Chapter 13

Before taking leave of Dr. AYRE, we cannot omit adverting, in a very few words, to a circumstance noticed in his preface, and which we think of some importance. He remarks, that if, in the prosecution of his task, he has had no acknowledgments to make to any individual as his guide and authority, he is nevertheless indebted for many important facts to the writings of the late Dr. WELLS, and of Drs. BLACKALL, ABERCROMBIE, and DUNCAN, jun. and particularly to the system of pathology of Dr. PARRY. He further remarks, that he entertained and taught for many years, the views advocated in this work, and that, after the manuscript had been sent to press, he had seen a copy of an abridged edition of the elaborate Dictionnaire des Sciences Medicales, in which the doctrine of dropsy, maintained in the larger work, is relinquished; whilst others are given in their place, conformable, in the main, with those which it is the object of his treatise to establish. Now it would appear, from these expressions, that Dr. AYRE wishes to inculcate the idea, that the English writers, whom he has cited, were the only ones who had published anything valuable, and conformable to his doctrine; and that prior to 1823, the year of the publication of the Dictionary above mentioned, the French entertained very different views of the pathology of the disease. We think it our duty, however, to rectify our author in this respect, and to show to our readers, that, even allowing full credit to Drs. WELLS, BLACKALL, ABERCROMBIE, &c. for their researches into the nature and treatment of dropsy, the American, French, and Italian pathologists are entitled to a much larger share than is allowed to them in the present work. A few references will be sufficient. Many years ago, our celebrated RUSH taught, that general dropsies "depend on a certain morbid excitement of the arteries;" and that hydrocephalus, "in its first stage, is the effect of causes, which produce a less degree of that morbid action in the brain which constitutes phrenitis." In 1812, Dr. BRESCHET, of Paris, published an excellent dissertation on active dropsies. In the early writings of BROUSSAIS, though more particularly in the propositions prefixed to his _Examen_, the opinion is maintained, that all active dropsies depend on irritability, either primary or secondary, of the serous and cellular tissues,--a theory more closely allied to Dr. A.'s, than all that is contained in the writings of Drs. WELLS, PARRY, &c. But what, perhaps, is more to our purpose, Dr. GEROMINI, of Cremona, published a work, in 1816, on the origin and cure of dropsy, in which he compares the dropsical accumulation to that of serum produced by the inflammation of a blister, or by fire; and in which he also maintains, that a slight inflammation occasions a flow of limpid serous fluid, whilst a higher degree gives rise to the formation of pus. From these circumstances, he concludes, that the hydropic fluid, which contains little albumen, is the product of a lower grade of inflammation. In the same work, he finally asserts, that in more than 200 individuals who had died of dropsy, he invariably found marks of inflammation or its effects; views which our readers will readily discover to be nearly allied to those supported by Dr. A. In making these remarks, however, we do not wish to be understood as asserting, that the theory advanced by our author did not originate also with him. We have too favourable an opinion of his honesty, to accuse him of plagiarism. Our sole intention has been to render unto each the degree of praise to which he is entitled, and, by pointing out this coincidence of opinion, to derive a further proof of the correctness of most of the pathological views, so ably defended in the present work.

ARTICLE VIII.--_An Essay on Venereal Diseases, and the Uses and Abuses of Mercury in their Treatment._ By RICHARD CARMICHAEL, M.R.I.A. _With Practical Notes, &c._ by G. EMERSON, M. D. Philadelphia, J. Harding, 1825; pp. 360.

One of the most important improvements in practice, which modern experience has established, is the reformed method of treating venereal diseases.

To the labours of several distinguished military physicians and surgeons of Great Britain, we are chiefly indebted for the facts and researches connected with this interesting subject. And although we may have much to learn in regard to the true nature of these complaints; yet the plan adopted by Mr. CARMICHAEL, of determining their distinct pathological characteristics, and applying the remedies accordingly, is the only one likely to subvert the empirical routine of prescribing mercury on all occasions, a practice which derives such strong support both from the indolence and prejudices of the profession.

In this country, many eminent practitioners have contributed to restrain the abuse of mercury; and it is believed, that Professor CHAPMAN has for many years, in his lectures, disseminated the most enlightened doctrines on this point. Dr. HARRIS and other surgeons of the navy have made a fair trial of the non-mercurial treatment, and with the most satisfactory results.

The great object, so desirable of attainment, is to form a correct discrimination between the diseases, which may be cured or benefited by the exhibition of mercury, and those which do not require this medicine, or become aggravated by its use; for it seldom fails to do injury, when its advantages are not very obvious.

Mr. CARMICHAEL has taken the most conspicuous part in this investigation for the last fifteen years, and from the extensive theatre, in which his inquiries were conducted, has had the best opportunities of arriving at the truth. He, therefore, who undertakes the management of these affections, may be justly pronounced culpable, if he neglect to make himself acquainted with the experience of this eminent surgeon.

In this enlarged and improved edition of his work, several subjects have not been treated of so copiously by the author, as was requisite to render it acceptable as a book of reference; but the judicious notes of Dr. EMERSON, whose attention has been profitably directed to the investigation of venereal diseases, have well supplied the deficiency.

A brief outline is here presented of the contents.

The author describes the various symptoms in plain and intelligible terms; rejecting such unmeaning appellations as syphiloidal, pseudo-syphilis, &c. as designating no particular phenomena, and therefore of no use in describing a disease.

He thinks there is a plurality of venereal poisons, and has divided the disease into four classes, from their different primary and secondary symptoms; making the eruptions on the skin the most certain criterion of distinguishing them from each other. These classes are:--the papular venereal disease; the pustular; The phagedenic; and the scaly venereal disease. The latter is the true syphilis.

First, the Papular. This is the most common disease, and the most easily cured. Its primary symptoms are, a simple ulcer without induration, without elevated edges, and without phagedena. Sometimes there is a patchy excoriation of the glans penis, attended with a purulent discharge. This disease and gonorrhoea are caused by the same poison. The constitutional symptoms are:--fever; pain in the head, shoulders, and larger joints, pain in the chest; dyspnoea; a papular eruption on the forehead, chest, and back, sometimes extending in a more scattered way over the extremities. It is often attended with iritis. It never gives rise to nodes. The sore throat is different from that of syphilis; the latter having deep excavated ulcers. If buboes accompany it, they are mostly of an indolent nature. The eruptions do not all appear at once; but follow each other. When on the decline, they are of a pale red or copper colour, not scaly, as in syphilis, but papular; disappearing and recurring repeatedly, and ending in desquamation.

_Remedies._--Venesection; cathartics; antiphlogistic regimen; antimonials, combined with decoction of sarsaparilla. Alterative does of calomel and antimonials, when the eruption declines.

The local treatment consists in astringent washes and simple dressings.

Iritis is to be cured by venesection, cathartics, mercury, blisters, and belladonna.

This disease will yield to the powers of the constitution. Mercury is always injurious in the early stage.

Second, Pustular venereal disease.

Primary ulcer of a reddish-brown colour; borders closely on the phagedenic character. The edges raised and well defined; not excavated, but on a level with or above the surrounding skin. In the commencement, a small itchy pustula; distinguished from the ulcer attending the papular disease by its well defined and elevated edges, and by the absence of the smooth fungous surface of the former; from the phagedenic by its well defined margin and its corroded-like surface, and the absence of acute pain; and from chancre by the absence of the callous edges and base. These ulcers are of a chronic nature, showing little disposition to spread. The ulcers from buboes partake of the same character, the edges being hard and the ulcer disposed to burrow. These edges Mr. C. removes with the knife. The disease is rendered extremely obstinate, where full courses of mercury have been given. The more closely the eruption approaches the papular, the more mild and manageable will be the disease.

_Constitutional symptoms._--The eruption is pustular, and often exhibits simultaneously new pustules; also scabbing ulcers, the crusts of which fall off, and leave discoloured patches of skin after healing. For these ulcers of the skin, the best remedies are, sulphur fumigations, nitro-muriatic acid baths, and ointment of tar and sulphur.

_Remedies._--Rest; gentle astringents; mild ointments; antimonials and sarsaparilla:--for the constitutional symptoms; venesection; cathartics; antimonials; sarsaparilla.

Mercury is decidedly injurious, until the disease is on the wane, when alterative doses may accelerate the cure.

Third, Phagedenic venereal disease.

The primary ulcer has a corroded appearance. It exhibits neither granulations nor induration. It spreads sometimes rapidly, sometimes slowly; healing in one part, while ulcerating in another. It is mostly situated on the glans and prepuce, and often attended with hemorrhage. In this disease, buboes most frequently appear.

The sloughing ulcer occurs also in this disease. Mercury is extremely pernicious, always rendering the disease more inveterate and rapid in its progress.

_Constitutional symptoms._--High fever precedes the eruption, but abates afterwards. Nocturnal headachs; tenderness of the scalp; slight dyspnoea; tenderness of the sternum on pressure; soreness of the chest; an eruption of tubercles, or pustules, or spots of a pustular tendency, which quickly degenerate into ulcers, with thick crusts, that heal from the centre, while they extend from the circumference, with phagedenic borders. The crusts are often of a conical figure. The ulceration of the throat is of the most formidable nature. It commences in the form of a small white aphthous sore; which usually attacks the velum or posterior part of the pharynx, mostly the latter. It extends rapidly, destroying the parts, and at last attacks the bones. It often attacks the larynx, after which, the patient seldom recovers. The affection of the bones of the nose is never joined with the papular eruption, nor with the scaly syphilitic lepra; but in every case with the pustular description, and when scales and ulcers were present. At the time of the eruption, pains in the knees, wrists, and ankles occur, attended with swelling and redness. He has never seen nodes in the disease, except in cases where mercury had been given. Full courses of mercury introduce the disease into the deep seated parts; for the bones are seldom or never affected in this disease, unless mercury has been given.

_Remedies for the primary symptoms._--Absolute rest; venesection; nauseating doses of antimonials; warm poultices and fomentations; opium; hyosciamus and cicuta in sufficient doses to lessen pain and irritation. For the sloughing ulcer, stimulating applications are often useful; such as Venice turpentine or balsam copaibæ, mixed with olive oil.

_For the secondary symptoms:_--Venesection; antimonials; sarsaparilla; Dover's powder. Mercury increases the ravages of the disease, except when on the wane, when it may be given in alterative doses, with safety and advantage. For the pain in the head, a blister to the nape of the neck. If the eruption appear scaly, then mercury is likely to be useful. If the throat and skin are affected, muriate of mercury in solution, and decoction of sarsaparilla. If the ulcer in the throat be small, touch it with the oxymel æruginis, or solution of nitrate of silver, grs. v a x to an ounce of water; but if there exist extensive ulcerations, fumigations with red sulphuret of mercury ought to be employed.

Fourth, Scaly Venereal Disease, or Syphilis.--Primary ulcer of a circular form, excavated, without granulations, with matter adhering to the surface, and with a thickened edge and base. The hardening is very circumscribed, not diffusing itself gradually or imperceptibly into the surrounding parts, but terminating rather abruptly. Its progress is slow, sometimes assuming a tawny appearance.

_Constitutional symptoms._--Sometimes the skin, at other times the throat, is first affected. There is headach, restlessness, and fever. The scaly eruption appears, but does not relieve the fever, as in the other diseases. This eruption commences with a small hard reddish protuberance; and as it advances, the sides are raised, and centre depressed or flat, and covered with thin white scales. It terminates in ulcerated blotches. This eruption appears on the forehead, breast, back of the neck, and groin; often in large copper coloured blotches, in parts near the hair. The ulcers of the throat mostly affect the tonsils, and come on without much previous pain or swelling; although there soon appears a considerable excavation of the tonsil, attended with evident loss of substance. The ulcer is foul, with thick white matter adherent to it, which cannot be washed away. The bones then become affected, those nearest the surface being most liable to attack; such as the tibia, sternum, clavicle, and cranium.

The remedies for syphilis are full courses of mercury, for both primary and secondary symptoms; except where a tendency to phthisis, or a delicate constitution forbids them. He thinks syphilis a rare disease now, compared with what it was formerly.

ARTICLE IX.--_Remarks on some Means employed to destroy Tænia, and expel them from the Human Body._--By LOUIS FRANK. M. D. Privy Counsellor of her Majesty, Maria Louisa, Duchess of Parma. [Lond. Med. Rep. April 1825.]

The symptoms produced by the presence of tape worm in the human body, are exceedingly distressing, and the sufferings of the patient are increased, by the obstinacy, with which these animals resist the operation of the most disgusting, and even painful and dangerous remedies. Improvements in the mode of attacking and expelling them, therefore, should be gladly received, and widely made known.

The numerous reports which we have received, concerning oil of turpentine as a remedy for tænia solium, have already given to that remedy the highest character; but many cases have been only partially relieved by it. The ol. tereb. seems to be capable of causing the separation and expulsion of portions of the animal; but while the head remains unexpelled, it is supposed to be capable of reproducing the joints, to a degree not yet ascertained. If we may believe medical writers, the tænia has been observed of the enormous length of 700 feet. It is probable that the reproduction, after the loss of large numbers of joints, is often very rapidly effected; as was the case in a patient treated at the Carey Street Dispensary, mentioned in their report for Aug. 1813,[18] This person always discharged very considerable quantities of joints or fragments, after the use of oil of turpentine; after which he remained free from the complaint for a few months, until the tænia recovered a troublesome magnitude; when it was again easily reduced to less uncomfortable dimensions.

We are not able to state positively, how long the oil of turpentine has been in use as a remedy for tænia. The Carey Street Report for Feb. 1810, informs us, that a mechanic in Durham, having been very successful in the treatment of tænia by means of this article, the circumstance was communicated by Dr. SOUTHEY, of that place, to Dr. LAIRD of London; and it was accordingly prescribed in doses of [Symbol: ounce]ss. to [Symbol: ounce]ij. at several of the London charities. It had been found, says the report, that ol. tereb. might be thus given, as safely as so much gin, and frequently caused the expulsion in two hours: Dr. KNOX says it has been in use in Germany for fifty years for the expulsion of tænia.

The experience of Dr. KNOX, concerning tænia, at the Cape of Good Hope, is the most extraordinary that we are acquainted with. Dr. SPARMAN, the traveller, had observed, that worms were exceedingly common in the northern parts of the colony; but Dr. KNOX, who was there in 1819, did not notice any special prevalence of verminous disorders, "previous to Oct. 1819, when the _tape worm became so general among the troops, as to resemble an epidemic_."[19]

Most of these troops had been employed on a short campaign to the east of the great fish river. They had been compelled to live on very bad beef and mutton, driven and starved half to death; and Dr. KNOX thinks he has proved, that the tænia in these cases did "arise from the use of unwholesome animal food; from the flesh of animals, which had been diseased." Two out of five of the troops, who had been thus employed and fed, were affected with worms. Of a detachment of 86 vigorous, healthy young men, 36 were found, on inquiry, to have _tape_ worm. Those who remained in the colony did not suffer so much, as those who had been out on the campaign, the ratio being as one to four; whereas of the others, it was two to five. Dr. KNOX had ample experience of the utility of turpentine during this singular prevalence of tænia. Concerning the 36 men above mentioned, he says, "the cure of all, who chose to adopt the means, was easily effected by small doses of the spts. of turpentine, after the failure of purgatives and various other remedies."

He considers ol. tereb. as the _most efficacious remedy_. He does not approve of large doses, because of headach, vertigo, and delirium, which have been produced by them in "many patients."

"I have generally found," says he, "that from one to two drachms of ol. tereb., given in a little water, morning and evening, for three successive days, were sufficient to destroy the tænia solium, (even in the most obstinate cases,) and cause it to leave the intestines, without the aid of any purgative medicine." He advises, however, to give a little castor oil each day about noon.

It has been a very common observation in regard to the dose of turpentine, that the patient suffers more cephalic distress when it is given in small quantity, than in a large dose. The writer of this has been obliged to desist from the exhibition of oil turpentine, in doses of [Symbol: dram]ij twice a day, in consequence of a vertigo so considerable, as to alarm and distress his patient very much. Perhaps there might have been in this case some peculiar liability to nervous excitation, which in another patient would not have been worthy of much notice. Dr. KNOX'S opinion is of great weight.

The celebrated remedy of CHABERT, Dr. KNOX thinks, owes its efficacy to the ol. terebinth. combined with it.

Dr. FRANK, whose name stands at the head of this article, was informed by the celebrated helminthologist, Dr. BREMSER, at Vienna, in 1814, that he had for ten years preferred the use of CHABERT'S remedy, and with invariable success.

CHABERT was a veterinary surgeon of Alfort, who used the animal oil of Dippel in many diseases of animals, as well as those of men. This oil he often gave for the purpose of removing tænia in his animals. He often combined it with spt. terebinth. and gave equal parts of these substances, in doses of [Symbol: dram]i.[20] The London Medical Repository states, that CHABERT'S remedy is prepared from

Ol. Corn. Cerv. Foetid. 1 part. Ol. Terebinth, 3 parts.

These are well mixed, and left at rest four days; they are then distilled in a sand bath, till three-fourths of the liquor has passed over. It must be kept tightly stopped, out of the light.[21]

The great objection to CHABERT'S remedy is its disgusting flavour; which is the more obnoxious, because the remedy must be continued for a length of time. Dr. FRANK cured two persons affected with tænia solium, after considerable perseverance with it: he cured two other persons with a preparation as follows:

Ol. Terebinth. [Symbol: ounce]ss Æther Sulphuric. [Symbol: dram]ij Pulv. G. Arab. [Symbol: ounce]ss Aq. Flor. Chamam. distil. [Symbol: ounce]xvj _m._

Two spoonfuls morning and evening.

Four of these mixtures were sufficient to cure the patients, who remained well two years afterwards.

A fifth patient, unable to take the last named medicines, was cured by the boluses subjoined:

Sem. Santonic. pulv. [Symbol: ounce]ss Pulv. Jalap. Ferri Sulphat. aa [Symbol: dram]i Ol. Corn. Cervi, gtt. viij. Syrup. q.s. Make 20 boluses.

One to be taken morning and evening. These 20 boluses being repeated three times, the patient found himself perfectly well. In the above 5 cases, the tænia was discharged in fragments.

Dr. FRANK does not say much concerning the bark of pomegranate root, which has come into vogue lately as a remedy for tænia. He refers to the Med. Chirurg. Transact. Vol. XII. for accounts by some English physicians, and remarks, that Dr. GOMEZ, the Portuguese physician, had cured 14 cases with this bark.

Dr. POLLOCK (vide Ed. Med. and Surg. Journal, Oct. 1819) treated a child, aged 14 months, with the decoction of bark of pomegranate root, so far back as the year 1811. This infant, under the use of the medicine, discharged at several times upwards of 30 feet of tænia solium, and was cured. We learn also from the Med. Repository,[22] that MM. DESLANDES, SOURYA, and BOURGEOISE, have employed pomegranate with great success; that the decoction generally expelled the worm in two hours; that it sometimes occasioned vomiting and griping pains; and that it has been a common remedy for tape worm, in the East Indies, and among the blacks of St. Domingo.

From the same source we are informed, that the French pharmaceutists recommend, before boiling the bark, that it should be allowed to swell (macerate) in cold water. [Symbol: ounce]ij of bark should be boiled in lbij of water to [Symbol: ounce]xii. Of this decoction, [Symbol: ounce]ij may be taken every half hour. The worm is here said to be passed often in twelve hours instead of two. It may be necessary to continue this plan four or five days, taking care to suspend the medicine, in case any vertigo, or intestinal disease supervenes. A dose of castor oil is recommended after the 4th bottle; even though the worm be happily for the patient expelled.