Part 3

The general objection amongst the French to the use of calomel prevails almost as strongly as at former periods; and certainly amounts to a prejudice. I learnt, on good authority, at Paris, that this medicine is usually found to act in a peculiar manner on the constitution of the French patient; as it commonly produces irritation in the intestinal canal to a degree that causes extreme discomfort. I need not relate with what freedom and satisfaction the English make use of this active medicine.

I apprehend that the difference of operation is to be ascribed chiefly to the respective nature of the diet in the two countries. The remark applies most particularly to the free use of light wines, amongst the French. The vin ordinaire must produce very different effects from the English malt liquor; or the use of plain or soda water, in conjunction with wines of more sound quality. Indeed the difference of regimen appears to me a sufficient explanation. I may here remark how very materially the action of mercurial medicine on the bowels is controuled by suitable preparation of the patient with mild mucilaginous drinks. If, on the contrary, the stomach and intestinal canal be charged with acescent liquor, vinous, or of any other kind, acescent food, and fresh fruits, irritation and disorder, more or less painful, may be expected as almost a certain consequence.

If the French employ calomel or other preparations of mercury too little, we doubtless run into the opposite error, of using them too much. It calls for the gravest censure, that, in almost every nursery, calomel should still be administered by the parent to young children and even infants, with as little consideration as if it were a simple domestic medicine. I am convinced that the infantile constitution is frequently most sensibly injured by so erroneous a practice, and that the scrophulous disposition, which might otherwise be dormant, is thus called into action at an early period of life. I think it ought to be an established rule, that mercurial medicine should not be administered to young children without the sanction of medical authority.

I wish, however, to be understood, that in speaking of the employment of calomel generally, I censure its abuse only. The proper use of it deserves our confidence and best regard; and I think that the French physician labours under great disadvantage in not having a just practical acquaintance with the virtues of this excellent medicine, which, as a remedy in various kinds of active disease, is without a rival.

Chiefly on the principle of avoiding the frequent use of internal medicine, it is a custom universal among the French to assist the bowels by lavement; which, under circumstances of disease, is variously medicated, but otherwise consists merely of water or gruel.

As an occasional remedy, this practice is most useful and important; and, in certain cases of great delicacy of constitution, it may be a very advisable substitute for aperient medicine, however regularly it may be required: but under ordinary circumstances, as a habit, it appears to me as objectionable in other respects as it is inconvenient. When the bowel becomes much accustomed to this artificial distension, it often fails to act without receiving such solicitation; and hence a mechanical necessity is established for this peculiar stimulus[5].

When the digestive powers of the stomach are unhealthy, and particularly when the functions of the duodenum and of the liver are also in error, as we usually see in established disorder of the chylopoetic viscera, the propagated influence which may take place from the lower bowel being stimulated to discharge its contents by means of the lavement, is insufficient to remedy the functional error existing so much higher up in the canal, and I have witnessed examples in which serious complaint in the liver has made insidious progress, from the circumstance of the patient having placed reliance on this palliative relief, and neglected the employment of an effective course of medicine.

The application of leeches, with a view to derive blood from the vessels which communicate with those of the lower bowels, is a practice quite common in France, and seems a favourite measure, whatever viscus of the body may be affected. I have no doubt of the utility of this mode of obtaining blood, when the lower part of the intestinal canal is in a state of congestion; and, I may add, in many cases of irritation. A gentleman had been troubled with diarrhœa, which was often painful, for two or three months. It had resisted the usual treatment by medicine. By one application of leeches near the rectum he was cured.

Nature often points out the propriety of relieving the overloaded circulation of the intestines, by the discharge of blood from the hemorrhoidal vessels, and when, therefore, the indications for such a mode of evacuation are presented, without any spontaneous relief having taken place, the use of leeches is important. Also in certain states of congestion of the uterine vessels, this method of local depletion will be attended with advantage.

In all cases of inflammation near the surface, in which the detraction of blood is proper, the application of leeches is a very eligible mode of treatment. I apprehend that blood is drawn from a greater number of capillary vessels by this method than by any other; such abstraction being favoured also by the gradual and protracted evacuation of the vessels. It remarkably relieves inflammatory action, either of the acute or chronic kind, in the stomach and bowels. It is by no means so effectual in maladies of the head and chest, in which cupping is a better mode of taking away blood; although occasionally, even in those complaints, the use of leeches may be more convenient, and even more appropriate.

Comparatively speaking, the practice of taking away blood by cupping is very rarely resorted to by the French, and they appear to prefer, in principle, the mode of bleeding by leeches, which they call derivative; thus for the relief of the head, they apply them in the neighbourhood of the rectum. That free cupping at the neck or behind the ears, or opening the jugular vein when the vessels of the head are in a state of congestion and increased action, is a far more efficacious treatment, appears to me most unquestionable.

I consider it to be an important principle of treatment in regard to the detraction of blood, in local inflammation, that we should make it from the system, when the action of the heart is much increased beyond the natural standard. When we have sufficiently reduced the pulse, or, if in the first instance the general circulation do not appear to be affected, it may be preferable to use cupping or leeches only.

In active inflammation of any of the important organs of the body, the _decided_ conduct of the English practitioner in using the lancet as his chief remedy, promptly and boldly, and persisting till the dangerous force of the disease is conquered, demands, in my opinion, an undoubted preference over the more tardy, and I must add, the inefficient methods of the French. This leading difference in the method of treating dangerous inflammations, appears to me to constitute the most remarkable distinction in the practice of the English and the French physician.

I believe that severe and dangerous diseases are much less frequent amongst the French than the English. There are physical and moral causes to explain this fact. Their climate is less variable, and less humid, than ours. They use a lighter diet; much more bodily exercise, and they are a more cheerful people, constantly cultivating amusement. Hence, probably, the general plan of French practice is simple; and the use of _tisanes_ and _lavemens emolliens_ is generally preferred to the employment of active medicines.

The pharmacien is not in any case permitted to prescribe; and no one can open a shop for the sale and preparation of medicines, without the permission of the authorities.

_La médecine expectante_ is still the favourite method of practice with many of the French physicians. I cannot undertake to say how generally. When the principle is directed by a clear judgment, there is much in it to be admired. A constant and too officious interference by means of active medicines, may do serious injury to the powers of the constitution; and, on such terms, the remedy may be worse than the disease: but, on the other hand, to look on passively as a spectator, and witness the formation of disease, forbearing all active treatment until formidable symptoms take place, seems more reprehensible even than excess of zeal in the use of medicine. I approve the maxim, _Venienti occurrite morbo_.

In inflammations of the most important organs of the body, if we allow delay, or want decision, the moment of being useful soon passes away. It is incumbent upon us always to pay due attention to natural indications, and to consider nature in the light of a good physician; but I maintain that, in all instances of acute disease, and for the most part in chronic, we may interpose our aid with certain benefit, if we form a correct diagnosis, and come armed with just principles of practice.

Within the last few years, new medical doctrines[6] have been introduced in France, by M. Broussais, Professor at the Hôpital du Val-de-Grâce at Paris; of which, the most important part relates to the inflammation of the mucous membrane of the alimentary canal. This inflammation is divided into acute and chronic, and is denominated according to its situation; _gastrite_, when affecting the stomach; _gastro-enterite_, when it extends from the stomach to the small intestines; and _colite_, when confined to the colon.

The great importance of the functions of the stomach and intestines, and the active sympathies which the stomach especially exchanges with every part of the body, almost as a centre of the nervous system, is one of the medical truths first taught in our schools, and is constantly demonstrated to our observation, both in health and sickness. But M. Broussais has extended to an unauthorized length, his theories founded on the inflammatory affection of the mucous membrane of the digestive canal; so that, if I mistake not, he assigns to it almost an universality of influence.

Our acquaintance with the _gastro-enterite_, is a key to the whole pathology of this Professor, who has taken a great lead in Paris, and formed a school of his peculiar doctrines. He considers that all the essential fevers of authors are only various forms of sympathetic phenomena, arising out of a gastro-enterite; that all the pretended nervous affections of the stomach are the result of a chronic gastrite; that the various dangerous disorders of the brain, for the most part, owe their origin to the state of the digestive passages, irritated with chronic disease; that in all the febrile phlegmasiæ, the stomach and small intestines are irritated in the commencement, if not during the whole progress of the malady; that the gout depends commonly on a chronic _gastro-enterite_, “which prepares and supports the irritation of the joints.”

He considers that _gastrite_ rarely exists alone, and that it is almost constantly joined with an inflammation of the small intestines.

He does not admit that there is any essential difference in the nature of gout and rheumatism.

This is a very concise epitome of the doctrines of M. Broussais, and is offered only as an outline.

The practice which is founded on this view of most of the diseases of the body is remarkably simple, and may be almost included in the free and repeated application of leeches to the most affected part of the abdomen; the use of fomentations and poultices to the seat of irritation; of emollient lavemens; of tisanes calculated to allay irritation; of the mildest nutriment, as veal broth with rice; also the greatest care is used to avoid every irritating material, whether medicinal or dietetic; and, to favour all these means by entire repose and time. The gravest fevers of the East and of the West; the plague itself; the fevers of our own country, continued or intermittent, typhoid or inflammatory, and the phlegmasiæ, appear to be all arranged under the same general principle of treatment.

From the observations which I had the opportunity of making at the hospitals in Paris, and from the attention I have since devoted to the examination of these doctrines, I am far more inclined to borrow, occasionally, from the opinions of M. Broussais, than implicitly to follow his theory or practice.

I am persuaded that the idea of inflammation of the mucous membrane, founded on the morbid appearance of the tongue, and a dry and heated state of the surface of the body, is often too strongly entertained. When the tongue is wholly red and dry, or red in part, with whitish or yellow fur on its edge, the inference may be fairly drawn, that the digestive organs are in a morbid condition, and which is further shewn by the loss of appetite, and by the state of unnatural thirst. I admit also that in these circumstances, there is a great susceptibility to inflammatory action in the mucous membrane of the stomach and small intestines; and the knowledge of this fact should make us extremely careful in the employment of any heating stimulus, medicinal or dietetic, in the treatment of fevers, or of the phlegmasiæ. I am also aware, that, in many cases of fever, terminating fatally, the morbid appearances on dissection will be found chiefly in the mucous membrane of the alimentary canal, but also in the mucous membrane of the bronchiæ; thus lending great support to the doctrines of M. Broussais. On the other hand, I have had occasion to notice deductions, in my opinion, too hastily drawn to be correct, from the mere appearance of redness here and there in the stomach and intestines, presenting to the zealous admirers of the doctrine in question, the full evidence of gastro-enterite. Respecting the precise interpretation due to such appearances on dissection, the best anatomists and pathologists will sometimes differ. I may here remark, that the inspection is now and then made too hastily and superficially: it is requisite that the state of the whole canal should be accurately traced. In the first view of the parts it may happen that scarcely any morbid appearance is discovered; but on extending the research, even the ulcerative process may be met with in patches: at La Charité I saw several examples exactly in point.

That an inflammatory state of the mucous digestive membrane is very influential upon the functions of the other organs, and of the brain especially, is unquestionable; but is it primary or consequential, in the order of occurrence? In reference to the question of continued fever, I apprehend that it is an effect, and not the primary cause of the general disease, which attacks the whole nervous system at once, afterwards producing disorder in parts of the body which are most predisposed to morbid action; and, certainly, it appears that such secondary disease most commonly falls upon the mucous membrane of the alimentary canal, and also on the bronchial membrane.

If in the outset of these observations I may seem to contradict my concluding remarks, I wish it to be understood that I admit the partial, but not the total, fitness of the doctrines in question. I object still more to the rigid practice which is enjoined of avoiding the use of purgative medicine, when the appearances of the tongue are such as I have described, notwithstanding that the patient may be free from nausea, or from tenderness or pain of the stomach or bowels. I consider that the preference is greatly due to our English practice of giving occasional doses of calomel, or some mercurial alterative, in combination with suitable purgatives, by means of which the vitiated secretions, always a source of irritation, are removed. But here again, I admit that we should look watchfully to the symptoms which may indicate the necessity or the propriety of applying, with freedom, leeches to the epigastric region, and subsequent fomentations, for the relief of inflammatory action, and of using purgative medicine, in such circumstances, with proportionate caution.

As a general statement, I would assert, that in the commencement of fever, continued, intermittent, or remittent, the action of an emetic, and of calomel joined with purgative medicine, is most beneficial and important; and the fear of producing _gastro-enterite_ by such measures, would lead us into the serious error of _omission_.

In cases of confirmed indigestion, our improved modern pathology leads us to the employment of those means which remove inflammatory irritation; as, the application of leeches, and other local remedies; the use of mild corrective medicines, abstinence from food, which calls the digestive powers into much action, and general regimen. We avoid using bitters and stimulants to provoke that appetite which nature has so wisely denied during the irritation of disease.

In active inflammation of the intestines, existing in conjunction with their obstruction, it must be our first care to remove the inflammatory action by general and local bleedings, and to refrain from the use of purgative medicines by the mouth, till this first object is accomplished, in case that such medicine causes sickness and vomiting, and evidently aggravates irritation. I do not doubt that much mischief is often produced by the solicitude of the practitioner to remove obstructed action of the bowels, instead of directing his treatment to the removal of inflammation, as the immediate and primary object to be fulfilled.

I will here take occasion to offer a few remarks on the subject of Gout and Rheumatism. The theoretical opinions advanced by M. Goupil to prove the identity of the two diseases, are to me quite unsatisfactory.

Gout never assails the husbandman who unites temperance with his labours; but he is not exempted from rheumatism in any of its forms. Gout is the disorder of peculiar constitutions, and of the adult age; but rheumatism occurs at every period of life, and to all constitutions.

On the assumption that gout is a _gastro-enterite_, with a developement of irritation in the joints, purgative medicines are prohibited, and the free application of leeches to the affected parts is recommended as the chief curative treatment.

I admit that in some circumstances of the gouty paroxysm, the mucous digestive membrane is affected with inflammatory irritation, requiring suitable and peculiar treatment; but, as a general principle of practice, I confidently advocate the use of alteratives and purgatives, and, with only occasional exceptions, disapprove of the employment of leeches as a remedy for the local part of the disease.

As in theory, so in practice, I believe that M. Broussais considers that rheumatism is to be viewed in the same light as the gout.

M. Laennec employs general bleeding in acute rheumatism; leeches in the chronic; and tartar emetic in both forms of the disorder.

An analytical examination of the points of doctrine and practice, which I have here briefly discussed, would lead me far beyond the limits which I have intended to observe in this Essay; but I could not overlook the most interesting novelty which has, for the last five years, engaged the French school of medicine.

It is still a custom amongst the French physicians to employ _tisanes_, which are decoctions or infusions of roots, herbs, flowers, or grains, as medicinal remedies on which they seem to place considerable reliance. The “_formulaire pratique des Hôpitaux civils de Paris_” contains nearly ninety prescriptions of different kinds of tisane. With us, the Lisbon diet drink, or the simple decoction of sarsaparilla, is the only medicine which we direct to be taken in quantity as a drink. But even sarsaparilla is given with more advantage, in a state of concentration, by using the cortical part of the root, exclusively, in which the whole virtue seems to reside.

I object to the general principle of using medicine in a state of large dilution. It is true that the French do not prescribe active substances in this form; but their fondness for these feeble agents, tends to establish inefficient and almost insignificant practice.

Diluent drinks are useful adjuncts to medicine; but I should think that a very limited number of tisanes would comprise all that can be considered either as useful or agreeable.

The nurse may safely act the part of the pharmacien in this department, but, at the same time, should be directed by the physician as to the preparation of suitable drinks. With this qualification, the attention of the French physician in nicely regulating the regimen of the sick chamber, is worthy of our imitation. The effect of the most useful and appropriate medicines will often be frustrated, unless a corresponding care in the plan of diet be strictly observed.

To this mode of practical medicine peculiar to the French, which I have here criticised as not worthy of the skilful physician, there are some striking exceptions.

At the excellent Hospital St. Louis, chiefly appropriated to the treatment of the various diseases of the skin, and principally under the direction of Alibert and Biett, arsenical and other active preparations are administered without apprehension. They prefer small doses of arsenical solution, twice a-day for a continuance, to the use of large doses for a short time. Tincture of cantharides, in the dose of twenty drops twice a-day, is one of their favourite remedies, alternately with arsenic, in the treatment of the order Squamæ. Before employing such medicines, however, they are careful to remove all inflammatory action from the system.

Subcarbonate of ammonia, dissolved in water, in the proportion of two drams to a pint and a half, and given in this quantity daily, is found useful in certain states of cutaneous irritation, apparently caused by a free employment of mercury for syphilis.

The inveterate disease called _lupus_ is very successfully treated by the application of an arsenical caustic. They allow the part to form a crust, before they apply a poultice or any emollient dressing.

Neither expence nor trouble is spared in making the artificial medicated baths. The alkaline bath, prepared by dissolving the subcarbonate of soda in the proportion of two pounds to the necessary quantity of water, is extremely useful when the skin is affected with scales.

The douche de vapeur affords great benefit in some obstinate local affections of the skin, when it is necessary to stimulate the vessels so as to bring about an entire change of action. This description of douche often proves useful in chronic rheumatism, and in sciatica, when existing in the chronic form.

I had the opportunity of witnessing the administration of tartar emetic in large doses, as a daily medicine, to patients under the care of M. Laennec. His method is to begin with one, two, or four grains, as the total quantity for the twenty-four hours.

A solution is made in the proportion of half or the whole of a grain, to half an ounce of simple or some lightly aromatic water, sweetened; and it is given every two hours. The patient is desired to drink very sparingly; for without this caution, the medicine would most probably produce too much of emetic effect. In the first instance, this result very commonly happens; but it is remarkable how soon the stomach accommodates itself to large doses of this active medicine. When its continued use produces sickness, syrup of white poppy is added, in the proportion of an ounce to half a pint of the antimonial solution; or, as an equivalent, a grain of extract of opium. The total quantity of the tartar emetic is very commonly increased to twenty grains and upwards in the twenty-four hours. I saw an elderly man, who had, in this space of time, on the preceding day, taken sixty grains without having experienced nausea, or any other inconvenience.