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THE

AMERICAN MEDICAL INTELLIGENCER.

Vol. II.

October 1, 1838.

No. 13.

ART. I.-EMPLOYMENT OF TENTS IN THE TREATMENT OF

CONSTIPATION.

BY M. LOUIS FLEURY, INTERNE OF THE HÔPITAL ST. LOUIS.1

The author of this article, after enumerating the different states of the system which may give rise to constipation, and after showing that in order to accomplish its removal those different conditions must be modified, observes, "That very frequently constipation itself constitutes the whole disease unconnected with any organic alteration, or appreciable lesion of functions, and for a long time is the only symptom which evinces that the equilibrium constituting health no longer exists; when other disorders make their appearance they are under its dependence, and disappear along with it. Its cause is entirely local, and does not extend beyond the rectum; it arises from atony of that intestine, the muscular fibres of which have lost the irritability and power of contractility necessary for them to overcome the resistance which the sphincters offer to the expulsion of the fæces."

Observation of many patients on whom the means generally employed in the treatment of this disease had not succeeded, prompted him to have recourse to a new mode of management.

M. Fleury has seen many patients, who, for a length of time, have been most actively treated for gastro-enteritis, diseases of the liver, &c., and who have been debilitated and tormented by diet, local and general bleeding, blisters, &c., without benefit. When the primary and only cause of the disease is recognised, the treatment made use of is attended with scarcely more efficacy; emollient lavements are the first means had recourse to, which afford, in fact, but slight relief; unfortunately they soon lose their effects, and are used by the patients sometimes three or four times in the twenty-four hours; purgative lavements are then substituted, which in as short a period become equally insufficient for producing evacuations; cathartics are. then employed, with the same results. Immediately on their being suspended constipation' recurs; their administration is daily repeated, the dose unceasingly augmented, and at length replaced by drastics. But the stomach often becomes inflamed, fever is occasioned, the treatment is obliged to be arrested, and constipation, along with difficulty of digestion, becomes more confirmed than ever.

Some physicians, feeling the necessity of acting immediately on the rectum, so as to put a stop to constipation, have, from its effects, extolled aloes, to which is attributed a specific and primary action on that intestine.

Aware of the inefficacy of all these plans, M. Fleury's attention was directed to the possibility of discovering more rational remedies; on reflection he thought that tents introduced into the rectum might perhaps fulfil this object; by acting as a foreign body, it appeared to him they would stimulate the intestine and arouse its contractility; he likewise observed

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that they frequently induced evacuations when introduced after the operation of fistula, and for stricture, or some other surgical affection. This means was tried in a patient whose disease had become very serious, and the history of which is related in the first of the following cases; it succeeded beyond M. Fleury's expectations.

On the 20th January, 1837, the Count de B, aged 29, officer of lancers in the service of the King of Holland, entered the Maison Royale de Santé, to undergo treatment for an affection, the history of which he related himself:

"Until the age of 26 I always enjoyed perfect health, uninterrupted by any kind of disease. My stomach, in particular, was so strong and active, that I frequently abused with impunity those qualities, by committing excess at table, and especially by drinking, as is the habit unfortunately of my country, and particularly amongst the military, rather large quantities of spirituous liquors. This mode of living until then was unattended with any unpleasant consequences; but at that period I observed some difficulty in my evacuations. I remained two or three days without going to stool, and, at the expiration of this period, I expelled with great pain only hard scanty fæces. This constipation occurred at the very time I led the most regular life; if on the contrary I committed excess, my bowels again became free. The discovery of such an easy means of relief perhaps made me abuse it; but it soon served only to fatigue my stomach, and I had recourse to the use of the pipe, having observed that it wonderfully facilitated my evacuations. Unfortunately this new mode soon lost its efficacy. I was obliged, in order to obtain a stool, to smoke several pipes in succession, to employ tobacco of increased strength, and even Manilla cigars, which ultimately were themselves unattended with any result.

Weary of this state I consulted a physician, who entirely changed my mode of life, and forbade me to use meat and strong drinks, even wine. I ate nothing but leguminous vegetables, and milk diet, and used a lavement daily. This regimen produced no amelioration; after a time I was obliged to employ three or four lavements daily; my digestion became more and more difficult; I was continually tormented with flatulence, which occasioned great distension; my respiration was short, and red spots appeared on my face. I became much emaciated; melancholy; every thing soured me; sometimes I had paroxysms of gaiety of a ridiculous kind, succeeded by great sadness. My military service had become extremely distressing to me; I could ride on horseback no longer; my strength failed me. I consulted another physician, who pursued a different plan: he ordered me cold meats, some glasses of wine, and black coffee. This nourishment imparted a little strength to me, but did not modify my constipation. I made use of purgative pills, the composition of which I am ignorant of, and which relieved me only for a few weeks.

I was now perfectly disheartened, and on the point of resigning my commission. Society became insupportable, and life such a burden that I resolved to put an end to it violently, when I was advised to procure leave of absence and to undergo treatment at Paris. Lexperienced the hope that I might succed in this trial; it shall be my last."

M. de B― was carefully examined by M. Fleury, who could not discover any affection of the stomach and intestinal canal. The tongue was pale, the abdomen every where insensible to pressure; the pulse, normal; no swelling was felt in any region. The patient was, however, emaciated and very weak; he had violent headaches; the cheeks were of a vivid red; the eyelids swollen; conjunctiva injected; digestion, although the patient ate very little, was laborious, accompanied by flatulence, eructations, distension, &c.; no evacuations occurred, except after several successive lave

ments.

At the end of three weeks he left the Maison de Santé, without receiving any benefit, and was attended by M. Fleury in private.

Eight days after, the idea of having recourse to tents recurred to M. Fleury, who proposed it to his patient; he consented, and at eight in the evening of the 9th of February a tent of the mean size was introduced, smeared with simple cerate, into the rectum. On the 10th the tent had given rise to rather vivid pains, and the patient was not able to retain it longer than two hours; it did not occasion an evacuation. I replaced a second tent, thinner than the first, covered with an ointment containing one dram of the extract of belladonna to an ounce of cerate. This second tent was retained until 4 o'clock in the morning; but the patient was obliged, in order to evacuate, to have recourse, according to custom, to several lavements. On the 13th, the third tent did not occasion any more pain; it was retained till the morning, and the patient on its withdrawal experienced a wish to go to stool. A small quantity of hard fæces was expelled. On the 23d, the size of the tents was gradually increased, and these occasioned an abundant and easy evacuation regularly every day. M. de B has given up the use of lavements and purgatives entirely; has appetite, and is put upon another regimen, and digests perfectly; his hemicrania haye disappeared; and his gaiety and strength recurred.

On the 1st of March, the tents were introduced for not more than a period of two or three hours; the stools continued to be regular. 5th. The tents are suppressed. M. de B- enjoys good health, and wishes, in order to insure the durability of the cure, to remain in Paris until the end of the month. At that period he set out for Holland, and the following is a passage from a letter addressed by him to M. Fleury

"I performed the voyage from Paris to Breda without any stoppage, and without experiencing the least constipation. I have not been particular as to regimen, meat, wine-nothing incommodes me. I have resumed my service, and our long manœuvres have not altered my condition; my friends were unable to recognise me.'

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The other two cases detailed by M. Fleury were similar to this, and met with like success from the treatment employed.

ART. II.-PHILADELPHIA HOSPITAL (BLOCKLEY).

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1.-Cirrhosis, General Anasarca, and Ascites. Reported by EDWIN A. ANDERSON, M. D., of Wilmington, N. C., Senior Resident Physician.

Ann Maria Hamburger, aged 65 years, admitted July 31st, 1838, was born in New Jersey; married; works in the open air at gardening. Has been subject to palpitations of the heart for the last three years; and severe attacks of dyspnoea, continuing for ten or fifteen minutes. Cough, attended with expectoration in the morning, and profuse sweating at night, for a long period. Appetite bad. Habits very intemperate. A month previous to her entrance into the hospital, had an attack of pleurisy of the left side, for which she was bled and purged. An attack of icterus supervened upon the pleuritis, followed by extensive infiltration of the upper and lower extremities, and effusion into the thoracic and abdominal cavities. The effusion into the thorax was so extensive, according to the voluntary account of the patient, that upon suddenly moving or rising she was sensible of a body of water rushing from one part of her chest to the other, the sound created by this movement being quite perceptible to her ear, and constituting the succussus of the old writers.

August 1st.-Came into the hospital labouring under excessive dyspnoea, obliging her to assume a semi-recumbent posture; lips pallid; skin of a deep yellow hue; conjunctiva of the same colour as the skin. She is of a

stout robust frame. Extensive infiltration of the upper and lower extremities; abdomen distended, presenting a very evident fluctuation; lower portion of both pleuræ dull on percussion; slight tremors of the hands when extended; tongue quivering; mind wandering, confused, symptoms of incipient mania à potu; pulse 90, full, hard, resisting to the finger; urine scanty and high-coloured.

Prescription.-R. Baccar. juniperi, Zi.; aqua bullienta, Oi.; fiat potus

indies bibendus.

R. Pulv. digitalis (American.), pulv. scillæ, aa gr. i.; hydrarg. submuriat. gr. ss.; fiat pulvis ter die sumendus.

August 2d. Secretion of urine increased; oedema of extremities very much diminished; abdomen tense; lower portion of thorax more resonant on percussion; pulse 100, of good volume and strength; respiration easy, but 40 in a minute.

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Continuentur medicamina.

August 3d. In the night, arose from her bed and walked out of the ward, delirious, calling upon and addressing absent individuals as if present and conversing with her. Now, constant tremors of hands, quivering of tongue when protruded; pulse 88, full, bounding; refuses to remain in bed; imagines her life is threatened; exhibits, in a word, all the symptoms of genuine mania à potu. She was accordingly transferred to the Women's Lunatic Asylum, to be treated for that disease also. The symptoms there became very much aggravated, and on the morning of the 6th she died.

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Necroscopy, July 6th, eight hours after death.-Exterior very edematous ; abdomen yielding a very evident fluctuation. Upon opening the abdomen and thorax, the cells of the cellular membrane were found greatly distended with serum.

Thorax.-Lungs healthy, crepitating, containing air; left lung slightly engorged with serum. Heart natural.

Abdomen.-Liver enlarged, weighing about ten pounds; granulated; surface raised into a number of round mammellated protuberances, of a tawny colour, closely resembling beeswax, none of them larger than a pin's head; substance of these granulations compact; when divided presenting a smooth, flat, even surface. Consistence of liver very firm, admits the finger with great difficulty, semi-cartilaginous, evidently greasing the scalpel when cut into; the whole organ presenting an excellent specimen of cirrhosis, combined with hypertrophy, not with diminution in bulk as defined by Laennec.

The gall bladder contained a dark-coloured bile. The stomach presented, along its greater curvature, a highly injected state of vessels; the mucous membrane was easily detached, beyond which the injected state of the vessels ceased.

The small intestines contained a small quantity of thin yellowish fæces. The mucous membrane was of a light rosy tint throughout the greater part of its course, and free from ulceration.

The large intestines were healthy.

The spleen and kidneys presented no unusual appearance.

E. A. ANDERSON.

2.-Case of Phthisis, Pulmonalis. Reported by A. M. VEDDER, A. M., of Schenectady, N. Y., Senior Resident Physician.

1

In No. 10, pages 154 and 155 of the "Intelligencer," will be found an epitome of a case of phthisis pulmonalis, No. 1. Since that note was taken the patient has died,

Note of August 11th.-Emaciation advancing; decubitus still upon the right side, any other excites coughing; appetite bad; hectic continues; no diarrhoea. The physical signs correspond almost exactly with those described in page 155 of this journal. Strength much diminished; intelligence clear; hemorrhage from the lungs commenced this morning.

August 13th. Since last hote the hæmoptysis continued, amounting during the last twenty-four hours of life to thirty-six ounces. Died August 12th.

Necroscopy, August 13th, twelve hours after death.-Exterior: emaciation advanced; no infiltration of lower extremities. Thorax left lung adherent throughout, and with the greatest difficulty removed; in removing it a large cavity was opened, which discharged about a pint of dark fluid blood. The pleura pulmonalis anteriorly was three eighths of an inch in thickness, hard and almost cartilaginous; on cutting into it the scalpel passed immediately into a large anfractuous cavity, occupying the whole of the superior, and about one half of the lower lobe; numerous firm bands traversed it in all directions (obliterated blood-vessels); two or three were of a light red colour, and, as it were, dissected out; they were still permeable; a probe could be passed into them. An imperfect, almost cartilaginous, septum existed, which could with difficulty be cut with the scissors, constituted apparently by the pleura, which dipped between the lobes. Numerous small cavities communicated with the large cavern, which varied in size from an almond to that of a pullet's egg. The large, and nearly all the small cavities, were lined by an old and polished membrane. Numerous bronchial tubes terminated abruptly in the cavity, which appeared as if cut off; these varied in size from that of a pipe-stem to double the size; one of them was about half an inch in diameter. On the anterior surface of the lung was an opening, which communicated with the cavity. It was known to be an old one by the characters of its border, which were smooth, rounded, firm and shining. The lung was here so firmly bound down that it must have prevented the passage of air into the cavity of the pleura. Only one mass of tubercles was met with in the lung, of about the size of an egg. A small portion of the base of the lung still preserved its vesicular structure; crepitated, and was engorged with blood. This was the only portion of the whole lung in which the vesicular structure was not destroyed. Indeed, except in this portion, it was one mass of dense cellular tissue. The healthy portion could be supplied with air only through the cavity, for no continuous bronchial tube led to it.

The right lung was slightly adherent; large, and some of the vesicles of the upper lobe were enlarged. It was distended with air, and contained very little fluid. A few scattering nuclei of tubercles were met with. In the posterior part of the upper lobe there was a small cavity lined with a smooth membrane.

No cavity was seen in the lower lobe, which was gorged with blood, and contained air.

The bronchial glands were tuberculous.

The pericardium contained about two ounces of serum. The heart was about the average size; both ventricles were collapsed, flaccid, and rather pale; no coagula in the heart.

The ventricles were rather thinner than usual; the left was four tenths of an inch in thickness. The valves of the aorta and pulmonary artery were soft and flexible.

The mitral and tricuspid were normal.

Other organs were not examined.

A. M. VEDDER.

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