Part 9

In this short account of the preventive treatment of cholera infantum, I have been less anxious to give a dissertation, embracing all that might be said on the subject, than to communicate those particular measures, which, according to my own experience, I have found most effectual. I will conclude the paper by the relation of a case, in which a strong predisposition to the disease was successfully counteracted. It will be proper, however, to premise, that the treatment of this case is by no means held out as an example to be generally followed with every infant, which may possibly become the subject of cholera. It is applicable in all its details only to those, in which, as in the present instance, there is every reason to apprehend, that the only alternative is between almost certain death, and the most careful prophylactic treatment.

CASE.--A gentleman of this city, whose wife had arrived at a period of life, when she could not expect to be the mother of many more children, consulted me respecting an infant daughter, their only surviving child. I was informed, that they had already lost eight children, all of whom, with one exception, had died of cholera. It may readily be imagined, that every feeling of parental anxiety was awakened for their babe; and that no degree of attention on their part was considered too great, which might contribute to its preservation. It was placed under my care, not to be cured, but that I might, if possible, devise some plan of management which would avert the disease they had so much reason to apprehend. I felt the responsibility of the trust, and endeavoured to find it to the best of my ability. Every opportunity which I could desire was afforded me; for the infant, from its birth was submitted to my direction; and both the disposition and ability existed, on the part of the parents, to carry implicitly into effect every measure which I might recommend.

As the mother was unable to furnish sufficient nourishment, the first step was to provide a healthy wet-nurse, who might be willing to submit to the necessary regulations in respect to diet.

I believed the children of these parents to possess a constitutional weakness in the alimentary canal; and, on inquiry, I was told, that they had been kept upon a vapid diet, under the impression that it would contribute to their health. In the present case, therefore, the principal object was to communicate strength to the stomach and bowels. With this view, the child was accustomed, from an early period of infancy, to a generous diet. When very young, portions of ginger tea were given to it daily; and as soon as it was old enough to suck the juice of meat, it was encouraged to do so. The nurse, during the warm season, was kept upon a nutritious diet, consisting principally of animal food, with the occasional use of ginger tea; and every description of recent fruit and fresh vegetable food was forbidden. Under this management, the first summer was passed without any symptom of the disease; but I looked forward to the second with no little anxiety, when the child would have to struggle with the irritation arising from dentition.

The same plan was continued during the second summer, and still more rigidly enforced. The child was now old enough to take animal food freely in addition to the breast. It was allowed as much salt fish, ham, beef-steak, essence of beef, &c. as it desired; ginger tea was given daily; a little sound old port wine was occasionally directed; and both the child and the nurse were restricted from every species of flatulent and indigestible aliment. So anxious, indeed, were the parents, and so careful to carry my directions into full effect, that they allowed no forbidden article of food to enter the house, and denied themselves their wonted comforts, lest possibly their child might be injured.

The gums were carefully attended to, and lanced whenever the operation appeared to be requisite. All those measures, which I have before mentioned as serviceable in obviating the effects of great heat, so far as they were applicable to the case, were adopted. The second summer was spent wholly in the country.

Very little medicine was required, and none was administered, except of the mildest description. Frequently, when summoned to visit the babe, I have found the mother trembling with fear, and anxious that something might be done; and often, under such circumstances, have I begged it off from a dose of physic, having determined to avoid a resort to every thing of the kind, unless real necessity should demand it.

By a strict adherence to the plan above detailed, the period of dentition was passed in safety; and it is with heartfelt pleasure I can say, that no symptom of cholera afterwards made its appearance.

ARTICLE VI.--_Case of Neuralgia cured by Acupuncturation._ Communicated by J. HUNTER EWING, M. D.

The attention of the medical public having been of late much excited on the subject of acupuncturation, I am induced to communicate the following case.

For eighteen months, Miss ---- had been afflicted, at intervals, with a severely painful affection of the nerves of the right cheek, immediately below the orbit of the eye, and extending to the angle of the lower jaw. On the 14th of January 1826, she was attacked more violently than usual, and the remedies, which had previously afforded some relief, now failed. Stimulating cataplasms, warm embrocations, laudanum, internally and externally, heat applied externally to the cheek by means of very hot flannels, produced not the slightest mitigation of the pain; and she continued to suffer excessively until the afternoon of the 15th; when acupuncturation being proposed, she consented to the operation with this remark,--"any thing to relieve me from this agony."

The needles were immediately procured, and three inserted about an inch from each other. Two in a line parallel with the inferior edge of the orbit of the eye, and half an inch below it; and a third below, and equidistant from the others. The first two were introduced to the depth of three-fourths of an inch; the last, a full inch. They were inserted very gradually and with a rotary motion.

The second needle was scarcely introduced, before the patient exclaimed, "the pain has entirely left me." When the third was introduced, she experienced a stiffness in the muscles of the cheek, and a creeping sensation, as if a spider's web had been drawn across the face; but no painful sensation whatever.

Such was the exhausted state of her system from the excessive pain she had suffered, that when thus relieved, she requested a pillow to rest her head on, and fell into a gentle slumber.

About two hours after the insertion of the needles, I again visited my patient, and found her still perfectly free from pain, and seated at a table reading. She thanked me for the relief I had been the means of affording her, and requested me not to withdraw the needles, lest the pain might return. Upon being apprised of the risk that might attend their being allowed to remain, she observed, that she would rather have a servant to watch her whilst she slept. The propriety of their removal being further urged, she at last consented. There was no return of pain.

The next morning, the patient remarked, that the stiffness of the cheek, and a numbness of the whole right side, continued through the night; and though she did not sleep very soundly, she was free from pain and rested well.

By the third day, the stiffness and numbness had passed away, and there was no return of pain. Several weeks have now passed, and she has had no relapse; although often since exposed to causes, which, heretofore, had always excited violent attacks. Previous to the operation, she seldom passed as many days without severe suffering.

Although I have performed this operation many times, and been present when others have performed it, I have never seen a case, in which its efficacy was so decided, or in which the relief afforded was more unquestionably attributable to the action of the needles.

ANALYTICAL REVIEWS.

ARTICLE VII.--_Researches into the Nature and Treatment of Dropsy in the Brain, Chest, Abdomen, Ovarium, and Skin, in which a more correct and consistent Pathology of these Diseases is attempted to be established, and a new and more successful method of treating them, recommended and explained._ By JOSEPH AYRE, M. D. &. London, 1825.

We have read the present work with the liveliest pleasure, and we dare hope with considerable benefit, and hasten to lay a review of its contents before our readers. Dr. AYRE is already advantageously known in this country, where his Essay on Marasmus has had an extensive circulation; but we are disposed to think, that, however he might be esteemed for the talent he displayed in his former composition, he is entitled to much more credit for his able researches into the nature and treatment of dropsy. We confess that we enter upon our editorial duties on the present occasion, with the two-fold intention of offering to our readers what we regard, on the whole, as a very correct view of the pathology of dropsy, and of showing to some of our medical friends, who shudder at the mere mention of what they denominate _hunch theories_, that the English physicians, or at least some of the most intelligent among them, so far from considering these theories as dangerous and unphilosophical, are beginning to entertain similar views with their Gallic brethren, in respect to the inflammatory nature of many diseases too long regarded as resulting from a state of debility, and classed by nosologists among the Cachexiæ.

By most writers upon the subject, dropsy has too long been considered as a _disease_,--constituted into a separate class, and divided into many species. Dr. AYRE entertains, however, a very different and, we believe, a much more correct view of the pathology of this complaint; regarding it as only one in a series of effects of a disease, and not always the last of that series. He remarks, that the true disease is to be sought for in that particular condition of the solids by which the effusion is produced; and that to appreciate justly the nature and treatment of dropsy, it is necessary to understand the nature of that condition, which constitutes the disease, and of which the serous and watery effusion is merely the result.

Of all the hypotheses that have been advanced to account for the nature of the morbid state, which gives rise to general and local dropsy, there are only three which our author regards as entitled to our notice. According to these, all dropsical accumulations arise either, 1st, From a want of tone or energy in the absorbent vessels, giving rise to a deficient absorption. 2nd, From an increased exhalation of the natural fluid, through a similar want of tone in the exhalents; and 3d, From a mechanical obstruction to the free return of blood by the veins, produced by tumours of various kinds, &c., by which a greater portion of it is forced into the exhalents, and a greater effusion of their proper fluids thereby occasioned. With these hypotheses, however, Dr. AYRE is not satisfied, and he endeavours, in the following manner, to show their insufficiency.

"1st. The opinion of a want of tone in the absorbents, as a cause of dropsy, is contradicted by the fact, that in those cases, in which it is assumed to prevail, it is found, that the adipose matter, or fat of the body, is removed by the absorbents; or, in other words, that emaciation takes place to as great an extent, and as rapidly in this, as in other diseases; and emaciation can only be effected by means of absorption. Besides, in these cases of dropsy, mercury, when rubbed upon the surface, or received internally, is absorbed as readily, and affects the system as early as under other states of the body. There is also no accumulation of the fluids in the joints, or in the _bursæ mucosæ_ in these cases, which, nevertheless would happen, if there was a general debility of the absorbent system; and _ecchymoses_ or livid spots, though easily induced in anasarcous limbs, are likewise easily removed from them by the absorbents.

"2nd. The opinion of a want of tone or energy in the exhalants involves in it one of the following conditions: namely, either, 1st, that the fluid of dropsy may escape mechanically from them, and that the fluid thus _mechanically_ separated may be identified in its sensible and chemical qualities with another fluid which is confessedly secreted; or 2nd, that if the fluid of dropsy be secreted, then that an _increase_ in the quantity of a secretion may continue an indefinite period, under a _decrease_ in the energy of its secreting vessels; conclusions to which experience and analogy are alike opposed."

In answer to the third hypothesis, Dr. A. remarks, that such an obstruction as contemplated, has never been shown to exist.

"In the case of the liver, which is commonly considered, when in a scirrhous or enlarged state, to be the seat of these mechanical obstructions, and thus, to be the cause of abdominal dropsy, we have no satisfactory instance yet shown to us, of any such precise condition of that organ. There are, indeed, numerous instances of abdominal dropsies, in those labouring under a scirrhous or enlarged state of the liver; but there are also, numerous examples of such states of the liver, as well as of the spleen and other organs, without any such effusion; and in many cases, when such effusion has taken place, it has been carried off by the natural passages or by tapping, without any return of the dropsy; and yet, without any visible change in the structural condition of the liver."

Dr. A. further remarks, that if the cause were mechanical and existed in the liver, the effect should be constant; which, however, is not the case. Besides, were this mechanical cause necessary, how could we account for the appearance of abdominal dropsy, where there is no disease of the liver, or in other cavities, where no mechanical cause is asserted to be present, and where the remedies by which the cure is effected, have no relation to such causes? Again, if the discharge depended upon a mechanical cause, the water should in every case be of a uniform fluidity, and the progress of its accumulation likewise uniform; so that the operation of tapping should have no tendency to induce a more rapid refilling of the cavity. Yet, the contrary of all this is a subject of daily observation. In addition to this, Dr. A. calls the attention to the fact, that in experiments, in which obstruction has been artificially made, by tying the vena cava for example, the experimenter has committed an error, in reasoning from the lower animal to man--assuming, that as ascites had arisen in dogs, it would in like manner have occurred in human subjects.

"But there was an effect, here overlooked, which was to be expected to take place in the abdomen of the dog, from the injury done to the surrounding parts by the operation itself, and which would be quite independent of any effect arising out of the experiment. In the human subject, the effect would be the highest form of inflammation, by which coagulable lymph or pus would be poured upon the surface of the peritoneum. There would, therefore, be inflammation excited in the abdomen of the dog; but as the lower animals are less easily acted on than man, the inflammation would in this case be in a lower degree. But every degree of inflammation has its particular product. The highest occasions a discharge of pus, whilst the lowest, when seated in a serous membrane, is a larger portion of its proper serous fluid. This, therefore, might be the product of the inflammation, which was produced incidentally by the experiment in the abdomen of the dog; and it would be just as reasonable to regard the coagulable lymph in the human subject, which would result from such an experiment, as an effect of the mechanical obstruction, as to consider the fluid effusion in the dog to be so."

In respect to those instances of diseases of the liver, connected with ascites, in which, in addition to its other morbid states, a partial occlusion of the vena portæ, by the effusion of coagulable lymph into it, is said to have existed, our author remarks, that they are very few in number, occurring, perhaps, in one out of several hundred cases of ascites with hepatic disease; and that we are justified, from analogy, to assume, that any obstruction given to the circulation by diseased vessels, would be quickly relieved by the enlargement of the anastomosing branches, and that no effusion of water into the abdomen would result from it. After referring to some cases, related by the late Mr. WILSON, in which the vena cava was completely obliterated, and no effusion took place; and some cases of morbid condition of the heart of an analogous kind, by which the course of the circulation became greatly obstructed, and yet, without being followed by effusion; our author concludes, that from these facts and others, to be presently noticed, it appears evident,

"That the dropsical effusion, in whatever part it may be seated, does not arise from any want of tone in the exhalant or absorbent system, or from a mechanical obstruction in the liver or other viscus; but, that it proceeds from a morbid action in the cellular or serous tissues, and that this action, as we shall now proceed to show, is allied in its nature to inflammation."

In support of this opinion, Dr. AYRE remarks, that all the phenomena belonging to cases of watery effusion, met with under one or other of the forms of inflammation, are common to those of dropsy. Thus the fluid, discharged under the cuticle in erysipelas or in inflammation induced by heat or a blister, or in cases of pemphigus, is a secretion, and resembles in all respects the fluid found in dropsy. In some cases of acknowledged inflammation, the fluid effused is found to vary greatly in its degree of tenuity, so as to be sometimes of quite a viscid nature. The same circumstance is met with in dropsy; the fluid of which varies sometimes in different forms of the disease, and at different periods in the same patient. With regard to the absence of pain, in ordinary cases of local or general dropsy, which, in the minds of many physicians, might seem to militate against this view of the subject,--since pain accompanies the inflammation of a blister, Dr. A. very justly says, that the difference is referrible to a different degree of sensibility of the parts affected; that, moreover, in pemphigus there is no pain, and that chronic inflammation of the serous membranes is little painful.

That the morbid action producing the effusion is only a modification of inflammation, our author thinks may be further shown by the fact that it obeys the same laws--being translated occasionally, like it, from one part of the body to another. On this subject, Dr. AYRE makes the very pertinent remark, that in these cases, the fluid alone has been thought to be translated; but that the metastasis, is without doubt, exclusively of the action which produces the serous discharge. Analogous also to what occurs in inflammation, especially of the erysipelatous kind, the action occasioning the effusion, as seen in anasarca, commences at a given point, and gradually extends from thence in a continuous course. It ought also to be noticed, that the results of common inflammation vary according to the intensity of the cause; the lowest degree of it, occasioning an increase in the quantity of the proper fluids of the part,--a higher degree, yielding for its product coagulable lymph, and a still higher one producing pus. All these several products of common inflammation, are more or less remedial of their cause; or in other words, are the immediate means of the cessation or abatement of the inflammation which produces them. This same power is likewise a property, though in a much less degree, of the hydropic effusion, when the inflammation which produces it, is idiopathic; or in other words, not created by a visceral or other disease, or some particular excitement of the general system, as is seen in cases of anasarca.

"And here," continues our author, "it may be proper to remark upon a common error, committed by those, who, mistaking the nature of the action which produces the serous effusion, look in the _post mortem_ examination, for some of the common signs of an inflammation having existed; and who conclude, upon not finding such, that the water was derived from some mechanical or other cause foreign to the true one. But in the higher forms of abdominal inflammation, the products are pus or lymph, and these are found upon the surface of the peritoneum, with sometimes a thickening and discoloration or ulceration of its substance; whilst in the lowest form of that increased action to which the serous membranes are subject, the only product is the serous fluid, and there can be, therefore, no visible alteration produced by it in the structure of the serous tissue."

"By the hydropic or serous inflammation, obeying the same laws which govern the other degrees of common inflammation, it follows, that upon a higher excitement being superinduced upon it, the serous effusion should cease. This, therefore, is found to happen in every case, where such higher excitement is brought on. This increased inflammation is sometimes occasioned by design or accident, and at other times, it occurs in the natural and progressive course of some disease, formed within the cavity, which is the seat of the dropsical effusion."

This is exemplified in the effects of the operation for the radical cure of hydrocele; or in the operation of tapping in some cases of ovarian dropsy; or even in some instances, of ascites from chronic inflammation of the liver, spleen, mesentery, &c. In all these cases, the serous membrane, which directly or indirectly was affected to a sufficient degree to occasion a serous effusion, takes on, from the extension of a visceral disease, or from some other cause, a higher degree of inflammation--lymph is thrown out, and the cavity becomes obliterated.