With great diffidence I venture to lay before the public my opinions upon worms: nor should I have presumed to do it, had I not entertained a hope of thereby exciting further inquiries upon this subject.
When we consider how universally worms are found in all young animals, and how frequently they exist in the human body, without producing disease of any kind, it is natural to conclude, that they serve some useful and necessary purposes in the animal economy. Do they consume the superfluous aliment which all young animals are disposed to take, before they have been taught, by experience or reason, the bad consequences which arise from it? It is no objection to this opinion, that worms are unknown in the human body insome countries. The laws of nature are diversified, and often suspended under peculiar circumstances in many cases, where the departure from uniformity is still more unaccountable, than in the present instance. Do worms produce diseases from anexcessin theirnumber, and anerrorin their place, in the same manner that blood, bile, and air produce diseases from anerrorin their place, or fromexcessin theirquantities? Before these questions are decided, I shall mention a few facts which have been the result of my own observations upon this subject.
1. In many instances, I have seen worms discharged in the small-pox and measles, from children who were in perfect health previously to their being attacked by those diseases, and who never before discovered a single symptom of worms. I shall say nothing here of the swarms of worms which are discharged in fevers of all kinds, until I attempt to prove that an idiopathic fever is never produced by worms.
2. Nine out of ten of the cases which I have seen of worms, have been in children of the grossest habits and most vigorous constitutions. This is more especially the case where the worms are dislodged by the small-pox and measles. DoctorCapelle of Wilmington, in a letter which I received from him, informed me, that in the livers of sixteen, out of eighteen rats which he dissected, he found a number of the tænia worms. The rats were fat, and appeared in other respects to have been in perfect health. The two rats in which he found no worms, he says, “were very lean, and their livers smaller in proportion than the others.”
3. In weakly children, I have often known the most powerful anthelmintics given without bringing away a single worm. If these medicines have afforded any relief, it has been by their tonic quality. From this fact, is it not probable—the conjecture, I am afraid, is too bold, but I will risk it:—is it not probable, I say, that children are sometimes disordered from the want of worms? Perhaps the tonic medicines which have been mentioned, render the bowels a more quiet and comfortable asylum for them, and thereby provide the system with the means of obviating the effects of crapulas, to which all children are disposed. It is in this way that nature, in many instances, cures evil by evil. I confine the salutary office of worms only to that species of them which is known by the name of the round worm, and which occurs most frequently in children.
Is there any such disease as an idiopathicWORM-FEVER? The Indians in this country say there is not, and ascribe the discharge of worms to a fever, and not a fever to the worms[40].
By adopting this opinion, I am aware that I contradict the observations of many eminent and respectable physicians.
Doctor Huxham describes an epidemic pleurisy, in the month of March, in the year 1740, which he supposes was produced by his patients feeding upon some corn that had been injured by the rain the August before[41]. He likewise mentions that a number of people, and those too of the elderly sort[42], were afflicted at one time with worms, in the month of April, in the year 1743.
Lieutade gives an account of an epidemic worm-fever from Velchius, an Italian physician[43]; and Sauvages describes, from Vandermonde, an epidemic dysentery from worms, which yielded finally only to worm medicines[44]. Sir John Pringle, andDoctor Monro, likewise frequently mention worms as accompanying the dysentery and remitting fever, and recommend the use of calomel as an antidote to them.
I grant that worms appear more frequently in some epidemic diseases than in others, and oftener in some years than in others. But may not the same heat, moisture, and diet which produced the diseases, have produced the worms? And may not their discharge from the bowels have been occasioned in those epidemics, as in the small-pox and measles, by the increased heat of the body, by the want of nourishment, or by an anthelmintic quality being accidentally combined with some of the medicines that are usually given in fevers?
In answer to this, we are told that we often see the crisis of a fever brought on by the discharge of worms from the bowels by means of a purge, or by an anthelmintic medicine. Whenever this is the case, I believe it is occasioned by offending bile being dislodged by means of the purge, at the same time with the worms, or by the anthelmintic medicine (if not a purge) having been given on, or near one of the usual critical days of the fever. What makes the latter supposition probable is, that worms are seldom suspected in the beginningof fevers, and anthelmintic medicines seldom given, till every other remedy has failed of success; and this generally happens about the usual time in which fevers terminate in life or death.
It is very remarkable, that since the discovery and description of the hydrocephalus internus, we hear and read much less than formerly of worm-fevers. I suspect that disease of the brain has laid the foundation for the principal part of the cases of worm-fevers which are upon record in books of medicine. I grant that worms sometimes increase the danger from fevers, and often confound the diagnosis and prognosis of them, by a number of new and anomalous symptoms. But here we see nothing more than that complication of symptoms which often occurs in diseases of a very different and opposite nature.
Having rejected worms as the cause of fevers, I proceed to remark, that the diseases most commonly produced by them, belong to Dr. Cullen's class ofNEUROSES. And here I might add, that there is scarcely a disease, or a symptom of a disease, belonging to this class, which is not produced by worms. It would be only publishing extracts from books, to describe them.
Thechronicandnervousdiseases of children, which are so numerous and frequently fatal, are, I believe, frequently occasioned by worms. There is no great danger, therefore, of doing mischief, by prescribing anthelmintic medicines in all our first attempts to cure their chronic and nervous diseases.
I have been much gratified by finding myself supported in the above theory of worm-fevers, by the late Dr. William Hunter, and by Dr. Butter, in his excellent treatise upon the infantile remitting fever.
I have taken great pains to find out, whether the presence of the different species of worms might not be discovered by certain peculiar symptoms; but all to no purpose. I once attended a girl of twelve years of age in a fever, who discharged four yards of a tænia, and who was so far from having discovered any peculiar symptom of this species of worms, that she had never complained of any other indisposition, than now and then a slight pain in the stomach, which often occurs in young girls from a sedentary life, or from errors in their diet. I beg leave to add further, that there is not a symptom which has been said to indicate the presence of worms of any kind, as the cause of a disease, that has not deceived me; and none oftenerthan the one that has been so much depended upon, viz. the picking of the nose. A discharge of worms from the bowels, is, perhaps, the only symptom that is pathognomonic of their presence in the intestines.
I shall now make a few remarks upon anthelmintic remedies.
But I shall first give an account of some experiments which I made in the year 1771, upon the common earth-worm, in order to ascertain the anthelmintic virtues of a variety of substances. I made choice of the earth-worm for this purpose, as it is, according to naturalists, nearly the same in its structure, manner of subsistence, and mode of propagating its species, with the round worm of the human body.
In the first column I shall set down, under distinct heads, the substances in which worms were placed; and in the second and third columns thetimeof their death, from the action of these substances upon them.
In the application of these experiments to the human body, an allowance must always be made for the alteration which the several anthelmintic substances that have been mentioned, may undergo from mixture and diffusion in the stomach and bowels.
In order to derive any benefit from these experiments,as well as from the observations that have been made upon anthelmintic medicines, it will be necessary to divide them into such as act,
1. Mechanically,
2. Chemically upon worms; and,
3. Into those which possess a power composed of chemical and mechanical qualities.
1. The mechanical medicines act indirectly and directly upon the worms.
Those which actindirectlyare, vomits, purges, bitter and astringent substances, particularly aloes, rhubarb, bark, bear's-foot, and worm-seed. Sweet oil acts indirectly and very feebly upon worms. It was introduced into medicine from its efficacy in destroying the botts in horses; but the worms which infest the human bowels, are of a different nature, and possess very different organs of life from those which are found in the stomach of a horse.
Those mechanical medicines which actdirectlyupon the worms, are cowhage[45]and powder of tin.The last of these medicines has been supposed to act chemically upon the worms, from the arsenic which adheres to it; but from the length of time a worm lived in a solution of white arsenic, it is probable the tin acts altogether mechanically upon them.
2. The medicines which act chemically upon worms, appear, from our experiments, to be very numerous.
Nature has wisely guarded children against the morbid effects of worms, by implanting in them an early appetite for common salt, ripe fruits, and saccharine substances; all of which appear to be among the most speedy and effectual poisons for worms.
Let it not be said, that nature here counteracts her own purposes. Her conduct in this business is conformable to many of her operations in the human body, as well as throughout all her works. The bile is a necessary part of the animal fluids, and yet an appetite for ripe fruits seems to be implanted chiefly to obviate the consequences of its excess, or acrimony, in the summer and autumnal months.
The use of common salt as an anthelmintic medicine, is both ancient and universal. Celsus recommends it. In Ireland it is a common practice to feed children, who are afflicted by worms, for a week or two upon a salt-sea weed, and when the bowels are well charged with it, to give a purge of wort in order to carry off the worms, after they are debilitated by the salt diet.
I have administered many pounds of common salt coloured with cochineal, in doses of half a drachm, upon an empty stomach in the morning, with great success in destroying worms.
Ever since I observed the effects of sugar and other sweet substances upon worms, I have recommended the liberal use of all of them in the diet of children, with the happiest effects. The sweet substances probably act in preventing the diseases from worms in the stomach only, into which they often insinuate themselves, especially in the morning. When we wish to dislodge worms from the bowels by sugar or molasses, we must give these substances in large quantities, so that they may escape in part the action of the stomach upon them.
I can say nothing from my own experience of the efficacy of the mineral salts, composed of copper,iron, and zinc, combined with vitriolic acid, in destroying worms in the bowels. Nor have I ever used the corrosive sublimate in small doses as an anthelmintic.
I have heard of well-attested cases of the efficacy of the oil of turpentine in destroying worms.
The expressed juices of onions and of garlic are very common remedies for worms. From one of the experiments, it appears that the onion juice possesses strong anthelmintic virtues.
I have often prescribed a tea-spoonful of gunpowder in the morning upon an empty stomach, with obvious advantage. The active medicine here is probably the nitre.
I have found a syrup made of the bark of the Jamaica cabbage-tree[46], to be a powerful as well as a most agreeable anthelmintic medicine. It sometimes purges and vomits, but its good effects may be obtained without giving it in such doses as to produce these evacuations.
There is not a morecertainanthelmintic than Carolina pink-root[47]. But as there have been instances of death having followed excessive doses of it, imprudently administered, and as children are often affected by giddiness, stupor, and a redness and pain in the eyes after taking it, I acknowledge that I have generally preferred to it, less certain, but more safe medicines for destroying worms.
3. Of the medicines whose action is compounded of mechanical and chemical qualities, calomel, jalap, and the powder of steel, are the principal.
Calomel, in order to be effectual, must be given in large doses. It is a safe and powerful anthelmintic. Combined with jalap, it often brings away worms when given for other purposes.
Of all the medicines that I have administered, I know of none more safe and certain than the simple preparations of iron, whether they be given in the form of steel-filings or of the rust of iron. If ever they fail of success, it is because they are given in too small doses. I generally prescribe from five to thirty grains every morning, to children between one year, and ten years old; and Ihave been taught by an old sea-captain, who was cured of a tænia by this medicine, to give from two drachms to half an ounce of it, every morning, for three or four days, not only with safety, but with success.
I shall conclude this essay with the following remarks:
1. Where the action of medicines upon worms in the bowels does not agree exactly with their action upon the earth-worms in the experiments that have been related, it must be ascribed to the medicines being more or less altered by the action of the stomach upon them. I conceive that the superior anthelmintic qualities of pink-root, steel-filings, and calomel (all of which acted but slowly upon the earth-worms compared with many other substances) are in a great degree occasioned by their escaping the digestive powers unchanged, and acting in a concentrated state upon the worms.
2. In fevers attended with anomalous symptoms, which are supposed to arise from worms, I have constantly refused to yield to the solicitations of my patients, to abandon the indications of cure in the fever, and to pursue worms as theprincipalcause of the disease. While I have adhered steadilyto the usual remedies for the different states of fever, in all their stages, I have at the same time blended those remedies occasionally with anthelmintic medicines. In this I have imitated the practice of physicians in many other diseases, in which troublesome and dangerous symptoms are pursued, without seducing the attention from the original disease. The anthelmintic medicines prescribed in these cases, should not be the rust of iron, and common salt, which are so very useful in chronic diseases from worms, but calomel and jalap, and such other medicines as aid in the cure of fevers.
Footnotes:[40]See the Inquiry into the Diseases of the Indians, p. 19.[41]Vol. II. of his Epidemics, p. 56.[42]P.136.[43]Vol. I. p.76.[44]Vol. II. p.329.[45]Dolichos Pruriens, of Linnæus.[46]Geoffrea, of Linnæus.[47]Spigelia Marylandica, of Linnæus.
Footnotes:
[40]See the Inquiry into the Diseases of the Indians, p. 19.
[40]See the Inquiry into the Diseases of the Indians, p. 19.
[41]Vol. II. of his Epidemics, p. 56.
[41]Vol. II. of his Epidemics, p. 56.
[42]P.136.
[42]P.136.
[43]Vol. I. p.76.
[43]Vol. I. p.76.
[44]Vol. II. p.329.
[44]Vol. II. p.329.
[45]Dolichos Pruriens, of Linnæus.
[45]Dolichos Pruriens, of Linnæus.
[46]Geoffrea, of Linnæus.
[46]Geoffrea, of Linnæus.
[47]Spigelia Marylandica, of Linnæus.
[47]Spigelia Marylandica, of Linnæus.
A few years ago, a certain Doctor Hugh Martin, a surgeon of one of the Pennsylvania regiments stationed at Pittsburg, during the latter part of the late war, came to this city, and advertised to cure cancers with a medicine which he said he had discovered in the woods, in the neighbourhood of the garrison. As Dr. Martin had once been my pupil, I took the liberty of waiting upon him, and asked him some questions respecting his discovery. His answers were calculated to make me believe, that his medicine was of a vegetable nature, and that it was originally an Indian remedy. He showed me some of the medicine, which appeared to be the powder of a well-dried root of some kind. Anxious to see the success of this medicine in cancerous sores, I prevailed upon the doctor to admit me to see him apply it in two orthree cases. I observed, in some instances, he applied a powder to the parts affected, and in others only touched them with a feather dipped in a liquid which had a white sediment, and which he made me believe was the vegetable root diffused in water. It gave me great pleasure to witness the efficacy of the doctor's applications. In several cancerous ulcers, the cures he performed were complete. Where the cancers were much connected with the lymphatic system, or accompanied with a scrophulous habit of body, his medicine always failed, and, in some instances, did evident mischief.
Anxious to discover a medicine that promised relief in even a few cases of cancers, and supposing that all the caustic vegetables were nearly alike, I applied the phytolacca or poke-root, the stramonium, the arum, and one or two others, to foul ulcers, in hopes of seeing the same effects from them which I had seen from Doctor Martin's powder; but in these I was disappointed. They gave some pain, but performed no cures. At length I was furnished by a gentleman from Pittsburg with a powder which I had no doubt, from a variety of circumstances, was of the same kind as that used by Dr. Martin. I applied it to a fungous ulcer, but without producing the degreesof pain, inflammation, or discharge, which I had been accustomed to see from the application of Dr. Martin's powder. After this, I should have suspected that the powder was not asimpleroot, had not the doctor continued upon all occasions to assure me, that it was wholly a vegetable preparation.
In the beginning of the year 1784, the doctor died, and it was generally believed that his medicine had died with him. A few weeks after his death I procured, from one of his administrators, a few ounces of the doctor's powder, partly with a view of applying it to a cancerous sore which then offered, and partly with a view of examining it more minutely than I had been able to do during the doctor's life. Upon throwing the powder, which was of a brown colour, upon a piece of white paper, I perceived distinctly a number of white particles scattered through it. I suspected at first that they were corrosive sublimate, but the usual tests of that metallic salt soon convinced me, that I was mistaken. Recollecting that arsenic was the basis of most of the celebrated cancer powders that have been used in the world, I had recourse to the tests for detecting it. Upon sprinkling a small quantity of the powder upon some coals of fire, it emitted the garlick smell so perceptiblyas to be known by several persons whom I called into the room where I made the experiment, and who knew nothing of the object of my inquiries. After this, with some difficulty I picked out about three or four grains of the white powder, and bound them between two pieces of copper, which I threw into the fire. After the copper pieces became red hot, I took them out of the fire, and when they had cooled, discovered an evident whiteness imparted to both of them. One of the pieces afterwards looked like dull silver. These two tests have generally been thought sufficient to distinguish the presence of arsenic in any bodies; but I made use of a third, which has lately been communicated to the world by Mr. Bergman, and which is supposed to be in all cases infallible.
I infused a small quantity of the powder in a solution of a vegetable alkali in water for a few hours, and then poured it upon a solution of blue vitriol in water. The colour of the vitriol was immediately changed to a beautiful green, and afterwards precipitated.
I shall close this paper with a few remarks upon this powder, and upon the cure of cancers and foul ulcers of all kinds.
1. The use of caustics in cancers and foul ulcers is very ancient, and universal. But I believearsenicto be the most efficacious of any that has ever been used. It is the basis of Plunket's and probably of Guy's well-known cancer powders. The great art of applying it successfully, is to dilute and mix it in such a manner as to mitigate the violence of its action. Doctor Martin's composition was happily calculated for this purpose. It gave less pain than the common or lunar caustic. It excited a moderate inflammation, which separated the morbid from the sound parts, and promoted a plentiful afflux of humours to the sore during its application. It seldom produced an escar; hence it insinuated itself into the deepest recesses of the cancers, and frequently separated those fibres in an unbroken state, which are generally called the roots of the cancer. Upon this account, I think, in some ulcerated cancers it is to be preferred to the knife. It has no action upon the sound skin. This Doctor Hall proved, by confining a small quantity of it upon his arm for many hours. In those cases where Doctor Martin used it to extract cancerous or schirrous tumours that were not ulcerated, I have reason to believe that he always broke the skin with Spanish flies.
2. The arsenic used by the doctor was the pure white arsenic. I should suppose from the examination I made of the powder with the eye, that the proportion of arsenic to the vegetable powder, could not be more than one-fortieth part of the whole compound. I have reason to think that the doctor employed different vegetable substances at different times. The vegetable matter with which the arsenic was combined in the powder which I used in my experiments, was probably nothing more than the powder of the root and berries of the solanum lethale, or deadly nightshade. As the principal, and perhaps the only design of the vegetable addition was to blunt the activity of the arsenic, I should suppose that the same proportion of common wheat flour as the doctor used of his caustic vegetables, would answer nearly the same purpose. In those cases where the doctor applied a feather dipped in a liquid to the sore of his patient, I have no doubt but his phial contained nothing but a weak solution of arsenic in water. This is no new method of applying arsenic to foul ulcers. Doctor Way of Wilmington has spoken in the highest terms to me of a wash for foulnesses on the skin, as well as old ulcers, prepared by boiling an ounce of white arsenic in two quarts of water to three pints, and applying it once or twice a day.
3. I mentioned, formerly, that Doctor Martin was often unsuccessful in the application of his powder. This was occasioned by his using it indiscriminately inallcases. In schirrous and cancerous tumours, the knife should always be preferred to the caustic. In cancerous ulcers attended with a scrophulous or a bad habit of body, such particularly as have their seat in the neck, in the breasts of females, and in the axillary glands, it can only protract the patient's misery. Most of the cancerous sores cured by Doctor Martin were seated on the nose, or cheeks, or upon the surface or extremities of the body. It remains yet to discover a cure for cancers that taint the fluids, or infect the whole lymphatic system. This cure I apprehend must be sought for in diet, or in the long use of some internal medicine.
To pronounce a disease incurable, is often to render it so. The intermitting fever, if left to itself, would probably prove frequently, and perhaps more speedily fatal than cancers. And as cancerous tumours and sores are often neglected, or treated improperly by injudicious people, from an apprehension that they are incurable (to which the frequent advice of physicians “to let them alone,” has no doubt contributed), perhaps the introduction of arsenic into regular practice as aremedy for cancers, may invite to a more early application to physicians, and thereby prevent the deplorable cases that have been mentioned, which are often rendered so by delay or unskilful management.
4. It is not in cancerous sores only that Doctor Martin's powder has been found to do service. In sores of all kinds, and from a variety of causes, where they have been attended with fungous flesh or callous edges, I have used the doctor's powder with advantage.
I flatter myself that I shall be excused in giving this detail of aquackmedicine, when we reflect that it was from the inventions and temerity of quacks, that physicians have derived some of their most active and most useful medicines.
For a history of the different names and symptoms of this disease, I beg leave to refer the reader to practical books, particularly to Doctor Cullen's First Lines. My only design in this inquiry, is to deliver such a theory of the disease, as may lead to a new and successful use of old and common remedies for it.
All the remote and predisposing causes of the tetanus act by inducing preternatural debility, and irritability in the muscular parts of the body. In many cases, the remote causes act alone, but they more frequently require the co-operation of an exciting cause. I shall briefly enumerate, without discriminating them, or pointing out when they act singly, or when in conjunction with each other.
I. Wounds on different parts of the body are the most frequent causes of this disease. It was formerly supposed it was the effect only of a wound, which partially divided a tendon, or a nerve; but we now know it is often the consequence of læsions which affect the body in a superficial manner. The following is a list of such wounds and læsions as have been known to induce the disease:
1. Wounds in the soles of the feet, in the palms of the hands, and under the nails, by means of nails or splinters of wood.
2. Amputations, and fractures of limbs.
3. Gun-shot wounds.
4. Venesection.
5. The extraction of a tooth, and the insertion of new teeth.
6. The extirpation of a schirrous.
7. Castration.
8. A wound on the tongue.
9. The injury which is done to the feet by frost.
10. The injury which is sometimes done to one of the toes, by stumping it (as it is called) in walking.
11. Cutting a nail too closely. Also,
12. Cutting a corn too closely.
13. Wearing a shoe so tight as to abrade the skin of one of the toes.
14. A wound, not more than an eighth part of an inch, upon the forehead.
15. The stroke of a whip upon the arm, which only broke the skin.
16. Walking too soon upon a broken limb.
17. The sting of a wasp upon the glands penis.
18. A fish bone sticking in the throat.
19. Cutting the navel string in new-born infants.
Between the time in which the body is thus wounded or injured, and the time in which the disease makes its appearance, there is an interval which extends from one day to six weeks. In the person who injured his toe by stumping it in walking, the disease appeared the next day. The trifling wound on the forehead which I have mentioned, produced both tetanus and death, the day after it was received. I have known two instances of tetanus, from running nails in the feet, which did not appear until six weeks afterwards. In most of the cases of this disease from wounds which I have seen, there was a total absence of pain and inflammation, or but very moderate degrees of them, and in some of them the wounds had entirely healed, before any of the symptoms of the disease had made their appearance. Wounds and læsions are most apt to produce tetanus, after the long continued application of heat to the body; hence its greater frequency, from these causes, in warm than in cold climates, and in warm than in cold weather, in northern countries.
II. Cold applied suddenly to the body, after it has been exposed to intense heat. Of this Dr. Girdlestone mentions many instances, in his Treatise upon Spasmodic Affections in India. It was most commonly induced by sleeping upon theground, after a warm day. Such is the dampness and unwholesome nature of the ground, in some parts of that country, that “fowls (the doctor says) put into coops at night, in the sickly season of the year, and on the same soil that the men slept, were always found dead the next morning, if the coop was not placed at a certain height above the surface of the earth[48].” It was brought on by sleeping on a damp pavement in a servant girl of Mr. Alexander Todd of Philadelphia, in the evening of a day in which the mercury in Fahrenheit's thermometer stood at 90°. Dr. Chalmers relates an instance of its having been induced by a person's sleeping without a nightcap, after shaving his head. The late Dr. Bartram informed me, that he had known a draught of cold water produce it in a man who was in a preternaturally heated state. The cold air more certainly brings on this disease, if it be applied to the body in the form of a current. The stiff neck which is sometimes felt after exposure to a stream of cool air from an open window, is a tendency to a locked jaw, or a feeble and partial tetanus.
III. Worms and certain acrid matters in the alimentary canal. Morgagni relates an instance ofthe former, and I shall hereafter mention instances of the latter in new-born infants.
IV. Certain poisonous vegetables. There are several cases upon record of its being induced by the hemlock dropwort, and the datura stramonium, or Jamestown weed of our country.
V. It is sometimes a symptom of the bilious remitting and intermitting fever. It is said to occur more frequently in those states of fever in the island of Malta, than in any other part of the world.
VI. It is likewise a symptom of that malignant state of fever which is brought on by the bite of a rabid animal, also of hysteria and gout.
VII. The grating noise produced by cutting with a knife upon a pewter plate excited it in a servant, while he was waiting upon his master's table in London. It proved fatal in three days.
VIII. The sight of food, after long fasting.
IX. Drunkenness.
X. Certain emotions and passions of the mind. Terror brought it on a brewer in this city. Hehad been previously debilitated by great labour, in warm weather. I have heard of its having been induced in a man by agitation of mind, occasioned by seeing a girl tread upon a nail. Fear excited it in a soldier who kneeled down to be shot. Upon being pardoned he was unable to rise, from a sudden attack of tetanus. Grief produced it in a case mentioned by Dr. Willan.
XI. Parturition.
All these remote and exciting causes act with more or less certainty and force, in proportion to the greater or less degrees of fatigue which have preceded them.
It has been customary with authors to call all those cases of tetanus, which are not brought on by wounds, symptomatic. They are no more so than those which are said to be idiopathic. They all depend alike upon irritating impressions, made upon one part of the body, producing morbid excitement, or disease in another. It is immaterial, whether the impression be made upon the intestines by a worm, upon the ear by an ungrateful noise, upon the mind by a strong emotion, or upon the sole of the foot by a nail; it is alike communicatedto the muscles, which, from their previous debility and irritability, are thrown into commotions by it. In yielding to the impression of irritants, they follow in their contractions the order of their predisposing debility. The muscles which move the lower jaw are affected more early, and more obstinately than any of the other external muscles of the body, only because they are more constantly in a relaxed, or idle state.
The negroes in the West-Indies are more subject to this disease than white people. This has been ascribed to the greater irritability of their muscular systems, which constitutes a part of its predisposing cause. It is remarkable that their sensibility lessens with the increase of their irritability; and hence, Dr. Moseley says, they bear surgical operations much better than white people.
New-born infants are often affected by this disease in the West-Indies. I have seen a few cases of it in Philadelphia. It is known by the name of the jaw-fall. Its causes are:
1. The cutting of the navel string. This is often done with a pair of dull scissors, by which means the cord is bruised.
2. The acrimony of the meconium retained in the bowels.
3. Cold air acting upon the body, after it has been heated by the air of a hot room.
4. Smoke is supposed to excite it, in the negro quarters in the West-Indies.
It is unknown, Dr. Winterbottom informs us, among the native Africans in the neighbourhood of Sierra Leone.
I am aware that it is ascribed by many physicians to only one of the above causes; but I see no reason why it should not be induced by more than one cause in infants, when we see it brought on by so many different causes in grown people.
The tetanus is not confined to the human species. It often affects horses in the West-Indies. I have seen several cases of it in Philadelphia.
The want of uniform success in the treatment of this disease, has long been a subject of regret among physicians. It may be ascribed to the use of the same remedies, without any respect to the nature of the causes which produce it, and to anundue reliance upon some one remedy, under a belief of its specific efficacy. Opium has been considered as its antidote, without recollecting that it was one only, of a numerous class of medicines, that are all alike useful in it.
Tetanus, from all its causes, has nearly the same premonitory symptoms. These are a stiffness in the neck, a disposition to bend forward, in order to relieve a pain in the back, costiveness, a pain about the external region of the stomach, and a disposition to start in sleep. In this feeble state of the disease, an emetic, a strong dose of laudanum, the warm bath, or a few doses of bark, have often prevented its being completely formed. When it has arisen from a wound, dilating it if small or healed, and afterwards inflaming it, by applying to it turpentine, common salt, corrosive sublimate, or Spanish flies, have, in many hundred instances, been attended with the same salutary effects.
The disease I have said is seated in the muscles, and, while they are preternaturally excited, the blood-vessels are in a state of reduced excitement. This is evident from the feebleness and slowness of the pulse. It sometimes beats, according to Dr. Lining, but forty strokes in a minute. By stimulating the wound, we not only restore thenatural excitement of the blood-vessels, but we produce an inflammatory diathesis in them, which abstracts morbid excitement from the muscular system, and, by equalizing it, cures the disease. This remedy I acknowledge has not been as successfully employed in the West-Indies as in the United States, and that for an obvious reason. The blood-vessels in a warm climate refuse to assume an inflammatory action. Stimuli hurry them on suddenly to torpor or gangrene. Hence the danger and even fatal effects of blood-letting, in the fevers which affect the natives of the islands, a few hours after they are formed. But widely different is the nature of wounds, and of the tension of the blood-vessels, in the inhabitants of northern countries. While Dr. Dallas deplores the loss of 49 out of 50 affected with tetanus from wounds, in the West-India islands, I am sure I could mention many hundred instances of the disease being prevented, and a very different proportion of cures being performed, by inflaming the wounds, and exciting a countermorbidaction in the blood-vessels.
When the disease is the effect of fever, the same remedies should be given, as are employed in the cure of that fever. I have once unlocked the jaw of a woman who was seized at the sametime with a remitting fever, by an emetic, and I have heard of its being cured in a company of surveyors, in whom it was the effect of an intermittent, by large doses of bark. When it accompanies malignant fever, hysteria, or gout, the remedies for those forms of disease should be employed. Bleeding was highly useful in it in a case of yellow fever which occurred in Philadelphia in the year 1794.
When it is produced by the suppression of perspiration by means of cold, the warm bath and sweating medicines have been found most useful in it. Nature has in one instance pointed out the use of this remedy, by curing the disease by a miliary eruption on the skin[49].
If it be the effect of poisonous substances taken into the stomach, or of worms in the bowels, the cure should be begun by emetics, purges, and anthelmintic medicines.
Where patients are unable to swallow, from the teeth of the upper and lower jaw pressing upon each other, a tooth or two should be extracted, to open a passage for our medicines into the throat.If this be impracticable or objected to, they should be injected by way of glyster.
In the locked jaw which arises from the extraction of a tooth, an instrument should be introduced to depress the jaw. This has been done by a noted English dentist in London, with success.
As the habit of diseased action often continues after the removal of its causes, and as some of the remote causes of this disease are beyond the reach of medicine, such remedies should be given as are calculated, by their stimulating power, to overcome the morbid or spasmodic action of the muscles. These are:
1.Opium.It should be given in large and frequent doses. Dr. Streltz says he has found from one to two drachms of an alkali, taken in the course of a day, greatly to aid the action of the opium in this disease.
2.Wine.This should be given in quarts, and even gallons daily. Dr. Currie relates a case of a man in the infirmary of Liverpool, who was cured of tetanus, by drinking nearly a quarter cask of Madeira wine. Dr. Hosack speaks in high terms of it, in a letter to Dr. Duncan, and advises itsbeing given without any other stimulating medicine.
3.Ardent spirits.A quack in New-England has lately cured tetanus, by giving ardent spirits in such quantities as to produce intoxication. Upon being asked his reason for this strange practice, he said, he had always observed the jaw to fall in drunken men, and any thing that would produce that effect, he supposed to be proper in the locked jaw.
4. TheBARKhas of late years been used in this disease with success. I had the pleasure of first seeing its good effects in the case of Colonel Stone, in whom a severe tetanus followed a wound in the foot, received at the battle of Germantown, in October, 1777.
5. TheCOLD BATH. This remedy has been revived by Dr. Wright of Jamaica, and has in many instances performed cures of this disease. In one of two cases in which I have used it with success, the patient's jaw opened in a few minutes after the affusion of a single bucket of water upon her body. The disease was occasioned by a slight injury done to one of her toes, by wearing a tight shoe. The signals for continuing the use of the cold bath, areits being followed by a slight degree of fever, and a general warmth of the skin. Where these do not occur, there is reason to believe it will do no service, or perhaps do harm. We have many proofs of the difference in the same disease, and in the operation of the same medicine, in different and opposite climates. Dr. Girdlestone has mentioned the result of the use of the cold bath in tetanus in the East-Indies, which furnishes a striking addition to the numerous facts that have been collected upon that subject. He tells us the cold bath uniformly destroyed life, in every case in which it was used. The reason is obvious. In that extremely debilitating climate, the system in tetanus was prostrated too low to re-act, under the sedative operation of the cold water.
6. TheWARM BATHhas often been used with success in this disease. Its temperature should be regulated by our wishes to promote sweats, or to produce excitement in the blood-vessels. In the latter case it should rise above the heat of the human body.
7. TheOIL OF AMBERacts powerfully upon the muscular system. I have seen the happiest effects from the exhibition of six or eight drops of it, every two hours, in this disease.
8. ASALIVATIONhas been often recommended for the cure of tetanus, but unfortunately it can seldom be excited in time to do service. I once saw it complete the cure of a sailor in the Pennsylvania hospital, whose life was prolonged by the alternate use of bark and wine. The disease was brought on him by a mortification of his feet, in consequence of their being frost-bitten.
9. Dr. Girdlestone commendsBLISTERSin high terms in this disease. He says he never saw it prove fatal, even where they only produced a redness on the skin.
10. I have heard ofELECTRICITYhaving been used with advantage in tetanus, but I can say nothing in its favour from my own experience.
In order to ensure the utmost benefit from the use of the above remedies, it will be necessary for a physician always to recollect, that the disease is attended with great morbid action, and of course each of the stimulating medicines that has been mentioned should be given, 1st, in large doses; 2dly, in succession; 3dly, in rotation; and 4thly, by way of glyster, as well as by the mouth.
The jaw-fall in new-born infants is, I believe, always fatal. Purging off the meconium from the bowels immediately after birth has often prevented it from one of its causes; and applying a rag wetted with spirit of turpentine to the navel-string, immediately after it is cut, Dr. Chisholm says, prevents it from another of its causes which has been mentioned.
This disease, I have said, sometimes affects horses. I have twice seen it cured by applying a potential caustic to the neck under the mane, by large doses of the oil of amber, and by plunging one of them into a river, and throwing buckets of cold water upon the other.
I shall conclude my observations upon the tetanus with the following queries:
1. What would be the effects ofcopiousblood-letting in this disease? There is a case upon record of its efficacy, in the Medical Journal of Paris, and I have now in my possession a letter from the late Dr. Hopkins of Connecticut, containing the history of a cure performed by it. Where tetanus is the effect of primary gout, hysteria, or fever, attended with highly inflammatory symptoms, bleeding is certainly indicated, but, in general, the diseaseis so completely insulated in the muscles, and the arteries are so far below their par of excitement in frequency and force, that little benefit can be expected from that remedy. The disease, in these cases, seems to call for an elevation, instead of a diminution, of the excitement of the blood-vessels.
2. What would be the effect ofextremecold in this disease? Mr. John Hunter used to say, in his lectures, “Were he to be attacked by it, he would, if possible, fly to Nova-Zembla, or throw himself into an ice-house.” I have no doubt of the efficacy of intense cold, in subduing the inordinate morbid actions which occur in the muscular system; but it offers so much violence to the fears and prejudices of sick people, or their friends, that it can seldom be applied in such a manner as to derive much benefit from it. Perhaps the sedative effects of cold might be obtained with less difficulty, by wrapping the body in sheets, and wetting them occasionally for an hour or two with cold water.
3. What would be the effect of exciting a strong counter-action in the stomach and bowels in this disease? Dr. Brown of Kentucky cured a tetanus by inflaming the stomach, by means of the tinctureof cantharides. It has likewise been cured by a severe cholera morbus, induced by a large dose of corrosive sublimate. The stomach and bowels, and the external muscles of the body, discover strong associations in many diseases. A sick stomach is always followed by general weakness, and the dry gripes often paralyze the muscles of the arms and limbs. But further, one of the remote causes of tetanus, viz. cold air, often shows the near relationship of the muscles to the bowels, and the vicarious nature of disease in each of them. It often produces in the latter, in the West-Indies, what the French physicians call a “crampe seche,” or, in other words, if I may be allowed the expression, a tetanus in the bowels.
4. A sameness has been pointed out between many of the symptoms of hydrophobia and tetanus. A similar difficulty of swallowing, and similar convulsions after it, have been remarked in both diseases. Death often takes place suddenly in tetanus, as it does in hydrophobia, without producing marks of fatal disorganization in any of the internal parts of the body. Dr. Physick supposes death in these cases to be the effect of suffocation, from a sudden spasm and closure of the glottis, and proposes to prevent it in the same manner that he has proposed to prevent death from hydrophobia,that is, by laryngotomy[50]. The prospect of success from it appears alike reasonable in both cases.