little, we doubtless run into the opposite error, of using them
too much. It calls for the gravest censure, that, in almost every
nursery, calomel should still be administered by the parent to young
children and even infants, with as little consideration as if it
were a simple domestic medicine. I am convinced that the infantile
constitution is frequently most sensibly injured by so erroneous a
practice, and that the scrophulous disposition, which might otherwise
be dormant, is thus called into action at an early period of life.
I think it ought to be an established rule, that mercurial medicine
should not be administered to young children without the sanction of
medical authority.
I wish, however, to be understood, that in speaking of the employment
of calomel generally, I censure its abuse only. The proper use of it
deserves our confidence and best regard; and I think that the French
physician labours under great disadvantage in not having a just
practical acquaintance with the virtues of this excellent medicine,
which, as a remedy in various kinds of active disease, is without a
rival.
Chiefly on the principle of avoiding the frequent use of internal
medicine, it is a custom universal among the French to assist the
bowels by lavement; which, under circumstances of disease, is
variously medicated, but otherwise consists merely of water or gruel.
As an occasional remedy, this practice is most useful and important;
and, in certain cases of great delicacy of constitution, it may
be a very advisable substitute for aperient medicine, however
regularly it may be required: but under ordinary circumstances, as
a habit, it appears to me as objectionable in other respects as it
is inconvenient. When the bowel becomes much accustomed to this
artificial distension, it often fails to act without receiving such
solicitation; and hence a mechanical necessity is established for
this peculiar stimulus[5].
When the digestive powers of the stomach are unhealthy, and
particularly when the functions of the duodenum and of the liver are
also in error, as we usually see in established disorder of the
chylopoetic viscera, the propagated influence which may take place
from the lower bowel being stimulated to discharge its contents by
means of the lavement, is insufficient to remedy the functional
error existing so much higher up in the canal, and I have witnessed
examples in which serious complaint in the liver has made insidious
progress, from the circumstance of the patient having placed reliance
on this palliative relief, and neglected the employment of an
effective course of medicine.
The application of leeches, with a view to derive blood from the
vessels which communicate with those of the lower bowels, is a
practice quite common in France, and seems a favourite measure,
whatever viscus of the body may be affected. I have no doubt of the
utility of this mode of obtaining blood, when the lower part of the
intestinal canal is in a state of congestion; and, I may add, in many
cases of irritation. A gentleman had been troubled with diarrhœa,
which was often painful, for two or three months. It had resisted
the usual treatment by medicine. By one application of leeches near
the rectum he was cured.
Nature often points out the propriety of relieving the overloaded
circulation of the intestines, by the discharge of blood from the
hemorrhoidal vessels, and when, therefore, the indications for such
a mode of evacuation are presented, without any spontaneous relief
having taken place, the use of leeches is important. Also in certain
states of congestion of the uterine vessels, this method of local
depletion will be attended with advantage.
In all cases of inflammation near the surface, in which the
detraction of blood is proper, the application of leeches is a
very eligible mode of treatment. I apprehend that blood is drawn
from a greater number of capillary vessels by this method than by
any other; such abstraction being favoured also by the gradual
and protracted evacuation of the vessels. It remarkably relieves
inflammatory action, either of the acute or chronic kind, in the
stomach and bowels. It is by no means so effectual in maladies of
the head and chest, in which cupping is a better mode of taking away
blood; although occasionally, even in those complaints, the use of
leeches may be more convenient, and even more appropriate.
Comparatively speaking, the practice of taking away blood by cupping
is very rarely resorted to by the French, and they appear to prefer,
in principle, the mode of bleeding by leeches, which they call
derivative; thus for the relief of the head, they apply them in the
neighbourhood of the rectum. That free cupping at the neck or behind
the ears, or opening the jugular vein when the vessels of the head
are in a state of congestion and increased action, is a far more
efficacious treatment, appears to me most unquestionable.
I consider it to be an important principle of treatment in regard to
the detraction of blood, in local inflammation, that we should make
it from the system, when the action of the heart is much increased
beyond the natural standard. When we have sufficiently reduced the
pulse, or, if in the first instance the general circulation do not
appear to be affected, it may be preferable to use cupping or leeches
only.
In active inflammation of any of the important organs of the body,
the _decided_ conduct of the English practitioner in using the
lancet as his chief remedy, promptly and boldly, and persisting till
the dangerous force of the disease is conquered, demands, in my
opinion, an undoubted preference over the more tardy, and I must
add, the inefficient methods of the French. This leading difference
in the method of treating dangerous inflammations, appears to me to
constitute the most remarkable distinction in the practice of the
English and the French physician.
I believe that severe and dangerous diseases are much less frequent
amongst the French than the English. There are physical and moral
causes to explain this fact. Their climate is less variable, and
less humid, than ours. They use a lighter diet; much more bodily
exercise, and they are a more cheerful people, constantly cultivating
amusement. Hence, probably, the general plan of French practice
is simple; and the use of _tisanes_ and _lavemens emolliens_ is
generally preferred to the employment of active medicines.
The pharmacien is not in any case permitted to prescribe; and no one
can open a shop for the sale and preparation of medicines, without
the permission of the authorities.
_La médecine expectante_ is still the favourite method of practice
with many of the French physicians. I cannot undertake to say how
generally. When the principle is directed by a clear judgment,
there is much in it to be admired. A constant and too officious
interference by means of active medicines, may do serious injury to
the powers of the constitution; and, on such terms, the remedy may be
worse than the disease: but, on the other hand, to look on passively
as a spectator, and witness the formation of disease, forbearing all
active treatment until formidable symptoms take place, seems more
reprehensible even than excess of zeal in the use of medicine. I
approve the maxim, _Venienti occurrite morbo_.
In inflammations of the most important organs of the body, if we
allow delay, or want decision, the moment of being useful soon passes
away. It is incumbent upon us always to pay due attention to natural
indications, and to consider nature in the light of a good physician;
but I maintain that, in all instances of acute disease, and for the
most part in chronic, we may interpose our aid with certain benefit,
if we form a correct diagnosis, and come armed with just principles
of practice.
Within the last few years, new medical doctrines[6] have been
introduced in France, by M. Broussais, Professor at the Hôpital du
Val-de-Grâce at Paris; of which, the most important part relates to
the inflammation of the mucous membrane of the alimentary canal. This
inflammation is divided into acute and chronic, and is denominated
according to its situation; _gastrite_, when affecting the stomach;
_gastro-enterite_, when it extends from the stomach to the small
intestines; and _colite_, when confined to the colon.
The great importance of the functions of the stomach and intestines,
and the active sympathies which the stomach especially exchanges with
every part of the body, almost as a centre of the nervous system,
is one of the medical truths first taught in our schools, and is
constantly demonstrated to our observation, both in health and
sickness. But M. Broussais has extended to an unauthorized length,
his theories founded on the inflammatory affection of the mucous
membrane of the digestive canal; so that, if I mistake not, he
assigns to it almost an universality of influence.
Our acquaintance with the _gastro-enterite_, is a key to the whole
pathology of this Professor, who has taken a great lead in Paris, and
formed a school of his peculiar doctrines. He considers that all the
essential fevers of authors are only various forms of sympathetic
phenomena, arising out of a gastro-enterite; that all the pretended
nervous affections of the stomach are the result of a chronic
gastrite; that the various dangerous disorders of the brain, for the
most part, owe their origin to the state of the digestive passages,
irritated with chronic disease; that in all the febrile phlegmasiæ,
the stomach and small intestines are irritated in the commencement,
if not during the whole progress of the malady; that the gout
depends commonly on a chronic _gastro-enterite_, “which prepares and
supports the irritation of the joints.”
He considers that _gastrite_ rarely exists alone, and that it is
almost constantly joined with an inflammation of the small intestines.
He does not admit that there is any essential difference in the
nature of gout and rheumatism.
This is a very concise epitome of the doctrines of M. Broussais, and
is offered only as an outline.
The practice which is founded on this view of most of the diseases
of the body is remarkably simple, and may be almost included in
the free and repeated application of leeches to the most affected
part of the abdomen; the use of fomentations and poultices to the
seat of irritation; of emollient lavemens; of tisanes calculated to
allay irritation; of the mildest nutriment, as veal broth with rice;
also the greatest care is used to avoid every irritating material,
whether medicinal or dietetic; and, to favour all these means by
entire repose and time. The gravest fevers of the East and of the
West; the plague itself; the fevers of our own country, continued or
intermittent, typhoid or inflammatory, and the phlegmasiæ, appear to
be all arranged under the same general principle of treatment.
From the observations which I had the opportunity of making at the
hospitals in Paris, and from the attention I have since devoted to
the examination of these doctrines, I am far more inclined to borrow,
occasionally, from the opinions of M. Broussais, than implicitly to
follow his theory or practice.
I am persuaded that the idea of inflammation of the mucous membrane,
founded on the morbid appearance of the tongue, and a dry and heated
state of the surface of the body, is often too strongly entertained.
When the tongue is wholly red and dry, or red in part, with whitish
or yellow fur on its edge, the inference may be fairly drawn,
that the digestive organs are in a morbid condition, and which is
further shewn by the loss of appetite, and by the state of unnatural
thirst. I admit also that in these circumstances, there is a great
susceptibility to inflammatory action in the mucous membrane of
the stomach and small intestines; and the knowledge of this fact
should make us extremely careful in the employment of any heating
stimulus, medicinal or dietetic, in the treatment of fevers, or
of the phlegmasiæ. I am also aware, that, in many cases of fever,
terminating fatally, the morbid appearances on dissection will be
found chiefly in the mucous membrane of the alimentary canal, but
also in the mucous membrane of the bronchiæ; thus lending great
support to the doctrines of M. Broussais. On the other hand, I have
had occasion to notice deductions, in my opinion, too hastily drawn
to be correct, from the mere appearance of redness here and there
in the stomach and intestines, presenting to the zealous admirers
of the doctrine in question, the full evidence of gastro-enterite.
Respecting the precise interpretation due to such appearances on
dissection, the best anatomists and pathologists will sometimes
differ. I may here remark, that the inspection is now and then
made too hastily and superficially: it is requisite that the state
of the whole canal should be accurately traced. In the first view
of the parts it may happen that scarcely any morbid appearance is
discovered; but on extending the research, even the ulcerative
process may be met with in patches: at La Charité I saw several
examples exactly in point.
That an inflammatory state of the mucous digestive membrane is very
influential upon the functions of the other organs, and of the brain
especially, is unquestionable; but is it primary or consequential, in
the order of occurrence? In reference to the question of continued
fever, I apprehend that it is an effect, and not the primary cause of
the general disease, which attacks the whole nervous system at once,
afterwards producing disorder in parts of the body which are most
predisposed to morbid action; and, certainly, it appears that such
secondary disease most commonly falls upon the mucous membrane of the
alimentary canal, and also on the bronchial membrane.
If in the outset of these observations I may seem to contradict my
concluding remarks, I wish it to be understood that I admit the
partial, but not the total, fitness of the doctrines in question. I
object still more to the rigid practice which is enjoined of avoiding
the use of purgative medicine, when the appearances of the tongue
are such as I have described, notwithstanding that the patient may
be free from nausea, or from tenderness or pain of the stomach or
bowels. I consider that the preference is greatly due to our English
practice of giving occasional doses of calomel, or some mercurial
alterative, in combination with suitable purgatives, by means of
which the vitiated secretions, always a source of irritation, are
removed. But here again, I admit that we should look watchfully
to the symptoms which may indicate the necessity or the propriety
of applying, with freedom, leeches to the epigastric region, and
subsequent fomentations, for the relief of inflammatory action,
and of using purgative medicine, in such circumstances, with
proportionate caution.
As a general statement, I would assert, that in the commencement
of fever, continued, intermittent, or remittent, the action of an
emetic, and of calomel joined with purgative medicine, is most
beneficial and important; and the fear of producing _gastro-enterite_
by such measures, would lead us into the serious error of _omission_.
In cases of confirmed indigestion, our improved modern pathology
leads us to the employment of those means which remove inflammatory
irritation; as, the application of leeches, and other local remedies;
the use of mild corrective medicines, abstinence from food, which
calls the digestive powers into much action, and general regimen.
We avoid using bitters and stimulants to provoke that appetite which
nature has so wisely denied during the irritation of disease.
In active inflammation of the intestines, existing in conjunction
with their obstruction, it must be our first care to remove the
inflammatory action by general and local bleedings, and to refrain
from the use of purgative medicines by the mouth, till this first
object is accomplished, in case that such medicine causes sickness
and vomiting, and evidently aggravates irritation. I do not doubt
that much mischief is often produced by the solicitude of the
practitioner to remove obstructed action of the bowels, instead
of directing his treatment to the removal of inflammation, as the
immediate and primary object to be fulfilled.
I will here take occasion to offer a few remarks on the subject
of Gout and Rheumatism. The theoretical opinions advanced by M.
Goupil to prove the identity of the two diseases, are to me quite
unsatisfactory.
Gout never assails the husbandman who unites temperance with his
labours; but he is not exempted from rheumatism in any of its forms.
Gout is the disorder of peculiar constitutions, and of the adult
age; but rheumatism occurs at every period of life, and to all
constitutions.
On the assumption that gout is a _gastro-enterite_, with a
developement of irritation in the joints, purgative medicines are
prohibited, and the free application of leeches to the affected parts
is recommended as the chief curative treatment.
I admit that in some circumstances of the gouty paroxysm, the mucous
digestive membrane is affected with inflammatory irritation,
requiring suitable and peculiar treatment; but, as a general
principle of practice, I confidently advocate the use of alteratives
and purgatives, and, with only occasional exceptions, disapprove
of the employment of leeches as a remedy for the local part of the
disease.
As in theory, so in practice, I believe that M. Broussais considers
that rheumatism is to be viewed in the same light as the gout.
M. Laennec employs general bleeding in acute rheumatism; leeches in
the chronic; and tartar emetic in both forms of the disorder.
An analytical examination of the points of doctrine and practice,
which I have here briefly discussed, would lead me far beyond the
limits which I have intended to observe in this Essay; but I could
not overlook the most interesting novelty which has, for the last
five years, engaged the French school of medicine.
It is still a custom amongst the French physicians to employ
_tisanes_, which are decoctions or infusions of roots, herbs,
flowers, or grains, as medicinal remedies on which they seem to place
considerable reliance. The “_formulaire pratique des Hôpitaux civils
de Paris_” contains nearly ninety prescriptions of different kinds
of tisane. With us, the Lisbon diet drink, or the simple decoction
of sarsaparilla, is the only medicine which we direct to be taken
in quantity as a drink. But even sarsaparilla is given with more
advantage, in a state of concentration, by using the cortical part of
the root, exclusively, in which the whole virtue seems to reside.
I object to the general principle of using medicine in a state of
large dilution. It is true that the French do not prescribe active
substances in this form; but their fondness for these feeble agents,
tends to establish inefficient and almost insignificant practice.
Diluent drinks are useful adjuncts to medicine; but I should think
that a very limited number of tisanes would comprise all that can be
considered either as useful or agreeable.
The nurse may safely act the part of the pharmacien in this
department, but, at the same time, should be directed by the
physician as to the preparation of suitable drinks. With this
qualification, the attention of the French physician in nicely
regulating the regimen of the sick chamber, is worthy of our
imitation. The effect of the most useful and appropriate medicines
will often be frustrated, unless a corresponding care in the plan of
diet be strictly observed.
To this mode of practical medicine peculiar to the French, which I
have here criticised as not worthy of the skilful physician, there
are some striking exceptions.
At the excellent Hospital St. Louis, chiefly appropriated to the
treatment of the various diseases of the skin, and principally under
the direction of Alibert and Biett, arsenical and other active
preparations are administered without apprehension. They prefer small
doses of arsenical solution, twice a-day for a continuance, to the
use of large doses for a short time. Tincture of cantharides, in the
dose of twenty drops twice a-day, is one of their favourite remedies,
alternately with arsenic, in the treatment of the order Squamæ.
Before employing such medicines, however, they are careful to remove
all inflammatory action from the system.
Subcarbonate of ammonia, dissolved in water, in the proportion of
two drams to a pint and a half, and given in this quantity daily, is
found useful in certain states of cutaneous irritation, apparently
caused by a free employment of mercury for syphilis.
The inveterate disease called _lupus_ is very successfully treated by
the application of an arsenical caustic. They allow the part to form
a crust, before they apply a poultice or any emollient dressing.
Neither expence nor trouble is spared in making the artificial
medicated baths. The alkaline bath, prepared by dissolving the
subcarbonate of soda in the proportion of two pounds to the necessary
quantity of water, is extremely useful when the skin is affected
with scales.
The douche de vapeur affords great benefit in some obstinate local
affections of the skin, when it is necessary to stimulate the vessels
so as to bring about an entire change of action. This description of
douche often proves useful in chronic rheumatism, and in sciatica,
when existing in the chronic form.
I had the opportunity of witnessing the administration of tartar
emetic in large doses, as a daily medicine, to patients under the
care of M. Laennec. His method is to begin with one, two, or four
grains, as the total quantity for the twenty-four hours.
A solution is made in the proportion of half or the whole of a
grain, to half an ounce of simple or some lightly aromatic water,
sweetened; and it is given every two hours. The patient is desired
to drink very sparingly; for without this caution, the medicine
would most probably produce too much of emetic effect. In the first
instance, this result very commonly happens; but it is remarkable
how soon the stomach accommodates itself to large doses of this
active medicine. When its continued use produces sickness, syrup of
white poppy is added, in the proportion of an ounce to half a pint
of the antimonial solution; or, as an equivalent, a grain of extract
of opium. The total quantity of the tartar emetic is very commonly
increased to twenty grains and upwards in the twenty-four hours. I
saw an elderly man, who had, in this space of time, on the preceding
day, taken sixty grains without having experienced nausea, or any
other inconvenience.
M. Laennec considers that the tartar emetic, when administered with
the freedom which I have described, exerts a highly useful power
in diminishing inflammatory action in continued fever, and in the
phlegmasiæ; and he is most satisfied with its action, when, after the
first day or two, it ceases to produce any sensible effect on the
stomach.
Reflecting on the extraordinary circumstance of the exhibition of
this active medicine in such immense quantity with seeming impunity,
I thought it probable that the French preparation might be weaker
than our own; but on comparing the crystals which I procured at
Paris, with those prepared according to the London Pharmacopœia,
I could not discover any difference; nor is there the least
essential distinction in the mode of preparation, as directed by the
London Pharmacopœia and the French codex. I have lately had many
opportunities of prescribing tartar emetic on the principle of
treatment which I have described; and I have been perfectly satisfied
with its useful agency; but I have usually commenced with one grain,
and never exceeded two grains, for the first twenty-four hours; nor
found it necessary to go beyond eight in the progressive quantity;
except in one case of insanity, in which sixteen grains were given
daily for a short time, with the greatest advantage. In the quantity
of two grains, it has usually produced considerable sickness for
the first day or two; but afterwards, even the increased doses have
seldom caused any nausea.