THE WESTERN JOURNAL OF MEDICINE,

(Formerly, "CINCINNATI JOURNAL OF MEDICINE.")

Thus it will be seen that if man has passions which impel him to the destruction of man, if he be the only animal who, despising his natural means of attack and defence, has devised new means of destruction, he is also the only animal who has the desire, or the power, to relieve the sufferings of his fellow citizens, and in whom the co-existence of reason and benevolence attests a moral as well as an intellectual superiority.-GRAVES' CLINICAL MEDICINE.

VOL. IV.

INDIANAPOLIS, JUNE, 1869.

No. VI.

ON OBSTINATE HICCOUGH.

BY J. W. MOORMAN, M. D., HARDINSBURG, KY.

Hiccough, though always viewed as a mere symptom, wonld seem to have as much right to a separate consideration as many other affections of a symptomatic nature.

Stillé, in his justly celebrated work on Materia Medica, says:

"Hiccup, it is well known, is sometimes exceeding obstinate, and cases of its fatal termination have been recorded."

Within the past few years, several cases of severe hiccough, independent of any other affection, save the disordered state of the nervous system, which is part and parcel of the affection, have come under my notice.

By some mishap, the full notes of the cases have been mislaid or lost, and I will be compelled to draw on my memory for the facts in the single case which I shall report.

Miss E, aged about twenty years, of weakly habit and of nervous temperament, rather anemic, had been suffering with menstrual derangement, from which, however, she had been free for about six weeks. Her appetite had been poor for some time, and the bowels were habitually constipated.

Some time in July, of 1866, I was called to see her, and found her

hiccoughing continually at the rate of fifty-six to the minute. The continuous diaphragmatic action interfered materially with respiration; the catamenial discharge had been natural in quantity and quality two weeks before; the pulse was irregular, weak and soft-eighty to ninety to the minute; tongue moist and flabby, indicative of anemia; no appetite; thirst continued; the quantity of any liquid swallowed was small, owing to the violent regurgitant action of the hiccough; skin moist and cool; extremities below natural temperature; slight nausea; bowels constipated for several days past. Ordered

R. Rhei Pulv.

Ext. Colocynth Comp. aa grs. v.

To be given every fourth hour until bowels were moved freely. Eighteen hours afterward, her bowels not being moved, she was ordered an enema, which brought away a copious stool of hardened fecal matter; no abatement of the hiccough; has had no sleep for forty-eight hours past.

Ordered one-fifth grain morphia every two hours until rest was obtained. For twelve hours she took the morphia as directed, and not inducing sleep, the dose was increased to one-third of a grain. On inquiry, I learned that heretofere she had been extremely susceptible to the influence of opiates. The third dose after increasing produced a kind of stupor, from which she was aroused by the slightest noise. The hiccough continued without abatement during the stupor. Almost the whole list of antispasmodies was tried, but availed nothing.

On the fifth day, she complained of soreness over the epigastrium, and the hiccough caused intense pain. The tongue became dry and cracked in the centre and of a fiery red at tip and edges; stomach extremely irritable and would retain nothing; thirst was insatiable but liquids were retained no longer than it took to drink them; they were not vomited, as there was no retching, but simply regurgitated in small quantities at each act of hiccough. Pressure over epigastrium caused much pain. Ordered blister to epigastrium, four by six inches, to be dressed with morphia and kept open for several days. Ice to be swallowed in small lumps ad libitum, and a simple enema every third day, to remove any accumulation of fecal matter.

On the seventh day, the hiccough was reduced thirty-seven to forty per minute; and from the ninth to the eleventh, there was an intermission of twenty-four hours, during which time she rested well, sleep being sound and refreshing. The tongue again became moist;

soreness disappeared from the epigastrium to some extent, and the thirst was much more tolerable.

After an intermission of twenty-four hours, the hiccough returned fifty-six to the minute, and continued for four days without intermission. During this time, she took the following prescription:

At same time, she took three grains sulphate quinine, three times daily.

On the fifth day after commencing this treatment, and fifteenth from date of attack, the hiccough ceased, and did not recur again with sufficient severity to attract attention.

She convalesced slowly, and is still very nervous.

Subsequently, (summer of 1868), she had another attack of a nervous character. Being absent, I was not called to treat the case, and am not aware of its exact nature.

She is now, (March, 1869), suffering with exophthalmic goitre, or Basedow's disease.

The causes of idiopathic hiccough are very obscure, having their origin, undoubtedly, in the nervous system.

Jones, (Functional Nervous Disorders, page 246), refers it to obscure nervous disorder, "such as is loosely called hysterical," and to malarial infection. Of the latter class, he cites a case recorded by Widal:

"The patient was admitted at first, suffering under the consequence of cerebral congestion. Five or six days after having committed excess in drinking, he was seized with violent hiccough, the incessant spasms of which compelled him to remain in bed, and resisted all treatment by antispasmodics. The hiccough was so intense and noisy, that it was heard outside the hospital. The number of diaphragmatic contractions reached fifty-five to the minute, and their energy was so great that all the muscles of the trunk participated in them. There was considerable dyspnoea, short inspirations, red face, white tongue, loathing of all kinds of food, pulse small-eighty.

"Opii gr. one-sixth, was given every two hours, and a blister to the epigastrium was dressed with morphia, but no improvement ensued. The patient had no sleep and his strength was failing. At last, quinine in pretty full doses was given, which speedily put an end to the disorder, after it had lasted nineteen days."

Jones (op. cit.) thinks the seat of the disorder central, but thinks it difficult to say precisely what nervous centre is affected; thinks it is about the origin of the fourth cervical nerve. Copland ascribes

it to irritation of phrenic nerve. Williams (Principles of Medicine, page 126), ascribes it to irritation of the medulla oblongata. Romberg denies that the phrenic nerve has any agency in producing it. He thinks it is caused by reflex irritation originating in the alimentary canal, liver or uterus, but admits that it is sometimes caused by disorder of nervous centres. From my own observations, I am inclined to think it originates in disorder of the nervous centres constituting a true neurosis, while I can not doubt that many cases can be traced to the causes enumerated by Romberg.

As to the treatment of non-malarious cases, the various antispasmodics are of use; and of these, asafoetida and valerian have been of more service to me than any others. In mild cases, mental influence, as sudden fright or withdrawing the attention by interesting conversation, may prove effectual. In the case reported as coming under my observation, swallowing pounded ice formed no unimportant part of the treatment. Every one is familiar with the domestic remedy so often prescribed-drink as much cold water as possible between inspirations. Cruveilhier mentions two cases treated successfully in this way. A more pleasant domestic remedy is a drachm of refined sugar in powder, to be swallowed at once. This is especially useful in hiccough, which infants are subject to from over-feeding, (Stillé Mat. Med., volume I, page 352.) An ounce of sherry wine, taken without dilution, will sometimes put a stop to a troublesome hiccough. I have found this useful in hiccough occurring in inebriates while passing from under the influence of alcoholic liquor. It may not be amiss to state that stimulants were used in the case reported; principally, however, ethereal, and although partially under the anesthetic influence of chloroform, the hiccough was not abated. Jones cites a case cured by taking three ounces of blood from the foot. He thinks we should mingle with our treatment as much of the "medicina mentis" as possible. Williams mentions hydrocyanic acid as a very efficacious remedy. Stillé speaks of cajuput as a remedy of marked utility in some cases.

In malarious cases the treatment is obvious. Stillé speaks of such a case after resisting all ordinary methods of treatment, yielded to a single dose of twelve grains of quinine.

Throughout the treatment, the mind of the patient should be diverted as much as possible from the contemplation of its ills. Even in bodily disorder, it is well known that the mind exercises much influence for good or ill, and in cases where the whole nervous system is, as it were, unstrung, the influence is much more noticeable.

The idea is prevalent among the uneducated, that hiccough is always a sign of approaching dissolution, and being communicated to the patient, will do much toward lengthening the case, which might eventually end in death from pure exhaustion. Such tattling busybodies should always be excluded from the sick chamber if possible.

RARE CASE OF MIDWIFERY, IN WHICH THERE WAS PROTRUSION OF THE OS UTERI EXTERIOR TO THE VULVA, DURING LABOR, AND PREVIOUS TO PARTURITION.

BY C. S. MUSCROFT, M. D., CINCINNATI, OHIO.

Was called this morning, January 2d, 1867, at seven o'clock, to see Mrs. S―, aged thirty-five years, of nervous-sanguine temperament, of active habits and general good health, in labor with her fourth child.

The membranes had been spontaneously ruptured four days previous, from which time until ten o'clock last night, she had no pain of a serious character; but from then until I saw her, thought she was in active labor, and more decidedly so for the last three hours, having strong "bearing down pains." She had been waited on during the night previous by a German midwife, who told me "the labor did not advance as it should on account of there being a good deal of swelling of the privates." Upon making an examination by the touch, the statement of the midwife appeared to be correct, but on meeting an obstacle which seemed to be great swelling of the external and internal labia, had much difficulty in bringing my finger in contact with the head of the child. The head was low down in the pelvis and pressing firmly against the perineum, and I thought at this time was extruded entirely beyond the os uteri, as no part of it could be reached by the touch in any direction that I could detect. There was also present that puffy condition of the scalp of the child, forming a tumor, presenting itself at what appeared to be the orifice of the vagina. The swelling of the scalp was such as is frequently met with when the head of the child has been detained for a considerable time by rigidity of the external parts.

Having at first fallen into the same error as the midwife in respect to the swelling externally, waited a sufficient length of time before