AN EXPOSITION yy/s ___M.£3JL.'U~ OF THE PRINCIPLES OF THE /^,/., NEW MEDICAL. DOCTRINE, WITH AN ANALYSIS OF THE THESES SUSTAINED ON ITS DIFFERENT PARTS. TRANSLATED FROM THE FRENCH OF J. M. A. GOUPIL, /*/! Doctor of Medicine of the Faculty of Paris ; Demonstrator ^f^^lg^ of Toulouse ; Member of the Medical Society of the same_C.ty of that ot Medicine, Surgery, and Pharmacy, of the Department of Eure of the Lindean Society of Bordeaux; of the Societies of Sciences, Ag- riculture, and Arts of Strasbourg and Agen, &c BY JOSIAH C. NOTT, M. D-. TO WHICH IS APPENDED A SHORT ESSAY ON LEECHES BY THE TRANSLATOR. 7763 COLUMBIA, PRINTED AT THE TIMES AND GAZETTE OFFICE. 1831. 39^. 4 Cup' COPY RIGHT SECURED ACCORDING T0*LAW WE ' ' ■ \T6l- TO SAMUEL JACKSON, M. D. I know no one to whom I can with as much propriety dedicate the following pages as to yourself—It was at your suggestion I perused the original, and it was from your lec- tures I received my first ideas of the doctrines it contained. You sir, were the first to raise the standard and fight the battles of Broussais in the United States; and with what zeal, talents and success, the profession has already decided. Your name will long be remembered as having most con- tributed to disseminate just principles of Pathology and Therapeutics in this country. 1 hope Sir, you will accept this as a tribute, however feeble, to your merit, and as the best acknowledgment I can now offer you for the many favors I have received at your hands. I remain, dear Sir, with great respect and esteem, Yours, &c. JOSIAH C. NOTT Columbia, June 8, 1831. ERRATA. Page 2, Line 9, for apercu, read apercus. 13, Caption of Chap. 2, read Local phenomena of irritation. " 21, Last line, read systematic for sympathetic. " 24, Six lines from the botiom, read or for of the parenchyma.. " 31, Line 17, read, by the pains. 38, Line 18, for designated, read degenerated. " 61, For petechias, read petechia. " 62, Line 17 from bottom, strike out fazwe. " 77, Line 20, for injudicious, read injurious. • 87, Line 1, strike out "takes place at the close of an articular inflam- mation, is like." • 88, Insert after the last line, "supervenes on an articular inflamma- tian, is like." " 96, For marasmus, read Tabes mesenterica. " 123, Line 7 from bottom, for of, read if. " 139, Line 3 from bottom, put the ( , )#comma after it. " 141, Line 11, for then, read they. " 151, Line 2 from bottom, for prescribe, read proscribe " 162, Line 13, for has, read have. " 205, Line 16, read Parenchymatous. " 221, Line 12, read, does not take place. " 240, Line 3, read, eight hours. '•'• 276, Line 1, read, Pyritologie. " " Line 7 from bottom, read arrives for arises " 292, Line 10, for causes, read case*. " 319, Line 6, for Sympathies of the stomach with the brain and nervous system. 178 " with the organs of sense. ^9 2 XABLt OF CONTENTS* " with the skin. ISO ■' with the locomotive apparatus. 1?4 " with the circulatory apparatus. 1D " with the respiratory apparatus. 185 " with the organs of secretion. 186 " with the genital organs. 187 Sympathies ofthe different parts ofthe digestive mucous mem- brane with each other. 188 Chap. 2. Etiology of Gastro-enteritis. 189 Thesis of M. Chauvin on this disease. ib Division ofthe causes of this inflammation, ib Immediate or direct causes. ib Stimulating ingesta. ib Irritating medicines. 190 Acrid poisons. 191 Intestinal worms. 192 Sympathetic causes. 193 Action of heat. ib Sympathetic stimulation exercised by inflamed organs. 194 Traumatic lesions. 195 Too active exercise. ib Sad moral impressions. ib Thesis of M. Lasserre, on pains in the passions. t 196 Jlfixed causes. 197 Example ofthe irritating properties ofthe bile in certain cases. 198 May its irritation be considered as a cause of gastro-enteritis ? ib Deleterious miasms. 199 Their principal action is exercised on the stomach. ib They do not act on the whole economy. 200 Circumstances favoring their action. ib Chap. 3. Local and general phenomena of inflammation of the di- gestive mucous membrane. 201 Art. 1. Phenomena of acute gastro-enteritis. ib Prodromes. ib Local phenomena. 202 Epigastric pain not constant. ib When it does not exist, other signs do not permit us to mistake the disease. 203 Sympathies on the brain and its membranes. ib Muscular prostration cannot be attributed exclusively to the concentration of vitality in the viscera. 204 It depends principally on irritation of the cerebral substance. ib Atony is the result of irritation of its surface and meninges. ib Sympathies with the heart. 205 Frequency ofthe pulse is not always in relation with the inten- sity of the inflammation. ib Sympathies with the organs of respiration. ib Gastric Cough. 206 Sympathies with the secretory organs. ib Mouse odour : explanation of M. Lallemand ib Sympathies with the mucous membranes. ib Signsdrawn fiom the state ofthe tongue. ib " thirst. 208 " inappetence. ib Sympathies with the skin. ib State ofthe face. ib TAB1A: OF CONTENTS. XI '•AGE. Parotids. 209 Sympathies with the articulations. ib Different forms of gastro-enteritis—what constitutes them. ib Inflammatory fever. ib Embarras Gustrique. 210 JJilious fever, ib Causus, ib .Mucous fever, ib Ataxic fever. 211 The predominance of concomitant encephalic irritation distin- guishes it from the other forms of gastro-enteritis. ib It appertains to gastro-enteritis like the other forms of essential fevers. 212 Adynamic fever. ib M. Broussais no longer admits that it can be produced by any other inflammation than that of the digestive passages. ib Contagious and epidemic fevers. ib Plague—Yellow fever—Typhus. 213 These are miasmatic gastro-enterites conplicated with other inflammations. ib Cholera morbus. ib An account of an epidemic of this affection in India by M. Gravier. 214 No fixed duration can be assigned to gastro-enteritis. 219 Its prognostic. ib Art. 2. Phenomena of chronic gastro-enteritis. 221 Thesis on this disease. . jb Its causes the same with those of acute gastritis. ib It may be primitive or consecutive to an acute gastro-enteritis. 222 Its symptoms. ib They present many varieties. ib Neuroses of Digestion. 227 They are almost always chronic gastrites. ib Dyspepsia. ib Proof that it depends, in almost all cases, on an irritation of the stomach. ib Sometimes produced by its debility. 228 It cannot then continue for a long time. 229 Signs by which we distinguish it from the former. ib Cardialgia, gastrodynia, pyroses and bulimia are symptoms of chronic gastrites. ~3..> Hypochondria depends on the same lesion. 234 The duration of chronic gastro-enteritis is unlimited. ib It passes frequently into the acute state. 385 The disease is then very serious. . . ib Cancer of the stomach, considered as a result of chronic gastritis. 236 Spontaneous perforations ofthe stomach. 237 Opinions respecting their formation. fo They are the result of inflammation of the stomach. 238 Ramollissment ofthe inflamed tissues, demonstrated by M. Lalle- mand. _ *u Cases of spontaneous perforations, in which the pre-existence of gastro-enteritis is seen. 239 Perforations supervening rapidly. 241 \rt. 3. Phenomena of acute and chronic colitis. 244 252 ib XJI iNABJ.fc; OF CONTENTS. PA G K. Diarrhoea and Dysentery are two degrees of it. 244 Causes of* Colitis. ^ Different forms of this inflammation. ^45 Complication of colitis with essential fevers. * 249 Art. 4. Alterations produced by inflammation ofthe gastro-iniesttnal mu- cous membrane. Thesis of M Scoutetten. Alterations observed after essential fevers. 1D " chronic gastro-enteritis. 261 Fluids existing in the inflamed digestive canal. 268 Alterations produced sympathetically in the organs by gastro enteritis. 270 " in the liver. 1° " in the spleen. ^D " in the pancreas. 271 " in the brain and the meninges. ib Chap. 4. Relation of gastro-enteritis with the essential fevers 979 OF AUTHORS. _ ■*• * All the fevers reputed essential are gastro-enteritis. ib Proofs of this opinion. 273 Objections made to this opinion and reputation of them. 275 Ordinary intermittent fevers are gastro-enteritis. 287 Proofs of this opinion. ib Recapitulation on the nature of fevers. 289 Chap. 5. Treatment of inflammation of the digestive mucous mem- brane. 290 Treatment of acute gastro-enteritis. ib Treatment of the Prodromes. 291 Appreciation of the effects of Tartarized Antimony at this stage of the disease. ib Employment of bloodletting in this disease ; rules to which it should be submitted. 293 Necessity of absolute diet. 296 Stage at which aliments may be allowed. 297 Emollient Topicals. ib Application of cold to the abdomen. 298 Revulsives. ■ ib Enemata. 298 Attentions required by concomitant central irritation. ib " hemorrhages. ib " external and visceral inflammations. 300 Conduct to be adopted when the adynamic state supervenes. 301 " when the disease is on the decline. 302 Treatment of chronic gastro-enteritis. 304 Difficulties which it presents. ib Regimen constitutes the most important part of it. ib Abuse of tonics in this disease. 306 Treatment of colitis. 307 It was very defective previous to the physiological doctrine. ib Curative Indications presented by this inflammation. 308 Treatment of Diarrhoea. ib " of Dysentery. ib Efficacy of Leeches in this disease. ib Necessity of diet. ib Good effects of Opium at the commencement and close of the disease. 209 1ABEEOF CONTK.VJW Xlli PAGE. Treuunenl of chronic colitis. 210 It consists principally in a severe regimen composed of fecula. ib Employment of Opium in this grade ofthe inflammation. 311 Treatment of intermittent gastro-enterites. 312 It is applicable to other irritation of the same type. ib Indications which it presents. 313 The patients should not be prepared for the bark by emetics and purgatives. The preparation consists in making the inflammation perfectly apyretic before the administration of stimulants. ib Cures obtained by antiphlogistics. 314 Precautions which the employment of stimulants demand. ib Modification of this treatment applied to malignant intermittent and remittent fevers. 315 When the inflammation has had little accession and is accom- panied with powerful reaction. 316 In the opposite circumstances. ib RELATION OF GASTRO-ENTERITIS AND OTHER INFLAMMATION. Influence exercised by irritation of the other organs on the sto- mach, ib '*' by Gastro-enteritis on irritated organs. ib Physicians have known these relations, but they have been mistaken on the nature ofthe affection ofthe stomach. ib Influence of gastro-enteritis on external chirugical lesions. ib Benefits received by surgery from physiological medicine. 319 Necessity of applying the latter to the former, v ib Art. T. Relations of gastro-enteritis with hepatitis. 321 Hepatitis is consecutive to gastro-enteritis where it is not produ- ced by external violence. ib This proposition is demonstrated by the examination of the causes of inflammation ofthe liver. ib " by that of the phenomena of acute and chronic hepa- titis. 322 " by the results of post mortem examinations. 323 Consequences drawn from these data in the treatment of he- patitis, ib Art. 2. Relations of gastro-enteritis with the cutaneous phlegmasia;. 226 Physicians did not know the bonds existing between irritations ofthe skin and those ofthe gastro-intestinal mucous mem- brane, ib M. Broussais shews that the former are under the dependence of the latter. ^ ib Thesis of M. Talma on eruptive diseases. 327 The fever of incubation appertains to gastro-enteritis. * ib The intensity of the eruption is ordinarily in proportion to that of the former. 228 The eruption produces a cessation ofthe gastro-enteritis ofthe prodromes, by operating a revulsion ofthe irritation. 329 The secondary fever is the result of the reproduction of the gastro-enteritis produced sympathetically by inflammation ofthe skin. ib Apyretic cutaneous inflammations (from an internal course) are consecutive to gastro-enteritis. ib Those which are produced by exterior agents are not' accom- panied by fever except by developing gastro-enteritis. ib Treatment of cutaneous inflammations. 330 vi'. TABLE Oi' CONTENT."*. PAGE. It is necessary to combat the premonitory gastrites and in order to render the eruption lighter. 330 It is necessary to calm the cutaneous inflammation to prevent the secondary gastro-enteritis. ib When this appears, we should combat it as it were primitive. 331 Ait. 2. Relations of gastro-enteritis with articular irritations. ib Gout and articular Rheumatism are only different forms of arthritis. 332 Thesis of M. Roche on these diseases. 333 The division attempted to be established between them is not well founded. ib Proof. ib Erroneous theories on the nature of Gout—Ontology—refuta- tion ofthem. 336 Recapitulation on the nature of Gout. 327 Part played by irritation of the stomach in this disease. ib Gouty constitution; in what it consists. ■ 338 How far gout is hereditary ; what is to be understood by it. ib Gouty principle; gouty diseases—refutation of them. 3S9 Displaced gout, it is a metastasis ofthe arthritic irritation. 340 Principles of the treatment of gout. 341 Necessity of treating gastro-enteritis, primitive or consecutive to arthritis. 342 Danger of purgatives in the treatment of this disease. 343 Art. 4. Relations of gastro-enteritis with cerebral irritations. ib Influence of gastro-enteritis over thedevelopement of cerebral irritations. ib Influence of encephalitis on the stomach. 345 Facts proving these mutual relations. 347 ASTHENIA. 350 Erroneous principles on this state. ib In v»hat manner it should be considered. 351 Causes which determine it. ib Its phenomena. 352 Asthenia of function and of nutrition. 354 Its treatment. 355 APPENDIX on the use and application of leeches. r-~7 AUTHOR'S PREFACE. When M. Broussais commenced promulgating his opin ions, they were soon published and supported in theses, defended before the faculty of Medicine of Paris. These dissertations have not a little contributed to propagate a doctrine which is that of all physicians desirous of keeping pace with the march of science. Many amongst them have been sought for with eagerness, and contain many precious facts and discussions full of interest, which are not met with elsewhere. These theses being very rare, and most physicians not being able to consult the collections of the faculties, I have thought that it would be useful to present an analysis of them, as Robert did on a former occasion for the doctrine of the celebrated Bordeu; persuaded more- over, that we could not draw from a purer source for the purpose of exposing the principles of a doctrine which has gained to its author so just a celebrity, and to his works such great success. I have frequently consulted also other writings, and I have never neglected to support the princi- ples which I have presented, with the very words of the creator of Physiological medicine—Instructed for a long time in his school, attached during two years to the hospital ofthe Vol de Grace, I am certain of never having altered. as has been too often done, the opinions which he professes. TRANSLATOR'S PREFACE. Although the name Broussais is familiar to every one, how few in the United States, particularly in the southern portion of them, know any thing of his history or of those doctrines which are now so deeply agitating the Medical Profession throughout civilized Europe. It is true that some of the works of his school have been translated into our language, yet none that I have met with exhibits his principles in a clear, concise, and forcible manner. The number and length of his own writings have hitherto deter- red translators, which is to be regretted, as he is the most authentic and best expositor of his doctrines.* I am happy to learn, however, that the Examen and Phlegmasies chro- niques are preparing for the press. Mr. Goupil's book, though inelegant and inaccurate in point of style, is the best elementary work of the Physiolo- gical School, especially for the younger members of the pro- fession, that I am acquainted with ; and will continue to hold its place, as M. Broussais has acknowledged its correctness. I have not been induced to give publicity to it from the be- lief that the system of M. Broussais is a perfect one. Like all medical reformers, he is enthusiastic, and his heated imagination has led him into the error, so common to genius, of generalizing too fai. But I am persuaded that he is nearer right than any one who has preceded him, and that no physician can read his works attentively without becoming a better pathologist and a better practitioner. Nor indeed * The works of Broussais are, 1, Histoire des Phlegmasies ou Inflam- mations Chroniques. 2, Examen des Doctrines Medicales. 3, Traite de Physiologic 4, De L' irritation et de la Folic 5, Commentaire des Propositions de Pathologic 6, A great number of Articles in the An- nales de la Medicine Physiologique, &c. 3 xviii translator's preface. should any one be ashamed to admit this, unless he should be prejudiced enough to suppose that medical knowledge had arrived at perfection, and that experiment and the press could teach him nothing more. Even the antagonists of Broussais have acknowledged the light he has thrown on the maladies ofthe digestive canal, the inflammations of the white vessels, the identity of chronic and acute phlegmasia?, the doctrine of sympathies, &c. So fallacious is experience in our profession, that physi- cians may differ widely, and at the same time differ honestly. I have, however never yet met with one who has studied the works of M. Broussais, and tested his practice, who has not modified his own to a greater or less ex'ent; but I have met many too devoid of candour to acknowledge their ob- ligations to him. It has become very much the fashion with those too indolent or too much prejudiced to keep pace with the science of the day, to ridicule the French Physicians and their followers, as vain theorists, and inefficient practition- ers who .sit quietly with their arms folded and see their patients die for want of assistance. But I would ask these gentlemen from whence comes the greatest part of our recent discoveries in anatomy, physiology, pathology, chemistry, &c? If they have watched at all the progress of science, they will at once answer, not from England or the English School, but from the Continent of Europe, and principally from France. Can it be then, that the men who have ad- vanced the other branches of the science to such a height, should have so failed in therapeutics (the most important of all) as to be utterly unworthy of notice ?—Nothing but ig- norance and prejudice could originate such notions. Those who declaim most against Broussais, will be found to be those who know least of his books. Not a few of the enemies of the Professor ofthe Val-de- Grace, have attempted to show that his ideas are not original— translator's preface. xix that they are to be traced to Baglivi, Bordeu, Prost, Bichat, Miller, &c. Yet, however, we may find insulated prin- ciples resembling his, who among his predecessors has elaborated and brought, a similar complete and connected system, into existence, and what is more important, put it into effectual operation ? Indeed, the amount of the charge- is, that Broussais is not the discoverer but the teacher of truth. No man, perhaps, of any age ever possessed in a higher degree than M. Broussais, the qualifications necessary for a medical reformer. He is enthusiastically devoted to his profession, endowed with an intellect acknowledgec by all to be of the first order, and his opportunities for obsevation have not been surpassed by any one of ancient or nodern times. He was for six years in the navy, afterwa.ds was attached to the grand army which he accompanied (or nine years through France, Holland, Germany, Italy an< Spain, and in 1814 was appointed Physician and Professor of an extensive hospital in Paris, (the Val-de-Grace,) v^hich sta- tion I believe he has held ever since—his private practice also has been very great. Thus he has been caled on to • treat every variety of disease, modified in ever^possible manner by diversity of climate, season, habit, andponstitu- tion. Under these various circumstances he hai studied disease with untiringzeal at the bed side, watched iithrough all its grades and changes, and not satisfied even )ere, he has pursued its footsteps in the dead body, and alvanced pathology to a degree of perfection hitherto unkiown. Such a man is at least worthy of a patient and candid hearing. OF IRRITATION IN GENERAL CHAPTER FIRST. OF all the forms assumed by irritation, inflammation was the only one which fixed the attention of physicians previ- ous to the origin of the physiological doctrine ; and not- withstanding its frequency and the great number of inves- tigations on this subject, all the modes in which it may ex- ist, were still not known. Sole model of all the descriptions which they have given of it, phlegmon was the type of all the ideas they formed of the phlegmasia and they mistook most of those not presenting characters as strongly mark- ed as inflammation of the cellular tissue. The history of chronic phlegmasia? had made still less progress: con- sidered as affections entirely different from inflammations, they formed several classes of particular diseases, according to the diversity of forms which they assume, and the organic changes which they produce in the tissues. The numerous irritations of the white vessels were completely unknown, and the nature of the diseases of this system was involved in the most profound obscurity. After having studied it under all its forms and in all the tissues, M. Broussais has created, if we may use the ex- pression, the history of irritation, and the science, at the present day possesses a complete theory of it. The new facts acquired with regard to this element of the greater- number of diseases, have changed almost entirely the face of pathology, and it will only be necessary for us to expose Jhem. to shew the exactitude of this proposition. ['* ] We do not find in any thesis a general history of irritation written according to the spirit of the new medical doctrine ; but several of its modes have been treated particularly of in a considerable number of inaugural dissertations. M. Vialle has given us some general considerations on irritation which, notwithstanding all the interest they possess, cannot be well analysed, because he has embraced too great a num- ber of subjects, on which he has presented us some valua- ble hints, (apercu) and because he has treated not one of them particularly. We will, however, extract from his the- sis a number of propositions to which we will add some de- velopments, taken, for the most part, from the same source from whence he himself has drawn. Organized bodies, says M. Vialle, are animated by two forces named by phy- siologists sensibility and motility, to which they refer the ori- gin of all the phenomena observed in these bodies. These expressions have the inconvenience of giving rise to con- jectures on the nature of organic actions, whilst it is inac- cessible to all our means of investigation ; we can perceive only the results of the modifications which organized mat- ter experiences from the action of external agents ; and it is only by induction, it is only by carrying the idea of motion into the molecular action of the tissues, it has been es- tablished that it is by virtue of sensibility and contractility, they respond to the influence of modifying agents. M. Broussais has opposed the division of this property of UTe organized tissues, and for the purpose of establishing its unity, he observes that the sensibility of the fibre is onlv evinced by its contraction, and that it is only because it has contracted w iivmv n.isilv broken, and that its concert-ration*? w L w ] more frequent, when the sum total of the forces is less.' — It has also been observed, that feeble individuals are more subject to visceral inflammations, and that in them these in- llammations ordinarily become very serious. Indeed, debility being never general, affecting only certain parts, others are left in a state of relative superexcitation which predisposes them toinflammations ; besides, the sympathetic irradiations produced by them, cannot create reactions in the debilitated organs which receive thein, and the concentration of forces in the diseased point not being counteibalanced by the ac- tion of the others, augments incessantly; the equilibrium cannot then be established. Many practitioners have observed that a small bleeding, far from diminishing the intensity of a pneumonia, only serves in general to exasperate it. Sanguine emissions do not in fact, produce any amelioration except when they are copious and so rapid as to produce an immediate effect on the capil- lary circulation of the inflamed viscus. M. Broussais explains after the same manner the irrita- tion of the sensitive apparatus manifested by convulsions which we observe in large sanguine deperditions, in death from hemorrhage. The activity of the nervous system is always in an inverse proportion to that of the sanguine and muscular systems ; to weaken the latter is to increase the former. This assertion is based on too great a number of facts of physiology and pathology, to require any farther explanations. From all that precedes, it follows then evidently that under the influence of debilitating causes, debility is far from being uniform, that irritation may co-exist with it, and that even in certain cases the latter is the result of debili- tation. Irritation of one organ brings on always diminution of the action of some other, and this phenomenon is more marked in proportion, as that of the first is greater. When it exists in the viscera, it is principally the muscular system that ex- periences this debility which we see carried to the last de- gree in gastro enteritis of the highest grade. The Bruno- nians, who only appreciated the forces by external ap- pearances, judged of the state of all the organs by that in which they found the muscles, and did not consequently al- low the inflammatory character except to lesions, accompa- nied with coloration of the face, force of pulse and energy [ n j ot the muscular system, and ranged under asthenia all thus. joined to an opposite exterior. This error has insinuated it- self into the theories of other schools ; external debility has fixed all their attention in the visceral inflammations which produce it, and attributing to it the fatal results pro- duced by the latter, they have made debility a disease and have addressed to it their curative means. Whatever be the extent of the parts whose action appears increased, the irritation always commences in a point. It ds only secondarily that it is transmitted tb others, and all of the tissues are never irritated at the same time. It is impos- sible indeed, that excitants can have an action general and every where uniform, that they can stimulate all the organs in the same degree; and whatever extension we may suppose- to their action, it will always happen that the most impor- tant organs, those which are most sensible, will be irritated in a higher degree than the others. Let us take an exam- ple : suppose an inflammation of the whole mucous mem- brane of the digestive passages which gives rise to a sym- pathetic irritation of the heart, of the brain and skin, the heat of which shall be increased, throughout its whole ex- tent, and one region shall even be affected with erysipelas ; suppose also that there be joined to these lesions an inflam- mation of the mucous membrane of the lungs and bladder, a hepatitis and a peritonitis; here certainly is the most se- rious assemblage of lesions which we can meet with ; and yet how manytissues are not affected. The febrile state is often cited as an example of general disease ; but we should carefully distinguish the phenomena of disease from the lesion which produces them ; and as M. Broussais remarks, if in fever we observe a greater activity of the circulation, and a more considerable heat in all the tissues, it does not follow from this that the cause of this exaltation of action exists in all parts and that the disease is general; its seat is often very limited, and no one will consider as a general disease, the febrile state often produced by a paronychia, an angina, an erysipelas, &c. The direct or sympathetic impressions of stimulants are at first felt by the nerves ; they are first irritated ; and as long as the irritation is limited to their tissue, no other phenome- na are manifested in the part than the exaltation of sensibi- lity. It is possible for the irritation to concentrate itself in the nervous capillaries.; for these to continue to be affected >\Lthout the vessels being moved. We observe then, the taorbid phenomena which constitute the neuroses ; but al- most always the irritation is transmitted to the sanguine capil- lary vessels, and it there presents itself under two different forms. 1st. The irritation calls the blood there, the circulation becomes more rapid and a larger quantity of this fluid tra- verses them ; it at the same time penetrates into the white vessels,and from these oiganic changes results redness, aug- mentation of heat", pain and tumefaction of the part, if its structure is of a nature to admit of it. These phenomena constitute inflammation. We designate by this word the. sanguine capillaries affected by irritation. Inflammation then is only an assemblage of morbid phenomena, of which irritation is the element, the generating cause. 2d. At the same time that the vessels are irritated, they sometimes have a particular disposition to open themselves and give passage to the blood flowing into them ; this is the hemorrhagic irritation. 3d. The phenomena of irritation are often confined to the white vessels ; the afflux of white fluids which it deter- mines there, and the tumefaction resulting from it, are the only changes which take place in the part; there exists here neither pain, heat, nor redness. M. Broussais has designa- ted this state of the irritated tissues under the name of sub- inflammation. It is to him that we owe the knowledge of this numerous class of disorders known under the names of engorgements, scirrhus, tubercles, &c. tth. When the phenomena of irritation exist principally in the nervous capillaries, we have said that they consti- tute the neuroses. " This system is never affected singly, says M. Vialle; whether the irritation be seated in its expan- sions which are interwoven with the sanguine and lympha- tic vessels, or whether it reside in its centre or cords, which are nourished only by means of these vessels, the latter ne- cessarily participate in it. This is proved by the alterations ©f structure and disorganizations that supervene in the parts where the neuroses remain for a long time fixed. It is then only one step from these diseases to inflammations : their causes and their post mortem appearances are analo- gous ; and they differ only in this, that, in the neuroses, the phenomena are more nervous, where as they are more vas- cular m inflammatory diseases than in the former case.— \. i» J fiiese phenomena consist rather in simple lesions of sen- sation and motion, whilst these same lesions determined in the sanguine or lymphatic capillaries are followed more promptly by alteration of the composition of the fluids and disorganization. We should be careful* not to make the symptoms which these diseases present, abstract beings, and not to treat them as simple errors of perception, it is neces- sary to materialize them in some sort more than has been done heretofore, if we wish to form a clear idea of them, and to arrive at the correct method of treatment." These distinctions of the different modes of irritation would pass for subtilties, if we thought that the author of the Examen isolates from each other, the affections of the capillary divisions of the nerves and vessels. But this is not the case; when M. Broussais says that inflammation is the irritation ofthe sanguine capillary vessels, he only means that the irritation predominates in the red capillaries, and at the same time affects the white vessels and nerves.— But as, in other cases, the lymphatic and nervous capillaries appear to be alone irritated, as there is no afflux and accu- mulation of red fluids, he has thought proper to distinguish the different states of the irritated tissues, the more espe- cially as in each of these forms, the local and general results of irritation present, and its treatment likewise, the most marked differences. Let us first study with all the details which the subject requires, the local phenomena of irritations, we will then present some general considerations on the influence exer- cised by them on the economy. qHAFTSR II. PHENOMENA OF IRRITATION. M. Duponchel who has given us a thesis on inflammation, in which he has exposed with fidelity the text of the lessons of M. Broussais on this subject, says, with other authors, that it is characterized by pain, redness, heat and tumefac- tion. Wishing then to appreciate the degree of confidence which these phenomena deserve, as signs of inflammation, he observes that these symptoms are not always apparent; frequently they are not all present and sometimes none of them are sensible. But because all these signs are not evi- dent, we should not on this account conclude that inflam- mation does not exist. If the inflamed organ is situated in- I 14 j iernally, the tumefaction, redness and heat will not be per- ceiveable. But the pain it may be said always exists, to enlighten the practitioner ; and when it does not exist, there is no inflammation. This objection is not well founded ; if "the disease is very extensive, if the organ has relations suf- ficiently intimate with the rest of the economy, to deter- mine numerous sympathetic symptoms, if the encephalon becomes affected, whether essentially or consecutively the pain will not be perceived by the patient and there will nevertheless be inflammation. In these three cases the sympathies alone can guide the practitioner ; it is because some nosologists have always had phlegmon before their eyes and have thought that they must constantly meet these four signs in all inflammatory affections, that they have so far limited the number of them." This important subject demands farther development; let us attempt to fill the void which the author of the thesis has left on this point. A proposition much too general has been laid down in saying that the phenomena pointed out above, constitute the characters of the inflammatory state ; for the latter would often pass without being recognized, if we were to persist in searching for these phenomena to es- tablish its existence. In fact, pain far from being insepara- ble from inflammation, as is asserted, M. Broussais has ob- served, does not exist in many ofthe most intense character. It is not manifested generally, except in inflamed tissues, submitted at the same time to compression; thus arachnitis, pleurisy, peritonitis, are accompanied with acute pains, which are very rare in inflammation of the mucous mem- branes. We have seen farther back that sensibility of rela- tion was only a function of the nervous system, correspond- ing to an exaltation of contractility determined in a point by stimulants, and transmited to the brain by the nerves, and that this functional result was not inseparable from super- excitement ; the absence of pain then cannot, in any case, permit us to deny the existence of inflammation ; we ought consequently to seek other signs to establish it, since in a great number of cases this does not exist. Besides it may lead us into error with regard to the seat of inflammation, or at least with regard to the principal source of the symp- toms observed by us; for inflammations produce sympa- thetic irritations in other parts ; and these in their turn pro- voke new sympathies, which transmit to the brain an [ 13 1 exaltation of the contractility of the part they effect as well as the primitive affection. We refer our sensations to the point where the impression has been produced by stimu- lants, because the brain, after this has been transmitted to it, sends back the former by the same nerves, to the point from whence the impression departed ; and it often happens when several irritated organs transmit at the same time to the brain, the increased excitement seated in them, that the painful sensation is referred to one and not to others.— Thus, as M. Broussais first observed, it happens that the parts sympathetically irritated, are often more painful than those which are the seat of the primitive inflammation. In gastritis, for example, the patient often experiences pains in the articulations, and none in the stomach ; hepatitis pro- duces severe pain in the right shoulder, whilst the region of the liver is free from pain, &c. this is the reason why, when the viscera are irritated to a great extent and several at the same time, the patient cannot determine the precise seat of the pain, which then takes the names of uneasiness, anguish, anxiety, &c. Pain being the result of sympathy exercised on the brain, it is evident that the most painful inflammations are those which excite the greatest trouble in the functions of relation ; but those not accompanied by any pain, may,according to what we have seen above, produce the same disorders. Thus in- flammation of the stomach and of the small intestine though rarely painful, produce often delirium, convulsions, &c. The increased afflux of blood into the inflamed part and its passage into the white vessels, determine a redness in these more or less vivid, continuing until the cessation of irritation in the sanguine capillaries. Let us examine the de- gree of certainty which this phenomenon possesses, as a sign of inflammation when observed after death. It has been pretended that the redness met with in the dead bodies of individuals who have sunk under diseases not acknowledged by all to be inflammatory, may be the result of atony of the vessels of the tissue in which it exists. But parts affected for a length of time with paralysis, the capil- lary action of which is weaker since these parts become atrophied, show during life and after death a manifest want of color. When we submit a part of the skin to the seda- tive influence of a refrigerant, it becomes pale, and its color does not ieappear until the action of the capillaries has re- L 16 J covered its energy. Atony of the tissues then, far from permitting an accumulation of blood in them, diminishes on the contrary the afflux of this fluid. It has again been pre- tended that the redness and sanguine engorgement produced by inflammation, may be the result of an infiltration after death ; but this phenomenon does not take place, as we know, except in the portions of the skin, ofthe cellular tis- sue, and of some other organs which occupy the most de- pendant position, whilst the body is becoming cold ; the tis- sue thus infiltrated may be brought back to its normal con- dition by macerating it for some time in water, and it is ne- cessary to remark that in cases where the inflammation was light or existed only for a short time, we may by the same procedure make the redness and engorgement disappear likewise. From all these facts, it is right to conclude, that except the cases in which it is a post mortem phenomenon, and it is always easy to recognize these, redness declares the existence of inflammation. But if we may draw7 this conclusion from the redness of the tissues, its absence does not authorize us to deny the existence of inflammation, where we have established the symptoms of it during life. Morgagni, Bichat and other anatomists, whose assertions merit all our confidence, have observed in the membranes and in the viscera, inflammations which have not left in the dead body any trace of phlogosis or engorgement. " We cannot," says the author ofthe Anatomie generate, " form an idea of the quantity of blood which penetrates the perito- neum or pleura when inflamed, by that observed twenty four hours after death ; the local irritation was a permanent cause which fixed the blood in the part; this cause having ceased, it escapes. A serous membrane may have been highly in- flamed during life and present very nearly its natural aspect after death. I have often been tempted, after the opening of dead bodies, to pronounce the non-existence of an in- flammation which had been present. The same remark ap- plies to the cellular tissue, to inflamed mucous surfaces, &c. Examine a subject after death, from an angina which, durin» life, had given a deep red color to the velum palati and parts around it; what is the result ? after death the parts have again assumed their natural color." Dr. Begin assures us that often the corrosive poisons destroy subjects before the slightest inflammation is devel- oped. " Post mortem examination4!." he adds," made bv a L n ] physician worthy of credit, a few instants after death, have shewn that at the termination of fevers, the mucous mehi- brane of the digestive organs, which we ordinarily see only partially phlogosed, is of a red color over its whole surface \ and that the inflammations thought to be light twenty four hours after death, have been found excessively violent in subjects just dead." M. Jeunesse relates the results of experiments made on living animals, which also go to confirm these assertions.— " I have opened says he; several guinea pigs, and by irrita- ting the peritoneum, 1 have caused an afflux of blood to it and produced inflammation ; the redness being intense, the heat having manifestly augmented, in short all the characters of active inflammation being developed, 1 killed the ani- mals, taking care not to produce hemorrhage, and saw to my satisfaction, the peritoneum become blanched and re-estab- lished in the conditions natural to it. We see then after this that it is possible not to find any apparent lesion after death from acute peritonitis; this in fact, is often the case." It is principally when inflammations have terminated by death, after a very short duration, that the organs in which they were seated, are presented in their natural condition^ and particularly when they are examined a long time after death. It is to cases of this kind that we must refer the ex- amples cited by the partisans of essential fevers, who assure us that they have not found in certain cases any trace of inflammation in the alimentary canal; for whenever a given series of symptoms corresponding to the inflammation of any organ presents itself, we must acknowledge the exists ence of the latter, cr throw aside every thing given us by induction. Considering the limited extent of the disorders often met after inflammations whose course has been rapid, certain phy* sicians refuse to admit that an affection in appearance so light can produce such grave consequences; but one must be an entire stranger to pathological physiology, if he does not know that there are few organs whose lesions produce ne- cessarily and alone, death. It is only violent affections of the heart, large vessels, lungs and brain, which lead to this result, because the respective functions of these organs can^ not be suspended or abolished without producing death. In all other cases, local disorders do not produce this dreadful consequence* but -"p. a mediate, secondary manner, and by [ is ] the sympathetic influence reflected to the heart or brain. Thus, it is not the inflammation ofthe stomach or of a por- tion ofthe small intestine alone which kills the patient,but he falls a victim to the disorder of the nervous and circula- tory functions, provoked sympathetically by the gastro intes- tinal inflammation. Why may we not conceive that, from the moment when an irritation becomes sufficiently intense to arouse sympathies which are reflected on important organs, it may in this way produce the most serious accidents, and rapidly bring on the death of the patient? But we will see that the development and intensity of the sympathies, are subordinate not only to the gravity of the inflammation, but to several other circumstances and particularly to in- dividual sensibility, and the importance of the affected or- gan; moreover, we have just seen that as soon as irrita- tion is established, important sympathies are often put in play, before the character ofthe inflammation is made man- ifest : we can then easily account for the death of the pa- tient, notwithstanding the lightness of the local lesion, es- pecially when we have been able to observe the symptoms ofthe affection to which he has succumbed. Let us now examine the changes which the inflammatory state undergoes when established. "Inflammations, if they do not cease spontaneously or by the aid of art, says M. Vialle, follow, necessarily, a longer or shorter course, but always variable according to the constitution of in- dividuals, and particularly in proportion as the individuals are more or less stimulated; in terminating, they do not give a preference to the seventh, fourteenth, twenty-first days over any other, notwithstanding the order given to them by the calculators of septenaries, or those who have personified diseases, and considered them indepen- dent ofthe organs and stimulants acting on them. They terminate in several ways: 1st, they abort spontaneously or by means of art; we then often observe a crisis or me- tastasis, which indicates always the transportation of the ir- ritation from one part to another; and the secondary phe- nomena consist either in the brisk re-establishment of se- cretions more or less suspended, or in a hemorrhage, or in the sudden appearance of an inflammation advantageous or mortal according to its seat: 2d, they may produce fatal congestions when seated in important organs; sometimes they terminate by red induration, which becomes chronic. [ 19 j if the organ is of little'importance or if life can continue without its participation—then necessarily interrupted; 3d, they may determine exhaustion and death, whether we con- sider them in the acute or chronic state; 4th, they terminate by gangrene or local death, followed or not by general death, according to the importance oftheorgim affected, according as the gangrene progresses or is arrested by a new7 inflammation and according as the effects of the miasms resulting from the putrefaction are more or less grave; 5th, finally inflammations may terminate by resolution or suppuration, which suppose always a passage of the irrita- tion to the white vessels, and an alteration ofthe fluid con- stituting pus. Resolution and suppuration only differ from one another in this, that in the first, irritation diminishes gradually, the pus is absorbed or eliminated by way of the excretions: this is the insensible solution or lysis of the old authors.. In suppuration,'on the contrary, the irritation is kept up ; the pus cannot be absorbed, it forms collections, cysts, infiltrations, or a continual excretion without. Sup- puration then is a continuation of the disease which may still, in this case, 1st, terminate after a longer or shorter time, by resolution, that is to say, the cessation of the irri- tation producing the pus, and its absorption,if it forms a col- lection : 2d, operate the destruction of organs and produce death, if they are important, or only disturb their functions by the compression occasioned by the collections; but these produce, ordinarily in the long run, irritations and fatal dis- organizations, if they are internal, and effects more or less grave if they are in the members and external parts; 3d, occa- sion hectic fever and death by the irritations which an altered and fetid pus carries into the principal viscera—qualities easily assumed by it when in contact with the air. " Of these different terminations of inflammations, there are only suppuration and red induration which can exist in a chronic state, and which tend thus to confound them- selves with sub-inflammations." Let us add some illustrations to what M. Vialle has just said on the terminations of inflammation. Its phenomena disappear gradually (resolution,) or rapidly (delitescence) under the influence of several causes differing in their na- ture : 1st, when the cause ofthe malady has ceased to act before this had arrived at a high degree of intensity; 2d, when we submit the inflamed part to the action of astiin- «ent substances or to the action of sedatives, such as cold and opium; 3d, when the inflamed organ has provoked in another part a sympathetic irritation, which has become su- perior to the original one ; 4th, when before the appearance of the inflammation, there already existed one more intense, in another organ, or which has acquired a greater intensity from the sympathies provoked by the secondary irritation; because the latter is always reflected on irritated parts ; 5th, finally, when we establish in one part, a more powerful ir- ritation than the one which existed in another point. Different circumstances may produce gangrene in the in- flamed part: an excess of inflammation w hich seems to exhaust the excitability by the too violent exaltation it un- dergoes ; the compression, the strangulation of inflamed parts, which not permitting their tissues to be distended by the fluids flowing into them, and which brings on their dis- organization ; finally the influence of certain deleterious principles, such as those productive of the malignant pus- tule, the carbuncle and pestilential buboes. Authors have attributed to these agents the property of destroying life in the parts on which they act, and they have admitted moreover with Brown that they exercised on the whole econ- omy an influence eminently debilitating, that plunged it into a state of asthenia, without taking notice of the concomitant phenomena of the local affection. Although admitting a disposition to gangrene in the parts on which the deleterious agents exercise their influence, M. Broussais remarks that the latter commence by producing an irritation, and at the same time that the gangrene is taking place, we see very often a violent reaction supervene in the surrounding parts and oftener still the viscera become inflamed ; and then, according to the degree of their irritation, we observe the symptoms of inflammatory or adynamic fever. From whence we have a right to conclude that these deleterious principles, notwitstanding their tendency to destroy life in the parts acted on by them, are no less, on this account, ir- ritants ; that they only produce death in a circumscribed point, while other parts are almost always inflamed ; that consequently, the modifications introduced by them into the organism cannot be the result of asthenia. Suppuration appears to be the end of inflammation ; at least the formation of pus is, in the majority of cases, the ter- mination ofthe inflammatory state : we see then the local phe- [ 21 ] homena and sympathies which it produces disappear, espe- cially when the pus is formed by an organ communicating externally ; but when it is collected in an abscess it keeps up ordinarily the irritation of the tissues in contact with it, and thus perpetuates the consequences. Besides, the mod- ifications undergone by the secretion and the nature of this fluid beiug subordinate to the disposition ofthe organs, can only be considered in the history of the inflammation of each one of them. We possess, on the sub-inflammations, several well written papers, in which we find the doctrine of Broussais on organic diseases : but before passing on to their examination, we will present several general consid- erations on the chronic state of inflammations. When inflammation does not terminate by resolution, and gangrene or death does not supervene, to interrupt its course, it passes into the chronic state. In fact, when the causes under whose influence irritation has taken place, do not cease to exercise their action, these phenom- ena continue, but they soon undergo remarkable modifica- tions, the exact knowledge of which is of the highest impor- tance. The sympathies called into play by the diseased organ often disappear; at other times they continue, but lose a part of their intensity ; the local phenomena of in- flammation also become more obscure, and often even when it effects an internal organ, is only appreciable by the dis- order of its functions: before the splendid researches of the historian of chronic inflammations, these affections were almost always misunderstood; the alterations produced by them were considered as particular diseases. No relation had been established between these and acute irritations, or if there was perceived between the two a resemblance of cause, they did not continue the less separated bya brazen wall. If a pulmonary catarrh or a pneumonia was followed by symptoms of chronic pneumonia, physicians saw no- thing but tuberculous degeneration. Chronic hepatitis, peritonitis, and gastro-enteritis, were obstructions, dropsies, nervous affections ; moreover, if the febrile state which the inflammation excited in its acute stage, continued chronic, they no longer saw fever symptomatic of inflammations, but hectic fever, the companion of organic lesions. If we consider that this ontology, in producing misconceptions ofthe nature of these affections, has diverted physicians from the treatment proper for them, since symptomatic ideas have more fro- L ** 1 quently been the base of their practice than empiricism, Ave may easily conceive how eminent is the service rendered to medicine by M. Broussais, when he connected together chronic and acute inflammations and when he demonstrated their identity. A number of facts present themselves to support this no- tion ; let us confine ourselves to the following proofs, they are indisputable : 1st, chronic irritations are produced by the same causes which produce acute irritations ; 2d, they are most frequently the consequence of the latter; 3d, ex- cept in intensity, their local effects are the same, they always consist in the exaggeration of the phenomena by which life are manifested ; 4th, they are extended like acute irritations, to neighboring and distant organs by means of sympathy; 5th, the treatment of the chronic is the same as that of the former, except that it is in general less active and should be continued for a longer time. We should here remark that the low degree of intensity in the local and general phenomena of irritation exists often from its very commencement, on account of the weakness of the stimulating action or from the want of vitality in the affected part. We must then admit primitive chronic in- flammations. We acknowledge that to be rigorous in our expressions, we should only employ the epithet chronic on irritations which have existed under the acute form ; but the science would lose by this exactitude in language, for to give a different name to this state of inflammation, would be in some sort to distinguish it from that succeeding acute inflammations; whereas they are identical. It is better then, with Broussais, to give the name of chronic to all irritations, of which obscurity and a slow march form the principal characters, whether it exist primitively or consecutively. However this may be, the organ which is the seat of chronic inflammation undergoes different changes according to its structure, the degree and duration of the irritation. In the tissues, rich in sanguine capillaries and cellular tissue, we see the inflammatory tumour continue and acquire a greater density; such are the hepatization of the lungs, the callosities ofthe skin and of the subjacent cellular tis- sue, the thickenings ofthe mucous membranes and those of the peritoneum, &c. This condition, which M. Broussais designates under the name of red induration, may continue indefinitely, unless it exists in an organ, the disturbance of [ ** I whose function interferes with nutrition; in this case it brings on the destruction of the patient. In other cases, after having existed for some time, the red induration is replaced by white induration. In place of producing these alterations, inflammation sometimes keeps up in the tissues a chronic suppuration, which is also often accompanied by their induration. When chronic inflammation continues for some time, we see the heat and redness disappear. The blood no longer penetrates into the capillaries of the diseased part; the white vessels then become the only seat of irritation, and the diseased tissue is transformed into a homogeneus, indo- lent white mass, in which are developed new tissues, me- lanosis, tubercles, scirrhus,&c. After a longer or shorter time, these formations become softened, liquify, inflame the parts in which they are developed and produce ulceration. The lesions designated under the name of organic dis- eases, are not then primitive, are not particular disorders, but are the result of another affection, of which physicians have described the last stage separately, just as in present- ing the picture of adynamic fever, they have traced, as M. Broussais observes, the last scene of gastro-enteritis. It will be easy for us to show the truth of this proposition, by supporting it with a crowd of proofs presented in the theses of several of M. Broussais' pupils. M. Palais observes that sub-inflammations maybe primi- tive or consecutive, that is to say, that the irritation may manifest itself in the white vessels, without having existed in the sanguine capillaries, and it may be also the result of inflammation of the red tissues. M. Palais remarks that primitive sub-inflammations are* incomparably more rare than the others. M. Broussais does not admit the possibility of it, but in the subcutaneous lymphatic vessels, and even here their irritations are often provoked by those of the red tissues ; .such are the sub-inflammations of the inguinal and axillary ganglions, produced by an ulceration of the glans, a whitlow, an ulcer ofthe breast, &c. Those of the inter- nal organs o.n the contrary are always consequent to an in- flammation and they are produced in two different manners : either they are developed in parts affected with sanguine irritation, or they are the result of an inflammation of a mu- cous membrane, on whose surface the lymphatic vessels open : since„ as Bichat has taught us. the ganglions and the [ ^ ] glands participate very often in the irritation of the mucous membranes, on the surface of which their excretory canals and absorbing radicles, open. Such are the irritation and swelling ofthe mesenteric ganglions, which are always pro- duced by.an enteritis; tubercles of the lungs which are de- veloped under the inflammation of the pulmonary mucous membrane, and which may also be produced, but much more rarely, by inflammation of the parenchyma and by that of the pleura covering the latter. In general the lymphatic ir- ritation continues long after the cure of the phlogosis that gave it birth. It is thus we see the ganglions ofthe neck, which become tumefied during the course of a tinea capitis, remain in this state long after the latter has disappeared. Not unfrequently inflammation of the skin, excited by the application of a blister on a part surrounded by ganglions, produces swelling in them, which persists often after the ulceration ofthe skin is cured. If, as we observe in many cases, the phlogosis which causes the sub-inflammation is repeated, the lymphatic vessels receive a new stimulation that hastens the progress of disorganization. M. Palais takes advantage of this against those who object, that tuber- cles do not form under the influence of irritation, since they often meet them in the lungs of individuals who did not pre- sent any symptoms of inflammation ; whilst in others who have died of acute pneumonia, they found softened tuber- cles. They do not take account of a slight pulmonary ca- tarrh which might have existed several months before; they are ignorant that it is not necessary for an inflammation to run very high in order to develope tubercles, and that a slight irritation is sufficient; but it must be prolonged and continual. It appears ev;en, remarks M. Palais, that this degree is the most proper to produce such an effect. Amongst the inhabitants of cold and humid countries, where the pul- monary mucous membrane has, habitually, to supply the ac- tion of the skin—-f mounting to almost nothing rn these countries—phthi£!§ often declares itself without oar having observed any intense symptoms of inflammation ofthe bron- chial mucous membrane of the parenchyma of the lungs; also M. Gardien observes, that it is most frequently slight contusions which give rise to cancer of the mammas, "in fact a powerful contusion will produce acute inflammation and suppuration of the tissues, whilst a slight stimulation will cause a chronic irritation which will persist and produce 'lisorsranizatiop [ to J However this may be, when irritation effects for some time the white tissues, they become dense and take on a greyish or whitish color; and if resolution of this induration be not produced, there is deposited in the diseased part a white, concrete, inodorous, caseous substance, which seems to infiltrate its tissue, first in the centre and then in every part of it: this is the crude turbercle (tubercule cru.) Some- times, and principally in the lungs of old people, there is deposited a black colouring matter, supposed by M. Brous- sais to be carbon ; this constitutes melanosis. These then do not as has been thought, form a particular kind of disorganization. After a longer or shorter time this substance softens and changes into a creamy fluid, analagous to the pus of the cellular tissue ; we say then that the tuber- cle is mature or softened. Meanwhile the irritation ex- tends to the sanguine vessels of the part in which the tu- bercles are developed ; these inflame, ulcerate, and suppu- rate ; sympathetic irritations are excited ; they are particu- larly felt by the heart and digestive mucous membrane, and we see the febrile state manifested, known by the name of hectic fever. The same phenomena are observed in all disorganizations ; as long as chronic inflammation is confined to the lymphatic capillaries, no sympathetic alteration in the viscera is manifested ; but at the epoch when softening of the tuberculous matter, scirrhus, &c. comes on, inflamma- tion is lighted up in the neighboring tissues, it is repeated in the principal organs and gives place to that assemblage of disorders which terminates organic diseases. It is not lymphatic ganglions alone that are capable of un- dergoing tuberculous degeneration ; we meet it in many parts where anatomy has not yet shewn their existence, and it is easy to conceive of it. Tuberculous matter is the product of the exhalation of irritated lymphatic vessels : it may then be deposited wherever these vessels exist. We also see in the parenchymatous structures, the membranes, &c. this substance at first under the form of very numerous little white points, which infiltrate, if we may use the ex- pression, the substance of the irritated organ, (miliary tu- bercles :) these points increase agglomerate, and end by form ing masses sometimes very voluminous. The tubercles then produced in parts where we do not see lymphatic gan- glions, are of the Same nature as those observed in the. btter. v, [ 2G r Since humorism has lost credit, diseases of the lymphatic, system have been attributed to its debility. M. Palais has very ably refuted this opinion, by showing us that the de- velopment of this system constitutes the pre-disposition to these diseases; and that since we admit that the develop- ment of all the other organs is connected with the exaggera- tion of their vital action, we cannot establish an exception for the lymphatic system. "When these vessels, says M. Palais, seem to cover all parts ; when the ganglions, large and full of fluids seem to be multiplied ; when all the white tissues are expanded, penetrated by the liquids which dilate them ; when all the white elaborations predominate, and when the sanguine apparatus is plunged into inactivity, what grounds have we to establish, that the organism is debi- litated and that the lymphatic system and white parts, are so more than the others ? Whenever we see that a man is florid, that his chest is larger, that he has a voluminous heart, and ample arteries, we say that there exists in him an increase of sanguine activity ; and when he is pale, when the white tissues are much expanded, some not only wish to pretend that the whole economy is in a state of debility, but the)' assert that all the most apparent tissues are more so than the others, and that the sanguine system which is scarcely visible, preserves the last remains of vital force. This conclusion is in contradiction with the preceding one ; wdiat is true in regard to the apparatus of red blood must be so of the lymphatic system." If then excess of action in the lymphatic system pre-disposes it, like all the systems to diseases, these cannot be the result of debility. Let us now examine the circumstances under which white indurations are formed, and we will see that they are all referable to stimulating influences. We almost always see them developed in the midst of inflamed parts, or behind phlogosed mucous membranes, on which the lymphatic ves- sels open, the latter extending themselves to the tumefied ganglions ; from whence we may conclude that irritation is propagated to their tissue. We confine ourselves here to the indication of these facts ; they will be developed far- ther on in detail. If, as will be then seen, the ganglions of the mesentery become tuberculous under the influence of an enteritis and if it is incontestible that the tubercles of the lungs, cellular tissue,&c. and those ofthe mesentery are iden- tical, the true nature of phthisis and scrofula, will be already I -'< j established by this ; but without recuiiiu- to analogy, vv< can directly show that pulmonary tubercles are produced also by chronic inflammation. The thesis of M. Palais con- tains a summary of the proofs on which M. Broussais has established this point of doctrine ; it will suffice to relate the following facts : 1st, Every body knows that a pulmo- nary consumption succeeds almost always a chronic pulmo- nary catarrh, and in cases where this affection has not been manifest, the patients have nevertheless been affected fre- quently with slight colds, spitting of blood and pleuritic pains. 2d, All the causes to which authors refer phthisis are irrita- ting : such are forced exercise of the organs of respiration, the little particles of substances introduced constantly with the air into the bronchiae in individuals of certain professions, and cold which has been pointed out as the agent produ- cing the greatest number of consumptions. It is in cold and humid regions this disease makes its greatest ravages ; it is in the winter that its progress is most rapid. The author of the chronic phlegmasia? reports, that when he accompanied our armies in Belgium and Holland, he saw a great number of individuals sink under this malady, and that as soon as the same troops were transferred to Italy, it became ex- tremely rare and only destroyed those who had brought from the north chronic catarrhs; now all these causes, and cold especially, produce chronic inflammation of the bronchial mucous membrane. It is often objected, that tubercles and other disorganiza- tions, are sometimes established without being preceded by apparent inflammation ; but as M. Broussais observes, do we not often see pus formed without any symptom of phlo- gosis, as is proved by cold abscesses, latent pleurisy, absces- ses of the liver following blows on the head ; and neverthe- less, will it be pretended that the formation of pus is not al- ways the result of inflammation? Again, besides that sub-in- flammations may be primitive, no one will deny that chronic irritation of the mucous membranes, which gives rise to them in the great majority of other cases, exists often for a long time without manifesting their presence. The greater frequency of hepatization in the lower lobe of the lung, and of tubercles in the superior, has seem#d a sufficient motive to argue against this etiology of tubercles. M. Palais has joined to the enunciation of this proposition the answrer which M. Broussais has made in his Examen.— [ *»'J U is necessary to remark here, that they have changed the question; for it was never contended that tubercles were produced ordinarily by hepatization ofthe lung; but M.Brous- sais has always contended that their formation depended most frequently on chronic pulmonary catarrh; now every one knows that in this last affection the superior lobe is principally affected because the inflammation extends but very rarely to the whole extent of the bronchise, that it stops almost always in the parts of the bronchial ram- ifications least deeply seated, and these parts are in the superior lobe : inflammation then of this part of the lungs is very common, since pulmonary catarrh is very fre- quent. This objection then evidently leads to error; but in reasoning according to the principle which it suppo- ses, it will not be more victorious ; for we often see in chronic red induration of the inferior lobe, tubercles devel- oped in its tissue; on the other hand it is not true, as has been advanced, that nothing is more rare than hepatization of the superior lobe. The influence observed of tonics in producing cures in scrofula, and of debilitants in their production has not a lit- tle contributed to make them be attributed to debility. Be- fore explaining the apparent discrepancy of these facts with the physiological doctrines, let us remark that in subjects af- fected with sub-inflammation, there exist two organic con- stitutions differing from each other: we see sometimes a very marked development, and great mobility of the san- guine system, united with a lymphatic constitution. In these individuals sanguine irritation is almost always connected with sub-inflammation ; this condition of phlogosis excites very active sympathies and very rapidly produces disorgan- ization : in these cases debilitants have never been seen to produce sub-inflammations, and we are not afraid to assert, that these have scarcely ever been cured by stimulants. In the other cases, more frequent than the first, the develop- ment of the lymphatic system is in an inverse ratio to that of the sanguine , now, we know that there exists neither general stimulants nor debilitants, that the same agent pro- duces different effects in the different systems; and when we come to the article on revulsions we shall see that the greater number of causes productive of scrofula are debili- tants to the sanguine system, which permits another sys- tem, and particularly that which is most active, to take a i. **> i greater preponderance. We will see also that tonics in cu- ring these diseases, stimulate the sanguine system, and by this means produce a true revulsion. We know with what energy M. Broussais has combatted the principle of innateness of tubercles, a doctrine invented by a distinguished pathological anatomist, in order to explain more easily the development of these products, the germ of which he contended existed in individuals. M. Palais has called up for the purpose of combatting it, this strange opinion, founded principally on the existence of tuber- cles in the lungs of some new born infants, as if we were ignorant that the foetus may experience in the uterus the greater part of the maladies which may affect it du- ring the course of the extra uterine life. They have admitted in the same sense the hereditary na- ture of tubercles ; they have asserted that children in cer- tain cases receive the germ from their parents. We find in the thesis of M. Herbelin on Scrofula, a proposition worthy of a place here, which is applicable to the subject we are treating, as well as to cancer and other affections, the predisposition of which may be transmitted by way of in- heritance. " Scrofulous affections," says this physician, *• are not hereditary in the sense ordinarily attached to this word ; it is only the disposition to contract them, which children receive from their parents, having an organiza- tion similar to theirs, and not the germ of these affections. The transmission of this pretended germ from parent to child is inadmissible; in fact, infants are born of scrofulous parents, and never have this affection if they are removed from the influence of the causes which produce it ordi- narily ; what becomes of the germ in this case ? Others born of healthy parents, have scrofula from the slightest cause ; from whence springs the germ in these ? Scrofula sometimes skips one generation and appears in the next; what becomes of the germ in the generation omitted ? They can only an- swer these questions by hypotheses. It is much better then to reject altogether the gratuitous supposition of a germ,which no one has seen and the admission of which does not at all en- lighten the history of scrofula." The hereditary nature of dis- eases extends then at farthest to the predisposition to con- tract them, a predisposition which may be transmitted as the traits ofthe physiognomy and other moral and physical dispo- sitions infants sometimes receive from their parents. L 3u J The two principles which we have just combatted have been the source of medical fatalism, in establishing the in- curability of organic diseases ; we will show the possibility of their cure when we speak of cancer ; let us continue our examination of the results of chronic irritations. Albumen accumulated in the tissues which undergo white induration gives rise sometimes to the organization of acci- dental cartilages and fibro-cartilages. At other times in the fluids poured out and subtracted from the vital action, are found gouty and calculous concretions,&c; these different pro- ductions then happen under the influence of sub-inflammation, like tuberculous matter. M. Broussais attributes the same origin to fatty, steatomatous, melicerous tumours,: &c. sub- inflammation of the skin produces herpes, tinea capitis, and other chronic exanthems. We must refer to the same cause softening of the bones ; their solidity depends in fact on the relative proportion existing between the unorganized parts, and the organized tissue ; the latter receiving a greater ac- tivity by irritation becomes relatively preponderant, and the saline substances are not sufficiently abundant in the bones for them to preserve their solidity ; perhaps also their nu- trition is changed. Of all the transformations which the tissues undergo, th? most remarkable and that which should most fix our atten- tion, is the disorganization physiological anatomists have described lately under the names of lardaceous, scirrhus, and encephaloid tissue. We are still indebted to the physiological doctrine for our knowledge of the nature of these alterations and of the only efficacious treatment which can be opposed to them. Amongst the theses in which cancerous affections have been considered in their proper point of view, we remark particularly those of M M. Lemercier, Chanriont and Marechal, who have satisfac- torily demonstrated, by the examination of their causes and phenomena, that they were the result of a chronic inflam- mation, or sub-inflammation. They have reduced to its true value, the opinion of the fatalists on the incurability of cancer, by reporting a great number of cures of this disease, whose rav- ages and consequences, formerly in all cases so dreadful, have made practitioners heretofore regard it as one of the most terrible scourges of humanity. M. Lemercier first considers the different forms under which cancer may appear, and divides them into cancer on [ 31 ] masse, and ulcerated cancer, corresponding to the scirrhus and cancerous ulcer of authors. When a part abundantly supplied with cellular tissue, is for some time the seat of a red or white induration, we see developed a tumour more or less regularly circumscribed, without pain, incompressible, without change of color in the skin, the volume of which increases gradually, most generally with slowness, but al- ways with a rapidity great in proportion as the part is stimu- lated. After a longer or shorter time, its surface generally becomes irregular and elevated ; at the same time lancinating pains are felt, first at intervals and after a time constantly.— This, says M. Broussais, is the signal of disorganization ; which takes place when the irritation, for a long time chronic and most frequently limited to the w7hite vessels, passes into the acute state, and inflammation seizes on the tumour. This is ordinarily carried to the highest degree of acuteness as is attested not only the pains but also by the burning heat the livid redness and the considerable swelling seated in the tumour. The circulation in the part is very active, the ves- sels become more developed and exhibit very marked pulsa- tion ; meanwhile the surrounding tissues inflame, ulcerate, and the induration which they undergo, soon prepares a new disorganization similar to the first. Hence results an ulcer of hideous aspect, with a violet surface, covered by fun- gous excrescences and terminating in hard, elevated, invert- ed edges. The more it is irritated the greater its ravages ; the violent pains are exasperated more and more under the influence of all stimulations, direct or sympathetic received by it; at the same time the ulcer continues its progress, in- vades the skin, cellular tissue, muscles, tendons, cartilages, and the bones themselves. Often the eroded sanguine ves- sels give rise to hemorrhages sometimes sufficiently abun- dant to prevent the effects of sympathetic visceral inflam- mations, which later in the disease would have infallibly de- stroyed the patient. In the mean time the lymphatic ganglions in the neighbor- hood of the diseased part become tumefied, and after a while undergo the same disorganization. For a long time, also, the actions of the viscera are troubled ; always, in fact, when inflammation lays hold on a scirrhus or tuberculous mass, the sympathies soon put in play, produce in the vis- cera irritations which become chronic, since the action of the cause is constant. These disorders supervene particularly [ 32 j in the digestive passages ; the patient is morose and loses his appetite ; the tongue is red on its edges, the thirst great, the skin of a straw color and of a pungent heat. These phenomena are more intense in the evening and taken to- gether constitute hectic fever. The chronic inflammation seated in the viscera, produces sometimes an alteration in the tissues, similar to the original disease. Finally, under the influence of all these disorders, the patient emaciates and sinks into the last degree of marasmus, marked some- times by partial or general infiltration of the cellular tissue. Since these secondary lesions are excited by the disor- ganizing irritation, authors have committed a very great er- ror in grouping them around tuberculous and cancerous af- fections, for the purpose of erecting these into diseases, to which they have given as attributes, the general disorders supervening during the course of the greater part of chronic irritations. It is by following this route that they have cre- ated morbid entities ; we understand nothing then by tuber- culous and cancerous cachexies, but the assemblage of sym- pathetic disorders produced by these affections. Bayle had already reserved this expression, otherwise perfectly use- less, for the state of decay exhibited by patients in the last moments of existence ; but he saw like other ontologists, in these general disorders the progress ofthe Being cancer, whilst he should only have recognized sympathetic irrita- tions provoked by the disorganizing inflammation, irrita- tions resembling in all respects those produced by any other cause. Cancerous ulceration does not take place in scirrhus and encephaloid masses alone; it may manifest itself in tissues which have not previously undergone these disoganizations. This is the form of cancer called cancerous ulcer. M. Le- mercier has established two species it. It may be primi- tive : it is thus that we see arise on the skin and mucous membranes under the influence of an irritating cause, a lit- tle vesicular pimple, an excoriation, or a simple desquama- tion of the skin, which are soon followed by an ulcer in every respect like an ulcerated scirrhus; at other times a simple ulcer or one kept up by a specific cause, as syphilis, after having been a long time stimulated, takes on all the characters of cancer. But in both cases the sub-jacent parts are ordinarily affected with an induration extending to r> greatrr or less depth. L 33 ] Let us establish now that the alterations, of which we have just seen the principal phenomena, occur under the in- fluence of irritation. We have already seen that their charac- ters appertain to this lesion : it is necessary to prove that all the causes productive of cancer act by stimulating; In order to establish this point it will be sufficient to relate, as M. Lemercier has done, the causes assigned by authors to this alteration. Blows, falls, pressure, contusions, and in a word, the causes to which they refer cancer of the breast ordinarily, can evidently act only by irritating this eminently sensible organ; one must be blinded by a preconceived idea, to pretend, as some modern authors have done, that these circumstances introduce into its tissue a debility lead- ing to disorganization. When an ulcer, long stimulated by any chemical or mechanical agent whatever, puts on the cancerous character, can we mistake the cause of this trans- formation ? It is the same in cases where the cancer is produced by chronic exanthemata or by the suppression of a habitual hemorrhage ; causes which all authors indicate as giving rise to this disease. Can any one deny that a chron- ic irritation determines sarcocele, when confessedly it suc- ceeds to an engorgement of the testicle, produced by the metastasis of a gonorrhoea or a contusion ? It is said that individuals employed in certain occupations, and particular- ly grave diggers, scavangers, &c. are often affected with cancer of the stomach ; who does not know that men occu- pied in these disagreeable and disgusting occupations, make continual use of strong liquors, which must necessarily pro- duce and keep up chronic inflammation ofthe stomach ? We know also that prolonged grief is the cause of many cancers of the stomach, amongst individuals of the higher ranks of society—frequently victims to the torments of ambition, of fortune, and of other ungratified passions. But what phy- sician is ignorant of the dreadful influence of sad moral af- fections over the production of gastritis ? M. Chanriont reports in his thesis, with which we are about to occupy ourselves, an opinion of Ledran too remark- able not to be related here. "We know, says this surgeon, that erysipelas degenerates into phlegmon, phlegmon into scrofula or scirrhus and the two last into cancer; ordinari- ly a suppression of the cataraenia or hemorrhoids, grief, melancholy, or finally scirrhus tumours tormented by active remedies, produce it. In all these causes it is impossible E [ 31 ] to see the introduction of a virus : we only find one thing which can produce cancer, viz : irritation, pain, and a pe- culiar erethismus." Subjects of an irritable constitution it is generally admit- ted are more frequently affected with cancer than those of a different temperament. Does not this circumstance mili- tate in favor of the opinion we defend ? The bilious tem- perament is considered as a predisposition to cancer of the stomach ; but the physiological physicians know that great irritability of the stomach and duodenum is constantly joined to the preponderant activity ofthe liver, which con- stitutes this temperament. Cancer of the mammae and neck of the uterus are more frequent in women living in celibacy and widowhood, and we see in authors that this af- fection was very common amongst women devoted to a mo- nastic life. Physiologists recognize here still a cause of irrit tation to the uterus and mamma?. In the same manner as unsatisfied hunger produces inflammation of the gastric mu- cous membrane, venerial desires, accompanied necessarily by superexcitation of the genital organs if they are for along time suppressed,must produce in the uterus a chronic irritation which is reflected to the mamma?, they being connected by the strongest sympathy. It is impossible to deny this mode of production to the cancers we are speaking of, when we see that the women to whom the privation of venerial plea- sures is painful, are affected with flouralbus and hysterea; evident results of irritation in the organs of generation. The abuse of aliments produce gastritis like abstinence; so the abuse of venereal enjoyments produce cancer both of the uterus and mammce. The explanations just given seem to us sufficient to remove the apparent contradiction of facts. After having pointed out these different causes of cancer, authors have admitted others which are inappreciable. " But why have they not been able to appreciate them, asks M. Lemercier ? it is because they have not taken ac- count of the physiological changes, operated in the individ- ual, and of the action of an irritant that has acted only in a low degree. Let them, however, follow back these changes to their cause and they will understand precisely its na- ture ; let them question patients affected w iih cancer, and all, with the exception of a few individuals of very obtuse sensibility, will refer the development of their disease to ■some irritation : thus, for instance, a woman will have re- L 35 ] ceived a slight blow on the breast, or will have been seized with violent fear during her menstrual discharge: or a man may have lightly bruised his testicle, &c. The first cause of cancer then always is an irritation, which the physiologi- cal physician may detect if he pays a little attention to it; but what is truly inappreciable by him is the predisposition of the individual to contract cancer." We agree in opinion with M. Lemercier on the impossi- bility of explaining how the action of the same cause pro- duces in different individuals, disorganizations of a different nature. No data possessed by us will enable us to resolve this question; and to admit morbific dispositions, a peculiar aptitude to contract one disease rather than another, is lay- ing aside the explanation of the difficulty and not resolving it. However this may be, it must be acknowledged, that we see in certain individuals a chronic inflammation produce no other consequence than induration, whilst in others the slightest excoriation is sufficient to determine a cancerous ulcer. A neglected pulmonary catarrh gets well sometimes after several months duration ? and in another individual the same affection methodically treated from its commence- ment, nevertheless produces a sub-inflammation of the lungs and the formation of tubercles. We should be cau- tious in considering, however, these predispositions uncon- querable : we may correct their effects; for it is necessary that stimulating causes act before the disease is established, and in many cases the march may still be arrested. We have already seen, when speaking of tubercles, what should be thought of germs, by which they have pretended to explain predispositions to disorganization. In unveiling the nature of cancer, the author ofthe physiological doctrine has overturned the idea of taint or virus, made to play, not long since, so great a part in the production and extension of this malady. M. Chanriont has ably discussed this ques- tion ; the following is his solution: if hemorrhoidal tumors, vegetations from the dura mater, induration of the pylorus produced by chronic gastritis, can pass into the cancerous state under the influence of stimulants, would it not be ri- diculous to suppose that this pretended cancerous virus has the property of producing at the same time hemorrhoids, chronic gastritis, &c. When a sub-inflammation remains protected from all irritating causes, we do not see it degen- erate into cancer. How can a virus so terrible as they sup- | 3y j pose it remain stationary r How does it happen that after" the extirpation of a cancerous tumour the disease is not al- ways reproduced? It is certain that we can develope, if we may be allowed the expression, a ci ncer at will, by ir- ritating a simple ulcer for a long time ; the disease then has arisen without any virus, or this has been accidentally de- veloped by stimulants. If the engorgement of the axilla- ry gangloins, in cancer ofthe breast, was produce;; by the resorption of ichor, how could they be resolved aftei the amputation of this organ ? Besides, ought not the infection to be general, and all the tissues likew ise to degenerate in- to cancer? Moreover, before admitting the virus, it is ne- cessary to show that cancer is contageous, for all virulent affections present this character. But, we are aware that we add little confidence to the observations reported by Tulpius and Peyrilhe, and every body knows the experi- ments of M. M. Duprutren, Alibert and Bieth, showing this disease not to be contagious. M. Chanriont repeats the remark of Broussais, that the idea of a constitutional cancerous virus, in reference to prac- tice, produces the most pernicious effects : because physi- cians who expect to meet an enemy invulnerable by nature, convinced of their impotency, dare not combat it; they conduct slowly to the grave, by useless paliatives, the un- happy victims trusted to their care, or rather they suffer them to die in the horrors of despair. Every one knows in fact, that patients presenting the external character of the constitution which predisposes to disorganization of the lungs, and those born of parents affected with cancers, were devoted to certain death, or to the chances of a capi- tal operation, if they wrere affected with chronic pneumo- nia or sub-inflammation of the breast. Every method of treatment seemed superfluous, the malady was abandoned to itself, and the continuation of inflammation bringing on disorganization of the tissues, the prognostic rarely failed to be justified, whilst a methodical treatment would often have given it a formal contradiction. The principle of the incurability of cancerous and tuberculous affections was then the result of this fatal theory of virus, of innate germs; and thisblindness was even carried so far in this respect, that when a tumour presenting all the characterso ancer, and which had been called by this name, or when a patient, af- ter exhibiting all the signs of pulmonary consumption, re- [ 3< ] covered, they pretended to have committed an error in the diagnosis, to have been deceived by false appearances; in a word it could not have been a cancer because this is incu- rable : and why do they say it is incurable ? because they have never seen it cured.—That is to say, the consequence furnishes the principal from whence they draw the conse- quence. But again, "who can assert, objects M. Broussais, that the disease would not have yielded to other means than those employed." However this may be, we possess at the present day, too many reports of scirrhus and even ulcerated cancers cured, to leave in doubt the curability of this disease. Amongst the particular histories demonstra- ting this, we remark principally those set forth by M. Mare- chal in his thesis. The question to which these fac*;s relate is too important for us to neglect bringing up again its an- alysis here; these are the most victorious arguments Ave can employ to show the true nature of cancer, and the pos- sibility of often curing it, when properly treated. "If the observations we have reported," says M. Marechal, "do not appear sufficiently numerous or conclusive to justify the conclusions drawn by us, we hope at all events that they will stimulate practitioners to repeat, without prejudice, the same experiments, if prejudice be not a more incurable dis- ease than cancer. We should, at all events, be indebted to M. Marechal for having laboured to combat this formidable enemy of truth; but we should reproach him for the care he has taken in concealing the source from whence he has drawn .He well knew the Examen and Histoire des phleg- masies chroniques ; after reading his thesis we are not per- mitted to doubt it: why has he named M. Broussais but once, and then only to criticise him ? Case 1. Adelaide Menestrier, seamstress, aged 20 years, perceived in the month of July, 1816, the development of a tumour in the left iliac region, accompanied by acute pain. A physician had leeches applied several times, (doubtless on the painful part,) prescribed a demulcent ptisan and emo- lient topical applications. The employment of these means were ineffectual during four months; the abdomen aug- mented so as to become very voluminous ; the patient for a long time passed purulent matter by the anus; she then found herself relieved and the volume ofthe abdomen di- minished. Having entered, at the close of December, into the hospital Saint-Antoine, where she passed six weeks ; [ M ] she was submitted to soothing treatment, from which she received no relief. Meanwhile, the symptoms continuing to increase, Adelaide entered the Hotel Dieu, 16th January, 1817. She exhibited on her arrival the following condi- tion : acute lancinating p>ins in the whole abdomen, parti- cularly in the left iliac region, where pressure was insupport- able ; all movements cause pain; the touch discovers a deformity in the neck of the uterus and a tumour as large as the head of an infant, occupying all the left side of this organ in the space comprised between the superior anterior spinous process of the ilium and the linea alba, and filling all the left iliac fossa. It was evident that it was developed in the uterus or its dependencies, since the finger applied to the neck of this organ perceived all the movements communicated to the tumour by the other hand. From the lancinating pains, the fetid odour of the fluids discharged through the vagina, it was more than once affirmed to be a carcinomatous tumour already designated. The debility is extreme ; for several months has lost sleep almost entirely; the fever undergoes every evening a paroxysm of cold, fol- lowed by heat and sweat. Diluent drinks, emollient injec- tions, baths, a dozen leeches on the left iliac region and nar- cotic cataplasms, are prescribed. 17th, patient is in the same condition ; same prescription renewed. 18th, pain has extended to the hypogastric re- gion: twenty-four leeches ordered to the left iliac and hy- pogastric regions. 19th, pains less acute, but the pulse still febrile and the evening exacebration more violent—thirty leeches are ordered to the same parts ; other treatment continued. 20th, the febrile condition continues, but the other symptoms are moderated ; diluent drinks, cataplasms, baths, broths, twenty-four leeches. 21st, syncope after the bath, violent pain over the eyes, insomnolency, fever, di- minution of the volume of the tumour, pain more acute, hunger; emollient drinks, baths, naicotic cataplasms, soup and pap. 22d, same condition : infusion of lime flowers, anodyne drink and fomentations, anodyne injection, soup, pap, eight leeches—during the day the patient felt better; the same prescription however was repeated on the 23d; on the following days there was an alternate increase and diminution in most of the symptoms: the same remedies are continued except the leeches ; to these were joined the use of calomel and opium. [ 39 ] 30th, the pains and fever have become more intense ; the next day fifteen leeches to the hypogastrium are added to the prescription. 3d of Februaiy, pain continues, pulse frequent, sensible diminution of the volume of the tumour ; same prescription. 4th, same condition ; six leeches and a bath—syncope in the bath; pains acute and more exten- sive ; fever high, mouth bitter, nausea, and increased pain ; diluent drinks, narcotic cataplasms and injections, soup— vomiting, fever intense. 6th, pain severe, abdomen tender to the least pressure ; twelve leeches, soup, bath. 7th, same condition ; injections and narcotic fomentations. 8th, remarkable amelioration, diminution of all the symptoms— narcotic cataplasms, bath, fomentations, whey, jelly (decoc- tion blanche.) This amelioration continued for several days: sometimes however interrupted by exasperation of the lancinating pains. 19th, the volume of the tumour is augmented ; the belly tumefied ; flaxseed tea, ten leeches on abdomen, five to the vulva; next day amelioration; same prescription. 27th, no notable change : twelve leeches. 28th, little relief; ten leeches—next day, blister applied to the internal part ofthe left thigh. 4th March, tumour ap- peared reduced to the size of an egg; but from time to time gives considerable pain ; eight leeches. 6th, more marked diminution in the volume of the tumour; absence of pain ; narcotic cataplasms and injections, opium internally ; about a fourth of her diet during health, allowed. 8th, exacebra- tion : fifteen leeches. 10th, ten applied to vulva—a slight sanguine discharge from the vagina—next day, feels com- fortable ; forces returning, tumour no longer painful; it is felt in the left iliac fossa like a small pullets egg flattened. 14th, patient left the Hotel-Dieu, three months after her entry, and nine after the commencement of the disease. Although Adelaide took little care of herself, she was soon restored ; her health strengthened daily ; the tumour became insensible and continued to diminish in volume ; and her strength, much increased, suffers her to take long exercises; she even indulged herself in the pleasures of love without any inconvenience. About the 17th April, her courses reappeared and the malady was still ameliora* ting. But at the close of the same month she relapsed ; the abdomen became painful; symptoms of gastro-enteritis and lancinating pains announced the return of the tumour; the application of twenty-five leeches, baths, emolient top C 40 ] icals and a blister arrested the symptoms promtly ; and af- ter the use of some aromatic vapour baths the courses reap- peared—four months after this relapse Adelaide was per- fectly re-establised—there could be felt on the left side of the pelvis a tumour about the size of a nut; but the neck of the uterus offered no deformity. M. Lallemand revisited her eighteen months after her departure from the hospital; she told him that she had several times felt severe pains in the left side ; to which she had, without consulting any one applied leeches and that the symptoms had promptly disap- peared. In what organ wras this tumour seated ? The movements communicated to it, by introducing the finger into the va- gina and pushing the uterus, would lead us to suppose that it was a,4esion of this organ ; but the rarity of cancer in the lateral parts of the uterus, the ovoid form of the tumour, its situation in the left iliac fossa, leads M. Marechal to think that the ovarium was affected. According to this hypothe- sis, he explains the purulent stools by a sympathetic irrita- tion of the colon, or an irritation determined by the contact of the diseased ovarium with the sigmoid flexure of this intestine. "But although, says he, the true seat of the dis- ease be unknown to us, the character of the pains, the hardness of the tumour, its tendency to reappear, the ab- sence of fluctuation, and the ichorous discharge poured out by the uterus, do not permit us to doubt with regard to the character of the affection ; we cannot mistake in this tumour a scirrhus already degenerated. In searching amongst au- thors for what has been said on this disease, we will find that they do not give more characteristic signs than these." Case 2d. Michelle Bahaud,of a feeble constitution, per- ceived at the age of twenty five years, a small tumour in the left breast, which at first rolled under the fingers and was the seat of lancinating pains ; at the end of six months it had acquired the size of a nut and very painful to the slightest pressure. After a year of fruitless attempts to discuss the tumour, the patient was informed that she was affected with scirrhus of the breast requiring prompt extirpation. She refused to have the operation performed ; the disease pro- gressed, symptoms of phtihsis were added, and Michelle entered the Hotel Dieu, the 14th December, 1816, in the following condition : a tumour, hard, swollen, unequal, size of a large goose egg, occupied the middle external part of the [ 41 ] ieft breast; the patient experienced habitually dull pains in. it and occasionally intolerable lancinations extending to all this side of the thorax and shoulder, had lost sleep for five or six months, her body was extremely emaciated, her skin dry, habitually hot and covered with furfuraceous scales; every evening she experienced a febrile movement which continued a great part of the night and terminated by an abundant viscid sweat; she had several attacks of haemop- tysis, coughed continually and expectorated a great deal of thick puriform matter. These symptoms of consumption. joined to the local disease, leaving no hope, only juleps, deluents, &c. were prescribed during a fortnight ; but the pains in the breast becoming exasperated, as well as the pul- monary symptoms and the patient earnestly demanding re- lief from her sufferings, M. Lallemand prescribed eight leech- es to the left breast, a bath and emolient cataplasams. The pains, fever and cough having sensibly diminished, the ap- plication of the leeches was repeated four days after. At the end of ten days, M. Lallemand found the tumor less hard, that the cough and expectoration had diminished, and that the fever had disappeared ; encouraged by this first suc- cess and no longer despaiiing of a cure of the disease, he con- tinued the same treatment, and prescribed from that time a severe regimen. Little by little the tumor became softer, decreased in volume, and at the end of two months and a half, was reduced to the size of a filbert; the symptoms of « the affection of the lungs had entirely disappeared, the pa- tient had regained her freshness and a good deal of flesh.— There were, however, in this short time, one hundred and twenty leeches applied, and the patient had only taken soups, broths, milk, rice and other like aliments. She thinking herself near well, would not wait the entire disappearance of the tumor ; she could not be prevailed on to stay, but af- ter her departure continued the treatment. At the end of a month and a half the tumour disappeared and Michelle recovered her vigorous health. This case proves very clearly the posibility of curing cancer, even after the development of lancinating pains ; or the existence, according to the observation of M. Lallemand, of diseases so closely resembling cancer, that it is impossi- ble to distinguish them. Case 3d. Elizabeth Gros, had been nursing her seventh child for eight months, when after being exposed to cold [ 42 j Whilst in a profuse perspiration, a small hard, glossy tumour, accompanied with slight pain, appeared in her left breast— Some days after, at the conclusion of a fit of anger, it sud- denly increased to the size of a fist and went on increasing rapidly. From this moment the pains became so lancinating and violent as to deprive the patient entirely of sleep. Per- suaded that it would be of advantage, she continued to suckle her infant from the diseased breast. The suction rendered the pains still more severe ; the volume of the tumor increas- ed from day to day, and its weight was so great that she had to support it constantly ; the least movement general or partial was insupportable on account of the pains produced. There existed then three elevated tumors, one at the supe- rior part of the breast, another at the internal part and the third at the external part. The nipple had entirely disappeared by their progressiye encroachments. The skin had a dark marbled appearance, abscesses soon formed ; ten opened successively ; and the evacuation of the pus only produced a momentary relief.— Until now the patient had employed nothing but emollient cataplasms : having at length asked medical assistance, a physician directed her to quit suckling her infant, and to have four leeches applied to her breast, which she con- tinued to cover with emollient cataplasms. The loss of blood was very abundant, and produced considerable . relief. Eight days after, four leeches were again applied, and the relief was more sensible ; but not being able to continue the treatment, the patient entered the hospital of Montpelier the 1st July, 1820, two months after the first at- tack of the disease. The breast was then about the size of a full sized foetal head ; the three tumors were still very sensible and hard, the openings of the abscesses were cica- trized ; one however existed still that discharged a white and somewhat fetid pus ; in the centre of the tumour was a pit in which the nipple was buried ; the lancinating pains were only felt at intervals and duiing the day. Eight leeches were prescribed, around the breast, emollient cataplasms, bath and diet—the blood ran freely and the next day the volume of the tumour was diminished. The pains were less fre- quent and less acute. On the 7th eight more leeches were applied, the bites of which afforded a good deal of blood.— From that time the pains ceased, the nipple became more prominent, and the breast was reduced gradually to its natu- i: 43 ] ral size. There being some little pain, on the 14th, live leeches were applied; the improvement went on and the patient was soon discharged perfectly cured. M. Marechel remarks that, notwithstanding the external appearances of the tumour, when the patient entered the hospital, and what authorshave said on the prompt develop- ment and rapid march of milk scirrhus or cancer, as they have called it, M. Lallemand did not judge the disease of Eliza- beth to be a true cancer and that he even predicted the prompt cure by means of topical bleeding and emollients. However well founded the opinion of this professor maybe, we should not attach any less importance to this case,—a case demon- strating the happy effects of local bleeding in irritations et the white tissues, no matter how deep rooted or ancient. Case 4th. M. Pons, a physician of Agen, has reported in the Journal Uniersel des sciences medicates, the case of a woman who some time after having weaned her third child, saw developed in her right mamma a little tumour which opened in two places, discharged a small quantity of pus and cicatrized. Two months after, a new tumour, larger than the first manifested itself. A physician consulted by her, pronounced the disease cancerous, and proposed an opera- tion ; the patient giving up in despair, refused the operation, resumed her labors without paying any farther attention to it, which did not appear to have any effect on the disease, whose progress was very slow ; for it was not until the ex- piration of about four years and a half after its appearance, that the tumour—about four or five inches in every direction —commenced to soften : a small point opened and discharged pus; the borders of this opening increased and formed an ulcer more than two inches in depth ; the edges everted, seemed formed of an erectile tissue. Notwithstanding the feebleness and extreme emaciation of the patient, on the 8th of May 1820, M. Pons had twelve leeches applied around the tumour, had it covered with emollient poultices, and prescribed a severe diet, nothing but gum water being al- lowed. Two days after six more leeches were applied, and from that time amelioration was remarked ; also the sixth day after this rigid diet, she was astonished to find that she had more strength than when she took more food with a view of increasing it. Five leeches were again prescribed, the cure advanced rapidly ; food was permitted little at a time, and by the 25th of July the patient was entirely cured, [ 44 ] Case 5th. A woman aged 52 years, in whom the period of the cessation of the menses had been attended by violent symptoms, felt in the month of August, 1819, slight pains in the left mamma, which returned periodically every month. Six months afterwards, a small tumour about the size of a filbert, was developed, rolling under the skin. It augmented gradually in volume, and three months afterwards had ac- quired the size of a goose egg ; it was hard, unequal, wrink- led and caused lancinating pains at intervals. The skin covering it, was tense, shining, and furrowed by small vessels. A surgeon prescribed frictions with narcotic tinctures, which rendered the pains more intense and continued. In the meanwhile the skin became thinner towards the middle of the tumor, an opening formed which gave exit to a purulo- sanguinolent matter of a fcetid odour ; the patient could not sleep, she digested badly and emaciation progressed very rapidly. Another surgeon advised amputation of the breast, but the patient refused. According to the advice of M. Olmade, a physician of Montpelier, narcotic and emolient ca- taplasms were applied, and renewed at intervals of four hours : every three or four days leeches were applied around the tumour, the bites of w7hich were allowed to bleed for several hours. The patient finding herself bettered by this treatment, continued it faithfully ; insensibly the pains disappeared ; sleep and appetite returned ; disgorgement of the tumour took place ; the openings cicatrized ; and in the space of two months, the patient was entirely relieved from her disease. During the two months one hundred leeches were applied. In the patient who was the subject of this case, the can- cerous affection was perfectly characterized, for it present- ed all the series of phenomena, which authors have assigned to cancer in the descriptions they have given. Case 6th. F***, of a nervoso-sanguine temperament, three years after being affected with a gonorrhoea, perceived that his testicle was augmenting in volume ; the tumefaction exempt from pain, yielded to emollient poultices ; but eight months afterwards the testicle commenced swelling slowly; at the end of some time lancinating pains came on, which the patient compared to the sticking of needles—seldom at first, but afterwards very frequent. The testicle was very hard, and its surface unequal and puckered. In a short time the pains became so intense, as to deprive the patient i 45 J oi sleep ; he entered then into the hospital St. Elol de Montpelier, the 6th of January 1820, presenting the follow- ing condition : the scrotum was engorged, the left testicle appeared about the size of the fibt, was painful, very hard and puckered on several points of its surface, The epidid- ymus and spermatic cord presented several points of en- gorgement ; the eminences of the testicle had contracted ad- hesions with the scrotum, which raised at the corresponding points, and depressed in the intervals, was red and shining. The right testicle was healthy ; every evening the patient became febrile. M. Lallemand prescribed eighteen leech- es to the perineum, an emollient cataplasm, mucilaginous drinks, and a light diet. On the 8th the engorgement of the scrotum was considerably diminished, the pains were less : twelve leeches to the perineum. Next day the pains were less frequent, and the fever had ceased , 11th the testicle seemed slightly diminished ; five leeches to scrotum and a bath. The following days there was a sensible diminution of the testicle which was no longer painful, but preserved its hardness and inequalities. On the 15th the testicle com- menced to soften and six more leeches were applied to the the scrotum. The emollient cataplasms were continued, repose and severe diet were enjoined. Insensibly the hardness of the testicle and the engorgement of the cord disappeared ; the parts assumed their natural size, and on the 25th the patient left the hospital perfectly cured. This case does not permit us to doubt of the cure of strongly marked sarcocele. In the 7th Case, M. Marechal speaks of an individual who, after a gonorrhoea, was affected with an engorgement of the right testicle, accompanied with acute pains; but as the tumour and nature of the pains did not present the cha- racters of sarcocele, it seems to us that we cannot draw any conclusion with regard to the curability of this disease by antiphlogistics. Case 8th. A woman aged 55 years, affected with amen- orrhcea during three years, felt after a fatiguing days journey a severe itching, at the internal canthus of the left eye, which she aggravated by scratching. During the night, her sleep was disturbed by lancinating pains: next day the lids were engorged ; an inflamed lump somewhat hard exist- ed at the internal angle. The patient employed without success, a poultice made of the pulp of an apple, and lotions [ 46 j of elder water. The hardness ofthe tumuor increased, very acute lancinating pains were felt, and there was joined to the evening fever, head ache and disturbance in the digestive organs. A student of medicine recognizing in the tumour a scirrhus character, advised the application of twelve leeches, emollient poultices and diluent drinks. Another person, on the contrary took it for merely a lachrymal tu- mour, although compression of the little tumour did not make any fluid escape from the puncta lachrymalia, and although it was incompressible and unaccompanied by epiphora. In order to clear up his doubts, the patient consulted M. Lalle- mand who confirmed the first opinion, anl attributed the tu- mour to a scirrhus development of the cellular tissue, which seemed about to produce ulceration of the skin. In order to remedy the evils pointed out above, he prescribed a bleed- ing of six ounces and a poultice. Next day the pain in the head had disappeared, the tumor was less red and less pain- ful ; the poultices were continued. The day after eight leeches were applied around the part; there only remained then a small inflammatory lump, which disappeared com- pletely in eight days by the use of poultices. In the following cases we will see the happy effects of lo~ cal bleeding in the treatment of cancerous ulcers. Case 9th. Antoine Durand was affected at the age of 45 years, with a little pimple in the middle of the inferior lip, that broke on the sixth day, and gave place to a small ul- ceration, which cicatrized after several applications of salt and nitric acid, but opened again six weeks after and remain- ed stationaiy for four years. Scabs formed on the surface, which either fell or were scratched off and were soon repla- ced by new ones. At the commencement of 1819, a sur- geon cauterized it with nitrate of silver, which formed an eschar, leaving a considerable ulcerated surface when sepa- rated. From that time the whole lip became swollen and painful. Another had recourse to applications of corrosive sublimate. All the symptoms augmented ; the pains became more acute and frequent; the borders of the ulcer became everted and it formed on the middle part of the lip, a loss of substance so considerable, as to prevent the mouth from clo- sing. On the 8th of May M. Durand entered the hospital Saint Eloi. M. Lallemand recognised the cancerous char- acter of the ulceration by the hardness and eversion of its edges, which appeared lardaceous and was the seat of Ian [ 47 J cinating pains ; he prescribed the application of eight leech- es around the lip, and an emollient poultice after they were removed. The hardness and pains in the lip diminished. On the 12th he had the same number of leeches applied and the amelioration became more marked ; on the 13th at the request of the patient, eight more leeches were applied ; the employment of the cataplasms was continued : on the 22d the pains had almost disappeared, and cicatrization had commenced : 13th June the pains had completely disappear ed ; there only remained a little fragment of border to the ulcer about the size of a small pea, which was removed by a bis- toury. A few days afterwards the patient left the hospital perfectly cured. Every thing is striking in this case, says Marechal ; the disease appeared spontaneously, that is to say, the patient did not know to what cause the appearance of a little pimple on the edge of the lower lip could be referred ; the ulcera- tion made such slow progress, as long as no remedy was applied, that it seemed to be stationary ; on the contrary it marched with rapidity from the first application of corrosive substances ; they created in a short time an ulcer which de- stroyed indiscriminately the teguments, cellular substance, and muscles. The patient, we should remark, very justly observed that the ulcer, before attacking the mucous mem- brane, only gained extent superficially and not in depth ; but that after the employment of caustics, as soon as this mem- brane became affected the ulcer made extremely rapid pro- gress. This circumstance is well worthy of remark ; be- cause it has been given by Bayle as one of the most charac- teristic signs of cancerous ulceration. Case 10. A sailor aged 62 years, was affected with a small ulceration on the upper lip, after having labored twelve years under a gonorrhoea which had been treated during four months by sudorifics and mercurial pills. This ulcera- tion after remaining some time stationary, although covered with chewed tobacco, made rapid progress and attacked the whole upper lip. The disease having been thought cance- rous, a plaster, the composition of which we do not know, was used, and the patient himself several times touched the ulcer w ith the sulphate of copper. Not obtaining a favora- ble result he entered the hospital Saint Eloi, April 7th, 1820. The upper lip ulcerated in its whole extent from its adhe- rent to its free border, and from one commissure to the oth- [ 48 1 er, presented at its middle part a considerable loss of sub- stance. The surface was covered with granulations and little fungous excresences ; it had a yellow tinge on some parts, and black on others ; its borders were thick and evert- ed, particularly at the superior part; the pains violent and pricking, became sometimes lancinating. Notwithstanding the cancerous character of this ulcer, as it could not be operated on, and as the antecedents seem- ed to indicate that it might have a syphilitic taint, M. Lal- lemand prescribed the liquor of Van Swieten : and some- time after, not seeing any effect from the treatment, had six leeches applied to the lip : the next day the pains had ceas- ed ; on the third day a new application of leeches, emolli- ent poultices, and a bath produced a still more marked effect; the edges of the ulcer sank, approached each other, and from this time the cicatrization went on rapidly. Towards the end of the month of May, a small fungus appeared on the upper gum ; it was cutoff; and as it was attributed to the corrosive sublimate treatment, this was suspended and the cicatrization made more sensible progress. On the 8th of June, leeches were again employed and the cicatrix soon formed. The patient was then directed to take Plenck's pills ; and on the 24th he left the hospital. In the following September another small white pimple formed on the upper lip, w hich soon became painful and ul- cerated. In a short time it occupied the whole lip ; but no longer had the same aspect it originally assumed ; it was greyish over the whole surface, superficial, the borders neither hard nor everted. The liquor of Van Swieten was again administered and emollient poultices applied ; in less than two months the cicatrization was completed. We see here an ulceration, at first venereal, afterwards become cancerous by the ill timed application of stimulants; for the first ulcer presented the characters of cancer : the surface was not grey but yellow and black on certain spots ; the edges were neither red nor perpendicular, but were thick, everted, seemed formed of a lardaceous tissue, and the ulcerated part was the seat of lancinating pains. The liquor of Van Swieten was unattended with benefit the first time used ; local bleedings and emollient applications, alone were beneficial. The second time, on the contrary, the ul- cer presented entirely a venereal aspect, and it yielded to sublimate, to the administration of which, it is true, the ap- [ 49 J plication cataplasams was joined. But doubtless it might have taken on, later, the characters of the first and then have resisted the mercurial treatment. In the patient who is the subject of the 11th Case, there existed near the internal angle of one of the eyes, an ulce- ration accompanied with scabs in the corresponding nostril. This affection yielded to local bleeding; but the characters do not appear sufficiently well marked for us to give it in de- tail. The following case is taken from M. Pons, who has also established the happy effects of antiphlogistics in can- cerous ulceration. Case 12. A woman, aged 59 years, had not menstruated for 12 years, and for the three last had been affected with leuchorrhoea ; about the first of June she perceived a small pimple forming on the upper lip which produced a good deal of pain during meals. To this pimple succeeded an ulcer, so promptly developed that by the end of July almost the whole of the upper lip was affected by an ulcer with everted edges, discharging an offensive ichor. M. Pons and another physician regarded this affection as cancerous. The latter proposed the application of the arsenical paste, or the removal of the disease by the knife. M. Pons in- sisted on trying the antiphlogistic treatment before resorting to these means. On the 23d July he had four leeches ap- plied around the ulcer ; he prescribed absolute diet, and only- allowed gum water ; 25th four more leeches were applied to the same part, and strict regimen was continued ; 27th the leeches applied again, and from that time the borders of the ulcer were lowered, its extent diminished one half, and its appearance very flattering. The 30th July four more leeches were applied and food was allowed ; every day the cicatrization progressed, and by the 7th of August this frightful ulceration had entirely disappeared, without leaving the.slightest trace. Case 13. 13th October, a woman aged 45 years, was af- fected for six years with an ulcer of bad character on the back of the foot; it was about the size of a dollar, with hard and everted edges, discharging a foetid, purulent sanies and surrounded by varicose veins. Various topicals were em- ployed without success. Lancinating pains manifested themselves at such short intervals, that the patient was for- ced to keep her bed. This ulceration wasjudged cancerous, by two celebrated practitioners ; 31. Batigue however, resi- [ 30 1 dent surgeon of the hospital Saint Eloi, did not despair of cicatrizing it by means of emollients. He had the foot en- veloped in cataplasms prepared with decoction of Hyoscy- amus ; he prescribed local baths of the same plant; a few leeches were also applied around the Ulcer, which under this treatment was completely7 cicatrized at the end of two months. During the six following months, the patient en- joyed good health. After this time, says M. Marechal, " she fell into a state of languor, was seized with a consumptive fever, marked by evening exacerbations, and she died one month afterwards, in a cachectic condition, characterized by an infiltration of the abdomen and inferior extremities ; we had no opportunity of making a post mortem examination." In the two following cases M. Marechal gives an account of two cancerous ulcers, whose cures wrere crossed by acci- dents that produced death ; these two facts are very re- markable, because they afforded an examination of the dis- eased tissues, which had been already moderated by the antiphlogistic treatment. Case 14. Francis Manuel, aged 59 years, had on the back of his hand, for several years, a wart about the size of a pea which he excoriated several times, and which was as often covered with a brownish scab. After having been 12 months stationary, pretty sharp pains began to manifest themselves; a little ulceration formed but made little pro- gress, until Manuel after having consulted a surgeon, cauterized it with nitrate of silver. From that time the dis- ease marched rapidly towards disorganization ; all the symp- toms became augmented ; the pains acute, lancinating and more frequent; they affected all the dorsal region of the hand. An ichorous, fetid and sanguinolent fluid was dis- charged from the ulcer, the borders of which became every day thicker and more everted. Manuel wishing to arrest the progress of the affection, employed, according to the advice of several physicians, a variety of irritating topicals, that far from diminishing the disease, aggravated it: the ulceration progressed every day; a pungent, burning heat was felt in the surrounding parts which by degrees became engorged. Finally, four years after the invasion ofthe dis- ease, he entered the hospital at Montpellier ; the ulceration then occupied all the dorsal face of the hand from the radio- carpal articulation to the first phalanx of the fingers. Its borders were hard, livid, everted, and seemed to be formed [ 31 ] ot a laidaceous tissue: brownish fungi, and gangrenous eschars were observed on several points; and a fetid ichor was discharged. The inflammation extended to the fore arm, all whose movements were painful. The straw color of the face, the deprivation of appetite, the langour of diges- tion, sufficiently indicated alteration in tHe viscera. Large emollient cataplasms were employed with decided effect; for on the third day of their application, the ulcer had already changed its aspect and assumed a rosy color; the eschars had disappeared ; the ichor was less fetid ; the lancinating pains less severe, and less frequent, permitted the patient to get several hours sleep. The 14th June, fourteen days after his admission, four w leeches were applied to the inferior part ofthe forearm, and six to the superior part of the phalaax. On the 15th, the pains had still farther diminished, as well as the engorge- ment of the forearm ; the patient slept the whole night; the movements were less painful; the aspect of the ulcer im- proved—17th, improving; the whole surface became of a rosy hue ; a slight itching had succeeded to the lancinating pains ; the disgorged borders were no longer hard and shin- ing, but were becoming even with the surface and approach- ing the centre ; in a word, the ulcer was progressing towards cicatrization, when on the 23d, the arm and forearm were invaded by a phlegmonous erysipelas, which destroyed the patient in eight days. Autopsy.—The borders of the ulcer, which were every where hard, thick,' laidaceous, and everted, when the pa- tient entered the hospital, had become softened and directed towards the centre of the ulcer; those of the superior part, on the side of the forearm, were animated, and no longer showed any trace of cancerous tissue ; the sub-cutaneous tissue was supple, injected with blood, and only slightly en- gorged w ith serosity. Those ofthe inferior part, on the side of the fingers, showed still in certain points, traces of the fibrous organization, and in others, the laidaceous appear- ance of the cancerous tissue. Case lS.-^-In the patient who was the subject of this case, the cancer commenced as in the preceding one, by a little wart, situated on the same region, that after being cau- terized several times, became painful. The patient wishing to destroy it, burnt it with hot pitch. The little ulceration resulting from this cauterization, acquired in a short time .Y> ] (he size of a 25 cent pi#ce and then remained for two years nearly stationary7. Towards the month of July, 1820, acute pains supervened suddenly'. A physician applied an unguent, composed principally of verdigris ; the patient used this for five or six days, but seeing the disease increase, the fingers becoming engorged and painful, he suspended the use of it for three weeks. Having consulted another physi- cian, he applied a red plaster, whose composition we do not know, but which augmented so much the pains, that from this moment he lost sleep, gave up all remedies, and entered the hospital Saint-Eloi, the 18th January, 1821. The ulcer was about four inches in diameter ; the edges hard, thick, irregular, and everted, particularly towards the superior part; large fungi arose from the bottom ; the forearm, the hand and fingers were enormously engorged. A black, fetid sanies was discharged from the ulceration ; the pains were sometimes lancinating, sometimes like the gnawing of an animal—the straw color of the face and conjunctiva, the con- traction ofthe features, the heat of the skin, which was dry and earthy, the redness of the tongue, the engorgement of the axillary ganglions, the lancinating pains experienced by the patient in the members and thorax, left no hope of cure, even from amputation ; but there was a hope of palliating the disease by employing those remedies which had cured the same affection in a less advanced state. On the 19th, twelve leeches were placed around the ulcer and emollient narcotic poultices. Three days afterwards the pains were calmed—23d, remarkable change; the borders of the ulcer seemed less thick ; the vegetations no longer bled so easily ; the sanies is almost inodorous : the ulcer assumes a better appearance, and has no longer those black spots; the pains are not so frequent or acute : poultice. 24th—improvement continues : wine of gentian, infusion of camomile—25th, the forearm has become swoln, red and painful: julep ; infusion of lime flowers ; sirup of poppies, two ounces ; opium, one grain ; lemonade ; six leeches to the forearm. The symptoms became calmer during the two following days ; May the 28th, phlegmonous erysipelas re- appeared, extended to the thorax, and the patient died the next day. Autopsy.—The diseased limb was infiltrated w7ith a great quantity of serosity ; the borders of the ulcer though very much reduced, were still in certain places everted, and form- L' 33 J ed in part a scirrhous, lardaceous tissue, The bones of the metacarpus were almost all carcinomatous, particularly to- wards their articular extremities. Some of the tumours observed on the ulcerated surface were formed of an ence- phaloid matter; but the borders of the ulcer which during life, were entirely scirrhus, had resumed, in a great part of their extent, their primitive texture. "There is no need of remarking, says M. Marechal, what influence the irritating corrosive applications, had in pro- ducing unhappy results, in the two preceding cases ; but a very important circumstance, worthy of being insisted on, is the change produced in the edges of these two ulcerations, which though scirrhous, lardaceous and everted, at the time of the admission of the patients, were made to resolve, and assume in a great part of their extent, their original organi- zation. Certainly no one could doubt the existence of these new tissues, the disease was not concealed; a simple in- spection was sufficient to make it known ; besides, in dis- secting the parts, after death, they were found in points where resolution had not taken place. We must then con- clude that these new tissues may disappear when we com- bat the irritation causing their development." M. Marechal concludes his thesis, rich in facts, with some general reflections on the incurability of cancers, which he refutes victoriously. The idea of a peculiar predisposition to contract the disease, a predisposition whose results they regard as inevitable, is one of the principal causes of the theory of the fatalists. It is incontestable, as has already been observed, that in many cases, cancers are developed in certain individuals by such causes as in others would have produced simple inflammation. But, because we must admit a particular disposition in certain organizations to the devel- opment of cancer, can we decide that this affection is incu- rable ? White tumours, caries, &c. which are developed after the slightest causes, and the predisposition to which is found in the lymphatic temparament, are not regarded as incurable, although the cure is difficult. M. Marechal ob- serves with reason, that if we make an abstraction of diseases produced by external causes, whose action is very energetic, almost all others require for their development a particular predisposition ; that, of a great number of persons exposed to the same influences, one is affected with pleurisy, another with hepatatis, a third with intermittent fever, a fourth with L 34 ] rheumatism. &c. whilst others are exempt from all diseases. We do not agree in opinion with this physician, when he says that the morbid predisposition of each individual, de- pends on an organic modification, of an unknown nature. It seems in general, easy to appreciate the organic circumstan- ces constituting these predispositions. Every one knows that the systems and apparatus, whose action preponderates in the economy, are those most frequently diseased. Thus the great development of the sanguine system predisposes to inflammations; that of the lymphatic system to sub-in- flammations : nervous system to nervous diseases; of the digestive apparatus, to hepatitis, gastritis, &c. It is evident then, that the predisposition to many disorders, exists in the general or partial predominance of the differ- ent organic systems and apparatuses. M. Marechal acknow- ledges himself that those orgens which receive a great many nerves, sanguine and lymphatic vessels, which consequently possess a high degree of sensibility, and are susceptible of becoming easily engorged, are the most exposed to cancers. Such are the different parts ofthe face, particularly the lips, nose, eye-lids, mamma?, neck of the uterus, testicle, glans penis, rectum, cardia, pylorus, and the ileo-coecal valve. It is also remarkable, that whilst these parts are the most sensible, they are most exposed to the action of irritating causes. We cannot conceive how a tissue, after undergoing a transformation in texture can return to its primitive state, and this is one ofthe strong arguments of the partisans of its incurability. If we oppose to them the great number of cases of cancer cured by the antiphlogistic method and col- lected from the origin of the physiological doctrine, they answer, that physicians are not certain of having cured a scirrhous tumour, that dissection alone can establish their true nature. M. Marechal observes on this subject, that the organization ofthe tumours which have been cured, must have been like those which have been extirpated, and in which scirrhous or encephaloid tissues, have been found, since these diseases were developed under similar cir- cumstances, had run the same course and presented cha- racters perfectly identical. He might have added, that if, by this strange manner of reasoning, they wish to invalidate the proofs drawn from analogy, the diagnosis of the greater number of diseases, of all that cannot be estab- [ 35 j lished de visa, can no longer be established ; the physician will then be almost always condemned to inaction, for he will be obliged to await the post mortem examination to re- cognize an apoplexy, a pleurisy, a pneumonia, or a perito- nitis, for fear of being imposed on by false appearances. But how can these fatalists object to the cures of cancer- ous ulcers and ulcerated scirrhous ? They will be obliged to acknowledge that such mistakes are impossible for any man who has seen much of disease. We will give here the an- swer made by M. Begin to the objection we refute. "We cannot see why," says he, "they admit the spontaneous for- mation of scirrhous tumours, against all reason, whilst they refuse to admit on the same authority, their disappearance. If they spring up without our knowing from whence they come, they should also be able to disappear without our ex- plaining where they go." Not only the cure of ulcerated cancers, demonstrates the possibility of the resolution of cancerous tissues, but we can give direct proofs of it. M. Marechal brings to mind the cases 14 and 15, where a complication produced death, at a period when the carcinomatous parts had changed character and were progressing towards cicatrization ; the dissection did not show any longer a trace of cancerous disorganization, in the points which had changed their aspect before death, whilst the others were composed of scirrhous tissues ; we can then, no longer doubt the possibility of the resolution ofthe latter. After the facts reported by him, M. Marechal establishes, that the most efficacious treatment against cancer, is that which calms the local irritation and diminishes the general erethysmus ordinarily observed in this disease. To this effect are employed sanguine evacuations, emollient and narcotic poultices, baths, diet, and diluent drinks. He dis- cusses very well the rules to be followed in employing each of these means. Not to weaken the interest presented by these considerations, we will let him speak for himself. "Sanguine evacuations have the advantage of disgorging the capillary system ofthe affected part; but we should not act as in an acute inflammation. In the latter the engorge- ment is recent; there is no change of tissue ; we may hope to cut short, by one or two bleedings, a sanguine afflux not established in a permanent manner. In cancer, on the contra- ry, there is a profound alteration of the inflamed tissues, a [ 36 ] continual afflux towards the affected organ ; it is never ne- cessary to employ general bleeding ; but we should draw- blood by leeches, little at a time, in order to leave nature force sufficient to effect the disgorgement, and to husband the means of repeating these evacuations, when the afflux is re-produced.* As the bites of the leeches augment the local irritation we should always have the precaution to apply them at some distance from the tumour or ulcer, and to cover them with poultices, which have also the advantage of fa- voring the flow of blood. The diseased part also, should be constantly covered with emollient poultices, renewed seve- ral times a day ; they relax the inflamed tissues and calm irritation ; they may be rendered narcotic, when the local pains are very severe. Narcotics, internally, are equally indicated, if the pains become general and violent; baths also, administered from time to time, are productive of very satisfactory results ; they calm the general erethysmus kept up by this kind of inflammation peculiar to cancer. "What hastens most the effect of the remedies we have pointed out, is a rigid diet which facilitates the disgorge- ment of the parts by augmenting the activity ofthe absorbent vessels. In depriving them of the fluids of digestion, we force them to draw from all parts of the body, materials proper to repair the losses ofthe blood ; they take up then, not only those held, by the economy, in reserve, as the fat, the serosity of the cellular tisse, but they likewise devour the tumour itself. It is thus we can explain the success of Pouteau, who only suffered his patient to take ice-water for several months.f "When leeches, emollients, and diet have diminished the general susceptibility, and local irritation, we may have re- * It is on the execution of this precept that depends, in a great measure, success ; the bleedings must be small, but often repeated. f It is doubtful whether we shall adopt the explanations given by M. Ma- lechal ofthe influence of diet over the cure of cancer ; this physician did not seem to be acquainted with gastro-enteritis : he is ignorant that it comes on and continues constantly, when there exists a chronic inflammation, an ulcer as painful as that bearing the name of cancer, in any part whatever of the economy ; and that if gastro-enteritis is provoked by the sympathies which this irritation excites, the latter is in turn influenced by the inflamed diges- tive mucous membrane. We know that ulcers soon become more painful and suppurate more, when the patient has taken a greater quantity of food than usual, and we see these lesions ameliorate and heal under the influence of diet, whilst the existence of gastro-enteritis would eternalize them if we may use the expression. These ulcen arc then under a verv dose depen- ■ rnceon this inflammation.—Author. l [ 37 ] course to derivative means, which keep tip a determination towards a point different from the one where it has con- stantly a tendency to fall. Purgatives have the double advantage of acting as irritants on an extended surface and of producing abundant evacuations ; setons, cauteries, mox- as, &c. may be employed at the same time ; they act on a circumscribed surface, but in a permanent manner. The only precaution necessary, is to avoid using them as long as Jhe phenomena of inflammation persist in a high degree and not to apply them too near the affected part." M. Marechal remarks, that if the cancerous affection is a sequel of syphilis, it is necessary to combine with the pre- ceding treatment, the employment of the means used against this disease ; but, after the justness of the opinions often manifested by this physician in his thesis, we see him, with astonishment give the same precept for herpes and scrofu- lous affections. Does he see any thing specific in these two diseases, and does he think that we can oppose to them a peculiar curative method, as is done in syphilis ? "Perhaps," adds he, "by following such a course, by overcoming the inflammation which has favored the development of the heterogeneous tissues, it will often be possible to remov6 these new organs. If, however, this treatment sometimes fails, and we are obliged to have recourse to an operation, we think that it will at least, have the advantage of favoring success, by diminishing the susceptibility of patients.—• We are moreover, firmly persuaded, that cancerous affec- tions will become more rare, when we have other ideas on their nature and etiology ; when in place of treating by stimulants and repercussives, simple chronic inflammations^ which by terminating in induration, become a new source of irritation, to the parts, in the middle of which they are found, we shall destroy this irritation in the part where it has fixed its seat, arid shall combat it until its entire ex- tinction." After having considered the local phenomena of acute and chronic inflammations and sub-inflammations, we should turn our attention to the two other forms assurnable by irri- tation—hemorrhages and neuroses. We do not find in any thesis an exposition of the physiological doctrine on these two modes of irritation ; but we will present themhere suuv manly, in order to fill up this void. The theory of hemorrhages, is one on which pathological H [ 5b 1 physiology has thrown the most light. Not knowing that the blood may be furnished by exhalation, physicians, since Hippocrates, have attributed its flow to the rupture of ves- sels. Morgagni, and more recently Bichat, by examining the mucous membranes which have been the seats of hemorr- hages, have done justice to this error. The other opinions admitted on the morbid condition of the tissues exhaling blood, have been by no means satisfactory. In short, he- morrhages were successively attributed by the animists to a salutary effort of nature ; by the mechanicians to inertiae of the capillaries, whose resistance had been overcome by the too energetic action of the heart; by the humoiists to the alteration and extreme fluidity of the blood. Stahl first recognized the true nature of hemorrhages, by considering all-sanguine exhalations as active, and giving the name of passive to traumatic hemorrhages alone. But soon, Brown— the erroneous principles of whose doctrine induced him to see only debility in nearly all diseases—pretended that all hemorrhages were asthenic, that they were the result of too feeble tension ofthe vessels, of the gaping of their extremi- ties, and ofthe penury of the blood. M. Pinel, observing that hemorrhages are sometimes preceded by general and local phenomena of excitation, and at other times not, ad- mits that hemorrhages were produced by two different modifications of the parts, excitement, and asthenia; he divided consequently, hemorrhages into active and passive. M. Broussais has combatted this theory and has sustained that all hemorrhages result from irritation of the sanguine capillaries, and that consequently they are all active, what- ever be the debility of the patient; it is easy to show the exactitude of this opinion. it is remarkable that on the presence or absence of the molimen hemorrhagicum exclusively, the ideas of acuteness and passiveness of sanguine exhalations have been estab- lished. If the celebrated author of the Nosographie philo- sophique, has rejected what in the opinion of Brown, is too ev- idently erroneous, he has sacrificed, notwithstanding, to the principle ofthe unity andindivisibility ofincitation, by admit- lng the passiveness of hemorrhages in debilitated individuals. But cannot the most intense irritations come on in the most de- bilitated subjects, as well as in those possessing the greatest force ? Do we not know also that they do not always excite sympathetic phenomna : if then the most profound debilitv [ 39 J does not prevent the development of an inflammation, and if inflammations may in a great number of cases, an ive at a high degree of intensity, and at the same time only develope symp- toms so obscure as to pass unnoticed, can we not conceive that the same may happen in hemorrhagic irritation which is always marked by a less intense exaltation of vitality than that constituting inflammation ? Moreover in an individual not already debilitated, the hemorrhage will be preceded by a pricking sensation, heat and heaviness in the part, by shiverings, small contracted pulse, soon followed by gene- ral heat and a large, hard, bounding pulse ; whilst in sub- jects weak and not irritable, the local phenomena of irrita- tion will be less marked, and the general symptoms will be entirely wanting. But in the latter case even, the part will always be redder, warmer, and the patient will always feel pricking and heaviness. The local disposition then is al- ways the same in hemorrhages ; the intensity only7 of the ir- ritation varies, and consequently that of the general phe- nomena, which are always subordinate to individual sensi- bility. The absence of the molimen hemorrhagicum,ia not then sufficient to establish the passiveness of sanguine dischar- ges. If it be true that the asthenia of a part produces hemorr- hages in it, those possessed ofthe least vitality ought to be thus affected more frequently than others ; but this is far from being the case. Look at the members withered by paralysis or old age ; are their pallid, unirritable, languishing tissues ever the seat of sanguine congestion ? So far from produ- cing these, sedative agents, cold for example, by diminishing the irritability of the parts on which they are applied, make them become pale, by preventing the blood from entering in such large quantities. The asthenia of the tissues cannot give rise to a sanguine afflux; we cannot pretend then that the debilitated capillaries suffer themselves to be dis- tended by the blood, and that then their orifices give pas- sage to it; passive hemorrhages therefore are impossible. Since they admit active hemorrhages, how can they also admit passive ones ? as if an identical effect could be pro- duced by two organic dispositions diametrically opposite.— Notwithstanding, however, the contradiction apparently im- plied by these two opinions we would be obliged to admit both, if they were equally well demonstrated. But we have seen that the passiveness of sanguine exhalations was a supposition ; that it reposed absolutely on nothing, since the L w J only argument given in support of this theory, is without any value. When an individual who presents all the phenomena of molimen hemorrhagicum has lost a great deal of blood, these disappear entirely and the hemorrhage often still continues. It is necessary then to admit that the hemorrhage, at first active, is become passive by the loss of forces in the patient. But how can we conceive that a complete change takes place in the organic disposition ofthe part, that its irritation makes room for its asthenia, and that the consequences of these two opposite lesions are always the same. But we have already seen that the local phenomena are always identical, that the part is always more red and warm, that they exist only in a less marked degree. We see often in the mucous membranes, hemorrhages al- ternating with inflammation : that is to say, the symptoms of the lat'er disappear when the sanguine exhalation comes on, and show themselves again when the hemorrhage ceases. Thus it is not rare to see a haemoptysis subside, at the same time when a more violent cough and the development of fever announce that the irritation of the mucous membrane has passed to a more elevated grade. But these phenome- na are seen as well in weak as in strong individuals, in those affected with hemorrhages reputed passive, as well as in those whooffer the phenomena of excitation; and would it not be ab- surd to maintain in the first instance, the passiveness of the hemorrhage ? for this would be asserting that the same tis- sue may pass rapidly from asthenia to inflammation, and from the latter to debility7. The effects of tonics and astringents in the treatment of certain hemorrhages has also been a reason for attributing them to asthenia. But do not these substances often pro- duce the same results in inflammations ? Do we not see opthalmias, gonorrhoeas,'even in their acute stages, leucorr- hocea and chronic colitis yield to the employment of astrin- gents ? When sanguine irritations are light, they produce a constriction of the capillary vessels, and consequently pre- vent congestion. When on the contrary, the irritation is high, astringents almost always exasperate it. The same thing happens in hemorrhagic irritations ; if intense and ac- companied by reaction, they are not arrested by astringents, or at least very rarely ; in cases of a contrary character they often succeed. We farther remark that in many circum- [■ tfl ] stances, astringents only remedy hemorrhages by adding to the irritation which determined them, and by making the hemorihagic irritation pass to the inflammatory stage. The effects of astringents prove nothing then in favor of the passive nature of hemorrhages ; besides we know that cold, though a sedative, arrests the sanguine flow, as well in fee- ble as in strong individuals. We see often the application of a blister on the chest or thighs, or a sinapism to the feet arrest hcemoptyses, menorr- hagias and epistaxes, presenting the strongest characteristics of passiveness. This fact would suffice of itself to prove that all hemorrhages are the result of irritation ; for revul- sives cannot restore its habitual vitality to a distant part, plunged in asthenia, it is evident that they can modify only the action of the parts irritated. It cannot be objected that revulsives relieve passive hemorrhages by preventing the blood from flowing in such great quantities to the tissues in which they are seated. This error has been exploded in our day, and we know well that it is not by the abstraction of the fluid from the irritated part, that revulsion acts. Be- sides, irritants applied on a distant point will not prevent entirely the blood from penetrating the tissue supposed to be affected with asthenia. Why then does not the blood still contained in the capillary vessels, escape, since they no longer vibrate, and their orifices are gaping ? The hemorrhages, echymoses and petechioe, seen in fe- vers of bad character, (gastro-enterites with adynamic and ataxic symptoms,) are regarded as essentially passive hem- orrhages ; but if these phenomena are the result of asthenia; why, as M. Broussais has observed, do they not always ap- pear in the last moments of life, when debility is extreme ? On the contrary the petechioe, become pale at the instant of dissolution, the fluids are concentrated in the irritated visce- ra and seem to abandon the external capillaries. We ob- serve these hemorrhages during the time of the highest ex- citement, when the action of the capillary system is most ex- alted ; and w7e see them disappear at the termination of the disease, when the sum of the forces is much inferior to what it was in the beginning. They cannot then be produced by asthenia. However, M. Broussais does not expl in the lo- cal organic cause which produce these phenomena, but he regards them always as a sympathetic affect of the irritation that then affects the viscera. i ** ] Scorbutic hemorrhages and petechioe are the last refuge of the partisans of passive hemorrhages. It is very "true that the debility of muscular power is one of the principal characters of scurvy; but it is impossible to pretend that debility alone can produce this disease. We see every day individuals exhausted by chronic diseases, by defective ali- mentation, by excessive evacuations, &c. who are not scor- butic ; and if we consider the nature of the causes of this affection, we see that it appertains most frequently to de- bilitating influences, and we know, moreover, that scorbu- tics are much oftener cured by the use of vegetables and acidulated fruits than tonics. There evidently exists in this affection an alteration of the humors, a change in the com- position of the blood, and consequently a depravation of nu- trition, and an alteration ofthe fibrine and gelatine. If the structure of the tissues be changed, if the blood no longer possesse the same properties as in the normal state, the ac- tion of the capillaries must also be changed. We can form no conclusion then from the extravasation of blood in the areola of the cellular tissue in scorbutics, favourable to the passiveness of hemorrhages ; and we cannot say that the organic disposition which gives rise to them in this disease is asthenia, since we have seen that in all other circumstan- ces, sanguine exhalations cannot be the result of debility. Let us farther observe that Scorbutics affected with inflam- • mations, may be also effected with hemorrhagic irritations; for the alteration have undergone by their tissues, has not made them lose their aptitude to irritation ; for the hot scur- vy, viz. that accompanied by thirst, frequency of pulse, heat of skin, &c. is complicated with inflammation somewhere ; and the division of scurvy into hot and cold is very correct. Scorbutics then may be affected with the hemorrhagic irri- tation like other individuals ; but this does not exclude hem- orrhages resulting from an alteration of the blood and of nutrition, and which take place even, rather in the substance of the tissues than at the surface of the mucous membranes. We have already said that we do not find in any thesis a history of nervous irritation ; we proceed to confine our- elvesas as we have just done in hemorrhages, to indicating on what principles this subject ought to be considered. As M. M. Broussais and Lobstein remark, nervous irrita- tion preceeds always the fluxion determined by the stimu- lation of apart; that is to say, before the capillary vessels [ «8 ] become affected, and the congestion takes place, the nervous capillaries are already irritated : the irritation then extends to the vessels, and it is not till then that exhalation takes place. We have before said that the irritation may remain concentrated during a considerable time in the nerves with- out the phenomena of inflammation being developed ; but if the nervous irritation is high, the sympathies may already be put fri play, and we have before observed that they may excite in the viscera, disturbances sufficiently grave to pro- duce the death of the patient, before phlogosis be establish- ed in the irritated part. Since all the phenomena of irrita- tions commence by that of the nervous capillaries, the latter cannot exact a separate study. It is necessary then in limit- ing the value of this expression, only to understand by ner- vous irritations, those not accompanied by an apparent af- flux. These are the lesions called by M. Broussais, active neuroses, in opposition to the diseases resulting from the ex- tinction or diminution of sensibility7 and myotility,and which he designates under the name of passive neuroses. The phe- nomena of active neuroses and the mechanism of their pro- duction varying in different parts of the nervous system we may establish between them the following divisions : 1st. Nervous irritations of the internal sensitive appara- tus, (the brain.) We ought to refer to them, hemircania, paraplegia, clavus hystericus, and a great number of the phenomena of mania and hypochondria, &c. They are primitive or sympathetic of a nervous or sanguine irritation of other viscera. 2d. These of the external sensitive apparatus (spinal marrow and the nerves arising from it.*} In the neivous cords they may be primitive ; such are the greater number of neuralgias produced by cold, punctures, &c. They may- be the consequence of a lesion of the brain or spinal mar- row ; of their inflammation, for example. Finally, they are more frequently sympathetic of some visceral inflamma- tion. In this case the stimulation is first felt by the brain, and from thence scattered through the nerves. 3d. Irritations of the nervous apparatus of organic life.— These constitute the neuroses of authors : certain fleeting dyspnoeas, certain coughs concomitants of irritation of the stomach, the convulsive movements of the heart, spasms of the oesophagus, of the intestines, hysteria, nymphomania, &p, Very often these neuroses excite sympathies which L 64 J are reflected on the brain and nerves of relation. M. Brous- sais has very much reduced the number of them, in show- ing, by the examination of the causes, phenomena,post mor- tem appearances, and the effects of treatment, that a crowd of visceral irritations regarded as nervous, and to which they oppose stimulants of every kind, under the name of antispasmodics, were only chronic phlegmasia? ; such are principally the greater nuumberof yieuroses of the stomach; bulimia, cardialgia, dyspepsia, pyrosis, hypochondria, &c— Hypochondria is always the result of a chronic gastro-ente- ritis, in an individual of a nervous temperament, in whom consequently the sympathetic irritations concentrate in the nervous system. They had already observed at the open- ing of the bodies of hypochondriacs, diseases of the liver, cancers of the stomach, obstructions, &c. ; they have also said that these lesions may produce hypochondria ; but they did not the lesson this account continue to regard this disease as essentially nervous. The neuroses of the respiratory or- gans also, have latterly have been very much curtailed in num- ber. After having always met diseases of the heart, of the aorta or lungs in the dead bodies of asthmatics, M. Rostan has called in question the existence of essential asthma, and M. Pinel himself no longer sees in angina pectoris, any thing more than a symptom of some organic lesion. Finally, we see that the nervous irritations, which suc- ceed at first to the action of stimulating modifiers, continue rarely without affecting the capillary vessels and giving rise to phlogosis ; that the neuroses are not in general primitive except in the expansion of the nerves ; that the greater number of nervons irritation, seated in the sensitive center and the nerves, take their origin in sanguine or nervous ir- ritations of some part ; that a great number in short, of the diseases reputed nervous, are only the phenomena of acute or chronic inflammation. L <>3 ] CHAPTER III. SYMPATHETIC PHENOMENA OF IRRITATIONS. The study of the sympathetic phenomena arising from irritations, constitutes one of the most important parts of pathological physiology. Without a profound knowledge of the relations existing between the modifications of the action of the different organs in a state of health and disease, it is im- possible for us to progress in etiology and symptomatology, or to establish the principles of therapeutics on a solid basis :it is by the aid of these that we are able to appreciate the relation existing between the causes of these diseases and their phe- nomena and the different effects of the action ofthe same cause on the different organs. The study of the sympathies, joined to that of pathological anatomy, has permitted us to arrive at the knowledge of the true nature of diseases, by making us refer the* symptoms to the lesions of organs, and by making us distinguish the primative affections, the source of all disor- ders, from those sympathetically excited in other parts ; this has unveiled to us the phenomena of metastases and cri- ses*; in short, it is on a knowledge of the sympathies that we often establish our principal curative indications. We are indebted to M. Moncamp for an excellent treatise on the sympathies ; he has enriched it with a number of remarkable facts, of judicious reflections and of physiological principles drawn from the new medical doctrine, whose author he has sometimes forgotten to name. We may also reproach this little book with some blemishes, marked by7 the sacrifices sometimes made by M. Moncamp to opinions, the errors of which no one can know better than himself.— Nevertheless, this treatise will be read with a great deal of interest", and wc think it our duty to present here a full analysis of it. This physician seems to us to have given a correct defi- nition ofthe sympathies, when he says, that they consist in the union, the agreement and correspondence existing amongst all the parts of the body, and which "re the cause that when a modification takes place in one portion ofthe ecor. - my, another similar one supervenes in one or several parts situated at a greater or less distance. What is the means of sympathetic communication of the different organs wti one -iiother ? Most of the moderns since Vieussens and Willis, attribute it to *hf nerves, und M. p-^ussate p.grfc-.V: in -;h> t GG ] opinion. According to him, the transmission of irritation takes place in the same manner as that of excitation in a state of health. Many physiologists have denied that the nerves are the agents of the sympathies: but the objections presented by them, and which M. Moncamp has related in his thesis, are fai from being satisfactory; and Whitt, to whom is due the greater part of them, has fallen into an evident contradiction, in saying it is the sensorium commune that establishes the sympathetic union of organs amongst each other. It is evident, if this be the case, that the nerves bring the impression to the brain, and that it is by the nerves also it is transmitted to the other organs. How does it happen, says M. Moncamp, that the parts not receiving the same nerves, can sympathize ? Such, adds he, is the disturbance of vision supervening during bad digestion, though there is no communication between the nerves ofthe stomach and optic nerves. There is here an anatomical error which will be corrected by all those acquainted with the distribution of the filiments ofthe opthalmic ganglion and those of the great sympathetic accompanying the opthalmic artery. Although the fibrous tissue does not contain nerves, objects M. Moncamp, when inflamed, a crowd of sympathies are developed ; but if this was the case, we would not pro- duce pain by twisting the articular ligaments, as we see happens in the experiments of Bichat. M. Moncamp con- tends that we are mistaken in attributing the transmission of of the sympathies to one system alone, since they are attri- butable, says he, to the relation uniting all the organs; it is their reciprocal correspondence which constitutes them, and they should be referred to all the parts at the same time. But by what is established this relation, this correspondence ? to this the question is reduced ; and in attempting to resolve it M. Moncamp has only translated it into other terms. 'Are not the sympathies manifested during diseases merely an exgeration of those existing during health, or are the phenomena peculiar to the diseased condition, unnatural de- velopments of the vital properties, as Bichat says ? M. Mon- camp justly observes, that it would be erroneous to admit exclusively, either of these opinions, since they are both true. Thus the encephalic irritation determined by gastro- enteritis, manifested by pain in the head, coma, delirium &c. is here only an exageration of the consensus of action uniting the brain and stomach, in health. In the inflarama- L «* j tion of the latter, the skin is dry and becomes humid when the disease terminates ; the same thing is seen during diges- tion. On the other hand, w7e observe during diseases, sympathies between organs that, in a state of health, seem to have no relations : it is thus we see vomitings come on during nephritis, and during the operation for cataract, &c. but we must confess that it is perhaps, on account of the little knowledge at present possessed by us of the relations existing amongst all the parts, which makes us regard these phenomena as anomalies. Tissot incorrectly distinguishes the sympathies into active and passive : if a metritis, for example, produced vomiting, he said that the uterus was the seat of the active sympathy, and the stomach that ofthe passive ; but evidently a sympa- thy is composed of two things—1st, of a modification in the action of an organ ; 2d, of the modification of that of one or several others, determined by the first. This false division arises from the distinction already made of sympathy, from sympathetic phenomena; the first expression corresponds to the active sympathy of Tissot, and the second to passive sympathy. But still, sympathy is only constituted by the simultaneousness of affections of two, or a greater number of parts. M. Moncamp rejects also the division of sympathies into those of contiguity and continuity. In fact, it is not proved that the continuity of tissues has a great influence over the sympathic transmission of irritation. The different parts of the digestive mucous membrane, sympathize less with one another than with the skin ; and the experiment of Bichat is well known, who after having cut transversely the oesoph- agus, saw tickling of the fauces produce vomiting. The ad- mission of the sympathies of contiguity does not seem to be better grounded : who would maintain, for instance, that there is not direct propagation of irritation, by means of the continuity of the cellular tissue, in the peritonitis produced by cystitis, metritis, &c. Bichat has classed the sympathies according to the nature ofthe vital properties brought into play; but the correctness of this division is subordinate to that ofthe admission of seve- ral vital properties, and if the greater part of those admitted by the author of the Anatomie generate, are only functional results of the action of the organs, it is evident that the distinction of sympathies into those of sensibility, and con- I V" j tractility, &c. is purely abstract; besides it is sterile, for it cannot serve to establish any principle, any law on the ex- ercise of the sympathies. In effect, the disturbance of the sensibility or contractility of relation of an organ, excites just as well in another organ a disturbance of organic sensi- bility or contractility, as that of animal sensibility or con- tractility ; and vice versa. Moreover, as observes M. Moncamp, in a disturbance where several properties are put in play, how will you class these sympathies of vital proper- ties ? Such would be the excretion of urine, which exacts on one part from the bladder the development of organic contractility, and from the abdominal muscles that of animal contractility. The same may be said ofthe division of sym- pathetic phenomena, into organic sympathies and those of relation, admitted by M. Broussais, and not spoken of by M. Moncamp. This also is entirely abstract, since the phe- nomena of relation are only functional results, and because, in all cases it is not the disturbances ofthe functions of rela- tion which are transmitted, but those of the organic pheno- mena ; from whence a change may follow in the phenomena of relation, if the organs whose actions are modified are charged with the execution of the latter. The author of the Examen, also says himself, that the sympathies of rela- tion never exist without the organic sympathies, whilst the latter may exist without the former. But evidently M. Broussais has only established this distinction to avoid the circumlocution of language necessary to express that the irritation of such an organ has produced such a disturbance in another. All parts ofthe body are united by sympathies, but these are more or less strict between the different organs. In general, those fulfilling the most important functions of the economy, are also those amongst which we see the most intimate connexions ; such are the brain and the stomach. The number and intensity of sympathies developed by an irritated organ, are subordinate to several circumstances, which are relative to the importance and sensibility of the organ affected, to the degree of its irritaion, its duration and to the individual constitution. The digestive mucous membrane, the brain, the lungs, the skin, and the heart, are the organs that provoke and receive the most sympathies; one amongst them cannot be irritated to a high degree, without the whole economy per- L «» J t eives it immediately, and the sympathetic disturbances are not proportioned to the pain accompanying the irritation ; for gastro-enteritis provokes many sympathies and is rarely itself accompanied by pain ; and on the other hand rheuma- tism> though very painful, often causes no fever, nor any other sympathetic disturbance. The intensity of the irritation determines also that of the sympathies, and these give ordinarily the measure of the degree of the first: thus it is principally by the violence of the fever we judge of that of the gastro-enteritis, pleurisy j pneumonia, &c. But according to the judicious observation of M. Moncamp, it often happens when an inflammation is very intense and affects a large surface, that the action of all the organs seem to be chained, that all the forces seem concentrated on the diseased part, and that there exists few sympathies. Under these circumstances, bleed the patient, and you will soon see them developed with activity; you will be tempted to think that the intensity of the inflamma- tion has augmented, whilst it has actually diminished. To this influence of the degree of the irritation on the sympa- thies, M. Moncamp should have added that exercised by its antiquity. In general inflammation is accompanied by gen- eral disturbances, more strongly marked in proportion as it is near the period of its birth ; in the long run the sympathies wear out, as it were, whether because the irritation less in- tense, provokes them more feebly, or because the sympa- thetic stimulation is no longer so vividly felt by the parts to which it is transmitted for a long time. A great number of chronic phlegmasiae present no other symptoms than their local phenomena and this is one ofthe principal causes ofthe obscurity of their diagnosis. The silence of the sympathies is prolonged sometimes until the period of the disorganiza- tion of the irritated tissue ; they are then awakened and put in play with greater or less activity. The constitution ofthe individual is one ofthe circumstan- ces which exercises the most marked influence over the development of the sympathies: we observe that it is in general in direct ratio with the sensibility. In individuals of an irritable constitution we see the slightest irritation, particularly when it effects an important organ, excite a crowd of sympathetic disturbances. On the contrary, in robust individuals, and still more in those of a lymphatic temperament, and full habit, the most serious inflammations L ™ J often limit their phenomena to the affected organ ; and it is as much perhaps on account of the obscurity of the diagno- sis in their diseases, which do not admit of active treatment, asof the facility with whi h sub-inflammations are established in them, that they are affected with so great a number of chronic phlegmasias. For the same reason the development of sympathies is subordinate also to the age and sex of individuals, and to the climate they inhabit. Women and children generally hav- ing the most irritability, greater nervous mobility, as we say, present in the irritations that affect them, a crowd of sympathies ; and in this respect old men, approach, on the contrary, the lymphatic temperament. Climate, which modifies in a remarkable manner individual constitutions, ought to produce the same results. A foreign body intro- duced into the foot of a negro, the impression of cold air on a negro child is sufficient to produce tetanus, while it w7ould very rarely be produced by the same causes in the inhabi- tants of Russia. Besides these general influences M. Mon- camp points out several particular circumstances that modify the development of the sympathies : thus the irritation of the same part, according to the mode in which it exists, and according as it is determined by different causes, will pro- duce different effects on the other organs. Thus, if the pharynx be irritated by a feather, vomiting will be produced, but this is not observed in pharyngitis ; titillation of the bottom of a healthy foot will produce laughing, and after a time convulsions ; if we tickle this part when inflamed we only produce pain. "Pathological sympathies may take place, in the physio- logical state, says M. Moncamp. Such is the vomiting and even syncope, often produced by the sight of a disgusting object." This reflection seems to us a mere subtility, for every notable disturbance in health is pathologist, and the first morbid phenomena, evidently arise always in the phy- siological state. After showing the most important and irritable organs to be those which develope the most sympathies, M. Moncamp ought also to have remarked that they are also those which receive most. Thus we see the digestive mucous mem- brane affected in almost all acute irritations : the same thing happens in organs affected with chi onic irritations. But we have already anticipated these facts by saying farther back, L and unhappily it is in this disease that they have been most la-s -i*hed; on acccun* of the externa! debility often accomp^ R [ 138 ] lying it, and of the complete ignorance we were plunged into, previous to the labors of Broussais, on the origin of the symptoms by which it is manifested. This subject will be treated with all the details belonging to it, in the history of gastro-enteritis ; it is sufficient here to point out the cir- cumstances which should warn the physician to resist the temptation to stimulate, when this inflammation is united with some indication for tonics. He should abstain from them whenever he observes redness on the borders of the tongue, thirst, loss of appetite, dryness and heat of skin and fre- quency of the pulse. M. Vallee correctly observes that these are the symptoms of well marked gastro-enteritis, and that there exists many other grades of this disease, which, though presenting themselves with less marked characters, do not the less on this account forbid the use of stimulants. We cannot then study too closely all the degrees of this in- flammation, since the state of the digestive passages must modify, at every instant, the conduct of the physician. We must say the same thing of the diarrhoeas which frequently complicate the last period of chronic inflammations ; as they add to the debility, w7e see most physicians then administer tonics, whilst it is only by emollients, &c. they can cure the inflammation of the colon giving rise to this disease. It is the same in cholera morbus, produced by a gastro-ente- ritis joined often to a more or less acute irritation of the liver. The only reason why it makes such ravages in In- dia and America is because they lavish the most active stim- ulants on those affected by it; it only affects so great a number of individuals because they make use of the same means, under the name of preservatives, when this affec- tion reigns epidemically. Stimulants are also introduced into the treatment of in- flammations of other mucous membranes. Every one knows the use generally made of balsamics, scillitics, kermes, and other incisives, at the decline of pulmonary ca- tarrhs and pneumonias, and in the chronic state of these diseases. When these substances do not produce a revul- sion on the stomach, they add to the inflammation of the organs of respiration ; for we know that they have the pro- perty of stimulating the bronchial mucous membrane.— When they cure, we again say, it is only by irritating the stomach; and to be convinced of this, it is sufficient to re- collect that physicians have given, in the same cases, ipe- L 139 1 eacuanha in small doses, repeated every morning, so as on- ly to produce nausea. They make also a great abuse of balsamics and astringents in the inflammations of the genito- urinary mucous membrane. They are often advantageous, it is true, when these affections are for a long time chronic, when the heat, redness and pain have disappeared, and when they are no longer manifested except by the augmenta- tion of the secretion of the membrane ; but then they ought to be employed with the greatest circumspection, principal- ly in women, in the treatment of vaginal catarrh. We can- not too much blame those practitioners who treat the most acute cystitis and urethritis by stimulants, because theyr suc- ceed in the chronic state of these affections. How7 many cancers of the neck of the uterus, suppressions of the men- ses, severe opthalmias, strictures of the urethra, sub-inflam- mations of the testicles, chronic cystites, are the result of the employment of astringents in the treatment of inflam- mations of the genito-urinary mucous membrane ! The tonics given generally in chronic inflammations of the serous membranes and the parenchymatous organs only prolong and augment the intensity of chronic pleurisies, pe- ritonites, pneumonias and hepatites. It is to their abuse we owe the greater part of the disorganizations brought on by these inflammations, and it is also the stimulants as wrell as the sympathies provoked by them, which produce the gas- tro-enteritis that complicates these affections and accele- rates the destruction of patients. We may say the same of the chronic inflammations of the muscles and of the fibro-serous system of the articulations. If sudorifics are sometimes useful in chronic rheumatisms, they almost alway7s add to their intensity when acute ; and if we wish these to produce a revulsion on the skin, it is only by the substan- ces, authors have called cold sudorifics, that is to say, warm aqueous or acidulated drinks. Whatever be the stage of the inflammation of articulations and the constitution of the individuals affected, tonics ought always to be proscribed in the treatment of this inflamma- tion, since, as we will see farther bn,nt is often sympathetic of a gastro-enteritis, acute or chronic ; and that in cases where it is primitive, the inflammation of the digestive mu- cous membrane often complicating, it brings back its parox- ysms more frequently, and renders them more intense. Hemorrhages are one class of the diseases in which ton-* i. M° ] jes have been most abused. Whenever they were accoin panied by debility and were not preceded by the hemorrha- gic effort*, (molimen,) remedies of this class were adminis- tered to counteract the relaxation and debility to which they were attributed. But it is only by changing the iieaiorrha- gic irritation into inflammation that they stop the flow of blood. They substitute a more serious affection for the one previously existing. Thus arise gastritis, chronic pneumo- nia, metritis, so frequently observed, when stimulants are op- posed to haematemesis, haemoptysis, menorrhagia, &c. We should never have recourse to tonics and astringents, when the hemorrhage takes place from an organ whose inflamma- tions are dangerous. We should then always confine our- selves to blood-letting, demulcents and diet, and recur to re- vulsives if these means fail, and the weakness of the pa- tient does not permit us to use them farther. We have already shown, sufficiently in detail, that organic disorganizations were only the result of chronic inflamma- tion ; and we have cited so many examples of cures by the antiphlogistic method, that it is unnecessary for us to stop and show that these affections are aggravated by opposing to them, as has often been done, tonics of all kinds. The physiological doctrine banishes these means of treat- ment even in scurvy, in which they have been administered with profusion. We do not speak of febrile scurvy only, that is to say, that accompanied by visceral inflammation; the contradiction here is so palpable, that any one, no matter how little versed in physiology, must know how to appreci- ate it. But this proscription extends also to cold scurvy.— M. Broussais has shown that this disease was not the result of weakness, but an alteration of sanguification and nutrition, which are developed under influences totally different from debilitants, and that it can only be remedied without danger by a pure, dry and warm air, by a vegetable regimen, and vegetable acids. All this crowd of stimulants, of acrid sub- stances, lavished under the name of scorbutics, are only fit to develope inflammation of the viscera, to which these pa- tients are more disposed than other individuals. If some light tonics are permitted, old wine for example, it should only be in cases where the digestion languishes, is painful, and where the defect of action in the stomach depends in reality on its asthenia. M. Valine observes, that the neuroses are the diseases in i Hi j which the administration of stimulants and tonics, given un- der the name of antispasmodics, has least inconvenience ; we ought, however, to denounce this practice also as dan- gerous, in a great number of these affections. Let us re- mark, indeed, that purely nervous irritation is most frequent- ly transient; then we administer stimulants ; but when the irritation affects for some time the nervous capillaries of a mucous membrane, it is almost always partaken of by the sanguine vessels. Let us farther observe, that those phe- nomena called nervous, manifested in other parts than those in which then have their source, are only the results of sym- pathies provoked by a chronic inflammation in an individual whose nervous system is predominant and consequently more irritable than all the others. M. Broussais has shown that most of the pretended digestive neuroses, dyspepsias, gastrodinias, spasmodic vomitings, hypochondria, &c. were only grades of chronic gastro-enteritis, that they are some- times even provoked by the disorganizations brought on by the latter. Let them judge then ofthe effects on the stomach of all. the tonics lavished in these cases. We would say the same as to the neuroses of generation. Hysteria and other nervous affections so common with many women, are nearly always the results of a chronic irritation of the uterus, ac- companied very often by that of the stomach ; we observe always that these women only experience relief from the use of emollients, baths, habitual exercise of venereal en- joyments, or on the contrary, abstinence from coition, ac- cording as the disease is produced by privation or abuse of the pleasures of love. And every every one may observe that stimulants lavished on those patients, under the title of antispasmodics, only deteriorate the constitution, aggravate and perpetuate the disease. The recent labors in patho- logical anatomy have very much restrained the number of neuroses of respiration and circulation; there are, however, certain troubles of these two functions which are truly the results of nervous irritation ; in these cases we ought to recur to antispasmodics ; but in this case, as in every other, we should always take scrupulously into account, the state of the stomach ; for a substance, which would be an anti- spasmodic if this organ were sound, would produce a contrary effect if it were irritated, because the increase of its irritation would develope sympathies which would be felt by the or- gans whose action w7e wished to modify. The truth of thi* I u* j proposition will soon be demonstrated in an article conse- crated to the examination of the properties of digitalis. It is superfluous to point out the dangers of stimulants in the neuroses of locomotion, since they are the symptoms of an irritation of the sensitive centre and its envelopes. Before following M. Vallee in the examination of another class of medicines, we should say a few words of a theory as strange as erroneous, 'which has been in vogue for several }7ears in Italy, and which is even spread amongst some phy- sicians, who admit with much more facility, the most absurd opinions, originating beyond the Alps, the Rhine, or the Thames, than the truths discovered by their fellow citizens. When Brown attributed the phenomena by which life is manifested, to the action of stimulants, on the organized tissues, he asserted that there did not exist debilitating agents, and that those regarded as such, were only stimu- lants whose less energetic action determined too feeble an excitement. Whilst pui suing most ofthe fundamental dog- mas of Brownism, Rasori and his disciples, have admitted on the contrary, the existence of agents which exercise on the tissues an action opposed to that of stimulants, which destroys consequently the effects produced by the latter, and which may give rise to diseases not to be cured except by excitants. Hence the origin of counter stimulus. The Brownists of Italy regard as counter stimulants not only cold, bleeding, and mucilaginous substances, but also purgatives, emetics, digitalis, all the bitters, the greater part of mineral medicines, amongst which they count scarcely any stimu- lants. One must be very little advanced in the study of patho- logical physiology, to regard as counterstimulants the pre- parations of aloes, antimony, &c. because the irritation they have produced in the intestinal canal has cured a pleurisy. "The Italian physicians," says M. Broussais, "have then never observed obstinate vomitings and hypacatharsis, which are only gastro intestinal mucous inflammations, produced by emetics and drastics ?" The author of the Examen is justly astonished, that they could attribute these effects to counterstimulants, and he asks if they are different from those produced by other stimulants, and if there be not a per- fect identity between the traces left by the pretended coun- terstimulants in dead bodies and those of diseases whose inflammatory character is avowed. "If sometimes," says M. Broussais. "the counterstimulators have seen diseases of L H3 J irritation cured, to which they apply excitants decorated with the title of counterstimulants, it is, either because they have paralyzed their pertuibating effects by copious bleed- ings, by regimen, and by the abundance of aqueous and mucilaginous liquids with which they had associated them, or because there came on a revulsive evacuation." It is then evident that the substances ranged amongst the counterstimulants by the Italians, are for the most part only excitants which diminish the irritation of another part than that on which they are applied, by determining in the latter a revulsive action ; and that counterstimulants, properly speaking, are only the agents we have before spoken of under the title of debilitants. The unfortunate results arising from the absolute want of application of physiology to pathology are particularly re- markable in this theory of the Brunonians of Italy. Is it still necessary to remark, that they have been led into this error by the habit of studying the economy in mass, as a homogeneous whole, if not in structure, at least in pheno- mena ? Because the use of emetics or purgatives by irri- tating the intestinal canal cures an ophthalmia or an erysipe- las they are counterstimulants ! According to this rule, cantharides, moxa and actual cautery are also counterstimu- lants. Is it not evident, that counterstimulation is here only indirect, is but the consequence, the contre-coup of the irritation produced by these agents in the part on which they have been applied ? Narcotics.—:M. Vallee examines, as he has done with re- gard to tonics, the circumstances counterindicating the em- ployment of these medicines, amongst which he selects opium as a type. Though in general medicines of this class are not abused as much as those of the preceding, it is not less important to designate the circumstances where their employment may be dangerous. The disposition to cerebral congestions, very often ac- companying plethora, suffices to banish opium from the treatment of affections to which this condition of the econo- my is joined. We ought also to be very circumspect for the same reason, in its employment in children and old people, as there exists a strong disposition to cerebral congestions at these two periods of life. Sleeplessness is one of the cir- cumstances which determines physicians most to recur to this medicine ; its employment however, may often have in [ 144 ] this case dangerous consequences. Whenever this condi- tion depends on high excitement of the brain, opium evi- dently will only add to the latter ; if the insomnolence is the result of stimulation produced-on the brain by an inflamed organ, the best calmantsthen will be antiphlogistics. What we say of insomnolence is applicable to the pain depending on an inflammation ; it is absurd then* to attempt to calm it by narcotics ; we cannot succeed in this, except by means proper to extinguish the inflammation producing it. If we succeed in these cases in silencing the pain, it is only by throwing the patient into a state of stupor, which checks all the functions by blunting the sensibility, and which render- ing the sympathetic phenomena more obscure, no longer permits us to judge of the state of the inflammation. Let us moreover observe, that the cerebral congestion which it de- termines, may have by itself the most serious consequences. In the contrary case where the pain results from a purely nervous irritation, we may oppose it with success and with- out danger by narcotics. All physicians agree in proscribing opium in the treatment of acute inflammations. It is very remarkable that it adds to the general stimulation, at the same time that it blunts the cerebral sensibility, by deter- mining a dangerous congestion in the encephalon. We should observe also that opium thrown into an inflamed stomach, stimulates it very actively, to such a point that we have seen the tongue often become dry and fuliginous after the administration of this medicine in gastro-enteritis.— Perhaps it may be employed at the commencement of some external inflammations with advantage ; at least, we have sometimes cut short gonorrhoeas by introducing into the fossa navicularis, at the time when the arder urinas announced the development of urethritis, a cylinder of crude opium formed by softening it in water. We will extend the pro- scription of opium, already banished by most practitioners, from the treatment of acute inflammations, from that of chro- nic inflammations also. If sometimes in this condition, as in the former, it has procured good effects, it is only by the property it possesses of producing perspiration ; and it is doubtless to this revulsive action that we should attribute Doctor Husson's cures of bilious fevers from laudanum, re- ported in the Annuairemedico-chirurgical of the Paris hos- pitals. But in the incertitude of obtaining this revulsive action, we ought to abstain in the nblegmasiae, from narcot- [ 145 J ics as well as tonics, since they may add to the intensity of the inflammation. There is, however, a case in opposition to this principle : M. Broussais has established, indeed, that opium produces advantageous effects in chronic colitis, Avhen there is no longer pain, fever, nor tenesmus, and when the dejections are no longer sanguineous, nor very abundant. Narcotics then, ought to be restrained to the treatment of irritations purely nervous. We may also recur to them with circumspection for the purpose of calming the pains accom- panying certain disorganizations ; finally, surgery reaps also great advantages from it, in limiting the progress of several ulcerations, and especially of those kept up by a syphilitic affection. Emetics.—So great an abuse has been made of this class of medicines, that there are very few diseases to the treat- ment of which they have not been applied ; in other words, there has scarcely existed a disorder that has not drawn down the fury of this method, which at different periods has inva- ded practice of medicine. Its success in cold climates, and in persons not very irritable, and the humorism Avhich has blind- ed physicians during so many ages, has given it credit in countries and amongst men, far from being under the same conditions. In vain did the frequency of its fatal effects and the extent of its ravages exclaim against this practice ; in vain did a great number of physicians, among Avhom we re- mark principally Hoffman and De Haen, revolt against its dreadful consequences and attack it with vehemence ; rou- tine and the spirit of system carried the day. Prejudice has resisted the evidence of facts and the most convincing reasoning ; and we shall still for a long time have to groan over the obstinacy of those men, in Avhose eyes the antiquity of a method is a title to infallibility. Humanity, however, has already perceived the benefits of the vigorous opposition raised by M. Broussais against this practice ; and among the many services he has rendered, the latter will be signalized as one of the most important. M. Vallee has presented all the counterindications op- posed by temperament, sex, and the nature of diseases, to the employment of emetics. Although we shall have to speak again in detail ofthe danger of emetics in gastro-en- teritis, Ave should nevertheless bring forward here what this- physician has Avritten on the counterindications to this meth- od, since it h?s been applied to all diseases, [ 146 ] The sanguine temperament and plethora forbid emetics on account of theinfluence of vomitingand of irritation ofthe stomach, on the production of apoplexy ; so also with early infancy and old age. Stoll abstained from emetics in old men for fear of cerebral congestions. The nervous tem- perament also is a formal counterindication to the employ- ment of these means, on account of the great irritability of persons endowed with it. It is not rare to see emetics pro- duce in them spasms, convulsions, and other nervous affec- tions. It is sufficient to knoAV that the bilious constitution depends on a great irritability of the liver, joined to a like condition of the stomach and duodenum, to proscribe emet- ics in the treatment of the diseases of individuals possessing this temperament. It is remarkable, that it is in these cases physicians, deceived by false appearances, have recommend- ed them most. Why have they not treated ptyalism by sialogogues ? To be consistent they ought to have done it; they would not have been more absurd in the one case than in the other : it is true that they Avere ignorant that the bile vomited did not pre-exist to the administration of emetics. Individuals of a lymphatic constitution, relaxed, loaded with obesity, and endoAved with obtuse sensibility, are those in Avhom emetics produce the least injurious consequences.— This circumstance is not sufficient to determine us to have recourse to them. Emetics cure inflammations only by producing a revulsion ; now, as the stomach is almost al- Avays the seat of it, and as in lymphatic individuals, gastritis is more dangerous than in others, on account of the facility Avith Avhich it passes into the chronic state, Ave should treat their inflammations by other means ; and if it be necessary to recur to revulsion, we should establish it on organs of less importance. Debility also is opposed to the employment of emetics. In Aveakly individuals, the organs are generally very irritable, and the state of violence into Avhich emetics throw the economy, Avould produce almost infallibly a con- gestion in some one amongst them. We should be still more circumspect in the employment of emetics in women than in men, on account of the greater susceptibility of the for- mer, and their more marked aptitude to nervous affections. We should interdict them rigorously during the menstrual floAV, for fear of giving rise to menorrhagia, or on the other hand, to suppression of the menses. Most physicians have prohibited them also during gestation, because they expose L 14? j women to menorrhagias and abortions. The lochial Aoav is a positive counterindication to the employment of emetics, not only on account of the danger of their suppression, but because all the abdominal viscera are then in a state of ex- treme irritability, and because the stimulation of the diges- tive passages and the efforts of vomiting might give rise to serious inflammations. M. Vallee remarks that there are few inflammations Avhich do not forbid the use of emetics, principally Avhen they are sufficiently intense to provoke sympathiesperceived by the viscera, and particularly the stomach. As this organ, hoAV- ever, presents signs of irritation from the commencement of almost all inflammations, physicians saAv an indication for giving emetics, because they are attributed to a saburral condition : thus at the commencement of cutaneous inflam- mations they administer an emetic ; having the idea of a mor- bific principle to be expelled, and knoAving the diaphoretic property of this medicine, they propose by this means, to favor the eruption ; and the same principle is extended to those cases in Avhich the exanthem disappears. But Ave know now, that eruptive inflammations are prepared by a gastro-enteritis, that it is by this that the disease commences, that the eruption is always proportioned to its intensity, that it only disappears by the exacerbation of the gastro-en- terites which produces a revulsion of it. Is it not evident that to administer emetics at the commencement of small pox, is to endanger the production of a confluent eruption, and that in giving them to recall the latter, Ave add to the intensity of the gastro-enteritis, the cause of all the mischief?— Erysipelas symptomatic of a foul stomach (embarras gas- trique) seems to form an exception in favor of emetics, says M. Vallee. We do not agree in this opinion ; for it is granting that it is preferable to treat the first degree of gastro-enteritis by emetics rather than by diet and emollients. We shall see farther on, Avhat method has most advantages and particularly7 least inconvenience. It Avould seem puerile, as M. Vallee observes, to place gastro-enteritis at the head of mucous inflammations, as positively counterindicating emetics, if Ave did not knoAV the frightful abuse heretofore made of them, and which too ma- ny physicians make of them in foulness of the stomach, (embarras gastriques,) and fevers, Avhich Avere only gastro- enterites, exasperated by7 this treatment until they put on MS j the adynamic character, against Avhich the formidable array of tonics opposed to them, failed. This subject -will, in another place, be examined in detail; let us be contented here with establishing a general principle which should admit of no" ex- ception ; whenever signs of gastro-enteritis exist, we ought to abandon the idea of giving emetics, notAvithstanding all the signs indicating an overcharge of bile, or sordes of the pri- ma? viae. M. Vallee remarks, that the inflammation of other parts of the digestive canal, is no less an enemy to emetics, because it rarely exists, without the stomachs participating more or less, and because the revulsive effect they some- times produce in dysentery7, presents too many unfavorable chances for a prudent physician to hav7e recourse to a prac- tice so hazardous. It is the same Avith angina ; if it exists alone, it would be erroneous to attempt a revulsion on the stomach, Avhen we can make it rapidly cease by an applica- tion of leeches. If it be complicated with irritation of this viscus, both Avill be cured by antiphlogistics ; and Ave cannot grant the same innocuousness to emetic tartar, Avhich more- over Avhen it succeeds does not produce such marvellous effects as their advocates seem to think. Inflammations of the serous membranes are so painful, are accompanied with such great anxiety, and awaken so many sympathies, that they should always exclude the employment of emetics.— The employment Stoll made of them in pleurisies and other inflammations of the thoracic viscera, Avas founded on the influence he attributed to the bile in the production of these diseases. This strange opinion is too superannuated to merit the attention of criticism, and Ave may affirm that, un- der another sky, and in individuals more irritable, it would not have obtained the numerous successes, Avhich in other climates, has been the cause of many ravages. Moreover, the whole question seems to us to reduce itself to the follow- ing reflections : emetic tartar opposed to inflammations can- not cure them, except by the revulsion it produces on the digestive mucous membrane or the skin, or by the evacua- tion of the bile, Avhich would be a cause of disease. We repeat if, this opinion will no longer be sustained by any practitioner, and if practitioners otherwise respectable, fol- low this practice, it is not because they make bile play this part, but because they are prejudiced in favor of the good effects of emetics, and because they have suffered them- selves to be deceived by the success of Stoll; and it is so [ »49 ] true that they depend more upon the authority of authors, than upon the results of their own experience/that if emet- ics give rise to accidents, they are far from attributing these to the medicines. Let us add also, that the bile vomited has not been secreted in greater quantity, except from the influ- ence of the stimulation of the gastric mucous membrane by the emetic ; in the same manner as the introduction of sialo- gogues into the mouth produce a flow of saliva. When then emetics produce happy effects in inflammations, it is only by determining revulsions. Now the revulsive method is very dangerous in acute inflammations, nor is there a reasonable practitioner who dares to recur to it in this con- dition of inflammations. We should not then oppose emetics to an acute pleurisy, and the less so, as they tend to ren- der an organ already too much irritated, and whose inflam- mations are serious, the seat of revulsion. On the other hand, if the disease become chronic, and we wish to em- ploy revulsives, it is incontestable that they Avill no where produce effects so advantageous as when applied on the skin, and that there they will be without danger. If Ave add, that bilious symptoms are the result of a higher or lower degree of irritation of the liver, joined to that of the stomach and duodenum, we will be able to conceive the danger of emetics in diseases called bilious. We see then that emetics ought to be confined in the treatment of inflammations to those extremely rare cases when we should chose the stomach for the seat of revulsion. What Ave here say of pleurisy, Ave apply to all other inflam- mations. M. Broussais proscribes emetics in every stage of perito- nitis ; we see in several cases reported by him, that they have given rise to this disease. According to him the convulsive effects of the abdominal muscles, and the compression re- sulting from these, in the viscera, may produce this inflam- mation, when there already exists some predisposing cause, and a fortiori exasperate it when it is developed. However imposing may be the authority of Desault, we should for- bid them not less rigorously in meoingitis ; the influence of the irritation of the digestive mucous membrane in the production of encephalic inflammations, is too Avell knoAvn at the present day for us to be permitted to recur to emetics, when Ave possess other means of revulsion quite as powerful. Hepatitis, being ahvays conjoined to gastro-duodenitis, will [ ^0 j be exasperated by emetics ; Stoll himself forbids them when it is acute : they should be banished from the chronic stages for the same reasons. They Avould also be injurious in ne- phritis and metritis, on account of their connexions with the stomach, and of the violence Avhich these organs, Avhen in- flamed, Avould experience during the efforts of vomiting.— We Avill not return to pneumonia; what Ave have said ofthe pretended bilious pleurisy, is entirely applicable to this.— The mobile character of articular inflammations, their fre- quent co-existence Avith gastro-enteritis, Avhether acute or chronic, are sufficient to make us see the dangers of em- ploying emetics in their treatment. They should be banished in all hemorrhages; besides that they favor and augment congestion, they have here another dangerous effect—that of augmenting directly the flow of blood, by the efforts they excite. We have already- pointed out above, the danger of emetics during the flow of the menses ; it is evident then that they would be injurious in menorrhagia, and many physicians moreover, have ob- served their fatal effects in these cases. Cullen has seen them aggravate hcemoptysis, and all therapeutists have point- ed out the dangers in individuals predisposed to this he- morrhage. The employment of emetics in apoplexy has been the subject of many controversies. The adA7ocates of this method have asserted that they are adA'antageous by producing a fa- vorable concussion which aroused the action of the brain, and by re-establishing the equilibrium of vitality and producing diaphoresis. Their adversaries have answered, that during vomiting, the blood Avas driven Avith violence toAvards the brain, that this act, being sufficient to produce cerebral con- gestion, must augment it Avhen it exists. The physiological physicians add, that by the diminution of the cerebral influx, the vomiting having become difficult in apoplexy, Ave cannot excite it except by enormous doses of emetics which stimu- late very highly the stomach ; that the irritation of this vis- cus is one of the most frequent causes of this disease, and consequently emetics can only add to the danger. M. Vallee has not ventured to decide on this question ; its solution, however, seems to us easy. Indeed Ave can only give emetics without inconvenience to lymphatic, pale individu- als, who are little disposed to sanguine congestions ; more- over, Ave are not certain of determining a revulsion. Avhereas [ 151 ] it is easy to produce it on the skin—a method exempt from all danger. Palpitations, convulsions, and all other neuroses, and still more those of the stomach, are positive counterindications to the employment of emetics. Authors have correctly add(;d to these latter, aneurisms of the heart and large blood vessels, irreducible and strangulated hernias; Ave may add to these, reduced hernias, for av e know that the truss has more than once given Avay during the efforts of vomiting, and that the hernia has been strangulated by this accident. Purgatives —Humorism has still more abused this class of remedies than emetics, and Ave may apply to them most ofthe principles established for the employment of thk latter. Like them, they act on the digestive mucous membrane, Avhich they irritate ; but they produce, moreover, an evacu- ation of fluid sufficiently considerable to be taken notice of. Another difference existing betAveen their action and that of the former depends on this—that the latter stimulate the stomach almost exclusively, Avhilst purgatives act principally on the intestines, and much more on the colon than on the small intestine. Purgatives should also be distinguished amongst themselves according to the degree of their action. Some, indeed, only produce a slight irritation, which seems to be confined to the Avhite vessels charged with exhalation ; others, on the contrary, produce a high degree of irritation, carried often even to phlogosis ; the former are called ordin- arily laxatives or cathartics, and the latter drastics. We agree generally in forbidding purgatives in very feeble in- dividuals, in those having great nervous susceptibility, in those Avho present a general exuberance of vitality and a marked aptitude to the development of inflammations.— Here, as AAith emetics, females merit a particular attention; sensibility, generally greater in women, should render phy- sicians very reserved in the employment of energetic pur- gatives. They should always be abstained from during the menstrual period ; they may produce in this function the same disturbances as emetics. The same caution should be observed during gestation, although Hippocrates permits purging from the fourth month to the seventh. We knoAV too many examples of abortions provoked by the mildest purgatives, not to act Avith the greatest prudence, principally with Avomen who have already aborted. We should pre- scribe them with severity during the Aoav ofthe lochia, for > L i^ J fear of metastases that take place particularly on the ab- dominal viscera, to the inflammation of which, Avomen new- ly delivered are but too much disposed. We should also use great prudence in the employment, and especially in the choice of purgatives during the period of lactation ; besides that the milk may acquire purgative properties, it is evident that the nurse is exposed to metastases Avhich may have the most serious consequences. Hippocrates himself forbids purgatives in the different periods of acute diseases : this precept of the father of me- dicine has been pretty generally respected. It is in chronic diseases Avhich have remained buried in the greatest obscu- rity until a very late period, that the greatest abuse of them has been*made. Moreover, emetics and purgatives became the familiar and common practice of most physicians ; for a long time it has obtained among the vulgar, who puke and purge themseves for the slightest indisposition, and even in a state of perfect health, under the pretext of preventing diseases: thus they excite and keep up those chronic in- flammations of the digestive organs, which make so great a number of victims. Let us examine, Avith M. Vallee, the advantages and the inconveniences arising from purgatives in the different irritations. We know to what accidents they may give rise in cutane- ous inflammations, and the fatal metastases Avhich may be the consequences of them ; danger exists even towards the de- cline of eruptive diseases. Halle has cited the example of a child who, having been purged during the desquamation of measles, was taken with croup and perished. Of all inflam- mations, none assuredly repels more decidedly these me- dicines than gastritis and enteritis in all their stages, since it Avould be placing the stimulant on the very seat of disease. After Avhat has been said on the employment of emetics in the same disease, we would deem it superfluous to stop for the purpose ofshoAving the exactness ofthisproposition. Pur- gatives Avould be dangerous in the acute stage of inflamma- tions of the genito urinary mucous membrane ; they Avouid, in most cases, increase the inflammation and cannot be ad- missible except in the chronic stage of these inflammations. Peritonitis forbids purgatives as much as gastro-enteritis, particularly in the acute stage. Besides that the augmen- tation of the peristaltic movement, determined by^these modicine«, in the intestines, would irritate the serous mem- [ 16* j brane, already inflamed, there exists between this and the intestinal mucous membrane a union too intimate for the latter to be irritated without danger to the first. M. Brous- sais, in this disease, forbids even emollient glysters ; as by distending the intestines they must compress the peritone- um. We cannot recur to purgatives except in the chronic state of peritonitis, Avhen Ave wish/to unload the intestinal canal of hard matters which fatigue it, or when Ave wish to produce a slight revulsion by augmenting the mucous secre- tion ; but Ave should only permit in these cases oily and saccharine laxatives. Hippocrates has pointed out the dan- ger of purgatives in pleurisy. They are injurious in all in- flammations of the chest, acute or chronic—Hoffman con- demns them even in catarrh. They are no less so in acut6 and chronic hepatitis, since they always tend to stimulate the liver, by irritating the intestinal canal, and because they augment thus the secretion of bile. It is necessary to re- mark, that in chronic hepatitis and peritonitis, purgatives produce most always relief, on account of the revulsive irri- tation they determine on the intestinal canal and of the evacuation they procure. It is in these tAvo diseases also, treated under the name of obstructions, that they have been most abused. M. Broussais has remarked, that this relief was never but momentary, because there exists between the intestinal canal and its appendages, a relation of action too intimate, for its irritation to produce a revulsion of the inflammation of the latter ; by making habitual use of purga- tives in these diseases, Ave add to the chronic hepatitis and peritonitis, a gastro-enteritis which must necessarily exas- perate them, and Avhiph hastens the progress of disorganiza- tion. In rheumatisms and gout, purgatives have the same incon- veniences as emetics, and for the same reasons. They can only produce disagreeable effects in hemorrhages : indeed, it is evident that they Avould be pernicious in haematemesis^ and that they would increase the hemorrhoidal flux, hematuria and menorrhagia, since they may even produce! these diseases. We forbid them also in haemoptysis, as in all other irritations of the organs of respiration. They AVould uot be less injurious in the neuroses of digestion, since these are almost always the symptoms of chronic gastro-enteritis ; and the use of purgatiA'es nevertheless, is one of the domi- cent phantasies of hypochodriacs, avIio find 160 manypbrsi- [ l->4 j cians disposed to satisfy them. Finally, purgatives would be pernicious in the different organic diseases, since they on- ly exasperate the gastro-enteritis ahvays supervening in these affections. Struck with the important results produced by the analysis of the tissues, the illustrious author of the General Anatomy annouced that the materia medica Avas to be entirely remo- deled ; that, to place it on a more solid basis, we must cease, as had hitherto been done, to seek out the mode of action of the different medicines in each malady, and study that which they exercise directly or sympathetically on the different organic tissues, by taking care to notice the modifications their effects experience from the sympathetic connexions uniting together all the organs. After having proceeded for some time in the study of the materia medica, according to these principles, we shall see the incertitude and diversity of opinions, existing on the properties of the greater number of medicines, disappear ; because they have been studied in . a manner purely empirical. The thesis of M. Gerard, Avhich is a repetition of the opinions of M. Broussais, on the action of digitalis, gives us a model of the application of Bichat's physiological method, to the study of materia medica, and furnishes us the proof of the certainty and importance of its results. Taken into the stomach in a large dose, digitalis is a vio- lent poison, Avhoseeffects have been known for along time, having been established by many physicians, and still later by M. Orfila. The symptoms this poisoning gives rise to, are head ache, tendency to sleep, Avhich ends by becoming insurmountable, titubations, vertigo, optical illusions, dilita- tion of the pupils, nausea, vomiting, alvine dejections, hic- cough, acceleration ofthe pulse, inexpressible anguish, cold SAveats, convulsions and death. M. Gerard, Avishingto establish the effects of digitalis on the circulation, made the folloAving experiment on himself. After having for several days examined the state of his pulse, Avhich gave habitually eighty-five beats a minute, he took half a grain ofthe aqueous extract of digitalis : in the ' evening there were only sixty pulsations, he felt droAvsy and a slept for a long time Avithout interruption. The next day if another dose produced very near the same effects. The A third day he swalloAved a grain : the pulse still counted sixty X pulsation", the appetite was good, the urine not ineron«ed": i 15 j j m the evening he experienced an ungovernable disposition to sleep. The third and fourth days he reached a grain and and a half, and his pulse sank to forty pulsations. The sixth day after taking two grains of the extract, the appetite ceas- ed ; at the middle ofthe day, the pulse Avas accelerated, pain in the head, debility, and tendency to sleep ; in the evening nausea and shivering, vomitings, redness of the tongue, burn- ing heat of epigastrium, great thirst, notAvithstanding he slept from nine o'clock until seven the next morning. After Avaking, had head ache, shiverings, titubations, mouth clam- my, tongue foul, but pointed and red on edges, continual somnolence, dilitation of the pupils. In the day profound and stertorous sleep. M. Gerard made use of a great quan- tity of acidulated drink and enemeta—and the persons Avho surrounded him kept him in a very fatiguing state of Avatch- ing. On the eighth day, after having taken a little repose, he experienced an erection which remained seven or eight hours, and returned the next day ; it was not accompanied by venerial desire, but by a general uneasiness, nausea, som- nolence, and very severe head ache. The ninth day a bleeding of ten ounces, dissipated all the bad symptoms ; and on the 22d he could leave off the ligid diet to Avhich he had been restrained. M. Gerard has established Avhat Orfila has said of the acoholic extract of digitalis. He injected into the jugular vein of a dog, ten grains of the watery extract dissolved in three drachms of Avater : three hours afterwards the pulse was thirtyr-eight in a minute, instead of eighty-six. Other- Avise the animal did not appear to be affected, and making his escape, ran off, He injected into the jugular vein of a middle sized dog, six grains ofthe alcoholic extract, diluted in two drachms of water: the pulse Avhich beat before the operation, from 100 to 105 times in a minute, soon rose to 135 or 140 pulsations ; the animal uttered several cries, seemed stupefied, experi- enced vertigo, turned several times around the chamber with his head down, and had evacuations both by urine and stool. Four minutes afterwards the pulsations were reduced to 60, and by degrees still lower ; the pupils became dilated ; the head was thrown back ; the paAvs were alternately contract- ed and extended ; the pulse became insensible, and death took place fourteen minutes after the injection. He injected tAvelve grains of the alcoholic extract into [ l-',; ] the jugular vein of an enormous dog, whose pulse Avas from 90 to 95 pulsations per minute ; directly he sankdoAvn, ex- perienced some convulsive movements and seemed to sleep. The progressive diminution of the pulsations might be ob- served at leisure—they were reduced to fourteen, five mi- nutes before death, Avhich happened tAVO hours and a half after the injection. "Digitalis employed in small doses, and deposited in a healthy stomach," says M. Gerard, "exercises a remarkable effect on the heart; the beats gradually sink to twenty-five or tAventy-eight per minute. The pulse also becomes more full and regular. The nervous system receives an influ- ence equally sedatiA7e ; we observe particularly a tendency to sleep, the muscular debility increases little by little, and it is greater in the lower extremities, probably on account of the use of these parts, destined to support the weight of all the rest of the body. "These effects which render digitalis Avisely administer- ed, a precious medicine, will never be obtained except by ihose acquainted Avith the different degrees of irritation the stomach is susceptible of; for if this organ Ave re irritated 0Aren sympathetically, we would see results Arery different from those we have pointed out. This explains Avhy authors Avho have Avritten on the properties of digitalis, have ex- pressed such different opinions. I believe their cases to be true ; but the consequences they have drawn from them are evidently false ; they would have been more exact, and like those I have deduced from them, if they had known the irritations of the stomach, on Avhich M. Broussais has fixed the attention in a particular manner." The property7 possessed by digitalis of rendering the cir- culation sloAver, has been long known. Murray7, who has pointed this out, has remarked also, that Avhen used for too long a time, it produces frequency of pulse. Sanders has likewise seen it become insensibly febrile. M. Gerard has had many occasions to observe that the pulse, reduced from one hundred and twenty to thirty-five, and even thirty a mi- nute, resumes often its former frequency. Many physicians have rejected digitalis, saying that its effect is merely momen- tary ; not knoAvinghoAV to appreciate the value of the symp- toms by7 which the stomach announces its irritation, they did not suspend in time the employment of this substance, or they counteracted its effects by stimulants ; then the sympathies L 15"! ] uniting the stomach to the heart, transmitted to the latter the superexcitation of the former. We may obviate this incon- venience by recuring to the iatraleptic method of adminis- tering digitalis; we are surprised that M. Gerard has not made this remark. The effects of this substance then Avould be the same on the nervous system, and it Avould not act on the stomach. We have tyvice employed the tincture of digitalis in frictions on individuals affected with hypertrophia of the heart. We made use of it for a long time, Avithout any sign of gastric irritation supervening ; in one, the pulse Avas reduced habitually to forty or forty-five pulsations ; in the other, to forty-five or fifty. These two individuals were cured ; but the employment of the digitalis Avas seconded by regimen and sanguine evacuations. M. Gerard remarks, that if we ought to stop the use of digitalis as soon as it produces a little heat at the epigastrium, inappetency, redness of the borders of the tongue ; a fortiori should we proscribe it when the stomach is already irrita- ted ; for then it Avould only augment the symptoms, and physicians Avho have regarded digitalis as a stimulant have based their opinions on cases Avhere they see an acute or chronic inflammation keep the stomach in a continual state of excitation. M. Gerard in proof of it, gives tAvo cases borroAved from Sanders. A young man aged eighteen years, convalescent from a haemoptysis, still had a strong cough with pain under the ster- num,insomnolence and febrile excitement. At the end often days these symptoms diminished, and were replaced by an abundant expectoration ; the pulse beat ordinarily 96 strokes in a minute : he prescribed eleven drops of digitalis. After having continued it during six days, the pulse beat 128, and the symptoms were so much aggravated, that he doubted whether he should persist. But as the condition of the patient Avas desperate, and as, moreover, the assertions of authors and practitioners justified the employment, he Avas resolved to raise the dose to fifteen drops, tAvice a day, at the same time observing the patient Avith the greatest cau- tion, in order to stop it if the symptoms Avere aggravated. Verv soon there Avas a frightful exasperation of the symp- toms, agitation, suffocation, lividity of the face, delirium, elevation of the pulse to 158 pulsations per minute. The patient showed a desire of taking no more digitalis, and his father being opposed to the administration of this medicine. L 155 j the three following days the disease was less intense ; the patient, hoAvever, expired after some convulsive move- ments. A man aged 36, showed all the symptoms of phthisis, and his pulse Avas75 per minute, when he was ordered to take fifteen drops of the tincture of digitalis three times a day : in a short time the cough increased, the chest became painful, the nightsmore agitated, the pulse more irregular and varying from one hundred to one hundred and twenty—in a Avord, all the symptoms increased ; there was also pain in the head so intense, that it was found necessary to recur to the anti- phlogistic method, Avhich dissipated it in a short time. On returning to digitalis, the inflammatory symptoms Avere re- produced with great violence, and its employment was no longer insisted on. After having examined the effects of digitalis on the econ- omy, M. Gerard points out in Avhat diseases it may be suc- cessfully employed. The sedative influence it exercises on the heart renders it precious in disturbances of the circula- tion, independent of inflammation ; thus it is very useful in aneurisms of the heart, Avhen the mass of blood has been diminished before hand ; this organ contracts then Avith less rapidity and in a more regular manner ; its nutrition becomes more active and, if the disease be not too much advanced, we arrest the progress, provided the action of the medicine be not counteracted by a stimulating regimen, violent exer- cise, &c. Of all the preparations of digitalis, the alcoholic extract, having the greatest sedative effect, seems to merit the preference; its effects are very marked, from a quarter of a grain diluted in two ounces of Avater. We may increase it gradually to one grain ; we employ also the AAatery extract in doses from half a grain to a grain and a half. The poAV- der is generally employed in doses of from tAvototen grains; but it is much less active and more promptly fatiguing to the stomach than the extract. Digitalis, exercising a very marked sedative effect on the nervous system, and diminishing the muscular irritability very much, produces good effects in epilepsy, Avhich is not produced by an alteration ofthe brain, or a permanent cause of irritation. M. Broussais has several times obtained per- manent cures of this disease by means of digitalis. There is another affection in which almost all remedies have hitherto failed, and in Avhich M. Gerard thinks, with M. Broussais. [ 159 ] that digitalis cannot fail to be useful: we allude to tetanus. The danger being pressing, Ave should administer, besides the resinous extract internally, the alcoholic tincture in fric- tions, in order to produce an action more promptly, without the danger of aggravating the symptoms by stimulating the stomach too strongly. The property digitalis possesses of diminishing the fre- quency ofthe pulse, has caused it to be advised in fever.— What has already been said shoAvs the absurdity of this prac- tice, which never had happy results, and which could only be injurious, since the stomach (whose inflammation gives rise to the febrile symptoms) is stimulated. M. Gerard refuses to digitalis the diuretic property so long ascribed to it. He founds his opinion on this, that 1st, in the cases where they attempt to prove the diuretict ac- tion, there existed a disease of the heart which produced dropsy, and which Avas calmed by the employment of digi- talis ; 2d, from the avowal of M. Chretien, it was often em- ployed Avithout the slightest success, and in most of the cases in which it produced any effect, it had been associated Avith Avhite wine, tincture of squill, and the acetate or nitrate of potash ; 3d, M. Alibert has put it fruitlessly in use at the hospital Saint-Louis; 4th, M. Broussais has always been obliged to order the infusion of juniper berries, frictions with the tincture of squill, &c. to dissipate the infiltrations of aneurismatics, to whom he had given digitalis; 5th, finally, he himself has remarked, in more than eighty patients, who used this medicine, that the urine Avasnotat all augmented.; and at the hospital la Charite, when he has seen it prescri- bed, it was associated, to insure success, with oxymel of squill, water of borage, and nitrate of potash. If it be true that digitalis does not merit confidence in dropsy, we should abstain from its employment, because it may produce very serious consequences, and it insufficient to be convinced of it, to recollect that a great number of dropsies are produced by chronic inflammations, and that in the cases were the stomach is not inflamed, it may become so by the action of digitalis ; for as we have often remarked, inflammations frequently spring up in the midst of debility. From all that precedes it results then 1st, that digitalis exercises a sedative influence on the nervous system, and consequently diminishes the muscular action ; 2d, that it renders the circulation slower by virtue of this property : [ iuo 1 3d, that it stimulates strongly the gastric mucous membrane; 4th, that the irritation experienced by the stomach after it has been for some time in contact Avith this substance, de- stroys the effects ofthe digitalis, by transmitting sympathet- ically its superexcitation to the heart. Article IV.—Of Convalescence. The name of convalescence is given to that state in Avhich the patient remains, from the termination ofthe disease until his perfect re-establishment. Although this has been a subject of many investigations, at the head of Avhich we place the dissertations of Hoffman and Adolphi, it has never been considered in its proper point of vieAv. Indeed, the nature of a great number of diseases being unknown, they must also have often misunderstood the cause of accidents Avhich happened to impede convalescence ; the feebleness accompanying aHvay7s this condition, alone fixed the atten- tion, and the obscurity resting on chronic inflammations, did not permit them to understand the true obstacle to the re- establishment of strength. It Avas then necessary that the light of pathological physiology should be applied to con- valescence as Avell as to disease ; seAeral pupils of the phy- siological doctrine have undertaken this in their theses, amongst Avhom Ave notice principally those of M M. Que- ment and Rennes. The latter undertakes first to show the necessity imposed on the practitioner, of watching over with as much care, the phenomena of convalescence,as those ofthe disease. "If it is praisAvorthy for the physician," says he, "to snatch the patient confided to his care from a threatening death, if it is his duty to lavish on him all the succours ofthe art, at the moment of danger, the task Avhich remains for him to fulfil during convalescence, though less brilliant in ap- pearance, is neither less important nor less difficult. Like a vessel saved from the tempest, after being rudely lashed by the Avaves, the convalescent is ill able to brave new dan- gers ; he has need of a Avise and skilful hand to direct him amidst the breakers surrounding his course ; and it is not un- justly that the physician, abandoning his patient during con- valescence, has been compared to an imprudent pilot Avho no longer takes care of the helm at the moment of entering the port." When an inflammation has developed sympathetic lesions in the principal organs, the broken equilibrium is onlv re- [ 161 ] established little by little. There must then take place a succession of changes of different stages, which form, as it were, steps conducting from the morbid to the healthy state. M. Rennes presents a picture of the different periods of convalescence, and considers successively its commence- ment, progress and termination. When the disease has completely terminated, convales- cence commences. There is some difficulty, it is true, in establishing a distinct line of demarcation between these two states; but it is not impossible, as physicians say who are strangers to physiology, to fix in a precise manner the mo- ment when the patient enters into convalescence. For the purpose of resolving this question, too much confidence has been put in critical phenomena ; if, in general, they produce a cessation of the inflammation in which they appear, we must acknowledge also, that they often only diminish its intensity. If we regard them as the signal of convalescence, it Avill happen in many cases, that we shall consider as ter- minated, diseases only palliated ; this is the cause of many chronic inflammations. The danger then of the false secu- rity inspired by the appearance of critical phenomena, when they are not followed immediately by the complete termina- tion ofthe disease, imposes on the physician the obligation of recurring to more certain signs for establishing the com- mencement of convalescence. The signs will be constantly furnished by the attentive observation ofthe changes which take place in the functions; and we will be informed of the termination ofthe disease by the complete disappearance of morbid phenomena, cessation of pains, uneasiness and anxie- ty ; a general feeling of Avell being, the return of sleep, na- tural state of the sensations, facility of perception, calm of the physiognomy, and the manifest expression of content- ment. In the mean time the pulse has lost its frequency ; it has returned to its normal state, or it presents only soft- ness and compressibility—a necessary consequence of the feebleness in Avhich the patient is left; the skin from being dry and harsh, has resumed its suppleness, and has again become the seat of a humid warmth ; the other exhalations and secretions are re-established ; the excreted fluids have returned to their primative quality ; the respiration is free, regular and easy ; the tongue clean and the taste returns Avith appetite. The most remarkable circumstances of conA'alesccncc are* u [ 1G3 ] on the one hand, as M. Quemont judiciously observes, a state of peculiar susceptibility of the organs Avhich have been the seat of any affection, and, on the other, a state of debility, of languor and prostration into which this affection has thrown all the other parts ofthe body, according to its intensity and duration. It is very important not to con- found these two different conditions in the treatment of con- valescence, in Avhich we should always propose tAvo results, viz. to restore to the first the degree of sensibility proper and necessary to them for executing their functions regular- ly7, and to the latter the force, the liberty of action and equilibrium they had lost. The greater number of physi- cians forget, on the contrary, the organs Avhich has been dis- eased ; many even have not knoAvn them and have only treated symptoms ; and during convalescence they fix all their attention on the emaciation, the paleness of the face, the feebleness and languor more or less marked of most of the functions. These phenomena are observed generally after acute diseases, and constantly after chronic inflamma- tions ; they are more or less marked, according as the dis- ease occasions a greater or less expenditure of sensibility. The disturbance itself experienced by the organs, is suffi- cient reason for the diminution of the forces ; but Ave should also observe, that the debility is never general: the organs recently inflamed preserve still, as Ave have already said, an increase of excitability, and all the parts of the economy do not participate in the debility. M. Rennes and M. Que- mont examine the state of the functions of the different ap- paratus in order to appreciate to what point each of them is affected by it. When convalescence really takes place, and inflammation no longer exists in the viscera, the Aveakness which charac- terizes the first periods of this state depends immediately on the Avant of energy of innervation, and less activity of the circulation. ' The blood more abundant in serum, less rich in fibrine, stimulates the organs feebly ; hence the feeble- ness of the pulse, the frequency of syncopes, the paleness of the skin, coldness of the extremities, the desire with Avhich individuals seek the impression of heat; hence also the general weakness of the agents of locomotion ; the mus- cles being feebly stimulated and receiving less nutritive matter; Aveakened also by inaction, become emaciated and sfoft, are incapable of sustaining long continued action : the i >«- ] walk also is painful and staggering, the speech slow, &i:.- • In general Ave may establish, that debility is observable in the cerebral functions, and in all those over which the nervous system of relation presides ; the sight is Aveak and confused, the ear loses its delicateness, the perception of odours, of tastes, and that of tangible qualities of bodies, is obtuse. It is necessary to distinguish here, these distur- bances in the action ofthe organs of sense, from the diminu- tion of their sensibility ; indeed Avhilst the former exist, the latter is more exquisite, and convalescents are more im- pressionable, although their sensations be less perfect ; thus their sight is less accurate, yet they cannot support the brilliancy of a vivid light; they distinguish sounds badly. and the slightest noise distresses them ; they cannot discern odours, yet perfumes notwithstanding give them head aches and even produce syncopes ; they are deceived about the tangible qualities of bodies, yet they cannot support the contact of any thing cold. This general nervous suscepti- bility is manifested very often in the genital organs. Adol- phi reports that old men, impotent before the disease, have recovered during convalescence a faculty7 Avhich they ^had for a long time lost. The intellectual faculties partake of this debility of action of the organs of sense ; the convalescent is incapable of pro- longed attention; the memory is impaired; the ideas are asso- ciated Avith difficulty, and the judgments are often erroneous. If Ave iioav considewthe state of the functions of nutrition, weAvillsee that the most of them far from being enfeebled, are more active than before the disease. The first pheno- menon which announces ordinarily conA7alescence, is the return of the appetite ; and we can easily conceive, if avc reflect that in almost all inflammations the stomach is affect- ed, that the appetite must be the first sign of its return to the normal state ; this feeling is often very strong, and more so in proportion as the disease has been more acute, and as it has exacted a long abstinence. But the digestive forces are not re-established as soon as the desire of aliments.— The digestive mucous membrane which has been inflamed, preserves for a long time great susceptibility ; digestion is tedious and painful, and aliments can only be supported at first in very small quantities. Physicians of every age have known the danger of satisfying too soon the keen appetites of convalescents. We knoAV that when we yield to their [ 164 J desires, the want at first very imperious, is gradually lost, and that the emaciation instead of disappearing, remains stationary, or still increases—phenomena announcing the existence of chronic gastro-enteritis. Hippocrates has point- ed out these truths in the following aphorism : A morbo belle comedenti nihil proficere corpus, malum. But when we know how to direct the action of the stom- ach, digestion is easy and complete ; absorption is exercised on the surface of the intestinal canal with an activity pro- portioned to the necessities of nutrition, and the economy ra- pidly repairs the losses sustained during the disease; for whilst the absorption is more active, the exhalations are less abundant than in the healthy state ; the subject takes little exercise, the sleep is more prolonged, in a word the losses are less considerable. When convalescence is free from morbid symptoms, its march is regular and leads promptly to the re-establishment of health. But many circumstances may shackle or inter- rupt its course, and keep it stationary or make it retrograde toAvards sickness. M. Rennes hwestigates the causes pro- ductive of these unhappy effects ; he refers them to two cir- cumstances : either convalescence meets obstacles that op- pose its progress, or it did not in reality exist—it Avas only apparent. Convalescence being real, tAVO causes may form obstacles to the return of health, 1st, persistance ofthe state of debi- lity, which characterizes the first periods of convalescence, or defect of nutrition ; 2d, the return of morbid phenomena, or relapse. Besides the Aveakness the disease itself has produced, convalescents find themselves submitted to a concourse of debilitating influences, such as a residence in Ioav and humid places, in the neighborhood of marshes, a cold and humid temperature, indigence, the privation of aliments of good quality,coition, masturbation, &c; hemorr- hages which supervene sometimes during convalescence ; abundant suppurations, furnished by ulceration ofthe sacium happening during the disease, or by a critical abscess. At other times inherent influences of the constitution itself of the subject, oppose the good effects of regimen : such are advanced age, a lymphatic constitution, a constitution broken down by misery or debauch. Under the influence of these causes, convalescence re- mains stationary, or the emaciation and debility continually [ 165 j increase ; all muscular action for any time sustained, is im- possible ; the pulse is feeble and slow, the heart is often subject to palpitations; the extremities are cold, the skin and the origin of the mucous membranes are colourless ; the cellular tissue of the legs becomes infiltrated; the tongue is pale, humid and broad ; the appetite languishes, digestion is slow and accompanied by eructations andborbor- rygmus ; the abdomen is often distended by gas, but it is supple and Avithout pain ; the fecal discharges are liquid ; the urine is pale ; the sleep light, and the skin is often covered with sweat, although its warmth be very moderate. This asthenia conducts the patient to marasmus and often to scur- vy and dropsy ; but before these results take place, there is ordinarily developed some local irritation and in the diges- tive passages oftener than any other organ. Then the symptoms of gastritis reappear ; this soon provokes sympa- thies, and hectic fever is declared. If we observe strictly, Ave shall discover that it is very rare, in these cases, as in all others, that the asthenia, which at first may be general, persists for a long time in all the organs, and that soon to these phenomena is joined those of a local irritation ; then the condition of the convalescent has become much more serious ; to the danger of exhaustion of the forces is joined that of an inflammation which this circumstance renders still more serious. We know that in debilitated constitu- tions concentrations take place Avith the greatest facility ; the equilibrium cannot be re-established, the proper means for combatting inflammation cannot be employed except with the greatest circumspection, and the patient succumbs more under the consequences of irritation, than of debility. It is very common to see the morbid phenomena repro- duced during convalescence ; the feebleness and great sus- ceptibility into which the subject then falls, renders him more sensible to the impression of stimulants; and this is especially felt by the organs lately inflamed, and which have preserved an overcharge of excitability. Relapses may take place at all periods of convalescence, and the causes producing them, are all those capable of stimulating directly or sympathetically the organs which have been disordered ; and the most frequent amongst them are the impression of humid cold, atmospheric vicissitudes, intemperance, forced exercises of the body and mind, powerful moral impressions, premature enjoyments of love, and the erroneous practice L '60 J of some physicians, who do uot think it proper to dispense Avith the administration of purgatives during convalescence or Avho rashly administer tonics, for the purpose of forcing the convalescent from the debility in which he languishes. Relapses are also more frequent in those seasons of the year subject to most frequent changes in the temperature of the atmosphere, and amongst individuals deprived by indi- gence or social position, of the necessary hygienic means during convalescence. In general, Ave understand by relapse, the return of the disease which has lately existed ; but sometimes another or- gan becomes affected ; thus during convalescence from a pleurisy, the individual will be more exposed to this affec- tion than to any other, because the pleura possesses then more aptitude to inflammation than any other part; but the immoderate use of aliments will sooner produce a gastritis, than it will recall the pleurisy. HoAvever this may be, re- lapses are very serious; they are much more so than the original disease, on account of the debility of the individual, the difficulty of treatment, and the greater aptitude of the diseased organ to sub-inflammations and disorganizations.— A remarkable observation and one not overlooked by M. Rennes, is that the return of the morbid state during conva- lescence, is not manifested ahvays by the marked symptoms that Ave designate under the name of relapse. The feeble- ness, the torpidity of the sympathies, favor in these subjects the chronic forms of inflammation ; their existence then is often unknown, debility alone fixes the attention, and the physician full of confidence in the tonics and aliments which he prescribes to raise the forces, seeks every Avhere else the cause of the tedious convalescence. Sometimes the physician suffers himself to be imposed upon by the almost complete disappearance of symptoms of an inflammation, and believes in a convalescence only appa- rent ; the irritation has lost its intensity, but has not disap- peared, it continues in a Aveaker grade ; the sympathetic phenomena no longer exist, the local symptoms are scarcely apparent and the patient no longer suffers : convalescence it is thought is established, and if some passing disturbances are observed in the functions they are taken for nervous phenomena and are regarded as the results of debility.— M. Rennes investigates the circumstances by Avhich the physician may thus be led into error ; and Avould establish [ 16-7 j as a general principle that these unfortunate mistakes depend most frequently on his ignorance, and that they are most frequently the results of ontology. He indeed, Avho only sees symptoms in diseases, thinks them terminated when the latter have disappeaied ; and how7 often do chronic irrita- tions only produce a slight disturbance in the functions of the organ they affect ! and then if the attention is not fixed on the latter, the lesion is misunderstood. M. Rennes just- ly observes that the passing of inflammations to the chronic state escapes us Avith extreme facility,* when their seat has not been sufficiently recognized during the acute stage, or Avhen the attention is not directed on the organ particularly affected. As long as latent chronic irritations continue, restoration of the patient is not possible, he neither recovers his strength nor embonpoint; the appetite languishes, and disgust suc- ceeds it; the patient is pressed to take aliments, they are varied ; the stomach is stimulated by bitters and the prac- titioner is astonished at the length of the convalesence : far from discovering the true source, he attributes it to debility. Under this impression he has recourse to all that is calcula- ted to keep up and exasperate the points of irritation re- maining in the viscera ; it is then very important to be able to recognize the obstacle to the re-establishment of health, which depends truly on the debility brought on by the ex- istence of a chronic inflammation. " When the convalescent," says M. Rennes, " is properly nourished, well clad, and placed under circumstances the most favorable in appearance to the re-establishment of health, Ave are authorized to consider the convalescence as doubtful, Avhich makes no progress ; and Ave are naturally- led to suspect then, existence in the economy of some latent point of inflammation, which destroys the strength by de- grees, and is opposed in spite of the alimentation to the re- turn of health. This suspicion acquires neAV force, if on examining with care the anterior circumstances, Ave discover that the ante- cedent disease is only imperfectly destroyed, that the crises have been incomplete or the treatment insufficient. These, notions, like the errors of regimen committed by the conva- lescent, or the injudicious administration of excitants ; these notions, I say, only furnish presumptions. What should particulaily fix the attention of the physicians, is the attcn- [168 ] five examination of the condition of the organs and func- tions. Thus we will first interrogate the state ofthe pulse ; if we find it active and frequent, this circumstance alone should put us on the track of the cause opposed to the re- establishment of health ; it indicates with almost certainty the existence of chi onic inflammation. If these two char- acters of the pulse be present, particularly after eating, and if at the same time heat of skin, head ache, uneasiness, in short febrile excitement, be developed, it is because the la- bor of digestion is painful to the economy, and particularly to the organs charged with its execution. " We turn our attention then from this point; and Avhen Ave find that the tongue is dry and red on its edges and point, foul in its middle, with thirst, and disgust for food ; that the bread seems bad and the wine bitter ; that the appetite is not awakened by any kind of food ; that the use of tonics only increases the uneasiness, developes a sense of heat at the epigastrium, and flushes of heat mounting to the face ; it is only a state of inflammation of the stomach Avhich can explain such symptoms. At other times the aliments clear this organ with sufficient ease ; but the intestines support their presence Avith pain ; the augmented sensibility of the mucous membrane covering them is manifested by slight colics, diarrhoeas or tenesmus, &c. Tihe absorption of chyle is performed with difficulty on irritated surfaces and the aliments are discharged half digested ; and the body is not profited, notwithstanding there is a good appetite. If Ave feel the abdomen Avith care, Ave find it ordinarily distended, elastic without suppleness, and it is very rarely that we do not discover in some point an obtuse pain augmented by- pressure, which becomes more acute at intervals. In other cases, we feel distinctly hardnesses, and engorged lumps in the viscera. Besides, the skin is dry and rough, cutaneous transpiration takes place Avith difficulty ; the other excre- tions are more or less altered, and furnish notions more or less exact of the seat of the disease. "If it results from an examination of the digestive system and its appendages, that they present no alteration, it is necessary to direct the attention to the chest; if there be a dead sound in any point, no matter hoAV trifling, wandering pains in the chest, dyspnoea at intervals, a slight redness of the cheeks, and a slight febrile movement returning every day after eating, in the evening or during the night, this is [ m ] sufficient to reveal a latent inflammation of the lungs.- A latent pleurisy produces very near the same phenomena; it is more common than pneumonia under this form, where- as the diseases of the pleura, acting less directly on the sources of life, ought to be more easily hidden, at least in the commencement, from the eyes of the observer. "I confine myself to the annunciation of these phenome- na, all of which relate to the irritations of the digestive sys- tem or pulmonary apparatus: these are in fact the most common. There is hardly any thing else than inflamma- tions of the organs essentially assimulatory,Avhich (existingin so feeble a degree as only to be manifested by vague and ob- scure symptoms,) can effectually oppose the return of strength and embonpoint, and sometimes end in the annihi- lation of life, by destroying secretly its principal means." After these considerations, M. Rennes treats of the atten- tions Avhich convalescents require ; their object should be, to second the efforts of nature which tend to the reparation of the losses the economy has experienced, and to abstract all the influences retarding the progress of convalescence, or occasioning relapses. The employment of hygienic means Avisely directed,is sufficient ordinarily to produce this double result; it is only7 in difficult convalescence or where it is imperfect, that we are sometimes obliged to recur to me- dicines. Atmospheric intemperatures retard very much the pro- gress of convalescence, Avhereas it is generally rapid dur- ing spring and summer. It is necessary then to protect the convalescent carefully from cold and humidity, by pla- cing him as much as possible in a dry and warm situation, and by making him Avear appropriate clothing. It is often necessary to advise convalescents a change of climate : thus, Ave often see physicians send the inhabitants of cold, damp countries, (who recover Avith difficulty after an inflamma- tion of the organs of respiration,) into southern countries, Avhere the action of the skin being greater, the excitability of the pulmonary mucous membrane becomes diminished. These journies are often advantageous by the diversion of mind they procure to patients ; and this is the principal, and perhaps the only utility derived from Avatering places. It is very important, after an epidemic, to remove convales- cents from the places of infection ; if circumstances Avould permit, it would be Avell also to make them leaA'e the wards i. no j ofthe hospital, where they breathe an impure air, take little- exercise, and are often overcome by ennui. Diet constitutes the most important part of the hygienne of convalescents, as is proved by Avhat Ave have just said on the cause of the accidents they experience. Nourishment should be allowed at first in very small quantities; the quantity and nutritive quality should be augmented pro- gressively, according to the effects they produce ; we should choose those articles Avhich are easy of digestion, Avhich furnish the most nutritive material in the smallest bulk, and Avhich are the least capable of stimulating the digestive pas- sages ; they should be prepared in the most simple manner possible : thus Ave should choose milk, eggs, broth, rice gruel, farinaceous vegitables, cooked fruits, white bread well fer- mented ; after a time, the white meats boiled or roasted ; it is better to eat little at a time and often, than to overload the stomach ; old Avine much diluted should be the drink. Active or passive exercise is one of the most useful means that can be employed during convalescence, to establish the equilibrium, to prevent the concentration of forces on the viscera, and to diminish the general susceptibility, by aug- menting the action of the muscular system. Exercise is very poAverful in long convalescences, particularly in those of chronic inflammations. We should, Avith the same view, caution the convalescent against every thing calculated to excite the susceptibility and increase it, as mental labor, coition, &c. Sydenham said that the phy7sician Avas often more useful in preventing the abuse of medicines than in administering them : it is principally during convalescence that he should fill this part; but Ave too often see tonics lav- ished to excite the appetite and restore the forces. " It is not the loss of blood," says M. Broussais, "which prolongs convalescence ; it is the points of irritation remaining in the viscera, and the tonics and stimulants often administered to convalescents who have lost a great deal of blood." This professor frequently remarks that the most tedious conva- lescences are those folloAving diseases A\7hieh have had the longest duration, and that consequently the best means of abridging them is to treat the phlegmasia? Avith actiA7ity : in- deed we may often observe that the recovery of patients is only difficult because the physician has been too timid at the close of the treatment, and because he has too soon stopped the use of antiphlogistics, after having calmed the first symp- I. 1<1 i turns. No doubt when we discover that feebleness and languor of sanguification, are the sole causes opposing the re-establishment of health, Ave should recur to the adminis- tration of tonics ; such as good wine, bitters and bark ; but it is of the greatest importance to be assured that the debi- lity is not the result of a point of chronic inflammation and particularly in the digestive passages. The physiological physician will never commit an error in this respect. To- nics Avill ahvays be employed Avithout danger by him Avho knoAvsgastro-enteritis Avel!; he will take care to stop as soon as the heat of skin, thirst, and redness of the edges of the tongue shall announce to him that the excitation ofthe stomach becomes morbid ; he Avill not forget that the most profound debility may be united to a chronic irritation ofthe diges- tive mucous membrane, and that under these circumstances tonics Avill only maintain and exasperate this irritation and produce fatal disorganizations. We find in the thesis of M. Dechenaux a fact justifying Avhat we have said on the circumspection to be used in the administration of stimulants in individuals whose debility ealls loudestfor their employment. "I have seen," says this physician, "a young woman only a few dayrs out of bed, in the most complete adynamia, from suckling two infants at once, and not taking nourishment in proportion to the losses she sustained. But her tongue Avas pale and humid, and there was no febrile movement. In order to restore her strength, they commenced by giving her tonics to an extent too considerable for her condition ; soon the tongue became dry, red, covered with a brownish coat, then black, as well as the lips and teeth ; fever came on ; the pulse Avas small and very frequent; the heat pungent, particularly on the abdomen; tympanitis and very fetid involuntary dejections supervened. The decoction of bark, (then her ordinary drink,) Avas suppressed, also camphor and other stimulants, which Avere replaced by7 simple lemonade and broth ; emol- lient fomentations on the abdomen and emollient injections Avere employed ; in a short time a sensible improvement Avas remarked, and the patient Avas not long in becoming convalescent." The inflammations sometimes developed during convales- cence demand the employment of antiphlogistics; they should then be employed with a great deal of circumspec- tion ; Ave should confine ourselves as much as possible to re- H2 ] vulsives, and if w e are forced to recur to local bleedings, they should be small; it w7ould4be dangerous to increase to the de- bility, and Ave should always recollect that it favors conges- tions in the viscera and particularly in those which have been inflamed. The vulgar are persuaded that the cure of a disease can- not be completed without the administration of several pur- gatives ; and Ave find too many physicians who, governed by humoralism, or directed by blind routine, are disposed to second these desires ; this practice is the cause of many relapses and chronic gastro-enterites. Purgatives heretofore so much misused, and suitable to so feAV cases, should in gen- eral be banished from the treatment of convalescence ; they can only stimulate the digestive passages and add to the de- bility. Perhaps they are sometimes proper to overcome obstinate constipation : but as this depends most frequently on an irritation of the small intestines, it is most Avise to be contented with demulcent means and if we recur to laxa- tives, they should only be throAvn into the large intestine. Practitioners also generally abuse opiates, Avhich appear io be solicited by the sleeplessness often tormenting con- valescents. M. Rennes correctly observes, that they ra- diate the vital action, and that if inflammation be developed, they have the great inconvenience of masking the symptoms and allowing it to progress Avithout the patient or physicians perceiving it. We should farther remark, that insomnolence depends ordinarily here on .an irritation Avhose sympathies constantly stimulate the brain, or on the inaction in Avhich the convalescent remains, and that then the best means of remedying this is, to put a stop to the first, and to make the patient take exercise every7 day, either active or passive, according'to the state of his strength. OF GrASrUO-EKTEUllIS. CHAPTER I. Connexions of the digestive mucous membrane with the other organs of the economy. On account ofthe great importance ofthe part played by the stomach in health and disease, the stomach is Avithout doubt, the organ whose lesions it was most important to study, and it is one of those which has least fixed the attention of patho- logists. They have noted the symptoms of its different affections, without seekingtheir cause, and they did not even suspect that the numerous symptoms the different degrees of its irritation develope, had their source in the stomach, because the latter excited sympathetic disorders, more evi- dent than the local symptoms; physicians have been led into error and have attributed to other organs the sympathetic phenomena, and more often still, have considered them as general disorders haAing no particular seat—in a word, not depending on any local lesion. A considerable number of morbid phenomena, howeArer, Avere referred to the stomach ; but the greater number of physiologists did not inquire, in Avhat the lesion of this viscus consisted, and those who Avish- ed to do it, only developed, on the nature of their affections, erroneous theories, which almost always conducted them to improper treatment. At length, BroAvnism, Avhich plunged in oblivion the small number of correct principles established before its origin, arranged under asthenia all the diseases of the stomach, and M. Pinel himself consecrated this fatal doctrine almost Avithout restriction. He only comprehended amongst the inflammations one of the grades of gastritis, and he referred to asthenia the neuroses of the stomach, hema- temesis accompanied by internal weakness, and the gastric symptoms seen during the course of another affection. Af- ter the example of Hoffmann, Sauvage, Boerhaave, Stoll, Cullen, and many authors Avho have preceded or folloAved them, M. Pinel has only described the highest grade of gas- tritis—that accompanied by pains, tension, heat ofepigastri L 1*4 j mn, and obstinatu vomiting; and like them,he has takenloi the type of his description, those developed by corrosive poisons. HoAvever Hoffmann, and after him Cullen, spoke of a less elevated degree of this inflammation, coming on with less intense symptoms and rarely terminating by death; but this distinction, understood only by these authors, was neglected by all their successors. It remained for M. Broussais to dissipate the obscurity. reigning over the most important part of pathology, or rather to discover truths, never even thought of before by his pre- decessors, whatever those may say who attempt to diminish the glory of his labors. The author of the Phlegmasies chroniques, first discovered that a number of diseases Avhose nature Avas entirely unknown and Avhich Avere described under the names of organic lesions, obstructions, and hectic fever, Avere only the results of chronic inflammations ; from that time a new field was opened to observation, another route Avas traced out, and better scrutinized facts accumula- ted from all parts ; a croAvd of truths sprung forth, and shed over pathological physiology the lustre with Avhich it shines at the present day. M. Broussais applied to the study of acute diseases the physiological method which had furnished such beautiful results in that of chronic affections, and soon unveiled the important part played in diseases by the diges- UAre mucous membrane. He proclaimed then, that the es- sential, (idiopathic,) fevers of authors Avere only the vari- ed forms of the sympathetic phenomena of gastro-enteritis; that this inflammation held under its dependance the erup- tive inflammations and constituted the danger of them ; that hepatitis was almost alway7s produced by the extension of irritation from the duodenum to the liver; that all the pre- tended neuroses of the stomach Avere the result of gastro- enteritis ; that scirrhus of this viscus Avas also a consequence of the same ; that delirium, convulsions, &c. Avere often only the sympathetic phenomena of acute gastro-enteritis; that mania, apoplexy, and the other encephalic irritations, had in most cases, their origin in chronic irritations of the di- gestive passages; that gout depends most commonly on chro- nic gastro-enteritis which excites and keeps up the articular irritation ; that in all febrile inflammations, the stomach and small intestine are irritated, if not during the whole course of the disease, at least during the first period of its existence; ihat it is also often the case even in apyretic inflammations ; L 175 ] that in debilitated subjects the digestive passages are fre- quently the seat of a chronic inflammation Avhich adds to the weakness and leads to fatal disorganizations ; that a great number of medicines Avhose actions are directed against other organs fail in their effect, or produce additional symp- toms, because they irritate the stomach or because this vis- cus is already inflamed. This perfect knowledge of gastro-enteritis Avas sufficient to change the face of medicine ; but joined to the no less profound study made by M. Broussais of the diseases of other organs, it has brought about the complete revolution this science has undergone, and of which the professor of the Val-de-Grace is truly the author. We cannot then at- tach too much care to the study of the different grades of irritation in the digestive passages and to the most exact knoAvledge of the signs indicating this affection, of the causes Avhich develope it, and of its local and sympathetic phenomena. It is in vain that they reproach the founder of these neAv principles with having exaggerated their impor- tance ; this imputation can only spring from ignorance or dis- honesty ; for all those Avho have given themselves up to the study ofthe physiological doctrine have been struck with the importance and extent of its results : the science of diseases has appeared to them then under a neAv light, and all have perceived that the author of the Examen did not go too far in saying that a knowledge of gastro-enteritis was the key of pathology. Nothing doubtless is more calculated to shoAv the exactitude of this great truth than the examination of the sympathetic connexions uniting the stomach to the other organs of the economy ; this preliminary study will, besides have the advantage of making us better understand the ac- tion of the sympathetic causes of gastro-enteritis and the development of its general phenomena. We should then commence the history of this disease by the relation of the facts Ave find assembled in several inaugural dissertations on this subject, which has been correctly treated by M. Fou- cault, and still better in the thesis of M. Moncamp, already mentioned. The stomach may be considered as an active centre from whence is radiated a crowd of sympathies again reflected over the Avhole economy, and like a focus to which tend all the impressions of other organs. If any one wishes to form an idea at once of the influence this viscus exercises on [ 1<6 J Hie organism, he has only for a moment to fix his attention' on the phenomena accompanying hunger; Avhenthe neces- sity of taking food makes us feel for some time in the re- gion of the stomach the indiscribable sensation Avhich has received this name, Ave experience a sensation of general Aveakness, sinking and uneasiness accompanied in a short time by syrncope, if it be not satisfied. The movements become more slow and less precise, the face is pallid and the eyes languishing; the skin is covered with a cold SAveat on the least motion ; the exercise of the intellectual faculties becomes Aveakened; vertigo and buzzing in the ears are perceived ; the heart is agitated by irregular palpitations; the pulse is slower and less developed ; the respiration be- comes sloAver; the heat diminishes, &c. But hardly has a small quantity of food, a spoonful of Avine touched the mu- cous membrane of the stomach, Avhen all these phenomena disappear rapidly, agreeable feelings succeed to uneasiness and the actions of all the organs resume their energy and regularity. To this fact, generally knoAvn, Ave should add another not less remarkable, Avhich proves still more evi- dently the great influence the stomach exercises over the Avhole economy7. Every one has remarked that individuals affected Avith gastro-enteritis support the longest abstinence Avithout ever feeling the necessity of taking nourishment, Avhilst if they be deprived of it during a state of health they succumb at the end of a few days. The patient it is said, is nourished at the expense of the fat deposited in the cel- lular tissue ; but Avhy is not this aliment sufficient for the man with a sound stomach ? It is because life is only kept up by stimulants according to the great principle of BroAvn, because the stimulation exercised by food on the stomach is extended to all the organs, receiving from this viscus princi- pally the excitation which calls their irritability into play. Their action then can be no longer exercised, as M. Brous- sais has first remarked, because it is no longer solicited when this source of general stimulation is abstracted. But if life cannot be maintained except by aliments and the exercise of digestion in the healthy state, the super-excitation of the digestive mucous membrane in gastro-enteritis is sufficient, Avith the aid of the sympathies, to stimulate the other or- gans, not only to the degree necessary for the execution of their functions, but also to produce a greater or less distur- bance in their exercise ; it is thus that life can be kept up t u< ] during thirty iiVe or forty days in febrile inflammations not- withstanding the most complete abstinence. It is to be re- marked that it is no longer the case in chronic gastro-ente- ritis, during Avhich the patients always feel more or less the necessity of taking nourishment, because the irritation of the stomach is not sufficiently acute to develope sympathies^ We knoAV also that the forces and feeling of comfort (bien- rdte,) reappear, that the heat augments, that all the phe- nomena accompanying hunger prolonged for a length ot time, disappear as soon as food has been introduced into the stomach, and consequently long before their digestion, ab- sorption, and assimilation have been completed; does not the instance of the savages of NeAv Caledonia, who, according to the authority of La Perouse, silence the appetite by SAvalloAving balls of clay, also confirm yvhat w7e have here said ? This substance contains no nourishment, but the stim- ulation it exercises on the mucous membrane of the stom^ ach is sufficient to solicit the action of all the organs, by ex- tending itself to them. We knoAV also that death produced by abstinence, takes place sooner in some individuals than others ; and if avc examine the details Ave possess on this kind df death, we shall see that in these Avho have sunk most rapidly, the debility has successively increased, that the heat has been extinguished by degrees and that they have remained continually in a state of calm and insensibi- lity. We see on the contrary that those Avho have survived the longest time have offered general symptoms of excite- ment, thirst, delirium and fever—phenomena of a gastro- enteritis developed by abstinence ; for the appetite not sat- isfied, is transformed into pain, and the irritation of the ner- vous capillaries of the gastric mucous membrane, may be extended to the sanguine capillaries, and give rise to an in- flammation sufficiently intense to provoke sympathetic phe- nomena. In the first, inflammation of the stomach has not supervened, or if established, has not aAvakened the sympa- thies Avhich, in the second case, have been called into play Avith so much activity. A number of facts drawn from physiology and pathology, shoAv the strict relations existing betAveen the gastro-intes* tinal mucous membrane, and each of the other particular or- o-ans. For the purpose of exposing them in order, Ave will examine successively Avith M. Moncamp and Foucault, the AV L 1<* j relation of the intestinal canal with the different systems and organic apparatuses. Sympathies ivith the sensitive apparatus. 1. Brain and nervous system.—It seems that in a state of health, the functions of the brain can only be alternate • Ave are at no time better fitted for mental labor than in the morning, as much on account of the repose of the brain, as of the vacuity of the stomach, which favors its action; moreover most men addicted to mental labors are remarka- ble for their sobriety. Sleep and Avatching are manifestly subordinate to the state of the stomach ; the dreams are painful and fatiguing when it is overloaded with food ; the nightmare is very often attributable to difficult digestion ; in acute gastro-enteritis patients are tormented by insomno- lence ; and in semiology a tranquil 3leep Avhich sometimes takes place in these affections, is regarded as a happy sign. A proper excitement in the stomach spreads a pleasant sensation throughout the Avhole economy ; hence the dispo- sition to joy during a prolonged repast: on the contrary a state of debility or irritation of this viscus, produces a feel- ing of general uneasiness and profound sadness. The pre- sence of certain substances introduced into the stomach, proves still the strict sympathy of this organ Avith the brain. In an experiment of Bellini, related by Boerhaave, Ave see that a grain of the yolk of a spoiled egg, produced at the moment when it was SAvallowed, disturbed vision, vertigo, great confusion of ideas and inexpressible anguish. We ask Avith M. Foucault, if Ave can explain in any other manner than by sympathy, the promptitude Avith which certain nar- cotic substances, (which Ave cannot suppose to be already carried into the torrent of the circulation,) exercise their action on the brain ? A fit of indigestion sometimes gives rise to very intense nervous symptoms. Every one knows that the varieties of gastritis and gastro-enteritis (known under the name oifovl stomach, (embarras gastrique,) and of bilious fever, have as constant symptoms, superorbitary pains. Hemicrania is accompanied by nausea, folloAved by vomiting which soon puts an end to it. How many habitual head aches, ence- phalites and even apoplexies are occasioned by gastritis.— Lethargy, coma, &c. ordinarily take their origin in the abdo- men, says Professor Pinel; the physiological doctrines have i ny put these assertions beyond doubt. If the most s«riuus af- fections of the brain, and of the nervous system are often the product of a cause seated in the stomach, this viscus also is often influenced by lesions of the brain. We will explain when Ave speak of the etiology of gastro-enteritis, the part played in the production of this inflammation, by long Avatch- ing, vivid moral affections, wounds of the head, meningitis. and encephalitis. 2. Organs of sense.—The affections of the stomach are expressed in the physiognomy and principally in the eyes.— In acute gastro-enteritis they are dry and red ; in chronic gastritis, they are downcast, languishing and surrounded by a livid circle, the patients often experience vertigo, and heaviness in the movements of the eyes and lids ; who does not knoAV the expression they present in the different de- grees of intoxication ? The presence of worms in the i»- testinal canal, causes dilitation of the pupils, and sometimes according to Richerand, palpebral convulsions. Opthalmia and styes are very often sympathetic of gastric derange- ment, (embarrasgastrique.) We know that increased action of the intestinal mucous membrane from the administration of laxatives produces the best effects in chronic opthalmia. Amauroses have often been cured by the employment of emetics. Who has not seen vomiting come on during the operation for cataract ? In fine we know that we eat with disgust any thing repugnant to the sight, and that nausea and vomiting are often the consequence ? The organs of hearing are connected to the stomach by- sympathies, which several facts demonstrate: vomiting is often announced by tinnitus aurium ; and we have seen deafness produced by gastritis. We see in an aphorism of Hippocrates a proof of the sympathy existing between the stomach and organs of hearing: " Quibus biliosmsunt eges- tiones, surditate superveniente, cessant; et quibus surditas est biliosis supervenientibus, cessat." Baglivi repeats the same thing in different words. Riga speaks of a General to whom the slightest irritation of the membrana tympana caused violent vomiting ; we have seen the introduction of a foreign body into the ear, produce the same effect -- We read in the Ephemerides des curieux de la nature that there are persons affected in the same manner by music ; Murray mentions several infants, who, poisoned by the aquatic cicuta, experienced hemorrhage from the ears. 1 wo The nose is often covered Avith pimples during chronic gastritis. The presence of Avorms in the digestive canal oc- casions a troublesome puritus in the nostrils; in acute gas- tritis we often observe coryza. The odour of food which is pleasant, gives birth to "appetite, and disagreeable odours act sympathetically on the stomach, producing vomiting.— Baglivi says he has seen persons purged by the irritation which the powder or smoke of tobacco produces on the pituitary membrane. We will not mention here the organs of taste, because Ave shall speak of the buccal mucous membrane Avhen we treat of the connexions of the different parts of the digestive mucous membrane Avith each other : we arnVe at the organ Avhose sympathies with the intestinal canal present the great- est interest. Physiology and pathology demonstrate to us the strict connexions existing between the digestive mucous mem- brane and the skin. When aliments are introduced into the stomach, Ave feel on the skin a sense of cold and spasm : it is dry7 and hot during the first hours of digestion, and when this process is completed, it becomes coloured, softer to the touch, and in a short time moist. The same thing is seen in gastro-enteritis: during the Avhole course of the disease the skin is dry and more or less Avarm; it becomes moist Avhen the inflammation is on the decline, and sweat more or less abundant follows. A glass of cold wa- ter introduced into the stomach speedily, arrests cutaneous perspiration, and a warm drink produces it long before the fluid has been absorbed, carried into the circulation and pre- sented to the exhalents of the skin; and reciprocally the action of a warm bath on this surface suddenly disturbs di- gestion, arrests spasmodic vomitings, &c. Cold and heat have on the skin and consequently on the gastro-intestinal mucous membrane, an influence which it is important to study. Heat, by exciting the skin, stimulates sympathetically the digestive mucous membrane, and the first effect of this irri- tation is, diminution of appetite and difficulty of digestion. If this action be carried farther, the irritation soon becomes morbid ; hence the frequency of inflammation of gastric and intestinal mucous membranes during warm weather, and in warm countries. Is it not a fact, that all the grades of gas- tro-enteritis are, in frequency and intensity, in direct ratio [ 1»1 j to the thermometiicaland barometrical elevation, a state of the atmosphere Avhich excites all the organs, but especially the skin ? Is it not generally under the same circumstances Ave observe epidemics of bilious fevers, dysenteries, &c. ? YelloAV fever, in Avhich no one can now doubt the existence of gastro-enteritis, commits its ravages in tropical climates, and do Ave not see the number of its victims progressivelv decrease, as the atmospheric heat diminishes ? Cold exercises on the digestive passages a sympathetic action no less remarkable. Dry cold produces on the skin a tonic action, which is transmitted to the digestive passa- ges ; also in the winter the appetite is greater, the digestion more active and nutrition more perfect. Under the influence of humid cold the appetite, on the contrary, diminishes, di-? gestion languishes, the stomach desires fermented drinks, and we feel Avell from the use of generous Avine. Cold, to any part of the skin, and particularly, to the soles of the feet, may occasion diarrhoea, colic, and even dysentery. Baglivi says, that a sculptor being seated for a long time on a block of marble at Avhich he was Avorking, experienced violent colics, lost his appetite and emaciated rapidly: these symp- toms yielded to warm pedeluAia and fomentations on the abdomen. Humid cold (hen, produces diarrhoea as Avell as heat. Physiology gives us a solution of this apparent con- tradiction. Indeed, heat determines inflammations of the large as well as the small intestine, because the irritation it produces on the skin, is transmitted sympathetically to the digestive passages. Humid cold produces diarrhoea or dys- entery, by a different mechanism. Tavo things here are to be considered; 1st, absorption should be in equilibrio Avith the exhalations; if then the cutaneous perspiration be dimin- ished, absorption in the large intestine, as in the serous cavi- ties and the cellular tissue, will also be less : the stools will often be liquid, and there may also supen7ene oedema or dropsy of one of the splanchnic cavities : 2d, the functions of the skin being diminished, the considerable exhalation taking place from it must be replaced by that of the pulmo- nary or intestinal mucous membrane, or finally, by the se- cretion of the kidneys ; now, according to sound physiology, Ave cannot admit, that the function of an organ augments unless its vital action be exalted ; it is not then surprising that the mucous membrane ofthe large intestine, Avhich is the seat of a vicarious exhalation, becomes irritated and inflam- Iry2 «;d; this may happen in different degrees, so as to-cause diarrhoea or dysentery. If we compare the effects of the sympathetic influence of heat and cold on the digestive mucous membrane and on that of the lungs, we will see that they are in these two membranes in an inverse relation. To account for it, it is only necessary to recollect that the bronchial mucous mem- brane is the seat of a continual exhalation, which is less ac- tive in proportion as that of the skin is increased, and vice versa ; thus it has been said that lungs are the vicarious or* gans (vicaire) ofthe skin ; if the action of cold diminishes that of the latter, and the secretion of the kidneys does not augment, the pulmonary mucous membrane will become the seat of a vicarious action, the exaggeration of Avhich may lead to inflammation ; this effect will be rapid in proportion as the action of the cold on the skin shall have been sudden. If on the contrary, the cold be less intense, but for a long time continued, the pulmonary mucous membrane slowly and continually irritated, will become the seat of chronic inflammation : hence the source of many consumptions.— What Ave have just said ofthe sympathetic influence of cold on the bronchial mucous membrane, enables us easily to foresee that of heat on this membrane. By exciting the ac- tion ofthe skin, it diminishes that of the pulmonary mucous membrane ; its inflammations are also rare in Avarm seasons and countries, and are very frequent under opposite cir- cumstances. It is also by this action of heat that many catarrhs which have been A7ery obstinate during Avinter, dis- appear in the spring, and that Ave counsel persons affected with chronic pneumonias to pass the cold season in tropical regions. From these facts it results that heat irritates the gastro- intestinal mucous membrane, and calms the inflammations ol the bronchial mucous membrane, Avhilst cold inflames the latter and renders thedevelopement of gastro-enteritis more difficult; as M. Broussais has also remarked, phthisis pul- monalis is the disease of cold climates, and gastro-enteritis that of warm climates. Pathology presents us a croAvd of facts which sIioav the reciprocal influence of irritations of the skin and digestive passages over each other. If the skin be affected with a pretty intense inflammation, Ave soon see thirst, anorexia, redness of the tongue, in short, all the signs of gastric irri- L I** ] tation, supervene : on the other hand, Avhenever the gastric mucous membrane is inflamed, we see the skin affected, from simple elevation of its temperature, even to gangrenous inflammation. We know that in all essenital fevers the skin is hot, and that its heat is proportionable to the intensity of the fever, that is to say, of the gastro-enteritis. Authors have remarked that in the cutaneus inflammations from in- ternal causes, the stomach first presented signs of disease ; thus boils, and cases of erysipelas, not produced by exter- nal irritating causes, depend upon that state of irritation of the stomach, designated by the term foul stomach, (embar- ras gastriqe,) and experience has clearly shovvn that the erysipelas in these cases does not demand any particular attention, and that it is the visceral affection Ave are called onto treat. All the maladies knoAvn under the name of erup- tive fevers, are simultaneous inflammations of ihe skin and digestive passages; but the affection of the latter always precedes that ofthe former: thus, in small pox, pain in the gastric regionyomiting and redness ofthe tongue appear four or five days before the eruption. When the latter has su- pervened, the first symptoms diminish in intensity, because the cutaneous inflammation is in some sort revulsive of that ofthe stomach, and if it becomes intense it reproduces the gastric disorder, because the sympathies it puts in play, are reflected principally on the still irritated mucous membrane of the stomach. What Ave have said of small pox, is also applicable to scarlatina, measles, &c. Let no one think that gastro-enteritis is accidental or symptomatic in these diseases; it is a constituent part of them ; observation even proves that this holds the other symptoms under its dependence.— Indeed, confluent eruptions are announced by precursory symptoms, much more intense than if they Avere to be dis- creet ; now, these symptoms are those of gastro-enteritis: to a violent inflammation ofthe digestive passages then, cor- responds an intense eruption; and vice versa. On the other hand, if we treat the gastro-enteritis, from the time of the appearance ofthe preceding symptoms, Ave diminish very- much the intensity of the eruption. But all these facts w7ill be exposed more at length AA7hen we shall speak of cutane- ous inflammations. We will not seek in the effects of re- vulsiA7es, other proofs of the sympathies of the skin and digestive passages, having already examined this subject sufficiently in detail in the chapter on revulsion. [ J»4 1 Sympathies ivilh the Locomotive Apparatus. Though less strict than in the preceding organic systeni>. the sympathies existing between the muscles, the articular tissues and the digestive mucous membrane, are also verv marked. It is indeed very rare to see a gastric irritation Avithout these parts being affected; every one knows the contusive pains, the sense of heaviness and torpor, experi- enced in the members, during foulness of the stomach and gastric fever. We have also spoken of the muscular pros- tration observed in the higher degrees of gastritis ; but it is principally, the articular tissues which present the most marked sympathies, with the digestive passages. We knoAV that almost always gastritis is accompanied Avith pains in the articulations ; they are sometimes so acute, that they may mask the principal disease. An officer entered the Val-de-Grace Avith intolerable pains in the femero-tibial articulations, Avhich were red and tumefied : he referred to them all his sufferings. The skin at the same time was dry and acrid, especially over the epigastrium, which was sen- sible, and the tongue red. M. Broussais ordered tAvem ty leeches to the epigastrium, and by the evening the arti- cular pains had almost entirely subsided. The next day tAvelve more Avere applied, and the third day the pains had disappeared. Acute arthritis, and still oftener chronic ar- thritis are in many cases produced by gastro-enteritis. We have repeatedly seen at the the Val-de-Grace, articular in- flammations (Avhich had resisted several applications of leeches on the painful part) yield only to bleeding from the epigastrium: We shall see farther on, that gout is almost always prepared and kept up by chronic gastro-enteritis; this fact, first announced by Van-Helmont and Hoffman, has since been put beyond doubt by DaiAA-in, Scudamore and Broussais. Sympathies ivith the circulating apparatus. The heart is in close connexion Avith the digestive mu- cous membrane. Every irritation of any degree of acute- ness, affecting this surface, is soon transmitted to the heart, Avhose movements become accellerated, and experience many modifications which, joined to some other disorders, constitute the febrile state. The changes experienced by the action of the heart in gastric irritations are infinitely va- ried, from the slight elevation of pulse observed during I ^5 J digestion, up to the pulsus trcmulus of the last stage of adynamic fever. We should remark that all the changes, inflammation ofthe digestive passages and that of the other organs give rise to, in the circulatory system, are not pro- duced by the modifications of the actions of the heart alone : in the condition called fever, a part of the phenomena takes place in the capillaries ; this order of vessels is doubtless intimately connected Avith these morbid actions. The modifications Avhich the circulatory system experi- ences in gastritis do not depend solely on the different shades of this inflammation, but also on different individual circum- stances. We know that the quantity of sympathetic influ- ence an organ receives from an irritated part is subordinate to the preponderance of action of this organ. If a subject in whom the sanguine system is highly developed be affected with a slight gastric excitation, the symptoms of the disease appertain almost entirely to this system. We will see hereafter that it is thus, that the inflammatory fevers of au- thors are established. Sympathies with the respiratory apparatus. The ingestion of a glass of cold Avater into the stomach, when the skin is SAveating, often produces an inflammation of the organs of respiration. The presence of worms in the digestive canal often causes in infants an inconvenient cough Avhich is made to disappear by the expulsion of these animals ; Andry has even reported a case of pleurisy pro- duced by a lumbricus. We frequently observe in gastro- enteritis a sympathetic cough Avhich has received the name of stomachal; Ave have observed on opening the bodies of individuals affected Avith this disease, that it Avas the neigh- borhood of the cardia Avhich Avas generally found inflamed. He can conceive that the diaphragm might then become easily inflamed. Pleurisy and pneumonia are very fre- quently complicated Avith intense gastro-enteritis ; this con- stitutes the bilious pneumonias and pleurisies of authors.— In phthisical patients there always supervenes in the last stages of the disease a diarrhoea depending on chronic colitis: a gastro-intestinal inflammation generally comes on to accelerate their destruction ; Ave also, in post mortem ex- aminations, meet ulcerations in the intestines ; we not un- frequently find in certain points, their tunics thickened and even lardaceous and tuberculous. Certain physicians con- 1SG tend then that the alterations found in the intestines are the result of a tuberculous diathesis which has manifested its effects in the lungs and the intestinal canal; as if it was difficult to conceive that in an individual whose lymphatic system Avas most developed, and Avho Avas consequently- disposed to sub-inflammations, the irritation has passed from the red to the white vessels of the intestinal canal and lungs. Therapeutics also offers us proofs of the sympathetic connexions of the digestive passages and the respiratory- organs. The ingestion of alcoholics and other excitants, arrest sometimes hcemopty7sis in feeble individuals, by ope- rating a revulsion of the hcemorrhagic irritation. We know that many pneumonias and pleurisies have been overcome in their commencement by the administration of an emetic; Ave know also the relief produced in chronic pneumonias and pulmonary catarrhs by kermes mineral, squill, ipecacu- anha, in small doses, and other stimulants ; it is then ahvays at the expense of the stomach that these dangerous succes- ses are obtained. Sympathies ivith the organs of secretion. Salivary Glands.—Ptyalism is sometimes symptomatic of gastric irritation ; the presence of Avorms in the digestive canal causes it not unfrequently. According to professor Pinel, the Aoav of saliva precedes and accompanies cholera morbus. We knoAV that in the prelude of vomiting, saliva floAvsin abundance. Liver.-It has been observed that the glands situated behind mucous membranes, on Avhose surface their excretory ducts empty themselves, entertain the strictest sympathies with these membranes. We know that the ingestion of a sapid substance into the mouth, causes an afflux of saliva; the same relations exist betAveen the liver, and mucous membrane of the stomach and duodenum ; the presence of chyme in the latter calls the bile to it. Whenever the mucous membrane is irritated, the irritation is propagated to the liver ; it se- cretes more, the bile Aoavs into the duodenum and reflows into the stomach ; it is thus that bilious derangement ofthe stomach is established, (embarras gastrique bilieux.) If the irritation be of a still higher grade it constitutes bilious fever; if it be carried to a still higher degree in a hot climate, it constitutes yellow fever. According to Broussais, hepatitis 1 *7 i depends on gastro-entei-itis, Avhen it is not traumatic. The alteration under the name of adipose Uvcr, (foie gras) is the result of chronic hepatitis, kept up by inflammation of the duodenum, and Ave always meet these two tissues simulta- neously in the dead body. Kidneys.-Nephritis and nephralgia are often accompanied by vomiting. Inflammation of the digestive passages modi- fies the action of the kidneys and the urine then undergoes various changes in quality and quantity. The bladder, Avhich we here place as an appendage of the kidneys, is often af- fected in gastro-enteritis ; sometimes there supervenes in this disease a retention of urine caused by paralysis of tin- bladder. We also observe catarrhs of its internal membrane, especially in the grade called mucous fever. The presence of a calculus or a sound in the bladder sometimes causes vomiting. Sympathies with the genital organs. Moderate excitement of the stomach disposes to the plea- sures of love ; venereal indulgences in robust men develope appetite ; during digestion they disturb this function, and reciprocally a laborious digestion after a copious repast ren- ders one unfit for venereal pleasures. How can Ave ex- plain otherwise than by sympathy, says M. Faucault, the effects of cantharides, of antispasmodic preparations and substances Avhich have a stupifying action on the organs of generation ; like insipid, mucilaginous drinks, such as the emulsions and preparations of nenuphar ? It is particularly in women that the sympathies of these organs Avith the stomach are best marked; the irritations of this viscus change the action ofthe uterus, and disturb the order of its periodi- cal evacuations. An emetic or purgative administered at the time of the flow of the menses, may produce a suppres- sion of them, or on the contrary give rise to menorrhagia. Haematemesis has often been the result of the suppression of the menstrual floAv. Metritis is almost always ac- companied by vomiting. Fluor albus is often joined to chronic gastritis. Conception is announced by pains in the region of the stomach, nausea, vomiting and fickle appetite. Hysteria, chlorosis, and especially masturbation, in the two sexes, uroduce chronic gastritis. The large intestine sym- pathizes very closely Avith the uterus : drastics sometimes cause abortion ; they are often employed to recall the men- ses • and clysters of cold water arrest uterine hemorrhage. Sympathies of the different parts of the digestive mucous membrane with each other. The mouth is hot and dry in febrile gastritis ; the lips are sometimes covered with pimples ; in the grade called adyna- mic, they are dry, black and fuliginous. In chronic gastritis, the gums become engorged ; and ulcerations sometimes form on them—only cured Avith the principal affection. Aphtha: are rarely idiopathic, and are connected most frequently to gastro-enteritis in lymphatic individuals. It has been very justly said, that the tongue is the mirror on Avhich all the affections of the stomach are painted ; whenever this viscus is affected in any manner whatever, it presents some nota- ble change ; in debility of this organ the tongue is flat, broad, humid and pale in its whole extent; in its irritation, the tongue presents very different aspects, dependant on the various grades ofthe latter, and which will be indicated in the de- scription of gastro-enteritis. The uvula has well marked sympathetic connexions with the stomach : titillation of this part is sufficient to cause vo- miting. The whole mucous membrane of the back part of the mouth sympathizes also with that of this viscus. Sym- pathetic angina, called bilious, is too Avell knoAvn to need more words on the subject. Strangulation or simple pinching of the small intestine, produces obstinate vomiting; that of the large intestine does not give rise to the same symptoms. Indeed the sym- pathies between the first portion of the intestines and the stomach, are much more strict, than between the latter and the second. It is very rare to see gastritis exist alone ; there is almost always joined to it an inflammation of the small intestine, and vice versa ; we very often see, on the contrary, colitis existing without gastritis. Irritating glys- ters sometimes develope the appetite and accelerate diges- tion. It is always dangerous to suppress a hemorrhoidal flux ; melaena may follow it; and reciprocally an anal hem- orrhage sometimes puts an end to this disease. On the oth- er hand, the influence of the stomach on the inferior part of the intestinal canal is such that we often see spontaneous or provoked vomiting arrest a diarrhoea, and we know that many physicians make use of this means in the treatment of dysentery. i 1*9 CHAPTER II. ETIOLOGY OF GASTRO-ENTERITIS. A great number of theses on gastro-enteritis have been writ- ten; but most of their authors have fallen very far short of their subject. Among the dissertations on acute gastro-enteritis, wo find none very remarkable except that of M. Chauvin, which presents a great deal of interest, and Avhich we will follow- in the description avc are about to give of this disease. According to the beautiful etiological method of M. Brous- sais, M. Chauvin divides the causes of gastro-enteritis into those stimulating directly the mucous membrane of the di- gestive canal, and those transmitted to it sympathetically.— He then admits a third order of causes, called by him mixed, which act at the same time immediately and mediately. He remarks that these influences deA7elope a more or less acute, or produce only a light degree of excitement, rendering the digestive mucous membrane more susceptible of contracting an inflammation ; in other Avords, these cause's are predis- posing or occasional; but an agent which only predisposes in one individual will become in another an efficient cause ; this division then is not regular, since it presents nothing- absolute. How7ever AA7e should distinguish those agents re- quiring a train of actions to produce inflammation of the di- gestive mucous membrane, from those Avhich develope it in a short time. Direct or immediate causes.—By contact Avith this mem- brane, these causes produce a super-excitation, Avhich, by reason of the continuity of their action, arrives by degrees at the inflammatory state ; at other times the agent being very energetic, developes rapidly an intense inflammation. The causes of this order comprise aliments, medicinal sub- stances and poisons. If the aliments are too exciting, or taken in too great quantities, they may produce, no matter how little the individual may be disposed that way, a gastro- intestinal inflammation, the degree of Avhich varies accor- ding to the energy of the cause and the susceptibility of the individual. Thus the black meats, game, salt food, pep- pers, aromatics, fermented fish, mustard and stimulating in- digestible vegetables : also exciting drinks, such as brandy, rum, Avines charged with extractive matter, very alcoholic, or adulterated Avith metallic salts^ finally increase the sus- ceptibility of the stomach and of the intestines to such a 190 j degree that the least cause, or the prolonged use of these substances alone, is sufficient to determine the most violent inflammation. The mucous membrane at first strove against the effects of these excitants; the intervals of digestion Avere sufficient to bring it back to the healthy state : but the action of the cause being prolonged, the effect has become more lasting, the repose is no longer sufficient to dissipate the irritation, and the organ has fallen into a permanent state of inflammation. Spoiled oysters and certain kinds of mushrooms deserve to be placed among the aliments suscep- tible of determining an inflammation in the digestive pas- sages. Muscles, under certain circumstances, produce anal- agous effects, and Ave have seen epidemics of gastro-ente- ritis, attributable entirely to their use. Mendicinal substances employed for the purpose of com- batting pretended debility of the stomach, Avhen the diges- tion is difficult and accompanied by7 offensive, acid eructa- tions, finally7 produce the most rebellious inflammations; the same remarks apply to emetics and purgatives. " Emet- ics, Avhatever may be said of their peculiar property of de- termining vomiting, observes M. Chauvin, are nevertheless irritating substances, Avhich, by reason of this quality, pro- duce serious consequences when employed on an irritated stomach, or Avhen employed too frequently. The routine custom of giving them Avhenever the tongue is foul, when there is head ache, Avhen in a Avoid Ave observe the symp- toms of a foul stomach, (embarrasgastrique,) produce eve- ry day an infinity of accidents Avhich should render practi- tioners more circumspect in the employment of agents so energetic. Hoav often have we seen gastro-enteritis de- veloped immediately after the administration of an emetic ! In the evening the patient to Avhom it has been given, show- ed only a slight sensibility of the abdomen, an alteration of the lingual mucus, a bitter taste, &c. but Avithout fever ; the next day the latter is declared ; the tongue is dry7 and red, the thirst intense ; the patient vomits sometimes every thing he takes; the heat of the skin becomes burning, &c.— Emetics produce inflammation of the stomach, especially, Avhen an affection of the encephalon no longer permits the latter to perceive the sensations Avhich produce the contrac- tions of the abdomenal parietes, Avhose action is indispen- sable to aid the stomach in the efforts of vomiting. The emetic, not being throAvn off, continues to act on the mucous L 191 J membrane, and ii is by this continuity of action that the in- flammation is produced. M. Series has cited a case of this kind in the Annuaire des hopitaux of Paris; the second letter of professor Lallemand contains several others also. "Purgatives also acting only by the production of a transitory irritation, from Avhence results an augmentation of secretion in the digestive mucous membrane, must espe- / cially predispose to an inflammation of this organ, or become an occasional cause according to the dose, the nature of the substance employed, and especially according to the state of the parts on Avhich the medicine acts. The names of ca- thartics and drastics indicate only different degrees of pur- gative substances. If Ave reflect that these medicines dif- fer from each other in their chemical composition, in the im- pression they produce on the living tissues, Ave should have difficulty in according to substances so different, a specific virtue identical in all, by means of Avhich they produce their effect ; but if Ave consider that purgatives are irritating agents, that their administration produces pains in the abdo- men,and all the symptoms of a high degree of excitement in the digestive canal, Ave AA7ill no longer hesitate to think that these medicines act only by their irritating qualities.— Besides if some say that purgatives act by a specific virtue, they will grant at least that they are at the same time ener- getic stimulants : this concession is sufficient to decide that whenever there is an inflammation of the mucous mem- brane, they must necessarily augment it, and that in the opposite case they must also produce inflammation by the sole fact of too high an irritation, proportionate to their na- ture and their dose." To pass from emetics and purgatives to poisons, in the consideration of the causes of gastro-enteritis, is not as M. Chauvin observes, so sudden a transition as one might sup- pose ; for administer jalap, aloes, senna, &c. in larger do- ses than those usually given, and you will have the symp- toms of poisoning ; employ7 a poison in smaller doses than those in which it produces such violent effects, and if it be not vomited, you will obtain those of a purgative. Amongst the poisonous substances capable of producing inflammation of the stomach and boAvels, it is sufficient to point out the numerous corrosive and narcotico-acrid poisons; the effects these different substances produce on the diges- tive canal we not always the same : sometimes the inflam- r ] <\ > j L 1J~ J ination has not passed the stomach, sometimes it extends to the intestines. Confined in some cases to the mucous mem- brane, it has in others attacked at the same time the muscu- lar and peritoneal tunics, and even the Avhole of the peri- toneum. Most frequently very acute, this inflammation may hoAvever appear under the chronic form ; its phenome- na indeed vary according, to the nature of the poison, the dose or the form under Avhich it has been administered ; ac- cording as it has been vomited a short time after its inges- tion, or as it has been retained ; according to the state of fullness or Aacuity of the stomach, the susceptibility of the individual, &c. Foreign bodies introduced into the stomach should be placed, after poisons, among the causes of gastritis. Worms have been ranged by many authors among the causes of gastro-intestinal inflammation. M. Chauvin doubts, with justice, whether they produce this effect, as they are not armed Avith teeth or fangs sufficiently strong to produce this effect. Perforations of the intestinal canal have been attributed to them, because they have been met with, in the peritoneal cavity, in cases where the intestines present this lesion ; but the latter Avas a result of inflammation and ulce- ration, wdiich they have taken advantage of, to introduce themselves into the abdominal cavity. HoAvever, M. Chau- Ain is far from denying the irritation caused by the presence of worms in the intestinal canal, Avhich a number of proofs demonstrate ; but he thinks, Avith M. Broussais, that it is by an error they,have been regarded as the cause of the gas- tio-enteritis, in which they have been seen : they are only the effect. Roederer and Wagler, in their treatise on the mucous disease, say7 that they have almost constantly met a verminous complication : but this only took place towards the end of the disease. M. Chauvin has heard it reported to professor Lallemand that, during one Avhole season, M. Dupuytren had lost almost all the children he cut for stone, from a verminous complication, the symptoms of Avhich soon made their appearance after the operation ; and although this able practitioner, enlightened by the first post mortem exa- minations, had administered anthelmintics during three weeks or a month, to other children on Avhom he Avas to ope- rate, and that these medicines had not evacuated any worms, they Avere nevertheless attacked by the same appearances. Is it not evident, says M. Chauvin, that here the generation of worms has been the result of the disturbance caused by [ !9o the operation in the digestives passages : Should avc then be astonished to find them so frequently in gastro-enteritis: Sympathetic causes.—The numerous connexions which we have remarked between the digestive mucous membrane and all the other organs of the economy have already anti- cipated the fact, that a great number of the causes of gastro- enteritis, are produced by the sympathetic transmission of irritation from the latter to the former. Amongst the causes capable of developing this disease sympathetically, avc should point out principally the action of the air on the skin, the inflammation of any organ Avhatever, the suppression of ha- bitual evacuations, natural or abnormal, strong passions, fatigue, and watching. M. Chauvin has not known how to appreciate the action of heat and cold on the digestive canal, and the mechanism of the production of gastro-enteritis, which the first of these agents developes. After having observed the effects of gastro-enteritis on the skin, and those ofthe cutaneous affec- tions on the digestive passages, physiological physicians have been led to think that the excitement produced on the skin by heat, must be transmitted in the same manner to the stomach and intestines. M. Chauvin does not admit this opinion : according to him the augmentation ofthe action of the skin, or the irritation of this membrane, must on the con- trary, prevent the mucous membranes from contracting an inflammation, by the habitual derivation resulting from it; because, the more the functions ofthe skin are exaggerated, the more those ofthe mucous membranes must be diminish- ed; and if there exist, says he, a coincidence betAveenthe affections of the skin and those of the internal tunic of the digestive canal, it is because these two organs having a great analogy in structure and functions, the cause, Avhatever it be, Avhich produces on the former a herpetic or variolous eruption, &c. must have the same tendency to produce an analagous effect on the latter. According to this princi- ple M. Chauvin attempts to explain the frequency of gas- tro-enteritis in hot countries ; he attributes it to weakness ofthe digestive organs, determined by the habitual exaltation of the action of the skin. The inhabitants of these countries use stimulants to excess for the purpose of remedying this : moreover, the stomach not having sufficient activity to di- gest the food, redoubles its efforts to overcome the difficulty, and this increase of action soon produces a real inflammation. [ 194 j M. Chauvin has Avandered very far here from the principles of physiology, which he has generally followed in his dis- sertation ; if this physician had been aware that we cannot study in mass, the sympathies of the whole mucous system with the skin, if he had known the inverse relation of the connexions of the gastro-intestinal mucous membrane Avith the skin, and that of the lungs with the same organ, he would have known also how heat predisposes to inflamma- tion of the stomach and small intestine, and actually devel- opes it, whilst cold renders these affections more rare ; and how these two agents produce on the mucous membrane of the lungs and colon opposite effects. The details into Avhich we have already entered on this subject relieve us from the trouble of recurring to them again here. A vast number of gastro-enterites have their origin in in- flammation of other organs. We have already seen, when speaking of the general phenomena of irritation, that in- flammation in any of the organs, sufficiently intense to pro- duce the febrile state, was accompanied with sympathetic gastro-enteritis, if not during its whole duration, at least during the first period of its existence. A great number of them owe all their danger to this complication. It is almost always to this sympathetic influence of irritated organs on the stomach, that we must refer what authors have said of the essential fevers which complicate the phlegmasia^. If all inflammations be susceptible of developing sympathetically a gastro-enteritis, there are some of them to which this con- comitance of action more particularly belongs. We will put in the first rank those of the skin, and in an article conse- crated to cutaneous inflammations, Ave will shoAv the rela- tion existing between these, and those of the digestive passages. A connexion almost equally strict, is noticed between this last affection and encephalic and arthritic irri- tations. Often these latter are predisposed, or even pro- duced by acute or chronic gastro-enteritis, and at other times they develope gastro-enteritis in their turn. It is not only acute inflammations which, by the sympathies they put in play, produce irritation of the digestive passages; we also observe it in a crowd of chronic inflammations, parti- cularly in their last periods, when they bring on disorgani- zation ofthe tissues they affect: then the sympathies which existed in the acute state, spring up again, and are exercised Avith new activity. Principally felt by the gastro-intestinal [ 195 ] mucous membrane, the inflammation which they there de- velope passes into the chronic state by the continuance of the action of the cause ; the inflammation is almost always extended to the large intestine, and terminates by producing, in the intestinal canal, ulcerations and other disorganizations: it is to this complication that we must refer hectic fever and colliquative diarrhcea, Avhich come on in the last stage of phthisis pulmonalis, of cancer and other disorganizing irri- tations, and which'are continually exasperated by the admin- istration of tonics, under the pretext of remedying the weakness they are attributed to. Amongst the causes of sympathetic gastro-enteritis, we should place in the first rank, wounds and surgical operations. Their influence on the digestive passages is sometimes in- stantaneous by the pain they produce. It is this complica- tion which gives rise to traumatic fever ; it is by the passing of this sympathetic inflammation to a more elevated degree that the first sometimes degenerates into adynamic fever, as the ontologists say. The suppression of a habitual evacuation, also gives rise to secondary gastro-enteritis, when a heating regimen or other stimulating influences predispose the stomach to in- flammation. We have explained in the article on revul- sives the production of these metastatic effects and will not here return to them ; Ave will confine ourselves to the recol- lection that often the gastro-enterites, which we observe after the suppression of habitual evacuations are not, as is suppos ed, the result of this suppression, but have really produced the latter by revulsion; only the inflammation then of the digestive passages becomes more intense, and itsphenomena are more strongly marked. Excessive fatigues, in those who are not in the habit of undergoing them, give rise frequently to acute gastro-ente- ritis; immoderate mental labor, and particularly long watch- ings, exercise also on the digestive passages a more serious and more constant influence. It is not rare to see close stu- dy determine an acute gastro-cephalitis ; most frequently it gives rise to chronic gastritis. We know that in general, literary men, have little appetite, difficult digestion, obsti- nate constipation—that they are lean, and that many of them are affected with pretended neuroses of the stomach, and principally with hypochondria. M. Chauvin has barely named the depressing moral affec- [ 196 ] lions amongst the causes of inflammation of the stomach: but their unhappy influence on this viscus is too important, from its frequency and serious character, to be passed over Avithout farther details. We find them in the thesis of M. Lassere, who has treated this part ofthe etiology of gastro- enteritis like a physiologist. After having fixed the atten- tion on the importance of the part played, by the intestinal canal, in the economy, on the sensibility of the mucous membrane, the sympathies which it maintains with the other organs, M. Lassere expresses astonishment at the unfre- quent occurrence of its inflammation, considering the great number of stimulating influences tending to produce it.— To those resulting from ingesta, and the lesion of the differ- ent parts of the economy, it is necessary also to add the depressing moral affections, to which man is so often a prey during the course of his existence. Allthe passions, strong emotions, constrictions of pain, all disagreeable impressions, are felt also in the region of the stomach ; its mucous mem- brane is affected in all the passions, and the impression which they produce there, determines as many grades of inflam- mation as there are shades in their development. A fit of choler, a strong fright, the pain produced by distressing news, gives rise to the most violent gastrites ; in the case, on the contrary, where the stomach is submitted to the in- fluence of a grief, for a long time continued, the impression which this viscus receives is less vivid, but it persists, and maintains, in its mucous membrane, a chronic irritation. The epigastrium then is often the seat of a painful oppression; the appetite diminishes and finally disappears ; the digestion is painful, there exists habitual constipation, the eyes are languishing, the face is discolored and yellowish, the sleep is disturbed by distressing dreams and nightmare, and the body becomes more and more emaciated everyday. The patient remains in this state as long as the cause con- continues ; it is very rare that the influence ofthe most metho- dical treatment puts a stop to chronic gastro-enteritis, as long as grief does not give place to contentment of mind, or at least to indifference. Under opposite circumstances, irrita- tion ofthe stomach, after remaining along time stationary, acquires often more intensity, whether by the exasperation of the cause which has produced it, or by the influence of other agents. The patient then falls into a state of hypo- chondria, which abridges his existence, or the chronic gas- [ 197 j tritis leads to disorganization of the stomach, induration of the liver, &c. At other times it passes into the acute stage and becomes ordinarily fatal in a few days. Such not un- frequently are the consequences of unhappy lov7e, jealousy, disappointed ambition, nostalgia, &c, Amongst the dis- tressing moral affections, there is not one which produces more unhappy consequences than the latter; to the gastritis Avhich it determines, is almost always joined an encephalic irritation. This double lesion much more rarely remains stationary than those produced by analagous causes. If the patient be notpiomptly restored to the object of his regrets, or if he be not sustained by the hope of soon seeing his own fireside, the inflammation often passes into the acute state ; it presents then the most serious form, and it is rare that it does not produce a fatal result. Those who have seen the practice of military hospitals have had frequent occasions of being convinced of this sad truth.* Mixed Causes.—M. Chauvin arranges amongst these causes the ingestion of cold drinks into the stomach, the ac- tion of miasms and the irritation of the liver. The action of very cold drinks on the stomach, Avhen the body is sweating, may give rise to the most violent gastro- enteritis. We read in the dissertation of M. Quincieux, on gastritis, that a soldier after having heated himself very much on a hot day, drank at one draught a bottle of beer which had been plunged in ice ; six hours after having taken this drink, he felt a violent shivering followed by heat; soon after he felt an acute pain, dry heat,and|a sense of tension in the epigastric region ; an inability to keep on the stomach even the mildest drinks. Two bleedings and emollient glys- ters did not calm the symptoms; the anxiety Avas extreme, the thirst ardent, the pulse frequent and the respiration difficult. The fourth day there was prostration of strength, small depressed pulse, shivering, sudden diminution of pain, livid face, hiccup, and death on the fifth day ofthe disease. * It was thought several years ago, that an irresistable argument had been found against the new doctrine, by alledging that the redness of the diges- tive passages scarcely deserved to fix the attention, because we often observe it in bodies of men surprised by death in full health, in persons for example who have been executed. Hence they conclude that this tint is natural; they doubtless did not reflect on the influence exercised on the brain by the cruel anguish which precedes the last moments, on all the causes of gastro-enteritis, to which those are submitted, who live, during several months, in a dungeon, under the weight of a condemnation for capital crime. L 19» j On the examination of the body, the mucous membrane of the stomach Avas found inflamed and gangrenous in several places; the cesophagean and intestinal orifices were very red. M. Majorlin reports in his lessons, that a surgeon, Avhen going into the country to see a patient, on a very hot summer day, drank with avidity several glasses of beer which had been plunged in a well: he died a few minutes after in the most cruel anguish ; and on opening the body, several gangrenous patches were found in the stomach. It is easy to conceive of the development of inflammation of the stom- ach under these circumstances ; cold is in truth a sedative ; but when its impression has ceased, a strong reaction is soon developed, which is then more A7iolent in proportion as the action of the skin is suddenly suspended and is replaced by irritation ofthe stomach. There is then double stimulation of this viscus; for the ingestion of cold Avater, Avhen the skin is in an ordinary state of heat, does not give rise to any disagreeable symptoms. We should then principally attri- bute gastro-enteritis, in this case, to the transfer of irritation from the skin to the mucous membrane, at the moment when its irritation Avas solicited by a direct stimulant. M. Chauvin places irritation of the liver amongst the mix- ed causes of gastro-enteritis ; Ave agree Avith him that in- flammation of this gland may determine sympathetically or by way of continuity that ofthe digestive mucous membrane. But he contends moreover that the irritation of the liver impresses on the bile irritating qualities, and that this fluid, by running into the digestive canal, may determine its in- flammation directly. It is very true, that secreted fluids may acquire irritating qualities, Avhen the tissues forming them are inflamed, as the tears and nasal mucus prove, Avhich in ophthalmia and coryza, irritate the skin when they touch it; as is also proved by the case reported in the Journal complementaire du dictionaire des sciences medicates, by Begin, who, Avhen opening with M. Broussais the body of a man dead of gastro-enteritis with adynamic symptoms, experienced an insupportable burning sensation on touching the matters contained in the intestine ; his whole hand became tumefied, and an abscess formed on one of his fingers. M. Broussais experienced the same sensations, though neither Avere Avounded by the scalpel. But can Ave conclude from these facts that the bile is capable of produc- ing gastro-enteritis ? This liquid only acquires irritating I 199 j properties under the influence of inflammations of the fivei. as M. Chauvin himself avows : but, we must remark that this inflammation is always developed (when it is not the result of external violence,) under the influence of an irritation of the stomach and duodenum, Avhich is transmitted to this gland. Thus then the alteiation of the bile, if it ordinarily exist and the fact reported by M. Begin be not an anomaly (une anormalie,) cannot be ranged amongst the causes of gastro-enteritis ; it may only in some cases add to the in- tensity of the gastro-enteritis ; and in asserting that in all cases where the liver is irritated, the bile is capable of producing inflammation of the stomach and intestines, M. Chauvin appears to us to have committed an error, Which would not be Avithout bad consequences in theory, and worse in practice. Amongst the mixed causes of gastro-enteritis, deleteri- ous miasms are without contradiction the most serious, and those which merit most our attention here. We shall con- found under the name miasms, as M. Chauvin has done, the putrid exhalations disengaged, from the human body, healthy or diseased, from animal or vegitable matters putrifying in marshes, lakes, and ponds while drying up ; from sinks and cemeteries, where the interments are not made Avith due precaution ; from anatomical rooms, hospitals, and camps, where a great number of people are collected together. The deleterious miasms operate with an activity and in- tensity differing, according to several circumstances : some- times their action is exercised w ith an astonishing rapidity, the nervous system is, if we may7 use the expression, para- lyzed : the principle of life is stifled ; and we see individuals perish a few instants after having penetrated into the infected area. Most frequently7 the action of miasms is less active : sometime after the infection, an inflammatory reaction, is developed, which ordinarily has its seat in the digestive passages, the brain and sometimes the lungs. These noxious agents penetrate into the economy by three different w7ays : by the skin, the lungs and the stomach.— The absorption of miasms by the skin is sufficiently demon- strated by the experiments made by Bichat on himself, and which he has set forth in his Anatomie generate. It is cer- tain that they are absorbed also by the air passages, where they penetrate with the atmospheric air. Lastly, mixed with the aliments and saliva, they are introduced into the [ 200 j siomach, on which they act directly. .No matter how mi- asms penetrate the stomach, it is incontestible that their fa- tal influence is exercised principally on this viscus. We cannot doubt the fact after seeing'those individuals who re- side in infected places, become affected with anorexia, vom- iting, colics and diarrhoea : we Can still less call it in ques- tion Avhen Ave obseive that the principle symptoms of ty- phus, yellow fever, the plague, and the alterations which these diseases leave on the dead bodies, appertain to gastro- enteritis. How can we explain the fact that miasms intro- duced by absorption from the lungs or skin irritate especial- ly the digestive mucous membrane ? It is certainly impos- sible to do it; but the fact is not the less true. Have we any more knoAvledge of the manner in which the virus of small pox exercises its first influence on this organ ? How does arsenic deposited in the cellular tissue or in the vagina, ulcerate the intestinal canal and leave the other tissues un- touched. When we compare the action of deleterious mi- asms to that of the tAvo last agents, nothing is proved in fa- Aror of the opinion of those Avho maintain the existence of general morbid causes. M. Chauvin observes with justice that the individuals on whom these causes act Avith most intensity, are those who are found in a state of debility, those especially Avho are in a febrile state produced by another disease, or who, addicted to table excesses, are ahvays in a state of excitement; thus it is observed that in epidemics of gastro-enteritis, those persons, Avho, in the hope of giving themselves strength, use stimulating drinks in large quantifies, bring on a fatal predisposition, and rarely escape from the danger they wish to shun. It h9s also been remarked that miasms do not act constantly Avith the same activity; an infinity of circum- stances may second, augment and even destroy their action. The habit of living in an infected atmosphere, may, in some sort, diminish the fatal influence of it: thus the natives of marshy countries resist advantageously the murderous caus- es which besiege them, whilst strangers succumb with as- tonishing rapidity. The activity of these emanations is greater in warm countries, and during the heat ofthe summer and autumn. The time most favorable to their action is the night: first, because the body fatigued cannot react with sufficient force to resist the introduction of these injurious principles ; next, because these miasms held in solution by t 201 j }he air, by means of the strong heat of the day, are con- densed and fall again after the setting of the sun, as soon as a certain quantity of caloric is taken from them. Such are the modifiers, (modificateurs,) capable of de- veloping inflammation of the gastro-intestinal mucous mem- brane. We pass on to the description of its phenomena; Ave should first observe that by the expression gastro-en- teritis, M. Broussais does not understand the inflammation of all the digestive mucous membrane, but that of the sto- mach and the small intestine, Avhich are always observed to- gether ; and that he designates the inflammation of the co- lon, (dysentery and diarrhaea,) by that of colitis : we shall folloAv this division in the description Ave are about to present, of these inflammations. CHAPTER III, Local and general phenomena of inflammation otf the digestive mucous membrane. Article 1st.—Phenomena of acute gastroenteritis* Gastio-enteritis does not ahvays begin in the same man- ner. The invasion is sometimes rapid, at other times sIoav. In the first instance, the patients experience during several days an unaccustomed heat after eating, a sensation of weight, of compression at the epigastric region, Avandering pains in the abdomen and of lassitude and uneasiness. The throat is hot and dry, the thirst more or less distressing, desire for cold drinks, the eyes are dejected, the complex^ ion pale or yelloAvish. The patientf, frequently, are al- ready affected with catarrh of some of the mucous mem- branes, such as coryza, ophthalmia or angina. The appe- tite is sometimes augmented, most frequently diminished ; digestion though still pretty Vvell performed, is frequently accompanied by slight colics, acid eructations, hiccup and nausea ; there is sometimes diarrhoea, and sometimes con- stipation. Often gastro-enteritis begins by symptoms of foul z [ 202 ] stomach, (embarras gastrique.) The patient has a disgust., for aliments, and a sense of fullness at the epigastrium ; he has a clammy mouth, with bitter taste ; the tongue is thick and broad with a white or yellowish coaling. Often this condition is soon dissipated under the influence of diet, the administration of an emetic or other stimulant; but most frequently also emetics exasperate the irritation, and allthe phenomena of gastro-enteritis are declared. This inflam- mation supervenes sometimes without any precursory symp- toms, Avhen the causes have acted Avith energy ; after a ta- ble excess for example. The disease ordinarily commen- ces then by vomiting ; the matters vomited are mucous or highly mixed with yellowish or greenish bile. The vomit- ings do not exist always ; they are sometimes replaced by alvine dejections, Avhich are more abundant in proportion as the seat of inflammation is near the termination of the alimentary canal; they are accompanied by colics *and te- nesmus. In some circumstances the vomiting and diarrhoea exist simultaneously; which, moreover, vary according to the predominance or equality of the inflammation of the sto- mach and intestines. M. Broussais, has, indeed, observed that when the inflammation of the stomach and small intes- tine predominates over that of the colon, diarrhoea does not exist. Ordinarily the patient experiences sensibility of the epi- gastrium, and if this region be pressed, the face is distorted and presents a manifest expression of pain, at the same time that he repulses the hand that increases his sufferings. Often in the sub-acute state of gastro-enteritis, and some- times even in that of the greatest intensity, pain is entirely Avanting, even when Ave attempt by pressure to develope it—Ave cannot attract the attention of physicians too much to this fact, already discussed, when treating of irritation in general. Practitioners Avould fall into a very great error, as M. Chauvin has remarked, if they believed that pain is an inseperable companion of inflammation of the stomach and intestines. To prove this, he has borrowed tw7o facts from Morgagni, and he might have draAvn a great number of others from the same author, from the Histoire des phleg- masies chroniques, and from several other works. Morga- gni cites a case of gastro-enteritis terminating by gangrene, in a man shoAving no signs of pain in the abdomen except on the first day of the disease, and who, through the sue- I M needing days up to the thirteenth, when he died, presented no other symptoms of inflammation, than thirst, dryness of the tongue and fever, which after having ceased, returned on the third day ; this threAv the physicians into a great per- plexity, for they were unable to conceive how the intestines could be inflamed, without the existence of pain. The same author mentions a Avoman aged 50 years, Avho after a trifling fall, was taken Avith vomiting of stercoral matter. As there Avas constipation, tAvo doses of mercury were given, of tw7o drachms each, which produced several stools. The patient died about the fifth day, from the inva- sion of the disease, Avithout the existence during all this imc of the smallest appearance of convulsions, pains, or fe- ver, and the post mortem examination notAvithstanding showed that the inflammation had been carried so far as to produce gangrene of the small intestines. Let us pass uoav to the examination of the sympathetic phenomena. It is rare that gastro-intestinal inflammation arrives at a certain degree of intensity without the brain being sympa- thetically irritated. Cephalalgia is almost incessant in this disease, and often the irritation giving rise to it passes to a more elevated degree. The exercise of the intellectual faculties is then disturbed; there is at first only slight aberrations of judgment, and if the gastro-enteritis pro- gresses, delirium is established; the patient is ordinarily mo- rose, and except in very irritable individuals, it is relative to the intensity of the inflammation. Sometimes the pa- tient is deaf and tranquil, and this condition is joined to a state of stupor more or less profound ; the sensibility7 of the senses is obtuse, when questioned he answers reluctantly7 or not at all, at the same time the muscular system is prostra- ted, the urine accumulates in the bladder, the dejections take place involuntarily, (adynamic fever ;) at other times the delirium is noisy, furious, and then the sensibility of the sen- ses is exalted, the ansAvers are quick, we observe convul- sive movements of the face and often also in the muscles of the members, subsultus tendinum, carphologia, &c. (ataxic fever.) The labors of M. Lallemand authorize us to think tha in the first case, the substance of the brain is affected by ir- ritation, Avhilst in the second it is confined to the meninges and surface of the brain. Thus then it is the defect of in- nervation, (a result of the irritation of the encephalic sub- 204 j stance and of the congestion of Avhich it becomes the seat,, (hat causes the muscular prostration, Avhich is still increased by the concentration of vitality in the inflamed viscera. The contraction of the muscles does not take place then, because it is no longer solicited, and not because these organs are af- fected with asthenia. It seems to us that in order to ex- plain the muscular prostration, physicians have not taken sufficient account of the cerebral affection, and that they have made the concentration of forces in the viscera play- too prominent a part. If this Avere the only cause of this phenomenon, we should not observe these tAvo forms of gastro-enteritis, ataxia and adynamia, differing so much; for this inflammation exists in one as Avell as in the other : but in the first, the irritation is limited to the arachnoid and pia mater and extends at farthest to the surface of the brain, whilst in the second it affects deeply the substance ; and Ave knoAV the different results of these tAvo lesions, to the mus- cular system. Finally, the constant co-existence of stupor, the suspension of the mental functions, w7ith the muscular prostration still farther confirm the opinion Ave here ad- vance. We knoAV that very frequently, when high delirium and agitation have continued for some time, stupor and prostra- tion take their place : it is very rare that death happens in the midst of the first series of symptoms ; Avhen the disease is to have a fatal issue, adynamia is joined to ataxia, to speak the language of the ontologists; that is to say, that the ir- ritation limited to the meninges and surface of the brain, is extended more deeply into this viscus, or that a purulent or sero-purulent collection forms in the arachnoid. M. Chauvin justly remarks, that Avhen the affection of the brain or of its membranes has arrived at this point, the pain produced by the gastro-enteritis diminishes or dis- appears entirely. The physician may easily suffer himself to be imposed on then by the absence of this symptom, may- mistake the principal seat of the affection, and find himself conducted in this manner to the most fatal errors in the treat- ment, if he did not consult all the other signs of the disease. It is necessary then, says M. Lallemand, to interrogate with so much the more care, the other phenomena, AA7hich being independent of the sensibility and will, do not vary. Thus, although a patient have a supple abdomen, Avithout any manifestation of pain Avhen Ave compress the epigastric, urn- I 205 j bilical, and right and left iliac regions, if the skin be dry and burning, if the tongue be red, the pulse frequent, &c. you Avill recognize, notwithstanding the absence of sensibility and contraction of the abdominal parietes, an inflammation of the gastro-intestinal mucous membrane. The heart, an organ eminently irritable, united by the most intimate connexions AAith the gastro-intestinal mucous membrane, receives as soon as the brain, the sympathetic stimulation excited by the inflammation of the latter. It beats with more frequency and quickness, and impresses on the pulse this double character which undergoes many modi- fications, according to the intensity7 of the inflammation and the individual constitution. In the commencement of the disease, it is sometimes as highly developed as in the pa- renhymatous inflammations ; but this circumstance is rare, and AA7hen it is presented after several days of disease, avc should fear that an inflammation of the organs of respi- ration is joined to that of the digestive passages. In the greater number of cases, the Arery considerable frequency - of pulse is almost always accompanied by littleness and concentration of the puliation of the arteries. These two phenomena appear to be a general result of very acu'e irri- tation of the viscera, which, far from developing the move- ments of the heart, depresses the action of this organ, Avhich no longer acts tumultuously. The pulse is then small, com- pressed, very frequent, sometimes intermittent, or almost insensible and convulsive. These last characters announce that the disease is very serious and that it tends to a fatal termination. The frequency of the pulse is not always in direct rela- tion with the intensity of the disease ; if there are individ- uals in Avhom inflammation of the digestive passages may produce the greatest ravages Avithout being pointed out by- pain, there are some also in whom the pulse presents very- little agitation, though the inflammation has arrived at a high degree. The lymphatic temperament is that in which avc most frequently meet this irregularity (anormalie ;) it is easy to be convinced of this by reading the observations laid open in VHistoire des phlegmasies chroniques. Hoav- ever this may be, the intensity of the febrile state responds always to that of the inflammation. The organs of respiration are influenced by acute gastro- enteritis : Avhen it is intense the respiration is ordinarily [ 2W more frequent, laborious and broken by a sdight cough com- monly denominated gastric ; most frequently it is dry, hut sometimes accompanied by a frothy expectoration, in some cases mixed with sanguinolent streaks, which has often imposed on practitioners, and made them direct their treatment against a symptom of which no trace could be found on opening the body. It is to the author of the Phlegmasies chroniques that Ave owe the knowledge of the etiology of this sympathetic disturbance of respiration.— The characteristic of this cough is, that it does not come by fits, as in inflammation of the lungs, but at short intervals ; it is often accompanied by a pain extending over the Avhole chest, or confined to its base. If the sympathetic irritation producing the cough, continues, it may bring on a real pulmo- nary catarrh or even pneumonia. The action of the secreting organs is always disturbed in acute gastro-enteritis. The liver, connected with the intes- tinal canal, by the membrane lining its excretory ducts, par- ticipates in its irritation ; the secretion of the bile is disturb- ed and almost always more abundant; the urine is scanty, red and often fetid, and its emission is accompanied by a pain- ful feeling; when the gastro-enteritis has arrived at a high degree of intensity, a remarkable mouse odour emanates from the patient, which professor Lallemand attributes to the absorption of a part of the urine, accumulated and de- composed in the bladder ; he Avas led to admit this cause because he has remarked the same odour in many individu- als affected with diseases of the urinary organs. This symp- tom supervenes almost always in an adA'anced period of gastro-enteritis; ordinarily when it approaches a fatal ter- mination. The other mucous membranes are also sympathetically irritated, especially at their origin. The orifice of the ure- thra is red ; the internal tunic of the bladder is sometimes affected, especially if the urine accumulate in its cavity by the inertia of its muscular tunic ; the conjunctiva is injec- ted ; the pituitary membrane is dry ; the mouth clammy in the first shades of gastro-enteritis, becomes dry and hot as soon as this inflammation has progressed. The condition of the tongue, as we have before said, is ahvays modified in all the grades of gastro-enteritis. The examination of this or- gan is then a precious means of diagnosis in this disease, and we cannot attach too much importance to the different L ^7 ] aspects it presents. In Avhat has been called foulness of the stomach, (embarras gastrique,) the tongue is Avhite or yel- lowish, and ordinarily broad and thick ; as soon as the irri- tation passes to a more elevated degree, the circumference and point ofthe tongue become red. This redness is more intense in proportion as the inflammation makes progress: it is the pathognomic sign of gastro-enteritis; whenever it is present the latter exists, and this proposition is subject to no exception. But the red border ofthe circum- ference is not ahvays seen, and the gastro-intestinal inflam- mation neA7ertheless exists ; the tongue then presents on its surface, and particularly at its anterior part, a multitude of small projecting red points, sometimes the color of blood, at other times violet, Avhich are painted on the pale color or on the mucous coating through which they break. This as- pect is presented rather in light gastro-enteritis and that Avhich is chronic ; and the red border is shown almost con- stantly more or less plainly in the acute state of this inflam- mation. Most frequently the centre of the tongue is whi- tish or yellowish, and this color is attributable ordinarily to a coating, easily removed in the commencement of the dis- ease, soon to be replaced, and Avhich on the contrary, in an elevated degree of the inflammation, seems like a white pellicle strongly adherent to the tongue. Sometimes instead of this color in the centre terminated by the red point and circumference, the tongue is of a bright red over its Avhole extent; one Avould suppose that it had just been dipped in blood, and sometimes Ave see this fluid oozing from its sur- face. This condition of the tongue announces a violent in- flammation, especially if joined to dryness Avhich is ordina- rily greater in proportion as the gastro-enteritis is more intense ; but the latter may be very violent though the tongue be still moist; but then it is very red at the point and circumference. The dimensions of the tongue also merit great attention in semiology. The more intense the gastro- enteritis, the narroAver it is. In the commencement of the disease it is broad ; after a time it contracts and narrows par- ticularly at its point. When the inflammation has arrived at its last stage, the mucus covering the tongue becomes broAvnish and eA7en black and scaly ; then it becomes dry, wrinkled and cracked. The gums, teeth, and lips are also covered Avith this fuliginous coat. The mouth, the pendulum palati, its half arches and the [ ** ] pharynx often participate in the redness of the tongue ; in lymphatic subjects and principally- in infants, there some- times takes place an apthous eruption in the mouth. Loss of appetite is one of the first premonitors of gastro- enteritis ; sometimes, however, we see it developed in an extraordinary manner before the appearance of the symp- toms of this inflammation. Absolute inappetency continues during the whole duration of acute gastro-enteritis, and the return of appetite is the signal of convalescence ; sometimes hoAvever, the desire for food returns as soon as the stomach is sound Avhilst the small intestine is still diseased. Thirst and desire for cold acidulated drinks, (which, how- ever, is not constant,) is also one of the premonitory symp- toms of this inflammation; it becomes more intense in pro- portion as the latter progresses. It is seldom, except in the last period then, that all the sensations are abolished and that the thirst ceases to torment the patient. Sometimes spasm of the oesophagus does not permit him to satisfy it; deglutition becomes impossible. When this ardent thirst does not diminish with the other symptoms, it is a danger- ous sign : the disease then almost always takes on a chronic character. According to M. Broussais the thirst is more intense Avhen the inflammation is extended from the stom- ach to the small intestine ; and he regards it as a sign of this extension. The skin is ahvays dry and parched in gastro-enteritis ; its temporature also is alway7s augmented ; it often presents an acrid and pungent heat, sometimes in its Avhole extent, at other times in certain parts, such as the belly and chest. All exhalation from it ceases, or partial sweats come on for a moment, Avhich is an unfavorable omen. Later and in the last degree of the inflammation, the skin is sometimes cov- ered Avith petechias or more extended ecchymoses. Gan- grenous eschars take place on the points supporting the yveight of the body. The skin at first is red, soon becomes livid, and passes into the gangrenous state, without having presented the symptoms of acute inflammation—vesications produced by epispastics and rubefacients experience often the same accident. The countenance of the patient announces suffering and anxiety; the eyes are red, at other times dull and down- cast ; the lids are half opened ; the cheeks are prominent and of the color of Avine lees ; the alas of the nose are dila- [ 209 ] led, and the lips dry. The hearing is generally weakened and sometimes there is entire deafness. This symptom may- arise from inflammation, which extends through the eusta- chian tube to the tympanum. Morgagni in a similar case found the tympanum and neighboring cavities full of a pu- rulent matter. He cites Valsalva, who had frequently seen the tympanum filled with Avater, in subjects in Avhom deaf- ness had supervened during acute diseases. It is not rare to see, during the course of gastro-enteritis, a phlegmonous inflammation appear in the parotid region, sometimes be- coming revulsive of the first, and at other times adding to its intensity. Besides the feeling of fatigue and contusive pains, the patient experiences in the limbs, gastro-enteritis not unfre- quently provokes an irritation of the fibro^serous system of the articulations, sometimes sufficiently intense to determine inflammation and suppuration of these tissues. M. Begin says he has several times observed, at the Val-de-Grace, in subjects who had sunk under violent gastro-enteritis, all the great articulations phlogosed on their internal surfaces, and filled with thick yelloAV pus, analagous to that of the cellu- lar tissue. We have seen three analagous cases in the same hospital, and tAvo in that of the royal guard. The symptoms of Avhich Ave have just presented a picture, do not exist in all individuals, nor Avith the same intensity. Several amongst them ordinarily predominate, according to the mode of reaction which the inflamed viscera exercise on the economy, according to the intensity of the inflammation, the causes which have determined it, the organ whose in- flammation happens to complicate it, and individual consti- tutions. M. Duponchel has pointed out, as M. Broussais has done, the different forms impressed by these circum- stances on gastro-enteritis ; they correspond to each of the essential fevers of authors. If inflammation of the diges- tive passages come on suddenly in a robust individual, in whom the sanguine system is predominant, the sympathetic phenomena consist principally in exaltation of the action of the sanguine capillary system. The pulse is full, hard, and frequent; if the inflammation be intense, it is small and concentrated, and rises after a bleeding. We observe a redness and and halituous heat of all the cutaneous surface. The respiration is frequent, the urine strongly colored, tlic head-ache severe ; in a Avord Ave sec inflammatory fever. x 2 [ 210 ] If irritation predominate in the liver, the gastro-enteri- tis is accompanied by bilious symptoms : this constitutes bil- ious or gastric fever. In the first degree of irritation of the stomach, of the duodenum and of the liver, we do not yet observe febrile symptoms. There is cephalalgia, anorexia, clammy, bitter mouth, and desire for acidulated drinks ; the tongue is thick, broad, and covered with a yellowish mu- cous layer; the patient feels a sense of heaviness at the epigastrium, and weakness of the extremities ; this consti- tutes Vembarras gastrique. Abandoned to itself, or treated by emetics and other stimulants, the irritation producing it may pass to a more elevated degree, and awaken sympathies. Then the thirst is distressing ; the patient ardently de- sires cold and acid drinks; there is often pain in the epigas- trium, constipation or diarrhoea of bilious matter and vomit- ings of the same nature ; the pulse is hard and frequent, the heat acrid and pungent; the skin dry and very hot, makes the patient almost ahvays experience, especially at the abdomen, that impression called pricking heat (chaleur mordicante.) The coloration of the skin is sometimes uni- ted to a yellowish tint, particularly marked around the alas of the nose. Bilious fever, it is said, may be complicated Avith inflam- matory fever ; this constitutes the causus or ardent fever ; that is to say, that gastro-enteritis may exist in a robust indi- vidual of sanguine temperament, with a predominance of hepatic irritation. Cholera morbus has also been ranged amongst the varieties of gastric fever, though it may exist Avithout fever, as well as Vembarras gastrique, to Avhich they have assigned the same place in the nosographic table. We Avill soon present some important documents, calculated to establish the true nature of this affection. In weak, lymphatic individuals, Avomen and children, the irritation sometimes predominates in the mucous cryptae; in such cases, one of the predominant phenomena of gastro- enteritis, is an augmentation of secretion throughout the Avhole extent of the gastro-intestinal mucous membrane; this is mucous fever. It is often accompanied with apthee on the tongue and parietes of the mouth, and worms in the intestinal canal. The pulse, in general not very frequent, is small and weak ; the tongue is Avhite and moist; the face pale, and heat inconsiderable. The forms of gastro-enteritis just examined by us, are not 211 1 generally attended with a great deal of danger ; but if the inflammation be neglected, or exasperated by stimulating treatment, the intensity is augmented; the sympathies are more active, and the irritation they excite in other organs, becomes sufficiently strong to increase the severity of the disease ; the meninges and the brain are then ordinarily ir- ritated. Delirium, carphologia, muttering, agitation, con- vulsive movements, and subsultus tendinum supervene.— The heat of the skin and state of the pulse experience al- ternate changes; the latter, sometimes slow and feeble, be- comes frequent and hard; the skin sometimes cold and moist, is in a few hours afterwards, hot and dry.—This constitutes ataxic fever. This, group of symptoms results then from the co-existence of an encephalic irritation, (more or less intense, elevated or not to the degree of inflamma- tion,) Avith gastro-enteritis. Many physicians have oppo- sed to this etiology, the nervous phenomena in ataxic fever, and have contended that inflammation of the digestive pas- sages should not be considered, in all cases, as the cause of encephalic irritation ; that these symptoms may be produced by this latter, which may also be the sympathetic result of any other inflammation than that of the stomach and intes- tines. No doubt that the irritation of the meninges or en- cephalon may be developed, directly or sympathetically, by any other influence than that originating in the inflamed di- gestive passages. But, one of two things must happen ; either the encephalic irritation will be sufficiently intense to excite febrile phenomena, or it will not be. In the first case, elevated to the degree of inflammation, it will produce sympathetically that of the intestinal canal; for in this grade it is accompanied by it always; and then it is of little im- portance in the question, Avhether the gastro-ententis be primitive or consecutive; it will exist, and its influence on the different organs and on the brain, already inflamed, will be ahvays the same. In the second case, we do not observe the ataxic fever of authors. The encephalic irritation may excite various disturbances in the nervous system; but thiist, repugnance to food, alteration of the lingual mucous redness of the tongue, disturbance of the secretions, will not be observed ; for if we did see them, there would exist a gastro-enteritis, and consequently, the general phenomena of each of the fevers of the ontologists. It is necessary still farther to.take notice, that, in cases Avhere the ence- phalic irritation is produced by a pleurisy, a pneumonia ot peritonitis, &c. the gastro-intestinal mucous membrane re- ceives, at the same time, the sympathetic influence exercised by these inflamed viscera ; for, as we have said elsewhere, every inflammation sufficiently intense to cause febrile phe- nomena, is accompanied by irritation of the digestive pas- sages, at least during the first period. The ataxic fever of authors then, appertains to gastro-enteritis, like their other essential fevers. All the forms of gastro-enteritis, except certain cases Avhich may cause death without passing to another state, end in adynamic fever, when the gastro-intestinal inflamma- tion takes on greater intensity. The skin presents then a livid color, the tongue is contracted, pointed, tremulous, dry, chapped, and covered with a fuliginious coat extending over the gums, teeth and lips ; the breath is fetid ; the dejections often involuntary and exhaling like all the excreted fluids, an infectious odour; the belly becomes tympanitic ; the pulse is contracted, small, and frequent; in certain cases an erup- tion of petechias takes place ; the patient is in a stupor; the delirium is tranquil; the muscular forces are prostrated ; he lies in a supine position, and keeps the same attitude. The symptoms of gastro-intestinal inflammation are too evident in adynamic fever for it to be possible, in some cases, not to refer it to gastro-enteritis. M. Broussais formerly thought that these symptoms might be produced, under some circumstances, by inflammation of any other organ. But when noticing the Pyretologie phy- siologique of Boisseau, who adopts this opinion, the author of the Examen declares positively that, though he admitted it formerly, he rejects it at present. Contagious and epidemic fevers present the same symp- toms and, consequently, the same alterations as those which are sporadic ; the same means of treatment are applicable to both; these are then gastro-enterites, produced by miasmatic poisoning, complicated almost always by another inflamma- tion, and principally by that of the meninges or of the brain. They should not then be distinguished from ordinary gas- tritis, except Avhen considered in relation to the external causes producing them. Contagious and epidemic feA7ers, especially those of our climate, do not indeed present any other peculiar characters, besides that of existing under the two folloAving forms, viz ; they depend on the existence of I *w J a centre of infection, from Avhence miasms emanate in- flaming with more or less violence the gastro-intestinal mucous membrane, or are transmitted from individual to individual, apart from any place of infection. In the Levant, they are accompanied by gangrenous inflammation of the skin, carbuncles and buboes, which, sometimes also become gangrenous (plague.) In America, and in some warm latitudes of Europe, they are sometimes associated with an inflammation of the liver, jaundice, and obstinate vomiting (yellow fever.) In Europe they7 are less violent, less fatal, and are complicated, as in the two preceding cases, by en- cephalic irritation, and frequently by petechial eruptions (typhus.) To prove that all these affections are not acci- dental modifications of gastro-enteritis, M. Broussais ob- serves that this inflammation may exist in the Levant with- out buboes or carbuncles ; in America, Avithout jaundice or vomiting ; that in Europe, it is sometimes associated with buboes and anthrax; that at other times it presents in our climate, during the summer heat, in persons addicted to alcoholic drinks, all the characters of yellow fever; that men Avhose brains are disposed to irritation from study, fear, griefs, &c. are affected with cerebral irritation as soon as the irritation of the stomach and intestines is manifested ; that the typhus fever of Europe is accompanied by violent pulmonary inflammation in winter, by cerebral inflammation in summer, and colitis during the autumn. He also remarks that in Egypt it does not present the characters of plague, except when produced by the emanations of infected marsh- es, spread by the south winds at certain times; that at other times it puts on its ordinary forms, and is no longer susceptible of reigning epidemically ; that in America it is not elevated to the degree of yellow fever, except during the great heats of summer and in humid places ; that in Eu- rope Ave see gastro-enterites much more violent in places where cleanliness is not attended to, in encumbered houses, and in marshes; that it is only contagious when it results from a place of infection, from whence emanate very active mi- asms. Cholera morbus is an extremely acute gastro-enteritis, announced by a severe pain at the epigastrium, extending often to the chest and abdomen ; obstinate vomiting of bil- ious matter, to which ordinarily are joined stools ofthe same nature, and accompanied by very painful tenesmus ; small- I 214 j uess and concentration of pulse ; in short, by allthe symp- toms produced by poisoning from corrosive substances. We see it reign epidemically under the same circumstances as the other forms of gastro-enteritis just examined ; like them it is caused by heat and moisture, by the miasms spread from places of infection ; and like them also, it owes its ra- vages principally to the stimulants lavished by Brownism, in these diseases, under pretext of remedying the asthenia, to Avhich they are attributed. No account of an epidemic is better calculated to shoAV the nature of cholera morbus, the dangers of stimulants, and the happy effects of antiphlo- gistics in its treatment, than that comprised in the thesis of M. Gravier, on the epidemic which ravaged India in 1817, and destroyed more than six hundred thousand inhabitants. This physician of course possesses an imposing mass of facts ; enlightened by a knowledge of the physiological doc- trine, he has interrogated dead bodies, compared the altera- tions they have presented to him, with the symptoms ob- served during life, and has been able to appreciate the terrible effects of the barbarous treatment employed by the obstinate Brunoniens who Avere around him. Cholera morbus is endemic in India; its existence de- pends on the cold and humidity frequently brought by the north Avinds, Avhich exercise a poAverful influence on the poor inhabitants who are badly lodged, badly nourished, passing the night on damp mats or under open sheds, where the cold is keenly felt, and especially during the rains pro- duced by the north Avind. All these causes were re-en- forced in 1817 by a great number of troops being brought together in Bengal, for the purpose of combatting several Indian Princes ; this large army was surprised by pro- found calms and excessive heats, succeeded, during the night, by cold and humidity. "We can conceive," saysM. Gravier, "that the disease readily took on the character of an epidemic, and even assumed the appearances of conta- gion ; for all these causes, joined to the encumbrance re- sulting from the collection of a great number of individuals, could not fail to develope points of infection in places Avhere men, healthy or sick, Avere assembled together, and where attentions to cleanliness and measures of public sa- lubrity Avere necessarily neglected. These circumstances explain the great mortality which desolated Calcutta : this immense city is traversed by narroAv streets, the houses are [ 215 ] low, and want openings to establish currents of air—thou- sands of individuals are buried in these kinds of hovels Avherethe sun never penetrates ; the disease also committed less ravage in places removed from Calcutta. These foci of infection extended their influence to considerable distance ; from the army of Bengal, the disease was carried to that on the coast of Malabar, and from there as far as Madras, and in all the neighboring country. If Ave observe that it Avas not transmitted from man to man without the infected area, and that it extended as far as Pondichery, notAvithstanding a very strong Avind bloAving in a direction contrary to its propagation, Ave are led to the conclusion, that the epidemic Avas not contagious, and that the nidus of infection can be transported from one place to another by means of the ca- lamities of Avar, and thus spread the disease as long as the causes producing it continue to act. An inexpressible disturbance in the economy7 and in the intellectual functions marked the invasion of the disease in many individuals ; others were attacked suddenly and al- ways at night. The following is a picture of the symptoms, presented by the greater number, in the order of their de- velopment: Vomiting of a limpid fluid, sometimes mixed with worms and alway/SAvith whitish mucosities ; alvine dejections with- out Avorras, pulse remarkable for smallness ; severe pains in the stomach ;• alteration of the features ; eyes haggard and sunk ; agitation ; tongue red over its Avhole surface ; thirst; exasperation of the same symptoms soon follows ; cold ex- tremities ; supine position ; violent pains in the stomach and lower belly ; carphologia, cold sweat, pulse almost insensi- ble, tongue dry, spasm and oppression. Treatment modified remarkably the march ofthe disease. If the antiphlogistic method was folloAved, hardly Avas the first bleeding practiced, before the face of the patient ex- panded ; previous to this, he did not articulate a Avord, and he then cried out Avith an inexpressible accent, I am saved. Indeed the tongue became moist; the vomiting, alvine evacuations and spasms diminished, and sometimes ceased ; the second bleeding produced ordinarily a remission of all the alarming symptoms. The patients experienced gen- erally then a desire to eat, which arose almost to frenzy ; and if their importunities Avere not yielded to, the symptoms immediately returned with greater intensity ; all succour [ M j became useless, they sank in the midst of the most horrible torments. Such also Avas the termination which super- vened almost constantly Avhere the disease Avas abandoned to itself, and especially when exasperated by a stimulating treatment. The evacuations became more frequent; all the ingesta were then rejected, or even could not be swal- lowed. The severity of the abdominal pains produced at first an extreme agitation, accompanied by Aiolent convul- sions, and dreAV from the patients the most lamentable cries: but this violent state was soon replaced by prostration, aphonia, delirium, carphologia, coma, cold extremities, and at the same time these unfortunate Avretches experien- ced in the boAvels the sensation of burning heat; the pulse ahvays precipitate,became thready, and life was extinguish- ed. This cruel disease was terminated ordinarily in the space of from one to three hours. [Days ? Edit.] In spite of the danger of opening bodies, Avhich, before getting cold, already exhaled an insupportable odour, and whose decomposition was very rapid, M. Gravier has not beendeterred from endeavoring to establish, by an examina- tion of the organs, the inflammatory nature of this disease, already sufficiently demonstrated by the symptoms and effects of the antiphlogistic and stimulating treatment. He did not meet with any alteration in the brain or in the organs of the chest; he found the internal membrane ofthe aeso- phagus inflamed, the cardiac orifice of a violet red, the mu- cous membrane of the stomach, in its whole extent, thick- ened and of a gangrenous broAvn; once only he found it ulcerated ; it Avas easily separated from the muscular tunic; the patient had resisted during three days* He has seen the latter perforated in an old Avoman, Avho had vomited up a number of Avorms ; the duodenum presented the same aspect as the stomach ; the redness gradually decreased in the small intestine, but all the traces of inflammation Avere manifested in the ccecum and colon. The stomach and in- testines were empty ; the bladder, phlogosed and indurated, resembled a piece of rumpled parchment. In general, the appearances of inflammation Avere less apparent in the bodies of persons Avho died suddenly7, and Avho had sunk rather under the pain and intensity of convulsive spams, than the disorganization of viscera ; many English physicians have found invaginations in the small intestine. The liver ha- not ordinarily presented traces of inflammation- [ 217 J From all the facts, M. Gravier justly concludes, that the cholera morbus which he has observed consisted in a high irritation of the digestive canal, producing at first, pains by its excess, and often exhausted the forces and sensibility, before having had time to rise to the degree of inflammation ; but which took on this character in the most evident manner, Avhen prolonged but for a very short time. M. Gravier constantly obtained the happiest effects from the antiphlogistic treatment when he was called in time.— At the commencement of the disease, he prescribed rice water with gum and a small quantity of acid, and glysters of the same fluid. These simple means sufficed often to calm the vomiting and stools. If the symptoms became more intense, announcing the progress of inflammation of the digestive mucous membrane, he had recourse to bleed- ing. It is to be regretted that this physician did not resort to leeches; for local blood-letting wrould certainly have had more happy effects than phlebotomy. The latter can- not be used in certain cases without danger ; for when the irritating agent has produced a great disturbance of the nervous system, when the sensibility is exhausted by the pain, and the forces are concentrated in the irritated visce- ra, large sanguine depletions are often pernicious; moreover, we know that local blood-letting is much more efficacious than phlebotomy against inflammations ofthe mucous mem? branes. At all events, M. Gravier assures us that he has always seen the latter produce excellent effects. He con- fined his patients the first day to an absolute dffet; and as the amelioration was as prompt, he says, as death, and as the appetite was extreme as soon as the symptoms had dis- appeared, he alloAved rice gruel; which most frequently completed the cure. The patients thus treated, were or- dinarily convalescent from the second day, and in a state to take nourishment; and on the fourth day they had recovered their health. M. Gravier, traces a frightful picture of the treatment adopted by the English physicians in this epidemic ; it will not be improper to present here an extract of it, for the pur- pose of showing hoAV far the errors of practitioners may be carried, Avho have not been enlightened by physiology, and who are still plunged in the obscurity of humoralism^ allied to the still more murderous theories of Brownism. The ultra-marine Brunonians published a manifesto in b 2 [ '■**« J Which they declared that the most dangerous character and circumstance of the disease, " Avas the total want of bile and acrid matters in the stomach and intestines, and that the prin- cipal end should be to reanimate the languishing vital powers, to re-establish the circulation,to prevent the violent spasmodic condition,to re-establish the action of the stomach and intest- ines." Consequently they prescribed under the title of pre- servative, and afterwards as a curative means, a tincture com- posed of pimento, opium, camphor, and cardamoms infused in alcohol. All the inhabitants yvere provided with this tincture, decorated with the title of antispasmodic, or vigor- ous supporter, and the use Avhich they made of it as a pre- ventative, should be set down amongst the principal causes of the ravages of this epidemic. When the symptoms of this terrible inflammation were manifested, they no longer limited themselves to their tincture ; the stimulation it pro- duced Avas too feeble to satisfy them : " Rub the epigastri- um," they add in their manifesto, " Avith the oil of turpen- tine, tincture of cantharides, and spirits of camphor. For the purpose of re-establishing the circulation, the action of the stomach and intestines, and for overcoming the spasms, take thirty drops of laudanum in a small quantity of spirit of mint; take then an opiate with fifteen grains of calomel. The same dose may be repeated as many as four times.— It happens that the patient falls into such a state of exhaus- tion, that the pulse is no longer sensible : for the purpose of re-establishing, if possible, the vital powers, give strong liquors Avith laudanum, ether, calomel, and bark." Here, as the four quarters of the globe, adds M. Gravier, does not furnish new stimulants to combat the pretended debility, the doses and repetitions of the latter prescriptions are left to the will of the individuals ; and, as if the genius of evil had rendered all the physicians deaf to the cries of nature, the counsel of Madras concluded by saying : " One of the most prominent symptoms of the disease is an ardent thirst and great desire for cold Avater ; but we have decided, that it is a means of destruction, Avhich would be folloAved by prompt death ; we should not then satisfy this desire."— Should Ave be surprised that the cholera morbus of India has SAvept from that country, in a few months, more than six hundred thousand individuals ? After what we have seen of the symptoms of the disease and the post mortem appearances, it is indeed easy to foresee what AA7ould be the 1 ^ i results of this incendiary treatment; of the application ot pepper, pimento, camphor, ether, cardamoms, colomel, brandy, &c. to the mucous membrane of the digestive pas- sages, already affected Avith an irritation of the highest grade. In spite, however, of the influence of all these stimulants, the patients did not all die; but it was only the small number of those in Avhom the agents produced revul- sions. M. Gravier assures us, that these cures cost dear to those who had the good fortune to escape from the disease and treatment, and that he has constantly observed that after those stimulating medications, convalescence Avas tedi- ous and painful, and that there remained ahvays chronic gastro-enteritis, which kept up a state of inappetency and langour very difficult to overcome. But let us continue the history of acute gastro-enteritis. The attempt at assigning to each disease a fixed duration is, Avithout doubt, one of the greatest errors of our prede- cessors. The duration of this inflammation and of all others cannot at all be limited ; it varies from two or three days to the most inveterate chronicity. It is not more possible to determine at what time the disease ceases to be acute and becomes chronic. The observation of symptoms alone can make this transition known, since we have agreed at the present day to call inflammations chronic, when the local symptoms lose their intensity, and when most of the sympa- thetic phenomena disappear. Let us for a moment rest our attention on the circumstances Avhich may enable us to fore- see the issue of gastro-enteritis. The prognostic is more unfavorable in proportion as the inflammation is more intense ; but it is necessary here to take notice of the condition in which the individual Avas, before the invasion of the disease. When he has been vali- tudinary for a long time, our fears of an unfavorable termi- nation should be increased; for this state is most frequently produced by a chronic gastro-enteritis, and experience has proved that Avhen it passes to the acute state, it is ahvays very serious and often fatal. The constitution of the indi- vidual also modifies the danger of gastro-enteritis : in those of obtuse sensibility, the sympathetic disorders are much less intense, and the disease consequently less dangerous ; on the contrary, in those endoAved Avith great sensibility, the sympathetic irritations are very much multiplied, and often rise to a high degree of intensity, especially in the [ 320 ] encephalon ; we also know the danger of ataxic fever. — When the inflammation has existed for a long time, the cure is much more difficult than when it is recent; when, however, it has not been exasperated by a stimulating treat- ment, we should still expect a happy issue. High fever reveals an intense inflammation ; but when it is not joined to other serious symptoms, it does not announce great dan- ger. But when from the first the patients are prostrated, the fever high, and pains manifested in some parts of the body, the gastro-enteritis will be very serious. When symptoms of adynamia and ataxia appear, the danger is very great; when the features alter, the stupor augments, as well as the other cerebral symptoms, we should fear approaching death. Obstinate vomiting announces that the inflamma- tion is very acute in the stomach, and adds to the unfavora- bleness of the prognostic. Tympanitis is a dangerous symptom ; it leads us to fear peritonitis, and when this su- pervenes in the course of a gastro-enteritis, it is ordinarily mortal. When to a little pulse, succeeds one larger and stronger ; and Avhen at the same time the other symptoms do not diminish in intensity, we must be cautious in thinking there is amelioration : this developement of the pulse arises from the circumstance, that the lungs are affected; the dan- ger on the contrary is greater, and the development of pneumonia under these circumstances, like that of peritoni- tis, is extremely dangerous. But Avhen the pulse becomes less frequent and small, Avhen the skin is less hot and dry, Avhen the forces increase, when the redness and dryness of the tongue diminish, Vhen thirst is no longer felt, Avhen the secretions and excretions are re-established, when the uneasines or pain, and cerebral symptoms disappear, we should look for approaching convalescence. An epistaxis is ordinarily a fortunate event, if not too abundant. When diarrhoea supervenes, it announces that the inflammation has extended to the large intestine and predominates there. If the frequency of pulse do not diminish, the danger is not less great; but if it becomes sloAver, and the other symp- toms lose their intensity, diarrhoea is a fortunate omen.— When there is established an external inflammation, coinci- dent with diminution of the symptoms of gastro-enteritis, it is ordinarily critical. A transient delirium, not accom- panied by symptoms of bad character should not make us establish an unfavorable prognostic. When on the contrary, it [ 221 ] becomes permanent and coincides Avith other severe symp- toms, it announces the deA7elopment of encephalitis. All things being equal the prognostic should be more unfavora- ble in infants and old people, than in adult age. When the cause of gastro-enteritis has acted slowly and during a long time, we have also less chance of cure than when its action has been rapid. We avoid speaking of the terminations of gastro-enteritis by resolution or death, for the purpese of occupying our- selves at once with a more important subject—its passing to the chronic state. Article II.—Phenomena of chronic gastro-enteritis. When resolution of the inflammation of the gastro-intes- tinal mucous membrane does take place, and it does not destroy the patient, it passes after some time into the chro- nic state. The phlogosis then does not destroy completely the digestive functions, it only excites slight sympathetic phenomena ; it only produces consequently, in the circula- tion and other functions, indistinctly marked disturbances, and often indeed it awakens no sympathy. This is the shade of gastro-enteritis which M. Broussais describes under the name of chronic. The study of this form of gastro-enteritis is not less im- portant than that of the acute, and the knowledge of it, due entirely to the labors of the historian of chronic inflamma- tions, has not shed on pathology a less brilliant light than that of the other. Chronic gastro-enteritis has been the subject of several A'aluable dissertations, amongst which we will cite princi- pally those of M M. Poutier, Schacken Archambault, and Merot, from which we shall principally draw the description we are about to give of this disease. The causes of chronic gastro-enteritis are all those we have assigned to acute gastro-enteritis, only they act Avith less intensity, or they exercise their influence on indivi- duals less irritable and little disposed to contract acute in- flammations. We content ourselves with remarking, that it is observed principally in individuals who present bilious or nervous constitutions, in men of letters, in all those who lead a sedentary life, and who exercise a great deal, at the same time, their intellectual faculties ; in those who are L m j habitually submitted to the influence of a distressing moral affection, who are guilty of frequent excesses of venereal pleasures or of the table ; in individuals retired from a busy- life to one of idleness and intemperence ; in those who make daily use of alcoholic drinks; finally, in almost all individuals Avho are affected Avith chronic inflammations in another organ. Chronic gastro-enteritis may be primitive, or consecutive to an acute gastro-enteritis. In the first case, the causes acting under the circumstances Avhich Ave have just pointed out produce a slight irritation, Avhich continues for a longer or shorter time, and the symptoms of Avhich are limited to the prodromese of acute gastro-enteritis; it follows the latter when treated by stimulants,or the antiphlogistic plan too feebly pur- sued. At other times the continuance ofthe gastric phlogosis, is the result of imprudences committed by patients or conva- lescents in the tonic regimen administered during convales- cence, under the pretext of restoring the forces. Moreover, in spite of the most methodical treatment, Ave see this in- flammation pass into the chronic state in lymphatic indivi- duals, Avho have a great aptitude to sub-inflammations: the appetite then returns, but digestion is painful, and the pa- tient experiences uneasiness whilst it is going on ; the forces return, but are not completely re-established; the fever ceases, but the heat of the skin is increased, and the pulse has a little frequency and hardness after eating. Finally, one or most of the symptoms of the acute state continue in a more light grade. Chronic gastro-enteritis presents a number of varieties in the development and intensity of its symptoms, in its dura- tion, march and the results Avhich it produces. These circum- stances establish as many degrees or shades of this inflam- mation, each of Avhich have been taken for different diseases. These different shades succeed each other often in the same individual, and it is impossible to submit them to regular divisions, they undergo so many modifications. We will describe then, collectively, all the phenomena of chronic gastro-enteritis, seeing the impossibility of uniting them in groups Avhich Avould establish the different shades of this disease. The patients complain of a sense of uneasiness, Avhich they refer principally to the epigastrium. They often feel there a pain more or less severe Avhich extends transversely [ 22^ J from one hypochondrium to the other, and which is ordinarily more intense in the right than the left. Sometimes it is continued, at other times irregularly intermittent; in all cases it is redoubled, ordinarily after eating, and they arc more intense in propertion to the quantity of food and sti- mulating substances taken. Other causes, and particularly grief, exasperate it also, and render it more continued.— We see it, on the contrary, diminish when repasts are light and composed of aliments easily digested, Avhen the patient takes exercise and removes himself from all troubles. This pain, situated at the base of the chest, presents different characters ; sometimes it is lancinating, pungent, burning, tearing, sometimes accompanied by a sense of constriction, which extends to the oesophagus (cardialgia.) At other times it is a sense of oppression which renders deglutition and respiration distressing, and Avhich the patients com- pare to the compression produced by a transverse bar, situa- ted at the loAver part of the chest. It is sometimes circum- scribed and at other times very extended. In certain cases the patient refers it to the chest; and very often they have been led into error with regard to the seat of the disease, especially when it is accompanied by a gastric cough. Its intensity varies very much : Ave have seen it in several wo- men sufficiently severe to make them shed tears. At other times the patients experience only at the epigastrium an exquisite sensibility, which does not permit them to bear the constriction which their clothes produce on this part of the body. Finally, in many cases the pain is entirely wanting. One of the most constant signs of chronic gastro-enteritis is anorexia; the patients eat without appetite, and often experience even repugnance for food.. Sometimes, on the contrary, they present an extraordinary development of appetite, (bulimia,) which is soon replaced by disgust.— They digest with difficulty; they are fatigued by eructations ordinarily acid, sometimes nidorous, and in some cases very acrid (pyrosis.) We see some who experience at in- tervals a sort of rumination. The uneasiness then aug- ments ; the patients complain of a sense of fullness at the epigastrium ; they are thirsty, and Avhen they have drunk several glasses of water whilst digestion is going on, they feel relieved. Very often they experience confusion in the ideas, heaviness of the head, disposition to sleep, and re- pugnance to movement; at the same time the skin becomes [ 224 ] hot, especially the palms of the hands, and the pulse soft and frequent in many cases. When the irritation of the stomach is more acute, or when the patients have ingested too gieat a quantity of food, the digestion cannot be com- pleted, or the stomach throws off by vomiting the substances fatiguing it. Under these circumstances, we see most pa- tients make use of tonics, which sometimes developes the appetite, and facilitates digestion ; but some hours after, their uneasiness augments ; they are forced every day, in order to produce the same results, to augment the dose, and the phlogosis makes progress from day to day—disorgani- zations supervene, and soon produce the destruction of the patient. Indh'iduals affected with chronic gartro-enteritis, expe- rience almost always obstinate constipation; they are seve- ral days without going to stool, and ordinarily these are only obtained by the aid of several clysters. This constipation is sometimes interrupted by a diarrhoea, lasting for one or several days, and the irritation of the large intestine which produces it does not continue except towards the close of the disease. We see then, an abundant diarrhoea take place, which is calmed indeed by emulsions, opiates and the ap- plication of a few leeches to the anus, but soon returns ; for ordinarily ulcers exist in the large intestine. Often in in- fants, and sometimes in adults, the mesenteric ganglions be- come irritated, swell up, and become the seat of tubercu- lous degeneration (marasmus.) Let us now examine the sympathetic phenomena produ- ced by chronic phlogosis of the digestive mucous membrane. Most frequently the tongue is narroAv and red on the point and edges ; sometimes the redness is not intense, but uni- form over the Avhole surface ; at other times it is Avanting entirely, and then it is replaced by the small reddish points of which we have before spoken. The middle of the tongue is often covered with a coat of mucus, yellowish or AA'hitish, more abundant in the morning and sometimes dry and resembling a pellicle which is detached in fragments.— The breath is fetid, and the thirst almost always greater than in the healthy state, especially after eating; very great thirst is even sometimes the most prominent symptom of chronic gastritis. Often the patients complain of feeling a sense of heat, of dryness and sourness of the throat. Gastric cough is more frequently observed in this shade [ 225 j of gastro-enteritis than in the acute state ; and joined to pain^ (which extends in certain cases to the chest) and to ema- ciation, it has often led to a belief of the existence of phthisis pulmonalis, as Ave have already remarked. We often ob- serve a disposition to silence, Aveakness of the voice, and even almost complete aphonia; the heart is not stimulated in the light grades of chronic gastro-enteritis ; only the cir- culation undergoes ordinarily after eating some disturbances, which are more marked w7hen the patient has committed an excess, or has been submitted to other causes of irrita- tion. ButAvhen the phlogosis progresses, at the same time that its different symptoms become more intense, the heart is stimulated ; and then we observe every evening a febrile movement terminating towards the end of the night, by sweat, and soon becomes remittent or continued : it consti- tutes one of the principal signs of disorganization, and then the phlogosis takes on again the characters ofthe acute state ; but when it is only transient, when it only comes on during digestion, and when it is not accompanied by other serious symptoms, the disease may still, according to Broussais, re- main in the chronic state. He remarks also, that when it is much prolonged, the febrile movement disappears, and that the heat and elevation of pulse coming on in the eve ning, cease to be sensible. The action of the secreting organs is not disturbed as in the acute state. The liver, however, is not unfrequently irritated ; the bile is then secreted in greater quantity, and flows into the stomach ; the mouth is bitter, particularly in the morning ; the face is of a yelloAvish tint, obscure, and sometimes even Ave observe all the symptoms of embarras gastrique. The liver may contract a chronic inflammation, and it is then, that on opening the dead body Ave find it adipose, at the same time that the duodenum is brown or black. Sometimes the secretion of urine is disturbed ; it is less abundant and reddish, and in subjects of nervous tem- peraments Avho experience sympathetic nervous symptoms, it is, on the contrary, limpid and more abundant. The ac- tion of the genital organs is most frequently debilitated ; it is not rare even to see patients affected more or less Avith impotency. It rarely happens that the brain is not influenced by chro- nic phlogosis of the digestive passages ; the irritation it ex- periences is often sufficiently intense to leave traces observ- [ 22'tf i able in the dead body. The patients are almost always sad? down cast, discouraged, taciturn, distrustful and irascible ; they support their misfortune Avith impatience ; they are ea- sily alarmed with regard to its consequences ; and soon lose the hope of recovering. In nervous subjects, given to men- tal labors, these phenomena aie often more marked; they exaggerate their sufferings ; they experience hallucinations, errors of judgment, and other disturbances in the mental functions, (hypochondria.) Sometimes indeed the brain is so deeply affected, that complete mania supervenes. In all these cases the attention is hxed exclusively on the nervous phenomena ; their source is mistaken, they are regarded as essential and treated by the whole series of antispasmodics, that is to say by stimulants Avhich increase, and finally ren- der incurable the lesion producing them. What we have said of the sympathetic influence exer- cised by chronic gastro-enteritis on the heart, applies al- most entirely to the skin. We should, however, remark, that the heat is often incre :sed after eating, Avithout the cir- culatory system being affected ; when the inflammation is not.sufficiently intense to arouse the sympathies, the skin is habitually colder than it is ordinarily, and the patients are then much more sensible to cold. The face expresses suf- fering, wrinkles numerous and profound alter its expression, its color is sometimes pale, and at other times straAV color, whilst the cheeks are at other times the color of wine lees. Towrards the close of life, similar spots are seen often in great numbers on other points of the skin. This sign an- nounces a rapidly approaching termination. The muscular system is more or less debilitated always, especially in the advanced stage of the disease ; the patients then have great repugnance to exercise, and are fatigued, no matter how little they take. The different articulations are sometimes affected Avith pains of greater or less acute- ness, which fix the attention of the patient and physician, more than the affection of the digestive passages. Often the volume of the muscles is little diminished, except to- Avards the close of the disease when they are almost always emaciated ; the subcutaneous and intermuscular cellular tis- sue sinks down and contracts, on the contrary, from the com- mencement of the disease ; the skin then becomes very ad- herent to the bones and muscles ; it sinks into their inter- stices and can no longer be displaced at the points where it I. 327 1 should possess the greatest laxity. This phenomenon, says the author of the phlegmasies chroniques, is peculiar to the marasmus produced by gastro-enteritis ; and joined to an ob- scure ted color of the skin like that of ochre or lees of wine, constitutes, according to him, one of the most constant signs of this disease. Such are the signs of chronic gastro-enteritis ; but we do not see them all united in the same patient. We observe in this respect the most multiplied differences in different individuals, and in the same subject according to the inten- sity of the inflammation, the remedies made use of, the kind of life, the regimen, constitution, &c. Sometimes Ave only observe one of these symptoms ; at other times we see sev- eral of them united together. There are individuals in Avhom the disease is announced only by slight uneasiness after eating, little appetite and constipation : in others we only see a remarkable thirst after eating. But after an im- propriety in diet, pain in the epigastrium and redness of the tongue, appear, and subside after a feAv hours employment of emollients; besides, however transient and faintly mark- ed may be the symptoms of chronic gastritis, they are al- ways sufficient to reveal it to the physiological physician, and inexperience, prejudice, or want of attention only cause it to be mistaken when it exists. Before examining the tendency- and terminations of chro- nic gastro-enteritis, we should, for a moment, fix our atten- tion on seA7eral symptoms of this inflammation which have been erected into diseases, considered mostly as neuroses, and treated by the greater number of physicians, with ton- ics and stimulants. When Ave consider the causes pro ducing these pretended neuroses and debilities of the sto- mach, the phenomena Avith Avhich they are accompanied, and the effects of the different means of treatment oppo sed to them, it is impossible not to attribute them, in almost all cases with Broussais, to chronic gastro-enteritis. Amongst the symptoms of this affection, of Avhich they haAre made distinct diseases, the most frequent, that which is common to almost all the shades of gastro-enteritis, is dyspepsia or difficult digestion. We meet every day per- sons who complain of having painful digestion, and every day we see a great number of practitioners, (who re- cognize debility of the stomach, and never its irritation,) advise in all these cases tonics of all kinds, without know-, L ^8 1 mg the nature of the evil they Avish to combat. M. Merot in hi3 dissertation on dyspepsia, has proved very satisfacto- rily that this morbid phenomenon was almost always produ- ced by irritation of the stomach. If Ave pay attention to the intemperance of the greater number of men, to the abuse of alcoholic liquors, coffee, spices, &c. ; if we consider that the sufferings of all the organs is reflect- ed to the stomach ; lastly, if wre regard the treatment of the greater number of diseases, Avhich to the present time has consisted in the administration of tonics and the most active excitants, Ave shall be little surprised to meet in society a crowd of individuals, Avho, as M. Brous- sais says, pass their lives in listening to their stomach digest, and who carry thus for a longer or shorter time, the germ of lesions too often irremediable. In pointing out the most frequent causes of dyspepsia, M. Merot insists very justly on the prodigious abuse of irritants in almost all diseases ; for, as he has remarked, it is one of those whose conse- quences haA7e been the most fatal to humanity. Setting out ahvays Avith the idea of debility, to which physicians have heretofore attributed all the disturbances observed in the di- gestive functions, they ingested into the stomach, with a blind confidence, the most energetic substances, the most incendiary medicines Avhich the ti.ree kingdoms can furnish ; they seemed to consider the digestive canal as an inert tube, in Avhich all stimulants could be placed with impunity. If we examine the causes under Avhose influence the ac- tion of the gastric mucous membrane may be sufficiently diminished to produce dyspepsia, we shall see that this af- fection can only depend on debility, under very rare cir- cumstances. Asthenia of the stomach may be produced by abundant hemorrhages, not accompanied by a chronic gastritis. It is not proper to place, as many authors have done, by the side of hemorrhages, the causes of debi- lity, repeated seminal evacuations, and abundant suppu- rations ; for the forced exercise of the genital organs, in- fallibly produces irritation of the stomach, and large Avounds furnishing pus abundantly, are ahvays accompanied by it. Humid cold, severe long continued diet, joined to the use of mucilages, may also throw the stomach into a state of asthenia; Ave have observed several examples of this, but Ave see no other causes Avhich can produce this effect. We AVill not place amongst them a gross diet of unsubstantial ali- [ 2>U ] meiits; for although they agree well with those who make daily use of them, they irritate the stomach"of persons habituated to more delicate food. A state of debility of the gastric-mucous membrane is then very rare ; for besides that the causes producing it are not many, they will not produce it in all individuals. Noav let us remark that it is impossible for this state to continue during a long time ; for the digestion only going on tediously and difficultly, the alimants, by remaining long in the stomach, fatigue its mucous membrane, affect it disagreeably, and finally ir- ritate it so highly that thu viscus unloads itself often by vomiting. Let us add that all men do not fail, under these circumstances, to take stimulants, such as wine, coffee, brandy, high flavored food, unless they be in a situation Avhere they cannot procure them. It is then evident that, from the fact that it is of long standing, dyspepsia depends on irritation of the stomach. At all events, the phenomena accompanying d}spepsia are different in the two cases, and permits us very easily to ascertain the state of the stomach which gives rise to it.— When it is produced by debility of the stomach, the face is pale, the eyes languishing, but the conjunctiva is not red ; the tongue is pale and at the same time broad ; this paleness extends to its edges and point; the patient desires stimu- lants, and does not experience thirst even during digestion ; the latter is accompanied by weight at the stomach, but we do not observe heat of skin or elevation of pulse ; the head is not heavy, &c. If the patient make use of generous wine, coffee, spiced food, digestion g^es on easily ; he ex- periences a sensation of comfort (de bi9n etre,) continuing after it is accomplished. In short, these means, joined to a bitter infusion, to the extract of rhubarb or bark, suffice to make the dyspepsia disappear in a day or two. All these phenomena are entirely opposed to those which accompany dyspepsia, produced by irritation of the stomach, and the description we have given of the signs of chronic gastritis, supercedes the necessity of relating them here. But if we examine a great number of dyspeptics, Ave will see that they present all these latter symptoms, and that the cases Avhere the difficulty of digestion depends on debility of the sto- mach, are indeed only exceptions. In vain physicians av ho treat dyspepsia ahvays by tonics, set up in opposition the cures they have obtained ; we will l 2:i0 j answer with M. Merot that if they are honest they will ac- knoAvledge that they have not only failed to cure many ofthe patients to whom they have administered these remedies, but that the greater number have remained a long time lan- guishing on their hands, and that their stimulants have con- ducted to the tomb, after a longer or shorter time, a great number of them, affected Avith cancer of the stomach, ob- structions, dropsies, or real consumption. The small num- ber of cures they have effected, prove nothing, because they have had to deal Avith dyspepsias'which wrere really caused by debility, and because Ave may cure slight irrita- tions by stimulants. It is thus that we dissipate incipient or chronic opthalmia by aromatic lotions and other resolvents; a slight inflammation of the skin by refiercussives ; urethri- tis by vinous injections; chronic dysentery by bark and other tonics, &c. Whatever may be the explanation given of these facts, they are demonstrated—they exist; we can conceive then that excitants may produce the same results in some cases of acute or chronic gastritis, of little intensi- ty. Lastly, the physiological physicians cure dyspepsias Avith great success by a severe calming regimen, mucilagin- ous drinks, &c. and they only find difficulty when the affec- tion is inveterate, Avhen the patients are unruly, or Avhen they are submitted to permanent causes of irritation; and, as M Merot has remarked, if we admit that the disturbance of digestion is always caused by debility of the gastric or- gans, how can we explain the cures obtained by antiphlo- gistics, Avhich far from dissipating them, should on the con- trary augment them ^ If they retort the argument, and ob- ject that the same difficulty presents itself against the cures performed by tonics, it is easy to answ7er that it is acknoAV- ledged that these last dissipate inflammations sometimes, Avhereas it can never be proved that emollients and diet have ever cured debility of the stomach. They often ask, if in persons of a lymphatic tempera- ment, of delicate constitution, convalescents exhausted by a protracted disease, old people Avhose vital action is Avorn out, dyspepsia is not rather the result of asthenia than of irritation, and if we can suppose its existence in individuals submitted to the most regular kind of life, who haAre never committed any kind of excess. It is never,'Ave have often repeated, from the exterior ap- pearance of strength or Aveakness, that we must judge of [ 231 ] the nature of the disease an individual is laboring un der, but always by the scrupulous examination of symp- toms and morbific causes, when we can appreciate them.— The most debilitated lymphatic subject, who shall be sub- mitted to a stimulating influence, will contract, as well as any other, inflammation ; it is the same with old men ; and the vital action being languishing in the one and the other, a chronic phlogosis will be established rather than an acute inflammation. In convalescents there exists great suscep- tibility in the viscera lately inflamed, and sometimes even they still bear a point of irritation. Besides, Avhen practi- tioners Avill consent to renounce the fallacious method of judging of the condition of the viscera from that of the face, of the muscles and subcutaneous cellular tissue, Avhen they will confine themselves to the interrogation of the suffering organs, they will always discover whether, in these cases, the dyspepsia is a symptom of debility-, or irritation of the stomach, and the first effects of the treatment they shall adopt, Avill soon confirm or destroy, in the eyes of the observer, (who is attentive and untrammelled by pre-con ceived ideas,) the judgment he may have formed. In persons leading the most regular kind of life, dys pepsia may, in the same manner, be produced by irritation of the stomach as in other individuals—since Ave often see them contract mortal inflammations. Constantly exposed to a thousand causes of irritation producing on us different im- pressions, can Ave always appreciate their effects, especially if Ave consider the difference of constitutions, and the va- rious modifications which the sensibility undergoes, not only in each individual, but also in each particular organ ; so that such a cause determining inflammation in one subject would not produce it in another, and such an influence which would not be followed by any result, might, a few days af- terwards, be very7 injurious to the same individual ? They object, also, that Ave exaggerate the effects of spi- rituous liquors, of acrid and spicy food, because habit blunts the susceptibility; and they add that, in individuals who have long made use of these substances, we should rather attribute dyspepsia to this, that these excitants, to which the stomach is habituated, is no longer sufficient to determine in this organ the degree of excitement necessary to the ac- complishment of digestion ; $nd they then advise more powerful stimulants. [ 232 J Habit, Avithout doubt, produces some modifications in the vitality of the stomach, enfeebles and even sometimes de- stroys the danger which should result from the continual con- tact of stimulants of the most active kind with the gastric mu- cous membrane. An impropriety in regimen will have differ- ent consequences in a woman habituated to a sober regimen, and in a professed brandy drinker ; but it would be errone- ous to conclude from this fact, that the empire of habit over the stomach is unlimited ; for it would result that every kind of life is of itself indifferent, and that it matters little Avheth- er Ave use the most powerful stimulants, provided we are habituated to them gradually ; this is Avhat no one, no matter Iioav limited his pretensions to physiology may be, Avould dare to sustain. If to some men custom renders less injuri- ous, substances hurtful to others, numerous facts present themselves to prove that the former always contract finally an acute or chronic gastro-enteritis, Avhich causes the death of the greater number. The digestive force of husband- men, w7ho only use the most simple food and Avater, surpass- es very far that of the inhabitants of cities, Avho habitually use high seasoned food, spirituous drinks, &c. Gastric affections, so common amongst the latter, are almost un- known to the former. If the absence of excitants, un- der whose influence the stomach is accustomed to act, observes M. Merot, may produce indigestion by depri- ving this viscus of the degree of vital action necessary to the elaboration of aliments, it Avould be absurd to contend that the prolonged use of irritating substances would produce the same effect. Analogy is opposed to the admission of such a hypothesis ; for if a stimulant placed ha- bitually in contact Avith the mucous membrane ofthe stomach should finally exhaust its sensibility so far that this organ could no longer fulfil its functions, because it Avould no longer be sufficiently excited, hoAV comes it that Ave see a number of old men, (particularly amongst those avIiohaAe been sober,) digest perfectly the same aliments which have nourished them for sixty years, although they be little stimulating; whilst yroung persons, Avho make daily use of spirituous and other excitants, are affected with dyspepsia, and lose at an early age the power of digesting ? If in them the abuse of stimu- lants has blunted the sensibility ofthe stomach, Avhy does that ofthe old man, which is stimulated for a much longer time, continue to act in a regular manner under the influence of t 233 j the same excitants, and how is it that the latter is not obliged to take rum alone for drink ? Besides, it would be curious to know how the Brunonians would explain the production of Aveakness by stimulants, without invoking the arbitrary and absurd principle of their indirect debility ? To resume, dyspepsia is almost always a symptom of chronic gastritis, and in very rare cases, of debility of the stomach, because men desire stimulants which sharpen the appetite and render the enjoyments of the table more ex- quisite. Dyspepsia produced by debility does not last, and all the difficulty of digestion, Avhich continues for a long time, is symptomatic of chronic gastritis. The latter exists in the most debilitated subjects, as in those wdio present the exterior of strength ; the abuse of stimulants always produ- ces finally gastro-intestinal inflammation, often incurable.— Notwithstanding a few cures of dyspepsia obtained by tonics, it should be treated by antiphlogistics, except in the cases Ave have pointed out, because the question will not admit of a dispute, Avhether stimulants cure more inflammations than debilitants. What we have just said of dyspepsia, applies to cardialgia, gastro-dynia and pyrosis ; indeed, since these affections are always accompanied by the first, and the latter are the re- sult of chronic gastritis, they depend then also on irritation of the stomach ; there is only this difference to establish— that these pretended neuroses can never, like dyspepsia, be produced by asthenia of the stomach, because where pain exists there is always irritation, and never debility. It is the same with bulimia : its causes, phenomena, and treatment prove, that it is also a symptom of irritation ofthe stomach. It is produced, authors say, by the abuse of bit- ters, acids, intestinal worms, and drastic purgatives ; they have seen it, they say, in infants affected Avith marasmus, in the course of certain quartan fevers, during the conva- lescence of many fevers, &c. Individuals affected with bulimia^ rarely retain the great quantity of food they have taken into the stomach—very often it is vomited, and in other cases there is diarrhoea. We knoAV that they are oppressed after eating, that they experience then all the signs of chronic gastritis, and that after a time, the bulimia gives place to dyspepsia. Finally, most authors agree in d 2 I. 2°4. j regarding diet, emulsions and mucilages as the most effiea^ cious treatment of this affection. Hypochondria is also a group of symptoms produced by chronic gastro-enteritis, and Avhatever may-have been said in favor of its idiopathic nature, no one can help discovering that all its phenomena have their source in the digestive passages. If we examine what are the causes of hypochon- dria, pointed out by authors, Ave shall see that they are all those Avhich exercise on the stomach an irritating influence ; such are, a sumptuous table, the abuse of irritating aliments^ alcoholic drinks, bitters, purgatives, venereal indulgences, onanism, suppression of a habitual hemorrhage, a cutaneous irritation, renal calculi, intestinal worms, intermittent fevers, the change from an active to an indolent life, immoderate exercise of the mind, culture of the fine arts, reverses of fortune, unhappy love, the torments of envy, ambition, &c.; lastly, we see dyspepsia ranged by many authors amongst the causes of hypochondria. What are the most prominent phenomena of hypochon- dria ? The disturbance ofthe digestive functions—those of the nervous system ; that of the first precedes always the alteration of the second. It is when for several months the patients experience pains in the epigastrium, anorexia, thirst, heat of the skin, constipation, uneasiness after eating, that Ave see supervene errors of judgment, hallucinations, spasms, convulsions, in short, the symptoms of cerebral irritation, produced and kept up by that ofthe digestive organs. Let us add also that on opening the bodies of hypochondriacs, Ave often find scirrhus of the stomach and intestineSj disor- ganizations of the liver, spleen, kidneys, &c—and always the mucous membrane of the stomach and intestine red or broAvn in the greater part of its extent. The causes, symp- toms and post mortem appearances unite to prove that hy- pochondria appertains to chronic gastro-enteritis, and to require the substitution of an antiphlogistic treatment in the place of the catalogue of tonics, stimulants, mineral Avaters, &c. with which hypochondriacs are gorged, and Avhich bring on disorganizations, under Avhich they sink. The duration of chronic gastritis is as unlimited as that of its acute state; treated methodically from its commencement, it is almost ahvays cured in a short time, but the patients very often retain a great aptitude to relapses. When it is primitive, its cure is ordinarily more easy than Avhen it sue- ! 23.3 1 ceeds acute gastro-enteritis ; Avhen it continues for several months, and still more, when for several years, the most regular treatment does not, in many cases, succeed in pre- venting disorganizations ; and the obstinate resistance of inveterate gastro-enteritis, to the best directed attentions, should make us consider it as one of the most dreadful of diseases. When it has been for some time exasperated by stimulants, the cure offers still greater difficulties, and it produces often the death of the patient; Ave should, how- ever, under the most serious circumstances, (unless avc have collected evident signs of disorganization,) hope for success and do every thing to obtain it; for we see gastro- enteritis cured, after several years duration, which had brought the patient into the most advanced stage of maras- mus. The march of this inflammation undergoes as many chan- ges as its symptoms. It presents ordinarily alternate ame- liorations and exacerbations, according to the treatment and the different sedative or exciting influences to which it is submitted. We often, after using a soothing regimen for some time, see most of the symptoms disappear ; sometimes even, none of them remain ; but the return of the convales- cent to his habits, an impropriety in diet, a distressing moral affection, soon bring on again anorexia, thirst, and sensibility of the'epigastrium. After a number of these successive exacerbations, and particularly under the influ- ence of the stimulants so profusely administered by most physicians in this disease, the inflammation rises to a more elevated degree, disorganizations supervene, and then we see the alarming symptoms already pointed out; the fre- quency ofthe Aromiting, the straAV colored tinge ofthe skin, the obscure red spots, the marasmus, the continued fever, the sweats, the marked alteration ofthe physiognomy, ac- quire every day more intensity, announce an approaching and almost inevitable death ; the phlogosis extends to the large intestine ; an unconquerable diarrhoea joined to the preceding symptoms hastens the progress of the marasmus and completes the exhaustion of the forces; delirium does not supervene ordinarily until the tAvo or three last days of existence. Not unfrequently the unhappy effects of chronic gastro-enteritis are anticipated by its passing to the acute state. Indeed, acute inflammation of the digestive passages, succeeding also to their chronic inflammation, is always very •serious and often mortal ; so that most individuals who sink under this disease, present Avith the traces of acute inflam- mation, those of chronic gastro-enteritis. The phenomena accompanying the last period of this affection are modified by the nature ofthe alterations Avhich it has produced in the digestive canal, and especially by scirrhus and the perforation of a point of its parietes. Cancer of the stomach is not an unfrequent termination of chronic gastro-enteritis; it is announced by all the signs of this disease, by the straw color of the face, by the lanci- nating pains in the epigastrium, ordinarily by the develop- ment of a hard tumour in this region and almost always by vomiting. These particular symptoms vary according to the seat occupied by the scirrhus thickening: when it affects the cardiac orifice, which is rare, the patient feels below the region ofthe heart, at other times in the back or pharynx, a fixed pain which is increased by the passing of food ; some- times the cardia is so constricted, that the food cannot pass, and mounts again to the mouth ; when it penetrates into the stomach, it is often rejected by vomiting, without having undergone any alteration. When the scirrhus occupies the body of the stomach, it is ordinarily at one of the curvatures, particularly at the small one, that it is seated. The patient takes but little food and drink at a time, because the distension of. the stomach they produce, makes him experience intolerable pains and nau- sea. They are almost always vomited a short time after taken in. Tumour at the epigastrium is not always seen; it is more frequent when the cancer occupies the basfond of the stomach ; it extends then from the epigastric to the left hypochondriac region. When the disorganization affects the whole body of the stomach, it appears that there is not vomiting, as we see in the case reported by M. Bourdon, which has furnished to this judicious physiologist, the sub- ject of his beautiful dissertation on vomiting. The pylorus is the part of the stomach most frequently affected with cancer. The patient experiences pains in the epigastrium, ordinarily lancinating, increased by pressure, which extend to the right hypochondrium, so that they may be referred to the liver. There exists generally a hard and resisting tumour be- tween the epigastrium, and right hypochondrium, near the anterior border of the liver. Tavo or three hours after eating, the aliments are rejected by vomiting, about the time that they should pass the pyloric orifice, and only a very small portion of them pass into the duodenum. The pylorus contracting more and more, the stomach becomes distended by the aliments ; M. Broussais, under these cir- cumstances, has seen it acquire a very great capacity.— When the scirrhus ulcerates, the matter which it furnishes always renders that vomited, black, grumous, and san- guinolent. The existence of scirrhus of the intestine is not manifest- ed by any particular symptom, we content ourselves with pointing it out amongst the terminations of chronic gastro- enteritis. We will not stop to prove that cancer of the in- testinal canal and marasmus are the results of chronic inflam- mation ; Ave have sufficiently- shown the etiology of tubercles and of scirrhi in the history of sub-inflammations. Before terminating the history of the phenomena of gas- tro-enteritis, Ave should offer some reflections on one of its most terrible results, A7iz : perforation of the stomach and intestines. It is to the physiological doctrine that Ave also owe our knowledge of its mode of production. Often attri- buted to the action of cprrosive poisons, Avhen it comes on suddenly, this lesion has been a subject of deplorable eirors previous to the researches, of the able professor Chaussier, to Avhom pathology, and particularly legal medicine, owe the honor of having proved that the perforations of the stomach are spontaneous, and of having laid before us a great number of examples of this kind. Before this John Hunter had attributed them to the dissolving power of the gastric juice ; and Avhen M. Chaussier called the attention of the profession to this disorganization, physicians explained it by a morbid erosiv7e action, (Avhich explains nothing:) others by a peculiar mode of inflammation, as if ulceration of the skin and inflamed mucous membranes, the seperation of the former, from subjacent parts, the distruction of the cellular tissue, the dissection of the muscles in phlegmon, were not sufficient to make us class these alterations Avith those Avhich occupy us, and refer them to the same cause ; but it seems that physicians were destined to exhaust all the errors of physiology and pathology before arriving at a knowledge of the diseases of the stomach and intestines. And lastly, others not finding this peculiar mode of inflammation suffi- cient to explain these perforations, have thought thedifficul- 1 to* J ty could be resolved by making an aliance of humorism and solidism. They have admitted, therefore, that this specific inflammation determined the secretion of a fluid which had the property of corroding the tissues. M. Laisne, in an able dissertation, valuable not on account of the doctrine Avhich it contains, but on account of the facts, the greater number of which have been communicated to him by professor Chaus- sier, says that it is possible, and that it happens indeed fre- quently, that the juices of the part then acquire consecutive- ly a dissolving faculty. We regret that Doct.'Desruelles, in his dissertation on the same subject, Avhen endeavoring to attach the theory of perforations to the physiological doc- trine, should have Avandered so far as to adopt this opinion, and to admit a deleterious secretion in the inflamed tissue, when the erosion does not take place rapidly, the existence of Avhich nothing goes to prove. Considering the causes producing them, and the symptoms Avhich accompany them, M. Broussais has referred perfora- tions ofthe stomach to gastritis ; but it still remained to ex- plain how the inflammation produced them. M. Lallemand has at length cleared up this point to pathological pyhsi- ology. His valuable researches on the ramollissement of the brain and other alterations of this viscus, have conducted him to the fact, that inflammation, by augmenting the density of the tissues, destroyed their force of cohesion, produced their ramollissement, and that then they fall into a state of dissolution (detritus) and disappear. He has proved that it Avas in this manner, ulceration of the skin and mucous membranes, destruction of the cellular tissue, wasting and perforation of the skin in phlegmon, Ave re produced; the section of arteries embraced by a ligature, and that of the parts included by a lead ligature in the operation for fistula in ano ; the long track pursued sometimes by balls buried beneath the skin or between the muscles, foreign bodies introduced into the digestive passages ; the perforation of the bladder by sounds remaining for a long time in its cavity; the ramollissement gclatiniforme, erosion of the mucous membrane, and the complete perforation of the stomach, are different degrees ofthe same alteration. With these data on ramollissement deteimined by inflam- mation, it is easy for us to prove that perforations of the stomach are ahvays determined by inflammation of the L 231) j stomach, which differs in nothing from all others. We es- tablish first as a principle, that almost always, the individuals in whom perforations of this viscus have been observed, Avere affected for a longer or shorter time, with chronic gastritis. It is easy to be convinced of this by reading the cases pub- lished on this lesion—if Avill not be out of place to relate a few of them here. Gerard reports that a man of forty years, sickly for some time, felt all at once, after having drunk a glass of wine, a pricking in the stomach, and vomited blood in pretty consi- rable quantity. During three months he experienced severe pains in the head and stomach alternately. At the end of this time the patient took a purge ; and the same day, after having taken a little food, he had nausea and vomited bile, with a large clot of blood. The pains then augmented : an cedematous swelling occupied all the left hypochondrium; and after four days the patient died suddenly- in the night. On opening the bedy a large perforation about an inch from the cardia was found, on the side of the great curvature. In the following cases, taken from the dissertation of M. Laisne, gastritis is not less evident. A small girl of five years became sickly, and languishing for three weeks. Suffering slightly in the stomach and belly, she was suspected to have worms ; convulsions came on sud- denly and the child died. On post mortem examination, an opening of three inches Avas found at the splenic extremity of the stomach. A woman eighteenyears old, had never menstruated; seve- ral months before she had had a quartan fever, and her spleen Avas habitually enlarged ; suddenly she felt in the shoulder a pain so acute, that she could not move ; fever was developed, the pain extended to the hypochondric re- gions, and especially to the left side ; there was vomiting from time to time, the belly swelled considerably, and the third day death took place. On opening the body, a per- foration was found toAvards the middle ofthe stomach. A single lady of thirty years, in the habit of lacing very tightly the lower part of the chest, for the purpose of render- ing her form more graceful, experienced, after some irregu- larity of diet, a suppression of the catamenia, and in conse- quence of this a dropsy7. She died suddenly, and on exa- mination a perforation Avas found in the part of the stomach corresponding to the spleen. [ 1-to J M. Desrueiios relates, from Geoffroy, that a lady aged for- ty years, Avho suffered during three years, very severe pains eight in the epigastric region, and vomited frequently, died hours after eating dinner. A perforation was found near the cardia. Perforations of the stomach have often been seen, after adynamic or ataxic fevers, that is to say, after acute gastro- enterites. But in all the cases Avhich are reported, and which details have been given of, on the condition of the patient before the invasion of the fever, Ave see also all the signs of chronic gastro-enteritis, Avhich has afterAvards passed to the acute state. In the space of tw7o months, I have seen at the hospital of the Royal Guard, three perforations ofthe stom- ach, in individuals who had died in a feAv days, of gastro- enteritis, under the adynamic form, and the information received from them at the time of their entry, satisfied me that they had been for some time affected with chronic gas- tro-enteritis. The mucous membrane had probably then been softened by the latter, as AA7e often see it in those who have sunk under this disease, and the disorganization Avas then extended rapidly to the other coats, Avhen a more acute inflammation supervened. In those cases in which we have no information Avith regard to the preA7ious state ofthe health of the patients, we can form no conclusion either in favor or against the pre-existence of chronic gastritis. Boisseau, hoAvever, says he has seen perforations in subjects who had always enjoyed good health. How7ever this may be, the patients who are the subjects of these cases have not expir- ed until after five, six or eight days of sickness and some- times even later; and there is not required more time for a phlegmonous inflammation, to destroy the cellular tissue, to attenuate, soften and perforate the skin ; or for an acute en- teritis, to produce ulcerations in the intestines. M. Chaus- sier reports several cases of perforations supervening in Avomen affected Avith puerperal peritonitis. But this inflam- mation cannot exist Avithout giving rise to concomitant acute gastritis; Ave would have seen its symptoms if the history of the diseases had been published in detail. In the only case in Avhich M. Laisne has not omitted these details, avc see all the signs of this inflammation. A Avoman of delicate constitution Avas happily delivered of her first child at the hospital de la Maternitc. The second day, fever and pains in the hypogastric region—(purgative mixture.) The third L 241 j day, the chill reappears ; tongue red and dry ; pains super vene in the left hypochondrium; no secretion of milk.— (Thirty leeches applied, Avhich procure great relief.) On the fourth day however, the symptoms reappear ; heat and dryness of the skin, hardness and frequency of pulse, pains in the Avhole abdomen ; lochia scanty. The application of leeches repeated, which stiil procure relief. MeanAvhile pains are constantly felt in the abdomen; the pulse preseiwes its hardness and frequency ; the skin, its heat and dryness; the tongue, its redness and aridity. The fifth day twelve more leeches are applied and two blisters, one on the ster- num and the other on the internal part of the thigh; these remedies did not suspend the intensity of the symptoms. Ten days passed in alternations of pains and calms ; but on the sixteenth day the abdominal pains returned Avith intensi- ty ; they Avere attended by the former symptoms, to which Avere joined frequent nausea and a very severe pain in the epigastrium. Three days passed in this manner and the patient sank. On opening the body traces of peritonitis were found, and towards the left part of the diaphragmatic portion of the stomach, a large opening two inches long; the corresponding portion of the diaphragm Avas greyish and softened. Finally, perforations of the stomach have been seen su- pervening Avithin a few hours, in persons apparently in good health : but, notAvithstanding this assertion, Ave see also, in several of those cases reported to this point, signs of gastri- tis pre-existing for a greater or less time. A soldier returned after several days of absence and entered the Val-de-Grace, affected w7ith a phlegmon in the right buttock, to which Avas joined signs of gastritis of moderate intensity7; three grains of tartar emetic Avere administered ; frequent and violent vomiting followed. A short time after, the tongue Avas red and dry, the skin cold, the pulse exhausted, and the patient speechless. When the epigastrium was pressed, his physi- ognomy presented the expression of acute pain. He died in the night thirty six hours after his entry into the hospital. On opening the body we saAV a lar£e perforation Avhich oc- cupied the bas-fond of the stomach, and more than half of its posterior face. The serous membrane alone existed, but this gave Avay at the moment Avhen this viscus was raised up for the purpose of examination. In the remainder of its extent the mucous membrane was black, and shoAVed some e 3 [ *te j traces of deep red ; on wiping it with a cloth, it Avas de- tached in fragments. One would have thought that these disorders had come on suddenly, if the patient had not made known, at the time of his entry, that during the latter part of his residence with his family, he had been guilty of great excesses at table, that he had continued them during his journey, and that on his arrival at his corps, having lost his appetite for several days, he had taken large quantities of brandy and hot wine to restore it. A young man aged thirty years, who for some time had been troubled with flatulency and other symptoms of this nature, was found dead in his bed. His body was examined juri- dically three days afterwards : the intestines appeared in- flamed and the stomach also ; besides, there Avas a perfora- tion at the basfond of this viscus. In the cases, where the signs by which gastritis manifests itself have been neither observed nor mentioned^ it perhaps existed notwithstanding ; for Ave not unfrequently see in- dividuals present the appearance of health, although they be affected for a considerable time Avith gastric inflamma- tion ; those who have studied attentively this disease, have had occasion to be assured of it. Besides it is not always possible for the physician to collect the facts with regard to the previous state ofthe patient; and if he present the ex- ternal characters of health, he may easily be led into error in this respect. M. Laisne reports as an example of perfo- ration supervening suddenly, a case which Avill furnish proof of what we here advance. A woman of the neighborhood of Montargis, after having walked tAvo leagues in the hottest part of a summer day com- plained of uneasiness and pain in the head. In the evening she supped, eat some pease and drank wine and water ; she passed the night without complaint. The next day she rose at an early hour ; but soon after she complained of great cold, pains over the whole body, but especially in the stomach ; her eyes Avere red and strength gone ; she experienced great thirst and had several alvine evacuations accompanied with pains. She expired in the night. On opening the body the stomach was found phlogosed, on the internal sur- faee from the cardia to the great cul-de-sac, and its posteri- or face perforated for a third of its extent. From these details Ave would think that this woman en- joyed very good health before the event. But her death i *« J gav e rise to suspicions of poisoning ; two individuals were put on trial, and a consultation of the faculty of medicine decided that the disorganization Avas spontaneous. M. Billiard, Avho has also reported this case in his thesis, says that a witness attested before the court of assizes, that three days before the ostensible invasion ofthe disease, the woman who was the subject of the case, on taking food before him, complained of a want of appetite, desire to vomit, and that she actually had some vomiting. We then also find proof here that gastritis had existed for several days. Nevertheless, M. Chaussier says, that sometimes perfo- rations form suddenly, in a few hours, in healthy persons. Most frequently, he adds, it is after several days of sickness. But these facts are far from proving that the disorganiza- tion is not the result of gastritis ; Ave see on the contrary, in these cases the signs of a violent inflammation of the sto- mach : the patient complains of an acute pain in the epi- gastric region ; soon he becomes prostrated, the pulse is small and compressed, and the skin cold; finally, the in- flammation is so intense from its commencement, and death supervenes so rapidly, that reaction cannot take place.— We see also in most cases of this kind, that the disease has been caused by powerful irritants—for example, by drinking ice water Avhilst the individuals were very hot. If a chronic inflammation take a great deal of time to soften and perfo- rate the tissue ; if an acute inflammation of ordinary inten- sity, produce this disorganization in a feAV days, we may justly conclude that a very intense inflammation, extending to all the tunics at once, may give rise to it in tAvelve or fifteen hours. Perhaps also there are some cases of rapid perforation of the stomach Avhich not appertaining to ramol- lissement, are referable to gangrene of the stomach, on which Ave do not yet possess sufficient exact data to be able to establish any thing else than a presumption. Besides the rareness of perforations of the stomach, produced in a few hours in a healthy man, would be in accordance Avith that of gangrene of the stomach itself. Further, perfora- tions ofthe stomach are almost alw7ays produced by a chronic gastritis which softens its membranes. In cases Avhere we observe it after an acute gastritis, the latter most frequently has been preceded by chronic phlogosis. When the symp- toms of perforation come on suddenly, sometimes it is the L ^44 j result of an obscure inflammation which has not been pel ceived ; at other times, of a very acute inflammation not promptly softening the tissues, or perhaps gangrene. In fine, there are also perforations resulting from scirrhus of the stomach. Article III.-Phenomena of acute and chronic colitis. M. Broussais describes under this name the inflammation ofthe mucous membrane ofthe large intestine, to which he refers diarrhoea and dysentery, two different degrees of it. This inflammation may be produced by all those causes Ave have assigned to gastro-enteritis ; it is, however, more particularly produced by aliments of difficult digestion, by those which leave a great deal of excrementitial residue, and those which have undergone some alteration ; by the use of stagnant waters, charged Avith organic substances, in a state of decomposition ; unripe fruit, eaten in excess ; by- exhalations from putrifying animal or vegetable substances; those which are disengaged from large croAvds of individuals, Avell or sick. We have often seen persons affected Avith diarrhoea, after being present at the opening of infected bodies. The fact related by Pringle, is well known, of a man Avho contracted a dysentery on account of having smelled a bottle containing some, putrified blood. Baron Desgenettes has seen a great number of persons affected Avith this disease, after having been struck by the infected odour, exhaled from the putrified skin of an enormous stag Avhich Avas carried through the streets of Cairo. . Hot and humid air favor singularly the action of putrid emanations, doubtless by becoming charged Avith these prin- ciples in larger quantity, than that which is dry and cold: it is also almost always under its influence that epidemics of dysentery have been seen to develope themselves in be- sieged cities, camps, barracks, prisons, and hospitals. These causes sometimes act with the greatest energy, and then most of the individuals who remain for some time in the area of infection, are affected with dysentery. These cir- cumstances have often imposed on those who have not established, between contagion and infection, the difference existing between these two modes of production of diseases. Many distinguished physicians have admitted the contagious nature of dysentery; but at the present day it is well known that it cannot be transmitted without the district of infec- [ 245 ] lion by a sick to a Avell individual,and that consequently it is not contagious : this character cannot be attributed to it, except when it is united to contagious typhus, as Ave see it in certain epidemics. The action of the miasms emanating from a place of in- fection where dysentery is developed, is not always confin- ed to the large intestine,—we see it often, in the epidem- ics of this disease, extend to the stomach and small intes- tine, as the author of the Phlegmasies chroniques remarks ; sometimes it is even confined to the upper part of the di- gestive canal, and the large intestine is exempt from inflam- mation. It is to this co-existence of inflammation of the latter, of the stomach and small intestine, that we must re- fer what authors have said of the complication of dysentery Avith adynamic and ataxic fevers. Cold, damp air, unless its temperature be some degrees above zero, does not seem to second the action of miasms, but it often produces also, inflammation of the colon, by suppressing cutaneous perspiration. We know that expo- sure of the feet to cold, is often sufficient to produce diar- rhoea. We have seen epidemics of dysentery developed in regiments which had been exposed to rain during several hours in cold Aveather. M. Broussais has remarked that, debilitated individuals and those who at the same time were very irritable, were most disposed to dysentery7, and amongst Avhom it made the greatest ravages in epidemics. In this respect, the depressing mor- al affections, and particularly nostalgia, produce a very mark- ed predisposition to inflammation of the colon. We knoAV that strong emotions sometimes give rise suddenly to diar- rhoea. Acute and especially chronic phlegmasia, and wounds suppurating for a long time, by debilitating individuals and exalting their irritability, predispose them also to dysen- tery. Colitis presents several forms very different in* relation to the degree of phlogosis and the accompanying circumstan- ces ; we shall describe them rapidly, our end being only to pause on the points of pathology which physiological medi- cine has elucidated. The irritation of the large intestine is sometimes so light that it only constitutes a trifling indisposition ; such is the diarrhoea often following bad digestion ; after two or three liquid stools, and some rumbling of the bowels, the action of the lara;e intestine returns to its normal state. L 24G J Diarrhoea comes on almost ahvays suddenly ; sometimes constipation precedes it for several days ; it is announced by wandering pains in the abdomen, particularly around the umbilicus, by borborygmus and a sense of fullness and hea- viness in the pelvis. These phenomena disappear after the evacuations, and return when the patient has passed a few hours Avithout going to stool; the intestinal or colicky pains are sometimes very severe, but it is only at intervals, and they are calmed by rubbing the abdomen, and compressing or covering it with Avarm cloths. The alvine evacuations are more or less frequent; they are ordinarily scanty. Dis- charges of very different aspects give rise to a sensation of heat in the anus during their passage, but this opening is not painful; if, however, the evacuations are often repeated, they are accompanied by tenesmus. The discharges, com- posed at first of softened faeces, are then liquid, sometimes mucous, at other times and more frequently serous; ordi- narily they are yelloAvish and fetid ; in other cases greenish, greyish or whitish, and then they exhale little odour ; it is according to these differences of aspect, of the discharges that this superfluous division has been established, viz. se- rous diarrhoea, mucous diarrhoea, stercoral diarrhoea, bilious diarrhoea, purulent diarrhoea, veminous diarrh&a, fyc. When the diarrheeic colitis (colite diarrheique,) is very light, it does not excite sympathies ; but if the evacuations be frequent, it is accompanied by thirst, anorexia, a clam- my state of the mouth, redness of the edges and point of the tongue, a sensation of Aveakness and lassitude in the ex- tremities, Avhich always become svery great in a short time. When it is primitive, it is very rare that it provokes an ir- ritation of the superior part of the canal, sufficiently intense to give rise to febrile phenomena. When the contrary hap- pens, it receives the name of dysentery ; either gastritis existed before it, or it is established at the same time. The duration of this degree of colitis is very variable ; most frequently limited to one or several days, it extends to twelve, fifteen, and twenty, if the causes producing it have acted with intensity, if the atmosphere be damp, if the pa- tient be imprudent in regimen, or if he be submitted to a stimulating treatment. Sometimes it rises to the degree of dysentery, at other times it passes into the chronic form.— But before occupying ourselves Avith the latter, Ave should speak of dysentery. [ *47 ] This degree of inflammation of the colon, is characteri- zed by severe colics, by frequent necessity of .going to stool, efforts often abortive, painful evacuation of a small quanti- ty of mucous matter, ordinarily streaked with blood. Most frequently the grade of colitis Avhich has received the name of dysentery, is not at first attended by the symp- toms characterizing the latter ; they are preceded by those of light inflammation of the colon, which at the end of some days acquire more intensity and give rise to more serious accidents. Sometimes, however, and particularly in epi- demics, it presents from its commencement, very great ac- tivity. The patient experiences at first a sort of commotion in the arch of the colon : it seems to him, says Pinel, that secretions are thrown off from it, which flow into the loAver part of the intestine. He is troubled with colics, becoming more and more severe, with a sense of twisting which seems to pass along the course of the intestine, from its su- perior part to the anus, a transverse constriction in the di- rection of the arch of the colon, compared to the sensation produced by a bai placed on the abdomen. Soon, frequent disposition to stool comes on, accompanied by painful tenes- mus, pruritus and an acrid pricking heat is felt in the anus ; the patient gets up every instant and wearies himself in fruitless efforts ; he, however, discharges from time to time a small quantity of glairy, viscid matter, mixed Avith bloody streaks, sometimes composed of pure blood, of a disagree- ble and sometimes insupportable odour ; these evacuations relieve the patient for a feAv moments and they become more and more frequent, in proportion as the disease pro- gresses. NotAvithstanding the intestinal pains which the patient experiences, the belly is little or not at all painful on pressure ; Avhen the sensibility augments, Ave should con- clude, according to the remark of Broussais, that peritonitis is developed. The patient is in a state of uneasiness and inexpressible anxiety. His strength is prostrated from the commencement, and the feebleness is greater in proportion as he is tormented by tormina and tenesmus; and as the evacuations are scanty. It is impossible for irritation of the colon to exist in so high a degree, Avithout giving rise to sympathetic irritations. From the commencement, Ave observe symptoms of gastro- enteritis, increasing Avith the colitis. The thirst, dryness of the mouth, redness of the tongue, epigastric sensibility. [ 248 j and the other local and sympathetic symptoms of inflamma- tion of the superior part of the digestive canal are then manifested, under one or the other of the forms Ave have before laid down. From the commencement of the disease the pulse is frequent; it is developed if the subject be strong and the pains not severe ; under the opposite circumstan- ces, it is small and accelerated. We will not speak of the sympathetic phenomena presented by the brain, skin, and secreting organs, &c. ; they are not manifested except "vhen gastro-enteritis exists ; and the co-existence of colitis not modifying them in any thing, Ave refer to the description we have given of them when treating of acute gastro-en- teritis. This extension of irritation to other organs, gives to dy- sentery very different forms, of Avhich authors have made species. M. Soudan, who has applied to the study of this disease, very successfully, the principles of the physiologi- cal doctrine, has correctly connected each one of these spe- cies to the organs from Avhence they spring, and has shoAvu that they all appertain to the different forms of gastro-ente- ritis, complicating colitis. Let us folloAV him in this exa- mination. Inflammatory dysentery is a gastro-entero-colitis, devel- oped in a subject Avhose sanguine system is predominant.— It comes on often after the suppression of a habituahhe- morrhage ; Ave see it in dry and hot seasons, after the abuse of stimulants. Cephalalgia, muscular pains, and a very in- tense continued fever, accompany it ; the pulse is full and strong, the face red and tumefied, the conjunctiva injected, the thirst ardent, the tongue of a vivid red on its borders. When the lymphatic system predominates over the san- guine vascular system, (as in children, Avomen, subjects submitted for a long time to debilitating causes,) and Avhen the irritation of the stomach and intestines predominates in the mucous cryptae, we observe mucous dysentery, that is to say, the union of the signs of colitis with those of mucous fever. The tongue is white and moist on its surface : and red on its borders ; aphthae often supervene on the inter- nal face of the cheeks and tongue ; the thirst is slight, the inappetency absolute ; sometimes Ave see vomiting of viscid matters ; the pulse is small and feeble, the heat of the skin pungent to the touch. This form often passes to the chronic state. [ 249 j When gastro-ehtero-colitis is accompanied with irritation »f the liver and supersecretion of bile, we see gastric or bilious dysentery ; it is often presented under this form in epidemics. It is characterized by a yellowish coating ofthe tongue, which, at first moist, becomes dry, and red on its bor- ders. If the inflammation augments in intensity, Ave see it followed by great thirst, a strong desire for cold aci- dulated drinks, horror of food, sensibility or pain of epi- gastrium, yellow and fetid dejections, sometimes bilious vomitings, pungent burning heat of skin, yellow tinge of the conjunctiva and parts surrounding the alas of the nose, frequency and hardness ofthe pulse, very severe cephalal- gia, sleeplessness and often delirium. In this form the tenesmus is more painful, and the colics more violent.— When it reigns epidemically, it produces ordinarily very- great ravages, by the facility with which the inflammation rises to a higher degree. When gastro-enteritis complicating the three forms of dysentery, we have just examined, acquires a very great degree of intensity, the tongue and lips become fuliginous, and the skin livid, the dejections are very fetid, the pulse small and very frequent, and the patient falls into a stupor : this constitutes adynamic or putrid dysentery. At other times, instead of rising to a high degree in the stomach and small intestine, the inflammation predominates in the brain, or its meninges, and then Ave see delirium, agitation, con- vulsive movements, subsultus of the tendons, carphologia, &c. This union of gastro-entero-colitis, Avith a high ence- phalic inflammation, has received the name of malignant or ataxic dysentery. Finally, colitis, often complicates in au- tumn, typhoid gastro-enteritis ; and in epidemics of dysente- ry, when the infection is very deleterious, the latter very frequently complicates colitis. The duration of inflammation ofthe large intestine is very • variable; when hoAvever,it presents no serious complications, it terminates ordinarily in eight, ten or twelve days, or loses its intensity. The tenesmus diminishes and ceases, the evacuations are less frequent, and return by degrees to their ordinary state ; at the same time the signs of gastro- enteritis disappear. When dysentery produces death in its acute stage, it is never by inflammation of the colon alone but bv the coexistence of that of the superior portion of the canal or of the brain, and frequently by both at tlv- [ 250 ] same time. When these complications, sufficiently grave to produce death, do not supervene, and Avhen resolution of the inflammation does not take place, it passes into the chronic state, and then often terminates by exhaustion.— Unless the colitis be light, and the gastro-enteritis accompa- nying it have little intensity, the prognostic is always unfa- vorable and it becomes very fatal Avhen it puts on the ady- namic or ataxic form. The danger is not only relative to the intensity of the gastro-entero-colitis, but also to the circumstances under Avhich it is declared. It is much less great in young and vigorous subjects than in those who are debilitated by excesses, by bad alimentation, by abundant deperditions, or Avho are affected by another inflammation, acute or chronic ; Avhen it is sporadic, than Avhen it is epi- demic. According to M. Desgenettes, dysenteric epidem- ics are more destructive than the plague. Dejections of pure blood announce a Aery acute inflammation. A small accellerated pulse, joined to alteration of the expression of countenance, to lividity of the skin, to coldness of the ex- tremities, to cessation of pain, are very bad omens, and should lead us to dread gangrene of the intestine, which hoAveA7er, according to M. Broussais, rarely takes place. Chronic colitis succeeds to acute diarrhoea or dysentery, or it exists primitively under this form, especially Avhen it follows gastro-enteritis, or when it is produced sympathet- ically, by the chronic inflammation of another organ, like that coming on in the last stage of phthisis pulmonalis. or of cancerous degenerations, &c. Under all these circumstances, chronic colitis presents the same characters. If it has at first been acute, a notable diminution takes place in the intensity of the symptoms; the colics and tenesmus disappear; the stools are more abundant and less frequent; they only take place three or four times a day, sometimes hoAvever, seven or eight; they present, as in the acute state, different aspects; they are ordinarily yelloAv and composed of liquid excrements ; Avhen the phlogosis is old, they are sometimes purulent; the latter phenomenon is very alarming, for it ordinarily announces the existence of ulcerations in the large intestine. When the colitis is not accompanied by chronic gastritis, the pa- tients have ordinarily a keen appetite, which they resist with difficulty ; and Avhen the disease does not arouse any- general phenomena of excitation, they experience an unusu- i to) j ;d desire for the most substantial food, generous wine and all the tonics. The ingestion of these substances produces at first a sensation of well being, but at the end of several hours, they experience colics and frequent evacuations of half digested aliments; sometimes the latter pass through the digestive canal Avith great rapidity, and are voided with- out having undergone scarcely any alteration (lientery.)— Besides, the number of evacuations and the uneasiness ac- companying them, bear a relation with the regimen followed by the patient. When he makes use of a small quantity of food, furnishing little excrementitial residue, they are rare and scanty ; and under the influence of this regimen and other means, they soon cease entirely, if no disorganization of the large intestine has taken place ; the patient recovers by degrees his strength and flesh, and returns to health.— If on the contrary, chronic colitis be not combatted by pro- per treatment, it continues. It may remain stationary for a long time ; Avhen however, it continues for several months, it produces the most serious accidents, unless it be frequent- ly interrupted. But in general, especially when united to another chronic inflammation, it gradually produces a mortal exhaustion ; emaciation makes rapid progress, the muscular forces are annihilated, the face is wrinkled, pale, and of a dirty yelloAV, the skin is dry and covered Avith a crust of an earthy aspect; morning sweats often hasten the progress of the emaciation ; sometimes the skin is habitually dry and harsh to the touch, and cutaneous perspiration seems no longer to go on. When chronic cc/litis has arrived at this state, it sometimes passes on to the acute state, or at least signs of acute gastro-enteritis are manifested, to which is soon joined encephalic irritation, and the patient dies in a delirium. At other times the chronic form of the inflam- mation continues ; but it is always accompanied in the last stages by a chronic gastro-enteritis, if the latter did not ex- ist from the beginning ; in the evening the pulse rises and becomes frequent, the cheeks are florid, aad the skin hot and dry. The patients die much emaciated ; but most fre- quently when the first mode of termination, just spoken, of does not come on, the lower extiemities become infiltrated, and Avhen the cedema reaches as high as the pulvis, an effu- sion of serosity takes place in the peritoneum. Death does not always happen in chronic colitis from the exhaustion it produces, or from the development of gastro- i 'Y* enteritis, or an encephalic irritation ; Avhen diarrhoea is pro- duced by another chronic inflammation, death is at the same time the result ofthe progress ofthe latter. Article IV.—Alterations produced by inflammation OF THE GASTRO-INTESTINAL MUCOUS MEMBRANE. It would be impossible for us to present a better descrip- tion of the lesions produced by acute and chronic gastro- enteritis, than that given by my friend, Doct. Scoutetten, (who has applied himself for several years to the study of pathological anatomy,) in his inaugural dissertation. These details, not admitting of an analysis, we will make use of them with the consent of the author, by inserting here in its OAvn language, the part of the thesis consecrated to the history of the alterations ofthe stomach and intestines. Acute lesions of the digestive canal, or alterations observed after bilious, mucous, adynamic and ataxic fevers of authors. I. Tongue.—This organ does not present commonly, ve- ry material, sensible alterations ; the tongue, hoAvever, is sometimes brown, black, dry and covered by A7ery tenacious mucus. Very small ulcerations, aphthae more or less nu- merous, sometimes exist towards its borders ; the folds of the mucous membrane called franges, shoAv in some cases, a manifest sanguine engorgement. 2. The palatine membrane may sometimes be excoriated : this is rare, Ave find one example of it in Prost. 3. The velum palati is sometimes red and dry; the in- flammation may be more or less violent, but there is no con- stancy in it. 4. The pharynx is not unfrequently inflamed. 1 have sometimes met in it an eruption of small Avhite pimples, containing an opaque, homogeneous, Avell formed pus. We find there also, ulcers very variable in size and form ; they however, are rarely of great, extent; most frequently they originate from the little pimples just spoken-of. 5. (Esophagus.—The mucous membrane of this organ is very often inflamed in one or several points, but most gen- erally at the inferior or superior part; the middle part then preserves the white or rose color which belongs to healthy mucous membranes. We sometimes me'et ulcers of con- L 253 ] siderable extent; I have found one situated a few lines be- low the union ofthe oesophagus Avith the pharynx; its breadth Avas about twelve lines ; all the tissues of the mem- branous canal Avere destroyed, the anterior face of a vertebra closed the opening, and prevented the effusion of fluids into the cavity of the chest. Baillie observes that it is Avorthy7 of remark that these ul- cers happen almost ahvays immediately beloAV the pharynx, or near the cardiac orifice of the stomach. Bonnet and Portal have also met with ulcers in the oeso- phagus, and the latter author reports that the inflammation may be so high as to be folloAved by suppuration and gan- grene. 6. Stomach.—The external surface of this organ scarcely eA'er presents signs of lesion ; and if Ave were to judge from appearances, Ave would suppose it to be perfectly healthy ; sometimes gases or fluids distend it, and in other cases, it is strongly contracted. It hoAvever happens, also, that it presents a red color, more or less marked; if the membranes be separated, Ave sec that it belongs almost con- stantly to the peritoneum, and that the inflammation has not been transmitted by the mucous membrane. The shades of inflammation which the mucous membrane may present, are extremely7 various, from faint spots occu- pying only very limited portions, up to the most violent in- flammation, not leaving untouched any partiof the internal membrane. In the lighter shades, the mucous membrane seems some- times to be doited Avith red, or there are ordinarily spots of a bright red, one or several lines in extent, formed sometimes by blood extravasated in the mucous tissue itself. These tra- ces of light inflammation are not often perceived at the first glance ; it is necessary to scrape off the mucus Avhich al- most always covers them ; we discover then easily the phlo- gosis Ave speak of. If the inflammation be more marked, the mucous mem- brane is affected to a greater extent: the red color is often uniform, and it is principally towards the cardia or pylorus that it is seen; a red circle, plainly formed, surrounds one or the other of these openings. In some cases, the redness seems to follow the direction of the sanguine vessels. The inflammation may be suffi- ciently violent to attack the whole mucous surface ; the co- [ 254 3 lor is of a red more or less deep, sometimes of a bright scar- let, or having an obscure tinge, almost brown ; often wc see the redness become gradually brown, and thus pass through all the degrees of color ; at other times the red and brown spots are intermixed, &c. All these shades are so variable, so multiplied, that Avoids would never suffice to represent them. Under some circumstances, when the inflammation of the , stomach is very acute, we observe a submucous emphyse- ma, a rare and very remarkable phenomenon. The mem- brane is elevated, and forms unequal eminences, of several lines in height; if it be pressed on one point, the air passes into the neighboring cells, and distends other parts; if Ave incise one portion of the mucous membrane, Ave see the air distend the cells of the tissue, often Avithout being able to escape. Perhaps some might Avish to attribute this extrication of gas to putrefaction, but this Avould not be correct. I have met this alteration three times, and in one case the body was opened six hours after death : moreover, all the tissues w re in good condition, and nothing announced a beginning of decomposition. In order to leave no doubt on this sub- ject, I have putrefied stomachs, md have never observed similar phenomena. I think, from this, it may7 be asserted that this emphysema is one of the extremely varied products of irritation, which has determined the cellular tissue to secrete gas. Prost reports a case bearing great analogy to the fact just cited, but there are neither details nor reflexions on this subject. A violent inflammation of the mucous membrane may sometimes produce gangrene ; authors report several in- stances of this kind ; I have never met with it. Ulcers of the stomach are A7ery rare in acute inflamma- tion ; there are merely slight erosions, scarcely abrading the mucous membrane ; I have never found any extending to the muscular coat. The follicles of the mucous membrane may be subject to severe inflammation ; in this case they become developed, presenting the aspect of small pimples resembling an erup- tion. Prost has seen them sometimes ; Roederer and Wag- ler have met them frequently ; I have also seen them, but rarely. I will return to the explanation of their develop- [ too ] ment Avhen 1 speak of the large intestine, where 1 have Ire quently observed them. If the stomach be found contracted in this state of inflam mation, the rugae of the mucous membrane are ordinarily strongly marked, and it is generally on these that the phlo- gosis is most marked. If they be unfolded, the vessels are extended, the mass of blood is diminished, and the red co- lor becomes more obscure ; but Ave can never make it dis- appear entirely, as has been asserted ; Avhich arises from this circumstance, that a certain quantity of blood, attracted by irritation, is identified Avith the tissues, and cannot then floAV back again into the vessels. 7. Small intestines.—Viewed externally, these organs seem almost constantly healthy on opening bodies. Often some portions are pale and dilated Avith gas; if Ave raise them up, Ave find below them portions contracted, lying in the pelvis, shoAving sometimes manifest inflammation, but not unfrequently also presenting no trace of redness. The explanation of these peculiarities seems to me suffi- ciently easy ; the inflamed portions are contracted ; the ga- ses not finding room there any longer, pass into the healthy- portions ; the latter suffer themselves to be dilated; thus puffed up, they are forced to extricate themselves "and to place themselves on the superficies. To account for this phenomenon, avc have said until the present, that the portions of the mesentery appertaining to the diseased intestine, contracted and retired behind those which are healthy; but nothing proves the contraction of the mesentery, which, if it took place, Avould retract the intestines against the vertibral column, whereas they fall in- to the pelvis. Sometimes, it is true, Ave find them retired towards the spinal column ; but the contraction of the me- sentery is still illusory ; indeed it is the ganglions, which by swelling, separate the two lamina of the peritoneal fold, and thus draw the intestine near the posterior Avail of the ab- domen. The mucous membrane of the intestines presents a fact very important to be remarked, viz.: the interruption of the phlogosis, which, after having existed in one space of greater or less extent, sometimes disappears all at once, to reappear a little distance off; this circumstance has imposed on many practitioners, and even on distinguished anatomists. They Avere pretty generally persuaded that, Avhen the in- [ tot j tlammation exists in these parts, it must extend from one extremity of the intestine to the other ; but this was an error ; the mucous membrane is like, the skin ; a very cir- cumscribed point may be highly inflamed, and the rest en- tirely untouched. The different parts of the intestine are more or less sus- ceptible of inflammation ; the superior portion is often healthy, Avhilst the lower presents dreadful disorders ; ne- vertheless all the intestinal tube may be inflamed ; but this is rarely met with in the acute state. If the inflammation be of alow degree, Ave often find the valvules conniventes phlogosed, Avhilst the intervals separa- ting them, are untouched. When the inflammation is of a higher grade, Ave find patches of greater or less, intensi- ty of color, and extent. Mucosities of very different na- tures cover it ordinarily ; as they adhere with great force it is necessary to remove them Avith the scalpel or to wash the intestine in order to appreciate correctly its red- ness ; Ave then see the sanguine vessels engorged with blood, and according to their fullness, display a strong or obscure red, so that we can almost at pleasure produce these varie- ties in color; I have done this very frequently, and it has demonstrated to me that these different shades are attribu- table only to the greater or less quantity of blood attracted by irritation. Another Arery remarkable fact is, the isolation of each of the coats of the intestines; they have a peculiar life Avhich seems to protect them and to prevent, in the greater number of cases, the irritation of one from being communicated to another. Thus, Avhen even the mucous membrane presents a very violent inflammation, (without hoAvever, ulcer or other disorganization,) Ave may separate it from the muscu- lar coat Avithout much difficulty, and be satisfied that the latter is not at all altered. It is the same with serous mem- branes. Moreover, it sometimes happens that the perito- neum becomes suddenly inflamed, produces a real revulsion, and displaces the inflammation which existed in the mucous membrane ; and Ave discover that the latter has been inflam- ed by traces more permanent than redness. The violence of the inflammation may determine gangrene. but this is more rare than is supposed. They often corn- found a black degeneration of the mucous membrane Avith true gangrene : when the latter exists, it may confine itself i -lOi j io the internal membrane, or attack the whole thickness oi the intestine. In all these cases, the parts are black, very soft and friable, separate with the greatest facility ; and if all the coats are gangrenous, the finger may be passed through vvithout meeting any marked resistance. Ulcers of the small intestines are very common in the acute stage ; they do not appear generally before we have descended the canal as far as the ileon ; they augment gra- dually in proportion as we advance towards the ileo-ccecal valve, and are sometimes so numerous in this part that all the mucous membrane is destroyed. The number, extent, position, figure, and depth of each one of these ulcers, A7ary singularly : sometimes only a line or tAvo in extent, they scarcely abrade the mucous mem- brane ; in other cases they extend deeply, destroy the mus- cular and serous coats, and give place to a perforation al- loAving the contents of the intestines to flow into the cavity of the peritoneum. The forms of the ulcers are singularly varied : ordinarily round or elliptic, some hoAvever, are found triangular or quadrangular. Their edges are perpendicular, and they seem to have been formed by a cutting instrument; at other times they are uneaAren, granulated, very thick and irregu^ lar. The bottom is often covered Avith a very tenacious mucous; sometimes they resemble an ulcer of the skim the bottom of Avhich is of a deep red. It is not uncommon also to see the muscular coat entirely bare ; its fibres are very distinct, and look as if they had been carefully dis- sected. The parts surrounding the ulcer are ordinarily highly inflamed ; it however happens sometimes that this does not exist, and even that the borders of the ulcer are alto- "■ether pale. The reason of this circumstance generally is this, that a high degree of inflammation being developed, a short time before death, in the peritonium or in a portion of the mucous membrane, more or less removed from the affected part, has produced a revulsion and destroyed Ac It is very important to know these facts, lest Ave should think that the ulcerations may form Avithout inflammation, and also lest we should pass too lightly over the colorless portions of the intestines, and say, as I have often heard said, that then1 is nothing, because no redncs is perceived. [ 258 ] (Jicatrices of Ulcers.—After having existed during a cer- tain time, ulcers tend to cicatrization, and it is not uncom- mon to meet with them perfectly cured. Researches sufficiently repeated have enabled me to dis- cover the march, nature folknvs in this cure ; I must trace it Avith some detail, because every day I see persons con- found different alterations of the intestine with true cica- trices. When the ulcer is small, only7 four or five lines in extent, the edges at first sink doAvn, if they are thick and unequal; then they contract, approach each other, and at length touch; then they became united, and some time after, there remains only a little eminence, finally disappearing. If the size of the ulcer do not permit the edges to touch, then about one of its points, ordinarily near the centre, a thin, whitish or rose colored pellicle forms, extending in every direction and uniting the opposite parts. If the ulcer be one or more inches in extent, the edges are not lowered Avhen the cicatrization has already com- menced ; as soon as one point is healed, others do not re- main stationary; soon they extend themselves, unite togeth- er and form a very thin pellicle, which seems to approximate the borders of the ulcer; the portion of the membrane surrounding it becomes Avrinkled, sometimes in radii, and forms thus a A7ery striking resemblance to a rose. The cicatrix thus formed remains for a long time more depressed than the surrounding mucous membrane ; but it finally ex- tends and the intestine resumes its capacity. Once, hoAvever, I found the ileon so constricted by an ancient cicatrix, that a large Ayriting quill could scarcely pass through it. The cicatrices are smooth, whitish, or rose colored, pre- senting no black point, as some persons have improperly thought. After ulcers avc should speak of a condition entirely op- posite of the mucous membrane, which consists, in a very marked thickening, presenting itself in patches of a pretty regular form. Already M. Petit, physician of the Hotel- Dieu, and several other persons, have fixed their attention onthis-sort of alteration. It is met Avith frequently ; avc proceed to give the march of its developement. When these thickenings begin to form, the mucous membrane is seen to ai range itself into folds more or loss marked, having a honey- L 25!) j comb appearance ; soon these folds augment, join together, and form a spot of one, tAvo or three lines in thickness, ele- vating itself above the plane of the mucous membrane.— The size of these excrescences ordinarily is from a few lines to several inches in extent; like ulcers, we find them more abundant towards the ileo-coecal valve than any other part; they are generally, untouched—I have however found some of them commencing to be corroded by an ulcer ; but this is not common. If we separate the muscular from the mucous membrane, we easily perceive that it is the tissue of the latter Avhich is thus swoln and disorganized ; Avhen Ave cut into these SAvellings, Ave find a reddish, greyish, or whitish tissue, of considerable tenacity. If Ave macerate for a few days a portion of the intestine presenting this appearance, Ave see developed, a great number of little openings which appear to be those of the follicles closed by the swelling. The intestines of young persons have more frequently presented to me this alteration than those of persons advan- ced in life. I have for a long time remarked, that we hardly ever find alterations in the other portions of the membrane, when these swellings existed. The follicles of the mucous membrane may be affected n two ways; in the first case, they swell, form a great number of little pimples, elevated aboA7e the mucous mem- brane ; at first hard and fleshy, they finally become soft, and sometimes contain pus ; often their centre appears de- pressed—this is attributable to the opening of the follicle. In the second case, the follicles are not savoIu ; their ex- tremities alone are apparent; they are often seen under the form of very numerous small points, forming brown circum- scribed spots, of various shapes, but most frequently elliptic, being sometimes of one or several inches in extent. The valvulse existing in this part are almost constantly de- stroyed, Avithout presenting the least trace of ulceration ; they disappear however as soon as the thickening ceases to exist. If we place the intestine before the light, we dis- cover that it is manifestly more opaque in this part than in . that surrounding it. Invaginations are very frequent during acute inflammation of the intestine ; they may take place in two ways ; the su- perior end introduces itself into the inferior, or the latter penetrates into the superior. The latter case is most rare ; I have only met Avith it three or four times. 2bO "j f'he iirst and middle portions of the small intestine aie more subject to volvulus than those nearer the ileo-coecal valve. Those persons who have advanced the contrary, doubt- less had not made a sufficient number of post mortem exa- minations, and were led to this conclusion from a few parti- cular facts. Invaginated parts, frequently present traces of inflamma- tion ; they are not however constant, and it even is not very rare to find them more pale than the healthy parts, which seems attributable to the compression produced by the con- stricting portion ; the latter more frequently presents traces of inflammation which is due to the irritation produced by the invaginated intestine. The length ofthe volvulus varies singularly ; sometimes it is hardly five or six lines ; in other cases it is several inches and even several feet. There exists some astonishing in- stances of this disease ; almost the Avhole of the small intes- tine has been seen contained in the large intestine. The formation of A7olvulus is quite simple ; one portion of the intestine contracts circularly; the neighboring part re- mains relaxed, or is distended Avith gas ; vermicular motion comes on, and pushes the contracted into the relaxed por- tion. This is not a hypothetical theory—it is the explanation of facts; Ave may constantly observe and be convinced of the reality of Avhat I have just advanced ; moreover, it is not rare to meet Avith cases where the invagination being on the point of taking place, Ave may by pushing the con- tracted intestine, terminate Avhat nature did not have time to finish. Gangrene may sometimes supervene on volvulus ; it is the result of violent inflammation. In this case the tAvo extremities of the intestine may unite; the detached portion be discharged by the anus and the patient recover. Several physicians have reported cases of this kind. 8. Large intestine.—Acute inflammation of the large in- testine is very frequent. The ileo-colic valve, the ccecum, and the superior portion ofthe colon are very often affected : the inferior part may be so likewise ; this is observed espe- cially Avhen certain causes have produced a great number of dysenteries. On the exterior, these intestines appear almost always perfectly healthy; they are contracted, if the inflammation be j 2G1 recent; but if it exist for ten or twelve days, the intestine is frequently distended Avith gas or faecal matter. Several intestines have been found, where a portion ofthe colon Avas sunken and dried in an astonishing manner ; one would have thought on beholding them, that he looked on a piece of yellowish parchment. Prost has met with this alteration ; I have seen it once only. I have found no exam- ple of it in the authors cited. The large intestine does not partake in all the divers modes of alteration Ave have observed in the small intestine; and it is very remarkable that tAvo portions of a membrane, which is evidently continuous and apparently the same, should enjoy a vitality seemingly so different. The ileo-coecal valve and large intestine often display a phlogosis very marked, discoverable by very numerous red points, by striae, or by spots more or less extended. The inflammation may become sufficiently violent to pro- duce ulcers, and the ileo-coecal valve frequently presents traces of profound alteration. The inflammation sometimes extends as far as the anus. I have never found on this mucous membrane those cir- cumscribed thickenings Ave meet so frequently in the small intestines. I have never met Avith invagination in the large intestine ; they are not, however, impossible ; M. Portal cites an ex- ample of this kind. This part of the intestine has never displayed to me em- physema beneath the mucous membrane, nor broAvn patches covered Avith follicles developed under the form of small black points placed beloAv the level of the mucous mem- brane ; but Ave meet not unfrequently a development of follicles near the ileo-coecal valve ; they diminish in propor- tion as they are remote from it; they form small isolated red elevations. Such are the grades of alteration ofthe large intestine in the acute state ; we see that they are much less numerous than in the small intestine—it seems that in the latter the functions being more multiplied, the disorders there on this account are more various ; in the former, on the contrary, the simplicity of the function seems to give rise to less nu- merous modifications in organic lesions. M. Scosutetten passes then to the description of lesions produced in the digestive canal by chronic inflammation, that [ 1'62 j is to say, oi alterations observed as consequences of dys- pepsia, cardialgia, hectic fever, &c.: he exposes them like the preceding one, according to anatomical order. 1. Buccal cavity.—When the stomach and intestines are irritated in a chronic manner, the buccal cavity rarely par- takes ofthe affection of these organs : neither after death do we find any appreciable alteration. 2. The pharynx sometimes shows ulcers more or less ex- tended in breadth and depth ; their characters are in gene- ral the same as those of ulcers met in the acute state; Ave Avill not then pause on these. 3. The oesophagus is almost constantly untouched ; nev- ertheless, serious alterations may be developed there.— Thus, besides ulceis, anatomists have found its vessels va- ricose, its cavity diminished and singularly narrowed by- thickening of the mucous membrane, and by cartilaginous concretions. Morgagni speaks of a dissection made in Germany of the body of a great prince, whose oesophagus Avas cartilaginous on the exterior, and even osseous towards the stomach for the extent of an inch. Scirrhus degeneration has sometimes been met Avith; most authors of treatises on pathological anatomy report in- stances of this kind. We find on this subject a very curious case reported in the inaugural dissertation of Gust. Kunze, published in Germany7: an ulcer having formed on the scirrhus membrane of the oesophagus, produced a commu- nication between the latter and a vomica of the left lung. I. Stomach.—One of the most frequent alterations Ave meet in dead bodies, is chronic irritation of the stomach.— The characters which make it knoAvn are not always easy to catch ; Ave should then attempt to describe them well, be- cause, though very important, they are often neglected and still more often misunderstood. On the exterior, the stomach often appears entirely healthy, sometimes contracted in its whole extent, at other times only at intervals ; it seems then to form two or three distinct pouches. This circumstance appears to have imposed on several observers, and has made them assert that they had found two or three stomachs in the same individual. Gases or fluids may distend it, and the splenic extremity of the stomach presents its sanguine vessels very distinct, dilated and as if varicose. This part of the organ is very often thinner than ordinary, friable, and gives Avay Avith the great- [ 2G3 ] est facility : we meet also, in some cases, a complete perfo- ration. On the interior, Ave observe the most varied shades of disorganization. One ofthe most frequent is attenuation of the bas-fond of this organ. When it exists, the mucous membrane is of various colors from, a dull Avhite or grey, to a red Avine lee. When it is scratched with the end of the finger, it is easily removed under the form of a pulp; at other times it is eroded, presenting in the course of the sanguine vessels almost bare, furroAvs of half a line or a line in Avidth. When the the blood fills these vessels, they have a bluish color ; if they are empty, their color is broAvn ; Avhen they are in great number, they form patches, broAvn or violet, and sometimes black, or rather they are beautiful netAvork. The alteration may be more profound, the mus- cular and mucous membranes be.destroyed, and the serous membrane remain bare. If the alteration be still greater, perforation supervenes : the opening is generally irregular ; the edges are fringed, and often contract adhesions Avith the neighboring parts. It is very remarkable, that often it i,s impossible to say positively Avhere the mucous membrane ceases to exist. In proportion as w7e leave the bas-fond of the stomach, this membrane reappears, becomes thicker, red, and frequently presents other degenerations. This kind of disorganization has received different names ; it has been called ramollissement, spontaneous perforations, gelatinous disorganizations, &c. All these expressions have this defect, that they tend to make this kind of alteration a particular disease, requiring causes, a course and treatment proper to it. Here, as in other disorganizations, it is necessary to look at the irritation and not its effects. Instead of attenuation or perforation, the stomach maybe very much thickened, its mucous membrane display a uni- form red color, as deep as scarlet. On the first glace, one might think it acute inflammation ; but if Ave examine Avith some attention, we see the Aessels distended, varicose, an- nouncing a chronic irritation ; and if Ave wish to be persuaded of it, it is necessary to macerate this organ for several days. The redness disappears, if the inflammation be acute ; if, on the contrary, it be chronic, the color will continue, and will even take on sometimes greater intensify. This circum- [ 264 ] stance is attributable to this, that in the former case, the blood not being identified Avith the tissues, separates from them easily, Avhilst in the second, the vitiated nutrition,Avhich has been going on for a long time under the influence of chronic inflammation, has combined it so intimately with the tissues, that it cannot escape from them. If ulcers ofthe stomach are very rare, as a consequence of acute inflammation, they are very frequent, on the con- trary, after chronic inflammation. I have met with them particularly about the cardia and pylorus. Their depth may be sufficient to destroy all the coats of this viscus. In a similar case, Lieutaud has seen the colon, applied against the stomach, receive into its cavity, by means of an ulcer formed in this part, the contents which otherwise would ha\re been discharged into the abdomen. Scirrhus disorganizations are very frequent in the stomach; there is no anatomo-pathologist who has not met Avith cases of this kind ; but a remarkable fact Avhich has struck me, is that they are almost always developed at the two extremities of the stomach, Avhilst the attenuation we have spoken of, is only seen in the bas-fond. When one portion ofthe stomach becomes scirrhous, the mucous membrane reddens and thickens; the Aessels are swollen and become varicose ; the muscular coat soon par- takes of the irritation ; the tumour becomes more developed and sometimes the Avhole stomach takes on this disorganiza- tion ; the openings ofthe pylorus or cardia are narrowed and sometimes entirely obliterated. An ulcer may be devel- oped on the surface of the tumour ; its aspect is ordinarily greyish, uneven, covered Avith a very fetid, sanies, or it re- sembles a blistered surface. If Ave incise this tumor, Ave remark very varied disorgan- izations ; grey, black, Avhite, red, &c. are mixed in divers manners ; or one of these shades exists alone, and consti- tutes Avhat authors have called melanosis, encephaloid, &c. We also meet parts Avhich have become cartilaginous or even osseous. Vegetations more or less voluminous are sometimes de- veloped in the stomach; they form genuine polypi Avith narrow pedicles. Morgagni reports that Paulina found tAvo in the same stomach ; one was of the size of a small apple, the other that of a large filbert. Morgagni seems never to have met this kind of alteration ; I haA'e met it once only, [ 20'5 j and this was in the ileon. The tumor was of the size of a llbert; it was hard, of a red color, enveloped completely by the mucous membrane, Avhich had preserved its thick- ness. The mucous membrane of the stomach is seen of a blu- ish slate color, more or less deep, sometimes partial, but of- tener general; it indicates a chronic state kept up by an ir- ritation of low degree. There is still a degeneration important to be known, be- cause it imposes on those Avho observe too superficially ; it is a black color of the mucous membrane, as deep some- times as that of charcoal, which causes it often to be mista- ken for gangrene of the stomach. This color does not come on suddenly ; it, on the contrary, takes a good deal of time to form. The villous coat commences by presenting very numerous small obscure points, leaving betAveen them greyish or reddish spaces ; these points becoming more nu- merous, touch, become blended and form small black spots ; these unite into others, and the mucous membrane, from its former red, presents only one large black surface. In this state, the membrane is not friable ; we may detaeh it from the muscular coat, and discover that its external surface is not altered. We become still farther convinced by scraping it Avith a scalpel; the surface is taken off and the rest of the membrane sIioavs its ordinary color. If we macerate this membrane for some days, the pigmentum is much less deep colored and the least rubbing removes it Avith facility. These researches lead me to think that this black color is only a vitiated nutrition of the internal surface of the mucous membrane. I have also seen on this mucous membrane a very remarkable green color ; but it Avas only- partial, and always surrounded by a red color, or mixed with it. 5. Small intestines.—Their exterior aspect varies singu- larly : sometimes altogether pale, distended by gas, attenu- ated and friable in certain parts; at other times strongly contracted, and so narrowed that their cavity scarcely cxists. Frequently we find in several parts of the intestine, red or brown spots, which declare internal alteration. They arc often surrounded by white tuberculous points ranged 'itcularly, appearing to be formed under the peritoneum : a 2 [ 266 ] they announce positively the existence of a deep seated ul- cer, ready to pierce all the coats. The alterations of the mucous membrane of the intes- tines have the greatest analogy with those of the stomach. It is worthy of remark that in the chronic state, the disor- ders are almost always more marked in the superior or mid- dle part of the intestine than in the inferior. We observe the opposite in the acute state; but often persons alloAv themselves to be imposed on in this case, because there is a mixture of acute and chronic inflammation. Indeed, Ave then find near the ileo-colic valve, considerable disorders. In the chronic state, ulcers are very frequent in the duo- denum and jejunum. They are also -found in the rest of the small intestine ; but they are not so numerous near the ilio-coecal valve. Their characters are the same as in the acute state ; in general, hoAvever, they are more extended and deeper. A particular degeneration of the intestine is very fre- quently met with; the natural whitish or rosy color is changed into a slate color more or less deep. Often this state is regarded as entirely exempt from alteration ; but we are persuaded of the contrary, Avhen numerous post mortem examinations have permitted us to examine the march it pursues. The intestine, at first red, looses by de- grees this color; its coats take on ordinarily more consist- ence ; the bluish color becomes manifested ; it is uniform, and never passes to deep black. If the tissues of the intes- tine are macerated, the discoloration is never complete. The small intestines are sometimes inflamed from one ex- tremity to the other; they present in certain cases a very- singular fleshy aspect: the valves are thick, straight and ap- plied against each other like the leaves of certain agaric plants ; the borders are uneven, pften denticulated, rugous, and break short on the least effort. In this case, all the membranes are intimately united and confounded, and pro- longed maceration does not enable us to separate them dis- tinctly. Scirrhous degeneration is seldom observed but about the ileo-coecal valve; the other parts of the small intestine present this appearance rarely; I have never seen it in the numerous post mortem examinations I have made. Bailhe has'twice met with ossification of the intestinal mucous membrane. L ~«0 < j 6. Large intestines.—Like the small intestine they are either dilated or contracted ; sometimes their capacity is enormous ; their coats may be separated by serosity or by an infiltration of blood forming ecchymoses here and there. The surface of the mucous membrane presents a great number of alterations; they are in general very violent about the ileo-coecal valve. In this part, scirrhi and all kinds of deep rooted degenerations are seen. The inferior part of the rectum presents the same alterations ; we see besides, in the latter, a peculiar development of vessels forming eminences more or less voluminous, called hemor- rhoids ; sometimes a varicose vessel is torn ; the blood in- filtrates into the surrounding cellular substance and forms a small tumor called condylomatous (marisque,) by some per- sons. The internal aspect of these tumors is ordinarily red or violet; a considerable quastity of blood escapes when they are incised ; these tumors frequently undergo the dis- organization called scirrhous. The follicles of the mucous membrane of the large intes- tine frequently participate in its inflammation ; Ave will oc- cupy ourselves with this subject for a moment, because ma- ny gross errors have been committed with regard- to it, which may have an unhappy influence. When the follicles are irritated, they at first appear un- der the form of a small black point, ordinarily surrrounded by a very visible areola. The point becomes more devel- oped, thickens, and the areola disappears; the little risin«\ about the size then of the head of a pin, is thick, fleshy and whitish or reddish ; Ave perceive no pore on its summit; but the fluids continuing to be secreted in the interior of the follicle, distend ii, finally open the pore and flows over the mucous membrane. The parietes forming the swelling, sink doAvn, become depressed, and present an opening in the centre. When the degeneration continues, the little swellings become white ; their base is ordinarily7 surround- ed by a red circle ; an opaque pus, well formed, comes from the extremity Avhere it is compressed ; in this state they re- semble someAvhat the pustules of small pox, and some per- sons little attentive, have even improperly regarded them as such. Sometimes several pustules unite together, and form a small abscess, which as I have twice seen, may contain a thimble full of pus. The mucous membrane of the large intestine, experien- L to* ] eino-a high inflammation, may communicate it to the subja- cent cellular tissue ; suppuration taking place in the latter, detaches this membrane in fragments, Avhich sometimes hold on for a long time by a kind of pedicle, and at other times they are entirely detached, and fall into the cavity of the intestine. When I met this fact, I observed on a pretty large piece of the mucous membrane floating in the intestine, and re- tained only by a very narrow pedicle, ulcers of several lines placed on the external surface, Avhich corresponds to the muscular coat. These cases aie rare, and Morgagni is not sure of having seen them ; he only thinks that they may- happen. We find also in the large intestine, black spots, isolated, which seem to appertain to all the coats ; I have only met with them tAvice ; I do not understand Avell their formation. The ulcers of the large intestines are sometimes very wide and deep ; they offer few other remarkable peculiar- ities. The black color of the mucous membrane has also been observed in the large intestine, but more rarely. The various alterations we have just described, belong- ing to the acute and the chronic state, are separated by very- marked characters, which it seems to me impossible to mis- take : but it is not unfrequent to meet these two forms uni- ted together, and if Ave may use the expression, combined, forming an intermediate state called sub-acute. This cir- cumstance is sufficiently easy to recognize, since the red- ness denotes the acth'ity of the inflammation, and the ex- tent of the disorganizations prove that they have already existed for some time. Another very important circumstance, and one Avhich it is very important to knoAV, is the sudden development of an acute, on a chronic inflammation. In this case the traces of a high degree of inflammation are displayed in cer- tain points, and in others we find signs of an old irritation. We cannot here unite these various characters ; the memo- ry may easily supply this defect, and a little habit will ena- ble one to recognize promptly their existence. The aspect of the fluids contained in the digestive canal is extremely variable ; their color is yellow, white, black and green ; sometimes it is pus, bile, or pure blood. Fluids are in greater or less quantity in the intestinal ca- 269 ] nal; sometimes they distend it powerfully ; in other cuses. they only form a thin layer, covering the mucous membrane. It very rarely happens that the fluids present the same as- pect, throughout the whole extent of the digestive cavity-; they are often yellow or green, in the stomach or duode- num, and white or red in the other parts. When the blood is poured out, it only presents in the greater number of cases, apartial oozing in small quantity; at other times it fills and distends the digestive tube. I once found the stomach, large and small intestines full; an enor- mous clot was in the stomach ; its color was an obscure red. In the small intestines, the color Avas very near the same but a little deeper; in the large intestines the blood Avas decomposed, of a tarry consistence, and its color completely black. The stomach.and intestines, freed from this blood, had a uniform red color, not removeable by Avashing ; the large intestine was entirely Avhite ; the exhalation only pro- ceeded from the superior part of the digestive canal. A phenomenon Avorthy of attention is that the fluids are almost ahvays found in abundance on the inflamed parts, to Avhich they stongly adhere, whilst the healthy parts are de- prived of them. Prost and Broussais have very closelv observed this fact, but they have given a different explana- tion of it. Prost says that the parts are inflamed, because the mucus being too abundant, becomes altered, and con- tracts stimulating properties, producing inflammation of the mucous membrane. Broussais, on the contrary, thinks, that the inflammation commences, then that the fluids, though free, are attracted by- the phlogosis towards the diseased parts. The latter opinion alone, appears to me admissible, unless Ave should wish to relapse into humoralism, from AA7hich avc have had so much difficulty in extricating ourselves. Is it not necessary, in fact, in order for the fluids to be more abundant in the intestinal canal, that some cause attract them there ? Now the cause can only be an excess of life in the parts—a morbid irritation. This proves alsojithat the fluids do not produce the first inflammation, and that it is bv curing the latter this abundance of fluids is stopped. The presence then of the fluids is only a secondary effect; thev may also be absent and the inflammation notwithstanding exist. The different fluids found in the digestive canal may dry [ 210 J sip and form false membranes; these are very common on the oesophagus, where they have the form of a very thin white pellicle, sometimes denticulated on its borders. In the intestines they may be sufficiently extended to form a complete circle, and resemble very closely the parts on Avhich they are moulded. This last circumstance has often imposed on practitioners, and has made them think that the patients had discharged a portion of the intestine Avhen in fact they had only discharged a false membrane. After having described the alterations produced in the digestive passages by the different grades of inflammation of their mucous membrane, M. Scoutetten examines the le- sions syrmpathetically produced in other organs by gastro- enteritis. The liver is almost constantly affected in this disease, es- pecially in hot countries. Acute inflammation is known by the volume and change of color Avhich this organ undergoes ; under the influence of inflammation of the digestive canal ;tlone, a phlegmon is rarely formed. When the latter has been irritated in a chronic manner, we almost ahvays find the liver altered. The most common change is a yellowish color intermixed Avith small red points; the Avhole organ participates in this change, or a part only. When this alteration is to a great degree, the name of adi- pose liver has been given to it. Numerous observations have convinced M. Scoutetten that this alteration Avas not produced by chronic duodenitis alone, but that inflammation of all parts of the small intestine may produce it. It is not rare to see the liver tuberculous and even cancerous. The gall bladder is rarely inflamed ; Ave, however, find it in some cases of a more or less deep red. When the ir- ritation is chronic, Ave sometimes see it entirely black; its mucous membrane may also ulcerate, and give rise to a mortal perforation. The color of the bile presents many varieties ; sometimes yellow, green or blue, Ave find it also black or entirely colorless like water. The ductus choledochus may present inflammation, but this is far from being constant. We cannot then attribute irritation of the liver to the continuity of the mucous mem- branes of the duodenum and of the duct. The spleen very frequently presents alterations, but they are by no means constant. Thus, after a very acute in- flammation of the digestive canal, the spleen avi'11 scarcely [ 271 ] present any change ; in other cases on the contrary, the in- testines will be slightly inflamed, and the spleen greatly- altered. The pancreas is not often affected; it is however, some- times found gorged Math blood, very hard and grating, un- der the scalpel—at other times it is very white and much softened. After chronic gastro-enteritis, M. Scoutetten has found it larger than the fist, shoAving scirrhous disorganiza- tion in several parts. The brain rarely presents traces of inflammation after gastro-enteritis, but this is not the case Avith its envelopes, or at least Avith the meninges.* M. Scoutetten had already announced in his thesis, the relation existing between the irritation of these membranes and that of the mucous mem- brane of the intestinal canal; but he has proved this propo- sition by facts, in a paper inserted in the journal universel des sciences medicates. He asserts from the examinations of a great number of bodies, that there exists a connexion so strict between the digestive passages and the meninges, that when the first are irritated in an acute or chronic man- ner the membrane of the brain participates always in the same shades of irritation. This sympathy does not exist equally between the me- ninges and the different parts of the intestinal canal. The stomach, and especially the small intestines appear to have Avith these, relations much more strict than the large intes tine. After acute inflammation ofthe digestive canal, the vessels of the meninges are injected, they form red patches on se- veral points of its superior face ; sometimes we see san- guine exudations more or less abundant. If the inflamma- tion of the intestinal canal have been violent, almost all the membranes are of a very deep red color, dry and shining.— Sometimes there forms beneath the arachnoid an albumin- ous exudation, exactly resembling pus. When the inflam- mation has been high, adhesions often form between the two hemispheres of the brain, and it is not without difficulty they can be separated. The prolongations of the archnoid penetrating between the convolutions of the brain, are very red and highly injected ; they adhere ordinarily with a great deal of force. * By meninges here is meant only the pia mater and arachnoid, a name given*to them by Chaussier. [ 272 ] After chronic gastro-enteritis, Ave find the meninges slightly opaque ; there is some serosity infiltrated into the meshes of the cellular tissue, its thickness seems singularly augmented, and it then assumes a gelatinous aspect. Some- times there is an effusion of serum into the A'entricles suffi- cient to compress this organ against the osseous parietes, and to prevent infiltration into the meshes of the meninges ; the latter then appear dry, but they are always thick and opaque. When the digestive mucous membrane presents traces of chronic inflammation, which has passed into the acute state, Ave find in the meninges corresponding lesions. In the acute state, these different alterations have their seat at the superior part of these membranes, on the ante- rior lobes of the brain principally. In the chronic state, it is especially about the great fissure that these alterations are seen ; the parts corresponding Avith the parietal and occi- pital fossae are those which display most frequently gelatin- ous infiltration. M. Scoutetten remarks that the inferior part of the men- inges scarcely ever present traces of irritation ; so that, in cases where there are doubts on the state of this membrane it Avill be sufficient to compare together its superior portion and that covering the inferior face of the brain, to recog- nize the slightest alterations of the first. CHAPTER IV. Relation of gastro-enteritis avith the essential, (idiopathic,) fevers of authors. We have said, with M. Broussais, that essential fevers of authors were referable to gastro-enteritis, simple or compli- cated ; and, in the examination we have made of the diffe- rent forms of this inflammation, we have shown that it Avas on the differences they present, that the division of fevers had been established. Notwithstanding its proofs, this part of the neAv medical doctrine has given rise to more contre [ *™ ] versy than any other, and has met more obstacles ; so many are the difficulties in overturning a doctrine, however er- roneous it may be, when it has received the sanction of time and of many celebrated men. All arguments have been ex- hausted by the advocates of the essentiality of fevers, and all have yielded to the victorious proofs of physiological medicine. At present, the question is decided amongst all enlightened and candid men: those Avho still deny the evi- dence, either have not studied this doctrine with sufficient care, or are actuated by motives which it Avould be painful to qualify. We Avillnot call up again the discussion this matter has excited ; it would be at the present day superfluous and fas- tidious. We will content oursehes with presenting a rapid recapitulation of it. Those who may desire to be acquaint- ed Avith the details of this controversy, will find them in the Examen of M. Broussais, in the Memoires of Ducamp and of M. Roche, in the Pyretologie of Boisseau, and in a great number of excellent theses sustained by the pupils of the professor of the Val-de-Grace, on the nature of fevers. We have already seen farther back, that intense irritations of allthe organs Avere constantly transmitted at their com- mencement, to the brain, stomach, and heart, and that, the Avhole of the phenomena produced by the irritation of these three organs, taken together, constituted the febrile state, Avhich, after some time of duration, may be kept up by that of the heart alone, Avhen the brain and stomach have re- turned to their normal state. These are the fevers authors have called symptomatic, Avhen ever they have knoAvn the organ whose inflammation excites the febrile phenomena. It is difficult to conceive Iioav they could admit at the same time the existence of fe- vers produced by a local lesion, and fevers dependant on a general affection of the economy, having no particular seat. The knowledge of the true nature of the former, ought to have conducted them to that of the latter, by leading them to the conclusion that there existed also other inflammations which they did not know, and the symptoms of which arc precisely those of their essential fevers. An examination of the causes, phenomena, post mortem appearances, of the different modes of treating these affections, will prove to us that they are only groups of symptoms produced by inflaim mation of the ea< tro-intestinal mucous membrane. i 2 [ toil ] i. All the agents Avhich develope essential fevers, irritate directly or sympathetically the digestive passages, because all intense stimulations, affect finally their mucous mem- brane. 2. The debilitating causes ranked amongst those of fevers act also by irritating the stomach and intestines. 3. Stimulating agents never act at once on the Avhole economy, and there exists neither general stimulation, nor debilitation, as we have established at the commencement of this work. 4. All irritations are primitively circumscribed; it is only secondarily that disturbances are manifested in the action of a greater number of organs. 5. The greater part ofthe symptoms of essential fevers are those of all the phlegmasia?. 6. Anorexia, disgust for food, alteration of the lingual mucus, redness of the point and borders of the tongue, are the premonitory symptoms of all essential fevers ; the symp- toms of gastric irritation are first brought into view ; their intensity augments progressively, and almost always it is in relation Avith that of the general phenomena. 7. When the febrile phenomena are manifested before the symptoms of gastritis, there exists another inflamma- tion Avhich excited the fever and gastro-intestinal irrita- tion. 8. Anorexia, disgust for food, thirst, redness ofthe bor- ders of the tongue, sensibility or pain in the epigastric re- gion, constipation or diarrhoea, and frequently vomiting, are the common symptoms of all essential fevers, as well as fre- quency of pulse, heat of skin and disturbance of the secre- tions. The signs of gastro-enteritis form then, as Ave may- say, the element of all fevers. They present besides, one or two phenomena more prominent than the others, around Avhich the ontologists have ranged these last, and Avhich, to them, have been sufficient to characterize this group of symptoms. These predominating phenomena depend on, the constitution of the individual, the degree of irritation, the causes producing it, and the sympathies it aw7akens. We refer for the development of this proposition, to Avhat we have already said of the diffeient forms of gastro-en- teritis. One of the physicians Avho sustains with most talenfthe physiological doctrine, M. Boisseau, whilst, acknoAvledging that every febrile state is the result of local irritation, con- tends that all the essential fevers of nosographers, all those not accompanied by signs of inflammation known to authors, are not produced by gastro-enteritis ; he excepts principally, synocha or inflammatory fever. He contends that we do not ahvays discover amongst its symptoms those of gastric irritation, and that in these cases, notwithstanding the ab- sence of every sign of inflammation of the skin, the articula- tions, the muscles, &c. synochus produced by insolation, a forced march, &c. is nevertheless produced by irritation of these tissues ; and he reproaches M. Broussais for denying this, because it does not present the characters of phlogosis, whilst he himself has learned to sieze on the most fugitive shades of irritations. Let us see hoAV well this opinion is founded. M. Boisseau asserts that the signs of gastro-enteritis, are not observed in all inflammatory fevers ; he certainly will not give this name to the momentary acceleration of the circulation, to the heat of skin and the heaviness of »icad observed after forced exercise, and disappearing after a few hours repose ; so slight a disturbance cannot be considered as a fever—it is exempt from all gastric irritation when it does not continue. But when the febrile state is really established, it is no longer the same ; at least I can assert that, since 1 have learned to recognize gastro-enteritis, I have seen in all the synochas reputed essential, alteration of the lingual mucus, more or less redness on the point and borders of the tongue, very often thirst, and always inap- petency or disgust for food, (incontestable signs of gastro- enteritis. ) Who is ignorant of the fact, that fever does not exist Avithout anorexia ? But, according to M. Boisseau, inappetence is not an undeniable sign of gastritis; there must, he says, be disgust for aliments. I cannot see in these two signs any difference but that of degree ; and moreover, when the stomach is healthy, it ahvays gives rise to the desire for food—Avhen there is inappetency, the sto- mach is then affected : but, according to this principle, ad- mitted by Boisseau himself, it is affected Avith either asthe- nia or irritation, and no one will contend, that in synochus, the stomach can be debilitated. Many physiologic! physicians have assured me that they have ahvays observed the symptoms pointed out above, and, on reading attentively the pages in which the author at the local symptoms appertaining to the digestive onians evince themselves before the general phenomena, wemusi necessarily- conclude that the affection of the digestive pas- sages is an inflammation, and that this is the cause of ail the symptoms constituting the fever. 14. In seme cases' no changes are found in the dead bodies. These cases are so rare that the adversaries of the new- doctrine have had great difficulty to collect a few examples in the space of several years, and these are far from confirm- ing the opinion they sustain ; we knoAV, indeed, that inflam- mations, very evident during life, have not left any traces after death ; this fact is substantiated by the most exact ob- servers ; and besides, if all .the proofs brought forward by the physiological doctrine, against the essentiality- of fevers, establish in the most satisfactory manner, that the symp- toms constituting them depend on inflammation of the gas- tro-intestinal mucous membrane—Ave must necessarily ac- knoAvledge its existence Avhenever Ave meet the phenomena which observation and post mortem examinations have taught us appertain to it. 15. The best practitioners have established the bad effects of blood-letting in most fevers. Granted : but it is only7 of phlebotomy they speak, and never of capillary bleeding, which Avas not employed in the treatment of fevers before M. Broussais; and Ave have said in another place, that the effects of these tAvo modes of bleeding were A7ery different in membranous inflammations. 16. The advantageous effects of tonics and stimulants prove that adynamic and ataxic fevers are not the results'of an inflammation. What is the method of treatment, no matter how vicious, which does not also lay claim to cures ? Those Avho treat peritonitis, pleurisy, and pneumonias by tonics, also allege cures as a justification of this method. In order to resolve the objection now before us, it is no longer necessary to re- cur to arguments—wre have only to consult figures ; it is of no importance to know Avhether they have cured essential fe- vers in spite of or with tonics, but whether they cured more by these means than by the antiphlogistic method ; and every one knows that in the hospitals, seven twelfths at least of the fevers treated by tonics die. How dare they then vaunt a method of treatment not curing even the half of the patients. " You Avait then," asks M. Roche, " until there does not [ 2M j escape one, before you begin to doubt the benificent virtues of your admirable specific ? You would do Avell to re- nounce this course, if it only gives you death as a result." All those Avho have followed the practice ofthe professor of the Val-de-Grace, and of other physicians who have adopted his principles, know7 that most fevers are arrested at their commencement by antiphlogistics ; that under their influence it is extremely rare to see bilious and inflammatory fevers become adynamic or ataxic; and finally, that they cure also many of the latter by debilitants, judiciously uni- ted with revulsives. Every one knoAvs also, that these transmutations are very frequent, on the contrary, in the practice of Brunonians. Let our adversaries put in operation the application of the principles of the physiological doctrine, and the compa- rison of results they will obtain, Avith those which humoral- ism and BroAvnism furnish, will soon convince them of the excellence of the former, and ofthe absurdity and danger of the latter. If their conscience does not permit them to make experiments Avhich they think dangerous, let them not dis- dain at least to Avitness the practice of physiological physi- cians, and to consult their clinical reports. This grand contest is not about speculations, vain theories. indifferent to the happiness and misery of humanity7; its object is to her dearest interests. We declare to physicians an error producing death ; Ave Avarn them of it; let them not believe without examining ; but honesty imposes on them the rigorous duty of enlightening their judgments. Such are the objections Avith Avhich they have attempted to overturn the new doctrine of fever. They all sink into ar- bitrary hypotheses, and denials of the most evident facts ; ive have seen that not one of them can stand the test of cri- ticism. It is not by such means that Ave can overturn prin- ciples deduced from Avell established facts, and the most rigorous reasoning. Instead of making advances on the grounds of their adversaries, the partisans ofthe essentiality of fever are always shut up in the vicious circle of ontology, thus preferring speculations, to opinions proved even to de- monstration, vagueness to certainty, and finally, if Ave must say so, absurdity and error to truth and reason. Before avc conclude, Ave should also examine for a moment intermittent fevers. We have established in another place, the intermittence of irritation, and Ave then saw that au- [ to', J mors had called by the name of malignant fevers, intermit- tent inflammations in which violent congestions take place ; and that they had qualified them Avith the name of the dis- eased organ, the signs of its inflammation were recognized, Avhilst they characterized them by one ofthe most prominent symptoms, (like their continued fevers,) when they saw no sign of local affeciion—such are cold fevers, syncopal fevers, cardialgic fevers, &c.; that they had named those in which the symptoms were moderate, and in which they7 discovered no local lesion, common intermittent fevers ; and finally, that they had qualified Avith the name masked fevers (fievres lar- vees,) intermittent apyretic irritations, not thinking that there were other diseases besides fevers, which could put on the intermittent type. We have established also the non-essentiality of ordinary intermittent fevers; it only re- mains then for us to speak of their seat. According to M. Broussais, these affections, as Avell as remittent fevers, are periodical gastro-enterites. He admits besides, that the en- cephalon and other viscera, are sympathetically irritated, the same as in the continued, and may also become the principal seat of irritation. The. folloAving considerations cannot leave any doubt Avith regard.to the exactitude of this opinion. 1. M. Pinel regards intermittent fevers as of the same na- ture as essential fevers, and by this judicious reconciliation he prepared the discovery of their seat. 2. Most authors are not agreed in placing the seat of intermittent fevers in the digestive passages and their ap- pendages. 3. We often see intermittent fevers become bilious, ady- namic, and continued fevers, and reciprocally bilious and mucous fevers transformed into periodic fevers. 4. Most of the causes assigned by authors to intermittent fevers act on the stomach directly or sympathetically. 5. A paroxysm of intermittent fever presents all the phe-* nomenaofa continued fever. 6. Anorexia, disgust, disposition to vomit, sensibility and sometimes pain in the epigastrium, are the first symptoms of the paroxysm. These symptoms, and in addition, thirsty redness of the tongue, aversion from stimulating drinks, desire for cold aqueous drinks, and sometimes vomiting, are seen during the hot stage. And we know-that all these symptoms belong to gastro-enteritis. [ 28b ] 7. Practitioners have discovered the necessity of anti* phlogistics, and the danger of stimulants during the par- oxysm. 8. They have observed also, that bark, administered be- fore restricting the patient to diet, and submitting him for some time to an antiphlogistic treatment; when the gastro- enteritis is not perfectly intermittent, and the patient pre- serves between the paroxysms, some signs of gastric irritation: Avhen there is even complete apyrexia, would very often exasperate the disease, render the fever continued, and make it sometimes pass into the adynamic or ataxic state. M. Broussais has frequently observed these circumstan- ces in Spain, at a period Avhen he attacked intermittent fe- vers from their commencement, Avith tartar emetic and bark. We know also that intermittent fevers, Avhen treated by- stimulants, frequently leave in their train, (especially in cases where patients have not previously used the precautions Ave have just pointed out,) dyspepsias, hypochondrias, and other morbid phenomena Avhich we know appertain to chro- nic gastritis, and chronic hepatitis, Avhich is always united also to the latter. 9. A great number of intermittent fevers, the half, ac- cording to M. Broussais, yield to bleeding from the epigas- trium, diet and demulcent drinks. We will return to this fact Avhen we speak ofthe treatment. 10. The intermittence of irritation and the perfect iden- tity of continued and intermittent fevers being demonstrated, it results necessarily, that ordinary essential fevers are in- termittent gastro-enterites. 11. HoAvever, in the same manner as the irritation of all the organs may produce a continued fever, it may also pro- duce a simple intermittent fever, as well as a malignant fe • ver ; but it is incontestable, that the stomach participates very often in the irritation. Is this deuteropathia as con. stant as in those continued fevers which have not their primitive seat in the digestive passages ? It is probable that the duration of the intermittent phlogosis being short, its influence does not extend ahvays to the stomach. But we do not possess a sufficient number of cases on this subject to be able to decide this question. When intermittent fe- vers shall be studied for some time yet in their true point of view, these difficulties will be resolved. 12. We should not be astonished to sec that the irastro- [ 389 ] iutesiinal phlogosis exists more frequently under the inter- mittent type than the other irritations. In the first place, gastro-enteritis is the most frequent of the phlegmasiae, next the stomach is one of the organs most submitted to intermit- tence of action in the healthy state, and finally, it is on this organ that act most of the causes Avhose intermittence of action M. Roche basso Avell established. If Ave recapitulate Avhat Ave have said on the febrile state we will see that— 1. Fever is the result of an irritation, of the heart. 2. It may be produced by the irritation of any organ. elevated to the degree of inflammation. 3. The latter stimulates sympathetically the heart, the brain, and the digestive mucous membrane ; and each one of these organs experiences this sympathetic irritation in different degrees. 4. The gastro-intestinal inflammation often becomes pre- dominant ; so does that also of the brain ; and then, in the language of the ontologists, an essential fever complicates the symptomatic fever. 5. All the essential fevers of authors are groups of symp- toms produced by inflammation ofthe mucous membrane of the stomach and small intestines, simple or complicated with another irritation. 6. The differences of fevers depend on the different forms assumed by gastro-enteritis. 7. The sympathetic irritations provoked by gastro-ente- ritis, may acquire great intensity, and become predominant, The latter then continues or diminishes, and new symptoms are added to those of the primitive inflammation, or super- cede them. 8. Intermittent fevers are periodical febrile inflammations. ■ 9. Ordinary intermittent fevers are periodical gastro-en* terites, most frequently primitive, sometimes sympathetic; perhaps they are produced in some cases by irritation of some other organ, without complication of gastro-enteritis. 10. Malignant fevers are intermittent inflammations of the lungs, pleura, brain* intestinal canal, &c. during the exacerbations of Avhich the irritated organs-are the seat of a very active congestion. 11. Masked fevers (fievres latvees) are inflammations. hemorrliaGftts neurones, or periodic and apyretic Sijb-i.nflam- 'jiations. k ?: • Jt sup posed them ; and we are not afraid of exaggerating, when Ave say, that the cases in Avhich they aggravate the disease. are at least, in the proportion of one to ten. Those Avho advocate emetics boast loudly of their cures, and are silent on the bad effects they produce ; perhaps they are honest. The principles they have adopted prevent them from attri- buting the evil consequences they see, to the treatment.— If they Avere not blinded they would except amongst the fortunate causes, 1st, those in which the gastric irritation, Avithout passing to an elevated degree, is however, sensibly- exasperated ; for they often see after their administration, the appetite completely disappear, and thirst replace it, the tongue becomes more foul and red on its borders, the skin dry, &c.; 2d, those in which the pretended essential fevers succeed to the first phenomena of gastritis ; 3d, finally, the numerous cases in which the state of the patient is amelio- rated for tAvo or three days, and after Avhich the embarras gastrique reappears ; and those in Avhich this momentary amelioration is soon folloAved by signs of chronic gastritis. The bile and mucous fluids vomited did not exist before the administration of the emetic, their secretion has beeu increased by the stimulation it exercised on the stomach. and transmitted to the liver ; and in supposing that a quan- tity of these fluids already existed in the stomach and irri- tated the mucous membrane, they doubly fail in the end Avhich they propose, by administering an emetic, since it must increase the irritation and produce a more abundant secretion of bile and mucosities. This in fact takes place, and if this exasperation be often exempt from dangerous consequences, it is because the stimulation of the stomach produces in the skin an extraordinary action inducing dio- phoresis, and consequently revulsion of the gastro-intestinal irritation. As the effects of emetics are very uncertain, even in the mildest grades of irritation, as they do not effect a rapid cure except in very feAv cases, as in most cases indi- viduals do not recover more promptly than by following another mode of treatment, and as they sometimes exaspe- rate the irritation and give rise to an inflammation too often fatal, they should be proscribed almost invariably in the treatment of gastric affections. They are generally advan- tageous when the irritation is very slight, when it is recent and when it has not been preceeded by chronic gastritis ; when individuals are fat, lymphatic and not irritable ; in ••old and damp seasons and countries; when the tongue is covered with a mucous coat, and when its borders and point are not red; when the epigastrium is not sensible ; Avhen the heat of skin and thirst are not augmented ; when the patient has no organ affected with chronic inflammation. But there is no doubt that even in cases the most favorable to the administration of emetics, it is still most prudent to abstain from them ; for Ave are not even here beyond the reach of accident. I possess three cases justifying this fear. In tAvo individuals I have seen emetics give rise to very intense gastro-enteritis ; in a third, placed like the two others under all the circumstances just pointed out, I thought that I might prescribe an emetic; unconquerable vomiting came on, a more acute inflammation was develop- ed, and in spite of the most active antiphlogistic treatment, it continued its progress, and the patient sunk on the sixth day, Avith the symptoms of adynamic fever. I did not have it in my poAver to open the body; but the patient had al- ways enjoyed good health, and I was Avell assured that he did not carry any point of chronic irritation about him. These reasons then should decide practitioners to prefer to a method often advantageous, it is true, but sometimes dangerous, a mode of treatment which can never leave cause of regret. Whenever an individual presents himself Avith the pre- monitory symptoms of gastro-enteritis, it is necessary at once to restrict his diet, to allow him only veal broth, chick- en water, cooked fruits, if he still have appetite, and to give nim for drink lemonade or other like preparations. If the patient be sanguine, and the heat of the skin be augmen- ted, we should not confine ourselves to these means; the application of eight to twelve leeches on the epigastrium, will arrest more certainly the commencing phlogosis. This treatment almost always restores the health in tAvo or three days, and if sometimes it does not succeed in arresting the irritation, it prevents it in almost all cases, from acquiring a great degree of intensity. When the fever is already declared, it is necessary to ap- ply a greater number of leeches ; this quantity is deter- mined by the intensity of the inflammation, its duration, age, sex and state of the sanguine A7ascular system. In adults, Avho present gastro-enteritis under the inflammatory 294 j wr bilious forms, it is also necessary7 to apply thirty or forty- leeches, and to be cautious in stopping the flow of blood, which, on the contrary7 should be promoted by emollient fo- mentations.* When leeches are used in too small a num- ber the irritation is calmed for some hours, but it most fre- quently returns with its former intensity, and the weakness experienced by the patient is so much loss. It is necessary to let the blood flow until the pulse looses its frequency and becomes soft, until the heat of skin diminishes, this mem- brane becomes moist and the face loses its color. Many circumstances produce on this precept modifications impor- tant to be known. In individuals having little blood, and in those Avho have been affected for a long time Avith chro- nic gastro-enteritis, Ave should be very moderate in the ap- plication of leeches ; an abundant sanguine evacuation Avould throw the patient into a state of debility Avhich it Avould take a long time to recover from, and Avhich would be the more dangerous iirproportion as the viscera are actu- ally the seat of congestion, which debility favors. We should only bleed in these cases Avhen the pulse is hard and resisting, and Avhen the face is florid ; it is then necessary to confine ourselves to a smaller number of leeches than that AA'e have indicated, and to arrest the flow of blood when the state of the pulse and heat of the face announce that it cannot be pushed farther with impunity. If the pulse, notwithstanding its frequency, have no hardness, if the skin be colorless, if the enbonpointhe much diminished, if, before the disease the subject Avas feeble, it is more pru- dent to abstain from blood-letting, local and general, and to confine ourselves to the employment of other means. In young persons, women and old persons, when even they are not under the circumstances pointed out above, Ave Should also practise local blood-letting Avith more modera- tion ; for if it be important to occasion a loss of blood suf- ficiently abundant to produce resolution of the inflammation rapidly, it is not necessary, notAvithstanding, to throw the patient into a debility which retards convalescence and fa- vors the establishment of chronic inflammations. The employment of leeches on infants, exacts the great- est circumspection and the closest watching; we should never apply but a very small number, even Avheri they are * The leeches of this country (United States,) should be applied in much greater number—from fifty to eighty will be required.—Tr. L ^0 J fetrong and the gastro-enteritis intense, because the capiiia ries of the skin are highly developed in early age, and the bites of leeches often furnish a great quantity of blood ; we hav-e seen infants perish bloodless because the cutane- ous hemorrhage had been abandoned to itself. The physi- cian who orders leeches to be applied to an infant should Avatch over it himself, and visit the child three or four hours after the application, in order to be assured that the state of the pulse and paleness of the skin do not call for an arrest of the flow of blood. It is not only in infants that we should fear the accident we are speaking of; we observe it in young persons and in adults having very delicate skins. A young robust soldier, in 1820 entered the hospital Val-de-Grace, affected Avith a slight gastro-enteritis; the day after his entry Dr. Damiron prescribed fifteen leeches to the epigastrium : the blood flowed abundantly and the nurse had twice to change the cloth applied. In the evening the patient com- plained of being weak ; but the attending surgeon Avas not apprized of it, and the nurse gave himself no farther trouble about the young man during the night. At five o'clock in the morning, he Avas found dead ; an enormous quantity of coagulated blood covered the abdomen and bed cloths. On opening the body Ave found all the tissues pale and the veins empty. The examination of the brain, of the tho- racic and abdominal viscera, discovered no alteration, and it Avas evident that the patient had died from hemorrhage.— M. Damiron informed me that he had witnessed a similar instance, in an individual aged about twenty five years. When the first application of leeches does not produce in the space of fifteen or tAventy four hours, a very marked amelioration, Avhen the pulse still preserves its frequency, Avhen the skin is hot and dry, the epigastrium sensible, the thirst intense, the mouth dry and the tongue red on its edg- es, it is necessary to repeat the application of leeches. We are sometimes obliged to recur to them a third or a fourth time. This perseverance is indispensable to arrest the inflamma- tion, and I have seen it a number of times, in the practice of M. Broussais, croAvned Avith the most happy success.— The debility is not so great, after these repeated sanguine deperditions, as one would suppose, and convalescence is not so tedious as has been asserted by the opponents of this practice who have never seen it put in force. The debility- is much more profound, when the disease has been alloAved to march on, or has been exasperated by tonics. [ 29U ] Often after an amelioration of one or several days, we see the first symptoms reappear Avith the same intensity ; it is then necessary to recur to leeches as in the first instance. But often it is necessary to renounce their employment be- fore obtaining the amelioration desired, because,, far from di- minishing the intensity of the inflammation, they only add to the danger. M. Broussais advises us to abstain from blood-letting when the inflammation has been preceded by a chronic inflammation, Avhen it has lost none of its inten- sity after the first application of leeches, and when the pulse loses its force while it retains its frequency ; Avhen several organs are inflamed at once, and to a great extent; if the anguish, prostration, and frequency of pulse be ex- treme ; " wre might evacuate all the blood," says he, " sooner than arrest the disease." The author of the Examen advi- ses us also to be A'ery circumspect in the employment of blood-letting when typhus is not in its commencement; be- cause, Avhilst producing inflammation in the viscera, the gas- eous poison weakens the vital poAver to such a degree that the losses can no longer can be repaired. In a former chapter we have sufficiently insisted on the superiority of capillary over general bleeding in the treat- ment of membranous inflammations, to excuse us from re- turning to it. We should only recur to phlebotomy when the inflamma- tion gives rise to a high degree of excitement in the san- guine vascular system and Avhen the disease is at its com- mencement, or when the gastro-enteritis accompanies a pneumonia, or when the blood is carried AA7ith force to the brain ; but in these cases, capillary bleeding practised on the epigastrium is not less necessary to combat the gastro-intes- tinal inflammation. We have said that as soon as the first phenomena of this disease are manifested Ave should forbid the use of aliments, and only alloAv patients broths ; but when the fever is light- ed up, the diet should be absolute. M. Broussais is the first who forbid broth in febrile gastritis, and conformity Avitli this precept is of the greatest importance to the success of the treatment. How often have we not seen a few spoonfulls of this preparation, administered when the patient Avas already better, suddenly reproduce the former symp- toms ? M. Broussais extends this proscription to all fluids requiring digestion, such as decoctions of farinaceous grains [ to) j and fleshy (charnus) mucoso-sacharine fruits. He says we should only allow for drink, Avater charged with a small quantity of sugar and gum tragacanth, Avhich is preferable to gum arabic on account ofthe extractive matter often color- ing the latter. The solution should only contain sufficient to be slightly unctuous to the touch; when gum cannot be obtained, flax seed, or allhcea officinalis may be employed. We should renounce niucilaginotis plants containing an aro- matic principle. Drinks made of gums are preferable to all others ; many patients, hoAvever, prefer the acidulated; we then give weak lemonade, prepared from lemon, or syrop of gooseberries or raspberries, largely diluted with Avater : if these cannot be got conveniently, tartaric acid may- be used, Avhich should be very much diluted. Acetic acid ahvays produces irritation, even Avhen the Avater is scarcely acidulated; Ave should then renounce oxycrate and syrrup of vinegar, as Avell as the mineral acids ; the same Avith sirop of mulberry, the acid of which is very pun- gent. If acid drinks provoke coughing, we should substi- tute mucilages. It is better to administer both cold, parti- cularly in the summer or Avhen there is vomiting; w7arm fluids stimulate the stomach ; the existence of cough, how- ever, requires that they be taken Avarm. The patient should not drink more than his thirst demands; and he should not take a large quantity at a time ; for then it ac- cumulates in the stomach, distends and fatigues it. Later in the disease, when it is on the decline, when the tongue becomes cleaner, and the patient has appetite ; and especially if he has been dieting for a longtime and is much Aveakened, Ave give nourishing drinks. For the former de- coctions of barley, we then substitute apples, bread, sweet- ened and slightly aromatized With orange Avater, diluted milk, &c.; and when the frequency of pulse disappears, chicken or veal Avater, and beef broth, as convalescence is declared. Several topical applications are of very great utility in the treatment of gastritis. We will place in the first rank, emollient fomentations on the epigastric and umbilical re- gions. They should not be applied of too high temperature, for fear of stimulating the skin. When the inflammation is very high and theie is a great deal of heat, if the individual be not too much debilitated, ahd he seek cool air, Ave should prefer cold applications We then place on the epigastrium [ 2-J> a bladder filled Avith ice or very cold Avater,(Avhich shouhi be renewed as soon as it becomes Avarm. If the lungs or pleura be irritated, M. Broussais advises the thorax to be covered with a warm cataplasm for the purpose of diverting from them the action of the cold ; and if, notAvithstanding this precaution, the cough be exasperated, he renounces this means. Cold on the abdomen is very efficacious under the circum- stances laid down ; it often dispenses Avith the reiteration of blood-letting, and M. Broussais advises its employment. especially in the summer, and in the treatment of the gas- tro-enteritis of warm climates. The revulsive method is but a feeble resource in the treatment of acute inflammations of the digestive mucous membrane, and most frequently it is very injurious. M. Broussais has often pointed out the dangers of using vesica- tories, which, before him, played so important a part in the treatment of violent essential fevers. The cutaneous in- flammation produced by them is not sufficiently high to cause a revulsion of an inflammation occupying a great ex- tent : most frequently they increase the general excite- ment, and add to the intensity of the gastro-enteritis. We read in the Annates de la medicine physiologique, several cases in which the bad effects of vesicatories are seen in the treatment of this disease. Several times I have seen M. Broussais obliged to recur to them when it Avas complicated Avith a thoracic inflammation, tending to the chronic form ; he always waited until the symptoms of gastro-enteritis had nearly disappeared. In almost all these cases, on the next day, the patient had a red tongue, thirst, heat of skin and frequency of pulse ; it Avas necessary to restrict the diet, and sometimes even to return to leeches. We should not then attempt a revulsion of gastro-enteri- tis ; Ave should only recur to revulsives Avhen it is complica- ted Avith cerebral irritation not calmed by blood-letting from the neck. We will speak of this hereafter. However, Avhen it is accompanied Avith vomiting, not relieved by the bleeding from the epigastrium, it is necessary to apply on the feet or legs warm cataplasms, which may be rendered more exciting by wetting them Avith cologne Avater or sim- ple alcohol. We may also recur to sinapisms, to be left on the skin for about an hour only, unless they do not act in this time ; but if Ave observe that the pain often determined by them, produces too much excitement, it is necessary to take them off, and substitute warm cataplasms. Stimulation of the skin is reflected Avith so much facility on the gastric mucous membrane, that warm baths often exasperate its inflammation. Whether there be constipation or diarrhoea, it is ahvays useful to administer two emollient enemeta every day. If the heat be considerable, if the colon be not inflamed, and if the patient be not very weak, Ave should prefer injections of cold Avater, or cold vinegar and Avater. The existence of diarrhoea, of tenesmus and colics, should never determine us to qdd opiates during the course of acute gastro-enteritis. When the cerebral irritation is light, and the patient only complains of head ache, it demands no particular attention ; but when the pain is very severe, and the physiognomy is animated, we should fear delirium, and calm, as soon as pos- sible, the encephalic irritation by the application of leeches to the temples or neck, and repeat the bleeding from the epigastrium, if the signs of gastro-intestinal inflammation, announce that it is still intense ; and, if there exist no eounterindication to the repetition of blood-letting, when delirium has supervened, Ave should join to this means the application of ice on the head, and that of warm cataplasms or sinapisms to the feet and legs. It is by employing simul- taneously local bleeding, cold and revulsives, that Ave often obtain the happiest results, which the successive application of each of these means would not produce. Cold and local bleeding, at the same time that they calm directly the en- cephalic irritation, prevent that of the skin from turning to its profit. It is however, necessary to be cautious in leaving the sinapisms long enough to produce pain ; for the latter sti- mulates the brain poAverfully, and Ave would thus increase its irritation. Often duing the course of gastro-enteritis, hemorrhages supervene, Avhich are sometimes advantageous, and at other times throw the patient into the greatest danger. When he is not debilitated before the disease, Avhen he still presents strong reaction, we should respect these flows., which often rapidly procure resolution of the inflammation. We should only arrest them when they become too abundant. In those cases, on the contrary, where the prostration is extreme, the pulse small and feeble, the skin livid, the mouth fuli- ginous, Ave should suppress them as soon as they appear ; .jUU L>ut we should not do it by tonics and asinngents, fiLe those who attribute them to adynamia; Ave should oppose them by revulsives, whose employment is Avithout danger. Thus Ave should apply extemporaneous vesicatories to the back of the neck for epistaxis, on the upper part of the sternum for hcemoptysis, on the abdomen for hemorrhage of the in- testines. What Ave have just said of hemorrhages applies to the external inflammations showing themselves in the course of gastro-enteritis. When there supervrenes an inflammation of the parotid, an erysipelas, a phlegmon, we should not interfere with them if we perceive that the intensity #of the gastro-intestinal inflammation diminishes. If, on the con- trary, the fever augment, if the dryness of the tongue in- crease, we should combat the secondary inflammation by- leeches, since so far from becoming revulsive of the gastro- enteritis, it adds to its intensity ; it is even necessary in this case to apply them also to the epigastrium, if the strength oi the patient permit. All visceral inflammations complicating gastro-enteritis. should be combatted by local bleeding, if no coimterindica- lions to their employment exist, because they manifestly add to the danger of the disease. Thus, Avhen in the first period of its existence, a peritonitis is manifested, Ave should apply leeches to the abdomen ; if difficulty of urinating an- nounce that the irritation extends to the bladder, Ave should place some on the hypogastric region ; the same also with the thoracic organs. If we only observe the hacking, dry- cough, without expectoration pointed out as sympathetic of gastritis, it demands no particular attention. If by ex cess of this sympathy a pulmonary catarrh be developed, Ave should apply leeches under the clavicles, or immediately above the sternum, between the insertion of the sterno- mastoid muscles. If the irritation extend to the parenchy- ma of the lungs, and the pulse become large, it is necessary to practise a general bleeding, or recur to leeches if the patient have already lost a great deal of blood. In the two cases, we should keep the breast covered by large emollient cataplasms, to be reneAved three or four times a day. The angina often accompanying gastro-enteritis, yields to an application of leeches and cataplasms. Sympathetic arthri- tis Avhich also supervenes sometimes, should be combatted bv the same means. of) i j Inflammation of the colon is oue of those must frequeuth complicating inflammation of the stomach and small intes- tine. We should treat this by emollient injections and leeches to the anus, Avhich are very efficacious in this af- fection, as Ave shall see Avhen Ave speak particularly of its treatment. When the treatment (the rules of Avhich Ave have just traced,,) is early applied to the mdst intense gastro-en- teritis, it almost always triumphs. But Avhen the affection has been preceded by a chronic inflammation, when seve- ral organs are at the same time profoundly affected, when the disease has not been attacked at its commencement, when the patient has taken before hand, tonics or emetics, the evil is often beyond the resources of art; and in spite of these circumstances, too often met with, there exists a marked difference in the mortality of different hospitals, and of the different Avards of the same hospital, where the pa- tients are treated by the antiphlogistic method, or by tonics and emetics. In the practice of physiological physicians, we see much feAver/eyers arrive at the adynamic form, than in that of physicians Avho follow the opposite plan. We know that danger only exists when this transformation takes place, or when ataxia supervenes. When under the influence of bad treatment or of anti- phlogistic means methodically- applied, the patient becomes prostrated, the mouth becomes fuliginous, the skin livid, and the. pulse feeble and at the same time frequent; or Avhen at an advanced period of the disease, delirium and convulsive movements are united, Avhat course ought the practitioner to pursue ? We must confess that he possesses but feAv means of combatting the danger, and that in general they are of little efficacy. Blood-letting is no longer admissible; in this state of the disease, it is often fatal in a feAV hours ; I have, hoAvever several times seen four or five leeches ap- plied then to the epigastrium, make the symptoms disappear A-ery rapidly ; but Ave cannot advise such rash conduct.— Can Ave recur to tonics ? All the symptoms Ave know de- pend on inflammation ; the prostration, the stupor, &c. arc the result of an increase of this lesion : Avhat then can ton- ics do, but add to its intensity ? We should, hoAvever, pre- scribe them notwithstanding this theoretic contradiction, if observation had proved them to be advantageous. But this is far from being the case. We knoAV how very feAV ady- L o02 } namic fevers eneapc under the stimulant treatment, onh successful Avhen it produces revulsi\Te actions in the secre- tory organs. We should then banish it even in the most desperate cases, since its advantages are very uncertain, and since when it does not promote the cure of the patient certainly hastens death. Besides, the physiological practice here, also offers resources w7e are not permitted to renounce in order to recur to da'ngerous means. In this alarming state of the disease, I have often seen the revulsive method com- bined with demulcents, snatch the patient from danger ; and in several cases, I have myself obtained from them the most advantageous effects; it is necessary to apply sina- pisms on the feet or legs, at the same time that fomentations are applied to the abdomen. If the skin be not livid and covered by a viscid sweat, we should apply preA'ious to the sinapisms, four or five leeches to the epigastrium ; they are then without danger, and favor the action of cutaneous ir- ritants : at least it is under these circumstances that I have seen them succeed. If, Avhen their bites bleed for an hour, the pulse assumes a little force and development, Ave should favor the flow ; and if, afterAvards'the amelioration is more sensible, we should apply them again, and reneAv the sina- pisms. If, on the contrary, Ave perceive that the smallness and feebleness of the pulse augment, we should immediate- ly arrest the hemorrhage. If the sinapisms produce suffi- cient irritation to cause pain, it is necessary to substitute for them Avarm flpx seed poultices, or a mixture of the latter with mustard ; if, instead of stupor, delirium exist^ we should insist on the application of cold to the head, at the same time that the lower extremeties are stimulated. We should at the same time, continue the use of mucilaginous or acid- ulated drinks, and give nothing which might add to the irri- tation of the digestive passages ; thus it is necessary to ab- stain from broths of veal or chicken, from Avhey, emul- sions, &c. When the malady is arrested in the first period of its ex- istence, the vomitings cease, the epigastrium is no longer tender, the tongue has lost its redness, the skin its heat, the thirst its intensity, and the frequency of the pulse is much reduced, it is useless to insist on blood-letting ; diet, diluent drinks, enemeta and fomentations, are then sufficient to complete the cure. When the frequency of pulse has ceased, we prescribe the nourishing; drinks of which avo [ 303 j have before spoken ; and Avhen the redness of the tongue has disappeared, Ave give broths, the quantity and nourish- ing quality of Avhich Ave gradually augment. Sometimes a keen appetite is developed, whilst the" fever still continues ; it is then necessary to allow a small quantity of broth ; for hunger, not satisfied, Avould add to the inflammation of the stomach. We should especially yield to the wants of the patient, Avhen he has for some time been in the adynamic state. But Ave should be cautious not to confound the ex- pression of a real Avant, Avith solicitations founded on the fear of dying from inanition, and the prejudice of the vul- gar, Avho think they cannot live Avithout taking food. When the patient makes use of thin broth for several days, we allow him soups, cooked fruits, then Avhite meats and old wine largely diluted with water. We will not re- capitulate here, all that has been said in the article on con- valescence, with regard to the cares and attentive Avatching it requires. We will only repeat that Ave should augment very gradually the quantity- of aliments and their stimulating nature ; that as soon as the convalescent complains of pain in the head, loss of appetite, disgust and uneasiness, we should stop the other food and confine him for a day or tAvo to broth and lemonade ; with these precautions the patient Avill soon be restored to his former state. We should re- collect also, that if in spite of the use of aliments of a pro- per nature and the observation of all the hygienic rules, the patient does not recover his strength and embonpoint, he still carries a point of chronic irritation about him neces- sary to be destroyed. When by the effect of diet, aqueous drinks, and blood- letting, the stomach is found in a state of debility, not per- mitting it to digest well, recognized by paleness and in- creased breadth of the tongue, by the absence of thirst, by- extraordinary heat of skin, by sensibility of the epigastri- um, &c. it is necessary to give some mild tonic to excite the stomach. We should then prescribe bitter and aromatic in- fusions, extract of bark, and a small quantity of generous wine ; but most frequently, as Ave have seen, there remains after the disease great irritability of the gastric mucous membrane, and Ave see established during convalescence a chronic gastritis. We thus find ourselves led to speak of its treatment, before occupying ourselves Avith that of in- termittent and remittent colitis and gastro-enteritis. t o04 ] The treatment of chronic gastro-enteritis is beset by a crowd of difficulties over Avhich the physician can only tri- umph by displaying all the resources of the art, and by per- sisting in the employment of the means it furnishes, with the most determined perseverance. This treatment exacts a number of modifications according to the different forms assumed by the disease, its duration, and the state of the patient. When chronic gastro-enteritis is primitive, when it af- fects a robust, sanguine individual addicted to good cheer, we should commence the treatment by the application of tAvelve of fifteen leeches on the epigastrium ; and recur to them, in the early stage every six or eight days, according as the phlogosis demands it, and as the forces of the patient per- mit. When on the contrary it succeeds to an acute gastri- tis, Avhen the subject is debilitated, or Avhen it is primitive and the patient has lost a great deal of strength and embon- point, we should renounce this remedy7 which Avould pro- duce a debility, the patient Avould be a long time recovering from, and Avhich would render more difficult the cure of the chronic gastritis. It should be recollected that Ave often have to Avait long on the latter, that it is necessary to per- severe for several months in the use of strict diet, and that Ave should consequently husband the forces of the patient, who will haAre to strive against the debility induced by the disease and its treatment. The regimen constitutes the most important part of the treatment, and often it is reduced entirely to dietetic atten- tions. The great art is to nourish the patient, Avhilst the gas- tric mucous membrane is stimulated as little as possible ; Ave should only prescribe then such aliments as are very light, mild, and contain most nourishment in a small bulk. It is necessary generally to banish from the regimen of in- dividuals affected Avith chronic gastritis, all substances taken from the animal kingdom, even gross broth. It should on- ly consist of very Avhite, well fermented bread, sago, salep, gruel, pap, milk, fresh eggs, cooked fruits and farinacious vegetables. We should vary these aliments according to the taste of the patient and his ability to digest them; for one individual finds himself A-ery Avell under the use of milk Avhilst another cannot bear it. These articles should be taken in small quantities at each meal, during Avhich, Ava- ter alone should be alloAved as drink ; the quantity of these [ 30o j should be gradually increased as the phlogosis progressive- ly diminishes. It is a precaution of easy execution and very important to note on account of the efficaciousness of its results, Avhich Ave should always recommend to the pa- tient, viz. that of refreshing the stomach after each meal by aqueous drinks, taken at intervals until the next meal or until the time for sleeping : the execution of this precept of M. Broussais cannot be too much recommended ; for we see the patients Avho submit to it, digest with facility, are almost always freed from the burning of the hands, the heaA7iness and sensibility of the epigastrium, and from the dryness of throat fatiguing them after eating. Robust individuals in Avhom Ave have recommended the employment of leeches, should be put during the first days ofthe treatment, on the diet of acute diseases. We should alloAV them only light broths and mucilaginous or acidulated drinks ; this severity should be particularly rigorous, if there be pain in the epigastrium, and if the disease be the result of table excesses. We should relax by degrees, Avhen the phlogosis passes to a more obscure grade. We have said, in the history of chronic gastro-enteritis, that this disease undergoes often, under the influence of stimulat- ing causes, and a Avell directed treatment, alternations of re- mission and exacerbation. Whenever it is exasperated, it is necessary to curtail a part of the aliments until Ave remark an amelioration, and also, if the epigastric pains be severe, Ave should apply leeches on the region of the stomach. Between meals, the patients should drink every hour, a cup of sugar and Avater, of mucilaginous or acidulated ptisan, according to their taste. These drinks should be taken cold ; Ave are under the necessity of varying them often, as Avell as the aliments ; for, at the end of a short time, both fatigue the patients and inspire disgust. Habitual constipation, in individuals affected with chronic gastro-enteritis, adds almost always to their uneasiness, to the heaviness of head and the epigastric sensibility—Ave should then remedy this evil by administering every day an emollient enema. Patients should every day take moderate exercise in the open air, especially after eating. We recommend to them, walking, which is preferable to exercise in a carriage or boat, (unless they be very feeble,) and to equitation advan- tageous only Avhcu the patient no longer experiences pains : [ 30b ] abstraction from cares of every kind, residence in the coun- try, travels to mineral waters, which should not be taken internally ; in short, they should give themselves up to all acts capable of increasing the vitality in the exterior parts, at the expense of the viscera and nervous system.— It is then indispensible to forbid, almost entirely to patients, closet labors, and every thing continually exciting the brain, as it always adds to the nervous susceptibility already too much exalted in most patients. Individuals affected with chronic gastritis, should not live in too warm an apartment; they should likewise shun cold, damp air, and not load themselves during night Avith too much covering. We often calm epigastric sufferings by the application of emollient cataplasms, and many patients feel better from the contact of a piece of flannel doubled, a swan skin or a delicate fur skin. Such are the principles ofthe treatment of chronic gastro- enteritis ; we repeat that this disease, ahvays very obstinate Avhen of long standing, can only be cured by patience and the docility of the subject, and the perseverence ofthe phy- sician in the employment of soothing means. When the signs of chronic phlogosis of the digestive mu- cous membrane have disappeared for some time, the pa- tient may return gradually to the Use of meat and Avine.— But during several months, and even during years, he should still consider himself as a convalescent, and use the greatest attention to shun all influences calculated to devel- ope aneAV the irritation of the stomach ; for this disease, Avhen it has existed for several months, very often under- goes relapses with great facility, Avhose cure becomes more and more difficult. Vesicatories, setons, and moxas, are very feeble adju- vants in chronic gastritis, and they often even add to the irritation. We should only employ them to re-establish an exanthem to whose disappearance the disease may be attri- buted. Chronic gastritis is of all diseases, that in Avhich purga- tives are most abused, and also tonics and stimulants under the title of antispasmodics. What Ave have before said on the nature of dyspepsias, of hypochondrias, &c. dispenses with the necessity of pausing to demonstrate the danger of these medicines in the different forms of chronic gastritis; inflammation of the digestive mucous membrane treated by i 3- modified ; but there is not one Avhich maintains with it such intimate relations, in health and disease, as the stomach. One of the most remarkable points ofthe physiological doctrine is, Avithout doubt, the knowledge of the relations existing between the irritations of the digestive organs and those of the brain and meninges. Whilst the labors of M M. Riobe, Rochoux, Parent, Martinet, Serres, Rostan, Abercrombie, and Lallemand, have cleared up the nature of the different encephalic affections, M. Broussais has shown that irritation Avas the cause of almost all the altera- tions we meet in the brain and membranes, that this irrita- tion Avas often consecutive to a gastro-enteritis, and thus established the treatment of these diseases on new curative indications. We will not here present the description of cerebral irri- tation and its different forms; it Avould be too extended an [ 344 J undertaking for us to expose the revolution produced in this part of pathology, covered as it Avasbut a few years since with the deepest obscurity. We could not do otherwise than re- late Avhat Ave find on this subject in the twro Examens, and in the excellent work of professor Lallemand ; we will confine ourselves here then to an exposition of the opinions of M. Broussais on the relations of gastro-enteritis and cerebral irritations, and to the presentation of a series of proofs put- ting these proofs beyond doubt. After having proved that apoplexy, mania, paralysis, cata- lepsy, tetanus, and epilepsy, should be classed Avith cerebral irritations ; that ramollissements, and atrophies of the brain, were, as Avell as purulent collections, serous effusions, and scirrhous indurations, an effect of inflammation ; that all ce- rebral irritations, whatever form they present, pains, con- vulsions, mental aberrations, &c. terminate finally in para- lysis, idiotism, and apoplexy ; and that the disorders Avhich the cerebral apparatus then presents, should be referred to inflammation and its consequences. M. Broussais estab- lishes as principles, 1st, that most frequently, and in cases where cerebral irritation is traumatic, it is consecutive to a gastro-enteritis ; 2d, that cephalalgia, delirium, and convul- sions provoked by stimulation of the mucous membrane of the stomach and small intestines, are the immediate effects of a sympathetic irritation of the brain, Avhich may be con- sidered as the first degree of inflammation of this viscus; 3d, that very often in the course of gastro-enteritis, this first degree progresses and rises to inflammation, Avhether in the brain itself, or in the meninges ; 4th, that, in subjects whose brains are predisposed, the sympathetic influence of the inflamed mucous membrane suffices to raise the cerebral irritation to the degree of inflammation ; then the cerebral symptoms predominate over those of gastro-enteritis, and on autopsy, avc find in the brain, or its envelopes, traces of acute inflammation ; 5th, that in cases Avhere the cerebral irritation is primative,it cannot endure for along time, nor rise to a high degree Avithout producing gastric irritation, and that this sympathy of the inflamed encephalon over the stomach and its appendages, ahvays produces a certain de- gree of gastritis, and sometimes hepatitis ; 6th, that mania is always the result of a cerebral irritation, and that, Avhen the latter has not been produced directly, it is sympathetic of gastro-enteritis, Avhich may itself have been developed and kept up by another inflammation. [ 345 ] In another chapter, Ave have already shown the sympa- thies existing between the digestive passages and the brain; let us add to what Ave have already said, other facts which Avill render incontestible the principles of the professor of the Val-de-Grace, on the connexion of their irritations. In the picture Ave have traced of the phenomena of gas- tro-enteritis, we remark signs of cerebral irritation from the commencement of the disease ; we see them increase at the same time with the intensity of the gastritis, from the head ache which accompanies embarras gastrique, up to the deli- rium and convulsions, observed in most cases of poisoning from corrosive substances. We have shown that the group of symptoms called ataxic fever, were composed ofthe signs of gastro-enteritis and encephalitis; finally, we repeat, that the researches of M. Scoutetten have established the traces of irritation of the meninges—always seen accompanying those of gastro-enteritis. Head ache, delirium, convulsions, in fine, all the signs of encephalic irritation complicating gastro-enteritis, called ataxic fever, often disappear after the application of leeches to the epigastrium. In the etiologic table of cerebral lesions, given by authors, we see table excesses, Avine, acoholic liquors, and coffee, placed near wounds ofthe head, insolation, chagrin, &c. The signs of gastro-enteritis make a part of the assem- blage of symptoms called cerebral 01 apoplectic fever. Redness of the tongue, thirst, dryness of the mouth, sensi- bility of the epigastrium, &c. are almost constantly seen in encephalitis and meningitis. Adynamic fever is often deve- loped at the close of cerebral affections, and particularly of apoplexies. Habitual anorexia, constipation, thirst, and a foul state of the tongue, are almost always seen in chronic ce- rebral irritations. All surgeons have observed that embarras gastrique and bilious fever were amongst the most frequent accidents com- plicating wounds ofthe head, and that there were very few of these Avhich were not followed by vomiting and other signs of irritation of the stomach. Examination of the dead bodies of individuals affected with cerebral diseases, has almost almost always displayed traces of inflammation in the digestive passages, and Ave have ahvays met them in those Avho had had fever. M. ^erres found in apopleetis, traces of ejastro-enteritis, but he r 2 [ oOi j has attributed them to the influence of stimulating treat- ment. It is particularly by the exasperation of the symptoms of cerebral irritation in adynamic and ataxic fevers, that the bad effects of stimulating treatment are manifested. M. Lallemand declares that emetics, empirically recom- mended in the treatment of paralysis, may give rise to ence- phalitis, and, a fortiori increase it when it exists. He has seen effects of this kind folloAv the administration of nux vomica ; he shows that tartar emetic, in the ordinary doses, and much more in a large dose, augments the cerebral affec- tions when it produces vomiting, and exasperates the gas- tro-enteritis Avhen it does not vomit; that coffee, arnica, acetate of ammonia, bark, camphor, ether, musk, and nux vomica, administered in these diseases, produce agitation, convulsions, tetanic rigidity, and adynamia. In the cases reported by this professor, we see, after the administration of purgatives and tartar emetic, the tongue become dry and red, the skin hot, thirst developed, and M. Lallemand shows clearly that encephalic inflammations alone do not produce fever. We meet in authors but very few cures of cerebral dis- eases treated by tonics ; since tht, origin of the physiological doctrine, we have, on the contrary, met a great many which have been obtained by the antiphlogistic method. To these facts I shall also add some others which I take from the memoir of my friend, Doct. Richond, on apoplexy. This Avork, filled with judicious views on this disease, leaves nothing to desire on the subject before us. Many physicians have contended that the phenomena of drunkenness were principally sympathetic of irritation of the stomach ; M. Richond show7s the justness of this opinion, Avhich has found a great number of opponents who attribute the cerebral excitement to the action directly exercised on the brain, by absorbed alcoholic principles. The following considerations do not permit us to misconceive the influ- ence of the stomach on the brain in the production of this state. 1. After vomiting and the ingestion of cold aqueous li- quids, we see drunkenness disappear very rapidly. 2. The ingestion of a few drops of ammonia in a glass of Avater, by changing the mode of excitement in the mucous membrane, rapidly produces the same result. [ 347 | 3. It absorption ofthe alcoholic principles was the cause of intoxication, it is evident that it should be more rapid in proportion as the liquors drank contain more of these, but it is not always so ; certain wines, such as Rhenish and Cham- pagne, contain very little, and produce intoxication often in a shorter time than those of Languedoc and Roussillon, Avhich contain a great deal more alcohol. 4. We know also, that when Avine is changed several times during a repast, one becomes intoxicated more rapidly than Avhen he drinks always ofthe same ; and it is evident that, in the latter case, the gastric mucous membrane be- comes habituated to the contact of the same stimulant, Avhilst several excitants irritate it more, although they be not more considerable in quantity. 5. Intoxication is rapid in proportion as the gastric sensi- bility is great; thus, it is more prompt in Avomen and chil- dren, in convalescents, and Avhen the stomach is empty, &c. We know that individuals, habituated to excesses, may in- gest enormous draughts of alcoholic liquors Avithout becom- ing intoxicated ; it is evident here, that the effect of the stimulant is less marked on account of habit. It is objected that the empire of the latter is not less over the irritability ofthe brain than over that ofthe stomach ; let them explain then, why some individuals become intoxicated Avith the greatest facility Avhen there is a gastric irritation ? We know that professed drinkers arrive at a point at which the least quantity of alcohol plunges them into intoxication, and we all knoAV that these men are affected, after a time, with chronic gastritis. These facts prove then, that it is the stomach, rather than the brain, Avhich becomes habituated to the stimulants. 6. Finally, Ave read in the dictionnaire des sciences medi- cates, a fact strongly favoring the opinion we sustain. Some sailors, Avho had remained for a long time in a state of entire deprivation, fell down dead in a state of intoxication, after having taken a single spoonful of brandy. We cannot refuse to attribute this extraordinary phenomenon to the exquisite sensibility of the stomach, developed by abstinence ; for, however active Ave may suppose absorption, however strong may have been the stimulation exercised by the alcoholic molecules, it is impossible that, disseminated in the mass of blood in so small a quantity, they could produce such an effect by stimulating the brain directly. L 0i* J Investigating the mode of action of intemperance, of rich diet, and other influences of the same nature, in the pro- duction of apoplexy, M. Richond asks if these causes only give rise to this malady by favoring, as is said, the develop- ment of a plethoric state. He remarks, that admitting this explanation, it will always remain to be known, why San- guine congestions, rendered more easy by the state of the plethora, take place in the brain in preference to other parts ; and supposing even, that they could give a satisfactory reason for it, we should still have a right to demand, why these congestions produce apoplexy ; for we know that, to be produced, this disease necessitates a preliminary irrita- tion, Avithout which it Avould be more frequently observed in the efforts during fits of coughing, lifting, labor, &c.; it is more exact then to attribute the influence exercised by these causes over the production of apoplexy, to irritation of the stomach which they develope very frequently, and of which the frequent indigestions and embarras gastriques, so often presented by intemperate men, are certain proofs. " Is it not by aggravating or by producing gastric irrita- tions," says M. Richond, " that mineral waters act, Avhich are so often fatal to paralytics and apoplectics, asWillesand Bordeu have observed ? that irritating medicines, such as emetics, purgatives, and tonics, employed so frequently against this disease, are often folloAved by fatal accidents ? Is it not for the same reason that persons who experience the precursory symptoms of apoplexy, cannot commit the slightest impropriety in regimen, without having vertigoes, and Avithout having to fear the explosion ofthe disease." Here M. Richond supports his opinion with the authority of a great number of authors Avho have established the in- fluence of these causes over the production of apoplexy.— This physician undertakes then to shoAV the influence exer- cised by acute and chronic gastro-enteritis, over other cere- bral diseases. We will not follow him in all these details, presented by us on a former occasion ; but we will stop to notice with him those lesions, vaguely designated under the name of nervous diseases. One may easily be convinced of the existence of gastric irritation in these affections, by- analyzing the symptoms given by most authors of them.— In the treatise on nervous diseases, by Whyt, Ave find the following picture of their phenomena : " Pungent heat in the belly, acid eructations, disgust, aversion for food, fre- i. 349 j quent vomiting, indigestions, a sensation of vacuity about tht region of the stomach, capricious desires for food, tension, constriction at the epigastrium, pulsations in the abdomen, colics, flatulency, and borborygmus." M. Richond shows that the nervous phenomena of hypo- chondria emanate from the digestive passages affected with chronic inflammation. We have already furnished proof of this assertion in the history of chronic gastritis. When Ave consider the causes of insanity, Ave see a great many which exercise their influence on the digestive pass- ages: and if we examine its phenomena, Ave also see that the greater part of those connected Avith delirium relate to their irritation. We often see indeed, paroxysms come on after eating, the delirium become more continued and more com- plete under the influence of exciting regimen, and contrary effects produced by a severe regimen. "The nature of the affections giving rise to periodic mania, and the affinities of this disease with melancholy and hypochondria, should make us presume that the primative seat of it is almost al- Avays in the epigastric region, and that it is from this centre are propagated, as by a kind of irradiation, the paroxysms of mania.—Insane persons, at the commencement of the paroxysm, complain of constriction in the epigastric region, disgust for food, obstinate constipation, and a sense of internal heat, Avhich makes them desire refreshing drinks." As continued mania differs only in type from that of which M. Pinel speaks, Ave may reasonably apply to it Avhat he says of the latter. 0¥ AST¥LEKIii. We have seen, in the commencement of this work, that the vital action may undergo two modifications, opposite in their essence, acknowledging sometimes the same causes, Avhose results are not unfrequently confounded. These tAvo states are, superexcitement or irritation, and sub-excite- ment or debility. Asthenia is that state of an organ in which the energy of the vital action is beloAV the normal type; that is to say, below the degree necessary for the purposes of its nutrition and function. This condition has only been well under- stood since we possess positive notions on the action of modifiers on the organs, on the particular vitality of each of them, and on their sympathies. Ignorant of all this know- ledge, Brown considered the economy en masse, and estab- lished, that excitability Avas one and indivisible, and that consequently, excitement (vital action) was identical throughout the organism, and that it could never augment in one part Avhilst it diminished in another, and vice versa. Setting out Avith these principles, the Scotch reformer only saw diseases at a distance, considered only the exterior of man, and seeing muscular Aveakness come on at the com- mencement of almost all lesions, Avithout taking account ot the nature of their causes, he Avas led to regard only the as- thenia and the indication for stimulating in almost all diseas- es. If, in proclaiming that life Avas only kept up by stimu- lants, Browii laid the foundation of correct physiology ; if, by the developments given to this truth, the science OAves to him the triumph of vitalism over the vain theories of hu- moralists, mechanicians and animists,w7e should acknowlege also, that all the applications made by him of this great prin- ciple to physiology and pathology, were very unfortunate, and that they established doctrines quite as erroneous, and still more dangerous than those which he overturned. By- establishing the unity of excitability and of excitement, the Edinburgh physician could no longer arrive at any truth ; he threAV himself into the path of error. L 351 ] The labors of Bichat raised an insurmountable obstacle to the invasion of Brownism ; they did not, however, pro- duce at once the great results Avhich they Avere destined to furnish a few years after. Although physicians were more struck with the necessity of searching out the seat of diseases, of studying the sympathies of the different organic tissues, and the lesions they may present, they did not the less con- tinue, however, to admit general diseases, and to regard as asthenic most of those affecting weak subjects, which come on under the influence of causes apparently debilitating, and sometimes disappearing under the use of tonics. They re- jected the asthenic inflammations of Brown, but they created adynamic febrile states : thus, what they destroyed on one side, they built up on the other ; and at the very time when BroAvnism was the subject of the most violent attacks, it insinuated itself into all the theories, and directed the prac- tice of all physicians. There remains nothing for us to dotOAvards circumscribing asthenia within the bounds in which it should be restrained; the principles presented by us on irritation considered in general, the description given of the different forms of gas- tro-enteritis, the relations we have shown between this in- flammation and other irritations, and finally the discussions in which we have indulged whilst attaching to superexcite- ment a crowd of diseases, before attributed to debility, liberates us from the necessity of making new efforts to prove that, in the doctrines M. Broussais has overturned, this modification of vital action played a much too impor- tant a part; Ave will then make it the subject of only a feAV general considerations. Asthenia should be studied after the same principles as irritation. It must be considered in each organ in particu- lar and in each organic system, the mode of action of the causes producing it examined, and the influence exercised by debilitated parts over all the others. Asthenia results 1st, from the partial or total Avithdrawal of the stimulants which put in action the irritability of the tissues ; 2d, from the irritation of another part. In the se- cond case, it is secondary, or indirect; in the first, it may be direct, or produced sympathetically, or, to speak with more exactitude, indirectly. We knoAV indeed, that the stimu- lants which keep up the vital action, are applied directly to the organs, or that the latter receive sympathetically, the • [ 352 ] stimulation exercised by other organs. They wiil fall thei. into a state of debility more or less profound, if one of these two sources of irritation be withdrawn. It is thus that the stomach will become affected with asthenia, if it receive but a small quantity of food, containing little nourishment, and be constantly in contact Avith mucilaginous fluids ; it Avill then no longer enjoy the degree of action necessary to the exercise of its functions. Now, this organ, entertaining Avith all the others the closest relations, and the stimulation Avhich it undergoes in a state of health, extending to the whole economy, the other organs, and especially the brain, the heart and muscles, are no longer sufficiently stimulated, Avhen the stomach is in a state of asthenia, and their respec- tive functions languish ; for the excitation which it sends to them, is indispensable to the continuance of their action. Asthenia produced by the withdraAvingof stimulants does not always continue for a long time; the debilitated part may react, and this reaction produce an irritation ; it is thus, that after the action of cold, Avhich makes the tissues pale and diminishes their sensibility Avhile it acts, we see redness and heat, and often a real inflammation appear.— Other circumstances may determine irritation in the tissues affected Avith asthenia; it is thus that Ave have seen, on a former occasion, when treating of dyspepsia, phlogosis of the stomach take the place of debility, because aliments re- maining for a longer time then in its cavity, and not being completely elaborated, fatigue and irritate the mucous membrane. Weakness depends oftener on the concentration of vitali- ty in another part, than on defect of stimulation. We will not repeat here what Ave have already said on this subject, when treating on the phenomena of revulsion ; Ave estab- lished then, in an incontestable manner, that when the forces are concentrated in one part, one or sev7eral others fall into a state of asthenia. This is the reason why the first sensation felt by patients, is that of Aveakness, Avhen a viscus is inflamed, and it is thus that gastro-enteritis produ- ces muscular prostration ; and reciprocally the excitability- diminishes in the gastro-intestinal mucous membrane Avhen it is increased in the muscles. We know that the stomach may support, without being inflamed, the most energetic stimulants in frightful doses, during traumatic tetanus.— 0 There is. however, a degree at Avhich stimulation is no [ 353 ] longer innocent: I have several times seen violent gastro- enteritis spring up during the course of this terrible affection, after the administration of musk and camphor; and twice, I have seen in the dead body the gastric mucous mem- brane, disorganized after the use ofthe tincture of canthari- des, recommended latterly in tetanus, by a German physi- cian, Avho wishes thus to establish a revulsion on the urinary- organs. From the knowledge of these phenomena results a very important principle, already established at the commence- ment of this Avork, viz : that, under the influence of debili- tating causes, weakness is never general; that irritation and asthenia are almost always met with at the same time in the same individual. We have just seen, indeed, that the latter is most frequently the result of inflammation, and, in cases where it is produced directly or secondarily, by the removal of stimulants, it still very often happens that it is accompa- nied by irritation in other parts; thus diminution of action in the skin, produces an increase of that of the pulmonary mucous membrane ; for in the same manner as the inflam- mation of one part gives rise often to asthenia in another, the latter produces irritation of organs having an inverse re- lation of action Avith those debilitated. We know that tissues which have been inflamed often, preserve for a long time great sensibility, and even a chronic irritation ; sometimes an appearance quite opposite takes place: Ave see, in the interval between the paroxysms of certain intermittent gastro-enterites, the tongue become white, moist, and broad ; a circumstance which, joined to want of appetite for food and drink, to uneasiness and weak- ness, denotes a state of asthenia of the stomach. We some- times observe the same phenomena in lymphatic individuals, after acute gastro-enteritis, wdiich has necessitated long abstinence and copious sanguine evacuations. In tissues affected with organic degenerations, they might suppose sometimes also, that asthenia has taken the place of irrita- tion ; but, on considering with a little attention what passes in these cases, one will soon discover this opinion to be er- roneous. Let, under the influence of irritation, there be developed in a red tissue, a fibro-cartilaginous tissue ; the latter will possess a less elevated degree of vitality than the part Avhich it has displaced ; but this degree being in rela- s 2 [ 354 ] tion with the organization of the new tissue, we cannot say that it is in a state of asthenia. Doctor Boisseau formerly asked if asthenia of an impor- tant organ does not promptly bring on asthenia of all the others, and if the bond uniting the organs together, would be less close in this case than in that of an irritation ? What we have said of the debility experienced by a part when it is deprived of the stimulation it receives from an organ ac- tually debiiitatod, ansAvers this question. Asthenia cannot be transmitted in the same manner as irritation, by nervous irradiations ; it extends, on the contrary, only by the cessa- tion of the sympathetic influence which the first exercised over the re.ond. In order thoroughly to comprehend the phenomena of asthenia, Ave should recollect that each organ presents tAvo orders of movements, the one relative to its nutrition, the other to its function. Asthenia may manifest itself by dimi- nution of the activity of nutrition, or by that of functions ; we Avill call the first, Avith Boisseau, asthenia of nutrition, and the second, asthenia of function—the latter may be connected with the former; it is thus Ave see atrophied mus- cles deprived at the same time of the faculty of contracting ; but more frequently the diminution or abolition of the func- tion dep. nds on the exaggeration of organic phenomena ; in other words, the asthenia of function of an organ, is most frequently connected Avith its inflammation ; thus the in- flamed stomach is no longer fitted for digestion : it is the same with the kidneys in the secretion of urine ; the mus- cles, for their contraction ; the brain, for the cerebral func- tions; the eye for vision, &c. If they had established this distinction, they would not have stimulated the organs whose functions Avere languishing, and they would not have criti- cised the definition of a nosographer Avho has said inflamma- tion was the exaltation ofthe vital properties; a definition which Avould be exact, if he had substituted the expression vital action for that of vital properties. Asthenia of nutrition may produce asthenia of function ; but it can never produce its exaltation. Abolition of the function of an organ may also bring on diminution of its or- ganic phenomena ; it is thus that loss of motion in the mus- cles of a limb is followed by atrophy, because the function itself is a stimulant for the organ executing it, as Brown has well established. It is remarkable, that in general the [ 355 ] causes producing exaggeration of organic phenomena, pro- duce asthenia of function, that those calculated to give to the latter more activity, actin an inverse manner, when compared Avith the former. We have just seen that inflamed organs were no longer fitted to the execution of their functions ; the excess of its exercise, and the too long continued action Of stimuhnts produce the same result. We know that amaurosis is freq.ient in individuals who are by their pro- fession exposed to the action of strong light; that venereal ex esses no longer permit but feeble erections ; that im- possibility of moving is the result of muscular contraction, too long continued ; and that exclusion of light, continence and repose restore to the retina its sensibility, to the penis its erectile power, and to the muscles all the force of their contractions. The treatment of asthenia is very simple, Avhen we know how to trace it to its cause ; it is evident, from the preceding considerations, that but two indications are presented : 1st, when the debility is the result of the subtraction of excitants, to restore to the organ which has been deprived of them its natural stimulants ; sometimes to recur to more energetic stimulants, or to stimulate the organ whose primative debi- lity has brought on secondary asthenia in another part; 2d, Avhen it is the consequence of an irritation, to overcome the latter and to stimulate the debilitated organ, if this can be done Avithout adding to the irritation of the other. The first indication is always easy to fulfil, but it is ne- cessary to use the greatest circumspection in the employ- ment of excitants; debilitated vitality resumes its normal type with the greatest facility. Avhereas we are never cer- tain of destroying the inflammations which we may give rise to by the abuse of tonics : Ave should fear it the more, since, as we have already established, the indication for stimula- ting rarely presents itself alone; there exists often, at the same time, a point of irritation which we should be cautious not to exasperate, or we have to fear the reappearance of the inflammation, during the treatment of which asthenia came on. It is never necessary, under these circumstances, to recur to poAverful tonics ; Ave should only restore to the debilitated organs their natural stimulants; for farther in- formation on this subject Ave refer to what Ave have already said on convalescence. Although the first indication is easy to fulfil, the second [ 356 ] often presents difficulties ; inflammations producing asthenia of a part of the organism are ordinarily violent or chronic ; and we know that too often both are beyond the resorces of therapeutics. However this may be, the debility accom- panying irritations does not allow of any other treatment than that proper to destroy the cause keeping it up, as long as the latter is sufficiently intense to be exasperated by tonics ; hence the daoger of their employment in gastro- enteritis, under the adynamic form, in chronic gastro-ente- ritis, &c.: as soon as the contrary takes place, says the author of the Examen, the debility furnishes indications which combine Avith those depending on irritation ; finally, when the latter has ceased, debility becomes the principal disease ; but irritability ofthe organs exacts careful manage- ment in the employment of stimulants. Amongst the last propositions of the Examen, are found some very important precepts on the cases in which it is proper to recur to tonics. Such is the only point of view in which asthenia can be considered ; what we have said on the subject is sufficient to show the clearness shed by the physiological medicine over its theory, and to answer the reproach which has been ut- tered against the new doctrine, of having studied and knoAvn nothing but irritation. F I N I * .- APPENDIX, MANNER OF KEEPING AND USING LEECHES, &C. Topical blood-letting, of late so much employed in Eu- rope and some of the larger cities of the United States, is scarcely resorted to at all, and its principles are imperfectly understood, by practitioners of the country and smaller towns—particularly at the South. This neglect of so important a therapeutic agent, is mainly OAving to two circumstances, viz : 1st, ignorance of its real value, and secondly, a Avant ofthe information necessary for catching, keeping, and employing leeches. From these considerations, I am induced to give a few details Avhich may not be unacceptable to those of the profession who have not had the facilities for acquiring information on this subject. Leeches abound in the Avaters of all parts of the United States, and no where are they more abundant or of better quality than in the Carolinas. An idea has gone abroad, that none but the Hirudo Medicinalis is fit for use, and that some of the species are even poisonous. This is incorrect; any leech that ivill bite may be used ivilhout fear of dan- ger. I have used them from several districts of South Ca- rolina, and found them to ansAver perfectly Avell. The Hirudo Medicinalis has not yet been found in this country. It is said that the best Spanish leeches will draw an ounce of blood each. Those I have seen will not draw more than half this quantity, and probably not average so much. Our leeches, when of good quality, will not average more than a drachm and a half. Their small size, however, I do not think an objection, but in many respects an advantage: They bite quite as Avell as the Spanish, cause much less pain and irritation, and the bites being smaller hre much less op: X I*. [ 358 ] to be followed by troublesome hemorrhage, Avhich is a fre- quent consequence of the Spanish leech in delicate females and children. We have only to multiply the number in the proportion of about three to one. Leeches are found most abundant in still fresh Avater—as ponds, and meadoAV streams. They are generally caught by boys Avho go into the water and muddy it; the leeches then rise to the surface or fasten on their legs, Avhen they may be taken up and put into a vessel of any kind. They are also sometimes caught by spreading a fresh sheep skin or any- other skin on the surface of the water, Avith the raAV side downwards, to which they will attach themselves. The method of keeping them Avhich I have found to suc- ceed best is the following—Take a perfectly clean cask and saw it in the middle, so as to make two tubs, then burn some shavings of wood in them for the purpose of purifying them and charring their internal surface superficially—a hole is then bored in the bottom in order to draw oft' the Avater, which should be changed every day or two. Very little Avater is required ; not more than one or tAvo inches in depth. There should always be put into the tub, two or three clods of marsh grass, with mud attached to it. This is an impor- tant direction ; for they never do Avell Avithout mud and re- quire grass or moss to wipe off the slime which forms on their bodies. If this be neglected, they become sickly. They are apt to crawl out of the tub if some precaution be not taken to prevent them. This difficulty is easily remedied by the following simple method.—Take a little Avet clay and smear the upper part ofthe tub for about eight or ten inches on the inside. When it becomes dry the leeches will not crawl over it. The tubs should remain uncovered so as to allow air freely—Avhen they are kept too close the leeches become languid, and bite Avith reluctance. Leeches are very cleanly animals, and require a great deal of particularity. Any disagreeable odour—even the natu- ral perspiration of the body, is offensive to them. It is therefore necessary that the part on Avhich they are applied should be washed perfectly clean, and be free from hair, otherwise it is often impossible to make them take hold. When they refuse Ave sometimes succeed by AA7ashing the part in hot Avater and rubbing it Avith a piece of flannel, so as to draw the blood to the surface. Wetting the part Avith a little sAveetened milkAA7ill sometimcsanswer. Generally j 35! > iiow-ever, tiie} will not bite unless the part be covered with blood. They should always be taken out of water an hour or two before they are used, in order to accustom them to the air. The best plan of applying them generally, is to put them into a tumbler or tin cup, about one third full of water. Then place the lip of the cup in contact Avith the part on which y7ou wish them to fasten and tilt it until the water is near running out. They will then crawl up and lay hold. They should be alloAved to suck until they become full and drop off, Avhich will be in about half an hour. If they are ta- ken off forcibly, they are apt to be deprived of their teeth. Those which fall oft* spontaneously, remain possessed of their teeth, and may be used repeatedly. In order to make them disgorge themselves, they should be put for a feAV moments into a weak solution of salt in Ava- ter, or Av'hat is better, into porter. The best plan, hoAvever. of getting the blood out of them,Avhich I have seen tried, is to make a small incision Avith a lancet, in the back near the tail, and strip it out with the fingers. FeAver die under this treatment than any other I am acquainted Avith. They will be fit for use again in a Aveek or ten days, and I have seen the same leeches bite ten or tAvelve times. If the blood be allowed to remain in them, it will be digested and they will bite again in about a month. But a much greater propor- tion die than Avhen the blood is abstracted from them. There may be some difficulty, Avith persons unaccustomed to their employment, in determining the proper number to be applied, under various circumstances. This difficulty, howeA'er, Avill soon be overcome by a little experience and observation. In all cases Ave should look first to the state of the general circulation. When this is strong, the pulse full and hard, a general bleeding should be premised, in order to reduce its force, before topical bleeding is resorted to. If this precau- tion be not attended to, the topical bleeding instead of prov- ing beneficial, will often aggravate the disease ; for while the vis a tergo of the large vessels is energetic, little or no impression can be made on the capillaries. The irritation caused by the leech bites or scarifications, will be extended to or reflected sympathetically on the inflamed part, and produce an increased afflux of blood into its vessels, already- laboring under superexcitement and engorgement. In this ■ I otiO ) nnmuer the good effects of the topical depletion will be more than counterbalanced. Rush said there was a blis- tering point. There is also a point for topical blood-letting in visceral inflammations, and this point must be determin- ed by observation. When the inflammation of any organ or tissue does not produce a marked increase in the activity of the heart and arteries, we may without any preparation re- sort to topical bleeding at once. One of the great advantages of cups and leeches is, that they may be used Avith safety and decided good effect, Avhere the local inflammation continues after the pa tient is too far reduced to bear bleeding from the arm. In these cases topical blood-letting is the most potent of all our means, and a person who has not been in the habit of Avit- nessing its employment, could scarcely credit the effect of- ten produced by the application of a small number of cups or leeches. Another very important fact, and one insisted on in the text, is the great superiority of capillary over general bleeding in membranous inflammations. Vene- section, so efficacious in the acute inflammations of Parenchymatous organs, seems but partially to reach those of the membranous tissues—those of the mucous mem- brane of the stomach and intestines, the peritoneum, the meninges, &c. for example ; in these cases a small quan- tity of blood by leeches or cups produces a much better effect than a large quantity from the arm. A great pro- portion of our fall fevers do not require the lancet, but are always benefitted by leeches to the epigastrium or head, Avhen the stomach or brain is much affected. I have often been asked the question, why the abstraction of blood from one part should produce effects different from those caused by its abstraction from any other part ? It is said that the blood moves in a circle and that it is immaterial from Avhat point it is drawn. Those AA7ho argue thus have studied very imperfectly the laws by Avhich the circulation is governed, and have yet a great deal to learn Avith regard to the effects of capillary bleeding. No one can deny the de- pendence of the capillary on the general circulation to a certain extent; but the most prejudiced mind cannot hon- estly investigate the subject without allowing to the capilla- ry system laAvs peculiar to itself. Facts satisfactorily estab- lish, that the motion of the blood in the capillaries, is not governed by the vis a tergo alone of the heart and arteries. 361 it Ave examine with a microscope, a point on the web ui w. frog's foot, irritated by a drop of concentrated acid, or in any other manner, we see the blood of the surrounding parts flowing to the irritated focus, without any regard to the di- rect course of the blood from artery to vein. How could this be if the blood moved ahvays in a circle ? How could any unequal distribution of blood take place if this were the case ? There must be a point also at which a portion of the blood escapes from the vascular tubes, else of what use could it be to the economy ? Hoav could any interstitial molecular action be operated, as nutrition, decomposition, &c. ? There is a point then at which the blood becomes emancipated, to a great extent, from the direction of the heart and arteries, and becomes subject to other forces. What these are Ave know not: they are inscrutable to our senses. But it is not my intention to enter into this dis- cussion here. No physiologist, from Bichat doAvn to the present day, doubts that the capillary system has laws pe- culiar to itself, and those who choose to investigate the sub- ject may soon be satisfied of it. Perhaps it may be somewhat difficult to explain satisfac- torily the modus operandi of capillary bleeding. How, for instance, a few leeches to the epigastrium can relieve a gas- tritis, when double the quantity of blood from the arm will make no impression on the disease. Howev7er difficult it may be to explain the quo modo, ike fact is so, and Avhoev- er tries the experiment will be convinced. I have repeat- edly seen patients laboring under a termination of blood to the head, w7ith indications of apoplexy, who had been bled from the arm until the pulse at the wrist was almost extinct. Still the carotids beat violently, and there Avas little or no mitigation of the local determination. Under these circum- stances a few leeches or cups behind the ears or neck calm- ed it almost immediately. These facts hold also in other local determinations. The number of leeches proper.to be applied must be re- gulated by the strength of the patient, the acuteness of the disease, its seat, &c. By the European waiters Ave see from ten to thirty or forty recommended, but our leeches should be used in much greater profusion. In adults, dur- ing the acute stages of violent internal inflammations, such as pleurisy, peritonitis, gastro-enteritis, encephalitis, &c. we should apply from fifty to one hundred, when it is impor- *ant to make a prompt and decided impression. To person,- unaccustomed to the employment of these animals, the number 1 have mentioned may appear extravagant, but I have had ample opportunity during seA7eraly7ears attendance on the practice of the Philadelphia Almshouse, (the most extensive hospital in this country,) of being satisfied of the truth of Avhat I assert. The bleeding from the bites, after the leeches fall off, should be promoted by warm fomentations, in order to over- come, by the depletion, the local irritation produced. This precaution should be particularly attended to when the leech- es are applied upon or very near the inflamed part; otherwise the engorgement of the capillaries may be increased, and all the symptoms aggravated. The flow of blood from the bites sometimes continues too long, and it then becomes necessary to employ means calculated to stop it. Generally the bleeding may7 be stopped by merely binding on a dry towel. If this does not answer, heating the towel very hot and binding it on firmly, Avill almost ahvays be sufficient. Some times, hoAvever, the bleeding proves obstinate, and a strong solution of sulphate of copper must be used. Cases have occurred Avhere it Avas necessary to touch the bleeding bite with caustic, sulphuric acid, or even a heated Avire. I have been told that dropping a little melted sealing Avax on the bite will certainly7 prove effectual. Cases, how- ever, are very rare in which any attention is required to stop the flow of blood. I have never seen a case, where American leeches were used, in which the bleeding could not be commanded by moderate pressure Avith a hot toAvel. On the contrary, the difficulty is generally to get the bites to bleed as freely as Ave Avish. Here arises a very7 interesting question and one of great practical importance, viz : Avhat point is to be chosen for capillary bleeding, one near the diseased organ, on the in- flamed part itself, or at a distance from it. Authors have differed widely on this subject. Barthez, Vitet and others, have advised us to select the most distant point from the seat ofthe disease. In affections of the brain, opthalmia, croup, &c. for example, the leeches should be applied to the thighs or legs, says the latter, &c. This notion is main- tained by few physicians of the present day. The practice now is to apply them as near as possible to the inflamed organ, and sometimes even on the inflamed tissue itself. In [ 363 j ihis they conform to the precept of Celsus, Avho &ays, *- when Ave draAv blood for the purpose of relieving the Avhole body, Ave should open a vein in the arm ; but Avhen it is to un- load a particular part, Ave should deplete from the affected part, or from that Avhich is nearest to it.^ The following directions are important, and I think may- be depended on : In inflammations of the gastro-intestinal mucous mem- brane, leeches or cups Avhen resorted to should be applied to the epigastrium, or Avhatever point of the abdomen may- correspond to the affected part. If the lower boAvels be af- fected, as in dysentery, leeches act best when applied to the anus. In inflammations of the appendages ofthe digestive canal, the liver, spleen, pancreas, peritoneum, for example, on the point corresponding to the pain or seat of the disease. In inflammations of the genito-urinaiy organs, on the hypogastrium, perineum, anus, thighs, root of the penis, track of urethra, on the scrotum, labia, and even the neck of the uterus, &c. In otitis, Ave should place them around the ear and on the lateral parts of the neck ; in croup and the different anginas, on the course of the jugular veins. FolloAving out these principles we should *ln opthalmia j place the leeches on the eyelids and temples. Some phy- sicians advise them even to the conjunctiva. Having, how-' ever, repeatedly seen acute opthalmia aggravated by apply- ing leeches or cups too near, I have been induced to abandon this plan. When applied too near, the irritation produced by leeches or cups, will, I believe, as often increase as di- minish the intensity of the disease—in these cases the leeches or cups should be applied behind the ears or neck- In chronic opthalmia they may be applied to the temples and lids, in subjects Avho are not very irritable, but after the leeches drop off the bleeding should be kept up by warm fo- mentations or poultices, in order to allay the irritation pro- duced. In these cases the smallest sized leeches should be used, as they cause very little irritation. In thoracic inflammations Ave place them on the point cor- responding to the pain. In erysipelas simple or phlegmonous, in inflammation of the cellular tissue and of the external lymphatic vessels and in cancer, around the inflamed part—so also in rheumatism L 364 j and goui. k lequentiy acute rheumatism and gout depend oi< gastritis and I have seen in such cases prompt relief of the articular pains from the application of leeches to the epigas- trium—even after general bleeding had been pushed to the utmost point unav7ailingly7. In inflammations of the brain and its envelopes, behind the ears, over the jugulars, back of the neck, and Avhen the pain is confined to the anterior part ofthe head, sometimes on the temples. These directions are of great practical impor- tance. I have very frequently seen leeches and cups on the forehead fail to produce relief from the encephalic symp- toms, Avhen a cup or a feAv leeches, behind each ear, over- came the pain, and local determination of blood immediately. When applied on the forehead, instead of relieving I have seen them aggravate the disease. I remember two instan- ces particularly Avhich occurred in the Philadelphia alms house. There was in each of these cases a strong termi- nation of blood to the head, and cups Avere applied to the forehead for the purpose of relieving it—the cups however, had been on but a very short time before violent convul- sions supervened. The explanation of these facts appears to me simple enough. When cups or leeches are applied to the forehead, the irritation and suction produced, call the blood to this'point and increase the activity of the circula- tion through the branches of the carotids, and the congestion in the brain must of course be increased. When on the contrary the cups or leeches are applied behind the ears, over the jugulars, or to the back of the neck, the blood is diverted from the brain. If Ave Avish to establish a hemorrhoidal or menstrual Aoav, we should apply leeches to the anus or vulva. It is better in such cases to apply a feAV leeches at a time and apply them frequently ; for Ave want a revulsive as much as a depleting action, and if a feAV leeches only are applied, the depletion will not be sufficient to overcome entirely the irritating or revulsive action produced by the bites. It may not be amiss to add a few very general remarks on the comparative effects of leeching and cupping. When the patient is irritable and the disease acute, leech- es are ahvays to be preferred; because they produce much less irritation than cups, and are therefore much less apt to cause sympathetic irritation on other organs. In acute internal inflammations, accompanied by high fever and i [ 365 ] great sensibility, I have seen the pain and irritation from cups aggravate all the symptoms. In inflammations of the abdominal viscera accompanied with fever, leeches are much to be preferred to cups; for there is so much adipose matter beneath the integuments ofthe abdomen, that in most cases very little blood can be abstracted by the latter—their effect then is more, that of irritation than depletion. Cups on the contrary are very efficacious in affections of the thoracic viscera. They are here resisted by very lit- tle adipose matter and draw blood freely if the scarificator be sharp, which is always a matter of importance. In these cases they answer nearly as well as leeches, Avhere the pa- tient is not very irritable. They generally answer very well in affections of the brain, Avhen applied to the back of the neck or behind the ears. As a general rule, leeches are to be preferred in all acute, and cups in chronic inflammations. For in addition to the depletion, scarified cups produce a pretty poAverful revulsive effect and this combination of depletion and revulsion is peculiarly Avell adapted to the treatment of chronic phleg- masia?.— Trails. GLOSSARY. Abnormal. By abnormal action we mean morbid action, or a deviation from the normal or natural action of a part. Asthenia. Langour of vital action ; debility. Atony. Weakness, flaccidity; diminution or loss of tonicity. Animism. Doctrine of Stahl, who contended that the soul pre- sided over all the actions ofthe organism. Animist. A. partisan of this system. Ancemia. Want of blood ; a disease in which the blood is not in sufficient quantity to support life, and appears to have lost its color, consistence and exciting qualities. Adynamia. Want of force ; debility, weakness. Adynamic fever, is according to Pinel, characterized by dimi- nution of the cerebral functions, and of the muscular forces ; ty- phus. Ataxia. Disorder, irregularity; trouble of animal spirits, of the vital principles, of the functions of the nervous system. Ataxic Fever. Pinel has given this name to the malignant or nervous fever, because it is announce by irregularity in its symp- toms. Carcinoma. Cancer. Deuteropathia. A morbid state which is developed under the influence of another disease ; sympathy. Diagnosis. The science which teaches the signs by which one disease may be distinguished from all others. Deperdition. Loss; a term frequently applied to alvine eva- cuations. Excitation. Partial or general exaltation of vital action; in- creased action of apart; applied also to the natural degree of ex- citement, Encephaloid. A morbid formation (thought by some to be can- cerous) resembling medullary matter. [ 368 ] Embarras Gastrique. A shade of gastric irritation, in Avhich there is loss of appetite, bitterness and clamminess of the mouth, tongue white or yellow, sense of uneasiness at the epigastrium, and sometimes pain in this region, with nausea and bilious vomit- ing : this condition is accompanied with head ache, lassitude and pains in the back and members. Etiology. The part of pathology whose end is the study or knowledge of the causes of diseases. Erethysmus. Increased sensibility and irritability. Expectantism. An expression used of late to designate the ma- nia of expectation, shewn by certain physicians, who taking Hip- pocrates as their model, abandon diseases to the efforts of nature alone. Expectation. To be contented with abandoning diseases, to remove the causes Avhich may produce them, or those which may trammel their march, by taking care not to administer any active remedy, unless some pressing circumstance require it: this is what constitutes the therapeutic method, known under the name of expectation. Essential Fevers. Idiopathic fevers; fevers supposed to exist without a local origin. Embonpoint. Good plight of body; fleshiness. Exutories. Artificial ulcerations established for the purpose of revulsion; such as issues, setons, &c. &c. Fuliginous. Sooty; term applied to the black appearance ofthe tongue in typhus, &c. Bypertrophia. Condition of a part in which its nutrition takes place with great activity, and by this means produces a conside- rable increase of volume. Humorism—Humoralism. A medical doctrine, in which all diseases are referred to a vitiation ofthe humors, in their nature, quantity or distribution. Irritability. A quality belonging exclusively to organized, living bodies, which makes certain parts ofthe body execute, (with- out the whole Being participating in them, or even feeling them,) sudden and more or less remarkable movements, whenever pro- voked by an exciting cause. Irritation. The state of anorganic tissue or of an organ, in which there is an excess of the internal vital movement, manifested or- dinarily by the increased activity of the circulation and exalta- tion of sensibility. Broussais defines irritation, "the morbid su- perexcitation of vitality." It is defined also, "vital excitation increased to a degree beyond the normal type, peculiar to the subject." Inflammation. State of an organic tissue, accompanied by red- ness, heat, tumefaction, and pain. Such is the definition of inflam; mation most generally adopted. Broussais contends that we should [ 369 ] give this name to every local exaltation of the organic movements, sufficiently considerable to disturb the harmony of the functions, and to disorganize the tissue in which it is seated. He has since extended the name of inflammation to irritations which do not produce disorganization ofthe tissues, and to diseases which,be- fore him, had been called, and are still called fevers Idiosyncrasy. " A disposition resulting from the greater or less vital energy given to such or such an organ in certain individuals, and which makes them present, either in the actions of these or- gans, or in the manner which they themselves are affected by ex- ternal agei ts, phenomena more or less different from those obser- ved under similar circumstances in most other men.'; A pecu- liarity of constitution, in which a person is affected by certain agents, which, if applied to a hundred other persons, would pro- duce no effect. Insomnolence. Inability to sleep ; sleeplessness; sleep disturb- ed by dreams, &c. Iatraleptic. The method of using medicines externally by frictions, unctions, &c. Lesion. This name is given to all the morbid changes which may take place in'the vitality of the organs, or in the accomplish- ment of the functions"1 which they are charged with. By organic lesions, we mean tnose in which the structure or organization of a partis altered; a wound, an ulcer, &c. are of .this kind; every deviation from the healthy state of a part is a lesion. Lardaceous. This name has been given to those tissues of the economy, which having undergone cancerous degeneration, as sumea lardy or fatty appearance. Melanosis. Laennec gives this name to accidental morbid productions, homogeneous, slightly humid, of a deep black, opa- que, having some analogy with the bronchial glands; at first hard, when they commence to soften, there oozes from them a thin red- dish fluid mixed with little black clots; when they are completely softened they are converted into a soft black mass about the con- sistence of pap. Motility. The faculty of moving. Mobility. Facility of changing place ; very great nervous sus ceptibility, united to a convulsive disposition ; excitability- very highly developed. Modifier. We designate by this term any external agent, which changes or modifies the actions of the tissues. Normal. By the normal condition or action of a part, we mean its natural or healthy state—when there is a deviation from this, the action is abnormal or morbid. Ontologist. M. Broussais designates by this term, those phy- sicians who have reasoned upon diseases as essences, as distinct Beings, existing independently of the affected organs. [ 37a ] Organism. The concourse of actions by which the life of a living body is accomplished; the assemblage ot the laws which govern the animal economy. This name is also given to the liv- ing body itself—thus the organism and the animal system are sy- nonymous terms. Orgasm. Erection—the state of a tissue or of an organ when the vital action is carried to the highest degree of intensity—ir- ritation. Phlegmasia. Synonyme of inflammation. Prodrome. The time which precedes the invasion ofthe dis- ease. It is characterized by various phenomena or signs, called forerunners, precursors, &c. Pyretology. Treatise on fevers. Pathology. The study or knowledge of the organs considered in a state of disease ; it teaches the seat and nature of disease. Physiology. The knowledge of the actions executed by the organs or apparatus of organs in a state of health: pathology ex- amines these actions when diseased. Physiological Doctrine—Physiological School. Titles assum- ed by Broussais and his sect for their school and doctrine. Prognosis. Judgement formed by the physician on the march and termination which a disease is to take. Prognostic. We name thus the signs from which we foresee what will take place, fortunate or unfortunate, in the course of a disease; and what will be its issue. Phlogosis. Inflamation. Ptisan, This name is given to medicated liquids, having wa- ter as a vehicle and in which the medicinal substance is so dilu- ted that they can be drunk in great abundance; most ptisans are infusions or decoctions of light vegetables, fruits, farinacious ar- ticles, &c. sweetened and flavoured. Repercussive. A name given to any medicinal agent, which, when aplied on a part towards which the fluids flow, by the effect of an irritation direct or sympathetic, produces a reflux of these fluids towards the interior. Resolvents—Resolutives. A name given to those remedies Avhich favour the resolution of an engorged or tumified part. Ramollissment. Softening of a tissue; supposed to be the re- sult of inflamation. Revulsive. A name given to remedies employed to avert an irritation from the organ on Avhich it has fixed its seat. Revulsion. Is the spontaneous or artificial augmentation of the organic action of a system, of a portion of a system, or of an organ; producing a cessation of that existing in other parts; a blister on the nape ofthe neck relieves an inflamed eye by revul- sion. [ 371 ] Sthenia. Excess of tone; rigidity of the tissues; excess ot force of organic action ; exaltation of vital action. Septenary. Space of seven days. Sedative. A name given to all pharmaceutic agents which moderate or lower the organic action. Sedation. The action of sedative remedies. Saburra. Crude matters, the residue of alimentary substan- ces which has surmounted the digestive action; altered humours, in a word, morbid matters which were suppossed to be amassed in the stomach and intestines, and to which was attributed the production of a crowd of diseases. Semeiosis—Semiotice—Semeiology. That part of pathology which treats of the signs of disease. Sordes. Dirt, filth, faeces: applied to the foul accumulations about the mouth, and also matters in the stomach. N. B. I have principally taken these definitions from the Dictionnaire des Termes.—Trans. f '^ '*22.:>~*"0 NLM017440211