DR. CORNISII
ON OPIUM AND IN DYSENTERY.
IPECACUANHA
(Concluded from page 220.) Hewaud, Esq., Surgeon, to Andrew Bf.hry, Esq., Acting Head Surgeon, Centre Division, and 3rd Member of tin; Medical Hoard, Eort St. George. Dated Wallahjabad, 15th
From S.
June, 1807. Sia,?In communicating to you
some account of tho great which lias lately taken place in II. M.'s 30th Regiment in this station, I have to observe that dysentery was tho disease from which this chiefly happened, and as tho like occurrence is commonly spoken of, on the deportatiou of troops, particularly to tropical countries, it becomes an object, to ascertain any probable part of the many causes which are found to be thus constant and uniform in their operation and effect. I should here premise that tho men of tho regiment aro mostly young, tho greater part of them from 18 to 30 years of ago. This being kept in view will explain to you in some measure the very aggravated form of the disease wo have hail to combat with, arising, generally speaking, from a habit highlydisposed to inflammations, and this accompanied with such a degree of irritation, as have but in too many instances ballled our best efforts to subduo them. The causo of tho diseaso I would refer to an existing predisposition thereto* in the European constitution, which exposuro to the sun, transitions from heat to cold, and other changcs which induce a suddenly checked perspiration, irregularity in, or change of diet, or intoxication from the common arrack of the bazars, will in most instances bo found among tho more obvious causes of the disease. I do not believe the diseaso was in any instance propagated by contagion, but altogether generated and kept up from the men, the women, and children of tho regiment being exposed to somo of the above causes ; for I ought to inform you that tho women and children were equally victims to tho diseaso, which in many among them went through a courso as rapid and acute, as with the strongest men of tho corps ; and in some of tho children, I am satisfied, the suu's influeuco alone brought on tho
mortality
complaint.*
From the increasing sickness which prevailed in tho regiment during the month of March, it had been recommended by you, that the men should bo conlincd to their barracks during tho heat of tho day. This measure was put in force on tho 31st of March, in which month the admissions had become unusually numerous, nearly all of them dysentery, attended with so great constitutional irritation, that it was common to receive into the hospitals from 10 to 15 of such cases daily. Tho confinement of tho men to their quarters was from tho hour of 8 a.m. till 4 o'clock p.m., and is still continued. This was attended with such marked effects, that in about a fortnight after, the admissions not only became fewer in number, but, what was also observable, the disease, from being highly aggravated in its symptoms, became gradually less so, and from that period took on daily more and moro the character of a common diarrhoea. Now as there was not during that time any chango from the or alteration in tho diet of the men, or deviation established discipline of tho regiment, which appears to bo guided by tho rules best calculated to preserve health, I am disposed to attribute this mitigation in the symptoms of tho diseaso to the confinement of tho men to their barracks; and the regulation having been found of such benefit and importance to tho soldier's welfare in this instance, I trust it may at no time be overlooked on the landing of a now regiment from Europe ; for I am persuaded, had tho plan been adopted on the arrival of tho 30th ltegiincnt at this station, much of that distress ami suffering in tho first placo would have been -avoided, and many subsequent deaths ultimately prevented. It might bo supposed that a disease so fatal in its tendency could never originate, without previously occasioning some clear and well-marked constitutional indisposition, but this is by no means uniformly the case ; for, at times the attacks aro so sudden and unlooked for, that the men are on guard, at parade, tho first thing complained of or in bed when taken ill, and then is passing a large quantity of fluid blood, but unattended with
either griping Most
or
tenesmus.
frequently, however,
tho diseaso comes on in tho
shape of
Idonot feel quite so certain about the non-contagion, as Mr. llewaril If wo knew a little moro about tho sanitary condition of appears to do. the barracks and privies at Wallahjabad, wo might not perhaps wonder ut the general prevalence of dyseutery there 03 years ago,?W, u, c. ?
THE INDIAN MEDICAL GAZETTE.
244 common
diarrhoea. The man, while the complaint continues so, from it, seldom reports himself till he
apprehending nothing sees
appearance of blood, or blood and slime, mixed with his and there is in this stage commonly a dull heavy weight, rather than pain, over the hypogastric region, with sometimes an occasional gripe ; but when this happens, which is by no means constant, on a more plentiful discharge of blood, the griping very often entirely ceases, leaving now and then tenesmus and straining, which continues more or less troublesome throughout the course of the disease. At other times the disease is ushered in by fever, head-ache, nausea, and retching, parched and burning skin, a small, irritable, quick, and sometimes full pulse, thick furred tongue, often tinged of a brown colour, but the tongue now and then assumes a red. dry, and harsh appearance. To these symptoms may now be superadded frequent ejections of little else but pure blood, sometimes mixed with a- little slimy matter, or froth, with occasional severe gripes, and tenesmus. A dejection of mind is often observable, but in those cases where the greatest irritation prevails, tlie patient is often in a high state of excitement, with the most apparent alarm and apprehension about him. In these more violent cases the course of the disease is not of long duration, and too frequently so unmanageable, that nothing but the warm bath, with large and repeated doses of opium, procures the unfortunate sulferer any respite from his agonies. Having thus given you a short history of the disease, as it appeared generally in the 30tti Kegiinenr, a more minute relation would be uninteresting, and cannot come within the meaning of this communication. From the foregoing it will appear evident, that the immediate indications to be aimed at in the cure of the disease, will consist of, first, a diminution or removal of every cause of irritation; and second, in restraining the determination of blood upon the intestines. This leads directly to the use of local and geueral blood-letting, purgatives, opiates, warm baths, blisters, &c., and to the whole of that class of medicines whose operation is known to determine to the surface of the body. In estimating the different modes of treatment which have been found the most efficacious in the cure of this affection, I cannot withhold my decided preference, and in these sentiments Mr. Pearse, the Surgeon of the 30th Regiment, warmly concurs, in favor of the new practice which, though not always successful, is still so in a very great proportion of the many cases in which I have now seen it employed. In the exhibition of the medicine, two drachms and a half of the tincture, or from 10 to 12 grains of solid opium, will in geueral be found an adequate proportion for one dose. I have not myself seen the medicine given beyond the quautity of 15 grains of the common extract, though I understand some have much exceeded it. The operation of the opium appears obyiously two-fold : first, by diminishing pain and irritation ; and second, by determining to the surface of the body. The first effect may in every case be observed, but the second, and most important, is less certainly produced, though, it is in this way chiefly, I believe, that the disease is carried off. In the combination of the ipecacuanha with the opium, this end, therefore, should be principally had in view, and the quantity regulated, so as to occasion nausea ; for this action upon the stomach seldom fails to produce a determination to the skin, which when once established is supported and kept up by the diaphoretic powers of the laudanum. But where there is a burning skin, great thirst, small quick pulse, parched tongue, with other symptoms of general irritation, the warm bath has the best effect, aud should then, perhaps, seldom be omitted. During the sweating process there will he little occasion to repeat the medicine ofteuer than once in 24 hours, as the flux, griping, or tenesmus seldom returns while the perspiration continues; but a recurrence ot tiie above symptoms, it will be found, ought commonly to be the signal for repeating the medicine ; though in this, the practitioner must be guided, as well as in numerous other symptoms which arise in the course of the disease, by circumstances only. During the sweating stage the patient must be supported by a little warm conjee and wine, frequently administered, for the exhaustion he undergoes during this period is very great indeed. The continuance of the diaphoresis from one dose of the medicine admits of much variety. In some it does not take place at all. At other times I have seen the patient under the sweating operation of the opium, after a lapse of more than 24 hours from the period of its being taken. When the opium fails of determining to the skin, the head is more frequently affected by it, than when sweating is produced. A rather frequent effect of the opium is strangury, out this symptom I have never found troublesome, for it either au
stools,
1 (
[Notembee 1,
I860.
goes off spontaneously, or is soon removed by a fomentation or the warm bath. In no instance have I seen more than, ordinary sleep brought on by the opium, though somotiines the of watchfulness and want of rest. I patient has have very often observed those eruptions, I recollect hearing you speak of, as appearing about the lips of those men under the opium treatment ; another, though less common appearance during the same period, is large pustules, and oftentimes bags oj a rather thick and yellow colored fluid hanging to the neck and breast like blisters. " This appearance is commonly met with where more than ordinary sweating has been produced, and seems to be a solution of the sebaceous matter of the skin, in the common perspirable fluid, but rendered too glutinous to fly off." In all stages of the disease where there is anything like an accession of fever or irritation, a blister applied to the belly proves of the greatest service; but by this I do not mean a blister of the ordinary size, but one which goes to envelope at once a greater part of the whole abdomen. Fomentations also are of the first utility, and injections, both anodyne and emollient, are in constant requisition. In tenesmus, that symptom so often troublesome, a fomentation to the fundament affords greater * * * relief than injection of any kind. Mercurial frictions and calomel were in many cases extensively employed throughout the disease,.but in the acute stage of it, except where a purgative was indicated, and that often consisted of a few grains of calomel, I caunot say that I ever saw any advantage from their use. Little or no benefit therefore, I am inclined to think, will ever be found to arise from the mercurial practice in that stage of dysentery, where the disease is attended with fever and other symptoms of irritation; but where these have been removed by other means, mercury then becomes the most powerful of our remedies, in finally overcoming the remains of every kind of visceral inflammation. In a few of the acute cases, the disease was translated to the parotid glands, which inflamed, in some suppurated, and recovery except in one instance followed. The men had then been confined to their quarters some days, and the disease was taking on a somewhat milder form. In one particular case, (see Valentine Tristan's, in the journals of April and May), the disease was transferred to the kneo joints, where the most severe pain was complained of, attended with a high degree of fever and irritation, which alone seemed to be the cause of his death, for the dysenteric affection did not, in my mind, occasion it. As there was something uncommon in the case, his body was opened, and on examination, the lower portion of the ilinium was found slightly inflamed, the colon in a like state, and internally numerous small points, scarcely amounting to ulcerations, were scattered in many places through the course of that gut. The rectum was still less affected, other viscera sound. I notice these circumstances merely as appearing unusual, and leave you to draw your own physiological deductions from the facts. From an examination of the bodies of almost all the men who have died of dysentery in the 30th Regiment, it can hardly be said that the disease is connected with visceral derangement, for in only one man was the liver found suppurated, nor have the other abdominal viscera, in any case which I have seen, been engaged in the complaint ; but where the habits and life of the soldier co-operate with a climate, too often productive of visceral obstruction, this unconnected state of the disease cannot be of long duration, when of course the present plan of treatment must be abandoned, and that by mercury principally trusted to for relief. (The next and concluding letter is from a medical officer of the Indian Service, who was deputed by the Commander-inChief to go up to Wallajabad and superintend the medical practice of the Regimental Surgeon of the 30th Regiment, during the epidemic of dysentery which prevailed there in 1807. The Regiment had but recently arrived in India; the British medical officers had noexperience of Indian diseases, and on these grounds, the Commander-ih-Chief applied to the Medical Board for the services of an " experienced medical officer" to advise and assist the Regimental Surge:n.? VV. R. C.)
complained
ON OPIUM AND IN DYSENTERY.
IPECACUANHA
(Concluded from page 220.) Hewaud, Esq., Surgeon, to Andrew Bf.hry, Esq., Acting Head Surgeon, Centre Division, and 3rd Member of tin; Medical Hoard, Eort St. George. Dated Wallahjabad, 15th
From S.
June, 1807. Sia,?In communicating to you
some account of tho great which lias lately taken place in II. M.'s 30th Regiment in this station, I have to observe that dysentery was tho disease from which this chiefly happened, and as tho like occurrence is commonly spoken of, on the deportatiou of troops, particularly to tropical countries, it becomes an object, to ascertain any probable part of the many causes which are found to be thus constant and uniform in their operation and effect. I should here premise that tho men of tho regiment aro mostly young, tho greater part of them from 18 to 30 years of ago. This being kept in view will explain to you in some measure the very aggravated form of the disease wo have hail to combat with, arising, generally speaking, from a habit highlydisposed to inflammations, and this accompanied with such a degree of irritation, as have but in too many instances ballled our best efforts to subduo them. The causo of tho diseaso I would refer to an existing predisposition thereto* in the European constitution, which exposuro to the sun, transitions from heat to cold, and other changcs which induce a suddenly checked perspiration, irregularity in, or change of diet, or intoxication from the common arrack of the bazars, will in most instances bo found among tho more obvious causes of the disease. I do not believe the diseaso was in any instance propagated by contagion, but altogether generated and kept up from the men, the women, and children of tho regiment being exposed to somo of the above causes ; for I ought to inform you that tho women and children were equally victims to tho diseaso, which in many among them went through a courso as rapid and acute, as with the strongest men of tho corps ; and in some of tho children, I am satisfied, the suu's influeuco alone brought on tho
mortality
complaint.*
From the increasing sickness which prevailed in tho regiment during the month of March, it had been recommended by you, that the men should bo conlincd to their barracks during tho heat of tho day. This measure was put in force on tho 31st of March, in which month the admissions had become unusually numerous, nearly all of them dysentery, attended with so great constitutional irritation, that it was common to receive into the hospitals from 10 to 15 of such cases daily. Tho confinement of tho men to their quarters was from tho hour of 8 a.m. till 4 o'clock p.m., and is still continued. This was attended with such marked effects, that in about a fortnight after, the admissions not only became fewer in number, but, what was also observable, the disease, from being highly aggravated in its symptoms, became gradually less so, and from that period took on daily more and moro the character of a common diarrhoea. Now as there was not during that time any chango from the or alteration in tho diet of the men, or deviation established discipline of tho regiment, which appears to bo guided by tho rules best calculated to preserve health, I am disposed to attribute this mitigation in the symptoms of tho diseaso to the confinement of tho men to their barracks; and the regulation having been found of such benefit and importance to tho soldier's welfare in this instance, I trust it may at no time be overlooked on the landing of a now regiment from Europe ; for I am persuaded, had tho plan been adopted on the arrival of tho 30th ltegiincnt at this station, much of that distress ami suffering in tho first placo would have been -avoided, and many subsequent deaths ultimately prevented. It might bo supposed that a disease so fatal in its tendency could never originate, without previously occasioning some clear and well-marked constitutional indisposition, but this is by no means uniformly the case ; for, at times the attacks aro so sudden and unlooked for, that the men are on guard, at parade, tho first thing complained of or in bed when taken ill, and then is passing a large quantity of fluid blood, but unattended with
either griping Most
or
tenesmus.
frequently, however,
tho diseaso comes on in tho
shape of
Idonot feel quite so certain about the non-contagion, as Mr. llewaril If wo knew a little moro about tho sanitary condition of appears to do. the barracks and privies at Wallahjabad, wo might not perhaps wonder ut the general prevalence of dyseutery there 03 years ago,?W, u, c. ?
THE INDIAN MEDICAL GAZETTE.
244 common
diarrhoea. The man, while the complaint continues so, from it, seldom reports himself till he
apprehending nothing sees
appearance of blood, or blood and slime, mixed with his and there is in this stage commonly a dull heavy weight, rather than pain, over the hypogastric region, with sometimes an occasional gripe ; but when this happens, which is by no means constant, on a more plentiful discharge of blood, the griping very often entirely ceases, leaving now and then tenesmus and straining, which continues more or less troublesome throughout the course of the disease. At other times the disease is ushered in by fever, head-ache, nausea, and retching, parched and burning skin, a small, irritable, quick, and sometimes full pulse, thick furred tongue, often tinged of a brown colour, but the tongue now and then assumes a red. dry, and harsh appearance. To these symptoms may now be superadded frequent ejections of little else but pure blood, sometimes mixed with a- little slimy matter, or froth, with occasional severe gripes, and tenesmus. A dejection of mind is often observable, but in those cases where the greatest irritation prevails, tlie patient is often in a high state of excitement, with the most apparent alarm and apprehension about him. In these more violent cases the course of the disease is not of long duration, and too frequently so unmanageable, that nothing but the warm bath, with large and repeated doses of opium, procures the unfortunate sulferer any respite from his agonies. Having thus given you a short history of the disease, as it appeared generally in the 30tti Kegiinenr, a more minute relation would be uninteresting, and cannot come within the meaning of this communication. From the foregoing it will appear evident, that the immediate indications to be aimed at in the cure of the disease, will consist of, first, a diminution or removal of every cause of irritation; and second, in restraining the determination of blood upon the intestines. This leads directly to the use of local and geueral blood-letting, purgatives, opiates, warm baths, blisters, &c., and to the whole of that class of medicines whose operation is known to determine to the surface of the body. In estimating the different modes of treatment which have been found the most efficacious in the cure of this affection, I cannot withhold my decided preference, and in these sentiments Mr. Pearse, the Surgeon of the 30th Regiment, warmly concurs, in favor of the new practice which, though not always successful, is still so in a very great proportion of the many cases in which I have now seen it employed. In the exhibition of the medicine, two drachms and a half of the tincture, or from 10 to 12 grains of solid opium, will in geueral be found an adequate proportion for one dose. I have not myself seen the medicine given beyond the quautity of 15 grains of the common extract, though I understand some have much exceeded it. The operation of the opium appears obyiously two-fold : first, by diminishing pain and irritation ; and second, by determining to the surface of the body. The first effect may in every case be observed, but the second, and most important, is less certainly produced, though, it is in this way chiefly, I believe, that the disease is carried off. In the combination of the ipecacuanha with the opium, this end, therefore, should be principally had in view, and the quantity regulated, so as to occasion nausea ; for this action upon the stomach seldom fails to produce a determination to the skin, which when once established is supported and kept up by the diaphoretic powers of the laudanum. But where there is a burning skin, great thirst, small quick pulse, parched tongue, with other symptoms of general irritation, the warm bath has the best effect, aud should then, perhaps, seldom be omitted. During the sweating process there will he little occasion to repeat the medicine ofteuer than once in 24 hours, as the flux, griping, or tenesmus seldom returns while the perspiration continues; but a recurrence ot tiie above symptoms, it will be found, ought commonly to be the signal for repeating the medicine ; though in this, the practitioner must be guided, as well as in numerous other symptoms which arise in the course of the disease, by circumstances only. During the sweating stage the patient must be supported by a little warm conjee and wine, frequently administered, for the exhaustion he undergoes during this period is very great indeed. The continuance of the diaphoresis from one dose of the medicine admits of much variety. In some it does not take place at all. At other times I have seen the patient under the sweating operation of the opium, after a lapse of more than 24 hours from the period of its being taken. When the opium fails of determining to the skin, the head is more frequently affected by it, than when sweating is produced. A rather frequent effect of the opium is strangury, out this symptom I have never found troublesome, for it either au
stools,
1 (
[Notembee 1,
I860.
goes off spontaneously, or is soon removed by a fomentation or the warm bath. In no instance have I seen more than, ordinary sleep brought on by the opium, though somotiines the of watchfulness and want of rest. I patient has have very often observed those eruptions, I recollect hearing you speak of, as appearing about the lips of those men under the opium treatment ; another, though less common appearance during the same period, is large pustules, and oftentimes bags oj a rather thick and yellow colored fluid hanging to the neck and breast like blisters. " This appearance is commonly met with where more than ordinary sweating has been produced, and seems to be a solution of the sebaceous matter of the skin, in the common perspirable fluid, but rendered too glutinous to fly off." In all stages of the disease where there is anything like an accession of fever or irritation, a blister applied to the belly proves of the greatest service; but by this I do not mean a blister of the ordinary size, but one which goes to envelope at once a greater part of the whole abdomen. Fomentations also are of the first utility, and injections, both anodyne and emollient, are in constant requisition. In tenesmus, that symptom so often troublesome, a fomentation to the fundament affords greater * * * relief than injection of any kind. Mercurial frictions and calomel were in many cases extensively employed throughout the disease,.but in the acute stage of it, except where a purgative was indicated, and that often consisted of a few grains of calomel, I caunot say that I ever saw any advantage from their use. Little or no benefit therefore, I am inclined to think, will ever be found to arise from the mercurial practice in that stage of dysentery, where the disease is attended with fever and other symptoms of irritation; but where these have been removed by other means, mercury then becomes the most powerful of our remedies, in finally overcoming the remains of every kind of visceral inflammation. In a few of the acute cases, the disease was translated to the parotid glands, which inflamed, in some suppurated, and recovery except in one instance followed. The men had then been confined to their quarters some days, and the disease was taking on a somewhat milder form. In one particular case, (see Valentine Tristan's, in the journals of April and May), the disease was transferred to the kneo joints, where the most severe pain was complained of, attended with a high degree of fever and irritation, which alone seemed to be the cause of his death, for the dysenteric affection did not, in my mind, occasion it. As there was something uncommon in the case, his body was opened, and on examination, the lower portion of the ilinium was found slightly inflamed, the colon in a like state, and internally numerous small points, scarcely amounting to ulcerations, were scattered in many places through the course of that gut. The rectum was still less affected, other viscera sound. I notice these circumstances merely as appearing unusual, and leave you to draw your own physiological deductions from the facts. From an examination of the bodies of almost all the men who have died of dysentery in the 30th Regiment, it can hardly be said that the disease is connected with visceral derangement, for in only one man was the liver found suppurated, nor have the other abdominal viscera, in any case which I have seen, been engaged in the complaint ; but where the habits and life of the soldier co-operate with a climate, too often productive of visceral obstruction, this unconnected state of the disease cannot be of long duration, when of course the present plan of treatment must be abandoned, and that by mercury principally trusted to for relief. (The next and concluding letter is from a medical officer of the Indian Service, who was deputed by the Commander-inChief to go up to Wallajabad and superintend the medical practice of the Regimental Surgeon of the 30th Regiment, during the epidemic of dysentery which prevailed there in 1807. The Regiment had but recently arrived in India; the British medical officers had noexperience of Indian diseases, and on these grounds, the Commander-ih-Chief applied to the Medical Board for the services of an " experienced medical officer" to advise and assist the Regimental Surge:n.? VV. R. C.)
complained
