CASCARA SAGRADA IN RHEUMATISM.

BY H. T. GOODWIN, M. D.,

Assistant Surgeon, United States Marine Hospital Service.

The effects of cascara sagrada in rheumatism I discovered by accident. About three months ago I was attacked with severe rheumatic pains in my shoulder, the slightest motion causing intense pain. The third day of the attack I commenced taking as a laxative ten drops of the cascara t. i. d. The first morning after taking it the pains were so much less severe that I could move my arm freely. The day following I was entirely free of all discomfort.

Although, as I have intimated, I had not taken the cascara with any idea of relieving the rheumatism, it occurred to me a few days later that possibly the sudden subsidence of pain might have been due to the drug. There being a few cases of rheumatism in the wards, I determined to verify my suspicions. Discontinuing the salicylates, iodides, etc.. which these patients were taking, I substituted ext. cascaræ sagradæ fl., 1 c. c., t. i. d. The result astonished me. Within twenty-four hours there was marked improvement in every case. One case is especially worthy of notice. The patient was a Swedish sailor, who had been admitted three months previously. He suffered intensely, and although almost everything had been given him from which relief might be expected, his suffering was not allayed. For a day or two after admission he improved on large doses of salicylate of sodium, but subsequently the pains returned as badly as ever, and the salicylate had no further beneficial effect. Iodide of potassium was given several different times, but, owing to an idiosyncrasy, could be continued only two days at a time, a profuse rash. making its appearance over the patient's entire body, the pains remaining as acute as ever. They were not confined to two or three joints, but felt in all, being more severe, however, in the wrists, finger-joints and ankles, all of which sometimes became cedematous. On the evening of February 5th, I commenced the exhibition of fifteen-drop doses of cascara sagrada three times daily. The following morning he was about the same; the second day he was much better; on the seventh he was so far recovered that he asked and obtained permission to walk out. From this on he continued to improve steadily, and on the 17th of February he was discharged recovered.

I have used the cascara in fully thirty cases, some ten of which were indoor patients, and, with the exception of three or four, in which there was a syphilitic taint, I have obtained the most satisfactory results. I commenced with 1 c. c., t. i. d., and have, so far, never had to increase it beyond 1.5 c. c., and even to this extent in but two cases. I have seldom had to wait be

yond twenty-four hours for beneficial effects. In two cases I had to stop it temporarily owing to its opening the bowels too freely. In such cases I would suggest that one of the preparations of iron be given (separately) at the same time. I usually combine it with syrup or glycerin in equal parts, and instruct the patient to take from thirty to forty drops in water. In one case, in which neither it nor the salicylate of sodium appeared to give much benefit, I combined the two with good effect. It is but seldom the bowels are opened

too freely by it, the cases above referred to being the only ones I have so far

observed.

Among the out-door patients upon whom I have used it were two intelligent officers of vessels. One was an old river pilot, who had periodically suffered intensely for years. I gave him equal parts of the cascara and syrup, of which I instructed him to take 2 c. c., t. i. d., and requested him to see me again in three days. He returned a month later, and then only to get the medicine renewed. He reported that he had never before had anything relieve him so quickly. The pains began to abate within twenty-four hours after taking the first dose, and in three days after left him entirely. He had had no return, but, for fear of another attack, had come to ask for a bottle to keep with him.

er.

The second case was that of Mr. R., first clerk on a large river steam

He was suffering so much from pain in the hip joint and thigh that he could scarcely get to the office. I put him on large doses of salicylate of sodium, with colchicum and iodide of potassium, and instructed him to return in a day or two. In a week he sent a friend to say that the pain, instead of lessening, was so severe that he could not get to the office. The salicylate, etc., were stopped, and he was given cascara syrup, thirty-five drops, t. i. d. This was on Friday afternoon. On Sunday he came to the hospital and reported that he had commenced taking the second prescription Saturday morning, and that on Sunday he felt decidedly better. He was ordered to continue the drops, and report on Wednesday. Tuesday he sent word that he should be unable to report, as he was sufficiently recov ered to resume his usual place on the steamer.

SOCIETY PROCEEDINGS.

TRI-COUNTY MEDICAL ASSOCIATION.

The Tri-county (Vernon, Cass and Bates) Medical Association met at Pleasant Hill, Mo., Thursday, July 12th, 1888, the president, Dr. W. H. H. Cundiff, of Pleasant Hill, and the secretary, Dr. S. W. Minshall, of Walker, at their respective places. After miscellaneous business, Dr. J. S. Gillette, of Rich Hill, read a paper upon

DYSENTERY.

This disease, he said, occurs occasionally in winter, but is far more common and fatal in summer. Most authors make a distinction between diarrhoea and dysentery, but it is often difficult to make any distinction, clinically, except that a simple diarrhoea, continuing unchecked, culminates in dysenteric discharges. A recent writer in a metropolitan journal says it is always easy to make distinction between the two diseases which he regards as essentially different; in diarrhoea there is always present in the discharges the coccus of diarrhoea, while in dysentery there will always be found the bacillus of malaria. But as we can not have a microscope at the bedside of every patient we must make out the diagnosis by symptoms alone. These are too well known to repeat as it is not a rare affection, attacking as it does the child at the breast, the adult in the full vigor of manhood, and those who have

passed into senility-in the first and the last often fatal. When a simple diarrhoea persists in spite of treatment until the tongue becomes foul (or sometimes whitish with the papillæ showing bright red, or again having a red and dry appearance), the teeth and lips dry and covered with sordes, a fever comes up-remittent in character and usually worse in the afternoon-sometimes vomiting, the abdomen tender with great pain and tenesmus, a frequent and irresistible desire to defecate, the stools (at first semi-feculent, or consisting of hard scyballæ) become scanty, slimy or gelatinous, mixed with blood and of a very offensive odor, and in graver forms having a very dark color, often watery and copious, containing shreds of intestinal mucous membrane-these should be sufficient to enable one to make a diagnosis without a microscope. Sometimes it is doubtless complicated with malaria, especially in those cases ushered in with a rigor, and very often the disease assumes a typhoid character with great nervousness, depression of the vital powers and incontrollable passages, accompanied by a weak heart. Every resource of therapeutics has been tried from the old-fashioned "root and yarb" teas and Perry Davis' Pain Killer to the microbe killers suggested by the researches of Koch and Pasteur, with possible inoculation in store; but the more remedies we try the less satisfaction we get from them. New methods have been, and are, many. The latest is the anti-septic treatDoubtless such drugs may accomplish much, but we must not look to them too much; rather should we, in the present light of our knowledge, rely upon the time tried remedies, especially opium in some form given by the mouth, by supposi tory or by enema. Astringents are sometimes of advantage though overestimated; the old formula of one grain each of acetate of lead, camphor and gum opium is excellent. But above all, complete rest in bed must be strictly enjoined, the patient not even being allowed to get up for operations, using a bedpan where obtainable; where not soft cloths may be used as a diaper. Then careful attention must be paid to the diet, nothing being allowed that is not easily digested and absorbed. No diet at all is better than the recent plan of crowding with milk, for milk is rich in casein, and casein is almost indigestible while the intestinal tract is in a dysenteric condition. The treatment may practically be summed up as fresh air, digestible food and opiates for the pain and tenesmus. If it arise from malaria or indigestion it is best to begin treatment by a laxative or even a cathartic to clear the alimentary tract of its fermenting, injurious contents; for this purpose mercury, castor oil, or sulphate of magnesia may be employed-preferably the latter. This should be followed by the opium to quiet pain, check the spasm of the sphincter and retard peristaltic action; then germicides may be used if so desired. Lately an injection has been used with considerable success, consisting of warm starch holding in suspension opium (or morphine) with either carbolic acid or minute doses of bichloride of mercury.

ment.

Dr. J. L. Warden, of Pleasant Hill, read an extract from a paper by Dr. H. F. Hendrix, of St. Louis, entitled

WATER AS A CURE FOR CHOLERA INFANTUM.

It recommended the free administration of ice-water to children suffering from this grave disease. In some years' active practice in St. Louis the author had not lost a single case since adopting this treatment. Reviewing "authorities" Smith advises to provide good food, good air, promote good digestion and check the diarrhoea -four things usually found to be impossible.

The formula of J. Lewis Smith has been highly extolled, consisting of

Misce.

Misturæ cretæ

Sig. Teaspoonful every three or four hours.

But even this often is inefficient. Eberlé advises to first bleed, then purge and then resort to opiates, astringents, etc., but Eberlé lived half a century ago, and we have learned that his treatment is attended with great mortality. Day admite that great judgment and care is necessary to bring a case to successful termination; he advises a dose of castor oil and rhubarb followed by krameria, laudanum, &c., a plan also attended with considerable fatality. The usual recommendations for re

moval to the country, placing in a well-ventilated room, enjoining the utmost tran quility, are, in a vast majority of cases, impossible to carry out. But ice-water can always be had in abundance and people should learn that its effect in dysentery is not poisonous as they are inclined to believe (just as was the case in fevers not many years ago), but is in reality a very valuable agent in treatment. The child, particularly if feverish, should be given a glass full of ice-water and allowed to drink to its satisfaction; the water will probably be almost immediately vomited, but the water should again be offered. A little longer interval will elapse between each emesis and the child will drink less and less each time until at last only a moderate amount will be taken, it will be retained and the thirst having been satiated the little patient sinks into a comfortable slumber. In one case recently fully a gallon or a gallon and a half was drunk before the child was satisfied and then it sank into peaceful sleep from which it awoke convalescent although it had apparently been upon the verge of dissolution. Dr. Hendrix does not depend upon this alone, however, but gives fifteen grains of bismuth every two hours until the discharges cease, and where the passages are very acid ten grains of bi carbonate of soda is given in water every time the child asks for a drink. Not only will this line of treatment check the summer diarrhoea of children but it will cure cholera infantum even in very young children; all facts seem to prove that the cause of cholera infantum is chiefly a want of cold water—the little patient acually dies from thirst, the alimentary canal being the first to feel the trouble. Cholera infantum will never occur where plenty of cold water is given a child. Prejudice against it should not weigh in making use of this plan of treatment. There is, practically, but one point in Dr. Hendrix's paper—the use of ice-water-and an expression of opinion from members of the society is desirable.

DR I. M. ABRAHAM, of Harrisonville: There is, as Dr. Warden says, but one point-ice-water given in abundance in the manner suggested I have often thought

of it but have never put it in practice. I have used ice-water in a different way whenever I could get the nurse or mother to lay aside their prejudice and obey; I direct the child to be given two teaspoonfuls of ice-water every five minutes when awake; but often it will not be permitted by parents. Good results have always followed the plan and though I have not followed the rule laid down by Dr. Hendrix, yet I beliexe it is rational. A good and broad rule in treatment seems to me to be to give whatever nature seems to be calling for. Careful nursing is all-important, to make the patient comfortable the first indication. The child should not be jolted on the arm of the nurse or rocked violently, but the strictest quiet should be preserved. To this end I give opiates-just sufficient to maintain rest, control tormina and tenesmus and check fretting. This is principally my line of treatment. As for medication the longer I live the less I medicate, in this as in other diseases; I sometimes combine elixir of lactopeptine with bismuth, and at the same time give aromatic spirits of ammonia when there is great weakness.

DR. I. W. AMMERMAN, of Nevada: The gentlemen say there is but one point in the paper of Dr. Hendrix-the free use of water. I admit that is important and probably useful, but it seems to me that they, as well as the author, attach too much importance to that and not enough to the very large doses of bismuth given. Did any of you ever try bismuth in diarrhoeas ? I mean bismuth in large doses and alone. It is so effective that I know of some who confine themselves to fresh air, proper food and bismuth. Others rely upon sulphuric acid exclusively. I think the bismuth must have considerable credit in the results claimed. I some time ago had a very severe case, and as it had resisted all treatment and was seemingly very low. I asked Dr. Dulin, of our city, what to do for it. He replied, "Put it on bismuth alone, in large doses, and hold it on bismuth." I did so, and in thirty six hours the child was almost convalescent. As for the water, it is certainly to be commended.

DR H. JERARD, of East Lynne: In this case, Dr. Ammerman, were the dejections sour?

DR. AMMERMAN : Yes, very sour.

DR. JERARD That explains the excellent results, then, for where there are acid dejections an alkali, like bicarbonate of soda or an ant-acid like bismuth will check the discharge quickly; lactic acid answers well in such cases also. But where

the discharges are alkaline, I have been most successful and obtained the quickest results by the use of

Misce. Sig. One teaspoonful every hour or two.

It acts almost like a "charm.” It seems to me, as regards the use of water in the manner suggested that if it does not produce emesis it might prove a source of danger in such large quantities; if thrown up it is all right, but I think I should be careful about giving it in such inordinate quantities. But plenty of water to quench thirst is imperative, especially if

there be fever.

DR. D. H. WEBSTER, of Austin: The use of water, as suggested, is perfectly right. If it is necessary for that child to vomit Nature will cause it to throw up, but if the condition of the stomach be such that the water is immediately absorbed into the depleted blood-vessels it is uncecessary for it to be vomited; if it isn't taken up it certainly will soon be ejected. As to opiates, morphine is too strong, usually, for children, as too much is likely to be given. Pulverized opium, or the tincture of opium is to be preferred, and seems to act better than the alkaloids. This may be given with advantage with bismuth and lactopeptine. I am a strong advocate of cold water, and shall certainly try this method of using it.

DR. WARDEN: It certainly is an innovation on the established line of treatment. It recommended itself to me and so I presented the subject to obtain the opinion of this body. Doctors usually favor such procedures but don't practise them; most men will be afraid to push it to the extent Dr. Hendrix has done. Personally, I shall try it whenever I get a case where the friends will permit. The objection that it will cause trouble if not vomited is not a tenable one, because it will be immediately absorbed and thrown off through the perspiration, etc., to the advantage of the patient. Dr. Ammerman's point is not well taken, because I think nine-tenths of all physicians have patterned after J. Lewis Smith, and have very thoroughly tried bismuth, especially in the cities; hence I believe the water has much to do with the phenomenal results of Dr. Hendrix.

DR. GILLETTE : Last summer I had a case-a child twenty months old, which was as bad as such cases usually get. I was very much discouraged, and finally gave up all hope. The constant cry of the child was • Water, water, water! My practice had been in these cases to withhold water as far as possible, although my concience has often condemned me for it, just as it used to do in the same treat. ment of cases of typhoid fever. But I thought it would die any way, so I told the folks to give it all the water it wanted. They gave it a teaspoonful of ice-water every two minutes for two hours before it was satisfied, and it didn't vomit it at all. The child got well and I believe the water cured it.

DR. MURRAY, of Holden: I would like to know what the action of bismuth is. I do not believe it is effective when used alone, but is excellent in combination with opium and pepsin. I do not believe in giving all the water asked for, as it will certainly prove injurious if not vomited, for in many instances it cannot be absorbed but must simply pass through the bowel and increase the number of watery discharges. One to two teaspoonfuls of champagne with an equal amount of shaved ice given every fifteen or twenty minutes will control the vomiting and quench thirst far better than the water. I like a combination of syrup of rhubarb and prepared chalk.

DR. W. H. CUNDIFF, of Pleasant Hill: Dr. Murray, what proportion of the human body is water ?

DR. MURRAY: Something over three-fourths.

DR. CUNDIFF: When the tissues become depleted by the exhaustive watery discharges, do you not think there is a legitimate demand on the part of the system for water?

DR. MURRAY: Well-perhaps; but we know that in these cases our medicines are frequently not absorbed, then why should we expect water to be? Water unabsorbed all will admit must of necessity prove injurious in such cases.

DR. WEBSTER: I would like to ask you, Dr. Murray, do you not think your