Billeder på siden
PDF
ePub

lating fat is the one characteristic of the dyspepsia of phthisis, occurring in 75 per cent. of consumptive cases.]

The greatest step made for many years in the treatment of consumptive patients was the introduction of cod-liver oil; and Dr. Hughes Bennett, to whom we owe this great boon, expressly states "that the great obstacles the practitioner has to contend with are the dyspeptic symptoms."

In cod-liver oil was found a form of fat which could, in many cases, be digested even by the impaired organs of consumptives; but the next step, viz., the search after some means of augmenting the secretious which are specially devoted to the digestion of fatty matters, has been hitherto neglected or unsuccessful. To pour oil into a patient's stomach, without at the same time taking measures to ensure its digestion, has always appeared to me a crude kind of therapeutics. Its simplicity has, it would seem, recommended it to the routinist; for there is probably no single remedy used in any disease with so little preliminary inquiry into the conditions favourable to its action. Experimental physiology has taught us that the only fluids in the body which have the power of acting upon fat, so as to render it fit for absorption, are the secretions of the pancreas and the duodenal glands. To these secretions therefore, we must look for assistance in the treatment of phthisical patients by cod-liver oil, for on the action of these glands must the assimilation of the remedy depend. And such healthy action can scarcely be supposed to co-exist with the inability to digest fat, which is so frequent in the disease under notice. As Bernard has shewn, the chief of these glands (the pancreas) is most sensitive to nervous influences, ceasing to form a healthy secretion from very slight irritation, and even from emotional influences. This fact, taken together with our knowledge of the peculiar character of the dyspepsia of phthisis, justifies the assumption that the pancreatic secretion is disturbed. Not long since, Dr. Dobell, holding these views, made some experiments with pancreatic emulsions of fat and pancreatine, which supported this interpretation of the phenomena, and shewed that fat when emulsified is more readily digested than in any other form. In this paper I have, however, to propose a mode of treatment which should, I think, in all cases precede the use of such remedies as pancreatic emulsion, because it aims at remedying the disorder, not by artificially complementing the defective secretion, but by stimulating the glands to renew their healthy action. Instead of throwing into the system a substance which may be yet formed in physiological quantities, it endeavours to promote the normal flow of pancreatic juice.

The drug which gives us this power is Ether, and I now propose to lay before the meeting the evidence of its physiological action, and afterwards to speak of its therapeutical effects. I had long sought, and sought in vain, for some means of acting on the pancreas in the treatment of phthisis, till one day, two or three years ago, when reading Claude Bernard's elaborate investigations on the properties of pancreatic juice, I found the long looked for clue; stated, indeed, so simply, and brought out in successive observations and experiments so clearly, that it has ever since been a matter of surprise to me that no previous reader should have seen the importance of the facts to practical medicine. In the following extracts, I lay before you the evidence of our greatest living physiologist on the mode of stimulating the secretions of the pancreas. The first passage which arrested my attention was the following, which occurs in Bernard's Leçons de Physiologie Experimentale appliquée à la Médecine, tome ii., p. 226. "The nervous influences which directly excite the secretion of the pancreas are much more difficult to determine than those which act on the salivary glands. In a dog, with a tube fixed in the pancreatic duct, I have galvanised the solar ganglion of the great sympathetic without a result, clearly shewing any modification of this secretion. But I have seen ether introduced into the stomach determine soon afterwards a considerable flow of pancreatic juice." This statement was so clear and unmistakable, that I at once proceeded to search in Bernard's other works for its confirmation. From his Leçons sur les Effets des Substances Toxiques et Médicamenteuses. Leçon 29, p. 426, I extract the following: "I would remind you only of the influence of ether on the intestinal

secretions. Ether is reduced to a vapour when introduced into the stomach, and may rupture it. When, however, this accident does not occur, then may be noticed a vascular congestion of all the digestive tracts, but this congestion never attains to inflammation. At the same time, the secretions are rendered active and the rapidity of absorption is notably augmented. These last effects to establish the non-inflammatory character of the congestion of the mucous membrane, for it is known that on an inflamed surface the secretions are dried up and absorption becomes more difficult.... The turgescence of the mucous membrane of the intestine, as well as the liquids secreted, present the same characters when produced by ether as when they are caused by their normal excitant-food. In comparing the pancreas of an animal, opened fasting, with that of an animal opened during the process of digestion, a great difference of colour, due to the difference of vascularity, is observed. After the administration of ether the pancreas becomes red and turgescent, as it is during digestion, and its secretory function is proportionally increased by the afflux of blood. I have accordingly been able to avail myself of this procedure to obtain pancreatic juice. Normally, this fluid discharges by drops more or less infrequent, but when a little ether is given to an animal having a pancreatic fistula, this discharge is seen to become more abundant, without the secreted liquid having lost any of its physicochemical characters." Demonstrating these facts to his class, the Professor continues: "Here is a rabbit, upon which we will show you the increased secretion under the influence of ether. The pancreatic duct is laid bare, and into it there is introduced a smaller silver tube. The intestines of the animal are red and very vascular, and contain ether in vapor. The tube introduced into the pancreatic duct plainly gives passage to a very active flow of pancreatic juice, while under ordinary conditions the liquid only flows out drop by drop with an activity much less." In another place (p. 422) summing up the results of his experiments, and alluding first to the effects of ether in promoting absorption of fatty matters, he says:-" Finally, in our experiments, the injection of the lacteals is due to the abundance of the pancreatic secretion, and to the extremely fine state of division of the fatty matters which occurs in the intestine. It is due, also, to the absorbing power having been augmented by the ether. This activity of absorption has been observed in the case of several poisons. We have already mentioned that the combination of ether with poisonous doses of strychnia and nicotine produced death more rapidly in the animals on which we experimented. The action of ether introduced into the digestive organs is, therefore:-1. To stimulate all the intestinal surface. 2. To stimulate the secretions which are poured into the intestine. 3. To modify and decidedly increase the absorbing power." In a short passage (page 428), at the end of the experiments referred to above, the following passage occurs:-"Ether increases the absorption of fatty matter, which it places at once in a state of fine division, and in contact with a more abundant secretion of pancreatic juice. In this way it produces a very marked white injection of the lacteals."

If necessary, I might multiply these extracts still more, but enough has, I think, already been quoted from the works of our first experimental physiologist to teach us the physiological action of ether. This action is twofold: (1) it stimulates the pancreas and glands of duodenum to pour out their secretions freely, and (2), at the same time, it facilitates the absorption of those very substances which these secretions are designed to digest. In other words, ether not only obtains for us the secretions required to digest fats, but promotes the absorption of these fats when digested. Can any physiological action be more clear, or any experimental proof be more satisfactory for the end we have in view?

I now come to the second part of my task; namely, the therapeutical application of the foregoing facts. Having found as I considered, sufficient evidence of the special action of ether on the pancreas, I determined to test the value of the discovery by administering ether in all cases characterised by inability to digest fat. In the out-patient departments of our hospitals, many such cases occur, which are generally classed as dyspepsia. Many

cases of neuralgia are also to be met with in which a most decided improvement follows the increased power of absorbing fatty food. To both classes of patients I gave ether sometimes in combination with cod-liver oil, sometimes alone before meals. The results were most satisfactory; the oil was digested more easily and the nutrition of the patient greatly improved. Of these cases I shall speak more fully on a future occasion. I next ordered ether in mixture to all my phthisical patients at the General Dispensary, selecting the Dispensary for my investigations, rather than the Queen's Hospital, because all the patients were out-patients, and consequently exposed to no new and favourable conditions while the experiment was being tried. The patients being also of a somewhat better class than those attending the hospital, were not, as is so often the case in our large towns, struggling to combat mortal disease while suffering from the effects of disease's chief ally-improper and insufficient food. For some months I pursued the treatment, seeing a very large number of consumptive cases, to all of whom ether either alone or in conjunction with cod-liver oil was administered; and the good effects were so decided, that I determined to investigate the subject more methodically, and to keep a careful record of each case. The good results observed in this preliminary inquiry were a return of the power of taking oil and fatty food, which had been previously distasteful or had even excited sickness; increased appetite, improved general nutrition and increase of weight, diminution of cough and expectoration, and cessation of night sweats. The general impression produced on my mind was so favorable that I began my more exact inquiries with much confidence. In my first cases, the ether had been given in water with hydrocyanic acid and bicarbonate of potash, twenty minim doses of ether to each ounce of the mixture. The ether was afterwards added to cod-liver oil, the æther purus of the Pharmacopoeia being used, and about ten minims (9-259 m.) added to every two drachms of oil at first, afterwards fifteen and twenty minims were occasionally given in the same quantity of oil. In some cases the ether was administered in water alone, and taken a short time before the oil. The effects were similar in all cases; but for convenience sake, and on account of its power of masking the unpleasant properties of the oil, I now, generally, give ether. mixed with cod-liver oil, in the proportions mentioned. In my second and systematic inquiry, I treated fifty cases taken as they presented themselves at the dispensary, each patient being carefully examined on admission and at least once every fifteen days during treatment. A brief record was kept of the progress of each case; but from former experience, I determined in this inquiry not to accept the statement of the patients themselves as evidence of improvement, but only to consider those patients better in whom the result of a physical exploration of the chest, in addition to decided increase in weight, confirmed the statements made. I therefore weighed every patient once a week. As it would be impossible to give a record of each case in a communication such as the present, I must confine myself to a brief stateent of the results obtained in the fifty cases.

Sixteen were admitted in the first stage of the disease; nineteen in the second stage; and fifteen in the third.

Of the sixteen in the first stage (or stage of deposition) seven improved in general symptoms and in physical signs, gaining on an average over 74 lbs. each; five remained stationary, all gaining weight slightly; and only four became worse.

Of the nineteen cases in the second stage, six improved in all respects, gaining on an average about 8 lbs. each, two cases gaining 144 lbs. and 10 lbs. respectively; six remained stationary; and seven became worse.

Of the fifteen cases in the third stage, seven improved, gaining on an average, about 5 lbs. each; five remained stationary; and three became

worse.

Of the total fifty cases, twenty improved, sixteen remained stationary, and fourteen became worse.

Six of the cases treated, in no instance for a less time than three months, and observed over a neriod of many months, retained their weight; were

troubled by no symptoms, and maintained the improvement in their physical signs. Only one of these were observed over a less period than fifteen months, three over two years, and two over eighteen months. These cases may be considered, I think, as examples of the arrest of the disease, for the patients have returned to their ordinary avocations, and are able to earn their liveli hood untroubled by their former disease. The only other remedies used in those cases were croton ointment, as a counter irritant, Dover's powder occasionally to relieve the cough, and in a few cases, a little linctus morphiæ. But as cod-liver oil was administered, as well as ether, the objection may very naturally be made that improvement was due to the use of the oil. For my own part this objection has not much value, for I had long used oil largely without obtaining any results at all equal to those stated. In order, however, to meet this objection the ether was stopped in ten instances, and the oil continued; six times there was a fall in weight during the following three weeks. In one case the patient, who had taken ether for some two months, continued to gain weight. In the three other cases the gain ceased, but was again observed in these patients, as it was in all, when ether was again administered.

In

These results are not only instructive, as showing the effect of ether in increasing weight, but also as showing that the digestion of fatty food is restored to its normal state, in many cases, after a long course of ether. the cases which have done best under treatment, that is, the cases which I think we may consider instances of arrested phthisis, the power of taking fats, which was at one time much impaired, has returned, and the gain in weight has been maintained over a period of many months, I may here also add that, in all the fifty cases there had been marked wasting before my treatment was adopted, in at least half the cases, cod-liver oil notwithstanding. Many of my patients have over and over again expressed their preference for the etherised oil; and many who have been unable to retain ordinary oil when taken, have been able to use etherised oil, not only without disagreeable symptoms, but almost with pleasure; "to drink it from the bottle," as some have expressed it.-British Medical Journal, Nov. 21 and 28, 1868, pp. 543, 570.

33.-RAWNESS OF THE TONGUE AND PAINFUL DEGLUTITION IN ADVANCED PHTHISIS.

By Dr. DOUGLAS POWELL, Physician to the Hospital for Consumption, Brompton. [The following is a note of the treatment which Dr. Powell employs with success in the above distressing complication.]

The combination of remedies most beneficial in these cases, which must be familiar to all and require no illustration, consists of chlorate of potash and glycerine in some syrup containing morphia. The proportions Dr. Powell commonly uses are-chlorate of potash, forty to sixty grains; glycerine, half an ounce; syrup to four ounces, with morphia, one grain and a half to two grains. A teaspoonful swallowed slowly acts locally on the parts affected, relieving at the same time the cough. Of course, in the latest stage of the disease this will but render the remaining hours of life more comfortable, or prolong life a little; but there are some cases where the disease of the lungs is considerable, though not incompatible with life, and the patient having been reduced very low by diarrhoea, vomiting, &c., this condition of tongue and throat will come on, and, rendering the taking of nutrients or stimulants almost impossible, the patient therefore dies from exhaustion. Indeed, the aphthous condition which follows this is usually considered a fatal sign in chronic disease; but it is not necessarily so. In these cases the above remedy relieves pain, cleanses the tongue, and enables the patient to take nourishment and remedies which greatly prolong life.-Lancet, Dec. 19, 1865, p. 799.

34.-ON THE TREATMENT OF ASTHMA BY BELLADONNA.

By Dr. HYDE SALTER, F. R. S., Senior Physician to Charing Cross Hospital.

[Dr. Salter in the introductory part of this paper states that he has during the last two years used belladonna extensively in the treatment of asthma, and with very satisfactory results.]

If I were to express what appears to me to be the peculiar excellence of belladonna as a sedative in asthma, I should say it consisted in its power of diminishing reflex irritability--a power which it appears to me to possess in a degree greater, in proportion to its other sedative effects, than any other sedative.

My method of giving it will be best seen in the following cases. I do not know that the tincture has any advantage over other preparations, only it happens to be that which I have tried. I should think that the liquor atropiæ might, from its uniformity of strength, be even preferable.

Case 1.-R. G., a lady aged 25, who has been liable to hay fever for eleven years, and to astlima for seven, came to me on May 18th, 1868, for the cure of her hay asthma. She had been suffering for nearly a month, and had not had a single night's rest, She was not troubled with her asthma by day, but only with her hay fever symptoms. As soon, however, as she went to bed on came her asthma; and lasted regularly all night. She was worn out for want of rest, and felt fagged and miserable. I ordered her ten minims of the tincture of belladonna three times a day, telling her to increase the quantity, day by day, till the characteristic effects of the drug were produced. She gradually raised the dose from ten minims to twenty. She felt better the first night af ter taking it. She took it for nine days, and had no asthma whatever. She then, thinking herself cured, and feeling her head very uncomfortable, omitted it for one day, and the following night got no sleep from asthma. She then resumed it, and has had no asthma since. She now regularly takes twenty drops three times a day. Her head is slightly affected, and her eyes decidedly so-misty, and she cannot read; but there is not a trace of asthma. has never found anything else prevent the attacks. The belladonna seems to have no influence whatever over the other hay-fever symptoms; the sneezing, running at the eyes, &c., go on as before.

She

Case 2.-Sarah P., aged 46, has had asthma ever since she was nineteen years of age-that is, for twenty-seven years. For the last five months she has been worse than ever, and for some time past has had asthma regularly every night. It begins between two and three o'clock, and after that she gets no rest. I ordered her to take the tincture of belladonna every night on going to bed--to begin at ten minims, and gradually to increase the dose till her head and sight became affected. She came to me on the 29th of last July. On the 14th of August I find the following entry in my note-book:

This patient came to me a fortnight ago yesterday. She has almost completely lost her symptoms ever since, having had uninterrupted good nights. She has gradually reached thirty drops of the tincture of belladonna, and now takes it every night. She looks wonderfully better, and is able to take long walks." From that time I have not heard anything of her.

Case 3.-Col. R., aged 40, has had asthma for sixteen years. For the last few years it has been gradually getting worse, and now he has it almost every night commencing at from one to two o'clock a.m. He has tried various things without any success-Indian hemp, chlorodyne, ether, the inhalation of chloroform, dry cupping, coffee, iodide of potassium, abstinence, &c. I saw him on September 16th, and ordered him to try the belladonna at night in the usual way. On the 23rd I find the following note:-" He has gradually got the belladonna up to forty minims without any appreciable inconvenience. The nights have been very good. The two last mornings there has been no oppression whatever, nor any sitting up in bed; he has slept right through the night. He walked this morning, directly after breakfast, from his house at Blackheath to the station-a mile-in sixteen minutes, and

« ForrigeFortsæt »