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ON THE WRITINGS OF SYDENHAM.
673
malady; Chomel, in twenty-six cases in which it was Original Papers. manifested, observed it only in ten from the commencement. In the present case, the suddenness and intensity of the attack quickly induced a secondary series of phenomena ; the blood ON THE WRITINGS OF SYDENHAM. especially was seen to have undergone material alterations, its BY GAVIN MILROY, M.D., &c. globules having become dissolved, their hoematiii mixed with the serum, and, either extravasated or blocked up in the (Continued from p. 156.) capillaries, had given rise to the large purple patches evident on various parts; the force of the vascular moving powers, No. VI. being lessened, had given rise to passive congestion in the CHOLERA AND DYSENTERY. various viscera, as the brain, lungs, spleen. That the cerebroHAVING examined, at considerable length, in preceding spinal system was affected, was evident from the temporary paralysis of the side, the twisted mouth, difficult deglutition, papers, the -views of the great English physician of the sevendeafness, diminished intelligence, and the difficulty in vesi- teenth century on the very important subjects of continued cating the cutaneous surface. We thus had three separate and intermittent fevers, and of small-pox, and explained the portions, the ganglial system, the blood, and the cerebro-spinal therapeutic principles which guided him in his practice in axis, each still further tending to depress the other-a state these diseases, I have now to solicit the attention of my of things rendering successful treatment hopeless, as the readers to a brief but faithful analysis of what he has written event proved, the partial amelioration on the fourteenth and on the history of two maladies of scarcely less importance, and fiiteellth days giving but little cause for hope, as such a black which must always occupy much of the thoughts of every one catalogue remained, the dark patches increasing in size and engaged in the active duties of our profession, whether we number, and the sphincters remaining unconscious, showing consider their fatal severity in many seasons, or the very that the state of the blood a:;d of the ganglionic system various and often conflicting modes cf treatment that. have remained unaltered. The post-mortem examination could been recommended for their cure. If I am not mistaken, the only show secondary clianges, and those chiefly as regarded time spent in this inquiry will be neither uninteresting nor the state of the blood, as its flllirlity, its congestion ill the uninstructive. It will be remembered that, when the Asiatic cholera. large vessels of the pia mater and of the lungs, its colour, staining the lining membrane of the heart, and the posterior r2aei1ecl this country in 1831, there was no little contention part of the lungs; these latter organs giving evidence of the among medical men as to whether tho disease described by gradual withdrawal of innervation, and subsequent hypo- our author was of the same nature with the pestilence then stasis. The spleen was in the condition in which it is usually so much dreaded, or whether it was but an aggravated form found in typhus, when the blood has become much dete- of the bilious vomiting a.ad purging" which occurs everv riorated. year in this country during the latter months of summer. It The second case illustrates the more usual occurrence of may not be unprofitableto haveour attention directed to this adynamic symptoms occurring subsequently to the invasion, subject at the present time, when there seems to be every allowing, perhaps, of a more favourable prognosis, as it reason to anticipa 4Le a second invasion of the Oriental scourge. showed that either the intensity of the cause was less, or that Let us first attend to the description that Sydenham gives there was more vital force present to resist it. Here we bad of the disease which he alludes to under the appellation of It is readily know," he says, by good evidence of the ganglionic system being primarily the cholera morbus." affected in fever; there was vomiting and epigastric tender- the following- symptoms: immoderate vomiting, and purging ness, with consequent cephalalgia, at the commencement, but of VITIATED humours,* with extreme difficulty and distress ; no delirium, and when this did subsequently occur, it was not intense pain ; inflation and distension of the belly and intestines; noisy and violent., but of a sorrowful and reproachful kind, cardialgia; thirst; rapid, small, and unequal pulse; heat and more sympathetic with digestive, than positive cerebral, anxiety ; most distressing nausea; sweating; spasmodic contracderangement, analogous, in a certain degree, both in its origin tions of the legs and arms; faintishness, coldness of theextreand cktracter, to the mistaken ideas of hypochondriacs. iiiit-Ics, and other such-like symptoms, which greatly alarm the The treatment of both cases was essentially stimulant: to attendants, and may prove fatal in the course of twenty-four hours." The spasms were unusually severe in the cholera cf rouse the organic nervous energy, and also, if possible, to prevent the further deterioration of the blood, by ammonia the year 1676; for we read, that "not only the abdomen, as is and wine, internally, and by pretty extensive counter-irri- customary in this disease, but all the muscles of the body, and tation, externally, to endeavour to make an impression on the more especially of the arms and legs, v;ere affected with the cerebro-spinal system, were the plans to be adopted, with most dreadful convulsions, so that the patient would somelittle success, as we have seen, in the first case, where, in fact, times leap out of’ bed;, and writhe himself in all directions to the difficulty and even impossibility of vesicating the skin mitigate their violence." The disease, as now described, seems to have appeared in seemed to preclude all chance of recovery. In the second case we had more success. With regard to the leeches London in the epidemic form, but with varying degrees of employed on her admission, wo are always cilary of lessening violence, every year about the end of summer—"almost as the amount of blood in the present epidemic, especially with regularly," says Sydenham, "as swallows do in the beginning a fat, flabby woman, whose powers of resistance are not of spring, and cuckoos in the heat of midsummer." It is supposed to be great; but here the complaint of intense heat, stated most distinctly by him, that it very generally began and the tenderness on pressure at the epigastrium, with the and ended with the month of August, rarely reaching into apparent inefficacy of cczinter-irritatioll the day previous, September. Now, it is to this annually-recurring autumnal seemed to justify the application of a moderate quantity; epidemic that he applies the term of the Legitimate cholera they appeared to have no control over the symptoms, so, morbus, in order to distinguish it from that form of the dishad little effect on the system; but, in only two ease which may occur at any period whatever of the year, is perhaps, more days, the time had arrived when in internal stimulation sporadic, and usually arises from a surfeit, ingluvie aut and external counter-irritation consisted the only hope. crapula,) the immoderate use of fruit, or other like cause. It is in this latter stage especially that the efficacy of That, indeed, such irregularities in diet may be, in not a few blisters is so apparent, cheeking, as they do, the tendency to cases, the immediately exciting and antecedent cause of the congestion of the intestinal mucous surface, and to diarrhoea, attack of the legitimate cholera, will not be denied ; but then and stimulating the nervous system generally. we can never account for the epidemic prevalence of the dis-
the
"
"
"
* Sydenham is more correct than
Cullen in his definition of the disease, respects the nature of the rejected matters. The latter has erroneous’)’ designated these as necessarily bilious:—" Humoris oilo,si vomitus ejusdem simul dejectio frequens," &c. ; and he even intimates, that when the discharges arc not of this kind, the disease wou’d be more properly referred to the genus diarrhoea. We find, too, that several writers in the seventeenth and eighteenth centuries have described under the bead or dysentery what was indisputably genuine cholera. The " dysenteric incruenta of Willis, a coteraporary ofgydenham, was obviously of this nature. Its symptoms Bveri: too characteristic to be mistaken :—"Sudden seizure, enormous vomitings and frequent watery stools, quickly inducing extreme prostration anc in good health have been dreaful fainting; so that patients brought to the point of death within twelve hours of lhe attack." The °dysenteria bilioso-contagiosa" of Degner (1754.) was a’.soofthe same kind. as
AMPUTATION.—" The proper periodfor amputation is a question upon which much discussion has taken place, since the use of the tourniquet and the ligature has made this operation more a matter of option than formerly. Ve are not now compellecl to resort to it as a desperate expedient, as a forlorn hope, after the failure of other means, but have the choice of adopting it from the first, wherever it may promise to benefit our patient by alleviating his sufferings, by shortening his confinement, or by affording him the use of an artificial limb, when we can have no hope of preserving the utility of the natural one-."-Ballingall’s Military SU1’gery.
previously
The reader will find much interesting and instructive information upon thi point in Dr. Harty’s excel’.ent work on dysentery.
674 a particular time of the year in this way. "For," purslain, or water-lily, to the draughts and enemata; but these Sydenltam, "although there remain exactly the Same substances (with the exception, perhaps, of the first-a mild causes which may occasion this distemper towards the end of sedative) could have no effect. The great object is, first, to September as well as in August, (viz., the excessive use of blunt the acrimony of the offending humours-the fomitem fruit &c.,) yet we find that the same effect does not follow ;" morbi-and then discharge them from the body. When this and a little further on he adds, " Whoever carefully attends business is over, which usually requires three or four hours, an to the phenomena of the true cholera morbus must acknow- opiate will very generally complete the cure. I have said that Sydenham strongly disapproved of the ledge that the disease, which occurs at other times of the year, although excited by the same cause, and accompanied practice (which was common in his day, and is too often rewith some of the same symptoms, is altogether different, sorted to in the present) of seeking promptly to arrest the (toto ccelo distare); as if there lay concealed in the air of this vomiting and purging by the use of any form of astringent particular month a mysterious and peculiar something, which remedies. IIe has alluded to this error in more than one part communicates to the blood, or leaven of the stomach, a spe- of his writings; and it will be seen, from the following short cific alteration adapted only to this disease." passage, how sound and far-seeing were his views on patholoHere we have the malarious origin of the disease rather gical subjects. Besides, says he, theinconvenience ofthereby hinted at than distinctly affirmed. With respect to the asser- prolonging the disease,"the acrimonious and corrupt humours, tion, that the sporadic and epidemic forms of the disease are which ought to be discharged, being, by this means, detained essentially distinct, it must be confessed that our author has within the system, exert their pernicious power upon the rather strangely omitted to point out any well-marked discri- blood, and occasion a fever, that is usually of a bad kind, and minating features hetween the two, and that, indeed, his own is accompanied with dangerous symptoms, so as scarcely to be expression, "alterins cst subsellii" —applied to the one as removed without giving an emetic, although there may be contra-distinguished from the other-more properly indicates then no longer any tendency to vomiting." The allusion here made, to the consecutive efforts of sordes a difference in degree rather than a diversity in kind. At all events, few, I should think, will hesitate in admitting that retained within the bowels, suggests a most important point of there is a much more decided line of distinction between the practice in the treatment of all febrile diseases, as well as of legitimate cholera morbus of Sydenham, and the malignant cholera. Whether, indeed, the typhoid fever that so often epidemic which visited this country in 1S31-2, than between supervened upon an attack of the malignant epidemic when it his two forms of the disease. For is it not the case that we visited Europe sixteen years ago, was the result of this cause, miss some of the most characteristic features of the Asiatic or whether it was not, rather, one of the stages, so to speak, of disease itself, cannot now be inquired into. But whatever pestilence, even in the very worst cases of cholera described by him ? The very circumstance of his mentioning that the opinion may he held upon this point, every experienced physpasms were sometimes so severe, that the patient sprang out sician will, I am sure, add his testimony to the soundness of the of bed in the hope of obtaining relief, clearly shows that there pathological position laid down by our clear-sighted author. Should the patient be in a state of very great exhaustion, was not that extreme prostration and sudden collapse of the vital energies which constitute so remarkable a feature in bad from the continuance of the evacuations tor ten or twelve cases of the Oriental malady. Besides, where is the rice- hours, the extremities being cold and the pulse scarcely perwater appearance of the ejections, with the utter absence of ceptible, before the physician has been called in, it may be all traces of bile; or the leaden blueness of the surface; or necessary to have immediate recourse to the use of laudanum the violently-retracted state (not the inflatio et distensio of our — sacram lciejus morbi anchoram as Sydenham somewhat exauthor) of the abdominal muscles: the suppression of the travagantly terms it,-" which is not only to be given during biliary and urinary secretions; the tarry state of the blood; the urgency of the symptoms, but repeated every morning not to mention the much greater tendency to consecutiveand evening after the vomiting and purging have ceased. typhoid fever, and the limitation of the disease within no until the patient recovers his former health and strength."* month or season of the year ? While, then, I cannot reco- The wisdom of the latter part of this advice may be fairly gnise in Sydenham’s autumnal epidemic the same disease as questioned; nav, it may be roundly denied. The use of any that which, issuing from amidst the jungles of the Ganges, medicine that is so apt to "lock up" the liver and other circumambulated the round world within the experience of abdominal emunctories, as opium unquestionably is, cannot be most of my readers, and once more threatens to visit oui judicious, when the immediate severity or danger of the shores, it deserves particular notice that his legitimate cholera cholera, attack is over. Then is the time for the exhibition of morbus, attended with the most alarming and often rapidly. mild mercurials and gently-tonic aperients, such as the infufatal symptoms, was a much more frequent malady in Londor sion of rhubarb, the compound gentian mixture, &c., with
ease
at
says
the
in the seventeenth than it is in the nineteenth century. Th( remark of one of the older commentators on our author, thai "for the most part it proves niortal; no distemper, except perhaps, the plague and pestilential fevers, being so suddenly destructive as the cholera," scarcely holds true of the diseas( in the present day. But we proceed to matters of more im Dortance.
Treatment.—Whatever may be thought of Sydenham’s views respecting the nature and origin of the cholera morbus, his treatment of the disease is, in my opinion, unexceptionably (or nearly so) most judicious, and well deserving the attention of all practitioners. Were the principles of his therapeutics better known, and more thoroughly appreciated by the profession at large, we should less frequently have to regret the frequent instability-not to speak of the occasional positive mischief-of medical practice. Regarding the vomiting and purging as truly efforts of Nature to get rid of the vitiated humours, whose presence in the stomach and bowels is the immediate cause of these symptoms, Sydenham condemns all attempts to check them at once by the use of astringents and opiates; while he equally disapproves of the exhibition of purgative medicines, which are liable to aggravate, unnecessarily, the intestinal irritation; and he lays down as the basis of all sound and successful treatment, the simple rule, "partly to evacuate, and partly to dilute the offending matters." For this purpose he recommends that the patient should be made to drink several tumblerfuls of any tepid demulcent beverage, (he particularly names very weak chicken tea,) while, at the same time, a large quantity of the fluid is administered, at several times successively, in the way of injection, until about three gallons have been taken into the body, and subsequently rejected He occasionally added an ounce of the syrup of lettuce, violets
alkaline medicines. Had space permitted, I might have wished to have entered at some little length into the treatment of the various forms of cholera, including, under this term, not only the mild and severe forms of the domestic disease!’ but also the Gangetic pestilence. But this would lead me far astray. I shall therefn nnlv;
ctrnnrlv rnrnmoonrl tn fhn thn"ohtfvil
brethren the general theraconsidema,t.ion of my professional brethren peutic principles which Sydenham has laid down as the guide of his practice, and leave the carrying out of the details to the judgment of each reader. The next subject that is to occupy our attention is oneof equal importance with that just dismissed-viz., the history of epidemic Dysentery, a disease which was much more common in England in the seventeenth century than it is in the present,! but is, alas ! anything but unfrequent in the sister island, not to mention almost all hot and many temperate climates. Sydenham saw a great deal of it, and the descriptions which he has left of its characters, mode of treatment, &c., have always been regarded as among the most valuable portions of his writings. First, of its symptoms: in some cases dysentery sets
considerationof my professional
* Thus, in a case briefly reported by our author in his account of the epidemic diseases that prevailed in London from t67n to 1680, he seems to have repeated the dose itwenty-five drops of his liquid laudanum) every half-hour, until the alarming symptoms were quieted, and then to have given it, in smaller quantities, at intervals, ad evs scilicet confirmandam. t Dr. Heberden says, that the mortality in London alone, from dysentery, in the seventeenth century, was never under 1000, and sometimes exceeded 4000 per annum, and that, at the close of last century, the number of deaths from this cause was not more than twenty in all. (On the Increase and Decrease of Different Diseases in London. 1801.) Sydenham alludes to the " endemic disease of Ireland," and expresses his ignorance whether it was the same malady as that with which he was so well acquainted. In Cromwell’s dispatches, we learn that the British army frequently suffered most severely from dysentery.
675 in with the ordinary phenomena of pyrexia-viz , chills and shivering, followed by heat. Often, however, there is lo sign of any precursory fever; the patient is at once seized with severe griping pains, and these are quickly followed by the
To appreciate as they deserve our author’s therapeutic principles, it is necessary that the reader be acquainted with his views respecting the rotiology of the disease. According to Sydenham, dysentery is not a local, but a general or systemic disease, induced by the introduction of certain noxious particles into the blood, and requiring for its cure the elimination and discharge of the peccant or offending matter from. the body. In more than one passage of his writings, he calls it " a, fever turned inwards," (febris in intestfna introversa ;) evidently because its exciting and proximate causes were, in his opinion, if not identical with, yet altogether analogous to, those of certain indubitable fevers; the predominant affection of the bowels serving, in a measure, to abate the distinctness and severity of the pyrexia, by eliminating from the system,
There is always an excruciating distress, and a of most painful forcing-down of the bowels at stool. The motions are frequent, of a mucous and not of a stercoraceous character, and are generally streaked with blood. Occasionally, indeed, a stercoraceous motion intervenes; and this (it is worthy of remark) is observed to be passed without much pain. In some instances, there is not any appearance of blood in the stools during the whole course of the attack. This symptom, therefore, is not essential to the disease; for if the purgings be frequent, mucous, and attended with severe tormina of the bowels, and with tenesmus, the case is justly in part at least, the acrimonious humours contained in the mass of the blood. That such is the case, he argues to be considered to be one of dysentery. Although the disease may not be ushered in with pyrexia, highly probable from the circumstance, that either cotempofever very generally supervenes in its progress, especially if raueously with, or it may be immediately before, the regular the patient be young, or when he has been treated by the use invasion of an epidemic dysentery, there has often been obof cordials; the tongue is covered with a thick whitish mucus, served to be prevailing a form of fever that exhibited much of the genius and character of that disease, the intestinal or it becomes even black and dry, if the heating regimen has been carried still further. At the same time, there is usually symptoms only being in a very mitigated degree. In his ingreat prostration of strength, much anxiety and depression of troductory general remarks on epidemic diseases, we find this alluded to:spirits, with every other symptom indicative of a bad form of circumstance " When dysentery is the prevailing disease of the season, fever. Unless very skilfully treated, dysentery is a disease attended not only with great suffering, but with very con- the fever of that year exhibits not a little of the same chasiderable danger. " If the vital energies become much ex- racter, (excepting only that in the former the morbific matter hausted by the repeated purgings, before the peccant matter is discharged by stool, and there are certain other circumbe expelled from the blood, and a coldness of the extremities stances arising from this peculiarity,) as is abundantly evisupervenes, death may occur within even the ordinary limits denced by the resemblance in their mode of attack, and by of acute diseases." Even although the patient may escape at the occurrence of aphthœ, and various other symptoms of the the time, not a few distressing and even dangerous symptoms same kind in both." await him. Thus, insteal of the sanguineous filaments that Such was the dysenteric fever, of which mention was made in the early stages of the disease were mixed with the in a previous article, but which we deferred to consider until motions, a quantity of pure blood, without any admixture of the present time.* mucus, may be voided with every effort at stool; an indiWhat, then, are the indications of treatment in dysentery?z cation of the erosion of some of the larger vessels of the Sydenham, influenced,unquestionably,too humoral bowels, and consequently a most unfavourable omen. In views of the disease, replies:-" To make an immediate revulother cases, the intestinal inflammation ’-arising from the sion of the acrimonious humours by venesection, to temper copious afflux of the hot and acrimonious matter to the the remaining mass of the blood, and to discharge the said affected parts," is so violent as to be followed by gangrene. humours from the body by means of’ purgatives." His pracThe occurrence of aphthæ in the mouth, towards the decline tice was therefore prompt and simple; he opened a vein in of the disease, is usually a bad symptom. When the disease the arm, gave an opiate the same evening, and a lenitive has lasted very long, " the intestines at length," says Syden- aperient next morning. If this acted rather powerfully, or ham, "seem to be affected successively downwards, until the the patient was much exhausted by the operation, an opiate whole mischief be settled on the rectum, and terminate in a was given in the course of the day. The purgative was not tenesmus. When this takes place, the expulsion of ster- repeated until the second day following, an opiate being administered morning and evening on the intermediate day, " in coraceous motions-very differently from what occurs in the early period of dysentery-occasions great pain in the bowels; order to diminish the violence of the symptoms, and obtain a the feces, in their descent, abrading the small intestines." respite, while the physician is engaged in exterminating the Had our author been better acquainted with morbid anatomy, peccant humour." The same practice was pursued on the he would, doubtless, have substituted the term " large" for fourth and fifth days-a purge on the former, followed by an "small" in this passage, as the tenour of his remarks evi- opiate, and two doses of the opiate on the latter. When the dently applies to the ulceration and constriction of the lower disease was more than usually severe, Sydenham advises the part of the colon and of the rectum, that are so apt to occur in opiate to be repeated more frequently-twenty drops of his laudanum every eight hours or so, and an enema of milk, old cases of dysentery. Before proceeding to explain his method of treatment, with an ounce of theriaca Andromachi (a mild opiate confecSydenham judiciously reminds his readers, that the character tion of that day) in it. He tells us that he never found any or type of dysentery is apt to vary not a little, in some partiinconvenience from so free a use of opiates, (the patient culars, in different seasons, just as we find to be the case with having been purged thrice, as just now explained,) and that small-pox and other epidemic maladies; and consequently, he had known several to take them every day for some weeks that the line of practice which may have been found to be running, when the disease proved inveterate.+ most successful in one epidemic, or at one period of an epiThe best drink during the course of the disease is " milk, demic, may require to be very materially modified under * In no part of his wi itings does Sydenham allude to other the dysentery altered circumstances. He alludes to the greater severity or the fever ever exhibiting any infectious character. But every and fatality of the disease in the beginning and early period, ieader dysenteric of his works is well aware how remarkably silent he is upon this than in the progress of most visitations-a remark, by the by, very important, and too frequent, cause of many d seases. Will’s, however, the same time, says, that although the ordinary that applies with equal truth to the plague and to epidemic who practised in London atwas not valde contagiosa aut sæpius lethalis," dysentery of the metropons diseases generally-so that although, with respect to the yet that sometimes it was highly malignant, and as it were pestilential, numbers of the sick," (as he says in one passage,) " the evil causing great mortality, and spreading wide " miasma suum per contabecame every day more widely spread, until at length it gium." t It is when describing the excellent effects of laudanum, judiciously arrived at its acme, when consequently more perished than administered, in dysentery, that our author records his gratitude to the on its first invasion; yet the symptoms were more violent at Almighty Being (&pgr;&agr;&ngr;&tgr;&ohgr;&ngr; &Dgr;&ohgr;&tgr;&eegr;&rgr;&agr; ∈&agr;&ohgr;&ngr; for bestowing so admirable a remedy So necessary an instrument," sa s he, " is this medicine the beginning than at the height, and much more than in the upon mankind. the hands of a skilful physician, that the art of medicine would be but decline of the visitation, and, other circumstances being alike, in lame and imperfect without it. Whoever is well acquainted with its use many more were swept away." To this may be added, that will effect more than could have been expected from any single remedy. the longer the disease continued, the more of a humoral or He, indeed, must be ignorant, and have but a very inadequate knowledge moist character it seemed to acquire; in other words, the dry of its virtues, who regards it merely as an hypnotic, an anodyne, and an astringent; for it is excellently well suited (like the Delphic sword) for gripings, the ineffectual tenesmus, the intensity of the fever,many other purposes, and is, indeed, the most potent cardiac (I had almost and other unfavourable symptoms, abated in severity; while said the only one) hitherto discovered." Dr. George Cheyne, in his wellthe stools became more abundant and more stercoraccous,known essay, On Health and Long Life, expresses himself in a very " until at length, the epidemic constitution ceasing, the tor- similar manner as to the virtues of opium. " In fine," says he, " Providence has been kind and to us beyond all expression in furnishing lnina of the bowels were scarcely felt, and the alvine dejec- us with a certain relief, ifgracious not a remedy, even to our most intense pains tions were more fxcal than mucous :’ and extreme miseries."
purgings.
IB
sense
much by his
’
.
676
_
boiled with thrice its quantity of water, or the white decoct’ion, cine, and never giving it for two or three days after the last But nothing tended so much to recruit the patient as as it is called, made of burnt hartshorn and the crumb of purge. white bread, of each two ounces, boiled in three pints of the free use of the air, as soon as the fever had left him." water down to two, and then sweetened with fine sugar." Notwithstanding some errors, and not a few omissions, in When the prostration is very great, it may be necessary to the plan of treatment recommended by our author in dysengive some Canary wine and water, boiled together, and then tery, there is much in it most assuredly to meet with very allowed to become cold. As to food, panada and broth, made cordial approbation. It is based upon the sound principle of of lean mutton, are especially mentioned by our author. regarding the disease, not as a mere local affection of the As Sydenham expressly states that dysentery, like indeed intestines, but as a constitutional malady, with, prominently every other epidemic disease, is not uniformly, and in all marked local symptoms.* If this be true, how injudicious seasons, attended with exactly the same symptoms, general must it be to substitute, as has been the fashion of late years, as well as local, we are prepared to find that his treatment such appellations as entero-colitis, coloititis, &c., for the old was modified according to the type and character of the preand infinitely better one of dysentery! It has been, I am vailing constitution. Thus, on the first outbreak of the dis- convinced, this very system of extravagant localization that ease, when the tormina of the bowels were more, and the has introduced, since the beginning of the present century, so purgings were less, severe than at a subsequent period, the much erroneous doctrine in reference to the true pathology practice that he followed with success was somewhat similar and treatment of many of the pyrexise. Far too much attento that which he recommends in the cholera morbus. If the tion has been not unfrequently paid to the discovery, upon patient was young and feverish, he first drew blood from dissection, of every lesion, however minute and inconstant, in the arm, and, an hour or two afterwards, he gave his patient each portion of the bowels, and, indeed, of every abdominal of viscus, while all the time the mind has been entirely withcopious draughts of cold whey, and had a large quantity the same fluid, tepid, thrown up the bowels. " I always drawn from the general history of the malady, its probable found," says he, " the gripes and bloody stools cease after the causes, the season of the year when it prevailed, the condition rejection of the fourth enema. This business being over, and of the patients when attacked, the influence of medicine and individual l’rlRRR- fJ,nc1 other circumstances which no all the whey discharged, (which, if expeditiously done, occuwill ever neglect. In the case of dysentery, wise was at to or three the once two put physician hours,) pies only patient bed, when he soon fell into a profuse perspiration, which was the intestinal affection is unquestionably not a primary, simple, to be kept up, but not forced, by cardiacs, for four and twenty or uncomplicated inflammation, nor can it be suddenly arrested hours-the only drink allowed during this time, and for the by the prompt use of vigorous antiphlogistic measures; and next three or four days, being warm milk." This method of even, if it could be, the subjugation of the local suffering drowning the disease (to use the quaint expression of our would not necessarily be followed by a cure of the whole author) by a plentiful dilution of fluid succeeded in very disease. The disease in the epidemic form (for it is of that many cases during the firstautumn of its prevalence; but it weare now speaking) does not arise from the direct appilca,failed afterwards when it had lost much of its subtlety, and tion of any irritant matters, derived ab extra, to the mucous become more humoral; in other words, when the dry gripings surface of the bowels; otherwise it might be extinguished ("juguler" is the silly word used by certain French writers) gave way to profuse and bloody purgings. With respect to that form or type of fever which existed in the manner mentioned. But it is not so; it is a bloodin London, with greater or less malignancy, during the whole malady, in which, as in many other poisonings of the circulat. period that the dysentery was the prevailing epidemic, and ing fluid, there is a predominant affection of some particular to which Sydenham gave the appellation of dysenteric, from organ or organs. We see this illustrated in poisoning from the belief that the two diseases were essentially of the same arsenic. When the poison has been introduced into the system, not by being received directly into the stomach, but by teing nature, however much they varied in point of the severity of the intestinal affection, the following extract will best serve applied to the skin, or injected into the veins, the whole body is unquestionably more or less impregnated or infected; but to explain his pathological and therapeutic views :" Having observed that the phenomena of the fever ofthmost conspicuous effects, in the way of inflammation,are many dysenteric patients were evidently the same asthose produced upon the stomach. Now it would be just as reasonwhich accompanied the solitary fevers of this season, it able to look upon the gastritis as constituting the only essenseemed but reasonable to believe that a cure might be; tial feature of such a case, or (to take another example) the effected by imitating, in a measure, that mode of evacuation sorethroat in scarlatina as the pathognomonic character of this which Nature usually employed to get rid of the acrimonious; fever, as to regard dysentery to be synonymous with inflammacorrosive matters which are the real cause of the dysentery tion of the coloi,. Notwithstanding these remarks,I am very far from underitself, as well as of the supervening fever. I had recourse, therefore, to the same plan of treatment, both as respects valuing the importance of attending to the local disease, or of bleeding and the repeated exhibition of purgatives; omitting, having prompt recourse to the use of active local means for however, the use of opiates, which, by detaining the peccant its relief. Nay, it is the very omission of such remedies that matter requiring to be evacuated, not only did no good, but constitutes, in my opinion, the chief blemish in Sydenham’s of leeches, and the perseveringly (very different from what was the case in dysentery) proved practice. The positively hurtful. For the first few days the patient lived continued use of hot-not merely warm—stupes or poultices entirely o;i gruel, barley-water, panada, and such like articles, to the abdomen, forms an indispensable part in the treatment warm small beer being allowed for drink. After he bad been of every case of dysentery. The soothing relief,that is or a little chicken other once or twice, light food was afforded by these means, is well known to all who have expurged allowed. The third interposing a day between each, perienced the truly distressing sufferings of this disease. moreover, makes no allusion to the employment generally terminated the disease, but sometimes further of Sydenham.and the continued was When emetics; yet, on the invasion of the disease, there is very required. patient purging not a more safe and-often, too—efficacious remedy than a weak after the fever had left him, and regained his but slowly, (aswas frequently the case in hysterical subjects,) full dose of ipecacuan to induce free vomiting. For not only I endeavoured to restore it and repair the loss of spirits by a is the stomach and upper part of the duodenum thereby small dose of laudanum, rarely, however, repeating the medi- promptly relieved of any offending matters which might otherwise have greatly increased the existing irritation, and * Morton and Willis, both cotemporaries of our author, take ve’y similar the liver effectually enrulged, but the violent detrusive action views as to the intimate reiatio..ship between the co-prevaiting dysentery of the bowels is often, at the same time, speedily miugated, if and fever. The former, after alluding to the frightful mortality in London from the first of these diseases,—from 300 to 500 dying each week,-goes on not arrested; while, immediately afterwards, a copious perto remark that it was replaced by a remittent fever, which exhibited during spiration is very generally induced, this serving as a most its pyretic paroxysms distinct dysenteric symptoms-,’ Whence," says he, * Frank, while he admits that the precursory pyrexial symptoms are "it is obvious that the dysentery could only be regarded as a symptom, sometimes so imperfectly marked as to be scarcely recognisable, has deand that the fever was the primary disease." WiUis tells us that this fever .
application
purge,
strength
often assumed a continued type, and was then apt to prove infectious. He expressly alludes to its being accompanied, in many instances, with dysenteric symptoms. Some of our best modern writers on epidemic dysentery have expressed very similar opinions. Frank says, that " when dysentery is an effect or symptom of typhus, it is a most unfavourable omen ; and Dr. Cheyne, in his excellent account of the epidemic in Ireland in 1818, uses these remarkable words :-It was sometimes converted into a fever, while, on the other hand, fever was frequently converted into dysentery; in short, these forms of disease were convertible the one into the other, ro that the opinion of Sydenham, that dysentery is a febris introfo’sa, received support from our observations."
fiiie(i the disease to be "corporis totius febrilis affectto, in intestina, maxime crasa, furicns." 1’ The late Dr. James Johnson remarks, with mnch truth, upon this subject,—"I am in every case inclined to regard inflammation rather as a of dysentery, as a contingent effect, and not asa sequence than a canse uniform result." " Innammation and ulceration secondary or ternary lmk, in the mo bid chain, and many a case of real dysentery is checked and cured bcfcie either of these takes place; that is, when thece is merely an increased afflux of blood to the mesenteric and portal vessels, a superinitation in the mucous membrane of the bowels, and an increased discharge of acrid secretions from the intestinal glands."
are
677 useful derivant to the inflamed mucous membrane. I should say that bleeding, (always supposing that the intestinal symp-
sufficiently acute to require this evacuation,) followed by an ipecacuan emetic, and, upon the completed action of vomiting, the steady application of hot fomentations to the abdomen, constitute by far the most appropriate and successful practice in the early stage of dysentery. Quite as much, if toms be
by the excessive administration of large doses of calomel by many of our own countryanen, as by the indiscriminate venesection that has been recommended and practised by a large section of the French practitioners. There is not a fact in therapeutics of whose truth I am more thoroughly convinced, than that calomel very often .acts as a most pernicious irritant of the intestinal canal, more especially when its mucous membrane is in a state of inflammation. Whether this effect may not, sometimes at least, be owing to the partial conversion of the chloride into the bichloride, from the presence of acid (muriatic?) in the bowels, I must leave to others to determine : the fact of its irritative - qualitiesin many instances cannot, I think, be gainsayed. This .circumstance has, for many years past, induced me invariably to substitute the much milder preparation, the hydrargyrum cum cretâ, for the more general favourite, calomel, whenever irritation of the bowels was to be avoided. In doses of from -five to ten grains, combined with double the quantity of the -carbonate of soda, and the dose repealed every two, four, or .six hours, according to the nature of the case, it may be given with very great advantage in a variety of circumstances. In dysentery, the addition of a grain of ipecacuan, and, if the intestinal irritation continue very severe, of the quarter or half of a grain of opium, will often prove of decided utility. And here I cannot but remark, that the valuable effects of ‘opiates in this disease are, in more respects than one, strikingly enhanced by associating them with some alkaline medicine. The extremely acid state of the dejections (in many cases at least) will account for this result-a result to which I particularly isxvite the attention of my professional brethren, from the unequivocal benefits which I have often, had occasion to witness by acting upon this simple therapeutic precept. A mixture, containing the carbonates of soda and magnesia, with the tinctures of henbane and opium, will generally answer exceedingly well : if the looseness be profuse, chalk will, as a matter of course, be substituted. When the bowels have once been quieted, or, indeed, earlier, if there is reason to suspect any offensive lodgment, a purgative should always be administered; and certainly a much safer, as well as more efficacious one than that used by Sydenham—viz., an infusion of senna, rhubarb, and tamarinds, sweetened with manna—is castor oil. During the stage of convalescence, some preparation of bark will very generally be required, more especially in the dysentery of hot climates. not more, mischief has been done
Fi!zroy-sqtiare,
Dec. 1847.
OBSERVATIONS ON
DR. SIMPSON’S ANÆSTHETIC BY ROBERT
STATISTICS.
BARNES, M.B.,
LECTURER ON MIDWIFERY.
commanded rather than recommended by Dr. apathize our patients during the process of natural The Edinburgh professor, in an extraordinary labour. sentence to address to an enlightened profession, "for his part more than doubts if any man (rejecting willingly its benefits) is really justified, on any grounds, moral or medical, in deliberately desiring and asking his patients to shriek and writhe on in their agonies for a few months, or a few years longer, in order that, by doing so, they may defer, forsooth, to his professional apathy, or pander to his professional caprices and prejudices." What is itthat emboldens Dr. Simpson to stigmatize ’" nineteen out of twenty, or ninety-nine out of one hundred," medical men as influenced by " indolence and apathy," by ‘ caprices and prejudices"? Does Dr. Simpson imagine that
WE
are
Simpson
to
any one rational man, accustomed to act upon calm reflection and logical deduction from facts, will thus be dragooned into adopting, in every case of natural labour, the use of ahazardous and doubtful agents? Can Dr. Simpson’s singular mode of argument be really directed to the medical profession; or is it possible that it is aimed rather to secure another class of converts—viz., those " zealous missionaries who set out to persuade other friends to avail themselves of the same ?" &c. Although the main strength of Dr. Simpson’s minatory
recommendation to employ chloroform in midwifery consists in the assurance that " medical men may oppose for a time the superinduction of anæsthesia, in parturition ; but they will oppose it in vain; for certainly our patients themselves will force the use of it upon the profession;" still it must be confessed that he endeavours to support his doctrine by pseudo-scientific arguments, albeit those arguments are as repugnant to the ruk’s of scientific investigation as are his extra-scientific arguments to good taste. His paper, published la Tns LANCET, and newly-edited, with additions, for general circulation through the post, consists of two parts-First, there is an imperfect cletail of cases; second, there is another exhibition of Dr. Simpson’s weakness in statistics. With regard to the cases, we find that they are ten in number, including one reported by Dr. Murphy. An examination of these cases shows that Dr. Simpson knows or practises no limit in the administration of chloroform. In Cases 2 and 4 he expressly states that the patients were kept under its influence until after the placenta was removed. In one of these cases the enormous quantity of four ounces of chloroform was used. " Audantes forttina juvat," and no doubt science and humanity would lose by excess of eaution; but to free himself from the charge of temerity. Dr. Simpson is bound to produce the evidence which first emboldened. him to use so freely an agent so powerful. What previous experiments on animals had he performed which justified him in putting human mothers"under its influence? Case G affords an interesting physiological fact, showing that thereflex function remains active under the influence of chloroform. Dr. Simpson foundthat" hewas able to increase the intensity and force of each recurring pain, by exciting the uterus and abdominal muscles through pressure on the lower part of the vagina and perinæum." But when Dr. Simpson further says, thathe has the conviction that in this case the forceps would in all probability have been ultimately required, provided he had not been able to have interfered in the way mentioned," we are at a loss to know how this conviction arose, or why this same manoeuvre could not have been employed upon the patientin a natural state without"inilicting great agony upon her." Case 9 was one in which haemorrhage occurred during the anæsthetic state. it affords a proof that chloroform secures no immunity from flooding. Having given his cases, Dr. Simpson things it incumbent on him to make out that the pains of labour may in themselves be fatal; and he accomplishes this in a remarkable manner. After several quotations, not much to the point, he makes another grand statistical effort, and presses the figures of Dr. Collins, after a most tyrannical fashion, into his service. The statistical professor siys, that " according to calculations he has made from Dr. Collins’s data, while in women whose sufferings were terminated within two hours, only 1 in 320 of the mothers died; where the labour varied in duration from two to six hours, 1 in 145 of the mothers died, &c.’ and out of all those whose parturient sufferings were prolonged beyond thirty-six hours, one in every six died." What is the use of this statement ? Is it not well known that pain in labour is not always or necessari’ly proportioned to its duration ; those whose labours ended within two hours may have endured more pain than those whose delivery was more protracted. Aloreover, who will admit, besides Dr. Simpson, that the greater mortality among those who were longer in labour was owing to greater paiu ? Are not ths deaths produced by certain well ascertained causes ? Did not some die of convulsions; some, of puerperal fever; some, of the consequences of contracted pelvis; some, of flooding ? Can chloroform avert all these evils ? Could the exhibition of chloroform vapour, by saving these nnfoitunate women from pain, have saved them their lives ? But Dr. Simpson does not confine his researches to obstetric cases ; he seeks a further reinforcement from "analogy, and from what is the fact in surgery." He believes that, "as a counteraction to the influence of pain, the state of artificial anesthesia does not only imply a saving of human suffering, but a saving also of human life." The proposition may be true as far as it concerns surgical operations, but I think it will be granted that the following statistical perversion does not prove it; certainly, it does not prove the assumed corollary of Dr. Simpson, that the diminution of the pain of labour will diminish the mortality. Dr. Simpson’s analogical argument is as follows:—Malgaigne found, inamputations of thigh, in the hospitals of Paris, that sixty-two in 100 died; in Edinburgh, fifty in 100; in Glasgow, forty in 100; in Phillips’ collection, forty in 100. The gross mortality in un-
the
malady; Chomel, in twenty-six cases in which it was Original Papers. manifested, observed it only in ten from the commencement. In the present case, the suddenness and intensity of the attack quickly induced a secondary series of phenomena ; the blood ON THE WRITINGS OF SYDENHAM. especially was seen to have undergone material alterations, its BY GAVIN MILROY, M.D., &c. globules having become dissolved, their hoematiii mixed with the serum, and, either extravasated or blocked up in the (Continued from p. 156.) capillaries, had given rise to the large purple patches evident on various parts; the force of the vascular moving powers, No. VI. being lessened, had given rise to passive congestion in the CHOLERA AND DYSENTERY. various viscera, as the brain, lungs, spleen. That the cerebroHAVING examined, at considerable length, in preceding spinal system was affected, was evident from the temporary paralysis of the side, the twisted mouth, difficult deglutition, papers, the -views of the great English physician of the sevendeafness, diminished intelligence, and the difficulty in vesi- teenth century on the very important subjects of continued cating the cutaneous surface. We thus had three separate and intermittent fevers, and of small-pox, and explained the portions, the ganglial system, the blood, and the cerebro-spinal therapeutic principles which guided him in his practice in axis, each still further tending to depress the other-a state these diseases, I have now to solicit the attention of my of things rendering successful treatment hopeless, as the readers to a brief but faithful analysis of what he has written event proved, the partial amelioration on the fourteenth and on the history of two maladies of scarcely less importance, and fiiteellth days giving but little cause for hope, as such a black which must always occupy much of the thoughts of every one catalogue remained, the dark patches increasing in size and engaged in the active duties of our profession, whether we number, and the sphincters remaining unconscious, showing consider their fatal severity in many seasons, or the very that the state of the blood a:;d of the ganglionic system various and often conflicting modes cf treatment that. have remained unaltered. The post-mortem examination could been recommended for their cure. If I am not mistaken, the only show secondary clianges, and those chiefly as regarded time spent in this inquiry will be neither uninteresting nor the state of the blood, as its flllirlity, its congestion ill the uninstructive. It will be remembered that, when the Asiatic cholera. large vessels of the pia mater and of the lungs, its colour, staining the lining membrane of the heart, and the posterior r2aei1ecl this country in 1831, there was no little contention part of the lungs; these latter organs giving evidence of the among medical men as to whether tho disease described by gradual withdrawal of innervation, and subsequent hypo- our author was of the same nature with the pestilence then stasis. The spleen was in the condition in which it is usually so much dreaded, or whether it was but an aggravated form found in typhus, when the blood has become much dete- of the bilious vomiting a.ad purging" which occurs everv riorated. year in this country during the latter months of summer. It The second case illustrates the more usual occurrence of may not be unprofitableto haveour attention directed to this adynamic symptoms occurring subsequently to the invasion, subject at the present time, when there seems to be every allowing, perhaps, of a more favourable prognosis, as it reason to anticipa 4Le a second invasion of the Oriental scourge. showed that either the intensity of the cause was less, or that Let us first attend to the description that Sydenham gives there was more vital force present to resist it. Here we bad of the disease which he alludes to under the appellation of It is readily know," he says, by good evidence of the ganglionic system being primarily the cholera morbus." affected in fever; there was vomiting and epigastric tender- the following- symptoms: immoderate vomiting, and purging ness, with consequent cephalalgia, at the commencement, but of VITIATED humours,* with extreme difficulty and distress ; no delirium, and when this did subsequently occur, it was not intense pain ; inflation and distension of the belly and intestines; noisy and violent., but of a sorrowful and reproachful kind, cardialgia; thirst; rapid, small, and unequal pulse; heat and more sympathetic with digestive, than positive cerebral, anxiety ; most distressing nausea; sweating; spasmodic contracderangement, analogous, in a certain degree, both in its origin tions of the legs and arms; faintishness, coldness of theextreand cktracter, to the mistaken ideas of hypochondriacs. iiiit-Ics, and other such-like symptoms, which greatly alarm the The treatment of both cases was essentially stimulant: to attendants, and may prove fatal in the course of twenty-four hours." The spasms were unusually severe in the cholera cf rouse the organic nervous energy, and also, if possible, to prevent the further deterioration of the blood, by ammonia the year 1676; for we read, that "not only the abdomen, as is and wine, internally, and by pretty extensive counter-irri- customary in this disease, but all the muscles of the body, and tation, externally, to endeavour to make an impression on the more especially of the arms and legs, v;ere affected with the cerebro-spinal system, were the plans to be adopted, with most dreadful convulsions, so that the patient would somelittle success, as we have seen, in the first case, where, in fact, times leap out of’ bed;, and writhe himself in all directions to the difficulty and even impossibility of vesicating the skin mitigate their violence." The disease, as now described, seems to have appeared in seemed to preclude all chance of recovery. In the second case we had more success. With regard to the leeches London in the epidemic form, but with varying degrees of employed on her admission, wo are always cilary of lessening violence, every year about the end of summer—"almost as the amount of blood in the present epidemic, especially with regularly," says Sydenham, "as swallows do in the beginning a fat, flabby woman, whose powers of resistance are not of spring, and cuckoos in the heat of midsummer." It is supposed to be great; but here the complaint of intense heat, stated most distinctly by him, that it very generally began and the tenderness on pressure at the epigastrium, with the and ended with the month of August, rarely reaching into apparent inefficacy of cczinter-irritatioll the day previous, September. Now, it is to this annually-recurring autumnal seemed to justify the application of a moderate quantity; epidemic that he applies the term of the Legitimate cholera they appeared to have no control over the symptoms, so, morbus, in order to distinguish it from that form of the dishad little effect on the system; but, in only two ease which may occur at any period whatever of the year, is perhaps, more days, the time had arrived when in internal stimulation sporadic, and usually arises from a surfeit, ingluvie aut and external counter-irritation consisted the only hope. crapula,) the immoderate use of fruit, or other like cause. It is in this latter stage especially that the efficacy of That, indeed, such irregularities in diet may be, in not a few blisters is so apparent, cheeking, as they do, the tendency to cases, the immediately exciting and antecedent cause of the congestion of the intestinal mucous surface, and to diarrhoea, attack of the legitimate cholera, will not be denied ; but then and stimulating the nervous system generally. we can never account for the epidemic prevalence of the dis-
the
"
"
"
* Sydenham is more correct than
Cullen in his definition of the disease, respects the nature of the rejected matters. The latter has erroneous’)’ designated these as necessarily bilious:—" Humoris oilo,si vomitus ejusdem simul dejectio frequens," &c. ; and he even intimates, that when the discharges arc not of this kind, the disease wou’d be more properly referred to the genus diarrhoea. We find, too, that several writers in the seventeenth and eighteenth centuries have described under the bead or dysentery what was indisputably genuine cholera. The " dysenteric incruenta of Willis, a coteraporary ofgydenham, was obviously of this nature. Its symptoms Bveri: too characteristic to be mistaken :—"Sudden seizure, enormous vomitings and frequent watery stools, quickly inducing extreme prostration anc in good health have been dreaful fainting; so that patients brought to the point of death within twelve hours of lhe attack." The °dysenteria bilioso-contagiosa" of Degner (1754.) was a’.soofthe same kind. as
AMPUTATION.—" The proper periodfor amputation is a question upon which much discussion has taken place, since the use of the tourniquet and the ligature has made this operation more a matter of option than formerly. Ve are not now compellecl to resort to it as a desperate expedient, as a forlorn hope, after the failure of other means, but have the choice of adopting it from the first, wherever it may promise to benefit our patient by alleviating his sufferings, by shortening his confinement, or by affording him the use of an artificial limb, when we can have no hope of preserving the utility of the natural one-."-Ballingall’s Military SU1’gery.
previously
The reader will find much interesting and instructive information upon thi point in Dr. Harty’s excel’.ent work on dysentery.
674 a particular time of the year in this way. "For," purslain, or water-lily, to the draughts and enemata; but these Sydenltam, "although there remain exactly the Same substances (with the exception, perhaps, of the first-a mild causes which may occasion this distemper towards the end of sedative) could have no effect. The great object is, first, to September as well as in August, (viz., the excessive use of blunt the acrimony of the offending humours-the fomitem fruit &c.,) yet we find that the same effect does not follow ;" morbi-and then discharge them from the body. When this and a little further on he adds, " Whoever carefully attends business is over, which usually requires three or four hours, an to the phenomena of the true cholera morbus must acknow- opiate will very generally complete the cure. I have said that Sydenham strongly disapproved of the ledge that the disease, which occurs at other times of the year, although excited by the same cause, and accompanied practice (which was common in his day, and is too often rewith some of the same symptoms, is altogether different, sorted to in the present) of seeking promptly to arrest the (toto ccelo distare); as if there lay concealed in the air of this vomiting and purging by the use of any form of astringent particular month a mysterious and peculiar something, which remedies. IIe has alluded to this error in more than one part communicates to the blood, or leaven of the stomach, a spe- of his writings; and it will be seen, from the following short cific alteration adapted only to this disease." passage, how sound and far-seeing were his views on patholoHere we have the malarious origin of the disease rather gical subjects. Besides, says he, theinconvenience ofthereby hinted at than distinctly affirmed. With respect to the asser- prolonging the disease,"the acrimonious and corrupt humours, tion, that the sporadic and epidemic forms of the disease are which ought to be discharged, being, by this means, detained essentially distinct, it must be confessed that our author has within the system, exert their pernicious power upon the rather strangely omitted to point out any well-marked discri- blood, and occasion a fever, that is usually of a bad kind, and minating features hetween the two, and that, indeed, his own is accompanied with dangerous symptoms, so as scarcely to be expression, "alterins cst subsellii" —applied to the one as removed without giving an emetic, although there may be contra-distinguished from the other-more properly indicates then no longer any tendency to vomiting." The allusion here made, to the consecutive efforts of sordes a difference in degree rather than a diversity in kind. At all events, few, I should think, will hesitate in admitting that retained within the bowels, suggests a most important point of there is a much more decided line of distinction between the practice in the treatment of all febrile diseases, as well as of legitimate cholera morbus of Sydenham, and the malignant cholera. Whether, indeed, the typhoid fever that so often epidemic which visited this country in 1S31-2, than between supervened upon an attack of the malignant epidemic when it his two forms of the disease. For is it not the case that we visited Europe sixteen years ago, was the result of this cause, miss some of the most characteristic features of the Asiatic or whether it was not, rather, one of the stages, so to speak, of disease itself, cannot now be inquired into. But whatever pestilence, even in the very worst cases of cholera described by him ? The very circumstance of his mentioning that the opinion may he held upon this point, every experienced physpasms were sometimes so severe, that the patient sprang out sician will, I am sure, add his testimony to the soundness of the of bed in the hope of obtaining relief, clearly shows that there pathological position laid down by our clear-sighted author. Should the patient be in a state of very great exhaustion, was not that extreme prostration and sudden collapse of the vital energies which constitute so remarkable a feature in bad from the continuance of the evacuations tor ten or twelve cases of the Oriental malady. Besides, where is the rice- hours, the extremities being cold and the pulse scarcely perwater appearance of the ejections, with the utter absence of ceptible, before the physician has been called in, it may be all traces of bile; or the leaden blueness of the surface; or necessary to have immediate recourse to the use of laudanum the violently-retracted state (not the inflatio et distensio of our — sacram lciejus morbi anchoram as Sydenham somewhat exauthor) of the abdominal muscles: the suppression of the travagantly terms it,-" which is not only to be given during biliary and urinary secretions; the tarry state of the blood; the urgency of the symptoms, but repeated every morning not to mention the much greater tendency to consecutiveand evening after the vomiting and purging have ceased. typhoid fever, and the limitation of the disease within no until the patient recovers his former health and strength."* month or season of the year ? While, then, I cannot reco- The wisdom of the latter part of this advice may be fairly gnise in Sydenham’s autumnal epidemic the same disease as questioned; nav, it may be roundly denied. The use of any that which, issuing from amidst the jungles of the Ganges, medicine that is so apt to "lock up" the liver and other circumambulated the round world within the experience of abdominal emunctories, as opium unquestionably is, cannot be most of my readers, and once more threatens to visit oui judicious, when the immediate severity or danger of the shores, it deserves particular notice that his legitimate cholera cholera, attack is over. Then is the time for the exhibition of morbus, attended with the most alarming and often rapidly. mild mercurials and gently-tonic aperients, such as the infufatal symptoms, was a much more frequent malady in Londor sion of rhubarb, the compound gentian mixture, &c., with
ease
at
says
the
in the seventeenth than it is in the nineteenth century. Th( remark of one of the older commentators on our author, thai "for the most part it proves niortal; no distemper, except perhaps, the plague and pestilential fevers, being so suddenly destructive as the cholera," scarcely holds true of the diseas( in the present day. But we proceed to matters of more im Dortance.
Treatment.—Whatever may be thought of Sydenham’s views respecting the nature and origin of the cholera morbus, his treatment of the disease is, in my opinion, unexceptionably (or nearly so) most judicious, and well deserving the attention of all practitioners. Were the principles of his therapeutics better known, and more thoroughly appreciated by the profession at large, we should less frequently have to regret the frequent instability-not to speak of the occasional positive mischief-of medical practice. Regarding the vomiting and purging as truly efforts of Nature to get rid of the vitiated humours, whose presence in the stomach and bowels is the immediate cause of these symptoms, Sydenham condemns all attempts to check them at once by the use of astringents and opiates; while he equally disapproves of the exhibition of purgative medicines, which are liable to aggravate, unnecessarily, the intestinal irritation; and he lays down as the basis of all sound and successful treatment, the simple rule, "partly to evacuate, and partly to dilute the offending matters." For this purpose he recommends that the patient should be made to drink several tumblerfuls of any tepid demulcent beverage, (he particularly names very weak chicken tea,) while, at the same time, a large quantity of the fluid is administered, at several times successively, in the way of injection, until about three gallons have been taken into the body, and subsequently rejected He occasionally added an ounce of the syrup of lettuce, violets
alkaline medicines. Had space permitted, I might have wished to have entered at some little length into the treatment of the various forms of cholera, including, under this term, not only the mild and severe forms of the domestic disease!’ but also the Gangetic pestilence. But this would lead me far astray. I shall therefn nnlv;
ctrnnrlv rnrnmoonrl tn fhn thn"ohtfvil
brethren the general theraconsidema,t.ion of my professional brethren peutic principles which Sydenham has laid down as the guide of his practice, and leave the carrying out of the details to the judgment of each reader. The next subject that is to occupy our attention is oneof equal importance with that just dismissed-viz., the history of epidemic Dysentery, a disease which was much more common in England in the seventeenth century than it is in the present,! but is, alas ! anything but unfrequent in the sister island, not to mention almost all hot and many temperate climates. Sydenham saw a great deal of it, and the descriptions which he has left of its characters, mode of treatment, &c., have always been regarded as among the most valuable portions of his writings. First, of its symptoms: in some cases dysentery sets
considerationof my professional
* Thus, in a case briefly reported by our author in his account of the epidemic diseases that prevailed in London from t67n to 1680, he seems to have repeated the dose itwenty-five drops of his liquid laudanum) every half-hour, until the alarming symptoms were quieted, and then to have given it, in smaller quantities, at intervals, ad evs scilicet confirmandam. t Dr. Heberden says, that the mortality in London alone, from dysentery, in the seventeenth century, was never under 1000, and sometimes exceeded 4000 per annum, and that, at the close of last century, the number of deaths from this cause was not more than twenty in all. (On the Increase and Decrease of Different Diseases in London. 1801.) Sydenham alludes to the " endemic disease of Ireland," and expresses his ignorance whether it was the same malady as that with which he was so well acquainted. In Cromwell’s dispatches, we learn that the British army frequently suffered most severely from dysentery.
675 in with the ordinary phenomena of pyrexia-viz , chills and shivering, followed by heat. Often, however, there is lo sign of any precursory fever; the patient is at once seized with severe griping pains, and these are quickly followed by the
To appreciate as they deserve our author’s therapeutic principles, it is necessary that the reader be acquainted with his views respecting the rotiology of the disease. According to Sydenham, dysentery is not a local, but a general or systemic disease, induced by the introduction of certain noxious particles into the blood, and requiring for its cure the elimination and discharge of the peccant or offending matter from. the body. In more than one passage of his writings, he calls it " a, fever turned inwards," (febris in intestfna introversa ;) evidently because its exciting and proximate causes were, in his opinion, if not identical with, yet altogether analogous to, those of certain indubitable fevers; the predominant affection of the bowels serving, in a measure, to abate the distinctness and severity of the pyrexia, by eliminating from the system,
There is always an excruciating distress, and a of most painful forcing-down of the bowels at stool. The motions are frequent, of a mucous and not of a stercoraceous character, and are generally streaked with blood. Occasionally, indeed, a stercoraceous motion intervenes; and this (it is worthy of remark) is observed to be passed without much pain. In some instances, there is not any appearance of blood in the stools during the whole course of the attack. This symptom, therefore, is not essential to the disease; for if the purgings be frequent, mucous, and attended with severe tormina of the bowels, and with tenesmus, the case is justly in part at least, the acrimonious humours contained in the mass of the blood. That such is the case, he argues to be considered to be one of dysentery. Although the disease may not be ushered in with pyrexia, highly probable from the circumstance, that either cotempofever very generally supervenes in its progress, especially if raueously with, or it may be immediately before, the regular the patient be young, or when he has been treated by the use invasion of an epidemic dysentery, there has often been obof cordials; the tongue is covered with a thick whitish mucus, served to be prevailing a form of fever that exhibited much of the genius and character of that disease, the intestinal or it becomes even black and dry, if the heating regimen has been carried still further. At the same time, there is usually symptoms only being in a very mitigated degree. In his ingreat prostration of strength, much anxiety and depression of troductory general remarks on epidemic diseases, we find this alluded to:spirits, with every other symptom indicative of a bad form of circumstance " When dysentery is the prevailing disease of the season, fever. Unless very skilfully treated, dysentery is a disease attended not only with great suffering, but with very con- the fever of that year exhibits not a little of the same chasiderable danger. " If the vital energies become much ex- racter, (excepting only that in the former the morbific matter hausted by the repeated purgings, before the peccant matter is discharged by stool, and there are certain other circumbe expelled from the blood, and a coldness of the extremities stances arising from this peculiarity,) as is abundantly evisupervenes, death may occur within even the ordinary limits denced by the resemblance in their mode of attack, and by of acute diseases." Even although the patient may escape at the occurrence of aphthœ, and various other symptoms of the the time, not a few distressing and even dangerous symptoms same kind in both." await him. Thus, insteal of the sanguineous filaments that Such was the dysenteric fever, of which mention was made in the early stages of the disease were mixed with the in a previous article, but which we deferred to consider until motions, a quantity of pure blood, without any admixture of the present time.* mucus, may be voided with every effort at stool; an indiWhat, then, are the indications of treatment in dysentery?z cation of the erosion of some of the larger vessels of the Sydenham, influenced,unquestionably,too humoral bowels, and consequently a most unfavourable omen. In views of the disease, replies:-" To make an immediate revulother cases, the intestinal inflammation ’-arising from the sion of the acrimonious humours by venesection, to temper copious afflux of the hot and acrimonious matter to the the remaining mass of the blood, and to discharge the said affected parts," is so violent as to be followed by gangrene. humours from the body by means of’ purgatives." His pracThe occurrence of aphthæ in the mouth, towards the decline tice was therefore prompt and simple; he opened a vein in of the disease, is usually a bad symptom. When the disease the arm, gave an opiate the same evening, and a lenitive has lasted very long, " the intestines at length," says Syden- aperient next morning. If this acted rather powerfully, or ham, "seem to be affected successively downwards, until the the patient was much exhausted by the operation, an opiate whole mischief be settled on the rectum, and terminate in a was given in the course of the day. The purgative was not tenesmus. When this takes place, the expulsion of ster- repeated until the second day following, an opiate being administered morning and evening on the intermediate day, " in coraceous motions-very differently from what occurs in the early period of dysentery-occasions great pain in the bowels; order to diminish the violence of the symptoms, and obtain a the feces, in their descent, abrading the small intestines." respite, while the physician is engaged in exterminating the Had our author been better acquainted with morbid anatomy, peccant humour." The same practice was pursued on the he would, doubtless, have substituted the term " large" for fourth and fifth days-a purge on the former, followed by an "small" in this passage, as the tenour of his remarks evi- opiate, and two doses of the opiate on the latter. When the dently applies to the ulceration and constriction of the lower disease was more than usually severe, Sydenham advises the part of the colon and of the rectum, that are so apt to occur in opiate to be repeated more frequently-twenty drops of his laudanum every eight hours or so, and an enema of milk, old cases of dysentery. Before proceeding to explain his method of treatment, with an ounce of theriaca Andromachi (a mild opiate confecSydenham judiciously reminds his readers, that the character tion of that day) in it. He tells us that he never found any or type of dysentery is apt to vary not a little, in some partiinconvenience from so free a use of opiates, (the patient culars, in different seasons, just as we find to be the case with having been purged thrice, as just now explained,) and that small-pox and other epidemic maladies; and consequently, he had known several to take them every day for some weeks that the line of practice which may have been found to be running, when the disease proved inveterate.+ most successful in one epidemic, or at one period of an epiThe best drink during the course of the disease is " milk, demic, may require to be very materially modified under * In no part of his wi itings does Sydenham allude to other the dysentery altered circumstances. He alludes to the greater severity or the fever ever exhibiting any infectious character. But every and fatality of the disease in the beginning and early period, ieader dysenteric of his works is well aware how remarkably silent he is upon this than in the progress of most visitations-a remark, by the by, very important, and too frequent, cause of many d seases. Will’s, however, the same time, says, that although the ordinary that applies with equal truth to the plague and to epidemic who practised in London atwas not valde contagiosa aut sæpius lethalis," dysentery of the metropons diseases generally-so that although, with respect to the yet that sometimes it was highly malignant, and as it were pestilential, numbers of the sick," (as he says in one passage,) " the evil causing great mortality, and spreading wide " miasma suum per contabecame every day more widely spread, until at length it gium." t It is when describing the excellent effects of laudanum, judiciously arrived at its acme, when consequently more perished than administered, in dysentery, that our author records his gratitude to the on its first invasion; yet the symptoms were more violent at Almighty Being (&pgr;&agr;&ngr;&tgr;&ohgr;&ngr; &Dgr;&ohgr;&tgr;&eegr;&rgr;&agr; ∈&agr;&ohgr;&ngr; for bestowing so admirable a remedy So necessary an instrument," sa s he, " is this medicine the beginning than at the height, and much more than in the upon mankind. the hands of a skilful physician, that the art of medicine would be but decline of the visitation, and, other circumstances being alike, in lame and imperfect without it. Whoever is well acquainted with its use many more were swept away." To this may be added, that will effect more than could have been expected from any single remedy. the longer the disease continued, the more of a humoral or He, indeed, must be ignorant, and have but a very inadequate knowledge moist character it seemed to acquire; in other words, the dry of its virtues, who regards it merely as an hypnotic, an anodyne, and an astringent; for it is excellently well suited (like the Delphic sword) for gripings, the ineffectual tenesmus, the intensity of the fever,many other purposes, and is, indeed, the most potent cardiac (I had almost and other unfavourable symptoms, abated in severity; while said the only one) hitherto discovered." Dr. George Cheyne, in his wellthe stools became more abundant and more stercoraccous,known essay, On Health and Long Life, expresses himself in a very " until at length, the epidemic constitution ceasing, the tor- similar manner as to the virtues of opium. " In fine," says he, " Providence has been kind and to us beyond all expression in furnishing lnina of the bowels were scarcely felt, and the alvine dejec- us with a certain relief, ifgracious not a remedy, even to our most intense pains tions were more fxcal than mucous :’ and extreme miseries."
purgings.
IB
sense
much by his
’
.
676
_
boiled with thrice its quantity of water, or the white decoct’ion, cine, and never giving it for two or three days after the last But nothing tended so much to recruit the patient as as it is called, made of burnt hartshorn and the crumb of purge. white bread, of each two ounces, boiled in three pints of the free use of the air, as soon as the fever had left him." water down to two, and then sweetened with fine sugar." Notwithstanding some errors, and not a few omissions, in When the prostration is very great, it may be necessary to the plan of treatment recommended by our author in dysengive some Canary wine and water, boiled together, and then tery, there is much in it most assuredly to meet with very allowed to become cold. As to food, panada and broth, made cordial approbation. It is based upon the sound principle of of lean mutton, are especially mentioned by our author. regarding the disease, not as a mere local affection of the As Sydenham expressly states that dysentery, like indeed intestines, but as a constitutional malady, with, prominently every other epidemic disease, is not uniformly, and in all marked local symptoms.* If this be true, how injudicious seasons, attended with exactly the same symptoms, general must it be to substitute, as has been the fashion of late years, as well as local, we are prepared to find that his treatment such appellations as entero-colitis, coloititis, &c., for the old was modified according to the type and character of the preand infinitely better one of dysentery! It has been, I am vailing constitution. Thus, on the first outbreak of the dis- convinced, this very system of extravagant localization that ease, when the tormina of the bowels were more, and the has introduced, since the beginning of the present century, so purgings were less, severe than at a subsequent period, the much erroneous doctrine in reference to the true pathology practice that he followed with success was somewhat similar and treatment of many of the pyrexise. Far too much attento that which he recommends in the cholera morbus. If the tion has been not unfrequently paid to the discovery, upon patient was young and feverish, he first drew blood from dissection, of every lesion, however minute and inconstant, in the arm, and, an hour or two afterwards, he gave his patient each portion of the bowels, and, indeed, of every abdominal of viscus, while all the time the mind has been entirely withcopious draughts of cold whey, and had a large quantity the same fluid, tepid, thrown up the bowels. " I always drawn from the general history of the malady, its probable found," says he, " the gripes and bloody stools cease after the causes, the season of the year when it prevailed, the condition rejection of the fourth enema. This business being over, and of the patients when attacked, the influence of medicine and individual l’rlRRR- fJ,nc1 other circumstances which no all the whey discharged, (which, if expeditiously done, occuwill ever neglect. In the case of dysentery, wise was at to or three the once two put physician hours,) pies only patient bed, when he soon fell into a profuse perspiration, which was the intestinal affection is unquestionably not a primary, simple, to be kept up, but not forced, by cardiacs, for four and twenty or uncomplicated inflammation, nor can it be suddenly arrested hours-the only drink allowed during this time, and for the by the prompt use of vigorous antiphlogistic measures; and next three or four days, being warm milk." This method of even, if it could be, the subjugation of the local suffering drowning the disease (to use the quaint expression of our would not necessarily be followed by a cure of the whole author) by a plentiful dilution of fluid succeeded in very disease. The disease in the epidemic form (for it is of that many cases during the firstautumn of its prevalence; but it weare now speaking) does not arise from the direct appilca,failed afterwards when it had lost much of its subtlety, and tion of any irritant matters, derived ab extra, to the mucous become more humoral; in other words, when the dry gripings surface of the bowels; otherwise it might be extinguished ("juguler" is the silly word used by certain French writers) gave way to profuse and bloody purgings. With respect to that form or type of fever which existed in the manner mentioned. But it is not so; it is a bloodin London, with greater or less malignancy, during the whole malady, in which, as in many other poisonings of the circulat. period that the dysentery was the prevailing epidemic, and ing fluid, there is a predominant affection of some particular to which Sydenham gave the appellation of dysenteric, from organ or organs. We see this illustrated in poisoning from the belief that the two diseases were essentially of the same arsenic. When the poison has been introduced into the system, not by being received directly into the stomach, but by teing nature, however much they varied in point of the severity of the intestinal affection, the following extract will best serve applied to the skin, or injected into the veins, the whole body is unquestionably more or less impregnated or infected; but to explain his pathological and therapeutic views :" Having observed that the phenomena of the fever ofthmost conspicuous effects, in the way of inflammation,are many dysenteric patients were evidently the same asthose produced upon the stomach. Now it would be just as reasonwhich accompanied the solitary fevers of this season, it able to look upon the gastritis as constituting the only essenseemed but reasonable to believe that a cure might be; tial feature of such a case, or (to take another example) the effected by imitating, in a measure, that mode of evacuation sorethroat in scarlatina as the pathognomonic character of this which Nature usually employed to get rid of the acrimonious; fever, as to regard dysentery to be synonymous with inflammacorrosive matters which are the real cause of the dysentery tion of the coloi,. Notwithstanding these remarks,I am very far from underitself, as well as of the supervening fever. I had recourse, therefore, to the same plan of treatment, both as respects valuing the importance of attending to the local disease, or of bleeding and the repeated exhibition of purgatives; omitting, having prompt recourse to the use of active local means for however, the use of opiates, which, by detaining the peccant its relief. Nay, it is the very omission of such remedies that matter requiring to be evacuated, not only did no good, but constitutes, in my opinion, the chief blemish in Sydenham’s of leeches, and the perseveringly (very different from what was the case in dysentery) proved practice. The positively hurtful. For the first few days the patient lived continued use of hot-not merely warm—stupes or poultices entirely o;i gruel, barley-water, panada, and such like articles, to the abdomen, forms an indispensable part in the treatment warm small beer being allowed for drink. After he bad been of every case of dysentery. The soothing relief,that is or a little chicken other once or twice, light food was afforded by these means, is well known to all who have expurged allowed. The third interposing a day between each, perienced the truly distressing sufferings of this disease. moreover, makes no allusion to the employment generally terminated the disease, but sometimes further of Sydenham.and the continued was When emetics; yet, on the invasion of the disease, there is very required. patient purging not a more safe and-often, too—efficacious remedy than a weak after the fever had left him, and regained his but slowly, (aswas frequently the case in hysterical subjects,) full dose of ipecacuan to induce free vomiting. For not only I endeavoured to restore it and repair the loss of spirits by a is the stomach and upper part of the duodenum thereby small dose of laudanum, rarely, however, repeating the medi- promptly relieved of any offending matters which might otherwise have greatly increased the existing irritation, and * Morton and Willis, both cotemporaries of our author, take ve’y similar the liver effectually enrulged, but the violent detrusive action views as to the intimate reiatio..ship between the co-prevaiting dysentery of the bowels is often, at the same time, speedily miugated, if and fever. The former, after alluding to the frightful mortality in London from the first of these diseases,—from 300 to 500 dying each week,-goes on not arrested; while, immediately afterwards, a copious perto remark that it was replaced by a remittent fever, which exhibited during spiration is very generally induced, this serving as a most its pyretic paroxysms distinct dysenteric symptoms-,’ Whence," says he, * Frank, while he admits that the precursory pyrexial symptoms are "it is obvious that the dysentery could only be regarded as a symptom, sometimes so imperfectly marked as to be scarcely recognisable, has deand that the fever was the primary disease." WiUis tells us that this fever .
application
purge,
strength
often assumed a continued type, and was then apt to prove infectious. He expressly alludes to its being accompanied, in many instances, with dysenteric symptoms. Some of our best modern writers on epidemic dysentery have expressed very similar opinions. Frank says, that " when dysentery is an effect or symptom of typhus, it is a most unfavourable omen ; and Dr. Cheyne, in his excellent account of the epidemic in Ireland in 1818, uses these remarkable words :-It was sometimes converted into a fever, while, on the other hand, fever was frequently converted into dysentery; in short, these forms of disease were convertible the one into the other, ro that the opinion of Sydenham, that dysentery is a febris introfo’sa, received support from our observations."
fiiie(i the disease to be "corporis totius febrilis affectto, in intestina, maxime crasa, furicns." 1’ The late Dr. James Johnson remarks, with mnch truth, upon this subject,—"I am in every case inclined to regard inflammation rather as a of dysentery, as a contingent effect, and not asa sequence than a canse uniform result." " Innammation and ulceration secondary or ternary lmk, in the mo bid chain, and many a case of real dysentery is checked and cured bcfcie either of these takes place; that is, when thece is merely an increased afflux of blood to the mesenteric and portal vessels, a superinitation in the mucous membrane of the bowels, and an increased discharge of acrid secretions from the intestinal glands."
are
677 useful derivant to the inflamed mucous membrane. I should say that bleeding, (always supposing that the intestinal symp-
sufficiently acute to require this evacuation,) followed by an ipecacuan emetic, and, upon the completed action of vomiting, the steady application of hot fomentations to the abdomen, constitute by far the most appropriate and successful practice in the early stage of dysentery. Quite as much, if toms be
by the excessive administration of large doses of calomel by many of our own countryanen, as by the indiscriminate venesection that has been recommended and practised by a large section of the French practitioners. There is not a fact in therapeutics of whose truth I am more thoroughly convinced, than that calomel very often .acts as a most pernicious irritant of the intestinal canal, more especially when its mucous membrane is in a state of inflammation. Whether this effect may not, sometimes at least, be owing to the partial conversion of the chloride into the bichloride, from the presence of acid (muriatic?) in the bowels, I must leave to others to determine : the fact of its irritative - qualitiesin many instances cannot, I think, be gainsayed. This .circumstance has, for many years past, induced me invariably to substitute the much milder preparation, the hydrargyrum cum cretâ, for the more general favourite, calomel, whenever irritation of the bowels was to be avoided. In doses of from -five to ten grains, combined with double the quantity of the -carbonate of soda, and the dose repealed every two, four, or .six hours, according to the nature of the case, it may be given with very great advantage in a variety of circumstances. In dysentery, the addition of a grain of ipecacuan, and, if the intestinal irritation continue very severe, of the quarter or half of a grain of opium, will often prove of decided utility. And here I cannot but remark, that the valuable effects of ‘opiates in this disease are, in more respects than one, strikingly enhanced by associating them with some alkaline medicine. The extremely acid state of the dejections (in many cases at least) will account for this result-a result to which I particularly isxvite the attention of my professional brethren, from the unequivocal benefits which I have often, had occasion to witness by acting upon this simple therapeutic precept. A mixture, containing the carbonates of soda and magnesia, with the tinctures of henbane and opium, will generally answer exceedingly well : if the looseness be profuse, chalk will, as a matter of course, be substituted. When the bowels have once been quieted, or, indeed, earlier, if there is reason to suspect any offensive lodgment, a purgative should always be administered; and certainly a much safer, as well as more efficacious one than that used by Sydenham—viz., an infusion of senna, rhubarb, and tamarinds, sweetened with manna—is castor oil. During the stage of convalescence, some preparation of bark will very generally be required, more especially in the dysentery of hot climates. not more, mischief has been done
Fi!zroy-sqtiare,
Dec. 1847.
OBSERVATIONS ON
DR. SIMPSON’S ANÆSTHETIC BY ROBERT
STATISTICS.
BARNES, M.B.,
LECTURER ON MIDWIFERY.
commanded rather than recommended by Dr. apathize our patients during the process of natural The Edinburgh professor, in an extraordinary labour. sentence to address to an enlightened profession, "for his part more than doubts if any man (rejecting willingly its benefits) is really justified, on any grounds, moral or medical, in deliberately desiring and asking his patients to shriek and writhe on in their agonies for a few months, or a few years longer, in order that, by doing so, they may defer, forsooth, to his professional apathy, or pander to his professional caprices and prejudices." What is itthat emboldens Dr. Simpson to stigmatize ’" nineteen out of twenty, or ninety-nine out of one hundred," medical men as influenced by " indolence and apathy," by ‘ caprices and prejudices"? Does Dr. Simpson imagine that
WE
are
Simpson
to
any one rational man, accustomed to act upon calm reflection and logical deduction from facts, will thus be dragooned into adopting, in every case of natural labour, the use of ahazardous and doubtful agents? Can Dr. Simpson’s singular mode of argument be really directed to the medical profession; or is it possible that it is aimed rather to secure another class of converts—viz., those " zealous missionaries who set out to persuade other friends to avail themselves of the same ?" &c. Although the main strength of Dr. Simpson’s minatory
recommendation to employ chloroform in midwifery consists in the assurance that " medical men may oppose for a time the superinduction of anæsthesia, in parturition ; but they will oppose it in vain; for certainly our patients themselves will force the use of it upon the profession;" still it must be confessed that he endeavours to support his doctrine by pseudo-scientific arguments, albeit those arguments are as repugnant to the ruk’s of scientific investigation as are his extra-scientific arguments to good taste. His paper, published la Tns LANCET, and newly-edited, with additions, for general circulation through the post, consists of two parts-First, there is an imperfect cletail of cases; second, there is another exhibition of Dr. Simpson’s weakness in statistics. With regard to the cases, we find that they are ten in number, including one reported by Dr. Murphy. An examination of these cases shows that Dr. Simpson knows or practises no limit in the administration of chloroform. In Cases 2 and 4 he expressly states that the patients were kept under its influence until after the placenta was removed. In one of these cases the enormous quantity of four ounces of chloroform was used. " Audantes forttina juvat," and no doubt science and humanity would lose by excess of eaution; but to free himself from the charge of temerity. Dr. Simpson is bound to produce the evidence which first emboldened. him to use so freely an agent so powerful. What previous experiments on animals had he performed which justified him in putting human mothers"under its influence? Case G affords an interesting physiological fact, showing that thereflex function remains active under the influence of chloroform. Dr. Simpson foundthat" hewas able to increase the intensity and force of each recurring pain, by exciting the uterus and abdominal muscles through pressure on the lower part of the vagina and perinæum." But when Dr. Simpson further says, thathe has the conviction that in this case the forceps would in all probability have been ultimately required, provided he had not been able to have interfered in the way mentioned," we are at a loss to know how this conviction arose, or why this same manoeuvre could not have been employed upon the patientin a natural state without"inilicting great agony upon her." Case 9 was one in which haemorrhage occurred during the anæsthetic state. it affords a proof that chloroform secures no immunity from flooding. Having given his cases, Dr. Simpson things it incumbent on him to make out that the pains of labour may in themselves be fatal; and he accomplishes this in a remarkable manner. After several quotations, not much to the point, he makes another grand statistical effort, and presses the figures of Dr. Collins, after a most tyrannical fashion, into his service. The statistical professor siys, that " according to calculations he has made from Dr. Collins’s data, while in women whose sufferings were terminated within two hours, only 1 in 320 of the mothers died; where the labour varied in duration from two to six hours, 1 in 145 of the mothers died, &c.’ and out of all those whose parturient sufferings were prolonged beyond thirty-six hours, one in every six died." What is the use of this statement ? Is it not well known that pain in labour is not always or necessari’ly proportioned to its duration ; those whose labours ended within two hours may have endured more pain than those whose delivery was more protracted. Aloreover, who will admit, besides Dr. Simpson, that the greater mortality among those who were longer in labour was owing to greater paiu ? Are not ths deaths produced by certain well ascertained causes ? Did not some die of convulsions; some, of puerperal fever; some, of the consequences of contracted pelvis; some, of flooding ? Can chloroform avert all these evils ? Could the exhibition of chloroform vapour, by saving these nnfoitunate women from pain, have saved them their lives ? But Dr. Simpson does not confine his researches to obstetric cases ; he seeks a further reinforcement from "analogy, and from what is the fact in surgery." He believes that, "as a counteraction to the influence of pain, the state of artificial anesthesia does not only imply a saving of human suffering, but a saving also of human life." The proposition may be true as far as it concerns surgical operations, but I think it will be granted that the following statistical perversion does not prove it; certainly, it does not prove the assumed corollary of Dr. Simpson, that the diminution of the pain of labour will diminish the mortality. Dr. Simpson’s analogical argument is as follows:—Malgaigne found, inamputations of thigh, in the hospitals of Paris, that sixty-two in 100 died; in Edinburgh, fifty in 100; in Glasgow, forty in 100; in Phillips’ collection, forty in 100. The gross mortality in un-
the