cases were admitted into the hospital in the
course of six or seven days, 58 of which terminated fatally. The
strength of the command at this time was about 1000. In Detroit,
the soldiers, then on their march to the theatre of Indian hostilities,
suffered greatly ; after indulgence in every kind of excess, and being
quartered in an old back building on the banks of a river in the
most filthy parts of the town. In a command of 200 men, there
occurred, between the 6th and 26th of July, 1832, 47 confirmed
cases of cholera, of which 21 terminated fatally. (Statistical Re-
port of the Sickness and Mortality in the Army of the United States,
p. 81, 86, 90-1.) The total number of cases of epidemic cholera
reported during the years 1832, 1833, 1834, and 1835, was 686, in
the United States army, of which 191 terminated fatally ; but this
does not comprise all, as many troops became victims to the disease
in the campaign against the Sac and Fox Indians in 1832, of which
no official returns were made, in consequence of the death of medi-
cal officers. Dr. Forry, from whom I derive this information, adds
(Climate of the United States and Its Endemic Influences): — "It is
a singular fact, that this epidemic exerted its fatal influence in nearly
the same ratio among all the troops whose statistics have been in-
vestigated : for example —
Years. pe
United Kingdom, 1832, 1833, and 1834 .
Gibraltar.....1834 .
Nova Scotia and New Brunswick 1834 .
Canada.....1832 .
,.......1834 .
Black troops at Honduras . . 1836 .
United States, 1832,1833, 1834, and 1836 .
Deaths.
100 cases.
32
30
28
36
34
32
28
I may remark on the above, that these proportions are not so
nearly the same as Dr. Forry indicates, the difference between 28
and 36, or 7 and 9, counting for something. In and around Paris
the proportion of cases of disease among the military was 25.66,
while that among the inhabitants generally was 22.75 per cent. In
India it was observed that the disease was more fatal to the Bra-
mins than to Rajpoots ; to Rajpoots than to the lower castes; and
to Mussulmen the least of all.
Race. — We have not data enough to enable us to institute de-
tailed comparisons between the different races of mankind, either
in regard to their susceptibility to cholera, or their proportionate
'34*
102
DISEASES OF THE DIGESTIVE SYSTEM.
mortality from it. The disease has, we know, attacked the three
great divisions— white, yellow, and black; and in all has committed
great ravages among them. In China, Siam, &c., its devastations
were excessive. It was thought, ti priori, that cholera would spare
or pass lightly over our black population, particularly in the south-
ern states; but everywhere, I believe, the deaths were proportion-
ately more among them than among the whites. Their depressed
condition socially, and their common degradation and poverty,
brought them too surely under the law of cholera mortality. In
Philadelphia the ratio of cases in the coloured population was 1 to
41 of their entire number: that among the whites 1 to 74. The
entire number in the former was 338, in the latter 1927. The
ratio of coloured people to the white population is 1 to 14^; that of
cases of the coloured people to the white number of cases, 1 to 6.
(Dr. Jackson, op. cit.) The actual mortality is not stated. In Cin-
cinnati, the deaths among the blacks, as we learn from Dr. Drake
(An Account of the Epidemic Cholera as it appeared in Cincinnati),
was forty-five, the entire number being 545; which gives them a
proportion of one-twelfth of the deaths. Their entire population
was 1500; and hence, the ratio of the loss was three per cent., or,
compared to that of the whites, as one to one and a half. In the
slave states the proportionate mortality was still greater. In
Louisiana it was enormous. At Honduras " none of the white
troops, and but few of the European population, died from cholera.
The fatal cases occurred almost entirely among the negroes and
natives, and it seems most to have affected those who were irre-
gular, drunken, and dissipated. The inhabitants of the Musquito
Shore, who have in general that character, suffered more than any
other; few of them having survived an attack longer than six
hours." (Statistical Report, fyc, among the Troops in the West
Indies, p. 78.)
In connexion with our present subject of inquiry, it should be
known, that in Mexico the mortality was frightful among its
Indian, which is its chief, population. In the States of Central
America, the disease committed dreadful havoc. At St. Salvador,
a seventh part of the population was cut off by it, and whole vil-
lages were depopulated.
Though not a comparison between different races, it is worthy of
remark, that the native troops, or sepoys, in the British army in
India, were more subject to cholera, and lost more of their num-
ber, than the European portion of the army. The circumstances
of food and diet generally must, however, be taken into considera-
tion ; the Europeans having greatly the advantage in these respects
over the natives. The proportion of deaths to admissions was about
19^ per. cent, in Europeans, and something more than 23\ per cent.
in natives.
When medical aid is early administered, and the constitution of
the patient is otherwise healthy, the recovery from an attack of
cholera is so wonderfully rapid, as perhaps to be decisive of the
disease being essentially unconnected with any very marked mor-
PROGNOSIS OF EPIDEMIC CHOLERA.
403
bid change in the several organs of the body. In the natives of
India, in whom there is ordinarily very little tendency to inflam-
mation, the recovery from cholera is generally so speedy, and
perfect, that it can only be compared to recovery from fainting,
colic, and diseases of a similar character; but, on the other hand,
when the attack was exceedingly severe, the constitution sank, with
scarce an attempt to rally; and in those who recovered, the stage
of reaction was mild and of short duration. In Europeans, in
whom there is a much greater tendency to inflammation, and de-
termination to some of the internal organs, the recovery from the
disease is by no means so sudden or perfect; on the contrary, it is
too often complicated with affections as various as the diseases of
various internal organs are known to be in India. The most
frequent of the sequelae of cholera are affections of the intestines,
brain, liver, and stomach. When cholera, howrever, is of long
continuance, and when the congestions appear to have been tho-
roughly established, few, either Europeans or natives, who outlive
the attack, are restored to health without considerable difficulty.
It has already been remarked, that recovery from an attack of
cholera is indicated by the return of heat to the surface of the
body, and rising of the pulse ; a deceitful calm, however, sometimes
attends these favourable appearances, which too often mocks our
hopes and expectations: whereas, on the contrary, patients have
been observed to remain for one, two, and even three days, in a
state of the greatest collapse, and yet, contrary to all expectation,
have recovered.
The tendency to death in cholera consists in a general suspension
of the natural, and gradual cessation of the vital functions, rather
than in the establishment of morbid actions. Cases have been
remarked, where the vital functions have been more suddenly
overcome, and where death took place, before the usual develop-
ment of the symptoms of the disease. Fatal terminations likewise
occur from topical inflammations supervening, as of the stomach,
intestines, or liver. The intestinal canal seems especially obnoxious
to the effects of cholera —numbers of those attacked with it having
been subsequently seized with dysentery.
It was almost uniformly observed that health was soonest re-
stored in those cases in which feculent, black, and acrid motions
were easily procured; and that, on the other hand, their absence
was almost uniformly marked by feverishness, sour eructations,
flatulence, constipation, and other signs of want of tone and slug-
gish action of the hepatic system. This is an observation made
by Mr. Corbyn, and is especially applicable to the subjects of the
disease in India.
Children, we are told, recover sooner than adults from the cata-
leptic or collapsed state. The first mark of rallying in them, was a
slight injection of the conjunctiva, with marks of general restless-
ness and tossing of the head. After these follow often all the symp^
torn of cerebro-meningeal, or hydrocephalic inflammation, which,
unless rapidly controlled, cut oft' the patient. In one case of this
404
DISEASES OF THE DIGESTIVE SYSTEM.
kind, Mr. Fife, of Newcastle, had leeches applied to the head twelve
times.
" The period of convalescence from the severer forms of cholera
has been usually protracted, and several weeks have elapsed before
the patient has regained his usual health : but as the subjects of the
disease have, in the great majority of cases, been persons with
broken-down constitutions, the tardiness of recovery cannot fairly
be attributed to any peculiarity in the malady distinguishing it from
others of equal constitutional disturbance; digestion continues im-
perfect : the bowels are liable to be disordered from slight errors
in diet: and, in some instances, chronic diarrhoea of great obstinacy
has supervened. In fact, great caution is requisite to prevent a
return of the original disease.
" When the patient dies with these symptoms, it is generally
within from two to six days from the commencement of the attack.
" The most decidedly favourable symptom in the second stage of
cholera, is a full and early secretion of healthy urine. On this
symptom we may rely with safety; and without it we can never
with confidence offer a favourable prognosis.
" The most enduring memento of cholera, however, is the irrita-
ble and debilitated state of the muscular system, which continues
painful on slight exertion, and subject to constant recurrence of
cramps. These attacks occur most frequently at an early hour of
the morning, on awakening from sleep; perhaps the patient is
aroused by them: they are also apt to attack after long fasting, or
on any slight disorder of the stomach and bowels."—Haslewood
and Mordey.
In general, they whose constitutions have been weakened by
fatigue and prior disease sink rapidly. The drunkard has rarely
survived an attack of cholera. Almost everywhere the poor and
needy, they whose lodging and food are bad, have been the greatest
sufferers, and often the disease was confined to this class. But in
Paris and London, it took, after a while, a wider range, and, in the
former capital particularly, it assailed at once those in good cir-
cumstances, who in considerable number fell victims to it during the
v/hole period of its prevalence. Casimir Perrier, the prime-minister
and favourite of Louis Philippe, died from this disease. It has been
said (Griffin's Recollections of Cholera in Limerick — Lond. Med.
Gaz., 1837-38), that although the rich are less liable to be attacked
than the poor, yet that the disease is much more fatal anions the
former than the latter. Previous high health even is thought by
some to constitute a similarly unfavourable prognosis ; but general
experience leads to a different conclusion. Pregnancy increases
the danger of a fatal result. A sudden onset of the worst symp-
toms indicates speedy death; such as excessive coldness of the
body, blue skin or cyanosis, and dyspnoea, and a rapidly failing pulse.
Dryness of the cornea and ecchy mosis of the sclerotica were indexes
of certain death. They who discharged reddish-coloured serum,
or had " port-wine stools," hardly ever recovered. Coma or deli-
EPIDEMIC CHOLERA—POST MORTEM APPEARANCES. 405
rium coming on before reaction were almost always mortal signs.
Cessation of the vomiting, purging, and cramps, favourable signs in
the first stage of confirmed cholera, are of bad omen in collapse
without reaction. Unappeasable thirst is a very bad sign.
A singular, and to those who see it for the first time, misleading
appearance, is exhibited in some of the cases of those who pass into
consecutive fever. It is hard to conceive, says Dr. Griffin (op. cit.),
how human life could come to its close in a more quiet way than
it did with some who lay down and died ; as if, a little wearied, they
were only enjoying a refreshing slumber. " This treacherous end
was slow of approach, and had its forewarnings. A beautiful blush
first appeared on the cheek, which the day before was of a corpse-
like paleness ; there was a constant drowsiness or disposition to
sleep, and when addressed, the patient usually answered, perhaps
with a smile, but always with a happy expression of countenance,
' I'm finely, sir.' On the succeeding day he was usually found in a
still sounder sleep; but when roused up and questioned, returned the
same reply. On the third day he was snoring; it was harder to
awaken him, and though yet muttering ' finely, sir !' to all inqui-
ries, there was ah appearance of stupor and wandering about him.
On the fourth morning he was generally fonnd insensible."
Post Mortem Appearances. — These were of two kinds:— 1,
the adventitious or occasional, though common; 2, the peculiar,
and, in a great measure, universal. The first depended very much
on predisposition to organic disease induced by climate, and its
actual occurrence owing to personal habits prior to the coming
on of cholera. A singular and, to the inexperienced, a terrific
trait, witnessed in some of the bodies after death, was automatic
muscular movement. The arms, extended at the moment of
death, have afterwards gradually been brought to the body, and the
hands at the same time performed a movement of pronation, as if
they were really under the influence of volition. Dr. Griffin relates
a case of a man who died in collapse, and over whose face a
blanket as usual was thrown until the body should be removed to
the dead-house. Some time elapsed before this was thought neces-
sary, when the surgeon in attendance observed the blanket stirring.
He and the nurses, now watching the result, " saw the blanket gra-
dually lifted, and the hand of the man moving with a tremulous
motion, until it rested above the head. Soon after, the leg at the
same side was lifted up with the same quivering movement, and
slowly crossed over the other, and subsequently it was brought back
again. The surgeon after this took the hand that was laid above
the head, and placed it on the breast where it was before; but it
was once more lifted up, and deposited above the head. There
was little or no movement afterwards. The body showed no other
sign of vitality all this time, and was in fact perfectly dead." None
of the faces, as this writer had just before remarked, have the calm-
ness observable in a short time after death by ordinary disease, but
each exhibits some peculiar expression of the pestilence, or of the
406 DISEASES OF THE DIGESTIVE SYSTEM.
agony with which it closed. " One, with pale and dragged fea-
tures,* looks as if he died after a violent struggle in some bloody
combat; another has a quieter yet painful expression, as if the hand
of the assassin had laid him suddenly low ; a third seems to have
sunk under some painful and protracted illness; a fourth, resting
against the wall in a corner, stares at you with glistening eyes, as if
an insane consciousness lit up life again, and he was angered at
your scrutiny." This last, in the experience of Dr. Griffin, is the
expression of the features of drunkards, "which usually remained
very much the same as it was before death ; the eyes continued open
and glistening, and the body maintained the position it had been
lying in, however different from that in the last moments of exist-
ence."
Another phenomenon, not more unexpected than the one just
narrated, is the sudden increase of the temperature of the body after
death, particularly if this event occurred in the stage of collapse.
In one instance the temperature of the body two hours after death
was noted at 105° F. (London Lancet, 1832.) Commonly this extra
heat is lost when cadaveric rigidity comes on.
I may mention, in this place, that which would have come in
more appropriately when inquiring into the question of the con-
tagiousness of cholera, viz., that dissections of subjects dead of
the disease were, I believe, in nearly every instance, performed
with entire impunity. Dr. Mackintosh, on this point, says: "In
the Drummond-street Cholera Hospital there were 280" bodies
examined. Two, and sometimes three, hours were spent in ex-
amining each body. The room where these examinations were
conducted was a miserable place, eight feet square; generally six
or eight persons were present, sometimes more; and, in an inner
apartment, about ten feet square, there generally lay six dead bodies.
Not one of those who frequented this den of death, and who had
their hands imbrued in the secretions of the dead for six hours
out of the twenty-four, were affected with cholera, although their
hands were irritated and punctured daily." (Practice of Physic,
p. 345.)
Internally the adventitious or occasional alterations in the viscera
are, as noticed in India, engorgement of the lungs, or an excessive
collapse of these organs, so as to leave the cavity of the thorax
nearly empty; congestion, or a lacerable state of the liver;
gall-bladder filled with viscid, pitchy bile, or nearly empty, and gall
duct impermeable; mucous membrane of the bladder and uterus
coated with a whitish coloured fluid. In the head, appearances of
congestion, and even of extravasation, were frequently observed.
Under this division of appearances may be ranked collapse or
spastic constriction, and at other times distention into bags or
pouches of the intestinal tube. The stomach was frequently thick-
ened and contracted, and the small intestines full of hard knots,
from one portion being forced into another. In many, particularly
ot such as died early, the stomach and intestinal canal were found
EPIDEMIC CHOLERA—POST MORTEM APPEARANCES. 4 07
full of muddy fluid, without the slightest marks of inflammation.
In others, the vessels of their inner coats were turgid, sometimes
highly inflamed, ulcerated, and gangrened ; these appearances were
more common in the bowels than in the stomach.
A quite common, but yet not an essential appearance, is the intestinal
canal being full of a muddy fluid, and its inner surface lined with
a clayey substance of the same nature. The quantity of this earthy-
looking stuff was sometimes so large as in a manner to plaster the
villous coat, and to leave a thick sediment on passing through the
sheet in which the body was wrapped. A soft and pulpy state of
the mucous membrane was often seen after this matter was re-
moved.
In Russia, or at least in Moscow, the following appearances were
noted by Dr. Keir, in those dead of cholera. The extremities in
general were more or less hard and contracted, and the skin of the
hands and feet corrugated; the features sunk and ghastly. The
bloodvessels of the brain, as well as of its membranes, were more or
less turgid, especially towards its base. Fluid was found effused
between the convolutions of the brain and in the ventricles. The
bloodvessels of the vertebral column and spinal marrow were more
or less loaded with blood, which was sometimes effused between its
arachnoid and pia mater; partial softening of the substance of the
chord was sometimes met with, and marks of inflammatory conges-
tion in the larger nerves. The lungs were generally gorged with
blood. The stomach and intestines were frequently found to be
contracted to a considerable degree, but in limited extent. A
whitish or yellow fluid matter, resembling the evacuations, was
frequently found in different parts of the alimentary canal. In
some cases, both stomach and intestines bore marks of congestion,
and of a sub-inflammatory state, varying from dark coloured spots,
of small extent, to several inches, affecting the whole internal cir-
cumference of the intestine; the colour of these parts varied con-
siderably, from dark coloured venous congestion, to light coloured,
rose coloured inflammation. The liver was generally pretty full of
dark coloured blood; the gall-bladder frequently much distended
with tenacious, ropy bile, of a dark yellow or green colour; the
gall-ducts sometimes contracted, at others not.
In Poland, M. Brierre de Boismont reports that subjects of
cholera exhibited after death a thick, pale, yellowish-white mucus,
and whiter colour in the lower than the upper part of the intestinal
canal, and frequently conjoined with a watery, serous-like fluid,
containing small white flakes diffused through it. The same mat-
ter was seen in the esophagus, the bladder, and, sometimes, also the
bronchial tubes. Occasionally none could be found, which was
the case when the patient died very quickly, or in a few instances
where signs of violent inflammation were found in the internal
membrane of the alimentary canal. The stomach, at times, con-
tained a black matter like altered blood. This organ usually pre-
sented patches and lines of a livid-red tint, and the villous coat was
408
DISEASES OF THE DIGESTIVE SYSTEM.
red and easily detachable. The outer coat of the intestine was of
a rosy colour, and its inner coat presented partial injection —
patches of redness, sometimes dark, and almost of a gangrenous
appearance — enlargement of the mucous crypts —and a peculiar
doughiness when handled. The spleen was often congested. The
gall-bladder filled with dark bile, but the liver was commonly in a
healthy state.
The lungs were sometimes much gorged, sometimes very little.
The vessels within the head were usually much gorged, the brain
sometimes soft, and,often, natural, and its cavitiesdistended with a little
serosity. In the spinal canal it was usual to find watery or gelati-
nous effusion, or extravasation of blood,and still more generally great
congestion of vessels, both of the membrane and of the chord itself.
In France, where the zeal and ability manifested in the pursuit
of morbid anatomy are so conspicuous, we may expect to find
greater minuteness in the specification of organic changes, al-
though there was probably not a single new feature in the disease
itself, nor of anatomical lesion different from those that were ac-
tually present elsewhere. The peritoneum was found to be quite
dry, and in general the serous membranes were in the same state,
and with little or no serous effusions in their cavities. But a
gluey matter has been sometimes discovered, particularly in the
peritoneum, which it covers with a fine layer, so minute as not to
be readily seen, until we gradually separate two portions or folds
of intestine which were previously in contact. We then see this
matter stretched out in the shape of fine filaments. Externally,
the digestive tube was observed to be very much injected, and of a
rose or violet tint. The surface of the mucous membrane, par-
ticularly of the small intestines, was deeply injected with various
ramifications and arborizations. Dilatation and contraction in
several parts of the intestinal canal and intus-susceptions were met
with, as they had been so commonly in India. A turbid fluid,
similar to that discharged by vomiting and stool, was found in the
digestive cavity. In the stomach, besides thi§ fluid, there was .
usually a considerable quantity of glairy mucus, more or less
adherent to the membrane ; and sometimes, in place of it, a creamy
matter, similar to that which lined the small intestines. This last
is adherent, and resembles, when scraped off by a scalpel, grains of
nee burst in boiling; another more fluid portion, consisting of a
muddy serum, like whey not strained, or a mixture of a decoction
of rice. A reddish fluid has also, like the grains of rice, been
noticed by some French writers as common in the intestines, both
large and small, of a dark red, or verging very often to a chocolate
colour.
The lungs were often flaccid and collapsed, and sometimes con-
gested at their posterior part. Any lesions in the liver, spleen, and
pancreas, may be regarded as accidental. The kidneys were
noticed to be usually injected with black blood; but unaltered in
EPIDEMIC CHOLERA—POST MORTEM APPEARANCES. 409
their tissue. The pelves and ureters were empty ; but a creamy,
viscid matter could be squeezed from their tubuli uniriferi.
No visible lesion was observed in the brain and spinal marrow,
or their membranes; except we regard as such venous injection
with black viscid blood ; and patches at the posterior part of the
cerebral hemispheres of sanguineous infiltration. The nerves in
connexion with the encephalo-spinal- centre were, like it, quite
sound. By some, alterations in the tissue of the ganglions and
plexus of the sympathetic were pointed out; but these lesions were
not of general, nor even common occurrence.
In Great Britain, the visceral alterations were analogous to those
already detailed — contractions of the stomach and bowels; these
organs, often injected and inflamed in patches, and the mucous
membrane, even when white, was softer than natural; their fluid
contents same as before-mentioned. As had been noticed elsewhere,
the mucous membrane of the intestines was more vascular, and
often minutely injected as if with size and vermilion. The lungs were
frequently much engorged, and in six or seven out of twenty-four
cases examined by Dr. Craigie at Edinburgh, he found calcareous
concretions in the lungs, and generally could trace them to
branches of veins. He also relates, that a doughy state of the
centre of the lungs was often found in the bodies of those cut off
by cholera. This lesion, in connexion with bronchial induration,
explains, he thinks, the difficult and oppressed respiration which
precedes the fatal event. The brain was sound in consistence.and
colour, but when divided it presented numerous circular apertures
of considerable size, and transverse fissures, which freely effused
generally a dark coloured blood. The part most conspicuous for
these sanguiferous apertures and fissures was, as in other cases, the
corpus striatum and the anterior part of the optic thalamus in each
hemisphere. (Edinburgh Med. and Surg. Journal, January, 1833.)
Next to the brain and lungs, Dr. Craigie tells us, the kidneys par-
took most of the general distention of the vascular system. "The
external cortical or granular .substance was always much darker
than natural, and, not only when divided, effused blood from cir-
cular apertures and linear fissures, proceeding from the outer to
the inner margin, but at the latter, where it unites with the tubular
part, presented numerous large vessels emitting dark coloured,
semifluid blood. The tubular or internal cones were also much
darker in colour than natural; and only when well washed or
macerated acquired their usual tint and appearance. The papillae,
when pressed, emitted always a small quantity of a milky, dirty-
looking, opaque fluid, which appeared to be albuminous urine.
This fluid, however, I have expressed from the renal papillae of
persons dead of other diseases." In another part of his paper, Dr.
Craigie observes, that the organs most frequently and remarkably
diseased in both sexes and at all ages, were the kidneys. In these
are witnessed every gradation and variety almost of the morbid
vol. i.—35
410
DISEASES OF THE DIGESTIVE SYSTEM.
changes delineated by Dr. Bright. Similar observations were
made by Dr. Mackintosh (op. cit.).
In the United States the post mortem observations in cholera
were the same as those made elsewhere; and I am not aware of
any new feature in the occasional organic changes having been
noticed. Of the peculiar and distinctive it is different, as I shall
soon have occasion to mention. Respecting the appearances
already described, they must be regarded as chiefly indicative of,
or effects caused by, the early period of cholera, and death in a state
of collapse. Most of them are referrible to the disorder of the circu-
lation, by which the venous system becomes singularly full and
congested, and the arterial always uniformly empty, and, as it
were, collapsed. That this venous congestion or accumulation of
blood in the veins of the organs exerted little influence in deranging
function or in causing the disease, we are allowed to infer from
the little deviation from the healthy state of the cerebral functions,
although the brain and its membranes exhibited the same venous
accumulations as the other organs. There must have been a
change in the vitality of the economy, anterior to that in the
vascular system or in the blood itself, a removal of which was fol-
lowed promptly by a return of this system and its contained fluid
to health.
But the stage of collapse survived and that of reaction or of
cholera fever begun, then there ensued new and diversified disturb-
ances of function ; and if the patient died afterwards there were
found organic changes of a different appearance, and, we may be-
lieve, character also, from those occurring in the early and sinking
period, ending in collapse. There was more capillary injection,
more inflammation of the tissues, and particularly of the gastric in-
testinal mucous membrane, and often of the brain or its meninges.
In fine, as the disease approximated to the character of typhous or
remittent fever, so did the state of the organs correspond'with that
observed in these diseases.
To my designating certain appearances of organic alterations as
adventitious in occurrence, it may be objected, that alterations of
the gastro-intestinal mucous tissue are recorded as present in cholera
subjects in all countries in which it appeared, and that they ought
to be regarded as essential and fixed features. But this is not
so; for, although common, as I have admitted them to be, they
were not of universal and constant occurrence. Mr. Scott tells
us, that in some cases the whole intestinal tube presented a blanched
appearance, both internally and externally; and, again, that the
duodenum and jejunum were often perfectly healthy. Sanguineous
congestion and even active inflammation are stated to have been
more common in the bowels than in the stomach ; but, on the other
hand, instances were very numerous where no such indications
were detected. Mr. Corbyn (A Treatise on the Epidemic Cholera,
&c.), in recapitulating the morbid appearances found in cho-
lera subjects in India, says, that slight traces of inflammation were
EPIDEMIC CHOLERA—POST MORTEM APPEARANCES. 411
occasionally observed in the alimentary canal; but, in most in-
stances, no mark of increased vascular action was perceptible. At
Moscow, both the stomach and bowels were frequently of a paler
colour than natural, as well internally as externally; but neither
thickening nor condensation from inflammation, nor ulceration, de-
struction of substance, nor abscess, was present in any of the dissec-
tions witnessed by Dr. Keir. But it is not necessary for me to adduce
additional specifications of a fact everywhere admitted; viz., that
in many instances there was no trace of inflammation of the gastro-
intestinal mucous membrane, and even where it had a deep suffu-
sion, commonly in patches, this was the result of venous congestion,
which, like that in the other organs, furnished no great, certainly no
fatal, impediment to the discharge of function.
LECTURE XXXIII.
DR. BELL.
Post Mortem Appearances in subjects dead of cholera—The occasional yet com-
mon ones mentioned in the last lecture—Peculiar and distinctive ones— Change
in the blood—emptiness and contraction of the bladder—whitish fluid in the
intestines—exudation on intestinal mucous surface—development and other
changes in the follicular glands—psorenterie—Dx. Horner's observations—a ve-
sicular eruption on the entire surface of the digestive tube—exfoliation of epider-
mic and venous lining of the tube—Great number of the gastro-intestinal mucous
follicles— Changes in the fluids,—in the blood,—in the secretions from the
bowels—Special pathology of cholera—Analogy to poisoning—Two orders of
functions affected—Experiments by injection of poisons into the veins—Dr. Na-
mias's experiments with cholera blood—Organs and tissues simultaneously af-
fected—respiratory, digestive mucous, and cutaneous—Mortality from cholera—
In India—Russia—Poland—Hungary—France—Great Britain and Ireland —
Berlin_Naples—Geneva—Leghorn—Sunderland—Glasgow—Quebec — Mon-
treal—New York—Philadelphia—Cincinnati—Law of Recoveries and Mor-
tality in cholera. '
Having in my last lecture described the occasional, and in some re-
spects, common post mortem appearances of the organs in subjects
dead of cholera, I now proceed to place before you the distinctive,
and as one must say, essential organic features of the disease.
The first and most striking to the observer is the blackness
of the blood, which is of a shining appearance, and when spread
on a white surface resembles in colour the darkest cherry; it has
also been designated as tarry, thick, ropy, syrupy. It fills the
right sides of the heart and the great veins, and is found of the
same character in the left side and in the arch of the aorta and
some of the large arteries. It is less serous than common, and
does not readily colour the inner surface of the bloodvessels, and is not
reddened so soon by exposure to the air as healthy blood is. The
veins and their ramifying capillaries, even on the membranes, con-
tained as much blood after death as during life, and blood could be
drawn almost as readily from a vein in the former as in the latter
state.
412
DISEASES OF THE DIGESTIVE SYSTEM.
Another and almost invariable appearance in the bodies of those
who died in the first period of cholera, and before reaction had taken
place, was contraction of the bladder, " so as to be as small and
denseasa virgin uterus," and its containing nourine,becausereceiving
none from the kidneys. But even to this there are exceptions, few,
it is true, in which there was an excessive secretion of urine, which
seemed to take the place of the discharges from the bowels (Am.
Journ. Med. Sciences, vol xi., p. 151-2).
The presence of a whitish or muddy-coloured fluid in the intestines
was also a distinctive feature of the post mortem appearances in the
bodies of those dead in the collapse of cholera. In some few instances
no fluid of this kind was found in the canal; but it had been dis-
charged freely both upwards and downwards; and its secretion or
exudation may be regarded as one of the characteristics of the
disease. It was generally watery, with shreds and patches, and co-
loured so as to resemble rice-water. In addition to this fluid there
was generally more tenacious matter, erroneously called mucus,
adherent to the mucous membrane, and requiring some effort to
scrape it off. Sometimes, this latter was as hard as coagulated
albumen, or curd; and, although of a white colour, it received in
spots a tinge of pink, owing to the vascular (venous) congestion
beneath. The thick mucus seemed to be produced first, and then the
thin fluid (Fergus—Hist, and Treat. ofMalignant Cholera at Vienna).
I have mentioned before these fluids as among the occasional yet
common appearances in cholera subjects. It would probably be
more correct to describe them, as I now do, as part of the distinc-
tive characters of the disease ; the exudation on the mucous surface,
and the more fluid exhalation in the intestinal cavity, bearing the
same relation to the morbid state of the gastro-intestinal mucous
membrane in cholera as the exudation on the pleura and peritoneum
or effusion into the cavity of the chest and abdomen do in pleurisy
and peritonitis. The flaky particles mixed with the serum con-
sist of albumen and some fibrin. The thick, exuded matter coat-
ing the intestine was in relation with, and, we may believe, a product
of the glands of the intestines.
As we have seen that there is nothing pathognomonic in the in-
jective appearances, or occasional and even frequent congestion and
inflammation of the intestinal tube, we must prosecute our inquiries
farther, and endeavour to ascertain whether there is not a more
uniform organic change in some other system than the vascular.
Let us, therefore, see what the amount of evidence is, tending to
show a uniform lesion in the glands of the intestines. If I adduce
the testimony only of those who have made their observations on
cholera subjects in Europe and the United States, it must not be
inferred, that the organic changes about to be described were con-
fined to these regions; but, that the inspection of the tissues was
made with more care, and with more minute anatomical knowledge
on the part of those who have recorded their observations. A very
frequent alteration in the digestive canal, says M. Andral (op. cit.), is
EPIDEMIC CHOLERA—POST MORTEM APPEARANCES. 413
that which consists in a development of the glands of Brunner.
This alteration is not always of the same nature. Sometimes it
consists of an eruption of small miliary vesicles, white and semi-
transparent, which are spread over the whole mucous membrane
of the small intestines. These vesicles are extremely numerous,
and appear to be filled with a liquid. At other times we meet
with true patches, having a dark and depressed centre; and seem-
ingly filledwith dense matter. On some occasions, in fine, we meet
with" true ulcerated patches, a change chiefly observable when the
cholera has reached the period of reaction, and assumes the typhoid
form. Venous congestion and follicular eruption; these, in the opi-
nion of M. Andral, are the sole changes in the digestive canal, which,
in all other respects, preserves its common properties. Is the mam-
melated appearance of the mucous membrane of the stomach, no-
ticed by MM. Louis, Andral, and others, and its effacement by
pressure, with the discharge of a white opaque fluid, connected with
a morbid state of the muciparous glands of this organ 1 MM.
Serres and Bouillaud have also observed the multitude of white or
slightly grayish granulations, with a hemispherical projection, dis-
seminatedoverthemucoussurfaceofthestomachandsmall intestines.
The follicles of Brunner, in fact,distended by a white turbid fluid, are
three times their natural size. M. Serres says, that they are so
numerous and developed in the small intestines, that the whole
mucous membrane seems as if made up by them ; their number
decreases towards the large intestines. M. Bouillaud remarks, that
it is not uncommon to meet, at the same time, with a similar lesion
on the clustered follicles or patches of Peyer; and, after speaking
of the extent of " this hypertrophy, this species of erection of the
follicles of the mucous membrane of the digestive tube," he adds,
" this gastro-intestinal eruption, sometimes distinct, at others con-
fluent, imitates, to a certain extent, the variolous eruption in its
first stage." He repeats the calculation of M. Lebut. by which
the whole number of follicles in the alimentary mucous membrane
is estimated to be forty-two thousand. (Am. Journ., ut supra.) So
far from our accusing M. Lebut of exaggeration, we shall soon
see that, in his estimate, he falls far short of the reality. MM.
Serres and Nonat believe the eruption to be tumefied papillae, and
designate it by the term psorenterie. They found it to occupy one-
half or two-thirds of the intestinal canal, beginning at the end of
the ileum, where it is always larger and more confluent. Once
they saw it as high up as the duodenum, the free margin of the
valvulce conniventes of which it had reached. Of the like tenor
are the observations of Dr. Mackintosh (op cit.), as when he says,
" The mucous follicles were generally enlarged, and Peyer's
patches, so rarely seen in adult age, were seldom wanting; they
were large, elevated, soft, and spongy, and sometimes slightly
ulcerated." Dr. Craigie (op. cit.), found that the agminated glands
were always rather distinct, sometimes elevated or injected, or red.
414
DISEASES OF THE DIGESTIVE SYSTEM.
dened ; and the isolated glands were also perceptible in the shape
of miliary granules of the size of pin-heads.
Doctor Wm. E. Horner, whose patience in investigating healthy
and morbid structure is made the more valuable to anatomical
science by his accuracy in describing, has given greater extension,
and at the same time precision, to the views of the French patholo-
gists whose observations I have just placed before you. In two
papers which appeared in the two successive numbers of volume
sixteen of the American Journal of Medical Sciences, Doctor Hor-
ner assigns the following morbid anatomical characters to Asiatic
(epidemic) cholera, as far as relates to the alimentary canal: —
" First. A copious vesicular eruption, entirely distinct from the
tumefaction of villi, muciparous follicles or glands, and which per-
vades the whole canal.
"Second. A lining membrane of coagulated lymph, which exists
in the small intestines at least, if not in the stomach and colon also,
and resembles in texture and mode of adhesion the membrane of
croup.
" Third. Vascular derangements and phenomena, which are con-
fined almost exclusively, if not entirely, to the venous system.
" Fourth. An exfoliation of the epidermic and venous lining of
the alimentary canal, whereby the extremities of the venous system
are denuded and left patulous."
The proof of the soundness of these views must depend primarily
on the correctness of the demonstrations of healthy structure made
and described by the author. Into the details of this subject I cannot
be expected to engage just now: but some of the chief points indi-
cated by Dr. Horner may be briefly stated. He tells us, that " the
mucous coat of the alimentary canal, in a healthy state and suc-
cessfully injected, appears to consist almost entirely of a cribriform
intertexture of veins; these veins being commonly empty at death,
present themselves as a soft, spongy texture, which gives rise to the
ordinary description of its sensible condition as a velvety layer."
Beneath this interlacement of veins, is the arborization of arte-
rial and venous capillaries. The meshes of the first "superficial
venous layer" are exceedingly minute and vary, in a characteristic
manner, in the stomach, small intestines, and colon. The epi-
dermis is also demonstrated, by Dr. Horner, to line the intestines
and to cover the superficial venous layer; and it forms, as I infer
from his rather circuitous description, by its folds, the villi of the
small intestines; " none exist either in the stomach or colon, for
these we have only the venous mesh." In cholera, it is the exfolia-
tion of this epidermic and venous lining which constitutes one of
the important organic changes in this disease, and which itself
gives rise to important functional derangement.
The follicles of the stomach and intestinal canal are estimated,
by Dr. Horner, from dnta which he places before the reader, to
amount to no less a number than forty-six millions, eight hund'red
and ninety-six thousand, of which the stomach possesses about
PATHOLOGY OF EPIDEMIC CHOLERA.
415
a million and three hundred thousand, and the colon nine millions
six hundred thousand. Within the circuit of every anastomosis of
veins a follicle is formed. The follicles appear "like puncta
lachrymalia disseminated by thousands over every square inch."
The surface on which this vascular and follicular structure is
spread presents, " in the aggregate, an area of about thirteen
square feet, the size of a small breakfast-table, whose morbid de-
rangements constitute the essential features of cholera." Dr.
Horner thinks, that the anatomy of the muciparous system requires
more exact attention than it has hitherto received, in order that we
may be able to distinguish between that part which is really
glandular, and the foramina or follicles now under consideration.
These latter, he is disposed to believe, are absorbent rather than
secreting bodies. The secreting process is performed by the glan-
dular bodies proper, viz., the glands of Brunner, or glandulce soli-
tance, scattered over the mucous membrane of the small intestines,
viz., the duodenum, at all ages, and in the continuous intestine
down to the ileo-cascal valve, particularly in infancy ; and the
glands of Peyer, or the glandulce agtninatce, situated in the length
of the ileum, and constituting about thirty groups or patches.
Dr. Horner's observations led him to a conclusion stated at the
outset of this summary of his views; and which, as he tells us, had
been reached before by Corbyn in India, and Girardin and Gaimard
in Russia ; viz., that the existence of a layer of coagulable lymph on
the surface of the digestive canal is diagnostic in cholera. They
add, that this layer is sometimes traversed by very fine capillary
vessels, which are remarked principally at the points that adhere the
most strongly to the membrane of the intestine. The inspissated
layer, more or less adherent to the intestinal mucous surface, and
described commonly by writers on cholera as mucus, is intimated
by Dr. Horner to be more likely of the nature of coagulable
lymph. I have already adverted to their probable mistake.
The last anatomical character of cholera, as stated by Dr.
Horner, is a copious vesicular eruption, entirely distinct from the
tumefaction of villi, muciparous glands or follicles, and pervading
the whole canal. The form of this eruption is that of a spherical
vesicle, commonly from one-eightieth to one-hundredth of an inch
in diameter, with parietes transparent and empty in a dried state.
" This vesicle," says Dr. Horner, " lies upon the surface of what
I have designated the superficial venous layer of the digestive
canal, perfectly distinct from the follicles; that is to say, having for
its base the venous portion between the follicles." The vesicles
are chiefly seen at the base of the valvules conniventes, and are
there closely disseminated, with scarcely an interval between
them ; but they decrease in frequency towards the summit of the
valvulcB.
1 have already spoken of vesicular eruption (psorenlerie) in
1832, by M. Serres and Nonat. By some pathologists in the north
of Europe it has been supposed to consist of tubercular granula-
416
DISEASES OF THE DIGESTIVE SYSTEM.
tions, connected with the lymphatic system, as they are easily
filled from it, but not from the bloodvessels. M. Dalmas (Diction.
de Med.) describes three degrees and stages of intestinal eruption ;
the first is of small, whitish, semi-transparent vesicles disseminated
over the surface of all the small intestine, but neither numerous nor
confluent. In the second degree are seen true white follicles,
which, M. Dalmas thinks, are the glands of Brunner morbidly
enlarged. The third degree of eruptive development is ulcerous
inflammation of these follicles. The eruption is seen, according to
this writes, in about two out of five cases of cholera.
No apology need be offered for details of the minute morbid
anatomy of the venous, glandular and follicular structure of the
intestines, as presented to us in the interesting observations of Dr.
Horner; since the knowledge thus developed is of that definite and
precise kind which is alone calculated to throw light on this part
of the pathology of cholera.
Changes in the Fluids in Cholera. — Chemistry has come in
aid of anatomy to enlighten us on the pathology of cholera. The
first attempt in this way was not, however, successful. Dr. Her-
mann of Moscow, who made a number of experiments by ana-
lysing the fluids of cholera subjects, was led to the inference that the
blood contained acetic acid, and that the liquid state of the former
was owing to this acid, which dissolved the albumen and fibrin.
The viscous and thickened state of the blood in cholera he attri-
buted to the loss of this acid by its discharge in the secreted sub-
stances which were rejected by vomiting and purging. Under this
idea of the cause of the thickening of the blood, he recommended
the injection of warm water into the veins and abstinence from
bleeding. But it was soon ascertained that there was no acetic
acid either in the blood of the healthy or the cholera subject; and
that the ejected matters are commonly alkaline and not acid.
Subsequent experiments made by Dr. Foy at Warsaw, MM. Rose
and Wittflok at Berlin, Dr. O'Shaugnessy at London, MM. Lecanu,
and Raver at Paris, enable us to reach more diversified yet more
accurate conclusions than those of the Moscow professor. I shall
place before you the chief points.
The blood of cholera patients is dark or black, viscous, with a
shining appearance like that of varnish. It is less readily oxyge-
nated when drawn and exposed to the air in an open vessel, than
blood most commonly is. It is also less readily reddened under the
serum. The blood in cholera contains much less water and saline
matters and more albumen than common or healthy blood. The
chief changes, therefore, in this fluid during an attack of the dis-
ease is in its serum, by the escape of its water and saline ingre-
dients, particularly the alkaline carbonates. There is also notable
diminution in the quantity of fibrin. The proportion of albumen,
on the other hand, is greatly increased. Dr. O'Shaugnessy found
innn Were l33 in Place of 7S Parts' lhe healthy standard in
luuu parts. Urea was detected in the blood of some cholera pa-
PATHOLOGY OF EPIDEMIC CHOLERA.
417
tients who had secreted very little urine for several days. Urea
has also been found in the bile of cholera subjects.
The fluid ejected from the bowels was found to contain carbo-
nate, acetate, muriate, phosphate, and sulphate of soda, coagulable
lymph, or a compound of albumen and fibrin, some mucus and
water. The sediment in the evacuations in cholera is com-
posed, according to Dr. Bohn of Berlin, of fragments of the ephthe-
lium of the mucous membrane of the intestines.
After the detail of the symptoms of cholera, and anatomical
lesions of those who have died of the disease, it is natural to inquire
into its special pathology, the intimate cause and nature of the
changes which constitute it. The first and most abiding impres-
sion is, that cholera is caused by a poison which finds entrance into
the blood, and through it affects the nervous system, and the tissues
and organs. But like other poisons, the transmission of its noxious
effects through the animal economy may take place at the same
time, through the nerves — and by its impression on the cerebro-
spinal axis, or some part of it, give rise to symptoms of muscular
disorder.
There are two series of functional disorders which it is worth
our while to note on this occasion, as making up collectively
the group that represents cholera. The first, consisting of thirst,
nausea, vomiting, eructations, frequent desire to goto stool,diarrhoea,
constriction, as if of a bar on the hypochondrium, heat of the sto-
mach and intestines, pains, colic, also tenderness of the epigastric,
umbilical, and lumbar regions on pressure, increased pulsation of
the CEeliac trunk or of the aorta, are abdominal, and manifest
profound disorder of the digestive system. The other series,
which includes cramps, convulsive movements, headache, a sense
of constriction in the temporal region, painful rigidity and reddish
injection of the eyelids, oppression and painful constriction of the
base of the chest, disposition to syncope on almost the slightest
movement, trembling of the limbs, rapid exhaustion of the strength,
slowness of pulse, cessation almost of the arterial beats, coldness of
the body, of the tongue, and breast, feeble and slow respiratory
movements, loss of elasticity of the skin, and its bluish hue, and
death by asphyxia, — all these are effects of derangements of ner-
vous centres, and particularly of the spinal marrow. These symp-
toms belong almost entirely to innervation, muscular motion, respi-
ration, circulation, and calorification, — functions more especially
under the government of the spinal marrow. Partial destruction of
this axis, particularly the upper portion, as in experimentson animals,
is followed by diminished respiration, and circulation, and animal
heat, and the animal perishes after a while in a state of asphyxia
analogous to the blue stage of cholera. In irritation or inflamma-
tion, on the other hand, of the medulla spinalis, we find all the
symptoms of cholera of the second series, or those which are not
abdominal, such as cramps and convulsive movements in one per-
sor)) — oppression, and retarded circulation, imperfect hematosis
418
DISEASES OF THE DIGESTIVE SYSTEM.
in another; palpitations, syncope, constriction of the chest in a
third, &c.
But, before proceeding any farther with this comparison, or at-
tempting to draw any conclusion from it, we must bear in mind
the fact that one of these two series of symptoms may be entirely
or nearly wanting in some patients with cholera. M. Roche,
whose course of illustration and argument (Diet- de. Med. et de
Chir. Pract., Art. Gastro-Enterite) I now follow, tells us, that he
has seen this entire separation of the two series, and appeals to his
brother practitioners of Paris as witnesses to similar facts.
In confirmation of the opinion, that the cholera poison produces
the group of symptoms indicative of the disorder of functions
already detailed, we may cite the histories of the effects of injec-
tion of poisonous substances into the veins, as furnished in the
experiments of MM. Roulin, Gaspard, Gendrin, Bouillaud, &c.
Among these, we note vomiting and diarrhoea; and when the ani-
mals on which the experiments were performed were opened, the
gastro-intestinal mucous membrane was red and tumefied in its
whole extent, and its follicles often enlarged. The symptoms indi-
cative of lesion of the brain and spinal marrow were not less dis-
tinctly marked, but varying according as the poison was narcotic
or irritant, or narcotic-acrid. Sometimes also, ecchymoses on the
heart and the kidneys were also seen.
Shall I cite, in confirmation of this view, the experiments made
by Dr. Namias, at Venice, during the prevalence of the cholera in
that city in 1833. He was desirous of ascertaining, whether the
blood of cholera patients possessed properties injurious to life.
With this view he took a portion of the blood from the heart of a
patient dead of cholera; and through an incision of the skin he in-
serted it into the subcutaneous cellular tissue of a large rabbit. The
animal seemed to suffer but little from the operation; but five days
afterwards it became dejected, its evacuations were less solid, ap-
pearances of white dejections were observed on the ground, and
the animal died on the tenth day. The blood in the heart was
found black and grumous, but without any particular lesion of the
organs. The blood of this rabbit introduced under the skin of an-
other, caused its death in twenty-four hours. These experiments
were several times repeated with the same results. In contrast
with these effects were the absence of any positive or deleterious
ones ensuing on the introduction of the black, liquid, fetid blood of
a person dead from intestinal gangrene, under the skin of a rabbit.
The animal's health was not at all affected by it. A similar expe-
riment with the blood of an individual who had died of aneurism
gave the same result. Experiments of this nature require to be
repeated and diversified before we can form positive deductions
from them.
I have frequently had occasion, in my lectures on Toxicology,
to point out the close resemblance in many, indeed most of the
chief and alarming symptoms of cholera, and those caused by certain
PATHOLOGY OF EPIDEMIC CHOLERA.
419
poisons. The same violent action is set up in the secretors and de-
purators to free the system from the deleterious agent in the latter,
as there is in cholera ; and of these the chief apparatus thus inordi-
nately excited in both is the digestive. (See Christison, passim.)
After having passed in review an enumeration of the symptoms
of cholera and the structural lesions which have been noticed in
the subjects dead of it, are we able to define the nature of the dis-
ease as to its causation, and the philosophy of its treatment? As
yet the reply must be in the negative. Too partial are the views
that would refer it to a kind of asphyxia — poisoning of the blood,
and suspended respiration; or to gastro-enteritis, follicular inflam-
mation, and plastic or lymphatic exudation ; or to a poisonous im-
pression on the nervous system. The error here is in assuming a
part, or concurrent symptom or lesion, for the entire disease. The
most plausible hypothesis is, that a subtle and imponderable poison
in the atmosphere, becoming more active in particular localities
and in certain individuals, and finding entrance into the system,
but whether by absorption into the blood of the lungs, or by primary
impression on the nerves, we cannot say, deranges all the organic
functions, and the greater number of the animal ones. We are
told that the primary affection, that on the continuance and exas-
peration of which all the other forms of disease depend, is gastro-
intestinal irritation and inflammation ; and often both these states.
In confirmation of this idea we are told that the great and peculiar
changes in the blood only ensue on the discharges from the stomach
and bowels. But such an argument is not very profound ; for there
must have been a morbid cause at work in the digestive canal to
bring about the discharges; and, although the disease becomes un-
doubtedly more alarming and complicated by them, yet it is just
as reasonable to suppose that this antecedent cause, operating on
the stomach and bowels, should also operate on the lungs and
heart, and on the nervous system common to all these viscera. The
fact of violent inflammation, even of the gastro-intestinal mucous
surface, found in many cases of undoubted poisoning, is hot proof
that the material cause was applied to it, or that the series of mor-
bid phenomena began in it; for they have been seen in cases in which
the poison was introduced by other channels than the stomach, or by
respiring it in a state of vapour, or applying it to a denuded skin.
Sometimes the person is killed by the poison without any phlogosis
of the stomach or bowels having supervened, — the fatal shock may
have been given to the heart or nervous system, as has happened
in the instance of arsenic being introduced into the economy. So,
also, it has been noticed, during the violence of cholera, that persons
have died in a state of collapse, without having had any evacuation
either upwards or downwards. If we were to compare cholera
to some eruptive fevers caused by specific poisons, we should find
many points of resemblance also, and the analogies would be adverse
to an attempt at locating the disease on one organ or tissue, and at
regarding the lesion of this latter as the primary or sustaining
420
DISEASES OF THE DIGESTIVE SYSTEM.
organic cause. In scarlatina we may assign the throat, in
measles the respiratory mucous, and in small-pox the digestive
mucous surface, as the parts, the inflammation of which, respec-
tively, gives rise to the chief phenomena of the disease, and in which,
after death, are found the most manifest lesions. But we cannot
be ignorant that death sometimes takes place after the introduction
and working of any one of these poisons in the animal economy,
anterior to the coming on of phlogosis, or even to the development
of the characteristic eruption on the skin. A person may die in
collapse from scarlatina, or from measles, or from small-pox —
without phlogosis of any organ or tissue; he may die from the in-
tensity of phlogosis in a more advanced stage, or he may die from
secondary fever after all the organic lesions have been removed.
Whether we study the operation of ihe probable causes of the
disease and the parts primarily impressed, or of the means of
cure, we must, it seems to me, direct our attention, in the first
instance, to the three great surfaces, viz., the respiratory, the
digestive mucous, and the cutaneous, which, both in their organic
and functional changes, play so important a part in cholera. De-
rangement of any one of these will produce much corresponding
disorder in the others, and thence in the whole system. How great
and alarming, then, must be the disease which follows the operation
of morbid causes acting on all three, as when the cholera poison is
inspired with the air, and disturbs the economy through the respi-
ratory mucous membrane, while the sedative influence of cold and
moisture following heat, is manifested on the skin, and the irrita-
tion of unwholesome ingesta — bad food and intoxicating drinks —
are at work on the digestive mucous membrane. Each one of
these morbid causes is competent to disturb both classes of func-
tion— those of nutrition and those of sensibility; for even if we
were to admit that a poison had once penetrated into the blood, and
become mixed with it so that its vitality was impaired, we cannot
but see that the nervous system must suffer almost at the same
moment. It does so under the influence of the obvious and mate-
rial causes already mentioned, which derange the functions of the
skin and digestive mucous membrane, as we see in the pain, and
cramps, and spasms, which accompany bilious colic and sporadic
cholera. But how much more impressible, by morbid causes
affecting it from the three great surfaces, must the nervous system
be, or rather how little prepared to resist the shock of these causes,
if it have been previously weakened by prolonged excitement of
habits of intoxication, or the deficiency of food ; and that less
thought of, but not the less real cause of nervous disorder, want of
personal cleanliness, and habitually impure skin in consequence.
But I cannot farther enlarge on these points now, nor even repeat
what I have before said on the subject, in the volume already re-
ferred to, (All the Material Facts, &c.,) but must pass to a notice
of the chief means of cure which were had recourse to during the
prevalence of the cholera epidemics in different countries.
PATHOLOGY OF EPD3EMIC CHOLERA.
421
Mortality. — It will be impossible to have accurate ideas of the
real value of the remedies, and treatment in general, in cholera,
unless we know the ratio of mortality from the disease, and the
modifying influence depending on locality, season, and, above all,
the duration of the epidemic. When we learn that, in nearly all
the countries in which epidemic cholera has committed its ravages,
the mortality has seldom been less than a third, and has sometimes
amounted to half of the whole number attacked, we might at first
be tempted to declare the nullity of medicine, or, at any rate, the
little advantage of one mode of treatment over another. In India,
out of a population of forty millions, it has been estimated that the
deaths were eighteen millions between 1817 and 1830, both inclusive.
But we soon recover from this gloomy scepticism on learning that,
without medical treatment, the vast majority of those attacked with
cholera die, and that if medical means were resorted to in the first
forming or diarrhceal stage, cholerine, a correspondingly large ma-
jority of those who are thus attacked can be saved ; and finally, that
under regular treatment, even of a diversified nature, many survive
who would otherwise have invariably perished. If all the cases of
every degree in which medicine has been administered were recorded,
the mortality would not be alarming. Dr. Taylor of Bombay gives
the following return :— Medicine administered to 7,450: of whom
died, 441. Being a proportion of nearly six to a hundred. It is
stated in the Report of the Medical Board at Bombay, that there is
reason to believe that of 1294 cases which received no medical assist-
ance, every individual perished ; and, it is added, that it is not ascer-
tained that any case has recovered in which medicine has not been
administered. Now, although we may not receive this assertion in
its literal extent, since undoubtedly out of a thousand persons at-
tacked with cholera in almost any part of the world, some few will
struggle through the disease by the unaided powers of nature, yet it
is in the main correct, and gives additional force to the experience of
an opposite course which I am about to narrate. According to
the documents collected by the Madras Medical Board, the
number of deaths in the army of that presidency during the year
1818 and four subsequent years, was 4,430, of which 695 occurred
among the European troops, and 3,735 among the sepoys. The
number attacked was 19,494, namely, 3,664 Europeans, and 15,830
natives. The average strength of the army during the period in-
cluded in the reports being 10,112 Europeans, and 73,254 natives,
it follows that, in five years, 23^ per cent, of the troops were at-
tacked, and that of these 22| per cent, were carried off, or 5$ per
cent, of the whole army. Of the natives 45 per cent. died. March,
April, and May are the months in which the disease generally pre-
vails at Calcutta, but May is much the most fatal. These statements,
though sufficiently distressing, are still a proud monument to the skill
of the medical men employed, and to medical science in general.
The number attacked in Moscow, from September, 1830, to
January of the following year, was 8130, or 54 per cent. In the
small town of Redischeft, of 800 sick, Dr. Reimann states that 700
vol. i.—36
122
DISEASES OF THE DIGESTIVE SYSTEM.
died in one week. Taking the whole number attacked, it is said
that the proportionate number of deaths were, at Astracan, as one to
three; in the government of Kertroma, a fraction less; in that of
Nishni Novogorod, one-half; in Casan and Moscow, as three to
five; and in Penza, the country of the Don Cossacks, as two to
three. In Jassy (Maldavia) the deaths were more than 6000 in a
population of 27,000. In the summer of 1831 the mortality at St.
Petersburgh, Riga, Mittau, Limberg, and Brody, according to the
Berlin Gazette, was about one-half, while at Dantzic, Elbing, and
Posen.it was about two-thirds of the whole number attacked. (Doc-
tor Robert Williams, op. cit.) In Archangel the deaths were 1200
in a population of J 9,000. In Dantzic the mortality was more frightful
even than that just stated. The whole number of sick was 1387,
of whom 1010 perished, in a population of 72,000 persons. It was
in this city that the most strenuous and systematic exertions, under
the direction of the government, aided by the military, were made,
by a rigid system of quarantine, to keep out the disease. The
result was a commentary on the absurdity,— ought we not to say,
in reference to all its effects, the wickedness of such an attempt.
The period of the season greatly influences the mortality, and the
proportion of deaths to recoveries observed in Moscow, at the various
phases of the disease, has been nearly that of all Europe. On the first
onset nine-tenthsof thenumberattacked perished; then seven-eighths,
and the proportion of deaths forms a gradually decreasing series of
five-sixths, three-fourths, a half, a third, till towards the close of the
season, a large proportion of those attacked recover. The uniformity
of this law, although the proportions may differ, in every country
attacked by cholera, whether India, China, Europe, or America, is
extremely remarkable. It may be added, that the influence of
locality was also manifested at Moscow, as the greatest number of
deaths occurred in the marshy sections bordering on the Moskwa and
Kanal. These rivers frequently overflow to such a degree that the
water reaches the lower windowsof the houses in the neighbourhood.
In Hungary, cholera proved fatal to 240,000 persons, during its
prevalence from July, 1831, to April, 1832.
In Paris, the mortality from cholera was 18,402, in a population
of about 800,000 persons. In all France, the deaths in 1832, from
this cause, were 95,000 and the cases 230,000. During the three
years it lasted in Great Britain and Ireland, not more than 30,000
persons fell victims to it. In Berlin, the cases in 1831 were 2271,
deaths 1426; in 1837, the cases were 3561, and deaths 2174.
The period of the first attack was 46 days; that of the latter, 16
weeks. In Prussia generally the estimate mortality among the sick
of cholera was 58.6 per cent. In the city of Naples, with a population
of about 330,000 persons, the number of cases from the second of Oc-
tober, 1836, to the last of January, 1837, were 9725 ; of which the
deaths were 5293. In Naples, the greatest mortality was in the un-
healthy districts, and among the poor and ill-fed inhabitants: at Genoa
with a population of 80,000 persons, the mortality was 2,151 out of
4250 cases; and in Leghorn, with a population of 66,000, giving
2031 cases, the deaths were 1146. °
PATHOLOGY OF EPIDEMIC CHOLERA. 433
In Sunderland, where the cholera first appeared in England, the
number attacked, from the 26th October, 1831, to the middle of Janu-
ary, 1832, was 534, and the deaths 202, in a population of 40,735.
In Glasgow, from the 13th of February to the 11th of Novem-
ber, 1832, the number of deaths from cholera was 3005 out of 6208
persons attacked, in a population of 202,426. The greatest mortality
was in the month of August, in which there were 1133 deaths.
In Quebec, with a population of 37,000 persons, the mortality
from cholera during the period of attack, or from June 9, to Sep-
tember 2, was 2218. The number of casesxiot stated.
In Montreal, the mortality was rated at 3000, in a population
about the same as Quebec.
In New York, with a population of 205,000, the cases of cholera
were 5814, from the 4th of July to the 28th of August, 1832, of
which the deaths were 2245. In 1834, in which year the disease
reappeared, the deaths were about 900.
In Philadelphia, in a population of 160,000, the cases of cholera
were, during its period of invasion, from July 11,or mainly 28, to Sep-
tember 13, 1832, 2314 — and the deaths, out of this number, 948.
In Cincinnati the mortality was 545, in a population at the time
of 25,000 ; and in New Orleans 6000, in a population of 55,000.
Law of Recovery and Mortality in Cholera. — Mr. Farr, from
9372 registered cases in 1837, published by the Roman Board of
Health, has constructed several tables illustrative of the chances of
recovery and death in this disease.
One of these tables exhibited the numbers dying and recovering
on each day after attack, and contained calculations from theore-
tical considerations, which closely approached the amounts derived
from facts. The following table will show this more clearly : —
Out of one hundred constantly sick :
Deaths. Recoveries.
Observed. Calculated. Observed. Calculated.
5th day . . 5.471 5.650 6.747 6.747
6th .... 5.684 5.056 8.295 7.929
7th .... 4.500 4.523 9.219 9.317
The following table expresses the probability of recovery and
death during the first ten days after attack : —
Days. Probability of Recovery. Probability of Death.
0......422.........578
1......542.........458
2.......668.........332
3......729.........271
4......763.........237
5......791.........209
6......821.........179
7......843.........157
8......862.........138
9......873.........127
10......883.........115
424 DISEASES OF THE DIGESTIVE SYSTEM,
From the tables may be deduced the following problems : — viz.,
1st, the mean duration of the disease ; 2d,.thp mean future duration
of the disease at any period ; 3d, the profiifcbility of dying at any
period of the disease. ,
The following table from different data presents the question
somewhat differently: —
Table of the Probability of Recovery from the severer Attacks of Cholera at the end
of 12 hours, and 1, 2, and, 3 days.
Cases. To Recover. To Die. Probability of Recovery.
0 hours 10000 12 . . . 9181 1 dav 7616 2 . .". 6793 3 . . . 6291 5093 5093 5093 5093 5093 4907 4088 2523 1700 1198 .509 nearly 1 to 1 .555 .... 1.3 .. 1 .669 .... 2 . . 1 .750 .... 3 . . 1 .809 .... 4. . 1
These facts prove that, in cholera, the probability is generally
not in favour of death ; they also establish the importance of early
treatment, for half the deaths happen in the first twenty-four hours.
What the practitioner does, he should do quickly.
LECTURE XXXIV.
DR. BELL.
Treatment of Cholera.—Study previously of its mortality, and comparison with
that in other diseases—Almost certainty of death, unless medicine be given__
The sedative class of remedies most useful in cholera—Evidences of increased
innervation—Increased glandular secretion—Indications of cure__Treatment
of the Diarrhceal Stage.—Necessity of prompt attention to the first symptoms
of irregular digestion—Mild purgatives, sometimes an emetic; laudanum ; dilu-
ents; rest; moderate warmth—Case—Selection of purgatives—Treatment of
Marked Cholera.—,An emetic—Bloodletting—Sedative or contra-stimulant
remedies—Calomel; :;Lts primary and sedative effect; is to be given in large
doses, sometimes alone, often with a full dose of laudanum—Opium.
Notwithstanding all the array of statistics of cholera, we are not
in possession of the requisite data, on which to draw the proper de-
ductions respecting the results of any one plan of treatment, nor of
course the most appropriate course to be pursued in future exigen-
cies. Patients have not been classed, nor have specific returns
been made of the different periods of the epidemic, and of its pro-
portionate mildness or malignancy ar.Jh.ese times. In another
important particular there has also been great want of uniformity
in the hospital and other returns of cases and deaths of cholera;
the period of collapse, for instance, conveying different ideas to
ditterent writers, in describing it, and the means employed for its
TREATMENT OF EPIDEMIC CHOLERA. 425
removal. In approaching the subject of the treatment of cholera
we seem, in our inquiries into dynamic forces and organic lesions, to
forget that there is in each individual an original, inherent, and
constitutional power of resisting morbid influences—poisons or other
destructive agencies, which may be aided, but not increased, by
medicinal means; and which, under similar circumstances of vio-
lence of assault, most -generally yield despite of all the efforts of
art. But as these circumstances vary often in a very short period,
we must endeavour to seize the most favourable juncture ere the
powers of life have been too fiercely assailed. Thus, a little
assistance on the inception of a disease will enable the constitution
to throw it off; the same on the following day will have more
doubtful efficacy; and on the third, will be utterly unavailing.
There are some in whom this constitutional power of resistance
is so feeble that they almost of necessity sink under any epi-
demic disease. They belong to the class of the weak, the sickly,
and the diseased; but not to these alone, for sometimes the robust
and those of full habit are found to be equally unable to resist
the morbid influence. It has been noticed, in more than one
place in which epidemic cholera prevailed, that, although the
better class of the community was less liable to an attack of cho-
lera, yet, if once they did sicken, they were more apt to die than
others less favourably situated. As regards the great mortality
in cholera, we shall be less disposed to call it excessive, by com-
parison with that in other diseases, if we refer to the ratio of
deaths in some of them. " In typhis fever the inevitable mor-
tality varies according to the virulence of the epidemic; among
the poor, from one in ten to one in thirty-two; among the rich
from one in five to one in twenty; being generally the same in the
same epidemic. The mortality in the simply confluent small-pox,
is, according to Dr. Gregory of London, three in five, which is little
short of that occurring in the collapse of cholera when judiciously
treated. In the confluent description the mortality is one in four;
and on the whole it has been computed that, out of every six
persons who take small-pox in the natural way, one inevitably
dies." (Griffin, op. cit.) In the Statistical Reports, &c, of the
diseases among the British troops in the West Indies, I find, under
the head of fevers, that the proportion of deaths to admissions in
" yellow fevers (Icterodes)," is stated to be 1 in li. Even in ' re-
mittent fever' the proportionate mortality to the cases treated, was
1 in 8. On the western coast of Africa, as we learn from another
report emanating from the same source, the deaths from remittent
fever are nearly one-half the admissions, or in the proportion to the
latter as of 1 to 2. In estimating the value of medical treatment
in cholera, such as has been furnished in different parts of the world,
and with the results of which we are in a measure acquainted, we
ought first to ascertain what is the amount of mortality in cases
abandoned to nature. At its onset the disease is always violent,
and causes death in a large proportion of the persons attacked; and
36*
426
DISEASES OF THE DIGESTIVE SYSTEM.
this is brought and admitted as an argument against the curative
power of medicine. But the last is not a legitimate sequence of
the first proposition. In the beginning of an epidemic people are
ignorant of its prodromes, do not know the real construction to be
put on their pains and disorders, think these are slight, and either
fail to procure medical assistance at all, or send for it when the
citadel of life is sapped and about to yield. The true data are yet
to be furnished on this point, viz., to enable us to ascertain what, if
any, is the difference in the success of the treatment of those who
are seized at the beginning, of those in the middle, and those at the
decline of an epidemic, under similar circumstances of age, consti-
tution, habits, and duration of premonitory symptoms.
I have already stated to you some facts, coming under the
observation of East India physicians, placing medical treatment
and abandonment to nature in strong contrast, and entirely to the.
advantage of the former. We may on this part of our subject lay
down the following proposition, which is almost entitled to be called
the expression of a law of cholera. It is thus enounced by Dr.
Griffin (op. cit.): — " That without medical treatment every person
attacked with it will fall into collapse, although they may not eventu-
ally die; and that such as recover do not do so by an arrest or
cessation of the disease, but by struggling through, and outliving all
its stages." In estimating, therefore, the probable chance of re-
covery in all cases left to nature, we may regard them as collapse,
the frightful mortality of which is everywhere acknowledged.
Sometimes it has amounted to nineteen out of twenty cases, and
under the most successful treatment, furnished in the most authentic
reports of large hospitals, never proving less than seven in ten.
But they who are allowed to run the course of the disease without
interruption by medicine, are not in the same category with those
treated for collapse; for, even if the former survive in a small pro-
portion, it must be after struggling through the period of collapse
into consecutive or cholera fever, or the stage of reaction, in which,
if unassisted, they will die. It is, therefore, correct to abide by
the opinion of some of the East India physicians, viz., that unless
medical treatment be rendered to persons attacked with regularly
formed cholera, they will almost inevitably die.
Before I proceed to specify, in succession, the remedies which
were employed for the cure of cholera, I ought to state that a
sedative and evacuating course is much more entitled to our con-
fidence than a stimulating one. Even although pathologists have
failed to prove the presence of inflammation in any one organ or ap-
paratus, in a majority of cases of cholera, yet the evidence is
abundantly strong to show that often the lungs are great sufferers
from pneumonitic congestion, and that the digestive tube, often the
seat of inflammation, is almost always that of irritation of its glan-
dular or secretory apparatus. The venous congestion which takes
place in nearly all the organs in distinctly formed cholera, but which
is most manifest during the stage of collapse, although often readily
TREATMENT OF EPIDEMIC CHOLERA.
427
removed, may and does complicate the state of things during the
period of reaction or of consecutive fever; and the danger in this
latter is often greatly increased by inflammatory congestion of
some important organ — the brain, the lungs, or the intestines. If
we look at what passes in the nervous system we shall find symp-
toms indicative of increased and excited innervation ; a craving for
sedatives, and especially for cold drinks ; an intolerance and dislike
of stimulants. It is true, that this innervation is not equally active
in all the organs of the economy; but, as in the case of the blood-
vessel system, diminished activity in one system only or region aug-
ments irritation and danger from accumulated action in another.
The skin, it is true, seems to be deficient in nervous power as do
the lungs; the former being cold, the latter not performing its cus-
tomary depuration of carbonic acid. But these and other pheno-
menon of apparent debility and weakened nervous power result
from the singular severance of function at this time of the ner-
vous and vascular systems in cholera. The two systems, as I have
already said, do not act synchronously with each other. " They
are not both torpid or dead for the time being, as in syncope and
some analogous states of the body, nor are they both active and
morbidly excited, as in the phlegmasia? and inflammatory fever. A
strong evidence, and at the same time effect of this interrupted har-
mony of action between the nervous and vascular systems, is defi-
cient calorification. This process requires both innervation and
capillary circulation — the former is a prime agent, but it is in-
competent to produce the effect without the latter" (op. cit., 118).
I had just before summed up the reasons for disbelieving that the
series of symptoms in cholera manifested a simple deficiency of
innervation or the operation of a sedative poison.
" 1. The brain, the grand centre of nervous power, retains its
energy: its peculiar functions in the display of the faculties of the
mind are, often not at all, [or slightly] impaired.
" 2. The spinal marrow, measured in its functions by the irre-
gular and yet often inordinate action of the voluntary muscles in
spasms, and even convulsions, and by the sensibility of the skin, is
in full energetic action. Its appearance after death shows it to
have been often preternaturally excited.
" 3. The senses generally are not impaired.
" As regards innervation in the ganglionic system, or the great
sympathetic, we have nearly as clear evidences of its activity in —
" 1. The strong spasmodic action of the muscles of organic life,
which it supplies, as the heart and the muscular coats of the diges-
tive canal.
" 2. The copious watery secretion, from the inner surface of this
canal, and the morbid coating of matter so often found after death
on this same surface.
" 3. The intense sensation of heat and thirst, and the craving for
cold and acid drinks."
Glandular secretions of all kinds, as of saliva, bile, semen, and
42S
DISEASES OF THE DIGESTIVE SYSTEM.
those from the intestines, are often augmented to a great extent
under general as well as partial nervous excitement; and hence, 1
am disposed to regard the immense outpouring from the intestines as
the result of such excitement, and by its very excess causing a dimi-
nution or entire suspension of other secretions. The predisposition
once laid, any irritantto the digestive canal is sufficient to excite thus
morbidly its secretors ; and we have, in consequence, vomiting and
purging" in alarming excess. Sedation of the skin from cold, by ac-
cumulating sensibility in the interior, indirectly produces the same
effect. If we place cholera on the same line with the eruptive
fevers, as the appearance frequently observed in the skin, and the
psorenterie or eruption on the gastro-intestinal surface, noticed by
MM. Serres and Nonat, and Dr. Horner, seem to entitle us to do
so, we can the more readily understand why there should be dis-
ordered and morbidly excited innervation in it, as there is so
generally in all the exanthemata?.
Proceeding to the administration of remedial means under these
views, our chief object, at first, will be to remove all irritants of a
morbidly sensitive nervous system, whether applied to the brain
through the senses, or to the ganglionic system through the sto-
mach and bowels, or the skin. In fact, it matters little at the
moment, whether there be indigestible food, a heavy supper for
example, in the digestive canal, or a changed state of sensibility
in its mucous membrane, by which common and healthy food
irritates it. In either case the phenomena are nearly the same,
and the mode of relief will not be essentially different. In the first
case, it is true, the call will seem to be more urgent for the expul-
sion of the offending matters ; in the latter, for altering or modify-
ing, either by direct impression, or by diffusing and equalising sen-
sation in all parts of the economy, the morbid sensibility. So far
the problem is comparatively simple for our solution, and, happily,
it is the one presented to us in the preliminary or forming stage of
cholera, cholerine of the French writers, and the symptoms of which
have been already described.
Treatment of the Diarrheal Stage. — The patient, for so he
ought to be regarded and addressed at this time, even although his
own judgment be faulty as to his real state, will generally ex-
hibit an atony of the skin, with some irritation of the bowels.
The twofold indication here will be to remove the former by ge-
nial warmth, and the latter by carrying off, by mild purgatives,
the offending irritant. Our treatment should be, at this time, pre-
cisely identical with that in common diarrhoea, when we are very
desirous of shortening its duration. We direct the patient to con-
fine himself to the house, and still better to his bed, as the best
means of securing a uniform temperature of the skin ; and by mere
rest, also, of abating the intestinal discharges. We prescribe at
the same time a laxative, with a view of removing any offending
matters, such as food, either originally indigestible, or still, after the
full period, indigested, which, by their stay, irritate the gastro-intesti-
nal surface. Nausea and occasional pains will be obviated by some
TREATMENT OF EPIDEMIC CHOLERA.
429
slight aromatic, taken either before or after the administration of a
laxative. The latter may consist of a few grains of calomel and
rhubarb or castor oil, with a drachm of oil of turpentine ; or you may
give rhubarb and magnesia with a little ginger, or blue mass with rhu-
barb in pills. Of the aromatic class, 1 should use tincture of cam-
phor, in doses of five or six drops, on a lump of sugar, repeated every
hour or so, or cajeput oil in doses of two or three to five drops,
taken on sugar or in emulsion. In the value of the first I have
great faith, from full experience with it both in this and in analogous
affections of common or sporadic occurrence. With the latter I am
unacquainted, except through the favourable reports of German
and some British physicians. During the operation of the laxative,
and after it has ceased, simple diluent drinks, such as barley, rice,
or toast water, should be freely taken.
This treatment will be found adapted to a great proportion of
patients in the first, or forming stage of cholera, who, if they ne-
glect themselves at tfte time, will, in large majority, sink victims
to the disease, in its more ^advanced and less curable stages. If
the symptoms continue after*tiie evacuation of the bowels by medi-
cine; or there be confusion of head, and increase or persistence of
cramps of the legs, with a pulse somewhat full, the safer practice
will be to draw blood from the arm, to the extent of ten or twelve
ounces, and even more if necessary to procure manifest relaxa-
tion; and then to give opium in the dose of a grain, or cam-
phor water one ounce, with twenty drops of laudanum. Nausea
and retching, with more or less pain distinctly referrible to the
stomach, and following the recent introduction of food into this
organ, will be best removed by a mild emetic, consisting of a few
grains of ipecacuanha, or two tablespoonfuls of common salt in a
halfpint tumblerful of warm water, the good effects of which ex-
tend beyond the mere removal, important as this is, of a now irri-
tating substance to the stomach. Our great object at this time is
to restore the lost balance of function ; and, whilst bringing back
the skin to its natural action, to restore the bowels to their healthy
secretions. These indications will be often met by the patient going
to bed, getting himself warm, and taking a draught or two of hot
herb tea. The warm bath and friction are good adjuvants to the
means already mentioned, as applicable to the forming or simple
diarrhoeal stage. If the prostration be considerable at an early
period after the coming on of the diarrhoea, it will be most prudent
to give at once a full dose of laudanum, say thirty drops, by the
mouth, or fifty by injection per anum, and afterwards, if the patient
complains of disease in any particular region, to follow out the
treatment already prescribed.
I know that exceptions have been taken to purgatives in the form-
ing stage of cholera, and cases are recorded of their use being fol-
lowed by hypercatharsis, vomiting, and the worst features of the
disease terminating in death itself. Even where constipation
had previously existed they have displayed these sinister effects. It
is not easy, in cases of this nature, to be able to say how far the im-
430
DISEASES OF THE DIGESTIVE SYSTEM.
minency of an attack coincided with the administration of purga-
tives, which may only have been not sufficient to ward it off, though
possibly not instrumental in bringing it on. But the practical ques-
tion is—Are thev adequate to prevent the coming on of regularly
formed cholera?" In a majority of cases a mild purgative, given
under the precautions already laid down, will, I believe, be found to
do so. I may here introduce, in connection with this subject, the
outlines of a case, evidently one, I think, of choleric diarrhoea,
treated by me in conformity with the views now inculcated. It serves
at the same time to show the gradual manifestation of epidemical
influence in a place sometime before the outbreak of the disease in
all its terrific characters. My patient, who had then, and still has,
charge of the rooms of the Philosophical Society, after having gone
to bed one evening in the month of May, 1832, as well as usual,
was awoke in the night with urgent desire to go to stool, which
was often renewed, and barely allowed of his getting out of bed for
the purpose. The discharges were profuse ;• resembling, as he ex-
pressed it, gruel, and at another time he compared them to rice
water. The comparisons were his own, and not suggested by me, in
questioning him about his symptoms and feelings. Some nausea and
heat of the stomach accompanied the discharges, which were very
exhausting. The tongue was white and loaded ; pulse small, and
rather frequent. He complained, also, of severe cramps in his legs.
On visiting him by times in the morning after his attack, I had
him bled to the extent of about twelve ounces, and directed rhubarb
and calomel pills, the proportions not noted at the time; and after their
operation in the evening gave him a grain of opium combined with
a drachm of carbonated magnesia. Under this treatment he was
promptly restored, and passed through the period of the cholera in
July, August, and September, without any inconvenience or com-
plaint. I am partial to the combination of magnesia with opium,
as the first and best effects of the latter are not interfered with, whilst
its kindly operation on the stomach and intestines, in the correction
of diarrhoea, is increased, and the tendency to subsequent costiveness
and diminished renalsecretion, in a good measure,obviated. In direct-
ing venesection in this case, I was not so much swayed by thecholeric
form of the disease, as by my knowledge, from former attendance,
of the proneness of my patient to enteritis. His habit of body was
spare: temperament lymphatico-bilious.
In prescribing laxatives or mild purgatives in choleric diar-
rhoea a preference should be given to these already indicated
over the saline, and, d, fortiori, over the resinous and drastic kinds,
neither of which can be administered without danger. Fail-
ing to procure the desired relief in the forming stage, the patient
is thrown into the second stage, or cholera proper. Sometimes this
stage is passed over at once, as it were, and the third or fatal stage,
that of collapse, comes on.
" The transition " says Dr. Craigie, " from the diarrhceal stage to
that of collapse, though rapid, is never made per saltum, as it were,
TREATMENT OF EPIDEMIC CHOLERA.
431
but in all cases, in however short a time, by gradual and successive
changes. In most of the cases in which I had an opportunity of
remarking this transition, the countenance became first slightly
blanched, and the skin began to assume a colliquative humidity.
When the pulse was felt at this period, it was not gone ; but greatly
weakened in force, and small in its size. The patient, at the same
time, complained of a sense of sinking at the breast, with an uncom-
fortable sense of thrilling heat and unsteadiness, as if unable to sup-
port himself; and though there were instances in which the patient
fell down at this period, from weakness, yet afterwards, when the
stage of collapse was thoroughly established, this extreme enfeeble-
ment of the voluntary muscles was not recognised."
Treatment of the Second Stage, or of Distinctly Marked Cholera.—
Bearing in mind the fact, that by far the most powerful causes,
both as predisposing and exciting, are to be found in the diet of the
persons attacked ; and remembering the habits of those who are
the most ready victims to the disease, as well as its great frequency
and mortality in countries, the rural population of which has been
compelled to use damaged or imperfectly matured grain, or vegetable
productions of an indigestible nature, we can hardly doubt of the
gastro-duodenal seat of cholera proper. The first symptoms — an
uneasy constriction or cramp, deeply seated in the epigastric region,
speedily followed by profuse vomiting and purging of watery fluids,
would seem to show the duodenum to be the part more immediately
affected. Farther corroboration of this view is furnished in the
effects of poisonous substances and putrescent animal matter taken
into the stomach. After a time, their ingestion is followed not only
by vomiting, but by great prostration of strength, cold and clammy
sweats, shrunken features, small and frequent pulse, and often vio-
lent spasms of the voluntary muscles.
Emetics. — The treatment under the circumstances just men-
tioned, which is generally deemed most serviceable, is to encourage
the expulsion of the offending matters by a mild emetic, and free
dilution, by draughts of warm water, or some other bland fluid. A
similar practice has been adopted in cholera, and, in many cases,
on good grounds, especially when the attack is recent, and the dis-
charges are either mixed with the food, or are white and inodorous.
Inflammation cannot be presumed to exist at this time. The sto-
mach had,up to the date of the attack, exhibited often its customary
craving for food, and was not oppressed by its reception — the
tongue and skin, and absence of thirst, did not betoken gastritis or
gastro-enteritis ; and hence we are left free to substitute one irritant,
or medicinal and controllable one, for another of a more poisonous
kind which is acting on the nervous expansion of the small intes-
tines, especially of the duodenum.
Some practitioners prefer ipecacuanha,others sulphate of zinc, and
some, again, mustard, in order to produce full vomiting in cholera.
Mr. Hall, in his account of " Epidemic English Cholera," prevailing
on the river Medway, tells us, that Ci having practically discovered
432
DISEASES OF THE DIGESTIVE SYSTEM.
the efficacy of exciting full vomiting by emetics of ipecacuanha, he
employed this in future, in every case, without exception. Several
of the cases were infants at the breast; some were pregnant
women, and one was a female above eighty years of age. In every
case an ash-coloured, slimy, consistent fluid of a peculiar smell,
as well as sourish taste, was discharged by full and efficacious
vomiting."
" if,'' says Mr. Greenhow (Cholera as it recently appeared in the
Towns of Newcastle and Gateshead), " the stage of collapse have not
yet established itself, and if, with bilious diarrhoea, the patient com-
plains much of nausea and occasional retching, the matter rejected
consisting principally of undigested food, we shall probably find a
dose of ipecacuanha, with or without antimony, answer the purpose ;
or even copious draughts of warm water will suffice to wash out
thoroughly the contents of the stomach."
I can testify, from personal observation, to the good effects of an
emetic of twenty grains of ipecacuanha in cases of cholera, in which
there was vomiting and purging, but absence of bile in the matters
discharged—extremities cold, and of a clammy feeling, pulse small,
respiration laborious, eyes suffused. The emetic procured a dis-
charge of bile, and arrested at once the purging, restored warmth
to the skin, and activity to the pulse. In one case in which
there was imminent danger of collapse, with most harassing and
exhausting efforts at vomiting and purging, and a discharge of a
turbid fluid, laudanum,in a dose of sixty drops, having been promptly
rejected, as camphor water with bi-carbonate of soda in divided
doses had been before, I gave the Russian vomit of salt and water, in
the proportion of two tablespoonfuls of the salt to a half-pint of water.
The effect was a speedy ejection of the contents of the stomach in
two efforts; subsequent composure of this organ; general quietness
and a refreshing sleep, from which the patient awoke in the morning
entirely relieved, and in fact convalescent. In Paris great faith was
placed in the virtues of ipecacuanha, as an emetic. Testimony of a
favourable nature is furnished also of the curative powers of tartar
emetic in doses of two or three grains; but this was given with a
different intention than to vomit, as I shall afterwards explain.
When moderate reaction is produced by these means, and no
urgent morbid symptoms are present, we may very properly follow
the advice of the French Academy, to rest satisfied as spectators;
ever remembering one important precaution through the whole
disease, viz., not to allow the patient to change his recumbent for
any other posture. The least muscular effort, as in rising in the bed,
is always exhausting, and has been fatal.
Bloodletting. — But should the patient be of a sanguineous habit,
or complain of pain in the abdomen, headache, or vertigo, with
an accelerated pulse, or the vomiting and purging be accompanied
with much epigastric weight, we should have recourse to venesec-
tion. This remedy is, of itself, when resorted to at the outset, suffi-
cient to cut short the disease. Even in cases of approaching col-
TREATMENT OF EPIDEMIC CHOLERA.
433
lapse full venesection ad deliquium, has, to all appearances, saved
life. In a somewhat more advanced period of the disease, in which
bleeding from the arm would be either difficult or of doubtful effi-
cacy, an emetic of ipecacuanha, followed by cups over the abdomen,
has been found a good practice.
Where the heat of the stomach and tenderness of the epigastrium
are considerable, leeches freely applied over the affected part have
given great relief ; but as they are slow in their operation, cupping
is in general preferable.
Bloodletting was the favourite remedy of the East India physi-
cians. It had also its advocates on the continent of Europe, more
particularly in Germany, Poland, and Russia. All those who pre-
scribe it, however, lay stress on the necessity of its being early had
recourse to— within an hour or two from the coming on of vomit-
ing, &c, and when the pulse is yet full. As in other diseases, so in
this, we shall be not a little guided by the age, constitution, and habits
of the patient, as well as by the violence of the symptoms and
the duration of the disease. I do not think that bloodletting
can be regarded as a favourite remedy among the practitioners
of Great Britain and the United States. In Edinburgh, Dr. Chris-
tie's method, " in cases with cholera, vomiting, purging, and great
epigastric weight, was to detract twelve, fifteen, or twenty
ounces, as the strength of the patient allowed" (On the Epidemic
Cholera in Edinburgh —Edinburgh Med. and Surg. Jour., 1833);
whereas, Dr. Mackintosh, in the same city, says," although I have
known venesection employed advantageously, and seen purga-
tives used, without producing death in that stage of the disease, I
cannot state the fact too strongly, that they are dangerous reme-
dies." The two remedies here placed together by Dr. Mackintosh
are not, however, to be used or omitted on the same grounds.
Hostility to purgatives need not imply aversion to bloodletting.
Sedative or Contra-Stimulant Remedies. —A remedy most akin
to bloodletting in its tranquillising effects in cholera, is calomel. It
is with no desire to give a novel turn to thedirection of your inquiries
into the curative powers of this medicine in cholera, and in some
other important diseases, that I invite your attention to the
immediate effects of calomel on the system, which are neither
dependent on nor proportionate to its operation as a purgative
on the one hand, or a sialagogue on the other. In India, Great
Britain, and the United States, the power of calomel to tran-
quillise an irritable stomach and irritable bowels, is a fact of
frequent, one might say almost daily, -observation in some form
of disease or another. In cholera we have had abundant manifes-
tations of its efficacy in this respect. But solely attentive to its
indirect effects, in promoting the secretion of bile from the liver,
and of mucus from the intestines, physicians generally have failed
to recognise its first beneficial and often eminently curative im-
pression on the nervous and sensitive surface of the digestive mucous
vol. i.—37
434
DISEASES OF THE DIGESTIVE SYSTEM.
membranes, and secondarily, or by sympathy, on the respiratory and
genito-urinary ones. Could testimony be stronger than that furnished
by men of skill and observation in three different continents, and with-
out previous concert or imitatingoneanother,than isfound among the
physicians in India, those of Great Britain, and those of the United
States, respecting the adaptation of calomel to distinctly formed
cholera ? Mr. Corbyn, in India, says : " Calomel, in doses of from
fifteen to twenty grains, is a sedative, and has the singular good
qualities of immediately stopping violent vomiting and purging,
removing spasmodic irritability, producing tranquillity of mind,
exciting the secretion of the liver; and preventing the progress of
inflammation." (Op. cit, p. 197.) This writer points out the stimu-
lating effect of calomel in smaller doses; and in thus drawing a
proper line of distinction, guides us in the use of the medicines, and
presents a proper reason, not an apology, for large doses. His first
prescription in a case of well marked cholera was 15 grains of
calomel, which he washed down with 60 drops of laudanum and 20
drops of peppermint, in ten ounces of water. In this dose laudanum
is sedative. In doses of 15, 20, to 30 drops, he found it to be a
stimulant: "the former produces sound sleep, removes pain and
irritability, whilst the latter excites considerable uneasiness and
convulsive startings." After the first attack is over, that is, after
three or four hours, if there are much spasm and irritability remain-
ing, the dose of calomel and draught must be repeated; the patient,
continues Mr. Corbyn, will then fall into a sound sleep, and awake
nearly recovered. Dr. Craigie places calomel and opium next
to venesection, and apparently on the same line, as remedies against
the open and distinct cases marked by vomiting, purging, and
cramps. The proportion of opium, half a grain to calomel ten
grains, leaves us to infer that the chief tranquillizing effects are
obtained by the latter medicine. This treatment will, he tells us,
infallibly remove the disease, if anything will. "In milder cases,
the usual practice, which, after many trials, was found, to be most
successful, was, to exhibit, either at once, 20 grains of calomel and
half a grain of the drug, at the interval of one, or two, or three
hours, according 1o the state of the stomach. The general effect of
this remedy was, first, to allay the irritability of the stomach, and
put a stop to the watery vomitings; and, afterwards, to suppress the
sero-albuminous discharges from the intestinal tube." Dr. Drake,
of Cincinnati, selected on this occasion to represent the therapeu-
tical opinions of his medical brethren of the west, who may all be
proud of so able an exponent of their views on other subjects also,
bears similarly favourable testimony to the beneficial effects of calo-
mel in cholera. He had before spoken of it as the best medicine
in the diarrhceal or forming stage, administered alone, or combined
with opium, and followed by some common, but not saline, purga-
tive. He, then, after adverting to some of the remedies in the
second or choleric stage proper, proceeds to tell us: "But the chief
reliance at last was on the calomel and opium, or calomel alone.
TREATMENT OF EPIDEMIC CHOLERA. 435
To be successful, it was necessary to administer them, especially
the last, in large doses, and in powder with sugar, so as to promote
their rapid diffusion over the surface of the stomach. There is not,
I presume, a physician in Cincinnati who cannot testify to the
efficacy of this practice. It was worth every other therapeutical
means, both external and internal. The most violent vomiting
would cease, whenever the stomach could be brought under the
influence of this compound, or of the calomel uncombined; and a
speedy return of the suspended secretions of the liver and skin
generally followed, after which the patient commonly recovered."
(Op. cit., p. 40.)
Two dominant motives influence practitioners generally in the
administration of mercury, and more especially calomel; the first
to procure a purgative—secondly, a salivating effect. Hence, if the
latter is not wished for, it is always thought necessary to com-
bine something with the calomel, or to follow its use by another
article with more directly purgative properties, to insure its being
carried from the bowels. But a third, and the most important, or
the soothing and sedative effect of calomel, is almost entirely over-
looked, or regarded as incidental and merely preliminary to its
stimulation of the liver and pancreas, and the muciparous glands
of the intestines. The proposition, that its good effects in cho-
lera and dysentery, and in some of the more violent forms of inflam-
mation of the pulmonary mucous membrane, are entirely irrespec-
tive of any evacuation following its use, would startle most of our
professional brethren ; but yet, if they put aside theory, and forget
for a moment the conventional language of the schools, their per-
sonal observation and experience will soon show them that it is the
correct one. It is now nearly twenty years since I first, and the
first, directed the attention of my professional brethren in this
country, after my return from travels in Europe and in the East,
to the new Italian Medical Doctrine of Counter-Stimulus (Dr.
Chapman's Med. and Physical Jour., vol. iii.), and endeavoured to
point out its harmony with our home experience of the operation
of certain medicines, and, notably, mercury and antimony. It
will be found, I think, invariably, that even when evacuations are
produced by calomel or blue pill, they are preceded by a renewal or
marked diminution of the more urgent painful symptoms, and that
purging in the early period of mercurial medication, like salivation
in a later one, is an evidence, rather than a cause, of its beneficial
impression and antiphlogistic operation. I would not deny that
there are often matters in the digestive canal — crude ingesta in the
stomach, retained hepatic duodenal secretion in the small intestines,
and scybala in the large, — the retention of which will irritate the
canal and cause general disturbance ; but that, even anterior to
their expulsion, the irritation of the mucous surface may be greatly
abated by the direct sedative effect of calomel. The restoration of
the flow of bile will follow the use of calomel,so it will venesection,
and sometimes opium. Saliva will be made to flow into a dry and
436
DISEASES OF THE DIGESTIVE SYSTEM.
parched mouth,in which neurosthenia prevails, by simple demulcents
and cooling drinks. In none of these cases do we suppose the re-
storation of secretion to be the result of, or to be accompanied by,
excitement of the glandular apparatus.
In a well marked case of cholera, after an emetic or venesection,
perhaps after both, we should not hesitate to give calomel, as a
sedative, to allay the inordinate gastro-intestinal excitement, call it
catarrhal, irritative, or inflammatory, as you will, and, to repeat the
medicine at intervals, watching its effects, until the desired relief is
obtained. A suitable time having been allowed to test the impressi-
bility of the system to its influence, we have recourse to other
remedies. The relief may be followed by bilious stools, or it may
take place without any such immediate or direct effects: but, be
this as it may, we shall not think it necessary at this time " to follow
up" the administration of calomel by purgatives : the union will not
be a happy one for the patient; it is not called for by the intention
with which we direct calomel in this case. Let us feel our true
position. We are not in the dilemma to which the common limited
views of the operation of mercury wrould subject us. Failing to
purge we are not obliged to salivate our patients. We shall be
content with the simply sedative operation of our medicine, and
not push its use so far as to poison the tissues and bring on a fever
of reaction, or ptyalism, with all its distressing accompaniments.
In cholera as in dysentery, and in bilious remittent and in yellow
fever, salivation is an evidence of the abatement, often perhaps crisis,
of the disease, but not a cause of this result. Patients are salivated
because they recover, but they do not recover because they are sali-
vated. In my lecture on dysentery I gave abundant proof to show
that the sialagogue operation of calomel or other mercurial prepara-
tions has neither a preventive nor a curative power in this dis-
ease. The same remark applies to cholera. Dr. Griffin (op. cit.)
ascertained by inquiries made in Dublin and Liverpool, as well as
by cases detailed to him occurring in Limerick, that, " not only had
patients in salivation for other complaints fallen into cholera, but
some who had been salivated for cholera had, during the salivation,
sunk back into collapse and died."
Happily, as regards the danger of its salivating, calomel is toler-
ated in the largest doses, repeated at short intervals, during the
intense or neurosthenic stage of cholera : "As long," says Dr. Griffin,
" as cholera existed, none of the usual effects of calomel appeared ;
it acted neither on the salivary glands, nor liver, nor bowels; I
suppose, on the same principle, that tartar emetic does not excite
vomiting, nor opium narcotise during the presence of inflamma-
tion." He states his having given it hourly, in scruple doses, to the
amount of two or three drachms or upwards, without eventual sali-
vation; and in one instance, in particular, he gave nearly two
drachms, within an hour and a half, with perfect success, and without
affecting the salivary glands.
If the views which I now advocate and endeavour to elucidate
TREATMENT OF EPIDEMIC CHOLERA.
437
be correct, we must stop the administration of calomel so soon as
the stage of collapse has arrived, and the pulseat the wrist is no longer
felt. The extent of neurosthenia and the evacuations caused by it
have now brought on prostration, insensibility to common agents,
and a state of the system demanding other than sedative remedies.
Calomel given in this state will, from the diminished and almost
lost susceptibility of the mucous tissue, and the organic systems
generally, have, it is true, little or no effect; but if its use be persisted
in, there will be a dangerous accumulation and the worst effects of
the medicine, manifested by salivation, nervousness, &c, should
there be reaction and the patient survive the collapse. The use of
calomel ought, therefore, to be restricted to the first and second stages
of cholera; in the first of which it is primarily sedative and indirectly
purgative; in the second it is primarily and mainly sedative, and
incidently purgative and cholagogue. Sometimes it is called for in
the fourth stage, or that of reaction with fever.
Dr. Griffin, in summing up the number of cases of cholera during
a month, in St. Michael's hospital, Limerick, in which calomel
was largely employed and chiefly relied on, found them to be 165,
in which there were 47 deaths, "or less than one-third, which was
not far away from the general mortality in most countries." But
on ascertaining the amount of the mortality in the separate stages,
he " was perfectly astonished to find that, while in the primary
stage, or that of rice-water vomiting, and purging, there were only
5 deaths in 119 cases, there were in those admitted in collapse 42
deaths in 46 cases." The inference which he draws, and that
which seems to be the correct one, is, that "the calomel practice
was capable of effecting a greater number of cures than any known
remedy in any other dangerous disease, so long as the patient was
placed under treatment before the pulse ceased at the wrist; but
after that occurred, it did nothing, or it did mischief; the recoveries
being perhaps less than might be effected if the cases were wholly
abandoned to nature until the period of reaction. Reports from
other hospitals in Limerick, the same treatment having been at the
time pursued in all, confirm the accuracy of these inferences. At
a subsequent period, when the disease made a second visit in the
latter end of August, Dr. Griffin and his three medical associates
" agreed upon a plan of treatment which altogether excluded the use
of calomel during collapse, and the administration of large doses
after reaction had taken place. No limit was placed upon the
amount which was given in the early stage of the disease." The
result was that, in a period of six weeks, out of a 126 cases admit-
ted, of which 59 were in the primary [not premonitory] stage and
61 in collapse, 8 only died of the former, although several of the
original number (59) ran into collapse; and of the latter (61) 43 died,
and 18 recovered—-"a greater number than had previously re-
covered from that state under the most sedulous medical treatment."
By thus classing the cases, and restricting the use of calomel to a
particular stage of the disease, all the best remedial effects of the
37*
438
DISEASES OF THE DIGESTIVE SYSTEM.
medicine were procured, and there were " few sore mouths and
no very bad ones." A different result used to follow the indis-
criminate use of the calomel and rubbing in by inunction, without
reference to the stage ; but with the effect of salivating the patient
severely after the chief danger from the disease was over. Dr.
Griffin, at the close of his remarks upon this important part of the
treatment of cholera, says : " It is now at least evident that, by the
judicious application of one remedy, we can control the disease, or
arrest its progress,in84cases outof 100,if the patient be placed under
our care before the pulse has ceased at the wrist; and if, after that,
no more than two or three can be saved out often, it is only to be
considered that the stage of collapse in cholera is like the stage of
muttering delirium and floccitation in fever, the almost fatal con-
clusion of the disease."
It is pretty generally known to the American practitioner, that
calomel has been given, particularly in some of the Western
States, in large and even enormous doses in cholera; but as we
have not been furnished either with the numeral estimates of cases
treated, or of the several stages of the disease in which the medicine
was given, or the proportion of deaths in each, little profit can come
of the reports of our home-practice in this respect.
I shall interrupt here, for a minute, a specification of the reme-
dies of a counter-stimulant nature advised in cholera, in order to
indicate the other points of treatment proper to be prescribed at the
time in which we are administering the calomel, and expecting its
beneficial operation. Experience soon showed the inefficiency of
common stimulants to the skin, and especially of high heat, which
was at all time intolerable to the patients, and elicited from them
the most animated and often evident demonstrations of dislike and
dread. By far the most successful mode of exciting the cutaneous
surface was by mild but steadily persevered in and prolonged
frictions with dry cloths, or the hands of assistants: and the ap-
plication of sinapisms to the extremities, inside of the forearms and
of the legs above the ankles, and on the epigastrium, or between the
shoulders. This practice should be had recourse to at once, when-
ever the surface becomes preternaturally cold, or cramp is felt.
Embrocations of turpentine was a common remedy with some of
the East India physicians, and particularly with Mr. Annesley.
While thus endeavouring to rouse the skin to its healthy action as
an organ of nutrition — by restoring its circulation and proper se-
creting and absorbing function — and to abate the inordinate neuro-
stheniaof the gastro-intestinal surface bycalomel, in thedosesalready
mentioned, it is advisable, indeed exceedingly important, to check
as speedily as possible, by enemata, the excessive and inordinate eva-
cuations from the bowels. These are but a symptom, it is true, but
they are also an effect, which contributes to exhaust the patient beyond
reaction and recovery. We do not hope to cure the disease bv this
rneans, but we may gain time for other remedies to operate in a more
diffused and permanent manner. Mr. Annesley, (Diseases of India,
TREATMENT OF EPIDEMIC CHOLERA. 499
p. 156,) who followed the calomel practice, by giving a scruple
of this medicine every two hours, until three or four scruples had
been taken,recommends small anodyne enemata with camphor, when
the bowels are very irritable, and constantly discharging a watery
fluid. Mr. Corbyn, at the same time that he directed a scruple of
calomel, 60 to 80 drops of laudanum and 20 drops of peppermint
by the mouth, had also 40 drops of laudanum, mixed with rice
water, introduced as an enema. Dr. Craigie found that the best
and most effectual means of stopping the purging, " was a small
enema of four or six ounces of dissolved starch, containing a drachm
of sedative liquor or paregoric, repeated every hour according to
its effects," and " injected as far up the intestines as possible."
Mr. Griffin was so fully convinced of the necessity of invariably
suppressing the diarrhoea in the choleric stage, that he constantly
made it a rule to give an astringent injection after each evacuation,
however frequent, until his object was accomplished. " The in-
jection generally consisted of half a drachm of the acetate of lead,
mixed with thin starch, to which a teaspoonful of laudanum was
added, either when the injections were repeatedly returned imme-
diately after administration, or the cramps were distressing and
resisted other remedies." The term sedative is much more appli-
cable than that of astringent to the preparations of lead ; whether we
have regard to their effects on the vascular or the nervous and
muscular systems. And, in fact, the enemata which the gentlemen
in India, Scotland, and Ireland, have found most useful, are of the
sedative kind, and in harmony with the other part of the treatment,
or giving calomel by the mouth at the same time. But, whether
we regard them as astringents or sedatives, we could not feel
ourselves justifiable in using enemata in this way, if we prescribe
calomel as a purge, and with a view to its procuring feculent and
bilious discharges, in place of giving it as a sedative. We should
have, in the one case, to wait its operation on the bowels before we
venture to prescribe anodyne or astringent enemata ; whereas, in
the other, we feel that we are giving by the mouth and per anum
remedies of the same class, and whose effects on the two parts of
the digestive tube will be in harmony with each other.
Opium. — In speaking of the remedies which experience has
pointed out as the best adapted to a disease, we must of necessity
mention them in succession, and in the order in which their use is
believed to be called for. But it does not follow that they are all
required in one case; and hence the student and younger prac-
titioner is sometimes embarrassed in making his selection. In the
disease before us emetics may not be admissible ; they may have
been administered without effect before our arrival, or the stomach
has been perhaps adequately evacuated of all remains of ingesta
which previously disturbed it. The state-of the patient, manifested
by want of any fulness or strength of pulse, or of any notable de-
termination to an important organ, may not justify venesection;
our confidence may not be great in calomel; yet the symptoms
440
DISEASES OF THE DIGESTIVE SYSTEM.
are violent; there is severe and torturing cramp, continued vomit-
ing and purging, and rapidly increasing debility. It may be that
this condition of things exists despite of the other remedies, and we
have not a moment to lose. What shall we do? We should apply
cups to the abdomen, plain or scarifying, sinapisms to the extremi-
ties and on the epigastrium ; and give at once a full dose of lau-
danum, from 60 to 80 drops. This will often allay the cramps with
which the patient is often tormented, quiet jactitation, and procure
sleep; in fine, remove neurosthenia. The patient should, at this
time, be kept in bed, and well but not heavily covered with cloth-
ing; warm applications are to be applied to his feet, and gentle
frictions practised, particularly over his lower limbs; in order to
encourage what the laudanum itself is so well calculated to pro-
duce— a gentle but diffused perspiration.
The opium practice was a favourite one in the East Indies. I
say practice, for more than one influential practitioner there relied
on it almost exclusively, when it could be given early in the disease
and in full doses. Mr. Orton deems it " probable that a single dose of
opium alone, given at the very commencement of the disease, would
be found, in a great majority of instances, to put an effectual check to
its progress." He warns us, however, against an excessive use of
the remedy ; but some might think that the dose of four grains which
he recommends is somewhat excessive. The medicine is to be re-
peated in diminished doses, at intervals of from three to six hours,
if a favourable change is not produced (Essay on Epidemic Cholera).
The opinion of Mr. Tweedie is still more strongly, perhaps also
somewhat extravagantly expressed, when he declares, that pre-
viously to collapse taking place the disease may be stopped quickly,
safely, and with human certainty, by full and energetic doses of
opium proportioned to the age, idiosyncrasy, and condition of the
individual. On the other hand, we know that both at the Pitii and
at the Hotel-Dieu in Paris, where this drug was at first largely
prescribed, the physicians of the former of these hospitals discon-
tinued its use, and those of the second limited its administration
chiefly to enemata and liniments. Many of the Parisian prac-
titioners continued, however, to use it through the whole course
of the epidemic. By some of the Polish and German physicians
it was objected to opium, that it was apt to cause congestion of
the brain and of the spinal marrow; but it was found that this
state of congestion, so common in the period of reaction, ensued
after other remedies of a totally opposite nature, such as cold water.
In cholera, the animal economy often displays a singular toleration
of opium in large doses, as we see it in other diseases of neuro-
sthenia, tetanus for example; and it may be laid down as a general
rule, that it is least efficacious, if not positively hurtful, in cases in
which it manifests no narcotic effects. To be useful in the dis-
ease it ought to be given early and in full doses.
TREATMENT OF EPIDEMIC CHOLERA.
441
LECTURE XXXV.
DR. BELL.
Treatment of Cholera (Continued).—Drinks; warm; cold; ice—Stimulating
drinks injurious—Tartar emetic as a sedative; its successful use—Ipecacuanha
with similar intention—Magnesia—External medication.—Warm, tepid, and
cold baths, all sedative — Stimulants externally; blisters; cauterising skin;
dry heat; continued frictions of the skin—Internal Stimulants; the milder
kind preferable; tonics; sub-acetate of lead and sub-nitrate of bismuth are seda-
tives—More active stimulants; ammonia, capsicum, camphorated ether—Treat-
ment of the stage of Collapse—Difficulty—Stimulants and sedatives often %
alike fail—External remedies; friction, ammoniacal liniment; friction with ice; '
the cold dash—Sudden collapse treated sometimes by venesection—Arteriotomy
useless and cruel—Cups to the abdomen—Astringent injections—Stimulant in-
jections—Astringents—Special stimulants ; oil of turpentine and capsicum—Ice
grateful and serviceable—Cold water treatment—Dr. Shute's views in directing
it—Tobacco enemata.
Drinks. — Early in the disease the patient becomes clamorous for
drink, and it is then a question as to the kind and quantity adapted
to his case.
A great diversity of opinion exists among the writers upon cho-
lera, on this point,' but these differences grow out of the different
constitutions and gastric habits, as well as idiosyncrasies of the
sick, manifestations of which we see continually in gastric irritation
and vomiting in fevers and other diseases. By some, diluents
of every kind were entirely prohibited, in consequence of a suppo-
sition that they increased the vomiting. The great desire of the
patient is for cold water—he appears to labour under the most dis-
tressing thirst, the calls of which, it must be evident, cannot be dis-
regarded, without materially increasing his sufferings, and eventu-
ally the disease under which he suffers. Mr. Scott, in common
with nearly all the best practitioners, concedes the propriety of
allowing some bland diluent, but maintains that it should be given
of tepid warmth—he conceives that cold drinks are always danger-
ous, and generally fatal.* This was the opinion very generally of
the surgeons in India. Mr. Annesley, however, gave cold water
with a slight impregnation of nitric acid. This was the common drink
in the hospital under his care, and was found to relieve that most
distressing symptom of the disease, the burning sensation at the
stomach.f From the experience of the European physicians, it
would appear very fully settled, that cold drinks are not only allow-
able but beneficial, and when desired by the patient they should be
freely given. According to Lefevre, iced lemonade has often been
taken with advantage,! and even the lower orders of the Russian
* Madras Report.
\ Annesley on the Diseases of India, p. 174.
t By Mr. Bell also, and some few of the practitioners of India, cold lemonade
was allowed. Bell on Cholera, p. 108. See also Searle's second publication on
Cholera.
442 DISEASES OF THE DIGESTIVE SYSTExM.
people drank their quass as usual, and with seeming benefit. The
diluted nitric acid, he states, may be added with great benefit to
the common drink. Fifty drops of the diluted acid, added to a pint
of water, sweetened to the taste, is a grateful beverage.* Mr. Or-
ton allowed usually only moderate quantities of a weak infusion of
ginger, with the addition of a little sugar and milk.f Dr. Dyrsen,
of Riga, says, that when the thirst is great, warm or even hot drinks
are the best, and are often retained and even desired by the patient.
He directs infusions of the various mild aromatic herbs, or when
these are unpleasant to the patient, of common black tea. But
when the latter desires earnestly cold drinks, they may be given
in small portions at a time, without fear of any bad consequences.
Fresh milk, moderately cool, he states, has been found very bene-
ficial, and when the diarrhoea is considerable, a decoction of rice or
pearl barley, thin tapioca, and the like, to which, when there is
entire absence of pain or tenderness of the abdomen, a little red
(port) wine may be added. A cup of strong coffee he has found
very readily to suspend the vomiting in this disease — he advises
the patient, in case of the drinks being rejected by the stomach, to
be allowed to swallow small portions of ice somewhat rounded into
the shape of a pillj — a practice also recommended by Broussais.
Dr. Craigie found, that the liquors which most perfectly quenched the
thirst, and quieted the irritation of the stomach, were coffee, tea, and
weak chicken soup. For patients who required a stimulus as well
as mere drink, he believed port-wine, diluted with two pints of water,
to be the best. Brandy, or ardent spirits of any kind, he rarely used ;
having discovered that they increased the thirst, caused burning sen-
sation at the stomach, and aggravated other symptoms, by increasing
congestion of the organs. And this, I believe, was the general expe-
rience.
The strongest testimony in favour of warm water, is that given
by Dr. Sturm, a surgeon in the Polish army. Writing from the en-
campment near Kamienka, he says, "the treatment which we now
pursue is probably already known to you, as Dr. Helbig had been
ordered to publish an account of it in the newspapers. It consists
in nothing else than giving to the patient as much warm, nearly
hot, water, as he is able to drink, in the quantity of a glassful every
fifteen or thirty minutes. By the time he has taken fourteen glasses
the cure is complete, with the exception of a slight diarrhoea, which
it is not proper suddenly to suspend. The effects of this plan of
treatment are so quick and effectual, that in two hours, or often
sooner, the patient is well, particularly when it is commenced with
sufficiently early."§ The inference from all these opinions and
clinical experience is plain, viz., that we may safely consult the
taste of the patients themselyes respecting both the temperature
* Lefevre on Cholera, p. 82, et seq. f Orton on Cholera, p. 309.
% Kurzgefaste anweisung die Orientalische Cholera, p. 37.
§ Beobachtungen uber die Asiastische Cholera, von Dr. Hille, page 92.
TREATMENT OF EPIDEMIC CHOLERA. 443
and the taste of their drinks. The chief restriction that we are
bound to impose on them is, respecting quality. Whether we give
hot water or cold water, we ought not to allow more than a mouth-
ful at a time. Pellets of ice gradually melted in the mouth, have
the advantage of cooling the inward heat and quenching the burn-
ing thirst, without oppressing by quantity.
A course of practice having been marked out, calculated to
meet the chief exigencies in the first stage of cholera proper, I shall
now resume and complete the view of the contra-stimulant or sedative
remedies, which the experience of some physicians has shown to be
of marked benefit in the disease. You will have seen that, so far,
even the digression made from the direct line of narrative in this
part of our subject, indicates generally the superiority of sedative
means. I have told you that high heat to the skin was especially dis-
agreeable to the patients, and aggravated if anything the disease ; and
I may now repeat, that internal diffusible stimulants of the stronger
alcoholic class were also injurious and often very fatal (Kirk —
Practical Observations on Cholera Asphyxia). I- next propose to
make a few remarks on the potassio-tartrate of antimony (tartar
emetic) in cholera, in reference to its contra-stimulant or sedative
operation, which it so decidedly manifests in some other diseases.
Tartar emetic has been employed in several countries (India
and on the continent of Europe) in which cholera prevailed, with,
in some instances, certainly a good effect, but as a sedative, not
emetic. When frequently repeated, it was found to operate in the
same way as in the phlegmasia, viz., abating the violence of the
symptoms, but without evacuations. A good measure, indeed, of the
propriety of its use in the disease was a prolongation of the periods
of suspension of vomiting. Dr. Griffin (op. cit.) introduces a sum-
mary of the results of the practice by some of the British physicians.
Mr. Steward, who, after vomiting with the tartrate, gave it in two
or three grain doses every hour, with one and a half or two grains
of opium, states, that he had seventeen recoveries and four deaths
in twenty-one cases; or about nineteen deaths in the hundred; which,
if they were all primary cases, was not far short of the success
with calomel, and, if several were in collapse, may be said to
exceed it. Mr. Steward says, that before he adopted this plan, he
had seventeen deaths in twenty-six cases! An anonymous contri-
butor to Dr. Ryan's Medical Journal (vol. ii., p. 528), who seems
to have been a very accurate observer, states that he gave this
medicine in doses of three grains every two hours, in the dry state,
until the vomiting subsided, which was always soon, and usually
after the third dose. If the vomiting continued, he sometimes com-
bined it with a grain of opium. The effect of it, however, uncom-
bined, was generally to check the vomiting, not to increase it, and
he remarked that the recovery was always speedier in proportion
as the interval between the fits was prolonged. The most accurate
report which we have met of the treatment by tartrate of antimony,
is that published by Mr. Longford of Manchester. He adminis-
444
DISEASES OF THE DIGESTIVE SYSTEM.
tered it in much smaller doses — half a grain, frequently repeated,
with toast and water, or whey, ad libitum, prohibiting all heat and
friction. The following is the statement of results in 94 cases
(Med. Chir. Rev., January, 1834) : —
" 1st Class. — Cases with the skin and tongue warm, and pulse
tolerable, 28 in number: all recovered.
" 2d Class. — Cases with skin and tongue cool, or icy cold, with
feeble pulse, 36 in number: 25 recovered, and 11 died.
" 3d Class. — Cases pulseless, 30 in number: 11 recovered,and 19
died.
"By throwing the two first classes together, a comparison may be
drawn between the tartrate of antimony, and the calomel, treatment.
They amount to 64 cases, out of which died 11, or at the rate of
about 17 in 100; the greatest mortality under the calomel treat-
ment in Limerick being 16 in 100.
" In the 3d Class, or cases of collapse, there were 19 deaths in 30,
or nearly two out of three ; that is, about three recoveries in ten,
which exceeds the amount of recoveries from this state when
calomel was used, and is equal to the amount obtained when the
treatment was limited to very mild cordials and diluents."
Influenced by analogy, a very uncertain guide, by-the-by, in
medicine, we should be the more disposed to put faith in the bene-
ficial operation of tartar emetic in cholera, from the resemblance of
the state of the bowels in this disease to that of the mucous mem-
brane of the larynx and trachea in croup; and as, in this latter,
the medicine is serviceable, even when no false membrane is formed,
so, in cholera, it may be equally so, although no exudation should
previously have lined the intestinal canal. In the collapsed stage of
croup, tartar emetic is not admissible,— in that of cholera it must,
& fortiori, be still more hurtful. Its sedative and depressing powers
are not required at this time; but, on the contrary, they must be
mischievous.
Ipecacuanha has, also, been used with some freedom in cholera,
as a sedative remedy. Already I have directed attention to the
fact of its special influence in dyspnoea and in dysentery. Its rela-
tions with the digestive mucous membrane cannot, certainly, be
measured by its emetic operation. It is not surprising, therefore,
that this medicine should have been employed with other intentions
than to procure vomiting in cholera. Dr. Thompson of Madras,
found it very successful, given in a dose of only ten grains, with five
every half hour after, until the vomiting subsided. The German
physicians were freer in the doses. In Paris, M. Recamier gave
the tartrate of antimony in the dose of two or three grains; ipeca-
cuanha in a quantity varying from fifteen to twenty, or more, and
repeated it at intervals. The vomiting at first increased, but soon
ceased altogether, and with it the intestinal discharge; a gastric
warmth followed, the skin was covered by sweat, the era mps ceased,
and tranquillity of the system was restored.
Mr. Corbyn ranks magnesia among the sedatives, which he
TREATMENT OF EPIDEMIC CHOLERA.
445
found to be useful in cholera. He attributes its soothing effects
to its neutralising acid in the primse vias : this explanation would be
too chemical, even if there were acid to be neutralised; but when
we know that the discharges are rather alkaline than otherwise, it
is untenable. The carbonates of magnesia and of lime produce a
peculiar impression on the digestive canal, and through it on the
system at large, not explicable by any chemical hypothesis. Their
operation is at times evidently anodyne; so much so, indeed, that
after prescribing chalk mixture to a child with gastro-intestinal
irritation, I have been repeatedly asked by the mother whether there
was any laudanum in the mixture, for the child slept so much more
than usual. The remarks of Mr. Corbyn apply, however, we may
suppose, to the calcined magnesia, as he speaks simply of magnesia
without specification ; and he recommends it in doses of two to
three drachms. In common, this article, in subjects of a sanguine
temperament and irritable bowels, is, I have observed, exciting, so
as toproduce heat and rectal irritation, and sometimes, where predis-
position to piles is present, a little blood appears mixed with the
last discharges. Magnesia might well follow calomel, if, in pre-
scribing the latter, we are intent on procuring some feculent stools,
in addition to its contra-stimulant operation. There will be no dan-
ger from it of increase of serous discharges, as there is from saline
medicines in full doses ; nor of hypercatharsis, by excessive irrita-
tion of the muciparous glands and exhalents, as from drastic resinous
purgatives. If virtues have been manifested by saline medicines,
in small and repeated doses, in cholera, I am inclined to attribute
the effect more to their cooling, sedative operation, than to any che-
mical changes in the blood by their being absorbed into the veins.
External Medication. — In that part of the treatment which con-
sists of the use of external remedies there was the same discrepancy of
opinion and practice as in that of internal remedies. Towards the last,
however, the fact was forced on the attention of medical men gene-
rally, that irritating agents were not serviceable either externally or
internally, and that other means must be had recourse to for the relief
of the neurosthenia of the skin analogous to that of the digestive mu-
cous surface. Of a mixed nature are dry frictions, which have been
found to be so signally serviceable in cholera. More directly seda-
tive, and as such allaying neurosthenia, excitement, and cramps, is
water employed as a bath, of a range of temperature from the freezing
point to within a few degrees of blood heat. Different as the cold,
tepid, and warm baths are to our sensations, they all come essentially
within the class of sedatives ; each on occasion varying in its effects
with the extent of excitement, and the habits or the constitution of the
individual. There are many instances of successful result recorded
from the use of the warm bath, when it could be readily procured,
and the patient was immersed in it for a length of time, without his
having been obliged previously to rise or assume any other posture
than the recumbent one. Let me now ask you not to confound the
warm with the hot bath, which most people, and I am afraid the
vol. i.—33
446
DISEASES OF THE DIGESTIVE SYSTEM.
majority of medical men, also, habitually do. The bath above 98
or blood heat, is a hot bath; it is a powerful excitant, and is appli-
cable to a limited number of diseases, compared with those in
™hich the warm and tepid are so serviceable. But I cannot en-
large on this point at present; and shall merely refer to my work
(On Baths and Mineral Waters), in which the requisite facts
and illustrations are detailed. You may, perhaps, impatiently
ask: whether it is proper or safe to apply cold water to the skin,
already cold and sodden with sweat, in the more formidable and
advanced stage of cholera. I reply, that this has beendone;
and with more alleged success than attended the hot bath and other
stimulating applications to the surface. t .
The early use of a blister, while calomel was administered inter-
nally, was a favourite prescription of Mr. Corbyn and other Last
India practitioners. Some express a preference for the hot water
blister. As this means of vesication will be found serviceable in
other cases of violent disease, in which prompt counter-irritation
is required, I shall repeat here the directions for its use by Mr.
°" Have readv a square pad of flannel, which has pretty long tapes
sewed to it, and crossed so as to bring one end out at each corner
of the pad ; the pad should consist of six folds of flannel, ana
should be about five inches square. The water being ready at the
bed-side of the patient, either at the boiling point, or at such lessened
temperature as may be previously determined upon, the flannel pad
is to be dipped into it. The operator, holding the pad by the tapes,
should give it a smart shake on withdrawing it from the water, and
apply it immediately to the skin. By shaking out all the superfluous
water, in applying it, the patient is saved from any scalding which
might be occasioned by its dribbling down from the pad. It the
water be used at boiling heat, a momentary application of the pad
will in general be sufficient to cause vesication. This point, how-
ever, must be regulated by the judgment of the practitioner, accord-
ding to the state of the patient's skin." .
Irritation or partial cauterisation of the skin by a mixture ot
nitric acid two parts, with water one part, has also been employed.
Strong ammonia mixed with lard or tincture of cantharides, will
give rtse to speedy vesication. Flannels immersed in a liniment of
liquid ammonia and oil of turpentine, and applied along the spine,
and then a warm smoothing-iron run over them, have been found
powerful means of excitement by M. Petit in Paris. Moxa, caus-
tic, and the actual cautery, have, severally, been applied to the
same region, with a view of producing salutary reaction.
More promising than these extreme measures, of but partial
effect after all, is the application of dry vapour, by burning alcohol
or sulphur, to the skin; or simple watery vapour, of an elevated
temperature, similarly employed. Dry heat, when heat is proper,
has been preferred by most writers on the subject. Mr. Kennedy
recommends it in the first stage, after bloodletting, the warm
TREATMENT OF EPIDEMIC CHOLERA.
447
bath, and other remedies which are immediately demanded. He
directs that, as soon as the cramps are subdued or have received
a decided check, the patient, with all possible expedition, should be
removed from the bath, and placed between dry, heated blankets.
Dry heat should be further applied by surrounding his body and
limbs with bags of heated sand or ashes, bottles of hot water, &c.
In the application of heat externally, as in the use of hot or warm
drinks or stimulants internally, we shall be guided not a little by
the sensations of the patient, and the pleasure or discomfort which
he experiences from their use. Again I must remind you of the
superior efficacy of dry frictions, in a uniform manner, sedulously
continued, by a mixed movement of pressing and grasping the
skin and muscles beneath, especially of the limbs and back.
Stimulants. — When medicines of this class were resorted to in
cholera, it was found, after some experience, that those of the milder
kind were the best. Carbonate of ammonia, oil of turpentine, and
capsicum, are among the safest; the first, by its alkaline proper-
ties, and the two second, by their special action on the mucous
membranes, seem to meet the immediate exigencies of the case,
without either causing inflammation of these membranes or over-
exciting the nervous system. In yellow fever and in puerperal
peritonitis, in which the stomach is so often distressed, turpentine in
small doses has displayed a very beneficial operation. By many
its use in cholera was held to be equally advantageous. When I
speak of its special action on the mucous membranes, I would not
have you to overlook its secondary powerful action on the nervous
system, by which it is of such signal service in epilepsy ; for, by its
double operation in this way, we can explain its efficacy in cholera.
More will be gained, I think, by giving ten to fifteen drops on a
lump of sugar with a tablespoonful of camphor mixture every
fifteen minutes, or half hour, than in drachm doses at longer in-
tervals. In the form of enema it has also been employed, but with
contradictory results. It is no bad succedaneum to calomel, espe-
cially in the more advanced period of cholera, short of collapse.
Capsicum was a frequent adjunct to calomel, in the dose of two or
three grains, repeated every half hour or hour. Another, and a still
more popular remedy, both with the profession and the people ge-
nerally, was camphor, held in solution in alcohol. Its efficacy
when manifested is chiefly through the nervous tissue and general
nervous system. The camphor alone can hardly be called a sti-
mulant. Its use in this state, or in that of mixture, would bring it
more appropriately under the head of sedatives.
Sub-acetate of lead was used at the time by Dr. Harlan of this
city, and has more recently been highly extolled by Dr. Graves of
Dublin, as a remedy peculiarly adapted to the disease, when united
to small doses of opium. The latter gentleman used it largely on
the second attack of the cholera in Dublin in 1834. Unquestion-
ably sedative as the preparations of lead are, their utility must
be more doubtful in circumstances in which, although the neu-
rosthenia is great, there is also feebleness of the circulating ap-
448
DISEASES OF THE DIGESTIVE SYSTEM.
paratus, on which, in a remarkable degree, lead exerts a depressing
influence. Dupuytren made trial of sugar of lead nearly in the
manner recommended by Dr. Graves, viz., by giving it in combina-
tion with decoction of poppy-heads ; but with by no means satisfac-
tory results. Dr. Graves's prescription is: R. Acetatis plumbi, £)i.;
Opii, gr. i. M. ft. secund. artem massa in pilul. xii., dividend. In
thepremonitorv diarrhoea,oneofthesepills is to be givenat first every
hour, and afterwards, as the stools become less frequent, one every
six hours. In the completely developed cholera, and in the collapse,
give a pill every quarter of an hour. In two hours their effect is
perceptible ; then a pill is given every hour. Many take more than
40 grains of the acetate of lead in twenty-four hours. Dr. Vena-
bles, at the Cholera Hospital of Bethnal Green, tried the acetate and
other salts of lead, but without any good effect.
Although classed among tonics by systematic writers on Materia
Medica, the sub-nitrate of bismuth is much more sedative than
stimulating, if we take its operation in gastralgia and cramp of
the stomach, sickness, vomiting, &c, as a measure of its reme-
dial powers. Dr. Leo (Ideen und Erfahrungen, Sfc), who saw
much of cholera at Warsaw in 1832, extols this article in high and
extravagant terms. The dose which he recommends, is from two
to four grains every two or four hours. Dr. Lefevre, who mani-
fests much judgment in his appreciation of the value of various re-
medies, believes that much good may be derived from the prudent
use of the sub-nitrate of bismuth. There is scarcely any other
article which seems to quiet the cramps and check vomiting more
effectually ; and, when employed in moderation,, it does not produce
those unpleasant effects on the nervous system which follow the
use of some of the articles lauded for their curative powers in cho-
lera. In large doses we no longer obtain its sedative effect; it
then operates as an irritating poison, causing gastro-enteritis, cramps
of the hands and feet, disordered viscera, &c.
When still more active stimulation was deemed advisable, tinc-
tureof capsicum,aqua ammonia, orcamphorated ether was used. But
these should be given with a sparing hand. Mr. Bell, author of one
of the best works on the subject, (Treatise on Epidemic Cholera,)
mentions that some individuals, in whom the disease appeared to be
checked by them at first, nevertheless eventually died from their
poisonous operation. Part of the stimulating treatment will be
injections of hot saline solutions, turpentine, &c, and blisters over
the stomach, or to the nucha, and lower down on the spine.
Stage of Collapse. — It is now generally admitted that the
resources of our art are chiefly available, first and mainly, in the
forming stage of cholera, or that with some diarrhoea alternating
with constipation ; and, secondly, in that' of cholera proper, ere
it has reached the stage of collapse. Sedative remedies, and, occa-
sionally, depletion, which were chiefly indicated in the antecedent
period of the disease, are now either injurious or of slight efficacy;
and the small excitability left, forbids the use of strong and diffusible
TREATMENT OF EPIDEMIC CHOLERA.
449
stimulants. With some exceptions to be soon mentioned, the physi-
cian is reduced to the condition of an observer, a keen, an anxious,
and a discriminating observer, it is true ; but one who must wait
for the turn which nature may give to the disease before he attempts
decisive action. For want of a precise definition of the stage of
collapse, we cannot derive the aid which might be expected from
the numerous indications and details of cure laid down by different
historians of cholera. The best and most easily recognisable test
of collapse, is the cessation of pulse at the wrist, which will serve, at
the same time, to define our position in reference to treatment.
Of the external means of rousing the sensibility, or perhaps we
should say, of diffusing it, and blending the excitement of organic
with that of animal life, as far as the skin is concerned, assiduous
friction with the hands of assistants, if they are near and willing,
or with a flesh-brush or soft flannel, aided by dry mustard-flour,
will be the foremost. If more potential stimulation be deemed
advisable, it should be applied along the spine, by rubbing in some
active ammoniacal liniment, or warm spirits of turpentine, in the
manner already mentioned. It has been alleged, and I fear with
too much truth, by Recamier and others, that sinapisms and all
rubefacients are equally as unavailing as internal stimulants and
tonics in the blue stage of cholera. The remark is strictly correct,
if applied to those agents which cause inflammation of the skin, by
which this system is merely killed; there is neither diffusion nor
transfer of the excitement to the rest of the skin or to the internal
organs. Remedies of an opposite effect from stimulants have been
tried, at this time, with some alleged success. Their use by the
physician, and still more their toleration by the patient, shows that
the neurosthenia, so dominant in the active stage of cholera, still
remains, though in a minor degree, in that of collapse. I refer now
to the cold bath, and even frictions with ice, which have been em-
ployed by some practitioners. Recamier directed, that water of
the temperature of 58° to 60° F., should be poured over the
patient for a minute or two; he is then to be well dried and put
into a warm bed. Internally he gave, at the same time, a solution
of the sulphate or of the bi-chlorate ofsoda, according to the state
of the stomach, every quarter of an hour.
If the collapse has come on suddenly without much exhausting
discharges, or any depleting remedies having been tried, and the pa-
tient be strong, robust, and sanguineous, might we not incline favour-
ably to the recommendation of Mr. Annesley, to have recourse to
venesection from the arm, or local detraction of blood by leeches, and
after reaction has been established, but not, as he advises, while the
collapse lasts, give calomel and purgatives. Arteriotomy, by open-
ing the temporal artery, was had recourse to in a number of cases
by MM. Magendie, Recamier, Gendrin, and others, in Paris; but
without any benefit. Some spoonsful of rose-coloured blood, with
impaired fluidity, trickled out, as if from a venous tube. In two
subjects, the radial artery was opened a little above the articula*
3S*
450
DISEASES OF THE DIGESTIVE SYSTEM.
tion at the wrist, but the jet scarcely rose beyond the lips of the
wound; and, even after reaction came on, there was no hemorrhage,
properly so called, and a ligature of the vessed was dispensed
with. Still less justifiable was the course of some Berlin surgeons,
who opened the brachial, and even the crural artery. No human
being ought to be the subject of experiments of this nature.
During the time that the blood is flowing, frictions of the limbs
should be assiduously practised in the manner already directed,
and continued perseveringly until some signs of reaction are
evinced. A warm, saturated solution of common salt, well rubbed
in and on the skin, promises to be useful at this time. Commonly,
however, venesection will neither be necessary nor admissible in
the collapse of cholera. Dry and scarifying cups over the abdomen
have been well spoken of at this time. But of all the common
means relied on, injections have been most freely used; and we
may infer with relative success : of these the astringent kind are
preferred. Some recommend the sub-acetate of lead, in dose of
half a drachm dissolved in a little water, and then mixed with
a suitable measure of starch enema. This was the practice in
the Limerick hospitals. In other parts of Ireland, the same
astringent was administered in half scruple doses only, com-
bined with equal proportions of the sulphate of copper and alum.
Dr. Griffin's plan in cholera was, whenever there was much pain,
or the injections were too readily returned, or the patient appeared
to be on the verge of collapse, and it was important to prevent even
one other evacuation, to add a teaspoonful of laudanum to the
mixture of the solution of the sub-acetate of lead with starch. In
making use of the salt of lead alone, Dr. G. was in the habit of
repeating it after every evacuation, however frequent. A pre-
ference is indicated by Dr. Jackson (op. cit.) for rhatany root in
decoction. Hot saline injections have been used in India and other
countries, but with limited success.
Stimulants of great strength are not admissible, even in this stage
of such extreme prostration, in which they would at first seem to
be so imperatively required. The powers of life are too feeble to
bear to be forced into sudden action, even if they manifest suscep-
tibility to stimulation. Specific stimulation, as by an emetic, has,
in some instances, been productive of salutary effects in this, as it
has undoubtedly so often been in the earlier, yet marked and
violent stage of the disease. The mustard emetic had considerable
vogue in Great Britain. Three tablespoonsful of mustard-flower
are mixed with half a pint of water, and the whole given as speedily
as possible. A tablespoonful of common salt, and the same quantity
of mustard, was also a common prescription.
The most approved remedies by the mouth in the stage of col-
lapse, are the astringent; such as the sub-acetate of lead, the sul-
phate of copper. Dr. Mackintosh gave strychnia at first, in the
dose of a twelfth of a grain, gradually increased to a grain, every
hour or two; and he conceived that, besides checking the discharges,
it had the effect of shortening the collapse, and rendering the reac-
TREATMENT OF EPIDEMIC CHOLERA.
451
tion more permanent. The observation of Dr. Griffin on this class
of medicines is a sound one: — "On the whole, I should say, as-
tringents, from whatever class they may be selected, and whether
given by the mouth or in the form of enema, should form an
essential part of the cure of cholera. But none of them have yet
been proved capable of absolutely controlling or suppressing the
disease to an extent that one would confidently trust to in general
practice."
The stimulants, whose action was more immediately exerted on
the mucous membrane, with but little secondary excitement of the
arterial or even nervous system, were sometimes of service at this
time ; such as oil of turpentine, in a dose of a few drops at a time,
with half an ounce of camphor-mixture, or eight or ten drops of
tincture of camphor on a little sugar ; and capsicum, in a dose of
ten to fifteen grains. Dr. Hodge, of the University of Pennsyl-
vania, in his paper on Cholera (Am. Jour. Med. Scien., vol. xii.)
speaks very highly of capsicum.
Our leading object at this time must be to aid the natural powers
of the economy in the severe struggle in which they are engaged,but
not to exhaust them by over-excitement. One of the chief indica-
tions is, to restore animal heat; but this is better done by aiding the
organs, and especially the nervous and capillary systems, to develop
and diffuse it, than to introduce it, as it were, from without by ex-
ternal applications. They would suggest, what experience indeed
has confirmed, viz., the good effects of impressions made on the
region of the spine, with a view to rouse the nervous system of the
medulla to increased action. For this purpose, assiduous friction
should be practised ; or, running a smoothing-iron, of a moderate
heat, along the surface ; and these means failing, then to apply the
ammoniacal liniment in the manner already stated.
There is nothing so grateful to the patient in the stage of collapse
and in that tending to it, and really so beneficial at the same time, as
cold water, and, still more, ice kept continually in the mouth by the
introduction of fresh pieces of a small size (pellets), so soon as the pre-
ceding ones are dissolved and the fluid swallowed. Sometimes even
the swallowing of the pieces themselves was productive of much
good. The cold water treatment, as it has been called, was first
distinctly recommended, in Great Britain at least, by Dr. Hardwicke
Shute, who had charge of the Gloucester Infirmary, when cholera
patients were received there. Dr. Shute watched the progress of
cholera, uninfluenced by remedies, in order to ascertain the natural
efforts of the constitution to free it from the disease. A result of
these observations, and of his cold water experiments, is to enable us
to determine, with some confidence, the real value, or, perhaps I
ought to say, the absurd pretensions, set up in favour of certain
remedies, which, when not negative in their effects, are too often
mischievous. Dr. Shute does not assume any direct or con-
trolling power for cold water over the disease; but he believes
that it satisfies one of those conservative instincts which may be
452
DISEASES OF THE DIGESTIVE SYSTEM.
observed in every disease in which a natural effort at recovery is
made. He has shown, that, where a patient in the collapse of
cholera is left to the ministry of nature, no amendment can be ob-
served in the first five or six hours, except some diminution in the
purple hue of the extremities ; that in the next six or eight hours,
there is a manifest improvement in the countenance of the patient,
and more disposition to speak, but often no restoration of pulse nor
increase of temperature; that in some cases, the pulse may not
become perceptible for twenty-four or even thirty-six hours; that
from this period the pulse, the animal heat, and the secretions, are
very gradually restored; and that, at the end of forty-eight hours,
or the third day from the commencement of the collapse, the patient
is convalescent. In asserting that convalescence took place in all
cases of the cold water treatment without consecutive fever, Dr.
Shute generalized wrongly, from what, no doubt was the result of
his own personal observations. By others who have tried the cold
water in cholera, its use has been thought in some cases to cause
more violent congestion of the brain, and very high consecutive
fever. But, as Dr. Griffin, with equal plausibility and truth, has
remarked on this point: " the intense thirst which prompts to such
continued and excessive potations of cold water, is indicative, as I
have already stated, of alarming if not fatal disease: and hence,
they who struggle through the collapse with this symptom strong,
may be considered as the worst cases ; and among whom, of course,
we might look for the bad form of consecutive fever."
Dr. Shute tells us very distinctly, that his observations on the ad-
vantages of the cold water treatment are intended to apply exclu-
sively to the stage of collapse. Reliance on it in earlier stages
would be a criminal waste of time, and loss of opportunity for the
administration of remedies, without which the disease would most
probably run into collapse. The results of Dr. Shute's practice were
most encouraging; but they are not presented in such a definite
form as we could wish; that is, the proportion of cases of collapse
in the entire number treated are not given; although he tells us
that the first cases gave twelve recoveries out of fourteen ; the pulse
having been nearly imperceptible in all. Dr. Griffin endeavours to
supply the omission of Dr. Shute, by classifying the cases of this
latter gentleman, as follows: — Of 26 cases in the primary stage,
died 2, or 8 in 100 ; of 26 cases in collapse, died 18, or 7 in 10.
Total deaths in 52 cases, 20; or more than one-third. This would
be the most favourable result we could expect under the common
treatment; but Dr. Shute lost only 15 out of the 52; and if the
cases of collapse exceeded 26, his success was still more extra-
ordinary.
Swayed by an hypothesis, that there is a spasmodic stricture of
some of the important organs, as of the ventricles of the heart,
the intestines, and of the duct of the gall-bladder, and the urinary
bladder, as well as of the secreting organs, some of the British
practitioners have prescribed a tobacco enema. It was used in infu-
TREATMENT OF EPIDEMIC CHOLERA. 453
sion, made with half a drachm to a drachm of the tobacco in a pint
of water. Mr. Baird, of Newcastle (England), the originator, I
believe, of this practice, tells us, that if his pathological "opinion
had been at variance with the fact, the powerful remedy he had
adopted must of necessity have hurled the patient into the grave;"
although the cases which Dr. Kirk appends to his essay on cholera,
would seem to entitle it to some confidence —yet we cannot for-
get that the symptoms produced by an over dose of tobacco on a
healthy man, are nearly the same as those met with in the collapse
of cholera — with this difference, that in the former case the neu-
rosthenia is of very brief duration, or hardly perceptible, and is fol-
lowed by complete and deadly prostration. As a sedative relieving
not tetanic spasm, but the cause of this spasm, excessive neuro-
sthenia, tobacco may be entitled to our notice. Dr. Kirk says, I have
seen ten cases of the exhibition of tobacco myself, and though in
two life was not saved, yet in all distinct reaction took place ; and
all the symptoms were improved.
LECTURE XXXVI.
DR. BELL.
Treatment of Cjiolera (Concluded).—The saline treatment—General experi-
ence not in its favour—Saline injections into the veins—Delicacy and difficulty
of the operation—Treatment of the Stage of Reaction.—This and the diar-
rhceal stage less common in India—Convalescence. — Prophylaxis. — Chief
means are temperance, cleanliness, and equable temperature of the body—
Importance of early attention to the very first symptoms of the disease—Con-
nexion between cholera and other diseases—Influenza—Influenza and cholera
in 1780 and 1781—Both have pursued a similar course, including divergencies
from the main line—Prevalence of bowel affections in cholera seasons—In-
creased mortality at this time from other diseases—Scarlet fever with cholera.
The saline treatment, as it has been termed, which consists in the
administration of small doses of neutral and alkaline salts, did
not accomplish the wonders which were promised for it at the time.
In India and Eastern Europe, the sulphates and muriates of soda
were employed, and they acquired some reputation for the cure of
cholera, but did not by any means secure the general approbation
of the profession. By many they were declared to increase the
disease and to diminish the chances of relief from other remedies.
Dr. Stevens, influenced by his views of the pathology of cholera,
its dominant feature, in his mind, being the dark and otherwise
altered colour of the blood, as well as by the change in these
respects caused by the addition of certain neutral salts to this fluid
out of the body, strenuously urged their use as all-sufficient cura-
tive agents in cholera. Trials made in different parts of Great
Britain and in this country, have not corresponded with these con-
fident anticipations. Dr. Mackintosh of Edinburgh, Dr. Tweedie
and other practitioners of London, and different physicians in
454
DISEASES OF THE DIGESTIVE SYSTEM.
Liverpool and Dublin, have tried it without success. Dr. Griffin
states that it was employed in every hospital in Limerick ; but it
proved in a great many of them a failure. The most advan-
tageous, and in some measure extraordinary, exhibition of the effects
of the saline treatment, as suggested by Dr. Stevens, was in the
practice of Mr. Wakefield, at the Cold Bath Field Prison, and of
Mr. Bossey, surgeon to the Convict Hospital-ship at Woolwich. By
the first showing of the practice at the former place among cholera
patients, the case stood thus: — 50 had bowel complaints, with
some degree of irritation of stomach ; fluids ejected, deficient in bile;
31 with the above symptoms; cramps to a greater or less degree; 19
are described as malignant, having been seized with the disease or
fallen into collapse in the cold wards of the prison during the night.
The population in the prison was about 1300. Out of the first 50
cases none died ; out of the 31 cases 2 died ; out of the 19 malig-
nant, 1 died; in all, 3 deaths, or 97 recoveries, in 100 cases. It
has been properly objected to this statement, that the introduction
of 50 cases in the diarrhceal or premonitory stage is not correct,
since the treatment was not anywhere a matter of difficulty, nor
can its success be received as a test of that proper in true cholera,
The next 31 cases had cramp with diarrhoea, a state of things
certainly demanding vigilance and treatment, but hardly entitling
them to be called cases of epidemic cholera. Still there were two
deaths in this number, — and it is probable that under the calomel
treatment not one would have been lost. A want of specification
of the real meaning to be attached to the term malignant, and the
group of symptoms characteristic of it, must prevent our knowing
whether they were approaching to or in collapse. If, however, as
Dr. Griffin has suggested, we were to take all the supposed cholera
cases together, or those compared in the second and third sections,
they would amount to 50, of whom three died, or six in a hundred.
This result is not more successful than that of the common treatment
tested in several hundred cases, in various hospitals, and under dif-
ferent physicians. " In a second incursion of the epidemic, which
Dr. Stevens describes as more violent than the first, there were 105
cases, and 15 deaths: if they were all absolute cholera cases, with
perfect suppression of bile and urine, there was, even here, as great
a mortality as appeared in the most unfavourable reports of any of
the Limerick hospitals, excluding the pulseless or cadaverous
cases." — Griffin.
Mr. Bossey has made more attempts at classification. He had
at first 65 cases, out of which 9 proved fatal; afterwards 61, out
of which 11 died ; in all 1*26 cases, — 20 deaths ; rather more, says
Dr. Griffin, than the proportion lost on the average of hundreds of
cases in the most unfavourable reports of any of the Limerick hos-
pitals, excluding the cases lost in pulseless collapse ; but less by
half than the mortality in those hospitals, if all the admissions are
taken together; for in that case, 40 would have been probably the
proportion of deaths in 126 cases, instead of 20. But the extra-
TREATMENT OF EPIDEMIC CHOLERA. 455
ordinary part of Mr. Bossey's statement, is the reporting out of
149 cases, 23 of which were of premonitory diarrhoea, no less than
126, or, in fact, the whole number of true cholera cases, as those of
collapse. Can we credit, that, in a place where a man who had
three evacuations while at labour was immediately placed under
observation, and the dejections examined, all the true cholera cases
should have run into collapse, unarrested by the treatment which
must have been instituted for them. The contrast is a strange one.
The most uncommon want of success in the first instance, allow-
ing in all the supervention of collapse, and the most singular and
unparalleled success in curing all these collapses except twenty.
There is yet one other report from an anonymous source, at
VVarrington (England), which states that out of 108 cases, 78 were
treated in various ways, and all without exception died; whilst of the
remaining 30, which were placed under the saline treatment, only 2
were lost. There is a still more violent contrast in this statement,
than in that of Mr. Wakefield, already commented on. All deaths
on one side — nearly all cures on the other.
After proper abatement for the extravagance of eulogy in favour
of the saline treatment, we may receive it as, on occasions, adjuvant
to other and more active means, such as venesection, and inter-
mediate between the doses of calomel, or following the operation
of an emetic. The formula recommended by Dr. Stevens is, as
follows: —
Bicarbonate of soda, Jss.
Muriate of soda, >}i.
Chloride of potassa, gr. vii.
Mix, and dissolve in a tumblerful of water ; to be given every hour,
until there is evident and well-established reaction. External irri-
tants and frictions, together with injections of hot salt and water,
have, in some cases, been used at the same time.
The tranquillising effects of carbonate of magnesia and bicar-
bonate of soda, in small doses, — as twenty grains of the former
and ten of the latter, — I have repeatedly observed, both in epi-
demic cholera and in analogous derangements of the digestive
canal.
Aqueous and Saline Injections into the Veins. — In speaking of this
kind of medico-chirurgical treatment last, I believe that I give
it the place to which it is entitled, whether regarded on the score
of safety or of remedial value. The hypothesis on which it is founded
is briefly told. It is, that, owing to the immoderate fluid discharges
from the digestive mucous membrane and the skin, the blood-ves-
sels have parted with an undue quantity of serum, by which the
blood, now thick and fibrinous, becomes prone to coagulate in the
great vessels and cavities of the heart, and cannot be circulated —
hence, asphyxia, with its concomitants of the collapsed or blue stage.
The indication, therefore is, we are told, to replace, by artificial
means, this loss. Unfortunately for this speculation, it happens in
many cases, that collapse is not preceded either by copious serous
456
DISEASES OF THE DIGESTIVE SYSTEM.
exudation from the skin, nor discharges from the stomach or bowels
— of course, the blood cannot, in such cases, have lost its fluidity,
or rather, its changes cannot be the effect of the loss of its watery
and saline parts, or of serum. At no time is there a well ascer-
tained or admitted proportion between the prostration of the func-
, tions generally, and the discharge of serum by the channels just
mentioned. The change in the blood is, in fact, an effect of pre-
existing derangement of important organs, those to which we have
already directed attention, viz., the digestive and respiratory mucous
membranes and the skin; and unless we alter and amend their
morbid condition, by appropiate means, they will neither act or be
acted on by the blood with any chance of permanently good effect.
Our attempts to modify directly one of these surfaces — the respi-
ratory mucous, or that of the lungs, by means of oxygen, nitrous
oxide gas, chlorine, ammonia, or ether, have not, indeed, proved
very encouraging. The natural hygienic agent of fresh cool air,
is, after all, that best adapted to the condition of the lungs, and one
which, in the hurry and eagerness to afford relief, and the crowding
around the patient of anxious friends, and intrusive and idle spec-
tators, is too often lost sight of. There remains the other two sur-
faces to be acted on by agents, and in modes already fully pointed
out.
Some of the objectors to the use of saline medicines by the
mouth have expressed a favourable opinion of a more direct
method of introducing them into the circulation. This has been
done by injections into a vein previously opened for the purpose.
Before resorting to so hazardous and daring a practice, we ought
to ask ourselves whether, 1st, in the particular state of the patient
at the time, there is no other remedial means which presents any
fair chance of reviving him 1 And ^Jdly, if this practice do not,
though affording temporary relief, introduce fresh causes of subse-
quent disease, and more certainly seal the patient's final doom ?
The notice of this practice, and the commentaries on it by Dr.
Griffin (op. cit.), are so pertinent, that I shall make use of them for
your benefit on the present occasion.
" Transfusion of blood into the veins of persons dying of hemor-
rhage was long since proposed and practised in this and other
countries; but Magendie was the first who proposed, and, I believe,
ventured to inject, water, or medicated fluids, into the veins as a
cure for hydrophobia, many years back. M. Hermann, of Moscow,
more lately, on observing the quantity of aqueous fluid ejected from
the body in cholera succeeded by collapse and death, suggested the
injection of warm water into the veins, to preserve the circulation
and volume of the blood which remained ; and this suggestion wras
subsequently carried into execution by Professor Delpech, of Paris,
though without any success. The practice in this country, however,
did not originate in anything which had been done on the continent;
it arose entirely out of the ingenious and clever papers of Dr.
O'Shaughnessy, on the analysis of the blood of cholera patients as
TREATMENT OF EPIDEMIC CHOLERA. 457
compared with that of healthy persons. As it appeared that the great
loss which the circulating fluid sustained, and which seemed to be
the immediate cause of collapse, consisted of water, albumen, and
saline matter, it occurred to the late Dr. Latta, of Leith, that death
might be protracted, if not altogether prevented, and other reme-
dies become available, by directly restoring to the circulation the
materials of which it was robbed by the disease. He instantly put
the remedy to the test, and his skill and ability are displayed in
nothing so strongly as in the fact, that his first inexperienced ap-
plication of it in the cure of cholera was more successful than any
trials which were subsequently made, when there had been exten-
sive experience of its effects. He saved three patients out of nine
in his first set of cases, and five out of seven in his second ; of which
number, on the whole (16 cases), it is acknowledged by all prac-
titioners in and about Edinburgh, two would not otherwise have
recovered, taking the ordinary mortality in such states there as the
standard. Injection by the veins seemed, notwithstanding the early
encouragement given by these cases, to be losing credit towards
the decline of cholera, after having been very freely tried; and it
is well worth consideration, whether this failure of reputation is
founded on judicious inferences.
"All the published cases of injection of the veins which I can find
amount to 282, among which there were 221 deaths, and only 61
recoveries. As all these cases were in collapse, sometimes very
deep and protracted, before this treatment was employed, it only
remains to see what portion might fairly have been expected to
recover if no such remedy had been resorted to. According to the
statements of Drs. Christison and Mackintosh, not more than one in
twelve recovered, in Edinburgh, under any previous mode of treat-
ment; and even this calculation of recoveries is looked upon by the.
latter gentleman as too high. Sixty-one recoveries in 282 cases
gives, on the other hand, somewhat more than two recoveries in
ten. It may be said, perhaps, that our own reports of the Limerick
cholera hospitals give an amount of two and a half, and even three,
recoveries out of ten. The average of all the reports from hospi-
tals in that city, however, does not exceed, if it indeed reaches, the
average recoveries by venous injections. At the same time it
should be considered, that no fair comparison can be instituted
between cholera cases occurring among the half-starved pauper
population, crowded together in the lanes of Limerick, with those
which occurred among the well-fed artizans and labourers of
Edinburgh.
" It can hardly be necessary to remind the reader of a fact re-
ferred to when treating of the mortality of the disease, that persons
living on a poor vegetable diet, though much more liable to fall into
cholera than those living on a sufficiency of animal food, recovered
nearly in the proportion of two to one comparatively. In Limerick
the recoveries from collapse among the wealthier classes of the
population, in private practice, were, I should say, quite as low in
vol. i.—39
458 DISEASES OF THE DIGESTIVE SYSTEM.
amount as the proportion named in the Edinburgh report; and even
in the hospital reports of St. Michael's Parish, the one in which all
the wealthy portion of the population of Limerick reside, and where
the class of patients admitted consisted chiefly of well-fed servants
and small shopkeepers, the average recoveries from collapse did not
exceed one in ten, while in every other hospital in the city it ex-
ceeded two in ten. The legitimate conclusion from all I have
stated is, that the average recoveries from collapse by injection
of the veins has far exceeded the amount by any other treatment,
in the same district and under the same circumstances, and has
equalled the utmost proportion which has been obtained on the
average of large numbers, in any district and under any circum-
stances,"
" There are certainly two points of great difficulty in applying
injection by the veins : 1st, a difficulty in ascertaining when enough
of fluid has been thrown in; and 2dly, in selecting the most oppor-
tune period of the disease for the operation. With respect to the
first, Dr. Lawrie's recommendations seem exceedingly judicious:
he says he would cease injecting whenever the pulse was steadily
improved — whenever the patient fell asleep, whether the pulse
were improved or not — whenever the respiration was much hur-
ried— and whenever acute pain was felt in the abdomen. In the
first instance, because injection had done all that it can do; and in
the others, because it had begun to do harm."
Dr. Mackintosh employed a solution of Jss. of common salt, 9iv.
of sesqui-carbonate of soda in ten pints of water, of a temperature
varying from 105° to 120° F.; this solution was injected slowly,
half an hour being spent in the introduction of the ten pints.
The most favourable time for injection would seem to be at the
earliest period of the collapse, or just previous to its becoming
quite decided. It is essential, as Dr. Griffin justly remarks, as soon
as the patient is a little revived, to resume the active medical
treatment, as if no such operation had ever been performed, and
we were only anxious, as before, to prevent the occurrence of
collapse.
The greatest nicely and delicacy of manipulation are required in
the introduction and adjustment of the injecting syringe, to prevent
phlebitis.
Treatment of the Stage of Reaction, or of Cholera Fever. — It would
be well if we could almost forget the existence of the previous
stage of prostration and collapse, if it so far occupy our minds as
to induce a dominant idea and fear of debility, and lead to the ex-
hibition of stimuli, in the reaction, or third stage. It is in the com-
plication of symptoms, by phlegmasia of the gastro-intestinal sur-
face, and oppression of the brain at this period, that the injurious
effects of the unrestricted use of brandy and laudanum in the early
stages, including the period of collapse, become evident. At this
juncture we must draw upon the resources of rational pathology,
and be guided in our practice by the symptoms of lesion and inflam-
mation of the organs. Patience and firmness are now virtues to
TREATMENT OF CHOLERA FEVER.
459
be put in requisition — the former to prevent undue haste in forcing
up the system to an imaginary standard of strength by stimuli, the
latter to induce perseverance in judicious local depletion and a
cooling practice, in order to moderate the excitement of particular
organs and prevent disorganizing inflammation in them — the sto-
mach, intestines, or brain.
In two important particulars there would seem to have been a
difference in the course and features of the epidemic cholera in In-
dia, from that occurring in Europe and in this country. These are
in the absence, or comparative infrequency of premonitory symp-
toms, as diarrhoea, &c, and of secondary fever, in India. When
this latter did occur, it partook very much of the nature of the com-
mon bilious attacks of those latitudes. There Avas hot, dry skin;
foul, deeply furred, dry tongue ; parched mouth; thirst; sick sto-
mach; depraved secretions; restlessness; watchfulness; and quick,
variable pulse, sometimes with delirium, stupor, and other marked
affections of the brain.* Generally, when the disorder proved fatal
after having reached this stage, it assumed the characters of low or
typhous fever, with black, hard, and furred tongue, teeth and lips
covered with sordes. In other cases, again, the secondary fever
ran a somewhat different course. The reaction was marked by
an unusual degree of energy—the brain was evidently affected;
pulse as high as 120; great heat, especially in the large cavities,
and distressing thirst. To this state of excitement that of collapse
quickly succeeded. Among other symptoms at this time, was com-
plete absence of the former unnatural irritability of the stomach.
In Europe, and in this country, the consecutive fever of cholera
was more common, and put on great varieties, the chief of which,
however, were due to the former habits and constitution of the indi-
vidual, and the kind of treatment to which he had been subjected
during either the second, or the subsequent collapsed stage. The
intemperate, the free liver, those prone in former times to phleg-
masite of the organs, are in danger from this reaction, as are also
those who have been freely stimulated by brandy, &c, during the
first periods of the disease. In speaking of the stimulating prac-
tice of Magendierin one of the Parisian hospitals, a writer in the
Archives Generates says; "this treatment has been followed by a
degree of reaction which it is often difficult to control. The cir-
culation excited by alcohol, soon produces congestions in the head
and digestive apparatus; and more than one patient sank with de-
lirium, and afterwards deep coma. This congestive state, local
and general depletion, were always as inadequate a remedy, as
the application of cold to the head, and the most active revellent
irritants to the feet."
Galvanism, electro-puncture, inhalation of factitious gases, are
remedies of experiment more than of available use, even if their
value were greater than has as yet been shown.
* Bengal Reports, p. 56.
460
DISEASES OF THE DIGESTIVE SYSTEM.
I must not conclude the subject of the treatment of cholera with-
out mention of the change of practice in India, or at least in Cal-
cutta, of late years, in this disease. Mr. Martin (OfficialReport on
the Medical Topography of Calcutta, with Brief Notices of its Pre-
valent Diseases, Endemic and Epidemic, 1839) tells us that the
plan of copious bloodletting, followed by full doses of calomel and
opium in the outset of the disease, and topical bleeding and mercu-
rial purgatives in the reaction, which was found most successful in
the early periods of cholera visitation in 1817 and 1818, is now
either inefficient or injurious. Mr. Martin adds a remark respect-
ing the stage of collapse, not very encouraging or flattering to
medical science at its favoured seats : " I repeat, that our European
and transatlantic brethren have not helped us through any of our
difficulties in the treatment of this stage of the disease."
Convalescence. — The diet of the convalescent should be simple,
yet nutritious, regard being paid, in the selection of articles, to for-
mer tastes and habits. With some a milk diet, consisting of rice and
milk, or bread and milk, custard, &c, answers very well. In most
instances the lighter animal broths—such as beef tea or chicken
water, are preferable, to be soon followed by the meats themselves —
chicken, mutton-chop, or beef-steak, with bread and rice. The
rigorous prohibition of stimuli during the period of the disease, does
not extend to that of convalescence. Hence, in those whose sto-
machs have long been accustomed to other than simple nutritive ex-
citement, we allow condiments to their food ; such as pepper, capsi-
cum, and mustard. The habitually intemperate, when such recover
from cholera, and the free liver and gourmand, may be indulged in a
little wine, of that kind which can be obtained the purest. Adulter-
ated as Port so generally is, it must not be the one selected. But by far
the safer practice, whether we regard the present period, or future
results, is to administer to these persons a simple bitter, and few are
so good as the sulphate of quinia, or, in its stead, chamomile tea, in-
fusion of columbo, &c, in the day, and where wakefulness is present,
to give an opiate at night. By pursuing this course, we carry the
patient entirely through the period of convalescence, without minis-
tering to his depraved appetite for strong drinks, and, in fact, we
rather wean him from his evil habit — certainly furnish him with no
excuse for after indulgence, when he is discharged from our care.
Prophylaxis. —The means of preventing an attack of cholera
readily suggest themselves to the reader, after he has been made
acquainted with the causes of the disease. The preventive and pre-
cautionary measures will consist in a careful avoidance of those
situations in which the air is foul, stagnant, and loaded with mois-
ture, and of everything which has a tendency to reduce the ener-
gies of the system, either by over excitement or direct debility, to
impede the functions of the skin, or to induce disturbance of the
digestive canal.
The first and most important rule for the avoidance of cholera is
to preserve habits of strict temperance — no excess of any kind is to
CHOLERA IN CONNECTION WITH INFLUENZA. 451
be indulged in, nor experiments made of what the body will endure,
either in the way of abstinence or repletion.
The next rule is to observe the strictest cleanliness of person,
clothes, and habitation.
The third rule is, to preserve the body, by means of warm
clothing, from the sudden impression of cold following heat, or cold
with moisture. More care is demanded at this time than under
ordinary circumstances, and garments of cotton, or still better of
woollen, next the skin, should be worn, even though they may be
thought a little too oppressive. The feet should, above all, be pre-
served warm and dry.
An avoidance of late hours, crowded assemblies, long continued
mental exertion and depression, will be so many circumstances
worthy of attention by those who would diminish the chances of
an attack of cholera.
Another important rule is not to sleep in damp beds, or in low,
damp, ill-ventilated apartments, and to shun exposure to the night
air, especially that of swampy or marshy districts.
In fine, no medicine ought to be taken during the prevalence of
cholera in a place, without proper medical service. All pretended
preventives and specifics for the disease, offered by advertising
quacks, ought to be ranked among the most effectual means of
inducing an attack of the disease. During the prevalence of the
epidemic at Montreal, the authorities very judiciously forbade
apothecaries making up and vending, without medical prescription,
the medicines and nostrums eagerly sought after, with the hope of
preventing or arresting the disease. Similar restrictions were
recommended in New York. Time is invaluable in cholera, and
much of the success in curing the disease will depend on the early
administration of suitable remedies. But urgent as may be the de-
mand for assistance, it ought not to be rendered at mere hazard —
with the risk often of increasing in place of diminishing the danger
of the patient.
The connection between cholera and other diseases merits our
notice. Its precursor, in a very remarkable manner in Europe and
America, was influenza, which pursued, also, very much the same
course as the cholera in those continents. This order of appear-
ance of these two great epidemics has occurred once before in India,
in the latter part of the last century; but at that time the cholera
did not pass that Peninsula, nor indeed overspread it then as it did
subsequently. But for English rule in parts of India at the period
referred to, we should be at this day quite ignorant of such remark-
able occurrences as are described by some of the medical writers
who were on the spot at the time, or who had early and direct
cognizance of the facts from the natives themselves. I shall first
describe the course of the influenza, in the words of Dr. Williams,
and then mention some of the particulars on record of the cholera,
which, about the same time, committed such ravages in parts of
India.
39*
462
DISEASES OF THE DIGESTIVE SYSTEM.
" In the month of September, 1780, an epidemic influenza broke
out in Bengal and on the coast of Coromandel, and continued to pre-
vail in India so long a time that the British army beseiging Negapatam
was attacked by it in November, 1781. Whether it spread thence
to China, or co-existed there, is unknown, but it prevailed in that
latter country also in 1780. From India, or, perhaps, more pro-
bably from China, its extreme eastern limit, it appears to have
made its way to the west through Upper and Central Asia, to To-
bolsk, a city of Russian Tartary, situated about 48° north latitude.
From Tobolsk, it continued to advance in the same westerly direc-
tion till it broke out in Moscow, a distance of not less than 1200
miles, in December, 1781 ; whence it spread to St. Petersburgh in
February, 1782 ; and these are almost the precise stages by which
the cholera penetrated into Europe in 1831-2. From St. Peters-
burgh it continued its progress westward, so that in April it infected
Denmark, and at the latter end of April in the same year, it ap-
peared at Newcastle-upon-Tyne, almost the identical spot where
cholera first appeared in England. It was certainly in London the
second week in May, and, as in cholera, without any of the interme-
diate towns being infected.. In Scotland and in Ireland,it appeared
rather later than in England. It is also exceedingly remarkable
that this epidemic, like the cholera, prevailed earlier in England
than in France, for it did not reach Paris till June. Again, it is
singular that, having reached France, it commenced a short retro-
grade course to the south-east, passing from that country into Italy;
there it prevailed in July and August, and also in Spain and Por-
tugal, which it attacked in August and September. A course pre-
cisely similar to that of cholera."
Continuing the account from where Dr. Williams stops, I shall
direct your attention to the fact, that in the spring of 1781, as
we read in that most industrious chronicler of epidemic visitations,
Mr. Noah Webster, the influenza prevailed in North America.
At the very time of the influenza prevailing in India, it is on
record that cholera destroyed, first at Hurdwar in 1780, 20,000
persons, while a festival was held there; and in 1781, assailed, in
its most malignant form, a division of Bengal troops then stationed
at Ganjam, the theatre of this terrific disease thirty-seven years
afterwards. An admirable account of cholera, which leaves no
doubt of its identity with that since prevalent, was given by Mr.
Curtis, who described it as spreading, in the year 1782, in Sir E.
Hughes's squadron, then stationed in the East; and as having
arisen from communication with an infected port in Ceylon. In
the Madras Reports, it is stated to have raged at Arcot in 1787,
and was accurately described by Girdlestone.—(See Appendix to
all the Material Facts, &c.)
The epidemic cholera which has gone round the globe, was in
Europe and America preceded by influenza. That the course of
this latter, as already described, " is not accidental, but according
to some definite law, seems proved by the fact of the influenza of
CHOLERA IN CONNECTION WITH OTHER DISEASES. 453
1830-1-2 having taken a similar course in Europe, and having
likewise passed the Atlantic. This epidemic immediately preceded
the attack of cholera, and is traced as far back as Moscow, whence
it spread to St. Petersburgh, and in eight months had infected all
Germany, and reached London ; at this point the stream bisected ;
one branch taking the usual south-east direction, infected Italy and
subsequently Gibraltar, reached America. One remarkable circum-
stance connected with the origin of this distemper is, that it pre-
vailed, also, in Australia." It seems to belong to the features of
great epidemics to affect some particular geographical range; as in
the instances of the great plague in the reign of Justinian, and the
black death or black pestilence of 1348-50, and the Egypt sweating
sickness which was months in Shrewsbury, but staid only three days
in Amsterdam, attacking 500 in a night in that city.
Along our Atlantic border, influenza prevailed in 1831-2 with
great intensity; the mortality was considerable, especially among
the aged and among those in the better walks of life. It was here,
as it was in the valley of Mississippi, the precursor of cholera.
The diseases which are more particularly blended or alternated
with cholera, are bowel affections in general, fevers of various types,
and scarlatina. Some persons have argued that the mortality from
other diseases was less in the year in which cholera made its inva-
sion : but this is an error. If the remark were intended to apply
to the year following the epidemic, it would be in general correct.
In India and in Great Britain it seems to be proved that the amount
of sickness and of mortality was greater than usual; throughout
northern India the epidemic year was remarkable for remittent and
autumnal intermittent fevers, diarrhoea, dysentery, and small-pox.
The medical returns of the Madras army, also, show a marked
increase of disease generally during the years that cholera raged so
severely in that presidency, the proportion being from one-fifth to
one-sixth greater than usual. In Europe, opinions have been
discrepant on the subject. In Russia, for example, it was thought
the total number of deaths was not increased. In France, however,
the mortality in the cholera years greatly exceeded that of ordi-
nary times. In the north of England it was said that typhous
fever disappeared: but in London this disease raged with great
violence, assumed new characters, and was more fatal and in-
tractable than it had been for many years: according to the bills of
mortality, the burials in 1832 exceeded those in 1831 by 5098, or
more than one-fourth (Williams, op. cit.).
Our home experience on this point is well represented in the
following table, prepared by Dr. Emerson, to whose partiality for
medical statistics, and industry in arranging and combining ma-
terials which would otherwise have remained isolated, and in a
measure useless, his professional brethren are much indebted. It is
called a
464
DISEASES OF THE DIGESTIVE SYSTEM.
Table showing the prevailing Diseases independent of Cholera ; what influence it
exerted over them ; and the rate of their Mortality.
DISEASES. 1831. 1832.
June. July. Aug. Totals. June. July. Aug. Totals.
Consumption, Convulsions, Cholera Infantum, Diarrhoea and dysentery, Fevers, .... Scarlet fever, Inflammations in general, . Inflammations in the chest, . Inflammations in the abdo-men, .... Dropsy in the head, . Do. in the chest, . Do. in general, Debility and decay, . Apoplexy, AU diseases, (still born de-ducted,) All diseases, (malignant cholera deducted,) Excess in mortality of 1832, Excess after deducting mor-tality from cholera, 35 18 45 18 17 5 32 16 16 22 2 6 28 9 294 294 41 26 132 28 24 29 19 10 9 22 4 12 33 8 467 467 33 29 82 49 35 10 26 8 18 29 6 11 29 4 490 490 109 73 259 95 76 24 77 34 43 73 12 29 90 21 1251 1251 44 28 25 15 31 23 28 16 12 5 2 3 16 4 369 369 75 75 52 29 131 47 35 17 43 15 28 33 4 10 45 8 785 689 318 222 73 39 157 P3 65 14 29 7 22 23 3 9 8 7 1431 618 941 428 169 90 316 145 131 54 100 38 62 61 9 22 89 19 2585 1676 1334 425
The mortality in the year subsequent to that of cholera, in 1833,
was less by 2259; and even when allowance is made for the mor-
tality from the epidemic cholera, in 1832, the amount still falls
short by 1311 of that in this latter year. The rates of diminution
are particularly evident, under the heads of Fever, Bowel Com-
plaints, Inflammations and Measles (Dr. Emerson.—Am. Jour. Med.
Science, vol. xv., p. 267).
The shortness of the period of its visit, in most places, may
explain why there has not always been a closer relation or inter-
change of features between cholera and those endemic diseases.
Dr. Drake, (op. cit.) did not find that so many cases of intermittent
and remittent fevers commenced and terminated with that febrile
type, as might have been expected, though the number was not a
few — considering that the epidemic invaded Cincinnati, in the
season when those fevers prevailed. It is worthy of remark, that
in India and the United States there has been a more manifest
affinity between epidemic cholera and paludal fevers, as far at least as
regards their localities, and the exposure to atmospherical influences
of the persons who have suffered, than between it and febrile, or in-
deed any other disease, except those directly affecting the mucous
membrane of the digestive tube, as set forth in the preceding table.
CHOLERA INFANTUM.
465
Somewhat to our surprise in Philadelphia, the first cases, and the
largest proportion afterwards in the hospitals, came from the out-
skirts of the town and open lots adjoining the Schuylkill, rather than
from the narrow streets and closescontiguoustothe Delaware, where
we were all on the look out, in expectation of the disease. We had
forgotten the Indian cholera, and had fixed our attention on the
badly built and badly ventilated and filthy houses, and equally filthy
population, of the parts of European cities which suffered most.
The scarlet fever prevailed to a great extent in Philadelphia
during the cholera year, as also measles. The deaths from the
former were 307, nearly a third of the mortality caused by cholera;
those from measles were, in the same period, 118. Throughout
the valley of the Ohio, scarlatina prevailed at the same time with
cholera; and was, as we learn from Dr. Drake, a coadjutor with it in
the work of death; but their attacks were made in alternation, and
seldom together. In New Orleans, cholera and yellow fever were
in conjoint operation for a while.
LECTURE XXXVII.
DR. BELL.
Cholera Infantum.—Is endemial in the United States—Scarcely noticed hy the
English and French writers—Dr. Cheyne's atrophia ablactatorum resembles
it.— Symptoms—Ushered in generally by diarrhoea—state of the circulation—
skin—discharges from the bowels—thirst—nervous symptoms—state of the
brain—expression of the countenance.—Prognosis.—Causes—High heat of
Bummer—Irritation of teething—Errors of regimen—Predisposition—Anatomi-
cal lesions — chiefly disease of the mucous follicles of the intestines—softening
of the gastro-intestinal mucous membrane—Billard's case—Entero-mesenteric
fever of Serres and Petit,—dothinenteritis of Bretonneau.
Cholera Infantum, the subject of the present lecture, is a disease
which may be considered as endemial in a large portion of the
United States. In some of its features, including symptoms and
anatomical lesions, it bears a no small resemblance to epidemic cho-
lera ; for, although generally less rapid in its course than the latter
disease, it sometimes runs to a fatal termination in twenty-four
hours. From European writers we need not hope to procure much
information, either as to the nature or treatment of infantile cho-
lera. Neither by Underwood, nor by his annotators, Drs. Merri-
man and Marshall Hall, is it even mentioned. M. Billard, in his ex-
cellent work (Treatise on the Diseases of Infants), after saying,
that the cholera of infants is not generally noticed in that climate,
proceeds, after due acknowledgment, to give the detail of the symp-
toms from Dr. Dewees's Treatise on the Physical and Medical
Treatment of Children. It is true, that he regards cholera as pre-
senting the symptoms of a violent gastro-enteritis, similar to that
which he had just described. M. Billard adds : " and although cho-
lera [infantum] is rare in our country, yet there sometimes exist
466
DISEASES OF THE DIGESTIVE SYSTEM.
instances of it, particularly in our hospitals, where children are
brought that are born in the midst of the most frightful misery,
scarcely protected by a few rags from the inclemency of the atmo-
sphere."
When yet a young student, I read with much satisfaction the small
essay by Dr. Cheyne on Atrophia Ablactatorum, or Weaning-brash,
a disease which, as described by this able writer, resembles more
nearly infantile cholera than any noticed in British productions
which have fallen under my notice, except the article Cholera
Fever of Infants, by Dr. Copland (op. cit.).
In many points, Dr. Cheyne's description is applicable to the
American infantile cholera ; as where he says, " The disease is
more frequent in children who have been weaned before the eighth
or ninth month, and, in particular, in those who, in consequence of
some accident happening to the nurse, have been weaned ab-
ruptly." In representing it as a disease of the antumnal months
which he seldom, comparatively speaking, saw before the summer
solstice, nor after the end of the year, and as most general in sultry
seasons, — he gives a parallel etiology, as far as regards atmo-
spherical distemperature, to that of our cholera. In the climate of
Britain, unlike our own, little uniform heat is experienced before
the summer solstice. The coincidence of weaning-brash with the
period of first dentition is another feature of resemblance. Dr.
Cheyne also mentions, that " the first symptom is a purging with
griping pain, in which the dejections are wholly of a green colour.
When this purging is neglected, and after its continuing for some
time, there is added a retching, with or without vomiting; when
accompanied by vomiting, the matter brought up is frequently
coloured with bile.
" These increased and painful actions of the alimentary canal
produce a loathing of every kind of food, and naturally are at-
tended with emaciation and softness of the flesh, with restlessness,
thirst, and fever." A physiognomical trait, which we so generally
notice in the subjects of our cholera, is also mentioned by Dr.
Cheyne : it is the settled discontent of the features, and also a con-
stant peevishness, the effect of unceasing griping pain, expressed by
the whine of the child. The discharges, he tells us, are sometimes
of a natural colour, at other times slimy and ash-coloured, and
sometimes lienteric. " Towards the end of the disease the ex-
tremitjes swell, and the child becomes exceedingly drowsy." The
anatomical lesions noticed by Dr. Cheyne are, singular contrac-
tions from the stomach downwards, with one or more intus-suscep-
tions, and the liver exceedingly firm, larger than natural, and of a
bright red colour, and the gall-bladder filled with a dark green
bile.
I refer the more willingly and freely to this little treatise of Dr.
Cheyne, from a feeling of gratitude for the assistance which I think
I derived from it very early in my professional career, and from
its being the only English work that described a disease analo-
SYMPTOMS OF CHOLERA INFANTUM.
467
gous to infantile cholera, to which, even at that time, I was not a
stranger. Dr. Armstrong's (Diseases of Children) description of
the watery gripes is analogous to that of cholera infantum.
Dr. Copeland, whilst referring to his personal experience of the
disease in London, and more particularly at the Children's Infirm-
ary, of which he was physician, draws, notwithstanding, nearly all
his description and the chief parts of its treatment from American
writers, and particularly Drs. Rush and Dewees. Drs. Evanson
and Maunsell (A Practical Treatise on the Management and Dis-
eases of Children, First Ed.) do indeed describe a disease under
the title of cholera infantum, but it is meagre in its details both of
symptoms and treatment. To home tuition and guidance must
the student look to be enlightened respecting the pathology and
treatment of this disease.
Symptoms. — Cholera infantum is mostly introduced with diar-
rhoea, accompanied with more or less pain and fever. After a
period of varying duration, the stomach manifests irritability, and
vomiting supervenes, which becomes more frequent and distressing,
until, finally, hardly anything, even to the simplest drink in the
smallest quantity, is retained. Sometimes, after anorexia and slight
fever, the vomiting first appears, and is very soon followed by ex-
cessive purging. Rarely do the vomiting and irritable stomach persist
with, at the same time, a regular state of the bowels. In the begin-
ning there is considerable pain and spasmodic action of the digestive
canal, fever, and restlessness; but as the disease advances, the con-
tents of the stomach are ejected with very little effort, and the
irregular motion of the bowels is manifested chiefly in straining
with tenesmus, from irritation of the lower portion of the great
intestine. The circulation is, at first, hurried ; the pulse being fre-
quent, but small, and sometimes resisting, though more commonly
it is easily compressed. The pulse may be called one of irritation,
by its frequency and want of volume. The skin in the first period
is hot over the whole surface, except during the paroxysms of
vomiting; but in the second, or more advanced stage, the feet and
legs are frequently cold, while the abdomen and head are preter-
naturally hot. At this time, and in proportion as the disease ad-
vances, the skin generally is cold and damp, or sodden, and the
cutaneous capillary circulation greatly enfeebled. The tempera-
ture of the skin will vary with the remissions and paroxysms of the
disease, which are frequent, but without much uniformity — the
fever being, however, in its intensity, in the main, proportionate to
the irritability of the stomach.
The discharges from the bowels vary, in appearance and con-
sistence, with the different stages of the disease. At first, they are
greenish, and contain some fecal matter, with bile, or consist of
matter having a chopped appearance ; after a time, they are slimy,
watery, and involving small whitish lumps, with a brownish colora-
tion ; and not unfrequently there is lientery, and the articles of food
pass off with little or no change. A pink hue in the dejections is
468
DISEASES OF THE DIGESTIVE SYSTEM.
regarded by Dr. Chapman as a bad augury. They often give out an
unpleasant, sourish smell, in place of the proper fecal one; and at
times, as mentioned by Dr. James Jackson of Boston, they resem-
ble water in which putrid meat had been washed.
Thirst is urgent throughout the whole of the first or febrile stage
of cholera infantum ; and the craving for cool drinks, and espe-
cially water, is continual. Often, I have no doubt, the child seeks
with avidity its mother's breast, in order to quench its thirst,
rather than from any call of hunger, during this time. The dis-
tinction in many cases is important, when we wish to save an
irritated, it may be sometimes an inflamed, stomach, from even a
nutrimental stimulus, beyond what is required by the most limited
wants of the animal economy. A few spoonfuls of water, espe-
cially during the oppressive heat of a summer night, will be both
more grateful, and certainly more salutary, under the circum-
stances, to the little patient, than milk from the maternal bosom,
which is so soon ejected after it has been swallowed, during the
inception and height of the disease. The appetite at first is small,
and at all periods of the disease unequal and capricious. Spoon
victuals are often taken by a child that has been weaned, from the
same cause that prompts, in other cases, its drawing food from
the breast, viz., on account of the fluid portion, which allays thirst.
The same advice is applicable, therefore, to this as to the other
case, viz., to allow the child plain water at not unfrequent intervals.
In this matter, however, the little sufferer soon contrives to make
its wants understood, after it has been allowed to choose between
its drinks and its common food.
The tongue, at first white and somewhat loaded, becomes sub-
sequently redder, and finally smooth and chapped at the sides. It
and the mouth are often the seat of aphthas at this time.
The nervous system is deranged in various ways, as might be anti-
cipated from an observation of the causes of the disease, which act
primarily on it, and of the irritation of the stomach and bowels, of
which it is made secondarily the recipient. Preceding the disorder
of the digestive system, the child manifests impatience, peevishness,
and excessive sensibility; and in the first stage of the disease, the
expression of the countenance is that of excitement and irritation,
as is seen in the contracted brow and shining eye. There is rest-
lessness, desire to change position, or going from one person to
another, or tossing about in the cradle or bed ; the limbs are some-
what drawn up, sometimes with spasm ; and, altogether, the mus-
cular system exhibits its participation in the irritated state of the
nervous. But as the disease advances, and it assumes the cha-
racter of chronic diarrhoea, the decubitus is on the back, and the
limbs are relaxed, and the head thrown back. The features are
puckered, rather than actively contracted ; the eyelids are half
closed during sleep. This sign, in advanced disease, was declared
by Hippocrates to be a bad omen, except in diarrhoea and other
bowel diseases, in which it is quite common, and has no longer
PROGNOSIS OF CHOLERA INFANTUM. 4gg
the same unfavourable meaning. Drowsiness and wakefulness
Alternate rapidly in the first stage of the disease ; but in the second
and advanced one, the child becomes indifferent to objects around
it; its fretfulness and impatience are exchanged for feeble queru-
lousness or languid indifference; it sleeps much, or is in a drowsy
state simulating sleep. To this state not unfrequently succeeds a
partial stupor, and symptoms of oppressed brain, which, by the by,
are manifested the more, the greater is the debility of the system
at large. If occasionally there be reaction at this period of what
may be properly called collapse, it shows itself more in augmenta-
tion of heat of the surface and renewal of thirst, and frequency of
pulse, than in symptoms of well marked phlogosis.
Rapid are the changes made in the nutritive system from infan-
tile cholera. A fat and stout child is reduced greatly in its dimen-
sions, even in forty-eight hours of violent seizure; and if the disease
pursues its course unmitigated, the absorption of adipose and cellular
tissue is very great, leaving the cutaneous integuments in folds; or,
at least, the flesh becomes flabby and destitute of any plumpness or
well defined outline. Even where death is long in making its ap-
proaches, the outlines of the Hippocratic face are well defined, — in
the tightly drawn skin of the forehead, sunken eyes and cheeks, ele-
vated eyebrows, nose sharp, and the alas compressed; cheek and
lower lip depressed. This expression of countenance has not the
same evil portent in intestinal as it has in other maladies; and if
proof were wanting in the adult subject, it would be manifested in
the disease now under consideration. Children will live for days,
and even weeks, with this physiognomy, and in some cases ulti-
mately recover.
The prognosis of cholera infantum is not easy, if drawn
solely from the intrinsic signs of the case. Thus, of two chil-
dren exhibiting analogous appearances of disease, we shall augur
a greater probability of successful issue of the one who still de-
rives nutriment from the breast of the mother or a good nurse,
over the one who is weaned and has no such sustenance. The
child in whom dentition has just begun will have more difficulty to
rally under the attack, than the one in whom this process has been
in a measure completed. If the subject of a case enjoy the advantage
of daily change of air, by a ride into the country or excursion on
the water, and a well-aired, spacious room to sleep in, he will be
more likely to recover than another who is pent up all day in the
city, and confined during the night in a small, close, and imperfectly
ventilated room, the air of which is rendered more impure by
several of the other members of the family sleeping in it.
In general we augur well of the termination of the disease, if the
stomach can retain food, and the bowels recover a better tone, mani-
fested by fecal and bilious discharges, even though these be still quite
frequent and not unaccompanied by pain ; if the pulse become fuller
and slower, the skin of a more equable temperature with a warm mois«
ture. Often, after convalescence has undoubtedly set in, and all fear of
vol. i.—40
470
DISEASES OF THE DIGESTIVE SYSTEM.
fatal result is over, the disposition still retains its irritability, and
the child is both fretful and cross. Where the appetite has been*
lost, and the patient begins to exhibit a desire for food, even though it
be for some unusual article, we regard it as an encouraging sign, un-
less in the midst of others which indicate approaching death. So,
also, is the abatement of the previously intense thirst. The renewal
of any of the former habits, although these may be called tricks
of the child, such as that of keeping a finger in the mouth when
it is asleep, or taking a particular, though an awkward and incon-
venient attitude, is favourable.
On the other hand, continued jactitation, only relieved by a drow-
siness, imitative of stupor rather than of sleep; increase of the vomit-
ing and purging, and spasmodic pain ; occasional convulsions ; con-
tinued heat of the head ; intolerance of light at first, or, afterwards
little sensibility to it; tumid and hot abdomen; dry skin, without any
remission by sweat, and unquenchable thirst, are unfavourable signs.
Aphthae is certainly adverse to speedy restoration; and in connexion
with any other bad sign, must excite great solicitude for our patient;
but we often, not to say commonly, notice their appearance in cases
of any duration, many of which end happily. Their increase and
extension, with a persistence of the bowel complaint, cold skin, and
weak pulse, indicate the probability of a fatal termination. Dr.
Dewees mentions one appearance, which he observed to be uni-
formly a fatal sign : " it is a crystalline eruption upon the chest, of an
immensity of watery vesicles, of a very minute size." This gentle-
man also noticed another symptom of bad augury ; " which is the
thrusting of the fingers, nay, almost the hand, into the back part of
the mouth, as if desirous of removing something from the throat."
I have already mentioned the symptom which Dr. Chapman,in his
fine description of this disease, regards as indicatingdeath, viz., a pink-
coloured discharge, or rather the napkin is stained in spots of this
particular hue : so also when there is passed from the bowels a
fluid resembling greasy dish-water. A cold, damp surface is bad
in connexion with other symptoms of sinking, and especially if no
nutriment is taken or can be retained; but I have often met with it
in cases in which, although the subjects were greatly reduced, they
finally recovered. Such a symptom is more common in protracted
disease and towards the end of the summer, and when the air is
much reduced in temperature, than under other circumstances.
Causes. — Physicians are generally agreed as to the obvious
causes of cholera infantum. Som6 are inclined to add not only
a less appreciable, but at all times a very doubtful, and in the
present case a very improbable cause—malaria. The disease
appears in our cities with the first heats of summer, and continues
through the months of July and August into September; but abat-
ing in this latter month, as the weather becomes cooler. But
although thus manifestly connected with high atmospherical heat,
cholera infantum cannot be said to be the product of this alone;
for otherwise it ought to increase in violence in proportion to the
warmth of the climate, or as we advance south; which is not by
CAUSES OF CHOLERA INFANTUM. 471
any means the case. Such ought to be the state of things, also, if
malaria were the cause. We believe it will be found that it is a
more common disease in Boston, forexample, than in Charleston; cer-
tainly it is more soin Philadelphia than in New Orleans. The expla-
nation I take to be this : that the system of a child, on the approach
of its first and even second summer, is very much in the same condi-
tion as that of a person newly arrived from the north at a southern
city. The susceptibility to heat being great, its effects are felt more
sensibly on the nervous system, whichit excites, and through it on the
vascular system, and even still more, the tegumentary ; the skin first
and afterwards the mucous membranes. These lastarekept in a state
of irritation short of phlogosis by the high and continued heat acting
on the skin; and the digestive ones,in their turn, transmit the irrita-
tion to the liver, which is often excited in consequence. Now, if in this
state of predisposition the person be exposed to close and impure air,
the circulation and nervous system become more and more dis-
turbed, and there is the very imminence of violent disease, which
only requires for its coming on an excess or irregularity in food, loss
of rest, or any morbid excitement of the nervous system, whether
from bodily pain or mental anxiety. In a child, the disease will be
cholera; in an adult, bilious remittent fever, or yellow fever. In both
there will be great gastro-enteric disorder, with hepatic and cere-
bral complications.
In recurring to the original proposition, that the disease is brought
on by high atmospherical heat in our cities, we cannot overlook the
fact of its being the chief and main endemial agent, — without
which other coinciding causes, such as the irritation of teething
and of indigestible food, would be generally insufficient for its pro-
duction. It is, however, the high heat following winter's cold
acting for the first time on an infant, whose functions have barely
acquired the necessary rhythm, certainly are not accustomed to
such stimulation. An infant, exposed from birth to a mild tempera-
ture, might be expected to feel less even the great heat of our
cities during the summer months. Atmospherical agency is made
manifest in the amelioration of existing cases of the disease, and
fewer fresh attacks during the interval of a few cool days at any
time in the summer; and, on the other hand, augmentation in both
during great heats, and particularly during a close and damp state
of the air, when the thermometer is at the same time high.
In a table now before me, I find the number of deaths from
cholera infantum in Philadelphia, during a period of ten years,
(from 1823 to 1831) to be 2323, or on an average 232 ; the maxi-
mum having been in 1831, or 303, and the minimum in 1824, or 155 ;
and those from cholera morbus during the same period, of sub-
jects over ten years of age, 114. You will have observed, in my
last lecture on epidemic cholera, that the cases of infantile cholera
were augmented in 1832, the 'cholera year,' to 316 in 3 months, as
were, indeed, all the diseases of the bowels in that year. In 1833 the
amount was 197, or less than it had been for eight years preceding.
The influence of a tropical climate, for under this designation the
472
DISEASES OF THE DIGESTIVE SYSTEM.
summer in one of the large cities of the Middle States is entitled to
be spoken of, is well illustrated in the following memoranda of dis-
eases of the digestive apparatus among children in Philadelphia
and New York, for the years 1838 and 1839. In the former city,
with a population of 200,000, the entire mortality of 1838 was 5118;
of which the deaths of children from cholera infantum were 382 : of
these, 364 were under two years, viz., 247 under a year, and 116
in the second year after birth. In 1839 the deaths from this dis-
ease were 230 ; the excess in 1838 being explained by the unusually
long period of high atmospherical heat in the summer of that year.
The number of children who thus perished within the first year from
, birth was 1.42 ; in the second 75 ; and between the termination of the
second and the fifth year, 13. The entire mortality from the dis-
eases of the digestive canal was as follows : —
1838. 1839.
Cholera Infantum.....
Diarrhoea ......
Dysentery ......
Inflammation of the Stomach and Bowels
572 477
In Washington, the proportionate mortality from cholera infan-
tum is considerable, as might, h priori, be inferred from the exces-
sive heat of its summers, without the mitigation of sea-breeze, by
which even Charleston and Savannah are made more tolerable for
infant life. Dr. Lindsly, in his article already referred to, gives us
some useful information on this point, which is best conveyed in his
own words.
" It will be seen by the following table, that of the whole number
of deaths in the months of July and August, nearly one-half, and in
two instances more than one-half, were under two years of age;
and that of this number, almost three-fourths died of what is usu-
ally termed here " summer complaint," under which general term
are included cholera infantum and simple diarrhoea of children.
Also, that the cases were much more numerous in July and August
than in June, that a slight diminution took place in September, and
that in October the number was again very small.
Whole No. of deaths, Und
1837.
382 . 230
65 96
45 . 68
80 83
June . 30
July . 31
August 52
September , 42
October 28
1838.
June . 18
July . 41
August 59
September . 50
October 33
ears of age. Cholera Infantum
14 4
14 . 10
21 . 14
18 3
6 . 2
7 2
25 . 15
28 . 22
26 . 14
13 , 2
CAUSES OF CHOLERA INFANTUM.
473
The ratio of cases of infantine cholera in the above table is about
the same as that exhibited by the record for several years past,
and this may therefore be assumed as the proportion of victims
annually destroyed by this fatal disease in Washington, during the
months referred to."
In Boston, also, we still find that the summer gives a tropical climate,
particularly for children under two years of age. For a period of ten
years, from 1821 to 1830, inclusive, in which the entire number of
deaths was 10,731, the mortality of children under two years, in the
months of July, August, September, and October, was 1537 ; the
whole mortality of this class, for the entire period, being 3182. Hence
we see that the deaths of children between birth and two years old,
m Boston, in the four months in which the summer temperature
predominates, was just one-seventh of the entire number, and one-
half of the particular class; or, in other words, the deaths are as
numerous among children of this age in these four months, as in
the remaining eight of the year. The deaths from cholera infan-
tum, during a period of ten years, was 149. That from 1831 to
1839, or a period of nine years, was 407 ; — the annual average of
twenty years was but a little over 27. This is quite a small pro-
portion of deaths from cholera infantum, in a population averaging,
during the entire period of twenty years, about 65,000, and which,
in 1840, was 93,470. But if we add the kindred, and probably
in most instances identical diseases, reported under the head of
gastritis, teething, and dysentery, the amount of cases of deaths of
children from gastro-intestinal disease, in the summer months in
Boston, will be more easily accounted for; and place this city, on
the score of infant mortality, in a line with, but quite behind, Phila-
delphia and New York. For much valuable information on the vital
statistics of Boston, I refer you to the paper by Dr. Shattuck in the
Am. Jour. Med. Scien., 1811.
The aggravation of disease by the irritation of teething is mani-
fest to every physician : it aggravates bronchitis in winter and
cholera in summer: it might even be said to cause them, by induc-
ing a morbid susceptibility — a predisposition to cold and moisture,
in the former season, and to great heat in the second, without
which these atmospherical extremes would be relatively innocuous.
But that teething is only of secondary importance in the etiology
of cholera, is manifest from the fact that, however suffering from this
irritation at other seasons,rarely will children thenhave cholera. The
same reasoning applies to weaning, and the additional irritation to
which the digestive system of the little being is exposed by new
and unaccustomed articles of food into the stomach. Still, that wean-
ing, or the privation of breast-milk is an active contributing cause,
is sliown in the greater proportion of children attacked at this time
over those which continued to be suckled. I may go still farther,
and while repeating the language used by me in another place
(Underwood on the Diseases of Children, Philadelphia edition), truly
say, in reference to teething and weaning, that " even these causes
40*
474 DISEASES OF THE DIGESTIVE SYSTEM.
combined, powerful as they would seem to be in the production of
disease, and at times fully adequate to bring it about, are borne
with relative impunity by a majority of children, as far as the
digestive function is concerned; unless the irritation of high and
continued heat, with its too common associate of close and confined
air, be added. Teething and high atmospherical heat frequently
give rise to the disease." Let it be observed, also, that children
have, on occasions, been attacked with cholera under the exposure
of heat, but without the irritation of unusual food or of teething.
It would be an error to suppose that cholera infantum is con-
fined to our cities, and does not prevail in the country. I believe
that in all parts, in villages and even farmsteads, as in cities,
in which the extremes of temperature in the seasons occur, this
disease will be found. Were it of malarious origin, it ought to be
most frequent in rural districts, and bear a close proportion to the
cases of intermittent and remittent fevers, diseases so commonly
accredited to this cause. But this is not the case. Dr. Blue
(Western and Southern Med. Rev., Jan. 1842) of Missouri, represents
infantile cholera to have been epidemic, within the sphere of his
own personal observation at Chariton, Missouri.
There is often a great predisposition depending on temperament
and constitution, to be acted on by the common causes of cholera,
so as to develop the disease. Thus, I know some families residing
in the eastern part of this city (Philadelphia), in closely built streets,
whose houses, though comfortable, are without gardens, and any
facility for procuring a ready renewal of air, the children of which
hardly ever suffer from cholera ; although they are not robust, and
I am often required to prescribe for them for other diseases. While,
on the other hand, some children living in spacious houses, and
sleeping in large and well-aired rooms, with opportunities for airing
in gardens adjoining, are frequent sufferers, and would sink under
the disease, notwithstanding my best efforts, but for a removal
to the country. If I were to hazard an opinion, derived from my
own observations, which were on a large scale, owing to my long
connexion with the Philadelphia Dispensary, and practice among
the class of our population whose children are the greatest sufferers
from cholera, I should say, they were most readily attacked by the
disease whose temperaments were lymphatico-nervous, and whose
constitutions might be regarded as anemic, and with a tendency, in
after life, to scrofulous disease. A great development of adipose and
cellular tissue, common in children of a strumous habit, is often an
external character in those who suffer most from cholera.
Connected with a knowledge of organic causes of cholera infan-
tum, is an inquiry into the extent and signification of the anatomical
lesions in subjects dead of this disease. The structural changes
are not identical in all subjects examined, either as regards the
degree of alteration or the organ affected. In some we find
follicular inflammation, with redness of the mucous membrane of
the intestines; in others a softening of this membrane, with scarcely
SYMPTOMS OF CHOLERA INFANTUM.
475
a trace of existing inflammation, although the latter is believed by
many to be a cause of the softening. By some, perhaps I ought to
say the majority of American physicians, the liver is regarded as
the organ chiefly if not mainly implicated ; although, for my own
part, I am disposed to regard the enlargement of this organ and
some other less frequent vices of growth, as an effect of the pre-
existent derangement in the intestinal circulation. But still,it cannot
be denied that, when hepatic disorder is once established, it may
become itself a secondary and powerfully disturbing cause.
The relation, if not identity of follicular gastro-enteritis with
cholera infantum, has been set forth in the strongest light by Dr.
W. E. Horner (A Treatise on Pathological Anatomy, p. 171-190),
who leans to the belief that it is a disease, like hooping-cough
and measles, peculiar to man. He has repeatedly seen, in dis-
sections of those who died of the disease, clusters of muciparous
glands or follicles of the small intestines, very distinct to the naked
eye, and with their orifices enlarged and tumid. " The same
condition of the muciparous follicles prevailed in the large intes-
tine from one end to the other; but they were larger and more
tumid, and gave to the mucous coat somewhat the appearance of
having been sparingly sprinkled with fine white sand." Subsequent
more careful inspection, after washing away the colouring matter
and mucus, and suspending the intestines (the whole of the large
and a portion of the small one) in spirits of wine, enabled Dr.
Horner to see more prominently the glands or follicles. Thousands
of them, the ulceration of which was previously imperceptible, are
now seen very clearly to be in this state. At this time, also, some
common erythemoid ulcerations were brought into view. If we
were to admit this kind of organic origin of cholera infantum,
we can hardly refuse our assent to the opinion of Dr. Horner,
that cases of violent disease may occur without evacuations, but in
which the most striking symptoms are convulsions. He adduces a
case of constipation, or rather of disease marked chiefly by consti-
pation, in which convulsions supervened eight hours before death,
and continued up to this date. Autopsic examination revealed no
other morbid peculiarity, except a hardness and somewhat yellow
hue of the liver, and cystic enlargement of all the follicles of the
colon, of the size and transparency of the itch vesicle; on being
punctured they readily gave out their transparent fluid.
A softening of the mucous membrane of the stomach, so that in
one case it could be scraped away easily in the form of pulp with
the finger nail, is mentioned by Dr. Horner, in describing the post
mortem appearances of some of the fatal cases of infantile cholera:
but he is hardly prepared to speak of this appearance as a morbid
peculiarity. By Billard, Cruveilhier, and other French pathologists,
it would be called a gelatiniform softening of the digestive mu-
cous membrane, of which there are two varieties described by the
first of these writers (op. cit.), viz., the inflammatory softening and
cran^rene, and the white softening of this membrane; the latter of
which is seen in children who die in marasmus, and who had
476 DISEASES OF THE DIGESTIVE SYSTEM.
suffered from insufficient food. Dr. Gross (Patholog. Anatomy,
vol. ii. p. 229) states, that he has repeatedly noticed softening of
the mucous membrane of the stomach and colon in the subjects
who had died of cholera infantum. In a few instances, it was
also seen in the lower half of the ileum. A few pages before,
he speaks of chronic inflammation of the mucous membrane of
the alimentary tube, as common in infantile cholera, " of which,
and of almost all the protracted fluxes of the bowels, it is the prin-
cipal cause, the affections themselves being merely the symptoms.
M. Billard records cases of inflammation of the follicular apparatus
of the intestines, which closely resembled the symptoms of our
cholera infantum. One of these I shall place before you : —
"Francois Tessont, aged thirteen months, entered the infirmary
on the 12th of September. For several days he had been very rest-
less, and had scarcely slept; the pupils were dilated; the tongue
red and dry; the skin very hot; the pulse very frequent. There
was neither vomiting nor diarrhoea. (Gummed barley water, sina-
pised pediluvium, cataplasm to the abdomen, three leeches to the
epigastrium.) On the thirteenth, a very abundant diarrhoea of green
liquid matters; abdomen less tender; child cried less, and appeared
enfeebled. From the eighteenth to the twentieth, there was no
change. On the twenty-first, diarrhoea less abundant, and vomiting
supervened. On the twenty-third, respiration was painful, and the
child exhibited a state of general prostration difficult to describe ;
the face was pinched, and the forehead, particularly, exhibited a
number of wrinkles which continued even after the cries had ceased ;
two livid circles appeared about the alae of the nose ; the pulse beat
from ninety to a hundred. On the twenty-fourth, the same general
state ; the feces were extremely fetid; great prostration ; extreme
marasmus; and the pulse became evidently enfeebled, although the
skin retained much of its heat. On the twenty-fifth, prostration
complete; fades hippocraiica, convulsive motion of the globe of
the eye ; the bites of the leeches had become violet; they ulcerated
and a purulent sanies flowed from them. The child died on the
night of the twenty-sixth. The examination of the body was made
on the twenty-seventh.
" General paleness and marasmus ; an escharof the size of a two-
franc piece was found on the sacrum ; mouth and oesophagus
healthy ; slight redness of the stomach. In the duodenum and ileon
there were found a large number of glands red and tumefied ; some
of them were open, and exhibited in their centres superficial ulcera-
tions. Twelve follicular plexuses, very red and tumefied, existed at
the end of the ileon. In the colon and ccecum there were a great
number of isolated follicles about the size of a hemp-seed, and
which, instead of being red like those in the ileon, were, on the con-
trary, surrounded with a blue circle. The circulatory and respira-
tory apparatus presented nothing worthy of remark. The brain
was injected, and contained in its ventricles a quantity of slightly
turbid serosity. The spinal marrow was healthw" °
SPECIAL PATHOLOGY OF CHOLERA INFANTUM.
In this case you must have been struck with the perfect identity
of symptoms with those of cholera infantum, aud of the post mortem
appearances with those described by Dr. Horner. The injection of
the brain and effusion of serum, particularly the latter, are common
in the advanced stage of protracted cases of cholera infantum. But
the remarks of M. Billard would give a different turn to our opi-
nion of the causes of the disease; as when he tells us, that it is not
until about the seventh, eighth, or tenth month, that this follicular
inflammation produces any peculiar symptoms, the assemblage of
which constitutes the disease described under the name of entcro-
mesenteric fever by MM. Serres and Petit, and dothinenteritis by
M. Bretonneau. To this form of disease, — diarrhoea with slow
remittent fever,— reference has been made by Dr. Stokes (Lecture
on Ileitis and Tabes Mesenterica). We may regard as analogous
in its character " Inflammation of the Mucous Membrane of In-
fants," described by Dr. Abercrombie (op. cit.); " it frequently oc-
curs about the period of dentition, and in many cases appears to be
connected with weaning."
LECTURE XXXVIII.
DR. BELL.
Cholera Infantum (Continued).—Farther dissections exhibiting inflammation of
the small intestines and follicles—Dr. Horner's opinion of the nature of cho-
lera infantum—M. Billard's view of the cause of follicular development applied
to the pathology of infantile cholera.—Resemblance between this disease and
epidemic cholera—Hepatic pathology of cholera infantum not sustained by
autopsic examinations—Mode in which heat causes hepatic derangement—
Contents of intestinal canal___Treatment—Indications to guide us—To re-
duce excessive sensibility and to remove irritations—Modification depending
on temperament and constitution—Treatment of first stage—Demulcents,
chalk mixtures,—an opiate, if the teeth irritate—Calomel in minute doses—
Oil of turpentine—Cold affusions and cold water injections—Sugar of lead.
Dr. James Jackson of Boston, in a well written account of cholera
infantum, under the heads of its history, causes, and treatment, gives
the results of numerous autopsic examinations made by himself and
Dr. J. C. Warren. Among these we find marks of disease of the
digestive mucous membrane in every case. In the stomach, one or
two small spots of irregular shape, of a red colour inclining to pur-
ple, at which also the membrane was swollen; in the intestines, the
duodenum invariably exhibited one or more spots larger than those
on the stomach, inflamed and swollen. In almost every case such
an inflamed patch has been found at the very commencement
of the duodenum. "In other portions of the small instestines,
other such inflamed portions of the same membrane have been
seen, varying in size." Marks of disease were rarely observed in
the large intestines, unless when dysenteric symptoms had ex-
isted. In one case, throughout the whole of the large intestines,
the membrane showed " strong marks of inflammation, and had
frequent small ulcerations resembling the canker spots of the mouth."
47S
DISEASES OF THE DIGESTIVE SYSTEM.
If minute anatomy had been as commonly attended to at that time
(1812) as it is now, Dr. Jackson would probably have noticed at the
inflamed spots of the intestine enlarged follicles, and have designated
the small ulcerations as those of the follicles.
In the New York Medical Gazette, vol. i., p. 291-4, two cases
of dissections after death from this disease are described by the
editor (Dr. Turner). In both there was much gelatinous softening of
the mucous membrane of the small intestines, with enlargement of
the mucous follicles; in one case at the lower end of the ileum
and the large intestines, and ulceration in the former; and in the
second case, there was development of the follicles of the duo-
denum, and still more, amounting to hypertrophy, of those of the
colon, particularly at the lower part. Dr. Swett (op. cit., ut supra,
p. 294) details the particulars of a dissection, in which the mucous
membrane of the small intestines was softened. The glands of Peyer
were somewhat enlarged, and some of the solitary glands at the
lower part of the ileum were ulcerated. The follicles of the large
intestines were generally enlarged, and many of them ulcerated in
their centres ; some near the rectum penetrating quite to the peri-
toneum.
Dr. Dewees describes the mucous coat of the alimentary canal
as manifesting the effects of previous inflammation during the life-
time of the patient. " Dark livid spots are disposed over this part
of the stomach and small intestines, particularly the duodenum near
the pylorus," coincident with the observation of Dr. Jas. Jackson.
" Coagulable lymph is also, in some instances, spread over the sur-
face, or is found in detached pieces."
A morbid state of the follicular apparatus of the intestinal canal
being admitted as the chief organic cause of cholera, at least of
the more urgent symptoms of vomiting and purging, with fever, it
remains for us to ascertain the circumstances under which these
glandular bodies have become thus morbidly developed and ulcer-
ated; or, in other words, why they should become specially the
seat of irritation and inflammation at this time. Dr. Horner leans
to the opinion that the follicular disease constituting or givino* rise
to cholera infantum is analogous to the exanthemata, both in its
anatomical characters, and in its attacking all persons, with more
or less intensity, at some time or another, and but once in their lives.
He asks : " May not cholera infantum, as a follicular disease of the
intestines, be the inevitable lot of every individual of the human
family, but under circumstances of various severity, being mild,
scarcely perceptible, in some; and in others aggravated by the
season of the year, by the local circumstances of the individual,
and by his early infancy 1 May not, in fact, the whole follicular
system of the body be successively under the necessity, in most
individuals, of undergoing inflammation, the symptoms of which
will of course vary according to the functions of the part in which
the follicles are placed, and give rise apparently to diseases having
no external analogies 1 As, for example, in the inherent follicular
inflammation of the skin, we have what is called small-pox, from
SPECIAL PATHOLOGY OF CHOLERA INFANTUM.
479
its vesicular or bladder-like appearance ; — in the inherent inflam-
mations of the follicles of the intestines, we have what is called a
cholera, or flux of children, because the bowels are constantly expell-
ing their contents, being too irritable in most cases to retain them ;
and is it not perfectly consistent with the laws of induction, that
when a similar innate inflammation attacks the follicles of the trachea
and lungs, we shall of course have symptoms suited to the organs
assailed ? In fact, what is hooping-cough but an ingenerate in-
flammation of the mucous follicles of the air-passages, manifested
by the immense transparent mucous discharges, which are some-
times brought up by the teacupful after a fit of spasmodic cough-
ing?" An inference from these remarks, and more particularly
from a query which concludes the passage, would be the contagious-
ness of cholera infantum, of which we cannot be said to have even
plausible evidence. The importance of the subject, both in its patho-
logical bearing and therapeutical applications to most of the dis-
eases of infancy, and certainly to all those in which any portion of
the digestive system, from the mouth to the colon, is implicated,
induces me to place before you, in his own words, the ingenious
suggestions of Dr. Horner respecting intestinal follicular disease.
His theory rests on what may be called inevitable pathology, — that
is, organic change and sympathetic functional disturbances, occur-
ring, of necessity, to every individual, although quickened into dis-
play earlier, and rendered more violent, by certain occasional causes.
There is yet another view of this subject, which I would say was
based on inevitable physiology, or the development of the follicular
apparatus, and its greater functional activity in every individual,
at a particular epoch, or, at any rate, period of his life. Disease may
ensue, but it is not a necessary consequence of the great suscepti-
bility of the follicles at this time. This is the view taken by M.
Billard,in reference to thegreater readiness of follicular inflammation
in the mouth, or follicular stomatitis, and of follicular gastro-ente-
ritis and entero-colitis in children, from the eighth or tenth month
to the first few years from birth. Aphthae or thrush (follicular
stomatitis), I have before told you (Lect. III., p. 37), is the most
common kind of sore mouth in children ; and it is that which is a
frequent accompaniment of chronic diseases of the gastro-intestinal
mucous surface in subjects of all ages. I ought to have said of
acute and chronic, for in the specification which follows most of
the diseases, and among them cholera infantum is mentioned, are
acute. Now, I wish to apply this view of Billard to the pathology
of infantile cholera. Coinciding with the period of first dentition —
from eight months to two years from birth — there is a very great
increaseof growth,andorganic and functional activity,of the follicles
of the whole digestive svstem, keeping pace with that of the lympha-
tic glands. Teething,"although of itself a physiological process,
and one that may be gone through without pain and disease, is often
productive of both, or at least of a high degree of nervous irritation,
which is readily converted by any occa'sional cause into serious
disease. We have seen that it is competent to impart a morbid
480
DISEASES OF THE DIGESTIVE SYSTEM.
excitement to the mucous follicles of the mouth and pharynx, one
of the manifestations of which is aphthas, or follicular stomatitis.
Nor does the irritation stop here : it is sometimes transmitted to the
stomach and bowels, the follicular apparatus of which is disordered,
and there is diarrhoea, griping, and sometimes vomiting; often loss
of appetite, and great thirst. But the causes which more especially
affect this division of the follicular system are, irritating ingesta act-
ing primarily on the digestive mucous membrane itself, and atmo-
spheric heat acting secondarily on it through the skin and pulmo-
nary mucous membrane.
If this view be admitted, we have a ready explanation of the
occurrence of cholera infantum in children at a particular age ;
that in which the digestive follicles are most notably developed,
and most susceptible to new impressions; and also that in which
this susceptibility is liable to be injuriously acted on by the irritation
of teething. But the physiological predisposition may and does
often pass away, if the process of dentition be easy ; and it requires
the operation of another cause to generate open and violent dis-
ease. This cause is found in high heat; and we see now why there
must be coincidence of a particular age or of a predisposition with
a particular exciting cause or even causes. Follicular develop-
ment and susceptibility, teething and high atmospherical heat, can
only be brought into conjointaction to the productionof disease within
a limited period : it is that in which cholera infantum takes place.
You cannot fail to have been struck with the resemblance be-
tween some of the symptoms, and still more of the lesions of the
follicular apparatus in epidemic cholera and in cholera infantum,
now that both have been detailed to you; and let us remember
that for a knowledge of the anatomical features which establish the
resemblance we are indebted to the same indefatigable and truthful
observer, Dr. Horner. Dr. Lindslv (op. cit.) mentions another
feature, tending still further to show the affinity. It is, an empty,
shrivelled state of the bladder—noticed by him in three or four cases,
in his dissections of subjects of cholera infantum. Diminished secre-
tion of urine, amounting to suppression, is mentioned by Dr. Aber-
crombie in the disease referred to at the end of my last lecture.
You will naturally inquire why adult age chiefly should have been
attacked by epidemic cholera, if my explanation of the patholoo-y of
cholera infantum be a correct one. The answer is ready: In the
first place, epidemic influences, of whatever nature, operate with
fearful power on an organic system or an organ; compared with
common sporadic, and even endemial causes; but more to the
point, because susceptible of direct evidences, is the fact that the
sufferers from cholera have been, in an immense majority those
persons who, either from intemperance in using alcoholic drinks,
or from depraved and deficient food, have had their digestive
ThT'Ji- Uf°rtl0ri> «he follicles of this latter, brought into a state
TZ Ja-v° ?" ,°r °f .hl§h Proposition, which°would require
vefoDedlt0^1, a° Say n£thlnS of an epidemic, cause, to de-
velop destructive disease. Farther points of analogy, of a patholo-
SPECIAL PATHOLOGY OF CHOLERA INFANTUM.
481
gjcal nature,between the two diseases, are seen in the follicular erup-
tion of a vesicular nature, and in the suspended function of the liver,
which are met with in both.
Deference to the expressed opinions of so many judicious writers,
as well as a proper desire to describe all the anatomical lesions
met with in autopsic examinations of subjects dead of cholera in-
fantum, require of me a notice of the condition of the liver. The
hepatic pathology of the disease is advocated by Doctor C. D.
Meigs of the Jefferson Medical College, (Medical Recorder, vol. iii.,
1820,) who thinks that cholera infantum depends principally on
a loss of the healthy functions of the liver; by Dr. Stewart (op. cit.),
who regards the disease of the follicles as a secondary affection
caused by the congested state of the liver; by Dr. Cross (West, and
South. Med. Recorder, vol. i.), who thinks that " the vomiting and
purging, so distressing and exhausting in cholera infantum, are
fairly referrible to an increased determination of blood to the ali-
mentary canal, which has resulted from congestion of the liver."
Stress is laid by Dr. Condie (Philad. Journ. of Med. and Phys.
Sciences, 1825) on the suspended or vitiated secretion of the liver,
owing to its irritation and engorgement in this disease; also by Dr.
Lindsly (op. cit.), who asserts, that " the liver is almost universally
engorged with blood, and, in cases of long standing, greatly en-
larged."
Dissections of subjects who have died of cholera infantum do not,
however, sustain the hepatic pathology of this disease. Beyond en-
largement of the liver, which was indeed sometimes considerable,
this viscus did not, except in one or two cases in which it was rather
-firmer than natural, present any other mark of disease in the ex-
perience of Dr. J. Jackson. In three cases described by Dr. Horner
the liver is declared to be healthy in two ; and in the third it was
" of a light yellow colour, without any other abnormal peculiarity.
Dr. Dewees, while he tells us that the liver, under almost all circum-
stances, and especially in cases of long continuance, is greatly en-
larged, so as sometimes to occupy two-fifths of the abdomen, adds,
that it " is not deranged in structure, merely swollen by congestion,
more firm and solid than natural." In acaseof dissectionof a cholera
subject, in which Dr. Parker assisted Dr. Gross, the liver was " nor-
mal," while the glands of Brunner were enlarged, and the elliptical
plates at the lower end of the ileum were distinct, their edges thick-
ened, and in an ulcerated state in many places (N. Y.Med. Gaz.,utsup.)
In Dr.Swett's cases already referred to, the liver appeared healthy.
The only case of very marked organic change of the liver was that
related by Dr. Turner (op. cit.). This viscus occupied both hypo-
chondria; and "it could be squeezed into a pulp between the
thumb and forefinger, and scraped away in a fluid state with the
knife; on incising it a drop of blood appeared at each venous ori-
fice." Dr. Gillman detailed a case to Dr. Turner, in which the liver
was healthy.
Dr. Baxter (New York Med. and Phys. Journ., 1836, p. 276) de-
YOL. I.—41
432 DISEASES OF THE DIGESTIVE SYSTEM.
scribes the post mortem appearances of a subject of this disease
which he examined; the liver was healthy; and a yellowish mucus
was found throughout the intestines.
The chief evidence of a morbid state of the liver in subjects dead
of infantile cholera, is its enlargement; as in the cases mentioned
by Dr. Lindsly, in which this organ " was so immensely increased
in size as to fill very nearly one-half of the abdomen." But we
should remember, that in children the liver still retains somewhat
of the large, and, as compared with the adult, disproportioned size,
which it had in the period of foetal existence. It is not easy to tell
to what extent hepatic enlargement and congestion, as the result of
disorder in the portal circulation, interferes with the secretory
function of the liver; but, considering how suddenly this is at times
arrested and as quickly restored, it is presumable that the sus-
pended secretion of bile in cholera infantum is owing more to mor-
bid impression transmitted from the duodenal membrane, than to any
organic vascular change in the liver itself. Both the frequency and ex-
tent of hepatic congestion, or of congestion of the abdominal viscera
generally, are greatly overrated, and are assumed on speculative
grounds as the necessary result, it is thought, of deficient action and
torpor of the cutaneous system, than demonstrated by the appear-
ances of these viscera on dissection.' I early advocated (in my Inau-
gural Essay upon the Liver), the doctrine of what has since been
called, by Dr. James Johnson, cutaneo-hepatic sympathy; but I
cannot consent to the common hydraulic explanation of the mode
in which the liver and skin exert a reciprocal action on each other.
The proper, it seems to me, and vital action, is that by which the
atmospheric heat excites the skin, and with it simultaneously the
capillaries of the portal system. In both, there is at first increased
activity of circulation and augmented secretion — of sweat from
the skin, and of bile from the liver. In both, after a while, there
is indirect debility from over-excitement, and then there is sus-
pended secretion ; the skin is dry and parched, or at times cold
and sodden ; the liver ceases to secrete, or separates a watery and
imperfect bile. This is, I believe, a truer representation of the stale
of things in cholera infantum, as well as in cholera morbus and in
certain forms of dysentery, as far as the liver is concerned, than the
hypotheses of flux and reflux, and congestion, owing to the blood
being driven in from one quarter and accumulated in another.
That derangement of hepatic function, manifested chiefly by a
diminished and depraved secretion of bile, is one of the complica-
tions of cholera infantum, is, I think, very probable; but that it
alone or mainly constitutes the disease, and gives rise to the chief
remote and sympathetic phenomena, I cannot, with a knowledge of
the inflammation of the intestinal follicles before me, admit. The
last is of uniform occurrence, or nearly so, in cholera infantum;
congestion of the liver and other lesions of its structure are only
occasional.
The character of the contents of the intestinal canal in the subjects
TREATMENT OF CHOLERA INFANTUM. 433
examined is a point of some interest—asshowing that thefunctionof
the liver is not implicated totheextent assumed. The largeintestine is
represented, by Dr. James Jackson, to contain feculent matter and
mucus, sometimes without bile, but usually coated yellow or green by
that fluid. This, it will be remembered, like the picture drawn by that
gentleman of the lesions of the mucous coat, is intended to represent,
without particular specification of period, a common feature of the
disease. Dr. Horner, in the three cases more particularly detailed
by him (op. cit.), found bile in them all. In the first, "the upper
part of the small intestines contained yellow bile, almost pure, ex-
cepting some mixture of mucus. In the large intestines the con-
tents were also bilious, but greenish, like the discharges which had
prevailed." The case had been of three weeks' duration. In the
second one, in which the disease lasted two weeks, the little mucus
contained in the small intestines was here and there greenish.
The large intestine contained no feces, but its two inferior thirds
were occupied " with pure pus, of a cream colour, proper con-
sistence, as well elaborated as ever I saw, and destitute of any
excepting a very faint odour." In the third case, Dr. Horner
found healthy bile in the duodenum, and abundant fecal matter
of a light yellow colour. " There was, also, fecal matter in the
caecum, of a light yellow and chapped appearance, but none in
any other portion of the large intestines."
The contents of the intestines are not noticed in the cases recorded
by Drs. Turner, Swett, and Parker.
As already mentioned, it is not uncommon to see, in the more
advanced stage of the disease, some effusion in the ventricles and
on the surface of the brain. The viscera of the thorax were, with
very few exceptions, healthy.
Treatment.— The symptoms of the disease and the post mortem
appearances indicate, with tolerable clearness, the course which we
have to pursue in the selection of curative means. They are, in the
first stages of cholera proper, to remove gastro-intestinal irritation,
which fs sometimes merely functional, but in a majority of cases
depends on follicular enteritis, associated not unfrequently with
erythemoid inflammation of the mucous membrane of the intestines,
and occasionally of the stomach. In the second stage, or the
chiefly diarrheal one, we have to bear in mind the probability
of softening of the intestinal mucous membrane taking place, and
that the follicular disease is either on the decline, or has reached
the stage of ulceration. Our treatment of cholera infantum would
be not a little modified, at least as regards energy, if we are to
believe in its being a disease dependent on specific follicular inflam-
mation, to which all are subject, and which when once fully deve-
loped must run its course, from inception to increment, height and
decline, and termination in resolution or ulceration, commonly
both, in different patches of the intestinal mucous membrane. 1 his
is the view suggested, rather than very positively affirmed, by Dr.
Horner. Against its accuracy we may object the very different
periods which the disease is observed to run in different individuals;
484
DISEASES OF THE DIGESTIVE SYSTEM.
its relapses, and distinct renewals after intervals of some duration—
a course of things quite at variance with the uniformity observed
in the exanthemata?, to which infantile cholera is supposed by this
pathology to be analogous. Taking the physiological basis, or the
development of the intestinal follicles and their irritability at the age
in which children are chiefly liable to cholera, we can readily under-
stand why, under a removal of the exciting causes, there should be
a return of the disease.
A review of the causes, chief symptoms of cholera, and of the
anatomical lesions observed after death, will go far to guide you to
the treatment, both hygienic and medicinal, of the disease, and, what
is yet more important, its prophylaxis. All the irritants by which
the mucous and respiratory membranes primarily, and the nervous
and vascular systems secondarily, are excited, must be removed, and
their force mitigated. They are, high heat to the skin, hot and im-
pure air to the pulmonary mucous, and new and disproportionately
exciting ingesta to the digestive mucous membrane. Unless we
succeed in reducing the morbid sensibility of the system, kept up by
these causes, we shall gain little mastery over the disease; and in
order to accomplish this end, we must, from the very outset, draw
on hygienic agents, viz., cool and pure air, cool water for bathing and
drink, and mild, unirritating ingesta. Without we enlist these in our
service, and from time to time, as the symptoms indicate, abate the
irritation of teething, by topical and chiefly surgical means, we
must not hope for much from medicinal means, prescribed with the
common intention of restoring the healthy secretions of the liver
and muciparous glands, and giving tone to the digestion, &c.
The different diagnostic value of certain symptoms will prevent
your becoming routinists, and reposing implicit confidence in a
mode of treatment for the whole disease, which is applicable only
to a particular stage, or for the beginning, which is only proper in
the concluding period. Thus, for example, heat of the skin and
a burning heat over the abdomen, a frequent and somewhat
active pulse, restlessness, intense thirst, scanty urine, bilious and
acrid discharges, will call for a different treatment from a cold
and clammy skin, small and feeble pulse, watery and nearly colour-
less discharges or scourings from the bowels, a moist tongue and
aphtha3,and heaviness and somnolency approaching to stupor — even
though in both we have vomiting. The modifications depending on
temperament and primary constitution, are not to be lost sight of:
they will form elements in our calculations as to the intensity of the
disease and the propriety both of selecting certain remedial means,
and of insisting with more or less freedom on their use.
In the first stage, or that of more manifest gastro-intestinal irrita-
tion with exalted sensibility, the treatment will consist in a prompt
withdrawal of all but the simplest nutritive articles, and an avoid-
ance of medicinal irritants. The drinks should be cool, mild, and
mucilaginous; the lungs should be subjected to fresh air; the skin
to tepid bathing. Suspicion of indigestible substances having been
TREATMENT OF CHOLERA INFANTUM.
4S5
recently given will authorise a mild emetic, as of ipecacuanha, or the
state of the stomach forbidding this, a laxative enema, to be followed
by simple mucilaginous ones. Vascular excitement being manifest,
a few leeches over the epigastrium will be of service, and the appli-
cation to be followed by emollient cataplasms or warm stupes,extend-
ing over the abdomen ; or if the temperature of the surface be un-
equal, the warm bath should be used. The state of the gums will
early engage attention, and if they are swollen and inflamed, or
spongy, and the teeth may reasonably be expected, the former
should be freely lanced. The more obvious and probable causes of
irritation in the gums and contents of the stomach and bowels
being removed, and any tendency to high irritation or inflammatory
action being abated or subdued, recourse, if need be, is proper to
different medicines and compounds, with a view of quieting the
stomach. Of these the simplest are to be preferred, such as muci-
lage of gum-arabic, alone or mixed with lime-water, or mint, or
peppermint, or camphor-water; then small doses of the alkaline
carbonates with mucilage, or chalk powders or mixtures; one effect
of which is to allay the gastro-intestinal irritation and to soothe
the nervous system.
The temporary controlling power of opium is often manifested
so far as to procure a cessation of the vomiting and purging, while
its hypnotic effects last; after which the symptoms return as before.
We gain little by persevering in its use under these circumstances,
unless the child be irritated and wakeful and restless by a pro-
truding tooth ; or in a state of great exhaustion by the prolonged
vomiting and purging, and want of sleep. A suspension of the
disease for a single day is often of great moment under these
circumstances. But narcotism is to be deprecated, as deranging
still more the nervous system, and increasing its susceptibility to
existing morbid causes.
Sometimes relief is obtained at once, though seldom a cure, unless
suitable prophylaxis be attended to, by the administration of minute
doses of calomel, as when an eighth to a twelfth of a grain, mixed
with five grains of gum arabic, is given every three or four hours.
Of late years I often prescribe, in place of gum, about the same
quantity of prepared chalk to be carefully mixed with the calomel, on
which it exerts of course a chemical, and, in reference to its the-
rapeutical activity, what might be called a reducing power. A
practice, occasionally successful, consists in giving in the early stage,
in advance indeed of any other remedy, one to two or three grains
of calomel, regardless of its causing a sickness of stomach and
vomiting itself, as these soon subside: the subsequent purging and
evacuation of green, slimy, and bilious stools are regarded as proofs
of beneficial action on the liver, by exciting it to freer secretion, and
thus unloading it of congestion. With similar therapeutical inten-
tions, small fractional doses of calomel, as above, are used by many
practitioners, especially in Philadelphia. There is not, I believe,
any one remedy which displays such strikingly curative powers, in
41*
486 DISEASES OF THE DIGESTIVE SYSTEM.
either arresting the disease or mitigating its violence, as this
does: but a recurrence or relapse is frequent after its use, and then
a repetition of the remedy will not be followed by the same sana-
tive effect as before. Oil of turpentine, in a dose of from three to
five drops on a few grains of sugar, has acted favourably in relieving
vomiting.
When the heat of the skin, and especially that of the abdomen, is
great, cloths dipped in cold water, or even affusions of cold water
on this region, have been used with, as we learn, very satisfactory
results. I have found such means afford temporary relief, by abating
the fever and restlessness; but they did not exert any controlling
power over the disease. More might be expected during the
period of febrile excitement and gastric irritation by the injection
of cold or even iced water, as recommended by Dr. Miller. He
refers to Cleghorn's report of the Spanish medical practice of
allowing the drinking of cold water to patients with violent cholera.
I have often directed, with soothing effect, an enema of water of the
common temperature of the air, at the time, between 65 and 70° F.;
and upon the whole, I am inclined to believe this to be the better
practice.
Sugar of lead is found to be well adapted to allay the vomiting
and abdominal pains, and certainly may be had recourse to'long in
advance of any other medicine of the class (astringents) under
which it is,but, as I conceive,somewhat arbitrarily ranked. The sub-
acetate of lead is certainly more distinctly sedative than astringent,
and is best adapted to follicular inflammation of a sub-acute or
chronic kind ; hence its use in chronic diarrhoea and leucorrhoea,
and as an injection in this latter disease and gonorrhoea. Failing
to tranquillise the stomach in twelve hours, the use of this medicine
should be withheld until the disease falls into the diarrhceal stage,
when recourse may be had to it with greater benefit. If its use is
thought proper in the stage of which I am now speaking, it will be
given in a dose of a fourth, to a third, or half of a grain, combined
with a few grains of gum arabic, every two hours. It is given
often in conjunction with opium, so often indeed in this as in all the
diseases in which it is used, that there would seem to be a necessary,
I was going to say inevitable connexion between sugar of lead and
opium. The fact illustrates both the strong adherence to routine
practice, and some mistrust in the therapeutical powers of the salt
of lead. Better, by far, particularly in the early stage of gastro-
intestinal disease, give it alone, and if it fail to produce the expected
effect, then, either to suspend its use, or to combine with it a minute
quantity of opium. The same remark applies with equal force to
calomel in cholera, as well as in many other analogous diseases.
TREATMENT OF CHOLERA INFANTUM.
487
LECTURE XXXIX.
DR. BELL.
Cholera Infantum (Concluded).—Caution not to irritate the stomach by needless
repetition of either food or medicine—Danger of relapse during hot weather—
Remedies for the diarrhoea after vomiting has ceased—Nitrate of silver—alu-
mina—Dr. Durr's cases, illustrative of German practice—Astringents,—of
secondary value—Treatment when the disease remits—Renovation by fresh
air—Treatment in the state of collapse with diseased brain—Proper food
for the patient—Drinks,—great importance of selecting them and regulating
their use—Removal of irritation from teething—Paramount importance of
pure air, day and night—Bathing—Continued watchfulness on the part of the
mother to withhold all irritating ingesta—Preservation of equable tempera-
ture of the skin—Prophylaxis,—cool air, cool bathing, cool drinks, and proper
food at stated intervals.
In the administration of both medicines and food at this period,
and when the patient is no longer harassed by vomiting, but still
has irritable stomach, it is a point of the greatest importance to let
suitable intervals elapse between the dose or the meal. Not un-
frequently we have the mortification of learning that the first dose
stayed the vomiting, while after the second it came on, must we
not say, was brought on. So in respect to food, whether derived
from the mother's breast or given by the bottle or by spoon, it
is deemed by many highly necessary that the supply should be fre-
quent but in small quantities. Now, this is a means itself of keep-
ing up perturbation of the stomach. The preferable plan is, to allow
the child nearly as much as its appetite craves at the time, and then
not present any food to it until a period has elapsed when we may
suppose it has passed from the stomach. Frequent feeding I hold to
be as bad as excessive repletion at long intervals. Nor can pro-
longed abstinence be recommended in the disease now under
consideration. It alone will render the stomach irritable, or at
least less able to retain and digest the proper allowance of food
afterwards.
Towards the decline of the first stage of cholera proper, or that
of vomiting and purging, the least indiscretion on the part of the
mother or physician will renew the sickness of stomach. The
slightest change in the food, as when the mother allows herself to
be irritated or needlessly annoyed, and secretes bad milk in conse-
quence, or carelessly gives cow's milk, which is ever so little turned,
or, yielding to the persuasion of the last intrusive gossip, some new
specific, will bring back the vomiting. Medicine continued after
the more pressing indications for its use in the first instance are
fulfilled, will sometimes have the same effect. Change of posture
from the recumbent to the sitting posture, or that approaching to
it in the mother's or nurse's arms, will also bring back the vomit-
ing ; and hence the injunction, on both mother and nurse, to keep
the child in a posture of half recumbency, whether it be in the
488 DISEASES OF THE DIGESTIVE SYSTEM.
arms in the nursery or in the open air, or in a carriage. A hot
night, during which fresh air has been excluded from the room, will
also have the same deleterious influence, which is not a little
increased, if, in place of quieting the restlessness of the patient by
giving it a few spoonsful of cool toast and water, or plain water, it
is attempted to be soothed by being put frequently to the breast, or,
more than all, allowed to remain at it asleep.
The vomiting once checked, and the more immediate distress of
stomach removed, there is often such an abatement of the other
symptoms as to promise speedy convalescence. This result cannot,
however, be considered permanent, so long as the great heats of
summer prevail, and the irritation of teething is continued. There
is a risk that the complaint, after a temporary cessation, will assume
a fixed diarrhoea, varying in its character; in its being sometimes
bilious, but more commonly serous or mucous, and gradually by
its persistence wearing out the strength of the patient. If it con-
tinue, the symptoms of cerebral disease increase, and towards the
fatal conclusion of the disease, they might impose on a person, who
had seen the case only in this stage, a belief of its being a true hydro-
cephalus, or a dropsical effusion on the membranes of the brain.
It is not necessary to enumerate the different remedies and their
combinations which are supposed to be applicable at this time, as
most of them have been noticed at the time when speaking of
'Diarrhoea.' Of those which maybe considered as of more recent
introduction and use in cholera infantum, sugar of lead stands high
in the opinion of some practitioners,— both in the first cholera stage
and,- still more, in the second or diarrhceal. Nitrate of silver,
also, you may remember, I pointed out to you as an available
remedy in dysentery, and in the chronic diarrhoea of children
(Lect. XIX., p. 253). Some years ago it was used in the case of
his own child, by Dr. Skinner, of Hertford, North Carolina (Am.
Jour. Med. Science, vol xi., p. 253). Dr. S. gave the nitrate, in the
advanced or diarrhceal stage, in a dose of a grain mixed in a tea-
spoonful of mucilage of gum arabic, every four hours; gradually,
after the first day, increasing the dose, and giving it at shorter inter-
vals. It was discontinued on the third day; all the urgent symp-
toms having been removed, and convalescence fairly begun. The
dose of one grain is larger than it would bo thought advisable to
begin with in a subject of the age of Dr. Skinner's child, which was
seventeen months old. M. Trousseau advises a fifth of a grain for
a dose, and a grain for an enema.
Prepared alumina (argil) has been extolled by same German
practitioners, and particularly by Dr. Diirr, as a remedy adapted
to even the earlier stage of cholera infantum. To be successful
with its use, the doses must be pretty large, as from half a drachm
to a drachm in divided quantities, in syrup, or any proper vehicle
during the twenty-four hours. It will not be without instruction'
if I repeat here the outlines of the practice of Dr. Durr, as some-
what illustrative of the treatment of the disease in Germany* where
it prevails, I should suppose, to a greater extent than in France or
TREATMENT OF CHOLERA INFANTUM.
489
England. I will even go further, and premise a sketch of the
symptoms as I find them laid down by the writer in question, in
the British and Foreign Medical Review, vol. i.
" The chief symptom, of this dangerous affection, which runs its
course in from two to ten days, is profuse vomiting, without any
effort, of a sour-smelling fluid, varying in consistence ; in many
cases diarrhoea had lasted a whole week, when the first alarm was
excited by the sudden appearance of vomiting. Collapse and rapid
emaciation of the body followed, with depression of the anterior
fontanelle : hollowness of the eyes, paleness,alteration and shrinking
of the features, cold extremities, hot occiput, and more or less fever ;
agrypnocoma, or a lethargic state without actual sleep, restlessness,
crying,'whining, throwing itself from one arm of the nurse to the
other, drawing up the feet to the abdomen, want of appetite, great
thirst, stiffness in the nape of the neck, and the stomach so distended
that it projected in the left hypochondrium like a distended bladder.
"Dr. Durr's practice in this disease was to quiet the irritation in
the stomach and bowels by emollient oleaginous remedies in com-
bination with the argill: to excite the activity of the skin by extr.
cicutae internally, and the application of an epispastic powder ex-
ternally. The immediate effects of this were diminished frequency
of the evacuations, the natural yellow colour returning, quiet, exco-
riations in the folds of the skin about the neck and groins. In very
young children the cerebral affection was often allayed merely by
the chlorine water (aqua oxymur.); in older children, or where the
symptoms were more violent, by leeches -to the scrobiculus cordis,
or behind the ears, according to circumstances; the dryness of
the skin, the lethargy, and coldness of the extremities, were treated
with baths of chamomile and salt, and with cold lotions to the head ;
warm stimulating aromatic fomentations were used from time to
time, and enemata of elder and linseed, to which the yolk of an egg
rubbed down with linseed oil was added. Dr. D. assures us that,
in other acute diseases also, where the rough, dry stale of the skin
had defied the usual remedies, gentle perspiration had followed the
use of these enemata. The epispastic powder which he mentions,
was first described by Autenrieth; it consists of fresh prepared
mezereon bark powdered. When the skin is not very delicate, it
not unfrequently fails to produce any effects. Dr. D. has used it
combined with calomel, and in very severe cases with corrosive
.sublimate, with great certainty and effect. The spot to which it
is applied usually becomes red in the course of:from six to twelve
hours, and in about as much more time, moist and excoriated. If
the powder will not stick, he moistens the spot with a little saliva
or lard.
" The result of his practice is decidedly favourable: of 67 children
from the time of birth to the age of fifteen months which he has
treated for this disease during 1833 and 1834, he lost only seven.
Dr. Diirr has given several interesting cases, both successful and
unsuccessful, together with the examinations of the latter after
490
DISEASES OF THE DIGESTIVE SYSTEM.
death. Great congestion of the cerebral vessels, and considerable
softening of the stomach, so that portions of it were quite pulpy,
were the chief features, and in one case there was perforation."
It is not necessary, nor to be expected of me, to enumerate every
astringent which by one practitioner or another has been used
in cholera. In their strictly curative powers, I have small faith.
Early in the disease they are injurious; later they may commonly be
dispensed with, unless we are assured that there is simple anemia,
and, as regards the follicular apparatus, a simple relaxation of tissue
without inflammation either of the glands or the intermediate mu-
cous membrane. When we have recourse to them, it is better to
take one or two from the class which contain in largest proportion
the tannic acid, or we may administer this latter itself ^n suitable
dose; and thereby avoid the risk of offending the stomach and
intestines by woody and inert extractive matter. Next to tannin
will come nutgalls in powder, tincture, or infusion, rhatany (kra-
meria), and kino. Country practitioners, on whose judgment in the
treatment of diseases and the relative powersof medicines with which
they are familiar, we may repose considerable confidence, employ
several indigenous plants of the astringent class in the diarrhoea of
children. Of these cranesbill or geranum, rubus villosus and r. tri-
vialis, or blackberry and dewberry roots, uva ursi or bear-berry,
and chimaphila, or pipsissewa, are the most esteemed.
In my own practice I rely more on the means before indicated,
both of a hygienic and medicinal character, for the reduction of gas-
tro-intestinal irritation, and of nervous and vascular excitement, than
on any specific operation from a particular remedy, or class of
remedies. Following out this course, if, after a subsidence of the
vomiting, and an abatement of febrile action, there should be daily
paroxysms or distinct remissions, I prescribe sulphate of quinia, in
a dose of from an eighth to half of a grain twice in the early part
of the day ; and a minute portion of Dover's powder, or a fraction
of a grain of calomel with chalk, or chalk and ipecacuanha in the
evening; and direct the warm bath at the same time.
In a degree of the disease beyond this again, it is not unusual
to find the little patient with the skin cold and clammy, and the
prostration and torpor of the system considerable. He lies nearly
all the time listless and unobservant of anything passing around;
but when roused, will take food with considerable avidity. It is
now that animal broths, especially beef and chicken, from which
the fat has been carefully skimmed, can be given with advantage:
but not to the exclusion of the farinaceous food heretofore used by
the patient. At this time I have myself derived the best effects
from sulphate of quinia administered in solution. It invigorates
the patient, serves to correct the morbid state of the bowels, and
every way exerts a cordial effect. Its use does not, of course,
prohibit the continuance of other remedies adapted to particular
symptoms, — such as the chalk mixture, Dover's powder, or ipe-
cacuanha and magnesia. Oil of turpentine is used, in the ad-
TREATMENT OF CHOLERA INFANTUM.
491
vanced stage, with benefit, and even in the earlier stages sometimes
quiets the irritability of the stomach. The warm, or if there be any
reaction the tepid bath, to be followed by assiduous frictions over
the body, and particularly the abdomen, along the spine, and the
lower hmbs, is an exceedingly useful adjunct to the remedies already
indicated. Rubefacients over the epigastrium or other parts of the
abdominal surface are to be preferred to vesication, from which,
and especially if repeated, I have seldom seen good to result. The
tincture of the sesquichloride of iron, the tinctura ferri muriatis, I
have found to check obstinate diarrhoea in children. Dr. Chapman
speaks highly of the bi-sulphate in solution with sugar, in a dose of
a fourth of a grain. The restorative effects of fresh air in cholera
infantum a-a <
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GIENE: — Reid's Experimental Investigation into the Functions
of the Eighth Pair of Nerves.
Ehrenberg's Microscopical Observations on the Brain and Nerves;
with numerous Engravings.
On the Combination of Motor and Sensitive Nervous Activity; by
Prof. Stromeyer, Hanover.
Vegetable Physiology. c3s<
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Mayer, of Bonn; with wood cuts.
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during 1836. By Pro. Muller.
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AN ESSAY ON HYSTERIA. With numerous Illustrative and Curious ^ -j 1 00
Cases. By Thomas Lay cock. J o
CLINICAL REMARKS on some Cases of LIVER ABSCESS pre-")
senting externally. By John G. Malcolmson, M.D., Surgeon Hon. E. I. ( «
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C. Service, &c. I S J r> 45
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ELEMENTS OF SURGERY, in Three Parts. By Robert Liston,
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&c. Third American, from the Second London Edition, with upwards .
of one hundred and sixty illustrative engravings. Edited by Samuel D. | "§ | * *^
Gross, M.D., Professor of Surgery, Louisville Medical Institute. Author '
of Elements of Pathological Anatomy, etc.. etc. 1 vol. 8vo.
THE HISTORY, PATHOLOGY, AND TREATMENT, OF PUER-"} f
PERAL FEVER AND CRURAL PHLEBITIS. By Drs. Gordon, | » I
Hey, Armstrong, and Lee; with an INTRODUCTORY ESSAY I g J *, Kf1
by Charles D. Meigs, M.D., Professor of Obstetrics and the Diseases (■%} *1 W
of Women and Children in the Jefferson Medical College, Philadel- 3 |
phia. 1 vol. 8vo. . . . . . . J I
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OF DIGESTION. By Robert Dick, M.D., author of " A Treatise on Diet
and Regimen." J vol. 8vo. 10 sheets. . . . . 1 40
DISEASES OF THE LIVER AND BILIARY PASSAGES, by^j „• f
William Thomson, one of the Physicians of the Royal Infirmary of I "S I
Edinburgh; and CLINICAL ILLUSTRATIONS OF THE LIVER \a{ 1 60
AND SPLEEN, by William T
of Calcutta, &c, &c, 1 vol. 8vo.
AND SPLEEN, by William Twining ; Surgeon of General Hospital j ^
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with notes by S. Merriman, M.D., and Marshall Hall, M.D., | " ]
F.R.S., &c, with notes by John Bell, M.D., &c. . . J 2 (^
LECTURES ON THE FUNCTIONS AND DISEASES OF THE"")
WOMB; by Charles Waller, M.D., Bartholemew's Hospital. I <&
ON DISEASES OF THE UTERUS AND ITS APPENDAGES; I g ,
by M. Lisfranc, La Pitie Hospital. /-«S l 1U
ON DISEASES OF THE PUERPERAL STATE; by J. T. Ingleby |
Edinburgh, 1 vol. 8vo. J ' ^
APHORISMS ON THE TREATMENT AND MANAGEMENT OF
THE INSANE ; by J. G. Millingen, M.D. 1 vol; 8vo. 4 sheets. . 0 38
A PRACTICAL DICTIONARY OF MATERIA MEDICA, Includ-"!
ing the Composition, Preparation and Uses of Medicine; and a large j °j
number of Extemporaneous Formulae: together with important Toxi- ! g j
cological Observations; on the Basis of Brande's Dictionary of Materia fis ] 2 25
Medica and Practical Pharmacy: by John Bell, M.D., Lecturer on
Materia Medica and Therapeutics, &c,&c. 1 vol. 8vo. j
OUTLINES OF PATHOLOGICAL SEMEIOLOGY. Translated from
the German of Professor Schill. With copious notes by D. Spillman,
M.D., A.M., &c, &c. 1 vol. 8vo. 9 sheets. . . . . 1 00
ARET.EUS ON THE CAUSES AND SIGNS OF ACUTE AND
C HRONIC DISEASE. From the Greek, by T. F. Reynolds, M.B., F.L.S.,
&c, &c. 1 vol. 8vo. 4 sheets. . . . . .50
LECTURES ON THE MORBID ANATOMY, NATURE, AND"")
TREATMENT OF ACUTE AND CHRONIC DISEASES. By I f
the late John Armstrong, M.D., Author of " Practical Illustrations of \-3s"i 2 75
Typhous and Scarlet Fever," &c. Edited by Joseph Rix, Member of [ ™
the Royal College of Surgeons. 1 vol. 8vo. J c"
BLUNDELL'S LECTURES ON THE PRINCIPLES AND PRACTICE
OF MIDWIFERY. Edited by Charles Severn. 1vol. 8 vo. 19 sheets. .2 00
Sept., 1842.
--------—---------------—--- •
OK
ANATOMY, MEDICINE, SURGERY,
AND
THE COLLATERAL SCIENCES.
PUBLISHED BY
ED. BARRINGTON & GEO. D. HASWELL
293 MARKET STREET, PHILADELPHIA.
Ill W03E&,
LISTON'S ELEMENTS.
ELEMENTS OF SURGERY, in Three Parts. By Robert Liston, Fel-
low of the Royal College of Surgeons in London and Edinburgh, Surgeon
to the Royal Infirmary, Senior Surgeon to the Royal Dispensary for
the City and County of Edinburgh, Professor of Surgery in the London
University, &c. &c. Third American, from the Second London Edition,
with upwards of one hundred and sixty illustrative engravings. Edited by
SAMUEL D. GROSS, M.D.,
Professor of Surgery, Louisville Medical Institute. Author of Ele-
ments of Pathological Anatomy, etc., etc. 1 vol. 8vo.
"We are here presented with a republication of Mr. Liston's admirable and much praised*
work on Surgery, which has been subject to the alembic of a critical, and learned friend,
Dr. Gross. He has added " copious notes and additions,'' such as the progress of surgery
in the United States demands in order to meet the wants of the surgeon. Professor Gross
has also given an entire article on Strabismus, and another on Club Feet, which were wholly
omitted in the English copies. They may be regarded important, inasmuch as they give a
completeness to an otherwise unfinished treatise. The execution of the book is good ; the
paper firm, and well secured in the binding. The plates are uniformly well executed, and
the impressions distinct."—Boston Med. and Surg. Jour.
" In another essential feature this edition is greatly improved. With the principles is
taught a,lso with it the practice of surgery; and both morbid structure and operations are
doubly described ; first by the author and editor, and next by the graver of the artist."—
Bull. Med. Scien.
" Mr. Liston's reputation as a clear, accurate, and scientific surgical writer, is so widely
known and admitted,that formal panegyric is quite unnecessary Dr. Gross has discharged
his duties as editor, with all the souh I sense, accurate discrimination, and experienced
judgment, which all who knew him expected. The additions and notes, are indeed profitable
and interesting; and our only regret is, that thev are not still more numerous than they are.
The volume is inscribed to Professor Parker, of the College of Physicians and Surgeons in
this city,—the beauty of its typography, and 'eeuing up,' will be readily taken for granted
by all who know the publishers,—and the illustrative engravings are executed in a style
very creditable to American art."—N. Y. Lancet.
5421
2 STANDARD MEDICAL WORKS
PUERPERAL FEVER.
THE HISTORY, PATHOLOGY, AND TREATMENT OF PUER-
PERAL FEVER AND CRURAL PHLEBITIS. By Drs.
Gordon, Hey, Armstrong, and Lee ; with an INTRODUCTORY
ESSAY by Charles D. Meigs, M.D., Professor of Obstetrics and
the Diseases of Women and Children in the Jefferson Medical
College, Philadelphia. .1 vol. 8vo.
" We have peculiar satisfaction, in announcing the publication of this very judiciously
arranged series of treatises, on one of the most important and interesting diseases, which
demand the attention of the physician." "Dr. Meigs'Introductory Essay is concise and judi-
cious, and will be read with profit. He speaks in the highest terms of commendation of Dr.
Gordon's invaluable treatise — a treatise which' cannot be too generally diffused and studied.
Altogether this volume presents the most acceptable and useful compend of the doctrines
and practice of the best authorities, with regard to 'Puerperal Fever,' with which we have
•ver met."—N. Y. Lancet.
DIGESTION.
DERANGEMENTS, PRIMARY and REFLEX, of the ORGANS of
DIGESTION. By Robert Dick, M.D., author of " A Treatise on
Diet and Regimen." 1 vol. 8vo.
* It is the fullest, most comprehensive, and decidedly the best account of derangements of
the digestive organs that we have encountered. While it embraces all that is important or
interesting to be found in the writings of other authors, it contains much original informa-
tion, which the physician will find of great practical usefulness."—Western and Southern
Medical Recorder.
" We recommend this volume most warmly to the attention of our readers."—London
Lancet, No. 937.
" This volume may, in fact, be denominated with no small degree of propriety, an ency-
clopedia of dyspeptic disorders, and we unhesitatingly commend it, as the most useful and
comprehensive treatise on this class of diseases, with which we are acquainted.—N. Y.Lancet.
" We have perused this work with pleasure and instruction. It is decidedly the best
compilation in the English language on the extensive' class of disorders and diseases
comprehended under the term dyspepsia, united with a very large proportion of original
matter, both in the form of able comments on other writers,and practical information
derived from the author's own experience."—Johnson's Medico-Chirurg. for Jan. 1842.
IiIVER AND SPLEEN.
DISEASES OF THE LIVER AND BILIARY PASSAGES;
by William Thomson, one of the Physicians of the Royal Infir-
mary of Edinburgh ; and CLINICAL ILLUSTRATIONS OF
THE LIVER AND SPLEEN, by William Twining; Surgeon
of General Hospital of Calcutta, &c, &c, 1 vol. 8vo.
" The present work we regard as remarkably well calculated to remove several of the
objections and difficulties now referred to. It is distinguished throughout by a much greater
degree of precision in the pathological history ofthe different morbid states ofthe liverthan
any work hitherto published on that subject. It contains not enly the most ample and
complete accounts of the various dynamic disorders and organic changes incident to the
organ hitherto given, but these states are described and distincuished in a much clearer
and more methodical manner than any other treatise yet before the public. In accordance
with this we observed, also, in the therapeutic principles and precepts established by the
author, a much more ratjonal development and application of therapeutic measures than it
has yet been our fortune to witness."—Edinburgh Med. and Sur. Journal. October, 1841.
" The work before us is an excellent compilation of the subject of hepatic affections,
functional and structural; and, as such, it is infinitely more valuable to practitioners and
students, than any original essay, however ably executed. We cannot do better, therefore,
than strongly recommend the work as the best in the English language, on the important
subjects of which it treats.—Medico-Chirurg. Rev. October, 1841.
" These two works, when united, form, we may safely say, one of the most valuable and
attractive volumes on this important class of diseases which have been issued from the
press. We may, en passant, remark, that the volume is got up in a very superior style."—
AT. Y. Lancet, March 26,1842.
CLINICAL REMARKS ON SOME CASES OF LIVER ABSCESS
PRESENTING EXTERNALLY. By John G. Malcolmson.M.D.
Surgeon Hon. E. I. C. Service, Fellow of the Royal Asiatic Society, and
the Geological Society, London, 1 vol. 8vo.
PUBLISHED BY BARRINGTON AND HASWELL. 3
MATERIA MEDICA:
A PRACTICAL DICTIONARY OF MATERIA MEDICA, includ-
ing the Composition, Preparation and Uses of Medicines,- and a large
number of Extemporaneous Formulae .- together with important Toxi-
cological Observations,- on the Basis of Brande's Dictionary of Materia
Medica and Practical Pharmacy ,■ by John Bell, M.D., Lecturer on
Materia Medica and Therapeutics, &c. '&c. 1 vol. 8vo.
. "Mr..Brande's is an excellent work, and with the retrenchments, additions, and altera-
tions of Dr. Bell, may be regarded as one of the most valuable works on the Materia
Medica, we now possess. It has an important advantage over many of the treatises on this
subject, ingiyingalarge number of prescriptions for the administration ofthe principal
articles. This renders it especially valuable to the young practitioner." —Bait. Jour.
A THERAPEUTIC ARRANGEMENT and SYLLABUS of MATERIA
MEDICA. By James Johnstone, M.D., Fellow of the College of Physi-
cians, aud Physician to the General Hospital, Birmingham.
" This book cannot but be particularly useful to those who intend to lecture or write
upon the Materia Medica; as well as to the students for whose particular use it is pre-
pared."— Brit, and For. Med. Rev.
-ETIOLOGY.
ARETiEUS ON THE CAUSES AND SIGNS OF ACUTE and
CHRONIC DISEASE. From the Greek, by T. F. Reynolds,
M.B., F.L.S., &c, &c. 1 vol. 8vo.
" The correct detail of symptoms, the nervous style, the graphic delineation of disease,
displayed in this author's work, the poetic and quaint fancies scattered throughout, give a
certain value and interest, that may fairly excuse an attempt to reinvest part of them in a
vernacular garb."
" We certainly have no hesitation in recommending this curious volume to the notice of
our readers. Its price is a mere trifle."—New York Lancet.
SEIVTEIOLOGY.
OUTLINES OF PATHOLOGICAL SEMEIOLOGY. Translated
from the German of Professor Schill. With copious notes by
D. Spillman, M.D., A.M., &c, &c. 1 vol. 8vo.
"The'signs of disease exhibited by the principal tissues and organs, are treated of in a
succient and comprehensive manner, by Dr. Schill, and as a work of daily reference to
assist in distinguishing disease's it cannot be too highly commended."—Bait: Jour.
" An elegant and accurate translation of a very ingenious and instructive work. We do
not know any other source from which we can so easily and profitably obtain all that is
really useful in the semeiology of the ancients; and the erudite translator and editor has
so very creditably supplied tpe deficiencies of the author's abrige of the labors of modern
workers, In this most important department of modern science, that we can in good con-
science commend the book as one of unequivocal merit."—New York Lancet.
VENEREAL.
HUNTER'S TREATISE ON THE VENEREAL DISEASE. With Notes
by Dr. Babington. With Plates. 1 vol. 8vo.
"Under the hands of Mr. Babington, who has performed his task as editor in a very
exemplary manner, the work has assumed quite a new value, and may now be as
advantageously placed in the library of the student as in that of the experienced sur-
geon."—Brit, ifr For. Med. Rev.
"The notes, in illustration ofthe text, contain a summary of our present know-
ledge on the subject; the manner in which these notes are constructed is at once clever
and perspicuous; and the modes of treatment prescribed, spring from a right apprehension
of the disease. We would recommend to the reader the note on the primary venereal
Bore ; the note itself is an essay in every word of which we fully concur."—Med. Qai.
A PRACTICAL TREATISE ON VENEREAL DISORDERS, AND
MORE ESPECIALLY ON THE HISTORY AND TREATMENT
OF CHANCRE. By Philippe Ricord, M.D., Surgeon to the Venerea
Hospital at Paris. 1 vol. 8vo.
4 STANDARD MEDICAL WORKS
GRAVES 6l GERHARD.
CLINICAL LECTURES; by Robert J. Graves, M.D., M.R.S.A.,
Professor of the Institutes of Medicine in the School of Physic,
Trinity College, Dublin, with additional Lectures and Notes, by
W. W. Gerhard, M.D., Lect. on Clin. Med. to the Univ. of Penn.'
Physician to the Philadelphia Hospital, Blockley, etc. 1 vol. 8vo.
" In the volume before us, a seriesof clinical lectures by Dr. Gerhard is given, and forms a
most appropriate and acceptable addition to those of Dr. Graves. Between these two dis-
tinguished physicians we can trace many points of resemblance. We find in both the same
professional zeal,— the same powers of close and correct observation, —the same discrimi-
nating tact,—the same disregard of idle theory,— and the same decision in the application
of right principles. No student or practitioner should be without this volume. It is in itself
a library of practical medicine.''—N. Y. Lancet.
"No man in the profession has done more for clinical instruction in this country than
Professor Gerhard. The lectures of Professor Graves have been long before the public, and
the fact of a second edition being called for, is proof that their value is understood. Our
space will not allow us to give a detailed notice of them, we can only commend them
heartily to our readers. To the student and young practitioner they are truly invaluable;
especially would we recommend them to students pursuing their studies in the country,
and who have no opportunity of seeing hospital practice. Reading, we all know, is but a
poor substitute for clinical observation, still where the latter cannot be obtained, the study,
not the mere reading, but .this study of these lectures of Graves and Gerhard, is the best
substitute we know of—to country students, then, in particular, we would earnestly recom-
mend this book. Ofthe lectures which Professor Gerhard has added, we will only say, that
they are worthy to be associated with those of Graves ; as Americans, we are proud of the
association, proud to see one of the first, if not the very first, of the European Clinical
Teachers followed " possibles aegiis" by our countryman."—N. Y.Med. Gaz.
"This volume contains a fund of practical matter, useful and interesting to the practi-
tioner and student. There are few works which will better repay a perusal."—Am. Jour.
of the Med. Sciences.
DISEASES OF CHILDREN1.
A TREATISE ON THE DISEASES OF CHILDREN; WITH
DIRECTIONS FOR THE MANAGEMENT OF INFANTS;
by the late Michael Underwood, M.D. From the ninth English
edition, with Notes, by S. Merriman, M.D., and Marshall Hall,
M.D., F.R.S., etc. ; with Notes, by John Bell, M.D., etc., of
Philadelphia, 1 vol. 8vo.
TETANUS.
A TREATISE ON TETANUS, being the ESSAY for which the Jacksomian
Prize was awarded by the Royal College of Surgeons in London. By
Thomas Blizard Curling,Assistant Surgeon to the London Hospital,&c.
" This book should be in the library of every surgeon and physician. It is a valuable
work of reference. It does not pretend to originality, for originality on such a subject
was not wanted. But a compendium of facts was wanted, and such a compendium is this
volume. We cannot part from Mr. Curling without thanking him for the information
we have received in reading his work, and for the matter it has enabled us to offer
to our readers."—Medico-Chir. Rev.
EXES.
A MANUAL OF THE DISEASES OF THE EYE. By S. Littell,
Jr., M.D., one of the Surgeons of the Will's Hospital for the blind
and lame, &c, &c.
"We confidently recommend the work of Dr. Littell to the senior, as well as to the
junior, members of the profession. It is replete with inforn.ation; yet so terse in style
and compressed in bulk, as at once to entice and repay perusal. It is no small triumnh
to the author to be able to say that he has introduced almost all that is valuable and
everything absolutely necessary to the student within the compass of 200 paces and we
would deliberately recommend our young friends to read this work."— Br $For Med Rev
GUMS.
THE GUMS; with late Discoveries on their Structure, Growth Connections
Diseases, and Sympathies. By George Waite, Member ofthe London
Koyal College of Physicians. 1 vol. 8vo.
PUBLISHED BY BARRINGTOX AND HASWELL. 5
CHEST.
LECTURES on the PHYSIOLOGY and DISEASES of the CHEST,
including the Principles of Physical and General Diagnosis, illustrated
chiefly by a rational Exposition of their Physical Signs: with new re-
searches on the sounds ofthe heart. By Charles J. B. Williams, M.D.;
Third edition, 1 vol. 8vo.
" Evidently written by a man thoroughly acquainted with his sul: ject."—Lancet.
" We strongly recommend this work to the attention of auscultators."—Med. Chir. Rev.
"I gladly avail myself of this opportunity of stronglyrecommending this very valuable
work."—Dr. Forbes's Translation of Laennec.
"Of all the works on this subject, we are inclined much to prefer that of Dr. Williams."—
Med. Gaz.
LECTURES ON THE DIAGNOSIS, PATHOLOGY, AND TREAT-
MENT OF THE DISEASES OF THE CHEST. By W. W.
Gerhard, M.D., Lecturer on Clinical Medicine in the University of
Pennsylvania, etc., etc. 1 vol. 8vo.
" A series of clinical lectures — concise, lucid, and eminently instructive. We have no
more able expositor of diseases ofthe chest than Dr. Gerhard, and any work of his on these
important subjects is certain of grateful acceptance by his professional brethren."—New
York Lancet.
" To our readers, therefore, we recommend the book of Dr. Gerhard as the fullest and
most judicious manual, in relation to the diseases of the chest, which they can procure."—
Western and Southern Recorder, June, 1842.
" These lectures constitute a useful and practical digest of the.existing knowledge of the
diseases of the chest (lungs, and heart)."—Bulletin of Medical Science.
A PRACTICAL TREATISE onlhe PRINCIPAL DISEASES of the
LUNGS. Considered especially in relation to the particular
Tissues affected, illustrating the different kinds of Cough. By
G. Hume Weatheihead, M.D., Member of the Royal College of Physi-
cians,Lecturer on the Principles and Practice of Medicine, and on Materia
Medica and Therapeutics, &c. &c. 1vol. 8vo.
PRACTICAL OBSERVATIONS onDISEASES ofthe HEART, LUNGS,
STOMACH, LIVER, &c, OCCASIONED by SPINAL IRRITA-
TION: AND ON THE NERVOUS SYSTEM IN GENERAL, AS A
SOURCE OF ORGANIC DISEASE. Illustrated by Cases. By John
Marshall, M.D. 1 vol. 8vo.
CUTANEOUS DISEASES.
A PRACTICAL TREATISE ON DISEASES OF THE SKIN, arranged
with a view to their Constitutional Causes and Local Character, &c.
By SAMUEL PLUM BE, lale Setiior Surgeon to the Royal Metropolitan
Infirmary for Children, &c. Illustrated with Splendid Coloured Copper-
plate and Lithographic Engravings. ] vol. 8vo.
Plumbe on Diseases of the Skin.—"This excellent Treatise upon an order of diseases't
the pathology of which is, in general, as obscure as the treatment is empirical, has jusr-
been republished, edited by Dr. John Bell, of this city. We hail with pleasure the appeaof
ance of any new work calculated to elucidate the intricate and ill-understood subject he
skin-diseases. The late Dr. Mackintosh, in his Practice of Physic, recommends it as the
' best pathological and practical treatise on this class of diseases, which is to be found
in any language.'"—Phil. Med. Exam., Jan. 17, 1838.
" This work is one of the most excellent on the Diseases of the Skin in the English
language."—West. Jour, of Med. and Phys. Sciences, Jan. 1838.
BANDAGES AND BANDAGING,
THE SURGT.OVS PRACTICAL GUIDE IN DRESSING, and in the
Methodic APPLICATION of BANDAGES. Illustrated by one hun-
dred engravings. By Thomas Cutler, M.D., late Staff Surgeon in the
Belgian Army.
" The Author seems to have spared no pains in procuring correct descriptions of all the
surgical apparatus, at present employed in bandaging anrf dressing, both at home and
abroad. He has given numerous illustrations, in the form of well executed woodcuts, and
has altogether proluced what we conceive to be a very useful, and by no means an expen-
sive publication."—Medical Gazette.
6 STANDARD MEDICAL WORKS
CLINICAL MEDICINE.
MEDICAL CLINIC; or, Reports of Medical CASES: By G.
Andral, Professor of the Faculty of Medicine of Paris, etc.
Condensed and Translated, with Observations extracted from the
Writings of the most distinguished MedicalAuthors: By D. Spil-
lan, M.D., etc., etc.; containing Diseases of the Encephalon, &c,
with Extracts from Ollivier's Work on Diseases of the Spinal Cord
and its Membranes. 1 vol. 8vo.
LECTURES on Subjects connected~with CLINICAL MEDICINE By
P. M. Latham, M.D. Fellow of the Royal College of Physicians and
Physician to St. Bartholomew's Hospital.
"We strongly recommend them [Latham's LecturesJ to our readers; particularly
to pupils attending the practice of our hospitals."—Lond. Med. Oaz.
TEETH.
A TREATISE ON THE TEETH. By John Hunter. With Notes by
Thomas Bell, F.R.S. With Plates. 1 vol. 8vo.
" The treatise on the teeth is edited by Mr. Boll, a gentleman accomplished in his
art. Mr. Bell has studied his subject with the greatest minuteness and care; and in ap-
propriate notes at the foot of the page corrects the author with the air of a gentleman,
and the accuracy of a man of science. The matter contained in these short notes forms
an ample scholum to the text; and without aiming at the slightest display of learning,
they at the same time exhibit a ready knowledge on every point, and an extensive in-
formation both of comparative anatomy and pathology.—Med. Gazette.
BLOOD, INFLAMMATION. ETC.
TREATISE ON THE BLOOD, INFLAMMATION, AND GUN-SHOT
WOUNDS. By John Hunter, F.R.S. With Notes, by James F.Palmer,
Senior Surgeon to the St. George's and St. James's Dispensary, &c, &c.
1 vol. 8vo.
LECTURES ON BLOOD-LETTING. By Henry Clutterbuck, M.D.
1 vol. 8vo.
HISTORICAL NOTICES ON THE OCCURRENCE OF INFLAMMA-
TORY AFFECTIONS OF THE INTERNAL ORGANS AFTER
EXTERNAL INJURIES AND SURGICAL OPERATIONS. By
William Thompson, M.D., &c. &c. 1 vol. 8vo.
A TREATISE ON INFLAMMATION. By James Macartney, F.R.S.,
F.L.S., &c, Ac. Member of the Royal College of Surgeons, London,
&c, &c. 1 vol. 8vo.
LECTURES ON THE BLOOD, and on the CHANGES which it
undergoes during DISEASE. By F. Magendie, M.D. 1 vol. 8vo.
MIDWIFERY".
A PRACTICAL TREATISE on MIDWIFERY; Containing the Results
of Sixteen Thousand Six Hundred and Fifty-four Births, occurring in
the Dublin Lying-in Hospital. By Robert Collins, M.D., Late Master
of the Institution. 1 vol. 8vo.
"The author of this work has employed the numerical method of M. Louis ; and by
accurate tables of classification, enables his readers to perceive, at a glance, the conse-
quences of the diversified conditions, in which he saw his patients.. A vast amount of
information is thus obtained, which is invaluable to those whoduly appreciate precision
in the examination of cases."—Bait. Ckron.
A PRACTICAL COMPENDIUM OF MIDWIFERY; being the
Course of Lectures on Midwifery and on the Diseases of Women
and Infants delivered at the St. Bartholomew's Hospital by the
late Robert Gooch, M.D. Prepared for Publication by George
Skinner, Member of* the Royal College of Surgeons, London,
PUBLISHED BY BARRINGTON AND HASWELL.
7
LECTURES on the MORBID ANATOMY, NATURE, and TREAT-
MENT of ACUTE and CHRONIC DISEASES. By the late John
Armstrong, M.D.; Author of " Practical Illustrations of Typhous and
Scarlet Fever," &c. Edited by Joseph Rix, Member of the Royal Col-
lege of Surgeons. ] vol. 8vo.
The British and Foreign Medical Review says of this work:
"We admire, in almost every page, the precise and cautious practical directions; the
striking allusions to instructive cases; the urgent recommendations of the pupil to
be careful, to be diligent in observation, to avoid hurry and heedlessness, to be atten-
tive to the poor. Nothing can be more excellent than the rules laid down for all the
parts ofthe delicate management of fever .patients: nothing more judicious than the
general instructions arising out of the lecturer's perfect knowledge of mankind. . . . . .
ffis prudent admonitions respecting the employment of some of the heroic remedies, as
mercury, arsenic, and colchicum, «ttest his powers of observation and his practical
merits." "The pious office of preserving and publishing, his Lectures has heen performed
by Mr. Rix, with singular ability."
INSANITY.
A TREATISE on INSANITY and other DISEASES AFFECTING the
MIND. By James Cowles Prichard, F.R.S. M.D. Corresponding Member
ofthe Institute of France, &c. 1 vol. 8vo.
" The author is entitled to great respect for his opinions, not only because he is well
known as a man of extensive erudition, but also on account of his practical acquaint-
ance with the subject on which he writes. The work, we may safely say, is the best,
as well as the latest, on mental derangement, in the English language."—MedicoChir.
Rev.
A TREATISE ON MENTAL DISEASES. By. M. Esquirol.
APHORISMS on the TREATMENT and MANAGEMENT of the
INSANE: with considerations on Public and Private Lunatic
Asylums, pointing out the errors in the present System. By J. G.
Millingen, M.D., late Medical Superintendent of Lunatic Asylum,
Hanwell, Middlesex, &c. 1 vol. 8vo.
"Dr. Millingen, in one small pocket volume,has compressed more real solid matter
than could be gleaned out of any dozen of octavos on the same subject. We recommend
his vade mecum as the best thing ofthe kind we ever perused."—Dr. Johnson's Review.
PHYSICAL AGENTS.
ON THE INFLUENCE of PHYSICAL AGENTS on LIFE. By W. F.
Edwards, M.D., F.R.S., etc. Translated from the French, by Drs.
Hodgkin anfi Fisher. To which are ad.ded„some Observations on Elec-
tricity, and Notes to the work. 1 vol. 8vo.
" This is a work of standard authority in Medicine ; and, in a physiological point of
view is pre-eminently the most valuable publication of the present century ; the experi-
mental investigation instituted by the author, having done much towards solving many
problems hitherto but partially understood. The work was originally presented in parts
to the Royal Academy of Science of Paris, and so highly did they estimate the labours
of the author, and so fully appreciate the services by him thus rendered to science and
to humanity, that they awarded him, though a foreigner, the prize founded for the
promotion of experimental physiology.
ANIMAL (ECONOMY.
OBSERVATIONS ON CERTAIN PARTS OF THE ANIMAL CECO-
NOMV", Inclusive of several papers from the Philosophical Transactions,
&c. ByJoHNHuNTER,F.R.S.,&c,&c. With Notes by Richard Owen,
F.R.S. 1 vol. 8vo.
8 STANDARD MEDICAL WORKS
SURGERY.
LECTURES OF SIR ASTLEY COOPER on the PRINCIPLES
and PRACTICE of SURGERY, with addltl«nal„tN^SmnaRn°
Cases. By Frederick Tyrrell, Esq., Surgeon to St. Thomas s
Hospital, and to the London Ophthalmic Infirmary. 1 vol. 8vo.
LECTURES ON THE PRINCIPLES OF SURGERY. Bi jom
Hunter, F.R.S. With Notes by James F. Palmer Senior^Surgeon t0
the St George's and St. James' Dispensaries, &c. &c. With Plates.
1 vol. 8vo.
"\ye have perused these lectures with no ordinary feelings of sati^*"™- ™g
embody an immense amount of important facts, directed w.tti no .common skill to
the illustration and improvement of medical science generally, and of the surgical depart
ment in particular. Indeed we have no hesitation in saying, that, w^™'™ ***
position of the reader in the profession, he will not relinquish the P™> °*pth*se.
lectures without the consciousness of having usefully employed the time which he may
have bestowed upon them. For they constitute, in the fullest sense of the term, a piiiJo-
sophicaldisquisition on the ecience of Surgery; and hence, embracing ( ,,gr£ 'J"?j
ciples on which the whole art of healing rests, their interest will be felt by all who regard
Medicine asa true branch of science, and who delight to witness the gradual development
of principles in the right interpretation ofthe phenomena of nature.
" We cannot bring our notice of the present volume to a close without offering our
testimony to the admirable manner in which the editor and annotator has fulfilled his
part ofthe undertaking. The advancements and improvements that have been ettectea,
up to our own day, not only in practical surgery, but in all the collateral departments,
are constantly brought before the reader's attention in clear and concise terms. —
Brit. Sr For. Med. Rev.
JOHN HUNTER'S WORKS.
THE COMPLETE WORKS OF JOHN HUNTER, F.R.S., 4 vols
8vo., comprising his Lectures on the Principles of Surgery; A
Treatise on the Teeth; Treatise on the Venereal Diseases; Trea-
tise on Inflammation and Gun-Shot Wounds; Observations on
Certain Parts ofthe Animal fficonomy ; and a full and comprehen-
sive Memoir. Each of the Works is edited by men of celebrity in
the Medical Science, and the whole under the superintendence of
Jas. F. Palmer, of the St. George's and St. James's Dispensary.
This is the only complete edition ofthe works ofthe distinguished
physiologist ever published in this country.
" One distinctive feature ofthe present edition of Hunter's works has been already
mentioned, viz: in the addition of illustrative notes, which are not thrown in at hazard,
but are written by men who are already eminent for their skill and attainments on the
particular subjects which they have thus illustrated. By this means, whilst we have the
views entire of John Hunter in the text, we are enabled by reference to the accompanying
notes, to see wherein the author is borne out by the positive knowledge ofthe present "day,
or to what extent his views require modification and correction. The names of the
gentlemen who have in this manner assisted Mr. Palmer, are guarantees ofthe successful
performance of their task."— Med. Gaz.
PATHOLOGY.
OUTLINES OF GENERAL PATHOLOGY. By George Freckletok,
M.D., Fellow of the Royal College of Physicians.
RHEUMATISM,
BOUILLAUD ON ACUTE ARTICULAR RHEUMATISM IN GEN-
ERAL. Translated from the French, by James Kitchen, M.D. Philada.
PUBLISHED BY BARRINGTON AND HASWELL. 9
HYSTERIA.
AN ESSAY ON HYSTERIA, being an analysis of its irregular and aggra-
vated forms; including Hysterical Hemorrhage and Hysterical Ischuria.
With numerous Illustrative and Curious Cases. By Thomas Laycock,
House- Surgeon to the York County Hospital. 1 vol.8vo.
UTERUS.
LECTURES on the FUNCTIONS and DISEASES of the WOMB,
by Charles Waller, M.D., Bartholomew's Hospital.
ON DISEASES of the UTERUS and its APPENDAGES, by M.
Lisfranc, La Pitie Hospital.
ON DISEASES of the PUERPERAL STATE, by J. T. Ingleby,
Edinburgh. 1 vol. 8vo.
" We can very cordially recommend them as affording a concise and practical exposition
nf the pathology and treatment of a most important class of diseases, and which cannot be
too attentively studied."—N.Y. Lancet.
"The present volume contains a short and succinct practical account of the principal mor-
bid states either of the functions or the strueture of the womb, the best methods of dis-
tinguishing them, and the means which experience has shown to be the most effectual in
removing them. The reader will find that he obtains, in a small compass, a distinct view
ofthe nature and treatment of each disorder."—Edinb. Med. and Surg. Journ.
CONSTIPATION.
A TREATISE on the CAUSES and CONSEQUENCES of HABITUAL
CONSTIPATION. By John Burne, M.D., Fellow ofthe Royal College
of Physicians, Physician to the Westminster Hospital, &c. 1 vol. 8vo.
" For some interesting cases illustrative of this work, the author is indebted to Dr. Williams,
Dr. Stroud, Dr. Callaway, Mr. Morgan, Mr. Taunton, Dr. Roots, Sir Astley Cooper, Sir
Benjamin Brodie,Mr. Tupper, Mr. Bailer, Dr. Paris, Mr. Dendy, Dr. Hen. U.Thomson,"
&c—Preface.
URINARY DISEASES.
URINARY DISEASES and their TREATMENT. By Robert Wil-
lis, M.D., Physician to the Royal Infirmary for Children, &c. &c.
" We do not know that a more competent author than Dr. Willis could have been
found to- undertake the task; possessing, as it is evident from his work that he does
possess, an accurate acquaintance with the subject in all its details, considerable per-
sonal experience in the diseases of which he treats, capacity for lucidarrangement, and
a style of communication commendable in every respect."
" Our notice of Dr. Willis's work most here terminate. It is one which we have read
and trust again to read with profit. The history of discovery is successfully given; cases
curious andimportant; illustrative ofthe various subjects have been selected from many
new sources, as well as detailed from the author's own experience, chemical analyses,
not too elaborate, have been afforded, which, will be most convenient to those who wish
to investigate the qualities of the urine in disease; the importance of attending to this
secretion in order to a proper understanding of disease is strongly insisted upon; in
short, a book has been composed, which was much required, and which we can conscien-
tiously and confidently recommend as likely to be useful to all classes of practi-
tioners.— Brit. # For. Med. Rev.
MEDICAL EXPERIENCE.
CURIOSITIES OF MEDICAL EXPERIENCE. By J. G. Mil-
ljngen, Surgeon to the Forces, Member of the Medical Society of
the Ancient Faculty of Paris, etc., etc
" Curiosities of Medical Experience. By J. G. Millingen, Surgeon to the Forces, etc.
The Author or Compiler derived the idea which prompted him to write this work from
D'lsraelfs'Curiosities of Literature;' and, in our view, he has made a book equally
curious in its way with that one. The heads of his chapters are numerous and varied ;
and all his subjects are treated in an agreeable and comprehensible style to the general
reader. The drift of the Author, too, is decidedly useful. We shall endeavour to give
some extracts from this work."—JVat. Gaz.
JO STANDARD MEDICAL WORKS
EPIDEMICS OF THE MIDDLE AGES.
EPIDEMICS of the MIDDLE AGES. From the German of I. F. C.
Hecker, M.D., &c. &c. Translated by R. G.Babington, M.D. F.R.S.—
No. I.—THE BLACK DEATH IN THE 14th CENTURY.
" Hecker's account of the ' Black Death,' which ravaged so large a portion' of the globe
in the fourteenth century, may be mentioned as a work worthy of our notice, both as
containing many interestingdetails of this tremendous pestilence, and as exhibiting a
curious specimen of medical hypothesis."—Cyclopedia of Practical Medicine—History of
Medicine by Dr. Bostock.
No. II.—THE DANCING MANIA.
'' Medical History has long been in need ofthe chapter which this book supplies; and
the deficiency could not have been remedied at a better season. On the whole, this
volume ought to be popular; to the profession it must prove highly acceptable, as con-
veying so much information, touching an important subject which had almost been
suffered to be buried in oblivion, and we think that to Dr. Babington especial thanks
are due for having naturalised so interesting a production. The style of the translation,
we may add, is free from foreign idioms : it reads like an English original."—Lond.
Med. Gaz.
RETENTION Or URINE.
AMUSSAT'S LECTURES on the RETENTION of URINE, CAUSED by
STR[CTURES ofthe URETHRA, and on the Diseases of the Prostate,
translated from the French by James P. Jervey, M.D.
DENGUE.
ON DENGUE; ITS HISTORY, PATHOLOGY, AND TREATMENT
B* S\I?ENRY DlCKS0N- MD-> Professor of the Institutes and Practice
of Medicine in the Medical College of S.C.
MEDICAL, EXAMINATIONS.
HINJSp°aNRIvE M?DICAL EXAMINATION OF RECRUITS FOR
• THE ARMY; and on the D.scharge of Soldiers from the Service on
burgeon s Certificate : Adapted to the Service of the United States By
Ihomas Henderson, M.D., Assistant Surgeon U. S. Army &c &c
PHYSIOLOGY AND HYGIENE.
ESSAYS ON PHYSIOLOGY AND HYGIENE; viz:
I. Reid's Experimental Investigation into the Functions of'the Eirrhth
Pair of Nerves. s
II. Ehrenberg's Microscopical Observations on the Brain and Nerve,
(with numerous engravings.) serves,
III. On the Combination of Motor and Sensitive Nervous Activity
by Professor Stromeyer, Hanover. AC«vity,
IV. Vegetable Physiology.
V. Experiments on the Brain, Spinal Marrow, and Nerves Rv
Prof. Mayer, of Bonn (with woodcu-s) By
VI. Public Hygiene.
VHI. Vital Statistics. 1 vol. 8vo
PUBLISHED BY BARRINGTON AND HASWELL.
11
MEDICAL. AND TOPOGRAPHICAL OBSER-
VATIONS.
OBSERVATIONS on the PRINCIPAL MEDICAL INSTITUTIONS
and PRACTICE of FRANCE, ITALY and GERMANY: with Notices
of the Universities, and Cases from Hospital Practice: With an Appen-
dix on ANIMAL MAGNETISM and HOMOEOPATHY. By Edwin
Lee, Member of the Royal College of Surgeons, &c. 1 vol.gvo.
" Mr. Lee has judiciously selected some clinical cases, illustrating the practice pursued
at the different hospitals, and he has wound up the volume with an amusing account of
animal magnetism and homoeopathy—those precious effusions of German idealty, for
which we refer to the work itself."—Meutco-Chirurg. Rev.
MEDICAL AND TOPOGRAPHICAL OBSERVATIONS upon the
MEDITERRANEAN and upon PORTUGAL, SPAIN, AND OTHER
COUNTRIES. By G. R. B. Horner, M.D., Surgeon U. S. Navy,
and Honorary Member of the Philadelphia Medical Society. With En-
gravings. I vol. 8vo.
"An uncommonly interesting book is presented to those who have any disposition to
know the things medical in Portugal, Spain, and other countries," and will doubtless
be read, also, with marked satisfaction by all who have a taste for travels. — Bost. Mea.
and Surg. Jour._____________________________
ON DkiW
AN ESSAY ON DEW, and several Appearances connected with it
by William Charles Wells, M.D., F.R.S., etc.
ANATOMICAL. EXAMINATIONS.
EXAMINATIONS in ANATOMY and PHYSIOLOGY; being a
complete series of Questions and Answers; designed and intended
as preparatory to Examinations at the different Medical Schools
throughout the United States. To which are annexed, Tables of
the Bones, Muscles, and Arteries. By Thomas Sydenham Bryant,
M.D., Surgeon U. S. Army.
NOTES AND REFLECTIONS.
MEDICAL NOTES AND REFLECTIONS. By Henry Holland, M.D.;
F.R.S., Fellow of the Royal College of Physicians, and Physician Extra-
ordinary to the Queen.
RANUNCULACE^.
HE MEDICAL PROPERTIES ofthe NATURAL ORDER RANUN-
CULACE^E,&c, &c. By A. Turnbull, M.D.
DR. P. S. PHYSICK.
Prof. HORNER'S NECROLOGICAL NOTICE OF DR. P. S.
PHYSICK; Delivered before the American Philosophical Society
May 4, 1838.________________.
JOHN HUNTER.
THE LIFE OF JOHN HUNTER, F.R.S. By Drewry Ottley.
1 small vol. 8vo.
"In the summing up of Mr. Hunter's character, Mr. Ottley exhibits equal judgment and
candour."—Brit. Sf Faft. Med. Rev.
DALE'S ESSAY.
ESSAY UPON THE QUESTION, IS MEDICAL SCIENCE FAVOR-
ABLE TO SCEPTICISM? By James W. Dale, M.D., of New-
castle, Delaware. Pamphlet.
JUST PUBLISHED,
STOKES AND BELL.
LECTURES ON THE THEORY AND PRACTICE OF PHY-
SIC. By William Stokes, M.D., Lecturer at the Medical School,
Park Street, Dublin : Physician to the Meath County Hospital,
etc., etc., and John Bell, M.D., Lecturer on Materia Medica and
Therapeutics : Member ofthe College of Physicians, Philadelphia,
and of the American Philosophical Society, etc., etc. Second
American Edition. 2 vols. 8vo.
The large edition of these Lectures, published in the latter part of the year
1840, being exhausted, the publishers now issue an entirely new work, not
only adapted to the student, but to the higher requirements of the profes-
sion at large, without reference to any particular section or interest. It will
embody the most valuable portions of the volume published as " Stokes on the
Chest," together with such additions as may be found essential to bring the
work up to the present state of Medical Science, without forgetting its obliga-
tions to those of former times.
In Press,
EVANSON & nZAUXTSELL.
A PRACTICAL TREATISE ON THE MANAGEMENT AND DIS-
EASES OF CHILDREN. By RfCHARn T. Evanson, M.D., Professor
of Medicine,—and Henry Maunsell, M.D. Professor of 3Iidwifery
in the Col. of Surgs. in Ireland. 2d Am. from the 4th Dublin edition.
"The authors of the work before us, have had the advantage of investigating the
subject of Infantile Diseases, conjointly in a public institution—an advantage which
no private medical man, however extensive his practice, could probably have. The
observations being made cenjointly too, offer a greater guarantee of correctness and
authenticity, than if they emanated from a single source, however respectable. From
their acquaintance, also, v^ith foreign works, they have been able to bring up the
Anatomy, Physiology, Pathology, and even Therapeutics, to a far higher level than is
be found in any previous work in the English language.
"The second chapter embraces the Management and Physical Education of Children.
This chapter ought to be printed in gold letters, and hung up in the nursery of every
family. It would save many lives, and prevent much suffering."—Medico-Chirurg. Rev.
"We know of no work to which, on the whole, so little can be objected in matter or
manner. It is an elegant and practical compendium of Infantile Diseases; a safe
guide in the Management of Children; and completely fulfils the purpose proposed."—
British Annals of Medicine No. VIII.
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