Clinical Illustrations OF DISEASES OF THE ABDOMINAL VISCERA.

NOVEMBER

Clinical

Illustrations OF

DISEASES

OF THE ABDOMINAL VISCERA.

BY STEPHEN H. WARD, M.D. LOND., L.R.C.P. PHYSICIAN TO THE

SEAMEN’S HOSPITAL, "DREADNOUGHT."

(Continued from p. 463.) DYSENTERY.

CASE 5.-Clit-oitic dysentery, affecting the descending colon and sigmoid flexure.—Robert B-, an Englishman, aged twenty-

four, of dark, bilious temperament, was admitted into the Dreadnought on January 30th, 1857. Six months ago, when in Hongkong, he was attacked with dysentery, for which he received no proper treatment, and which has continued, with varying severity of symptoms, up to the present time. He exhibits much emaciation, and a general anæmic condition; has about ten motions in the twenty-four hours, attended with much forcing and straining, and consisting of fetid, pultaceous, feculent matter, more or less mixed with blood, and of separate blood and mucus voided subsequently. There is much tenderness on pressure over the sigmoid flexure and descending colon, and tenderness, less marked, over the transverse portion of the gut. Pulse rather frequent; tongue slightly furred; with smne heat of skin. Ordered, an injection of acetate of lead, starch, and opium at night, and eight grains of Dover’s powder, with catechu and decoction of logwood, three times a day. Milk diet, and to keep in bed. Feb. 2nd.-Much griping, with some tympanitis, and appa-

rently retention of lumpy fæcal matter. Ordered, a large injection of gruel, which gave decided relief. 7th.-No marked improvement; stools still loose, frequent, and bloody. To omitthe other medicines, and take the following :-Gallic acid, five grains; tincture of opium, ten minims; mucilage, one ounce and a half, three times a day. 12th.-Stools still very loose, somewhat bloody, paler, and deficient in bile. Ordered the following pill three times a day: - Acetate of lead, one grain; powdered opium, chloride of mercury, ipecacuanha, of each halfagrain. Under this treatment the stools became less frequent, more bilious, and less stained with blood; but on the 16th they were still frequent and loose, and there was rather more tenderness over the sigmoid flexure. He was now ordered ten grains of Dover’s powder night and morning, and an ounce and a half of the decoction of Bael fruit three times a day. Under this treatment

the motions which before varied in frequency from seven to twelve in twenty-four hours, were rapidly reduced in number, and in less than a fortnight, he was passing but one tolerably well-formed, healthy evacuation in the twenty-four hours. CASE 6.—Chronic dysentery; prolapsus ani and Itepatic de-

rangement.-James S-,aSwede, aged twenty-two, admitted into the Dreadnought on Sept. 3rd, 1856. He is a small, spare-built man, of lymphatic temperament; has been usually very healthy, but not always of very temperate habits. About three months ago, while at Constantinople, he was attacked,

he says, with tertian ague, which lasted for rather more than two months, and greatly reduced him. At the end of this time, diarrhoea supervened, accompanied with much straining, and followed, after ten days, byprolapsus ani; the diarrhoea meanwhile merging into dysentery, which has continued, without treatment and increasing in severity, up to the present time. He now appears quite anæmic, is much emaciated, suffers from hectic nushes at night, pulse scarcely perceptible, and countenance sunken. Placed on milk diet, beef-tea, and wine, and treated, for the first fortnight, by opiates and astringents, (tincture ofopium, catechu, and logwood.) The stools continued very loose, of a slimy and mucous character, though generally free from blood; he complained greatly of pain from the prolapsus ani, which, however, only came down during defecation, and could readily be returned by himself. Sept. 5th.—Ordered an injection of five grains of acetate of No. 1785.

14, 1857.

lead, forty drops of laudanum, and two ounces of starch, to be given every night; and, as the stools were quite extra. bilious, it was thought advisable, notwithstanding his depressed state, to try cautiously the administration of mercury. He was ordered, therefore, three grains of mercury and chalk, with five grains of Dover’s powder, three times a day. This was continued, with occasional intermissions of one or two days, np to October 6th, when, his gums having become slightly tender, it was discontinued. Under its influence, the action of the liver was, in some degree, restored, but the secretion of bile seemed very irregular, as there were observed in the stools only here and there a few patches coloured with it; the greater portion remaining, as before, almost colourless.

On the 19th of September, as there was increased straining, with now and then the appearance of blood in the stools, a scruple of gallic acid was substituted for the acetate of lead in the injection. Under the action of this, the bowel became less and less irritable, and, by the middle of October, the prolapsus entirely ceased. The exhibition of mercury having been stopped on October 6th, the stools again became extra-bilious, and somewhat looser, and various astringents, as krameria, benzoin, sulphate of copper, were tried without benefit. He was, however, greatly improved in aspect, having gained flesh, and being less anasmic. On October 22nd, he was placed on a course of nitro-muriatic acid and opium. From this time he rapidly improved, the stools becoming formed, and voided only once or twice a day, and the secretion of bile gradually returning. On December 9th, all astringent remedies were discontinued, and he was put on a course of quinine and iron, with full diet

and porter.

Dec. 23rd.-Discharged, cured. In the above case there was, in all probability, but little, if any, ulcerabion, the condition of the mucous membrane being that of relaxation. The prolapsus ani, and the hepatic clerangement proved troublesome complications. They were, however, removed by treatment specially directed to them, and the nitro-muriatic acid did good service in restoring and altering the secretions of the liver. CASE 7.-A Malay, aged twenty-five, came from Calcutta with fifty-five others in ship. They had vinegar, salt beef, rice, and biscuits, and for only the first five weeks of the voyage the usual allowance of lime-juice. This man, and another Malay, who was admitted into the Dreadnought at the same time, weretaken ill shortly after the exhaustion of the lime-juice, and one of them had spongy gums. They both had tenderness along the course of the colon; frequent stools, not deficient in bile, but with more or less mucus. They were ordered the decoction of Bael fruit, lemon juice, milk diet, and wine, and rapidly recovered. CASE 8.-John B-, aged twenty-four, admitted April 13th, 1857. Has been ill for ten months; was first attacked in the East Indies, and has been better and worse since. Before this attack he suffered from ague for eight months. He attributes his seizure to the combined action of heat and wet. In answer to an inquiry respecting provisions, he says that the buffalo beef which they had on board was not good. Much wasted and anæmic; bowels acting six or seven times daily; motions loose and bilious, with, occasionally, mucus and blood; tenderness over junction of transverse, with descending colon. He was ordered the decoction of Bael fruit, with a few drops of tincture of opium, three times a day; at first fluid, and afterwards ordinary diet. He rapidly improved, and was discharged cured on May 4th. On May 25th he again presented himself, having been leading a very irregular life in the interval. His bowels were now acting seven or eight times daily, and there was frequent desire to go to stool, with marked irritability of rectum. He was placed on milk diet, ordered eight grains of Dover’s powder three times a day, and a starch and opium injection at nights He gradually improved, but was not allowed to go out until recovery seemed to have been for some time quite established. CASE 9. -A gentleman, aged fifty-six, contracted a severe attack of dysentery in one of the West India Islands, where he had been residing for some years. For this he had been suecessfully treated as far as the acute attack was concerned, but symptoms of the disease in a chronic form still remained, and with the view, by change of climate, of effecting a perfect restoration to health, he came over to England in July, 1857. He was seen by me at the end of this month, and was then suffering from some irritation of the lower bowel, with two or U

three loose motions, containing mucus, in the twenty-four hours. The weather was then very hot, and I at once undeceived him as regards an idea which he entertained, that travelling about would soon put him to rights. I advised him to keep quiet, in the recumbent posture, on the sofa, during greater part of the day, enjoined strict rules with respect to diet, and prescribed the decoction of Bael fruit, with a few drops of tincture of opium, three times a day. At the end of a week or so, he was passing but one well-formed, firm motion in the twenty-four hours. He was then put upon some iron, and recommended to try the air of the Highlands. The above illustrates a large number of cases in which the disease, though reduced to a minimum, still exists ; and under exciting circumstances may reasoume the acute character or run into an intractable form of diarrhoea. These relies of a previous acute attack should, therefore, not be neglected. They are in most instances tolerably amenable to treatment. The following case is an example of the more acute form in which the disease sometimes shows itself in this country ; and also of symptoms attending implication of the upper part of the

eolon.

CASE 10.- A gentleman, aged forty-five, of full habit of body, under my care in September, 1854, for what appeared to be, at first, ordinary bilious diarrhoea. After a day or two, however, the stools became somewhat sanguineous in character, and, on examination, there was marked tenderness over the ascending and transverse colon. The skin became hot and dry, the face flushed, the pulse frequent and sharp. The calls to stool were now very frequent, preceded by griping pains in the large bowel, and attended by tenesmus ; the motions being deficient in bile, fluid, and uniformly stained by blood. Leeches were applied over the seat of tenderness, and followed by a hot linseed-meal poultice over the entire abdomen. He was ordered ten grains of Dover’s powder with three of mercury-with-chalk, three times a day, and a dose of oil or large injection of gruel when necessary. Under this treatment, the disease gradually subsided, the secretion of the liver was restored: astringent medicines were then given, and at the end of three weeks he was convalescent. I have endeavoured, in the above selection of cases, to give illustrations of the different varieties and degrees in which dysentery may be met with in this country, whether as indigenous, or as the sequel of the acute disease contracted in tropical climates. I shall now proceed to make some observations in reference to treatment. I would remark, in the first place, that slight cases get well rapidly under rest, diet, and astringents, which, if neglected, would, under the lest exciting cause, assume a more acute and unmanageable character; and that it is, consequently, important not to allow an individual to go about with a half-cured dysentery. I have found the truth of this observation confirmed by the fact that patients who, contrary to advice, had left the Dreadnought before a cure was quite established, had returned in a week or two, with considerable aggravation of symptoms. I would observe, in the next place, that the worst cases, when not complicated with incurable organic disease, generally do well, even although the period of cure may, as in Case 1, be extended over several months. The great amount of mischief that has to be repaired, renders it evident that the cure must be very protracted. In the treatment of the more chronic cases, it is essential for the practitioner not to be enamoured of, or obstinately persevere in, any special remedy. Remedies which, when first exhibited, produce most satisfactory results, quite lose their efficacy after they have been administered for a few days or a week or two. It is a point insisted upon by all who have had large experience in this disease, and well illustrated by one or two of the foregoing cases, that most benefit is to be expected from a succession or change of remedies. There are two other practical points to which I would direct attention-viz., the suddenness with which,’ certain cases begin to mend, that up to a came

have proved most troublesome, and the importance of not giving up the treatment prematurely. In the treatment of sub-acute and also of chronic dysentery, the first thing to be insisted upon is rest :aposition-the recumbent-in which the bowels are best supported and kept quiet. In the sitting or standing postures there is no efficient the bowels; in walking, the peristaltic action is support ofand the bowels are directly irritated by the action increased, of the abdominal muscles. Position, alone, produces most beneficial results. I have found patients who had previously been travelling or moving about, at once relieved by rest; their stools diminishing in frequency even before any medicine was given. The action of the skin, which it is so desirable to proThe application mote. is also more evenlv maintained in bed.

time,

488

of

a

broad flannel roller tends to carry out the indication of

support, and determination to the surface. The invalid should be gives least work to the bowels, which least stimulates peristaltic action, and which is most likely to be assimilated should there be, as is often the Drs. Abercrombie and case, any - mesenteric complication. Jackson and Mr. R. Martin insist strongly upon this point. The latter says. " There is no consideration of more serious importance than the diet; a diet which barely sustains the system, and which is bland and unirritating, being all that ought in any case to be allowed. Neglect of proper diet not only retards the progress of cicatrization, but it tends to reproduce and to extend ulceration, and thus to cause dangerous and even fatal relapse. A deprivation to the very verge of starvation would, in many cases, prove salutary, by calming peristaltic acting, and thus affording time for the healing of ulcerated and abraded surfaces." My own experience is in entire accordance with the above; and I cannot indorse the opinion of Dr. Graves, founded on the results of his own practice, that meat is far too much abstained from. I have invariably found the too early recourse to meat diet to be followed by marked irritation and griping, and aggravation of symptoms. I am, of course, speaking of cases where there is more Milk is the aliment best adapted or less extensive ulceration. for patients suffering from the disorder under consideration. Farinaceous articles of food are also admissible. Wine should be administered where there is much prostration. The special therapeutical treatment will necessarily vary with the degree and character of the disease. In the sub-acute cases, and in the severer form of the dysentery of this country, I have found no remedy equal to the Dover’s powder, in tengrain doses, given every six hours, with an occasional dose of castor oil, guarded by a few drops of laudanum, for the removal, of faecal matter. The administration of a large injection of gruel, which may be combined with a little turpentine if there be tympanitis, is sometimes followed by marked relief; dislodging fæcal matter from the large bowel, and acting as an internal fomentation. If there be a deficiency of bile in ther motions, a few grains of mercury-with-chalk may be combined with the night-dose of Dover’s powder. If there is much painand tenderness, great benefit is derived from the application of a few leeches to the anus if the sigmoid flexure or rectum beaffected, or over the ascending or transverse colon if these be the seat of disease. In sub-acute cases confined to the rectum, medicines exhibited by the mouth do but little good; here, leeches to the anus and soothing injections with opium are best calculated to relieve the inflammation and the resulting tenesmus, and to induce discharge of faeculent matter. In the purely chronic form of the disease, the treatment consists in the administration of mineral and vegetable astringents combined with opium, in the occasional use of aperients. for the removal of fasces and foul secretions, in the exhibition of mercury or nitro-muriatic acid, for their alterative action, when the hepatic secretion is either deficient, irregular, or unhealthy, and in injections of different kinds for the relief of tenesmus, for local astringent action when the lower portion of the bowel is affected, and for the removal of matters accumulated in the intestine. When the ulceration has been confined to the lower extremity of the colon or the rectum, and attended with discharge of blood, I have used, with a view to direct astringent action, and with much advantage, either an injection of acetate of lead, in the proportion of ten grains to two ounces of starch or gruel, or of nitrate of silver, in the proportion of three or four grains to two ounces of distilled water, followed in an hour or so after, by a soothing injection. Gallic acid and sul. phate of zinc, administered in a similar way, have also done good service. The value of timely injections of gruel, or doses of castor oil, for the removal of feculent matter and putrid secretions, can scarcely be over-rated. Such accumulations not only keep up irritation, but they prevent astringents from acting upon the ulcerated surfaces. There is, indeed, no rea. son we should allow foetid discharges to remain in contact with an ulcer in the colon more than with one occurring upon the leg. When the upper part, or more or less of the entire tract of colon is involved, astringents administered by the mouth prove most serviceable. When there is much ulceration, attested by sanious, muco-purulent stools, the mineral astringents, as sulphate of copper, acetate of lead, &c., seem to answer best. The mercury and chalk, or nitro-muriatic acid’’ act well in altering or promoting hepatic secretion. The emaciated forms and cachectic condition of patients labouring under this disease, generally contra-indicate the exhibition of Next in moment to rest is diet.

placed upon that kind of diet which

why

A few years ago, during a tour in the Pyrenees and the north of Spain, I paid Biarritz a passing visit in September, and was struck by the mildness, indeed the warmth, of its climate, and by the excellence of the sea-bathing. This ye3r. wishing for a few week weeks’ bathing in a warmer temperature than that which our English coast affords in the autumn, I recollected Biarritz, and settled there at the beginning of September, remaining until the end of the month. The climate of Biarritz is modified by its geological as well &c., are very useparia, simaruba, the gum-resins, gallic acid, as by its geographical position. From Borde!J.u;: to Bayonne, I found none to have Mi. Of all the vegetable astringents, equal a strong decoction of the rind of the Bael fruit of Bengal. a distance from north to south of nearly 200 miles, and peneThe plant which produces this is the Œgle Marmelos, belonging trating inland to a considerable depth, extend the vast sandy to the natural order Aurantiaceœ, and the pulp and rind of plains to which the French give the name of Landes. This the fruit are native Indian remedies, to the value of which which has an area of 3,700 square miles, is often called district, testimony is borne by Drs. Royle, J. Hooker, Wight, Mr. R. a but, in reality, it is merely an immense moor, and is desert, and other medical men whose enables them Martin, experience to speak to the subject. Dr. Hooker, in a letter in answer to covered with pretty nearly the same vegetation as our own " some questions upon the point says, I have given the Œgle, moorlands-viz., heather, ferns, gorse, and pines; only, the and seen it used with great effect." The which is climate being very much warmer and drier than our own, now entered in the Dreadnought Pharmacopœia as Decoctum vegetation is much less luxuriant, more stunted, and thinly Œgles, is made by boiling three ounces of the dried rind of the scattered. Indeed, the Landes of France may be said to occupy fruit with a pint and a half of water down to a pint. Of this, a medium position between the heather and fir-clad sandy an ounce and a half is given with a few drops of laudanum, three times a-day. Although I have decidedly found this the moors of Surrey, for instance, and the arid sandy plains of most useful astringent in the purely chronic or milder forms of Spain or of Africa, where a greater degree of heat and dryness dysentery, still, as I have before said, we must not be wedded all but entirely destroy even the vegetable tribes that are to any one remedy, but ring the changes if necessary upon peculiar to such soils. This sandy tract is of course remarkseveral. The possibility of a case being complicated with, and irri- able for the warmth of its temperature, which in summer is tation kept up by haemorrhoids, must not be lost sight of. intense. Although it ceases at the Adour, a river which passes Especial treatment must be at once directed to these when through Bayonne, and which throws itself into the sea about they exist, or astringents, &c., will avail but little. Prolapsus two miles to the north of Biarritz, it exercises a considerable ani also, which results occasionally from the severe straining over the climate of the strip of land some fifteen or in the earlier stage of the disease, becomes, in the later stage, influence itself a source of irritation and consequent diarrhoea. It may twenty miles in depth, which extends from the Adour to the be relieved in some instances, as in Case 6, by strong astringent foot of the Pyrenees. Thus, Biarritz, although out of the injections; in others, by removing portions of the loose hyper- district of the Landes, participates to a certain extent in the trophied external integument with which it is constantly asso- summer heat and the winter mildness of that region of the ciated, or by the direct application of the nitrate of silver or Gascony of former days. nitric acid to the portion of thickened and relaxed mucous The heat of summer is tempered at Biarritz by a sea-breeze membrane which is prolapsed. In the treatment of any case of old-standing dysentery, we which constantly blows inland during the day, and by its situ,must, as I have before said, look to the possible modifying in- ation on a different geological substratum-viz., sandstone Suence of some constitutional taint. Indications of scorbutus, rocks. The Biarritz lighthouse is built on the first sandstone or the pre-existence of this at some recent date, must be met which appears south of the Adour, the coast of the by the administration of lime or lemon juice. I am, indeed, projection formed by low ridges of sand. The village of Landes being inclined to think, that the citric acid which must be contained in the pulp of the Bael fruit is an element in the success which Biarritz is situated around two small coves or bays, themselves "has attended this remedy in India. When there are evidences occupying the centre of a vast bay, formed on the north by the of tuberculous diathesis, as cough, hectic, bad family history, &c., low coast of France, and on the south by the base of the ’the cod-liver oil should be given in conjunction with the mineral Pyrenees, and by the province of Biscay in Spain, into which acids. Sometimes the leaven of old intermittents still lurks the Pyrenees extend, rising tier over tier. As the coast at in the system; and then quinine is a useful adjunct to other’ Biarritz attains a considerable elevation, and the two small remedies. A course of iron, generous diet, and change of air, bays are strewn with large rocks, worked by the ceaseless are necessary, when the dysentery has been quite cured, in action of the powerful Atlantic swell into every conceivable order to remove the cachectic, anaemic state of system asso- shape, the character of the scenery is highly picturesque. The ciated with the more severe and protracted cases. coast with which I should feel the most inclined to compare it is that of Ilfracombe in North Devon. It has not, it is true, the stern grandeur which the geological formation there imparts-to that beautiful spot, but in some respect it is even more irregular and wild. The friable nature of the sandstone rocks BIARRITZ AND ITS SEA-BATHING. offering less resistance to the action of the Atlantic ; they are excavated and fretworkediuto every conceivable shape. BY J. HENRY BENNET, M.D., Until the 25th of September the weather was uniformly fine and dry; no rain falling except a little during the night, on PHYSICIAN-ACCOUCHEUR TO THE ROYAL FREE HOSPITAL. two or three occasions. The sky was clear, generally cloudless, the sea blue, and the sun powerful, so much so as to render an BIARRITZ, a village five miles south-west of Bayonne, is umbrella all but indispensable between nine A.M. and five P.M., picturesquely situated at the bottom of the Bay of Biscay, a when walking in the sun. The wind varied between S.W., S. short distance only from the Spanish frontier. It has long and S.E. When in the S.W., which was mostly the case, been resorted to by the inhabitants of Bayonne and of the there was always a heavy sea rolling in from the Atlantic, (Mf rather from the Bay of When in the S.E., which only Pyrenean district, in summer, for its excellent sea-bathing ; but occurred for a few the sea was much calmer. On one ocdays, was all but unknown to fame until the present Empress casion, for forty-eight hours the wind was due south. Daring brought it into notice by making it her marine autumnal this time the heat was very oppressive, although the thermo, residence. Notwithstanding imperial patronage, the position meter only rose one or two degrees, from 74° or 75° to 76°. I was ef Biarritz is so secluded, and the distance from the French told that such was always the case in summer, when ’she Trent d’Espagne, or south wind, reigned, and that it was feared like - capital is so great - 523 miles - that both its natural and the sirocco on the Mediterranean coast, to which it was commedical advantages and capabilities are but little known and The thermometer, in a cool, shaded room, varied; from pared. appreciated, a circumstance which has induced me to lay 70* at night to 72°, 74°, or 7$° in the day-time ; until the before the profession the following details aweather broke up on the 26th, when it descended, to. 70° early mercury for its specific action; although, in one case which came under my care, amelioration dated from salivation and tender gums accidentally induced. The repeated application of slips of blistering plaster, when there is much tenderness, or any thickening of the coats of the bowel, is followed by good results. In the more advanced stages of the disease, and in the milder cases, when the stools, though frequent, are bilious, and contain but little blood or mucus, where, in fact, we have a healing but partly ulcerated and generally lax state of membrane, the vegetable astringents, as catechu, logwood, cus-

decoction,

the

Biscay.

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