its course is generally rapid, and the cure difficult; partaking, as it
often does, of the two-fold state of debility and excitement. When
detected early, the lancet must be promptly used. Cups and leaches,
followed by the warm bath, blisters, and cathartics, must also be
resorted to.
"Diuretics, which are so beneficial in the less acute forms of
dropsy, are commonly too inert and slow in this, unless given
in doses to act immediately upon the vascular system, when the
infusion of digitalis, as given by many practitioners in all
the other states of the disease, may be resorted to; since the
treatment here is not so much to remove the water, as to
prevent, if possible, its farther effusion; for when a
discharge suddenly takes place into the chest after scarlet
fever, it will generally prove fatal, even though the quantity
collected be inconsiderable, and only such as would occasion,
if gradually effused, a moderate degree of inconvenience to the
lungs."
In respect to tapping, our author remarks, that the circumstances
calling for this operation are, where, from the very considerable
accumulation of water, and the consequent distension it occasions, a
permanent and morbid stimulus is given to the peritoneal membrane, by
which its serous inflammation is perpetuated or increased; or where so
much pain and irritation are produced, as to risk inducing a similar
disease in the chest, and of bringing on likewise an ulcerative form of
inflammation in the peritoneal lining of the abdomen.
"Whilst the objections to its employment consist in the danger
which is incurred, where there is much visceral disease, of its
causing a destructive form of inflammation in the peritoneum;
and the probability of its occasioning, under the most
favourable condition of the disease, a more rapid renewal of
the serous accumulation."
Our limits not allowing us to enter on the treatment of ovarian dropsy,
we proceed to offer a few remarks on the means recommended by Dr. A. for
the cure of anasarca. As in the treatment of every other form of dropsy,
it is necessary, in attempting the cure of anasarca, to advert to the
nature and causes of the disease.
"If it be idiopathic, and unconnected with any dropsy of a
circumscribed cavity, and the pulse at the same time be soft,
and the urine free from serum, it may be treated solely with
the view of procuring the absorption of the effused fluid, as
in such cases, the watery discharge in all probability will
have removed, in a considerable degree, the excitement which
caused it."
It is in such cases that recoveries take place under almost any plan of
treatment, and that bark and other tonics have been found beneficial.
Their utility, however, in these cases is very limited, consisting only
in aiding the removal of the effects of the disease, and keeping up the
strength of the system, whilst the absorbents perform their function,
and remove the fluid. Dr. A. recommends, in these cases, puncturing and
bandages; but he very justly adds, that they must not be employed,
whenever there remains any inflammation in the parts, as they would then
tend to aggravate it.
"To oedematous swellings, in which the serous local
inflammation, whether symptomatic or idiopathic, still
subsists, I am accustomed to direct the application of leeches
and cold evaporating lotions, observing not to commence the use
of the latter, until twelve hours after the leeches have been
used, that inflammation may not be produced in the wound."
"When anasarca arises from a general excited state of the
system, as denoted by the pulse, and by the serous quality of
the urine, venesection becomes necessary, combined with the use
of leeches, applied to the extremities, or to those parts of
the body, in which the serous tissues are most affected, along
with the active use of the general means already alluded to."
In anasarca, an error is sometimes committed, especially by young
practitioners, of estimating the degree of danger, and the necessity for
active treatment, by the single consideration of the extent of the
oedematous swelling. This, however, should be guarded against, as the
swelling may be very considerable, and the disease subsided, or of
little consequence; whilst, in other instances, the reverse may be the
case. In the first instance, where the disease is not seen early, the
treatment must sometimes be limited to those means which promote the
absorption of the water, and neither venesection nor leeches will be
required. In such cases, the practitioner must be guided by the state of
the pulse and urine; the presence or absence of vascular excitement; the
history given of the case up to the period when visited, and
particularly by the progress of the swelling.
"When the dropsy of the skin is considerable and long
protracted, and symptomatic of some visceral disease, as it
most commonly is in these cases, and is attended by a serous
state of the urine, and a general failure of the strength, the
cachetical state of the system may be considered as
established, and the treatment is then beset with difficulties.
For the general means, which are useful in the earlier states
of the disease, and when the vital strength is entire, become
injurious in this, by the tendency they have, aided by the
effects of the visceral disease, to diminish farther the vigour
of the system; whilst, at the same time, the treatment, which
is suited to support the declining strength, can contribute
nothing towards lessening the constitutional and local
diseases, but will frequently increase the morbidly excited
state of the circulation, which, analogous to what occurs in
diabetes, will continue and increase under the most decided
marks of general constitutional weakness. Pending the
continuance of that inflammatory state of the system, in which
the urine is charged with serum, the debility will be mainly
derived from that drain of its nutrient parts, which is thus
established in the body, assisted by the weakening effects of
the organic disease. If blood be drawn, it will be found, in
many of these cases, to exhibit the usual signs of
inflammation; and the treatment of the tonic kind, when
employed to support the strength, will be found to act
unfavourably.
"The plan to be pursued must consist in the use of such means
as shall assist the powers of digestion and assimilation; so
that, by a highly nourishing but plain diet, the drain from the
system may be somewhat counteracted; and, at the same time, the
cause of the effusion is to be corrected by the use of local
depletion and blistering, and by the temperate employment of
those general means, which are useful in the less aggravated
forms of the disease."
The diet of patients, in the symptomatic forms of dropsy, should be
plain and unirritating; and in the idiopathic states, the antiphlogistic
regimen should be rigidly enforced; particularly an abstinence from all
fermented liquors, until the inflammatory period of the disease be
removed. The clothing should be moderately warm, and selected of that
kind, best suited to promote the insensible perspiration of the surface.
Before taking leave of Dr. AYRE, we cannot omit adverting, in a very few
words, to a circumstance noticed in his preface, and which we think of
some importance. He remarks, that if, in the prosecution of his task, he
has had no acknowledgments to make to any individual as his guide and
authority, he is nevertheless indebted for many important facts to the
writings of the late Dr. WELLS, and of Drs. BLACKALL, ABERCROMBIE, and
DUNCAN, jun. and particularly to the system of pathology of Dr. PARRY.
He further remarks, that he entertained and taught for many years, the
views advocated in this work, and that, after the manuscript had been
sent to press, he had seen a copy of an abridged edition of the
elaborate Dictionnaire des Sciences Medicales, in which the doctrine of
dropsy, maintained in the larger work, is relinquished; whilst others
are given in their place, conformable, in the main, with those which it
is the object of his treatise to establish. Now it would appear, from
these expressions, that Dr. AYRE wishes to inculcate the idea, that the
English writers, whom he has cited, were the only ones who had published
anything valuable, and conformable to his doctrine; and that prior to
1823, the year of the publication of the Dictionary above mentioned, the
French entertained very different views of the pathology of the disease.
We think it our duty, however, to rectify our author in this respect,
and to show to our readers, that, even allowing full credit to Drs.
WELLS, BLACKALL, ABERCROMBIE, &c. for their researches into the nature
and treatment of dropsy, the American, French, and Italian pathologists
are entitled to a much larger share than is allowed to them in the
present work. A few references will be sufficient. Many years ago, our
celebrated RUSH taught, that general dropsies "depend on a certain
morbid excitement of the arteries;" and that hydrocephalus, "in its
first stage, is the effect of causes, which produce a less degree of
that morbid action in the brain which constitutes phrenitis." In 1812,
Dr. BRESCHET, of Paris, published an excellent dissertation on active
dropsies. In the early writings of BROUSSAIS, though more particularly
in the propositions prefixed to his _Examen_, the opinion is maintained,
that all active dropsies depend on irritability, either primary or
secondary, of the serous and cellular tissues,--a theory more closely
allied to Dr. A.'s, than all that is contained in the writings of Drs.
WELLS, PARRY, &c. But what, perhaps, is more to our purpose, Dr.
GEROMINI, of Cremona, published a work, in 1816, on the origin and cure
of dropsy, in which he compares the dropsical accumulation to that of
serum produced by the inflammation of a blister, or by fire; and in
which he also maintains, that a slight inflammation occasions a flow of
limpid serous fluid, whilst a higher degree gives rise to the formation
of pus. From these circumstances, he concludes, that the hydropic fluid,
which contains little albumen, is the product of a lower grade of
inflammation. In the same work, he finally asserts, that in more than
200 individuals who had died of dropsy, he invariably found marks of
inflammation or its effects; views which our readers will readily
discover to be nearly allied to those supported by Dr. A. In making
these remarks, however, we do not wish to be understood as asserting,
that the theory advanced by our author did not originate also with him.
We have too favourable an opinion of his honesty, to accuse him of
plagiarism. Our sole intention has been to render unto each the degree
of praise to which he is entitled, and, by pointing out this coincidence
of opinion, to derive a further proof of the correctness of most of the
pathological views, so ably defended in the present work.
ARTICLE VIII.--_An Essay on Venereal Diseases, and the Uses and Abuses
of Mercury in their Treatment._ By RICHARD CARMICHAEL, M.R.I.A. _With
Practical Notes, &c._ by G. EMERSON, M. D. Philadelphia, J. Harding,
1825; pp. 360.
One of the most important improvements in practice, which modern
experience has established, is the reformed method of treating venereal
diseases.
To the labours of several distinguished military physicians and surgeons
of Great Britain, we are chiefly indebted for the facts and researches
connected with this interesting subject. And although we may have much
to learn in regard to the true nature of these complaints; yet the plan
adopted by Mr. CARMICHAEL, of determining their distinct pathological
characteristics, and applying the remedies accordingly, is the only one
likely to subvert the empirical routine of prescribing mercury on all
occasions, a practice which derives such strong support both from the
indolence and prejudices of the profession.
In this country, many eminent practitioners have contributed to restrain
the abuse of mercury; and it is believed, that Professor CHAPMAN has for
many years, in his lectures, disseminated the most enlightened doctrines
on this point. Dr. HARRIS and other surgeons of the navy have made a
fair trial of the non-mercurial treatment, and with the most
satisfactory results.
The great object, so desirable of attainment, is to form a correct
discrimination between the diseases, which may be cured or benefited by
the exhibition of mercury, and those which do not require this medicine,
or become aggravated by its use; for it seldom fails to do injury, when
its advantages are not very obvious.
Mr. CARMICHAEL has taken the most conspicuous part in this investigation
for the last fifteen years, and from the extensive theatre, in which his
inquiries were conducted, has had the best opportunities of arriving at
the truth. He, therefore, who undertakes the management of these
affections, may be justly pronounced culpable, if he neglect to make
himself acquainted with the experience of this eminent surgeon.
In this enlarged and improved edition of his work, several subjects have
not been treated of so copiously by the author, as was requisite to
render it acceptable as a book of reference; but the judicious notes of
Dr. EMERSON, whose attention has been profitably directed to the
investigation of venereal diseases, have well supplied the deficiency.
A brief outline is here presented of the contents.
The author describes the various symptoms in plain and intelligible
terms; rejecting such unmeaning appellations as syphiloidal,
pseudo-syphilis, &c. as designating no particular phenomena, and
therefore of no use in describing a disease.
He thinks there is a plurality of venereal poisons, and has divided the
disease into four classes, from their different primary and secondary
symptoms; making the eruptions on the skin the most certain criterion of
distinguishing them from each other. These classes are:--the papular
venereal disease; the pustular; The phagedenic; and the scaly venereal
disease. The latter is the true syphilis.
First, the Papular. This is the most common disease, and the most easily
cured. Its primary symptoms are, a simple ulcer without induration,
without elevated edges, and without phagedena. Sometimes there is a
patchy excoriation of the glans penis, attended with a purulent
discharge. This disease and gonorrhoea are caused by the same poison.
The constitutional symptoms are:--fever; pain in the head, shoulders,
and larger joints, pain in the chest; dyspnoea; a papular eruption on
the forehead, chest, and back, sometimes extending in a more scattered
way over the extremities. It is often attended with iritis. It never
gives rise to nodes. The sore throat is different from that of syphilis;
the latter having deep excavated ulcers. If buboes accompany it, they
are mostly of an indolent nature. The eruptions do not all appear at
once; but follow each other. When on the decline, they are of a pale red
or copper colour, not scaly, as in syphilis, but papular; disappearing
and recurring repeatedly, and ending in desquamation.
_Remedies._--Venesection; cathartics; antiphlogistic regimen;
antimonials, combined with decoction of sarsaparilla. Alterative does of
calomel and antimonials, when the eruption declines.
The local treatment consists in astringent washes and simple dressings.
Iritis is to be cured by venesection, cathartics, mercury, blisters, and
belladonna.
This disease will yield to the powers of the constitution. Mercury is
always injurious in the early stage.
Second, Pustular venereal disease.
Primary ulcer of a reddish-brown colour; borders closely on the
phagedenic character. The edges raised and well defined; not excavated,
but on a level with or above the surrounding skin. In the commencement,
a small itchy pustula; distinguished from the ulcer attending the
papular disease by its well defined and elevated edges, and by the
absence of the smooth fungous surface of the former; from the phagedenic
by its well defined margin and its corroded-like surface, and the
absence of acute pain; and from chancre by the absence of the callous
edges and base. These ulcers are of a chronic nature, showing little
disposition to spread. The ulcers from buboes partake of the same
character, the edges being hard and the ulcer disposed to burrow. These
edges Mr. C. removes with the knife. The disease is rendered extremely
obstinate, where full courses of mercury have been given. The more
closely the eruption approaches the papular, the more mild and
manageable will be the disease.
_Constitutional symptoms._--The eruption is pustular, and often exhibits
simultaneously new pustules; also scabbing ulcers, the crusts of which
fall off, and leave discoloured patches of skin after healing. For these
ulcers of the skin, the best remedies are, sulphur fumigations,
nitro-muriatic acid baths, and ointment of tar and sulphur.
_Remedies._--Rest; gentle astringents; mild ointments; antimonials and
sarsaparilla:--for the constitutional symptoms; venesection; cathartics;
antimonials; sarsaparilla.
Mercury is decidedly injurious, until the disease is on the wane, when
alterative doses may accelerate the cure.
Third, Phagedenic venereal disease.
The primary ulcer has a corroded appearance. It exhibits neither
granulations nor induration. It spreads sometimes rapidly, sometimes
slowly; healing in one part, while ulcerating in another. It is mostly
situated on the glans and prepuce, and often attended with hemorrhage.
In this disease, buboes most frequently appear.
The sloughing ulcer occurs also in this disease. Mercury is extremely
pernicious, always rendering the disease more inveterate and rapid in
its progress.
_Constitutional symptoms._--High fever precedes the eruption, but abates
afterwards. Nocturnal headachs; tenderness of the scalp; slight
dyspnoea; tenderness of the sternum on pressure; soreness of the
chest; an eruption of tubercles, or pustules, or spots of a pustular
tendency, which quickly degenerate into ulcers, with thick crusts, that
heal from the centre, while they extend from the circumference, with
phagedenic borders. The crusts are often of a conical figure. The
ulceration of the throat is of the most formidable nature. It commences
in the form of a small white aphthous sore; which usually attacks the
velum or posterior part of the pharynx, mostly the latter. It extends
rapidly, destroying the parts, and at last attacks the bones. It often
attacks the larynx, after which, the patient seldom recovers. The
affection of the bones of the nose is never joined with the papular
eruption, nor with the scaly syphilitic lepra; but in every case with
the pustular description, and when scales and ulcers were present. At
the time of the eruption, pains in the knees, wrists, and ankles occur,
attended with swelling and redness. He has never seen nodes in the
disease, except in cases where mercury had been given. Full courses of
mercury introduce the disease into the deep seated parts; for the bones
are seldom or never affected in this disease, unless mercury has been
given.
_Remedies for the primary symptoms._--Absolute rest; venesection;
nauseating doses of antimonials; warm poultices and fomentations; opium;
hyosciamus and cicuta in sufficient doses to lessen pain and irritation.
For the sloughing ulcer, stimulating applications are often useful; such
as Venice turpentine or balsam copaibae, mixed with olive oil.
_For the secondary symptoms:_--Venesection; antimonials; sarsaparilla;
Dover's powder. Mercury increases the ravages of the disease, except
when on the wane, when it may be given in alterative doses, with safety
and advantage. For the pain in the head, a blister to the nape of the
neck. If the eruption appear scaly, then mercury is likely to be useful.
If the throat and skin are affected, muriate of mercury in solution, and
decoction of sarsaparilla. If the ulcer in the throat be small, touch it
with the oxymel aeruginis, or solution of nitrate of silver, grs. v a x
to an ounce of water; but if there exist extensive ulcerations,
fumigations with red sulphuret of mercury ought to be employed.
Fourth, Scaly Venereal Disease, or Syphilis.--Primary ulcer of a
circular form, excavated, without granulations, with matter adhering to
the surface, and with a thickened edge and base. The hardening is very
circumscribed, not diffusing itself gradually or imperceptibly into the
surrounding parts, but terminating rather abruptly. Its progress is
slow, sometimes assuming a tawny appearance.
_Constitutional symptoms._--Sometimes the skin, at other times the
throat, is first affected. There is headach, restlessness, and fever.
The scaly eruption appears, but does not relieve the fever, as in the
other diseases. This eruption commences with a small hard reddish
protuberance; and as it advances, the sides are raised, and centre
depressed or flat, and covered with thin white scales. It terminates in
ulcerated blotches. This eruption appears on the forehead, breast, back
of the neck, and groin; often in large copper coloured blotches, in
parts near the hair. The ulcers of the throat mostly affect the tonsils,
and come on without much previous pain or swelling; although there soon
appears a considerable excavation of the tonsil, attended with evident
loss of substance. The ulcer is foul, with thick white matter adherent
to it, which cannot be washed away. The bones then become affected,
those nearest the surface being most liable to attack; such as the
tibia, sternum, clavicle, and cranium.
The remedies for syphilis are full courses of mercury, for both primary
and secondary symptoms; except where a tendency to phthisis, or a
delicate constitution forbids them. He thinks syphilis a rare disease
now, compared with what it was formerly.
ARTICLE IX.--_Remarks on some Means employed to destroy Taenia, and expel
them from the Human Body._--By LOUIS FRANK. M. D. Privy Counsellor of
her Majesty, Maria Louisa, Duchess of Parma. [Lond. Med. Rep. April
1825.]
The symptoms produced by the presence of tape worm in the human body,
are exceedingly distressing, and the sufferings of the patient are
increased, by the obstinacy, with which these animals resist the
operation of the most disgusting, and even painful and dangerous
remedies. Improvements in the mode of attacking and expelling them,
therefore, should be gladly received, and widely made known.
The numerous reports which we have received, concerning oil of
turpentine as a remedy for taenia solium, have already given to that
remedy the highest character; but many cases have been only partially
relieved by it. The ol. tereb. seems to be capable of causing the
separation and expulsion of portions of the animal; but while the head
remains unexpelled, it is supposed to be capable of reproducing the
joints, to a degree not yet ascertained. If we may believe medical
writers, the taenia has been observed of the enormous length of 700 feet.
It is probable that the reproduction, after the loss of large numbers
of joints, is often very rapidly effected; as was the case in a patient
treated at the Carey Street Dispensary, mentioned in their report for
Aug. 1813,[18] This person always discharged very considerable
quantities of joints or fragments, after the use of oil of turpentine;
after which he remained free from the complaint for a few months, until
the taenia recovered a troublesome magnitude; when it was again easily
reduced to less uncomfortable dimensions.