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|L^l^g«|Bj
m^^{
Library
or
Dr.a.C.DicKson
A
Manual OF Medical Treatment
OK
Clinical Tukhapeutics
A
Manual OF Medical Treatment
OK
Clinical Tiikrapeutics
WORKS UY DR. BURNEY YEO.
A Manual of Medical Tkbatmemt,
OR Clinical Thekapeutics. (AVa»
aaJ Revised Edition.) 7w I'oli.
Food in Health and Disease. {£n-
largtd Edition.)
The Thekapeutivs of Mineral
Sfri.sgs and Climates.
CASSELL & COMPANY, Limited.
LONDON, PARIS, NEW VOR K &• MELBOUR NE.
A MANUAL
MEDICAL TREATMENT
CLINICAL THERAPEUTICS
•V
I. BURNEY YEO, M.D., FRCP.
KHEItlTri* fHtintMNOR or MKIiR-lSC IX Kllio'tl I ni.l.KfilC, LUNrMUl ;
(VMPULTIJin PlirDiriiN tit KINCj's iXiLLMitK tlOaflTAL ; HOM. rMLI.OW iir
RiJinV ikiluqge; riiHMititLr mo^-KsMori or tmb I'RiNt-irLJw akd I'kArrii r
or MKDK-IHII. AKD OP LM-IMllAL TUKKAfKI'TICTt IX KIX'i'll UOI.LKdII, AMt>
KXAMIXKH IX HCnil'IKM AT TUK KOVAL l-OLLKIIK Of flJ VIICUH*.
AiniuR or "rooD in ucAi/ru and uiskadr." ktc. n\-.
VuL. I.
CASSELL AND COMPANY. Limited.
lONlioy, PARIS, SEW YORKd: HELliOURNE. MCMIV
AM. nionT? KK3KRVIt>
&.«£•
Fini Ediiion, 1S9.11.
Rf^rint^d January Mtd Atarck 1B94.
Rtviud Jmrnumff 1895. Rf^rinttd Se^ttmhtr 1895. 1^97, 1899, Jmn
Si^Umbtr 1901. R^vUtd 1901. RfPrimttd 1903, 1904.
u.
Co
Mia nusMDi kxTt prpn.1
imOXOIT ms PART AXb FUIUKKT STl'UIMn
or
XIMO'S COLLBOM iiMrrrM.*
TKU WUHK
IS DIDICATEtl lir THK acthoh.
00S79
PREFACE TO THE NEW AND
REVISED EDITION.
Since tlio |iul>licjiti<)ii of tiio first etJition of this work
in 18'J3, it. Una b<»en the Author's privili-ge to receive
from all parts of the Kmpiro the most flatleritig
acknowle<lginenta of its value nnd Mscfulncss, And it
now becomes his Brat duty to n>turii his wiirmeHt
thanks to tlie medical profession for thoir gratifying
estimate of hiB lalxjtirs. Tlic preparation of a iitfw
and mvitod edition, wiiich he might ho(Mt would
be, in some respects, worthy of the very favourable
rect'ption accorde<l to its prcdectMaor, has 1m'<>ii rm
light tjutk.
The vai*t amount of material — not all, certainly,
of cx^ual value — which is being no rapidly produced
in eonnection with the subject of Thenipeutica has
uecoesitatei] a most careful examination and sifting
in onier to retain what is likely to be of hutting
service, and to discard that which, at best, can only
^^H l>c destined
^H out this atl
^^fc author true
^^B real value.
^^H frieudly ci
^^B received cc
^^1 treatment
^B Cerebral T
^^M Fever, and
■jV^^i^^^H^^^^^^^^^^l
Preface to New Edition. ^^^|
to a tempoi-ary popularity. In carrying ^H
tempti to the best of his judgment, the ^|
its he has not i>vorlo«ke<l anything of ^|
III accordance with the suggestions of ^|
-itics, cerUiiu additional HubjccU have ^|
msideration in this edition, such as the ^|
of Hay Fever, of Paralysis Agitans, of ^|
unionrs, of Erysipelas, of Cerebro-spinal ^^^B
of Rickets, Scurvy, and Purpura. ^^^H
Slrirl, Miii/fiiir, ^^^^|
<Mi<-r, 1903. ^^^1
1
1
EXTRACT FROM PREFACE TO THE
FIRST EDITION.
The object of IIuh work ia the study of disease from
the point of view of trentment. Tlio. teaching' of
Therapeutics is here approached from the side of the
disease, and not from the side of the drug or remedy
— a niutbod which has been tliouglit more natural
and more interesting than the one usually adopted.
It has not, however, been attempted to discuss
questions of treatment apart from consideration!^ of
the clinical history, course, and pathological characters
of each disease.
It is dear tliat any, or every, ijai-t of the natiiinl
history of a disease may bear, directly or indirectly,
on its treatment, hut some parts far more than
others; and it would be most unphiiosophical and
unedifying to discuss the therapeutics of a disease
without, at the same time, considering the true
nature of the phenomena we are endeavouring to
control.
Preface to First Edition.
It is by examining into thn mode of eatMa<ion
of disease, by investigating the true nature of the
morbid changes which underlie the jiht^wmena of
disease, and by an exact ktiowledge of tlie properties
and mmle of action of the agencies wo introduce for
the purpose of influencing favourably its course, that
what are termed rational indicaliont for treatment
are arrived at.
It has been the Author's aim, therefore, in the
following pages, wherever it was possible, to deduce
rational indications for treatment from an examina-
tion of tlifi pathological natuii} and the clinical course
and characters of the diHcase under discussion.
Selections of formulte, published for the most part
by well-known physicians, ai-e added to most of the
chapters, for the purpose of giving completeness and
brearlth of view to the subject. Those in the first
chapters are printe<l without any abbreviation, solely
for educational reasons.
— >^
CONTENTS.
fart I.
DtSRASES OP THE ORGANS OP DIOBSTION.
I — TauTMnrr or Diuaiis ur Tui Muitii, Toxkiia, txn
PntRTXX
II.— T««*T>i»»T or DlwctsEii or tiik lK"orn*.ii« ....
III.— DiKKtciia ci» Tiii SroMAcn— TinATwiKT or Arvrt *»i>
CUKONtU OAXmic C4tAKKH
JV.— I)uiit»«Ks or Tun STOM.i(n— TmutTiiiim or Uu-kk or tm«
ttTiiytrH «xD or OotCM or tui Hrtmutt ....
v.— UitiAiiu or TUK HTOiLAni— TasAiMBt: or DiuiTtTioN or
mc Sn'Mtcn, on GiiTiiO'Kr.TAM>
VI.— Duiuiin or niii Htuiuch— THitTMnicr or H«mat(mib««,
VOMinilO, AltD Oastbilou .
Vll— UlHKAim or T«» 8TOMACII — 1 HfcATlil:«T ur In-.rilr'iA —
MoDiM GAimiic Mn-iiuin
Vltl.— I>msa*» or riiK iKTBcrixiK— Thkatmicxt or Kirru>4uiu
Ott Cuut: . . . ....
IX.— DusA«as or nii iNnunmts — TKiATunrr nr lUKirnAi,
CoXRTirATtiiK
X. — UURAJIMa Ol TIIK iMItriNK- iHrAlill-hT •>>- lilABHll'XA,
IniMTIKAL CaTAKIIH, A' I It. AMI LllBOBIl ....
XI.-r-DuiuBB or mit IirrBiTiiiitH— TsKAranrr or PniTrruuTia,
OR ArrcXMcms, asu or DvaKKTItnv
ti
04
\M
CoirrENTS,
I'HAp. rut*
XII.— Dm»8Ci or thk Iktbitixbi— Tiu!«ti«jit of Vmanrtht
Ordthuctiun «W 1
XIII.-I)|91U<KH 01' TIIK iKTCirTIIIlia— TRSATHKXT OT IHTSSTIiltL
rARA]iirKs 284 ]
XIV.— DlKEAHIII I'K TIIK I NTMTISIB— TECATJIKItT nr PeRITOKITIH . 906 j
IJnrt n.
DISEASES OP THE HEART AND ni.OODV F.88EL8 ; AND
OF THE BLOOIt AND DUCTLESS GLANDS.
1 Tmkatmcnt or Acittr AprRCTioNH nr tiik TIkabt and
PMicAROtna . . . S2S
IL— Tmatmkmt or CHitomc Arnionoin or thii Cabdiac Valtb S40
III,— Ma«aou(x'T or SriciAL HrMmiim OEpmcEirr o« Cmiosic
VAtVlltAR DlBEASK . ' 858
tV.— TMATHrjrr or CARpiAr HrFKBTRoraT and Dilatatioh; aici)
or DanuiHATiuxii or mc MrocAROiiTH .... ISO
v.— TnitATMitBT or Cardiac N(URaaBi—PAi.riTATKi!>— Cardiac
PAts— Akoina Pectoriii 403
VI.— TMAnnr or DmAm or trr ARmtm: Artcrio-
SvutRORia (Athsroma, on ENDARTRBma DcroRUAKii) —
AlTBtnilBH 496
VII.— TRaATHorr or An.«miai .... . . . 46S
TIM.— TReA-mRKT or ccrtaik Blood DiirAiiica: LrtntxHiA—
UoDaKiys Dibkabr- ADDisoM'if DiaKAKF— ExoruTnAtsiic
Oonmz— HrxuDuiA 478
CoKTEirrs.
nil
fart in.
DISEASES OF THB ORGANS OP BKSPIK.VTIOX.
PAca
L— TnzATmn or CAT/iiutBAt ArmTioii* ut th« RcsniuTamT
OiotM: tkcon Axu OkOKiv Xaul axo Labtin»ai.
Catabuu SOS
IL — TKXAmBCT or Catamuiai. ArtKLTium ur rm Kupiratubt
OaoAM : AitTS Dkoucmul C«T*iuku K*
III.— TftSATHKVT or Catakrhal Arrx-Tiom or the RcinitiToitY
Qiir.Axt : Cniutxir Buomiiial CATAiun »iO
IV.— TUAmiuiT ur Aithva (SrA^oioiHi' .tmimt, Unoxi uial
AvruMAX Hat Fmut, akh Em-HraciiA . . . . VM
v.— TkBATMixT or PinrHOKiA* (lOI
VI.— TKiuTtiiun OK PueciuMiM . MJ
fart IV.
I'liTUlSlS, OR C0X80JIITI05 (PLLMONABY
tuberculosis).
I.— IxnirATioKii t!<i> rkururLAXi" STl
tl. — RjKalUlXAL TMLATMIUiT or I'irTHMIIIt IXCLCUIStQ **Ba»A-
tvaiVH " TUATMSSI .... , . «M
LIST OF ILLUSTKATIONS.
k
tng. I,— ApparaliM fnr R<<ct«l FiK<ltiii!
Vyg. 2 — Bluiiiach Syphon ,
rig. ».— moniarh Syplinn (TVIxivi-'si lldillcaUun)
Fix- *- — 3f<l<) uf U«lng f>(unucli Syphuti
Kfg. S.— Aorrtlicr M'mJi' of URing i^tnmftcb Sjrphnn
Flu. 6.— Stuiiuicli TiiIh; mill IrrlK*t«r
Fig. T. - nipr .Viciiidlll i>r TitH(a KiHain
Jnt. i.—Ml-e HefiiiPUl ut Tniilo miiitiala
Fig. ».— Rl|iti SeglniMit of ItoOtrimphalia li'tui
rig. lU.— A, lie*!] cif ru-nlii «>{Huil(<i. M, tluntl of llotlirKKeplUitiu
tntut^ Men from tin* aide (nin^illtril). r, Tlie wiimw ewit
fKilo ilovn (natural olic). u, EnUrKcO Uoxl of Tixitia
mttivm ...
II, — Painful HimU In ■ cue of Aortic Regtirgtlitlon
Fig. 12,— Painful .S)iot« In a caw of Anrtk' IIImiim!
Ptg. la.— Piliifiil Np'il* in n •iix' of HUrnl Dltntac
Fig. I <.— Painful 8|HiU> In • lauw of KuncUonal Canllac UiiwaiM-
ni5. Ifi— I'r. Yi'o't It^Hplratflr ....
Fig. 1(1. - Chart of Cam* of Afulc* IjitlMt Pnciinioiila
Fig. 17.— P'tttttD** Apj>aratn« for Tliormi'ont^fti* .
rig. IS.— Cabot'a FuliU'il I irainagc-tulxi tut Empyema
_*!<. W.- Sanitary Ciupldnr
~ to.— Dottwclliit'a IVM-ket Flaak
III Cliliareu
AitR
ll«
III!
117
lla
liu
'.'SA
I'M
■iKIl
4l:t
411
»l.\
llr,
'.V.
nlU
O'U
tt.1i
6K'J
M A N U A I.
or
Medical Theatment.
IJart h
DISEASES OF THE ORGANS OF DIGESTION.
CHAPTER I.
TIIKATMKXT OF lUSKA.SES OK THE MnUTIt. T(iXSII,.S,
AND PHAItVNX.
StOMatitih. — luHiiinmalioii of llio Mouth— Viirictit-s: (1) Sitniilo
('otarrhjil Slcirmtiti*— Synifitnnis- Cause*— Iiicliciitioin for
Tivatinpiit. (2) Vwiniliir or Aphthous Stomntitin — Chiinic-
teM arnl Symptoms- Cauwitioii — Tn-atnu-nt. {'i) Fara^^itic
Stoiuatilia. Aj/hthic or Thrusli — Sympti'ms— Cause*— Indica-
tions for Trratuiont -Prctjihylaxift. (I) L'Irrrutivt* or P^piulo-
Meiuliriiuoiii' ytoinatitii"- Sjnnptoini ami C'harartort — Causa-
tion—Indiratiou«forTroatini'iit. (5) Oanifrcnous Stoftiatitis,
CiLticruiu Dris, Xonia — Causation — Characters and Syniptoni-i
— Trpatmpnt. (Rl Mprrnrial Stnmalitlfi SymptoniH— Treat-
ment. To>8IiLITia. — Varieties- -t.'auftt'5 - .SympUiros— Sup-
piirativo Form— Treatment— rrojihylaKii — C'hr< nic Hyper-
trophy of TouHh— FolliculnrTi'Dsilli'ti*. Acxtk Piiarynokai,
Catahhh. —Angina, or .Sore Thniat — Characters— Cauiic»—
Sjmptoros— Tnailmeut. Ciinosii- I'iiabynofai. Catarifi. —
Varieties : (i») Siniplc. (4) Folliouhir, or Granular — Cau>a-
tjou— Symptoms— Treatment — Mineral Watere. Additional
Formula;.
D1SRA8R8 OF TUB Mouth.
TriEnE ftiv" sovoral farms of inftiiiiimativn o/lhe mouth,
tlic trt'Hlnu'iit of wliii-li w(> liiivn to consiclpr ; unci
ultlioiigli (lie itulii,-Ntii)ii> fur Ireutnu'iit iiif in mn.Ht of
llinn siniilHr. Vfl for the wikc of clearni'88 it will lj«
fK-sirnblc to treat of each form separately and in the
following oriler : —
n
Medical Treatment.
[Pan I.
I. Niiii|»lc rsilai-iiiiil !«l«>nialiii<>, or fninrrli
of the luoiilli. -'I'lii- [ni)Ki|i<il syni]>toiiis of lliis
iiQ'ection are r''(tiii'«, ti'U(leini'».s, and swelliivg of the
mucous meinhnintj of tlif fliet-ks, giitiis, and tongue.
Tli(* toiij^ui' is also coverod willi a thick fur, and shows
the ituleutatioiis of tlie tt^eth. Tlie secretions of the
luouLh arc increased, and its cavity is covere<l with
lliick yellow tiiucus. The senst'nf taste is lilunte<l and
jMirverted so that the luitietit furujilains esju'cially of
a "bad" taste, or a slimy, clatnniy, sometimes hitter
taHte, nnd u "foul" Kmell. In the form whicli
accompanies dentition in iufaney thi-iv- is often much
constitutioiiat distress, and convulsions are aometinies
induced.
The usual raiisos of this condition are dentition
in infancy, cutting the wisdom teeth in adults, the
{ire.sence of carious or of liiwlly arranged artificial teeth,
the abuse of tobacco, of too iiighly-seasoneil food and
too hot beverajjes, and insutticient cleansing of the
teeth and mouth.
It is frequently associated with the f'ebn'U; state,
and often accom|iaiiies ga.stric catarrh ami habitual
constipation. It may also be propagated from ad-
jacent inflamed organs, an in facial erysipelas and in-
rtamiiiation of the throat. It is occasionally referrible
to obscure n»'rxou.s states.
The iiiili<*9iliotis Tor lr€>atiRC>nt are, _/fr«/, the
removal, when jtossible, of any of the CJiuses enumer-
ated above that may be found toe.tist ; the sharp irri-
tating cdge^ of cjirious teeth must be removed, the
snioking of strong cigars foibirlden, and errors in food
ami drink corrected. Constipation must 1m' relieved,
and a saline aperient is altuost always desiitible. Co-
existent gastric catarrh may require theadmirdstration
of bismuth and alkalies. SefDndly, emollient cleansing
and antiseptic washes are needed t<i remove the foul
BCCi'etions, and to keep the oral cavity clean, and to
soothe tiie irritjition. At first lotions of t<>pid gum-
water or barley water, witli 5 or 6 grains of bicarbonate
of soda to the ounce, should lie used. The carbonates
hap. I] Catarrhal asd Vesicular Stomatitjs. 3
uf t)ic alkalies exert a solvent action on mucus, and so
serre to detadi and wasii away thn foul sticky uu)co\ia
secretions covi>ring tho inf]iini>?rl mucous mombntne.
Lime water, Iwrax waslius, »nd borax t^ililoids are
usef(d. A WHsh cout^iining salicylic acid 1 part,
dissolved in 5 partes of alcohol, and added to 25U
(Htrts of water, bas llie advantage of actinj; both as
an anti8e|rlic and an antesthetic, or boric acid solu-
tion may be used. Preparations of eucalyptus or
hydrastis may l)e added to h>oiax washes. A.s an
notringent lotion a solution of alum (5 grains to the
ounce) is sometimes useful.
In troublesome cases tho mucous membrane may
be brushe<l with a solution ot corrosive sublimate (I
iti 5,000) or of nitrate of silver (2 grains to the
ounce). If there is diarrlxea astringents and opiatfts
may bt' neede<l. .Sucking fragments of ice will often
relieve the heat and sensitiveness of the mouth.
The following is a good formula for a mouth wash : —
9} Boracis
S<idii liirarboniitia ..
Tinctuni' eucalypti folinniin
Glycfrini
Aquo!
drBchnina duna (5ij).
gninu i|iiailiaginta (gr. xl).
iiiiriiim (ij).
Hcnii iiiii'inm (Jon),
ad iincin§ octo (Jviij).
Miix'c, (inl InMo. To bu uicd freely mixod with an eqiisl
quantity of wurni water.
2. Vehicular •iluiiialiliit, also terniej tipli-
Ihons Ktomnlilifi, and lii-rpr!* of inoiilli, and
a|>lilliH> - In this affection small white s|Kits (often
termed nphthie) appear on the mucous mendirane of
the mouth, the spit.s are surro'.nided by a nnl bonier,
and are .said to be at first ■vfswnlitr, but this is doubtful.
The white sjiots are probably an exudation from tho
free stirface of the mucous niembi-ane beneath the
epithelium ; these spots are thrown "B", iin<l raw ex-
coriated surfaces left. They occur on the anterior
littlf of tlie tongue, on the inner surface of the lips
and cheeks, and on the hard palat«» ; they are round,
a1>out the size of lentils, often numerous and apt to
run together into confluent irregular patches. There
Medical Trkatmbnt.
(Part I.
is usually aim tid.iiit mucous catarrh of \\\o immtli, and
iiicreiisfil siilivaiion. The lnvatli is foul fmm (K'f.'ivinj;
e[iitli('liutu, and tlie nioiitli is Imt anil )iainful. There
lire also feverishness uikJ loss of iijipf tite.
\VitIi legard tii its raiiNiitioN, it is more frequent
in children thiiii in ndult.s, uiid it is prone to occur in
feehle, illiiourisliefi, scrofulous children during the
jM'rirxl of detention. It isal.so olwerved to ucconipnny
certain exanthemata, anil particul.irty nie»Nlcs, as well
as other cutaneous nffeotions. It seems at limes to
\xi epidf'Tnic, CRpecially iimongst parturient women
(stoiiindtiif mnternn), anil to spireaii liy ufuitagion. It
in often found to occur in institutions where children
are crowded to!,'ether, with insanitary Kurrottndimjs,
and unsuitable or inHuHicient food. It freijuently
accompanies exhnustinj; and deliililatiug di.sea.se8.
Excessive humidity ami inuiiihitionMare»iid to favour
its nppearanee.
Tlu> treiiliiH>iit slionld he begun with a mild
antJicid laxative, such as rl)uhai°1> and iiui<;nesia. If,
however, there i.s diarrlnea, a powder consisting of
2 to 4 jcrains of subnitrnte of bismuth and 1 to 3
grains of coni]>i>und kino powder ^.•^c^■ol^iin/; to the
age of tlie child), and 2 to 4 f^raius of sodium bicar-
bonate may be given three times a day. Potussinui
chlorate used to be regarded us a valuable remedy,
but it hafl recently been denounced by some American
writers as causing great jiain and doing no good.*
Tlie loral trvatmeiil must consist at first in
the use of demulcent idkaline niul antiseptic washes.
A variety of aiiliupptlr washes have been suggestetl,
e.g. a solution of sulphite or In'posulphite of stKliuni,
30 grains to the ounce, creiisote water, boric acid in
saturated .solution, borax washes, chlorine water, chlor-
inatefl soda 8olutir>n, carbolic acid lotiiin (.3 to 5 per
cent.) -this ha.s the advantage of being nnasthetic —
the application by means of a camel-hair brush of dry
alum, borax, or bismuth. If the 8i)ot8 are slow to
* Hare's "System of Fractical Ther»peutics " (new editinii),
vol. U. p. 238.
I.I Vesicular AWD Parasitic Stomatitis. 5
heal they inny be touclied with solid nitrat* of silvpr,
or witli a strong «iohi(i<iu of tlie same (Od ^(raiiiK to the
ounce), or with a Nolutiotiof cu|iricHiil|)halt< ( 10 iiriiiiis
tt) the oitnc-i;), or zinc sul{ihnt<> {'10 grains lo the ounce),
or mercuric chloride (1 grain lo the ounce), or iodo-
fonn may be applied.
Or the spots may be touched with laftU di-
riniui, which is made by fusing togetlier equal part:*
of cupric sulphate, alum, and pota.>wic nitrate. In
cachectic cases tonics must be given internally.
Quinine in ^- to 2 grain d<«<'S with 2 to 5 minims of
dilute nitric iwid throe or four times n day. The
diet should be bland but nutritious, and stimulants
are fi-eely needed in bad cjises. In young children
milk and barley water, mixed, should lie given, in
preference to l)eef tea, as lieof ten may cause smarting
of the mouth.
jiUolut) Emolliriil ami AiitiJi'ptu Mouth n'nth.
If Glyceriiii iiciili curWici... ... ecmi unciam (j«).
Sudii bii'iirboimliB .. ... dnichmiih dima (^ij>,
Dwocti iilllia'to ... ... . hJ iiiuinit ik;Io (Jviij).
liiM-o, tint lotio, Tu Im.i iiaod with an e(|iml qiuinlity ul
Attitthrr.
ft} AoiOi borici ... . . (Imihmtu duos (3!]).
tilycvrini .. ... dtarhmas dima (3!)°).
DfCM'ti hordci ... ... ... nd uncias octo (jviij).
Misce. Itat lotio.
3. Parn«ilir bioiiinliliM, apliiliHr, iliriish.—
This diseaHC IniK been confounded with the preceding .
it is, however, a special form of intlanmiiition of thi-
immth due to the development in its mucous membrane
of a paruisitic, fungous growth, the oidliim idbiciint.
It commences with dusky redness, heat, dryness and
tenderness of tiie mucxms membnine, accompanied by
an acid reaction of the buccal .secretions ; this is
followed by the (i|>pearancc of circular milk-white
HJightly prominent sj.ki1s, which run Ingether into
irregular flukes or patches, covered with a jieculinr
Medic A i. Trea tment.
IPart I.
white curd-like secretion. It is found on the doi-sal
siirfiict* of thf tongue, on the insitle of tlie lips luid
checks, unil esppdally on the folds eoiitiPL-tinjj; the
gums with the li[is and cheeks ; it extends also to
other parts of the huccii! memlji'ime, and inti.i the
phuryiix, ■whence it ilesccmis iiilo the fesophagus. It
has lieeii found iti the Klonriich and the necuni (where
the secretions ure acid), and in cachectic states it is
not unusual to find it round the anus and genital
organs. The mouth is extremely sensitive, and suck-
ing or masticalinn lU' any attempts at feeding by the
moutli are painful and rliHieult. 8onietinieK it is at-
tended liy vomiting and diarrliten. When it supervenes
on low ciiehectie states it is usually "f e\il omen.
It is most common in infants during the Ijrst two
weeks of life, and it is generally eau.sed liy want of
cleanliness and deficient care in feidiuff, thus inducing;
a morbid acid condition of the oral secretions. It
appears to he often conveyed frum child to child by
hotth--fce<ling. In older children, in adults, and old
jieople it is apt to appear towai'ds the close of ex-
hausling, cachectic diseases. It is contagious.
This fungus seems to require an acid medium for
its develo]nuent, and its occurrence in young infants
has been sujtjiosed to be due to the ])reponiierance of
mucus, which is prone to turn acid, over the alkaline
saliva, in their oral secretions.
Hut some legiird the acidity of the buccal secre-
tion to be rather a rcsidt than a cause of llie growth.
The iii<iirnlif»ii<> Tor Ircalinriil in lliisall'ection
arc, apiirt fmm those dependent <ui any co-existing
cachexia, to remove the parasitic growth from tlio
mucous membrane, and by restoring a healthy con-
dition of the oral .secretion to prevent its ix'-develoj>-
mont. As a prrvrvthv mensure it is desirable to
wash out the mouths of weakly infmits after suckling,
und especially after tising the bottle, with a piece of
Wf.t lint or a camel-hair brush soaked in water. To
remove the parasitic patches it is b^st to rub them off
gently with a piece of soft linen wrapped round the
. cleanse the cavity of the
intiseptic wash, such r^ a
: i\ i>r sofliuiii ljonzi>ate. Tlie
II lit? used evei-y two or throe
I una ili-Kchinas qiialiior |
dmc'hma) dims (jij).
kd uiitias oito (jviij).
Mifc.-!', (iut lotiu.
. draohmua tro« (3iij).
gruiin ccntiiio (gr. c).
... lid iinciiui decern (Jx).
Mince, fiitt lutio.
also be used as u s])niy foe tlie
it. Honey is to be avoideil (us ia
It maj' aggravate (U'id fennentatioii.
i.ses the juitohes (iifter wipiiij,') niiiy
' 1 solution of argentic- nitrate (1 to 2
i]iii<.- sulphate (2 gmins to the ounce),
(2 grains to the oiiiici'). Solutions of
rid and of salicylio auid, mid even of
■ lie, have been found useful. If there
iirhovi, as is not iineoiiiiiion, small doses
.irlioniite with elmlk mixture may be
k it, Forchhriiiior savs sniail doses of
ike aspecific in intestinal tioiibles due to
With infants, whenever it is possible,
.-ihould be preferred to artificial feeding.
lU 15 inipniuticable great care must be observed
HI' preparation of the infant's food — sterilised
Kiilk mixed with a little lime water or a small
jiy of a 5 per cent, solution of swlium bicar-
■tliuuld be use<l so as to insure its having an
line reaction. Can- should akso be taken that
buttle, tlie nipple, and any vessels used in the
••lit ion of the food are thoroughlj' clean. Plenty
>li air and good sanitaiy surroundings should be
i
8
Medical Treatment.
ip»ii I.
secunxl. If owing to tlic xensilivciiess of (hi' tnoutli
the cliilil rcfuscHto feed, a tube attacluHl to a. funnel
may be passed ulonj; the Hoor of the nose into the
pharynx iiiiil Hnid nourLshinent thus nrhiiini!itere<i.
When this diseji.se occurs in conneetioii with sorae
general cachexia, tonics nnd stinnilants* ajijiiopri.it«*
to the tt-entment of tfie constitiitiona! aH'eclioii must
Ije given.
4. I"I«'€»rali%-o slomnlitis or pseudo-membran-
ous Btiiniatilis. — Tliis form uf stomatitis is usually
unilaierul, and aHecta m<ist cornnvnnly the left side.
The ulcers generally appem- tir>t on the outer border
of the gnms, especially of the lower jaw, and on the
corresponding surface of the cheek iiud lip. They
may extend to the tongue and palate, and the roots
of the teeth are often Liid bare by tire ulcerative pro-
cess. The ulcers are covered, n» a rule, by whitish or
dirty grey neciosed patflies of niucmis njembrane,
and surrounde<] bj- a red, swollen rim ; they bleed
easily. The tongue is swollen mid thickly furred,
indented by the teeth, and ulcerated nt its edges.
Tlienj an" usually much fa-tor of the breath, sali^-a-
fion, slight fever, and great sermitjvcnesi of the iiumth,
and conseijueiit dilhcultv in eating and swallowing.
The submaxillary, sublingual, ntid retro maxillary
glands on the affected side, are swollen. If neglected,
this disease may cause necrosis of the alveolar pro-
cesses and disrttptiou of teeth ; but when pro|wrly
treated the ulcers clean and heal rapidly, but leave
cicatrices.
This affection is usually found to arise in connec-
tion with in.s;iiiitary dwellings and hnbils, insuHicieitt
and iinprojwr fiMxl, and other ilepi-essing agencies.
It is often ejiidendc in hospitals, scliools, prisons,
camps, etc. It is es|peciaJly prone to attack children,
particularly feeble ones, between four and ten years
of age, after measles. Carious teeth may act us nn ex-
citing cause. It is probably contagious and microbic.
The in<li<*Hlion<s for troutntrnl aro to remove
unhealthy Rurroundings, improve tlie general health.
W Bnm mt^mmttj
I kcaDr. ChiUicA mmt g^ 9 •• 3 grauts
10 te 30 ^niM «fa«« «r fa«r tMOs * dKT.
he praKsA;d looilr i& a MiMlh vi^
10 to 20 fVMM to U^ •«•& Am mH
to baescratod aaelMUifNi w
Ihealhw. Other Mcfcl laml apfilHrtiam «i» wvdws
»w«w»ii; bocieacadi, aali^lie acidl, or ewbolic aeid.
m^j be aBmytd fagr •■MuiS * Uh^ «m«m to
tfe irmAtm UmI h« «9hL TKr moalh skottld be
tbotuujebly «^*— «— <* with «*na ««l«r after vvmt
meal, aod tbe gnmt and teeth mav be eW«i»c<i
with a bit of •baorbent ootton wool. Aft^ this
it has been reeommetided to vash tlie gums with a
Bitxt«« ol i partA of gtrcerine of borax and 1 part
of tinetsre of mrrrh. If the olorrs are slow to h«*i,
they Btaj be touched tvic^ dHily with a solution i^f
nitiwte of silver < 10 grains to the ounc^), or with dry
alum, or with tincture of icxliue, or »itli io<lofiirin. As
these apiilications aiv very painful, tin- uKvi's may U*
firW mopped with a solution of cocaine Imlrocliloridf,
JLoow teeth and loose fmgiucnts of nccmstil l«>nr
boalU be promptly removed.
. Tonics of quinine and imn, Itigetlu-r with coil
liver oil, will be needed in mast casw, with pxxl air
:ind fptot] food : the Utt<>r sliould Iw nourishint;, l>ul
unirritating and easy of ilifp-stion. During llu< iicutu
jicriod, milk, beef-ten. soakiMl hiviiil, nnd oIIkt
nourisiiing fluids will be best
Aiituejitic and SoothiHg Mi'utli W'ath ,
V) l'ol8»iiii thiomliii ...
Kxtnicli opii liquiilii
Aqiltb InuiKroriit^i ... ... iim i m •
Dwcicli liorcli'i inluii'i.-
MIm'i' liiit loiiii,
8
secured,
file child
may be
I'hiirynx a
When thi
general
to the ti
l>e given.
4. rie
ous Btoinai
unilateral,
Fhfi iilcei>
of the gmni
oorresj>ond ^
niaj extenrf^
of the teetli
cess. TiiB
dirty grey
and surit>u
easily. Th«i
indented
There mv i,^
tion, siijjht f«i
II nd ciin8ef|u«i{
The subninxf
/{lands on th
thi<ii disGa.se
cesses and (
treate<I the
cicatrices.
This nfTw,
tion with in.sai
anij inj}iii)|)er
It is often e
CMinps, etc.
partieulurly
of age. after ni
citinpc«u»e. It is pro'w.
The iniliralion* for
iinheallhy surniundina* ,
, M* of nm m*
Altmr
iafrtiMiim ori
tliewmtkafi
fioUoVMJ
of tfe
«c
Um cheek. OtiMr lead lypKeetieM rcpivted to kavs
bean CoOowai kgr good Rsoltsare A» pne tinctav
of {tereyeride of mm, wistaoa of cufti nilphirw (30
gnua* tu tlw cMneeX ewl mlmitnUe of btsmaUi. 8ac-
cnsfol trf twiat of tkk albedoa bee been reported
br '<w«fai]uig tlir okwrated eorfeces with » I in 1,000
Milation of pecdilonde of nerearT.
For cieooniig the mooth cUoriiuted aoda louons
may be naed (lupnr andie dilorinatjp, I oonc« ; »qiw
m1 16 ottnoeB). or • 5 pt-r cent, solution uf carlulic i»citi.
T nld be freely pfea, especially quitiiiw
anil 1 '• of iron : an well aa an abandancr of
r I and stimulant« ; as iiiucli wine iin«l
I iiijil will t«ki» — 3 to 4 ounces in twenty-
fnur ii'Min f<ir a child of live yeai-s. K;;;r* luNit'-n up
will) milk, strong sou|>s, wine whey, pounilwl meat, an-
tlie best fo<MU. Nutrient eneuiHta iniiy !)»• given if
KUliicient fool cannot he administer<<<1 hy the nioiith.
The trt)ul)li;soinc scars and deforntities left licliiml
in cases that recover may be reinetlied by appix)i>i'ittte
surgical treatment.
6. iHerrurial stomatitis, or mercurial Mtliva-
tion, is caused, am its name implies, by int
10
Medical Treatment.
I Pari I.
AiUite/itw 'Sulici/lu' Lotion.
^T Acidi aalicylici ... ... nemi drachmam (jss).
Spiritus vini roctiBcati ... lirathmim ina (jiij).
AquBs cAiiiphorai ... ... :id iinciuB octo (Jriij).
]^Ii»c>-, fint lutio. (Dissolve the acid in the spirit und then
odd tho wuliT.)
5. OauKi'cnoiiN KtonialiliN, cnnrriim oris,
nomn. — Tliis very jfravc iilTectiou i.s, liiippily, nirc.
1 1 iKcui's ill children between tlirc*^ and six vpai-s
of age. u.sually fis a seipiel or coiieoiiiiumt of soniR
cxhau.stiiij; dibensv in tlmse that are ill nouri.-ihefl und
of a .slruiiitiUH diathesis. Mettsles and enteric fever
are the di.seases it most conimuiily folliiws. It has
also been encountei'e<l after wluioping cough and
typhu.s. The e.xce.ssive use of nvereury has been .said
to favour its occurrence. It hegins a.s a swelling of
the cheek on one side, and .s|)reads over the face.
The nraeoiiB oMubnuie lining the corrcMfKniding buccal
surface is found to be ulcerated, and this ulceration
spreudK to tlie adjacent guni.s, so that the teeth be-
come denuded and looseiK'd, und the bone itself may
be attackeil and undergo necvosi.s. There is usually
a hard, rounded nodule to Iw felt in the centre of the
swollen cheek. A fo-tid, gangrenous odour proceeds
from tho mouth. Gangrenous scare form both ex-
ternally an<l int<'rnally. These se]iarate and leave a
hole in the cheek, exjiosing (ho di.sea.sed Jaw ami
denuded teetli. Infective broncho-pneumonia often
suiwrveneji, an<.l dinrrho-a, and the disease is conunonly
fatal during the second week. Recovery .sometirneH
occurs before the cheek beconies pert'onited, but ordi-
narily great deformity in left behind from extensive
gangrene of the lace, nose, and adjacent parta. It
is said tu he fatal in at least scventy-tive per cent, of
cases.
Trt'iitmciil. — This consists nmirdy in local cau-
terisation, under chloroform, with the actual cautery
or pure nitric acid.
After cai-efully drying the parts witli lint, sticks
should be dipped in strong nitric acid and then rubbed
Cliap. t.|
GAJfGXEJfous Stomatitis.
II
wt'll into tbe edge« of the sloughint; pfirts, and over
llio surface of the fjmns, suiy loose sloii^rhs being pre-
viously cut aw»y and sequestra reraoviHl. Cure must
be taken that the acid does not run over the sound
skin. It will 1k> usually neeessrtry to make several
applinitions, the parts beinj; well-dried between eiich.
A little ioflofonn should lie subsequently [Miwdered on
and the surface smeared with carbolic oil. Some
prefer hydrochloric acid or the acid solution of mer-
curic nitnite, and others prefer the use nf Paqui-lin's
cautery. After cauterisution, antiseptic waslies or
injections or spra3's must lie used day and ni^rht to
cleanse the mouth of dead and decomposing; nuitter.
Beneiicial rcMuli.s have Ijeen reported from the
local application of undiluted carbolic acid, followed
by tho frequent use of a 2 per CKMit. wa«h of the
same ; one case recovering without perforation of
the cheek. Other local applications reported to have
been followeil by j^ood residts are the pure tincture
of perehloride «if iiim, solutiim of cupri sulphatis (30
grains t<i the ounce), and subiiitrate of bismuth. Suc-
cessful treatment of this aH'«'clii>n has l)e<'n reported
by swabbing the ulceratetl surfaces with a 1 in 1,000
solution of jMrchloritle of mercury.
For cleansing the mouth chlnrinated siida Iniions
may be used (liquor sixlie chlminatie, 1 ounce ; aipue
at! 10 ounces), or a ."i ii«Teent. solution cif carl Mjlic acid.
Tonics should lie freely given, especially quinine
and perchloiide of iron ; as well as an abundance of
nourishing food and stimulants : as m\ich wine and
brandy as the child will lake — 'i to 4 ounces in twenty-
four hours for a child of live years. Kggs beaten up
with milk, strong soups, wine whey, pnunfied uieat, are
the best foods. Nutrient enemata may W' given if
Buflicient fmil c^uinot be administered by the mouth.
The troublesome .scan) and deformities left behind
in ca.se.s that nx-ovcr may be reme<lieil by appropriate
»tirgical treatment.
6. itivrriirlal siointitilis, or mercurial saliva-
tion, is caused, aa its name implies, by intoxication
13
Medical Treatment.
tP.n I.
with mpn'iirv, either given as a raeflicine, or from
contact with the tnetal in tho arts.
Tlip syiii|itoiiia consist of a iicculiar f(vt<>r of the
liiffitlt, 11 niet^illic tiust<;, sureneas of tlie fj;uuis and
niuiuli, an<i jir<ifuM> nccretioii of wiliva. The lips, the
t(inf;ui>, anil the whole of tin- liiuxiil mucous tiH^m-
liniiie liecoine invo!ve<l. The lyniphntic gltind.s of the
lower jaw are enlari^tfi and jiainfiil ; the tongue is
Bonif'tiinos greatly swollen, iirid nioatication and
swallowing are dirticult. If this iviroction jiroceeils
iHichRcked, it may take tho fnnn of ulcerative stoma-
titis and occasionally necrosis of the lower maxilla
(wcurs. It varies greatly in severity, and in its
manifestations and duration.
The IrrnlilU'iit of this form of stomatitis re-
quires, in the first ]ilace, that the patient should be
withdrawn immediately from the influence of the
metaf. It is said that the admitiistration of
potassic clilorat« acts as a prophylactic with workers
in the metal. This is also one of the hest remedies
for the disease : 30 to 60 grain.s a day is usually
quickly followerl by amelioration unci cure. It
soon ivuKivcs the cluiracteristic fietor. Anti»e])tic
and cleansing mouthwashes ai-e needful, to which
some opium may he added (as well as given internnlly)
to relieve )>ain. The best are sohitions of potassic
chlorate, creasote water, bora.x with tinctures of
myrrh and cinchona, saprmitied emulsion of co«U-tar,
brandy and water lotion ( V/nlgon). Sometimes a
wash of acetate of lead (10 Brains to the ounce) proves
very soothing, and some think highly of an io<line
wash (idram of the tincture to an ounce of water).
Ca\iteri.«ation is occasionally needed either with nitrat«
of silver or hydrochloric or chromic acid (1 in •")). To
check the excessive saliv.ation a tannin lotion will
prove serviceable (I dram of glycerine of t.aindn to an
ounce of rose-wat-er); or this distressing symptoiii may
l>e controlled by belladonna (."> to 10 udiiims of the
tincture every four or five hours), or a hypo<lennic
injection of atropine (-jj,; grain) may be given.
i1
ToifSILLITIS.
'3
Jntf^mvMij, Ik'suIus |K)t«s>tif chlnnit^, as alreiuly meit-
tioiiiHi, totiics lire indicate<l. iitnl nitric acid hiis l>e«'n
fduiifi i!ipeciftlly useful — 10 nnniiuN of tlii' dilute acid
with a jtTain or two of quinine in an ounre of water,
tliree or four tiiiip.s a tlay.
As niusticAtion may I* iiiipossilile and swullowing
rlifficiilt, either fluid or soft pulpy f<.xKln must Ik? >u1-
niinistered. Jlilk, l)et>f-ten, whipjjed ejiK*. jwunded
■neat mixed with nouriMhin^ soups, soaked stale lireiid
ma<le, into a thin pap witli milk, oiitmeal gruel, and
other fluid fo<Kl.s, may he gixcu. If .swallowing; shoulil
be e.s|>ecially ditticult and pninful, nutrient enemat4i
ninst lie administered.
DlSRASRS OF THE T0N8ILS.
Ton«illiliK. — The tonsils in some persons are
very prone tu iiitlammation. Throe prinei|ml kiniis iif
tonsillitis have been describe<l. First, a i-uIuitIiii/ or
»uf>frficitrl form in which the mucous meinhriuie only
is inflamed, but this is only a {>art of an ordinary sore
throat or catarrhal pharyngitis (angimi catarrhalis).
Secondly,^ /'oHiru/nr or lacunar tonsillitis, when the
fullicles eupccialh/ arc intliiineil and plugged with
exudation ; this also may 1k.< a luvrt of a general
pharj'ngitis. Neither calls for any sp«_'cial treatment
apart fmni that of the genenil ufl'ection of the pharynx.
TliiriUy, a jinrmcln/ninloiis or m/ipurative tonsillitis ;
this is commoidy known as ql■in^y, and is the form of
tonsillitis which will chiefly now occupj' our attention.
As to the ciiu^rg of t^jnsillitis, constitutional prc-
disjKisition is a very prominent one. Some person.^
iipjie^r t<t inherit r |»e<;uliar susceptibility to inflam-
mation of the tonsils, and will sufl'er during their lives
from rejient^d attacks. " Scrofida" is particularly
apt to Ik* found assoi'iatetl with the more chronic and
permanent forms of early childhoiKl ; rheumatism and
gout with the severe acute forms of youth and adult
life. Attacks of acute rheumatism have often been
observed to be preceded by attacks of acute ton-
^llitia; and it is thought probuble that the specific
u
Medical Treatment.
[Put I.
poison of rheumatic fevei- gains entrance into the
l>i)dy tliiougt) till' tonsils. Tlie exanthemata are
aswK'iatod not uiifr('<)Ufntly «itli tonsillitis; indeed,
the belief is giiiniiij,' ^'rouiul tliiit the tonsilM play an
iniporUint part in iwlniitting into the system the
various [tathogenotic niiciohea that give rise to in-
fectious diseases, while its own aflections are doubtless
the consequence of tuierobic svctivity.
The Ki/iiipt-oms of acute parenchymatous tonsiilitia
are highly characteristic. Fever is usually present
from the onset, and the tomperatui-e often readies
10 r or lO.'j', Pain, often e.xtending into the ear,
and dirtictilty in swallowing and u feelin;^ of soreness
and heat in tho throat, call attention to that part, and
on lookiii;; into the ihroiit one or both tonsils will be
found to be red, Hwollen, and projecting into tlie
phnrynx. ISotb may be involved to^^'cther ; often they
will be Mecii ncjirly or quite touching one another, ami
filling lip the whole of the entrance to the pharynx ;
more coninionly the intlainmation of the second t-onsil
follows that of the first. The soft palate and uvula
share in the intlaiuniation, the mucous nienibnine
being intensely red and inflamed, ami the whole uvula
being swollen and elongated. The itiflumed part.s, at
first dry, soon become covered with a viscid, sticky
mucus, and owing to the obstruction in the throat
^and consequent dilhculty of .swallowing, the saliva
'escapes freely from the month. Pain anti swelling
about the angle of tlie jaw, which sometiines extends
to the adjacent salivary glands, make it difficult for
the jjatienl to open the mouth so as to fK-rmit of full
inspection of the throat, and the forefinger must be
intiwluced to explore the condition of the tonsils.
Besides the other symptoms of fever there are usually
headache, restlessness, a thickly-coate<l tongue, foul
*"^at.h, nauseji, los.« of appetite, constipation, and
•ty, high-coloure<l urine.
'lie inflammation of the tonsil may end in resolu-
or suppuration.
n the former cAse the parts may be restored to
Oij«. 1. 1
Acute Tonsilutis.
their natural eontlition in t«n or twelve dnys, but
frwjuentljr more or less permanent t-ii]«rgement of the
tonsil remains. In suppurative caKes, after fonr or
five (layH, the occurrence of slight rigoi-a and the com-
pliMut of throbbing pain and great tension in the in-
daluttl tonsil, indicate? that pus has fonuMl there.
Usually the absees-s burntH suddenly, sometimes durinj;
Bh-ep, and its contents iiru swallowed ; or it is dis-
charge*! from till- mouth, j^reat and immediate relief
accompanying this termination.
In the tr<>alin(>iii of^c-ute tonsillitis much may
bt' done, if the case is seen early, to prevent suppura-
tion, or, when this result is inevitable, to ha.sten it.
In young childi-en, and in some young adults, most
aciitc throat aft'ections are very amenable to the
inflaence of aabjiiie. It is of little use in older
{Atirnts, and^R use, in nil ca-ses, is pretty well
limited to the first twentj'-four hours. If it ha»
not had by that time a marked effect on the fever
and the throat discomfort it is as well to lay it
nide for Home other remedy. A child lietween live
tld ten vejirs of age siiould be given 1 or ^
minims of tincture of aconite (or a pilule of nconi-
tine containing jjj, of a grain), with a drnm of
lii|uor ammonii ocetatis and a liitle syrup of orange
peel and water every two or three houi-s, for six
closoii ; from 10 to 15 years, 2-minini, and above
l-'j yeai-s .3-ininim doses may be given. This remedy
will sometimes remove rapidly the early inflammatory
throat affection in chihiren. A saline aperient should
always be given at starting.
For children a |.towder that is tnftelesa has such
an advantage over other me<licines that we may
ffive one containing a grain of calomel mixed with
3 grains of sugar, and wash it down with two
lbles|>oonfuls of Dinneford's Huid magnesia mixed
1th a teospoonful of syrup of lemons ; this mix-
ture makes a pleasiuit, cooling drink, which may
be repeatotl every hour until the bowels ai-e freely
relieved. Mouthfuls of icetl milk and wat*r are
t6
Medical TREATMEm.
(Part 1.
useful in this sUif»o, combined with ice-cold com-
[in'sses t'xtor-iiallv.
For older piitients «-e think hi^'iily of the renip-
tlial etfects of i/iutuicutn ; piitieiits wlio luvve i;ono
ihroiigli fiinni-r nttjicks with iiiiil without this dni^»
know its viilue, nlthouKii they dislike taking it.
An ounce of the guiiiiicuni mixture of the B.P.
should he given every four hours ; or a teaspoonful
of the aminoniat^d tincture may he added to half
a, glass of milk, and this mixture may he used as a
gargle and titcn swallowi-d^ It should he taken every
two hours, until it begins to purge ; or in mild cases
guaiaeuni lozenges — 5 to fi a day — may be allowed
to dissolve slowlj- in the mouth. ,Sa/ol in large
doses has also been hiyhly commended. In very
pronounced rheumatic ca.ses sodiiim^gbcylate may
Ih" given in doses of 10 to IT* graiflWjvery two or
three tmurs until relief is felt. Some apply salicylic
acid directly to the surface of the tonsils.
The following formula has Ix^n suggested : —
K Acidi wilicyliri . . <lniihrniiB diriB (5!]).
Sodii bicarbonalis ... dr«chin«m oiim semiwe (3J(is),
(ilycerini ... nncinin (Jj).
Aqiiie menthie piperita! . .. ad uncliu qiiatuoi (.^iv).
Misce, fiat mistuni. A Itthlespoonful every 2 or 3 hours.
An active saline purgative must also lie given, such
as 2 drams of sodium or magnesium sulpliate, with
20 grains of magnesium carbonate in an ounce of
pepi>eniiint water every four hours until free .iction
of the bowels is estnblistied. We have seen advan-
tage foHow the addition of S minims of ipectcu-
anliu wine to each dose of tiiis api>rient mixture,
especially wliPii the pjitient comes under treatment
in the moi-e advanced sUigc, and -.vhen it is desired to
hasten suppuration.
The attack can sometimes be arrested at the very
commencement by scai-ilication of the inflametl tonsil,
the incision.* being aUowed to ble«l freely. The
subsequent application of a 10 per cent, solution of
Cbfk I.J
Acute Tonsillitis.
17
line to liie surface of the tonsil appears to ha9t«n
Dlution. Wlieii tlie diwiise cminot f>? arn-sli'il,
cocaine mny nlso he of st-rvic* in allaving sulfering.
A 4 to H jwr cent, solution may l»<* .■<.|>rttyeil «in to
tlip tonsil for ji fow spconds at a time, the nozzle
I of the atoiiiisrr U-ini; iutriKliiciHJ llet^vl••■n tlie teeth
and tliiivtcd toWnls tlin t<>n»il. "r a Kprny of
Cocaine (I per cent.) conil>ine<l ^th menthol (I'J i>er
cent.) (licHolve<l in paroleine, will relieve the pain.
The menthol has the advantage of bein)< also an
antiseptic Sucking ice will often afford relief.
In severe cases, and 9k hastening suppuration, we
liave found notliing more etlicaciouH than a gargle of
kpt water contitining aV)out 2 grains of l>oriix or of
wdium bicarbonate to the ounce ; the patient should
be directed to keep gargling or holding thi.i in his
mouth as consCntly as possible. Inhaling the steam
of hot water, or hot water containing nonie aromatic
substance such as benzoin, camotiiile, Kige, ho|K, cam-
phor, or opium, is nlso very useful. Externally pro-
I fuse hot fomentations, applied frequently with a large
sponge, the head and neck Ijeing held over a large
basin, and in the intervals ha^ moist sponges fastened
round tne throaty greatly hasten the progress of the
case. If we can distinctly satisfy oui-selves that
there is a supertici.il collection of pus which we
can easily reach by a guardecj bistoury, we should at
once let it out, but patients constantly complain of
being uselessly put to |Xiin by tlie.'ie punctures, which
appear to give no relief. The swollen ancl owleuiatous
mrface of the tonsillar swelling often gives a fallacious
^nse of iluotuutifin to the finger, which indu«'s the
medical attendant to puncture prematurely.
I If the teuiix-rature kee|i« high in caae« of acute
tonsillitis it is advisable t*.i give full doiUM of
quinine, 4 to 5 grains dissolved in lemon juice aikd
«'ater e%'ery 3 or 4 hours, until the temperature U
I reduced.
After supjjuration and discharge of the ahaocws
tonic treatment is needed — bark and ammoniA , '
c
r8
Medical TREAmEirr.
(Part I.
rheumatic cases, or quinine and acid in ndti-rheumatic
caaes, or iron and quinino in cases of great debility.
The following antiHeptio gargle in acute tonsillitis,
after incision, is recouiuienrled by Sclitutzler: —
"° I on.i gmnn m^adrnjifintii (^, xl).
I^ Sodit salicyktin
BoraeiB
Aqiite lauroceraai _ ... drachmam (3J)
Aqiis; d(.*8tillHt»; ... ad uncins octo (jviij).
Miaoe, fiat gHrgnrisma, 1
In children we have seen retrogif-ssion of the
chronic enlargemetit, which remains after the acute
stage, promoted by the u.se of Bourboule water, from
2 to 8 tiibl('s|)oonf»il.s, according; to n^'e, ^iv^n with a
little hot milk night and iiinrnini,'. The emplnynient
of a weak iodine fjnrgle (one dram of tincture of
iodine and half an umice of ^IjceritiAo fi oiince.s of
water) is also of use for this purpose, a.s is the .synip
of the iodide of iron with cod-liver oil, especiiilly in
scrofulous aises ; in which also change to the sea-side,
if the season is suiUible, with local and general sea-
bathing, favours complete recovery.
Food during the acute Bt«ge must be fluid, and
milk is the be.st. In the early stage, and whilst there
are prosp<'cts of securing i-esolntion, the milk should
be mixed with ice water, but in a more advanoi'<l
stage, and when the object is to hasten suppni-ation,
it shouiil be diunk warm, or even a-s hot as it can be
tolerated, diluted with a \ part of .seltzer or Ap(X)li-
naris water. Pei-sons prone to repented attacks of
quinsy shouhl bu recomniended, as a prophylactic, to
sponge the tltroat and buck of the neck daily witl^
cold water, or direct a cold spray douche over tlie.se
parU. The throat should also be gargled every
morning with cold water containing i or .'J gniins of
borax and a few drops of tincture of myrrh to the
ounce.
C'lironic rnliir{frin<>iit of tlic loniiils (hyper-
tropliy), which is often found in children and itaches
at times to such a degree as to cause deafness and to
roup. I.I Tonsillitis. Pharyngeal Catarrh. 19
serioiislv embarrass respiration, requires the removal
of tLo liypertrophied organs. Slighter degrees of en-
largement fulluwing acute tonsillitis m»y be greatly
lienelitecl by iodine gargles (as Hlrea'ly suggested) or
I he rubbing in under the angle of the jaw of *oap
liniment containing 2 drams of iodide of pitiissium
to the ounce. The local application of glycerine of
tanniu in a<ivantageouB ^rhen the tonsils are soft and
spongy. If removal is det««rmined upon, the best
^H inNtrunient for the puqiose is Mathieu'a guilhjtine,
^H unless the tonsils are very large., long, and narrow ;
^^H then it is liest to use the vulcellum forceps and a
^f blunt pointed bistourj*. Excessive bleefling may be
•• btopped by the application with the finger of a j.>owder
Icomp»ed nf one third alum and two-fhiid!i tannin.
In the rolliralnrtoiiBillilia which often accom-
panies certain f<>rni.s of phitrviigitis, a gargle of
oroolin has l)een found very useful. The throat
should be gargled several times a day with eijual i>art»
of a 1 per cent, solution and warm water. The prick-
ing sensation it leaves in the throat may Ije relieve<l
by gargling afterwards with pure warm water.
DlSKABES OP TIIK PUABYNJC
Acute pharyogeal catarrh (tort throat,
ati^iiia) — In this disease, as in tonsillitis, the inflam-
mation is nut ciiufiniNl toany 8[>e>-ial part of the throat,
but extends usually to the whole thn>at. The soft
pHlate and uvula are ulmOHt invariably affrcted, and the
fitucial arches often more ku than any other |>art ; the
catarrhal state also commoidy extends to the back of
tlie nose (post-nasal), into the mouth and to the
epiglottis and larynx. Hence the more general term
" sore tliroat " is preferable.
Usually, and in niilj forms, there is simply an
erylhcmatous inflammation of the mucous membrane
of the pharynx, iKihite, and tonsils, which, undi-r
favourable conditions, sub.sides in a few days. In
more severe cases there is more swelling itnd great
relaxation of the mucous membrane, which may be
30
Medical Treatment.
tPart I.
intensely congpsted an<l nflonifttoiis. Tlie mucous
fiilliflns iin? nft^iii swiillun, and tin- imicons nicm-
lirjiiu' is usually covcrcil with :i sei'ivtion of dirty-
lookinjr, (Irviuli, sticky mucus. Tlii^ uvula also is
I'lonfjated and swollen. Siifipuratiun (suppurative
phiiryngitis) is apt to occur iu enf«'ljlfd pfrs<jns, as
well iws in severe traumatic cases. Ulceration (ulcem-
tivc pliarynj^itis or ulcerated sure tliroat) frequently
occurs, especially in septic cases.
The nio.st common caiine of the .simple forms of
acute pliiirvn^ilis i.s e.\po.sure to colil and damp :
the ulcerative forms (when not sperific) are usually
cause<l liy lireatliing a .septic atmosphere, as in the
so-called "lios|iital throats," "drain throats," etc.
Phar_viij;itis may, of course, be caused liy cojitnct with
mechanical and chemical irritants in the solid, litjuid,
or Ka.seons form ; or may be excited liy the contact of
highlydieat*>rl steam or other hot lliii<l or solid sub-
stances. Jt accompanies most of the exanthemata,
and in scarlet fever occji-sionally a.Hsunies a very
serious n.spect. It is soinetimes epidi'mic, and may
acconijiany epidemics of tt iie iii])htl)cna.
It is doubtless in many cases due to microliic in-
fection : in others it is asisociateJ with the rheumatic
or jjouty fliathesis.
The syin}iloiii» commonly complained of are heat,
dryness, tension, and uneasiness in the throat ; some
dysphagia, slight moditicution of the voice, and occn-
sionnl hoarsene.s.s. There is usually .some fever, and
in some persons, if the temperature is taken in the
mouth, it will lie found out of all projKirtion to the
gen«ral constitutional state. We have often obsj-rved
a temjwrature as hiijfi as lO-t' F. for a few hours
during the heijilit of the inflammation ; lOT to 102*
is, however, far more common. In cases which are
referrible to chill there is often complaint rif pain or
aching in the back and limbs; the cervical glands are
occasionally swollen.
The irenlmonl of the milder cases of sufterfioial
pharyngitis is simple. Confinement to the house and
Chap. I.J ACUTF. PHAKrifGBAL CaTAKSU. ai
the Strict aruidanceof exposure to cold currents of air
ore essential. If the bowels have not been freely re-
lieved, and if the tongue and mouth are foul and
Kticky, a saline aj>erielit should bo given — a seidlitx
]Miwder, or 3 or 4 ounces of l>iiineford's duid magne.-<ia
with a t«'aspoonful of lemon-juicf, will often lie sutti-
cient. This is often, however, advantageously prp<'ede«l
hy a pill of 1 grain of calomel and 2 grains of extmc-t of
henbane. If there hits been troublesome constipiitinn
licfore the attack a stronger dose will be needed, and
an ounce anri a half of the nii.stura sennie c<>)iip<Mita
may be ordered. If the attack ha.s been brought on
by exposure to cold and damp, and w accoin|uiiiiud by
puin and aching in the limbs, a rliaphoivtic draught
should Ije given at lied-tiuie, and the patient be en-
joinefl to keep hi.s room at least for a day or two.
This draught may consist of : —
I^ .Silii'ini grunn quiiiilecini ();r. XV).
Li'iiioris aiiiinonii nuctulis ilnichiiiiu tn'< (5i>j).
Kpiritiia iHheria iiitrodi ... draclimnm l^j).
Aq<i!e cniiiphorii.'... ... nd uiuiitin (.um wmissv (JjaaJ.
Miice, tint haustus. To be taken nt bed-time.
If there is much )xi\n in the throat, an eighth to
a sixth of a grain of acetate of morphine may be
added to this draught. In young children, if there
is n high temperature, tincture of aconite or granules
of aainitine (jjj,, grain), giv«Mi in the muniier already
described for tonsilliti.s, will oft<>n act remarkably
well,
In septic cases, with much depression of strength
as well as fever, we prefer, after the Iwwels have been
relieved, to give quinine an<l potas.siHm chlorate in
cfl'ervescence, as follows :—
ly Polufuiii chlomtia grnim di.'i-im (gr. x).
r<>ta«ii liiciirhonntiB . .. Krnxn vJKinti (gr. zx).
Ammonii cui'bonatiit granu (|iiiiu|iit< (gr. v).
S)'rii|>i ttumnlii ilrui'hiimm (j^).
Aqiin; ... iid iinci»m (jj).
Miac«, IihI liatutuit. Tu be given evvry three or (our boura
with the foUowjog powder : —
aa
Medical Trbatmekt.
(Parti.
' ' t granatrp8(gT. jssaduj).
Acidi cilriti ... g^na viginti (gr. xx).
Misce, fiat pulvig.
Half these doses can begiv'en to children between
seven and fourteen years of age. The tlryness and
heat of tlie thr<«it niiiy he relieved by .suekinjj; frag-
ments of ice or Hipping; iced Icniuntidc. A cold com-
press applied to the throat is also useful. When
a8.'4ociut<'d with rheuniatisju, saliciu and the Halicy-
lates are indicated, and when witli gout, colchicum
and alkalies.
The th'et should be light and nouriHliing, and may
con.sist of milk, of whipped egg.s, of oatmeal gruet, of
broths, beef-ten, fruit jellies, and the like. When
there i.s nmeh relaxation of the mucous membrane,
and imid) sticky mucus tiaiigitig about the throat,
grvat comfort is experienced from the use of an alka-
line and astringent gaigle .such as the following,
which elcans away the mucus aiul braces up the
relaxed mucous membrane :- -
V) Sodii bicnrbonHtis
Glyeorini borscis
rot»g«ii chlorBlia
Tinctune cattxhu
Aquee roiiB
Miace, fiat gargarisma.
dmchmam (3J).
iineiBm (jj).
dnichniiu diiaa (3>j).
diHi'hmaa duns (5ij).
adum iis duodi'cim (jxij).
To !» uiiej warm.
In cases of intense inflainniation, witli much swell-
ing of the mucou.s membrane and great pain, so that
gargling is not possible, a spray of warm water con-
taining .5 grains of sodium bicarI)onate and 2 or 3 of
sodium chloride, and of "20 minims of glycerine of car-
bolic acid to the ounce, is very comforting.
Aft«r cleansing the throat of adherent mucus by
a warm alkaline gargle, great comfort may often be
given by the npjilication of a .5 to 10 per cent, solu-
tion of cocaine by means of a camel-hair brush.
Later, when the relaxation of the mucous mem-
brane is chiefly distres-sirg, sprays cuntJiining alum
(5 grains to the ounce) or tannin (5 to 10 grains to
OUfL I.)
Pharyngeal Catarrh.
23
the ounce), with or without amraonium chloride (5 to
10 grains to the ounce), may be used with advantage.
In wjnie low forms of ulcerative (septic) sore
throat, vigoi-ous t 'uic treatment may be needed, and
a mixture containing 2 or 3 grains of quinine and 15
or 20 minims of tincture of pt-rchloritle of inm sliould
lie given every four or live hours. Thn'c ur four
({loKseH of sound fiort wine are often also n'.'odcd
daily. In these ca.ses the throat sliould Im.' wailic^l
out (the attempt to gargle i.s tio painful) with an
iintiseplif wash ; a saturut* d .solution of horic acid to
whirh a little tincture of myrrh is added will answer
the purpose.
The inhalation of vapour of benzoin given off
from very hot water c)iarg«;'<l with altout 5 per cent,
of the tincture is soolliing, but of no great cunitivo
fllicJicy,
Chrnnic phiirj'itKOHl ralairrh {chronic »ore
throat). — This has been divided into two variotien
according as the glandularyo//<c/»'* are or are not con-
spicuously affected. In the latter case we hiive (1)
tirnpU chronic calitrrhat »ore throat, and in the former
(2) Jollicnltvr or yrunuUir i)liaryMgiti.s, or clergyman's
sore throat.
The chronic form of catarrhal sore throat usually
follows repeated attacks of the acute disease, and has,
therefore, the same etiology. 'V\\o follicular form is
predisposetl to by sedentary occupations an<l un-
healthy habitations, and the exciting causes are
usually e.vccHsive use of the voice in speaking ond
singing, or local irritiition from tobacco or alcohol, or
fcMKl and drinks too highly spiced or too hot, or too
hot nnd too colil together. It sometimes follows aiute
pharyngitis, and sometimes seems to be chronic from
the outset. It is common in the scrofulous, and not
infrc<iuent in the rheumatic and gouty.
In fol,licidar pharyngitis the pharynx is seen
covered with small projections varj'ing in size from
that of a pin's head to three or four times this size.
Patches of dirty yellowish or brownish adherent
24
Medical Treatment.
|P>rt I.
mucus also cover the surface of the mucous mera-
brane. In very old cases of this kind, when atrophy
of the gluudular structures has tAken place, we get ii
variety known an pharyngilis aiaa or atrophic pharyn-
gitis (dry catarrh). In these eii.scs a scanty, diy
secretion is seen covering the thin, hard, glazed
mucous nieniljianc.
The !t>'iii|»l«ui!i cipinpliiiiH'd of in chronic pharyn-
geal catarrh are an umroinfortabk.^ sticky feeling in
the throat, with a const-ant desire to "clear the
throat " Vij' coughing or "■ hacking." There is usually
more or less expectoration, and if this is dry and
sticky, and not easily detached from the mucous mem-
brane, there may lie a good deal of dry irrit-stivo
cough. The cough is often trouhleaome on lying down
at night, especially when the catarrhal condition ex-
tends into the posterior niires. This, we l>elieve, is
cau.scil ijy the larynx, in the hori/rmtnl position,
falling hack against the jiosterior wall of the pharynx,
so that the excessive secretion from the catarrhal
mucous membrane drains, ax it were, into the laryn.\',
or hangs about the glottis and excites efforts at
coughing to get rid of it. The voice is often thick
and coarse, ami the throat get-s " fatigued" after roach
vocal exertion, its in public speaking, singing, etc.
In the Ircatiitful of chnmic pharyngitis, im-
provement of the general health must be our lirst
consideration. If there is co-existent gastric catarrh
wo must etideavour to remove this by cai-cful atten-
tion to diet and habits and a proper regulation of the
Ijowels, Strong alcoholic drinks and all hot and irri-
tating articles of food must be forbidden, as well as
the use of tobacco, which undoubtedly is the cause of
much troublesome catan-h, both gastric and pharyn-
geal.
If there is chronic constipation, a small pili
containing half a grain <>f powdered ipecacuatiba,
a grain of aloes, and hiilf a grain of soap, should
be taken daily immediately before ilinnev, and a
tumblerful of hot Carlsbad water should be drunk
1.1 Chronic Pharyngeal Catarrh.
«5
the fii-st thiiiK in the inuriiiui;. Tliis will cleanse
tlie Rtuniaoii of aHheiTnt mucus aiirl promote ita
liiNilthy nefretioiiB. It is an excellent plan also to
drink and at the same time gargle the throat with
a wanii alkaline water about an huur before «ach
meal — Ems or Vichy water will do.
In sfTofulouH conditions, as noon as the tongue \n
dean and tlie stomuoli in K<>od orfler, we should jfive
co«l-liver oil and syrup of ili« io<liile of iron, and in
aniemic and rlebilitat«d ciuHt!ti rpiinine and Hlrychnine
and tincture of the perthloride of inm. In 8on)e
g«mty and rheumatic cosert small doses of i<xlide
of j>ot:4s.siun> with a bitt«r vc>{etiible tonic will lie
of use, ttud in others the alkaline and arsenical
Bourlxjule water will l>e found of great service ; 4
to G ounces should he drunk vnnn night and morn-
ing, und an liour IxM'ore dinner ; it should l>e
drunk slowly, and kept in contsct with the throat
while swallowing. Topical ustringents are of gre^t
value in many c-ases, but they should not be
applied until the throat has been first cleAnsod from
adherent mucus by gargling with a warm alkalinu
solutioiL
The free application of a solution of nitrate of
silver, from 3 to 10 grains to the ounce, in that
form of chronic pharyngitis which follows acute
AttAcks, is exoeedingh' useful. A solution of chloride
of zinc, h to 10 grains to th(< ounce, is also an excel-
lent «j>pliaition, applied daily to the throat with a
large soft brush. Some apply a mixture of nitrate
of bismuth with glycerine, 10 grains to the ounce,
rith a brush, and iind it relieves the local dis-
tort ; a solutiim of tannin in ether has l>ecn
onimended by others. It is said to answer
admirably in some cjtses, as it leaves » thin film
of tannin on the surface. All these applications
require to be made by a me«lical man ; it is neces-
Bar)', therefore, to have other resources which we
can entrust to the patients themselves. Sprays
arc very useful for this i>urpose. Tar-water applied
26
Medical Tseatmeut.
IParll.
in this way often renders good service ; or a warm
solution of l«3rax (8 to 10 grains to the ouncft), or
a solution of sodium bicnrbonatc hikI iiininoiiiuni
chh>ri(l«> of the wmie strength. In niiki, clironic
cfljies gargles art; of mucii service. An ounce of
glycerine of borax and half an ounce of tincture of
myrrh with 12 ounces of rose-water makes a pleasant
anil useful gar)j;le.
If the nuK'ous tiii'nilirane and iivuta are much
relaxed a good astringent gargle may Im? made with
5 draniK of glycerine of alum, 20 minims of tinc-
ture of cajwicuin, and 8 ounces of the acid infusion
of rosea.
Thei-e arc many useful forin.s of lozenges for these
cases ; some serve lo tJetnch the sticky mucus nnd
promote expci-tomtion und so relifve cough, such hm
the aminotditm chloride lozenge.s, the Soden pas-
tilles, and the yiiustilles r>eth»n (a French chlorate
of potash lozenge (lavoured with benzoin). t>r the
astringent lozenges are more useful in other cji.ses,
such ii.s the rod-gum lozcnige, the rhat^ny, catechu,
and tannin with capsicum lozenge.
(Siiaiacuni pastilles are useful in rheumatic forms,
and codeine pa.stilles to relieve the troublesome night-
cough so often a source of annoyance.
Old cases of /ollictdar pharyngitis are exceedingly
ditlicult of cure. Some specialists recommend appli-
cations of very strong solutions of idtrate of silver
(1 drum or 2 di-ams to the ounce), or iodine and
carltolic acid (1 dram of cjich to an ounce of glycerine).
The dilated capillaries are said to be sometimes bene-
fited by the loi-al application of the liquid extract
of ergot, or a solution of ei'goliue (10 to 20 grains
to the ounce). The local destruction of the enlarged
follicles is also a favourite method of treatment,
either by such caustics as solid nitrat* of silver, or
chloride of zinc, or caustic ]K)tash, or the incande8c«ut
electric cautery.
We have found in the less inveterate cases
nnich service from the use of Bourboule water, as
eAL Catarrh. 27 ^^H
' 'los, or the Caut«ret ^^H
1 .< suits from a course ^^H
Excellent results ;ire ^^H
ians at Ai.\-la Cliiipclle, ^^^H
iiiliaJHtions of tlie com- ^^^|
'K'ir saline Kulpliur water. ^^^|
'>nic treatment is alwayx ^^H
^^^^^^^^ in reconiinenrlfld im a kcmhI ^^H
^^^^^^^V
" threnteneil " Hore lliroiit, ^^H
^THiia (luodoi'im (gr. xij). ^^H
iiiinimn qiiinqiin (ii\ v). ^^^|
i;r;<iiu triitintH (i(r. xxx). ^^H
... Mini uncinm (.^xi). ^^^H
... ud uncin!) trcH (^iij). ^^^H
^^^^^^^^ Itiroat to be iminti-d willi ^^H
^^^^K ^B
^^^^^^^K vitre
Otrg;le or ipray for acuto ^^H
^^^^^^^^B
pbaryngitta. ^^H
K Ac'i'li L'tir)>4>li<'i, ^j. ^^^H
Cuoaiiitu hy(lrtic)iluriill, ^^^H
^^^^^^V
viij. ^^H
niyc'criiii boracls, >iv. ^^^H
Atiuit* rriH]t< lul \\Vy ^^^H
^^^^^^V H Ml
M. f. KorKiir. (or Mirnvl. ^^^|
^^^^^^^^^^1
^^H
^^^^^^^^B
Otrgle for aoute tondUllU, ^^|
^^^^^^K
K PliciiaXDiii, ,^ij, ^^^1
Potiuwii iwriiiaugivniitll, ^^H
^^^^^^^^^B
^^H
^^^^^^^^^H
Aquiv mt >,iiii, ^^^1
^^^^^^^H
^^^1
Application for ohronlo ^^H
^^^^^^^^H
pluiryiij:eal oatarrli. ^^H
^^^^^^^H )<>
A Iridi jiuri, f^r, iij, ^^^H
^^^^^M
I'otiuaii ioili, gr. sxx. ^^H
^^^^^^r "
Glyceriui, ^^^H
M. f. piuriiiKiituni. To (hi ^^^|
npiiliixl to tlic tliroat. ^^^|
t\rfnltf:fri\) ^^^B
ImuflUtlon for pbaryngeU M
ulcers. ^^M
R. lodofiirmi. ^ij. ^^^H
Cuflfoii' iiiilvuria, .^ij, ^^^H
H. f. pulv. (ScAniUhr.) ^H
^^^^^^^K {tic^HUttef.)
_^^^_^H
28
Medical Treatment.
(Pari I.
Gargle In c&tarrtutl pbaryn-
li Alumciiis, .ij^:».
TinctoTH) opii, 5M.
Mellis, }ij.
Syrupi rosn. iiij,
AqiuB lul Jviij.
M. f. gargnr. {/iumttnyrt',)
llDatli'Wash (or mercurial
BtomatlUa.
H Fotttwiii cklonitis, ,^ij.
Tiuctiira' opii, ni xx«
AiiiiR* laiirocenui, Jj.
Aqiin; ud JTJ.
M. f. lotio. {Ou'M-'iu.)
Oargle for relaxed throat.
R TiDctuni' rirwiri, .sj.
Aridi tjmnici. ^j.
lufusi rosjD acidi, Svj,
Aqiw nd .^x.
M. F. gargiir.
Avtrlngent gargle for re-
laxed Uiroat.
H Alumenig, .\iv.
Aeidi taiiiiici, ij,
Mullin, .^j.
Aquip roMi' ad Jviij.
M. F. gorgar. {PreMiil.)
Oargle for cbronlc pbaryn-
gltie.
IL Ulyccriiii ucidi carboUci,
3iij.
Acidi tannici, S'lf.
Tiiictursp cap«i<'i. .ii.
lufuii roaa; acidi ail %xij.
M. f. gargar. To be lined
fri-jiiciitly. (ir/iitla.)
Qargle In cbronlc pbaryn-
gltu.
& Ammunii cbloridi puri,
5JW.
Mellis, 3J.
SjTiipi rosa-, ij.
Aqim* ad Sxiv.
M. (. gargar. { Bamhrrijir )
Application for apbtbe.
R Buruiis I -. ^■
Amyli pnlveria j '"' ■ J'
Qlyoerini, Jv.
M. f. applic. (O. Sir.)
Oargle in mercurial saliva-
tion.
& Bonicis, .\ij.
Tiuctunc myrrhte, jij.
Mvllis, .liv.
Aquie roiuc ad .^viij.
M. f. garg&r. (Briwilr,)
As an antimptic mntith-wash, in varioua forms nf (tomatitis, n
•olution of peroxide of hydrogen, 2 to 10 percent., luw been found
very ofRcacious in c'loaimiDg the buccal cavity. It act* by the
liberation of nascent oxygen.
CHAPTER IL
TKKATVXffT or
KkUI rmfag '~'
AcTR (EsoPBAiam.
This b s ooiinpM»tire]j rare disease except in
ciatioii with d>e «wmDowing ot irriUnt
sodi aa caustic potaoas, or as a result of dirset Be-
chaaical injanr. It mar, boweT«r, ooear as aa
extension downvards of an aeate pharyngitis or np-
wards of an acat« gastritis, but its importance ^nd
treatment would be then subordinate to that of the
original disease ; tlie same remark ap^ilies to its
occurrence as an extension of di)>btheria, or as a
complication of certain acute specific diseases.
Tlie chief ajroiploiii of acute inflammation of tlir
n!.s<'>phaeus in dy^hagia. Pain is felt along the coursi<
of the tube, which may l>e intensitie<l, if ulceration
has occurred, at one particular spot. Attempts at
swallowing food may be so painful as to excite spasm
and the ejection of the fixxl mixed with niuous, and
possibly blood, pus, or shre«ls of membrane. Thirst
and feverisliness accom]>auy these symptnuis.
The indications for treatment in thiH afllr-ctinii
are to relieve pain and allay irritation an<l Kp«sm.
Opium must he given to relieve pain, and it may Iw
administered in the form of hyp<Kleriiiic iiiji'ctionn
of morphine, but if swallowing is nt all possible the
loenl iMintiict of a solution of o|>iuni vvitli lln* iiillanied
mucfius tiiiTitbrjine is calculateit to lie vriy sonlliiiiR.
A solution of cocaine may also biv swiilluweil, if
8w:illo\ving is possiljle, or a cotnbination of cocaine
and opium. A teospoimful of iced tliiid coulniiiinK
a J grain of extract of opium and \ grain of hydro,
chlorate of cocaine dissolved in it may be placed in
3°
Medical Treatment.
(Pan I.
the mouth and slowly swallowed, every quarter of an
hour, until four to six Josea have been taken, or
cocaine lozenges may he slowly sucked. Another
suitable medicine wliii'h may be given, after the
preceiling, is u mixture of oxycliloride of bismuth
with tragacanth emulsion and a small quantity of
opium ; thus would afford some sort of protective
soothing covering to the inflamed mucous mem-
brane.
Food must be given in the form of nutrient
»!nemata so li>ng as the dysphagia is severe. The
thirst may l>e allaye<l by sucking bits of ice, and
as soon as a little iced milk or cream can be taken
it should be given. A milk diet should be main-
tained, or a diet composed of wholly iininituting
fluids, until all undue sensitiveness or dysphagia hu
passed away.
Strictuhe of the CEsophaous.
Stricture of the a»ophagU3 may be either apaa-
modiu or organic.
1. Spasmodic Mrictiirc, Bpnsni, or wso-
phaifisiiiiis.— Spasmodic contraction of the muscles
of the (vsophiigus arresting the passage of food
and drink into the stomach is a neurotic atlection,
often, but not always, a.sHociateti with hysteria. We
have ourselves observed it most frequently in males,
associated with 8ym|)toms of the gouty or rlieuniatio
diathesis. Olten the exciting cause is busty euting
of iiidigealible food or di'inking ttio hot or too
colli fluids. Sometimes it will occur uii atlcni|iting
to join in a social mad, and the patient is obligetl
on that account to avoid eating except in private.
The attacks may occur frequently, or long inter-
vals may occur between successive attacka The
attacks sometimes come on quite suddenly and at the
lieginning of a meal ; at other times, after more or
less dyspepsia from some error in diet, it occurs on
the next attempt to take food. Sometimes the
spasm is complete, and neither fluids nor solids can
Chap, ii-i Strjcture of the (Esophagus.
3»
1)6 taken : at other times fluids can be swallowed,
liut not solids. Sometimes the spasm Ih only *<xcited
by certain kinds of food. Occasionally much flatu-
lent distension of the stomach and alxlomen accom-
panies the attack. Persistent attempts at'swallowing
are generally attended by forcible rejection of the
food, or they may give rise to severe pain. E.\plora-
tion with a bougie will usually delect the stricture
either at the upjier or lower end of the gullet, and
sometimes at lioth end.s. When at the upper eml the
bougie can generally, with n little steady pressure,
he, made to pass through the constriction, but it is
often fur more diliicult to overcome the stricture
when at the lower end. In some en sea the bougie
passes easily.
The general nutrition is often greatly disturliotl,
and such {tatients have frequently a thin an<l wa.st«d
Mpect
The trealiiiriil of this aflfection must be deter-
minc<J, to some extent, by the particular constitutional
8tat« of which it is the e.\pres«ion. In puitly neurotic
or hysterical cases anti-spasmodics and nerve seila-
tives must I>e given. The bromide of ammonium in
combination with valerian is very useful ; as<if(eti(la,
camphor, musk, valerianate, and oxide of zinc,
Ijelladoniio, have all been suggested. A c»ciiin«
spray is useful when the spasm is limited to the
upjier part of the gullet. In tin; intervals cold
douches to the neck and up|ier part of the spino
will improve the nerve-tone and tend to prevent
Burrences.
In gouty and dyspeptic casott, antacids and saline
aperients are useful, and these patients can often bo
got to swallow a doso of medicine when they reject
everything else. Local tn-atnient i.s of great service,
and the systematic jjassage of the bougie will often
effect a rapid cui-e. If there is much hyfierii'sthesia
the tip of the lx>ugio should 1».' dipped in a strong
solution of cocaine. It Ls often dtsiirable to make
the patient take food iu the presence of the physician;
3«
Medical Treatment.
(Pan I.
it gives him coiifidciiw and overcomes his nervous-
ness. The |i(issnge uf llii; liougie, or str.nmc-h ttilie,
throiij»h which tlic jiiitictit C4iti lie fed, sliouhl ho re-
pented t'loni lime to time until the tendency to s))iiHm
lias liceii eoin(>letely overcome.
The diet, in dyspeptic cases, must he earefully
looked to, iind those artieii's of food that hi»ve heen
known to excite .spasm should lie ii\oidetl. The food
should he sirii[>le, nutritions, and easy of digestion ;
it shouhl lie nhvays thoroughly masticated, and eaten
slowly and deliherately.
Electricid stimuhition of tlie vagu.s and counter-
irritation along its course or aloivg the spine, as
suggested Ijy some i)hy8ieian8, have not appeared to
us t<j be of any real service.
2. Oritatllr Siridiire. — Stricture, or niirrowing
of the a?sophagus, may he caused by any injury which
produces loss of substance, ulcenilion, nnd suhse(pient
cicatrisation of its coats, as by caustic substsinoes
swallowed aecidenttiUy or pnr{K>sely, or by nieclianical
injury, or wounds in whatever nrimner inHieted.
Stricture of the (esophagus may also arise from
syphilis. It is said to arise occiusionaily from hyjier-
trophy of the muscular and connective tissue, caused
by the chronic lesophagitis nf sjiirit diinkers. The
presence of nioibid grnwths (cancenjus, pajiillomatous,
or tibroid) in the o'sopliiigus may l>e the cause of
stricture. The tesophngus may also be compressed
from tumours arising ext-ernally to it, as from en-
largement of the thyroid body, or of the cervical
or hr-onchiftl or niediustinal glands ; from cervical or
mediastinal absce8.se8 or cancerous or other tumours;
from aneurisms ; from exostoses.
Stricture may occur in any part of the oesophagus,
but is most frequent in the lower third. Above the
constriction the walls are thickene<i and the tnnal
dil»tt.<l — lielow it, on the contrary, the walls are
usually thinnetl and the canal collapsed.
The chanicteristic iiyiii|tioin of (esophageal
strictui-e is i/ijfictilly in swallowing. When the con-
Itj SrKicrpjtE or the (EscritAccs.
li
~atriction is ■ ' '-> iliSealtf mmx not be oaa-
sUitt, anrl li r when l«ii;e nmmt» nil *ala4
food ar« |ias>Kti iuiv tiie gvllet ; omU yntitini of
ijaitc soft food anii fluicU maj (»•• tarfly. Aa tW
stricture grows narrover difficultj Bwy bvcxfmaacad
in every attempt at swalloiring — mocc lwt»*r, aft
one time tlian another — but aatall portioaa of «eO>
fnaslirated solid fuud mar Uill be swallwcd vitJi ao
great difficuHv if washed dovn «itJi mamm flmdl Aa
tlie disease ailvauccs, Howvrer, titn lieghititaaB tA all
solidji beoomea impomble. rnttA otiiy flflida cbb I»
swaUowed : and finally, iu iiicaraUe cmmmi, tkia mmf
also become iiuputisilile. Togptfaer witk ilj »|ifca^|ia
there is usually rt-gur^ntation of tiie Cood ■uxbI
with frothy mucus, and as iIm* iBaapha^fva allc*
rJila/m into a (^louch o£ eoaaidafmlile «ak aborvv dae
stricture, fooiJ iu»y be re(au>«d tikere lor torn* tim»
and regurgitated in a ktatr of deeoo^onUoa. Fco4
regurgitated from the usuptiaglia ia naaalljr aUmhmti,
unlike tliat regur^ptateid {ro«a thm ■taaukcb, «tiieli ia
acid. If the ointruction ha ctnoetiMM, UwautuU at
the morbid growth, with jm» and Uood, and iwwitli
and frothy tnucuii, may aiao be diathtyd with thm fe-
gurgitatetl fuo<l. Great emaciation aad obatinatc ttm-
sti|>alion are usually ' lad otK^r ajraptaaaa aaajr
B|ip<»nr. not peculiar . .-•!•«% bat i '
1 1 -anse, which uuy i« giving riaa to |
on structures. TL- attMspi to paii aa <
bsgeal bougie will deoioiuttata ifca aalKeneg of tJw
^•tricturc, and its Hitaatiua aa<l estcnt.
The irealinriti •! mtri*tmrr ol tba mnptajia.
when of a non tnaligiuint and cicatricial f harart* r.
consists in att^-mpt^ at iliiatatioa b? the parwagn of
liouijies gradually inciea>iiig in wue. Great etie ■«■*
In- n*f<\ in [lassing thefc itiNtranMittta, aikd no attoapi
at forcible dilatation nia»t oa any accnoai ba laili
until we are a««ured tltat the strirture is mC doa to
'Carcinomatous disease or to external pcwnn* aa a#
'•nenrisDi. In such cases any attempt at tka forafala
paaMige df a bougie may be attended by very aniona
D
34
Medical Treatmf.st.
I Pan t.
results. If utteniptsnt nifcliaiiical dilaUitioii are well
borne, instrunients for this purpose may be passed
daily, or on altenmte days, or at lonj;nr intervals,
accoi-ding to the toleration of the jiationt. The
(litatinj; Hoiind, or bougie, Nhould be retained in the
canal fur a few ininut«s, and when withdrawn an
instrument of still lar^rer size slictuld lie itilro(hi(.e(l for
a monieut and then ri'mavefl. This Inst dilator should,
preferably, lii' hollow like a stomach tube, so that a
nie;i! of Huid or sen)! tluid foml can l)e given by it, and
the osopliagus tlm.s kept ipiite at rest for some hours.
When the canal has been suHicienllv ililated to allow
of free deglutition, the freipient pi'i-fonniince of tho
operation may be discontiiuu'd ; but the bougie should
l>e still passed fn>m time to time, every week or so, to
ascertain that the dilatation is ranintAtned. Con-
tinuous dihitjition ha,s been muintiiined by passing a
tiilje through the nose and retaining it in the resopha-
gus for weeks and months. More risky measures
which have been suggested and employed are (I)
forcible dilatation by a (loiible-bhuii.'d metallic sound ;
(2) destruction of cicatricial ti.Hsue by caustics ; and
(3^ division of the stricture by internal (rao|)hago
tomy.
To<lide of potjissium may be given in eases in
wliich a .syphilitic <;irigiu seems pmssible.
In cancerous cases opium will lie needed to relieve
pain. Small pills fOin|iiised of opium and creosote or
thymol are useful, both for theii- amesthetic and anti-
septic properties ; or hydrocblon'de of cocaine may
take the place of oiiiuni if it seems desirable. The
following is the formula for these pills : —
1^ Ojiii cxtrBcli (re/ coouiniu liyJroililoridi), Rr iij.
Crctt-soli, miij (I'f/ thymol, gr. vj).
Piilvuris Mponis, ((uantum gufltriat.
1U lint mnMH in iiilulas duoUcuiin ilividendn. Iliu.' eriT}'
iioiir to relieve pain
These small pills will probably dissolve in the
lesophagus ; lliey may be swallowed with a tea-spoonful
of iced water.
Ck^ ILl STKICTCntS OF THE (ESOFNAT.CS.
35
HypoJennic iniectioiia of nioqAiiie WKf be tmam
ury in nianj caaea.
The contitiuons administrstaoii of NfliMalc ia
small (loses is credit«d vitli tlie power of ivtardiag
the proj^ress of mali^anl diwBMC, ami tiken oaa bit no
obj<s:^tion to trring it in theae cuesw SomU pflal—
of npttfiiioiis acid (^^'q grain) or vi aivMuato of Mda
|.i. i^in) may l« taken twice or tknae t4aMs * d^.
The foo<i in tbeae caaea niMt be a»iap<»*l to Ike
powero of <l' ' ' I or to tlie cafabiliiT of a fac^ag-
tolic lieins i i into tbe itatBaeh. ^w loaig aa
milk and tiuiil iVxla oaa be tnimdaeBd iato Aa
storiMch, the life of the patient laay ba (
this way ; but when the Htn<-tiif« \
impassAhle, feeihng liy nutrient wwaiata Maal he
resnrtf^l to. It will, indeed, geaetallj br
Uj have recourw to oocaxiooal frarting by tlH
some titue before the atnctaia haa heeo«* ifatte
impassable ; atid it has bvcn oftea iwtinad tJMt
Uiree or four days of exctusitr rcetel f ""
with re«t in bed, the patieat liat beai ■giB ^Ma to
t«kc Btiid food bj tlie <nephaf;aa.
During th« coarse of tlieiw eaaea iba bpwala «fli
rr^iuin- to lie rcjiered bf eneiaata, and it ia a (lad
plan to <-.irly **^tabliab tiw< ha>)tt of waafcia^ ooft tfca
Imwel daily with a pint or ptal mad a balf of wafar
having a teaspoonful of etMBOMn aUt ill— llilll ia iL
In oaaai of malignant atvictaia^ vkaa it ia ao
laager poaaiMe to nwaUow rren f aid fao4, eitbcr wf
two reaouroes may b* adopted ia crier to pnirw^
life. Theae are (1 ) the laeCkod of IvLay* rmriMmUj
saggested b^ Dr. Krtriialiar, of PlwM,aa4 amditef iif
Mr. Chartent J. Synoo^ af Oay'a Hnapital ; aad
(2) gtutrogtomy.
Mr. 8}riDoniiii' roetlaid ia to past tlifnag^ aad
n>iain in the strictam a abort, fnaad-aka|nd tal»e.
the tipper expanded {an of which taite on iJmi tap of
the atricturixJ p<jrtioa of the aaaaL It ia famaA
tlowQ to the strict are hjr laeana of aa ocdinafy laialad
Iwagie fitted into the faoa*!, aad after the (aafkal
36
hfEDiCAL Treatment.
IPut I.
tulx) is Kxed into tin; stricture the bougie is with-
drnwn, a strong silk tliroarl hnving been previously
fastened to tlie funnel end of the tube long enuugli
to extend beyond the mouth and to be loopetl
over the ear, behind which it i« fixed by a piece
of strapping. These tubes are made of gum elastic ,
they are 6^ inches long, the funnel end is A to
\ inch in diameter ; it ends in an ordinary catheter
end and eye. Mr. Synionds maintains that this
tulxi has proved of the greatest service in the treat-
ment of malignant stricture of the a^ophagus, u[ion
which its pressure produces no irritjiting or injurious
edt'cts. It is prevent«<l slipping down through the
stricture by the silk cord attached to it, as well jus by
the funnel expansion, and by means of the cord it oiii
be easily withdrawn. Its advantages over the long
tnbe projecting from the mouth are obvious ; it Is not
unsightly, it lioes not interfere with deglutition in
any way, it dot^s not irribite the larynx, and it docs
not cause a constant escape of saliva fitjm the mouth.
In the first cjise report(!d by Mr. Synionds the patient
was kept alive for eight months in comparative
cnuifort, and never felt any inconvenience from the
tubes ; the stricture diluted considerably, and on post-
mortem examination no injurious efl'ect couM be
traced to it« pressure. In the latter stages of the
disease it was necessary to remove the tube iw-
(juently, as it became blucked with sputum and fixxl.
Life has lx?eu ])rolonged for periods varying from
four to eleven months by the use of these tubes.
The tulxM do not usually re<iuire changing oftener
than eveiT three or four weeks ; No. 12 or 14 is the
si/* usually worn. They are durable, and the same
tulj(* Hiid silk have been used for more than three
months. Mr. Symonds apfiears to think that the use
of these tubes will generally obviate the necessity of
having recourse U> gastrostomy, with its attendant
diingei-8, and the distress from excoriation of the skin
around the external orifice of the gastric fistula.
It is only, then, in cases in which the application
Ctup. II.)
Rectal Ferdinc.
37
oi tnhaije seems quite impracticable that the operation
of riastroKlnmy siiould be resorted to. It should also
be always borne iu iniiul. that aUliough when lirst
admitted intn the hospital a patient may be (juite
unable to swallow, yet that after a day or two's rest
in bed and the aijministi-ation of nutrient enemata
with opium, the power of swallowing will often be to
sonic extent restore<l.
Many cases have been reiKtrted of malignant
stricture of the resoplingus in which gastrostomy
apjHjars to have prolonged life, in a state of comjiara-
tive comfort, for considerable period.s, during the
whole of which time no food has hoi-n taken except
through ati artificial opening in the stomach. It is no
doubt liest, when ga.strostomy is the only means
available to relieve the patient's distress and to pre-
vent him dying of starvation, a fate which abso-
lutely stares him in the face, that the ojieration, in
onler to be successfid, should Ix; done before the
patient's strength and endurance are exhausted.
Note on Tordinii by lli«> roctuin.— We shall
SI) frequently have to recur to the subject of rectal
feeding that this .seems the best place to offer a few
remarks on that subject It is imjMjrtant to remem-
ber that the lower part of the large intestine does
not exert any direct digestive action on alimentary
substances introduced into it. It can only absorb
water and salts and predigested, i.e. peptoiiinect, sub-
stances. It is, therefore, very doubtful, when
onemata of beef tea and of milk are given, whether
they are of any real nutritive value, as it is proliable
that only the water and salts are absorbed. They
are stimulating, however, and allay thirst, and nuist
not be regiirded as useless. Wine and alcohol can
also lie absorbe<l by the large intestine.
Hut food given by the rectum in order to be
ttlrsorbed should lie jx-plmiijifil, and it is also necessjiry
that the rectum be washed out with iiu enema of tepid
watiT liefore each nutrient injection. It is also
desirable to avoid using a syringe. A funnel, or
38
Medical Treatmbst.
[Part I.
irrigating vessel, is best. Nutrient suppositories are
of doubtful value ; we have known instances '\i\ which
the large intestine hiis Lcen found iTiiiumed with them
on pust-niortem exaniiiiution. Nutrient enenieta
should lie given by niennB of a tube about 10 or 12
inches long (not too tlexiblc, or it may bend back on
itself), passed as liijjh up as jiossible, so tlint the Huid
muy be brought into contact with us Inrge an extent
of ahsorbinj; surface ns practicable, and the patient
should be, preferably, on his left side, with his hj|>s
raisid on a j>illow, and the injection should be allowed
to flow in very slowly. Tie superior rectal and
sigmoid veins coniinunicate with the portal system,
while the veins from the lower ^ of the rectum com-
municate with the inferior vena cava, and their
contents do not pass to the liver ; hence the ad-
visabilitj' of introducinf; nutrient eneniata as hiy;h up
HS j)06siljle. Not more than 4-U ozs. should be
injected at a time, and less, of course, in a child. The
patient should remain recumbent for an hour after
the injections, and it is advisable to compress the
anus for 10 or 12 minutes with a woi-m towel, s<i as
to promote the retention of the enema. Wc may
mention some suitable forms of nutrient eneniuta.
Dujardin-Beaumetz advised tlie following : — The yolk
of an egg is beal^-n up with a plos-sof milk, and to this
is added either two tb'.'^serl.spoonfuls of solid peptones
or two tablespoonfuls of lii|uid peptones, o dro|»s of
laudanum, and, if the peptones are acid, 7 or 8 grains
of bicarbonate of soda. The secretion of the largo
intestine is alkaline, and ucids irritate it, and in ciises
where prolonge<l ulimeutntion by the rectum is
necessary all irritation of itM mucous membrane must
be carefully avoided.
Catillon kept a dog alive in good condition for
thirty-seven days by rectal injections consisting of,
daily, two lavements, each composed of three egg.? and
a dram and a half of liipiid glycerine of jH'psine ;
given witliout the pepsine the dog wasted rapidly, and
when this was replaced by fluid blood he rapidly sank.
•CkM It.)
NurXIStTT Ejf£MATA.
39
Dftn-niberg, in a cam of rtrictut-e i'>f tlie ifsoj.ilia;;u8,
kept M p»uieni alive for fourto-n tiiontlis, »nd with a
•Lii" I'll) of urra niiiountiiii; to fruni l-'l'S to 300
Hr. I'-uii* f>f |ie|>t<>nuM-(J eneruata mncie in tlie
fiillouiii^ uionner ; Into a gla.<is or other suitabU-
vtrsM'l introfiiicc ~,5fK) i;n«in8 of meat i4>i lemt ati
pootihlo, inincrd fine ; pour on tlii<. atxnit I'K) ouiiocx
«rf pure water fto<l hji ount* of livJrochloric ac\<\ of n
Hrttdity of 1-15. To tliiH wAA 40 ^nius »f tin- purv^t
and btttt |iepsin6. Dig<est this mixturt- for four liuun
uf 11.' P. Ttirn poor it into •
H \vt it hnil, jukiiDg mnuiwlule a
.\r of ujAa (17 grain* U> thr
vtare hM » aiight idkaJinc n^
ri- 5 la S Mmoaa ed tkm lofvtioo.
r«« tfae
le to •
or 6W iRUieBa. iiaif Uim ia gmn lljr
at a trnip«*ratur«-
vnnel iif poro' ' -
Miliitioii (if '
oil 1 1
lirl t
Si.
in
tl..
Ernat.! 1
■ci.f>]rtrfl ijj';
to inanrr 1 1
fimnnla ia \i,
of eoM water
in upfmaiffcw lo tlie gcBomDy
- prfAaatMtwt t* iwt I
'« of Botrirst
->i ■<!< 2 or) «St* vttb a '
Id linO aa macii Mf tbr rcty I
ma. win gu «« Uw paint <4 a kaiCe «t& a 90 1
soluliiiD of S^vp^ *<is*r. and aiM a '
winr ; t}im to miir thr v^ tiwij
whfTt it Ha« CTtf>W<l. llw^fcfcM «M» S
b* itb 3 o«iKn id krtl4a» I
ah f braadr. JajuwIaawtW ydfca «< f*
I i<> 4 tlraaa </ dnr pepse. 1W laHrwiac « *
lurfiil f'>m. aad n f»a1y
with 3 or I tmacr* U
■{looafal of !•
aariinm lMcarfv«aae. A tat^
beaiidML TViiifiliii irfdhfaMtaf.
graiita lA cAch <
Pint A. R
40
Medical Treatment.
I Pail
bluiKl lis till' best ivct«l fojti. He injects 3 ouiio'S
every four hours. He has oliserved tlmt it is nipiflly
iihsorbcMl, and in ciuses of hicuiatonipsis he thinkH it
the most elficiicious remedy for overcoming the pr»>-
found ana'mia usually present. An obvious objection
\a this eneniii is the diffieulty of obtuinini; it wlieu
reijuired.
Another good nutritive enema Tuay Ik- i)repaied
with 4 ozs. of warm pe|itonised milk, the yolks of 3
eggs, half a teaspoonful of common salt, a tertspoonfiil
of arrownwit first carefully mixed with an ounce of
warm water, and a dessertspoonful of brandy.
Nutrient euemutii should be f;iven warm, about
9S° to 100" V.
Shouhl the reilnni U' very irritable, 5 to 10
minims ot" tincture of opimn may be addi'd to each
enema >ls well as t<i the injection of tepid water with
whifh till- rectum is pieviciusly wa-sherl out.
The .•ipjiaiiUus riepicted on this pilge(Fi>r. 1 ) is
■ MALL PVNNEL
FLEXIBLE CATHETER
Fig. 1,— Appwiitii* till BretAl renting.
recommended for rect-al feeding by Mr. Jime.s-Hiim-
phreyK* It consists of a small funnel, a piece of
plnxlic tubing ]th of on inch in diameter, u gloss tube
* British UrHintI Jouynal, April I'Cth, 1890.
OfV. II. I
Rectal FkEDisc.
4t
4 inches long, by which th* fluid can he wntchwl
desceiuiinf; ; joined on to this is An ordinarj* flcxiMo
cnthet«T. The fluid is slowly forciii int^i tlit' rwtuiu
by Htinuspht-ric prtsssure. At>sorption, thou);h hIow,
is Bjiid to btf ('fticient. Mr. Jones- Humphreys L-lninix
for this mi-tluxl sini|ilicity (the juitierit ln'in;" nble to
piisily jiaKs the ruthcter intotlie liowel liiniMolf), i-heMiv
ness iiiul cIoJiidiiicRs. The xlowntwi of the pu-HHugc
of the Huid he does not consifler itii objection.*
* Furthw dftnila on tlii» •uhjrct will l»< foaml in Ihu ftatlior**
work ou " Food iii Urallh oud DiMsaM; " (tivw «<lltion), p. M%.
4^
CHAPTER HI.
DIBXASSa OF rilE STOMACH — TKEATMKNT OF ACUTK AXD
CUItONIC GASTRIC CATARRH.
Acute f!AsiKrri8, ob Acitb OAfrrRH' Catarbh. — Caua«s —
S.niipt.iins— ludioatioiia (or Trculmi'ut— Lavage — Emetics —
Puigulives — Host — Cnrcful Diet- Ir<>-li[ij{ — Cnuiiter-
imtaliou— Oiiiat™ ond Sedatives— Alknliue Effervati-cuts—
Calomel— Cure iu Coiivulpscoiicc. CiiHOxicliABTBic Catarbb.
— CaiiButiou — Symptoms — ludicaliou^ for Treatment —
Lavii(j;o— Emetics— Purgative aiiit other Mineral Wutcn —
Aiiti-fenrii'iitivcs- Bipiiiutli— Objeit and Use of Alkaliat —
Iron in Anninic Cases— Hyilrocliloric Acid and Pepsiu —
Aperients — Dietetic Managoment. Additional Fumiulaj.
Acute Gastric Catarrh.
This rliscas«i hii.s also l>een t(.>!'nti>d " itiflaninialiity
()ys])c[i.siu, ' !iii(l it in a form of fly.spf])siri iiinsniiKh as
it usuiiUy ari.si'S in i-oiineotioii with wiiii*' (iitltcnlty in
tlie process of st<iinin,'h digestion. One of tlif must
coniiiion prttliH|M).sing causes of ncute gnslric vutiirrh
is a defective secretion of ^iistric juice, which is eitlicr
deficient in quantity or tJefective in quidity ; hence
arises abnornial decomposition of the ingesia, owing
to their undue detention iu the .stoniac)), aiirl tlius is
set up irritative inHainiiiiitiim of the iiim ous nieui-
btiine. iSiicli a condition iiMiiilly accoiupanie.s feliriht
iiiahulics, and it also occurs in I'ceble and debilitated
aniemic states ; and so it happens that quite slight
errors in diet will prove sufhcieiit to excite an acute
gastric catarrh in convalescents frotn exhausting
diseases, and in the weak and tinteniic. Ewidd says,
"a convalescent jiatient gets acute gastric eatan-li
from ii beefsteak which the satne man managea
easily when he is well.'" He also believes in an
iniieriU'd tendency to this afl'ection.*
Persons who ha>e sufferetl from malarial affec-
tions, and gouty antl rheumatic persons, are also
• We do not jiropos« to consider here the treatment of oases
mused by irrit'int poisons, miiioral or vegutablo, as that subject
iwrtoins to Toiicolog}'.
Oup. Ill]
Acute Gastritis.
4i
predisposed to attacks of this (lisea^e. The excitituf
cause of iittackn of acute gnstric catarrh is coiuiuoiily
to Ik; fouixi in Home error in iliet. Tlie footi nmy
iiiiujily Ije excec^ive in qunntity, s(i that the gnstric
juice secretetl is not suftieient toch'gest the whole ol'it,
and the uiidigeet<>il residue undprg(M>» abnormul de-
composition within tlie Ktotiincli ; or the food nmy l»e
uf rnarse and indi^(«tihle <|uaiity, and the i!t>«tric
mucous nienibriini; may, )kl the Kiune time, be con-
stitutionally sensitive and irritable ; or the food
mny be diHicult of digestion on account of im-
perfect mastication, so thiit the g>»8lrio juice
cannot punetruto it ; or the same may ^Je the
case from the fcKxi lieint; snakeil witli fat or rich
sauces. Or the aiticlfs of f<x>d and drink may Ix- iti
themselves irritatin;;, from being too hot or too cold,
or too pun};ent, or in a state of dcconipasition, and
the products of alboniinnua deconipottition act an
p<jwerful irritants t^i the Rtoinaeli. The strou^fer
Jcoholic beverages an- especially prone to set up
stric catarrh : too long use of certain medicini-s
Bnic especially) ; " catcliin>{ cold " in certain
ernons ; the painful emotions, anxiety, fenr, anger,
etc. : all ihe.ne seem to be capable of exciting Cfttnrrh
of the stomach.
The continued anil habitual une of narcotics, «uch
OS opium, by dimiuiKliing Ixith the M^cn^ting and the
projielling force of the stoniHch, may lea<l to retention
and abnormal decomixtsition of the ingesto, and so
excite gastritis.
In certain cases of blood contamination in infec-
tive and other disea-ses it is piobnble ihiit toxalbuinins
may be excfUd by the stomach and then exi-rt a direct
irritant action on the gastric mucou.s membiane.
Acute gastric catarrh may, of course, alsi.) occur
as a consequence of other gastric diseoscK, simple or
Miidignaiit.
The foivgoing are the raii«»«'» we shall chiefly
have to liear in mind in considering tlie appropriate
treatment of cases of acute gastric catarrh.
44
Medical Tkeatment.
(Pwt 1.
The symptoms which usually accompany this
disease are tlie following : —
A scnwe of fultipss and untmsirioss in the stomach,
with flatulent distension and tenderness on pfessure
over the epigastrium. I^ coated tongue, foul breath,
a bad ttist* in the mouth, thirst, loss of aj'petit^?, in-
creased flow of saliva, nausea, and "heart-bum,"
Hcconipiinied by eructations of &f>ur, acrid, ftetid sub-
stances resulting from the morbid decomposition of
food in the stoinacli. In severe cases there is vomiting,
the vomited matters consisting of altered foofl, mucus,
bile, and occasionally streaks of blood. If the catarrh
of the mucous membrane extends to the duodetiuin
there may be some icteric discoloration of the skin
fr-om involvement of tlie orifice of the common bile duct.
Sometimes there is constipation ; at other times, when
the catarrhal condition extends to the small intestine,
there is diarrhiea. The urine is scintv and high-
coloui'ed, and deposits urates. In arlditiori to the
loi-itl symptoms there are usually general nialaise and
lx)dily and mental depression, severe frontal headache,
coldness of the extremities, and often patches of herpes
on the lips. To severe cases of this kind, with some
rise of temperature and a quick pulse, the term
" goiitric fever " has oft^n been applietl. The depression
and other nervous symptoms observefl in connection
with this malad)' may be due to the absorption of
poisonous substances generated within the alimentary
canal.
The ln<iicnlioii» for treatment in acutn giis-
tric catarrh are the following : —
1. To remove from the stomach any irritating sub-
stances that may be retained there.
2. To rest the inflamed stomach as completely as
possible.
3. To administer only fluiil, unirritnting, and easily
absorbed food, in small quantities at a time.
4. To apply such direct remedies as will relieve the
pain, hypenemio, and in'itation of the gustric
mucous membrane, prevent morbid decoui|K>si-
.IILI
ACVTE Gastkitis.
45
Hon of tlie inge»ta, and correct exceasitv
acidity when it Hxiste.
& To enforce the obscrvanoe of sound dietetic
rules, during and after cunvalesoenoe, so M to
guard against a return of this malady.
1. When it is evident that the gastric catarrh »
excited or maintained by the piresence of deconipcsiii;:
food in the stomach, means must be taken to rvniovr*
it. In caK«» where there is obvious dilatation of the
stomach, as well as ucut« catarrh, it will pntbably l»-
Uvit, liy means of the stomach pump or the si|ih<iii
tube,* to empty and tlipn to wash out the stonin<?h
with some warin, weak alkaline solution, »n as to
detach and carry away any sticky, ropj' niucu* whirli
may be adhering to the mucous membniOf. Km* or
Vicliy water, or a weak solution of bii.-arljomUe of
Koda (3 grains to the ounce), will do for this puqiONc.
Wlitn there art? objections to, or diliiculties in, the
s}if>lication of this method, it may be n<tefnl to gi^ir
so emetic, esjKscially in the case of youn>r childr«i
and persons who vomit easily. From 5 to 20 gniinn
of powdered ipecacuanha, according to age, in from
one to four tabh-spoonfuls of warm water, will act
well witJi most persons, and with care in the »ul>-
soqaeiit treatment it will rarely he nece«iiary to
repeat thi:*. Some prefer to give a hyp<xl«»rniic
injection of j',tli t<.i ^',th of a grain of tijmmorji
but it niub-t he borne in mind that ihiit drug in . ' : ■
depressing to some persons. Others advi.H« giviiiq
large draiighte of warm water, and if this is not
vniiiit«d, to promote vomiting by tickling the fancrs
■with a feather, so that the water may he rejcctffl.
nd the irritant contents of the stomach thu<i washed
"away. In other cases we may succeed in emptyin::
the stomach by means of mild purgative>i, togcthi-r
with gentle manipulation or massage of the stomach ;
t)ie prftssure on the dLsteuded organ being dirrclrd
from left to right, t.«. from the cardiac towards the
• &• tiie dnplv on Dilabaion of th« Stomatb, f. 102 H ttq.
46
Medical TsEATMEifT.
(Part I.
pyloric end. My mild ineasures of this kiiiil, tojjethor
witii coni[ilete abstiiieiiue from solid food, we may !«
enabled to empty the stomKcli of its contents in ii
manner ]ierhaps more agreeable to the patient than
liy either of the preceding ways. A suitalile aperient
for cliildren is the compound rliuburh powder, 10 to
20 grains, and for adults 1 or '1 drams of Carlsbad
salts dissolved in warm water, twice a day. Wheji
we have succeede<l in cleansing the stomach from all
irritating contents we have
2. To enforce rest oj' the injlamf.d nrt/iin. In
severe cases the entire exclusion of all food from
the stomach for two or three days will be of great
service. Nutrient eneraatii should lie administereil,
the patient should be kept in lied, and allowed simply
to sip iced water, or to suck small fra;;uients of ice.
It there should Vje any cr.iving for food, or any
rextlessness or pain, a morphine siifipository, or the
addition of n few drops of tincture of opium to each
enema, will usually relievo the.se symptoms.
When such complete abstinence is not indicntetl,
or is impracticable, then we must limit the food to
bland nutritious fluids, >jiven cold, and in small
quantities at a time, sucli as a few spoonfuls every
hour of cHjual [Mvrts of milk and lime-water iced, or
milk and Vichy water, or one or two tabluspoonfuls
of thin water arrowi-oot three or four times a day.
A strict diet of this kind will, when the patient
is kept at rest in bed, suflice for a few days, and the
stomach will be thus maintained almost in a state of
complete physiological iTJjt.
3. The third indication is pi-actically a continu-
ntioa of the second, and directs us to exercise the
greatest caution in i-egulating the diet while the
acute condition is passing away, giving only the
lightest kinds of food in small quantity at a time and
if necessary in a pre<ligested form.
4. The fourth indication applies especially to
medicinal treatment. It is rarely neces-sary to
abstract blood locally I'V applying leeches (two or
uijp. m.i
Acute Gastritis.
47
thit^) to t.lic e])ignstrium, its has lieen suggested ; this
iiieosure may, however, be founil useful occitsionally
ill febrile cases with much local (miii ami irritability.
A ponltico slioiihl In- itpjili^.-il ufter tlin li'eclies have
lioeii i-emoved. The a|)|ilicHtiiin of cold couiprrssps
or of the icebii-j; to the epigai<triuiii is a fnvourite
remedy with soiiif jihysiciiin*. This ine.vsure, t«)gether
with Ruckitig small frngnierits of ice, is often etKcaoioiix
in arre-stitig vomiting, while it also relieves thirst.
A inustiinl poultice t<> the e|iigiustrium is sometinie.s
useful and more agreeable to patients than the ire-bai;.
Pain must be relicveil by opiaten, nr by a combination
of opiiiiii and hydrocyanic acid, together with bismuth,
which is an excellent gastric sedative. When the
pain is acute a hypodermic injection of morphini',
y or I of a grain, will be attended by immediate relief,
and this is the lK«t way of administering a nariMtie
in case.s where the stomach still contains irritating
substances. IJnt when the ntomach is known to Ix!
free from irritating contents, the irritation attending
the iiillammHlion of the mucous membrane is, jierhapsi,
better nllayeil by giving opium by the stomach.
The following is a suitable prescription for adul|j<: —
V) nimnuthi snlioyUtis (pr/oxyrhloriiliV.. gr \\\,
Exlracti opii Kr. ij.
Aiiili hyrlroi'ytinici dilmi mxviij.
Sudii bioirlniiuitis y\.
Muciltitiriia tiit|{iicantlin' ^;.
Aqnn3 ... ■«'l.'S''j'
Mifoe, Hat miitiira. Two tiblonpoonfuh every three or
four lioun.
When there is a jireat tendency to vomiting (without
much local pain), and distre.ssing thirst, ellervescing
drinks are often very useful and grateful to the
patient. The following may lie prescrilied : —
^ 8o<lii bimrbonntii*
Aquic liiaroceriui
Aquns
Miscv, til
■ 3 ".1-
... ^iv.
ail jviij.
48
Medical Treatment.
[Pan t.
I^ Acidi tnrtarici ... jij.
Divide in pulveros octo. A powder to be diasoUxd in a
Uible»{>0(mfiil uf iTHlir, and u'ldod tu two lablosjiooiifiiU of the
tnixtiire, and taken while efferveecing every h'Jiir or two.
The enictjitioiis of gas which follow the introduc-
tion into the .stomuch of such alkaline eH'ervr'sceiit
fluids are useful in linngiiig iiway other deleterious
giLses which may have roliected there. The excess of
alkali is also unefid in neuti'sLUsiug the contents of tlit<
Htoniuch when acid, and in loo.'H.'ning and detachin<{
tough mpy mucus which may have accumulated
on its surface. Inilet;d, if the patient complaiiia of
mur eructations, we should give the alkaline carbo-
nates freely to relieve tlii.s.
Wo must be cautious how we attempt to arrest
the diarrhiea which oco«sioniilly Accompanies such
cases as we are considering. This is often a con-
servative measure, and carries away ott'ending 8ul>-
stances, and by unloading the tributaries of tlie
]>ortal vein it tends to reduce the liypt^rnmia of the
gastric mucous membrane. Indied, some iihysicians
liave recoiumended that it should he encouraged or
induced by the udminiatiation of i|>ecacuanha and
calomel. Ewald is "a great advocate" of caloniol
in these cases.* A few grains of calomel may be
mixed with a little sugar of milk and placed dry on
the tongue, and followed by 2 or 3 ounces of fluid
niKgnesia or Apenta water. In convalescence and in
protracted aniemic cases it is often desirable to
augment the activity of the gastric secretion by-
giving G or 8 grains of |>epsin with 5 to 10 minims
of dilute hydrochloric acid with each meal of animul
food. Those rare case.s of acute gastric catarrh
which can lie directly traced to the effects of chill
should be tre:ited by diaphoretics, rest in bed for a
few days, and restriction of the diet to unirritating
fluid foods.
5. Finally, there is th« lost important indication,
* "lAJcturM on Diseiuea of the Stomach," vol. ii., p. 601.
Sydenham Society's tnuuUtion.
I hit). Ill
GA^rKic Catakkh,
which U clirecU-iI to the avoi'Unce of iho5P error* in
diet which in:*V have r.rijtinnlly provokwl thp lunNulv.
AfUr rccovrrr ire should iiiMist tbitt only e:o.ilv
digfsted fooJ l)e taken, in iiiodenile <|U«nfifv nn i ii
sufficient ititervAU: that ihu foosl Ixjei' :irid
thoroughly n)asticat<xl. All exi.vs^ of m n'l
l)Mit>«, all ticli cnti'HP.s, all po-stry, iind all -
cilciilated to s»'t ti]i forineiitittioii in tho
should lie strictly forliihk'n. Any M'ljdoncy to consti-
pation mnst lie ovi-rcome by rej^uliir exerci*.', 8uilal>lt>
food and an occasiontd aloetio pill or valine a{>crtt!Qt.
.CnROyiC OaSTIIIC CATAJIKtI.
Chronic catarrhal inflaiiimation of the luucoai
tut!mliram* of the stomach it frequently a •wijuel
of one or more attacks of acute jjiLstrifix, nnd it»
causation must in such ca<i<«» he rfferrcl to tln"*-
influi^nces which prodace the acute atTiH-tijii. TIk*
chronic fonn of giistric c.tlairh i«, howevi-r, espK-itjIly
prone t'> follo»" the almse uf tohiicco and of uleoholic
lievemges, and particularly tlie as«r of nrdont spirit'*
and acid wint« ; it is often due to the haliitnnl
indulgence in excess of food, or in articl</« of dift
of a puDgvnt, iudigcitihle. eicitiui;, and irriintin>;
character, or to the alm«e of drugo. Briefly, frrur*
in diet, long continur-i. ar** \.\\f chief catinen n!
chr>inic }(a.Htric catarrh, which Ewalil dexcrilxM w-.
"the l>e«t-fost<'red and wiilcapn-iul of this wnri 1
ilU I " Those fierson'*, aluo, who in their or-iMipiti.>[i.
are c-Jinjielled to •'Uis.tc'" things, a« wiim ' la'^ter-i,
tea " taittiTA," and cfioks, are »u1>ji."Ct to thia div-AM-.
Persoa* who etit t^xi rapidly, who drink lo-i much at
tneaU, and so over dilute the ^ivttric juice ; ihoMe who
I'jit pastry male with rancid fat, or who take hir;;-
quantities of sugar, ore apt to Kuffer from chr n
gastric catarrli. Fivlilc, ana'niic, an<i rblori'tir
(■atienla^ with weak di;;i-xtive pow^n owina u> de-
fpjlive >«i?crelion of i; i ■ ' ' ' r
ili'Kcient in i|UiiDtity lii
whom the digention of fo^ ii> thereby rctuxUcd and
so
Medical Treatmekt.
(Paid
the ingpsta are detained so long in the stomach as to
unHer};o morliid deconiiKimtion — these also are sulject
ti) chronic gastritis.
It uccoinpHnies cortain chronic discnse.s, such ns
phthisis and tl.osc disorders which are attended with
obstniction in the |)ortal syslein, as hepatic cirrhosis,
or those chronic structural changes in the heart and
lungs whicli lead to dilatation of the right side of the
heart and obstniction to the outHow from tin- inferior
vena cava and the hejiatic veins. All these nioihid
states cause (lassive hypeneinia of the gu.stric iiun-ons
menihruno, and so induce chronic gastric catarrh. It
occurs also in those diseases in which exciftion is
defective, as in gout and renal affections.
The syiliploiHS which accompany chronic gastric
cat«rrh resemble in many respects tliose of simjilb
functional dyspepsia ; Ijut in the cases we are now con-
nidering these symptoms often de[)end upon structural
alterations in the mucous membrane of the stomach,
— induration from pniliferation of interstitial tisrtue,
and degeneration from fatty change in the cells of
tiie gastric tuhule.s. Tlie patient comiihiins tif loss of
apjKjtile, of a sense of weight, fuhies's, or even j>ain in
the region of the epigastrium, increa.sed liy taking food.
He has flatulent and acid eructiitions, accompanied
by a sensation of heat or burning, extejiding frnm
the stomach along the n-sophagus to the ])harynx, and
commonly known as " henrt-burn."
He often sufl'ers from nausea, and occasionally
from vomiting. Thevomit«d oreruct^ited matters me
highly acid, and liave lx>eii found to contain acetic and
butyric, as well as lactic acids, and other abnormal
products of morbid fermentation, including sarcime
and torulie.
In the chronic gastric catarrh of the alcoholic
there is usually a morning vomit of watery Huid
mixed with mucu.s, to whicli the term '" pyrosis " or
" water-brash "' is applied. This consists chiefly of
<>alivn swallowed dui'ing the night mixed with gastric
mucus, the secretion of saliva in this complaint being
p. fill Chkpnic Gastric Catarrh.
51
oft<'ii greatly iriorvased. Tliere is often eonsirlfrnl'lc
ilutuleiit ilitjteiiBion of tlu'sniiill inleKfirn',dufto tlic pro-
senceof food umlorgoi tip almorimi I putT-efnotivt- changes,
and ithliougli tlirrp is gpiieriilly olmtinate constipation,
there may lie ot'cnsionally dianlia'a from co pxistiii';
iiit«8tinal catarrh. If llie cAttirrliul condition extends
to the duodenum and afl'ects tho common bile-ducts
the symptoms of jaundice limy iippenr. Tlie mouth is
often foul, and the tongue dirty anil tliihliy sud in-
dented liy the teeth at its edjjes. This, however, iH
not always the case, and the lontfue is not unfre-
((uently small, red, and pointed.
The wr/Kf UNUnlly depiMiifa urates, as well as
crystals of oxalate of lime, and occasioniity it is
phosphatic. Tlie nervous system usuiiUy siilTers
considenilily in well marked cases. There are great
mental as well ss physical dulnesa and lussitude,
great depression of s^iirits, ncconipsnied with much
irritaliility of temper, frequent headache, and now
and then distressing attticks of vtrlujo. These ner-
vous symptoms hiive lieen referred to the probable
alisoipti'iti of toxins, the products of iinjierfcrl digi's-
tion. The cardiac rhythni is occasionally disturbed,
and tho heart's actif.n Wcoines rapid and irregular.
The general nutrition usually sul)'ei>i coiitidenibly, es-
pecially in rates of long duration, as iiliKorption from
the mucous uiembrune of the stomach is interfered with
by the. presence tif a layer of tough mucus on ila sur-
face, so that tlie jiatient enmeiateg and lo«es strength.
An examinatiiin of the gastric contents after a
test-bn-akfast (Kwald's) shows iliminu/ieil acidity —
either no free hydrochlorif acid, or only a nmali
quantity. Tlie two ferments, pepsin and rennet, are
present; achroodextrin and sugar are abundant,
but erythrTHlextrin is present only in small amount.
Inch mucus may be found in the contents of the
toinach in some )>atients, but iti others it may he
absent. When the stomach in washrd out in the
morning, fa.sling, the water returned from tlie utomaoh
luuallT contains much mucus.
5»
Medical TREATMErrr.
(Part I.
lu t.lie Irenlinenl of cbronic gastric cutarrli the
lirat indifnliou is to rt-move, if possible, th*" ex-
citing cause of tlio cjttarrh. When it is <lue — ns it
so oft<"n is — to the aliuse of alcohol, abstineoL-e from
alcoholic (Irinlv's must be iusistetl upon. When it is »
consequence ol' those orj{iinic diseases of the liver,
lungs, or heart, whieli Jeid to secondary enu'orgement
of the mucous menibniiie of the stomach, the ti-wit-
nient which is beneficial to those diseases will be also
remedial of the citarrh i»f the stomach. When it
liiw been induced l>y obvious errors in diet, these
ujust lie corrected. When it is a conset^uence of
debility and anaemia, totiics and blo<Kl restoratives
must form part of the treatment. When it is
associated with some incurable organic disease of
the stomach itself, or has advancetl to the condition
of senile atrophy, palliative nieiusures alone arc
possible.
ISesides attending to the preceding indicationx
for treatment, it is also necessary that we should
adopt measures for arresting; tlio morbid fermenta-
tions goin;; on in the stomach, and for relieving
the stomach of al! decomposing substances and clean-
ing its mucous surface of the layer of tough, ropy,
tenacious mucus which usually wivers it and blotrks,
OS it were, the orifices of the seci-eting tubules. Other
indications are to relieve excessive acidity of tho
gastric coutent-s when it exists, to allay existing
irritation of its mucous membrane, and to preserve
it from further irritalion by great care in the choice
of food and by enforcing such dietetic measures as
shall insure to the stomach as much fum-tinnal rest as
is possible.
Let us now consider liow the above indications
may be be!.t curied out in detail.
In aggravated cjt&es where we have evidence of
the retention of decnuiposing ntatters in the stomach,
one of the most ethoaciims measures is to begin by
emptying the stomach nieciianicuUy of its contents br
nieaus of the stomach pump or syphon tube, and nk
Chnp III.) CftKoif/c Gastric Catarrh.
53
the same time wnsliiiiif out tlie stoinacli* in the
iiiorniug, fasting, witli sonio weak wiirm alkalino
solution ; for tliis purpose we may use warm Vichy
water, or warm wat«r containing 2 or 3 grains of
Hodiuin bicarbonate and 5 or 6 grains of common s«lt
to tlie ounce, or a weak solution of borax, 3 or 4
grains to the ounce. By this measure we shall not
only eH'ectually remove the irritating results of the
abnormal fermentation of the food, but we shall also
cleanse the njucous membrane of the storaacli of the
viscid mucus which adheres to jL
When the jiaticnt ]>ositively refuses to submit to
mechanical treatment of this kind, or when? we
encounter dilliculties in carrying it out, other
niethmis of emptying anil clennsing the stomach may
Ik? adopted. An initial eniellf of ipecacuanha or of
aponiorphine, or of wann water, as mentioned on page
45, may be administered ; or a better process, in many
case.a, is to i^arrj" awnj' the contents of the stomach
through the intestinal canal and wash ita surface at
the same time bv the ]irolorigod and systematic
adminstration of pnr|{ntivr u'nl('r>>, mid especially
of mintTid waters like those of C'arlsbad, Tarasp,
and Marienlmd, which contain the alkaline soilium.
bicarlMHiale as well as the purgative so<iium sulphate.
The alkaline carlxiniitc neutralises the excessive
acidity of the stomacli contents, while the aperient
sulphate sweeps them away through the iutestiiial
canal without setting up any irritation of the intestinal
mucous membrune. These waters must be given in
the morning fasting in sufficient quantity to cause
sm-erai watery stools ; in this way the sUimach is
daily washed and cleansed of all lingering decompos-
ing food and adhesive mucus.
Whenever practicable this treatment is best carried
out at C'arlsbnd itself, where the strict diet enforced
greatly contribut^'S to the cure; but the same rules
• Tlie f<'phiiiy'ii' nf tliis method is dewribed in tho chnptcr ou
the trentmcnt of nilaliitioii of the Stomiich I p. IH).
54
Medical Tkf.atmext.
I Purl 1.
ivikI iiu'tlioil may be enforced and carried out at liomc
witli t lie frank and ot)«dient C(>-o|»enitiouof tlie patient.
After a time, or when it is ck^r that a dt'cided
aperient action is not needtii.but the object is ^imiilv
to cleanso tlic niucmis nicniliriini' of the stomach of
tho morbid, viscid, c^atorrliiil mucus with whicii it is
covered, then the siiii|ilo nlkidine Eoiiium bicarbonate
watei-8, such ;us warm Vicli}-, Ems, or Vals water, or
simple Jiot water, containing 2 or 'i grains each of
sodium bicurbouato and of common salt tn the ounce,
may Ik.' used insteiid of the Carlsbad water. Two or
three tumbierfuls sliould be drunk in the morning
faHting, and no food should b« taken till an hour
after the last glasa "The lesultji from this treat-
ment," says Niemeyer, "are the most brilliunt tluit
are ever attained in medicine."
In some ciironic, ohstinate cases in neurotic, sen-
sitive subjects, in which the symptoms are not very
severe, but rather annoying and troublesome from
their persistence, the giuseous chloride of soditnu
waters of Kis-singeu often prove most elKcjicious, and
appear to agree better than the stronger aperient
waters. Ewald considers the chloride of sodium
■wnteTS are indicateil in the casts of chronic gastric
catarrh with depressc<l ghindular secretion.
If we use a simple liicarlionate of soda water, it
will often be an (ulvantage, especially in gout^' subjects,
to order a tumblerful tis hot as can be drunk comfort-
ably, to Ik" taken half an hour or an hour before
lunch and dinner and at bed-time ; the object l)eing
to wtt.sh away all residuid mucus or other subst^mcea
remaining from the previous meal before another is
taken, and also to neutralise any excess of acid which
may remain in the stomach, and to atiniuiute a
held thy secretion of gastric juice.
Other measures may at thi; same time be taken to
check or arrest fermentive action in the stomach;
two of the bei-t remedies for this purpose are cix-osote
and thymol or menthol, given in jiiils immediately after
food. The latter may be prescribed in this form : —
. Ill.l
CHKOtftC GAfTKK CaFAKMH.
ff Tkyaol er iwUlinl
Piil«c(UM|nab ...
K.-iii'.n. rtni rwJHk^ti g* _
T L To W tekxn t«M w UttM tJiH« • 4af .
imn. >t%ooi.
The foIkiwiti^iB»goodfamfargiTugeftaaate —
ralnriacalicail-x I ^' r~^
1'alrem apeak „. ». .. n. •■■
Mttn. Sfti pilata. X* W lakva ttrW or ikim liaM •.
dttr, after food.
In aame irritatirp <tate» of tiie i
and naa^ea aft^r food, or wlteo thM« b prroM^ tbr
pnepwationa of MvaiMlk — tiw MibckcMe, tW cm^
bomrie »od tli» oxydJoriile — arc tctj ■wftil. Tkae
prMianUwtM of bwiiMilh not oelj act aa astaefUei
ana anucida, bat they alao cxcit a onfol wtri»^mt
effect on the relaxed and tlgwyil ■■com wMilmiiwv
anJ firoliahir act also neciMiumllT hv aSmfinga aort
of |irr>tpctive oorrriiij^ to the trrit^tcd ■wmwia iiiifcn
It U .,rr<-M iuK ir.tA|{i>(Mi« to ooatbine tlw btnralh vitk
ail y when ibitv iseonfiaint «i ** baart-
baiii. i<---..i'-i •with add emetatioas.
Tbe following b a nsaal praaeriptiaa : —
[v taiaitiaii*
Or it may be preaeribed in a mixtare aa UOcm* : —
ff Biaaaiki carteBatj* ... fr zr.
Mucneaic foadciwr |.
8oifii bicnbnati* ... , u cr r.
Maeilagmia tn9Manlba>
i ...... ~.»nt|tiB fiftfUm . *; ^
.•lotiu. T« be tafcta bdf aa bwr '
thr. »r.
An excwIWut eomliioation tor tbe porpuai- of
mlievitig tb« pain •nd nan«» vhicb ao often aeeoM-
pany Nggraratfld coiMlitioa* of Ihia malady b iW
foIlowin){ : —
S6
Medical T/tBATMEjfr.
(Pari 1.
ly llismiitlii Ciirlioiintis
Acidi hydrocyniik'i ililiili
Lii|iiori8 (ijiii svOalivi
Minilngims trigiiciinlhiv
Aqxii- iin-Mlhn' [jiiiirilii"
... gr. X.
Ill V.
vx V.
Misci.', fiat hnualiiD. To bt- titkrn lialf an hour before food.
or wlicii in |i:iin.
In advniicod cases in whicli tliere in much irrita-
bility of the giistric mucous iiu'inbrjiue, ami puiti iifUT
taking; food, benefit may :ilso oftt-n be dfi!\ tul fruiii
tlir Adiniiii.'ilr.ition of nrgentic uitrnti' in ixmibiimtion
wil.h small do.ses of ojiiuni. Given in a pill in doses
of J Id A a grain, conibinwl with J, gniin of extract
of opium, liiklf i\n hour b«'forc each lueal, it will often
lilive .1 valuable sedative eflifct.
Some American authors rrcommend an intrn-
giistric spray (1 in 1,000) of this salt, or to wash out
the stoma cli with a 1 in tJ.OOO solution.*
In cases where we find much loc^nliscd tenderness
in the epigastrium the rejieatod application of small
bIislei-8 hits Wen found >'ery serviceable.
In mild cjises n cure may often lie effected by
careful regulation and limitation of food, and by the
judicious use of alkalies ctimbined with vegetiible
bitters such as quassia, calumW, gentian, nux vomica,
etc. The alkalies neutralise the morbid acidity of
the stomach contents, the bittei-s apjiear to give tone
to the stomach, and both appear to promote the secre-
tion of hejilthy gastric juice. They should be given
nlxiul h»lf an liour or an hour liefore a meal. Tlic
following prescription is a useful ono : —
R? Sodii biiMilKinalis ... ... :.i \v,
TinctiiriL' nucis vomii'Du ... i., i
Infusi rjduinlKe ... ... ... ... ^.
Mix'c, tint llllu^lua. To be iMkeo three liinu« u diiy an hour
Upfor' fvKMl.
It is iinporlaiit to understand thoroughly the
object and right use of MlkHlivs in the treatment
of ihi.s disease. They are u.seful and necessary for
* Hetnmrtvr : '- OivAwj of the St03iaeh," p. 44B.
Ch»p. III! Chkosk Gastkic Catakkh.
57
Ihe |inr]»i)se of ceutmlifiing the aciAn, «ooh iw ncrtic
ami bulyrio, which result from fhn rrmrliid fcriiij-nln-
tion of certain articles of fonl in tlio t-toitKidi, liat
tJipy niUht not Ik' ;;iwii so n4 to ueutmii»'' ilie ii»IiiihI
ncid of tlie {•antric iuic<». Tli*-*- nre lln-r-fxr" -•
given at the end of tlie dijt^sfive procesw, ar^l ■'
H short ilistJince of the in-xt meal. At tliis ■
answiT other useful [lurjioses ; pivon in liiltn.
wunn, they (lissoU'e and wash away, n.s we have
alri'iuly piiiited ool, the sticky tnorliid catarrhal niii>-ii«
adhering to the gimtrie niucouit nieinlinin<>, iumI they
mIhT) promote »nd Mtiinulate the SHon-iion •■' ■/■-•'i-
jui(^' for the iippruneliing meal. Tut it is al
frequently neccRfiiry to )(ive ulkalirs in tunny (nin'pn
Mouie t'a.ses of chronic gMStrie cnlarrli, evi-n rlurinu ih'-
<Jis{ejilivp process, to relit '' i
rauwd hy the iiipid and >
of acidf; in the f>t<)tii»ch. We nlioulii.
tlieni witli caution an<l in not too InrL'
is U-st then to coinliine an insnliiMc «ilh n «<>lul<lr
alkidi, for thi? former will only disjuilve in an ariil
metiiuni, niid so soon as the offend ini;)f -id i* neiitnili-i 'I
it will remain practically inert, A do^e of 10 gniiit*
of sodium hicarlionat« *ith 1 0 i^Taii^s of Ivjlit magncMa
ill an ounce of peppennint water in a guml fonn for
tliiH purpotte.
In anieniic ca-sieK. in which Ihe unntric •
doe to su\ iuifierfect IiIimicI hu|>|iU' «»i'1
M>cn*t:<in of jjastric juiw, it ih ••'
tonic con'ftininj» iron and a few di
chloric Mcid to re«t/ire the due propurtion
the ga8lric juice, 800II lifter inch inmL Th" i ^
is a good fnmi : —
tt !" (Cr. ».
.'■■ ;••' "■•'iS. ■!«,
Ai\am> »(| jj.
Ui«ce, lUl luiiwlu*. To liv tnkrn aflcr fowl tfaie* timoi ■ day.
In such ciMes it may also be neceaaur to giv« a clo«o
of pepsin at or immmliatcly *ft«r meals.
58
Medical Tkbatment.
(P«ii t.
In atlvaiic«l atrofihic cases, in whieli fitjiii wasting
of the gastric glands there is a j,iput deticieiicy of
digestive secietions, and sometiniea an almost entire
aliseuue of hydrneliloric acid and [lepsin in the
stomach, the indication is to administer full doses
of this acid, with pepsin, after taking food. Rwalti,
who seems scarcely sufficiently to appreciate the
value of alkalies in many cases of this disease, is,
on the other hand, a vigorous advocate of the free use
of hydrocldoric acid. *' It not only,'' he 8«ys, " i-e-
places the deticient secretion of the glands, and forms
the necessary acid alliuniinates for pe])tonisation, but
it j)revents organic fermentations, or limits those
already existing." He gives it "in as concentrated
watery .solution us possible ; that i.s, as acid as the
patient's mouth will stand, three or four times, every
quarter of an hour, after eating," and continues this
treatment " lor months without any bad ellect."
Pepsin he only gives " in advanced cases of mucous
catJirrh ami atmphy of the stomach," and then in
large doses, 7 to 1.') grains dissolved in hydrochloric
acid and water, about lifU'en to twenty minutes after
meals.* We regret we cannot fully sliai-e Prof.
Ewrtld's views as to the great advantages to be
realised from these large doses of hydrochloric acid.
In this country, at any rate (and it would appear
to Ijo so also in France, judging fn>m the writings of
French physicians), it is far more common to 6nd
the subjects of chi-ouic gastric catairli to be suffering
from hyper-acidity.
In coHQn that are not being treated by purgative
waters, the tendency to constipation must be cor-
rected, and the bowels kept freely open by some
suitable aperient. A pill of 1 to 3 grains of extract
of aloes with half a grain or a grain of ipecacu-
anha powder, or 5 grains of the compound [lill of
colocyuth and henbane, should be given at btii-time,
and occasionally a grain of calomel or 3 grains of blue-
' Lectures on Diwiisaa of the Stomiich," vol. ii., p. 38.
Chip. Ill I CuKOiVic Gastkic Catarrh.
59
pill may advantageously be iMldecl. iSoiue autiiuritiett
think lii;;tily of tho use of small doses of caloini-l in
protracted cases of clirouic gastric cutarrh. " The oiio-
fiftli of M grain of calomel, combined with bismuth or
bicarliin.'ite of sfMliimi, may be given for wfeks with-
out daugerof Nilivation. Excellent results sometimes
follow this treatment. In small Aotmn calomel is
undoubtedly sedntivu to the mucous inembnine of the
uppcT portions of the digestive tract." (Professor W.
H. Welch.)
In ctt*C!! that apptair to have bern brought on by
cliill, a Turkish bath may Ije useful, togi^thcr witli
cold affusion and friction of the kurface ; a llaiincl
be4t worn round the abdomen ]ui8 bccu found an
excellent preventive, eepecirdly in muhiriouii di!itrict«.
The action of the skin shouKI also be promoted by
the linbitual use of warm clothing.
Persons of indolent, tjedenlaiy habita should lie
encounxged to take adtvpiate exen.ise in the open air
AS an essential part of the treatment ; and, un the
other hand, excessively energt-lic and restless patientn
liould b<< made to understaud that a due amount of
»t is often an important curative agiuit when the
iKxly is feeble and ill-nourished.
JrUratftutrir fartidinalion bail been applied in
ne of tiiese casoji, and is commended by «omo
American autlioritics on K^s^ric diM-nies;* but we
have never found it needful to recoinnicnd its apidi-
cation, all hough it might doubtless be of use in the
neurotic forms, for thest' patients are never so icippy
khrii tliey are being submitted to much elaUt-
Me nioriipulation.
Kinally, we have to con.iider tln" dl«*lctlr man-
a^eturiit of thrw cases, which, it nwi) Krurcely be
snid, i« of the tirsi iiii[iort«nce. It must U; borne in
mind that our first object i^ to give the stotnach m
much functional rest us |iOMsible, anil we must thern-
fore give the miiiiiuuin amouut of foti<l consiate'nl
The mctbcMl of a(i)>lriug thi> i* ilMcribcd io Max Elulicini'a
;tuiiucb,'*p. HI.
•' DiMMM of the Stuiiucb,'
Medicm. Tkeatment
(Pari I.
icli (Iif due iimiiiicnaiicp of tlie nutrition of tiie
hcMly, and wo iiiust give it in tlic most easily nsstu\il-
aIvIc form. In very spveif ciisfs it may lie desiralilt-
to givo the stonmoli absolute rest for a time, and it
may Ih" ncoessary to support tiip jKttient for a. few
days exclusively by nutrient i-neiii.ita, iillowiuf; only
n little iced water liy the nioutli or iced Vicliy wat^^r
to allay tliirst and neutralise acidity. Leube prefers
the " i)Hncreatic meat emulsion " for rectal fectliiig in
such ea-ses.*
Ue.striction to an exchisively milk diel lias been
stiougly advocate*! in this malady, and it certainly
provi's of the greatest value in certain casec, allowing,
MR it doe^', a consideraljle amount of functional repowe
to the stonmoli, and moflerating the acidity ami
irritating character of theirnstric secretions, especially
when we dilute the milk, as is often aljsoliitely
necessary, with an ecjUiil ((uantity of Vichy or Apol-
linaris water. We uiust, however, watch for in-
dividual idiosyncra-sies with regard to this diet, as
some patients digest milk with great ditticulty. We
must not give large ipiantities at a time; 3 ounces
of milk with 3 ounces of an alkaline water every three
hours will he enough lit Hrst. The constipation
which is apt to attend such a diet should Vje coirected
hy a dose of Carlsl)ad sidts — two or three teaspoon-
fuls in a tumhleiful of hot water the Hrst thing
in the morning. We ha\e rarely found this diet
well sujiporttil unless the patient is, at the same
time, kept absolutely nl vkI. Hiilleriiiilk in which
the casein is already curdled and finely divided
agrees with some persons lietter than fresh milk,
and has been warmly advocatetl by sonte German
physicians.
Curl«iliydrates, except in very small (|uanlitic8,
am generally l*C5*t avoided in ca.-^es of stomach catarrh
with hyper-acidity ; they tend to undergo iicctons and
butyric fennentation, and often greatly increase iho
* .Sc t]iv ttuthor'g work on " Fond in Health siid Diseato"
(new edition), p. bih.
Ill I CuKostc GAsmic Caiarrh.
6i
morbni ncidity of the gastric content*. A littl'?
cruiuli of st/ile bread or a little thin dry toilet usually
agre<'.5 best.
All frit* and fat sauces must be rigidly forbidilmi,
as iht-y tenil to tlie fornintion of f;«tty acids in llie
stoiiKicli, and by ix'iidfM'inif tl'C food iimrc or lows iin-
periii«il)l>" to till- gastric juice, rct.ird 'ligfstioii. It is
uftcn of u>ie, as soon as the |iatit<nt is thought abl'_ t<i
take solid food, to give a te-.i8.|)ooiiful of glycerine of
pepsin or of Benger's liquor pepticus with each meat
meal. Great regard should be puid to iudicuhuil
peculiarities. Nionieyer has jx)int.ed out that certain
dyspeptics digest salt and Miinokeil tnetits Itettvr than
fresh ones, and accounts for this liy the circuinst;ince
that thoTC preserved nieuts are less rea<lily deconip<tsed
than fresh meat.
The meals of these p.iti(>nt>4 must be Rmall in
quantity, not bulky, and, as their digentive proce«se»»
are often very slow, ample lime inunt l>e allovvwl
between the nicAls. The Ijost and tmderest portions
of the lean of meut, chicken, giinie., and the lightest
kind of fish should b<? selected ; and if the teeth are
defecti>e, and mastication, in consei[ucnce, imperfect,
it is necessary to give these in a finely-divided form.
Small <|uantittes of fresh vegetables and potato may
be [K'nuitttHl, in the form of purees.
With reg.inl to beverages, it is udvi.salile to forbid
alcohol altogether, oh well lis strong ten or coH'ei-. If
a liftli- wiiio se<>m5 to l>e needed, a light itordeaiix or
Rhine wine of gwnl ipmlity mixed with Ajiolliimrix
water is the best. The plan of giving some alkaline
wat«'r, warm, half an hour before foofl, such as \'ichy,
Vttis, or Ems water, not only has the advantage of
cleansing the mucous membrane of the stomach, as wc
have ain.vidy cxplaine<i, but it also tends to lessen the
desire to drink while eating.
The following may be taken as a suitable diet in
average ca-ses at the cointnciicement of treatment —
admitting of moditications in accordance with tho
preceding general remarks : —
63
Medical Treatment.
[Part I
Bie«k/ntl, 8 a.m. — One or two ponchcd or lightly biiilwl egg» ;
2 oz. iif thin toaiit: }j at.. u( butter; u nip of China teti
(infu.sed 3 miiiutcx) with one-third milk,
11 A.M.— A cup of ronsommp or bovril or Dthcr nie«t jiiiee.
1 to 1..10, l.«nch.—',\ OK. of tondpr Unn of meat or chicken
(not {>ork or vciil) : 2 oz. of maslx?*] poUito or piir6o of
spinuch : 1 OK. of thin dry toust ; } oz. of butter.
4 to .5 I'.M. -A cup of Chinii twi, as nl bniikfiist ; ono or two
slices of Ihin (stiilc) brwid nnd butter.
7 I'.M. — A grilled or Viilod soleiir whitini;, iibout 4 o». ; nr
B grillod mutton cutlet (free from fill), nbout 3 oK. ; or
breast or winR of chiikcn cr phe/isjinf, with 'i c«. of
l)oile<l rice, and wat< r-i-rt>s» or muMlard-and-crers,
A tablcspoonful of brandy (i^ood qu.-ilily) with 4 ox. of water
mny be taken at lunch nnd nt dinner.
(This diet will, of couine. need increiuing ((■ giutrio lono
u restored.)
ADDITIONAL FORMULAE.
In acute gastric catarrh in
infants with nausea and
Tomiting.
It .\(idi tartiirici, pr. xv.
A((uu' Inurocerusi, ntz iid xx.
8yru|ii inori. sij.
Aquti; de!>tillatte od 5*.
M. f. mist. A deMertsjKHiu-
ful every two hour^.
(/'tv*/*. MfMlft,)
If with faver.
II Aeidi hydroeblorici diluti,
ni V nil X.
.Syriipi siniplipis, .^ij.
A(]un: ilcntillatii^ od .%tij.
M. f. mist. A desscri-'poon-
ful every two hours. (.Voiili.)
When gastric Irritability has
disappeared, but feverlsb-
ness continneF.
II (Juiniuie hydrochhiridi, «■. v.
Aciili hvdrochlorici diloti,
mv. ■
.Syrupi siinplicii, jJM.
Aquic dp-stid-itii* Jul .vij.
M. f. mist. A tt-ai"|KwnfuI
every two houra. {Muiili )
Powders for chronic grastritU.
It ItJMiitithi AultuitnitiK, ^xii.
Bit-nmthi i«u)>^iiiluti!>, :^iv.
M. et rliviiie m pnlv. xxiv.
One jiowder in a wnfer four
tinie« (iftdy. {Utmmfhr.)
For clironlc gaatrlc catarrh
with pyrosis.
II Ili!<niuthisubnitnitis,KTlxxx.
Morpliinic liydrochtoridi,
Kr. J.
Sjdii biciirbonatis, gr. xxx.
M. et divide in pnlv. x. A
nowiler to lie taken every two
hours. {ftiiinftnyri.)
Do. with loss of appsUta.
n Extmcti gi'utiuuie, gr. xxx.
Syrupi .iiinintii ciirticis. iv.
Aquii* destilliitji' ltd ^vj.
M. f. uiist. A tiiblespiKtuful
Ijel'orc each menl. i^/imiiliriyfi; )
Or
B Tinctunr nucia vomirit'.
nixxx.
AquK! liinroccrnid. .^iJM.
Tiiicturn* ipuisjtite ad ,^j
M. f. nii»t. Kifln'u (lr'5^ie to
be lAkeu, in water, three ttmra
a dny. {Bumlryfti'.)
Oi.p. Ill I Chkoxic Gastkic Catarrh.
63
li
Pot- o/'nt« n-fl«ti-i^ CAtUTtU
A<|uip nicMlhn pipvriUe
mi ^ij.
M. Tn \tv taken ia a taUe-
»|K.>oiiful of wuU'r vrery one,
twci, or tluiw koan,
(/I. 1). Slfirarl.)
aedaUve mixture in acnt*
EastTic c&taiTtL
Hi-n.u!!ii I . ■ ■ -v.
Lt
K
"1"
<.'l)loriili, .iij.
Mucilo^iiis Acaciip, int<.
Aqtiir clilorc'fnnnj o'l Sir
31. f. mi>t. A UiiAjHKjnfiil
four tiiij&4 a tl;iv lmfor»* IiwmI,
(WAif/fl.)
For cbroDic K*^trie eaUirh
In childran.
n Swlii bicirlHjimtu, jj.
'•' ■ iii, KUtt« ir.
' M'jir, q.j.
ij.
4 111 i • iijiiainimij, ^iitttr IT.
Aqun- puru' c| <. nl =.iij.
|H. / miM. y - 'il.l of
■ui. t& ffnmll ' III a
UtLi.> water !- " ^ ' iiU.
iJ'f'if. Iri'prr.)
Tot uiarazia in dironlc gaa-
trttU.
R StrjchiiinaD sulphatu, g. ^.
Aciiii bTdrorhlarid dilnti.
Elixir gcntiiuia, ml i rj.
M. i. miat. A tablaapooBfol
in a wiueglaaa of water, aiter
maala, ( HrmmrUr. \
In aoQto gastric oatairli In
ehUftren.
M Biamntiii cnrbonatis.
Soilii liicnrbonntis. ait gl. ij.
I'ulvwris rhui, (tr. as.
Piilveria arnrantici, ft. j.
M. f. puW. T.. 1k! t«k«n be-
fore each moil,
For cbronlc K«otrlo cMarrh.
B Argrati nitratia, ^r. rj.
Bvniiithi •nliiutratit, gr.zxs.
Extracli hycmcyami. gr. xJ.
H. et iliritle in pil. xl. Chiw
momin); and evening. (,Millrt.)
64
CHAPTER IV.
DISEASES OF THE STOMACH — TREATMENT OP ULCER OK
THE STOMACH AND OF CANX'EH OF TUE STOMACH.
V
Ui.CiB OF TOK Stomach.— Cliariictors—Ciiuwition of, obwuni —
Syi«ptoin<s nn<1 Course — Puiii — Voiiiitin^ — H.i*iiinrThiige —
liidiciitimm for TreiitiiiPiit. — Washinif cut th« Stutniioli —
Alinipiitation -The "Roit" Cure- Drugs, eto.—Tmimfuiiioii
- Treatment of I'erfornti(ai -Gftstro-enfcrootomy — After-
treutnieiit. Canckk or the Stomach. —SitHtttiou- lliagiiosin
—Symptoms — liiiJiintions for Treiitnieiit — Diet — \Vii»liiM^
out the Stonmeli — Anti>fHnueutive litnl Antiseptic Rt^mtKlii**,
etc. — ( 'ouduruugo — Operativo (Surgical) Treatmi'Ut — Ail-
(litiunal Fomiuln?.
Ulcer or the Stomach.
Thk ilisefvse the trentinent of wliich wp are now
about to coiisidci' lias Ikmti viiriDUsly naiiicd "sinijile,"
" round," " perforating," and " chronic " ulcer of tlic
Rtoinacli.*
The ulcf-r is usually single, riccosionally niulti|ile ;
it vai-ies in siice fnjiii tlint of a kIxikmico tn tliiit of a
crown piece ; the smaller ouch ure circiiliir, tli'i larger
ellipticul, iind those formed hy the coidescence of two
or wore are of irregular outline. Its edges are usually
clean cut, and it has tlie appesirance of lieing punched
out; the edges, however, become indurate<l and
thickened in the more chronic form. As it peiietnites
tlie dilTerent coat-s of the stomach it does ho to an iin-
ecjual extent, so that it hiusa funnel-sha[ie<i or shelving
aspect ; and when it leads to jx-rfitrntimi of all the
coats, as it is prone to do, the peritoneal opening is
smaller than the gastric. It tends to be located
(^specially on the posterior suiface, along the lessor
curvature and at the pyloric end of the stomach, lis
healing is attended liy cicatrisation and puckering of
the adjacent mucous membrane, and when this occurs
extensively in connection with large or multiple
* Fenwick, in contrndistinctiDU to other autlior^, iusists on
diotinguisliing " two dintiuet funns,*' viz. " ncate " ^antrir ulcer
and "chronic" gastiio ulcer. Vidr " I'Icer of Stomach and
Duodcuum," p. 131.
^
Chap. IV.)
Ulcek of the Stomach.
65
ulcero extcudiog trunsvereely from the lesser curvm-
tare, it may cause bour-gIas8 conti-action by drawing
up the K'^A^'' cui^ ''^ire towards the lesser; or if
situated near the pyloruH, it may prodtice pyloric
stenosis and consequent diUtatioii of the stomach.
The chief dangers attending thin fi)rm of ^;n>*tric
ulcer are perforation and hieniorrliage. If the ulcer
I perforates all the coats of the stomaoh before inflam-
H niatory iidliesiou has taken place between it and one
^Kor otlier of the adjacent organs, peritonitis, often fatal,
^Hklftpidly set up ; if one of the larger blood-veneb
I^^Homea eroded, a large and fatal htemorrhage may
result ; smaller hiemotrhages are of common occur-
Irencc, as we shall see, in the course of the chronic
fornis of this disease. Owing tu the greater mobility
of the anterior wmII and greater curvature, ulcers in
tJiese situations an- attended with greater danger
of [lerforation. I{eliip»e« are frequent even after
cicati'iMition, an the cicatricial tissue, it must be
r»meml>ered is of low organisation.
Very little is known with certainty a» to the
rlialoiO' of this afibction, and very little help there-
fore in framing inciicntions for treatment catt Im>
derived from etiological considerations.
It is ceitaiuly more common in women than
in men, «nd anainuc, chlorotic, and debilitated con-
Iditions seem tu prodispoKe to its occurrence. It is
said that in women the tendency to perforation ia
cepvcially uinrked about the age of twenty. Gastric
ulcer liuR Ijeen observefl to Ix; "' most fre<|uent in the
doss of maidservants liotween the age of eighteen nnd
that of twenty-five " (Budd), and also to lie of frwjuent
occurn-nce in cooks, who have to taste hot things, nnd
in tipplers. The general conclusion arrived at i» that
some local affection of the vessels of the mucous
mendirune ut the seat of ulceiation is atletideil by
thronil>osi.<i and obliteration of the vesseU of a small
Vascular area, with consequent necrosis of the corre-
sponding mucous surface — that this is attacked and
^ diaaolved by the gastric juice, and perhaps a condition
66
MtnicAL Treatment.
I Part t.
of hyperacidity of tliis secretion may determine
the Roliition of th*- subjacent tissui's and tlie rii|iicl
fonnation or deepening of the ulcer. Uiicterial agency
is believed by some to be an important factor. How-
ever, as already stated, the etiolouy of simple gastric
ulcer is adniitte<lly obscure. Tt is, however, a well-
established fact that chlorosis in young women pre-
disposes to gastric ulcer.
The symploms of this affection must next be
examined in detail. This three nnjst important are —
(«) pain ; (6) vomiting ; (r) luemorrhage.
(n) The pain of gastric ulcer usually comes on
•lirectly after taking food, but it may Iw delayed for
half an hour or longer. It is comminily locali.sed in
A circumscribed sjiot in the epiga.strium. Paroxysms
of more diffused pain are also common, spreading
over the whole epigastric region and extending through
to the lower ilorsal or interscapular region. Coarse,
indige-stible, hot, and pungent foods are especially
prone to excite this jiain. It usually continues as
long as food remains in the stomach, ami is relieved
when the contents of the stomach are discharged by
vomiting. The pain is generally increased by pressure,
and there is almost always some tenderness on pi-essure
over a circnmscribcd spot in the epigastrium even
when the stomach is empty. When the tenderness
on jiressure is exceedingly severe, it is reganled us a
sign of the occurrence of peritonitis around the seat
of the ulcer. The pain of gastric ulcer is .sometimes
radiated to more distant nerves — the lower intercostal,
other branches of the vagus, etc. — and pains may
arise from cicatricial adhesions to other orgaTis and
the involvement of nerve fibres in these cicatrices,
and it must be borne in mind that sitch jMins may
(•oulinittt ajltr the h«alin</ of (hn uleer.
The pain following the taking of foofi is regarde«i
as caused by the movements then excited in the
stomach irritating the surface of the ulcer, and this is
further njigravated by contact with the acid gastric
juico secreted on the introduction of food. There is
Ch«p. IV. I Ulcer of the Stomach.
67
often a cotiii>lftint of more or less cuDtiiiuous dull
aching pain Lu tlie epigastric region in the intervals of
digestion. It in importaTit to V>ear in mind that in
9ome latent and obscure cases severe pain is wholly
absent, and fatal perforation or serious Ita^morrhage
may occur suddenly and une.x|>ect«dly, the only
preceding symptom being a little nnea-siness during
digestion.
(b) Vomitirtg is rarely absent in cases of gastric
ulcer. It usually occurs, as the j)ain dries, shortly
after taking fcxxl ; it is ordinarily preceded and
accompanie<l by pain, which the vomiting, when
complete, relieves. The vomited mattei-s consist of
food more or lees changed, uiixc<l with mucus and
acid secretions in which sarcinn* may often Ije found.
An abnormal amount of liydrocliloric acid is often
present, as well as lactic acid, in the matters
vomited ; and Max Eiidiorn* suites that the
acidity may reach as much as three or four times
that of normal gastric juice. It has Ijeen noticed
that the vomit in gastric ulcer rarely contains bile.
The vomiting is provoked by irritation of the nerve-
fibres in the ulceiute*! surface and by the freipient
co-existence of gastric catarrh, and it is especially
excited by improper and irritating food. Its effect
is to exhaust the patient by the continuous with-
drawal of nourishment, unless it be checked by
treatment.
(r.) Hietnorrfutge. — Probably in all cases of
gastric ulcer some bleeding takes place into the
stomach from the surface of the ulcer, but a small
htemorrhage into the stomach neeil not leacl to
vomiting ; it would, however, probably reveal itself
in an altered colour of the stools if these were
watched. But when there is frequent vomiting in
caaas of gastric ulcer, the vomited matters usually
at some time or other contain blood. The vomit is
often of a dirty brown colour, due to the action of
tbe gastric juice on the hsmoglobin. It has been
* " Diica«M of the Stomach " (wcunil edition), p. 211.
68
Medical Treatment.
[Part I.
estimaU'd tlmt iv coiisiderablu haemorrhage occurs in
about one-tliii'{l uf tlie cases; some authorities (Lebert)
coiisiilcr tliut it cwcurs in a fur greater proportion.
It is absent, as a rule, in the acute perforating cases.
The haimorrhnge may vary considerably in amount,
from a little oozing just sufficient to dis(;olour the
vomit to lai'ge gushes of blood seriously iniperitling
the life of the patient, and soiuetinies sufficient at
once to cause fatal syncope. The occurrence of
profuse hiemorrhagf shows that the ulci-ration has
extended deep enough to reach anil erode the larger
vessels. In such cases the blood vonnted is often
pure and of a bright colour, not having remained long
enough in the stomach to l>e altered by contact with
the gastric juice. All the blood that thus esca])es is
not, of course, vomited, but much jxasses away through
the intestinal canal, giving rise to what are termed
" tarry " stools ; and in rapidly fatal cases there may
be no escape of blo<xl by the mouth, as it may iin-
me<liat*-ly over-distend the stomach and remain there.
The non-fatal hicniorrhages tend to recur frequently,
as the movements of the stomach— ^ind esptjcially
tliose induced by the ingestion of food — lead to the
re-opening of the bleeding vessels. These repeatetl
losses of blood either induce a profound ancemia or
lead ultimately to death by exhaustion.
In addition to these three prominent symptoniSi '
most sufferers from gastric ulcer present the more
common symptoms of the dyspeptic state, as a con-
dition of chronic gastric ea(!arrh often acojmpanie.s
ulceration of the stomach. (Jases, however, occur
in which no symptoms of dyspepsia are complaine<l
of. But usually there are loss of appetite, heart-
burn, and acid* eructations, nausea, a sense of weight
• Ewald, RiMgd, Hemmct«r, and others state tliat the i^ojitric
juice withdrawn from the Htomach in cjutes of siin{)le ulcer !«,■
almost always, mnro ariii than iu health : hut Fenwick rcmarkti
that " while hyi>eracidity is an important cause of the r/iivniriltt
of an ulcer, the tiiuaw iturlf m utuitUu the {•atiMe and Hot the rou-
trqunm of the hi/pertrrrrtioii, since any form of local irntatiun in
the stomach is sufBcieut to induce a reflex secretion of the gaatric
juice " (" ricer of StomacK" p. 90).
Ch.ip. IV.]
Ul.CER OF THE StOMACH.
69
And oppression in the epi^^astrium, thirst, bod taste
in the raoutli, and tlie usual symptoms of chronic
gastric catarrh. In advancod casea, owing to iinpair-
nient of the niovenieiits of the Btomach by ndliesion
to other organs, or by contraction of [>arts owinj; to
extensive cicatrisatioiix, dilatiition of the stoniacli
may be developed with . retention and decomposition
of food.
Cuiulipalioii \s a usual accompaniment of jjastrio
ulcer ; this is chiefly duo to the small amount of
food digested, the greater part being rejected by
vomiting. Dreschfeld has noted the occurrence of
acetonuria in certain cases of gastric ulcer.*
A condition of gf?neral debility with great depres-
sion of spirit* is usually inducetl by chronic ulcer
of the stomach, but we meet with exceptional cuws
in young women who remain fairly plump and Wfll-
nourish^.
Amenorrhtea is a symptom also conmionly met
with in this disease.
It hus been cftlculat«l that per/oration into the
general peritoneal cavity occui-s in about 7 jwr cent
of all ca.ses of ulcer of the stomach ;t it occui-s twict>
or three times more frequently in the female than the
male, anrl in the former especially between the agi-s
of fourt^-cn and thirty. It is important to bear in
mind, from the }w)int of view of treatment, that the
immediate cause of perforation of gastric ulcer is often
the existence of some condition producing tension of
the stomach walls, such as distension with food or gas,
retching and vomiting, straining at .stool, coughing,
sneezing, violent exertion or sudden movement of tiir
body, and mechanical pre.ssure on the epigvistriuni.
Perforation of a gastiic ulcer is re])orted to have
iK-curred from knea<ling the abdomen to relieve (hitu-
lence in a patient in a hydropathic establi.shment, {
• Arb'de on " nopr of Stomach." Allbiitt's " Sy»tem of
Mwlicino,"' voL iii'., y. 'i.'i-l.
i Fiaiwiik. " IMirr of the Stomach and iJnodi'uum," u. 200.
; Palton, Traiitar(>hn» of the New York ruthologicttl Society,
vol, I, p. 263.
70
Medical Treatment.
[Part I.
frutu the piissagc of a bougie (Fen wick), and from the
jHjrfornianci-. of lavage (Ewald).
The syinptonis of perforation are — Srst, severe
and agouiBing pain in the epigastrium, which spreads
all over the aUdoraen. This is accompanioi with
symptoms of collapse, a small, quick, thready pulso ;
face palo and pinched ; skin covered with cold,
clanuny ppr-ipiratioa ; voice feeble, res[>irations shallow,
quickened and thoracic. The tempernture is at firs';
subtioriiiid, but rises if the p,itient survives for a
time and peritonitis ensues. The tongue gets dry,
there is thirst and often much retchin;;, although no
vomiting. There is marked constipation. The secretion
of urine is dtininished and may be suppressed.
The abdomen is usually distended and tym|>anitic
»nd the liver dulness is absent or much diminished.
If the jmtient does not die at once from collapse, the
tempernture risers to 102' or lO.'i from peritonitis,
the pulse gets harder, respiration more shallow,
hiccough occurs, and death crjinrnoiily follows from
exhaustion.
Gastric ulcer in the majority of coses is completely
curable ; it must, however, ba remembered that
cicatrisation of an extensive idcerated surface of the
gastric mucous membrane and subse(juent contraction
of this cicatrix, or adhesions between the stomach and
surrounding organs, maylead to troublesome symptoms
Inter on, such as gdstralgia, vomiting, and other
symptoms of dy8pep.sia ; or contraction of the pyloric
end of the stomach tnay cause dilatation and its con-
sequences, as has already been pointed out.
The ymal ani piramount iwlinntion in the
Ireiilment of gastric ulcer is to promote healing and
cic«trisation of the ulcerated surface. This will be
best effected by such means as will remove all sources
of irritation and secure the greatest amount of rest,
mechanical and functional, to the stomach ; the
avoidance of irritating movements being an_ im-
portant condition of the healing proce.88. The patient
must, therefore, for a time at any rate, bo kept
«P- iv.i
Ulcer of the Stomach.
7«
rest in bed, and the stomach uiust be kept
empty as ]K>S8ililp, sijice the pn-soiice of fcKxl ex-
cites mcivementji in it By keeping tho stom.ioh
empty we iilso asuid the irritating contact of foo<l
id gastric juic* witli the ulcei-nted surface ; and thi>
ttstric niucouH memlii-ane heing thrown into folds, in
the contracted Rtat« of tlio stomach, the extent of tlie
ulc«^rated surface is thereby diminiflhed and its healing
pnjnioted.
An appropriiUs mellKxi of fftdiiig is, then, the
must ijnjiortant part uf lli» treatment of such cases.
Medicinal remeilies may also be of value (a) by pro-
ducing a protective covering to the ulcerated surface,
and 80 preventing the contact of irritating substances
with it ; (6) by nrrentiiu/ Infiiuirrhajji' ; and (<•) by
relieving pain.
As to the practice of tnathiu'/ nut tlie stomach,
wliich lias Ijeen advocated by some physicians, in this
diseaj^e, we iigree with S«ks Leulw, and Kwald that
it is not unattended with danger of sovere and fatal
hx7morrhage, and that it is not to l^ conin)endc<l. It
is also inconsistent with the idea of keeping the
st^nuat-h at rest. In certain c/ry chronic cases,
accompanied with chronic catarrh and dilutjition of
the stomach, and the protnietetl retention and decom-
position of food iti that organ, cautious and careful
washing out, using u soft rubber tulie and adopting
the syphon jinx-ess, may possibly be useful. But
wlien there is any risk of exciting hemorrhage, this
method must ije strictly avoided.
\s to the niorle of alimentation best calculated to
promote raechanicjil and functional resl of tho
stomach, and so contribute to the speedy healing of
the ulcerate mucous menibrano, we have elsewhere
formulated rules for this piupose* which may l)e thus
summarised.
In all oases of gastric ulcer, and more especially
where severe and dangerous hieraorrhages have
occurred and njay i-ecur, it is necessary to keep the
* " Food ill Health and DiMue" (new edition), p. 377.
Medical Treatment.
IP«rl I.
stomach absolutely at rest and empty. For five
or six days nt i<-ast the patient should be fed
exclusively with nutrient enemata.* To allay thirst
a few fragments of ice may be sucked, and enemata
of normal saline solution have been given (Ewald) to
relieve intolfnihle thirst. As we have already
jK>inted out, conijilete rest in lied must be enforced.
After live or six days of rect<d feeding, some
jfiiiti food, in small iiuantities at a time" (not more
than 1 or 2 ounces\ may be given by the mouth every
three or four hours. When a/l immediate risk of
further hiemorrhage ay)pears to have ceased, feeding
by the stomaoh may be carried out on the following
principles :- -(o) All food that can either niechanically
or chemically irritate the surface of the ulcer mufit be
avoided, (i) Food that is c«kulatcd to stimulate,
the acid secretions of the stomach must be forbidden,
as these act as irritants to the ulcerated surface ;
therefore predigested foods, or foods that will puss
through the stomach and be digested in the small
intestine, are indicated, (r) We must l)e especially
c«reful to avoid dwtending the stomach by giving any
great quantity of food at a time, for. as we have
already said, by maintaining the stomach in a con-
tracted condition its mucous membrane is thrown
into folds, the margins of the ulcer are relaxed, and
its superKcial extent tliereby dimini.shed— circum-
stances which favour the filling up and cicatrisation
of the ulcer, The quantity of Huid or semi fluid food
should therefore b«^ limitetl to between 2 ami 4 ounces
at a time. As a rule, restriction to an fj-chinve/y
milk Ji'jt will fulfil these indications. It is essential,
however, that we should obviate the possible danger
of the formation of a considerable ma.ss of milk curd
in the stomach by taking measures to prevent any
firm coagulation of the casein of milk in that organ.
The milk should in nil cases be ili/uffd with an
alkaline water, and pun- uiidiliited milk should ne\'er
be given except in convalescent cases and in persons
* FormuliB for niitable cnomnta will be found at p. 37,
anVklV.l
UtxEK OP THE Stomach.
73
nho have betrt found to digest milk vith &cilitT.
The luiik may be diJuted with an equAl qoaiititir of
lime water or Vicby water, or to eadi cap of nilk
and water a powder may be added cmnposed of
Bicaibooato of §c«lii
Ligiit magnesi I
ID giaiiML
Four onnces of milk aud water tfaas treateti may
'liSgiveii ever)- two or three hours. If we desire to
givf the patient more concentrated or more .sapportihg
food, an egg may be beaten up with two tablespoon-
fuls of Ixiiling water, and then straineti through
muslin, and to this 2 ounces of milk and water may
bu added ; or about 1 ounce of the crumb of a stalA
roll, well sooked previously in hot water and nibbed
through A siere^ may be mixed with 3 ounrea of
miJk and water, and given twice or three times *
day. It is especially inipi>rtant also not to give food
too frtHjugntly, even tluid food, lest it should accumu-
late in and over dixtend the stomach.
In case.s where we encounter a di.stinci intolerance
of a milk diet, small quantities of meat or chicken
nmy be given, reduced to a pulp (the lean only),
mixed with a little weak broth or eontomwe*
Ldibe'g mAublr meat is much used in Germany in
caiieti like these. Tliis preparation is usually mixed
with slightly salted broth and taken lukewarm; some
milk and !;ome well-soak«'d bread may b*^ added.
Dreschfeld speaks highly of scraped raw lieef as
well Ixirne. if given in small quantities. He gives it
"early in the course of the case."t
All wine and spirits should he forbidden. A little
weak tea with milk may be permitted, but nut nmre
Uisn three-fourthn of a small tencnpful at a time. If
• 'llje lean <if itieiit (row) | my.'**' --Mig)! nn .\nirncan
miticff. nnil then iTHikod f'lr twrlv. ;i n Imttt murtr willi
n i;(ii.. ,..,., ...II 1.. I, .,111,1 a uni.tHI , , ... .l.tMauil muiiy <>th>.>r
, ' two trj,--f»o.>iifijiii of thij mcMt may tw
II iifiil or two t,t r\eat (oijp.
t -Viti.-k- (jii " licit of Stomaeh " in Allbatt*a " Sfitam of
Medicine," vol. iii., p. 643.
74
Medical Treathent.
IPatl I.
oatmejtl gruel ik given (and it may l>e advantageously
mixed with milk) it slioiild be prepared with tinely-
powdered oatmeal, and not with coarse groats, the
rough particles of which are apt, hy their contact,
to set up initAtiou of llie ulcerated surface. Pep-
tonised foods, especially milk and gruel, are distinctly
valuable.
Rest in bod, we repeat, is a most imjiortant con-
dition in the graver cases, as it not only avoids
movement of the iujuretl organ, but it lessens the
nutritive wants of the syptem as much as |)0ssible.
In le.'is serious or in convalescent cAses, although a
certain limited amount of gentle exercise may be
permitted, the advisability of physical rest must still
lie kept in mind.
When there is reason to believe that cicatrisation
has been establishinl, a cautious and gradual return
toordinarj- diet may be jierraitted, care being observed
that the foo<.l is of a kind easy of digestion.
Tti chronic cases, associated with much chronic
catarrh of the stomach, ihe advantage of clearing out
and cleansing the stomach and alimentary canal by
rcpeate<l dniughts of Carlifluid water or a solution of
Cartsliad salts* in hot water has l)een urged by many
nutiiorities. The sodium sulphate in these salts, by
stimidating |ieristaltic action, jiromotes the e-xpulsioii
of the cont«ntH of the stomach into the small
intestine ; the sodium bicarbonate dissolves .stringy
and t'Cnacious mucus, and also aids in its detachment
and expulsion from the stomach, while it acts also
usefully as an antacid ; the sodium chloride is a
stimulant to digestion and an antiseptic. Tlie object
in view is the same as that aimed at by lavitge, the
danger of which' it avoids, viz. the regular removal of
the decomposing and irritating stomach contents from
contact with the ulcerated mucous membrane.
* Artitlciitl ('nrlnbtu] s<s ore best made by comliiiiiiii; todium
lulphstct, iKxliuin bicarbonate, and lodium rliloriilc, in tiie pro-
jHirtion of K oit. nf the firvt, nn ounce of Hie •econd, and J ox. of
the thii-d.
Chap. IV.)
Ulcsr of the Stomach.
75
Ttie following is the be«t way of c&rrjring out tliia
treatment : — A teaspooiiful of the C&risbad salts is dii»-
alvfd in 6 oz. of warm water (about I Oil' to 120' F.),
jid four 8iicL doses are taken at intorvaU of ten or
iiftci'n uinutes, in tlie morning, fasting. Dre-aikfast
must not be taken until half an linur after the last
dose. After breakfast the patient usually hii» two or
three loose actions of the bowcU. If tlio lK>wels are
too freely acted U)X>o, a somewhat nnialler ijunntity of
the saltH should be added to ea^'h glass of water ; and
if not suflicieutly relieve*!, the »|UJintity of the Nalta,
but not of the water, niuxt be augineated.
The " rest cure " adopted by some Uennan
physicians in the treatment of gastric ulcer differe
little from the foregoing. It requires the fwitient to
remain in l»ed for two or three weeks, during which
time warm linseed poultices are a|>plied to the
epigastrium. If there has been much pain or vomit-
iiig, feeding by the rectum is practised for two or
three days, and only a few fragments of ice arc taken
by the mouth. For the first fortnight the diet v*
restricted to milk absolutely, diluLe<i usually with
barley or oatmeal water. The milk is slightly warmed
and slowly sip|)ed, about 3 oa. being given every hour.
In the third week bread and milk, milk pii(lilin;.'s, and
(KMiciied eggs are permitted, the (xitient b<'iiig fci at in-
tjTvals of two hours. In the fourth week some (Miuiided
raw or slightly grilled meat is given once or twice a
day. If the patJe.nt's pmgreaa is satisfactory a
gradual return to a solid dietary, cotnpoaed chiefly of
white fish, game, sweetbreads, potatoes, and broths,
is permitted. Some authofities consider that strict
dietetic ti-eatment should be mnintained for a year or
eighteen months, es]»ecially in long-standing chronic
cases; in that case, for from tlii-ee to si.x months' milk
must form the staple diet, but after the second month
some .solids may be addeil, as bread and milk, lightly
b'.iili'd eggs, scrape<l or pounde<i raw meat, etc., and
iH-lween the sixth and twelfth or eighteenth month a
gradual return to ordinary diet may be ]>ermitted by
76
M SDK Ah Treatment.
[Part I.
the progressive introduction of the more easily di-
gested kinds of tish, giime, jjoiiltry, etc.
In thf i.e.vt ])Iiu'e we will consider the value of
certain nipdiciiu-s which have b<>en employed — (a)
for their hjciil citvitrising action on the ulcer itself ;
(6) for the relief of pain and vomiting ; and (c) for
the arrest of hieniorrhage.
It has been maintained, and we think justly, that
the administration of lilkalinc rni'ltonnlos, by
neutralising the hyperacidity and so lessening the
irritation of the gastric secretions, assists in (iroiiioting
healing of the ulcerated surface, and tlmt they pro-
tuote the passage of the food into, and its digestion
ill, the sniiill intestine. The ohjections put forth by
some physician.s, on physiological giounds, tliat the
administration of alkalies provokes the secretion
of o(-i(/ gastric juice, is really not applicable to those
morbid states in which the gastric secretions are
already excessively acid from undue retention and
fermentation. To urge such objections betrays a
want of discrimination and of practical exjierienco.
Physiological observations are applicable to normal
physiological c(mdition8, and Ijcfore they are applied
to morbid, pathological states, they must be corrected
by practical clinical experience ; and the latter afiords
aliundance of evidence of the value of alkalies
administered at suitable times in such cases.
Niemeyer, who was an admirable clinical observer,
says, " The therapeutic use of the alkaline carb<.mates
has a wonderful effect in chronic ulcer of the
stomach." •
A combination of sodium bicarlxmate, magnesium
carbonate, and bismuth carbonate or sub-nitrate, is
one of the most efficacious prescriptions (together
with a milk diet) in the treatment of average cases
of chronic gastric ulcer as we meet with them in
hospital practice. The magnesium carbonate, being
an insoluble substance except in the presence of
an acid, will continue to neutralise or dimini.sh the
• "Text-book of Pntctioal Medicine," vol. i., p. 51.1.
IV 1
Ulcer of the Stomach.
77
astric acidity so loug oa any of it rem. litis uiidis-
}|ved. And we think there can be little duuht
that when the st^imach is empty nnd contracted,
and the |)atient lying recumbent in bed, the mix-
ture of bismuth nnd magnesia must form mure or
less of a protective covering to the ulcer, and so
favour the healing process. The following is a suit-
able formula fur these
I^ Bismuthi c&rbuimtia ... ... gr. xx.
Ma^pesii carbonntis . . gr. X.
Sodii bicarbonatis . . . . gr. ▼.
Aquo! ad Jj.
Mifco, fiat hau«tua. To bo taken J an hour beforj fooil,
three tiiiioii a day.
Much larger doses of bismuth than tliis are given
by French and (Jennan physician.s. Rosenheim given
a» much as loO grains for a do.so. in the morning
fasting, mixed with 6 ounces of water. Ewald also
approves of these large doses. Fleiner has also
adopte<l a successful method of treating gastric
ulcer with large doses of bismuth, but he resorts to
the u.se of the stomach tube, through which the
bismuth salt, snsjiendetl in water, is ixiurcd into the
stiMnacli. We think the use of this tulxj objection-
able and needless, and prefer a modification of his
method such as the following: Let the patient,
in the early morning, ilrink slowly about 12 ounces
of wann water containing, in solution, GO grains of
sodium bicarlx>nate and 20 grains of sodium chloride
to wash the mucous membrane; about half an hour
afterwards let the patient Uike a mixture of 200
grains of bismuth carbonate shaken up with 6 ounces
of warm water. The patient should remain in bed,
and if there is any reason to believe tluit the ulct'i-
is on the anterior wall of the stomach he should lii'
on hLs face. This imiy be given daily for a f<)rt-
night or three M-eeks.
In more troublesome chronic ca.se8 we have found
nitrate orsiU'er of considerable value. We believe
that suitably administered it forma a protective
78 AfBDlCA/. TKEATMBlfT. |P»ri I.
coveiing to tbe ulcerated surface an<J proinotee heal-
ing, but uiucli, no doubt, depends on the situation
of the ulcer; it is (]uite conceivable that Hn ulcer
on the posterior wall of tlie stomach would be
much more amenable t<i such action than one on
the anterior surface, and it would lie necessary also
that the stomach should be as nearly as ])08sible
emiitj' at the time of its iwlmiiiish-atiim. The following
pill may lie ju;iven three or four times a day alHjut half
an hour before giving food : —
Argi>iiti nitratis ... ... ... ... gr J.
Ungucntiim knolin, quantum mifBcint.
rt flat piluln.
Max Einhorn * prefei-s giving the argentic nitrate
in solution in distilled water, from \ to .', a grain dis-
solvetJ in a wineglass of distilled water half an hour
before meals three times a day. As the ulcer is
more commonly situated at the pyloric end of the
stomach, it has been suggested that the patient
should lie on his right side after taking such a
dose.
The antiseptic action of lioth bismuth and nitrate
of silver may have something to do with their iK'ne-
ficial ertects in these cases.
Some |>hy«icianst have advocated the use of the
tincture i.if ](en-hioride of iron as a remedy which
promotes a healthy, healing action in the ulccriited
surface and allays pain. It certainly seems likely
to be u.seful in certain low cachectic or aniemic
cases. It may be given in 5-niiniin doses in two
t-ablespoonfnls of water several times a day. In castas
where aperients cannot l>e given by the mouth it is
desirable to wash out tlie Ixiwel daily witli a copious
enema of tepiil water.
Of the various remetlies used for the relief of
pain and vumiting, in addition to tho.se incidentally
mentioned, we have opium, chloroform water, hydro-
cyanic acid, cocaine, ereiisote, ice, applied externally
* " Diseases of the Stomach" (aeoond edition), p. 2,10.
t Uerhardt and Lutoo.
, IV.)
Ulcbk or THE Stomach.
79
and internally, hot fomentations, nnd counter-irrita-
tion.
F(»w cas(« of chronic ulo^r of the atoimicli can
l>e satisfactorily treated witlioul the occasioniil use
of opinill, f'.«jH>ciiilly for the jmrpo>»>» of cahning
thosH severe attiicks of pain and vomiting which
commonly occur during the course of the di.se*9e
Brinton maintained that over and above its influence
in relieving pain, opium was fMrulial to the cure of
gastric ulcer ; we are unaM«> to share this view, as
we have re(>eate<lly seeti rapid recoveries from jjaatric
ulcer without the administration of a single dose of
opium.
A pi'l of the extract of opium (A grain or a grain)
may he given two or three times in the twenty-four
hours until the pain is relieved ; or 5 to 1.5 minims of
the lii]uor opli sedativus, according to the severity of
the pain, may be added to each dose of the bismuth
and magnesia mixture, already mentioned ; or it
mjiy bo given combined with a tablesjioonful of lime
water ; or if there is grt^at irritability and intolerance
on the part of the stomach, a hypodermic injection of
to J of a grain of hydrochloride of morphine may
given ; or small doses of morphine (^',3 to \ grain),
combined with dilut*' In'drocyanic acid 3 to 5 minims,
in a tables|<onnfuI of «at<"r, may be given by the
mouth every three or four hours with good effect.
As an alternative to thi^ employment of opiates
when any objection exisU to their use, cocaine may l)e
given. It produces anavslliesia of the gastric mucous
membrane, and so allays pain and lessens the sensa-
tion of hunger. A tAblespoonful of the following
nmy be given from time to time : —
H? Cotainai liydrochloridi . (?•■. tj.
Aqua- Inuroctiiagi ^vj.
Aquo! n't jiij.
MiBco, fiat misluru.
Creasote shaken up with water in the proportion
of 1 minim to 2 oances, and given in doeea of one
8o
Medical Treatment.
IP.irt I.
tablespooiiful every two or three hours, hiis been
found to relieve botli pain and vomiting iu sonic
troulile.sonie chronic cases ; its antiseptic and antifer-
nicntive action may lierc be of value.
The internal and external use of ice lias been
found of service in allaying gastric irritability and
relieving pain. I/jeches to the epigiistrium, hot
poultices and blisters, have their res]>ective mlvocates.
liOube and Ziemnisen employ warm linseetl poultices
by day and a cold conijiross at night. In obstinate
cases of fixed pain referred to the epigastric region,
a small hli-ster applied to the painful spot may !«• of
benefit, and the raw surface may be dre.ssed with
tnorphitie.
In hiemorrhagic cases the strict dietetic method
already outlined must l)e rigidly apjdied, and all food
for a time must lie given by the Ixiwel. Small frag-
ments of ice should be sucked or swallowed, a bladder
of ice applied to the epigastrium, and mustard plasters
to the feet a.8 derivatives. The hypotiermic injection
of ergotine, perchloride of iron in "20 minim dose.s
with an ounce uf iced water by the mouth, and such
other measures as are referred to in the chapter on
hwmaUmesiis may be employed. The most complete
physical rest must, of course, be enforced.
Traiisfiisiou, in cases of alanning htemorrhage,
with symptoms of collapse, is rarely adopted now, as
a subcutaneous injection of a physiological salt solu-
tion has taken its place— 4 to 6 parts of sodium
chloride to 1,000 part.s of distilled water — twenty to
thirty ounces of this solutiim, warmed to the bli>od
temperature, may lie itijceted into the connective
tissue under the skin, in the (lank.
Although perroration of the stomach as a
consequence of gastric ulcer is often 8p<!edily fatal,
recoveries are now more frequent since the adoption
of operative measures has become more common.
If, for any reason, operation cannot be had recourse
to, the patient should be brought quickly under
tlie inHuence of opium — preferably by hypodermic
Chip. IV. I Ulcer of the Stomach.
Si
iujections of morphine or by opiate enemato, aa
it is undesirable to allow anvtliinj^ to pass by
the mouth into the stomach. Twenty tlrops of
tinctare of opium in 2 ounceis of thin starch niucLhigo
may be injected every hour into tho rectum, or
^ grain of hydrachloride of nior[>liine may be given
hy]>oilerniically every hour for three or four tloses.
Ice cold compreises to the abdominal surface are
««cf\il in allaying peritonitis ; some, however, prefer
warm fnmeiitations, tn which some tincture of opium
may 1h' iuided. Tlii' free use of opium will, nt any
rate, ivlieve the sufferiiij^'s of the patient, if it docs
nothin^j; more.
Thirst may be relieved by sucking sniitll pieces of
ice, or warm water may be injected into the rectum,
and if stimulants are needed they must also 1)p given
iji enemata or injected hy[>odermicAlly.
In order to prevent the further escape of the
stomach contents through the perforation, Scliliep has
resorted to the cautious use of the stomach tuiie with
success.
We must now r«>fer brietly to the snrKit'iil
measures which have l^een ])ri)po>teil in coiiiu'clion
with the trwitment of gastric ulcer, especially in con-
nection with hiemorrbage and perforation. May"
Rolison* and Moynihan state tliiif, according to their
late«t statistics, the m<jrtality of gastric ulcer treatetl
surgically is only 5 per cent, wliich they contrast
with 25 per cent, of deaths in eases treated medically.
Mayo Robsfm thinks that " metlicid should give place
to surgical treatment at a much earlier period than
has hitherto been the custom," but he is by no means
in favour of a "sweeping change'' in this din'otioii,
but that the nunlicAl treatment should be " moiv
rigid ami more prolonged.'' Ho considers "in all
cases of gastric ulcer, t-xcept in cases of perforation,
medical trentment should be first tried." But when
tho symptoms of ulcei-alion recur and prove intract-
* " D>wu«» of the Stoaioch and tbuir Sut){tciU Treatment "
(mi). —
82
Medical Treatmbnt,
(P>rl I.
able to medical treatniont, gattro-enterostomi/ should
be iterfornied. This operation secures " physiological
rest by means of riniinag-*", tfius (illnwing the ulcer to
hejil without being subjected to the irritation of ucid
secretion, accumulation of food, or freijuent stoinnch
movement." It also remedies " the hyjwrchlorhydriii,
relieves pyloric sprtsuis, and, while preventing the
stagnation of fluids, cuits or materinlly diminishes
gastric dilatation.''
If the operation has been undertaken for the
relief of obstinate and serious hivmorrhage, and if an
ulcer lie discovered, it should, if possible, Ihj e.xcisetl,
OH that operation offers tlio likeliest method of cure.
But except for the cure of hiemorrhage, direct treat-
ment of the ulcer by excision is unnecessary.
It is in chronic cases that tiie best results are
obtjiined from operation, but in caaes of acvU
iueiuorrhnjrc Mayo Rolison thinks it best to rely
upon medical treatment, which has been found to
succeed in 'J3 jjcr cent, of cast>8, as operative treat-
ment in these cases is attended by a very high rate of
mortality. Surgical treatment may al.so lie needed in
dealing with such complications as adhesions, pyloric
contractions, dilatations and hour gla.ss contractions,
leading to loss of tiesh and impairment of health.
It is especially in cases of rep,-a(ed chnmic
Itteiuorrhages that oj)eration should be resorte<l to.
For of)eralive details we must refer to the work
already quoted.
The results of surgical treatment of jx-rforalion
ai-e now much more favourable than they were
formerly, a circumstance doubtless greatly due to the
fact that operative measures are adopted much earlier
than tiicy used to Ix". liobson and Aloynihan*
estimate the mortality after operation for j>erforation
at 40 to 50 per cent, — although in the fii-st 100 cases
operated on the mortality was between 70 and 80 per
cent. The death-rnte in cu.ses of perforation treated
• '■ DinensoK nf th<> Stoiniich and their Surgicnl Treatment"
1901), p. 1U2.
tlMp. IV. 1
Ulcer of the Stomach,
83
without surgical operntion lias been estimaU'ci, \>y all
authorities, as over 95 per cent. Operation ought
therefore to be undertaken on soon as the diagnoHia
of [lerforation is mivde. For details as to the methwl
of operating we must refer to surgioil treatises, hut
we may s:iy generally that it is usual to adopt every
precaution against shock — an injo.-tion of strychnine
is given — the operating table is heate<l, and the
patient's limbs are enveloped in cotton-wool. The
abdomen Ls oj»ened by a free incision in the middle line
above the umbilicus and the perforation in the walls
of the stomach rapidly and carefully searched for,
and when found it is sutured. Excision of the ulcer
is not necessary or usual unless it makes suturing
easier. After the ulcer has been closed the peritoneal
cavity is thoroughly and methodically cleansed.
The nftiT-lrt-alincnl of casics of cured gastric
ulcer must be conducted on general [)rinciple3. The
anwniia must be treited with mild preparations of
iron, the dyspepsia by careful and cautious feciling ;
the fre<]uent coexistence of constipation should l>c
treated by enem.'ita of salt and water (a teaspoonful
to u pint of water), or by a dose of Carlsbml sjilts ii\
the morning ftisting in the nianni-r already indicated.
I<eul)e recommends a course of the Franzensbad or
Elster waters on account of the iron they contain, in
addition to aperient sulphates, and in recent cases
Oerhai'dt and Baniljerger strongly recommend the
course at Carlsbad.
If |)ersistent cardiulgia and dyspepsia are found to
follow the cicatrisation of gastric ulcer, it is probable
either that the cicatrisation has led to the compres-
sion of some filaments of the gastric nerves, or that
adluwions to adjacent organs have formed, producing
|iaiiiful dragging or tension during the movements uf
the stomnch in the processes of digestion. Extensive
cicatrisation near the pyloric end of the stomach may
lead to stricture and subsequent dilatation of the
stomach, the appropriate treatment of which con-
ditions will be considered hereafter.
84
MsDiCAL Treatment.
I Pan I
Especial care must he taken of the patient during
the inenstruiil peiiml, as it is generally reco;inised that
nieiiNtruatiiin has a tendency to intiuencea recurrence
of hicinoirhage.
Fiiiiilly, when we are in doubt wheJier a case is
one of gastric ulcer or not, it is l>est, especially if we
liave to do with a young nr clilorotic girl, to treat the
case as if it were one of ulceration, for it is precisely
in this class of patient t!i;it perfoniting ulcer of the
stomach is apt to run a latent course and to cmi sud-
denly in perfoiation or be attended witli sudden and
profuse hieuiatenieJiis ; (itid even if the case sliould not
be one of ulceration, but simply one of functional
disease, the strict dietetic trejktment appiopiiate to
the former condition cannot do harm in the latter, but
rather good — indeed, it may serve as a propiiy lactic
measure, especially if followed by suitable tonic treat-
ment.
Oanceh of thk Stomach.
Cnnccr of the hIoiiiiicIi int.s been universally
regarded as an ineurabhi disc'a.se, and its treatment
as mainly symptotnatic and palliative, considered
apart from those surgical proci-d tires which have,
in recent years, been appHinl to certain forms of this
affection. It is a diseasi' of frequent occurrence, for
cancer affects the stomach more often than any other
organ, and its frequency is said to be steadily in-
creasing.*
Although cancer of the stomach is an incurable
malady, we have had reason to believe that the
rapidity of its course, in some of its fomi.s, may be
considerably modititHl by appropriate medical treat-
ment, and the comfort and strength of the patient
maintained even fur many years.
As the cnnses of cancer, and the conditions
that give rise to its development, are, at present, but
little known, no causal indications for treatment can
be formulated. The attainment of a certain age
* Eiuhoru : " Diseaies o(ti>e Sioiniich " (second edition), p. 249.
Ch»p.iv.i Ca/tcer of the Stomach.
85
seeiDS to bo one of the conditions of its occurrence,
can«<r of the stomach being especially a disease of
middle and advanced life. It is mrely encountered
in persons under thirty years of age, it is most
common Ijetweeii forty and sixty ; but a goodly
number of cases occur between thirty and forty, and
after sixty.
It is widely believed that chronic gastric ulcer is
m predisposing factor, and many cases have been
observed in which cancer formation was found to
have developed on the rim or scar of a ga«tric ulcer.
The opinion that cancer is of (rarositic origin w a
popular one, although it cannot be said to lx>, as yet,
estalilished.
The seat of cancer of the stomach is, in the great
majority, viz., in four-fifths of the cases, limite<l to
that coiuj)aratively i^mall portion of the stomach cou-
taining'ita two orifices — the cardia and the pylorus —
and the intermediate lesser curvature. The fundus
is very rarely affected, in not more than 1 \ j)cr cent,
of all the cases. The pylorus, or its immediate
neighbourhood, is the part most freijuently attacked ;
three-fifths of the cases of gastric cancer are seated at
the pylorus, and it is in this proportion, of all cases of
cancer, that the morbid conditions we have to treat
are those resulting from pyloric obstruction.
Gastric cancer is aliiioHl. always primary.
Cancer, located at the cjiitliac or jiyloric orifices,
naturally gives rise to mechanical ditticulties cither in
the entrance of food into the .stomach or in its escape
from it, and to the symptoms and morbid manifestA-
tions dependent theriHin. Cancer not involving either
nf t.he.se situations, and not iiitcrfering with the
entrance or exit of the food, nuiy long e.xist without
giving rise to any characteristic symptoms, and
may even remain undetected throughout it« whole
course.
It i.^ important to bear in mind, especially in
eatimnting the probable residt of surgical operation,
that gastric cancer is often attended by secondary
Medical Treatment.
(Part I.
caiiceiouH deposits in other organs, Hiid most fre-
qacnlly in the liver.
The syiiiploniR of cancer of tlie stomach are not
aiwjij^s cleurly liiagiiustic, inaHiniieli ;is many of them
aie common iilso to cases of chronic gastric catarrh
with dilatiition fiom other causes, and to cases of
chronic ulcer. Tlie losa of appetite, the pain after
taking food, the flatulence and djspepsiii, the vomiting,
the sour eructation.s, the progressive emaciation, tlie
occurrence of hiemateniesis, the constipation, the
presence of hlood in the stools, the t«'iidenies8 in the
epigastric region, and the signs of dilatation of the
stomach may all exist without the exi.steiice of cancer;
and it is on this account tliiit it liu.s liecn thought im-
pos-sihlc to diagnose, with accuracy, the [uv.sence of
t-ancer of the .stimiach, unless there are clear signs of
a tumour in the epigastrium.
There are, liowever, certain appearances which,
taken collectively, jKjint strongly to the existence of
cancer, although neither of them alone may ho
aljsolulely diagnostic. One of these is the jicculiai-
colour of the comph-xion, wliicli is associated with the
progressive emaciation — that aspect which has l)een
termed "earthy," or "waxy," or " fawn-jellow," or
" dirty-yellow, cachectic colour," none of the teims
expressing very well the peculiar type of complexion
which so commonly accompanies nmlignant visceral
disease, but which is readily recognised by the
experienced eye.
The loss of appetite is usually much more complete
and persistent in cancer than in chronic ulcer or
chronic cabirrh.
The jiaiii of cancer is often idmost contiuuous,
and not mei-ely excited by the presence of food, its in
simple ulcer, and when it is dependent ou the
presence of food it usually apjK'ui's not immediately
after taking food, as in ulcer, but wlien digestion is
more advanced ; this is es])«cially the cose in pyloric
cancer.
The x!onti(ing usually occurs a longer time after
Chip. I V.I Caxcek of the SrotiACH,
87
biking food than in gustric ulcer, ami in caMea ul'
cancerous obstruction of the pylorus it inuy not come
on until some hours after tlie recoptiou of foot!, and
may be extreniuly copioun from tlio coexistence of
greiit dilatation of tlic Ktoiiiacli. When the uirdiac
orifice is the seat of cancer there is usually some
ilysphagm, and the food i.s rogurgitjited nither tiiun
vomited almost imnie<liate1y after it is taken, un-
channcd, or simply mixed with mucus. Whenever
we find this persistent regurgitation of food, with
signs of atrophy of the stomach, such as sinking in of
the epigiistrium, iiiul .a difficulty or inability to pass
the (esophageal bougie, together with the presence of
a cachectic asppct, the existence of cancer of the
cardiac orifice of the stomocli is pretty certain.
" Coflee-grounils" vomit, or vomited matters
coloured blackish-brown, from the presence of blood
oozing from the ulcenite<l surface of the cancemus
nia-ss, and altered by contact with acid gastric secre-
tion8,is observed in many ea.ses uf 5ome«"hat ndvancetl
g.Hstric cancer. Coi'iow) lueinorrhage is far more
common in chronic ulcer thiiii in cancer. The pre.seneti
of lilood in the stools (ma-lena) is otUm observed in
gastric cancer, when there may be no blood in the
matters vomited, or when vomiting is ab.nent.
Uccasionally cancerous piirticles may Ixi found in
the vomited matters ; we have recoixled such a case
in which the diagnosis was otherwise doubtful.*
The eiiiaciatiun and aiurmin in cancer are usually
more marked, more unint.crrupted and progres-sive,
and more distinctly cachectic than in chronic ulcer or
chronic gastric catarrh.
The occurrence of fever has Ijeen .several times
noted in the most a<lvanced stage of this disease, and
is of evil import. The rise of temjwrature is not
usually very high, and it has been observed, in some
rare casejs, to Ix- perioilical, and to resemble a malarial
pyrexia. It may be accounted for either by the
occurrence of an iiillaMimatxDry process in the vicinity
• LiiHctl, J»iiu».ry 21)lh, IHTll.
88
Medical Treatment.
(Part 1.
of the growtli, or, more fominoiily, by the alisorption
of toxins from its uloeratetl Hurfaco.
It liiis been statt'il thiit tho absence of fr<?e
hydrochloric acid in the gastric juice is characteristic
of (liiiilation of tiie stomach due to cancer, and that
this gastric juice lias a very feeble digestive p>wer
for albuminous substances. Although the absence of
fret! hydrochloric acid in tho gastric juico may be
discovered in other diseiusea Ix'sidcs cancer, tliere
seems to be little doubt that its invariabh prmenre
is strong evidence against the existence of cancer.*
It lias also b?en asserte<l that the presence of
laelic acid developed in the stomach is diagnostic of
cancer, but this has l»een controverted by others, al-
though it is generally ajhiiitted th:\t the presence of
lactic acid and the absent'c of free hydrochloric acid
help to establish a correct diagnosis. Mii.x Einhornf
states, "Among the cttses of gustric cancer that I have
seen during tlie last few years, I knew of six in which
free hydrochloric aciii was present, either in normal
or in greater quantities "' ; and he adds, " this synip
torn loses still more importance if we consider that
absence of free hydrochloric acid is associated with
many other conditions besides cancel-," such ns .severe
gastric catarrh uin! atrophy of tin- stonmcli. Osier,}
in the HI cases he analysed, foiniil free hj'drtichloric
acid alisent in VI 2 per cent.
CoimlijMUioii, which is usually very obstinate,'
and is probably due to the small amount of food
digested and passing out of the stomach, is a symptom
which has to I* considered in the treatment of the.se
oases. The occasional occurrence of diarrlitea is not,
* Ewnid auyt : "In the lurge majority of cases of cunnnomnof
the «toiiinch thnre in no free hydrochloric acid. This is, however,
not cjinsiil by tho mystic iiilluencc of tho cnrciuonm on tlie produc-
tion of hydr'M'hIoric iicid, hut simply by the accom|uiiiyint(
0it'iiT)itl iiiUamiimtioii or atrophic conditi'jii of the mucousmem.
hraiie of the stomicti. ShotiM these conditions be absent, then
there will be a copioiu secretion of hydrochloric acid (" Dueose*
of Stomach," vol. ii., p. H!)7\
t "Piteascs of Stomach " (socoml edition), p. 27S.
X " Cancer of Stomiu'h," p. 42.
rh»p. IV.) Cancer of the Stomach,
89
liwwever, uticommoii. Tliis iimy Ix? due to tlu> irri-
tation of undigested food, or to the existence of
intebtinnl catnrrh, excit«d hy decomposing matters
proceeding from the ulcenit«tl surface.
The cai-efnl analysis of each case as it conica before
US, esfiecially with reference to the symptoms enumer-
ated, will usually enahle us to arrive at a. coiTect
diajpiosis ;* but the continuation alVoitled by the
prewence of a painful tumour in the situation of the
cardiac or pyloric orifice would be desinvble before
operative surgical procedures would be justitied.
After these preliminary considerations \\>- niny
now proceed to consider the indications for irmlmrul
in cnses of gastric cancer. The first of these is 11
imitablr tffjvlntion of diet. Tn arranging the diet of
a patient with cancer of the st^ mutch we must endeavour
to supjily ais much nutriment us will ade(juately meet
the demands of tlie Ixnly so as to dieck the [irogn-wiive
emacintion, and at the same time reduce to a niinimliin
the Work of gtistric digestion, and the pain and distre.s.s
cunmcted with it. The foo<l we give should either lie
easily almoibable by the ve.s.sel8 of the stomni'li itself,
mid cause little or no irritation by its jireseiice there,
or it should pass readily out of the stomach and
Ik- absorlied lower down in the alinienlar)' canal.
We must not, however, underestimnfc the digestive
.pacify of the stomach itself in nil patients witli gastiii-
rcinoma, for in some it is very considerable, <"«i>e-
cially in cases of slowly jirogressing wirrhus pylorus,
where the grt«at«"r part of the gastric mucous mumbnine
I^taiiis its functional activity. We have known such
CAses in which a fair amount of solid animal food was
taken and digested, for many yeai-5, with oidy occaj-ionn!
attacks of severe dyspepsia An imfMirtant j>oint to
keep in view in the feeding of canes of cnncerouK
* OiJer }K)iut8 out that & o^rtAiii tiiinilH-r f4 r.i-M^-9 of r-.'tn-inonui
of tiie stooacb iu tliuir ofieot nii'l coiii>«- r<-«< itit<lf /uuitnuut
nmrniur, niirl tliat n blnod count twluw l.iiOil.iMN) nil MoihI mr-
putcle* ifi strongly in favour of ii^miciottH nn.-i'itii.-i. M*'^iiliilil(i«t«
rarely, af tvcr, occur iu cuicvi of lUf itouiaeh ;" Cancer of tlio
Stomooh," p. I'M).
Medic A l Tr ea tment.
I Part 1.
stricture of tlie pylorus is to give sucli food as ciiii Ijc
digested and alworixMl in the stomach — or prcdigested
rtiiid food — so that it niij not have to puss in any
ijiittiitity tlirouj;!) thi" narrow pyloric outlet (or set up
any iiritiilion there), in oriier to lio digeKt<.-d lower
down. Thf stiirehy, farinaiitHjUH fonds should ihtTe-
fore lie avoided iiidess predigestcd, for they cwunot he
digested in the stomach, and we know there exists
an obstruction to their passing out of tlrnt organ, and
the iiftsult Ls that they are retained there, where they
give rise to the development of lactic and hutyric
acids, and coiiser|uently to the occurrence of much
piiiii, with tmublesoiiie niiu«ea and vomiting. When
farinaceous tViocls aiv found to give rise to pain,
gastric distension, and vomiting, they .sliould V»u
supi>re3sed, and the diet restricted alwolutely to
concentrat-ed meat soUilio>t» and foods llial can be
aboorbfd in (hi; ntuinarJi ; or, on account of their
perfect fluidity, pass easily into the small intestine.
If the cancerous growth do«s not involve the pylorus
there is not the same oljjection to the carbo-hydrates,
IxMaiUse there is not then the same risk of their
retention and acid decomposition in the stouiach.
In cancer of the slonmcli the foo<l genemlly speaking
sliould he (luid and concentrated, so as to he of small
bulk. Milk, when well borne, is excellent in small
(juantities at a time. It is desirable to dihite it
slightly with some alkaline water, anil the addition
of a little .salt to boded milk makes it more paliitJilile.
When ordinary fn-sh milk disagrees, peptoiiisod milk
may be substitutetl for it.
In hannorrhagic cases it may be necessary for a
time to feed the |>atient entirely by means of nutrient
enemata so as t-o kee[) the stomach a1)soIutely at I'est ;
and indeed, in non-ha.-morrliagic cases, it is a good
expedient from time to time to feed the patient for u
few days pur rectum, so as to give the stomach periods
of entire rest. Some pi-efer small enemata of 3 or 4
drains of beef })eptonc8 mixed with 2 or 3 ouni-es of
wanu water. Tin; late Dr. Gi-eix Smith advocated a
•p. iv.i C'tycex OF the Stomach.
9«
lai-ger i)uaiitity, for, as lie rightly olw-Tved, ii cerUiiii
amount of water is e.ssential to nutrition, nucl he
prescriljed an egg bi-aten up with 10 ouno-K of milk
and 2 or 3 t«l>lespooufuls of [leptonised meat jelly,
with or without brandy, to be passed into the Ijowei
very slowly ever}' five or six hours, when it will be
I retiiined without ditficully. Peptunised milk may
also be used. The injection once or twice daily of ii
pint of tepid water into the liirge intestine, as advised
by Dr. CJreig Smith, we also think a wise expe<lient.
Professor Bauer corroborates our own view of the
desirability in carcinoma of the stomaoh of giviiij;
"itnimai, iiighly-nlliuminoiis foods, us milk, eggs, and
tender tneat, and meat juice*, in preference to those
which, from the large amount of hydro-carlx)ii they
(Hintiiin, are easily prone to abnormal and acid
fernientjition."
Ill tlieiie cases a ceilain amount of choice may lie
afl'orded tiie patient, who has often learnt by observa-
tion the particular kind of <liet that Muita him best.
Hut it should always be in muM quanHitij ut a time ;
on this point few patients can be left with safety to
their own inclinations.
In a few cases a dry diet has boen found to agree
better than a fluid one. Much, no doubt, <le[K-nds on
the seat of the disease and the secondary change-s,
such as dilatation, etc, to which it has given rise, so
that esicli individual case mii.st be studied carefully as
t<j the facility with which different articles of fo<Hi can
be digextcd. In cancer of the cnrdioi- oritice we are
riwtricted to Huid food, as solid food would tjc arresteil,
and would accumulate in the icsophagus and cause
dilatation. If the stricture of the cardiac oritice is
considerable it may Ije advi»iblo to introduce a
stomach tube through the stricture and in this way
inti-oduce food into that organ ; or nutrient cnemata
of peptonLsed fofxls may be given, such as the /mnrreti:!
antl meat eneuiata, already referred to.
Besides appropriate dieting, tiie ti
reai
Medic At. Treatment.
IPartL
of gastric carcinoma involves the utili.sation of such
nicnns as are at our disjinsnl— (a) for tlie arrest cf
tfie iilmoinial clwuinfmsition nrnl ftTiiiontution of tbe
foo<l retained in the stonnirh : (b) for the relief of
pain, acidity, inul vomiting; ('•) for the arrest of
hjinnoi rhage ; (c/) for tlie regulation of the bowels.
Finally, in certain cases the adoption of surgical
meaRurcH to remove the diseased ]>arf may lie fea«il)le.
AVhen the cancer is wtuiiteii at the ])yloru8, and
there is considenil lie dilalation of the stomach, very
good rcsidts have hecn nlitained hy washing out the
stomach by means of the syjihon tiibe,* or stouiach
pnmp, as recommejided by Kussmanl. The mucous
nuiiibrane is cleansed by this process, and the acid,
irritiiting matters resulting from the ytrolonj{ed iii'ten-
tion of food in thestoriinch are rcmnved. TIh> feelings
of distension and heartburn are relieved, and the ten-
dency to ha'tnoirhiige dimiiiisiied. Const ifmtioii is
nlso frequently removed by tliis process, probably by
improving the geneml tone and facilitating the passage
of food along the intestinal canal. It is unsuitable
in cases of great debility or when ha-inorrhage is
actually talcing place.
Charcoal in 10- to 20grain doses, three or four
times a day, has been found to relieve tlie flatulence
and acidity suffered from in these cases ; or a powder
composed of e<iual parts of charcoal, subnitrate of
bismuth, and curbonat*.' of magne.sia lins b»>en used for
the same purpose. Ewald, however, condemns the
use of charcoal as " irrational," and we are inclined
to think its value has been overestimated.
We have found the greatest benctit fmm tin- use
of creosote or thyinoL together with a suitable diet,
in cases of cancer of tlie pylorus ; the tendency to
flatulent decomposition of food in the stomach being
often completely avertetl. A minim of creasote in a
capsule may be given thrice daily immediately after
taking footl, or a grain of thymol, made into a pill
witli powdered soap and a little spirit, may be used
* Vtilf chapter on Dihitation n{ Stomach, p. 102.
rK»p. IV I Caxcek of the Stomach.
93
inst«ad, especially when the palipat o)>ject9 to tb«
udoiirof creasote. We have often seen xui-h <>xeelkfiA
L, results in cases of scirrhiis pjlonts fruni tli« pM»
vering use of creosote that we ha\e Ix^n led to ihiikk
it must exercise a retarding effect on tbe growtii lif
the cancer. lifsorcin is preferred bjr sone^ and
bismuth salicylate hy others.
The risks of morbid fermentation will alao btt
diminished and digestion profnot*<d l>y givini^ 10 or
15 grains of pepsin, with 10 tu 20 minims of dilate
hydrochloric ociil, aftpr each meal coatahiing «lb«-
minous food. This will supply the MUAeaey at hj4r»'
chloric acid and of digestive aotivitr in tb* ^Mtrii
juice of such |wtient8, and eii*i>l<* theMi to digaft
small ijaantities of pounded neat, eggt, fiak. He,
Tu relieve t)ie pain of gastric eaooer it will eittm
be necessary to give opiuoi ; bat when the pain is
associat«d with, and depoadnit apon, aiciditj ol llw
oont«iit« of the stowacli, the admtniatfliea «( «■
alkaline carbonate will frequently effect tlua obpet
withont the need of liaring rccoarae to the pwyim-
lioiu of opium. ISoth pain and voaubBx nay oft«a
be relieved by the following eonliUMtiaii -. —
1^ Sodii bicarbon itia
Marnecii rarUxuili*
AcMi hyincymaid ditaii
Aqiur mrtki
, fiat hanstiw. Ite be
ft. i».
il
Serrre attacks of pais will,
use of opiniii. A great oimttian to ita mm ia
checking the li«{i*tic aod iatmlinl
diminiakiog pemubia, it agiciaTafaa tim
and reoKyvea erea the little affieiite tie
have. Ita etaployoMBt ahoald Ue iWiwied i
poaxible. Moqihine, gi««a hjfodttwmaBf
bitied with atropine, ia, niifh«|i^ the b«it i
administering it ; | gnua of «dffcal« «i
and yj, RTftin of
quantity n ait be
•ttofiae wjD mmmBj
■ u
94
Medical Treatment.
(Pan I.
(loses of ^ or i |^in, is a good sul>stitute for opium.
Anotlier Kuitoblc iiiwIp nf iitlininistcring opium is to
combine it witli clieny-liuucl water, a8 in the
following : —
"Sj Liquoris opii scdativi nir.
Aqurt? lauroocrftfi nixxx.
Aqiin? chlorofomii ... ... ad jj.
Miace, fiat haustus. To lie given wlien the pain in severe.
Tf vomilmg is persistent and unrpiieved by lij'dro-
cyaiiic acid, or this conihined with opium, oxahitt? of
cerium will sometime.s succeed in arresting it. One
or two grains mixed w ith u few grains of sugar of milk
may be given every thi'ce or four hours.
Or hydrocliloriile of cocaine may l)e given —
^7 Cocainn> hydrtK'hloridi gr. ij.
J^<lUln liiuroccraci 5j.
Aqiiii' do!>tilliita' .. ... ... ud ^iv.
Misce, list tnietura. A tublcfipoonrul evrry hour until reliered.
Iced water or effervescing soda water or iced milk
may be at the same time t^iken in siiuill ipiantity, or
fragments of ice may be sucked. Cold compresses to
the epigastrium have been found useful. When the
patient does not itbjnct to washing out the stomach
this nieiisure will contiilmte to tiie relief both of pain
and vomiting.
'1 he occunvnce of serious kctviorrhaye will require
the same nio<le of treatment aa that described for
ha-morrhage from simple ulcer.
The constipation accompanying gastric cancer is
best relieved by enemata, and these by uidoading the
intestine often greatly relieve the MilTering caused by
flatulent distension. Jn some cases a grain or two of
watery extract of alws, with two of soap, in a pill,
daily, at be<ltime, is well tolerated ; or half a dnun or
a dram of the aromatic syrup of cascara sagrada.
Cajuput oil hiis been recommended for the relief
of flatulence. It may Ije given in cajisides, cr it may
be dropped on a small lump of sugar and swallowed.
Chap. IV.l CaXCBK OF THE StOMACH.
95
Wljen the more urgent dyspeptic symptoms have
been relievod, anil the patient is enabled to take and
dige.st a sutliciency of suitahlp food, the anit'inia :»ud
deliiiity which are always present in these case*
indicate the use of tonic remedies. We tinvo found
the following combindtion answer well:^
Vf Ferri I't nnimonii dtratig gr. v.
Liiouoris bisiniithi ct aiimionii cilratii... n\.xx.
Scxlii bicnilRitiftti* gr. x.
Infiisi cnliiiiibn' ... ... nJ jj.
Misue. fiiit liAUStus. 'I'o tx/ Uik«n lhi'«o timet fk,diiy, itn hour
Or the following : —
I^ Feiri •■' ■"■t,,,, .. citnitii
.\cnli I ,; 1 loi diluli
gr. V.
nvv.
Uisoe. tkt hauaiiig. To be taken an hour oftrr (uckT, ttirioe dnil}*.
Conduranyo bark was introduced by Friedreich aa
a remedy for caticcr of the stonuich, and recently it«
use and etticiicy have again been testifietl to in the
treatment of this disease. The most remarkable
effect.** have been ascribed to its nst^ ; 30 ;{riiins uf the
|:iowi|er may be jjiven four or live times a day, or »
decoction may \>c used. It has lieen said ly sonie
that it lia.H always given ndief, the pain has dinap-
pearcd, the digestion has improved, and the tumour
has either censed to increase in size or has disappean-d
entirely. But it has not given such brilliant results
JW these in the experience of the majority of those
who have tried it. It has, however, Ijeen estaVdished
by experimental tents that it dues increa.se the digi-stive
secretions, the gastric juice, the bile, and the pancreatic
juice especially the two latter ; and that it may in
this way do good in chronic disease of the stfimnch.
(Jerhardt has found it useful in the treatment of old
Btric ulcer, and in cancer it has improved app«*tite
id lesseueil pain and ciitarrli.
Max Einhnrti also states that he gives it in tha
greater numl>er of cases of cancer of the stomnch.
96
Medical Treatment,
(Pan I.
Reiss has made elubontte investigations into the
effects of ron<luriiri£;o in j^ustric cancer, and he con-
cludes that nil iiuprfjuiliced observer, after wiitcliinj; »
large nunilifrof ca»*es, would be of opinion that life is
greatly piolonjied by a course of treatment with it.
Ewahl also states that he has repeattnlly observed the
good effect of this drug on the general symptoms of
cancer of the stoiiwu>h, and he considers the obser-
vation of lleiss most iaiportnnt, and that his advice
to give large i|uantitie.s of this remedy should be
followed.*
Soiliuni iodidr has l>een given by Boas in a case
of lesophiigeal cancer for more than six months ('10
to 45 grains a <la3'), and the patient gained weight
and reiiinincd free from .symptoms the whole time.
Kinhorn has also noted " transient goo<l results" fi"oin
this drug in several cnses of cardiati stenosis. The
latter authority also mentions arsenic (3 minims of
Fowler's solution tlirice daily) as sometimes attended
with benefit.
Methyl-blue {I'yiiklaiiiti) has been given in
cases of gastric carcinoma by Max Einhorn, and he
states with beneficial effects. In three ca-ses out of
eight in which he atlministei-ed it he noticed "a great
improvement of most of the morbid phenomena," and
in one he thought the gastric tumour became some-
what smaller after three weeks' use of this drug.
This patient took it for eight or nine months regularly,
and was all the time free from pain and did not
lose flesh. But the improvement was not maintained.
He gives two or three grains in gelatine capsules once
or twice daily.
Ewald and Einhorn both speak highly of a 3 per
cent, solution of chloral hydrate, a tablespoonful
every two or three hour.i, for the alleviation of the
discomforts causeil when ulceration is in progress or
decomposition of food is taking place.
The surgical operative procedures usually prop
for the relief of gastric cancer are tho following : —
* " UuwuM of the Stomach," vol. ii., {i. 4ty.
•^ IV. 1
Ca.\C£K of the Stomach.
97
1. OnstroojIoHt)'. — TbU operution may Ije re
sorted to in cases where the cardiac oritice of the
stoniocli is constricted by a cancerous growth, espe-
cially in cases of annular stricture ; it is less applic-
alile ill cases where the new growth is extensive and
iuvuhes anv considerable jwrtion of (.he anterior wall
and greater curvature — nor in any ca.se is it likely
tu do more than prolong life for a short time. The
operation is usually perfornn-il in two sUiges, and the
stomach is not opened until lulhesiuns have been
etttabliithed between the wall of the stomach and that
of the alxlonieiL But when the urgency fnr adMiinis-
t«ring food is very great, it is ensy to give some con-
centrated tluid food in small quantities before the
8t<jmuch is opened, by means of a larger kind of
hyjiodermic syringe with a long needle — n syringe
cttpable of holding half an ounce or an ounce, wliicli
can Ije repeatedly refilled while the needle remains in
the stomach. Mayo Kobson says of gastrostomy,
"If it be performed sufficiently early, and if it be
done acconling to the best methods, it may be
included among the most useful and Ijenelicent
erationa the surgeon is called upon to perform."
With regard to the Nub«)ei|uiMit introduction of
mI into the stomach, it has been suggested that
"solid foo<l may first Ix" subjected to thorough
inasticjition and insiilivation, and then transferred by
the jiationt from the month to n small funnel con-
nected with the distal end of the catheter, where it i.s
made to enter the stomach by blowing it through the
tuln*, or it may l>e aspirated Ijy the patient's sudden
respiratory eflbrtti. ^lasticatiou of foo<l om a pre-
liminary step to its introduction into the stomach,
s&tisfieti, at lejist in |mrt, the sense of hunger."
2. Pjrlorerlomx, or resection of the pylorus, an
operation which is, of course, designe<l for the relief
of malignant stricture of the pyloru.^. It consists
in the removal of the pylorus and as much of the
adjacent portions of the stomach and diioflpnuni an
may he involved ; the divided walls of tlie stomach
98
Medical TREATHEifT.
\V»n I.
and the Iwwol are hronglit to^j^ther iiiul iiiiiti-il Ijy
sutures. Another metlioil, now fretjuently lulopted,
is " to close completely both the stonmcli and
(luoilenal openings, eitlier hy a purse-strinj; suture
or liy a double row of stitclies, and tiien tr) connect
tlie iKjwel t»> the stoniiicli, making either a giistro-
duwk'nostomy or a gastro-jejvinostomy.'"* Professor
Kocher prefers this o|)errition, whicli hiis heen very
Kuccessful in his Imnds.
The objections niiide to |iyh)rectoniy are — (n\ tliat
it is itself a very fatal openitii>u ; (A) thiit there
is a giciit tendency to early (Jitriisiou of malignant
disease when situated within th».^ peritoneal cavity,
and there is little chunce of corn[dete removal of the
cancerous deposits ; (<•) the tendency of the growth to
tlie contraction of tirm iidhesions to surrounding
part* ; [d) th<' great length of time reipiired for the
operation; and (<•) the riHk of speedy recurrence. In
opposition to these objections it has Iwen urged that
the operation is usually t<io long postponeii, and that
when performed early innch better results are obtained.
In ."i72 cases colleclod by Mr. Mayo Robson the
mortality was oidy .'50I per cent., whereas in some
previously jmldished statistics it was an high as 7<)
per cent.jt hut it must be renyei(d)eied that in earlier
stages thei'e may be consideralde uncertainty in
diagnosis, and that many cases of scirrhiis disease
of the pylorus tend, with suitable fewling and
medicinal treatment, to run a very ]irolonged course,
and live for many years in tolerable comfort.
.'1. <iiiiKlru-eiifi-roNlt>ni]', that is, the cstablish-
inant of a permanent fistulous opening between the
vtoiuitch and some part of the small intestine, usually
the ujijier part of the jejtinnm.
A considerable number of such operations have
now been successfully peTfornufI, and the statistics of
the more recent operations are far more favourable
* Mmyo Itobaon, " Hnnterinu Lectures on the Surgery of tba
Stomut'h."
•|- Treves' *'Oi>erativo Surgery," vol, ii., ji. 436.
M
Cascek op the Stomach.
99
than tlioiie formerly reported, a result, no doubt, due
to the circumstance that operative proceedings an*
uon- had recourse to much earlier than used to ba
the ca*p.
In thin operation it is, of course, extremely im-
|iortunt to make the communication between the
Ktomach and the upper part of the jejunum as near the
pylorus as possible. Cases have lieen examined po$l
mnrtrm in which the juncture wna found to Iiave been
nrnde but a short distance from the ileo-ca-cal valve !
This ofieration affbnis, perhaps, the l>est chance of
successful |>alliMtiou in cases of malignant stricture of
the pylorus, when the sufferings of the patient are
ur::eTit and the failure in nutrition is rapidly pro-
gres-iing.
4. JeJiiiioMomy. -When owing to the situatiun
of the carciiKHiiatoiis growth it is not practicAblo to
make any operation upon the stomach itself, life ha?
pruUibly been prolonged by making a fistuloua openin;i(
into the jejunum and introducing foo<l through this
channel.
5. TolHi or ixiriini iciiHirtM-loiny.— The bold
operation of i-etiioviiig the entire stomach for cancer
was successfully |H'rforiiied by .Schlatter, of Zurich, in
lHli7, and this o|x'ration has been repeated by sevenil
American surgeons since, and in a few instances with
, miccess. Schlatter's on.se survived the operation
fourt«'en months.
Partial gastreotoiny for giustric cancer has l>e«.'n
re|>ealt><lly |K'rfonneil. I...ingenl>ach in liSSJ exci8»,'<l
-aeven-cighlhB of the stomach and sutured the pylorus
to the small cardiac portion of stomach remuiuing,
and the patient made a good recovery.
The progress of gastric surgery hoa certainly
Ijeen most remarkable iin<l rapid of late yc«iti ; but
to ensure satisfactory results in caM.<8 of malignant
disease it is most e^^sential that surgical aid shonUl lx>
sought for early ; and when the dingnosit !•« doubtful,
but the Bytnptonis urjji'ul, iin f.xploiutory lu|iiiri>tomy
should \jc advised.
Too
Medical The a tmejvt.
[Part I.
I^ret-a's operation for the forciblu divulsion with
the fingers, after gristrostoiny, of a stricturt' of the
caniiac or pyloric oriHcu of the stomach, is only appli-
cable to nou inaligna.nt cast's, and tlit'u the opera-
tion of pyloroplasty is generally preferred.
AlUnriONAL FORMUL.«.
Mixture In gastric alc«r.
R Biemufhi carbouatia, jij.
Acidi lij'Jrocvatiici diluti, jj.
Li<(Uonn mornhimD hydro -
chloridi, >j.
Muoila|j:iiiin. 5vj.
A<jU[t* cliloroformi ad Jij.
M. f. mist A teomxKiuful
eTery Ihiw hnurs. ( li'/iitlu. )
In convalescence ft^m
gastric ulcer.
ft SjTupi uiiraiitii eortids, sv-
I>iM»cti condiinuigo (I to!)),
ad jvj.
M. f. mist. A tablespoouful
three titnei«aduy. {/tfitnWiyn-.)
Mixture In gastric ulcer.
ft Bismuthi carbonatis, .^ij.
Sodii bicarbotiatis, sj.
Tinftiinr bollodounip, .^j.
lufiisi ^eutittJiii' ad ,',vj.
M. f. mist. Two tahlcapoon-
fuU three times a day. ('Jrd.)
In gastric ulcer with
tuematemesls.
K Plumbi iK'otrtti"*, pr. iij.
Morphiuo; hydruchloridi,
gr. jim.
Socchari albi, Sj.
M. et divide in ]iulv. x. A
powder every two faouTB.
(Biinilinyei:)
Or
ft Acidi tauuici, gr. xii.
Opii palTeria, gr, jss sd ij.
Sacchari albl, .^j
M. et divide in pulv. vj. A
powder every two hnum.
(Adm/w lyr r. )
In gastric ulcer irltli flatu-
lent dyspepsia.
B Potn&vii iodidi, gr. vj,
Putatisii bJcarbountiit, .^jss.
Tujctiine niirautii, .^iii.
Lnfnif] (vilumba? ad .^vj,
M. f . mint. Two tiblespoon-
fuls au hour after food.
{BriHlOH.)
Kesorcln and condurangpo for
gastric cancer.
ft Resorcin puri, gr. xxx.
Tinetune rhei, .IJM.
Synipi iiunintii, .^v.
lieeoeti coudurungo (1 in 12)
ad 5vj.
M. f. mist. One tableiipoou-
(ul every two hours.
{11. .V. ;«•*<•.)
Condurango Mixture for
gastric cancer.
ft Coudaniugo corticis, gr. cL
Aiiuee, S>>j.
Boil for teu minutes, and add
Syrupi, .^v.
A'|ua< ad Jvj.
M. f mint. A tablespoonful
every hour or two. (Itriiw.)
As an antiseptic in gastric
carcinoma.
ft Sodii aulphitia. Sua ad Sj.
Infusi ijuiLwin', jjss.
M f. hiiiist. To be taken
three times a day, ^Jtnntr.)
Chap. tV.I
Additional Fokmut.-k.
lot
Alkaline and rhubarb pow-
der for traatrio ulcer.
tl Smlii bicarbonatis, sij.
r-ttiissii liicttrhonatin. 3ij.
I'lilvfris rndiriii rhci, yvt.
Siirrhari Urtia, Sj.
M. t. )>u1t. Aa much u will
gn nil Die ond of a kuife to be
taken dry pverj- hour. (EirnU.)
Tonic in gaitrlc cancer.
R Extnu-'K ooniluraugo, ;xii.
Str^rhninee lulphatu, g. |.
Aculi hydrochloric! diluti,
siii.
Elixir Ketitiono! ad Jnii
M. f. mist. A tablenmon-
ful. in n wiiieglon of water, to
be titken through a tube nfler
nienlit, {Htmtiuirr .)
102
CHAPTER V.
DISEASES OF IPE STOMArn — TIIF. TnEATMEXT OF DILA-
TATION OF THE STOMACH, OK (i ASTRO ECTASIS.
Dll^TATlON OF THB Stohacii- Causes — Svmptomti — Vomitiiig
— Phjsical Examiuation — Indifatioiu for Treatmont— Dietetic
Heuurec — Model Dietary — Emetics — Purgatiyes - Carlabad
Water — Tonics— Electricity — Massage— An tisejilics — Lavage
— Hyilrolhorajiy— The Storaacli Syphon ami Pump — Surreal
Treatment— Pvloropliuitv — Ooatru-plii'ation— Lurge Doses of
niivp I )il.
Dilntalion or the Momncli is u necessary con-
sequence of Htricture or olwtruction at tlio pylorus,
malignant or nonuiiitigjiant, arisinf; in tlie walls of
the striiiiach iUsflf or external tr» it, and the trentinent
of this condition has been incidentally referred to
in discussing the management of cases of gastric
cancer.
But thei-e are other causes of gastric dilatation,
and it is to the«e we nnist, in the lirst place, refer.
The iiabitual consumption of excessive quantities
of food or drink is ealcuJated to lend, in course of
time, to dilatation of the stomach, by repeated al)-
norinal distension of that organ, so that it is common
in habitual beer drinkers. Dilatation roiiy also
orif,nimte in an eiifeeblement of the muscular coat
iif the stomach, brought on by debilitating diseases,
such a.s chlorosis and atuemia, tuberculosis, typhoid
and other fevers. Ailhesion of the stomach to nn
adjacent organ, a-s, for instiiuce, from the local peri-
tonitis set up liy a perforating ulcer, may also cause
dilatation by interfering with its muscular movements.
Hroiulbent suggests that it is sometimes due to nn
aiiatomii-al peculiarity which hinders the expulsion
of the products of digestion : "The pylorus is sus-
pended high up in the epigastrium by a short lesser
omentum. ... If the stotnach is distended and
oveploade<l it is dragged down by tlie weight of its
Chap. V.I Dilatation op the Stomach.
103
contents, und an acut« flexure is formed lit ibe
junction of the duodenum and pyloruji, which con-
stilntes an obstacle to the |)a.ssage of the chvme."*
Bennett argues thut " extreme dilaUition " niav be
si.iDietiuies due to " sfiasin of the pyloric sphincttr ; "t
nnd several authorities have called atieiitioo to the
fact that a inovjible right kidney may be the caa«e of
intermittent Kastric dilatation.
Mayo Rolison also points out that, in some caae^ of
pall slones, adhesions set up lietween th«? pylorus and
the ;d;HlI -bladder and lirer may give rise to dilatation
of the stomach.
Chronic gastric catarrh is a common cjus** of
dilatation of the stouiitch, fur nut only dues it lea<l to
iinpairmeiit of muscular contraction fn>m d«foctiv><
nutrifirjn, but as tlie secretion of gimtric juicn ix
ilefective and absorption therefore ret*nled, the f'XxJ
Ls delayed in the stotuach, abiioriiinl fenuentation Lt
set up, and flatulent distenHion, a.<i well oa accuuni
l.ited imresta, increases and aggravates tin* diUtAtion
due t-ii enfeeblemcnt of it« walls.
KfititiiiPfl ingesta, from whatever cauMe, and en-
fi«blement of the muscular wall.t of thtt >>toniacti,
however produceJ, are the essential condition* of
ga.><tric (lilatAtion ; increase of pressurn from within,
or diminishe<l resistance iu the walls of thi« stomach,
or both together.
Cases of aenif dilatation seem, in all instance*, to
be due to atony of the muscular walls, brought about
usually by exliausling illoMaea.
Many careful ol»terverB have directnl attention
to the freiqueut occurrence of gastric dilatation ic
rickety infants and young children. D illi in breast
fed and h.ind-fed infants of f»'-bli< 4iig....,tive power
this morbid xlnXv may be detecte<l — the di^uttirr
[irx-enses are ivuirded, and as the chiM is constAntly
f'iiig fed. food acciimiilntos, and is abnormally re-
riAine<l in the st^jmrvch, where it undergrKit form^nlive
cluiliges.
• Brit MrJ Joiini , Dw 2n.l, ItC.Ul. f //, ' I
I04
Mr. PICA I. Tn ea tmf.st.
IPnrl I
The coiiicidfncp of gastric dilatation with symp-
toms of nervous depression, hysteria, and hypo-
chondriasis, has prompted the suggestion that the
nervous conditions may have prece<h'd and causetl
the dihitation.
It lias hpcn poitit<><l out that an uit^cr sitiiatetl
near tlio pyliiras may caiiso sposnvoflic stricture of that
orilice, and c(mNe(|uent diliitation of tlie stomach, and
if the ulcer is heale<l the stricture and dilatation will
disappear.
The c<mse(Hiences of dilatation of the stomach,
howe\er imluced, arc the lingering of foo<l in tlmt
organ and the setting up of morhid fermentation
and the prtwhiction of toitio putrid subst-iinces, such as
poisonous ptomaines. So that not only is the general
nutrition gravely compromised, hut the ahsorption of
toxic substances tpiids to further seriously disturlt
the hPHlth of the |iiitientv
The s)'iii|iloni8 of dilatation of the stomach when
this is caused by pyloric stenosis will, of course, have
been [ueceded by those of thi- original disease. But
diliitatirm of the stonuKli, from whatever cause, is
usually attended with a group of moi-e or lens
characteristic syrajitoms, soni" of which are, however,
common to other forms of dyspepsia.
There is usually a sense of weight and fulness
about the epigastric region, aggravated by taking
food, and notunfreipiently accompanied by a constant
wejiring pain, referred mostly to a particular spot in
the e]>igastrium which is sensitive to pressure. Heart-
burn and nausea, with fou), acid eructations of fluids
and ga-se.s, the latter sometimes not only putrid but
even combustible, are complainetl of, and the )iafient's
countenance is usually thin, pale, worn, and anxious.
There ai-e also usually great general emaciation and
loss of strength.
Vomitinff, although not nn essential symptom, fre-
quently occurs, and in cases of considerable dilatation
is very characteristic. The quantity vomitwl is some-
times enormous, and it gushes out as if pumpeil n\>
Ch«p.V.| DiLATATIOK OF THE StOMACH.
105
froiu the .ttotnarh, and in ofli-n iiimlti-ndct] by tiaUHMk.
The voniiletl matters consist of turhiil, »our, IhmI-
srnelling liquid, wmposfd of t«nAcious mucus anri the
residue of hidf-dij^estfd food in » stale of fertnentive
decomposition, with sarcinii* and other low organisms ;
If it contains jiIbo dark coffec-jfround matters, thert« in
reason to fear the existence of jnloric cancer, and if
bright blood be [iresent, that of }(nstric ulcer. One of
the most characteristic points to be notieetl in the
substances vomited is the presence of portions of
undigested food taken long, it may '>e days or even
weeks, Ijefore ! The vomiting often occurs at regular
intervals of twenty-four or forty-eight hours, or even
longer. There is usually loss of npjx'titc, but occn-^
sionAlly there may lie a morbid cniviiig for foo<l,
due to the defective nbst>rption of nourishment.
DisturlinnicH of cardiac action are often com-
plained of, such as palpitations, intermittent and
irregular pulse, and rly.spnrt-a, especially on lying
down at night, iind these are due to displacement
upwai-ds of the diaphi-agm and pn>s8ure on heart und
lungs fi-om the dilated st/immch.
Coiuitijfation is a common accompaniment, con-
sequent on the imperfect emptying of the stomach.
Owing, also, to the smalt absorption of fluids, the
urine, in advanced cases, is frequently diminislu«d in
quantity. Coldness of the extremities is usual, and
ernmp» of the voluntary muscles iiave been often
ob«erve<l by Kusgmaul, and rcferrttl by him to tho
abnormiil dryness of the muscular aii<l nervous tissue*
from <leficiency of water in the blood.
Mayo Rohson * has also calletl attention to the fact
that "severe muscular tpasms of a tetanoid chanicler
. . . are frequently associated with dilatation of the
stomach." The cause he considers to he "a doublr-
one. . . First, the aljsoqition of some poison from the
dilated stomach, which increases the excitability of
the nervous system ; and, secondly, a reflex effect
produced by tlie painful contraction of the pyloruB."
• Umcrl, SUrch 24th, IW),
io6
Medical Treatment.
tPwtl.
In such eases he suggests that "surgical ti-eatutent is
well worth considering."
Pliysicnl Examnialioii of the region of the
stomach airorcis an iiiipwrtiint aid to diagnosis. In
cases of great dilatation the stomach may be seen to
bulge the ahiloniinal wall, and its outline may be
defined with distinctnes,s. The outline of the stomach
may be renilereil more distinct by di.stenfling it with
carbonic acid gas (as suggested by Frerichs), by Hint
giving 30 grains or more of bicarlionate of soda, and
then immediately afterwards 20 or more grains of
tartaric acid, e4»ch dissolved in a little water. Move
ments uf the stoiriucli, I'.speciiilly if its museuhir walls
be hypertro|»hied, may also lie sometimes seen through
'the thinned abdoininiil walls. A splanhiny noise may
often be produced on shaking the {Mitient when up-
right. Tliis would not be diagnostic of itself, as a
somewhat similar soun<l may proceed from the colon,
but it would lend weight to the signirtcance of other
syniptoms.
Percussion in the recumbent ])osition usually
reveals an extended arcji of gastric resonance, streteh-
ing upwards above the left hypuchondrium, and iJown-
words t^j or below tlui (imliiiicus; and on the erect
attitude being assumed, a band of duliiess will usually
be detected (caused by the gravitation of the tlnid
contents of the stomach) over the lower jiart of this
area. It is rarely nece.ssary to n-se Leube's stomach
sound, but when introduced its jxiint may usually be
felt below the iindiilicus, and it then indicates the
lowest level of the greater curvatui-e.
It is important in this connection to remember
that the size of the stomach varies greatly in difl'erent
individuals. Ewald pHtimates the maxinuiiii normal
capacitj' at 1,(100 c.c. (50 oz. = nearly .'! pints).
As Clifford Alibutt points out, in acute or early
cases, before the whole stomach is dragged down, it is
as important to notice the situation of the upper line
of the stomach ns that of tlic lower, which he has
found to reach ns high as " the fourth or even the
CJunV-i Dilatation of the Stomach.
107
third rib." This seems very liigh, and would in-
volve consideraVile dyspotpa and pulpitation, as the
dijiphragm would \>e pushed up to this extent, and the
Action of the heart and the expansion of the lung
much cnibHiTRsscd.
We have often found the upper limit of gastric
resonance conMidurably raiseii, but never to high M
the third rib.
Having now passed in brief review the causes and
symptoms of gastro-ecta-sis, we must, in the next
place, consider what modes of treatment ore I**!
calculated to cure or alleviate this affection.
Tlie following indirationN for ircatmpM ^rv
sufficiently clear ; the only 4uestion is how best to carry
them out : —
1 . To remove the decomiKising residue of food, and
cleanse the stoinacli.
2. To prevent putrid fermentation by ontisrpticm,
and by other means, such as careful dif-ting.
M. To im])art tone to the feeble muvulnr walU of
the stomach, to promote gastric digestion, and
to supply nourishment, if neeewgtry, in other
ways.
4, To remove constipation.
5. To have recourse to surgical meaaarm when the
dilatation is due to pyloric ob<ttractioii, oad
doe« not yield to medicinal An<l divt«tic
treatiiieut.
In advanced cases, with great and long exiating
distension, it will be difficult tn carry out thcM: indica-
tions except by the mechanical emptying and washing
out of the stomach ; but in li-ss aiKniice<l comm of
simple dilat^ition from atony of the goKtric woOa, and
not de(>endent on organic obNtniction, oth^ mntw^
medicinal and dietetic, will Miffice, if diliu -ied
out-, to effect a cure. Wlien tliere i« • , ^i«n
on the ]>art of the patient to " lavage " of the ntoiiiaeh,
and nothing in the history of the individual com* to
oontra-indicate it, it may be aiiplird in both cUmhb* of
coses ; but great reluctance to Hubmit to this treoUnrbt,
io8
Med/cai. Treatment.
I Pan I.
especially in slight coses, is often enconnteroci, and
it is necessjiry, therefore, to be ready with other
measures.
Leaving for subsequent consideration the appli-
cation (if " lavage," we will proceed to consider those
other remndic'S.
And first, witli regard to the npfossaiy dietetic
measures : it has Ijeen said that in such cases we
should order small tjuaiititios of focxi frequently : it
is certain that tho foxl should be amall in quantity,
concentrated and easy of digestion, or pre-digestetl,
but WH entiivly object to /reipienci/ of feeding.
Insucli patients the process of digestion is often
excessively slow, and even small quantities of foofl,
if given fi(V|uently, will tend to accumulate and
undergo morbid feriiientation.
The HUpply of lir|ui<ts .should he strictly limited,
and only a very small quantity allowed tu be tak<-n at
meals — not n;ore than 3 or 4 ounces ; and it is lietter,
if possible, to put off taking even this amount until
an hoitr after the meal. When there is a craving for
Huid.s it is a gooil plan Ut let the patient sip a tea-|
cupful of hot water half an hour before a meal ; we
shall thus lessen the desire to drink during the meal
And us II ecrttiin amount cif water is needed for the
physiological requirements of the IxKly, and is also
useful for cleansing the stomach, it is easy to supply
this by causing the patifiit to ilrink a small t<'acupful
of warm water or warm alkidine niineial water, such
as Vichy, V^als, or Apollinni'is, half an hour before
each meal and at Ix^-titne.
Ewald lays great stress on the need of attaining
from liquids ; he says, " I only allow a small quantity
of milk, from a tea- to a table-spoonful, taken at short
intervals." Still, aa we have already said, a certain
amount of water is a physiological necessity, and
this, therefore, should be supplied in the way and at
the times we have indicated, or, if needfid, the
requisite amount of water may be given by rectal
injections.
ciu|.. V) Dilatation of the Stomach.
109
As the food must \w in Ktnall qimntity. and there-
fore concentrated, it should be chiedy antniul. The
}«an of t«nder meat fruni which all tibrous and
jiendinous structures have Ix-en removed is the Ijest,
and when there is any uncertainty as to its due
nia.<Nticalion by the patient, it hud Ijetter be mechani-
cally rlivided by niinriitK or pounding before it ik
taken. Chicken, wliite game, tish (the more delicate
kinds), lightly-Ixiiled eggs, are also suitable forms of
animal food. Bi-eud and other starchy foods (carlio-
hydrates) must- be taken in small quantity only, as
they are prone to linger in and set up acid fermenta-
tion in the feeble, dilated stomach. All vegetable
substances that tend to produce tlatnlence must Ije
rigidly discarded. A small quantity of the most
easily-ilige.sted fresh veget-ables may be tjikeu iu the
fonn of purees. Some (jf the light furinnceou.s foods
muy also be taken in small (juantities at a lime, an
tapioca, sago, rio«, and macaroni.
It is highly desirable, however, that the animal
ltd vegetable foods should not be taken toyetlin; but
certain meals should consist ahnost irlitJly of concen
trateil animal food, and others wholly of carbo-
hydrates or purees of fresh vegetables. Corbu-
hydrates Ijeing digestefl in the small intestine, their
pre^MK-« in the stomach together with animal f<M)d
only retanls the digestion of tlie latter. If the
dilatation depends on stricture of the pylorus, it
fltill be desirable to limit the food entinii/, at any
ite for a time, to such substances as can be ab-
sorbed in the stomach, /.«•. to itilrognnoua animal
aubstance-s. Butter, sugar, and all rich sauces must
Ije forbid'len.
It may be deairnble, in some severe cases, atteude<l
with troublesome vomiting, to adopt for a time a
strictly milk diet, giving the milk mixed with crushed
ice in small quantities at n time and at suitable
intervals. Condrnsed peptoniaed milk is warmly
praised by Ewald
Professor Bouchard has rightly insisted on the
no
Mf.dical Treatment.
IFtot.
necessity of keeping the niculsas far apart, as passible ;
nine hours, he s<iys, should inltTveiif between breiik-
fast and dinner, anil fifteen between dinner and break-
fast. We have ourselves no doubt that one reason
why dietetic tnoasures fail in some of these cases is
that food is allowed to l>e taken too frequently,
gastric digestion l)eing wry slow in many of these
patients. Dujardin-Beauinetzalso insisted that tliere
aliould l>e no eating between breakfast at 11 a.m. and
dinner at 7.. '50 ]r.ni.
If the jMitient complains of faintness with cravings
for food because of these long intervals lM?t\veen nie*ls,
he may be allowed to take occasionally a small wine
glassful of meat juice or some other liquid food, such
as panopepton or liquid peptinoids.
The best beverage is pure wattT, but a little red
wine, well dibited with water, may lie allowed. Tea,
coffee, or cocoa, certainly during the early part of the
treatment, should be wholly forbidden. Subsequently,
when digestive [jower has been to a certain extent
regained, a little unsweetened tea or coffee may be
occa-sionally permitted.
Much U.SC nuiy l>e made, as Ewald i>oints out, of
■iiilrii'iil ciirinHtii in these cases. They prov<' an
essential aid to the supply of nourishment, and by
their help we may for days keep the stomach almost
entirely unoccupied. They also afford a means of
supplying water to the syst«'m, which is greatly neede<l.
If a long tulie is usetl, and passed up as high as it
will go without bending on itself, the patient In-ing
in the kne<!-ell>ow position, a considerable quantity
(H or 10 oz.) of fluid food will be retained at u
time.
Tlie following sketch of a nrodel dietary for cases
of diliitation of the stomach may prove useful: —
8 A.M. — Bie<it/<ul. — Two ponclitd or lif^htly boiled eggs, or
d smull (lulled a.ilo lluvourcd with Icmuu-jiiico, 1 uz. of
thin toiii-t, lollowt-J l.y i lo 4 oz. of bevomge — watur, or
liol milk mid walvi (if milk iigri't'»).
1.30 I'.M. — A small tcacupful of hot WHler.
»p. V) DlLATATIOtr OF THE STOMACH.
I I t
2 r.sc — LuHcfitoH. — 4 to 6 ot. of boiled rico.'j
or tMoioca, or sago, with it little fruit I •* lil"'" '•waiu
jiJly ; or m.caix.ni. with a little gratoa ['"*'' ,^"T^ '"
ihcefc; 4 oz, o( water, or weak brHinly I ihcM.
and wBtiT. J
7.30 r.u.—A. cup of hot wator.
8 i-.M.— The Inan of a mutton chop; or a slice of the leiui tif
roaat ur l>oileii uiutton or chicken (About 3 u/.) ; I oz.
of purpe of [>otAto, 1 ox. of dry toaat ; 4 uz. of water,
nr wp/ik brandy and water.
II y.H.—A tumlilerful of Vichy water (raadc hot).
A cup of milk and water or two or three tiiblfspounfuU of
p.inupepton muv be taken during tho oiglit if the need for food
be felt.
This dietary admits of obvious vHriutiond, in aiiordanM
with the |irinciples laid down, and the quiintitiiMi may he
inert osed as the patient's condition improves.
It ie ginerally udvi>ahlc to ki-cp the patient ohnluhly at ml
when following a ri'strieled diet of this kind.
Kussmattl lias adviscHi that ttie putient should
wear au abdominal baiulage, and sliould lie ou the
right sirle liie greater part of the ilay, so as to |iroriiotii
the C8ca|>e of food from the dilated stoniach. Th>^
bandage, especially if acconipaiiied hy a light epi-
gastric pad, cau!tt« more iiitinmte contact of llie ooii-
tx*nt.'« of the stomach with its walls, and C)<iis)'i|(ieiit
increti.se of movement mid secretion.
Before proceeding t<j apply some siicli dietary, or t<i
make use of the medicinal mean.s we nliail immediately
dwtcrilM', it is undoubtedly th^sirable to cleanse the
stomach of its decomposing contents and iiiorhid seere-
tions ; and when tin- patient olyecUs to this lieing dom-
with the Htoiiiach pump, or syphon tulje, there are still
two other measures, cither of which may prove sutis-
factory.
We may empty the stomach, as recummende<l by
Dr. Hare, by means of an emetic. He used to pre-
scribe 24 grains of powdered ipecacuanha for this
purfKwe with excellent resultJs* It ha.s, however,
been objected to the use of emetics (Leulje) "that
they nc'.-er secure a complete expulsion of the fer-
menting iugesta," and that in advanced oises the
* Trmutti-littiit of Medicai S'idcty ol London, vol. li., p. 2U.
112
Medical Treatment.
loss of muscular tone is so great that it is difficult,
if not inipossiblt', to excitR vomiting.* In such cosex
the use of purgativcH is preferable, anfl goixl result*
liavo been ohtaincil by the use of Carlsbail water
for tliis puri«isc. A jfluss of llic water should be
{{iven cuM every half hour, in the luornirifj, fasting,
until it causes an action of the bowels. \'>\ this means
the residue of ingesta is carried o(i" through the pylorus,
and the Carlsbad water relieves also the co-existing
gastric catarrh. It is often necessary to increase tlic
purgative effect of the natural Carlsbad water by add-
ing a leaspotinful of tliu Carlsbad salts to each glass.
We consider this a. good plan of treatment in dilatation
due siiriply to atony of the gastric walls, and we have
also known instances of organic obstruction greatly
benefited liy the Carlsbad course, but this method is
not of course appiicablo to oases of advanced stenosis
of the pylorus.
The plan of atteinpting to incn-ase the digestive
activity of the stomach by giving 10 or 15 drops of
dilute hydrochloric acid after each meal, with or
without 6 or 8 grains of pepsin, lias many advocates,
and certainly slioulrl not be overlooketl. Ewald
advises this dose of hydrocbloric acid to Ije given
every hour, in a tablespoonful of wat^r, through a
glass tube, and in cases of carcinoma to give it in
an infusion i)f condurango. Bitters to pronjote gastric
seci-etion and strychnine oi' nux vomica to restore
tone to the gastric muscle are useful in many cases.
Three or four nn'ninis of liijuor strychninie, or 10 to
1") minims of tincture of nux vomica, with 10 of
dilute hydrochloric acid and an ounce of infusion of
calumba, shouhl be given an hour after food thi-ee
times a day. Or if there ai-e acid eructJitions or
complaints of heartburn, it may lie liett<{r to give the
tincture of nux vomica and the infu.sion of calumba
with lo or 20 grains of soiiium biciirbonate half an
hour before meals.
* Von Ziemssen'is " Cyclopndia of the I'riiotiee of Hedicinp,'
vol. vii., p. 332.
I
I
^VT DlLATATKK OF THE StOMACH.
»»3
I
ExtcrDft] Candic apfilioitioB* Imtv aks keen faaad
of use in restoring tooe to tlie |paitrie — clw.
Miutaijt has likewibe been faond adTBatageoM^ aad it
seemE possible, by this neMarc, BOt only tp pctMkOto
the passage oat of the rtowMcrfc of the raidoe ol tke
food retained there, boi alio to nmmt, to • eertaan
degree, the tone of its mascnlar w»lls.'*'
Coimlipatiofi, vben it e-xista, Bint lie onnwiwy
either by saline a^ierienta, m CarislMMi wmttr, Uktu
in t}ie manner alrrady described, or bj a pill of aiom,
soap, and ipecacnaoba every night if Decv»arv.
tV Ato«s pulveria gr. j ti Qj.
IpecaciiaobH- pulrcrin ... Sr- I-
><«poni8 gr. J-
>Ii»re, nt fiat pilola.
Ewald hu8 given gulKutaneoas injections of aloin
with good results.
The usefulness rrf anii»4>plir agents for the
purpose of preventinj; putrid decomposition of the
contents of the stomach is now widely rt-^-ognised .
Pills of creasote or of thymol, taken immediately
after food, or stilphuroiiK acid in dram doses, or
salicylate of bismuth (R Bismuthi salicylatii!;, niagnesii
carb. ia •') ^lins ; m. f. pulv.; to be taken after each
meal), or diloroform water may be given lioth for its
jative and antiseptic effect-s.
t Sir Wni. Hroadbent recommends sodium sulphite
♦ HindiVierg (" Miima^u do I'abdomcTi." Bull, dr Thirap.,
1^87, t, cxii., p. "4H} HHHimraeudi the following loode of applyiSft
^ I in taies of ililntution of Uie Rtomnch : —First, by mean* of
)tm Bii'l ■i!«'»'it»i»inu th^ lower limit of thp dilatiMl orifan is
mftit. ■ ' ■ 111 tlic piilin of one or^f both bBudu (ircfimre,
Bt t< :i'l itftvrwanl'* ^ratlimlly aaffnieDted. ia inuile,
pa.5-:^ ! and lower limit towortls the pyloric region.
Then, jiIjii'Iuk I'le end« of the tingvrs »tretcbe<l out over the in-
ferior snil left hoiindnrr of the stoniaeh, light prtacure i« made
will. "* • * ■ '" * i% ;irdR the pyloru.s. Tlie jireMinre,
ot ' •ively increa«c<l. .\fter five or
fiix ^ ' : "^t kiieniling nnd compreraioti of
the stoiuacli i>iiuulii lolluw ; then pnaliing the fingeni down as fai
M pouible, wc nhould try to knead gently and lightly the contents
of the stomacli, prewing at the saiuo time w^ilh the hands from
below upHordt and from left to right.
I
if4
Medical Treatment.
n-uii.
in f) t«i 10 grain doses, with sodium bicailiOluvte and
mix vomica l>etweeii meals wlipn the gas eruct«t«d
has the odour of sulpliurett«i hydrogen. He also
speaks highly of u mixture of sodium siilpho-carholato
ill doses of 5 to 10 grains with sodium bicarbonate,
spirits of ammonia, and gentiiin, given iit a certain
interval aftfr nieuls. He has also found benefit arise
from the use of a pill composed of -\ grain of per-
cidoride of mercury, -^-^ grain of strychnine, and
1 minim of creasote t«ken between meals.*
An important adjunct to these otlier measures is
regular exercise in tlic open air — preferably the air of
the country ; gentle gyiiinHslic exercises aie also useful,
and tlie circular douche applied to the region of the
stomach, the spinal douche, and other tonic hydro-
theni]H'Utic treatment, by raising the gonenil tone of
the nervous and muscular systems, will often jirove of
gi'eat assistance in treating these cases.
We now ajiproiich the consideration of the raotle
of treating diliitation of the stomacli so strongly
advitcated by Knssmaul and Tx,nil>e, and adopted by
many other jilrviicians, \\t.. the mechanical emptying
an<l waMiiiiK <»■< the stomach by the stomach pump
or syphon tubi\ Lcu1m» says, " With the introduction
of this priK'tice the treatment of dilatation of the
stomach has for the firet time Iwconie a rational one,
and all other remedicH sink by comparison into the
second and third rank"; and Ewald says, "The ad-
vantages resulting from this method are evident,
and the imly wonder is that it M-ns not made use
of earlier." This radical measure, when it is well
tolerated by the patient, is no doubt one of the
most eflicacioi's of curative processes, but it is
intolerably repugnant to many. Ebsteint has applied
this method even to inf tints under a year old, u.'<ing a
No. 8 to 10 Nf^latoti's catheter, anil washing the
stomacli out with warm water containing a little
benzoate of magnesia.
• Bril. Mril. Jouitml, Dccemlwr Pth
+ Jrrk. fill- KMidfrhrilkund., Bd. iv. s. 32ij,
DiLATATIOS OF THE StOMACH.
"S
Plaiu warm wttt<?r or water c-oiitniiung a little
liorax in solution may be used. Souie uw Um
stomach pump at first when the contents of tlio
stomach are "bulky and lumpy." The .syphon tube
can be employed later, and may be managed by the
patient himself.
Leube prefers tlie stomach pump, and does not
approve of the patient bt^ing left to waah out bi^ own
Etomacb. "The syphon has the disadvantiige that it
can withdraw from the stomach only tluids or sub-
stances which Hi"e very nearly lliiid, and resort mu»l
\m: had to the ]iuuip to remove the remnants of tlie
ingesta . . . and the removal of the ing'ftfa to tho
fullest extent possible is altogether the ni'Wl iMi[>ortAnt
indication. . . . The operation of wunhinK out
the storaafh when entrustetl to the jinticnt alone i*
uttendeil with ho many risk^ from hin luiavnidaiily
awkwaid movements in connection with the protru-
sion of the lower wall of the stomach by the end of
the tube, that I cannot but regard tlie reirgatiim of
the operation to the [latient himnelf aa estreiiMly
hazardous."*
When, however, the htomach tul»<» is made vX soft
rub)>er, as in the instrument to be deitcribed, then is
danger of the patient injuring himself^ Mtd tb*
unplicity of the xyphon arrangi-nient has noeh to
mend it, although no doubt th<t vasbtog 4nI of
AiB stomach is not so complete as witb tfc« stmBMli
pump, and it may be adviHsble to ootumeBM villi tiw;
latter instrument.
The klomarb »> phoH, as drscribnl (qr VmorXtn,
consists of a u-jfi rublxT lube Dot !(•■ IJMa SO or
60 inches in length piotiJed witJi ■ firnjf tiwg Mrt
to show to what deptli it slxioM be alkrtrad to mm
down into the stoiuadL Tbcae Uibes <aa be oMai»*4
three sizes (Nt«k 1, % and •'^/, )my'vu% Wfwaiitrfy
diameter of 8, 10, and \'l \u\\\\wfiSTK A gfUa
funnel is fitted to itsuut«r rail. iMbtrre'* ia«»liArat^«
*<4. u., ^ tm.
• lisobe Ml "tM o( I
■ CrrlopiidSa •< dw rnctin of
it6
Medical Treatment.
|P»rt I.
is Homewhat less supple iviiil more resistant, so that
it cnn be pushed more easily down the n«opliagus and
int*j the stomach.
Fig. 1.— Btonueh Bjrphon.
Ill first using the stoaiaeh tul>e it is Ijest to begin
with the smaller siw3, and when the patient is accus-
tomed to its use to employ the larger ones. The tube
is introduced into the pharynx iu the same manner ns
an awdphageal bougie; you then direct the patient to
iDiiku etlorts at swallowing as you push the lube down
into the resophagiis.* The tube sluiulil lie di]>ped into
milk to moistea it before passing. Wlien the tube
Fig. 8.— Slonuch 8n>1«»> (t>«bore'a MndincatlonX
has passed as far as the index marked on it you affix
the funnel to the out«r end, and fill it with the fluid
you wish to introduce into the stomach {Fig. 4) ; the
moment you observe that the fluid has nearly dis-
• Most putieiits prefor the soft though Uirgprtube of Faucher,
wliicli is pasftwl rapinly tuto the awophAgiiB. in/A thr rhitt Jrpi'raMtti.
Ro(piih<>iin uses a tube witli oereral lateral openings as well as a
terminal one.
auip.v.] Dilatation of the Stomach.
«>7
appeared you lower the funnel rapidly, and the liquid
contents of the stomach flow out into the vessel you
have placed to receive them (Fig. 5).
Sometimes some difficulty occurs in the introduc-
tion of the tube owing to its provoking nausea, or
efforts at vomiting, or even attacks of dyspntea. This
is especially the case in persons with great irritability
Fiit t.— Mode or Uiing Stonurh Sjrpliiin.
of the fauces and pharynx : in such [>er8onB it is best
to |»aint these part« witli a Ti por cent, solution of
chlorhydride of cocaine about ten minutes liefore
attempting to introduce the syphon. Toleration of
the presence of the tulw in the pharj'nx anil
resopliagus i.s, however, rapidly egtabli.she<J, an<l the
patient may after a few days be encouraged to |>asM
the tube himself.
It is usual to employ some slightly alkaline water
for washing out the stomach — warm water contain-
ing about 2 grains to the ounce of sodium bieiirbo-
nate is the b««t. Sometimes it is desirable to use an
antiseptic fluid, such as a saturated solution of lK)ric
ii8
Medic A l Tr ea tmf.nt.
(Part 1.
acid, or ci-easote water, or a 1 per cent, solution of
stidiuni siilicylate, or siMliuni sul|il)o-ojirliol:itf, or some
tiiictm-e of myrrh may lio addwl lo tlie water in
oases of atonic dysitepHiii. If tiiere is ciiniplnint of
jwin in tlie stomacli, you may mix some subuilrute of
liiHmuth with the water put into the funnel, and
allow it time to deposit itself on the mucous luem-
brnnc of the stomach, or you may use chloroform
%
Fig. r..— Mod* of Uslntt StoiDMh Sj'iihon.
water (2 per cent.) with the hisnmth, and this liaa
both an ana'sthetic and an antiseptic action. As to
the quantity of Huid to 1)(» used at each wn.shing, this
will depend on the toteriiiice of the patient, and the
degree of dilatation of the stomach ; hut, if possihle,
washing out should be continued until the fluid that
flows out is as clear and pure as that which is flow-
ing in.
Occasionally the outHow of fluid suddenly ceases,
especially if the tube has only one opening at ita
gastric extremity (it .should have two or more), owing
to thLs opening Iwcoiniii;^ btm-'ked by particles of
food ; this CJin usually be washetl away by allowing
80III0 more fluid to flow into the stomiu-h. Some-
aup.V) Dilatation OF the Stomach,
119
times the openiiig of the tube in tlie stomach may
not be in contact with its liquiil contents ; this may
occur when the dilatation is very si'eat, and the tube
fails to rejich the conteiit-s ; or if loa niucii of the
tube has been introduced it may bend on itself, and
the opening may thus reach the upper and empty
part of the stomach. A little manipulation of the
tnl)e will usually surmount either of these dilKcuities.
The best time to practise wtishing-out is in the morn-
ing, fasting, and once a day is often enough. A fter
a little time, onc« every two or three days will
be enough.
The syphon, however, will not sutKce, a.s Leul)o
has stAted, for all cases. In cases of malignant
tricture of the pylorus, with enormous distension of
he Rtomoch with putrid substance-s, the stomach
pump will often be nece.Hsiiry to adequately cleanse
its cavity.
Another method of f-mploying the syphon tube,
devised by Rosenthal, is shown In the accompanying
illuHtration (Fig. 6).
To the outer end of the stomach tul>e is fised a Y-
shaped gla.ss tube, one branch of wliich is connected
with an elastic tube running to an irrigator con-
tiining the fluid to be introduced into the stomach,
and standing at some height above the patient's head ;
the other branch is connected with the outflow tube,
which descends to a suitable receptacle. Fluid runs
into the stomach through the tube connected with the
irrigator, the outflow tulje Jx'ing cunipresHetl by the
fingers of the left hand. If the outflow tulje be kept
open while the fluid is flowing from the irrigator, and
if then, after the estaljlishment of a column of water
in the outflow tulje, the irrigating tulje be compressed
with the fingers of the right hand, or its stop-cock
closed, a syphon communicating with the stomach Ih
formed, and emptier this organ of its fluid content.n.
The i-esults obtained frDui the ajiplicntion t»f the
method of washing out the stomach vary in liitferent
casck. In some immediate relief and ultimate cure
I20
Medical TKEAr.us.vr.
(Pari I.
are observed ; in others we find more or less speedy
relief and apparent care, but frequent relapses,
reiiuiring rcapplication of the treatment; there are
other cases in which n^cnvery is slow and gradual,
Fig. (1.— Sloinncli Tutj«' nn^l Irrigator.'
antl the treatment necessarily prolonged and tctlious ;
others in which benefit attends the application of the
method, but it has to be continued for t!io remainder
of the patient's life ; and others in which no l)enefit
is obtained.
I
Ch»j».v.i DtLATATtoy OF THK Stomach. m
It must also be borne in mind that there are
eertain coses in which the use of the stomach tube
18 roanter-indiraied — for instance, when the
attempt to introduce it causes so much phatrngeal
>q>asm or distress from nausea and vomiting as to be
seriously injurious to the patient; the existence of
great debility : the recent occurrence of hKmorrfaage
from the stomiich ; most cases of gastric nicer ;
cancer of the cardiac orifice, or uf the wsophagna, and
aneurism of the aorta. In all these circumstanoea we
must have recourse to those other methods of treat-
ment already detailed.
Tt liius (iIho been objected that lavage is not indicated
in simple atrophy — as in that case there is no obstruc-
tion to the oulllow, but only a lowering of perixtalsis,
which is not markedly benefited by lavage.
It has been said that it is " highly probable that
nearly every case of extreme dilatation of the stomach
has some mechanical explanation, and oin only l>e
eflBciently tre8te<l by surgical means. '^* We must
thpn'fi.rre in concluHton consider, vi-ry briefly, th<'
ftnrRirnl measures tlial have been propoaed for the
relief of this condition.
If the dilntation is dependent on aJhemms around
the pylorus of a simple kind and such as can be
detached — and this, of course, otn only be determined
by an exploratory operation — the setting free of the
pylorus by their detachment may effect a cure.
If, however, an exploratory operation discloMfs
the &wt that there is pyloric ttrnmnn, this may be
dealt with according to the nature of the Htrinture.
Lorota's operation of forcible diittlntinn of the
pylorus in cases of H|>asm, or hypertrophy of the
circular muscular fibres, ulthough it appears to havi-
succeeded well in his hands, has not lieon so favourably
regnrde<l by English surgeons, and Mayo Rolwon
"decideilly"' preftTS "pyloroplasty where no active
Mnyo Bobaon, " Tha Surgery of tha Stomarh." l^mivl,
March ifth. 1900, p. 7V>.
Medical Trkatuknt.
(p>m
ulcei'atiiiii is going on, ond gastro-enlerostomy wheie
the pyloruH is ulccriitoil."
I'yIurojilnKlii consists in dividing the narrowed
pylorus loii;3;itudinitlly and closing the wonnd trans-
vprsely. Miiyo RoVjson uses a deealsiliod Iione-ljobbiu,
which seems to facilitate the operation, and servi-s to
maintiiiii an oprn channel. In chsps i.if ''had organic
stricture" this mithurity advises pylomplusty together
with " partial excision."
If the surgeon slioulil find " firm adhesiouK, active
ulecrution, and the pre.Hcnco of new gnnvtii,." gastro-
enternsloniy may be the better operation.
In some ea.sea of stenosis from nialign;int growth,
" if the growth be limited and there i.s no .secondary
infection," pylurecbomy may he iiidiealed.
Sir \\'. Bennett believes that in maiiy ca^es of
giistric dilatiition this condition is due to spatmodic
contraction of the pyloric sphincter, and that the
a{i|n'opriat<? treatment is to tipen the stomach on the
cardiac side of the pyhinis ami forcibly stretch the
coutractwl sphincter "until it will allow two or three
fingers to lie loosely in it." This measure, he thinks,
"should bo adopted before the stomach walls have
undergone degenerative changes which may lender
their return to a healthy state impossible."*
As to the value of the openUions of gnatrorrhaphy
or gastro-pliciition employed for the reduction of a
dilated stomach to .something like its normal capacity,
there has not been, up to the present, sufficient
experience in this country to justify the expi-ession
of a positive opinion. Mayo fiobson and Moynihan
think the " re|>orts show that the operation is a most
beneficial one if ihe ca.ses be well selected, "t
Paul Cohnheim has recently reported a series of
obsenations and experiments to the effect that a
number of cases of pyloric stenosis and consequent
gastrectasia can be relieved by means of large closes
• Sill. Mrd. Jummil. Fchnmry .'Irtl, 1900.
t " Diseases of the Stonmch and tlieir Sureical Treatment."
p. 218.
CJi»p. V.l DiLATATlOS OF THS StOMACH.
'^3
of olive oil. The cases 8uite<i to this cure are
tlio.s« of spasm following ulcer or fissure and cica-
tricifil cases. The oil is given at the temperature of
the Ixxly tlirough a tube, either in tloses of 50 c.c an
hoiu- Ijcfore meals, or in one dose daily of 100 to
150 c c. He infers that the resistance cause«l by
friction is lessened by the mechanical effort of the
oil — that it causes relaxation of spaxm and improves
nutrition, being absorbed when it reaches the small
intestine.
In cases of ulceration the oil acts on the .s|ia.sin
as a nai-cotic. It does not relievo purely nervous
r cramp.
He nmintains that Uiia method of administering
olive oil will, in many cases, render surgical inter-
ference superfluous.
We would point out that the patient after taking
those large doses of oil should be directed to lie on
his right side to favour its outflow from the ol<jmach
through the ])ylorus.
ADDITIONAL FORMULAE.
Per distension and discomfort
IB earl7 gastric dilatation.
& Sodii sul|>ho-carb<iliri, gr. v.
ad X.
Stxlii hicarbonatiii, gr. xr.
Sp. ammcin. arom. , Ju.
Tiiictunc gentiuDa) ro. . .18«
Aqiiit- ctilorofonni ad ;}.
M. f. haunt To be takeu au
[ bour or two after meola.
MomlnK dranght in th« same
R Soflii pboephatit, S\ ad
.sij.
Sued tnnuBoi, }j wl 5iJ.
Aquiv ad Sj.
M. f. hauit. To be lukan
in !iot wntcr wirly in tlie
morning.
(BrtmUhtnl.)
"4
chapt?:r vi.
"Diseases of tub stomach — the treatment of'
nj!MATEMESia, VOMITINC, AND (i A8TRAL(;l A.
SjiOLkTBltESiB — Caiuea — Symptoms— Diiignosis — Indication* for
Tretttment — Prophvliixis— Ergotiii— Styptics — Supra-reual
Extract — Gelatine Solution— Local Application!! — Aporients
— Tonics. VoKlTiuo — Its Nature — Prevention — Pothology
of Qoctric Irritability— Treatmput-SiKlativM — Counter-im-
^ tation— Anti-fermcufivcB— Sen-Sickni'8». CiA3TIi,lloia, ob
Oasteic Neukosis— Its Causes, Diugnosie, and S}Tnpton»8 —
Indicntions for Treatmpiit — Ann'mic, Malarial, Hysterical
and Goutj- Forms — Treatment of Paroxysm. Additional
Formula",
H.CMATEMESI8.
In considering the treatment of gtistric ulcer and
gEistric cancer we have had to remurk the frequent
occuri-ence of haemorrhage from the stomach in these
disejiaes. There are many other conditions which
may cause the effusion of blood into the cavity of
the stomach, anil it is the occurrence and treatment
of gastric htemon-hagc from these other conditions,
and in a general sense, that must now occupy our
attention.
One of the most common causes of escape of
Wood into the stoniiicli is vfiwttg cotif/ealion of its
mucous meniVirane from obstruction to the circulation
tln-ough the livt-r, especially from cirrhosis of that
organ leading tu compression of tlie branches of the
portal vein. Any otlier obstruction to the circulation
in the portal vein will produce a like effect ; such (is
obstruction to the outflow of bile from closure or
8trict\ire of the hepatic or common bile duct ; the
bile ducts then Iwcome distendi-d, and compress
the lirancliea of the portal vein in the liver. Throm-
bosis of the portid vein would id.so have the same
effect, itnd so, of course, would |u-es.sun> upon it fi-om
a tumour of any kind in the transverse fissure of
the liver.
I
Chap. VI.)
HjKMA TEMESIS,
J 25
DiBcaseH whicli lead to the plugging or destruc-
tion of tlie capillaries of the liver, siicli, for instance,
as acute yellow atrophy, may also cause congestion
of and hieniorrhage from the gastric mucous mem-
brane.
Increased pressure in the portal sygtem from
arrest of a regularly recun-ing hiemorrhoidol flux is
sometimes attended with liB»matenie.sis.
OliHtruction to the circulation through the heart
and luiigH, 88 in valvular cardiac disease and in
pulmonary emphysemn., may le-ss directly, through
the hepatic veins, tend to h.fmorrhiige from venous
congestion of the stomach.
Haemorrhage into the stomach may occur from
dirtease of the coat« of its vessels atheroma, vari.x
or aneurism, or from a morbid perm^ahi/ili/ of tlie
vascular walls, tfigetlier with a morhid stJite of the
liloo<], us in the so-called ha-morrhagic diathesis
(hamophilia), in malaria, in scurvy, in yellnw fcvfr,
Mnd some other affections, or the Meetling Nossel may
be at the lower jwirt of the u'sopliagus, from the
existence of a dilated and varicose condition of the
veins there, a not uncommon development in hepatic
cirrhosis, by means of which a collateral circulation
is established, allowing the bloxl fmm the portal
vein to reach the heart without ]>a£sing thniugh the
liver ; und the IjIockI thus extra^Tisated may tlow
into the stomach and accumulate there : or it may
flow Ijack into the stomach from the duodenum ; or
an aneurism of an adjacent artery may ruj>ture into
the Btoiuach.
We have seen how hemorrhage into tbn stomach
may be produced by erosion of its ressels from
simple or cancerous ulceration : and eroaion from
the entrance of corrosive sut^tances, or rupture of
vefsels from mechanical injury, will, of courw, \m
attended with the same results. Violent acu of
vomiting sometimes les<l to lia-morrhage. In some
cases of severe and fatal hn-morihage from the
|l^^0inach it has Wen found impottoible, on j>o$t-
!26
Medical Treatme^tt.
tPart I.
mortem examination, to discover the siiurce of the
bleeding ; it must have been wholly cnpiilary ami
congestive.
Some of these mysterious cases of capillary
InemoiThage have been found to occur after certain
surgical oiierations — especially operations connect«d
with the abdominal cavity and the omentum. Mayo
Robson remarks (hat these cases are " neither well
recognised nor well undenttood," yet they are " often
serious and at times fatal."*
Iti the female sex, tlie occurrence of the menopause
and of menstrual irref^ularities seems to exert on
important inHueacc on the frequency of the occurrence
of ga.stric liicmorrlnige.
The symptoms which reveal the occurrence of
hiemorrhiige into the stomach are the following : in
the first place, there is usually vomithuj of blood, but
this symptom may be absent, and a small quantity
fif ijlmxl extravasJited into the stomach maj' paas away
by the bowels ; when a large (juantity of bloo»l has
lx3en rapidly poured out, ceitain symptoms may
precede the actual vomiting of blood, s>ich as a sense
of weight, fulness, an<l warmth in the epiga-strium,
accompanied by nausea, an unpleasant, sweetish taste
in the mouth, and a f'cfling as of fluid rising in the
a'sophitgus. As the hwmorrliage goes on the patient
Itecomes pale, and complains of giddiness and faint-
ness, of noises in the ears, and sparks of light in the
eyes. The pulse is Mmall and ra]»id, and the skin
cold.
Tliese .symptoms may, liowever, be aljsent in
smaller hieniorrhages and in robust persons. The
blood vomit«d passes through the mouth, and some-
times througli the nose, and is partly fluid, partly
clotted ; a portion may enter the larynx and excite
cougliing, and this mu.st l)e Vionie in mind when the
ha-morrhage is said to have l>een attendtnl by coughing.
There are occasionally cases of large hsemorrhage in
* Huntcrian Lectures on "The Sur([vrv of the Stomach,"
Liiicl, March 10th, 1900, p. 079.
Ctap. Vl.l
//.VMATEMESl!;.
»»7
which the bliwd is retained in the stomncli and not
vomited, and percussion over that organ shows that it
is distended and dull from the presence of blood clot,
while the general symptoms of severe internal
hftimorrhage are present, such as pallor and coldncfw
of the surface, collapse, pulselessness, tremors, and
convulsions. Sooner or later, after the hwniorrhage,
blood appears in the n'lotions, usually in the form of
a black, tar-like substance.
The appearances presented by the lilood vomited
depend on the time it has l)een detained in the
stomach. If vomiting occurs iit once, the blood may
t»e of a bright red colour and eiitii-ely tluid, but more
commonly it is partly coagulated, and has the appear-
ance of coflTeegrouuds or of so<it mixed with water,
the change in colour being due to the action of the
ga.stric juice on the hietiioglobiu. Sometimes portions
of food, bile, and mucus may be mixed with the altered
bloofl.
The usual symptoms of antemia follow the loss of
blood if it ha.s lieen large : great jmllor, coldiiesn of
tlie extremities, giddiness and faintness, spots before
the eyes, and other aflections of vision.
The aliirming symptoms of giiatric hemorrhage
usually pass away, and the patient nicovers ; and
in coses of cirrhosis of the liver, some of the symp-
toms of the original disease have, occR.Mionally, been
anieliofHted Viy it-s occurrence.
Hut if it recui-s, as it is prone to do, fre<juently
and in large amount, the patient must, of course,
ultimately sink from exhaustion, if he does nut die
suddenly during an attack.
A few considerations a-s to diaKiiowiii are
necessary l>ef<'re we enter upon the discussion of the
IreatmeTit applicable to those cases. There is usually
little difficulty in deciding as to the source of the
hipinorrhage when we have been familiar for some
time with the previous history of the patient, The
difficulty arises chielly in thos*; cases in which a loss of
blood occurs suddenly and iiriex|>ecteilly in a person
128
Medical Treatment.
(Parti.
wlio luis not been recently under medical saper-
vision.
This may occur sotuetitnes in coses of perforating
ulcer tif the stotimcli, of in those cases of liR.'iiit>rrliage
from the stomach or lungs associated with menstrual
irregiiljirities ; and in cases of early unsuspected
phthisis. We must also bear in mind tlmt blood is
hometiraes intentionally swallowcil, and that it may
be so, accidentally, when ponreci out from the mucous
membrane of tlie nose, plmryn.\, or even the air
pitssagps during sh^ep.
We niny conclude that the blood proceeiis from
the stomach in the following circumstances: The
bringing up of the lilood is preceded by nausea and an
incliimtion to vomit ; it is of dark colour (uidess very
considerable in ijuantity, when it may be bright) ; it
is coagulated, contains no air bubbles, may lie mixed
with food, and has an acid reaction. It is followed
by tar-like motions. It Ls noi followed by the coughing
up of blooti-sticined expectoration, nor are there any
localised moist rales or any area of loss of resonance
to be discovered in the lungs.
The indiralioiis lor (renlnifiit in ca.ses of
luematemesis must neces.sarily depend on the nature of
the original di.sease of which it is but a symptom.
Many of tliese diseases are incurable, as will Ije
I'vident in referring to what has be<?n .said under the
head of cau.sation ; and when ha-mateniesis occurs in
the course of gastric cancer, or of chrgnic disease of
the liver, heart, or lungs, it is only as an incident in
the course of these afiections that its t]-eatment has to
lie considere<l. The treatment appropriate to gastric
ulcer generally we have already discussed.
In certain coses the opportunity of apjilying pro-
phylactic measures may occjisionally be .itlbrdeil ; if
gastric lia-morrhage tends to occur at the menstrual
period, a few leeches may be applied to the cervix
uteri at the time the attack is threatened, and all
physical exertion at the approach of and during the
catamenial period should be strictly forbidden ; if it
Chap VI. 1
HjKMA TEMESIS.
129
I
I
is known to be dejiendeiit on hejintic cirrltotiis, Icrclies
uiay, in liku manner, )x: applied to the anuD so as to
witlidmw Itlood from the hternorrhoidal veins ; in
chlorotic and scoi'lmtic fierwjns the gvueml health
should bo strf ngtiieueil by irr>n tonics Mid a hyj^'ienic
rfgimen ; and certain periotlioilly returning attadcs
.■iuted with malaria have been permanently
3t4>d \iy the administration of i{uinine.
When hioinorrlioge has actually incurred, the
j>aramount indication i;) to diminish vascular prv<^
surtv so far an possible. Foriunnt<'ly, tho etM»pe of
bhioil itM.'lf tends (o du tliiM, e))|Hx'ially when it
causc-H synco|K<, ku that it has l>eoome an uxium that
haemorrhage tendii to cure itselL In order, tlien, tu
quiet the action of the heart as much as possible,
the most complete rest in the rectiuilient or 8t>n»i-
recuinbeut position uhould be insisted upon and
maintainerl. If the patient should Imve fainted on
the occurrence of the hieniorrhage, he should not
be moved, but treated where he is found, so that
absolute rest may be maintnined, at any nitr, for
some hount. The jiatient's anxiety should be calmed,
and his room kept cool and rjuiet. No ifnA
should Ije given by the stomach for some days, that
organ being kept quite at rest so as to avoid the risk
of dislodging the fibrinous iilu>;s in the bleeding
vessels. 8ach nutriment as is needed must lie ad-
miuisteretl by the rectum.
A hypodermic injection of morphine or a small
opiate euema should Ijc at once given ; it lowei-s
vascular tension, six)thi« the fxitientnand contributes
to mental and Ijodilj- rest.
Hut what means ore there at our disposal for
arresting the bleeding when it continues or recurs
at short intervals 1
Much difference of opinion exists as to the value
of the hyjKxlermic injections of erijotin in arresting
gastric hiemorrhage. Dreschfeld and Leech of Man-
chester both think they may do good, and with this
ur own experience accords. We certainly
13°
Medical Treatment.
I Pari 1.
cannot lulopt llie very adverse views expressed by
Professor Walter Smith on the use of tliis drug.*
They swru to uh inconsistent with the ln'it clinical
testimony.
The French phy.sieians mostly pi-escrilxi the
erf/otinine of Tauret — he makes a clear unirribit-
iug solution well adapted for hypodermic use.
This is the prpjiaration we have used, and we think
witli go<jd results. From \'y to 20 minims is the
dose.
The so-cnllcd ati/plica, ferric perehloiide, lead
acetate, tuiinin, alum, turjH'iitine, can be of little or
no use when tlie stoiimcli is partly filled with blood
and half-digested food, as they could not then come
into contact with the bleeding mucous membrane ;
but they may be of value in arresting the oozing of
blood from the surface of the stomach after its
contents have been removed by vomiting.
Alum ami »ti//ihuri-c a<:icl, 5 gniins of ulum and
20 minims of dilute .sulphuric acid in an ounce of iced
water, may be given in quickly repeated doses in
cases where we have reuson to think there is continued
oozing of blood into tlie stomach ; or we may give
20 minims of solution of perchloride of injn in an
ounce of iced water for the same purpose. We have
seen remarkable benetit from the use of ferric
jierchlorido in coses of recurrent hiematernesis.
The following mixture may be found vuliiablo
where there is njuch gastric irritability with eon
tinuouii oozing of blowl : —
ly rlumbi acctatia 5M.
Acidi lutilici diluti ^ij.
Liqaoris opii st'daliW jss.
Aqucc cnr.vophylli ... ad jvj.
Uisco, iiat misluni, A tsblospoonful every hoar.
The administration of xupra-renal exlrart has
been advocated in these cases, but there is very little
reliable clinical evidence in its support.
• Bnl. Mrd. Juiirnal, October 1,1th, liRtO, p, 1,070.
H.KUA TEMESIS.
»3'
'Die sunie luay be said of the tuhcuUxucotui injection
11/ ijelntiiis dissolved in noriuttl salt stjluliou (coiilaiii-
iijg 2 [ler cent, of gelatine). One of the recent mlvo-
ciit«s of its u.se * Imses hi)^ re<tinimpndHti<in.s on trials
in which he " found it advinjiMe to combine the
gelatine treatment with uioi-pliine itnd acetitte of lead
or ergot." We fail Uj see how, wiien such u mixture
is used, it is possible to conclude what |)recise share
in the rfaiult is rightly attrilmtuble to any one of them.
Such ol)8orvatious sei'm to us useless in estimating
the value of a new remedy. But the subcutanei>u»
injection of xolutionii of gelatine has disagreeable bye-
effects, such as pain at the seat uf injection, fever,
^ urticaria, etc., and fatal results have followed ita
use in several instances. It in a method of treat-
ment which we arc not disposed, at pi-eseut, to
recommend.
m Tlie loail application of cold is usually an effi
Bicious remedy. Ice pounde<l and mixi?d with bread
crunilm may )je applied to the epigastrium in the form
of a poultice ; small fragments of ice should Ije fre-
quently swallowed ; this also relieves tiie thirst and
I checks the tendency to vomiting.
The tyncope may hi' relieved by liie horizontal
|)o!utioii, the head lx:ing kept low. Smelling lalt*
may lie applied to the nostrils, and cold wat«-r
sprinkled on the fncr, and the templcH bathed with
I eau de Cologne. When the syncop«' is dangoroaii,
I one of the Ijeat measures to have recourse to it the
hypodemuc injection of ether, 20 or 30 niiuiUM at a
time, re|ieat(.'d at ^hort intervals ; or ktrychnine and
ether comliined may lie used.
Giving Rtimulanta bj the stomach should, if
possible, be avoided.
In cases where life is endaitgered by the pn>>
f useness of the haemorrhage, the bypodermic injoetion
of artificial serum (2 to 6 oz.) may U- adrijwbln.
If tliere is a troubleaotiie t'-ndi-ncy to rooiit,
sinapisms may be applied to the epigastrium, and 3 or
• Oruuow, Btrl. Kit- »'ar*.. AapuA IIU. 1001.
'32
Medical Tkbatment.
I Part I.
4 miiiinis of dilute hydrocyanic acid in a table-
spoonful (;f iced water may !« given every hour or
two for four or Hvi; tiniesi. A small quantity of iced
clifiiniui^iini is occasionally useful in clu'ckiug the
voniilinij;.
In those remarkable and ill-underdtood cases
mentioned liy Mayo Hobson of capillary lia>miirrha^e
from the stomach following cerUiiii operations, he
advises free purgation by calomel and wholly rectal
alimentation.
lu cases of cirrhosis of tin* liver the nj'ter Irtat-
wi-iil, %.>•: aftor the htumurrhage has eijased, should
inehulo the ilnily use of an aperient coni(x>scd of the
alkaline sulphates ; this will tend to relieve, or pre-
vent, engorgemeut of tlio portal system.
1^ Sijdii »iiljph«lis ... ... 5J ad jij.
Magnosii ifulphntis ... ... .. ^hs ml 5].
Aqii» ciDiiamumi Jjas.
Misce, tiut himatu!i. To bo tnkan early in the morning.
The resuniptioti of feeding by the stomacli must
l)c attempted with great caution, and nothing but
fluid and non-irritating foods administered for some
considerable time.
Restorative blood tonics will be needed in many
cases to remove the annmic condition consequent on
the loss of blood.
VoMiTimf.
Vomiting is, as wo have seen, a symptom common,
at some time or other, to most diseases of the stomach,
and it occurs also in a number of other diseases, e.g.
in whooping cough, in phthisis, in renal disease, in
uterine and ovarian disease, in meningitis, in hysteria,
etc. etc., and its appropriate treatment as a symptom
of these several maladies must necessarily be con-
sidered when we discuss the treatment of these
diseases themselves, for it would serve no good
purpose to discuss the treatment of vomiting, which
occurs as a symptom of these diseases, apart from
the consideratiou of the treatment of these diseaaas
ap. VI.I
VoMiTrrfc.
«33
B belie
■ the
^^ mtiHi
I
I
I
themselves. But vomitiiig alsfj not un{ref|iit'!itly occurs
as a morliid jiliPiioiiienon occupying liy itself almost
the whole of lln- staet-, w.i to s|H>ak ; tis, for instaiir<>, in
sen-sicknpss ; nnil it will l>e convenient ami protilAblp
hei* Ui consider liriefly its treatment in a jjeneral
8«n8e, and ua itoccurs uii('oniieete<l with miy detinitn
'Bfttho1i>{S(ical lesion.
The act of voiniliiiK. wliether the irritation
causing it be central or periphernl, consists, we
believe, at first in contraction of the muscular wnlUof
the stomach itself, the ]>yloric orifice being utiially
mivlically clo8e<l ; and 8econ<lly, the irritation '\m
niunicnted reflexly to the diaphragm and the
muscles of the abdomen, which, by their cfur
powerfully aid the expulsive cllbrts <»f the
and its contents are thus mom or 1<-m viol«iitly
ejected.
Threatened vomiting from irritating ingivtn oui
often 1)C prevented by simply diluting the irntiittnj[;
contents of the stomach with water, wb*-n then- ia no
•ctnal disease of the stomach prenent. In ni«b fsw
oert«in kinds of food or drink, accidc^ntAlly or m^
cautiously taken, remain in the atoroadi an aniwlly
long time, and provoke a gra»t UBMntA ei afidi
tation. Under the circum!<lut |iylorMa
tnictA spasmoilically so as to | .<• mmmmtft
tlie small intestine of tlii« highly »iM\ or iiywItUy
formi-H ehvme ; two or ilireft f^tmm <4 pwm valcr,
or ooBUiiuBg 10 or 15 tfnlxm ti
so I each gUw. will mtin-jy wa^ra
the tendency to vomit io «iieli ekara, aikil it vimM
snem that when this <-xorsnt'« McidHy ci tba faauie
cont«nt« is diluted, or n^^traJianl, llw ffionm nitMtm,
and allows the contents of xtm atOMflb ttt pSM «•
into the small int««tine.
Care and ofaaerrBtkm in die* wfll mmtmBf i
to cure thia ttadeatj to roauC wUdi i
on an abnumui] irritahtlitj at Cjia atosMdi C* (
ingpsta. Iced dnnks aad dbrrnEMf alkaSa
are often of modb aaa in aadi mca, uad ia
-t34
Medical. Treatment.
(Pant.
iiistiincea complete abstinence from food and repose
of the Htomacli for a short time iniiy 1» advisahle.
In cases of Hitnple j^stric irritabilitj- tlie food may
l)e limit<Hl to ii mixture of milk, ice, and ApoUinaris
or Vicliy water for a time; and tliis should be sucked
tbrougli a straw or a glass pipette ; in addition, an
ordinary effervescing mixture, with excess of alkali,
may be prescribed.
We have found 20 grains of sodium bromide dis-
solved in an ounce and a half of dill-water taken an
hour before a meal check or arrest the tendency to
irritative vomiting iu some neurotic persons. Feed-
ing by the rectum ia not very successful in these ca.sea
of gastric irritability occurring in nervous persons, as
the repeated efforts at vomiting are often attended by
involuntary expul.siori of the nutrient eneniata.
The piitliology of the.He stivtes of temp<jrary or
recurring gastric irritahility, in the absence of any
disease, is somewhat obscure,* but they are |)rol>ably,
in many instances, states of liypcripsthesia of the
gastric mucous membrane analogous to those forms of
cutaneous hypenusthesia which occur in localised areas
of skill in some hysterical persons, or to those cases
of irritability of tlie vesical mucous membrane, with
frequent micturition, which we often encounter. But
this condition of stomach calls much more urgently
for treatment than those othei- hyperassthetic states
to which we have alluded, for in the hitler the nutri-
tion and general health of the patient are not
endang<Ted as they are in the former. It is, there-
fore, not only justifiable, but necessary, to apply
anB»sthetic remedies freely in those cases until the
irritability of the gustric raucous membrane is over-
come. It may be nece.s.sary to liave recourse to
opiate and belladonna suppositories or to hy|>odermic
* Somii nntliot* make n more or lom artiftcial cloaiiilicatioii of
Mmo of Ihoso formi! of vomiting, na " iiiTVom vomiliiiK," "reflex
voniiliiid," " invciiile TomitiriK." " iiiiopatliic oorvous vomiting,"
" jioriiiilio voiniliug," etc. Theso iin- of little vulac from the
point of view of treatment. Vnlr Mux Einlioni and Hemmeter,
•' DiM^ases of the Stomach."
I
Chap VI.)
VOMITIKC.
'35
injections of morphine and atropine, or to the int«*rnal
ailministrution of cocaine, chloroform water, or other
sedatives.
I'K^fore, however, resorting to these, we should try
the effect of more simple measures. I.ime water has
often a renmrkably sedative effect on the ga.stric
mucou.s membrane, and we should never omit the
trial of tiihlespoonful do.ses of lime water every hour
or two. ClierrA'-laurel water or hydrocyanic aci<l is
also most useful, and the latt-er would succeed more
frequently than it doe«i were an adequate dose given.
In cases of extreme irritability we should begin by
iving 3-nunim doses of the dilute hydrocyanic aciil
"of the B.P., and increase the dose to 0 or >* niininiH,
watching carefully the effect of the remedy. We
have known larger doses than this given with rr-
inarkable success ; but such large dosoHof a |K)i.H<>nuua
agent must only be given by, or in the presence of, a
medical man.
Mustanl planters or blisters to the epi|4a«triurii
or opium plasterx have Ijecii advocikt<^d, and are all
worthy of trial in troubleM>me caittM.
Another remedy which wdl gucoee<l in arrmting
vomiting in Rome cixses is creanotc water, or rren-
sote and lime water — u minim of creMOte aluikvn up
with an ounce of lime wat«r ; or the ortMoto may
given in the form of pilhi made witb powdered
Carbolic (leid and its derivativi-, rttorein, have
both been wanidy advocated as reuiralicii for vomit
ins, and they act, doubtU-ns, in the mtoe way ae
crcaiM)te ; the former may Im; given in 2-grain 'Man
frequently repeated, made into a pill with liqaorice
powder ; and rfjtorcin in 5-gTain dcrttm, well dilalMl
with water and flavouml with ■jrup of otMMMiael.
It is said U} he valuable to aea^kknoM. JftmilLal m
also u^ful ; it can ho praaehbed in the tfmn lA
tnb|ot«, each of j\,th of a grain. eooibiBed with
chocolate. Two of tiioae may be Ukcn tntntrnttf.
j: II — . — nttiirfced anti paraaitie »nii
These remedies all
136
Medkak Treatment.
(Part I.
anti-fermentative projierties, and they are also |)Ower-
ful Bedntives.
Ci-easote and cnrlwlio acid li«vo Iwen pi-escrilied
in the following forma for the rolit-f of vomiting : —
I^ Crpusoti mx.
Aridi ncotici ... ... ... ... ... m.TX.
Morphina- snlphalis , . gr. »»■
AnuR> nrl 5j.
Miecc. fiat miftura. A teMpoonful every half hour for thr
or four doses.
V) Acidi carbolic! gr. j.
Chloroformi m iv.
Spiritus villi reclifieati jsn.
Aquii' ... ad 5j-
Misce, fint niigtum. Half to b<< tnken iinmodintcly and
repeated in half nn hour.
Many of the remedies we have here indicated arc
efficacious in checkinj; tire .symptomatic vomiting of
cerelji'al, ronal, and other iivn.iadie8.
Max Einhorn states tliut ho hiis seen many case
of " nervous vomiting,'' which have continued for^
many years in spite of various raixles of treatment,
" l)erfectly cured by the funwlic current."*
AVe may now refer especially t<.) two forms of
Bicknes-s which we shall have no other opportunity of
alluding to, namely, sea-.sickneas and the vomiting of
pregnancy.
And tii-st, with regard to «««-«* irk lies*. We
doubt if anything can prevent sea-sickness (except in
short voyages) in certain persons and in certain cir-
cumstances, but we are satisfied that much of the
distressing nausea and retching which fuliow the tirst
or second act of vomiting can be, in most persons,
effectually relieved, the indication being, after the
stomach has been evacuated, to allay tlie liypenesthesia
of the gastric mucous membrane.
It is undoiiliteiUy of great importance to follow a
cart^ful and simple diet for a week or two Ijefore
undertaking a sea voyage, and to t^iko two or throe
* " Diieaiea of StoouMh " (second edition), p. 444.
SgA-SxKjress.
'.'.:
p^fioQ
of aperient in«dicin« dorioK ih»e
befon* ernlMvrkitig.
For voyages of live u> ten hoan, ii
aickne«8 maj be obtained by lakiiig a i
of chloral au<l aninHHiiam liruiide to twwjue frtv to
ten hours' sleep ; 30 f^^n* of e^li ef tboM is aa
ounce of chloroform water ahoald tie taken half an
hour befort* the veaM-l starts, in whicb a eaafovtaUe
sleeping bertli should he secured. Certain peraona
liare a tendency to vomit even in taking kmg raSvay
jonmeys ; {lotwisiain broniide will often pretenC tbv
tendency.
In short but ittonuy tunnpe we have fannd tfca
following druught very UHeffd. and allkoo^ it amy
fail to prevent the first act qf vomiting aad liae
discharge of the contents of tlte tto— cli, it kaa had
the eflfect of taking away mnch of the diitinn of this
vomiting, and has proved of jEreat v-aloe in prerenlittg
further nausea and retching. This drau)^ ronsiiils
of half a grain of cocaine hydrochloride, 30 niininM of
vmfonn, and ■ dmm of oompoond tinctare of
nonis, mixed n-ith an ounces and a half of
It should 1>« given as soon as any aerioiis
is felt, and althoagh it will not prohaUy,
'as we have said, prevent the tirxt act of vomiting, it
will, if anothtT ilosse be taken immediately after
this, prevent in many persona a rccnrrence of the
Hckne<M.
Tliere i% a c<inNi<ier«ble amount of evidenee in
favoar of the uttofulnesti of chloral in combating aen-
sicknesa. Dr. (>ira.ldee and Dr. Obet, both qooted
by Dojardin-Beaumetz,* bear testimony to its sneeem
— the former in his own person in »hort paamgea
the English Channel, and the other in his
ctii« as physician to the Tranmtlantic Company —
in dose» of \'> to 45 graim* — ie«d rhmnpajfne being
given ot the same time to allay tiiirht.
In those exceptionally grave cases in which the
vomiting pentiists in spite of chloral and other measorea,
** Iie<;oiia de CUniqtie Therapeotiqae," tdL i., yi MO.
138
AfEDICAt TrSATMENT.
IPnrt I.
we should not hesitate in the free usp of morpliine
unci atropine, injected liyptKlenniciklly ; it is only hv
such nieaTis tliiit the risk of fatal exhaustion ciin l>e.
averted. We slionhl liegin with ft rjuarter of ii grain
of mor|>iiine and y\g grain of atropine, and, if
necessary, increase the morphine to doses of hiilf,
three-quarters, or even a whcile grain. Iced cham-
pagne or bniudy and soda-water should he given
if it can be rel'ained ; if not, it is advisable during
the continuance of the nior]:)hine sleeji to administer
enemata of milk and brandy or beef-tea and hrundy.
Tliere are, however, .-iome persons in whom mor- ,
phine itself excites troublesi.mio vomitini; as well as *
great cjirdiac depres-sion, and in such cases we must
avoi<J this drug and have recourse t<> cocoiiir or
ehloTo/urm. One or two drops of tlie latter on a
lunip of sugar, or in a wine-glas-s of iced -soda water,
may l>e giveji every fifteen minutes until relievetl ;
or a solution of liydrocJiloride ef cocaine in the
projiortion of 1 grain to the ounce may lie given
cautiously in do-ses of one or two teaspoonfuls every
hour or two.
A tightly applied alMloininal belt has l)een advo-
cated as a useful preventive to sea-sickness, but it has
provctl of little remedial efficacy in severe cases and
on long voyages.
Amraoniuni bromide is regaixled by some ship
surgeons ivs the best of all remedies. It should be
begun a day or two Wfoi-e embarking ; a do.se of
20 grains in an ounce of chloroform water with 15
grains of sodium bicarlxjnate twice or three times
a day. It will remove acidity and promote gastric
ana-sthesia.
CMorohrniii, which is a mixture of cbloralamide
and jiotassium bromide, .30 grains of each to the ounce,
llavoureil and coloure<], has t)een found of value in the
Iri'atment of tliis malady. The dose is two to four
drams, repcatwl if necessary.
Other remitlies that have been suggested are
the application of an ice-bag to the spine, and dnip
*(. vii
VoMlTlffG OF PkFGKAKVV.
«39
I
dooes of tincture of iodine in a t««spoonfal of w»ter
nvery half hour. Resorcin in 5 to tO-gnin doaea,
and aiuyl nitrite in doves of ), n minim, dissolvcl in
20 drops of spirit of wine, and nuxe<l with a t«»-
sf)oonful of water, every liour.
OxaInU of atrinm will, occasionally, miooeed in
allaying vomiting after other retnedieit have faile<i ;
2 to 3 grains should l>e given, mixed with a little
powdered sugar, every two or thir* honrii. This in,
however, usually found of most value in the next fonn
of vomiting to Ije considered, viz. that dependent upon
Blrro-tcestntion. This is a form of vomiting often
excessively troublesome to arrest, and in extrwMl
coses can only be relieved by rlilatittioa of the cervix
uteri, or by i-emoving the uterine contents. Tu some
cases a small enema consisting of 20 miniin.-< of liquor
opii sedativus and 30 grains of potassium bromide in
2 ounces of water has Ijeen found very valuable ; or
15 grains of sodium bromide in a Uiblespoonful of
lime water may be ^^ven by the mouth twior a day.
The stronger alcoholic liqueurs are often aiteful in
these cases, and .small quatktities of rum, cognac,
Chartreuse or Kirsch may be given, dropped on ■
lump of sugar from time to time, IjArge <loMii of
pepsin, 7 to 8 grains, have been a'lvoctited as of
great service. The lat« ProfesBor [.Asi-gue was a firm
believer in I he ethcjicy of tincture of iodine in such (:a«e»,
given in 5- to 10-drop doses with «yrup and wnter.
VrnijiolK is sometimes very us<>ful in arrestiny tbi*.
(well as other forms of vomiting ; (to also \n nfittliul .
Fifteen grains are dissolved in five drams of alcohol,
and an ounce of syrup is addetl. A teaspooufnl of
this mixture is given every hour.
Hemmeter recommends the following mixture: —
I^ Cerii oxtlatis
C'ociiinir hydrochluridi
M<>nthol
!"■ ' ilicylatii
1 iid»
M. Im.. „
limes doily.
g». I«.
gr. ili.
gr. lii.
5'- ,
. d. A laljleipoonful on lui empty stonvu-h (001-
T40
Medical TRRATMEtrr.
iPart. \.
Engcliiiiiiin has i'cc<»nli?<l a ease in whicli the
exlmustioii mul emaciation wore extremp, and in
whicii 1r^ jirfsfHlicil tfii (iropN of a 10 per cent,
sohition of (Micniiir- three tinu's a day. Aftor the
firat doso water was i-ctaiticd in the Htoniacli, and the
followinff day the patient was able to keep down a
cup of coflee, and suhsequontly some soup. Two days
afterwards the dose was diminiKhed, and the treat-
ment wa.s soon discontinued without any return of
the voniitinjf. In this case all the other remedies
tried liad failed.
Cocaine has also been given hypodemiically in
these cases with success — ^th of a gmiji just before
taking food twice or thrice daily.
Iiiijlvriii has been found by Pajtp to arrest this
form of vorailing. He gave four (grains half an hour
before food, and two tjililes])oonfuls of a I )>er cent,
dilution of hydrochluiic acid immediately after food.
Frommel has ohtftincd very good results from
basic or /'.nil*
Lublesky, of Warpaw, and some other foreign
physicians have strongly advised the use of the fthei
sprat/, applied to the epigastrium by means of a
Richardson's pulveri.ser for three or four minutes
at a time, liefore the patient attempts to take food.
Injections of chloral, inhalations of oxygen, feeding
by means of the syphon tube, and vanous other
expedients have been aiivocatcd for the relief of
this troublesome symptom. Sometimes quite simple
measures ai-e sufficient to afford relief, e.if. a table-
spoonful or two of lime water every two or throe
hours, olonc or with an equal quantity of milk ; or a
simple ett'er\'escing mixture, with .'5 to 5 minims of
dilute hydrocyanic acid in each dose ; or 2 or 3 minims
of liquor opii sedativus with a few grains of sodium
bicarl>onate in two tablespoonfuls of hot water half
an hour before attempting to take food.
Hinger advocates minim doses of ipetacitaidia
wine, witli or without small doses of nux voniicn, to
* Hemmeter, " Oixeaaes of the Stomacih," p. 634.
Cli»|.. VI. I
VOMITISC OF PkF.CXAKCY,
141
Ije f^ven evc-i-y hour for this and ntluT kinds of
vomiting. This Hhoiild certivinly be tried, but we
have not found it at <UI 80 rfficaciouK n» Kingcr hiix.
Chloretttnr, recently intrtxlucetl h8 a hypnotic, huM
Ijeen r«|K>rteil to poxsess auwHthetic propertien anulo
goiis to tliMist' of L'ocaine, and U> havo been found
of valui* in the rvXwi of vomiting of puitric) orij^in,
inoludiuj; sea sickness and liic? vomiting of ]iix-giiani;y.
The dose is 3 to 5 grains, in tablets or oiipsuli-Ji
Dr. Kt-nny, of Tallow,* ha« statfd tliaf lie Iiiih
found thu application of a blister \\ inch long
and lialf an ineh wide over thu pn>.<uniogaxtrtc
nervas at the anterior l>ord«?r of the bU'ruonianUml,
relieve permanently uiast distren-sing vomiting occur-
ring during and after delivery, when the usual drogs
ha*i been given without any result.
Mitchell t states that he has succeeded in oon-
tnilling the most persistent vomiting by applying
towels wrung out in ice-cold water anil changed ei'ery
minute till the vomiting has cease^i.
The cases of " Perio'licnl Vumilini/," fW-s'Tiliod
by Ije-yden, sieeiu to uh to lia\e a dosi: r' ■ 1.
with thoEM? cases which we term "sick lieai'i u
this i-ountry. Their periodical rvcurn-ncr, without
any w^nrning, when the patient may Ijc in good
health, the circulatory depression, thn int/rouc h'-od-
ache, thu acid vomiting, the loss of ap|intit<-, th«
tendency to recur for many years, codiJ"»»»' a patho-
logical piicture very familiar to EngliHh phynciana.
GAilTRAL>UIA, GaSTKOUVSIA, SpA-SM utt (-'RAMP Of
THE Stomach.
Tliese several designations are appli««i to c>rt.iin
painful conditions of thf Mtomach rtferrible (<» r»fi
arteclion of the ga.stric n 'Uiooif>«'
(he «ym|)athetic — and ii^' •trurtur^i.
ease or functional alteration <it lu miHeabr <ir mooxM
structures. Whether dependent oo loeal irritaiMO,
* Brititk Mrdieal Jvurnrnt, /aoofT faA, V0L
t Piiuliti4n>»r, Ttbraagy, I9n, p. M.
«42
AfEDICAL TkE.ITMENT.
|t>an I.
iiiiinediiitc or reuioto, or general constitutional stHlcs,
tht-se conditions must l>e consitlered us ntrurttlf^ic, ami
their treatment must be ;(uificd to some extent by
the HAme pritiui|ilcs us Jetennine the treatment of
other iminful tiPiiros€"!».
Those [(iiinful aliections of the stomach are oft«n
asKOiiiited with iin.-eiiiia, cliloi'OMis, and iither debili-
tatinj; influences, an<l wimld apjiear in such cases to
Ue due msiinly to an imiH)verished stjitc of the
l>l<x>d. In hyst^erieal cases, and especially in those
connected with organic or functional disorder of
the female sexual oi-gniis, attticks of gastralgiu arc
exceedingly couimuii, and they are apt then to
occur exclusively, or with ejipecial severity, at the
mcnstnml p(?riods. So alsfj in diseases of the
ab(h)minal viscera, ijiutniliiin may Ijc excitetl by
irritation conveyed along tlie branches of the sym-
pathetic. It may occur in those morbid states of tlio
bloiKi determined by nmlaria, by rheumatisiu, gout,
and by other dyscrasiii'.
AtUicks of giistralgia may also be of centra]
origin, and depend »v\ disease of the gastric nerves at
their source, or in their course before they reach the
stomach, as from thickening i>f their sheaths, or from
the pit'ssure of tumours ujwn them, such as aneur-
isms, et*\
It is obvious that the cause of such attacks must
occasionally be obscui-e, and difficult of discovery.
When attacks of gastralgia are induced by certain
ingesta which would not cause pain under normal
conditions, we must regard the attacks ns due, to
some extent, U) a, morbid hypci-icsthetic state of the
extremities of the ga-stric nerves.
Ctastralgia, like other neuralgias, is apt to occur
in any circumstances which lead to general mal-
nutrition, and csfiecially to tln^e which produce
exhaustion of the nervous systeiu, so that masturba-
tion and sexual excesses must be included amongst
its causes. Excessive use of tobacco luvs also been
stated to be a cause of this aifection.
,VM
Gastkalc.ia.
•43
The siicoiwKful trnUitttnU of gAStraliria will de-
pend, ill the first |(iiu.-e, on uue'n ability to dihtin^uinh
it from other morbid stntt^s giving riHC to piius in
the region of the htomach ; we must, tht-rvfurv,
ider brieflj the chiiracteristic •>>'inptoni» of
nilgia.
The pain in this affection I* rt\>t to inni.' -.u
Haddcnly, and in paroxysmii, and th^n t-j |iii.ij. ,i»:i\
completely for a time, lu soate cueu the pain is very
viol<<nt. " Severe griping pttina in the pit of the
stoniiich, usually &]>n-iuling into the )>a(.'lc, faiiitne9.-s
shrunken countenance, cold hands and fi-et, and small
intermittent pulse. The epigitstrium is either puffed
out like a ball, or, as in more fre<]aeutly the caxe,
■ retracted, witli tension of the ainiominal wallH. Tliert-
ia often pulsation in the epigtuitriuni. External
pressure ia well borne (unlike the |>ain uf ulcer and
H cancer), and not unfn'vjuently the patient pmnm th<-
H^ pit of the stomach agiiinst wime firm gubntaticr, or
^L^4[^presaes it with his hands. The attack
^FlMtii from a few minut«s to half an hour , titen the
H^ {tttin gradually subsiden, l»tving the patiiewt Bmdl
V exhau.^teil, or else it cease.i suddenly with eroetetiaa*
of gas or watery fluid, with vimiiting, witli gpntlr
{terepiration, or with the ]iaasage of pale or r««i(ii«h
urine."* There ia sometimes a craving for food, and
the pain ix rcliovftl by talnog food — a eireainaUaM
which also differentiate* thia diaeaae from omiI otkcr
morbid states of the stomach. Cotaplete low «i
ap|>etite is, however, not tuicomaiDn. Nor* or lem
long intervals between the attacks also ntn to 4i»-
tinguish it from the more or leas oootiiUMNB pais fd
cancer and otlier atrectinoa. When da« to nmLuiai
causes the attacks may lie periodic
One of the most iiii|H)rt«iit eutuideratioos ia to
reooKiiiae and digtingnish the Icim iwTt^rc fbma ul
gastralgia occurring in dilorotic girlt from gmtrk]
ulcer, which is also so freqa«ntijr fouitd to ««Mt ia
such patients. The {lain of gMtric mletr i* mmMj
I
•44
Medic A /, Trea tmest.
Il'ut I.
Bglin^vatod, and not relieved, by taking food ; and a
careful diet or complete abstinence will be attended
with the hent reBults. Abstinence will, however,
often aggravate the gostralgiu of chlorosis. The
occurrence of lefl-gi/h-d pain is exceedingly common
in chlorotic and fiysterical gills, and it is sometimes
referred to the gastric and w.nnelimes to the cardiuc
rogion«, und souietimes more vaguely to the left side
generally. It is oftt^n very difficult to detenuine the
nature of this left-sided pain ; in some cases it is iloubt-
less gastralgic, in otliens it is de^iendent on neuralgia uf
the lower int-ercoftiil nerves, as may lie detected by
prtsHure over the lower interspaces ; in others it would
seem to lie acLuidly cnnliiili/ir, and deiwndent on a
hyiM^i-sensitive state of tlie caidiac muscle, as jiressure
witfi the tip of the linger over the cai-diac ajKJx is
distinctly painful.
It is often difficult at first to distinguish between j
attacks of bilianj colic and gastnilgia, and when
there is no jaundice or other sign of biliary oIh
atruction, we must l)e 'guided chietly by the history
and antecedent and concomitant circumstances of
the case.
We have also to bear in mind that gastralgia uiny
co-exist with other diseases, organic or functional, of
the stonmch, or other abdominal visc>^ra. But having
aatisBed ourselves of the neurusal character of the
disease, the question that has here to be discussed is
how it can best be relieved or curetl.
When we are able to trace the gastralgic attacks to
some obvious cause, tlw incliratioiiM lor ireitlmenl
are dii-ect and clear. If they are found to occur after
taking particular articles of fixxl or drink, these must,
of course, be eliminated from the dietary. Tea,
coffee, tobacco, particular kinds of wine, even milk
and eggs, certain kinds of raw fridt and vegetables,
some varieties of fish or shell-fish, will induoe in
certain persons attacks of gastrodynia. In such
persons very careful observation should be made of
the effects of different aiiicles of food, and a suitable
Oui^ ;i
Gastkalcia.
MS
dictar}' coiixlructMl, frunt wliich thooe which disagree
with them are excluded.
In ehlorotic and antemic cases our efforts should be
directed to restore a normal condition of hlood and
nutrition. For this purpose ferruginous and other
tonics must Ije given. Some jireparations of iron
agree much lietter with th*«e patients than others.
Loubc * prefers the laclatr. of iron, or the frrrttm
rfdactiim in .'J-grain closes, n]ixe<l with .some aroiuatic
powder, or with extract of cinchona. He ali»o
recommends in such cases ■*< drops of dilute hydro-
chloric acid in a wineglawful of water two hours
after food. We have found the following modilicii-
tion of Blaud's piUs very useful : —
»
Fcrri "''•■'■'■•'' r-xeiccalH- ... ... gr. ij'
Poln- tin ... gr. 1.
1'iiIm ^ 'inic.a' . If. J
MaciliiKinis i|nantum milBeial.
Ut flit pilutn. Odv thtoe times a liajr an buur oIwt bed.
Another combination we have found u.«eful in
these cases is the following : —
Vf Ferri i-t quininii; citratin gr. x.
Liquoria strychninu' ... "liij-
Audi hydroc'hlurici diluli i>|T,
AquH; cUIoroformi ... ... ■<! Jj.
Mikce. fist liatutiis, Tu be taken na hour «ftcr focni tbrw
ttini.<a daily.
Dr. Hueliard tinJs the following pilk vnluahle
in these cases : —
Vj Ferri tarUrati .
Elxtracti gentianu'
Extract! nucia Tomicia
Extrai-ti cipii
Miwc, ut diviiie in |iiliiliui Diimoro centum,
tukon immediately befjn' Uicli meal.
:: I-
grana ir.
Two to bo
Ewald prefers an albuminate of iron which he
roughly prepares by adding the solution of [H>rchIoride
* ZiesDHCu'i " Cyclo{iie<liii of the Practice of Mediciiw,"
Tol. rii, p. 306.
K
146
Medic A l Tk ea tmeni .
[Pan I.
of iron to u mixture of egg albumen iwd water
1 to 5.
The saccliarated carbonate of iron is a mild and
easily-digested form of iron, nnd can be given in a
powder of 5 to 10 grains after ni<\ils tlipee times a
day.
Strychnine has Ijeeii found cuiutive in Bonie in-
stances. From ^i,lh to ij^th of a praiii may be given
hypodecmically ; or three minims oi the li(]iior .strych-
nine in a tablespi.ionfnl of clilorijforin water may l>e
given twice or three times a day, an hour before food.
In ana'mic cases which fail to benefit by the
pharmaceutical prepanitions of iron, it may lie
aiivantageous to i)rescribe a course of iron water at
Spa, Schwalbacli, Pyrmont, or St. Moritz.
When masturliatioii \& the cause, Ijeuhe n(lvLse.s
cold frictions of the whole body and ivmoval to the
sea-side for sea-baths, or to 8t. Moritz for its moan-
tain air and iron springs.
Ciuses having a malnrinl origin must be treated
with (juinine or ai-sonic. (jninine must be given in
ade<|uate doses — .5 to 10 grains dissolveil in lemon
juice three times a day ; if quinine is not well borne
or fails to relieve, arsenic should Vie given — 3 or 4
minims of the liquor arsenicalis aller meals three
times a day, Or it is sometimes better to give a
gmaU dose of arsenic, one minim of Fowler's solution,
in water, imiiiediately liefore meals, for some con-
siderable time ; and this method is applicable to
other than nialttriul c.ises.
The purely hj^loridil forms are often very
difficult to i-elieve ; the lironiides, alone or in combina-
tion with valerian and other antispasnxidic drugs,
should be tried. The x-alenamilv o/zinc or of iron in
grain doses in jiills three times a day after food is,
I>erhapK, one of the l<est remedies in these cases ; or 10
to 16 grains of bromide of sodium or ammonium in an
ounce of infusion of valerian with 20 minims of spirit
of chloroform, an hour before meals twice or three
times a day, may be given ; or 5 grains of the piL
Chap. VI I
Gastkalcia.
'47
uaftptido- conip. thrice daily. Seji-batliiiig, if it can
home, is likely to be of more permanent use than
'drugs in these cases ; or the judicious use of cold
OompretHMH or douches in a hy<lro|>athic e.stabli;:ili-
meiit., togftlior witii niassane, or the application of
tho constant current ; the latter is sometimes very
efficacious.
Max Einliom advocHt«.s as c«|Hii:ially beneficial
Hie intraci'itlriculnr method of applying this galvanic
current. He says, " It rarely fails to relieve the most
intense and obstinate cases of idiopathic gastralgia "
if applied for a perifKl of from four to six weeks.*
Hemraeter also refers to the galvanic cuiTent as a most
effective remedy. He uses "large feltcovere<I copper
plates dipped in water as hot as the [Mitient can stand,
the anode placed on the epigastrium and the catliodo
on the spinal column extending from the cervical
region downwnnl iKjtween the scapulie." For this
purpose he u.ses " very strong currents, not less than
25 luillianipi-res."
If the attacks are dependent on some uterine
affection, appropriate local treatment must be insti-
tuted.
When they are a^isociated with the gouty or rheu-
matic state, the constitutional condition on which they
depend must be attacked The gouty attacks will
require very careful dieting and eliminative treatment
— the free ejchibition of draughts of hot water, or, if
there is much acidity, warm Vichy water ; if there is
constipation, warm Carlsbad water, in addition, taken
in the morning fasting.
Hot compres.ses or mustard poultices to the
epigastric region, and warm baths, will be useful in
both gouty and rheumatic cases.
In the gouty cases attempts to provoke revulsion
to the joints may be made by the use of hot foot-baths
of mustard and water or niu.stard [)oultices to the feet.
It is also advisable to give some diffusible stimulant
to relieve the aense of general depression and appre-
* "DJMMM of Stomudi " (Mcond odition}. p. 413
148 Mi: PICA/. T/iEATME.vr.
iioiiaiun which usually accompanies gouty gastralgia,
such as tlie followin{| ; —
ly Ammoiiii carbonntia ... ... ... gr. v.
Spiritua irthcris compositi... .. ... in xx.
Aqiiii' munlliiy piimritii' ... ... 3J**-
Misce, tiat h.-iiiittua. To b» taken overy thrfo or fuur hours
until rulioved.
Many other remedies have been suf^gi^stotl, .nuch as
alum in 15-grain ilosps thri-e tinu's a clay, tetween
meals, poLiissiuni iodide, .siilicin, and sodium salicylate ;
the last three would certainly merit a trial in rheu-
matic cases.
pjissing now from the fulfilment of the causal
indit'atious when these e.\ist, we must consider next
the troaiineiit of llic iilliirk when the cause is
unknown, or when the immediate relief of suffering
Incomes the p.-u-amount indication.
In most of these ca.sc!», opium or morphine in one
or other of itjs forms will be needed. We should
eiuleavour, however, to u.se as smivll doses as possible,
and to avoid their fref|uent repetition ; for not only is
there the fear of inducing a craving for opium or
morphine, and the creation of an opium habit, but
these drugs have the great di.sadvantage of arresting
the hepatic and intestinal secretions, and, therefore, of
causing constipation, loss of ap|ietite, and sluggish
digestion, so that the general nutrition becomes greatly
impaired by their frequent u.se. We must not, how-
over, hesitate to use them for the relief of pain when
this is severe and when other means fail. The liquor
opii sedativus (/iatl/'t/) is the be^t form for giving
opium in these cases, and it Ls well to combine it with
ammonia and some aromatic, ns in the following: —
iy Liqiinris opii sedativi nvvadx.
Kpiritiis Hmmoniio aromfttiri y»,
Aqiiio luriii... ... ... 5j.
Misce, U.it haiistua. To be tnkon when tho pnin 19 Kverc.
Or we may give a sixth to a third of a grain of the
hydrocldoride of morphine hypodermic ally, with j-ggtb
4
ch»p. n.i
Gastralgia.
»49
of a grnin of atropine to relieve the paroxysm. When
the pain is less severe, Imlf-griiin doses of pho8]ihnt4i
of co<lein every 8 hours have l)een 8ugge8U<d, also 8up>
positories of opium and I)elliidonnii.
CnnniAia iruliat lias been found most useful in
many cases in relieving the paroxysms of pain ; it
may be given im follows : —
Bf Tinrtum' cunniibisindica' ... ... 3J.
MiiciUf^inis Hcaoin>.. . . . ... 3J'
Aqiiiu clilonifonni ... ... ad jW-
iliooe, fiat miilura. Two tabtespootidilR for u dow.
In acute gastralgia accompanied with uncontroll-
able vomiting Struver has given cocaine and antipyrin
' i3eonibine<i with advantage. (•S'e»r formulnt.)
Many French physicians l^-iieve that we may avoid
the too frequent re<vinrse to opiates in some of lUi-m)
casea by giving chloroform water — a tttlilenpo<jnf!il of
the aqua chloroformi of the B.P. with .'iome aromatic
water — every quarter of an hour. (_>r a few dn)pN of
chlorofonn on a lump of sugar may be .swallowi-d from
time to time. It has the advantage of acting a« an
antiseptic as well ivs an anu-Hthetic, and of checking
putrid fermentation in the stomach if any complication
of that kind exists. Corninf h>jdroc)ilorulr may aUo
serve the same purpo»e an opium if the gnstntlgiA
de{)end8 on r hypeni'^thesia of the p^ripherul endu of
the gftntric nerves. Half a gnvin diKHolve<l in ^ an m.
of chloi-ofonn wat/<r may be givi-n for a do«e ; or in
more chronic forms, a quarter of a grain may l<e madr
into a pill, with a gniin of extract of valeriun, and
given three times a day.
In hysterical casea as8(iciate<l with vomiting and
spasm, Ewald has found the foUowiiig drop* usefal ; —
R? Morphinii- hyilrwhli)riJi RT- iij.
C'-aiino! hycirochl'.'ri'li ... kt. vajriij.
TincturiH tielladunDn' 3J ■"' 3*]-
Emwlsionis ainygdalu auuua.- ... ad Jj.
Ten to tiftean dn>p« ertry hour
Bitmuth tubnitraU is oft«n found navful in chronic
'SO
Medical Treatme^o:
(Part f.
cases. ItH action would seem to be entirely local, and
it should tlierefore be given in large doses, such as
30 grains three times a day, together with 3 to 5
minims of dilute hydrocyanic acid and an ounce of
mucilage and water. Occa.sioiially purgatives must
be given when these large doses of bismuth are used,
to avoid the possibility of concretions of this drug
forming in the bowels.
llydrorxjanic acid alone will often relieve the pain
of gastralgia, but it is a somewhat uncertflin remedy,
and we probably fear to give it in adiHjuate doses.
Nitrate of silver may al.so be tried in chronic
obstinate cases, a quarter of a grain in a pill with or
without half a grain of extract of opium, an hour
before tjtkiiig food, twice or thrice daily.
Benefit is sometimes derived from the application
of an opium or belladonna plaster to the epigastrium,
or from frictions of this region with opium or bella-
donna liniment ; or a combination of equal parts of
opium, belladonna, and chlorofonn liniments.
ADDITIONAL FORMULA..
For liBmatemeaU.
R Plunilii accUitiii, ^j.
Aciili nec'ti diluti, >jss.
Liijiinris iiii:>r]<liinii' acfitntia,
.sijsg.
Aquic liwttilltttw ud jviij.
M. f. mist. A tiiblespooiifiil
ill a little water every two
bour."i. {n hillo.)
Hypodermic inJecUoB for
■ea-sickneu.
ft Morpliiii.T hydrockloridi,
gt. iv
Atrupiniv sulptiatia. gr. j|.
Aqua' Itturocemsi, 5<».
M. f. aolutio. 16 mininis in
a dose. (Jhijnnlin-Jlriiiimrl:.)
Mixture for hiematemeslB.
H < )U'i tort'))ijilhinip, ^iij.
KxtniPli digitalis lluiai, sj.
Miiciliiginin n<ndir, ^iv.
Aijusc incnthic piperitm ad
M. f. mist. A tablmpoonful
every three hniufl. {UarlholoK.)
Cacbeta for acid gaatralgia.
II Bieinuthi sulmitmtis '\ jj
Mii({iii;»iaf pouderoiue \pf
Crcto' prpparatn! f ""'
Ciili'is (ihoKphatiM j 3
M. {. pulv. To be diTided
into 10 raphets, aud oue taken
before every meal.
( DHjariiin-Bfmmitelt.\
kap. VII
Additiosal FoRHVLjK.
»5»
BasordB pllU fbr ma-
ilokseu.
R R<«eorcmi puri, gr. jss ad ij.
Sui-chari Isctis. gr. ij.
M. I. pil. To be taken every
two hoiini. {U . Mrnchr.)
PUI( for tbe Tomitlng of
pbthlsli. of pregnajioy, and
of gastritU.
R Co" . ' '; I.loriili, gr. V
Oiiii ,\.
tiiV' _ _ ilvfri*. q.s.
M.'ut 1. j.il.' To J* tnkm
five or MX limci a <lny, teu
niiuut4>j bfforc tiilriug focnj.
■UtoTC for the Tomiting of
pre^ancy, and in otber
forms of vomiting of botb
peripberal and central
origin.
ft Cocaiusp, gr. ij.
Antipyriiij gr. xvj.
Aquii", :,iij.
M. f. mUt. A tsupoonful
every half hour or hour.
(.SVucr,-.)
Enema for vomiting of
pregnancy.
A Sodii bromidi > .. ,
Chlnnilliyclrafof**'"-
I.ACtii et lujuu.' ail Jix.
H. f. eiiemit. {fitthuol,)
For tea-iicknest.
H Mrnthol, gr. iJR«.
("nc»iiiifiiyilrocliloriili, gr.xi.
Alcohol, jiij.
Syrupi, jiw.
M. f. mist A triu|>oonfu|
every half hour. (/.ncn/frV.,
Another,
ft Chlorofomii,
Tr. tiiiciH vomicJT, uil, «li.
Tr. InvniiJ. co. si.
.\qiin', Sx.
M. f. iiii«t. A t<>n>>pi>oiiful
every hour until nlifvi'd.
( Iliirl'Cf.)
For gutralgia asaodatad
with mild putrefactive pro-
ceiaea.
R Chloral bydnte, kt. Izzz. ad
Mj.
Aquip od ir.
M. f. mist A tableipoonful
every two hour*. (AhuA/.)
For gaatralgU.
' R Quioinse lulubatiA, Sa.
Kxtracti belladonna, gr. ▼.
Extmcti valerisnie, q.s.
M. ct divide in pil. xv. Oue
thrice daily. [Hill,!.]
. For gaatralgla.
I R Cocainic liydrochloridit
Chlornl hydrate, gr. x.
Ai|H«p menthit' piperitie, 5j.
H. f. liauxt. To be taken
occaaionally, (KiraM.)
AnUapasmodic for painful
gaatrlc spaam and Datu-
lanco.
R •'^piritus ammonia! aromatici,
5m.
Spiritug irtherii cumpoeite,
Mj.
Liquoria morphinit! hydro-
chloridi, sj.
Aquir nieutlui* piperibv, ad
jviij.
ftl. f. niiat. A lables}X>onfuI
for « d<j«o.
PUla for gaatralgla.
R Argonti nitnitin, gr. iv.
Pulv. rinii, gr. iij.
I'ulv. rtiel.
Kxtmeti lupnli, U gr. xij.
M. et divide in pil. xij. A
(lill twice or thrice doily luilf
an hour Iwfore food.
Powders for gaatralgla.
R t'odt'inii' I>ho>^|dmti1, gr. J.
Bisninlhi tubnitratin, gr. v.
Socchari Inctie, gr. iij.
M. f. jHilv. fa be taken
every two hours. (A'itmW.)
'52
ClTAFrER VII.
DIBKA8E8 OF THE STOMACH — THE TREATMENT OF
PYSPEPSIA — MODEBN GASTRIC MF.THODS.
Oaubes of AtoBic Dyapcpsia — Defective Bolatinno between Diet
and Digestive Capaoitf — Dyspepeia of Enrly Infiimy— (Iver-
feeding — Drinking at Mid before Heal.i — Hiisty KeeJing. —
Smrrrojis of Functiouiil Drsjiepaia distinguished from tho«
of Unatrie t'jitanh— Pseudo-anginal Symptoms — State of
Bowels and Viiue— IiKulnilal Nervous Symptoms—" trastric
Cnim]>," or Paroxysmal Pyrosis. Trkatjcent : {\) DiiMir—
Importance of careful Mastication— Selection and Preparatioa
of Toads — Intervals between Meals— Beverages— (2) Jirui-
minal — Exorcise and Fresh Air— Change of Air and Travel —
Hydrotherapv — (3) Mrdieinal — iHiliealiom - Vegetable
Bitters- -Hyrfrochloric Acid and Pepsin — Strj-ohnia — Alka-
lies— Soda — Magnesia — Ammonia — Khuborb — Bismuth —
Croasote— Thymol— Charcoal— Lnwnges to promote Salivary
flow —Hot Water — Value of I'urgatives— Mineral Water* —
Dinner Pills— Calomel, /iilrnlimil Iii/iii>rptiu — "Secondary
Dyspeiwia " — " yrniiiu Jjfhiliti/ " — Hydrotlierapy — Masgaga
— Eloctricity — Change of Air — Pupaiu as a Suostitute for
Pepsin— ModeTn Gastric Methods. Additional Formulnt.
The sornewhat vagne temi d>'spep«fn, when used
alone, as the designation of a morliid Htate, refers
generally to a di.st«rl>cd condition of the digestive
functions, the existence of %vhi<-h is itidejjcndent of any
structural or infliiinniatoiy cluviige in the stomach
itself. There is undoubtedly some force in the re-
mark of Dujardin-lk'iiunietz that the tenii dyspepsia
ought to disappear fi'otn our list of diseases, as it
is a symptom, oi' rather a more or les.s varied collec-
tion of symptoms, common to different diseases of the
stomach.
So also in most serious organic and constitutional
affections, such as the specific fevers and acute and
chronic \'i8ccral itidammntious, some amoutit of dys-
pepsia, i.e. distnrl)ed digostion, is an altuost constant
symptom, the functions of the digestive organs shar-
ing in the geneml functional disturlinnce. In such
cases the dyspe]>sia is either simply a patl of a general
Oap VII. I
Dysprpsia.
»53
malady, or ii disorder excited by or dependent on
disease of another organ.
There are, however, some morbid states accom-
piinicd with disturV>ed digestion, in which it is not
always clear whether the dyspepsia stands in the
relation of cause or eflect to the other co-existing
malady ; as, for instance, in such diseaiies 8m ^ut and
rheumatism, as well us in some vague atfections of
the nervous system.
It is difiicult, therefore, to treat the suVyect of so-
iled "fnnrtifriial" dyspe]mia with any great precision.
To omit it i»lt<igether, as Leuhe does in Ziem.ssen's
"Cyclo()H'(lia." or to class it under the gastric neuroses
as other writers do, sppears to us eciually unjustitinlile.
For there is certainly a practicnl need for its separate
consideration, and although inuny cases which were at
one time groupe<l under the vague heading of dyspepsia
now find their place more appropriately under the
more precise designHtions of iicute and chronic gastric
catarrh, dilatation of the stom.ich, aiui gastralgia, theru
yet remains a very large group of sufferers from dis-
orderejl digestion who cannot be so classitied. It is
to their condition that the terra dysjicpsia must be
applied, and it is to it« trentment that our attention
must now be directeil.
The search for a cauMstl indiciilioii for treat-
ment in many of these cases is exceetJingly ditliciilt, and
in their investigation the skill and practical sagacity
And penetration of the physician nro often most
flerverely taxwL
It is assumed that in most canes of dyspepsia the
gastric juice is altere<l or defective in quality or quan-
tity, and that an iW?(/A'<'icre< secretion of gastric juice,
together with deficiency of muscular action, are the
determining conditions of " atonic " dys|)epsia.
Hut we hnve then to consider what ani the causes
of this defective secretion of gastric juice and this
lack of muscular tone in the stomach walls.
No doubt depressing agencies of all kinds may
directly or indirectly impoverish or vitiate the gastrin
'54
Medical Treatment.
|I>aitI.
secretions, and so induce a dyspeptic: state. Elx-
haustiiig illnesses ; over-\»ork, physical and mental ;
depreiising emotions ; nnxiety and worry ; insanitary
surrounding and habits, or an unhealthy climate or
residence; sedentary occupations ; vicious indulgences,
indolence, and want of exercise — all these may induce
imperfect blood formation and tlic aiuemic state, and
a consequent defective secretion of the digestive fer-
ments. It has been suggested with great probability
that in some cases, and especially with Americans,
dypepsia is hereditary. The eager and hasty struggle I
for wpAlth, and the inordiniite activity and mental
excitement dejiendent thereon, together, proljaV)ly,
with faulty habits of feeding, seem certainly to have
made of the modem American a dyspeptic tyj)e, the
signs of which ai-e seen even in early childlnKxl.
One very certain and common cause of dyspepsia
is the neglect to discover and establish a ilu« rdaliiyn
belioeen the diet or food taken and the Tutfnrnl
digestive capacities or peciilinrilies of the iiuliridnnl.
These natural jjeculiarities, or idiosyncracies, are of
great importAncc, and should be carefully incjuired
into and observed. One person secretes haVjitually a
large quantity of salivaiy ferment, another a com-
paratively small amount ; or one individual secretes
naturally a targe quantity of gastric juice, another a
comparatively small quantity ; so with the bile, as we
frequently see, and so, no doubt, with the pancreatic
and intestinal ferments. Now it may happen that
the persons who secreto a large qusntity of gastric
juice* may secrete a cotiiparatively small ijuantity of
saliva and of bile ; or vice vn-sd. If the individual
who secretes a large quantity of gastric juice and a
* With regard to the sonroe of the acid in aritt dywpetmn. Sir
William Robert* miuntaiui that it i« derived exclusively frnm
eocoeniTe secretion or nccumiilatioii of Bostric jiiirc. am) not from
liny fermentiTe process, "The sort of wiiidv turmoil." he Siiys,
" which goes on in the atoinnoh of the (ly«i>eiitio hns led otieerven*
too hastily to f Jie analogy of vinons fcmicutation. A more precis*
exiuniuatioD of the incicients of arid ilys|iei)siB lends no support to
tliii view " (" Digettion and IHot," p". "ill).
dun VIIl
Di'SPEPsrA.
<5S
I
Kmall quantity of salivary ferment and bileeAtalaigelj
of farinaceous and fatty foods, he will become dys-
peptic froiii inaViilitr to digest them ; bnt if he «Ua
largely of animal albuminates and sparingly of starches
and fats, bis digestion will be good and efficient. On
the other hand, if another subject who secretei a
minimum of gastric juice and a maximum of saliTa
and bile, eato largely of animal flesh and but sparingly
of carl>i>hydratc« and fab*, he may become dysfieptic
aiiri badly nourished.
That these differences exist cannot )« doubted
when we note liow greatly the amount and character
of other secretions, such f.tj. as that of the skin, differ
in different persons. It i« our duty, then, to study
each individual dyspteptic closely in order to be able
to estAblish an accurate relation lor to correct an in-
accurate one) between his diet and his natural indi-
vidual digestive peculiarities ; and the establishment
of thi.s relation may be all thnt is neeiled to cure his
•lyspeiwia. The food also must \te adapted lo ago
and condition. Of the weakened and lesH active
digestive functions of a<lvancing age, leMs mu.><t be
rwjuired ; and strength will be better maintained, in
many cases, by diminishing rather than increasing the
quantity of food. The too frf/pitnt taking of solid
food and the insufficiency of the int<>rval» between
meals is a common cause of disturlM-d digmtion in
feeble persons. Indifference or inattention as to the
quality and the prtparaiion of food is also the caoae of
mncli dyspepsia. The frequent occurrence of disorders
of digestion in early infancy is to a great extent due
to ignorance of, or inRtt<'ntion to, the physiological
oondilioim of the digestive wicretioim and the natural
digestive capacity iit tliHt early age, and nothing less
than a careful study of these conditions can enable us to
treat tJiese dyspeptic troubles of infant life successfully.
We must refer the reader elsewhere for a full
discussion of the subject of infant feeding,* Tlie
• 8rr the chapl<T on '• Food iu Relation lo Age and Condition "
In the autbor't woik ou " Kood in HeoJUi And Dimue" (chap, xi,}.
'56
Med re A l Tr ra TttEXT.
(Part I.
syniptouis of dyspepsia at this age are ratlier intrs-
tinal than gitntric, owing to the liriefiiess oi the
sojourn at tJiis age of milk in the stoniiich, and i\»
rapid passage into vlic intestine. The child is
tormented with griping colicky pains after each feed-
ing, the abdomen l>Pcomes distended and tender to
pressure, exuggiTated intestinal peristalsis, accom-
pauiod with gurglings and rumblings, is evident ; the
stools have lost their natural bright yellow colour and
uniform consistence of iieiilth ; they are gramous,
presenting wliite masses of coagulated, undigested
caBein, and are of" a somewhat offensive odour.
The infant becomes cross and irritable, its sleep
is disturbed, and it is clamorous to he constantly fed ;
and each feetling is followed liy eructations or vomiting
of coagulated milk. If this condition of things is not
remedied, the child becomes feverish, emaciated, and
symptoms of gastro-enteritis appear. The suitable
treatment and appropriate remedy for this state is
to be found almost solely in an appropriate hygienic
diet. The value, however, of antacids iind gentle
aperients as a<ljuvants in these cases is undoubted.
Lime water with a little milk, or calcined magnesia,
which has the iidvantiige of being aperient as well as
antacid, or, if there is diarrhtea, a few grains of
Bubnitrate of bismuth, may lie mixed with the
magnesia, or a small dose of (.iregory's powder, or IS
to 30 minims of cast^ir oil made into an emulsion with
a little syrup and mucilage nmy l>e given. One or
other of these renip<iies is often useful to remove
acidity, to allay irritative diarrhn-a, or to sweep away
offending sultstances from the bowels.
But the simple fawit of the introduction of too
much food into the stomach is responsible for much
of the dyspepsia of modem life, and a too great
eagerness to follow a so-called "supporting" method
of treatment in dealing with ana^nic conditions and
states of nervous exiiaustion has been to some extent
the cause of this. It should be borne in mind that
in these cases the digestive powers of the stomach
Chap. VIM
DrsPEPsiA.
■57
share in the general enfeeblement, and Uwt Uwj
netxi relative rest and a (Uminution of work in order
I restore tlieir tone and vigour.
The habit, also, of drinking largely a/ ntm^ vhil«
"it must interfere with the chemical activity of the
gastric juii-e, alsn tends to enooara^^ too htrgi- a con-
sumption of food. Man ia, perlHipa, the onlr animal
who (irinki^ and eats at the aamiB tune. The desire to
continue i^atini; is greatly leaaened if no beverage be
taken at meals, and hence aonie of the succem
attemiing llie abstinence from tluida during meala in
the treatment of obesit}*. A certain amount uf water
ia, of course, necessary for the wanta of the system,
and mo6t articles of food coiit^iin a venr larjije pro-
|xirtion of water in their composition ; and no physician
would object to a good draught of water, jireferably
hot, half an hoar or so before eating, when it dilutes
or washes .iway the residue of the former meal, and
refreshes and |)rcpares the stomach for the next
Haste in eating; and itii|>erfei-t mastication and
insalivation are aUo fruitful sources of dysjx-jx^ui. The
food is not sufficiently crushini and sulxlivided by the
teeth, and it is not sufficiently iniH>r|>orated with the
frothy saliva which a^-ratex it, so to s{M.«k, and makes
it readily permeable by the gastric and intestinal
secretions.
These mot'liHtiical changes in the mouth are,
doubtless, of jjreaUT inip<jrtance in digestion than the
clif.mical action of the salivary fennent, which can 1m>
supplemented lower down by the action of the
pancreatic and intestitial juices, but once pu.s.sed out
of the mouth there is no other agency in the whole
alimentary canal for mechanically cruishing the food.
In the foregoing observations we believe will be
found enumerated the chief caunen of functional
dyspepsia.
Before, however, proceeding to the question of
treutiiient, it will lie desirable to enumerate briefly
the ^ymploms which are usually found to accompany
this form of disordered digestion. They are much the
i^S
Medical Treatmest.
IPaitl.
same aa those which accompany chrouic gastric
catarrh, and it is, tht'refore, not always easy to
KC'parate these, two afl'ections. But fuuctional dyspepsia
occurs nioit? conimouly in tcnipoi-ary attacks, recurring
more or less frequently, and is induced by slight causes,
such as a trivial error in cliet, some mental worry or
over-exertion, physical or mental ; or it may be
noticed when the juitient's health becomes depressed
from any cause. It must Ije reuiembered. iilso,
that the dj'spcptie person is e»|)ecially likely t«j \yi-
coine the subject of gastric catarrh, or of gastralgic
attacks. Loss of appetite and an uncomfortable sense
of weight and fulness after taking food, flatulent dis-
tension of tbo stomach, with aciil eructations, " heart-
burn," dy.spn«.'a, pnlpitutiun and flushing after fooil,
all these symptoms are usually observed. An absence
of furring or coating of the tongue, and of any bad
odour in the breath, are often means of distinguishing
atonic dy.spepsia from clironic gastric catarrh. Stimu-
lating articles of food, such as spices, pickles, and the
like, will often relievo the distress of the atonic
dysjieptiu, while it will increjise that of the catarrhal
one. f^me dyspeptics complain of pain between the
shoulders extending to the left arm, and resembling
the ]>ain of angina, and if this is associated with a
weak and irrcguliir action of the heart, it may be
dilhcult to distiiigui.sli thejie attacks from true angina.
The fiict, however, of their occurring itfier food, and
not coming on after physical exertion, together with
the presence of other symptoms of dysjiepsiii, will
generally help us to distinguish between them.
Sometimes an examinatiou of the heart will show
that it is really feeble and dilated, and in such cases
treatment must be directed to restore the tone of the
heart as well as that of the stomach.
The ab.sence of thirst, of tenderness in the epigas-
trium, and usually of nausea and vomiting, is also
relied upon as distinguishing functional dysjwpaia
from gastric catarrh.
Constipation is a very common and troubleaome
Chip. VII.)
Dyspepsia.
«59
syujptoni in these cases, and must never Ik) overlooked
iu their treatiiieiit. Tlie uriiit; iniiy l>f piilo uiiil al)iili-
dunt, l>ut it Ls »1su oftc-n liigli-coloured, uiiri deposit!)
lithat<-s on cooling, owinjf t«j imperfi'ot inteiitinai
assimilation. Its s)»!cific (jrjivity nmy ocoAsionally
be »o hij^ii .-IS to excite the suKpirion of dialietoa,
but this in usually duo to an increase in the
ordinary urinary solids. It is often much darkened
by Ixtiling and nitric acid, assuming vuriouit
shades of the well-known niahogauy hue. In the
neurotic it will often deposit an excosx of phos-
phat«s ; at other times crystals of oxalate of
lime may lie detected in the deposit on tnicroocopic
Kami nation.
VariouN occasional and ineidtmtal syniptonis are
aasociated with attacks of dyN|>ep8ia. Son)e of thcar
arc prolMibly uau.s<'<l by the non-elimination and th«r
abi>ori>tion into the bIcKxl of t4)xic suiMtaneen occa-
sionally produced durinj^' stomach or intestinal dige»
lion ; or these substances niaj- he producetl noniially
during one part of the assimilative pnxreiw and
destroyed in a later jiart ; and the failiirv of this
later act in the assimilative proccHs may be tlie cmih
of some of the symptomn observed.
(iidd'tnr.t* Vi o\w of the most alarniiQ|< of ihCM
symptoms, and is proluibly causcrd by Home ituddcn
va.so-motor disturbanoe. Alore pnitnictwl oervou
atfe<;tinns in the form of migraine hiufbutlina, ocuUr
migraine, hemiopia, and other visual diitturUuKM an
not rare.
Lan^'uor, drowainess, depreaaioa of qMita, or
irritability of temper and tle<plwii>M mc alao
frequent.
The occurrence of "«/attrie cramp or f>arojr^*utal
pyrwris" as an occasional sjnnptoni in thr? courxt of
acid dy8|)epsia has )>een mentioned by .^ir William
Roberts * a."* a " (lei-uliar and chAract/-ristic nympU^ro."
It consists in a tiudden attack of craiop at tb» rtowcb
with sudden profuse Kalivali'jn, l«jt<m half • I
* " THgaMtm and Diot." ^ VT,.
i6o
Mkdicai. Trf.a tment.
[Vtn I.
to ft minute. He suggests that the terru " pyrosis "
tiiiould be confineil to these paroxysms. There is
but little sense of nuu)>ea during the attacks, and
they rarely culminate in actual vomiting. The saliva
gushes from the mouth in great abundance, and it is
unusually alk'iline. The jmroxysm only occurs when
then' is sui-jilus iicid in the stomach, ivnd the relief
which follows the immxysm is due to the lurxe quantity
of alkali conveyed to the stomach in the saliva swal-
lowed. These imro.\ysni8 of pyrosis may occur once a
day, or once in two or three days, sometimes only
once ft week, once a month, or once a year.
The Irciilinfiil of functional dyspepsia may \ra\
considered under three headings — (1) dietetic, (2)
regimenal, and (;i) medicinal.
(I) Dirlrlif ircniiiK'iit. — We have alreatly
eiilli-d altontion to the [lurt ))l:iye(l in the causation of
dyspepsia by imperfect nuuttication and insalivation.
This must be strictly enquired into and reme<iied.
Defective teeth should be seen to, and when this
defect cannot Ije rectihed, food should be given which
needs but little mastication ; the crumb of stale bread,
thin dry toast, and some kinds of biscuit re-adUy
disintegrato in the mouth, whereas jmh/j bread forms
tough, coherent masses there.
Vegeta.ble-s should be retluced to the form of
purees, ]>otat*)es especially should l>e maghed fine,
and ufw potatoes which are " waxy " should be
prohibited. All fats sbould be finely divide<l and
mixed with other footls, and not eatvn in lumps. If,
owing to defective teeth and temlenie-'is of the gums,
mastication is jminful, lean of meat should be pounded
or reduced to jiulp. The American mincer may be
used for this purpose.
The shorter fibre meats are the be.ht for dyspeptics,
as they ai-e more easily disintegrated. The quality of
the meat should be looked to — different qualities of
mutton, l>cef, or fowl will differ greatly in their
digestibility. White-fleshed game is more digestible
than the dark kinds ; the delicato sole, whiting, or
Clap. VII I
Drspsi'siA.
lOi
tlountlcr timti iln< (inner and riclier-flfslieil mullet,
salmon, etc. Foods 8!iturat<-il with liutttr or iaXn
must Iks avoicled ; they <i>°r> alinost iiiip<^netml>ii> tu
the git«lrio juice, Sweetctietl ilislicsi iiic ftlno to he
nvoidiHl as prone to excit<" acid feriiu'iitntioii. as well
ax all unri})C' fruits, nuts, and the celluloHe I'overinjpt
of vegpt<iljk's, a.s ditlioull of (]i^;i',stion. It is hardly
ucces-saiy to inhist that the preparation and cooking
of the food should l>e g'X>d and wivoury. Sauces and
uielt«(l butter should not Ih; txken : with fish, plain
butter, if rtMiuii-ed, and a little lemon juice may bt?
U8e«j. The bread should Im? carefully R<'lect«fJ, us
some kinds of bren<l are apt of thcinsolviw to cause
dyspepsia ; luid too larj;e a (|uiintity of ini|ierfectly
iuasticate<l bread is a common source of disonlcred
gestioiL A good bread shnuld be [lorous, crumble
Btly, and not mass together in the nioutii in nin.sti-
ottion. Some kinds of w/iolrtiieiiJ bread, Rllhou;{li
very nutritious and plea-sant to eat, are dillicult of
digestion, and will certainly aggravate the dvNpepsin
of some persons.
The fweuls of a dyspeptic should lie small or
very tnodcrate in quantity, and our object should
be lo telnet a tlirt which, wliile it itffunit tlm ntiret-
sari/ amount o/ nourulimciit to tlm boili/, im/MU<t» ihf
mnallfsl iiiiiiiunt of labour on the utonuicJi. Thiite small
meals should lie eaten slowly, and a surticieiit time
kUoweJ to elapse l»etweeii them U) insure the complete
digestion of one meal liefon- tlie next !■» taken. Sotiil
food fakes from five to eight hours to digest,* accord
ing to its nature and <|uantity, and ni old age ami
in persons of feeble digestion it may tiike longer.
ThU U one of tlw. /act» o/ /<'t>hU diijfutwn mo»t 'lijfi-
eiill lo ijft aerfipleil, rwt only hi/ Iht patient, but ojifn
also by the doctor!
Persons with no occupation are very apt to take
* The estiiiialo iiiiMUIkhI in lx^>ki<i>ii IIm* |ili}"uol<i|[y of (]i|rn.
tion, of ttiP porifvln iif tiiin- r«|iiir<-it t<.r tin' •lii;r«tion 'it <litl.r<'iil
artiolc* III (hot iu tlio stoiiiiich, will ]»• (miiii'I. wIhu t<'>l'-<l l>]r
proctire, eftiteoially nuiuuKat tliu ilyi4|M.*ptJc ."iii'l i'«;rv>ii*i ot mi>Mlir
and kdvoQced life, tu be f&r too brief.
Medical
t62
fooi too frequently, and to.siiffer in consequence from
dyspepsia.
The dyspeptic sliould rest for i\ short time before
a meal, and for a longer time after one. Ahu.se of
idcoliol and tobacco, of tea and coffee, should be
interdicted, In some cases of atonic dyspepsia a
small i(iiantity of sound wine or spirit with water,
tjvken just Ijefore or after a meal, seems to ser\-o as a
useful stimulus to gastric secretion ; the same pur|)Ose
will be l>etter served in many by 4 or S tablespoon fuls
of hot, clear soup at the beginning of the rei)ast.
The use of tea* and coffee re<]uires di.<icrimin!ition.
When the dy.spepsia is associated with irritability
of the nervous system it is be.st to avoid Iwth.
In other cases it is ailvisable not to take them with
or soon after food -they then often retard digestion ;
but taken three or four hours after a meal, and taken
alone, and not too strong, they appear to promote, in
some [lersons, the final stage of 8t»)n)ach digestion. A
cup of liot wat^'r, slowly sipped, and taken instead of
tea or coffee three or four hours after a meid, proves
very useful to most dyspeptics.
In aniemic cases a moderately stimulating diet is
best : agreeably flavoured animal food and soups ai-e
more easily digested than farinaceous ones, which have
a tendency to undergo acid fennentation in those
with feeble digestions.
Individual peculiarities, as we have already said,
must be cjirefully studied, as they may depend on
physiological variability of function.
Uncookinl and green vegetables must lie avoidetl,
OS they are very prone to give rise to tlatulence.t
(2) The r^fflnio, or nuxle of life of the dysjieptic,
requires careful attention. Sedentjiry habits must
be given up, and free exerci.se in the open air in-
sisted upon. Removal from the town to the co<nitry,
* It ia imjiortaiit to the ilysiHiitic timt lio nhoiiM drink
China 011(1 not Iiidiiui tea. Titc latter oontaiiut ui injuriom
proiwriion of ta.iiniii.
T Further detuiU lU to diet in indin^tion will be found in Iho
■Dthor'a work on "Food in Health and Di«eaae."
VIM
DrspBPSiA.
163
to tlic scii side (with sea-ljatliing^, or a tour in
.Scotland or amongst the Swiss Alfw, will Ijc fouiul
sufficioiit to cure iiiiiny tr<juble*onifcaJM>si>f dyHpcpsia.
When this is nut eonvfiiifiit. a cuurscof li_vdrt)tiieri»py
in n well organiseil liydropulliic estnltlislinicnt, where
at the sttiiie time the fwKl hu)>its »re ciin-fully at-
tended to, will oftPii Ijfi lit fjrcHt sPFvicf.
Jlore confirmed cust-s, eHpffially when compIi<'-Ht«<l
witli hypochondriacal syniptoniN, may rwiuiro n more
prulutiged p<?ri<xl uf travel an<i frequent chauge from
place to place. '
(3) Klcdirlnal Ircnlmrni also will he needed
in most cases*; (a) to jiri)inot« tlir jiniftiinial nelifitij
of Uic mutnilnr cout and teer^tiwj glamlt of tlm
$lomneh.
For this |niri«i<*e the vp;»t'tftlile bittern, ijuanHia,
gentian, ciilunilia, tinx voniicu, chiratii, hitter oranj^--
jiecl, hoji, etc., coniliiiiwl with an iillcali -if tlieii!
is e.xiicss of acidity with sour eructations ; or with
8 mineral aciil if thi'i"c is reason to Kuspect a
defici»«tiey in the acid of the gastric juice — are
of undouhted value in promoting the activity of
the digestive functions and exciting appetitt*. It is
difficult U3 explain how t!ie»e vej;etal>le bitten* act,
but fi-oin recent observations it would appear that,
given a short time before a meal, they promote the
tteeretion of free hydroehloric acid, and in rvAVt^ where
thei-e is a tendency to delicieiiey of this acid in the
gastric juici-, they pixive ellii^icioiis gaitrie tonics.
Either of those nienlioned may be us<.'d, I'Ut the
coniliination uf cnluinba or gentian with iiux vomica
has appeare<) to us a most useful one. In ca-ses where
there are a<^id eructations tho addition of sodium
■ \' ' !' liviilmldvuptTt-
■iii I I m. In tlielint
th<ii. . ; , ..ir action in the
stoinnrh : in Uip mH-nnii llirtc i^ mi tiiit)n<' s<'iTcti()ii nrHct-tunnlation
of «/'i<l in th" (itoiiiM'li, i..i.i-< 1 illy r.rn.ii'l* tlv l^itrr Aw^iy* of
iIi|;f<ii1ion. Wi; ri»i-":-' -'tif.il v/ilic i^i'iuinoiic
in(iifntiijn» fur mv' un'iit. It with the
diriidriu of French luto tnjituch ml limite-
rhlirrh>/drir ilyspvpsiu i.
MsniCAL Treatment.
I Purl 1.
luciirbonatQ is most useful ; its r<Hect in promoting
the secretion of tlie gastric •jbuuls when given on an
empty stoniiich is generally lulmitted. We ttre in the
iialjit of prescrihing the following drAUglit iis one
of the Uwt i-eniedios for iitonic (IyHpe|>sia when ttiken
half an hour or an hour before inouls : —
I^" Sodii liiearboniitis ... ... ... ... gr. xv.
Tiiictuno nucis vomiiiD ... ... ... nvxv,
Tincturju cjiluinba) ... ... ... ... jwi.
NpirituB Hiiimi<niH! aruuiutii'i ... ... 588.
InfuNi aiiraiitii ('<iiiii>»siti ... ... •'"lij-
Misco, Bftt bnu«tii9. To bi- takvn throe times daily, hiiK an
hour or an hour before focxl.
If, on the other hand, we find there is gwut
slowness iiml torpor of digestion, prolmVjly from insuf-
ficient acidity of the giLstric juice, we may give the
aliovc nii.\tur(\ leaving out the soda ami aninioniit,
and adding 10 niinim.s of dilute hydrochloric acid,
G or 8 grains of pepsin, and 3 minims of tincture of
capsicum, immediately or soon after meals thrice
daily. It is better sometimes to give the pepsin
during or at the conimenceriieiit of a meal, and the
acid iiitter mixture an hour or two afterwards.
When there is great muscular debility and nervou.s
exhaustion associated with the dyspepsia, 5 minitiisof
the liquor strychniua? may be given insteud of the uux
vomica with euch do.se of the acid mixture.
{h) To relKVc acid eructations and Jlaluhnt dit-
Iciuiivn.*
One of the roost annoying troubles of dyspeptic
patients is attAcks of tiatulence with sour eructations
• Tlio remnrkubic fnct that, in riisos of ncicl (lyKj>ef»iii, llm
ingestion of u meal will Kouietimea relieve the Uyi!pe|i!>iii, im Urn*
pxiiliiineil by .Sir Williiuu Roberts: "The neid rcstiilniini is not
i-ntircly got rid of when the neit menl arriven ; in this cii3«> the
sour muouis for a short siwce of linif float* on tlie snrfitri! i>f the
new meal, and theeructatiouit areconntMnu'iitly acid ; but {iresuntly
it. mingles witli the meal, aiid the dej^ec of uci'lity of t)ic totitl
f;n«trie cnutenU in thereby reiluciMl by dilution, and the cructn-
tion« oi'iise to Ik* sour.*' Such jKirsons *' are cured, much ti> their
>nr|in.'><', by takini; a fidl meal, the f.ict being that the new UK<al
gives the xuqduii nciil work to do and bo ends the attack "
(■' Digeatiou and Diet," p. 238,
cb»p. vir.i
Dyspepsia.
165
and " liiuirtlHirn." Some wiiiiii stoninohic and iilka-
line mixture shtiuld lie given tlio |ititiiuit for occa-sinnal
use when tlicsi- jittvivks occur, which they often do, two
or thrw hours iift»>r a nieal. Fifteen to 50 graiii.s of
bioarbonato of soda in half a tcacupful of hot water
will often sutficc. The following tlraught is also very
officacious : —
Tiniturti' rhci ...
Sodii bicarlKinnti.--
Mttifnpsii earboniitis ...
8pintii>> atnnionin- nr<JinAtici
Aqua.- wriii ...
Miwv, finl luustui. To 1mi takun oi'casioi
5J-
KT. Jir.
pr.jt.
Uii \\M.
nallv.
Hiiiitiuth lozenges are useful oxjiedients for this
purjKJse, and are largely usc<l. Tlie aocln-mhit tablets
are also good, but all these dissolve too slowly to give
immediaU; relief.
When the flatulent distension of the stomach is it
very troublesome sympt.om, a pill containing cr<uiiiol«
or menthol given iininedintcly after footl is often very
cllicacious in arresting it.
CreiLsote may Ik? given in capsules, each containing
1 minim, and menthol in gniin doses also in the same '
manner, t'rea.sote, however, will pnivo irritating to
some patients if given pure in capsules, and it is
better to give it made into a pill (and menthol also)
with powdere<l soaj).
Vf Jlentljnl, \^T. j (iW riiiixjti, rn"")
V'ulvfiis napimis, ({iiiintiini siittirint.*
Vt fiiit t'ilulji. To b(' tiiken after food thrii-c doily.
JiiniitHlh will also be found verj- useful in relieving
canes of acid flatulent dy8|iep8ia, and it seems to have
a touic effect resembling that of iron in some of these
* A little spirit may he iiBoIed to make ttif mcutlicilainl luwp
into a pill. The followiiig has beeu givan ai a good formula for
iiuikiiiK crt>aH>te iuto ]iillit: —
Creft»ole lA Kniinii.
Powdered liciuoriee root (uot dccortiiNitod) ... 30 gminii.
Sot andc for a few miuiitca, aud tliru jidd :i dro)w of dixtilled
wat4>r. Rub litem togetUer, aud dividu t)ie mute iuto the inimbvr
of pilla doaircd.
r66
Medical Treatment.
[Pan I.
CU8C8. We are aocustouied to prescriljo the following
mixture : —
I^ Liquoris bi«mtithi c<t ainmonii citratis
Smlii liicaHioniitiB
Sjiiritus ihlorcfiinni
Iiifiisi caluiiiliio
lul'
5J-
gr. X.
nvxx.
Misci', (iiit bnuHtu8. To be taken an hour before food three
timos a ij.iy.
Some cosos of acidity, especially tJioso due to
butyric or acetic fernipntsUion, siiMii to Ik; more aiiipn-
able to treatinont witli ililutf liytlrocliloric acid. It
should be given in small tlosps, Ul to IT) minim.*), with
some light bitter infusion just before food. It acts as
an iintifcrnienlive.
Ch«rcoa,l is a popular remedy for ga.stric flatu-
lence*, but we havp not foiintl it j-o etHcacious att the
above bismuth inixture. It is sometimes given in
coml)ination with bi8inulli — 5 to 10 grains of fmw-
dered woo<l charcoal with 5 grains of bismuth. Tliis
powder may be tiiken in a cachet immediately liefore,
or soon after ii meal, according to the perio*! when
the Hatulence is most complained of. Sir 'William
Roberts has sujrgested the sucking of guni lozenges to
promote the natural flow of saliva, and so diminish
the acidity of the stomnch's contents by neutralising
it with alkaline saliva.
A very simple and eflicacious remedy for some
forniK of «(v»(/ dyspepsiji, those forms especially which
are mj common, of an excessive formation of acid
towanls the end of stomach digestion, is the nd-
ministratioTi of a draught of hot water three or four
hours after a meal. This dilute.^ the acid conti-nLs-
of the stomach, and the di.scomfort or even pain
caused by the excessive m-idity is at once relieve<l.
If, however, liio amount of acid is very great, it is
advisable to adil a few gi-ains of nmgne.sia or of
sodium liic.irlionate to the hot water.
Dr. liuchard advcK'iites very hirgr> iloses of the
dOfHiiDi liietirbdiintr lor the relief of st'Veif juirosyams
of gastric pain arising from hyitereecretion of liydro-
Oup. VIM
DrsPEPsiA.
167
chloric acid. In a case in •which extremely severe
pftiiis, with pyrosis, oc(-urn-<l nt 1 1 a.tn., 3 p.m., aiid
ini<lnigh(, ami lasted an hour or more each time,
fU-r trj'iug various modes of treatinent without any
good re.suit, he at IcngUi gave fre<|ueiit large d(>s<-B of
sodium bicarbonate with complete HUcce.iH. }{e holds
that in these cases there is a continuous secretion
of hydrochloric acid, ««/ limited to the periiMls of
digestion, but occurring also during the intervals ;
tliHt the contact of this acid with the surface of
the empty stomach induces a lo.s» of power in the
muscular wall.s, while the excess of ucid during
digestion arrests the conver.siim of starchy foods
into sugfir, aini these fcnnrnt in the stouwu-h, Hud
this fenin-nt)4tinn, together with the loss of t*irin in
the muscular wall, stai-lH a tendency to ililntnlion.
At the Nutue time there is also a great tendency to
the occurrence of ulceration of the mucous mora-
brnne from (piite slight causes, an f.g. a blow on
the epigastrium.
An ade<|uate ullaiUiie trcAtment is, therefore.
urgeuUy indicatMl. llie ftaticnt referred to was
given 6,i drums of so<^lium bicarl)onate in twenty four
hours in repeated doses of I") grains, together with
alkaline water nt his meats, and milk mixed
*irith lime water. The next day the patient was
greatly relieved, and the iui|ir<<vi'uient iiicre.'i.sed
from day to day. Some preparinl chalk was added to
the sodium bicarbonate, as the latter is too soluble,
and its neutralising action is, therefore, too socm ex-
haust«%l. Tlic insoluble lime salt acts more slowly,
and is dissolved only in pro|>ortion to the acid
I'lxjted. For the accompanying constipation the
patient had also two largo spoonfuls of calcined
magnesia daily. Tlie patient was cured. Dr.
Huchard refers with justice to tlie " riilieitlout
j'car of an alkaline cachexia" which pn-vents
nnny practitioners from giving ade(|uate doses of
7iodiuni bicarbonate in cof^es like this.
(e) To promote coinpltlfi Himinnlion of the bye-
i68
Medical Treatmekt,
(Pan I.
jtrwlu^U of a sluggish and disonlereil dlgegtiim, and
to rfiHoiv! iioxtous accumidalioiis in the intestinal
riniid.
The paruniount importance of relio%'ing tlie con-
stipation that accompanies most outea of utonic
dysjwpsia is evident. It is, perhaps, iu nuinj cases
the original t-vil. TJie retention of noxious bye-pro-
(Uicts of digestion in the intestinal caiial and their
absoq>tion int(j the blood is proliably the cause of
many of the getifral symptoms present in chmnio
dysjiepsia, e.g. the headaches, the giddiness, the
languor imd drowsiness, the mental de|iression,
and the liypoi-hoiidnasis ; while the tendency to
ai>di)ntinal venous stasis which must necessarily
be associated with an inactive state of the intestinal
walls natundly leads to an impairment of the secret-
ing functions of the glands of the stomach anil
intestine.
It is in responding very tlioroughly to this indica-
tion that courses of mineral waters prove so valuable
to dyspeptic patients. No more brilliant results are
ohUiined in metlicine than from the application of
such co>irses of waters as may be obtained at Carls-
bjid, Marienbad, Kissingen, Tarasp, or Brides lea
Bains in crises of dyspepsia with habitual constijia-
tion. Some practitioners tell their patients that such
courses are " too lowering " ; but they are, on the
contrary, health-restoring, and, therefore, tmiie in the
best and truest seJise. They frequently prove tonic
and restorative after all the so colled tonics, such as
iron, quinine, strychnine, arsenic, etc., have utterly
failed ; and they do so by washing the intestines
clean, by removing toxic accumulations, by firomoting
the abdominal circulation, by stimulating the secre-
tion of the liver and all the ptptic glands, and, in
short, liy ]tromoting due elimination ; and these
excellent efl'ects are associated with the hygienic
influences of a suitable, well-regulated diet, and a life
largely sj)ent in the open air.
b^or cases of chronic atonic dyspepsia, dependent
ChMf. VIl.J
Dyspepsia.
169
on defective pastric seciftion, and niusculiir wiiiit of
lonp, the waters of Kissin^^on, Hoinburg, or iJridcs-
Ics-Baiiis are most suitable. Tlie Ragoc/y 8[irii)g at
Kissiiigen is especially renowned for its curative
influence in cases of atonic dyspepoia. In cases of
irritative dysj>epsia of a gotity nature, or in pU?-
tlioric persons, the wann alkaline-sulphatic springs
of Carlsliad are especially valuable. ^^'hen tlie
dyspepsia is as8ociat4xi with loss of nervous tone,
and a more bi-acing inHuonce is needed, the greater
elevation of Marienbiid or Tarasp is particularly
suitable. In cases where theit* is iniii'h ga«tric
irrital)ility, and a tendency rather to diarrho'n than
constipatioti, the watcm of Vicliy or Nenenahr ans
more afiplicable.
It is quite practicable, if patients will submit to a
strict re'ijivir of diet antl exerciiw, and ifsiHe in a
healthy, o|ien situation during the treatment, to
follow a, course of these waters in England. \Vk
have i-ej>etttedly prescribe*! and <iirecteil such courses
with excellent results. The waters of I/»an>ing-
ton and Harrogate are suitable to si^tiie of these
cases.
But other means may be adopted, an<I, indeed, are
require<l to relieve the constipation, antl these will
answer better with some persons th;«n mineral waters.
One of the l)est of these is a pill of a grain or two of
extract of aloea, \ or I oi a grain of powrlered
ipecacuanha, and a grain of soap, taken just Viefore
the principal meal of the day. If the aperient effect
of this pill is not suDicient^ it can lie supjili-nient'tl by
taking next morning, fasting, in a tamblcrful of hot
water, this fiowder :
I^ 8o<iii «ttlph«lia
Sodii bic«rlionnti« ...
Sodii chlnriili
Miscn, flat pulrid.
On the other hand, there arc cat(~> which arc very
Bsitive to the action of a|ierienta. They rt^iuiro
gr. ».
I70
Medical Treatment.
IPan I.
a|)iTion(s, liut lliey must Ih' mild ones. Witli hucIi
liiiticiits \.\w following pill sorvcs not only as a gentle
apei'inni, but iilso a.s nn excellent stuniachic, and
stimulates ji^stric secretion : —
I^ I|)eOiii'unnhu' pulveris ... .. ... gr. J nil J.
lihoi exinu'ti ... gr. ij vel iij.
Nuris voiniiio I'xtnicli .. B''- J-
]tli!>i'0, liiil piliilii. To bo titkcn hnlf an hour before food,
twiri! or thrco times a day.
In other cases no remedy seems so useful n.s small
doses of fulomel, i(s nMiipdinl action being greatly <lue
t<) its efficacy na ftn iule.vtinal antiseptic, and iUs
jM)worful (le.stru(tive iiiHuenco on an.ierobic bacilli.
Dr. Carter, of Liverpool, has testified strongly to
the value of enloniel in controlling the abnormal gtistric
and int<'slinal fermentations in cliildreu. He pre-
scribe.s .}q grain of cjdoinel with 1 grain of boric acid
with the child's food three times a day.
Under the designation iiiU'-xtiiinl (ly^prp^in, a
variety of conditions have been described, dependent,
some on functional or organic disease of the liver and
pancn'as, some on acute or chronic inte-stinal catarrh,
and .soTne forming really a part of the phenomena of
gastric indigestion. Tlie.so last only concern us now.
Tht! normal course of intestinal digestion will
noces-sarily Ije disturb*.-!! when the results of stonmcli
digestion are abnormal, and the food is passed on
from the stomach to the small intestine in an imper-
fectly prepared state. This may arise simply from
over feeding or from admitting into the stomach fijod
that cannot be digesteil there. The dysfM-jisia of
infants is often of this character. It may occasiunally
happen, but this is jirobably very rare, that tlier«<
exists what has been termed an " incontinence of the
pylorus,' which relaxe-s too .soon and allows of u pn--
mnture- piussiige of the food from the stomacli into
the duixlenum. It might thus hap[H-n that more un-
digested fo(Kl fo\iiid its way into the .small intestine
than coidd be digested there, and intestinal colic,
Oiap. VIM
Dyspepsia.
171
tlittuleiicc, and dinrrlni-n iiii;;ht. tlius l>e set up. So,
also, in cases of acid dy8|ic|wia, tlie cbvuie {tastiing
iiilo the small intestine may be so exct'-ssirely acid as
to destroy or grently weaken the digestive powers of
the alkaline bile and pancreatic juice, and so symptoms
of intestinal indigo«tion would he aroused. Dumlenal
catarrh and catarrhal jaundice may also thus Ite
sione<l.
But the treatment appropriate to these atatm i.s
Jniously tliiit a<lapt<Hl U.i llie anielioration of the
di«turlied yastrio functiuuB upon wliich they are
dependent.
Tlie treatment of so-called S4'<-oii<l»i->' dy^-
pppsin, a-ssociated with cardiac and hepatic disease,
witi chlorosis, scrofula, tuiierculo.sis, gout, rheumatlKin,
and organic nervous affections, will lie dealt with
when we come to conHider the treatment of these
morbid states.
We may, however, discusK briefly here tlie treatment
b<*t suii^-d to thoMf not unnrunmoii fornm of dyMjx'psia
wliich lire associated with what is termed " ii<-i'v<>M«
debility,^'' and which arc often induceil by worry and
anxiety. Many of tlie >4yniptonis complained of must lie
dealt with nn the general principlcH ali'ea<ly laid down,
but we must not overlook the necewity of applying at
the sjinie time restorative treatmetit to the exhaUKtrd nr
irritable nervous RyHt.em. Such cases are often marvel-
loiiitly benefited bya course of hydrotherapy associated
with HioMfiy*',* or with Iheappliciitiun of the continuous
* Miujiaitt M var^' imcfiil in nuiiie ohm's iif utoliio <lyiilH-|mi.'i. It
f)ioii])l )•♦» iip^Oi»Ml ill the frtllr»wr»fi«» fiuuiniT: Tho iinti**iit, twn or
llii " ' 111 Ilia back with
tt.' "II tlio iM'Ivii*, the
lij' _ , - . it!;i^*.'»i. The* j>hv-
Kiciiiii eli'iiild in'giii liy lujijiiiigur atriikiiiif gtriitly luitl HiiiiorHotally
ovrr tlir rr'i/ioii nf tliti Ktiinuich ; diiriiiff tlip.*c* tiitiitipiihitiouH )to
fcli- ' ' " ' , ,. the uinoiint i/i prtswuro t'iii|tIoyc<i, till,
r. : 'iuu*. Jii;i'*'r<liiiji to th<' ci'iiflilivfiicMK i»f the
]M ' iniiehly Iciicail thu «tninach. All llio«o
luutiijiiihitiuit^. wiiith dhotiUl not hiAt hinder than .'ibmit ton
miutili'H, flhi'iild be niiide in Iho raiiuf? din*<*ti(.>ii, *,f. from tJie riir-
liitti^ mil mill tlii'xreiiti>r< nrvnlurc townnU lliri.yliirir- ''' " t
of lh>» niuiMt)!!) la tu aroclfnite the pii.'«'ii(>c 01 tho I
172
Medical Treatment.
I Pan I
galvanic ciirrpiit ; change of cliiimto, es|«!ciiilly to
tnountrtiii air {the swi-sicle ofU'ii flisagrees witli such
patients), and almnrlunre of out-ofnloor exercise nre
also of great vulue.
Sonic luirvhif niodicines are also of use. In
uaseij chiefly of nervous exhmi-gtion, a pill of a grain
and a half or 2 grains of mlfrinnate of' qitinine
with lialf a p^ain of extract of mix mtmico, an hour
l)efore meals tlu-ee times ii day, will be found valuable ;
and in cases of irrilabUity of the nervous system it
will souK'tiines be found better to give 10 or 15 grains
of hrttiiiiilf iif sodium, with half a dram nf tinctiirtt of
»erpei\lnr;i in an ounce of caraway water, half an hour
before lunch and ditiiier.
As the gastric juice secreted liy these jMitients is
often defective in (|uality or deficient in <|uantity, or
both, it is often jwlvisable to supplement this by the
adniinistration inmifidiately after food of n digestive
ferment such as a dniui of Benger's lirjuor pepticus
or 6 or 8 grains of ^fn«{ pejiin, with ") to 10 minims
of dilute hydrochloric acid, H minims of fiiiuor
strychninnj, and 3 minims of tincture of capsicum, in
an ounce of couiiKunid infusion of bitter orange peel.
I'aiMibi has licen advocated as a more reliable
and moi*e certain digestive ferment than pepsin ;
we have not, however, been able to aati.sfy our-
selves that it is .so. It is the active ]irinciple of
the Carica papaya, or South American tuelon tree.
duodenum aiid to prevent it« too prolonged stay in the stumiirh,
iind aim to erncante the stoniiivh of niiy lingtrinc impcrfui'tly
di|;e>t(.>d milMtaucei remiiiuinfc from a previous meal. It (urtlier
roMBca tlie rontroctility of tlie niiisculiir runt i)f llie ntomaoli. aud
iucreiutes the secretlnn of gafltric juioe. J/rt.vi./yr of tfir tiii,itiiif/t
•kould lie fijllowe<l hy muKsage of the iiitcttiues for nhout four or
five minute!*, to overeome co-extHtiug conHtijjation : the miiuipuhi-
tioa nhoulil of course follow the large intestine from ciefum to
sigmoid Hexuro. The following resultji hiive heen otwervcd to
follow this treatment : n sense of relief :iTid oimfort immediiitely
after the frunt'f, the disappearance of the di^tre5«ing feeling nf
weight nnd heaviness so common, during the digestive process, with
the«e imtieuts. A desire to sleep is often experienced, and tlie
hypochondriasis from which dys{)cptics so often suiter is givotly
relievoil.
[ I
Dyspepsia.
«73
The pitpttin extracted by Profi>ss«ir Finckler"s prowss
is considered to Ije the best. It is suid to liiivo tin;
advantage over other digestive ferments of nctitig
either in an Hcid, alkaline, or neutral niciliuin. It
is also iitute<i to l>e antiseptic in itt< action, and to
exert a local tonic and sedative effect ou the
stomach.
The dose of papain Finckler is 2 to 5 ^jrains dis-
solved in half a wineglass of water after nienls.
!WriI>KUV rj.vSTKlC METIirjD.i.
In the |irec4«din|,' chapters we have dealt with the
treatment of the c/ii«/' clinicnl ty|ies of gastric dis-
orders. It would occupy much space, and woulrl 1*
of doubtful practical titilitv, from the point of view
of clinical therapeutics, to consider the various sul>
divisions and forms of dyspepxia, a.s set forth in Mouie
recent treatises on gnstric diseases — such lus "Achylia
Castrica," "Neurasthenia Uastrica," " Hyperchlor-
hydria," "({ustnvsiiccorrhtea," etc. etc. et*-. NV'e must
here, as elsewhere, be on our jjuard against the growth
of mere phraseology, with which, to our thiukin;;,
medical science is alrcidy ^{ravely ovcrloden I It
will be found that the ti-eutn>ent of most of the Kymp-
toms corresponding to these names have, in fact,
l>een considereii in the foregoin-; pagna.
We must, however, in this place, call att<.>ntion,
brielly, to certain methiKls of inve!tti;;«tion iiiid tnfat-
ment of i^nstric maladies wliich take a mon; or h-iw
prominent position, nowadays, in sjiecial treati.-Mii on
these artections. These methofis have their liniil<-<l
uses, but they have also, unhappily, their ainiont un-
limit«.>d abuse-s. The introduction and a<lvo<vM.'y of
elalxirate technical and mechanical contrivonuea in
the treatment of diseases which hitherto have Ixwn
cur«^d without them, is not altogethiir n nmtti-r of
congnttiilation.
Certain mejisures have been invenl«?«l witli the
.object of testing the etliciency of the fanclioiis of the
Stomach: (1) the functions of socruliou ^ (3) thu
»74
Mf.dica l Tr ea tmbst.
[Pan I.
functions of aV>sorption ; (3) tlie motor functions ; and
(4) tlje meclmnical functions.
1. lu order to examine whether tiie gastric se-
cretion ia normal or not it is usual to give the patient
a "<««< tn«af," (in.l then t<j withdrjuv some of tho
contents of the stoniiti;li, for detaileii exnmiiiittiun, a
certain tiiiu' after tin- tiical. Several test meals have
been pro|>oseil liy ditlereiit physicians, but the simplest
jind best and tlio one most generally adopted is the
tent brejikfnat of Ewald and Boas. It is given in the
morning, fasting, and consists of one or two rolls of
bread (about 2 nz.) and a cijp of tea or water (S to 10
oz.). The st^imach contents are examined aijout an
hour after I lie meal. They may be obtained either
by the method of nsjiirnlion or expres»ion. In either
case a soft rubber tube is introduced into the stomsich
in the usual way, and for anpirntion a rubber bulb is
attached to the outer end of the tube, and this bulb is
first coui[ire.sse<l and then released in the ordinary
manner, and the gastric contents are thus made Ui llow
into the bulb.* The expression method, which is con-
sidered the best an<l easiest way of obtaining the
gastric contents, consists in causing tho patient to
exercise pressure iqion the stfimach by means of his
abdominal musclejs. He first inspires deeply, and then
compresses his atwlominal walls as in the act of
defecation. Tiie pres,suro thus exerted on the gastric
contents exp<'la them through the tulje into a suitable
receirtnicle held in the ]>atient's hand.
Max Eitdiorn admits that this examination is
often unplejisant and repugnant to the ]iatient, and
that some "absolutely refuse to submit to it."
To overcome this difficulty he has devised a
"stomach-bucket"- — a small silver capsule (Ij cm.
long, j cm. wide), with a large opening at the top and
an arch to which a silk thread is tied, and a knot made
ill it Hi inches from the attai-hmeiit. The patient is
made to swallow this bucket with certain pri>caution8
* Siv Max Einhoru's
oditioii), p. 12.
'Du«-.isce of tbe Stumiicb " ii'.'iiimr
Chap. VIM MODBRS GaSTKIC MbTHODS.
'75
itix allowiy] to remain alrant iive minutes iu thu stom-
, nnil is then withdrawn and its contents exnminR<l.
« sbiaU detiuls have to be Httr-n<led to in thin
proeei^ vhich Einhorn deiicril>(<s.* He says, "Thin
method ae^tuH to bo e«pocially lulHpti'd tu ivll ciut)ft
whifro there is suspioion of an hIcit in tlie stoninch,
and wiien we desirt" to avuid thf tul*. It is aliso
suitable for the jTr-neral pmotitioniT who does not
intend to niak<- an exact analy-is of the •;astrir
contents, but wlio d<>»ires to ilt^terniini' whetli<-r then-
ist)* in them free hvdrochlorie acid or not."'
The coiit*nt« are tested first with lilinim papfr — if
this is nxldened ihu contt?uts are acid ; second, with
Coiufo f>a|ier — if this is tunxwi blitt it shows the pre-
sence oi/ree. acids ; third, it i.i tested for the prcacncc
of /re< hydrocldoric acid. For this purjKiw one drop
of the contents is mixed thoroughly with mn- dntp of
GOmhuri/'t solution t in a white jxin-i-lain dish, thra
hcati^ over a spirit lamp, when the lluid rvaporatf-a, '
~~ a cherry-refl colour apjiean*. free hydrochloric
ad is present.
If the crmtiMitsof fh<' stonisch rontinne to give thi«i
reaction when ilil.'ited ei;;lii l<> t'-n times, the umounti
of acidity, it is state^l, in prob»bIy iiortnul ; if it can lioj
diluttMJ to over twelve times and still yields this nvictioaj
it is prolvibly too acid (hy]wracidity) ; and if it failk toj
do Sf.i when dilated five times or lew* it coutaina loo
little acid (snlMu^idi(y).
liut we must not place too much raliaace on
inf<'renc<vi.
The chief value of this exaniinntinn to Uni gooonil
}>ractitioncr is the proof i( •five" <>f ihc pmmioe of/rM
hydrochloric acid in the ' ' ont«nt8. A OMMV
detailed examination of 1 1 ■ -.try of th* (lutric
•ecretion must be left to tlie pfttti"|i>:,'ii-nl ..litrrjiHt, aa
it will re<|uire fur more time and mun- anulyticul Nkill
than the gfrnenil practitioner can pomibly hart* at bia
t n"» •• ^
iug jihlorugio'
aJraboL
'III. |i. r.l.
.11 Ijn nuiUr hj iliauir*
,.-ratii#. ill I oonoa «(
176
Medic A l The a tment.
(Part [.
(lispowil. And we have uo hesitatiou iu repeating
that llip. value and import of such examination has
been gi-eatly exaggerated tiy some specialists I
2. To test the absorptive functions of the stumiich
it is usual to give 2 or 3 grains of potassium iodide
(l>referahly when the ntomach is nearly empty)
enclosed in a gelatin (.-aiisule, and to examine for its
[ireaence in the saliva every minute or two, liy
rnoistenittg.i piece of sturcht^d paper with the patient's
saliva atul then adding a drop of nitric acid, when if
iodine is present the characteristic violet or blue
colour appears on the starch pa[ier. In nonnal con-
ditions it takes from eight to tifteen minutes for tliis
reaction to ap{)ear in the saliva
3. To test the motor function of the stomach tlie
"l«.\st and easiest way," according to Kinhorn, "is to
examine this organ, liy means of the lulni ami lavage,
in the morning, in the fasting condition, after the
ingestion of a suL.stanlial supper on the night previous.
Normally tlie stomach is empty, and therefore when
the organ is found to contjiin a i|Uantily of foo<l, this
is the best sign of retarded motion."
Kwald has reconmiended another method, which,
as Einhorn rightly states?, is by no means absolutely
reliable. This is the stilol test, and is based on the
pix>i>erty jwssesst^d by this drug of bre.sking up in the
presence of a weak alkaline Huid into phenol and sali-
cylic acid, while it is not decompoKed in ac'id .solutions.
The salol, therefore, will not undergo any change in
the nc'id contents of the stomach, but on leaving that
organ and meeting the alkaline juices in the small
intestine, it splits up into phenol ami salicylic acid,
and the latter entering the hlor«l is eliminated in the
urine as sjilicyluric acid, and can Ix^ ile tec ted therein
by it.s producin;; a violet colour when neutral ferric
chloride solution is added.
To apply this t<'st the jMitient is given two gelatine
capsules tilled with salol (about 7 grains in e4ich) half
an hour after a slight meal (having emptied his
bladder immediately before) ; he then urinates erery
VIM Modern Gastric Methods.
>77
If hour for twu or three hours. All the sp<>ciniens
are tlien tested with ferric chloride, mid we note in
which the violet colour first appoaiu Norniftlly it
should appear in aViout an hour, hut if the motor
function of the stomach is feeWe it may not appear
for two hours, or even lonjjer. A delicjilc way of
applying tliis lest is to moisten a piece of filter jMiper
with the urine and then l>y nieiins of n >;liis.s n«rl lo
phu-e a drop of ferric chloride solution on the middle
of the moiiitene<l paper. The edges of this drop will
assunio a violet colour if tlie smallest trace of
Mvlicyluric acid be present.
4. To text what has l)een terme<l the "mechanical '
function of the stomach, i".<-. the changes pnxluced in
the physical condition of fiMids by the cliuminf;
motions of the stomach, Einhom has devised a con-
trivance which he t-ernis the " gnstrogrnph." For an
account of this app-nratus and the motle of applving
it we must refer to the author's description.* Of
thiH aud of the " Hemmeler-Morit/. '' nietho<l of
testing the gastric j^eristAlsis, we have come to tlm
conclusion, after much cnreful consideration, that
however useful they may be in [ihysiologieal investi-
gations, they can never become- permanent or proKtulile
metho<ls of clinical medicin& They are an outcumu of
excessive specialisation !
<,'cus(roduiphiiTiii is the term applic><l by Kinhom to
A method of transilluniinating the human Ktnmnrh for
the puipofwi of detenuining its 'mk-I /"mitioH and tizf,
or for lucertahihtJj lli« ejnuti'uci' i>f Inmoura ijt thicken-
ings of the ant4rrior wall by their luck of traiLHimri'ncy.
An I'^lison lamp, fiisteneil at one end of a i»j{i rubber
tube by means of a small uietid mountini;, in intro-
duci'^d int.o the stomach, an«l is connecte<l by wire*
witli the Itattery. At some distance from the rubber
tube is a current interrupter.
" The patient, in a fa»tiug condition, drinkii one or
two ghtsses of water ; the apparatun, muiifmefi with
* Max Binlioni't " Diman of the Monudi " <>r<-an<l nhliiia)
11.89.
178
Medical Treatment.
(Put I.
water, is tlien inserted into the stomach and con-
nected with thy hattery. The examination is made
in a perfectly dark room. Tlio stomach trunsmitH the
ek'ftrii" light through the abdominal walls, and it
thus hr-conu's visible as a red zone at that ]ilace of ,
the ahdoineu which corresponds with the position of''
the stomach. In case the jEpistric front wall is occii-
jiied by a tumour, the latter will not tninsmit tlie
light, and will be recognisiihle as a shady sjKit within
the red zone of the transilliiiiiiiiated organ." Max
Einliorn gives drawings showing the application of
this method to cases of gastrectasis, gastroptosis, and
gastric carcinoma.*
We have already described fully the method of
lavage of the stomach ; we must now refer to a
method of xprnyhiij the stomach suggested by
Einhoni. Its object, acconling to its author, is to
enable us to apply me<licines of a toxic or irritating
character, without i-isk of producing poisonous effects,
by using them in tbo form of a spray, "l)y moms of
which hirge surfaces can l)e covered with a com-
paratively small amount of fluid." We can thus
either {a) disinfect the mucous memlirane of the
stomach, or (h) exert an astringent etlect, or (c) pro-
d\ice analgesia in gastralgia defiendent on ulcer,
cicatrix, or cancer. The apparatus consists of an
ordinaiy spray apparatus in which there is a soft
Nelaton tube 70 cm. in length inserted between the
nozzle and the liard rulil>er branch proceetling from
the bottle ; within the Nelaton tubing another soft
tube of thinner calibre connects the inner capillary
t'ibe with the nozzle.
It is, of coui'so, only possiljle to »prny the stomach
in it-s emi)ty state ; it can only be applied when fast-
ing or after a preliminary lavage. Einhorn maintains
that spi-aying the stom.ich has proved very us«iful in
eroti'tiu of the mucous membrane, in cnses of chronic
giulric attan-h with abundant secretion of mucus
and in cases of hyperstefelioii and hyju'riu'idity.
* " OiseoM* of the Stnmach " (second editiou), )i. 37.
up. Vll.l MODERS GaSTKK METHODS.
«79
We hiive incidentally alliideiJ in prcce<Un>r paj^
to the uae of rlfctririty, ftpplieil extf-rnAlly, in
tbe trefttmciit of giwlric di>i>.ird(<rs ; wo p v
refer agHin in nvtlier more ileliktl to tlie :., n
of electricity in these iiffeotinu» both I'xU'ruaUy
(|>ercutJiiieously) ami internally ("direct electri-
sation ").
'Die method usually iKloptwI for the fj-l^nuil
applicAtion of electricity in to apply one electrn<ie to
the neighbourhood of the spine at alxiut the Aixth
dorsal vertebra on the left side, iiml the second elec-
trode to the epigastrium. Tblt mode of applying
electricity, combined with gencml eliHrtrisation, has
l>een found of much value in treating nervous dy«-
pe]»ia8. It has also been found to ]jro<luce a more
ubuiiilant secretion of gastric juice, and to ameliorate
tlie mi)tor function of the stomach.
Kutismn\d was one fif the first to practise liir^ct
electrisation of the stomach by introducing one of
the electrodes into the stomach itself through a
stomach tulw ; he treated several |iAticnt» with
dilated stomachs in this way. llaniet devised
another method which was an im|>rovement on Kuhs-
uiaul's ; but \mi\\ metluMU were found, in practice, to
lie verj- exhausting to the patient.
Einhoni * has suggestcfl another method which he
considers avoids jnuch of the inconvcniein-c atletwling
the prece<ling. He UM'swhnt he teriii» ;i "ili'^-liitalile
stomach electnxle,"' which is constructisl on the snuie
principle as his stoiniich bucket. This, containing
the electrode, is swallowed, and, inslT'iiil of the silk
thread, a verj' fine riiMier tulx' is Httaclml to the
bucket, through which a very fine, soft, conducting
wire* runs to the Iwitlery.
" The end piwe of the electrotle consists of a hard
rublier capsule with many ojx'nings. In this ca|N«ile
lies a nipt.-illic button, which is nmnected with the
wire. The rul>l)or capsolo serves to avoid the direct
contact of the metal with the stomach wall ; the
* " Diaeaan of the Stomach " (aecond edilimi), p. 1 13, H|;. 37.
i8o
Medical Tkeatmi-st.
I Part I.
circuit is completed by the water tbe stoniacli con-
tains."
For II ilctailed acpount of tho tnfthorl of applying,
Ijy this inimns, directly to the stonmoli gaKtro-fHradisa-
tion and guatro-galvanisation, we must refer to Mux
Ei idiom's work.* He st/vtes that he has fouiul the
method valuable in non nialiguant chronic di.sea.ses of
the stomach, especially severe and olwtinate {jastralgia,
cases of atonic non-obstructive dilatation i>f stomach,
also cases of relaxation of the cardia (eructjitions)
and relaxation of pylorus (presence of bile in
stomach ).
Another instrument lias recently been devised for
" int<.'rnal inaswige " of the stomach l>y l>r. Fenton B.
Turi'k, of Chicago. It is termed the ijyromelf, or
revolving sound, and consists of a flexible cable, to
the crul of which is fixed a sponge covering a spiral
spring. The calll<.^ jiasees through a rubber tube,
which is attached to a revolving apparatus, for the
purpose of producing revolntions of the s[X)nge.
Tliftse who are not sceptical as to the fitness and
value of these nieclianical nietliods of treating the
long-suffering stomach will find this in.struinent
figured and described in Gillespie's " Manual of
Modern Gastric Methods," pp. 132-134.
ADDTTIOX.VL FORMULAE.
To promote appetite (In
atonic dyapepsia).
TiiiRtiinr ca-ocarUIiB, .^ijw,
Tini-tiinc rtipi, .^v.
Tinctuni' uacisvoinicni, sijss.
Tmctura> K('u(>»iiin, .^<t.
Tiuoliirn- uiiroiilii ii(i .?iv.
M, f. tinctuni. Two ten8|Kiou-
fuU, in water, a kliort time be-
fore a mcul, {Hiir/infd.)
For chronic dyspepsia with
deficient gastric secretion.
H Acidi nitro • bydrochlorid
diluti, .ITJ.
T,ii|uoris strychiiinii', sjss.
Tinrtiini' uurantii t,-,Aii
Infu'ti fifcntiiiiiin nd %x.
M. f mist. A t(il>lef{inon{ul
in a winnKliissf nl of water Uu'Mi
ttmra It duy uftvr food.
* "Disease* of Stomach/' (tecoiid edition), p. 147-
Chap. VIM
Additional Formulm.
i8i
To promote appetite in
dyspepsia.
II Anitiiuiiii i^irlKJtiutiii, .sj,
IiifuMchifiktfi' ml S*j.
M. f. niiflt. A talile^pounful
thrpf timcsuciiiy. (''mh.V/i*.)
In atonic dyspepsia.
R Extractiiiur.i»yomica',gr.iv.
Exfnicti qiiASsur, gr. xx.
Quiiiinfl- tulphatt«. gr. xL
11. et divide in pil. xz. One
thrc« times a day after meaU.
tjiare.)
Or
R Extract] chiratA;, gr xL
Kxtracti KPntiAiin^, gr. xL
< )leo-r«>iiiie caiMici. m v.
M. i<t dik-ide iii pil. xx. One
aftei oach meal. ^JI*rr.)
Powder for atonic dyspepsia.
IL Snilii i>icjtrltoiiatL4 exsiccata*.
MtiKi"^ inrlirinati', gr. X.
I'ulvpris rliei, gr. vj.
M /. pulv. To fw taken
before niculs tliror times a day.
OUorofonn mixture for
Batolenl dyspepsia.
H Till. 1 '■ ' Mj.
A411 ■Titii, f,i\\
Ai|U ' iiii(sutunita'}
ad ^viij.
M. ( iQi*t. A deawrt«)0<>u-
f 111 t<> 1m.- talceo beforv or during
■ French Codox.
For acid dyspepsia with
pyrosis.
K MflgliPsin-. gr. ij.
BtAinutlii Biibiiitnitifl, gr. v.
I'lilvi^ 0|iii. gr. »».
,Ii. t. pulv. Tu l>e tjtkcn
for« enting. (/*io< /•</.)
Resorcin mixture for acute
gastritis and dyspepsia.
It Rcsorciiii { imir whilf, tnntii'
lilUiltrilS, >««.
Acidi ! ' ' ' ridpuri, 5«S
Hyxuy '.V.
Ai|ii ' id .^vj.
M. f. misL One tubie<>[>oon-
f ul every two hviim.
,11. MrHfhr.)
For dyspepsia in Infknta
bom twfore term.
R Peiwinit* glyeeiini, .^iJM.
Acidi hydrm'Ulorici diluU,
"ix.
Ai|iiif lid jiij,
M. f. lllift. A U<Aiip<iniifut
t«iu miutitn iiftnr rach meal.
(/Vii/. Monti, firitiia.)
Alkaline powders for add
dyspepsia.
B Ilismuthi suhnitrutiit |
J5«>dii bir-ariiMiinti^ ) ^
M. Dividi.' Ill pulv. xxx. One
to bu tiiketi iHjfijri-' nieaix.
( fhtja frfi II - UnmmrU. )
For flatulent dyspepsia.
H Tioctuni; uitdiuiiouii com*
pivntip, .".iT.
Tinoturui' /:iui;iberi*, .^iij.
Sjiiritux ininuiiiiu' aroinatici,
Sptritus cblorufonui, ,%ij.
Acidii hydrorynnici dilnti,
mxl.
Aqil.'i- ••■■inii nil '.v j
M. i, niiAt. .\ tiiljl<-4|M>']uful
occuaioually. [t'fuiiUrt*,)
For obstinate flatnlaao* with
pyroala
K \- • '■• •• v.
/r.UJ.
1 ■ iv.
M. tt dividf in pit. i.j. On*
thrice a day. (Bartuv.)
l82
Medical Treatment.
IParl I.
Aa a digestive tn flatulent
dyspepsia.
It Paiirri'atino \ .^
S<jdii bk-arbonstis J-"-
Mai^ncsiie ]>oii(lL*ro8ir I ll
Nucis vomica" pulvcris, gr.vj.
M. ct divide in pulv. (or
cadiet*), XX. One nt the liegiii-
ning of each meal.
(/7. Uurhard.)
Fleiner's treatment of
bjrpercblohydiia.
2) t4> h dnu'hniM tif lii5muth
Bubiiitratc' niisptmded iu water,
nad givcu through tlic ci-so-
phjigt'al tube, whuu the
stomach is empty, Iwfori"
brfakfaat, for 20 to' 'in days.
Drops for flatulent
dyspepsia.
H Chlomfomii, iTi\l, adlxxx,
Tiiictunt" aiiixi, .<ij.
Tiucturn'iiuci« voiniwi*, .sij.
Tiiictura' geiitiaiiH', sij.
M. Take l«ii to twimtv dro)>a
in a little wntt.'r, at fi-iutt a
quarter of uii hoiir before n
loe'il. (//. Ji»</i,i,il.)
For flatulent dyspepsia wltb
dilated stomach.
R Hjdiargyri pcrcUloridi, gr.
A
Strycnniiiii' aulphatis, gr. ^.
Crcasoti, n|j. ad ij.
M. f. pil. To be takeu lief ore,
between, or after meals.
[Bioat/imt.)
For offensive eructations
(H..SI In cases of gastric
dilatation.
H Sodii iiiliibitif', gr. V ad X.
Sodii bi(-*ar)>ountis, gr. xv;
Tiucturie uucis vomicic,
mxv.
Aqilli) lul ;j.
M. f. haust. To be taken
between meola. {Druiuihtiit.)
Pills for flatulent dyspepila.
li A»afii'tidii>, gr. xxiv.
I'ulv. rliei, gr. xij.
<->! cajiipiiti, 'Uvj.
Extract! nnthemidis, gr. xij.
M. et divide in piL xij. Due
or two to Iw taken at bedtime.
Tonic and antacid in tbe
dyspepsia of the debili-
Uted.
R Lii|iiori« ammoniip, tiiL\xx.
Tiiittiira- aurnntii, Jj.
Iiiftisi cbiratu' ad .^viij.
M. f. mint. Two tablespoon-
fiilii twice or thrice daily an
hour iiefiire mrala.
i83
CHAPTER VnL
DISEASES or THE INTESTIKES— THE TERATIIEXT OP
KNTUlAU;lA OB COLIC.
Cim'n — Irritating Ingests — Fscal Concretioiu— Wor-':- -'■■^'.
tt<niei! — Impiwjuml Oues — Catbartir I)rii);»- 1
Cfilil— NViinwil ami Keflex CaK^-Ix-mi-Hv^t
fbiMi and Dio^tKtstic Signn. /
Itflii'f of I'aiii - Opitim - Knt'H
— Pargativc-a— Ca»lor Oil— CiiI'j.'i.^. ■-.•i ;..,. .u
of Morjihiuo and AtrojiinQ — Uu of IJt*ltaUunnd — Uouljr
Cmtf^ -Atfcilip^ and Cylcnicuni — r«Ar tn infant* — AutAciiii,
Oin ind Purgalivi'ii — Bromide of PoiaHnum Liiuv
W..' 't'nt rif R/trtim^tttr iirjd Hi/^trrtrttl Kiirmn —
CriJ. riijmfil in Hnbitunl (.V.lic — MaMmgc-yuinine
in Malanai Ca**;* — Milk lUet — yiurulyn^ (/ojm'? — ti;ilviiai«in
— Ar""nii-— Vajpn'simte of Zinc — Winn f'loiliiiii; -I fil i,.l,r
and ~^^ , <-#-3 of \ji I ! '
T: .titand !:■
— C ,- , J -^ui — £uvmaT^ 1- - - - .ui
Iodide — Electricity. Additional Fonnttla;.
)t cntrritl{;in, ur culic, is meant all tlioM* /i<iin/iil
r<-ctioti8 of tilt,' whIIs of llie iiitcstiiifs which ur** not
cau8e<1 by intlani Mint ion or l»y lUiy strii<:tiiral chnti^i-n
in Ihein. It- is an afieotiou of tlip si-nsory ni.TV(>s
of the int«*tino, analo^out* to gnstrnlpu, or to the
neumlgic affectionH uf other Bi>n*ory nerves. It must,
however, lie rememben-d that the same c»us«« wliich
excites a colic may, if it is* not removed, produce
intinmiiiatioa.
Enteralgin is not a dinetue or [uithological entity,
but rather a grotip of symptoms of a more ur letts
definite ehHrn<.-lcr.
As til tlie rniisi?* of enteralgia, they may be of
two kinds— first, those which act by setting up
irritation of the perijilieral i^nHs of the sensory nerves,
».»•. cansesnctinj; within the int<-stinal cniial itnelf ; and
secondly, eatistti iK-lin;,' on the 8yni|«»tlieti' nerve trunks
passing to tlie inlesline, eitlier ihrouj^h rcMex excite-
ment, or through pliysical change in ti>ose nervea,
aa «.ij. iutlaiumatory thickening of their sheaths, or
any other cliaiigo wliicli produces an abuorinul irri-
taljility in thinu.
A frcquetit cause of colic is tin* pit-sence of
some iiritating suhsUmco in tLc iutcstiue, as indi-
gestible or iioiHunoiis articles of food, or niccbaniciil
dist<'n8ioii us fn>m the passage of gall-stones, of hard
ftecal concretions, of miisses of intestinal worms (colica
verminomi). The distension of the bowel by J'acal
iiiipivlion (colica atfrcorarea) may cause great irrita-
tion of the intestinal nerves from jiressure on them.
The i-oteution of gas (coficn jliilulriila) from constipa-
tion is a comnion cause of colic, " the gas enclosed
Iwtween an impacted fa>cal mass below and a
descending; mass of ficces aljove gradually distends this
circumscribed (lortiuii of bowel and excites severe
pains, wliicli, however, disajtpear as soon as the flatus
escapes.'* Flatulent colic is, however, more frequently
pix)duced by undigested fermenting ingesta, especially
in infants ; such articles of fooit, undergoing abnormal
decompo-sitiim, produce llatulent distension of the
bowel and traction upon the intestinal nerves. Mere
excess of otherwise wljolesome food may cause colic ;
or the habitual ubc of fooil containing some eoai-se,
indigestible |)articles, as we have seen hap|)en from
the long continued use of coarse brown bread. Some
cathartic iiietlicines, such as " senna,' are known to
cause colicky' pains.
Reposiire to cold is a common cause of colic
(colica rfieuriiatica). It is difficult to understand
precisely how this acts — probably in the same way as
when an ordinary rheumatic myalgia or neuralgia is
pro<luceil. It is probably cither a reflex phenomenon
excited through the iu)iire.s.sion of cold on the
peripheral nerve-s, or it is eaused by the retention in
the lilood of excrement itious subst^vnces which ought,
onlinarily, to be eliminated liy the skin, the excretory
function of which has been suddenly arrested by the
chill.
* Leubs, ill Voti /ieiusscu's " Cyutopu-nlia of Practical Metli*
cine," vol vii. , ji. 160.
Vlll.)
ESTERALCIA OK COUC.
i8s
I
A tnirrhiii statr. uf (.lie synipathetic nerve trunks,
or of their central conuections, appears, in other
cases, to lie the cause of ent«»nilgia, as in thost; rar«
inHtauces of nttiicks of colic asMx-iatetl with dis-
ease of the fipinal cord, or thoee coiiui?ct«d with
uterine, ovarian, renul, and other vHsceral afiectioiM.
Lead colic seeuis to Ix*, to a great extent, uf this kind,
as distinct nnatomicul changes liave been found in the
ganglion and ncnc trunks of the RyinpAthctic in acute
cases.
Hyfterxa, the parent of many forms of neuralgia,
is also a ciiuse of intestinal neuralgia.
The sympiom* of enteralgia vary very greatly in
intensity, the pain being in some cases but slight, and
in othei's so severe as to be almoKt unbearable. The
attack will sometimes come on quite suddenly, at other
times it nmy l)e precefled by nausea, slight griping
pains, and flatulent commotion. The pain is usually
most severe in the umbilical region, from whii-h it may
radiate into the flanks aucJ groins. Finn pn-MHure
with the hand seems generally to afford a little relief;
sometimes, however, this cannot be Iwrne. When
the pain is severe, it is accoinpanietl with great n-st-
lessness, a pinched and anxious countenance ; beads
of cold sweat stand out on the forehead, with
cold extremities, a slow unci small pulse, and great
general depression. The abdominal muscles are hard
and tense, and participate in the spa-sra. liy placing
the hand on the alxlomen spasmodic cnntrsction of
the intestines may be distinguished in some i>art>i and
tlatulent disten»i<m in others. The attacks of pninare
soinetiiiies [leriiHlic ; they are apt Ut cease suddenly,
with a feeling of CKinplete relief. This oft<-ii occurs
on the discharge of fu'ocs or tliilus from the iKiwels.
Usually there is roii«lipniioii. C)thor syiiipl<jni.«
which may acc<»nipany the attacks of intestiniil jjuin
are vomiting, hiccough, dyspnuii, di-aire to micturate-,
giddiness, fidutness, and, in young cbililrcn, st^ni-timrMi
convulsions. In infants the.se attacks cause great rcat-
leasness, constant crying, and retraction of the liniUe.
i86
Medical Tkeatment.
tPart I.
It is inijiortant U) l>e able to cliHtinguish the pain
of coiif from tlittt of iiiHamniatoiy affections of the
iiit<^s(inul tiHifous iiienihrano and from disease of the
appendix. This is not usually diflicult ; the sudden
onset of severe pain, the absence of febrile symptoms,
the relief aflbi-ded to tlie pain by firm pressure, the
sudden disappeaninee of the pain on the escape of
gas or the jiassage of a motion, niid the history of
previous attacks, will usually eniiMc us to arrive at a
eoiTect diagnosis.
In searching for further indivnliuns for Ireai-
itlPilt we !>honId note whether the attack lias Ijeen
preceded by vomiting t>f indigi.'stible foot), or by
obstinate conKti|iatioii, or if there is evidence of the
presence of nodular musses of indurated ficces in the
course of the large intestine ; if there is much ab-
dominal distension and commotion from locked-up
flatus ; if worms have been passed, or symptoms have
been complained of jioiiiting to their presence.
The rhmiiinlic nature of such an attack may
l>e inferred when it has oocurrc<l directly after
exposure to chill, and from the absence of other
causes.
From commencing peritonitis it may be difficult
sometimes to separate it, especially in hysterical
women ; but the absence of thirst and fever, and tlie
fact that deep pressure is not more painful than light
superficial pressure, and the position of the patient,
the legs being drawn up and the body kcjit still in
pcriloniti.s, whereas there is often much twisting
al>out of the bo<ly in colic, will usually serve to
distinguish Iwtween them.
It is necessary to see that there is no liernia or
other evidence of organic obstruction.
If the colic is due to lead poisoning, the history
will usually disclose this. The longeontiniied obsti-
nate c-onstipation, the presence of a blue line on the
gums, the loss of jiower of the extensor muscles of
the wrist, the scanty urine, and general dyscrasiu
are sufliciently characteristic.
. Vltl)
EXTERALCIA OK COUC,
187
I
»
Willi tlipse prcliiiiiTiarv considemlious wo nuiy
pass on to the ironimcui of entcriilgiji.
Th*- piiin of ailic can almost nlwiiys Ijo relieved
by vpium, nn<l it is to this drug tlio pi-actitioncr
usually ut first rt'sorts. Tliis is not, however, aluniyt
coiitniendaljie. It must lie renienibt-red that opium
tend.'; to arrest the intestinal secretions, and espe-
cially the outflow of bile ; it lessens peristaltic
action (one reason, indewl, for )jivinj; it), even to the
extent^ if it is pushed in largo doses, of fMirnlyitiitii tlie
muscular coat of the Uiwel. So that while it relieves
the pain it does not remove the cause of the colic,
which may be, and frequently is, the prcsimce of
oH'ending ingesta or of old fieculent occunmlations in
the intestines.
It Ls far better and safer practice, unless we have
gooil reason to know that there are no offending
substances or fH-culent accumulations in the intestine,
to administer at once a large enema of warm Noap and
wat-er (from 1 to 2 pints), with which we should mix
1 or 2 tablespoonfuls of castor oil, and, in cases of
flatulent distension, a tables|>oonful of spirits of
turpentine. If the first enema come.s away without
atibrding much relief, another should be given after
half an hour. At the same time a hot llannel or
linseed poultice sprinkled witii laudanum may U*
api)lied to the alKlonien, or the surface of the alxionien
may be rubbed with opium or bt'lladonna linimont,
and at tin- Hame time gently kneaded with the warm
ttand in tlie ilirection and along tlr; course of the large
inte.stine, There is not the same objection to tlie
external use of opium as tlioro is to its internal
lulniinistration. If the enema, re(»eated two' or thriM?
times, fails to relieve, we may conclude that the
large intestine does not contain any fiei'al accunnda-
tion, an inference which would be corroliontt^'d by
percu.ssion over the caecum ajid colon. In this ia«e
wn should give some mild cjitlmrtic by the mouth,
such as a tablcspoonful of c^istor oil, or, if thi» in
rejected by vomiting, -1 or 5 grains uf calomel may bu
i88
Medical Tkeatment.
[Part 1.
tlirown otj the toiijijuc, and if tlin pain in still severe, a
small (litsc of tiioi'pliini' (j^ or j^ grjiin) coinbinod with
it ; or 5 or 10 iniiiiuis of tho lii|Uor opii amlativus may
lie added to the ciustor oil, iitirl this dose may be
repeatwl after two hours if uet-wsary.
If tlip piiiii is so severe ivs to point to persiiitenl
spasmodic contraction of the small intestine or to
some intrinsic lesii>n of the intestinal nerves, it may
1)6 advisidjle to administer hypodermically |th to J-rd
of a grain of morphuie with , Jjth to -g^ih of a grain
of atropine.
The \ise of opium is chiefly valuable for relieving
intestinal spasm, and when it does this it may actually
promote and assist the action of aperients on the small
intestine. It is not, therefore, to this rational use of
opium that we object, but to the routine and excessive
use of this drufj;, which we Iwlieve not unfrequ'»ntly
converts a comparatively unimportant colic into u
serious case of obstruction, by jmralysing the ab-
dominal walls. It is Lest, therefor*^, to cure an
attack of colic without opium, if po.ssible, and in that
case the cure {with evacuants) will be speedy and
complete.
It hss \«'cii objected that aperients in these caae%
ore apt to increase intestinal s|>nsin.s, esjwcially if given
alone, but this objection cannot apply to rnrmata, with
which the treatment of these cases should always be
l>egun.
In cases where there is great intolerance of
])ain, one initial dose of opium (or a hy|M>clormie
injection of morphia) may be given at the same
time that etforts are miule to evacuate the bowels by
enemata.
There is not the same objection to the use of
belladonna and atropine in these cases as there is to
that of opium and morphine ; there is reason to
lielieve that atropine le.Hsens or i-emoves the irritability
of the intestinal nerves, and so ndieves intestinal
gpasm OS completely as opium without locking up the
contents of the bowel and ai'resting biliary and other
ESTERALGIA OK CoLIC.
189
intestinal secretions, as opium does. We may, tliero-
forc, pK'svribe a wami canuinative mixture containing
belladonna, such as : —
Vj 'finctiira- belladoniMP ... ... yi>.
Tinctune cardainomi cumpoailH! ... ... 3VJ,
U
5'J-
SpiritoB amiuunia' urumntici
Hpiritus chloroformi ...
Sodii liicarbonatis. ... ... ... ... jj,
Aqiifl! cariii ... ... ... ... nil Jvj.
Miscc, fiut miHtiini. Two tu)jlc8|K)on(uli cvtiry hour until
relieved.
»Vtl'
should give enemata. Or
of n grain of atropine
At the same time vie
we may at once give
hypodennically.
In cases which appear to Iw of 11 Konly luiture,
i.e. occurring in persons who are known to Iw tlio
suhjects of gouty manifestations, we must give warm
allcaline medicines and an aperient pill with colcliicum
each night for a few night«, as the following :—
Vf Amim'nii carlionalis ... ... gr xl,
S)dii bicnrbuniitiB ... ... gr. Ixxx.
8piritii» ihloroformi
Tinctur.r zingibiris
Aquir cinmimcinii
3J;
. . ... «d jviij.
SluH.-p. fiiit mistum. Two tHblcgpnonfuU with oiu- c>l
hot
water i.'vory three nr four hoiin<.
1^ Extrscti colchici
PUuliB rhfi c'onip<jBilie
Kiut piluln. To bf tdkiii vvcrj night.
In infannj the coli(! is very frciiuently caused by
unduly irritating acid cnritents of the intestine
from abnormal dccomjiosilion of fiKxl, and this is
accompanicHl with jiniiifid distension of the intes-
tines with flatus. Such cases are best relieved by an
antacid aperient and carminntivr mixture such na the
following : —
ly ridveriii rhoi coiti]Hii!il«> 3].
.Spiritus Hinmiiiiiii' firtidi ... . . ... 5«i.
Tinctiinn cardiiraotni comjMmitr . ... ^iij.
S]iiritiis chloriifonui ... _%M.
Aqu;i" i-ttnii ... ... ... ... ml jj**.
SIiBce, fi.'it mi«tiira. A t«wpoonful or two according to iige
every hour until relieved.
tQO
Medical Trea tment.
ir»n I.
If there is decided constipation, a dram or two of
castor oil may lie given or a grain of calomel may lie
tlirown on the tonj^^e and washed down with the lirst
dose of tlie above mixture ; and if there seems to be
niufh painful 8|iiismo<lic contra<-tion of the intestine,
half a ;,'riun or u grain, according to the age of the
child, of compound ipecacuanha powder should !«
mixed with the ciiloinel ; that would be ./jth or ,'„th
of a grain of opium. If there should be a difficulty
in getting the child to take medicine by the mouth, a
clyster containing an emulsion of castor oil and a
little oil of rue should he thixiwn up into the bowel.
The following is a suitnlilc formula : —
H? Olei ricini ... jjailvij.*
(Hoi nit4i> niij au >i\vj,
I'ntnsBii cnibonnlis (jr. v. ail iv.
Aqua? »d 5ij nil jiv.
* According to the age of the child.
This must be given with a rather long tu>)e, or it
may not be retainerl. If, after free evacuation of the
bowels, there is still pain and distress, 1 or 2 minims
of tincture of opium (if the child is over six montlis)
may be given in 1 or 2 ounces of stiircli emulsion as
an enema.
IlingerH|>eaks of a form of colic in young children
which is only relieved by bromide of pntai^siuMt ;
the belly is i-etnicted and hard, or the intestines
"at one s[>ot are visible, contracted into a hard lump,
the size of a small orange," which can be felt " tnivel-
ling from one part of tlie intestine to another." These
attacks arc, he says, " nncouuectcd with constijMilion,
diarrha'n, or flatulence." They cause " excruciating
pain," and are sometimes " a.ssociated with a chronic
aphthous condition of the mouth." Two to five^rains
of lironiide of jwtassimn or sodium may be given every
hour in a dnini of ilill-wntcr.
In colic in suckling children caused by the indi-
gestion of milk, lime water with which a few grains
of calcined magnesia have been mixed should be
Chap. VllJ.I
ESTERALCIA OR CoLlC.
191
I
given after Ruckling to prevent the coagulation of the
milk.
Ill attacks of colic due to cbill, or of n rheumatic
n*tinv, hot apjilications to the surfiice of the abdomen
I've ipost useful, hot flannels sprinkled with turpentine
rbt hot linseeil-nieal or bran fioultices, after friction
with opium or belladonna liniment. Warm drinks
are also useful t-o promote diaphoresis, such as a
break fast-cupful of gruel, with a tablespoonful of
brandy. A full dose of Dover's powder, 10 to 15
grains, should be given at bed-time, and some mild
saline aperient the next morning, such as 80<lium
sulphate or phosphate, one or two teaspoonful.s, in
half a tumblerful of hot water every hour until the
bowels are rclieve<l. A fliinnel bunil »hould Iw
always worn round the alwloinen to prevent re-
ciirrence« of the attack. In chronic cases of this
kind iodide of jMta.ssium or salicine may be found
useful.
In liy^lericnl cases, usually attendtni with ),reat
flatulent distension, antiKposiuodic encniata are very
servii^eable., in combination with a|)erients. Four
ounces of the enema txtnfirlidn may be mixed with
4 ounces of the itiuniin alov» and 4 ounces of wnnn
soa|i and water, and administt-red with a long tube ;
or an enema may be made with :"> minims of oil of
nu mixe<l with 2 drams of aviinonuitfd (iucliire of
vtilfTMii, and then added to 10 ounces of warm
infusion of va/rrian. One or two dmps uf cajuput
oil on a lump of gugiir may lie taken int<'rnally to
relieve flatulence. Five grains of the aloes and astt-
fcetida pill may lie given night and morning ; or lictter
atill, a pill containing I A grain of powdei-ed aloes,
\jgrain of asafcctida, 1 minim of oil of clo\'es, and ti
' kin of powdered sfiap.
If we have evidence that the colic is caused by
inioMiiinl \vorin% we must give the remedies
necessary for their displacement.
One of the best renieilie.«i for slight but hahitnttl
flatulent colic is croaaote or menthol ; eitbrr of thcw;
192
Medical Treatment.
[Put I.
remedies givon iiimiediately or soon after food prevents
undue fprmeulation and developtuent of giis. Hulf a
minim of crefl.R(>tf or 1 grain of menthol may be made
into a jiill with 2 grains of powdered iliuharh and
1 of soap, and taken after each nieul. AlHioininal
massage is also useful in these cases. In ciuses that can
be distinctly traced to malarial inHuence (piininc in
full doses must be given ; or arsenic if ijuinine ciuinot
be tolenited.
A strict viilk cliff will cure some obstinate coseii
by removing all possible sources of irritatiou from
imperfect digestion of food.
In tlie piirth) in'iiriiliric cases more ditliculty
will be encountered in obtaining speedy relief. The
anodyne ren)e<liea already mentioned will, in most
case.s, afford temporary relief, but for [lermanent
cure we shall probably ho obliged to have recourse
t-o other means.
The general indications for treatment applying
to other fonns of neuralgia will apply in these
cases also. Galvanism has proved xery useful, and
is highly eonnnended by Leube, especially for the
relief of nieteori.sni. Arsenic 1ms been strongly
reconimende<l, especially liy Clifford Allbutt, in the
treatment of neuralgic colic. In some exceptional
cases, when the flatulent distension has been extreme,
good results have followefl puncture of the dis-
tendetl colon with a tint' trocar, or with an exploring
needle.
Valerianate of xinc, 1 grain three times a day, has
proved u.seful in enleralgia arising reHexly in connec-
tion with uterine diseases.
Persons prone to attacks of colic should Ix' particu-
larly observant in their diet, and carefully avoid those
articles of food wfiicli appear to predispose to the
ntUick. They should also clothe wariidy, and wear a
tlannel belt round the tdidomen ; tliey should avoid
sedentary habits, as well as any great fatigue or
exiiausting efforts, IxKlily or mental, and they should
never suffer the bowels to become constipated.
. VIIM
Lead Colic.
>93
The niarmgement of cases of lea*! colli* recjiiircs
iul consideration.
Alt)iou<;h lend colic as woll as other sj-mptoms of
[xiisoiiiiig ocL-ur iucidt^nlnlly and occusiouiUlv
from the inti-oduction of lead corii[iounds inU> the
lio<ly ill water, food, alcoholic beverages, hair dy«*,
Hnuir, etc., yftt it is chiefly amongst the worker* in
lead factories that it« severe cliaroctoristic forms are
so freijneiiily encountered. Plninliers and painters,
also, from the nece^Hity in their occuftatioas of coming
tuucli into contact with lernl, are prune to suffer from
plumhisiTi. Whenever we encounter the symptoms of
lead poLsoning, in others tlmn those who are known to
lie brought into contact with thU metal, or iUs com
{KiundH, in their occupation, it is nect'ssary to make a
very close inquiry — first, into the source of their
water supply, and, if this Is found free from all po»-
aible contamination, secondly, into all tlin source*
and modes of preparation of all the articles of food
ami drink consumed. Wine, cider, *)ur milk, bow,
finger- Iteer, lemonade, huir dyeH stronglv iropre^nattfii
with leA<J, have all, at time.s, been found to give ri*e
to lead colic Flour, bread, and aiknt hare alto
been found to coutAin lea<l, and t4) gire rito to
plunibism.
The symptoms of acute l»<ml cotic are Uum <le-
Bcribetl by Oliver*; —
" The ]>atient is suddenly neixed with mi acat*
pain in the alKlometi. ContintMj to the rvgioa of tW
nmbilicuii, sonictimes a little above it, bat nor» fre-
quently to the left, the pain is either of ■ Iwulin^
or grinding nature, or it create* a mims of w«igitt
and con<itriction. TlicMie pains are iiimptT cxcrvaatnig.
Sometimes the patient receives relief tmni pranire,
sometimes from wannth ; at other tinin» ha it maUr
to l>e touched. The colic subsides, onlj to rcntr ia
Earosysms, and with a tetuleucy to noctamal esaanr-
ation. Generally, after the acu(en«ai o( the paia
* " Legid PouoniaK in its Aeote sod Ckrooie Fmb." Tsaaa
J. Fentlnud. 18BL
194
Medical Treatment.
(Put I.
has subsided, natisea, retelling, or vomiting of a thin,
greenish liquid ot^curs, aceoinpliKheil with difficulty,
and accompanied liy restU-sanesx. The secretion of
the urine is diiuini»lKHl, and the pulse ie hard and
slow. In such a case under treatment, the pain,
gradually subsiding in severity, keeps returning in
milder and milder paroxysms ; the vomitin>» abates,
the bowels yield to purgatives, the spirits improve.
In a few days the piitient is convalescent." Together
with these painful nhdoiiiinjd symptoms we olKserve
other general symptoms of plnmbiism — pallor an<l
sallowuess of the complexion with ana>mia, pinched
features, a small, rapid jmlse, a characteristic UluAt line
on the gums, a metallic tiiste in the mouth, headache,
weakness in the limbs, sometimes e.xtremo wasting of
the ejcten.sor muscles of the hands and " drofjtr.d
torish," lo.ss of appetite, and most obstinate constipa-
tion. With other symptoms of plunibisni we arc not
at ])re.«ient euneeriied.
The tri'iniiiriil of lead colic may be prophy-
lactic or remedial. For the former purpose we sliould
carefully see that in the stoi-age and conveyance of
drinking water it should como into contact not at all,
or its little as possible, with the metal lead, nor should
any orflinary foods or beverages be storetl up or
wrapped in kyiden receptacles or envelopes. When
it has been found itiipraclicablc to prevent altogetlier
the contact of drinking water with lead, the addition
of carbonate of lime in the proportion of 2 grains to
the gallon causes a protective coating to form on the
interior of the ]>ipe, and the risk of lead j)oi80ldng is
thus greatly diminished, or wholly prevented. Silics
acts in the same way. Persons employed in lead
factories should bo regularly examined for symptoms
of plumbism, and when any of these are detected
those persons shoidd ut once Ije sus[»ended from work .
As in white lead works the powder enters the body
commonly by inhalation through the respiratory
organs, or from want of cleanliness in feeding, the
powder collecting on the hands being conveyed with the
I
Lead Colic.
'95
food into the luouth, obvious precautionary me^isurtss
are to insist on tho operatives wearing suitable
respirators, and bathing the body, and especially
carefully washing the hands liefore taking food. Kul-
pburtc acid lemonade, a drink ncidulate<l with sul-
jihuric acid, and sweetened with sugar, or a drink of
sulphate of magnesia (!), acidulated with sulphuric
acid, is kept in most lead factories, and the workers
are encouraged to drink it in the l>elief that any
soluble compounds of lead that might i-eai-h the
stumocli would be thus converted into the insoluble
8ul|ihute, and so be rendered harmless. Such drinks
certainly have a preventive influence, but the
workers cannot be induced to drink theu as freely as
desirable. This can readily be understood if the
bitter and unpleasant sulphate of magnesia is lulded
to iheni.
Oliver* considers "that no man or woman
should Vie allowed to l)egin the toil of the day
without having had a substantial meal, experience
and experimental investigation having shown that
during the proce.ss of digestion little or no lead is
dissolved and absoi'l>ed." He also thinks that " total
abstinence is a physiological necessity " to lead
workers.
The nedirinnl treatment must correspond to
the following indications: — (1) To relieve the con-
stipation and pain ; (2) to promote the elimination of
the lead from the body. In response to thf firtl
indication, it is usual to give the aperient siilphntes
in combination with sulphuric acid, for not only do
they, 88 purgatives, relieve the constipation, but aa
sulphates they precipitate any soluble salts of lead
there may be in the ijitestinal canal in the form of
the insoluble sulphate. Castor oil also may be k>^'*^i><
but the sulphates are preferable. Should the pain be
very severe, a hypodermic injection of morpliinu
(I grain) and atropine (Jq grain) may at the same
time be given ; or an opiate and belladonna liniment
• Op. tit.
IQfi
Medical TREATUEirr.
(Pull.
(lin. opii, lin. IxrlladonniB, na \ ounce) may be rulibed
, freely I'ound tbc navel, or a large warm enema of
ip jiiitl watfir, one or two pints, may be given,
Vith which 1 ounce of castor oil, A an ounce of
turpentine, anil 20 minims of liiutianum should be
mixed.
The following mixture of aperient sulphates may
be prescribed : —
s»5J«.
I^ Matrnosii nulphatis
Suilli aiil|)liiili.4
Aciiii sutphitrici aromnlici ... ... 3J.
Syrnpi zingiberis ... ... Jsm.
Aquii? cinnamomi ad 5x1],
Mi9C4', flat mistiira. Four tablespoonfuls ever)- hour until
thp boweU are t'omplctely reliaved.
The action of this mi.xture should !« aided by
large enemata if necessary. The aperient doses may
be repeated as required.
Bdladouna has been found very efficacious in
the relief of lead colic by some physicians. Small
doses (\ to \ grain of the e.xtract) should be given
frequently, every hour or half hour, and the do
should be increased until the full physiological eflectil
of the drug is e.stalili.Hhed.
Rectal injections of ether vapour liave been found
useful in lead colic. An india-ruhber tube is pa.ssed
into the rectum and connected with a tlask containing
ether, which is placed in hot water. Relief is
u.sually ol)t«ined after the vapour of about 15 minims
of ether has passed into the bowel. A dose of castor
oil should then lie given.
To fulfd the gi-cond indication, viz. to procure the
cliniinaliaii of the poison, pota.ssiuni iodide must
be given. This salt forms a soluble compound with
the lead deposited in the tissues, which is then re-
al>8orbe<I into the blood, and eliminated by the kidneys.
The presence of lead in the urine may lie detected'!
soon after the administration of the iodide. It may^
be combined with sulphate of magnesia.
, vni.i
Lead Colic.
»97
Tbe following is an ejccelleut formula, to be pre-
scrilied after the relief of the severe colic : —
Rr Potassii iodidi ... gr. xL
Bla^efiii sulphatis ... ... ... Jj.
Tinctiuii' Diicis vomiiTC .. jij.
AqiiH- cimiamoini . ad Jviij.
M iscc, tint mist uni. Two lalilespooii {ul.« night and early momiiig.
So rapid is the solvent action of the iodide in manj
caaes that Uliver calls attention to a cei-tain amount
of risk attending its use when there is a large
amount of lead deponited in the tissues ; he baa known
the general symptoms of plumbisro to increase under
its influence, and sudden death to occur, "doe in
great measure to the rapid entrance into the blood of
a large amount of Holuble lead salt.." Caution most,
therefore, be observed in its uxe.
ADDITIONAL FORMUUE.
For eoUe.
11 Piilrera rhoi, .<•».
Tini'tiirip rhei, >iij.
MafTiieini carboiiotiv, .^j.
uTii)ctuni> ojiii, "1 itr.
rSl'intiiA auisi, "Ivj.
8]iiritii(iiDenthii"jiiperitiB,.<ij.
Aquc ad ivj.
M. f. mist. A tablnmoonfut
thn-c limes s day. (yaptitti.)
fl
For flatulent coUc.
i ■ro/ormi
ifdamuui
'Is
M. t. mist. A t«a*poonfal
evcrr holflionr in water.
\hartholaw.)
For the pain of coUo.
R Clilnroforrai, .«j.
Moqiliiua- acctatis, gr. iu.
Olei «ni»i, Koll*" viii.
(>]ci mentho' |ii|K'rit«-, guttio
viii.
tSynipi nca/Hir, .^ij.
lAqaiP '.'ompliorie ad Mj-
f. mist. A toaspoouful
for a dote. (JaMok. )
Enema for BattUeat coIi&
R '■'-■ •.•■•.•••'•■■.- tj.
I *
i . 1 Sm.
Aperient dranght for eolle.
n. OIci riciui, »TJ.
Tinctur* rhri. 5ij.
Tinctar*- ojtii. m %x.
Aquir ritinomomi ad .^ij.
U. I. haiut To be taken Ib-
mvdialvljr. i M'A>Ma.)
For aatulent eoUe la
women.
li 8|jiritusnliimoniii' uMmati'l,
Fiiintu* chli>Tof"nnt, .sij.
'Iiiii.iuni- Kin^n^»•'^i•. \ij.
Tiurtiirif l^IijMlonim*. ^j,
At|uti* weiitKii- pi|M riljf; ad
Uj.
M. f . niiat. Twu tabiaepoOB.
fuU «T«7 (our h»iira.
{.Thrrf. Oa.)
■ 98
Medic A l Tr ea TAikXT.
(Pan t.
For colic and reitleMneu
In infants.
K Potajisii broiniili, .>J.
Olei aniiii, iriij.
MuL'ila^iiifl acocijp, .^ij.
AqiuK uie»tlin< pi]ioritir ad
jij.
A twt!iiK>oiiful evcrj" half-
liour iiiilil roli'.'vcii.
Dmugbt for flatulent colic
wiUi conBtipatlon.
H Olei rujuputi, iilir.
Sacchoi'i aibi, gt. x.
^Tere et ttdde)
Tinoturar jolaiHe, jj.
Deoocti aloea compositi nd
SJ89-
M. f liaiist.
For colic TTota Impacted
fascea
ft Strji-hiiinii.', pr. j.
Gxtnii'ti belUidniioa-, |^. it,
Po<lo|ili}lliu, (jr. iv.
PulverU ferri eulphatis,
gr. XX.
Aloes, socotrinir, gr. xx.
8yriipi, (jiuiututn aufflciat.
M. I't dividp ill pil. xx. One
every eight houif.
{Miittlgomny.')
For infantile colic,
li Miiin><wii carboiiutiK, gr. xx-
Syrupi zin^riberig, .iiij.
Spirilus clil'irofomii, nixx.
A(}Uie aiiethi nd ,^ij.
M. f. iiiiRt. A t«iu4}K>onful
every hour if iiwessary.
For severe colic in infants.
R Tiiietiim.' ciiscarillir, itlx.
Tinctuni' krameriif , mx.
Olei anthciiiiiliii.guttir j lul i j,
Syrupi simjvlieiB, 5ijw.
Aqun ad jij.
M. f. mist A toanpoouful
every two hours.
(/'/■o/*. H'tttrf/iofri-, 1'irttHa.)
Enema aloes,
ft Aloes, 4(1 KTiuiiii.
Carliomite of {lotanium,
I A gmins.
Mucilage of stiirch, 10 ox.
Mix for one eiicnut.
Mtzture for InnintUe coUa
B .SpiritiLs nmnioiiiH> fietidi,
"IX.
Olei nuisi, ni iv.
Tiuctunp opii, miv.
Maguesii carlKiiiatis, gr. xx.
Pulveris rhci, gr. x.
Syrupi xiinpliiis, 5j.
AijUii' ad =,ij.
M. f. miiit. One or two tea-
spoonfuls every three hours.
( Birrrtim. )
Alum mixture for lead coUa
H Alumeuis, .\ij.
Acidi siilpliurici diluti, >j.
Syrupi limonis, 5j.
Ai|ui» nd jiv.
M. f. mist. A tablespooiiful
ever)' hour or two. {linrlhitlnw.)
For tbe constipation of ead
colic,
ft Maguesii sulphatis, Jj.
Aeidi sulphuric! diluti, .^j.
Aqua: ad sW,
M. f. mist, A tablespoonful
every three hours. {Bartholoir).
Mixture for flatulent colic.
ft Magnexii levis, .^M.
Olei cajuputi. .is.".
Spiritusamnioniit'aronmtiei, '
.lij.
TiDctani< cardamomi com-
jHiiitie, .^iv.
Aqua- ad jvj.
M. f. mist. One or two
tahlespoonfuls for a dose (one
or two teaspoonfuls for a
child).
Enema asafostlda,
ft Amfa'tidip, 30 groins.
DtstilUn] water, 4 ox.
Rub the asafo'tida with th
water, added gmdually so as \Oh%
form an nrnnMon, for one
enema.
199
CHAPTER IX.
DISEASES OF THE INTKSTIMi — THE THE.VTMKNT Or
HABITUAL CONSTIPATIOX.
--Ii.
Int.
Insnffirient InifMtinn of Writer
i'* — Lo« of Muscular Tnup iii the
ut.'M to loUcit Actitin of H*>wpl^
I'le* — Hcadadie — Defectirc Nutri-
Kesttennea — PreaureSyniptoiiin
— CircuLitur\ :iiiti Ncurt^iaJ DiRtiirtiancen — Trratmriit — fiit/i^
mtiont-{\) y/if/f^ir— Water- Frwh Vegetable* nml Fruit» —
OatniMl. eto.— Fntf. oiid fhU— tir»pe»— Lin»eerl— (2) Urfi-
miiial — Exercine — OymnaAtic*— Hamige — Cold Affnsioni ami
lociU Douch<j« -Elei'iricitjr— Abdominnl Belt— (.'I) Mrtinmal
— Saline and other PurciitiTe« — EneniiitA — Mechanical Ue-
movol of Indiiniteil M/u»e*— tilyi'eriit« Injt_»ctiouH — Chola*
COKue* — Cftlimiel — I'MlophvIIin — Dinner Pilln — Bitter
Water* — Carlnhod Salta — <^ur<C9 of Mineml Wnter —
Hydrotherapy — Belladonna — Opium — Nux Vumicn and
Tonic*. Aaaitioual Formulir.
CossTlPATlOTt, for oar present pui^xxe, must Ixj
regnriltHi dimply hh nii almormally pnilotiged rfteiition
of tlie ftPt'ss, or tliC'ir hahitual expulKinii with diffi-
culty nnd in defectivf quantity ; and thin is UHUally
■HOcoinpanied by more or less disturlmnce of the
gnicral IipaUIi.
In fxmsiHeriiig tlip rnii«i'« of habitual consti-
{mtioii with a vi(?w to iU suowssfiil treatment, we
niiist, ill tlf Ixrut jilitcp^ point out how oftt'ii it di-jx-nds
on faulty dielellr habits, fspe<Mally in tht,- addiction
to too highly concentrated fixidB, and to the too
sparing; use of water. A diet cnm|ios<?d almo«t
exclunively of easily digested animal food will ieavo
but little wa.Hle n« a result of it.s dige.ition, and so
produce consti(iatiun by not supplying that stimulus
to the nerves of the intestinal mucous niombrano
which a nonnnl iiniount of indigestible residue woulil
do. Constipation may also follow the use of articiea
of foo<i leaving too highly stimulating a residue,
the repeatwl contact of which tinally exhausts
<oo
Medical Treatment.
tPartt.
the cxcitahility of the intestinal walls. Often tcio
dry a diet may be the cniise of constipation ; the
water taken Ijeing in insutlicient ijuantity to keep tlie
contents of the intestinal canal in u lliiid, semi fluid,
or soft condition ; the freer -.ilso tiie supply of water
to the blood the more abundant and Huid tlie in-
testinal secretions are likely to Ive ; whereas a
fective supply of water will naturally diminish the
nount of the fluid secreted by the intestinal glands,
comparatively dry condition of the intestinal canal
is thus induced, and the pro;a;res8 of the residue of the
food iilonj; it is therein' retarded.
The Msinie result will follow the excessive loss of
fluid through the skin, kidneys, or lungs, if this loss
be not cr>nipeiisate<l for hy an adequ.ite increase in
the water ingested. E.vcessive muscular exertion, or
exerci.w, in persons disposed to perspire freely, may
thus contribute to the constipated habit, and we must
hear this in mind when preaeriliing exercise for its
cure., or in ordering Turkish baths. Diabetes, and
certain nervous states, attended with an excessive flow
of urine, liyfier-lactation causing a loss of water from
the blood thro\igh the maniniary glands, and feverish
states, which increase both cutane<jus and pulmonary
transpiration, as well as lessen intestinal secretion, all
tend to produce constijvition.
An exclusive milk diet, as well as so-called
"fasting" cures, causes constipation by leaving an
insuflicient residue to excite intestinal peri.stalsis.
Too great unifomdly in diet will tend to have the
same effect by leading to diminished sensibility of the
intestinal canal.
Sfcondly : Deficiency of the intestinal seci-etinns —
of hih and intestinal juices, irrespective of dietetic
habits, may cause habitual constipation. In many
persons tliei-e would seem to l>e a constitutional ten-
dency to defective secretion of bile and the intestinal
juices, just as in others there Ls a tendency for the
cutaneous secretion to be defective.
Thirdly: Chronic coustipatiou may be due to a
Chap. IX]
Habitual Coxst/patjoa:
aoi
want of tone^ a loss of nusctilar propoIsiTe power in
the intestinal walls, either from defective nutrition, or
-imiierfect innervation, or from intrinsic strtictaral
|chan;;es. Under this head vre include the cases
rhich depend on bodily innctivitv an<l insiirticicut
Bsercise in the open air, associate*! with swientary
habits', or too exclusively intellectual oc<-uj-i«tions, or
Dm whatever other cause. Hysterical, ans'nuc, and
hy^iochondriacal states, although often, to some extent,
eff'tcts of constipation, may also c<intribute to coti*?
this state by the defective innervation and nutrition
of the muscular system generally which they induce.
We may also here include tho«e cases of constip*-
(ion depen<lent on pnralysing lesiona of the spina]
cord, which affect not only the motor nerve* of the
intestinal canal, but also those of the abdominal
muscles.
Or the loss of lone may depend on structural
chiinsre* in the intestinal walls ; a« an cedemntous •.•on-
dilion from chronic renal or cardiac disease or de-
generation or wastin)! of the muscular i-ont, as in
convalescence from exhnuMting fevers, and in the
cachexia of many chronic diseases, aa well as in
senile degeneration.
Fourthly r A cximmon causc of chronic constrpation
is a liabit of in<lolonce or car<'lessness in neglecting to
solicit a regular {Jeriodical evacuation of the liowoU.
The natural impulse to defiecation is at (in»t ditire-
gsrded, the sensibility of the rectal mucous mHtnbnine
is thereby blunted, considerable accumulations occur
in the rectum and sigmoid llexure of the colon, and
many diiys often pa.«!s without a stool. Women are
e«|>eciHlly mlilictcd to this injurious habit. Occasion,
ally it is dependent on some painful condition of the
anus (fissure, eczema, etc.), and the natural impulse to
evacuate the t>owel is voluntarily resisted in dread of
the pain caused by a motion.
Fifthly : Tt has l>een fiointed out that women ftr«
more prone to constipation than men, not only on
account of their more sedentary habita and indolent
Medical Tkeatment.
(P.irt I.
disi-eganl of the calls of nature, but also from organic
cause". " At every menstrual period the utt^nis
enlarges and exercises a greater compression on the
rectum. A tender and enlarged ovary (and at the
menstrual epoch the ovary is always tender and
enlarge<l) exercises an inhibitory action upon the
muscles which bring the fieces in contact with it in
their downward ]ias.sftge. In the married woman
recurring progiiancie.s lead to the habit of constipa-
tion from the long continued int-ssuii; ujK)n the colon,
sigmoid flexure, and rectum, from the extreme
stretching of the ulxloniinjjl muscles, and from the
paralysing cflfect of compression during lalwur. The
relaxed condition of tin- jielvic and alHlominal organs
after labour otFere no rcsistunce to the distension of
the rectum and sigmoid lle.xure. The cessation of the
catamenia is accompanied with constipation, nervous-
ness, and a feeling of ill-defined a])prehen8ion when
the bowels are moved, or abdominal pains deter many
persons, chiefly women, from habits of regidarity.
All ut«rine and ovariim dt'rHngenients by mechanical
or reflfX means bring about the same result."*
On the other hand, habitual constipation tends to
produce iii women hyperteniia of the uterus, with
menorrhiigia and uterine catarrh, and even more
sciious (liseflso of that organ.
Habitu.'d constipation is often accompsnied by a
<tisagri'eable train of sjinploms, which may here lie
briefly enumerated (some of these are probably due
t^i the mechanical and obstructing effects of the
retained fajces, atul others to the absorption into the
blood from the intestinal surface of toxic substances
resulting from putrefactive changes in the reUiined
excrement) : loss of appetite, coated tongue and Ijad
taste in the mouth, impaired digestion, tiatuleiit
distension and oppression causing palpitation and
dyspnoea, defective nutrition, wasting and anien)ia,
headaches, flu.shing of the face, sfKJts l)eforo the eyes,
• ProfcHwr W. W. Johnstone's urtide " ConstipaUoii,"
I'epper's " System of Practical Medicine," Tol. ii, p. WO.
Clap. IX.I
Habitual Cosstipatios.
great depression of spirits and irritability of temper,
tbe Bleep disturbed by dreamti and the nights rmlliiiii
Cutaneous eniptiong aoroetimes appear.
Owing to local pressure of the retained fa»es on
the vessels and nerves in tJie neighbourhood of the
rectum and sigmoid flexure, we may, occasionally, get
(cdenia of the feet (froiu pressure on tlie iliac veins),
but more commonly "'W feet, htpmorrhoids (from
pressure on hTjiogastric veins); men luay have trouble-
some erections and seminal emissions (from pn-ssure
on the pudic veins), and tsciatica, and neuralgic |inins
in the legs, and a feeling of numbness due to pressure
on Uio nen°es of the sacral plexus, A fnotrUh state
is not uucommonly induced in some canes of habitual
constipation, the temperature rises to 101° or 102' F.
(some physicians have observed mui^h higher tcnijK'ro-
turee) ; with this rise of temperature there are usually
n dirty tongue, a bad taste in the mouth, hiiihcoluured
urine, complete loss of appetite, and v^rei't pliysiciti
luid mental depression. These symptoms are, no doubt,
causeil by the absorption of to.xin.s develofx-d in the
retained fieces. The fever may last a considerable
time, even if the bowels are well Bcte<l ujion, and the
loss of appetite often lasts much longer.
The trcntment of habitunl constipation must
respond to the following indications : —
1, A suitable regiilntion of the diet and regimen.
2, An enforcement of healthy habits of life.
.1, The adoption of such remcdinl measures
(medicinal or other) as shall immediately overcome
the existing constipation, and prevent its recun-ence;
the latter by improving the digestion, promoting
intestinal secretions, und giving tone to the intes-
tinal walls.
And (Xy, a* to diet.
When we have i-cason to think an insuHicient
uount of water is taken, that deficiency must lie
topplied. A tumblerful of cold water should be drunk
slowly while dressing in thfi morning, again on going
to bed at night, and half an hour before dinner — the
9&4
Medic A l Trea tment.
(Part I
latter may, preferablj', be taken hot. Thia wat«r
should be as free as possible from lime-salts ; slightly
uiinenvlised efferv'e«;ing waters will iilso serve the
purpose, such as Seltzer water, Apolliiuvris water,
etc. Beverages containing tannin slioulil be avoided
— such a.s certain rvi\ wines, strong tea, etc. It is i>n
. this account that Oliiiia tca.s are .so nuicli more whole-
some than Indian and Ceylon teas, which contain a
much larger amount of tntinin. Brown or rye bread,
fresh vegetftblejv — spinach, Sorrel, Ijeet-root, watercress,
salads, plainly iKjiktl Spanish onions — and ripe fruits
should form a regular part of the diet ; plums, prunes,
grapes, figs, baked apjilcH, 8t*wed pears, oranges,
bananas — foods leaving a considerable amount of
undigested residue which exercises a stimulating
action on the intestinal walls, and increase.-* the
bulk of the fseces. But it is an error to irritate
the bowel by too large quantities of coarse and in-
digestible sultstjinces. The amount of animal food
should be limited, and the projiortion of vegetable food
incre4ise<J. An excess of eggs, milk, and farinaceous
foods, as they leave but little indige.stible residue,
must be avoided. Although milk by itself is con-
stipating, it is not so when mixed with coffee, and the
stimnlating influence of a cup of caff an hit on rising
in the morning will often produce a laxative effect.
Maize and oatmeal ai-e slightly ajierient, and may be
taken with advantage. Honey and treacle are also
slightly lii.xative, and may be tjiken with oat-
meal porridge or with brown wholemeal br»?afl.
Gingerbread which is made with honey is deciiledly
laxative, Honey and marmalade, eaten with bread
and butter, are good for this purpose. A due pro-
portion of fats and oils is also beneficial, as to some
extent tliey escape dig(>«tion in the small intestine,
and serve to lubricate and soften the fieculent mass
which pa.s8es into the large intestine. Plenty of fresh
butter is, therefore, useful, and so, too, is olive oil
taken freely witli salads ; or a dussertspoonful of this
oil may be mixed with ^wtato, beetroot, or other
a»p. IX. I HabItoal CoMSTiPATioir. ?o5
vegetable at lueaJs. The Imxtttive eflect of 4 to 6 IIjs.
of gTa|>e« taken as ft " gi-a[>e cure " daily, has been
found of valiio in overooiiiirig chroniL- constipation.
Linseed — such as lin»ecd-t«a is made with — ha*
been recommi-ndetl by some Frendi physicians as a
good remedy for habitual constipation. A little water
is poured on a rles-sertspoonful or tablespoonful of
Iin8e<>d, allowed to stand for one hour, and the whole
drunk immediately liefoi-e a meal.
When from defectis'e appetite or painful digestion
an insulficient quantity of foo<I is takon to yield
the neces.sary stimulus to peristaltic contraction in
the inteiitinal oxnal, measures must be directed to
removing the dyspepsia and im]iro\iiig the appetite.
(2) The enforcement of lienllliy liable* of life is
of grwit importance. Physicar inactivity, from indo-
lence or from too studious habits, or from tooiwtsiduous
devotion to sedentary occupations, is a fruitful caune
of habitual constipation, and in all such cnaeM an
•de«iuate amount of regular exercise should 1)6 iiisistetl
upon.
Bodily exercise is a means of exciting peristaltic
etion in most persons (provided it is not attended by
Bch profuse perspiration as to lead to an oxcessive
lo«s of water by the blood). Rejtpiration is tlu-reby
iu;celentted, the action of the diaphragm ami alxJnniinal
muscles is increased, and the circulation of the blinnl
promoUnl : at the same time the tone of the int^'stinnl
muscles is improved, and in this way peristaltic action
is i|uickened.
The influence of bodily exercise may lie aidtnl by
methodical abdominal massage and suitably devistid
g3' in nasties.
The following is the method that should l>e
pursued in applying abdominal nuissage for the cure
of constipation : — liegin by kneading the aUlomiual
integuments and muscles, pressing gently over the
cum with the tips of the fingers (pnlmar surfaces) ;
ben, by means of the closed fists, we should apply
but deep massage along the whole course of th«
2o6
Medkal Treatmekt.
[P»rt 1.
colon. Tht> pat.ieut should empty the bladder before-
liiind, niul tht' process should not last longer than
from IT) to 20 minuUw fsach time.
The iiiedioil attendant should at first apply or,
at any rate, su[)ervise this massage himself, as it is
im[iortanf that the operator should know the course
1111(1 rcliilions of the colon ao as to apply pressure in
thi? right direction ; otherwise more hann than good
may result from abdominal massage.
The importance of Imhitually soliciting an action
of tlie bowels prriodicallv, «.''. at a given hour daily,
sliouUl be in all cases pointed out. This i.s par-
ticularly tiecessary with young girls lit the age of
puberty, when tliey ai^ apt to be very neglectful in
this respect, and so lay the foundation of much future
trouble through inattention to the daily evacuation of
the liovvels. The daily hiibit of cold sponging, or
bathing, with friction of the surface, is of much use,
anil this may lie rciiiforcMi by cold douches or cold
atbision, or the application of cold compresses to the
abdomen. Prof. Turck lias suggested icf-imiHsat/t of
the abdomen, to be ajtplierl after the patient has
taken a hot bath -as Lot as he can bear. The wliole
of t)ic abdomen is then rubbetl and massasjerl with a
cake of ice placet! in a suitable rubber-l>ag. The
stomach, intestines, and solar-plexus are thus [wwer-
fully stimulated. Measures of this kind, when per-
severed in, have proved successful in curing obstinate
cases of c<.mstipatinii, esiiecially when dependent on
atony of the intestine.
Perineal and anal douches have also proved useful
by exciting locally the iiiusi-les of defa-cation.
Any habituiil pressure from tight clothing round
any part of the abdominal cavity should lie rectified.
We are not greatly in favour of electrical treat-
ment or treatment by Swedish movements, unle&s in
very obstinate ca.ses with fa'cal retention that cannot
be relieved by other measures. These two modes of
treatment have seemed to us to make patients far
too dependent on their continued application, and to
C-bap. IX.)
Habitual Constipat/oi/.
foster that morbid intro9j>ective attention to their
bodily sensations which they are already too prone to,
and which is, in itself, a malady. Wlu're, however,
the constipation seems to depend on feebleness of the
abclominal muscles and great loss of intestinal tone,
the regular application of the interrupted current
may be of use in promoting their better nutrition.
In such cases, especially after repeated pregnancies,
the wearing of a well-Htting elastic nhdoininal belt
shoulii V»> insiste<I upon.
(3) Finally, we have to consider the mrdiciiiiil
measures that may l.>e ert'ei.tujil in curing constipation.
Acindcntal or ocriuinntil consti|)ation is usually readily
overcome by Home simple aperient dose. One of the
iQOBt effectual is a pill cotnjKwcd of A a grain of
i^^oaiel, 2 grains of extract of ahxs, ami 1 grain of
extract of henbane, to be taken at bed-time, and
2 drums of sodium sulphate or phosphate in a
tumblerful of hot water the fii-st thing the following
tnoraing. This is a very effectual dose, which mn-ly
causes any griping and relieves the bowels completely.
A seidlita powder in a large tundilerful of cold water
early in the morning for the next few days will
usually Ije all that is needetl to restore regularity to
Uie bowels in such cases of occasional and accidental
constipation.
Catitor oil is another useful aperient drug for
occasional use, aii<l has the advantage of acting, as a
rule, ijuickly. From h a teaspoonful to a table-
spoonful may he given as a dose, according to the age
or susceptibility of the (mtifnt, in warm milk or a
little bramiy and water.
The medicinal tn-atment of lutbitiuil consti{)ation
is, however, more ditlicult. Whenever it is easy or
possible to overcome the habit of constipation by
siniple measures without recourse to drugs, these
should certainly l>e avoided ; but in very many
es it will certainly be necessary to use some
aedicinal aids to initiate a more healthy action of
the bowels, and no good can arise from needles
208
Medical Trea tueitt
(Panl.
alarming patients about tbe injurious effects of
laxatives.
At tlic outset, then, it is most importjinl to com-
pletely clear the intestinal canal of all fecal aocuiuu-
lations, and to ascertain by suitable manipulation
that the large intestine, throughout its entire course,
is thon>ui;hly emptied and contracted, and not the
seat of dry and hard retn.iued f;ecjil masses. For this
purpose such a dose as we have just suggested may
l}e given tor three or four con.secutive days, or until
by exainiiuitioii uf the motions and by palpation and
percussion uf the abdomen we are satisticd that uo
fiecal accumulatiotis have been left behind. If, how-
ever, we [lerceive evidence of hard lumps remaining
in the large intt?atine, or if small, dry, light concre-
tions tlont on the surface of the Hiiid evacuations, we
must wash out the large intestine )>y encmatM.
Those eneiuata must be administered by means of a
long tube, and the jiatieiit must be placed on his left
side, or, better still, in tlie ktiet'ling i>osture, with his
head and shoulders depressed and the buttocks ele-
vated ; ill this position the ttuid will flow of its own
weight into the large intestine, ami remain long
enough to soften old, Iwrtl, ilry fiucal concretions
which may be retained tli(<re. Each enema should
be retained for 10 to 15 minutes. The enema may
be best composed of warm soap and water (tein(>era-
ture about 100" F.), from a pint to a pint and a half
or two pints, according to the capacity of the colon.
Some recommend the introduction of much larger
ijuantities of water into the colon for purposes of
irrigation than those we have mentioned. Such very
copious irrigations maj' be advi.sable in certain cases,
but they must be u.sed with great caution, and always
by the me<licai attendant himself. The enema, wltich
is simply for the purpose of washing out the colon and
softening any hard concretions that may be iu it,
should be given daily until we are satistietl it has
accomplished the purpose for which it was ordered.
In very chronic and obstinate cases it will be advisable
Chmp. 1X1
Ha bit UAL Coxs tjpa Ttoir,
209
to oonlinue the daily a!«e of iin enema (in ike
position of tho body), which should no«
Mlher biniply of a pint of cold water, or • pint ai
cold water with u tca.s|K>onful of common salt and
half a t<>a.spooiifiil of sodium bicarbonate diaaolved in
it. This (Uily use of such a cold enema for nme
months together, with a propterly regulAt«d diet and
a daily dinner pill (preferably immediately leTon
dinner), i-onsisting of 1 or 2 )<ruinB of exlraot of
»loo^ half a grain of powdered i{iecacuanha, balf a
grain of extract of nux vomica, and a grain of aoaf^
we have seen completely restore the health of Ihcae
who have ailed for yeiirs in conseijuence of dirunir
constipation.
Ill old, bedridden, and {laralyned (x-ople it w not
unusual to tind in the rectum very l&rge luxuiniila-
tiouH of hanl fieces which no enema tuU- can
penetrate ; in such cases it is necess.-\rT, by niejuvn
of the finger, or a Kpoon or scoop of »MU>e kin'l, to
mechanically dislcMlge from the rectum h« nuK-h i4
this accumulation as can be reacbi.ti. :iii<l lb>-n to
use softening enemuta until the large mtentine ia
thoroughly emptied, and to continue the didy uae ol
an enema to prevent future acxiiimulation.*. In caMai
like the«e, as, it may be ini{io88ible to plac* tlie paki«ak
in the poHture previously dchcriU**!, be imy be tunwd
over on his left side, or the buttockn nwy be ratied hj
placing a hanl hair pillow under them : unksM mnM!
contrivance of tins kind is adopted, or a very long
tube use<l, it will l)e found tiiat the enema is often
immediately rejocttvl, and does not get beyonil tti«
rectum.
Enematu of olive oil «n<l of ox gull have \)f*fu
recommended in cases of long-standing fjpcal retrnlioii
for their softening effect on the (axtm. Large i|u«n-
tities of olive oil — 8 to 10 ounce*— have lieen intro-
duced into the large intestine utone time, and rrtaincd
there with excellent result*. Wo have used wmMtx
quantities than these — 4 to ft oooeei — with MTOii
advantage in the constipation that oftea fuTlowa
210
Medical Treatment.
|P»n I.
typhoid fpver. The toin[)erature ol" the oil shuuKt be
raised to iihout 100 F. If tlie patient is «n his back
the pelvis iinist he raised a little by placing a hartl
lusliicm under it, and the oil allowed to How from an
irrigator into the bowel (•>•/•)/ ahtwhj tlii-ouitfli a long
eolon lube introduced for about 10 inches. From 15
1o l!0 minutes should be allowed for this process. 'Jlio
patient should, after the injection, remain in V)ed for
im hour on bis back, but turning, from time to
time, on his right side and then on his left. The
oil will often remain in the bowe! for 3 or 4 hours,
sometimes a whole nigiit If a motion docs not
follow after 4 houra it may be promoted by u sniull
injection of wiit<-r. This operation may lie repeateil
(hiily until the juotions l>ecoti)e ijuite soft, regular, and
nntuial.
Tlie use of a small injection of r/li/cerine for
the relief of n loaded rectum has niarkp<l an
advance in the treatment of some forms of con-
stipation.
When the fiecjil accumulation is in the rectum
a l>atient can now make certain of an action of the
bowels in ii few minutes instead of having to wait
the numU'r of liours it may tiike for an aperient pill
or draught to produce its eHect. The glycerine seems
to cause a free secretion of fluid from the rectal
mucous membrane, and ho promotes the discharge of
indurated fwces.
It is, however, chiefly to tlie relief of an accumula-
tion in the rectum that this apfilies. It is, therefore,
valuable in cases where the rectum is subjected to
metlianical pressure, as in pregnancy and other
pelvic t.uniour.s, ami also in those |>ersons who ex-
perieni-e a difliculty in <lefa!cation owing to the
dryness and hardness of the fa-cal mass. It is,
however, of oidy auxiliary service in the treatment
of most cjises of chronic consti])ation. A teaspoonful
or two of glycerine mii\' be injected by means of one
of the small syringes supplierl for this ])ur[io8e, or
sup|K>sitoriea containing >r|ycerine may be employed ;
HABnuAt. Constipation.
211
^
lese latter have l)e«-n found convenient of application
in children. In some instances we liave found a
tablespoonful of Klycerino mixed with 2 or 3 ounces
of water answer better than pure glycerine.
Wlien the constipation i.s lussociated with what is
calle<l " biliou<»iiCNi),"nnd thetonguoisthicklyco«te<l,
the complexion sallow, the conjunctivae bile-tinted, and
the stools pale and offensive as well as scanty, and tlie
mine high coloured, or when troublesome ha;mor-
rhoirls are present, it is necessary to- promote tlie
outHow of bile by the use of cholagogne renieflies,
and in the Iat.t<?r co.se by causing a free outHow of
fluid from the intestinal vessels we relieve venous
congestion and thereby remove hieniorrhoidal diiiten-
sion. We should in such cases prescrilie n grain of
i4|Jon>el or 2 grains of blue-pill, or ,Uh of a grain of
Wrin of |XHiopliyllum, with •"» grains of compound
rhubarb pill, or with o grains of colocynth and hen-
bune pill, at bed-time, and a teaspoonful or two
of CarlsViad salts in a tumblerful of hot water the
follpwing morning. Podophyllin proves a very
irritating and unpleasant purge to some persons, but
others are able to take regularly a teaspoonftil of a
tincture made by dissolving a grain of podophyllin in
an ounce of compound tincture of cardamoms, without
any unpleasant effects, and we have seen it provM
very efficacious in the relief of hii-morrhoids, no iloubt
by the amount of fluid it cause.s to Ijc dischargf<l from
the intestinal surface.
There are a number of medicinal expe«Jient» for
relieving the milder forms of habitual const i|Kif ion ;
few are better than the niurt< or lea rvguW oae of
a diiiii4>r pill such as the following : —
I^ Alfjeti i^xtnicti
IperttCunnJiic piilvi-ri*
^ucta vomicn" cttmcti
Quioinic aiilphntik .. .. ffw. }-
tiit|K.ini« ... . ... ip. ■•■
MiiKi', fiiit pUuIa. To hn liiken iinina<lia(«ly h»tiitr dtnnrt.
.. gt. Im.
;}<u»T.»c
A tumblerful of cold water, or, if proferml, of mi
Medical Treatment.
[Put I.
effervescing slightly alkaline water, Hucli as Apollin-
aris, may he at the same time taken night und
niorning.
Some patients prefer taking their aperient in the
nHiriiiiig fasting in the shape of one of the natural
piirKHlivc waters, such as Apenta, Friedrichshall,
Pulliin, Birnn<nstorf, or Rubinat ; these contain the
aperient aiul bitter magnesium sulphate, and hence, in
tJermany, they are called bitter xrniU^rn. A few
ounces, 3 to 0, of any of tiiese waters taken fasting
act rapidly with most f>ersoiis and produce one or two
loose motions. Carlsbati s<iUs, composed ohielly of
sodtiim sulphate, act more comfort.ibly with some
I)atient8 than tlie bitter waters. The dose is one to
three teaspoonfuls dissolved in a tumblerful of hot
water.
In place of these waters we can prescrilje • '
morning di'aiight, containing 1 dram or more of
ni.ignesiiiiu suipliato, 1 dram of sodium sulphate, 2
drniuH of syrup of ginger, and I.' oz. of cinnamon
water. .Sodium phosphate is [ireferred by many, as
it is mild in its action, and almost tasteless.
In cases in wliich habitual constipation is asscKj
ciatc<l witli a tendency to corpulency and loade
alidominal veins, what the Germans call " nlKlominal
plethora," excellent results are obtained from a course
of waters at Carlsbad, Marienbad, Tarasp, Brides-les-
Bains, or, at home, at Harrogate, Leamington, or
J-hindrindod.
In more purely dyspeptic cases, and where there
is much want of tone, in the whole alimentary canal,
the gaseous sodium chloride waters of Kissingen and
Honihurg answer exceedingly well.
In such cases a course of ordinary hydrotherapy
in a well-conducted hydropathic establishment is also
often of great value.
HAIiidonna, ever since Trousseau warmly advo-
cated its use in chronic constipation, has been largely
employed in its treatment. It is believed by some to
act by relieving intestinal spasm. It may be given
HaBITVAL COSfSWJtTtOX.
combined with dux
ipecacvaaha, or other •[
to try its elfiMt tiottt, or m
vomictt ; frooa | to | gnn of vatraet of
, grain or | gtmin of extnet of
\y be ti^reo in a ptll rvety ai^bt at
this fiuU it maj be eeoahiiiBd inth aloea, or
a&ho, or both.
The following fonnnla has been Cgand • good
one : —
H' Aloime ■ • ^ I-
StrTchniiut- nal)ik.iii« .. gr. ^V
Kxlracti Iwllad/nn* liriiijt .. ft. \,
I'ulvcri" i[«-Ticn»nL;i' gr> \,
Miwe ct fwi piliila. T« be t«kai daitr.
Employed alone, belladonna teems to be mora
elGcaciouH iu women than in bmo, and appoara
espectAlly applicable to thoae caaea of constipation
where a painful condition of some of the {Mrlvic
viscera (uterus or ovaries) tmds to constipation by
inliibition of intestinal peristalsis. Opium in yery
small doses has been said to act aa an aperient in
similar cases.
It is only ne<*s8ary to enumerate a nnuilier ol
other useful «|ieriwit medicin<;ti whicli liave jirovwl of
value in the treatment of chronic conntipation : com-
pound liquoria; fowder ; confection of senna ; sulphur
ill the form of confection or lorenf;en, or tAVijulds ;
coscarn sagradu, now very liirgely used in u variety
of forms ; euonyrain ; citrate of magnenia ; all these
are useful in appropriate coses, and ctiiable us also to
change the aperient from time to time, which will be
found ad>'i8a1>lo.
Of all these |)erha|>8 catcara is at present the most
popular, and it is presented to the public in every iiossi-
ble fonn— syrups, extracts, tinctures, capsulen, lo/i.'nges,
tabloids, etc Il« protomjed use, two monliis or mure
at a time, has been especially otlvocated for the relief
of habitual constipation. It is, however, somewhat
tl4
Medical Tkea tmest.
I Pan 1.
ditiicult to estimate accurately the rioso that is be
suited to individual cases, and it is highly desirable
use the smallest dose that is consistent with efti-
cacy ; 20 or 30 minims of the Huid extniot may
be given at bedtime, and its effects noted, and
the subsequent doses regulated accordingly. An
aroDintw ai/nip has been iiitrodm-ed into the B.P.,
and this may be given in doses of from a half to two
teaspoonfuls. If taken in large purgative doses it
is usually followed by constipation, and the point in
its admieiistration is to give just the (juantity needful
to procure one soft evacuation daily, and no more.
Hume find it best to give a small dose — 5 to 10 minims
of the tiiiid extract — three times a day, directly after
mortis, nitlier than a single dose at night ; attempts
should be made to diiiiiiiish the dose, and finally,
if possible, to do without the drug entirely.
We ha\'e found the sugar-coat^ed tabloids of
Burroughs and Wellcome a most convenient and
cfiicacious form. These are marie of three strengths,
containing one, two, or three grains of the solid
extract.
Cases of chronic constipation associated with
general debility and ansemia, and dependent on want
of muscular tune in the intestinal walls, require tonic
as Well as ajx-rient treatment. In such cases nux
vomica or sti-j'chnine wilh ([uinine and iron is
especially useful. In the constipation of chlorosis
the following prescription will be found %'aluable : —
I^ Fi?rri el quininii! oitrati!' ... ... ... gr. Ixxx.
Iiiqiiori!' strychninie ... ... ... r\ x\.
Syriipi simplicis ... ... ... ... Jj.
AquiB lid jviij.
Mitic'o, Hut miKtura. Two tablespoon fiiU to bs taken twico
M (l»r, nn hmir lieforo food, and
V} Alow cxtmcti ... ... (jr. ij.
Ik'lluiioiinir. I'Xtracti ... ... ... gr. J.
Mii«to, Hill pilitla. To bi' taken cvpry night.
Or the following, which is very etficaciouii, but not so
agreeable to take : —
, IX.)
Habitual Cohstipation.
»«S
H? Kf;iTi stulphiitit
M»eac'Sii «ulphnti«
(juininic siilphiitis
Liquori? atrjchninn!
Acidi aulphuriri diliiti
Aquio
gr. x»J.
«rr. xij.
■nil-
Ill xl.
1.1 Jviij.
Miavc, fiat mistuni. Two tablespooaluU twice • lUy, an
ar lefore breakfatt and dinner.
This mixture will often succeetl in overcoming
constipation iu anii-iiiic women after most other
aperients have failed, and it also acts as a blood
tonic.
In certain cases in which it ha.s ;kppeiirp<l un-
desirable to give medicines by the stoiimch, hypo-
lieruiic injections of a sleriiiiwsl '2 per cent. s<jlulioii of
mtignrnium tuijihati" have l>een eniplo\ed succeSKfully
to overcome constipation. From 3 ilranis to an ounc«!
uf this solution is inj<:«.-t«<l ittilx-utaneously with the
UMual antiseptic precautions.
ADDITIONAL FORMULA.
OMoara mixture for habitual
eonetlpation.
ft Extrncti ca«cani< (agnidip
lii|uiili, .^ij.
Tiuotuni! uucii vomica*, ^iij.
Tiuclum- bellwlonuu>, .siij.
fjlyc^riui tA jir.
M. i. mi»t- A feaspoonful
■light and morning for four
lUya, then onlv at uight.
\irhtllu.)
Anotber.
R Extriuti cMcara- liiiuidi. .'•v.
Tinctura? uucis voniicip. rv*-.
A'juip laiinjccrusi. jm.
Syrupi !iimpUi:i.i, %».
AquiF a<I Sr.
M. f. mi»f. Throe or four
(aiuiKXnifuls in the day.
{ItuJardiii-BrHMiiirU.)
Aloes and Iron pUli for
otMtinate conitlpatlon.
R Kxtrai'li iilo<'» lupi mi, gr. j.
Fcrri lulpluttio, ur. ij.
M. vt ft. pil. Oueto Im! taken
three tinu's a duy ifft«r eaL'h
meal for a wi.-ck, then one twin)
a day for u firtuighl, then one
every night. (Sprnilrr )
Dinner pllla.
K Extract! aloes foootriua-,
gr. »«-
Extructi uuciBToinica-.gr.as.
rulvrris ipecacuanha', gr *a,
PuWcris capsici, gr. j.
M. f. pil. To ho taken daily
lifter dinner. ( «'*<//-».)
zi6
Medical Treatment.
ir»rtl.
For constipation in very
youns infants.
H Maiiiiii!, .sijss.
M. f. iniat. A doiaertspotm -
ful ever}- hour until it ocU.
(Uonti.)
For infants with rickets and
Intestinal atropby.
ft OK'i fnnrrhua', ."^ijss,
Svruni HiiTipliciK. ,>ijsf*.
MuL'iliL^ii» iiciniir ii'l jiij.
M, f. tnmt, A denBcrlMtioiiu-
ful throe times n day. {Mnnti. )
Dr. BilUie's dinner pilla.
ti Extrurii iilops WM'<»trirr(i\
(ir. xy.
PiilverisijK'carunnhjf, gr. vi.
I'ulveri» ziiigiberin, gr. xxiv.
Synijii, ij.ii.
M. et (liNnde iu jiil. lai. A
pill t(i In" tjikcn bt'fort' diiincp.
Dr. Gregory's pill for
constipation.
ft Extract! alou.* uquoM.
Sapouij«.
Pulvcriii rhei.
Pulvrris ipecacuanhn*, .'fa'i,
pr. xii.
M. et divide in pil. xii. One
or two for u dono.
Aperient lemonade.
ft Aoidi citrici, .^v.
Mugml^ii i-arbnuuti». .^iii.
Svriipi Kiinjjlicii!, jiij.
Tiuotune hmuiii*, nixx.
Aqitti' ad jx.
M. {^f,ll/,iru.)
Fills for constipation.
R Aloiiiio V .
Extracti iitxris vomiciB I S
Ferri aulpbHtis ' h^
Piilveris iiiyrrhiB I ,?
SajKiniH / '3
M. f.pil.
If livti.t are ilry add —
I|icciieiianba' piilveris, p. w.
If t)ie pill gripes add^
Exlrnrti lielliidoiiijfp. gr, v,
Oui% nr just as much uf ou«
M lufBoes to pnjcare a natural
iii'tiou next iiiomiii);. to '*
tJikeu half iiu hour boforo the
]tist meal ul the day. As an i
nitt'mntive, fi to 20 drojis ofl
fluid extract of caiwnrtt Mit/raitM'm
in an ounce of water niny baf
taken ut bed •time, or b«foraJ
dinner ; or both failing to ngr»e,.l
'2 or 3 grains each of dried car* i
bonate of soda and pitwdcred ■
rhubarb may be taken before
the mid-day meal. {I'liiri:,)
Podophyllin pills for cbronle
constipation.
H I'Mi|"plivlli rir<it]:i', {;r. j.
Extracti aloes aqnosi, gr. z.
Extructi rhui, gr. x.
Extru'ti taraxaci, gr. xv.
M. et divide in pil. x. One,
two, or three at beil-time.
(.V.)/Aimj/'7.)
Iridin and aloes pilla for
constipation of the gonty.
ft Iridin, gr. xxiv.
Aloe* pulvcris, gr. xviij.
Extracti hyo8<'yami, gr. vj.
M. et tlivide in "pil. xij. One
at licd-time, to tw follnwtd by
a glass of Carlsbad water the
foUomng morning.
puis for habitual
constipation.
ft Quiuiuip sulphntis, gr. xv.
Extracti aloes aquon,
gr. XXX.
Pnlverii glvcynhi»D, q.s.
rt f. pil. Ix.' Take three pilla
night and morning.
Or
ft Pridopliylli resiniD, gr. It.
Extmctl liclladouua', gr. ij.
Extracti goutiann\ ips.
Pulveris menyanthis. i|.s.
I't f. nil. XXV. One to three
pills in the morning.
Or
(in morv obstinate cases)
ft Pulveris rhei I Aft
Extracti alu4^ aquosi \ Sss.
Extracti colocyuthidis, gr.iij.
Hcllis, q.s.
pif
Ut f
daily.
Tiro to four
(BaHibrrffr.)
€ai:tpL net
Additiohal FOKMi'L.t:.
J<7
Cliolagxigiie paTK>tlTe piUi.
R Ilv'lnr-^vn «iit"-lilnri'li,2r.l.
!•■ er. j.
r ii.f. pr. J.
r . ...... ii» ft lijro»-
r:yiinu, "gr. iii.
)L f. pil. at bed-time.
(JTrtuv.)
Aperient and stomaobic.
R ShIu tiiiarUoiutii, gr. »v.
Si>ihliu>>mmoiua: aroma tici,
nit
Tini-tani! atmuB cnmtinritw,
m i:r-XKX.
Iiifusi ^^tianie compoMli,
a<t ji.
M. r. haiutiu. To be taken
three tima a day five minulM
Ixjfore meoli. (Jtmtr.)
Asotber.
R Pulverin rlioi, gr. x.
S"'" ' ' ''-, gr. xy.
'I , "I I.
^l ■■rmniitict,
Aiinii' moiilliic iiiperitjc,
a'l .^i.
M. f. Iiniulus. To Ik titkrii
hiilf an hour bvforv fiMxl twic*
daily.
Another.
R liifu^ rlici, jim.
Tioctiinr gontinuai oompu-
.*'•> illltis, (fT. ».
.^1 ' ifiimii. m ».
A<(.i.< i>M ittliiit |iip<*htit',
•■1 Si.
M. f. tuustiin. Tn \k lakm
Iwicv or Uiricv daily, half an
hour boforv food.
2|8
CHAPTER X.
I>»KAS<E8 OF THE INTESTINES— THE TREATMENT OP
DtARKH(EA, INTESTINAL CATAKKH, ACUTE AND CHBONIC.
I liARantKA a DuHiase iis wull ua a Symptom — An luflummutor}' aiid
a Non-Inflaiiimatnry Form. (\ih ry of Acute aud ChroDioi
Dinrrhavi : Locul Irridition from oflcndiug Iiigestn — Iiifluenoa]
of Colli— SuroiKlary to Organk' or Coustitutional Diaeaac— 1
Euiicmic or Eiiideinie iii Hot Weather, and pmtiohlj Microbwi
Olid Spt'citic — SoiiietuiiM Elimiuatire of Toxic Sjubataocea iu
the Blood — lufaucy prediapoKc* to loteetitiid Catarrh— OM/t
S>/mpl<im» of Aoiite Intcstmal Cntiirrh. Tiratmriit : Diet —
Jiillc-Fnrinnceoini Foods— Food for Chronic Cose* — Raw
and i^uudtHi Mejit — Rest, general and l(K*ttl. Mritn-tiutt
Trraliiuiil : Eluniiiative — Eiiemattt— Castor Oil — Caloiiipl —
U»c of Alkalies- tipium— Fnrraulip for Infant*— Astringent* .
— Salts of Dismiith— Chalk — Taiiiiiu — Intestinal vVntJKi'ptic* I
— Sterilised Milk— Culoincl-fialol-Besorciu, etc. — S-\aph-
thol — Lactic Acid — IteiM"- Yeast — 6'A/7/Hir I)tiiirh*ra — Quinine
in Slnlanal Case*-'-Milk and VicJiy Water — Peptone*^
Mineral Astringents— Kissin^cn Water — Intestinal Irriga-
tions. Additional Formulie.
It haa been said that dinrrlio'ii is a symptom
and not a disease, and that the disease of which it is
a symptom is inflammation of the intestttui/ mttcvut
viembrnnf, or iiittUinal catarrh. From the f>oint of
view of treatment this question is not, perhaps, of
much importance, and we may regard liiarrlueu both
as a symptom and as a disease. Certainly their are
forms of diarrluea which ar* not inHauimatory, and
cannot Ije rightlj' considered as dependent on iiijlam-
mnlion of the intestinal mucous membrane, and in
which the symptom is of almost sole importance,
and it may, therefore, be justly regarded as »
functional di.sease.
In this chapter we shall regard diarrhoea as oft«n
dependent on acute and chronic intestinal catarrh,
especially when the catarrhal comlition is general,
and affects a large extent of nnicous membrane ; but
as occurring also in other states which are chiefly
characterised by a morbid flux from tlie bowels.
Ch>|.. X.|
DlARRH(EA.
ai9
I
We consider, tlit-n, tbut there is justification for
tiie division of diarrbora into inflanitnatorj and non-
iaflatninalory : the latter including those casex of
emotional origin, or nervous diarrheea, analogous to
the polyuria of a hysterical attack, and those of mere
exaggeration of physiological function, habitual in
Boue i^iersons, and in many instances dependent on
any slight excess in the qunntiiy of the ingeiittt. In
these cases, tot>, the matters discharged are ordinaiy
fwcal matters simply, in an unduly litjuid stute. in
cas«» of diarrhoja dependent on inflamiimt-ory catarrh
of the intestine the Hux from the lx)wel consists in
part of inflammatory exudation front the cutiirrliul
mucous membrane, in part of intestinal secretions
harried onwards by tiie exnggerated peristjdsis at-
tendant on the intlamniution, and in part of unabsorljiMl
food, piirfiftlly or wholly undigested. In I'liroiiic
diurrha'a. tlue to chronic intestinal cuturrli, abundant
muco-puritlfnt secretion may be pr«?sent in the dis-
charges.
With these few preliminary remarks we may ]>asa
on to the consideration of the caa*M»» of acute and
chronic diarrho«.
We must bear in mind that the intestinal mucous
membrane is particularly liable to catarrhal intlani-
mation, and that comparatively slight irritation is
safticient to excite it, especially in certain indi-
viduals in whom the intestinal mucous memlirane is
peculiarly sensitive.
1. The most common cause of intestinal hypenemia,
catJtrrh, and diarrlnea is local irrilntion, and the
most usual local irriUint is soai)' ii|]ijn<liiig iiigesta.
A variety of foo<l substances will, under certain con-
ditions, excite diaiThiea, either substances unsuitable
in quality, i.e. in themselves indigestible, ami acting
OB irritating foreign bodies, or substances in a state of
commencing deconi]>osition, and capable of acting as
chemical irritants, or simply fix)d t'X) copious in quan-
tity, or badly prepared. The pouring out of an excj«s8
of bile, or bile of an uhiiiniiKLl <jiiality, tuay act in ilir
Medical Tkeatmext.
'•Tjo
Haini- way ; on the other lifiiiil, an absence of bile, from
iiilltiitiniatory c-losure of tlif cnnimon duct, may mIso
lend to liittiriiii'Ji, for in tlio absence of the alkulitio
bile, whicli usuiiUy iicutrrtliseH the acidity of the
chyme as it passes out of the stomach, tiie~conlenta
of tiie small intestine leniaiii acid, and therefore act
as an irritant, iitid set np an intestinal catarrh from l
the lack of bile. The loose motions ai*c in such case*
found to bo white, or olay-coh>uit><l, and often very
offensive, as a due admixture with bile also preventa
the formation of irritating products of putrefaction by
its known antiseptic action.
Long-retHined indurated fieces (intestinal con-
cretions) may set up catarrhal intlammution of the
intestine, not only by mrchnn'ful irritation, liut also
by the toxic suljslances developed by tlie putrefactive
changes they underfjo.
'.'. <'liill to the surface is a common cause of
intestinal catarrh. The Cfitarrh so causetl is probably
dependent on a n;fle.\ vasomotor influence arising
through the cutaneous nei-vea.
3. The int<>stinal catarrh may lie s«»condary,
and due to a morbid state of the intestinal mucous
mend)rane, which may itself be caused by some other
organic or constitutional disejise — e.y. obstruction to
the circulation througli the liver or in the portal vein
causing \enous hypenemia of the intestine, or a more
genera! and more permmient venous congestion depen-
dent on chronic (luluiormry and cardiac disease. It
will be readily understood how easily a diarrlxea may
be excited in these morbid hyperaMnic conditions of
the intestinal mucous membrane by any slight irrita-
tion. Such liyperajmic atatoa may, however, exist
without diarrhoea. Lardaceous degencmtion — tuber-
culous, cancerous, dysenteric, or typhoid ulceration
of the muc<ius niembraiip, do not directly concern us
now, as they will be dealt with in other chapters, but
they also ai-e well-known causes of diarrha>a.
■1. Many instances of enilciiiic or cpi€lt*inir
diarrhoea, such as are especially prone to occur in hoi
DlAKKH<EA.
2JI
weather, are doubtless infective •'uid of mlcrobic
origin : and the elevation of t4einperatun.>, w}iich has
been n^gat-dwl ns, a cause of diarr)i>:t>a, may only act
by calling tlio infective organisnis into activity, or by
pniiiiolinft the activity of putn>factive pnK:«'ss«>» in
fiiorls niid beverages. Uiider this heading we slioiild
group those cases which occur after drinking water
from suspected sources, and {irobably contnminAt<*d
with sewage inatterft, and tho«e as^x'iuted with
malarial infection.
5. Some attacks of diarrhu-a are rlimiiinlive,
an»l are fxcite<l by the presence of toxic sulist.iiin-s
in the lilood, a« in ui-a^iio. ft<-.
6. Infancy 8»>ems to )>e a pn^linpoMinf; cause of
intestinal catarrh, which im very wntnion in nuniug
children. This in duo not only to the extreme
senHitivene^s of their intestinal mucou^j niembranp,
but also to tiio frequent absence of that extreme care
and cleanlineas which aro ueedtHl in iho selection and
prei>anition of their food in order to avoid pxcitin^
i;;iiHlro-inteMtinul irritation. The tuo early recounwi
to farinaceous foods in especially rf.<i|ion«iibIc for
much of the (^a-itro^intestinul disorders nf inriincy.
r)iurrhii'a is often the only >»yn»ploiii of artUt
intestinal cntarrh, but at other tiiiiCM attacks of (nin
and coli<- |iri«cede, and are relie\»'d by, evacuatiouM
from the IjoweU. Some tlutulent ili<it4Mi.sion of the
ab<iomenan<l tenderness on pressure arc also nimmon.
Fever is presi-nt in some cases, es{H-ciallv in those
caused by chill and those causiil by the lu-tion of n
ii]i«cif)c contagion. Thirst is generally complnini:d of
in acute diarrluva, owing to tlie considerable Iomh of
water from the bloo<l.
One of the chief points in the trraimrnl of
diarrhtva, whetJier a«'alf> or chronic, is a suitable
reflation of the diet, and when the diarrha-a lia.>t
been caUH<?d by faulty feo<bn(,', this, together with rest
in be<l, will often alone ellect a cure. Then- in one
general rule which applies to all ig^n. fif diarrlio a,
AOd that is the avoidanc<< nf all {* h Ic^vu
222
Mf.dica l Trea tmen r.
(P«t L
much indigestible residue, and tliat nmy, therefore,
tend to maintain irritjition of the intestinal mucous
inenidrane. Only such foods should Ix- pfescribed as
leave an unirritalinj^ residue us a result of their
digestion, and have no tendency to undergo do-
coin|>ositioii into irritating acid suhstancca in the
intestine.
It is scarcely necessary to point out that all
vegetables, fruits, nuts, brown l)read, all fat-, rich, or
acid dishes, all forms of animal food that are hard or
tough, and, therefore, ditKcult of digestion, siioulri !«
avoideti.
In cases in which milk is readily and easily
digested it is one of the best foods. It should Iw
first boiled, and given diluted with water, or lime
water, or soda water. In cases in wliicli milk is not
easily digested, and when we find the curd of milk
passed in the motions, we must prescrihe unirritating
farinaceouN foods — arrowroot, sago, tapioca, or groimd
rice, prepared with water and flavoured with some
aromatic spices, such as cloves, cinnamon, or nutmeg.
Egij <iltiniii'')i has lieen found an e.xeHliont finid for
chihh'cti with diarrhiea when milk disagrees. Tlie
white of one or two eggs slioidd In- whipped up with
half a ]>int of water, a little salt iidded, and a few
drops of bnindy. This may be given freely.
Many cases of acnte diarrhiea may Ixj quickly
curetl by limiting the food, for a day or two, to water-
arrowiwot, flavoureil with a little port wine or cognac.
Clear soup or cormomm^, when this is prefeired (or as
a variety), may be given, thickened with arrowroot,
siigo, or tafiioca.
The best beverage is soda water and milk, with h
small quantity of brandy, iceil if there is much thirst
and fever. Port wine and water may be given if
preferred.
t)n the subsidence of the acute attack a gradual
return to ordinary diet may be [>ermitt€d. For a few
days, however, we should restrict the patient to clear
soup, or mutton or veal broth, thickened with a little
DiAFRHfXA.
a»3
I
cmnili of fctale 1>i'«ad, tti[iiocA, or HHgo. Boiled
chicken, pbeuaant, or partriilge, witli rice, uii«_v l>e
p^nuitttHl, or some J>oiled or grillefi wliitin^ or sole
anil a liltln mashed poUito. A little woiik lirandy
and water or port wine and water may be allowed as
a lieverage.
The dietetic treatment of chroiiir diitrrlia'ti
is of no less iuiportanc«, liut it is dillicult to carry
out, owing to the impatience of most persons of
the continued restraint which a suitiilile <liutiiry
iinplie.'.
The general principle to l)e lM)rne in mind is timt
the food sliotdd lie concentratetl and smwll in hulk,
easy of digestion in the Htoinnch, and lenvin;; hut
little residue to irritate the itite^itinal mucous mem-
brane in its passage along it.
A strictly milk diet —unless in the exceptional
cases in which milk does not ayive — is the lw"*t. The
milk sthonld Vh: boiled, and dduti'd with snnie alkaline
water, such as V^ichy or Apollinaris. Six ounces of
milk with 2 ounces of Apollinarin water ma}* l>e taken
at first every three hours, an<I afterwards every two
hours, if well liome. Pejitoni.sed milk or other pri'-
chgested ffMxls may Vie usc<l in thime cases in which
ordinary milk Ik not well liotiie.
It must be rememl)er(>d that an exclusive milk
diet is rarely well liome, unites the patient is at the
Slime time practically confined to lied. Indee«l, nst
in lied is an importunt condition in the treatment of
all severe and troublesomf" forms of fliarrhaja.
Some French physicinns strongly advocate the use
of raw meat in the treatment of chronic diarrhiea.
This may be combined with the milk diet, if desired.
An ounce of the lean of beef or mutton, thoroughly
.separated from all fat or tibn>us tissue, in scrape<J or
pounded to a pulp, and mixeil with powder»>d sugar or
currant jelly, or with a little thin ta[iioca or weak
wine (port) and water, and takim twice or thre«» tinies
u day. Or, if this is objectetl to, some pounde^l
underdone meat may be mixinJ with milk aiid water
224
Medical Treatment.
IPvtL
or a little Inritli or clear soup. We should begin with
quite atiiall qimntilii's, ami tliesc can Ikj increaKed if
the diet is wuli liotiie. If tliu diarrha-a ceasts with
tliis plan of feeding we should return gradually to
the ordinary articles of diet, selecting, of course,
those which ure most e^isily digested, and taking care
to avoid too copious a dietary.
In treating llje chronic diarrliiva of infants and
yiiung chihheti the greatest care must l)e given to
their feeding. Minute investigation must he made
into every detail as to the kind of food given, and its
mode of preparation. It will con.otantly he found
that some important physiological consideration has
been overlooked or some error in the pi'eparation of
the fooil committed, or some form of foo<l is l>eing
given ])ei-sistently wliirh causes irritation, and which
rci|uircs \n be suppressed or changed.*
Jf the dlnrrUttix has been eau.sed !>)• chill, rest
in bed will lie needed, and a warm poultice or hot
flaiine! should bo applied to the iK-lly, anci as a
]>n>phylactic an abdominal belt of llannel, or tlaunel
(in<lercIotfiing, shoidd be woin.
The ■n4>flieiiiiil lreitlin*>iit of diarrhiea must
be adnjited to the circunisUince under which it bos
occurred. Wheti it is clearly traceable to the presence
in the aliiiient-ary canal of irritating ingesta or retained
excrementitious substances, we should aid this elFort
of Nature to eliminate them. If from examination
of the colon we have reason to think indurated fieces.
are retained thei-e, or if small scybalie are seen
floating on the fluid stools, or if obstinate coimtipntion
has preceded the attack, copious enemata of warm
soap and water, with or without a tablespoonful or
two of castor oil, usually succeeil in evacuating such
accumulations as are in the large intestine. If, on
the other hand, the irritating substances appear to
be still in the small intestine, as is usually the case
• For fvirtlipr tldtjiiled foiisitlunitiim.i on iiifaut fuc<lin)( ref»t
to tbe iiutlior's work on " Fowl in Health and Diaeoco," put L,
phapter xi.
DlAKKHtAA.
225
when stcvere colicky (inins aro ooinpluinol of, it in
iiflvisftble ki };ivi-a iniM liut fllifii'iit catlmrtic : a dos*"
of 2 or 3 gniiiis of c-aloint'1 lias tin- lulviintiiK^. of l)«.ini;
tastclit«ii nnd w«?ll iMjrne t-vt-n hy nii irritiiliU- stoinni-h,
and it is usually t-flwliiiil ; or ii sumll d<«<> of castor oil,
and Ijest in the form of an i-mulsion, may l>c givrn.
R7 Ulei riciiii 5vj.
Pulvrris trtgnrnotiia compociti 3j.
Sympi 51 ».
Aqtiw rjirni ml jiij.
Mi»re, fiat iiii»tur7i. A t'lbUviMXinfiU urrry hour or two
nntil rflicTvJ. A smallt-r Jcxe mimt Ih' )ri<r('<> I" Tory yuiinK
childmi -000 01 two tiA»|KK>nfiils. according to ago.
Or^ory's powder (ptiJria rliri cnmpnntiit) i« »lilo
an excelloiit medicine for childn-n for tlit>si> attackfl,
in (logcui of '■ to 'Jfi jirains. KlitilKirli. it inuat (ic
renieinbiTed, liiu tim valuable property of m-lin^ ajt an
astringent after its purgative olFeL't hii» [)iut.Hc<J away,
A iin.<>e or two of this kind, with projicr allontion Ut
(lift, will usually BUn-ocd in curing ciuu-s of acut«<
diarrhoii, dfpondcnt on t'lO j>rcj*<.'ni'<' of irritating
8ulj8tance4 in the. intestine.
But many of the cuniinuUf-.l foriUH of diarrhiist
seem to depend un an unduly arM condition of the
inttwtinaJ c<>ut4mtti, [lotssibly due to the abknncn of
suificient alkaline hile in the (.moll intmtiae ; at any
rftt<>, tlipy aro easily curnd by alkalin« otmlicinmi
without the une of any direct attringcntJi. In iiii<h
casei you do not give in"<liciiio fur tin; piirf"»«»« td
iminrdiately arnwtiiig t)i« flux froui tlw l>ow<U, hat
for the |iur|>o;«e of \<\
few dose!) of the follii
at the .lanie tini<' to
brandy, will quickly cui' \u.\'.r.
of acute diarrb<r« : —
r: irbonati*
.mBK'jnijf 4fTiuiati<i
I n u I u .•- ranlamoiHi lumyuuiim
AqiiiF cinnaa>"tnl . . .„
>liM«, lUt mistsr*. 'r«<i t>l
two or time houra ■alii f*lt«<Hi
P
tl4 <xMttini>aor>i A
•in-, Itrt'i^ifr.' ''f^ i'ltri
226
Medical Treatmkat.
I fait I.
Tbcrc is a distinct advantage in cniing a (liarrhcea
by such simple means ratlier tlian liy the iisc of
astriugeuts and opiates, as tlie latter interfere with
the action of the liver, and an- ajit in some persons to
be foHoweil by Ioms of appetite, constipation, bead-
ache, and other discomforts.
Hut many cases of acute diarrhn'H cannot be
arrested by such simple means, and we are obligi'd
to have recourse to remedies which exercise a more
direct influence over tlie catarrhal mucous membrane.
There are many such at our dispo^l, but. there
are none so immediately and strikingly successful as
ii|iiiiiii. This dru^ has a most remarkable influence
over thi' circulation in mucous membranes in most
juTstins. It has also the property of relievinj; pain
and spiisiii, and when these accompany an acute attjick
of diarrlm'a it will rarely be wise to withhold a <iose
or two of this drug.
A stiiull pill of ^ a grain of extract of opium may
1)C given with eiich of the two or three first do.ses of
the mixture we have just prescribe*!, when something
more efficient is needed to relieve suHerinj? and arrest
the catiirrhal flux. Young children do not tolerute
opium well, except in very small doses, and yet
they, perhaps, more than adults, nee<l opium to
allay the hyper-sensitiveness of the intiameii mucous
membrane.
If there seems any good reason why opium should
not bo given internally, it may tie applied in the form
of the liniincrUuiii ojiii, exteniiilly, on hot Ihtnnels,
or on cotton-wool, or sprinkled on a linseed-meal
poultice. Such warm opiate applications are most
useful in relieving pain.
There are several preparations in the Phnrmneopmn
which enable us to give opium in sufliciontly small
doses even to very young children. One of the
best of the.se is the piilvi* kinu compimtug. Onegmin
of this powder contains only .j'„th of a grain of
opium, and this dose may be given to a child of the
age of three mouths. Oreat care roust, of courae, bo
Chip. X.)
DiAKKHCBA.
^
observed in re|H.-Ating the dose, and it should not be
left to a hur8i\ but lu it medical iniin, to dol^rmine
this. The following is a useful formula : —
I^ Piitvcrin kinii roiiipositi gTT. jr.
PiilvPiix cri'tii' HTomntiri ... ... ... ptr. »vj
.Sodii liicnrbuiutis ... ... ... ... gr. viij.
Misct: et HiviiK- in pijvcri» (|untii»r. \ powiler to W Kireii
in a t'liJlKHmful of «iit«r-arii>wrout every iWrc or /our b»ui>
until ri'UfVud. In vrry youii); infuiita, uifW thrxo nionthii, •
h.ilf of om." of thenc jKiwders, cipia] tu ori>--furti(lh of a gntin of
opium, may be given.
A safe and useful plan of giving small doao of
opium in ortler to airest infantile diarrlnrii .and to
relieve the paiu and restlessness attending it, is by
means of Hinall eueuiata. A tablespoonful of (lie
following mixture should be shaken up with an
ounce of thin warm st<ireh and injected into iIm.-
bowel : —
I^ rulreiiif i]iecacuanhir compusili ... gr, ir.
iDover'i powder)
Acidi tannici gt. sij.
Mii('ilaf;iniK acacis* ... ... ... .. jij.
Mis'.e, fiat pncma. A tulilotpooafttl (or each injection.
As there is ^^gth of a grain of opinni in eavb
grain of Dover's powder, niid as given in this way th«
opium Ls very slowly and gradually abaorbed, it (urui*
a perfectly !Mfe mi'th'j<l of administering opium to
young children ; but unk'ss the diarr^Mra m at owr
arrested much of Uie enema will Le discharged willi
the next loose motion, and it may, th«ri*forr, rei|uir«;
to Ix- soon re]ieAted. A larger done — 'i to 3 graiiis of
Dover's jKjwder — may be given to ol<ler children (five
years and upwards) in this way.
Some writers object to giving opiom to yoanjj^
children, in any dose, for this purpoa« - bat phyocuuia
of ripe experience who have som the wonilvrfiilly
calming and curative etfei-l of quite ininat« Atmt% of
in such ca»es will not heHit^ite to avail tiMtii
[of this valuable re»«ourc«. If a loedieal nan
'has not learul /toio to iiae o|iiuni safely uotbr
228
Medic At. Treatment.
|P»nI.
circuinstnnces, be cun hardly he said to kno\e Lis pro-
fession. In tlie acut« choleraic diarrliipa of children,
Oslei- r<"c<)ninierulH morphine hypodermiciilly. He saw,
"This ilriij; alone coniniiinds the situation. A child
of one year inuy he given iJj,,th to n'^th of a piiiii,
to be repeaU'd in an hour, and again if not l>elt«;r."*
In adults, if there is much gastric irritability as
well as intestinal |iain and spasm, relief may be almost
immediately obtained by a hypodermic injection of
^lli to \K\\ of a grain of the sulphat« or bydrochlorate
• of morphine.
In severe, protracted, or recurrent forms of acute
diarrh(i'4i, a.s well as iii the chronic cases, it may be
needful to have recourse to the direct a<>lrin|{c'nl«,
of which there are many, or to one or other of these
in combination with opium.
The pivpiirations of liiKiniilli enjoy, and justly,
a great reputation in the treatment of intestinal
catarrh ; the oxy-carbonate, the oxy -nitrate, and the
oxy-chloride (preferred by many) are all etKcacious,
and the salicylate is also largely use<l on account of
its antiseptic properties ; but it is probable that all
these preparations of bismuth act to some extent as
antiseptics. The fuihrylaU should be chosen in the
ca»e of infectious or putrid diarrho-a, or when the
evacuations are very offensive.
These j)reparations of bismuth are tasteless, and
cjin, therefore, Ije easily given to children. They
jirobably act to some extent locally, by uffordini; a
protective covering to the inflamed mucous membrane.
They further absorb, sulphuretted hydrogen, which
may be a part of thair curative action, and are
eliininatetl in the form of hiack sulphides. The oxy-
nitrate not only acts as an inert powder and as an
absorbent of ga.se8, out it ha^t also marked antacid
projierties. It is a very basic salt, and is thus enabled
to neutralise the excessive acidity of the inti«stinal
contents. It is often advant^igeous to mix I'ismuth
with prepared chalk, which also has both antacid and
* " Prindplei and Practice of Medioina" (fourth edition), p. SIK.
\
DlAKRHCEA.
229
nbKorbent properties. The following fiprmiila for b»-
luuth and chalk in jiowdt-rH is siiiinliU- for cliil(ln.'n : —
R7 Bismiithi sulmilratis .. 5m-
Cretff prepaniln? ... gr. xviij.
Sodii bicarbonslis gr- >>j-
I'lilrerii tiogacantha- compointi gr. xz.
Hisce et divide ia pulveies i>ex- A ptiwder in a dsascrt-
_ fal of Ihin arrowroot crery lhrt« or foar huuis. Ualf
Olid doM may lie giren to infanU and rery youog cbildien, sod
twice the dow to elder one*.
For odulta the following mixture nmj be pre-
scribed : —
fif Bitmuthi carbonatia .. gr. Inx.
Pulrerii crettt' aromalici ... irr. cli.
So<iii bicarbonstiB ... gr. zj.
Sljiiridu ammoniie tromatiii ... Jit.
Mucila^inia tnigacantha- .. 1 aa xi
-A.M.. .>.i.rofornii ( ■• 3'J-
.A inonii ... «d 3™j-
Misi' . ; ura. Two tablfii>ouofub I'teiy two uitlirce
hdon.
In many cases larger doses of bisinulli than tliis
should \>e given. It is now frequently given in doM*
of 20 to 60 grains three times a day.
TliH addition to this mixture of 20 minims of
liquor opii 8edativus makes a valuable comhination for
the relief of intestinal jiain and irriliition as well ua
of dinrrluftt.
Tannin and the various vegetable astringents oon-
tsining it, such as catechu, rhatany, kino, ba-matoxy-
lum, are valuable remedies in the treatment of acute
and chronic diarrba-a. They are usually used in
Bmbiiiation with antacids, bismuth, o|iiiim, etc.
'I'nnnin is most useful for administration in
enematA, and, as we have nlready said, a hmall eneron
of I to 3 ouncet* of warm thin starch containing 5 to
20 crains of tannin and 1 to 10 grains of l>over'«
powder, according to the age of the |)Htient, ia very
clhcaciouH in arresting severe forms of acute <)iiirrhftn.
The eamj/oum/. prnedfr of calfchn of the B. P. ia
useful form, its value depending not only on tb«
23°
Medical Treatment.
[Pan I
tannin contained in the catechu, lint alao on the
canninativc snlistances combined with it. Tlie dos4?
is 10 to 40 gniins.
Sonic new ]irepiii-ations deriM'd from Unnin hiive
been recently inti'xluced for the treatment of diarrh«si
by mamifiicturing chemists. The advantage claimed
for them is that they pass througli tlie stomach un-
changed and exert a local action on the intestine.
TiiniiiiUiin, a compound of tannin and albumen, is
a tasteless in«ohilile powder given t<i iulult.s in doses
of 8 to 1.") grain.s. 7'aiiiwj'orin is also a powder in-
soluble in water, and is a compound of tannin and
formic aldehyde. It has been used ns an intestinal
anli-septic and astrin;.;eut. Tanniyen is, jierlmps,
the most jiopuiar i>f these novelties. It is a compound
of acetic iicid and tannin. It is a tasteless insoluble
powder, only dissolved (and tannin reformed) in the
alkaline intestinal secretions. The dose is 2 to 5
grains for a child, ,5 to 15 grains for an adult, three
or four times a tlay.
A u.seful prescription for an attack of diarrlura
which is tending to become chronic, and which appears
to be maintained by a certain amount of loss of tone
in the inte.itinal mucous membrane, is the follow-
ing:—
ly Tinctiine catcrhu jiv.
t^odii bicarhonntia ... ... )p'. Ixxx.
•Spirit iia amitioiiiie nromatici .. ... jiv.
'I'inetimi/ nufis vomiciu mlxxx.
Infusi caliiiiiba> »d Jviij.
Misco, Hot iiustuni. Two tablvspoonfuU three times a day
nn buur )>e(ore taking fooU.
In other coses a better effect will be obtained by
giving doses of 10 or lo mitiinis of nroninlie tttlp/ntrie
(trid in the alxjve mixture in the place of the soda nn<l
ammonia.
We have found some troublesome forms of diar-
rhiea (especially those of phthisis and aJKO some
neurotic forms) more anienabh* to the tiiictnrf of'
coto bnrk or itt alkaloid cotoin than to any other
DiARRnrEA.
23«
remexly. If the tincture is used it rci|uiri's to J>o
mirfd airr/ul/y, or inucli uf it« rifsiiious ])rincipie
will l>e (ie{>OKilo(l and Itjtst. A ilraiii of the titic-liire
kIiouIH lie niixiil witli '2 drains of sjiiril of clilorofonn
and 4 drnniK of tincture of ciiinaiimn, mid this rulilK-d
down with nn ounce of niucihigi', iind tlicii ililutcd
with 4 ounces of carrawny water. A tftlj|eM|)m)uful
of this mixture niuy be given to an adult every three
or four hours, and one or two tea5]HX)nfulH tu a
ciiild.
Attention bus for some time lieen direct«<l to the
use and efficiency of certain iiit«>«liniil iiulispplir*
ill tlie treatment of some forms of 'acute diiirrhieu
(cnteriliH and enten>-colitiB) of supposed niicruhic
origin, especially in young children.*
The interesting researches of Hscherich, Vignal,
Iliiyein, Uricger, A. (jHUtier and others havi- thrown
much light on the action of the nuineruus fornix of
micro organisms found in the alimentary canal. There
are nn niicrolies to lie found in the inteotinnl citiial of
the new-lwm infant, but they begin to appetir there
soon after birth, entering, no doubt, by the muuth
from the surrounding air. If the chihl is fed by otIiiT
thiin it.s molher's milk (unless the millc um'd is Kteril-
ised) uiicrolxis may also enter the alimentjiry canal iu
its ffKKl. At any rate, an iiiiiiien>ie numlier of micro
organisuiH are found in the alimentary canal of an
infant a few days old. .Some of these microbe* may
tually take |>art in the physiological priMi-AMts of
similation ', others mar, under normal condilioni,
be quite inoffensive and iniJifli-rent : the sulMtanciii
they contribute to form, although toxic in Urge
quantity, are in the minute quaulitiea prorlaced
readily eliminated, and ppjve hamilnM. Ajootigst
these are various organic acids, xnlphuriiltMl atid our-
buretted hydrogen, nmmonia, It'uoine, tyroune, liiilol,
1:1,
by lie- •.
Euluritu.
Till- -imm'Hc .').;.!. uii' r .nil ! ■! .rrTuiii. kIimTi ^im* t»i»B
'.' <>l 1 1 1,1 III '.in lis ~|E.|iiiteniu: k^atrnnu*^ *jr /^mv.im
23J
MEniCAI. TRE.4TMENr.
IPattl.
Rcut«l, nii<l al>nve all, cortain poisonous alkaloids
known as plimisiiin's. ]Jut if from (hi< |in:valcni'0
of c«!rt-uiii conditions, kik-Ii as the oecuneuce of great
heat and niuihtun', or die |>rofluction of some nbnomial
change in the clieiuical reactions of didrestion, the
contents of the st^oniach and inte-stines become trans-
fornu'd into a nifdiuni jiarticidarly favourable to the
cultui-c and multiplication of these microbes, if they
encounter putrescent sidjstances iu abundance, the
toxic substances already mentioned lire developed in
such increased fiiiaiilitios tlmt they cannot be elimi-
nated with sufficient ra]iidity by the excretory organs,
and toxic sympfoms make their apjiearance, diarrhira
being the most frei|ueiit of these. This symptom
seems to be excited especiidly by the organic acida
and the (ilkaloirig formed by niicrobic action. The
simplest and commonest, forms of diarrluea are prob-
ably provoked by the irritiint action of these aciih on
the intestinal mucous membrane, and the graver
forms, notable for the suddenness, violence, and
seriousness of the attack, are probably due to the
poisonous effects of animal alkaloids.
It is clear from these considerations that the
rational treatment of such forni.s of diarrho'u must
involve the adoption of means (both alimentary and
medicinal) to promote intestinal antisepsis. All food
must lx> rejected that may add to the number of
microbes in the intestinal canal or favour their multi-
plication. There are no microbes in milk sucked from
the nurse's breast, so that the transferrinjf of a hand-
fetl infant to a wet nurse is nn antiseptic measure.
Sterilising the milk used for feeiling an infant is
anotlier antiseptic proceeding.*
One of the simplest medicinal measures for the
jjromotion of intestinal antisepsis is a purge, which
carries away the undigested and fermenting products
of a faulty alimentation, us well as the microbes with
* Methods of nterilifiiii; milk will 1>e found descritwd in the
author'* work on " Food iu Hnultli and DiiwaM '' (new edition),
p. Mr.
Chap. X.J
DlAftfimEA.
»33
wliicii they swarm. In rMlonifl we have a rnpdicin*
wliioh is Ixjth ]>urgiitivo and antisoptic, ami htnco its
gn:at value and sucwrk in the tiratuient of infantilo
diarrhtta of a choleriforni t.V|>e when administered at
the onset of tlie attack. The dose to he given must
depend on the age of the chiUI, but small dones fre-
quently repeated are the best ; \ grain every hour
for five or six doses, mixed with \ grain of sugar of
milk, and thrown on the child's tongue, is a gomi way
of giving it. Some physicians give from 1 to 4 grains
at a dose, and some prefer ijrftj )vnrder, a.s it« action
if) milder.
^alol has been warmly advocatini ati au intestinal
antiseptic in these cases, and esjKicijdly by Dr.
Moncorvo, of Rio, in the treatment of the acute
diarrhuea or enteritis of children, of malarial origin.
Soon after commencing its use the diarrlia'H lesM^ns
and dii5ap|>ea.i-s., the stools lose their ftetiJ otlour, and
the vomiting and the tintulent colicky puins cca.se.
He considers it perfectly innocuous even to tho
youngest infants.
The doses he has employetl have varietl, according
to the tige of the child and the severity of the attack,
from 2 to 30 grains in the twenty-four hours. It has
been estimaUnl that a child of six months should take
\ grain every two hours ; onr; of two yearH, 2 grains;
and one of live years, 3 grain>«. It may lie ijest given
to children sus|>ended in a mixture with a little
mucil-Hge and .syrup.
The following formula is suitable for odulla and
in chronic cases : —
19 Salol
lliemuthi ntlicyUtia
Hodii liicarboiiiiti* ,
..ikk
Klitcv et divide in pulrcres triginta.
3'J»
One to be taken before food twice or three tiotM
i day. Many other substiinces have Ix-on suggeiiti'd
intestinal antiseptics and for the treatment of
tliefif! fornis of diarrh(£a
234
Medic A l The a tmb.vt.
IPwtl.
An Pinulsioii nf /irlrnliinn (33 {M?r cent.) )v.u^ Iw'on
found (^IliciicioiiM. It is ilouljtlrss very s<Mi(liiiijj to
(lie intcsliiiiil nuicims nn'inlirjine.
KcMorfiii lias liiul iimiiy advocates. It iiiiiy
\ie given in doses nf li to 5 gi-nins in a niixtiirt',
or ill fonn uf powder, according to the following
formulee : —
IV Itesoroini gt. xij.
l}lyci^rini jiv.
Tiiiclunc opii kVXtJ.
Ai)tiie ciniiutnomi nd jiv,
Jliscc, flut tnisliini. rose, one tablespooniul (or an adult,
one or two teatipoonfuls for a child.
Or:—
gr. xij.
58!..
»r- vj.
IV Kosorcini
ItUmutlii cnrboniitis
Pulveris ipccacuiinliH' compositi ,..
(Dover'<i powder)
Miaco Gt divide in pulvcres sex. A powder every (oar
hours. For cliildren over fire yean of ago.
Cn»asote, airljolic ucid, oreolhu", unjilitlinline, nien-
tiiol, tliyiinvl, Hodiiirn sitlii-ylnti" and benzoato, nitrate
of silv(M-, liyihoehloric acid ami pepsine, tincture of
io<line, liavi- all luul their advociitos for this jturpose.
/3-N(nplilliol and hydronnphthol. in doses of 1 to
2 grains every two to si.x hours, have been found very
useful iw iiit<>stinal antiseptics in various forms of
dittrrha;ii : the gi-een diarrluea of infanta, the diarr)icra
of typhoid and tubercular disease, and the common
forms in adults.
Ichthalbin, a combination of u-lifJiyol and nlhumin,
has been given by Roily, of Heidelberg, with much
I>enefit, in the chronic enteritis, with diarrha'ii, of
children. It acts as un inte.stinal antiseptic. He
gave from 8 grains up to 4'i grains three times a day.
Copious enemata of warm water mixed with
10 per cent, of alcohol or .', per cent, of salicylic acid
or creolin water (\ to I per cent) are of use when wc
wish to exercise an antiseptic action on tlie l»rja^
intestine.
'
o.«^ x.i
DlARRH<EA.
235
Thr> re«earL'Iie!i of Profe«8or Huveni ineo«(»» iiAturp
of llif mnallwl " gr«'n iliarrhn-u " nf trlfilrlt^ \uv- \f-\
t« tho intmciiictioii of larlic arid as a rviiM->K fi.>r
ttiiii and <illicr fimns of ilinrrlm-a. 'I'tir prf»'iiit- of »
sfM><M.il WcilluH ill theH<> onsr* Ims Jm>ti diiiiniiitrmtrtl
by him, and when isoliiU<d aud cultiiafcl it fi*.* V«-*i3
found to produce thft jfr**" niatt^r by • sort -if p'ri>
cess of excretion. Havem otis«frv«<l dial ll«r >uiuitr<l
niatt«r8 and tlie stools in these cumt* vrre trilbrr
neutral or (tlkaline, and this l«J him to Uw diacoTcry
th»t tiiJH bacillus could nor live in an ncki mnliaai.
Hrdrocliloric luid lie found • good rcaxdj, bat ila
action wiu uncertain, and h)> wu led Ia tr]r the ofcet
■ if liu-tic acid. lie gave a t«it<<]ir>»nfal nf a 2 yrr eeat.
itoliition t'l the infant a quarter of an bonr atter •■di
suckling— from ■'■ to ^ l«Mpoonfttls in CwvntT-faor
ffurs. Tlie vomiting, if |ireaetit, auoa ecMMl, tlw
ptions lost their ijr«rn culuur aiMl beoMB* jclkrvi^
ltd in a short time liecaine n*-"""' '" 'nniiwiun aad
fre<.|uency. It wait ncc<<9Mirj i Um roBitad
Bul)sttinc£8, the motions, and tlir vMim nhjfrratim
thetu with a solution of corraaira luUiBiale.
M. Hayeni ronKident thix form of diarrlMttiaipnwd
hy contAgion, and that the i^fciitt of ijif«ciMMl vn IIm
gcriii8 deposit^l on Uin linen aoilad by Uw aotiMka
Altiioub'h Ixetic acid given by the awatli b l*(>^^
abiiorlMxi in the HtoniacJi in tbc Conn ol ladatea, j»4
given in »uthciently large iloaea it <«n, ia part, \m
found in the diarrh<eiL- crarxiataoaa, aad it oul, (Jmt*
fore, exert its topical and geraictd* action ia Uk*
intestine.
Iiitmlinal irriyatiom (eatmtdyait) hmt alao baai
a<ivouat«(J in the ■yi'l^B't- irtwnMrr imnhmm td
children as a valualw adjitnci to other
(.'old or ice water i* awd wltn tlw
high with the olijcct of redwing^ it. Tina
teiidii l4i cleaiihe the howeU uf otteiMaf* i
and to diminish or coaatcffnat or Umifmlm ttm
(latigeroua eflecla of the rniiiwwi aafaai
which niay have been derelofied. lu
236
Medical Treatmest.
(Pwil
oiiiployiiKMil 1ms l>LM-n said to ameliorate tlie symptoms
atul to shuitcn llii" cuuisL' t>f tin- ilJHOiise.
Aiidtlicr iciiieeiy wliifli lias Ixien highly n-coiii-
iiicrulfci iHtcly in tlm liviitiiicnt of the j^astn (•enteritis
of infants and in iin;ilo|;uus afl'ectiona in the n<lult is
hetr i/ennt. Its inotle of action lias not as yet Ijeen
explained, It lias been suggested that it may cany
on its own cell-growth at the expense of other gemis,
or that il may act simply by secreting a bactericidal
suhstAnce. It is best given in the dry form as pre-
pared in llayem's lalwriitory in Paris. In infants
it is usually given in tlie form of eneniata ; after
washing out the bowel with warm water an enema
com|ioiiiid of a teaspooiifid of yeast dissolved in 2
ounces of te]iid water that has been boiletl is given in
the ordinary way by a IkiII syringe. The child's nates
must bo held together for a few minutes to prevent
its rejection. This may be repeated twice or thrice
daily. If the diarrhcea still continues, the same dose
of yea.st should be given by the mouth, dissolved in
boiled water'.
It has been found to act better when given by
the nioutb than when luJministered /wr rxclnni, and
adults can take - or 3 tjiblesjMjoiifuls daily dissolved
in l>oile<i water — a tablespoonfnl to .'{ ounces of water.
The rlironic forms of diarrhu-a are generally
those which have resisted the treatment usually applied
during the acute stage, or those which are act(uired
in tropical countries, or those which depend on soino
constitutional tendency to chronic intestinal flux, or
to exce.ssive peiistalsis unduly hurrying the footl
through the intestinal canal.
These cases are often difficult of cure, and tax all
our therapeutic resources. We have already pointed
out the necessity for a searching examination into
the food habits of such patients, and the neces.saiy
dietetic prescriptions to be enforced. It is also, of
coui-se, extremely important to a.scertain that the
diairha'a is not depejident on the existence of organic
disease.
DlARKltaiA.
»37
Ca8es uf iimhkrial urigin have be«i) rapidly cured hj
tlie adminLsti-ation of quinine ; it i« ni^ceaiukry, thernforn,
not to overlook huch a possilile origin of the diMMeL
In some forms of chronic iliarrhrea in hfftbrrical
women a prolonged rvJit-fure is tlie I»e8t reiinJy,
associated with cbano;e of air luid scene. If it sliould
tdiici to increa.sed and sbnoriiml {lemtttUiA, thr
midet) muv provi? ust^fuL
Ttte casos of chronic diarrhiet which origioaUl
amongst Europeans in tropical countries are ImbI
treated hy dietetic measures. Dujardin-Beaumetx
maintained that the only efficacious treitnjent mn-
sisted in i-ostrictiog the )>aticnt to a diet of milk
mixed with Vichy WHter. Dr. Keris (quot/vi by
Duj.irdinBeauraetz) found it Ijettt-r to treat them
with WiV/ pfptonrf, from 3 to 6 tiihl<-x|)oonful!i a day,
alloA-ing at the same time li pint/* of milk d>ii!}'.
In chronic diarrlm-a, Ijuiiiml/i and the ve^rfiitiln
astringent* already mcntione<l, with or without o|iiiini,
will usually have been trie<l. and havt? faile<| U} do
more than procure temporary relief. In suchca«««, if
ma^ive doses of bismuth iiave failed, we nimetiiue*
find tiiat the stronger mineral astringents will »ucc<*«d
b«>tter, such as oxide of zine, acetat*' of Icail, 8ulphat/>
of copper, nitrate of silver, or pemitrate of iron, per-
chloride of ii-on, etc.
The oxide of zinc may be niven in ."» to 10 grain
doses in pills combined with a little chalk and opium,
^follows : —
(^ Zinci (ixidi gr. tij.
CroUe pre|iamtio... ... *gr. ij.
Kxinicti opii P- i
Mui'ila^inis <|imnliiiii •nfficint
ut 6at piliilas duo. To be taken lhrt« or four timra a tUy.
Hie (tfrtaU. of Ifa'i ii a very effectual aiitrin^ont
in chronic diurrhu>n, but Wing it«elf a |M>iArin it is
not usually r»«*orteil l<i until more simple remediew
have faile<i : it in not a remedy that should Ix' Kiv«>n
* Thia if jkIiIcO tn (Toitl the pomibility u( tomi! clilorule of
zinc being formed b^ tlw acid of tlie gaabio Joke.
»38
Medical Treatment.
IPmi I.
for long periwls at a tiiiio. It is Ijcst given in tho
form of a jiili combined with opium : — -
ly riiimbi ucptnlis ... ... gr. ij.
K.tlraoli ojiii ... ... . Rr- "».
Jliscc, fi:il jiiiiilR. To 1)0 tJitiiu Ihicg liiiii'S ii day.
Sii/p)iiiU of copper is a still more eHV-ctual remedy
for clironie diarrha'a ; like the prpceding, it is usual
to comljinc it with opium. Sinall dosos only must Iw
given at first, on acM.<ount of its irritating ett'ect on
the stomach.
Vf C'upii 8uli)hiilis .. pr- U-
Pulvpris ciiinamomi gr. xij.
I'lilvoris opii Rr. "J-
MiailH^iiil!) .. ... ... quantum sutlieiikt
ul Bui |)ilula.i duuilei'iiii. Oiio|iin, which niiiy be iutrcased to
two, lu be taken three times h diiy.
Nilrate of silver also may be given, in troublo-
some cases, in doseH of ^ or ^.rd of a grain in a pill,
with tlie saniu quantity of extract of opium. These
astringent pill.s should Ik; coated with kerntiiie and
given when the stomach is empty ; they may then
pass into the intestine, and exercise a favourable
influence on ulcerative processes there which may
po.s.sibly be keeping up the irritation and preventing
a cure.
The perjiitrtiU of iron has been found nseful in
fiirmt of chronic diarrh(ea as8ociate<l with defective
tone and general anieniia. Thi- following mixture
Hiuy be pnxcrilied : —
1^ Licjuorit. forri ]M<mitrati»
Liquoris strychnins
Aquii' chloroformi
Infusi caluinhte
Mince, tint liaustiis. To bo taken three limcii ii Jay.
•nil',
"lij
Small doses of Kissingen water have be«>n found
useful in the treatment -of some forms of chronic
diarrho'ic intvstinal catarrh. In small quantities,
according to Leul>e,* it has a constipating ntther than
an aperient eflect, and as it promotes gastric digestion,
* ZiomsBeu'a " Practical Medicine," vol rii,, p, 390.
Chip. X.]
D/ARRHCEA.
I
tbe olivine entering the intestine 18 in a condition
more fcivourablt- for abscir|ition..
Kcctal or intestinal irrigations with cdUI wntrr
hare been found to hiive a s<x)tliin'j and fuitringcnt
effect in some forms of chronic dinrrlHva, lioili in
children nnd in luliilts. By irifatiH of i\ long tube, and
hy placing the patient in :i suilulile pjsition, the wator
should Ih- iimdtf to piisH as high up ns possible. Sonic
astringent salt may be added to tlip wat<>r, such a«
alum, suljihate of zinc, or acetate of lend, in the
projiortion of 4 or 5 grains to the pint.
We must not omit to mention the excellent
reiNnlt.<! that are often obtained in caxes of cbnmic
diarrliu'ii (imtarrlial enteritiv). especially in the gouty
and rheumatic, from a coui-se of treatment at I'lmn-
hikTK», where the nttrendiiui Hoiirhn is rxlen«i»nlv
applif^i. Very grnat benefit has been derived fnxu
treatment at that 8|jii, even In mi>it inretenUe mmJ
troublf*inie ciuses.
Many other drugs have been iMcd by vaiiooi
physicians with a<lvantage in the treatment of chronic
diurrhcca ; exainpleti of most of these will hi foaiid io
the following formulw.
AnDITIONAL
For acute dlarrbcaa of bs-
fiuitB, and to check putre-
factive cbangei in intes-
tine.
ft Hydr«rgjri biiiirxlidi.Kr. t'j,.
of potomiiiio, and uild 'hloml
Uydnitv, I ip-iiu. fnUt iloan
IT be u^veri in a tc&^toouful
two of dill-vrnfex.) {Luf.)
Qvoline In tlis treatment of
acat« g«itro-«nteiltli of
infknca.
Ft Crwtlifii. giitt-i' iij.
8yni]>i allhii-n-. sv.
Aqilti' nuielliii ail ^itj.
M. f inL't, \ tm.^x>nf<il
erery liouf fvt very fouiig
infantik
FoioirL.t:.
Fowd<?r ''>r »f?Mnlfl<?
n SiKlii I .
I'mIt. ru rhu, gr. ;«•.
I'lih, ru nanamnad, «, j.
U. I. H' To I. ta£n
twieeeiUf. Hri„tU.)
Tat dlarrtuaa la '^*^irt-
i'ujtma IMOnMU* OOB-
• Polfwb «o*Hi alM. ft
xJr.
U. H atvUa ill H'- >
Mivdcr •r««Ty two Of «»<r'-
DOtin. {J/imit )
nv daw way h« doaliM fcr
oldct dbOdraii.)
240
Medical Treatment.
(Parti
For profuse dlarrhma In
infanta wltbont dyspepsia.
II Tiurtiini- kranii-htr, .itw.
Tiuctuni' pjiii, n[JK!».
Syriipi slmjilicis, .lijiw.
Aquu' dvKtilliit»\ jiij
M. f. mist. A (lesscrtspoon-
fiil evory two liourn. {Mimli. )
Powders for chronic diarrbosa
In infants wltb annmla.
R Kerri cajlKiuatid, ^x. jss.
I'ulvi'ris ippcncuanho) com-
imrili, gr. JM.
PulveriK KUThori, Kr xlv.
M. pt ilivide in ]iiilv. x.
Three or four iwwdcni dnily.
(.tfvNfl.)
Salicylate of Iron In tbe
foetid dlarrboea of Infants.
Frrri btil|ih:iti!4, gr. xx.
Soilii Falicylaliji, gr. xjc.
tilyceriui, .^iij.
Aqiw, Siij.
iJiBKolve tfie rulplinte of iron
and the snlicylnto of >od:i
Mnamt«ly. iiiul then iniit. A
tal)l<«|>oonful every liuur until
the ttouli liecomo bUclceued.
[JlrnilAirititt )
A drlnlc in Infantile
diarrluBa.
li Acid, hirtic. ^.'1 grniiis.
Aqun- Hor-aurruitii, jj.
A<|Ul■^ ud .nviii.
M. A lahlejjioonful every
two hours.
For stunmer dlarrhcea.
H Kxtmcti hii-nintoxyli liquidi,
Mj.
Actdi milpburici aromatiri,
.uj.
Siiirituii I'hlorofnmii, >TJ.
Iinitune ojiii laniphont'^ .^
Tinrtnni- rardainonii > "^
eouiiKtsitfi' I IS
M. A teB«|)O0ufiil, in wnttr,
aft«r rach action of tlw bowels.
Arsenite of copper In cbronle
diarrhoea.
U Cupri anseniti^t gr. ^'j,
A<|Uir, Jv ad .*xt.
M. A teaapoonfu] every
fifteen to forty-flvo ininutei
until the diarrhcpa coii^e<.
(llrMllei,.)
Nitrate of silver ii^ectlon in
ulcerative colitis.
H Argeuti nitrati.*, .M» ad S).
Aquiv d(9tilhitn>, O j adU ij.
Elevate the hip«. and let the
injection flow in slowly from a
syphou-bag. ((>.«V».)
Pills for chronic diarrhosa.
H Kxtracti kruinehie 1
Kxtruuti monesiji' I •{
I'ulvcri* calumbw > •«
Pulverig ipecacuanha! j
conijwsiti J
(Jlei auMt, guttjr ij.
H. et divide in nil. xl. Six
to ten to be taken <lailr.
Miztore for chronic
dlarrhiaa.
R Tincturie ciitechu I .-
Tinctiine kino |' "" *'J-
Tini-tum- opii, .»j.
^[iihtu-4 c:iiu]ihiim>, .^j.'«.
MiHtuni' rrctn' od Siij-
M. ( mint Two teaap<>ouful*
every four hours. (7f"Ai//«,)
For chronic diarrhoea with
DatQlence.
H Tiuctuni' upii, irixv.
Extract! bivmatoxyli, gr.
Ixxv.
Ryrupi torliois aurautti,
.MJM.
Aquic meuthie piperita^ ad
^''■
M. f. mist. A tabletpnoiiful
every two hours,
{B*>niergtr.)
Pills for atonic dlarrtaiM.
K A' idi t.uiriiri, .Vjm.
KxIr.K'ti iijiii, gr. jj.
Kxtnii'ti i:nluiubu', .\u
M. et divide pil. xx. Oue
erery Ihrvv hours.
(Bamifrgtr.)
Additiosal Formul/e.
J4l
Powtfan for tbe lame.
H y^Liici Btilphntia. ^t, xv,
f ipii piilvcris. gr. iij.
Nicthari albi, jiJM.
M. ft ilJTiite in pulr. ii. A
powJer three timea a day.
Antiseptle powden.
H Beiiw-iiiiplilhol, gr. ij.
Bismutlu -ulii'vUktu, gr. r.
Beaoiciu, gr. i).
M. et f. jmlr. (>ne cTcry thrwi
ho an,
(;v»/. W. W. JoAmtmt.)
343
CHAPTER XI.
0I8F.ASRS OF THE INTBST1\KS — THE TBEATMBVT OF
I'ERITYPHLITIS OR APPENDICITIS ASP OF DYSEN-
TERY.
The MeAniuj; and Nature of Perityphlitu. ArrisxDinTTS, it»
Nnture and Causes — Symptoms of AppendicitiB — Trentmrut
of Acute CafiO!( — Sjinptoma and Tre»tiuent of more Chronic
Forms -Of IMti/iKiiifi autl of Siifipiinitirr Forms — Fwcal
ImpiK'tion Ctt'«us — Symptoms — Indiration for Treatment —
roulion in Use of Opium— Loe.ll Measures — Evacuonts —
Enematn— .'ijiliiies — t'nlnmol — l^lium Sulphate— Intestinal
Autisepti<*s — Siilol — The Question of Oiwration -Prophylaxis.
Dtskkteuv— Etiology— A Specific Genu - Syraptome- Varieties
— Indications for Treatment— Opium to relievo Tain — Appro-
priate Foo<l— Intestinal Antiseiwis- Aporietits- Ipemcimnlift
-Aperient Sulphates— Antiseptic Imgatiou— AstrinpenU—
Quinine and Arsenic in Malarial Cases— Supjiortiua FikxI
and Tonics- Chonge of Climate — Pnipliiiliij'iii. Additional
Fonnului.
Those local morlji<l conditions occurring in 'the
right iliac region, in the neighbourhood of the
cKcuiii, find formerly described under the desig-
nation tyjihlitis and perityphlitis, are now tnorts
couinionly spoken of as ca.si's of appendicitis, since it
has been sliosvn that the appendix venniforniis plays
a predotninunt pnrt in the origin of this iiH'ection.
Treves, however, prefers the term " perityp>hlitis,"
and spenks of " appendicitis " as an " uncouth
name."* "Perityphlitis," he observes, "indicates
with siifticient clearness the predominant pathological
feature of an affection whicti may arise in more ir<ii/*
t/i<iu onr, and wiiich hn-s no precise clinical indi-
viduality until the peritoneum in the ciecal region
has become itiflamed." Treves is coramendably
undogmatic in treating of this disease, and avoids
and condemns the almoKt reckless statements made
by certain other writers on this somewhat hotly-
debated subject. Treves, wliik> admitting that
* Allbtitt'* ' ' System of Medictoe, " vol. iii., art. Perityphlitia.
^n&i>^ XI ]
Perityphutis or Appesdicitis.
»43
in the vast iimjority of CAses tlie trouble liegiiis in
tlie appendix, recoginsee a fact wliioli others hnvc
vciiture<l to deny, viz. that thp diswise .sonietimr^
takt-H its origin in the ca'cum, although vjch a mode
of origin is unconimon.
In discussing this point Osier argues that
l9jMie cajcum is rarely, if ever, filled with hanlenod
As we doubt this, and as it has a bearing
on the appropriate treatment of such cases, we ven-
ture again to quote Treves' observations, with which,
in the main, we are in sgieenient.
"The commonest cause,'' lie says, "of such cas«.<s
of perityjihlitis as arise in the ca>cum is the utTcorti/
u/rrr, due to the mechanical jiressure ami the cheniicnl
irritation of fa>cal masses which have long lieen li><ly;e<l
in the ca;cuni. . . . In cases of cunsidenibln fni-al im-
paction the ijTt(Ui'»( utrant/ftUn ii/>on the ciroim, and in
absolute ubstructiun of the colon low down, the bowel,
if it gives way, trill give I'^ny it> the cfcal rug ion,
. . . Inasmuch as fiecal impaction ia most eomnwn
in the ca.'cun), it is no matter of wonder that the
stercfjral ulcer kIiouH lie mu8t common in that part
of the colon. If the ulcer acquires a sufficient depth
to allow the peritoneum U) be infected, [lerityiihlitis
results." Treves claims, as we do, "a definite
position for the stercoral nicer iu the production of
perityphlitis." The remarkable tiling is that it
should ever have been disputed '.
/'',ri<///i///i'/i"*, thcn,is a term with JiMomewhat larger
, meaning than the name ajipendicitiji, hm it includes
in which the apjwndix may Ik; free fnim disease.
By nppcndirili* we mean inflammation of the
Vfmii/nrm nppeudtjc^ usually determined by the pro-
'senoe uf some fiecal concretion, or foreign InKly,
, within it, which may lead by ulceration ti> |KTfont-
tion, and t4> the extension of the inflammation to the
tissues surrounding the appendix.
In case of fK<rforation a local su]ipiiiiitivc peri-
• •• Priiiriplf* null Prartico of Medicine" (fourth wlitif.m
»44
Medical Treatment.
(Pwtl
totiitis may be excited, limited Ijy adhesions, and
ending in liie formation of an abscess which may
point towards tlie surface. Or if perforation occur
l)efore adhesions have talicn place, very serious general
septic peritonitis will be aroused. Or the a|ipendiciti8
may t^ake a more chronic form, and appear as a series
(if n'liip.sint; attacks, and this tendency has le<l some
to liken the ajipendix to an abdominal tonsil, prone,
like the tonsil in some persons, to recurrent attacks
of inflammation, which occasionally run on to sup-
puration.
Or suppurative peritonitis may arise from the
[Missage of uifective micro-organisms through llie
walls of the appendix into the peritoneum. Broca*
maintains that in many instances the inHanmiation
of the ajppeniiix is only a part of a general entero
colitin. which recovers auil passes away in other
parts of the intestine, but lingei-s and recurs, fit>m
structural reasons, in the app*^ndix.
It is evident, from its anatomical situation, that
the loud inflamtnalion attending an attack of appen-
dicitis may ext<nid to the oecum and to the tissue8
around, ami it has been as.serted that 00 per cent, of
the cases of perityphlitis are the n?sult of disease of
tlie vermiform appendix.
As to the cnuses of tins affTOtion, the tendency to
it would seem to "run in familie&"t It is most
commonly observed in young fulidts, but is found to
occur also in young childn^n and in old people. It is
far more common in miile.s than in fernal<.«. It is
more common in summer than in winter, and it is*
frequently referrible to injury, as blows, strums, and
violent exertion. It is a question worthy of con-
sideration whether the modern devotion to cycling
has not had some relation to the reinarkabU' increase
of late years in cases of appendicitis, with which it
has coincided.^ The connnonest exciting cause,
• " I,'.\i)].<.n.luit<-." Taria: J. 1). lUilliJr* ft fiU, iyiK>.
+ Trcvon, *tfK lit.
X Brocn tliinks Uim iuHiieiiza cpiilomic tiiu had to do wilb
this (•' L'Appciidicitc," ^Bri^ lUOU).
Oaqi-XM
Appesdicitis.
«45
according to Tr<>ves, is tlie lodgment of undigested
niattens or uf fa-cal moKScs in the I'olon, and iR-noe
its fre<nicncy in clironic ilyspi[itirs nnd pernon*
who eat hastily and do not jiroperly ni/uiticaip thoir
food. Ho would give pi-oiuinenoe, as Brocii does, to
colitis from irritating ingestA uk a ciiuse of jieri-
typhlitis. T)ie entrance of foreign bodies into the
ap|iendix is not nearly 80 frequent a cause as was at
one lime supposed, tiout or rheiiniatiMm has s»H!nw<l
to have a causiil relation to some coses in winch,
possibly, the appendix was not itself involved, and
in which the syniptoniH hiive <|uickly disiip|)eared on
the adininistraticm of s>idiutii M«licylate.*
Tlio »>'in|>toni« nf npp<-ii4irili« and the tr<nt-
nient indicuti-d will dlH'rr according to tli»^ a<'ut<'ncw
ami form of the ntt.ick. in the mo$t tte\il« form, when
perforation occurs siiddenly, the patient is H«ize<l witli
a sudden, serere pain in the iliac region, and tbui ia
rapidly succetslwl liy the signs of acute peritonitis,
with a tendency Ui early c<»llajisi! nnd deHtli. The
alxlonien becomes distended and •■x<{ui«itidy tender,
the legs are drawn up, the respiration* nr*- hurriird
and wholly thorai-ic, there are usually x^i j tho
otlier Kyriiptoms of aciit<" oupjiunitivi- [.■ Jn
«neh a Cii.se there has Ijeen a saddi-n xwy
'Cerated portion of the apfienrlix liefore ii'ii!' i •^ \
take place, and an e-sc-jjie of fwcal matter iulo (Mr prn
toneuin, setting u]i a difTuseiJ suppumtitr [amtofiiti*
Some niaintain that thepiMaageof microor^nitmi
through the walls of the appendix ailitoul perfunb-
tion is Ritllicicnt to s<.-t up such an attaek.
The Irrntmont appropriate to Mieh a eaae ia tiM
imini-stration of ojtiuin t^ relievti pain, •« in M«te
'peritonitis ; imniediuti< aUlominal Mctioa, birfbt*
colla|me sets in. followed l>r tr«tiMtr a# Um aW
duininal cMvity. Kuooeaa can only be lM|icd lot whan
operation is resorted to TCty «arij, M there >• OMrkad
tendency to rapj.l collapaci, and then ofier»iir« inter-
ference would be uselea*.
• &* caM )i)r tlic Author, tint. UM. Jmr—I, t«l. L, \>/.
246
Medic A t The a tmknt.
[Pvt 1.
If cipemtion is impnictic.ihlc from any ciroum-
sUvnce, the treatiiiejit iituy (.'oiisist in Piirlcavouriiig to
bring the patient quickly umler the iiiflueiico of
opium, pei-scvering with its adiniuistratiou aa set
forth in our ilirectious for the treatment of iicut«
peritonitis.
Sumotiines jierforatioii is not so sudden, and the
patient may have coniitlaine<l for a few days, or even
weeks, of vague pains in the riglit iliac region, with
some syni])tonis of dys])ppsia, fiatulence, and con-
8Li(iation. There may lie a rigor, an evening rise of
tem])(^rature, loss of appetite and thirst, then some-
what suiJdeii symptoms of perforation may appear,
from lupturo of an abscess which has formed round
the ajipendix, and tlio discharge of its contents into
the |)eritoneum. Such an untoward event has l)een
even known to follow medical examination. The
treatment of such a case is, of course, the same as the
preceding.
Hut of the more coinnion and <-hroni4- formsi of
npitPiiiliritiN we may distinguish two groups —//;•»/,
the casss of soealled rclajisiiig appendicitis, reganied
by some as " catarrhal '' foiins, with little tendency to
suppuration ; and aeroml, those cases which terminate
in Incidisfd suppurative peritonitis, limited by
adhesions, and caused usually by ulcerative perfora-
tion of the iippciidix.
The symptoms attending the liret of these groups
consist of recun-ent attacks of pain in the right iliac
fossa, days and weeks, and even mticli longer periods,
of freedom from pain intervening between the
attacks ; and on local exnmination a tumour is often
to l>e felt deep in the right iliac region, tender on
pressure. The attacks may l>e accompanied by
sickness, flatulent distension of the alHlonien, and
constipation. With nbsoliite lest in be<l. ojiiate
fomentations, and belladonna and opiate liniments
applie<l locally, a diet restriet<,'d excliisivcly to fluids,
sueli as broths, clear soups, and the like, and daily
large enemata of warm soap and water with olive oil,
APPElfDtCtTfS.
«47
Boften and bring away nil fivcnl iiocumulAtions
witlioiit causing any irritjition or fXcit«MiuMit of tl«>
tiiusculiir coat of the ImiwcI ; witli surli cairfuj e.\-
pecfcmt tifAtiiient tlif j^reat majority of tlii.'S*; cust-s
([uiet <lowu and get well.
When, however, thesu attacks continue to recur
and become more severe at each recurrence, when
there is a distinct tumour perceptible in the region of
the appendix, and when the patient i» disabled from
work and anxious for relief, Treves' suggestion
may bi< carried out, and an operation undertaken,
"during a quicHcent interval,'' for the removal of the
enlarged and intlained appendix.
In tliese relapsing nonsuppurative cases it must
l>c rememUircd tiiat the recurrent attack.s of localised
adhesive peritonitis ait; apt to leiid to constrictioi;
of the bowel, and thus to cause serious obstruction ;
a potsible re.sull which may be avoided by the removal
of the ap[)endix.
In the ttcond group of cases, where there is
evidence of suppuration having occurred, after a
brii'f delay to observe the efl'ect of suitablo treat-
ment by rest, careful feeding, and opiates, if there
is no marked improvement, Vjut rather an aggra-
vation of tlie symptoms, with a daily evening rise
of temperature,* the absceas round the appendix
sh<iuid t>e freely opened by an incision directly
over it, the ptis evacuated, and the absm.'ss cavity
drained. A brief search may be made for the ap-
pendix, but this must not be pushed too far, owing
to the rink of lireiiking down adhesions and opening a
communication with tlic general peritoneal cavity. If
found it should bt; ligatured and removed.
Punctures with exploring rieetlles should be avoiiled
in these casci*, as serious di.sa.sters have followed such
explorations.
* SrnaK littve urp«1 that rapiiiity of palae is n ii)i«riHl indii-a-
tioii for nponitinn ; but tho ]iul«« rate u ao vnhftbic niiil iiii<v*rtJiiu
ill urrvouf pemoOB, and wi in y ran/y raiM.il lU or 20 lients, that,
latcn hv ittrlf, wt< do uut rogard it as a trustwurtliy iiidii'tttion,
248
Medical Treatmrht.
(Pull.
With rogaril to the treatnipnt of those comparatively
rivrt; cases of pt'rityphlitis from fiecal im|siclioii in tlio
cipcuni ami stercoi-al ulct-r, which sometimes occur in
young or mi(lcile-age<l {>ersons who siifl'er from a. ten-
dency to obstinate constipation, if we are enabled to
an-ive at a diagnosis to this effect, as a careful con-
sideration of the history of the case will often enable
U8 to do, we sliould be in no hurry to have i-ccourse to
operative inlerfei'f'nce.
8uuh attacks are preceded by constii>ation, in-
testinal discomfort, flatulence, distension, and piiin
especially referred to the li^ht inguinal or lumbar
region. Some localised tenderness will lie found
over the situation of the ca'cum and adjacent portions
of the ascending colon, not limited to any pjirticular
spot, as is sometimes the case in tip/tendicilis,* but
difl'used over those portions of the first part of the
large intestine we liave mentioned. On palpation
and percussion this part of the intestine will be felt
to be distended and dull ; indeeil, to the experienced
physician there is very little difficulty in distinguishing
this comparatively mild form of puriiyjihlitix from the
more serious appendix cases already refiTretJ to.
There is often some rise of temperature, but rarely
higher than 101° or 102' F., with restlessness, a
fiirre<i tongue, foul bre-ath, and a bad taste in the
moutli.t These febrile symptoms arc not always
caused Ijy 11 local peritoniti.s, but are sometimes
dependent, we believe, on superficial catfirrhal ulcent-
tion of the mucous membrane and absorption of
fiecal toxins.
Now the paramount indication Tor irenlmrnl
in those cises is to evacuate the fojcal matters which are
* MoBiirnoy has jiomtcd out that the most impnrtttnt dioe-
noctio siira iii connectioii with iuflnmmalion of the appenilix U the
inTuiabTe preieoce of a luinuti? point of exquisite teudenirai,
almost exactly two inchen from the nuterior iliuc apiue, oq a llnM
drawn from this ^rooen through tho uniliilicuii ; bat the InTariabtol
pmoDce of thin Bi^n a uot uuirenally admitted.
f For a fnller account of this form, ut Tnma, on
"Thu Cnwiil Form of Perityphlitis," Allbutt's "System of
Mc'iiciuf. "
Cbap.Xt.1
AfPENDICITlS.
»49
I
retained iu tliis portion of the int<*Atinp, and which
am (lisU-nciing it and irritntiii^ it, and {giving rine to
tlie symptoms detaile<l. If such a euse Ik; treated lui
niAny Hiithorilies direct an appendix <.iu>e to lie trnativl
(and some seem to include even tliese mild forma of
perityphlitis in their general directions for treatment),
and opium be freely given internally, the caae will be
made u protracted one, the tendency to olnt ruction
will be intensified, the general Bul>-fcbrile •.-onditinn
will l)e aggravated instead of relieve*!, and the |>ntient,
who might have been compamtivrly well in a few
d»y!s will very likely be ill for weelcH ; for opium
aggravates the pitresis of the iut4<Btinal walU (and we
have seen its adniinintration pushed until an almont
paralytic condition of the intestine has liecn induce] ^,
it diminishes all the intestinal secretions, »n<i increaweo
the febrile otate due to absorption of rct*inc<l excre-
mentitiouH eulMtAuces.
There is, however, no possible objection to tb«
loc/tl ajiplication of opium, atid it will getier«lly U*
found that the pain cAn lie effectlMlij rvUeved by tkn
application of hot linseed fioaUioai iimnklt^ vtih
laudanum; or the mixed opium and br:!
ment« may l>e applied on warm tint or
the M'ut of [lain and tendemeaa
In these cases, as well m in otlMn M «l .■
appendix is involvrrl, but which do ooi cmll fur oftr-
ation, although the symptoma arv pcmuteai, tb*
application of 5 or *> h.-echen u>er the urat t]( wwtMimg
and paiu haM lieen recuwmendcd. Trmrca says '
measure very oft«!n lias a magickl irflioet,"
To evacuate the cont««t« of Um
should at first trust entirely to •tmMte; )■>■>
of warm soap and w*ter, with whiA S or 1 1
olive oil have lieea mixed, thooM h* ilawW ia
with a long tube, the patient'* battocka bony
so as to favour theretenttmeif thecacaa. Aa <
of thijt kind should be adarinBtand tf»*tj
until complete relief baa beaa ob<Ha«L
ir we find that thcrr is no l«if«r aajr U^omk pmtH
few h*/mn
250
Medical Treatment.
(Parti.
or tenderness, gentle manipulatiun of tlie tlLstended
bowel nmy serve to assist in dislotiging any n-maininj;
iinpiii;teJ fieces ; and no Imrm Ciiii now iirise from tbe
use of a gentle saline aperient with u small «losi> of
calomel. A powder composed of \ grain of culotnel
witli 2 or 3 grains of sugar of milk, and followed by
4 or G ounces of Dinncford's fluid magnesia, to which
a tea.sj)oonful or two of leniun juice should lie aiided,
is as gentle an aperient a.s it is possible to give, and
causes no e.xcitement of the muscular wall of the
intestine. When it is clear that a .somewhat stronger
aperient cjin bn given without any risk, two drum
doses of sodium sulphate dis-solved in \\ ounce of
pe[)perniint. water may l>e given every four hours,
until the bowels are completely relieved.
Then; is a wide difference of opinion between author-
ities as to the use of aperients in cases of appendicitis.
Osier maintains that the "use of saline purges early in
the disease is a most injurious practice," but then Osier
is one of those who tliiiik "there is do medicinal
treatment of appendicitis."* Treves, on the other
hand, says, " If the onset be mild a purgative should
bo given at once. Over and over again an attack has
been cut short by a promptly administered aperient."
The explanation of this divergence of opinion lies, we
think, in the fact that sume writers have only the ex-
petience of hospital cases before them and know little
about the great number of mild cases, a.ssociated with
chronic dyspepsia and habitual constipation, that are
seen in [irivate practice. The e.\perienced physician
usually has little ditBculty in distinguishing the ciises
in which an aperient may be given from those in
wliich it would act injuriously.
When all tendernes.s has disappeared, and there
is no longer any rise of temperature, a mild aperient
should still be given daily for some time, until the
bowel has recovered its tone. To promote the latter
a tonic cont-aining nux vomica, gentian, and ammonia
will be useful. Intestinal antiseptics should be given
* " Priaciple*aud Pntctiofl of Medicine " (foaitli edition), p. 530.
»^1tl.l
ApPEifDiarts.
«S'
thy till? mouth in thi'se cosi's, if there is cviilonce of
|fc«»c»il intoxication such (is foul hronlh, a bad tnsto in
Ithe mouth, and a slight liiurnul rise of tcnipt-nttiirc
ySnlol in 10-grain closes threo times a day will answer
l>is purpose, or a grain of thijmol mode into a pill
»-itli soup powder and s]iirit may Ik' given instead.
[Ruoh intestinal antiseptics would also favour the
IbealiDg of any intestinal ulceration that may poiwiMy
I exist.
The patient hIiouM, of course, l>e kept at rent in
|be<l for riomc time, and until tjuite free from puin, nixl
[onlv Uuid food, such ns liroths, clenr soup, gruel, and
locca-sionftlly a lieaten-up egg. should he pre»erilK>«l.
[A cup of te« or cottee with j'wptonised milk may also
I be allowed.
The uccasionnl recurrence of pain and t<-ndcmcM
' over the c«oum and ascending colon, which not
imfrcquently foliowi? an acute attack, we have found
relieved by the application of iodine paint.
We cannot dismiss the Hubject of the tmtni'-nt
I of appendicitis without a brief nfrrr-ncn to liw
I controversy that has ari.scn with negurd to tbw pro-
' priety of early operation in ne&rly mII cmw ; mmA
tho statement, repeated by many, that ''tberv ia
I no twdtml treatment " of this diir—r Brook* kw
I recently protested strongly againat what ke imaa
' the fievre op^aloire, and oljMrrTi!*, "HiooB I kave
I leaiTit to weigh the indicati'"< </^» ...-~i",». •nauaul
I of upemting always and imi: ro tkm
mortality diminish." Mon^Mir, ••m'ii m tiw ratmm im
which he considers o[)erations to be JnAkmlfA. Ur
op{.>oNen the idea that ojM-mtioa jhwlii Iwi Aam hmtilf
and inime<iiately, and br |i«adMS mtUatrnt to dktm
that '^ I'operalujii intinr'diiiU rtt jjtu frmm ifut fm»>
jterlnlion aniit'r," and he )»<iut» 'lat tkai " wdk *m^
able and early mc<lical tKaUutaX, CM
is frequent, and amelionrtaoB » tb« rata.' Tr
also, is stoutly oppoaMi to
LopcnttioD, Mid is not «a tk* i
•1m Atttiimm
25»
Medical Treatmkxt.
rFuti.
" tlierc is no mrdinal troituient of appendicitis." He
believes the niortiility from this disease has l>eeii
greatly exajigerated owing to the elimination of the
slighter cnses in hospital st'iitistics. " It is j)robiible
the mortality of perityphlitis, taking all phases of the
disease together — the most triHing attacks with the
most serious — is about 5 per cent" Again, Treves
remarks ; " The nunil)er of cases which undergo sjkjb-
tiuieuiis cure form an overwhelming majority, and
cannot be last fight of ; nor can the opening of the
alxlomen througii the muscular parietes over the
caecum be regarded as a triHing procetlure." With
regard to the statement that "cases have endt>d
fatally within the first 36 hours by perforation Into
the general peritoneal cavity," he observes : " .Such
cases are exceedingly rare ; they cannot Ik* anticijiated,
and they are not ditiicutt to recognise." As to re-
lapsing cases, he says, "The circumstances which
would Justify an operation in these coses must bo
precisely defined, and it cannot b« loo emplinlieoUy
sUiUd tliat in a fair pro]>ortion of instjinees in wliich
the trouble has rela()sed, ?jo siirgiotl iiUfrJerence is
calletl for In some examples of the relajwiug
form, much can be done by the medical means already
descrilwd, by diet, by attention Ui the bowels, and by
placing the patient under conditions more favourable
to a state of peace within the aljdoraen."
We have (juoted hirgely from Sir F. Treves'
article because, although writing us a surgeon and
with a very large surgical ex(>erience, he fully recog-
nises the importance and efficacy of med'ti'iil treatment
in the uiajority of ca.scs of perityphlitis.
Finally, as to prfvenliiv measures in persons who
have recovere<l from an attack. All indigestilile
substances should lie banbshed fi'om the dietary, nil
vegetables must be reduced to the form of soft partes,
coarse brown bread must be ovoided, the soft pulp
only of fruits taken ; milk sliould be freely diluted
with barley water or some alkaline minend water, so
that it may not accumulate as indigestible curds in the
Ck.p. XJ.l AFPBJIDKITtS. DvSKMTatT.
«53
«in. All solid foods mut be w«fl wnAaJbeA ; Um
neals should l>e sumll in •moaot, and elf aioiwijr.
Pnre wat«r should lie fredr cowmnil, Iwt it •IkmIcI
not 1>e hard wat«r containing muck lime aalta. A large
[i\aas of wat«r at bed-time and another on liuBg ta
the moniing should he taken. The Imwela mast be
made to act daily— for this parpoae a dinner pill maj
1)6 prescribed, or a claret glain of Apenta water dnmk
lining in tlie morning. Alt violent aod active
'flfeertions must he avoidMl. An abdoaiinal ImjU
should be worn.
l>rsE9rrEBY.
Dysentery ia a. diaeaae, or, aa some beUerc, a gronp
of diseases, characterised by synapioms referrible to
intiainiuation, usually associated with ulceration of the
mucous menilirane of the large intestine.
Much difference of opinion has existed with regard
lo the r.tiology of dysentery. Some hare r^arded
climatic conditions, such as great heat and moisture,
as in tropical countriex, or great and rapid alternations
of temperature, or marsh malaria, as of themselves
efficient causes of dysentery, tithers have referred
the occurrence of the disease to exposure to cold and
wet, to over-fatigue, and Ut eating unri[)e fruits. But
Pfttr the tnore generally Hcoi-pt«l view i.s that its
flttentiul cause i« a «p«M-iar leerin or k****'*** (>'ary-
ing according to the imiticular form of the disease),
and that the disease iN propogatcyl by contagion and
infection. The amahn coti ha.s bcon described as the
cause of a special type of dysentery, hence termed
arinchi): or trojnfiU di/iniilvr;/ ; but it cannot be
.rded as conimnn to all forms of dysentery, for
most careful and e.xpcrienced obnervers have failed
to find it in many outbreaks,'* iiml it lias not boon
' ' - ' ■ i sliiilicii Imvc liw.Mi iiiiilirlukin 1>V many
il, «« yt't, iiri iMiiii|>U>ti.)y ili-Hiiitt« :iiMt tvrUiii
t ililiiliiil. A uooil aiiininl iif tlii-w' iiivi'«linn-
jB ^jtvf.ii l>v i'rtift'sHor FiexntT {Jtrtt. Mnl. Junttiul^ Scii)<
tenilx-r -'yili, lOOU, '• Ktiolriny of Tropiral Dvsenlfry "). Willi
nl to the umurtet] uuutol rclutiou i>f unituinr witti (iyM'iitery,
I
m causi
I arinc
■sr
c«i.
fW-ul
tions
254
Medical Tkeat.vf.nt.
IPanl.
found in tlie form of dysentery encountered during
tbe war in South Afrioi.
It is siud to occur sjiorculically in very hot seasons
in temperate climate?, but this is very rare ; eiidi'inic-
ally, it is found to occur continually in certain hot
countries, such as Hindostan, Cochin-China, Algiers,
Egypt, etc., and although it may in some instances
be found to coexist with malarinl aB'ections, such as
ague and hepatitis, yet it Ls founfi also to occur in
countries quito free frctm malaria, and to lie absent
from othets where malarinl affoctiotus are common.
It would ap|)ear, therefore, to have a diU'erent origin
to that of ordinnry iiialarial diseases.
Its extreme fre(|uency and fatality as an epidemic
amongst armies in the field show clearly tl\at the
mossing together of great numbers of men imder
conditions of life which must necessarily, at times, lie
the reverse of hygienic, is most favourable to its origin
and propa^tatjoti. Thi.s fact is not inconsistent with
the opinion that it is propagated by a specific germ ;
for in camps there often exist all the conditions most
favourable to the difl'usion of such a cause of disease,
wliilc every jivdinposinf/ cause, sucli oa over-fatigue,
exi)0.sure to wet and cold, mental depres-sion, unsuit-
able or insufficient food, and overcrowding, are at
times in operation.
The disease may originate in the use of impure
water for drinking, just as typhoid fever does, and
then be rapidly propagated hy the further contamina-
tion of the water supjtiy by dysenteric stools. In
wHr, foul latrines, in which the air becomes charged
with f<Etid organic emanations, are stated to lie a
common cause of dysentery,* the effluvia from
dysenteric stools being especially injurious.
he concludes that " while nmcphtr nre cnnimnnly prevent nud nro
coiiLfnipd in Uic |>rodii<-tioii of the Uttioiii* of sub-ucuti' aiid chrviutc
dywiil^ry. they liave ut.t tlnm Inr beou shown to Iw Hquullv con-
uecteil will] thn nciitc ilyscntorics ovon in the tropic*, lu th«
fonner viirictips I'lirlcrinl iissociiitinii protiHbly hu« much influrarv
upon the luillioftrnic jiuwers oi the untcbn.'."
• Pnrkes' "Hygiene."
CIup.XI.1
Di'SEtrTEnr.
m
The reason of its constant endemic preraJeucv in
certain tro[>icn! countries is to be accoanted for by the
fact that heat and moisture favour the propagation
and diffusion of the sp«>cific genn, and alao prohably
by the unhygienic habits of the natives.*
The ti>-niploiBs presented by sufierent from
dysentery de[i«nd on whether the diaease is acute or
chronic, on the type or form of the disease, and on
the extent to which the inflammation, ulceration,
sIou(;hing, or thickening of the intestine have spread.
We >>hall only here enumerate the more cha-
racteristic ones. Tn acute c^ses at first tht-re are
alxlomiiiiil pain and <liarrh<Ea, the motions soon
Ijecoming ilij»r-nl>-rxr , that is to say, they contain a
mixture of yellowish-while mucus and blood. The
evacuations are precede*] by painful tene>iimus, especi-
ally referred to the region of the anus, and often
involving the bla<lder, and there is a constant desire
to evacuate the bowels, which usually only results
in the passage (with much straining) of a small
quantity of mucus and blood. There is pain and
tenderness along the course of the large intestine,
and the mucous membrane of the rectum is hot
and inflAmefl, and intensely sensitive. As the
ulcerative process advance*!, the motions are found
tio consist chioflv of tjlairy mucus, pure blood,
i and shre<ls of mucous membnine, which Imve been
B(token of H8 "intestinal scrapings," with which hard
firoil mas-ses are occasionally seen to be mixtnl. In
severe epidemic cases the patients are hai"a.ss<^l with
a constant desire to go to stool and to urimitc, which
they do from fifty to 200 times in twenty-four hours.
The |iain is relieved after each stool. As the disease
adviince.s, the motions become horribly ftrtid, and
the mucus gives place to a reddish sunious fluid,
• Dr. Man*.!! klluilri te " r> very Titiil tyi>f nf .lyw-iitery,
iMiiihi'iiii<i!i'-3*ny IpniHHl •i-oiitiH,' wliicli in tin* voiir;^** "ii'l diii-
gn'i' "f 7ii-rr' tliin nn** c»f oiir Knu'li^^i InirxTi'- ii*v turns "
(•• !■ I ii.'W cditidii, i> ' ^^ 'ii"i
hiu ' f Hint this iath> •'< l>"
,i „,.„.,. .,..,ili A/rico ((V.Miiui - '• „■ - . ■"").
256
Medical Tkeatuext.
IPmiI.
containing fragments of membrane, and mixed witli
a considerable quantity of pus. Togetlier with these
local syniptouis there is in some forms much thirxt
and fever, with di'y skin, rapid emaciation, loss of
strength, and ejchaustion from the constant intolerable
pain, tenesmus, and loss of blood.
Sporadic cases usually run a much milder course,
and the symptoms arc by no means so severe. Dr.
Wnshbourn, from his experiences in South Africa,
i.s dis|Kisc<l to regard those cases th.at have Ijeon
described as "simple colitis " and " ulcei-ative ctilitis,"
such as prevail in certain lunatic asylums, as sporadic
cases of the same disease.*
Several clinical varieties of dysentery have been
described.
1. A benign tporadw form, in which there is little
or no fever, not more than ten or twelve evacuations
in the day, and which ustially results in cure in seven
or eight days.
i. An iiifltnnwalori/ form with high temperature,
hard, ra[iid jiulsc, dry, raw, red tongue, and nut very
frequent stools.
3. A Itilious form, in which the stools are diar-
rhvtic as well as dysenteric, and eoiitjiin yellowi.sh or
greenish bilious matters. There are nausea and
vomiting, a coated tongue, and only slight fever.
4. A r/ieitiiiatic form, with on allection of the
joints resembling sometimes gonorrhojal rheumaiism;
more commonly fugitive pains appear in the joints,
muscles, and intercostal spaces (pleurodynia).
5. An i/itenitiltent form characteiised by remissions
and exacerbations of severity.
6. An itd>jiiaiiiic or Dialii/mtnl form marked by
great prostnition, and prominence of symptoms
referrible to the nervous system, muscular tremora,
restlos.sne8S, dcliiium, an<l fatal coma.
7. A cJirvnic form, a .sequel usually of several acute
Attacks. The stools are sero-puruleiit, but usually free
from blood ; the anus ia relaxed; a dull, heavy pain
• ClimcrtlJoHiNiil, Aug. :i8tli, 1901.
DrsEXTES y.
^57
aocs thv. tenesmos ; the lelly is flat ami rc<(scted.
iintl painful vhen prened on. Tbere i* no frrer and
the appetite is often good, bvt tbere h generaOj gnsat
eninciution.
8otne authors noti<?e [larticulitrlr the absence uf
bile in the stools, and it lias liecn jiointed o<ti tliat in
8overo cases all the dig>:«tire secrptioas are dtai^ed or
entirely checked. The saliva becomes acid, and loan
its glycogenic properties, the gastric juice beaMtea
alkaline, and can no longer form peptooes, vhUe the
secretion of bile is wholly arrested.
Attention to the following ladicatlMU will aoaiat
us in the Irvaimopl of cm** of dyp^nltry : —
|i. I. To relieve the pain and tenesmoi in acate
'1. To avuid all irritation of the inflamed uiacous
nienihrane.
3. To remove foul aociunulations from, and to
arrest putrefactive processes in, the large intestine
(intfMinal anlisfj)*is).
4. To pi-omote (especially in chronic caaes) a
re»toration of healthy action in tlie catarrhal and
ulcerated niua>U8 meniVtrane.
r>. To counteract any morbid septic agency in the
blood.
6. To stipjjort the patient's strength.
7. To prevent the diffusion of the disease by stiit-
able prophylactic measures.
1. Whatever differences of opinion may exist with
gaitl to the free U8t< of opium in ac>it»< dysentery —
and there are Home who ubject strongly to its adminis-
tration— there can be none its to the neoessity of its
limtied ai>plication, to allay the extreme distress of
the patient, until other mor<? slowly acting reniedieii
can take effect. There should be no he.sitation in
attempting to at once relieve the pain and tene.sniU'*
in the rectum by the local use of oj>ium. It is not
intended to cheek the action of the bowels by its use,
or to lock u]i offending fiecal ma.'v^es in the inHame<I
Pel, but it is simply given to relieve pain and to
R
25
•S
Medical Treatuknt.
(Part I.
niodcriito and modify the morbid painful muscular
contractions of the large intestine. For this purpose
ii morphine suppuHitoi'y is convenient, if it can Ix- re-,
tiiiiicd in the Vinwcl, or opium in tlic form of a snntU
eni'iiiii luiiy l>e given, whieh inaj- lie repeated in half
an hour if the first one or two should !>« quickly
rejected. As the anid orifice is often excessively
t<>nder and sensitive, the enema must be given gently,
iukI with care, a small tte.xible tuhe being used, which
.should be passed up several inches into the bowel. If
there should l»e any ditlicidty on account of iiritabilily
of the anus, this may be readily overcome by brushing
the anal mucous membrane with solution of cocaine.
The enema tube should also be well oiled.
Each enenm should consist of 15 minims of
laudanum with 1 ounce of cold mucilage of stArch.
iSonie pi-efiT to give a hypodermic injection of
mciijiliine, ^th of a grain. Whichever method i.s
adopted, it must be remembered that it is only u
temporary e.xpedieiit for the relief of a distressi
synipt-om.*
2, To avoid all irritation of the inflamed mucous
memJirane, the patient nwst keep absolutely at
i-est, and, in all but the slight«st cases, at rest in
bed ; he must pass his motions into a bed-pan, and not
be allowed to resort to a water-closet. The nlidorainal
surfivce may be gently rubbed with opium liniment
and hot flannels kept applied there ; hot bottles hIiouM
also lie applied to the feet, and the ^latiunt kept
thoroughly warm with plenty of blankets.
-All irritating ingesta, or food which leaves a
ivsidue prone to decomposition, must Ije avoided.
Milk is tite best food, if it can be prevented from
clotting ill the bowel. It may be boiled, anfl then
diluted with iced water, and marie slightly alkaline
by adding to each glass a few grains of so<Hum
bicarbonate. It is exceedingly undesirable tliat any
* Dr. \V.-uth1.iniuii states that he has seen livas aaTwl iu South
Africa by ivIieviiiK the distreaaiiig tonesmus by morphine sup-
podtorius (/ti-i'. JM, Journal, June Ititb, I'MO).
DysEXiEKy,
»50
andig«sl«<l curd of uiilk should rvacli iIr' lari;i.< iutc-s-
tinn ; Uic milk should tbt^refore be- diluted and rendtred
distinctly alkaliue, or it may be (Hiptotiised. A littlu
thin un'owToot may bo mixed with the milk, and
foniw a U!*pful and uuimt.atiiijj fooil, while it provcnts
ihf milk forming hard cuitjs.
<>i'eat oljjwtioii has been taken to the um* nf
strung meat extracts in dyHcnlery on accuuiit of th«>ir
proneness to decomposition, but we can ttee nn
possible objection to light Itroths and eli-ar ttnupH
flavoured with the expresswl juice of fre.sh vegetable*,
fut these leave no solid residue, and they are often
grateful and refreJiiiig tu the feverish «nd ex-
hausted ]iatient. Some authorities object even to
milk in the most acute stage, and when the tun;^ue
is foul they would limit Ihu fiMxl to weak chicken
broth, barley water or rice water, and « little cg}{-
albumen, until the tongue cieanii.
Stimulants, unless in uiiHea of much exhauntion,
should be avoided, and when given nhould i'<inNist of
small quantities of brandy and water nr bnindv ar»i
milk. A teaspoonful of brandy with a tabli'SfKXiD-
ful or two of warm coffee is an excellent Htituiilant.
3. The next indication is to remove foul accumu-
lations in contact with the inflamed and ulceratt-d
mucous membrane, and to check tlie pulrefactiv«
processes in the large intestine. This is, in Mhtirt, to
carry out iuieMinHl niilisfpitia. Then- am two
ways of ert'ecting tlii»--{((; by gently a<-ting ajierienu,
wl)i(-h will sweep away toxii- anil putrid a4.rumidit-
tious from the intestine ; and (//) by irrigation, or
washing; out the intestine by cUwujriing or antiw-ptir:
fluids.
After we have allayenl tlie tie verity of the p<in
and tenesmus by morpliini> or opium, a% alri-;»<ly
de^;ribe<l, we ne<.-<i luive no diriiculty or bn«itJilion n\
carrying out the present indicAtion.
As an aperient an initial doMo of ciMtor oil may )««
given, an<l this may lie followed, in acu(« caaea, eitber
by the ipecacuanha treatmeDt, or treatment by tba
26o
Mkdica l The a tment.
li-artt.
api'i'ient siiljihates of inagnesiuni or soflium. Both
methods an- umlnubtcdly effieaciouH, and t-ach has its
advoc4it«s. WtishlKjurii, from his r'eccnt experience
ill 8ou(h Africa, ooiiRiders ipecaciinrdiaund iiiagnesiuin
sulitliatt! both spei.'itics for the disease, but he reganU
iinv-acuanha as the most ethcacious, as he has seen it
cure cases wliich had resistetl the action of sulphate of
uiugiiesiimi.
Iiwcacuunha iias been jj^ven in various ways and
doses, isorae physicians' give it in large doses, 20 to
40 gralua eveiy four to twelve hours, according to its
tolerance by the patient. Its tolerance is promoted
by the administration previously of a dose of opium,
or by thi' addition of some opium to each dose of
ipe^-acuanfia.
The patient Imvin;,' been kept a few hours witliout
food, the plan usually adopte<i is (.0 first (|uiet tlio
stouiaeli by a dose (if iipiuui(IO minims of Battlev's
solution will sutKce), and tlien to givi-, an hour after-
wards, ;?0 -jiniins of powdewd ipociicuanlia in as little
Uuid as possible, so as to avoid its rejection by
vomiting. The jMitient is told to keep very still in
beil and to try and not vomit. A little ice may lie
sucked, or a tablespoonful of iced water swallowed.
After four to eight hours another dose should l>o
given, and the remedy .should be continued for some
days, if nece.ssary, in diminishing doses.
Ipecacuanha has also been given in the form of
Kiivmnlii, and wc may resort to this method when
we encounter great intolerance of this drug by the
Bt4>mach, and in young children. One or two ilrams of
tlie powder should be infused in 10 oiuio-s of boiling
water, luid when cold, a half or the whole of thii
may l)e injected with a long tube into the Iwwel.
It has been stat(>d that ipecacuanha from which
the emetine has been extracted —i/wwriwAa rinn
tmi'liita — is e<|ually useful in dysent+'ry, and haa
the advantage of not causing vomiting oven in lar^j
doses.
But experience with this form in South Africa has
OuH. Xl.l
DVSE.VTSKV.
a6i
not 1xK.'ii natisfiictory a>iiI it Is tloiititful if it I'an take
lliu )>!»<■»• yf tlie uimltvnfl drug.
Till' fxiH.'ric'Hce of Anu'riam ]i|ivsiriat)8 is (int
fttVournl>le Uj tlic ipecucusiiLa ti-eittiiieiit, uikI llicy
pn'fcr the Mae, in avut« ciusvk, of the nprrirni
«nlpliiitiK,* a nicxk- uf treatment wiiicli nii*<.-ts niso
witli Miudi favour in tliis coimti-y. Mji!j;nrttiuin
or Kodiurn sulphate t niay lie tifittl, iiiid in tlm
following inimner : — One dram dis-solvod in half
an ounce of wati-r is given every hour until tin*
niotionH l>econie firoal. and contiuuecl, le.-ut frf<)urntly,
for twenty-four hours. Aftt-r the di.'iiiiifM-nmnce of
the ncut<' symptoms the diiirrh<ea which irmainh miav
be treatc<l witli liixiiiiith and ojiiiim.
Thi^ methu<l itt ri.ally (infiVy/Zic and eliininativ<% •■
it aims at swi«ping away from the iutcntinea irri-
tant toxic and putrid gqtistances.
A more dii-ect way of carrying into effect th*
indication we aiv conitiderin^, aiirl a u>«"fiil ntipplenient
often to the preeediny, is the irripnlinn of Uir lar^e
intestine hy ailli^rplir Hnids ; it is, however, more ap-
plicahle to sul) nculc and chn>nic than to acute ca."H'«.
A solution of lx>rax, 5 graing to the ounce, or of
borax and bicarlionate of 80<la, .5 gniinx of eoi-h t« th<;
oance, with ii few drops of sfiirit^ of camphor or
tincture of eucalyptus, makes an excellent irrigution
fluid for this puquwc. The solvent action on mucoa
of the alkaline 8<;>lution helps to detach and briug
awny foul iuHpissated mucous maasen adben-nt (<> tii«'
diaeosetl membnine. and to cleanse the »urfaci- of thf
ulcers and proroot4' their healing. No tr»-«»(iii»-i]t ..i:i
be more rational or n'«pon<l mor' . t,, •(,,.
anatomical and HvmptoiiiHtie indic:t(. - iiiM-a.«e
than tliix inethoti of - irrigatii^n.
Various other >•■, h«v<j lj»*u uitj m
(•nemata in dyMent«rj — some of ihmi morr for thoir
* r,rU HuTp'n "f'.yttvm of l>nirtial TVvafvalia.'* Ml «.
p. I«l (»ecoll^^lJltitinu^, U«)l. ^
f VtH, Hni. Mrd. Jimnsl, FeK. lOth, inm Mtk, M4 \fm. tak
U«K): ttud Jnu. ■.'Clli, 1901. ^^
:6j
Medical Treatment.
(Pwl I
astringent thnn ttii.'ir anti.sc|itic nctioii, But in acute
ciiMCs the siniple iitiil imiiTitutin^' autiHoptie enematH
ait; the beat.
Large irrijtatiiif; injections of wilution of nitrate
of silver, 20 or 30 grains to tho pint, have fouml
Miucli favour with American physicians. Osier in.sists.
on tlie noce-isit.y of litiy injections of from 3 to 6 '
pint.s, thr warm lluid l)eing allowed to (low into tho
Iwwel tlinnigli a long tube. He has also used warm
injections of quinine, 1 in 1,000 to 1 in .5,000, in
anio'bic dysentery with great benotit. The amtcbn*
arc rapidly killed by it.
lodiiir has also been emj)loyed with advantage in
the proportion of 1!0 to 30 minims of the tincture to
an ounce uf water.
Satieylic acid, charcoal, chlorine water, crcaaota
euiulsioiis, porclilciride of mercury, and decoctions of
biirk .ind cluunoinile have all been atlvocated for the
sjirne purpose, and some use simple iced water.
iMieiuata of creulin, | per cent, or 1 per cvnt.
Holution, have been given with much success by some
Continental physicians. Large enemaUi, from 4 to
6 pints, have been given, twice or three or four
times a day. They are said t<i he absolntely non-
irritant to the bowel.
That this treatment by irrigation should lie suc-
cessful it must be c«rriefl out by the physician himself
or a thoroughly trustworthy assi.stant. From .'{ to 4
pints arc as much as can be safely introduced in the
adult. The patient shouhl lie on his back or on his
left side, with his head low and the hips raised, and
the injection be intruduccfl slowly by a funnel, or
fountain and tube. "This should always bo done
under low pn-ssure and slowly, in order that the lluid
may have time to distribute itself l)eyond tiie points
of entrance. This will avoid the danger of ovcr-
di.stension and possible rupture of the thiu-walli'd
intestine when ulceration has occuriHxl."* If pain is
• Hare's "Syitora of Practical TliemiiciiticM," vol. ii., |>, -183
(aocoiiil cditiuii), I'JOl.
ChapLXM
Drsf.fffEKV.
263
oomplnincil of, we ihuhI Ufnigt itij«;tiiij< for u ft-w
liiiriiiU-s. aii<) llicii iiijui-t iiiort-, uiilil tin' iim.viiiiuiii
jiOHxiljli- is re!icli«l.
It lias been siiul of these irrigations nml large
pneinntA tliat " they i-^uso gveat distress nnd no
apjirecinlile Ix'^netit," and that tiiev aiv " risky,"* owing
to ttie iiKvratod and «off<«n«l fttnto of the oKits of t\\c
bowel ; and tliat they cannot Ixi made to reach the
CJecuin except by " violent massage " ! To apply
"violent massage" ought not to be thought of, and
the mure suggestion of such a proce«<ling excites thn
suspicion that insufficient c^kntion and CAre in tlie
application of this nietlio<l has led to these objec-
tions to it.
4. Tlie next indication Iihk lieen tn a great extent
anticipated in the prece<iing, for inlrttiiml nutinrjwii,
pro)»erly carrif<l out is better calculated than any
other nicaus (o pi-omoir a restoration nf liealthy action
in the cjitarrhal and ulcerated ruucou!i lueinbnme.
Hut in chronic and sometimes in acute cas<-8 the
catarrhal state set up by the disease in the in-
testinal mucous membrane needs the emiiloyment of
N«lrinf(pni mnedies.
l.ti'tiiHitli (the siilmif rate, carbonate, or oxy-chloride)
is one of the Ixwt remedies for this pur]K)M.'.
Twenty grains of (he subnitratc with ."> grains of
Dover's fiowder, 5 grains of light magnesia, a dram of
mucilage of tragacanth, and an ounci- of infuHJon of
iiarulia may be given twiw or thrice a day. Much
»rger di.>8es of bismuth than this have been given -.10
to 60 grains every two hours ; theie large doN<.'H act,
lierhaps, as much by their antiseptic us their astringent
property. Stronger astringents are iionti-tinir« re-
quiredr-a drum of tincture of cat<>chu may be n<ldr<l
to each dose of the preceding, or 10 grains ol extract
of logwood.
In old and obstinate casen ucelalc of lead (4 grain*
the yil. jiliiinbi ruin ujiio tlini- timt^it a day, or a
Mpjtotitoria jjlutiihi mm ofiio twice ii day), or sulpliala*
Watidns-Pitofaforl. Bn'. ifrd. Jtunttl, Nor. imh. iwn.
364
Medical Treatment.
iPaFi r.
of copper (] grain in a pill with 3 <{raiiis of Dover's
povvrliT, lliri'e times n (lav, or a rectiil injection of 10
gniiiis (if sul])liiitc iif if>pin>v, 20 ininirns of tincture of
opium, Mini i uniiocs of wnler), or nitrate of silver (J
grain tiiiulc into a ]iill witli 2 ;^rains of kaolin ointment,
and with or without \ a \^m\\ of jiowdered opium,
thi-ce tiniL's a (lay), liave all Ijeen found useful.
5. The fiftli indication is t-o correct any morbid
.septic agency in the bloixi. It seems probtible that
ipwactiiirdia may act as a microhicide, and arrest the
development of the s|)eeilicgerni of this disease.
In cases in which the dysentery is clearly hbso-
ciated with malarial intoxication, quinine must be
iriven ill full doses.
Maclean recommends that 20 grains of quinine in
solutittii (we would suggest in lemon juice) should l>e
given before the iiMVncuanlia treatment is iM-moin. and
that then these two drugs should be given alternately
until the characteristic effects of both are produced.
In chronic malarial cases it may be desirable to
j)re8crii)e arsenic ; j'gth of a grain of arsenious acid, or
.jSgth of a grain of arsenate of soda, gradually in-
creased, may be given in a pill three times a day after
food.
In scorbutic cases the fresli Bael fruit has been
stronglj' commendext by Anglo-Indian physician.s.
Lemon and lime juice may also be given, and fresh
ripe fruit and vegetables, ^[anson speaks well of a
decoction of nimaiaho in sub-acute and clirouic cases ; *
and a tineture of Moiison'ui in-ata, a South African
plant, has lieen highly praisetl by Dr. Moberly.t
G. We must Kujiport the patient's strength by
nutritious food. During the onset of the acute attack
little food should be given, as little as can be assimilat«^d,
08 the residue would simply act as decomposing
foreign substancvs irritating to the dise^ised intestine.
Milk is, as we have said, the Ijest food in these cases,
diluted with water or barley water, or mixe<l with a
* '•Troi)ic«l Dim-iues" (new edition), p. 31.1.
t Imerl, Feb. 6th uui 13th, 1B97.
DrssvTEJii:
26s
littlo tliin nmjwi-ool. If wc iiotii'i- that mini of milk
passes in the stools, we must rcj>liice llie milk liy whey
or weak aiiiriial lirothn iiiid thin ii<:iu|M.
Ill earning out the iiiecaeuiuilm trentmeut, if
mueli niinsea and vomituig are excited, it in impirtunt,
in order that the patient's strength lie not exhauBt<yl,
that sufficiently long iatervali^ l>etween the dtmes
should he allowed for the admiuisitration and assiniila-
tiou of nourishment.
If tliere is great prostration, alcoholic stimulants
must Ik? given : a puiv spirit, either brandy or whisky,
or sound port or Burgundy, mixed with water, may
be prescriiied in the cpiantity necessary. Ether and
Teine hj'jKxlermically, and saline injections, have
IIB employed with succeA'^ in cases in which life
"■ ' Ui be endangered by lia-morrhoge and
with prostration and collapse.
After tlie severity of the acute stage is over, and
when a|ij>etite and digestive pt>wer have returned,
a more liberal diet should be allowed. Eggs, whip|>ed
up with l«oiling water, and a little nutmeg and
brandy and cold milk added, are an agreeable and
highly nutritious form of food. Poiiuileil sweetbivad
or chicken, or Knely-diviiled raw meat, or pounded
meat anil crumb of stjile bread may Ix." added to broth,
clear soup, or thin cocoa. When convalescent, tender
meat, fowl, tish, eggs, milk, rip<i fruits, and fresh
vegetables may lie given at suitable intervals, and in
proportion to the digestive capacity.
We should seize tlie earliest opportunity of further
supporting the patient's strength by suitable tonic
medicines. Bark, quinine, nux vomica, simarulia,
nitro hydrochloric acid, the several j)reparation8 of
iron, may all in their turn, alone or combined, lie
given with a<lvantage.
Dujardin-Beaumetz maintained that tliere woh
only one treatment for rhronic- dysentery, viz. an
exclusive milk diet: beat taken, together with Imths,
at Vichy.
Change of climate is often nece«iary to nt^toro
266
Medical Tkeatmeht.
ip«t r.
conipli'tely llic stivrifjtli of tlie dysi'iiteric juiticnt. A
sca-voyagf, reiuoval to a hi-acing sea-coast, or a
moderately high nxiuntain resort, or a dry, bracing
upland, may be chosi-ii, nccoriiing to circuiuMtancps.
If troiibk'sonip constiputioii Imj a sequel, a course
of iiiinfn\l W!itei-8 at Carlsbad, Kissingen, Tara.sji, or
Uriili's-lfs-Hainw may prove very serviceable.
7. We finally come to tlie important indication of
adopting proper propli) liii-lic ineasurps.
One of the nioHt impoitant of those i.s the projier
treatment of the dysenteric stools. They should
eitlier be mixed with sawdust and burnt, or buried in
the soil !v few feet below the surface, boiling water
having Iteen previously thrown on them. They must
not be emptied into water-closets or privies. If it is
not pos.iible to avoid this, they should be ftrst treated
freely with carbolic acid and boiling water. The
sick room shonld Ijc well ventilate<l with ojK-n
windows, tlie bedding fre(|uently change<l, and nil
articles soiled by the discharges plunged int-o l>oiling
or very hot water.
Individuals exposed to contagion and during
epidemics should avoid all pii-disfiosing causes. All
drinking water, unless absohitely fr<?e from possible
su.spieion, should be Ijoitetl, antl milk also. All articles
of food should be avoidetl that have any tendency to
excite intestinal catarrh, and that ai-e indigestible, tui
unripe fruit, coarse vegetables, etc. Avoidance of
foul latrines and water-closets should l>e insisted ujion.
Warm clothing, and especially u llannel band round
the nlKlomen, should be worn, as chill predisposes to
most infectious microbic diseases. Removal from
the infected area, when possible, is, of course,
advisable.
Tn the management of itnnies and other large
boflies of men it is especially important to look to the
supply of drinking water, to avoifl overcrowding, to
provide proper food, properly cooked, and to secure
habits of personal cleanliness and the proper disposal
of n-fuse.
DrsESrrefy.
**7
Al>I»TTH)NAL
Aitiiogent pUU in dyient«r7.
H Aiv»*w*i nitrati*. gr. j.
~ I nil To be taken an hoar
rmeab. (/liriaW.}
Enemau in djrMBtezy.
g/aiX subatiuum hare
(uoenrfullyspplietl in i
Fl«a irngation witli
water bit* Men fouod m oMfal
uony. (^Korjtim.)
One ijer cent. tahitMow etf-
boiicaad.
BtrUonde »/ tm'rmrf, duty
in ioctioii of 7 MU of a I m S^M)
•alutjan.
H (Jutiu'iui- tiul)itiati«, gr. x.
Tiiicttirw" rjtinjOiarw earn*
}""'■'■■ -iv.
!)«•• 1 5j.
llm." iKiDJartind
jmji" !»' ra>wp| ha* bam
" out with l\ laal <rf
ima«r. (/"ejruJlrr)
r'rmltii, I dram to apioi of
WntiT. (WmtMm.)
.Mum, i <ij. fi> } pint nf wxtn
t» i'f ■l/iily I Ih)^'-"—
in U <». trf vaicr twio* daUjr.
(JtkuUf.)
SulutMU tf fvpfrr, 10 gnaw
1 drum of laodaDsm aad
FOKMUI.^
•Ottli
t| 0*. of water. ( £a*y-)
H Argtmti nitzmtia, gr. ij ad
gr. riij.
(Fur cbildicB, gr. jn.)
Aqm> de^lktv, i*.
To naake four iiiiiBMti, twf'
to he p^tm daihr. ( fi«aiaprr.)
H Kaphthalioi,' gr. Ixrr.
OluotiTa-, »T.
To be injMted higk M Omc
or fonr tna a day. (JVuwrK )
SuppocitMlM
>ii» I hi n, I ia Cm* «•
likljAi.
(<— <«r>i r.) •■et«rt«««a4ay.
a6S
CflAPTER XII.
DISEASES OF THE INTF.STIXKS— THK TRKATMRST OF
IN'TKSTIWL OIISTIU'CTION.
Intvstiiinl I Histrurtimi, Arute and Clinmii:: lU Xaturw anil Svnt
often <lifliciilt to a-trertaiii — It« Cuitscs : (1) Aci'uiutilatious
within the Canal : (2) romiirmsion or t'oustrictiou (rniii witli-
out : (3) Striotiirc, Malignant, Cicatricial, or PfTitonitir : (41
Straugulalion or Inearccration, KxttTnal and Intenial : (i)
Po^itiouul Lesions (Intus*usooption. Twisting. Kinkiiiu. ctr.^;
(*!) Panilytie or Suli panilytH' Condition of tli>; lnle!<linal
■ WalU. Iiuiijnmlir Mwuiuri'S— Rectal Exi)lonitton--Ext<<rnal
Mauipnlation— PcrcuMJon— Ociiiral Symptfims- .\cutf In-
tuasusct'ption — It« Symptoms— UaIl-Stoni'R—I*reviou« At tack*
of Peritonitis. Trmtmnit of Simple Compression or Traction
— Fa'cal Inijmction- .Stricture — Cantion in n»»e of (Ijiinm —
Needful in Acute Cu-wit — External Apiili<ation!< — Icr —
Wiirmth— Opium— Taxi-s—Ijarge Eiieniatnof Warm Walt<r—
InttiFsufTCption Ca«e8— Injection of Air -I'rolonjr^l Warm
Baths— Puncture to relieve Distention— Nutrimt and Suji-
porting Enematii — Operative Measures — Diet.
Obstruction or closure of the intestinal canal inay
ftii.se from a variety of causes, but certain Kvmptonis
are necesstti'ily ctimuion to all. The chief I'liiiical aufl
symptomatic distinctions will depend upon wjieflier
the closure of the intestine has lieen brought about
suddenly and unexpectedly, or slowly and gradually ;
whether, in short, it is what is termed ncuU or
chronic.
Certain diflerence* also in the clinical nianifesta-
tioiiK will ariso according to the situation of the
obstruction, i.t. according as it 18 situated in the
up])er or lower part of the intestinal canal, and
further, iiccortling to the cunipleteness or inconiplete-
iiess of the obstruction.
Although from the similarity, and, in many in-
stAncc<s, the identity of the phenomena at tending those
ca.sos, the trejitment ai>pr'>priate to them is the saiue,
even when their causal relations reuuiin obscure, yet
in all instances, in order to institute the most appro-
priate treatment, it is desirable, and in many cases it
is essential, to arrive at on accurate estimation of the
IciM|i.xiii lifrEsriSAi. OnSTRUcrioif.
3 ft 9
-nature hihI sent of the obstruction. It will, th«ix'fore,
be necessary to- review briefly the chief oiiusen of
intestinal Dbstruction, unil lo mention wluit<?ver flis-
tiiictive symptoma linve lieen observed to eharacteristi
the diffi'reut varieties.
1. The intexfiiial cnnni miiy be Vtlocked by Hub-
gtances that have nrrumnlntt'd within it, !<uch iu
iiidigestilde sulmtuiices tiikeri «ith tlie lowl, nr foreign
tKMlies of any kind, iu8olul)le iiiatters taken in the
fonn of inedicities (large and rejieated doses of
peroxide of iit>ii or magnesia), masses of int'CHtinal
•u-orms, or of indurated fa-ces, and by large biliary
and intestinal concretions. (Oallstones large enough
to olistruct completely the «inall intestine sometimes
ulcerate their way from the gall Itlarlder into the
iiitcstine through the wullsof both ; calculniLsdepoMitH
also ocoasionally form within the intestinal canal
it-self, composed jji'iierally in great jiart of concrt^tions
of phosphate and carbonate of lime.)
2. Tlie intestine may be obstructed by rom|ir«'«-
i»ioiifir»'oii»lrirtiOM:irising(v<»THrt//»/toit. 'rninouni,
glandular, vascular, or visceral, l)cnign or malignant,
or displaced vist-era, may comjiress adjacent intestine,
and caatie its partial or complete occlusion. In this
way the rectum may be eompres.sed by a displace*)
uterus, or by a uterine or other pelvic tumour.
Sometimes one [lortion of diseaNed or displaced
int<>stine may i^mpress another, either fiy its own
weight, or liy dragging on its inesent<-ric attnrhm<-nt,
3. Strii'tiirt' is a conimoti cause of ol»8truction,
e»|K'cially of the rectum and Urge intestine. ThiK
may lie, and frequently is, malignant, and ilej»>ndent
on a cancerous growth in the intestimil walls, or it
may Iw simply cicatricial, the result of the healing of
dynentric, syphilitic, or other forms of intestinal
ulceration. Simple liypertniphic stricture is rare.
Oljstructing j>olypoid growths (xcasionally occur.
Stricture may also depend on chronic perit4initis
matting together piortions of the intestine and con-
stricting them.
270
Medical Treatment.
Win I.
\. OliHtrueliou may lie due to »traii|;iilnlion or
iiicHrc<*rulioii of the intestine, aj in heniia-. Ex-
ternal lierniiil protrusions iire obvious, ami readily
rccojfiiiscd, but the stran^ulutiou may be xnttnuil. A
portion of intcsttiic insiy gt-t incarcerated by fibrous
lianils strctcliing across it^the result of furnitT
pt'ritonitia ; or it may get into an accidental or con-
genital li'ssure in the omentum or mesentery, or into
some; natural aperture, as the foramen of A^'inslow,
or one of the oi)ening8 in the diaphragm. <)r strangu-
lation may Ik- caused by the venniform appendix or a
diverticulum from the intestine becoming adherent by
its free end, anfl so fomiing a kind of ring in which
the intestine may be caught.
5. PoNiiionnl Ivslons of the intestinal A^-alk
Under this beiuling we must group cases of ix/i/o-
nucepliun or iiifugimition, as well as those dei>endent
on ttrisluig, roliilion, or a giidt/rn hend of the intestine.
(J. A itiirnlylic or »Hb-pHrnl)tir condition of
the intestinal walls. This cijnditiou is dependent on
a vaiiety of causes —as (<i) local injury, surgical or
accidental ; (6) fatty degeneration of muscular cojit of
liowel in certain cases of e.xcessive obesity ; (<•) hysteria;
(d) the degenenitivo changes of old ago ; and (t)
extreme nervous and muscular exhaustion following
infective fevers.
It is aj)piirent from this survey of the various
causes of intestinal obstruction that a great nunilxir of
these cases are not amenalile to wiliriiud treatment,
and that they can only be remedied by surgical inter-
ference. If it were possible in every case to, at once,
determine with accuracy the cause of the obstruction,
we should be able to summon surgical a.'^sistance,
and by eurh/ operation many lives would prolwibly Im
saved. Hut this is not po.ssible, an<l in many
instances it is only after the failure of sucli meAsures
as wo shall |ire.sently describe, to overcome the olistruc-
tion, that we are enabled to conclude that the lesion
is of such a nature as can only \>e reme<lied by sur;gicikl
operation.
I
Chap. XIJ.l IXTESTjyAL OBSTRUCTION.
271
A thoit>ugh and systematic examination of every
case will, however, usually eimbie as to arri\'o at an
approximately accurate liiiigiiosis.
We will aSKuriiH tliiit the jwssibilily of the fas<.'
lieing one of acute peritonitis has been consiilered and
eliminated, and that the possible existence of a
strajigulatetl external hernia has not been overlookeil.
In an old person, or one of middle age, the
frequency of obstruction from faecal accumulation,
or from stricture of the rectum, will point to the
prfj[irietj' of an immediate digital examination of the
iTctuni, which would at once detect the existence of
a fwcal accumulation or the presence of stricture,
llie histoiy and previous symptoms of the case would
lurroljoiate tlii^ c^tnclusion. Obstruction from fwrni
nrrnmiilalionti is usually preceded by habitual
constipation, and the occasional jmssiige of very large
motions. Fa'cul tumours may often be felt in tlie
course of the colon, and we may tind that u like
attot^k has occurred liefore, and been relievetl by free
evacuation of fiecc«. In stricture of the rectum,
malignant or otherwise, the previous history would
afford abundant evidence in corroboration of the
inference from hx-nl exploration. Pelvic tumour com-
pressing the rectum would also Ix! det<.<cte<l by careful
examumtion made by the rectum and vagina, together
with external manipulation.
If the iMitient sliould be a child, and the caw be-
one of intussusception, a rectal examination woultl
also l>c of value, for if the invaginatcd mass had made
its way into the rectum, as it sometimes does, we
should Ik) able to detect its presence tlier*.
Much assistanco in diagnosis may be derivi'd
from the consideration of tbe mode of onset of the
olistruction, whether acute and sudden, or chronic
and gradual ; we should also endctvour to determine
whether it i.s situated in the small or lari;e intestine.
Severe and early vomiting, iiitensi> pain, scanty
urine, and, generally speaking, the acuteiiess aud
rapid progress of tbe case^ point to the small intestine
»7»
Medical Treatmhnt.
inwtL
as the seat of the lesion ; while less severe pftiii, 1
temleney to \ornitiiig, ami average flow of urine, alsal
a gradual unset and slower projjress of the case, po
to tlie probaViility of the obstruction being in the In
intestine. Evidence on perciis.sion, over the lumbar
and cpii^astrie regions, of great distension of the colon
wuiild iiittundty [loint to the obstruction iM'ing in tlie
large inti'stlne, while, on the other hand, evidence of
a non-distended and contracted condition of tlie
colon would indicate that the oUstmction whs in
the small intestine, a conclusion which would Ik;
strengthened by the presence of much distension and
tlatulent i-otntnotion in the umbilical and liyjiogastric
regions.
If we are satisfied that the obstruction w situated
in the small intestine, and if the patient is a young
child, we should first think of liiliixsuscrption. This
is usually acute, the rare cjises of chronic intus-
.susception iieing conmionly observed in young adults
The chariicteristic symptoms of intiis»n»f4>ptioil
are sudden and severe, but intermitting, colicky pains,
diarrha'tt and tenesmus, with mucus and blood in the
stools, the detection of a sausage-shaped tumour in
the aWomen, increasing in size, ^md changing its
position, and the possibility, occasionally, of feeling
the terminal part of the invaginate<l gut in the
rectum.
The diagnasis would be confirtued if we found
gangrenous shre<ls, or a complete cylindrical portion
of intestine passed prr rtnitm.
Otiotrnclwn In/ |riill-«lont> is usually situated in
the small int<'StiiU', Ix-tween the. finixlenum nnil the
iliociecal valve, in the neighbourltoiHl of which it nniy
Ije aiTested. It usually occurs in middle-aged women,
and, in favourable circumstances, a correct diagnosis
seems possible. It would be founded on the occurrence
of the symptoms of obstruction imraetliately after a
severe attack of biliary colic with jaundice, and, pix>-
bably, with a history of former attacks of obstructive
J'
Lundi<
Chip. XI 1. 1 IXTESTISAL OnSTRUCTiny.
273
The lijstorj- of previous attacks of |>eritoiii(i«
will lend probability to the existence of lulhesions
between coils of int«*.tine, or the presence of con-
striction from bands of adhesion. But these, nnd
many other conditions, such as twisting, strangulation,
etc., it is impo8.sible to diagnosi' with any ajtproacli
to certainty. The j)o.ssibility of filling tlie colon with
fluiii enemata is another means of distinguishing
whether the obstruction is in the small or the large
intestine.
Carefid physical examination of the alKloniitiul
ca\-ity should enal)le lis to detect the existence of any
tumour capable of causing obstruction of the int<>stiiie
by compression.
In con.sidering the ironlinenl of cases of intfis-
tiual obstruction we shall detil with the simpler ones
first.
When the obstruction is ascertainetl to Ije caused
by the compri'ssioii or Irnrtion of an abdominal i>r
pelvic tumour, or an cnlargs-d or displaced visciis, our
cBbrts must be directed to the mechanical removal uf
this pressure or traction. Wo may tw enaliled by
manipulation and posture to shift the position of a
tumour of the abdomen or pelvis and retain it when-
its pressure M-ill Ix? removed, if not jiermanently, yet
from time to time, ho iw to H«lmit of the introduction
of an enema or the action of a laxative. The pressure
of a cyst may be relievetl by puncturiug it, that of n
displaced womb by its replacement. Tn such ca.se8
it will al.so bo necessary to soften any accnmidntion
of fii'ces above the point of compression by gentle
laxatixes and by largo enenmta, the (piantity of fluid
injected being regulateil by the situation of the
obstruction. Warm soap iin<l water, with 2 or 3
tablespoonfuls of olive oil added to it, is the best
enema to us<\ Iftherelms b<'en a prolongi>d retention
of fieces .so that they have become very hani, and if
there is no great urgency in the ejise, it is often a good
plan to inject witb a long tulie, pusMed up ixx far a.s
it will easily go, t ounces of olive oil, an<l to let it
8
274
Mhdica l Tkea TMEA'T.
IPmi t.
remain for twelve or twciitv-four hours, when n lHrf<e>
enoiuu of warm soa]) mid water may Ix* Kiveu iinJ
repeated until all the hani acoumulateil fji'ces have
been evacuiitod. A tabIesp(X)nful or two of castor oil
iuixe<l with a little warm milk may ut the same lime
be given, or 2 or 3 ^'i-ains of calomel follnwetl by
a draught containing 3 or I dran\s of so<lium sulphate
and i an ounce of tincture of senna in 2 ounces of
peppermint wat*r. After the bowels hiive thus Ijeeii
thoroughly relieved it ni.iy be desirable to i,'ivea daily
aperient, so as to keeji the motions senii-tluid or soft,
and prevent future accumulations. A teaspoonful of
a confection consistiii]^ of ei|ual parts of the confections
of sulphur and senna of the RP. may answer this
purpose ; or a daily dose of two or three teaspooufuls
of fTarlsbmi salts dissolved in half a pint of hot wiiter.
The diet, also, should be so arranged as to favour
Huidity of the motions.
When the ol)struction is due to iin|>ii«'iioM of
firrosin the Iwrge intestine, tlie indicaiinns for treat-
ment are obvious, and easily fulKlled. Hard fieculent
accumulations in the rectum that can bo re»ic)ied by
digital exploiiition may reipiire to be broken down
and removed by the HngcM', uideti by a metal scoop or
any suitjible Vilunt in.strunient. Tlie rest of the treat-
ment for these cfuses and for the accumulations higher
up in the large intestine must l>e conducted much in
the same manner as that just riescribefl for accumu-
lations from compression. Many, and rapidlyrepente«l,
largo enemata, intrixluccd high uj) by means of a
funnel and siplnui tube, will lie retjuired to get rid of
a<'cumM hit ions in the tirst and second portions of the
colon, aii<l the enemata must be retained as long aii
possible in t>r<ler to exert I he necessary softening efiecl ;
they should, therefore, l>e given in the knee and left
shouhler |iosition, with head and shoulders depressed;
or the pelvis may lie raised on hard pillows or cushion.<i.
In thi.s and in all forms of intestinal obstruction the
• •ueiriivta should Ix- given by the meilii-al attendant
hinjself, who will know how best to promote the
. MI
/.V TES TtKA L ObS TRVC TIO.Y.
275
>iit aiid retention of the iiaid. Gentle laxatives
should l>e given at thp same time l>y the nioutli, m
aJiove desoriliod.
Ill obsiriKtioii from glricttirf. which is usually
situated in the rectum ur sigmoid flexure of the colon,
if llie stricture is imiia-ssuhji-, which is r»rtlv the cane
at first, an operation must lie resortrd to for the
relief of the ohstruction liy making an artificial
anus ; but if the ulrirlurr is not complete, and if
it can Ihj reached hy the fin^r ur a ret-ial liougie,
it may be dilated and the accumulutionH aljove it
softened by eiit-mata of warm water or warm .soap
and water with olive oil, or an enema of olive oil
alone, at lirst, as already mentioned, wliich may be
injecte<i by means of a small IuIk; jiasscd throu(;h
the stricture. At the same time, laxittive medic-iiieo
should l»e -{iven lo coftcn and miike lluiil the evacua-
tions, and thi'su should Xte continued so long as tlic
ulrirlurr remains.
tSimulfanrousIy in nil these cases, if much alt-
dominal pain exi^tJ^, iis may be the ca.so from
Itatulent riiHtenijion of the intestine, opium must
lie jriven to relieve the pain, but only «'• miiall
quantity, and just .suflicient to relie^~c the pain and
no more ; 5 to lO minims of liquor opii sediitiviiN
may be given with a dose of castor oil, and repeated
with a tiecond dose if the jiain is not relii'Ved. Or
a hvpodemiic injection of J 111 of a grain of hydro-
chloride of morjiliine, and , ,'.i,th of a grain of
snlphnte of atropine may be given, and repealed
after three or four hour«, if needed.
Hut in these foniis of intestinal obstruction it
is exceedingly important to In- .sparing and eaieful in
f-lhe use of opium, iind to reniemUr thai it is better,
when possible, to relie\'e them without the use of
opium at all ; for opium tends to paralyse the
muscular walls of the intestine, and if given in
lai^e and repeat^'rl do.'ifK, eKjirciiilly in old peojile,
it will i|o this so edectuully (li:it it will be exceed-
ingly dilllcult to njuse the over- distended and
276
Medical Treatmbnt.
IPml.
paralytic intestine to activity, and afipcal obstruction,
especially when situated high up, may he rendered
iiiinio\'al>le, or, at any rate, very diiiicult and tedious
to remove.
Necessary fus the judicious use of opium is in ihe
treattncMit nf mo8t cases of intestinal ohstruction. we
have seen iinicli harm result from its indiscriminate
employment, and we consider the common dogma that
" in intestinal obstruction opium is our sheet anchor "
mischievous and dangerous, for it leads the young and
inexi>erienced practitioner to give opium largely and
indiscrimiuatoly in all these cases.
The same objection does not apply in the same
degree Ui bi'llntloiiiisi, and Mr. Bryant has warmly
advocated its use in these cases, applied externally,
the extract mixed with glycerine, and given internally,
with or without opium.
In all ca.ses, however, of arale obstruction, or
obstruction attended by acute symptoms, suggestive of
enteritis or peritonitis, or intestin-il s|>asm, opium
should be given, although it must honestly be
admitted, seeing that nine out of every ten such
eases end fatally, the opium, in the great majority
of cases, simply contributes to euthanasia ! Dr.
Hunter ifcGuire, referring to the use of opium in
these Cases, observes : " To carry it farther thin
sliijlit narrosin and art'^st of the most painful
ai/iiiptdniK of iilmlruciion i* an nhitsf. of thf.
rtrm<:dij. Hy such abuse the symptoms will be
masked, anil botli patient and practitioner do-
ceivwl."*
The application of poun<led ice to the aUlonien
in acute strangulation of the small itttestine is said
to have been attended with good results ; it lessens
the risk of peritonitis, and has occasionally over-
come the ob.struction ; but warm applications are
generally more soothing and grateful to the patient,
such as hot ftiinnels or a hot linseed-meal poultice
well sprinkle*! with laudanum.
• I'i'Jiiht'9 "System o( Practical Meiliciiie," vol. ii., p. 86.1,
t.1 Js'TESTisAL OnsiRVcrioy.
Alxlotiiinal Uixis hns Ins-n |iii>|ily c<>iiiiiii'ii(lfi| ns
afTortliiig n chance of overiinnini; (In- olisl ruction, if
applii'il I'arly, licfore tlif sliHU^'ulntion Iuih Un-n fixed
liy iiilliimniatory adhesion : it Iiiih Ix'Cii uUvnijitin] in
the warm bath, or with the patient under chloroforiu,
or while heing j^ven large pncinata of warm wiitt-r. It
oh^-ioHsly afTonhi a clianoe, but quite a Ulind chance,
and anless applied very gently it may do bartii by
compromising the success of 8ubftc<|U(<nt nperaiive
nicausareit.
Obstruction from a Iarg« gall-ettoue, iiufiactecj
in the small intestine, has been gucc<>!(.HfulIy In-atrd
by rest, small dosc^ uf a|)ium, and abdnmiiiid
iiMamges.
The occasional value and uxefulnewi of lar^e injec-
tions of warm water, even in acute obstruction
, aitiiated in the sniall inicstine, is adtuitte<J, and no
operation i^hould be iitteinpted until this
has betm tried. The wat«r may be iniro-
duce<l by means of the syphon tube and i;liu« funnri,
the patient being plact><l in the kni-e and left xhoulder
position, with the head depresHcd and the buttock*
raised. The injection should be made slowly and
^ulualh', so as to allow time for it to pa«H ilin>ugh
the eoils of inteslinc
Caaeanf inliiMi>iikr«>|tlioii r<*tjuires|M!ciaI cunsider-
ation. When n definite diiipiosis citn be made and in
the case of ile<>-ca>cal and colon invai^ination it i>4 often
possible to naich the lower end of the invaKiiiated
iiowel by digital exnminatiun in the rectum — or when
the presence of the |ieculiar tumour, and the di<H.'harge
of blood and mucus from the bowel will diHtingnish
this from other forms of obstruction ; in hucIi caw>it,
after quieting the patient, and relieving piin by tlii'<
use of opium (in »mall dof>es in children), att«nipt«
must be nia<le to reduce tlie invagination me<.-hanically.
In order that these may I* sucj.r's»ful, lliey munt lie
made early, Iteforc time has bcim allowed for the in-
vaginatcd portion t<j become adht.-rent or gungrenouN,
We should first push back the mass in th<;r njclum vixlV
278
MEmcA I. Tkka tmext.
I Pan I.
till- fitij^ors, or ii K[>oii<je sminrl, tin- npunge lH>iiig woU
oiled, mill {i|i|>lif(l with tiriii Init gentle )iri',s»ur<'. Jly
this means we may iMirlially rt'ilnce tlii? invjigi nation,
and wc sliuulil then endciivour to complete it by the
injection of a considerable c|uantity of warm water
or of air. It is usual to Hrst place the patient under
the influence of an ainetithetic, and in a position which
will mechanically Jiivour the replacement of the
intestine. The air may lie injected l>y means of a
riUtKl's insiitlhitor. Air is Ijetter than water in these
cases, and succe»s has not unfreijiicntly followetl
it-8 use. Serious and fatid accidents have, however,
also att<'nded this forcible inflation of the intestine
with air. It is only applicable to quite rtetnt
oljstruction.
Prolonged warm bntlis have lieen found to relieve
the pain, and may certainly favour the reduction of
internal strangulation.
For the relief of the extreme distension of tho
intestines by pent-up gasos, which cause so much
distress in many of thewo cases, punctures with a fine
exploring trocar has been advocated. Tlie trocar
should be carefully disinfected by pas.sing it through
the (lame of a spiiit lamp, and then dipping it in
Ciirbolic solution, and it should be phinge<l into such
parts of the intestine as api)ear from p<'rcu8sion to
lie specially distended and superficial. By removing
the occunudated gas wc relieve the intraintestiDul
pressure, as well as the dysynia'u caused by the
mcteorism. It must be reraeml)ered that the tnKar
may sometimes pass between the coils of intestine,
but this is of no consf(|ucnce, and when there is
great distension it cannot lie ditlicult, with care, to
avoid this. This method is, however, condemned by
many " becau.se of its bliiidn<'ss and inadequacy."
An important point in the management of these
ca-ses is to support the strength of the patient and
warrl ott' fatal collapse by the lulministration of suit-
able nourishment. When the olMtruction is high up,
auii tlicre is much vomiting, it will he necectiiitry to
Ckip.xii.1 JimsTiifAt. Obstruction.
279
luive rocour** to frrviuoiit small ••iiPin.'vta nf iinirri-
tatiiig HuljutaiiecM. A few ouiiceK nf warm jK'jitoiiiwd
milk or l>eff-i«i, wiih a kiiuiII iitiuritity of litiituly, will
iswer tlic purpose liest. A little iced milk or iced
oH'ce Olid milk may be given by the mouth if ugree-
ible to the patient, and if it does not excite vomiting.
When thiTc is st,crcoriicoou.s vomiting greiit relief iw
ofU'n ntfoiYlcd by ii-<uJiiii'i nut thr gtonuvh with some
antiseptic tliiid, such ns a sutuntted siolution nf boiic
acid at a teiuperatun- of 100 to I (»;")' F.
" In some cases it pnxluces not oidy relief, but Ib
iibsoliitely curative. L'ursolinmnn ranks washing of
the stomach next to opium iw 11 palliative and .urative
DnL , . . . Plain wat<»r may lie uxed, or a normal
' solution, or miJd antiseptic lotionti.''*
But in inuHt uuse» of aculf obstruction, esjit^-ially
when it seeius to be in the small inti-siine, or pwsiMy
connocte<l with disease of the vermiform ii[ifK'ndix,
kt^>ping in mind the great mortality that attends
tlii'sp cases under ordinary medical trealirient, w»'
should not hesitate to recommend early recourse
to surgical exploration. We would rejieut our
caution as to the use of opium. This drug, when
given in large doses, is apt to east a delusive calm
over the aajtcct of the case, and to leail to n falw;
sense of security ; the fHct that nine out of every ten
such cases end fatally gives little stipjiort to the
extreme laudation which this dntg Uoa tvcfi\m\.
When given in large r|uatitilii.*s in cusnt of fveal
impaction, it induces a sulvjiaralytic condition of the
intestine and protracts recovery gr>.-atly. and, we
believe, tends often to au erroneoua diagnociit a* tA
the nature of the obstructiou.
It is a good rule in nil castia of inteiitin«l obiitmc-
tion of a doubtful nature, eitpecially wbnn tb«i ttnml
and the symptoms ait- acute, to iwek •orgio*! advM*
and co-operation early in tho caae, and U> ragtrd opiain
aiuiply «s a temporary calmative. Moreover, in thijM
* Profeanur E. Mkrtiu. in '■ Hu«'* 9]n>t«m r>f Prvtl/al ItiM^
{■eutici" (weood editiuii), rot. iii., p. in, V\iA»»\r\^»y V*s\
Medical Treatment.
ItUrtl.
few cases of eicute obstriictii)n wliicli rfcovor without
sufgical iiit4>rferenc(', it must always be iloulitful
whetluu- tliore has bcfii im ni-tual mechiinical con-
striction of tlie Ik)wo1, ami whether tiiey are not
simply instances of faH;al iiii{>uction. Treves observes,
and no doubt with reason : " In not a few
instances the previous treatment has compromised
the success of any interference by ojKjration. The
engorgement of the bowel lias been increased by
aperients, and the normal rfjU.jxs liave been im-
paired or annHiilaled by excKgnive doses of ojiiiitii and
bfl/adoniKi."*
In the tnoHt iiritont runes of acute obstruc-
tion, as Treves ]ioints out, the chief object of
surgical interference is to relieve the "dangerously
engorged liowel above the occluded part," and tlie
removal of the cause oj obstruetioii may, and indeed
in many cases must, be postponed.
The engorged bowel is " filled up to the very
stomach with a foul and fjeculeiit fluid, by which the
patient is being poisoned. The gut is paralysixl, the
norniml reflexes are lost, there is no peristaltic wave
to free the many bends and twists which roust \te
uniloiK" to secure a free passage, and the patient dies
with some pints of the foulest and most putnd matter
still lodged in a viscus possessed with an instinct to
absorb its contents." It is the complete evacuation
of tliis that is the urgent matter.
" Eiitvroloiny," Treves goes on to say, " may
appear to be a somewliat unsurgical proceiliire,
and not a very brilliant or complete opei-ation, but
still it can claim results which appear to indicate the
direction in which surgical measui'os should tend."
No ana'sthetic should be given in these cases.
The abdomen should be opened in the median line
below the umbilicus, and an enterotomy performed.
"The incision shoidd be its small as possible, just
large enough to allow one distended cod to Ije drawn
forwanl with the finger. There should be no search-
■ " tlpenitire Surgery," vol. ii., p, 380.
XIU I.WTBSTttrAL OtlSIKOCTIOX.
381
injr fur tin- ciitiw* of Ihe oli!itructii>ii. Kvery iiiiniiU-
18 of (.•ons<'(|iieiire. The IkjwcI is ra|)i<ily fixed to the
[tarietiil wound l)y n ft-w sutures, which do not pent'
trat* beyond the suhmueous Ofuit, and the gut may bf
best evacuated by a large trtK^ir and canuitt, to th«i
end of which a long indiarub>>er tuUi is fixed. Thn
contents of the gai are thus carried away from tho
wound. A way for the trocar tlirou>;li the outer coats
of the intestine must lie made with a .scalptd. Am
the bowel is emptyinf; itself, it may be more accu-
rately secui-ed to the njiirgiii>i of the parietjij wnutid
by a few more suturea" The stomach should \to
waslied out, either before or after the o]>eration, with
hot water cuntnining Home boric uci<i in solution.
The pulse is iwprove<l and the patient revivetl by the
hot water. In less urgent casi's a rapid search may
be made for the obstruction ; but if thiit ih not quickly
found no time must be lost, and the bowel should be
immediately opened.
In other cases still less urgent, after washiDg oiit
the stomach with hot water, an ani>«thetic may I*
cautiously a<lministere<l ; it must not, however, h©
pushed to complete insensibility. An incixion should
then 1k' made in the median line between the umbilicuji
and the pubes lanje fitcurfli to admit llir hand, and
search made for the site of the obstruction. " As
soon as the alidomeii has ljc«n opened thre; lin(;en)
may be introduceti, and the ciecum examine<L" If
empty, the obstruction is in tJie small int<stine ; if di»-
tended. then protxibly in the colon, an'l the direction
of the further search is detcrminMl accordingly,
" After the cause of the olMtruction haa been found
and relieved, it will in very many inatanceN still l«e
wi.Ht^ to evacuate the distended bowel. The opctiin;(
made may b«" c1os*h1 ais Hoon as the gut is ironiii'b'red
to have Kutiicie 11 tly emptied itself; but it may with
greater safety be left ojx'n for tin- time l>eiiig, and if!
cloned by subsequent openktion."*
* Further precoe dcMk will bp found 111 Sir P. TravW «<>tV.
'Iri-iwly meiitionad.
282
MF.DICAt. TRF.ATMBirr,
(Pan t.
All iiiiiiactc'd (/aUslori'' or piiterolith iiiiiy ixissililj
lie brijkcn up or cruslii'il without ojH'uinf; the iiitpstii»e,1
but for this purjwsc it must be moved l'it)ni the sent
of iin])!iction, where the intestini' may be inlhiiiierl,
ulcerated, or gangrenous. It should Ihj moved up-
wurds into the distended and bealthier bowel, anil
dealt with there, either by crushinj^, or, if this is not
practicable, by removal by an incision in the fre<!
bonh-r of the bowel, au(l in iti long iixis. If tlie ifut
should be gangrenous at the obstructed part it must 1)C
resect<'d, and an artificial anus established.
In cases of jmnili/fii; dist^^usion the pa-wage of
the rectal tube is often of much service, especially at
the onset of such castas. " It excites perisUilsis, and
by overcoming the resistance of the sphincter, relieves
tension by allowing <|uantities of gas to escape." In
sucli cases also MuUite purtjiUivf» are of gi-eat utility.
"Administered in the first stage, before paralysis
has fairly ilcveloped, they seem to have the power of
re-establishiug ])eristalsis, of restoring tone to the
muscular coats of the bowel, and of sweeping from
the int^'Stiiial tracts the partially-digested matter
rii>e for fermentation aufl putrefaction. . . .Salinen,
then, should be aduiinist^^red freely in the Ijeginning
of this form uf obstructiotL''* They must not, how
ever, be used in adNTinced cases where vomiting has
set in ; in such cases the faradic current, fidl dose
of strychnine, lavage of the stomach, brandy /jrri
reHitm or hypodermically, and as a final re«ort —
when death seems imminent from septic atjsorption
or over-distension— we must have recourse to lapar-
otomy and incision of the bowel, anil formation of an
artificial anus,
In cases of chi-onic obstriu'tion, when the iliseaa
is in the colon or rectum, colotomy, tumlint or iluiCt^
is usuallj- peiforiued, and an artiticiiil anus eKtablishcd,
For fuller details as to surgical measures we must
refer the render to modern works on operative surgery.
* ProfosMir K. Mnrtiii, in " Hnre's .Syalv.ii uf Practical ThtT
peutia " (iecond wlilicm). I*liilailcl|jliiii, \W>\.
CJup. xii.) Inirstinai. Obstruction.
t%\
Willi ri'j«(ioc-t (o lAV/ in cases of aouU- olistruotion,
it is obviously irmtioiml tu give footi or drink liy thf
mouth ; lit most ii littlt' icc-wutor may U? sijijied or frag-
ments of ice sucke<L Not only is thci-e no digestion
or ftliHorption l>y tlie Htuniacli, but any food introducwl
into it will provoke fresh vomiting, and add to the
matter undergoing decomposition in the intestine.
Peptoni-icd fooils (milk, lj<<ef, eggn) and stimulants
must !»<• given /»er rfctmii. To relieve thirst. Pro-
fessor E. Miirtin reconmiPTuls injecting a jiint of
normal .sitline solution into tlio loirer howel every
2 hours. To relieve threiitcmtl cardiac failure and
collapse, he giveH, "by means of a fountjiin syringe
and H fine canula, 3 oz. of whiiiky, dis-Milvwi iu '1 pints
of warm 8tt<rile saline solution, tlirown by gravity
into the loose cellular tissue of the loins or buttock*.
By gentle friction ovej* the scat of injection rapid
ftbiiorptioii is obtained."
284
CHAPTKU XI IT.
DISGARER OF TIIK INTKSTINKS — THE TUKATMRNT OF
INTESTINAL PARASITES.
Panisitic Worms jMH^'iiUar to Mim — TajH'u-ofmM : Symptoms —
Diiufi'™'". Tmlmeiil — Prepiinitnry — Vennicidal — Filix Miw
— Koii!»o — r<)mi-gnumt<! — PelUitiennc— Tiirpciitim- — Knmiila
— Piiiii]ikin Scwls— Tlivinol, Chloroform, et<'. I.innhrtri, or
Itniniil lloimt : Symptoms — 7'r>«(iH<«<—Snntoiiiii — Kiirajil«, '
(ixi/ufi> rermtntlai-iii, or Tftnuiiirvrm : Causes— S\^n|ltonul — I
Tinilmriit — Diflicullies — Eiu'iiuita — Suppositories— Purpa- "
lives — Tonirs. Titehuei/>haliii> liitpar — Aneh^lnilommi) iWO-
tifiiair, AdiiitioDol Formula:.
TiiK successful ti*eatment of intestinal parasites
(le[i'*n(]s on its adaptation to the different species,
aiic! requires a knnwlt'ri;ije of the habits and mode
of develo|itnent of each kind. Prophylaxis also
must lie fuunded on a thoroui;h knowledge of their
natiirai hialory. Cieiinliness and care in personal
liftliits, .iiid in the selectiini and prefKimtion of foo<l
iiiiil drink, will, however, certainly jiroteet us from
many species. Atl animal food should lie sulficicntly
cooked, all .suspected water carefully filterctl, and
more care should be oljHerved in our association with
domestic animals.
The seven kinds of parasitic worms fiemdinr to
man chiefly concern us here. Three of these l>elong
to the topeirorm class, viz. : —
Tu'niii solium, Tiudih mediocnnellatA, or SHginiiln, iind
Bothrioc^plmlus latus.
Four to the class of round worms, viz. : —
Ascarjs lumhricoidcs, Oxyurid vcrmiculnris, Triohocrphivliu
dispnr, and Aiicliylostomum diiodonnlc.
TappwormN. — The mature tapewortn as it is
found in the intestinal canal of man and other animals
is a soft, Hat, white, tape like looking worm, having a
sniall head furnished with suckers, and a circlet of
hooka, by wliich it clings to the mucous ineinbraiio.
Qiap. xiii.i IxTESTiNAL Parasites.
»8S
I
A slender neck succfwlR tlio head, aiul ),'fftdually
widens into the bod}', which is compostnl of sj-jfinents
(ciillwl proglottides) which Iwconn^ iarpcr and larger
the farther they are from the neck, until they acquire
their full size, when they become detuched, singly,
or several linke<l together. The worm has neither
mouth nor intestinal canal, Imt derives its foo<l by
imbibition from the intestinal juices in which it lies.
The mature segments consist ulnirist wholly of sexual
organs of both kinds, and are, theri'fore, self-ini]>reg-
nating. In the eggs contained in these segments a
six-hooked embryo is developed. These eggs when
ilisi'hnrgi-'d from the intestinal canal, either free or
enclosed in the proglottis, for the most jwrt perisii,
but if they Ijecome 8wallowe<l by animals, as they
sometimes do, then the six-hooked embryo is set free,
and by some mpJins or other' niigriite.s from the diges-
tive canal into the liver, muscles, or other organs
of the animal. In favourable circumstances it there
a$.sumes its scolex or larval form. This usually cmsists
of a cyst, with an invprtc<l head and neck ii-senibling
that of the parent tApewoi-ra. Now, if the IIchIi of
animals containing thi'se scoliees, in an active slate, b<!
eaten by another animal,the scoliees may !« set free by
stomach digestion, anil passing into the small intestine,
the head of the scolex iM-comes everted, and fastens
on to the int4^stinal mucous membnine, the cyst (li»-
uppears, and by .successive budding another tujie-
worm colony becomes developed. This brief account
of the life history of a tapewoi-ni is siillicienl for our
present purp<3se. For a tapeworm to lie develnpi'd it
is only necessary that a living i>nibryo Ik; intro'luc<:sl
into the stomach, and this is usually done by eating
animal flesh containing them, either raw, or oioki!*!
insufliciently to kill or arrest the further development
of the
nbry
Tfriiin ••oliiini ♦ usually arise*i from eating
* Tbp Ttriit^ ntitiiH ill itft i<iiil>r>''iiM<' itato is known ria tliw
Pt/tHcnriu eitluloM, and dMrt'IU iu tlio iiitcnuiuciiliir roiiiitHlivn
tinne Hud other (wrtii of the \nft.
286
Medical Treatment.
ip>ii I.
imperfectly cooke<l i>ork, Hud To-nvi siujiiiatu from the
flesh of the ox. ChildiTn tire said to lin\ e ncquirecl the
lutter from eating grated raw-beef )^vpn thcni by
medical jirescription. I'ftnin sulimn is only found in
the huiiiim small iiitestiup, usually in its upper third,
into the mucous meiiiliranp of which the houl is
very firiiil)- iixcd, the neck and the first sojjnient of
the worm lyiii;.; coiled up in a mass uniund the head.
The worm may reach to the lower third of the small
iutestino, but rarely to the cifcuni. 1'. saijinatit, also
peculiar to man, diffei-s fj-om T. sulinm in its head not
having a circlet of hooks, in place of which it ha» a
snntill frontal sucker besides tlie four powerful sucking
discs ou its head, which is far larger than that of
T. gulium. It is a much larger, stronger, tliickcr,
and fatter worm, and may grow to n length of nearly
20 yards.
The only other tiipewoim frecjuently found in man
is the /lot/irioc-fi/iiihtM /(ttiin. It is not, however, like
the two preceding, peculiar to the human being, iis it
lias often been met with in dogs. It is the longest of
all the tapeworms that iniuibit the intestine of innn,
and niny reach 25 yards in Ir'ngth. The hciul ditiers
in form fi-om that of either of the preceding. It is
ahiion(l-shaj>ed, and hiis a lung elliptical sucker on
eacli side. It ha.s a dull bluisli-grey colour when fresh,
It dirt'ers further from T. m>liuin or T. amjiiinlti by
having its genital orifice in the centre of the brood
surface of the .segments, not on the margin, and this is
always on the same ventral aspect. The uterus, dis-
tended with eggs, ap|>ears in the mature segments,
whidi are nearly .square, or nn hnmil tis t/ie;/ nrr lunij,
83 a cnlrnl rosette-like group of jiouches (Fig. H).
The eggs, i/ left in nutter for some numths,
.develop within them a six-hooked embrya Tlipy
open by easting otf a lid, and then the embryo swims
al>out by means of a ciliatttl envelope, which is tliniwu
ofl' aft<>r four to six days, retaining .still a tnin.Hparent
albuminous coat. It.s further fate is unknown, but it
is thought highly probable that its intermediate stAtc
Ch;i(i. XIII
IsTEHTiNAi. Parasites.
t%i
of (levvlnpnieiit tnkes plncp in »ome a(|untic atiiinnl.
IjBtelj- the scolices hove been fuiind by Hraun, of St.
Petersburg, in the muscles, liver, jdkI or^mis of
generation ol' tlie pike, trout, ami Hclp<:iut, niicl by
causiiii; fills and <log» to fee<l on these the fully tie
velci|ied tiipeworni liius been produced. It would,
therefore, seem probrible tliat man might be infectiul
by enlinj; such fish raw orinsuHiciently cookeil. This
tapeworm Iwis not been found except in Europe, and
it is especially freijucnt in \\ esteni Switzerland, and in
Poland, part-s of Swetleu, Finland, St. Peterxlmrg, and
the I'taltic Provinces.
Tlie H}'inptoms due to t}ie presence of one or
more tapeworms in the intestinal canal may be bo
in.sigiiiticant as to escnpe notice, especially in the cage
of children, and their t xi.stenc»> may not be suHjtccted
until its segments are Hiseovt're<l in the motions. In
many cases, however, troublt'some syniptoniK due to
the presence of the worm in theKmall intestine make
themselvjss manifest. Va;{ue diffeiitive and nutritive
disturbances, unpleasant feelings in the abdomen,
BOmetimes colicky pninH are coinpliiiiied nf, miml
troublesome during fasting, or after (liirticular articlen
of dieL Tliew an." relieved by eating, and es|)ecinlly
by certain kiuds of fiHNl. Sensations of ravenoun
hunger, feelings of fainting, n sense of disten-sion in
the abdomen, diarrha-a alternating with oonstipation,
a frilling as if some fureign iKifly were moving about
in the intfstiiies— all these have l)ecn complMimil of
in connection with Uqxnvonii. The following reflex
phenomena have also been noticed : — Itching nb<^ut the
anus, tickling of the nose, salivation, vomiting, head-
aches, singing in the eai-s, palpitation, gostrulgia, and
many convulsive nervoiis affections, such ns chon'a,
cramp, etc.
So far as diagno-sis is concerned, it is coninionly
by the ol>servution of eegments of the worm in the
motions that we conclude a fiatient hiut ta[H'worni. If,
however, we have not had an opportunity ourselveH of
any of these segments, a mild purgative will
288
ATf.dica l Tr ea tment.
I Tail I.
usually l)ring iiwny some, if a tiipeworni reiilly i-xists
in the small intestine. Tt must \if it'iiiemberi;d tliut
it is not uiicoiutnon for patients who pass larKi" shreds
and strings of tough mucus owing to chronic caUrrh
Fig. T.— Bll"! Si^iiciit of Prui'o
Fl(f. 8. -Kii* .Sotcmciit iif
«, QmlUl ltor«. *Mavnlfttftl 6 ilteitU a, OeitlUl iKJfe. (^aifnidnl A illnm.t
rsi
PiK. '.>.-lli|n' ^hiiK'nl of ItoMrt'jMpViliti Miu. (Hhkniiu'I n <ii.im> )
of the large intestine to regard those oa portious of
tapeworm.
As Tiriiln siujiimla is said to he much nion.' dilli-
cult to exjK'l than either J'lmin nuliimt or JJothrio-
cephnlmi laltu, it is desirable, Iffort- Ixiginniiig the
treatment, that wo should ascertain which kind we
liave to deal witli. The segments of Tii-nia snt/inala
(Figs. ^, 10, A) are much stronger, thicker, ami more
o|)a(]ue than those of Trmia solium (Figs. 7, 10, d).
If we sjireail out some of the segments on a glass plate,
and allow them to dry, we can distinguish the smaller
number of lutoral branches goiug otl' from the uterus
Clinp. XI 1 1. 1
/y/£sr/.VA/. Parasites.
289
in the T. solium, from the numerous lateral In-nncbes
—from 15 to 20 — in the segments of T. soijinaUi,
The rij:)c segments of Holhriocephaltig liilita are
almost sKjiiare, and the uterus in the centre is seen in
the form of a brown rosette (Fig. 9).
The heads of these tliive kinds are also here
figurwl (Fig. 10) :—
Pig. 10.— A, IlMd nt TiTHtit mijiiutla. u, llml nl Bukrugrpiutm
Uitiu, soiiti from llic kfiU (iiufniitluii >. i-'. Thu Mime iti>tMi fruni above
(uatunU k1s#). t>, Bitlarge^J HvmI nt Tiritlit toliun.
A cure can only Ije said to be radical when the
head is found in the cvncuations, or if more than one
wonn exist, the head of each.
Occnuioniilly the whole worm is expelled in one
pitfco, as a (lenKely-ooiled mass, and the head will \>e
found hy tracing the segments, from larger to smaller,
until nt IiLSt we find the suiallest segments terminating
in the slender neck and broader lumd of the worm.
More fre(|ue«tly we tind the smaller segments broken,
and then the evacuaiion Biust l>e washed sevend
times with water, hy fwuring clean water upon it
again and again, allowing it to stand each time for
10 minutes, and then pouring it off till it is scarcely
coloured. Then we should transfer the worm, coil by
coil, tf)a vessel of clean water, and search for the head
amongst the residuum of single segments and smaller
T
290
Medical Tkeatment.
IParl 1.
fnignit'iits. If the head is not seen, it is to be fenred
it remiiins, not dislodged, in the small intestine. We
must then wait for three months (the worm requires
eight to ten weeks to arrive at maturity), and see if
any fresh segments are expelliil. If no segnients hove
been expelled, we iriny cundudo that the head was
discharged, althongk not found, and that the cure is
complete.
After takin;^ a vermicide and vermifuge dose, it
Is a good plan to direct the jiatii^nt to pass his evacua-
tions into a vessel three parts full of wartn water ;
this will greatly facilitiite the sejirch for the head of
the worm.
Before ndininisteriug the reniwly hy wliirh we
hope to procure theexpul.siou of the worm, some prc-
piiriilury tr«>nliii<-iil is advifiidile in order to give
the remedy the tie.st chance of success. It isohviously
desiratde to clear away from the intestine, as much as
[lossiljle, all the solid fieculent matter that may Ixi
present there, so that the remedial agent shall come
in contact with the worm, dihited only with the lluid
secretions of the intestiite. Wo may also hope that
the worm when detached will thus be ex{>elle<l more
quickly, and as we should have only fluid evacuations
to examine, we shouhl have less difficulty in discover-
ing the head in them than in a mixture of solid and
fluid excrements We should therefore administer
gentle laxatives for two or three days as a pre|mra-
tory meaBUi-e ; not strong pui'gatives, which break the
wonn, and cause portions of it to come away, so that
what remains may Ije more difficult to tli.slmlge.
We may give from 1 to 2 drams of sodium
sulphate w^ith 1 or 'J drams of syrup of senna in
1^ ounce of cinnamon wat*r each morning fasting,
and an enema of soa]) and water each night. The
food during these two or three djiys should \yp. mostly
fluid and concentrated, not leaving much uniligested
residue, such as the lean of meat, meat broths and
soups, with bi-ead crumb, fruit jellies, milk diluted with
water, tea, cofl'ee, wine and water, or mild beer.
Chap. XIII 1 IXTESTINAL PaRASITKS.
291
Tlie patient's l>owels Laving been completely
eviicuateil the evening or day before, and no solid
food takon afterwards, on or soon after waking the
next morning the vermicide medicine siiould be given.
The following are the drugs that have been found
most successful in getting rid of Ta^tia . —
Malt ftrt% (61ix mng] ; Kou—n, or Cnuo (the dried p^iiiicl'^
of Bntyoia luithclinintico) ; VninrgroHalt (the drii.'d bnrlt of the
ruol of Puiiica granrituin) : I'eltelitriiie aiilphatt' iind titnnntu
(nn alkiilold o)>tuini.'d (lom pumfgraniite) ; Kitmaln ; Turpen-
tine ; I'limpkin tndf (lliu soiKlg of ihe Ciiuiirbita p<'po) ; TAi/mot.
The mix mas, or male fern, is an efficient
Tieniacitie. It lias been said to Ije more poisonous
t<> the JM/irioc^phains than to the Tirniir. The
liquid extract is usually iiseH, and it is important that
it should 1)6 as freshly miule, from the fresh root, as
piissible.
It may be given in capsules, each containing
15 minims. A capsule should be given every quarter
of an hour until four lo six have been taken. They
may be wa.shed down with a little caj'i! nit /nil : or the
extract may be made into an emulsion by rubbing
down 60 to 90 minims with half a dram of conifiouud
tragacanth powder, and slowlj- adding -' ounces of
peppermint water. One-tliii-d of this draught should
!» taken every quarter of an hour.
Or the liquid extract may be made into a con-
fection by rubbing up GO Ui 90 minims with
4 drams of powdered male fern root, and a sulHcient
quantity of honey. A sixth part should be taken
every quarter of an hour.
If, after two hours, no aperient action has followed
these doses, a purgative should be given — a table-
Bjtoonful of castor oil is the best, which may be repeateti
in half an hour if necessary. A smaller dose of the
male fern extnict may Iw given to childivn, but we
l>elieve that when it fails to bring away the wliole of
the worm it is often because an insufficient dose has
been giveit
29J
Mkdica l Tkjsa tment.
I Part I,
Some prefer to combine nu iipcricnt witli the oil
of malt' fern, mid for this ]mi'po>(e fajwulen arc
miide, each coiit«iiiiu;i 7', minims of extract of male
fern and a {jrnin of calomel. Sixteen of these are
taken for a dose,two every 10 niiuutes.
Hnmberger* is reportetl to order the large dose
of 5 drams of tlie fresh ethereal extract, with an
equal f[nantity of castor oil at one dose !
KoiittKO, or Cusso, an ancient Abyssinian
remedy, has been wannly advocated by Heller, and
it is, no doiilit, an crticacious vermicide. An in-
fusion may be made of tli<: IIuwits, in coai-se powder,
2 to 4 drams in 4 oum-cs of hot water, ullowrd to
stand for I'l minutes; but tlie compressed drug
encloHed in gelatine capsides is said to act l>ctter.
If the infusion is ■ use<l it should not be strained
from the herb, but tlie whole should be swallowed.
It should be followed in less than two hours by
a purgative. It is a very unpleasant drug to take,
ami not unfrequently causes nausea and vomiting ;
it is also costly, hence it is not largely used in
England.
Heller states tliat 5 drams are needed for ex-
pelling the 'J'a.nid nolium and 7.} drams for the Twnia
sugiiuila.
Prof. Widerhofer t makes an electuary by mixing
'1\ drams of powdered kousso with (5 ifninm of
honey, and gives this in two doses : and I5.un))erger
occiisionally conibintw kousso witli male fern,
mixing Ih minims of extract of mule fern with 2J
drams of piowdered kous.so, endojiug this in 30
capsules, and giving four every ijunrter of an hour.
Koii<>*>iii, an aleuhnlic extract fi'om kous-to, ha.s
been found successful in iloses of 30 grains, and it
has the advantage of not exciting nausea.
Poincifra naif.— Tlie bark of the root of Punica
granatum lists Iwsn highly extolled by Kiichen-
* " FormuUirc de la Facultv de M^deoiae de Tienns," b; Dr.
T. Wiotho, 1888. p. 91.
t^ " FormulaiM dc U F»';ulW d.' Modcoins dn Vionn»."
Chop. XIII. I Intestinal Parasites.
29i
ineistcr. Ho directs that 3 ounces of the fresh
bark sboultl l>e juacon»tod in 12 ounces of water
for twelve hours, nnd the infusion concentrated
to one-lialf It must be tiiken within an hour in
three or four (iotes, ami if no purgative ett'ect
follows in an hour or two, a dose of castor oil
must he given. There is a decoction in the B P., the
dose of which is \ to 2 ounces.
It hs-t l>een objected to tliis dru;; that it causes
much abdominal disconifort, together with nau»ea
and von)itii)g, and of late years an alkaloid ilerived
from the bark of the poniegrHiiate root — the iniiiinle
of prllcli<>iino has been used in itH stead. This
is a yellowish white ]>owdcr, insoluble, or almost
so, in wafer, and is on that account better suited
for a vermicide than the 8ul])liate, which is soluble in
water and, therefore, inon^ liki'ly to lie partly absorbed
in tlie stomach. The dose is 5 to S grains, given
fasting, mixed with a little water. A tumblerful
of water should be drunk 10 minutes afterwards,
and half an hour later an aperient should hi: given —
either a table8]io<inf\il or two of castor oil or 1 or 2
oun<'es of infusion of .-icnnii. This has proved a most
efticueious poison to the liij)i'worm ; but it is (juestion-
able whether it may not produce toxic effmts in
children.
Tiirpoiilinf hut^ been found an efficient remedy
for tapewoim. It must Ik- given in a large dose,
and is liest combined with an e(|ual quantity of castor
oil so as to insure its lieing carried (|uickly through
the bowel, and not absorbed into the circulation, in
which case it would be likely to give rise to trouble-
some renal irritation.
The mixture usually ordered consists of 1 ounce
of oil of tuqientine and I ounce of castor oil made
into an emulsion with yolk of egg ; but tliis is very
disagreeable to take, and if we select turpentine as
a tii'niacide, it is best to get an ounce each of
turjientine and castor oil mixed and enclosed in
about 30 gelatine capsules. These may be swallowed
994
Medical Treatment.
I Part I.
one lifter the other in a few miniitoa, thp pivtient
wusliin^ Uit'iH fiown witlj niouthfiils of wniiii milk
and waU'r. If this dose Ijo tHkeii fasting it will
usually act quickly as a purge, and lining away the
dead worm.
Kninnla. — This is an orange-red powder, prob-
ably of a resinouB nature, and consisting of the
glandH and liairs from the eapsulcs of a euphorbia-
ceous plant. It is f|uit« insoluble in wiitf r. It should
be administered in dose.s of ^50 to 100 grains, acconl-
ing to the age and vigour of tlif patient, and usually
two doses are given at an interval of half an hour.
It may be made into a confection with honey, or it
may lie suspended in gruel or chocolate. An a[>erient
should be given witliin two hours. It is usually
efiScacious in expelliiiw the wonn.
Davainc prefers the liiirliire made by macerating
1 part of kainala with '1 of rectifie<l spirit for two
days, and (lltering. (The B. P. tincture is 1 in 5.)
A dram of this with a ilram of synip of orange-peel
and an ounce of cinnamon water should be given
every hour for four doses, and if the worm is not
expelled within two hours of the last dose, an ounce
of castor oil should Ix- given.
I>iiin|>kiil seeds hnve been found a mild and
tjseful tieniiicide for children, and not unplea.sant to
take. Their etiicacy appears to depend on tlie pre-
sence of a re.sin in the pcrisiicrm, to which the name
pejtoregine has been given. About an ounce of the
seeds may be given a child for a dose, and they may
be pounded up with sugar and honey into u paste,
which chihiren will r«'adily eat.
Thymol.- -Tills drug has recently been st^ated to
be efficacious in the destruction of tapeworm.
The advantage is claimed for it over most of tlie
other remedies that it does not cause any gastric or
intestinal disturbance ; that it both kills and expels
the worm ; that, compared with other rerae<lie.s, its
mlministration is rapid and simple. It is admitted,
however, that, given in doses sufficient for the purpose
I
Chap. XIII. I Intesti.val Pakasites.
295
in Wew, it jiroduces a certiiin amount of ilepression,
thu pulBe becomes more frequent ami more feelile, tbe
respiration.'; and tlie temperature are loweiinl ; it is,
therefore, nece.ssary to (wcompany it.s lulmini.stratioii
with some stimulant such as brandy or whisky.
Dr. Numa Campi has given it in the following
manner : — In the morning an ounce of castor oil, and
then during the day 10 grains of thymol every quarter
of an hour, and twenty minutes aft«r the last dose
again an ounce of ca.stor oil. A few minutes after-
wards a In-nia mfdio-cannclatn was expelled entire.
We are disposed to consider tlie«o doses large, and
we should ))rcfer in trying this drug, which is some-
what caustic, to give not more than 3 to 5 grains
for a dose, and we should make this into pills with
a little powdered soap and spirit. Two pills*, with
2^ grains in each, might lie given every 20 minutes
with a wineglassful of warm milk and water anil a
dessertspoonful of brandy. The patient should, of
course, take nothing in th(> way of food during the
time he is taking the thymol. (Jtlicr antiseptic sub-
BtAnces have been used to kill taenia, and, it is
"stated, with success- ^.(/. nn/ihlha/ine, in doses vary-
ing from 2 to 20 groins, mixed with powdered sugar,
twice a day ; and cmo/in, 15 grains in a capsule
three times a day.
The following hits lieen stated to be an efficacious
ta-niafuge : —
19 Olei crotoni)- I^iitln j,
Clilororomii .. ■ ■• 3j-
Glyfcriiii ... ... ... 5*.
Miece, tiiit niintara. Hiilf to lie taken fnattng, anil repvatod
in tinlf an hour. .Vb.^^tineiiro from fooil Dm nveninjf lioforo.
Cblorororm in lo or 20-minim doses, mixed with
simple syrujj, has also l>een said to prove oflicacious in
getting rid of tap«.'worni. A dose is given every two
liouix, and subsequently a dose of castor oil, If it
escape*] complete volatilisation in the stomach and
nwclied the small intestine, it might intoxicate the
worui, and so detach the head.
296
Medical Treatment.
IPut t.
It uiust b<> V)orne in mind, in ailminiHtering dnigs
for tapeworm, tliat ilip oKjoct in to poison and kill or
paralyse tin- worm, so (lutt it may i-elax its hold on
the int«Ktinal walb*, witliout poiiionui^ tlie jiatient ;
and tliose remenlies, therefore, wliicli are insoluble or
verj' slightly soluble in water are liest suited to our
purpose.
Infusions and decoctions which may be lai-gely
absorlied in the stomach are objectionable, for two
reasons — first, the absorbed substances may produce
disagreeable toxic effects on the patient ; and, second,
if a portion is aljsorbed in the stomach it fails to
reach the wonn in the small intestine. Hence we see
nearly all the successful ta>iiiacides «ri' i-ither oils, or
resins, or oleo-re,sius. The propliylnxix consists in
scrupulous cleniiliiiess and care in the preparsition of
food, which should be completely cooked, raw and
undenlone meats being avoided. And in n.s8<)ciation
with domestic iiniinals great care should be observed.
.4Hrnri9 lambriroideii. — The lumbrieu», or
round worm, inhabits the small intestine, but wanders
sometimes to other parts. It is cylmdrical, usually
of a light brownish or dirty white colour, and tapers
»t each end. The female is usually from 6 to 12
inches long, the mole is smaller. Five or six are often
found together, and occasionally a much larger num-
ber. Tlic mature female produces an enormous
number of eggs, which are di.scliargpfl in the evacua-
tions. These eggs have gifat fiower of resisting
destructive agencies, and probably n't«in for years
the capacity of development. We have no certain
knowledge of the complete life history of thus parasitic
womi, or how man beconjes infected ; but it seems
most likely that the eggs gain entrance to the human
intestine in contaminated drinking water. It is
much more common amongst the jwor and uncivilised
than amongst the better and more civili.scd classes,
wlio are traine<l to habits of cleanlines.i, and whose
food is more carefully .selected and prepare<l. It is
also far more common in children than adults.
Chap. XIII. 1 TnTF.STINAL PaRASITRS,
297
The prpsonce of tliis worm in the intestine is
usually tlisniivprefl liy thn uj)pearnnct' of one in the
motions, or thfv i"»y wiitnl»'r into the stflninoh nii<i be
vomittxl, or owiiaioMtilly tlit-y liiive iipjieari-il at the
ncstrils. Chililreii are, however, often su.spected of
having worms wlien they present certain synipUjius
that are othenvise tliflicult to account for, such aa
itching at the nose, capricious ap[(etite, foul breath,
colicky paiiiK, with swelling of the alxiomen, emacia-
tion, nocturnal ri>8tleRsiies8, Imd dreams, and grating
of the teeth in sleep. Convulsions and epilepsy have
been occiisionaliy ciiusod by them.
The Ireiiinn'nl of these worms is simple. The
best Vermicide for them is sitntunicn, the uiiexpande<l
(lower-heads of urdtininin innriliina, or its active
principle Mniiioiiiii. It kills them speedily and
certainly. The drug must, however, be used with
great caution in very young childivn and infants, as
it has been known to caii.se toxic symptoms which
have even proved fal-al, viz. purging and vomiting,
with convulsions and coma. Santoitiit is very spar-
ingly Holiiblo^ in water, and i.s often given in lozenges
(13.1'.), each contJiining 1 grain. The dose is "J to 3
grainx given . fasting or after a mild purge, and in
combination with some aperient such as castor oil.
Professor Heller objects to castor oil as a mcdiurn for
the drug, a.s he says, it has the property of dissolving
sanUjnin, and, therefore, promoting it.s ab.sin'ption and
the production of to.\ic effects. Kiichenmeister, how-
ever, maintains that it ivcts better when given with
cAstor oil tlian in any other way, and ProfexHor
Whitia continns this observation, "after seeing its
administration in some thousands of instances in the
practice of a children's lios|)itHl. l'ii]>lea.saitt symptoms
were jiever oberved, though the drug was given in
full doses; thr. ni/ ii/ipidm to les-scn very consideralily
the risk of any '^vil elVeeta." He gave 2-grain doses
to children two years old at l<ed-tinie, mixed with a
large teasjxxinful of castur oil, and more oil in the
morning if necessary. If castor oil is objected to
298
Med ical Treai ment.
(Part I.
tlie drug can be given mixed witli 2 or 3 grains of
cAloinol and h little powdered siignr. Or lo/enges
luay l)e njiwlc, each containing I grain of calomel and
I gniin of santonin; two or three of which would be
a dose. For older children from five to ten years of
age the following niixtnre nmy tx' proscriljed ; —
H" Siintoniiii ... ... ... . ... gr- vj.
Olei ricini .. ... ... ... ... 3iv.
Syriipi aurantii ... ... .. ... jiij,
Mucilnf^Mis acacim ... ... ... jvj.
Aqii.T) carui ... ... ud ijiij.
Hiecp, tint miHtura. Take half iu the morning lasting.
One of the hye-eflects of santonin, coming on
shorth' after the dase i8 given, i.s yellow viNioii, and
the urine isoft+'ii stained yellow or orange. Kainalu
also is etficacious in the euro of lunibrici.
Dr. H. H. Hare says,* "The careful physicinn will
also .se« that the patient receives, immedintely after
the action of the purgative medicine, a copiou.s rectal
injection of salt-water, in order that tlie bowel may
be thoroughly wiished out, and in thi.s liquid, when it
is expelle<l frnm the bowel, there will be found i|Uito
fre<juently additional worms to those freely pii.s.sed.
. . . The head of a tjtpeworm wnll perhaps be washed
out of tlie bowel by this niean.s."
Oxyiiritt vrriiiiritlnrift, or ilircadwoiin.
— This is a small, white, round worm, tapering at
each end. The female, which is longer than the
male, is aboiit \ inch long, the male only one-third or
half that lengtli. The posterior extremity of tlie
fenial(h is drawn out into a Rne-pointed tail, that of the
male is blunt and curved upward.
This worm, fi-om the egg to maturity, spend.s its
whole life in the human intestine. It is only found
in the human intestine from the jejunum to the anus.
It is an error to suppose, as has often l)een stated,
that thi.s worm specially inhabits the rectum. The
young animals and the mature males chiefly inhabit
the small intestine ; the impregnated and mature
• Harc'i "Systom of IVaotical Tliornjieutics " (second
edition), vol, ii., p, 491.
Ch»p. XIII.l ISTESTlNAf. PARASITES.
299
females the circuiii. In the firmm tliey are most
abuiKiaiit, M\i\ tin- females gradually collect together
there until niatuiv, atid cnimnieti with egjjs. They
are prone to collect in the ivmii/orin ajipendij-. Heller
has n<>en with the naked eye as many as nineteen
females mid nineteen males in the appenilix. Tiiey
then pass slowly down the large int«stine, and finally
deposit the chief part of their eggs in the rectum.
They sometimes even crawl out on the moiut skin
around the anus. Finally, both males and females are
mechanically expelled with the faices, and (lerish. It
is generally ltelieve<l that the ripe eggs must be
swallowed, and their .shells acted upon by tlie ga.stric
juice of the stomach, in oi-der that the embryo may
he set fj-ee so as to affect the liunmu intestine. Hut
certainly one observer has seen the embryos escaping
from the eggs in mucus taken from the rectum.* But
this is regai'ded as a very excejitional circumstance,
and in general the enibryos are first set free in the
stomach, and at once (lass into the up]>er part of
the small intestine. They arrive quickly at maturity.
Young worms have Ijecn expelletl fourteen days after
swallowing the eggs. They are often excessively
numerous, covering the whole mucous membrane of
the iiit*;stino.
As to the 4'aii«f of the presence of this worm
in the intt>stine, it must be concluded that the ripe
eggs are always swallowed, and that it is a t'im.sei|uence
of want of care and cleanlines.s. Scrujvulons cleanli-
ness is neede<i to prevent self-infection. As the eggs
soon perish in water, it is not likely that they are
introduced in drinking water, but it has been suggeste<l
that, under favoumble conditions, they may l>e trans-
mitted in the dust of the atmosphere. They occur at
all ages, but are more common during chihlhood.
The |>articular and ciiaracteristie syiuptom this
worm gives rise to is irritation of the lower part of the
rt^ctum just within the sphincter. The worms descend
U.) this part to lay their eggs, and their active Iwring
• Vix, qnoted in Von Zicinaien'i "Cyclopttdin," vol. xii., p, 76S.
300
Me PICA L Tr ea tment.
I Part T.
moveuients cause an intense tickling iimi itcliing
alniOHt intolemlitc. This is csiitM^iolly noticed at
tiiglit in bed. \\\ ffiimlfn, tlie wnrins tlmt have escaped
troui the rectum may creep Vietwi-en the vulva and
into the vagina, or may Ih:> carried there Uv the hands
in scratching, and there hy their wriggling, boring
movements they set up gn^at irritation of the sexual
organs, and may lea<l to mtisturlHition. By exciting
sympathetic irritation of the genenitive organs they
have been known to cause troublesome erections,
nymphomania, pruritus, etc.
The successful lr»»nini*'iil and complete dislodg-
tiU'iit of this parasite is fifti'u ditticult ; for not oidy
have the Wfrrms to lie dinlixiged from the rectum, which
i« not veiy dithcult, but they have t<i lie ilestroyed in
their favourite* abiding place, the cax;um, and in the
appendix vcrmiforniis.
To dislodge them from the rectum the best plan
is to administer daily an injection which shall wash
away the worms and their eggs, together with the
inDcus in which they are imljedded. Various
substances have l)een reoominended to be used for
these enemata — as decoction of qunsxia (made by
Ixiiling an ounce of i|uassia chips in a pint and a
half of water down to a pint and straining ; an
eflectual remedy), decoction of eucalyptus, lime
water ; salt and water (tAvo teaspooi\fuls to a pint
of water, iin|iroved by the ad<lition of half a tea-
spoonful of bicarlionate r)f soda) ; natural sulphur
water; glycerine and water (e<|ual parts). Heller
prefers an enema of soaji and water, 2 or 3 grains of
castiie soap to each ounce of distilled or rain water.
This is without an}' unpleasant action on the intestinal
mucous meinbrHne, while it quickly destroys Iwth
worms and eggs. He recommends the ailoption of
Hegar's method of washing out the whole length of
the large intestine by means of a long llexible tulje
and a syph<iti arrangement, the patient being placed
on his liands and knees. After the bowel has lieen
fi-eed from ftccea, in the ndult (for whom alone this
Cba|i.XIII.|
InrEsriNAL Parasites.
30'
treatment is practiciiblo) the bowel njiiy be washwl
out with liirge quantities of soap unil water — as much
as can be tolemtcd without fxcitinjj jiersistent strain-
ing efforts — from 3 to 6 pint«, intro<luced slowly.
This method is only necessary iu very troublesome
cases.
Excellent results have l)een said to be olitained by
enemata of naphthaline (15 to '20 gr;iins) in olive oil
(IJ to 2 oinices) in young children. Larger doses
must be ewploye<l for adults, and in this case n tur-
pentine enema, 1 dram to a pint of soiip and water,
is very usefnl.
Injections of cod-liver oil, pure, or maile into an
emulsion with yolk of egg, have also been found
useful, and they have the advantage of ln'ing non-
irritating.
The inti-odtiction into the rectum of mercurial
fiiritnicnl. diluted with viusoline, which win be passed
in with the Kngci- or on a small piece of sponge, or a
ni4-rriii-iai Nii|»poHiloi-y, is a good plan in cases
whurc the employment of eneniatii is difficult. The
white precipitate ointment should also be applied
freely to the external part.s to de.'sti-oy ova or wander-
ing jiarasites. If there is much local irritation still
unrelieved, the anus nnd tlie mucous membrane just
inside it may lie brushed with a 4 percent, .solution of
hydrix"hlori<le of cocaine.
Dr. ArchamVwwlt, when lie finds enemata of 4
to (> ounce.s of lime water fail, u.ses solutions of per-
chloride of iron (5 per cent.) every night for five to ten
nights, or a small lavement (3 ounces) containing
\ grain of corrosive sublimate.
Supijositories of tannin, and of extract of qxinniila
mixed with c^icao butter, have been well spoken of.
With regard to internal remedies, the free ad-
ministration of itarffalives is, no doubt, very usefid ;
they mechanically sweep iiway the parasites. In
adultM we may gis'e a combination of the siil|)liiite8
of magnesia and soda, a teaspoonful of each dissolvetl
in B tumblerful of cold water, early in the morning,
302
Medical Treatment.
|p«i I.
repciitiii'' the dose every liour until free purgation is
eHtfililisliMl. Ill chiklivn ii couibiimtion of oiloniel,
jaliip, iinil sciuiiinony answers well, sufli us the follow-
in^', given «t Ited-tiiiie-or in the early luoniing : —
Vf Hydrargyri sxilichloridi, gr. ij.
Tiilvoris souinniunii compositi, gr. x. ad gr. xx.
(iiovordiiig to iigc).
Ur twu gruins of calumtl maybe givon, with 10 tu 30 gmiiia
o( confci'tiim of siammony, at the snino hour.
Or the eti'ect of •iiilnliur may be tried as an
aperient, aud this, lieiuf? iiisokihlo, will certainly come
in coutiict with the worms '\\\ the cajctiui. Half or a
whole tejispoonful of the confection of sulphur should
Iw given every uiglit, ami an ounce of the compound
senna mixture (H.P.) the following morning. By
mean.s of purgatives internally, and diligently washing
out tfie rectum with ene ma ta, these parasites can he
kept under, and if no reinfection takes place they
may in course of time he got rid of.
Dr. Sydney Martin hsui had good results from the
use of rhuharb iti small doses, and the worms have
been so freely o.xpclled that there lias been uo need of
injections. He gives the following dose three or four
times a day ; —
H? Tinctura' rhci ... .. ... ... niiij.
Mugnesii curbonutis 8T. iij-
Timtuno EJngiboris ... ... nj.
Aquie lid 3J.
Mi«co, fiat dodiH.
The regidar use of lonirs of vegetable bitters and
iron will further this result, and so will the use of
cod-liver oil, in thin and strumous children. Twenty
or 30 minim.s of the syrup of the phosphate of iron in
two teasjwonfuls of infusion of calumba may lie given ,
to children one hour after food three times a day, or
half a ten-spoonful of vinuni ferri citratis to quite
young infants, or a grain or two of reduced iron in a
powder with sugar.
Ill adults we have found the continued use of the
Chap. Xiri.l
Intestinal Pakasites.
l°2>
gr. J.
gr.i.
I da
following pill useful in preventing the reappearance
of the piirasite ; —
If Kerri ^iilphAtin oxaiv«ut(u
UuiLSsiii' {iiilveria
Snjxjnis
Misce, liat pilula. Two or threo to be taken Ihricp daily an
hour Kfli'f fiiod.
The onlinary vermicides .seem to have little effect
on these parnwitt^s, jiartly Itccause Rome of these are
absorbed licfore they I'each the ciecuiu, and partly
because these worms seem to be able to lOKist the
net ion of such agents. Heller states that he has
found them i^ritiVe HveUf under a dressing applitnl for
venereal disease consisting of a fairly strong solution
of carbolic acid.
The /iroji/iy/iu-li^ measures arc too obvious to neetl
mention.
The trii'lin<-«>pliiiliiH «li«<piir, or long thread-
worm, whifh al.so is fouinl inlmbitiug the ciecum of
man, is nirely seen in England. It is attende<l by
no 8|tecial .symptoms, and i.^i not amenable t<j any
pnrticular treatment.
The auclij'losloniiiiii diiodpnnle, which is
very prevalent in Kgypt and in most tropical
countries, is not known in the north of Europe, nor
have any delinite rules for its treatmeiii b4'cn es-
tablishe<l. Fetleriei hiw, however, Htatc<l that thymol
ttcted successfully in killing the parasites in some
cases which occurred among the miners of the St.
Gothard Tunnel ; its use is also recoramended by
Manson.* As much as HO grains have lieen given
in a cachet early in the morning and repeated after
two hours, followed in another two hours by a purge.
Dr. MacDonald, of Colombo, we are informed,
treats this disease by giving 30 grains of thymol,
with 30 grnins of sagar, in llu< early morning, having
given a senna purge the night Ix'foi-e ; eighteen hours
afterwards a dose of castor oil is given. This treat-
ment is repeato*l after four to eight days.
• "TruiiiojU I)iiieii»f»," p. o91 (now edition), 1900.
304
Mhdical Treatmkst,
(Pattt.
ADDITIONAL FORMUL.T..
For tapeworm.
li liiidids cvrtiuia gnuuiti, sjaa
1x1 jijss.
Macerate for twcuty-four
hourg, tlien boil iu—
Aquir dMtilliittr, iixij,
Bvnporuti' to 6 nz. uu»I udci —
Extract i tilicii marin ii-thur. ,
sij.
A third jNirt In lii< tnken
(futing) ever; half hour. Take
n suliuo ujic'riciit the night
before, nud ii» food iith«r tliau
wiujt or \ka or a wdt hcrriug \
Another.
R Kouiwo i)ulvori», »,v.
lufusn ill boiling water (half
a ]iiut) for a unarti'r of an hourf
strain, uud aild half u tcuHpoou-
ful of lemon juice. To be tjikeu
fluting. {BiitHhrigrr.)
It will be uecegmry to give
one or two tablenpoonfula of
castor oil if the veruiicido does
not act as an npcricut.
Anotlier.
R Extmeti fliicis marii lethcr.,
gr. xxjt.
Pulveris ladicis tilicia niariii,
gr. xxi(.
Confcctioiiis ro«H', ((Uiuitum
sufficiiit
ut f. (lil. X. From two tu four
pillg every half hour.
( Itombetytr,)
For children,
li Kouffto jmlveria, .^ij.
Exxnvcti lilicis mana o.-ther.,
Euclone in twenty-four gela-
tine i^iwulen. FourtobetJiken
every ijnarter of an hour.
{linmtirrijcr.)
Dran^ht for tapeworm,
n Extracti lllicis liiinidi. ?j.
Ovi vitelliiiu. :vj.
Aquie chlorofonni el •yriipi
dimpliris, ii.s. ad Jij ,
M. /. baurt. To be taken in
Black oxide of copper for
tapeworm.
fihiok oxide of coiipor.llO gruinr.
Prepared eholk, HU gruiiu.
Kaolin, 180 grains.
(Jlycerin, q.9.
M. divide int4} 120 pills.
Two to fie taken four times a
day for u week, and three pilU
four times u day for a second
week. Then a good tio«e of
cimtor nil. (.^cids must be
avoided during this tretitiiicnt.)
Strongly advocated by Sau,
Confection for children.
H I'ulveris kanialii'. .w.
Extracti Hlicis maris icther. ,
.^iJEUf.
SynipiauniUlii)-^- ,
Pulvensaeaciii' ) '
Ut f, clectuuriuni. To bo
given in cachets. {Muiiti.)
PUIS for ohUdrea
K Extracti rudiciri granati
recentis, gr. xl.
Extracti HliciK maris, gr. xl.
Pulverin riulicis granati,
gr. viij.
f. v"
the morning.
(H"Aif/«.)
Ut fi piL xl. Half an honr
after giving the child a I'lip of
milk, give Ion of thew pills
every half-hour, keeping ten in
reserve in case some of the
others should lie romited. A
few hours afterwards a dose of
iiistur oil. (/'Vri*rA«ni«M.)
Jelly for children.
Vk Extrni'ti lilicis maris lii|uidi,
Hydrargyri subehloridi. gr.
Saci-lian albi, .^ij.
livhttin, ((.s.
rt f. elertuarium. Quarter
of this may be given every half -
hour. i^DucMnt.)
Chap. XIII.)
Additional Formul.t..
305
For lumbrtd.
R Sautonini, gr. viij.
Extructi spigoliif Huidi, .ivj,
ExtTBCti BDimn' fliiidi, ,^ij.
M. A tcasjKKMiful for a dose
for tt cLild of five years.
(/'lYi/. /.firn Smith.)
Enema for ascarides.
H Al'M'.^ barltii'teii'^i-. .vs».
I'flljttMi C'llllnjlliltifi. gr. XV.
Defo<.'U uuiyli, ;x.
M. f. euumu, {OMichon.)
Povder for lumbrtoL
fl Sjintonini, gr. j!»i.
Hydnirgyri nubcliloridi.gr.ij.
Snci'linri lootis, gr. xv.
M. f. jiulv. To bo given iii
honer to ui iufoiit two ream
ol.I. ■
Enema for ascarldes.
H Liiiiiciri» ciilcis. Siv.
Dt'C^MJti ulthirji*, ,\j,
M. f. onenu. {lta>iirt.)
Another.
It 01. cnjiiimti, iilxx.
Magiiexiii' lerii, gr. r.
.M uciliiginis utiiyTi .'iir.
M. f. oueiuit.
3ot)
CHAPTER XIV.
OI8BA8BS OF TIIE INTESTINES — THE TREATMEIfT
OF PERITONITIS.
Acute PEBrroxnta usunllv Svcondory to Traumatic Lesioiu or
Visceral Diseases— .SomefiiiiM Local iiiiil Partial. SymptoHu
of Acute General Pmtoiiitis. Tmifnu-iit .■ Blood-fettios —
Leeches— Cold Applicilious— Opium— Kt'st— Mode of Fecdmn
— Nutrient Euimmtii, etc. — Treatment of Voniitinff and Tym-
panitcB— Puncturing the Intestine- -Quiuiue — Influence of
Opiuzn — Caution to l>e observed in itn 17 »e - I^urj^e Doses iu
Puerperal Cases— Reaction against itn tiidiKcrimiunte Use, iind
Advocacy of Saline Ancrieutii in Early .SUige of Disease —
Enemata of Warm Water — CnlomeL Niinjual Treatment.
TI7BEBCUI.AJI PuRTroNrriB — Tabes Mcaenterica — Lotenry
and Obscurity of Peritoneal Tubercle. Siimpluim : Awites —
Sacculated Exudation. Tifntmriil : Spnntaucous Cure— Local
Applications— lodino—Moreury— Coil-liver Oil and Iodoform
— Lnparutomy, when advisable! Additional Formulm.
Acute pcrilonilift may l>e priinitive or secondary,
partial or genenil. J'rimitiiv iwritonitis, from exposure
to cold and lience often spoken of a.s rheumatic peri-
tonitis, is extremely rare; still it does occasionally
occur.
Peritonitis is, however, most commonly mot with
OS a consequence of some other disease or injuiy.
Wounds and contusions of the alxloinen, accidental or
surgical, may give rise either to partial or general
peritonitis. Tlic most common cause, however, of
peritonitis, and especially of general peritonitis, is
some disease of the ahdoiiiinal viscera, such lus simple
perforating ulcer of tlie stomach or duodenum ;
tutjcrcular, typhoid, dj'seateric, or cancerous ulcera-
tion of the intestine ; di.sease (abscess, ulceration, etc),
of the vermiform appendix or cwcuni ; intestinal
obstruction ; diseases of the liver, such ns abscess of
liver or cysts, or acute hepatitis; ulceration and
perforation of the gall-ldadder or bile ducts ; diseases
of the pelvic viscera, as iiirtumniation of the uterus
(puerperal fever). Fallopian tubes or ovaries, or disease ,
of tlie bladder. In all these coses the {veritonitis i
Chap. XIV.l
Acute PEgiroNrris.
3°7
^^m ranst be ri-garded as septic, Jind tlejjonding on the pas-
^^1 sage of niicro-orgiinisnis into the peritoneal cavity.
^^H Acute peritonitis also tjccurs in connection with
^^B certain general di.seaseu, a& in Ilrigiit's disease, iu
^^H scpticiemiu, and in some exanthemata. Wlien it
^^1 accompanies tensions of the abdominiil and pelvic
^H viscera it is often local and partial, and limited to
^^ the vicinity of the visceral disease causing it ; the
same is al.so frequctitly the case when it i.s due to
external injuries and surgical openitions, but when it
is caused by perfomtion of the stouiach, or any of the
hollow viscera, and their contents escape into the
peritoneal cavity, it is usually severe and i(eneral.
Tuheri^ulnr |»pritoniti8 is a special form of peri-
tonitis which will be considered apart.
The characteristic «yni|>loinM of acute difluse
peritonitis are these : vry severe ahdoininal pain
arid Undf.rnfss — often accompanied with grave col-
lajite — the pain is so severe that the patient dreads
the slightt'Rt touch or movement, and, therefore, lies on
his back with bis knees drawn up so as to relax
the abdominal walls as much as iMJssible and keep off
the pi-essiin? of the bedclothes. Abdominal di»tfnnon
and tijmpntiitfs : This is believed to be due to the in-
Hammation involving the external coat of the bowel,
or at any rate Ivailing to such a disturliance of inner-
vation of the muscular coat that a sub-paralytic
condition of the intestinal walls is produced, so that
they Ijecome greatly dilated ; hence the tympanites.
Hence also another sympttmi that almost invnrialily
attends acute ditTuse peritonitis (unless it should
hap|ion to have supervened on some other affection
which has Ijeen attended with diarrluua), and that is
alisolut-e constipnliou. Owing to the great pain attend-
ing any movement of the intestines or abdominal wall,
and owing also to the pressure on its lower surface of
the distended intestines, the diaphragm moves but
little in respiration ; the insjiirations are therefore very
shallow, and the ri'xpirafioiu are greatly ijnii'h'ned
and wluolly, or almost wJwlly, thoracic.
3o8
Me PIC A L Tr ea tment.
|P»n I.
Tlie tligfistive t'uncliotis are practically siippressetl.
There is entire loss of appetite ; the tongue ami mouth
are red and ilry ; there is thirst, nausea, and
vomiting, and the matters vomited have often a
(/reen colour. The (.■ouiitenance is usually pale, the
features pinched, and the expression anxious. The
pulse is small, hard, and rapid, of the kind that is
termed wiry. The skin is dry and hot, and the
temperature raised often to 104' F., or even 105'.
The urine is hiiili-colourud ami scanty, and passed
with pain and cliilu-ulty. If much serious cH'usioii
should occur later on, percussion will disclose some
(Julness in the flanks.
In the gravest cases, viz. those due to perfor.ilion
of the stomach or intestines, there is usually marked
■ collapse, and, in the great majority of coses, a rapidly
fatal issue.
When the exciting cause has not lieen of such
extreme gi'avity the symptoms may subside, and
the patient recover. A'lhesions between coils of
intestine, or between the walls of the intestine and
the abdominal walls, arc apt to be left behind, and
habitual consti[iation may thus originate.
In some cases the peritonitis is Intenl, and not
disclosed liuring life by any markeil or characteristic
symptoms.
The history and symptoms of local partial peri-
tonitis, as, for instance, in the right iliac fossa, are
usually mergwl in those of the dist>asc of which it
is a complication ; these have been discussed under
appemlic.itui.
We may now proceed to consider the lrvnt«
mc'iil of acute peritonitis. In all cases the chuso ,
must be searched for an diligently as circumstances ,
permit of.
The suggestion that in a case of acute peritonitis
resulting from a poi-foraling gastric ulcer the stomach
should be washed out with the stomach |>ump in
order to prevent further extravasation of its contents
into the peritoneal cavity, is scarcely a [tructicablo ,
Chip. XIV I
Acute Peritokitis.
309
onp. Generally the patient is in a state of collapse,
when such n pi-oc.t'dure would be impassible ; and
even if otherwise, the di-sturlmncc of the patient
which such ft procedure would necessitate might cause
more harm than tjood, and lead even to more injury
to the |)eritxjneuin than a nio<le of treatment calcukti'd
to keep the stomach perfectly still and at re«t.
In a great many cases in which acute jieritonitia
is de]>endent on intestinal obstruction, or on the
entrance of septic substances into the peritoneal
cavity, and tlie exudation is purulent, surgical inter-
vention, and the opening of the peritoneal cavity
by lapari'loiiiij, and it,s irrigaliou by warm water or
some aj^eptic solution, may be the l)est iU(xle of
treatment — a jirocedur*" to (he consideration of which
we propose to return.
We are not disposed to recumuiend j^ieneiul blei'ding
in any of these cases, but the advantage of the
local abstraction of blood by leeches, and its influence
in relieving pain, is generally admitted. In an acute
peritonitis in which no definite and obviously remov-
able local cause can \» <liscovered, the treatment
may •«' commenced by the applit-ation wf from ten to
thirty leeches to the alidominal surface, and par-
ticularly to tJiat part which seems to be especially
painful ; this mny be followed by the a|>piiciition
of a light hot linseed fioultice sprinkle<l well with
laudanum. Ice-cold compresses repeated every ten
minutes, or the a])plication of c<ild by means of
Leiter's tul)es, have Ijeen found of value by some
physicians, especially in Germany ; but in England
patients rarely seem aV>le to bear them, and warm
applications are much more gnitcful.
In robust or jireviously healthy subjects it is
quite possible that if the case be seen ijuite early
lie treatment by ice-cold conij)»t?sses may be of
eat utility, but in onler that they may produce
ft gooil efTect it is necessary that they should be
renewed nl tlwrl aiul regular interval* trilh i/ri-nt.
atinduity.
3»o
Medical Treatment.
(Pari t.
Tlierp. are two views prevalent as to the itiediciiml
treatment of acute jieiitonitis : one, the oMer and
perhaps the more germrally accepter) view, is thiit tiie
lK)wels should he kept nl re»l. l>y the exhibition
of opium ; tlie other, it modem \iew, that the Ijowels
should be cleansed of their septic conteu,t8 by saline
purgatives. We |irapose to refer first to the older
method, and in the next place to the mo<lerii one —
the latter is not, of course, intended to apply to
cases of gastric or intestinal pirfonition, in which
any excit^mient of intestinal ]>eri8talsis would prob-
ably be disiiHtrous.
In order to relieve the piiin and vomitiug, and
to keep the bowels at rest, ofiiuui must be given :
1 grain of *tha extract or powder may Ins given
every hour until the patient Ik brought distinctly
under tlie influence of the drug, i.e. i.s free from
pain. In cases of gastric ulcer and perforation,
when opium cannfit be given by the mouth, and in
cases of obstinate vomiting, a few ^-grain doses of
sulphato of morphia may be given hypodermically
every two hours, or small starch eneinata each con-
taining 2(1 minims of tincture of opium may be
administere<l every hour. It is important to re
memlwr that opium is very batlly borne by persons
with Bright's disease, and it will be rarely advisable
to give thi.-i drug, even in small doses, in cases of
peritonitis o<.-curring iu the course of that atTection ;
and in all cases it sLonld bo rememberetl that the
object of giving opium is to relieve pain and shock,
and that when the pain is relieved the opium should
be discontuiued.
It is scarcely necessary to say that the patient
must Ije kept absolutely at rest ; indeed, all movement
is so painf\d that he will rarely show any indisposition
to oliey this injunction. Treves calls attention to
the natural tendency of patients with acute peri-
tonitis to hold the hands above the head — a postui«
whicli, by acting on the lower part of the thoracic wall,
assists in diminishing the tension within the abdomen
Chalk XIV.)
Acute Peritonitis.
— ami he points out that "it isi cruel to insist that
the hands shall lie kept benoath the bedclothes," as
Bonic nui"8eH may he prone to do.* A cnullc may be
anivn^ed over the bo<lj to keep oft" the weight of the
b««dclothe8.
l>uriiig the acute stage the digestive functions
of the stomach are in abeyance, and it is U!ieles8
to attempt to give nourishment hy the mouth ;
the thirst should, however, be relieved by sucking
quite small fragments uf ic-e, or if the |>atient prefer a
little iBarm fluid, a few sjxwnfuls of hot water or hot
weak tea may be given. The thirst may also Iw
relieved by injecting 6 to 8 ounces of warm water
into the rectum. Nutrient unemuta and stimulants
will in most ca.ses have to be given by the rectum to
maintain the jvitient's strength and prevent collapse.
When the vomiting has ])as.scd away a little iced milk
and water, or thin gi uel, or cold oonsommi, may be
given by the mouth, and if the other severe .symptomn
subside, a gradual return to stomach feeding may be
adopted, except in cases of perforating gastric iileei',
and in the rare case of recovery from this form of
acute peritonitis (and some cases do recover) rectal
feeding Miu.st l)e maintained for some weeks.
If the vomiting is very trotiblesome and there is
no reason to fear the existence of gastric perforation,
we may enileavour to reliere this sym[itoni 1)V t-uble-
spoonful dot-es of lime water, or small rffervescing
draughts containing 4 or 5 minims of dilute hydro-
cyanic acid in each, or by crcasotc in Iniinim doaea
shaken up with iin ounce of lime water. Distre88
from excessive tympanites may be relieved by passing
a long tube into the rectum, or, if the acute stage has
passed away, by the administration of a turpentine
enema and the application of tvirpentine stupes.
Oreig Smith f recommended puncture of the in-
testine for the relief of this symptom ; he maintainrd
that by allowing the escape of large volumes of gas
* Allbutt's " Synteni of Medicine," vol. iii., p. 6'i6.
t " liiteniatioiittl ("liiiicn," 1803 (thinl •eries), vol. i
, p. 1114.
3'J
Medical TRBAnrsifT.
(Part 1
it relieved tlie bowel of dangoi-ous internal pressure
and the hejirt and lungs of pqually dangerous external
pressure ; but it is a method that has never obtained
general acceptance.
As the inllaiiiujation aubsideK and the bowels
recover muscular tone, spoiitnrieous discharge of thoir
contents will take place, and it" this stionld In? too long
delayeil it may \xi hastened by the ailiuiiiistratiim of
enenmta of olive oil mixed with soap mid vvat-ir. In
protracted cases of a low adynamic typo full <lose8 of
(/uliiiii'' may lie needed to maintain the patient's
strength.
Also, when the peritonitis is local and partial, the
application of leeches and the use of opium, especially
its pxtenial local application, are the best means of
affording relief.
These are the measures which are generally
ado|pted in the management of cases of acute peritonitis
which are not considered to call for surgical inter-
ference.
But much di.scussion has arisen with regard to
the use of opiiini. No doubt this tlnig has a remark-
able action through t.he vaso-motor nerves on the
cnpillaries of srrous as well as of mucous membranes,
causing their contraction, and so diminishing con-
gestion and li'ssening exudation. Opium, therefore,
when given at theon.set of the intlammatiou, probably
exerts a direct remedial local efl'ect on the vessels of
the inflamed raemVirane ; it kee]i8 the inflamed parts
at rest by checking peristAltic action, and it quiets the
nervous system and saves the strength of the ])atient
by relieving pain.
In ca-ses cau.sed by perforation of one of the liollow
viscera, by arresting peristaltic movement it prevent*,
to some ext«nt, the further escape of the stomach or
intestiral contents into the jieritoneal cavnty ; anil in
cases where these fonugn substances ai-e shut off from
theivst of the jjeritoneal canty by local adhesions, by
keeping parts at rest it prevents their breaking
through.
Chap. XIV.)
Acute Pekitositis.
l''}>
The question ns to the amount of opium that may
Vie given must be deti-nnineil by each individual ease.
Some patients are very sensitive to its effects, and are
readily narcotised by even small doses — others require
much lnrj;er doses to produce narcotic etTects ; and it
must always lie borne in mind that the presence of
intt'use pain and acute intlanmiation seem to exhaust
and dissipnte, so to speak, a grcAt deal of its naivotic
efl'ect, and, therefore, rei-y much larger doses are
needed in order to produce the full remedial effect of
the drug. The criterion of the sufficiency of the dose
is the relief of pain, and it is be.st to give one full
dose at startinj;, and repeated nuKlerate doses at short
int^ervals until the pain is relievetl. The e<|uivalent
of 2 grains of s<ilid opium may I.* given at first, and
1 grain every hour until its full effect is produced.
This plan of administerinj; o))iuin is not advisable in
ohilrncticn cases, in which hard, impacted faeces may
poRsihlj' l)e the cause, ami in such cjises the sub-
paralytic condition of the intestinal walls is aggra-
vated, and it becomes exci^ssivcly dilticult to excit«
them afterwards to ellicient contraction. But in such
cases the peritonitis is usually localised and not
general, and would have been precede<l by a history
of olistinate constitution or a clironic intestinal
catjirrh. We must be most sparing in our use of
opium in these cases It would be Iwst to limit it to
local and exteninl application or to ii single hypodermic
injection of morphine and ati opine. So also in the
c«*»*8 dependent on causes which are oidy remedial by
surgical operation, the prolonged and excessive use of
opium may no doubt relieve the pain in such cases, but
by masking the symptoms it protlucea a false sense of
security, and precious time may be lost and the
patient's chances of recovery greatly diminished.
In gi^^ng opium it is imiiorlnnt to give it in a
fonn that can i>e readily absorbed. When there is
giTat gastric irritability and vomiting there may be
some ditflculty in ensuring the retention of opium in
the fluid form in the stomach, and it will then be
3«4
AfF.DICAL TrEATMRHT.
tPnrI I.
advisable to give it in the form of »mall [liils, and in
orcler that these may dissolvp readily tliey shoidd be
mttdc in a apeciiil manner. iSix griiins of the extract
of opium Hhottld be rubbed down with (> minims of
the tiui'ture of oj»iuiii, and enough powdered sugar
added Ui umke it into the fonsistency for nuiking pills :
the mass should then be divided intti twelve pills, and
one of these given every quarter of an hour until the
desired eHect is produc<'d. Morphine may, of course,
be given hypoderniically, but it is iipt to aggravate
the nausea an<l sickness with some patients, and it
often exerts a far more depressing effect on the heart
than opium given by the stomach.
As we have already [>ointed out, a sort of reaction
has recently set in against the routine ad n)inist ration
of excessive quantities of oj)ium in all cases of acute
peritonitis, and the consequent paralytic condition of
the intestinal walls and the locking up of septic
substances in the int'estinal canal to which it gives
rise. And it appears to 1k3 worthy of consideration
whether the indiscriminate use of opium is always
wise in cases of the kind we are discussing. Meigs
has argued, from his experience after surgical opera-
tions, that tlie exhibition of salines in large doses at
the ceri/ uiixi^t of an attack of peritonitis is found to
check the indanimatory process by with'lrawing fluid
from the int^-stiual and alxlominal ves-sels thmugh the
wat«ry stools they produce. And it is possible that
such a method of treatment in such cases as he lias
in view may be more useful and more rational than
that of locking up excretnentitious matters in the
bowels by opium. But the physician rarely sees casus
in that very early stage, and the risks attending the
excitation of the action of the bowels by purgatives
at a subsequent jieriod of the disease are too real to
be lightly disregarded. We think, however, that
there are many cases in which the aseptic or anti-
septic action of washing out the large intestine by
copious eneuiatii of warm water uiight well Ije com-
bined with just OS iruch opium as will relieve pain
Oup. XIV.I
Acute Pfritoxitis.
3'5
and ni^rvous distreRs, tind it niiglit, by diminishing
uieteoriHni and painful distension of the bowel, renlly
minister to the comfort of the patient. We also
would urge greater moderation in the use of opium,
especially with a view to the po8.sil>]e early inter-
vention of the surj^fon, whose chance of successful
oppration is often gr-eatly dinunishe<l by the intestinal
muscular and reflex paralysis induced by the too
free exhilntion of narcotics.
Graves, and many of the past generation of
physicians, combined calomel with opium in the treat-
ment nf acute peritonitis, and they may not, after all,
have l>ecn wrong ; fur the calomel would act as an
int^MlinaJ (nilufplic, and the opium would prevent its
having any immediate jmrgative eflect, while after
the severe symptoms had subsided, and the use of
opium could lie sii»pende<l, the eliminative action of
the calomel would probably come into useful plav.
The method of treatment by saline purgatives has
been ably advocate<l by Professor (.!. E. Fowler,* of
New York. Recognising the septic origin of perito-
nitis, and that the chief danger in the disease consists
in the absorption nf toxic products, he maintains that
measures sliould l>e a<iopted to eliminate thase pro-
ducts througli the intestinal canal, and thus also
relieve distension and promote the absorption of
peritoneal exudates. Free catharsis should, how-
ever, be institute*! farly, before vomiting has become
persistent and intractable. Later on, when general
]>entonitis is fully deve.lo])ed, the period of usefulness
of (lurgatives is passed, and they only augment the
nausea and vomiting and increase the discomfort of
the patient. The employment of opium, he admit",
" now finds its legitimate place in the case."
The jmrgative he employs is magnesium sulphate,
in the dose of 4 drams in just enough water to dis-
solve it, followed by dram doses every hour, until either
" decided response to its action result.-*, or it becomes
* Hare's " SysU-ni nf Practical Therapeutic*," vol. iil, p. 438
(■ccoud edition), 1901.
3-6
Medical Treatmbst.
(Part I.
evident, by the increase \\\ the nansea and vomiting,
that it is useless longer to expect it to act." In
some cases he finds it lietter to give Jth of u grain
of calomel hourly. He has found this sometimes
jnodiK'e free catliareiH without vomiting.
To return to the question of mirglcnl intfirvenlion
in cn.ses of acute peritonitis. It is admitted on all
hunds that severe acute general peritonitis, especially
ill oliildren, is almost invarialily secondary to some
visceral lesion, and is septic. In adults, we lielieve,
there are certain cases — very few — wliicli <iriginate in
chill and are of a rheumatic nature, and for these the
salicylates should he pi-escriljed ; we are also satisfied
that some slight and piiitial cases occur in young
children, either from chill or from irritating ingesta,
or from hoth. But we sliould he disposed, from our
own experience, to assert that the.se two latter forms
can be distinguished by their relatively less severe
symptoms, and by their responding quickly to warm
local opiate applic.ttions, and to enemata. of warm
water, with or without a saline or calomel aperient,
as may Ix" judged ex|x"dieiit.
But the great majority of cases belong to the
former type, and we strongly urge that in these cases
early surgical co-operation and consultation should \te
invited. Many of the.se cases are connected with
suppurative appendicitis, and in such, and, indeed, in
all suppurative and septic cases, laparotomy and
flushing with a hot aseptic lotion and drainage of the
abdominal cuvity seem to oft'er the oii/i/ chance of
cure.
It 18 clear from the foregoing that the appropriate
treatment of individual cases of peritonitis depends
upon many considerations, and needs highly skilled
discrimination. Some cases claim o]iium treatment,
cautiously tmrricd out ; a limited number, if seen at
the tins<»t, may be Ijest treated by saline purgatives,
and in others surgical measures must Ix? a]>plied as
early as possible. It may be as well, here, to
mention that Treves' experience does not give much
ch»p. xiv.i Tubercular Pbritonitis.
3'7
8up]iort to the advocacy of purgatives iu this diseaso.
He says, " When geiiei-al peritonitis has ouce eata-
bliMhed itself an aperient \<i unavailing."*
Tiibcrfiilur pcriloniliH is more frequently
f/ii'inii<: or .sul>acut<i than acute. It niaj-, however,
occur as a part of a general acut<! miliary tuberculosis,
but that in not a condition with which we are now
concerned.
The occurrence of tubercular peritonitis is usually
associated with the presence of tutjercle in other
organs ; aa e.<j. tuliercle of the se.xuid organs, the
uterus and Pallopian tubes in women, the testes iu
men ; or tuberculous ulcers of the intestine ; or tuber-
cular deposits iu the lungs or pleura. In children
it is often a.ssociate<l with intcHtirml tubercle and
secondary tuljercular allection of the mesenteric
lymphatic glands, and it then presents that form of
disease which is known as Tubes mvannUrica.
It would seem, from the successful treatment of
tubercuhir peritonitis in children by laparotomy and
other meifins, that tubercle of the peritoneum must be
in some ca^cs primary, and more prone to undergo
curative changes than tulwrole in other organs. This
fact has riH."ently been established, t
The early symptoms of tubercular peritonitis are
often very obscure ; sometimes it comes on abruptly
as a severely acute |>eritonitis, and then its nature is
very likely t*> lie misunderstood ; one such case which
came under our observation had been diagnoseil as
one of p->rfoiation of the bowel ; ami sometimes the
diseaso is i|uite latent, and it has been discovered
accidentally in operations for hernia or ovarian
tumours. Shifting abdominal pains, with emaciation,
and perhaps diarrluea, loss of ap{)etite, a ino<lerate
evening rise of temperature, J tenderness on pressure
over the abdomen, the surface of which may feel
• AUbutt's "Sv«teiii of McJirine," vol. iii., p. (V29.
t Sff Cliiikiul toctiirc by tlii) Author, Lnncrl, M;in.-h ICitli, 1901,
^ •Sub'uorinfil ttfiiip^riiturei have uot uufrtit{iioully bH'U
reeorJcd ,
3i8
Mrdical Treatmeht.
[Pari I.
hot ns well iis hard antl resistant, are the symptoms
that may be looked for. There may lie retraction
or there may be swelling of the abdominal eavity ;
and in the latter case the effusion of Huid may give
rise to (luctuatiou. When this disease occurs in
children it is much easier of detection than in adults.
The tueiiid, tender belly, resonant in parts and dull
in parts, with oi-oasiontiUy a lumpy feeling, the
pinched face and wasted linilm, and general discomfort
and fretfulness, together form a fairly characteristic
picture. Aforeover, in many the omentum is found
to be curiously indurated and roUed-up, as it were,
into a roundish or elongated tumour, stretching
across the abdomen al>ove the umbilicus. We may,
of course, have at the name time evidence of the
deposit of tubercle in other organs.
Ascites is common, but the exudation is often
sacculated, and has often been mistaken for an ovarian
cyst.
The successful Ireatinoiil of these cases of tuber-
cular peritonitis, .surgical or otherwise, must, of
course, depend greatly on whether the disease is
limiteil to the peritoneal cavity,* or whether the
l>oritimeal tul>ercle is only a part of a more widely
spread tuberculosis. A far more lio|>efid view is now
taketi of the.se cases than formerly pn; vailed.
In a previous edition we i-eeorded a rapid wcovery
from tuljercular })eritoniti.s, with much ascites, in a
lx)y of twelve ; this was a chronic or sub-.icute form,
and the treatment consistetl chielly in painting iodine
paint over the ahdnmen daily, or on alternate days, as
it could bo borne, and then smearing this with a layer
of olive oil to pix^vent evaporation. At the same time
he took half a grain of iodoform flissolved in a dessert-
spoonful of cod-liver oil, after food, three times a day.
The improvement began early, and was steadily
maintained. We have still more recently published
• Prof. W. Osier ( " Tuborculiir Peritouitis," Johus lIo|ikin«
Hospitftl Jlr/xiitf) siiy»: " lu inauy cjumj* the iiroccais is entirely
local. lu five of eevcinUtvii rjisw nf wliioli I hiivp poit-morlem
notrai the eouditiou wa« couftiieil to the peritoucuni."
t:h«p. XIV.I TODERCULAR PeRITOXITIS.
3«9
the particulars of three consecutive coses in wliich
cures followed a similar line of treatment. loilofunn
was given internally in half gi-ain doses, and an
ointment composed of equal jisirta of iodoform oint-
ment and cod-liver oil was rubbed into the surface
of the abdomen twice daily.*
It is hif^lily probable, as suggested by Osier, that
spontaneous eure occurs in many cases of peritone^il
tuljerculosis just as it does in pulmonary tuberculosis,
by the tubercle undergoing retrograde, fibroid, and
sclerotic changes.
Fagge t remai-ks " that in children tubercular
peritonitis is capable, in the majority of cases, of
being cured by the local application of linimentnm
hydrariji/ri." The liniment is spread freely over the
surface of a tiannel belt, which is stitche<l round the ab-
domen. He has seen the greater part of the ascitic lluid
removed within a few days under such treatment, to-
gether with improvement in health and strength. Cod-
liver oil and syrup of the iodide of iron may be given
at the same time.
In cases with much ascitic fluid in children re-
peated aspiration or tujiping has been attended with
successful results.
But a very imi)ortant (piestion in connection with
the treatment of tuljercniar peritonitis is, what are the
cases in whicli we should recommend the operation of
lajnirofnmy /
According to Prof. Watson Cheyno } the bi'si
results are obtained in the early stage, and when there
is always more or less ascitic fluid in the peritoneal
cavity ; in this stage there is " not necessarily any
matting together of the intestines or shrinking or
adhesion of the omentum and mesentery." But in
advanced chronic case^ you may find adhesions and
fibroid induration of the omentum and mesentery
* J'k/i" C'liiiiral Leoturc by the Author ou tlic '• Treatment of
Tul»crt'uInuH Peritonitis." /.fnirc/, Murch Itith, 1*.K>L
t " Principles mid Priictioe of Meiliciiu'," vol. iL, p. 3'2().
^ Hiirreiuu Lecturr* on the " Treatment of Tuberculous
DiiHMueti iu their Surgiral Ajipactjs," 1000,
320
Medical The a tmest.
[Pan I
— tliey becoine matted together, thickened, and
shrunken. Tho inttslines may also be bound to-
gether liy ni'w tibfou.s tissue, the tul)erck'B, too, may
t>o fomid coalesced into large niaH«es undergoing casoH-
tion, and the mesenteric glands may be enlargeil and
caseous. When the disease has reached this stage
tlie ciinditiotia are dislinef ly uufuvoundile both for sur-
gical auil uieilical Iieatnient. Rut Watson Cheyne
thinks it an error to o|>orate too soon, for if opera-
tion is done too early the disease is apt to return.
He reconiniends that medical treatment should be
given a reii.sonable time, which he estimates at from
four to six weeks in the acute cases anti from four to
six iiioiitlis in the chronic ones. The operation he
recommends is a very simple one : in cast« with
effusion without adhesions the abdomen .shotild bo
opened in the midillo line below the uiuliilieus and the
Huid allowed to run out, aided liy turning the patient
on hi.s side and " perhafis removing some of it by means
of spongess,' then stiteliiug up the wound again. He
does not recommend washing out the peritoneal cavity
unless the effusion is purulent ; in that case he ad-
vises the use of salt solution for this purpose and then
introducing a little iodoform and glycerine enudsion
into the cavity before chising it. He also urges that
medical measures shoulil !»■ supi'radded to the surgical
ones as soon as possible. Ebstcun also supiwrts
Watson Cheyne's opinion that "simple opening of
the jieritoneum " is best, " without antiseptics and
without washing out or drainage.''
Some writers drow a sharp distinction between
cases of tuberculous [leritonitis with ascites anil the
plastic form in which the |>eritoneal cavity is ob-
literated by adhesions, and they maintain that oper-
ative interference in the latter is '-useless and
worse than useless." Watson Cheyne does not
hold this view. He says : " All, even the gravest
forms, show some good results, and there is no form in
wliich we can say that laparotomy is ab.solutoly
useless." He states that he haH " bad success in the
ciiAi^ xiv.i Tubercular P/iRiTotfiT/s.
.;»«
I
dry form as well as in the ascitic." Jle coiisi(I«!n»
that the most favourable cases are tliose with localised
ascit«.s, aud the next those with diffitsnd ascites. Then
comes the fibroatlhesive form — when niwlerate in
extent and no ascitfjs. In case^i where the abdomen
contains large caseating mii-sscs, succe^es are nut
fivquent, but he maintains that they do sometimes
occur. He does not consider the co-existence of early
phthisis a counter -indication, but with advanced
phthisis the results are not good. He is doulitful if
lapai-otomy does any good in cases with intestinal
ulceration. Then as to the proportion of cures in cases
of)enited on. The same authority tells ns that some-
thing like 70 per cent, aro improved or cured by
laparotomy, but he believes that if all aises were
operated on, not merely selecting the most favourable
ones, 50 per cent, would proba!)ly Imj tlie outside limit
of improvement or cure. If, on the other hand, the
more favourable cases only wen' treatt^d by laparotomy
the percentage of 8uccc.s.scs would be much higluT,
Second or third oiierations may succeed where the
first fails and lluid re-iK^cumulates. As to the rationale
of the cure of tuberculous peritonitis by this .simple
surgical operation, Watson Cheyne admits that we
are "absolutely in the dark." We think, however,
his own suggestion is a reasonable one — viz. that
after the removal of the fluid from tlie peritoneal
cavity by incision, serum having anti-bacteriiil pro-
])erties may )>e poured out, and so the morbid process
\)ii arrested.
The important fact resulting from tliese observa-
tions is that an api>arently very flight cliniujc in the
environment of a pathogoiiitic organism sutiices to
arrest or nullify its activitie.s, and to lead to its disajt-
p<?arance. This consideration led us to reflect how
iodoform inunctions (together with iodoform inter-
nally) act in curing tuberculous peritonitis.
When iodine of potassium is given by the stomach,
in a short time the presence of iodide can l)e tletetited
in the saliva and in the urine. So when iodoform is
V
322
Medical The a tment.
IPail I.
rulilipil info the .skin of the (iVxlomeii in a young person
it prolMibly rupidly enters tlie blood and is, if rejjiilarly
applied, continuously elirainatefl in the secretions,
iitcliifiing the secri-tioru htln l/if nn-niiit cacltinti, and as
these do not pass out of thf liody »« the secretion of
the kidneys iloes, tliey must, in courBp of time, become
pretty richly charged witli iodine coni|ioujid8 — at any
rato HUlKciently so t<i aft an antitoxin to the tubercle
toxin or as unti -baotnrial to tin- Imciili. The first
thing to l>e d«'t<>rnntic<l wjis wiiothor the iodoform in
the ointment, when riihl)e(l into Ihe ididnmiiial surface,
was absorbed into tiie blood ijuiokly and eliminated
by the secreting organs, such us the kidneys. Dr. Still
has been so good ms to make tius observation for us
at the Chilrlreu's Hospital in droit (•rniond Street.
He found, lii-st, that iodoform ointmeni, is excreted
and easily reoognisable in tiie urine as iodine or the
salts of iodine ; and, secoiiilly, that tlie rale of excre-
tion is very ra]>id. Wheii half a dram was applied
to the abdomen it was recognisalile in tlie urine four
hours later, and apparently, after a second application,
it reappearwl in the urine in two hours' time. When
only irt grains were ap]>lii'd in another case it was
recognisable in the urine 1")) hours after a]>plication.
We have proof here of the rapidity with which io<lo-
fonn is absorbed by the skin, entei-s the blood, and
circulat.c« as an iodine coiiipoiinfl through the tissucu
of the body and is cliTuinated into the secretions.
Now, it is an interesting circumstance in this con-
nection that the idea that iodine is an antitoxin to
tuljerclfi has long been iu the minds of physicians. Wo
use the won! " antitoxin " in a wide and general sense.
Quite recently* two Italian physicians have re-
corded a c!i.se of tulierculous f)eritonitis in which a cure
<|Uickly followe<l the injection of a solution of iodine
made by dis.solving 1.5 grains of iodine and 30 graina
of iodide of [>otJiSBium in one and a half ounces of
water. They injected first half a syringeful and then
a syringeful in the genital region (laily for ten days,
• Brit. J/W. Jomval, Epitome, .Sei>tembeT 9fh, ISiW.
"Chrin. XIV.l TVKERCULAR PEKITO^tlTIS.
l^i
Wifl then on aU^Tnat^ days. After about a fortnight
Bine of the fluid was withcii*awn from the pfritoneni
cavity and i-xuuiined l)ttctoi-iolo;^ically : culture pre-
piinitions were inwli', and guinea-pigs were exjieri-
tiient<?d on, but no tulKjrcle was found. After ten
weeks of treatment, the patient was dischargeil cureil.
Professor Thoiiia, of IJeneva,* ha-s advocated the
treatnjent of tuberculous ])critonitis by creasot* j;iven
in eneinata. He gave at first 5 niinim.s, increased
afterwards to 1') minims, in four ounces of eniulsiifieil
co<l-liver oil, once dnily. lie continued this for .some
weeks, and then interrupted the treatment for five or
six days. He obtained good results. He remarks
that " laparotomy is no doubt the U-st and quickest
of all iiietJKids for dealing witli those cases in which
the perit<meum is covere<l with miliary tubercles,
but," he very sensibly adds, "it is always a serious
opi'i-ation, luid one alstt wliicli not every practitioner
is competent to perform, and moreover parents often
object, and pliysicians woidd gladly welcome other
method 8."
ADDITIONAL FORMULA.
For dlarrbaa in peritotUtli.
II Aciili laiinici, k>'. ^v.
Opii )iuri, ^. Jw ml iij.
I'lllvi^ri" IICJuH"', .ij.
M. ft ilivitlc ill |iulv. X, A
jwwdcr every twi> hour*.
(/'rv/. Jtiaim.)
For severe vomiting In
perl ton! tia.
tl Mur]iliiiiii' Ijvilrdcliloriili,
.\<juii' Iiiurv'Cvnuii, .^jw.
Mmtiinf amt K'lalic, Jvj.
H. f . mist. A tabletiiHxiuful
overy hour. {Bntim.)
Opium powdera for peri-
tonitis.
li Pulvcris oiiii, gr. ix.
Sni'cliari aibi pulvoris, >jn(i,
H. ct diriilo in pulv. xij. A
l>owdcr every two hours.
{/lam/irifrr.)
Oplom and belladonna
for peritonitis.
ft Pulvtri!<
Extnuli
"l"i. gr. J.
llH'lladoniiii'
bolici. gr. J,.
Blfliiiuthi iixydi, gr, j.
pUll
(iloo-
M. f. i.il.
tiine« II iluy.
To
hv taken four
{H'/i,ll,i.)
♦ Limn-t, Jmuary I6th, 18B", ji. 1-W.
3*4
Medic A l Tr ea tmen t.
(Pan I.
Aconite and opium in
peritonitis.
II Tiucliini* aooiiiti. >ij.
Tiiirtiini' opii lul -J.
M. f. tinct. Tcu t*) Hfti'cii
dru|w every hour or two.
(/JorMo/uw.)
Morphine powders for
peritonitis.
fV Moriiliiua* hydrochloridi,
.Succluin nlbi, gr. xix.
M. ct 'liviiic in pulv. vj. A
powder every hour or two.
(/iroHn.)
Napbtbol camphor In tuber-
cular peri ton! tia
After the withdniwul of
ritthiT more thiuia |iiiit of lliiid
frt;>ni thv uMomeu lu a caae of
tiilKTi-uhir peritoiiiti* in a boy
thirteen yi'an< of age. u)>out
.1 <ir:tms nf a solution of u»p)i-
t.hol nimphor wuk injected iuto
the abdomen, and complete
recovery followed. Xaphthol
camphor is a nscid liquid mode
by mixiDK 1 ]>art uf 0 uuphthol
with 3 parts of camjihor.
3'S
|)at-t HI.
PISEASKS OF THE lIKAliT AXU IlI.O<iI)VESSEl-S
AND OK THE IJI.nol) AND Dt'tTUESS GLANDS.
CHAPTER I.
TREATURNT OF ACUTE AFFECTIONS OF TIIK HEART
AND PERICARDIUM.
AcuTB PEEirARDiTls. — KliotiKiy : Acutc Rliciininti-mi — Brislit's
Difieajse- (tout— 8«'urTy — Piiibotea— PiioriM^nii Si^ptica-iniii -
Scarlet Kevpr — Tuberculo»i». Fonni« nf I'cricaniiti*— Ofloti
latent —SymjitoDi*. Imlieationt fur 'l\enlmml: Sodiuni Snli-
cylate— Alkalies nnd Aconito— Opium— A|)orieut»- Ice-bajf—
Leeches— BiiMxlinc — Wunn Fomcntntiom — (juluiiie in KffiT-
Teacence — BliHtfrit— l(>ilinG— Potajwium Iiiditltj uiifl Dii^'tiiUn
— Mercurial Inunctions — Touica — Fix'd and Stiniulnnttt —
Puncture ami As|>inition— Inciniou in Purulent Effusions.
Actm Endocabditis.— It* Nature — Etioln(iy — Micro-orpiuiimm.
iMitiralions /or Trfatmrnt • UnwUy t\\iiiK of Acute Uheuni-
nUnm — AJJcalie* — 8alicin and Quinine - Value of Wat#-T—
Formula.' — 0|iiuni — Ice-lnif! — Hlintem— Alcolml— Diptali» —
Perchloride nf Iron— liuUndonna Platter — Rest — Potniwiuni
Iodide— Dr. Cuton's Tnjutmcut.
M.iUasA>rT on I'l-CEnATiVK ENKOCAHDniB.— It» Relation to Sep-
tir Processes ami to Micmliic Acti'tn — Septic Emboli— Ooiier-
ally Ends Fatullv — Treatment with AntifiepticK, witli Quinine,
Araenic, Yeant Culture, Auti-itrcptococcus Serum, Nuclviii.
Additiou/U Fonnula*.
In coTi.sidfn'nj; the subject of tlip frrsiliiK'iil of
dJsenseH or the heart, we »liiill lie cliielly mii-
cerned with ll)os(" chronu; affections of tliat organ
which involve some lesion of one or other of its sets
of valves, or of its muscular structure, or of liotli ;
l)Ut we shall also have to discuss the treatment of
anile ttflections of the heart, and of its covering, the
jiencfiniiiiin. Tliis, however, will Ik* done lirietly,
lieoau.se ilu-se «(-«/»> inflammations genenilly arise lus
coniplicntioiiH of otlipr diseases, the full exaiuwAtvcsw
3^6
Medical Tkeatmsht.
IPi.rt 11.
of IIk' (rojitiuoiit of wliicli will In? found uihIi.t tlii.'ir
ujijirujiriHte liuadiiigs.
Pekicabditis.
PciicaniiLis r.irely occiirn us a primary ifHo-
patliic disiNvse ; sotnp autliorities, however, Iwlieve it
does so in childliotKl ; it ih aliuost invariatily sfoondnry
to some yeiu'nxl iimlady, or it occurs as an extension
of inflanHiiatioii from sotiie adjiH-<>iit part. Frequently
it is only a part of a geiioral inll;iii)mation of the heart
which affects the niyociirdiniii also, and sometimes
the endocardiiiiii.
Aciili' I'iK-iiiiinliNiii is by far the most common
cause of pericarditis, esjyeciaUy in children and y*)ung
adults, and the pericanlitis has Ix^on ol)serve<l, more
pai'liculiii'ly in the former, occasionally to precede the
joint aflection. tiright'ii dUfage is another common
cause of pericanlitis. Gout, scurvy, and diabetes
liave also been regarded as causes of this disease.
Pei'icarditis is also a]it to occur as a consequeiu^e of
certain septic jiroccsses, as e.i/. in puerpienil fever. It
sometimes apfiears as a complicittion of the orupitivp
fevers, particularly of scarlet-fever, in cliildhrKxl. A
tultfrniJoHs form occurs in connection with tulier-
cnlosis of the serous ini'iiilirancs. It may arise by
extension from left picurij pneumonia, and it may
occur in conse((uenc« of disease of the adjacent
chest-wall, or mediastinal structures, or neiglibouring
abdominal viscera, and it may be caused by pywmic
abscess of the myneardinni.
In many of these connections it is simply one of
the nntnifcstalions rxrurring in the progn^ss of an
inevitably fatal malady.
Three forms of poricaditis liave been described : —
1. A tin/ form, in which there is simply a fibrinnas
exudation on the .surface of the serous monibi-anc.
2. Perii«i-ditis, with fffuHtou, either sei-ofilirinous,
hiemorrhagic, or purident.
3. An adhesive form, in which tiie perictirdium
becomes adherent to the surface of the heart.
Chip. I.)
AcuTR Pex/caroitis.
'J'lio pliysiciil sijfns of acutt' jK'ricuwIitis hIiouIcI Ih'
«yin>fiilly lociketl for in tin- course of all tliosc aH«'tious
w}ii(.-li an." jiroiie to give rise U) this liisciiwe. This is the
more iin|iortJi)it, as it ix npt to lie lltU'Ul, especially
when it occurs in couneetioii with Urij^lit's (.lifiea-se,
Jiiid i/rnrrtil si/iiiptoiim may 1"' entirely aliMent. Mm-e
commonly, howover, ci^implniiiC of /lain in the prie-
cordial re;j;ion is the first indication of the occurrence
of iiericarditis. The/«ii« isofteii intense, and radiates
over the chest and down the left arm, and th<>re in
great tcndeniess on preasure over the cardinc and
epigastric regions. Great and distressing tli/gpnun is
also another [ironiinent feature in acute pericarditis,
esiH-cially when there is a large amount of etiiisiou.
Sometimes theit? is a great disturbance of the cardiac
action, wilii palpitation and a rapid and iriTgular
pulse.
The indiratioiiM for Irt'iituicnl are, lirst, to
inoderat<> and rcdiici' the iiitlamniation a.s rpiickly as
possible, by regulating the cardiac action and lessen-
ing its rapidity ; secondly, to relieve pain and distress;
thirdly, to promote the absorption of the eHiwion ;
and fourthly, to remove it by operation when its
presence and amount give rise to dangerous symptoms
from pn-ssnre on the heart. Absolute rest in hed is,
of course, essential.
In rheumatic ca-ses, suiliiun gn/ifi/tatf or gnliein
in combination with poliuaiuin fiifirboituli: may be
given 80 long as the arthritic symptoms remain un-
ivlieved. >Some American writers on therapeutics
object to the use of salicylates in cases of rheumatic
jii;ricnr(Jitis, but urge the use of alkalies, together
with full doses of aconite to lower the cardiac action.
We cannot share this view, for if the salicylates (or
salicin) are indiw»t«i in the treatment of ordinary
attacks of jHjlyarthritic rheumatism, the additional
afl'ection of a visceral Joint — a.s, in a certain sense,
the pericardium may l>e terme<l — can hardly contra-
imlicale its use. Moreover, if a depressing drug liko
iuxinit« is indicated in these cases for the sake of
3*8
Medical Treatment.
iPart ir.
ii'iiiuiiig tli<' i-jiidisic lU'tioii, wliy ii"t siKlium siilicy-
late, tlic ri'tiiediiil ffl'i-et nf wliicli in .icuto rhininiatisin
is usually Hccnnipatiied l>y ii riipid lowering of the
pulse freijuency f We often find, on the tliini duy of
trentnienl with sndiuni siilicylate in tieutp rheiiniatisni,
tlip pulse licut refluced to (50 in th(? minute.*
Ophiiit conditned with saline diajthorclics is very
uscfid in those cases in wliieli there is iiiueh )»fieeordial
pain. We prefer to ip^f it in t)ie form of l>over'N
powder, Ti grains with a drum or two of liquor
iininioiiii aoetntis. every three or four liours, until
(hf! )Hiin is 8ul>dued. To ensure a free action of the
Uiwels, eKjx'cially during this ojiium treatment, an
efficient saline aperient should l)e given daily. Two
or three drams of sodium sulphate in an ounce and
a liidf of infusion of .senna usually answers well.
The application of an icp-lmu to the pnvcordial
region is a valnahle remedy for allaying the iiiHam-
liiation and (|uieting cardiac action. It is not veiy
popular ill England or in Ainerica.t but when
applied earli/ and thoroughly it has proved in many
cases very elKcacious. Satisom warmly advocates
its employment.* When the use of the ice-hag is
ohjectetl to, the pain and distress may generally
be gi-ratly relieve<i by the application of a few
leeclies over the hternum, followed by a hot linseed
poultice siiiinkled with laudaiuim. General bleeding
is rarely called for, although Fagge observes : "When
there are symjitonis of enibarra.ssed circulation with
nrthopno'a and distress, an irregular pulse, arterial
ann>niia, and venous congestion, the ahstraction of 4
or 5 ounces of blood from the arm is found in some
cases to give remarkable relief, and probably is never
injurious."
• Wo shall have to discum the ubo of thu mlicylates in ncute
rlicumntiKm in a !iu)>Ke<|Urut chapter.
t Amongtt Amt-rirui auttiont Prof. Osier savs, "Tlie ice-has
if of (friiit viilue " (•■ Principle and Prorlicc of Medicine," fourth
eilitioii. p. (ifii'i), wliilo Prof. W. H. Thomsfiii ohifnea, "My
expt'iienee* with it have mil l>eou favouruhle " (Haro'n " SyRtem
of Pnirtical 'I'licmjieutios," second editiou, vol. ii., p. 310),
; f.iimrl. 11100, vol. i., p. 924.
Chalk t.J
Acute Pericard/tis.
329
I
Wami applications, Jis hot (lanrn-Is, hot cotton
wool, ami lifit poiillicca t"i lln; pruruiiliiil surfiicc, arc
usually cunifdrtinjt;. in ilit'iiniiilic oumch, wlien tlic
ck'pressinp; cfl'ects of the salirylates is to l»e Icftrwl, oi-
■when the joint inHniiiinatioii is subdued, ipiinine
in moderate doses, 1 to 3 grains, may Ik- jjiven in
ftlervescence in cOTnldnation witii potassium citrate.
When we have a large «>trusion to (le«l with, tho
aliKorption of whicli we are anxious to promote,
blifitering will frequenllj' lie found most useful. In
rheumatic cases large tfl'imions will constantly lie
found to disappear rapidly after the application of a
full-sized blislpr followed liy hot poultices. In renal
cases cantharidiiu' applications are, however, to Ih?
avoided, hut we may then resort to the use of strong
iodine paint. PotjLssiuni iodide alone, or condjined
with digitali.s and other diiUM'iics, will lie found, in
llie lat*r stages, a valualih- agi.>nt for promoting the
disaj)pearance of the eft'usion. MeiTuriid inunctions
are still advocated for the removal of slowly di»-
tt|i])earing efluaions.
If cardiac failuif slnuild tlwenteii, supporting
reinediett must l>c freely applitnl, as Imrk. i|uiniiie, and
strychnine, with ether, aminonia, alcohol, etc. Light
fo<Ml, but not with loo much fluid, for fear of
inci-easing the etl'usion, shoulil be given. Light
pudflings. whipped eggs, milk, or bread ami milk, oat-
meal gruel, and the lighter kinds of fish are suitable.
When a large effusion is seriously compressing the
heart and embarrassing its action antl causing gnivu
dyspn<ea, and e-sjiecially if it has resisted the applica-
tion of blisters — or if there is nyison (from explora-
tory puncture with a liypoflermic syringe) to U'lievo
the effusitm to lie titiiulent — removal of the tlnid by
n<ipii-ntion or iiu'lNioti of the pericardium luus to
lie considered.
Aft«r mrefully ]iercus8ing and outlining tl>e area
of dulness, the nature of the fluid effusion should first
be asctirtiiined by puncture with the necille of a
]iypr>derniic syringe, carefully rendered aseptic. The
330
Medical Tkeatmrxt.
[»
III.
bent aitnation for UiLs niiil suliHeqiient puncture or
incuion i* the fimrlli or fifth left intercostal spnoe,
about HI) inol) ext^-rnally to the left margin of the
•toniuiu,* HO AM to avoid tfae internal niiuuman' taXery,
Tf the fliiifl iH fterous or iiero-tibrinous, then a fine
iu])irating needle or trocar should !« introduced in the
Minie Hpot, and the fluid, or a portion of it, very
•lowly withdrawn. If the fluid is found to be ptuni-
UtU, then an incision must l>e inaile into the peri-
cardium in the situation already nientioneil. The
inciKion Hhould l)e Hmull at first, and cautiously
tndarged. It may be enlarged by cuttinj: or dilating
with sinus forceps. The pus having been allowed to
(scape, a soft drainage-tulje must be inserted, and the
cavity may Ite washed out, if necessary, from time to
time with a warm boric acid solution. This will often
be ntweMary in onler to detach and n^niove fibrino-
purulirnl caseous niasw^s. But thi.s irrigation tiiust lie
Iterfonned with groat care and caution, and we should
jiartiiMilarly see that there is always a /re« otitUt
initintnincd fur the csca[ie of the irrigation fluid, as
suddenly fut«l mishaps have occurred fii)m the pressuiv
of irrigation fluid on the heart, owing to the accidental
plugging of the outlet tube.
.J. II. Uoljerts t recommends an oiKjration for
Muppurntivr pericnrditis which cousista in " raising a
trapi-door of the 4th and 5th costal cartilages and
connecting wjfl fwrts and using the tiHsues of tlie 3ni
int^THpuce as a hinge. The internal mammary vessels
and left plcuni are thus exposed and pushed to the
left " : the object is to avoid the risk of opening the left
pleural cavity. Of twenty-six collected cases there
were ton recoveries and sixteen deaths. At least
nine of the latter were septic, and all the rest had
eoniplicafitig huiions.
During eonvalescenct the patient should he carcfull}-
• "In Urgt' cfTun'oiu tho ]iericmr(liuin cnn silw^ I"' n-mlily
nachod without dniiger, by thriixting thii ncodle upw^ud nnd
Ineliwai'd Aims to Uic costkl margin iu t)w< Mt cofito-xiplioid
aiiRic" {0>lri\.
,j)Mit'il AVi/«, May 8Ui, 1807.
Otiip. I.)
I
Wiitchi'ii Hiiil |iix>t('ftc<l ayiiiiisl iill ciopn'ssinji aj{i'iici<'s.
A proKiiifjoil |)i'iio<l of iiluiiisL jilisuluto ivst nhoiild W
ilisist4>cl IIJM311, as tlic iiiyociinliuni is oftt-ii iiivoh t'<i, and
the risk of agj^riivating any insulting cardiac dilatii-
tioii is not to lie overlooked. Light hut nourishing
food should 1m' order<«i, and the diet carefully watched
to not* if any digestive disturbances arise. Prof,
W. H. Thomson* givps small doses (gr. v.) of iodide
of potas.siuui combined with tincture of belladonna
during convalescence. He think.s it allays a tendency
to jMilpitjition. But in mild weather reclining in the
open air hax lioth a quieting and Htrengthening
influence.
AcUTR Endocahditis.
" Siiiiplp " or " bfiiiirn " endocarditis, the rnriii
which i.s commonly met with, is not regarded by
some palliologists a.s pre,senting any essential difference
in nature from that rarer form which, from its fatal
character, is spoken of as " vialupmnt " or " u/cfriitiv<t "
or " infective " endocarditis. Osier says ; " Thei-o is
no efisential anatomical difference, as all gradations
can be traced, and they represent but different degrees
of intensity of tie- .same process."
Dut elinioillij, in course, symptoms, and results,
the distinction between the two forms is very obvious.
We must consider brielly the patlioh);,ai.-al nature
of this disoaite, so far as it is at pnseiit understoixl,
before we can establish rational iurliailioiis for it*i
treatment. In simple endoairditis minute vvKCln-
li«n»i appear on the endocardium covering the valvea
or lining the cavities of the heart. These vegetations
are often attached by very slender pedicles, so that
they have a caulillower-like form. They hfive an
iii-egular, cnicked surface, giving theiu a warty aspect.
The appearance of tlies<! vegetations is accompanied
by a proliferation of the subendothelial connective
tissue elements. A deposit of fibrin from the blood
• HttTo'n "Sjstwu of Prnoticiil Tlii'ni|M'ut>cs," vol,u.,v.XVV
new I'ditioii), I'.iei.
J
33*
Medical Treatmekt.
IP:irl II.
occuiTi on the suifiu-c of these j)rojpctioiis, «o tliiit ii
veye.ltitiou liiis Itcen tlcscrilu'd n.s ]njiftica)lj "aNiiiall
urea nf jiraiiuliifioii tissm.' ru]>|i('(l willi liluiii. " Micrii-
oryimisiiu) are nften foiliul i'ntiin;j;li.'il in tlic deposited
fibrin,
In the majority of cases tlie grniiuiation tissue
undefyo<'8 cicatrisation, and leaves only a sliglit
nodular thickening of the valve. It is rare in acute
felirilc endocarditis for a vegetation to be detaclied
and cariifd as an omboliis to a distant part of the
circnlation, but this acci<l(jnt is not uiiconiinon in that
form f>f endocarditis which attacks old Hclerotic valves.
The daiii;i'roiiK part of an attack of simple acute
pndociirditis is the tendency to slow progressive
sclerosing changes in the valve tissues, and the ulti-
mate- contraction and dcforniity to which it leads. It
is renuirkable thiit it is almost invariably the fe/( side
of the. heart that is airected, except in foetal life, when
the right side uf the heart is found aflected also, and
it has been suggostetl that the iiillaniiiiatory ]x>ison
tnust need oxygenated arterial Idood for its activity.
The mitral valve is more frequently ailected than llie
aortic.
With regaixl to the pliolojfy of simple acute
endocarditis it must be borne in mind that it (lo(<s
not occur lus a disease of itself, but is always a coin-
j>lication of some other iiflection, and in tlie vast
majority of cases that affection is nrule r/ieumatism.
It has l»een suggestefl that it tiiay be caused not bj
anything in the disease itself, but simply by an altered
State of the fluids, " a reduction, perhaps, of the lethal
influences which they nornndly exert, i)ermitting the
invasion of the lilood by cert<iin micro-organisms "
(Osier); It also occurs in connection with chorea,
tonsillitis, scarlet fever, acute pneumonia, phthisis,
cancer, gout, dialx-tes, and Blight's disease. It is
also pmnc to occur in a recurrent form, attacking
those valves already disabled and crippled by former
attacks.
The inilirniions for IreiiliiiMit arc neccssariljr,
Acute Endocarditis.
333
I
1
I
in the first place, those which apply to tlio disciiso of
which it is » complictUioii ; iitul us this is gcniTiilly
acut« rheuiiifttLsni, it is scarcely possilile to consiilor
the trcutmenl of siniplo acute endociirriitis apart fr«>in
that of acute rheuiuatisiii. The first indication for treat-
ment is, therefore, to modify, if possible, the disortlered
state of the blood which hns excited the inHammation.
The second indicution is more directly applicuhle to
the state of the heart itself — it is to moderate and
reduce its more or less excite<l action, for mechanical
activity of the valves tends to increase and aggravate
the inflammatory changes. We must strive to procure
for the inflamed ht.«.rt. the greatest amount of relative
rest.
In the case of rheumatic endocarditis the free use
of alkalies so as to maintain and increase the alkalinity
of the blood hiw many advocjites. " When they are
given promptly,'' says one writer,* "and with the
one object sj)eedily to alkalinise the urine and to keep
it alkaline, the heart may be reasonably regarded as
H»ife from serious attack " ; and the same author maiii-
t»iins that "heart inflammations have increaseil in
frequency since the introduction of the sivlicylates in
the treatment of rheumatism .''
We arc not aware of any substantial facts that
can l)e advanced in support of this statement ; we
K'licvo the best treatment for these ciises is a com-
bination of alkalies and s<alicin, with which we
would also combine some moderate doses of quinine.
AlkalicH and salicylates reduce arterial pressure by
stimulating the functions of the skin and kidneyw.
Another means of modifying the blood con<lition ami
its irritating effects on the endocardium is the free
administration of diluent fluids, and especially uli jmrn
iifUer. Instead of giving the patient strong meat
essences and broths to drink, which, for aught we
know, may have a very injurious inlliience on the
blood condition, we prescribe as much pure warm w.iter
' Prof. W. n. IlioiusoD, in Uiire'a " System of Priuiticiil
TtieraiKUtioM," vol. u.. p. 301 tnow Hdition), ISOl.
334
MmoKAL TtttAryEST.
I Part It
W V* «*B gK absorbed, sUifhtij flavoured with l«woa |
jnlea, and we giw no fixxl in the early stages (when
lIuMV arc no «t^u uf I'xhaustioti), but milk freely
dillttad with nil alkaliue wat«r, a little warm wcjik
bmth, ami thin gruel. All tbroutth the early acute
Ktugr the ftKul shoiilii !)»> very lij,'ht. The indication,
wt> vtMttuiv to urgv, is to wash the coutaniinatcd blood ^
by pacing larjtv* quantities of pure water rapidly fl
(hrut«){h the cirvulatin;; lluid. The alkaline medicines ^
Hhould lie given /ary«^y diluted witit ir-jter. The
*toniacii cannot aluorb larjfe quantities of foo<l and
water at the same time, .-unl we consider the latter of
tile ttrtMter iiajx^rtantv at the outset of this diseasa.
We HUi{i;vNt tho followitiji; formula as a most useful
i-oinliinntion iti t-aj«s of rheumatic eudixiarditis, either
threatening or est:»lilislu-sl : —
19 Salirini •■• SJ-
Potaisii 1'" iri' 'H ii^- 3iv.
SoJii .■.itl'omtii jij.
A<|UH< ... .id Jiij.
Mi««% flat mirtow. Two tabUv|«unful8 prcry two honn
whiln the itcutt' iobrilu stattf (.■ontinucs, with two tablopuonfuls
i)( llic fiilluwiiig mixture : —
1^ t|uiniiiii> <iil|>liHti!i ... (ir. xiiv.
Aciili eilriei ^iij.
Tinclurn) hniuuU . ... -y.
Aiiuw ad jiij.
Mis>-c, flat misturu.
In this way the patient will get GO grains of salicin
and 24 grains of quinine in 24 hours dissolved in
24 dz. of alkaline solution.*
It has l)een suggested by Bniadljeut t that :ilkali(s
may lessen the tendency to deposition of (ibrin on the
cardiac valves by diminishing the iwvguiability of the
blood, and be calls attention to the circumstance that
• Priif. W. H. Tliomnoii cliuwifii'
I tifpirA.ittntit {op, rit,). Wi- jirt? iiiit
jiiKtify this. Cortiiiii )>luiriu»cr>li>|^i
Hiirh u (iljit*>ineiil. ImiI it <l<>i>» ii>>i un;
lit uny nito, when givni in moJuniti
t " Hoftft Disivuui '■ (thinl oditio
iifli<«miiiiiii« an
* wnou|T«t rantiitc
'"^ llMirtll faLt« to
We arc iiwarr,
ex peri t?!!!-* —
336
Medical Trea tmen-i-.
[fail II.
must be observed, niui due elimination maintained
by the Judicious use of aperients.
Dr. Caton * luis strongly advocated a raetbod of
treatment in acute rheumatic endocarditis, which bu
nmiiitains ho has found very effecti\e in preventing
tlise:use of the valves. There is nothing whatever
that is novel in his method, or that has not been
rocoinuieuded by other physicians ; but he asserts
that he has carried tliis inetiiod out more thoroughly
and ejirncstly than othera have done !
First, he insists on a [imloni/fd period o/regl inbrd.
That lias, we believe, b«?n urged by every authority
who has written on this subject. The ditKciilty has
always been to enforce this rule amongst the class
from whom liospitjd patients are derived. Of its
extreme importance there can lie no doubt.
SfComUfi, he a«lvocat€.'i the application of a series
of small blisters, al>out the .size of a florin, over the
I'cgion between the clavicle and the nipple on the
right and left sides. He believes the counter-
irritation acts by " direct stimulation of the vaso-
motor and trophic nerves of an ailing part." Here
again we may remark that blistering the prrecordial
region in rheumatic endocarditis is an old measure
which has had its advocates and its olyectors. We
remcmlK-r in our student days how the late Sir
CSeorge Johnson used to oVijcct to it as interfering with
his auscultation, and, he thought, "doing no good."
Ur. Cat<jn considers it of some importance that tlie
blisters should Ixj applied along the course of the
first four dorsal intercostal nerves, as they arc closely
asBociated with the upper and middle cardiao
nerves.
Tliirdly, he adopts ft view ami a practice which
we have always advocated, and set forth in this
work, viz. that sclerosing and deforming changes in
tlio cardiac valves as a consequence of endocarditis
may be to a great extent prevented or lessened by the
* "Tlio rrcvcnlion of Valvular Duouc o( the Heart.'
Lonilon : Clay 4: Son*. I WOO.
Chap. t.|
EfTDOCARDITtS.
337
long-c<intiiiU(><l use of Rodium or p<>t4i.ssiiiin iodide.
The removal of any inlluiuniatory cti'usioii into the
sulistance, or on the surface of the vnlve, may also Wy
this means be promoted. At any nite, we have
obst'rved, as wc have already said, the physical signs
of valvular incompetence to disappear under this
trwitment in young persons.
During convale.scence the prasenco of anwmia and
cardiac asthenia will constantly tlemand the employ-
ment of some cardiac toni<\ A combination of iron
or arsenic and strychnine ;^enenilly answers well. It
may bo aHsociated with the simIIuui iodide already
referred to. Occasionally small doses of digitiUis may
Ik; needed to steatly the canliac action, but this drug
is to Ijc avoided as long as any iuHamniatory process
is going on.
MALKiNAST, Ulcerative, oh
Enikm^akihtis.
Infkctive
This is believed to occur occasionally as nprinmri/
affection of the endocardium ; it is mui-ii less fre-
(piently a complication of acute rheuuiatisni r.liati tlin
Kunjilc form ; but the endcx-Hrditis which i.veasioiiHJly
occurs as a «)m|ilieatiou of acute |incuniO[iia is apt to
lie of this mali;jnant type. Tt is prone to occur in
connection with all kinds of gtppiii- processes and
all forms of septiciumia. It is chanicterised, a.s its
tuimo implies, by ulcerative and suppurative prrices.ses
affecting chietlj' the valvular eiidi>carcliuni. The
necrotic process leads to superficial or di-op ulcerfititm
which may even [>erfonite a valve or a si'ptvim ; and
small abscesses may Ix- found at the ba-sf; of the
vegetations. Various mii'roi>rr/auii<iiiii have been fouml
a.ssociatetl with these ulcerntive changes ; those u\osl
fre«piently met with hi'long to the pyogenic group,
streptococci, staphylococci, :iu<l others, and in pneu-
monic cases pneuinucocci have U^cn seen. The transfer
of septic enilxdi from the liwirt to various parts of the
Ijody where they si>t up septic suppunilive processes is
one of the most .serious conseijuences «V V\»"w Avwowws;.
IT
338
Medic AT. Treatment.
I Pan II.
Sometimes nu ulccralivp j)rocoss Bttiicks the
eiidccHrdiuni in cases of chnmie viilvuliir disease,
Hnd syiiiptoiu.s iliio to liitlust'd emboli ufti-ii iittend tho
closing stt'iK's of clii-oiiic lit-iirt ikHectiniis.
Most raises of ulcerative endocaitlitia terminate
fatflilly and run a soniewhat rapid course ; the chief
exceptions to this rule occur in some of the cases that
are seen in connection with old sclerotic valve disease.
Tlii're arc, as might lie anticipated, few diroct
indications in this disea-se for elHcient treatment.
" In the severer cases the treatment is i>ractically that
of septiciemiiv " (Osier). Quinine in Full doses, pre-
parations of iron and arsenic, mercuric chloride,
Bodiui^i sulphocarlwlat*", nodiniu heuxnate, and salol :
as large doses of these and other autiseiitics as can
conveniently he given have heen .advncateil, iind appear
to answer the oidy rational indication allbrded.
Biomllient * reports a case iu which recovery
followed the free ailmlnistration of mercuric chloride,
and two other cases in which the hypodermic injection
of pure cultures of yeast ajiparently anested the
disease in one, and caused a marked temporary im-
provement in the symptoms in another, but he is not
disposed to place any reliance on the.se remedies.
Itouglas Powell t states that arsenic is the only
drug under a course of which he has seen the disease
get well. With regard to the use of nnti-Mti'cptu-
rori'lis ><*i'iilll, he has collected notes of 11 cases in
which it was tried; of these, three were reportetl
cured and 1 1 were not successful. The dose of anti-
streptococcus scrum in these cases varied from 10 to
20 c.c, twice a day, the larger dose Ixjing gradually
rwluced.
He also refers to a cn.se that recovered after the
injection of yea.st culture (20 to 30 minims each second
day).
Douglas Powell also suggests the possibility of
nuclein (emjdoyed by Professor Vaughan of Michigan
• •' Hciirt rHsHiJw" (lliir.1 «liti>-.ii), IIKMI, p, M.
t Luniloinn Lecturn, ISUi', |>. Ifi'i.
MALICy.i\r ENDOCARDITIS.
339
in tiilx^rculusix) being of use in this affection, Imt
no very definite report ot" its success \a iit pi-esent
availnbie.
There in certainly a (lis|K)8ition prevailing to give
further trial to injections of Hnti-streptocfMrcus senini
in tiiis disease. Dr. Mitchell Clarke has reiKiiled :i
successful result from its use,* He piive doses vary-
injj! from 10 to 20 c.c. of serum olitnined at the
tienner Institute. He thought the 20 c.c. do8e loo
large, as it was followed by faintness anfl a feeble
pulse. It is best to \x^m with 5 c.c. and increa.se to
15 or 20 c.c. if nee<lful, giving one injection daily.
AriitP ni}-o«-iirdili», which sometimes accom-
panies acute pericarditis and acute enilocarditis,
presents no sjiecial therapeutic indications apart from
those already con.sidi'red.
Ai>i)nioNAL kormuljt;.
Cooling acid mixtnre In
perlcardltU.
H A<iili iilionjihorici diluti,
Syrtijii iiiori, iv.
iii\wv ml Jvj.
M. f. mist. A tablonpoonful
every hour. {Bamberyei:)
k» a cardiac tonic and febri-
fuge In pericarditis,
R Quiiiiiiii' sii]]ilititi8, gr. vj m)
xviij.
Saochnri iiUii, gr. Izxx.
M. »'t iliviiU) ill pulv. vj. One
every tliroc h(jur».
{Biimbergtr.)
In ulcerative endocarditis,
& Qtiiiiiuu- sulpliatw, gr. xij
ltd IX-KYJ.
Ai-idi citrici, gr. xiiv. oA
l\.tij.
Syru|)i limoiiis, .=,j.
Aqiin' dilorofiimii, a<l .',vi.
M. f. mist. A tulilfuf.otiiiiul
eviTV thrf(! or four hnuri*.
Mixture In convalescence
from endocarditis.
R PotusKii iixliili, ^1. x.\.\ij.
f'obigsii biuiritoittttij*, gr.
Ixxx.
Spirit, nninioii. arrmiatici,
Siv.
Tinotiini' cinchouip comp.,
•J'
Aquit' u<l .TViij.
M. f. ttiinf. A talilc9l>ooiiiiil
throe timos n <li<y.
• Lancet, vol. ii., IIJOO, p. liiH.
34°
CHAPTER 11.
TIIK TRKATMKNT OF CHRONIC AKFECTIOSS OF
CAUTHAC VALVES.
riiK
Chbohic VAi.VT7t.AR Lesioss.— Oonenil Thrnipeutic Indicatioos —
Etiologj'^Meclmiiieal Effects nud CoiisequeiiCM — Hj-per-
trophy anil Oilutatioo. Treatment of l.'omprjimlfit Ciwes :
Keifimun — Exprci»e— Clothing — Avoiiianco of Excitement —
Fno(l iiud Stiniulont.'i — Alctiliol — Ten — Coffee — Tobocio—
TIkitiihI Treiitinent — Ajwrients — Climnto — Drugs rarely
neoilcil— Digitalii — Iron — Arsenic — I'otoacium Bromide —
OjKiU-tiir Life. TrcMmeul of Xoit-rinHpeittutcdCixiU}^: Effect*
of Miliiil Failure Pulmonary EugorKement— Dyspnowi —
Cough — Ex|KX'tonitiun—Hifmontym»— General Venoua En-
?orgement — Eulurgenieut of Liver — Oastro - Intestiiwl
^tarrh — Con»ti])iition— .S«mty Albuminous Urine — Cyanunu
— Dropsy — Effect* of Failure of .ii>rlif Valves — Pallor — Cere-
bral Anii'mia — Pal]>itatiou — Piini — Drspua-a — ( trthopniiia
— Frequency of Embolism — Cftiff 1 brnifjrntic Iniiiraliim
— To raiac the Cnnliac Tone Imijorfancc of atjiiolute Rent —
Caniiac Tonirtt — Digitalii^ — Stropnanthu» — Caffeine -Conval-
laria— .Sparteine —Adonis venuilU — Cuetu* granOiflorui —
Slrjchuine— Quinine — Coca— Kola— Iron — Aperient*. Addi-
tional Fomiulic.
•
We now pass on to con.sider tlie maniigeinent of those
chronic disorders of the cardiuc iiiechaiii.-itii dependent
on diseafi; of its ru/iv-s, and of the several nmrhid
states wliich iirise thcrpfrom.
In conHidering the niaimfjcnicntof valvidar disea.scH
we shiill liave to draw a marked distinction between
coiitpeiun(ed and noii-coin/if-iisiilid ca.ses.
Apart from the treatment uf certain coniplicationii
ami .special symptoms, the therapeutic prolih^m pre-
sented to us in dealing with these easeti may be
sumniurisetl in the tliree following indications: —
1. To arrest or ivtard degenerative processes.
2. To diinini.sh the mechanical work of the heAft.
3. To riii.se the tone of the cardi.ac iiniHcle.
We shall show, as we ])roceed, what means we
Imvc at our disposal fur I'lillilling thesi- indications.
With n>gnrd to rliroiilf valviiliir Ifiiioiis,
we have already seen that these usually originate in
Chap. II.) Chronic Vali'vlar D/ssass.
341
an attack of Hcuti' etHlocartlitis, iiiul espt-oiiilly in
rlicimmtic eniliKvuilitis; the tliickcnin-j; and fleforiuitv
of the viilvo nitiy l>e but sliglit at tlie imkI of the
acute attack, but the valve so injured is liable to
undergM further deformity by becoming the seat of
cliTOiiie endocarditis, wliich may ultimately lead to
serious) impairment of its functions.
But chronic endocarditis leading to sclerotic
changes in tiie valves may arise from other causes
than rlieuiiiatisni, as from syjihilis, gout, or alcoholism.
Another cause of chronic valvular disease, especially
of the aortic valves, is glrain from e.\ce8si\e muscular
exertion. In athletic exei-cises or in severe and
sustained muscular Inlxiur there is an increased strain
imjKised on the aortic valves during the ventricular
diastole, and this iu time setn up chronic endo-arteritis
and .sclerotic changes in the valve segments. In some
CAses the chronic atfection of the aortic valve is asso-
ciated with allteroinnlou» changes in the adjacent part
of the aorta.
The cH'ect on the mechanism of the heart of these
Vhlvular changes is either to narrow and constrict the
opening guarriiHl by the valve (glftiofvi) and so di-
minish the outflow through it, or to render the valvo
inconi{>eteiit to close the opening as it should do
{iiigulticlmcy), and so to allow of an aVmonnal back-
waiil flow of lilmxl into the chamber from which it
had lieen propelled. In either case dilatation of one
of tlie chojnbers of the heart must o<'cur from incn«ise
of bloo<l pressure witliin it. When, as is often
the case, constriction of the opening is combined with
incompetence of the valve, not only is there an
abnormal (mechanical difficulty interjsjsed in the pro-
pulsion of the blooil from niif chiimber to the other, but
there is ail aililitioiinl niecliaiiical distending or dilating
influence from the over-lilling of one of the chumliers
by an obnormnl reflux of bloul, so that the chamber
receives a biickwnrd as well as a forward cuirent.
These changes tivke place, as a rule, gradually, and
not abruptly, therefore the insufliciency and conse-
342
Medic A l Tk ea t.ment.
[Part II.
iiuent. liiliitjition are, at lirst, imly niodci-atc, ami the
tiatura) ivsi^rve force of th«' cardiac iiiiiselo is e^^iial to
overcoming the diHicutty. But when tlie inHuUiciency
is consi<lei-abl<>, obviously the cMrtliac chauiljer eliii.'Hy
afTcc'trd itmnt riecil groatly incn-asfKl uiusouiar force
to jirujic'l so larf^i'ly increased a voluuie of hlood, and
this is {irovided l)y an increase or htipiTtroplnj of its
muscular walls, and so long as this hypertrophy is
julei|Uat« to overcome the mechanical (Hrticulty pro-
cewling from the disease<i valve, the vaividar lesion*
is stiid to be conipetisated, and the circulatory equili-
iirinm is maintained. But when the hypurtrophied
nmscle begins to degeneratt;, and to \n'. inadequate to
overcome the cUect of the valvular lesion, coiiifKiisa-
lioti is said to /nil, and 8yni[itoms dependent on
<listurlianoe of the circulatory etniilibriunr begin to
make their a[i]>earance. We see, from the foregoing,
that cardiiic dilatation an<l hypertrophy are common
and iieceK,sary eonscqtience.H of chronic valvular
disease, and that the hypertrojiliy cannot be regarded
as in itself a disejise, since it unually arises as a natural
conservative process.
But hypertrophy and dilaialion of the lieait
also arise without the existence of valvular disease.
Whatever increases the work of the heart may cause
its hypertroiihy : as, for instance, adherent peri-
cardium, which interferes with and impedes the
I'egular cardiac contractions : and continuous exces-
sive action of the heart, •' palpitations," due either to
nervous ilisturbance, such, for instance, as is asso-
ciated with exophthalmic goitre, or to the action of
stiumlants, such as teo, cottee, tobacco, or alcohol.
Or the increased work may depend on peripheral
obstruction, as in general arterio-sclerasis, or on con-
traction of the smaller arteries from the presence of
toxic matters in the hlowl raising the intravascular
tension ; or it may l)e due to prolonged and excessive
muscular exertion, which, by compressing the small
vessels, acts in the same way, and greatly increases
arterial blood-pressure. In all these conditions the
Chap. U.\ C/fSOA'IC VALyULAR D/SBASE.
343
work of tho ventricle ia increased, unci it tliert-fore'
liypertropliieii. IlypiTtitipliy of tlif riijlit ventrii'li;
8iiiiiliirly occurs (ajwrt from vitlvuliir diseiise) wiien
any obstiTictioii or increased re.si. stance is encoiinteied
in the puliuoniiry circulation, ii« in i>ulinonai'y eniphy-
Benia, pulmonary cirrhosis, etc. Nn ttfutnitut can
be, or indeed should be, directed against this form of
hypertro|)liy, apart from tlie niorl)id stale that has
excited it, as it is mainly compensatory- and lieneKcial.
Dilaliiliwii often accompanies hyi>erlrophy, and
is dependent on the same tviuses, i.i; on whatever
increases the intra cardiac pressurt; — which may be
either an increiuse<l volume of blo<(d to Iw pro[)elled or
an increased resistance to l>e overcome. This reijuire.s
no more treatnu-nt than does the co-existing hyper-
trophy. But it is not so with all cii.se.s of cardiac
dilatation and strain, and we shall reserve what wo
Lave further U) say on the etiology and treatment of
dilatation of the heart until we have considered the
treatment of chronic valvular atlections.
We will first consider the Irealnn'iii of those coses
in which compeiisntlon is perfect and complete.
Such cases reipiire cai-eful and iliscriminating
management. It may not be nece.ssary to administer
drugs, it mny even be injurious to do so, but in order
to maintain adeijunte ci>ni|K-naation, and to prevent
or post|K)ne any disturiiance of the same, the most
judicious regimenal and hygienic treatment is con-
stantly needed.
Tliei'e exists some dill'erence of opinion amongst
physicians whether patients who are founil to l>e
the subjects of a compensated valvular lesion should
or should not bo informed of the fact. We think thai
in by far the great majority of crises no liarin, but
often great good, results from explaining frankly to
the patient the ti-ue state of the ease. The public
are rapidly learning that " heart di.sea.se '' does not
necessarily mean premature and sudden death ; and
if anything could prriuiote such a termination it is to
leave them in ignorance of the importiuice of that
344
Medical Tkeatuent.
IPurtll.
judicioHs wire anil caution in thfir manner of living
iipiiii wliicli a continuiince of .sound licaltli de|H.>ncl8.
A few liijilily nervous peraous may, pei'lm|>s, tie bettor
Iffl in i^'norance of tlie fact ; but wlion we reflect how
conunoii sueli nfl'ections are, and that discussions with
j-egnrd to tlieir effects on longevity are constantly
occurring, without any kind of reserve, in connection
with proposals for life jissumnce, etc., we are iuclLned
to conclude that the niystilictition occasionally re-
sorted to is unwise and attended with no good result.
It often produces more real alarm than a frank
expl.ination of the actual state of matters. We rarely
attempt to conceal from a patient that he has phthisis,
Of cancer, or Bright's disease; why then should we
tjike pains to conceal from him the fact that he has a
far less serious niiiliwiy ]
The iiioelo of liliu pre8criljc<I for such a patient
should, in the first place, Ihj fife from all slniiii or
over-e.xertion, physical or mental. He should Ije
particularly cautioned against indulging in athletic
competitions, or undertaking violent or protracted
muscular etfort of any kind. Oentle, nioilenite, and
regidar exercise is useful and necessary, but all
running, climbing, rowing, or hurrying of any sort
siiould tie condemned. Sudden rupture or failun' of
compen.sation cau often Ije traced to some indiscretion
of thi.s kind. Occupations entailing great muscular
effort or fatigue, or attendeil by exposure to injurious at-
mospheric conditions, should be avoided. The clothing
should be warm and shoulii fit easily and comfortably.
All emotional cxcitement,worry,and anxiety should
lie OS far as possible avoided. Sexual relations are,
in some forms of cardiac disease, especiidly injurious.
In the male the existence of aortic incompetence
makes st'xual intercourse particularly risky, and in the
female the presence of mitral stenosis renders utero-
gestation es[»ecially dangei-ous.*
• We have known several instiuioes of premature tlciitli in
yoUDg womeu witJi mitral Blenosis, who have Iwconic jiregimiit
aud havedied during prvgnnncy, or aoon nfter delivery.
Chap. II.) Chronic Valvular Disease.
345
Tile food mIiouIiJ l)e plnin, nourishing, iind
digestible, unil not cxoeKsivp in quantity; over-
filling of the viiHcular system or over-distemlinj; the
Btomnoh with excess of food and drink ia to lie
greatly deprecale<l. The habitual use of nlcohol
should be forbidden, and tea and coHee should
be tiiken only in veiy moderate amounts, and
when they are notictxl to cause cardiac excit<>-
nient they should bo avoided. Tobiux-o is always
injurious in these case.s. The occurrence of cardiac
intermissions in such patients may often \w traced
to the use of tea, coffee, or tobacco, and when
thme are left off they will disap^iear.
The Rulijects of cardiac valvular diwase should
avoid seii-bathing or Turkish Ixiths, or baths too
cohl or too hot ; but daily tepid sponging followe<l
by friction of the skiu is advantageous.
Constipation siiould be guarded against by tho
occasional use of gentle ap>crients, such as n mild
aloetic pill at night and a dram or two of sodium
or magnesium sul|>hate the following morning.
A modei-ately warm, dry, and equable t'liiiinlo
is that l)est suited to caiiliac patients, where a lair
amount of sunshine can be met with in winter, and
where protection from damp and cold winds can be
obtaine<l.
It is not necessary to prescribe drugs in these
coiii|)ensated cu.ses, so far as the valvular lesion is
concc;rne<l. Neither digitalis nor iron is neetied,
ami may prove injurious ; but the coexi.stence of
antemia may call for the usn of the latter. Arsenic
is Hometimes more beneficial in tho aneemia of these
cardiac co-ses. 8odium bromide is occasionally neede< I
to allay the nervous disturbances which are not
unfreipiently encountered in conq)en.sate<l mitral ca.ses
in women.
When, however, failure of compensation seems to
threaten and the cardiac action tends towards irre-
gularity and increased frequency, the long-continue<l
uae of some mild iron tonic is often o{ tVve ^A°«in.\je»V
J
346
Medkal Tkbatment.
I Pan II.
sen-ice. It may be ooinbinwl with small iioK«s of
sodium IjroniiiU'.
In the next jilace we will rvviow brietty the
vftrious morbid conditioQH which follow the /nilur«
of compensation in chronic valvulitr fli?i'iiso. And
first we will consider the cjuse of a iioii-<"oni|»rii-
»nlrd leMiou of the mitml vtil«'«>.
Wliethcr the IfRioii be insiitficiency and regurffita-
tion, or stt>nosis iiiui •■btitructioii, tlij- effect on the
circulation will be much the same when conipt-nsa-
ttoii fails, but it Is rare to find ti ^ierious ubstructive
letiion of the mitral without some co-existent iii-
.siifficiency. In pure mitral stenosis it is through
failui-e of the right ventricle especially that com-
pensation is broken.
Tracing the elTects of failure of compensation
Iwii'kwanls step Viy step, we find that the over-full
and dilated left auricle Iteinj; unable to empty
itself completely as usual into the left ventricle, an
impediment to the onttlow from the pulnionaiy veins
arises, and as the right ventricle Ls no longer able
to fully overcome this, dilatation of the puhnonniy
vessels and engorgement of the lungs follow. Tills
congestion of the pulmonary vessels and retardation
of the bloo«l current in them gives rise to imperfect
aeratiiiii of the blooil, and to resjiiratory dyspnn-a,
together with a tendency to Iwiiioptysis, as the over-
distondcd vossels are apt Ut give way; and there is
also a ilisposition to congestive bronchial catarrh,
with cough and watery or sanguineous exp«'cton«tion.
Tlius we see thiit the first sviiiptoms that are liable
to arise as the result of failing compensation are those
due to jinssive pulmonary engorgement : dyspnoea,
cough, ex|)ectoriUi(in, and sometimes hwnxiptysis.
At the same time the iK^tion of the heart become*
foeVjIe, labouring, and irregular, and jxilpitation ia
oomplnined uf. The strain also makes itself felt
on the rij.»ht cHvities of the heart, and the right
ventricle yields to its exccs-sive laliour, the right
auricle l>ecumea over-distended, and the outllow of
^^ f-fc.
Chap, til Chronic Valvular Disease. 347
hlotwl from the vena? ciiva? nnd the Bysti'inic veins
is liiiidoroil.
The livtT Mit<l till' other alKloiniiml viscera fcol thi«
obstruction in I hp venous ciuTPnt. their vessels become
overfilled, and the liver often becomes greatly en-
larged. Hindrance tn the portal circulation in the
liver leads to congestive caUirrh of the ntomach and
intestinefl, and pressure on the liile ducts by the
distended vessels within the liver gives rise to a sub-
icteric staining of the skin, to n diminished discharge
of bile into the intestines, and thus to constipation.
histension of the renal veins and retarded circula-
tion iji the renal vessels cause sc.inty, higli-culoured
urine, wliieh may cont^iin albumen, oasts, and blood-
cells.
Evidence of obstruction to the circulation is seen
in the superficial veins ; tliey iwcome tlistended and
stand out prominently from the surface, the venuk'Jf
dilate, and tlie skin becomes cyanotic ; general dropsy
may then set in, l>eginning in the feet and iinkles and
extending upwards, usually aflecting also the al»-
dominal cavity, which is especially prone to ascites
from the co-existence uf olistruetion to the portal
circulation. Dropsy of the upfier extremities anfl of
the other serous cavities may supervene.
These are the chief morliid conditions which follow
failure of coinpensation in iiiitntl disease.
Wo see, then, that, our thr'ra[M'utic measures must
Ik- directed not only to raising the tone of tbn cardiac
muscle, but also to the relief of the visceral congestions
and to the rumoval of dropnical Kilusions ; but it is
clear that we cannot carry out the two hitter indica-
tions unless we also succeed in fulfilling the former.
In cases of norllc *'nlvo disease, unless the
mitral valve be also involved, as is not unlVequently
the case, failure of compensation is attended with
somewhat <liHerent phenomena. Aortic insulficiency,
iilthougli a more serious aU'ection than the like lesion
in the mitral, may through hypertroj)hy of the left
ventricle remain for many years perfectly compen-
348
Medical TRF.ATMF.^n;
I Pan II.
sated, and may gi^•e rise to no niorliid symptom. But
when from ilcgcnfralivc clian|L;e» in tlu' liyjicrtropliied
muscle, iind a coincident scleixitic condition of the
aortic ardi anil the orifices of the coronary arteries,
codipensntion h('i.jinN to fail, the following symptoms
usually prcsp[)t tlicm.sc-lves : —
Ovvinji to the sudden emptying of the vcs-sels of
tlio head and face <lue to aortic regurgitation, great
pallor and thinness of the face are often oltservetl,
together with symptoms of cerebral anroniio, headache,
diiizine.s.s, swimming, and tendencies to faint, especially
on sny .sudden alteration of position, as in getting out
of bed, or rising suddenly from u reclining positiou.
Paliiitatiuu may arise on the slightest exertion, and
psiiii rel'errible to the cardiac region m es|)ecially
l)rone to occur in aortic cases with failing coni[>cn.sa-
tion. This pain may be limited to the caitlioc region,
liut more commonly it radiatea into the neck and down
the ann.s and into the fingers, especialh'of the left side.
Attacks of anKiiiH p<>rtoris are frequently asso-
ciated with thi.s form of valvular lesion.
As failure of comf)en8ation progresses, painful
attacks of dysjinaja are liable to occur, especially
duHiig the night, with orthopntea. Although general
dropsy is rare, some ledemaof the feet is common ; so
also is pulmonary congestion and <pdema with trouble-
some coiigk Death is often sudden, and rarely
lingering, as in mitral case«. Symptoms due to
emlMjlism, cerebral, splenic, and renal, are frequent, as
piralysis, hematuria, and splenic enlargement.
As a general rule we may say that when eomjH'n-
.sation in aortic cases begins seriously to fail it is
usually less i-emediable and more rapidly progressive
than in mitrocasea.
When mitral insnttieiency is developed secondarily
t<^» aortic incompet«-nce and stenosis, the scrius of
morbid changes uhi'ody described as dependent on
mitral disease of course arises.
The printnry in<li4-iiiioii for irfniinoni in all
Cardiac Tonics.
349
I
Ihese casus of luptiii-ed compensation ix to oncU'iivour
to restore it by raising the tune of tlie enrdiac luiiscle,
Hiid in many cases, espei-ially thosn of mitral lesions,
wti jire able to do so again and aj^ain. We Lave
already pointed out the iniporUince, in tbe tn-atment
of cardiac diseaaeji, of ilxmitusUintj the. mfchamcid
ux>rk of Ihc heart. Tliis is itself sufficient in many
cases to restore the broken compensation. Kent in
b«d, with appropriate food, for a week or ten days,
will frcqui'utly succee<l in removing all tlie evidences
of circulatory disturbance in chronic mitral disease.
Canliac irregularity, visceral eon(|{estions, dyspmea,
droiisy, will all disappear. Insist, then, as an essen-
tial couditiun to successful tn?atment, on jihysical rt-gt,
rest in the recumbent ]>osition, and maintain this rest
until you have gr»od reason for believing that a certain
amount of com|ien.sation has been restored.
Hut we have at our dispcsal some very reliable
medicinal resources for raising the tone of tlie cardiac
muscle when it Ite.gins to feiil, and these are the
various drugs known as cardiac Umiai, which we
must now juiss in review.
Of all canliac tonics digltnliK remains the most
reliable and trustworthy. Its power of restoring
tone to the enfeebled canliac muscle is remarkable,
and- is unequalle<l by any other drug. Under its use
the systolic contraction of the ventricles l)ecome8
more vigorous, the period of diastole is prolonged, and
the pulse, at the same time, becomes slower and more
regular OS well as stronger. In mitnd regurgitation
the iniprove<l tone of the right ventricle raises the
tension in the pulmonary veins and the left auricle,
and count4TactB the backward flow through the incom-
petent valve, and the more vigorous and complete
contnu'tion of the left ventricle causes a larger
quantity of blood tii l)e projected into the arterial
system. DigitalLs also acts as a tonic to the arteries,
stimulating mirnial contraction of tiirir mnsculnr
fibit'B, and so furthering a steady and continuous
Mow of blood onwards through the capillaries.
350
Medic A l Tr ea tmen t.
(P»t II.
It is this Iwdj'old tonic action on the forces of
tlie circulntion that is so valuiibic in tjigitiili.s, for the
lotiic contraction of the peripheral vessels* is an
iniportiint aid to the circulation, and is especially felt
in the capillaries and the venous radicles ; hence it is
that iligitalis acts so powerfully in the relief of cardiac
dropsies, and often so largely increivses the How of
urine. Prof. H. C Wotxl has shown how digitalis
aids the nutrition of the heart itself: l.st, by com-
pletely emptying the vessels of the heart during the
Bustjiined and 8trengthene<l systolic contractions;
and, 2nd, by promotinf{ the more complete filling
of its arteries during the prolonged diastole, and at
the same time atfordini; the necessary rest to the
cardiac muscle. Hence the pvrmrtitmit improvement
following its use.
A few nuKJerate doses of digitalis combined with
rest in bed will ofti'n reduce the caaliac bejit from
120 or 130 to t'.0 or 70 in the minute.
In the advo<'acy of substitutes for digitalis, now so
common, a great deal is often mmle of the so-calWl
drawbacks and dangers attending its use. Tt is said
to aecu^lulat^? in the system, and after a time to pro-
duce smldeu dangerous sj'mptonis. After a long and
considerable experience of its use in cardiac dLseose we
have rarely met with such a circunistnncp. That it
occasionally causes gastrointestinal irritation, esjM'ci-
ally if administered unskilfully, or in to<i large doses,
or for too long a perio<l, is i-ertaiti. But with cure
in its administnition — and all tlitiyn s/ioutil be ail-
miiiistitred with care — and occasionnl interruptions
in its use for two or three days at a time, it will
be found that it very rarely disagrees.
In the palpitation not unfrequently encoun-
tered in cases of mitral stenosis in women without
other signs of failing compensation, digitalis will
often j>ro<luc(' distressing symptoms, even in small
• SufKciiiiit (listini-lioii is not made lictwecn tlio nlMtrurtiiiii to
tlio circulitlioii caused tiy tiKnliitl tpnuin of tho iirtcrioles. and the
iiii/ 1(> thn circulatiou which improved tone uf their mtiacli* afTnids.
Clup. II 1
Cakdiac Toy/cs.
35"
doses. One patient descrilicd its efiect as making her
furl "as if her lienrt was gnispwl in the lianil." In
such cast's, if rliji.'it'iilis is given, tlip pulse iiiny l>econic
Hmnll and irregular and the urine scanty, It is now
geuerully admitted that this drug raivly acts well iu
cases of uncompliatted mitral stenosis. In thcHe oiiim»
tlie nilritft are more serviceable.
Some importance must be attached to the choice of
a .suitable preparation of the drug and to it^ oibninia-
tratioii in suitable doses. The preparations usually
cmployi<tl are the powdered leaves, the tincture, and
the iiifiisioti, and also digilnliu. The |iowtler is
especially prone to caus<> giistro intestinal irritation,
and should be avoided. Pilules of rligitnlin will In*
found useful and convenient in the slighter functional
caixliao disturbances, but it has not the diuretic iketioii
of digitalis leaves. Of tiie .several digitalines uinnu-
factured, the crystalline form of .Vativr/Zr is the most
potent — it is said to consist niniost entirely of
digito.xin — the dose is from , J,,th to ^'^th of a grain,
8ansoin i-eports good results from the liypodei'inic
injection of digit4iliii, in cases where digitalis given by
the mouth had failed ; he use« Savory and Moore's discs,
each containing j,', „th of a grain — the dose should not
excecil two of tliese.* There remain the tinc(ur<! anil
the infusion ; the former is a handy and useful pn-
partition, but a gi-eat many physicians prefer, and, wr
think, with good reason, the fr<.'«hly-prepar(>d infusion.
Then as to the l>e»t dose. In ca8«« where it is im-
|)ortant to establish the diuretic action of the drug
as quickly asi)OSHible, we sliouM begin with full doses,
which we can diminish whi-n full diuresis has biw-n
established. Half an ounce of the infusitm, or 10 to
15 ttiinims of the tim^ture, nindiined with a dram of
the sjiirit of juuiptT, niny be given every six hours
until the diuretic aotion of the drug lias hwieu pro-
duced.
In cases where ihcro i.s no dropsy, smaller
doses, which raay lie continuerl for a considerable
• AUbutt'ii "Syrtom of Mediciac," vol. v., p. IWO,
352
Mkdical Tkeatmevt.
IParl II.
period, act better, mid we frequcatly give ilaso« of
5 minims only of the tincture or a dram or two of
the infusion three times a day. If there is any
teiKk-ncy to givstric initation, it is as well to combine
with these small doses 20 or 30 minims of the
aivdjiatic spirits of ammonia and some aromatic waller.
AVhen thei« is great g.ostric initalnlity, digitalis has
been given by the rectum in the form of small
enemata ; an ounce of the infusion with 2 ounces of
warm water may lie thus administered twice or three
times a day.
Wlien digitalis fails, it is usuiiUy becausn (he
cardiac muscle is in an arlvanctKl stage of degenera-
tion ; then, indeed, it is useless, and its administration
shoiitd not Ix^ continued.
Ihichard has pointed out that i-hililrun liear
digitixlis well because of the integrity of all their
organs, but., being a toxic drug, it shoidil be given to
them cautiously and in small doses; whereas old
prople liear it badly owing to the probable presence of
lesions of the cardiac niusfle and of the blood-vessels,
as well as of the kidneys and liver ; to them it should
Ijc given, therefore, also with great caution, especially
when there exist obvious signs of rirlerionr/erimis.
We have already said that this drug is counti.T-
indicated in most cases of mitral ^letiosit, anil should
only be given with gi-eat caution and when there arc
symptoms of failure of the right ventricle. BnMuUx>nt
points out that "in uiitral stenosis the blood cannot
be forced through the coiistrictetl mitral orificf'ljeyond
a certain rate of sp*«d, and if the right ventricle is
stimulated to contract more than is refjiiireil for this,
it encounters an iasu|ieratile ulistructiim and Ijecomes
cmbaiTassed in its action, its energy lieing needlessly
expeiide<l. A common result is irregularity in the
beats, acc«tnpanie<i by a sense of priecordiitl
oppression."* I'.ut when the action of the heart is
fc«*hle, rapid and Uutt<>ring, a few doses of digitalis
will oftt-n prove of service.
• " Ueart Dueaae" (lliinl wlilioii), \>. IM.
hap. II. I
Cardiac Tomes.
353
^B be
Next, perhaps, in valup t« diffitalis as a cnrrlino
tonic we must reckon «troplinuiliii««. It is a direct
stiniiilimt of the cardiac muscle, and not only does it,
like digritalis, reyulate the cardiuc rhythm, slow the
pulse, and strengthen <ind sustain the ventricular
systole, but in some cases it also, like digitalis, acts
as an efficient diuretic ; and, in our own experience, it
is often in those coses in which digitalis fails to act as
a diuretic that strojihanthus succeeds. Complaint has
tieen ma<Jo of the uncertainty of its action, and it must
he adtiiitted that it is not to be sogeneralh' relied u]ion
as digitalis, especially in serious failure of compensa-
tion. But in cases of cardiac feebleness, associated
witli corpulency, flatulence, and tlyspepsia, or follow-
ing acute illnesses, we have found it, in some cases,
most useful an<l liiuch belter tolerated than digitJilis.
Tills drug is also useful ss a suliatitute for digitalis
when we think it necessary or desinible to suspend for
a liuie the administration of the latter; and we shall
sometimes find that when we have, as it were, ex-
hausted the sensitiveness of the cardiac muscle to
digitalis, it is a good plan to resort to strophanthus,
and return, aft<'r a time, to (Hgitalis. The fact that
strophanthus is more entirely a cardiac tonic, and does
not act on the arterioles like digitalis, seems to point
to it as the better drug of the two in gout and other
cases in which vascular tension is high from contracted
arterioles.
The action of strophanthus is not cumulative like
that of digitalis, nor have wo found, in small or
m<xlerate dose^i, that it produces, as has lM?en stated,
gastric or intestinal irritation. As to the best dose
and j>reparntion, we have found from G to 10 minims
of the tincture every four to six hours answer well.
A most valuable cardiac tonic, the u.se of which
had, until lately, been somewhat neglected in Great
J5ritain, is ratlieint-; and in gnive cases of cardiac
failure its administration by hyjjodermic injection,*
• Vox tbis piirpiMt", iw well ns for iiiturunl usb, raffoinv onn
be dissolved iu sodium benzouto or ulieylate in t)u> foUowiug
354
Medical Treatment.
(Part II.
«*pocialiy wtien from tlie existence of gastric ilisorder
oilier cunliac toiiies ciitinot well 1h3 j;iveii, is often
uLtetidi'tl with ri'iiiiirkiilily ^jmid n'.siiU.s. It is to the
moiU'ni French schodl of jilij-siciiiiis thai we chipfly
owe tlio advoojuA' of caffeiiui as a cardiac tonic. Ex-
|ierinif'nts on animals have given rise to the most
conflicting opinions as to its action on the heart and
circulation. It ha.s Iieen said to quicken and to slow
the action of the heart, and to augment and to
diminish arterial tension, and we may note somewhat
similar results in the ust- of exces.sive quantities of
coH'ee ill dilFerent individuals. Tn some it will cause
very rapid cardiac action ; in otiiers it will slow the
jiulse, and cause canliac intHniiissions distinctly
sensible to the ]Kitient hiiuHclf. It is to elitiicai
exjKirience, therefore, we must refer for guithinec in
the use of this drug as a cai-diac tonic. Dujartlin-
Beauinet2 taught that it is " especially in the last
itago of cArdiac disease, at the perio<i of it^ynlnln, and
when we have exhausted the effect of other cardiav
tonics, that caffeine will lie found of signal service."
He also maintaiiifd tliat it has oft«n been given in
insufficient doses, iind tliat iia much as 30 grains a
day must he given in order to obtain the best resulta.
Whitla considers its diui-«itic action more rapid than
that of digitalis, and he lias "seen excellent results from
the administration of .3- to iigrain doses of the citrate
in miti-al regurgitation, with much anusarca and con-
gestion of organs, where digitalis was not well borne."
Caffeine may also be usefidly combined with
digitalis, the comijinatioii producing diuretic effects
superior to what can be obtained fi-oin either given
alone. Some prefer the sodio-sal icy late of theo-
bromine to caffeine, as having a stronger diuretic
action, and not causing nervous agitation an<l sleep-
lessness. This is tlie jireparation known as (liiiretiii.
'flie dose is 15 grains every four hours.
pniportioiu: — Caifeiue, 30 graini; smliiiin benxoate, 35 gniiiu;
uiatillod WKtcr to miko '.!00 miuimi. An injection of 20 minims
will cuntuiu 3 graini u( caffeine.
Chip. Il.l
Cakdiac Tvnks.
355
4'<>nvalinrin iiiitl the ■jlnooKidt? ronnillainariiie
have Ik^^'ii onijilnycil ;is cjirtliiio Ionics, and no doubt
thoy jioHsM-ss the piii|>eity of anguu-ntinj^ the contrac-
tile force of the hwirt., and mo promoting; diuresis.
They arc, Imwcver, greatly inferior to tlie jirecttding,
and llieii- une should l>e reservt-d to cert«iii c^vses iti
wliich tlie.se do not agree, or where, for some rea.soii,
it seems deMirable to vary the treatment. A tincture
of eonvnllaria is made, of which tlie doHe is 5 to 20
miiiinis, three to six times a day, or convallam&rine
may )m- given in half-gniiii dost-s twiw daily. Kaiisom
thinks it of use in cases of niitritl stenosis, when
digitalis is counterindicate<l. He has found it in-
Hiience favourably the cardiac irregularity aiul act as
a iiowerful diuretic*
8piirtciii<> is another carrliac tonic which has
scarcely renlised the e.xpectntiong of its advocates. It
is usually given in the form of sulphate, I to 2 gruina
three times a day. It hius l)een said to ])ro4luce
diuresis very nipidiy ; Imt, like so itiany other drugs
of this class, its .action has been found very uncertain.
It has its value, however, in cardiac artections when
other resources fail, or as an alternative when it is
not desirable to exhaust the effect of some other drug.
Some consider the ra]iidi1y of its action to esp<!ci«lly
indicate its use in acute enfeebloment of canliao
tone in acute diseases. A quarter of a grain to
a grain may lx> given three or four times a day.
It is the active constituent of infusuin scoparii,
which may be use<l as a vehicle for other cardiac
tonics.
Adonis vprnalis and a gliicosidu derived from
it, ndoiiidiiir, liave also lieen given as cardiac tonics
the latter in doses of i\th to \rti of a gniin ; but littlu
reliance can lie placed on them.
C'lii'.lUH KrHiidifloruK is another cardiac tunic
recently introduced as [Kjs.sessing the pinwer of regu-
lating and strengthening the carrliac contractions in
organic and functional cardiac affections, especially
• AUbutt's " System ot Mwlieine," vol. v., p. 1032.
356
Medical Treatment.
IPart II.
tlie lat.ter, but, like the preceding, it appears to be
uiireliiible.
Nii-}<-liiiiiif, qiiiiiiiio, «-oru, koln, aiv all
mluiilik^ (.-iiniijic as well as ;{ein'ial t«nics, and they
liiid tlieif proper use in ciisus of cardiac dilatation
associated with general louacular and nervous as-
thenia.
They do not appear to have any direct special
action, like dij^talis or stri>|ilianthus, on the cardiac
muscle, but they act rather tlirou«,di their ijeneral
tonic inHuence on the nervous centres ; they aiv none
the less valuable on that account, and we have found
strychnine, (|uinine, and coca of the very greatest use
in the treatment of coises of cardiac asthenia following
acute dise^ise ; but they cannot take the j>lacc of
digitalis and its analogues fur the purpose of regu-
lating cardiac rhythm and promoting diuresis in
grave cases of valvular disetise with failure of com-
pensation.
There are few cases of chronic valvular disease,
with failing compensation, that will not, at some
period in their course, be greatly benefited by the
judicious administration of some pifparation of iron.
The mildei' ]>reparations tisually answer best, such as
the atniiioiiia citrate, the phosphate, and the tartrate.
The attention of medical practitionei-s h,as l)een so
strongly directed of late years to other cardiac tonics
that the value of ferruginous compouTids is in ihmger
of being overlooked, and it is necessary, therefore, to
insist on their undoubted value and etHcjicy,
In mitral cases, accompanied with symptoms of
arterial obstruction, as in chronic Bright's disease,
it is often advisable to combine with the cardixc
tonic, such as digitalis, an arterial relaxant, suuh
as sodium iodide, nitrou.s ether, nitro-glycerine, or
erylhrol nitrate.
Finally, we must not omit to refer to the great
value of raorcurial aperients in the management of
these cases. It i.s always desirable to give a pill of
alooa and blue pill, or blue pill and colucynth, before
Chjp. II.] Cukokic Valvular Disease.
357
ln'tnntiing the use of digitalis. Moreover, such aperient
do.ses must be given fretjuently, in order to promote
elimination, to unload the alxloniinal veins, to relieve
tliercby the right heart, and to stimulate hepatic
functions.
ADDITIONAL FORMUL.'E.
Cardiac tonic powders.
H Piilvcris di^tiilL>, pr. iij. "
Qtiiniiup culiihatis, pr. xviij.
I'ulveris rhfi, gr. xviij.
Sodii biciirhttualii*. pr. xviij.
M. vt divide in jiulv. x. A
powder tirii'e a day.
{Schnittlir.)
Cardiac tonic mixture.
K Iiif iiisi iiiliilii!< vrnirilU (iniidc
Iiy iiifuf^iiii,; (lOpniiiih of tlio
Icuves ill \ lit. of waterj,
sir.
Spiritui lucutbo! pijM-rilni,
niv.
M. t. mint A t»)>U'iip<Kiiiful
four tiiiRt II day. (Hrhiiitzti r.)
Sedative drops to allay
cardiac excitement.
H Extnvcti l*lliiii"ini"', pr. iij.
Tiiictunf dipitjili.s, .>iJM.
Ai|iiit' Inuroci'nisi ad 5j.
M. {. mist Tun drojw threo
timn n diiy. (Schnilzln:)
Cardiac tonic
11 Syniiil floris aiiruiitil, .<iiv.
Iiifui^i convitllunii* innjiiliK
(miide by iiifuniug 2^ dninia
n( Ui« plAiit in li 01. of
wttUr) ud jvj.
A tatilespoouful every two
hours. {JIamieiyrr.)
Iron and digitalis cardiac
tonic.
U Tiiictura* ilipitiilin, tuclx.
Tiuctiirii' furri p«>rrbloridi,
.^iij.
Spirituii cliloruformi, .^lij.
(tlyi'eriiii jmrl, %].
A<|uii' ili'Dtillnlii' nd l^iv.
M. f. iiii.'!l. .V IcuHiHiiiufiiliu
n wini'plnss of wiilpr imir limes
» dny, iiftiT food. ( If'kitla.)
Caffeine miature.
II CiilTi'iiiii', gr. xvj.
Sodii lirti/.i)itti!i, (fr. xvj.
.Syru|ii HoriHnumntii, siij,
Aqiiii' lid iiv.
M. f. nii«t. A tuliloiijiooiiful
for a dose.
3S8
CHAPTER III.
THK MANAfiEMENT OF SPECIAL SYMITOMS UKPENOGNT
ON CHRONIC VALVULAn DISEASB.
SrMProxs dub to Vknou* EyooROESiBNT— Bleciliiig- Purgativej
— Tre.itmcnt of Dysinifra — Brombbil Tntarrh uuil Cough —
Hii'irioptvuin — Ilysiicptif SymptDiu* — Ur>>|>«y— Piiirctica —
Milk Diet— l[yJra);oi{uo Ciitlmrtii's — Uia|ihorotica— Iiieisiims
into Suljciitjiuuous Tissm? — Multijilo I'uiii-tunjs — I'lirucout^i'nji
Abdominiit — Mn-Mago--'rreHtmciit nf He#tl<\MiiPfi» :ind Iii»
•omnia— Caiitiuii iu Tsl- of (iimitiM - Codriia — Tlio Hromiilcs—
Sulphonnl — ParaMohydo- Troatniput 8iMj<^iuUy approiiriatc to
Aorlir ifsiu/ii — Food and KogiiiiL-n — Disitnlis ami Inin —
Consequences of HYJiertropliy — Arterial Strain — Au};innl
Attackn — Symptnmii due to Cerebral Anii'inia, to Hvpertro|iliy,
to Embolism— Value of Ilest — Avoidance of tlxcitenieut,
phvoiial nud meiitnl — Food and Stimulants— (Jentle Aperient*
— Digitalis — Treatnieiil of Attnrks of I'ttiti — PotoMiuni loilide
— Nitro-Ulyo<>riue--lt]Mum and Morphino for Hyipnocs and
Iiuomuia. Adilitionnl Formula'.
In the next place we will consider, in detail, the
appropriiitf" treatment of the . several niorbiti conditions
which iirise in coiispqupiicn of the hre.ikriown iu the
cardial' iiiei'h.aiiisiii from failurp cif compeiiHation.
Ill tln^ first place there are (lie syiiiptoiiis rffi^rrilil*
chiefly to the pulmonary engor^'oiin'iit — dyspno-a,
cough, liseiuoptysis ; and secondly tlnjse due to the
over-distension of the right side of the heart, and the
systemic and portal veins ; cyanosis, gastro-intestioal
catarrh, jaundice, albiindunria, and general drojisy.
Now some of these conditions may be relieved by
dimini.shiiig the volume of blood in the right side of the
heart and in the veins, so that their over-distension is
lessened, t(jgether with the pulmonary engorgement.
We may diminish tlie volume of blood direi-tly by
the abstraction of Idood liy hlfedillK, or inilin-ctly
by the withdrawal of water from the blood by means
of hydragogue purgatives.
If the right ventricio retains a fair amount of
contractile power, as evidencetl by a forcible right
ventricular impulse, tlie relief of its over-distension by
Uni.iry of Bleeding.
359
iiften
tli(? abstraction of 6 to 10 ounces of IiIochI
very remarkable.
The indications for the eni|)!oynient of this nieiLsuru
usiiivlly arise only in the ultiiniite sta^os of the disease,
when the relief adbitJed may be l>ut temporary, and
the struggle for life only prolon;;eil for a brief period.
Bleeding should be reserved for the relief of canes
of nitense dyspnii-a with cyanosis, arising from a great
amount of backward pressure and over-distension of the
right side of the lienrt with pulmonary engorgement;
it slioidd bo immediately folhjweil by cardiac stimu-
lants and tunics, and it should rarely cxceeil ten
ounces at a time. It is chiefly ust^ful in enabling
restoratives and tonics to act more etliciently, and it is
more likely to answer well in young and robust
subjects than in the old and debilitated; in the latter
it will randy j)rove a judicious expedient. By jiost-
poning fiir a short period the fatal event, it may,
however, prove a valuable measure in enabling the
patient to transact important business, which would
otherwise be left undone.
We may mention a ease in point in which the
abstmction of a few ounces of bloiKl (4 or 5) led to
the most ast'Oni.shing revival of a canliac [xitient who
was on the point of death. She wa.s relieved of her
breathlessness, and Itegan to eat and drink again with
appetite, and to convei'se cheerfully. Besides aortic
obstruction and regurgitation, she had evidences of
mitral stenosis and regurgitation, and on post-mortem
examination the tricuspid valve wn.s also found to be
disea.sed, and there was immense dist^'usion of the
right auricle, which the bleeding had relieved. The
revival, however, only busted for about a fortnight.
Sometimes the application of 6 to 10 leeches over
the liver in the epigastrium may suitably take the
place of venesection.
There are few cases of heart disease, with notable
venous obstruction, that arc not greatly relieved, at
some part of their course, by the adnunistration of
suitable piirgiitiv<-K.
360
Medical Treatment.
IPnrt n.
The unloiiding of the portal system tlius induc*^
tends (lirt'Ctly to the removal of the congestion of the
liver and tlie concomitimt giiBtro-iutestinal catarrh,
ami so assists in the nssimitatioii uf fooil, wiiile it
indirectly relieves the distensiou of the right side of
the heart, the over-loaded systemic veins, and the
])iiltiionary congestion ; Bscitcs and general dropsy
may be also greatly diminished, if not completely
removed.
The purgative shovdil lie given in the early morn-
ing, when the stomach is empty, so as to avoid any
disturliance of the patient during the night, and to
sweep away the debris of food only, and not to imperil
the nutrition of the i)atieiit.
We usually select wlien there is lueilen either
saline purgatives, such as miu/iu'DiuiH ttuZ/ifiale, or
hydragogue cathartics, such as scammony, jalap,
gamboge, senna, and elateriurn.
A full dose of nuignesiuni sulphate (3 to 6 drams)
dissolved in as small a r]imntity i>f water as [mssible,
shotdd bo given in the morning, fasting.
The compouiitl jalap jmiKiler of the B.P. is a
favourite purgative in these cases ; from 30 to 60
grains may be given every morning. The compound
scammony powder is also a useful purge. It may be
given alone in 1.")- or 20-gi-ain doses or combined with
the compound jalap powder ; or we miiy give 10- or
IS-gniin doses of a combination of eipial jKirts of the
compound colocynth and compound gamboge pill.
We should reserve ehtermm for cases in which the
preceding fail, or do not cause a sufficient discharge
of fluid from the Iwwels. It varies a good deal in its
activity, and is sometimes very dejiressing. The
compound powder of elateriurn may Ije given in
3-grain doses. A little ether, or sal volatile, or
brandy, should be given if much depression attends
jt-s action.
In cases where these strong cathartics are not
needed or are ill-borne — and it is only in ca.se8 compli-
cated witli dropsy that they are needed — milder ones
Chap, III. I PuRCATIi-ES IN HeART DISEASE.
361
should he re.sorted to, such as the compound liquorice
powder, CarlHbad salts, or colocynth and heiiliane pills.
The cardiac patient should uevcr be allowed to lieconie
constii>at<?d, as constipation raises the tension in the
alKliiniinal vessels, and augnieuts the work of the
heart.
As a rule these patients Iwar purgatives well.
A good and yentle aperient for habitual use in
the^e cases is a pill of a g^rain of caloiuel and 0 grains
of rhubarb at night, and one or two drums of
sodium sulphate in a wineglassful of hot water the
morning following.
(Jlher mea-sures may be needed to relieve the
dyfipnira, liirinopiyfilH, or bronrhiiil rnlarrh,
with coiij;h and expectoration, dependent on the
pulmonary congestion. CounterirritAtion is here of
rnudi service ; mustard pla.sters or tur|)entiiie stuiies,
applied over a large surface of the chest, give much
relief ; or turpentine embnjcations may be rubbed in
freely. Dry cupping over the back of the chest is
oft*ii of great U-nelit. Bli.slf^rs are occasionally useful,
but we prefer must-ard plaHtcre, as they can l)e often
repeated, and do not nee<l troublesome dn^ssings.
When the dyspnoea is due to over distension of the
pulmonary vessels, as it usually is, tem|>orary relief
may often Ik* obtnined by administration of the
nitrites, nitrite of amyl, iiitrtt-glycerine, or sodium
niti-ite, as they cause a temporary dilation of the
ves.selH of the lungs.
llH>inopl)'MiM, which ia especially liable to occur
in mitriil stenosis, unless it is excessive or dangerously
prolonged, does not cidl for any active interference
for its arrest. Its effect must lie to unload the
pulmonary vessels and to relieve the congestion
wliicli has induced it. Osier * mentions a medical
man who hod many attackt) of hnsmoptysis in associ-
ation with mitral inconifietvnce, and whose condition
was invariably better lifter the attack. As, however,
the .symjitom is unually an alarming one to the patient
• "Practice of Medicine," p. 731.
362
Medical Treatment.
I Pill II.
and liis friends, they should Vic t,oId that its effect is
sometimes salutary ; and at the same time some
sinijile remetlic-s may l>o prescrilieil. Perfect i-ej)Ose
must, of course, Ije insisted on, and a few doses of
ma<;ncfiiuni sul]ihate, with dilute Kulphuric aci>l and
infusion of roses, are useful. Nervous agitation
and palpitation must l>c allayed liy .some sedative,
and for this ]nir|>ose we may give a dose of Jth or jth
of a grain ol" niiir|)hiiie with a dram of clierrydanrel
wat.er.
Ill tlie Irejitment of the roiiith of cardiac cases
we should follow much the same nu:tho<ls as in the
treatment of chronic hnmchial ca(nrrh (see Part IIL,
chap, iii,), Ijiit in cardiac cases expectoration may he
promiited and the coujfh ndieved liy stiiuuianto
directed to hel|« the strujjtfling heart, such ns
aininonium carhonale, with spirits of etiicr or cidoro-
form, nux vomica, and senega, and, as a drink, hot
nulk with ajiollinaris water (equal parts), and a few
teaspoonfuh of whisky or hrandy may Iw given.
Stimulating expectorants, comhine<l with sma/l doses
of opium, have a goml ed'ect, such as the ipecacuanha
and squill pill of the B.P., 5 grains once or twice
a day.
The ifn<<li'l<' symptoms dejiendent on congestion
of the liver (wliioh is often greatly enlarged) and
engorgement of tiie portal venous system, such as loss
of appetite, Hatulence, nausea, and vonjiting, aifjofti'n
very difficult to relieve.
It is well to begin by giving non-irritating and
non-depressing aperients. Half a grain or a grain
of calomel with 5 grains of colocynth and henliane
pill may he given every night, anil 1 or 2 drams of
sodium 8ulphat« and J a dram of siMlium liicjirbunate
in an ounce or two of hot water the tirst tiling in the
morning. For the uauwa elFervescing saline draughts,
with an excess of sodium bicarbonal'« and r)-minin)
doses of dilute hydrocyanic acid, may W' given three or
four times a day. Large hot linseed and mustard
poultices over the rigjit hypot:hoiidriac and the
Oup. 111.]
GAsr/t/c iRRiTABiLirr.
epigastric reirions frequently afford great relief. Tlio
flatulence will lie relieved by a graii) of menthol or
tliyiiiol or \, a iiiiniui of creasote in a pill twice or
three tiinea a flay after taking food. Olistinat*
vomiting will rt'<|iiiro the .susfieusion of all food
except a little iced milk or milk and lime water.
Small quantities of iced water, or effervcscinj; drinks,
such as iced chanipaj^ue with Apolliniiris water, may
be given to allay thirst and to supjKirt the patient.
Oxalate of cerium in 2- or .'{-grain doses, mixed with
a little sugar of milk, will sometime-s relieve the
gastric irritability in these casus after other meaturoA
have faile<l.
Digitali.s is u.sually very badly borne in cjises of
this kind, but we can sometimes give mix vomica with
advantage after the vomiting has l>een cliecki'*!.
Fift*«on to twenty drops of the tincture combined
with 10 or 15 grains of .sodium bicarUmate Hliould be
given three or four times n day when (he stoinach
is empty.
Oi*at care must Ix' otservetl in feeding these
eases of gastric irritability. The food should bo tluiil
or serai-iluid, in small quantity, and pre digested.
Peptonised milk or l>eef and chicken jelly, or jiep-
tonised gruel or cocoa, occasionally a cuji of clear
soup, all these may be used so as to vary the dietary.
Hut one of the most urgent symptoms which
we have to treat in connection with venous engorge-
ment from failure of compensation is dropny, atid
we will now consider in detsil the best mra.HU res U)
adopt ill order to relieve the dropsy of cardiac disease.
The use of purgatives for this purpose we have already
referred to.
The removal of the serous llutd which hiis accumu-
lated in the subcutan(*ous connective tissue, or in the
serous cavities, may lie eHecteiJ in various ways : (I)
It may l>e removed by excessive dinri'tiji through the
agency of the kidneys ; (2) it may Imj drained away
from the intestinal vessels by hydragoguo cathartics ;
(3) it may bo got rid of, to some extent, by stima-
3*54
Medical Treatment.
(Pari II
lating the cutaneous excretion, hy iHuphoreties ; and
(4) it inay Ijc ditiined off by direct puncture or
incision of the skin and connective tissue, or, if tlie
serous cavities are involved, by puncture and aspira-
tion.
Most of those drugs which we have de-scrilied
OS cariliiir toiiirM act altio ns diiirf>tir!<. They
raise the l)loi>d -pressure in tlit> ronul glomeruli liy
fitrpngitluMiint; tlie cardiac contractions, and whilt,' they
thus incrwise the How of urine, tiicy at the same time
tend to remove t/ie cruise of tlie dropsical efl'usions.
We usually, thcrefon', commence the treatment of
cardiac dropsy hy the attempt to excite excessive
diuresis, and for this purpose wo administer those
drugs wliicli net also as caitliac tonics. The diuretic
effect of digitalis is sometimes most renuirkftbli;, and
it is common to see a considerable anioiint of general
anasarca disrtj>i>ear in a few days with rest in IktI and
treatment with digitalis. The fresh infusion of the
leaves seems to be the preparation which lias the
most powerful ciinretic ofl'oct. We should Iwgin by
giving a full <losf, such us J an ounce, tliree times a
day, and diininiKh the dnsi.' a.s (he diuretic effect
U'comes estidvlishcd. This is a In'tter plan than to
lose time by beginning with an inetiicient <lose and
gradually increasing it. The only caution necessary
is that it sliould not be permitted to accumulate in
the system, and that it certainly cannot do at tlie
commenceiiient of its use. If digitulis fails,
stiYjphanthus may 1«! tried in .5- to H) minim doses of
the tincture every three or four hours ; this drug will,
in certain cases, cause free diuresis after the failure of
digitali.s. Cnffeinr may next be tried : its diuretic
power is often very considerable. It may he given in
3- to fi-grain doses four or five times a day, either
by the stomiu-h, dissolved in water with the aid of
sodium iKjnzoat*', or by hypotlermic injection. The
other cardiac tonics may be tried if the.se fail
It is customary to combine squill with digitalis as
fonning a more effective diuretic than either singly,
-th'^'^l:^
ChAp. III.)
Cardiac Dropsv.
365
and the addition of blue jiill or citloiiiel to a pill
contuiiiiiig squill and digitalis has long bet>n a favourite
foriiiuhi. Ciiliiiwl its(^lf acts as a powerful diuretic iii
some cases of cardiac dropsy, and its piti|tloyiiient is
indicated when the class of cardiac tonics fail, or to
aid tlii'in when they pmve inetticient. It sometimes
acts rapidly ; its diuretic action is somewhat dilKcult
to ej-plain, but it is probably associated with its action
on the liver and intestinal ciinal. It has been given,
in these cosi-s, in doxea of 1 A tn 3 gruins, three or four
times a day.* Its us<> should not be continued after
its diuretic effect has l)ei'n establishe<l. It should not
be given in advanced cases.
Putassiuin iodide often proves a serviceable
diuretic, alone or in coiid)lnatiou with digitalis.
Diiivtiii (sodium tlie<»l>romine .salicylate) has been
atlvoeated as a valuable diuretic in cardiac dropsie-s.
Cases have lioeri publislie<l in which its diuretic jwwer
has l)een reported ii*j marvellous; at the same time it is
not pretendeil that it can take the place of digitalis or
other cardiac tonics, but rather that it may be used
in the place of such a diurotic as calomel and with
more safety. It is given in doses of ]•') grains every
four or tive hours. It is said to be a very unslalile
preparation, and that it readily decomposes, and this
fact may account for the conUicting astimates of its
value that ha^e liecn published.
It is often fotiiiil that a combination of diuretics
will answer Ix.-tter thim either alone. .Some of the
most useful of these combinations will be found
amongst the furuiulie at the end of this chapter.
The elFect produced by diuretics will depend on
the condition of the heart and the kidneys. If the
eanliac muscle is in a state of a<Ivanced degenera-
tion, and if the kidneys are also un.sound, very little
good can be ejspect<5d of them.
* ( tu the Contiu«ut it liiis bonn (fiveu in V'-ry liirno iIduo'. even
to t)i(! |Ji'oduction ni diarrlia'it and aiiliriitiou. It i» said tlMt it ia
only iu siicli liirKt; (Iuimm that it8 diuretic efTuct is {irixlucud. We
hare sevii ill i'lli<ct« follow thia practice.
366
Medical Treatment.
I Put II.
When diureticH fail to relieve the dmpsy, itH;oiir8«
is liivil, ill the next place, to those Inidriiijo^jite eath-
aiiics, the wse anil application of which we have
already described, and it often hitppotis that after a
certain atiiouiit of the dropsical exudation has been
removed by tlie action of these drugs, iliuretics will
be found to have recovered their power, and inay be
re-administered with advatitAge.
Useful !i.s tiiiiitliorelir measures prove in the
treatment of rcnat ilnipsies, they are of little etticacy
in the removal of those of ciinliac origin, and when
diuretics and cjitliartica fail us we have only one
other rcHOurce left, viz. to drain awny tin- ilropsical
fluid by punctui-es or incisions into the subcutaneous
tissue ; or, in <lropsy of the peritoneum or other
serous cavities, to remove the fluid by paracentesis.
These measures are ofl«n neede<l in the last stage
of heart diseiuse to relie\»< the distress of th(! patient
from the enormous swelling of the legs, which may
become quit<> immovable, or from the groat accumula-
tion of (luid in the alKloiiiinal cavity preventing the
descent of the dia[ihragm. It is remarkable the relief
that is artbrditl by these nieasure.s in some cases, and,
when accompanied or followed by appropriate tonic
and supporting remedies, the patient is occasionally
restored for a time to com[>arative comfort.
There are different niethofls of etfecting this dniin-
Bge. Home make free inrisions half an inch to an
inch in length through tlie skin and sultcutaneous
tissue over each inalletilus ; the legs are kept in a
deiMsndent piisition, and the patient's body is niise*!
into the sitting or Hemi-recund)eiit attitude. Large
quantities of fluid will thus l)e drained away, to the
greAt relief of the patient. Most careful antiseptic
precautions must be followed in the performance of
this openition ; the skin must be clean.sed by washing
it with soap and then with an antiseptic solution, and
after the incisions have been made, the legs must be
wrap|K<<l in flannel soaked in antiseptic fluid. With-
out such minut(! care, and in some cose-s in spite of
^^ Chap. III.l
Cardiac Dkopsv.
367
it, owing to the low vitality of tlie skin, iiifliiiiimation
and Hlousliiii):; will attack tlio-se wounds.
I.fHs risk is thought hy some to attiich to
mullipli; piinrliirok, made with the sanio anti-
septic lu-ccauliiiii.s, either with the jxiint of a l»i8toiiry
or with a snilalile needle, thoroughly cleansed by
being jia.s,s»'d tliruugti tiie llanie of a spirit lamp, and
al.so dippeti in antiseptic fluid. The patient should
lie seated, wlien practicable, in an easy reclining
chair, and his feet ]>laced in a tub containing warm
water saturat<>d with boric acid, and from 15 to 20
punctures should be ijnickly inudo between the knee
iind ankle. Muiil will u.suiilly flow rapidly from
these puncture.H. The legs shoiihl then be enveloped
in anti.scptic wool or other appropriate antiseptic
dressing, which should be maintained in position by
a light flannel bandage. Small multiple punctures
thus made and carefully treated usuiilly heal ri'adily.
Some recommend the use of what are eiilte<l
" Southey's tuli<;H," small perfmateil silver cnnula-,
which are introduced tlirou':;h the skin into the sub-
cutaneous tissue, and atta(?hed to a length of fine
indinrublier tubing, through which the fluid may be
conveyed away into a suitjible receptacle. These are
intendeil to avoid the discomfort and trouble attend-
ing the continued escape of large quantities of fluid
from the patient's legs, espeeially when he is confined
U) l»etl and cannot sit \ip ; but they do not always act
80 well as multiple punctures.
It will occii.sionally happen in old cardiac cases
that the areolar ti.ssue of the legs has become so
indurated that no fluid escapes on puncture, and we
must be prepared for a disappointment of this kind.
In some cases of cardiac dropsy a large accumu-
lation of fluid occurs in the j)eritoneal cavity, em-
barrassing the rtrspiration atnl circulation by pressing
up the diaphragm, seriously interfering with the renal
functions by pressure on the kidneys, and, by com-
pre.ssing the alxlominal veiiis, further retarding the
return of blood frum the lower extremities. In these
368
Medical Treatment.
[Pari II.
caaea of cardiac otcxtet, when other measures, such as
we Imve cli'Hcril>c<l, fail to make any impression on
tlieninount of fluid, and serious coiisoiuenees threaten
from the pressure it ia causing on sun-ouniling parts,
fiiiracfiiti-gig abduniinin uhoukl Ix; |>ert"ormitl for the
rcuiovHl of at least a. portion of the fluid ; firm pressure
slioiiiil also he jippHcd to the exteniid surface of the
fthtionieii Iiyii tlduurl himler liotli during und after the
withdrnwal of the tlutd. If such pressure is pro|)erly
applieil und maintained there will Iw little risk of
syncope. Some diH'usihle stimulant should lie given
to the patient hefore the ojieration. It will often be
found that when the pressure of the luscitic fluid is re-
moved from the kidneys and the alxlominal veins the
action of diuretics and jiurgatives may lie re-estab-
lished, to the great advantage of the patient.
Passive elTuKioiis into one or other pleural cavity
{hijdro-lhorax), when of suHicient amount to interfere
seriously with respiration, must he removed, at any
rate in part, hy puncture and a.spiration.
!Tlii»«iii{{4> hiLs hoeti applied successfully to relieve
the <i>dema of the extremities, and also the ascites of
cardiac disease wdien not too far advanced. The
tendency to stasis in the venous capillaries is remeflied
to some extent, and the return of venous circulation
promoted l>y suitable manual compression and stroking
of the surface as in miissage. Massage of the ex-
tremities may he accompanied by alxiominal massage
"and jwrcus-sion and strong stroking over the kid-
neys" ; diuresis may he thus established, and the redema
of the feet and legs, in the early stages, may often be
caused to disappear ; but less effeut is observed to
follow when there is much ascitic fluid in the alxiom-
inal cavity, doubtless liecause in these cases the
cardiac failure is more serious, and the lesion less
remediable.
The rerobriil <'onK<'Nli<>n dependent on venous
stasis in advanced initidf ili><ea8e may be attende<l
with various unplenHant symptoms, none, however,
more distrensiug to the patient than the restlessness
Clap. III.] Opivm in Cardiac Disease.
369
ftnd iiieoiiiitia it sometimes induces. There is much
difference of opinion as to tlie propriety of ft<lniinisler-
ing opium or moi-pliiiie in these cases. In aortic
cases, to the treatment of which we sliall presently
refer, where there is cerehrejl aritniiia, opium is u far
more suitable remedy for cardiac 8lee|)le8snes8 than in
luitral cases, with cerebral venous congestion.
But wlienever the cardiac muscle is thin and weak
there is danger in the use of opium. It is tiue it
onswei-s well with some persons, who are not very
sensitive to its de))n'ssing iifter-effect, but in others
we must not be surpri.sed if we Hnd the use of opium
has simply promoted eutli:\nii.Hia. If we are com-
pelled to have recourse to morphine, as is some-
times the ctkie, we should give it in 8m:dl doses, not
more than the Jih or JJth of a grain at a time, anti
combine it with some stimulant such as the aromatic
spirits of ammonia and the spirits of ether. Others
are less reserved in their use of o|)ium in cardiac
cases. In mitral cases congestion of the liver and
defective bile secretion are almost always present, and
the latter is always aggravated by o|>iuui.
If there should also be some renal complication,
opium is still more dangerous. The safe use of opium
ill ciirdiiic disease requires, in onr opinion, the greatest
skill and discrimimttiou. We especially oVyect to the
hypodermic use of iiiorpliiiie in these cases on account
of the rapidity with wljicli the drug is then absorljcd.
We prefer to give it by the stomach, if at all, and
combined with a cardiac stimulant, or us a supjKisitory.
Broadbent, while praising the comforting ed'ects of a
hypodermic injection of morphine in some cases of
aortic incompetency, admits the risk attending it.
"Occasionally," he says, "a patient, after a good
night's rest procured in this way, will soy he fi-els
Ijetter, sit up in ImhI, and suddenly fall back dead."*
Codei/i, in ([uite small doses, answers well in some
cases. In a case of combined aortic and mitnd
disease, under our care, it never failed to procure
• '• Heart Diacaac" (third edition), p. 171.
r
370
Medic A l Trea tuent.
IParl II.
sleep during the last two years of the jiatient's life.
C/i/ornl is a most iiiiKiife ilnig on account of the
eardinc de])re8sion it causes.
iSodiuui hromulr is one of the safest remedies for
the insonini.'i of niiti-al eases. We have often fount]
a coinljiuation of 20 jtsrains of >'odiuni bromide and a
dram of tincture of Imps in an ounce of chloroform
wftter answer well ns a liyj>notic in these cases.
UrelliHuf. we have found it very uncertiiin hypnotic.
iSitlp/tonnl, however, is useful, hut it nets slowly, and
it is best to give it about an hour liefore the last meal
of the day in order to obtain its hypnotic effect during
the nij^ht Parahkhydr may also be used.
Hitherto we have lK»en considering chielly the
treatiiietit of mitral lesions and the circuhitory dis-
turbonces they involve. Tt will be convenient now
to examine the treatment adaptwl to the cfTccta of
aortic lesions which have not yet led to secondary
insufficiency of the mitral, for in the latter case the
preceding considerations would be as applicable as to
cases wiiich were primarily mitral.
Aorlir Mono<«i» without ins\ifticiency is the
least serious of all valvular aQ'ections. The induration
of the valves upon which it depends is usually
associated with general arterio-sclerosis, and not on
endocarditis, and it. is, therefore, commonly a disease
of advanced age. When the obstruction is but sliglit
it is usually completely comjiensated by a small
amount of ventricular hyi>ertro])hy, and the |>otient
may be for many years free froni any subjective
symptoms and uncon.sciou8 of the existence of any
valvular lesion. When this is the case no active
treatment is necessary, or only sucli as may •«
required by any co-existing general arterio-scleroais,
or gouty or other blood states.
If, on the other hand, the stenosis is considerable,
and imi>erfectly compensated by the ventricular
hypertrophy, syniptoms dependent on scanty filling
of the arteries arise, such as pallor of the face,
a tendency to syncope, giddiness, loss of memory,
Cliap. Ill I
Aortic Stenosis.
37«
(lixtut'btinci-s of vision and hearing, mid othcv signs of
cen'liral iinirniiii.
The indication for Irenlmoiil in those cases is to
maintjiin or improve the nutrition of the cardiac
muscle and to prevent degenerative cliangcs nnd
secondary dilatation ; therefore the most suitable treat-
ment for this state is mainly regiminal. Regular
gentle exercise may he permitted, but all physical and
mental exertion or excitement should he guarded
against, ('omplcte physical re{)ose may at times be
lieneKcirtl. Being miuli in the open uir when the
weather is j)ropitiou8 is advantageous for its tonic,
restorative, oxyjienatiii}^ induence. Tlie diet should be
nutritious, but it should be carefully adapted to the
digestive tajmcities of the jiatient. Wlien a diet
largely composed of milk is well liorue and agreeable
to the patient, it should be recommended. Animal
food, fish, nnd game in modenition may, however, suit
other cases better. Pur«5e8 of vegetables are most
useful for the avoidance of consti])ation, nnd a small
<iunntity of sound wine, or spirits and water, may be
prescribed with advantage, especially for the ag<KJ.
]f with other signs oif imperfect comjiensation we
observe increased rapidity of cardiac action, witli a
small, (juick pulse of low tensioti, indicating that the
ventiioular systdle is too brief for the ventricle to
com])lctely discharge its contents through the stenosed
oriti<-e, and symptoms of twckward pressure arise, we
should give digitalis in small doses — 5 to 10 minims
of the tincture three times a day, and we may often
usefully combine with the digitalis small doses of iron,
such as b grains of the umnionio-citrate.
But, OS a general rule, digitalis is not indicated in
ca.Hos of aortic stenosis. Paljiitation in these cases
may be relieved by the use of uitroglj'cerine or sodium
nitrite, which le.ssens periplienil obstruction.
If there is iTiison to think that the valves liuve
Ijeen injured by chronic inllainmatory jiroccsses of
sj'jiliilitic origin, full doses of potassium iodide may
bo indicated and are of great Bervice.
372
Medic A i. Treatment.
|P;irt II.
Aortic insuilifienc) is, ])4>rliap.s, tiiu must
serious of nil valvular lesions. The Kcriou-sness of
the lesion is, however, dt-pendent on the amount of
regurgitation which the incompetent valves allow of
during the ventricular diastole. It is aluinst in-
variably accotnpanii'd by considerable ventricular
hyiJertrophy. and when this form of valvular disease
occurs in the young and vigui-ous, the extent of the
hyjieitrophy may be taken as an index of the amount
of the ivgurgitation. Aortic insufficiency necessarily
causes the left ventricle to receive two currents of
bloo<l during its diastole, one pi-oceeding from the left
auricle — a direct current — the other from the ini
perfectly-closed aortic orifice — a backward cuirent.
If this back-flow he but small in amount, the contents
of the left ventricle wilt be but slightly augmented,
and its consequent dtlatiition and hyfiertrophy will
be inconsiderable ; but if the backward (regurgitant)
current Ik- large in aniount, the contents of the left
ventricle will Ije greatly increased, and its conseijuent
dilHtation iind hj'pi-rtrophy will Xte veiy consi^lerable.
So we may generally conclude thai an enormously
hypertropliied heart associated with the signs of
aortic insutficiency point to a large regurgitant current
through the incompetent valve.s. This great rlilata-
tion of the left ventricle may lead to the development
of secondary mitral insutficiency, and thus we shall
have the same series of morbid changes, on failure
of comi«nsation, which we have already traced.
But we are now dealing with those cases of aortic
insutficiency in which the mitral valve remains com-
jietent. Owing to the enormous dilatation and
hyjiertrophy of the ventricle which occurs in many
cases of aortic insufliciency a very greatly increased
volume of bkxxl is discharged, with greatly increased
force, into the aorta and the arterial system at each
ventricular systole. This pro<luues a certain con-
stantly-recurring strain on the arterial walls, leading
to chronic inllsmmation ami induration of their coats,
and, in the case of the aorta, often to great dilatation.
Chap. Ill I
Jto/l TIC Is'SUIFICIEKCY.
373
The occurrence of nngxtud Byniptoms, or ;«iin in the
cardiac region, is a common incident in these cases, a
sabject to wliich we shall have to refer liereafter.
A grent amount of regurgitation through the
aortic valves must neccHSurih' affect the cert'hriil circu-
lation, the suihlen em(>tyiiig of the large vessels which
convey blood to the brain, from the ix'Hux through the
inconip.'tent aortic valves, leads to symjitonis de-
])«ndent on cerehral aniemia ; sustained intellectual
effort becomes dilKcult, and great irritability of
temper is often noticed. Any sudden change of
position, especially from the recumbent to the erect
position, is apt to be atteniled with giddiness nr even
fainting, and sudden fatal syncope is not uncommon.
Certain syniptonis iniiy V>e caused hy the concomibmt
cardiac hypertrophy, such as headache, dizziness,
disturbance of vision, or even pamlysis frtun cerebral
baamorrhage. Symptoms due to enibulisin are also
especially jirone to occur in advunced stages of aortic
disea-se. Eniholi may be carried into the cerebml
vessels or into those of the spleen, liver, or kidneys.
Against some of the symptoms which may arise from
failure of compensation in aortic valve di.sease we
have no remedies ; but for others, and especially for
those dejjendent on cerebral aniemia, we may do
much by judicious management. Rest in the re-
cumbent position and the avoidance of all physical
and mental excitement are of great value. Supporting
food and a moderate amount of alcoholic stimulants
are necessary. At tlie same time the bowels should
be kept regularly relie»'i"d by gentle af>erient«.
We must bear in mind the risk of suilden <ieath
in these cases, and caution such patients against all
hurry and overexertion ; and we should insist on
periods of complete repose in the recumbent posture
from time to titne. It is most striking the improve-
ment that follows a few weeks of complete rest in
some of these cases.
Some differences of opinion exist as to the
propriety of giving digitalis in cases of aortic rcgur-
374
Medical Treatment.
fPait II.
gitiitioii vvitli failing cumpensation. It has lieen urged
in opfMJsition to its use that V)y prolonginjj the diastolic
pcriwi such a fall in blood pressure may lie induced as
to incur the danger of fuUil syncope. But we believe
the true test of the value of digitalis in these ca-ses is
the state of integrity of the cardiac muscle ; if it is the
seat of advanced degenerative changes (and this is not
inconsistent with enormous increase in size), then
digitidis will be of little use ; hut if t lie cardiac muscle
is fairly sound, and in a condition to respond to the
tonic effect of digitalis, we believe that the sustained
systolic, contractions promoted by the judicious and
cautious use of t)iis drug will far more than com-
pensate for the pniloiigeil diastole, pmvidetl always
that the piitient is kept in the rccunibuiit {)osition in
bed, and the pulse carefully watched, so that the
heart's action is not allowed to lie too nnuh sloweil.
Moreover, it must he borne in mind that a //oWiy
muscle will offer no re«ist«nce to over-distension from
a considerable back-flow, but, on the other hand, a
fairly sound ventricular muscle contracting vigorously
under the tonic influence of digitalis, and liettcr
nuurishw] by improved intracardiac sanguification
thus induced, is much le^ss likely to yield to the
distending effect of the arterial rolhix than a flabby
muscle with no such sustaining help, and therefore the
emptying of the arteries would be greater in the latter
than in the former case. And, further, these considera-
tions are consistent with clinical observation. In
subject* of aortic regurgitation attacked with palpita-
tion from failing heart power, we have seen the moat
striking imjirovement follow the regulating effect of a
few doses of digitalis, together with i-ecumbency. Ten
minims of the tincture, with 30 minims of aromatic
spirits of ammonia and 20 minims of spii-its of ether
or chloroform, may be given every five or six hours.
The iiHrili's are very useful in allaying palpita-
tion and poin in these cases, but their influence is
very temporary, and the doses have often to be rapidly
increased to produce any beneficial effect.
Ch»p. iii.i Digitalis in Aortic Dixbase. 375
Prof. W. I{. Thomson strongly advocates the coiu '
bination of nllro-(jl>corliir with digiUtlis i>i lh<.>«j
cases for tlie purpose of correcting tlit> coiitrivctiiig
cH'cct of tlin latter drug on tlie arteriolm, aiid with
thi«o two he coinbines strychnine and nox voniioji.
His prescription is 10 niinims of tincturo of di^talLt,
10 minims of tincture of nux voniicit, nnd ,'^th grain
of iiitro-glycerine for a dose.*
Dr. Barnt, of Leeds, writili<{ on tliin siiliji'ct,t very
justly observes that the objection to the twe of digitiiliM
in aortic disease is nither the conNty|iieiice of the il prinri
tcocliing of ]ihnnniicology than the outcome of clinical
experience, and he expres.ses his slronj^ conviction, the
nault of a " fairly lurge exjH'ricnce," that, given in
811 Dicient doses, "digitalis is just as much a reme<ly
for aortic as it is for mitral diseas<.\"
For Dr. Balfour's elaborate argument in favour of
ihe use of rligitalis in aortic disea.se wo must refer to
a paper he publi-thed some years ago on the subject,}
but we niny cjuote his conclusion. " VVIkmi," he sjkys,
"from any cause compensation is ruptuix-d, an aortic
heart will l>e found as amenable to the lieneticial in-
fluence of digitalis as any other failing heart, but
larger doses are required ; but little intluence is pro-
duced by less thaii three times as much as would suffico
fur u mitral heart. Even should the pulse uiuler
treatment become abnormally slow, which is not at
all usual, and certainly not needful to s«!cure lieneiit,
wo may rest a.ssiire<l that exces>>ive regurgitation ia
not then promoted, and though sudden death is not
at all unlikely to happen, in a badly compensated
aortic hefirt, whether it xa trc;iled with digitalis or
not, digitalis is never to blame for this. On tlu^ con-
traiy, the judicious use of digitalis is the most effica-
cious treatment in all awes of failing heart, wliethor
that failure be accompanied by aortic or mitral
* Hare's " SyRt«in of Practical Thentpeutica," rol. u., p. 335
(necoud edition), 1901.
t Bnt. Meil. Jniirnal, March I'ith, 1892.
j llnl. yCtH. Journal, June Itli, 11*92.
376
Medical Treatment.
IPatt II.
reffurgitatioii. In failure dejiendent on arteriosclerosis
nlune, the tonic influence of digitalis on the heart is
hindered, unlesH we combine with it some drug which
unlocks the ai-t<^rioles, and so prevents an increase
of bloml-pressure, already ahiiornially hii,'b.'' We
would only repeat that the dose of di;L;itiili.s siiould l)e
carefully watched. When we have iirouulit the pulse
down to 00 or 70, the dose should lie diminished,
and when giviiiju; larger (loses we should keep the
patient recumbent in Ijeci for theiv is much more
dangtjr in greatly pmlonjiing tlio diastole when the
patient is in the upright position, with excessive
regurgitation, owing to the risk of completely emptying
the cerebral vessels.
Broadbetit considers iligitnlis valuable in aortic
regurgitant dise^ise when symptoms of mitral incom-
petence are added to the pliysical signs of aortic
regurgitation, i.e. distended pulsating jugular veins,
liver enlargement, and dropsy. l!ut he thinks it is
rarely of service in the absence of mitral symptoms,
and may do harm by setting up vomiting and thus
cause serious astheniii.* Douglas Powell agrees in
the main with Ualfour, and argues that when the
early sympt-onis of heart failure occur in aortic
regurgitation, " by the timely employment of an occa-
sional course of digitiilis the more des|jerate symptoms
may be long post.poned."t
It is certain that great discrimination and judg-
ment are i-equired for tlie right use of digitalis in
cases of aortic regurgitation.
For the relief of the attacks of paroxysmal pnin,
often of a truly anginal character, which freiiMeiitly
occur in aortic cases, we shall reipiire to have recourse
to various remedies. Potassium iodide in full doses,
10 grains three times a day, is often very efficacious in
the relief of this symptom. Nitro-glijcerine, of the
effects of which we shall sp'ak more fully when con-
sidering the treatment of angina pectoris, may also in
• " Heart Dl«ciu»" (Uiird uditiou), p. 17.!.
t "Treatment of Diieaaes uid Diiordera of the Heart," p. 66.
Chn,, III.)
AoKTic Disease.
377
many cases be given with benefit. We have given
Rodium nitrate in grain doses combined with sodium
io<lide in 3-grain doses thrice a day, wit}i great
temiKjrary relief in siicli cases. If the pain T-esetnbles
that of aortic aueufism, the aljstraction of 4 to 6 oz.
of blood has sntnetimes been found ett'ectual in
relieving it.
Hut for the relief of this syn)ptoni, us well as the
«l}'«|»n4ra and nocturnal Hlet'plrsHneiis of aortic
insiutljcifnoy, we shall often be obliged to have
recourse to the preparations of opium or morphine ;
and in order to avoid as much as possible their re-
mote depressing eU'wts it is well to combine them with
ammonia and ether. There is not the same objection
to the nse of opium in these aortic cases as in those of
mitral disease, with pulmonary engorgement and
dropsy, as we liave ali-eady point^etl out. Many authors
maintain that opium increases the amount of blood cir-
culating in the brain, and therefore ndieves the cere-
bral anieniirt. liut we b^Oievo the beneficial action of
opium in tbe.se cases to be cliieHy due to its sedative,
regulating eflect on the exciter! cardiac muscle. It
steadies the heart, and enaldes it to do its work more
eftectively, and it removes cardiac and cerebro-spinal
hypera»sthesia. In this '^'ay, no doubt, it may indi-
rerthj improve the cerebral nutrition. It is well to
use smidl doses at first, nnd to administer some
idcoholiu stimulant at the same time. If we give it
by the mouth— and we prefer that to tlie hypodermic
inclhod in cardiac diseases — it is desirable that the
stomach slioidd contain little or no fi>od, so that
stomach digestion is not interfered witli. We may
give occasionally a draught containing 20 minims of
lifjuor iuorphina> hydrocliloridi, or 10 minims of the
liquor opii seilativus, with 20 minims of spiritus
a'theris comp., in an ounce of peppermint water.
Our objection to the hi/jiodfrtnic use of morphine
in chronic valvular disease is founded on the know-
ledge of serious conditions of cardiac failure which we
have occasionally seen follow this method of giving it —
378
Medical Treatment.
[Part It.
owing, we liclieve, to its very rapid absorption when
thus administered — hut we have not sei^n these .serious
results follow when it is jfiven by the mouth uonibined
with a stimulant.
It must Ite liiiniu in mind thiit it in nfver safe to
give even small diises of opium or morphine when
there are evidences of renal chiin;;i'H, or of advanced
degeneration of the cardiac muscle, At all times wo
prefer roil^ia, if it proves efficacious, atid it should lie
tried before we liave recourse to morjthiiie. Some
give 20-griiin doses of chloralamide, nnd others have
recommended tincture of henbane in hot Umndy and
water. Attacks of cai-diac asthmii from aortic incom-
petence are often reli(!ved Ity alcohol ; strychnine in
combination with sal volatile and Uofi'man's anodyne
has also lieen fo\nid of value in the same cases.
Tliu ordinary ether iitid ammonia mixture is useful
but evanescent, so is the inhalation of chloroform.
Tt must be admitted that the intrmluction of the
nUrilf)! into ciirdiac therapeutics has been a great aid
in the treatment of this class of ca-ses ; for although
they have the disadvantage of soon losing their effect
if given consUintly, for occasional and temporary use
they are of great value. In most cases of paroxysmal
cardiac <ly8pno*a their influence will prove beneticiiil,
as well as in cases of paro.xysmal attacks of pain of
canlio-vascular origin. But the point to bear in mind
is that they are only of temporary value ; they may
act at times as useful auxiliaries to oii-diac tonics, but
if aflniinistered continuously for long periods they
tend to act as caitliac depressants.
CkaiTLlILI
Camd/ax: DisE.tSM.
379
ADDITIONAL FORMULA
IB mattkt liciWfliTi. vttk r>r ■tttml ISmmM. with >w-
R TiactnrB di^Uli*. iijM.
Potaau iodidi, ^tij.
Extimcti oocar liqukii, Uj-
8|uitus aUwra nitiaB, Jj.
Aqiup ct ^yocrini ad |i*.
)l. f. milt. A teupoooful
in two tstileniooof aU »( wnlcr
four timaa a ttay after iorA.
(Ilk-lla.)
Diuretic mixture in beut
& Potmaii iodidi, .^je«.
Spiiitiii ammoiiiir aromntiri.
3iT.
SttocBi tcopuii, SJM.
Tinetun: oigitaliK, 3ij.
Infuii neneg"- ti Svj.
H. f. miat. A tiibli)a]>oonftU
in water erery sic hours.
(H'hilla.)
Cardiac stimulant and
diuretic combined.
II Potttmii ncctatin. gr. xx.
Tiiictuni- (liptalis, mx.
Tiiicliinu M'illa', mxx.
Liquori^ i«trychiiiuit) Jjy-
rlrarhloridi, Tiiv.
lufusi Benojni'. nd o^
H. f. liitufftiifi. Tu bo taken
every four hours. (Ilrurr.)
% TlMtns miSite. 5ij.
TfaMtaoiB JigitilK .vij.
Am* fiim, aJ ivj.
ILLaM. A talilM|»oufBl
rrery low honra (Btlfimr.')
Dinretic calomel powdera.
ft HT<lran(yn subchlondi, nt.
iij.
Bxtiarti ojai pulTem. irr. I
»d }.
8acc]ian lUbi, xt. v.
M. f. pulT. To tH> l:llkl-ll
three tines ■ day for \\\t\v
days : tfafcn sucprmwd fur tlirm
or four diiy«, and rvni'wnl, if
well horuc. vl'w n chU'rato of
puUah gari^p at sanw time.)
{Bamttiyrr.')
For bronchial catarrb of
cardiac origin.
H Qiiitiii>a' i^uIiilKitio, itr, viij,
A. ' ■ ', (rr. ii).
K.1 _'r. luv.
M. • II iiiilv. vj. A
iwwder every two linura.
(Bambtfftr.)
Cardiac tonlo.
R Tiiiiluni- ili({iliiliii, itl v.
Tint'tiirn' fern iicrcbliiriili,
mit.
Acidi |iho«i>)iori<si dilnti, m
Ai|UiL', ltd ii.
M. f. luiuift. Ttj lio tiiltMii
tlireo timet a dny iniint'ilint«ly
of t«r moala. {limn'.)
38o
CHAPTER IV.
THE TIIKATMENT OP CAKDIAr II Vl'EKTROPil Y AND
dilatation; and ok dkuknf.uatiovs oc tiik
myocardium.
Frinuiry Cardiac Hyp«rtro]ihy rare— CaiiBCs— SjTnptoms — Tmtl-
mnit — B^miniil uiid liittotii; Tlie " Unipo Cure" nnd
"Whey Cure" — Usefulness of mild Awrienta— Digitalis to
be avoided— Aconite aud Vcnitrium virido — S'nipti- litlnliition
nnil Ciirdiar Wcnin— CauKcs - ExwB.'ive riiysicnl Exertion —
Maluutritiou — Exhnu»tion of Acute Oiseiue — Tolncco —
Aiin:mu\- St/ifiptoHt* — Tyrattui'itt — H«*t — S«i Voyage — Hydro-
thcmpy Open-nir Life— Nutritious Diet — Suppreaaioa of
Tolmcco Car<linc Tonics— Formuln?— Importance of Restand
careful FeediuK in oJlvauceil Ca-tes— Millc Diet -Advantage
of Apcrienlg— romiiiliB.
Dboenbbatioxs : Fibroid Depeneration— Fatty Degeneration—
Causes— Syiuplonis — rmi/iiKvi^— Digitalis — Best — Food—
Stimulnuta — Stryliniue — FormoliB— Free Ai-'ralion — Iron —
Aperients— Sedatives for Restlessness aud Insoniuia— f«</y
Overi/vowlh: O^iims— Treat nirnt — Dietetic- Mineral Waters
— Exercise — Urilrt't C'irr — Additional Formula' — Tlie
"Schott " Movements or Exercises — Artificial Nauhvim
fiatha.
We must next refer briefly to the trentment of
certain cliroiiic clianj^jes in the walls of tlie heart,
occurriii;,' iiKlcjietidently ut' any valvular lesion, suoh
as li)'|>«'i'li-<>|iliy. (lilatalioii, and de{;cnera-
tioitN.
Ilyperlropliy of the heart, indeiieiident of some
olistructicm in the course of the circulation, is a
coinjiiinitiveiy rare affection. As we encounter it
cliiiicitlly it is usually a consequence either of
valvular disease or of aome obstruction in the
peripheral vessels, such as general arterial sclerosis,
and tiiis may be caused either by changes originat-
ing primarily in the walls of the vessels, or tnay
be secondary to .some morbid state of tlie blood, as
in 8y|i!iilis, gout, and chronic Bright's disease.
But cardiac hy|)ertrophy does occasionally occur
as a primary disease, ancl it is then usually caused
by agencies which excite the heart to over-action.
Chap. IV.l
Cardiac Hypertrophy.
38'
Nervous excitement may do tins, by aiusing
hahit.iiitlly increased cardiac- actiun, Tlie excessive
use of ton, coffee, alcoliol, and toliacco, and liabitual
exc<«s in eating and drinking gcuerall}', and sexual
excesses, lead to cardiac liypt'rtrophy from over-
action. Excessive muscular exertion, as in rowing,
clind)iiig, and other athletic s]>orts and exercises,
or in certain laborious occupation.*;, has a two-
fold influence in exciting cardiac hypertrophy ; first,
liy increasing the action of tlie hi'art and causing
pal]iitation, a condition which in .some cases con-
tinues after the exciting cause has Ijeen removed ;
and secondly, by the obstruction to the peripheral
circulation and heightened bltKKl-piessure caused liy
undue compression of the small arteries and ca|til-
laries during the excessive and sustained miiscular
contractions.
It must be Ijorne in mind that while muKculnr
compression of the blood-vessels by increasing the
bhxMl-pressure excites cardiac hy}>ertro|>liy, this
hyfiertropliy itself tends to still further increase
the arterial leiisioii, iind the bloo<l-vessels exposed to
this additional strain Ix.-oome the seat of chronic
iiiHammatory changes, so that cardiac hypertrojjhy,
besides being a consei|uence, is also a cause of
arterio- sclerosis.
When cardiac hypertrophy is simply compensa-
tory, as in certain valvular lesion.s lio suliji-clivo
symptoms arise as a couse<iuenco of the hypertrophy,
and no treatment ncetl Ije directed to it ; but when
hypertrophy results from abnormal morbiti excite-
ment of the cardiac action, then certain chanic-
teri.stic symptoms may arise and call for treatment.
Palpitation is one of the.se, flushing of the face, spots
before the eyes, noises in the ears, headache, gifldi-
ness, these and other symptoms are dependent on
he cerebral vessels, and
rfilling
may.
certain r.ire cases, lead to cerebral haemorrhage and
apoplexy.
The Iroaimt'iil of simple cardiac hyi^rtrophy
382
Medical Treatment.
(Part II.
of this form is fliiefl)' rcpiminal and (iietetic. All
causes of cxciU'ineiit imiKt Vh- it-iuoved. Athletic
exercises and laborious occupations must 1)0 stopjwd.
A ■wholeKonie out-of-door life, willi strictly luodi'rate
and tran(]uil exercise and luuolt rest in the liori-
/.ontul or semi hori/ontnl po.sition, aliotild he enjoined.
Daily cold ati'usions or 8j>riiiklin>,', espi'cinlly to the
head and sjiine, ai-e usi-ful as eahnalive.s, and good
results Imve l>een oUserved to follow the ii]){ilicntion
of a vessel tilled with ico-cold water over the cardiac
region.
The strictest moderation in diet must lie enforced.
Aiiiirial fo(j<l should ho lakiMi nnivin small quantities,
and fresh vej^etnliles, well L'«H>ked, should enter largely
into the daily dietary. All alcoholic stiiuulantii
should I>e prohil'ited, as well as the use of tea, coffee,
and tolnieco. The amount of lluid consumed should
not Ije Jtrnat, and should lie eruitiried to the wants of
tiie system, as it is umlesirahk' icj over-distend the
blood-vessels with Huid. Rijir cooling ftuits may,
however, l>e permitted. Tlic "grajie cure" has been
advocated in these conditions, but when largo quan-
tities of grapes are consumed daily other food nnist
be restricted to within very narrow limits. The
" whey cure" has also been found useful. We must
watch that the diet jirescribed be i-e.-idily anfl easily
digested, and if it cause flatulent distension it must
be suitably modiHed. If there is any tendency to
alxlominal plethora, free daily evacuation of Uie
bowels will lie a necessary measure in order to remove
l)rt>ssure from the aVidoininal ve.ssels. A mild aliK-tic
pill at night and a teaspoonful of CarlslMid or Horn-
burg salts the following morning, in half a tumblerful
of cold water, will usually accomplish this result.
We must be careful not to give digitalis to check
the palpitation of simple cardiac hypertrophy.
Small doses of acoiiit*? and of vcratrium virido
have liceu a«lvocated to diininisli bloo<l-pressure, and
tu act ascardiac sedatives in these cases, but we have
never seen the necessity of drug treatment of this
Cll»p. IV.l
Cardiac Dilatatiok,
383
P
kind in CAses of cardiac hypertrophy, ami wc shotihl
muoli jirrfur rt-lyin}; on such general mcAHures as have
alt-cady Ijeen indicated.
We must next eon.siiler the treatmont of clilala-
tlon of the heart, unconnected with valvidiir lesions.
Tlip f'xtieme forms of cardiac dilatation are attended
liy niuili tlie 8tiine symptoms a.s accompany chronic
valvular disease wlien conipenf-ation liits ciini|>l<-tely
hrokeu clown, and they, naturally, r»'f)uirt! the sanie
ti-piitniPiit. In this se<'tion wc are oon.siilering chielly
the treatment of moderate dej^rees of dilatation, in-
stances of which Iinve <pf hite ycai-s Wen very frequent.
The most common cause of simple (lilnldtiou of the
heart infiiininiii/iefi renntmirj; in itn walls from impair-
ment of muscular {wwer. This state is a common sequel
of exhausting disea.ses, as the infective fevers, influenza,
or of any condition which has lowered the general
nutrition, asanamiia, hnniorrliHges, privation, etc. It
is apt to follow ])eric«rdial adhesion.s, and the changes
in the ciinliac niu.scio whicli iiecompany acute endor-
carditis and pericarditis.
It may also arise from i7tereated pre*»ure within
the cavities of the heart from habitual high arterial
U-nsion, liut in that ca-s<> the dilatation is rarely
simple : it is then usually accomimnifd by hyjiei tni[)|iy,
uidesH the increased jircssure should Ije associated with
diminished resistance, and then the dilatjitioii will be
sim]ile and rapid, as happens when severe nuisciilar
exertion is attempted by persons in weak or failing
health, or as in overworked men of middle iige, who
tiy to "walk themselves into conflitiim " during an
autumn lioliday, when their condition is one really
re<(uiriiig prolimged physicnl rest.
The same inuy be observed in feeble youths who
attempt to emulate the physical exploits of their
stronger comrades. In tin' working classes excessive
labour, with insullicient food, may lead to similar
results.
In all such cases increased pressure within llie heart
384
Medical Treatment.
(Pan II.
is associated with diminished rosistance in its muscular
walla Attacks of inllucnza art; especially prone to
be followed by eardiiic dilatation. Dilatation and
syniptoins of "enrdiar strain" are also observed,
not unfrequontly, both in youth and uiiddie age, from
tlif! uliuse (if tobacco. Young men, in a])parently good
health, niid in active exercise,, will occiisioiially, and
somewhat unaccountably, sutler from attacks of pal-
pilntion and faiiitness. and on examination the
physical sif^ns of cardiac dilatjttion will be Ibuiid. Such
a condition i.'i sometimes found associated with Imbits
of sexual excess or masturbation, or simply from
an amount of physical exertion in excess of their
powers ; but in cases where none of these causes
exist^s we shall often be able to trace the cardiac dila-
tation either to the cvecsftnY xtse of tolmcco or to its
persiflent US1 by young men who are conslitntionnlly
sensitive to its de|)rf'ssing effects. In middle-uged
men, after smoking for 20 or 30 years without n1)\ious
illetfect, it will not seldom ha|i|ien that symptoms of
cardiac dilatjitiou apjicar somewhat sudilenly, and it
may he dillicult to convince tlieui at tirst that it is
due to the tolwcco which they have used so long with
impunity.
Anscmia, nervous excitement, anxiety, faulty
habits of life, especially with respect to food and
exercise, are common causes of caixiiac asthenia and
dilatation in women, and less frequently, also, in men.
Indeed, whatever leads to defective nutrition of the
cardiac nmscle must prcdis|iose to dilatation.
Dilatation, accompanied with more or less hyper-
tropliy, is often observed as a result of the over-
exertion attending certain occupations, as in .soldiers
after forced marches or from excessive drill, and in
miners and others engaged in very laborious occupa-
tions.
Broadbent enumerates amongst the causes of cases
of cardiac dilatation condng under his own observa-
tion " injudicious hydro|>athic treatment," certain
methods (^Banting's) of reducing obesity, and the
Ch^i.. IV. 1
Cardiac Dilatation.
l^l
iiilmlatioiiH iif Himrod's powder for the rnlicf of
tustlirtia.*
It must !«' reiiK'iTiViercd that in all cases i»f dilativ-
tioii uimttciiiieil by hypcrtropliy tlit- >entricles fail to
ex[>el tlie whole of tlieir content*, and in advanced
cases only a small jtmportion of thi- hlood contained
in the venli-icli-s is ilriveu into the great vessels at
each ventricuiiir systole.
Tht' chief Nynipionn* of cardiac dilatation and
asthenia are recurrent attiiclvH of palpitntion and
irregular action of the. heart, on any exertion : they
often also occur at ni^dit, causing the patient to awake
fioni .sleep in ninch alarm. I^yspno'a on walking up
hi)( or ascending stairri, or on making any muNcular
elFort, is also common. In females complaint of
cardiac /xiih is fre<|uent, and '.in deep [irc&sun> over the
cardiac apex with the \mwi of the finger some hyper-
scnsitiven».«H of the cardiac tnu.sele can often be made
out. Liability lo fatigue on slight exertion, with
languor and feebleness, both ])hysical and mental,
accompany most cases. The jmlse is usually quick,
compressible, and often irregular. Tlie irregular and
insiifticient supply of blood to the brain gives rise to
lack of mental energy, failure of memory and atten-
tion, irritability of temper, and a tendency to attacks
of gtihliness and faintness.
The Irt-almrni of these forms of cai-diac dilata-
tion must, in the tirst place, consist in the withdrawal
of the ]>atient from the influence of all those conditions
which have cjiused it. In these cases in which over-
exertion has led t<i cartliac strain we must insist on
the avoidance of ail kinds of muscular etrort, gentle
exercise alone being jieriiiitted, and this restriction
must bo enforced for an mlequate length of time.
When this condition has been induced by over-excite-
ment, emotional or mental, or by addiction to evil
habits, these causes must be sought out and correctetl.
An open-air life in the country or at the seaside, u
proper amount of regular exercise, always 8top[>ing
• " Heurt Diaeiue " (third wlititm), p. iV
386
AfSDKAL TxEATiieST.
|I>>nlt.
short uf fatigue, a noarishing l>ut light itiid digtstiblo
<Uot , regular att«iitioa to the bowels, and early retire-
ment to rest, arv remedial mwisure* too ohvioua to
iieeil insisting upon. Wlirn the disease can be travetj
to the use of tol>accu, or is aggravated \>y it, this
must Ik" wholly forbidden, and thei-apid impros-ement
in health which usually- follows the relinquishment of
this habit will rarely fail to reconcile the patient to
the sacrifice.
Some rar«lin«- Ionic will genertilly l>e advixable,
and will, indeed, be indispensable in those forms uf
ranliac diUt^ktion and feebleness which occasionally
follow attacks of acute febrile and septic uiiiliidics.
Mid also in aiia>n]ic ciises. It will rai-eJy, however,
in mild cases, In? necessary to have rei'ourse to digitalis
except where there is much dyspno-a and trouble-
some jMilpilation. In such cases small doses of
digitalis may lie given in combination with iron,
such as : —
V} Fern ct ammonii citmtii
l*) Del line iligiUili*
BpirituB ammonia' kromutici
Infiui calumbii)
.M)i<cu, fiat misluni.
Iiour Hfter meal*.
gT. tuuc
ad 2|Tnj.
Two tiiMe«poon(uli twice a day, >n
We, however, prefer, in the less serious forms, to
employ slroplianthus, or strychnine, or nux vomica,
with coca, in combination with iron, quinine, or
arsenic, as may Ke«.Mn desirable. \Ve have found
one or other of the following formulie very service-
able : —
Vf Qiiininii' suljihiilis
Tiiiclinn' niici* voniiiu'
( Vtl. tincturii- strophantlii
Kxtrncti cocii' duidi
tjpirilii* chlorofurmi
AquiP
Miiii«, fiat miatura. Two Uil>li^
hour hefore fooJ.
gr. xvj.
rvj
"ixl.)
Vv.
•nlxxx.
nd .^viij.
-•-« • day, aa
1
CIm|i. IV. I
Cardiac Dila ta tion.
387
Or,
H? Ferri pt (luininip '-itnitia ... in'- Ixxx.
IjiqiiuriK utrythninii' m xxxij.
SjiirituH chlorofomii mlxxx.
Atitiac ... .. ... aii Jnij.
Slisco, fiat iniiitura. Twu tabl«»poonfulg twicu ii day, two
boiirs aftor food.
Or,
I^ Fcrri unenHtiK
(jiiinin.'f v&loriiiiiiititi
Kxtracti iiiicis vumktif
gr. iv.
■ I aa gr. xxiv.
Mi8(.-4! el divide in pUuUs xxiv. (Jtiu tlircu tiinvti a dny nfter
food.
lu purely jiiiseiiiic Ciuscs iron atui iiux vomica,
together witli some aperient to ensuro a regular action
of the Ijowels, will bo most serviceable, as : —
I^ Ferri sulphalis cxsiccatw
tNiponiB ...
Pulverid nuciB vomicto .
Aloin
Miscv i<t divide in iiiluUi;* xxiv.
twice ditily, ufter lunch and dinner.
.. gi". xxxvj.
gr. xviij.
gr. xxiv.
gr. iv.
One or two (s8 necessary)
Tn coaeB of Bomewhat acute dilatation, however
induced, the hypodermic- injection of .strychnine in
doses of ^'n*'' ^ /o*-'* "^ " grain will sometimes be
attendixl with rtMimrkalily good resultn.
So far we have lieeti only considering the milder
forms and moderate degrww of cardiac dilatation, but
in extreme eases the same series of morbid phenotrn-na
indicative of cardiac failure will Ih3 encountered as
we have already descrilied in nou-com|>en8ated
valvular disesuto, and the same tieatment will be
needwl. But in these grave instances of cardiac
dilatation the ventricular muscle will usually Ih)
found to Ix" in a state of advanced degeneration, and
digitalis and other cardiac tonics will usually fail in
producing any restorative or strengthening effect on
it. Our chief resource in such a case must Ije the
mowt nbstoliite repose, with careful attention to
388
AfEDICAl. TkBATMENT.
Part II.
the geiK-nii nutrition. Liglit, easily digested, or pre-
digpKted, liijuldy nutritious food must lie jirescribeil
— such US pounded nu-at very lightly ci)okpd, Ijcivteii
U|> <"gj{s, I'hickcn and game puninia, a littli- \vliit<? ti.sli
when iigreealilo, milk, and a small ijuantily of good
souud wini', or a little weak limntly or whisky and
water, but thfi total amount of fluid taken must be
strictly limit(Hl so as not to augment the volume of
blood. A regular action of the bowels must lie
inaintuincd by snitiilile ajuTifht)?.
I'l'i'f iK-lioii ol lli<> I>o«v<'Im is very udvan-
ttigpous in nejiriy all cast-.s of cnrdiac dilatation and
feebleness, as we have previously explained. Ap<.'ri-
eut.s should, however, be so given us to clear away
only the residue of digestion. For this purpose the best
method is to give an aloetic pill aft-er dinner or at
bed-time and asidine do.se early in tlie morning, aliout
an hour before breakfast. Careful attention must,
of course, be given to the individual sensitiveness to
aperient luediciueii. The folio wirjg will be found
api)licable to most cases : —
ly Kxtracti hIoos
Ipcoaciiiuilm" imlrcris
Extracti hyoscynmi...
SliRO" I't divide in pilulns duodeoim.
or at Ix-dtinif.
}\7 8odii gulphntiH
8o<lii tiir«rbonnliB ...
Sodii chloridi
Jlidco, fiat piilvis. To bi' ffivin early in thi- morning, after
th« pill, diHitolvt.<d in half n tumblcrfal of hot H-iit<'r.
In those extreme cases in which from Ijnckward
pressure the liver is enlarged, much relief is often
felt from the application of G or 8 leeches over the
lieputic region. A hot poultice should Ije applied
after the leeches have l>een removed to encourage
the bleeding.
Hroadbent strongly advocates the use of mercurial
purgatives in these cases because of their sctimt in
• tf.
xij »d xxiv.
.. p-
"}•
■ ST.
vj.
■ ^■
Ili-
One uflur liito dinner
5.1
ad 5ij.
fC-
XX.
gr.
X.
Chap. IV, I
CAHniAC D£GElfSKAT10N.
389
"diniinishiug urIerio-capUlary remstaiice and of lower-
ing arterial toiision, Hiirl tlierefori- of relieving the
heart." He ^ifives iit tln' nutset one or morn full
doses of calomel or liliic i>ill roinbined with rliulmrli
pill or colocynth iiiid lieiilwnc, followetl by h mihl
saline, and then 11 niililec ilnse every second or third
ni^ht. Cardiiic tonics should nlso ho given at the
same time, and other nieuxiireK a|iplie(i such as we
have already described in the preccrlin;^ chapter for
the relief of the various symptoms of cjirdiac failure.
The scope and value of the Oertel and Nauheini
methods of treatment will he considered at the end
of this chapter.
l>c>|{«>M<>rnlioiiN uf the cardiac muscle do not
offer much scofH' for therapeutic tnauagement : some
form.'*, descnlied as "fibroid disease" of the heart,
and (lepenilent on chronic myocarditis or ol)lit<'i-ative
eiulartr-ritis of hrauches of the coronary artery, and
often associated with hypertrophy, are very dithcult
of diagnosis and offer no other indications for treat-
ment than such syniptcnis of cardiac failure and
circulatory disturbnnces as may accompany tht>m,
and uH are also cuuimon to rlVnUiliim and to non-
conifiensated valvular lesions ; and these we have
alrejidy dcscriWd, and their np]iropriate treatment
lm« I>een jioinled out.
There are, however, two conditions of the myo-
cardium which may now claim a brief considerntion
from a tlRiafveutic point of view, viz. "llUly rt«>-
Kvliri-Hlioit," properly so-called, and the "liilly
ovorKrowili " which so commoidy accompanies
excessive obesity. The former of these is a true
granular and fatty degeneration of the cardiac muscle,
which becomes pale and tlabliy. It arises in con-
nection with defective nutrition, and may therefore
Ik- merely a senile chan<;e ; it occurs also in cachectic
anil wasting diseases, and after pi-olonged attacks of
the infective fevers, and especiiiUy after diphtheria.
It may be the result of acute and chronic ana-mia,
especially of that form which is termed pernicioH» ;
39°
AfF.n/CA L Tk F.A T.%tF.,\T.
(ParlH.
it is a well-known consequence of iiliOKplioi-us poison-
hijj ; it Kouietinifs follows attacks of pericarditis ;
it may l>e dep«;n(lent on disease of the coronary
arteries ; and it is a common feature in the degenera-
tive changes of ohrotiie hypertrophy.
The s3'mptotns of fatty degeneration are those
common to enrdiac failure from any cause ; the
diagnosis of this condition is therefore difficult, es-
pecially if a systolic a|iex murmur should happen to
bo present. The existence of very marked signs of
cardiac failure without any histoiy of preexisting
valvular disease, or exjtosure to the ordinary causes
of endocarditis, may excite a wellgroumled suspicion
of the existence of fatty degeneration.
The lireakdown is also often comparatively sud-
den ; dyHjma'4i is coTiiphiitK'd of on the slightest
exertion, with sighing ami a sense of op[ire.Hsiiin in the
chest. Tfiere is great muscular deKility and incjipn-
city for any exertion, physical or niental. Irritalnlity
of teni]K'r and other mental ilisturhances are prob-
ably dependent ou an insufficient blo««l supply to
the brain. The patient often feels cold and de-
pressed, and his ptdse is found to lie slow, feeble,
iiTegulnr, anil intermittent: it may sink as low as 40
or 30 in tlie minute. The extremities are often cold
and blue. The cardiac impulse is feeble, perhaps im-
perci'ptilile, the first sound weak, and the action
arliythmic ; a systolic apex murmur may or m«y not
Is? pre.sent. The area of cardiac dulin-ss is often
notably increiused. .Sleep is often riisturlwd hy dis-
tressing attacks of carriiac asthma, so that the patient'
fears to fall asleep. Anyiiial attacks occur in some
cases. Qi/ieraa of the lower extremities is of gi-ave
itniwrt. Thejse are tlie symptoms our trentinent
must Ix- directed to relieving. In all such cases we
should begin by giving liyiitalin ; the less advanced
the degeneration the more likely it is to be useful,
and it can do no hanu ; but if we lind no response to
its use in the .shape of improved cardiac action, it is of
no avail persisting with it. We should not, however.
c:h«p I V.I
Cardiac DECEyERATioy.
39 «
givH digitalis when the pulse is very slow and iiTegiilar,
with .'I tf ndency to synco|ie.
In the more lulvanccil and serious cases al)solute
i-est ill the srnii-recunilieiit position is for a time of
prime iiniiovtniice, and, at regular intervals, a proper
amount of IIkIiI, e^isily-digested, nourishing food must
be given. If tfie ptitient i-esjionds readily to sninll
amounts of alcoholic stimulant, such as a few tea-
spoonfuls of brandy or whisky in a litlle hot milk,
there is no good reason for withholding it, although
we must Ik? especially cnreful not to yield to any
morbid craving in this direction. To remove the
sense of faintness or threatened syncope, and the
distressing feeling of oppression at the chest, some
diffusible stimulant will certainly be frequently necea
sary, such as the following : -
V) .SpirituH (fthpris oomixisiti ...
8i>iriliiB unimoTiiii- iiromntioi
linoturn' micJB voniicin
aa 3»«''
Tinctiim' Invanduhu compofiitiR ... jiv.
Aquii- ctiriii ... ... ... ... lul jviij.
Slisoc, flat niifitiira. One or two tiiblespooafuls, with a
tabli'spoDiiful of wilier, whi'n nwt'ssary.
SlrychniiiK ia a very useful medicine in theae
cases, and it may sometimes be combined with coai
with good effect, as in the following : -
nixxxij.
ud .^viij.
9} Liqiioris dtrychninii!
Exlrncti cooic liquidi
Spiritiis c-hlorofotinl
Aqua> riiiriHniomi
Miace, tint miHtum. Two tablevpooafulu three tiinen a day.
Oxygen inhalations nre valuable as a canliac
restorative, stimulating ciiiTliac nutrition and pitMnot-
ing metabolism.
If, perchance, there should be anginal attacks
attended with a hard, liriii pulse (which will rarely bo
found), H nitro-glycerine tablet containing the equiva-
lent of one minim of a 1 per cent, solution may be
given, and its effect nated.
39»
Mr.D iCA L Tr ka TMEirr.
[Pan II.
Biding niucli in the open air, tlie fresh air of the
country, in onior to proTnote as complete oxygenation
of blood as possible, is extremely desirable ; a
luioimock, or some nuitable couch for reclining out of
doom, is neede<I in these cases, and when the patient
is strong enough to tnivel, much gcK>d will often
result from passing the winter in a warm, sunny
climate.
Such patients are vei-y sensitive to cfiUI, and
require very warm clothing. In the less serious
forms a certain amount of regular, gentle exercise
may be permitted in tine weather, although there
is a tendency, nowmlays, rather to over-do physical
exercise in ca.ses of cardiac weakness, and as cases
of fatty degeneration are notoriously difiieult of
dingiioKis the benefit that lias been observed to
follow jdiysical exercise, in some instances, may
have been due to the fact that they were not cases
of true fatty degeneration, but of fcem|M)rary cardiac
asthenia with dilatation. In all these cases the
uflect of exercise should be carefully watched, and
its influence on the cardiac action noted. It must
be reniembei-ed that anginal attacks are not uncom-
monl_v provoked in these casea by unwise attempts
at physical exertion.
Preparations of iron are useful in the less advanced
cases. We may combine the citrate of iron and
ammonia in 10-grain doses with k a dram of aromatic
spirits of ammonia iind an ounce of infusion of cal-
urnlia, iind give it three times daily ; or we may give
10 gruiiis of the citrat^j of iron and <|uininn and 3 to
5 minims of lifjuor strychninie in \ an ounce of
chJoi-oform water in the some way : or we may give
a pill of a grain of valerianate of iron and a grain
of extract of nux vomica after meals three times a
day.
What we have before said about the nse of
aperients in coses of cardiac failure must- still he
l)orne in mind, and the regulation of the bowels and
the digestive fmictions generally must Ixj dnly seen
Chap. I v.)
Cardiac Degeneration.
393
to. Unless there is iiny dropsy it is best, however,
not to jtirxlaw watery motions, and a dinner pill
of aUicK, rhubarb, nnd ijiecacunnhu will be most
suitable.
As the difjestive functions ai-e generally very
languid, it i.<* <)ft<"n iiHefnl to give 5 or 0 grains of
pepsine or a t«'as]toonful of ucid glycerine of pepsine
aftt-r each meal uf unininl food.
Restlessness and in.'>on>nia are often distressing
symptoms in these cases, and although it is, for niany
reasons, undesirable to give opium, we shall uociusion-
ally l>e obliged to liave recourse to it. Wf should
first, however, try the efTect of siKliiini bromidi' in
15- to 20-grain doses, alone, or combinoii with 1 or
2 drams of tincture of hops, or 20 to 30 minims of
compound spirits of ether. If these fail we may
try .^-gniin and grain doses of cotleia ; and if we
are ohligetl to give opium or morphine we should
begin by giving Jth of a gmin of sulphate of mor-
phine with \ a dram of aromatic sjiirit ol' umnionia
in an ounce of chloroform water, and if this dose
agrees well and causes no faintness, but seems, as will
aometimes Ik? the case, to improve the cardiac action,
it may be repeated after four or Hve hours. We dis-
approve of the hypodermic umh of morphine in these
cases, as it will, if administered in this way, some-
times exercise a seriously tlepressijig effect on the
heurt, and fatal results have lieeu known to follow.
Notwithstanding the recommendation of eminent
authorities we must pei-sist in our objection to this
mode of administering moiphine in cu-ses of great
cardiac asthenia. The extreme rapidity of the ab-
Bor])tion of the drug given in this way augments
its tendency to depress the action of the heart.
When given by the mouth it can be combinetl with
a cardiac stimulant, and it is not so rapidly absorbed.
Recourse to the hypodermic syringe is far too com-
mon, and requii-es limitation and more discrimination.
Fatly owrirrowlh is associated with a general
tendency to the disposition of fat, and is often
394
Medical Trratmf.nt.
I Pari II.
eiicouiiterpd in tlio ol>ese. It may simply amount to
fill cxix'ss of (he imrnittl quiintity cif fiit uiidorlying
th*- iKTicnnliiitn. Tii other ciisps the fatty dpiiosit
penetriif<'s into tlic musciilnr suhstiiucf of the lieart,
and is found as an infiltnition Ixjtweeii the muscular
fasciculi.
In extevnic cnse.s of tlii.M kiml the heart becomes
enveloped in a thick coverinj; of fat, nnd on section
fat is found freely deposit»Ml amongst the muscular
fibres, and this fiitty infiltration may extend to the
muKouli [mpitliircs. Some of the muscular fibres are
found atrophied, anil others in a sUite of fatty degene-
ration. It follows naturally that the walls of the
heart become flaliby, and its ca\'itics dilated, and
symptoms of cardiac failure appear, and are more
or less serious, according to the extent of tlie fatty
overgrowth or degenpnition, and the dilatation thus
induced.
The chief rniisrs of this condition are indolent
and luxurious habits of life, over-feeding, over-
indulgence in alcoholic beverages, especially in Ijeer,
together with institlicient mu.Hcular ex-i^rcise.
The freHlin«>nt appropriate to these cases will
depend upon the stage tlie disea.se has reached
when tlie patient comes unrler observation. In
the later stages the symptoms of cardiac dilatation
and failure which pi-esent themselves will require
precisely the same kind of innnagcnient as has
just been descril)ed. In the earlier stages, where
it may be presumed there is simply an excess of
fatty deposit on the surface of the heart, and no
.serious amount of infiltration of the heart substance
or atrojihy of the muscular filires, much may lie
done, with tlie frank co-operation of the patient,
to ameliorate his condition and check the tendency
to fatty deposition. In the (ii-st place all exce-sses
in eating and drinking must be at once suppressed.
No alcoholic beverages must be permitt*il, or at
most a little .oound claret or liocfc diluted with
wat«r. Drinking at meals must be forbidden, and
Ch.p. IV. 1
Fatty Oi-ercrowth.
3<55
such fluid lis iH neeiled must he. drunk either half
an lioiir Itefore a nieiil or nn hour or two after.
This will at once diminish tlie iiinoiint of food
taken at each meal and ensuri' its more complete
mastication. A jjlass of hot water half an hour
Ixifore a meal and at Ix-d-tiine, to which a slice of
lemon may be added for Hiivour, will Ije usi'hil hotli
in promoting digestion, in llushing away waste
pro<hicts, in allaying thir.'it, and in promoting the
secretion of hile and the regular a<ition of the bowels.
As in the treatment of obesity,* fatu and carlx)-
hydrates should be as far as ])OKsiblM eliminated
from the daily dietjiiy, and nitrogenous fooil taken
iu its stewl. The lean of butcher's meat, chicken,
game, and white tish, preforal>ly re<Juce<l to mince
or pulp and liclitly cooktfl, may be freely takea
Green vegetaliles and ssiliuls and x\\a' fruits iu
moderation may lie pennittotl. In tlie early stages
of this tttfection much benetit often results from
one or more courses of mineral waters and baths
at Marictibad, Carlsbad, Kissingen, Brides, or Harro-
(^t« ; or a combination of grnduatetl physical exercises,
together with gaseous saline baths, as pnictised at
Nnuheiui.
Moderate regular exercise, walking or riding,
should also be insisted on.
We may hei-e take occasion to refer to wliat
is known as Oertels cure for cardiac diseases, and
especially for this form of disease. It may be
described as consisting of graduated and systema-
tise<l tiill-cliiohiwj, a method of treatment of some
value in a limited cla.ss of ca-ses, l>ut not unattendwl
with danger when widely or indiscriniinately applied
— a fact that has had some serious atid notable ex-
em plilications in the land where it originated.
In many health resortH in (Sermany and Switzer-
land this so-called " Torrain-Kur " was added to
their other attractions, and systenuitised mountain-
climbs were marked out and adaptt'il to <li(b>rent
* For which, trt the author's " Food in Health atul Oikcaw."
396
Medical Treatment.
IPul II.
degrees of caidiiic ilisubility. But it lias fallen into
conipiii-ativfi disuse. It was not suite<l to unconi-
peiisuted oises of valvulnr disease, and I'Oinjwnsated
cases fouiul the system moiintDnnus ami tedious.
Gentle elinilnng exercise in eoinpensated cases
of valvular disease, in light, bnieing air, amidst
agreeable scenery, may .serve to niaintoiu and im-
(irove compensatory hypertrophy and promote general
nutrition, especially' in those who are prone to
habits of indolence and inactivity. But it is
especially in cases of fatty lieart, fatty infiltration
without degeneration of the muscle, that this sys-
tem may be of service, as it insists on regidar,
graduat«d exercises, a most important auxiliary to
other nuvins of cure, such as baths and frictions,
inass»(je of the muscles, a suitably regulated diet,
with strict limitatiuii of liijuid, and perhaps a course
uf mineral waters at one of the spas we have
named. The object is to get rid of the excess of
fat and t<i realrire the cardiac tone. It is occa-
sionally adopted as a sujiplementary course to what
is known as the Schott methods, to which we must
in the next place refer.
The Sclioll or Kniiliciiii system of treatment
of heart disease consists in the application of " re»'\»V-
ancf cfrrciwK," and the use of the satine and gaseous
baths at Nauheim.
The rmgldiivf fXi-rrlnen are systematic and regu-
lated movements of the ilifferent groups of muscles,
gently resisted by the physician or his assistant.
These movements are never repeated twice in suc-
cession, and are always followed by a period of
repose. The patient is, of couree, carefully watched
during these exercises, and at any sign of circula-
tory or respiratory trouble, or of muscular or nervous
exJiaustion, the movements are at once Husj)ended.
The seventeen or eighteen movements of which the
exercises consist will be described under the aildilional
formuhr. In commencing this treatment it may be
propel- to apply only a portion of these exercises.
Chap. IV. 1 Scnorr OR NAUHF.iAf Tkeaimexi. 397
wliicli may be cautiously inc-reased. It lia.s Ijeeii
not«d that the effect of these exercises is to cause
a .slowing of the pulse-rale, and an increase in the
pulse volume. It is also maintained that they
lasseu the area of cardiac dulneas nnd wlmn dila-
tation is present cause the apex lH.>jit to return
towards its normal position. In addition to these
exercises the 8chott method comjtri.se.H the np|)lii'a-
tion of the siiiino Imths of Nauheim in the follow-
ing niamicr. Tlie i-liicf constituents of the Nanlieiin
springs nw sodium chlnride (21) to DO parts in
1,000), ami cftlcium carl>onnto (2 to 3 |>arts in
1,000), together with a large amount of free car-
bonic acid, and they are of a 't<Mnperature varying
betweeen 82" and 95° F. These waters are used
cither as (n) brine Imths, or (6) effervegciw/ halh», or
(c) effervaeiiiy current hnihe.
The first arc without free carlxjnic acid and are
used in graduated strengths.
The second contain the natural carbonic acid gas,
but are varied in temperature to suit particular cases.
In the third or stream baths the water i.s allowed
to stream through the baths while in use.
The effervescing baths are said to lessen tlie pulse
rate, increase its volume, nnd raise the tension. They
also, at first, quicken and deepen the respirations.
The treatment usually bejfins with the weak brine
baths at a temperature of about 0.5' F. and a dura-
tion of five minutes. After a time the tem|iei-ature
of the bath is lowered, and its strength and duration
increa.sed (to t<^n minutes).
The brine bjith is changefl to an effervescent bath as
soon as the patient is thought able to bear it — at a
temperature of 92 to 95' V. and a duration of ulwut
six minutes. The t<>mperature is gradually lowered
and the duration increased.
The effervescent gtreai/i bath is finally applii'ii
in such ca-ses as can liear so strong a stiiiuilunt.
Artificial, imitation Nauheim baths can be easily made,
and they have the same effects as the natural springs.
398
Medical TKP.ATMEsr,
IPnil II.
Tlie formula for lliese baths will be fouixl at
the end of this chapter. The patient must repose for
II time after each hath, and he should uot take more
thau three (ir four haths u week.
Unfortunately this niethorl of trentnienl Iijik lieen
foinnterrinllii liooiiie</ toiin e.vtfnt which has rendered
it more and nioredithcult In form a jvi.st and accui-ate
opinion as to its true vmIui- anil applicahility.
As to the conclusinns that have been advanced by
some with respect to the reduction of the area of
jiercuKsion dulnesH observed after these baths and
exercLses, they arc certjiinly for the most ]>ari
fallacious, as are also the tigures with which Ihey
have been illustrattMl.
The result of a series of careful observations made
Ly us in King's College Hnspilnl hs to the elfect of
these batliK on tlie area of cardiac dulness appeared
to sliow clearly that the tJimiiiulion of this area was
caused mainly by a mcHjttication of the tyjie of
i-espiration — the nieasureiiient-s of the chest circuni-
fureuce showed tlint there waw an increased expansion
of the upper part of the lungs, tlie portion least used
in ordiimry quiet breathing ; that, in short, the type
of respiration Ijeeomes ciianged, and a superior costal
ty]>e taken the ])lace to some extent of the more
habitual inferior costal and abdominal tyjie. "This
accounts for the rise in the level of the diaphragm and
the position of the apex beat noted by Schott and
others. It accounts Ui a great extent for the rapid
contraction in the right boundary of the area of cardiac
dulness, as the marked increase in the caparity of the
upper regions of the lunp would greatly widen the
respiratory area, and would thus exercise a decided
intlueiiec on the condition of the right side of the
he«rt in the way of promoting and facilitating the
emptying of its cavities."*
That the method is useful in a certain numtwr of
casea of cardiac asthenia cannot be doubted, and when
the influence of mere fashwm has passed away, we
* Hn the author'* paper in I»trm<ilio»al Clinie; July. 1S9U.
ai«p. IV 1 Sci/OTT OK NAVHEm TtiEATMEXr.
399
sliall lie belUT nlilo to fonu u soWr and accuraU:
estimate of it« ajijiliculiility.
It is curious to iiotice how even eniini>ut
autlioritieK differ in tluH respect. One saj's, " [ii
cases of intr<>si)ectivc peoplr with neurotic hearts, the
treatment is liest avoided."* Wliih; another nmin-
tain.s that "the l>e.st re.sults will be obtjiined in
' futietional or imaginary heart disoiise in neumtie
individuals. ''t
It is in auses of cardiac iksthenia and dilatation
folhiwin}^ acitte disea.se timt wo have seen the liest
results from this treatment, and also in uervous
persons with dilatation from stniin and over-exertion,
mental and idivHical.
It is only in (Exceptional eases of valvular distMisu
that it is rightly applicable, while in many it may
prove injurious. Cardiac patients are often very
ivstless peopU', and this method of treatment give.s
them something to do and something to think al)OUt,
and ill this way it may prove, to such persons, a com-
fort and a help.
ADDITIONAL FOKMUL^.
In hypertrophy with aortic
regnr^tation.
II Tiuctunu iicoiiiti, mi.
Tiiictiira-vorntriTiriain, lUiij.
Tiuctiini' zingiberu. Hlvij.
Aquip ad 5j.
M. I. huiut. To lie takeu
three or fuur timca a day.
(Ai Cottn.)
Another.
H Tiuitiini' iuoiiiti, niu.
PotiiHiii lirdiuidi, ,>ij.
SiiirituD irtlieii» iiitrmu, .<v.
Aquu* camphora', ««1 .iiij.
M. f. miat. A toaspoouful
every two houm. ( H'hit/a.)
Powders for cardiac
hypertrophy.
A Anpuruj^n, gr. x.
Vohv^aii broniidi, .^ij.
8««.'han' albi, ^iij.
M. et divido in pair. .\.
thrice diiilv.
Ono
(Matlafi.)
puis for cardiac dilatation.
R Pulverin diifitalis. gr. v.
Extraoki bollndonnit.', gr. j.
Forri redftcti, gr. xl.
M. et divide in piilv. xz. One
tlirii-e daily. (/*« Oatn.)
• Powell, " Trcatnioiit of Diieosea of the Heart," p. tW.
t Brottdbent, " Hfjirt Disease" (third edition), p, ilH.
400
Medical Tskatment.
ii'nri a.
BUzture for simple
dilatation.
R Extmrti rr(;i.Ur (luiiii, J.iijia.
Tinctiirii* difjilalis. ^t»s.
M. 1. mist. A truniKxniful
tliree timo a day in wntor.
(JInrlhvlua.)
In cardiac astbenia, and
dilatation
R Pulverif. <timtalit', gr. iij.
QutuiuiL' flinphulit*. fO'* ^v,
Piilvms rliei, (jr. iv.
Sodii IncartioimliH, gr. xv.
M. ct (liTidi- ill ]iulv. x. Olio
twice a (lay. (.S'/iwi/r/'C.)
PlllB for cardiac dilatation,
ft Fvrri l:iotuti»>, .%(*».
rulvnris (liijittilis, gr. v.
M. ct f. pil. XX. I Mic thri>e
timed a (111 y. (/>ii >'<i>l<i.)
In fatty degeneration.
11 Siiiritiui iithiris, Jj.
Tiucttint' iNMlji<l(iiifitis .iij.
SpiritiisHnimoiiia' uruinntioi,
Tiiictuni' ziugilieriii. .^vj.
M. f. DUBt. A tea«]HX)iiiul iti
a wiueKlos^ful "^ water wlieu
dyspnica in wfTere. (Whilln.)
For cardiac asthma.
K TiiH'turir digitjili-, .sj^'s.
Tiiictuni' lubeliii*. ,ijw*.
Alalia- luur(>c«m«i, .^iij.
M. Five dropn evi^ry hour.
For cardiac dyspnoML
Ik Potamii iodiili, gr. XX.
ad. XXX.
Chloral hydrato, >ss. ad h'y
Mucihipiuis acadu-, .^iv.
Syrupi Horis aumntii, i\v.
A(jmr nd .'.iv.
M. f. mist. A tabl(»pooiif ul
cviTV twd hours. (f<'. Srt.)
Hypodermic injection of cam-
phor in cardiac diseaae
when OiKltalis fail! lit
»oiiicliine» rciK'Ws tliO
clTeot uf di^tiilis.J
& Campbora> .^j.
Old olivip, six.
H. Fifteen drops for u <lot«.
(^AltruHilrr.)
Hypodermic injection of
caffeine and morphine.
(Tlic .aftijiiK.- U ii.lilfl fur the
puriMiwof nvdiiliiij^tho doprcM-
ing cftuot of tlic morphine.)
ft C'uffeimi', gr. »».
Morphiniv eulphutiii, gr. \.
Atmpinii- sulphiitis, gr. ,)o'
.Vtiuir ciiniphorai, iHxx.
M. t. injcetio. {I'nehiiiur.)
The Schott movements or
exerdaea
Karh fjceivttr i< maih agniHtt
ulifhl rtwlniur n/iiiliril Ay
llir ///iy»i<iii» or >i Itiinuil
1 . niv arniK art) extended in
(runt of the l«j<ly at the level
of the fllionlder. with the palms
of the luindc toiu'liiui;. The
two anno aru then moved
slowly ciiitwonls till they arc
in a luie with eaeh other ; the^
are then brought buck to their
urigiiinl ]>o»ition.
2. The arm and hand hang-
ing down with the palm turned
forwards, the forearm is flexed
upon the arm (which if kept
still) until the fingers touch the
shoulder. The foreunii is then
extended to its origiiuil ]x>«i-
tion. This is first done witli
one arm and then with the
other.
3. The arms, hanging down
OS in Xo. 2, are raised outwards
until the thumbs meet over the
bend : they are then retiuiiijd
to their original position.
4. With arms dependent, the
ftngen, at the first phalangeal
joints, are pressed together, and
the arms are then raised until
the Iiaiids are above the head,
after which they are brought
luick to their original pomtion.
.1. Tlio anus, lianging in the
position of "attention," nr«
lulviuieed forwards jiurallel t/i
each other until they are ele-
voted to a vertical position ;
they lire tlicn liroiight Imck to
where they were befnn-. '
Chap. I V.I ScHorr OR Nauheim TuBAr.vEffT. 401
r>. Same tu Xo. 1, but with
fists clenched.
7. Same as Xo. 2, but with
fintj! firmly clenched.
l<. Tho urinHf KUirtiiif^ from
the iHuitiou of " ottention."
descnbe a circle by mo%nu({ for-
wurda and upwanLi until they
are miseil vertically ; thi'n aicli
]>rilni is ttirniMt otitwanlH and
the annn desci'ud liackwanla f<i
their f onner tioBition.
tf. Tlie Iwjdy 19 bent forwards
and then brought bade to the
erect j)Ointion, the loioex not
being moved.
Kl. The body is rotate<l, with-
out any movement of tlic feel,
first to the right and then to
the left, and then back to \i»
ori^nal position.
1 1 . The body is flexed later-
ally, as far on poiwiblc, lirnt to
the one tide nnil then tu the
other, and jift**rward.s restored
\o its f»rikrii»al erect position.
12. The itatient, standiuK
witli the feet side by «ide and
»nppi)rtiu({ biuiRelf uy ieanioK
Willi one hand upon any object,
fleies the oji|i(i9itc thiifh as far
a^ it is i»oftsible, iind afterwards
cxUMidi it until Iho fcHsl are
again Ride by side ; then, leau-
iug on the other hand, be
cairriex out a similar movement
with the other thigh.
13. The patient, Hupportiiig
hiiuMiU by nn«.< hand, ait in 12,
su'l the knee being kept
straight, each leg in turn is
raitMtd a<4 high as posaiblc in
front of the IhmIv, and then in
the saiuo way behind.
H. Supporting himself by
phicing both hantli) in front nn
the Imck of a chair, the jialient
first flexes one leg and then the
other upon the thigh as fnr as
he can.
1.5. Each leg in turn is ab-
ducted as far as posaiblo, the
knees bGiug kept straight, the
patient resting ou one or other ■
baud the whiM.
A A
Hi. Tlio arms, held hori-
zontally outwards, arc rotated
forwards and backwards at the
shoulder joint.
17 and IH. Flexion and ex-
tension, Hptt, of the wrists, and,
rtccond, of the aiUdes.
In rej*i^ting these raovemouts
the oistrator places the [Kilm of
his luinil on that side of the
|Hitieiit's lirnb or body towards
which the movement is to bo
made. In the movements of
the wrist the operator closes
his thumb and forefinger round
that joint.
Artificial Naaheim Batlu.
The weak bath which Lt used
at the cnnnieucement of the
tr(uktnn'nt cjin be maile by dis-
solving 1 lb. of sodium chloride
and 1 J on. of calcium chloride
in 10 gallon>4 of water at a
tem|)i.>ruture of U.i" F. The
duration of tliis Initb should lie
Hvc minut«a<. The strength of
the bath is (gradually increased
until the full strength of .'(lb.
of sfidiuin chloride and lAoz.
of calcium chloride tu lOgallons
is reached. Thednratinnof the
luth is also gradually lengtli-
eneil to fifteen or twenty
minuttvi and its t>*niperature
gjiuluallv lowered till it reaches
(<.■)>' F. 'I\i make the etferveHc-
ing IniIIi sodium bicarlxinale
and hyilnichlorie a<'id are added
to the fidl strt-'ugth of the brine
bath, .\fter dissolving 3 lb. of
stMjiiim chloride and t^oz. of
calcium chloride in IM gallons
of water, 2 ox. of sodium birar-
boiuite is to be thoroughly
mixeil with the water ; thcu,
ju'st before the bath is used,
3 on. of hydrochloric acid are
addetl. Tliu strength of the
buth is incroLscd (lay by day
until M OK. of the alkali and
12 oz. of the aciil are used for
a bath of 10 gallons.
402
CHAPTER V.
Tlin THEATMENT OF CARDIAC NEUKOSKS — PALPITATION
— CAKD1AC t'AIX — ANIilNA PECT0K18.
Pii/piliilioH—lli Nature and t'liunea—" Irritable Heart"—
" Faroxymuil tachycuilia " — " Bradycardia " — Tiralmriit
of Palpitatiou — Open-air Life — Rogimeu— Diet — Canliac »ud
other Touics— BromidoB for SleeplBusuew— Antacids— Ajw-
ricats— Uyrterical Canes.
Cardine Piini — " Sub-niammarT Pain" — Its Nature — Value of
Local Counter-irritation— Digital Exploration of PrsecordiiU
Region— Casea of Cardiac Pain — Relation of these to Cnaosof
true Angina— Aortic Strain.
Angiiiii Prctoiit — Symptoms — Cuusea- Clamitication— Objectioua
to the rft»o-iini*fM hypotliesis — Cuu^rti ImltriitKiim fnf Tr'fitt'
iiirht — Hygienic Treatment —Treafinent of Dysiwptic States—
Avoidance of Toxtr Agouta — Removal of (ioutj- and other
Blood Contamination— Imt>ortauce of Elimination- .IMiVimi/
Mouure* in the hitrrral-n — In the /'aroj-i/fint. Additional
Formula?.
We must next consider the treatment of those aflfec-
tioDs of the heart whicli are regarded, mainly, as
disordorH of cartliac innervation, and which may occur
indei)eiKU'ntly of tlie existence of structural di.sease.
It mu:it, however, ')e obvious that the presence of
stnictural disease i.s no impediment to the manifesta-
tion of (li.sorders of caiiliac innervation, and that
althoujsrh we are now al>out t*i con.>(ider t}ie«e affections
as distinct and independent morbid states, they do,
very commonly, co-exist with structural diseiise of the
valves and walls of the heart, and may be more or less
closely connected therewith.
Palpitation.
l*al|>ilation may be described as a consciousness
of the heart- beat
the \wi\vl percept Ihle to the individual'
The heart-beat is usually in health unconscious,
except that in most pei'sons the heart-beat tn;iy be
renderetl conscious by the assumption of certain
poaitiona, Tiiere are many healthy individuals who
an " irregular or forcible action of
Chap. V.l
PALPJTATIOtr.
403
^
on lying down at niglit in betl on the If/t side l>ecoine
conscious uf tlie hpfl.rt-iieat. Tlie explanation of this
would sppin to lie that the heart suffers more displ.'ice-
nient wlteii one lies on the left side than on the right.
But ]mlpitati(>ri as a inorliid eondition is more
coninionly referrilile to some distuibance of ciirdiac
innerviition. Pid]titiitioii usually iin-ans that the heart-
l>eat is not only conscious, but that it is actually
increased in force and rapidity. Cases are, however,
encountered, though rarely, in which the palpitation
is wholly miijfciiiv, and although the patient may
complain of the most disti-essing feelings of beiiting
anil throbbing at the heart, on physical examination
the heart is found to Ik; acting with perfect regularity.
Such a conditii.in is doubtless one of cardiac hyper-
esthesia, and we have found, in sucli easoM, that
pressure made iitiinwliateiy over the cardiac apex will
elicit an exfiression of pain, which will not lie felt by
making the same kind of pressuiv over adjacent parts
of the surface of the chest.
But commonly the complaint of [Milpitation is
accoutpiinied by increased rapidity and force of the
cardiac contractions; the jiatient's Ixjdy may some-
times be seen to shake with the force of the heni't
Ijeat, and the coverings of the l)od to be lifted with
each im|>ulse ; at the same time the carotids throb
violently. There is a sense of oppres.sion and dis-
comfort in the cardiac region, a feeling of fulness
in the head, of giddiness or faintness, and even an
apprehi/nsion of impending death.
The cHiiscK of this condition are various. It
woulil certainly seem to be fre<|uently central, and
dependent primarily on some disturbance of the
emntioHid centres ; in some cases it would seem to
depend on a disorder of the vaso- motor nerves ; and
in others on rrj(,:x irritation of the cardiac nerves.
Emotional disturbances of any kind will induce
palpitiition in many persons, l)Ut especially in the
feeble and excitable, so that it is )iiu>'h inure common
iu females than in males. Anwmia and chlorosis, &t\d.
40-t
Medical Treatment.
IPirt I
all ciobilitAting iiiflupnci?s, corUiinly predispose to, if
they ilo not aotimlly cause, palpitation.
Excessive mental labour, together with sleepless-
ness, will give rLstv to paipitiitiou. But it must be
rememljered that pnlpitaiion is itself a cause of
sleeplessness liy tlie quickened circulation throuf^h
the l)r«in which it |tr<xhices, as well as the discomfort
attending it. The palpitations ohserved in youths of
both sexes, about the age of puberty, nre fre<juently
associated with Iiysteria, sejcuul excitement, or mas-
turbation.
Hyperlactation has been nienlionetl as ii cause.
It is especially prone to accoin]iany neurasthenic
states, disoniers uf menstruation, and the troubles of
the climacteric period.
A combination of nieivtiil excitement i«ud excessive
muscular effort seems to have l)een the cjiuso of the
" irritable heart " oliserved by Da ( 'osta amongst
the young soldiers in the American Civil War.
The chief .symptoms were pa1|)itation with greatly
quickenetl ]iul8e, dyspnoea, ami inore or less cardiac*
pain.
Dyspeptic states and flatulence are frequent causes
of palpitation. In such in.stance.s, not only may
there be rellex irritation of the cardiac nerves from
offending inge.sta, but when there is over-distension of
the stomach and iiite-><tines by jjn.s or by excess of
food or flrink, as in gr(>at eaters and drinkei'S, then
there is the further disturbing influence of upward
displacement of the heart by the pres-sure of the
distended stomach and intestines upon it. The
palpitation associated with constipation is often of
this kind, although it has been regarderl as reflex
and referred to the irritation of the alidoniinal nerves
by scybnla.
Disease of the pelvic vi.scera an<l especially uterine
displacements and intlainmation are frwjuent causes
of palpitation.
Whatever causes diminished blood-pi-essure by
dilating the small arteries and lessening the obstrac-
ch»p.v.i Palpitation; Tachycardia.
405
tion the heart norlually has to overcome may excite
palpiUition, us alooholic intoxication, exposure to
excesHive heat in )iot batlis, Turkish Wtlis, etc.
Tlie cardiac nerves, in certain persons, are prone
to be dLsturl)e(l by certain substances in common use,
such as tea (especially certain kinds, iis green lea),
coffee, toliacco, etc. These Homt times disturb the
cardiac rhytlim and produce iiregidarity and inter-
mission together witii viigiie, uncomfortulile feeliiij^s
in the region of the heart, without causing; actual
palpitation. And it is generally their excessive or
prolonged use, not their moderate or occasional use,
that causes these disturbances of cardiac innerva-
tion.
It has been stated that the occurrence of palpita-
tion about the period of puljerty is often due to the
heart not developing in proportion to the rest of
the Ixnly. We have alreaily said that it is a common
incident of organic heart disease, and it forms one of
the most striking symptoms, as we shall see, in thut
singular affection, " exojj/it/mlinif ffoilre."
TnrliycnrdiH is the name that lias l)een in-
vented to distinguish the *' ntf/id heart" from the
heart affected by palpitiilion. It is useil to express a
fact which is common enough, viz. that some fK.'i'sons
habitually have a rapid pulae rate, just as others has'e
a slow pulse rate. Pnroxytiiuil tnchf/cardia is used
to expi-ess the fact that certain persons sutler from
rapid action of the heart occurring in paroxysms,
generally assiKuateil with palpitation, and not un-
frequently accompanied with dj-spmca and cardiac
pain. The dyspnojii may lie so severe as to suggest
an attack of asthmn. This affection would nppe^ir
to be frequently dejiendent on the Nime causes as
palpitation, but it has also l)een found connected
with structuiiil lesions of the medulla and vagi
(tumour or clot). One of the most remarkable
instances we ever saw, in which the pulse rate was
200 to 230, was associated with utero-gestation.
An tiuusual »loniu^ii of the pulse, which is tlie
4o6
Medical Treatmeht.
(Part II.
noniitil poiidition in some individuals,* and is said
to occui- paroxysinally in otlipi-s, Ims received the
deFKjriiiniition of brachyrnrdia or bradifcardia. Aa
a. morbid pheiioraonon it is found in states of ex-
iiausdon from |)rotract<>d acute and other del>ilitatiiig
disi-a-so-s ; in certain chronic dyspeptic states, ami
jaundice ; in carfliiic degeneration ; occasionally in
pulmonary omphysemu ; in unemiu and other toxiemic
states ; in certain diseases of the nervous system, apo-
plexy, tumouis. sunstroke, etc. etc.
The irviiliiK-ril of these disturbed stnt«B of
CAnliac innervation, and psi)ecially of palpitation, must
now be consideifij.
The first and most important indication is to
endeavoiir to seek out the caust- of this disturbance,
and if possible to remove it. When it is clearly
dej^eiident on emotional excitement anrl disordered
mental states we must take measures to sulxlue them,
and especially we must reassure the patient, and try
to convince liini that the symptom is not a dangerous
one ; when it is associated with debility we must
prescribe appropriate tonic reme^lies. When due to
sexual aberrations or hysterical comlitions we must
fi-ankly explain the cause of the malady and j>oint
out the only sure metho<l of cure. When produced
by excess of work, physical or mental, we must
insist on the remedial effect of rest. When accoin-
jmnying disorders of the female f)elvic organs those
must l>e taken in hand and properly ti-eated. If de-
pendent on dyspeptic states, flatulent distension, and
constipation, dietetic and medicinal measure.'? must
be directed to their removal. When clearly traceable
to the toxic influence of some habit, such as the
excessive use of tea, coffee, or tobacco, these must be
forbidilen. When it is connecteti with some organic
lesion of the heart, the i-emedies alreafly set fortli as
appropriate to them must Ik> applied. And tirially,
wlien it is M symptom associated with incurable lesion
* Nnpoleon ii mid to have hail a pulse rate of 40, and Tnlley-
raud to haVB slwsyi had a very tlow and intormittciit pulse.
Chip. V.)
Palpitatiok.
407
P of the nervous system, we must have recourse to
L certain sedntive agents, which may at least afford
^H temporary relief.
^H Nothing is perha|>s more generally useful and
r ai>|>licaMo to many forms of palpitation than roffulnted
^^ exorcise in, and free exposrtre to, the open air. In
^^1 dehilitat.e<l states, when the cardiac muHcle is weak,
^^" much walking exercise is undesirable, but gentle
r driving exercise is most useful, and sitting or reclining
^B in the open air has both a tonic and sedative itiMiience.
^H Bo<lily restlessness, which in some persons accompanies
^^ mental disturbance, must, however, be kept under
control, and nine or ton hours' rest in l)ed should he
insisted upon. In many nervous cases judicious hydio-
therapeutio ti-eatment, sucli as warm aftusion npj)rn.Hl
generally, followed by cold sprinkling, es|>eoially along
the spine, which may in time be altered to u brief cold
douche, succeeded by brisk friction of the skin, will be
P found most beneficial.
In these nervous pivtienLs nothing is more certainly
opposed to sucoessful treatment of their co-existing
dys(>eptic troubles than the "little and of ten " method
of feeding by which they attempt to still their abnormal
" cravings." We .should, therefore, insist on duo and
surticient intervals l)et wet^n meals ; if we have eWdences
of a slow and feeble digestion wo should allow at Iea.st
five, and of t^n six hours*, to intervene Ijetween successive
meals. Nothing whatever slioidd fie permitted between
meals l>eyond a cup of hot water with a few teasptjon-
fuls of milk, or a small cup of light broth or mnxummf.
Tea, coffee, tobacco must be prohibited, but small
quantities of sound wine and pure spirit, well dilutwl
with water, may l>e pernritted at meal times. The
meals them.selves should con.sist of a moderate amount
of easily digestible and nouri.sbiui; fiXMl, chiefly animal,
previously minced or |ioiitided, if any masticatory
carelessness or defect exists, and a small quantity
of vegetable purees. The fluid at meals should bo
strictly limited.
It may be necessary in neurasthenic cases, with
4o8
Medical Treatment.
(Put It.
anorexia and great inanition, to apply tlie Weir-
Mitcliell system ligorously.*
In discs asKOciated with unn-mia or exliaustimi,
especially after ucut« illnesses, much benetit will
follow the ndiiiinistr.ition of some suitable form of
iron conihiiied with strychnine. Strychnine and
nux vomica act l»etter as cardiac tonics in many of
the-se cases than digitalis or strophmithus ; we should
always, however, Iry the cHect of digitalis in small
dosos, as it sometimes acts remarkably well, but if
it does not quickly produce a go<j<l effect we should
relinquish its use. Belladonna is ihought by some to
be more useful than digitalis, especially if combined
with sodium bromide.
The following formulse are useful : —
V} Fcrri et quinino- cittatis
Liqiioris ftrychninu' ...
Spiritiis cliloroformi ...
Aci(li liydrnliromici ...
Aquii'
.. gr. xl. ad Ixxx.
... nixl.
3ii.
mlxxx.
ad 3>iij.
MiBcc, lint mistiira. Two tablespoon! uls twieo or thrco timea
% day, an hour heiora food.
Or this :—
I^ Ferri ct ammonii citratis ... ... gr. Ixxx.
Tinctiira' iiiicis Tomiow nilxxx.
So<]ii broniiiii ... ... ... ... gr. Ixxx.
Spiritufl nmmoiiis; ttromntici jiv.
Aqua; ... iid Jviij.
Miscc, 6iit raiftui-K. Two tahle!>pooDfuls three times a day.
In more distinctly neurotic cnaeB valerianate of
riiic and iron will Ije found very valuable A
grain of either of these made into a pill with half
a grain of extmct of nux vomica may be ordered
twice a day an hour after food. It may often
be desirable, when sleeplessness nccompanies palpi-
tation, t« give a full dose of bromide at night ;
15 to 30 grains of .sodium or pota.ssium bromide
in an ounce and a half of chloroform water should
* Hfr tlic author's
adition) , p. 4C7.
' Food in Health rind Diseue " (new
^^^^^niap. V.I
Palfitatios.
409
be ordered at bod-time : it is generally advisable
at the same time to recommend the patient to
sleep with his head and shoulders well raised on
pillows, so as to prevent the abdominiil contentB
from pressing on the cardiac region, and to allow
of nothing but a little sonp or other light food for
some hours before bed-time.
When palpitation acconipiinies organic disease of
tlie heart, or ih iu>iK)ciated with cai-diac hy^ier.estliesia,
as evidenced by tenderncFs on pressure over the
canliac apex, a piaster of belladonna or opium applied
over the priecorciia is of grtMit use.
In a troublesome case of paroxysmAl palpitation
accompanying aortic iind mitral disease in a young
wnman, we found painting .strong iodine paint
along the course of the pneumogastric nerves in
the fieck was quickly followed by relief of the
piilpitation and reduction of the pulse rate from
VIW to 80.
When symptoms of chronic gastric catarrh are
associated with palpitation, a gastric sfjdativo and
antacid should be prescribed, such as
V) Kinnuthi itirbonul i.i
Maguosii ntibunatis
Bodii bicarboniiti» ..
Aqun? luiirocorairi
Aquie I'jiryophylli .
• gr. X.
(fr. V.
gT. X.
a.l Jj.
WsCK, fint hniiBtiii). Tu be taken on hour beforo food twK'(> a day.
Suitable aperients should also be ordere<l in case
of constipation, and in obstinate cases with retained
scybala, enenmta of soap and water, with a few
tablesitooufuls of olive oil added, should be adminis-
teri^d with a long tube. In hysterical cases a
conil)ination of valerian and bronddes often proves
useful — 20 grains of sodium or anunoniiun bromide
with half a dram of the Htiimotiiated tincture of
v.'dcrian and an ounce of chloroform water may be
given for a dose.
Various expedients have been recommended for
the treatment of the paroxysmal forms, such as an
4IO
Medic A I. Treatment.
ip»ti II
ice-bag over the cardiac region, a tablespoonful of
brandy in a little water (dangerous on aocount
of the risk of exciting a craving for ulcohol), a
mixture of sal volatile and compound spirits of
ether with tinctures of lavender, henbane, cannabis
indica, etc.
IjriW].dl>ent observes that " to arrest an attack
of palpitation it is sometimes only necessary to
take II dozen deliberate deep hrpAths."*
For iMiroxymnnl " heiirt-liurry '' tin' bromides and
belladoiwiu have been foutifl useful ; Jiti ice-bag or
Leitcr's tubes over the lirart, and the application
of the continuous gulvjinie current jtlnnf; the course
of the great nerve trunks in the neck, have also
been recommended. This condition is, however,
not very amenable to modical treatment. The sloio
pulse, when constitutional, neefls no treatment, but
individuals with this peculiarity requii-e more active
stimulation and a moie supporting rt'ffime when
attacked by any acute illness than others. When it
is a symptom of cardiac e.xhaustion or degeneration
it needs the siune 8Upi>orting and tonic remedies
as we Lave already fully describe*].
Cardiac Pain.
Before we pass on to consider that grave car-
diac aHectidii known (vs amjinn jiectnrin, it will be
well to refei' to other less serious form.s of cardiac
pain wliich we encounter. All experienced pruo-
titioners are aware of the fact that when a patient
complains of " pain at the heart " it is an expression
frequently used very vaguely, and simply refers to
the existence of piin about the anterior part of
the cheat on the left side, which may not be of
cardiac origin, but dependent on rheumatism, or
intercostal neuralgia, or costal periostitis, or acute or
chronic pleuritis, or some Hatulcnt or dyspeptic state.
There is, however, a particular form of pain fre-
(jueiitly complained of by young cblorotic women
* " Heart Diseiuie " (thin! edition), p. Vi6.
^
a»p. v.i
Cardiac Pain.
411
who are at the same time the subjects of men-
strual irregularities, and which is tertnefl " snb-
mninniiiry |»niii." It is frequently aHsociated
with oviiriHii irritation and tenderness, especially on
pressure over the left ovary. We have liarl occa-
sion to believe that this sub-iniimniary pain is, in
many crises, really cardiac. An attentive exploration
of the region of the cardiac apex with the tip of the
finger will often reveal the fact that this is the
pretnse seat of the jiain c<:)mplained of, and Hrm
pressure here with the Hnger-tip will greatly aggra-
vate it.* With such patients you may press with
moderate firmness on various parts of the sui-face of
the chest with the tip of the finger without provoking
any complaint of pain, hut the instant the pressure
falls over the cardiac apex the patient starts back with
a decided expression of siilTeriiig. Dr. Balfour, in the
first edition of his valuable lectures on " hisease.i of
the Heart,'' spoke of this " subiimmniary pain " as
"wholly external,'' Vjut he inoditied this view in bin
second edition, and says : " In most the pain is
truly cardiac in chai-acter." But it sometimes
(x-cui's in its most obstinate forms in young wouum
who are not aniemic, hut who suffer from ovarian
irritation. In these cases a |)eculiar hyperiesthe.siaf of
the cardiac sulwtance seems to be set up, fio.ssihly of
a reflex nature. When 8ub-nian)niary pain is a.s»ociated
with ana-mia it will di8.i])pe«r as the aniemia dis-
appears, and will retjuiio the same treatment ; but
when it occurs in robust, florid girls, with sexual
irritability, we have found tlie repeated application
of small flying blisters over the cardiac apex and over
the painful ovary (almost always the left) the moat
effective mode of treatment.
• A'w a clinical lectnre by the author, on ' ' Pain at the Heart
ami PaIi>itation," in the Lamrt of Au({. 12tli, 1882.
t Haney hail the opportunity of making some observations on
♦he Duke of Montgomery, whouc heart wan partially exposed after
the healing of a severe wound of tlieche«t, und he cmvinwd hini-
>elf that tne heart in a healthy state wa« entirely wantinfj in
Bonribility.
4'2
Medical Treatment.
IPArt II.
Professor Peter pointed out that in some of
tliesi" conclitions of cardiac pain, certain distinctly
painful spots iiiiiy be niadc out on exploring the
anterior surface of the chest with the tip of the
linger. If there is a hvpenesthetic state of the
myociirdiuni, pain on pres.surc will often Ik; found
to exist in the fourth and fifth left intei-co.stiil spaces
near the sternum, and also over tlie cardiac apex. In
case.s of " toliacco-heart " in middle-aged men, Peter
noticed that pressure over a very limitol point in the
third left intercostal space, near the sternum, gave rise
to acute pain, and he thought this pain corresponded
with the auriculo-vetitricuhir groove, and that it was
proliably due to a morbid condition of the ganglion of
Reinak, causerl liy tol^cco. Cmmcicnui cardiac inter-
missions accoiii|iany tiiis state of the tobacco-heart, as
they also do some eases of coffee intoxication. The
pain, on jire.ssure, which is found to exist in some
coses of disease of tjie aorta and its valves, in the
second left int.er8j«ce close to the sternum, and over
the steniuiu itself at the same level, is, according to
Peter, not due to the lesion of the aorta itself, but to
a neuritis propagated from the diseased aortic tissues
to the nerves lying on it. Neuritis and neuralgia of
the cardiac plexus is revealed by pain on pressure with
the tip of the fingor (attacks of angina have been
provoked by too utroii;/ exploratory pressure) either
in the tldrd, second, or first left intercostal space near
the sternum, and especially the second, a few lines
from the stenium. In these coses there is some
tenderness on pi-essure over the vagus, just at the root
of the neck, inside the anterior border of the stemo-
nnastoid.
In connection with the co-existence of valvular
<Hsea.He it is certainly noteworthy how much less
fre((uently we have coni]>laint of cardiac pain in
mitral than in aortic c«.ses, although cardiac ilisconi-
forty not amoutiting to severe pain, is common enough
in mitnd cases. It has been suggested that the re.a,son
of this proliably is, that in aortic disease there is
Chap. V. I
CARDtAC Pain.
4'3
r
^H often a chronic inflammatiou of the coats of the aorta,
^H wliich extemls to the contiguous nerves of the cardiac
^^P plexus.
^^1 The aunexe<l diagram (Fig. 11) shows the situation
^^1 of spots of well-marked tendemes.s on pressure in a case
^^1 under our care of aortic valve disease, together with
^^B signs of aortic dilatation. The patient (who had had
^H four attacks of acute rheumatism) complained of pain
^H at t/if heart sh(K)tiiig through the left breast to the
^B back, and also of sudden pains across the chest, causing
him to stop short when walking. He also had some
Tig. 1 1 .—Painful Spot6 in n ctiao of Aortic RegurgittttioD.
dyspncea, cough, and blood -stained cxpeotor<itiou. He
WHS pale and emaciated. Pulse K'-l, small. This
patient was greatly benelited by the following trt'at-
ment, and the pul.>*e was i^educed to HH : flying blisters,
the size of a Horin, over tlie upper stcniHl and pne aortic
region, 5 minims of tincture of digitalis, 10 grains of
atninonio-citrate of iron, and an ounce of infusion of
caluniba, thrice daily.
In another case of aortic regurgitation in a lady
32 yoai-s of age, who had been under our observation
for aonie years, she at one period, after a shock owing
to the death of a sister, complained of much nervous
4M
Medical Tkea tment.
[Part II.
distress imd sleeplessness, but especially of ;»a»M t»i
</ii? cardiac region, shooting down both arms to the
elbows, and af»t,TftViited by the least exertion ; also
of fialpitiition ; pulst" 120. There was in this cose J
distinctly niie, but oidy one, painful spot on pressure
with the tip of the linger over thi- front of the
cheat, and this wils at tlie 8t<!rnal end of the second
left iiiterspiice. She wa.s grnatly lx<ni.'fited, and this
tender spot disappcan'd, an<l the pulse cauie down
from 120 to 80, by the same treiitment as that just
descril>ed, viz. couuter-irritation over the prse-oortic
Fig. 12.— P&iiifiil Spots iu a cjue of Aortic Dia«aw.
region by means of Hying blisters and a combination
of digitalis and iron.
In another aortic case (obstructive and regurgitant
murmurs), a young man 22 years of age, under our
care in King's College Hospital,* coniphiint of cardiac
pain was a most notable symptom. The pjvin, com-
mencing in the caixliac region, would .slioot down
the loft arm. and wa-s at times very severe and pre-
vented liiin from sleeping, and was much aggravated
by exertion. Countenance pale and anxious, much
* Thia caaa waa corefolly noted by Ur. Silk, the then hooaa
phj-nctsn.
Chap. V.I
Cakoiac Pain.
4«5
cardiuc hvpertrnphy, apex lieat in sevcuth interepiice
\\ mvh outskle nipple line. Mucli goneral iirtcria!
thickening. The exploration of the chest and neck
revealed several points where there was great tender-
ness on pressure. They are shown in the accom-
panying <liagrain (Fig. 12).
There are two points cliwe together over the
diffused apex heiit, othei-a in the first and tliird left
interi-paces close to sternum, another in the second
right interspace close to sternum, and two {)oint« over
the course of the vagus in the ueck, just in front of
fig, 18. — Painful Spots in a case of Mitral Dueiue.
the anterior border of the steruo-mastoid. This patient
was greatly relieve/! by the following treatment : rest
in bed, a diet cinnposed largely of milk, sinidl flying
blisters over the base of the heart, small doses of
digitalis with am monio citrate of iron, and sometimes
with ether an<l ammonia, and occasionully, when the
canliac pain was very severe, hypodei-niic injections
of morphine. In this case there probably existed not
only neuritis of some of the nerves of the cardiac
plexus, but also some chronic myocarditis and more
or le«8 degeneration of the cardiac muscle ; hence the
paiu at the apex, where the degeneration is usually
most advanced.
4i6
Mbdica l The a t.ve.v i:
(Part II.
In another aortic case* soniewhiit resembling tho
foi"ej;oing, painful jioints were foutid on pressure over
tlie vaj!;us in tlin neck, as well as in the first and
second left iriterspjiecs close t^j the sternum, and relief
was at firet experienced from countei'-irritation ; but
subsequently the patient wns attacked iit nisjht with
paroxj'sins of pain and dyspncca of an aiij^^nal
chariicter, which were i-elieveil by inhalation of niti-itt)
of aniyl.
The preceding diagram (Fig. 13) shows the painful
Fig. 14. — Painful Spots in a case of Fuuctiounl Cordiao Vnaimm,
points noted in a case of mitral stenosis, with incom-
petence, in a female 32 yeais of age, who couipl.iined
greatly of severe " pain at the heart," extendiirg into
the buck between the HJioulders. In this case, owing
to the co-exi8t«»nce of iiliroid diseiuse with retraction
of the left lung, tlie surface of the hrart was largely
uncovei'ed. Cardiac jiukation was viKJlde in all the
situations of the painful sjHjts, and doulitless some
chronic inflammation of the cardiac muscle had con-
ferred u])on it a morbid sensibility. Counter-irritation
in the form of small tlying blisters, rest in bed,
• CftrcfuUj- obwrvMl ami iiotcJ by my former clinical clerk,
Mr. C. O. HodgBOU, u( BriKliton.
Chap. V.)
CAKDiAC Pain,
4'7
occasional frictions witli tlie niix«l Itt'llndouna ami
clilorot'orni liniments, small d(>se.s of digitalis and in>n,
leil to the relief of pain, to regulation of tlie cardia«
action, and to great improvement in the general
heal til.
The next diagram (Fig. 14) shows painful pointh
observed in a case in which the cardiac disturbanov '
was purely functional. A housemaid, 25 years of age,
accustomed to ovrry heavy tray.s upstairs, complained
of " pains at the heart darting throusjli the chest " and
palpitation. She cmilfl not iiiov<> without distressing
pnlpitjition, accompanied with rlyspnfea, and '' throb-
bing at the heart." The pain was worse after foixl
and on atU-mpting t,o mount stairs. She sutTered
also from dyHmeiiorrh<ca, constipation, and llatulence.
She liiwl U'cn in the hiibitof drinking a (/i/rtd^i/i/ oflm
three times a diiy. Her ciieeks were flushed, but her
lips and gums wei-e pide and bloodless. The heart's
impulse was greatly exaggerated, and the large vessels
• at t he root of the neck pulsatefl strongly. There were
no murmurs. ( 'n exploring; the cardiac sensibility the
following painful points could l»e made out : one over
the apex and other's at ttie sternal end of the first,
second, and third left interspac-es. She was ordered
to abstain from tea, and she was given 8 mirriiHS
of tincture of digitalis, with ammonio-citrate of irorr
and infusion of calurul>a, thrice daily, arrd a daily
dinner [lill of aloes and nux voruica. She lapiilly
inrpr-ovwl, the painful spots l>ecarne less sensitive, and
thoir disappeared ; the pulso was r-etluced from 120 to
81, and in a month she was quite well, and the
cardiac pain and sensibility had disappeared. This
was a cHse of disturbed cardiac innervation with
livfrenesthesia, induced by excessive tea-dr'iriking, and
arrgUK-nted by the severe muscular efl'orts she had to
perform.
The affinity between these minor atti\cka of car-
diac pain and the graver ca-ses of angina pectoris is
illustrated by another c*se, a housemaiil also, aged 21,
who complained of severe pain iu the »irdiitc region,
D u
4i8
M EPICAL Treatment.
tPMit.
ljrouj;lit oil liy carrying heavy trays upstairs. Tlie
pain came on siiddfixhj two or threo times ii <lay, and
extended down the left arm, wliich, she said, " went
stone cold." She suffered ai.so from loss of flesh and
headaches. Pulse 100, feeble. No murmurs. There
wa.s marked teiideniess on pressure in the thiixl left
interspace, extending tioui the sti-nium outwai-ds for
t]iree-quart«<rs of an incli. Tlicre was duliuct loriilina-
tlim of extreme tentli'rnfit)i mer this spot. Tliere was
also a tender j>oint, Imt much less sensitive, over the
apex. She was firsf trfiiled with iron and caluinha
thrice daily, and cliloniform iind l>ellndotnia liniment
locally. This, iiftcr a month, had given Imt little relief.
Five grains of potassium bromidf wciv then added to
each dose of the mi.xtuie, and a (lying blister, the size
of a tlorin, was ordered t<_i be applied for two hours at a
time over contiguous spots at and near the sternal end
of the third left interspace. Under this treatment the
tender points disappeared, and the pain in the cardiac
region and left arm disapjjeared also.
This case was <louljtless one of true cardialgia,
[irobidply induced by over-fatiguo nnd cardiac strain,
and it had niauy jwints in common with angina pec-
toris. It is noteworthy how in this and other like
crises the cardiac lendertiesa socms to }>e specially
localised aliout the st^ernid end of the second or third
left interspace, and how speeilily the symptoms were
i-elieved V>y counter-irritation over this spot Another
ease wliich came under obser\'ation before we hod
adoptoil this method of exploring the CArdiac sensi-
bility is of interest as having apparentlj' the same
causation as the preceding. She was a waitress,
21) years of age, and had in her occujuition to carry
lieavy trays upstairs. The nttacks of cardiac jmin
were more distinctly paro.xysmal and nearer still
in character to those of true angina, and the case
tenninafed fatally after only a few months' i91ne.ss.
The causal relation Ix'tween these last three caaes
is oV)viou8. They were all young women in fairly-
good health, with no antecedents leading to cardiac
Chap. V.I
Cardiac Pain.
419
flis*'ttKf, save that they were all en>{figeil in the siiiiie
occupation, and all complamed of the effects of carry-
ing heavy trayw upstairs. In the tirst and slightest
of these cases the cardiac disturliance was iindoubtetlly
aggravattnl by the abuse of tea. In all three, ami
especially in the hist two, the symptoms complained
of bore a striking likeness to one another. Tn neither
of them, when lii-st seen, was there any definite
cardiac munnur. May we not trace the vailing
eUccts of cardiac or vascular strain in cucli of tliem ?
As we have alniuly pointed out, in nevere and
sustained muscular ellbrts there is increased action of
the cardiac muscle on the one hand, and increased
resistjince at the perijihery from muscular compres-
sion of the arlenoles and capillaries on the otlier.
If the cardiac ninscle is ill nourishcil and weak from
co-existing amemia, then the ventricular wall may
yield and become dilated, and we nuiy get cardiac
palpitation imd ]iain from fatigue, malnutrition, and
hyiicrte.sthesia of the cardiac inuscle. But if the tone
of the cardiac muscle is fairly goo<l and its contnic-
tions sustained and vigorous, then we should expect
the stiiiin to be chielly felt at the commencement of
the aorta, for in sustained muscular ell'orts it has to
bear a two-fold dist<>nfliiig influence : it ha^i to bear
the augmented impetus of the ventricular outflow,
increase*! both in force aufl frtjcpiency, as well as the
increased i-esistance in the perij>heral vessels. In these
circumstances it is not remarkable that it should be-
come the st?at of chronic inflammatory changes, which
nniy extend to and involve the nerves of tlie caitliac
jilexus in relation with its walls; or a portion of its wall
nuiy yield and l>ecome the seat of ancurisnial dilata-
tion, as was most likely the case with the l&tt patient.
Anoixa Pkctoius.
The consideration of the preceding coses of
cardiac pain may jxissibly help u.s tu the due under-
standing of the pathology and Ireaiiiieni of anginii
lirctoriB, which wo must now examine.
Medical TKEATMSfrr.
(Part II.
The syinptoiMs of the griiver attikcks of aniu^ina
pectoris — those of the minor foriiiii will lie gathere*!
from the in-pcwling cases — are well known. The
attack is prone to occur, especially on the first occa-
sion, on the patient usceiirling some rising ground or
making some sliglit inu.scular efl'ort after taking
food. Tli(> pain, which is very severe, suddenly seixcs
the ])aticut in the sternal region, and is uccoin-
pitnied by a feeling of constriction of the chest, as
though it were compressed in u vice; the pain shoots
til rough to the back and down the left arm usually,
but sometimes also down the right. The agony is
so great that the patient stands motionless, dreading
sudden dissolution, and fearing to draw a breath,
ulthough the respiration is pei-fectly free. The face
is usually pale and the hands cold. The pulse is
very variable in character, sometimes weak and
irregular, sometimes (juite regular, and sometimes
of heightened tension. The attack, as a rule,
passes off suddenly, after a few minutes or even
seconds, but it may last much longer, with varying
intensity, or may assume the form of a series of
jmroxysms. As the attack passes otT there is usually
some eructation of gas, and often a cojiious discharge
of urine. The attacks may only ot^mr at long inter-
vals, or they may bo of fi-equent occurrence in the
more serious forms. Mental emotion is often an
exciting cause, and so are |)hysical exertion and errors
in diet, and dysjieplic states ; distension of the
stomach, with flatus, being especially prone to induce
an attack. Unless, as is roost fre(|uently the case,
(here is serious disease of the heart, the health during
the intervals between the attacks may be quite satis-
factory- Although, in the greater numljer of cases,
the attacks are apt to follow physical exertion and
emotional excitement, it is not so in all cases ; some
if the most serious ca-nes have occurred when the
patient has been at rest, or have actually aw^oke him
from sleep.
The classiGcatiou that has been attempted of cases
ch»|.. V.J
Ancina pF.cToni!;.
4ii
of nii<,'iii:i jxK^tori.s, iiiid (lidr sfpanitiim into (li.Hliiu:!.
f;ri>u]>K, ajijK-ar to us soinowliiit furi'L-*! ami iiiiniitiiral.
We regard anrjina a8 ii lU'urosiil incidfnt of cardiac,
organic, or functional disease — most fre<|ueiitly tlie
former. It is not a <lise!Lse in itself ; it is a plieiio-
menon or manifestation of disease. The cauliac lesions
underlying the anginal att«ek.s may vary in their
nature, but the anginal attacks maintain their re-
semblance to one another, fiiH'ering only in their
severity. We do not a<linit the fmnii/o-an^ina, of
some authors. Hysterical imitative aiiginiuj, however,
certainly occur. But, as tbe ca-ses we have qiiotol
conclusively show, there is sini]>ly a gi-adati<tn of
severity and i-urability between the so called cases of
|>«etf</»)-angina and those of Iriie angina. The oidy sure
ground of classilication i.s the ascertainable absence or
presence of cardiovascular chaTiges. In all the gi'nver
fomis of angina, we Itelieve, thei-e exists a serious
organic, cardi.ic, or vascular lesion, although not
always detectable ; and in the milder or curable fornm
we have simply to do with a cardiac neuralgia, or
hyperoesthesia, induced either by temporary conditions
of cardiac malnutiiti<»n or canlio-vascular strain ; or
it may be dejiendent <in an inflammatory aflection of
branches of the cardiac plexus, itself dependent on an
aortitis ; or else it may be brought about by states of
blood contuminution ; and in the latter case it is
associated with vaso-niotor excitement and increased
arteiial tension. AVc object to the term vasomotor
anginas as resting on a hyf)othesiH that is by no
meauK estaVdished or consistent with ext<Mided clinic^il
observation. We have seen reason to ivgard the
heightened orterial tension and " vaso-motor s|>iisni "
which has l>een a.ssunie<l by some physicians to be the
enn^K of anginal attacks as merely an inritli-nl of the
same — an aggravating incident, no doubt, but not
Ijearing a cnnsul i-elation to the origin of the attacks.
f)n further clinical observation it will l)e found that
lieightcnetl arterial tension is a frequent inci<lent,
prol)ably of a reflex nature, in other nenralgins, ami
412
Med/ca l Tk ea r.VE.v t.
(l„
noUibly in iK-iiralgiu uf tlic liruiiclir.s of tiie fifth niTv«i.
We liave seen in jMiticnitH in oilier lespeclij in perfect
heivUli, and free from tieinotic tenileucies, iin attMck
of ncunilgia of the sufxn-ior ni;ixillary nerve from
deiitdl irritntlon titU'iulecl witli rnnrked increase of
vancular tension, with a Hhc of 20 to 30 in the pulse
rat*', and tiio attack passing' ofl" witli an excessive flow
of clear urine.
It would seem that the shock or irritation of
certain kinds of pain is able of itHelf, in some
instjvnces, to raise viwoular tension to a remarkable
degree, and we lielieve that in those cases of angina
in which the arterial tension has been fi>und to Ite
increased (and there is no evidence that it is so in all
cases, or even in the majority), this augmentation of
vascular tension will be found to be a sequence, not a
precursor, of the attack, a consequence of the shook of
jiain, a reflex irritation of the vaso-niotor centres.
Iluchard, in his writings on Angina Pectoris,
miiiivtains that true angina is always due to degene-
rative dise^ise of the coronary arteries and consequent
cardiac ischieinia, and that all other cases are cases
of pseudo-angina and may be of neuralgic origin.
Our present object, however, is to seek for iiidlrn-
tion«i for Ii-fHlmcnl, and we must, tlierefore, brieHy
consider the known modes of ctiiiDution of att^icks of
angina pecUiris. And, lirat, with regard to those
gniver cases which are as-sociated with serious struc-
tural disease of the heart and vessels. Now, when we
consider that in by far the greater number of *lt>itths
from organic disease of the heart, in which we find
all the various lesions present that have been found
in fatal cases of angina, yet no true anginal attacks
have ever lx;en coniplaine<l of ; wlien we consider thiB
well-known fact, we must admit thei-e is some other
additional circumstance neede<l to iiccount for the
angina. C'ertainlj", obstructive disease of the coronary
arteries has been found a.Hsociated in a considerable
numlx-r of cu-ses with fatal attJicks of angina, hut
extreme aortic regurgitation, extreme degeneration
Chap. V.I
AxGijfA Pkcwrix.
4^3
the iiiyocartliiini, aw(\ (extreme dilatation of tlic ca\ i-
tic'K of tlip li<"art have no ni-cvsnarij i'a\isal rcliitinn t<»
nttacks of angina. Tlie most s(.'riuU!i forms of an>,'ina
seem to liave a complex cauMition : first, tlii>re inii»t 1)0
u iifiiTosal element, the nervoH of the cardiac plexus
sufter irritation, and a cardiac neuralgia or cardiac
nerve pain of an intense character is excited ; this
acts as a. shock to the motor nerves of the heart,*
mill in fatnl cases the lieart luusde on the verge of
failure from organic causes is shocked by the attack
of nerve pain, and if some reHex arterial spasm
shotrld be excited at the same time, it v?ill have to
encounter an augmented peripheral resistance as well.
In such cases the nipidhi) of the fatjil is-sue is no
argument against the neuralgic nature of the angina.
Wew there is a cnuiplfjc jussocialion of depressing
causes in the struggle with which the heart nniy
fail and sndden death occur ; or it may struggle suc-
cessfully with the ea flier attacks, but as its struggling
j>i)wer hecomes exhausted it must finally succumb.
We have pointixl out how in certain conditions utraiii
is apt to fall (when the aortic valves are competent)
rather on the first part of the aurta than on the
ventricular surface, and this more especially is tlio
case in habitual high arterial tension ; and we are
disposed to think that anginal nttacks are more prone
to occur when the stiiun falls es()ecially upon this part
of the vascular system, which is in such close relation
with the nerves of the cardiac ple.\u», than when the
mitral or aortic valves are incompetent, and the strain
is felt on the interior of the cardiac cavities. Certainly
enonnous distension of the Ifjl auriclf snd of the Irji
vnlride may long exist without j)roduciiig any .symp-
toms analogous to angina. The late Sir T. (Srainger
Stewart ^ remarked that he had "more than once
• It >» quite iKwsible, if the imrnutUate prr-iim/iniil state of fho
eiroiilntioii were knowu, or had liei-ii obirved. thut » i-oiulitiuii
of rnrdiuc excitement, of iucreaMHl fiiu^ciilar iictinn, niiiMtd tho
onset of extreme iirirr jmiii, tlie sliix'k of wliii'li Inui-rnl the Ltirdiiu'
action, luitl no Iwl to t)ie relief of the ]iiiin. This would expluiii
the ahort dunitioo uf many of the attscki).
424
AfF.tncAi. Tkeatmkxt,
iKrl 11.
seoii i) fiiitic'iit. dcRcrilx' ii eiirvo on liis clii'st like thiit
of tlie iiitrtii to indicaU^ the sil« of liis piiiii," luiil wo
havf ]iointo() nut liow ciiunt^r-imUitum over tliia
rc'ifiiin will ofton pi-ovc most cnective in icliovinjc! the
niildor forms of caitliiic pain.
In the next ])liife let us inquire what is the
riiuiuihnii of the less irnive and more entirely remedial
forrnB of angina. In these al.<so the causation is in
many instanccH complex. We may have a feeble, ill-
nourished, cardio-vascular system, from niiicmia, sulv
niitted to undue stniin, as in the cases we have
previously described, the strain, as we havi; just state<l,
falling, we believe, especially on the first part of the
aurtii ; or we may have some into.xication, such ns
that of tea, tobacco, alcohol, gout, or some intestinal
toxin, irritating the cardiac and the vaso-niotor
nerves, causini; central irritability, increasing peri-
jiheml resistance, and so exciting anginal attacks,
which may altt)gether pjuss away ami Iw completely
recovered from. Vasomotnr g/mmn as a unique cause
of attacks of angina must, we think, l)e .set aside as
inconsjistent with extendt'd clinical experience. Caneft]
of angina i)ectoris, Iwth of the milder and graver
forms, occur without any evidence of vasomotor
spasm or of hoichtened arterial tension, ami the condi-
tions of lieightened arterial t^/nsion, together with a
feeble cardiac muscle, very commonly co-exist without
any tendency whatever to the development of anginnl
attacks ; and we have already given reasons for
concluding that when anginal attacks are found
associated with heightened arterial tension, the latter
may be a reflex conse<|uence of the cariliac pai».
The argument in favour of a vaso-motor causation of
anginal attacks has Ix^en inferred from therapeutic
experiment and the relief to the [mroxysm that lias
attended the \ise of aj;cnts which cause ait<'rial relaxa-
tions. Ibil most, if not all, of the.se voso-dilators are
also anirst/ietifs, and, an Balfour has pointed out, it is
to their anodyne action on llif cardiac sen.sory nerves
that they owe their chief efficacy ; and Sir T. tJrair
Dwc. V.I
AsciNA Pectoris.
4^5
Sltnvjirl ;ils(i itoiiittil out tlisil iiitriti- of iiiiiyl lifis a
• lircol pll'ft.t on iirrvous stnu-tuM-s, mid tliiit it relieves
other forms of iieui-aljjia. We liavo seen a patient
witli liis counfenan<v jnirple juhI the peripheral
vessels intensely ililiited under the intlueni-e of
nitrite of ainyl, without the slightest it-lief to his
nnglniil iittiick. Hut we readily mlniit that nitrite of
aniyl and its allies do relieve many unginal attacks,
and, to a certain extent and in some cases, by the
lowering of the vascular tension they produce, with-
out, however, ndniitting that there is a direct causal
relationshij)l)etween the anginal attacks and heightened
nrt.<'rial tension.
With these preliniinarj- considerations we an^ now
in a position to formidate certain ili«ll«"Mlions for
lr(>Hliiii-iil. Tlu«e are : —
1. To niitintain, or improve when defective, the
general nutrition, to avoid all strain, physical nml
emotioiml, and so to ri'lieve cardiac feebleness and
effort.
2. To relieve dysjwptic conditions and flatulent or
fiBcal distension of the stomach and int<'KtineH.
3. To forliid the hidiitual consumption of agents
which may exurci.sc a toxic action on the heart, as tea,
coflee, tol.iacco, alcohol, etc., or which nuiy introduce
or develop toxins in the alimentary canal.
4. To avoid and remove all gouty and other blood
contnminationH.
0. To give such tonic ivmedies as may improve
the cardifu; tone and lessen existing tendencies to
card io- vascular degeneration.
fi. To relieve the paroxysmal attacks by sedatives
and stimulants.
1. Anginal attacks occurring in persons who
present signs of anicmia, and defective nutrition
generally, must he encountei-ed, in the first place, by
attention to hygienic measures. Such patients must
l)e removed from all causes of physical or mental
strain. Their life must be one of comiilete repose
of iiiiiul ihkI body — a repose alternated with gentle
426
Medical Treatment.
IPAr. II
phyNieal I'xorcise, al wnys .sto|>]iiiiK slioii of the sli;rlitc'St
fatigUL" : it is good for tlii'iii, linwpvi'r, Lo U- inucli in
tlie open air, driving, s4iiUng, or rt'fliniiif;, anil in u
mild cliniatfl, wlu-n [Kissiljlf, so tlmt tliey shall lie
]iri.itr-ct<>d from the injurious efft'cts of cold, exposviro
lo which certainly favours the occunence of those
attacks, not oidy hy lowi^ring ihe nervous force, but V>y
cheeking free cutiineous circulation and elimination.
Much atl-ention shotdd also Vh> paid to their diet.* It
should be of the most nutritious natni-e, so far as is
consistent with ease of digestion. A n almost exclusive
milk diet will be found to he of great service in many
cases. When the digestive [lowers are greatly weakened,
it may be necessary to liave recourse to pre-<ligeste<l
foods, or to give with the foods some artificial digest! vo
Hgent, such as pejjsin or pnncreatine. We have found
a wineitiassful of cieam mixed with the same quantity
of hot water, and a teas|}oonful of sal volatile added,
an excellent food on getting uji in the morning. The
lighter kinds of fitth — soles, wliiting, flounders, etc. —
simply grilled, and eiiten with a squeeze of lemon and
plain uncooked butter, are excellent : lightly lioiled or
(loached eggs are permissible ; and also good con»nmtnf,
llavoured with vegetables ; the lean of fresh meat,
well iniiiced and lightly cooked, is most digestible
and nourishing ; fresh vegetables in the form <if
pun'-es are useful, and so is the pulp of cooked fruits,
as affording the necessary variety in the food and
promoting the action of the bowels. Light milk
jMiddings are also conimendaV)le, but they should be
taken alone, not together with other kinds of food.
We should also see that a sufficient fjuantity of pure
water, and preferably iitirni, is consumed, for elimina
tive as well as assimilative purposes.
2. This first indication cannot, however, be thor-
• It i« Torv CHiraraon to .'((hnao guch puticnts to tnke food at ^iutrt
iiitcn-ttla. Now, if this instruction i» (tivoii, it uliould be pointed
nut that the food must \w Jliiiil, nm\ mint remain /fwifl in the
8touuic)i. The iligostive function.i of a jhtsou in fct'l)U' lu-alth ana
not t/«>(vt-f;«i^, hut the contrary; und to give (xiliil fcxnl ttt short
intcrvnls in «neh cii»™ i« only to ag;n°aviite (^y»p«^lti(• stntes.
Oiop. V.J
Angisa Pectoris.
427
nu>;lily c«mc<l out witlimit clue n-ganl lo the .•mm.-oikI
— VJ2. to rulirfi! i/i/ti]iijitic fonditliiiiti andjldliili^ttt ami
Jirenl diitlfiision of the uluiimc/i mid iiUvsthf^. The
co-ex istpuce of dyspeptic slates must l>e tri>At«'(l in
acconliince with the principles iilreiuly hii'l down in
aiiotlier chapter. An :ilkiiline bitter storuiichic, coni-
pose<l of soiliuni bicarbonate, nux vomica, and
cHliimba, an lioiir liefore the two principal meals, will
be found valuable. Or in other cases a dose of dilute
hydrochloric iicid in compound infu.sion of orangopeel
lifter food, with th« addition of a few ^'rains of f>epsin,
may lie given. Flatulent difitension during digestion
will often be eirectually relievwl liy a pill coiitaininj<
a fjrain of thymol or menthol, or a drop of creasote
taken directly after food. Ucfoilar evacuation of
the bowels is most essential — checkiuf,', us it does,
the formation of injurious toxins in the intestine,
eliiiiinatiiin waste substances, and i-elieving abdominal
di.stension. For some persons the best aperient i«
a dinner pill, containing a ^niin or two of aloes,
half a grain of powdered ipecacuanha, a grain of
nux vomica [towder, and a grain of soap ; this may
be taken before or after dinner. Should such a
pill prove insuflicient, it may be followed by a
tea.s[Hionfnl of Carlsbad or lloniburg salts in half
a tumblerful of hot water the next moriiinjr. In
cases where there is a sluggishness of livw, with
bile-stained conjunctiva, a few grains of tilne pill,
or Jrrl or I a grain of c^ilomel at bed-time, with
2 or 3 grains of compound rhubarb pill, may take
the place of the dinner pill.
3. The next indication is also an important one ;
for certain of the sligliter fonn.s of angina are no doubt
dependent on, and the more serious forms may Ijc
provoked Ity, the habitual use of certain substances
which come, in course of time, to exercise a loxir
action on the hcftrt* The action of tliese toxic agents
is all the more subtle because they may Ik.> taken for
many year-s without apparently prtxlucing any
injurious efl'ect, and it is often difhcult to convince a
4^8
Medical Trea thexi:
iPftrttt
IKilicnt tliftt wimt 111' lias so lon>x ilniic willi iiii]iiinitv
has at leiij;(li 1m*ci>iiii' iiijuriiiUH. This is p;irticii):irly
the case with lol»iic«'o, the tuxic t>irect« of which on
the heart are oft»'n dctivyi'tl until, or even after, middle
av'e, wlien they will )ierlia])s soiuewliat sudileuly make
themselves felt. With rejfivrd to alcohol, it iis singular
to obaerve how in ititferent individuals its toxic »vnd
degenerating influence will soniotinies fall on one
or};;an, and HOiuetiriies on another. Thecardio-va«cular
system in some persons is especially prone to undergo
seritius degenerative clianges under its iiiHiience, while
in others it nlniost entirely escapes, and lieputic and
gastric trouliles more especially arise, and in women
the peripheral nervous system is most prone to !«
afl'ected ; hut whenever anginal symptoms arise, we
should always insist either on complete alwtinence
from alcohol, or on its very sparing use in a very dilut«
form. Tea and coffee are often provocative of the
slijjhter miinifestations of cardiac pain and discomfort,
and it is noteworthy that they are particularly pn.>ne
to be ajfgi'avated by any emotional disturbance. All
these toxic agents must be forbidden so long as any
tendency to anginal attacks exist.s.
4. The fourth indication is to remove and avoid all
gouty anil other blood contamination. The im[)ortance
of pliininnlion in (lie ti-eatment of angina pectoris
is univeiTially admittetl ; and we desire to eni]>hasiso
the imj>ort<ince of a free evacuntioTi of waste products
from the system. When renul elimination isflefective
from the co-existence of jvnal »iegenerntion we must
act fre<'ly on the bowels anil on the skin. When th«»
kidneys are sound, the free use of pure water or
wjme suitable minenil water, having some slight
stimulating action on the kidney.s, may avoid the
necessity of free purgation ; but in all ca.ses a thorough
daily evacuation of Iho bowels .should be procure<l,
and five action of the skin should Ih- maintained by
warm baths and frictions. In gouty cases, and in all
cases of defective elimination, a careful and spare l»ut
adequate diet should be prescribed. Animal food
Angina Pectoris.
4*9
■
should Iw tuken in strict moderntioii, anil frpsth
vegetuljles and fruit, carefully cooked and prepariMl
80 as to lie mivde easy of digestion, should take a
prominent place in th« dietary. Alcoholic stimulants
should be avoided as far ax [)0S8il)lt' ; and when milk
is not unacce|)table to the patient u few weeks of an
exclusive milk diet may Ix' advantageous ; hut a diet
of this kind require* the patient to remain eiUireli/
at rrnt during its adoption.
0. In the fifth place we come to the coosideration
of the medicinal treatment of these cases, and first of
the appropriate treatment in the intervals.
In anwmic aises and cases of leniporai-y cardiac
debility from removable malnutrition, we shall find
the milder |U'ejiaralions of iron combine<l with small
doses of digitalis, such as we have already describeil
in the e^irly part of this chapter, of great service.
In other cases we shall finil ars<>ni<' of greater
value than iron ; there is a general consensus
amongst exj>erieuoed physicians as to the value of
arsenic in the treatment of cases of angina pectoris in
the int<Tvals between the paroxysms. Balfour asserted
that arsenic is " indispensable in all forms of weak
heart, accompanied by pain."* lie advi.sed that it
should be given in the form of Fowler's solution, 3 to
5 minims, eombiia-d with iron and strychnine, twice a
day, after food. We cannot too strongly insist on the
value of nfri/r/iiiiiie as a cardiac tonic, especially in
remediable slates of cardiiic asthenia. In highly
neurotic casi-H much bt^nefit may be derive<l from a
combination of iron or arsenic and sodium bromide,
in 5- to 1 ■5-grain doses , and in the same class of cases
the valerianate of zinc is also of great service ; it may
l»e given in grain doses in a coated pill thrice daily, after
food; and sometimes the combination of ,,',,th of a
grain of phosphorus with it renders it a more valuable
nerve-tonic.
We have already pointed out the usefulness of
digitalis in the milder cases, the cases which some
* " Disousci uf tlio Heart " (moond mlition), p. 31.'1.
430
Medical Treatmsht.
IPurt II.
autliors t^Tiii finfudo-nngiiiit : and we hnvp socn long
jit'rimls (if immunity from attacks apparently brought
alKWt by occasionnl recourse to n mild iron tonic, witli
.i-minim dows of tincture of digitalis, or a pilule of
Nativelle's digitaline (,,',„th grain). The idea of
giving a cfluiliinnlion of nitro-glycerine and digitalis,
during the intervals, is a concession to the vaso-niotor
hypotliesis of the mode of causation of the attack, to
which vie shall immediately recur.
Digitalis is not a very suitable tonic in any case
wliei-e there i.s greatly heightenetl arterial tension —
in such cases stroiilmiithu« or tMitteiiie has the advan-
tage over digitalis of not cuiitraeting the arterioles.
There is another remedy which is of very great
value in the treatment of angina pectoris, especially
when it is associated with obvious signs of caniio-
voKcular degeneration and of the gouty state, and tlit«t
is potasaiuni or sodium iodide. It checks the progi-ess
of degenerative changes, it stimulates glandular organs,
and etiiciently promotes elimination, and it appears also
to prevent vnso-niotor irritability — all these effects
may depend on its eliminntive properties. It is one
of the most etiicient auti-neuralgic agents in other
foruis of nerve pain. It may !« given in 5- to
15-gruin (loses, three times h day.
Huchard maintains that the iodides alone are
capjilile of curing tliis diseaae. He prefers the
sodium iodide.
In coses ti'aceable to malnrial intoxication, if
aiTseuic fails to relieve, quinine should certainly be
given ; but in such cases e%'idence of arterio-sclerosis
will usually be present, and will in<licate the use. of
[lotasaium or so<liuni iodide. It has recently been
stated that cocaine, in doses of Jrd of a grain, twice
daily, has the power of entirely preventing attacks
ofangina ; but Huchard thinks it a dangerous drug in
this disease, and lie would argue that these were not
cases of trilf but of /)^<''ll<lo-^^nyi^tn.
Kumpf * lias suggested a mode of treatment of
• Sim hiietitiimrr, October, l«Hl, p. 47>.
ANCitTA Pectoris
thi8 disease founded on the theoi-y that it is depen-
dent on cjilcifioition of the CDronary arteries, and
designed to dtcah-'tfij tlieni liy iriiTciising tlie elimina-
tion of lime. A diet jxxjr in lime is prescrilted —
meat, « ounces ; bread, fish, jwttitoes and apples,
each l^ ounces, and the following mixture to lie
taken daily : Sixlium bicarbonate, 150 gra, neutralised
by a sufficiency of lactic acid, to be added to 150
grains each of lactic ucid and of sugar, and 6 ounces
of distilled water.
Strange to say, lie does not point out the im-
]H)rtance of avoiding drinking/ waters containing lime !
He reports a remarkable success in 2.5 per cent, of
the cases in which he applied this treatment.
6. It oidy remains to consider the indications
for the relief of the paroxysmal attacks. Those wiio
see in the causation of the niigiiml paroxysm the pre-
dominating iriHiience of vaso-motor spasm considiT
the nmin indication for the relief of the paroxysm is
to administer medicinal agents which are known to
Lave the [lOwcr of relaxing the arterioles, and so of
lowering arterial tension, and, to that extent, to relievn
the heart of a certi»in amount of the peripheral resist-
ance it has to overcome. They thoreforn advocate the
use of the iiilrites, such as the nitrite of amyl, nitro-
glycerine, and so<1ium nitrite. That these agents do
relieve the paroxysm in many cases of angina is
certain ; that they do ,so wholly by their action
as vaso-dilators is ejcti-emely doubtful. They are
cjipable of relieving the anginal attack when there
is no certain evidence of the existence of voso-motor
spasm. Douglas Powell says he hoH found them " far
more reliable in the graver cjirdiac coses than in the
pui-er vivso-motory,"* but it is in the latter that they
should prove most effiou-ious if the prevailing theory
of their action wen^ true. Hnlfour and Gminger
Stewart lioth maintained that they act as direct
analgesic agents, utul that they have the power of
relieving pain in other neuralgias as well as in cardiac,
* Traiivulioiu of Medical Society, vol, xir., ]>. '.'76.
432
Meuica I. The A tmkn t.
I Part II.
imiependuntly of tlieir relaxing action on ihi- blocKl-
vessels ; and this view we adopt, as the most coiisLslent
witii the clinical history of this discaHe.
Nitrite of amyl is best administered by inhalation.
A capsule containing 3 or 5 minima shoulil lie broken
in a handkerchief, and iidialed. In some cases, how-
ever, it entirely fails to relieve, although it may pro-
duce, in n most marked form, it^i characteristic effect
of dilating the vessels. Nitroglycerine is preferretl by
others, and it hiis Im-i-h pushed until verj* large doses
have been taken— as much as HS <lropsof a 1 per cent.
solution liiivelteengiven and repesited at short intervals
during an attack, and 7 minims three tunes a day in
the intervals.* We sliuuld Itegin, however, with much
stnulier doses -1 to 'J. minims of the 1 per cent,
solution. Whitln recommends still smaller doses
(rfiOo) ^'^T frequently, so as to maintain the effect
and avoid the severe hejidaches wliich often follow tlie
larger dosos. Sodium nitrite may also be employc<l
for the same purpose : its effect is said to be more
lasting than that of nitrite of amyl and nitroglycerine.
It is given in tiiblets of 2 A grains ; one to four of the.se
may he given for a dose. At the onset of an attnckj
in addition to the inhalation of nitrite of ainyl, which,
owing to the rapidity of its action, is thi- most suitable
remedy to start with, wo may give some warm ililTu-
sible stimulant, such ns 30 minims of sulphuric ether,
or a dram of nitrous ether, with a dram of sal volatile
or a little brandy in an ounce or two of peppermint
water. Tlie feet and hands, if cold, may be placed in
hot water Balfour complained that he had l>een dis-
appointed in the action of nitro-glycerine, and preferretl
inh.ilations of nitrite of amyl ; and when these fail —
as they often will — he i-esorted uidiesitatingly to
chloroform inhalations, and hoailduced a i;reat weight
of evidence in favour of his contention that " so far
from being unsafe in car^liac disease., it is often of tli«
greatest use in these cas(.«."t Sulphuric ether is userl
• Trail narliaiit of Moilical Society, vol. xiv., p. 291.
t " DiwiifBB t>f tho Heart " (Kcoiid edition), p. 300.
Chap. V.l
Ahgina PncroKis.
433
ftlso for the same purpose, but, as Halfour said, " it ii«
not rapid enough. Chlorofonii act.s more quickly, even
more efl'ectually, and is porfectly safe." He gave it
poured on a sponge, in a .smelling-bottle, and the patient
was told to breathe it through his nose as deeply as
possible. " In this way relief is obtained in a few
seconds, and so soon as the narcotic inthience is pro-
duced the stnelling-ljottle drops, and witli it rolls away
all risk of any overdose."
PnifesNor Bradljury, of Canibriclge, introtluced
eri/tJiriil Utra-nitritln iis a vaso-dilator and a remedy
for angina pectori-s. It.i use has also Iwon commendetl
by otlu-rs who have employed it. It is less rapid in
producing it« ettects than ainyl-nitrite or nitro-
glycerine, but its iiiHueiico is uiui'h more lasting. The
dose is I grain in ak-oholiu silntion or in tablets.
Oibson* thinks highly of the inhalation of iodide
of ethyl. ItsS beneficial action he believes to be " due
to the liberation of free io<ilne, which is nijiidly
absorbed by the btood."
In severe and protracted attacks we may Ik)
olilifjed to have recourse to hypoilermic injections
of morphine, A sixth or a quarter of a grain may
be injected for a dose. Morpliine so<^ms to be better
tolerated in cases of cai-diac pain with a weak lieart
than when it i.s given to relieve other neiinilgiiis in
the same circumstances. When it is given to relieve
cardiac [lain there seems to lie less risk of its
causing cardiac depression. It is, however, a good
plan to give .some ether ami ammonia mi.Kture at the
same time, to counteract any such possible depression,
or a Hcnnll dose of strychnine (gr. ^',y U> t/,,) may be
combined with the hypoilermic injection of morphine.
The ethereal tinctures of valerian and of castor have
been found useful. The itdialatioii of pi/ri'line has
iMjen said to give immediate relief, but the unpleasant
IHjnetruting ndnur of this siibstancre makes patients
object gn-ally to its use. liromide of ethyl has also
be«n used in inhalation. Wi^ have idready remarke<l
• " OiieMMn of the Uonrt anil Aorta," ji. "W.
C 0
Medical Treatment.
(Put It.
on tlie valut? of counter-imtation in the form of flying
blistei-s in those cases where a clironic aortitis inny
Imvt.' involved contiguous bi-anehes of the cardiac
plexuB. A hot mustard poultice to the prsucordiai
region may be useful at tinie.s. The application of the
eontituious electric current along the course of the
vagus, in the tieck, and down tlie arm, in cases where
a distinctly painful ok-jvi is ex|it'rienced in the hund,
liiis lii'eii fdtnid useful in wauling oH' itttacks. T^ieeches
applied over the sU'rual rejrion and repeated small
liiccilings from the arm have heen found useful in
some cases.
ADDITIONAL FORMUL.^.
Drops for palpltatton.
II Tiiirturir ili^jitiilis. .\ij.
Tiiictuni' viileriaiiii'. sij.
Forri acetntia iHlierin, .^iij,
M. f. mint. Tweuty-flve <lroi>s
in water tlireo timoB a diiy.
{Srhml-Jr,.)
For functional palplt&tion.
li SjiiritUMLtununiiji' (iromatici,
/Etheri« suljiiiurio, sij.
'I^inctunii tiiigilwns, .\iij.
Easciitiii' meuthn' piperita-,
Mij.
Siiiritus cnniiiliora'. ,^iij.
'luicliini' amliininnii coni-
|.io.<iit)i' lid ^iij.
M. f. inifst. A nmall tcuspooii-
fill ill a wiDCgloM of wiiter cvi-ry
iiftct'ii luinutes whilst the jml-
jiitntiuii null diflioulty of hreath-
iiig lire severe. ( H'/iilln.)
Anotber.
Bi Acidi hydroliroraii'i diluti,
.nj.
Tinctnnp helhulonuip, sHj.
Tiiiclunr iiucis vomiojr, .<ij,
(ilyoorini puri, .^jss.
Tiiictiini* qiiiiiinn- nd :,vj.
M. f. mist. A dessortupooii-
(iil ill two bililespiiiiiifulit iif
Wilier iJiree liiiit'B ii diiy htrfore
nicalr. ( U'/i il/n, )
For neurotic palpitations.
}{ Tiiu'tiirif digitalis, .^ps.
Fnta^i hroraiili, >v,
AquiK ud sx.
M. f. mist. One to three
tnhlespooiifuU dailr.
' iHiirhnril.)
For palpitations connebtad
with masturbation.
K Potas8ii hi'fimi'li, >v«i.
Tinrturie di^itAli», .siJM.
Iiifuei eriacuriUii', jiv.
M. f. mist. A dessertspoon
ful two or three times u any.
(//rt Conla.)
Pills for nerrons palpitation.
It Pulveris dijiitnli;), gr. Ixxv.
t'ulvrriaafuif'rttdir, tfr. Ixxv.
Syrupi. (iiiuntum .siiJKciat
I't I. lululii- oeiitum. Mnc to
four pills diiily. ( If'ilhrnni/.y
For the anginal parozynn.
ft Spiritusaminiiuiit' nroniktiei,
Sodii bicarliouatis, gr. z.
I Tinctiine cardumomi eom-
jmsitir, .>j.
I Spiritiid I'hlrirofortni, mxx.
Solutionis iiitro-glycvrini (I
jier cent.), mj.
Ai|uir< ail .^M.
M. t'. haiist. To be slowly
sijipeil nil the voiiimencenieiit
of symptoms. (I'lurril,)
Chap, v.]
Angina Pectokis.
435
In anginal attacks.
li Ktliyli brooiidi, :^ss.
Aqiiii' <leHt.illutJi', :>xij!>8.
M. Two to four tal>les]iooii-
fuls tvt a dole. (Sryi'in.)
For the interrala In ang:ina
pectoris.
ft Quiiiiiiii- 8ul|iimtiii, .^ss.
Aci'li iirseniosi. ^. bs.
E.xtracti vnlerifinii-, q.g.
Ut f. \n\. XXX. Two to four
doily. {Oalloit.)
For the anginal attack.
R Tiuctunr difritnlis
Tiuctiirii' bellniloiinu'
Tiuftiini- vuIi.TiauiP
t>|iintiiii irtlieris coin-
po«iti
M. f. tinct. Ten to tw«ity
dropi during tbu attack.
{Uallum.)
Tot angina pectoris.
H Sodii ioilidi, (rr. W "d UV)
Sodii nniciintia, gr. ).
Aquii' <le8tiUiitti', ad .^v.
M. f. mist Two or throe
tnupooufub rlaily. (^2luf/iiirii.)
436
I
CHAPTER VI.
TMK THUATMENT OF DISKASES OV TIIK ARTBRIKS :
ARTE1II0-8CLEU0SI8 (ATHEROMA, OR KNDAItTKHITia
IiKFiiHMANs) — ANKfHISM.
Abtebio-sclebosis, or Atheroma — Its Xatiiro unci Cuiiaittirin —
Heredity— VnK'uInr Strain — AtlilRlic Expri'i»<M — ToxiL'mic
Stales— Dietetic Exce«ie-? and Errors— Kllects i.'f heigliteueil
Blood Pressure — Xeceiwity for Trmlmmt in curly ^^tngos —
Potassium Iodide— EUminative Mensnres — Miuoral Waters —
ExeriiBe— Foo<l - Hvgicue.
IXTEBNAL AsEUHiSJf— Causation— DegeneroliTe Changes — Sud-
den Strain— Syiihill«—.S".'/'«/''<""'»— The Form of the Aiieuriiun
influeuoea ita t_'iirabiUty — ItttheatiotiM for Trnttin*-nt — Blood-
letting—Ucst and n^<tricte"I Diet— fhc Tiiffntll Method —
Objections to it — Modiflrations of \t -VtttiifiMinm JwiiHr —
£fer<ro/v«i«— Introdnctiou of Foreign Bodies into Sac— Dintal
Lifftiturr— I*rtirututf /V-^MHir — AlncEwon*B Method— Ergot
ttud Ergofin — Gel:i tin Inject inns — Ice — Trfutment «l Siimptomt
— Pttiu -Dyspuiea — Anginal Attacks. Additiimul Formula".
TiiK arteries «re prone to undtTj^'o ilcgenerative
cliaiipeH, fatty, calcareous, and hy.'iline ; liut that
whicli chietly concerns us here is tlie di.sejwe affect-
ing the walls of arteries, known as ntln'rottta, or
endnrlvrilU ili-fornmng, or nrterlo-M'l«»rosis, tlie
existtMice uf which in the large vessels is one of
the chief eonilitions on which the occurrence of
aiinii'it>ni rk-penils.
A RTERIO-SCLER08IB.
This affection of the arteries appears to Ije a true
artei-itin, the inHannnation attacking chiefly the middle
coat (^iif^nffi-ritU), and involving also the advenlitia
(jKrinrti'rUiH) ; it is atti'n<lc(l with inKltrativo anil
fi<"gen<M'ative changes, and weakening of the walls of
the vessiM occurs in conse(|uence. The pi-oliferative
changes and thickening which at the sjinie time occur
in the iulima an> regarded as coiiififnaiilory, and in
the e^ifly stage l)efore these occur rapid dilatation n,t
the weakene<l sjxjt nwiy take place, and thus an
uneitritin bo forniwl.
.1
Ar TEKIO-SCLBROSIS.
437
Atlic-rania 18 a proc<>Ks of chronic inflatninatioti
followi'd by degeneration. Thoso-callftl " nllieromaloug
ulcer" is fornifsi by iIh^ breakinj; down of the degen-
erated tissue and rupturi' of tlie einlotheliinn, with the
]oriMluc(ion of a " branny detritu.s,'' or molecular tli'lirin.
l>irt'u.se arterial changes of tliis kind are couuiion.
They occur in old people as a «CMiIo change, and are
caused by the wear and tear or natuial strain to which
the arterial tubes are subject. But .such changes also
occur preuiaturely in certain conijKiratively young
persoiLS, when their arterial tissues are eB]>ecially
vulnerable, so that chronic arteritis readily ari.ses from
relatively slight irritation. This vulnerability would
seem, in some cases, to be inheritetl. " Entire families
8ometiine.8 show this tendency to early arterio-
sclerosis— a tendency which cannot l)e explaine*:! in
any other way than that in the make-uj) of the
machine bad material wa-s used for the tubing."*
Slrniii of the arterial wnils from exce.ssive int«rnal
blood pressure is the chief factor in the direct pro-
duction of these changes. One of the most common
causes is the pmctice of athletic exercises by persons
not well adapted by their original conformation to
such efforts. Severe athletic exercises, even in the
muscularly strong and robust, if pushed l>eyond a
certain degiee, tend to be followed by the morbid
resultj* of arterial strain ; how much more so must
this lie the case when such exercises are undertaken
hy persons of feeiile organisation, whose nervous
energy and emulation prompt them to these une<|ual
contests 1
These arterial changes are also induceil by consti-
tutional blood conditions, acting either as ilirecf irri-
tants to the ftrtcTial ti-ssues, or nulirectli/ by causing
heightened blotxl-pressure. jVlcohol, gout, rheumatism,
l(»il, syphilis (this last probably excites a spfrifir
arteritis), may any of them cause endarteritis. The
l»oison8 of certain fevers, especially malarial fevers,
have the same efTect on certain constitutions.
• Osier, " Pmctiec of M«<ti«iue " (fuortli edition), p. 770.
438
Mf.dical Treatmest.
1 1 -art Iir
OviT-tilliiig of the hloixl-vessfls froin exct>s.'« of
footl iiml drink, wlion coinliiiK'tl witli imlolcncc, may
also Iji'cutiii; a c-uusc of this i-uiulition.
iJirt'used nrlrrio-eclj'rcysiii (arlerui-cajnilary fibrosin)
is oftt'ii fuuMcl associatetl with mud changes, caiiliac
liypertrtipliy, and " fibrous niyocurditis." In some
casus tlie ruiiaf changes may Ik? primary and the
iirl^^rial SLfondai'y ; but in many otliers the urte-rial
sclfrosis appears to precink' the renal atfectiun.
In thn jmlmoiuirif arUrij and its branches
sclerosing changes ore found, as a con8e<|uence of
continued increased tension in the pulmonary ve.tsels,
caused by mitral disease and emphysema. Similar
changes have been found in the venous Hystcni
(pliUbo-srIcnisis) after exposure to lieightened bloo<l-
pressure.
Considering the serious nature of the many morbid
changes (apart from large aneurisms, which will be
considere<l separately) to whicli arterial degenenition
gives rise, the lr«»nlmenl of the earlier st-ages of this
affortion has scarcely received adccjuale attention.
When we encounter, on examining a patient who may
be thought t<j be sound in health (a candidate for life
assurance, for instance), or who may complain of isoiue
trilling derangement, a pulse of high tension, arteries
more or less palpably thickened, elongated, and tor-
tuous (we should examine the hracliiah for this
puipos(? as well £ui the raJialg), some evidence of
ventricular hypertrophy, and an accentuated iiortic
second sound, we should estimate ade<piatoiy the
danger to which such a jierson is exjMWed. Should
the coTonnry arteries become involved there is tlje
probability of attacks of atiginn jiectorin, and the
cerlJiinty of cardiac degeneration. Shoidd the cerebral
arteries be especially atlected, we may eucount«'r
symptoms of cerebral degeneration, or of cerebral
ha-morrhage from rupture of miliary aneurisms. De-
generative pulmonary t'in|)hysema and asthma aro not
uncommon accompaniments of this disea.He. Jifnat
degeneration and wasf«(l kidnejrs may be a conserjuence.
Chap. VI. 1
j4/t rSX/O-SCLSJiOS/S.
439
as well as a cuiise, of arterio-sclerosis. Are we help-
less to prevent tlic development of these serious
morl.iiil Ktiites? l>y no iiieaiia. If .such patieut.s will
be eoiiteiit to follow a rational and a Htriet ret/imr,
Lygienif, dieli-tie, and medicinal, not only may thew*
risks be kept in abeyance, but u distinct improvement
in the condition of the arterial sy.steni may lie brought
about. In the lirst place, it is necessary to seek out
evidences of any constitutional vice that may need
rectifying. Syphilis ought never to be overlooked ;
and even shoidd we be in error in susjiectiug its exist-
ence, a mild anti-syphilitic treatment cannot do harm ;
and it is a great advantage that Bn\all doses of potns-
itiiiiii or sutiiii III iutlidi' long continued are as useful
in the gouty and rheumatic !iH in the syphilitic forms,
and Mjany Continental |>hysicians maintain that this
drug is a true tonic to the luuirt. We do not share
this view, but we believe that the improved cardiac
action whiih is observed to follow its use depends
rather on its n'markabh; elimiiiative eflects and its
conseijuent iiilluence on the blood-vessels, removing
peripheral resistance, and so diminishing arterial ten-
sion. We should give it in 3- to 5-grain doses three
times a day, combined with 5 to 1 0 gruins of potassium
bicarbonate, 20 minims of aromatic spirits of ammonia,
and an ounce of a bitter infusion, such as calumba,
gentian, or wrpentary ; we !>iiould continue its \i&e
with occasional interruptions of ten or twelve days
for three or four months at a time ; the bowels
should Ije always kept freely relieved by some
suitable aperient ; and if dyspeptic symptoms and
constipation are prouiinenl conditions, occasioanl
courses of mineral waters will prove of much valui*.
Hut their use must Ix; wisely directed, as any over-
filling of the vessels nmst be guaitled against, and it
must be seen ibat the wat-er ingested passes freely
away by the kidneys or bowels, or by both.
In the corpulent the waters of Marienl>ad, Kis.s-
ingen, Tarasp, or Brides, or others of this class, arc
more suitable ; for the thin aii< 1 ill nourished dyspeptic,
440
Medical Treatment.
(Pan It.
Vifliy, Royat, Neuoiifilir, linden- Baden, Jiiul »l30
Kitisingen, may Ijc vocoiimit'iided. Tepid liatlis of
short duraticin, cninbiiu'd with frictioTi of the skin,
are of value for promoting ciitanpous excretion, hut
long-continued hot liaths must Ix- avoided. Rt'guliir
njodcrute exercise in good air, ahvHy.s stopping short
of fatigue, is to be encouraged, but all violent or
RtreiiuouB muscular exertion and all participation in
athletic conte-sts should l>e strictly prohibited.
In some cases with tbreatenings of cai-diac failure,
from post-hypertrophii; degeneration, as indicatiil by
iri-e^jular mid intermittent heart-ljeat, attacks of
ilyspniea on slight exertion, or from Hatulent disten-
sion of the Ktoniacli, and occii»ional attacks of giddi-
ness, a few small doses of nitroglycerine from time to
lime will generally give relief.
The food kIkiuIiI l>e limited to the actual wants of
tlio system. The meals shouJd be small, and taken at
.ide(|UHte intervals ; they should be eaten slowly, luid
tio llnid slumld be taken with the meal, but afterwards.
Fresh vegetables may be eaten fn-ely, but animal food
and eggs only spaiingly. Alcohol and tol^acco sliould
lie absUiined from. A milk diet proves very useful in
some cases, especially when it promotes free diuresis.
■Se.xual excitement in advanced ca.ses is certainly
undesirable ; and emotional disturljance* should, as
far as possilile, be guarded against. The body should
be warndy clad, and exposure to extivmos of heat and
cold avoided ; a bright, genial, sunny climate in
wint<?r is a gi^eat advantage.
Wo now pass on to the consideration of the most
serious manifestation of arterial disease, namely,
Ankubism,
The medical aspects of aneurism are confined
almost exclusively to those aff»*cting the aorta and
the laige arterial branches that spring from it within
the thorax and abdomen, «.«. to " iulermil aneurisms."
Aneurisms of the arteries of the h'nibs, often truiiniatic
iti their origin, fall under the care of the surgeon,
Anevkism.
441
and ai-e ospooiully amenable to mryicat treatnieut —
eoiiipressiun, ligaturc^ctc.
Ant'iiriKnis usually oris^ from n weakening of
Bome piirt of the wall of an artery, sucli us tlie aurta,
Ijy chronic inflummution and degenerative changes
such as we have already df!scril)cd ; the wall of the
artery is predisposed to yield in consequence of
these changes, but some sudden strain, accidentad or
otherwise, is often the immediate cause of an aneuris-
mal dilatation. Mechanical violence, or any stniin put
upon the arteries, suddenly or repeatedly, may lead
to the production of an aneurism of the aorta when
its walls are weakened by chronic disease. Syphilis,
as the cause of a upecific form of arteritis, is frequently
concerned in the etiology of aneurism.
The »jiii|»loiii«i of aortic aneurism are chiefly
those de])eiiilcnt on pressure of the tumour on
adjacent parts or oi-gans, antl they vary, therefore,
according to its situation and mode of growth in
relation to surrounding structures. The dangers
attending it are partly dependent on those pressure
symptoms and partly on its tendency to rupture.
An aneurism, for instance, affecting the arch of the
aorta, situated as it is in the vicinity of most
important structures, may, it is clear, in its develop-
ment and growth give rise to the most serious and
distressing symptoms from compressing adjacent
structures, and these have to be consideretl in the
treatment of the ca.se, as they fre<|Uently lead to a
fatal issue indejiendently of any rupture i)f the sac.
The/orin of the nneurisinnl dilatalifin will greatly
influence the probability of cure by .suitable tn>at-
meut. A cylirulrieu} oyj'iini/hnn aneurism, afl'ecting,
that is, the whole circumference of the aorta, is not
amenable to curative measures, and a gacculoti-d
aneurism will be more or le.ss so according as its
communication with the artery is by a nniall or largo
o|M<ning.
Internal aneurisms are cured by the deposition
of layers of congulat«-d filniu within the sac, their
442
Medic A l Tk ea TMHfrr.
[Vml ti
orgaiiisiition and the suW«)Uf?nt obliteriitiori nf the
sac liy foulriiftioii or intianiiniitiriii. Tlic- iiltlicai-
liou!» lor Irvntnifiil, thorcfoiv, uie to losseii ll»e
force and fie(|U(iicy of tlie heart-l)eat, and so slow tlio
current of blood in the aneurisniiil siic ; to lessen
arterial tension ; to increase the coagulability of the
bloixl in the sac. By these menus we may hope to
prfiii!ot»^ ohlitci-ition and contraction of the sac, when
the antitoniical conditions are favourable.
Various methods have, from time to time, Ix-en
suggested and pnictised for the purpose of giving
effect to these indications ; many of them have coui-
plet«ly failed, uiul are no longer employed.
The repeated abstraction of blond with the view of
reducing bhjDd-[iiOH«ur<', .slowing the current of blood
in the sac and so favouring coiigdhition, was iidvocat«<l
by Valsiilva nnd ]>racti.seil by I'r. Hope* to the extent
of withdrawing 12 ounces of blood daily for sixteen
consecutive days. This niethtKl was comliincd witli a
strictly litiiited diet and prolonged and absolute repose.
But this method, insl-eud of quieting the heart-beat,
often caused cardiac excitement and irritability, and
too great i-estriclion in diet lessens and does not
inci^Ase the coagulability of the blot>d.
Another method, somewhat analogous to tlie jire-
ceding, without the blee.diiig.'<, has had many advocates.
It consists in a sc^vere restriction of tiie diet, Iwth in
solids mid liijuids, together with absohrte rest in the
recumbent position for a. profntcted period. It has
lieen termed the "r«»»t and "ilnrvsiliou " metho<l.
Its objects are to reduce the i(uanlity anil tluidity of
the blood and so increft.se its coaguliibility, to lessen
intra-arterial tension, and to reduce greatly the
frequency of the heart-beat.
Tufnell, who adopted this method with some
success, pointed out. that for this treatment to be
successful three conditions were essential : first, the
aneurism must spring from the front of the vessel;
* Utijardiii-BeaumctjE, " Cliuiquti Thrrapeutiquc " (fifth
editum), ToL i, p. 196.
Chap. VM
Ankukish.
443
sci'Diid, the sac luiiBt Ix; perfect ; anJ (.hird, tlu-re
iiiu.sl lif a. Kbrinatiii^ jiower in tin; blood. He litnite«l
tlie <|Uun(ity of lliiid tnken to 8 ounces in tlie iliiy — 2
ounces of milk or cocoa nt breakfiwt, 4 ounces of
wat<jr or light claret nt dinner, and 2 ounces of milk
or cocoa at i-eu or siijiper. There is, however, in
jiractice, K'*«t diliiculty in keeping the fluids down to
thiis limit, and some patients tind the thirst attendinjt;
the attempt iiit*>lerable. The solids were limited
likewise to 10 ounces daily- -2 ounces of breail tiud
butter nt breakfast, 3 ounces of cooked meat and
3 ounces of bread or potatoes at dinner, and 2 ouncea
of bread and butter at tea or 8U[iper.
Tliia treatment by enforced rest in the recumbent
position and the above diet was to be maintained
for tlirt* months or longer. Great difticidties occur
in carrying out this method. Certain tempera-
ments bear the enforced rest badly : they become
introspective and fretful, and tlie heart's action
becomes hurried and irritable instoatl of being quieted.
Others become weak and ana-mic, and the injury
to till' general nutrition they sutler seems to aggravate
their c<niditioti and to ]iroinote the further advance
of (iegeiieiiif.ive changes. In such in.stauce.s this
method should be almndoned or greatly modilie*!.
In fairly strong and vigoi-ous patients of calm and
placid temperament, successful results may, no doubt,
occjisionally be obtained from this treatment. In
applying this .system it is important to see that the
patient's bed is comfortable, that the surroundings are
cheerful, and tfiat he is spared all worry and excite-
ment. The tendency to constipation which necessarily
attends tliis method must l>o overcome by suitable
a|KTients or enematn, as straining at stool must not
Ije permitted, and .sexual intercourae must, in idl
coses, be strictly forbidden,
A moditication of this method, in which the
patient is kept fix much at rest as b consistent with
his comfort and general health, the consumption
of liquids is restricted to the quantity absolutely
Mr Die A L Tkea tment.
ii>.»t n.
lieccKsary, and a soinrwlint greater qiiniitity and
vai'ioty of foml aw jxriiiilU'd, will lie found to
afteiult'd with us much or even greater benefit in
the iimjoi ity of cfiscs.
One rif tlie most generally iiccepteil nietlioil.s of
treatment of aortie aneurism, and that from whicli we
liave ourselves oMain**! the best results, is the
administration of full doses of polnnsiuin iodide,
t«igether with a careful mode of living, especially as
to diet and exercise. The dose should Vie from 10 to
20 or 2"! grains three times a day. Some ditference
of o])inion exists as to the dose that should Ije giveiu
Some consider 15 grains three times a day the limit,
others think better result.s are obtained from largiT
doses; 15 grains three times u day we have found
sutlicient in many cases, but in others we have not
obtaine<l the best results until we have iucrea.sed the
dose to 30 and even 4(1 j^niins tliriee daily.
Amendment is often obseived to speedily follow
the institution of this treatment; pain is relieved,
the force of the puLsation in the aneurism is distinctly
lessened, and the area of dulness diminished, aiiil in
some crises complete consolidation of the sac seems to
be induced. It is somewhat difficult to explain the
moile of action uf this remedy. Balfour thought it
exerted a speciid intluence on the wall of the sue,
causing thickening and contraction. It certainly
lowers blood-pre.ssiire iind so favours contraction of
the sac by relieving tension within it. It lias been
suggested that it may thicken the lilood by incix'Hsing
the secretions, especially that of the kidneys.
One great advantage of this treatment is that
it does not necesstirily demand a ce.ssation uf all
occupation, and one of our own |uitient.s, an en-
thusiastic and n>stle.<is musician, conducted a large
oix-hcstra for many years with n large aortic aneurism,
while takuig 40 grains of potassium iodido thrice
daily.
In determining the dose most suitable to each
case, one should be guided by the pulse-rate; if
Ch»p. VI.)
AlfEUKtSM.
445
lai'ger doses increase the pulse-rate, we slioiikl return
to the smaller ones.
The giniium iudid" hus been ri'ooniniendetl by
I/uc/iurd as less depressing imii better tolerated than
the poUissiiiin iodide, and it nmy Ite employed when
any diHieulty is cxiierienced in tiiking tlie latter.
Cnlcmiii chUin'de, whicli has the property of
increasing the coagulability of the blood, has also
been given for the cui-e of aneurism, and good results
have been reporUnl, but we doubt if any reliance can
1k" placed on it as n remedy.
The known eoajiiilaling pjwer of the elertric
riirrcnl nn nllmmen has led to its ap]>lication in tlie
tieatnienl of aiienrismal tumours, with the object of
producing ciMitrnlatiun within the sac. The elecfnjlytic
treatment of Miicurisni has been extensively applied,
and mucli was hojied fronj it, but it has lost some uf
its repute since the potassium iodide treatment has
iHMjn founri to be attended by such gofMl results.
This method is, however, still ooc4isionally applii-d,
especially t<) aortic aneurisms in which the sac pmjectn
considerably on the surface. Two, three, or more
needles, according to the extent of the sac, shoidd be
intnvJuced, and they should be directed rather towards
the peripliery of the wu- than towanls the aorta, as it
is of fjreat im|>ort4ince to avoid the formation of a
cfwifridiun near the genend l)loo<l current. The needles
mii.st be covered at their upper part with a protective
noa-conihicting coating, to avoid the corrosive action
of the electric cniTent on the tissue pierced by them.
Tlur needles may, in the ciise of a largo sac, be intro-
duce<l into <]ifferent parts of the sac at diBerent
sittings. It seeniK Ijest to connect the noodles with
the ponitiiv pole oidy, us the clot formcil is firmer
than with the negative [wle, and to apply the latter
connected with a larger copjier el«!ctr«io to the
adjacent surface.
The sittings kIioiiUI last for U:n t<i fifteen minutes,
and the strength of the current nIiouIiI not exceed 10
to 'JO milliampcres. In some succeusful casco tliero
446
Medical Tkeatmext.
lP«t1
have l>eeii as iniiny as thirte«a sittings At intervals of
tlireo Km six days.
In tliis, as in all other methods of treatuient, the
more completely BiicculKte<i the aneurism is, and the
narrower is ita orifice of coiumunication with the
aorta, the better are the results likely to be.
The intnjiluction of foreign h(.»Ur» into the sjk' of
the aneurism, with the view of promoting coagulation
in it, such as considei-ahle hmgths of watch-spring,
of iron or silver wire (with or without electricity), of
horsehair, etc., need not detain us, as the eflect of
these methods of trentineut lias been, in most cases
of aortic aneurism, dinastrous.
A case lia-s, however, been reported by itr.
Langton* of uneurtsni of the abdominal aorta which
was successfully treiitt^d by the introduction of silver
wire into the sac. Ijaparotnmy was first perfornietl,
and the aneurism was found to be a saccular one pro-
jectitij: from the anterior part of the aorta, an
anatomical condition altogether favourable for the
0|>eration. Even in this case alarming sympt-oms
occurred about three weeks after the operation, ajul
Mr. Ijxngton remarked that " it was only bj' prompt
and active ti-eatment that the case Wiis not relegated
to the long list of failures."
The method of illslnl ligiiliirc, that is, the
aj>plication of a li^^'ature to the vessel (or its branches)
lx\V"nd the aneurism, and not lietween it and the
heart, has lieen suggesteil and apjilied in cases of
aneurism of the aorta and the intiominate. Ligature
of the left carotid has been undertaken for aneurism
of the aortic arch, and ligature of both the right sub-
clavian and carotid for aneurism of the innominate or
of the first part of the aorta. When cure of the
aneurism folhiws this ofwration, it has been suggestetl
that it is thmugh the formation of a clot on tho
proximal side of the li;{atuiT, and the extension of this
down the artery int<i (he sac. It is otdy applicable to
a very limited number of ca.seN, anil shoulil not be
* T^wtiMcfiom of ClitiiiAl Sociuty, vul, xxxiii., ]>. llUi,
I
Chip. VI-l
AKEURtSM,
4-47
resorted to in iiny case until other less serious njethmls
have been tried iiud have fail(!<l to arrest the progreKs
of the amnmsniid tumour ; twenty-three out of
thirty-five oisos iti whiuh this operation was perfoimeil
"dii'd (lulrifjlu, or were hastened to a fatal termina-
tion by the oiieration.''* A cure is said to have
resulted in six of these caaes, hut Itrnporaiy arrr^nl
would seem to be the titter term to apply, as a survival
of 4i and 3.\ years is scarcely the same thing as a
cure.
It is unsuitable in ease^ in which there is evidence
of general atheroma or of valvular <;ardiae disease, or
of any visceral complication. It is most promising in
distinctly sacculated cases arising suddenly from over-
exertion or injury.
The methiid uf proximal pressure. I.e. pressure
ajiplied to the aortji lictwoen the heart and the
aneurism, has l>een applied successfully in a certain
nuuilicr of cases of aneurism of the alidominal aorta ;
the oliject of the operation being to slow or obstruct
the blood current sufficiently to allow of coagulation
within the sac, and so cause it^s obliteration.
The cases in which this method lias l)een successfid
have been healthy young men in whom, it may lie
assumed, the rest of the vascular system was free
from disease, and in whom the local ilLsease probably
originated in injury or over-exertion. The methiKl of
oporat ing is as follows : the patient being ansesthotisetl,
a Lister's tciuriiif|uet is caii'fully adjusted in [H>sition
over the abdominal aorta and above the tumour, antl
slowly screwed down, care being t.akcn to avoid, as
much as pos.silile, injury to the intestines. The aorta
is oompre-ssed until all pulsation in the aneurism
and in botli femorals is arrested. The lower limbs
are at the same time envelope*! in cottonwool and
flannel, and kept warm by hut-water Iwttles. In Mr.
Durham's successful case the compression was main-
tnined for 10', Imurs. (IrenTdiow had a successful
ca.se it) which tin- aVHlooiiiial aorta w;is compressed
* Pepper'* "Sy»t«in iif Practic«I Mwliciue," vol. iti., p. 819,
Medical Treatment.
(Part II.
first for t hire-quarters of an hour, again for 4 hoiinf,
and again, after some days' interval, for 8 hours.
This method is quite unsuited to coses associated
with general arterial degeneration, for by shutting
oil* the blood from the lower half of the body tho
tension in the arteries of tlie upper half becomes
extreme ; it is a method ob^^ously attended with
grave risks, and in a considerable proportion of tho
cases in which it has been applied divath has resulted
directly from the effect of the opcnition ; it would
seem to lie suitable only to tho-se cases in which, the
rest of the arterial system being healthy, the tumour
is rapidly enlarging, and when milder means have
failed to arrest its growth.
l>r. MiicEwcn has de-scribed a method of pro<luc-
ing what he terms "^\^lite Tlirombi " within the
ancurisinal site by the process of inflammation excited
in the wall of the sac by irritation with the point of
a pin passed into the sac with strict antiseptic pre-
cautions, and carried across it until it reaches tlie
opposite wall, where it is left for .sonic hours, so that
the movement iini>arte<l to it l)y the blood current
may cause it to scratch tlie surface of the sac and
excite the necessary ajriount of irritation, Ditlerent
parts of the sac may be noted upon liy the same
needle without its withdrawal. He believes that
this illustrates an important principle in attempts
to procure consolidation of an tineurisuial sac ; the
eases he cites in support of his views, although hut
few in nundwr, appear to merit further consideration,
and tho method he describes has this to recommend it
— that it is eas\' to carry out, and involves none of
the serious risk which attends most other surgical
modes of treatment.*
The administration of erijol in large doses, and
the hy]>odermic injection of nyoliii, have been
advocated in the treatment of aneurism, the former
* For full details of thi* mcthoil wo must refer to Dr.
Mm'Ewm's puiicr, which will be foiiml iu the British MnlietU
.rmirtial for Sov. 15lh anil 'J'Jiid, ISIK*, "
Clmp. VI 1
AXBUKlSAf.
449
hy Sibson iind tlio latter by Lniigenl)eck ; Itotli these
authorities appear to have thought that thtst drug
could cause contraction of the sac by its action on
the niiiscultir tihre in its walls, but repeated examina-
tion liftK flenioiistrated the absence of muscular fibre
iu the ooiiU of the aneurism. It has, however, l>een
maintained that ergot, when given in large doses,
dues diminish the volume of the aneurism and
greatly lessens its pulsation.,* and that it acts by
diminishing the ventricular diastole, and limiting the
output of blood. On the other hand, the rise of
bliiod-jiressure which attends the use of ergot would
seem to counter-indicate its admiuistration in internal
aneurism. It is oertjiin that this method of treat-
ment has gained few supporters.
llecently Laucei-eaux lias advocated the sub-
cutaneous injection of (/datimmd serwii in the
treatment of aneurism, in t)ic belief that the gelatin
is absorl)e<l and increases the coagulul>ility of the
blood. This method may be carried out by the
subcutaneous injection (the best situation is in the
intermuscular tissue in the buttock) of 3 ounces of
a 2 jHn- cent, solution i.(f gelatin in normal salt
solution warmed and sterilised. These injections
may be given every other day ; some give a series
of 12, niid tlien wait for a tiine and give another
series. As many as 60 injections liave been given
in the same case.
The value of this method has lieen very variously
estimated. Oood result* have been published in
France, Italy, and Germany, and failures have also
l>een numerous. In this country very few successful
results have been obtaitiefl. There seems to be little
doubt that its application has, in certain instances,
been follouwl by some relief of the subjective
symptiiiiis, together with a diminution in size and
puluition of the sac. Kut vi^ry serious ami even
fat^il symptoms have followed its employment iu n
* Sir Win. Bmiiilbcut, Trimnaetiaiu of tbo Meiliiiil Houioty of
London, vol. xiii., p. 133.
D D
Medical Treatment.
(PlMlt.
number of instances, and much \mC\n is caused locally
br the injections. Kniboli seem to bo cnusi"! atxl
carried into the circulation in some chsob. Clotting
of the bltHxl may occur in other parts of the vascular
circuit than the aneurismal sac, especially in some
of the veins where the circulntoi-y flow is lanj^ui'J.
Altogether the method appeal's to be attended with
Buch serious risks that we cannot recommend ita
adoption.
Huchnrd's experience of this method ia that it
is in!>ujjici''nt, and he prefers to j)ut his tnist in
remetiiea which diminish arterial tension, such b.s
jKitiissium iodide associated with trythrol letrn-nitrnte.
He also objects to a meat diet on account of the
toxins in animal food, Which lie mainttiins have a
powerful vasoconstrictor action, and he strongly
commend.s an ab.solute milk diet.
Fraenkel has called attention to the great value
in syphilitic cases of mercurial inunctions, with a
milk diet, rest in bed, and the local application of
the ice-bag.
Tlie application of Ice or of refrigerating mixtures
to the aneurismal tumour, when it ]>rojects on the
surface, has been advocated not only for the purpose
of allaying pain, but with the idea that it may
possibly promote cuagulntiou ; and, no doubt, if
applied over the region of the heart, it tends to
moderate its action. But, as has been {)ointwl out
by Dujardin-Beaumetz, cold retards and does not
piomote coagtilnlion, and he is disposed to refer
whatever beneficial results have l)een found to follow
these applications either to a contraction of the sac,
or rather to inflammation in it caused liy the pro-
longed application of cold. He also calls attention
to certain dangei-s attending these applicjitions, snch
as diminished vitality of the -skin, when external
rupture is imminent, and p>ulmonar>' congestion uttd
bronchitis from chill. Wi' have ourselves very
thoroughly tried the pi-otmctod looil application of
ice to thoracic aneurisms j>r<.>jecting from the cheat
J
Chip. VI.I
ANEURiSM.
4S«
wall, but, Ixiyond a t<'niiKir«ry reductifin of the fre-
(jiiency of tbe liOMi-t-ljcat, we have not been able to
observe any curative effect.
In the course of aortic nneurieiin many very
painful si/in/itoDia arise, calling urgently for relief
atitl [lallialion. The re/ie/ of fxiin may require the
hypoih«rniio use of morphine and atropine, and the
hxvil application of opium or belladonwi liniments or
|jliiRt«r8. Phenacotin and aiitipyrin have both l»een
found very useful as Hnalgesics in thes<< cases. In-
halations of chloroform may be neede<l when jircssure
on the air-poHsages causes distressing dyspnieiv. We
have found small bleedings of value in relieving
venous distension and some forms of |>ainful dyspnci-a.
Tracheotomy or intubjition may occasionally be
needed, but ihis operation is only calculated to lie
of use wlien the urgent dyspmca is laryngeal and
due to bilat<»ral ahfluet-or paralysis ; most commoidy
tlie dyspniFA is due to pressure im the trachea near
its liifurcation, and can only l>e relieved by antcs-
thetics. Anginal attacks may he relieve<l by nitro-
glycerine, and biirium chloriile has also been found
useful for the same purjioHC in doses of I'^th of n
grain thrice daily. Great comfort has been derived,
in certain situations of tho external tumour, from
a well-applied elastic support.
ADDITIONAL FORMULiE.
PiUi for arterlo-scUroila
with feeble beart,
R Solii itNlitii, sj.
•'^pnrtciuiu miljihntiii, gr. xv.
I'ulvcria (flyt-yrrliizii', q.».
Vl f. |>il. xl. Four t<i six
daily. (To he kept in a dry
plMe.) {Jfite/iHrd.)
Hjrpodenntc tnjection of
ergotln In aneurlam.
R Erpotin (Bonjean), fpr. xl.
iSpiritiis riiii rcctifirati,
mlxxx.
Qlyrerinj, nilxxx.
M. f. Kilut. Injwt llirfu
c<>iiti);n>raiiio!i under the nkiu
«vt<r tlio tumour.
{iottftnlicck.)
45 «
Meoica l Tk ea tment.
(PajI II.
Combinatioa of iodide and
bromide In aneurism.
H PotHuii ioilidi. .^tj.
Soilii broriiiili, >ij.
.Syriipi lloria iiuruutii, Aiv.
X*lllrt' »<i svj.
M. f. luisU A tubloapoonful
throe times u day, {Jateoiut.)
For aneurlam.
It r«tii«gii i(Kliili, .iiij.
Iiifusi ohinitif, i(vj.
M. f. mint. A tHblesiHKiufuI
three times n liny. (Ilal/oui:)
For the cougb of aneorlBm.
Morphiutt' hydrochloridi,
Acidi lirilrochlorici diluti,
iriv. ■
Addi hydrocj'Miioi diluti,
Ml.
Synijn scjllip, 3j.
Aquir, sj.
M. f. mist. A tcit»poonfiil
oci^on iiUy. {Hnl/oHr.)
Or
R Syrupi aciUit% 5ii.
Kliiritus lavanauln.' com-
positi, Siv.
Tinctunv opii ammoiiint.i',
3iv.
Rynipi ■■iinplicis, 5j.
Aquif moiithn' pi|>oritn', Jij.
M. f. mist, A bibletiK-Kinliil
cTory tlirt'e lioiira, uml l.i mio-
ims of I'lilnrnilyne iii ivlditiou
whoD retniired, {JhttJ'our.)
To relieve tbe pain and
restlessneM of aneorlamal
pressure,
& Miiriibiiiii' liydrocbloridi,
§f- i ad (,.
Spintiis A'tliPnn sulpbunci
coni|xniti, Sm,
Aipi»' mi'Utb»> piiH!ritn' lul jj.
M. f. hniut. To bo Uken
ociaisioimUy,
To relieve aneurlsmal
neuralgia.
(i Exfnuti iK'UiiiloiiuiL', .>ij.
Kxtnicti opii, 5j,
.Spiritiis villi rectificuti, 3a!>,
(Ayceriui, js»,
M, f. liii. To be applied ex-
tcrnnlly to the ])aiuful purt.
453
CHAFIER VIL
*
THE TREATMENT OF ANAEMIAS.
A:(.I!XIA : Definition— Stiine physicnl CharactftrB of Healtliy Blood
null of Hcd Bloo<l (>)rpuiicle«,
Aiiirmin, Scromlorj- or SjniiitomBtic. r'A/((iu*i»— Cttusution —
Sviiiptomn - TyraUiitiil — (\) Dietetic, (2> Hygienic, {'X)
Slodiciuiil. AjK-rienls. Irun, \t» various Propiirationg anil
Modes of Administration— Naturiil ChalyU'iitc Waters and
Baths — Affinifantsr — Arst-tiic — i}sytj*n InhiittttumK.
JVrninotf* Anirmia. — Cbamctera — Blood Chiinyw. Ti'riitmntt —
Arsenic in large Doses— Uamige — Diet — Bone-Mnmiw —
Transfusion — AnfiseirtieB — Scnim Treatment. Additional
Fomudii'.
Bv nuirmin is incaMt either a reducliuu ia the
wliole volume of hlooU or a reduction in the nuinbei
of red cor[)uso!es, or a reduetiou in its most important
con!<titUfUt, the ha moijlobiii or colouring matter of
tlie foipnsflf.s. It is chiefly a " poverty of the blood
in normal fuiietiomil red corpuscles."
A few facts with legHitl to the physical characters
of the 1j1oo<1, and the life-history of the red cor-
puscles, had bett-<^r be stittcd before we approach
the subject of the treatment of the se\enil forms of
ansemia.
The specitic gravity of healthy blood varies
l>etween alKuit 10-tO and 1070, that of the plasma
ulone, without tiie corpuscles, between 1026 and
1U2'.I. It liiLS a distinctly alkaline reaction. The
average si/.e of the red corpuscle is 7'5 /i (niicro-
millimetres) in diameter, and the range in he»Uth
varies between 6'r> and 9 /i. In embryonic and
infantile life the itingc is jgreater, viz. from 25 to
11 /i. The smaller have beun termed micrucynU, the
larger iiifi/aloci/gtu.
The red corpuscles have no di.stinct inemljnme,
but consist of a stroma, coui|ioKed of globulin, cotuuri'd
with a red [ligiiient, the biruiOKlohiii. This is only
loosely combined with the stroma, and can be split up
into anulbununate and a red pigment which is termed
454
Medical Treatment.
(Put II.
/ttmnathu TIio depth of colour of the re<l corpusol»>s,
and their fiinctioiial activity, depend on the aniimnt
of liii'iiiogliiljin they conUiin.
The .iverage nuniher of red corpiLsolftH in heiilthy
blood is 5,000,000 per culiio luillimctre, Imt tlie number
may lunge l.etwpon 5,500,000 and 4,000,000.
Niirhdtril rt'd c(ii'p«Roli'.s are found, normally, only
in llie emliryo, and it is generally a<lmitted that a
nuc'leatfld red blood eorpuHcle is the immediate ante-
cedent of the fully-develojjed non-nucleated one. The
red cor]>useles are now lielieved to oripnate mainly in
the bone-marrow, and only to a slight extent in the
spleen and lymphatic glands. Observers are nut
agreed as to the pi-eci.se manner in which they
originate in the marrow, nor as to the part, if any,
taken in their formation by the white bliKxl cells.
It is thought that only in the case of exceptional
demands en the blood-forming functions is there any
formation of n-il e<jrp\i8cle8 in the spleen or lymphatic
glands.
The avei-age life of a red blood corjiuscJe has lieen
estimated at fourteen days. The precise manner in
which it imdergoes disintegration is not known. Its
destruction would, however, appear to take place
chiefly in the portiil vessels, and the spleen and gastro-
intestinal mucous menibrane seem to be the most
active seats of bhxxl destruction. The lilieiiited
hirnioglohin is cjirried to the liver, and there con-
verted into pigment. The only other seat of hlood
destruction, so far as is at present known, is the
bone-marrow.
In an!i.'niia the number of red blood corpuscles, and
the amount of hiemoglobin contained in them, may
vary very greatly : the red corj>usclea may be reduced
to Ijctween f-O and 20 percent., and the gravity of the
cose will depend on the amount of the loss. Hayeni
has reported a casei following puerperal hiemorrJiftge,
in which the number of red blood corpuscles fell as low
as 830,(100, or only 17 per cent., and in which th«
patient recoveretl.
Chap. VII.]
AtrjsM/A,
4SS
It has )>e('n ciiHtomary to clivtsify ana'uti.is iiilo (>i)
si/inploviatie or »i'eotuiary, i.e. tliuise c«ses in whicli
the anieinia is rather n Kymptoin (liaii a cliscnsp,
owing its I'xiHtimce to the presence of other inorbiil
states, nnd (6) primari/ or " iiliojxttJtic" aiiR^iiiiHH,
iuclu<1in<; eVoroHin in the latter. But tFiin classifi-
cation in, iu the pivijoiit state of our knowled^'c, of
doubtful accuriwy, and for therapeutic piirpoies we
niaj- consider the tresitment of the ordinary forms of
8ymj>tomatic .<iti:emia togetlier with liiat of cidorosis.
Any disea-se or injury wliicli leads to hiKitiorrlfuje
niu.st reduce the r|Uantity of the blootl ami so cause
anteniia; so idso any disease which interferes directly
or indirectly with the process of hlootl formation, or
is att<?ndetl with abnormally active blood destruction,
must also l>e attended or followed by aniemia. In
hiemorrhayic cases the lo.ss may be rapi<i «nd sudden,
or gradual and continuous. Succeasive hiemorrhages,
at intervals, are found to be more tlangerous than
a single h;eniorrliage exceeding them in amount, as
they interfere more with the regenerating proces-ses.
In some cases of large hfpinorrhage the i-egeneration
of the blood is very rapid — ii week or ten days being
adequate to reprotluce the normal amount. The
corpuscular elements are, however, restored much
more slowly than the watery, saline and albuminous
constituents, as these are rt'adily absorlied from the
gastro-inteslinal tract. The hannoglobin also is
restoi-ed more slowly than the corpuscles. Uesides
the direct 1o.hs of blootl fwm haMnorrhage, other
morbid statej< may cause aniemia, such as chronic
suppuration, aUniminuria, hy(ierIactation, rapiilly-
growing neophisiiis, cancer, etc.
Or the defect may lie in the direct or uidirect
supply of blood-making material to the organism —
as inanition from insutlictont or unsuitable food
supply ; or from assimilative ditHcultics, as imperfect
mastication, ossophageal obstruction, gastric cancer, or
chronic dyspeptic states.
Or the functions of the assimilative and blood-
4S<5
Medical Treatment.
rPvi II.
making orgnns may lie disturbeil by ncute febrilo or
chronic wustiiig (lisetises, und aiift-niic stat€S follow
tlie former and accoiiiintny the latter; but in such
instances the treatment of the nniemin is but a part
of the general inaiiagenient of these iliscn.ses.
The K>'iiii»l«»iii« thiit may be olj8er\Pcl in cases
of severe sympJoinattc aniemia iin? pallor of the
eoiintenance, mid esjieeially of the visible mucous
membranes; loss of pink colour of the nails ; digestive
disturbances, siich as loss of njnietite, vomiting, gas-
tralgia, coii^tiputUm ; j)alpitation and breath lessness
on exertion, oft<»n with increase of caidiac dulness,
owing to dilatation ; tho presence of murmurs over
the heart and large veKstds. The dysjuia'a is due in
part to cardiac feebleness and in part to the deficiency
of oxygen-carriers in the blood ; some oetlema of the
feet and ankles oft«!n occurs at night and disappears
after rest in IxhJ ; the nervous system generally
presents some signs of irritability, and hysterical
manifestations are not uncommon, together with a
tendency to neuralgic alt^icks ; in acute aniemia from
large hiemorrhages delirium and convulsions may
precede fatal coma. Slight pyrexial states may occa-
sionally occur, but they are far more common in
the other forms.
Anwmic states, however caused, are attended with
a tendency to hiemorrhage, particularly to retinal
httimorrhage, dependent on the extent of tho corpus-
cular loss, especially when this exceeds 50 per cent.
ChloroHifi is the t^rni applied toaclinioHl form of
ana/niia \isually regarded as less directly traceable to
any antecedent disease than the secondary fomi, and
although it has many featui-es in common with the
cases we have juat been describing, it lias other well-
marked characters which we will briefly describe.
Chlorosis is almost always a disen.se of young
girls, especially l>etween 14 and 17 years of age. Ita
caustUion is doubtful, but it seems often to be asso-
ciate<l with sexual disturbances, such as ameiiorrhcKa,
dy8nienon'lia>a, leucorrhcea, and with hysterical states,
Oup. Vll.l
AyjBiriA.
457
I
I
but tlicw may be sequences and not ontecedenta
of this ilisPAse. Lick of exercise and fretih air,
eiuotioniil disturlwnoes, the absorption of leuco
mainen and ptomaines from the hirge intestine as a
oonseqnenco of habitual coimti[>ation, have all been
saggested as posMible causes.
Stockman* maintains that it " does not arise from
excessive destriietion of red corpuscles, but is due to
deficient formation or to actual loss of blood," and
tliat " exact ivsearohc* have demonstrated the
absence of any special sepsis in the alimentary canal."
HIm co)iclusion is " that the direrl causes of chlorosis
may l)e reduce<l to tiro, viz. insuHicient supply of iron
in tlie food and loss of iron frmn the Itody by
menstrual or other bleedinfj." The onset of i)uberty
and the conseipient strain of rapid growth and
development are important determining intluenccs.
Hereditary inlluence has also l>een invoked.
Virchow has gone so far !%s to attribute it to a
developnientnl clefect in the circulatory system, but
that is inconsistent with the transitory and curablo
nature of the niala<iy.
The genenil symptoms resemble those we have
de8cribe<l as common to moderately Ht-vere forms of
secondary antcmia ; the complexion is, how^ever, of a.
yilotnji/i grei'n colour, and not merely pale, as ia
anieniia ; the skin occasionally shows areas of pig-
mentation, especially abijut tlie joints ; the eyes are
jieculiiirly brilliant, and the sclerotics sky-blue. We
have already spoken of the breathlessncss, palpitations,
faintings, cardiac and vascular murmurs, neuralgias,
digestive feebleness, constipation, (wlema of the feet,
which are common to this nnd symptjimatic anwmia.
In chlorosif, especially, the subcutaneous fat ia well
maint«in«l, and the patients have an aspect of
plumpness.
Hut it is in the chanicters of the blood that tho
chief (litrei-cnces are found between this and the other
form of aniemia. In chlorosis the re<i corpuscles may
* Hare'i " System of Practical Tbenpentici," vol. I., p. 677.
4S8
Medical Treatment.
(Part II.
lie scarcely at all rcduoerl iti iiiimWr, but t.licy ftro
very poor in lnt'iiioy;lol)iii. It ix llio hn'iiioglobin
wliicli JK ili'lick-ut in iIuk (lisiMisc, atul it may be
rcflucud to fi-om GU to 30 per cent, of tlie normal.
Ill the morn severe cases the red corpuscles are
also (Jiniinished, but the ha-nioglobin ia always dis-
proportionately reduced. Cases have been observed
in which tin' gluliular ridiness wiw over S.i per cent.,
sind the lui'tiioghiljin nidy iio per cent.
Another cliiirucfer of the blood in chlorosis is the
frequent great inequaiity in the size of the corpuscles ;
manj' a.w much snialler than nornml, 3 to G /i, and a
few are larger. There may be a slight increase of
leucocytes. Uiilikc other forms of ameniia there is
little liability to lueniurrhage ; optic neuritis is, how-
ever, often pi-e,sent.
The Ircalinenl of cfdoronU and the aniemic state
will l>e be.st considered from three points of view : (1)
dietetic, (2) hygienic, and (3) tn<'<licinal.
1. A defective or iinsuit-able food supply is one
of the most frequent causes of ameniia. With a diet
comjioswl exclusively of non-nitrogenous food it has
Ijcen proved that the percentage of hicmogloViin in
the blfK)d undergoes a notable diminution, while
it is augmented by a diet rich in nlbuiiiinates.
Defects in this respect will often be found in the
dietaries of girls' schools, where anaemic conditions
frequently become develo})ed. Growth and develop-
ment, 80 exceeilingly rapid in girls us the period of
jmlierty approache.s, can only take place by the
agency and at the expense of the nutrient fluids and
their active elements, especially the i-ed corpuscles,
and these require a frequent and abundant .supply of
nutritious food for their constant regeneration. In
LuMiiorrhagic cases i-ecovcry is often very rapid with
suitable food, and the loss of liloixl, especially its
fluid part, is soon repaired. But not only must we
see that there is an adequate and suitable supfily of
food, we must also look to its digestion and assimila-
tion The digestive secretions in these cases are apt
Chap, VIM
Aif/BurA,
459
I am
K
to l)e ilefectivt", Iwlli in quantity and quality. It lins
also iK-en iioticwi tliat in iiiuvniic persons the con-
ditions of normal nieta)iolisiii are sonicwliat tiaKlilit'd,
and especially that thtre is incrwiscd uietalioliKni of
tlio alhnminat^'S with an increased .secretion of nrca ;
ut the nietahx^liain of fat appears to be diminished,
d while their muscles are feeble and wasted, they
iftve a plump appearance from the preseiice of an
abun<liince of adipose tissue ; this hius been referred to
defective oxygenation, due to decrease in the rod
corpuscles, and consequent iinjierfect combustion of
the fats and carlKihydiiites.
The f<X)d shoiilil iit first be in small or moderate
■ juantity, so as not to overtax the feeble dijsjestive
IHJwers, and it should be in a readily dijjestible form.
Milk, when easily digested, and cream, and all forms
of animal food, presented in a form easy of dige.stion,
arc useful. Haw or slightly cooked meat, reduced to
pulp, and mixed with a little pleasantlyHavoured
cunwmiii^ or broth, is of value as a blood restorer.
G. See gave as miicli as 14 or., of raw meat daily
in cases of chlorosis, snd this with hydrotherapy
lie stated he hati found succeed as a blootl restora-
tive after iron had failed. The digestive power
for nitrogenous or other fcKwls must Vje carefully
watched, and, if necessary, aided liy a few^ grains
of i>epsin and a few minims of dilute hydrochloric
acid.
Besides animal albumiiiate.s, which should pre-
dominate in the diet at first, some easily digestilile
fat, esp*'ci.illy if there has lieen any loss of flesh,
should be added ; progress iu blood-making will often
fail U> lake place until some digestible fat is added to
the dietary. A moilerate amount of butter or cream,
or a ileMertsjKKinful of cod-liver oil daily, may be
ordered. The j'olk of egg is an ejvsily digested form
of food, rich in iron. In ann-mia with cardiac feeble-
ness and loss of appetit<', the yolks of two or three
oggs, beaten up with a little lioiling water and
flavoured with sugar and some spice, and with a tea-
460
Medical Treatment.
IPut II.
spoonful or two of brandy Htlded, is an excellent
concent ruled form of nourish nient.
liaufr remarks " that the reproduction of tlie
most essential components of the Llood, especially of
the red corpuscles, would be greatly favoured if
relatively more albumen were consumed in the
food of such patients than is proper under physio-
lo;;^cal conditions."* Food must be presented to
such patients in an attractive and palatable form,
e.specially when there is grt"at indis]x>sitii>n to take
food from entire loss of appetite. In .such circuni-
stancets pleasantly-tlavoured fluid or semi-iluid foods,
not requiring mastication, must be our chief resoui-ce.
A certain amount of wine, such as good sound
Burgundy, with or without water, will be found
useful, both as a stimulant and a sedative ; or a glass
of porter or stout may sometimes be taken with
advantAge at bed-time, with a biscuit or some bread
and butter.
2. Not less important is attention to the personal
/lygiene or habiln of life of the patient. One of the
nio.st important of these is a life pa.s.seil much in the
open air in a .salubrious rural district, or by the sea-
side. Still greater inij)rovement is often observed by
a residence in eleviited health re-sorts, of which there
are many in Switzerland ranging from 3,(100 to 7,000
feet above the seji level. Free exposure to the
vivifying influence of sunlight and good air is one of
the best blood restoratives we hava Hence it proves
of great advantage tti ana-rnic patients to Ije able to
pass the winter in a climate where it is pos.sible to be
much in the o\>e\\ air, for .such patients often tolerate
badly exposure to cold and inclement weather, and .
when we advocate a life in the open air we wish to
bo undei-stood to mean under genial climatic conditions.
Such patients are often urge<l to take more ])hysical ex-
ercise than they are able to without incurring injurious
fatigue and exliaustion ; and at first, at any rate,
• "Dii'torj-of tho Sick: (Did in Ann-miu ami Hydrvmi*),"
p. 27.''.
»
I
Anmmia
it is best to restrict them to passive motion through
the air, as in rlriviiig or .sailing, nml when some progress
has Ijeen miide in bloo«l reyenenition, to gradunlly
encoui-jige wnlking or riding exercise with a certain
liinitf:^! amount of intere-sling ','ymnastics. But witli
young and growinij ai>a?mio girls it will generally be
found that rii/orced roH will often start an improve-
ment that exercise has faih'd to bring about, and in
Rucli iMuses we often insist on .iti extra hour or two in
bed of A morning, and an hour or two's re|>08e in the
afternoon, with the most manifest advantige. Many
of these cases, standing as they do on the lx)rder-land
l)etween pure ann-mia and neurasthenia, re<iuire some-
what the same management as the latter, and massage
and ]>assive niovementa, together with electricid stimu-
lation of the musoles, maybe needed.
The usefulness of baths and the application of
the methods of hydi-otherapy to the euro of amemik
lmvoha<l many advocates, and we are greatly in favour
of a judicious use of these method-* in cases of
anaemia whieli are found to be making but slow pro-
gress towards recovery. The application of douches
and affusions to the skin, at first warm and then tlie
tempeniture gradually reduced, or cold sprinkling of
the surface, and especially of the spine, following
warm affusion, and then brisk friction, is a great
stimulant to nutrition and circulation and a c^dmative
to the usually iiTitable nervous system. Such applica-
tions, combined with gentle ma8.sage, are of especial
value in cases nB.sociat«d with insomnia. Oare in diet,
a life passed much in the open air, a careful apportion-
ment of rest and exercise, the judicious u.se of liydro-
thera|)y and massage, the strict limitation of both
mental and ph3raical work, the retnoval of all causes
of emotional strain or excitement, and cautious
inquiry into and correction of any possible sexual
HlKTrations (for the evil habit of mosturbition is a
fruitful source of ana>mia in both sexes), these are
the principal hygienic means for the restoration of a
normal blood state.
462
Medical Treatment.
[PlUt tt.
;!. AVf must in the nest place consider tho
tiicdii'iiinl agents which are best calculated to pro-
mote blood regeneration. In the first place we will
dispose of the question of the value of ajwrients.
Wlieii there is constipation, and this is u very
common accompaniment of anieniic staten, its removal
must occupy the firet place in our uie<.licinal manage-
ment of tlie case. Wo have not seen reason to believe,
as has been urged, that constipation frequently stuuds
in a causal relationship to aniemia. The cases which
we have been accustomed to regard as cases of fiecal
iutoxicalion, induced by chronic constipation, we should
place in 11 dill'orent category, and indeed we have in a
former chapter alluded to them ; aniemia is certainly
present in many of these cases and can ordy bo remedied
by remedying the constipation. But we have never
yet found those physicians who say they would j)refer
aperients to ircm, in the treatment of ameinia, carry
their pivfcrence to the extent of prescribing a})<:;rient«
only and witlili'tlding iron ! Nor do we think if they
began this method they would long adhere to it. We
say this the more unhesitjitingly because we have always
advocated and practised the free use of aperients,
in conjunction with ii-on and other remedies, in all
cases of anii-niia where constipation existed. But
not in others. In some ciuseii with irritable liowela,
and no tendency to consti{>ation, we have often found
a combinfttion of bismuth and iron answer far better
than iron alone. The reason why aperients are of
such undoubted value in cases of amemia with con-
stipation is obvious. They j)romote the activity of
nutritive changes in a most direct manner, they
remove abdominal congestions and quicken tho
sluggish circulation through the jiortal and other por-
tions of the vo-scular system of the alimentary canal,
they stimulate the actiim of the liver ami of all tho
abdominal glands, they thereby increase the (piantity
and improve the quality of the digestive s(!cretiou8 ;
at the .same time they sweep away any toxic sub-
stances which may possibly l>e formed from rutaiued
htp. VIM
Ajf.KtrrA,
463
fscculeut mallpr, and whirh might )>e absorlMxJ into
the blood ; and further, no douVjt the excessive
devolopnipnt of sulpiiidcw from the decomposition of
retuiuod fiwes loads to the fonnntion of irisolulile iron
Bulpliides, and so the iron in the food or that taken
iia medicine is wasted and lost. We see, then, what
important agents aperients are in promoting bluod
regeneration when chronic constipation is associated
with anaemia,
The bowels, then, must be kept ftdequatoly
relieved, but in vety obstinate cases we have found
it far lietter to discard all aperients by the mouth and
to trust to long tiilie enemata of simple wiit-er, or
soap and water, with ulxloininal massage. (laving
succeeded by suitable methods in overcoming the
constipation, we should, in our further tn-atment,
take measures to prevent its return, and to maintain
the due and regular activity of the bowels ; for this
puqiose it is often a gooil practice to combine some
aperient with such pi-eimrations of iron as we may
select.
Iron, iu the various forms at our disposal, is
still, an<l pnibably always will be, the chief medicinal
remetly for onlinarv nnieniic states. We are not able
to say in what precise manner iron acts as a bio.id
restorative ; it has been stateil, on experimental
grounds, that all the iron given by the mouth may
lie rocovere<I from the fa?ce.s ; such statements hove
been received far too I'eadily, and it is difficult to
conceive such a series of experimental observations
ever having been devised as would justify such a
sweeping statement. Tt is something worse than
foolishness to make such inferences from the results
observed after injecting iron into the bloodvessels
of dogs and rabbits. Ibit it has been conclusively
shown that inoiganio iron salts are absorbed by the
mucous membrane of the iMiwel, although the amount
is always .^mall, a few milligraninies a day. "After
alworption it seems to lie stored up in the liver, and
to be converted into organic compounds resensblin
464
Medical Treatment.
[Hurl II.
hiciiioglobin in constitution, but more simple ; »titl
tliese ultiniiitely fonn the ha^noglobin of tim red blotxl
corpiisdc-s."* It must, of courae, be aihnitted tbat
in ca-ses of imiuinia iron may be absorlitnl from tlio
fofxl ill Hutlicieiit «|aiintity to restore the loss of red
forimsi^lcs !iii(t hiemoglobin, and that therefoi"o an
aliundance of good food and good air and other
hygienic conditions may be attended by recovery,
without the use of preparations of iron, or even after
iron preparnlions miiy have failed. But these are
exceptional instances, and some of the more sever©
and more intractable forms of anteinia will l>e found
to arise in the midst of the very best hygienic sur-
roundings, and will only recover whfii some suitable
form of iron is administered, and adniiuistered for a
long period.
We have pointed out that it is m>t impossible
that the prejMinitions of iron, taken as iiu-dicine, may,
by combining with the sulphides formiHl in the intes-
tine.s, preserve the iron in the food from decomposition
and waste.
It is well known that it is by uo means a mutter
of indifTerence wliat form or jireparation of iron is
used in difTerent cases of ana-mia, and nothing is
more common than to find a particular pi-eparation
succeed after many others have faileil. In the first
place we should examine carefully into the state of
the digestive functions ; if, with a coated tongue,
tiiere is loss of appetite, Uatulent distension, and
other signs of dy8pe|)8ia, we must endeavour to
improve the digestion bt'foro wo prescribe any fortii
of iron, and some such formula as the following should
be ordered : —
}^ liiunoris bismnthi citr»tiii . .
Sodii birarbonatis
Bpiritus aininoniie aromulici
Tincliirtu niioiit vomica;
Iiifimi caliimbiD
5>*-
3.V.-
V'J-
> 3.V.-
ad ^viij.
Mimo, fiat mictura. Two tiibli'spoonfiils tin hour 1>efora
• Storkman, in Hure'n "System of Practical 'rherapeutica "
(new edition), vol. i., p. 080.
Chap. VIM
Anemia.
465
^
Ibod twice a day. If there U oonstipation Uio following pill
should be given daily, immedintoly before or aftor dinner : —
R7 Aloes exlrncti gT. JM.
IptM'uciuinha) pulveria gr. m.
t^uinimi- aulplmlii gf- j-
Baponia gr. M.
MiKe, fiat piliiln.
Orfxiii latninti in 6 grain closes, given an hour
before meals, has been reporte<l to be of great service
in some cases of anitpnua with loss of appetite and
emaciation.*
After a week or ten daya of thi» tceatment, we
shall usually be able to begin with one of the milder
preparations of iron, and we niiiy tlien add .") grains
of the animonio-citratc of iron to each dose of the
above mixture, and a grain of ferrous sulphate to
each of the pills. Subscijuontly we may be able to
replace the nii.xture with a nuxliHcation of fUnud's
pills, which we have found most useful. In the
m(xiilication which we use, m-o do not attempt, nor
desire, to decompose the whole of the ferrous sulphate
by potassic carbonate, but to leave an excess of
sulphate in the pill ; we Lave no doubt of the
superior efficacy of the following formula to that
commonly used : —
... gr. Ixiij.
.. gr. xij.
... gr. xxiv.
... gr. vj.
To 1)0 con ted with n
}y Perri Hiilphatiii oxKJccatfD
I'olussil curl)onntig
I'ulverin nucii vomicm
>Saponis
Mi<ce et divide in pilnlas xxiv.
suitable covering. One (o throe after aich meal. In ordinary
cnaes in which, ns in the rule, conatipntion is a proniinvnt
Rymptoin, the following modification of 11 very oM formuln is
one iif the most efliciiciotiH and rapid blood rcatorcni wo are
aoqunintud with : —
^ Kern siilphatig gr. xvj.
Aridi aulphurici dituti ... ... ... nixl.
Linuoris Btryehninie ... nixlviij.
Mngnoii Rulphiitis ... .. ... jj.
Aipiiu chlornfornii ... ... nd Jriij.
Miaoe, flat iiii»lura. Two titlilcKpoonfula twi<'<i or three
tinuit a day, iin hour before minla.
• ZrtwW, vol. i., 1900, p. 1013.
E K
466
Medical Treatmeitt.
(Part II.
Some ])rpfcr to give the in»oluhh jirepftrations iif
iron itninediat^-Iy or about an hour after food, in order
that tlicy may \n- dissolved by the gastric juice and ho
alisorbi'd with the food; and in some cases where
there is an intolerance of iron jirepamtions this is
ft goo<J plan. T\w ferritin ndavlttin * in '2- or .'l-grain
doses may l>e given in pill or powder, or the Jerri
carbnnnn sticc/iarufus in 5- to 10-grain doses in the
same manner thrice daily after foo<i.
The best test of tiie iictivily of any prepaiution of
iron is now at our service iu the luethoij of counting
the nuiiiljer of retl coipusclea, and of estimating the
amount of luemoglobin (luring its administration. It
is desirable to api'ly this method of estimating the
etlV'ct of our remedies on the process of bliKMl re-
generation, occasionally, iluiing the treatment.
Many other pre] lar.at ions of iron are of especial
value. The ferrum tat-taratum and tlie vinum ferri
fti-e useful mild prepnnitions of iron, and the latter is
often acceptable to children. The .syrup of the phos-
phate, the compound syru]i of the phosphate, and tlie
compound syrup of the (lyjwphosphites are all valuubfe
forms of iron especially useful for children and young
growing people. The la.st-nained contains quinine anU
strychnine, and is very useful in the forms of anmuiia
following acute febrile and infiaunnat4>ry diseases.
The citrate of iron and (piinine is also a very useful
form in these cases, and is usually easy of digi»stion.
The syrup of the iodide of iron is particularly
valuable in anainiias of scrofulous children with
tendency to glandular hj'pertrophy. Ijivctates, albu-
minates, and peptonatcs of iron have Ik-cii prepared,
and preHcril«'d with a view of ))resenting the iron in
a pre-digf'sted and readily assimilable form to ])atient»
who find a ditliculty in digesting other forms of iron.
With the .same ol>ject in view, a aifriip i>J' /i<rmo</loltin
' The Koliilulity of retimed iron in ({astiic jui' ■
cstiiiiatod t»y (Jiieveuiie. When 50 tteiiliji^timnea {'
rvduttvi iron were trcatoil willi KKI gtummes l3o/.., ,
juioe, ol luilligninunes were diaaoWed, or about ous-tetith.
»p. Vll.l
An-vmia.
467
Iia« beeu prepantl in France from tlie blood of animals.
The dose of tlie syiup is 2 or 3 tablcspoonfuls a day.
Ffmitiii, a coiiil)ination of tlie iron salts with egg
albumin, has recently been introdiieed to imitate the
organic compounds of iron found in the tissues. It
contains al)out 7 per cent, of iron, and, in doses of 15
to 30 grains a day, has been found of service as a
bloo<l restorer.
Attempts to administer pi-eparations of iron by
the hypodermic methoti and by rt-etal injection have
been made, but not with any .striking succe.ss.
Tliere is one point that mu.st not be lost .sight of
in the treatment of amemias by iron, and that is that
the first effect of iron is to increase the number of
corpuscles without increasing to a corresponding
degree the amount of hiemoglobin, that the latter is
of slower regeneration and it needs a lonj;er time to
re-establish it in the nornuil amount; we should
thei-efoi-e continue the administration of iron for simio
time after the regeneration of the corpuscles, and,
indeed, for some time after the apparent restoration to
health, as relapses are exceedingly common.
Certain inconveniences sometimes attend the ad-
ministration of iron, but most of them are trivial or
avoidaVjlo. Constipation is said to U; frequently
provoked by the presence of iron in the fieces, to
which it inijmrts a lilack colour, rlue more proljably
to the conversion of the iron into sulphide lliiiii into a
tannate, as has l>een sugge.sted, for tlie black colour
has iK^en found even when the diet has beei: exclusively
of milk. \Vc have already insisted on the necessity
of combining an aperient with the iron when there is
any tendency to constipation. Then it is said to
stain the teeth black ; this certainly cannot be the
case when given in the form of ]>ills, or enclosed in
cachets, and very little risk would bo incurred in
taking the Unid forms of iron if tiie mouth wi'rc well
rinsed out with pure water before and after the
dose ; and by pouring the dose well into the throat
there need be little or no contact with the teeth.
46S
Medical Treatment.
IPart II.
Gastralgin has also l)eeri said tt) be provoked l>y pitv
jjarations of iron, but this is scarcely jiossible if the
preparation selected l>e a mild one, and the dose given
small or moderate. We are aware there is a pre-
vailing belief that large doses an; necessary in the
treatment of severe forms of an:euiia, but wo are
satisfied that (j;re)it care in the selection of the
preparation, and in its mode of administration, will
often avoid the necessity of tho!5e large doses, ind we
shnll insist immediately on the activity of very small
doses of iron, when given in the form of natund
niint-ral waters. Dujardin-Bcauniptz showed how
.small is the actual quantity of iron lost by the blood
evcti in the most advnnccd forms of chloro.sis. Ac-
cording to his calculation, in u woman weigliing GO
kilognmnnes (a little over 9 stone) the amount of
iron in the blood does not exceed 2 grammes (30
grains), and tho most extreme aniemia does not
reduce this amount by more than 50 centigramniea
(7i grains). But we must also bear in mind that the
assimilation of iron, ami the fonnation of hiemoglobiiL,
ai'e ill such case* often very slow.
The etiicaey of natural iron waters, in the
treatment of ana-mic states, makes it clear that the
furiu and not the ipiaiility of iron is of diief im-
portance in blood regeneration. It is futile to assert,
as some do, that it is the mode of life lefl at imii
spas and not the iron water that is the chief rest.<:in»-
tive agent, l>e(;ause just the same mode of life can lie
led at any bnicing seaside resort, but without the
same results. No one with any knowledge of the
localities would maintain that the air and life at
Schwalbach were more tonic than at Folkestone, or
the air and life at Spa than at Cromer or Whitby.
At St. Moritz, no doubt, a very bracing and stimnlat-
ilig air comes to the aid of the iron cure, but many
of the more feeble aiiieniics bear the St. Moritz cure
badly, tinlejis they are prepni-ed for it by three or
four weeks at Spa or Schwalbath ; then they are
enabled to benefit by the more bracing climate of
AHMMiA.
469
tbe Engadiue, which will otherwise chill and depress
thera.
At. these iron spas the water is richly chiirgt-d
witii free carbonic acid, and the value of an iron
spring is greatly dependent on the amount of free
carbonic Hiid in it. Wiien these waters are exporte<l
some of this carbonic acid is necessarily lost, and there
is a great tendency in the bottled waters to deposition
of the iron in the form of oxide, which detracts greatly
from the value of iron waters in bottle.
Sj)a, Schwalbach, St. Moritz, Pyrniont, are the
Ix-'Sl known of chjilyI>eato springs ; there ai-e many
others, aliiiost as useful, which cannot here be
enunicmted. Tunbridge Wells hns an iron spring,
but it contains very little free carlwnic acid. At all
these Continental spaa the water, richly charged with
free carbonic aciii, is iined for baths, and the stimu-
lating effect on tlie skin and circulation these baths
exercise is unttoulttcdiy of etHcacy in many cases.
It is rarely thought desirable to prescribe large
quantities of these iron waters. One to two glasses
(6 o/,. each) abovit two hours after breakfast (11 a.ui.),
drunk slowly, slightly warmed if nece.ssary, and at
intervals of twenty or thirty minute.s, and one or two
more about five in the afternoon , are the usual amount^
beginning with the smaller and rapidly increasing to
the larger quantities.
•Since many of the natural iron springs, as those of
St. Moiitz, contain a considerable amount of salts of
limei they iiccasionally cause constipation, and tlus
must lie guanh-fl against by the use of some aperient
water or salts, taken early in the morning. It i.<i
remarkalilo how cerUiin anteinic patients, who do not
improve with iron medicjition at home, appear to
assimilate rapidly the iron of these chalyl>eate springs
and quickly recover ixith tone and colour.
Preparations of iixiiiyiufjte have been vaunted as
blood re.storativeH equal in value to those of iron,
and many physicians have combined tlie two, but
Professor Hayein maintains, as the outcome of his
470
Medical Treatmskt.
(Part ir.
ciirpful nud elabonttf reseai-ches, that they are not
only useless, but injurious, as they interferr witli the
action of the iron salts.
CIdoridf of gold and sodium bas some reputation
in America as a blood regenerator, in doses of j'g gr.
increased to ,\j gr.
Arsenic we have not found capable of replacing
iron in the treatment of ordinary syniptomatic
ani«niias, but some intcresling olwervations have Ijeen
niiule by Aperti* a.s to the rationale of the use of
iron and arsenic in the treatment of ana-mia, iu which
it is shown that tliese suljstances act diH'erently : while
the arsenic increases the miinber of the corpuscles,
the iron increases the total quantity of hiemoglobin.
Iidialations of uxygeu have In^en advocated in
refiactory eases, and although they have U^en shown
to liave little direct etfect in causing i-egenerution
of the blood corpu.scles, it seems probable that by
stimulating the nutritive functions they may favour
the a.ssimilation of iron. Ccnnprvtf.d-nir baths have
hI.so been u.sed with advantage to stimulate the
respiratory and nutritive functions, and so to lead
indirectly to bhxid regeneration.
In acute unwiiiia following severe hsRmorrhages,
truunfiixii'ii of blood has l)een practise<l with e.voellent
results, and in the same class of cases the sulicutaneous
injection of saline solutions has proved a valuable
res<iurce.
In chlorosis it is imfwrtant to continue the ad-
ministration of iron for three months or more, a*
there is a great tendency to relapses, and all tht>
medicinal, dietetic, and hygienic measures we have
referred to will often be needed to correct the defect.
In the febrile cases we should esjiecially .see
that the bowels are frfM»ly evacuated daily, and we
may combine quinine or arsenic with the preparation
of iron given.
A preliminary treatment with an intestinal anti-
septic, such OS /3-n<i/'A//io/, before commencing the
• Imtetl, \Vm, vol. i., p. IMS.
Chap. VI 1.1
Fekjucious An^uia.
47 »
k
adtninistralion of iron, has been found advantageous
in ct'i'Lain cases.*
Tlie addition of snukll doses of digitivlis to the iron
tonics has l>efn found valuable in some cases where
syuiptoms of ciirdinc lieliility were |iron)inent.
PeniifioiiH iiiin-mia. — Tiiere is a tendency
to regard this iny8t«riou8 iind renmrkalple disease a.s
fiathoiogically related to the [ireceiling, liut in its
ciiuicAl features, its course, and its inti-actjibleiiess to
ahnikst all forms of treatment it differs very widely
from it. This disease has often l)een olwerved to bo
preceded by symptoms of gastro-intestinnl disturbance,
or by nervous shock or worry, l)Ut it is usually
insidious in its approach, and the first devintions from
health noticed are languor and pallor of countenance,
muscular feeblencs.s, and intlispi^iMition to exertion.
Feelings of faiiitnrwi and brentlilessness with a ten-
dency to jHiljiitations follow. The nutemic aspect is
intensitietl, the visible mucous menibranes iMicunie
pale, and tlic skin assumes a waxy, " fiuled-leuf,"
or " Irmon " tint, the muscles become flabby, the
appetite is lost, and the sigtis of cardiac and general
feebleness become most marked ; there is usually
■edtima of the feet and ankles, " the patient falls
into a prostrate and half-torpid state, and at length
expires." Pyrexia is common though int-gular, the
temperature rising to 101°, 102', or even im*^', but
it rarely remains high long. The plumpness of the
body is often reUiined to tlie last, (iastro-intestimil
syniptom.s, vomiting, and diarrhtea are common. The
changes found in the liloud in this iliscase are
remarkable. Its spec i tic gravity is loduced to lO.IH to
1028, its alkalinity is lessened, and the soliils of the
plasma are diminished. The coqmHclcs no longer
adhere in rouleaux, and their numU-r is greatly
reduced, often below 30 j>er cunt., and in fatal
c^sea they have lieen found as low as 7 '5 jier cent.
They also presi-ul great variations in form and size
(yoikiloci/logig) ; some are very small (mici-oi'i/trii),
* Allbutt'i '■ Sjntem of Mfidiciite," vol. v., p. 61A.
472
Medical Treatment.
(Pan It.
while a liiigp iiumlxT aro above the nornml size, 8 to
12 fi ; the cohiiiritig mutter separates readily from the
struma, and blood crystals also form readily. Another
interesting (wint is that the reduction in hie;noglobin
ia not 80 great as the reduction in the number of
the red corpuscles. Nucleated red corpuscles are con-
stantly present. Retinal and other lisemorrhages are
common. The nrine is sometimes, but not always,
found of a dark colour, due to the secretion of large
quantities of pathological nrohilhi, and regarded by
some as an evidence of e.xceisive destruction of lud
blood corpuscles. Thi?i disease is supjiosed to lie
dejteiulent on excessive blood destruction and defec-
tive blood formation.
Striking changes in the red bone-maiTow have
been found in this disease as well as in leuka-mia.
It is not within the scope of this work to enter into
the consiilenition of patliulogicjil discussions except in
so far as they niay iniiuenco our views of trentnient,
but a very brief i-eference to the main differences of '
opinion that exist amongst authoritiejsas to the nature
and causation of this malady may not lie here out of
place. Many, like Stockman, aigue that peraicious
anaMuia is only an extreme condition, not a special
form of ana'mia, that there is no real difference
between it and the antemia of ha'morrhago or wasting
disease, and that its aggravated character is due to
the occurrence and absorption of interstitial capillary
haemorrhages throughout the body ; and Stockman
would include in this group those remarkable cases
of ana>mia ob-served to occur in connection with
the presence of certain parasites in the intestinal
c&nal (Bothriocejihalus latus and Anchylostoma duo-
denale). Hunter and othei-s, however, hold that the
aniemia of wasting and malignant disease is absolutely
distinct from ]>erniciou8 nna-mia, that failure in blood
formation plays little or no part in its production,
but that the essential nature of the blixul change,
according to Hunter, is exi-essive blood destruction,
the portal blood being the chief seat of this process.
Cha^ VIM
PsKtrtcious AsjKMIa.
473
He concludes that ()emicious anipmia is an in/rrliee
disease, caused by tlie presence, under certain favour-
able conditions, of organisms of specific nature witliiu
the giistro intestinal tract.* He regai'ds i*ral wp*i*
(i]e]>endent on dental caries) as the chief cause of
the infection.
Unlike chlorosis, males are more frequently affected
tlian females. Tim youngest person Osier had seen
with this disease was a girl of 20, but coses in much
younger subjects have been reporte<I. Also, unlike
other forms of aniemia, iron seems to have little or no
remedial effect. Arsruic, sujjgested by Byrom Bnini-
weli,ap|)ear8 to l)e the only drugthat has b«'en'eniployetl
in the Ironimenl of this disease with any good
results. It has lj«!en given now in a great numlier of
cases, and in many with undoubt^'il l)enefit. The only
difference of opinion which appears to exist as to its
remedial effects is whether they are permonent or only
temporary. It is usual to give it in the form of
Fowler's solution, Ix-ginning with doses of 3 minims
after food thrice daily, and increasing the dose every
five or six days, first to 5 minims, then to 10, then 15,
anil finally 20 minims.
These large doses are nsually well tolerated.
Osier mentions a case in which the dose was gradually
incn^o-sed to 30 minims, and the iK-neficiid effect |)«>r-
f.ist<'d for nenrly three years. When arsenic jiroduces
gastric irritation it may be administeretl hypo-
derniic«Ily. It, of course, fails in some case.i to
produce any good effect, and there are grounds for
believing that many coses re[)orted as recoveries from
the use of arsenic have 8uljse<|ucntly relajised ; it is
c-ertiiin, however, that coses have remained well for
from two t« four years after the arsenic treatment.
Its mode of action is at present undetermined. It
has been suggestetl that it stimulates the formation
of new corpuscles by the rod Iwne-mari-ow. During
the conuuencement of the treatment, at least, the
{)atient should be kept in l>ed, and massage, with freu
• Hunter, " Pemidoai Anicmiii," 1901.
474
Medical Trea tment.
Part II.
exposure to fresh air and sunshine, have been found
useful auxiliaries.
Pi'of. T. H. Fniser has reconled n case* in whicli
he gave hoiv-marroiv, with the result that the patient
made a nniiarkable recovery. Tlic case was a very
severe one, and repeated examinations of the blo<*l
displayed all the characters of pernicious aniemia.
Arsenic and iron were iirst administered without
pnxJucing any good results. Ox arid calf Iwne-marrow
was then given to the extent of 3 oz. daily for five or
six months. For a consideraljle part of this time
salol (30 grains daily) was al.so given as an intestinal
antiseptic. Ban's and others liave also recorded
instances of recovery from the use of red bone-marrow.
Hut further experience with this substance has not
corroliorated these favimralile views, and unless com-
bined with arsenic, no reliance can be jilaced on bone-
marrow.
Stockman t l^elieves that iron is often useful in
certjiiu of these ca-ses when comVitued with arsenic.
])r. W. CarttTjJ of Liverpool, has reported a
recovery in a man who was given 1 minim of solution
of perchloride of mercury, 1 minim of tincture of
percliloridii of iron in a dram of water every hour for
eight hoiire daily ; 'i drams cf desiccated ox-blood
ditfused in 4 oz. of water was injected into the bowel
twice daily ; he was also kept in l>ed. Afterwards
he was given " rtnidinun rulirmn " and St. Kaphael's
wine.
If diarrh<i-a is a troublesome feature it must be
controlled by large doses of bisoiuth — 15 grains each
of the salicylate and carlionate, mixed with mucilage
and cinnamon water, may be given three or four times a
day. Cases associated with the presence of intestinal
parasites must be treated with parasiticide remedies —
lltyntol for the Anchylostoma duodeualc and Jl/Lr uku
• Jlrilith MriliiaUmimal, June 'lw\, 1»94.
+ Hare's " ."ystcm of Practical Thonipeutics " (ne«r editionV
vol. i., p. <m.
X LuHcrl, ToL i., inOO, p. 780,
Chap. VII.J
Pernicious Ahmmia.
475
for the 15othriofi'pliaIus liitus iirul other tape- worms.
Trantfitsiim has been tricil in neveral cases, and one
or two recoveiicw liave been rejiortetl. Hninim 1>looil
is alone suitable, and of this ( to (i oz., immediately ■
on its withdrawal, should he mixed with one-third
the quantity of sotliuTii phi)S|ihate solution of
B|). gr. 1028, and kej)t at the Iwdy temi^)eniture.
This |)i-events coagulation. It shrvuld Iw transfused
vry aloidy into one of the large )triiehi;il veins of the
patient. Temporary iniprovciuent usually occurs, but
it is nirely maintained.
Hunter, in accordance with the theoretical view-
he luloptsof the cause of pernicious amemia, advocates
antiseptic treatment. The presence of oral sepsis,
which he believes to be an almost constant condition,
must be got rid of by the removal of carious teeth
and the use of antiseptic washes. The septic catarrh
of the stomivcli, consei-|Ucnt on oral 8e|jsis, can be dealt
with either by lavage, or, he thinks, equally well l»y
giving sucii antiseptics as salicylic acid or bismuth
salicylate.
If the intestine is the chief seAt of trouble, such
antise.[itics as salol, naphlbol, calomel, and mercuric
chloride are indicat-iMl, aiut if the folon is involved,
sulicylic acid enemata. Tlie diet must be !ida}ited to
the digestive capacities and peculiarities of individual
cases -he leans towards milk and farinaceous foods.
To coniljut the action of the poison in the blood after
altsorption, he supgests the systematic trial of serum
treatment, and as he believes that pyogenic organisms
are always concerned in the ieifection, he would use
aiitialr''pU)coccir gfruiii. A successful result ol)tjiined
by Dr. Elder after tliis treatment, in the J^eith
Hospital, Lb fully repoi-ted in Dr. Hunter's book.*
• "Pcruiciou» Anninia," p. IW'i ; ulao Laurrt, vol. i., 11)03,
p. 1I9H.
^^■^^^B
^^^^^H
^^^^^ 476 Medical Treatment. (Part 11, ^^^B
^^K ADDITIONAL
FORMUKf:. ^M
^^^^V Fiiii for anminlii.
Pills lor the same. ^^^H
^^H H Ferri et sodii pyropho«pli.,
B Ferri valurianiitis, gr. xr. ^H
^H
Castorei, gr. xr. ^H
Extracti i-hei, qa. ^H
^^H Extructi rhui, gr. xIt.
^^H Extract! alrten, (p-. viij.
ITt f. pil. x.\. Two to ten to ^H
^^H Extract! t^iraxiid, q.s.
l)e taken doily. ^H
^H rtf. pil. 1. Two to be taken
( Dtf/nrrliit-Beaiimrlz.) ^H
^^H iiiglit unci iiioniiog.
^^^^M
^^1 {Siim/inytr,)
Mixture for chlorosis. ^^^H
E Ferri siil]jlmtifl, gr. xxir. ^^^^|
^^^^^T Powders for anninia.
Mugnesii Hiilph:iti:<, 5vj. ^^^^H
Acidi aulphurici oromatici, ^H
^^H H Fvrri cnrlioualismcchnratii',
^H
^H KT-
Tinrtune ziiigibcris, }ij. ^H
^^^1 Soui'lmn aUji, gr. Ixxv.
lufiifii gentiauii- compositi ^H
^^H M. et divide in pulv. Tj. One
ud j^viij. ^H
^^H night and nioruing.
M. f. mist A six til part ^H
^^^^ l^llamhrrgmr.)
twice u day. {Sir A. Clrtit.) ^H
^fl
^^^^^ Aperient iron pills.
h Ferri iiiilphntia. pr. xxir. ^^^^^
8<Hlii liii'.irtmnatia, .^ij. ^^^^H
^^^1 li F'crri F(ul|iliatiH, ^r. xx.
Tiiirtunr zingilienit. .sij. ^^^^^|
^^H Puta-Bii carboiiutis. gr. xx.
^^H Mvrrhti- pulverin, .^j.
.'^I'irilus I'hlorcifomii, .^j, ^^^^H
^^H Alot'S 8(U'utriiui', in.
Iiif ua quaasiif ad Sviij. ^^^^|
^^1 M. et divide inpiL xxx. Two
M. i. mist. A sixth part ^H
^^H or tliree n day. {Briiiidet.)
twice a day. (Sir A. Clark.) ^^^H
For hypodermic injection. ^^^|
^^B Pills for chlorosis.
.\ 1 per cent, mlutiou of ^H
citrate of inm. 411 to 6(1 minims ^H
^^H H Ferri amnionio chloridi, }«s.
^^H Quininif ^ulphntis, gr. xL
injected into the l)Uttock» twice ^^|
^^H PuWeris aloes, gr. xx.
daily. When irnu is not well ^H
^^H Blxtracti taraxnci. i|.s.
borne, by stomadi. {Ltpint.) ^H
^^K^^ Ut f. pil. Ix. Four to six ilailjr.
^H
^^^^^^ (Frtrieht.)
^^^^^1
Pills for annmia wlUi ^^^1
gastralgfla. ^^^H
^^1 Hizture for chlorosis In the
H Ferri tartaruti, .^ijs^ ^^^^H
^^B nervous and hysterical
Exiracti gentiano', sij. ^^^^H
^^H R Frrri ritrnli>, h'y
^^H Potasirii broiiiidi. .^ijssad Siij.
Extract! Tomiea, ^^^H
gr. iv. ^^^H
Extract! opii, gr. iv, ^H
M, et divide in pilulan ceo- ^H
^^H Viui (Malaga), jriij.
^^B M. f. mist. A talilespoonful
turn. Two before each meaL ^H
^^H tlirce times a dny. (Hirnlrt/.)
(ifMcAnrrf.) ^H
Chap. VII.]
PkRNICIOUS AN/SMIA.
477
PastUles of Uicut« of Iron.
R Pulvoris ferri liictatts, gr.
Irxv.
Pulverig sacchari, Jiij.
"Vniiille migur," gr. xlv.
Huciliigiuis trogacantha?,
H. Divide iuto 100 pMtilles.
Two to nx daily.
{Frnifh Cbdrx.)
Arsenic &nd iron mixture
for annmla.
1^ Tinctura' furri jicrihloridi,
Liquorin arsenicalia, ij.
Ulycorini puri, jj.
Aijuii' ad siv.
M. f. mutt. A teospooiiful
Uireo times a day iii n wiiiu-
glassf ul of water after food.
{IIAitlii.)
Quinine and iron mixture.
II TincturiL' ferri ix-rcliloridi,
.IV.
Quiiiinji.- fiulphatis, gr. xl.
Olyccrini piiri, jj.
.\quic ud .Mv.
M. f. mist. A teavpooiif ul in
water throe times a iluy iLfter
food. (Illntln.)
A combination of arsenic and
iron for clilorosls.
It Liquiiris iirseiiiculia, iMxxiv.
Ferri et ammoiiii citratis, .^i.
Liqiioris nmmonin.' furtis,
mxij.
Spiritus chloroform!, }j.
Aipin*, ad Jvj.
M. f. tniut. <.>ue tableniMxin-
fiil, after food, three times a
day.
478
CHAPTER VIII.
THE TREATMEXT OF CERTAIN BLOOD DISEASES :
LEUK.KMIA — HOIWKIN's DISEASE — ADDISON's
DISEASE — EXOPHTHALMIC OOITRE — HTX(£DEMA.
Levk-emia OB LBU0O0TTH.i!>ni. Churaotora — Symiitom* —
Cotirsu — Tftvtine^t — Tonics — Araenic — Sodium Cacodylate —
Phospliorus — OxyK«u luhiiiliitiou!' — Excision of Sjilccn —
Duiicnes — Elwtricity.
HoDOKIn's DliiEASE, Psir.UDO-LEUKJEmA, OR LTMrUASBHOKA.
Chn.mctvn—Trriiluienl—'Etcisiou of Olauils— Anenic — Phoa-
plioriw, i>tc. — Animal Extrui-ts.
Addicon'r DisKAHK. Cluimctitn) -SyioptoDU— Intlicotioiui for
Tri'atmout — Siipra-rfiml Kxtnict.
RxOPIITBALinO (jOITRE, IiBAVBs'h OB BiSBDOW'B PlSKASK.
Churactere— Courw.*— Syin|»t<inj8 — Trratmrnt — (I) Hvgieuiti —
Sea anil Moiintaio Air— nyilrotbenipy— Diet— (li) Local and
Electrical - (3) Medicinal —(•!) Surgical.
MyX(£I>ema. Cbunictcr and Nature of Disease — rira/iwM/ —
Thyroid Oraftine- Tliyroici Extnict* — Thyroid Feediug—
lodothyrine. AdditiouiU Formuloi.
Lei'k.kmia.
Lfiikn-niia cjr lt>ii<'0(>yiliH>iiii:i in a mysterious
bloo<! (lispiuse, of tho ciiusatiori aud iiitiniiite nature of
whifli we havn but little precise knowledge. This
disensc is chiiraul«riscd by a persistent increase of
tlio white blood corjiusoles, accompanied by con-
sidernble enlargement of the splei'ii and changes iu
the bone-marrow, Kplonic or splriio-inedullnry
Iciikivinin, and (here may also be enlargement of
the lymphatic glands, esjiecially lata in the disease,
but they are not usually enlai'ge<l. There are other
cases in which the spleen is not greatly etdargcd, but
the lymphatic glands and bone-marrow are atlected ;
these have been termed cases of lyiiiphutiv
It'nksriniii. As there a.ro few, if any, thcra|>eulic
indicntiong to lie derived from a consideration of the
pathology, so fur as it is known, and the symptoms
of this disease, we .shall briefly de.scril>e only the
more salient [>oints in its course and features. Of
^^^^T^iap. Villi
Leukmmia.
479
^
its etiology we may 1)e said to know notliing. It has
been suggested ttuit it may l)e caused l)y a micro-
parasite, but tliis is purely bypothetical. It would
seem, in a certain jiroportion of cases, to l)ear some
relation to previeuvs, though often long distant, attacks
of ague ; Vmt in by far the great majority of cases no
sucii antet'edent Iim« been discovered. It is much
more common in males thaTi in females, and it is of
most frequent occurrence between 30 and SO years of
ago. It is, however, more common in children than
was formerly supposed.
It is an interesting and important fact that this
disease is one which affect* the lower animals, as the
ox, sheep, pig, dog, cat, and othei-s.
The enlargement of the spleen may be very
great, ami may reach from 2 to l8 lljs. in
weigiit.
In hfinphntli- Irukatiiia the cervical, a.\ill;iry,
mesenteric, inguinal, and other lymphatic glands may
be enlarged. The liver is also fn-quently enlarged,
and has been recorded to have attained, in one case, a
weight of more than IS lbs!* Remarkable changes
have been observed in the Iwne-marrtiw.
The ttjniptoiiis of this disease come on in-
sidiously ; progressive abdominal ejdargement from
splenic hypertroj)hy, or enlargement of superficial
lymphatic glands, is tirst noticed, accompanied with
pallor, dyspntea, pjilpitation, and other signs of
iiniemia. Then? is a givat teinlency to lucmorrhage
from internid organ.-*, aiul es[H>cially to ejastaxis, and
retinal ha-morrhages are also common. Gastro-
intestinal symptoms, nau.sea, vomiting, and grave
dian-ho'a are freipient. As in jiemicious anosmia, an
irregular pyrexia is often observed, and the tempera-
tuix- may rise at night from time to time iis liigh as
103°, or even higher. Various other symptmiis nuiy
appear, de|)endi'tit on the ilefeclive nutrition of oigans,
from till- altered st^ite of the blood, or from pressure
of the .splenic tumour. Recovery is rare, and the
• Allbutt's " System of Medicine," vol. v., p. ((43.
48o
Medical Treatment.
(Part II.
^'cater numljer of cages end fatally in from one to
three years.
An acute form has also been Hescribeil in which a
fatal result niny fallow as early as four or five weeks
after the first symptoms have liecn noticed. The
disease presents the same characters ns in tlie chronic
form, only intensified in degree.
The diagnosis of this affw-'tion must be based on
a microscopical examination of ihe blood ; various
changes from the normal have been noted in the
colourless elements of the blooti, but tlie main point
is that the colourless corpustdes are greatly increased
in number and the number of retl corpuscles much
diminished. The average number of white corpuscles
per cubic iiiillimetre in health is estimated at alx>ut
6,000, or aljout 1 of wliitc to from 500 to 1,000 red ;
but in this disea.se the pmjHjrtion of white to rod
may be as high as 1 to 1 0. or 1 to ft, or they may even
exceed the red in number ' The Inemoglobin is also
diminisbe<I in ainount, usually in the same proportion
as the number of red corpu.scles.
With regard to the Irralinriit of this dise^asc :
it has Wen stated that cases in young children, in
whom there has been a great increa-se in the white
corpuscles of the blood, together with splenic enlarge-
ment, have recovered during the administration of
quinine in large doses (iJO, 10, and 6 grains daily to a
boy of ten), or other tonics, such as coil liver oil,
syruji of the iodide of iron, and phosphorus. In
pui-ely malarial ca-ses quinine is likely to be of value ;
but the best results seem to have l>een ilerived in this
disease, a-s in jiernicious anxmia, from the use of
arsenic. Large doses have lieen given, as much as
20 minims of Fowler's solution three or four times a
day, and a great reduction in the proportion of white
corpuscles has iKwn registered under this treatment.
But it is best to begin with orflinary doses and
increase them gradually. Osier stJites that ho has
repeatedly seen improvement under its use, but, at
the sarao time, points out that there are "curious
LECKJKmiA.
-rrn.)
in tkis Axwmmi wbidi raider tbera-
pealical dedactMHW xtxj faUactovsw'* He kas smq
OMrlcod iaipcvrefnait vitlMmt apecwl trMtment in •
patUBk vln, "fram a bed-nddeti, vretclwil oondiUun,
tgcoieied attcngUl wwwigh to enable him to attend
to ligbt dotin." B«<tMi C«tr*4lylaie, a nun-
irritatijig fiDrm of arsenic, which can b« giTeu in
much lafger doaes than the ordinary official prepara-
tions, has >>efn given in this disease botli liypoilfr-
niically and by the rectum, and very ginxi n-isulta
have lieen reported, in 8onie instances. For liypo-
dermic injection a sterile, standardised Holutiuii can
be obtained in capsules, the daily dose lieing \ grain
or 1 cc, of the solution. For rectal injection llie
sanio dose is pven, but wore diluted — i.t with about
4 drams of boiled water. Phosphonis nls«i ha-s Ikh'U
given in doses of ^',, grain in pills, thrice daily, some
have thought with benefit
There is no scienlilic or rational basts for the
administration of Itoim-iiiarrotv in this tlisease. It
has, however, byeii given, and gomi results have
been reported.
Da Costa Hiid others have iiiivocaUul tlui usi< of
oxygen inhivliitions. The former has given 100 gallons
daily with lii'iiflit. 8tiokcr of Cologne has also re-
ported a miukt'd (JcLTcasc in the actuitl and n'lulivo
number of while cor|iusclos under the inlliience of
oxygen inhalatimis, together with a large alixolutu
increase in the red <(iies. Tho im[irovenuiMt was not,
however, umintainwl, the spleen continued to incrt'ase
in size, and the patients micoumljcd tu the diHciisti a
few months later. It would havt- been rciniirknljle if,
in the present " surgical agii," itxcixion of the iciikn'inio
spleen had not lieen proposed lut a remedy for tliia
disease. This o]>erattoii has l)ei<n performed forty-
five times with three recf>verie» ! •
The hpleiiio I'ldargeriieiit hiis been Miid U> have
been reduceii by iiiHaiiH of cold doiiuh<w to tlio left
hypochondrium, or by jiaiming a galvanic or farudic
* Odvr. ■■ rrnrtJ'-o of M<><lirin« " (fmirth wlitiMi), p. WHt.
F r
482
AfEDtCAL TkEATNEXT.
IPirt II.
current tliroitgh the lij-perti-ophicd ori;nn, tJie positive
pole lji>in|j; jiluced over thf leiitli rilj tiii<i the negiitive
over l-lie eiihirgeil spleen.
Ju all these ciises it is neeJfiil to protect the
ptitient from tlin iutluenee of nnfnviiuriilde surround-
ings. He shoukj, when possil)le, live in an airy,
healthy locality by the sea coast, or in tlie ojjfu
eountry in a dry situation ; he should have a care-
fully adapUid, nutritious, and well-prepared diet ; ho
should l>e made a.s free frouv uienUii worries as
pOKsiblo; and he sliould Iw protected from all ex-
posuiu to cold and from tlio danger of Kuddon
ihill. Physical rest with pleasant surroundings is
jirefendde to .-tttempts at active e-xeroise, which
tend to rapidly exhaust and enfeeble such patients.
As ill most incurable luaiadies, luany other remedial
Bgeuts have been tried, but none, iwyond those
that have been uientioiied, with any notable beiietit.
Hodokin's Disease, Pseui>o-Leuk£mia,
on Lymfhadesoma.
This disease, whicli is supposed to have soiue patho-
logical atlinity with the i»receding, is chai-acterised by
a progressi\e enlargement of the lyiiiphutic glands,
together with symptoms of ana'mia. yecondary
growths of lyuijihoid tissue have also been found
in the liver, spleen, anil other organs. The spleen
has been found enlarged in tliit^e-fnurths of the
cases but not to anything like the sjime ext«nt as >
in leukiemia. The causation uf this all'ection is as'
obscuie as that of the preceding. It is more prevalent
in males than in females, and in young than in old
persons. In some cases the ghindulnr enlargements
liavo been thought to be tracejible to local irritation
(Tromseau). Murray * thinks " the changes we
find in the adenoid tissues and lymphatic glands are
most easily explained by ajisuming that they are the
result of the action of some pathogenetic parasite,"
and this view he considers receives 8up>{)ort from
* AUbutt'* "S>-stom of Medicine," vol. ir., |>. 587.
Chap. VlII.l
Psbvdo-Leukmmia.
483
the favt that this disease apix'Bi's in cattle, (logs,
horses, and other animals. Organisms have tjeeii
fuund in the enlargwl glainls by some observers,
but no definite conclu.sions on this head are at
present warranted.
The fii-Ht syuiptomii noticed are, usually, enlarge-
ment of the glands of the neck, axillii, or groin ;
these are at first distinct and movable, but they
tend to fuse together, and may come Xo form
tumours of considerable size. When the dcejier-
seat'ed glands Ijecome affected, as, for instance, the
bronchial and mediaslina! glands, serious pressure
sigtis may deveiop, the cliiet of which are [lains in
the chest and dyspno-a : and the symptoms ivsullitig
from pn'.ssun.' of the immensely enlarged glands in
othet situations are often iimongst the most serious
manifestations of this disease. Progressive aiu-emia
accompanies the glandular enlargements. There is
apt to Ih' great variation in the rate of growth and
size of the glands. The rod blood ef)rpu.scl<'s ai-o
dtuiiiiished, and in certain ca.scs the numl>er of
leucocytes is grejitly increased, bringing this affection
into close ivlationsliip with splenic leukiemio. As in
the latl«r disease, there is a tendency U) limmorrhage,
and especially to episUixis, and the temperature of the
l>oiiy, too, often rises to from 100' to 103' or higher.
Curious ague-like paroxysms have Ikwu observe<l in
some cvises. When cases do not ti>rmiiiatu by pres.sure
of the eidarged glands >n\ important structures, the
couree of the diseii.se is somewhat variable, but with a
decidetl tendency to a fatal termination.- Some cases
run a lupid course, group after group of glands being
successively involvetl, and deAth may occur in two
or three months ; or |)eriod8 of cjuiescenco may alternate
with periods of activity, and chronic cases may last
thr(M> or four yeai-s. As the fatal event approaches,
which is usually from exhanslion, after the develop-
ment of a cachectic state witli [irogressive ann!n)i)i, the
glands have, in some instances, been observed to
diminish in size and even dinapfieav'.
484
M EPICAL Treatment.
(Pan II.
Tr4>ii(ui«>iil in Mises of this, as in tlio preced-
ing iiffL'ctiori, lins not l)een attended with any great
aniuunt of ]iermanc-nt succen.'^, and in this disejise,
as in the other, the strongest testimony is in favour
of arsenic.
Two indications are obvious. First, to prevent,
if possihlc, tlio spread of the <liHe.iso by attacking the
structures iirst iitfected ; and, secondly, to strengthen
the resisting power of the j'litient.
When the glands are small and localise<l, removal
has lieen ativocHt<;d so as to cheek the spread of
infection from Ihetii. Hut this is only to be recom-
mended when the enlargement is confined to a single
group of glands, when the spleen is not enlarged,
wheji fever is absent, and the ann?inia is not advanced.
In a few instances on record such operative interfer-
ence seems to have checked for some years, at any
rate, the iwivanee of the disease. Oj>eration may
also ho thought necassary if an enlarged gland should
compress the trache.a or some important nerve or
vessel. Other local measures have been tried, such
as injection into the substance of the glands of
carbolic acid, iodine, arsenic, and otlier drugs, the
applicutions of galvano-puncture, massage, hot and
cold douching, blisters, iodine externally ; but all to
little purpose. Tn^atment at Kreuznach or Wood-
hall Spa has l>een thought serviceable in some cases.
liut of all remedies the internal u.se of a/raenie
seems to be the only one in which any confidence can
be pluceil. At the connncncement ordinary doses
may lie given — viz. 3 to 5 minims of Fowler's solution,
and this may lie increaseil gradually uj) to 20 minims
three times u day, in the absence of toxic symptoms ;
should such arise, the drug must be discontinued for a
few days. It is best given immediately after food, in
milk or milk and water.
It« remedial action may lie germicidal, or it may
antagonise some chemicnl poison. Phosphorus has
also been given, and a reduction in the size of the
glands hiis been not^^i during its use. Oenernl tonics.
f Chap. VIII.!
Pseudo-Levkmmia,
485
such as (quinine and the phosphates and iodides of
iron, may be given, but more jmrticiihirly gootl air
and good and supporting food should be carpfiiUy
provided.
It would have been remarkable if, in the some-
what irrational tendency prevailing at the presejit
time, the employment of animal e.xtracts had not
been recommended in tliese ca.sea. Thymus extract,
splenic extract, and Ixmeniarrow have nil been tried,
but we are not aware that any decisively good results
have been obtained.
Addison's Disease.
Thi.s is anotluT disease which (iffurds very little
scope for therapeutic eflnrts, as it UHually terminates
fatally in spite of all renieilies tliat niuy be ap])lie<l.
It is u.sually associated with tuberculous or wasting
disca.se of tlie suprarenal bodies, or with morbid
cliNiiges in the abdominal sympathetic nerves and
ganglia. We have no definite knnwledgeof its causa-
tion or its pjUlidlo^y. but some cases B]ipear to have
fallowed hlitws u[k>ii the back or nlxiomen, and othei-s
tt> have l>(>cn f)receiled by c'lries of the spine. Much
disi-ussion has arisen, and much hihorious investiga-
tion has Iteen carried oiit, with the view of thixiwing
light on the manner in whicii the changes in the
Bupra-renul bwlies pi-oduce the symptoms of this
disease, and the prevailing opinion is that they are
due to an ina(le<)uatc supply of supi-a-renal .secretion.
The disease is characterisetl by great asthenia, especi-
ally atlecting the circulatory organs, by gastric
irritability, and by a ]>eciiliar plgn\entation of the
skin and some of the mucous memliranes, as those of
the mouth, conjunctiva, and vagina. .Symptoms
which may require treatment are nausea, vomiting,
<h'arrho>a, and great canlinc and general feebleness
and tenilency to syncojte. The disease usually ends
fatally, and sometimes I'uns a rapid course, terminating
in a few weeks. Occasionally it is prolonged for
years, and in rare instances recovery appears to have
486
Medical Treatmknt,
IParl II.
taken pliico ; at nny rate, long periods of iiiiprovemcnt
hiive been obHerved. The indicatioiig for ircntmeiK
are chiefly syraptoiniilic ; for the gastric irritability,
lime water, crea.sote, oxalate of cerium, hyilrocyAnic
acid, iced chamjmgne, may in turns he required ; and
for the diarrhcea bismuth and catechu may be pre-
8cril)ed. Iron has been given in full doses with
apparently good eflect in some cases, and arsenic and
strychnine have proved valuable at times. The
internal luid external use of iodine was 8Uggeste<l by
Fagge, but we are not aware that it has been found
to lie attendul with any remedial effects. Alcoholic
and other stimulants, such a.s ammonia and ether,
may be needed to ward off attacks of syncope when
they threaten.
Tlic piitieui's strength must Ije considered by every
possible means. All wony and excitement must be
avoided, and when the ii.sthenia becomes extreme rest
in l>ed must be enforced, The tendency to death
from syncoiiu must be borne in mind and provided
against.
Acting on the hy[>otliesi8 that the symptoms in
this disease are duo to supra-renal inatleqiiacy,
attempts have been made to relieve them by giving
supra renal i/lnnd svlistance nnd fj-trarl.
The supra-renal Ixidics of the aheeji have been
given, 2 drams daily, with benefit. Tablets con-
taining 5 grains of the extract have also lieen
employed. Different exti-actti seem to act differently
according to various observers — one mising the blood
pressure, and another having an opposite effect. It
is generally believed that the medulla alone con-
tains the active physiological principle, and that the
cortex is inert. Improvement seems to have been
obtained in many cases, but on the whole results
have beeii disappcjinting ; further observation is,
however, desirable.
Goo<l liir, and light but nutritious fix>d, are great
aids in supi>orting the patient. Some piitientR are
said to do best on an exclusive milk diet.
h
Chap. villi Exophthalmic Goitre. 4S7
KxnriiTiiALMic G01THK, Gkaves's Disease,
Basedow's Disease.
IL will he convenient to consider in tliis chaptt-r
tlie tri-atiiu'iit of this reinark.iWlf affection, wliicli.
tilthuiigh often dealt with under diseivses of the
thyroid gland, in especially tniirkeU hy circulatory
and nervou.s dLiturlmiicos.
The three well-known and characteristic signs of
this disease are exo|ihthuluio3, or prominence of the
eyehails ; enlarj^emcnt of the thyroid ; and functional
excitement of the heiirl, or piilpitation. Fts iiiodo of
origin is obscure, Imt it i.s uaicli more frecjuent in
women than in men, and is most apt to occur between
20 and 30 years of age. Depressing emotions, worry,
fi-ight, or nervous shock of snine kind have frei(Uently
Ijeen notice<l to precede the onset of this disease, and
hereditj' woidd appear to have an intluenee in some
coses.
The onset of the symptoms is usually gradual,
and the disease generally runs a chronic coni-se ; but
Osier refers to two rapidly fatal cases occurring in
the Pliila>lolphia hospittd — one with marked cerebral
.syir)|itiim.s, and another in which death occurred from
vomiting aii'l iliarrluea, on the third day of the
illness. Palpit-ation is usually the first symptom
complained of, with shortness of breatii, and the
heart's imiiulse is felt to be greatly increased in
force, and all the visible arteries are ol)served to
throb and ijoat strongly. The heart-beat may vary
from 100 to 100, or even more, and it is reailily
excited by any emotional disturlwnce. Soft systolic
murmurs at the base of the heart are common. The
prominence of the eyeballs is early noticeable ; at
tii-st slight, it may become so considerable that the
eyelids cannot close completely, and it has been
known to i-ench such a degree that the eyeball has
been dislocateil from the orbit. What is known as
Von (Jraefe's sigu is that when the eyeball is moved
downwards the upper lid dpes not follow it. There
488
Medical Treatmmxt.
(Part II.
is alao sbmetitncs spasm or retraction ot tlie upptr
lid. The Piilarjjeiiieiit of tlio thyroiil iimy be j^'cnei-al,
or it may Ite limiteil to one lobe ; it* vessels are
inui'li (lilat^'il, an>) the whole ^liind is fuunil to pulsate
with a. thrill. The piitient.s are ii.sually, at the same
time, anieniic, etrmi-iati-d, fi'brile, and hijjhly nervous.
There is often marked muscular tremor. Tliey
cotiijilnin of painful flushin;^ iiml di-stres-sing jverspira-
tion. Pigmentnry changes in the skin ai-e often
observwl. Uas(ro-int(%tinal irritation, with vomiting
and diarrhieo, is not infrequent, and in grave CJtses
the latter symptom may prove veiy intractable.
Great irritability of t.emj>er and mental depression
usually manife.st themselves.
Recovery is not uncommon in the milder cases,
tind is sometimes nipid, but many of the severer
forms prove intnictjiblc. Kolupses are also common.
It has been noted that myxwdema sometimes follows
closely on exophthalniic goitre.
This disease lias been regunled as connected with
some nervous lesion ; the cervical syni]Mithetic has
been pointed to as the seat of injury, and coai-se
anatomical chanj^es have lieen de8oril>ed in the lower
cervical ganglion. Othem refer to the medulla and
ujjjier cervical portions of the conl as the more prob-
able seat of the legion, and we have oureelves given
reasons for sup|»osiiig the emotional centres may Ije
directly or indirectly involved ;* recently the sugges-
tion has been advanced that it is due to over-activity
and hypei"section of the thyroid itself. But there ore
great difliculties in the way of iiccepting this view,
indeed the [lathogeny of exophthalmic goitre is far
from settled ; it is highly probable that there is n
combination of factors varying in degree in different
cases, and which combine to i>roduce the phenomena
of this disease.
We may consider the li'oalin«'nl of this affection
under three headings — 1. Hygienic, iiidutliiig change
• A Ca»o of Exophthalmic Ooitru with Nvw PheiioineDn.(^r«/.
Mtd. Joum., Mutvh 17th, 1877).
^
ch»i>. vni.) Exophthalmic Goitre.
489
P
of air, hydrothei-apy, and suitable fooil. 2, LocaI,
and esjK'oiully electrical trentincnt. 3. Medicinal,
including the tnahiifut of synipt^mis.
1. Chang!" of air and scene, with restful and in-
vigorating surroundings, is of the very greatest im-
portance in the treatment of these cases. lu spite
of statements to the contrary, we desire to state
emphatically that we know of no such remedial influ-
enctH, in remediable cases of this aH'ection, as a pro-
longed residence at a suitable seaside resort or a well-
selected mountain resort of moderate elevation. We
should not recommend patients with this disease to
seek, as a rule, an exciting climate like that of the
Western Hiviera, nor should we recommend them to
incur tlie risks of the frec|uently chilling air of such
elevations as Davos or the Engadine ; but in such
seaside resorts as IJrighton, Westgat«>, Folkestone, or
Biarritz, which present a combination of the setlative
and tonic effects of sea-air, or at such moderate eleva-
tions as (Jlion, Sonnenberg, Aussec, or even Engelberg
and fSt. Beatflnburg, some of the very best ifsulta have
Ijeen obtained ; we refer, of course, to the summer
season in the mountains. AVe are supported in our
view of the good eU'ect of niounUiin air by so great an
authority as Notlinagel, who considers a "sojourn in
mountain regions most important,'* and also by
Stiller, of liudapesf., t who lnus recorded two inst^inces
of the succes.sful treatituMrt of Graves's disease, with
pronounced cardiac faihire, by residence at an elevft-
tion of 1,000 metres (S.'J.'VO feet), about the elevation
of Engelberg. Eulenljtrg also has advrwated high
nltitittle sanatoria, but be prefers sub-Alpine ones
when dyspna'ic symjitoms are prominent. Much nds-
apprehension exists as to the efl'ects of such nioilerate
elevations as these on the circulatory organs ; in the
first place, the sedative elFect on nervous states which
such re-sorts commonly produce reacts most favourably
on the circulatory organs, and the purity and tonic
• ilrdital I'rru, December lioth, l.SSO, ji. Uoo.
t CimlralbhnfUr klin, Mnl., 1888, No. 'M, p. 017.
49°
Medical Treatmest.
|P:irl tt.
quality of tho air litt\e n general strorijj^heiiing and
restorative eirect. In a good season sitting out of
doors for many hours of tlic dny is {K)88iblo, and the
moi-al edeit of uhet'rful surrouniiings and pleasing
scenery is not to Ix" overlooked. Whenever, then,
the patient is able to Ijear the fatigue (and tho
expense) of removal, either to a suitable sea-coast or
mountain i-esort, this should be the Krst consideration,
and we can assert that it is capable of etlecting a cure
in many cases without any other treatment.
A modified course of liyiirotlioi'Hpy in a good
bracing locality has also much to recommend it, and
has Ijcen found of decidetl benelit in certain cases.
Nothnagei i-econimends tepid half-baths, irrigations,
packing, and the cold sjiirial bag. .laccoud advises
t«pid or warm douche.s thiily for 1)3 or 30 seconds.
After ji time their temperature may be reduced until
lit last they may he given (|uite cold ; but he very
properly warns against beginning witli cold doncRes,
as in the.<!e nervous ]mtient8 they often aggravate the
cardiac excitement.
The diet should be of a nutritious but bland and
unstimulating chanicter. Alcoholic drinks, and tea,
coffee, and tobiicco shoulrl be avoided. Great re-
liance is placed by some physicians on a milk diet ;
when the heart is weak some additions may be made
to this in the form of pnuiuled meat, or lish, or
chicken, or clear souj>, and a little red wine, in some
cases. Whenever disordera of the digestive organs
are present, such as gastric catarrli, or iliarrhu'a, groat
attention must be paid to the <liet, which should
consist ciiietly of nulk and bland farinaceous foods,
such as tapioca, sago, arrowroot, and the like.
Pancreatic emulsion has l>een found beneficial in
many cases.
Sluch repose in the recumbent position is advis-
able, but, except in extreme case.s, the patient netnl not
be lonlinefl to bed, especially if such confinement
is felt to be irksome and annoying. All cause of
excitement, mental and physical, should 1m> carefully
^
Chup. VIIl.;
Exophthalmic Goitre.
491
avoidef], and everytliing that is possible hIiouU] lie
done t(i promote a (.-lieerful mid li(ip<?ful friiiiie of
mind.
2. la tiie next place we must con.sider the value
of local, and especially of oloclrical, treatment.
The application of coltl to the pnucordial region,
or over the lower part of the neck, ha.s been found
useful by many in quieting the palpitations Notli-
nagel uses an ice-bag, aird Osier recomniend.s cither
this or Inciter's tulte.s. These applications, however, lire
not unattended with danger, if iiiciuitioiisly employed,
and they occasionally cause intliimiiiation and .slough-
ing of the distended skin over the" thyroid.
We Would urge that it is neces.>)ary, in making
such applications, to have particular regard to the
hyjier-sensitivc stat* of these patients, and to consult
their feelings, and to watch cttr<.'fully the eflect on the
circulation.
A Martin's bandage has been applied round the
throat by day and removed by night, to restrain the
pulsations of the thyroi<I ; and a compress and bandage
have laeen found useful, applied over the projecting
eyeballs during sleep.
Testimony as to the efficiency of local electrical
treatment is almost universal. Fagge Ls almost alone
in stating that giilvaiiic treatment has been followed
with little advantage. We have ourselves observed
it cause great aggravation of all the symptoms in the
case of a highly nervous and sensitive patient, but we
thought that the electrical specialist in thi^i instance
applied far too strong a cun*ent.
We also note that in all the cases reputed to have
been l)enefUed by this method of treatment, it has
been applied legularly for six tnontln ; now we have
observed very remarkable improvement from change
of air alone in this period, and the value of this
treatment, upon which we do not desire to throw any
doubt, must rest on the benefit it confers on [latients
who cannot, at the same time, avail themselves of
suitable change.
49»
Medical Treatment.
[P*n II.
Nothiiagel iidvisps galvanism through the uiediilla
and the cervical sj-iupathetic. Charcot recnnmiftided
the faradic current to l»e iipjilied to the cyeliiis, the
thyroid, and the cardiac region. Osier udiiiitB tliat
many cases have derived tenipornry impro\enient I'ruin
tlie use of the galvanic current, the catliode being
placed at the back uf the neck, and the anode along
the course of the sympathetic or over the heart
Jaccoiiil considers the best form of electricity to
employ is bilateral galvanism of the neck, daily, by
means of weak continuous ascending currents.
3. We now come to the question of niedi€in»l
treatment, an<J here we encounter, as might be
exjjected, great divoi-sity of opinion. We agree with
Nothnagel in believing that mediciiies " are of little
use " as direct curative agent.s, but we believe that
as auxiliaries and for the relief of symptomatic con-
ditions suitable medicines will be fouinl of very great
value. Fttgge asserts that iron seldom or never does
good, and tluit digitjiHs has no power in tranquillising
the heart. Dsler, on the other hand, advises a com-
liiiialion of digitalis and iron when there is marked
una-mia, and Nothnagel commends a combination of
iron and bromides. We have fre<|uently given iron
in combination with strdium bromide with vei-y great
a<lvantj»gc in the milder forms of this disease asso-
ciated with and'mia in young women. We always
use a mild preparation of iron, generally the am-
monio- citrate, and we give 5 to 10 grains of this
thrice daily with 10 grains of sodium bromide, with
the effect of lienefitlng the anjemia, ipiieting the
nerv ous excitement, and lessening palpitation. Digi-
talis we have found a " two-edged sword " — in some
c&ses it will tjuiet the action of the heart and reduce
the pulse rate, but in others it seems to increase the
cardiac excitement and to make matters worse ; and its
tendency to cause gastric irritation is more manifest
in this disease tbau in any other. On the whole, we
think it should not Ijo commonly [)rescribed in this
disease. Several irustworiliy observers testify that
Cliap. VIII.I
Exophthalmic Goitre.
493
P
strojihnnthus, 5 minims of tlie tincture three tinier
.1 (lay, ijiiiets tfie cardiiic action anti is of real
service in this iiuviiuly. Cticltig grnndijlorim, the
Huid extract and the titietui-e, the former in dosas of 5
minims, and the latU:"r in doaes of 10 to 45 ininiiiis,
three tiniea a day, has also heen found of marked
value in some cases. Friedreich advises the continueil
use of quinine ; we agree with Jaccoud that it often
fails to iigree with these patients. Arsenious acid is
a favourite remedy of Jaccoud ; he gives i,^ gniin,
twice a day, with the food, aiid increases the dose,
with intermissions, up to -^^^ j^i-ain. Cacodylato of
sofliuru has \x!c\\ found useful iu m;ktiy cases, and
is ;v preparation whiidi permits of the use of arsenic
in larger doses. Besides the liromides, which ans very
useful in allaymg the troulilesome nervous symptoms
and iusuuinia, we hiive idso fouml valerianrtte of zinc,
a grain three times a <lay. vulual)l« for the same
purpose. Tlie l)romide and iodide of strontium mixed
have been given with much improvement in certain of
the symptoms.
Belladonua has a certain amount of testimony in
its favour, nnd made into a collodion it has been
painted over the thyroid enlargement. We do not
advise the use of such <lepreasors of cardiac force as
aconit<; and veratruin viride, recommended Ijy some
autliorities : the cardiac force does not need depres-
sion, but regulation.
The use of sodium piiosphate — from \ a dram
to 2 drams daily — bus had uiany advocates. It is
(juitc hnrndos.s, and .should therefore im-rit a trial.
Dr. Meltzer combines the use of thymus gland
with this salt.* He gives the thymus minced raw
in wafers.
The gastro-intestinal troubles may require the
exhibition of bismuth, hydrocyanic acid, and alkalies ;
the dinrrha-a in the later stages of this disease often
becomes most intractable, ami may require the use
* Hure'a "Systom of Pnifticiil Tlicrniwutirx" (lu'w ciiitinn)
roli., p. GI7.
494
Medic A i. Tr ea tment.
IPutU.
of opiate eiieiuata- — 10 grains of Dover's powder ami
20 grains of tannin mixed with 2 ounces of Htardi
may lie thrown into the bowel twice a day if necessar)-.
We have found the, tincture of coto, in 10 to 20
minim dose8, mixed witli a dram of I'oiupouud
tincture of cardainuniB, u dram of mucilage, and
an ounce of chloroform water, one of the l)est in-
ternal remedies for this symptom. Tlie use of the
ai'omatic sulphuric acid, in 20-minim doses, three
times a day, has been found to give very good results.
Dr. Minor,* of Ashville, N.C., has reported h
successful treatment of twu cases on the idea that
tills disease arises from " intastinal auto-intoxication."
The drugs given included salol, beta imphthol, re-
sorciii, guaiacol CArboimte, and an occa-sional dose of
calomel, and also free intestinal irrigatum with hot
water. Dr. M. P. Jacobi has also imblished a suc-
cessful wise treated on the same lines.
Thyroidrriomy, ligature and division of the
isthmus and partial removal of the ghind, lina
i-epeatedly l>eeu performed with the object of relieving
tlie dyspncea caused by pressui-e on the trachea, but
t'he operation is a serious and dangerous one, and
although goixl results liave Ijeen claimed for it, in
some instances, it has never been gent>rally regarded
with favour m cases of true Graves' disease. The risk
of fatal haMuorrhage is always present. Recently
surgioil measures have again been advoc^ited and
practised in Germany and elsewhere. In several
cases resection of the thyroid has been successfully
carried out and enucleation in others. It has Ijeen
stated that all, or almost all, the clinical symptoms
have been relieved by these operations ; but more
evidence is still needed in order to justify surgical
interference. Section of the cervical. in/iii]Xithelic
has been done in a certain number of cases, and
benefit is .said to have followed. Attempts have
also been made to treat this dise^ise with thyroid
and 111) iHiis exirncts.
• Intm-t, ToL i., IIHX), ji. 116.
h
Chip. VIII.) Exophthalmic Goitre.
495
(.)rd und Mackcnzio * stale that they have not
olisiTvi'd any cases in which thi- patient was decidedly
benelite<l by this treatment, whih", in some instunccs,
the ])Jitient'8 HVinptonis were dislijictly aggravated
even by small doses of thyroid extract.
In extremely violent attacks of palpitation,
jeop.'irdising life, which have been rejwrted, but which
we have not witnessed, various expedients have been
su^gestcul, such as venesection, the free use of ether
and other stimulants, the ice-bag to the heart, irdiala-
tions of nitrite of auiyl, and hypodermic admini.stra-
tion of morphine and atropine.
My.v<edkma.
This singular disease, to which inueli alleution
has of late years been din-cted, nmiuly lliroujih the
olisei'vations of (lull and Dnl, seemn tu be de]K'ndeiil
on a morbid condition of the thyroid liody, and to bo
patliotogicatly related to those case.s of sjwnidic
cretinism in which there is a congenital absence of
that gland.
Tlio disease to which we are now referring was
descrilwd by Sir William Gull as " a cretinoid stute
supervening in iulult lifo in women." Ortl and many
other observei-s have investigate*! and fully described
this all'ection, and have shown that it is not restricted
to women, although they are far more frequently
affected with it than men.
Tiie mode of origin of the disease is obscure, but
it lias licen referred to nieutid anxiety and distress.
The anatomical condition appears to be wasting or
degeneration of the thyroitl gland. It may be much
diminished in size, or it may be completely atrophied
and converted into a fibroid mass. The presence of
an enlarged thyroid is not, however, inconsistent with
the manifestations of this disease, as, although enlarged
iu size, the gland may, functionally, have undergone
degenerative changes. The chief symptoms and
clinical features of this <liseasc are the following ; —
• illlbutt's "System of Hfsdicins," vol. iir., p. 607
496
Medical Tkeatment.
(Pan It.
Great Iosm of muscular energy, so that tlic (latient's
inovcnii'iita l)ecoine remarkably feeble and slow, ami
liis guit unBteody and " swagfjeriug " ; his s|K;ec.h also
becomes slow and delitentte, and sometimes indistinct,
and the toiig:ue is thick and swollen ; mental opera-
tions, too, are slow and flagging. The face ha« *
peculiar and characteristic ap|>earance. It is swollen
and cxpre-ssionless ; the complexion has a waxy
aspect, and there is a bright red spot on each cheek
caused by dilatjition of veins and capillaries ; the ala;
of the nose are thickened and the nose itself is
flattened and spread out ; the lips are thickened,
swollen, and often cyttnosed ; the eyelids are also
swollen, I'lVJgy, or puffy, and transpan-ut, but on
puncture no duid exudes ; the eyelashes and eyebrows
often disappear, and the hair dis4ippears also from the
axillie and puV>es and in ]>art from the head, so tliat
the patient may be nearly bald. The l>ody generally
incretuses in size and weight, and tlie abdomen becomes
protuberant. The hands arc notalily swollen, clumsy,
ami "spadolike," their backs are especially so, the
fingers are thick and sensation is defective. The
" (vdema " is unUil, and does not pit on pre-saure.
There is further a jieculiar swelling of the suljcu-
taneous tissues in the supraclavicular regions. The
skin is observed to l)e very dry and rough, and the
patient rarely or never pei-spires. The circulation is
languid, the pulse slow and feeble, and the heart
sound.s weak. The temperature is usually sub-normsiL
Allmniinuria is sometimes presei\t.
The clinical study of this disease, and especially
the successful eflbrts that have lately been made in
several quarters to deal with it therapeutically, have
thrown much light on the functions of the thyroid
body, and have raised, if we may use the expres-sion,
the physiological rank of that organ. It is dear, from
the results observed to follow disease of this gland, as
well as from its removal in men and animals, as re-
ported especially by Kocher of Heme and Horsley in
England, that it elaborates, normally, some secretion
Omp. VIII.)
Myx(edkma.
497
which passes into the general circulation and exerts
there an important induenco in tissue metJil>olisni.
We will now briefly consider the therapeutic
measures thiLt have been applied to the anielionition
and cure of the aiyxaileiutitous state. At first the
application of hot b;iths and keeping the body warm
ami well protecteil from chill, and promoting the
action of the skin by the exhibition of jahnrandi, was
all that seemed clearly indicsit«d, and some improve-
ment in the symptoms and general cotidition bad been
oljserved by Ord and others as the residl "tf this treat-
ment. But most remarkable results have been
obtained hy tiie adoption of a iuetho<i of treatment
which inaugurated a new departure in therapeutics,
and which hius lH»en followed by nuiny innovations in
the same direction that have been attende<l with a
variid;le degrt'e of success. Ilemediul agencies, in the
shape of drugs, had hitherto been looki-d for chiefly in
the mineral and vegetable kingdoms ; we have ex-
tracted the juices of many veyelitble orgaidsms, and
applied them to the relief of human suffering and
intirmity. We have now turned to the animal
organism to scH.'k curative and jireventive powers
for certain morbid states in the juices of animal
tiss\ies and organs. Th«^ observation of the fre<juent
occurrence of a peculiar morbid attite (^cac/iexiii strinni-
jrriva), closely allied to cretinism and myxiederaa,
in jiersons and animals (monkeys) whose thyroid
glands had been wholly or partially removed, and
the knowledge of the fact that in ca.ses of con-
genital or sporadic cretiiusm the thyroid gland is
cougenitally absent ; and further, the discovery that
in cases of inyxoedema the thyroid Ijody is often
found shrivelletl and completely atrophied, led up to
this i-emarkable therapeutic discofery.
The first attempts were made with lliyroid
KrHl'lhifi;. This had lK>en carried out with good
results in iv/c/cifm atriuni/irlva, in sporadic cretinisnt
and in inyxAHd^ma, by Kocher, Horsley, Bircher, and
by Cribson, of Brisbane. In a case of sporadic
o G
498
Medical Tkeatment.
tPari ic
cretinism fully reported by Gibson,* the jsrafting
wa8 done by renlo^^Ilg yx)th lobes of an a'therise<l
lamb's thyroid, incising them longitudiually mid intro-
ducing them (1) witliin the sheath of the pectonil
muscle, and (2) on another occasion into the child's
alidouien. The improvement in the child's condition
which followed was most reuiarkable. Jluniiy, of
Newcastle, was one of the first to suggest and Jidopt
the use of an csli'ju'i of the lliyroid (tlniids of
sheep, injected hy|todt'rriiicHllv, in llie Iroatnient of
these cflnditious, tind I'cmarkable results were
obtained, t
It must be borne in mind that the too rapid
introduction of the thyroid estnict into the blood, or
its introduction in too large ((uantitj at a time, is
unsjife, and is a]>t to be attende<l by unplea-saut
pheiiuiuena, such as flushing, nausea, lumbar pains ;
and even lass of consciousness and tonic miisculur
spasms liave been induced. There is also another im-
portant caution to be kept in view, and that is that
such patients* must not lie allowed to return too soon
to their former niiHlc of life, after their ajiparent cure,
for in some the cardiac muscle remains very feeble,
and sudden death from cardi.ic failure has been noted
in some patient.s on making etForts to which they have
long been unaccustomed. Of course this kind of
treatment, which has for it« object to supply the
defective thyroid secretion, must in mo.st ca-ses i
be more or less continuous, and on its entire dis-
continuance relapses must be ex|)ected. But the
hypodermic method of administering the fluid
extract is now largely supplanted by the use of
dry extract*, and e8i>eciaJly of that made in the
tabloid form.
It is l)e«t to coniliience the treatiu(<nt with small
doses. One of Burroughs and Wellcome's smaller
tabloids (grain 1^) may be given once or twice a
day. This dose .should Ije gradually increaseil up to
6 grains daily. Then after a few clays' interval a
• Br\t. ilfd. Joum., Jau. Hth. 1893. t ll><<i., Aug. 27tli, 1892.
Chap. VIII.)
Afyx(EniiMA.
499
slowly progressing increase may Ije again adopted,
provided no nntowanl Fj'iuptoms are iuiiiiifL'St«d.
Throe doses of .5 grains each pi?r diem Mlinuld be
regarded as the maximum. The oocurn'ncc i^f h«id-
ache or [mins in the muscle.s sliould iit once l>e
regardoil as signals for diminishing the ilose, and
should more serious toxic svmptJinis opjicar the driig
must lie discontinued for eight or tvn clays, and the
patieut carefully watched. The treatment may then
be returned with quite snuill doses. It has been
found that patients bear this treatment lietter when
kept mainly on a suitable vegetable diet. A small
do.se of stryclitiine ( j'„ to ^j, grain) three times .1 day
is helpful in supporting the patient's strength during
this treatment. After the full eflect of the thyroid
treatment has been obtained, the question arises as to
the best niethofl of contitiuing its use so as to avoid
relapses. The Itest results seem to have Ix-eti
obtained by giving 10 or 12 grains three or four
times a week for thrt»e or four weeks. Then the
drug is for a time discontinuetl until some signs of n
relapse a]ipear, when small doses (3 grains thrice
daily) for a week will generally suffice for their
removal ; then return to tlie thrice weekly dose,
and .so on.
Iiidolliiirinf, a substance separated from the
thyroid gland, containing nearly 10 per cent, of
iodine, mixed with sugar of milk, so that 15 grains
of the powder is equal to ab<iiit 15 grains of fre.sh
gland, has \mh;x\ introduced for the treatment of
myxii'denm and other affections. Meltzer has found
it serviceable in this <liseJise.* He did not find it so
active as the other prejmrations of the gland, but it
had the advantage of being t<derated in large doses —
30 grains a day for many weeks — without giving rise
to any UTipleasant syinptom.s. Tt is certain that
iodothyrine rejiresents oidy a (wirt of the active
HubstAiicc of thyroid, but Meltzer considers there la
* Hare's "System of rractical Therapuutidi " (now edition),
vol. L, p. 002.
5O0
Medical Treatment.
I Part ir.
Homc Advantage iii this — for, as it does not contain
albiiiuinous mutter, it must be free from toxic pto-
maines, aiul does not decompose even after months
— hence prohiihly the reason why, unlike other
preparations of the gland, it so rarely causes dis-
agreeable symiitoins.
The fresh thyroid glands themselves have been
given by the mouth in many cases, and thus taken
they appear to be quite efficacious. Half a sheep's
thyroid seems to be a suitable dose for an adult. It
must be eaten raw, and may be minced fine and
mixed with a little weak spirit and water, or wine and
water, or syrup. Besides the tabloids of Messrs.
Burroughs and WisJlcome, each 5-gniin tabloid lieing
equivalent to -,'j th of a lobe of the fresh thyroitl gland
of the Bhce]», there are many other preparations in use.
The tabloid form, however, seems the most convenient,
and affords the greatest facility for regulating tho
dose.
The resultsofthis mode of treatment in niyxiedema
may be thus summarisml : the swelling diminishes and
the natural e.xpiTssion of the face returns, the skin
peels oH' itnd the cutiineous surface loses its harshness
and dryness, ami liecutnes soft and moist, and the
patient is able again to pei-spire freely. New hair
grows on the head. After a brief period of feverish- ;
i\e«s the previous subnormal temperatures approach
the normal. The hands and the rest of the lx)dy
become siuiillcr, uud there is usually a great loss
of weight. Mentid as well as bodily activity is
to a great extent restored. Increased diui-esis is
common.
In cases of sporadic cretinism the commencement
of the treatment has lieen frci|uently marked by some
febrile disturbance with mentiil excitement and rest-
lessness ; after a little time the (edematous infiltra-
tion of the ti8.sues b(^gins to subside rapidly, and in
a few weeks disappears. The skin, as in myxoedema,
peels and liecomes soft and smooth, and the hair grows
over bald areas. Tho child becomes more lively and
Chap. VIII, 1
MrX(EVEMA.
SOI
intelligent, and there is a moat remarkable growth of
the skeleton (in one of Byrom Braniwell'a aiaes the
child gi-ew 6J inches in six months !).
ADDITIONAL FORMULA
For ezophthaimic goitre. |
R Furri carUumtiB succhiirobi*, i
KT. X.X.
CJiiiiiinn' sul]iliatis, gr. xxz. '
Extract! ct pulvoru glycyrr- '
Ut f. nil. XXX. Thrco to be
takeu uailv nfter niools.
{llnirHikl.)
For the Mme.
R Palveris ipcciu'unuliit', ^r, ss.
Pulverin fuliorum digilAliB,
Extrarti opii, gr. i.
M. f. ])il. Four to six to be
taken dail}-. {Dimlafay.)
For exophtbalmic goitre.
ft 'Jiuctunr fcrri acotutis
iith?ris, .ij a<l .<ij.
Potju.«ii iodidi, .^ij.
Aqua; ad jvj.
M. f. mi«t. A tca«poonful
tbree times a day ; auo fric-
t iona with iodine ointment.
( Lmlortti/.)
Iron And bromide mixture
for the same.
li Fcrri ct nminoiiiii' cittnlis
Smlii brnmidi, gr. Ixxx.
Spiritiii) ununouiip aromatici
.^ij.
Aiiuif ml STJij.
M, f. milt. Twn tablespooD-
f Ills twice a day.
S02
DISKASES or rilK CiBGANS OF RESPIUATION.
CHAPTER I.
THE TREATMENT OF CATARRHAL AFFECTIONS OF THE
RESPIRATORY ORGANS : ACUTE AND CHRONIC NASAL
AND IMRYNGEAL CATARRHS.
AcuTK NiSAl. Catabhh or CJoktza.— CauBe«: PredunodUon —
Chill — Dust—Sjinptoma— Treatment : («) Proph jlai^tic— (A)
Gciipral— Propnnitious of tlpium mid Moriihiue— Qiiiuine —
Salieiiie— Aconito — Bolludoniia— Cuniphor — The " Dry " Cure
— (r) Louil — Inhdlution.'' — SpravB -Iu8uffliitioii»-Su]jm-rf!ial
Oland Extract. Cueonic N'asai, Catakbu.— Astringeut
SnuiTsand liijeotiona— Alkaline Injoctwnt—OzirHa or Almii/iir
y?/ii/iifi»— Olwcurity of its Nature and Cause. Trcatnirut ;
Indications— Cleansing Douclies— Formulie — Antiacptit' and
Deodorising Points— Sprays — Injcrtious — Boogies and In-
iufflstions— Formnlff. Actrrn Lasyxdbal Cataeeh. — Causes
tascmble those of Acute Nasal Catarrh — .Svioptonis -Trtnit-
ment: Codeia'or Morphine — Alkaline Drinks or Mixtures —
Comitcr- irritation— Cold Compresses— Cocaine— Inhalations
— Severe Dyspnteic Fonn in Children— Leeches— Enietirs —
Scarification — Tracheotomy — Sedatives and Expcctomnts.
CiiKOMic Lab^'NOBAi. Catabbh.- Causes— Symptoms— Treat-
ment : Mineral Waters — Local Applications — Inhalations —
Insufflations — Sprays — Massage — Climate. Additional
Formulie.
Acute Nasal Catarrh or Coryza.
The plienoiuenu att«nding an attack of acute nasal
catarrh, coryza, or " cold in the head," are so familiar
as to scarcely need description. The disease is inter-
esting and instructive, iiowever, as a type of catarrhal
affections generally, since the intlnined mucous mem-
brane is, in this case, acocssilile to view.
The rnnst'8 of acute nasul catarrh are the same
88 tliose of other ctitan-hal affections of the air-
passages, viz. exposure to some local irritant, or to
Chip. 11
Acute Nasal Catarrh.
503
chill of the surface of the body, or to rapid changes
of tein[)eratnre : but exposure to these exciting cHuses
does not necessarily pro<luce this ilisense, unless a
predisposition " to take cold " exists in the individual.
This cciiiHtitutional piTilisposition is very marked in
in.'iny pi-fRons, and is not •»asily accoiinlefl fur.
Cidarrhsof the nasal and other mucous membranes
are the result often of refffj' rather tlinn of direct
irritation A current of cold air fallitig on the head
or face, or some other part of the body, will, in pre-
ilisposed persons, give rise to an attack of acute uasal
catarrh.
Dust is another fi'e<|uent eause, especially the foul
dust of the streets blown about by a cold east wind.
In certain instances this disea.se seems to be
infectious, and will sometimes spread from one
memVx'r through a whole family.
The j)liysical cliaiigf^s which are observable in the
nasal mucous memltrane when affected by an acute
catarrh are these : — The membrane is more or less
red and swollen, so much so, sometimes, as to com-
pletely block up the nasal passages ; the swelling is
due to dilatation and congestion of the blood- vessels
and exudation into the tissue of the mu«)U9 membrane.
At first the surface is dry, but sism the fluid exudation
is so considerable that it flows away from th(^ surface
as a colourless, thin, saltish lluid, often very irritating
to the orifices of the nose and the adjacent skin of the
lips. Tjiter the swelling; and congestion diminish,
and the discharge l)ccomes thicker and less transparent
from the presence of abundanee of young cells.
The sjiiiploms accomj>anying this condition are,
firet, a sense of drj'ne.ss and stuffiness in the nose,
with a great desire to blow the nose — to "clear it" —
sometimes there is a tickling feeling with an irresist-
ible tendency to sneeze; the feeling of dryni»8s is soon
succeeded by the flow^ of fluid just described, which
may 1)ecome distressingly abundant.
There is usually a smarting, painfid feeling about
the foi-ehead and eyes, due to the extension of the
S04
Medical Treatment.
IPirl III
catarrhal inflammation to the conjiinctivie and the
frontal sinuses ; sometimes it extends to the fauces,
and causes jmin in swallowing, or into the larynx, and
(ifivcs rise to an irrit«ltle cough, or along the Eustach-
ian tube, cuusiiig some pain and noises in the ears,
and slight temporary dnufncss. With some persons
there is usually a certain amount of fever present,
with quickcneci pulse, slijjht rise of temperature, thirst,
high-coloured urine, fhillini's«, and aching of the
limbs. With careful treatment this disease usually
disappears in from three to eight days, l)ut if neglected
it may tfruiiiiiite in cliionic catan-h, which may
extend to llu; larynx, or even to tlie bronchial tulies.
The trrntinent of acute nasal catarrh may be
conveniently considered under three heads : — (n)
projihylactic, {l>) general, and (c) local.
(« ) Prophi/ltirtic Ireatment. — Tliis should consist
ill the adoption of some hardening pn)ce»8 which
shall have for its object the removal or diminution
of II certain hvper-sensitiveness of Hm' skin tuid
mucous membmnes which charact-erises audi patients.
Avoidance of sedentary habits and free exercise
in the ojjen air are of great value. Cold aOusiou over
the head and neck, begun in warm woAther and
steadily maintained throughout the whole yei»r, is of
undoubted efficacy.
One of the best prophylactic measures against
attacks of nasal catarrh is residence in a dry, bracing
locality.
Removal for a season to the dry, cold, brasiiig
climate of the Engadine, or some similar i-esort, is of
especial value in lessening the morbid sensitiveness of
t)ie surface, so far as it tends to the production of
catarrh of the respiratory tracts.
Next in value to mountain air is well-directed sea
bathing, during the summer months, associated with
abundant exposure to the open air of the seaside.
Such patients should not be allowed to remain long
in the seA at a time ; it is better they should make
repeated plunges, for it is the bracing shock to the
Chap. 11
Acute Nasal Catarrh.
SOS
P
surface that is required, not the continued contact of
tlie culd sea-wnter.
(i) Of ijunitTdl remedies, diaphoretics are un-
tloubtedly most useful, and one of the most eH'eotual
of thpHG is opium. It acts best wlien combinc<l with
other (liaphoreticH. If it fails to cure the cold, it at
any nite relieves the most distressinj; sjniiitonis,
Ojiiuni undouliteiily exercises a remarkable effect
upon the capillary circulation in the respinitciry
mucous meuibnines, iiut it is by no means n matter of
indifference what method of administering the opium
is adopted.
When the cold is quite in it« initial stage, when
the nasal mucous membrane is only a little swollen and
dry, and there is an uneasy feeling over the frontal
sinuses, and before the occurrence of any great
amount of fluxion, the following is perhaps the liest
method :—
Supposing the patient to have had a good meal in
the middle of the day, no more solid food should be
taken that day, but about three or four hours before
bed-tiiue a pill of ;^th of a grain of acetate nr Bul]<hate
of morphine should be taken with a small cuj* of
weak tea ; and at bed-time another ^th of a grain
with a wine-gla.ssful of whisky and water.
If the patient is feverish or is of rheumatic
tendency it is an excellent plan to combine 10 or 15
grains of saU-cine with the dose.
A saiino aperient — such as a seidlitz powder
in warm water, or a few ounces of Apenta water
(warmed), the following morning — is also useful.
This measure alone will constantly arrest a cold in
the head if adopted in the initial stage. If it fails, it
fails frcmi want of attention to small details. It
makes all the difference whether this small dose of
nior|)hiiui be Uiken when the stomach is full or empty,
whether it he al^orbed into the blood in a few
minutes, or whether it be mixed with a mass of food
and aljsorbed slowly. The result in the two cases is
wholly different. In the first case you have a definite
So6
Medical Tkeatmb.}it.
IPafI III.
quantity of the remedy immediately al»orlied into the
blood ; in the second, the reine<ly is slowly al>8orbed
in imlefinit* quantity, and there is no reason why some
of it Hhould not pass out of the bo<ly in the residue of
the food.
If the dry initial stage is passed, and the nasal
fluxion is thoroughly estahlished, with a distressing
feeling of oppression and stuBiness about the nnsal
]ia8snges and frontal sinui*ea, the following diaphoretic
dniught, containing opium, is nf the {(reiitest use : —
1^ liiqiiuris opii aedatiri
Villi ip<-cariiftiihii"
Sitlioiiii puri...
Liqiioriit animonii acolotit...
Aquii) camphoric
nvV.
gr. XV.
lid 5J98.
9iliNC(i, fiut haustua To be taken at bcd-tinic.
If the patient is able to remain in the liouse, or,
better still, in a moderately warm room for a day or
two, a single dose of this kind will not unfrequently
remove all the catarrhal symptoms permanently as
well OS immediately.
But even these small doses of morphine or opium
are not well borne by some persons ; the use of these
drugs, in some patients, is usually followed by nausea,
a furred tongue, dark -col oureil urine, pale, clay-
coloure<l stools, and a feeling of general mnlaite.
These are persons commonly known as " bilious."
The functions of their liver cells are ca,sily inhibited
for a time, especially by opium. In such cases it
is best to avoid opium altogether, and give other
diaphoretics, such as two t<iblespo<mfuls of the
following mixture every four or five hours: —
l^T Spiritus n<thorit nilroii Jtv.
Liqunris ammoDii acctntis Jij.
Salieini puri ... Kt. xl.
Villi ipocacunnhiu . .. mul.
.\qiiiv ounphonn . . ml Jviij-
Miscc lint rai«tur».
Tliis is also a useful mixture for young children,
Chap. 1 ]
Acute Nasal Catakrh.
507
P
PotaHsii bicnrbonatis
{m3J.
Sodil bknrljonatis ...
AmmoDii c-Hrbonatis
.. 3SS.
Syriipi siuniiitii
■ .V8-
Aquai
ttJ jviij.
Miice, fint mbtura.
in doses varying from two teaspoonfuls to a table-
spooivful.
After the firnt twenty-four hours, or even sooner,
it is often advantageous to give soous qniiiine,
especially whon there is feverishness and a feeling
of depresbiou. It is best given in an eft'ervescing
saline mixture as follows ; —
"^
Vj Qiiininni siilphatis ... ... gT- xij.
Pulveri* aciui citrifi ... 3ij.
S(icchu.ri luctia 3J.
Slisce nt divide in pnlveres nx. One of th« powders, dii-
Bolvcd ill wntor nnd mixed with a sixth part of the mixture, to
l)e taken thtve times 11 day.
In children and young people, when an attack of
coryza is attended, n-s it often is, with rleeideil feverish-
ness, and particularly if the throat is involved and its
mucous uicniKrane is frmnd red and swnlli-n, great
l*netit will follow tlie tul ministration of a few doses
of aconite, Iiideed, aoonitc will lie found most
valualjlc in all tlie ephemeral and sjnnptiDmatic fevers
of children and young people. A convenient fomi is
Schiefflin'.s pilule>! of J)uquesnir8 aconitine, ^J^ gi'ain
in each. One of these slK)uld Ije given every two
hours for three doses, or 1 to 5 minims of the tincture
of aconite (according to the age of the patient). As
a rule, aconite is a drug that produces an immediately
beneficial efl'ect, or it is of no value ; it i.s therefore of
much use in the inilial stage of febrile maladies, but
of little use in the advancetl stages. It is a drug,
therefore, which should never be given in largo doses
with a view of obtaining better eflects than from
small or moderate ones, nor should it be persevered in
when it fails to atford immediate relief.
Camphor is a popular remedy for coryza ; a few
So8
Medical Treatment,
(!>*rt III.
drops of the spirit of camphor, on sugar, or taken
in water, every half liour, will in certain persona
arrest a cold in the hi-ail,if taken in the initial stage;
but it is not to be cotnpartHJ in efficacy with opium or
morphia, given in tlie manner enjoined.
Whiit is called the " dry " cui-e consists in stopping
the supplies of nil li({uids ; and so, by not adding any
water t^) the blfiod, while the system wiilulniws from
the IiUkhI the Hiiid rcijuired for the natural secretions,
tiRMjuiintity of tliiid in the blood-vessels is diminished,
and the local hyi>enenii(i thereby lessened. The
catarrh cea.ses because the .supply of Hiiid to the blood
is cut off. The amount of fluid permitted is a tuble-
8]>oonful of milk or tea with the morning und evening
meals, and a wine-glassful of water at bed-time. But
this has never been a popular method — the remedy
appearing to many persons worse than the disease !
(c) Lastly, we have to consider the action of
retneJifS ap/iNi'd locally.
A common and po[)ular method of attempting to
cut short an attack of coryza is to inhale the vapours
given oti*by a mixture of ammonia, carbolic acid, and
rectilietl spirit :
I^ Liquoria ummuniiu fortis
Spiritiis vini rcctificati
Acidi carbolici
AqiiR-
iliscf.
3^:
3J-.
5'J-
This nd.\turc is dropped upon some absorbent
substance, and the vajiour is inhaled by the nostrils.
The following is also an excellent inhalation (dry)
in the earliest stage of nasal catarrh ; it can be
inhaled fram the bottle in which it is contained : —
V} I'iuol ... . 5ij.
CftDipbonD )fr. xl.
Liquoria ammoniaj fortis ^.
Spuitui reutiticati .. 5J.
MUcc, fiat inhabttio.
The inhalation of the vapour of nicnthol we have
found the most useful of all in recent nasal catarrh.
Chap. I.l
Nasal Catarrh.
509
When tlie secretion is profuse and tlic nostrils feel
blocked up, benefit is often obtaineti by the uppli-
cution of a warm spra_v or douche of a weak solution
of common salt or sodium bicarbonate (3 to 6 grains
to the ounce), oi' Ems water, four or five times a day.
Brushing the nasal mucous meml)i-ane with
glycerine has been found useful, and the iipplication
of an oily spray often proves vtny cocnfortiug.
Relief t^i the sense of distrexsing fulness may often
111* obtained by applying pli-dgels of cotton-wool soaked
in a 2 to 1 |>er cent, .solution of cocaine, or by inhal-
ing menthol dis-solved in chloroform, a few drops at
a time from the palm of tlie hand. The excessive
secretion may be checked by injeetions of hazeline.
The fact that supra-reiMl i/land ej-tract acta as a
powerful local astringent when applied directly to
mucous membranes, causing bhuiching and shrinking
of the infliiiiicd ti.ssues, has led to its locitl application
for the relief of eoryza, and it is preferretl by some to
cocaine, which they regard as a dangerous drug. An
aijueoiis solution of the strength of 1.'0' grains of the
dried extract to S oz. of water has beeti used. This is
applied on (iletlgetw of cotton- woo!, the nose and naso-
pharynx having been previou.sly cleansed by an alka-
line lotion."
The recurrent form of nasal caUirrh will often
yield to change of air — from the town to the sea-side
or the 0[)en country.
Chronic Nasal Catarrh. Oz.kna.
Many chronic forms of nasal catarrh are associate)]
with structural changes in the na.sal |)assage8, and are
only amenable to special surgical treatment, and,
therefore, do not concern us here. Other forms are
perhaps better termed recurrent than chronic, and are
MSSoeiat*il with the tendency to atUicks of acute
eoryza already referred to. These are l>est treated by
change of air, and by tonics, of which, as we have
• Burroughs and Wellcome prepare forextemul use "Soloidn,"
eiicb cuutaimng holf-a-grain of supra-reiuil gland «.\truct.
S'o
Medical Treatment.
IParl III.
already said, ai'senic, or arsenic with iron, is the best.
Injections of Imzeline clilutfii with an equal quantity
of watPi- nrc also useful in these recurrent forms, and
so also are injections of acetate of lead {-t to 16 grains
to the oiincp of distilled water).
Dry inlmlali<jiis of pitio!, eucalyjitol, fui'jientine,
nientiiol, ami ioilint^ may all lie tried with advantage
in diflVifnt eases. If tliere is a tendeney to the
formation of crusts of inspissated mucus in the
iiosti-ils, these should first be washed away by
douching the niuud passages with warm solutions
of sodium bicarlionate and common salt (2 to 5 grains
of eiicli to the ounce), and the above astringent in-
jections or inhaliitions should be applied subsequently.
Oily spi-ays applied by means of an oil atomiser
are very useful. Liquid filbolenc and pnroleno may
be employed as the basis of such spiays, and 10
minims of tei-ebene to tlie ounce may be ad<led.
The most troublesome and serious form of chronic
nasal catarrh is that known as oxtrnn or atrophic
rhinitis, chaiact<'rised by the peculiarly ofTensive
fa'tid odour of the discharge from the nose, and of
the e.xpirod air.
The anatomical condition corres[)onding to this
somewhat obscure malady is a wasted or atrophic
condition of tlie tissues within the nose. It is not
known, with certainty, how the atrophy is brought
about, or what is its precise relation to the fretor
which characterises the disease. The ffctor would
appear, however, to be dependent to a great extent
on the scanty secretion of mucus, and its tendency
to dry up into crusts which decompose witliin the
nasal cavity. It has lieen suggested that the
particular kind of jiutrescencfi that occurs in ozaina
may be due to the action of some specific microbe.
The tr<>nlin('iil of these cases is mostly symp-
tomatic and palliative, rarely radical and curative.
The first indication is to remove <iU the crusts of
inspissated aiid decomiK)sing mucus retained witliin
the nasal cavities. This is often a difficult matter.
Cli>)<. 1. 1
OZ.KIVA.
5"
The second indication is to prevent their formiition
or re-accumulation ; und the third is to improve
the general health so as to modify tlie inurbid
tendency.
The cleanKing of the nnsal ciivities of the nclherent
crusts of mucus is nKUdlty eU'ectori \>\; means of the
nasal douche, which, when projjerly applied, allows the
stream of cleansing lotion to tlow in at one nostril
and out at the other, niukinjj; thus a conijilete circuit
of the nasal passiiges. The Uuiil usually einjdoyeil
for this pur|x>se is a wai'ni solution of bicarl)onate
of sodium (1 per cent.), and a large quantity
must be passed through the nose until all the crusts
are removed ; steaming the no.se. or .syringing it, or
applying a probe covei-eil with cotton-wool may be
used as auxiliary means for removing portions of dry
mucus not detache<l by the douche. Sulphur-water
with 2 jier cent, of potassium chl i irate ; tar- water with
1 or 2 per cent, of 80<linm chloride ; a weak solution
of soili\nn salicylate, or of carbolic acid ; these have
all been used for irrigation of the nasal fos-sje.
Schnitzler uses for this purpose a lotion made with
3 drams of ammonium chloride, \ drams of sodium
bicarlM>nate, and ten dro2>8 of carbolic acid to a pint
of distilled water.
This cleansing process should be applied twice or
thrice doily. As soon as the nasal cavities are com-
pletely cleansed, antiseptic and deixlorising substances
are applied either in the form of ])aints or injections,
or sjirays, or bougies, or insufflation.s.
ydinitzler uses as a paint, to bo applied with a
brush, zinc cldoride, 16 gniins, glycerine and water,
of each | aii ounce. Bamlx»rger uses iodine 5 grains,
potas.siuni iodide 45 grains, dissolved in glycerine
10 drams. Lowenstein employs aristol, one part dis-
solved in ten parts of flexile collodion ; or it may be
used pure as an iiisiitllation. He claims admiruhle
results from its use. lIo.se!ibnch uses balsam of Peru ;
he paints ihe mucous membrane of the nose daily with
it, and leaves in the nose, as deeply placed as possible,
•I "MT-fc- anM If
£■ <«]£\r i^ silk. S
■-■MTT V-..
v-1 :. — ■-
'S'lDBf -■^-■■■■"Hll|^0t
•t iimr. aiu. jiL
Chap. I.) ACUTK LaUVXCEAL CaTARKH.
S'3
propliylacfic measures deBiruble to be taken by jiersons
predisposed to tliut afl'ectioii, apply with equa! force
to tliose who are prone to sutTer from attacks of acute
catunli cif the hirynx.
The tmilineiit appropriate to tlie acute attack
itself in luhiUs is uIho by nu incHiiH di»siniilnr. lu
the early stage the mlvantage of small doses of o]iiuiii,
codeia, or morphine in allayinj: irritation and relieving
the congh is most marked. It is well to combine
them with small doses of ipecacuanha, or, better still,
of tartarised antimony. Tlie administration of an
eigiith of A grain of acetate of tiiorf)hia with one-twelfth
of a grain of tartaris<'d antimony every four or five
hours ; or 4 or 5 grains of the compound ipecacuanha
powder every five or six hours, will usually relieve
most of the distressing ni/mptnum —i\w tickling cough,
the soreness in the larynx itself, the riitlieulty in
swallowing fiometimes present, and the lioarsenesa
or inipaimient of voice. We have nlso found
Scliieftlin's pills of heroin (gr. j',) and terpine hydrate
(gr. 2J) excellent for this purjiose. Warm alkaline
drinks are also of much value in thinning the tena-
cious adhesive mucus which oft<>n hangs about the
glottis and upper piirt of the l«n'iix, and is dilhcult
of expulsion ; for this purjiose a f liiril of a tumblerful
of Ems, or Bdurbuule, or Ajiollinaris water, to which
a tablespoonful or two of liot milk may lie added,
should be drunk every two or three hours ; or the
following mixture answers quite as well : —
I^ Sixiii bicarlionnlis jj.
Sixiii chloridi gr. xxx.
8iiiritii8 ( lilotofomii ... nixxx.
AquR> cauiphorm ... ad 3VJ.
Miacc, Bat mistura.
ijf this mixture two tablespoonfuls should be taken
every two or three hours with two tablesp'oonfals of
hot water or milk.
Some prefer amniunium chloride in 10-grain iloses,
instead of the sodi\ini chloride in the above mixture,
H U
S»2
Medical Treatment.
IPan lit.
a plug of cotton-wool soaked iu it. Oil of turpentine
has also been used.
As a. s|)ray Schriitzler uses a sublimate solution of
1 iu 1.000, or the patient sniffs up a lotion consisting
of 1^ drams of boric acid, 1^ drams of cherry -laurel
water, and S ouuces of water ; or \w prescribes an
insutUation of equal parts of iodoform and roasted
coffee in line powder, or iodoform and benzoiite of
soda, of each 75 grains. Some prefer a spray of
meiitholiseil oil, Nasal bougies of io<loform, each
containing ^tli of a grain, are used by Schrietter.
Numerous other applications have been employed ;
some, after anaisthetising the mucous membrane by the
application of a 4 per cent, solution of coc«ine, apply
pure tincture of iodine ; some an insufflation of ten
parts of boric acid and three of aimphor, three or
four times a day.
Recently * the application of cilrxr acid by
insufflation (citric acid, 7u parts; sugnr of milk, ^5
parts) has been highly commended in this affection,
the crusts having been previously removed by alkaline
washes. The powtler is used three times a day. The
fojtor is said to disapi>ear rapidly under this treatment.
Curetting and also electrical cauterisation of the
diseased membrane have been recotumendcii by certain
specialist«.
In cases where any diseivsed Iwne can be dis-
covered, this must of course be removed, and as these
are likely to be syphilitic cases, appropriate general
treatment must also be ap[)lied.
The genenU treatment must be determined by the
individual character of each case. Some (scrofulous
cases) will require cod-liver oil and the iodide of iron,
others arsenic, others hypophosphite of lime, and all
will ncH'd careful dieting and good air.
AcuTK Lauvnobal Catarrh.
The remarks made with regard to the etiology
of acute nsLsal catarrh, and with regard also to the
* I'nudlitiiirr, August, IIMHI, p. iST.
cbnp. 1.1 Acute Larykceal Catarrh.
5'3
prophylactic meiisures desi ruble to l>e taken by {lersonB
f)redisposc'd to that aH'ection, ap|ily with e(|ual force
to those who ai-e prone to suffer fix>m attacks of acute
catarrh of the larynx.
The trcalin<>nt appropriate to the acute attack
itself in adults is also by no means dissimilar. In
the early stage the ml vantage of small doses of opium,
codeia, or morphine in allaying irrit<ition and relieving
the cough is most marked. It is well to combine
them M-ith small doses of ipecncuaulia, or, Ijetter still,
of tart-'iriseil antimony. The administration of an
eighth of a grain of acetate of morphia with one-twelfth
of a grain of tartari.sed antimony every four or Kve
hours; or 4 or 5 grains of the compoiiiul ifirciicuanha
powder every five or si.x hours, will u.sually relieve
most of the distre^ssing Ki/inptomg — tlie tickling cough,
the soreness in the larynx itself, the difticulty in
swallowing sometimes present, and the hoarseness
or impairment of voice. Wo have also found
Hchieltiin's pills of heroin (gr. j',) and terjtine hydrate
(t;r. 2A) excellent for this purjioKe. Warm alkaline
drinks are also of much value in thinning the tena-
cious adhesive mucus whic-h ofton hangs about the
glottis ami ujijier pint of the iHrynx, und is difficult
of expulsion ; for this pur{x)se n tliiril of a tumblerful
of Ems, or Hourboule, or ApoUinaris water, to which
a table.'ipoonfid or two of hot milk may be added,
should Ije drunk every two or three hours; or the
following mixture answers quite as well :—
IC Sodii bicarlioiiatii* ... ... ... ... jj.
SiKiii thloridi ... gr. xxx.
Spiritue (hloroformi ... ... ... it^xtx.
Aqua? camphoric ... ud jTJ,
UiMO, fint mistunt.
Of this mixture two tablespoonfuls should 1)6 taken
every two or three hours with two tiible.spoonfuls of
hot water or milk.
iSouie jirefer ammutiium chloride in 10-grain doses,
instead of the sodium chloride in the above mixture,
B H
5'4
Medical Treatment.
IPArt lit.
fnid 5 miniing of vinum ipecacuauha', or 10 luinitns of
viiiuiu aiitiiiifinialis, may 1j€ given with each dose if the
cougli reiiiiiiii.s hard and dry.
(.'(luiitfr-irritutioii mid wiinntli in thn s)).ij3e of a
small poultice of mustard and linseed iiiiplied over the
larynx are of great service. Some, however, prefer
ice-cold compresse*, and these arc most nseful i£
applied at the very beginriitig of an attack.
The following liniment is also of great service,
when nilibed into the throat over and adjacent to
the larynx : —
I^' Olci pini sylvcstriB ...
LitiiiTKiiti foiiiiiliono compositi ...
Liiiiineiiti sapuni» ...
Miuvc, flat linimentam.
... 51J.
... 31 V.
ad 3 J Kit.
If the howel.s are coidined and the tongue furred,
a Balinc miericnt will be useful ; 2 or 3 dran)3 of
Carlsbad salts, or the same quantity of sodium
sulphate in half a glass of hot water, will be the beuU
It i.s of the greati«t iinportiincc Ui avoid all causes
of further irritation. The patient should therefore l)e
ke]>t to the house, and in one uiiifoi'tn tenijK-rature.
All exerci.se of the voice should be forbidden, and the
desire to cough should be so far as possible resisted.
The inhalation of the \apour of hot water or warm
alkaline sprays containing some ammonium chloride
(5 to 10 grains to the ounce) are nseful when the
cough is hard and dry and when there is ditticulty in
soft'Cning the tenacious and scanty mucous secretion.
Schnit/.ler considereti the following solution ap-
plied with a hand-spray as tile most eflicacioua of
remedies : —
H? CocainiB hydrochloiidi gr- iv-
I'oluKsii chlonitis ip-. Ixxr.
Aqiiii' liiiiriic-crnsi ... nxlxxv,
Eseentiic mcnthic piporitio niij-
Aqmu ... lid Jviij.
Slisco, Kut miBtum.
In severe attacks it is generally an advantage to
ch«p. i.i Acute Laryngeal Catarrh.
S«5
difluse the steam of hut water througli tlie iittnosphere
of the patient's rooui liy means of a broncliitis kettle,
or by iiiiy otiier suitable means for kce)>ing the air
charf,'ed with hot vapour of water.
Direct local applications are rarely ailvistible in
coses of acute catarrhal laryngitiH, but they are of
great service if the catarriial comiition persists and
the case iKiOoines chronic.
Acute laryngeal catarrh in adults is usually not u
serious disease, but in a siiljarnte fonii it often occurs
with tmubiesoiiif fre(iiiency in persons who have to
use the voice much in singing or speaking, uinl it is
then more diflicult to treat, and tends to become
chi-onic.
Inhalations of the vapour of litictnre of benznin
are very useful in this suljaiute form. Half a tea-
spoonful of the tincture should Vie inhale<l from time
to tittii" from the surface nf hot water. This is best
done jtist Iwfore l>ed time, or when the patient can
remain in his room so a.s to avoid any exposure
afterwards.
In ywiitiif fiiil<lri*n acute laryngitis is often
a grave malady on account of the attacks of noctnrnal
dysjinn-a which frequently accompany it. Tliese
attacks often assume a very alarnn'ng' a.Hpect, and
are constantly mistaken for attacks of trne croup,
especially by anxious parents,
A young child becomes affected with what is
apparently a mihl catarrhal atl'ection, attendeil with a
little sneezing and coughing, but without any liyspnrea
or other alarnnng symptom : but in the mickili' of the
night it wakes up with an alarming attack of liyspmea,
accom|mnied with loud stridulous inspiration, a dry
hacking cough, and lioai*seness of voice. The
dyspnn-a is often intense, and is attended with great
restIe.Hsness and anxiety. Careful iiis|>ection of the
throat will satisfy you that the attack is not due to
any membranous or diphtheritic exudation. The
dyspniea is due to the fact that the larynx and glottis
in young children are small and im|K)rfectly developed,
S'6
Medical Treatment.
IPirt III.
aud tlie uatiin'tial swelling of the mucnus membrane,
together, probably, with the iiccuinulation during
sleep of dry, teniicious muciiN on tho niiii-fjins of the
glottis, is sufficient to cause consideraljlc laryngeal
stenosis and inspiratory obstriK-fciou. In some cases
spasmodic, contraotiou of the laryngeal muscles no
doubt contributes to the dyspnoea. As a rule, these
uttiiok.H of dyspiKi-ii |)iiss off after a longer or Mhorter
intervjil. and arc unatt<'iidt'd by dangei- ; but the
attacks have sucii a nerious and alarming appearance,
and the anxiety of the little patient's relatives ia
generally so great, that some active treatment is
urgently demanded to allay their fears, and is usually
rewarded with much apparent success.
Professor Widerhofer (Vienna) considers these
attacks to be causetl by drying of the phari/nijeal
mucous membrane during .sleep, and tlint the proper
treatment at first is to give the infant warm drinks —
a tablespoonfu! of warm lemonade, or syrup — an<l
to apply a warm wet compress to the throat, and to
surround the cliild with the steam of hot water. In
winter the air of the child's bed-room should l)e kept
moist with the vapour of water, and the infant shoulci
be kept awake for an hour or two, so as to lessen the
risk of developing the exciting cause.
If the child is a vigorous one, and there is
turgescenco of the vessels of the neck and face, no
harm, and jiossibly some good, may be done by the
ap]ilication of a leech, or perhaps two, over the manu-
brium sterni. It is a proceeding which usually com-
mends its«lf to the distressed parents, and it is a
mistake to suppose that the abstraction of a small
amount of blood in such cases can do any harm. The
relief, indeed, so often afforded by this measure
would seem to show that it does influence favourably
the engorged or swollen or irritable laryngeal mucous
membrane.
Hot sponges applied to the laryngeal region ore
useful ; and whih' sumo think highly of a few small
and rapidly repeated doses of aconite in these cases,
Chap. 1. 1 Acute Laryngeal Catarrh.
others think better of emetic doses of ipecacuanha
and tartarised antimony. Certainly ii quarter to a
sixth of a grain of tartari.sed antimony with 30 to 60
niininis of ipecacuanha wine, mixed witli two or tliree
teaspoonfuls of warm water, will often cut such
atUicks sliort in a striking manner, probably by
tliinning the tenacious mucus adherent to the larj-^n-
geal mucous membrane and obstructing the glottis.
After vomiting ha.s been produced, it is well to
keep up a slightly nauseating effect by small doses of
ipecacuanha or antimonial wine eveiy hour or two in
some saline mixturt! ; and the child's Iwwels should
b6 actei] vipun with a few grains of calomel or grey
powder and a grain or two of jalaj)ine.
If, however, there is wdema of the glottis, which
cannot be thus relieved, and scarirication is imjrassihie
or fails to lie efllcaciotis, while tiie dyspnaa continues
to be alarming, then traclieoton)y must be perfonned.
Attacks such as these are usually limited to cliihl-
hood ; but it d(3€S occasionally happen that o*df»uni
ofllio glollls sudilcidy sets in in the course of an
acute laryngitis in the adult. In such casea, if the
dyspno'a is alarming and the laiyngeal stenosis cannot
Ite overcome by scarification, no time sliouhl lie lost,
but recourse hod speedily to tmcheotomy. Happily
these coses in adultn are very rare.
tscarification of the swollen epiglottis is not always
an easy operation, and in children you can rarely
avail yourself of the aid of the laryngoscope. If the
miiutli can be kept open the index finger may be used
as a guide to the epiglottis, and a guarded curved
bistoury used to puncture the wdeniatous organ. An
emetic may Ijc its<-ful after scarification to mechani-
cally press out the aMieinatoits fluid. Small pieces
of ice may be sucked, and hot .sponges kejit apjilied
to the neek. I'ut tracheolomy should not be un-
necessarily delayed in tliese cases.
In cases in which (here i« constant irritative cough
without any dysjma'ii, from 1 to 6 gniins of Dover's
powder, according to the age of the child, should be
Si8
Medical Treatment.
(Pan III.
mixed with a few gniiiis of Rugnr of milk, and divided
into six [lowilpi's, and one nf tlicMe ^sjiveii every liour
or two until tlie cough is rt-lieveil. To promote
expectoration when this is dithcult, as is the case with
most children, the following mixture is useful : —
}^" So(lii chloiiili gr. xvj.
Sodii lijoirlionalis ... ... ... ... gr. xxiv.
Synipi snnegaj ... 5iv.
Aqua'... ad jiv.
Mi»c*i, fiiit mi»tiini. A dessertspoonful (warm) every two hours.
CiiROMC Labtngeal Catarrh.
Rpjiositcd and neglected attacks of acute laryngeal
catarrh lead to the eBtuhliKliment of a chronic catarrhal
condition of the larynx, which is often ti'dioua and
ditticult of cure It is fretjuently l)rou},'ht on by over-
taxing the vocal organs in jiuhlic-speakiiig, Hinging,
etc., so that it is common to find this ttlTection
amongst clergymen, public singers, and actors.
It is also, in some caw.s, duo to an ext<'nsion of n
catarrhal condition from the pharyngeal mucous mem-
brane, as in drunkards, and inveterate and inmioderate
consumers of tobacco. The lioarse voice of drunkards
is well known. It also forms a part of the morbid
changes whicfi affect the larynx in phthisis and
syphilis. We shall here only consider briefly tiie
treatment of the simple fonn of chronic laryngeal
catarrh characterised by three prominent symptoms —
lioaii5enc.s.s, cough, and expectoration.
The ti-eatment of this tri)ulilesonie aflfection
requires, first of all, the removal of the exciting cause.
Absolute rest of the organ must be insisted ujion in
the case of public speakers, actors, and singers, and
the advantage they often derive from a few weeks'
residence and treatment at such spas as Cnuterets,
Eaux Bonnes or Mont Dore probably dep<>nds as
nmch on the enforced repose ami the liealthiness of
of the out-door life they lead there in pure, tonic air,
as on the use of the mineral waters of those springs.
Oiap. 1.) Chronic Laryngeal Catarrh. 519
liocal applications aits mainly to Vjc relied u|>on in
the treatment of this disease. TJie.sn are applied to
illl^ larynx by tlie )ihysicinn himself, usually liy means
of a brush and with the help of the laryiigoseope.
Various astringent remedies are employed for this
pur|K)8e, and each physician usually has his favourite
remedy. Ziein.«sen extols the use of stroni,' solutions
of nitrate of silver, 16 grains ami upwards to the
ounce, and they are, doul)l!es.s, amongst the most
erticHcious renic<lies : the goixl etl'ect lasts much lonj;er
tliati that of milder astringeiit.s, so that an application
once a week or once a fortnight will suHice. SolLs
Colieii also thinks highly of painting the vitcal coHs,
in obstinate cases of chronic laryngitis in those who
have to use the voice much, with solution of nitrate
of silver. He applies a solution of 10 grains to the
ounce daily for a few days, then at longer intervahs,
and finally he applies, once a week, a solution con-
taining 40 to 60 grains to the ounce. Others prefer
the chloride of zinc (20 grains to the ounce), others
chloride of iron (20 grains to the ounce), alum (10
grains to the ounce), Uinnin (10 grains to the ounce),
an<l .so on.
Inhalations of the vapour of oil of turpentine
(five to twenty drops), or of pinol, with camphor,
evaiioniti'd fi-om the 6urfac:« of liot wat^^r, are often
useful. The inhalations should be used twice or
three tinics a day fur from ten to twenty minutes at
a time.
When there is troublesome uiglit cough a pill at
bed-time of heroin (gr. j',) and teri)ine hydi-ate
(gi*. 3i) will bf found veiy useful. This dose may lie
i-epeuted during the night if necessary.
lii<>iiniiitioiis of various powders are in common
\ise iti these ca.si's : tnnniii, or alum, or bi, ric acid, or
bisnnith .subnitrate mi.xed with e<)ual parts of sugar
of milk, may l»e usetl, with or withiinl the addition of
a small amount of morphine hyilrocliloridc.
In the intervals of, or as alterimtives to, these
applications, the use of oatt-ingent or alkaline sprai/a
5»o
Medical Treatment.
(Part lit.
may be beneficial. Tlipse may be opplied with an
ordinary band-spray, but Siegle's steam-spmy pro-
ducer is, perhaps, the best api>aratus for theii- pro-
duction and application. Ah an astringent, a .solution
of tannin or alum, ."i grains to the ounce, is perhaps
the best. The spray shouhi l)e applied twice a day
for about five minutr-s r-ach time.
In cases where the rauctiUH secretion is scanty and
tenacious and difficult of removal from the mucous
membrane and vocal cords, warm alkaline sprays are
of much value. A solution of soflium bicarbonate and
coni!n<m salt, al>ont 5 grains of each to the ounce, is
one of tbo best. It is often advisable to cleanse the
mucous meiiil'rano first with a warm alkaline spray
before using the astringent applications. Throe or
four ounces of Kms or Hourboiile water, drunk with
a little hot milk, night and morning, will also be found
useful ill proiiiotiug tln' solution and expulsion of dry,
inspissated mucus. We have seen very great and
periimnent x\s well as immediate tienefit result from
the diligent use of warm Bourljoule water, applie<l
locally to the larynx by means of a liand spray, in
subacute, irritable cases.
From the numljer of priest*, singers, and actors
with laryngeal catarrh found frequenting the springs
of Mont Dore and La Bourboule, and also the sulphur
springs of Eaux Bonnes and Cauteretfl in the Pyrenees,
we may ainclude that they derive benefit from these
waters, as well as from the course of life j)rcscribed
for theui at those plac(?s.
Schnitzler recommends that tna»aitg« should be
applied to the front and sides of the neck for two or
three minutes at a time, the fingers of the operator
being well covere<l with pouiade.
One of the niost efiicaoious remedies in the treat-
ment of chronic or rt>cwrr«'nt laryngeal catarrh is
cliange of climate. In some instances a change from
a luw-lying or damp iidand district to the s<>asidr!,
or to a mon' elevated and drier locality, is sufficient
to bring about a cure, or very great amelioruliou.
Chap, I.I
Laryngeal Catarrh.
S2»
Rut in more oVjstinnte aises, and wlieii it is practicable,
removal to a more eqmible and milder winter climate
than can be met with in Great Britain is desiralile ;
the winter climate of Madeira, tlie Canaries, and »ome
of the islands of the We*t Indies, or a sea voyage in
southern seas, is perhaps IwHt suited to the majority
of cases. Some cases, liowevcr, do well in the drier
climate of Egypt, especially j>er8ons who find them-
selves better in a dry and bracing atmosphere. High
elevations are not suited, as a rule, to these cases,
save in exceptional instances and in exceptionally
tine seasons ; the rapid changes of teiDporature, and
the occa.siotial occurrence of severe weather, with cold
mists and lieavy snow-falls, are apt to aggravate the
catarrhal state of a sensitive larynx. Moderate
elevations, however, such as that of Glion, or
Cauterets, or Meran, often protluce groat benefit
in these aises.
ADDITIONAL FORMUL.«.
Htxture for acute
laryngitis.
1} Liqiioriii inorjihinn' hydro-
cliloiiili, .Mj.
Villi nntimnnialiB, }\\.
SuccuH couii, .^vj.
Liquaris Ruunonii ncctativ,
jij.
Aqun- caniphofH' lut \x.
M. f. mist. A tji)>Ie9i>(>oiiful
CVLT)' four hours. {Wh'xttn,')
Hlztore for acute suflocatlve
laryngritU In children.
Aftrr nil Kinttir,
R Kcmu«tiiiiicmli«.(fr. J to IJ.
Timturif ncoiiiti, mv. imI x.
Tiui'tuni' 1>olUiltiniifr, mv.
ail X.
Syrii]ii florin nurniitii, Sj,
Aqim* niiitti n<\ Iv,
M. f. mift. .\ duaertHjHwnfal
every hour or iialf-hoiir.
(.Sfmon.)
For acute laryngitis in
cUldren.
H Ai>nniori)hiiin- hydroch)or-
iiii. gt. \.
Aciili hyilroclilorici ililuti.
t^ttn' iij.
S3TUl)i seuegu', .sv.
Arjuii' uil Sju.
M. f. mint. A teiwpoonfiil
Kvcry lioiir. {Muuli.)
For tbe subacute laryngitis
of vocalists.
I. All iijK-rii'ut,
'2. A Iuryii^(*a) Npniy of 1 j>or
o«iit. solutiiiii of (HM'aiuu.
M. Tlio followiiif^ toxeiitfee —
II Moriiliiuii' liinKM'oii/ktii), gr.
ifin*
Cocniuii* liydrnchlnrii, gr.
Tuictunr acoiiiti, in \,
Radicis ntltitfit* pulveris,
in each, oik- to Iw tiikiMi fre-
(luuully.
t. Aa u iir(>i<aratiou for s
•
Medic A l Tr ea tment.
IPart HI.
vocnl effort nflOT «cuto ririii]i-
Inlim ll»vi' Bul)Ki(Uil, c'n U'"'" "'^
ftfrycliiiine iiftiT l>reaklii^t mid
liiiii-ti.ai!il.VsBrniunftoriliimer.
{Vttullmrr.)
As ui expectorant In oa-
tuTbaJ laryngitis In children.
n Potawii iodidi, ft. xv. iid ix.
Synii"! M-ipfgw, .viij.
A.)ii(i' lul 5uj.
M.f. luist. A dcnerisnoonf ul
erery two hours. {Mimli.)
Sedative spray or gargle in
laryngitis.
H Cocuiiin lijilrochlnriili, gr-
viij.
fllyfcriiii ncidi eiirlH>lici, .^ij.
A<pin- ro«i* fui 'viij.
M. To 1)0 used oioiiBioiiiilly
as a Rnrglo, and fr»|ui<iitly iis
a spray. (?/'A(?A/.)
Tablets for acute coryza.
II M>ii|i|iiiiii', ^T. ,\.
Alnt|iinii', yr. ,Jj.
CVkltrillll', gr. i.
H. C& S. Sithop.)
For atrophic rhinitis.
Foniiiilin in nipn'oiii. wilii-
(ions, 1 ill 1,000 K.l'.WIl.
T<i )ni injected with iiusnl
►yringo. ( Hronurr.)
For larynglamui stridulus.
K IVtji.wi l>roiiiidi| .<ij.
Cliloral hTdruiis, .mm.
Syrupi Icliitani, .*iT.
Aqun', nd jij.
M. f. mist. A traixpnonfiil
evpry huKhour for a child two
years old.
Inhalation in acute catarrhal
laryngitii to relieve heat
and tickling in the throats
li Ai(ti:i' laurtn;t»iju*i, Sj"*.
Spirittis villi rwtincati, lul
jiij-
M. A dessert or tiilihispooii-
ful to he iiihnled iiiirlil and
nioriiio);. (.s'(/n'i-((c>'.)
Inhalation or spray In chronic
catarrhal laryngitis.
A Acidi taiini'i, (jr. xv.
S|iiritus viui lectilicilti, .^iJA.
Aiinii' (id ,^ij,
M. (S-Am-Z/rr.^
Inhalation for chronic
laxyngllU.
IV Olei jmii syWeatris, Sij. ml
,*iij.
Ma):iii><ii ctirhuiiatia Icvis,
Sj. mi .^jM.
.\t]ii''' lid 5iij.
A tru-'ix'oiidil to he udded to
u iiiiit nf H'iit<!r lit Xnky V. and
iuhnled for live miiiiila two ur
three tiiiuw u dny. {iftifkmiif.)
Oargle for hoarseness from
fatigue of voice.
R AHdi luiiiiici, .^j.
(llyceritii b*tniri8, \ij.
'I'iiictiirie nqwici. hjv,
Iiifiitfi rowf acidi iid ,>x.
M. f. giirgnr. To Iw us«d
frei|ii«iitly. ( U'hitln.)
Treatment of chronic ca-
tarrhal laryngitis.
1. Drink infusion of piuf
cotHW (1.^ drun to n pint of
writer).
i A (tliuw of sulphnr wnter
in the niomini; (Kimx Ihmncs,
' Cttiiteri'lji. or Knghien).
3. Iiihiilu tiir vapour.
4. Apply to the liiryus the
following; solution : —
K Zinri chloriili, i;r. xv.
Aquie destilliiUi', ;j.
M. f. wdut.
! {.\'uiiifitii-r Krmiflt:)
Chap. I.I
Additional Formula.
r .1 .»
5'J
Powders for catarrhal rhinitli.
No. 1.
H Aliimiiiiii |iiilvoris, h*».
Bonicis, .sw.
Mtntliol, gr. \.
/itici tiuiiiatif*. ^. xlr.
BiBDiullii tsionatiii, gr. xlv.
LycopoJii, .rij.
M. f. pulv.
No. 2.
II Zinct sulicylntu, .^j.
Btsniuthi tADiiatia, .^j.
Borncis pulveru, Jss.
Siilul, pr. »!.
TiJc, .^ij.
M. f. pulv.
Snuff in clironlc rhinitis.
H f 'nrttiiiir hyilrdtlilor., gni. '.'J.
Cumphnni', grs. I J.
.\luinitii'<, gn. I|.
Meiitliol. gr. J.
Siiooliari pulv., IJ.
M. f. pulv. (Jf«>w«/.)
Application for deep ulcera-
tions in oznna.
a Aristol.
01. rit'iui, M gr. 1>)0.
Collodion, gr. 1,200.
M. To 1» npplieil on pled-
gets of cotton-wool. (Kixinu.)
524
CHAPTER II.
THE TREATMENT OF CATARBHAL ArFECTIONS OP THE
RESPIUATOBY ORGANS (fONTINUED) : ACUTE BUON-
CUIAL CATARBH.
AcTTE BBOjirHiAi. Oatahbh. — /'/vi/j/K/^/r^V mcrwu/r*— Trentmoiit
of ilifffrent Form* — .l/i7rf Foriim — Diapliorctirg — Alkaline
\V;it«rs -Til rtariseil All tiiuoiiy— Opium— Aconite— Poultices —
Aperients— Alkiiliiit* Expectorniits — (rrnrer formit — Indica-
tions forTn'atiiietit — lAn-*cluw— Ory-ciippinK — BItjod-lettitig —
Counter irritation— Tiirtariwd Antimony nml Opium — Stimu-
lating IJinjihorwlic Drinks— DiiiiKPt* of Upium — Inlinlntiona —
Cold Air — Atju(HiuB ViijKJur — Alkdliiie Spmvs— Conium nnd
Bellndounii Sprnyii-CcmiprcMed Air -Cnrljolic Acid Spray —
IlMTjicuaulia and other Expeetorautu— SfiuilU — S«nc^ —
Amniouia- Stimtilnntfi and Tonirs — PotiiA^iuro lodido and
Aramoninni ("Chloride— Kmetici -Oxyjcen luhuliitiou iu Capil-
larj- UroncliitiK of CliiMreu- Quinine and Arsenic in Febrile
CaM« -Aleohol — Ether — Diuritjilis — Stryelmine — Loholin —
Chloroform InliaUition— /'if^ Additional FonnuliB.
In considering the ruanajEreineiit of cases of bronchial
catarrh, wo shall first call attention to propliylartic
lupasures.
Young diilrln'ii with a tendency to such attacks
should lie carefully guardetl against exiwsure to chill,
or to rapid and great changes of temperature ; at the
same time every opportunity should l>e taken to brace
and harden them so as to diminish the morbid sensi-
tiveness of surface u|.ion which the liability to
catarrhal attacks depends. In the warm season cold
afTu.siou or sponging should be cautiously practised,
together with vigorous friction of the surface.
Abundant exercise in the open air, tlie child l)eing
warmly and suitably clad, with flannel next the skin,
is of use also. But exposure on raw, cold, windy days
must be esiiecinlly guaitleil against, parliculiirly with
very young children.
The general nutrition of young cliildren with this
predisposition must also be looked to, esjiecially if
there is any tendency to scrofula or rickets. In such
Oiap 11.) Acute Bronchial Catarrh.
525
cases the tonic iiiHuciice of tlie phosphntos of lime and
iron and cod livfr oil is particularly noticeuble.
With old people Imving a ten<lency to this malady
great caution is necessary in ])rotecting them from
exposure to changes of tempeniture, to draughts, to
cold, damp air, and they should not reside in cold,
dauiji loculities. They should puss the winter, when
possilile, in H warm, eqiiiil)lH, sunnj' climate, or, if
this is not possible, hecontvnt during the Ijad weather
of (lie British winter and spring to remain in a set
of jifinrtinents kept at a unit'unn tcniperHture.
The lr«>3itiiifiil of ariilf Iti-ttiii-liiiil <-:iliiri-h
will, necessarily, depend on flic piirliculav furni of the
malady with which we may have to deal. It may,
and often does, occur as a coinpai-ativoly slight malady,
unattended with any risk or danger if ordinary care
and caution in its management be adopted.. On tlie
other hand, it also often occurs as one of the most
.serious and dangerous maladies we encounter, fre-
(juently fatal, and taxing all our skill in its treatment,
ihali of its seriousness dejiendson the age and vigour
of ttii- patient attacked, on the extent of the bronchial
surfiice involvwJ, and on the coin[)lic[itions that may
attend it. An nttJtck of acute bronchial catarrh may
Ih" limited entirelyto the trachea and larger divisions of
the bronciii, and show no disposition to spread beyond
them. These are the slight cases, but an attack of
acute bronchial catarrh may also be dilFusecl over a
wide extent of the bronchial surface, and extend even
i(\ the finest ramifications of the bronchial tubes.
The.se cas<?s of ciipUlary bronchitis are of the gravest
import. Such attacks prove very fatal to children
and to feeble and aged persons, and are of great
gruvitj'even when affecting robust adidts.
In the first phice we shall consider the treatment
ap|)r<)priate to a mild case of acute bronchial caUirrh
in a previously healthy adult, and limited to the larger
bronchi. Such an attack will usually be attended
with a slight degree of fever ; there will lie mure or
less cough, usually at first dry and painful, attended
526
Medical TkEATMEtrr.
IParl 111.
with a feeling of soreness or rawness referred to the
upijei' sternal region, i^ry, sonorous, rlionclial, anil
sibilant rJ/«« will be lienrd over both sides of the
chest, loudest over the u|ijier |iiirl. I'sually there is
Imt little dyspnrea, unless the attack be complicated
with Honio 8pa.sinodic iuithraa.
The patient shniild be kept in bed in a room the
tenip<'rature of wliieh should at no part be lower than
65" F. nor higher than 7ti"' F. The air of the room
should be kept moist ami unirritating by causing the
stejiiii of hot water, by inoans of a bronchitis kettle, to
be freely diffused through the nj«irtment. The treat-
ment may often be advantageously commenced by
putting the patient in n hot bath in which a bag
of bran has been well wruns; out. NV'arm mucilagin-
ous or slightly alkaline drinks should be given freely,
and varieid according to the taste of the patient —
barley-water, linseed t<'^a, thin gruel ; but many
patients prefer a mixture of hot milk and seltzer,
or Apollinaris, or soda water. These alkaline drinks
have a beneficial influence on the secretion from tlie
inflamed mucous membrane; they diminish its tenacity,
and so promote ex))ectoration, and in this way
relieve the cough. The addition of 2 to 4 tea-spoon-
ftds of cognac, whisky, or nini to 3 to 6 ounces
of hot milk and seltzer water makes an excellent
soothing expectorant drink,
But there is no remedy which relieves the dis-
tressing ilryness of the mucnus membrane in the early
stage of acute bronrhial catarrh so conii)let«.'ly aa
larlarif><-d sinlinibny. (juite small doses of this
drug, combined with smull doses of morphia, uudcia,
or opium, will 1m? found most elficacious in relieving
these sligiit attAcks of acut« hronchial catarrh. We
prefer it greatly to aponmrphia, and think it a safer
drug to handle. The opium relieves the irritating
cough by lessening the sensitiveness of the bronchial
mucous membrane, and the antimony greatly increusos
the secretion from it, and so relieves the dryness
and swelling which accompany the first stage of j
Chap. II. 1 Acute Brokchial Catarrh.
527
lironoliiiil cutiinh. Or a tlniuj^lit containing 5 to
1<I grains of Dovor'.s pow<ler, 1 dmm of spiritus
BPtlioris nitroHi, 3 drams of liquor aninionii ncetatis,
mid 1 \, ounce of camphor water, at bed-lime, and
a saline a]ierient the morning foliowing, is an ex-
cellent remedy in mild forms.
When tliei-e is much fever a few doses of aconite
■will l>e found useful nt the commencement of the
treatment, enpeciiilly in younjf peojtie. Wlien thui-e
is not much fever, and the chief object is to relieve
the cough and the dryness and .soreness of the
mucous uienil/rane liy promoting expectoration, this
mixture may U- given to adults : —
I^ Vini nntimoninlU
I.iqiioriB morphinin iicotiitis
LiqiKiris ttmnuinii .ici'tatii .
Aquns Iniimcxmsi
Sirupi...
Ai|nip .
.. 5JB».
■ 3'j-
■ 3"j-
iiJ jvj.
MIdoe, liut iiiiitura. Two tablespiionfula every 3 ur 4 hoim.
It should be pven le.ss fre(|ueiitly as the .symj)toins
are rclifved. In the case of jiersons who do not hear
iiiorpliiue well, codeine may be usetl in its place in the
dose of J or J of a grain.*
If there is much fever, tlie following is useful : —
tU Tini-tiirii" oconiti
Villi untiiiioninlix
liiqiiori^ inorphiiup iM'i*tttliH
] .iqiiuris Hinmunii nietntin ..
A(|tiie ciiiiii>horn'
in XXIV,
ltd 5V11J.
Misco, tint niisliini. Two tiitiloiipoonfub every 'i uv 3 hoiiis.
If for yiiung children the morphine should Ihs
omitUul, and i an ounce of .syru|tof tolu addi-d. The
dose would Ito I or 2 teaspoonful» according to the
child's age.
• It murf lie remeJiilxTwl tlint nlil p<'i'«oii(i, mtiiiy pergoiin witli
wixik lii'arts or witli tliicmic rLvjiintlory lUnicultr, nr with ri'iial
ili.<uit»i<, fur tlic mimt pnrt l)«:ir n|iiiiti?a K-idly, uuil tlii^ir use slionld
be uv<iii)e<l in xiiili ciiw-c.
5^8
MsDicAf. Treatmkmt.
(Part III.
Much relief is also given by a large hot poultice of
linseed ami iiiusttirri, applied over the top of the chest
ill front, and also Viehind, between thft Bea|iulie.
All a]»erient is often necesisary and useful. One
or two grains of extract of aloes with 1 grain of
powdcitxi ipecacuanha in a pill at bedtime, and tlie
following morning two teospoonfuls of Carlsbad .salts
in half a tumblerful of hot wat«r, will hv found
an ellectual purge, and if ilie tonguo Ih thickly
coatwl, and the urine higli-colouretl, .*. a grain of
calomel may l>e ailde<l t<i the pill.
With this treatment in those milder forms, the
acute stage will rarely lost more than u day or two,
and the white, scanty, frothy, sticky exy>ect^>ration of
the first stage will \k. rephired by a more abundant,
iiiuco -purulent secretion. Tliis change in the character
of the secretion is an indication that the attack is
passing off. It is now desirable to discontinue the
antimony and the morphine, or to give them only at
night for the relief of cough. It should be Ixime in
mind that remedies like opium, antimony, and aconite
are only given to relieve definite syiiiiitonis, and when
those are relieved these drugs should be at once
discontinued.
An alkaline, mildly stimulating ex]>ectoraDt is now
useful, such as the following : —
Sij.
Si-
I' 148 gr. xxir.
I^ Infusi senegn.'
Sodii biiMirbonntis...
Sudii ehloriiU
Ammouii mrboniitis
Syriii)i tolutjini ... ^iij.
Ai|uii' ... ... ... ... nd jvj.
Jlispe, fiat raipliini. Two tablo^I>oonfaU every six hour*.
A jiill i>f a gniin iind n liiilf of quinine, nnd n qtiartvr or
half II grain of powdorcd iiiocacimnhn. may at tbo tainc time
lie'givi'O twice or tlin^- timea a djiy, and will promote
convalescence.
A table«poonful of brandy or whisky in a t<'acuj)ful
of hot milk and water, two or tliroe times a duy, is an
excellent expectorant.
ch«p. 11.) Acute Bronchial Catarrh.
529
With this mi'thod of treatment patients may
usually be carricil safely through these commoner and
[liter forms of iioute bronchial ciitanb.
Next as to the treatment most 8pproi)riate to the
Umver forms of Jifiitc broiirhilis: to those cases
in which the catarrhal inflammation is ditt'used over a
great extent of the bronchial mucous membrane, anj
affects not only the larger tubes, liut those also of
medium size, tind sometimes even the smaller ramihca-
tions.
Such cases, when they occur, even in vigorona
adults, are very gmve, and require most careful
management ; but when they occur, as they often do,
in young and delicate children or in old and feeble
pei-sons, they are attended with the greatest danger.
When the tiner bronchial tulies become attacked,
and their calibre diminished by the inflammatory
swelling of their lining membranes, and when many
of them Income blocked up by the accumulation in
tliem of viscid secretion, it can readily be understood
how imminent nntst be the danger of death by apna'a.
The objects we should keep in view in the treat-
ment of such cases are these: — a. To diminish the
inflamraat-ory hyperemia and swelling of the bronchial
m\icous memlirane. 6. To thin and lii|nefy the
catarrhal secretion when it is dry and scanty, c. To
lessen it when excessive, d. To promote its expulsion
from the air-passages, and so obviate their obstruction,
e. To allay excessive sen-sibility of the brtjnchial
mucous membrane, f. To maintain and promote tlie
circulation in the lungs, and prevent pulmonary
engorgement and distension of the right side of the
lieart. g. To red\ice fever and maintain the general
strength.
The several details of treatment by which these
indications may be carrie<i out will have to be
modified and adapted to indiviilual cases.
Much will necessarily de[)end on the age and
vigour of the patient, as well ns on the stage which
the disease has reached when it first comes under
1 1
530
M EPICAL Treatment.
(Part III.
tn«tnipnt Reine<Ji«'5 most ftpproprmte iii tlie earliest
atMite, anil in a young and vigoi-ous adult, niiglit lie
~ltij"'-tlipr uiisuit*'d to mori- advanced staged, to a
ouiiji chiKI, or to an old and feeble person.
We will first consider the treatment of a severe
attack of acute bronchitis in a young and robust
adult seen at its onset. The air of the npartnieiit
must be kept warm aiid moist, as ali-eady pointMl
out
If there is much oppression of breuthing referred
to the upper piirt of the stenuini, iuilf-.a dozen leeches
applied over the manubrium sterni will be a judicious
luethofl, and vviili this may Ije associated dry cupping
over the liack of the client and in the interscapular
regions. Tliis measure will alt'ord much relief in robuKt
persons when the dyspiicea and sense of oppression
are severe.
(IrMvrid bleeding is rarely neces.sary ; it nmy, how-
ever, be had re<;ourse to in certain very acute cuseft,
when the dyspnoea is extreme, the surface livid, and
the danger of death from apniea imminent. The
removal of a few (G or 8) ounces of blood will relieve
the engortjement of the light side of the heart, and,
at the siimo time, the pulmonary venous congestion.
"The disea-se is not arrested by this treatment, but a
special danger is averted, and time is gained for the
employment of other measures " ( Wihon For). But
venesection is never desirable in children, nor in old
or deliilit4it<-<l persons.
In mo.st cases it will be luKisable to apply liirgo
linseed and mustard poultices over the front ami ImvcIc
of the chest ; and when the skin is too tender to allow
of further counter-irritation, a hot jacket-poultice of
linseed meal niu.st be used instead.
The hot jacket-poultice proUiiily acta by dilating
the veKscls of the surface, and so reducing blood- "J
jirt'Ssure in the veins and the right side of the heart,
whilst by it.s heat it acts as a cardiac stimulant.
We lio not think any form of counter-irritation
acts l)ett«>r than the lin.seed and mustanl poultice
ai»p. ii.i Acute Bronchial Catarrh.
S3'
when well made and i-rti-efuUy applieil. But it is
soiiieliiiies uimle luidly, iuiil .i|i{>li(xl curelessly, so that
it is not very unusuiil to KikI ji )»oultiee ai-ound the
I>utient's loinn instead of his fhest !
We would will spi:fi<il attention to the iinjtortAnce
of ajiplying these moist poultices carefully, nuatly,
and accurately. We occosioiinlly see patients in a
stiite uf jtrejit discomfort fmm the untidy ujiplicution
of moist cloths and poultices to the chest, which soon
lose their warmth ami lieconie a source of tlanger as
well as discomfort. It is letter to apply hot, ilrii
llutiiiels sprinkled with tur|]enline than unskilfully
made poulticas. Indeed, we think the applicatiun of
the moist poultice is often overdone, and continued
too long. After a time it is Iwtter to rnplace it
with a simple layer or two of warm eottoii-wool
sjirinkled with a little turpentine or pine oil, especially
when tlie patient complains of discomfort from the
moist application.
Of internal remedies wo are quite of Btokes's
opinion that " there is no remedy that ]K)ssesses such
a di'cided jiower over acute bronchitis '' as Uiriarl»ed
Hiiliiiiuiiy ; Ijut its success depends nmch on its
early adniinisti-ation, /.<•. when the lironchial mucous
meniljrane is dry and tumid, liefoM' si'cretion has
become aljuiidant, and when the skin is hot and dry
and the pulse hard and frecjuenU It should Ik- f,'iven
in i\mUi small repented do.ses, combined with other
(liaplioretics, viz. 10 to 20 minims of the aiitimonial
wine for adults, and 5 to 10 minims for children. In
these small doses it ofton produces less nausea than
ordinary doses of ijiecacuanha.
ly Villi unlimomalis ... jij.
Spiritus M'theriii iiitrusi ... ... ... jiv,
LiijiiDria Hinnionii aci^talid ... ... ... Jij.
Tiactiirie eainphorii' cumpuaita< ... ... jij.
AqiiiP'. nU jviij.
MitCK, fint miatura. Two tablexpoonfula every three or four
huum.
Warm alcoholic drinks are needed to keep up tiie
force of the circulation, while, at the same time, they
S3*
Medical Treatment.
[P»rt lit.
favour diaplioresis, reduce fever, and promote expeo-
toriilirm. Two or three oiitices of liot milk, with an
equal (|uniitity of seltzer or sotla water and .1 deasert-
spomful of linmdy or whisky, should lie given every
three or four hours.
The advantft<;;e of procuring profuse diaphorfitia is
undoubted ; whether it acts by lierivation from the
bronchial mucous membrane, or in some other way, it
is certain that it is constantly attended with marked
relief to the catan-hal symptoms.
Free evacuation vf the bowels should be regtdarly
obUiiiiefl, soa.s to favour the descent of the diaphra^i
and ationl as complete expansion of the lungs in
breathing as possii)le ; while by mdoadinj; the [wrtal
system of veins, any tendency to distension of the ri^ht
side of the heart is to that extent relieved. For
ailultH it is as well to give at bed-time occasionally
A a grain of calomel in a pill with a grain or two of
the watery extract of uloe.s, and n t«i8po<Jnful of
Carlsbad salts, diasolverl in hot water, the following
morning. In the cose of children \ of a grain of
calomel may l>e given with 2 to 5 grains of compound
scammony powder.
It is iitH-e.ssaiy to insist strongly on the importance
of usirii; the grraUH di»erelion in the administration
of opiutn in tlie.se cases of severe dillti.'ipd acute bron-
chial catarrh. The more diflused the cntanh the
more cautious must we be in the ailministration of
opium. In old people and in young children opium
is scarcely at all admissible, and even in aduU^i, where
there is much obstruction to the entrance of air into
tlio lungs from the abundance of secretion in the
air-passages, opium is a very dangerous drug.
The effect of opium is to check cough and diminish
secretion ; the former it does partly by lessening the
sensitiveness of the bronchial meuiVjrane, and the
latter by modifying the capillary circulation in it.
Hut in cases of "sutTocative " bronchitis, while we
might desire to diminish the secretion, we dare not
deaden the sensitiveness of the bronchial mucous
h
Chap. II.)
AcvTE Bronchial Catarrh.
533
meiiibrune, or do anytliing to check tlie coiigli. So
long as the air-pussages are ol>8tnict«l by catarrhal
exudation we depend upon the cough to clear and set
free the obstructed air-paKsnges, and we oidy desire
to make it more erticient to that end.
It is extremely important to l>ear this in mind
in connection with tlie use of opium in liroiicliial
catarrh ; a dose of 0](iun) given injudiciously may
produce a fatul somnolency, and, by quieting the
cough, lead to fatjd blocking up of the air passages.
If you give opium at alt in sucli cases, give it only
in very small doses, mid only when the patient is
watchwl by some thoroitghty trustwortliy person ; but
never give it at night tu |>rOL'ure sleep, however trying
the (xjugh may Ije, or however urgent the patient or
the attendants may be for a sedative.
Remember that opium is rarely ever admissible in
the diffuse bronchial catarrhs of old jjersons and
young children. When it is very necessary to secure
a few hours' sleep, it is better to give from 5 to
15 grains of trionai, with an e<|ual quantity of bromide
of sodium ; and then the pitient must not be allowed
to sleep moi-o than two or three hours at a time,
unless the resjiinitious are free and reguliir, for the
secretions tend to aicumidate in the bronchi during
sleep, and hinder the access of air to the air cells. It
is often iie<;essary to give the patient on waking from
slei'p sumo diffusible stimulant to aid him to expel the
mucus which has accumulate<l in the air-passages. A
little brandy with hot milk and seltzer water is best
for tills purpo.se.
An agreeuble and useful atmosphere for the
patient to inhale is pro<luced by dropping twenty
or thirty drops of piiiol on to the watt>r in a lironchitis
kettle ; the vapourof the pim)l is thus diffused through
tlie room together with the hot aqueous vapour given
off by the wat«r in the kettle.
In the acute bronchial catarrhs of children, espe-
cially those accompanying infective diseases, such as
aieasles and pertussis, we have found the frequent
534
Medical Treatment.
IPart III.
inliiilation of a warm spray containing bicarlxmate of
Bodji and glycerine of tiirbolic acid of the greatest.
Korvice in promoting expectoration.
We use the following proportions : —
ly Sodii bioarbooAtis ...
Cilyet'rini acidi oiirbolici
Aquit' d(<iitilliitji<
Mim'c, tu bo used warm.
5J-
SJ-
By means of a Seigle's steam-spray ])ro<Jncor the
.spray should bf allowed to play freely before tho
child s mouth and nose, so that he /hm«< inhale it with
the inspired air.
As soon as the first stage is over, and the scanty
and t-cnacious glairy secretion ha.s been replaced by an
abundant miico purulent one, we must discontinue
the \iso of tartiiri.siMl antimony, or rei)lace it by small
doses of ipecacuanha ; and now is the ajiproprialv
period for the administration of the stimulating
exi)ect<Jtants, such as squiUg and Dtnwga, in uoinbino-
tion with carltonatt* of ammonia.
S]>irit of chloroform is also an excellent expectorant,
wliile it at the same time soothes and allays tlie cough.
A suitable formula is the following : —
ly Intusi scnegii' Jiv.
Ammonii carbonatis ,.. gr. xxxij.
Tinctuni" Bcillii: in Ixxx.
Spiritns rhlorofonni jij.
Aqiiic ud Jviij.
Misce, flut mistura. Twb tablespuoafuli every four or five
Iiuiin.
If the cough remains troublesome, it nmy be
advantageous to atld to each dose of the aliove
mixture •} minims of wine of ipecacuanha and 20
minims of coni|>ound tincture of camphor.
<.)n tlie other hand, as convaUwcence advances, tho
tinclur*' of squills in the alxive mixture should be
rejihiced liy l-<lrani dosea of tincture of cinchonnw
In all such c;vses symptoms of de1)ility and loss i
power must l«' immediately enc-ountere<l by
administration of alcoholic stimulants.
p
Chip. II. 1 Acute Bronchial Catarrh.
535
In dfihilitfited ]iersons, and when we do not
encoiiiitor tlie case in its earliest sta^^e, a com-
bination of carbonate of aiiiinonia, ipecacuanha (in
Kiiiall doses), and bark, as in the subjoined formula,
witli warm stimulating; drinks, and the inhalation of
Warm alkaline sprays to thin the secretions — these
are the measures to be relied u}>on.
ly Amnionii carbonatis
Villi ijM>oacMwiihii' ...
Tinctura' oinchonaj
Aqtiii! chlonifMrmi ...
Misce, fiat mi«tiirH. Two tnhliisjiiioiiluU ovury four boim.
... gr. xl.
iiy xl.
Hrt JVllJ.
In somewhat ;ui\an(X'd ciistw, e.specially in the
rh(?umatic or gouty, when the ex|>ectoration is tena-
cious, scanty, and difKcult of expulsion, potassium
icxlidc is a most valuable remedy : it may be combined
witli soiiium chloride, as in the following formula : —
V^ r<itii«<U ioilidi .. ... ^. xl.
^>0(lii chloridi ... . ... jifr. l\.xr..
Aininonii cjirbon.itiK
SoJii liiciirbonatia ...
Tinuturic si-negif
Aquir ihlorofiirmi ... ... ... «tl Jviij.
Misco, tiat miatura. Two tnblespuonfub, with two u( hut
water, thruo or four timijs s day.
■•• jaaffi-. xl.
In the case of yo<uig chil'li-en who cannot expec-
torate, we must give ocavsioiud eiin'tlcs. Ipecacuanha
is the l>e.st. Twenty grnin.s of j)owder of ipecacuanha
mixed with a tiiblesf>oonful of syrup and water will
usuidly have the desired i-esuH. The effect of the
emetic is not oidy to promote ex]»ectoration, but by
the mechanical compression of the lung it induces it
tends al.so to relievo congestion. The sticky nmcus
which nccuniulates in the child's n)outh after vomiting
should lie eari'fiilly removed.
Some prefer tin.' hydrochloride of apomorphia as
an emetic in these cases. One-twentieth of a grain
injected hypodermically can usually be relied upon
to produce vomiting in ten minutes. When a
536
Medical TREATMEtrr.
[Pari ir
cliild cannot be induced to swallow an emetic,
this is obviously a valuable alterimtive ; tlie objec-
tion to its use is that it sometimes produceH great
depression.
Emetics are also useful in cases other than those
of children, when, owing t-o debility of the bronchial
muscles, the catarrhal secretions are retained in the
nir-passages. This state " may Ije detect4,'d when,
immediately after the act of coughing, the r61e$, in-
stead of subsiding for a time, persist with scarcely
any diminution. In such an emergency, should the
expectorants fail, an emetic is imperatively indicated "
{Nwmfyer). Ipeciicuaidia or zinc sulphate should l)e
used.
In order to ward oil' the tlnnj;er of pulmonary
coHnpse in young child reii, the cliilii m.iy be roused to
more active respiratory I'fftn-Ls liy putting him into a
hot liath, and sprinkling citld wiit<,M' on the chest
while in it Nor shoidil he be allowed to fall into
a prolonged or dee|) sleep, but should be aroused
from time to time, and some stimulant given.
The iiihalnlioH of oxygen lias been found of
remarkable value in some cases of capillary bron-
chiti.s in infants after all other means have failetl.
It has rapidly relieved the dyspnica and the cyanosis,
and led to ultimate recovery.
In cases in which thei-e is a tendency to the
maintenance or recurrence of fever, quinine must be
given, or, if this is not well tolerated, arsenic. Tlie
latter drug may be given in comliination with nux
A'omica, ammonia, and cinchona, as follows : —
I^ Liquoriri aivpniciilis nvxxir,
Tincturn- cinrhoiiip compositiu jj.
Tiiicturu] niiciti roinitiu ... ... ... 51-
Aiiimonii cHrlHiiintis ... .. (n"- xn>J-'
Aciuie uhlorofonni ... ml '(viij.
Miiic«, ilit misturtk. Two tal>U<sp<>onfuli< ihrw times u day.
Quiiune may be given in combination with expeo-
torants, as in the following prescription : —
[
Chap, n.i Acute Broscjiial Catarrh.
537
K Tincturaj sencgn» ... ... jiv.
TincturH) nucifl vomicu* ... 31.
SpirituH chloroformi ... ^tij.
Tinrtiirii' i]uininn< nminiinintip ... ad .''Jiij.
Jlisco, fiat mixtura. Two teasixMinfula in ;i wini'glMS of
water three timea a duy.
In aged patients, and. especially when acute
bronchitis is accompanied by old cmpliyseiiia of the
lungs, together witli dilatation of the ri<;ht side of the
heart, there is often ditlicujty in promoting expec-
toration and in maiiitjiiniiig cardiac action. In
sucli cases we must give stimulants frefly — a table-
spoonful of brandy or whisky, with a little hot milk
and .seltzer or Apolliiiaria water, every hour ; or in
some cases champagne way be given if the patient
prefer it.
A mixture of ether, ammonia, and digitalis may
be of" use to stimulate the failing cardiac power : —
I^ Tinctiiriu di^talis nilxxx.
Si>iritiiB ii'theria ... ... ^iv.
.Viiitnniiii cnrbnnutii gr. xl.
Aqiiiii oil jviij.
Jlistc, tiat miHlnni. 'IVo tableepnonfuU every two or thrcn
hours while necesaary.
Or the action of tlie heart may be maintained by
hyf>odermic injections of strychnine, and the dyspntca
relieved by oxygen inhalations. Stryclmini' acts
powerfully on the respiratory centre, and its ad-
ministration is an invaluable expedient in the later
exhaustive stages of acute bronchitis.
Spnsmodtc dyspmra, with dry rilUs, may refjuire
the administration of the ethereal tincture of lobelia.
This may be given combined with ammonia and smiill
doses of morphine, rcmemboring tlie caution wo have
already given about the use of the latter drug.
ly 'I'incturro Inbi'liii." iithuriii" ... ... ... 51.
.'\iiiiuoiui earfiuiiatig ... ... ... t^si,
Liqiiorifl moriihiiia^ hyilrochloridi ... 'jj.
Aqiiui «d Jvj.
Misce, liiit mistum. One or two UbloipooafuU every two
or three hours until relieved.
538
Mbdicai. Treatmest.
rPart in.
The inlialntioii of chloroform may sometimes lie
necessary to relieve si>asmo<iic dyspiia'a. If tlie dyspncea
is caused or aggravated Viy intestiiml flatulence, and if
this lias arisen from an unwise disinclination to keep
the bowels well relicve<l by aperients, the desirability
of which we have refwatedly insisted upon, then we
may administer a turpentine or rue enemii, and give
the foiluwinj; pills aiici draught : 5 grains of the
compound riiiiliarb pill with 5 grains of the alo«»
and asafd'tida f>ill, followed by a draught containing
'1 drams of sulphate of soda, .'5 drams of tincture of
senna, and 1 J ounces of caraway water.
The di«>t during an attack of acute broneliitis of
any severity should hp fluid in the main. Milk when
it is well borne and easily digested is e.xcellentr— it
should usually be given warm. Nourishing soups,
gruels, and broths which favour diaphoresis should
also be given. Ueaten-up eggs, the yolks of lightly
boiled or |K>achcd eggs, and custard ]nidiling, are all
useful. Light ]itiddiiigs, tapioca, ground-rice, or
arrowrot.it> are [K-rmissible, and if the tongue is fairly
clean a little pounded meat or chicken may l>e added
to the animal broths. An occasional cu]> of light tea
is i-efrt'shiiig and stimulating. In the slighter cases
Bsh and chicken may be allowed. In convalescence
we should prescribe a nourishing diet carefully
adapted to the digestive cai>a(nties of individual
patients.
In severe cases, the patient's position iu bed should
be arrnngefi so as to counteract the tendency to
passive or hyfwstatic congestions ; he should, there-
fore, be almost rai.sed to the sitting position, and ho
should not be allowed to rest long ou one side.
^
Ch»p. ii.i Acute Broxcuial Catarrh.
ADDITIONAL FORMUL.^^.
539
Powders for acute bronchitis
with abundant stringy ex-
pectoration difficult to expel
R Acidi iK'ii/oici, gr. xij.
Ptilvoria gummi acacia.',
gr. Ixxv.
U. et divide in riiilv. tJ, A
powder every two hourm.
{Itm/ifintfrr.)
Powders to relieve the cough
of acute bronchitis.
R MorjAinip liydrodiloridi,
(fr. jra.
Pulveris iiH'cacuanlin'. ct. iij.
Sodii binirbouiitiis, gr. Ixxv.
Saocliuri albi, gr. Ixxv.
M. ut divide lu pulv. xij,
One every «ix h"ur9.
Mixture for acute bronchitis
in children.
R Villi iiutiiiiiMiiiilia, sj.
Villi ipecaouuuii)i% 3ij.
Liquori* ainiuooU aceUitis,
.^iv.
8yriii»i tt.ilutjiuij iiv.
AquiL> ad }ij-
IL f. mist. A teiwiioniifiil
OTtfy two hours furn child two
yeanold. {ir/nila.)
Ulzture for acute bronchitis.
R Aiuoiouii diloridi. gr. xxx.
TincturH'opii, nixijad xxiv.
Syrupi ReiiRga*, .^vj.
Decooti altliini^ ( 1 iu 10 or 20)
lid jviij.
M. f. mist. Two tj»lile»po<jn-
f uls every two hours.
[Bamtetyei:)
Mixture for acute capillary
bronchi tls.
R Viui iiutiinoiiialiV, >!%•.
Spiritiis chloroforiiii, .^iv.
Spiritus auiiiiouiit* uromuUci,
Liqtioris iiiuiiioiiii acvtatif*,
■Vj.
Ai{iu» od !;viij.
M. t. mist. A tublespoouful
ever}' two houre. ( If'hidu.)
Mixture for acute bronchitis.
R Tinctiira-veratriviridis, .ijse.
Viui uiitimoiiii, .^iv.
Tiuctiinp opii caiuphonitir,
jiJM.
Liquoris ammonii ncotutis,
.^ij.
M. t. initt. A teas|>oouful in
11 ttililuKlxj'iiiful of water t'vury
two, tlirec. or four lioiir*
(suuillcr doses for children}.
{J'rof. ShriM, M.lt., CItieaiju.)
Spray for inhalation to re-
lieve cough from excessive
hyperaesthesla of bronchial
mucous membrane.
R Extmcti cuiiii iiiiu^uluti (dis-
eolVL-d ill rvctiUcd spirit),
gr.iij.
Aquii' luuiDceran, nixx.
Potiu'sii uirlKiiiatis, gr. viij.
AiiiiH' ilcstillatJi', 5J.
M. i. iulml. To be used
warm. (jUipih.)
Belladonna spray for bron-
chitis and asthma.
R Extructi lielkidanmn, gr. j.
Aqiiip, jes.
M. f. B«l. To be Ufwil with a
Seijilo's Bpniy-pr<Mlui:L'r «vory
few houii.
{Dr. Davitt, af ShfrtxirHt.)
CocUlana (burk)
and naregamia (root)
liave been iutrinluced in
America as cx]i«ct(imuts iii
" dry cntarrlu*,'' and lui pr(t-
fernblo to tartari*vd antiiuoiiy.
T)ie dose of the foniiur is iu
grniiis of the jKiwdcriKl Uirk
every four or six liuurs, aud of
the flitter 'JO grains of the iww-
dered nvjt. Little is n-nlly
kiiowu ut present about these
drugs.
S40
CHAPTER III.
THK TKEATMEST OF CATAKRIIAL AFFKCTIONS OF THE
BESPIEATOUY OKCANS (CONTINUEF)) : CUKONIC UKOM-
ClIIAL CATARRH.
CitBONic Bbonchi.\i, CATARKU.—i^^io/oyi/— Varieties: "Clironic
Winter roiipli" — "Dry" CtttniTh — I'ituitous CataiTli ur
BroiichdrrlnL'ii— Brouihiectii«l«— Itroncliiti»Putri<in— Plivsifnl
Sijitis- ludicatiutis for Tn*utiuput — Trimtmcut of (*nfinnry
Winter Cough— of Dry Catiirrh— Alkuliiif Drinks ami Spmya
— Hot Aijuoous Vn]>our for Inhiilutiou — Mini'nil Waters —
Ems — AjKilUnariB — Dourboulo — Seltent — Fonnulii- — Saline
AperionU — roUiRsiuin aud Sodium Iodide. BromchorbbiKA
— BaUumA aud (juiu liosius — f 'oiicut«— Turjicntino in Mix-
ture* and luhiit.itions. INIIAI.ATION Kkshibatok.— Deriva-
tJTM from Tur|wtitini'— Tcrpino— Terpiuol — Torehi-ne— Tar —
Creaaoto — Menthol — Baliwinis of Peru, Tolu, Benzoin, and
Stomx— Ammouiiiciim — Sijuills. Bronchitis Fitbiua. —
Anti«cptir Inhalationa — Santal Oil— Myrtol— God-liver Oil —
Astringent Sprnv" for profus« Seorctiou— Aictiito of Lend,
Alum, Tunuin. Perchloride of Iron, etc. — Senega— Value of
an occaaioual Emetic— Meehanical Compression — Counter-
irritation — Puciiiuatic Treatment —Climate — Mineral Watem
— Treatment of Associated Constitutional Tendencies. Addi-
tional Formula'.
There w, perhaps, no diseaso which is met with
more fr«|ui'ntly in Great Britain than fhronlc
broiK-liial raiiirrh. Tho iiisuhir, humid, change-
alile climate is fspeciiilly favourable to the maintenance
of catarrhal conditions of the air pa8.sage8 when ouce
they are established. •
The chronic form of bronchial catarrh is often tlio
result of repeated acufe attacks, or it in due to con-
tinued exposure to unfavourable meteorological con-
ditions. It is often secondary to other disea.ses — to
typhoid fever, to heart disease, to phthisis. Tt is
sometimes c^iused by occu])ations which entail ex-
lK).sun' to irritiitin^' dusts or gases. It i.s frei|uently
a.sHociat'cd with pulmonary emphysema, in the pr
diiction of which it plays a predominant part. It
oft^-n encouutere<l in connection with the goiiM
diathetiis us well a» in association with rlieuinatisit
scrofula, and syphilis. But whatever may be
Chap. III. 1 Chkon/c Bro.vchial Catarrh.
S4«
yirfditpoting catisea, the two ercUiiig caospfl, apnrt
from iiipclianical or chemical irritanU, are almost
invarialily ati inheriteil oracqiiired hyper-sciisitiveiiess
of the lirmii-liinl tuucnns nicmbniiie, and oxixjsure to
atiiiosphfric viciKsitu<lp,s.
It is met wit)i at all ages, and ia most troublesome
to deal with and most dangerous at the two extremps
of infancy and old age. It is sometimes companitively
slight, recurring regularly in severe weather in the
form of what we call a chronic winter cough.
There is also the " dry " form, the eatnrr/if «*; of
French authors, chm-acterised by violent irritjvtive
cough, and scanty, tenacious expectoration difficult
of exjiulsion. This is rpgai"de<l by some rs a "gouty"
form. There is also the form, attended by abundant
mucopurulent secretion, the " raturrhr. pitiiih-iix" of
tlie French ; the " bronchorrhiea " of other writers.
Occasionally chronic bronchial catarrh is accon)-
pHiiied by structural changes in the walls of the
bronchi, leading to dilatation of these tubes, and to
the formation of the so-called bronrliit'i'lnlir
cavities.
The stagnation and decomposition of bronchial
secretion in these cavities may impart an otFensive
odour to the breath and to the sputa, and this may
also arise from putrid ulceration of the bronchial
mucous membrane, giving rise to what is termed
broncJiitin piilridii, or fretid bronchitis.
It is scarcely necessary to enumerate the familiar
symptoms and physical signs of this veiy common
njnIiKly : the cough more or less severe, the expectora-
tion more or less abundant, the dyspnara more or less
grave, according to the extent of the ditTusion
of the disease or the presence of complications;
the combination of good, often exaggerated, per-
cussion resonance with diffused harsh n'spiration,
and various sonorous rtJlrt, rhonchal and sibihint,
crepitating and humid, or musical and dry, while
gurgling r<7l>'s are heard over the broncliial dilatations,
in some cases there is notable emaciation.
54*
Medical Treatment.
(Pan 111.
The indiraliunoi for ticalnirnt will vary with
the natvun uf the fiise.
It is, in tlie Hrst instance, iiii|ir>itaiit to i-eniove nil
source of injury or irritation to tiiu lironchial mucous
uicniliranc-, in which the <li.se(i.sc nirty have origiiiaUKJ,
<ir wliicli may favour its continuance.
If it is (l>|)eiiclent on occupation, cliange it ; if on
climate, let your patient seek a better one. Is it
deiM-ndent U](on the existence of some other iiisea.se or
constitutional state, as heart disease, syphilis, scrofula,
gout, etc., then our remedies must heselecteil with due
regard to the original disease or diathesis.
There are other indications for treatment wliich
may ho deduced from the symptoms of the disease
itself. These are :
«. To iMiiilify the morhid .seci-eting tiction of the
lii-oiicliiid iiiticous nieiidinino.
h. To promote tlie e-\pulsion of the morbid secre-
tions wliich tend to accumulate in the-air tubes.
c. To calm irritative cough.
d. To give tone to the enfecliled bronchial walls.
v. In fo-'tid bronchitis, to suppress the putrid
decomposition of the bi-oiichial secretions.
Little is needed in the way of mc<lical treatment
for those slight forms of brotidiial catarrh which are
almost Imhitual with some jiersons during the winter.
General hygienic measures should be preserihed, such
as sullicietitly warm clothing, residence in dry and
protected localities, and in well- warmed and well-
ventilated apartments ; avoidance of all exposure to
draughts or chills of any kind. A respiratur may
sometimes be worn with advantage during cold, dump
weather. The food should ije light and nutritious,
and the liowels kept ojwn by gentle saline aperients.
The most troublesome symptom in these cases is
usually a more or less harassing cough on rising in the
morning, w ith some ex|)ectoration which may at times
be dithcult to expel. The best remedy for this is ;"> or
G oz. of an alkaline wat«r, such as Ems or Apollinaris,
with a little ifoUutg milk, early Ln the morning.
Chap. II 1. 1 Chkoa'ic Bronciiial Catarrh. 543
In cases of "dry cntnrrh" we meet with severe
paroxysms of cough, attendrHl by a very scanty
secretion, wliich is tenacious and sticky, and ditticult
of expulsion, and when it is expelled is in the form
of small pearly masses. The seat of this form of
catarrh is in the smaller bronchi, and it is often
asBOciiited with the gouty constitution. These cases
are j^reatly benefited by the free administration of
warm alkaline drinks and the inli.tlatiori of liot Haliiie
alkaline sprays, or the steam of hot water. Thu
mineral waters of Ems, Apolliiiitris, Bourhoule, nnil
Seltt^rs are excellent for this purpose. Four to six
ounc«8 of Eras or Apollinaris, with two ounces of
hot milk or whey, should be taken four or five times
a day, and the hot 8j)ray of these waters inhaled
twice a day or oftener.
If these mineral waters are not available, a very
good substitute is a mixture containing bicarbonate
of soda and chloride of sorlium, and with this mi.xLino
we may often advantageously combine sonic p^lls
containing tarlurised antimony (or ipecacuanha) and
morphine, the latter for tlie purpose of allaying the
irritative, hypertusthelic condition of the bnitnchial
surCace, the former to increase the amount and
fluidity of the bronchial secretion, and so facilitate
its expulsion.
The following prescription is useful : —
ly Sodii birar>ion»lia 5J.
Sodii rhloridi ji*.
Ammonii carbonntiii ... 3ML
Spiritm chlorofurtni .VJ-
A<iiin' .. ad jvj.
Slisco, fint mifitura. Two lablenpoondili, with two of hot
water, every four to six hours.
1^ Anlimonii tartjirati gr. V
{rtl pulverij ipecacuontue, gr. j.) I
'Morpkinn aoetatu [vel codeins, gt. m.) gr, |
Extmcli hyowynmi ... .. .. gr. ij.
Mince, flat piliila. To li« taken iit b>.>d-time.
* Refer to what i> aaid at page ,V12, »»'«, ua to the iuh! of npiaiu
ID Uieae eaiea. The morphine aboujd uot be proacrihed for the n|^.
544
Medic Ai, Treatment.
(Part in.
CiKleia should ho preferred for tfouty persons.
In the Kouty thiB treiitnipiit shouM he combinetl
with a suiliiie aperient every inoniinc, such as one
or two t«iuspo<infuls of Ciirlsbml .siilU in a gla.s.s of
hot water.
Pi)t4ts.xiu)ii, socHiim, and ammonium iodides are
valuabh- riTiirdies in gouty forni.s of chronic lirnnehitis ;
3 lo 5 graiiiH of either may he added to faeh dose
of lire preiv<hii<f mixture.
Pdta.ssiuui and .sodium iodide also prove of lunch
benefit when there is a tendency to asthma, and the
bronchial secretion is tenacious and difficult of
expidsinn ; liirye doses, from 5 up to 15 grains, of
pnta-ssiuni iddide mny be reijuired to rt-lieve these
attacks of rlyspiKea in this form of chronic bronchial
catarrh.
In cases of chronic bronchial catarrh with profuse
swretion, or hroiKliorrliwsi, tho object of our
treatment should be to modify the morbid secretin<;
action of the bronchial mucou.s membmne. Several
drugs are believed to possess this ix>wer in some
degree; notably, certain "balsams "and "gum resins."
Copailm, turpentine, tar, croivsote, the balsams of
Peru and of tolu, ammoniacum, are membei's of this
group of remedies.
Some of these drugs contain substances which
are eliminated by the bronchiid mucous nien^brane,
and may thus exercise a locaJ influence over the
existing morbid conditions.
Copaiba is often given combined with titr in
cap-sules, or according to tho following formula : —
IV Copsibie .Vj.
Miiciliigiois acaciiD ... jvj.
Spiritns cJiIoroturmi 5W.
Aquw caraijhoni' ... ... ... nd jvj.
Misce, But mistiim. Two taUospoonfuls three times 1 dny.
Tarppntiiit' is mure agreeable and as eificHcioua,^
It may be prescribed in capsules. Or it may be J
given as an emulsion, thus : —
h
Chop. III.) CuRoxic Bronchial Catarrh.
545
R7 Olci torobinlhintp ... 51.
MucilBjfinis acuciiii ... Jij.
Mistuni' amygjiilii- ... "'1 3*'j-
Hisce, Sat miatura. One or two tnblespoonliib for a dose.
Turpeiitirie is also well and readily administered
by inhalation. A t<>a.spoonful of the oil of turpentine
rnaj' l>e vapori.sed from the surface of hot water, and
directly iiiliuled with the viijwur of water from any
Fig. !&.— Dr. V«o's Kapintor.
suitable vessel, or twenty or thirty drops of spirits of
turpentine may be added from time to time tu tlie
wfiU'r in a lironchiti.s kettlf, when its vapour will bo
uickly diHuHed into the room ; nr the patient may
wear a li^'lit perforated zinc inliiilatioii r<>.>>|>irutor *
tlie Sfionge of which is charged from time to time
with spirits of turpentine (Fig. 15).
Professor S. Solis Ooben says this is "one of the
* ThU litUe iiiliitlittioQ respirator wua ilDviscd by th« author,
and is mode by Mumrs. .Squire, 413, Oxford Street, Ix)udoii.
Meaan). Wyotb, of I'bilailelphin. alao make it iu a slightly
modiDed form.
J J
546
Medical Treatment.
IPartlll,
most useful, as it is one of tlie simplest, devices for
the inspiration of niediciiml vapours.''*
Various derivatives from turpentine have bt-en
iiswl in the treatment of chronic liroiicliial catarrh.
Teiyinol antl terpiite /lydrate are very po]iu!ar in
France. Terpinol is an oily substance with a ja.sniine-
like odour: it is said wiien taken internally to be
wholly eliminated by the respiratory passages. It
is beat given in capsules, live to ten cJaily, each
containing a minim and a half ; also in pills according
to ii forniulit to be found at the end of this chapter.
Terpiiie /ii/driif" is a white cryst-nlline botly,
" bihydrate dn iMbeuthene," and it seems to act on
the respiratory mucous membrane in tlie sami.' way as
tm*pentine, but it has the advantage of not disturbing
the digestive organs. IxSpine lias used it with grejit
success in cases of broncl)orrha>a. It is (july slightly
soluble in alcohol, so it is beat to give it mixed with
alcohol and glycerine : •
Vf Torpinc hydrate . . P- l»iv »<i Ixxx.
Alcohol . jv.
Glyeorini . "J 3'j-
SIi.4oe, fiat mistura. A tuoxjiounfol iu some aromatic water
thrt'e nr four tiroea a diiy.
Pills containing terpine hydrate (gr. 2| or gr. 5)
and heroin (gr. Jj) are made by Schiefiain, and are
very useful in catarrhs of the larger bronchi.
Tereljeiif has also Ijeeii given for the chronic form
of winter cough. It may be given in capsules, or
dropped on sugar, in doses of 5 to '20 minims ; or
it can be made into an emulsion with mucilage of
tragacanth, or inhaled as a spray, or from the sponge
of the little respirator just descriljed.
Tar is another remedy for bronchial catarrh ; it
is frequently given iu the fonn of capsules, or as tar-
ftvUer, or in pills, and as an inhalation. It is of value
in the treatment of chronic bronchial catarrh. It la
an expectorant, as well as a tonic to the bronchial
* Hare's "System of Practic&l TheraiieuUca," toI. i., p. i'ib.
ch*i.. 111.1 Chronic BROifCHJAi. Catarrh.
547
muL-oiis nienil)miie, amJ it hiw l)een sugjjestej that it.
exerts itH liftieficinl tonic efl'pct on the respiratory
mucotiH nienibnine in tlie act of its oliniinatiou,
stimulating the (>](ithplial plenients and their cilia.
Tar-water can W made by stirring one part of tjir
with ten of wati^r for fifteen minutes, and decanting.
A wineglassful may Up taken several times a day.
Tar can also Ik> made into pills either with
li<(Uorice-powder or jiowdered gum acacia. Equal
parts of tar and liquorice-powder may be mixed
together and made into 5-grain pills, two or three
of which should W taken three times a day.
Or the syrup of tar of the United States Phar-
niac(i|>a»ia can be used. A stront;er form can
be oliUiinwl l>y washing the tar with an alkaline
water, or using tinctura quillaja unpcmaria iu its
pre]>arution.
Tar may I>e inlmled in the form of s]>niy liy pulver-
ising tar-water in a Siegle's s]iray-pri)ducer ; it may
also be used as a fumigation ; for tliis purpose good
shi|)'K tar should be employed, to which 10 per cent,
of carbonate of soda should he added to neutndise the
pyroligneous acid contained in it, which might Ijo
irritating to the re.spiratory passages. At first it is
ln^st to dilute the mixture with water, so as to get at
the same time tlie emollient action of aqueous vajM>ur
on the part affected ; suhse(|uciitly the amount of
water may be reduced, anil at la-st the pure tar
mixture with scxla may lie etuployed ; this is Mimply
poured on to a flat dish, and heated over a spirit-lamp.
The tar vapours are evolved in the vicinity of the
jwtient for a quarter of an liour or more at a time,
once or twie<? n <lay, but it isde-sinibie that the patient
shouhi remain all day in the room the air of which lias
Iwen iniprtignatcd with tar vapour.
Much that has been .saiil with regard to tar applies
also to «T»'n«iole. It can be given in the form of
capsules, ami then a few tablosjiooiifuls of warm milk
or soup should Ik- taken Iteforelmnd to avoid gastric
irritation, or cue or two tabtespoonfula of the creasotc
548
Medic A l Tk ea tmk.vt.
[PttrtllL
mixture of tlio Britisli Pharmacopfi-ia can be given
tliree times n day. It win also 1x3 given in the form
of pills, each contiiiiiiiig a niiiiiiii, mixed with soap
and criinsb of Invad.
Or it may ''l" mixed with glycerine and any agree-
able tincture, with a, view of covering its taate, such u
the following : —
Ig) Croasoti
Tiiictune chlorofurmi comjioBitu,'
(ilyeerini
Sliscc, fiiit mi8tum
or four tiiiioH a Any,
... niSTi,
:::}5a5i.
A teMpoonfuI in water or milk tbrce
We have also given it mixed with cod-livor oil —
2 minims of crefisote with two drams of co<l-liver oil —
three times a day in cases of browhilu putrida with
riHimrkubly good results. A mouthful or two of milk
should Ije taken before and after the dose.
But creasote is especially useful for inhalation,
and it can Ije very readily inhaled by means of
the perforated zinc respirator already referred to
(Fig. 15, p. 545).
If there is much bronchial irritation ns well as
profuse secretion, the sponge of this inhaler can be
charged with equal parts of creasote and ether, or
creasote and chloroform ; oi' if a less decided sedative
is required, an excellent mi.itUTO for the purpose con-
siats of equal \yasia of creiusote and spirits of chloro-
form.
If it is desirable to combine the emollient effect
of the vapour of water with that of creasote, the
latter may be vaporised by dropping it on the
surface of very hot water, and their vapours inhaled
together.
The employment of turpentine, tar, and creasote
is especially indicated in cases of profuse bronchial
secretion (bronehon-ha>a), particular!}' when the sputa
are offensive owing to the existence of putrefactive
jiriKjesses in the air passages, or the presence of
bronchiectatic cavities.
ch»p. HI 1 Chronic Bronchial Catarrh.
549
TliL- inliulatioii of in«*iilliol ih useful in tlie sanio
cliisHof cases ; it is fouiul to allay cougli as well as to
]ironiote expectoration.
The biil!>iiinK of I'oi-ii and tolu, liciizoiii
and •ilitr{«\, art' also given in clironic bront'liinl
catairh to niodifv the morbid secreting action of the
resjiiiatofy tnticous niendjrane. The well-known
tincture in the L5.P. containa three of these — Ijcnzoin,
storax, and tolii — and is often found of great service
in lessening the amount of secretion and diminishing
the cough. It is necessary that this tincture should
Ije ruldjed up carefully with thick syrup or mucilage,
so OS to make an eniul.'iioii with the gum-resins it
contains, or it will not mix with water, as :
Vl) Tinctuni' bcn/.oini composita'
Tinctiirii> toliitiinn- ...
OxyiiipUit scillie
MuriU^fiiuB aciiciii' .
Vini ij>ei'«L'iianha- ...
Aquoi
5'J
31a.
ml Jvj.
u
}tIiM.'f, liut miituTa. Two tslilespooiifiils three tiiiivs n day.
This tincture may also be inliHle<l from hot wat<'r.
Another gunvresin of value in the treatment of
the chronic bronchial cutarrh of old people is nni-
iiiOMiiK-iiiti. It is of much value as an ex|H:'ctorant
in (.•rrfain coses. It is given rnlibed up with water, as
in the tnistura ammoniaci of the British Pharma-
copreio, or combined with squills, as in the following
fommhi :— ■
It Tinrtuiii' caniphone compoiiitii' I „. ...
tlxyinrlliH.dL ... j '^S-'J-
Mjstiirii- uniiiioniiui... ... ... ad jvj.
lli»ci>, fiiit ini!*tiira. Two tKl)k'8]Ki<:>n{ulii for » doso.
It is also one of the constituents of the pihda
scillie composita and the pilula ipecacuanha* cum scilitt
of the British Phurm;icopo'ia.
Mqiiill it,Helf is a useful expectorant in many
cnscji of bronchitis, especially in those coses which
ore intermediate between the acute and chronic fonns.
350
Medical Treatment,
I Put 1 1 1.
It is ofUvn cum billed with small doses of ipevucuaulin
aiid ii|iiuni, as in tjif pilula l/tcttriiitn/iiu cum gcillA of
the R.P., of which 5 to 10 groiiiH may Iw given at
IwMl-timi' with much advantage in many cases of chronic
hiMiiiiiiul c-iittirrh.
Some have found a Turkish Ijatli (taken at homo)
most useful in cutting short intercun-ent acute or sub-
ocuti^ iittafks. As soon us free perepinitiou is induced
the tightness on the chest is relieve<l. After the bath
tho patient should retire to a well-warmed bed, and
sonic tereljene should lie inhaled from the oro-nasai
respirator described on p. 515.*
The following formula t is a good one in tho«e
casejs interiuetliate between the acute and chronic
forms to which I have just referred : —
Vf TincI araj scillw ... ... yj.
TinctuDi' ciimphone compositaf I aa lii!
Siiirilmi irtht'ria nitrosi ... .. ...J 3* J*
Liquoris nminoiiii act'tiitJ!! ... ... ... Jjra,
Aiiiiiv camphorif ... iid jvj.
Sliscc, lint ini«tuni. Two tablespoonfnli every five or »ix
hours.
In those eases ill which the expectoration tends to
lH<oome fu'tid, cjuses of so-called putrid bronchitis.
and of broiicliirftniiis, our treatment should be
di«!Cted to preventing or arresting the decomposition of
the bronchiid secretion. Inhalationsof antiseptic agents
whicli act also as expectorants are specially indicated,
such a.s turpentine, tar, creasotc, carl>olic acid, etc,
after the manner already described. In such cases]
the inhalation of a spray of a 1! to 4 jier cent, solution
of carbolic acid is exceedingly u.seful. Inhalation of
chlorine and iodine has also been recommended.
Da Costii has found xnitUit oil of great value in
these cases. He gives five drops three to 6ve times
a day. Myrtol lias also been liighly extolled in tho
treatment of putrid bronchitis. It is a volatile oil
obtained from the leaves of the common myrtle ; when
• S*t " Disea.'es el the Lunxs," by Fowler anil Godley. p, 109,
t Iknmptnn HfW|>ital Phamuuxtpieui.
chap. III.) Chronic Bronchial Catarrh.
55'
taken interually it is eliminated chiefly l>y the lungs,
and acts as au antiseptic ami tlttxloriuit. It is i^iven
in capsiileM ^ich containing 2 minims, and two of thesu
arc prescribed every two hours, and its administra-
tion is attendefi by a diminution of the expectoration
and a disappcanince of the offensive odour. Tincture
of euciilyjitUH, turpentine, creasote, or tar may also l>e
given internally. In these ca.ses it is also advisable
to combine tonic remedies with expectorants, so as to
maintain the genei-al strength ; we should also sec
that th« patient lias a nutiitious diet. The patieTit's
apartment should be well ventilated, and the air dis-
infected ; for this latter purpose nothing is more
agreeable than oil of eucalyptus or ])inol. A mixture
of one part of eucalyptus oil or )iinol to six parts of
rectified spirit may be diffused through the air by
mcAHs of (I hand-spray, or by dipjiing oloths in it and
susfH-Muliiig them in the room. An atniosphei-e so
charge*! with eucalyjittis va|iour has a decidedly sooth-
ing and soporific effect, a real advantage in many
cases.
The following is an excellent tonic and ex-
pectorant for such cases : —
(^ Ammonii carbonutis ... ... ... gr. xL
TinctiiriL' Htifis vomii'ii- .. ... .. ^.
Tincturu' finchonii' comjwsitit' 3iv.
SpirituH chlorofomii ... ,., 5ij.
Iiifusi scne^>. ... Mljviij.
Hisco, 6iit inistiim. Twd tiibluspouiifiila three timca ii Jny.
Or, when a more decidedly bracing tonic ia re-
quired, we may give this ;
IV Tinctiini' ferri p«Tohloridi . 5ij.
Li(jiiuri8 atrythniiiie ... nul.
Spiritiii chloroformi ... . . 5!].
Aqun> ... nd jviij,
Misce, flat mistura. Two taMeapoonfub three tiniM a day.
We have already referred to the good results to be
derived from the a<)ministration in these cases of cod-
liver oil with creasote. Cod-liver oil is of very groat
u
5S2
MtnuAL. Treatmfmt.
(Part in
valno in tlic ciimciatinf; forms of chrouic bronchitis
with j>rofuM' st'iTPtiiiii.
In hTwiirliJerlaMM and other cost's with fa-tifl
sputum, iiitra-triiciical injections of menthol (10
IMiits), guiii.'icol (2 parts), and olive oil (1S8 parts)
have lieen advised. A dram of this mixture is in-
Ject<?d twice a day into the trachea, care lieinj; taken
that the nozzle of the sj'ringR iias passed beyond the
vocal cords. Gtx)d results lui\e been reported from
this mode of treatment by tiuiny ])hy8icianH.*
Fowler has found treatment by crenaotc vapour
linlhs the most eUectnal iikeiuis tor jireveuting the de-
eomposiliou of the broiicliiul secretion in these cases.
These vapour baths are given in a small room suitably
arranged for the pur[)ose. The creosote is vaporised
from a metal saucer on ii tripod by means of a spirit
hiniji. The patient'a clothes are protected by wearin;sf a
sort of sniock-frock, his niwtrils are pluggtnl with
i-otton-wool, and his eyes also protected by goggles or
It mask. The rontn is tilled witli dense clouds of
vapour. The imniediate eH'ect is to cause the patient
to cough violently and to expectorate profusely. At
lirst the bath is given on alternate days for tifteeu
to twenty minutes ; then, if well borne, daily, and the
duration gra<1ually increased to an hour or an hour
and a half. A remarkable increase of appetite is said
to follow the use of these baths.t
In cases of l>roiirlioiTli<rn tlie indicationa for
treatment, as we have ahciidy seen, are
1. To endeavour to prevent the formation of the
niuco-purulent secretion, and
2. To promote its cxpitlsion.
Now, besides tlie reme(h"es directed to these ends
already referreil to, there are others to which we
may have recourse. Some authors arlvise the direct
application of astringent remedies to the mucous mem-
brane of the air-passages in the form of spr<iy» ; fluids
* Bnyal Meilicnl anil LliiruTgical Souioty'a 'JVnntatlion;
Xurember 27th, 1S<)4.
+ " rHiieaBCB of the Luii(;»," by Fowlar uid Oo<Uey, p. 138.
Chap. III. 1 Chronic Bronchial Catarkk. 553
|iulvori8c'(l !))• means of u. 8iegle's spriiy-jtrotlucer,
contuiiiiiig in solution such iistriiigent substances luj
acetate of lead (5 grairiK to tlie ounce), tjinnin (.5 to
10 grains to the ounce), alum (5 to 10 grains to the
ounce), perchloriile of iron, rhatany, etc.
Tliese remedies have lieen found useful in the
after-treatment of cases of bronchorrliwu and putrid
lironchitis. Aft^-r the fu-tor of the sjiutu, and the
decomposing processes in the bronchial tubes upon
which it depends, have been arrested by antiseptic
inhalations, those astringent sprays are said to be
useful to remove the swelling, serous infiltration,
hyj)encn3ia. and engorgement of the bronchial mucous
membrane, but it may Ik- doubtetl if they i>ass far
beyond the trachea and large liroiichi.
We have already fii'^'f" instances of the value of
senejja as a stimulating expectorant in cases of
chronic catarrh of the air-passages, and the following
will Im; found a useful mixture in cases of chronic
bronchial catarrh with profuse, stringy, wlhesive
secretion, such as is often met with in aged people ; —
'■■ } aii gr. xl.
H. Ammonii cnrltonatis
Sodii bicarboiiittis
Tincturn- camplioiic comiXMiita.-
Spiritiig chloroformi nvclz.
Infiiii Miiogic ... ... ... ad jriij.
B(ij<(-e, fi«t minium. Two tableipoonfiiU every 6v(' or «ix
hours, with two toblespoonfuls of hot wutir; thu hot water
nintciiuU}' increium its expectorant i>owet.
The addition of 5 to 10 grains of swiium chloride to
each dose of this mixture often promotes its ^pector-
ant effect.
It will 1)6 note<l that this mixture contains a small
quantity of opium (in the compound tincture of cam-
phor), but it is a very small rjuantity, only one-eighth
of a grain in a dose, for it is necessary to be ver}'
cautious in the use of opiates in such cases. As
we have nlready .said, they are often extremely
biully home by old people, for, by diminishing
the sensibility of the bronchial mucous nienihrane,
554
Medical Treatment.
IPvl III.
the oll'orts of coughing are diininished, and the
patient iniiy fall aalee|i, never to wukc again ; for
in this sleep the mucus accumulates in the air- passages,
the access of air in the air-cells is more and more
interfered with, ciirlwnic acid accumulates in the
blood, and the patient dies poisoned by it. It is
essential always to bear this in mind in treating the
coughs of aged jicrsons.
Tt is well also t/j remendjer the value of an
occasional rmellf in those cases of chronic bronchial
catairh with profuse suffocative secretion. The
raex;hanical compression which the lungs undergo in
the act of vomiting not only tends to the expulsion
of the mucus accumulated and retained in the air-
passages, but it also relieves pulmonary engorge-
ment by Himultaneous compi-ession of the blood-
vpKsels.
Cierhardt has strongly recommended the a[)plica-
tion of maniinl fompression to the chest and
abdomen in cases where it is difficult by ordinary
means to procure free expectoration and unloading
of the air-passages of the morbid secretions accumu-
lated in them. Me maintains that manual pressure
on the external surface of the thorax and alxlomen.
applied during expiration, leads to tlie following good
results : —
1. Elevation of the diaphragm and a consequent
reduction of the pulmonary dilatation.
2. Increa.sc of vitiil capacity.
3. Diminution of the frequency of respiration.
4. Pixtmotion of expectoi'ation.
Casea in which the air-passages are occluded by
viscid secretions, which the feeble muscular power of
the patient is unequal to expel, are specially suitable
for this Dic;chanical treatment The expiratoiy eftbrt
is directly strengthened by the associated manual
pressure from without, and exj)ect<ii-ation is also,
indirectly, promote<l by the more vigorous muscular
activity resulting fnnn increa.sed supply of oxygen.
Gorhardt mentions the case of a patient with large
*
I
ci.»p. nil CiiRoKic BKOiKHiAt. Catakrii. sss
hroiichiectatic caviUi'M in tli>> lower loVw of tin; left
lung, iu which by inhalalionii of turpentine he 84ion
Hucee€«lwi in rcnRivin;; thi> odour of the HputA, liutth*^
expcctorniiun mom small, mid pliyitical uxjiiiiiiiutinn
sliowf^d that the f«\itii'H reniainn<l for Mt-verul days
together con«tantl_v tilled. He then cndcnvourwl t<)
promote and increase the ••xpiratory clFort nicchatiic-
ally hy placing the patient on hin right >iidi', uml
daily employing manual presHure, by which niemiH
he succeeded in preventing tlie retention of thi'
sputa.
Stokes catimftted highly the etToct of couMlcr-
irrilMiioa and rcvulntre trcatnvent in chronic
bronchial catarrh, and our own exiicricncn con-
fimiH his view. Stokeit uited to order a large portion
of the che«t to Ix.- Hpotiged daily with a liniment com-
|iosed of x]iirit of tuqu'tilint- and acetic acid, so lui to
keep up an erythenmUjUH Mtatc of the ekin. He
thought thai, bexidex the ivuntiT-irritiition thus pro-
duceil, Home of tlie iiigredieut* were absorbed by the
mirl'ace.
No doubt t}ic viijHjur of the more volatile con-
stituent (turpentine) may be inimical, and thus act
locally on the bronchial mucouH meinbnuie. Patients
theniHelvM learn Uie value of thew." embrocations, and
ask that they may lie renewed. The linimentuin
terebinthinie of the B.P. is a useful form, to which
may be addc<l, in the coaes of scrofulous cbildi-en, a
dram or two of tincture of iodine to the ounce. The
linimentuin tcrebinthina.' aceticum (H.P.) is also very
valuable ; it contains oil of tur|)entine, acetic acid,
and camphor.
The linimentum crotoniii is likewise useful, as a
revulsive, in some obstinate cases of chronic
bronchial catarrh ; the disadvantage attending its
use is that it brings out an unsightly eruption of the
skin, which may be avoided by diluting with twice
its bulk of linimentuni saponis.
The following is the formula for Stokes's embro-
cation : —
^
55*
Mf.niCAi. Treatment.
[Piul III.
ly Spiritua lurul
liin
DiiniL' . .
5''i-
Acidi aoclici
.. 5M
Vitclli ovi
• 3J-
(llei limcinia
5J-
Aq rosn-
... 5vj.
iMincP;
, tint liiiimintuiii.
We must now consiiler, briefly, the value of
alit'rntioii.ii of niniosphrrir pressure in tlie
treatment of chronic liionchial catarrh. This " pneu-
matic" method of treatinfj clironic catArrh of the air-
paHsages is moro <'omiiion in other European countries
tlian in Knj^hind, and most of tiic hir^e cities and
many hejilth resorts on the dintinent possess "pneu-
matic institutions " for tin' treatment of pulmonary
affections by alterations of ntmosphenc pressure.
Various portiible apparatus for this jiurpose,*
notably one ilevised liy Waldenberg and another by
Schnitzler, are also in use in Oermany and Russia.
The "Pneumatic Chamber,''* in which the pitient
remains for some time, is chiefly employed for
inspiration of compressed air ; but by means of
suitable arrangements he can lie made to intpire
compressed air and i-jinrt into rarifieti air. So, also,
by means of the portable a])]iaratus mentioned, he
can either iTwpirff compressed or rarefied air, or iiis/nre
the former and expire into the latter.
The compressed air can also l)e made, by a slight
addition to the apparatus, to How through solutions
of tar, creasote, eucrdyptol, pinol, etc., ami so liocorao
impi-egnatecl with vapoui's having a specific action on
the bronchial mucous membj-ane.
It has been found that chronic bronchial catarrh.s,
even wlien obstinate and of long standing, are favour-
ably influenced by pneumatic treatment. The pressure
which compressed air exerts upon the swollen and
hypenemic re.spiratory mucous membrane lessens the
calibre of its vessels and reduces the afflux of blood,
while it promotes the efflux of bJood and the fluids of
the tissues, and in this way diminiahes the swelling.
* Tlicsc ure fully ileacribeU in the uuthur'a transUition of Ocrtol'i
"R«Bpiratory Therajieutics. "
Chap. Ill 1 Chronic Bronchial Catarrh, 557
This diminution of the flow of blood to the
mucous niemhrano and promotion of the efflux of
fluids from it lessens the amount of secretion and
widens the lumen of the tidies, giving freer passage
to the iti-flowing air, and thus increases the amount
of air that can enter and leave the air-cells, and
greatly aids pulmonary ventilation.
If there is but little secretion in the bronchi, and
expectoration is difficult., wliile the tubes remain
permeable to compressed air, then this air of higher
U'Hsion rushes into the partially collapsed air-cells
beyond the tu1)cs, and thus imparts increased
expulsive power, and facilitates expectoration.
ExfMictoration is also promoted by expiration into
rarefied air, as by a simple ydiysical process it removes
hindrances to the otitHow of iiir from the air-passages.
It is not needful hcixv to enter more fully into the
theory of pneumatic treatment, but those wlio have
hml the large-st opportunities of watching its results
maintiiin that it.s beneficial efl'ect in the majority of
cases of chronic bi-unchial catarrh is {)ermanent, that
tlie catarrh is often entirely cured, and, even in
incurable cases, dependent on some more deeply
seated pidmonsiry lesion or cardiac aflection, it is
greatly allcvinted.
At lieitheiihall, near Salzburg, a very complete
establish ment exists for the treatment of respiratory
affections in the Fneuniutio Chamber.
The influence of rlliliiilc in the alleviation, as
well as in the cau.sation, of chronic bronchial catarrh,
is universally known.
Those who suffer haliitually from bronchial catarrh
in the winter should, if possible, p<iss that part of the
year in a climate where they may be exjx)8ed as little
as possible to sudden changes of temperature, to
chilling fog and mist, and to cold winds, and where
they can get, without lianger, a certain amount of
exercise in Ihe ojicn air with plenty of sunshine.
The choice of any particular jdace is often deter-
niinetl by considerations of convenience, expense, or
SS8
MSDJCAL TXEATMEyr.
IPatl III.
society. In England the best wintering - places
for roost cuaes of cliranic bronchial catarrh are
Torquay, Falnioutii, Tenby, Penzance, Bournemouth,
Ifie Underclitl' in the Isle of Wight, and St. Leonards.
Hut a drier and warmer winter climate than can
lie olitained in P^ngland is advisable in many cases,
and for these we can choose from the various resorts
on the Western Hi>*iera, one of the best of which is
Mentone ; or, if we consider the climate of the
Uiviera too exciting, we may select Algiei-s or
Tangier, Oratava, or Las Palmas ; or, if we wish a
very dry climate, there is the desert climate in
Egypt.
Madeira, Huelva, Malaga, Ajiiccio, Palermo,
Corfu, and many otlior places otfer also suitable
winter quarters for the catarrhal .subject. Perhaps
the best ior the tiiajurity of patients is Madeira,
which is now accessible by the fust Cape steamers in
three or four days.
Some German physicians prefer the more bracing
but dry and sunny climate of Meran and Arco for
their catarrhal patient-s in winter. At Meran
treatment in the Pneumatic Chamber can be
obtaitn>d, and in the appropriate seasons the grape
or milk or whey cures can lie had.
A course of miriornl M-nlcrs is often prescribed
with advantage for sufferers from chronic catarrhal
affections of tlie air-passages.
In France it is very conmion for such patients to
be sent during the summer months to a sulphur * spa
in the Pyi-enees.
The French physicians are fond of dividing their
catarrhal ca-ses into thi-ee classes — the scrofulous,
the arthritic (or rheumatic and gouty), and the
dartrous. By the " dartrous " they mean constitutions
prone to cutaneous eruptions. This classilication
ha.s always appeared to us somewhat artiKcial, but
• .Suliihiir in ■J- to lO-jfniin dowja throe times a flity wiu* rnroin-
uiviidinl liy Gruve« iu tlie trcjitniout of aerere clirouic lirnnchilia
witli ttbuudont expectoratiou. IIo maiutainctl tliat it loaeueil the
amount of Mcretion and facilitut«d its exjiulsiou.
Chap. Ill I CUKONIC BrONCKIAL CaTARRH.
559
they found upon it indications for tho a|i|ilicution of
their different niineml springs to individual cases.
The (vrthritic or gouty cases are sent to Eaux
Bonnes, Uauterets, or St. Sauveur in tho Pyrenees, or
to St. HononJ in the Department of Mievre; if the
catarrh is irritative anti congestive, to Mont Dore,
■ IjIi Bourboule, or Ploinbiferes. The scrofulous are
sent to Bareges in the Pyrenees, to Aix in Savoy, or
the adjacent Challes, or to Uriage. The "tiartrous "
or " herpetic " are sent to La Bourlx)ule or Royat.
Tlie Geriuan physicians, on the otlter hand, con-
sider those mineral springB which contain chloride of
sodium in sitinll (jiiantity, or, still better, chloride of
sodium combintnl with carlwnate of soda, and contain-
ing some free carbonic acid, as specially suitable to
the treatment of chronic catarrh of the air-piissages.
Em» is pre-eminently the spa for this purjKJse, as
it cont^iiins Ixith chloride of sodium and curlmnutti
of soda in small quiintity. Neu^tiahr has somewhat
similar properties, linden, near Homburg, is also the
ty|)e of a weak chloride of sodium-water, containing
free carlx)nic acid, and it deservedly enjoys a great
reputation in Germany for these cases.
ReiclftnliaU offers salt springs, and "»aliit«»" where
patients can promenade and inhale the emanations
from the "graduation houses," as well as facilities
I for pneumatic treatment.
Wi'Usenljcrg, near Thun, in Switzerland, with a
hot sulphate of lime spring, and a moderate elevation,
is considered by the Swiss physicians an excellent
su
til
HU
P«
at
b>i
summer resort for sufferers from chronic catiirrh of
the air'|>assages.
When chronic bronchial catarrh occurs in oliesc
middle-aged people who are free livers, a course of
some more active mineral spring is indicated, and such
patients derive advantage from a few weeks' treatment
at Kissingen, Marienbad, or Carlsbad.
In all these health resorts the various kinds of
baths available enable the phy.sician to subndt his
patieut, if be wishes, to those " repeated energeti'
56o
MsniCAL Treatment.
IPirtlll.
8weatinp;s " of which Niemeyer speaks so highly,
jiowerful revulsion to the skin being inidoubtedly Rn
efficient nieiins of relipving bronoliiiil congestion.
After one of these eomnos, which, it must be
remembered, are only t^ik^n in tlie warm season, it is
usually advifiable to spend two or three weeks in some
moderately elevated, bracing nionnt.iin resort, and'
amongst pi((«-forests, such as may h« found in tiie
Black Fort'St, or in Switzerhind.
If, us hiia already been wiid, the bronchial catarrh
is aRsociatcd with the existence of some other disease
or constitutional state, we must not lose sight in our
therapeutic efforts of the original disorder.
In tlie case of scro/uhiu chiUlren, we must look
carefully to the general nutrition, give cod-liver oil.
enjoin residence at the seaside, the use of salt-water
baths, free exercise in the open air in suitable weather,
nnd mix some iodine with our embrocations.
In these cases the syruji of the iodide of iron is
very useful, and it may be combined with coddiver
oil. Uypnplwsphite o/" /jHie is also often of remarkable
value in treating the chronic bronchial catarrh of
children and young people.
In the gouty, as we have already jiointed out,
alkaline wat-ers, saline purgatives, |iotassiuui iotlide,
and ammonium chloride are the best remedies, a
few doses of colchicum being occasionally required.
Opiates are to be avoided.
In cases associated with a tendency to oataneoua
erujjtions, arsenic will be useful.
If there is a well -market! syphilitic taiut, we
should of course employ iodide cif [M^ta-ssium.
When chronic bronchial catarrh is a complication
of heart disease, it will often be neceswiry to enjoin
strict repose in a warm but well-ventilated apart-
ment ; wo must also give supporting food and medi-
ciiuwi, and some form of alcoholic stimulant is of
great value. In many cases of mitral regurgitation,
digitalis will be hel|>ful, and in feeble aniemic ca-ses it
may be combined with iron.
Chap, 1 1 1
It is especially necessary in these cases to olitnin
free and regular evacuations from the bowels, for hj'
unloading the iiit<'stines the descent of the diaphragm
is facilitated, and any derivation of Hiiid from the
portal venous system tends, iirdirectly, to relieve the
enjiorgenient of the right side of the heart.
A very usefid form of aperient for such patients
which is etticacious without being depressing, is a pil!
of 2 or 3 grains of watery extract of aloes, and A or
J of a grain of ipecacuanha powder at bed-time,
followed the next morning by 1 or 2 teaspoonfuls of
Carlslmd salts in a tumblerful of hot water.
ADDITIONAL FORMULi*:.
Blizture for ctu-onlc bron-
cbltlB with empbysema.
W AiiiiiioTiii carlfniiitifi, gr, xl,
Tuietum> uuda vomica',
nilxxx.
Tiiictu™- RcilLr, Jiv.
Iiifii!«i serpi'iitiiriii' mi Jiviij.
M. f . mijit. Twn tabli*5i>()ou-
fulsforadosv. (Digitilisshoulil
bo oddud whun tliorc is diliita-
tinii of right aide of lipart. )
(Fulllriytll.)
"Rontine" mixture for
cbTonlc brondiltia.
11 Ammoiiiiairbouiitis, gr. xjtiv.
TincturH' siillir, sij.
Tinctuni- eunniliortc uomjio-
sitn;, ?ij.
Iiifusi neiioga' ad Xviij.
M. f. mist. Two tahleapoon-
fulft for tt ilowi. (fwltitr of
fitttiiKniuni isadiled if oxpoctora-
tion is difficult: hhtlia if there
iH imich dyspuip^i.) {.V«rA7i«y.\
Expectorant mixture In
chronic bronchitis of old
people.
11 Aiumouii cldoridi, ij.
TincturK camphom- compo-
ritw, 5j.
Miatiira- ainmoiiinci iid .^xx.
M. f. niiiit. A table»{Hxiiiful
four tiiuea a dny iu wat4;r.
( IThilh. )
K K
Fotaaslom citrate sjrmp sis
an expectorant In chronic
bronchltla.
R PiitiLwii citratis, jj.
SiKTU.f lini'iiiis, Sj™.
Svnipi ipi'oii'uuiilift', js».
Tiiictunr campbonif comjio-
sitji-, .^iij.
Syrupi, jiij.
M. f. .HjTup. A de88ert«])Oon-
ful every two hours.
{TTiirap. Gai.)
Creasote pUls for chronic
bronchial catarrh.
B GrcoMjIi, mxij.
Pulvuris siipoiii*, gr. IT.
Mi«i' p:ini!i, 58a.
M. ct iiivid« iu pit. xij. Ono
or two three times a (hiv.
(fr7.i<to.)
Inhalation for bronchorrhcsa
and bronchitis fcettda.
ft Auiili curbolici, .^ss.
Tinctunr opii camiihoratjc,
.Wj.
11. A toosiiuonful to be in-
haled freely from half a piut
of hot water. (/*"/. I)aru.)
56a
Medical TREATMEtrr.
(Put HI.
Inhalation for bron-
ohorrboBa.
ii Acidi corboliri, mriij.
r>lpi piiii jiiiiniliuiiiii, nixx.
AquH' ml 5j.
M. To lie liiffiiowl from Uio
oiirfaco of water kept boiling.
(/»)•. n. /.«.)
Antiseptic Inlialatlon for
loBtld bronchltli.
» Tliymol, .^j.
Aci'di rarboUd, 5ij.
Ocnsoti, sij.
SiiirituK dilorofoniii, 5j.
M. f. iiilml {Whilln.)
PillB for cbronlc broncUtiB.
y Pulvoris Rpiiepi'. jj.
Piilvcris ipecttcuauhH-, gr.
Vij88.
( >Ioi fcrpMlitlitnn'. Jj.
Pulvcris allliiiii', q.*.
Mii'ilui^nia ucuciic, q.«.
M. f. i»\. 1. (To he kc}>t iu
orris iKiwder.) <Jiie three or
four timi's a ilny. (Banil'erijer.)
Pills for cbronlo broncblal
catarrh.
Pulv. ttinnioiiinci, gr. xlriii.
Pulv. acillii', gr. xxiv.
Pulv. ipecar. comp., gr.
XTXTl.
Syni|ii sinii). , tyif.
M.' ct (liviilu 111 pil. xxiv.
Two every four or five hours.
Mixture for chronic bron-
chitis and bronchorrboea.
R Extract! eucalypti fluidi, Jj.
Anrnionii chloridi, iij.
Extmcti glycyrrhinp, Jij.
(ilyccriui, .^iij.
M. ' A toaspooiiful (iu water)
four to six times a day.
{Bartliiilov.)
An expectorant in bronchial
catarrh.
It Tiiictunp winguinnrin', Jj.
l^nctuni' lotioliir, }.}.
Villi i^KTaciiimhii'. .%ij.
8yrupi tolutiiii, ^n.
M. AtensjKM>iifiilevervtlin>c
hmiT«. {flartiolmc.)
Mixture for Broncborrhosa.
B Bulnami oopnibii', .^iJM.
P»lTori.»guiiimincacui?, Jijn,
Synipi mciithip, yr.
Aqun' inditliif ail sri.
M. (. mist. Two tablcspoou-
f uls night aud morning.
(Bitmierger.)
Mixture for "dry" chronic
bronchial catarrh.
H. Potamii iodidi, Jw.
Potanii bicurbonatis, .f m.
Anutionii chloridi, .^ij.
Liquorin morphinir bydro-
chloridi, ."ij.
Ai|uir chloroformi ad jriij.
M. f. mist. A tablcupoonfiil
every four or six hours, or a,
teaspoouful every two hour*.
(W'Aif/o.)
Terpens mixture for chronic
bronchial catarrh with
profuse secretion.
R Tt-ri^ne, gr. vijsa.
Alcohol, 5v.
Syrupi catcuhu, jj-
Aquni ad Jir.
M. f. mist A tableapoonfnl
erery three hours.
( Diijiitiiin- Beaiimett. )
Mixture for rhenmatle
bronchitis,
n Sodii Bttlicv 1.-1 lis, Jvj. I
filycerini. Its.
Villi rolchici rutlicin, 3vj.
Sjrupi s<:illin compositn-.Jjss.
TiDcturw oi>ii camphorafVt
iij.
M. f. mist. A tAantoooluI
in a little water every tbree or
four houm.
(Ar/. /),iM.. .!/,/>., CAiotyo.)
Compound tar pills for
chronic bronchial catarrh.
1> Pioi.*, gr. xviij.
PiilveriB beiizoiiii. gr. x>Tij.
Pulvtris ipec.'iciiauhir com-
r«ta-, ({r. ii.
pil. xij. One or two
three times u diiy.
(.V. Oufurim dt Muuf.)
Chap. III. I CHKOJftc Bronchial Catarrh.
563
Terplnol piUs (or chronic
bronchial catarrb.
IJ Tcqiinol, gr. jus.
Sodii beuzoatiB, gr, jsg.
SvTupi, q.«.
TTt \. pil. Three or four of
thoae puis are grircn Uiroe timus
a day. (Diijaiilni- IlrauHirtz.)
Terplne pills.
B TfrpinCj gr. xix.
.Socchnn allii, q.a.
Acacim gummi, (i.s.
T't f. pil DC. One thrieo daily,
iinmodiately after food.
Unctos for irritative congh.
li Succi limonu, .^ij.
Mucilnginis ncaciii'.
Syrupi sinipliciit, u, jr.
Aqoie ohlnroformi, .iiv.
M. f. linctua. One or two
teupoonfulfl occaiioiially.
Cough syrup for bronchial
or laryngeal catarrh.
K .\ntiinonii tiirtoriiti, gr. j.
Ammoiiii uhloriili. gr. Ixxx.
Exlraoti glycyrthisc, pr. xx.
Morphiua; hydrochloridi,
gr. j.
Synipi toliitani.
Aqaii' liiuroccnui U jj.
H. f. Byrap. A tca&poonful
erery two, three or four lioure.
This should not be prescrilwd
(or 'M p<!oplo on account of thu
inorphini' it coutoinii, or nuly
witli grt'ot caution.
Simple expectorant mixture.
E Tini'tum' beozoiui comp. , .^ij
.Svru))! tolutnni, .\iij.
Siistunf luuVRdaUo, ad .>,vj.
M. f. mist. Two tablespoon-
fuls (or a dose.
5<'4
CHAPTER IV.
THE TREATMENT OK ASTHMA (SPASMODIC ASTHMA,
BRONCHIAL ASTHMA), HAY FKVER AND EMPHYSEMA,
The GuBeotial Naturo of an Anthmntic Paroxysui — Two Foruis,
the .S/in»mo(/ic and the Calarilml — Therapeutic ( )b«erTritioua
throw Light on its Pathology— Diwcription of the PnroxyBm
— Auscultatory Sigus — Asthma a He"piriitory Neiironig.
Tt'eatmfrit of the I'aroxi/fim — Morjihiiie — Atropiue— (.'hlnnj-
form— Ether— Nitrite of Amyl— Iodide of Ethyl— rjrridiiie
— Chloml Hydrate — Fumigation — Cigarettes — Tobacco —
Nitre Papers — Stroiuoniurn — Datura tatulii — C'igiirutteH
d'Egpic — "Ciirton Fumigatoiro"— Himrod's and other dirt's
— Areeuical Cigarettes — (Coffee oiid Caffeine— Ice — Ainmoniii
Vapour — Emetics — P(ttas»ium Io<lide— Belladonna — Lobeliii
—Euphorbia PiluUfera — (iriiuielin — Coniuni— Ilynsi-ine — Tlie
Bromides — Sti^ctiuitic — Arsenic — Adrenal Suliitauce — De-
pendence of Asthma uccnsionally on Nasn-jiharyngea] Disease
— Electricity— Piieunmtic Treatment — Inliiilationn of Oxygen
— The Mont Dorc Cure— The correct Pathology dwlucilile from
Therapeutic Observation* — Prof. Fruscr's Observations on
the Action of the Nitrites — Climutio, Dietetic, and Hygienic
Management.
liny Frrrv, or Hay jjht/iiiiii • Two forms, the Calnrrhal and the
Aithniatif — Causes— Syraiitoms-Inilications for Treatment —
Change of Climate- (Mly Sprays — AntL">eptic [Lotions, etc. —
Cocaine — Atropine anil Morphine — Inhalation* — Sfpra-
renal Extraet—Opentire Meaaurea — Constitutional Tnwt-
mcnt
Empliywmii ; Causes— Indications for Trcatmeut_— Pneunuitio
Treatment— Additional Formula-.
Asthma.
The esHftitinl condition of nii nttnck of nslliiiin is the
existt'nct' of ji state of spnsniodie contraction of the
broncJiial muscles— of those unstrijx-il muscular tibros
that have long been known to enter into the striicturo
of the walls of the bronchial tul)6s, unci to extend even
to their finest ramifications, Upasm of these muscular
fibres is the tstentitil element in the n.stliinatic attack.
In a case of purely D/xisiDoJir asthma, of the ordinary
transitoij character, this condition of bronchial spasm
is a couijilcto and simple oxphniation of the phenomena
Chap. IV.l
Asthma.
S'^'S
of the iisthinatic paroxysm. But asthma ih not itlwivvH
such a simple matter. In what is termed "bronchial
ast)ima " tlie asthmatic attack is a.ssociated with brcm-
c/iuil catarrh, and the cattirrhal condition seems
ftvqueiitly to liear a causative relation to the ii.sthniatic
piiro.xysni, a.s well as to intensify it antl to render it
less transitory and more continuous.
Clinically, then, we have to deal with two forms of
a.st)ima, the one aimply nfffinniDflic, the otlier spasmodic
aho, as its essential element is spasm, but ciimpUx
also, as there is co-e-xistent bronchial catarrh.
We have atjited the case thus simply at the otitset
for the sake of clearness. These statements, however,
have been the sulijeet of much controversy— a con-
troversy which we shall not be able altogether to avoid.
The treatment of nsthnia is a remarkable illustration
of the fact that a therapeutic observation is oft<Mi an
experiment in pnictical pathology, and is calculated,
in some obscure morbid conditions, to throw great
light ou their true nature and causation. In such
instances, the pathology of the morbid state under
consideration can l*e more clearly and fully e.\ainined
(«/?<T we have considered the manner in which its
phenomena are inHuenced Ijy the iiitrotluction of tliose
modifying agencies which we sum up in the woitl
" treatment."
A severe paroxysm of spasmodic asthma may be
thus described : —
Suddenly, without any warning, often in the
middle of the night, or Itetween two and four in the
morning, the subject of asthma wakes up with an
attack of urgent dyspno'U upon him. In some cases
pi«uionitory signs are noticed, which vary greatly in
character. Some complain of flatulent dyspepsia as a
forerunner of the attack ; others of languoi-, headaclie,
depression, and s[eepine,s8 ; others of unusually high
spirits ; and many notice a tendency to pass large
(juantities of j>ale urine of low specific gravity, as in
hysteria and other emotional nervous states. Some
comjilain of slight cough, and a feeling of irritation
566
Medical Treatmest.
[Part ItL
about tlx; ii|i]ii*r uir-paiisiiges, and a slight sense of
constriction in (iit- chest before the onset of the
jiai-oxysiu.
The dyxpna-A usuall)' increases rapitlly in intensity,
and we tind our jwvtient sitting up in bi-d with amis
lixed, shouhiers raised, and liead tlirown back on the
pillows, which are piled up behind iiim to support
him in tliis position ; we find him gasping for breath,
taking short, foi-cetl inspirations, followed by relatively
prolonged, noisy, wheezing expirations.
He is unable to move, or even sometimes to arti-
culate a single word. The extremities are cold,
owing to the interference with the circulation wliich
this pulnioriary .spiusin presents, while the face is often
covered with beads of pprspimtion.
It' the attack occurs in the daytime, the patient
will remain rivete<l in his chair in this same attitude,
with liis arms fixed and rigid, until the violence of
the paroxysm subsides ; or you may Knd him in the
en"ot attitude, grasping some convenient supjwrt.
The coiintemmce is sometimes pile and anxious,
sometimes tluslieil and congested, sometimes dusky
and livid.
The chest is usually distended and hyper-resonant
cm percussion, and the dia])hragm is depressed.
There is plenty of air in the lungs — too much, indeed
— but it cfinnot get out and be reneweil I On auscul-
tation peculiar prolonged cooing, or whistling, or
wheezing sounds may be heard, with varying intensity,
at over the chest, especially during expiration.
If the attack is associated with the existence of
bronchial catarrh, sonorous, sibilant, and crepitating
r<it will also 1^ heaixi on au.scultation.
As the attack comes to an end there is usually,
but not invnrutbli/, a small amount of characteristic
expectoration consisting of small, trans]iarent, pearly
pellets the size of a pea, or smaller.
What is the nature of this remarkable paroxysm 1
M'e regard a.Hthma as a renjnratari/ nrurosiK, and
the asthmatic seizure &s esseutially a disturbance of
CJup. iV.1
Asthma.
567
respiratory innervation, what Trouswnii called an
"■ epile}*sy of the. lungs."
Tliat the attack may Ijc dependent on the develop-
ment or retention uf some toxin in the liloud, the
outcome of disturbed metabolism as intiintniiied liy
some writers, is proliaMe eiiougli.*
Those wiio n»luiit tlie essentially nervous sjmsiniHlic
nature of the a'sthmatic jiaroxysm are not nil agit>ed
as to the precise extent of inuscuUr area over which
the gpanni extends. For some it is a spasm of the
diaplirngm chiefl}' — the diaphragm, it ia said, is
rigidly and convulsively fixed in it« extreme inspini-
tory position ; for others it is a spasm of all th<'
inspiratory muscles — the diaphragm, the intercostals,
scaleni, trapezii, and all the muscles that take part in
in8]>iralioii ; for others the spasm is limite<^l to the
broncliini muscles, the involuntary muscles that are
found in the smaller hronchial tubes, and for them
the asthmatic paroxysm consists in a spasn\orlic
contraction of these muscles, diiiiiiiisiiing the calilji-e
of the smnllei' air-tuljes, and resisting alike both the
ingress and egress of air; finally, tliere are others
who thiuk that l)oth these sets of muscles are
aft'ected, the bronchial luuscles rc'Uhin as well as the
Liispii'atory muscles without the lungs.
Such an attack iis we have descril.ied, if unrelieved
by any remeily, may last, with some variations in its
severity, from two t<j six hours ; the patient may
then fall asleep, and awake perfectly well ; or there
nuiy remain a slight tendency to wheezy and difficult
respiration for a day or two.
Sometimes, however, the paroxysms will recur,
with longer or sliorter incomplete rf-missious, for four
or five days (or iiiglits), and then the attack will
pass away iind the normal state of health be re-
established, and months, or even years, may elapse
without any return.
• Tliis view it fully develoiwd in aii able paiier l>y Dr. Adim
of UuiuiltoD, oil "'file Nftturc ."luil Treutment of Astliiiui." —
tilnogow Hospilal R-pnrtt, I'JOl.
Medical Tsbatment.
(Part III.
During these intervals tliere may be no discernible
pviflciice of tilt' exist-eiice of any disease of the chest,
iinlcHs tlie attacks have lieeii niiinerous, and have
ri'ciirred within conipiiratively short ]K;rioda of time
during many yetirs ; then, lus you may suppose,
tlicso continued, repeated, and violent disturlMinces of
the respiratory functiun lead to permanent injury
and disease of the thoracic viscera ; pulmonary
emphysema and chronic bronchial catarrh Ix'como
estrtUlishi'd, there is more or less constant dyspncea
on any exertion, and as age atlvances the right side
of the heart dilates, and finally embarrassment of the
circulation with tricuspid insutliciency and dro[)8y
may lead to a fatal issue. Hut these latter con-
ditions are the coimf/jnrnci'g of asthnm — they are
not Hsthnia — the diseas<- with which we are now
concerned.
•Sufferers from asthma, however, do not all have
attacks of the severity of the one described ; attucks
of minor severity are very conniion. The duration
also of the severe attacks, in certain very bad cases,
in much longer, and may continue with little inter-
mission for many weeks.
Asthma then, we repeat, is a retpiratufy mnrotis,
attended with 8{)asni of the bronchial muscles, p»"e-
venting both the ingress and egress of air in respira-
tion. In some cases it is associated with bronchial
catarrh, in others it is not.
With these few preliminary observations we are
now in a ];>osition to enter on the consideration of tbo
treatment of asthma.
And first, with regartl to the treatment of the
asthmatic [taroxysm when it is established.
We know of no remedy so generally efficacious in
cutting shoit a serere Ht of asthma as morphiae
administ(<red hj'podermically, and we are accustomed
to add a small dose of atrojiine to the morphine. We
give from ,',tli to Jitl of a grain of the acetate or
hydrochloride of moi-phine,
grain of the sulphate of atropine.
with ii,,th or
,'/h of a
A hypoderutic
Chap. IV.I
Asthma.
569
injection of this kind will ofton suMue the moat severe
paroxysm of spasmodic .'isthma in a. few niinuN's.
It is a reniedyi however, wiiit-li Los to l>c used
■with great discretion, and which should lie strictly
i-escrved for the very severe paroxysms. It has this
drawback, that it is not safe to leave it in the hands
of the patient or his friends. It must lie reserved for
administration hy the physician himself. Sofjner or
later, however, the patient acquires for liiniself the
knowledge of the relief which an injection of morphine
lirings, and then he learns to apply it to himself, and
ill this way the morphine lialiit liecomes occasionally
estahlislied.
It should iwccr tie employed in the brondiitic
asthma of aged |«o]ile, i.>r whenever there are signs
of coexisting profu.ie bronchial witiinh, uidess the
suffering from dyspniea is extreme and other remedies
have fai!e<l U> give relief ; and in that case otdy a
small dose should be given, and its ctl'ect carefully
watchcci.
The late L>r. W. E. Steavenson, of St. liartholo-
mew'a Hospital, himself a sufferer from spiamodic
asthma, in a valuable thesis written by him on this
subject, speaking of suitable remedies for the paroxysm,
observes :
" Aliove all in value I should place the hyf)odennic
injection of morphia. This has never faile<l to relieve
an attack in myself, and I have never seen it fail in
other patients.
'■The objection to it is that, if often used,
the dose must bo increased ; but it is Ijetter to in-
crease the dose of morphia than suffer tlie agonies
of asthma.
" I have now used morphia for live years, but uiy
attacks are so (juickly relieved, and so reduced in
frequency, that I have never had yet to increase the
dose I commenced with, namely, ,\th of a gniin."
Tl»e inJuUjilion of rliloroforiii is a favourite
remedy with some to reli(.*v<" the asthmatic paroxysm,
and it is undoubtedly a valuable resource in niiiiiy
57°
Medical Treatmeht.
(Part lit.
CAaes ; but there are [latientfl who have a great dread
of iuhnling cliloroforiii, and its use xhouUl \k icsen'ed
for those cases where tliere may be );(X)d reasons for
avoiding the employment of inorphinc, and, wht'ii
given, it should not be pushed to complete insensi-
bility. Dr. Staavenson's personal exi>erience wiw
that it " never failed to subdue a paroxysm, but tliat
its effects were as evanescent as the drug."
Steavenson found ether in the form of Hoffhian's
anodyne often give temporary relief, and so would
also chlorodyne.
The inhalation of nitrite of nmyl, 3 to 5
minims (lH:'£t in ca|>sule8), also gives temporary relief;
but its etfex:t is evanescent, and in severe cases the
improvement does not Itint more than ten or twelve
minutes, when the dyspncea gradually returns. The
effect of nitro-glycerine also passes away quickly, but
that of sodium nitrite is more lasting.
Attacks of paroxysmal dyspncea which occasionally
come on in lulvanced stages of renal disease — the so-
called cases of uriemic or renal asthma — are beat
treated by inbalations of chloroform or nitrite of
aniyl, and must on no ateounl w/ialtvrr be treated by
opiates. If you give opiates in any form in these
cases, you may relieve the dyspnwic paroxysm, but it
may be at the expense of your patient's life !
The inhalation of iodide ot ethyl— 10 to 15
minims or more on apiece of lint, held in the palm of
the hand — has l>een strongly advocated for the relief of
the asthmatic parox^'sm, and we have found it useful in
many cases of not great severity, and in cases associated
with bronchial catarrh. Martindale's capsules of
chloroform (10 minims) aod iodide of ethyl (5 minims)
nmy be used.
The inhalation of pyridine has been used to
relievo the asthmatic paroxysm. In young children
it may be dropped (5 to 10 minims) on a hamlkerchief
tied round the neck, and for adults a teaspoouful may
be placed in a heated saucer, and inludej three times
a day, or it may l>c simply placed near the patient.
Chap. IV.|
Asthma.
S7«
It is said to lessen the sensibility of the vagus, and
to ilimiuish the excitability of tiie medulla. It ijuickly
appears, after inhalation, in the urine. Its unpleasant
nausojjting odour Ls a very great drawback to its use.
ClilornI liydrnio is another remedy in great
favour witli some physicians. It must be given in a
full dose — yO to 40 grains — and its adniinistration is
fre([uently followed by partial, if not complete, sub-
sidence of the paroxysm.
It does not, however, agree with some jMitients.
Dr. Steavfiison, for instance, says, " Instead of
i-elieviiig me, it added to my already uidiappy con-
dition by inducing delirium ! "
111 many instances the paroxysms of asthma,
especially the less severe cases, can be arrested, or
favourably modified, or more or less kept under, by
fiimiKHlioiiH of various kinds.
When the paroxysm is not so severe as to disable
the patient from smoking, a convenient mode of
inhaling the fumes of the remedies employetl is by
smoking cigarettes composed of or impregnated with
thejte dinigs. If the patient is unable to smoke, these
remedies may be burnt close to him, and their fumes
diffused through the air of his apartment.
Simply .smoking lohacco, to those unaccustomed to
its use, will occasionally subdue an attack ; but its
use is attended by the well-known nausea and faint-
ness experienced by beginners in the use of the weed.
Inhaling the fume.s of nilrv paper, i.«. paper
which has b<,*en soaked in a strong or saturated solu-
tion of potassic nitrate, is a popular as well as very
efficacious remedy in many cases. Paper so charged
may be rolled up in the form of cigarettes and
smoked ; or it may be freely burnt in the jMitient's
apartment. It is es|>ecially in the purely spasmodic
form that these fumes are most useful. In most cases
it is necessary to burn this paper very freely so that
the room may become filled with a dense cloud of
these fumes.
Many pei-sons who are subject to attacks of
57»
Medical Treatment.
(t>s>t itl.
asthma kee|j nilre paper at hand in their bedrooms,
and begin liurniiig it an tlie first warning of the
approach nf an iittack.
Most i>f the luetiicated cigarettes and powders
wJiicti are sold for the relief of asthma cuittain
Nlniniitiiiiirn or belladoima, or both ; the former is
ji drug wliiili hits long maintained, and justly so, a
very high position as a remedy for asthma.
.Some of these cigarettes contain ojiium also. The
Datura l^ilu/a, a plant closely allied to the Daliint
HriinioniuiH, is the basis of others of the.se remedies.
'Vhc. cclebi'ated Cigarettes d'Esph: are said to be
nmde of the following ingredients : —
BuUuduiinu Iiiuvos ... ... .. Tii pait«,
HyoscyumuB Iciives ... ... . . 'if „
Strumonium leaves .. l'| „
I'lielliiiidriuni aquntieuin 1 pnrt.
Extnict of opium ^ .<
Cherry -laurel wiiter ... ii suHieiency,
The dried leaves, stripped of their stems, ai* cut
smalt, well mixed, and then moistened with the opium
dissolved in the cherry-laurel water. Tlie paper used
for making the cigarettes is also soaked in an infusion
of those leaves in cherry-laurel water. Usually ia
making these cigarettes a little nitrate of potash is
added to the infusion to make them burn freely.
The fumes of stramonium at once relieve certain
asthmatics, but they fail to do so with others — espe-
cially, it is said, with those who use tobacco haVutually.
Some of the fuming-papers that are sold for the
relief of asthma contain potassium iodide, and others
potassic chlorate, as well iia potassic nitrate.
The " Carton j'umigaloire " of the French Codex
is a very useful preparation. It contains nitre com-
buied with powdei-cd belladonna, stramonium, digitalis
and lobelia leaves, and myrrh and oliban. Pieces are
burnt in the patient's room.
Some of the jwwders sold as patent medicines,
and now largely employed by asth unities, are often
very useful in relieving the dyspntea, but they are
Chap. IV.]
AsTHi\fA.
573
used much too freely, ami jire apt to produce ii
seri(«isly depressing effect on the heart.
This raay certainly be said of " Hiinrod's Cure for
Asthma " and of "Senier's green powder."
It has been stated that Hinirorrs cure does not
contain straniuniuni ; it certainly contains a drug
whicli causes dilatiition of tlie pitpils. It has also
be^'ii stated that the following is a "ood imitation
of it :—
I^ Lnbf-lifi, powdured ... \
Ulin'k tea, jjowdort'd >«Ach I ox.
Stnimoniiim leaves, powdered ... ...)
Ponr upon this mixtiiro 2 o^. of a Mtaratvd sohition of
nitrate o{ potniih, mix thoroughly, and dry.*
Tlie fumes of arsfiiicitl cigarettes priive of gi-cat
service to many astlimiiticH. They are usually mode
liy di.s.soIviiig 15 jrraitiH of arsenite of |)otash in
half an ounce of distilled water, and saturating
unsized [paper witli it. This is afterwarrls drietl and
cut up into twenty pieces, each of which is rolled
up into a cigarette. The siiinke from the cigarett«3
must be drawn into tlie brunchial tubes by a slow
inspiration.
Strong coffee is a popular and good remedy for
the relief of asthma ; it .should, however, be taken on
an empty stomach, for it is necessarj' that it should be
very strong, and the tniinin it contains, if tjtken on a
full stomach (as Dr. Steavensou lias pointed out), pre-
ci](itates the jveptones, and thus disturbs digestion,
and may bfcoiiif another exciting cause of dyspuica.
But iiiHteail of cnflee, crtlTelne, or the <"llrnl«' ol
<'ntrriii<>, is iii>w extensively used in the treatment of
|>arn.\ysiiinl neuroses, and we have found it of un-
doubted edicacy in the treatment of iiKthma, especi-
ally in preventing the attacks or in diiiiinishing their
severity. Two or thn'u grains should be given
with a little sugar of milk in a (lowdcr about an
hour before l)e<l-tinie, and again during the night if
* Other formula- will l>o found at the end ot the chapter.
574
Medical Tkeatmf.nt.
IPart III.
neoeasary : or it may be tnken ita a pi-ecautioniiry
measure au hour l^efore lunch or dinner.
It mny also l>e given hypodcrmically made into a
solution with sodium henzoate.
The vapour qfaiiimoiiin is ftdviititageous to some
asthmatics, and cases arc on record of pei-sons, prone
U> these attacks, who have fouiul an immunity from
them when constantly exposed to an atmosphere con-
taining ammonia, as in the air of stables.
The use of cinelics for tlie relief of the asthmatic
attack has been higbly commendod by some, and we
have seen very groat l>enelit follow the unexpected
emetic action of a hypoilermic injection of morphine;
but in such cases there is usually a co-existing
bronchial catarrli, and the emetic effect is attended
with the discharge of much stringy, tenacious mucus
from the bronchi.
In asthmatic children an emetic of 20 grains of
ipecacuanha will sometimes be of use by emptying
an overloaded stomach, as well as by expelling catarrhiU
secretion from the air-passages.
In certain phases which asthmatics will some-
times yjresent — such eajHjcially as the occurrence of
almost continuous liyspna-a, with signs of dry catarrh,
i.e. a good deal of irritating, hacking cough, and
very little expectoration — we have found great benefit
fix)m the administration of small, nauseating doses of
tartar nmetir, together with small doses of morphia
and potassium iodide.
The following we have found a useful prescription
in such conditions : —
Vf Antimoiiii lartarati ... gr. j.
Liqnoris tnorphina' bydrocliloridi 5ij.
I'otauii iodidi ... gr, xl.
Spiritus chlorciformi ^ij.
.\qiin" »<J Jiv-
Minco, fiat inifitum. One toblogpnonful, with "one of hot
wnlct, cvory three or four hours uulil relieved.
Steavenson observed in liis own case that the
relief aflbrded by emetics preceded vomiting : " when
Oup. IV.l
Asthma.
S7S
the fii-st sense of nausea and faiiilness is experienced
the relief is immediate ; " and he argued that that
proved " conclusively the nervous cliaracter of
asthma ; " the emetic acted through its power of
reli<n'iiii,' iiiiiscular spasm.
lodi«l«> orpotasMiim is one of the most reliaV)1e
of remedies for asthma, both during the paroxysms
and in the intervals. It may lie given in 5- to 15-
grain doses twice or three times a day, and one of
these doses should lie given at bed-time. In old rases
of lironchitic asthma it is a good plan to give a small
dose of the extract of stramonium with the iodide of
potassium. The following is a very good formula : —
ly rotouii iodidi
. . ^. T ad XV,
Extracti Btntmonii
.. «'\<^\-
Spiritiis dilorpfortni
<nxx
Spiritus mnnionii arumatici
... inxx.
AqiiiB
lid jjas
Miscc, fiat hau^tus.
This draught may l>e token at bed-time only, or
it may be taken more frequently, according to the
rei]uin'ment8 of the case. The extrai-t of stramonium
is, however, often found a very uncertain drug.
Different extracts seem to be of very unequal activity.
When the extract is gootl it usually gives ri.se, at
first, to some unpleasant dryne.s8 of the throat and
mouth, some di.Hturbnncc of vision, and sometimes a
little heaidache and loss of appetitfl. These effects
worry some patients exces.sively, and they will often
refuse to continue its use.
It is for these reasons that it is best to give the
stramonium at night only, when its unpleasant effects
can be to a great extent slept off!
Brlladonnn. when given alone, is not nearly so
useful a remedy for asthma as stramonium. It is,
however, commended in large doses (A dram of the
tincture) by some authoi-s. It causes a moKt di.stress-
ing sense of diyness in the throat, be.nidcs unpleasant
disturljani«s of vi.sion in many. (.'o/;i6in*t/ with other
drugs it enters int<i the composition of many remedies
•• •••••isa
Chap. IV. 1
Asthma.
been highly extoUwl by »onie Americun physiciiius
for the relief of .sj)asni<xlic asthma. Hartholow suiys
" few cases fail to lie relieved at once."
Couiiim, in full doses, has been advocated for
the relief of this, as well as of other spasmodic
affections.
HyoarAne has also been found useful by some
practitioners.
lihiihruniides of |)otas8ium, sodium, and ammonium
have been given frequently iu cases of asthmii. They
are too slow in their action to be of much use in the
trentnieiit of the paroxysm, but they are cei-tainly
useful <lurtug the intervals, especially in highly
iiinirotic subjects, and a])pear to diniitu.sh the
frcijuency of the attacks. We .should strongly i-econi-
meiicl tiieir employment on the tirst incidence of
spii-suiodii.' asthma in young people.
Strychnine alone or, better, combined with atropine,
ill hj'podermic injections, lias Ijeen found very useful
in keeping off the paroxysms. At tirst a daily dose
of ,'„ grain of strychnine and j^^ grain of atropine
should Ije given, and this may be slowly increased
to j', grain of strychnine and ^^,; grain of atropine.
If the amelioration is maintained these medicines
should be discontinued. Wc have given with benefit
the arssiutle of slrychiiia in j'.j-gniin doses, three
times a clay, in pills with extract of valerian.
Another most valuable remedy in the treatment
of asthma, especially the brouchitic and also the gouty
forms, is aritt'iiic. We have frequently obtaine<l
most excellent results from the long-continued ad-
ministration of this drug. The following is a good
formula : —
ly Iii(|iiorii« nmcnJealiH... ... ...nixxxvj.
Spiritiis iimmoDiH' Hrumutici . 5iv.
Sjiiritus chloroformi ... ... . . jij.
Aqiiii' cjiiin;hiir«; ... .. ... nd *vj.
Misw, fl«t mistura. One talilcspoonful throo times ii ilny
in wuU'r an hour after food.
Or ursenioiis acid may be given in combinatioit
I. L
S76
Medical Tkeatment.
(Pari Ml.
for iistlinm, and we have already pointefl out how
useful its iilk.-iloid atropine proves when combined
with inoi-j>hine.
Some putients cannot take potassium iodide with-
out sti tiering from lachryuiation, frontal headache,
and other signs of coryza ; and in some it ciiuses
intense depression. In such eases you niay give tlio
bromide of potassium ; and in some excitable, highly
nervous subjects this salt hiis been found useful in
keeping of!" the asthmatic paroxysm, when given in
10-gi-ain doses twice or three times a diiy.
The evidence as to the vulue of lobelia in relieving
the asthmatic paroxysm is not altogether sjitisfactory.
It is a very uncei-tain remedy, and it should not be
hft<l recoui-se to until other tnore reliable remedies
liave failed. Besides its uncertainty, its effects are
often very disagreeable, causing «|uite an alarming
sense of faintne.ss and sickne.ss. Still, in the trewt^
ment of the paroxysm of asthma, we must not
altogether discArd any resource wliicli hits l)een found
efficacious by trustworthy observers, and some appear
to value it highly. It shouhl he given in small doses
fre^iuently (5 minims of tlie ethereal tincture every
ten minutes until it produces some decidetl effect).
As soon as nausea is e.v|(erienced it should lie
stopped, and only rei>eated at intervals of four to five
hours, supposing its effect is beneficial. By giving it
in this tentative manner the dose ap[iropriate to each
individual will be a.Hcertained, It is best suited to
the treatment of the broncliilic form of asthma.
We know little at present of the real value of
Euphorbia pilnli/ern, except that its effects in
bronchitic asthma have been highly praised by some
Australian and AmericAn physicians. It is said to
liave a slightly narcotic effect, and to induce sleep in
the asthmatic sufferer. It can be obtained in the
form of tincture, the dose of which is 10 to 30
minims.
(Irindflia, the fluid extract of the leaves of Grin-
<M*a robtula, in doses of 10 minims to 1 dram, has
B Chap. I V.I
Asthma.
577
l>een highly extollwl by some American physiciHD8
for the relief of H}msmodic astltma. Hnrtliolow says
" few cases fail to he relieved at once."
Caiiium, in full doses, hoa been advocated for
the relief of this, as well as of other spasmodic
aflToctiona.
//yo»ct«<" has also been found u.seful by some
pi'actitioners.
The hroiiiides oi y)0ta88iuiu, sodium, and ammonium
have been given frequently in cases of asthmu. They
are too «low in their action to be of much use in the
treHtineiit of the piiroxysm, but they am certainly
UMefiil during the intervals, especially in hif;hly
iieurntic .subjects, and appear to diminish the
frequency of the attacks. Wo .should strongly recom-
mend their employment on the first incidence of
spiisniodic asthma in young people.
Stn/cfiniiw alone or, better, combined with atropine,
in hy]Kxiermic injections, has been found very u.seful
in keeping off the paroxysms. At tirat a daily dose
of j'.j grain of strychnine and ^ j^^; grain of atropine
should be given, and this may be slowly inereiised
to j', grain of stryclmine and ^Jy grain of atropine.
If the ainelionition is maintained these medicines
should be discontinued. We have given with benefit
tlie ameiiai* of strychnin in jSj-gniin doses, three
times a day, in pills with extract of valerian.
Another most valuable remedy in the treatment
of asthma, especially the bronchitic and also the gouty
forms, is nrsonic. We have frequently obbiined
most excellent results from the long-continue<l ad-
ministration of this drug. The following is a good
formula : —
Wf LicjiioriH amenicRlid... .. nixxxvj.
iSjiiritiiH ammoniii:< aromatioi jiv.
Spiritus uhloroformi ... .. .. 5ij.
Aqiiip cvimphorw ... ad Jvj.
iliace, flat misliira. One tabU<«poon(ul three tunes a day
in wutiT an hour after food.
Or arsenious acid may be given in combination
S78
Medical Tkea tme.xt.
IPan 111.
■with (niiiiiue and atropine, as in tlie following
ijrc'Jiciiptioii of Sebort's ; —
I^ (|uinin»' miirintis . . 5j.
Ai idi iininnioiii f^' }•
Atropinn} sulphntiB ... ... p.m.
Extraoti geii(iBiiii< ... ... ... 5J.
Misce ft iliviilc in {liluUs Ix. One to four duily.
Another cunvcniont mode of giving iirseuic in Iho
intervtilH between the attack is in pills of solium
arsiiuat^.^ and nux vomica.
I^ Sudii iirwniitis
Kxtracti niieiK vomicw
AliiK-e ot divide in piluluH x\iv,
iifUT foud.
gr. xxiv.
(hie twice n dav, iiii hour
At the suuiu tiiiit' 1 to G oz. of Bourljoule water,
which contiiLiiH urKenat« of soda, should he drunk
warm night and morning.
Dr. S. Soils Cohen * Iijih ilescrilxid a form of
OKtlnna in which he h.'us fuuiul niui-ii benefit follow
the UHe of adrenal giibslance. There are case-s in
which he believe.s the va.sonKitor coiitntl is weak, and
therefore, va.seuliir dilation unci cuti.'ieijuent swelling
of tlie bronchial mucous iiieniliraiie arise and cause
the (iysimiea. Jri <ine case he began with o gi-s. of
Burroughs and \Vellc<inie.s tabloids daily, and finally
increiwed the do.sc t<> ',»0 grH. per diem. In eases of
true NpaKniodic a.sthma he thinks this drug nught
prove injurious.
It has been suggested that the asthmatic
paroxysm is frefjucntly liependent on dUeasn of the
niiKiil an<l phuniiKcal cavities, such as the pre-
sence of jiolj'pi or hypertrophic and catarrhal condi-
tions, or other morbi<i states, and that more attention
should Ijc given to the investigation of these cavities
in considering the etiology and tn>atment of asthma.
The removal of naso-pharyngeal poly|)i and the radical
treatment of diseased conditions of the nasal and
* ' ' The tTic of Adrenal Substaniw in the Treatment nf
A*thma." — Journal of Ammran Mnticat Attmnttum, May 12th,
1000.
.tv.i
Asthma.
579
pIi.iiTngeal cavities lmv« occa.sioiially l>een iillundMi
Ij_v iliwijipeai'ance of ostlimutic attacks.
Dr. Aflaiii,* nf Hamilton, limls tlio apiilicatimi to
the iifLsal IIUICUU.S int'inbraiie uf Mitlutiiitis of cucaine
and supru-renal sulistaiicc often allayn tbe a.'tthmutic
paroxysms. H'.' is a stfonj; advooat-e for na.sal
treatment.
In all cases, and especially those oa-urrin;; in
children and young ptMpIe, the nfusal fossre should Ix'
thoroughly t"xplon»d, as well iui the throat ; eidufffc-
iiient of ^laiididar and oth(«r structures of the tlirojit
and neck hy conipres.sing the vaj;us or it« l)raneht<fi
may be concerned in the production of the asthmatic
paroxysm ; the possibility also of enlurged bronchial
ijlniuh acting as a source of irritation must not bo
overlooked, especially when asthmatic attacks follow
acute infective diseases attended with much bronchial
catarrh, as measles, etc. The remarkable curative
effects of the iodidea and of arsenic in many cases of
asthma suggest the possibility of these drugs acting
through their well-known influence over glandidar
itiUnmin.ition and hypertrophy.
We Ijelievc we were almost the first t to call atten-
tion in Engliind to the success which had attended
the application of the induced eUctric current along
the course of the vagus in the neck in some cases of
asthma. This niotle of treatment had at that time
been strongly advocated by Dr. Max Hchiiffer, of
Bremen. The idea was that the source of irrita-
tion in some case^ could be traced to the r 'elling
of the laryngeal, pliaryngeal, or nasal mucou* mem-
brane, causing pressure in the neck on the vagus or
other nerves in connection with the respiratory tract.
The current must be of good strength so that it can
be felt as passing through the soft palate from one side
of the throat to the other. It should be applied to the
throat in the situation of the great nerve trunks, the
vagus and sympathetic, each pole being applied just
• Oj). nl.
f Laneet, November 13th,
I8l»0.
S8o
Me Die A L Tr ea tmknt.
(Put III.
helow the angle of the jaw, and in front of the stemo-
iiiastoid. Sir Peter E:«le Kuhsequontly * reported the
sucufssful tijiplicittiun of this method in u ciise of
hronchitic asthma, with severe paroxysms of dyHpiicea,
which was under liis eare in tlie Norfolk and Norwich
Hospital. The patient had bi^en ill and tiinier treat-
ment for Hpven months licfori' admission to the
hospital. For more than two months he had Ijeen
wuhmittvd in tiio hospital to vai-ious remedies, including
chloral, iodide and hromide of potiissium, lobelia,
stramonium, ii>ecacuaniia, opium, coniuni, carlK>lic
acid, el<;., without any satisfactory result, when it
was determined to try the eBect of the galvanic
current in the manner we liave dcscriljed. " The
jiatient was at once relieve<l, and was nearly cured
in eleven days, while he was able to report
himself as completely recovered in two or three
weeks more.''
With regaal to the piM-iimnlic tr<>ntmcMi of
asthma, either by the portable apparatus or in the
Pneumatic Chamljer, it is clear that these niethode
are not applicable, or very raix'ly so, to the relief of
the sei-t-re asthmatic paroxysms. These often occur
suddenly, and at times and in places when it would
be out of the question to apply treatment of this kind.
Waklenburg, however, nuiintains that he has cut
short the less violent paroxysms of asthma by the
inspiration of comi>rtsfied air.
But it is in the intervals bt-tween the attacks, and
e8]>ecially in the cat.arrhal form of asthiua, that most
may be expected friiUj pneumatic treatment, in re-
moving or lessening the emphysema which invariably
develops after a serieo of quickly recurring attacks,
and in relieving the chronic catarrlial condition of
the bronchial mucous membrane. Alternate inspira-
tion of compressed air with expiration into rarefied
air ia therefore valuable in the intervals, leading to
improvement in the emphysema and to a prolongation
of the intervals between the paroxysms. In some
* Bntiik Mtdiral Jonrtul, tioptoiuber 22ud, 188.3.
Chap. IV.]
Asthma.
581
cft-ses it is useful to combine warm aquraus vapour,
iiiiliregiiatt'cl with aniinoniuni chloride, with iiispim
tion of conipres8C<l air.
Treatment in the Pneuinnlie Cltamhrr is chiefly
directed to produce an aiiti-catarrlml effect, and is,
therefore, far more tiseful, as wo have snid, in the
ciilarrfinl than in the nfri'oug form of asthma.
Iii/ittlalioim of oxyiii'n have been advocate<l for the
relief of the asthmatic paroxysms ; there can be no
objection to trying this ex{>edient, but we have not
found if 80 useful in the severe paroxysms of nervous
asthma as in the more continuous (lyspnreii of the
bronchial form ; in these coses, and especially during
the intervals of rapidly recurrinj; attacks, it has
seemed to l>e of much l)enefit and comfort to
patients.
One of the most interesting and successful methods
of treating bi-onchial asthma is that carried out at
Mont Dore,* in Auvergne, wluch we have descrilxxl
at length elsewhere.
Ha\iiig reviewed most of the remetiies that have
been employed in the treatment of asthma, both
during the pamxysm and in the intervals, we are now
in a better position to consider its jmthology.
After a careful consideration of all the argument*
that have lieen adduced against tin- nervous theory of
asthma, the more we see of cases of asthma, the more
impossible it seems to us to resist the conviction that
tliere ia a nervous element in every cose, and that in
very many the nervous element is altogether the pre-
dominant one, Let us illustrate this remark by
reference to a ca.se of so-called " renal " asthma, not
dependent on pulmonary osdema. Here we have
blood contamination as an obvious cause of the
• The Mont Doro KpriiiGrii huve lieta orroneoualy descrilvd as
" Sulpljututi-d Walots (Wilsou Fnx's " DiM-nsoi uf tho Liiiiki,"
I». 7t>). 'riicy are reully very w<-'a.k hot alkiiliiiL' wiiters. eontaiu.
me about 7 or S grainii of bimrboiiiito of rodn aud n or t> Kruins of
cliloride of Bodiuiu in tho litro. There in also about .'5th of a groin
of nremate uf soda in the s»me i|uautity. and for tliis reosou tlioy
have been termed arsenical ^|>riugs.
Medical Treatment.
[Part III.
^^t Ji*rvo«s disturliftiice, and the chain of phenninena is
^^n ^Olvi^l'ly complt'tp. A pnti(;nt, towivrdn the closing
St<oii«>s of IJriijht'.s disoa-sp, witli contnicteil >,'oiity
kidney, and hypt-rtrophied heiirt and thickened
»rt<'ri(«, jfft.s sudd»Mi iittacks of idanning dyspntea,
ftTLsing iippnrently vvithdut any cuuse, sometimes when
sitting; lriini|uilly by liis tire-side after dinner, some-
times in the niiddh? of the night, or at any other time.
Ht« has no cough, no moist rrf/cv, but expiration is
rtirtieult and prolonge<i, just as in the usual form of
HKthmn ; moreover, if you let him inhale chloroform
va|M»ur, the paroxysm of dyspntea disjippoars. Now,
it would seem that in such a case either we liave u
urn'Uiic irritation of tlie I'espiratory centre setting up
a sort of convulsion of the bronchial muscles, a sort of
pulmoniiry epile[isy ; or w-e may have a reflex excite-
ment of the bronchial spasm in the following manner :
an unusual proportion of the retained urinary excre-
ment is being eliminated at the respiratory surface,
and this irritates the peripheral terminations of tlie
respiratory nerves, and so excites in a reflex manner
contraction of the broncliiiil muscles. The urinous
odour in the breath is always very marked in tlicse
cases.
An explanation which holds good with i-eganl to
these renal cases of s]iasmodic asthma will hold good
with regard to others in which the original disturbing
cause is not so manifest. The nervous irritation may
1)0 central, or it may be peripheral. A cert<iin
inherited vulnerability or excitability (hypenestheain)
of portions of the central or (Hsripheral nervous
system doubtless exists in certain persons. When it
is the respiratory centre or the i-espiratory peripheral
nerves which are th\i8 aflt'cted, we encounter tlie
phenomenon of spasmodic usthnm, occurring fi-om
causes of irritation sometimes so slight and evanescent
as to entirely escai)e discovery.
But there is another jtos-sible view of the mfKle of
action of the " nervous element " in asthma. I allude
to the view put forwanl by Weber. He maintains
Chap. IV. 1
Asthma.
583
that, " for many form.s of HHthina, the fxist«>nce must
!>(■ iwliriitl<'<i of a tutiiefactioii of thn liroiichial min'ous
iiit'inhiaiK- in consiMiuuncc! of ililatation of its V>loofl-
vi^sseLs through vaso-motor nervous inlluences.' Those
attacks of astiima wliich are oliserved to altornate
witli attacks of urtir.'aria, ami in .some of wliich
patches of swollen mucous nienibiane have heeii
actually ob.served in the jiharynx, would fall under
this head. In comnientinj; on this view, Kiegel
observes : " We may suppose that whenever an irrita-
tion affects tlie bronchial mucous membrane, this
irritation may excite vascular tnrgescence in this
rcijion ; that the acut<i tumefaction of the mucous
meuibraiie of the bronchioles is the primary element
in a.sthma may exphiin the milder attacks, lait not
the severe fortns, where a s«H:ond factor (muscular)
must be a-ssociated ; how otherwi.ie shall wo explain
the fret|uenlly oliserved ' rapid ameiionition aft^-r
chloral hydrate, and like remedi«?M?'" and he eon-
eludes that aiithma is a " spasm of the bronchial
muscles with simulbaneous congestion of the bronchial
mucous membrane."
But it must be admitted that the majority of cases
of asthma are associated with, and often complications
of, a pre-existing bronchial catarrh. Hut in these cases
there is always a nervous element upon wliich the
gpasmoflic paroxysmal nature of the attack depends.
In the first place, tlie subjects of purely spasmodic
asthuui may, and do often, Ijocome simultaneously
the subjects of bronchial catarrh. There is every
ituison why they should, |>os>«>ssiuju;, as they do, a
hyper-sensitive respiratory surface. But there yet
remain a considerable nuinlier of caties in which the
bronchial catnrrh certainly appears to lie the oxcitinj;
c.iiuse of the asthma. Now such patients may lie con-
sidered lo suffer from hy|)eriBSthesia of the bronchial
meiiibraue, just as others suffer from cutaneous hyper-
le.sthesiu, and in them the presence of tenacious, thick
mucus in the liner air-pansagos acts as an irritant,
and prcluces that amount of muscular spasm which
S84
Medical Trf.atmbnt.
IPart III.
is sufficient to give rise to a paroxysm of nstlinia.
Thus it can lie shown tlint in every case of iisthiiin
there is a, nervous element ; l>ut in some cases the
nervous state is the only one that needs to be dealt
with thei-ajieutically, whili' in others, whei-e tlie
bronchia! irritation (.Icpeiuls on the jjresence of a
catarrluil state, tlie removal of this catarrhal con-
dition must be the basis of any successful medica-
tion.
The many practical illustrations that must occur
to every one who has seen much of asthma, of its
neurotic chai-actcr, seem to us overwhelminj;. We
will allude to a few only ; and first to the frequently
observed nlternation of iittucks of asthma with other
neurotic affections, as migraine, angina, liysteria, and
certain cutaneous diseases.
It must littve occurre<l to many liow very rare
it ia to see a purely asthmatic paroxysm in the wards
of H hospital ; yet cardiac diseases and advanced
emphysema and bronchial catarrhs ore excessively
cx)inmou. If asthma were simply a catarrhal disorder,
as some have maintained, its manifestation would l>e
frequent instead of rare in our hospitals.
We have shown tlie remarkable intluence of seda-
tive and antispasmodic remedies in the relief of the
asthmatic piiroxysni. Numerous other considei-ations
occur to us in support of the neurotic character of
asthma ; but they seem to i)e scarcely needed in onler
to establish a position already so strong. We sliould
like, however, to point out one analogy with a well-
known nervous and hysterical phenomenon which
seems never to have been i-enmrked upon. We uUude
to the great distension of the lung which is observed
in many cases of asthma — a distension which has
often been thought difficult of explonation ; but may]
we not trace an analogy l>etween this great distension]
uf the lung in asthma and the very remarkable andi
hitherto unexplained tynipanitic distension of tliQ
intestines often encountere<l in some casea of hysteria ;1
a condition that will sometimes arise as suddenly i
TV.l
Asthma.
58s
the astliitiatic paroxysm, nml which seems to be
<>ntirely neurotic in its orij^in I
But Professor Froscr's extremely viilu.able and
intei-estin/^ ohHervutions * rm tlic iiidiienct^ of the
tiitritrji on the dynpnii-a of ivsthnm ami bronchitis
ttffonl an expurinientnl corrolwrntion of the theory
of bronchial spasm as tlie cause of the astliinatic
paroxysm, nncl a refutation of the oUl eatarrhiil theory,
as well as of Weber's theory and its nuxIiKcation
[)roi>ounded by Sir Andrew Clnrk, tliat the cause
of asthma is a vaso-motor disturlwince attectiiig the
vessels of tlie bronchial mucous membrane, and
causing narrowing of the broncliial tulH's by vascular
intumescence of their lining membrane.
We have now reviewed most of the remedial
iiieasurps [iroposed for the treatnrent of astliina, both
during the [Mvmxysni and in the intervals ; it will lie
foun<l that, numerous as these remedies are, one
cjinnot have too many resources in ilealini,' with so
capricious a disease as this is, and that remedies that
will Ix' most efficient with one individual will fail with
another, or will tje unable to Vjo |)ersevered with on
iU'count of some disftgreeaV>lp collat<iral effects. If we
liiid to 8»dect a limited nuniber of these remedies to
which we were to be restricted, we should chiwse the
following: Afor/ihiiir with atropine.; chloroform ; the
nitrilfs ; Jinniyrition/> with nitre and utrainoninm ;
Ktraiiionium ; cnffrinf, ; iodidf of jio/iusiuiii, and
ursfnic. Cases occurring in the "gouty," and
associated with defective elimination, are especially
benefited l)y potA.ssiuni iodide in condiinatiou with
an alkaline C4irbonute ; they require also a mercurial
j)urge from time to time, combine<l with small doses
of colchicum. The treatment, in short, must be, to
some extent, directed to the gouty constitution, and
sedatives and opiates, so far as possible, must be
avoided. Cases associated with chronic bronchial
* " Tlio PysiiiKTa of Aalhnia am] Btonchitis: its Ciiufution
nn<l thf Infliii-nce nf Nitrite* I'lon It." By Th<w. B. Frastr,
M.D.. K.K.S. Edinburgh : Oliver aud Boyd. 188H.
586
Medical TuEATMEfrr.
IPait 1
cntnrrli (iiicl cnipliy^faia will, of course, not I)e cured
so long as the liroudiial ovtarrli reuiiiiiis nncuivd,
and our iviiiPilics must l)t' directe<l to i;unur; tlie
c'^itarrliiil condition accordinj; to tho prinoiplcH laid
down in tlif last chapter. All physicians .are agreed
as to the utility of free action of the liowels in
warding otl' a threatein>d attack. A dose of calomel
will, in this way, often Ije of service. Large dosos
of alcohol have heen commended by some, but we
should henitat* aljout prescribing the.se, as we think
there is soiiif danger of establishing an alcoholic habit,
and this would cei-ttiinly favour pulmonary degenera-
tion and emphysema.
We have still a few remarks to make on tho
suVjiject of the climatic, dietetic, and hygienic manage-
ment generally of tin- ii.sthniatic.
As to the 4'liiMutir and atmospheric conditions
which are favourable to the cure of iistLma, it )ins
generally l^en taught that patients should be
removed to a place which presents tlie precisely
opposite conditions to those which prevail in the
locality where the asthma has attacked them, and
it has been especially insisted tlpon that the den.sely
populated, smoky, and stniVy districts of large cities
are the most suitable for the ndief or prevention of
siMisniodic tisthnia. Unquestionably, many cases hare
l)eeii observed by eoini)etent ol»servers in which dis-
appeanince of the asthmatic paroxysms had atteude<l
the removal of the patient to crowdecl cities ; and
it is, perhai)s, rather a curious circumstance how
few suflerei-H from spasmoilic asthma are found
amongst the population of the poorest districts of
Ixjndon.
But we are disposed to think that too much has
been made of this, and our own experience would
point to more numerous instances of the cure of
a.sthnia by removal to what might be callctl aitti-
citlnrrhal districts ; and if it is true, as has been
stated, that SO jier cent, of all ca.ses of asthma are
complicatfid with bronchial catarrh, this result
Clap. IVl
might be nnticipat^l. It is the purely nervous
cases that iife so c<i])ricioiis with regard to climate
.•mil atmospheric conditions ; and tliLs capriciousness
will be oljservuble even in the cuhc of seaside resorts
in close pi-oximity to one another. Wc have known
a patient leave London, on account of asthnm, for
Deal, and on reaching this place find his usthnui worse
than in London, hut on moving a few miles along the
coast to Folkestone his asthma left him iinmciliately.
Ner\'ou8 cases, or case,s in which there is a sti'ong
nervous element, especially in youn({ people, will
often do well in high altitudes, as in the Engadine,
and a few catarrhal cases also, in tlie young and
vigorous, will do well in such localities if they
ejicounter a tine season, but in bad seasons they are
sometimes injuriously affected. Cases complicated
witli clitfMiic bronchiul catarrh and emphysema should
never li<> sent to these resorts.
Cases in which bronchial catarrh has l>een tho
exciting cjvusc of luthma will, some of them, recover
completelv at Madeira. They leave England feeble
invalids, and we have seen them return robust ami
well. It is as well, however, when they are in a
position to do so, that they should return to Madeira
for a few months, for three or four succt»8.sive winters
—from Decfniber to May. The Canaiies offer an
alternative re-sort. At Arcnchon, I'iairiiz, Pan, and
at Amelif les Mains we have found asthmatic patients
do well in winter. We have known some very luid
cases who have avoided returning to England by
passing their winters at Pau and their summers at
Bagneres de Bigorre. The Riviera resorts caniiot bo
relied on in asthmatic c«sos, but some asthmatic
patient* have done remarkably well at tinisse and at
Cimiez. Some of the emphysematous and catarrhal
asthmatics obtain advantage in the summer from
moderate elevations like Moiiti-eux or Glioii, Lugano,
Aussee, Reichenhall, and Meran ; in the last two
places they can have the odvantage of well-arranged
pneumatic treatment.
S88
Medical Trbatmf.st.
fPart MI.
In Kngliind wr> have known the climate of
Folkestone and Eii»tlx)urne, in the summer, to Ije
very useful to some cases, and that of Bournemouth,
Ventnor, and Hastings in the winter. The piue
district around Woking, Weyliridge, and Aticot baa
also been of service in tiunierous instances.
Bronchitio cjwes should be warmly clad, should
avoid all causes of catarrh, and sliould live in well-
wanned, suitably ventilated apartments, and shonld
not be made to sleep in c.olil tetlrooms. It is worth
noting that the asthniatie paro.xysm often occurs
during the coldest part of the ni}{ht, viz. between
2 and 4 a.m. We know nmny sensitive [lersons who
at once wake up in the night if there is a fall of
temperature, ami it is tjuite conceivable that, if an
asthmatic woke up in such circumstances, he would
wake up with an attack of imthina. i*>uitable gynmaitvc
eaiercMfJi have been found useful in keeping o9° attacks
in children. Exercise hi the ojwn air (not /aligning
exorcise), and cold sjjonging, when it can lie borne,
followed by friction with a rough towel, ore f[fxA
hygienic measures for removing undue sensitiveness
of the surface.
As asthmatic paroxysms are often induced by
digestive disturbances, it is of the highest i]n]Kjrt)ince
to see to the proper regulation of the diet and meals
of an asthmatic patient, in the intervals between the
attacks. All indigestible articles of food should be
avoided, but e8j>ecially those which he has learnt by
cx|>ericnce are ]irone to induce a paroxysm. Suppers
and late dinnei's are to )>e forbidden, and the principal
meal should be taken in the middle of the day.
Codlive.r Oil has been found of great service in
certain badly-nourished patients.
The adoption of a vegetarian dietary has been
found of value in some ca.ses.
Tendencies to constipiation and flatulence shoald
be guanled against by some suitable ajierierit An
aloes and ii)ecacuanhn pill after dinner is the Ijest in
many oases ; and an occasional dose of Carlsliad salts
Chop. IV.) Asthma, Hay Fevbr.
may be added. Any diwjrtler of the female sexual
organs must, of coursp, lie i*emt(dieil.
All depressing euiotion should be iivoided ; but
plejisurable ones souietime-s have the effect of dis-
sipating the attack.
Hay Fbvbr or Hay Abtbma.
This malady is also known by other names, as
" rose cold," " Vatarrhis ^Eslitmn," " Corijza vato-
moloria," and " rhiitiltii /ii//ierwsthetica."
It may occur in cither of two fonos — the catarrhal
or the imlhiiiatic.
Tlip lirst form resembles an acute coryat, coming
on with sudden irritiition of the ntuHid, conjunctival,
and fiiiKvil mucous membranes, and attcndtfl with
distressing sneezing. The asthiiuUic form usually
comes on a week or so after the catarrhal form ; but
the asthmatic symptoms may also develop eiirly,
Often on tlie appearance of the asthmatic symptoms
thi' nasal «ynipt(ims cease.
The cause of the.se jKiroxysmal attacks is three-
fold : — First, the contJict or influence of an exUrruil
irritant, acting, secondly, on an lajpcneHhrJii: mucous
membrane in, thirdly, jHirsons of a lutnrotie (often
iidK'iit«il) coiLstitutiou.
The most common external irritant is the pollen of
certain grasses (hence the name " hay fever ") and
of other plants. The existence of these irritating
agent« in the air at curtain aeiitoiia accounts for the
fact that in F^urope this disease is esfiecially prevalent
in the spring, while in America it is most common in
autumn, i.e. innn thu middle of August to the latter
|)art of September.
In this country the pollen of several of the grass
family have been proved t« be capable of exciting
this disease, but in America the pollen of Ambroiiu
arlfinijiifr. fulitt (lag-weed) and that of Solidofjo odora
(golden-rod) have been especially in)[ilicated. The
odours of roses and other sweet-smelling jilants have
the same effect on certain persons. Cei-tain powders,
5yo
Medical Tkkatmekt.
I Put 111.
oilier lluin jMilleii, such im ipecacuanha, lyeopo-
dimn, etc., hiivo been found to give rise to similar
symptoms.
It is, Iwwcver, certain that tlie pollen of plants is
the principal exciting caii.se of hay fever.
It hius been asserted that in nmiiy persons jirftne to
this malady t)ie nusal mucous memlirane is diseased
(JiypertTophic rhiuitig), and is excessively sensitive, so
that the merest touch with a pi-obe will bring on an
attack. Others,* however, maintain that there is uo
essential connection betweeii the two.
The tii/iiiphiinx complained of in the catnrrluxl form
arcf those of an intense coryza, viz. distressing irrita-
tion and congestion, with exce-ssive secretion from llie
eyes, no.se^ and u|)per air-pas-sage-s, usually attended
with frout^ii headaclie, more or less cough, ilistressing
sneezing, and considerable depression of spirits.
In the a.sthiiiatic form we encounter the Byraptoms
of bronchial asthma, which may follow the preceding
or alternate with them.
la many suffeix'i-s there is a liability to a return of
the malady aimuHlly at the same date, which will,
however, be found to vary with the seasons, acojfding
as they are early or late.
Many authorities cousider the ijouty constitution
an im|>ortant predisposing influence in the develop-
ment of this disease.
In the etiology of this affection we have thus to
admit : Ist, an external irritant ; 2nd, local hyper-
sensitiveness ; and 3rd, a constitutional tendency —
neurotic or gouty, or lx)th combined.
With these few preliminary considerations, we
may now enter upon the question of Irentnienl.
The indications for treatment are like the causation,
threefold : —
1 . To avoid or suppress the local irritant.
2. To diminisli the local sensitiveness and to
relieve the local congestion.
3. To modify the predispo-sing constitutional state.
• £.g., Garel, " Le Rhump clea Foim," Pons, 18i>9.
r
Chap. IV.I
H-ty Fhvsr.
591
1. The KUitint ine^ins of avoiding the looiil irritiitit
is, when pmcticiilile, a vhawje <</* cHmnt". If the
Huffo rev from hay fever cuukl iilwiiy* live on the sea
during that period of the year when tlie pellen of
grasses and otlier plant» in carried by winds into tlio
air lie hiks to l)reathe, lie would escape the altiicks.
Retnovid also to jihices on the sea-coivst which are
situated at a distance from cultivated laud and
vegetation is almost as gooil. High altitudes, where
the land is not cultivated, will answer as well. In
Anioricii the White Mountains of New Hiim(isliii'e is
a favourit.o resort.
Much, however, may be done to avoid the irritant
caust5 by thosi' wlio may not he in a position to avail
theni8<-lvcs of change of climate. They must avoid
cultiviit^Hl districts, fields, woods, and gardens, when
the grasses are flowering. They must avoid exposure
to the o[M'ii air during high winds, when dust may lie
blown iiboitt and enter their air-piussages ; exposure to
liright sunshine is irritating, and travelling bj' rad, by
motor or bicycle, on horseback, or in an open curriage,
are all to be avoided because of the exposure to ilust
which attend such means of locomotion. Large, ilark
Hpect4icle8, fitting close to the orbits; broail-brimnied
hat.s to kceji oft' the sun's rays, thick gauze veils, are
all useful pi'Ot^.Mjtions and preventives.
2. A vast number of expedients have been
suggested and tried for the relief of the local
sensitiveness, congestion, and irriUition. One of the
simplest is the application of an oily spray to the
nasal mucous membrane, such as liquid vaiieUne or
alhohnr, containing al)out 5 per cent, of menthol
dissolved in it, This can be applied by a special
pulveriser for spraying oily Huids. It covers the
mucous membrane with a sort of protective varnish,
which .shields it from external irritants or lessena
their irritating effects. The menthol, at the same
time, acts na an antiseptic, and also allays existing
irritation. Great relief has been experienced from a
spray of cod-liver oil (the UrixUirUed oil is used)
592
Medical Tkeatuent,
iPan 111.
ajtiiliod to the nostrils by means of a hard rubt)er
atuiiiixtT every tlirue hours, or oftener if necessary.
Various aiUUe/itic lotions huve b«en recoinnieuded
iind found 8orvice«l)le. viz. carbolic acid in strong
solution, applied by a brush to the sensitive areas —
previously anu<8thetised by cocaine — a solution of
fiorchloride of mercury, 1 in 3,000 — a combination of
thettf with quinine (bichloride of mercury 2 grains,
hyilr(K'hloride of quinine 30 grains, and glycerine of
oiirlMjlic acid 5j). Resorcin (after removal of any
cliMmso<i condition of the na»a] mucous membrane) has
been stattMl to give e.vccllent results; it has been pre-
scribed as a lotion, as follows : Resorcin gr. li, sodii
chloridi gr. 4, acidi aceti v\ 2, aquw ad \j. This
should he applied frequently.
Miiller, of Vienna, combines resorcin with tnenlhol :
Resorcin 5iss., menthol 5iss., alcohol ^v.
Protaiyai, a non-irritiiting silver salt, has been
used in Professor Fraonkol's clinic in Berlin. A
^ per c«ut. solution is used at lirst, and stronger ones
stibseijuently, if they cause no irritation. They are
applied with a sort of massage to the nasal mucous
membrane. It is recommended to commence this
treatment as a preventive three or four weeks before
the expected attack.
Hydrozoiw, a prejMiration of hydrogen jwroxide,
1 oz. to 1 2 oz. of steriiise<l water, has also Ijcen used
successfully as a preventive. It is applied as a
douche, tepid or cold, four times a day for a foitnight
before the periot) of the attack — its strength l>eing
gradually increased.
Cocaine has iieen very largely employed in tliis
affection, alone, or in combination with some of the
preceding, as an antesthetic. Latterly the dangers
attending the use of this drug have been much
emphasised, and perhaps a little exaggen-uted.
Apart from the risk of exciting the cocaine habit,
it is urged that there is danger of reaction after its
use, and the j)roiluction of local paresis of vessels.
It is undoubtedly a useful (>alliative — it has been
Oiap. IV. 1
Hay Fever.
593
a|>pliu(i in a 2 per cent, solution, with u small spray-
producer, with great relief to .symptoms, using aVxiut
i grain (25 minims) at a tiuit?, uiul spmjing the eyes
lightly at the same time, witii lids half closed.
Atropine (and belladonna) and morphine (and
opium) have been given, together and separately, to
relieve the distressing symptoms ; and this they do
as in ordinary attacks of coryza. One authority has
given as much as ^^ grain of atropine daily ; but
such remedies can only be palliative, and they are
attended, when given in full doses, by very disturbing
effects of their own, and in our opiiuon should only
bii t-mployed very occasionally, and in moderate
duses, and at the onset of attacks, to allay severe and
distressing symptoma
IiihaUUiojis of chloroform, iodine, or alcohol have
occasionally given relief, and the distressing itching
of the conjunctivie has been l)enefited by lotions of
borax or l»oric acid dissolved in cjimphor water, 10
grains to the ounce.
But recently the use of mtjrrn-reiuU mtlmtance, or
extract, liiis been greatly vaunted by S. Soils Cohen and
others in the treatment of this affection. Holis Cohen,
himself a sufferer from this malady, took a 5-graiu
tabloid of supra-renal substance (Burroughs and
Wellciiiiie's) live times a day, the last at l)e<I-time, and
derived very great lieiiefit from the treatment. He
allowed the tabloids to dissolve in the niuuth. He
considers it acts by increJising the vascular lone, and
In'ingitig aljout contraction of the blood vessels of the
misul mucous membrane. This remedy should be
applied locally as well as internally. For the former
purpoKc a solution can be prepared by shaking up 6 to
12 percent, of saccharaterl dried extract of the supra-
renal gland with water, allowing it to stand, ami
removing the clear solution, which may be applied
either as a spray or on plugs of cotton-wool sJiturated
with the .solution.
Stiil more recently a crystalline principle sepa-
rated from the supra-renal gland, nnd termed
M M
594
Medical Treatment.
IPnrt IlL
"ndr«Jialiu," has been used for local a{>|)]ications — a
solution 1 ill 5,000— and applied in the some manner
aa the precfdiuj^. A stronger solution has also been
iisetl up to 1 ill 1,000, combined with 2 per cent, of
ehloretone, as an anaesthetic and preservative. It Ls
said to " i-educe tlie extreme engorgement of the
turbinal tissues, and allay the intense imtAtion."
Surijicnl oprrativn tnea^iiren commend themselves
greutly to many six>cial ists, iind they are doubtless
needful in certain forms in which local discjiae exists
in tlie ua-al cavities. " The removal of na.sal jiolypi,
or any spur from the septum that impinges upou the
outer wall, linear cauterisation along any hypertrophied
or tumitifd turbinated bodies, and, imwt impijrtant of
all, the siiperlioial cauterisation of all places found to
l)e extremely sensitive " * are the measures to be
carried out.
The galvanocautery is generally used for theaej
cauterisations as by far the most sjvtisfactory.
The operations are recommended to Ix? done
not during the attack, but in the free months
preceding it.
3. As to geaer&l constitutional treatment. Tn
the neurotic, nerve tonics, sucli as preparations of
phospliorus, arsenic, and strychnine, are indicated.
Valerianate of zinc has been found useful in such
cases by many practitioners — 2 or ."i grains three times
aday may be given. A combination of sodium bromide
and infusion of valerian lias also Ijeen found service-
able. When obvious debility accompanies neuras-
thenia, pre|)arations of iron, i:|uinine (the hytlrobro-
mide) and cod-liver oil may prove useful, especially
in helping to ward oft- expected attacks.
In the gouty and dyspeptic, alkaline mineral
wat«rs have been found of benefit, combined with
aperients containing a little colchicum or some other
hepatic stimulant.
* Prof. Ingale, " Hare's System of Priictical Therit]ivutica "
(new oditioiO. toI, iiL. u. 730. Dr. Uatel, "Le Bliuiiu! Uea
Taiiu," p. 8* : Paru, \m.
p
" Oiap. I V.I
PuLMOSARY Emphysema.
595
POI-MOKARV EXPIITSEMA.
We are unable here to enter u|K)n the cimR'uiera-
tion of the many int^ereating quostioQS that ai-e
concerne<I in tlie iliHcussiun of the pathology and
etiology of pulmoniiry eui])liyseinn, mid we can only
refer, very brielly, to those pointH which have an
e^ssential bearing on the indications for treatment.
Pulmonary emphysema was correctly and brielly
delined by Laennec as "au excessive, permanent, and
abnormal distension of the air-celk" This, of course,
applies to " vesicular " emphysema, for " Interlobular "
emphysema — i.e. the patwagu of air into the connective
tissue betVeen the lolmlcs of the lung — -does not here
concern us, as it is a condition practically removed
from effective treatment. We may geniTalise the
f'Hiiaes of vesicular emphywema by sjiying that it is
either due to excessive strain on the interior of the
noriiwl air-cells, whereVjy they lose more or less of
their elasticity and become dilated, as in violent
in.spiratory and exjiiratory etl'orts, and especially the
hitter ; or it is determined by degenerative and atro])hic
changes in the walls of the air-cells themselves, by
which they lose their normal resisting [tower ; or the
two conditions may, to some extent, be co-operative.
We encounter pulmonary emphysema in various
degrees, sometimea very slightly doveloited and
sometimes in a very advanced stage ; sometimes
partial — i.e. afl'ecting only certain portions of one or
both lungs — and sometimes general. The |>artiiil
forms are often what is t^-nned " compensatory " — i.e.
a dilatation of certain groups of air-cells to take the
place of others that are collapsed or for some cause or
other rendered ineffective. These " compensatory "
forms are often rather conservative than injurious,
and iMirtake of tlie nature of compensatory hyper-
trophy, and do not therefore concern us here.
One of the chief indications in the Irontmonl
of this disease is to prevent slight cases becuDiin;;;
severe ones by withdrawing the patient from the
596
Medical Treatment.
[Pan III.
intlueuco of those conditions which produce it. The
early stages of enipliyseinatous dilatation of the air-
cells very commonly arise from the strain of athletic
exercises during the period of growth and develop-
ment, especially in oonii)aratively feeble organisations.
On examining the chests of youths who have sub-
mitted themselves io strain of this kind, it will be
found that the inspiratory expansion is very limited,
the excursion of the chest in passing from tlie forced
expirt»tory to llie fiirced inspiratory position often
not exceeding an inch or an inch and a quarter. This
is often overlooked, and the subjtjcts of it are not
cautioue<I, as they should be, against pursuing
sportu or e.ff:n:Ufn for which they arc nnsuited, and
which lead in course of time to both pulmonary and
cardiac strain.
As this disease very frequently originates ia and
becomes aggiuvated by repeated attacks of bronchial
catarrh and the |)nroxysins of coughing which accom-
pany them, the proi)hylactic indication points also to
the removal of such patients from the prcdis|H>8ing
and exciting causes of .such attacks, especially re-
moval ill winter to a more congenial and anti-aitavrhal
climat«>, if the patient's moans admit of this. Emphy-
sema frequently has it-s origin in severe and pro-
tracted attacks of whooping-cough in early life, &
disea.se which we shall ho|>e to show is much more
ameniibic to rational treatment than is generally
recognised.
Anl/una is a disease which usually, in course of
time, leads to the production of emphysema of a
severe form. Wlien em]>hysema is a complication of
ttgtliiiKi, or is associated, as it so constantly is, with
chronic bronchial catarrh, the indications for treat-
ment lioth prophylactic and remedial must be sought
to a great extent in what wo have said of the
management of tliose diseases, which we need not i
now repeat.
The avoidance of all physical tlrain, and thestriot
limitation of physical exarcises to such as are gmttlsj
Chap. tV.l
Pulmonary Emphysema.
597
and in no dpgroe excessive, and the protection of the
patient from all causes of catarrhal attacki;, arc the
chief indications in the treatment of emphysema, and
for preventing thi- slighter degrees from advancing
into the more serious forms.
Tliere is little in the way of remedial measures
that Clin he directly applied to the dilated and
atrophied lung tissue, to the restoration of the lost
elasticity of the air-cells, or to tl)e restoration of the
obliterated capillaries in their walls. Arsenic and
iodide of i)ot«*siuni have lx)th been credited with the
)>ower of retarding degenerative changes, and both
are of use in the treatment of catarrhal and dyspnreic
stiit^s, as we have aliemly shown. When emphysema
is as.sociated with an iveiite catarrhal comlition of the
air-passages, whatever can free the air-pissages from
tiie secretions ol)structing them by i>ron]oting ex-
p<»otoi-ation will, of course, be beneficial. For this
purpose saline, alkaline, and ipecacuanha sprays have
been applied and found useful.
Free evacuation of the bowels, and measures to
relieve any llatulent distension, are very needful in
cases of emj)liyRema to take off from the diaphragm
any pressure from ImiIow, and to allow it to ilcscend
as freely as |iossil)le. With this view also the fooil
siiould be concentrated, nourishing, and not bulky.
Tf we ap|)ly ourselves to dealing with the emphy-
sematous condition of the lungs apart from coexisting
catarrhal states, our chief resource must l>e those tonic
and hygienic measures that are calculated to improve
the general nutrition — air, climate, food, exercise, and
tonic medicines, such as iron, ai'senic, strychnine, co<l-
liver oil — selected and adapted to individual cases
and on general princi]>les. We must rememlier that
we have, in all advanced cases, a state of dilatation
of the right side of the heart to deal with, which will
also be benefited by this general tonic treatment.
Attempts have been made to remedy the pul-
monory condition, and to improve the respiratory
functions in emphysematous cases, either by causing
L
598
Medical Treatment.
[Pare III
them to breathe compresseil air in the Pneumatic
Cliamhcr, or by means of a portable apparatus * to
incpire compressed air and expire into rarefied air.
No douVjt great relief to the dyspmea such patients
siiirer friini is often experienced from expiration into
raiTlifiJ air. The suction action exerted on the air in
the lungs leads to iriore complete puhuonary ventila-
tion, to the removal of stagnant air in the aii'-cells,
and to the free entrance of fresh air. Tlie ])hysical
signs also often show a marked improvement in the
condition of the lungs.'f When there is co-existing
bronchial csitnirh it is necessary to precede the
expiration into nirelied air l)y inspimtion of com-
pressed Jiir, else irritative cough is excited.
Treatment in the compressed-air chamber lias
also been attendee! witli good results, in not too ad-
vanced cases, and it is es|>ecial]y applicable to cases
ciitnplicatetl with chronic bronchial catanli, which it
relieves. At Heichenhall inhalation of the saline
spray is combined with treatment in the Pneumatic
Cliambor. How this method acts lia.s been the
subject of much discussion ; it probably increases
the flow of blot»d through the lung, and so improves
its nutrition.!
* The various forms of apparatus devised and used for this
piir|>ci80 will lie found fully deacrihed in the author's tmnaUtiou
of Uortel'ii " Hosiiirafory Thcrapoutics." (Smith, Elder uud Co.)
t /''I'/., p. oi\.
t H^ Oertel's " Resjiiratory Tlieropeutics," p. 698, for a full
discussion of this ijucstiou.
Chap. IV. I Asthma, Hay Fewek, etc.
599
ADDITIONAL FORMULAE.
For tbe non-parozyBmal
dsrspncBa of asthmaUcs.
II t'liloral liydnitis Sij.
Ainniiiiiii chlon<ii, irr. Ixxv.
Miprjihiuii' hy<lro<hl., gr. j«.
Aiitiniouii tartaniti, gr. j.
Qriiideliic robiutni fluidi ez-
tracti, .^vj.
SjTupi glyi'yirliirae, Jj.
Arjiiu^ u'l Jiij.
M. f. mist. A tcasivMJiiful in
water every three to aix hour*.
(N. S, Ditru.)
Or
II <"hl..ral, T,v.
Swlii Ditritis. gr. xIt.
Tinctuni' Rtminouii, ^ijn.
Syrupi iiiiiii>liei8 a«l .iiij.
M. f. mist. .\ tc'iu4[xK>nful
ill water every four liours.
{tf. H. Duttt.)
Antl-astbmatic mixture.
li Pi>tasftii iodidi, Mj.
Lic|uori« Fowlc-ri, ij.
Vini ijiettiicuajilia*, .^iv.
Tiuctunt' Iiyoscynjni, .^iv.
Aqurt- cliloroformi ml SWij.
M . f. miat, A tablcspoonful
threa times a day in water after
food. {inmla.)
BUzture in bronclilal aathma.
tt Extrucli quoliracho, .^j.
Jlorjiliinii; liyilrochi., gr. •».
Syrujii Bimiihois, .\v.
Aqua.- mollina* od .Mv.
H. f. mist. A tnlilespoouful
every two or throe hours.
t^liamfirrytt;)
Aaother.
R Chloral hydrate 1 ,s .„ ..
Pottt«ii ir^didi /**»?■. zz.
Syrujii nlmiiHcis, jm.
Aiiuti', .iiv.
M. f. uubI. A fourth part
every two to four houre.
{SchniUltr.)
Lobelia mlzture for the
asthmatic paroxynn.
R Till, turn- Ir.tioliii'. sj.
Anintiiiiii iodiili, .^ij.
Aniinfiiiii lirrtiuidi, .^iij,
."<yriipi tolutiinif, jij.
M, f. iniht. A tciipponnfui
every one, two, three, nr four
hour*. (liilrlholotl.)
HlxtuTe for asthma.
R Tinctuni' lobt*li(f, .ivj.
Potusaii iodidi, .^ij.
Tincturu' camphoru* com-
poaitir. .ivj.
Decociti seiiegiT' ad ,^vj,
M. f. miat. A tallies! looufnl
for a <lo9<*. {ftftt'ii.)
Bromide and iodide mixture
for spasmodic asthma.
K PotHssii hroniiili, Sj.
I'ota.'isii iodidi. ?,*?.
Aqtiii' ad .^iv.
M. f. luist. A teaapunn-
ful ill sufficient water every
half hour or hour,
Another.
R Extrncti eriiideliie lluidi, ^ij.
Extract! Tobeliu- tluidi, jj.
Extnii'ti bclludounn? Huidi,
3M.
rntiueii iodiili, .^jge.
Glycerini, 5j»».
M. f. miat. A toaapooutui
fur o dose. iJImlAolow.)
Tills for nerrooa asthma.
R .Sodii ioilidi, 5jaa.
Pulveria et extracti glycyr-
rhiziF, .^j.
M, et diviile in pil. Iz, Five
to eight to be taken twice a
day. {Dmriiikl.)
Powder for fomig-ation.
Stramonium leaves, I drama.
Oreen tea, 4 drama.
Lobeliie, \\ dram.
Mix and pouroi^ the mixture
enough aaturateil aolutirin of
nitre to wet it. flry it and
preaerve in n closely stoppered
botUe. (TYtttt/,)
6oo
Medic A l Tkba tmekt.
|P»n IIL
Anotbar.
Stnimnnium leaveH, coKiaely
powdered, 2 ox.
Aniae fruit, powderod, 1 oz.
Nitre, powdered, 1 <a.
Mix. A little of this to b«
placed on a ptuto and iguitvd.
{Saw fin.)
Another.
Butura tiitulu, 2 dnunn.
Stnunciiiiuin leaves, t draniii.
Caniinhia indieu, '1 ilranu.
Powdered nitre, 2 ox.
Oil of cucttlyptuo, I di«in.
Mix thoroughly. Put a toa-
xpooiifiil on wliito paper in n
»au(Tr, iind biirti in Ijod-room.
(7V)i« ptiwdir M in.v warmlji
rvcrmtmrnifri/ by Jh', Wwnlwayd^
of irhirrntn:)
Another.
Strunonium leaves. I ol
Lobelia, } ok.
BellsdoDua, i oz.
(Oriud tboroughlrin u milL')
Nitre, powdered, } o*.
Laudimum, J oz.
I'i«solv(; the nitre in tJie
smullest pcMsiblc uuautitv of hot
water, itud udd tiie Inudonuni :
with this thoroughly satumt^
the miiirwi uiid grctunil kiaves.
and dry at ii gentle hcul.
When dry, mix well with jkiw-
dered camphor uud keep in a
stoppered bottle. {S. £.)
Mixture for catarrhal
axUuna.
& Viui ipecacunuhiP, .^j.
Tinctunp lobelito ictfaerete.
vjiss.
Miaturo! ammoniad, JUj.
Aqua: ad Jvj.
M. f. mist. Two table.
spoonf ub for a dose.
{liupill < 'III ft UoMMflll )
6oi
CHAPTER V.
THE TRBATMENT OP PNEUMONIAS.
I. AcuTK LoHAR Pkt.uiioiiia.— Syniptoms, Physirnl Si^ui', ntid
Aimtoniii-al Lt-rioDp- Etiology — Pueumoiiia a Specific in-
fcctivc Fever — Iiitlueiice of Chill — Climatic iiud AlmnsjiliiTic
liifliioucef — rredi)"i»08in|? (.'inisos — Evidence in Fuvour of its
Specitic Microbic Uripn — Imliraticna for Ttriilmitil — Geueral
ContideratioiiH dcducible from the Xntiirul History of the
Disease — Quinine — Mode of Employing It — Fonuulii' — Tem-
perature Clinrt — Aconite — .IiirBensen'B Estimate of Quinine
— Antiseptic Agents — IMcuinotox in and Anti|incuni»tnxiu —
Spfittn Trcaluwiit — Tiratmrul of iSi/uipJowf— Vyrexia and
Hyperpyrexia — Cold Baths — Varying Opinions— Local Appli-
cations of Cold — Irebnjn — Digitnlin — Antipyrin — Phenacetin
— 8<Hlium Salicylate — Pain — Leeches, etc. etc. — Dyspnoea —
Blood-letting— .Strycliniue by Hj-j>odcrmic Injection— Oxygen
InhulatiouF — Ether and Jlorjdujie in Nervous Forms —
Delirium — Sleeplessness - Cough— Qostric Catarrh — Diarrhrva
— Troitmrnt i>f thr Taidrnetj to Cardtitt Faiture — Foo<l —
Alcoholic Stimulants — Hypodermic Injections of Ether jind
Caffeine — Siil'iir Jli/jmlrniiir Injeetiom — Disinfection — Trrat-
tnrnt of Vonraiffrrftcf.
n, Catabbiul, LoDtTio^B, or Broncuo-Pukchoki*. — Mode
of ()ri(nn — Course— Anatomical Lesions — Symptoms and
Physical Signs. Iiidiaitwiinfur TiTatiinnl — Emetics— Spmys —
Solme Drinks— Treatment of .S^^^ptoms— Cough— PyrexiJi —
Uaatro-intestinal Symptoms — Ner\ou« Symptoms— heapira-
tory Failure — Stimulants — Foo<l— Convalescence.
in. Seoomdary PuEtTMOSiAS.— Oangrene of Lung. Additiona
Formula'.
In (k-alinf; wiili tliu imjinitJiiit sulijcct of tlip ireai-
ni4>iil of |Hifiimc>iiiu<4 our tii.sk will lie facilitated
by dividing tlieiii into three cliissps : (1) acute Miar
pneumonia, the "croupous" pneumonia of Gernmu
writers; (2) cntaTrlnxl, lobular, or broncho-jnieniitonia ;
and (3) leconiiary pneumonia — i.e. pneumonia siipt-r-
veniug in the course of other diseases,
" I. — ActJTE Lobar Pneumonia.
We shall first deal with acute lobar ]>neumonin,
characterised by the following syniplwiiiH, pliyMirnI
Blg'ns, nnd aiintwinii-al ICHioiiM:—
6o2
Medical Treatment.
rp*« ui.
The attack usually Iiegins suddenly with a well-
marked ngor. The tenipernture rises rajiidly, aart
may reach 104" in a few hours from tlie initial rig«>r.
The skin feels to the touch peculiarly hot and dry ;
after \\w. chill, a bright r>:d jlu»h is noticed on one or
both cheeks, especially over the uialar region, Ibo
eyes are glistening, the expression anxious, the nostrils
working, and there is oft*n a patch of herpes on the
lips. There are the usual symptoms of 'fever —
loss of appetite, thirst, furred tongue, headache^
aching of the limbs, general malaise, scantj', high-
coloured uritie. The puls<; is i|uickened, as are the
respirations, and it has iM^en noted that, in most
cnses, the pidse and respiration ratio is disturbed ; but
this is not so unifunnly the cose as some authors
maintain. The respirations may be accelerated to
thirty, forty, up to sixty in the minute, while the
pulse-rat-e may range between 100 and 130; but it is
not uncommon to Imil a much higher pulse-rate during
some part of the course of the disease.
Besides these genentl symptoms, there arc others
complained of, referrible to the local lesion. These
may not appear until twelve or twentj'-four hours
after the appearance of the general symptoms.
I'ain in the side is one of these, and is dependent
on the existence of jAnuritu over the portitm of
iiiflame<l lung. It is sometimes extremely severe (in
a few cases it is absent), and it is aggravated by the
respiratory movements : the patient endeavours to
check these, and so increases the shallowness and,
therefore, the rapidity of the respirations. Cow/h is
another symptom, which is re8traine<l by the patient
an much as possible on account of the pain in the side
that attends it. The cough is accompanied by exprc-
'torttiion which is broiight up with dirticulty, as it is
^Boanty, and extremely tenacious and \-i8cid. It
usually contains blood mixiil with it, altered in
colour, so as to give to the sputum a "rusty '' hue, or
it may be bright red or of paler tint. Cough and
expectoration are somotime^baent in children.
:
AcuTB Lobar PitEUMOiriA. 603
When the disease nina the usual average course
it is coujinon for the fever to teniiinate by "crisis,"
generally lx;tween the fifth and eighth days, some-
timps a day or two earlier or later. The teni|>erature
falls rapidly, and in from six to twenty-four liuurs
may reach or descend lielow the normal. From this
moment the convaieseeuce is often rapid.
AR80ciat<>d with the.se symptoms the following
phynieal sii/ns may usually be found on examination
of the chest Usually over the base of one lunt; (the
right most frequently), sometimes over the upper lobe,
some loss oj rrsonnnce, increiuting as the diseaae
advances t^o complete duluess on [wrcussion, i.<< found ;
over this area of dulncss fine cr''/tUiUi(nts can usually
be lifanJ, with the inspii-ntion, at the onset of the
attack. When thi" lung, liowever, becomes solid from
exudation into the air-cells, this .sound disappears.
Friction sounds are also frequently detected over the
intlanit'd lung from involvement of the pleura in the
inHiiinination. Tvlulm; //rortc/iitif breathing, and
bronrhophony art" also usually to Ije heard over the
affected jKirtion of lung ; there is also, commonly,
incrensrd vocal J'remil its in this situation.
These physical signs and the p«///iomjry »ympt«mis
ilep<'nd uj'on the presence, first, of acute hyjienemic
engorgenient of the lung ; and, socondly, of exudation
into the iiir-cells, thi.s exudation consisting chiefiy of
fibrin mixed with red and white hloo<l corpuscles and
epithelial cells.
No onK has rvfjr seini the appearances presented
by a liviiK/ lung in pneumonia, and such descriptions
OS are given in text- books of the different stages
of pneumonia are, it must be remembered, merely
desciiptions of post-mortem appearances.
It is common to speak of three stages: — First, a
»/<T(/»» of <^t<ioTgeii>ent, or vascular dilatation and disten-
sion ; secondly, a stage of n-d hfpalisatiim, when the
air-cells are filled with a solid exudation ; and thirdly,
a stage of grey liepatisation, when the exudation
into the air-cells is undergoing degenerative changes,
6o4
Medical Tkeatuekt.
{p»n III.
bat this change in colour may be only a post-morUm
appeai-nnce. Aa we are only concerned now with
the clinical history and course of pneumonia, enough
has l)een said to r/iaracterun the fonn uhicli we are at
present considering. As recovery proceeds the exuda*
tiou into the air-cells melts down, and tlisappenrs,
some of it being exjiectorated, but most of it being
absorbed. The pulmonary tissue again becoiues
permeable to air, the physical signs disappiear, and
the normal conilitiou of the lung seems to be
completely restored.
The mjiiiploiiui we have mentioned us attending
the course of acu(« )ineumonia assume, in some
coses, an aggravated cliMracter, uiid are accompanied
sometimes by others even more serious still. We
shall have to consider these fully : the piiiii in the
side may be intense and almost unbearalile ; t]ie
cotigh may be so frequent as to threaten to exliaust
the patient ; the yyrrxia may be so great aa to demand
active interference for its reduction ; the dyapturta
may Ihj extreme, and life may be threatened either
from the extent of the inflammatory exudation, or
from collatoi-al pulmonary engorgement, or from
cardiac distension and enfeelilement. SUeplessiiess and
dfilirinm are liotli serious and distre.ssing symptoms
which are often present, and i-e(|uire careful attention.
The most serious condition of all is the tendency
to ean/iac /ailurc, the ilanger of which in severe
cases should never l»e lost sight of.
We have yet to pass in review the question of
etiolog)' before we can satisfactorily set forth rational
inilications for the treatment of this disease.
The opinion that this form of pneumonia is not
merely a local disease, with symptomatic pyrexia, as
.was formerly believed, is now universally adoptod,
nd primary, acute, lobar pneumonia is regartled as
an acute sj)ecific general disease, a fimnfic inferlive
fever, causal by a tfcijic poison, an infective microbe,
the lung affection being sim}>ly tlie characteristic local
lesion.
I
Oup. v.]
Acute Lobar Pneumoxia.
The idea formerly so prevalent that pneumonia
wfts generally caused by rllill has been shown to be
erroneous, for careful investigntiou has proved that
but a small percentage of cases of acute lobar pneu-
monia can l)e traced to chill. .Still, in a certain pro-
portion of cases, cliill from exposure to cold seems to
be a contributing cause. This is not inconsistent, as
we shall see, with the view that its exciting cause is a
specilic organism. With regard to f/ima<«c and ntmo-
splffic influences, all that can be positively asserted is
that the prevalence of pneumonia is not determined by
cold alone, but that the presence of gi'eat vici»situdi«
of temperature, and especially exposure to cold winds
from the iKjrth-oast, seem to be related causally with its
periods of greatest prevalence. In Great Britain it is
most prevalent in April and May — a |>eriod when
there is much exiKisure to easterly winds, rapid and
great variations of tempenvture, and at times high
degrees of atmospheric moisture.
It is notorious that the state of the general
health is louvred fluring the prevalence of these
atmospheric conditions, and the constitution is less
capable of resisting the invasion of infective germs.
And, as we have pointed out elsewhere, " winds
are carriers of dust as well as ab.stracters of heat ;
and wliile, on the one hand, they carry away heat
from the surface of the body, on the other hand
they gather up dust of all kinds, and blow all manner
of micro-organisms into our itir-passages. Any de-
pressing agency may predispose to pneumonia, such its
exhaustion from physical fatigue, and depressing emo-
tions : and it may Ix' that exposure to a cold wind acts
both as a predi-sposing cause, by depressing the noruuil
resisting power by i-apid abstraction of heat, and also
as an exciting cause, by means of the micro-organisnis
it blows into our air-passages."
DebilitAting condition.s, early chiidho<xl, and
advanced age, in association with unfavourable atmo-
spheric iidluonces, arc, therefore, predisposing causes.
There also would appear to be an individual predis-
4
6o6
Medical Treatment.
[PArt III
]K>Hition to this diaease, some persons having safTered
from a number of attjioks.
The »pc«'lflc K^^rin which is regarded as the
ciiUHc of pneumonia is the micrococcus latuxolaUu
of Fraenkel. It is n slightly elliptic or lance-shaped
coccus, united in puirs — ^hence the name diplococcus;
it is also often termed the pneniiuicocciiii. It has
lieen found in the mouth, the nose, the Eustachian
tubes, and the larj-nx of a certain proportion of healthy
persons. It is found in the lungs in about yO per
cbnt. of all cases of pneumonia.
It is thought probable that other micro-organisms,
such OS Friedlauder's bacillus, Eberth's bacillus, and
the strefitococcus of erysipelas, may also Imve the
power of exciting pneumonia. The germ is probably
received into the lungs by itihalalion, so that these
organs are first ali'ected. But the toxins it forma
are soon dilfu.sed throughout the organisms, causing
I a general infection.
Having referred thus briefly to the clinical
characters and the etiology of ai-ute lobar pneumonia,
we may now pro«?ed to the consideration of tlie
iiidiriilioufi for its troalmeiil.
1. The tirst indictvtion springs out of etiological
considerations, viz. to eiidnityour, if potsihle, to
antw/unisif tin' injuriotu iti/lneiwcii o/ l/i« specific
in/ectivf onjiniisni on the hUiod and tlte tistttfa.
2. The second indiciition is obvious, viz. to relitns
and to riidnavour to mbdut dan^/eroHs or diatreasing
ayiiiploins.
3. The third indication is also obvious, vit to itup-
port the p'ltifitt's ativiufth, aiu/ to fiidfacoiir to r>^nu>ve
or intxlrralf. nil conditions t«ndituf to ex/iaustioti,
^ We lieliove these three indications will cover the
whole ground of the rational treatment of pneumonia.
Altliou),'h [losscssing a certain historical interest, it
would lie a wanle of time to ejcaniiue here the various
routine ruelhods of treatment of pneumonia formerly
pursued, and now abandoned — such as repe<ited blood-
letting, large and repeatMi doses of tartar emetic,
b
Chap. V.)
Acute Lobar Pneumonia.
607
calomel, and otlier so-callctl untifhlorfislic measures.
Nor shall we occupy valuable space by extended
references to stati.stica The fallacies underlying this
method are esjjecially evident in their application
to (he treatment of such a disease as pneumonia, as
it takes no account of an iuKnite variety of modifying
conditions that affect results, apart from the piarticular
jK>inl this method may lie called in to investigate.
Skoda anil Dietl, in 1847, may be regaixled as,
to Horiie cxtc-nt, the founders of the modern treatment
of jiiieunionia, for they showed that whereas, when
ca,ses of pneumonia were practically left to tlieiiiselves,
or ti-eated on the so-called expectant uietho<l, the
mortality waa rather less than 8 per cent., when
treated either by bliiod-httuig or by lurtur eiiuftic tlie
mortjility was nearly 21 per cent.
Having regard to the relative success of the
cxp<>clllilt method, and to the natural hi.story of
ca-ses of pneumonia, it lins been maintained that
the attempt t-o draw any conclusions as to the
efficacy of any particular medicinal interference in
the treatment of this disease is so beset with
jiossible fallacies us to be useless ; for suice pneu-
monia is so prone, when left to run its natural
course, to terminate suddenly and rapidly in com-
plet-o i-ecovery, therefore it is tjuite unjiistiliable,
however gtKxl the results that follow any line of
medicinal treatment may be, to niaintuin that they
are rftt? to that troatiucnt, and not merely the
natural issue of a series uf remarkably liciiignant
examples of the malady. This, it seems to us, is to
as.sert loo miie/i. Surely a practitioner of experience
and judgment, of acute observation and (juick percep-
tion, acquires the faculty of distinguishing a prolont/ed
striet of'<:otuieq^(ences from a prolonyed aeries o/' mure
coincidences.
To deny such powers of discrimination to others,
or t« pi-etend to reserve them to ourselves, is both
unjust and egotistic. If such a practitioner sees that
he obtains, in a uniform manner, better results with
i
6o8
Medical Treatment.
a particular luetliod of treatment than with other
nictliofis of treatniont, he miiy surely trust the
observation of his o\vn senses, and conclude that
it has had something to do witii the better results
obtained. And it must be romeinbereil that the
careful and guarded impressions of such an observer
are worth more than the eWdence of l)liudly and
luechauically compiletl statistics, accumulated by a
variety of pei-sons with very variable faculties for
accurate observation and just inference.
We have, ourselves, been led in (his way to the
eonclusiun that quinine frequently exercises a bene-
ficial influence over the course of ncut*3 pneumonias
of the class we are considerinjij. And this Ijelief has
imprt'ssed itself on a considerable nunil>or of other
observers. We do not, however, look upon this drug
merely as a depressor of temperature, as some apjiear
to do, but we regard this effect as uicideutal to some
direct action on the infective morbid agent, or on its
activities. We have been led to conclude, from facts
observed, that (pitninc is in some degree an nntiloxin
to the toxins of many infective germs, in what precLso
manner it is impossible at present to say. To call this
effect " (7<'r;nici</rt/ " is unjustifiable, because it may
possibly act in some way quite unconnected with the
death of the germs.
We have not given quinine in tlie larf/e doses
advised by Jurgensen and others ; but we have
always given it in a special manner, which w«
Ixjlievo greatly influences its favo\u-able action. We
give from 1 to 3 grains every two to four hours,
according to the age of the patient and the apparent
severity of the attack, and we give it dissolved in
citric ncid, and then added to an alkaline mixture,
80 that it is really taken in an effervescing saline
draught.
We have liafl abundant reason for lielieving that
quinine given in this form has quite different activi-
tie.H from what can l>e oblitined from it in the solid
form or dissolved in naneral acida We therefore
B
Ch»p, V.l
Acute Lobar Pneumonia.
609
i-pgard the adoption of this form of usiug it aa all-
iuijHjrtatit.
The following is the formula wt< asually pro-
scribe : —
i^ Quinuuu Hiiljibatia ,,. ;^. j. »d iij.
Auidi citrici gr. x r'I xv.
SucdiArj* luctii! ... ... ... gr. x.
Mispc, fijtt pulvia.
This powder is dissolved in a little water and
added to the following draught : —
19 PoUuicii biciu'boniitis ifr. x iid xv.
Ammunii uiirbunulis ^t iij jul v.
Synipi iiamntii ... ... ... 3J.
Afiiiic ... "d 5j.
Misce, lint haiiatuD. This dose is given overj- two, tlu-w,
or futir hours, ac<^ording to the ago of the patient and the
Bwerity of tho i.-aso.
We ai)pend copies of tin; uharts showing tlie
course of the pyrexia in three consuoutivc and typical
cases thus treated (Fig- 16). They were cases of quite
average severity. One (cose 2) was an alcoholic case,
and one (case 3) was a boy with pneumonic consoli-
dation of the xoluUfi of the right lung.
Cvu I. — Male, aged 40. PiirHiiiotiia, lower lobo riglit lung,
with pleimlii; friction; had i-hroiiir )iron(:hiul i-utarrh
before Iho iittauk. Syst^jlic murmur at ninliiic u|>ux.
Highfi't rospinition nito, 5'i ; high"st piil»o nite, 160.
Tongue brown, dry, and trcinidoiis. Stimulant, 0 to 8 oai.
of iiranily in twenty-four hourv. Convnlescenoo un-
interrupted.
Can 2. — Mall', aged 32 ; alcoholic. Hunmonia of light lower
lobo and ploui'itie friction, complicuted with delirium
Ircintni (not violent). Highest i-espiRition rate, 30;
highest pulse rat<', 126. Tongue very dry and brown.
Votti'iiletetnte rajiid and uninterrupted.
Can 3. - A boy, aj^i^d 7. ftirumoiiia of icli<ile of right lung ;
dulni'its iiliKoIiit<' (I'oni biLw to iipcx, Ixiek und front.
I'loiiritic frictionx at base, (l^dcnuttou.'i crepitation at
extreme base of Itft lung Highe*t respiration riito, 54;
highest pulse nite, 180. In addition to quinine in
* The sugnr is oeeessary to prevent the acid nnd the quiuiuQ
\ (ram coking together and sticking to the ]Kkpcr.
M M
6io
Medical Tkeatmk.vt. iPaniii.
Chap, v.!
AcvTE Lobar Pneumosia.
611
pifci'vesc'.nce, had 1 minim doses of linclure n( Hroaito
every three hours f^r three dows only. Koiisc physician's
note: " Itrought down Icimparatiirc from li)4 to lUT."
Convaloscence rapid iind uninteiTUptcd.
It will 1)0 Sferi Uiat tliree dosns of linetiire of
aconite —I iiiinim every tlirec lioufs — wore given to
case No. IJ, ami the house |ihysiciiin .icltled this note,
" Brou;,'ht down teinpcraturo from 104 to 101°."
We ill! not advocate the use of aconite yeneralli/
ill tmoumoiiifi ; indeed, we are strongly opposed to its
continued use as a routine remedy, or to more than a
limilt'd uunil)er of small doses. But given in small
(loses tn oliililren and young people at the very on.sot
of an attiick, ami for twelve to twenty-four hours
only, wo aro bound to Ix^ar testimony to its reuiark-
olily good effects. We have not seen any particuliuly
good results follow its use in adult.s, nnd we should
consider itn administriition most iinjustidable in .sgod
people. But it has some nubile influence, which we
are quite unable to explain, over uiany of the febrile
iiffectious of children and young people. It allays
the distressing sense of heat, it calms restlessness, and
it promotes .sleep. AVe give from 1 to 3 minims of the
tincture every three or four hours for throe to six 'loses,
or one of iSchielllin's pilulns of lu-nnUhv, each contain-
ing -^\r>^\\ of a grain, Wo never give more than si.x
doses ; and we restrict its use to the first forty-eight
hours of the illness, and we must repeat that it is only
ill the 1/011111/ thiit we think it of value.
But to return to the cpiostiori of the administra-
tion of qviuine in pneumonia. .lurgensen,* who La
one of the strongest advo«ites of the use of i|uiniue
in this disen-se, seoms to regani it simply as a i-eilucer
of tenn^raturo. He is a warm advocate of an mili-
/«/rff/ic treatment of pneumonia, because he considers
the piirr.xin causes cardiac exhaustion, and that failure
of heart power is lln: special and particular danger
we have to combat, But it is clear thai if (juinine
• Von ZieinsBon's " Cyulopojdia of the Praolico of Medicine,''
vol. v., p. i6i.
6l9
Medical Treatmrst.
[Part lit.
HntAgonises the activities of an infective organism
upon wliich the pyrexia and all the disturbances con-
nected wath it depend — and there is as much reason
for supposing that quinine acts in this way as in any
other — then tlie value of quinine as an antitoxin
must be far greater than that of a mem depressor of
temperature — as, for instance, the cold bath — for not
only, on thin hypothesis, does it lower the temper.iture,
but it acts also as a direct antagonist to the toxic
agent in the Iwdy.
We give in a severe ciiso 3 grains of quinine
every throe hours — that would amount to 24 grains
in twenty-four hours. We ha\-o never found the
slightest difficulty at any time in a-s-suring the tolera-
tion <tf these doses.
It will he si-en that we iiave brought the use of
iiuiniue in pneiiiuiiiiia \inrler the first indication, "to
cndi'avciur, if |M)s.sibli», to antatfunise the injurlotis
xHjhMiiceg of the s/'ec\/i<: infective organitan on the
blood and the tissues.'' We regard its action in
pneumonia as analogouH to its action in ague, and we
do not give it, as we have already said, siinply as
an antipyretic. Finally, we may remark that all
physicians are agreed that quinine must be given
freely in those forms of pneumonia which arise in
association with exposure to malarial influences.
Those who have written against the use of quinine
in pneumonia cannot have taken the trouble to employ
it in the way we have iudicttted, and as, in the business
of duily life, it is easy to "damn with faint praise,"
so in therapeutics it is easy to "damn" with careless
or nnskilful upptication.
Various mtfineptic agents have been suggested for
the cure of pneumonia, with the idea of their exerting
a, ijermicidcd action ; such as sodium benzoate, iodine,
ethylic iodide, the salicylates, and carbolic acid. We
are not aware that any jiarticularly good effects have
been obtained fit)m the use of these agents. We should
be disi>osod to jilace the itihalation of turpentine,
which lias been advocated in pneumonia, amongst the
ciup. v.i Acute Lobar Pneumonia. 613
antisi^lic iipcnts. Equal parts of turpfntine, oil, and
plyoc'rine have liecii mixed with three times aa much
distiileti wat^ir, and used as a spray in Lew-in's steaui
atomiKer. Such a mixture is inhalwl from five to ten
niiniiti.'S iivc or six times a day. The patient is
directed to take, fruni time to time, five or six very
deep inspirations. In the intervals he should breathe
in the ordinary way. It is said to stinitdate respira-
tion and to exercise a favourable influence on the
general course of the disease.
Some ten years 1^0 G. and F. Klempcrer stated
that when the specific " pneumococcus " enters the Ijody
of nn animal it generates a poison, which they named
" pnetiniotOTtn" and that the pneumonic fever depends
upon the presence in the l>loo<lof this substance : that
after a few days another substance, "an<i-;)»j«(Hio^ori«,"
is fonned, which neutralises the pneuniotoxin and
aiTest"! the pyrexia. As soon aa sulficient anti-
pneunioto.xin has been produced to neutralise the
pneuniotoxin the " crisis " takes place. Hence they
maintained that animals may he rendered " immune"
l)y the inoculation of any nutrient medium in which
the " pneumococcus " has Ijeen cultivated. The serum
of such an immune animal contains anti-pneumotoxin,
and may therefore be used to cure pneumonic
intoxication.
On this is founded the "sernia" treatment of
pneumonia, which has Ijoen jipjilied in many cases Ijy
diflTcretit observers with somewhat uncertain reault«.
.Successful and gratifying results have been reported
by some, while a want of success has been reported by
others, much ns in other methods of treatment of this
disease. The serum is obtained by rr'ndering an
animal immune to the disease by inoculating it with
a gradually increasing dose of the pneumococcus.
Bokenham * thus analyses its effects; "The serum
does not seem to reduce the duration of the disease,
nor U) produce a ' crisis,' nor to cut short the
pneumonic processes in the luiij^s. It does ajipureutly
• Britith JfediitaljMintiU, October loth, lUOO, |>. I()80.
6i4
Medical Tkeatjurvt.
iFteillL
preveut a geiici'ul HCpticwinia, nn<l may thus in moiiio
cHses help to save life. lt« iikm1i> of iicttnii is uot
IjHCtericidal, as piiL'umooocvi will grow ivaclilv iu it . .
but wlien I.I10 gcrinii is wiinbincd either •wit li noruioj
leufoi'vtes, or even with dwid ones, a mixture is
obtained which is capable of changing tind shrivelling
pneunuMNM.'cL When thert=:fore pneuinococci are
injoeU'd into on animal which has either been
vaceiiiatotl or treated with anti-pneumococciis iseruiii,
the tininial shows immunity because the seruin hns
combined with the 'alexin ' contained in its leucoc\-tes.
This combination then acts on the microbes, which
become shrivelled, and are then clearinl away by
phafjocytes. The chief difficulty in the cliiiical use
of this serum arises from the immense number of
bacteria present in the lung exudation, and from the
fact that the action of the serum seems limite<] to
preventing the entry of the organisms into the blood
vessels."
Further trials on a large scale will certuinly be
made of this method, and authoritative eoncliisioiia
arrived at before long. Pane's serum has been the
one most generallj' employed, and the dose is 20 c.c,
given hypodermically twice daily, until the patieut is
convule.seent.
We may now pas.s on to the consideration of the
MCOnd indication, viz. ; To relieve and to emleannir
to subiltuf danyerous and dittrensing siymfitoms.
The tii-st of these we shall consider is pyi'f'xia
or hyperpyrexia.
Jurgensen maintained that the chief end to be
aimed at by treatment in pneumonia is the reduction
of t-emjxirature, as the chief danger is from cardiac
a&lheuin, determuied, Ln part, by the obstruction to
the circulation presented by the pulmonary lesion :
and that the continuance of the fever is esjieeially
dangerous to the force and integrity of the canliac
muscle. Wilson Fox,* however, doubt^nl, and we
are disposed to share the doubt, whether the high
* " DiiMMUC* of tho LunKn," p. 3(J3.
Chap, v.i Acute Loiiar Pneuhonia. 615
temperature liiis n gnvit<.-T influence in ctiusing caniiuc
failuru than the action of tlie speoiHe |)oison on tlio
nervous system ; the stat« of the pulse may, there-
fore, be taken as a better gtiitle to treatment than
the teinperiiture. Wilson Fox's experience also lo<l
him to the cunclusion that a tempei-ature up to 105' F.
has very little apparent influence on the nioi-tality in
pneumonia, and that death.s at a temperature Ix'low
are nearly as frequent as aliove 105'; the mortality
depending chiefly on age, on complications, or on
preceding or co-existing debility, from whatever
cause, or from tlie amount of lung implict^ted,
and e«])ecially from the implication of both lungs.
A careful examination of the evidence of the
effects of the cold baili in the treatment of pneu-
monia is not 80 satisfactory as to warrant its general
cm|)loyinent or i-econimendalion. For, idtiiough the
statistics publisiied by some Continental practitioners
show fairly good results, it must lie borne in mind, as
has bt!cn painted out by Wilson Fux, that in some
ciinditiniis, such as great deliility, extent of lung
iiivolvi'il, iiijiidity <>f i-espiration, a^ivancwl ago, and
the aleoholic liiibit, " which must increase the danger
from pneumonia, this treatment has been uonsidereil
inapplicable by those who have most largely employed
it," so that it has really Ijeen tested chiefly in
tthcted cases ; and Wilson Fox came to the conclusion
that " cold batliing does not diminish the mortality
of cases with tem|K'raturea aV>ove 104^ F.'' He
thought the ni'thod useful, however, in a few cases
of pneumonia in chiUlliood with danger of collapse
of adjacent portions of lung. " The eUect of the cohl
bath in advancing cyanosis is of a most markedly
beneficial kind. It causes deep inspiration and the
refilling of the lung, and may be, occasionally, the
means of saving life." He thought, however, an ice-
cap, and a spimil ice-bag, in some cases, were often
useful in allaying nervous excitement, as well as in
lowering temperature and dimiTiishiug the rapidity
and impn^iving the strength of the pulse ; and he also
6t6
Medical Tkeatmext.
(Part lit.
approvcfl of a water ln'il tliroiigli which a stream of
cold wnU'r is kept consstaiitly lluwiii".
Th(! cold liatli has Ik-cii foinsd in Ik? daiigerouR in
some co«ps, and its application has been attended by
shock, collapse, iiiul return of rigors.
We are not ourselves partisans of the general or
indiscriniiuate use of the cold liatli treatment of
pneumonia : its routine application to all cases where
the temperature is not more than 102° or 103', as
has been advocated, we consider wholly unnecessary
and unjustifiable. The arguments that have been
used in favour of oxi)ectanc3", and in opjiosition to
drug or other active treatment, will certainly apply
with quite c<jual force to the routine use of the cold
bath.
The focal application of cold, however, has had a
nitniber of advocates. The practice of applying cold
to the surface of the chest over the affected lung
originated no doubt in the idea that it would influence
favourably the local pulmonary lesion, and also relieve
the pleuritic pain. But it seems far more probable
that it acts as an antipyretic, and influences favourably
the coui-so of the pyrexia. Niemeyer was a warm
supporter of this mo<le of treatment, and regarded it
as of great value in relieving pain, in lowering some-
what the temperature, and in abbreviating the course
of the disease. He used cold compresses to the
affected side, which were frequently renewed. The
application of an ice-bag has been suggested as a great
imjirovement on this method, as it does not need
frequent renewal, as the cold compresses do.
There appears to be some risk of chill and collapse
if this treatment is applied to feeble children, and the
temperature in all case^ should be frequently taken
during its application. The ice-bag should be re-
moved if it falls below 100', and it may be reapplied
if the temperature rises again to above 1()2'. The
ice-bag should not be applie<l over the pneconlial
region, as it is liable to exercise a depre.ssing influence
on the heart. If symptoms of cardiac depression
Oiap-V.) Acute Lobar Pxeuawsia, 617
appear, bnindy nauKt be given nnd heat npplioil to tlio
extremities.
Tlie local npplication of ice to the chest or to the
spiiu' certaiuly has a ptowei-ful influence over the
tenijieniture in this disease, anil appears to sulHlue the
pyrexia quite as surely as cold baths, while it is much
more convenient to apply nnd far less cxhaustinj» to
the |Mitient. Dr. Barrs applies icelmgs to the abdomen
in this disease.*
Many drugs have Ijeen advocated to reduce the
fever in acute pneumonia ; of the use of aconile we
have already exjircssed our opinion.
DiyUnliii is another drug the use of which has
been givatly extoliiMt in the treatment of pneumonia,
and it has this advaiitiifje, that while it reiluces the
temperature nnd the pulse-rate, in moderate doses it
ai.'(s Hi a tonic to the heart. Niemeyer considered (ts
use indicated whenever the pulse was of great rapidity.
Jnccduil approves of its use, and considers its good
etlect is chiefly conlined to lowering the tempeniture.
Prof. Anders t has found nitro-glyceriue considerably
aid the action of rligitalis in cases with cardiac weak-
ness— he gives 10 minims of tincture of digitalis with
A minim of solution of nitro-glycerine evnry three or
four hours. He considers the latter "especially
indicated when the renal .secretion is scanty and the
urine contains more than the usual trace of albumin."
The great tolerance of digitalis in pneumonia has
led to the giving of very large doses. We should
recommend that the doses given should not exceed
2 drums to J ounce of the infusion, or 10 to 20
minims of the tincture. Tliese doses may be given
togftlier with 20 or 30 grains of potas.sium citrate or
sodium tartrate. Wilson Fox refers to the tendency
digitalis has to intensify or prolong the great critical
fall of temperature, "a result by no means to l)e
desired," and we agree with him that its use should
• Briliih Hfri/n-al Joiiriiitl, June 10th, 1900, I). 1463.
f " Text-book of the Practice of Medicine ' (fourth eilition),
vol. i.. p. 165.
6i8
Medical Tmeathmitt.
(PwilL
Ijc liniitc«l to tiinse cases where at an earij ppriod
there is remarkable frequency an<i feebleness of poise,
Mul in caaes where, owin^ to circulatory feebleness,
the expectoration is profuse and bLxxiy. He also
advocates its ufie in alcoholic cases, especially when
attended with profase sweatings : in snch caaes tlie
" liencHt from its use has been of the most marked
nature," given together with alcoholic stiuiulanta.
As digitalis is often somewhat slow in its action, it
should not be continued for lung at a time ; its eflects
must be carefully watched. It sliould not be given to
old people.
In short, digitalis is a drug from which much
good may be obtained in the treatment of [>neumonia,
but its use requires great discriniination.
We are not greatly in favour of the use of modern
untipyri'tic drugs in the treatment of this disease, on
account of the cardiac depres-sion they notunfre«)uently
jiroduce. In the pneumonia of children aniipyrin
has l)eeii said to allay restle-ssness, quiet delirium ancl
cough, and promote sleep, as well as reduce tem-
perature ; it has been given in 2- to 6-grain doses
every six or eight hours, according to the age of the
child.
We prefer /jAejMioe/tn to antipyrin as a depressor of
temi^erature. It has not the same tendency to cause
cardiac debility. We have given it with excellent
results in quite stixall doses in severe cases of
influen7Jil pneumonia. In (me, a very severe form
of influenzu, the temperature reached 106°. There
was extensive pneumonic consolidation of one lung,
the lower two-thirds, and congestive hj-periemia, with
dulness and (e<JematouH crepitation at the base of the
other lung. There was active delirium. The t<ingue
was dry and furred, the respirations 60. The patient
— a young woruan — was given 1 grain of phenacettn
with 1 grain of hj-drobromide of quinine every hoar
for nearly three days, during which the temperature
fell, the delirium disappeared, and the lung began to]
clear, and she moile a rapid and uninterrupted 1
Ch«p.v.| Acute Lobar PtiEaMoNiA. 619
recovery. Sljc wiis watched very carefully for any
sij|j;ns of cai-diac doiiressimi while Hhe was taking the
phenacetiii, hut no sign of any such effect wiw
observed.
Sodium salifijlntc liaa bsen wlvowited hy some ns
of value in the pyrexial utage of pneumonia. It is,
in our opinion, too depressing a drug to be used in
this disea-se.
Pnin, which is due to acconijiiinying pleuritis, is
a Rj-niptoni we should do our best to relieve, for not
only does it tend to eAhaust the patient by preventing
slee]) nftd causing r(«tlessne8s, but it aggravates the
dyspn<i>a by inducing the piitient to make very shnllow
inN]iirutions for fear of increjising the pain. Tlie
appliciilion to tiie jmintui side of three to six leeches,
fdlldwi'd by a hot linseed poultice R])rinkled with
l.iudiinuni, is one of the best remedies. At night
10 grains of l)()vcr'8 powder in a drauf;ht with
'i (Iruiiis of solution of acetate of ammonia, and i
ounce of camphor water, is also useful. This is safer
tliau a hypoilerniio injection of morphine, for in some
caaes morphine will cause great cardiac depression,
and it must, therefore, on no account be given to
feeble and aged patient-s. A combination of a small
dose of morphine with ono of strychnine, or with a
Bniall dose of nitro-glycerine, has been suggested as
safer than morphine alone. Ice-bags and ice-fioultices,
together with the application of strapping to the chest,
liave been found cirectual also in relieving pain.
D>'spiia'it, when it occurs in an aggravated
form, with extremely rapid, shallow respirations, and
accompanieii by cyanosis, is one of the most serious
symptoms we have to conibat in pneumonia. It is
usually dependent on the rapid extension of the
piieumenic exudation, so that a large tract of lung
become« in(iltnite<l and rendered useless for respira-
tion. Owing to the obstruction this also offei-s to
the circulation through the lung, the right si<le of the
heiirt becomes distended, and the pulse small, weak,
and rapid. In more u<lvauced stages of the disease
620
Medical Tkbatmrst.
IPm« nl.
bilateral cniigpstion and irdetiin of tlio iuijg mar
liavc njoi-e to Ho with tlie eatisalioii of tbe dx-iipniiit
tlian Uie extent of pneumonic inliltmtion. Thorw io
also a nervous form of dyspnoea, due it is beliovttl (o
an intense action of tlie Mood-jwison on tJie iior%-ons
systt-m, and characterised Ijy extremely rapid resj>ira-
tions, and by the (jhsenco of the marked cyanosis
which accompanies tiie preceding,' fonu.
In the first of these forms of dyspnfisi blood-letting i
is indicated, in order to atlbrd immediate.* relief to tb<
over-distended rigiit lieart. From 4 to 10 ounces of
blood should be withdrawn from a vein in the arm ;
in feeble persons not more than 4 ounces, in the
robust S or 10 ounces. This measure usually niTordK
temporary relief, and so time is gained for the applica-
tion of otlicr remedies, and this, indeed, is the chief
value of venesection ; for its remedial effect is often
brief, and if it be repeated fretjuently it will com-
promise the patient's chances of recovery by dii-ectly
contributing to cardiac asthenia. Stimulants, there-
fore, must at the same time be given, and auinioniutn
carbonate, ether, and digitalis to maintain tlie cardiac
action.
We have said nothing as to the pi-oprietr of
bleeding in the early stage of this disease, whicJi was
at one time so common. It is but rarely that we 8e«
a case in which it is indicated, but wc agree with
Osier,* who says it is "gfKxl practice at the very
outset in robust, healthy individuals in whom tlie
disease sets in with great intensity and high fever."
In such cases it i-elieves ])Hin and dyspnwa, reduces
temperature, and allays cerebral excitement.
The hypodermic injection of gtrychnine is a valu-
able resource in the.se coses of grave dyspmi-a with
struggling cardiac action ; from 7,',th to jVnd of a
grain may be given at intervals of an hour for three J
or four doses, hilmlation of oxygrn has also
found of great value in maintaining life under such '
conditions, but it should be continuous, for even after
* "Practice of Mcdidne " (fourtli editiou), p. 135.
Chap. V.I
Acute Ia)bar Pneumonia
it has caused a complete rally, and the danger seems to
have been overcome, the dyspntea and cyanosis ore
apt to (juickly return on the dlscontinunnce of the in-
lialatiou of the gas. Its use ha.s been contintic<l for
fimr (lays and niglits by one practitioner, and for 106
lunirs liy another ; in the latter instance an average of
200 gallons of the gas was consumed in twenty-four
hours.
The inhalation of oxygen might oftenbeemploye<l
earlier in tlio course of the disease than it now is with
a<lvantagc — its application should be Ijegun whenever
feebleness and irregularity of pulse and blueness of
the lips indicate increasing feeblenes-s and distension
of the right ventricle.
Dry -cupping has l>een found useful by some phy-
sicians. Wilson Fox thought dyspnoea in children
■was best treated by the cold bath, as we have already
stated.
The nervo-M form of dyspncea may be relieved by
morphine and ether ; ith of a grain of acetate of mor-
phine and \ drani of spirits of ether may be given in
peppermint water, and repeated if needful ; or ^th of
a grain of morphine may be injected hy|K)dermically.
We must, liowever, l)e qnUr 8itre that the dy.spniea
i» imrvous, as it would be a serious eiTor to give
niorphiiu' if the dyspna'a were due to respiratory
oljstruction.
Driiriiiiii, wlien it occurs early, as it is apt to
do ill till' cimrseof pneumonia, is usually rlopondenl on
the intensity of the fever, and on the st«verity of
the action of the fever [)oison on the nervous system.
At this period it is best dealt with by such means as
reduce the pyrexia, and those we have already
detailed ; an ice-cap to the head, or an ice-bag to the
spine, or the local or general application of cold, or
the u.so of the antipyretics referred to above. But
when the delirium depends on a special excitability
of the nervous system, or on exhaustion, at a late
stage of the disease, some special means must be
adopted for its relief. Mtuk was a favourite remedy
623
Medical Treatmfmt.
[PArl in.
with Trousscrtu for this Bvniptoni, given in .'i-grnin
(ioB(^, nnil Proffssor H. C. Wood hi« also advocated
it« u«e given in 10- to 15-grain doses, \>y rt'ctal injec-
tion, suspended in mucilage, every six liours. A moi-e
trustworthy remedy is a combination of chloral and
lirouiido of poUissiuin ; 'JO grains of the former an<l 30
grains of the latt«.T drug shttnld be given at once, dis
solved in an ounce of eariiplior water, and repeated
when necessary. Douglas Powell has recommended,
for violent delirium at ttiis perio<l, fretjuenlly-repeateii
doMes of alcohol, given with some fluid food, and
followed lpy a hy|K^eruiic injection of raoqjhine and
atropine,
alcfplAiSSiifSg may precede and accompany the
delirium, and requii-es similar management ; but
when it is dependent on fMiin, couyh, dyspntra, or
exhaiMlion, it can, obviously, only bo relieved by
remedies which relieve these other symptoms and
states. The surroundings of the patient should, of
course, Ihj such a-s tend to promote sleep : a tiuiet,
cool, well-ventilated room, a comfortable lied, etc.
C-'oiigli is a symptom which, when frecjuent and
distressing, requires trentment. So long as the cough
ia attended by e.\|x>clornti<jn of the i^culiar pne\imonic
sputum, or of fi-othy iimcus from co-existing bronchial
catairh, it would obviously be mischievous to give
sedatives to arrest it. Such a cough is es-sential and
useful for clearing the air-pjissages of obstructive
secretion. « But it sometimes hapipcns that there is
much and disti-essing irritative cough, unattended by
expectoration ; this may be due to the extreme
viscidity and tenacity of the sputa, and the con-
sequent dilliculty in detaching them and ex|>ciling
them friiui the air-passages, or it may ilcpend on
some laryngeal irritation which may lie the seat of a
coincident dry caturrli. A cough of this kind, if left
unrelievetl, will add grejitly to the )iatient's distress
and exhaustion, as it will prevent sleep, and the mere
(uuscuhir efforts of ineftectual coughing are moBt
exhausting. If the cough is due to the difficulty of
Chap, v.) Acute Lobar Pneumonia. 623
expt'lling Jry viscid sputum, then warm alkalim.; sprays
(KuiK, or Vicliy, or Ikiurboule wiit<?r is HuiUtble) will
be found most useful. The following is a very good
foruiulii : —
19 Sodii liii^ir1>0Dali8 ...
gr. X.
Sodii chloridi
(P-- ».
Cilycerini iici'Ji tarbolioi ...
y*-
Aquii' luurocerasi
5'j-
Aqooi
«d 3j.
Miseo. To be used as a spmy.
This should be applied hot in n Sioglo's steam
spray-producer. At the same time the patient should
be given an occiisional drink of alkaline water (Ems,
Vichy), mixetl with a little hot milk and a teiispoonful
or two of brandy or whisky, or a mi.xtmt) containing
animoniiim carbonate and spirits of chloroform may
promote expectoration. If this fails to relieve, iind
the cough seems due to laryngeal irritation, from
2 to 5 grains of Dover's jxiwder mixed with a little
chloroform water may be given occasionally ; small
doHes of tartar emetic are often extremely useful in
allaying this sym[)toni. A teasjKXtnful occa-sionally
of the following linctus will rarely fail to relieve such
a oough : —
1^ Villi unfimoniah'K .. jij.
Aminonii carUniuiliN gr. xviij.
Li(iuorig morphinip hydrwhloridi ... jj.
Aqiiic Ifturocerasi ... jiv.
Syriipi siuipliciu .. ... ... ad Jj»s.
MIsco, tiat liiictiii. One teiupooaful {or a do»e.
(•iiNlrif riilsiriii of an acute form and
dliirrliu'H are apt occasionally to occur in some
cases of acute pneuninnia, which for this reason have
l)t!un termed cases of bilious pneunnnu'i. These
syni])toms ai*e not uiifrpi|uently induced by injudicious
feeding ; by an over-anxiety to give footl when the
stomach is not in a state to digest it, when the
tongue is thickly coated, and the mouth foul and
covered with a drj'ish, sticky secretion. On per-
cussion of the atomach it will often lie found to be
624
Medical Theatmhnt.
rp«ri in.
diluted from indiscreet over-fee<iing with food that
cannot be alisorbod. Vomiting will occur in such
circumstances, and sometimes diarrhcco. To prevent
these 8ymj)tom8 it is a good plan, if we see the cAse
cjirly, to give, at the very onset, o. grain or two of
calomel followed by a saline aperient, so as to sweep
away any foul, irritating siilftitaiices that may be
retained iu the alimentary canal ; or the same
remedy may be applied when the symptoms of
gastric catjirrh present tliemselves. The food should
bo restricted to milk diluted with an equal quantity
of water, and containing 10 or 15 grains of bi-
carbonate of soda to each cupful. A little water
arrowroot with a small quantity of brandy may also
be occasionally given. A mustard plaster to tho
epigastrium will relieve the tendency to vomiting.
It will rarely be necessary to have recourse to ju»y
other means than tliese to relieve the gastric catarrh
and arrest the dlarrliaa. If the latter symptom,
however, should be troublesome, it can usually be
controlled by a few doses of Dover's powder (2 to 5
I graius) with bismuth stibnitrate (.5 to 10 gniins).
We now reacli the third indication, " I'o support
I the patietU's gtrength, and to en'Uavour to remove or
moderate ail conditions tending to exhaustion." Some
of the means at our disposal for res|>onding to this
i:idication liave already been considered in the pre-
ceding remarks on the treatment of symptoms.
It is generally adniittefl that the great danger to life
in pneumonia is the tendency to cardinc fnilarc,
I and it is to prevent this, in the lost stage of the disease,
that all our efforts must be directed.
It is hardly necessary to point out that the
patient should be kept absolutely at rest in a coui-
fortablo bed in an airy, well-ventilated room, and
us quiet as possible. He should not be disturbed
unnecessai-ily, or moved about and exhausted by too
freijucnt physical examination. His diet shoulil Ije
fluid and light, and adapted to the enfeebled digestive
powers, and to the febrile state. Milk, diluted with
Chap. V.|
Acute Lobar Pnevnonia.
625
■water, or some effervescing alkaline water when there
is any tentiency Ui 8ickno<t8, is a good and conveniont.
fiioil. The occasional vuiiiiting of conf/ultUed inilk
should be carefully noted, for it then usually re<)uirt'.s
further dilution with some alkaline water, or itsfiould
be peptoniHed. Light clear aoups and liroftis may
iilso l>e given ; there is no liann in a cup of well-
made tea or coffee now and then, and they are l)otli
cardiac stimulants. Stnjng coffee is too little used in
these cases. It has a tonic effect on tlie heart. Thirst
may be allayed, and the mouth kept clean and moist,
by sipping iced lemonade, toast and water, or barley
water, according to choice.
When more stimulating food seems called for, eggs
may be given beaten up with boiling water, which
partially cooks them, and one or two dessertspoonfuls
of brandy or whisky added. .Strong beef-tea, or meat
juice and arrowroot nmy also be given with some
jKlded spirit in the same way. If there is coexistent
broncliiid catarrh, and the exiiectoration is viscid
and dilheult of expulsion, hot milk and seltzer water
in etjual parts, with two or three teaspoonfuls of
brandy, serve IkjIIi as a stimulating food and a useful
expectorant
With regard totlie use of nlroholir «liiniiliiiil«>,
we arc eoiivincetl that in more than two-thirds of the
cikses of acute pneumonia, as they are generally
encountered, thei'e is no need for them whatever. The
routine ndministration of alcohol in ]>neumonia,
especially in the early sUiges, with the idea of pre-
venting cardiac failure lattir, is, we think, a s'Twuii
error. Alcolml produces vaso-motor jxtrrtis, and
causes dilatation of the vessels, and it must, there-
fore, aggravate or induce tendencies to vascular
engorgement. It acts like a poison on many pcrson.s,
an<l causes considerable, nervous and general depression
after its first stimulating effect passes titl"; it increases
the amount of toxic substances in the blood, and the
elimination of considerable quantities of alcohol must
impose a severe strain on the already overtaxed organs
o o
626
Medical Treatment.
(Pan lit.
of exci-etion. When we further consider the large
quantity of iuijnire spirit — brandy and whisky —
wliioh must be used in hospital practice, for the pure
and l>est kinds are very costly, we are disposed to
lielievt" tiiat some <if the nmri." serious forms of cardiac
failure, with allmuiitiuiia ami gastric and hepatic
congfbtion, encountered in the later stage of pneu-
monia, are, to a certain extent, contributed to by the
excessive and premature use of impure alcohol.
The mrly i-outine use of alcohol takes from us
also the power of reporting to it as a fresh resource in
advanced stages, when in exceptional cases it may be
of undoubted use.
The very same olyection that has been made toj
inferring from results iis to the v.ilue of any particul
remedy in a disease like pnenmnnia, with so strong a
tendency to terininat* in a rapid crisis iind complete
i-ec^jverj', must apply with equal force to the inferences
that have been drawn from the routine u.se of alcohol.
Tn well-marked adynamic ca.ses, however, the use of
alcohol is indicated, and we should make some efforts
to nbtain it pure. In the pneumonia of drunkards,
aud of the aged, it is especially needed. We should
In-gin with moderate amounts — 4 to 6 ounces of
whisky or brandy in twenty four hours — and increase
them if necessary. Dr. Wilson Fox thus formulatedl
the indications for its use : " rapidity, in-egularity,
intermittence, and dicrotisra of pulse, great rapidity
of respiration, cyanosis, with a rapid, feeble pulse,
irregularity of breathing, and signs of pulmonary
(cdenia, tremor, subsultus, muttering delirium, oi
delirium in patients oddicted to alcoholism, and pn
fuse sweating during the febrile period, are
indications for alcohol. When these symptoms are
severe alcohol must occasionally bo used unflinchingly
and unsparingly."*
A moderate amount of alcoholic stimulant in the
form of good, sound wine, such as port or Ijurgundy,
or champagne if it is preferred, or 2 or 3 ounces of
• " Diseiuei of the Langs," p. 372.
V.J
Acute Lobar Pneumonia,
627
whisky or brandy in the day, is often npcdetl after
the wisis, and during convalescence. It will then
be of much help in restoring the strength of tlie
patient.
Cardiac failure may arise in two ways : eitlier,
owing to the extent of the pneumonic consolida-
tion of the lung, and the obstruction to the circu-
lation in the pulmonary vesfiels and the venous
■yatem generally, so produced, the right side of the
heart Ijecomes over-distendod, and there is a tendency
to clotting in the right heart and arrest in diastole ;
or, owing to the intensity of the septic infection and
the pyrexia, there is a gfiifrnl loss of canliac |)ower,
with well-marked nervous di.sturbtiuce, and great
genera/ prostration. We have already alluded to the
ix)s.sible usefulness of vii^ieHion when the first forin
of cai'diac failure is seen to be impending ; the great
objection to its employment, o.xoept in vigorous
persons, and in auiull amount, is that if it fails to help
tlie struggling heart over the critical period it may
leave the patient in a worse condition to tight througji
the final stages of the disease tlian )»efore. With this
exception, the treatment of both forms of cardiac
failure is the same.
Hypodermic injections of ether to stimulate the
heart in these grave cases of adynamic pneumonia, 20
to 30 minims, quickly repeated if necessary, have iKfU
found a valuul)le resource in many instances. (luclmixl
comliines injections of ciijf'<'in'^ with injections of ether.
He Ijelicves the former to be purely tonic to the heart,
and the latter only stimulating. He dissolves the
caflTeine in distilled water with the ai<I of sodium
salicylate — a dram of cati'eino and 45 grains of sodium
salicylate are dissolved in li dnini of warm <listille<l
water — one-tenth of this, containing G grains of
caffeine, is injecteil at a time, and may be repeated
six or eight times in twenty-four lioiire.
Professor von Koranyi,* of Huila Pesth, luis luivo-
cated the use of saline intravenous injection.s to
• Britith Mrdirat Joiiriiar, April 2Hlh, UW, ]), lOVi.
Medical Tkeatmbnt.
[Fan III.
assist the henrt and promote diuresis, and Professor
Anders * tliinks tliat saline injections given h_v|>o-
dernuciiUy lire " valuable in overcoming circulatory
depression, which is often threatening to life." He
leconiniends that 1 to 2 pints should be allowed to
flow under the skin from a rubber liag, and repeated,
if necessary, at intervals of eight to twelve hours.
Some consider that means for diaiufiction should
Ix" )ip[)lied in cases of pneumonia, more especially in
its ejiidemic forms ; the linen shoulil be treated hs in
other infectious diseases, and the sputa should be
destroyed. As it seems possible that the germs may
linger in the mouth in a state of activity, this caxnty
should be disinfected by means of antiseptic moulli
washes ; this would lessen the danger of rela]>se and
the risk of infecting others, A tablesptxinful of
LinlfriiK: in a wineglassful of warm water would
answer the puqKwe.
ConvaUicmce from acute pneumonia is often
rapid and uninterrupted ; at other times, especially if
the a^ute perio<J has been prolonged, and the crisis
late, or if the pyrexia has terminate! gradually and
not by crisis, the convalescence may be protracted,
and re(]uires care and watching. A light, sustaining
diet, with a moderate amount of wine or other
stimulant will be needed, as well as quinine, strych-
nine, and iron as tonics, and a slow disapfiearance of
the lung infiltration may require the application of a
few flying blisters or iodine j>aint over the area of dul-
n©88. We have found such counter-irritation promote
the disappcAi-ance of the exudation : indeeil, we regard
this as the 8i>ocial use of counter-irritation, and in
ordinary cases we reserve its application for this
stAge of the disease. In strumous ca.se8 we ha\-«
seen iodi<ie of iron in combination with co<l-liver oil
of much use in <|uickening tJie di$a]t))flarance of the
exudation, and the cvwipletc clearing up of the lung.
It will often, however. W ncii-ssarv to Imvo n*coursc
L
• " Text-book of the Pru ti.
vol. i., p. 155.
^fourth sditioo).
a.»p.v.i
BRONCHO-PyEUMOfHA.
629
to change of air. lo removal to tin.' sojisidc or to some
bmcuig uiuiiiitain rpsort, to coiniiletely rebtore the
ati'euted lung to a healthy condition.
II. — CaTARRUAL, Loill'LAIl, OK BkdN'CUO PNEfMoMA.
Cases of this form of pneumonia differ in many
respects from the preceding — in their mode of orif^n,
in their course and termination, in their aualomicid
lesions, and in their symptoms »nd physical signs.
The iudicalious for Ircatmcnt will also differ
somewhat
These case« usually originate in a pre-e.xisting bron-
chitis, the inflammation of the bronchioles extending to
the contiguous n.ir-cell8,and they are, therefore, cniHipd
by tile same conditions as induce bronchitis ; and
these we have already considered. They are, however,
very prone to oi-cur in those fonns of bronchitis
which accompany the infective fevers, such as measles,
whooping-cough, influenza, diphtheria, etc., ami
especially when these diseases attack children, or
others who are living in unfavourable hygienic
conditions.
Various oi-ganisms liave been found in the lungs
in bronoho-pneunionin., but it is scarcely possible to
say at present whether or not they are casually
connected with thi.i disease. Streptococci, stapliylo-
cocci, the micrococcus lanceolatus, and the pneumo-
coccus of Fricdliinder have all been found. These
organisms are commonly present in the ornna-sal
cavities, and under certain circuni.stances and con-
ditions of the air-passagea they may be drawn by
inhalation into the air-cells.
Attacks of bronchchpneumoniaare very common in
enrly chi/(Uii>i.id, but they are not so generally restricteil
to that periotl as ha.s been thought. In ejjidemica of
influen/ji they occur at all ages, and Ihey are common
in old age and in debilitated states. The e.vistence
of heart disease and pulmonary emphysema favour
their occurrence. Constitutional syphilis, scrofula,
and rachitis in children predispose to these attacks.
630
Medical Treatment.
Waxl III.
Tbey diffrf in their rnurse from croupous ptieu-
monia ; the invasion is usimlly grndual, being prccinled
l>v the onlinary signs of In-onchitis. They run no
definite cydicttl or typical course, as du cases of lol)!ir
tmeuaionia ; tlieir course is variiible and in-egular,
sometimes terminating fatally in a few days, sonietiniea
Ifvsting many weeks, and ending in a slow and gradual
convalescence. The mortality is much greater.
They diB'er in the characteristic imalomical
Ittiont, and their distribution. The inflammation,
I creeping on from the bronchioles, aSects scattered
■rroups of lobules, hence the name lobndar ; the^e,
however, may coalesce, and so considerable tracts of
lung tis-Hue may beafl'ected. This Ijecomes associated,
to a greater or less extent, with collapse of other
lobules, an important lesion the mode of occuirenco of
which we need not now stay to explain. But these col-
lapsed air-cells ai"e aj)! themselves to become the st«at
of pneumonia. The'.rKrf^Ytox into the air-cells differs
also from that of crouiwus ]meumonia in being com-
posed chiefly of epitlieliiil colls, and the cells of
catarrhal bronchitic exudation drawn into them during
inspiration, together with leucocytes, a few red blo<xl
corpuscles, and only a scanty proportion of fibrin. The
bronchial tubes are prone to undergo dilatation,
especially small globular dilatAtion of the fine tubes.
These scnUered lesions usually affect both lungs, so that
the disease is commonly bilateral. The bronchial
■rlands are usually affected, and become inflamed and
swollen.
The secondary lesions, such as dilatation of the
right .siile of the heart, and congestion of the liver,
omach, and kidneys, dejiend on the obstruction to
lie pulmonary circulation.
The attacks differ in their tymptoms and physical
as ; these are, of course, to .some extent, those of the
ompanying and antecedent bronchitis, and they
"vary uTeutly in their severity, according to the extent
and inteii.sity of the local iatlammation or the attend-
ant constitutional state. The covt/h is usually an
Chap. V.I
Broncho-Pneumonia.
63-
important and troiiljlesonie. syniptoni, and is apt to
occtir in severe siirtbcative paroxysms. The diis^nurn
may \tc very grent, an«l the respirations very rapid,
rising even to 100 in the minute, according to the
amount of obstiiiction to tlie access of air to the air-
cells. The expiration ia usually prolonge<i and
lalxjured. The spuld are bronchitic or |)uriform, nut
rusty ; they are very tenacious, and young children
rarely expectorate them.
Tlwjevfr is somewhat irregular ; at first the tem-
perature may be that of acute bronchitis, or of the
infective disease of whicli it is a complication, and
nmy not exceed 102' to 103°. Subsequently it may
rise to 10+° or 105°, and there are often considerable
daily fluctuations. The defervescence is gradual, and
not by crisis. When the temperature is high, and
tlio respirations are rapid, the pulse is aLw very quick,
and usually small and feeble, and may reach IGO to
200 ; the face is cyanosed. In severe cases there is
also marked tendency to (jastro-inleslinal caUnTh, with
great thirst, a brown and dry tongue, and diarrhuia,
an<I there is likewise a great tendency to cerebral
disturbance, restlessness, delirium, convulsions, stupor,
and coma.
In cases that recover the convalescence is not so
rapid as in lobar pneumonia, nor is it often so com-
plete. Recovery is gradual, and there is a certain
tendency to the sequence of chronic pulmonary disease,
or the development of rachitis, or the occurrence of
gastro-intestinal irritation.
The jihynical »i<jiu differ from those of croup-
ous jmcumonia. There are, of course!, those of
the co-existing bronchitis — viz., sonorous and
sibilant, di-y and moist nUen heard over the greater
part of the chest ; and there may also be the
signs duo to catarrhal obstruction of the air-
passages, and attendant collapse and emphysema,
viz. immobility of the chest, and sinking in of
the lower ribs.
But the physical signs dependent on the onset of
C3»
Medical Treatmeht.
|P».« Ml
this form of pneumonia are oomcwliat obscui'e, unless
considemble areas of lung n»ar the surface are
involved. Tf the pneumonic spots lu-e stuall inejctent
and surrounded by heallliy lung, they will yield no
chanicteristic signs to percussion or auscultation.
The portions of lung, however, most liable to pul-
monary coUivpse extend from the Ijase upwaitls, in »
somewhat conical form, along each side of the spiu(\
and here gentle jiercussion may show the presence
of dulness on lioth sides. Fine subcrepitaut r&les may
also l>e heard o%'er the dull lu-eas with lilowing ex-
piration. The ]>hysic<il signs, however, of puluionary
consolidation are usually much less evident than in
eases of croupous pneumonia, hut careful and skilfbl
percussion and auscultation will usually detect in
some part of the chest the signs of spots of pneu-
monic iutiltratiun.
From this brief hkelch of the character and conrso
of broiifho-iiiit'iiinouiu, we may be assisted iu
formulating iiuiicalions/or iCs irentmcill.
The first of these is lo pruniote the removal
of ohslr^ictions in (ha air-jMunageg, and so favour
luiiij exinnuion and prevent the txUntion of Inng
collapne.
The second is (o relieve digtresnitg and exhautting
Kymptoiiis, such as cough, dyspnma, /ever, diarrhcta,
cerebral irritation, etc.
The third is to support th« ilrength of the patient,
and ward off debility and exhaustion by every possible
means.
Obviously the remedies which will respond to tlio
first indication will, to some extent, aid in the second,
and those which answer to the first and second will
further the third.
The lii-st thing that will strike any observant
practitioner in the care of cases of broncho-pneumonia
is the desirability of the application of remedies that
■will promote the expulsion from the air-pnssages <rf
the t-enncious, adherent mucous secretion that is
obstructing thorn. The w)">i« scries of morbid
Chap. V.) '
Broncho-Pneumonia.
633
]ihenoiiipun observwl in tll(^8e. casos follow from tliis
obstruction of the air-tubes.
Emetics have been rocomjnended for this purpcwe,
and especially ipecacuanha, to promote the expulsion
of the uiucuN that accumulates auil obstructs the air-
]>asuages, and an occasional emetic of 10 to 20 grains
of ipecacuanha powder, mixed with a little wiirm
water and syrup, may with ailvantage be admini.stored.
The effect of the emetic is to relieve dyspmea, to
lessen cyanosis, and to prevent the tendency to
colla|>se.
Tiie hyfKxiermic injection of fj/)<><((()?7j//tfl«; (^'.j grain
for adults, ,V, for children) has been used and com-
mended for this purpose, but it lias been found to bo
occasionally attended with such very depressing effects
th&t it cannot be safely recommended for general
application.
Thi^ dniwliack to the use of emetics is tliat thoy
cannot be ftvijuently repwvted without producing
much exhaustion, and that tliey are apt to excite
gastric irritation, to which there is a distinct pre-
disposition in these cases. We have found another
expedient most useful in promoting tlu' expulsion of
the mucus from the air-pas-sages, and in lessening its
viscidity. It is the use of be-nzoate 0/ soda internally,
and the frequent application of warm alkaline sprayt
containing some glyccriim of carbolic acid. In those
cases occurring in connection with infective diseases
the benefit attending this method of treatment will
often bo found remarkable, while it is a therapeutic
method absolutely free from any possible objection.
From .') to 20 giuins of benzoate of soda, accord-
ing to the age of the ]>alient, with 1 to 4 drams of
ehliiioforrji water, should be given every two or
thn;e hours, and a warm spray composed of 10
to 1.^ grains of bicarlxinate of soda and 1 dram of
glycerine of carbolic acid to each ounce of water
should be freely sprayed in front of thtj mouth and
nose of the child (when it is too young to inhale
voluntarily), so as to be inhaled with the respired air.
634
Medical. TRF.ATMEirr.
lf%n\
TIlis cjin easily be arranged by mounting a good-
sized Siegle's steam spi-ay-producer at a suitable level,
anil allowing the steam spray to flow under the
hoo<l of the child's cot or to play freely in front of its
luouth and nose. {See Fig. 2, vol. ii., p. 591.) It
is desirable in these cases that a flannel tent should
surround the child's cot or bed, so as to shut in this
warm, moi.st atmosphere, rendered additionally so if
necessary by a steaui kettle. The increased duidity
which such iin atmosphere gives to the bronchitic
secretion is of the greatest importance in promoting
its expulsion. Warm saline drinks serve the same
purpose, and the patient should be made to drink
frequently a small quantity of hot milk mixed witJi
about twice as much seltzer or Apollinaris water, to
wliioh a little whisky or brandy should be added,
from ten drop.s to one or two tea-spoonfids, according
to the age and condition of the patient. These
measures alTord relief also to the cough, the distressing
jmrcxyains of which are caused by the violent expi-
ratory efforts to expel the tenncioua mucus adhering
to the air-tubea and obstructing respiration. As
these violent expiratory etforts tend to cause pul-
monary collapse, it is important they should be
iuo<ler«t«d and controlletl, and if the measures just
tle.icribed du not sufliciently control the cough, some
sedative must be cautiously administered for the
purpose. The greatest caution must, however, be
exercised in the use of opiates, lest they should by
any means interfere with expectoration, and so add
siill further to the respiratory obstruction. This may
l)C.st bi- obviated by giving very small du.sc», and
couibiniiiii them with expectonmts and stimulants.
One gn<at advantage, which can scarcely l>e over-
estimated, attending tlie occasional administration of
minute doses of opium, is the relief it u.sually affords
to the restlessness and nervous distiirltance. Dover's
powder in dose^ varying from [ to lA grain may be
given to children from 3 months to 5 years of age,
with .', grain to 2 grains of ammonium carbonate, and
dup^V.]
BnOffCHO-PNEUMOiriA.
63s
u
a little syruj) and water, once or twice in the twenty-
four hours.
In older ptHjple, iinri in more chronic cases, the
ordinary expectorant i-emedics may be prescrilied, but
we have found thcni of little use in young childrea
who do not know how to expectorate. A useful form
for adults is carljonatc of ammonia, ."J grains ; cldoride
of ammonium, 10 grains : ipecacuanha wine, 5 minims ;
and infusion of senega, 1 ounce. This dose may be
given three or four times a day.
tStimulating embrocations <the compound camphor,
mustard, or turpentine liniments) to the chest are
useful. Wo think well also of turpentine inhalation,
and a ready and convenient method of applying it in
the cast! of young children is to j)our twenty or thirty
drops of spirits of turpentine on a piece of lint tied
loosely muurl the child's neck. A quilted cotton-wool
jacket should be worn over the chest, and this we
consider preferable to hot poultices, as the jacket
admits of the ap[ilication of liniments, or mustard, or
iodine, whereas the wet poultice often gets cold, fatigues
by its weight, leads to dangerous exposure in its
r<mewal, ami, if unskilfully made or npplieil, often
slips and niake.s the patient damp and unconifortu)>le.
However, the early application of a mustard plaster
over the bases of the lungs has often proved useful,
and if there is )>leuritic pain a hot linseed poultice
will usually relieve it.
In the initial stage, if there is much fever, with
a hot, bunung skin, a few sinall doses of tincture of
aioidte, \ a minim to 2 minims according to the age
of the cfiild, every hourpr two for three or four doses,
with a little )*cetate of ammonia or citrate of potash,
will often allay the fever In a remarkable way, and
soothe the little patient greatly. Its use must Ije
limited, however, exclusively to the early stage of the
diiiease. We have not found i.|uiuine so invariably
useful in tlii>i form of pneumonia a.s in the preceding,
but most other authorities speak highly of its beneficial
effects In some cases, Wilson Fox commends the
636
Medical Treatment.
iroii Hi.
B(lniiniKtnition of <)uiiiine, but rather ns a tonic than
a« nil nntipyretic*
Uul oni' of lli« most iipprovod methotls of tn*.iting
llic pyri'xia of catarrhal pjicumonm is by the applica-
tion of fold, either in the form of the cold bath or by
liM-nlii])plicatioii tothn chest. This treatment, advocated
by .lurgensen, Jlartels, Ziems-sen, and many others,
found a warm supporter in the late Dr. Wilson Fox.
In serious febrile cases, with inci-easing cyanosis &u(l
(ly-'*pM'i?a, " immersion for a period of one to three
ujtiiutes in a bath of a temperature of 65° to 70*
Kahr. will," he says, " induce deeper inspiration, and
apparently, as I have repeatedly witnessed, restore the
vitality of the patient. . . ^Vny prolongetl immer-
sion is undesirable in young children, though with
recurring cyanosis the liMths may be repealed." He
also approved of the local application of cold lij' means
of cloths wrung out in cold water and applied to
the chest and back, or the ice-bag in the manner
already described ; and olaervcs of this method, " It
appears to ojjerate favouj-ably in two directions —
both by increasing the strength and depth and bjr
lessening the frequency of the respiration, and also \yj
the reduction which it effects in the tem|)erature, a
result which a|)]x?Ars unattainable by any other agent,
at least in an equal degree." It is of si)ecial value ia
promoting expansion of the lung, and warding off the
danger of increasing collapse.
The reduction of temperature brought about by
this method is often very considerable, but it is not
permanent, for after a few houi-s the temperature
rises again if the application of cold be intcrmitte<l,
and several days of this treatment may 1)6 needed
before a permanent reduction to normal is induced.
The pulse- and respiration-rate also fall, and the
cyanosis diminishes. But this method is not without
risk, and has to be watched carefully, for some patients
are far more sensitive to the depressing effect of cold
applications than others, and the long-contiuued
* " OiMOM* of the Lungs," p. 400.
k
^
Chap. V.I
BRONCHO-PNEUMONIA.
637
application of colil has l)cen observed to lie followed
by very serious sj'iuptoms of depression. Wlien any
signs of Bucli depression are observed, sucli as pallor
of the countenance, coldness of the surface, a small
and very feeble pulse, the njiplicatiou of cold must at
once Imj interrupted and stimulants freely given.
We prefer the niethotl of cold ntliiitioii— the
dashing of cold water over the chest and spine — to that
of immersion in the JMith. The stimulating ellect is
greater, and it provokes, more completely, those fuller
inspirations which are desired to overcome the danger
of collapse. Tiie lower part of the body may l)e
immersed in hot water or hot mustard and water while
these cold aftusions are applietl to the cheat.
I.«eches to the chest followed by poultices have
been advocated by some physicians to relieve the
dyspiirea attendant on pulmonary eitgorgement. We
liave not seen occasion to adopt this recommendation,
nor can we advi.se it.
Any ^yvayiwa^ oi gaslro-'inle.stliud crt/»ir;7i, such as
voinilini/ and diarrlurn, occurring in the course of the
illness, must be promptly relieved, because of their
lowering temlency. If vomiting occurs early in the
case, with a furred tongue and confined bowels, two
or three small doses of calotnel may be given with
advantage— a | or ^ a grain, with 2 to 5 grains of
bicarbonate of soda, every four or five hours until the
bowels have been freely movecl. If there is also a
tendency to diarrha'U, me or two of these powders
may still l^ given ; Vmt should the diarrhcen continue,
it will l>e necessary to replace them by others, each
containing Dover's powder, ^ to 2 gi-ains, according
to the age of the child, with 2 to 1 grains of carbonate
of bismuth, to be given twice daily until the
diarrhcea ceases. Symptoms referrible to the nervous
tystem — restlessness, delirium, etc. — may be so
severe as to require treatment by sedatives. We
have already spoken of the use of cpiura, and the
caution necessary in its lidministration. Given,
afl already directed, in iiiiiiinnim doses and in
638
Medic A l Tr ea tment.
[Viil III.
combination with aminonia and ether, it is often
valulll>k^ in (lUnying those nervous xyoiptoms. Pro-
fessor Pfpppr lia« found the following suppositories
valuable in iiUaying extreme restlessness and sleepless-
ness : Asafcetida powdered 1 dram, sulphate of cjuinine
30 grains ; to Ite made into twelve suppositories with
oil of thcoliroma, one to lie introduced every three or
four hours. He also recommends chloral hydrate in
the form of enema. 5 grains for a child live years of age,
and 20 grains for an adult. Jie sjiys it affords great
relief to the nervous symptoms. Active and reHtless
delirium in the adult he has found fpiieted liy hypo-
dernuc injections of At/dsci/cii/i/n'!, Tf'nth to y^oth of u
grain. P^lnemata of chloral and sodium l>romide, 5 tu 20
gi-ains of each, according to age, may also l>e used for
the relief of this symptom. Professor IL C. Wood
uses enemata of musk suspended in mucilage.
But the most imperative indication in the more
8<>rious forms of this disease is to eiier<jf.tiriiliij tiipfmrt
the slrciigtli of the jiatient and to overcome the tendency
to respiratorj' failure. In addition to the measures
already jioint«d out, there are still other means to
which we may have recourse. Strychnine, us a stimu-
lant to the respiratory centre and to the resi]>initory
muscles, is a valuable remedy in these coses. It may
be given in combination with bark, thus :
ly Strvehuin.'o
Acidi hydrorhlorici diluti
SpiriliiB chliirtifcirnii
Extracti cinchona) liqiiidi
Aqunj...
... gr J.
51V.
... 5iij.
ttd 51 V.
Miitcc, fiat misturn. For a cbdld Ave years of nge a t«a.
Rpoonful (=TiT gi""'"} ""ly be given, in one or two of water,
avery three or four lioiin.
In urgent cases larger doses may lie given, and
preferably by hj-podermic injection, so as to ensure
a speedy effect.
ItilinlatioH of oiygun may l)e adminiKterod with
good eil'ect when signs of asphyxia a|)[H*ar, Imt to be
offtTtiml it must l>c given long and continuously.
Chap.V.|
BKOXC/fl> PxXVJItOfftA.
639
As canliftc stimulaiitji, r/firr iiinl rit//'i'iii.' iimv Im<
given hypo<lernucnlly, us nln-ftdy tni>iitiiini<<l in ti-<>uiiiit(
of loliar pninirniiiiiiL.
Alcoholic sliiiiiiliilwn will Ih< iiooJihI in niiwl uaai'i
to prevent prostration and niiiintiiin Iho stivn^tii. Ill
very youn^ uliildrcii 10 or 1") ilropn of briiiuly or
wliisky may be k'^g" '" "■ f"^ tonupcHinfiilN of hot
milk and water every hour, and tliin dowi iiiuy '"'
increased to half a toa.M|>i>(iiifi)i nr a teaMpimnful fcir
older eliildron. When collnpxe in threntetied, liriitidy
or wliinky may Iw given hyinKletinicidly, or, niixiMl
with some tluid foo<i, by tlio reuluiii.
The general liygienic RurroundiiigN of thi) pntioiit
must be carcfnlly att^-nded to. The air of tlii) NJiik
room must lie raised to a temjxirature of liotwnon (}ft*
and 70', and whilst good ventilation in provided, all
cold current* of air muNl \n: <<xcludi!d. The diffuMon
of the vapour of water throUKh thn room by nte»rM of
a steam-kettle xhould l>e xteoriily maintained ; and hy
intHMlucing a nmall pifH>o of »iKUige or a roll of
blotting'p«p<.'r iiioisten(<d with pinol or micdypt'^l
the spout of the kettle, an agreeablfl ftlM] UMul *'
■phere for the patient i« pr<HJueM].
The food tnunt be light and nenriniiinM; fMxl
brotlw, be«f tea, gra«l, niUc. whip|Md tfgt with mUikt
or whtj may be given. If tMrs •hoald tc aiMii
ytrir uritMi/ility, or dilBctilty in airaik;«r(iw, from
grant 45iya(iB% nat«inu ennoMte innrt b« admittM«rMi
Hw period of tmmvm9m*€Mme* maai b« «•!•>
faOy vnleftMd, mmI taidemAm to nUfms pmriti
althmfmril
■Vj f CWvwHIy MM I
«|iMi«iii ,^
640
Medical Treatment
iPiit III.
purpose is the lti/popfu>sphile of lime combined with
quinine, iron, and stryclinine. Arsenic is very useful
in some cases, and the arsenical water of La Bourboulc
we Imve found particularly valuable, given niplit iind
morning in dn.s(»s of four to eight taVilespoonfuls with
a little hot milk. ('o<l-liver oil is most useful in all
strumous cases and in cases of defective nutrition.
In summer, change to the grasitk and cautious bathing
with sea-water greatly favours complete recovery,
and in older children mountain air is often of very
great service, ])roraoting as it does a sort of pulmonarv
gynmiistic, and le«<Hng to more complete expansion
of the lung. It tends to favour the disai)peaiiince of
residual deposits and to promote the re-expausion
of collapsed portions of lung.
III. — Seoondaky Pneumonias.
These are apt to occur in the course of tlie acute
fevei-s and in the last stage of many chronic diseases.
These are not true pneumonias, but are either "'hypo-
static " and dependent on passive hyperieniia and
collapse, or they are local inflammations, set up
probably by the morbid, infective stiite of the blood
associated with the original (lisea.se.
There is little to be said with regard to their
treatment, which must necessarily depend greatly
on the nature of the disea.se of which they are
complications. They are usu.illy associated with a,
tendency to cardiac failure, anfl all those measures of
active stimulation which we have describe*! as tt|>-
propriate to the linal stages of the two forms of
pneumonia already considered will onlinarily be
applicable also here. At the onset of such congestive
conditions, warm mustard and linseed poultices are
often useful, or liot flannuls sprinkled with turpentine.
Ether, ammonia, bnrk, strychnine, alcohol, will be
found useful in most cases, atlministered according to
the dii'cctions already laiil down. I>igitnli3 may also
be useful in some instances. But it would Ix* nn-
scicntilic to attempt to dictate the treatment of one
Chap. V.l
Gascrens of the Lung.
641
i
of those Becoadary pneumonias, sipart from that uf the
co-«xistiiig original ilispiisR.
<iiaiiKrfii<> ot lli<* lung:. — It happens but rarely
that, as a result of pneumonia, a portion of the lung
tissue sloughs, anil this is evidenced by tlio expectora-
tion of intensely fu-tid sputum ttiiii the presence of a
horriljly fa'tid odour of the breath. Oangrene may
also occur from the Io<igment of septic eiolioli iu
the lung, or from other sejilie or mechanical injury to
it The object of ircalmi'iif, in sucii cAses, in
addition to supporting the patient's strength by
suitiible stimuhmts, fooil, and tonics, is to tlisinfect
and deodorise the sputum and the respired air. The
local use of disiufectants (vapours and sprays) and
the internal administration of antiseptics, which may
be i-liminated at the pulmonary surface, are the
remedial measures to l>o adopted. Nothing is so
suitable as the continuous wejiring of the open zinc
respirator figured at page bAb. The sponge in it
should be kept saturated with eucalyptol, or creasote,
or turj)ontitie, or terebene, or a solution of carbolic
acid with campdior or iodine in spirits of chloroform.
The patient should also be made to inhale freely,
from a steam spray-producer, a spray of a 2 to 5
per cent, solution of carbolic acid twice a tlay, so
OS to disinfect more completely the air-passages ;
oxygen inhalations have prove<l useful. Tlie vapour
of turpentine or eucalypt4)l slioulil also be diUuse<l
freely tlirough the patient's a[)arlment. Internally
capsules of creosote {1 to 3 minims) or turpentine
{b to 10 minims), or emulsions of these nnH.>-eptics in
combiniifion with quinine, strychnine, iron, and other
tonics should be given several times a tiay. Surgical
operation with the view of ditiining the gangrenous
cavity or area will usually be advisable.*
* See Fowlor uid Uodley's " Diauuses of tlie Luii|{s," p. ilti.
P I*
54*
Medic A l Tsea tment.
iPan III.
Al>l)ITIONAL FORMUL.^-:.
Digitalis ajid Ipecacuanha
mixture for pneumonia.
II r)i|;iUlis|iulTcri» liiujtr
Ipi'iTK'imuliii' pulveris I lij.
Ai(iiii', jvj.
(Mukv mi iufiiKion, and ndd)
Aipui' latiriM*rasi, >ji».
Syi'iijti iin'ti, ,^j.
M. f. mist. A UiMfiiiioonlul
CVW)' hour. (Iliimlmilil.)
To lower pulse and tempera-
ture in same.
H Smlii Koliiyliitif!, .*jii».
Syrupi simpliciis J».
Anna- uj jviij.
M. f. iiiisl. A lablHiiKifinhil
oviT)' hour. {Jtamlirrilfi.)
Chloral enema in lame.
11 f'lili.ml hvilriite. gr. xxx. «<1
»l, " I
M ucilnio'nis nrncM', Jitw.
A<|Ull', IJM.
M. f. dioiiia. (Uniultiytr.)
Mixture for catarrhal
pneumonia.
R Ammouii thlnritli, gr. Uxx.
Syrui»i willii' fr / wuopt', ^iij.
Ij(]tjnn8 tiinnjonii »cututi» ad
jiv.
M- t. mut. -A il>-««>rt»)>oon-
fill iu MaUr •■••
One or twii 'i '■
Koouilii iiiuy I ' 'j
du«<> ntrefully waU-hiUK Ute
vffect.
iia jiifc
Another.
It .\rauiouu carbonatu; gt.
xlvl
Murtlii(^iu acaciii.' I --
."•vnijii I
'I'iurtura' lavanduke cmn-
IHKiita', )ij.
Aipitc ud jiir.
M. f. mint. One teaspoonfnl
iu water ovfry two or thrv«
hours for u chilil three yviira
Another, if respiratory
failure threatens
U (Jniniuii' Kiilphittii. ;,t. xxlr.
Strvt'huiiiu*. gr. \.
A(.'uli hyilrochlurivt tUluti,
"I XV.
CilycrTiiii, >iij.
I.i<|^uni'is pcfiHiiiir od %vt,
M. t. luist. '■ • nftil in
watrr rvi'ri' t i imun
for II chihl Hv _'i'.
il'/iptr.)
Powders in catarrhal
pneumonia,
li Ilydnirgvri •*ulMhlorini,gr.J.
Sodii liir-iii'tM.niitiA, ^. xxiv.
M. It div. ill pulv. xij. tjiie
nr two ■.■very thn'u houn, until
till' bowels ore moved once or
twiiv.
Digitalis mixture for
pneumonia.
K S|)iritiiB nnifnouia.' am-
miitid. ;,•«.
Extructi digitalis fluidi,
.Mj»».
Olyccrini, q.s. a<l Sir.
M. f. nii.it. A tt';i.«]><Hiufu1
evi'ry tiirp** or ffiur ii'-nrn, to
Ik* iucreoAvd OS the ctuv may
reqture.
(Dr. a. J. Bmid.)
^43
CHAITKH VI.
THK TREATMKST iiK I'LKUniSIES.
CtnMtJirnttint of Plt'iiriidtw itCcnrdiiig U\ thnir Causation, CoursOi
anil liesulU.
Simpli Ihfi rtriiiiurt — Symptoins — Latent Apicnl PU'urisie* —
Tlicir Rccopnititm anil 8ipuifiei«nee — Treatment of Dry
rieuriKies— yVfii/iAiVii with ><t ni-fihiiH'Uii Htfiuum — («) Treat-
mritt of Cawcs with Small EflFuflionH- Let'chi'K— thiium —
Countor-im'tntiou— Cnld A|ipliooti<in« — Aju'iients— Dnirutic»
— AiitipyretiiS— (/<! Timtmnil ui Muilrriilrlii Lnn/r £iTuai<>Di
— Countcr-irritatiou— Mercurial Inuuctiouii — Limitation of
Fluids — Change of Air iu Chronic Ca»es — Milk Diet —
Diuretics, etc. — (r) Trratmrnt of /.aii/r EfTusiuna— Plinicsl
Sifrn*! — Pilocarpine — TfioriicettfrMm — Dangers of Delay —
ludicutioua for Oiierutiou — I'lincturo with Anpirittiun —
Apparntun- Metho<i of (Ipemting— ytrniMfioM necosnry —
Accident* and Dangers.
PhurtKirn with ISiruitnt KxudHtion--^*m;;j/f-fiia//f — Etiology —
Biictcrial Influence — Diognonis— Value of Eiploratory
Puncture — Mode.« of Termination — Posnibility of S]ioiitunaous
Alwfirption- t)i>enitiTo Muaiuren— Aspiration— Pleurotomy —
Simple Incision— Boaeetiou of Rib— Dmina^— Irrigation —
Antiseptic Dressings— Thoracoplasty. AiMitional Formuhe,
TiiK llicmpeutics of influtnmiitions of tlin pleura are
not grwitly deixjiitlent on etiologicul cuiiHidcratioiiB ;
they arp more directly coneerued with considerations
of the severity and course of each particular case.
Still, it is necessary to examine briclly the classiHca-
tion of pleurixies, both etioluf^ical and clinical.
Pleurisies have been dividwl into primary and
gPWT('inri/.
Primary acut« pleuritis has generally, hitherto,
been referred t« chill, and lias been looked upon us
related to rheumatic intluiuinatioiis. But it has been
suggested that " catching cold " does not of itself
expliiiii the origin of these cases. Cold, it is urged,
only )ire|iares the soil for microbic infection, and the
microljes themselves may reach the pleura, through
lymphatic channels, starting, for example, from the
tonsils. But this, at present, is only speculation,
644
Medical Treatment.
(Put III
while tliere can he no douht of the occurrence of
attacks of acute jileuritis after exposure to chill.
Many cases of pleurisy are certainly tubercular, but
it is an extmvagant conclusion to teach that they
are nil of this nature, ns some French authors do.
Seeondnry pleurisies may be excited by a variety
of causes. They may lie traumatic, and produced by
wound.s, contusions, and other injuries of the wall of the
chest ; they may accompany dUaisfs of the luitfft,
perieitrdiuiiijiand iin-iliiuiliuum, inflammatory or malig-
nant ; they may be due to morbid atat/'s of the. blood,
coiistilntioiud or infective, as in septic or urtemic
states, and in the tubercular, rhenmatic, and si/phililie.
Pleurisies may also be classilied according to their
course and results. They may be acute, sub-acute,
chronic, and latent, and the result may be an <id/wsive
exudation (lir^ pleurisy), causing adhesion of opposetl
surfaces, or a sero -fibrinous, sero-purnUnl, or
lurniorrhuijic Huid exudation (i)leurisy with elfusioD),
which may accumulate in the pleural cavity, and vary-
in amount to almost any extent.
The chief considerations which atfect the trnit-
■neut of pleurisies are (1 ) whether they are primnry
or secoitdary ; (2) whether they are attended with /?m»<^
or adhfsioe exudation (i.e. with or without etfusion) ;
(3) whether the effusion is sero-Ji(n'iuoiui or sero-
purulimt ; and (4) whether the effusion is siiuilf,
nwderate, or large in amount.
First, with regard to !aiiiipl<> dry plonriHieH.
In the.se cases there is merely inlliumiiiitory thicken-
ing of the pleura — due to proliferation of it<8 normal
connective tissue — and adhesion of its opposed surfaces
ns the usual result.
Some forms of drj' pleurisy are almost completely
latent, so that dry pleurisy hfis been said to have " no
symptoms," and adhesions of the entire ]>leural surface
have been found jHist-morlem in the iKnlies of persons
who never have been seriously ill.
Attacks of dnj /Jeurisij affecting the apex and
upper part of thn lung — i.e. those parts of the cheat
I
Simple Dry Plburis/es.
645
which are iiliiiost niotionlcss in orflindvy tran(|uil
breathing — are much more likely to be " latent " — to
pass nnobRerved — than similar nttncks involving the
lower and more movftble parte of the chest.
Scanty fibrinous exmliitions in the latter situation
are commonly nttt-ndod with the follovvinm' Kymptoms:
»/iarp jmhi.OT "stitch"' in the .side, on itiKpiration, or
on cdtighinw or sneezing ; fendTtifim on pressure over
ccrtuin ribs or interccstal space.s ; shaflow, cautious
inspiration, the Ixxly b<'ing usually inclined towards
the side affected ; rottgli may be present or absent ;
& /rift ion sound, or "pleuritic rub," can be heard ou
auscultation of the attectcd side of the che«t.
Tlie trontiiinit of ordinary uncomplicated ca.seH
of dry |)lt>iii'isy, affecting the loiver part of tlie chest
an<l iitfeiulcd bv tlie symptoms mentionetl, is simple.
If the jiuiji, "the stitch," is very severe, and if
the temperature is i-aiscd two or three degires, as is
frei|uently the case, a few leeches applied to the seat
of pain, followwl by a hot linseed poultice or a hot
c<jmj>i"e8s, is usually very efficacious in giving relief.
Some German phj-sicians iidvocatc the local a|ndi-
cation of cold (cloths wrung out in ice-cold water) in
such cases, but this nn'tluid is i-epugtiant to many
patients, and should the pleuritis lmv« a rheumatic
origin it might prove injuriou.s. Limiting the move-
ments of the ribs, etc., in breathing, by the firm
application of a flannel roller, nr a Viruad l>and of ad-
hesive j>laBter, around the base of the chest is valuable.
A few small doB(»5 of opium in combinafiori with
mild 8aline.s has an excellent sofjtliiiig and fnio<lyric
efte^'t in these cases of severe pleuritic pain. Tho
following is a good formula : —
19 Pulverig ipecacuanhfii compositat gr. v.
PoliiKsii citratiB gr. xx.
I.ii|nori!i amnionii acotntix... ... ... ^ij.
.\i(uni campliorii" ... ... ad ,^.
Mince. Iliit Iinu8tiis. To )>o taken ovory tfirou or four hours
until tlio pain ia relieved. In rhrumatic Ciises it miiy be nRrvicn-
Bbie to ndd 10 graliuof BlllicillCor •iodilllll Nillil-ylltlC
to each dose.
646
Medical Treatmf.at.
[Pan III.
The l)owels should in all cases be kept freely
relieved by inenns of 1 or 2 drnius of sodium siilph&t«
dissolved in 1 or 2 ounces of warm water the first
thing every morning. If the tonj{ue is thickly coRted
and the urine high-coloured, it will be advisable to
give also at iii;^lit a grain of calomel with 4 grains of
colooyntli and henbane pill. After the tkcutc- pain
has disappeared, und if friction sounds are still heard,
small (lying blisters over the seat of the friotinn or
rc'fM'atod npplications of iodine paint aiv of use.
Scjine physicians recommend the iminediat'- ajiplioitiun
of a blister, but we do not think this is desirable, as
most of these cases of dry pleurisy get quickly well
with the simple meAsures here descril)ed. The patient
should Iw, of course, confined to his ro<»m, and, if
there is fever present, to his l>t'd.
Tile irt'Hlnipnl of pleurisies with more or less
M'rn-flbriiioiiH pfliiKion must he to some extent
determined by the imidunt of the ellusion and the
interference with function produced by it.
The amount of eflusioii in these cases will vary
from a few ounces^ust enough to give rise to three
or four finger-breadths of clnlness at the base of tlie
chest: — to several pounds, Riling up the whole of one
side of the chest, compressing and flattening the lung
completely, displacing adjacent organs, and causing
serious dys]Mne,'i frum interference with the respiratory
and circulatory functions.
The treatment a]ipropriate to these varying con-
ditions must also vary. We pnjpfwe to consider : —
1st, the treatment of c^kses with amnU eflusions;
'Jnd, those with iiiodrriU<- effusions ; and
3r(l, tho.se with Idrgi^ effusions.
1. The treatment of cases of acut« pleuritis with
only a smnll tunount of Huid effusion, giving rise to
three or four finger-breadths of dulness at the base of
one lung, may Ih- conducted on much the same plan
as that of iwrute diy pleuri.sios.
At the onset of the att^-ick we shall usually find
more or leas fever, a temj)erature of 102' to 103*,
«p. Vl.l PLEURrStES WITH EfPUSIOS.
647
and more or \vm pain in tlie sifli; ; and tin' indiciitinti
for tnaitment is to relievo these syniptoiiis imd to
dimmish the intniuitif of (he ftlennil euijonjcinrtit, and
so prevent tlie further effusion of fluid or proinotv the
absorption of that already effused. Severe ;>rtin in
the siiJe must he met hy the application of six or
eight leeches, followeil by a hot linseetl (>ouItioe, an<l
tliiM suweeiled by a flannel bandiige applied tij;litly
rounfl tlic chest, so as to limit the respiratory
movements. If the |iain still continues, flannels or
spon^io piline wrung out in hot water, and freely
sprinkled with Inuilancini or ri|iiutu and l)ellailonna
liniiuetit, will lie useful. Re|ieiited niOflerale doses of
opium, internally, shouiil also l<e given to iillay the
distn^ss of breiithiiig, to etilm the patient, and to pro-
duce a sulijective condition favourable to recovery.
There is no doubt, al.so, that opium exercises a coii-
tn)lling effect over the capillary circulation in the
inflamed serous membrane, and so tends to moderate
the inttamraatory chanijeH. When there is much
fevor, it may be combintnl with milicin or nodiain
tnlieyltile and a saline diaplioretic, e.specially iii
rheumatic cases, as in the following formula : —
I^ Extmrti opii liqnidi
... nx.
Siiliciiii
gr. X.
I'otiKsii citnitix
gr. XX.
Liijuoris »nim<inii acetatifl
^i'j-
A<|u«>
ad ii.
iUnco, fiat hiiiistiiR. To bo tHken ovory three houm nntil tb«
pain is relieved.
It is desirable at the same time to obtain one or
two loose actions of the Iwwels daily, and this maybe
secured by giving the a|ieHent pill and the sodium
stdphate, as already described. The o|)iuui should bo
discimtitiued as soim as the pain is relieved. If there
is much irritative cough, it inity be allayed by giving
the ])«tieiita nntr|>hia an<l ipecacuanha lozenge tosuck
from time to time. As soon as the fever has subsided
— whicli will usually Iw in from two to seven days —
648
Mhdical Txeatment.
\V3.n III.
countiT-irritation should be Applied over the seat of
tho I'fl'usion.
The best fomi of coimter-irritation is the "yfytjijr "
blulcr ; i.e. instead of one large blister kept on for
several hour» over the same spot, repeated small
blisters not bigger than a crown piece are applied
in succession to diflereut, hut adjacent, parts of the
chest over the area of dulness, nnd kfpt on from two
to four houi-s, according to tiie effect produced, which
will vary with different patients. By the use of .small
blisters, retaioe<l for onlj a short time, we avoid ajiy
extensive ve.sication, a.s well as any renal or vesiciil
irritaticm in persons prone to cantharidism, anrl we
an) ena)jle<l to reapply thenj, after a short time, over
the same spot.
By blistering and by dry-cuppiiuf, which some
employ, we obtain a ])0werful derivation to the skin,
for they both ivct by dilating the vessels of the skin,
and so we diminish the over-distension of the vessels
in the pleura.
The local ajiplication of iodine is a valuable
measure, which acts similarly to a blister, iind is more
convenient in small effusions tending to become
chronic.
Of course, while there is any fever the patient
must be confined to bed, and kept on a light diet-, the
chief constitiients of which should be milk, gruel,
beeftea, light clear soups and broths, and eggs beaten
up with milk.
The uw of diiirolirs to promote the alidorption
of the lluid cH'u.sed has been atlvocated by some, but
little reliance is to be placed on them. Pottutsiom
iodide has, however, been found of value for this
purpose in cases of rheutnatic origin.
By measures such as these most caae.s of onlinary
pleurisy with small effusion in hralthy persons will
Hotm be cured.
It will Ix". siien that we have said nothing of the
use of general blfifdiittj, or of titrlar enirtn; or of
mercnry, in the treatment of acute pleuritis, and it is
Chip. VI. 1 Pleurisies with EpFVstoy.
liocause we do not consider tbey have any place in
the rational treatment of this disease.
Aiilipi/retivs, such as antipvrin, antifobrin, salol,
and phenacetiu, advocated by some pliysicians in the
acut« febrile stage, are rarely needed, but if the
temperature is unusually high wc see no objection to
a few 3- or 4 grain doses of phenacetiu given in
combination with 3 or 3 gi-ainti of hydrobromide of
qiiiniiif every two or three hours. We should not
continue the phenacetiu after the temperature ha.s
been reduced. The importance of allaying coti</h,
■which aggravates the pain of tlici acute stage so greatly,
has lieen dwelt upon by most writers; opium is,
kwe have .said, the best remetiy for this piirpos«\
The constipating ctlect of opiates should be anti-
cipated by the administration of an initial dose of
2 or 3 grains of calbmel, followed by a saline
aperient ; by thus getting riii at starting of all
accuinuhitions in the alimentary canal, we shall have
less lit'.silation in giving opium freely to relieve pain
and cough. A|M'rients should be repeated when
recjuiiTMJ, but we see no good reason for disturbing the
patient by frequent purges.
Tonics of (juinine or hark, l«)gether with strychnine
or inin, will bo usofui during convalescence.
2. AVe have next to cotinider the treatment of casus
with inod«'riHi»l>' InrK** eH'iision, with percussion
diilness, extending up t^, or a little above, the angle
of tlic .scapula.
Tlio .same plan and principles of treatment which
have just Ijeen 8ket<:he(l af>|)h' equally to these cases,
except that counlerirritation will probably require
to be more vigorouHly carried out and continued
longer ; and if the cUusioti lingers long, and shows
signs of increasing rather than diminishing, and is
uninfluenced by this t.rcatnu-iit, and e.specially if the
patient liegins to suH'er from dy.spiiu'a on slight
exertion, or his general health appears to l)e uttected,
then, even in the ciise of mwlentte effusions, wo may
wisely liave recourse to paraceutetis for the with-
Medical Treatment.
(Part III.
k««l of the fluid, or a portion of it ; for it is not
tinoit to find the withiliitwdl of even a small
'•(MAiility of fluid from the ph'uiiil cnvity to Iw
K«lK<wtHl lij' ni]«id al)sofpti()ii nf thf rt'mainder.
We sliould, liowever, be in no ii.i.st<?, in these (uses
of uiodpriite effusion, to advise paracentesis. Well-
dir»v»«d and rejieated counter-irritAtion, sometimes
iu tho Ibrra of flying blisters, sometimes in the
form of iodine jiaint, and sometimes, us su;^-
v^ytlod hy Nieineyer, the ruhljing into the chest of
half a dram of mercurial ointment* twice? daily, until
s*>mo slight eflect on the gums is pnxlucetl, will
promote the removal of the efl'usion, antl avoid any
necessity for an operation, which some sensitive
patients drea4i.
The fiisappearance of some of these modern te
pfl"usioiis iiiny U* promotetl by a strict limitjition of
the amount of fluid consumeil : only just suflicient
li(|ui(l Ix'inf; allowed the patient to prevent his suffer-
ing fntm thirst.
It will not iinfrequently hapjM?n that after a certJuii
amount of the effusion has disapjiearcd the remainder
will linger unaljsorhed and uninfluenced hy any of
our reme<lies ; in such cases it is often of great service
to jirescriho change of (lir, especially when the season
of the year is favourable. Removal to the seaside
will in some cases \m» attended with immediate im-
]irovenient, or, still better, ehiinge to a Swiss Alpitui
resort, where, in addition to the tonic effect* of fi-e.sh,
pure, bracing air, a certain amount of lung gymnastic
is imiuced, will promote the absorption of the lingering
exudation and the re-expansion of the lung.
Pleural effusions have l)een rejKirted as rii|iidly
disappearing under the diuretic influence of cnfr-ittf
comliinetl with sodium bcnzoate, alKiut 40 grains of
ejicli, daily, a-s-sociatfil with a milk diet. Tho
iulmiiiistrHtion of drastic, hydragogue ciitliarticK, like
elftteriuM, we oidy mention in order to ctmdenin.
• Fiiintjipl also advises loprcatia)
' Cyolo|Nedia," vol. iv., p. 086.
inuiiclioiut : /ienxMeu'l
I
Chap. VI. J FlEUKISIES H^ITH E FPUS ION.
65'
3. In the next place, we imist consider the treat-
ment of pleurisies with a Inrgc amount of stro-
Jibrinoug effusion.
The co-existence of the following physicKl signs
may bo regarded as indicjitive of the presence of a
large effusion in the jileunil cavity: — (1) VLsible
and measurable distension, with immobility of the
affected side of the chest (2) Absolute duiness on
percussion over a great extent of surface, frunt as well
as back. (3) Alwence of vocal fremitus over the
dull area, ax well as a sense of fulness and absence of
elasticity conveyed to the hand placed on the chest.
(4) Entire alwence of respiratory murmur on auscul-
tation over the greater jiart of the affected side. (5)
Considerable disjilacement of adjacent organs, of the
heart Ui the riglit or left, of the liver downwards
on the riifht side, and the spleen on the left.
It must, however, l>e borne in mind that a very
considerable effusion may exist without the co-exist-
ence of all tlx^se physical sign.s, and we must, thiTC-
fore, attend to such evidences as may be furnislied by
other symptoms, such lus great dy.spnwa on making
even slight movements, cyanosis, evidenix' of cardiac
feebleness, and distension of the right side of the
heart — as a small irregular pulse, palpitiitton on any
exertion, scatity, iiigb-colo\iied urine, etc.
We must also Iwnr in mind that the largesteffusions
are often found in casus in which the symptoms develop
slowly and in an almost imperceptible numner.
In the mamigement of larf/f effusions during the
early febrile stage the same measures maybe adopt<.!d
B8 we have described as a]>plicabie to the treatment
of small and moderate effusions, and if we see any
signs of diminution in the amount of the fluid effused,
we may ])ersevere with these measures, and wait
{Mitiently for a further subsidence of the exudation.
There is no occasion for alarm or huri-y so long as no
serious signs of circulatory or re.Npinitory failure make
their appearance and no great amount of cardiac tJis-
plactrment is detectable. But if after the febrile stage
652
Medical Treatment,
IPsrt III
liius ])ii8se(i away, and at the end of the second or third
week of the ilhiess, there still remain the evidences of
a large effusion which shows no sign of diminution, it
will lie rarely raivtsiible to waste time in further mndi-
cinal treatment. The hy]'oderniic injection of Jth of a
grain of pi/ucarphir: has been advised in the treatment
of these large effusions, the profuse diaphoresis and
salivation thus jirothicetl having been found, in some
iuHtuuces, to favour the disappearance of the exudn.-
tion. But it must he rciiieml)ertNl that pilocarpine
jiroduces serious circulatory depression, and w)iei«
there is no particular reason to fear the effects of
puncture of the pleund cavity we should Iw disposed
to prefer it. While we are by no means diBf>ose<l to
advocnt<! liasty or early resort to paracentegis thoracit,
especially in cases in which there appears to be a
reasonable chance of removal of the effusion by absorp-
tion, we are nevertheless avoi'se from unnecessary
waste of time in the application of inefficient measures
for the removal of a large effusion, atu-nded with
serious respiratory trouble, or of long duration, and
which shows no signs of disappearing. The incon-
veniences and dangere accomjmnying such delay are
not imaginary, while the operation of puncture with
or without aspiration, periformed with the precau-
tions and care we shall immediately insist U|X)n, is
one of the simplest and safest possilde. No doubt tlio
o]>eration when first introduced, and when perfonned
with insutticient cai-e, caution, and skill, was not u»-
frequently atten<led with certain drawbacks and
dangers, Imt these are rai-ely heard of now.
Delay in the removal of some portion of an exten-
sive effusion may be attended by serious resiilts. Not
only does it lead to over-di.stension and enfeeblement
of the'right side of the heart and hypernsniia of the
opposite lung, not only is there some risk by un-
reasonable delay that the compressed lung nmy become
bound down by firm liands of lymjih, or become the
seat of fibroid changes, and so l)e prevj-ntwl from re-
expansion, but tlie danger of sudden death from dis-
Clap. VI. 1
THOKACEirrssis.
6S3
pliiceiuont of tlie heart when the fffusinu i.s large and
situated on the b-fl side must he borne in mind.
As we liave already said, we should not Ije in haste
to puncture in rvceul elfusion, even if e.xtensive,
although early puncture in the febrile stage has had
many advocates, and even so careful an observer as
Potttin has seen no objection to thoracentesis as early
as the second or third day : but we do not consider this
operation juatitied during tlie febrile jieriod, unless the
eflusion is so lur^je and the interference with i-espira-
tion and circulation so great as to endanger life ;
then, of course, there should lie no hesitation, and
the pleural cavity should l)e at once punctured, and a
certain amount of the ellusion withdrawn.
We may conclude, then, that llioracenlcsis is
indicated, whether in the ucui': or chfonif. stage, when-
ever tlie effusion is so large ns to interfei-e seriously
with the functions of respiration and circulation. It is
als<i indicated when the ellu.sion is consideralilo and
shows tio tendency to diminution with other methods of
treatment ; aiwl it is also in<iicated when the effusion
has existed so long that there is danger of the lung
remaining jieinmiientty compres.sed and inexpansible
unless the jnessure upon it br ruuioved. The existence
of etlusion into Irath [ileunil cavities may also point to
the need of withdrawing a portion oi the fluid from
one, an expetlieiit which will oft«n \>e followed by the
absorption of the fluid in the other.
When we advocate thonia^nUiris for the relief of
pleuritic effusion, we refer to the combination of
lutpiraliofi with puncture, as is now usually practised.
The appanitus necessary for this openition is ipiite
siuiple. We need (1) a small trocar or a hollow, sharp-
fwinted, (|uill.8hape<l ueeille, for piercing the chest ; (2)
an exhaust(>(i receiver — any ordinary Uittle or Ihisk
will do ; (3) an exhausting syringe or pump ; anil (I)
air-tight tubes connecting these. The use of hollow,
sharp-jtointed needles is very common in England,
but wo consider the objection made to them a valid
oae — vix. tliat there is a danger, as the lung expands
i''iiiiriiii(iiiMii iiii'
654
Medical Treatmekt.
(Pan III.
at civcli inspimtion, of its surface becoming woundfHl or
irritiited liy contfict with the poititedendof the needlr.
The most suitable and convenient form of apparfttiis
for the pur|H)8e of thnnicentesis is that known x
Potuin's. The nccoiiiptinying Hnvwing (Fig. 17) show*
tltc appiiriitiis in use, and nr-eda little explanation : —
Fig. 17.— PotAin'a Appontos for ThoniMDUns.
H is an onlinary Ixtttle or Hask, in which a Taouam
in inadt" l)y the oxhiiiisting syringe a. 0 is a tube
connecting the exliausUxl receiver with the trocar,
which is used for piercing the chest wall, and K is the
. stylet withdrawn from the cannula u, which can be
re-iiitro<luced Hhould the latter become obstructed
iluring the exit of the effusion.
The trocar und nee<llea vary in size. We prefer
the tmollfT ones, as we.jffiEJitly object to the rapid
evacuation of the fluid," ^v larger instruuiciita
I
Cliap. VI. I
THORACEIfTESlS.
6SS
oncouriige, and whicli was, we liclieve, together witli
want of suflioicut cU'anliness, the cause of most of the
dangiTS which liave been (lescrihed as attemliiig this
operation. Witli a small trociif the operation Ls
less painful and less di-eaded hy the patient. All
that can be said in favour of the large hollow
needles, which we have oft<in seen used, is that tliey
save the time of the operator ^au unworthj' considera-
tion, which shunld never bo allowed to weigh with us —
and are less likely to be obstructed with fragments of
lymjih tloating in the pleural eft'usion. But in Potain s
apjwnilus the cannula can readily be cleared by the n?-
introduction of the stylet. We have seen the large
needles also become blocked, and in that ca.se a fresh
puncture has to be made. A ti-ocar with a diamoU'r
of y', th of an inch is large enough.
It is of extreme importance to examine every part
of the apparatus l>efore using it — to ti'st the stop-
cocks, and to see that the tulies and needles are (|uite
clear. It is also of the very greatest consequence that
every portion of tlx; apparatus, and especially the
trocar and cannula, should be ]>ei-fectly asfjHic. It
WHS undoubto<lly owing to a disregard of antiseptic
precautions that to j)uncture and aspiration was
formerly frei[U('ntlv attributed the conversion of a
serous into a |iiu'ulfiit edusion.
The i)uncturiiig part of the apparatus, whether
needle or trocar, should be washetl «'ith a 10 per cent,
solution of carbolic, and afterwards ilij)ped in alcohol
ami passed through the flame of a .spirit-lamp, and
some warm 5 j»er cent, carlxilic solution should be
a.spirate<l through the tubing attached to the troc«r.
The part of the chest selected foi- puncture should
Ite ole.'insed with soap and water, and tinally wiped
with cotton-wool soaked in an alcoholic solution of
carbolic acid.
As to the best place to make the puncture, opinions
differ .somewhat, but there is a certain consensus of
opinion in favour of the axillary region, and the par-
ticular intercostal place selected must depend on the
656
Medical Treatment,
IPixl \\\.
iinioinit ut' the effusion ; on the right side, the fifth or
sixth interH]iuce, am] on the left siile, the sixth or
seventh nmy, as a rule, Le sjifely chosen. Wc are
accust4.iuied to iulroducu the trocar ab<jut an iiueh in
front uf llf poHerioi- nxiUary line and into the inter-
costal Kpjice wliicli lies just below the angle of the
Rcapiila, when the arm is advanced and drawn across
the chest, as it slioulj lie for this (jperatiun.
This situation has these advantages : —
(a) It is easily found.
(6) The patient is able to assume a comfortable
pasition, and one convenient to the operator — i.n.
raised in bed on pillows, with the arms crossed on the
chest.
(c) The patient does not see the puncture.
{it) If we go nearer the spine the intercostal sjihcss
become too narrow, and the wall of the chest Ls thicker
and more ditKoult to pierce through, and the position
is not so convenient to the patient or the operator.
(«) You run 111) risk of wounding any important
organ.
You must feel for the dejireasion of the intercostal
space with the point of the left index tinger. This is
somewhat diHicult with stout piitienta. Then, sup-
porting the trocar, which should \ii: ])reviously dipped
in carlwlic oil and Ijegrasfietl firmly by the righthand,
against the left index, you thrust it(|uickly and firmly
through the intercostal Sfwce into the pleural cavity,
taking care to avoid the situation of the intercostal
vessels and nerves which lie under the lower border of
the rii) above. The skin, it' it should appear to be
very thick and tough, nmy lie divided by a. slight cut
of a knife, but this is rarely necessary when using a
small trocar. In sensitive patients it is advisable to
aniBBthetise the skin before puncturing, and this is
beat done by the hypodermic injection into the sub-
cutaneous tissue of a few drojw of a 5 per cent,
solution of cocaine hydrochloride. If the trocar should
unfortunately come aguinst a rib, it must l>e partially
or wholly withdiawn and rc-introduced.
^^^^Ch»p. Vl.]
TnOKACElfTESlS.
6S7
It is a gooH plan to tell the patient to take ii flepp
inspiration and hold his hreatli for an instant when
you are alicint t^> jiuncture. The int«rcostal spaces
are thus expanded.
After the intrtxiuclion of the Inx-ar the stylet is
withdrawn and the tap of the trocar closed. At the
saiue time you open the tap connected with the
exhausted bottle, and the liquid flows into it from the
pleural cavity.
It will sometimes hapjien thiit the cannula nr
needle Iteconies blocked by a \'\»y^ of false membrane,
which has been .sucked iuln it fmm tli- [deiiral cavity,
and which prevents the (low of lluid (hrouj^h thi' tul*.
To reniovi! thi.s, the trocar is again p;is.sed through
the cannula, or, when a neeflle is used, a blunt-pointed
plunger, whicli is connect«Hi with some needles, is
pas.se<l through the tube of the needle to clear it.
Some think tliere is danger, in doing this, of intro-
ducing air into the pleural cavity, and prefer to make
a fresh jmncture : but it must be reineralMjred that,
tritling as the operation of puncturing the chest may
seem to the openitor, the patients themselves par-
ticularly object to it, and there is always a tendency
ill the patient's mind to believe there has been .some
bungling on the part of the operator if the puncture
has to be repejited ; and if cai-e be taken to have
a close-fittitig plunger or tr«)car, well oiled with
carbolic oil, and if the apparatus is refilly well made,
there ought not to be any danger, on re-introducing
the trocar, of admitting air into the pleural cavity.
It is not necessary, nor is it usually advisable, to
withdraw as much fluid as you can from the pleural
sac. Indeed, it is rarely desirable to withdraw more
than SO to 60 oz. at one asjiiration. For it has Ijeen
often ob.served that when aspiration has been carrie<l
to a greater extent than tliis, tlie patient, on returning
to tlie horizontal position, ha.s been seized with
violent and persistent atta<'k8 of cough of the most
<li.stre8sing kind. This is ul! the more likely to occur
if the fluid has been withdrawn rapidly. If it is
658
Medical Treatment.
ytan III.
wisheti, for any reason, to remove a considerable
quantity of fluid at one aspimtion, it should be done
very slowly und with interruptions, so as to allow of a
ffradnal return of the coinpressed lunj? to the altered
physical conditions.
We have always been in the habit of terminating
the uspirution at once if, after the withdrawal of a
certain amount of li<]uid, the patient begins to have a
troublesome cough* or to conijilain of severe pains
•within the chest. It is certainly moat undesirable to
remove a large quantity of fluid wry rnpidly, so as
to expose the previously conipres.sed and displaced
viscera to 8u<]denly altered physical conditions ; by
using a fine trocar, and by occasionally interrupting
the outflow by compressing the tube connected with
the pleura, we avoid a too sudden disturliance of the
pre-existing physical conditions within the chest. It
has also been observed that jirofuse expectoration
of albuiniiioiis Jluid sometimes follows a too rapid
removal of a large mass of fluid from the pleural sac,
and this has been shown to be due to sudden conges-
tion of the previnusly coinpressed lung, the vessels of
which may well have lost some of their tone and
natural physical projverties, after long compression, so
that on the sudden re-entrance of blood into them
some of its albuminous constituents are allowed to
escape through the vascular walls.
In certain rare cases of sudden deatli after
aspiration, tins hiis been thought to be caused by
sudden cei-ebral, and especially bullxir, ana-mia, due to
the afflux of blood to the liitlierto compressed lung.
It is a goixJ plan to gi\o the patient a little brandy
and water liefow the operation, and to rej.K-at the
dose, or, if necessary, give some ether and ammonia
during the operation, especially if any feeling of
faintneiis is complained of.
* The tiM! nf a tniinonieter to iiiUiinte the nmoutit of ttitm-
plpurnl ffimicni in iiii uiiii«<c«»arj- romilicatinii of the opemtiim ;
uuil wo iif^'C with Si-Jtrcibcr thnt "th(! )thy«tiologitjil }»henumriui
wliich promptly iiulicntv the existence of JniifteruuH tviiiduu-
rcdurtioii oru i<ven aofer iudiocs thui the mtuiometcr."
^^Chop. Vl.l
Thoracentesis.
6S9
Having withdrawn the iiccos.snryi^uaiitity of fliiifl,
the cunnuhi or neodlc shouki Ik; ri-iiioveil jjently,
ooniprcssiiig tlie ijkin arouud it with thi- Kiigcrs a»
you do so, so tliat no air fthnll entin- the i-huut ; and
then a pledgt^t of lint, dipped in collwlion, should be-
at once appli<'d over the jmnoture, which should be
covered with another fold of lint iixin] with a strip or
two of udhusive plaster; a. tlatiind bandage should
then be applied tightly round tije chest.
Wc fmve been accustomed to apply, after aspira-
tion, a liroad piece of adiiesive plaster very iirndy
round the atfeote<l side, so us to restrain as much as
possible the respiratory movements of the chest wall
and to keep the lung at rest, and to prevent any un-
pleasant eliectji after the operation.
A poi-tion of the eflusion Imving been rtJUioved by
Hspiratioo, not nnfrei^nently the remainder is ab-
sorbed ; or the level of (he rtui<l in the pleura may
remain stationary ; and in order to promote its
alworption we may have to employ connterirritanta
in the manner already de«cribe<l in s|K>aking of the
treatment of moderate and small cfliisiuns.
( *r the lluid may slowly re-ticcumulate and neces-
sitate another aspiration. But if the Huid re-
nceinnulatrs rapidly, it must be borne in mind that
its re-acciinmlation may Ik- due to the fact that the
compressed lung is bound down by |H.>rman<>nt bands
of false membrane, and cunnot expand when the lluid
is withdrawn. In that case, to continue withdrawing
the Huid by aspiration would simply exhaust the
patient, as we should be repeatedly draining oH' the
serum of the blood into the ])leui-al cavity.
It is advi.sable, IxTon; resorting to aspiration, to
make sure that the diagnosis is correct, as well as to
ascertaiu, with certainty, the nature of the exudation
we have to <ieal with. For this purjKise an exploring
puncture sliouhl be made with a hypodeimic syringe,
provided with a rather long an<i stout needle. After
carefully cleansing the neetlle with carbolic solution,
it should be introduced into the chest (the surface of
66o
Medical TuEATttSNr.
irui in.
wliich has also been made aseptic), below tlie level
of duliiHH4, and if tlien the pistun of the syrin<,'e be
drawn up, tlie barrel <if the syringe will become tilled
with tluirl, and you can see whether it is serous,
or purulent, or hieniorrliajiic. The working of the
syringe must Iw tested beforehand, or the t«8t may
fail simply fi-om the <Iefective condition of the
syringe.
If iifti'r aH|.iratioti the juitient is troubled with
cough, small di.ises <if tiiurphine — „',th of a grain —
in half an ounce of chloroform water, should Iw
given every hour or two until the 8ym|itoni is
relieved. VVann milk and seltzer or Apfillinaris
water, with a little brandy or whisky, every few
hours, will also contribute to relievo this cough,
which is probably often due to the presence of a
little iKlhesive teniwious mucus in the long-com-
jiresseil bronchi.
Much was written formerly about the dangert
atteiiditig the operation of thoracentesis. We have
already ailuiied to one of these, viz. the occurrence of
albniiiinou^ ej-fM^Honitinrt. This occasionally assumed
serious proportions, and was due to inten.se con-
gestion of the previously compressed long. This
accident was undoubtedly caiLsed by the too rBpid
withdrawal of too great, an amount of Huid ; and, as
has lieen urged by Dieulafoy and other experienced
physicians, it is of the greatest impiirtance not
to withdraw large amounts of fluid at one sitting,
especially in old cases where the lung has been
long compressed.
Other dangers or accidents cite<l by authors are :
wounding the intercostal vessels, injury to the fiU,
puncture of adjacent viscera, liver, sjilcen, anfl heart,
failure to withdraw fluid owing to plugging of needle,
aalmission of air and conversion of a serous etfiusion
into a purulent one, production of serious paroxysms
of cough and severe intrathoracic pain ; all these
dangers and acci<lent« may be avoided, as we have
shown, by caution and care in the performance of tbej
Chap. VI.l
Empyemata,
661
o[>ei'»tioM anil proper nttention to the fitness of the
iiiBtruHientB employed.
The Irmliwnt r</ puriilfiit 4'iriisioiis must next
occupy our attention.
This form of plouritis is far more common in
childhood than in adult life. It often occurs then as
u com plication of broncho-pneumonic attacks, or in
Rssociation with measles or scarlet-fever, or other
infective uudadies. It also occurs sometimes in the
puerperal state, and is not rarely depiondent on
pulmonary' tuberculosis. It may have u more or
ie.s.s olivious local origin, as from abscess in tlie chest
wall, due to disease of bone opening into the pleural
cavity ; or the same may happen witli an heftatic
abscess or a hydatid cyst ; or it may be associated
with intrathoracic cancer. It would seem at times
as tlioiigh merely a low, depressed state of the
general heallli deU-rmiried the purulent transforma-
tion of a pleuritic exudation, .so that it may result in
this way from a ])riiivarily serofibriiioiis effusion.
It has been maintaine<l that jyrimitry purulent
jileurttis is e.rlr':iiiehj rare, and that, in almost every
case, the effusion is at first sero-fibiinous, and Ix-comes,
for some reason or other, suliseiiuently purulent
Modern bacteriological research traces the origin of
pttntlent (deural exudation to the influence of pi/oyenic
micro-organisms. The serofibrinous exudations, it is
said, are the result of tho action of non-pyogenic
micro-organisms, whereas the aent-puritlent exuda-
tions are determined by the i»rcscnce of pyogenic
liiu'teria ; or both kinds may be present, giving rise
to a tuijred infection.
Pitrulent pleuritis niay, we are also taught, vary
in its characters and tendencies, and, therefore,
in the therapeutic measures most suitable for its
relief, accoi-ding to the particular varioty of jiyogenic
microbe associated with its origin.
The most anieiiiible to treatment are those — and
theyare the great majority — causeil by thepneuniococci
(Diplococcus pneumonicus) ; they are usually connected
662
Medical Tkkatmekt.
\t%ntn.
witli attacks of piieunmiiia, and are moat frec{nent
ill the pleuritic etfusions of diildbood. This micro-
orgaiiiKin is L-oni]iarativelj )>enign in its tendeucic«,
mill siin(>le citpiratioii is often Nullicieut to effect a
cure of the einpyemata caused \>y it. The physical
chamcti-rs of this exudiition are the following : it is
_/(6r/ji«-jiunilent, ha\ing a large quantity of fibrin
in suspension intheforiuof flakes or false nieoihi'ones ;
it has a slightly greenish tinge, is odourless, and is
more fluid than ordinarj- pus.
The Streptococcus pyogenes appcuuns to l»e the most
coiutuon cjiuse of enipvcinata in ivdults. These micro-
organisms have a progn.<8!nvoly destructive tendency ;
they are never spontaneously alMiorbed, hut must be
treated by free incision and <iniinagc, with strict anti-
septic precautions. Tlii.s form of pus is found in the
onipj'ciuata associated with infective diseases, scarlet
fever, measles, pywmia, etc., or which follow tht-
puncture of scro-filirinous effusions with instruments
that arc not aseptia It is usunlly of a greenisli
creamy iLspect, thicker than the jireoeding, and may
be darkonifl almost to a chocolate- colour by an
admixture of re<l blooil corjiuscles. Then Uicre
are the putrid and i/aru/r<-iioua varieties, due to
the presence of snprop/ti/lu- organisms, and easily
reooguiseil by tlieir odour and aspect ; these forms
require not only aseptic plfiirotomi/, but also ntUi-
septir irrigatunu.
Finally, there is the luliercvUir variety, charac-
terisefl by the presence of Koch's iHicilbis. This form
of ]>us Ls not easily identitied, especially as it may
also contain pyogenic micro-orgiinisni.s, and a search
for the tithfirde bacUlut is more often unsuccossful
than successftd.
Are there any signs or symptoms by which we can
del'^miino that a pleuritic'exudution is purulent ?
The i)hysical signs are the same as when the
effusion is serofibrinous, but it is commonly stat(>d
ua n mark of distinction that in cases of empyema
there is lednnin of the wall of the chest ; this.
however, is cerUviiily as often alfsent ns present in
such coses. Greiiter intensity and lunger duration of
ptiiii arc also naid to diatinguisli purulent and tuber-
cular from serous eflusions.
Better and more reliable evidence is the continu-
ance of fever, which tissumes a hectic type. When
the subject of an effusion into one or other pleural
cavity continues to present the symptoms of a certaiji
type of fever — a temperature, with considerable
diurnal Hiictuations, rising in the evening and falling
towiird.s the morniii);, t^jgether with occasional shiver-
ings and sweatings, a hectic flush on the cheeks, or an
unhenltliy, muddy complexion, with loss of appetite,
einiiciation, etc. — in such a case we may ju.stly suspect
that the effusion is purulent. If any doubt remains
in our minds as to the natur« of the effusion, it can l>e
rendily removed Ijy a simple e.\plorat<.iry putii-ture
by mi'itns iif a hypodermic syringe
This simpli! and almost painless means of estali-
lisliing our diagnosis should always be employed.
It is as well to make the exploraU>ry puncture,
unle.ss there should be any reason to the contrary,
in the same spot that will Im; ufterwanls select<Ml
for the radical o|>er.Htion, sliould this be ulfi»iati.»ly
recpiired.
Iktfore we consi<ler the best means of dealing with
such an effusion, it may ))e as well to inquire what
lia(i|)i'iis when such an effusion is loft to itself.
In till! first [ihice, it may cau.se necrosis of a small
portion or s)>ot of the pulmonary pleura, aiul .so lend
to a cnmmunicivtion between the pus in the pleura
and the air-pasiMgus, through which the pus may
from time to time be discharged in large or small
quantities.
In such a case a fit of coughing will sometimes
be accompanied by a profuse discharge of pus from
the pleural cavity through the niri)a.s.sages. If this
pus has an offensive putrid orlour, it shows that air
has (irobably passed into the pleural cavity from the
lung thixtugb the necrosed 8{)Ot in the pulmonary
664
Medical Treatment.
(Pirt HI.
pli'unt, .-iikI that a pyopneumothornx liivs heconie
esUbliKlifd. If tlie jius expectorated is sweet, it
shows either that tho opening' into the lung is of such
a nature that, ulthuuglt it admits of the passage of
fluid from the pleura to the iiir-pussages, it does not
admit of the passage of nir from the air-cells into the
pleura, or that, as Lord Lister maintains, the cilia
of the air-passages are able to prevent the entrance of
putrefactive organisms into the doep portions of the
lung.
It is possible for an empyema to Ix-come cured by
such a mode of tennination, but such an occurrence is
extremely rare.
In the second place, the jina may, after necrosis of
a portion of the pleura cosktli», penetrate between the
muscles of the thorax, and i>oint externally, appearing
under the skin as a tumour of variable size, usually
near the slernum, about the fourth interspace, where
the Willi of tlif t'licst is thinnest. If this burst, the
external opening is found usually to communicate by
a fistulous tr;tct, which may be three or four inches
long, with the opening in the pleura. Through this
opening pus will continue to discharge for yeura, and
often gives rise to caries of the ribs. In either of
these modes of discliarge of an empyema a fatal
ter mination may almost certainly be ultimately looked
fori probably after many years of illness and suffering.
These are the cises in which we encounter such
remarkable deformity of the chest and spine, owing
to slow and continued retraction of the walls of the
pleural cavity.
There is, however, a third mode of termination
certainly jMjssilde in very young subjects, and that ia
disappeamnci! of the etTusion by ahmn-iilwH. This
has bern occasionally observed in childhood, but it is
a rnre occuni-nce ; indeed, it never occurs when
streptococci, staphylococci, or tiibei-clo bacilli aro
present in the morbid exudation, owitig to the
resistant vitality of the pyogenic bacteria.
What Ircatini'iit should Iw adopted in dealing
^
Chap. VI. 1
Empyemata.
665
with these cases of purulent efftision into the pleural
cavity '/
III the ca.«!e of younf; cliilrlren, when tho fHusiou
is moderate in aitiouiit, ami the genenil health i.s fairly
well maiiitaiiKnl, we must hear in miinl the possibility
of spontaneous cure by absorption, and not Ije in a
huny to iwlopt operative measures ; esjjooially if on
examination of a portion of the pus witliflniwn by
exploratory puncture with a hypodermic syringe,
we find that it is caused solely by the |)resenc'e of
pneuiiuicacci, and that there is an absence of pyogenic
organisms.
If the empyema has communicated with the air-
passages, and pus is being ex[)ector:ited. and that pus
is sweet, not oH'ensive, it is well to wait for a time
and see if there is any tendency to spontaneous cure,
but if the general health is failing, or the expectora-
tion is fretid, it is l>est to operate.
What kind of operative procedure should be
adopted f
Tn most recent cases, and especially in the cases
of children, it is advi.sable to remove the pus once or
oftener liy /ispiration. In sevei-al instanci-s in the
case of childr(Mi aspiration has been followed iiy cure ;
sometimes even after a single aspiration, but more
commoidy after three or four.
Aspii-ate then first in all cases of young subjects,
and if the effusion re-accutriulates slowly, and is of
thin and sero-purulent aspect, repeat the aHi>iratiun ;
lint if it re-accumulates rapidly, and is ihivk, it is
best not to aspirate more than twice or thrice, but
then to have i-ecourse to free incision and dniimoge.
There is a distinct advantage in aspinititig, at least
once, iK-fore having recounto to incision, for the
pleural surfaces, which by this measure are brought
into contact, may become luihereiit to sonio extent,
and the ad lip-sions tlius formed between the jjuhnonary
and costitl pleura contrib«t»3 to a favounible result
after incision, as they leave a less extensive suppurate
ing Burfnce of pleural membrane.
666
Mrdicai. Treatment.
IPart III-
In liy fur tln^ great majority of cases of empyema
it will 1m) necessary to niaku a free opening, with
strict antiseptic jirecautions, into the pleural ciivity
(pleurotomy), through which the pus may be dis-
charged and free drainage of the pleunil cavity
luaintiiined.
The next (|ur'fitiou that arises is, Where is it best
to make thiif iipcnin;;? And then another (juestion :
Ih it U'st simply to make an incision tlirough au
inU-rcostal space or to remove a jwrtiou of a rib I
The axillary i-egion ia a convenient one for this
opemtion, iis it im'olvcs no disturbance of the
patient's position when sitting up in tied ; it is also
convenient for the intro<luction and removal of the
drainage-tubes, and it ia not pressed upon when the
]mtient lies down, as an opening farther back would be.
If a portion of rib is excised, the sixth, seventh,
eighth, or ninth, according to circumstances, may l>p
8eh»ctfd in the niid-iixillary line.
It is advisable to iivnid making an opening too
low down, as the diaphragm soon rises and conies into
contju-t with the wall of the chest, and so might
interfere with etlicieiit driiiiiage.
If, as occasionally happens, an accumulation should
collect at the base, a 8ulKiei|uent incision may be made
behind, in the tenth or eleventh intcrs[Nice.
If a spontaneous opening has already been made
by tlie pus working its way to the surface of the
chest, it is .-idvisuble to make use of it, but if in the
front of the cliest time would probably In; saved by
making a counter-opening behiud and {lossiug a tul>e
through.
The jidvantages gained by excising a portion of a
rib are tht'se : in the tii'st place, you obviate an in-
convenience that sometimes arises from simple incision
when the intercostal spaces are nan'ow, for as the
chest wall falls in they become still narrower, and
you may find, after a time, that it is impossible to
intro<lucc a drainage-tube. Secondly, by excisiug a
portion of a rib you are enabled to exploit; the pleural
Omji. Vt]
Empysuata.
667
cavity witli tlio fin{;i'i", mid somotiinea ili^lwljje large
miksses of cMirdy tiiiiloriiil, uiifl secure clKcieiit clrninnge
throughout the ]iix)grefi8 of the case.
Simple incision is usually sutficient in children,
and ill some recent caseii fur udults, l>ut in chronic
c&ses, in which the lung is Wind down by adhesions,
and is not likely to expand rejulily, or wlicre contrac-
tion of llie chest hiui brought tlio ribs close together
and narrowed the interspaces, or where preliminary
a.s))iratioii shows the pus t^i U.' putrid, resection of a
portion nf one or more ribs should be detcTinined on.
Hut wlicn the intercostal spaces are wide, and
when the incision is made in the front of the chest, a
simple incision in an intercostal space is usually
odeipiati' for tlie purpose.
In making a simple incision, perliitps the best
situation to select is the eighth or ninth intercostal
space on the left side, and the seventh oi' eighth on the
right, just in front of the jjosterior axillary line; the
skin in this region must 1>o thoroughly cleansed and
disinfectefl. The skin is iK-st pre|Miit'd by thoroughly
wjisliing with warm wat<^r luiil ( ierniau green soiip, then
ether or alcohol is nsed to remove the fatty matter,
and linally, a hot sterilisefl towel, steeped in 1 in 1,000
snliliniiite solution, is laid over the seat of O|)en»tion.
The hands and nails of the o|)erator should l>c
scrupulously chained and brimhed in the manner
recomniende<l for the patient's surface. The instru-
ments should be dipped in a pircelain pan containing
5 per cent. cjvrlx)lic solution. Treves atlviscs cliloro-
fonn OS an nniesthetic, and in children it is practi-
cally imiK>saiblc to operate without a general anaes-
thetic ; but in certain cases in adults, where there is
much exhau.stion, and when simple incision only is
intended, local anwwthetics may lie safer. Dujaniin-
Heaumetz recommended tlio injection at eiu^h end of
the line of the proposetl incision of a few rintps of a
50 per cent, solution of hydrochloride of cocaine, so
that the whole of the sul>cutaneous cellular tissue
witich is to be incised should be bathed for four or
668
Me Die A L The A tmen t.
IPart III.
five minutos in tlio solution. " An incision from
1 1 to 3 indies in length is mnilc transversely, so a«'^
to correspond to the upper bonier of the lower rib
bounding the space. The intercostal niu.scles are
divided close to the rib ; a director is then gently
thrust through into the pleural cavity ; the opening
iiiarti- is subsefjuently enlarged with dressing forcejw
mid the tinger. The pus, if considerable, should I*
allowed to esim])e slowly. The abscess cavity may be
examined with tlie forefinger as the fluid is escaping,
or after it has been entirely evacuated. All thick
curdy material withiu reach of the finger should be
removed."* A short length of common drainage-
Pig. 18.— C»l>ol'< Folrti-il l>niii»j;i''liib« for Enipyeion lu ClillJnn.
tube, which should lie large and not too stifT, should
1k' introduced and kept in during the earlitT days
of after treatnvent. "Later, when the cavity ia con-
tracting, a bent rubljer tube, like a soft tracheototny
cannula, answera the purpose." The droiiiuge-tube
must lie rare/ntly secured from slipping iiit-o the
pleural cavity. For this paqtose it may Ije jinivided
with a shield like a tracheotomy-tube, or a tube folded
uiwn itself and transfixed with a long safety-pin, as
iigurcd here (Fig. 18), has been found useful in chil-
dren's ca.ses ; t the pin can l<c finnly fixed to the
wall of the chest by a strip of adhesive plaster.
After fixing the ilrain;ig<'-tulie securely, the skin
is cleansed, the wound is dusted with iodoform, and,
" ITeveB, •• iiperauve eurgery,-' vol. It, p. 741.
t Keating a " Cyolopa-din of I)isetu«i of Children," 188«
vol. lL,p. 741.
Cb*p. VI.]
Empyemata.
669
several layers of antiseptic gauze arc npplieil. An
oil silk or wateri>roof proU-ction is plaoed over this,
and the whole secure<l by a hamlage. Freijuent
chiinge of dressing (twice tl:iily) will, at tirst, be
needed.
In some cases a counter-opening may have to be
made lower down.
The drainage-tube must, in adults, be rettiined in
the pleural cavity until the discharge ha-s ulniust
ceased. If after its removal there should \k any
signs of re-accuinulatioii, it must be at once re-
i ntrodueed.
When a portion of a rib is excised for the reasons
we have already stfited, it is fii-st bared of periosteum
in order to avoid the intercostal artery, and while
steadied with forceps it is divided in two places
about 1 inch or 1^ inch apart with a fine saw.
"The section may be complete<i with cutting
forcfps, but any attempt — especially in adults— to
divide the entire rib by forceps is to Ije deprecateti.
By such division the bone is unduly cruHlH<d and
splintered."*
The sac of |)erio»teum is then cut away and the
interco.stal artery secured. The operation is termi-
nated as in the case of simple incision.
■Seun makes some sound practiciil observatioiu9
on this matter. He says :—
" A great tleal of information is gained, a-s soon as
the incision int<j the chest has been made, in niference
to the expansibility of the lung. If this hiu4 not
lieen much impaired the pus will escajte with much
force, especially during iuspiration. Rapid evacuation
is atteniled with some danger from over-distension of
the heart and vessels in the lung, and must be guarded
against by interrupting the flow from lime to time by
int-erting the index finger into the o]>ening. If the
lung expands promptly, its lower margin can often )>e
seen through the opening towards the end of the
evacuation. The more the lung expands the lesH the
• Tpbto*, " Oiieratjve Surgery," voL ii., p. 743.
670
Medical Treatment.
(Pan Ill-
amount of tiir niKliing tliruiigli the opening into the
clicst. Jn oriler lo ]in'vent syncopt- upon the sudden
diininutiiiii of intrathora^^ic ]ire8.surfi]iin'ii}; the evacua-
tion of the pus, 1 have Viwn in the habit of atlniinist^r-
ing, liefore the aiiiesthetic is given, , \t,^.\\ of a grain of
atropine with ithof agrainof niorpliia hypoderniically,
with an alcoholic stiiuuknt l«y the inoutli or rectum.
If, as is often the caae, the pleura is lined with thick,
partially detiiclied membranes, these should lie removed
with fi dull cui-ette, as they are invariably infected
with pus inicix>t)os, and their presence in the pleural
cavity wouM ]>rolong infection and retard i-ecovery."
It usiyl to b>? a coiniuon practice to ii-ix»U imt Utr-
pfeiira after pleurotoniy, but far greater circumspection
is now observed with regard t<i this jtractice, which
has been shown to be not without danger. It is super-
fluous in the absence of f't'tor and of saprogenic organ-
isms, and it is useless when there exists a broachial
fistula. It should be reserve*! for the putrid fomis of
einj)yeina, and those in which extensive false nieni-
branes are found fulherent to the pleural surfaces.
The following iliiicls have been suggest«'d as quite
luinnlesK for this puqiose : — Boile<l water tillered with
a t^easpoonful of common suit to each pint ; Thiersch's
solution of two parts of salicylic acid and 12 of boric
to 1,000 of sterilised w^ater ; LabarrB(]ue's solution of
chlorinated so<la, 1 in 15 or "JO of water; a 10 to
50 ]ier cent, solution of jieroxide of hydrogen ; a
solution of acetate of alumina, 1 to T) per cent. Care
must Ih.< taken that the solution is of the same
temperature as the body, and the irrigation should
always 1m- mode with a small, steady siphon stream,
and with a free outlet.
Iri-iiriilioii by snltiiifrKion has been adopted
in America by S. .A. .\danis in empyema in chililren.
The child is placed in a Itatli of Ixiilrd wat<'r at a
tompcrature of 100 F. for tift^'en minutt's— the
temjieratuii' lieing kept constant ibiring this )ierio»i
by iulditions of warm water. " With e\ery itisjnra-
tion the water would run into the two ojienings luij
Chap. VI.I
Empyemata.
witli expimtioii it would return laden witli ]iiih, wLIcb
would Kink to the bottom. The entire liody wji.s kept
under water until expii-ation exf)t*lle4j clear fluid. . . .
Sixteen liatlis were given, extending over three weeks."
This mode of irrigation is siiid to lie very thorough
iind very comfortable to the patient. It is, of course,
only applicable to causes in which there is an opening
or openings of sutticient size to allow of free ingress
and egress of the water.
As we have already said, great attention must be
]>aid to seciu itig the most i)erfect anti8e|>si8 in dre-ssing
the wound, and this must Ije maintained thntughout
the whole ])eriod of healing. The average duration
of treatment aiU-\ operation has been estimated at
four month.4 in adults and two months in children.
Much quicker r.tcveriea are, however, common.
One of the most rapid we remember was a clu-onic
case in a man of middle age, in which there existed a
bronchial (istulii, with a periodical discharge of large
quantities of pus by the mouth. Pleurotomy was
performed by Lord Lister, with resection of a portion
of a rib, and the patient was quite well within three
weeks !
Another case which we saw with Dr. Sealy, of
Weybridge, waw operate<l upon by Professor Watson
Clieyne, and the recovery was rapid. In this case
also there was a communication with the luirg and
profuse purulent expectoration. The great value of
an exploratory puncture was strikingly exempHlied in
this case. We hail jmnctured with a hy|)™lermio
syringe over a .somewhat cirt^umscrilx'd area of dulness
in the i)ack, and found pus, but on the excision of a
portion of a rib just in front of the site of the
puncture no pus was to be found, nor could any
collection of pus be reached ; but as we were certain
of the existence of pus where we had punctured,
another ojx'ration was made, and a fi-e.sh jmrticin of
rib was excised immediately over the mark of the
exploratory puncture, and puH was of course found.
This was a Hmiill localised empyema communicating
672
>J//i Die A L TrEA TMKNT.
(Pan III.
witli (lie hiiiL;, iiml as there wna no tension on its
walls t'roiii acounuilatioii of |ms, the abscess cavity
oould not 1m> fn\inrl i^xcept l>y incision directly over it.
Before the o|ieration tlio patient apjieared to be sink-
ing from suppurative fever, but us soon as an outlet
through the chest wall was niiide for the pus and the
cavity drained, she recovei-ed rapidly.
In .some chronic cases we lind, after the pus has
been evacuat<'d and the pleural cavity drained, that the
lung rlof?.s not expand. It Is bound flown pfvinancntly
by adhesions, and there is no chance of the pleural
surfaces conung together, so that a fistulous opening
remains in the chest, coniinunicating with the pleural
cavity, and constantly discharging pus.
To remedy this stateof things operations have been
pro|io8ed and carried out V)y Estliinder, Schede, and
othera, which have for their object the obliterating of
this cavity by the resection of a numl>er of ribs on
the affected side. Each operation hiis to be specially
devLsed for and adapted X*> each individual ca.se, and
it« extent must depend on the situation and extent of
the cavity which has to be closed. The operation is
necessarily a severe one, and is usually attended with
considerable shock. For methods and details we
must refer to works on operative surgery.*
ADIVTTIONAL FORSlULiE.
Dlnretic to promote absorp-
tion of pleuritic effusion.
il ("afleiuw, gr. xL
Sodii Ixsnzoatis, gr. xl.
M. ot dividn in pulv. nij. One
ill a little wuter every three
bouni with milk diet. (CumAi/.)
For pleurisy in the adolt
H Mor|i)iiai>' liyiirocliliiridi,
gr. JM.
Qiiiiiinir luliihutin, )(t. xxij.
Soinhari ollri, ff. Ixxx.
M. et divide in |>ulv. xij. A
|iowder every tliree or four
bouni. \Uamhti<)tt.\
' .\ii arcuunt of thost.' tliumeo-]>Uutic npcrations will be found
1 Treves'* " Operative Surgerj-," p. 744.
Chip. VI,]
PtEUKtSIES.
mixture for the same.
Or,
A Potanii acetatis,
Ix.
gr. zx. ad
li Pulvorw ipjcacuauha^jgr.xij,
I'ulverus digitalis, gr. xij.
Aiiuu" fervoDtii, jvj.
(loiiua for a quarter of an
hour aud add)
Potaaaii aoetatis, .^ir.
M. I. mist. A tahlespoonful
everj- two hour?, {llitinlitrijn.)
Diuretic mixture for pleurisy
in the adult
R Fotossii ucotutis, %si.
Tinotunp cindiouti! compo-
sitJE, Ita,
Dococti duchouic od jviij.
M. f. mist. Twotablo«pooa-
f uls OTery six houn.
(Fraiilut.)
For pleurisy in debilitated
persons with anamla.
II Ferri curlwnuli" niic-hanitrt',
Qiiiiiiiiti; 6iil[>hatU^ ^r, xij.
Sodii bicartxiDAtis, gr. Ixxx.
Snixliart nibi, gr. Ixiut.
M. et. divide* in pulv. xij. A
powder three or four times a
day. {ISainhtrytr.)
For pleuriay with effusiott
in clilldren.
R Potossii acctatis, gr. xx. ad
Ix.
Synijii nimplicis, .\iij.
Iiifiisi digitaUs ad siij.
H. t. mist. A teaspoouful
every two hours.
• TImvw iniwitcni slioiitd only be used when the {Kin t> very severe
SDtl when Uit're is nu csrdisu feeblencsa.
Syrupi aurantii, Siij.
Decocti ciiichonie ad iiij.
H. f. mist. A tenspoouful
every two hours.
( n'idn-Ao/r,:)
Antipyretic and analgeilc
mixture,
ft Autipyrin, gr. xx,
Pheoacotiu, gr. xx.
Svruiii, .^ij.
Mut-iiagiiiis awiciie, 5ij.
Spiritus villi gnllici, 5m.
M. f. mist. (>no touspooiiful
every hour until fever and [uiiu
are relieved; theu evorv two,
three, or four hours, {iffala.^.)
Powders for the same
purpose.*
R Quiuiiiii' Bulphatis, gr. xx.
Autipyrin, gr. xx.
Phunacotiii, gr. xx.
Morphinn- «ulphutis, gr. j.
M. ; iliviilc into eight parts
(in cachets). Oue to be taken
at half-hour iutorvals, until
pain aud fever ore controlled.
(.»/.i</n.)
Ooraon'R paint for counter-
Irritation in chronic pleural
exudation.
ft Oloi ti^lii, .^ij.
iEthuns, Jiv.
Tiueturm iodi compoait<e ad
jij.
H. f. pigm. To be painted
over the affected part every
morning.
B R
674
^art hW,
PHTHISIS, (lit CONSITMITION (PULMON'AKV
TUBEUCUL.08I8).
CHAPTER 1.
INDirATIONS ASD PnoTH VLAXIS.
DeHnitioii — Imtieiitumx fur IWittiiinit — ri'tiftht/ttirtir MoiuiitrtQ —
AvoiJiini'e of l"ii6uit*blc Murriuges — Mcauurcs to Iw cnfmreil
ou thofto with Ifert-tiititrt/ Pri?(lm|HiAitinn— Muiingvincnt of In-
fiiiii-v mill CliilillirMwl — Of I'ulicrty mid tlio Pcrimi of Rufiiil
Pf'V»'lo|inieiii -Vnltu? tif Sea-air and Sou-buthM for th»?
ScrufuKius— TeuiluiH'y to Kinuciatioii to bt' checki'd— ''ii/drj/in/
Attui'ka to be guanlcd iiK/iiiiBt— L'tibty of Pulmonury (lym-
uastii'ii - ATdidaiioe of UiMiealthy OccojiotiouK— Meanurra for
prevLmtiug DiH8Uiiiiimtioii of thu liifectivo (Jorms Kin)c« of
^^lllo-lllJh•flull—Dilnuil.'cl\<>u of Sputum, Liin'ii, A|>iirtnumt8,
I'tc. isU:
PuLMONAHV tuberculosis, or " consumption," is an
infective disease, originating in the introduction into
the hitigs of a 8j)ecific infective organism, the develofv-
nient and spread of which de[)end on its encountering
a suitable soil, or an inherited predisposition for its
culture and growth, or defective resisting power owing
to a depressed »tj«to of the organism.
The inijmirnietit of nutrition which we encounter
in this disease, when it has not pre-existed us ii
determining cause, is a consequence mainly of the
infective fever which att^ends the clevelopment of the
b;tcillus tuljerculosis and other infective organisms,
and the toxins they seci-ete.
The essential iiitlirntions for Iroiitmriil in
pulmonary consumption are the following : —
1. To prevent or amend those faults of constitu-
tion, organisation, and development which predispose
to the acquirement of the disease.
2. To prevent or cure those local puluionjiry
afl'ections which may induce a tendency to this
Chap. I.J Phthisis : Prophylaxis. 675
disease, even where no constitutional predisposition
ejiists.
3. To prevent the spread of tli« di.seftse by the
conveyance of its j,'erms from tlioso who ure infected
to others.
4. To fudeavour, if jjossilde, to antagonise tlie
morbid iiifluftices of the infective organisui-s on the
lung tissues and on the constitution. To attempt to
liindcr its extension to the sound [larts nf the aft'ected
lung, and alito to tlic sound uniiD'ect«d hmg, and to
prevent the infection of other organs.
fl. To lessen and remove the fi-ver and other con-
stitutional disturbances dependent on the infection of
the system, as well ius on lucnl inllnnunation.
fi. To lejsseu and arrest the catarrhal and in-
flaiumittory changes excited by tbo infective organisDis
ill the lungs.
7. To improve the defective nutrition by nil the
resources at our command — regLminal, medicinal,
and climatic.
8. To relieve the various distressing symptoms
and remedy the several serious ctimplications which
occur in the course of the nmhuly.
And, tii-st, with regard to proplij lacCic Ircat-
ni)>nl. The prevention of pulmonary consumption
nuiy lie regarded from three princijial points of view:
(<j) the prevention of the transmission of the phthisical
disposition or tendency from parent to offspring ;
(6) the prevention of the development of the disease
when the [iredisposition exists ; and (c) the prevention
of those unhealthy conditions, habits, and circuiii-
stiinces of life which are knoMn to favour the acquii-e-
nient and ]»ropagation of phthisis.
(«) The hereditnvinesH of the lendency to phthisis
has been placed lieyoiid doubt, but fn^m tin; point of
view of prophylaxis it is important to reriierid)er that
by the hereditary nature of phthisis we do not mean
that |ththisical ])arent8 convey to their olfspring a
CI institution which must necessarily, at a given jieriod
of life, develop tuberculous disease, but rather that
676
AfEDICAL TrEA TMENT.
Il'jrt IV.
they tniTisniit to their children an organisation which
rentlei-s them more prone than others to be attacked
by the tubercle bacillus.
Marriages between persons who are known to
inherit this tendency should be discouraged, and, of
those actually infocled, forbidden.
(b) Next, lu to tlie boat menus of preventing the
development of phthi.sis in those i>ersons in whom a,
tendency to that malady is known to exist.
An infant bm'ii with such a tendency will rei|uire
the mo.st careful management. On no account sliiiuld
a mother with phthisical tendencies lie allowefi to
suckle her offspring. There is danger in thi.s both to
mother and child. For such infants a vigorous and
healthy wet-nui-so should be selected, and if possible
they should 1k' brought up in the free open air of the
country, rather than in the confined atmosphere of
crowded cities.
The chest and limbs should not be cramped by
any tightly-Kttiiig garments, but allowed perfect free-
dom of movement. The nurse should be particularly
cautioned against permitting awkward attitudes which
tend to compre-ss the chest and to hinder its free
ex|>ansion.
Attem[)ts should early Ije made to wanl off that
morbid sensitiveness and vulnerability of the cutaneous
surface so common in those predisposed to phthisis,
which i.s, in a measure, the index of bronchial
sensitiveness and irrit*bility. We should even in
the early month.s of infant life adopt mildly bracing
measures, wliich may afterwards give place to a
more vigomus hardening system. For this ]>urposc,
it is a good plan, after the child's morning bath, to
sponge over the surface of the bo<ly rapidly with
cold sea- water, or water containing soa-salt, to which
a table.s-|>oonfuI or two of spirits of wine or eau-<lo-
cologne have been added. This process has a bntcing
and invigorating effect, especially stimulating to the
functions of respiration.
When it is impracticable to obtain a wet-nurse, the
W^^Chap. I.)
Phthisis : Prophylaxis.
677
child should lie jjinpii iM-rfpctly fresh cow's milk, boiled,
slightly (lilut('<l with witter, ftuil with a little sugur of
milk atUlcd, At the |icri<«l of toc-lliiiii; a little bcef-
juiw. nmj \sv inldi'd tti tliu milk, and if (k'litition be
tardy or difficult, sonio ](re|iaration of lime is useful.*
More than (irdiimry care is needed in wa tubing
these children tlirougli the common ailments of child-
hood, especiiilty nieaHkH, whooping-cough, and scarlet
fever. MeaslfH and whooping-cough are especially
dangerous to such cliildren, for the catarrhal and con-
gestive attacks of the respii-atory organs, which so
con.'4t4mtly accompatiy these nfl'ections, are prone lo
linger and predispose to pulmonary tul>erculo8i3.
When the cliihl reaches five or six } ears of age,
judicious and careful attempts to further bmee and
liiirden the con.stitution should be systeniaticnlly
p-ursued. For this purpose free exercise in the open
air, wisely deviswl g^ nuiastic exercises, and cold
sponging, cold aB'usion, or very brief cold douches,
should bo daily employed.
The removal of hypertrophied tonsils and " aden-
oids " is advisable, as they impede respiration and
diminish cliest ex]iansion.
It is necessary to watch cjtrefuUy the education
and school-life of such children. Close application
to study in crowded achoolrcioms must be positively
forbidden ; overtaxing the physical iind mental powers
must be carefully avoided, and all faulty attitudes
and |>0Bitions during school studies should be cor-
rected.
There are two periods of life whicb have been
regarded as specially dangerous for those wlio inherit
a predisposition to phthisis. One is the period of
puberty, and the other is the period Ijetween the ages
of 30 and Xy.
At the period of puWrty we have to guard again.st
the depressed nutrition so often associated with the
* Full (letiiila as to thd preparation of suitable fowl for infonti
and young chilJrcn will be fnunil in tin- author's work on " Food
in Uoaltli uud Diaeose " (ucw editiuii), part i., chap. ix.
678
Me Die A I. Tr ea tmk.vt.
(Part IV.
exliiiu.sUiiy; inHiKjrice of rapid growth. A life of
wliolesonit* activity in the open air, out-of-door exer-
cises and o<.'cu|iation8, a nutritious but unstimtilating
diet, as well as the provision of liealthy food for the
mind and tiie avoidance of romantic and erotic
literature — thi'se are wisp and necessary precautionary
meiisures at this period of life.
Wlipn the strengtii and nutritive power seem
seriously inipaire<i liy rajiid gi'owth, it will l>o advan-
tat'OouH for such case.s to seek a sunny clituato in winter
and tonic mountain or sea-air in summer ; in both
cases in situations where an outofdoor life is {lossible.
The extreme value of sea-air and sca-hatha in
combating the tendency to sci-ofulous aB'ections lias
been established by long cxjierience, and for delicate
children and young po<i[)!o presenting the signs of the
scrofulous diathesis, prolonged residence at the seaside
and the regular use of sea baths, cold in the summer,
and, if neces.sary, warmed in the winter, are of the
greatest benefit.
Sir Herman Weber * and others have warmly
advocated the establishment of .sea.side sanatoria for
the reception of poor children suffering from these
scrofulous complaints.
The occurrence of loss of flesh is often one of the
first evidences of impending danger. But it would
be inoori-ect to conclude, on that account, that all the
subjects of progressive emaciation are on their way to
l)ecome tuljerculous.
The emaciation which is bo frei|uently regarded as
the precursor of piilmonnry phthisis is jirobably, in
most instances, but the tirst nyniptom of the actual
presence of the di.sease ; a vigilant pi-ophylaxis then
roijuires us to be on our guard, lest we allow a
tendency to progressive emaciation in the young and
delicate to proceed unnotictnl. In such cases we
sliould exercise a cai-eful supervision of the diet, lutd
see that it is suflicient in nil re>ipects, and that it
includes an adequate proportion of fat and (lesh-
• Srit. Mai. Joum., Angiut 3rd, 1901, p. 317.
Chap. I.) Phthisis : Pkophylaxis. 679
foriniiif; too(i in easily iJifjestiWlp fonii«. Much Hrn>-
iiess often nwda to Ije extTciseil willi ilolicate and
lanfiful (.-(liMrfn to ensure their cousuuiptiou of 11
Huliiiicnt iiiiiiutity of suiUiblo fooJ.
Aljundant gentle — not exhiiiisting — exercise in
the open air is Ijeneficiiil to such persons, oa liorse, or
carriage, or lx>at exercise.
(<!) All such jiersons as we have been referring to
should be protected in every way from the causes of
eatiirrhiil, congestive, or inflammatory attacks of all
kin<ls ; from indiscreet exposure to changeable or
inclement weather ; and from llic dangers of over-
excitement and pxcesi5es of all kind.s.
Suitable gynmastic exercises for the purpose of
increiisiirg the capacity of the thorax, generally small,
Hat, and narrow in .such persons, of strengthening
the respiriitory muscles and tliose of the upper limbs,
and so of promoting lung ventilation, are of un-
doubted value.
A few weeks during summer, or a longer period if
any troublesome catarrhal attacks have occurred,
spent in some- mountain district, from 4,600 to (>,<J00
feet above the stsa-levcl, is valuable, not only for
its general bracing eflect, but for the pulmonary
gymnastics which a residence in the rarefied air of
the.se regions neces-sitates, and tlie more complete
pulmonary ventilation thereby secured.
All occupations should lie avoided which entail
corifiticnient in close, ill-ventilated apartments or
workshops, »is well as those which necessitate cramped
attitudes and positions that interfere with proper
expansion of the chest and free aeration of the lungs ;
s<» also should all employments which involve exposure
to irritating vapours or dusts, or other injurioii?
influences, suoh as sudden and great changes of
temperature, which may excite or maintain catarrhal
cotiditirins of the air-fyassajjes. The choice of out-of-
duor (iccu[iutions and tlie avoidance of sedentary ones
shuuld he ui'ged on uU those who inherit a tendency
to phthisis.
m
680
Medical Txeat.vent.
I Pun IV.
The close relationship between wetness of soil and
the jirevidence of plithisis should \>e constantly Iwnio
in initid, imd thost; with a disposition to this disease
should avoid such localities.
The iinjiortimt point of the prevention of the
transuiissioit or romiiiiinifHtioii of the tul>erclc
germ from the sick to the sound must next he con-
sidorfd.
Phthisis is spread by conimnnicntion, <'liifjlij
Ihrouyh the agency of On- itjnihiiii, which, whoa dried,
is converted into dust, and carried into the attno-
sphere, or "by coughing, and even spitting, it is flung
into the air in little dix»j)8, that is, in n moist con
(tition, and can at once infect j)ersons who hajipen
to be near the cougher."*
Disinfection or destruction of the sputum of
phthisical patients is of frrime importance in prevent-
ing the spreati of tuberculosis. In most cases of
phthisis the sputum contains tubercle banlli, often
in great numbers. Tlie beat m(»ns of disinfecting
sputum containing these bacilli is to mix it with a
five per cent, solution of carlwlic acid. But even this
requires a contact of twenty-four hours. Exposure
to boiling water for ten minutes, or to steam at a
temperature of 212° F. for half an-hour to an hour, is
also etTective.
The danger of auto-inJection cannot thus be
obviated. " A patient on the road to recovery may
be reinfected by his own sputum." If during e.x-
pcctoration some of the sputum should be accidentally
aspirated into the sound lung or the sound parts of
the aflecte<l hing, fresh centres of infection may lie
startexl. Some may also be swallowed and infect tlie
intestinal canHl. A remedy for such <liingers is the
regular use of antiseptics, internally and by inhala-
tion— antiseptic vajwurs, sprays, and mouth washes —
the two latter expressly for the purpose of ensuring
the expectoiiition of the contents of cavities in contnoi
* Brouardel, " .^ddremi at Brituli Cougreas ou Tuborculoua,"
D>il. Melt. Juuift., July -'7th, IDOJ.
Phthisis : Prophylaxis.
with nil niitiseptic niediuu). Tliosc who have foolishly
spoken slightingly of iintif-eptic inhnhitioii.s have
fvidoiitly iiiil i-ealisetl the useful prophylactic nature
of the services they can |ierforiii, csixH-iiilly in some-
what advunceil cases.
Linen, handkerchiefs, underclothinj:, sheets,
pillow-cases, etc., which liave inournxl the risk of
contamination with phthisical sputum may be <Jis-
infeoteil l>y boiling; water ; Mankets, niattres-ses, etc.,
by exposure to steam for uii liour, or to a dry heat
(as in a disinfe<'ting stove) of 250° F, for several
hfiure.
The risk of infection by the dust of dried Bputiitn
ma)- be provided against, to some extent, by the
following precautions: Phthisical patients must be
warned not to spit on the floor, rugs, or carpets,
nor in tFie streets nor into handkerchiefs, unless
■Jajmnese paper ones, which can lie burnt immediately ;
but as some .sensitive patients will .scarcely l>e pre-
vented from using handkerchiefs for tliis purpose,
these should be plunged into l)oiling water as soon as
they have been uscfl. Convenient .spittoons should
Ije provided for every patient, containing a little 5
per cent, carbolic solution to disinfect, and keep the
8])utum moist. These can lie made of pasUilioard,
enclosed in a tin case, s<j that they can be burnt after
use, and the tin case scalded with l>oiling water.
Fig. 19 shows the j>attern of one commonly used
in America, and termed " Sanitary Cuspidor."
Dettweiler has devised a convenient flask for carry-
ing in the patient's pocket, so as to avoid the necessity
of spitting into a handkerchief or in the r.treet ; it is
shown in Fig. 20.
It is flat, made of blue glo-ss, and holds about
three ounces. It will be seen that it has an opening
at the top and liottoni, fitted with screw cups. To
the uj>f)er oj>ening is fitted a tightly shutting spring
cover or lid, .tnd a polished metal funnel, which
i-eaches lialf-way down into the tlask. This funnel
iiCts like that of certain ink-bottles, and prevents the
682
Medical TREATMErrr.
I Part IV.
spilliii<; of the contents of the Hask even if the
Clip is left oped. The lower opening allows it to
be thoroughly cleansed. It ia purtlj filled with ilis-
Fig. 19.— Sanitary Caii|>»l' i
infecting (iuid, its contents are freijuentljir burnt, or
ili.schargcd into the drains, and the ve&8el is cleansed
with boiling water.
Spittoons sFionlfl be kept coirml, \estJtUs settling
u|K)n sputum .should bo. the incaiis of currying infec-
r\f. M.-np(lwelli!l« rock<'t Flmk.
tion. Tn clubs ami public places spittoons should
\ie filled with sawdust saturated with a solution of
carbolic acid, and their contents frequently burnt.
Chap. !. 1
Phthisis : Prophylaxis.
683
It is best to provide the phthisicftl patient with
9e|)ai'at<:' kiiivcM, forks, spoons, jiurl othur tjililf utensils,
und fo SCO timt they tirr thonm^hly t'li'iinsi'ii;vfU-r using.
As the iiair, espcoiully that of the iK-iiid, iind the
nails of phthisical patients nuiy liecoine soiled by
sputum, the hair and beard should be worn short,
and tlie nails and heard frequently washed with
(lisinfeoting soap. Dust should Ije prevente<l from
eollei-tiiig or depositing itself in the rooms oceupied by
phthisicul patients. The w.ills should bo niblwd
down with new bread, which is then burnt, and the
furniture freipiently wijied with 11 ulotli dauiped by
some antiseptie solution. Th<^ floor .should besprinkled
before sweeping, and the sweepings burnt, ('arpets
and curtains are be*t dispensed with altogether. The
rooms should lie kept thoroughly ventilated by widely
opened windows.
(.!los« intimacy with tlie subjects of advanced
phthisis should 1x3 avoided, and the bed-room of a
lihthisieal patient shoidd not be shared by anyone.
Kissing on the lips should be forbidden. The rooms
that have been occupii^l liy phthisical patients must
be thoroughly cleanseil, and, when practicable, re-
papered, [)ainte<l, and whitewo-shed before they are
lived in by others.
In New York careless spitting has been made
penal. It is certainly <lesiriible that information as
to the manner in which this disc-ise is prtipagateil
should be dillused widely amongst the public, and
voluntary notifications encouraged (in Norway and in
New York it is compulsory). The free examination
of spiituui should be )>rovided for by the public
authorities, as well as the means for the disinfection
t)f infect<'d housesand arcA& It is exceedingly desirable
that it should be practicable for tuberculous subjects
amongst the |»oor V> Ix^ removed to and treate/1 in
suitable imnatoria, and that asylums for incurable cases
should be provided. It is impossible in the dwellings
of the |K)or to provide adex]uatc means for the pire-
vention of the spread of the disease.
684
ClIAPTEU ir.
thk reoiminal treatment ok phthisis, ircluuino
" sanatohu'm" treatment.
Iiiipoilance of HyiriPnic Trentment — Food— In reUitinn to the
Fever— Value of Fot« nml Ciirbnhyclniton— Care in the Pre-
paration of Fix>d — Millc null Crpani -Kounii-is — Rnw Meat
— " Zoinolherapy " — Furitiaccciu* Foo<l«— Alcohol —W/»»<c»f«-
/iu» loirrg—lywt tihoLild bo viirieti and attructive — Dailjrj
Dietary— Air anil Ventilation — Value of UiH'U-air Trcutmenq
in Sanatoria— Pneumatio Ti-eutment— EtTectn of Inspimtionl
of Compressed Air and Expiration into Karet!e<l Air — Bodily
Exercise — Lnn;; Ventilotion — Hydrothenipy — Baths and
Douches — Sponging — Clothing — Summnr}'.
We propose in this chapter to consider tlie regiminal
or liygionic traitinent of phthisis, the snpreine im-
portance of wliich is now fully recognisctl. A disease
whicli is so |prijfiuni(ily influenced by the state of
nutrition of the liody must be encountered by the
most scrupultiuK regiml of all those diiily and hourly
conditions and tmbits of life which tend to Rup|>ort
and strengtlien the constitution, and imjKirt to it a
resisting power.
A very great purt of the undoubted advantage
which phthisical patients gain from residence in
" sanatoria " must Ije attributed to the constant
detailed and intelligent supervision they receive in
these institutions.
" J III A'luinen grospt " — " Great in small things " —
is the motto cliosen by f)r. Deftweiler, of Falken-
stein ; whicli means that every detail of the daily
life of the phthisical ])atient, with regard to food,
drink, exercise, clothing, slee|>ing, etc., is regulated
and fixed by medical authonty.
First, as to the food of the phthisical patient.
In a disease like pulmonary consumption, attitnded
with a chronic febrile condition, and consequent con-
tinuous loss of weight, unless this progressive wasting
is counterbalanced by tlie supply and annexation of i
Chap. 1 1.1
Diet in Phthisis.
685
au adequate amount of {oo<l, the patient must, in
couree of time, succumb to the disease. Tultercuhir
]>atic'iit8 with active disea.se rei|uiro a inuch larger
aiiiouiit of fixxl than persons in iiealth, in order to
compensate for the increased tissue waste. It is well
known that if wc are able to estiiblish an improved
stAte of nutrition, the disease itself becomes favourably
influenced thereby. Our success in this effort will
depend much on the amount and tjq>c of the febrile
state which accompanies the malady. When there
are distinct intermissions or remissions in the febrile
movement, and when the fever is quite moderat<?, we
may succeed in jirocuriiig the a.ssiniilation of a con-
gidci-ahle quantity of fiKxl, providecl great care and
disci-etion be iMnploye<l in its selection ami ]>repara-
tion. IJut when the fever is considerable and per-
sistent, and the digestive functions (as is usually the
case ill such circumstances) are greatly impairetj
and appetite is entirely absent, ittmiy be diHicult or
even impossible to obtain the appropriation of a
sufficient quantity of food to exercise any adequate
check on the wasting process. In such cases we are
coiu|)olle<J to have recourse wholly to fluid and easily
absorbable foods in much the siinie maTiner as in the
dietetic management of acute febrile <lisea.ses.
It is a generally accepted rule that m the diet of
the consumptive, fats and carbohydriit.e8 — i f.. the
especially fattt-niiig forms of foo<l — should Ije at any
rate adequately, if not superabundantly, repre.sente<l.
One of the greatest difliculties we encounter in
providing a suitaVile and adeijuate diet for consump-
tives is the frcMjuency with wliicli they complain of
digestive troubles, want of appetite, an<J, occasionally,
of pasitive disgust for footl. In such circumstances
it is most important to [irovidn wellcookal, a|i|)eti8-
ing, and attractivcly-scrvofl food, varied as much as
pos.sible, and, so far as is consistent with wholcsome-
ness, agreeable to the tasl«s of the patient.
We are, liowever, assured that at the Nordi-acb
sanatorium even febrile patients are induced, by Dr,
686
Medical Treatment.
|P»rt IV
Wnlther's persuasive skill, to consume large quantities
of solid ftKxl of the most siilistantial kind.* And
Osier and Flick liavt' pointed out that it is not difficult
to induce the phthisical patient to take a largo
number of I'liw eggs daily — a very excellent and
nourisliitig food.
Phtiiisical patients whose digestive functions are
unimpaired nmy \k allowed \jo pai-tnke of the various
nouriHliinj; forms of food that enter into the ordinary
diet^iry of the heiilthy, in addition to which two or
three glasses of milk slioulrl be taken at convenient
intervals between meals, and one of these glasses of
milk should be taken the li«t thing at night, or even
pivfcraltly during the night, if the jialient is awake.
6V«!((m t may also Ije made digestible and accept-
able to many patients by mixing it with an eijual
quantity of hot water, and adding to each teacupful
of the mixture half a t^iaspooiiful of the aromatic
spirits of ammonia ; some prefer a teasjioonful of
brandy. In otlier cases we may use peptonis^l milk.
Koumiss, or fermented mare's milk, has acquired
a great reputation in Russia in- the treatment of
pulmonary tulierculosis, and the Russians i*esort in
considerable numbers to tliose stations on the borders
of the Caspian Sea, amongst the Kirghis and Tartar
tribes, where the kouujiss cure is cjirried on.
It is an appropriate beverage in felirile cases, as
it quenches thirst, and can often be retained in the
stomach when all other food is rejected ; indeed, its
special value is in those cases of inveterate dysiiejisia
and gastric irritability in which all attempts at giving
other kinds of food have failed.
The use of rntv meat was, a few years ago, highly
extolled by Professor Fuster, of Montpellier, who
claimed the most brilliant results from its administra-
tion in ca.ses of phthi.sis. These i-esults were not,
however, confirmed by other ob-servers.
• .Sw a rcraarkiible i»apfir in the " TuViercaloaM *
the rrnclil\„i,rr, July, IWH, hy Dr. Moudor Smyth.
+ Wo refer to fluid cream.
uuinbet of
^^^^s5^-
Diet in Phthisis.
687
Recently its mkp, or that of "iiiii»cle jiiiijc," lias
been revivwi by Messrs. Ricliet et Hiiricourt, under
tlifi title of " Znmo-thfrnpy," * and strongly advocated
in the treatment of tuberculosis. If the patient can
take and digest raw meat in lurijn quaiUiti/ (300 to
•too gnimme« in the first stage, and 000 to 800
grauiuies in the second stage of {ihthisis) he need not
bo given muscle juice, the preparation of which is
always a tedioas and difficult process. But if he
ciinnot take raw nteut, then fie must consume a large
quantity of the juice of very fresh steak, expressed in
the manner and with all the precautions <letniled. In
the third stage, or in the acute form, he must ab.sorb
daily the juice of as much as "J to 3 kilos of raw beef.
The rest of the dietary will tie normal, but with the
exclusion of eggs. All drug treatment must be
stopped, but cod-liver oil may be continued. By this
method M. Ilericourt is i-eportefl to have obtained
"striking," "rapid," and " unexjiectcd " cures.
Whether the nmsde plasma »cts as an antitoxin, or
stimulates phagocytosis, or is only a special tonic to
the nervous system, the authors of this method have
not yet decided. Still more recently, C Fraenkel
and (J. Sobernheimt have carefully tested these results,
and have come to the conclusion that a raw meat diet
has no influence on the course of tuljcrculosis, and
they cannot agree with Richet and H('*ricourt that
the method is worthy of a trial on human subjects.
The dillerent kinds of farinaceous foods are all
usi'ful and appropriate articles of diet. Whole meal
or well-made lirown bread is, on account of the phos-
phateij contained in it, better suited to young con-
sumptivas, if they digest it well, than white bread.
Lentil Hour also is valuable, aa it contains notable
proportions of phosphates and of iron. Oatmeal is
rich in fatty matters, and the Hour of maize is still
* Fur a full uit'ouut of this mctliod refer to ao article under
this heading, by Dr. L. Robinson, in the VracMiimrr for July,
1901.
t litrl. Klin, rrof/i., July Tith, I'JUl.
688
Medical Tkratment.
|P»ti IV.
richer — a fact whioli renders them botli very suitable
adfiitious to tlic diet of the tuberculous.
With regard to the use of alcoholic btveraijeB, mtich
diffei'cnco of opinion exists.
We shall find, practically, that the use and need
of alcohol vary gi-eatly in difl'ererit individuals. In
some it diminishes appetite and retards digestion : in
others it promotes both ; and we shall encounter very
few cases of phthisis which are not benetited, at some
period of their course, by the discreet administration
of alcoholic stimulants.
It is exceedingly nece.ssary that the lieverage,
wliether wiue, spirit^), or beer, should be pure and of
the best quality.
When the piitient is able to drink fermente<l niall
liquors, he may be allowed two or three glasses daily
of good, sound bitter beer, or porter, or stout ; of
wines, a half a pint to a pint of really good Hordeuux
or Burgundy, or of some of the better descriptions of
Hungarian, Italian, or Greek wines.
In febrile cases, small quantities of alcohol given
frequently have an excellent eflect in supporting the
strength ; and especially during the night is it ini-
poi-tant to give two or tlireo tablespcxinfuls of brandy
or whisky, alone, or with a little fluid food, such as
milk, or Iwef-tea, or a whipiwd ei;g.
What was ternietl by French physicians "alimen-
laiionforoie" — i.e. forced fending — has, in the manner
originally applied, fallen into disuse, but the principles
involved are generally applictl as a part of sanatorium
treatment, and jiatients in such institutions arc urged
to consume a large amount of foo<I as a necessary
means to their restoration to health.
While we should do all in our power to encourage
our ])hthi.sical patients to take an abundance of
nourishing food (and for this purjtosc we should make
their diet as varied and attmctive as )K>ssible), we
must l>e careful not to admit into their dietary forms
of food which, although attractive to the patient,
tend to exhaust his digestive forces without rendering
Chap, tt.l
DtET Iff Phthisis.
689
I
I
liiin an cqiiivnlcnt; amount uf Htipport ami nouriHh-
iiient. We should, therefore, exclude pastry, uucooked
fruit«, salads, pickles, and all forms of indigestible
footl.
It would be umlesii-able to fix too rigidly the
daily dietaiy of the phthisical, but the following
scheme may serve om a generiil guide — a sort of plan
of route from wl\ich wide excursions may bo made
under the guidance of a discreel physician: —
On irnlciitij in the iiiomiiu/, a tumblei-fnl of milk
should lio taken mixed with a little hot water, to
which it is often useful to nd<l a few grains of common
salt and bic.-ulionate of siKla, which greatly promote
exiiecUiratKii), especially when a certain amount of
accuraulaleit nmcus has to be got rid of. There is no
objection to taking a little ten, cofl'ee, or cocoa at this
hour, with milk or cream, if preferred. .Sometimes
in advanced cases the stinmlus of a tablespoonful of
brandy, rum, or whisky is needed at this time. This
Hrst meal is ott-en best takcti in be<l. About an hour
aflerwaixis a substantial breakfast shouhJ bo taken,
consisting either of liroiled bacon and lightly-lwiled
eggs, or some fresh tisb, or some cold meat or game
or poultry, and with this meal milk, or cocoa, or coffee,
or tea, or some gcwtl sound liglit wine and water may
bo taken, according to taste.
Supposing this meal to lie taken alwjut nine or
ten o'clock, a ghuss of milk or a cup uf cocoa should
Ik> taken aliout noon.
Half-past one or two o'clock is a go<xl hour for
the chief nienl of the day. This should consist of
some fish, when it can be procured fresh and good,
together with some meat, chicken, or game, and
potatoes and fresh vegetables ; and some light milk-
pudding with n little marmalade or other cooked
fruit. With this meal half a pint of good Hungarian
wine, light claret, or Burgundy may be taken.
At five in the afternoon another glass of milk
should be taken, or a cup of chocolate, or tea with
plenty of luUk or cream ; or the yolk of an egg beatcu
88
690
Medical Treatmexi;
IPanlV.
up with a little brandy aiul water may be Kulwlituted,
if prefi'rreil. It is itirelj desirable to order any solid
food at this hour if il is intended tliat the {Hitieiit
should make another siibstuntial meal at seveu. At
this hour a meal similiir in all respects to that taken
at 1.30 or two o'clock should conclude the substantial
feeding of the day.
About half an hour before bed-time (which should
not Vjie later than lU or 10.30 p.m.) another gias.s of
milk, prepared in the same manner as tliat in the
moi iiin^', together with one or two tublesp<x)nfuls of
lintmly or whisky, (ir a cup of arrowroot, or beef-tea,
or tapioca soup, tiocording to taste, may be taken.
And, tinally, .some [irovision of light nourisiiment
mixed with 11 liltle stinmlant should be {irovided
to lie taken during the nigiit, when the patient is
wakened by coughing, or after perspiratiou, or when
ineivly restless.
In distinctly febrile eases a much more fluid
dietwy will have to be followe«l, and the food will
iXKiuire to be taken at shorter intervals. Dr. Mander
Smyth descriijea a "typical dinner" at Nordrach,
wliere he was in bed with a febrile e.xacerl^ation, au
consisting of " a plate of pork and pot^itoes, a leg and
wing of a chicken, salad and more potatoes, and, to
linish, a large we<lge of very solid pa.stry " 1 •
Air and vcntilnlioii.— It is exceedingly neces-
sary to watch o\er the i-espiratory functions of the
phthisical, and to see that they breathe a pure, un-
taintc<l atmosphere. ^Vherever and whenever it is
safe and possible to be altogether in the open air,
there the sufl'ercrs from phthisis should be. Hence,
the value and importance of treatment in sanatoria
as these ai-e, or shotdd be, in situations where free
exposure to the open air is possible without the risk
of encountering injurious agencies. At Falkenstein,
fidbersdorf, and other sanatoria for consumptive
patients, hammocks are swung among the pine trees
around, and, whenever the state of the weather will
• I'lfH'titiviirr. July, 1901.
Chap, ii.i A/K -lATP VnxTiLATiOiV IX Phthisis. 691
permit, thp pntients are encouraged to l)e in tiie
open ail- as constantU' iv") possible. At Xorclmcli Dr.
MHnder Smyth, referring to his befl-rootii, sivys, " The.
windows of my room, constituting lu'urly the whole
of one side of it, were open night and day, and a
strung draiight played throngh them, breathing of the
pine-cKvi slopes."
The advantage of a southern aspect for the sleeping
apartment of the phthisical, in a nituation sheltered
from pr<'vailing winds, is chiefly that the windows
can he always open, and the apartment thus con-
stantly kept filled with piire and fresh air, which the
rays of the sun warm and vivify.
It is to the [)os8ibility whicli it often afTords of
being much in the ojien air, even in wint«T, that
cJiange of dininte owes its great value.
Even in England it has been shown that in
properly selected localities, and in well-organised
saiiatdria, it has lieen jwssible for patients t^i be kept
imioli in t)ie open air all the year mund.
In advanced ca**e8, wlien the patient i.<f, of
iiecesaity, eunch conliried to his ttwm, a cDiiifortiible
reclining couch should be jtrovidtsl, so that even if
very feeble or feverish he need not !>e conline<l too
closely to his ImkI. The bed should be free from all
hangings, and if the windows arc kept open, lus is
desirable, the patient should be very warmly clothed
or covered, 80 as nut tr> feel eulfl. The temperature of
the room should range between 60' and 65' F., accord-
ing to the feelings and condition of the f)atient. In
very cold weather, wdien tlie temperature of a room
quickly falls, and is often with dilliculty renewed, a
temperatun> of (Jo will not l>e found too great for
atlvanced cases. An open tire-place is the most cheer-
ful source of heat, and it also promotes ventilation.
The ini|iortiince of rest in Ix^d ibiriii^ tlie f>'brili'
poriod.s, or the intercurrent inthinniiatory attacks
which not iinfreipiently occur in the course of phthisis,
must not Ix? overlooked ; and howeviT injportant and
suitable ia the majority of eases oj>en-air treatment
(l()2
Mf.hica I. 2'k ea tmeat.
IP.iil IV
may be, we must by no means disregard the need of
shelU'r from cold for f(*rUiiii highly sensitive nnd
cativrrliiil cnses; iiiiieed, cILscretion niul discrimiuatioii
in this respect are &» important ass in the question of
food.
The advantage of sanatorium * treatment is not
limited to the opportunity it aflbrds of hypemrratiou
of the lungs liy being almost always in the open air ;
hut, as has already been pointed out, depends also on
the coustunt detailed supervision of the patient's life,
in every minute particular, which is ensured.
When it is pmcticjible, a combination of climatic
and sanatorium treatment is preferable to sanntorium
treatment without climatic advantages. But recent
experience has shown that very good results can be
obtained in wellplauned t^nnatoria in carefully selectefl
localities in En;^liind and Germany, whoso climate,
taken alone, could not be i-egurded as especially
favourable to phthisical patients.
In the construction and arrangement of such
institutions it is of chief importance to seek pro-
tection from jirevailing winds, a dry, absorbent soil, a
southern exjiosure, and the avoidance of localities
lial)le to much damp and fog. There should also bo
an agreeable enviionnienl for taking exercise suited
to the capacities of diflerent patients. Drawbacks io
this mode of treatment are the length of time nee<led
to eHect a cure and the evils attendant on prolonged
mental and physical inaction.
This will l>e a convenient place to consider the
utility and value of the pnoiimntic trcMlmeat in
phthisis — a mode of treatment which has for its
object the complete aeration and ventilation of the
lungs, the promotion of the pulmonary circulation, aiitl
the removal of inllanunatory exudations and intillm-
tions, by e.st.ibli.sliiiig a sort of lung gymnastic, either
Viy the employment of portable apparatu.s, or by
residence in the ])neumiitic chamber, or " compressed
air-bath." This method is no doubt valuable as a
* A litt ul Saimtoriii will be found in vol ii., y>. 98.
chup. 1 1. 1 Pneumatic Treatment in P/ithisis. 693
moans of {H'opliylaxiH, but nmnvContinentftl physiciaiiH
maintain that it is etricaoiousal»o in the tivatinent of
certain forms of chronic plitliisiii.
JiK'coud asserts that it should be applieti, either
by the portable apparatus or in the pneumatic
cbamVjer, during the whole period of the " initial
apyretic phaae " of phthisis. He prefers the apparatus*
whii'h allows of the inspiration of compressed air, and
expiration into rarefied iiir. He maintains that its
"ininimitm etfect" is to i-etard considerably the
extension of tlie disease, and this etTect he believes to
!« constant ; in a certain number of cases, in from
six weeks to three months, he has observed a distinct
diminution in the extent of the pre-existing changes,
so that they have recedetl to only one-half their
former extent ; and in a few exceptional cases,
falling under the category of apex catarrhs, he has
observed an entire disa|>pearance of all physical aigns
of disease.
IiuipiralioH of compretaed air leads to a more
complete expansion and a njore perfect ventilation of
the lungs ; it increases tFie intrathoracic respiratory
pressure, and quickens the jiulinouary circulation. The
frequency of reapiration and of tlie pulse is lowered,
while the force of the latter is increased ; an increase<l
<|Uiintit.v of o.tygeii is absorbed into the blood, and an
increase<l quantity of carbonic acid is expired ; these
conditions are favourable to the maintenance of
nutritive activity, and unfavourable to the develo[i-
uient of microbes.
Expiration into rarefied air leafls to more perfect
ex|)iratory contractit^n, and cnn84Mjuently to a diminu-
tion in the residual air, and, therefoit;, to more com-
plet'e pulmonary ventilation. Roth processes tend to
more perfect expansion and ventilation of the lungs,
and more perfect aeration of the blood.
Judiciously-arrangotl gymnastic exercises, walking
* For a full ilesoription of all Die apparatus used in pueu-
matii- truatuivot, tr tlie uuthnr'n tntn.Hlntiou of (^tortel's " Respira-
tory TlicnipeuticB " (Smith and Elder).
694
Medical Treatment.
I Part tV.
up gentle incliniM, residence in elevated districts, serve
the R.'inio pni-piise, and may load to the same results.
Bodily cxprrise is of all things most etsential
in the treatment of chronic and afebrile forms of
phthisis, as witliout it nutrition languishes and the
l>odily strength steadily diminitihes.
Sy<lenhatn maintained that daily and continxious
horse exercise was the best treatment for con-
sumption.*
Regular walking and riding exercise (always
stopping short of fatigue), and slow, regulated
clinihing, bringing into play a certain amount of lung
gymnastic, hip mo.st useful in promoting initrition,
limiting the .spreatl of locjil disease, and favouring
retrogressive and curative processes, by promoting
complete expansion of the sound portions of lung,
and thorough )iulnionary ventilation, and more {)erfpct
oxygenation of the blood. Consumptive patients
shuulcl be taught in their out-doorexerci.se to j>nictiae,
fram tiniF- to time, taking the deepest possible inspira-
tion, followed by the completes! possible expiration,
and by this lung ventilation carried out with gentle-
ness, and without any luidue efiTort, they shrmid lie
given to understfind that they make the Ije.st jKj.ssible
use of their 0])i)ortunities of breathing pure, healing air.
When walking or riding is too fatiguing, can'ioge
exercise, or exercise in a l)ath-chair, or in a rowing- or
Kailing-l>oat, on sea or river, is admissible in fine
weather, provid«i undue exposure to cold currents
of air is always guardefi against. ()l coui-se, these
remarks apply only to afebrilt cases.
We have spoken in the chapter on prophylaxis of
the great importance of a hraciv//, tonir truatwmt of
tli« xkin, which is almormaily sensitive and impres-
sionable in phthisical subjects ; a treatment that is
intended to diminish the tendency to chills, which
often react unfavourably on the lung condition. Willi
ew some physicians who have had tlie
nbject
• Avinpcr by the niiUuir on " The Treottnont ol Coiisump-
Uon by Climate,''^/;../. Unl. Jnnninl. July 'JTtli, lOCll.
Chap. Ill Hydrotherapy .ly Phthisis.
695
special care of patients with phtliisis liiivf iK-cri led
to employ and advocate a modified lljdrotht'ril-
pciilir roiirsi* in the manugenient of the more
chrc>uiL' foniis, and this '\% included in the lieoliug
resources of many sanatoria.
It is scarcely necessary to say that the application
of the cold douche in such canes requires the greatest
caution and circumspection. Sokolowski studied the
etfect of the cold-water treatment on 105 patients
with phthisis, at ('obersdoif, and he reported that out
of these there were thirty-nine complete cures, thirty-
four greatly benefited, nineteen slightly Ix'nefited,
seven derived no benelit, two wen^ made worse, and
four died. He poiiit.s out the necessity "f .'ireat
prudence in its appliaition, and that it ia only .suited
Ui those cases in which the local lesions are not
extensive ; that it is counterindicnted in cases of
profound aiuetnia, in hectic fever, and in idl cast<s
which lire not at once benefited by the first few
douches. The douches should be of very short dura-
tion, commencing with four to five seconds, and in-
creasing to thirty seconds with females, and fifty
seconds vvitli males. At Davos the application of colil
douches of short dui-ation to the chest has entered
largely into the practice of some of the pliysiciiui.s.
No doubt these cold douches of short duration
have an excellent general invigorating effect ou those
who can supp<»rt them, and who react vigorously to
them, especially when they are commenced during the
hot season ; and they undoubtedly tend to strengthen
the skin, and to remove that tendency to take cold
from tlie slightest exposure which is so troublesome
in the i)litliisical. But those, even, who are quite
unable to support the cold douche may derive much
lienefit from cold or tepid ;geiieral sponging of the
skin in their own ai>artmentH, and it is often an
udvantau'c to add a little alcohol, or eaude-cologne,
or toilet vinegar, to the wafer used. Only a portion
should be uncovered
liwly
s]>onged
time. But often the whole Iwdy may with advantage,
696
Medical Tkeatmext.
once a day, be rapidly sponged over with cold wftt4<r,
provided this is done iu a warm room. If, for llm
sake of ventilation an<l freshness, the patient's bed-
room is not kept very warm, he should puss into a
f/uiW: warm drcssiug-rooDi liefore the cold sponging is
applied. It is the combined contact of aAd air
mid coid water that causes the latter to bo ill-
borne.
After the application of cold or tepid sponging
the surface of the body should 1^ well ruliljed with a
warm, dry towel.
Tbeclolhlnif of phthisical patienUsbouldl»c light,
but warm ; light woollen material is the best. As
they are iisiially very .sensitive to cold currents of air
and to changes of temperature, they should always
have an e.xtni wrap or warm covering at baud to put
on when feeling the least chilly. It is a mistake to
wrap up their cheats, as so many do, with layer after
layer of dannel, oottou-woi>l, rabbit skins, "chest
prot<?ct«r8," i>orou8 plasters, etc. When such u
patient removes all these coverings you will often
fin<l the surface of the body wet with confined i>er-
spiration, in which the skin is, as it were, soaked, and
rendered thereby much more sensitive.
All the clothing should be change<l at night, and a
thin llannel or cotton nightgown put on ; too much
clothes must not be henped on the lied, cHpi'cially
when there is a tendency to nighlsweals ; and when
the bed-cliJimlier is kept at a suitable and equable
teniperalure a great tjuaiitity of be<l coverings is not
needed, but when the [tatieiit's Inidroom is freely ex-
posed t-o the open air, winter and summer, it is highly
important that he should have an abundance of warm
coverings that he may not feel cold.
END OF VOLl-MF. I.
I'nulvl by CAaslix h OoMVANr, LImitM, La BoUs BanvwWt Lumlan, K.C.
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