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390 by diseases of the thoracic viscera,
119 by cachectic diseases.
270 were caused by diseases of the encephalon,
158 by cachectic diseases. Hence there was a total of 760 deaths from encephalic disease, 1258 from thoracic, 1322 from abdominal, and 385 from cachectic disease.
It is, however, more than probable that, in very many of the cases arranged under the thoracic and abdominal sections, there was co-existent cerebral disease -the cause of the insanity, although not of the fatal termination. The influence, which disease of other cavities has frequently on the state of the cerebral functions, is strikingly exemplified in many cases of insanity. M. Belhomme alludes to several cases in illustration of this remark, and more particularly to that of a phthisical patient, in whom the paroxysms of madness regularly alternated with the free flow of the purulent secretion, or its suppression. Ibid.
COMPARATIVE VIEW OF THE STATISTICAL REPORTS From the Hospice at Charenton, the Lunatic Asylum at Rouen, and the Tables
furnished by M. Desportes from the Metropolitan Hospitals. The report from the establishment at Charenton embraces a period of eight years; that from Rouen of ten years; and that of M. Desportes, as already stated, of nine years.
In all the three establishments the admissions were more numerous during the hot than during the cold seasons. The number of female lunatics exceeds that of the male at the Salpetriere; but is inferior at the Charenton and Rouen establishments.
In all, the age of the greatest number is from thirty to forty years. At Charenton the number of the milliners and seamstresses is very large, as already men-tioned to be the case at the Salpetriere.
In the Charenton, and also in the Rouen establishments, the number of single women is very large. At the former, bachelors are also very numerous Perhaps the reason of this is, that a great many soldiers are admitted.
As to the causes of mental derangement, M. Esquirol, the physician of Charenton, states that, in one-fourth of the cases there, hereditary predisposition can be clearly traced.
Ia M. Desportes' report, the influence of this state is not reckoned so high.
In closing his resumé, M. Belhomme alludes to the growing frequency of insanity in France, if we may judge from the increase of admissions into the public lunatic establishments. Perhaps this is owing, partly at least, to the eircumstance of families concealing the infirmity in any of their members less than formerly; but it cannot be doubted that there has been a positive increase in the malady during the last half centnry. We need not repeat, that the frequent political changes and public excitements have contributed not a little to this melancholy fact. It is gratifying, however, to be assured at the same time that, if the malady is increasing, the success in the treatment has of late years been den cidedly greater than in former years. The improvements which have been effected in the various establishments throughout the kingdom, and the greater attention in respect both of dietetic and of therapeutic measures, have done much for this most desirable end. One of the most valuable of all the improvements is decidedly the practice of employing the insane in some regular occupation, whenever they are capable of it.
M. Belhomme says, “ A very efficacious means to effect an improvement in the mental state of the insane, is to engage them in some regular occupation. Dr. Ellis, physician to the asylum at Hanwell, which contains between four hundred and five hundred inmates, has for a number of years employed his patients in the duties of the kitchen, wash-house, garden, &c. Many of the outworks of the establishments have been built by them, under the superintendence of a master."
M. Desportes has followed this example with great benefit in the Parisian hospices. By the aid of the patients alone, he has had large workshops erected, and there the inmates are constantly occupied in some light and useful occupation. Journal des Connaissances Medicales, from Med. Chir. Rev.
PATHOLOGY AND THERAPEUTICS.
DR. GRAVES ON PHLEGMASIA DOLENS. Let me now direct your attention to the case of Rebecca Howard, who came into hospital on the first of this month, eight days after her accouchement, with painful swelling of both lower extremities. From the history of her case it appears, that three or four days after her confinement, she got severe pain about the heel and inner ankle, accompanied by swelling, which, commencing about the same situation, extended rapidly up the thigh as far as the groin. A similar swelling appeared likewise in the other limb, but instead of commencing below, it appeared first in the upper third of the thigh, and afterwards spread dowowards, attended with violent pain, apparently in the course of the great sciatic nerve. Along the course of the veins a number of hard cords, extremely tender to the touch, could be distinctly felt; the lymphatics, though somewhat tender also, did not seem to be so much engaged, and there was no inflammation of the glands of the groin.
Here we had a case of phlegmasia dolens, or in other words, painful infiammatory oedema of the lower extremities, involving the skin, subcutaneous cellular tissue, veins, and lymphatics, more or less distinctly. I have before stated to you my opinion, that this affection does not necessarily depend on phlebitis ; on the contrary, I think that in the majority of cases the disease commences in the subcutaneous cellular tissue, and afterwards extends to the veins and lymphátics. Observe the course of the inflammation in both limbs. In one it commences in the vicinity of the inner ankle, and extends up the thigh ; in the other it is first observed in the upper part of the thigh, and spreads downwards. Now, where ædema is the consequence of phlebitis, or where it is artificially produced by tying or compressing one of the large venous trunks, it is always first observed in the lower part of the limb. You perceive, then, that those who explain the occurrence of phlegmasia dolens by referring it exclusively to phlebitis, are not able to account for it as commencing in the thigh and spreading dowowards. But how much easier is the explanation, if we look upon it as a peculiar inflamnation of the subcutaneous cellular membrane of the limb, involving in its progress to a greater or lesser extent, the veins and lymphatics, and sometimes extending to the joints. From this view of the pathology of phlegmasia dolens, you can understand why the upper part of the thigh may become primaTily affected, and that effusion may take place above before it occurs below.
So far with respect to the pathology of the diseases: now with regard to treatment. In attempting to remove this inflammation, we were obliged to keep clear of any measures calculated to increase constitutional debility. The woman, though young, was of a delicate constitution ; and there is this peculiar difficulty in the ireatment of diseases after parturition, that they occur at a time when the patient has been more or less debilitated by the efforts of labour and its cor.sequences. Our object, therefore, was to reduce the local inflammation, at the same time that we endeavoured to support the woman's strength by a light and nutritious, but not heating, diet. We commenced with the application of leeches, to the number of ten, along the inside of each limb; these we repeated do the same amount on the following day. In the application of leeches in cases of this kind, you must be guided by the circumstances of pain, tension, and swelling; these are sometimes greater in one portion of the limb than in another, most frequently in the course of the veins ; but you should always take care to have them applied over those spots in which the inflammatory process seems to exist in greatest intensity. Our next step was lo open her bowels by means of purgative injections, to be repeated as occasion required. In addition to this, I directed the limb to be gently rubbed with an ointment composed of one ounce of mercurial ointment, two ounces of lard, and three drachms of extract of belladonna. I have already dwelt so often on the local, antiphlogistic, and narcotic effects of this composition, that it is unnecessary for me to say any thing of it at present.
With respect to internal remedies, I ordered her to take five grains of Plummer's pill every night and morning ; but as this produced griping and a tendency to diarrhea, we were obliged to change it for hydrarg. c. cretả, with Dover's powder. On the 24th (the fifth day of her treatment) her mouth became affected, and the pain along the sciatic nerve, as well as the general soreness of both extremities, decreased. I forgot to observe, that from the commencement we had given opiates freely; indeed, this was one of the principal parts of our treatment. She first took the liquor of the muriate of morphia, in doses of twenty drops, three times a day; this we exchanged for opiate injections, when her bowels became irritable under the use of Plummer's pill. On the 24th there was a considerable improvement in her symptoms, as I have already stated ; but she was very weak; there was still considerable soreness of the extremities, and she complained of pain and tenderness in the right groin, showing that the lymphatics as well as the veios were engaged. I ordered the opiate enema to be repeated, and allowed her the free use of chicken-broth, rice, and a small quantity of wine. On the 25th she was directed to take a pill containing half a grain of opium every third hour. Next day the report states that she finds herself much better, that her bowels are quite natural, that she feels no pain in the lower extremities, except when pressed or moved, and that she has regained the power of her limbs. Two days afterwards she was able to stand, and at present she is so far recovered that I intend to dismiss her to-morrow.
The treatment of cases of this description involves some very curious and important considerations. With the exception of leeching, the treatment which we employed in this case cannot be called antiphlogistic; for throughout the whole course of the disease we gave opium freely, allowed her a nutritious diet, and after the first four or five days the use of wine. This shows that, in diseases called inflammatory, no general rule of treatment can be laid down, and that our practice must vary in the most remarkable manner, according to circumstances. Had I treated this inflammation by leeching, low diet, purgatives, and aotimonials, it is very probable she would have sunk. But while we were endeavouring to subdue local inflammation by leeching and mercurial ointment, we supported the constitution by a proper diet, nourishing but not heating, and afterwards by the use of wine. At the same time we gave opium in free and repeated doses, with the view of diminishing pain and irritation, and procuring sleep-a most important matter in the treatment of all acute affections combined with irritability. We also gave mercury internally, because it has been found extremely valuable in such cases, when given rather as an alterative than with the view of rapidly and violently affecting the system. Under this plan of treatment her convalescence has been very rapid. It is a plan abundantly simple, bot one which I can recommend to you with confidence.
With respect to the after-treatment of this case, I have merely to observe, that as soon as the hyper-sensibility of the limbs became diminished, I ordered them to be rubbed diligently twice a day with warm olive oil. How this acts I cannot distinctly say; but it appears to diminish tension, to promote absorption, and to increase the pliability of the limbs. Latterly we have given up this, and had recourse to dry friction and bandages. At present she is taking, three times a day, a mild tonic draught, composed of tincture of orange peel, half a drachm; tincture of hops, twenty minims ; carbonate of soda, five grains ; water, an ounce.-Med. Gazette.
OBSERVATIONS ON THE USE OF CERTAIN REMEDIES IN TYPHOUS
FEVER, AND ITS COMPLICATIONS. By Alfred Hudson, M.B.T.C.D. Physician to the Navan Fever Hospital.
The pathology and the treatment of typhus stand the best chance of being enriched, at present, from the seven millions.”. The “finest peasantry on the earth” are the victims that typhus rejoices in, and their physicians enjoy ample opportunities of observation.
We refer to the paper of Dr. Hudson, principally for the sake of ascertaining the results of his experiments with remedies exhibited in particular forms of typhus, or for particular symptoms of it. The extracts therefore must not be expected to display any necessary connexion.
A. Treatment of Fever. “I have been disposed to look for its indications to the condition of the viscera, and those symptoms which may daily arise, and not to the adoption of any routine system. I believe it is better to do too little than too much, and I therefore abstain from all hazardous modes of evacuation, once the disease has become established ; such I conceive to be bleeding, purging, and sweating. If the type of the case be pure continued fever, I usually content myself with ordering the diaphoretic mixture of the hospital, consisting of equal parts of camphor mixture and aqua ammoniæ acetatis, with an occasional small dose of calomel, reserving all more active measures for such complications as may arise. Of these, the most frequent is the gastric. In more than half the cases of synochus, the prominent symptoms were those of gastrite, and the relief afforded by leeching or cupping the epigastrium was constant and remarkable. In many cases, crisis followed immediately; in all, the patients expressed them. selves relieved from prostration, weight, tightness, and similar feelings. As regards prostration in particular, my experience leads me to co ider leeches, indicated by its existence in the early periods of fever, as certainly as is the necessity for wine by the same symptom in its advanced stage."
B. Headache and Watchfulness. “In those cases in which headache and watchfulness are complained of, I am in the habit of adding opium to the diaphoretic mixture, in the proportion of twenty-four-drops of the acetous tincture to eight ounces; and I have contantly found all the good effect described by Fordyce to follow this medicne, (3d Dissertation, p. 236.)”
c. Catarrh in Fever. “ Another very frequent and most serious complication of the continued fever of this country, is catarrh. As I have already stated, all our fatal cases of synochus suffered from it, and in many others it was with difficulty subdued. Antiphlogistic treatment seemed to have little power over it; when once it was established, it ran into the secreting stage, and then the patient's only chance was derived from a liberal supply of wine and nourishment, and the exhibition of the stimulating expectorant medicines ; of these, the decoce tion of polygala, with carbonate of ammonia, was commonly given; and in very severe cases, a bolus of carbonate of ammonia, camphor, and musk, was found to be a most efficient remedy. In some instances, especially in old persons, I found warm punch of eminent service, when wine seemed to have lost power. I do not substitute it for wine in any instance; and these are the only cases in which I have seen any benefit from conjoining it; but here it produces sudden and powerful effects when wine has failed, giving force to the cough, and caus. ing copious expectoration, restoring the warmth and natural colour of the surface, &c."
D. Stimulation in Fever. In the “general management of a case of severe continued fever, it is usually found necessary to change gradually from the expectant to a stimulating mode of treatment. I am in the habit of commencing the change (as soon as there is any appearance of the prostration of the advanced stage) by adding carbonate, or aromatic spirits of ammonia, to the diaphoretic mixture, and, as occasion requires, modifying this still farther by withdrawing the acetate of ammonia, and adding serpentaria, nitrous æther, &c., as may be indicated by the symptoms. As a general rule, also, I commence the exhibition of wine on the patient's first complaint of weakness, if the fever has advanced beyond the tenth day. I usually begin by ordering four ounces in the twentyfour hours, and increase this gradually, as may be necessary, afterwards withdrawing it in the same manner; the daily allowance seldom exceeded ten ounces ; in some cases it rose to sixteen, and in a few to twenty-four ounces. The total amount of wine consumed in the two years was 267 bottles."
E. Treatment of Gastro-enterite and Diarrhæa. “ Gastro-enterite occurred very seldom in the course of the fever. We had not in all more than twenty cases of diarrhea, which may be attributed, I think, to several causes : Ist. The practice of leeching the epigastrium early in the disease. 2d. Abstaining almost entirely from purgatives, and trusting to enemata for freeing the bowels; and perhaps to my seldom giving porter as a stimulant, as I found it so apt to produce purging, that I almost entirely relinquished its use.
In the instances in which diarrhea occurred early, it yielded to the application of leeches over the cæcum, and small doses ot' mercury with chalk, and Dover's powder, with mucilaginous drinks. In the more advanced period, a blister 10 the abdomen, and a mixture of port wine and mist. cretæ succeeded very well. In some of the fatal cases, diarrhæa came on with sweating, exemplifying Baglivi's aphorism, . Si eadem tempore in acutis et gravibus morbis, duæ crisis, sudor scilicet et alvi fluxus superveniant cum pauco levamine symptomatum, fere omnes moriuntur ut sæpe vide.'.-Praxeos Medicæ, lib. i.”
F. Chloride of Soda in Typhoid Fever. “The general treatment and complications of typhoid fever differ materially from the preceding. As regards the former, I have found, in some instances, bad effects from even small bleedings, and should in most instances, if the typhoid type were fully ascertained, prefer relieving local congestions by blisters alone, or at most, by a very small number of leeches. As a routine practice, I think the solution of chloride of soda is to be preferred to any other, provided that it be given as soon as possible after the type of the fever is known, which in many cases means, of course, as soon as the fever has set in. I cannot say that I have seen such good effect from its use in more advanced stages, though I have prescribed it in a large number of such, and still do so; not, however, to the exclusion of any one of our tried and approved remedies. But I have noted forty-seven cases of typhoid fever in which I commenced its use as soon as the patient was admitted, or the type of the fever was evidenced by the appearance of petechiæ, &c., and in every instance with the best effect, this being, in many cases, the only medicine given; the dose was from ten to fifteen drops. In some of these cases, the effect of the chloride was evidenced by the change of colour, and diminution in number of the petechiæ, * taches rosées,' within twenty-four hours, showing, I think, that its action is exerted directly upon the blood, and not as a stimulant of the nervous system, as a late writer in ihe Dublin Journal seems (erroneously surely) to have in ferred from Dr. Graves's paper on this subject.* For myself, while my limited experience leads me to place the fullest confidence in the chemical effects of this medicine, given early, I have not the least reason to attribute any stimulant powers, nor indeed any good effect whatever, to it in that stage of prostration and adynamia, which Dr. Graves has so graphically described, and in which he considers the chloride a remedy worthy of confidence."
G. Treatment of Delirium. “In the mildest forms, a blister applied to the neck, and small doses of opium, generally sufficed to remove it: but we had many cases in which these measures were quite insufficient; in some of them wine was found to be the best soporific. In six cases I tried Dr. Graves's mode of giving opium, viz. in combination with tartar emetic. In one, a case of furious
• “Dr. Mateer's Statistics of Fever, Dub. Med. Jour. No. 28. Dr. Graves's paper, read before the British Association, August, 1835. Dublin Journal, No. 22.”