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Absorption of Pus in Small-PoxAuthor(s): John BarrettSource: Provincial Medical and Surgical Journal (1840-1842), Vol. 3, No. 7 (Nov. 13, 1841), pp.127-129Published by: BMJStable URL: http://www.jstor.org/stable/25490702 .

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ABSORPTION OF PUS IN SMALL-POX. 127 discharged from hospital on the 26th of Malch.

More than a year afterwards M. Moreau mnet him, and was assured that he continued to enjoy per fect health.

CASE III.-A young patient, shortly after his admission into hospital, handed to M. Moreau a letter, the following extract from which sufficiently exl)lains the nature of his delusions. " Give me

my liberty at once, that I may pursue my object, an(l (lestroy aU the kings of this eartlh. Mly earnest desire is to regenerate the human race, and I am destined to die at the head of a power ful republic. From the age of eight years up

wards I have always resolved, like Romulus, to build a city in my native forest of Lorraine. For the last twenty years, heavenly voices announce to

me the most curious particulars concerning the kings of the earth and my chartge at nurse."

This patient had been formerly an inmate of the hospital, but the symptoms of insanity were not very strongly marked, and the medical men were (livided in their opinions on his case; at presenthe is in a constant state of excitement; the whole day he is occupied in corresponding with the king, Prince Metternich, and the Pope; when he is sent to work on the farm, he is constantly looking up at the clouds, where he fancies that he sees miraculous symbols, legions of armed men, &c.

This patient remained at Bicetre during a month without receiving any benefit; ten days after his removal to the farm, M. Moreau gave him two grains of stramonium daily: at first he comn)lained of constriction about the throat, and

wveight on the head; there was some somnolence; he slept more tranquilly, and was less excited, but the delusions continued unabated. Towards the end of January, (the patient lhad now been seven teen days under treatment,) the delusions returned under a new form, but again gradually disap peared, and the mental excitement was completely removed. The patient continued the use of stra inonium in the doses already indicated, when an accident changed the face of affairs altogether. Bleing convinced himself, from his improved con dition, that he required no more medicine, M.

M., instead of taking his pills night and morning, suspended their use, without acquainting the phy sician, and then swallowed five (ten grains) to gether. Two hours afterwards he was seized with nausea, vomiting, pricking in the eyes, constric tiorn at the throat, and a dreadful sense of weight in the head; vision was disturbed, and there was a violent ringing in the ears; he experienced al ternately a feeling of great heat and cold in the limbs, wvhich were affected with trembling. These symI)toms of poisoning continued for some time, an(l when they began to subside, the patient had a successiorn of the most extravagant ideas; to var(ds evening, however, nothing remained but a ,;ense of weakness in the lower extremities. On tlle following morning he was found perfectly quiet, and free from delusion. " I had doubted hitherto," said he, " the power of medicine, but, after wvhat I have just felt, I shall never doubt again."

From this period the state of the patient's mind continued most satisfactory, and for the last three months he has been perfectly well.

In another case, the symptoms of mental de rangement occurred in a person subject to epi

le)sy, and were evidently excited by the fits of that disease. Here, also, the patient accidentally swal lowved a strong dose (twelve grains) of stramonium, exhibited for several hours symptoms of poisoning, and was completely free from delusion on the fol lowing morning. A month afterwards the pre

monitory signs of epilepsy manifested themselves, and the patient became insane; he was given one grain of the extract of stramonium every half hour; after the ninth dose symptoms of poisoning al)peared; the patient lay in a state of deep stupor for an hour and a half. Here, also, as soon as the poisonous effects of the drug disappeared, the patient was restored to reason, and has not suf fered a relapse for three months.

It is unnecessary to transcribe the other cases related in this interesting memoir; we shall there fore conclude with the closing remarks of the author.

The principal facts deducible from the preced ing observations are as follows:

1. Of ten persons labouring under mental de lusions, and presenting several unfavourable cir cumstances, seven were completely cured, one

much relieved, and two resisted the action of stramoniuxn.

2. In the first eight cases the delusions had preceded the other symptoms of insaniity, but in

the latter two, the reverse was the case. 3. The duration of the disease had been two,

three, six, and nine montlhs; two years in one case; twlo l)atients had accesses which lasted for several montlhs.

4. In the different cases a cure was obtained in four, seveI, and thirty days, with moderate doses; in five, eight, and fifteen days, with large doses; and in twenty-four hours with poisonous doses.

5. The period of convalescence had extended, at the time of writing the memoir, to two, three, and four months.

Before concluding, we may ask wvhat effects we may expect from the use of stramonium in cases of hallucination connected with chronic mania or chronic monomania?

The author does not possess facts to enable him to answer this question. Cases of chronic inania and monomania, uncomplicated with dementia, are excessively rare; in the chronic wards at Bicetre,

where one hundred patients are confined, there is only one, with regard to the state of Nvhose moral faculties some doubt remains.

Theorically speaking, the success seems )ro bable; the cures already obtained with stramnonium in acute cases appear to justify the hope that it

may exercise a beneficial effect on cases where the delusions were primary, and constitute the chief element of the mental disorder.-Gazette Medicale, No. 43.

ABSORPT'ION OF PUS IN SMALL-POX.

TO THE EDITORS OF THE PROVINCIAL MIEDI

CAL AND SURGICAL JOURNAL.

GENTLEMEN,-A re-perusal of Dr. Symonds' comprehensive and interesting retrospective ad dress of July 1839, particularly that part of it de tailing the researches of Dr. Mandl, Mr. Gulliver, and Dr. Davy, relative to the existence of pus

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12S ABSORPTION OF PUS IN SMIALL-POX.

globules in the blood, bas recalled to my remem brance some cases of small-pox bearing on this subject.

It we are to depend on the statement of Mr. Gulliver, the question of wvhetlher pus is ever absorbed and carried into the circulation, is (leter

mined in the affirmative; for he states that " in almost every instance in which there was either extensive swelling without a visible deposition of pus in any of the textures of the body, he has repeatedly detected pus globules in the blood," and we cannot therefore be surprised that he regards " the contamination of the blood by pus, as the proximate cause of the sympathetic inflam

matory, sympathetic typhoid, and hectic fevers." Dr. Davy goes still further, for, in every case wvhere during life there were purulent discharges or col lections, he states that he detected globules like pus globules in the blood. But it would be unfair to dismiss from our consideration the explanation of these appearances resulting from the researches of Dr. Mandl, that the supposed pus globules are nothing more than the white fibrinous globules of blood held in solution by the serum, which in sul)puration escapes from the capillaries by exosmosis, and when out of the vessels, coagu lates, and resolves itself into its elementary glo bules; and, certainly, the strongest doubts as to the absorption of pus have been entertained by practical men. I remember Sir B. C. Brodie stating some years ago, in the wards of St.

George's Hospital, that in one case he thought he had seen an abscess absorbed, but of this he was not certain.

But whilst microscopic investigations give us such conflicting testimonies, we are tempted to turn to pathology with the hope of deriving from it information on a subject which possesses really

more than a theoretical interest; and thouglh we may not be so iumoral, (I hadl nearly said so humorous,) as to affirm with Cullen, that " it is evident that the contagion of small-pox is a fer

ment with respect to the human fluids, and assi milates a great part of them to its own nature," and that the quantity thus assimilated " passes again out of the body partly by insensible per spiration, and partly by being deposited in the pustules ;"-yet those who have carefully watched cases of small-pox during life, and examined them after death, will, I think, bear me out in saying that there are circumstances in them tending to produce a strong conviction that their symptoms are at times dependent on, at least closely con ne(cted with, the absorption of the morbific matter fromi the pustules, and consequently the entrance into, and vitiation of the general circulation.

Nothing is more painfully striking than the rapi(lity with which patients occasionally go off in this disease. To uise the words of Dr. Elliotson, when describing variola confluens, " Now and then, patients labouring under this form of the dis ease die rather suddenly-they suddenly sink."

The last sentence is equally true and expressive, nor have I yet foirgotten the feeling nearly of self reproach, which I experienced when my first case of this sudden description occurred, lest I should have overlooked some important premonitory fea tures in it. But subsequent observation has taught me that this sudden sinking may take place

with few and slight, perhaps without any, premnoni tory symptoms, and has led me to believe that its

cause may be the absorption of the morbific matter contained in the pustules.

I attended a young man, wt. 23, in small-pox, who died on the 13th day of the eruption. He Nvas under my care for the last eleven days. At first the eruiption, in some degree confluient, was fine, and the pustules wvell filled. There was pyrexia, and he needed active opening medicine; but when the bowvels were freely opened, dilute sulphuric acid and sulphate of magnesia were sufficient to keep under the pyrexia. About the loth day of eruption, the symptoms changfed, assuming a typhoid type. As he got worse, there was delirium of a lowv character, with restlessness, a quick weak pulse, and dark loaded tongue. The eruption did not scab, but the raised cuticle be came loose, as if the contents of the pustules had been partially absorbed; in some places it was rtubbed off, leaving large raw places. 'Tlhe treat

ment latterly was ammonia, opium, bark, wvine, &c. &c., and a blister to the nucha, but he sank, as before stated, on the 13th day of eruption. 'i'he post- mortem appearances were a dark red state of the mucous surface of the larynx, trachea, and large bronchi ; about three ounces of straw coloured fluid in the pericardial cavity; the right side of the heart flaccid and empty, lbut the left looking tense, and containing dark black blood,

with which also the coronary arteries were in jected; both large and small intestines distended with flatus, and both their serous and mucous surfaces of a dark red colour. The structure and isurfaces of both kidneys wvere healthy and un inflamed, but in the pelvis of the left were about two drachms of purulent fluid, and about three drachms of the same in the bladder, which was

much contracted, but healthy. I examined the head; the veno-us sinuses rather full, and perhaps the braini rather softer than usual; it was twenty hours after death; the softness was not well

marked; the muscular fibre of the body very dark, and it seemed that putrefaction would soon com mence.

Here then we have a case in which a change takes place from fever of an active character to typhus, the eruption not running the course wNhich observation shows it to do in general, but having a longer duration, and the pustules not scabbing, but becoming flaccid 'by absorption, and this change being coincident with the change of the symptoms. The train of symptoms set up closely resembles that attending secondary abscesses, and after death pus is found in an organ presenting no appearances in its structure to account for its ex istence there.

I attended a child, met. six months, in small-pox. I first saw her on the 2nd day of the eruption; it came out thickly, and in some parts was con

fluient, but without bad symptoms. On the loth day of the eruption, some of the pustules were turning, but the child appeared to be doing very

well, and was considered so by her parents. On the 11th day of the eruption, I was called to her in the morning, and found her in the greatest danger, breathing quickly, loudly, and puffing the lips; the feet cold and blue; she was pulseless. I was particularly struck with the appearance of the erup tion; the pustules were flaccid; not dried, but nearly emptied of their contents, and looking whitish, not yellow. This was particularly the case on the legs. By the stethoscope, the res

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POISONING WITH OPIUM. 129

piratory murmur was very audible over the chest; no rhonchlus. The cllild wvas not insensible, but seemed dying from exhaustion; all means were ineffctuial, and she died in about half an hour after imy arriv al. In answer to my inquiries, the

motlher informed me that she first perceived an al teration for the worse in the night; the child was unal)le to take the breast, not insensible nor un willing, but apparently unable from weakness; about 7 A.M. she first perceived the breath to be come hurried, but she was not alive to the danger till shortly) before she sent for me, when she found the feet cold. She then observed the alteration in the appearance of the eruption, and her friend, in answer to my question, said, she was sure it had not this flaccid appearance the day before.

Post-mortem Examination, forty-eight houtrs after death.

The pustules were very flacci(d and empty; the child generally fat ; soine serumi effused beneath the dura imiater and in the ventricles of the brain, the vessels of whiclh were congested, but not to any, great degree. D)ark fluid blood with clots and polypus on the right side of the heart, the left side em)ty; some slight emphysema of the left lung, bhut the structure and tubes otherwise healthy, neither congested nor loaded with mucus; no ef fusion of serum in the cavity of the pleura, the large intestines distended wvith flatus, the small contracted; the different viscera healthy. On di viding the right kidney, about a drachm of pu rulent fluid escaped from the pelvis; this was not the case in the left; neither kidney had any ap pearance of disorganization or inflammation; the bladder contained about one ounce of urine, hav ing a purulent appearance, and the peculiar odour attending a patient in small-pox. I examined the aorta, the venm iliacae, externa and interna, and the vena cava, but could find no appearance of disease nor any lpus on their inner coats; they wvere very empty; there wvas no pus in the coagula or polypi of the heart.

In this case, the only bad symptom was the tardiness with which the pustules turned; with this exception, there did not appear anything to war rant apprehension, but rather the contrary. It is to be observed, that in this case the flaccid state of the pustules took place about the same date in the disease as in the first case, i. e. about the loth day of the eruption. In the first case there fol lowed a train of typhoid symptoms, against which nature struggles for a few days, but without suc cess; in the second case, rapid and extreme ex lhaustion, and the patient suddenly sinks. The rapid transition from one state to another, so ob servable in the diseases of childhood, perhaps the high power of absorption connected with early life, causing in this instance the morbific matter to be rapidly and consequently more destructively thrown hack on the system, wvill, I think, explain this difference between the symptoms of the two cases.

'T'he last case I have to mention is that of a girl aet. 4 years, whom I first saw on the 5th day of the eruption of sinall-pox. There was moderate pyrexia with slight chest affection; the pustules were tolerably filled, and but slightly confluent. T'he treatment was gently aperient, refrigerant and ex pectorant. fiU the 8th day of the eruption there was no marked change in the symptoms; their general tendency was rather towards depression than excite

ment,but not so much so as to make me think stimu lants allowable. Now, however, a decided change for the worse too place ; she became restless, the pulse wealk and quick; there waas rather a want of animal heat; diarrhwa, the evacuations being pale and watery; tongue moist; somiie dyspnwa, but it seemed to arise more from debilitl than obstruc tion; slight rhonchus mucosus, but the respiratory

murmur feeble; the pustules showed no disposi tion, but became flaccid and wvhitish. She had bark, amnmonia, catechu, opium, wine, &c., but no improvement took place, andl she died on the follow ing mnorning, that is,;on the gth day of the eruption. I regretted that I could not prevail on the parents to allow a post-mortem examination, for there was similarity enough between the symptoms of this and the last-mentioned case to induce me to ex pect I should have found the same appearances.

What shall we say, then, wvas the cause of death in these cases ? In neither of these was there such a confluent and se'ere state of the disease as to have warranted apprehension from the first that the patient's strength would be unable to bear up against it, nor was there that bad state of the general health which might have justified the same apprehension; still, wvhen scabbing ought to have taken place, the vital powers became rapidly de pressed, and at the same time the pustules were emptied of their contents by absorption, for that absorption of pus did take place, I cannot doubt; the cuticle had not allowed the contents to escape by rupture, for it was perfect, uor had the surface of the body that appearance which the oozinog of

pus from numerous pustules would of course give it, and the existence of pus in two cases in a

healthy kidney and bladder, seems only to be ex plicable by absorption. Is it not, then, fair to sup pose that the circulation, loaded with the contents of the pustules, which absorption had introduced into its current, was incapable of affording that stimuluis and support to the different vital func tions, without which death sooner or later must supervene ? But whether this explanation be allowed or not, one point of practice at least lhas b)een strongly impressed on my mind by these cases, viz. the necessity of paying close attention to the appearance of the eruption, (a point I do not

think sufficiently insisted on by authors,) and of forming a most unfavourable prognosis w,hen such a change as that I have mentioned occurs.

I am, gentlemen, Your obedient servant,

JOHN BARRETT.

17, WVestgateBuildings,Bath, 8th Nov. 1841.

RECOVERY

FROM

TAKI'NG A LARGE QUANTITY OF TINC TURE OF OPIUM.

B13Y JONATHAN TOOGOOD, ESQ.

SENIOR SURGEON TO THE BRIDGEWATER FNFMRIlARY.

THE wife of a seafaring man obtained posses sion of a medicine chest, which had been just fitted up for him to take to sea, and drank from a bottle ten drachms of laudanuin, for the purpose

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