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THE
AMERICAN JOURNAL
OF THE
MEDICAL SCIENCES.
No. XLVIL— May, 1839.
1
COLLABORATORS.
Elisha Bartlett, M. D. Professor of Pathological Anatomy in the Berkshire Medical Institution,
Jacob Bigelow, M. D. Professor of Ma~ teria Medica in Harvard University, Boston.
A. Brigham, M. D. of Hartford, Con- necticut.
N. Chapman, M. D. Professor of the Institutes and Practice of Physic and Clinical Practice in the University of Pennsylvania,
B. H. Coates, M. D. one of the Physi- cians to the Pennsylvania Hosfpital.
Reynell Coates, M. D. of Philadel- phia.
D. Francis Condie, M. D. of Philadel- phia.
William P. Dewees, M. D. Late Pro- fessor of Midwifery in the University of Pennsylvania.
S. Henry Dickson, M. D. Professor of the Institutes and Practice of Medicine in the Medical College of the State of South Carolina.
Gouverneur Emerson, M. D. of Phi- ladelphia,
Charles Evans, M. D. Attending Phy- sician to the Friends' Asylum, Frank- ford,
John D. Fisher, M. D. of Boston,
E. Geddings, M. J). Professor of Patho- logy and Medical Jurisprudence in the Medical College of the State of South Carolina.
William Gibson, M. D. Professor of Surgery in the University of Pennsy l- vania.
R. E. Griffith, M. D. Professor of Medicine in the University of Virgi- nia.
Thomas Harris, Surgeon U. S. Navy, and one of the Surgeons of the Penn- sylvania Hospital.
E. Hale, M. D. Physician to the Mas- sachusetts General Hospital.
George Hayward, M. D. Professor of the Principles of Surgery and Clinical Surgery in Harvard University, Bos- ton.
C. A. Lee, M. D. of Ne w York.
Samuel Jackson, M. D.Professorof the
Institutes of Medicine in the University of Pennsylvania,
Samuel Jackson, M. D. late of North- umberland, Pennsylvania, now of Phi- ladelphia.
William E. Horner, M. D. Professor of Anatomy in the University of Penn- sylvania.
Valentine Mott, M. D. Professor of Pathological and Operative Surgery in the College of Physicians and Surgeons, New York.
James Mac Donald, M. D. Resident Physician to the Bloomingdale Asylum, New York.
Reuben D. Mussey, M. D. Professor of Surgery in the Medical College of Ohio.
T. D. Mutter, M. D. of Philadelphia.
G. W. Norris, M. D. one of the Sur- geons to the Pennsylvania Hospital,
R. M. Patterson, M. T>. Late Professor of Natural Philosophy in the University of Virginia.
C. W. Pennock, M. D. one of the Phy- sicians to the Philadelphia Hospital, Blockley.
R, R. Porter, M. D. Late Resident Physician to the Friends' Asylum, Frankford,
Thomas Sewall, M. D. Professor of Anatomy and Physiology in the Co- lumbian College, Histrict of Columbia.
Ashbel Smith, M. D. Surgeon General of the Tcxian Army.
Nathan R. Smith, Professor of the Practice of Medicine in Transylvania University.
Thomas Stewardson, M. D. one of the Physicians to the Pennsylvania Hos- pital.
A. F. Vache, M. D. of New York.
John Ware, M. D. Professor of the Theory and Practice of Physic in Harvard University, Boston.
John C. Warren, M. D. Professor of Anatomy and Surgery in Harvard University, Boston.
Edward Warren, M. D. of Boston,
John Watson, M. D. of New York.
Thomas H. Wright, M. D. Late Phy- sician to the Baltimore Alms-house In- firmary.
EDITOR — Isaac Hays, M. D., one of the Surgeons to Wills' Hospital for the Blind and Lame, §rc.
THE
AMERICAN JOURNAL
OF THE
MEDICAL SCIENCES.
VoL. XXIV.
PHILADELPHIA!
I. EA AND BLANCHARD,
SUCCESSORS TO CAREY & CO.
1839.
69427
Philadelphia :
T. K. & P. G. Collins, Printers, No. 1 Lodge Alley.
TO READERS AND CORRESPONDENTS,
The interesting “ Gleanings” of Prof. Mott, reached us just as this sheet was preparing for the press. They shall have a place in our next No.
We have been unable, from want of space, to notice several interesting works to which we are desirous of calling attention; among these we may specify Churchill on the diseases of females, Wardrop on the diseases of the heart. Dr. Dunnel’s annual report of the interments in the city and county of New York, for the year 1838, and Pancoast’s edition of Wistar’s Anatomy. Each of these shall receive early attention. We have also several other works on our table, which reached us too late for notice for the present No.
The following works have been received: —
A Treatise on the Diseases of the Chest, and on Mediate Auscultation. By R. T. H. Laennec, M. D. Translated from the third French edition with copi- ous notes, a sketch of the author’s life, and an extensive Bibliography of the dif- ferent diseases. By John Forbes, M. D. F. R. S. &c. To which are added the notes of Professor Andral, contained in the fourth and latest French edition, translated and accompanied with Observations on Cerebral Auscultation by John D. Fisher, M. D., Fellow of the Massachusetts Medical Society, with plates. New York: 1838. (From Dr. Fisher.)
A system of Anatomy for the use of Students of Medicine. By Caspar Wis- TAR, M. D., late Professor of Anatomy in the University of Pennsylvania. With notes and additions, by Wm. Horner, M. D. Professor of Anatomy in the University of Pennsylvania. Seventh edition, entirely remodelled and illus- trated by numerous engravings. By J. Pancoast, M. D., Lecturer on Anatomy and Surgery, and one of the surgeons of the Philadelphia Hospital, &c. 2
vols. 8vo: 1839. (From Dr. Pancoast.)
An Inquiry into the Influence of Physical causes upon the Moral Faculty. De- livered before a meeting of the American Philosophical Society, February 27, 1786. By Benjamin Rush. With an introductory notice by George Combe, Esq., of Edinburgh. Philadelphia: 1839. (From G. Combe, Esq.)
The Nature and Treatment of the Diseases of the Heart; with some views on the Physiology of the circulation. By James W”ardrop, M. D., Surgeon to his late Majesty, &c. London: 1837. (From the author.)
Outlines of the Principal Diseases of Females. Chiefly for the use of Stu- dents. By Fleetwood Churchhill, M. D., Licentiate of the King and Queen’s College of Physicians in Ireland, Physician to the Western Lying-in Hospital, &c. &c. Dublin: 1838. (From the author.)
Practical Surgery: with one hundred and thirty engravings on wood. By Robert Liston, surgeon. With notes and additional illustrations, by George W. Norris, M. D., one of the surgeons to the Pennsylvania Hospital. Phila- delphia: 1838. (From Dr. Norris.)
Outlines of the Institutes of Medicine: founded on the Philosophy of the human economy, in health and disease. In three parts. Should we build facts upon facts until our hill reached the heavens, they would tumble to pieces, unless they were cemented by principles. — Rush. By Joseph A. Gallup, M. D.
Author of Sketches of Epidemic Diseases of Vermont, late Professor of Theory and Practice in the Vermont Academy of Medicine, &c. &c. Boston: 1839. 2
vols. 8vo. (From the Author.)
Catalogue of the Officers and Students of the Medical Institute of the city of Louisville: January, 1839. (From Professor C. W. Short.)
Introductory Lecture delivered by H. Willis Baxley, M. D., Professor of Anatomy and Physiology in the University of Maryland. November 2, 1837, Baltimore, 1839. (From the author.)
Annual Announcement of the Medicaf Department of Transylvania Universi- ty; containing the circular for the present year, the catalogue of pupils of session 1838-9, and the list of graduates at the late commencement. Lexington: 1839. (From Professor T. D. Mitchell.)
On the methods of acquiring knowledge. An introductory Lecture to the course of the Institutes of Medicine, for the session 1838-9; delivered in the Uni- versity of Pennsylvania, November 6, 1838. By Samuel Jackson, M. D. Philadelphia, 1838. (From the author.)
1*
VI
TO READERS AND CORRESPONDENTS.
Transactions of the Medical Society of the State of New York.^ Albany: 1839. (From the society.)
A Lecture on Loxarthrus or Club Foot. By Thomas D. Mutter, M. D., Lecturer on Surgery, Fellow of the College of Physicians, &c. Philadelphia, 1839. (From the Author.)
Annual Report of the Interments in the city and county of New York, for the year 1838, with accompanying remarks. Presented by Henry G. Dunnel, City Inspector. New York, 1839. (From the author.)
Monograph of the ligneous plants indigenous to Ohio. By John L. Riddell, M. D., Professor of Chemistry and Pharmacy in the Medical College of Lou- isiana. (From the author.)
Opinion of the Court of Appeals of Maryland, in the case of the Jlniversity of Maryland, delivered by Buchanan, Chief Justice. Baltimore, 1839.
The Annual Address to the candidates for degrees and licenses in the Medi- cal Institution of Yale College, February 26th, 1839. By Thomas Miner, M. D., Member of the Board of Examination, and late President of the Con- necticut Medical Society. Published at the request of the Class. New Haven, 1839. (From the author.)
An Address delivered to the Students of the Louisville Medical Institute in the presence of the citizens of the place, at the commencement of the second session of the Institute, November 13th, 1838. By Joshua B. Flint, M. D., Professor of Surgery, Louisville, 1838. (From the Author.)
Archives Generales de Medecine, September, October, November and De- cember, 1838. (In exchange.)
Revue Medicale Fran(;aise et etrangere, August, September, October, No- vember, December, 1838. (In exchange.)
Journal de Medecine et de Chirurgie Pratiques, September, October, Novem- ber, December, 1838. (In exchange.)
Bulletin General Therapeutique Medicale et Chirurgicale, September, Octo- ber, November and December, 1838. (In exchange.)
Gazette Medicale de Paris, August, September, October, November and De- cember, 1838. (In exchange.)
Journal des Connaissances Medico-Chirurgicales, September, October, No- vember and December, 1838. (In exchange.)
Journal des Connaissances Medicales, September, October, November and December, 1838. (In exchange.)
La Lancette Franqaise, August, September, October, November and Decem- ber, 1838. (In exchange.)
Journal de Pharmacie, September, October, November aud December, 1838. (In exchange.)
Zeitschrift fiir die gesammte Medicin mit besonderer Riicksicht auf Hospital- praxis und auSlandische Literatur. Nov. 1838. (In exchange.)
The London Medical Gazette, November and December, 1838, and January, 1839. (In exchange.)
The British and Foreign Medical Review or Quarterly Journal of Practical Medicine and Surgery, Januai‘y, 1839. (In exchange.)
Edinburgh Medical and Surgical Journal for January, 1839. (In exchange.)
The Medico-Chirurgical Review, for January, 1839. (In exchange.)
The Medical Examiner for February, March and April, 1839. (In exchange.)
The American Medical Library and Intelligencer, for February, March and April, 1839. (In exchange.)
The Boston Medical and Surgical Journal for February, March and April, 1839. (In exchange.)
The Southern Medical and Surgical Journal, February, March and April, 1839. (In exchange.)
The Select Medical Library and Eclectic Journal of Medicine, February, March and April, 1839. (In exchange.)
The Transylvania Journal of Medicine and the Associate Sciences, for April, May and June, 1838. (In exchange.)
The Western Journal of the Medical and Physical Sciences for May, June and July, 1838. (In exchange.)
/
CONTENTS.
ORIGINAL COMMUNICATIONS.
MEMOIRS AND CASES.
ART. page
I. Account of the Asylum for the Relief of persons deprived of the use of
their Reason, near Frankford, Pennsylvania, with the Statistics of the Institution from its foundation to the 31st 12th month, 1838. By Charles Evans, M. D., Attending Physician to the Asylum. - - - 13
II. Observations on the Nature and Treatment of Telangiectasis, or that
morbid state of the Blood-vessels which gives rise to Naevus and Aneu- rism from Anastomosis. By John Watson, M. D. (Read before the New York Medical and Surgical Society, March 2d, 1839.) - - 24
III. Chronic Cerebral Affection: long continued, intense headache: double consciousness: extraordinary memory of events: inefficacy of treatment: diagnosis doubtful. By Elisha Bartlett, M. D., Professor of the Theory and Practice of Physic, and Pathological Anatomy in Dartmouth College. 42
IV. Case of Cancerous Ulceration of the (Esophagus opening into the
Trachea. By Morrill Wyman, M. D., Cambridge, Mass. - - 58
V. On the Remedial Powers of the Persesquinitrate of Iron. By T. C.
Adam, M. D., of Lenawee county, Michigan. - - - - 61
VI. Remarkable Case of Partial Sweating. By Samuel S. Marcy, M. D.,
of Cold Spring, N. J. - - - - - - - 66
VII. Case of Epilepsy. By Charles A. Porter, M. D., of New York. - 67
VIII. Bite of a Spider on the Gians Penis, followed by violent symptoms — recovery. By Isaac Hulse, M.D., U. S. N. Fleet Surgeon, W. I. Squa- dron. ---------69
IX. A Brief Account of Scarlatina, as it prevailed in the Orphan House, Charleston, South Carolina, during the months of June and July, 1838.
By George Logan, M. D., Physician to the Institution. - - 71
MONOGRAPH.
X. On Pseudomembranous Inflammation of the Throat. By E. Geddings,
M. D., Professor of Pathological Anatomy and Medical Jurisprudence in the University of the State of South Carolina.
Synonymes — Pseudo-membranous inflammation of the throat. Angina Pseudo-membranacea. Angina tonsillaris membranacea. Angina Plas- tica. Angina Diphtheritica, (Bretonneau.) Angine Couenneuse, (Guer- sent.) Hautige Braune. Germ. - - - - - 73
CONTENTS,
vm
ART. PAGE
Bibliography. - -- -- -- - 89
BIOGRAPHY.
XI. A Memoir on the Life and Character of Philip Syng Physick, M. D.
By J. Randolph, M. D. - - - - - - - 93
REVIEWS.
XII. Lectures on the Morbid Anatomy of the Serous and Mucous Mem-
branes. In two volumes. Vol. i. By Thomas Hodgkin, M. D., Lon- don: 1836. 129
XIII. First Principles of Medicine. By Archibald Billing, M. D., &c. &c. Third Edition, considerably Enlarged and Improved. 8vo, pp. 282. London; 1838. -------- 145
BIBLIOGRAPHICAL NOTICES.
XIV. The kiinstliche Pupillenbildung in der Sclerotica; Nebst einem an- hange iiber die Verpflanzung der hornhaut, Keratoplastik. Nach eigenen Versuchen. Von Dr, B. Stilling, Gehulfarsarzt am Landkrankenhause zu Marburg. Marburg, 1833, 8vo. pp. 144.
On the Formation of an Artificial Pupil in the Sclerotica, with an Appen- dix on the Transplanting of the Cornea. By Dr. B. Stilling, &c. - 163
XV. Appreciation de la Doctrine Phrenologique ou des localisations des Facultes Intellectuelles et morales, au Moyen de I’Anatomie Comparee.
Par M. .Jules Lafargue, ancien interne des hopitaux.
An appreciation of the Phrenological doctrine, or the localisation of the intellectual and moral faculties, by means of comparative anatomy. By M. J. Lafargue. - - - - - - - -168
XVI. Die Gefassdurchschlingung. Eine neiie methode, Blutungen aus grdsseren Gefassen zu Stillen. Von Dr. B. Stilling, prakt arzt zu Cas- sel. 8vo. pp. 152, Marburg, 1835.
Die natiirlichen Processe bei der Heilung durchschlungener Blutgefasse mit besonderer Riicksicht auf den Thrombus. Aus einer grossen reihe Von Versuchen an Thieren abgeleitet. Von Dr. B. Stilling, &c. 8vo. pp. 304, Eisenach, 1834.
Geschichte einer amputation des oberschenkels, wobei die* durchschlin- gung der art. fern., art. prof. fern, und der vena fern, in anwendung gezo- gen wurde. Von Dr. B. Stilling, &c. 8vo. pp. 32, Hanover, 1837. - 172
XVII. Recherches Medico-physiologiques sur L’Electricite Animale: Sui-
vies d’observations et de considerations pratiques sur le precede medical de la neutralisation electrique directe, notamment appliquee au traite- ment de I’Ophthalmie, de I’Erysipele de la Face, de la Cephalalgie, de la Migraine, des Derangemens de la menstruation, des Affections rhuma- tismales, de quelques Affections nevropathiques, &c. Par J. F. Cou- dret, M. D. P. &c., Paris, 1837. pp. 496. pi. III. - - - 176
XVIII. A Treatise on the Diseases of the Chest, and on Mediate Auscul- tation. By R. T. H. Laennec, M. D., Regius Professor of Medicine in the College of France, &c. &c. &c., translated from the third French edition, with copious notes, a sketch of the author’s life, and an exten- sive Bibliography of the different diseases. By John Forbes, M.D.F. R.
S. &c. &c. To which are added the notes of Professor Andral, contain- ed in the fourth and latest French edition, translated and accompanied
CONTENTS.
ix
PAGE
with observations on cerebral Auscultation, By John D. Fisher, M. D. Fellow of the Massachusetts Medical Society. With plates. New York, Samuel S. & Wm. Wood, 1838, pp. 784, PI. II. - - - 178
XIX. — A Lecture on Loxarthus or Club-foot. By Thomas D. Mutter,
M. D., Lecturer on Surgery; Fellow of the College of Physicians, &c. Philadelphia, 1839. pp. 104. 8vo.- ----- 178
XX. Practical Surgery; with one hundred and thirty Engravings on Wood.
By Robert Liston, Surgeon. With notes and additional illustrations, by George W. Norris, M. D., one of the Surgeons to the Pennsylvania Hos- pital. Philadelphia, James Crissy, 1838, pp. 374, 8vo. - - 179
XXL Tenth Annual Report of the Inspectors of the Eastern Penitentiary of Pennsylvania. Philadelphia, 1839, pp. 28, 8vo. - - - 179
XXII. An Introductory Lecture to a Course of Lectures on the Theory and Practice of Medicine, in the University of Pennsylvania: Delivered at the opening of the Session of 1838-39. By N. Chapman, M. D.
Prof. &c., Philad. 1838, pp. 19. 8vo. ----- 184
SUMMARY
OF THE
IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES.
FOREIGN INTELLIGENCE.
General Anatomy and Physiology.
PAGE
1. Case of Natural Somnambu- lism. By Dr. Verdet - - 185
2. Observations on the Fluid of the Vesiculae Seminales of Man.
By Dr. John Davy. - - 187
3. On the Veins of the Uterine Decidua. By Dr. Robert Lee. 188
Pathological Anatomy
6. Exostosis of the Pelvis of
unusually rapid growth. By Wm. Lawrence, Esq. - - 191
7. Hepatic Abscess opening into the Stomach by three perfora-
Materia Medica and
9. Kermes Mineral as an emetic and purgative. By Dr. Toul- mouche. - - - - 195
page
4. On the Venous Circle of the
Mammary Areola. By Profes- sor Sebastian. - - - 19(>
5. On the accessory Supra-Renal Capsules. By Professor Sebas- tian. ----- 190
AND General Pathology.
tions; also into the Pericardium.
By R. J. Graves, M. D. - - 192
8. Silver Spoon swallowed — after- wards discharged through an abscess in the epigastrium. - 195
General Therapeutics.
10. Method of determining the genuineness of Ergot. By Mr.
T. H. Wardleworth. - - 196
X
CONTENTS.
PAGE
11. Medical Properties of Zinc.
By G. G. SiGMOND, M. D. - 196
12. On the Properties and Thera- peutic powers of Camphor. By
G. G. Sigmond, M. D. - - 198
Special Pathology and
14. Treatment of Irritation of the
Stomach. By Jonathan Os- borne, M. D. - - - - 201
15. Neuralgia of the Testicle. By
Dr. Graves. - 204
16. Method of preparing Sina- pisms for the purpose of with- drawing Gout from the vital organs to the extremities. - 204
17. l^eatment of Permanent Hy-
pertrophy of the Tonsils. By Dr. Graves. - - - - 205
18. Spasm of the Glottis or La- ryngeal Asthma. By Dr. T.
H. Burgess. - 205
19. Efficacy of Emetics in remov- ing Paralysis of the Facial Nerve. By Dr. C. J. Heidler. 211
PAGE
13. Value of Creosote as compar- ed with other remedies. By Dr. Da Luz. - - - - 201
Special Therapeutics.
20. Hepatic Abscess. By Dr.
Jackson. - - - - 212
21. Case illustrating the History, Symptoms, Pathology and mode of Treatment of Simple Ulcera- tion of the Stomach. By Lang- ston Parker, M. R. C. S. - 214
22. On Simple Ulceration of the
Stomach, with observations on those forms of gastric irritation which more commonly precede and. accompany it. By Lang- ston Parker, Esq, - - - 215
23. Experiments on the applica- tion of narcotics in the form of Vapour. By C. W. Hufeland. 221
24. Heart diseases not seated in
the heart. By C. W. Hufeland. 222
Surgery.
25. Encysted Dropsy of the Thy- roid Gland. By Dr. Selwyn. - 224
26. Division of the Prostate in
Lithotomy. By H. M. Phil- lips, Esq. - 224
27. Fearn’s case of Aneurism of
the Innominate, treated by liga- ture of the Carotid and Sub-cla- vian arteries. - - - - 225
28. On the cure of wryneck by dividing the sterno-cleido-mas- toid muscle beneath the skin.
By Prof. Dieffenbach. - - 226
29. Hydrocele. By M. Dujat. - 231
30. Dislocation of the Radius for- wards. By Mr. Coley. - - 232
31. Extirpation of the Tongue.
By M. Regnoli. - . - 232
32. Case of Ileus in which Gas- trotomy was performed. By
M. Monod. - 233
33. Desault’s apparatus for frac- tured femur. - - - - 235
34. Hydrocele treated by acu- puncture. By Dr. Davidson. - 235
35. Dislocation of the Humerus,
attended with a grating sensa- tion on motion, leading to the supposition that the case was complicated with fracture. By Wm. Lawrence, Esq. . - 236
36. Malignant Ulcer under the left ear cured by chloride of zinc. By Wm. Davidson, M. D. 237
37. Treatment and Causes of Ery-
sipelas. By Wm. Davidson, M.D. - - - - -238
Ophthalmalogy.
38. Glaucoma. By Dr. Wm. Mac- kenzie. - - - - - 240
39. Use of the essential oil of
Turpentine in diseases of the Eye. By Dr. A. Trinchinetti. 242
40. Hereditary Hemeralopia. By M. Florent Cunier. - - - 242
CONTENTS.
xi
Midwifery.
PAGE
41 . On the Position of the Placen- ta in the Womb during pregnan- cy, and on the manner in which the latter organ expands therein, as also of its subsequent contrac-
PAGE
tions in the process of Parturi- tion. By Hugh Carmichael,
Esq. - - - - - 242
42. Unconscious Delivery. By Robert Hall, Esq. - - - 243
Medical Jurisprudence and Toxicology.
43. Poisoning with Arsenous acid I 44. Effect of Respiring Carbonic
successfully treated by the Hy- j Acid. By C. T. Coathupe. - 244
drated peroxide of iron. By Dr. Deville. - - - - 243
Medical Statistics.
45. Vital Statistics of Glasgow.
By Dr. Robert Cowan. - - 246
46. Periodical Mortality of the
Human Race. - . - 250
47. Greater number of still-born
in illegitimate than in legiti- mate births. By Prof. Jorg. - 251
48. Pauper Lunatics and Idiots in England and Wales. - - 251
Animal Chemistry.
49. Urea in the Blood in Chole- 150. Analysis of the Liquor Amnii. ra. By Dr. Rainy. - - 251 | By Dr. G. O. Rees. - - 252
Miscellaneous. '
51. Revaccination. By M. De- | New Books, - | - 252
zeimeris. . - - - 252 j
AMERICAN INTELLIGENCE.
On the Catoptric examination of the Eye. By the Editor. - 255 Expulsion of one twin Foetus, the other retained to the full period. By S. Jackson, M. D. 256 Closure and obliteration of the Os uteri, during pregnancy. By Samuel Weber, M. D. - - 256
Case of Club-foot treated by division of the Tendo Achillis.
By Thomas J. Garden, M. D. - 257
New Vaccine Virus. - - - 258
Report of Thomas Lawson, M.D. Surgeon General of the United States Army. - - - - 258
Malignant Pustule. - - - 259
Osteo-sarcoma, and excision of a large portion of the lower jaw. By Dr. J. Wort. - - 260
Wound of the Stomach. - - 261
Dr. S. & G. H. White’s Lunatic Asylum at Hudson, N.. York. 262
XU
CONTENTS.
PAOE
Massachusetts General Hos- pital. - - - - 262
Philadelphia Medical Society. - 264 University of Pennsylvania. - 264 Transylvania University. - - 263
University of Maryland - - 264
, V-
PAGE
j Dartmouth College. - 264
I Medical College of Georgia. - 264
(Geneva College. - - - 264
Louisville Medical Institute - 264 I New Works. - 264
ERRATA.
It is stated in the review of Professor Jackson’s Report on Typhoid fever, in our No. for November last, p. 132, that there is^vidently some mistake in the cal- culations. The writer of the article was led into this error from a misapprehen- sion of the manner in which the tables of the author were drawn out. These tables are made to show how frequently each symptom considered separately, presented itself; but, as in some of the cases, two or more symptoms occurred together, without it being stated how often this happened, one who was not aware of this fact, might readily suppose the number of cases to have beeu greater than it really was, and thus infer an error in the calculations.
We may notice at this time a typographical error at p. 134, next line to bot- tom, in which none is placed for one. It should read, in one there was perfora- tion of the intestine.
These corrections should have been made in our preceding No., and we owe many apologies to our estimable and respected correspondent for the omission.
1
/r'.V. Z///.
THE
AMERICAN JOURNAL
OF THE
MEDICAL SCIENCES.
Art. I. Account of the Asylum for the Relief of persons deprived of the use of their Reason^ near Frankford^ Pennsy Ivania, with the Statistics of the Institution from its foundation to the 3lst I2th month, 1838. By Charles Evans, M. D., Attending Physician to the Asylum.
Of all the maladies to which the human system is obnoxious, those which affect the manifestations of mind have undoubtedly the strongest claim upon our sympathy and care. Notwithstanding this is now generally acknow- ledged, yet it is comparatively of but recent time, that the public sympathy has been effectively demonstrated, by providing adequate and appropriate means for the cure of persons afflicted with those diseases; or for alleviating the distress and securing the comfort of such as may be beyond the reach of remedial aid. All experience has proved, that in the great majority of cases, separation from friends, and seclusion from society, are indispensable to the recovery of the insane; besides which the peace of their families, and the well being of society, demand their restraint; hence, places for their reception have been common in all Christian countries: but until the. pre- sent century, these institutions appear to have been conducted, mainly, with a view to the security of their wretched inmates; provision for their medical and moral treatment, being altogether unheeded, or made of very secondary consideration. Left to the conduct of the ignorant, the selfish, and the unfeeling, whose principal aim was to escape trouble and secure their own emolument, the mad-houses (as the English termed them,) embraced more heart-sickening degradation, and more unheeded suffering, than could be found in any other receptacles of human misery. The real state of the No. XLVIl.— May, 1839. 2
14 Evans’s Account of the Frmikford Asylum.
houses for the reception and treatment of the insane, in Great Britain was first disclosed to the public by the report of a committee of the House of Commons, published in 1816. Credulity itself is staggered at the recital, of the before unheard of cruelty practised, and misery endured, within the walls of most of those institutions, many of which, the public had been accustomed to regard with pride, as monuments of their liberality and bene- volence. There were, however, a few honourable exceptions, and conspi- cuous among these was the Retreat near York, which was projected by the Society of Friends as early as 1792, the same year in which Pinel com- menced his celebrated reform in the Bicetre at Paris. The plan of that Institution originated with a few individuals in the society, who, having acci- dentally become acquainted with the manner in which the insane were habitually treated, resolved to rescue such of their fellow professors as suf- fered under that pre-eminent affliction, from the misery which surrounded them, and to place them in a situation where they would be subjected to a totally different course of management from that pursued in any of the existing establishments. Accordingly grounds were purchased, buildings erected, and in 1796 a considerable number of patients received, and a course of treatment carried out, such as had never before been practised towards the insane, and which gave a rational ground to hope that their cure would be effected, or, at all events, their comfort and welfare secured. The Retreat was soon resorted to by others than Friends, and in a short time the success obtained there, demonstrated beyond contradiction, the superior effi- cacy, both in respect of cure and security, of a mild and humane system of treatment in all cases of mental disorder. To the philanthropic members of that religious society, who founded and conducted the Retreat, belongs (toge-. ther wdth Pinel, who made some reformation in the horrible abuses of one of the Paris hospitals,) the credit, whatever it may be, of changing the course of treatment long pursued toward those deprived of the use of their reason, and restoring to them that sympathetic kindness and control which their affliction jpeculiarly demands. The example thus set was slow in ex- tending its iniuence, as is evident from the state of the institutions through- out Great Britain, when the investigation before alluded to, took place. That it had, how'cver, a decided effect in awakening the public mind to the im- portance of a reformation in the insane hospitals, is shown by several parts of the evidence given before the committee of the House of Commons. Dr. Weir, Inspector of Naval Hospitals, states in his testimony, that “the object of almost every insane institution, whether of a public or private description, had been the security of those pitiable objects; comfort, medi- cal and moral treatment being in great measure overlooked; happily, how- ever, for that class of society, the Quakers’ Retreat at York, has at last convinced the world, how much may be done towards the amelioration of their condition.”
From the time the subject was thus brought before the public, the
Evans’s Account of the Frankford Asylum. 15
arrangement and economy of asylums for the insane have become the sub- jects of attentive study and experiment, until, under the influence of an enlightened philanthropy, they have been radically changed, so that within the w^alls of every such institution properly conducted, are congregated, not only the various resources of medical science and art, and every thing calcu- lated to divert the mind from its erroneous associations, and give new vigour to its powers; but also, all that needful care, decided control, and well-di- rected kindness, which, owing to perverted feelings, the sufferer rejects, or cannot appreciate while within his own domestic circle, but which are gene- rally accepted with thankfulness from the hands of a stranger, and contri- bute powerfully to lessen his distress and restore his health.
In 1812, motives, similar to those which actuated the founders of the Retreat in England, induced a large number of the members of the same society in Pennsylvania, to attempt the establishment of a similar institu- tion. They associated themselves together under the title of “ The Con- tributors to the Asylum for the Relief of Persons deprived of the use of their Reason,” for the purpose (as expressed in their constitution,) of pro- viding for the suitable accommodation of that afflicted class of our (their) fellow members, and professors with us, (them) w'ho are or maybe deprived of the use of their reason; as well as the relief of their families and friends.” Subscriptions were opened, and in the course of a comparatively short time, a sufficient amount of funds having been collected, the institution which I am about to describe was built, and in 1817 opened for the reception of patients. At that time there was no asylum in this country which could serve as a model for an institution of the kind, those existing only answer- ing to show how entirely inappropriate for the accommodation of the insane were the plans upon which they were constructed.
The Asylum for the Relief of Persons deprived of the use of their Rea- son, is situated in a healthy and retired part of Oxford township, distant about five miles north from Philadelphia, and one mile westward from Frankford. The whole building, which faces the north, is three hundred and twenty-two feet eight inches in length, being made up as follows:
The centre building is sixty feet square and three stories high above the basement; having two wings standing back about eighteen feet from its front, each one hundred feet long by twenty-four feet in depth, and two stories high; terminating in end buildings, which project four feet in ad- vance of each wing, and are thirty-one feet four inches in front, by twenty- eight feet four inches in depth, and three stories high, exclusive of the base- ment. From each of these end buildings, a wing, running south, at right angles with the front, extends twenty-six feet eight inches in length, by twenty-two feet six inches in depth, and corresponding in height with the front wings.
The first story of the centre building contains four large rooms, divided from each other by halls running at right angles, one of which leads directly
16 Evans’s Account of the Franhford Asylum,
through the building from north to south, and has the staircase in it, while the other opens into each wing. The two front rooms are appropriated, the one as a parlour for the superintendant, the other as an office and re- ceiving room; the two in the rear, which respectively communicate with the wing of the side on which it is situated, are used as day-rooms for the patients. The second story of this building also contains two large rooms, situated with respect to the wings like the two below, and like them appro- priated as day-rooms for the patients, besides which, there are four smaller rooms used by the family of the superintendant. There are four large, and three smaller rooms in the third story. One of the larger is occupied by the resident physician, and one as a sitting room for the convalescent female patients; the apothecary shop is also on this story. The wings each con- tain twenty good-sized rooms for patients, with a lobby or passage ten feet wide, running the whole length in front of them, at the extremity of which is the staircase. The end buildings, or lodges, as they are called, though united to the wings by the front wall, yet have their other walls entirely dis- tinct; and in the lower story, are separated from the wings by a passage five feet wide, leading to the airing yards. Immediately over this passage, is the staircase leading from the second to the third story of the lodge. The rooms, both in the body of the lodges and their wings, are on the west side, with an entry six feet wide running in the rear of them on the east side; these entries are lighted by a window at each end, the wall on the side next the wings being unbroken and of extraordinary thickness. This sepa- ration of the two lodges from the rest of the building, is for the purpose of preventing the transmission of sound, and is found effectually to prevent the convalescent and quiet patients, who are kept in the wings, from being in- jured or annoyed by the noise of the violent and unruly ones, who are con- fined to the lodges. The first story of the lodges contains the bath rooms, a day room and two rooms for patients; the other rooms in the different stories, for the accommodation of the patients and their care-takers, are about twelve feet square.
In the centre building are the refectory, kitchen, ironing-room, and store- room; rooms for cooking, washing, <fcc., are adjoining under the wings, where also are the furnaces; furnaces are likewise located in the basement of the lodges. The whole building is covered with slate, and may be said to be nearly fire-proof. The basement story is paved with brick or flags, and arched, while the bottoms of the floors, and the joists in all parts of the house are thickly plastered with mortar, and then ceiled in the usual manner. In all parts of the building accessible to the patients, the window sash is of cast iron, and stationary. The lower one in each window is glazed, and outside of the upper is a wooden sash, glazed, which is hung, so as to be raised or lowered at pleasure. This arrangement, while it en- sures security from escape, prevents the appearance of a place of confine- ment. The rooms in the centre building, and the patients’ day rooms, ex-
Evans’s Account of the Frankford Asylum, 17
cept those in the lodges, are warmed by means of stoves and grates. The wings and lodges have heated air, conducted from the furnaces before men- tioned, as located in the basement story, into the lobbies and each room. The openings for the admission of the warm air into the rooms, are near the ceiling, and covered with wire-gauze, and the air can be stopped off at any time by means of dampers, situated so as to be regulated only by the attendants. Some of the rooms are provided with shutters for the exclusion of light when required, as also with wire protection to the glass.
Immediately under the roof in each wing is a large reservoir for water, supplied by means of a forcing-pump, from a never-failing stream, which issues forth a short distance from the house. From these reservoirs the water is conveyed to the bath rooms, and various other parts of the building.
The great extension of front in a building intended for the accommoda- tion of but sixty-five patients, was deemed necessary in order to give to each, a separate, well proportioned room, having all the advantages to be derived from the free admission of light and air. Where the rooms are arranged on both sides of an entry of the usual width, these two essential requisites to health and cheerfulness cannot be commanded; added to which, the patients occupying opposite rooms are very liable to be mutually annoy- ing, and in every respect (unless it be that of saving money), that mode of building for the insane is highly objectionable. On this account the plan adopted at the Friends’ Asylum is worthy of imitation.
On one side of the wings are situated the chambers, ten feet square, each having a window, four feet six inches in height, by two feet ten inches in width. These rooms open on to the lobby, ten feet wide (as before mention- ed), and directly opposite the door of each room is a window corresponding in size with that in the room. Over each door is fixed a cast iron sash, thirty-two by twenty inches in size, fitted with a moveable glazed sash, to be opened or shut at pleasure. Ey this arrangement, a full supply of light and a free circulation of air are secured, and the lobbies being comfortably warmed in cold weather, they afford pleasant places for walking and exer- cise of different kinds.
The kitchen and refectory, situated on the back part of the basement story of the centre building, open on to an area, which is fifteen feet wide opposite the centre building, and connects with one ten feet wide running the whole length of the western, and past that of the eastern wing. These areas are paved with brick, and have a well, fitted with a pump in them. The outside of the area is sodded, and rises regularly to a level with the garden and yards in the rear.
A neat vestibule, having its sides enclosed with Venetian shutters, sixteen feet in length, and corresponding in width with the large hall running through the ground floor of the centre building, is thrown over the widest part of the area, and leads directly into a flower-garden. In the rear of the
2*
18 Evans’s Account of the Frankford Asylum,
wings and lodges are the airing yards, each surrounded by walls ten feet in height, enclosing about half an acre of ground, for the use of such of each sex, as are not well enough to be allowed to walk, unattended, in the gardens and pleasure grounds. Each yard is subdivided by a board fence, cutting off about one-third of it; into which the idiotic and filthy patients are put, that they may not offend those who take more care of themselves. These yards are made pleasant with trees and summer-houses, the passages leading to them, as before mentioned, are between the wings and end-buildings. The entrances to the privies are from these yards: a door opening through the wall into them; there are no water-closets or other accommodation of the kind, within the buildings. Between these yards is a large flower- garden, and immediately beyond them the vegetable garden; the two con- taining about two acres of ground. At the termination of a gravel walk leading directly from the house through these two gardens, at the distance of about three hundred feet, is an ornamental house, surrounded on all sides by a piazza, fitted up as a library and reading room, and containing nume- rous specimens of natural history, maps, drawings, &c. &c., affording a most agreeable resort for such patients as may be considered by the physi- cian well enough to enjoy it.
Over the spot where rises the stream that supplies the institution with water, at a short distance from the eastern end of the building, is erected a stone house, two stories in height, beside a basement; the lower story of which contains a forcing-pump so arranged, as to be easily worked by four of the patients; while the upper one is fitted up as a work-shop, with a turning lathe, tools, &c. Here many of the patients find interesting em- ployment.
Connected with the various buildings described, is a farm of sixty-one acres, the greater part of which is under cultivation, and by giving the pa- tients the opportunity for various agreeable and active out-door employ- ments, affords the most powerful means for their restoration to health and reason. The woodlands cover about eighteen acres of ground, and are made up principally of the chestnut, beach and oak, affording a deep and delightful solitude and shade. Abroad serpentine walk, more than a mile in length, winds throughout them, and a large summer-house and seats in various situations, are provided for the accommodation of the patients. Near the entrance to the woods, and enclosing a small part of them, is a park containing some fine deer.
Experience having proved that the comfort and cure of the insane are materially affected by the construction of the building in which they are placed, numerous plans have been suggested and acted upon, each of which has its admirers. All however who have had any practical know- ledge of the treatment of those labouring under the disease, and their liability to be acted upon by the objects which surround them, unite in the senti- ment, that that plan will prove the^ best, which, with equal conveniences,
Evans’s Account of the Frankford Asylum, 19 >
combines the most means for introducing well-adapted employment and ex- ercise, with the best arrangement for an extensive classification which can be kept permanently distinct.
Where the conveniences for classification are wanting, the most lamenta- ble consequences must necessarily be witnessed even in institutions which may otherwise be conducted in the most unexceptionable manner. The employment of moral remedial means, is either absolutely precluded or ren-. dered nugatory, when the patient upon the first dawn of reason feels the horror of being constantly surrounded by his pitiable associates, in all the different gradations of maniacal phrenzy and idiotic imbecility. These evils are guarded against at the Asylum by such a classification as is allow- ed of by the arrangement of the building.
The male patients occupy the eastern, and the female the western side of the house, both sides being arranged alike. The end buildings, or lodges, are occupied (as before mentioned), exclusively by the noisy and imbecile. Such of them as are fit to be out of their own rooms, have the liberty of a well-lighted and cheerful day room, situated in the southern extremity of the lower story of the wing of the lodge. Another class of patients oc- cupy the lower story of the main wing, and have for their sitting roonfi the large room described as forming part of the lower story of the centre build- ing. The upper story of the wing is devoted to a third class who are more nearly well, and such as show no violence, and conduct themselves gene- rally with propriety; they likewise have a day room for their peculiar accommodation, situated on the second story of the centre building, corres- ponding with the one below. All these patients, however, have access to the same yard, excepting that the worst are confined to a small part of the yard, which is boarded off, as before described.
For the accommodation of such of the females as are nearly restored, there is a large room in the third story of the centre building fitted up as a drawing room, where they can pursue their various amusements and em- ployments entirely undisturbed by the other inmates of the house. There is no such room for the men, but the same class of patients among them, usually resort to the library, when circumstances will not admit, or they are not disposed to walk abroad. Such of the patients as do not eat in their own rooms, take their meals in the day rooms attached to the respective parts of the building where they are placed.
The government of the institution is lodged in the hands of a steward and matron, and resident physician, whose whole time is devoted to fulfil- ling the various duties of their respective stations. An attending physician visits the patients regularly twice a week, and as much oftener as the urgen- cy of a case may require. A Board of twenty Managers, appointed yearly by the Association, have the supervision of the whole, and by a committee of three, inspect every part of the establishment once in each week.^
20 Evans’s Account of the Frankford Asylum*
In the treatment pursued at the Asylum, endeavours are used, so to com- bine medical and moral agents, that each shall render the other its most efficient aid, and jointly exert their remedial powers with the greatest cer- tainty and effect. The therapeutical treatment of course varies accord- ing to the disease, which by affecting the brain, disturbs the manifestations of the mind. An accurate account of such treatment and its results, is con- stantly kept, and at some future day may afford data for ascertaining the relative advantages of the course pursued.
The moral means employed are various. Where it is found necessary, mild and gentle yet firm restraint is imposed, while the earliest gleams of returning reason are watched and cherished.
In the house, there are provided, games of different kinds; reading, writing, drawing, &c. The females sew, knit, quilt, The library is
furnished with ^ooks, periodicals, drawings, &c. Exercise in the open air is always promoted, and the patients encouraged, whenever the weather will permit, to engage in walking and riding. A carriage and horses are always in readiness, morning and evening, for their accommodation. In the lawn fronting the house, is located a circular rail-road about four hundred and fifty feet in circumference, with a pleasure-car on it, large enough to accommodate two, which is moved by hand. Riding upon this road is a very favourite amusement, and as it is attended with considerable exercise, it is found highly advantageous. Every exertion is made to interest the male patients in gardening, and in the various employments afforded in the cultivation of the farm. The diet of the patient of course varies according to the prescription of the physician, but in general it is plain and nutritious; fresh meat and a variety of vegetables being served up every day. Tea, coffee, and milk are all abundantly supplied.
The Asylum was opened for the admission of patients in the 5ih month of 1817, and the following table exhibits the number, sex, and social state of those received yearly, up to the conclusion of 1838.
|
Year. |
Whole number, |
Men. |
Women. 1 Single. |
1 Married. |
CO & o TS g |
Widowers ) |
Year. |
Whole number. |
1 c ! « 1^ |
Women. | |
[ Single. |
1 Married. |
Widows. |
1 Widowers. |
|
1817 |
18 |
9 |
9 13 |
5 |
0 |
0 |
1828 |
18 |
1 S |
10 |
9 |
6 |
3 |
0 |
|
1818 |
21 |
13 |
8 9 |
9 |
2 |
1 |
182.9 |
19 |
no |
9 |
11 |
7 |
0 |
1 |
|
1819 |
17 |
10 |
7 10 |
5 |
0 |
2 |
1830 |
19 |
12 |
7 |
11 |
6 |
0 |
2 |
|
1820 |
23 |
13 |
10 14 |
8 |
1 |
0 |
1831 |
28 |
14 |
14 |
15 |
10 |
2 |
1 |
|
1821 |
22 |
13 |
9 15 |
5 |
2 |
0 |
1832 |
33 |
21 |
12 |
15 |
18 |
0 |
0 |
|
1822 |
20 |
6 |
14 13 |
5 |
2 |
0 |
1833 |
24 |
10 |
14 |
10 |
5 |
9 |
0 |
|
1823 |
18 |
10 |
8 10 |
7 |
1 |
0 |
1834 |
40 |
20 |
20 |
16 |
21 |
3 |
0 |
|
1824 |
18 |
10 |
810 |
5 |
2 |
1 |
1835 |
53 |
24 |
29 |
25 |
16 |
8 |
4 |
|
1825 |
28 |
13 |
15 12 |
9 |
5 |
2 |
1836 |
56 |
31 |
25 |
30 |
22 |
4 |
0 |
|
1826 |
26 |
15 |
1112 |
8 |
4 |
2 |
1837 |
49 |
29 |
20 |
24 |
24 |
1 |
0 |
|
1827 |
21 |
10 |
11 10 |
8 |
3 |
0 |
1838 |
63 |
30 |
33 |
32 |
25 |
5 |
11 |
Evans’s Account of the Frankford Asylum. 21
|
Whole number of admissions, |
- ■' |
- |
- |
- |
“ |
|
|
(( |
Men, |
_ |
331 |
|||
|
(( |
Women, - |
- |
- |
- |
• |
303 |
|
u |
Single, - |
- |
- |
. |
- |
326 |
|
it |
Married, - |
- |
- |
- |
- |
234 |
|
it |
Widowers, |
- |
- |
- |
- |
17 |
|
it |
Widowsj |
- |
- |
- |
- |
57 |
|
Of these there |
were below 20 |
years of |
age. |
_ |
- |
28 |
|
From |
20 to 30 years, |
. - ' |
- |
187 |
||
|
ti |
30 to 40 |
a |
- |
■ - |
141 |
|
|
it |
40 to 50 |
it |
- |
126 |
||
|
, |
it |
50 to 60 |
it |
- |
- |
83 |
|
ti |
60 to 70 |
it |
- |
48 |
||
|
it |
70 to 80 |
it |
- |
- |
15 |
|
|
it |
80 to 90 |
a |
- |
- |
5 |
|
|
a |
90 to 100 |
ti |
1 |
- 634
Of these 634 admissions, 127 were re-admissions granted to 81 individuals, and leaving 507 persons who have been under care.
The following table shows the duration of the disease at the time of ad- mission of these 507 cases, and the results of treatment.
|
Duration. |
Number, |
Restored. |
Much Imp. |
Improved . |
Stationary |
Remaining |
Died. • |
|
Less than 1 year, |
261 |
152 |
26 |
27 |
18 |
4 |
34 |
|
From 1 to 2 years, |
57 |
18 |
8 |
8 |
9 |
7 |
7 |
|
From 2 to 3 years, |
36 |
17 |
3 |
3 |
4 |
5 |
4 |
|
From 3 to 5 years. |
45 |
14 |
7 |
6 |
9 |
3 |
6 |
|
From 5 to 10 years. |
47 |
13 |
7 |
3 |
8 |
11 |
5 |
|
Over 10 years, |
61 |
0 |
7 |
5 |
22 |
13 |
14 |
|
Aggregate, |
507 |
214 |
52 |
52 |
70 |
43 |
70 |
The proportion of cures in these cases is 42.21 in every hundred; but if we deduct the sixty-one cases, which at the time of admission had been deranged over ten years (and which included twenty who either were idiots, or had been imbecile from puberty), five cases complicated with epilepsy, and five which entered the institution with the paralysis peculiar to the insane, it leaves 436 cases, properly subject to treatment, and the cures are in the proportion of 49 in every hundred.
The per centage of cures in cases of less than a year’s duration, taking
22 Evans’s Account of the Frankford Asylum,
the whole twenty-two years is 58.23. Within the last six years, it has been 66. Nearly all of this class, discharged as “ much improved,” were almost well; but either pecuniary considerations, or the anxiety of their friends, oc- casioned their removal as soon as the disease was so overcome as to render their perfect restoration probable; and in many instances information was afterwards received of their perfect recovery.
Of the seventy deaths, six occurred within a week of the time of their admission; nine within two weeks; seven within three weeks; and three within four weeks; these were mostly cases of acute inflammation of the brain, or its meninges, many of them being brought to the Asylum after all hope of relieving them at home was abandoned. Ten died between a month and a year’s residence, and the remainder varying from one year to twenty.
Of the eighty-one patients re-admitted, there were discharged
Restored, - -- -- --36
Much Improved, 4
Improved, - -- -- -- 6
Stationary, ------- 7
Died, - 17
Remaining in the House, - - - - 11
Twenty-two returned a third time; of whom there were discharged — Re« stored, 14. Improved, 3. Stationary, 3. Died, 3 — and one remains in the house. The other re-admissions, were of three individuals, who being liable to periodical insanity, have been accustomed to resort to the Asylum at the commencement of an attack, and to remain there until again restored to the use of their reason.
The following table exhibits the ages of the persons re-admitted, and the duration of the attack at the time of their first admission.
|
Age. |
No. |
Duration of Disease. |
No. |
|
Below 20 years, |
2 |
Less than 1 year, |
3y |
|
From 20 — 30 |
24 |
From 1 to 2 years, |
7 |
|
From 30—40 |
21 |
From 2 to 3 years. |
7 |
|
From 40 — 50 |
15 |
From 3 to 5 years, |
7 |
|
From 50 — 60 |
10 |
From 5 to 10 years, |
10 |
|
From 60 — 70 |
4 |
Above 10 years. |
11 |
|
From 70—80 |
4 |
||
|
From 80 — 90 |
1 |
||
|
81 |
81 |
Forty-one of the eighty-one had been originally discharged cured. The interval between the discharge and re-admission, was as follows.
Evans’s Account of the Frankford Asylum.
23
|
Less than three months, |
17 |
of whom 8 had been discharged cured. |
||||
|
Between three and six months, |
9 |
of whom 2 |
do. |
|||
|
ti |
six months and 1 |
year. |
14 |
do. |
11 |
do. |
|
ii |
1 and 2 years, |
- |
11 |
do. |
8 |
do. |
|
u |
2 and 3 years, |
- |
8 |
do. |
2 |
do. |
|
ii |
3 and 5 years. |
- |
7 |
do. |
4 |
do. |
|
ll |
5 and 10 years, |
- |
13 |
do. |
5 |
do. |
|
Over |
10 years. |
- |
2 |
do. |
1 |
do. |
In some of the cases where this interval was so short as to be within three months, the second indisposition should no doubt be considered as a relapse; the organs not having been restored to perfect soundness after the original attack. But when we recollect how prone an organ which has once been diseased, and especially the brain, is, to resume the morbid action upon the occurrence of even a trivial cause, and also that that organ is liable to be affected not only by the causes which produce disease in other parts of the system, but likewise by the moral feelings and emotions of the mind; it is not to be wondered at, that a recurrence of disease should often be witnessed where persons are taken from the seclusion and regular habits of an Asylum, and ushered into the cares and excitement of society, as soon as healthy action is believed to have been restored. It is a difficult matter to convince a patient, or his friends, that prudence dictates his slay should be prolonged for a considerable time after he is apparently well, yet it cannot be doubted, that where such a course is pursued, the security of health is greatly increased.
As has been before observed, the Asylum was originally intended for the accommodation of those in membership or profession with the Society of Friends alone; and it continued thus exclusive, until the year 1834, when the contributors withdrew the restriction, and opened the institution for the benefit of all, with the proviso, that “in no case should a member or pro- fessor be excluded.”
An accurate record of the place of nativity of each patient, and whether member or not, has been kept from the opening of the institution. By this it appears that the average number of the members of the General Meeting of Friends held annually in Philadelphia, which were under care (including idiots) during the first ten years in which the Asylum was opened, was thirty-one. That meeting includes the greater part of Pennsylvania, New Jersey and Delaware, and during those ten years was composed of between twenty and twenty-three thousand members; which, taking the medium, twenty-one thousand five hundred, which I believe is nearly correct, gives the proportion of one in every six hundred ninety-three and a half. In 1827, a large body seceded from that meeting, and its numbers are not now so accurately known; the ratio, however, has not increased.
Dr. Burroughs in his Commentaries, gives currency to the opinion that insanity occurs in a greater proportion among the members of the Society
24
Evans’s Account of the Franhford Asylum.
of Friends, than the population generally, and assigns as a reason, their intermarriage with each other. This however would be entirely insufficient to account for the greater prevalence of the disease among them, if such were really the case, as in Great Britain, from whence he draws his data, there are nearly if not quite twen,ty-five thousand members; a number so large as to do away the probability of its being attributable to hereditary taint.
As the records of the two institutions for the insane, belonging to the So- ciety, show that intemperance and want, so productive of mental derange- ment among others, cannot be assigned as the causes of it, in, more than one case in every hundred and fifty occurring in the members of that society, and as they are known to be exempted, at least equally with others, from the sources of anxiety which disturb the social state; there would appear to be no other causes for the disproportion of diseases affecting the manifesta- tions of mind, did it really exist, than either defective cerebral organization, or some peculiarity in their religious principles or practices. The former, no one will believe to be the case, and religious mania, as it is commonly but improperly called, is a form of the disorder which so rarely occurs among them, that as a community they may be said to be almost exempt from it.
The true reason of the apparent disparity in the proportional number of those afflicted with derangement in that society, and the community at large, lies in the very defective statistical information obtained of the latter rela- tive to a disease which the ignorance and prejudices of the people lead them to conceal, and upon which incorrect data, a false estimate has heretofore been made. While in the Society of Friends, an accurate knowledge of all the members, liberal provision for the support of their poor, and institutions for its cure under their own care and government, bring nearly every case of idiocy or insanity which occurs among them, under notice.
Art. II. Observations on the Nature and Treatment of Telangiectasis, or that morbid state of the Blood-vessels which gives rise to Nsevus and Aneurism f tom Anastomosis. By John Watson, M.D. Read before the New York Medical and Surgical Society, March 2d, 1839.
By Telangiectasis, as the etymology of the word implies, is meant a dilated state of the extreme vessels. The term was first employed by Graefe, it has since been used by other writers of Germany, France, Eng- land and America; and as applied to a morbid condition of the blood-vessels, it is synonymous with the nsevus maternus of the older writers, the aneu- rism from anastomosis of John Bell, the tumeur variqueuse or fongueuse sanguine of Boyer, the tumeur erectile of Dupuytren. I have adopted it
Watson’s Observations on Telangiectasis. 25
as more applicable to the cases about to be related, than either of these other terms; it covers the whole ground occupied by a natural group of maladies; it alludes to the actual state of the blood-vessels without referring to the cause, real or imaginary, that gives rise to this; it involves no theory as to whether these diseases be seated in the veins, the arteries, or both; it im- plies not that these diseases should in all cases exist at birth; and includes those that are deep-seated, as well as such as are visible or superficial.
Previous to the time of John Bell, the superficial forms of telangiectasis were denominated naevi materni or mothers’ marks; and the French in allu- sion to a prevalent notion that these marks are caused by longings and men- tal impressions of the mother during gestation, have commonly termed them envies. But the deeper forms, or such as lie beneath the skin without involving it, before the time of Bell, had no specific name assigned to them; they were either described as anomalies, or confounded with a variety of other affections. Without attempting to enter at present upon the pathology of the tumours which Bell has described under the head of aneurism from anastomosis, it may here be well to remark that this name is defective and improper; first, in implying that the disease is seated solely in the arteries; and secondly, that the anastomoses of these vessels are more abundant than natural.
Mr. Wardrop has attempted to show that the vascular nmvus is a disease entirely different from the aneurism by anastomosis, and finds fault with other writers for confounding them: yet none of the distinctive signs which he has specified, can be taken in any other light than as pointing to mere varieties of a disease common to both veins and arteries, frequently confined to the capillaries, but often extending to the other vessels.
Many of the French writers, and some even of our own country who have treated on this disease, have confounded it with that variety of carci- noma which Hey has described under the name of fungus hematodes. Some too, after having discovered this error, have committed another in retaining the name fungus hematodes in their account of the severer forms of the disease now under consideration. Even Dupuytren, who takes to himself the credit of having first illustrated the pathology of what he calls erectile tumours, has aided in perpetuating this confusion: for, under the head of his erectile tissue he includes aneurism from anastomosis as de- scribed by Bell, fungus hematodes as described by Hey and others, and a great variety of normal structures, both in men and other animals, which serve as the type of these two morbid growths. Bell indeed had previously pointed out the analogy in structure between the aneurism from anasto- mosis, and the normal tissues which Dupuytren has included with it; so that this latter writer has added nothing to our pathological knowledge by his labours on this subject.
The cases of telangiectasis requiring treatment that have fallen under my own observation, have been neither suflSciently numerous nor sufficiently No. XLVII — May, 1839. 3
26
W atson’s Observations on Telangiectasis.
diversified to illustrate this point of pathology in all its bearings; I shall be obliged therefore in the course of my remarks to refer, for some of the severer forms of this disease, to the cases of other "writers.
Case I. — In March, 1837, I saw with Dr. Stevens an infant ten months old, the daughter of Mr. K,, who had for some months past been under treatment for a pulsating tumour on the right side of the face. The tumour was still increasing, and when first seen by Dr. Stevens (March 23d) it extended from just below the inner canthus of the eye, downwards and outwards on the cheek, presenting a circular elevation an inch and a quarter in diameter, lying mostly beneath the integuments, but raising the skin about three-fourths of an inch above its natural level.
The spot from which the present deformity originated, according to the mother’s account, was not observed until some days after the child’s birth, and when first noticed, it was a mere point of bright red colour under the inner corner of the right eye. When the child was three months old, the swelling was as broad as the mother’s thumb nail, somewhat elevated, and throbbing. At this period the parents became alarmed, and consulted Dr. Mott, who applied caustic potassa to the tumour. This produced an eschar which separating, left an ulcerated surface W’hich continued open about eight weeks, and during this time hemorrhage occurred occasionally, but never to any alarming extent. The ulcer finally cicatrized without chang- ing the character of the tumour. It still continued to grow, and in Novem- ber, 1836, its diameter at the base was about an inch.
The parents at this time applied to Dr. Bushe, and he pierced the tumour with three cautery needles heated to whiteness. This operation caused some hemorrhage at the time, and was followed by considerable inflammation, but not of sufficient severity to change the character of the tumour, or to arrest its growth. The operation was repeated in February, 1837. No hemorrhage followed the second application of the needles, the subsequent inflammation was slight, and the final result of this cauterization was as unsuccessful as the first.
From a drawing taken at Dr. Stevens’s first visit, (I did not see it until after he had operated upon it,) the disease appears to have originally involved the skin, and to have afterwards extended to the subjacent tissues. It is re- presented of a light pink colour, interspersed with minute scarlet points, and with larger spots of a purplish hue.
Having learnt the nature of the previous operations, and dreading the de- formity, not to speak of the danger, likely to result from any attempt at extir- pating the tumour. Dr. Stevens, with the view of exciting inflammation sufficient to change the character of the vitiated growth, determined upon introducing a seton. A blunt-pointed needle, armed with several silk threads, was accordingly passed from the inner towards the outer edge, and com- pletely under the swelling; the needle was withdrawn, and the silk threads left as a seton in the wound. No hemorrhage followed the operation;, the threads were sufficiently numerous to fill the track of the needle, and thus to prevent bleeding.
On the fifth day after the operation, suppuration was established along the course of the seton; the inflammation gradually extended to the tumour, and continued to increase until April 15th, (twenty-three days after the insertion of the threads,) at which time the external character of the swelling was suddenly changed, and purulent matter was evidently forming within it. On the following day the existence of pus was still more manifest; the bright
Watson’s Observations on Telangiectasis,
27
red colour of the integuments had given place to a pale yellowish tinge; and the whole tumour had the appearance of a large phlegmon about to burst. .The circumference, however was still red; and on the edge next the eye the original character of the swelling was still perceptible.
^pril llth. An eschar formed in the centre, and the abscess broke, giving issue to a copious flow of dark brown consistent pus. This continued to ooze out in considerable quantity for several days afterwards.
April ‘IMh. The seton was withdrawn from beneath the tumour. The inflammation excited by it had, since the bursting of the abscess, already much abated; and the tumour was reduced to one-third of its former size. A purplish spot, however, still existed at the upper edge, indicating that the portion of the tumour at this point was still unaltered; but, with this excep- tion, the whole of the diseased tissue had become indurated.
June Sth. The swelling was still further diminished; the purplish spot still observable; the abscess not yet entirely healed; and the appearance of the integuments about it, such as are usually presented in the normal tissue under chronic inflammation.
After this date I lost sight of the case until December, 1838. On examin- ing the child, at this period, not the slightest vestige of the disease remained; the integuments were of their natural colour, and the cicatrix was only ob- servable on minute examination.
In accordance with the distinctions attempted by Mr. Wardrop, between naevus and aneurism from anastomosis, this tumour would belong to the latter class. It differed from his subcutaneous naevus, first, in having ori- ginally manifested itself at some time after birth; secondly, by originating in the skin, and extending afterwards to the subjacent tissues; and, lastly, in having a pulsatory movement. In short, the morbid development appears here to have been seated in the capillary arteries, whilst in the disease de- scribed by Wardrop, the corresponding veins were the vessels most affected.* It is worthy of further observation, in this case, that the caustic potassa, and even the cautery needles, appear to have excited so trifling a degree of in- flammation; and even when this w'as effectually established by the seton, its progress was unusually slow, several months having intervened between the formation of the abscess and its final closure. This same observation, I find, has also been made by Mr. Lawrence, who states that, in one portion of these morbid structures, inflammation may progress to mortification, without exciting inflammation in other parts immediately adjacent.f But, when once inflamed, these tissues are apt to sphacelate, as may be seen by consulting the cases of Pelletan and others; and perhaps in the ca-e just related, the abscess might have for a long time been prevented from closing, by a portion of this mortified tissue remaining at the bottom of it.
Case II. — Mr. H.’s son, three months old, was seen. Sept. 18th, 1837, having three n^vi on its back, and another on its arm, near the elbow. The largest of these was about two inches in diameter, and seated behind the left
* See his remarks in the Lancet, vol. xii. p. 394, (June 30, 1827,) and his earlier paper on this subject in the Medico-Cliirurgieal Transactions, vol. ix. p. 199.
t Lancet, vol. ix. p, 163.
28 Watson’s Observations on Telangiectasis.
shoulder, involving the skin in its central part; but extending beneath the skin without involving it in the circumference. It was also somewhat ele- vated, and had an ulcerated spot in the middle, as large as a ten cent piece. It had existed at birth, and had grown considerably since; and, when pressed, it communicated to the finger an obscure thrill, or pulsating movement. The second was about one-fourth as large as this, and was seated on the opposite shoulder. The third one was very small, and lay immediately below the preceding. These two, as well as the spot on the elbow, were not observed at birth; they had not grown so rapidly as the first; they were apparently confined to the skin itself, and were somewhat elevated. Their colour was a bright purple; but the subcutaneous portion of the first one had a different hue, as if caused by the purplish colour striking through the healthy skin.
Through the largest of them Dr. Stevens introduced a seton, passing it, as in the preceding case, beneath the apparent base of the naevus. The second spot was removed by excision, the knife extending to the sound in- tegument, a line or more beyond the boundaries of the naevus. Very little blood followed the operation: the integuments were drawn together over the wound by a suture and adhesive straps. The third spot was not molested at this time; but in a few days afterwards it was touched with cali purum. The spot on the elbow was left entirely to itself.
In a few days after these operations, the seton had ulcerated its way through the centre of the principal spot, without producing much irritation or inflammation. Another seton was introduced in an opposite direction, add the surface of the spot was brushed over with cali. The wound left by the incision had not united by the adhesive process, and was left to granu- late. An eschar had formed over the third one, to which caustic had already been applied.
On the 30th of September, the part upon which the incision had been made was nearly cicatrized; the spot beneath it was granulating, but not so far advanced in cure. The large naevus was now an open fungous ulcer, and at first sight it might easily have been mistaken for a fungus hematodes. The second seton had nearly ulcerated its way through. Caustic was again freely applied over the surface of the sore, and a compress and roller em- ployed, in order to repress the fungous growth.
Subsequent to this date, the two small spots on the back required no fur- ther treatment. The last application of caustic had the effect of destroying the fungus; the ulcerated surface gradually closed, and at the end of three months the disease was completely eradicated. But the integuments over the principal spot preserved a bluish tinge for some time afterwards. The spot upon the elbow still persists, without any disposition to grow larger.
The spots in this case appear to have been confined to the capillary ves- sels, and to have originated in the skin. The rapidity with which the setons ulcerated their way through the large naevus, does not prove that the vitality of the tumour was very great; but, on the contrary, that it was less than natural; and the slight degree of inflammation produced by the threads, is confirmatory of this remark. Judging from this case, the seton does not appear to be well adapted for the cure of superficial nsevi, especially where the base is broad; — the caustic, in this case, was evidently much more effectual.
Case III. — Mr. S.’s daughter, six months old, had a congenital naevus on
Watson’s Observations on Telangiectasis. 29
the right side, near the lower margin of the thorax: it was altogether cuta- neous, of a bright red colour, and somewhat elevated; it did not pulsate, and was about an inch and a half in diameter. When first observed, it was not elevated above the surface, and was not larger than a five cent piece; but within the last few weeks, it has been rapidly increasing.
On theL2d of November, 1838, Dr. Stevens, embracing the diseased por- tion of integument with a pair of forceps, elevated it, and removed it by one stroke of the bistoury. A small artery was observed in the centre of the wound thus made; which, from its brisk hemorrhage, appeared to be much larger than the cutaneous vessels usually are. The blood poured from it in jets, and a ligature was required to arrest tlie hemorrhage. On examining the extirpated portion of skin, the continuation of this vessel was observed entering at the centre of the diseased spot; and, even in its contracted state, its calibre was sufficiently large to admit a thick bristle.
The edges of the wound were approximated by adhesive straps, and in a few days afterwards the child was entirely w&ll.
The organization of the naevus in this case, was apparently the same as in the preceding cases; and that the capillary arteries were the principal seat of disease, is proved by the dilated state of the cutaneous artery, through which the rnorbid structure was supplied with blood. Was the naevus in this case owing to the dilated condition of the vessel leading to it? or was the ililaiation the necessary result of the increased flow of blood towards the diseased tissue? By consulting other cases, in which the expansion of the vessels was much more marked than in this, we find that the increased de- velopment of the larger vessels always begins at or near their capillary ter- minations, and gradually progresses on towards the heart; that the dilatation is often, but not always, attended with thinning of the coats of the vessels, but without ulceration, or any other sign of inflammatory action, in the great majority of cases. The vessels too are not merely dilated; they are also much increased in length, and twisted on themselves, and convoluted in a great variety of ways.
Case IV. — Mrs. Geer’s son, aged five months, was brought to me on the 19lh of June, 1838, with a naevus on the breast just over the centre of the sternum. It manifested itself soon after birth, and has since gradually in- creased. When I first saw the tumour it was about three quarters of an inch in diameter, and was elevated at least half that extent above the level of the skin; it was of a bright red colour, appeared to be extending to the sub-cutaneous tissues, and had a thrilling movement.
I passed a curved needle armed with silk threads from above downwards through the base of it; and lying these threads tightly on either side of the swelling, I attempted to strangulate it.
June22d. The ligature on the right side had produced partial ulcera- tion and sloughing at the base of the naevus. On the opposite side the string had become loose; and slipping upwards on the side of the naevus, had forced the blood out of its spongy tissue without completely strangu- lating the part. The ligature was again tightened.
June 2Sth. The ligatures ulcerating their way through the diseased skin; but at a point somewhat above the outer edge of the naevus, so that a small rim of the morbid tissue is likely to be left.
3*
30 Watson’s Observations on Telangiectasis.
After this date, I lost sight of the case until the month of December fol- lowing. I now found the central portion of the naevus replaced by healthy skin; but around this there was still remaining a ring of the diseased tissue. This ring was not elevated, it gave out no pulsation, its colour was bright red, its diameter was about half an inch, and its rim was not more than a line in breadth.
February 18//i, 1839. The spot has extended to the sub-cutaneous tissue, and is again becoming elevated. When pressed with the finger it gives a doughy feel. Its colour in the centre is that of the healthy skin; but in the circumference it is much darker than formerly, and the sub-cutaneous veins extending from it towards the top of the sternum, are fuller and more distended than natural; so much so as to be remarked by the mother herself. She is much concerned lest the spot “ should begin to grow more rapidly and bleed, as the vines begin to grow in the spring.”
From this case we see the propriety, when it is possible, of removing the whole of the morbid tissue; and we have in it another evidence of the difficulty with which inflammation is brought about in theso structures. Had the outer rim of the naevus been sufficiently inflamed by the liga- tures, and subsequent ulceration in the centre, the diseased portion would have been altered, and made to assume its normal character as in the first case related. The disease in this case is now clearly connected with the veins.
Case V. — Miss M. W. when a child, had a nasvus on the right side of her forehead. It appeared soon after birth, at first of a faint pinkish hue, which gradually increased to a bright red; it continued to increase for about two years, at which time it was nearly as broad as a quarter of a dollar; it was elevated above the surface, but flattened on the top; and so far as I can recollect, it gave a thrilling motion to the finger. Its degree of turges- cence, and its colour varied with the state of the circulation. It remain- ed stationary for a year or so longer, and then began gradually to be effaced. At the end of eight or nine years, the skin had assumed its healthy appear- ance in colour and structure, and there is now no remaining evidence on the forehead that a naevus had ever existed there.
From this case we learn that these tumours may occasionally disappear spontaneously without ulceration; a fact contrary to the opinion of some writers, and one by no means common: for, though they often become eflfaced, yet it is exceedingly rare for them to disappear and leave the skin of its natural colour.
Case VI. — Mr. C., a Scotchman, about 45 years old, in consulting with me for another disease in July, 1838, requested me incidentally to examine his back. I discovered a flattened sub-cutaneous tumour, somewhat irregu- lar on its surface and in its shape; and, to speak within bounds, covering about a square foot along the right lumbar region, and so on up the back and round towards the right side. Towards the centre of the tumour the integuments were involved for about two inches square, and were of a deep purplish colour verging to black. Over the remainder of the swelling, the skin was of its natural colour and texture. The tumour was very yielding and inelastic, like soft spunge, and had no unnatural pulsation. The dis- coloration in the centre of the swelling had existed since birth: but was
Watson’s Observations on Telangiectasis, 31
originally very small. During his youth it extended to the sub-cutaneous tissue, and for a time grew rapidly; but for the last twenty years or more, it has remained stationary. At times it becomes turgid and distended, and then again subsides into its present state. It gives him no inconvenience except when it becomes turgid, and then it is attended with burning and stinging pains.
Nothing but post-mortem inspection could render it more clear, that the tumour in this case was owing to a dilated condition of the capillary veins. The colour, the inelastic spongy feel, the entire absence of pulsation; all show that the minute arteries formed no prominent part of it. In this re- spect it corresponds with the sub-cutaneous n^vus of Wardrop; but it differs from that in having spread originally from the skin to the subjacent cellular tissue.
Case VII. — In the summer of 1828, a young woman from the country came to town to undergo an operation for a round and prominent swelling of a purplish-black colour, about the size of a wild cherry, on the margin of the lower lip near the left commissure. It had existed there since her inhmcy. It was removed by two incisions, one on each side of it, running obliquely downwards so as to meet each other beneath its base. The wound in the lip was afierw^ards drawn together by a stitch and adhesive straps. In a few days the parts had become adherent, and the deformity caused by the removal of the V-like flap, was scarcely observable.
This, like the preceding ease, is one in which the venous capillaries were chiefly involved; scarcely any portion of the tumour however extended beneath the integuments.
Case VIII. — The facts of the following case have been generously fur- nished me by my friend Dr. Alexander Hosack of this city.
Dr. Hosack, about six years since, had charge of an infant four months old, with a congenital naevus on the side of its head. The tumour appeared to be situated wholly beneath the skin. The integuments over it were in- flamed, and the tumour was rapidly increasing. It did not appear to pul- sate on pressure; it was much elevated, spongy, and easily emptied of its blood; but after removing the pressure it rapidly filled again with a sort of pulsatory action. At the time of attempting its removal, it was about the size of a dollar. It was removed by excision. Brisk hemorrhage followed the operation; before the surgeon or his assistants had time to arrest the bleeding, the infant had swooned, and in ten minutes afterwards it expired.
The nasvus in this case was connected with enlargement of the temporal artery, which beat very forcibly; and Dr. H. is of opinion that the tumour was formed by the immediate ramifications of this vessel. A case similar to the preceding is related by Mr. Wardrop. The tumour was sub-cutane- ous and situated on the back of the neck. “It was of the form and size of half an ordinary orange,” and was rapidly increasing. On the tenth day after its birth, the skin gave way and a profuse hemorrhage followed without reducing the size of the tumour, which felt warmer than the surrounding parts, and was compressible to one-third its ordinary size. “ Conceiving the immediate extirpation of this tumour the only chance of saving the
32 * Watson’s Observations on Telangiectasis,
infant,” says he, “ I removed it as expeditiously as possible, and made the incision of the integuments beyond the boundary of the tumour; aware of the danger of hemorrhage where such tumours are cut into. So profuse however, was the bleeding, that though the whole mass was easily removed by a few incisions, the child expired.”"*^
Case IX. — An infant about three months old was brought to the New York Hospital to be treated for a swelling on the right side of the neck be- hind the slerno-mastoid muscle, and just above the clavicle; it was of a flattened ovoid shape, about two inches long, and not quite so broad; it was entirely subcutaneous, and quite moveable; it was easily compressed, had a doughy feel, and was free from all pulsation. The integuments over it were healthy, but had a tinge somewhat darker than natural from the colour of the tumour beneath. The swelling was gradually increasing.
I saw this case but once, and know nothing of the result. It is the only case I have observed to correspond in all respects with the subcutaneous naevus of Wardrop.
Case X. — An infant was brought to the New York Dispensary with a small cutaneous naevus on its forehead. The child had not been vaccinated, and the vaccine physician proposed to apply the virus over the naevus, stating that he had cured several similar spots in this way — the virus was accord- ingly inserted, the eruption that followed was smaller than usual, and after its desiccation the naevus still persisted.
Case XI. — -Ann Scarlet, aetat. 23, admitted into the Cheltenham Hospital, November 17th, 1828, with a congenital naevus extending in detached por- tions on the outer side of the limb from the upper part of the thigh to the extremity of the little toe. When she was about seven years old, the veins of the leg first began to enlarge. At ten or thereabouts, a vein under the naevus on the outer side of the knee, gave way; she thus lost sufficient blood to produce fainting; the bleeding was finally arrested by pressure. From this time the limb enlarged rapidly, and every autumn scabs formed on different parts of the naevus which ulcerated and bled considerably. In June, 1827, she was married. During her pregnancy the limb increased more rapidly than formerly; and in the centre of the large portion of the naevus, after considerable inflammation, an abscess formed and discharged a teacupful of pus mixed with blood. She aborted at the end of the fourth month, and subsequent to this the limb had somewhat diminished.
At the date of her admission, she was pale from the frequent loss of blood, and her form was slender and much emaciated. A considerable portion of the naevus on the thigh was in a state of ulceration, and bled at every change of dressing; a similar bleeding ulcer existed near the ankle. The veins of the leg on the outer side of the limb, says Mr. Averill, were in a more varicose state than any he had ever seen; while those on the inner side of the limb were entirely unaffected. The diseased thigh was an inch and a half more in circumference than the other; and the calf of the diseased leg was five inches and a half greater than that of the sound limb. She suffered great pain in the limb, had occasional discharges of blood from the hemorrhoidal veins; and sometimes, when sick, threw up blood from the stomach.
* Medico-Chirurg. Transact. Vol. ix. p. 202.
Watson’s Observations on Telangiectasis. 33
The disorder of the stomach was relieved by the internal use of nitrate of silver, aided by a blister over the epigastrium. Bandages were tried for unloading the veins of the limb, but these were found to bo painful and of no avail, and were consequently abandoned. An elastic stocking and thigh- piece, contrived for the occasion, answered a better purpose; the thigh- piece however was not applied until after the ulcer had healed. She con- tinued the use of the apparatus until leaving the hospital, (January 23d, 1829) being restricted, in the mean time, to light and easily digested food. Her general health was now restored; her thigh was reduced to its natural size, and the leg very little larger than the other. The veins were also much diminished in size. She was directed to continue the use of the apparatus.
This is one of the most striking cases I find on record of general dilata- tion of the larger veins of a limb connected with a nsevus. A case, no doubt of the same kind in which the vessels of the arm and hand were in- volved to a very great extent, is related by Mr. Abernethy. Mr. Adams has reported some cases in which naevi, situated on the tongue, were connected with great enlargement of the veins. This form, he says, “ grows slowly and has no pulsation. At other times it assumes a sudden increase of size, particularly in females during the menstrual period.”* But as a still more positive proof that the veins are ajt times extensively involved, we may refer to a preparation of this sort in Guy’s Hospital Museum, presented by Sir Astley Cooper.f
Case XII. — Catharine Micart had two congenital spots of the colour of wine lees, one upon the left ear, and the other on the left parietal region. In the course of a few years the two spots united, and produced considerable tumefaction. About her eleventh year, the tumour began to increase, small openings occurred spontaneously upon it, and gave issue to arterial hemor- rhage. A free incision was made into it, from which a great quantity of blood escaped; but this was permanently arrested by pressure, and in a month afterwards the wound had cicatrized. In the mean time the tumour con- tinued to increase. In September, 1805, the patient, then eighteen years old, entered the Hotel Dieu, in consequence of bleeding produced by a puncture which had been made some days previous at the upper part of the ear.
The tumour at this time occupied the whole of the temporal region, and appeared to be composed of arteries enormously dilated. The ear was red, large, and agitated throughout by pulsations synchronous with those of the heart. At the top of the helix was a cicatrix which gave way at the slight- est touch, and the crevice resulting from its rupture furnished a brisk and obstinate hemorrhage; and this was renewed at every attempt to change the dressings. Pressure applied over the temporal artery arrested the move- ment and pulsation in the anterior part of the tumour. Permanent com- pression over this vessel was therefore commenced as a means of cure; but
* Dublin Journal, (from the report of the Transactions of the British Association for 1835,) Vol. viii. p. 218.
f Catalogue of the Anatomical Museum of Guy’s Hospital. London, 1829, preparation 1538, marked “Nsevus Maternus of Foot; it consists of a congeries of dilated veins, which are filled with wax.
34
Watson’s Observations on Telangiectasis,
it was found to be too painful to be continued. M. Pelletan next undertook to secure the temporal and occipital arteries: but in the operation the tem- poral artery was transfixed, and only partially taken up; and in passing the needle under the occipital artery, blood gushed out from both extremities of the puncture; but after dividing the integuments over it, this vessel was se- cured, and pulsation ceased in the tumour. Compression was again em- ployed, but it produced a slough, in consequence of which it became neces- sary to dress the part oftener than usual; at each dressing the hemorrhage recurred; and the pulsation, though less strong than formerly, was renew- ed. In the course of treatment, constitutional symptoms ensued, erysipelas appeared on the face, an abscess formed in the centre of the tumour, and another over the sternum; the occipital artery bled frequently; and finally, at the end of two weeks from the operation, the patient sunk.
In the post-mortem examination, the integuments of the scalp, and of the left ear, were found of their natural structure. There was a cicatrix at the parietal protuberance: behind this, the opening of an abscess; and upon the helix, a small opening filled with clotted blood. Under the skin, from the zygoma and occipital tuberosity up to the top of the head, existed a thick layer of dense cellular tissue infiltrated, or rather interspersed, with small and distinct masses of pus. The cellular tissue of the ear was very red, and was formed by the interlacing of a great number of dilated veins and arteries.
All the arteries comprised in the tumour below this tissue, were dilated, tortuous, and nodulated in a very irregular manner; and filled either with coagulated blood, or with a white thick humour. The temporal artery was dilated and pervious to within an inch of the ligature; that portion of the vessel which had not been included in the ligature formed a fibrous cord at the bottom of the wound. The vessel higher up, and its branches, were en- larged, as before stated; and the branches of the occipital artery were also knotted, tortuous, and dilated.
The arteries throughout the body, according to Dupuytren’s testimony, were thinner than natural, and the smaller ones collapsed like veins, from which they were with difficulty distinguished. This wasting of the parietes of the arteries was much more remarkable in the vessels of the fifth or sixth order, than in those of larger size. Purulent depositions were found in the liver; and there were evidences of recent inflammation of the pleura, the lungs being united to the parietes of the chest.
This case has been differently related by Pelletan,* * * § who had charge of it, and by Dupuytren, who furnished an account of it for Breschet’s Essay on Aneurism, j* It is also related by BoyerJ and other French writers, and ap- pears to have been the first case that called the attention of the French sur- geons to this subject. § The patient’s death may be attributed, not to the
* Clinique Chirurgicale, tome ii. p. 59.
t Me moires de I’Academie Roy ale de Medecine, tome iii. p. 154.
t Maladies Chirurgicales, ii, p. 374.
§ Pelletan, CKnique Chirurg. tome ii. p. 65. Other cases of this disease, recorded as anomalies, are to be found in the works of several of the older continental writers. One of the most striking and graphic of these is quoted by Boyer, tome ii. p. 378, from the Mem. de I’Acad. des Sciences de Montpellier, tome i. He also refers to cases of the same disease in the writings of Fabricius Hildanus, Severinus, and J. L. Petit.
Watson’s Observations on Telangiectasis. 35
irritation of the tumour; but rather to the inflammation of the vessels, and the secondary abscess following the operation. It is evidently a case in which the naevus extended from the capillaries, its original seat, to the larger arteries; but that there must have been also some congenital weakness pre- disposing to this disorder in the arteries, is probable, from facts observed by Dupuytren. Breschet relates a case similar to this, on the right side of the head, in a woman over sixty years of age, who died of exhaustion from fre- quent hemorrhage. The structure of the tumour was similar to the prece- ding: “ The right carotid w^as much dilated, tortuous, and three times its natural length. An' analogous disposition was observed in the whole course of the aorta; but not to so marked a degree: the same condition was observed in the primitive iliacs, but the vessels of the extremities were natural. In every part where the arteries were dilated and twisted, their parietes were thin, soft, flaccid, and more like the parietes of veins than of healthy arteries.”*
Breschet also relates another case of this disease, in which both veins and arteries were enormously dilated. The tumour originated in the left thyroid gland. The patient was a boy about ten years old; and in the course of a year the swelling had grown to be as large as a child’s head at birth. An attempt was made to extirpate it; but the violent hemorrhage during the operation deterred the surgeon from proceeding: a metallic ligature was drawn round the base of the tumour, the bleeding was thus arrested; but the child became convulsed, and died in the course of the night. “ The thyroid veins, but more especially the arteries, both the upper and lower on the left side, were tortuous, and essentially composed the tumour by their numerous branches, the calibre of which was developed to ten times their natural size.”f
The few cases of Telangiectasis now related are sufficient for illustrating its pathology; and when considered in connection with other cases of similar character, recorded by J. Bell, Abernethy, Pelletier, Boyer, Travers, Dal- rymple, Wardrop, Law’rence, Marshall Hall, Macilwain, Roux, Breschet, Dupuytren, Bushe, and others,:}; we have a collection of facts sufficient for establishing its various forms, as well as its identity, under the variety of names and arbitrary distinctions that have hitherto been assigned to it.
How much soever then the morbid structures denominated naevi materni, aneurisms from anastomosis, pulsating vascular tumours, varicose tumours, bloody tumours, erectile tumours, angiectasis, telangiectasis, &c. may differ
* Memoires de I’Academie Royale de Medecine, tome iii. p- 177.
t Ibid. p. 133.
X Rayer, Maladies de la Peau, tome ii. p. 664, refers to an ^extensive paper on this subject by Claudius Tarral, in the Archives Generales de Medecine for 1834. This I have not as yet been able to obtain.
36 Watson’s Observations on Telangiectasis.
from one another in their symptoms and progress, they all essentially depend upon a preternatural and irregular development of the minute blood-vessels; the disease in most cases, if not in all, occurring primarily in the capillaries, from which, in progressing, it may extend to vessels of much greater size.
That the capillaries are the vessels primarily affected, is sufficiently esta- blished by the fact that when the disease is effectually arrested in its early stages, either by excision or otherwise, the morbid growth is invariably pre- vented from extending to the larger trunks; and that in those cases where the vascular development never progresses to the formation of a tumour, but produces merely a discoloration without any elevation on the surface of the skin, no other vessels than the capillaries are involved. I do not find an instance to show that the dilatation ever progresses from the larger to the smaller vessels; but, on the contrary, the disease, commencing in the capil- laries, may extend to all the vessels of a limb, or even to the largest vessels of the body.
This mode of progression is of some importance in showing that the dila- tation of the capillaries is an active state, and not the result of passive dis- tention. These minute vessels, so to speak, draw the blood towards them- selves, and call upon the larger vessels immediately beyond them for an increase of action; and hence the gradual and progressive development of the latter from their extremities upwards. It is also of further importance in pointing out the distinction between the dilated condition of the larger vessels in this disease, and that which is observed in aneurism proper; the one being the result of actual growth; the other of inflammation, ulceration, or of passive dilatation. It might indeed be argued in favour of the passive dilatation of the vessels in this disease, that their parietes are sometimes thinner than natural; but this is not invariably the case, and never to such a degree as to allow their calibre to be dilated to ten times its natural di- mensions, much less to allow the whole vessel to be increased to more than three times its natural length. In the case No. 3. the parietes of the ves- sels were rather thickened than attenuated. The disease, indeed, admits of an increased thickness of the parietes as well as an increase of calibre, and an increase in the length of the vessels. In this respect the vessels of the morbid tissue resemble those of some of the normal structures, which, under peculiar circumstances, undergo an active development, as in the vessels of the impregnated uterus, or in those that supply the stag’s horns during their rapid evolution.
The period at which the disease may extend from the capillaries to the larger vessels, and take on a rapid development, differs greatly in different cases; in some commencing almost immediately after birth, in others a few months later, or at any time during childhood, adolescence, or afterwards. In the majority of cases, perhaps, the disease never extends to the larger vessels at all; but after existing in the form of an elevated and discoloured spot on the surface of the body, as the individual grows up, this finally shri-
Watson’s Oh serrations on Telangiectasis.
37
vels, and sinks to the level of the skin, and afterwards exists as a mere dis- coloration; or even the discoloration may be effaced, and the skin present its natural appearance. The size, colour, and turgescence of these tumours, vary materially with the state of the general circulation. It is stated that they are more apt to take on a rapid growth about the period of puberty than at any other age; but after referring to the history of a great number of these cases, I am satisfied 4hey are no more liable to active development at this, than at any earlier period.
The same class of vessels may be involved, and the same train of symp- toms may follow, whether the disease be congenital, or induced at any period subsequent to both; and hence the particular period of life at which it first becomes manifest, affords no sufficient reason for establishing the patho- logical distinctions which some have attempted between naevus maternus proper, and aneurism from anastomosis; or between the congenital and the accidental naevus.
These vascular growths possess but a very low degree of vitality. Du- puytren, in comparing them with the erectile tissues of normal character, states that their supply of nervous influence is small. Their sensibility indeed bears no proportion to their supply of blood; they are not easily irri- tated or inflamed; and when once inflamed they have a tendency to slough; and where mortification does not ensue, the inflammation does not readily extend itself to the surrounding parts of the diseased tissue, and is slow in passing through its several stages. In the case first related, the potential and even the actual cautery were several times employed without exciting actual inflammation to any extent around the immediate spot upon which they were applied. The same amount of irritation in any of the normal tissues receiving an equal or any approach to an equal supply of blood, would have excited much more acute and extensive inflammation. Are we not then justified in concluding from this fact, that something more than great vascularity is requisite for inducing inflammatory action even in the healthy tissues? These, under a given supply of nervous influence, in pro- portion as their vascularity is augmented, have their irritability exalted, first within the range of health, but beyond this, to the production of mor- bid sensibility and actual disease. We are told that in the bones and other white tissues, inflammation is not readily induced, because their supply of blood is small. Might we not also add, because their supply of nerves is equally deficient? Where nervous influence is weak, then, even in the most vascular tissues, inflammation is not easily excited, nor is it so active in its progress, or so apt to spread, as under other circumstances. If these points be admitted, (and the facts above noted are sufficient to establish them,) the agency of the nerves, in determining the phenomena of inflammation, will be rendered more manifest, and shown to be of more importance, than has hitherto been generally acknowledged.
No. XLVIl.- — May, 1839.
4
38 Watson’s Observations on Telangiectasis,
Breschet* and others, admit that the disease under consideration, may manifest itself in almost every tissue of the body. “ It is developed,” says Dupuytren, “in all parts of the body, but most frequently in the lips, doubtless in consequence of their spongy and vascular structure. It has been met with on the arm, fore-arm, thigh, scalp, ear, cheek, and organs of gene- ration; in the tissue of the skin, in the muscles, the periosteum, the bones, the kidney, the liver, &c.”f One case is recorded by Cruveilhier, and another by Pelletan, in which this disease is said to have originated in the brain.f
Without questioning these authorities, I must nevertheless observe,^ that in most of the cases on record bearing intrinsic evidence of belonging to the disease under consideration, the morbid growth has had its origin either in the common integuments, the mucous membrane, or in the cellular tissue. Doubtless it may originate in other textures, as in the case quoted from Breschet, where it commenced in the thyroid gland; but many of the cases in which it is said to have occurred in the bones, in the viscera, among the muscles, <fcc., are, to say the least, equivocal; and no doubt some of them were of a carcinomatous nature.
The various forms of telangiectisis may be divided; first, in relation to their seat — into the cutaneous, the subcutaneous, and the mixed; secondly, in relation to the class of vessels affected — into those involving the capilla- ries only, those extending to the arteries, and those extending to the veins.
Is^. Of the Cutaneous Ncevus, — This is the simplest form, and the one best known to the profession. It is almost invariably congenital, and is manifest either at birth, or within a few days afterwards. In some few instances, however, it originates spontaneously at a much later period. A few years ago, I observed for the first time a bright red spot, on my own face. For a length of time it appeared to be a mere point; this gradually increased in size, and two or three similar points, not quite so superficial, were to be ob-
* Memoires de la Academie Royale de Medecirie, tome iii. p. 128. In his essay pub- lished in this work, Breschet refers to the Repertoire d’ Anatomic, tome i. for 1826, in which he records a case of this disease originating in the bone. This case I have not the means of referring to, but I am informed by my friend John Hamilton, Esq. of Dub- lin, that after studying Breschet’s case attentively, and the cases which he quotes from Dupuytren and others, as aneurism by anastomosis in the bone; he is convinced they were of malignant character, “ obviously fungus hematodes” — and his opinion is confirm- ed by a similar avowal, made to him in relation to the same cases, by Mr. Hodgson of Birmingham. The impression existing in France, even up to the present time, in rela- tion to these two very distinct forms of disease, is sufficient to account for Breschet’s mis- application of the term “ aneurism by anastomosis,” — and the same may also apply to some of the cases of erectile tumours of Dupuytren. Dr. Bushe, I conceive, has com- mitted a similar error in a case which he relates as telangiectasis originating in the me- dullary cavity of the tibia. The case has to me more of the character of the malignant fungus. See the New York Medico-Chirurgical Bulletin, vol. i. p. 59.
t Leqons Orales de Clinique Chirurgicale, tome iv. p. 51.
X Mentioned by Bushe. Loco citat. p. 65, from Cruveilhier, Anatomie Pathologique, tome ii. p. 133 — 83. Pelletan, Clinique Chirurg. tome ii. p. 76.
Watson’s Observations on Telangiectasis. 39
served about it; the whole giving a slight elevation to the skin, and feeling like a little pimple or fine grain of sand under the finger. Some months ago I punctured the principal spot with the point of a needle. It bled for half an hour, and continued dripping slowly afterwards for several hours; the single puncture must have given exit to more than two drachms of blood; and since that time the spot has somewhat diminished.
These nsevi are, at birth, unattended with any tumefaction; hut as the child grows the discoloration spreads, and sometimes the spot becomes elevated above the level of the skin. Continuing to increase, it demands an additional supply of blood, and the vessels leading to it are consequently increased in size, and the temperature of the part is greater than natural.
The cutaneous neevus has rarely a strong pulsatory movement, but still a feeble thrill may be at times very perceptible on pressure. After continuing to spread for some time, it may become stationary; and finally, falling to the level of the skin, exist afterwards as a mere stain upon the surface; or con- tinuing to increase, it extends to the subjacent tissue, and thus constitutes what may be called the mixed form.
'2d. Of the Mixed Nsevus. — The subcutaneous cellular tissue becoming involved, the disease now produces more deformity, elevating the integu- ments in the form of a soft bosselated tumour. The original cutaneous spot still exists in the centre; but the rest of the swelling is marked by no dis- coloration, or at most, only a faint tinge of purple or red; caused by the colour of the subcutaneous portion of the tumour striking through the healthy integuments. The swelling now communicates a whizzing or vibratory movement to the finger when pressed upon; the blood is easily forced out of it; but, on removing the pressure, the swelling soon regains its former size. The veins in the neighbourhood of the tumour are some- times observed to be much fuller and larger than natural, and the arteries also in some cases beat strongly over a great extent of surface. The integ- uments occasionally ulcerate, and the patient is then subject to hemorrhage from the slightest abrasion of the surface. Sometimes the whole tumour, ulcerating or becoming inflamed, sloughs away, and a spontaneous cure is the consequence.
^d. Of the subcutaneous Nsevus. — This possesses all the characteristics of the last, except that it does not originate in the skin, or even extend to it. This swelling, too, is moveable at first, and appears to be covered by a proper coat of dense cellular tissue. The pulsation in it is not generally very strong, and sometimes is not to be felt at all. The irritation produced by it among the surrounding tissues, as in the case of the mixed naevus, may excite inflammation, ulceration, or even destructive action; and these morbid changes extending to the surface, necessarily give rise to frequent hemor- rhage; or progressing in other directions, injure or destroy the muscles, fasciae, and even the bones themselves.
40 Watson’s Observations on Telangiectasis.
The divisions of telangiectasis founded on the particular class of vessels involved, are the most proper for illustrating the anatomical structure of the various tumours grouped under this head.
Telangiectasis of the Capillaries. — It is probable that in the majority of these spots, whether cutaneous or deep-seated, the niinute arteries and veins next in order above the capillaries, are also more or less affected. It is onl^^ therefore in cases where important vessels participate in the disease, that we must refer the tumour from this to the other varieties. When the ca- pillary naevus is examined, it is found to be seated sometimes in the venous, sometimes in the arterial portion of these vessels, and sometimes affecting both. Its colour is modified according to these circumstances, being of a brighter or darker hue, according as the arterial or venous blood prevails in it. When the swelling is cutaneous, the vessels themselves constitute the great mass of the nasvus; for here the cellular tissue is not found in suf- ficient quantity to form any important portion of it. But when the tumour lies in the loose tissues beneath the surface, the enlarged and elongated ca- pillaries are bound together by a matrix of cellular tissue; and they are often so much dilated and contorted as to form irregular cells of themselves. Some have indeed described them as being composed of cells into which enlarged vessels enter. “ The tumour,” says Bell, “ is composed of small and active arteries, absorbing veins, and intermediate cells. The irritated and incessant action of the arteries fills the cells with blood: from these cells it is re-absorbed by the veins: the extremities of the veins themselves per- haps dilate into this cellular form.”* Mr. Wardrop in describing a subcu- taneous naevus, states that “ the boundaries of the tumour appeared distinct, some healthy cellular membrane surrounding it, which was traversed by blood-vessels. On tracing these vessels to the diseased mass, they pene- trated into a spongy structure composed of numerous cells and canals of a variety of forms and sizes, all of which were filled with the injection, and communicated directly with the ramifications of the vessels.” Several of the vessels, he states, from the thinness of their coats, appeared to be veins much enlarged, — and some of them sufficiently big to admit a full sized bougie. “ These cells and canals had a smooth and polished surface, and in some parts resembled very much the cavities of the heart, fibres crossing them in various directions like the columnse tendin3e.”j' More recent ob- servers state that this cellular appearance is deceptive, produced by the particular mode in which the tumours have been examined, and by the irregular shape, size and course of the vessels themselves. That they are almost entirely composed of arteries and veins, has been proved by Mr. Sheckleton, who injected them with wax, and afterwards corroded the soft materials, so as to show the true form and course of these vessels.:];
* Principles of Surgery. By John Bell, vol. iii. p. 386. London, 1826,
t Medico-Chirurg. Transact, vpl. ix. p. 204.
t See a notice of Mr. Sheckleton’s preparations, Dublin Journal, vol. viii. p. 219.
Watson’s Observations on Telangiectasis. 41
Telangiectasis extending to the larger Arteries. — In many of the cases on record, the larger vessels have become diseased only after the capillaries have existed in a morbid condition for a number of years. In other cases, however, there appears to have been a congenital weakness of these vessels, co-existent with an evident disease in the capillaries: such was probably the fact in sortie of the cases of Breschet to which I have already alluded. The diseased arteries are sometimes simply dilated; sometimes they present great irregularity as to their calibre, their length, and the thickness of their pari- etes; and in almost all cases they are convoluted, or rolled upon themselves; sometimes constituting a mesh of vessels united together by cellular tissue, so as to present a soft fluctuating and pulsating tumour, which, by its growth and constant action, produces disturbance in the surrounding parts; sometimes winding along the limb in an irregular course, as in varix of the lower extremities, without forming any distinct tumour, or congeries of ves- sels. It has been supposed that the vessels in this disease form more fre- quent anastomoses than in their healthy state; such, however, has not been proved to be the fact, and some who have written on this subject, have denied it.
Telangiectasis extending to the larger Fei/is.— Instances of the disease extending more particularly to the veins than to the arteries, are by no means frequent. The veins, it is true, are generally enlarged in cases where the arteries are dilated; but not to so great an extent. Case X. is an instance of this disease in which the veins were principally affected. The appearances presented are nearly the same as in ordinary varix.
Diagnosis. — The diseases with which telangiectasis is most liable to be confounded, are different according as it is superficial or deep-seated, and ac- cording as it affects the capillaries only, or extends from these to the larger arteries or veins. It may be mistaken for aneurism proper; for varix; for aneurism by erosion, or the aneurism of Pott as it has been called by the French; for cephalsematoma or the bloody tumour occurring on the head of new-born infants; for encysted or other non-malignant tumours; and for Tungus hematodes.
With aneurism proper, Breschet has indeed grouped one of the forms of this disease, viz. that in which the dilatation is extended to the arterial trunks, calling this the cylindroid aneurism when the calibre of the artery is dilated regularly, and circoid aneurism when the dilatation is irregular and the vessel tortuous and nodulated. But the gradual progress of the dis- ease from the smaller to the larger vessels, the co-existence of nasvi from which the dilated vessels appear to emanate, the want of coagula in the dila- ted trunks, their tortuosity, and the irregularity in the thickness of their parietes, independent of inflammation, ulceration, rupture, or cartilaginous or earthy deposit; not to speak of the age and class of patients most frequently affected; may be sufficient to characterize this disorder. But in those per- sons, in whom the parietes of the arteries are thinner than natural, it is pro-
4#
42 Wa,ison's Observations on Telangiectasis.
bable that causes, insufficient to excite proper aneurism under ordinary cir- cumstances, might here induce it; and thus the two disorders might be found C07existing in the same subject. Again, in some cases of aneurismal varix, the disturbance in the circulation, produced by the unnatural commu- nication between the artery and vein, may lead to irregular dilatation, twistr ing and elongation of these vessels. But in all such cases the causes of these changes must be sufficiently apparent.
The varicose state of the veins produced by stasis of blood, or by inter- rupted circulation in these vessels, as seen in the lower extremities, and sometimes in other parts, (as in the spermatic cord,) might be mistaken for this disease. The freedom from cutaneous nsevi or from pulsating tumours^ the age' and habit of the patient affected with varix, its seat, and its excit- ing cause, are sufficient to distinguish it. The disease sometimes called Pott’s disease of the leg; sometimes the aneurism of Pott, or aneurism by erosion of the artery, may be mistaken for some of the severer forms of telangiectasis. Cases of the disease now referred to, are given by Pelle- tan,* * * § Hodgson,t and others: and as I have never verified it by dissection* I must refer to Potts’ original description of it.ij:
The only case of cephalaematoma, that has fallen under my observation, might have readily been mistaken for a subcutaneous nsevus. The tumour was seated over the sagittal suture, was as large as a pullet’s egg — ^it existed at birth, and the integuments over it were of their natural character* The tumour, however, did not throb; and though it had a soft doughy and inelastic feel, it could not be diminished by pressure; and no enlarged ves-^ sels were observed in its neighbourhood. §
The subcutaneous neevus may be mistaken for encysted and other tumours. The thrilling or pulsatory movement of the nsevus, the ease with which it may be diminished by pressure, and its almost immediate return to its for- mer size when the pressure is removed, will distinguish it from these.
In some cases of superficial nsevus where the integument has ulcerated, and the disease is shooting forth in the form of a spongy tissue, bleeding at the slightest touch, it may be difficult to distinguish it from fungus hema- todes. But the early history of the case, the strictly local character of the disease, its continuance for years without involving the general health fur- ther than by the loss of blood which it may occasion, or by the pressure and consequent disturbance which it may cause in the adjacent tissues; the ab- sence of carcinomatous growths in other parts of the system, and the im-
* Clinique Chirurgical, tome ii. p. 37. et seq,
t Treatise on Diseases of the Arteries and Veins, p. 448, et seq.
X Surgical Works, voL ii p. 321. Philadelphia, 1819.
§ See Bushe’s paper on “ Hematoma of the head in new-born children,” in the New York Medico-Chirurgical Bulletin, July, 1831. Also, a monograph on the same subject, by Prof. E. Geddings, in the American JournaLof thejMedical Sciences for Feb. 1839.
Watson’s Observations on Telangiectasis*
43
munity of the patient from all chance of its recurrence after having been once fairly removed; are sufficient to distinguish it from fungus hematodes.
Causes. — Boyer has divided this disease into two kinds, the one congeni- tal, the other accidental. In the great majority of cases the derangement in the vascular structure which constitutes this disease, is attributable to a primitive defect in the organization of the capillary vessels, and perhaps also in some of the vessels of larger size. That form of telangiectasis which involves the arteries, and which is marked by strong pulsation, and rapid and obstinate growth, is, I believe, the only one that has been described as occasionally resulting from local injuries. Travers and Dairy mple recite cases in which this form occurred spontaneously within the orbit in females during pregnancy. Long continued pressure, severe blows, and various kinds of local irritation, have been advanced among the exciting causes.
Prognosis. —The. danger to be apprehended from naevi varies with their size, their seat, the class of vessels principally involved, and the rapidity of their growth. When confined to the skin, unless undergoing rapid devel- opment, or becoming ulcerated, they require no special attention. When seated in the subcutaneous cellular tissue, or when they extend to this from the surface, and especially when the vessels leading to them are much en- larged, they never entirely subside of themselves; they may continue to grow for years, and then either become stationary, or by exciting irritation in the surrounding tissues, produce caries of the bones, or ulceration of the soft parts; and by frequent and profuse hemorrhage, finally exhaust the patient.
Treatment. — The treatment applicable to the different forms of telangiec- tasis has, within the last thirty years, been the subject of much speculation and experiment. Without attempting to dwell upon the various operations that have been suggested, and all of which have been practised with more or less success, we may remark, that they have hitherto been devised for fulfilling either one or more of the following objects:
1st. To prevent the undue ingress of blood, and thus to allow the morbid growth to contract to its natural: condition.
2d. To remove the diseased tissue, and to allow the wound or ulcer, thus left, to cicatrize.
^d. To induce a change of action in the diseased tissue, by which it may be consolidated and deprived of its undue supply of blood, and thus allowed to assume its natural appearance and character.
The means employed for fulfilling the first of these objects, are, for the most part mechanical; and act either by compressing or constringing the dis- eased. vessels, or by cutting off the channels through which they are princi- pally supplied with blood. The means for fialfilling the second object, are destructive: among them, are grouped excision, caustic and corroding appli- cations, and the ligature en masse. Those for effecting the third object are physiological i and have been instituted for exciting inflammation and the
44 W atsori^s OhsermtioM on TeldngiectasU*
consequent effusion of coagulable lymph within the diseased structure; and thus, on the subsidence of- the inflammation, to reduce the vascularity of the part. Among these means may be enumerated, 1st, the introduction of the cataract needle for lacerating the central portion of the tumour: 2d, the in- troduction of heated needles: 3d, vaccination and the production of artificial pustules immediately over the diseased mass: 4th, injection of stimulating liquids among the diseased vessels; and, lastly, the introduction of the seton beneath them.
Isjf. By Compression.-^This is rarely or never employed for removing the cutaneous nsevus; and for the deeper forms it is generally a tedious and uncertain means of cure. Bell has staled that compression tends rather to aggravate than to remove these swellings; yet in the hands of Pelletan, Boyer, Roux, and Dupuytren, this mode of treatment has been occasionally successful. A striking example of its efficacy is related by Boyer. His patient, an infant, had a pulsating tumour near the lower part of the septum of the nose; the position being such as to prevent complete extirpation, he advised the mother to foment the tumour with alum water, and to press it between the thumb and finger as often as she could. I attached, says he, but little importance to this advice. It was followed, nevertheless, with all the perseverance that maternal tenderness could inspire, the mother often spending seven hours at a time in compressing the spot without removing her fingers. This perseverance was followed by success so complete that in August, 1809, having been consulted anew concerning this young person, now twelve years old, it was impossible, he observes, to recognize any re- mains of the tumour.*
2d. By Pressure and Cold combined. — This practice was first instituted by Abernethy. Finding that, in some forms of the deep naevus, the tem- perature of the swelling was greater than natural, he concluded that the dis- ease was owing to “ a kind of inflammatory action of the surrounding arte- ries,” and therefore resorted to these means as the most applicable for diminishing the tumour and reducing this action. His first case was one of mixed nsevus, complicated with great enlargement of the vessels over the hand and forearm. A manytailed bandage of sticking plaster was applied over the limb, and the whole kept moist with cold water. Whatever we may think of the pathology upon which this practice is founded, we cannot question its success. In six months from the time of commencing treatment, the disease was cured. He relates another case treated successfully by cold alone. The naevus projected from the orbit, closing the eye, and forming a tumour as large as a walnut. “ Pressure, to any extent was here evidently impossible; but the abstraction of heat, and consequent diminution of inflam- matory action, might be attempted.” He therefore recommended “ that folded linen wet with rose water saturated with alum, should be bound on
* Maladies Chirurgicales, tome ii. p. 382. Paris, 1831.
Watson’s Observations on Telangiectasis. 45
the projected part, and kept constantly damp.” At the end of three months the tumour had shrunk within the orbit, and the child could open its eye.* * * § ^d. By Ligature to the Artery supplying the Tumour. — This process is applicable only to those severe forms of nmvus or aneurism from anastomosis in which other means have failed, and in which the disease has extended from the capillaries to the larger vessels, particularly to the arteries. Pelletan was the first to institute this practice. His case I have already quoted — (see Case XL) The carotid artery was first successfully taken up for the cure of this disease by Mr. Travers;f afterwards by Mr. Dalrymple;ij: and since these operations several other successful cures, have been recorded. In not a few instances, however, this practice has been unsuccessful in removing the disease; and in several cases it has been the immediate cause of death. — Bushe relates a case of extensive and increasing nsevus in an infant between six and seven weeks old, for the cure of which, without attempting any other previous treatment, he took up the common iliac artery. The child lived about five weeks after the operation. § Judging from the cases on record, in which the larger arteries have been taken up for the cure of these tumours, we may fairly conclude that much harm has been done by rashly resorting to this practice; that it should never be attempted until other means have failed; and then, only when the urgency of the case is sufficient to warrant it. The danger of operations on the brachial or femoral artery, or their imme- diate branches, for pulsating naevi, is not usually so great as operations on the carotid, or the larger vessels of the trunk. But even operations on the large vessels of the limbs are sometimes insufficient to arrest the growth of these tu- mours. Mr. Lawrence relates a ease of aneurism by anastomosis on the finger in a woman twenty-one years old; the disease was congenital. In 1815, Mr. Hodgson, finding that the beating could be arrested by pressure on the radial and ulnar arteries, attempted to cure the disease by tying these vessels. The immediate consequences of the operation were a cessation of the beating, collapse of the swelling, and relief from the pain; but these symptoms all recurred in a few days, and were just as bad as before. Mr. Lawrence finally cured the patient by making a circular incision through all the soft parts of the finger above the tumour, excepting the flexor tendons with their theca and the extensor tendon; and afterwards allowing the wound to heal as an ordinary cut. In this case the digital artery was found equal in size to the radial or ulnar of an adult, and was the principal nutrient vessel of the disease. 11
^th. By Excision. — The mode of destroying naevi by excision was recom- mended and practised by J. L. Petit, and has been in general use ever since
* Abernethy’s Surgical Works^ vpl. ii. p. 37. Hartford, 1825,
t Medieo-Chirurg. Transactions, vol. ii, p. 1.
X Ibid. vol. vi. p. 111.
§ New York Medico-Chirurgical Bulletin, vol. i. p. 54, j] Medico-Chirurg. Transac, vol. ix. p. 216,
46
Watson’s Ohsenations on Telangiectasis,
his time. In the cutaneous nsevus, of no great size, it is the most effectual, the readiest, and least painful practice. It is not, however, applicable to very large nsevi. In the subcutaneous nsevus it has been followed by fatal hemorrhage; and it is altogether improper in those forms of the disease which are complicated with extensive dilatation of the larger vessels. In resorting to excision for the removal of these tumours, in order to avoid hemorrhage as much as possible, it is important to carry the incision through the healthy tissues surrounding them, and not into the diseased mass.
Mh. By Caustic Applications. — In the small cutaneous naevus, where a slight and single application of caustic may be sufficient to destroy the spot, as in the spider n^vus; and especially when such spots are situated on parts of the body where the cicatrix left by the application may not disfigure the individual, this practice may be employed with advantage. It is rarely ad- visable in extensive naevi, never in those that are deep-seated, or connected with enlargement of their nutrient vessels. Dr. Hosack informs me that he has seen the caustic potassa applied to a small nsevus on the side of the nose, and the effect of it was so severe as to completely destroy the cartilage, and expose the cavity of the nostril. The great objection to the use of caustic applications is, that the extent to which they act can never be precisely re- gulated. When applied cautiously they often fail in effecting a cure; and sometimes, merely destroying a part of the morbid tissue, they allow of fun- gous growth and frequent hemorrhage from the part remaining.* * * §
Various caustic applications have been used, as quick lime and soap in equal parts, j* the butter of antimony ,:f potassa,§ nitrate of silver, the mineral acids, tartar emetic ointment. In short, any corroding application may be employed for the purpose.
Qth. By the Ligature en masse. — I’lie application of ligatures for the pur- pose of arresting the circulation in these tumours, and allowing them to slough, was suggested, if not practised, by J. Bell. Pelletan has also re- corded a case in which he applied it;]] but the attention of the profession was first particularly directed to this important means, by the success attending it in the hands of Mr. Anthony White.1T It is applicable to the elevated and
* Boyer, Maladies Chirurgicales, tome ii. p. 395. Paris, 1834.
t Recommended by Callissen. See Cooper’s Dictionary.
t Pelletan, tome ii. p. 76, states that, while he was a pupil, he had seen this caustic application used, in a severe case of varicose tumour of the head, by M. Moreau. The patient died; and, on examination, it was found that the pressure of the tumour, growing from within, had produced an obliteration of the frontal bone, and through the openings in the bone the corroding liquid had entered, and excited extensive inflammation of the dura mater and parts within the skull.
§ Used by Pelletan, tome ii. p. 69. Mr. Wardrop, however, has the credit of being the first to employ this and the nitrate of silver extensively and with success.
II Loco citato, p. 71,
f Medico-Chirurg. Transac, vol. xiii. p. 444, See also this Journal, vol. ii. p. 220,
Watson’s Observations on Telangiectasis,
47
subcutaneous nsevus. The ligature should be introduced doubled, by means of a needle, under the base of the nsevus, and should be drawn sufficiently tight to arrest the circulation in every part of the diseased tissue. The prin- cipal inconvenience attending it, is the excessive pain, (which is sometimes so severe as to excite convulsions,) after the ligature has been tightened. — In cases where the tumour is entirely subcutaneous, much of this suffering may be avoided by the practice recommended by Mr. Liston, which consists in dividing the integuments by a crucial incision over the. swelling, dissecting back the flaps, and applying the ligature around the base of the tumour with- out including the skin.* * * § The ligature is generally allowed to remain until the nmvus has sloughed; but in some instances it has succeeded, even though removed before disorganization had commenced.!
7th. By Lacerating the Morbid Tissue. — This practice was introduced, and successfully employed, by Dr. Marshall Hall;! and has succeeded in other hands. It consists in puncturing the neevus with a cataract needle, and carrying the blade of the instrument in various directions through the tumour- After withdrawing the needle, pressure is to be applied for forcing the blood out of the diseased part. The inflammation following this process is in some cases sufficient to effect a cure without causing a cicatrix, or leaving any de- formity. It is applicable to the cutaneous, the small subcutaneous, and the mixed nsevus.
Sth. By Vaccination and Factitious Eruptions. — Vaccination for the pur- pose of exciting inflammation in these spots, was first proposed by Mr. Hodg- son ;§ and in some cases of cutaneous naevus it is sufficient to effect a cure. The virus should be introduced at several points around the base and over the surface. Where vaccination has already been performed, and the patient is no longer susceptible of its influence, Mr. Young, of Glasgow, j] has recom- mended antimonial ointment, with the view of producing an eruption, and effecting a cure in the same way as with the vaccine virus.
9^/i. By the Cautery Needles.- — The first notice I find of this practice is in a case in which Mr. Macilwain employed it unsuccessfully. The case was one of subcutaneous naevus. He endeavoured to excite inflammation by pass- ing red hot needles through its substance. “ These measures were repeated thrice at intervals of about a week; each puncture was followed by a single jet of arterial blood, and produced considerable constitutional disturbance, which continued for about tw*enty-four hours; but they were followed by no diminution of the tumour, which, on the contrary, increased slowly but pro-
* British and Foreign Medical Review, vol. iii. p, 557.
t Lawrence, in the Medico-Chirurg. Transac. vol. xiii. p. 436.
t London Medical Gazette, vol. vii. p. 677.
§ Medico-Chirurgical Review, July, 1827, p. 280. See also this Journal for April, 1828, p. 170. Also, Lancet, vol. xii. p. 604 and 760, and London Med. Gaz. vol. iv. p. 32.
II Glasgow Medical Journal, vol. i. p. 93. See also this Journal, vol. ii. p. 460, and vol. XV. p. 251.
48 Watson’s Observations on Telangiectasis,
gressively.”* * * § ** The late Dr. Bushef has reported several successful cases of small cutaneous naevi treated in this way; but in the case which I have re- lated at the commencement, he had completely failed. In his published cases he recommends a common cataract needle heated to whiteness; he af- terwards employed a fine piece of steel, with a blunt point, and mounted on a handle. The great objection against these small cautery needles is, that they do not retain their temperature for a sufficient time; they lacerate rather than cauterize the tumour, and do not excite inflammation to any great ex- tent around the immediate point at which they are introduced.
IQtk. By Injection. — So far as I am aware, Mr. Samuel Cooper first pro- posed this practice. It was first successfully employed by Mr. Lloyd.;}: The injection consisted of from three to six drops of nitric acid dissolved in a drachm of water; it was thrown into the tumour, by means of a syringe, through a minute puncture near its base. During the operation careful pressure was made in all directions round the tumour, to prevent the fluid from entering the general circulation. The next case on record, in which this practice was employed, was attended with an instantaneously fatal result. §
l\th. By the Seton. — For this practice we are indebted to Mr. Faudington of Manchester.}] It has also been employed with marked success by Mr. Macilwain, in cases of deep naevus, where no other mode of treatment could have been advantageously employed. It has also succeeded, under similar circumstances, in the hands of Mr. Carmichael, IF M. Lallemand,*^ and in Dr. A. H. Stevens’s case, which I have already reported. It does not appear to answer so well for the cutaneous naevi as for those that are situated in the tissues beneath the skin. In resorting to this practice the seton should be passed completely under the tumour, and not into its spongy texture; other- wise it ulcerates through the morbid mass before exciting inflammation suf- ficient to consolidate it. In the cases reported by Mr. Macilwain, as well as in that of Mr. Carmichael, several setons, consisting of silk threads, were passed in different directions under the swelling ; in Dr. Stevens’s case, a single seton only was employed; and in all of them the threads were allowed to remain until free suppuration was established, and the tumour itself had undergone a change of character; a process which, under different circum- stances, may require for its completion from a few weeks to three or four months. The advantages of this practice are, that it is attended with little or no danger; that it may be employed in many cases where other means are inadmissible, and that no permanent deformity is left by it.
* Medico-Chirurg;. Transac. vol. xviii. p. 193.
t New York Medico-Chirurgical Bulletin, No. 2.
t London Med. Gazette, vol. xix. p. J4, Oct. Isl, 1836.
§ Ibid. Dec. 30th, 1837.
II See Mr. Macilwain’s paper in the Medico-Chirurg. Transac. vol. xviii. p. 189.
IT See a notice of Mr. Carmichael’s Case in the Dublin Journal, vol. viii. p. 219.
** Observations Relatives k Divers Precedes Operatoires employes centre les Tumenrs Erectiles: republished from the Archives Generales de Medecine.
Bartlett’s Case of Chronic Cerebral Affection,
49
Art. III. Chronic Cerebral Affection: long continued, intense headache: double consciousness: extraordinary memory of events: ineffcacy of treatment: diagnosis doubtful. By Elisha Bartlett, M. D., Professor of the Theory and Practice of Physic, and Pathological Anatomy in Dartmouth College.
The following case has appeared to me to be one of sufficient import- ance to justify me in presenting it to the public. The report of it may possibly seem to the reader to be unnecessarily prolix and minute, but I did not see how it could well be made less so, without sacrificing that com- pleteness, and fulness of detail, upon which the interest, and the value itself, of the case depends. The present would be a very proper place for some general remarks on the subject of chronic cerebral disease. There is no single department of pathology, which offers to the scientific inquirer pro- blems so surrounded with difficulties, and yet so filled with interest as this, but as the report of the case occupies so much room, I shall simply present it to the reader, omitting, at least for the present, all note or comment^ either upon the case itself or upon the general subject to which it belongs^
April l^th, 1838. — R. M , the subject of this case, was 15 years
old in October, 1837. She was born in England, and came to this country about seven years ago. She has a fair complexion, light hair, is conside- rably fleshy and fat, and has a pretty large, well developed head. She is good tempered, and is intelligent for a girl of her age and education. She enjoyed uniform and excellent health, till she was thirteen years old. She then menstruated, and at that time began to complain of headache, and of pain in the back and limbs. The pain in the back and limbs soon went oflT, but the headache continued. During the first year it was not constant, although she had more or less of it nearly every day. This pain gradually became more constant and more severe, and since the close of the first year, she has never for a single moment, so far as can be ascertained, been free from it. Until the expiration of the first year, she was able to work part of the time in a woollen mill, and a part of the time she was at school, although she W'as frequently obliged to leave both her work and her school on account of the severity of the headache. The seat of the pain has always been through the head, from the forehead to the occipital. She never feels it at the top or at the sides of the head. It never changes its seat; it never intermits. It has not done so for the last year. It is very much more severe at some times than at others. Generally, though not invariably, it grows worse as the day progresses.
There has been moderate intolerance of light and sound from the begin- ning. This is pretty regularly increased in degree with the increased se- verity of the pain. It is never, however, excessive. The vision has not No. XLVII-— May, 1839. 5
50 Bartlett’s Case of Chronic Cerebral Affection.
been much affected. It is rather feeble, but correct. On looking steadily at an object, it grows dim and indistinct. There is frequently some ringing in the ears. The sound oftenest heard is that of running water. Epistaxis has been pretty common for the last year. During the two past weeks, it has occurred every day, and has, some days, been repeated several times. It almost always occurs in the day time, oftenest in the latter part of the day, continues pretty freely five minutes or so, and is never attended or fol- lowed by any mitigation of the pain. Within a few weeks she has com- plained of some numbness of both feet and of both hands: that of the feet is greatest. This numbness comes on several times a day, remains fifteen or twenty minutes, and then goes off. Occasionally she feels a pricking sen- sation, especially in the hands. Once, some weeks ago, while walking across the floor, she fell.
The mind has been perfectly free, till within six months. She has become somewhat forgetful, but there has not been the slightest aberration. She is remarkably patient and quiet. There is no fretfulness, and no change of temper.
The appetite has been poor from the beginning. The quantity of nutri- ment which she has taken for the last year has been very small, and it still continues so. There is no emaciation. The bowels are regular, and are easily moved. The discharges are not very consistent, but sufficiently healthy in appearance. There is no flatulence, no acidity, no nausea. The tongue is, most of the time, mode^-ately coated. Thirst is constant and pretty urgent. Nearly all the time there is a sense of chilliness over the body generally. Through the head, corresponding to the seat of the pain, she complains of a burning heat. The hands and feet are constantly cold. They are white and bloodless, looking like alabaster. The scalp feels hot to herself and moderately so to the hand. It is also, occasionally, in various parts tender to the touch. The face is usually flushed, and much more so at some times than at others. The pulse varies from 76 to 100, and is neither full nor hard. The urine, for some weeks last summer, was copious and limpid; since that time it has remained natural. A few weeks ago she had a short, dry cough, which was principally troublesome on account of the great increase of suffering which it occasioned in the head. It seemed to be of a nervous or spasmodic character, and ceased immediately on the ad- ministration of Prussic acid. It returned once, subsequently, and again subsided on giving the acid. Up to this time the respiration had not been affected.
She has always had very bad nights. She has distressing, fatiguing dreams: and running through them all, and through her disturbed and un- refreshing slumbers, there is an ever present consciousness of the unremit- ting and intolerable headache. The vulture never sleeps and never lets go its hold. She lies with one hand constantly to her forehead, and very frequently says in a suppressed, moaning tone, “ O dear! my head!” She
51
Bartlett’s Case of Chronic Cerebral Affection.
speaks in a low voice—usually in a whisper. There is frequent deep sigh- ing, and occasional yawning.
Until within a month she has been able to sit up and to keep about house, during the forenoon. She is now wholly confined to the bed, and is unable to hold up her head without great increase of the pain. She says her head feels very heavy.
Another strong feature in the history of this case, thus far, consisted in the effect of treatment. I'his was wholly unavailing. It never mitigated the severity of a single symptom. More than this, almost invariably the effect of treatment was to render her worse. The details of the treatment it is unnecessary for me to describe. The depleting, revulsive, sedative and anodyne medications were, one after another, and variously combined, re- sorted to, and all to no purpose. General and local bloodletting, emetics, active cathartics, blisters, permanent drains in the neck, the cold dash, and mercurials carried to ptyalism, were all made use of. Preparations of iron, quinine, arsenic, opium and other narcotics, were tried in their turns with the same unsatisfactory results.
During the first year and a half, or so, of the disease, [ had felt very con- fident that the case was one of nervous headache merely; that there was functional disturbance, — intense, morbid, painful erethism of the brain, but no structural or organic lesion. Resting in this diagnosis, I had thought, that the patient would finally recover. But the obstinate persistence of all the symptoms, and their gradual increase in severity, notwithstanding the active and various treatment that had been opposed to them, induced me to doubt the correctness of my opinion. I begun to suspect, very strongly, the existence of some fixed, organic lesion, in the central portion of the brain, or in the cerebellum. The age of the patient led me to think that the disease might consist of a tubercular tumour. But if this were the case, there should have been, also, tubercular matter deposited in the lungs; and of such desposition there was no evidence depending either upon local signs or general symptoms. There were no indications, physical or rational, of phthisis. The resonance under both clavicles was good, and the vesicular murmur was soft. There w^as no cough, no expectoration, no pain in the chest, no hectic, no emaciation.
I shall now continue the history of the case from the date of my first re- cords, April 10, 1838, to the present time. For this account I rely upon notes taken, not at every visit, but from time to time, as changes manifested themselves in the condition of the patient.
April 25th. — There has been little or no alteration in the symptoms for the last fortnight. The pulse to-day is 80, soft and feeble. The numbness of the feet is now* nearly constant, and when the numbness goes off it is succeeded by a headache. Last night, as usual, she was dreaming of dis- tressing pain in the head.
May 24:th — She is apparently more feeble. She now has, several times a
52
Bartlett’s Case of Chronic Cerebral Affection,
day, short chills or tremors, consisting of a general and pretty violent shak- ing of the whole body. They are not accompanied by any increased feeling of coldness. She has, also, frequently during the day, paroxysms, lasting half an hour or so, of rapid breathing, or panting. I counted 72 respira- tions in a minute. There is a quick, quivering motion of the eyelids and lips. There is occasionally, for a few minutes, loss of consciousness, or something like it. She is awake, but does not know where she is. The thirst is still very great. The tongue is clean, bright red, sore, and fre- quently bleeds. The bowels are rather sluggish. The right leg is some- what more numb and painful than the left. Tears are now and then forced from her eyes by the excessive -severity of the headache. For some weeks past she has not kept her hand to her forehead: she says she is too weak to do so. Pulse, 72.
May 2Qth, — The respiration is now quiet and regular. She does not speak, except in the faintest possible whisper, and very reluctantly then. She says that the act of speaking hurts her head — that it feels as though something struck it, like a hammer. The epistaxis continues, and occurs, usually, just at night.
June ^th, — For several days past she has not spoken at all. The only vo- luntary motion which she makes, consists of a slight movement of the fore finger of one hand, when she wishes for a drink. She does not open her eyelids. When the eyeballs are exposed, they are seen very forcibly rolled up in the sockets, constantly agitated with a rapid tremulous motion. She is unable either to move or to support her head. The head is warm; the hands and feet still pale, cold, and moist. The thirst is still urgent; the urine continues free. She had her menses about a month ago. There has been less epistaxis for several days. She hears very quick, as is evident from her noticing conversation that is carried on in the room. She does not notice any thing said directly to herself but very frequently smiles at remarks directed to some one else. Her mother thinks that she can- not see.
She was visited and examined a few days since by Mrs. T. a somnambu- list. Mrs. T. says that the tongue and throat of the patient are sore, for which she must use alum and marsh rosemary: that the head is diseased, but not primarily; and that the original disease is a kind of a cancer, — but not a cancer — situated between the stomach and lungs. She prescribed, further, shaving and blistering the scalp, blisters to the ankles, friction, from the hips downwards, and bathing with brandy.
June ZOth. — The patient remains in nearly the same state, except that for about three weeks she has had, pretty regularly every day, and several times a day, the severe rigors or attacks of general shivering. She, also, frequently clenches her hands suddenly together, and throws them violently, with a motion that seems to be half voluntary and half spasmodic, over her
Bartlett’s Case of Chronic Cerebral Jlffection,
53
head upon the pillow. This motion is accompanied with an expression in the countenance of great suffering. The hands and arms are invariably suffered by the patient to remain in the position above tbe head: she never removes them herself. The bowels have occasionally required moving with gentle medicine.
July \2th. — On the 4th July, the patient was found in the morning talking, in a low whisper, to herself. She had not spoken a syllable before for a month. She answered readily, in the same low tone, when spoken to. She said she did not know why she could not talk during the month. She said the pain in the head was not quite so had. She now and then laughs very loudly and heartily without any apparent cause. The violent motion of the arms and hands, already noticed, has become more general, and she throws herself with great force from one side of the bed to the other. These are most common in the afternoon. The shivering fits have occurred most fre- quently in the forenoon.
It has become perfectly evident, since the patient began to talk, that there are, so far as the brain and its mental manifestations are concerned, two very distinct and different states. One may be called the natural and the other the preternatural condition. During the first she appears very much as she has during the course of the disease. She is then perfectly herself. She lies very quietly upon her back, occasionally sighing, with a quick, half spasmodic inspiration, indicative of pain, and occasionally affected with a short transitory rigor or shudder. Her countenance is composed and sad, but she rnakes no complaint, unless it is to say, as she frequently does, “ O, my headP'' She answers questions readily, describes all her sensations, and is perfectly conscious of every thing about her. During the preter- natural condition, the whole scene is changed, and various phenomena of a character somewhat singular are exhibited. It is during this state, that the fits of throwing herself from one part of the bed to the other occur. It is also during these fits only that she talks, at other times never speaking except to answer a question, or to state somewant, or to give utterance to the sense of pain. It was observed, by her mother, that when she commenced talking on the morning of the 4th, her con- versation was wholly upon subjects with which she was familiar before she left England. It should be stated, that some peculiarities about her memory had been noticed by her mother, for several weeks. She was first confined to her bed, up stairs, and she had subsequently been removed to a lower room. She never could recollect how or when she came down stairs. On asking her mother, one day, how long her daughter had been confined to her bed, she referred me to the patient herself, and added, that she could tell me how many weeks she had been sick and how many visits I had made to her. I questioned her as to the latter point. She answered, immediately,
5*
54 Bartlett’s Case of Chronic Cerebral Affection*
“ this is the fifty -second.'^'* On referring to my books, I found forty-eight visits charged, and I had seen her a few times, I cannot say positively how' many, without making any charge. I then asked her when Mrs. B. called to see her: she said, ’■'four weeks ago to-day f which was true. The fits of tossing herself violently about, of which I have spoken, continued with but little interruption, for several hours, the day before yesterday. The next day, they commenced at half past five, in the afternoon, and continued five hours. They were present three or four hours in the forenoon of to-day, and they again occurred in the afternoon. During the presence of these paroxysms, day before yesterday, she commenced talking about the scenes of her early life. She narrated, minutely, circumstantially, and correctly, a great many occurrences of her earliest childhood. Her mother said she had told almost every thing that happened to her while a child. For instance, at the age of two years, her father bought for her a pair of small ear-rings. After wear- ing them for a short time, they were missing from her ears. She had been at play alone in a yard, or field, near the house, and the parents never knew whether the child had lost the rings from her ears, or whether some one had stolen them. Her father took her in his arms, and carried her into a cer- tain part of the field, which he distinctly recollects, to endeavour to find them. Yesterday, she related, and repeated, again and again, all the cir- cumstances connected with this event. She said that a person took the rings from her ears — that her father took her into the field to seek them, and that when her mother carried her to the doctor to have her ears bored, she cried, like a child, which she would not do again. She also said, that once when her mother was sick, she herself was rocking the cradle, that her grandmother came in and told her she need not rock it any more, but that she might go to her house. She said she went and they had light pud- dings for dinner. At this time she was three and a half years old. All these circumstances are recollected by one or by both her parents, and there is no doubt as to the precise dates of their occurrence. I give them as illus- trative of the subjects and tenor of her conversation at this time. She had a great deal to say about Dr. Webster, their old family physician, and about all the persons with whom she was most familiar, while a young child, but whom she had not seen, and whose names she has rarely heard mentioned for eight or nine years. She says but little of recent events, with a single exception. At different times during her sickness she has been visited by two gentlemen who have attempted to produce in her that state of the sys- tem, constituting artificial somnambulism. She has also been examined and prescribed for by two other individuals — females — themselves somnambu- lists. A fifth person, a physician — has a few times seen her, and once pre- scribed for her, cowhage. These five individuals are frequent subjects of her remarks. She gives them all the title of doctor f and whenever she speaks of them her whole manner becomes animated and even boisterous.
Bartlett’s Case of Chronic Cerebral Affection, 55
She laughs with great glee, claps her hands, directs her eyes towards the ceiling, and talks in a loud tone of voice. She frequently exclaims, “ There they are! O, how mad they will he! O, how silly they look! They can't get in! I have locked them out!" And so on. She always speaks of her phy- sician with great kindness and confidence. Every thing that is right she attributes to him; every thing that is wrong to some one else. Speaking to some one of her old associates in England, she said, Give the doctor a good bed, it's no matter where I sleep."
During this state, the sense of pain in the head still seems to be present. In her most violent motions, she often clasps her head with both hands; and, for a moment, buries it in the pillows or in the bed. This afternoon, during my visit, she said, “ Jane, don't let mother know how my head aches!" fre- quently repeating, also, “ O this poor head! O my poor head!" At these times, she pays no regard to things or persons about her. Once, when the paroxysm went off, and she had returned to her natural state, she said, “ Where have I been?" She is then exhausted, and feels sore. She retains no recollection of the occurrences of the paroxysm.
July \Qth. — Last Thursday or Friday, the paroxysm commenced about fifteen minutes past ten o’clock in the evening, and continued till towards night, the next day. Her first question, on the return of natural conscious- ness, was, “ Has it struck eleven?" Another paroxysm commenced on Satur- day evening, and with some very brief, fugitive glimpses of her natural state, continued through Sunday, and was still present at my visit, this forenoon, Monday. All through yesterday, she talked as though the day was Satur- day— spoke frequently about the children going to Church to-morrow," &c. This morning she still had the same consciousness, in regard to time, although, in answer to a question, she said to-day was Monday, because her father had told her so. The state of the patient’s mind, during this preternatural con- dition, has changed, in one respect, since yesterday. She is now perfectly conscious of surrounding things — recognuses persons about hier— talks with them — answers questions, <fec.; but the tone of her voice is still bad, and her manner violent, animated and wild. Her eyes are open, and the balls not rolled up in the sockets, excepting at intervals, and then only for a moment. At times, during these periods, she amuses herself with her books and letters; then she will call for her slate and pencil. During my visit to-day, she sud- denly exclaimed, “/ know how to cypher! I know how to cypher! I can tell how many minutes there are in a day! I can tell how many seconds there are in a day!" She had neither slate nor pencil; but she turned her face down- ward towards the bed, smoothed the sheet with her right hand, and, for a few seconds, moved her fingers rapidly, as though she was occupied with a pencil in doing a sum. She then gave correctly the number of minutes and of seconds contained in twenty-four hours. Whether she gave these results from memory, or whether she actually went through the calculations at the time, I have no means of knowing. There were manifested, at different
56 Bartlett’s Case of Chronic Cerebral Affection,
limes, various other phenomena, which seemed to show extraordinary quick- ness and acuteness of some of the senses. The transitions from one state to another are becoming more frequent, and they are always instantaneous; in the twinkling of an eye, quick as a flash of lightning, the tone of her voice, the expression of her countenance, and her whole aspect and manner are changed. She has nearly ceased talking of old affairs. The physical con- dition of the patient remains essentially the same.
August 2Qth. — For the last month, she has, in some respects, been slowly improving. She is still subject to the two states, which have already been described. Her loud and violent manner has, however, almost wholly ceased. These periods occur now, most frequently, in the night. For the most part, she is, during the day, quiet, and has her mind fully and perfectly. She has only a confused and very indistinct remembrance of the occurrences of July. She remembers imperfectly some things, when they are told to her, but says they all seem like dreams. She is able to sit up during most of the day. She has a few times rode and walked out of doors. Within a few days, she has had her menses, after an interval of three months. Her appetite is almost entirely wanting, and she takes but a very small quantity of food. The headache still continues, although she says it is not quite so bad.
October \Sth. — After August 20th, I was some weeks absent from home, and did not see the patient. Nearly two months ago, she was carried to the sea coast, where she remained only ten days. Ever since that time, she has been in a very bad state. The two conditions still continue, and she is con- stantly and frequently passing from one to the other. Some days, during her crazy turns, as her mother calls them, she is noisy, tossing herself about, and screaming. When these are absent, she is, as she always has been, still, quiet, perfectly self-possessed, conscious of her situation, with a sad, dis- tressed expression of countenance. For some time past, there has been ex- quisite tenderness of the scalp. She starts, shudders, and screams at the slightest touch. She avoids touching her head with her own hands. In the severest paroxysms of pain, she clenches her hands, grates her teeth, and literally shudders with suffering; but she does not put her hands to her head. The headache is just as bad as it ever was; there is no remission, no miti- gation of its intolerable severity. During the preternatural state, she talks for hours together about her head, and about not letting anybody, and espe- cially her mother, know how bad the pain is. Within a few days, during my visits, I have heard her say — “ O what pain! what pain! I don’t want mother to know — I never told anybody; no, and I never shall — my head is on fire — my eyes are on fire — 1 can’t hide it much longer — I try to hide it from my poor mother — I try to get up and he cheerful; hut O ivhat agony, agony, agony! — Nobody knows; 1 shall never tell anybody. ’’’’ At these times, she seems to be sensible to surrounding objects; but she very rarely takes notice of any thing which is addressed directly to herself.
Bartlett’s Case of Chronic Cerebral Jiffection, 57
November 12th. — The patient is still in nearly the same state. There is no relief to the headache. She said to me to-day, it has never been so bad as it has for a few days. She says that she does not mind the external soreness so much as she did, because the headache is so severe. I found her to-day sitting up, in a rocking-chair, with a book in her hand. She had read be- tween sixty and seventy pages. She said she could remember most of her reading, as well as she ever could. Her cheeks were of a bright rosy red. She said that her head felt hot; but that her whole body, inside and out, was chilly. She has often complained of this. She takes but very little food. She has pretty often gone forty-eight hours without taking a particle of food or drink. Her mother says that she does not take, on an average, for weeks together, more than a single cracker daily. She drinks lemonade and coffee. Her pulse is about 80, feeble and soft. Her bowels are regular, and her tongue clean. The numbness of the feet is almost constant. For the last week, she has been, most of the time, conscious, and free from her wild paroxysms.
January 2Qth, 1839.— No essential change has taken place since the last entry. For a few weeks past, her talking has consisted mostly of expres- sions of resignation, religious hope in the future, recitations of hymns, and quotations from scripture. While I was sitting by her bed, a week ago, she said — “ My suffering increases every day. O, mother, don’t trouble your- self about me. When 1 am gone, you have plenty more. No creature can tell the suffering that I have had for three years and three months — O no creature can tell. I will soon go to my Heavenly home, where the wicked cease from troubling and the weary are at rest. Heaven will repay all that I have suffered here. As St. Paul says — When this earthly tabernacle is dissolved, I have a house not made with hands, eternal in the Heavens.” — She moans almost constantly; and at times shrieks with the pain. She suf- fers, also, exceedingly from the exquisite sensibility of the scalp. To-day, her father, while engaged in writing the names of his children in the Bible, miscalled the date of the birth of one of them. He was immediately cor- rected by the patient. After my visit, she said, “ I suppose they won’t be- lieve it, but I remember distinctly when John w^as born.” She was then seventeen months old. The quantity of her food is still exceedingly small. More than once, she has passed forty eight hours without taking a particle of solid nutriment, or a drop of drink. Since November, 1838, she has had three very violent attacks of the convulsive cough. They did not yield to the Prussic acid, but were removed in a few days by free doses of the extract of belladonna. The distinct mental states still continue, with their quick and frequent transitions from one to the other. Most of the tinie, she is in the preternatural state, or, as her mother says, she is lost.
February 20i5^.— For the last three weeks, the patient has been slowly improving. The headache is less violent, but not removed; and there is less
58 Wyman’s Case of Cancerous Ulceration of the (Esophagus.
tenderness of the scalp. She has been constantly conscious. She gets some sleep nearly every night, and has been able, for the last fortnight, to sit up several hours, nearly every day. There is less flushing of the face, and less coldness of the hands and feet. The sense of heat in the head still continues, and although she takes food rather more freely, it is not because she has any appetite for it. I asked her, a few days ago, if she was confident about her recollection of the time when her brother John was born. She smiled, and answered, that she remembered it as well as though it happened yesterday. She said that she had no remembrance of this event before her present sick- juess. Most of the events of her sickness, except in relation to the lapse of time, are very indistinctly remembered.
Lowell, Mass., 25/A February, 1839.
Art. IV. Case of Cancerous Ulceration of the (Esophagus opening into
the Trachea. By Morrill Wyman, M.D., Cambridge, Mass.
R. -B. came under my observation, July 10th, 1838. Patient tall, large frame, much emaciated; aetat. 70. Reports he has not been in good health for eight or ten years. During several months past, has lost flesh and strength. Three months since, while at dinner, first perceived difficulty in deglutition. The morsel, a piece of meat, was arrested in the oesophagus, and he was obliged to return it to the mouth by hawking. From that time to the present, deglutition has become more and more difficult, forbidding the use of any other than liquid or soft solid food. He suffers no pain in the oesophagus, except an occasional burning sensation. Feels assured that his food always passes down to the same point, midway of the sternum, be- fore it meets with any obstruction, or is returned to the mouth. When it is returned, it is not by any exertion on the part of the patient, but by an in- verted action of the oesophagus.
OEsophagus examined by means of an ivory ball-probang, one half an inch in diameter. Instrument passed readily to seat of stricture, ten or twelve inches from the teeth, but there stopped suddenly without being in the least engaged in it. A similar ball, three-eighths inch in diameter, became slightly engaged, but with moderate force would not pass; a third, one-fourth inch in diameter, passed readily into the stomach. Stricture about eight inches from pharynx, one and a half inches in length; passage small and apparently rough from projecting masses along its sides.
July 22(1. — Called to patient, who informs me he was able to swallow as asual, till thirty -six hours ago, since that time has swallowed no food whatever;
Wyman’s Case of Cancerous Ulceration of the (Esophagus, 59
is faint and exhausted. Says he is very hungry; lakes food frequently, but in two or three minutes it returns again to his mouth — “ shall surely starve, if not soon relieved.” The smallest ball-probang passed through stricture; still patient couhl neither eat nor drink. After some difficulty, a very small stomach tube was introduced, and a half pint of milk porridge thrown in by means of a pump; in four hours, a pint more of the liquid was administered in the same way.
23d. — Reports he was much revived by food; in evening was able t© swallow again. This morning, has taken breakfast (ginger-bread made soft in tea,) with much more ease than usual. At noon, ventured upon a small piece of pork, w'hich also passed. Still very weak.
30th. — Since last date, deglutition has improved gradually; none of his ordinary food has been returned, but is careful that it be either soft or in very small pieces. Strength increasing.
During latter part of summer and fall, patient has been employed about his house as usual, doing such things as his strength would allow. About once in ten days, has had ball-probang, one-fourth inch in diameter, passed through stricture. This has never been done, however, unless he has been obliged to submit to it by a fear of complete closure of the oesophagus, and consequent starvation. At each time the difficulty in passing the probang was increased, not only by the narrowed passage, but also by the difficulty experienced in finding it. The instrument required a certain direction, or it w^ould slip into a little excavation at the side of the true passage, through which there was, apparently, no opening into the oesophagus below the stricture.
October 17 th. — On withdrawing the probang, it was found besmeared with a brownish coloured, slimy, very fetid matter. During two or three days following, skin hot and dry; tongue coated; pulse accelerated. These symptoms soon passed off, and he recovered his usual state of health, with an ease of deglutition greater than he had enjoyed since the July previous.
This state continued till the last week in December, but with no improve- ment in strength or flesh. He now began to have cough, with some dys- pnoea. The cough was increased on taking food, which he said produced “ a terrible burning” behind the upper part of sternum. Food frequently rejected, even when liquid, after remaining a few minutes in the oesophagus. During the following week, became more sick. Thirsty; skin hot and dry. Pulse, 108; tongue coated; dry. Weaker, and, if possible, more emaciated than before.
January 9th. — Took to his bed on account of extreme debility. Cough in- creased; expectoration principally mucus, with some of the liquid he has attempted to swallow. Chest resonant on percussion; coarse mucous rales in both backs; sound of respiration distinct. Pulse, 110, small. Craves cold water only; thirst great. Two liquid dejections daily, not large. From this date, cough more distressing. Difficulty of deglutition not increased,
60 Wyman’s Case of Cancerous Ulceration of the (Esophagus.
although burning sensation behind sternum is still complained of. The pulse became more rapid till the evening of the 12th, when it was at 120 per minute. During the night of the 12th, extremely restless, and on the morning following, after being turned in bed by his attendant, immediately expired.
The body was examined thirty hours after death, in the presence of my father. Dr. Rufus Wyman, and several other medical gentlemen. Exter- nally, body extremely emaciated; muscles very distinct; chest large; abdo- men very much sunken. Tongue, pharynx, oesophagus, stomach, and the contents of the chest removed together. Pharynx appeared healthy through- out, as did the tongue. Epiglottis large, healthy. Nothing abnormal dis- covered in removing the oesophagus until its connections were destroyed as far as the fourth dorsal vertebra, where such strong adhesions were found between it and the periosteum, covering that bone, that they could be separated by the knife only; adhesions hard and grating under the edge of this instrument. (Esophagus of the usual size at its junc- tion with the pharynx: below this, larger than usual till near the level of the fourth dorsal vertebra, where its sides became thickened and calibre diminished by a rough tuberculated surface to the diameter of one-eighth of an inch. This contracted portion extended about two inches of the length of the canal. This part in a state of ulceration with fetid matter adherent. Two ulcerations were observed deeper than the others, and, on gently in- serting a probe into one of them, it passed freely into the trachea. The trachea and bronchi being then laid open, another ulceration admitting a full sized dressing probe was seen in the posterior membranous part of the trachea exactly at its bifurcation. This, too, communicated with the cbso- phagus at its thickened, ulcerated part. The trachea and bronchi near the openings, showed evident marks of inflammation; mucous membrane red, roughened, and in some parts a purulent secretion upon its surface. On the tracheal side, the openings were smooth, with the edges thin and well de- fined; on the opposite side rough, with ulcerations leading directly down to them. Some adhesions of long standing existed between the lungs and pleura costalis, but otherwise these organs were remarkably healthy. Sto- mach~carefully examined at its cardiac and pyloric orifices, but no thick- ening or schirrous appearance observed.
Cambridge, Mass., February, 1839.
Adam on Remedial Powers of Persesquinitrate of Iron,
61
Art. V. On the Remedial Powers of the Persesquinitrate of Iron. By T. C. Adam, M. D., of Lenawee county, Michigan.
For upwards of five years we have been in the habit of prescribing, almost daily, the liquor ferri persesquinitratis, a remedial agent first dis- covered and introduced to notice, we believe, by Wm. Kerr, Esq.; though Dr. Graves, in a clinical lecture, quoted in No. XXXV. of this Journal, ascribes this merit to Dr. Christison, of Edinburgh. We have derived from its use very remarkable assistance in the treatment of several diseases, especially diarrhoea, and other affections of mucous membranes accompanied by discharges; and as its virtues seem not to be so generally known in this country, as they deserve to be, we have been induced to lay before our brethren a few observations illustrative of its value as a therapeutic agent.
The formula for the preparation of this remedy, as given by Mr. Kerr, will be found in the No. of this Journal for May, 1832, p. 235.
Our first trials of this remedy were in cases of diarrhoea^ and from its employment we have derived highly beneficial results. We must not be misunderstood to mean that this astringent is applicable to every case of diarrhoea, or that it has been found indiscriminately useful. We have not thought proper to administer it in every variety of this complaint; but of its beneficial effects in such cases as the following, we can speak with much confidence.
In January, 1832, a child of six months of age became our patient, on account of a diarrhoea, nearly habitual, but aggravated by dent/ticn. Im- mediate relief was obtained by meads of a free incision through the gums, down to the tooth or teeth. The fretfulness ceased, and the diarrhoea sub- sided to its usual degree. Two drops of the nitrate vere then ordered three times a day, and to be continued for at least ten days after the cessa- tion of the diarrhoea. The effects of this treatment were a cessation of the habitual diarrhoea for at least eighteen months, ^fld an improvement in rud- diness of complexion, and in temper or feeling^ of comfort.
In April, 1832, a lady applied for advice, probably in consequence of the threatened invasion of cholera. Her Vowels were very readily moved, generally tender or uneasy; she was languid and weak, pale and emaciated, and was much troubled with cold ffet and profuse perspirations. She had been subject to diarrhoea from tb^ slightest causes for several years. Intelli- gence of an unpleasant nature would almost invariably produce it. For her I ordered frictions with salt *vater to the surface, and the nitrate, in doses of 15 to 25 drops, four time^ a day. After using the remedy a few days, this lady commonly improved; but from giving up its use too soon, the relief was not of long continuance.
We have generally ordered the medicine to be continued for at least ten days
No. XL VII.— May, 1839. 6
62 Adam on Remedial Powers of Persesquinitrate of Iron,
after the disease disappears; and have continued its use as long as four months after every threatening of diarrhoea was gone. The diarrhoea never returned for several months, if the medicine was faithfully taken for ten days or more; hut, as in the case of this lady, we have had relapses in those who neglected the usual order so soon as amendment took place. This lady’s case closely resembles that alluded to by Dr. Graves in No. XXXV". of this Journal. We may remark in passing, that Dr. Graves prescribes the nitrate in much smaller doses than we have been ac- customed to do. We prescribe ten drops at a dose, two, three, or four times a day, frequently twenty-five; whereas Dr. Graves gives seven, gradually increased to fifteen drops in the course of the day; and we think we have obtained a more rapid amendment, from the larger dose.
A lady, about 30 years of age, had had diarrhoea for ten months pre- viously to her applying to me. It commenced as soon as she got up in the morning, and continued all forenoon; in the afternoon it subsided almost en- tirely. It was accompanied with but little pain; but there was considera- ble thirst. During the ten months she had tried a variety of proposed remedies in vain. She has never been free from her complaint except for about two weeks, after having taken some purgative pills, which operated very pow- erfully. In constitution and symptoms, this case was exactly parallel with those referred to by Dr. Graves^ in the XXX Vth No. of this Journal. She took ten drops of the liq. persequinitr. ferri, gradually increased to twenty drops, three times a day. In four days she was nearly quite free from the diarrhma; and in two weeks felt stronger and in better health than for ten months previously. For about a year, as long as we knew her history, she had no return, of diarrhcea, or bad health.
A gentleman', about 30 years of age, had recently moved to Michigan, when he applied to me on account of diarrhoea, accompanied with conside- rable uneasiness and griping pains. He attributed these complaints to the changes he had been obfiged to make in his diet, especially to eating more pork than usual with him, ^jid partly to the water he had to drink. I could ascertain no other causes in b^eration, and thought his own etiological theory probably the true one. To less^ the irritability of the mucous membrane, and at the same time restrain theN^ischarges, I could think of no medicine more likely to be effectual, than th^^nitrate of iron. Fifteen drops were taken three times a day in water, and dtv^the third day he reported himself much relieved from the griping pains and \neasiness in abdomen. By con- tinuing the use of this remedy for not more\han ten days, this gentleman obtained complete relief from his “new coum|*y” complaints, which had existed upwards of six weeks before the nitrate wfc^ prescribed. From the efiects of the remedy in this case, and from some sf^^ilar observations in other cases, we were inclined to believe that this nitrate, like some other metallic nitrates, had the property of subduing morbid sensibility of the
Adam on Remedial Powers of Persesqiiinitrate of Iron. 63
organic nerves. In the paper of Dr. Kerr, will be found a case remarkably confirmatory of this theory.
Since we commenced the use of the nitrate of iron, there has seldom been any long interval between our cases of children who were habitually subject to oft-recurring attacks of diarrhoea, and who occasionally had attacks of what mothers call worm fever — infantile remittent. In such cases diar- rhoea not unfrequently alternates with constipation. It is seldom such cases are put under medical treatment, except when the remittent fever or the diarrhoea is more than usually severe. We have generally had children of this description put under our charge when they were labouring under fever. With doses of calomel and rhubarb, followed by oil in the morning, repeat- ed every second night, and conjoined with a bland, easily-digested diet, and with attention to ablution, quietude, and Warm clothing, vve have usually succeeded in alleviating or curing the fever. We have, then, in a majority of cases, recommended that the child should, for some w^eeks, have a bland nutritious diet, consisting chiefly of well-boiled farinaceous articles, and make use of the nitrate of iron regularly. In several instances we have failed to procure a steady employment of this medicine for a sufficient length of time; in some, again, the parents have continued it, of their own accord, for upwards of two months; and in all the cases in which it was regularly administered for a period of three weeks or more, we do not know that such children were again attacked with fits of diarrhcea, or suffered from infantile fever. Of several we can affirm confidently, that they were altered subjects; formerly pale, exsanguine, peevish, delicate, and requiring much anxious attention, they have become hale and fresh-coloured, strong, playful, and easily taken care of.
Sucii are the varieties of diarrhoea for which we have most frequently prescribed the liq. persesquinitr. ferri. They are all of a chronic nature, and the temperament of both the younger and the adult patients has had a large admixture of the nervous. This wq incline to attribute to the irri- table condition of the mucous membrane of the intestinal tube, and to the debilitating effects of frequent diarrhoea. Numerous cases, similar to those given, might be produced from our case-book; but our purpose is, solely to indicate clearly the kind of cases in which we have employed this medicine most frequently, and in which we have found it without a rival. For this purpose we have given, we hope, sufficient narration, and avoided “ vain re- petitions.” We will now add a few explanatory observations.
The dose which we employ in adult cases is, as we have already inci- dentally remarked, much larger than that which Dr. Graves is reported to employ. We seldom order less than fifteen drops at the commencement; and after a few days of employment of the remedy we increase the quan- tity to twenty, twenty-five, and thirty drops at a dose. For children we proportion the dose according to the age. We have only in one case that we recollect of, that of a Mrs. J. Dunlop, had occasion to reduce the quan-
64 Adam on Remedial Powers of Persesquinitrate of Iron,
tity. In this case, which, by the bye, was one of recent, not habitual diar- rhoea, the usual dose did not produce any alleviation of the symptoms, but seemed rather to increase the griping pains; we, therefore, reduced the quantity to seven drops, and in less than twenty-four hours, the amendment was very marked. We have administered, and we have taken as much as a hundred drops; but, lately, where the usual quantity does not produce re- lief in two or three days, we prefer adding a little laudanum, or employing some other auxiliary, to the employment of more than thirty-five drops. At the same time, we have never experienced any bad effects from so large a dose as even a small teaspoonful, which we have frequently known to be taken three and four times a day.
The time during which the nitrate will keep good, that is, clear and trans- parent, varies considerably. Dr. Graves says about a week — some of my acquaintances and correspondents say three and four weeks, while I myself have never had any become turbid in less than five or six weeks, and gene- rally I have it quite transparent for two months or upwards. I have also used it turbid without any sensible diminution of its astringent effects. Mr. Kerr, however, thinks that when it has become turbid, it is not so powerful. It is only in a few instances that we have employed it after this change.
In cases such as we have above described — cases of habitual diarrhoea, from birth perhaps, in children, and in cases in which there seems to exist an excess of irritability in the digestive tube — we know of no medicine which produces a more beneficial, immediate effect; and certainly, in its power of preventing similar attacks in future, this remedy is without any rival, so far as our experience extends. In cases of children, we have found its long-continued employment produce the most satisfactory results.
We have endeavoured to guard against any misconception of our ideas as to the cases or morbid condition to which our remedy is particularly appli- cable. We meet with chronic diarrhoea in two forms — persistent and what may be called intercurrent. The former is generally the consequence of a severe acute attack; by the latter, we mean to designate such cases of this disease as consist in a tendency or predisposition, or in the frequent occur- rence of slight attacks of an acute kind, the usual state being more or less normal, or rather inclination to constipation. In the majority of cases of both kinds, the proximate cause, as the pathological condition has been called, undoubtedly consists, not so much in the application of foreign irri- tating matters, or on faecal accumulations or morbid secretions, or on an undefined debility or relaxation of the mucous membrane, or on congestion or inflammation, so much as on an excess in the sensibility of the organic* nerves which supply the digestive tube. It is not for chronic diarrhoea— b, name for a symptom not a specific condition, that we prescribe this chaly- beate astringent and sedative; but when, by investigation, we have satisfied ourselves that the diarrhma is dependent on the above named condition, we
Adam on Remedial Powers of Persesquinitrate of Iron* 65
then employ this remedy in preference to opiates, or any other anti-diarrhoeal medicaments.
Having thus laboured lo indicate, with precision, those forms of disease in which we have derived from the use of the liq* ‘persesquinitr* ferri the most satisfactory and beneficial results, we will now briefly notice a few ad- ditional forms of disease, in which we can speak favourably of its reme- dial effects, though not with the confidence we feel as to our previous obser- vations.
In Leucorrhoea, we have employed the nitrate of iron with excellent suc- cess. But to procure benefit, we are careful in the selection of proper cases. These we think are such as seem chiefly dependent on a laxity of fibre, or on an over-secretion without inflammatory action. The persons in whom we meet with this kind of leucorrhoea, are generally pale, exsanguine, feeble, languid. We would not administer the nitrate where there was rea- son to suspect any disease of the uterus. But in the former kind of cases, we have employed it very successfully, using it internally, generally, and always topically, in injection. We add to four ounces of water such a quan- tity of the nitrate of iron as will produce in the vagina a gentle degree of heat or smarting. The internal use is prescribed where it is probable that the system by this means may be so roborated as to aid in the cure of the local disease. Almost all the preparations of iron are useful in such cases, and we think this not inferior to any in this respect.
In several cases of Menorrhagia, we have found this astringent and tonic of much service. We think it may be preferred, in cases accompanied with anemia, debility, and relaxed fibre, to any astringent in common use. We know of none equal, save a mixture, in equal proportions, of the sul- phates of alumina and iron.
We have made trial of the remedial power of this medicine in such cases of almost all the diseases in which astringents are usually prescribed as we thought the most appropriate. We do not know of any case in which the nitrate enjoys a marked superiority to the common astringents; but judg- ing from our experience, we presume it will be found a convenient and useful addition to the list of such remedies.
Dr. M. A. Patterson, of Tecumseh, informs me that he has found the nitrate of much use in the treatment of aphthous sores, or what is vulgarly called “ canker.” Our experience, though small, confirms the utility of this application of the medicine.
A gentleman, in whose house a bottle of this remedy was at a time when he had the toothache, applied a few drops sud sponte, and obtained relief. May the nitrate of iron not possess a sedative or anodyne effect like the ni- trates of silver, bismuth, &c.?
In fine, it may be mentioned as no small recommendation of the prepa- ration, that it is cheap and easily procurable, and as each practitioner can prepare his own, it may be depended upon as uniform and unadulterated in
6*
66
Marcy’s Case of Partial Sweating,
any important emergency. Those who have felt the deficiency, in purity and uniformity, of many of our remedial agents, will account this as not the smallest of its recommendatory qualities.
Art. VI. Remarkable Case of Partial Sweating. By Samuel S. Marcy, M. D., of Cold Spring, N. J.
The subject of the following case, John Fallopius, setat. 45, of san- guine temperament and of strictly temperate habits, has never suflfered a day’s sickness, with the exception of the ague and fever, and is in every respect a healthy, athletic man. From the year 1823 to ’30, he was attacked with every variety of ague and fever, from the slightest chill perceptible, to the most violent ague possible, embracing the tertian, quartan, quotidian, and double quotidian type; and much of the time accompanied with excessive night sweats, equal to a Thompsonian sweat. Now, and for the last six years, has been free from that or any other disease, but is subject to profuse per- spiration on taking much exercise, perspiration greatly disproportionate to the exercise or labour; while in a recumbent posture, the perspiration is con- fined to the upper half of the body and extremities; the opposite, or under side perfectly void of any moisture; temperature natural; change his posi- tion to the opposite side, and in a short time perspiration subsides on the side he is laying upon, and commences on the upper side again, and so on as often as he chooses to change his position. A line of perspiration would be correctly marked by a line drawn from the centre of the frontal bone to the pubes, including the extremities. The patient has often amused him- self and friends, by noticing his one-sided sweating propensity on changing his position from side to side. While in an erect position, the perspiration was uniformly diffused over the whole surface. During the past extremely warm summer, his eccentric perspirability continues even in the erect posi- tion, and he continues to amuse his friends by exhibiting one side of the face covered with pearly drops of perspiration, while the opposite side is en- tirely free from any moisture. Since it showed itself in the erect position, it is confined to the left side exclusively, and so continues.
I submit the facts to the profession as I have often witnessed them, con- fident that there is no deception in the case, leaving them to give the why and wherefore. I cannot give a reason that will satisfy myself.
Cold Spring, Cape May, Aug. I5th, 1837.
Porter’s Case of Epilepsy,
67
Art. VII. Case of Epilepsy, By Charles A. Porter, M.D., of New
York.
In the number of this Journal for November, 1838, there are given the results of M. E. Esquirol, in the treatment, cure, &c. of Epilepsy. Our expe- rience so well accords with those results, that we are induced to report the following case recently treated.
February 7th, 1838. — I was requested to visit Miss D. of this city, aetat. 17, who has been subject to fits for three years: produced at first by anx- iety of mind. In her infancy she was sickly. But since she was attacked by these fits, her health has been excellent. There is considerable regu- larity in their recurrence every fifth day. Her mother remarks that such is particularly the case when there is a new moon. After this, and espe- cially at the full of the moon, there is an interval of seven and more days. On a careful examination we find heat of head slightly abnormal: extremi- ties cool. Temperament nervo-lymphatic. Menses regular. At their com- mencement and cessation, she has a fit.
Appetite always good, craving fat, hearty food; free from pain in the epigastric region, and indeed over the entire abdomen. She has been in- dulged in her desire for food. No regard, as I am informed, has been paid to diet by her medical attendants, of whom there have been several; one a homoeopath. Pulse so small, that it is with difficulty it can be felt, and preternaturally frequent. The tongue denotes gastric irritation: pa- pilla red, shining through a white fur. I directed a mild, unirritating diet, as mush and milk; abstinence from tea and coffee; the frequent and repeated use of revulsives, as foot baths made stimulating with cayenne pepper, mustard and nitro-muriatic acid; a large poultice of mustard and Indian meal over the bowels; and a similar poultice over the spine, as there is tenderness about upper dorsal region, and after that apply a tartar eme- tic plaster to the same spot. By this plan of treatment, she escaped her fits just one month, until March 7th, when she had a fit, which was very light.
This was followed in five days, March 12th, by another occurring in the morning, which was severe, and lasted nine minutes. There was a loss of consciousness, which remained for two minutes before the patienl; fell. 4fter the fit she complains only of dulness in the anterior portion of the head. Pediluvium for the evening, made stimulating with mustard.
March \^th. — Patient feels well in every respect. Dorsal spinal ten- derness present, but in an inferior degree. Bowels rather confined; direct- ed a pill of mass, hydrarg. grs. v, and sulph. magnesia 5ij following morn- ing. Our patient, it should be mentioned, is operated upon by very little medicine.
15^/i. — Commenced giving tincture of stramonium. Directed two
68
Porter’s Case of Epilepsy,
doses that day, sixty drops each. We were careful to obtain the seeds of a gentleman who collected them at the proper season, and had the tinc- ture made under our own direction with ^iv seeds to alcohol Oj. Sixty drops were repeated three times a day until March 18th, when I discovered sensible efiects from the medicine. Pupils much dilated, with double vision, and stupid look, similar to a person with the first effects of inebriation. Directed medicine discontinued for that day.
IQth. — Find that the dilatation of pupils is removed, and patient can discern objects naturally. Directed the tincture continued in thirty drop doses, three times a day: a pill of mass, hydrarg. aloes and rhubarb at night, and a pediluvium with a large cupful of mustard. Continue to irritate the spine with tart, antimon. unguent.
2^th. — The tincture was taken twice yesterday. The pill had no effect. Repeat the pill at night, and salts in the morning, if requisite. The pulse gains more force, and is near the natural standard — 70.
22d. — The pupils are considerably dilated. There is a w'ild appear- ance of the eye: the patient complaining of imperfection of vision. Directed medicine to be continued in fifteen drop doses.
23d. — Directed for the evening dose thirty drops.
2Uh — Continue medicine in thirty drop doses.
April Uh. — The stramonium has produced looseness of the bowels; but pretty constantly since last date, thirty drops have been taken three times a day. She is at present menstruating. I have directed a pill three times a day, containing oxyd-rubr-ferri grs. ij, extract conium-maculatum, grs. ss. And to an ounce of the tincture, I have added sulph. morphia grs. ss.
bth, — Takes gtt. xv of tinct. for a dose.
8<A. — Takes pills four a day.
The pills and the tinct. are regularly continued until May 10th. Nine in the evening, had a fit of short duration. Two days previous she com- menced her menstrual period. This was very immoderate, her mother comparing it to one who had miscarried. Just prior to the fit, there was a great flow. After the fit they ceased entirely. It is proper to remark here that the patient had felt so well, and continued free of the fits for so long a period, that she had not observed her usual regularity in taking the medi- cine. Besides, on the day previous to the fit, she had taken an unusually long walk.
Mayllth, — I have directed the tinct. in doses of 40 drops three times a day with tinct. opii gtt. xv in each dose, as there is a great tendency in the stra- monium to run off by the bowels.
21tJi. — Had a fit at mid-day. She had taken gtt. 60 that morning, and gtt. 45 just prior to having the fit. She felt badly in the morning, and had eaten heartily of fried eels, contrary to all directions.
2Sth. — Have rigidly enforced a plain diet of mush and milk: apply all over the abdomen equal parts ol. terebinth, and ol. oliv.: pediluvia with
Hulse on the Bite of a Spider.
69
mustard, a plaster of extract hemlock, camphor and opium to spine — gtt. 60 of tinct. for morning dose, and continued so as to keep the pupils constantly dilated. The bowels now costive; this to be remedied by a pill of mass, hydrarg. aloe and pulv. rheum.
June 28th, — Had a fit, and another five days after.
July ISth. — Directed the following R; 01. terebinth. 5ss: Pulv. sacc. alb. 5ij: Puiv. gum Arab, aa: Aqua destill, ^iv. Tablespoonful three times a day.
nth. — Had a fit — the menses in large quantity, amounting almost to a flooding.
23d. — Had a fit. The tongue denoting gastric derangement, we have discontinued the ol. tereb. mixture, and with our consent, the patient has gone for a time to reside on the Brooklyn heights, for the benefit of purer air-r— all medicine discontinued. Diet to be observed, and take warm salt water baths, (recently established by Mr. Gray of Brooklyn.)
Remarhs, — First. On stricter inquiry, we are led to believe that although this young lady has been subject to fits in their open, undisguised form, for three years, she has been predisposed to them from birth — for, in her earliest infancy, she had an attack — and had several of what are vaguely termed “ inward fits.” When congenital and hereditary, says Esquirol, it is never cured.
Secondly. We were induced to consider the fits depending on the concfition of the menstrual discharge, and directed our treatment accordingly. We ^cceeded with act. plumbi grs. ij and opii grs. ss, frequently repeated, in moderating the discharge, but not in preventing the fits.
Thirdly. We are led to agree with Esquirol, not from this solitary ease; for, during two years residence in Philadelphia Alms-house Hospital, there were many, very many cases, under every variety of treatment, not except- ing even animal magnetism; and we regret to add, with no more beneficial results. The disease is a truly deplorable one; and thrice fortunate would he be who can point us to a certain remedy, even in a small number of cases.
280 Broadway y January ^ 1839.
Art. VIII. Bite of a Spider on the Gians Penis y followed by violent symptoms — recovery. By Isaac Hulse, M.D., U. S. N. Fleet Surgeon, W. I. Squadron. i
On the 7th of August last, Mr. Q. of this place, while in the privy, per- ceived himself to be stung by a spider on the glans penis. The pain, which was not great at the moment, continued to increase till 1 p. m., an hour
/
70
Hulse on the Bite of a Spider,
after the accident, when it had become extreme, and I was called to see the patient. 1 found him lying upon a cot, and writhing under the most acute suffering. The place where the sting was made, showed no marks of irrita- tion nor swelling. I however applied to it a strong solution of carbonat. po- tass, which I happened to have about me, and ran to the apothecary’s for medicine. My absence lasted but a few minutes, and on my return, I found him vomiting with great violence, and complaining of deep-seated pain in the abdomen, extending up into the chest, and of sensations of choking and suf- focation. The vessels of the neck and face were greatly distended, and of a dark hue. 1 opened a vein in the arm and let blood copiously through a large orifice, and commenced immediately to give aqua ammoniac and lauda- num in doses of a teaspoonful of each every ten minutes, which were ejected as often from the stomach — pains and spasms along the spine and extremities now came on, and the agony and anxiety were, if possible, increased; Strong volatile liniment, tinct. cantharides, and spirits terebinth, were alternately applied to every part of the body by the patient’s numerous friends who had assembled round him, and common injections were administered as fre- quently as they conveniently could be, with a view to open the bowels. The ammonia and laudanum were assiduously plied and occasionally some tinct. camphorae, likewise; at the suggestion of Dr. Edwards of the navy who was called in, the oleum olivarum was freely administered. At 3 p. m. the paroxysms of pain came on at longer intervals, and the vomiting was less urgent, but the intensity of the pain when present, was undiminished. The principal medicine relied on, viz. the ammonias and laudanum, were con- tinued every half hour, and at about 5 o’clock, after the exhibition of fifteen injections, faecal evacuations were obtained from the bowels. The patient became much easier in the course of the evening, and was able to retain a dose of castor oil, which purged him freely; but the pain in the legs con- tinued through the night, which he passed without sleep.
On the subsequent day, sinapisms were applied to the legs without effect, and the evening brought little or no mitigation of the pain. Veins were now opened in both feet, which were placed in warm water, and the blood was allowed to flow till an impression was made on the pulse. In an hour after the bleeding, the patient enjoyed perfect ease; he slept well that night, and on the following day was able to walk about the house. He recovered in health very speedily.
This gentleman is of dark complexion, short stature, and powerful mus- cular development.
I saw several spiders in the place where he received the sting. They were of large size, of a dark brown colour, covered with hairs over the legs and body.
In this case four ounces of laudanum and an equal quantity of aqua am- moniae were administered in the space of four hours.
Pensacola, February 2d, 1839,
Logan’s Account of Scarlatina,
71
Art. IX. A Brief Account of Scarlatina, as it prevailed in the Orphan
House, Charleston, South Carolina, during the months of June and July,
1838. By Geo. Logan, M.D., Physician to the Institution.
The summer commenced with very unsettled weather, the transitions of temperature were frequent and sudden. On the 2d June, a storm occurred, accompanied by rain. On the 4th, the heat was oppressive; again on the 7th, Fahrenheit’s thermometer fell to 60°. From this date to the close of the month, the season was dry and warm; an inflammatory constitution of the atmosphere resulted.
This was manifested by the character of the prevailing diseases. Catar- rhal affections were general, and in several instances assumed the form of pneumonia, requiring the lancet; harassing hooping cough (still lingering in the institution) was aggravated to a degree which rendered depletion and blisters necessary. Anodynes could seldom be employed with safety: al- though the suflferings of the little subjects were protracted, they were all restored to health before the middle of July.
About the second week in June, the much dreaded scarlatina, which had afflicted a part of the city for eighteen months previously, first appeared in this institution. Its distinctive character was strikingly developed. The first eleven cases were unattended by any malignant symptoms, passing favourably through the several stages. Swellings of the tonsils, pain and soreness of the. fauces subsided on the fifth day; desquamation of the eruption took place on the sixth, and convalescence on the eighth and ninth days.
The subsequent cases were more violent, confirming the observation of certain distinguished physicians, “ that in large institutions, epidemics in their progress often acquire a malignancy.” To obviate this as far as possible, the commissioners with a solicitude and kindness becoming guar- dians of the “ publics’ children,” consented to appropriate the spacious cha- pel as an hospital, into which thirteen subjects then under treatment, were transferred. Disinfecting substances, as chloride of lime, and afterwards the fumes of vinegar and nitre were introduced into the dormitories and other apartments.
The most alarming instances were ushered in, with languor, shivering, pain of the back, tenderness of the epigastrium,