LECTURES ON CLINICAL MEDICINE, DELIVERED AT THE HOTEL-DIEU, PARIS. BY A. TROUSSEAU, bate Professor of Clinical Medicine in the Faculty of Medicine, Paris; Physician to the IIutel-Dieu; Member of the Imperial Academy of Medicine; Commander of the Legion of Honour; Grand Officer of the Order of the Lion and the Sun of Persia; Ex-representalire of the People in the National Assembly; fc. fc. $ c. VOLUME FOURTH. TRANSLATED FROM THE EDITION OF 1868, Being the Third Revised and Enlarged Edition ; BY JOHN ROSE CORMACK, M.D. Edik., M.D. Paius, E.R.S.E., Fellow of the Royal College of Physicians of Edinburgh, formerly Lecturer on Forensic Medicine in the Medical School of Edinburgh, and formerly Physician to the Royal Infirmary and Fever Hospitals of Edinburgh ; Corresponding Member of the Academy of Surgery of Madrid, SfC. tfc. PHILADELPHIA: LINDSAY AND BLAKISTON. MDCCCLXXI. PRINTED BY J. E. ADLARD, BARTHOLOMEW CLOSE. CONTENTS. LECTURE LXVIII. DYSPEPSIA. Dyspepsia is not so much a Disease as a Phenomenon common to many Dis- eases.—In the cases in which, from its predominance, it seems to consti- tute a Morbid Species, it is subordinate to numerous different conditions. —General Considerations upon Aptitudes of the Organism, and Manner in which particular Organs accommodate themselves to the Stimulants which act upon them.—Application of this fact to the question of Dyspepsia.— Dyspepsia, the consequence of Increased Excitation of the Gastric Secre- tions and Muscular Movements of the Stomach.—Reflections upon that Neurosis, which I have called “exhaustion of incitability ” [epuisement de l’incitabilite].—Asthenia consecutive upon very prolonged excitation.— Dyspepsia the result of Sympathy with diseases of the liver, stomach, in- testines, and other organs .... i—15 Forms of Dyspepsia.—Dyspepsia associated with Chronic Gastritis.—Boulimic Dyspepsia.—Flatulent Dyspepsia.—Acid Dyspepsia.—General Disturbance of the System caused by Dyspepsia, such as Anaesthesia, partial Analgesia, Neuralgia, and Disturbance of the Intellectual Faculties.—Disturbance of the Circulation.—-Anaemia .... 16—24 Treatment of Dyspepsia.—The most important part of the Treatment is the Regimen.—The best Regimen is that which the patient has learned by ex- perience agrees best with him.—The Specific Character of the Phlegmasia must be taken into account.—Connection of Dyspepsia with the Herpetic Diathesis.—Remedies which produce a Local Modification of the Gastric Inflammation, such as Emetics, Purgatives, Mercurials, Subnitrate of Bis- muth, Precipitated Chalk, Alcalies, Lactic Acid, and Hydrochloric Acid.— In Bulimic Dyspepsia, are given Opium and Belladonna in small doses, Zinc, and Antispasmodics.—In Acid Dyspepsia, both Acids and Alcalies available, as they do not act as Chemical Remedies: Narcotics, Mineral CONTENTS. Waters.—In Flatulent Dyspepsia, use of Alcalies : Bitters, Quassia, &c.: Tonics, Cinchona, &c.: Aromatics : Mineral Waters, containing Chlorides of Soda: Hydrotherapy: Sea-bathing.—In Dyspepsia connected with Dis- eased Liver, use of Alcalies, Alcaline Mineral Waters: sometimes, Acids.— Acids particularly indicated in Dyspepsia associated with a Chronic Morbid Diathesis, particularly in fully declared Phthisis.—In Dyspepsia connected with Marsh Cachexia, Alcaline Mineral Waters, and other weak Mineral Waters are of great use.— Dyspepsia connected with Affections of the Uterus is beneficially treated by the Local Treatment suitable to such affections, and also by General Treatment, particularly by Sea-bathing and Hydrotherapy.—In Dyspepsia resulting from Habitual Constipation, ad- vantage derived from Belladonna, certain Purgatives, Mineral Waters con- taining Sulphate of Magnesia and other Sulphates.—In certain severe cases of Dyspepsia, the Inhalation of Oxygen Gas is resorted to 24—56 LECTURE LXIX. CHRONIC GASTRITIS. Existence of Chronic Gastritis improperly denied in the present day.—Pituitous Vomiting attributable to it . . . 57—63 LECTURE LXX. SIMPLE CHRONIC ULCER OE THE STOMACH. Gastralgia with Stitch in the Ensiform and Rachidian Regions is not exclusively a Symptom of Simple Ulcer of the Stomach.—It may be absent in this affection, and it may also be met with in Diseases of the Stomach of very different Characters.—The same is true in respect of Haemorrhage from the Stomach and Intestines independent of Organic Change (in supplementary Haematemesis, for example), and in Chronic Gastritis.—Haemorrhage, a character common to Simple and Cancerous Ulceration, may be absent.— In Cancer, Haemorrhage is sometimes as profuse as in Simple Ulceration, although generally the Haematemesis of Cancer is less than the Haema- temesis of Simple Ulceration.—The positive Diagnosis of Simple Ulcera- tion is enveloped in much obscurity.—Treatment . . 64—93 CONTENTS. LECTURE LXXI. DIARRHOEA, Classification according to Proximate Causes, that is to say, according to the Mechanism by which the Diarrhoea is produced.—Catarrhal Diarrhoea. this may be a Specific Affection.—Sudoral Diarrhoea [Diarrh6e SudoraleR —Nervous Diarrhoea.—Catarrhal Diarrhoea, in which the Affection is con- secutive upon increased Secretion from the Digestive Canal or its Append- ages.—Diarrhoea, resulting from Increased Tonicity.—Diarrhoea resulting from Indigestion.—Diarrhoea associated with Organic Disease.—This Classification is Artificial: the different kinds are blended with one another 94—118 CHRONIC DIARRHOEA. Diarrhoea complicated with Fever and Nocturnal Sweats is almost always asso- ciated with Tubercle.—Chronic Syphilitic Diarrhoea.—Herpetic Diarrhoea. —Chronic Diarrhoea depending upon Simple Chronic Catarrh of the Intes. tines.—Chronic Diarrhoea, the result of Insufficiency of Food.—Treatment varie according to the Cause,—The Use of Raw Meat , 119—130 LECTURE LXXII. INFANTILE CHOLERADIARRHOEA OF CHILDREN. Infantile Cholera is different from Asiatic Cholera-Morbus.—Conditions under which it is developed: influence of Season.—Particularly occurs at the period of Weaning.—Symptoms.—Prognosis.—Treatment.—Diarrhoea of Weaning Infants treated by Raw Meat . . . 131—145 LECTURE LXXIII. LACTATION, FIRST DENTITION, AND THE WEANING OF INFANTS. Lactation : natural, artificial and mixed.—Lactation in respect of the Woman. —Conditions essential to a Good Nurse.—Influence on the Lacteal Secre- tion of Menstruation, Conjugal Relations, Pregnancy, and Intercurrent Diseases.—Lactation in relation to the Nursling.—Weighing the Infant is the only means of ascertaining whether it is sufficiently suckled.—First Dentition:—Mode of Evolution of the Teeth in Groups.—Order of Suc- cession in which they appear.—Casualties of Dentition.—Febrile Discom- fort.—Convulsions.—Diarrhoea.—Weaning . . 146—164 CONTENTS. LECTURE LXXIV. DYSENTERY. Most formidable of all Epidemic Diseases.—Its Causes unknown.—Eating Fruit blamed without reason.—Opinion of the ancients on this point.— Different Forms of the Disease.—Character of the Stools: Tenesmus.— Bilious, Inflammatory, Rheumatic, Putrid, and Malignant Forms of Dysen- tery.—Anatomical Lesions.—Treatment: Evacuant the most useful: Em- ployment of Saline Purgatives, Calomel, Emetics, Topical Remedies, and Caustic Injections.—Dangers of Opium.—Sequelae of Dysentery, viz. Dropsy, Paralysis, and Abscess of the Liver.—Intractable Diarrhoea.— Intestinal Perforation .... 165—183 LECTURE LXXY. CONSTIPATION. Constipation is not necessarily a state of impaired health.—Cases. Treat- ment : Influence of Will and Habit: Cold Lavements: Suppositories of cacao-nut butter, soap, and hardened honey: Mucilaginous Lavements: Belladonna, with or without small doses of Castor-Oil.—In Obstinate Con- stipation have recourse to Drastic Purgatives.—Hygienical Measures: Regimen, Bran-bread . . . . 184—194 LECTURE LXXYI. FISSURE OF THE ANUS. Treatment by Rhatany.—Constriction of the Sphincter of the Anus is the Effect and not the Cause of Fissure.—Fissure is very common in Women Recently Delivered: why it is so.—The Curative Effect of Rhatany depends on its modifying the character of the ulcerated surfaces, and tonifying the parts.—Its action ought to be promoted by Belladonna, which is a remedy for constipation.—When Rhatany fails, recourse must be had to a Surgical Operation; that which seems the best is Forcible Dilatation ..... 195—204 CONTENTS. IX LECTURE LXXVII. INTESTINAL OCCLUSIONS. Their Causes.—Their Mechanism.—Their extreme Gravity.—Treatment by medical men.—Gastrotomy may be resorted to in serious cases 205—225 LECTURE LXXVIII. HEPATIC COLIC: BILIARY CALCULUS. More common in Women than in Men.—Rarely occurs in Children.—Composi- tion, Form, and Volume of the Calculi.—Biliary Gravel.—Cause of the disease is not known.—Sometimes hereditary.—May be coincident with Urinary Gravel, and be a manifestation of the Gouty Diathesis.—Hepatic Colic.—Diagnosis often very difficult.—May be mistaken for Gastralgia, Colalgia, and Heptalgia.—Pain and Jaundice are not essentially pathogno- monic signs; and may be absent.—They may be the symptoms of other afFections, as of hepatitis, heptalgia, or of the hepatic colic caused by ascarides or hydatids.—Presence of calculi in the stools is the only positive diagnostic sign.—Symptomatic affections caused by the calculi: Acute Hepatitis: Retention of bile in the liver, in the gall-bladder: Dropsy of the Gall-Bladder: Rupture of Gall-Bladder and its excretory ducts.— Biliary Fistula;.—Paraplegia, reflex and consecutive.—Treatment of Calculous Disease of the Liver . . . 226—262 LECTURE LXXIX. HYDATIC CYSTS OF THE LIVER. Case occurring in a child six years of age.—Two cases in which Hydatid Cysts opened into the Thoracic Cavity.—Hydatids : their mode of development. —Hydatids of the Liver.—Symptoms.—At first, nothing characteristic, except sometimes the appearance of a Tumour in the region of the Liver. —General symptoms : Disturbance of the Digestive Functions : tendency to Hemorrhages and Gangrene.—Functional Disturbance of Neighbouring Organs.—Hepatitis.—Purulent Infection.— Spontaneous Opening of Cysts into different passages; through the abdominal walls; into the blood- vessels ; into the biliary ducts; into the digestive canal; into the pleural cavity; and into the bronchial tubes. TREATMENT :—Simple Puncture with the Exploratory Trocar.—Puncture with the Permanent Canula.— Begin’s Method of Successive Incisions.—Recamier’s Method of opening by Caustics.—Opening the Cyst by the Trocar, after establishing adhesions by Acupuncture.—Iodised Injections . . . 263—296 X CONTENTS. LECTURE LXXX. MALIGNANT JAUNDICE. Malignant Jaundice [Ictere Grave] is a general disease—totius substantiae— analogous to Typhoid Fever, and the Bilious Fever of Tropical Climates. —Retention of Bile in the biliary ducts does not constitute Malignant Jaundice.—Typhoid Symptoms at the beginning of the attack.— Yellow colour, and Green colour of Skin and Conjunctivae.—Hemorrhages from the mucous membranes : Epistaxisj Gastrorrhagia, Meloena.—Hemorrhages from the Skin: Ecchymosis, Purpura.—Decrease in size of Liver not constant.—Secondary Nervous Symptoms.—Death the most common termination.—Morbid Anatomy: Change in Structure of Liver not constant.—Primary Alteration of Blood.—Notice of the Fatal Jaundice of Infants.—Malignant Jaundice is not Yellow Fever . . 297—323 LECTURE LXXXI. SYPHILIS IN INFANTS. Syphilis in the Fcetus :—Abortion: Pemphigus: Suppuration of the Thymus Gland and Lungs. Syphilis in the Infant :—Pox rarely shows itself before the second week, or after the eighth month.—Slow Form : Subacute Form: Symptoms: Coryza: Fissures: Ulcerations and Mucous Crusts at the mouth, anus, and folds of the skin: Cutaneous Eruptions, Roseola, &c.—Peculiar Tint of the Face: Characteristic Physiognomy of the Syphilitic Infant.— Cachexia.—Visceral Lesions.—Pathogenic Conditions of Syphilis in the Recently Born Infant. Hereditary Syphilis ;—Transmission by the Mother : by the Father. Acquired Syphilis :—Syphilis may be transmitted to Nurse by Syphilitic Nursling.—Has the Nurse been infected in coitu, or by her Nursling ?— Transmission of Syphilis by Vaccination.—Transmission of Syphilis from the Foetus to the Mother.—Treatment of Congenital Syphilis. 324—353 CONTENTS. LECTURE LXXXII. GOUT. Preliminary Considerations.—The word “ Gout ” is much to be preferred to any of the other names which have been proposed in place of it.—Gout, acute and regular.—Premonitory phenomena.—Disturbance of Digestion: Disturbance of the Nervous System: Disturbance of the Urinary Organs. —Catarrhal, Urethral, and Ocular Affections.—Arthritis, its progress and appearances.—Acute Gout in the form of short Paroxysms which either succeed to, or run into one another.—The paroxysm may supervene under the influence of an immediate appreciable cause . . 354—368 Regular Chronic Gout.—Consecutive Deformities of Joints.—Tophus, a mani- festation only met with in Gout.—The Visceral Complications are very different from those which constitute Anomalous Gout and Paludal Gout . ... 369—376 Larvaceous Gout.—Comparison of it with Palustral Larvaceous Fevers.— Megrim: Asthma: Neuralgia in various forms: Gravel: Hemorrhoids : Cutaneous Affections: Anomalous or Visceral Gout.—Bright’s Disease.— Pulmonary Catarrh.—Suppressed Gout . . . 376—386 Parallel between Gout and Rheumatism.—Articular Rheumatism: Chronic Rheumatism: Nodular Rheumatism.—Nature of Gout . 386—396 TREATMENT OF GOUT .... 396—407 LECTURE LXXXIII. NODULAR RHEUMATISM, ERRONEOUSLY CALLED RHEUMATIC GOUT. The disease is very rare in men: it is more common in women.—Generally chronic, supervening all at once.—Sometimes subacute at the commence- ment.—It i3 a manifestation of the rheumatic diathesis.—Pains and Mus- cular Retractions.—The Heart is seldom affected.—Rheumatic Complica- tions, however, have been observed in the heart, pleurae, lungs, brain, and kidneys.—Essentially a chronic disease in respect of its duration.— Successful Treatment by different medicines.—Tincture of Iodine, given internally, ought to be preferred . . . 408—431 CONTENTS. LECTURE LXXXIV. ACUTE ARTICULAR RHEUMATISM AND ULCERATING ENDOCARDITIS. Very great frequency of Acute Articular Rheumatism.—A Diathesic Disease. —Peculiarly an affection of the Fibro-Serous Tissue.—Rheumatism of the Large and Small Joints.—Primary or Secondary Rheumatism.—Rheu- matism of the Heart, the origin of organic diseases of the organ.— Rheumatism of the Pleurae, Lungs, and Membranes of the Brain and Spinal Marrow.—Rheumatic Metastases.—No Specific Treatment for Acute Articular Rheumatism.—Rheumatic Ulcerative Endocarditis.— Ulcerative Endocarditis Independent of the Rheumatic Diathesis.— Atheromatous Endocarditis.—Visceral Emphraxis.—Capillary Embolism —Alteration of the Blood consequent upon Ulcerative Endocarditis.— Typhoid Symptoms ..... 432—470 LECTURE LXVIII. DYSPEPSIA. Dyspepsia is not so much a Disease as a Phenomenon common to many Diseases.—In the cases in which, from its predominance, it seems to constitute a Morbid Species, it is subordinate to numerous different conditions.— General Considerations upon Aptitudes of the Organism, and Manner in which particular Organs accommodate themselves to the Stimulants which act upon them.— Application of this fact to the question of Dyspepsia.—Dyspepsia, the consequence of Increased Excitation of the Gastric Secretions and Muscular Movements of the Stomach.—Deflections upon that Neurosis, which I have called “ exhaustion of incitability’ [epuise- meni de Vincitabilite].—Asthenia consecutive upon very pro- longed excitation.—Dyspepsia the result of Sympathy with diseases of the liver, stomach, intestines, and other organs. Gentlemen :—We nearly always have some dyspeptic patients in the clinical wards. You sometimes see me prescribe alcalies, and at other times acids, to relieve the symptoms from which these persons are suffering. There are also cases in which I order preparations of cinchona, quassia, or strychnine; and there are others, in which I order opium, belladonna, and antispasmodics. In fact, I vary my treatment in an infinity of ways. The reason of my thus acting, as if I had no fixed rules to guide me, really arises from there being nothing determinate in dyspepsia itself. In it, more than in any other morbid condition, the physi- cian, free to act on the suggestions of the moment as they arise, is forced to feel his way as he proceeds, inquiring into the indications, which vary with the case, with the person, and which may also differ in the same person at different times. There is nothing sur- prising in this, when it is remembered that difficulty of digestion 2 DYSPEPSIA. —for that is the etymological meaning of the word dyspepsia, derived from the Greek word Svenraipia—is a symptom common to a host of acute and chronic diseases; and that it is subordinate to morbid conditions differing very much from one another, even when it is so predominant a feature as to seem to be entitled to be regarded as a pathological species. I take up this subject to-day, without the least intention of attempting to give you a complete account of dyspepsia. I only propose to enter into some general considerations, to lay before you some of the cases which I have seen, and to formulate some of the indications which most frequently present themselves at the bedside. I shall not shrink from going into details, which, in a subject so vast and so obscure, appear to me to be of greater practical utility than a dogmatic description however elaborate. A short preliminary excursion into the domain of normal physi- ology is requisite, to enable you to understand the facts which I shall have to lay before you. There are three things which have to be considered in the per- formance of every function, as has been said by Professor Recamier, one of my most illustrious predecessors in this chair; viz. the stimulus, the support of the stimulus, and that which he called reciprocal capacity [capacite reciproque]. This last expression is not, perhaps, very clear; and I shall, therefore, substitute- for it functional relation [relation fonctionelle], which is more intelligible. By “ support of the stimulus,” Becamier understood the organ in its totality with its anatomical and physiological accessories, the functional apparatus which ought to be in communication with its physiological excitant, its stimulus, the excitant of the stomach which is all that brings the support into operation. Aliment is the stimulus, the excitant of the stomach which is the support of the stimulus: and light is the normal excitant of the eye. The “reciprocal capacity,” which I propose to call the “functional relation,” is the mutual bearing on each other of the support of the stimulus and of the stimulus itself; and it is from this mutual bear- ing that there results the normal performance of the function. Having made good this position, let us endeavour to study the different modifications which may take place in the support, and in the stimulus: let us see what are the results and modifications in relation to the function. Suppose, for a moment, that the support of the stimulus is normal, DYSPEPSIA. 3 and the organ healthy; and suppose, at the same time, that the stimulus is abnormal, it is evident that there will be disturbance of the function. Take the eye, for example, and apply to it light differing in quality and in quantity from that which it habitually supports, and you will produce functional disturbance of vision. Or, make your experiment on the stomach—give it aliment of abnormal quantity or quality—and you will induce a perturbation of its functions. Suppose, on the contrary, that there is an abnormal disposition of the normal stimulant, and also of the support of the stimulant. In the case of the eye, suppose the light, sufficient in quantity and normal in quality, acting upon the morbid organ in one or another mode: in the case of the stomach, suppose food to be given normal in quantity and quality, but that the organ from some cause or another is not in a proper state to receive it, and the functional rela- tion no longer existing, the physiological action of the organs will be—as in the first hypothesis—necessarily disturbed. It may happen, howrever, that although both the stimulus and its support are in an abnormal state, the functional relation may remain in a regular state up to a certain point. This is what I have called the accidental or fortuitous functional relation [relation fonctionelle acci- (lentelle,fortuite] in diseases. Tor example, it may happen, that the eye may be to a certain extent in a morbid state, and that the light may likewise reach it in a form and in quantity which are not normal: under such circumstances, the light becomes adapted ['coadajptee], if I may use the expression, to the morbid state of the eye, and thus vision is accomplished. Let us apply this illustration to the stomach. If we administer to the stomach wrhen in an abnormal state, an ali- ment which is to a certain extent abnormal in respect of quantity and quality, the functional relation will be established accidentally and fortuitously. Digestion will be performed in a nearly normal manner, although neither the stimulus nor its support are in a quite regular state. In virtue of this accidental functional relation, some empirical methods of treatment prove successful in certain diseases of the stomach in which the food administered to the morbid organ is perfectly well borne by it, which wmuld not have been the case had the organ been in its normal physiological condition. Man is unquestionably the animal capable of becoming most easily adapted to diversities in the external circumstances necessary for maintaining life. The first individual of our species did not 4 DYSPEPSIA. assuredly come into existence in lat. 50°: his body not being pro- tected by hair or feathers, like other animals of the higher classes, proves that the Creator called him into being in a climate sufficiently mild to enable him to dispense with clothes, which in our climate are absolute necessities. However, the territory of man's origin becoming over crowded, emigration took place to other regions. Covering the surface of the globe from north to south, and from east to west, everywhere adapting itself to new climatological condi- tions, the human race became able at last to live as well in polar as in equatorial regions. This adaptation, however, to the greatest possible diversity of climate is perhaps less remarkable than the adaptation of man to great diversity of food. Advancing from the simplest possible regimen, consisting principally of slender rations of vegetables such as rice, with water and a little milk for drink, a regimen similar to that which the Indians and other peoples still subsist on, man has reached that generous fare of northern nations which contain so large a proportion of animal food. His organization has become habituated to conditions totally different from those in which he was originally placed: it has well adapted itself to them, and has by means of the new regimen, made the man of the north, a much more vigorous man than the man of the equator. This wonderful faculty of adaptation to circumstances, belongs not only to individuals of the same species taken separately, but also to different organs of the economy. The support of the stimulus, the organ remaining in a normal condition, becomes at last adapted to the action of an abnormal stimulus. It is true that, at first, the result is a certain amount of morbid action; but in virtue of the aptitude to accommodate itself to a change of circumstances, the economy is modified and rearranged in harmony with this new impression; and after some time, the organs getting into tune with the new stimulus, the functional relation is established with regularity. Under certain circumstances, the physician, assisting nature, may contribute to place persons in favourable, accommodating conditions : he may do this by means of employing pharmaceutical and physio- logical alteratives : he may be able to establish, for a longer or shorter period, accidental functional relations. He may be able to accom- plish for particular organs, the same that he can effect for the entire economy. Tor example, in respect of the stomach, the organ with which at present we are more particularly engaged, it may be placed DYSPEPSIA. 5 by the physician in the conditions specially required to regulate the acts which it is destined to fulfil. Let me now deal with my subject in a more direct manner. In relation to the stomach considered as a support of the stimulus, we must take into account its anatomical structure, or in other words, its muscular and mucous coats, its glandular, circulatory, and nervous systems: we must also consider its movements and its secretions: we shall then see what are the modifications, organic and functional, which produce that condition which we call dyspepsia. hirst, then, Gentlemen, in what manner, and under what influences are the secretions of the stomach modified ? They are modified by excess or insufficiency of a stimulus. In an animal into whose stomach a fistulous opening has been formed, a great quantity of gastric juice can be caused to flow by merely exciting the mucous membrane, by introducing a glass tube into the stomach through the artificial opening. By this excitation, there is produced a secretion which in respect of quantity is extra-physiologi- cal, but, in respect of quality, is quite normal. Should the excitation, however, be increased beyond a certain degree, it becomes inflamma- tion, the secretion of gastric juice ceases, and from the fistula there flows only mucus. Similar disturbances occur apart from any mechanical excitation. Under the influence of fever, which is perhaps nothing more than a great modification of the functions of innervation of organic life, the secretion of gastric juice is disturbed and arrested. This expe- riment has been made not merely once, but many times, by Professor Claude Bernard.1 By producing fever at pleasure, in animals, in which he studied the phenomenon, he was able to suspend the se- cretion of the gastric juice, although, there was no inflammation of the mucous membrane of the stomach—although, consequently, there was no trace of gastritis to explain the occurrence. And, Gentlemen, observe, that what takes in respect of the stomach is not at all different from wrhat we see elsewhere every day. When the first phenomena of inflammation have disappeared after the occurrence of a traumatic lesion, and the condition is progress- ing to resolution, wre may regard every cell of adventitious tissue as 1 Claude Bernard —Lemons sur la Physiologie et La Pathologie du Systeme Nerveux. Second vol. p. 374. Paris: 1858. 6 DYSPEPSIA. a little stomach into which the arteries pour the food, and from which the veins and lymphatics carry away the residuum, after the functional plastic exudation has taken place. In the particular case, the functional exudation, accidentally normal, consists of plastic lymph and pus. Should fever light up, we see the secretion from the cellular tissue become modified, and the tendency to consolida- tion become arrested — the semi-cicatrised wounds reopen, and secrete an ill-conditioned ichor, as different from plastic lymph and normal pus, as the mucus of the stomach is different from gastric juice. You know, Gentlemen—and it is again to Claude Bernard that you are indebted for the information—that section of the pneumo- gastric nerves causes an immediate suspension of the movements of the stomach, and a diminution in the secretion of gastric juice. You know also, that when, in our experiments on animals, we irritate the ganglia of the great sympathetic, which send nervous filaments to the stomach, energetic contractions of the stomach are produced, and the gastric secretion becomes more abundant. We thus obtain a demonstration of the changes which take place in the stomach when the cerebro-spinal and sympathetic systems are acted upon. To come closer to a class of facts which are more clinical in their bearing, I ask :—who has not seen the influence on digestion of de- ranged innervation ? Who does not know that great mental emotion suspends digestion, and induces indigestion ? Who does not know that prolonged anxiety produces a very injurious influence on the digestive organs, and is a frequent cause of dyspepsia ? Local pains, neuralgia of the stomach and intestines, likewise disturb the secretions of the digestive organs. The same takes place in respect of them, as in respect of other organs. Neuralgia of the eye brings on a more or less violent congestion of the parts, raises their temperature, and increases the secretion of tears : in the same way, neuralgia of the stomach produces analogous effects upon that organ, augmenting its secretions to such a degree that they are poured forth, not only when food is ingested, but, also, irrespective altogether of digestion. These are some of the effects consequent upon augmented normal excitation; and we shall now see what the results are of this same augmented excitation when it has been too long continued. I have often spoken to you of the effects produced on the economy by the abuse of excitants : I have told you that, if an organ is subjected to DYSPEPSIA. 7 excitation repeated too often, or pushed too far, it ceases to respond to its stimulus, and that that state is soon induced which Brown called “ asthenia.” What was his explanation of asthenia ? Let me now repeat what I have so often impressed upon you on other occasions; and I make this repetition without any scruple, for it is most im- portant that you have should a correct understanding of these views, the only opinions, perhaps, really judicious and practical which are embraced in the great theory of the Scottish physician. Brown, convinced that life was maintained solely by excitants (an opinion nearly the same as that afterwards taught by Broussais), thought, that every organ was endowed with a peculiar capacity for excitation, to which he gave the name of “ excitability •” and he believed that "this excitability was exhausted by being merely brought into exercise. He said, for example, that the brain, the spinal marrow, and the muscles, have an aptitude to enter into simultaneous action, to execute the function of locomotion. Now, if the excita- tion exercised by the mind upon the muscles through the medium of the spinal nervous system, which it commands, is exercised for too long a time, the nervous system and muscular apparatus will at last cease to respond to the cerebral excitation, whereupon they will lose their capacity of being excited—their excitability—and will fall into a state of asthenia, which may here be interpreted powerlessness. According to Brown, it was only by means of repose that the mus- cles and the nervous system could regain their lost capacity for excitability. But if excitation is continuously carried beyond its normal limits, the excitability exhausts itself in a proportion greater than that which can be restored by repose ; so that the being habit- ually excited will deprive the organs of the power of bringing into play the normal stimulus to which they formerly responded, and will cause them to require a more powerful stimulus. Let me give you an example:—The eye accustoms itself to support light in certain proportions, regular in respect of quantity and quality. Suppose that we represent the quantity by the figure io, and assume that the visual apparatus is in a normal physiological state: let us assume that this quantity of light (the eye remaining in its previous con- dition) , is suddenly increased to 20, the result will be the produc- tion of that peculiar abnormal phenomenon called dazzling. It is not asthenia; for if only 10 degrees of light are again afforded to the eye, it will regain the regularity of its functions which were tem- porarily disturbed. But if, in place of quickly and temporarily 8 DYSPETSIA. augmenting the stimulus it is gradually augmented—if day by day, the eye is accustomed to a stronger and stronger light—the time will come when the visual functions will be performed under the influence of that strong light, exactly as they were originally per- formed with a much feebler light: moreover, the time will come, when vision will be impossible unless the eye receive an amount of stimulus in excess of the originally required quantity. In an indi- vidual, therefore, who has been accustomed for six months or a year to 20 degrees of light, and all at once receives only i o, the excita- tion of the retina produced by this diminished quantity of stimulus will no longer be sufficient to bring the visual functions into play. Under the influence of an excitation greater in amount and constantly repeated, the excitability of the organ is exhausted, and asthenia is produced : the result is inability of the eye to perform its function, unless it have a quantity of stimulus twice as great as that which originally sufficed. Similar results follow similar causes in the stomach. An indi- vidual, for example, lives on plain fare, partakes very sparingly of spiced dishes, abstains from condiments, and drinks alcoholic liquors in small quantity : the stimulus and its organic support—that is to say, the food and the stomach—are in a state of functional relation which is perfectly sufficient and normal, so that digestion is per- formed with regularity and ease. But the individual, little by little, increases the quantity of spice taken with his food; day by day, he uses a little more alcoholic drink; and, in a word, he takes more excitants. He may, on the first day, have suffered from this change of regimen, but he soon becomes accustomed to it, and in proportion to the gradual augmentation of the stimulus, there is, on the part of the stomach, a gradual adaptation to the new impressions. What would take place, if this individual were abruptly to resume his former style of feeding? The stomach being imperfectly excited, would not yield its necessary secretions, and difficult digestion wrould be the consequence. To combat this dyspepsia, you wrould then be obliged, either to act in accordance with Brown's recom- mendation and keep the organ at rest for a certain time, to enable it to regain its original excitability, lost through abuse of excitation; or, else, be forced to resume the excitants to which the stomach had become habituated, and even to have recourse to other excitants more and more energetic. In the remarks which I have now been making, I have only had DYSPEPSIA. 9 in view what takes place in respect of the secretions of the stomach; but it is also very necessary to take greatly into account the mus- cular apparatus of the stomach, which is as essential as the secretory apparatus, for the performance of the function of the organ. Unless the movements of the stomach and intestines take place with perfect regularity, digestion cannot be accomplished in a normal manner. Now, there are different ways in which the gastro-intestinal mus- cular system may be disturbed. Its excitability may be diminished, enfeebled, when the individual will digest badly, because (if I may so express myself) there is an arrest in the contractions of the stomach: on the other hand, the excitability may be increased, when the individual will no longer digest rightly, because the con- tractions of the stomach are too frequent and too energetic. In the latter case, the alimentary substances will be propelled quickly from the stomach into the duodenum, where they will arrive imperfectly chymified or not chymified at all. Being insufficiently prepared for the new process to which they are submitted in the first portion of the intestine, their digestion will go on badly, and dys- pepsia will be the result. Just as wre have seen in respect of the gastric secretions, the in- creased contractility of the stomach may depend upon the superven- tion of a disturbance of the nervous system—of the cerebro-spinal system, consequent, for example, upon mental emotion—or of the ganglionic system. Likewise, also, the cause may be the abuse of excitants taken into the stomach, they acting more or less directly upon its contractile apparatus. In the same way, also, that increased and long continued excita- tion of the secretory system leads to asthenia of that system, so does long continued augmented contractility produce asthenia of the muscular apparatus. This asthenia has also, however, other causes, and one of them, which is not unusual, is taking food in too large quantities, so as to cause abnormal distension of the stomach. There then occurs in respect of the stomach, what occurs in respect of the bladder when, after prolonged distension from retention of urine, it becomes paralysed, in consequence of forcible distension having annihilated the muscular tonicity. The same thing takes place in the other hollow organs. As I have been saying, this is not an unusual cause of asthenia of the stomach. It is observed in great eaters, like those wdiose his- tories you will find in books, who devour from sixty to eighty pounds 10 DYSPEPSIA. of food in twenty-four hours. In these persons, the stomach be- comes distended to such a degree as to assume the capacity of the rumen of an ox. You can understand that the organ, from being thus distended, will lose its muscular tonicity, and that after a cer- tain time, to revive it, it will be necessary to have recourse to the use of artificial excitants, the energy of which will have to be in- creased in proportion to the deficiency of contractility, to the asthenia, which is progressing day by day. This muscular asthenia of the stomach, provided the exhaustion of excitability depend on that species of paralysis which is produced by forcible distension of the organ, like secretory asthenia, is the imme- diate cause of the dyspepsia to which great drinkers and large eaters are subject. We shall see how such patients have to be treated : we shall see that they require particular treatment which is much more efficacious in this than in other kinds of dyspepsia. There is another form of asthenia which has strange charac- teristics of its own : it is observed in the muscular apparatus of animal life, and probably has its analogue in the muscular system of organic life. This singular affection, to which I have long directed my attention, has certainly been seen by a very large number of prac- titioners, and yet it has never been studied in relation to its special character. The name which I have given to this neurosis is “ exhaustion of incitability” [epuisement de Pincitabilitf]. Let me give you an illustrative case. At Tours, ten years ago, I saw a young, newly-married lady, -who had nothing the matter with her health, except the strange nervous affection of which I am now going to try to sketch the picture. She described herself as being paralysed : but upon examination, it was found that the powers of motion and sensation were intact. When the patient was asked to rise and w7alk, she did so in a deliberate manner, and with perfect precision and exactitude. Scarcely, how- ever, had she proceeded fifteen paces, when she was observed to walk with less confidence, and after a few hesitating steps, she sunk down, and was unable to proceed another yard. I then caused her to be seated; and before a quarter of an hour had elapsed, she had regained her powers, and was once more able to walk the same short distance which she had previously accomplished. When interrogated as to the nature of her sensations, she replied, that after walking some steps, she felt such an extreme degree of fatigue, as to be unable to DYSPEPSIA. 11 proceed any further: she compared the sensations which she expe- rienced to feelings she had sometimes had when in health after a very long walk. The condition, therefore, was really not one of paralysis, but of exhausted excitability. Since the occurrence of that case, I have met with many persons presenting exactly similar symptoms. They all recovered—the majority under hydropathy and sea-bathing —some under electricity—and others under treatment by prepara- tions of nux vomica. Let us now return to the subject of dyspepsia. Hitherto, Gentlemen, I have only referred to what is called in scholastic language, idiopathic dyspepsia, that is to say, dyspepsia in which the cause is directly referable to the stomach as the seat of the disorder—dependent upon the state of its own internal organiza- tion, or dependent upon implication of that portion of the cerebro- spinal or ganglionic system which presides over its muscular movements and secretions. I have now to speak of those forms of dyspepsia which may be called sympto7natic, those in which disorder of the function of digestion is merely the influence on the stomach of disturbance which has supervened in other organs with which the stomach has more or less intimate relations. The forms of symptom- atic dyspepsia to which I allude, or these sympathies, if you prefer that expression, demand our serious consideration. Disorders of the intestines, particularlarly constipation, here occupy a prominent place. It is a striking fact, that in the majority of dyspeptic patients, the bowels are moved seldom, and writh diffi- culty. Is this the cause or the consequence of the dyspepsia ? "We can understand that from the mere circumstance of an individual eating little, the faeces will be less in quantity, and that in this sense, dyspepsia may be said to produce constipation; and we can also under- stand that the constipation may lead to disorder of the digestion. When an opportunity occurs for my addressing you on the subject of diarrhoea, I will show you that affections of the large intestine, that irritation of the very lowest part of the digestive canal suffice to excite a flux from the ileum—anal irritation producing its influence upon the small intestine. This sympathy between the large intes- tine and the other parts of the intestinal canal, is illustrated by the most common everyday experience: for example, indigestion will be produced by a lavement taken immediately after a meal by one un- accustomed to such a proceeding. If in place of taking a lavement, the individual introduces a suppository, a similar result is produced, 12 DYSPEPSIA. or at least there pass stools, which at first are solid, being the con- tents of the rectum and colon, and are afterwards liquid or semi- liquid, formed by the contents of the csecum and lower portion of the small intestine. Notwithstanding such decided effects, the sup- pository need not have penetrated more than four or five centi- meters within the anus : but this local limited irritation is propagated much farther by sympathy. Any irritation of the lower portion of the large intestine will act in the same way, and will not only pro- duce semi-liquid evacuations, frequent desire to go to stool, and tenesmus of the rectum from local irritation, but will likewise give rise to liquid excretions, an abnormal liquid secretion from the intestines, a diarrhoea often profuse and intractable, in consequence of the local irritation which causes it being permanent and not temporary like the suppository. It is evident, therefore, that there exists a synergy in the different portions of the muscular apparatus of the digestive canal, in virtue of which the large intestine exercises a sympathetic influence upon the stomach and small intestine, in the same way that the stomach and small intestine may act on them; so that the regularity of the contractions in one part are dependent upon the regularity of the contractions in the other. You can now understand howr constipation may be a cause of dys- pepsia. The large intestine being sluggish, that is to say, its mus- cular apparatus contracting badly, that of the digestive canal, and that of the stomach, likewise relax their movements, so that diges- tion becomes slow and difficult. There then occurs a state the opposite of that -which I described in relation to diarrhoea. So true is this, that there are some patients in whom nothing more is required for the cure of the dyspeptic symptoms than to induce regular action of the bowels by rousing the muscular synergy of the intestines by administering the ascending douche or simply by giving lavements. Here, Gentlemen, we have to consider a matter of detail in the differential diagnosis. Pains in the transverse portion of the colon are often mistaken for pains in the stomach. It is no exaggeration to say, that perhaps in half the cases which are called gastralgia— particularly in old and elderly men, and in a great many young women—the affection is nothing more than colalgia. That such a mistake should be made is not remarkable, when we consider the anatomical relations of the transverse portion of the colon, which is DYSPEPSIA. 13 situated in the epigastric region, contiguous to the great curvature of the stomach. The pain felt by the patient may then be attri- buted not only by him but also by his physician, to the stomach, in the same way that pain developed in one of the hypochondria, and having its seat in the ascending or descending colon is often sup- posed to be hepatic or splenic pains, merely from the relations which these parts of the intestine have at certain points in their course, one with the liver, and the other with the spleen. Upon carefully ques- tioning the patients, it is found, that the so-called gastric pains supervene, not during the first stage, but in the latter hours of diges- tion ; that they are coincident with obstinate constipation, or some- times, are followed by diarrhoea accompanied by a more or less profuse excretion of mucus, with which the faeces are covered; and that sometimes also, wrhen the alvine evacuations have been kept waiting, or are passed with pain, they have the appearance of bands or white ribands, which have been compared to pieces of macaroni. These mucous excretions are often mistaken for fragments of tape- wrorm; and every practitioner has had to correct mistakes of this kind, and to reassure patients labouring under the belief that they had passed fragments of a parasite which they then were exhibiting to their medical adviser. Be that as it may, obstinate constipation may become the cause of real inflammation of the colon, accom- panied by enteralgia which may be taken for gastralgia, although there is nothing wrong with the stomach. I repeat, however, that functional disorder of the large intestine very frequently leads to functional disorder of the stomach, so becoming the starting-point of dyspepsia. Dyspepsia is a very usual epiphenomenon of disease of the liver : and it is easy to understand, that an organ which is the largest gland in the body, is immediately related to the stomach, performs a very important part in digestion, has exceedingly intimate sympa- thies with the other parts of the gastro-intestinal apparatus—it is easy, I say, to understand, that the disturbed action of which it is the seat reacts more or less powerfully upon the functions of the stomach. Hepatic, will also often be taken for gastric pains. We shall have occasion to revert to this fact when we come to study hepatic colic. The occurrence of errors in diagnosis are quite accounted for by w'hat we know of the relations of contiguity between the stomach and liver. Renal affections, or to speak more correctly, affections of the 14 DYSPEPSTA. urinary apparatus, are likewise frequent causes of dyspepsia, particu- larly in old men. When you are consulted by elderly patients, who complain of impaired digestion, loss of appetite, gastric pains, belch- ing, and vomiting, direct your attention to the state of the kidneys and bladder, and you will often find that the only urinary symptom complained of is habitual retention of urine. The relation which diseases of the uterus bears to the develop- ment of dyspepsia is not less remarkable. We ought not, however, to be surprised at this, if we bear in mind the important part which the function of generation performs in the female economy, and recollect the powerful effect produced upon the whole system—par- ticularly local and general effects on the nervous system—by the mere physiological modification of the state of the reproductive organs. These disorders of innervation, which show themselves, moreover, by an assemblage of symptoms (not necessary to be now described) suffice to explain the derangement of the digestive functions which frequently supervene. Every one knows, that in many women menstruation is accompanied by gastric disturbance. Does not this gastric disturbance, of which vomiting is one of the most marked symptoms, sometimes become very serious during pregnancy? It is not surprising, then, that pathological changes in the uterus of a more or less serious character, should act in a manner similar to the physiological changes which the organ undergoes. Dyspepsia is almost the necessary concomitant of chronic affections of the womb characterised by catarrhal discharges, by leuchorrhcea, and by other local symptoms with which you are acquainted. It must not, however, Gentlemen, be forgotten, that leuchorrhcea is often not the cause, but the effect of the dyspepsia by which the menstrual function is disturbed and the catamenia suppressed: it must not be forgotten, that many patients attribute to the leuchorrhcea by which they are tormented, the stomachic symptoms from which they suffer, while, in reality, the stomachic is the starting point of the uterine dis- order. Among the exciting causes of dyspepsia must be reckoned dis- eases of the heart, nearly all of which in their latter stages are accompanied by a disturbance of the digestive functions tending to accelerate the fatal issue. The disorders of the digestive functions so commonly associated with the different cachexiee, are more frequently met with in patients of tubercular diathesis than in any other class. Dyspepsia not only DYSPEPSIA. 15 shows itself in the last stage of pulmonary phthisis, but in some cases, it also supervenes as one of the symptoms of the incipient malady before the other signs of the thoracic disease are in any way declared. Under such circumstances, it often misleads the physi- cian, who, although he take every means of detecting them, frequently fails to detect any material lesions, and concludes that the case is one of idiopathic dyspepsia, although, in reality, the dis- turbance of the digestive functions is only the indication of an organic disease which will burst forth at a given moment, exhibiting its peculiar characteristics. There is also another class of causes of dyspepsia to which I must solicit your attention. I do not at present mean to refer to those forms of dyspepsia which are associated with the gouty and rheu- matic diathesis, for I shall afterwards speak of them in a more special manner, when I lay before you the history of gout: at pre- sent, I propose only to speak of those dyspeptic affections which are dependent upon the herpetic diathesis [diathese dartreuse]. The stomachic affections which are coincident with cutaneous affections, and often are, nay most frequently are, coincident with the disappear- ance of chronic eruptions, or alternate with them, have always been recognised by observers. Apart altogether from the humoral hypo- thesis, the coincidence and alternation to which I refer is explained by the synergic connection of the external and internal tegumentary membranes. As was said by Lorry:—Primarium cum cute con- densum Jiabet ventriculus. Gentlemen, I must enumerate to you the different kinds of causes by which dyspepsia is produced, for although they are all ultimately resolved into that increase or diminution of the activity of the gastric secretions which I have stated to be the proximate cause of dyspepsia, it is essential to establish the differences which exist between that dyspepsia which is symptomatic or sympathetic, and that which is idiopathic. In a nosological point of view this is necessary, but in respect of treatment, it is still more requisite to do this. To combat the one, we must direct our measures directly to the stomach; but to combat the other, we must first of all combat remote causes, that is to say, organic affections, diseases which have in the first instance attacked another apparatus. 16 DYSPEPSIA. Forms of Dyspepsia.—Dyspepsia associated with Chronic Gastritis. —Boulimic Dyspepsia.—Flatulent Dyspepsia.—Acid Dyspepsia. — General Disturbance of the System caused by Dyspepsia, such as Anaesthesia, partial Analgesia, Neuralgia, and Disturbance of the Intellectual Faculties.—Disturbance of the Circulation.— Anaemia. Before entering upon the question of treatment, there is another point which we have to study. Dyspepsia, whatever its nature may be, does not always present the same characters. Let us attend to its principal forms. One of its forms is associated with chronic gastritis. In inflam- mation of the stomach, its muscular fibres lose the normal regularity of their movements : and the secreting function of the organ is dis- turbed. This kind of dyspepsia is accompanied by loss of appetite, and a bitter taste in the mouth. The tongue is generally covered with sordes. Nausea, vomiting, and retching commonly occur. There is frequently vomiting of food, preceded or followed by vomit- ing of a glairy matter, usually called “ phlegm” [joituite]. Some- times, though rarely, the ejecta are acid. Frequently, there are corrupt-smelling eructations, tasting of hydrosulphurous acid gas, or as the patients say “ tasting of rotten eggs.” It will generally be easy for you to ascertain the cause, when dys- pepsia presents itself under this form. Temporary irritation, such as is occasioned by a fit of indigestion, will be the starting point of the symptoms which will be as transient as the affection originating them; but in other cases, when the dyspepsia has become chronic, you will find that it is dependent upon permanent irritation of the stomach, upon chronic gastritis, an affection the existence of which has been denied with far too much dogmatism in recent times. Gentlemen, every one of you knows how leading a part has been played in pathology during the last fifty years by gastritis, acute and chronic: or at least, how great a part has been assigned to it by Broussais and his followers. Exaggerating the import of the facts wiiich he observed, and reverting I may say to the theories of Van Helmont, who placed in the epigastric centre the principal archaus,1 1 Basil Valentine invented the word archceus (French, archie) from apxn, DYSPEPSIA. 17 to the empire of which he held that the whole economy is subser- vient—going even beyond these theories, Broussais maintained that the cause of all diseases is in the mucous membrane of the stomach. He maintained that inflammation of that mucous membrane was the source, not only of all phlegmasiee and pyrexise, but likewise of nearly every morbid affection, both chronic and acute. The din of the famous controversies of that period, in which the doctrines of the Val-de-Grace were supported and opposed, has been heard even in your time. Though the celebrated chief of the school of Physiolo- gical Medicine pushed his principles to excessive extremes, we seem, in the present day, to have fallen into opposite extremes, and, to avoid being reproached with the extravagancies for which Broussais is j ustly blamed, we are ready to argue that gastritis never exists. There is a disposition to hold that the internal coat of the stomach is proof against inflammation, though no one denies that every other mucous membrane is subject to it. It is admitted that the mucous membranes of the nasal fossee, pharynx, trachea, bronchial tubes, uterus, vagina, and even the mucous membrane of the intestine itself, are subject to inflammation; but it is alleged that the stomach is not under that liability. Is it not so in everything ? The fear of falling into one particular evil, causes us to fall into another:— la vitium dacit culpte fuga, 3i caret arte, as Horace said. In medicine, as in everything else, we hardly know how to keep ourselves within correct limits: for example, medical men, after believing that they saw gastritis in all diseases, now deny that it ever exists. Nevertheless, it does exist. Acute gastritis is a rare affection; but it is sometimes observed, and cases as to which there can be no doubt may be cited. Chronic gastritis is frecjuently met with. It is true that it often remains masked; but on making a study of the patient, we soon detect, under the veil which covers it, the gastritis which causes the more or less serious disturbance of digestion. There is another form of dyspepsia in which bulimia takes the place of loss of appetite. The patient has a constant feeling of the beginning: it was afterwards adopted by Paracelsus and Van Helmont. By Van Helmont the chief archceus was regarded as an immaterial principle existing in the seed prior to fecundation, presiding over the development of the body, and over all organic phenomena. He placed this chief “ archseu3 ” in the upper orifice of the stomach : he said that besides it there are others subordinate to it, situated in dill'ereut organs.—Tkanslatoe. 18 DYSPEPSIA. emptiness in the stomach : two hours after eating, or it may be only one hour after his repast, there is a keen renewal of the appetite, which perhaps is not a real appetite, but only a craving for food. This hunger, even when it is satisfied, is accompanied by a great feeling of weakness, particularly in gastralgic women. In this form of dyspepsia, neither eructation, flatulence, nor vomit- ing occur, as in that which I have just described. Constipation is one of its usual symptoms : sometimes, however, there is diarrhoea, the result of the food being too rapidly propelled from the stomach into the duodenum before there has been time for the accomplish- ment of the first part of the process of digestion—gastric digestion. I shall not upon this occasion repeat my previous remarks on the mechanism by which this is produced; and I shall also reserve some additional observations till I have to speak upon diarrhoea, when the details of the pathological physiology of this subject will be more in place. When we come to consider the treatment of that form of dyspepsia, we shall see that the diarrhoea may be combated by very simple measures, and that we are the more easily able to master it, the more directly we attack its cause. Flatulent dyspepsia is characterised by the secretion in excessive quantity of the gases which are normally developed in the intestinal canal. Immediately after the ingestion of food, these gases are pro- duced, more or less abundantly, in the stomach and intestines, which they distend; and this distension leads to such increase in the size of the abdomen as obliges the patients to loosen their clothes from inability to bear their tightness. An attempt has been made to explain this phenomenon by supposing that there takes place a rapid fermen- tation of the ingested feculent substances—that there is a production of carbonic acid gas, the result of a fermentation in the digestive canal exactly similar to that which occurs in the wine-maker’s mash- tub. Matters do not, however, proceed after that fashion. As Graves remarks, persons subject to flatulence have gas developed in the intestinal canal with almost equal rapidity, whether they eat food which can ferment, or whether they confine themselves almost exclusively to animal aliment. In the latter case, one cannot say that there has been fermentation. That some gas is always produced from the alimentary mass during digestion is, however, a fact which is certain ; but the principal source of the gas is secretion from the intestinal canal. A proof that this secretion is independent of the coction of the aliments is afforded by the fact that a hysterical woman DYSPEPSIA. 19 will sometimes become tympanitic in ten minutes: under our very eyes and hands we see and feel the abdomen attain a great size. That certainly could not be explained upon the fermentation hypo- thesis ; for I am supposing the patient to be seen before or after a meal at a time when there could be no food in the digestive canal: but, granting that alimentary substances are present in the canal, it is impossible to admit that the fermentation takes place with such rapidity. Consequently, the formation of gas is the result of dis- turbance of the nervous system : an increased secretion of gas takes place exactly in the same way that there is under a similar influence an increased secretion of tears, saliva, or urine. This remark is important; for if, on meeting with such cases as I have now alluded to, you reason after the manner of the chemists who regard the stomach in the same light as the glass vessels in which they experi- ment ; if you say that there is an excess of carbonic acid gas, and, that this being the result of fermentation, your business is to put a stop to that fermentation by the means which chemistry supplies for accomplishing that end—by acting thus, you will be mistaken if you suppose that you are curing the malady: for you do not really obtain any good result. If, on the other hand, you act the part of the physician, and have recourse to baths, cold affusions, and the administration of a few drops of ether; or if you employ any other treatment the good results of which you have learned from experience, your intervention will be useful. The flatulence wdiicli is characteristic of the form of dyspepsia of which I am now speaking, requires to be treated by remedies with wdiich I shall make you acquainted. There are cases in which the acids of the stomach are generated in large quantities. Almost as soon as the patients have swallowed their food, they have sour eructations; and after meals, they some- times bring up acid matters in greater or less abundance. So great occasionally is the acidity of these matters, that without exag- geration it may be described as setting the teeth on edge like currant or lemon juice; and when received in copper vessels, they cover them almost instantaneously with a green coating of lactate of copper. This you have had frequent opportunities of seeing at the bed-side of the young girl of bed 27 St. Bernardos ward, who has every day been vomiting an acid fluid such as I am now speaking of. A chemical explanation of what takes place in such circumstances has not been wanting. It has been said that the glucose contained in the food, 20 DYSPEPSIA. having undergone digestion in the stomach, is transformed into sugar, which sugar is transformed into alcohol: but here chemistry is again at fault, for the formation of acid products is often more abun- dant when the patients are fed on animal food, than when their diet consists of starchy substances. The very opposite of this, however, sometimes occurs. Nevertheless, it is sufficient in some cases similar to the first to have clear proof that the acids of the stomach are the result of a peculiar secretion, and not of a mere chemical decompo- sition as some allege. Graves taught in 1828, and Berzelius repeated the lesson seven years later, that the acid secretion owes its acidity to lactic acid. The abundance of this secretion in the form of dyspepsia now under consideration is due to a peculiar excitation of the gastric mucous membrane, an excitation wholly under the influence of the nervous system which presides over the secreting organs. Whatever forms they may assume, the disorders of the digestive functions have an influence upon the whole economy, the effects of which, however, are chiefly seen in the nervous system, in the moral powers, and in the constitution of the blood, thus giving rise to what Beau has called the secondary symptoms of dyspepsia.1 So great is this influence, according to my honourable colleague of the Hopital de la Charite, that certain diseases are sometimes purely symptomatic of the gastric affection. It is so not only in hypochondria, which, according to many physicians, is related to dyspepsia, but also in other diseases, among which hysteria may be mentioned. Without adopting this view of the matter, which seems to me to be rather far-fetched and calculated to lead us back in some degree to the theories and doctrines of Yan Helmont, I consider that it has the merit of keeping prominently in view an important element, a serious complication of these diseases, which the talented observer whom I have named erroneously regarded as caused by dyspepsia, while they are only aggravated by it. In relation to the effect which dyspepsia produces upon the nervous system, Beau has laid great stress upon the fact that nearly all dyspeptic persons labour under nervous symptoms, analogous to those from which hysterical women suffer. He says that nearly always in both classes of patients there are peculiar disorders of sensation, symptoms of analgesia and of partial anaesthesia occupying sometimes one point and sometimes another point in the skin, in the 1 Beau :—Traite de la Dyspepsie. Paris : 1866. DYSPEPSIA. 21 hands, arms (particularly the internal surface of the forearms), the trunk, or the face. This paralysis of sensation is sometimes so decided, that one may pinch in the most vigorous manner, prick the skin, and even transfix it with a needle, without the patient feeling what is being done. I have on many occasions repeated this expe- riment in your presence, so that from your own observation you can verify the statement I have now made. Sometimes patients, while they lose the sense of pain, retain tactile sensation : they distinctly feel when they are pricked, pinched, or touched: they tell you even when you prick them or pinch them, and yet they experience no pain. Along with this analgesia and anesthesia there are often symptoms of local neuralgia—neuralgia in the neighbourhood of the parts struck with paralysis of tactile sensation. The influence of dyspepsia upon the nervous system extends to the intellectual and moral faculties. You all know, and some of you perhaps know from sad personal experience, that difficult digestion greatly interferes with intellectual work, impedes the expression of thought, and that, when the difficulty is habitual, the disturb- ance of the gastric functions assumes the character of melancholy and hypochondria. You will often meet in dyspeptic persons with great mental lethargy, showing itself in an inaptitude for work, sometimes in an impossibility of forming or clearly expressing ideas. Some tell you, that their memory is gone : and many complain of pains and weight in the head, accompanied by a very distressing feeling of emptiness. It is in such cases that there supervenes vertigo a stomacho Iceso, an affection regarding which I recently addressed you in a special lecture.1 After meals, the patients experience an invincible tendency to sleep, a sort of torpor or at least an insurmountable repugnance to move : their sleep is disturbed by agitating dreams, and nightmares. Generally, the persons thus affected have an excessive degree of nervous irritability. They are melancholy, morose, exceedingly pusillanimous, and so irascible that they can- not bear to be thwarted in the slightest degree either by word or deed. When the disease goes on for a certain time, the influence which it exerts upon the constitution of the blood is shown, by symptoms to which Dr. Beau has given the name of “aglobulie.” This 1 See page 537 of Third Volume of this translation. 22 DYSPEPSIA. diminution in the quantity of red globules along with an increase in the normal quantity of the serum, is characterised by phenomena which it is hardly necessary to describe in this place. The integu- ments have lost their colour, and probably present that pale yellow hue, which is met with in anaemic subjects. The patients are liable to buzzings in the ear, disturbed vision, and palpitation of the heart. On auscultation of the heart, an anaemic blowing sound is heard at the base, which is prolonged into the cervical vessels. Ultimately, there is met with the entire series of nervous symptoms which pecu- liarly belong to individuals whose blood is impoverished. When this impoverished condition of the blood proceeds to an extreme degree, the disorders of the circulation may occasion cedema of the extremities and anasarca, although it has been alleged that the latter is not met with in the circumstances now described. Sometimes there is even slight passive interstitial hemorrhage, spots of purpura, for example, appearing on different parts of the skin. The emaciated condition of the patients shows the greater or less disturbance of the nutritive functions. But the disturbance of nutrition, is characterised by a special sign to which Beau was the first to call attention. It is the ungual furrow. This ungual furrow is a transverse groove in the nail, such as would result from a loss of substance in the external layer. This appearance admits of being remarkably well studied in the nail of the thumb : from the thickness of this nail, the furrow is more marked. The ungual furrow met with in diseases of long duration, such as serious fevers, is hollowed out more or less deeply and is more or less wide. It often happens that there are several furrows arranged in series and separated the one from the other, by spaces in which the surface of the nail is uneven, rough, and sensibly less elevated than the rest, presenting sometimes a milky colour, and on pressure showing an evident dimi- nution of thickness. The cachectic condition into which patients fall, who have been long subject to dyspepsia, frequently misleads the physician and induces the belief that there exists a bad diathesis. The idea suggests itself that there is pulmonary phthisis, a supposition all the more natural, that there exists cough, the frequent accompani- ment of gastric disturbance. This cough, the cough which so often accompanies gastric disturbance, is dry, coming on in isolated attacks or in urgent fits, accompanied by a very painful feeling of strangulation and angina, occurring periodically in paroxysms at DYSPEPSIA. 23 certain hours, particularly in the evening. This stomach cough excites serious anxiety as to the state of the chest, which does not always upon examination dissipate the fears which have been formed: it is in some cases only after repeated examinations that it is admitted, that no signs of tuberculization exist. This supposition that there is tubercle has all the more appearance of being correct, from cough, emaciation, and debility, being present, frequently co-existing more- over with neuralgic pains in the walls of the chest, particularly in the back, whence they shoot into the sides. Although the absence of the tuberculous diathesis diminishes the gravity of the prognosis in these cases, it is necessary to be aware of the fact that dyspepsia in this extreme stage, and presenting all the characters to which English physicians have applied the name of “ dyspeptic phthisis,” is in truth a dangerous malady. Gentlemen, if for convenience of description, and with the view of the better adapting them to their appointed places in nosological tables, we isolate from one another the different forms of the same disease, if we divide one malady into genera and species, in imitation of the methods adopted in the study of the natural sciences, it will be found that such classifications are seldom suitable in medicine. If, with a view to render our views more precise to those to whom they are addressed in lectures or in books, we are obliged to unite, to group together certain facts, in such a way as to form a more or less com- plete picture, we ought to recognise the fact, that all such classi- fications are artificial, and contain nothing positive, when tested by a comparison with the reality. In natural history, and in botany, the species have a certain number of characters, which are invariable and immutable, and which enable us to distinguish the one species from the other. This is not the case in pathology. The same disease is far from presenting immutable phenomena exclusively belonging to it: different species have characters in common, which commingle and blend with one another in such a manner, that the nosologist has often a difficulty in assigning to them a place in the classification which he has drawn up. This is particularly the case in respect of dyspepsia. Although we distinguish many species of dyspepsia by resting their distinctive characters upon the predominance of one or of several morbid phenomena which appear to characterise them, these species often blend into one another, their reputed characteristic symptoms commingling, and alternately assuming the leading place. It is necessary to make this remark; for, hearing me speak of 24 DYSPEPSIA. the different forms of dyspepsia, and seeing them formulated with so much precision by certain authors, you might suppose, that nothing was easier than to distinguish them from each other; and when you found yourselves alone at the bedside of the patient, you would feel yourselves peculiarly at a loss, to be no longer able to recognise what appeared to you so plain and simple in the lecture room. You would experience great embarrassment in deciding upon the appropriate treatment, and in vain wrnuld you look out for the indications which you had imagined were always to be met with. Proceeding conse- quently at hap-hazard, you would fall into serious therapeutic mis- takes, mistakes which would lead you to become unbelievers in medi- cine. On the other hflnd, if you remember, that there is a possibility of this commingling of the different forms of dyspepsia, you will be enabled, when you meet with it, to adapt your treatment to the actual nature of the case, to watch its manifestations, and combat its individual symptoms by different means, in place of resorting to one uniform mode of treatment. You will have recourse to mixed methods of medication, applicable to the different symptoms which in the aggregate constitute the disease with which you have to deal. It is, Gentlemen, a general rule in medicine, that, except in a few exceptional cases, when a specific disease has to be treated by a remedy which is also specific, we are obliged to attack the different elements of disease by following the indications which they seve- rally present. Treatment of Dyspepsia.—The most important part of the Treat- ment is the Regimen.—The lest Regimen is that which the patient has learned by experience agrees lest with him.—The Specific Cha- racter of the Phlegmasia must le taken into account.—Connection of Dyspepsia with the Herpetic Diathesis.—Remedies which produce a Local Modification of the Gastric Inflammation, such as Emetics, Purgatives, Mercurials, Subnitrate of Bismuth, Precipitated Chalk, Alcalies, Lactic Acid, and Hydrochloric Acid.—In Bulimic Dyspep- sia, are given Opium and. Belladonna in small doses, Zinc, and Anti- spasmodics.—In Acid Dyspepsia, loth Acids and Alcalies available, as they do not act as Chemical Remedies : Narcotics, Mineral Waters. —In Flatulent Dyspepsia, rise of Alcalies: Bitters, Quassia, fyc.: Tonics, Cinchona, Sfc.: Aromatics: Mineral Waters, containing Chlorides of Soda : Hydrotherapy: Sea-lathing.—In Dyspepsia con- DYSPEPSIA. 25 nected with Diseased Liver, use of Alcalies, Alcaline Mineral Waters : sometimes, Acids.—Acids particularly indicated in Dyspepsia asso- ciated with a Chronic Morbid Diathesis, particularly in fully declared Phthisis.—In Dyspepsia connected with Marsh Cachexia, Alcaline Mineral Waters, and other weak Mineral Waters are of great use.— Dyspepsia connected with Affections of the Uterus is beneficially treated by the Local Treatment suitable to such affections, and also by General Treatment,particularly by Sea-bathing and Hydrotherapy. —In Dyspepsia resulting from Habitual Constipation, advantage derived from Belladonna, certain Purgatives, Mineral Waters con- taining Sulphate of Magnesia and other Sulphates.—In certain severe cases of Dyspepsia, the Inhalation of Oxygen Gas is resorted to. Having made these preliminary remarks, I am now in a position to enter upon the question, so difficult and so complicated—the treat- ment of dyspepsia. From what I have said to you, you will perceive, that it is im- possible to formulate precise rules ; and that I must confine myself to mentioning a series of measures, applicable only to a limited number of cases, in which the disease has well defined characters, and useless in the majority of cases, unless combined with other remedies selected according to the special indications. When dyspepsia is associated with well marked chronic gastritis, its treatment is subordinate to the treatment of that affection, and consequently consists in the use of remedies for inflammation of the stomach. In this, as in every form of dyspepsia, regimen constitutes the most important part of the treatment. The first requisite is to reduce the quantity of food taken, so as to render it proportionate to the aptitude of the stomach : this does not imply the necessity of putting the patient on low diet. The selection of the particular kind of food which ought to be prescribed is found, by the majority of physicians, to be a great difficulty. We doctors have all a strange manner of advising our patients on the subject of diet. If we our- selves are fond of tea or coffee, we are indulgent to those who use them habitually or even immoderately. If we prefer this or that kind of wine, if, for example, we prefer Bordeaux to Burgundy, we prescribe Bordeaux to the exclusion of the latter : if we have a fancy for strong meat—beef, mutton, or game—we prescribe strong meat for patients with bad digestion: if we order our patients to eat the flesh of young animals—veal or chicken—or if we advise them to take 26 DYSPEPSIA. fish, it is because we ourselves like to eat this kind of food. In fact, it is not unusual for all the clients of a physician to be placed by the physician on the same diet as he himself adopts. The law by which we ought to be guided in regulating the regimen of a patient is to recommend the food which the patient has found to agree best with him. This is the only really good and reliable rule to follow. The physician, therefore, ought at once to inquire into this matter. Should a person tell you that milk acts on him like a purgative, you will avoid ordering him to take milk, although it is perfectly well digested by you as by most other persons—you will avoid ordering an article of food which might induce vomiting, diarrhoea, and absolute indigestion. Nevertheless, how many phy- sicians, without considering individual peculiarities, invariably order milk diet in chronic affections of the stomach ! Therefore, interro- gate your patients carefully, so as to ascertain exactly their dietetic aptitudes, and find out even their fancies, if you will allow me to use the expression, which vary with the person's state of health, and still more, perhaps, with the state of his disease. A man who has been suffering for some time from dyspepsia has a wonderfully correct knowledge of the aliments which will best agree with him : fiud out what they are, and recommend him to use them, even though they should seem preposterously unsuitable, and though personally you should have an antipathy to them. I must add, however, that there are certain ordinary rules, which ought not to be neglected. Taking into account individual pecu- liarities, it may be stated, as a proposition which generally holds good, that light soups (made with or without animal food), poultry, fish, and non-farinaceous vegetables suit cases in which there is chronic inflammation of the stomach. Such is the regimen which ought to be prescribed by you in this class of cases, provided the articles which compose it have not already been found improper by the individual’s own experience. The same remarks which I have made on food are equally appli- cable to drink. Always making due allowance for individual idiosyncrasies, the general rule is to allow only a very small quantity of fluid to be taken, and to recommend fermented drinks, wine, or sometimes beer, diluted with water. Regularity in the hours of meals is a point of no inconsiderable importance. Here, let me mention a matter of detail. It not unfre- quently happens that dyspepsia, and the chronic irritation of the DYSPEPSIA. 27 stomach on which it depends, arise solely from imperfect mastication, caused by loss of teeth, or by the patient swallowing his unchewed food. In such cases, to indicate the cause of the malady, is also to indicate the means of cure. The question of regimen, I repeat, takes the most important place in the treatment of dyspepsia. Under a well appointed regimen, without the use of any other means, the symptoms will disappear in a great many cases. The reason is obvious : a daily succession of fits of indigestion will be avoided, which wmuld have been pro- duced by unsuitable food, and by which the disease would have been kept up, just as a pulmonary catarrh will remain uncured so long as the patient is subjected to the evil influences by which it was originally occasioned. Generally, howrever, dyspepsia is not cured by a return to regular habits and a judicious system of alimentation. The gastric symptoms continue with inveterate obstinacy, dependent upon the deep seated character of the chronic inflammation, which is characteristic of chronic inflammation of all organs. The obstinacy of the disease may also, to a certain extent, be due to the inflammation having the stamp of a special diathesis. • This remark renders it incumbent upon me to revert for a moment to what I explained to you in one of my previous lectures. When speaking of the sudoral exanthemata1 I recalled to your recollection the fact that diathesic manifestations may declare themselves in internal organs, as well as in parts accessible to direct examination. Taking the herpetic diathesis as an example, I stated that the mucous membranes were very often the seat of its manifestations: and, with a view to show the transition of herpetic affections from the external to the internal integument, I asked, if we did not every day see individuals under the influence of this diathesis, take consecutively eczema of the face, occupying the upper lip or the external orifice of the nares, and very obstinate chronic coryza? In another indi- vidual a granular sore throat will supervene: in a third there will be deafness, occasioned by the extension of the irritation from the nasal fossae and pharynx, to the mucous lining of the Eustachian tube. In women, certain uterine affections, certain leucorrboeal discharges are simply the result of an extension to the internal genital organs of a herpetic affection of the external parts. 1 See page 297 of the Second Yolume of this translation. 28 DYSPEPSIA. In these eases, in which we have as it were the opportunity of following the affection step by step, as it progressively advances from without inwards, no one will deny the nature of the affection, be it coryza, sore throat, or uterine inflammation; but some physicians still refuse to admit, that these affections of the mucous membranes may be the sole manifestations of the diathesis, that they may have supervened consecutively upon the spontaneous or artificial disap- pearance of similar affections which had for a long time previously occupied a more or less considerable extent of the skin. Neverthe- less, Gentlemen, clinical experience demonstrates beyond the possi- bility of doubt that such metastases, such repercussions, to use the old phraseology, do occur. Experience tells us, that herpetic affections may not only invade the mucous membranes of the nose, larynx, and uterus, which are continuous with the external integu- ment, and within range of visual observation, but that they may also invade more deeply seated organs. How frequently do attacks of bronchitis and diarrhoea, and, to return to our immediate subject, how often does dyspepsia depend upon a herpetic affection of the bronchial, intestinal, or gastric mucous membrane ! The occurrence of such cases did not escape the observation of our predecessors ; and it would not be difficult to collect from their writings a goodly number of cases similar to that described by Schmidtmann, of car- dialgic dyspepsia alternating with eczema of the face, so that, when the eruption disappeared from the face, the patient experienced gastric symptoms, which did not subside till there was a re-esta- blishment of the cutaneous disease. Your teachers, my honourable colleagues of the Hopital Saint-Louis, entrusted with the wards specially reserved for diseases of the skin, have taught you this fact, which I have now pointed out to you as resting upon my own per- sonal observation. Few weeks, indeed few days pass, in which I am not consulted by patients affected with dyspepsia, evidently dependent upon a herpetic diathesis. This diathesis imparts to the visceral affections which it produces, that characteristic obstinacy which belongs to it, just as it similarly impresses with the stamp of obstinacy every affection, acute or chronic, occurring in persons under its dominion. This specific character of the gastric affection ought therefore to occupy a leading place, when we come to consider the question of the treatment of dyspepsia. But, leaving out of consideration for the present this specific element of the chronic inflammation, let us inquire, how we are to modify the inflammation, DYSPEPSIA. 29 independently of diathesis. Here, it must be admitted, that our available means are limited. In fact, we can do little more than remove causes, which is not always in itself sufficient, or resort to the employment of certain modifying topical agencies. 'When the affected parts are situated upon the exterior of the body, so as to enable us to apply directly our remedies, intervention is more easy, and is likewise more efficacious. In chronic ophthalmia, for example, it is easy to apply to the eye, different liquid collyria or powders— solutions of sulphate of copper, zinc, or nitrate of silver, or, in the form of powder, calomel, or oxide of zinc.* If the inflammation be situated principally in the eyelids, we may use greasy applications : the pomade of Regent, into the composition of which enter the red oxide of mercury, crystallized acetate of lead, and camphor; the pomade of Desault (de Lyon), and many other unctuous applications of a like nature. In chronic inflammation of the nasal mucous membrane, in ozsena, we may cause the patients to snuff up mercu- rial powders, and inject caustic solutions, which are also peculiarly suitable in pharyngeal sore throat, and in vaginal and uterine inflam- mations. In a word, we may attack directly these inflammations, by modifying agents with which we are acquainted, and the action of which may be assisted by the use of remedies directed to the diathesis, or rather to the general state of the system upon which the local affections depend. We act with much less certainty by means of topical agents, in inflammatory affections of the stomach. However, when dyspepsia is dependent upon a chronic inflammation, which has retained to a certain extent its acute character, topical modifying agents, substi- tutive remedies, are indicated. Among them, emetics hold the first place. Their part does not consist in freeing the stomach from the saburral matter or bile, which load it; for after the ingestion of aliment a part of this saburral matter or bile is evacuated; however, the mucous membrane thus cleansed, if one may use such an ex- pression, remains inflamed as much as ever, and continues more or less to produce morbid secretions. To seek merely to evacuate these secretions, would be as useless as to sweep away the morbid secretions which cover the skin affected by eczema. Here the abnormal secretions do not continue the less, and are scarcely re- moved from the surfaces which they pollute, when they are repro- duced. The same thing happens in respect of morbid secretions of the stomach. Though, in a case of poisoning, the action of an emetic 30 DYSPEPSIA. is mechanical, by causing violent expulsion of the deleterious agent which has been ingested, its operation is of a totally different nature in dyspepsia. In dyspepsia, emetics act as substitutive agencies, as modifying powers, as I shall now endeavour to explain. Tartar emetic, for example, when brought into contact with a mucous membrane, acts in the same way as upon the skin, that is, by determining violent inflammation; but this inflammation, subor- dinate to the quantity of the agent by which it is excited, undergoes spontaneous cure; and this occurs more quickly when the tartar emetic has been given in suitably graduated doses. The inflam- mation, therefore, is transient, and that is the characteristic of every inflammation excited to produce a therapeutic result. We may say the same of sulphate of copper, a topical irritant, quite as irritating to the gastric mucous membrane as to the mucous membranes of the eye or nose. When, therefore, we administer an emetic—tartar emetic or ipecacuan, polygala or veratrum album, sulphate of copper, or sulphate of zinc—we substitute for the pre-existing gastric inflam- mation, another kind of inflammation transient in its character, and which will cease spontaneously. We act absolutely in the same manner as when we employ irritant collyria, to combat inflammation of the ocular mucous membrane—in the same manner as when we treat by caustic injections the catarrhal affection of the urethra, called blennorrhagia. Exactly in the same way emetics act bene- ficially, in the treatment of dyspepsia. It is also by modifying the gastric inflammation, and not by causing evacuation by stool of the saburral matter, the bile, and the morbid secretions of the stomach, that calomel, grey powder, blue pill, and other mercurials prove useful in numerous cases. These modifying remedies however—emetics or purgatives—must be cautiously administered, for we cannot with impunity induce frequent vomiting in a dyspeptic subject. We might run the risk of going beyond the limits proposed; and the therapeutic action of the remedies being exceeded, we might see, in place of the chronic inflammation which we wished to supersede, a very violent inflam- mation, not at all of a transient nature, and calculated to induce serious symptoms. In employing these remedies, having first of all found that they are indicated, it will be necessary to substitute other modifying agents, which, whilst they must be less energetic and less rapid in their effects, will at the same time not be less active. Such remedies are DYSPEPSIA. 31 the subnitrate of bismuth and precipitated chalk. Employed daily as topical means, in certain cutaneous affections (as in the chafing of the skin of infants) these remedies are useful: their efficacy is like- wise incontestable in certain chronic inflammations of the large intestine. My friend Dr. Lasegue has made known the beneficial results which he obtained in such cases, both in adults and in children, by the employment of injections, containing sub nitrate of bismuth and chalk. Their utility is not less in the dyspepsia of chronic gastritis. They ought to be given in large doses : from five to ten grammes of the chalk may be administered in the course of the twenty- four hours mixed with an equal quantity of subnitrate of bismuth, and divided into packets containing from two to four grammes. These powders ought to be taken (as a general rule) before meals. The secretions of the stomach resume their normal character, on the cessation of the inflammation of the gastric mucous membrane. It is necessary, however, in some cases, to give special aid to the secretory functions, which have got into a state of greater or less disorder. Certain acids, such, for example, as lactic and acetic, or better still hydrochloric acid, which you have often seen me pre- scribe, are excellent remedies in the dyspepsia of chronic gastritis. At the same time—and the fact is remarkable—while some persons are benefited by acids, others derive no good from them: to such it is necessary to administer alcalies. It is difficult to determine which class of remedies will prove most suitable; and it is also diffi- cult, to state the manner in which acids and alcalies act. The chemical explanations which have been given are open to great objection, particularly as we see acids and alcalies produce equally beneficial effects in different individuals, whose cases are, apparently, exactly similar. Without stopping to consider the interpretation which chemists have given, of the manner in which these medicines operate, let us for the present be satisfied with the knowledge we derive from clinical experience. We know that in chronic affections of the stomach, when the patient, after having been subjected to the previous treatment of which we have just been speaking, retains difficulty of digestion, sometimes alcaline mineral waters, and some- times, though not so frequently, acid mineral waters, are administered with success. When I come to speak of acid dyspepsia, I shall return to this point: I shall then discuss the probable manner in which acids and alcalies act. Eor the present, let it suffice to call your attention to this subject, reserving for a future occasion the 32 DYSPEPSIA. remarks which I have to make upon the circumstances which seem specially to indicate one or other class of remedies. Gentlemen, in pointing out the different forms which dyspepsia may assume, I have told you that there is one form of the affection accompanied by bulimia, or to speak with more precision, by a feel- ing of emptiness of the stomach soon after eating. I told you, that in this form of dyspepsia, the disorder of the digestive functions was characterised by diarrhoea, supervening almost immediately after eating. Patients who are thus affected will tell you that they digest very rapidly—that their food is not heavy on the stomach—that their stomach is in excellent order—and that the disorder is only in the intestines. I have told you the way in which I explain the cause of the symptoms in cases of this description : and I shall enter more into details when I come to treat in a special manner of diarrhoea. This, however, is the suitable occasion to state the means at our dis- posal for the treatment of these cases. I begin by speaking of opium. This medicine, although sometimes deplorably misapplied in the treatment of diseases of the digestive organs, is, in the class of cases now before us, more useful than any other remedy. To derive from it, however, all the benefit it is capable of imparting, it requires to be given with the greatest circum- spection. It is impossible for me to tell you the exact doses in which it ought to be administered. In each particular case, the physician must decide this question by considering the tolerance of the indi- vidual for opium. There exists great diversity in this respect, not merely in the differences of tolerance in individuals, but also in the difference between the degree of tolerance which the same person has at different times, according to the varying circumstances in which he may happen to be placed. Some persons can bear enor- mous quantities of opium; and I mentioned remarkable examples of this peculiarity when lecturing upon epileptiform neuralgia. Others are affected by a single drop of laudanum: this statement is appli- cable to adults; but young children are sometimes narcotised by even one fourth of that quantity. Nothing is so difficult as to judi- ciously manage opium. On this fact I cannot lay too much stress : for no remedy is dispensed so improperly, so prodigally, and with so little inquiry into the idiosyncrasy of the patient. Note well, Gen- tlemen, that this observation has a general bearing, and does not only apply to what is done in the treatment of dyspepsia. During my clinical lectures, I shall have frequent opportunities of raising my DYSPEPSIA. 33 voice against tliis abuse. In the malady before us to-day—bulimic dyspepsia with constant diarrhoea—opium is, however, a wonderful remedy, provided it be administered in moderate doses. The lauda- num of Sydenham is the most convenient preparation to employ, for its doses are the most easily apportioned. It is prescribed at first in doses of a single drop, the dose being augmented if necessary. The patient ought to take it before, and not after, eating. To obtain a successful result from the remedy, this precaution is indispensably necessary. The small quantity of opium received into the stomach before digestion has commenced is sufficient to keep duly quiet and regular its muscular excitability, the inordinate extent of which causes the symptoms you have to combat; this, too, it accomplishes without suspending organic sensibility. Opium, on the contrary, administered in large doses, producing effects beyond those intended, causing slumber both of the muscular excitability and organic sensibility, arresting at once the muscular movements and the secretion of the gastric juice, increases in place of calming the disturbed state of the digestive function, to the performance of which regular muscular movements and secretion of gastric juice are indis- pensable. Belladonna is undoubtedly useful in this form of dyspepsia, though its beneficial action is less decidedly beneficial than that of opium. Perhaps you are surprised to hear me praise this medicine in these cases, as its usual effect is the very opposite of that which we wish to obtain in them. You are aware that belladonna, in common with all the poisonous solanece produces relaxation of the bowels, while opium causes constipation. So decidedly is this property charac- teristic of belladonna, that the physician avoids administering it to patients affected with diarrhoea. But while there is a reason for not prescribing it in cases of diarrhoea in which the cause of the fiux exists in the intestine itself, it would be wrong not to employ it in the cases to which I am now directing your attention. I have no hesitation in stating in the most positive manner, that cases of this class occur in which belladonna renders services very nearly equal to those derived from opium itself. Here, a word of explanation is necessary. Expe- rience tells us that the poisonous solanece are very often our most powerful means of conquering constipation. You all know the effects of tobacco : to some individuals, a cigar is the best laxative; and there are persons whose only security for a daily stool is a daily cigar. There are others upon whom tobacco produces no laxative DYSPEPSIA. action, but upon whom this is produced by a pill containing a grain or half a grain of the extract of henbane. These substances perhaps owe this singular property to the poisonous principle which is the active base of all the solanece. Belladonna, the utility of which in some cases of constipation is so well known, particularly since the researches of Bretonneau, acts in virtue of this principle. Here the same remark applies which I made in respect of opium: it can only be administered in very small doses. A centigramme [the seventh part of an English grain] is generally sufficient; though one is sometimes obliged to give a somewhat larger dose, say, for example, a centigramme and a quarter, or two centigrammes and a half, but there is rarely any necessity for exceeding these quantities. It might appear, that what I have just said contradicts my former statement regarding the administration of belladonna as a means of arresting diarrhoea; but this contradiction is only apparent, for, if the diarrhoea depends upon an increased excitability of the sto- mach, the belladonna will calm the excitability and suspend the diarrhoea, by moderating" the abnormal condition upon which it depended. Though the poisonous solanea, particularly belladonna, may be of great service in these cases, we must not forget that their abuse, par- ticularly the abuse of tobacco by smokers, is a cause of dyspepsia. This is an important fact. The nicotine absorbed by smokers in greater or less quantity diminishes the physiological excitability of the stomach. In such circumstances, patients experience almost always a sensation of weight in the epigastric region; stomachic digestion proceeds exceedingly slowly, and it is in vain that we have recourse to treatment calculated to rouse the inactive stomach, unless we get the patients to discontinue, or at least to moderate, the inju- rious habit of smoking. It is important, therefore, in prescribing belladonna, or any other remedy derived from the solanea, not to exceed certain limits, other- wise a sort of paralysis might be induced, which would have to be treated by aromatic or alcoholic stimulants, or, better still, by the pre- parations of nux vomica. It is consequently necessary, as I have just said, to begin with small doses, increasing them if necessary. In the same category as the solanea, certain antispasmodic reme- dies, such as valerian, assafcetida, and oxide of zinc are indicated. All of these remedies ought to be giveii in very small doses, and always at the beginning of meals. DYSPEPSIA. 35 Gentlemen, acid dyspepsia—often associated with flatulent dys- pepsia—is a more common affection than that which I have just been discussing. The physician frequently makes serious mistakes in the acid form of the disease, in which sour eructations and copious secretion of gas occur during digestion. We physicians have the misfortune to be very bad chemists. I am not doing an act of injus- tice to any one, when I say, that of the 300 now present 299— myself included—deserve this reproach. Nevertheless, with an amount of assurance proportionate to our ignorance, we do not hesitate to apply to therapeutics the little knowledge of chemical theories which we possess. Laboratory experiments having taught us that acids neutralise alcalies, we lay hold of the fact: taking it as starting point, the treatment of certain cases of dyspepsia seems sim- plicity itself. The stomach contains a large quantity of acid, which, say we, must be neutralised: w7e can obtain this result by adminis- tering magnesia, bicarbonate of soda, lime-water, or chalk. Not- withstanding our reasoning, the evil increases, the acid secretion becoming more abundant in place of diminishing. We nevertheless still cling to our original opinion: in the increased severity of the symptoms, we only see an additional reason for insisting more stre- nuously than ever upon our treatment. We immediately double or triple the doses of the alcali, when we find that wTe have obtained no beneficial results from the doses first prescribed. Soon afterwards, very probably, the patient is seized with diarrhoea: in place of any benefit having resulted from our treatment, matters have become worse. Being thus baffled in our curative efforts, we are obliged to impute to the obstinacy of the disease consequences entirely due to our untoward interference. In such cases, as well as in many others, a certain amount of physiological knowledge will suffice to prevent our falling into the errors towards wdiich chemical theorising tends. Physiology teaches us that the gastric juice is naturally acid—that this acidity is its constant condition both in man and the lower animals, irrespective of species, sex, age, or food—that it is due to the presence of phos- phoric, hydrochloric, and lactic acids, but particularly the latter, which alone is found in a free state. These acids are secreted in greatest abundance during digestion; and their secretion is indis- pensably requisite to the due performance of the functions of the stomach. When digestion is not going on, the gastric secretion is less abundant, and feebly acid; or sometimes, it is neutral or even 36 DYSPEPSIA. alcaline. As I have already mentioned, the normal secretion ot gastric juice is sometimes partially suspended : but there are other cases in which it is secreted in too great quantity, and this is the point which I have in view. Irritation of the mucous membrane of the stomach, provided it neither proceed to the extent of inflam- mation, nor too far, causes increased secretion : excessive irritation or inflammation arrests the secretion. This has been exclusively established by the experiments of Beaumont on his Canadian,1 and by the often repeated experiments of Claude Bernard.3 Mental emotion and protracted occupation at the desk occasion increased secretion; and are, as you know, very common causes of indigestion accompanied by eructations and vomiting. In cases of this description, you cannot counteract the acidity by bicarbonate of soda, nor indeed by any other alcalies acting as chemical agents. Farther—and from the practical position upon which I take my stand, the fact is of paramount importance— the experiments of Claude Bernard upon animals prove that the se- cretion of gastric juice, and consequently the acid fluids of the stomach, increase when bicarbonate of soda, magnesia, or other alcalies are administered; while the secretion is delayed or dimi- nished by giving acids. These positive facts entirely set aside the trivialities of chemical theory, which are of no use as guides in the treatment of disease, and can still less lay down therapeutic laws to us, as some consider ought to be the case. When chemists tell us that alcalies are useful in a considerable number of cases of acid dyspepsia, they only repeat what we had previously learned from clinical experience. But when they state that the benefit is pro- duced by the alcalies neutralising the acids, we reply that no neu- tralisation has taken place, or if there has, it has been only to a very limited extent. On the other hand, we maintain that these remedies act as powerful modifiers, which not only place their stamp upon the organ, but also impart a peculiar modality to the whole economy, in virtue of which the functions are regulated, and the abnormal acidity of the secretions is corrected. Let me give another illustration of my view of this matter; and 1 Beaumont:—Experiments and Observations on the Gastric Juice and the Physiology of Digestion. Plattsburgh: 1833. 2 Bernard (Claude)Cours de Medecinc du College de France: Liquidcs de l’Organismc. Paris : 1859. DYSPEPSIA. 3 7 one which, I think, will enable you better to understand it. A person affected with gravel, who has passed some gravel during or soon after his treatment, will remain for six months, eight months, or a year without passing any, when under the influence of a season passed at Pougnes or Contrexeville using the waters. Now, will any one say, that these feebly alcaline waters have maintained an alcaline action during all that time ? Certainly not. The proper answer is, that these waters, by restoring the economy to a healthful condi- tion, or (if we wish more to localise the effect), by modifying the urinary apparatus in a salutary manner, have restored the kidneys to the natural performance of their secretory function, and have so prevented uric acid from being formed in excess. If they have exerted any chemical influence upon the products of excretion, it has been very transient. In fact they have an action—a vital action—which is much more powerful than any chemical action, and which, when once set in motion, continues for a much longer period. The same is seen in dyspepsia. If the waters of Vichy, of Pougues, or of Vais have no other action than that which takes place in virtue of the chemical reaction caused by the alcalies which they contain, to be logical, it would be necessary to insist upon the patients continuously using these waters to maintain their supposed neutralising effect. Their beneficial operation is no more chemical in dyspepsia than in gravel: it depends upon their im- pressing on the economy a certain modality, in virtue of which the gastric secretions are so regulated as not to contain more than a normal quantity of acids. The remarks now made in relation to the action of alcalies in gravel and dyspepsia, are applicable to many other articles of our materia medica. Therapeutical action does not admit of chemical explanation : it is essentially vital, or if you prefer the expression, essentially physiological. A healthy woman, for example, takes iron in large doses. Men- struation is disturbed, and the catamenia are suppressed, in a great many such cases. What has taken place ? The iron, given in- opportunely, has deteriorated the health of the individual, the result of which deterioration has been suppression of the menses. But supposing that we give to a chlorotic woman the same remedy in even larger doses, the result will be entirely different—menstrua- tion, which was before imperfectly performed, will become normal. 38 DYSPEPSIA. Chemists will have no difficulty in explaining the last fact; but I should like you to tell me, how they can explain the first. If other proofs were wanting to support this medical view of therapeutic action, or (to return more directly to our subject), to explain the action of alcalies in dyspepsia, are should find the required evidence in the fact, that in many, perhaps in most cases, we easily cure dyspepsia connected with an excess of acid secretion, by the employment of other means which I am now going to men- tion, and which can hardly be explained by any chemical hypo- thesis. Graves stated that abnormal gastric secretion was powerfully and favorably modified by medicines acting specially on the nervous system. At the head of this class of remedies he placed opium, given in very small doses. He, it is true, combined it with the sub- nitrate of bismuth. The particular medication from which he de- rived marvellous effects, consisted in administering a mixture of two milligrammes and a half [24- seventieths of a grain] of sulphate of morphia, or five milligrammes [5 seventieths of a grain] of thebaic extract with from fifty to seventy-five centigrammes [;-£ to 12 grains] of subnitrate of bismuth and an equal quantity of mag- nesia. This is administered twice or thrice daily a short time before meals. The choice of mineral waters in the treatment of acid dyspepsia is regulated by the causes which produce the disorders of digestion, a fact which supports the thesis I sustain, to the effect that che- mical explanations of therapeutic action are worthless. The indi- cations for the use of this, or the other mineral water, do not depend upon the acidity, more or less decided of the stomachic secretion, but upon the general state of the economy, with which the per- verted gastric function is associated. Thus, when acid dyspepsia is associated with chlorosis, ferruginous mineral waters ought to be prescribed in preference to all others. Of this class, are the waters of Spa in Belgium, of Schwalbach in the Duchy of Nassau, and of Pougues, Bussang, Porges, Passy, and others in Prance. Dyspepsia in hysterical women, in hypochondriacal men, in all very nervous persons, in great eaters, and in old people, is chiefly -flatulent; that is to say, characterised by the formation of a large quantity of gas, and accompanied sometimes by acid eructations supervening immediately after meals. In this form of dyspepsia, alcaline preparations are also of some use, if given only for a few DYSPEPSIA. 39 consecutive days, and immediately followed by the administration of bitters. Thus, for five or six days, the patient ought to take at the beginning of his two principal meals, and on going to bed at night, a powder composed of magnesia, chalk, bicarbonate of soda—from thirty to forty centigrammes to 6 grains] of each. These powders ought to be mixed immediately before they are taken in about a fourth part of a tumbler of wrater. This treatment is to be followed up by the employment of bitters, among which I think quassia ought to occupy the chief place. In the morning fasting and at mid-day, at an equal interval between the two principal meals, the patient ought to drink a cup of the infusion of this bitter wood, prepared by leaving a teacupful of cold water for fifteen or twenty minutes, in a goblet made of quassia; or (which is still better) by macerating twro grammes of quassia shavings in cold wrater, for from four to six hours. I have seen this form of dyspepsia yield much more rapidly to this simple treatment, than to the long continued use of alcalies. In these cases, wine of cinchona is also indicated. It ought to be given either immediately after meals, or immediately after the patient has taken a small quantity of food. By proceeding upon this plan, we prevent pain in the stomach, which is apt to be excited when wine of cinchona is taken fasting. In flatulent dyspepsia, also, decided advantage is obtained, by the use of certain liqueurs administered after meals. Those which I prefer are anisette fine de Hollande, and the yellow liqueur of the Grande-Chartreuse, which is simply an alcoholic tincture of various aromatic plants. I need hardly add, that these liqueurs must be taken in very small quantities. Other aromatic preparations may be substituted for them. Tor example, we may give the infusion of illicium anisatum (or star anise), one of the ingredients of the anisette de Hollande, or we may give an infusion of a mixture of star anise, common anise, ginger, and cascarilla bark. These sub- stances, when reduced to coarse powder, are weighed out in packets containing fifty centigrammes of each ingredient. Their infusion is taken immediately after meals. Mineral waters are of undoubted utility in these dyspeptic affec- tions : but we must not send the patients to Vichy, Carlsbad, or Pougues; for the waters of these places are contra-indicated. We must recommend them to go to Niederbronn or Torbach, where the predominating mineral ingredients are the same as those of sea-water. 40 DYSPEPSIA. We may also recommend Nauheim, So den, and Kissengen, which also contain chloride of sodium. The waters of Homburg are like- wise in the same category; but unfortunately, the too celebrated gaming tables of the town damage the reputation of the springs. Without leaving Germany, we may mention the water of Selters, in the Duchy of Nassau, better known in France by the name of ean de Seitz. Each litre of this water contains about two grammes of chloride of sodium, one gramme of carbonate of soda, nearly half a gramme of carbonate of lime, and carbonate of magnesia, a small quantity of sulphate of soda, a minute proportion of carbonate of iron, and an indeterminate quantity of carbonic acid. Its tempe- rature varies between 150 and 20° C. Its agreeable taste has so vulgarised its use, that it is served at the tables of the inns and eating houses as commonly as artificial ean de Seitz is similarly made use of in Paris. I may remark in passing, that artificial does not in any respect resemble the natural eau de Seitz. Some French mineral waters, such as those of Plombieres in the Vosges, and of Bagneres-de-Bigorre in the Hautes-Pyrenees, though containing only a minute quantity of mineral ingredients, are also very useful in flatulent dyspepsia. Hydrotherapy is a method of treatment in this kind of dyspepsia which is not less efficacious than those I have now reviewed. Its use in other forms of dyspepsia is not great. Let it be understood that the hydrotherapic treatment which I now speak of is hydro- therapy methodically applied, and carried out in a regular manner. Sea-bathing, I place in the same category as hydrotherapy. The patient ought to remain a very short time in the water, if he bathe on the coasts of the Manche, or on our northern ocean-coasts. On the sea-shores of the south-west of France—in the Mediterranean— the duration of the bath may be longer, as the climate is warmer. In these regions, in addition to bathing in the sea, the patients may use baths of sand naturally heated by the sun. Patients ought to remain in these baths of sand for from fifteen minutes to an hour—in fact till a decided reaction has been established in the skin. Unfortunately, sea-bathing, travelling to mineral springs, and hydrotherapy in a hydrotherapic establishment are means of treatment which are not accessible to all. Business necessities and expense— matters which we must always take into account—often place these remedial measures beyond the reach of our patients. In such cases, the hydrotherapic treatment may be pursued according to a plan which DYSPEPSIA. 41 I am now going to describe; and which though no doubt less effi- cacious than the methodical system of a hydrotherapic establishment under medical direction, is nevertheless really beneficial. Home- hydrotherapy consists in enveloping oneself on getting out of bed in the morning in a wet sheet slightly wrung out of cold water. After remaining for one or two minutes wrapped up in the wet sheet, you rub yourself or get yourself rubbed with it, you are then rubbed with linen which is quite dry, but not warmed ; after this, you dress, and as soon as possible start on a walk which you continue for three quarters of an hour. The hydrotherapic operation may be repeated at night before going to bed. Great advantage may also be derived from immersions (not exceeding three minutes’ duration) in cold salt-water. Hydrotherapy pursued after this fashion will suffice in many cases so to modify the action of the whole economy, as to cure the gastric disturbance and restore to the stomach its lost tonicity. Gentlemen, I have hitherto spoken of forms of dyspepsia having their causes primarily and directly in the stomach. Before com- pleting what I have to say to you on the subject of dyspepsia, I must speak of the treatment of those cases of dyspepsia which are to a certain extent independent of the gastric apparatus—indepen- dent in this sense, that the apparatus is only indirectly involved, that the disorders of which it is the seat are the result of sympathy between affections of the stomach and different parts of the digestive tube; and likewise between the digestive and other organs of the economy. The forms of dyspepsia of which I am now going to speak are those which so frequently accompany chronic affections of the liver and uterus, dia- thesic diseases such as scrofula and tubercle (particularly pulmonary tuberculisation), and marsh and other cachexise. I must go over this ground rapidly, otherwise, as you can easily understand, I should run the risk of exceeding my limits, and ranging too widely over the domains of pathology ; for there are few maladies in which dyspeptic symptoms do not play a more or less conspicuous part. I shall, therefore, make no attempt to exhaust the subject: on the contrary, I shall limit myself to giving you some practical indications, having specially in view the cases which we have observed together. In respect of diseases of the liver, of which we have had a certain number of cases under observation, let me say, that in the dyspeptic symptoms which arise in connection with them, alcaline mineral waters are marvellously efficacious. Among them, such waters as 42 DYSPEPSIA. those of Carlsbad, Vichy, and Vais, which no doubt owe much of their usefulness to the bicarbonate of soda, their predominating mineral ingredient, are very preferable to the waters of Pougues and the like, in which the bicarbonates of lime and magnesia predo- minate. However, whilst I proclaim the efficacy of the alcaline waters, there are cases in which I prescribe acids. You have seen me order acids to be taken by many patients who were unable to digest their food unless they took a small quantity of hydrochloric acid after each meal. The equality of success which attends the use of alcalies in some, and of acids in other patients, might seem to imply a contradiction; but this is a notion against which I must guard you. The contra- diction is only apparent: it is in fact an additional confirmation of the remarks I have just been making as to the worthlessness of chemical explanations of vital phenomena, which belong to the domains of physiology and clinical medicine. We must bear in mind the fact derived from clinical observation that both alcalies and acids have a general action, not only on the whole intestinal canal, but also, and still more, upon the entire economy. So much is this the case, that it is not a matter of in- difference which particular acid or alcali we select. Mineral waters which derive their alcaline properties from bicarbonate of lime or from magnesia, are, as I have already pointed out, much less efficacious than waters containing bicarbonate of soda, in the dyspepsia now under consideration. The case of one of our patients in St. Bernard's ward afforded a remarkable example of the difficulty which occasionally exists in instituting a regular plan of treatment, and of the necessity which sometimes arises of combining the use of means apparently the most diverse. The patient to whom I refer was a young woman who occupied bed No. 9. She came into hospital on account of severe colitis, characterised by glairy, sanguinolent stools. She was between the fourth and fifth month of pregnancy; and her malady brought on abortion. “ If," said Hippocrates, “ a pregnant woman is attacked with profuse abdominal flux, there is reason to fear that she will abort." I detected great hypertrophy of the liver with effusion into the peritoneum. For a long time, the patient remained in a condition of considerable danger: nevertheless, convalescence was established, although the liver continued greatly hypertrophied DYSPEPSIA. 43 and very painful on pressure, and although digestion was still very badly performed. I tried alcaline remedies, without any good result: the symptoms continued, and there was a speedy return of the diarrhoea. It then occurred to me to try hydrochloric acid. The patient began by taking, after each meal, one drop in a quarter of a tumbler of sugared water: this was found to promote digestion. I then increased the quantity of the acid : first, the increase was to three drops daily, one drop being taken after the morning, and two after the evening repast: subsequently, two drops were taken after each of these meals. From that time, there was a complete cessa- tion of the feeling of weight in the stomach, and of the sensation of fulness after eating : and it is a remarkable fact, that along with this improvement in the digestion, the bulk of the liver diminished : there was nevertheless increased diarrhoea. Under the circumstances, I deemed it advisable to suspend the use of the acid, and give in place of it prepared chalk, which I have always found useful in intestinal flux. The result was arrest of the diarrhoea, and re- appearance of the dyspepsia. I then again suspended the alcali, and reverted to the use of the acid mixture, whereupon the dys- pepsia again yielded, and the diarrhoea returned. I was greatly perplexed how to act: and at last resolved to combine the use of both medicines, prescribing the chalk at the beginning and the acid at the conclusion of the meal. This combination proved successful: the patient was relieved from all her morbid symptoms. This history possesses great practical interest: it shows the phy- sician that, in respect of such cases, he in reality knows next to nothing, or absolutely nothing. "We search for explanations, and for so doing we cannot be blamed, as in no other way can we systema- tise our knowledge, and establish for our guidance certain laws, which no doubt may be more or less defective, but which neverthe- less prevent us from acting as mere empirics. Unfortunately, our explanations are generally incorrect. Here, you see is a case of dyspepsia associated with severe disease of the liver in which there could be no doubt as to the utility of acids. They are also useful in numerous cases of dyspepsia con- nected with chronic maladies. How was I led to adopt this mode of treatment ? Long ago I had read in the English medical journals accounts of cases treated and cured by mixtures having hydrochloric acid as their principal ingredient: I knew that Cullen had said :—“ All the acids seem to 44 DYSPEPSIA. have the power of stimulating the stomach, and consequently of increasing the appetite : the acids, particularly used with success are vitriolic acid and marine acid [hydrochloric acid], and that acid which is formed by the distillation of vegetables, and that derived from tar-water.” I had also observed in different works published in Prance, particularly in the work of Dr. Caron, that acids were advantageously prescribed in certain disorders of the digestive system. I had never found, however, the special indications of this treatment formulated with sufficient exactness. I consequently was somewhat incredulous, and inclined to believe that the patients had recovered, not through taking hydrochloric acid, but in spite of having done so; but some years later, when one day sitting at dinner, next to one of those indefatigable tourists who seem to personify per- petual motion, I was informed by him, that he (being compelled by his constant peregrinations to adopt a great diversity of regimen, and to take his meals very irregularly) was indebted to hydro- chloric acid for the recovery of his digestive powers lost through the irregularities described. He never travelled without his precious remedy. He always carried with him a little bottle of dilute hydro- chloric acid, of which he took from four to eight drops at the con- clusion of each meal. I was very much struck by this statement; and after a long conversation with my tourist, I became quite satis- fied that his custom was not the result of a mere fancy, but was a positive necessity. I then set myself to study the English authors : the indications which I gleaned from the works of Cullen and other authors, were not more precise than those gathered from conversation with the traveller. Nevertheless, I tried the treatment upon some private patients : at first, I proceeded timidly, but soon found that in certain cases, not however very distinctively characterised, real benefit was derived from the hydrochloric acid; I continued my expe- riments, some of which you have witnessed in the treatment of our hospital cases. As I have just stated to you, it is in dyspepsia associated with chronic disease, that the benefit derived from this treatment has appeared to me to be especially marked, although it is likewise seen in cases of another description. 'When speaking of the treatment of dyspepsia arising from chronic gastritis, 1 have spoken to you of the utility of hydrochloric acid, but it has always appeared to me to be more decidedly indicated in cases connected with chronic disease. 45 Iii bed 23 of St. Bernard’s ward, we had a young woman, affected with obstinate chronic diarrhoea, who had fallen into such a state of ansemia and emaciation that I thought she had tubercular phthisis, although, upon the most attentive examination, I was unable to detect any sign of that condition. In addition to the intestinal flux, the patient had that peculiar form of dyspepsia characterised by the state called great fulness of the stomach. I ordered her to take hydrochloric acid at first in doses of one drop, then in doses of two drops, and afterwards in doses of three drops, at the conclusion of each meal: digestion soon became improved; but it was necessary to continue the treatment for a long time, for whenever it was discon- tinued, difficulty of digestion immediately returned. It is true, that the diarrhoea did not yield. Some of you, no doubt, will recollect this patient, whose curious case has been, for more than one reason, reported in the wrork of MM. Gros and Lancereaux.1 The symptoms with which she was affected, and the nature of which we did not for a long time detect, depended upon constitutional syphilis: they did not disappear till after the patient had been subjected to mercurial treatment. In the same ward, there was at the same time, a patient suffering from very manifest pulmonary tuberculisation. The progress of the tubercular affection seemed for a time to be arrested; lost flesh was regained, and the general condition became improved. The local signs were also modified: moist crackling had succeeded to slightly prolonged expiration mingled with some disseminated mucous rales : when fresh hemoptysis took place, the moist crackling reappeared; and to these symptoms dyspepsia was added. Tour or five hours after eating, the patient experienced a feeling of weight in the sto- mach. Hydrochloric acid given at meals remarkably aided digestion, which was only properly performed so long as the use of the remedy was continued. In bed 27 we had a similar case. This woman, who was also the subject of tubercle in a state of softening, was becoming weaker day by day. During the night, she had burning fever followed by pro- fuse sweating. There was hypertrophy of the liver, as is very often the case in phthisis. She suffered from indigestion and diarrhoea. Hydrochloric acid promptly cured the gastric symptoms, but did DYSPEPSIA. 1 Guos et Lancereaux:—Des Affections Nerveuses Sjpliilitiques. 8vo. Paris: 1861. 46 UYSPEPSIA. not, of course, arrest the progress of the tubercular disease. 1 could give you histories of a number of similar cases. Indeed, it is chiefly in dyspepsia supervening in phthisis that I have found the acids of great use. I too have tried to found a little theory of my own upon the results of my experience. I have reasoned thus:—During digestion, the stomach contains a certain quantity of lactic, phosphoric, and hydrochloric acids : does, said I to myself, my medication prove successful because it supplies the gastric juice with a certain amount of acid in which it is deficient ? I tried lactic acid in doses larger than those I had given of the hydrochloric acid : I began with ten and went on increasing the dose to twenty drops, but, still finding the dose insufficient, I gave as much as two and even three grammes. The results were very variable : the lactic acid, however, I found did less good than the hydrochloric ; so for the future I preferred the hydrochloric. To sum up these remarks, Gentlemen:—"Without giving any account of the action which takes place in the digestive canal under the influence of acid or alcaline remedies, let us always remember that alcalies are not the only therapeutic agents available in the treatment of dyspepsia connected with chronic diseases; that acids are also indicated, but that the indications cannot be formulated in advance with exactitude, and that they can only be discovered by attentive observation in each case. I have now come to a very important part of my subject—the treatment of dyspepsia coincident with more or less anaemia, and more or less hepatic and splenic engorgement. Such complications observed in persons who have long suffered from marsh fevers, or in persons who, though they may not have suffered from marsh fevers, have lived for a long period in marshy countries and been subjected to their miasmatic influences, must be carefully distinguished from the similar complications which characterise leucocythaemia. This is very important; because leucocythaemia is a disease against which medicine is powerless; whereas under the other conditions described there is generally rapid recovery. Whether dyspepsia and its accompanying visceral engorgement depend on anaemia or be its cause, I cannot say; but in either case the gastric symptoms, the hypertrophy of the spleen and liver, are very often successfully treated by means which one certainly never would expect to be useful. At the military hospital of Yichy, for in- 47 stance, which contains a large number of patients suffering from paludal cachexia, characterised by hepatic and splenic engorgement, and dyspeptic symptoms of more or less severity, we see recoveries or at least very rapid ameliorations under the use of the Yichy thermal alcaline water, which is specially efficacious in that class of cases. So general is the fame of the efficacy of the waters of Vichy and Pougues, in affections consecutive upon paludal poisoning, that it is a constant practice of patients to resort thither from the Nivernais, the Berri, the Bourbonnais, and Auvergne for their cure. This is a case in which popular opinion and medical observation entirely agree. The medical practitioners of Vichy unanimously proclaim the virtues of their thermal springs in dyspepsia and other functional and organic disorders depending on paludal cachexia. My lamented colleague Dr. L. de Crozant, late medical inspector at Pougues, published interesting works with a view to make known the usefulness of the waters which he administered with so much science and intelligence.1 These remarkable properties of the waters of Vichy and Pougues have been long known to, and admitted by, physicians. I ask you whether there is, at first view, anything more anomalous, more opposed to chemical theory, than to administer to patients whose blood is in so dissolved a state that dropsies and passive he- morrhages are of frequent occurrence, alcalies which are looked upon as peculiarly possessing the properties of blood-solvents ? Whether the predominating ingredient be bicarbonate of soda, as in the waters of Vichy, or bicarbonate of lime, as in the waters of Pougues, the waters administered are alcaline, and their good effects empha- tically contradict the statement of the chemists in relation to the action of alcalies upon the blood. I know very well, that it is customary at Vichy, to prescribe the Lardy spring to persons suffer- ing from paludal cachexia and that this Lardy spring contains a certain very small proportion of the bicarbonate of the protoxide of iron—about twenty-eight thousandths of a gramme. I also know very well that the waters of Pougues contain bicarbonate of iron nearly in the same proportion as the Lardy spring of Vichy; and that both contain carbonic acid gas, and that their beneficial effects may be attributed to the iron and the carbonic acid gas. However, at Vichy the same class of patients recover by using the Grande- DYSPEPSIA. 1 L. de Ckozant :—De l’Emploi des Eaux Minerales de Pougues dans le Traitement de quelques Affections Clironiques de l’Estomac. Paris : 1851, 48 Grille spring or the Hbpital spring, as completely as, though less rapidly than when they drink from the wells of Lardy ; and still less rapidly than patients who go to Pougues. It appears certain, there- fore, that the honour of the cure ought to be attributed to the mineral alcali. I have been desirous to point out these facts to you, that I might put you thoroughly on your guard against chimiatria, which, parti- cularly in its applications to therapeutics, leads to deplorable mis- takes. I am not at all afraid of recurring too often to this topic, so strong is my conviction of the correctness of my views, founded as they are upon long practical experience, and on an attentive observation of cases. Distrust the theories of the laboratory! ltemember the remark of my honourable scientific friend Dr. Lasegue, to the effect that, though chemistry is capable of rendering to medi- cine the most important services, the chemist goes beyond his legiti- mate sphere when he draws clinical inferences from the experiments of the laboratory; and that chemistry does not approach any nearer to medicine, when teaching the art of preparing and analysing medicines, than it approaches painting, when it furnishes fixed and durable colours. This proposition, true in respect of the general articles of the materia medica, is specially true of mineral waters, although for them chemistry is endeavouring more than ever to monopolise the right of explanation and to constitute herself the decisive judge. Whatever may be said to the contrary, mineral waters are not simple medicines : whatever may be the mineral ele- ment which analysis shows to be predominant, that element does not act alone : by associating with it quantities more or less notable of very various principles which the chemist can isolate, as well as others which have not yet been discovered, nature has given to the mineral element a something which we seek every day to imitate in our prescriptions, when wre endeavour to increase or diminish the effects of a particular medicine, by associating it with other medi- cines. In taking into account, however, the particular effects of this or that ingredient of mineral waters, we cannot attribute them to a single principle, however dominant chemical analysis may show it to be; it is by clinical experience alone that we can arrive at a correct judgment on this point. So true is this, that the forms of dyspepsia associated with a formidable paludal or other cachexia are beneficially modified by waters very different from those of Yichy or Pougues, by waters, the mineral ingredients of which elude, so to DYSPEPSIA. DYSPEPSIA. 49 speak, chemical analysis, such as the waters of Plombieres and of Bagneres-de-Bigorre. Although the first are placed in the class of sulphurous soda waters, and the second are considered as sulphurous lime waters, they have so small a proportion of mineral ingredients that the predominance of one or other mineral ingredient either de- stroys the classification or renders it purely artificial. If we compare them in respect of their composition with the waters of the Seine, taken at different points of the river as it passes through Paris, with the waters of Arcueil, or with thosjs of the artesian well of Grenelle, the superiority will rest with the latter, at least so far as the waters of Plombieres are concerned. But, nevertheless, medical experience tells us that the waters of the Seine have no other peculiar property than that of occasioning diarrhoea (generally slight) in persons not accustomed to use them, which cannot be attributed to the small quantities which they contain of the salts of soda and chlorides. So far as I know, these waters have never yet been inserted in any of the voluminous lists of mineral waters which have been published. In thus instituting a parallel between the waters of the Seine, Arcueil, and Grenelle, and those of Plombieres and Bagneres-de-Bigorre (to which I would add the waters of Neris or Mont Dore which are scarcely more mineralised), I am far from wishing to deny the efficacy of these justly celebrated thermal springs. Plombieres and Bagneres- de-Bigorre in the particular class of cases now before us, triumph over rebellious dyspepsia, in virtue of a therapeutic action the nature of which eludes us, and which I do not even attempt to explain. Under their salutary influence, the appetite is restored, and the con- stitution renovated. Patients affected with dropsy and visceral engorgements who have arrived at Plombieres or Bigorre in a deplorable condition leave these places after a single season in a notably improved state, and often recover in a manner quite unex- pected. Gentlemen, the sympathetic dyspepsia which so often accompanies uterine affections, such as displacement of the womb associated with chronic catarrhal inflammation, is often cured simultaneously with the spontaneous cure of the uterine affection. In these cases, local treat- ment, cauterizations of the neck, for example, which will modify the catarrh when dependent upon ulceration, properly applied bandages, hypogastric bands, more rarely the use of pessaries—local treatment in fact—will prove very useful, not only for the uterine lesion, but also for the gastric symptoms which depend upon it. These means, 50 DYSPEPSIA. however, are not in general sufficient in themselves; it is necessary to have recourse to general treatment, in which an important place must he assigned to sea-bathing and hydrotherapy. You will some- times see women restored, as it were from death to life, after not more than eight or ten days of sea-bathing. But then it is essen- tial that the sea-baths be taken in a proper manner: by a proper manner, I mean, that they be of short duration, at the utmost not exceeding five minutes. The best way of proceeding is to admi- nister the sea-bath a la lame. You all know what this means : an attendant taking the patient in his arms, presents her five or six times in succession to the wave, which passes over her. Powerful reaction succeeds this rapid immersion; the temperature of the skin rises. Sometimes after the fourth or fifth bath, the skin becomes the seat of a peculiar eruption, to which the name of maritime urticaria (iurticaire maritime') has been given. This reaction pro- duces a wholesome derivative action upon the internal organs, as well as a salutary influence upon the digestive apparatus : the gastric functions become normal, the appetite improves, and the dyspeptic symptoms disappear. Simultaneously with these beneficial changes, the uterine lesions likewise improve, the catarrhal affection ceases, and the uterus loses its morbid susceptibility. The general health becomes better, the patient acquires tone, and is able to bear those variations of temperature which formerly occasioned uterine catarrh, just as they might occasion in others pulmonary catarrh, coryza, or sore-throat. Similar beneficial results may be obtained from a course of hydro- therapy conducted at a hydrotlierapic establishment; or, if that can- not be obtained, by hydrotherapy carried out at home in accordance with the plan which I have already described to you. Before concluding this long series, I have still some words to say upon that form of dyspepsia associated with sluggishness of the large intestine and obstinate constipation. A remedy lauded by Bretonneau, I mean belladonna, is marvel- lously efficacious in cases of this description. We must begin by prescribing it in very small doses: a centigramme of the extract incorporated with the same quantity of the powder of the leaves, may be administered, in pill or powder, morning or evening. If the constipation does not yield after one or two days, the dose of bella- donna may be gradually increased, according to circumstances, to one, three, four, or five centigrammes; but five centigrammes in DYSPEPSIA. 51 one day, must never be exceeded. Thus administered, belladonna is perhaps the most active remedy with which I am acquainted in this kind of dyspepsia. It is generally sufficient to produce regular stools, and, at the same time, to re-establish the digestive functions so thoroughly, that individuals who had fallen into a state of de- plorable debility and emaciation, rapidly regain strength and plump- ness. The remedy, however, acts in these cases only in an indirect manner, that is to say, by restoring to the large intestine its lost activity : but this activity is communicated synergetically to the other parts of the digestive tube, and thus it is, that the stomach regains its original energy. When the belladonna proves insufficient, its operation may be assisted by giving the patient every evening a teaspoonful of castor oil, simultaneously with the belladonna: the castor oil may be admi- nistered in a capsule of gelatine. When the bowels are regularly open, these means may be discontinued. This treatment, I repeat, is sovereign in the cases now under consideration: but it is in an espe- cial manner sovereign, as a means of restoring regularity to the dis- ordered functions. To secure a continuance of these beneficial effects, the co-operation of the patient is required. In the acts of animal life, habit plays an important part. Upon this subject might be written a long and interesting chapter of general medicine. You know, that according to country and social condition, persons become habituated to eat at regular hours, and except at these hours do not feel the want of food. In the same way, the large intestine may become accustomed periodically to contract itself, and the bladder to discharge its contents at regular times—which times may be at pleasure approximated or made more distant. This is a fact, which may be profitably borne in mind in the treatment of such cases as we are now considering. Patients affected with obstinate constipation dependent upon sluggishness of the intestine, ought to go regularly to the closet every day at the same hour; at first, their efforts may be unavailing, but they must nevertheless persevere, and if they do so, the results will ultimately prove satisfactory. Should these means—should the belladonna treatment—prove inadequate, injections are permissible. But, if used, it is essential that the injections should consist of cold water, and be administered in very small quantity: injections of tepid water ought to be ex- pressly prohibited, for their use ultimately leads to an increase of that atony of the intestine which we are endeavouring to combat* 52 DYSPEPSIA. Let us suppose that the constipation has resisted the use of all these means; it is then necessary to have recourse to purgatives, particularly to aloetic preparations, such as dinner pills, grains de sante, and similar remedies. Immediately before eating, from one to four of these or such like pills may be taken. Rhubarb in a dose of from fifty centigrammes to a gramme may be advantageously substituted for the pills, without causing diarrhoea, and with the effect of producing only one stool regularly in the 24 hours. In these cases, certain mineral waters are likewise indicated. I refer to the waters of Seidschiitz and Sedlitz in Bohemia, which contain sulphate of magnesia, as well as to Bor bach, in the depart- ment of the Moselle, whither patients are sent for one or two seasons. I intend afterwards to treat more fully the important question of constipation, which to-day I cannot do more than touch upon in a sketchy manner. Gentlemen, I beg your attention for a few minutes whilst I speak of a new treatment which you have seen me employ, with decided benefit in a very severe case of dyspepsia in St. Bernard's ward. The anatomical integrity of the blood, if I may use such an expression, is a condition essential to the normal performance of the functions. Whenever the blood is seriously altered, either in the pro- portion of its constituents, or by the addition of some septic or toxic principle, it necessarily follows that each organ is modified in inti- mate texture, or at least in respect of nutrition; it also happens that each organic molecule in contact with vitiated blood no longer bears a normal relation to the nutrient fluid, and that the due perform- ance of the functions is in consequence seriously impaired. Hence arise the mal-nutrition of tissues, and the disturbance of the organic functions. To speak only of anaemia :—we understand perfectly well that the blood deprived of one essential constituent is no longer sufficient for the formation of tissues, and that the nervous centres of animal and organic life are destitute of their natural excitement, and can no longer exert upon the organs which they supply an influence which they have lost. It is evident then that the digestive functions are disturbed, because the tissues are no longer in a normal state, because the ganglionic nervous system no longer regularly sup- plies the required influence of nervous power, and because the organs themselves, even if in a state of perfect anatomical soundness, DYSPEPSIA. 53 cannot extract from the blood all the materials which ought to enter into the secretions. When anaemia is associated with chlorosis properly so called, the preparations of iron prove rapidly beneficial: even in cases in which iron is badly borne for a few days, it generally at last triumphs over the disease. But the anaemia which follows excessive uterine hemorrhage, particularly that which slowly supervenes as a conse- quence of great physical fatigue, protracted moral suffering, excess in venereal pleasures, bad feeding, too protracted lactation, a con- tinuance in unfavorable conditions, that anaemia so common in hospitals, particularly in very young girls who have become mothers, and attempt to perform their maternal duties, though ill-fed and hard worked—anaemia of this kind is not in general improved by ferruginous remedies; and, as it is accompanied by excessive debility, and insur- mountable dislike of food, we cannot always restore the aptitudes of the stomach, the organ to which, in the first instance, we make our appeal, knowing that good nutrition is the primary condition essen- tial to recovery. Whatever wre do, the patients die oppressed by an insurmountable loathing of food, burning fever, and ardent thirst. On anatominal examination of the bodies, nothing morbid can be detected, except universal paleness of the tissues, and a colourless condition of the blood. Gentlemen, let me relate to you the history of an illustrative case. On the 5th January, 1864, a young woman, 25 years of age, was admitted to St. Bernardos ward; She had been confined three months previously, under the very deplorable moral and hygienic conditions commonly met with in girl-mothers [files-meres]. Poor and iso- lated, she was compelled to engage in a toil as ceaseless and fatiguing as it wras ill-paid: besides, she suckled her child, and was without sufficient food: she was thus the victim of twofold exhaustion. She gradually fell into a state of extreme anaemia and debility, wdiich it is not easy to depict. Her emaciation was excessive; her debility was extreme. The skin presented as pale and cachectic an appearance as it is possible to conceive. She coughed : she had constant fever, which redoubled its severity at night; and her appearance, as well as the general phe- nomena of her case, indicated the existence of pulmonary phthisis. It was, therefore, with extreme astonishment that I could not discover any abnormal sounds in the chest, and that I heard the natural vesi- cular murmur in every part of the lungs from base to apex. 54 DYSPEPSIA. The most minute investigation, moreover, revealed nothing morbid in any other part of the organism. It was therefore necessary to admit that the case was one of febris alba virginum. From the 5th to the 10th of January, the hectic fever continued, and, in spite of all our efforts to prevent it, the strength progres- sively declined. The following is a description of the patient’s condition on the 10th January :—the pulse in the morning was 120, and in the evening 130; the fever was ardent; the skin was dry and burning : diarrhoea alternated with constipation. Nothing ab- normal was met with on auscultation. On the nth, the patient had the initiatory symptoms of small-pox—rachialgia and bilious vomiting. The pulse rose to 140. On the 12th, thirty-six hours after these prodromata, a few scattered papules appeared, as anaemic as the skin itself on which they were developed, and more sensible to touch than to sight. On the 13th the papules continued in the same state, and were not surrounded by any areola. There was great prostration. On the 14th, the patient died. During life, the blood was examined, and found to contain very few wdiite corpuscles. At the autopsy, the organs were found generally in a colourless condition. The heart was small, and exceedingly anaemic. There was no trace of tubercles in the lungs, which, as in severe cases of fever, wrere congested throughout their two inferior and posterior thirds. The spleen was voluminous, tense, hard, and of a hepatised appearance: the Malpighian bodies were evidently of increased size. The liver was bulky, and colourless. I have 110 doubt that this woman sank from anaemic cachexia, and that the attack of small-pox was only the immediate cause of death. The organism was in so exhausted a state, from the daily loss to which it was subjected, and the want of reparative aliment, that, as in the animals experimented upon by Chossat,1 a degree of inanition had been attained which rendered death inevitable. I have already, Gentlemen, often had occasion to deplore mv inability to be of any use in cases of this description, and I long sought vainly for a weapon to serve me in the circumstances. I am indebted to my friend and hospital colleague, Dr. Demarquay, for having enabled me in some cases to restore women to life, whom I had been looking upon as virtually dead; and who were in precisely the same position as the young patient whose sad history I have just related to you. 1 Chossa.t:—Recherches Experimentales sur l’Inanition. Paris: 1843. DYSPEPSIA. 55 The curative agency to which I refer is the respiration of pure oxygen gas.1 You have seen in our clinical wards the successful results of this treatment, results which have not astonished you less than they have astonished me. The results were as remarkable when looked at from a therapeutic point of view as they were physiologically unexpected and para- doxical. The woman whose case I am now going to describe was admitted on the ist April 1864; and is now a patient occupying bed 7 of St. Bernardos ward. She is 22 years of age. She had been, like the other woman whose case I have just described, recently confined: like her also, she was anaemic, and exhausted by lactation. Her face was exactly like that of a dead person. The first step in the treat- ment was to separate the child from the mother. There was, how- ever, no improvement between the ist and 14th April, that is to say, during the first fourteen days in which she did not give suck. On the contrary, there was a continuance of the fever : the pulse ranged between 120 and 130 : the skin was dry and hot: and the debility wrent on increasing. So great was this debility, that the patient could not sit up in bed without fainting, and on this account, auscultation wras almost impossible. Nevertheless, it was ascer- tained with certainty that the lungs were healthy. As there no tubercular disease, as tonics and ferruginous remedies had failed, and as there was complete anorexia, I resolved to try the effects of in- haling oxygen, with a view to restore appetite and promote diges- tion. The patient commenced this new treatment upon the 14th, but wras so weak, that after the second inspiration of this gas she became insensible from the effort made in inhalation. However, I recommended her to persist, and to inhale during the day, at in- tervals, a quantity amounting to five or six litres. Bor three days, she inhaled much less than that quantity, and during that period, the amelioration was not very perceptible. But, from the 19th, the patient could sit up in bed with im- punity; and could eat a little. The pulse wras not more than 104 in the minute. On the 21st, she was able to leave her bed for an hour : she asked for food, particularly for vegetables. The pulse wras not more than 92. The skin was cool. Upon the 24th, the pulse was 80. On that day, the patient went down into the garden 1 Demarquay :—Essai de Pneumatologie Medicale; Recherches Physiolo- giques, Cliniques, et Tlierapeutiques sur les Gaz. Paris : 1866, DYSPEPSIA. and ate voraciously. To-day, 30th April, and for the four preceding days, the pulse has ranged between 72 and 80. The young woman feels herself so well that she wishes to leave the hospital. I have however asked her to remain, telling her that her cure is not yet complete. In fact, she still continues pale, and the fibre has evidently regained its tonicity to a greater extent than the blood has regained its normal constitution. One strange and unexpected phenomenon which accompanies the inspiration of oxygen is the production within the chest of an agree- able sensation of coolness by each inspiration of the gas. The pulse, being 84 on the 30th April, when the patient began to inhale the ten litres of gas, had fallen to 76 by the time the in- halation was completed, and remained at that point during the re- mainder of the hospital visit. The pulse becomes thready after three inspirations of oxygen, and so continues for the two or three minutes of the duration of the operation. These facts prove— were proof required—that hematosis is not accomplished in the lungs, but in the general capillaries—that during the inspiratory act, there is a simple exchange of gas in the organs called the organs of hematosis—and that, finally, the oxygen acts almost immediately upon the vaso-motory nervous system, producing contraction of the vessels. I have now terminated my remarks upon dyspepsia. Let me again repeat, that I have avoided attempting to give more than one short chapter of a long history. In pointing out to you in a very sum- mary manner the diverse forms, and the still more varied treatment of dyspepsia, my only object has been to show you, and smooth for you the right road, so that you may be able to follow it in your practice. However incomplete the notions may be which I have attempted to present, they will at least cause you to think. Never forget that dyspepsia will present itself to you, under aspects, and under forms the most varied. According to diversity in symptoms and individuals, it demands remedies, for employing which, general indications can hardly be formulated in a didactic manner, as their application is subordinate to a host of circumstances, impossible to foresee, impossible to point out in advance, and the appreciation of which depends entirely upon the tact of the practitioner. LECTURE LXIX. CHRONIC GASTRITIS. Existence of Chronic Gastritis improperly denied in the present day, Pituitous Vomiting attributable to it. Gentlemen :—In the present day, to pronounce the word gas- tritis is considered equivalent to the intimation of a desire to renew useless controversies raised by a defunct school. Even during the life-time of Broussais, the very existence of his famous “ gastritis,” which he attempted to install as the originator of all other diseases, was denied by the majority of physicians. It has not yet recovered from that negation. Erequent the different services of our hospitals, and I question whether, in a long space of time, you will even hear gastritis named! Gastritis is nevertheless a real disease. I am speaking, you un- derstand, of idiopathic gastritis; for no one denies, that gastritis is produced by the ingestion of certain poisons. There is also such a thing as gastritis spontaneously developing itself. I admit that it is a rare, a very rare affection. It is easy to understand that it should be rare. The stomach, from the nature of the functions with which it is entrusted, ought to be so organized as to resist energeti- cally the causes of inflammation, which it may have daily to en- counter from irritating alimentary substances. Moreover, a con- siderable degree of excitation is often indispensable to bring into play the functions of the organ. However enduring the stomach may be, its tolerance has limits. To pass these limits, it is neces- sary that (according to individual tendencies) the irritating causes should be somewhat violent, more protracted, and more recurrent than when they act upon organs of greater susceptibility. Consequently, that irritating causes produce any serious result on the stomach, they must be very violent and deep-seated. 58 CHRONIC GASTRITIS. Pathological anatomy has made us acquainted with the lesions which characterise acute and chronic gastritis. After saying a few words upon chronic inflammation of the sto- machy I shall proceed to consider the cases now particularly under our observation. I shall not discuss at length the different morbid colours pre- sented by the mucous membrane of the stomach : I shall only state that grey, slate-colour, or brown, seem chiefly to belong to chronic inflammation: that the morbid colour appears in the form of spots, sometimes round, sometimes irregularly shaped, and sometimes uniformly spread over a greater or less surface. The morbid tint is in some cases black, as when the inflammation is produced by cer- tain poisons, but the shade of black is never so deep as in cases of poisoning. Let me caution you against confounding the appearance of which I am speaking with the dark hue so frequently the result of cadaveric imbibition. But the most essentially characteristic lesion of chronic gastritis is the alteration and hypertrophy of the coats of the stomach. Sometimes the mucous membrane alone, and at other times all the coats, mucous, cellular, and muscular, are thickened: this thicken- ing may be partial, or it may be more decided in particular parts. The stomach then assumes an aspect similar to that presented by the bladder, when it has been the seat of chronic inflammation of that description which is called columnar bladder [yessie a colonnes]. This is rarely seen: nevertheless, here is an example derived from our own clinical service. At the beginning of the year 1856, a man, aged 50, was admitted to our wards, who told us, that for some time, he had vomited all his food. He stated, that he had lost more than 40 pounds in weight during three months. He likewise complained of obstinate constipation. The disorders of digestion and nutrition had never been accompanied by fever. From my very first visit, I was struck by a fact, which appeared to negative the idea of cancer of the sto- mach, which was, I confess, my first impression: the complexion of the patient was remarkably fresh. Nevertheless he had incessant vomiting. Irrespectively of meals, irrespectively of the ingestion of alimentary matters, this man vomited a large quantity of a glairy matter, similar to that contained in the urine of persons affected with catarrh of the bladder. Moreover, the glairy matter was sometimes mixed with blackish matter resem- CHRONIC GASTRITIS. 59 bling suspended soot, like tlie melanotic vomiting which generally characterises cancer of the stomach. Upon examining with greater attention, and upon several different occasions, almost every day, the epigastric region, I was unable to detect the presence of any circumscribed tumour. However when, with my hand upon the pit of the stomach, I told the patient to take a deep inspiration, I felt under my fingers a sort of rubbing, which appeared to me to be produced by a stomach which was indurated. Notwithstanding the absence of any appreciable tumour, my dia- gnosis was—carcinoma of the stomach. This induration, as to the existence of which I had no doubt, the incessant vomiting, the pre- sence of black melanotic matter in the fluid ejected by the mouth, both after meals and during the intervals between meals, and the notable emaciation of the patient, justified my conclusion, although the pink colour of the integument was essentially different from the cachectic pale yellow hue of persons affected with cancer. .The dis- ease made rapid progress, the emaciation increased rapidly as the patient could not be nourished; and ere long death occurred. On opening the body, my attention was immediately directed to the stomach. It was diminished in volume, and its interior pre- sented an appearance exactly similar to that of a urinary bladder which had long been the seat of chronic catarrh. I found no trace of a tumour, but the mucous membrane was exceedingly hypertro- phied, and was so blended with the cellular coat, as to adhere inti- mately to it by fibro-plastic tissue. The mucous membrane seemed to be destroyed. At some points, the walls of the organ were two and a half centimeters in thickness. I begged my distinguished colleague Professor Charles Robin to examine the stomach carefully, and to find out whether it presented any elements of cancerous disease. In giving me an account of his examination, he informed me that he had several times seen stomachs in a similar condition, that is to say, presenting only hypertrophy of the fibrous structure, associated with nearly total destruction of the mucous coat, and presenting no trace of heteromorphous products. Here then, Gentlemen, is a case in which the autopsy placed beyond doubt the existence of chronic gastritis. Our patient who leaves the hospital to-day, and whose case has originated this lecture, evidently had similar lesions, although no doubt they were less decided and less advanced. This man was admitted about five months ago. His very emaci- CHRONIC GASTRITIS. atfcd condition, and the pale yellow tinge of his skin, showed that lie was suffering from extreme cachexia. On admission, he stated that the beginning of his symptoms dated back six months or more. He had in the first instance loss of appetite, and soon afterwards vomit- ing, which for the last three months had habitually occurred after ingestion of the smallest quantity of food. Diarrhoea was then added to the other symptoms; and it alternated with invincible con- stipation. The general debility, and the great emaciation, were the results of disordered digestion. In endeavouring to trace the malady to its source, we could only ascertain that the patient had lived under the most unfavorable hygienic conditions. He pursued the occupation of an itinerant seller of neck-ties, by which, for a long time, he had been scarcely able to provide a bare existence. He was ill fed, and probably worse lodged. He assured us, that he never committed any drinking excesses. The matter vomited was chiefly of a glairy, stringy, and glutinous character: it was sometimes ejected, so copiously that the spittoon was filled within the 24 hours. Upon examining the epigastric region with the greatest care, I could not detect a tumour either in the situation of the great or the small curvature of the stomach : nevertheless, the excessive emaciation of the patient, his cachectic hue, his loss of appetite, and the constancy with which vomiting was occasioned by the ingestion of food, led me to write upon the sheet, “ Cancer of the stomach” as my dia- gnosis. At the same time, I had not then formed an absolute opinion, and was waiting for the result of treatment to see whether or not the view which I took of the case was right or wrong. Gentlemen, you have very often found me, under similarly embarrassing circum- stances, postponing my diagnosis and refraining from announcing it absolutely, till I had tried several different plans of treatment. It is not, as some might suppose, from any desire to shirk trouble, by avoiding an exact diagnosis at the first examination, that I act in this manner: on the contrary, I use from the first my utmost endea- vours to make my diagnosis as rigorously accurate as possible. There are cases, however, in which hesitation is allowable; and there are others in which, although an almost absolute certainty has been obtained, there is still room for hoping that we may be deceived, cases, therefore, in which we look out for new elements to guide our judgment and correct previously formed opinions. The facts of the CHRONIC GASTRITIS. 61 case now under observation will enable you to understand clearly the explanations I wish to make to you on this point. Prom the first, our patient seemed to labour under cancer of the stomach. This diagnosis necessitated my avowal of inability to do any good, and condemned me to absolute forbearance from active treatment; because experience had told me, that cancer of the sto- mach is an incurable disease, in which it is not only useless but even injurious to employ energetic measures. My only remaining hope was, that I had been deceived. Without, therefore, ceasing to believe that the case might be cancer of the stomach, I endeavoured to discover whether there was anything in the symptoms or progress of the disease, upon which I could lay hold, as possible signs of a curable malady. The phenomena which I observed seemed to present a certain analogy to those presented by the patient whose case I have just laid before you; and I asked myself the question, whether this case was not also chronic gastritis. I clung to the possibility of its being so, and directed my treatment as if it were that disease. To combat the vomiting of glairy matter, which was the predomi- nating symptom, I had recourse to lime water, while at the same time I administered, according to the method of Graves, very small doses of opium. The first trial of this plan proved successful. The vomiting became less profuse; and the patient began to take a little food. Diarrhoea, however, having supervened, I substituted for the lime water and opium, nitrate of silver, giving from eight to ten centi- grammes during the day, in the form of pill, each pill containing one centigramme of the nitrate. I pursued this plan of treatment, exactly as if I had been endea- vouring to modify a catarrhal affection of the mucous membrane of the bladder or pharynx by injections or caustic applications. During six weeks or two months, I thus combined my thera- peutic measures, alternating opium and alcalies with nitrate of silver. Under the influence of this treatment I have had the satisfaction to see so great an amelioration in the symptoms, that the patient is able to-day to leave the hospital with restored appetite and good digestion, and notably increased plumpness—in a word, in a state of health relatively most satisfactory. Although this case, which I consider to be an example of chronic gastritis, leaves some uncertainty as to its nature, it is not the less 62 CHRONIC GASTRITIS. valuable to you as a source of instruction. Granting that we have only arrived at an imperfect result, that result, so far as it goes, is good. When I come to speak of diarrhoea, you will see how often that affection is the consequence of an intestinal inflammation similar to that which attacks the bronchial tubes, and supervenes under the influence of the same causes. Very recently I saw, in my consulting room, a young lady, presenting all the symptoms of chronic gastritis, with, however, very frequent attacks of a more acute character. Whenever she was exposed to cold, she had these acute attacks, and then there immediately supervened vomiting of glairy matter. It is easy to understand why it should be so; nay, Gentle- men, let me add, that I do not see how it could be otherwise. A thousand times we see exposure to cold produce or aggravate cystitis, uterine catarrh, pulmonary catarrh, catarrh of the mucous membrane of the nasal fossae, and why should we expect that the internal membrane of the stomach should alone be exempt from affections to which almost all other mucous membranes are subject ? It is in this form of chronic gastritis, that sulphurous baths, hydrotherapy, and sea-bathing, are pre-eminently useful: it is in such cases, too, that patients, after annually making useless journeys to Carlsbad, Yichy, and Plombieres, are speedily cured by the Luchon waters, sea-bathing, or hydrotherapy. I am unwilling to leave this subject, Gentlemen, without saying a word upon the affection called vomiting of phlegm [la pituile]. Under this name, is generally understood, a disease characterised by vomiting of glairy matter, the vomiting occurring chiefly in the morning before eating. The quantity of mucus ejected is sometimes very considerable. I am not speaking, Gentlemen, of that kind of glairy salivation,which is so often the precursor of vomiting, and which is evidently the product of the salivary glands and the muciparous glands of the pharynx and mouth, but is not vomiting : what I refer to is glairy vomiting. This is most frequently observed in persons addicted to excess in alcoholic drinks,1 and is usually coincident with great want of appetite: it is not, however, at all incompatible with obesity. I have always considered this kind of vomiting as a sign of chronic gastritis, and I place it in the same category with the vesical 1 See the Lecture upon Alcoholism, p. 421, Volume Third of this Transla- tion. CHRONIC GASTRITIS. 63 catarrh which follows acute cystitis, and the glairy stools resembling the spawn of frogs, so frequently observed after acute colitis and dysentery. I know quite well that certain persons may have this pituitous vomiting without any apparent deterioration of health: but do you not know many men with chronic cystitis, whose general health is unexceptionable, and many patients with bronchial catarrh, and profuse glairy expectoration, who are invalids only in a small degree ? Can we on that account deny that there exists an inflam- matory affection of the vesical or the bronchial mucous membrane ? The treatment of pituitous vomiting in no respect differs from the treatment of chronic gastritis. LECTURE LXX. SIMPLE CHRONIC ULCER OE THE STOMACH. Gaslralgia with Stitch in the Ensiform ancl Rachidian Regions is not exclusively a Symptom of Simple Ulcer of the Stomach.—It may he absent in this affection, and it may also he met with in Diseases of the Stomach of very different Characters.—The same is true in respect of llcemorr hag e from the Stomach and Intestines indepen- dent of Organic Change [in supplementary Ilcematemesis, for example), and in Chronic Gastritis.—llcemorrhage, a character common to Simple and Cancerous Ulceration, may he absent.— In Cancer, Haemorrhage is sometimes as profuse as in Simple Ulceration, although generally the Ilcematemesis of Cancer is less than the Ilcematemesis of Simple Ulceration.—The positive Dia- gnosis of Simple Ulceration is enveloped in much obscurity.— Treatment. Gentlemen :—In bed 8 of St. Bernard’s ward, there lies a woman, aged 34, whose history is exceedingly interesting, but which I can only recapitulate in a summary manner. According to her state- ment, her disease is of old standing, and the result of a blow on the stomach. I do not attach as much importance to this blow as she does. There are two other facts, however, which seem to me to be of special value. In early life, this woman was periodically subject to bleeding piles. This is in itself a somewhat curious symptom, remarkable to this extent at least, that it is seldom met with in young women, at least in our country. She afterwards had periodical headaches, which came on every week, with the usual nausea and un- comfortable feelings; they continued to recur till she became preg- nant a year ago. At that time, her circumstances became so bad that she scarcely had the means of procuring a bare sustenance; she was moreover illtreatcd by the man with whom she lived; and had a severe fall when at the third month of her pregnancy. She did not SIMPLE CHRONIC ULCER OF THE STOMACH. 65 at the time of its occurrence experience any very remarkable effect from this accident; but on the following day, was seized with bleed- ing from the nose, and, some hours later, with rather profuse vomiting of blood, preceded by a peculiar feeling of distress in the region of the stomach. The epistaxis complicated the diagnosis, for it became a question whether the blood which she vomited came directly from the stomach, or whether it was not derived primarily from the nasal fossae—being first swallowed and then vomited. There were other symptoms, however, which elucidated this point. The patient com- plained of very violent boring pain in the stomach, resembling the sensation which she fancied might be produced by a stake pushed through the ensiform cartilage into the stomach. This pain radiated through the corresponding dorsal region, and presented all the cha- racteristics of the pain which Dr. Cruveilhier attributes to simple ulcer. She miscarried, had profuse diarrhoea for three months, and upon one occasion passed blood by stool. The diarrhoea ceased, but the pain in the stomach became more acute. Every four or five days, sometimes more and sometimes less frequently, she vomited pro- fusely a liquid resembling coffee grounds, or, to use a more exact comparison, soot dissolved in water. Probably the stools were of a black colour; but upon this point we obtained no information. When I first saw this patient, I was struck with her extreme emaciation, sunken eyes, and deep yellow tinge of skin. There was nothing, however, distinctive in this colour of the skin. She told us that her skin was naturally brown; so that it was difficult to appreciate howT much of the cutaneous appearance was respectively dependent upon anaemia and cancerous cachexia. She complained of a total want of appetite, and her disgust for food was increased by the dread of arousing pain by ingestion of the smallest quantity of aliment. Pressure over the pit of the stomach occasioned pain. The question -was, whether these symptoms depended upon cancer of the stomach, upon simple ulcer of the stomach, or merely upon sup- plementary hemorrhage. In relation to the last point, remember that I told you, that this woman in her early youth had been subject to bleeding piles. Give special attention to that fact. It is not uncommon for men at the period of puberty and adoles- cence to have periodical epistaxis, and at a more mature age periodical bleeding from piles. Now, the fact that a flux of this nature occurred in our patient, may indicate an unusual tendency to 66 SIMPLE CHRONIC ULCER OF THE STOMACH. hemorrhage. This individual passed from infancy to puberty, when the menstrual function was established: the bleeding from the piles then ceased, and headaches supervened, which continued to torment her for twenty years, but did not recur from the time that she first became pregnant. It was then that the gastro-intestinal hemor- rhages supervened. Is there not ground for supposing that these hemorrhages were analogous to the former hemorrhoidal fluxes which had been replaced by the menstrual uterine flux ? May it not be asked whether the menstrual flux being suppressed consequent upon pregnancy, the hemorrhagic tendency was manifested in the stomach ? Admitting that this hemorrhagic tendency did not constitute the whole disease, it certainly played a great part in it. The frequent re- turn of the symptoms without that periodicity usual in supplementary hemorrhages, the boring pains by which they were accompanied, their predominating seat being the ensiform cartilage and corre- sponding dorsal region, disposed me to adopt the idea that there wras a serious lesion of the stomach; and in what I saw, I had no diffi- culty in recognising the symptoms attributed to simple ulcer. The age of the patient, the total absence of any tumour or indu- ration in the epigastric region (which the excessive emaciation and the great flaccidity of the abdominal parietes enabled me thoroughly to explore), led me to conclude that cancer did not exist. I adopted the more willingly my diagnosis of simple ulcer of the stomach that I felt of how little use I could be in the event of this woman’s malady being carcinomatous. My powerlessness for good would in such a case have been all the greater that the hemorrhages recurred twice or thrice a week, a frequency of recurrence which did not allow me to entertain the hope of being able to prevent them. Adopting, therefore, the view that the patient was suffering from simple ulcer, I at once had recourse to the use of preparations of nitrate of silver. I began by giving five centigrammes during the day, divided into five pills; at the same time, with a view to assuage the pain, I prescribed the extract of opium in pills contain- ing one centigramme, of which she never had occasion to take more than four in the twenty-four hours. My object wras to act upon the visceral lesion by the nitrate of silver, just as I should have endea- voured to act upon an ulceration of the pharynx or skin by the solid nitrate. The symptoms moderated after some days of this treatment: SIMPLE CHRONIC ULCER OE THE STOMACH. 67 there was no return of the hemorrhage: the pain abated; and digestion, till then painful, and even impossible, became normal. I gradually diminished the dose, but did not discontinue the opium and nitrate of silver. Even when there was good reason to suppose that the cure was complete, the patient continued to take every day a pill of opium and a pill of nitrate of silver. As she bad diarrhoea I likewise gave her a gramme daily of the trisnitrate of bismuth. This treatment, upon the supposition that the hematemesis did not depeud on the existence of a simple ulcer, and was supplemen- tary to the menstrual flux, could do no .harm, and might prove beneficial. It would tend by topical action to modify the conges- tion and abnormal condition of the surface of the stomach. Whether it arose from the treatment, or simply from the improved regimen and better hygienic conditions of the hospital as compared with her home, it is certain that the black vomiting and pains ceased, that the appetite, digestion, and menstruation became normal, and in fact, that the recovery was complete. When she left the hospital, she had regained flesh to a great extent: she left at her own request, feeling that her health was sufficiently restored to enable her to resume her usual work. In connection with this case, which possesses more than one interesting feature, I shall now mention the case of a man who occupied bed 17 of St. Agnes's ward. It is more interesting than the former case, in this sense, that the autopsy disclosed a lesion of the stomach, the diagnosis of which had proved embarrassing during life. The patient was thirty-seven years of age, in vigorous health, and by occupation engaged as a labourer in forming earth works. He stated that three or four months before admission to the Hotel-Dieu, he had vomited an enormous quantity of blood, and that for two or three consecutive days his stools had resembled tar in colour and consistence. Erom that time, he lost strength: digestion was badly performed; but he affirmed—and this is a point to which I specially direct your attention—that he had never had pains in the stomach. Digestion became more laborious than before: after a certain time, though he continued to eat as usual, he felt, to use his own expression, that the food did not go through him so well. After the vomiting blood, he often suffered from a general feeling of discomfort: he found that the resuming of his work was too much 68 SIMPLE CHRONIC ULCER OF THE STOMACH. for him. He was pale, short-breathed, and panted upon the least exertion. Three or four months had passed without his experiencing any- thing note-worthy in his condition in addition to the symptoms now described; when, some days before his admission to hospital, he had a new attack of hemorrhage from the mouth, followed by black stools. During the two succeeding days, the hemorrhage recurred at short intervals; and he died on the second day, from an attack in which he lost several litres of blood. These vomitings of blood were accompanied by melanotic stools, and every day the vessel (which I ordered to be kept for examination) contained from a quarter to half a litre, and sometimes even a litre of matter resembling tar. It is unnecessary to add, that an extreme degree of anaemia was the result of these great losses of blood. The skin of the patient had that peculiar tint of old white wax, which is to be seen in women exhausted by profuse hemorrhage. In exploring writh very great care the region of the stomach, I was unable to find the smallest trace of a tumour. The patient, when interrogated, stated that he swallowed food with perfect facility; and this statement was of itself sufficient to exclude the idea of his having carcinoma of the cardiac extremity of the stomach, which on account of the deep situation of the parts would have escaped discovery by manual examination. There might, how- ever, be a tumour near the smaller curvature, or at the bottom of the large pouch, and which consequently, we should also be unable to feel. Nevertheless, the attacks of hematemesis, the great embarrassment experienced during the first stage of digestion, led me to conclude that there was cancer. There was one element wanting in this diagnosis, viz. pain in the epigastric region; for the patient had never complained of more than discomfort. Let me add, however, that pain is a diagnostic sign, which is often absent in cancer of the stomach. At the autopsy, the stomach was found full of blood. At about from two to three centimeters from the pyloric orifice, there was a depressed velvety surface bounded by an elevated edge, about the size of a two-franc piece. In the centre were seen two open mouths of arteries, sufficiently large to admit a small probe; and one of them was plugged by a clot. These vessels had evidently been the source of the hemorrhage; and I may remark in SIMPLE CHRONIC ULCER OP THE STOMACH, 69 passing, that this is one of the most unusual ways in which hema- temesis is produced : I shall afterwards describe to you its ordinary manner of production. It was, however, the microscopic examination which enabled us to detect the error in diagnosis : there was no trace of cancer—the lesion was simple chronic ulcer of the stomach. At a time when the researches of my scientific colleague Dr. Cruveilhier,1 imparts fresh interest to this important question, I cannot neglect the opportunity afforded by these cases of speaking to you about an affection, the reality of which was for a long time disputed. To Dr. Cruveilhier unquestionably belongs the merit of having first described simple chronic ulcer of the stomach, as a disease, special in its nature, and quite distinct from cancer of the stomach, with which it had till then been confounded. In 1830, that is to say more than thirty years ago, this distinguished professor devoted a special chapter to simple ulcer; five years later, in the 20th fasciculus of his atlas of pathological anatomy, he added new facts, and new drawings; and in 1838, he published a memoir upon the subject.3 In 1839, Professor Rokitansky, of Vienna, published his work ;3 the subject was taken up afresh in 1856 by M. Cruveilhier; and we find in the Archives Generates de Medecine for February and March of that year, the memoir which a short time previously lie had communicated to the Institute of France. While I acknowledge the great service rendered to medical science and art by my honourable colleague by his having established decisively the existence of a disease previously unknown, I cannot help thinking that he has somewhat exaggerated the frequency of the cases in ex- agerating the significancy of the symptoms. What are the symptoms? At the beginning of the disease, the patients complain of discomfort, of dull pains in the region of the stomach, of a feeling of weight during digestion which is difficult and painful. The appetite diminishes and is gradually lost: at a certain period of the disease, the repugnance for food is increased by knowing that eating occa- sions pain. The sensation of wreight and fulness arouses and intensifies the acute pains of wRich I have been speaking, and at 1 Cruveilhier :—Anatomie Pathologique du Corps Humain. Polio. 2 Revue Medicale. 3 Rokitansky :—De l’Ulcere Perforant de l’Estomac. (Eater. Med. Jahrb. 1839 : quoted in Archives Generates de Medecine, 1840. 70 SIMPLE CHRONIC ELCER OF THE STOMACH. last the patients are never at ease, except when they have the stomach empty. Though there is observed in some cases, instead of anorexia, an ex- cessive, craving, capricious appetite; and though in some individuals relief from pain is experienced after eating, such cases are exceptional. Wasting, which rapidly progresses, is the consequence of this defective alimentation. Although the patients continue their usual occupations, they go on day by day losing strength, and visibly become more and more emaciated. At the same time, their mental state is affected; they become sad, melancholy, and easily irritated. Up to this point, you see, that there is nothing characteristic in the signs, which are likewise the signs of many forms of dyspepsia, as well as of incipient cancer. But, at a certain time, the symptoms become complicated with others of real importance, viz. pain and hematemesis. The pain has something special in its character. It is generally confined to the region of the ensiform cartilage. It has a boring character. Or, the pain which is occasioned may be compared to that resulting from a burn, a raw wound, or a violent pinch. It comes in paroxysms, and has exacerbations several times during the day. It is increased by pressing the hand upon the pit of the stomach, and is excited by ingestion of food: supervening sometimes, it is true, a little later, it continues during the whole period of stomachal digestion, and is never so severe as at that time. To this stomachal pain, when it has acquired a high degree of intensity, there is added pain of a similar nature occupying the corresponding dorsal region, that is to say, over the first lumbar vertebra or the three last dorsal ver- tebra. In some cases, in place of remaining confined to an epigastric, ensiform, or dorsal situation, the pain radiates upwards, behind the sternum, in the direction of the oesophagus, extends into the intercostal spaces and region of the kidneys. Let us stop for a moment to consider this symptom, and to in- quire whether it possesses the importance, which some have attri- buted to it. Whatever may be its importance, its signification as a diagnostic sign of simple ulcer is far from being absolute: in the first place, it is met with in affections which have nothing in common with the disease we are at present studying; and again, notwith- standing the assertion to the contrary of my honourable colleague, it may be wanting, in this affection. No doubt this is a rare occurrence, but that it does occur is conclusively established by the SIMPLE CHRONIC ULCER OF THE STOMACH. case which I have just related to you, as well as by the history of a case reported by Dr. Louis Gubian to which I shall afterwards refer.1 In cancer of the stomach, we often observe pain in the stomach, characterised in the same manner as the pain accompanying simple ulcer. I therefore think that it is drawing too subtle a distinction to say that the pain of cancer caused by the spasmodic contrac- tions of the stomach is analogous to that caused by contractions of the bladder in retention of urine or by the contractions of the wromb in labour; and that the ensiform and dorsal pains of simple ulcer are of an entirely different kind. According to the admission of M. Cruveilhier himself, the sole peculiarity by which one can distinguish idiopathic gastralgia from the pain which accompanies simple ulceration, is that in the latter, the symptoms are permanent with alternations of exacerbation and remission; while in the former, the pain is temporary, supervening and ceasing abruptly, and being, moreover, at once relieved by opium. You can understand, Gentlemen, how impossible it would be to grasp these delicate distinctions as elements of diagnosis. In simple ulceration also, although the pains may not be so acute and boring, M. Cruveilhier distinctly admits that they may be decidedly sharp, boring, and intermittent. In respect of the characteristic sign derived from absolute relief being afforded by opium when the affection is only neuralgia of the stomach, the remedy being inoperative when there is a simple ulcer, I reply, that the most unequivocally idiopathic gastralgia will often resist opium, which on the other hand will mode- rate or perhaps completely remove pains depending upon simple ulcer or cancer. This we have seen in our patient of St. Bernard's ward. I say, therefore, that the pain, however special its character may appear, is insufficient to enable us to distinguish the disease of which I am now speaking. A similar remark is applicable to black vomit, hematemesis, and the melsena usually accompanying it. In fact, though gastrorrhagia, is observed in the majority of cases of simple ulcer, it is a symptom which is sometimes wanting: more- over, it is a phenomenon also belonging to cancer of the stomach, which sometimes shows itself in non-ulcerous chronic gastritis, and is likewise met with in a considerable number of cases, presenting 1 Gtjbian :—Gazette Medicate de Lyon, 1856. 72 SIMPLE CHRONIC ULCER OF THE STOMACH. no apparent lesion of the organ which is the seat of the hemor- rhage. This part of the subject possesses so much clinical importance, that I must devote some minutes to its discussion; but before doing so, allow me to say a word upon the mechanism of these hemor- rhages. They often originate in the arteries or veins involved in the ulceration, their walls being ulcerated and destroyed. This was the state of matters, in our patient of St. Agnes's ward, whose case I have just described. At the autopsy, we found two arteries with open mouths. You can understand that under such conditions, hemorrhage will be more or less profuse; and that it may suddenly destroy life if an important vessel be involved. Generally, the hemorrhage takes place from small vessels seen at the autopsy upon the surface of the ulcer, eroded and jagged, some being obstructed by very tenacious solid clots, and others by soft clots which become detached upon the least handling. It is from these small vessels, that the hemorrhage proceeds: it is slight, and takes place almost daily, becoming mingled with the food, thus giving rise to black stools and black vomit. However, matters do not always so proceed, and the hemorrhage is frequently the result of a vascular lesion invisible to the unaided eye, situated around the ulceration: in the same way, there is hyper-secretion of the gastric fluids. Here, the same thing occurs as in cancer of the stomach; for, in the first instance, in cancerous tumours not yet ulcerated, the hemorrhage does not take place from the surface of the tumour but from the mucous membrane. This is the case in simple ulcer, hematemesis being the first symptom of the affection, and continuing when ulceration has not involved the parietes of the vessels. I have said, Gentlemen, that gastrorrhagia is a usual symp- tom, of simple ulcer of the stomach; but I have also said that this symptom is sometimes wanting. During the year 1858, I saw in consultation with my friend Dr. Beylard, a young man, an American, who sunk in a few hours, under formidable abdominal symptoms. In this case it was difficult to obtain an account of the immediate antecedents of the patient. We only learned that he had arrived from London, where he had given himself up for about a week to daily excesses of the table. When I saw him, he had symptoms of cholera, viz. cyanosis, coldness, cramps, absence of pulse, and suppression of SIMPLE CHRONIC ULCER OF THE STOMACH. 73 urine. Both Dr. Beylarcl and I were struck with the remarkable circumstance, that there were neither alvine dejections nor vomiting. The dead body of this young man was taken to America, where by desire of the family an autopsy was made. The physician en- trusted with its performance was good enough to send an account of the details to Dr. Beylard, from whom I learned that there had been found indications of subacute peritonitis, occasioned by a perfora- tion in the centre of a simple ulcer of the stomach. Now I was well acquainted with this young man, being in the habit of seeing him daily at the house of his mother, whom I was attending for an affection of the uterus; and he then appeared in the enjoyment of perfect health, digestion being in a perfectly normal condition. From the absence of characteristic symptoms, and in particular from the absence of hematemesis, this case presents a great analogy to the other case which I have just detailed. Allow me to read to you from the Gazette Medicale de Lyon for 1856 Dr. Louis Gubiaffis case :— “ In number one of the medical clinical ward, there lay, on the 24th August, 1856, Clement Favorain, forty-seven years of age, a stone-hewer. This man, of very so-so constitution, having in a marked manner the lymphatic temperament, and a small amount of intelligence, had always led a morose and pitiable existence. He was first an excavator of earth works, then a hewer of stones, either in the quarries or on the roads, exposed to all the vicissitudes of the seasons, often without work, ill-fed, drinking only water, either plain or mixed with doctored beverages, taking alcohol very rarely and in very small quantity, and not having aliment sufficient in quantity or adequatively reparative. The appearance of the patient, on his admission to the hospital, denoted a condition of misery and suffering. His face presented a colourless appearance, which he said was usual: and his emaciation dated back for several years. “ He only complained of some pains in the epigastric region which he had not felt for more than a few days. They were not intense: they were wandering, slightly increased by pressure; and their maximum intensity was not at the ensiform cartilage. For about three months, his appetite had diminished; and during that time, digestion was slow, difficult, accompanied by bitter, nidorous eructations, tension of the epigastric region, and some flatulent distension of the abdomen. He had not had any kind of vomiting. SIMPLE CHRONIC ULCER OF THE STOMACH. “ Palpation of the stomach indicated nothing abnormal, nor did it reveal the existence of a tumour. “ The tongue was thick, and a little whitish at the base. The patient had neither appetite, nor disgust for particular kinds of aliment. He had no repugnance to butcher meat. He usually suffered from obstinate constipation. “ Notwithstanding the discomfort which he felt, he had no fever; and had continued his severe and toilsome labour as a stone- breaker. “ Prom the symptoms of which he complained, there was reason to believe that his malady was simple dyspepsia, and as such it was treated till the 15th September: during that period, no new symp- toms supervened. On the 15th September, however, he complained of pain in the abdomen particularly on the left side, of incontinence of urine, and of oedema of the scrotum. Next day, the face pre- sented a puffy, cedematous appearance. These symptoms alarmed Professor Teissier (of Lyons) who had on that very day resumed charge of the clinical wards. Upon an attentive examination of the organs, there was only discovered dropsical infiltration, which was greatest in the sides, accompanied by acute pain in these regions, particularly in the left side posteriorly, and in the neigh- bourhood of the kidney. The urine, when examined by nitric acid, showed no trace of albumen. “ In the evening, the patient had oppressed breathing; and ere long the mucous rales of the last agony were heard. At this time, the pulse became quick, small, and irregular: afterwards, the circu- lation became slow, the extremities grew cold; and death occurred during the night. “ At the autopsy, a litre and a half of fluid was found in the peritoneal cavity. There was great thickening of the coats of the stomach in its two inferior thirds : its internal surface had a shrivelled, plaited appearance, presenting elongated elevations formed by very flexuous folds separated by deep depressions, resembling those sometimes seen on the muscular coat of the bladder, and which are known by the name of columnar bladder. Near the cul-de-sac of the stomach, about the middle third of the great curvature, there was a depressed, velvety [tomenteuse] ulceration, slightly twisted by the folds of mucous membrane which marked out its circumference by an elevated margin perfectly circular in form. The diameter of the ulcer was about that of a two-franc piece : in SIMPLE CHRONIC ULCER OP THE STOMACH. 75 depth, it reached the muscular coat, which was fully five or six lines in thickness. This ulcer seemed to be in progress of cicatrisation: it was not surrounded by any vascularity. The mucous membrane presented neither marked villosities nor pultaceous nor gelatiniform softening: it was only injected, and slightly hypertrophied, in which latter condition, the sub-mucous tissue participated.” I have now laid before you a case in which the symptoms characteristic of ulceration were presented in the first instance, and in which it might erroneously have been concluded that there was cancer of the stomach. On ioth December 1863, a woman, aged forty-nine, came into St. Bernard’s ward suffering from an abdominal affection. She had fever, greatly altered countenance, and suffered from severe pain in a zone comprised between the two hypochondria and the epigas- trium. She had a constant, dry cough, and great oppression of the breathing. On palpation of the abdomen, there was felt a hard, resisting mass, which extended towards the right side, moved with the diaphragm, and was evidently the enlarged liver. The epigas- trium was manifestly protuberant: on percussion, a tympanitic sound was elucidated. In the line between the epigastrium and left hypochondrium, there was discovered a hard, oval, pretty regularly shaped mass, which was painful to the touch. Except in this situa- tion, the abdominal walls were tolerably supple. On percussion of the chest, there was perceived a notable dulness about the inferior third on each side. At the base of both lungs, fine subcrepitant rales were heard on auscultation. In these situations, there was an almost bronchial reverberation of the voice. The following is the history which this woman gave of herself:— About nine or ten years ago, she had had vomiting of blood for the first time : it came up in enormous quantities. At this period, she suffered from very acute pains at the pit of the stomach, and diges- tion was very much out of order. After this, her health was restored; but again, one or two years later, became deranged: she had vomiting of blood, and black matter was ejected. Subsequently to this period, she from time to time vomited her food, having acute pain at the pit of the stomach and in the back: after these attacks all became calm again for an interval, and then the same symptoms reappeared. At last, they ceased to recur; and there seemed to be a return to health and strength. The plumpness also, which had not, however, been much diminished, was restored. The patient 76 SIMPLE CHRONIC ULCER OF THE STOMACH. thus enjoyed passable health for two or three years, that was till about three months before her admission to the hospital, when she was again seized with vomiting : on this occasion, the matters ejected were not sanguinolent: in the region of the stomach, the pains were violent; and they darted through the diaphragmatic region. Henceforth, she had fever, dyspnoea, and cough. This conjunction of symptoms brought her to our wards. The difficulties of diagnosis were almost insurmountable in this case. To me it was evident from the woman’s story, that she had had ulcer of the stomach. Yomiting of blood, black vomit, acute pain in the epigastrium, the cessation of the symptoms, and the long interval between the times of their recurrence, were all facts in favour of that diagnosis. On the other hand, I found at the pit of the stomach, a soft, indolent, tympanitic tumour, which certainly seemed to be the stomach distended by gas. But then, in the left hypochondrium, there was a hard painful tumour, which might be formed by a cancerous alteration of the stomach. It seemed, more- over, to be independent of the liver, because the soft epigastric tumour was interposed between that organ and the tumour in the left hypochondrium. There was, however, an element of doubt in the case: I refer to the known antagonism, so to speak, between round ulcer and cancer of the stomach. Be that as it may, the physical signs were of such a character that it was more rational to conclude from them that the disease was cancer. This woman had likewise the signs of inflam- mation of the diaphragm: respiration was accomplished chiefly by the abdominal muscles, and the morbid physical signs were those of double diaphragmatic pleurisy. There was ground for believing— and in point of fact, I did believe—that the cancer had produced inflammation in its neighbourhood which had extended the diaphragmatic peritoneum, diaphragm, and base of both pleurae. I was not mistaken as to the existence of inflammation: the parts now named were the seat of inflammation: but its cause was not that which I had supposed. I shall not recapitulate the different stages of the disease, which, however, I may remark, were very short. You know that the diffi- culty of breathing went on continually increasing; that palpation of the abdomen became more and more painful; that the patient frequently vomited the fluid, as well as the small quantities of solid SIMPLE CHRONIC ULCER OE THE STOMACH. 77 food which she took; and that at last she died, having had for twenty-four hours preceding death the signs of general peritonitis. At the autopsy, there was found purulent peritonitis, with nu- merous adhesions matting together the intestines. The liver was greatly enlarged, and presented a marbled appearance: it was throughout the whole of its convex surface, adherent to the diaphragm: and by a part of its convex surface, it was intimately united to the anterior wall of the stomach. In the situation of the left lobe of the liver, there was a purulent pouch circumscribed by thick false membranes, evidently of old date: through a slight fissure in one of them, some pus had entered the peritoneum, and had there developed recent inflammation. There was, at the bottom of the purulent pouch, a circular perforation of the anterior wall of the stomach. When this organ was incised in the course of the small curvature, it was at once seen, not to be in a cancerous condi- tion ; and in a circular line around the pyloric ring, was observed a series of ulcerations, three of which were cicatrised, while a fourth, still in ulcerative activity, showed a perforation. One of the cicatrised ulcers was very regularly circular, another was oval: both were remarkable for the induration and callous thickening of their surroundings : the tissue of the cicatrix which formed this elevated surface, was fibrous, and resisted, but did not creak under, the scalpel like scirrhus, of which it had, moreover, neither the appear- ance nor the structure. The size of the perforating ulcer was about that of a two-franc piece. It had the form of a crater; the walls were somewhat thin, and at the point of perforation, there was destruction of all the coats of the stomach. The perforation re- sembled a lentil in form and diameter. It was situated in the neigh- bourhood of the sharp anterior border of the liver, so that the abdominal wall was glued to it by false membrane, which for a certain time had prevented the contents of the stomach from entering the peritoneal cavity. On the other hand, the adhesive inflammation extended round the transverse colon: and it was the arch of the colon enormously dilated, placed in the epigastric region, in front of the stomach, which formed the soft and tympanitic projecting tumour, mistaken during life for the stomach itself. The colon wras, moreover, projecting between the two lobes of the liver in such a way that at the right side one could feel, through the abdominal parietes, the right lobe of the liver'—at the epigastrium, the arch of the colon—and at the left side, the left lobe of the liver, which 78 SIMPLE CHRONIC ULCER OE THE STOMACH. might have been considered as an abnormal tumour, although there was a sonorous tympanitic space between the solid mass on the right (which was evidently the liver) and the indeterminate mass on the left. Now, from the nature of the gastric symptoms, it was very natural to infer that there was a cancerous tumour of the stomach. To conclude the description of the autopsy :—There was a diaphragmatic pleurisy, and adhesions closely uniting the base of the lungs to the pleura: there was no effusion : the inferior third of both lungs were congested and solidified. I specially call your attention, Gentlemen, to the details of this case. Tirst of all, it is very remarkable, that there should have been a succession of ulcers, and that the numerous ulcers should have been grouped exclusively at the pylorus by a sort of elective affinity. Then you see that this woman, who had had several years previously, and upon several different occasions, the signs of simple ulceration, presented numerous ulcerations. There had been periods of remission, and even of apparent cure ■, in fact, some of the ulcers were cicatrised. It was the most recent ulcer which determined the perforation, the cause of the peritonitis and pleurisy. Observe, that this case is an additional proof of what may be called the law of antagonism between the simultaneous existence in the stomach of round ulcer and cancer, like the law of antagonism between the suc- cessive presence in the uterus of fibrous and carcinomatous growths. In this case, moreover, you find an example of perforation of the stomach, a symptom rather frequent, and often very formidable, in conjunction with simple ulceration. The perforation may give rise to a series of symptoms of which it is necessary that I should speak. Tirst of all, peritonitis is a necessary result: it may be either partial or general, according to the rapidity with which the perforation takes place. When the destruction of all the coats of the stomach is accomplished slowly, adhesions have had time to form, between the perforated stomach and the neighbouring organs: usually, the pancreas, the left lobe of the liver, or the mesentery, compensates for the loss of substance, so that the matter contained in the stomach is prevented from flowing into the peritoneum. At other times, as in the case of our patient, the neighbouring organ is so disposed as not to supply completely the loss of substance, and con- sequently, peritonitis is produced, which in its turn, originates a new series of complications, such as diaphragmatic pleurisy. Tinally, the perforation may have taken place with such rapidity as to allow SIMPLE CHRONIC ULCER OP THE STOMACH. 79 no time for the formation of adhesions, so that through the per- foration of the stomach, a part of the contents of that organ will pass into the abdominal cavity; then, as you can easily under- stand, the necessary consequence is, a very acute, and speedily fatal peritonitis. On the other hand, when solid adhesions attach the perforated stomach to the neighbouring organs (the liver or pancreas), one of two things may occur :—there may be no alteration in the organ which furnishes to the stomach an adventitious wall, or at least a new fibro-cellular formation, which imparts thickness to it:— or again (and the fact is much more curious) the ulcerative process continues and attacks the annexed organ, so that the ulcerative disease, primarily localised in the stomach, extends by a mechanism, of which I cannot give a very good account, to perfectly different tissues, such as those of the liver and pancreas. The adhesive inflammation in the neighbourhood has nothing in it to call forth our astonishment: the occurrence is very common. But that the inflammation, at first simply adhesive, should become ulcerative, in respect of the liver and the pancreas, as it had been in respect of the stomach, is, I confess, a very remarkable fact, affording an additional proof of the specificity of morbid actions, a specificity which is more related to the essence of the disease than to the nature of the tissue which is attacked. This is the fact, to which I have been desirous in a special manner to direct your attention. In contradistinction to certain cases in which the existence of simple ulcer of the stomach found at the autopsy, but not discovered during life by any special symptom, and which has not notably given rise to hemorrhages, even of a very slight kind, there are others in which black vomit and melaena of considerable extent are met with, independently of any appreciable lesion of the stomach. Six years ago, I was called in by my honourable friend Dr. Riem- bault, to a lady aged 65, living on the Quai des Celestins, and who, I was told, had vomited, and passed by stool, large quantities of blood. My first impression, produced by the pale yellow, cachectic complexion of the patient, was that she had cancer of the stomach : this was also the opinion of the professional brother by whom I was called in, and the look which we exchanged, when examining this lady, only told too eloquently, that we held in common the same opinion of her case, and had not a favourable impression as to her situation. The patient told us that she had been four days in Paris, where she had arrived in perfect health, never having experienced, in SIMPLE CHRONIC ULCER OE THE STOMACH. relation to her digestion, anything to attract attention. Her appetite was regular: she had never had pains, nausea, nor eruc- tations, and she had been surprised by the vomiting of blood, which had occurred, without appreciable cause, on the day after her arrival in Paris. The previous history of the case scarcely agreed with the idea that there was a cancerous lesion ; although there are cancers of the stomach which are completely indolent, and do not reveal any serious disturbance of the economy. Completely reserving our diagnosis, my colleague and I placed ourselves in the position of persons who had to treat an essential hemorrhage : we prescribed preparations of iron and rhatany. Three days after my visit, the stools had ceased to be black, and there had been no more gastrorrhagia. Next month, the lady returned to the country. Her health became good; and five years afterwards, I learned that it continued excellent. At the beginning of August, 1861, a man, 33 years of age, was admitted to our wards. At the very time of admission, he was seized with an attack of vomiting, and died suddenly. He had arrived in a state of profound prostration, unable to speak, and unable in any way to give information of his case. All that we knew, we derived from the persons who had carried him to the hospital on a stretcher, was that he had been long ill. The hospital attend- ants were struck with the yellow colour of his skin, and the great bulk of his belly. The matters vomited, which were carefully preserved, were formed of blood altered by its admixture with the gastric juice: it was a liquid of sepia colour, with a deposit of solid matter finely granulated and resembling soot, of which a portion was suspended in the liquid. At the autopsy, the abdomen was found to contain peritoneal effusion, as if encysted. The stomach having been removed with the greatest possible care, was examined, and found to present no morbid change. Its cardiac and pelvic orifices were free, and there was no trace of cancerous tumour; upon the mucous surface, the colour was like the lees of wine. We did not discover the smallest ulceration. In the duodenum, there was no appreciable lesion. The lungs, heart, and brain were healthy. The appearance and quality of the matters vomited in these cases, can leave no doubt in the mind as to their nature; and it is very evident also, that the hemorrhages had the stomach as a start- ing point. The progress of the symptoms, their happy termination, SIMPLE CHRONIC ULCER OE THE STOMACH. 81 in the first case, the results of necroscopic examination in the second, clearly showed that there was neither cancerous lesion nor ulceration of the stomach. The profuse sanguineous exudations came from the mucous membrane of the stomach, just as they come from the surface of other mucous membranes : this we sometimes see in the intestine, as in the following case, which I have many times had occasion to narrate to you. A former functionary of our Faculty was seized, about seven years ago, with serious symptoms, all the details of which are worthy of being reported. Though generally of very good health, he was subject to con- stipation of such a kind that he never went to stool more than once in ten or fifteen days; and then, he only passed a very small quantity of hard black matter like goat’s dung. One evening, without having previously experienced the slightest derangement in his habitually excellent health, without having com- mitted the slightest excess at table, he suddenly felt an indescribable sensation of discomfort, and immediately afterwards fell down in a state of unconsciousness. For nearly twenty minutes, he remained in this state. He was taken home in a carriage; and after a good night, during which his sleep was tranquil, he, on the following day, resumed his usual duties. The occurrence now described took place on a Thursday : on the following Monday, w'hen sitting in his office, he wras again suddenly seized with symptoms precisely similar to those which characterised the attack he had had four days previously. On the following day, he twice experienced a recurrence of the same symptoms ; but matters assumed a more serious appearance, for through extreme feebleness he was obliged to remain in bed. I saw him upon the Wednesday, during the afternoon. His complexion, generally good, was of such a decided cadaveric paleness, as at once to arrest my attention. Experience made me at once suspect the existence of intestinal haemorrhage. I requested that his stools might be shown to me. I found, however, that he had neither had any alvine evacuation for eight days, nor had he had any vomiting. I immediately prescribed a purgative, the salts of Seignette, so far as I can recollect. The result wras, the evacuation of an enormous quan- tity, estimated at five or six pounds, of black pitchy matter, resembling the tar used for ships. My diagnosis was thus confirmed : I had to do with a case of melsena. The antecedents of this individual, the progress of the symptoms, 82 SIMPLE CHRONIC ULCER OP THE STOMACH. and the careful examination of the abdominal viscera by palpation, caused me to reject the idea of haemorrhage depending upon a lesion of the stomach or intestines; and I comforted the family by assuring them that the malady was simple melaena. My prognosis was com- pletely verified. For three months, it is true, the patient retained his anaemic colour; but, under the influence of rhatany, cinchona, and iron, he regained his usual colour, and his former good health : he has not had, up to this date, any recurrence of the symptoms. Examples analogous to the case which I have now related are more common than is generally believed. Persons, when in good health, are suddenly seized with an undefined feeling of discomfort; they are observed to become pale and to fall down in a faint. One or two hours later, when they go to stool, their motions are as black as pitch, and this colour of the motions is retained for one or two days, after which it ceases. For some time afterwards, however, the patients suffer from debility, loss of appetite, slight gastralgia, buzz- ing in the ears, and paleness of the skin. The appetite and the strength return: convalescence is complete. The symptoms may nevertheless again occur at a period more or less distant; they recur in the same form, and are often not observed by patient or physician till a more profuse haemorrhage suddenly produces prostration. This is a rare occurrence : usually, they are not observed till a complete cure has taken place. When, in the course of your practice, you meet with patients who complain of passing blood by stool, or rather when they tell you that their stools are as black as tar, that is to say, presenting the charac- ters of melsena, carefully interrogate them as to their antecedents— ask them, if they have never become suddenly pale, and continued so for a week or a fortnight; and ask them, also, whether these symptoms have not recurred several times. These phenomena will enable you to clear up your diagnosis, and to state that the patient has had intestinal hsemorrhage in his former attacks, as well as when he has noticed stools of a red, black, or bistre colour. Let me now return to the consideration of simple ulcer of the sto- mach. The gastrorrhagia which usually accompanies it is, therefore, not a symptom of sufficient diagnostic value to enable the physician to pronounce definitively; for not only is it sometimes absent, but it may be present independently of any appreciable lesion, as in the cases I have just mentioned; as also, in the cases in which hsematerne- sis is supplementary to habitual haemorrhage, as, for example, in SIMPLE CHRONIC ULCER OE THE STOMACH. 83 some women suffering from disordered menstruation; in some patients affected with haemorrhoids, in whom the menstrual flux is suppressed ; and finally, also, it is a common phenomenon both in cancer and in simple ulcer. It has been said, I admit, and the fact is one which clinical observation will enable you to verify, that vomiting of blood and black motions are to a certain extent more characteristic of simple ulcer, than of cancer of the stomach, inasmuch as they belong to all the stages of simple ulcer, of which, moreover, they frequently consti- tute the earliest symptoms. On the other hand, we see that in many cases of cancer, there is neither black vomiting nor black motions; and that when they do occur, it is generally at the last stage of the disease. It is also a clinical fact opposed to general opinion, that profuse haematemesis and suddenly prostrating melaena belong much more to simple ulcer than to cancer. However precise this proposition may be when applied to the majority of cases, it is essential to recollect that the exceptions to the rule are sufficiently numerous to prevent its being regarded as an absolute sign that simple ulcer exists. In cancer, haemorrhage from the stomach or intestines sometimes supervenes, during a condition of apparently perfect health, as the first and only symptom of the disease which will inevitably carry off the patient. A very near relation of my own, 60 years of age, when in full health and strength, was seized one day at table with syncope accom- panied by slight convulsions, such as are commonly observed as a complication of loss of consciousness. I was present, at dinner, with my relation; Bretonneau, who was also present, believed that the seizure was an attack of epileptic vertigo. The state of syncope continued for a long time. The patient was put to bed : for a fort- night, he was very feeble, and deadly pale. I did not, any more than Bretonneau, suspect the nature of the case. A year later, the same person left home to visit one of his estates: all at once, whilst he was giving his orders to his managing servant, he fell down as if struck with a thunder-bolt. He was restored by sprinkling some drops of cold water upon his face : when restored to consciousness, he felt an imperative desire to go to stool, and passed a great quan- tity of blood. Immediately after this haemorrhage, he became deadly pale, as on the occasion of his first seizure. We now clearly saw what had taken place the year previously. Bretonneau and I SIMPLE CHRONIC ULCER OF THE STOMACH. then understood that upon both occasions there had been an intes- tinal haemorrhage. The patient got well; his health appeared to be perfectly re-esta- blished, when again, some months afterwards, he was seized for the third time with similar symptoms. He had risen early in the morning to speak to his work-people, when, feeling a desire to go to stool, he hastily returned to his room. Soon, his domestics hearing a great noise in the closet, ran to his assistance, and found him stretched upon the floor, vomiting blood in large quantity : the basin of the water-closet was filled writh bloody matter, and his clothes were also soiled with similar discharge. After this event, he remained for a fortnight in bed, being unable to put his foot to the ground, so extreme was his debility. He, however, again regained his health; but from that time, he complained of lancinating pains in the epigastric region, where we discovered the existence of a tumour, of which we were able to follow the rapid progress. Soon, all the symptoms of cancer of the stomach were evident; and three years from the date of the first seizure, by which the beginning of the disease had been announced, my unfortunate relative died. Six years ago, a man living in the environs of Paris frequently consulted me in reference to a frightful vomiting of blood, which he had had a few days previously. He told me that his appetite then was, and always had been, good : he never had had the slightest pain, nor the slightest uneasiness in his stomach. The haemorrhage had supervened when he was in the most perfect health. He estimated at about a litre the quantity of black matter which he had vomited. This great loss of blood fully explained the anaemic paleness of his skin. Upon examining, I discovered in the region of his stomach an enormous tumour, occupying the great curvature, and quite painless on pressure. Notwithstanding this great lesion, the man had preserved perfect regularity in his digestive functions. I pre- scribed preparations of iron and rhatany, not certainly because I expected to cure his cancer, but to satisfy the inclination of restoring the economy, deeply disordered by the haemorrhage of which he had informed me. Pour months afterwards, he returned to consult me. He had regained flesh and a good colour. Never- theless, the tumour was greatly augmented in volume. Six months later, another attack of haematemesis supervened, wfiien I was again consulted; I again prescribed rhatany and iron, which once more produced a good effect. Soon afterwards, however, the usual SIMPLE CHRONIC ULCER OE THE STOMACH. 85 symptoms of cancer of the stomach were developed, colliquative diarrhoea set in, and the patient died. The Vice-president of the Courts of Law in one of our most impor- tant towns, was seized during the year 1849 with vomiting of blood and great intestinal haemorrhage, which brought him to within an inch of death. He speedily recovered, and was able to return from quar- ters in the country to which he had retired, to resume his magis- terial duties. He came to Paris for medical advice: it was then ascertained that there existed an abdominal tumour occupying the anterior wall of the stomach. Prom this date, similar attacks occurred nearly every six months; and on each occasion there was a great loss of blood both by the mouth and the anus. There was, nevertheless, no disturbance in the digestive functions. The appetite was good : in fact, the patient was a hearty eater : he sometimes expe- rienced acute gnawing pains in the stomach. He constantly com- plained of a state of great debility, which prevented him from taking much walking exercise, or going up stairs without being winded. I cannot say that he was fat, but he had preserved a certain amount of plumpness : his integuments generally were exceedingly pale, and his skin presented a slight straw-yellow colour. I found that his mother had died from cancer of the breast. He himself was perfectly aware of his situation, and spoke constantly of his approaching end, fulfilling, however, at the same time, all his duties with exactitude. In September, 1856, consequently seven years after the first attack, he went to spend the vacation at his estate in the country: some months previously, he had had hmmatemesis which, like all his previous attacks, was accompanied by melsena, and lasted for several days. All at once, without any appreciable exciting cause, or premonitory symptoms, he was seized one Sunday with enormous haemorrhage from the mouth. The bleeding recurred on the follow- ing Tuesday, Thursday, and Saturday. On each occasion, the quan- tity of blood vomited was sufficient to fill a large basin; and also, on each occasion, there was an evacuation by stool of black master resembling tar. The patient, exhausted by loss of blood, fell into a state of profound debility. He died during the day time of Sunday, ] 6th October, eight days after the frightful symptoms now described. Although in the case now described, the evidence to be derived from post-mortem examination was wanting, there could be no doubt 86 SIMPLE CHRONIC ULCER OF THE STOMACH. as to the diagnosis. The tumour was perfectly appreciable to palpa- tion ; and its existence was ascertained by Dr. Gendrin, and my former chef de clinique, Dr. Blondeau. You see, Gentlemen, from these examples, that stomachal or in- testinal haemorrhage, however profuse and however frequent, cannot, any more than gastric pain, be given as a positive sign of simple ulcer of the stomach. I may say the same of the vomiting of glairy matter, which is sometimes very profuse in persons affected with this disease. This kind of vomiting is the result of irritation of the gastric mu- cous membrane in the vicinity of the ulcer, which irritation causes an increased secretion from the stomach. This symptom has still less diagnostic value in this affection than the other symptoms of which I have just spoken. In a very large number of cases of perfectly simple gastrodynia, increased gastric secretion is an or- dinary symptom, it is likewise met with in some forms of chronic gastritis and dyspepsia, and is very frequent in hemicrania. Neuralgia is often sufficient to excite the secretion of the stomach in excessive quantity; and then, the occurrence is analogous to that which takes place in other parts of the body under the influence of somewhat violent local pain. The statement of a case will be the best means of enabling you fully to grasp my views on this subject. An individual takes masked intermittent fever, which declares itself in the form of suborbital neuralgia. At the beginning of the attack, the eye is perfectly free from injection and lachrymation. Pain begins: as it increases, the mucous membrane of the eye becomes injected, and sometimes the injection proceeds to such an extent as to be a real chemosis. Por five or six hours, matters remain in this state: there is redness and swelling of the eye, with a profuse secretion of tears. The attack then passes off, the neuralgic pain abates, and the epiphenomena disappear, not returning till recalled by a new attack of the neuralgia. In the same way, violent neuralgia of the stomach will suffice to excite profuse secretion of fluid by the stomach, which fluid will be ejected by vomiting. This copious secretion will also take place under the influence of any irritation of the stomach, be its nature what it may—in gastritis just as in gastralgia, in cancer as in simple ulcer; and consequently, glairy vomiting cannot be considered as diagnostic of the latter. Though the presence of a tumour in the epigastric region excludes SIMPLE CHRONIC ULCER OP THE STOMACH. 87 the idea of a simple ulcer, and declares that there is a cancer, it does not follow that the absence of a tumour is a positive proof of the presence of an ulcer; for it is by no means rare that a cancer completely escapes detection from the peculiar position which it occupies. The most important element in the differential diagnosis between the two affections, as Dr. Cruveilhier has shown, must be deduced from the progress of the disease. In simple ulceration, the alterna- tions of better and worse are thus marked : improvement attends spare diet, and there is always an aggravation of the symptoms when this regimen is departed from. In cancer, on the other hand, the disease advances steadily towards a fatal termination, irrespective of regimen and of treatment. My honorable colleague, Dr. Cruveilhier, in enunciating this pro- position, implicitly admits that, so long as the disease lasts, the diagnosis is impossible—that is to say, so long as neither death nor recovery takes place : in the latter case, he concludes, of course, that the disease is simple ulcer. Here, however, the diagnosis may still be at fault; for, from the cases which I have brought under your notice, you have seen that there are sometimes, in cancer of the stomach, long intervals during which the disease shows no symptom, and during which, consequently, we may suppose that a cure has taken place. Eecall to your minds the magistrate whose case I related. Dor three years the only morbid phenomena which presented themselves were hsematemesis and melsena, recurring at pretty distant intervals; and if examination of the epigastric region had not enabled us to detect the evident existence of a tumour, we might have more than once supposed that recovery was about to take place. The final cessation of symptoms, and the complete restoration to perfect health, the less necessarily implies that the case is one of simple ulcer, inasmuch as I have seen non-ulcerous chronic gastritis sometimes accompanied by stomachic haemorrhage and pain in the ensiform and dorsal regions. Such occurrences are rare, I admit; but as they do present themselves, they are quite sufficient to make us form our opinions with some reserve. To sum up : profuse and repeated stomachal haemorrhage, with or without accompanying melsena, violent gastralgic pains, apparently localised for the most part in the ensiform region, and in the correspond- ing region of the back, when coinciding with an entire absence of any SIMPLE CHRONIC ULCER OF THE STOMACH, appreciable tumour in the epigastrium, justify us in supposing that there exists chronic simple ulcer of the stomach, particularly when the symptoms terminate in recovery. This is a general rule, but bear in mind that it is a rule which has numerous exceptions, and that, in the present state of science, the diagnosis of simple ulcer of the stomach is surrounded by much obscurity. No doubt this obscurity is dispelled when, independently of the symptoms which I have just indicated, there appear other symptoms which essentially belong to cancer, symptoms which vary according to the seat of the disease. When the cardiac end of the stomach is atfected, you meet with phenomena similar to those which presented themselves in one of our patients in St. Agnes’s ward, whom we were obliged to feed by the aid of an oesophageal tube. There is a form of dysphagia, charac- terised by regurgitation of the food, which at first seems to be easily swallowed, but which, in point of fact, only accumulates in the lower portion of the oesophagus. At the beginning of the disease, this regurgitation takes place immediately after deglutition, because the oesophagus then reacts much more powerfully upon its contents, as it has not yet become accustomed to distension. In proportion as it acquires this tolerance, the food is only rejected from the mouth at an interval more or less protracted after ingestion; but at first, individuals affected with cancer of the cardiac end of the stomach can only take liquid or semi-liquid aliment, and that only by swallow- ing it rapidly. There is, however, a fact with which I must make you acquainted. You will see patients who have complained of having been subject for a longer or a shorter time to regurgitation of aliment, to such an extent as to be unable even to retain liquids, and who eat -without difficulty, swallowing even bulky mouthfuls. You must not allow this apparent amelioration to impose upon you : it depends in some cases upon the tumour which obstructed the cardiac end of the stomach having become softened, thus allowing the passage into the stomach to be temporarily free from obstruction. In some days, however, this obstruction may be reproduced, by new cancerous growths forming around the opening. If the lesion occupy the pylorus, there will generally be frequent but not profuse vomiting: it will occur less and less frequently, but will become more abundant. You can understand, Gentlemen, the reason of these differences. SIMPLE CHRONIC ULCER OF THE STOMACH. At first, the stomach rebels against the presence of alimentary matter, which, after having undergone chyinification, ought to be propelled into the duodenum, the entrance of which is shut. At a later stage, the stomach becomes more tolerant, and accustoming itself to the contact of its contents, allows itself to become dis- tended till the quantity of ingesta is greater than it can retain. In cancer of the pylorus, there likewise exists great constipation, provided the cancer be not deeply ulcerated; in which case, while the vomiting becomes less frequent, there sets in a diarrhoea which soon becomes lienteric : the alimentary matter escapes through the permanently open pyloric orifice, before having been subjected to sufficient elaboration in the stomach. In general, we can detect a cancerous tumour by palpation, a cir- cumstance which facilitates the diagnosis of cancer of the pylorus. In exploring the region corresponding to the inferior orifice of the stomach, we find a more or less bulky tumour fixed in the situation which it occupies : while a cancerous tumour of the great curvature of the stomach will change its position as the stomach may or may not be distended. Mobility is also a sigu of great value in de- tecting the existence of tumours of the liver, of which organ they follow the movements, rising and falling with the diaphragm in respiration. Apart from the local characteristic phenomena of cancer of the stomach, there are others of equal importance. Under the influence of great disturbance of digestion, a patient visibly loses flesh; his skin assumes a straw-yellow tint, which, I know, may also show itself in persons who have had profuse haemor- rhage, but which, in cancer of the stomach, will occur where there has been no loss of blood at all. Cancer diffused over the mucous surface—that form which has been called cancer en nappe—much more frequently eludes our means of direct exploration. You recollect a woman, aged fifty-five, who was admitted to the Hotel-Dieu in the beginning of September, 1861, and who presented extreme cachexia and emaciation, loss of appetite, pain in the abdomen, particularly in the right side, great flatulent distension of the stomach, ejection of gas and acid water by the mouth, vomiting of several months5 duration, and diarrhoea. At a subsequent period, it was observed that the matter vomited was of a blackish colour, and deposited a sediment resembling soot. There was well-marked tympanitis, particularly upon the left side, occupy- 90 SIMPLE CHRONIC ULCER OF THE STOMACH. ing the hypochondrium and iliac fossa: there was also tympanitic distension of the hypogastric region ; and on the right side, there was a sensible depression in the hypochondrium. It was supposed that this tympanitis arose from distension of the transverse and descending colon, and also of the sigmoid flexure. The cachectic state of this woman, and the black matter which she vomited, scarcely left any room for doubt as to the diagnosis. Still, to make it certain, we were anxious to find a tumour in the region of the stomach; and, not having found any such tumour after having several times carefully examined the abdomen by palpation, I thought that meteorism of the large intestine caused an obstacle to investigation by palpation and percussion. By the end of September, the vomiting had become more frequent; the patient always had in her mouth a blackish acid fluid; she could no longer take food ; and at last died without a struggle on the 29th of September. At the autopsy, I found upon the face streaks of blackish matter issuing from the mouth; tympanitic distension of the belly in the same region in which it had been observed during life; and a sensible depression of the right hypochondrium, imparting to the abdominal parietes an anomalous appearance which arrested the attention of those present. The abdomen was opened carefully, when it was perceived, to the great amazement of everybody, that the special form of the abdomen depended upon a great gaseous distension of the stomach, which began in the cardiac region, occupied the right hypochondriac and the hypogastric regions, and terminated at the margin of the right iliac fossa. This distension, therefore, was ver- micular, and had for its superior and inferior extremities the cardiac and csecal regions. The whole of the small intestine had fallen into the pelvis : the large intestine retained its normal relations, except- ing that the transverse portion of the colon had been a little dragged downwards by the great curvature of the stomach. There was no gas in the intestinal tube. The pyloric extremity of the stomach was in juxtaposition with the csecum, and, in subsiding, had dragged down the upper portion of the duodenum. The liver, which was atrophied, had descended in front of the kidney. When the stomach was opened, it was found that its parietes had their natural con- sistence and thickness ; it contained a large quantity of black liquid; and in the pyloric portion, the mucous membrane of the stomach was the seat of diffused cancer, which extended over a surface of four or five centimeters beyond the pylorus. The edges of the cancer were SIMPLE CHRONIC ULCER OF THE STOMACH. 91 denticulated, pale, like the remainder of the cancerous surface. The duodenum was intact: it contained a small quantity of blackish fluid. The seat of the cancer, and its diffused character, accounted for the extreme distension of the stomach, and also for the difficulty—I may say the impossibility—of determining during life whether or not a tumour existed. In fact, it was necessary to take the pyloric end of the stomach between the fingers to ascertain that it was increased in bulk. There was no cancer in any other part of the body. The lungs showed cicatrices: and also tuberculous deposits in both sum- mits. On the right side of the chest, there were cellular adhesions, the remains of an old attack of pleurisy. When the cancer is beyond the reach of our ordinary means of investigation, as in the case 1 have just detailed, there is a valuable diagnostic sign which I shall now point out to you. The sign to which I refer is obliterative phlebitis \_phlebite obliterante], to which I directed the attention of pathologists fifteen years ago, being then, I believe, the first who had noticed it. Should you, when in doubt as to the nature of an affection of the stomach, should you when hesitating between chronic gastritis, simple ulcer, and cancer, observe a vein become inflamed in the arm or leg, you may dispel your doubt, and pronounce in a positive manner that there is cancer. One day, my lamented colleague and excellent friend, Dr. Legroux, showed me in his wards a very anrnmic man of sixty years of age. He never had had haemorrhage nor vomiting: he only complained of gastric symptoms, and his chief complaint was of loss of appetite. The patient presented exactly the appearance of a person with leuco- cythemia. Although neither the spleen nor liver was of abnormal size, I was disposed to adopt that diagnosis, when, upon uncovering the inferior extremities, I found that one of the legs was very oede- matous, and that the posterior part of the calf of the same leg was the seat of acute pain. There was, in fact, well marked phlegmasia alba clolens. That was sufficient to inform me that the gastric symptoms depended upon cancer of the stomach, a view of the case which was confirmed some w'eeks later at the autopsy of the patient. I have several times, in the wards, called your attention to similar facts; and have at the same time pointed out to you that obliterative phlebitis is not a symptom which belongs peculiarly to cancer of the 92 SIMPLE CHRONIC ULCER OF THE STOMACH. stomach, but that it is equally symptomatic of cancer of any other internal organ. I propose on some future day to return to this important point, when I shall have an opportunity of entering fully into the subject of phlegmasia alba clolens. Before concluding this lecture, allow me to add a few words on the treatment of simple ulcer of the stomach. Regarding the treat- ment of cancer, of which I have incidentally spoken, I need scarcely tell you that we cannot arrest the disease, and can do no more than administer palliatives. In simple cancer of the stomach, I usually institute the following- plan of treatment. I order two or three grammes of trisnitrate of bismuth to be taken an hour, at the least, before meals, three times a day. It ought to be suspended in mucilaginous water, so as to be well spread over the surface of the stomach; but should the patient have a strong dislike to take the medicine in this form, it may be administered in an envelope of moist wafer-paper. My object in confiding the medicine to the empty stomach is to render its action more immediate, and consequently more efficacious. In this affection, bismuth, as well as other therapeutic agents of which I shall have to speak immediately, acts in the same way as if it were applied directly to a wound, or to the mucous membrane of the vagina, nose, mouth, or eyes, in the chronic inflammation of which it is a topical agent of great value. Bismuth, in point of fact, consti- tutes the basis of the treatment of simple ulcer. After having administered it for ten consecutive days, in the manner which I have described, I substitute for it pills of nitrate of silver, each pill con- taining one centigramme of that salt: the patient takes, for five consecutive days, three or four of these pills during the day, each pill being taken at least an hour before eating: 1 then, for ten davs, resume the bismuth: after that, for four or five days, I give to the patient, before breakfast in the morning and at midday, a powder composed of one centigramme of calomel and fifty centigrammes of sugar. After this course of medication, I resume the bismuth and proceed with the other medicines in the order already detailed. Again and again, this routine is repeated for three or four months. When cessation of pain, and a return of strength and appetite, lead me to conclude that the cure is complete, I suspend the treat- ment for a month. I then resume the same treatment for two consecutive months; then I suspend it for two months, and recom- mence it, continuing it during a month. I proceed in this way for SIMPLE CHRONIC ULCER OE THE STOMACH. 93 at least two years. It is by pursuing this patient plan that simple ulcer of the stomach is cured, and its recurrence prevented. I need not tell you that ferruginous preparations must not be omitted when there is great anaemia caused by profuse haemorrhage or imperfect nutrition. To combat the violent pain I have recourse to opium, which I am always careful to administer in small doses at meal-times. Haemorrhages are treated by rhatany, sulphuric acid, and ice; when they have been arrested, and when the pain has been subdued, I prescribe bitters, such as the decoction of cinchona, infusion of quassia or of columba root; sometimes also certain medicines which combine bitter with slightly purgative properties, such as rhubarb. Finally, I administer the preparations of iron. But the grand point in the treatment is the regulation of the diet, which ought not to be of an exclusive character, but specially adapted to the peculiarities of the patient's digestion. Professor Cruveilhier says, while insisting upon the advantage of milk diet, that “ the great problem to solve in the treatment of simple ulcer of the stomach is, to find an aliment which shall be borne by the stomach without producing pain, and, in relation to this point, the instinct of the patient is a surer guide than all the rules of art/’ When the stomach becomes a little more tolerant, other kinds of food must be tried; for diversity of food is perhaps the most useful medication in the dyspepsia which accompanies ulcerous gastritis, as indeed it is in all other kinds of dyspepsia. I cannot too often repeat that the stomach likes variety; and, in opposition to the plan which I see followed by most of my professional brethren, I require that my patients make a meal of several dishes. I do not say that this can be carried out by sheer force, or at one bound; but it is a point which must be attained, and, moreover, it can be attained much more rapidly than is generally supposed. LECTURE LXXI. DIAKELHCEA. Classification according to Proximate Causes, that is to say, accord- ing to the Mechanism by which the Diarrhoea is produced.— Catarrhal Diarrhoea : this may be a Specific Affection.— Sudoral. Diarrhoea \Diarrhee Sudorale.]—Nervous Diarrhoea.— Catarrhal Diarrhoea, in which the Affection is consecutive upon increased Secretion from the Digestive Canal or its Appendages. —Diarrhoea, resulting from Increased Tonicity. — Diarrhoea resulting from Indigestion.—Diarrhoea associated with Organic Disease.—This Classification is Artificial: the different kinds are blended with one another. Gentlemen :—When the alvine excretions are abnormally fluid, frequent, and profuse—when they consist of an undigested or im- perfectly digested alimentary residuum—when they consist of the products of secretion from the intestinal mucous membrane, from the pancreas, or from the liver—when they contain, or do not contain, blood or debris of mucous membrane—we say that there is diarrhoea. Of all the diseases which the physician meets with in practice, diarrhoea is undoubtedly the most common; it is also that which requires to be combated by the most varied measures. This diversity of remedies being necessitated by the multiplicity of causes, it is essential to know what these causes are before we can institute a rational mode of treatment. With a view to facilitate the study of the subject which I have to bring before you to-day, I distinguish several kinds of diarrhoea. The division which I adopt is quite different from any of those which you will find in classic authors; but, without attempting to discuss the merit and the advantages of one or the other, I propose to lay before you my own views, because I thus understand the subject, and because, before everything else, I practice medicine upon prin- DIAllRHCKA. 95 ciples derived from my own experience, submitting them to your appreciation, and entirely delivering them over to the control of your judgment. I consider that there are seven kinds of diarrhoea : one is catarrhal, or inflammatory diarrhoea; the second is sudoral diarrhoea; the third is caused by increased intestinal secretion from disturbance of innervation; the fourth is also a catarrhal form of diarrhoea, but it is a catarrh supervening consecutively on an excessive intestinal flux ; the fifth is diarrhoea from excess of tonicity in the intestine; the sixth depends upon unsuitable aliment, or aliment bad in quality either absolutely or relatively; and, finally, the seventh is associated with different organic diseases. The catarrhal diarrhoea is the most frequently observed form of the affection. All mucous membranes—the mucous membrane of the eye, the nose, the ear, the mouth, the pharynx, the larynx, the bronchial tubes, the uterus, the urethra, the bladder, the kidneys— are liable to inflammation. Trom the nature of the tissue attacked, the inflammation generally assumes a peculiar character, which con- stitutes catarrhal phlegmasia. The mucous membrane of the digestive canal is not any more protected from attacks of this character than the other mucous membranes, and perhaps it is even more subject to such attacks than they are. Like every phlegmasia, catarrhal phlegmasia may be simple and genuine; but likewise, whatever may be its seat, it may be specific, and so form a certain number of species, each of which, bearing a certain relation to its origin, will run a special course, manifest symptoms peculiar to itself, and related to its specific cause. These different kinds of diarrhoea do not resemble one another, but they do resemble themselves when they occur in different indi- viduals. They differ essentially as to their symptoms, their duration, their degree of severity, and also as to the therapeutic measures required for their cure : this latter point is one of which you must never lose sight. In catarrhal phlegmasia of the ocular mucous membrane, for ex- ample, along with those simple inflammatory affections occasioned by exposure to cold, or the introduction of a foreign body under the eyelid, you will have that epidemic catarrhal phlegmasia vulgularly called cocotte. You will have also purulent ophthalmia, blennor- rhagic ophthalmia, and the like, which are very different in their symptoms and in their modes of termination. 96 In catarrhal inflammation of the mucous membrane of the nasal fossae, besides simple coryza, you will have the coryza of measles, scarlatina, smallpox, glanders, scrofula, syphilis, &c.: no one will mistake these affections; for their characteristics are differential and distinctive. We likewise have both simple and specific catarrhal inflammations of the intestinal canal: the intestinal inflammation, for example, is specific which accompanies measles, scarlatina, and the onset of confluent smallpox: it is also specific when related to the herpetic or other diathesis. I have already at some length directed your attention to these facts when lecturing on other subjects, particularly when dis- cussing dyspepsia. These inflammations, whether specific or non-specific, have cha- racters in common, in addition to the characters which distinguish the one from the other. Some of these common characters belong inherently to the anatomical structure of the mucous tissue : I refer to flux, and increased discharge from the mucous membrane, the secretions from which are modified both as to quantity and quality. The others are subordinate to the seat of the inflammation, that is to say, to the organs affected: they are functional derangements, for in that way alone is an organ diseased—the function allotted to it is more or less disordered, and perhaps is entirely in abeyance. It is unnecessary to add, that the functional disturbance necessarily varies according to the particular organs implicated. If it be the nasal mucous membrane which is inflamed, the sense of smell is enfeebled, perverted, or lost. If it be the bronchial mucous membrane, the disturbance is much more serious. The digestion of oxygen, if I may use that expression, being badly ac- complished, hsematosis takes place imperfectly, and according to the degree in which the catarrhal inflammation is more or less exten- sive, more or less deep-seated, or more or less persistent, the dis- order of the function of hsematosis may attain such a height as to induce cachexia. Should it be the mucous membrane of the intes- tinal canal which is implicated, digestion will be disturbed, and the nature of the disturbance will depend upon the portion of that passage which may be peculiarly affected. When inflammation attacks the stomach, its secretory apparatus immediately performs its functional office in an abnormal manner, and the gastric juice being no longer appropriate in quantity and quality, chy unification is imperfectly accomplished. When the stomach, remaining healthy, DIAlUtlltEA. DIARllHCEA. 97 the intestines are affected, chylification will either be performed badly or not at all, in proportion to the degree in which the inflam- mation has disturbed the intestinal secretions. But, whilst this increased secretion of gastric and intestinal fluids leads to a vitiated elaboration of the food, this badly elaborated food in its turn acts as a foreign body upon the mucous membrane of the digestive tube, augmenting the secretion and the profu- sion of the flux. It also irritates the muscular coat of the intes- tines, exciting its contractions in such a way as to render the peristaltic movements both more frequent and more rapid. This increased frequency and rapidity in the peristaltic movements, which is excited also by the presence of the excrementitious principles of the bile, which, as I have just said, is poured in large quantity into the duodenum—this increased frequency and rapidity in the peri- staltic movements explains the increased frequency of the stools. In diarrhceal catarrh, then, the flux consists of the residue of badly elaborated elementary matter, of humours secreted by the intestinal surface, and of secretions produced by sympathetic influences upon the great glandular organs of the digestive apparatus, the pancreas and liver. As you know, Gentlemen, when the extremities of the different canals of a gland open upon an irritated mucous membrane, the irritation is propagated by sympathy to the gland, and its secretory functions are thereby often augmented. Simple irritation of the conjunctiva, passing by sympathy to the lachrymal gland, produces an abnormal flow of tears, the affection called epiphora. Excitation of the mucous membrane of the mouth, caused by chewing the root of anthemis pyrethrum, or any other sialogogue, will occasion pro- fuse salivation, the result of sympathetic irritation of the salivary glands. So, in like manner, an inflammation or irritation of the mucous membrane of the duodenum will react upon the pancreas and liver, causing an increase in the pancreatic and hepatic secre- tions. In proportion to the degree of this sympathetic excitement of the liver, will be the greater or less amount of biliary matter in the diarrhoeal discharges. The cause, then, of the first kind of diarrhoea is an irritation or inflammation of the gastro-intestinal apparatus, a gastro-enteritis, or an enteritis, to use expressions which some physicians of the present day seem to have erased from their vocabulary. Let me here repeat what I have said elsewhere. It is quite right DIARRHOEA. to impeach gastritis and gastro-enteritis, as understood by Broussais; but to deny the very existence of such affections is proceeding too far, is indeed proceeding to the opposite extreme of his error. I certainly do not believe that inflammations of the stomach and in- testines occur so frequently as Broussais supposed, and still less do I believe that all the general symptoms which he attributed to them can be charged to their account. I do not see—as Broussais saw—gastro-enteritis in every disease; but neither do I see why the mucous membranes of the stomach and intestines should alone be exempt from attacks of inflammation. From the very nature of the functions which it has to perform, it is, I admit, more enduring, less sensitive, than other mucous membranes ; nevertheless, that form of inflammation, that catarrhal inflammation, which, so to speak, only strikes the surface of the organ (whatever may be its cause) is in it not the less common. In fact, it is a much more common affection than is generally supposed. I have now to speak of the second or sudoral form of diarrhoea• The details into which I entered regarding it, when lecturing upon the sudoral exanthemata were so full, that I might on the present occasion pass over the subject lightly, were I not anxious that you should clearly understand what I mean by the term sudoral diarrhoea, so as to grasp more thoroughly the different therapeutic indications which correspond to the different causes of the intes- tinal flux. Such of you as have already had some practical experience in our art, particularly if your practice has been among children, must have observed the kind of diarrhoea to which I wish to call your attention. You must have seen persons in whom the influence of a slight increase of external temperature, arising, for example, from an excess of bedclothes, invariably produces more or less diarrhoeal discharge. This observation has been made in respect of the lower animals as well as in respect of the human species : some horses, ere they have run half a league or a quarter of a league, have their skin covered with sweat, and, at the same time, have liquid alvine discharges. The diarrhoea and sweating are both phenomena of the same class, and arise from an abnormal secretion, the one from the internal and the other from the external integument, the result respectively of a fluxion to the secreting organs of the intestines and the skin. There are other cases in which it seems as if all the emunctories DIARRHOEA. 99 were scarcely adequate to disembarrass the blood of the excre- mentitious matter produced in it in excessive quantity: then there occurs as a physiological, that which we have seen as a patholo- gical, phenomenon in measles and other eruptive fevers; or, as I have said, the exauthemic fluxion has taken place simultaneously from the skin, intestines, and bronchial tubes, manifesting itself by the characteristic eruption, diarrhoea, and bronchial catarrh which accompany the earliest of the pyrexial symptoms. The concurrence of profuse sweating and intestinal flux is likewise met with in the fever accompanying suppuration: in this case, the diarrhoea is explained by the irritation of the tegumentary membranes caused by the serous part of the pus being absorbed, and trying as it were to become eliminated by its natural emunctories : this is explained by the establishment of a sort of sympathy between the adventitious membranes of the suppuration and the mucous membranes. If excessive sweating and intestinal flux show themselves simul- taneously, the latter is in general only supplementary to the cuta- neous secretion. Let me explain. You are acquainted with that sort of compensation which exists between the functions of the skin and mucous membranes—particularly the intestinal, bronchial, and urinary mucous membranes. You know that their secretions are destined, besides accomplishing other uses, to modify the composi- tion of the blood by removing from it effete matters useless for the maintenance of life : there can be no change in either without a dis- turbance of their equilibrium : hence is it, that an increase or dimi- nution in the action of one or other of these secreting organs will occasion a diminution or an increase in the action of the other. Nowhere is this antagonism of secretions so conspicuously mani- fested as between the skin and intestinal surface. You will now be able to understand why such a disturbance of the functions of the skin as prevents the secretion of sweat will often induce too profuse a secretion from the intestine. This is the explanation of attacks of diarrhoea supervening upon chills and suppressed perspiration. Intestinal fluxes are sometimes so excessively copious as to lead to serious consequences. These are the fluxes which the older writers called colliquative, and of which a typical example has been furnished by the well-known circumstances which occurred to Morgagni. When travelling post on a fatiguing journey, he had a sudden attack of diarrhoea, and in twelve hours discharged from the bowels “ at least sixteen pounds of nearly limpid water.” This discharge, which was 100 DIARRHOEA. accompanied by only slight pain, ceased after the vomiting of a greenish matter resembling a small leaf of cooked grass. Morgagni adds :—“ On the following day, I realised the danger I had been in, when I looked at my body, but particularly when I saw my face and hands as flaccid as if I had emerged from a very severe long illness : I felt great dryness in the mouth and throat, disgust for food, and a sense of lassitude. The symptoms lasted only for two or three days, with the exception of the anorexia, which continued for a longer period.”1 There is another form of sudoral diarrhoea, one which is rather frequently met with in women at the change of life. As you are aware, in the majority of women at that critical period, the approach of the final suppression of the catamenia is indicated by flushings of the head and of the skin of the whole body, accompanied by a pro- fusion of hot sweat, before there is any irregularity in the flux. These inconvenient flushings and sweatings sometimes recur from twenty to forty times in a day. By and by, the menstrual periodicity becomes modified, and at last the flux entirely ceases: the hot flush- ings, or what women call the “ bouffees de chaleur,” then begin gradually to diminish, although they may continue for some months longer, and even, sometimes, for two or three years. Now, in these women, it not unfrequently happens, that the hot flushings disappear for a time, being then replaced by a serous intestinal flux accompanied by borborygmi occurring in a strangely sudden manner, either in connection writh, or independently of, mental emotion or errors in diet. I have thought it well, for reasons which you can appreciate, to place this form of diarrhoea in the sudoral class, although, in reality, it ought rather to be classed with the forms of diarrhoea which I have called nervous; and of which I am now going to speak. The influence of the nervous system on the secretions is a physio- logical fact so exceedingly well known, that I hardly require to recall it to your recollection. The beautiful experiments of Claude Bernard upon the functions of the liver have shown us, that by pricking the floor of the fourth ventricle in a particular place glucosuria is produced, polyuria by 1 Morgagni :—Recherches Anatomiques sur le Siege et les Causes des Maladies. Lettre XXXI. DIARRHCEA. 101 pricking it in another situation, and albuminuria by pricking it in a third place. These facts, so clearly elucidated by experiments on living animals, have been conclusively demonstrated by pathological observations: as you all know, neuralgic pain excites secretion in the glands near the affected parts, and toothache is often accompanied by excessive salivation, just as neuralgia of the fifth pair occasions lachrymation. Similar effects are produced upon the secreting organs by the passions, by even moderate excitement, and by intellectual en- grossment. Pain, joy, a tender affecting sight, draw tears from the eyes. The mere idea or the recollection of a delicious dish, excites the salivary secretion; and, to use the popular expression, makes the mouth water. Mental disturbance, if somewhat intense, will cause a frequent desire to make water. Similar mental influences are observed in the lower animals. Of the correctness of this statement, I require no better proof than that which is afforded by that wonderful phenomenon, the rush of milk to the mammary gland. It has been alleged, says Muller, that the mere sight of her colt will excite the lacteal secretion in a mare.1 It is certain, that the manner in which cows are milked marvellously modifies the result of the operation—that a cow, milked by a gentle person, one who knows how to proceed, will give more milk than when operated upon by an individual who milks roughly. It must, however, be remembered, that, although the cow retains her milk when she dislikes the clumsy or coarse manipulation of the milker, there is also a special action, an excitation by the hand of the teats, which excites the secretion of milk, just as the soft agreeable sucking by the lips and tongue of the infant determines a rapid rush of milk to the nurse’s breasts. I have told you, when speaking of the convulsions of children, how much mental emotion, a fit of anger, fear, or cynic spasm, may modify the lacteal secretion in women. Let me here add, that, to con- stitute a good nurse, it is not merely necessary that the breasts should be well formed, with the skin marbled by numerous veins, indicating a copious circulation in the organs, but that the flow of milk, generally made known to the woman by a peculiar sensation, 1 J. Muller :—Manuel de Physiologie, traduit de 1’ Allemand par Jourdan. [2nd ed. Paris, 1854.] 102 should take place with ease and rapidity : this rapid rush of milk is generally coincident with an easy erection of the nipple, an erection which is often of a voluptuous character. The secreting apparatus of the mucous membrane of the digestive canal, and its afferent glands, the pancreas and liver, are no exceptions to this general law. And again, in relation to the influence of men- tal emotion, the effects of the first cannon-shot upon the raw soldier are universally known; and further, we see children seized with diarrhoea upon being threatened with chastisement, or when anything has frightened them. Neuralgia in the region of the eye causes an increased flow of tears ; and in the same way, a local pain propagates abnormal excite- ment to the secreting apparatus of the intestines : hepatalgia will induce an excessive flow of bile. Along with the increased secretion there will be, as in the example which I have just cited in relation to the influence of disturbed innervation upon the lacteal secretion, a morbid change in the composition of the product secreted. Here, then, is an abnormal flux, having for its cause a peculiar modality impressed upon the nervous system, in fact, a nervous diarrhoea. The diarrhoea, thus originally excited, will be proportion- ately the more abundant that the afflux of fluids into the intestinal cavity produces indigestion, from a change of relation between the food which ought to be elaborated in its passage through the canal, and the juices which ought to accomplish this elaboration. It was necessary, Gentlemen, that I should enter into these details, because nervous diarrhoea is one of the most frequent forms of the affection, and is at the same time one of those in which the physi- cian can be most useful, when he knows how to recognise it. In the fourth species, the diarrhoea is also catarrhal as in the first; but there is this essential distinction, that, while here the increase in the intestinal secretion is dependent upon irritation primarily deve- loped in the intestinal mucous membrane, in the species of which we are now speaking, there is, on the contrary, a secretion which is at once excessive in quantity and vitiated in quality, which produces irritation, catarrhal inflammation of the intestines. The morbid changes which occur in other organs under analogous conditions will enable you the better to understand my views. A coryza which lasts only for some hours produces in the upper lip, however little susceptible and delicate the skin of the individual may be, an irritation which, if the coryza last, will cause excoriation of DIARRHOEA. DIARRHOEA. 103 the parts. Observe, Gentlemen, that it is not only the flow of mucus more or less thick to which we must attribute the phenomena which I am pointing out; for you will see nothing similar supervene in children who are badly attended to and snotty (morveux), provided they are otherwise healthy. The mucus must have some peculiar pro- perties ; it must be the product of a morbid secretion, like that which accompanies the simplest catarrhal inflammation of the Schneiderian mucous membrane. The consecutive irritation deve- loped in the skin may develope itself under the same influence in the pharynx : and I am convinced that many catarrhal sore throats have no other cause than the contact of irritating mucus which proceeds from the posterior orifice of the nasal fossae affected by coryza. In this case, the patients complain of feeling the mucus fall from the nose into the throat; and, in point of fact, if you look into the throat, you see that the posterior and upper wall of the pharynx is covered with stringy purulent mucus, which, after a certain time, by contact, produces catarrhal sore throat. Does not a profuse flow of tears cause a somewhat similar effect upon the cheeks ? Although this flux be in no degree inflammatory, there will be produced redness of the eyelids, occasioned much less by the contact of the tears, than by the individual constantly rubbing his eyes. But, should the lachrymation be dependent upon an oph- thalmia, of however simple a character, the epiphora will ere long be accompanied by an irritation of the parts which are bathed in tears; you will see the skin become the seat of erythema or eczema, and a greater or less extent of excoriation will follow. ■ Uterine catarrh, which under certain circumstances may be com- pared to catarrhal inflammation of the nasal mucous membrane, will often be the starting point of ulceration of the neck of the womb. Nay, let me say, that in four fifths, or perhaps even in nine tenths of the cases, the excoriations have no other cause, and it is as super- fluous to treat them as it is unnecessary to treat eczematous affections of the upper lip consecutive upon coryza. Both undergo spon- taneous cure, when the catarrh in which they originate has ceased. Ulcerations of the cervix uteri are, moreover, not the only conse- quences of catarrhal inflammation of the womb. It is by no means unusual for irritation occasioned by leucorrhoeal discharge to extend to the mucous membrane of the vagina, to the vulva, and even to a greater or less extent of the skin in the neighbourhood of the genital organs. DIARRHCEA. Let us apply these facts to the occurrences which take place in the digestive organs. Let us first of all recollect, irrespective of its cause, that which we see daily in young children suffering from diarrhoea. Do we not then see the skin of the nates and legs covered with an erythematous redness or eczematous eruption ? Do we not frequently see, in such cases, more or less deep excoriations ? You certainly cannot have forgotten a fine child of nine months old, who was admitted to bed 16 of our nursery ward in November, 1861. There was visible, round her anus, an elevated ridge of mucous crusts, resembling syphilitic mucous crusts. Now there wras nothing in this child to indicate constitutional syphilis: the mother was perfectly healthy, and the child herself had had nothing the matter with her till then, excepting a rather violent diarrhoea which had continued for twelve days. There had been, first of all, a little redness round the anus; then, the diarrhoea continuing, the skin became more inflamed, when she had local symptoms apparently of a very serious character. In two days, the diarrhoea was modified: then, by applications of a liniment containing glycerine and tris- nitrate of bismuth, these manifestations, apparently so threatening in character but really so little serious, disappeared. Although we cannot positively assert what supervenes within the intestinal cavity in such a case, we may conclude that there is a similarity between the condition of the digestive mucous membrane and the condition of the parts which are visible. There is ground for believing, that a secretion, profuse in quantity and vicious in quality, whether proceeding from the stomach, duodenum, or upper part of the small intestine, or from the annexed glands, the liver and pancreas, will induce irritation of the mucous membrane of the ileum, csecum, or large intestine, precisely in the same way that diarrhoeal matter will produce irritation and excoriation of the skin in the neighbourhood of the anus and of the legs. This irritation, this consecutive inflammation of parts in the first instance not affected, will cause an excessive secretion in these same parts, which will show itself as an intestinal flux or diarrhoea. Gentlemen, I have now to explain to you what I mean by diarrhoea resulting from augmented tonicity, that form of diarrhoea which con- stitutes the fifth species which I have named. When a horse is killed, and the mass of intestines is removed from its still palpitating carcass, we see their contractions continue for eight or ten minutes : these contractions are sufficiently energetic in DIARRHOEA. 105 the colon to cause the excrementitious matter to he propelled from the upper to the lower parts; so, in fact, as to accomplish defe- cation. In this way, we can witness upon the anatomical table exactly what takes place during life in the abdominal cavity. There occurs a series of movements separated by intervals of rest, move- ments influencing the whole length and breadth of the intestinal canal, but which, though they present great irregularity and appa- rent confusion, show a predominance of what is called the peristaltic motion alternating with that other motion which is called anti- peristaltic. The object and the result of these movements is, to mix more thoroughly, by a sort of churning process, the materials under- going digestion, so as to enable them to undergo more intimate reactions, and to multiply their points of contact writh the absorbing surfaces. I do not require to say more regarding the phenomena which pertain to physiology : I would only add, that the slowness and the rapidity of the intestinal movements are proportionate, in the different species of animals, to the necessity for alimentation which varies with the species. I would also recall to your recollection that, in a normal state, these movements are performed more rapidly in the upper than in the lower part of the intestines—that they are more rapid in the ileum than in the large intestine—in the jejunum than in the ileum—in the duodenum than in the jejunum. But, however great their rapidity may be, it is proportionate, I repeat, to the necessity for alimentation, in such a way that the alimentary mass may have time to undergo, in each of the parts of the digestive canal, that elaboration with which each part is entrusted. "When, for one reason or another, this rapidity is augmented, the elaboration is incomplete, digestion becomes disordered, and is performed badly or not at all; the food entrusted to the stomach ought to remain in it for a certain time before being converted into chyme, and passing into the duodenum, where it will be subjected to a new process. If the stomach, contracting too energetically, propel the imperfectly elaborated aliment into the intestine, the aliment will there act upon the organ, as an irritating foreign body, from the organ not being prepared to receive it in the conditions in which it is presented. The organ will rebel against it, and try to get rid of it as quickly as pos- sible. The alimentary mass reaching the large intestine with part of its elements in this state, which, in a normal condition, would have been converted into chyle and absorbed, undergoes a process analo- 106 DIARRHCEA. gems to that which we see when beef-tea or milk enemata are administered. It is, in fact, an error to believe that injections of this kind can be used in place of food. The large intestine is not made for the reception of alimentary substances, until they have been subjected to the previous treatment of digestion in the stomach and small intestines. The large intestine, far from assisting in their absorption, kicks against them (allow me the expression). Their presence excites energetic contractions, excites secretions, and, in a word, acts like a purgative. Augmented tonicity of the stomach and intestines is a cause, then, of diarrhoea. Diarrhoea thus induced is lienteric; or, in other words, the stools contain a certain quantity of the food in the state in which it was eaten. This augmented tonicity itself is, like the augmentation of secre- tion of which I have just been speaking, under the influence of the nervous system. When we come to speak of treatment, we shall see that this kind of diarrhoea yields generally in a remarkable man- ner to narcotic medication. Though the causes which bring into play this increased tonicity generally act directly upon the parts affected—though, to express my idea more exactly, we must seek for the starting point of that form of diarrhoea now under con- sideration in the stomach or in the small intestine, the starting point is also often found in the large intestine and in its lowest part. In this lecture, I have already explained to you that irritation of the extremity of a canal is sufficient to cause irritation of the entire canal; and I have referred to what takes place in different secreting glands, to illustrate what occurs in respect of the liver in intestinal catarrh. Similar phenomena are observed consequent upon irrita- tion of the lowest part of the large intestine. This irritation is transmitted by sympathy from the rectum to the colon, and from the colon to the small intestine. Does a day pass in which we do not meet with cases proving the truth of this statement ? Is not this the explanation of the manner in which a lavement acts ? Certainly, two hundred or three hundred grammes of water injected into the rectum, do not pass very far up the large intestine, but they are nevertheless sufficient not merely to cause it to contract, but likewise to induce contractions in the entire intestinal canal. An example of a very limited local irritation, propagated by sympathy to a great extent of surface, is afforded by intestinal contractions 107 DIARRHCEA. and frequent stools being excited by the introduction of a simple suppository into the anus. This is the mode of action of hsemor- rhoidal tumours, the presence of which will not only produce tenesmus, but also frequent diarrhoeal stools. You can now understand how such a lesion as ulceration of the rectum, or chronic inflammation, may cause obstinate diarrhoea, which will not yield till the treatment has been made to bear directly upon the local condition giving rise to it. The sixth species of diarrhoea of which I have to speak, is diarrhoea originating in indigestion. It is not an unusual affection in adults, but it is more frequent in children, particularly in infants at the breast. Although—as I have already said over and over again—the stomach is exceedingly tolerant of very coarse ingesta, its tolerance has limits; and sometimes, it rebels against its contents when they are excessive in quantity or unsuitable in quality. Under such circumstances, the stomach will always endeavour to get rid of contents which incommode it. Substances which it has failed to elaborate, or which it has only imperfectly elaborated, will be rejected through one or other portal—through the cardiac or pyloric opening :—they will be vomited (perhaps the most fortunate alternative), or they will pass downwards into the duodenum. If they pass into the duodenum, they will excite abnormal secretions, and peristaltic movements, in virtue of the mechanism which I described when speaking of diarrhoea from excess of tonicity, the result being diarrhoea. Excess in the quantity of food may lead to this result. To select one of the simplest possible examples : nothing is more usual than to see diarrhoea supervene in infants nursed by women whose milk is very abundant and rushes too quickly into the breasts. This disorder of the bowels, to use the common expression, neither arises from the food being of bad quality, nor from the stomach being in an unfit state for its reception, but from the food having been taken in too great quantity at one time. I have selected this illustration, because it gives me an opportunity of putting you on your guard against a mistake which is often committed. A child suckled by a woman having every appearance of being a good nurse has diarrhoea: the family, and sometimes the physician, are in haste to change the nurse, when nothing more is required than to order that the infant be not allowed to suck too long at one time. 108 DIARRHOEA. Though diarrhoea from indigestion is less common in adults, it is also observed in them pretty frequently. While in adults, as in children, it may depend on excessive ali- mentation—diarrhoea ah ingluvie—it may likewise depend on the bad quality of the food, and this bad quality may be either absolute or relative. Every one knows what is meant by food absolutely bad in quality; but it is necessary to explain the meaning of the food being re- latively bad. It is a fact generally admitted, that certain aliments and drinks which agree perfectly well with some persons are not borne by others; while the same persons who cannot bear these tolerate quite well the dietetic articles not supported by the other individuals. These stomachic antipathies are so essentially special to the individual, that it is impossible to lay down any rules on the subject; and it is only by personal experience we discover what will and what will not agree with the stomach. In speaking of dyspepsia, I have already stated the practical con- clusions to be deduced from these data: I called your attention to the unfortunate tendency which we all have to regulate the diet of our patients in accordance with our own tastes and digestive aptitudes. The importance of the subject justifies my recurring to it to-day. I knew a man who suffered from diarrhoea for years, notwithstand- ing the trial of every sort of treatment, and whose general health was seriously impaired by the affection. The symptoms disappeared, as if by enchantment, upon the patient, of his own accord, discontinuing tea to breakfast, which for twelve years he had been in the habit of taking. I attended the family of a ship-builder of Havre whose children were unable to tolerate milk for the first seven years of life. A suc- cession of nurses was tried for all of them : lactation with the milk of the cow, the goat, and the ass, was also attempted : but all proved futile. A few mouthfuls of any kind of milk at once caused diarrhoea and vomiting. It became necessary to have recourse to farinaceous drinks, such as decoctions of grits and pearl barley : by this regimen, these children were reared as successfully as others fed in the usual way. This was certainly a very rare exceptional case; for, as a rule, diarrhoea supervenes in infants when a premature attempt is made to feed them with farinaceous food in place of milk, their natural aliment. When I come to speak to yon on the subject of weaning, DIARRHOEA. 109 I shall have to return to this point, and to treat it with all the fulness which it merits. Here, I conclude my remarks on the different forms of diarrhoea, or rather upon the different modes in wdiich they are produced. I intentionally omit speaking of diarrhoea caused by organic disease, reserving that subject for a special lecture, materials for which will be furnished by the cases of several of our patients affected with chronic diarrhoea. I shall merely add that all the forms which I have discussed are far from presenting themselves with the sim- plicity which I have assumed in my descriptions, for the purpose of enabling you the better to appreciate their causes : sometimes, they may present this simplicity, but in general, they have not that dis- tinctiveness of character with which I have invested them. It is for the physician in each case to disentangle the predominating element as the symptoms evolve. Gentlemen, all artificial divisions of disease are devoid of interest, if they lead to no therapeutic results. In establishing these divisions, my aim has been to simplify the treatment of diarrhoea, an affection the cure of which is too often attempted by one and the same routine of means, irrespective of the diversity of causes in which it originates. In treating catarrhal diarrhoea, we must always bear in mind that the catarrhal element is the same in character as in ocular, nasal, bronchial, urethral, or intestinal catarrh; that it is impossible to predict its duration; and that here the specific element plays an important part. Simple coryza is an affair of a few days; but syphilitic coryza is essentially chronic. The pulmonary catarrh of measles is a transient affection, while the catarrh of influenza long and obstinately resists all our therapeutic efforts: an ordinary catarrh, though ceasing more quickly than the bronchial affection of influenza, has nevertheless a very uncertain duration. So is it likewise with intestinal catarrh. Diarrhcea consequent upon a chill is, in ordinary circumstances, a very transient affection. The treatment is simply dietetic. All required is that the patient for a day or two be put on light food in the form of soups, so that the intestines, having little to do, may be allowed to rest; and thus the symptoms will spontaneously cease. Cases, however, occur in which it is difficult to carry out this regimen. I refer to cases in which the catarrhal affection, appa- rently localised in a particular part of the intestinal canal—at the 110 end of the ileum or beginning of the large intestine—causes no loss of appetite, the stomach not being disturbed in the performance of its functions. The expectant system and low diet will certainly accomplish a cure, while ingestion of food will keep up, and may even increase the disorder. Under these circumstances, nevertheless, it is proper to assist nature; and I do not know of any medication so decidedly calcu- lated as the substitutive to accomplish this object: the best reme- dies, I mean, are purgatives. The selection of the purgatives to be employed is not a matter of indifference : those to which we ought to have recourse are the sulphate of soda, the sulphate of magnesia, and the salts of Seignette, which is the double tartrate of potash and soda. Patients affected with this kind of diarrhoea ought to take in the morning (fasting) from 2$ to 40 grammes of one or other of these medicines : the result will be a temporary augmentation of the intestinal flux, but generally at the end of twenty-four hours the symptoms will have entirely ceased. When the catarrhal inflammation has lasted a little longer, when it has acquired (if I may use the expression) a right of domicile, the substitutive medication is still indicated. If the stools show super- abundance of bile, if, at the same time, the tongue is saburral and coated with a thick yellow fur, if there be loss of appetite and a feverish condition, emetics are specially indicated; and the emetic assuredly the most efficacious is ipecacuan, given according to the plan which I have already formulated to you. The patient is allowed to rest the day after the emetic has been given, and then, on the following day, he takes a saline purgative. Emetics and purgatives are topical irritants, and act simply by sub- stituting for the catarrhal inflammation another and a special inflam- mation which yields spontaneously much more quickly than that which preceded it. What takes place in the morbidly affected mucous membrane of the digestive canal is exactly what takes place when caustic collyria, nitrate of silver, sulphate of copper, sulphate of zinc, or acetate of lead, are employed in the treatment of catarrhal inflammation of the conjunctiva with a view to substitute for it an inflammation excited by the topical agents, and which will spon- taneously cease. Should the diarrhoea have lasted ten or fifteen days, the saline purgatives ought to be administered in another manner. On the first day, for an adult, I prescribe 25 grammes drachms] of DIAR1U1CEA. DIARitHCEA. Glauber salts, and on the five, six, or seven following days I give io grammes [2| drachms] : under this treatment, the patient will come to have not more than one or two diarrhoeal stools in a day; and sometimes, even constipation supervenes. The treatment must then be stopped. To children, I prescribe the salts of Seignette, giving 5 or 6 grammes on the first day, and only three grammes on the fol- lowing days. The substitutive method is likewise available when the catarrhal inflammation has assumed a still more chronic form. The medicinal substances to be employed are, however, not those of which I have been speaking. Though, occasionally, saline purgatives are useful, mercurials are much more efficacious. I prescribe from five to ten centigrammes of calomel divided into eight or ten parts, one of which I order to be taken every hour for eight or ten consecutive hours. The same medication may be repeated daily, for not more than three or four days, care being taken to observe its action and avoid giving it up to the point of salivation; for when the gums become sore and swollen from calomel, a special form of diarrhoea sets in, in which the stools are of a greenish colour, and the flux much more obstinate than that which it is wished to subdue. At the end of three or four days, it is time to stop this treatment. Sometimes, the symptoms are definitively subdued: the desired modification in the condition of the mucous membrane of the intestine is produced by the calomel, just as a modification of the state of the ocular and nasal mucous membranes, when catarrhally affected, is produced by mercurial topical applications. Generally, this treat- ment does not prove sufficient in itself; and to render the cure com- plete, it is necessary to give a neutral salt. In place of calomel, you have not unfrequently seen me give hydrargyrum cum creta. To children—for whom I prefer this pre- paration—I give, for one, two or three days, twice a day, from five to fifteen centigrammes. To adults, I give from io to 25 centigrammes of the English blue pill mass in the evening, following up this dose next morning by a saline purgative. "When the diarrhoea has resisted all other measures, you have more than once heard me prescribe a pill in which I combine calomel, opium, and ipecacuan. This is my formula :— 112 DIARRHOEA, Ipecacuan . . . . 2 centigrammes. Calomel 5 milligrammes. Extract of Opium . . .5 milligrammes. To be made s.a. into one pill. During the twenty-four hours, the patient takes, in the interval between meals, from one to three of these pills. This medication is continued for from five to ten days. If it be longer continued, the mercury almost invariably acts upon the mouth, a result which ought to be guarded against for reasons I have just stated. I very frequently employ the crystallised nitrate of silver. It was long ago recommended by Boerhaave as a drastic purgative in dropsy; but I use it as a substitutive remedy in rebellious catarrhal diarrhoea. I make a pill containing in solution one centigramme of the lunar salt: this solution is dropped on a quantity of crumb of bread, traga- canth, or starch, sufficient to make a pill. From four to ten such pills may be given daily, during eight or ten days, as much as possible in the intervals between meals. Neither nausea nor any other disagreeable consequence results from the use of this remedy. In some cases, like saline purgatives, it temporarily increases the diarrhoeal flux; but, as a rule, it promptly arrests the diarrhoea. It is principally, however, for the treatment of chronic, tuber- culous diarrhoea (regarding which I shall have to address you in a separate lecture), and for other forms of intestinal inflammation that the nitrate of silver administered both by the mouth and in lavement ought to be reserved. Of all the remedies employed to cure somewdiat obstinate catarrhal diarrhoea, the subnitrate of bismuth is that which I most frequently have recourse to : I generally give it along with prepared chalk, which is the precipitated carbonate of lime. This prescription proves useful, and never produces any bad effects. The powder which I usually order consists of equal parts of chalk and bismuth, from 4 to 10 grammes of each; but much larger doses may be given. One of my colleagues, Professor Monneret, administers it larga manu— in tablespoonfuls—without ever seeing the very slightest inconve- nience result. The English chalk mixture produces the same effects : it is com- posed of 30 grammes of prepared chalk, and 60 grammes of a wreak infusion of mint leaves, aromatised by the addition of 30 grammes of orange flower syrup. These preparations are often in themselves sufficient to cure DIARRHOEA. 113 catarrhal diarrhoea; but it likewise often happens that they do not act beneficially, unless the intestinal inflammation has been previously modified by a purgative. Some persons are seized with diarrhoea, whenever they are exposed to the slightest chill. Patients of this description derive a marvel- lous amount of benefit from hydrotherapy, and, when it can be had, from maritime hydrotherapy : this treatment tonifies their whole system, and enables them to resist variations of temperature, without contracting the intestinal catarrh from which, under similar circum- stances, they were previously in the habit of suffering. I was speaking to you about specific catarrhal affections : and at the beginning of this lecture, I told you, that the specific element showed itself quite as much in intestinal as in other catarrhs, I referred to the diarrhoea dependent upon the herpetic diathesis, as well as to certain forms of bronchitis and coryza. These diarrhceal affections occur, at longer or shorter intervals, in persons subject to cutaneous eruptions. Here, sulphurous remedies are exceedingly useful; and of them the best are the natural mineral waters, such as those of Luchon, and Aix in Savoy, but particularly the former. Arsenical treatment will also prove of great service in these cases : to prove effective, however, it must be long continued. I11 employ- ing this treatment, Gentlemen, I cannot too strongly urge you to formulate your own prescriptions, so as to be quite sure of what you are about. The arsenical solutions of Pearson and Powler require to be administered with the utmost caution, for the slightest error may produce most serious symptoms. I prefer the following solution : Arseniate of Soda . 5 centigrammes. Water . . 125 grammes. Each teaspoonful of this solution represents about 2 milligrammes of the arseniate. The dose may he increased up to one centi- gramme. The patient takes this solution daily for a month, when it is suspended for 1 o days, to be again resumed for another month; and I continue to repeat it, at similar intervals, for a long period : for do not forget the precept, that for chronic diseases (and as such we must regard all diathesic maladies) chronic treatment is requisite. A 114 DIARRHOEA. combination of this arsenical medication with the sulphurous treat- ment generally cures the kind of diarrhoea of which I am now speaking. The treatment of sudoral diarrhoea is naturally suggested by what I have said regarding the causes which excite increased intestinal flux. The preventive measures consist in not covering the body too warmly, and in abstaining from violent exercise after eating. When the affection actually exists, cool drinks and light food will generally suffice to accomplish a cure. That, therefore, is a subject into which it is unnecessary to enter at greater length. The treatment of nervous diarrhoea is less simple, and requires that I should go into some details. In this affection, obtunding and antispasmodic remedies are peculiarly indicated. Opium takes the first place in this class of medicines : but it is a remarkable fact that almost equally high in the list is belladonna, which perhaps you will be surprised to hear me laud as a curative agent in diarrhoea, knowing, as you do, that along with the other physiological pro- perties which it has in common with henbane and other medicinal solanece, it relaxes the bowels, and is consequently prescribed with advantage in some kinds of constipation. The contradiction which seems to exist between the opposite results obtained from the same remedy is only apparent, as you will easily perceive by reflecting upon the mode of action of belladonna. In virtue of its obtunding powers, it is, according to the nature of the case in which it is given, either purgative or antidiarrhoeic. When constipation depends upon a sort of spasm of the intestine, belladonna relieves the spasm, and so acts as a purgative : when diarrhoea of the form now under consideration depends upon exalted irritability and increased nervous sensibility of the intestine, bella- donna soothes this irritability and calms this sensibility, in the same way that it arrests the lachrymal flux in supra-orbital neuralgia by calming the neuralgia which was its exciting cause. In nervous, but only in that kind of diarrhoea, belladonna is of unquestionable utility: when the cause is a catarrhal phlegmasia this medicine aggravates the symptoms. It may often be very advantageously substituted for opium ; but like it, it requires to be managed with extreme prudence, and only to be given internally in small doses, such as from one to three centigrammes in the twenty- four hours, and distributed in several pills : when the diarrhoea is accompanied by gastralgic and enteralgic pains, its use may be re- DIARRHOEA.. 115 stricted to frictions of the abdomen, particularly to frictions over the pit of the stomach. For reasons similar to those now stated, antispasmodics are like- wise admirable remedies in nervous diarrhoea. Of this class, ether is assuredly the most powerful agent; and it can be very con- veniently administered in the now commonly used gelatinous capsules. Nitrate of silver, which I mentioned as a useful remedy in catarrhal diarrhoea, is likewise useful in nervous diarrhoea, its action, however, in the latter, being that of an antispasmodic, and not that of a substitutor. This treatment (devised by Graves) requires to be directed with circumspection: it must not be continued for more than four or five days consecutively; and within the twenty-four hours, there must not be given more than four pills, each pill con- taining one centigramme of the salt. When combined with bella- donna or opium, nitrate of silver has an exceedingly good alterative effect in those attacks of diarrhoea in which borborygmi supervene in nervous women and hypochondriacal men. Although neuralgia of the abdominal viscera—gastralgia, ente- ralgia, and hepatalgia—are usually associated with obstinate consti- pation, it is not a very rare occurrence for them to occasion diarrhoea, the profusion of the flux being proportionate to the intensity of the pain. It is in such cases, that we interpose usefully by adminis- tering opium and antispasmodic remedies, the modus operandi of which we can explain. Benefit is also derived from the essential oil of turpentine, which is a very powerful remedy in a great many forms of neuralgia, although I cannot give you an account of the way in which it acts. Here, too, opium must be administered with great circumspection; for if the doses are too large, the consequence is—if I may so express myself—an extinction of the aptitudes of the stomach, a stoppage, or at least an impediment to digestion—indigestion. In administering the essential oil of turpentine, certain precautions likewise require to be observed. Above all, we must avoid the old practice of giving it in the form of emulsion ; for so administered, it will irritate the upper and least tolerant parts of the digestive canal, the pharynx and cesophagus. The best, nay let me say the only proper mode of giving turpentine is in gelatine capsules, each capsule containing fifteen or twenty drops. When thus administered, patients can take from 100 to 150 drops a day, without experiencing 116 DlAIllllilEA. any inconvenience except eructations, which, however, are less fre- quent when the medicine is given in capsules, particularly if taken immediately before a meal. It is very unusual for turpentine to occasion vomiting. To put a stop to, and also to prevent a recurrence of nervous diarrhoea, hydrotherapy and maritime hydrotherapy are beneficial, as in catarrhal diarrhoea; but my former remark must be remembered, that sea-baths are useful only when they are of short duration. It has often happened in my experience that patients who have during one season derived the benefit which I looked for from sea-bathing, have in the following year experienced no advantage from it, simply because they thought they might with impunity deviate from my prescription, to the effect, that they wrere to remain only a very short time in the water. The treatment of the fourth kind of diarrhoea—that in which the intestinal catarrh is the result of an abnormal secretion from the digestive canal and its annexes—is at once that of original catarrhal diarrhoea and of nervous diarrhoea. The inflammatory disturbance being more specially localised in the large intestine, it is necessary, independently of saline purgatives, to have recourse to topical treatment, acting directly upon the affected part. This topical medication consists in the administration of lavements. We generally take up very erroneous notions as to the way in which lavements act. When, at the anatomical table, we measure the capacity of the large intestine, it seems as' if it might quite well contain three or four litres of fluid between the anal orifice and the ileo-csecal valve. This may be perfectly possible in the dead body, because by death, the intestine has entirely lost its contractility, but it is otherwise during life, the contractility existing. Dr. Briquet, my honourable colleague of the Hopital de la Charite, has disco- vered, upon examining the bodies of persons who have died soon after taking lavements, that the 500 grammes of wrater of the lave- ment had gone as high as the caecum, and had, in some cases in which force had been employed in injecting the liquid, entered the small intestine, having forced the ileo-csecal valve. Dr. Briquet's observations show, that while lavements do not always ascend so high up in the intestinal canal, they generally do so; and the fact is im- portant, inasmuch as it proves, that we may hope to be also able to introduce as high np in the canal the different topical agents by D1ARRIKEA. 117 which we may try to modify the state of the inflamed organ. The topical agents most suitable for the attainment of this object are the neutral salts: when the affection is obstinate, caustics, such as the nitrate of silver, and the sulphate of copper are indicated; and when the catarrhal affection is associated with the herpetic diathesis lave- ments containing from five to thirty centigrammes of the sulphide of potassium or sodium will prove of great benefit, by acting upon the mucous membrane of the intestine in the same way that sul- phurous lotions act on the skin in herpetic affections. The treatment of diarrhoea arising from excess of tonicity consists almost wholly in administering opium. There is no medicine from which good results can be more easily obtained; nor is any medicine more improperly employed. This arises from our impotence being concealed by opium giving temporary relief from pain, when it pro- duces no curative effect on the malady. Herein lies an evil ten- dency against which we know not how to be on our guard : forgetful of the quidquid meditetur et faciat, si natura non obtemperat naturae non imperat, the physician believes that the disease cannot baffle him: when he is unable to put an end to it, he tries to keep it quiet, though it be only for a very short time. In general, opium is the knout most willingly employed to stifle the manifestations of the disease. But beneath the compulsory quiet induced by the opium, the disease will continue, and will be all the more dangerous, that it is so masked by narcotism that its characteristic symptoms can with great difficulty be recognised. Alarmed at the symptoms which he has been the means of setting up, the practitioner completely abandons the use of a remedy which he had not the ability to use with moderation, and so loses the very great benefit which he might have derived from its judicious employment. Opium is the most powerful remedy we possess for the form of diarrhoea now under con- sideration ; but to obtain success from it, we must know how to admi- nister it. Given in small doses it does much good, and not the least harm. In my lectures on dyspepsia, I insisted at considerable length upon this point. I said that in some cases five centigrammes of the extract were often sufficient to produce the best results in affections of the digestive apparatus. There is no medication in which it is of more importance to take into account, not only the idiosyncrasies of the patient, but also the exact time for administering the medicine. Recall to your recol- lection the two women who were patients in St. Bernard’s ward in 118 DIARRHOEA. whom a single drop of laudanum produced narcotism, not on one occasion only, but every time we renewed the treatment. In infants at the breast, half a drop taken in the twenty-four hours sometimes induces similar symptoms. The economy is most tolerant of opium when it is administered immediately after or during meals—in this sense, that it is least apt to induce drowsiness when not received by an empty stomach. Administer opium in small doses. One drop given to an adult, and one quarter of a drop to an infant, fifteen or twrenty minutes before eating, will calm the state of erythysm of the digestive canal and prevent a diarrhceal flux, which, when it comes on two or three hours after taking food, proceeds from a morbid excess in the peri- staltic movements. It is only by opium that this kind of diarrhoea can be calmed and cured. In cases in which opium alone is insufficient, it will at least assist other medicines by allowing their presence to be tolerated so as to remain longer in contact with the intestines—medicines such as the subnitrate of bismuth, chalk, nitrate of silver, and calomel, which prove beneficial by their modifying action upon the mucous membrane. When diarrhoea has as its starting point irritation localised in the lower portion of the large intestine, as is the case after a dysenteric attack, the treatment required is essentially topical. Lavements containing nitrate of silver, sulphate of copper, or better still, lave- ments consisting of a sort of hasty-pudding mixture of subnitrate of bismuth, prove of marvellous efficacy. When the contractility of the parts renders them intolerant of these remedies, laudanum will intervene most beneficially in doses of from one to fifteen drops, according to the nature of the case; it will calm excessive irritability, and so allow the lavement to be retained. I need not at present stop to discuss the diarrhoea which arises from indigestion. More interesting topics on which to address you are the diarrhoea of prematurely weaned infants, and the infantile cholera which so often accompanies premature weaning. Several such cases which we have had in our clinical wards I propose to make the subject of a special lecture. Here, I stop to-day. At our next meeting, I shall address you on chronic diarrhoea, illustrating my remarks by cases at present in our wards. 119 DIARRHCEA. CHRONIC DIARRHCEA. Diarrhoea complicated ivith Fever and Nocturnal Sweats is almost always associated with Tubercle.—Chronic Syphilitic Diarrhoea. —Herpetic Diarrhoea.—Chronic Diarrhoea depending upon Simple Chronic Catarrh of the Intesthie.—Chronic Diarrhoea, the result of Insufficiency of Food.— Treatment varies according to the Cause. —The Use of Haw Meat. Gentlemen :—In bed 27 of St. Bernard’s ward lies a woman who has suffered from diarrhoea for the last eight months. Every kind of treatment has been tried with a view to stop the intestinal flux; but it has never yet been checked for more than two days. When I saw the patient for the first time, she had very evident signs of peritonitis : the abdomen was hard and painful, giving everywhere on percussion a dull, or at least an obscure, sound. Some days before admission to the hospital, this woman had had acute bron- chitis accompanied by intense fever. The opinion I formed was that the diarrhoea depended upon chronic enteritis, complicated, as it often is, with chronic peritonitis. Upon inquiring into the previous history of the case, I ascertained that from the very first appearance of the symptoms, she had had night sweats, evening fever, and considerable wasting. I concluded that she was the subject of a tuberculous abdominal affection. I was not led to this conclusion by the obstinacy of the diarrhoea, but by the existence of nocturnal sweats and fever. The state of the respiratory organs did not present any significant indication, for although for some time past, there had been such an amount of cough as to arouse our fears, repeated and very careful examination by auscultation and percussion did not reveal the slightest pulmonary hepatisation. Mucous r&les, characteristic of bronchitis, were heard disseminated throughout the whole chest. It was, then, the coincidence of night sweats and fever with diarrhoea and peritonitis which led me to the conclusion that the patient was under the influence of the tuberculous diathesis. In forming my diagnosis, I was relying, so to speak, upon the long and valuable experience of Chomel. How often has my lamented predecessor repeated to crowded audiences in this place, that chronic diarrhoea accompanied by fever and night sweats is an almost certain sign of 120 DIARRHOEA. tuberculisation, a proposition which I have had many opportunities of verifying in the course of my medical career. An additional confirmation of the proposition is afforded by the case now before us: the patient has succumbed after languishing about six weeks in hospital. At the autopsy we found tubercular deposit on the surface of the peritoneum, and in the lymphatic glands of the mesentery. Tubercular matter wras also found upon the pleurae and in the bronchial glands; but, strange to say, no trace of tubercle existed in the parenchyma of the lungs. This then is an additional case to add to those exceedingly rare cases which con- stitute exceptions to the famous law formulated by Louis, to the effect that whenever tubercle is found in one viscus, it will also be in- variably found in the lungs. Here, however, I must remark that this rule, though generally true in respect of adults, is not applicable to children. In them, it is exceedingly common to meet with tubercular lesions of the encephalon, abdomen, and even of the bronchial glands, without finding any in the lungs. We have at present, in the same ward, in bed 28, another patient suffering from chronic diarrhoea. In her, the symptoms date back six months. From that time, she began to lose strength, and visibly to grow thin. Her breathing was oppressed; and she became winded on the least over-exertion: she had nocturnal sweats; and every morning (about seven o’clock) a paroxysm of fever, setting in with rigors. At the time of my visit, the fever still existed. I observed in this patient a peculiar formation of the fingers and finger-nails: the nails, particularly of the thumbs, were beginning to grow inwards. You are aware of the value which Hippocrates attached to this sign : in his second book Be Morbis, he says :—“ Quum quis tabescit, ungues contrahuntur” I think that this patient is affected with chronic tuberculous diarrhoea. Although auscultation does not enable us to detect any sign of pulmonary disease, I am convinced that this woman is phthisical; and I certainly believe that, although we may not be able to find any thoracic lesions, there exist abdominal lesions similar to those detected in the other case of which I have just given you the history. However decided my convictions as now stated were in this case, they have not caused me to lose courage: I have striven, and I shall still strive, to subdue the symptoms, hoping to moderate, should I fail to cure them. My aim, first of all, has been to put an end to the quotidian DIARRHOEA.. 121 fever. In giving cinchona, however, I have been well aware that the paroxysms of fever were not those over which that wonderful medicine exercises an influence. I knew very well that the fevers which respond to the cinchona treatment are seldom quotidian and are generally diurnal—that intermittent night fevers being generally symptomatic resist antiperiodic remedies. I nevertheless tried the sulphate of quinine; and I gave it in high doses. This treatment did not modify the fever, which unfailingly returned every night notwithstanding scrupulous exactitude in administering the sulphate of quinine. But to my extreme surprise, the diarrhoea entirely stopped for more than a month. The patient at the same time regained appetite, strength, and even a certain degree of plumpness. Digestion, nevertheless, remaining somewhat painful, slow, and laborious, accompanied, likewise, by weight in the stomach after eating, you saw me prescribe hydrochloric acid, after having in vain employed alcalies. This woman took daily, at the beginning of her breakfast and dinner, three drops of the acid according to the plan which I described to you when lecturing on dyspepsia. The digestion became easier in consequence of this treatment. Nevertheless, though her state is improved, my un- favourable opinion of her case remains unchanged, because the fever and night sweats continue. Sooner or later, this patient will sink from pulmonary phthisis. In the bed next to that which she occupies—in bed 22—there died, a short time previously, a poor woman who also wTas exhausted by an obstinate diarrhoea of two years' duration. In this case, however, the intestinal flux had no relation to any such causes as those which existed in the other two patients. When she came into hospital, she was exceedingly emaciated, and so anaemic that the first question I addressed to her was an inquiry as to whether she had profuse uterine discharge. The extreme paleness of the in- teguments, and the bellows-murmur in the vessels warranted my suspicions. They were really, however, unfounded. In this case, I set aside the idea of tuberculous diathesis, because fever and sweating were absent, and the state of the respiratory organs was good. The history obtained was sufficiently ample to enable me to explain the symptoms. The patient stated that two years ago she was living in Champagne, when she was obliged, by the pressure of poverty, to seek a home elsewhere. Accompanied by her husband and one child, the sole survivor of six, she came 122 to Paris to seek a subsistence. In this attempt she failed, and in place of obtaining the hoped for relief, she got involved in still deeper misery. Her husband fell ill: she, he, and the child had nothing to eat save the ration of bread allowed by public charity. This state of matters has continued for two years; and consequently, for the last two years, this poor creature has been wasting for lack of sufficient food. The diarrhoea then, in her case, arose in the same way that we see it occur in animals allowed to die from inanition. It might be supposed that restorative diet, substantial alimentation, would have put an end to the symptoms. Unfortunately, the problem which had to be solved was not by any means so simple. A result had occurred such as that which happens in all similar circumstances. Deficient aliment had produced impoverishment of the blood. In its turn the impoverishment of the blood had caused alteration of the gastric, intestinal, hepatic, and pancreatic secretions, so that digestion was imperfect, even when the food was highly nutritive and of faultless quality. We were evidently shut up within a vicious circle. It was neces- sary that we should feed the patient, but the food, however good it was, caused a succession of attacks of indigestion. Not only was the diarrhoea persistent, but taking the smallest quantity of food, caused vomiting. I tried to assist nature by sometimes giving hydrichloric acid, and at other times opium by itself, or in conjunc- tion with astringents : I likewise administered ferruginous remedies and alcalies: in a word, I put in requisition many modes of treat- ment. My efforts, however, were unsuccessful: ere long, hectic fever wras kindled, and the patient died. At the autopsy, no appreciable organic lesions were found, except some small superficial erosions in the large intestine. The spleen, liver, and lungs presented nothing abnormal except a pale appearance. Such of you as have been attending my hospital visits for some time past will remember the history of a young woman long resident in our wards, whose case—interesting for several reasons— has been recorded by Drs. L. Gros and Lancereaux.1 I refer to the woman who latterly occupied bed 34 of St. Bernard's ward. DIARRHCEA. 1 Guos et Lancekeaux :—Des Affections Nerveuses Sypliilitiques. Paris, 1861. DIARRHOEA. 123 I am not going to narrate the case in all its details. I will only remind you that the patient came into hospital for an obstinate diarrhoea which lasted thirteen months, was complicated with lientery, gastralgia, and vomiting; and which, after resisting many medicines, ultimately yielded to mercurial treatment. This woman's diarrhoea, the cause of which I was long in discovering, was the first, I may say the only manifestation of constitutional syphilis; and if we may believe the patient’s statements, the venereal taint had not been in- dicated otherwise than by the appearance, two months previously, of a greenish vaginal discharge and acute pain in making water. I was led at last to the correct view of the case by the patient suffering from pains in her head, notably aggravated at night, principally osteoscopic and seated in the course of the membranes; by her having tumours over both tibim, then over the right radius, and a little later over the left humerus; finally, a gumma [r/omme], which ulcerated, on the calf of the right leg, placed beyond question the accuracy of the diagnosis. The diarrhoea, I say, yielded to mercurial treatment. Yan Swieten’s liquor, which I first tried for twelve days, and other mer- curials afterwards administered internally, were not supported: sublimate baths were consecjuently resorted to, and under their influ- ence all the symptoms rapidly yielded. After a residence of twenty- three months, the patient went out completely cured. I have been desirous, Gentlemen, to lay these facts before you in juxtaposition with each other, that I might once more show you how different, according to the nature of the case, is the diagnosis, prognosis, and treatment of a phenomenon the signification of which appears, when looked at by itself, to be identical. It appears, then, that chronic diarrhoea, whether dependent upon intestinal catarrh, or on a more deeply-seated phlegmasia, may result from very different pathological conditions, In the first two cases which I cited, the intestinal flux evidently proceeded from the tuberculous diathesis: the recurrence of the fever and nocturnal sweats every twenty-four hours, and their resistance of all treatment, led me to that conclusion. Unfortunately, in respect of the patient of bed 27, the autopsy confirmed the accuracy of my opinion. Though anatomical proof is wanting in respect of the patient of bed 23, the law laid down by Professor Chomel is of too general an application to permit us to hope that we have to do with an exception to it. 124 DIARRHOEA. This is a point which you must constantly bear in mind. When— particularly in persons about the age of puberty—you have to treat a case of chronic diarrhoea complicated with fever and night sweats, be reserved in announcing your diagnosis. Do not expect to master the malady too easily ; and if you succeed in moderating or modifying it, do not count on the amelioration being of very long duration. Beware of exciting in the relatives hopes in which you cannot participate. Generally, indeed I might say always, in such cases, there exists the tuberculous diathesis; sooner or later, it will explode, and the patients will succumb. Foreseeing the danger, you will not be exposed to annoying mistakes. When you have exhausted all the resources of your therapeutic arsenal, you will not be surprised at having failed to subdue a disease which from its nature is incurable. The case of our patient of bed 34 is an example of the rare exceptions to Chomel’s law which I have referred to as being occasionally met with. During the first period of this young woman’s stay in hospital, I observed that she had an intermittent fever of quotidian type, which led me to think that the diarrhoea might be dependent on the tuberculous diathesis. Although I examined the chest daily with some care, I was unable to detect any sign of pulmonary solidification: and there was neither cough nor expectoration. The fever soon assumed a well-marked tertian type, a circumstance which was in itself sufficient to exclude the suppo- sition that the tuberculous diathesis existed; symptoms which showed themselves at a later date dispelled all my doubts, and inspired the hope that we should soon cure a diarrhoea which was symptomatic of a malady usually very amenable to treatment. Mercurials fulfilled the therapeutic indication, just as sulphurous and arsenical preparations would have fulfilled it had the intestinal flux been dependent upon a herpetic diathesis. The chronic diarrhoea with which the patient of bed 23 was tor- mented being independent of diathesis, we should have been justified in hoping for recovery, had not the symptoms dated back two years, and had we not had to do with an utterly broken down constitution which made no response to any dietetic or medicinal treatment which was tried. The unfortunate woman, from the long period which her alimentation had been insufficient, was exactly in the position of an animal perishing from inanition. The blood being deprived of the materials required for its renovation, the intestinal secretions were DIARRHOEA. 125 vitiated, and the digestive functions exhausted, so that we could not count on treatment which, under apparently similar circumstances, is unquestionably useful—that is to say, in chronic diarrhoea uncon- nected with organic lesion, such for instance as occurs in the con- valescence from serious and protracted maladies. The treatment to which I refer consists in nourishing the patients with mincedraiv meat. When I come to treat of the diarrhoea of infants at the period of weaning, I shall revert more in detail to this plan of treatment, which may appear strange to such of you as have not seen me employ it. Fifteen or twenty years ago, I was summoned to a lady of 23 or 24 years of age who had been suffering for six months from an intractable diarrhoea. I was one of four physicians called to this con- sultation. After a careful examination of the patient, and a most minute inquiry into all the circumstances, we entered upon our deliberations. I cannot now recall the conditions under which the diarrhoea had supervened : I only recollect that from the long con- tinuance of the diarrhoea, we suspected the existence of the tuberculous diathesis. However, the general aspect of the patient, her antece- dents, the absence of fever and of all symptoms characteristic of phthisis, caused us to reject the tuberculous hypothesis, and to consider the diarrhoea as a local affection, the result of chronic irritation of the intestinal mucous membrane. All the methods of treatment usually adopted in similar cases had been tried; and they had all completely failed. When each of my brethren had stated the treat- ment which he recommended, I gave my opinion as to the plan which ought to be adopted. I stated that the resources of pharmacy had been exhausted, that not only could no good be obtained from the farther trial of drugs, but that I looked on pharmaceutical interven- tion as mischievous. It would, therefore, I argued, be necessary to rely entirely upon dietetic treatment. My brethren replied that regimen had been tried in every form, without the least impression having been made on the disease, that the patient had a great disgust for every kind of food, and that every kind of aliment was at once rejected by the stomach. I then proposed the use of raw meat. My proposal was received with sceptical derision; but I was not dismayed, and maintaining my opinion, supported by a case in which the raw meat system had proved wonderfully successful, I begged that it might be tried. The ordinary physician of the family, though equally sceptical with the other two as to the attainment of that success which I hoped for, consented to make the experiment. It 126 DIARRHCEA. then became necessary to induce the patient to accept the proposed treatment; and this, it was thought, might not be easily accom- plished. Are not the individuals few in number who wrnuld at once take to such a diet, though in point of fact the repugnance to it is nothing more than the result of habit ? Consider the question, and ask wherein lies the difference between cooked meat and raw meat ? Be that difference what it may, it is the result of habit; and-we all know that habit is a second nature difficult to change. I went to our patient and asked her whether she would have any objection to eat the under side of sirloip of beef ie under done ” [ filet de bceuf peu cuif\. She replied that she would willingly take it. I then gave my instructions to the cook, telling her to place the meat before a very strong fire for a few minutes, just long enough for the outer layer to be acted on by the heat, the interior remaining absolutely raw. Farther, I directed that before serving the meat so treated, its most cooked part should be removed, the remainder only being minced for the patient’s use. All this was done in accordance with my directions; and on the first day, the lady ate and perfectly digested two slices of raw meat. Next day, she ate three slices: she then took four slices, and at last took a tolerably large daily portion. In less than two weeks, the diarrhoea had ceased, and complete re-estab- lishment of health had taken place. The great advantage of this treatment consists in its at once reconstituting the mass of the blood, so fitting it to fulfil all its functions. In this case, there was no relapse. My stratagem succeeded to the utmost of my wishes. When this stratagem fails me, there is another to which I am in the habit of having recourse. I give the raw meat under the name of “ conserve de Damas.’n Why this name ? I confess that I should be greatly puzzled were I to try to answer the question. In fact, I adopted the name which first suggested itself. The conserve de Damas is simply raw meat reduced to a pulp, and mixed with currant jelly or conserve of roses. When I prescribe it, I take care to give notice to the apothecary of what I intend him to give. You can quite understand that remedies of this description can hardly be in- troduced into the pharmacopeia. An uninitiated person never recognises raw meat in this disguised form, and therefore generally takes it without the least repugnance. 1 Reveil :—Formulaire Raisonne des Medicaments Nouveaux, et des Me- dications Nouvelles. 2nd edition, p. 69. Paris, 1865. DIARIU1CEA. 127 It seems extraordinary that stomachs and intestines incapable of bearing or digesting even the lightest kinds of food should so soon become accustomed to aliment of so strong a description. Bear in mind what I said in relation to this point when I was lecturing on dyspepsia. When a patient complains of disordered digestion, our first idea is to put him on a diet easy of digestion. In certain cases, how can this be done ? Food easily digested by some patients is not easily digested by others for whom it is prescribed; and the conclu- sion naturally arrived at is, that a diet still more rigidly plain must be tried. The patient, however, grows weaker, his dyspepsia increases, and his diarrhoea continues : all the consequences of inanition supervene, the blood becomes impoverished, the secretions of the digestive organs become altered; and to avoid one evil, a greater evil is fallen into. Ten years ago, a very busy and very skilful Parisian physician—a great worker—became dyspeptic. In consequence of a chill, he was attacked with gastric symptoms, which, in the first instance, he successfully combated by restricting his diet. Whenever he resumed his usual regimen, he felt pains which made him return to more moderate fare: he was satisfied to live on beef tea and diluted milk. Under this system of feeding, he soon fell into a state of great debility; fever lighted up, and vomiting supervened. He consulted Chomel, who suspected cancer of the stomach, with- out discovering, however, any material signs of this disease. Chomel advised the patient to continue the regimen which he had adopted. I was next consulted : I concurred in Chomel's view of the case, though as unable as he had been to discover any distinctive signs of cancer. However, upon obtaining additional information regarding the previous history of the case, it appeared to me that there was some ground for attributing the symptoms to inanition; and I therefore recommended more substantial nutriment. I urged my suffering brother to take a basin of meat soup: this he did in obedience to my wishes, but as he felt the pains more severe on the following day, he lost heart, and resigned himself to die. I endea- voured to give him hope, and at the same time urged him to pursue the dietetic course which I had recommended. “ You have,” said I, “ the melancholy conviction that you are a hopelessly doomed man : very well, then, having realised the worst, confide your case to me, and let me do what I please. As a favour to me, I ask you 128 DI Alt MICE A. to eat, from this day, the wing of a partridge very slightly cooked.” He granted my prayer, without however counting on obtaining the benefit which I promised, him from his compliance. To his great astonishment, three hours after his repast, digestion was accom- plished, and he felt revived; next day, he took double the quantity of aliment, eating two wings of partridge. On the following day, he felt a return of strength. He now became hopeful of recovery, rejecting the idea of cancer, and taking the same view of his disease as I took. He was soon quite well, and he has ever since remained well. My honourable brother is now in the enjoyment of the same excel- lent health which he used to enjoy, and he pursues his professional avocations with very great talent and admirable devotion. Gentlemen, this case shows you that it is frequently impossible to know a priori the food which will agree best with a patient. Many persons will digest pork and ham whose stomachs cannot bear a light panada. Do not interrogate me as to the wherefore of these singular diversities, for I know nothing about idiosyncrasies and special aptitudes of digestion. The physician cannot lay down for himself fixed rules whereby to regulate his dietetic prescrip- tions : he must feel his way by experimental trials, which will occa- sion neither danger nor inconvenience if judiciously directed. It is important not to forget the necessity of varying the nature of the alimentation. When a patient continues for more than five or six days to live upon the same kind of food, he is apt to loathe it : his stomach is wearied with it, and the symptoms reappear. It is then supposed that the treatment instituted is unsuitable, where- upon the new direction is abandoned, and the patient is allowed to fall into the old rut whence he had emerged. Again I repeat, that I have obtained real service in certain forms of apyretic chronic diarrhoea from giving minced raw meat. Alone, I have often found it sufficient to accomplish a cure; but frequently, it has also been necessary concurrently to have recourse to agents of the materia raedica. Occasionally, under certain circumstances, it is necessary to give very small doses of laudanum before meals: occasionally also, alcalies are useful, and at other times, bitters or tonics are of service. Nux vomica and its substitutes take the first place as tonic remedies in many cases. There are other such cases, again, in which ferruginous medicines are indicated; as, for example, when the diarrhoea is complicated with great anaemia—wdiether this DIARRHOEA. 129 be produced by the profuse intestinal flux, or by an impoverished state of the blood, and consequent debility, as is frequently the case in young subjects. In this class of cases, in addition to the characteristic paleness of the integuments, and the great emaciation which accompany the diarrhoea, there sometimes occur sanguineous exudations into the subcutaneous cellular tissue, and there are seen, more or less dis- seminated over the body, ecchymotic spots. Another very common symptom is oedema of the lower extremities, and even a state of pretty general anasarca; but these dropsical symptoms are unaccom- panied by albuminuria. Cinchona, bitters, and in a special manner ferruginous medicines will powerfully aid a tonic regimen. When iron cannot be borne internally—a not unusual occurrence—prescribe ferruginous baths, each bath containing 500 grammes of the sulphate of iron. In obstinate chronic diarrhoea, you will also find hydrotherapy and certain natural mineral waters very useful: you will likewise obtain specially beneficial results from sea-bathing and maritime hydrotherapy. I must not conclude my remarks on chronic diarrhoea without saying two words upon the good effects of saline purgatives. How often, for example, have you seen me persist with a sort of obstinacy in the use of Glauber salts. Gentlemen, this is a very important method of treatment. I begin by giving not more than 10 grammes of the salt dissolved in a very small quantity of water, and I recommend the patients not to drink for some time after taking the medicine. On the following day, I do not administer more than 5 grammes; and on each succeeding day, for a fortnight, I repeat this dose. If (as is usually the case) the diarrhoea cease, I only give the remedy once in two days, always selecting as the time of administration, the morning before taking food. Should the patients feel great repugnance to the medicine dissolved in wrater, it may be given enclosed in wafer paper. Rhubarb in very small doses—say from 10 to 15 centigrammes— administered in the morning before taking food, is sometimes exceed- ingly useful. Lastly, let me recommend to you a combination of remedies which you often see me prescribe in the wards. I prescribe pills, in each of which there are two centigrammes of ipecacuan, half a centigramme of calomel, and half a centigramme of extract of opium: one of DIARlttf CEA. these pills is taken morning and evening for five days. I then return to the saline purgatives or rhubarb : and afterwards, I again resume the pills of ipecacuan, calomel, and opium. I’or two or three months, I pursue this routine of treatment, interrupting it, how- ever, occasionally, and always paying great attention to the regimen of the patients. LECTURE LXXII. INFANTILE CHOLERA :-DIARRII(EA OE CHILDREN. Infantile Cholera is different from Asiatic Cholera-Morins.— Conditions under which it is developed: influence of Season.— Particularly occurs at the period of Weaning.—Symptoms.— Prognosis.—Treatment.—Diarrhoea of Weaning Infants treated by Raw Meat. Gentlemen :—Some days ago, when we were getting into the very hot weather, I said that most probably we should not be long without seeing cases of the disease which in France is called “ cholera infantilef and which American physicians have described under the name of “ summer disease.” My anticipations have been only too completely realised. The day before yesterday, a child who occupied bed 13 of our Nursery ward died, after having suffered for a short time from this disease. I accept the name “ cholera infantile ” because its use has been ratified by long custom, and because I am opposed to the introduc- tion of new names, when the old ones are familiar and well under- stood. Were it not for these reasons, I should prefer to call the disease by its American name, because I think it is much more appropriate. Infantile cholera is essentially different from cholera-morbus, though the latter does not spare very young children. The influence of season, which in America has given this affection the name of the “ summer disease,” would appear to be its prin- cipal cause, irrespective of that which belongs to the individual. From the earliest ages, this disease has been observed : during the hot season, it appears every year in every country. Cholera-morbus, which did not make its appearance in Europe till less than fifty years ago, only returns at certain epochs, and its advent is irrespective of season : while it ravages numerous localities it does so, not simultaneously but in succession like epidemics, its INFANTILE CHOLERA—DIARRHOEA OF CHILDREN cause being as yet unknown. In these respects, the two diseases present fundamental distinctions; and they do not the less differ from one another in respect of the symptoms by which they are respectively characterised. Asiatic cholera-morbus, both in children and in adults, has special features, which we all know how to distinguish from those of cholera nostras.1 The two kinds of cholera, no doubt, have some symptoms in common, which, if considered separately, might lead us into confusion; but there is something specially distinctive in the aspect of the patient, in the appearance of the tissues, in the changes which take place in the temperature of the skin, in the aggregate of the general phenomena, and in the respective course and gravity of the symptoms. The same sort of comparison may be instituted between these two diseases which may be made between many others. In the same sort of way, we might compare influenza with bronchitis or simple catarrh; and dysentery with acute colitis. Amid the simi- larities which these affections present, they show dissimilarities still greater, so that it is impossible to confound them with each other. The points of dissimilarity are so well marked, so clearly defined, that they evidently bear the stamp of specificity. To follow out the same illustrations which I have already used—- simple bronchitis is, at least generally, a mild and transient affec- tion, but when this bronchitis, the result of a cause which we cannot detect, prevails as an epidemic, that is to say, when it is influenza, it assumes an entirely different character in respect of severity and inveteracy. Who does not know, that under these circumstances the intensity of the evil, the high fever, the pains in the back and chest, the general feelings of discomfort and prostration, in a word, all the general symptoms consequent upon an attack of influenza, bear only a slight resemblance to those observed in bronchitis, even in an attack of the most violent character P Similar remarks are applicable to acute sporadic colitis, and epidemic colitis which takes the name of dysentery. In both, the large in- testine is the seat of the characteristic lesion: in both, the stools are composed of bloody, glairy secretions. In sporadic colitis, however, 1 See the Article on Cholera Asiatique, by Dcsnos—Article on Cholera Nostras, by Gombault—and Article on Cholera Infantile, by P. Loraiu :— in 7th volume of Nouveau Dictionnaire de Medicine et de Chirurcjie Pratiques, published at Paris in 1867. INFANTILE CHOLERA DIARRIKEA OF CHILDREN. 133 the intestinal disturbance is transient, the accompanying pain and tenesmus are slight, and the fever is moderate: notwithstanding the local symptoms, the general state of the economy is good. In dysentery, while the severity of the local inflammation, generally so intense as to produce some amount of mortification, may to a certain extent account for the severity of the general symptoms, it is, on the other hand, not uncommon for the symptoms to assume a cha- racter more formidable than those of acute sporadic colitis, even when the local lesions are insufficient to explain the profound disturbance of the whole system. In a word, if influenza and dysentery are inflammatory diseases, they are inflammations nosologically the same—the one belonging to the genus bronchitis, and the other to the genus colitis; but this epidemic bronchitis differs as much from whooping-cough, and this epidemic colitis differs as much from common catarrh of the large intestine, as the natural history of one animal or vegetable species differs from another animal or vegetable species of the same genus. When we read the description left us by Sydenham of cholera as observed by him, and as we find it described by authors who wrote at the beginning of this century, bearing in mind at the same time the symptoms presented by epidemic cholera in 1832, we at once perceive the greatness of the difference between the cholera described by Sydenham and the Asiatic cholera-morbus which ravaged Paris in the year just named, which same disease has since reappeared here at several subsequent epochs, and has also desolated many depart- ments of Prance and many foreign countries. Having already sketched in a few words, the great differential features of these two diseases,I now proceed to consider the subject more immediately before us—infantile cholera. It is when infants are being weaned, that they are most liable to this disease. Not a day passes in which I do not call your attention to this important fact at the bed side of patients in our Nursery ward: I am constantly telling you, that it is whilst infants are being weaned that they are most exposed to serious disorders of the alimen- tary canal. During the period of lactation, so long as they live upon the natural aliment supplied by the nurse, there is seldom much reason to fear such affections; but should the weaning be badly managed—even if the infants are as old as fourteen, fifteen, or sixteen months—should they be suddenly deprived of the maternal milk, without the observance of certain rules (which I shall point out to INFANTILE CHOLERA DIARRHCEA OF CHILDREN. you), indigestion will be caused and maintained, which will lead to diarrhoea, and this diarrhoea again, under certain circumstances,-will become the starting point of infantile cholera. The disease usually manifests itself suddenly, and is announced by symptoms of which I shall now give you a rapid sketch. The physiognomy of the child rapidly changes. On looking at him, you are at once struck with the very sunken appearance of the eyes, and with a bluish line encircling the lower eyelids. You hear the child uttering incessant cries, often as if being suffocated; for (as in Asiatic cholera) the pitch of the voice is altered, although it be true that the degree in which this alteration takes place is not great. The skin is cold. These phenomena having occurred abruptly, have very naturally alarmed the family, who ‘on the evening before they showed themselves, or perhaps immediately before their appear- ance, were but little alarmed at the diarrhoea. Vomiting previously absent, or existing only in a slight degree, has nowr become an exceedingly urgent symptom. The little patient vomits all fluids which we try to get him to take. He is, however, tormented by burning thirst, as is indicated by his cries,his impatience, and his alternately opening and shutting the lips, as if for the purpose of sucking in cool air. If a spoon or tumbler be placed near his mouth, he will raise his head, however great his debility, and with voracity clutch it, that he may swallow the liquid presented to him. The matter vomited is bilious and green. The stools are no longer licnteric; but consist of a greenish serosity, in which floats a substance resembling chopped spinage or sorrel, and which is found deposited upon the swaddling-clothes; or sometimes, the stools (very liquid) have a slightly yellow, yolk-of-egg, tint. They are always absolutely serous, but never have that appearance of rice-water, so characteristic of the stools in Asiatic cholera-morbus. The abdomen is usually sunk in : its skin is soft and flaccid, and when pressed between the fingers, it retains for several minutes the fold which has been made. This want of tonicity in the skin is found everywhere, both in the extremities and trunk of the body. Sometimes the collapsed condition of the body follows tympanites ; but tympanites, an unfavourable symptom, is never so great as in the subsequent stage of the disease. The pulse becomes exceedingly rapid, and the temperature goes on falling; the extremities, nose, chin, and tongue become as cold as in Asiatic cholera-morbus, with INFANTILE CHOLERA DIARRHOEA OF CHILDREN. 135 this difference, however, that there is very little cyanosis, and very seldom viscid sweat, in infantile cholera. On the contrary, the skin remains dry, and it is only the nails which acquire a bluish colour. The countenance has a leaden hue, but not that peculiar colour which is presented in cholera-morbus: the features are notably drawn and obliterated. Too frequently death takes place in the first stage, indeed very soon after the invasion of the .disease. If the child resist death for a longer period, other phenomena show themselves. Yomiting then seems to recur more frequently, while it very often happens that the diarrhoea stops at the same time. Then, also, the tympanitic distension of the abdomen becomes great. A notable elevation in the temperature of the skin succeeds the fall of temperature of which I have just spoken: the skin at the same time regains its tonicity to such a degree that the folds made by pinching it do not remain, as was formerly the case. The tongue is red and dry ; the eyes are injected. Infantile cholera now begins to enter into a new stage—the typhic stage, which though analogous to the typhic stage of Asiatic cholera-morbus, differs from it in several characteristic particulars. Sometimes, simultaneously with a cessation of the vomiting, the diarrhoeal stools reappear. They have a bilious colour, more or less decided, and sometimes they bear a strong resemblance to the evacuations in epidemic dysentery from their glairy, sanguinolent, and at times even purulent appearance. Then, the tympanitic dis- tension of the abdomen diminishes a little, but does not disappear. During the continuance of these symptoms, the child falls into a stupor. This state of stupor, combined with the injected, up- turned eyes, give the child the aspect of a patient affected by cerebral fever: appearances are the more calculated to mislead from the patient occasionally uttering that plaintive cry heard in hydroce- phalus, and which may occur in the tache cerebrate as well as in ence- phalo-meningitis. I have stated that infantile cholera sometimes proves rapidly fatal to children. If the cold stage continue for more than twenty- four or twenty-six hours, death is almost invariably the issue. "When there is a sensible diminution in the evacuations, life is prolonged; and the typhic stage may last for three, six, or even eight days. However serious the prognosis may be in this disease, which 136 INFANTILE CHOLERA—DI ARTIFICE A OF CHILDREN. every year snatches numerous victims, there is always a hope that the child will recover, if placed in favourable hygienical conditions, and treatment be steadily carried out such as I am now going to describe. The most important prescription is rigidly low diet: as suitable drinks, we ought to order the decoction of barley or rice, and the eau albumineuse, which is made by diluting the white of four eggs with a litre of water: this albuminous water is sweetened to taste by adding sugar, and aromatised with orange-flower water. I look upon the mustard bath as the most powerful medication in infantile cholera, when the disease is in its first stage. Into a bath containing twenty-five litres of water, we put fifty grammes of flour of mustard formed into a porridgy paste with cold water, and enclosed in a little linen bag, just as is done in preparing a bran bath. By squeezing the bag, a strongly sinapised water is obtained. Observe that the mustard paste is to be made with cold water: the use of hot water, in place of promoting, prevents the extraction of the essential oil, which is the active principle of mustard. It would be a similar mistake to use vinegar, with the view of producing a stronger sinapism. The little patient is immersed in this bath for twelve or fifteen minutes, a time required to obtain reaction, which comes slowly, from the state of the skin. The child is then wrapped up in very dry linen : and the same treatment is repeated two, three, or four times during the day. The proper duration of the immersion can be estimated by the person who supports the child in the bath. The nurse ought to be told, that as soon as she feels her immersed arms smarting with heat, the child must be taken out of the bath. Gentlemen, in connection with the mustard bath, allow me inci- dentally to direct your attention to the remarkable effects which you have seen it produce on more than one occasion in women in St. Bernard’s ward, for whom I prescribed it in many very diverse circumstances, a subject regarding which I shall probably have to speak to you on some future day. You, no doubt, have been surprised, as I myself have been, to hear patients complain, that some minutes after immersion in the sinapised water, they have experienced an exceedingly painful sensa- tion of cold. It seemed to them, they have said, as if they were in freezing water, the ice on the top of which had been broken; and (to use their own comparison), they felt as if cut in two by the cold. 137 INFANTILE CHOLERA DIARRHOEA OF CHILDREN. If we are present when such patients get their bath, we will observe that they shiver with cold, that the cutaneous surface becomes intensely red, and assumes the appearance called goose-skin. So severe is the feeling of cold, that some of our female patients beg to be taken out of the water before the lapse of the prescribed time; and they even continue to shiver for some minutes after they have been replaced in bed, well wrapped up in woollen blankets. Reaction, however, is not long in being established ; and the icy coldness is soon succeeded by a notable elevation of temperature. Having made this statement, I now resume my remarks on the treatment of infantile cholera. In the first period of the disease, the sinapised bath is, I repeat, one of the most powerful medications— perhaps the most powerful medication—with which I am acquainted. Concurrently with it, however, you require to employ other remedial measures. You will, in the first instance, have recourse to ipecacuan. To a child between one and two years of age, administer from 30 to 40 centigrammes in the 24 hours, divided into two or three doses. This, Gentlemen, you will find is a new application of the substitutive method, the good effects of which in affections of the digestive organs, I have already pointed out. Next come diffusible stimulants. Ether, in the form of syrup, is the most convenient preparation to employ. It may be given in dessert-spoonfuls every hour or every half-hour; and, in fact, as it contains only a small proportion of ether, the patient may take from too to 200 grammes of it, without any inconvenience, during the 24 hours. You, at the same time, prescribe the distilled waters of mint and balm-mint; and, as a tisane, you order the “ decoction blanche” of Sydenham, or, better still, the “eau albumineuse.,n In the cold stage of infantile cholera, purgatives, as well as emetics 1 The “white decoction” of Sydenham is a remedy much used in France for chronic diarrhoea. It is prepared by adding the following ingredients to tcoo grammes of water :— Calcined hartshorn, 8 grammes ; Crum of white wheaten bread, 24 grammes; Gum Arabic, 8 grammes; Simple syrup, 60 grammes ; and Distilled cinnamon water, 8 grammes. The albuminous water is described in the preceding page—Translator. INFANTILE CHOLERA DIARRIKEA OF CHILDREN. are indicated. The purgative which I prefer before all others is the hydrargyrum cum cretd, a remedy of which I have formerly spoken, one greatly esteemed on the other side of the Channel, but which is too little used in Trance. This medicine (which is mercury killed in chalk) administered in doses of from five to ten centigrammes, gene- rally stops the vomiting, wrhile it also modifies the character, and diminishes the quantity of the stools. Along with these useful remedies, there is another—opium—of which I have already spoken as a medicine which there is a great temptation to use imprudently. This is a point on which I have already stated to you my views : I cannot express myself too strongly against this agent: I repeat, that I am not acquainted with one more disastrous in its effects, nor more frequently and more im- prudently employed. I often see it prescribed in doses so large, that if they were not in great part vomited, the patient would inevitably be poisoned. Recollect the statement I made in a previous lecture: I told you that a single drop of laudanum suffices to throw a year-old infant into a stupor which may last for forty-eight hours; and nevertheless we find that five, six, seven, or eight drops are fearlessly given in potion or lavement. Opium is largely given in the form of syrup; and when there exists timidity in giving that preparation, none is experienced in administering the syrup of white poppy, 30 grammes of which contain 30 centigrammes of the extract of poppy, which, though supposed to be a very harmless dose, frequently acts more energetically than five centigrammes of extract of Smyrna or Con- stantinople opium. Syrup of lactucarium is also prescribed, the action of which is dependent on the quantity of opium it contains. But perhaps there is no opiated medication so dangerous as a lavement of decoction of poppy heads. This preparation, generally looked upon as harmless, and constantly being given without medical advice to very young infants, is one of the most treacherous which can be used, in consequence of the variable amount of the quantities of the active narcotic principles contained in the head of a poppv. Not a year passes in which we have not deaths to register from the improper use of this medicine. The best method—in my opinion the only proper method—of administering opium, particularly if the patient be a child, is to give Sydenham's laudanum, the doses of which it is easy to graduate. We INFANTILE CHOLERA DIARRHOEA OF CHILDREN. may begin with a quarter of a drop or half a drop, progressively in- creasing the quantity, according to the observations we make on the susceptibility of the individual patient. Thus acting, we may proceed in all security, because we know what we are doing. This is an absolute rule which must never be deviated from. I have already formulated it to you many times: nevertheless, I again insist on it to-day, for its importance is so great that it cannot be too earnestly proclaimed. In the disease, now specially before us—in infantile cholera— opium in every form ought to be rigorously avoided. Though, in some cases, it put a stop to the vomiting, it too rapidly leads to the typhic stage, which is most to be dreaded w'hen it comes on early in the course of the disease, exactly as in Asiatic cholera. Mustard baths, emetics, diffusible stimulants, and mercurial purgatives, are the most important remedies in the cold stage of infantile cholera. By their use, we may obtain very successful results; and when we cannot arrest the progress of the disease by employing them, we may at least prolong the patient's life, and so enable him slowly to pass without drawback into the second stage, during which there is an increased chance of recovery. In the second period, the indications are to continue the albu- minous and feculent drinks, and to use mild laxatives, such as the neutral salts, but particularly calomel in very small doses. "When vomiting has ceased, and the diarrhoea is quite established, we administer levigated chalk, trisnitrate of bismuth, and lime water. The cold bath is a very useful means of subduing nervous symptoms. Should the diarrhoea persist, recourse must be had to nitrate of silver: in potion, the dose is one centigramme—in lavement, from 5 to 25 centigrammes, dissolved in from 60 to 100 grammes of distilled water. You must, however, remember, that the cases in which recovery takes place are few in number, death being the usual termination of infantile cholera, particularly when it attacks children prematurely weaned. We augment the chances of recovery in such cases by providing a good wret-nurse. Do not suppose that although a child has been a long time without taking the breast, it will be impossible to induce him to resume it. No doubt, the longer the period which has elapsed since an infant has discontinued the habit of sucking, INFANTILE CHOLERA—DIARRHOEA OF CHILDREN. the more difficult will it be to get him to begin again to take the breast: but with patience and perseverance the object may be attained, even after three, four, or five weeks have passed without sucking. The younger the weaned infant, the more readily will he be induced to resume sucking, because his actions are more the result of instinct than manifestations of volition. The most serious consequence resulting from premature weaning is infantile cholera. It is something more than an excessive intestinal catarrh proceeding from enteritis caused by continuous indigestion in itself sufficient to determine a vicious alimentation, out of harmony with the digestive aptitudes of the individual. The influence of season by putting its stamp upon it, makes this enteritis a special enteritis of a character so malignant, as too often to baffle our thera- peutic efforts. In these cases of intestinal catarrh, in which the special element of infantile cholera is absent, the treatment ought to be conducted in accordance with the indications which I described in a general manner when lecturing upon diarrhoea. Here, the raw meat system, of which I spoke to you when discussing chronic diarrhoea, plays an important part. Some months ago, you saw me prescribe this treatment for a child who occupied (along with his mother) bed 19 of St. Bernard’s ward. This child came in with an obstinate diarrhoea, which, in the first instance, resisted all our curative measures. I then resorted to the use of raw meat: from the second day of this treatment, the intensity and copiousness of the diarrhoea decreased. This treatment is not a novelty. I have employed it for many years: and it has also been adopted by others, particularly by Drs. Blache and Henri Roger, my colleagues at the Hopital des Enfans. Notwithstanding its efficacy, it has hardly yet taken its proper place in practice : many physicians are hostile to it: at least, when I pro- pose it, I find my proposition treated with ironical incredulity by some of my honourable brethren. It came to us from the north, thirty years ago. A Russian phv- sician, Dr. Weisse of St. Petersburgh, introduced it to the notice of the medical profession. He wras led to make use of it from circum- stances wffiich I shall now describe. Eor some months, he had been treating a year-old infant, ex- hausted by colliquative diarrhoea and reduced thereby to the condi- tion of a skeleton. One day, the mother asked Dr. Weisse to INFANTILE CHOLERA DIARRHOEA. OF CHILDREN. 141 allow her to give raw meat to the child; and he consented, recol- lecting that some physicians allege they have obtained good results from its use in disease accompanied by a hectic state. Next day, he was amazed to see the child chewing a bit of raw meat. Having found portions of undigested meat in the stools, he ordered that in future the little patient should not have more than three spoonfuls a day of very finely minced meat. Digestion was performed easily; and in some weeks the patient, formerly supposed to be hopelessly lost, was completely restored to health. Dr. Weisse’s remarks having come to my knowledge, and similar facts having also been reported to me by foreign physicians, I, in my turn, made experiments; and have ever since had occasion to speak favourably of this mode of treatment. My observations, which were at first confined to children, were afterwards extended to adults; and when I was speaking to you of chronic diarrhoea, I cited the case of a young married lady who was cured by the raw meat system. But there is no condition in which this singular method of treatment is more useful than in the diarrhoea which supervenes at the period of weaning. Whether weaning take place prematurely, or after complete dentition, the digestive canal is unaccustomed to the new description of food. Under what form ought the raw meat to be given ? Take a piece of lean beef, mutton, or fowl—beef or mutton, however, being preferable—cut it up into very small morsels, so as to constitute a sort of liachis, and then put it into a mortar and with the pestle work it into a thick mass. The pulp so made is forthwith passed through a cullender, so fine as to permit nothing to pass except the juice of the meat, the fibrin of the blood, leaving behind only blood-vessels and cellular tissue. By this means, a real puree de viande is obtained, which is collected by scraping the external surface of the cullender. The preparation of the meat, as you see, demands a certain amount of patience. When so complete a result cannot be obtained, wre may substitute for the puree de viande, meat chopped as small as pos- sible; for this can be digested easily, though with less facility than the puree. The proposal to use this singular remedy is generally received disapprovingly by mothers, who estimate the probable repugnance of their children by their own actual disgust. You also run the risk of opposition from servants, who greatly dislike to add to their 142 INFANTILE CHOLERA DIARRHCEA OF CHILDREN. usual routine of duty, a task so troublesome as the preparation of the puree de viande. As for the children, it often, nay it generally, happens that they show none of that repugnance to this kind of food which they have been expected to manifest. At once, they take it without the least grumbling. Prom the very first day on which it was given, you saw our little patient of bed 19 devour daily his 125 grammes of raw meat. In this, there is nothing which need surprise you, when you see children take, not only without disgust, but even with satis- faction fish oil, which very few of you would like to taste. There are some, however, who have a profound aversion to raw meat. Tor them—allow me the phrase—we must gild the pill. There is nothing more easy than to do this. We make the pulpified or minced meat into little balls with salt, sugar, fruit-jelly, or con- serve of roses, the mixture and selection of ingredients being regu- lated entirely by the taste of the patient. Raw meat, when well prepared and disguised in this manner, is easily taken: its taste is masked in such a manner as not to be at all disagreeable. Should the meat not agree with children when mixed up with salt, powdered sugar, jelly, or conserve of roses, it may be put into a clear gravy soup, as if it were tapioca or sago. It may likewise be mixed with chocolate, made with water; and although such a combination is in direct opposition to the ordinary rules of the culinary art, it is one which patients find much to their liking. By trying these different combinations, which admit of being in- finitely varied, we discover the one which is most readily accepted. Children soon become accustomed to the use of raw meat, and ulti- mately take it, not only with pleasure, but even with so much vo- racity, that on their little allowance being consumed, they will demand another supply, just as if it were the most dainty dish. In adopting the raw meat regimen, it is necessary to proceed with a certain amount of caution. Begin by administering small quan- tities ; for if you all at once give the patient large quantities, there is a risk of aggravating in place of curing his indigestion; and on the other hand, by commencing too, abruptly, you may create invincible disgust for your aliment. Nothing is more simple than to measure and weigh the quantities to be given in the twenty-four hours. This requires no special ap- paratus : our current Trench coins will serve very well as ordinary weights, and will be more easily remembered. As you know, a silver INFANTILE CHOLERA DIARRHOEA OE CHILDREN. 143 twenty-centime piece represents exactly one gramme—and a silver five-franc piece weighs twenty-five grammes. We may begin by prescribing raw meat equal in weight to a five- franc piece to be taken daily in three doses. If these 25 grammes are well digested, the daily allowance may be at once doubled, and progres- sively increased from day to day, according to the manner in which the child bears preceding doses, till a daily administration of from 100 to 150 grammes is attained. Having reached this point, the child must be kept at it for some time. If the appetite be keen, and health be evidently returning, the daily quantity of raw meat may be increased at the rate of 25 grammes a day till a daily allow- ance of 200 grammes or even of 500 grammes has been reached ! During the time that the raw meat regimen is being pursued, it is indispensable to forbid the use of every other kind of aliment, and all drinks except nutritive drinks. The nutritive drink which is specially appropriate is the eau albumineuse; it is useful from the modifying influence which it has upon the diarrhoea, and from its being so agreeable that children take it willingly. For some days after the commencement of this regimen, it is very usual to find the raw meat almost unchanged in the stools of the children; the faecal matter, at the same time, contains a large quantity of decolorised fibrin. That ought not to surprise you; nor ought it to discourage you from persisting in the treat- ment. Assuredly 75 or 100 grammes of raw meat in passing over the intestinal surface must leave some nutritious matter to be ab- sorbed. In point of fact, it is soon seen that the little patient has regained strength. After the lapse of a certain time, sometimes after four, six, or eight days, the excrementitious matter begins to be moulded in the gut: its smell is exceedingly foetid, recalling the odour of the excrement of purely carnivorous animals. This little inconvenience is of slight consequence, and need not be a cause of anxiety. All that is necessary is to know that such an effect is produced, and to give the relations notice of what may be expected. It is difficult to fix a period for the duration of this treatment. Sometimes, it does not admit of being suspended, from the children becoming so habituated to the raw meat that they will take no other kind of aliment: and sometimes also, a change of regimen, brings 011 unfavourable symptoms. One of my grandsons was an example of this. When sixteen months old, he was attacked by diarrhoea, which resisted bismuth, IN FAN TILE CHOLERA D1ARRHCEA OF CHILDREN. chalk, nitrate of silver, rhatany, monesia, opium, and in fact every remedy, till I gave him raw meat. Prom that time, his malady yielded, and health was re-established: I continued the regimen, however, for more than a year. The child at last was taking daily 500 grammes (rather more than an English pound) of pulpified raw meat. Whenever I suspended its use, the diarrhoea returned; and to maintain recovery, it was necessary to continue the treatment. Gentlemen, I certainly do not announce this medication as an infallible means of cure: I only say that in a great number of cases it has proved remarkably successful in my hands, and in those also of others; and that I have obtained cures through its instrumen- tality when all hope of recovery seemed to have been lost. Twin sisters, aged 17 months, daughters of one of the largest manufacturers at Mulhouse, were brought to Paris at the time of the Universal Industrial Exhibition in 1855. They were in a frightful state of emaciation. They each weighed between fifteen and sixteen pounds (French), their skin was covered with petechial patches, some of which were equal in diameter to a five-franc piece. They vomited all food that was administered to them, and even vomited the sugared water which they took. For three months, from the date of their weaning, they had been exhausted by serous diarrhoea. Considering the formidable character of their symp- toms, and the radical deterioration of their constitutions, I could only entertain very slight hopes of improvement. We were, at the period to which I refer, in the full tide of summer. The family lived in the Champs Elysees, where the poor babies were daily dragged about under an ardent sun in a little carriage. Upon one occasion, their nurse returned from the promenade in a state of great excitement, declaring that she did not wish to go out with them again, as she had been taunted by passers by, who had expressed themselves as indignant at seeing children taken out who appeared more dead than alive. I narrate this little incident to show you the terrible state to which these wretched little crea- tures were reduced. Though I had not much hope of being useful, I was anxious to try something. I recommended raw meat. The result exceeded my hopes. Digestion was re-established : and when the little girls left Paris, they could not have been recognised as the children who had arrived. They had regained health, and a sur- prising amount of plumpness. The raw meat regimen was continued INFANTILE CHOLERA : DIARRHCEA IN CHILDREN. 145 for a year. Some time later, their father, in testimony of his gratitude, sent me their photographs. It is a curious fact, that one of the little girls was affected with tsenia solium during the course of her malady. The extract of male fern soon brought away from ten to twelve meters of tapeworm. Six months later, and during the time she was eating the raw meat, the same child had a second taenia solium, which she got rid of by the use of the same means which were employed on the former occasion. Are we to attribute the presence of these worms to the regimen which the child had been following? These entozoa, as you are aware, are frequently met with among the inhabitants of Abyssinia, who habitually make use of raw meat. We may ask, whether we are to attribute the worms in this child to her having passed a portion of her summers at Bale (in Switzerland), where tsenia may be said to be endemic ? I am inclined to believe that the regimen was really the cause of the tsenia in this child, because several physicians, including Weisse, Braun, and Yon Siebold,1 have often observed 'worms, particularly the tsenia solium, in persons whose exclusive aliment was raw meat. Be that as it may, the verminous affection was no obstacle to the cure of the diarrhoea, which was the cause of my having been called in. To assist the beneficial action of, and facilitate the tolerance for, the raw meat, it is necessary to employ agents of the materia medica in conjunction with it. Opium administered in minute doses, in accordance with the rules which I have given you, is a valuable resource. When it fails, I give chalk, and subnitrate of bismuth, at meal times, and in the interval between meals, in doses of from one to four grammes. Along with these medicines, I sometimes give the sesquinitrate of iron, a preparation specially commended by Graves : I prescribe it to be taken in doses of two or three drops during meals. Finally, when the circumstances call for it, I also recommend tonic treatment. In this class of cases, I find the tincture of nux vomica a very useful tonic. Of this I order to be taken, in the course of the twenty-four hours, only one drop, which is prescribed in a liquid mixture, so that it may be taken in three separate doses. I have also had good results from the use of hydrochloric acid. 1 Buaun and Siebold :—Journal fur Kinderkranhheiten for January and February, 1858. Erlangen: 1858. LECTURE LXXIII. LACTATION, FIRST DENTITION, AND THE WEANING OF INFANTS. Lactation : natural, artificial and mixed.—Lactation in respect of the Woman.—Conditions essential to a Good Nurse.—Influ- ence on the Lacteal Secretion of Menstruation, Conjugal Relations, Pregnancy, and Intercurrent Diseases.—Lactation in relation to the Nursling.—Weighing the Infant is the only means of ascer- taining whether it is sufficiently suckled.—First Dentition :— Mode of Evolution of the Teeth in Groups.—Order of succession in which they appear.—Casualties of Dentition.—Febrile Dis- comfort.—Convulsions.—Diarrhoea.—W eaning. Gentlemen :—The subject of my last lecture was infantile cholera, which I told you was the most serious affection which resulted from premature weaning. I reserved for to-day's meeting some considerations regarding lactation, the first dentition, and weaning. Every one knows the meaning of the term lactation. It signifies the alimentation of the infant, by its sucking from the breasts of its mother or another woman. In the definition of natural lactation, feeding wTith the milk of animals has been sometimes included; but this more properly is considered as comprised in artificial lac- tation, which for the most part consists in giving the milk of the cow, or the goat, by means of a feeding-bottle or spoon. Mixed lactation, the system usually adopted, is a combination of the two others. Natural lactation, as I shall tell you forthwith, is undoubtedly the method which ought to be preferred: but from this general rule, there are exceptions. Before considering how lactation ought to be conducted, the question arises:—What are the conditions required in a good nurse ? LACTATION : FIRST DENTITION : WEANING. 147 First of all, a woman, to be a good nurse, must be in the enjoy- ment of perfect health : but from this proposition—to which self- evident truth gives a character of common-place—it is not to be inferred that every perfectly healthy mother is fit to nurse her infant. Some puny-looking women are very good nurses. There are also vigorous robust women whose breasts secrete an insufficient quantity and a bad quality of milk; and this inaptitude to nurse occurs without our being able to assign a reason, or when consulted to predict its occurrence. However, with the reservation now stated, a healthy woman will in general make a good nurse. We judge of the state of health by the woman’s appearance, by examining the state of the different organs, and by such additional information as we can obtain. No very great importance can be attached to the complexion and colour of the hair: fair and dark women make equally good nurses. Beautiful teeth, so important in the opinion of some persons, have really no other advantage than increasing good looks. The manner in which the menstrual function is performed may, to a certain extent, be regarded as an indication of the manner in which milk will be secreted. If menstruation be irregular and scanty, there is a fear that the lacteal secretion will be badly accom- plished : and nursing fitness is also improbable when the menses are habitually too abundant, for the chances then are, that after giving suck for two or three months, the menstrual flow will recommence, the mammary fluxion, hitherto energetic, being counter-balanced or annihilated by the uterine. The presumption is in favour of a woman making a good nurse, if she be regular in her menstrual function as regards time and quantity of flow. I use the word pre- sumption, because we cannot, I repeat, give in advance an absolute opinion. The state of the breasts, even, does not give us sufficient evidence by which to decide the question, although it furnishes information of positive value. We must judge of the breasts less by their size, than by their form, the appearance of the skin covering them, and the shape and development of the nipple. The largest and roundest breasts are not always those which yield most milk; for it often happens that mammary development is due to a predominance of cellular tissue and fat, while smaller pear- shaped breasts indicate development of the gland itself, promising 148 LACTATION: FIRST DENTITION : WEANING. therefore a more abundant secretion of milk, particularly if their skin is marbled by veins, testifying richness of circulation. As to the nipple: it ought to enter easily into a state of erection, and be of size sufficient to enable the infant’s mouth to get a good hold of it in sucking. When there is to be an abundant secretion of milk, it begins to be secreted long before parturition. The breasts, which from the very commencement of pregnancy had been somewhat swollen and tender to the touch, and at the third month were surrounded by the characteristic areola, show, towards the end of the fourth month, an oozing of colostrum, which is sometimes so considerable as to stain the woman’s linen. Immediately after delivery, this flow of colostrum becomes more copious; but four or five days elapse before the secretion has all the characteristics of milk. It is usual to press the breasts, with a view to determine whether the milk is or is not abundant; but this manipulation requires cer- tain precautions, and the taking into account of many details. It is essential to practise this sort of milking with the greatest possible gentleness, otherwise unpleasant mental emotions may be caused in the woman when under examination, which will prevent the secretion of milk, just as it is stopped in the cow and other animals which furnish a less supply of milk when the operation of milking is roughly conducted. Tor the same reason, it is necessary, in addition to being careful to make gentle pressure, to avoid producing a sudden feeling of change of temperature in the skin, by using a cold hand. When these precautions are properly taken, the milk spurts out vigorously through several orifices in the nipple, unless indeed these apertures are partially plugged by milk which has remained in them since the woman last gave suck: under such circumstances, the nipple ought to be washed before practising the manipulation. It often happens that when the secretion is very abundant, the milk spurts forth spontaneously, not only from one breast while the infant is sucking the other, but even from both breasts when the infant has not been sucking for some time. This spontaneous secretion—this rush of milk \jnontee du lait] as it is calle’d—is announced by a peculiar sensation, a sort of itching which, though generally agreeable, is sometimes painful. The quality of the milk generally corresponds with its quantity. It would be wasting your time, to enter here into all the details of LACTATION : FIRST DENTITION : WEANING. 149 this subject. I shall confine myself to recalling to your recollection facts which I have had occasion to bring under your notice when speaking upon other questions. The milk of a woman may be per- fectly good for a particular child, and exceedingly bad for another : certain circumstances may modify the good qualities of the milk; and I must also remind you, that there are a few exceptional infants whose digestive organs cannot tolerate any kind of milk, whether it be woman’s milk, or the milk of a cow, goat or ass. Although, as a general rule, women do not menstruate when giving suck, there are some in whom the menses reappear during lactation. If the menstrual discharge is very abundant the secre- tion of milk not unfrequently ceases if the menstrual flow be mode- rate, the lacteal secretion and lactation suffer, whilst menstruation is going on. Besides being injured by having less to take, the infant sometimes suffers from intestinal symptoms, such as diarrhoea, and colic. A nursing mother grows fat during the first months of lactation ; but towards the end of the first year, this plumpness is lost, showing that the lacteal secretion is too great a pull on the health. In these cases, the infant requires supplementary diet. I have still a few concluding remarks to make on lactation in its relations to the woman. Conjugal intercourse is not injurious to nurse or nursling, provided it be regulated by great moderation. Pregnancy supervening during lactation produces no other bad con- sequences than a diminution, or complete drying up of the lacteal secretion; the milk, however, does not acquire any bad properties from the existence of pregnancy. If the infant begin to ail, it is because its food is no longer sufficient in quantity. Supplemen- tary alimentation then becomes necessary; and this may lead to the bad consequences which I have brought under your notice, as liable to occur wdien the nursling is not old enough, or otherwise not in a suitable condition to be weaned. It has been alleged that lactation favours recovery from inter- current diseases, the idea being that convalescence is shortened by the mammary fluxion establishing a sort of derivative action of a very energetic kind. Without giving quite so affirmative an opinion on the subject, I may say, that, according to my own experience, lacta- tion does not complicate acute diseases, and that it even seems as if a wToman by discontinuing to give suck during the course of a malady, probably of short duration, does that which was dangerous 150 LACTATION : FIRST DENTITION : WEANTNG. both to herself and infant. Should, however, the disease continue for a month or six weeks, nursing must be suspended, as it then proves a cause of exhaustion additional to that arising from the in- tercurrent acute affection. The discontinuance of nursing may be not a matter of choice but of necessity; for the long continuance of a febrile state may diminish or quite dry up the supply of milk. You know, moreover, that the lacteal secretion, particularly in a good nurse, recommences very easily, becoming as abundant as before, even after having ceased for a fortnight, three weeks, or a month. I have even seen it begin again after having been suspended for three months. I have already told you how necessary it is that the nipple should be so developed as to give the infant’s mouth a good hold in suck- ing ; this suitability of development is also an important matter for the mother, for when the nipple is short and difficult to lay hold of, it is irritated by the infant’s difficult attempts at sucking, and so rendered more liable to erosions and fissures, which latter are some- times very deep and painful. The fissures, too, may become the starting point of inflammation, which, reaching the mucous mem- brane of the mammary canals, will cause them to become obliterated, and so lead to the breast being affected with engorgements of milk constituting “ the hair” \le poiQ, an affection which terminates in the formation of numerous abscesses.1 "When erosions and fissures begin to form, it is necessary, when they are limited to one breast, to cause the infant to suck, as much as possible, only from the other breast. The fissures ought to be washed with Goulard’s water, a decoction of rhatany, or a decoction of oak bark : they may be dressed with pomades of tannin, rha- tany, white precipitate, or red precipitate : or, better still, they may be touched with the solid lunar caustic. If there is a tendency to the formation of new fissures, the woman must adapt an artificial teat to her nipple. It ought to be small, and so constructed as to embrace the nipple. Before it is used, it ought to be washed in warm water and sugared milk; and the nursing woman ought to 1 “ Le poil ” is the vulgar name in Trance, for mastitis; and is really a trans- lation of the Latin, “ morbus pilaris This absurd term was originally applied by the ancients to mammary engorgements, from the strange notion of Aristotle, that they were caused by accidentally swallowed hairs passing from the stomach into the mamma!—Translator. LACTATION : FIRST DENTITION : WEANING. 151 press her breast in such a way as to facilitate the infant's exertion of sucking. So much then for lactation in its relations to the woman: let us now see how it ought to be conducted for the benefit of her nursling. The infant has just been born ! As soon as the mother is able to sit up—by that I mean, two or three hours after delivery—the infant ought to be put to her breast, even although the milk may not yet have come into it. This practice is, on the one hand, useful as the suction fashions the nipple : on the other hand, it frees the ducts from concreted colostrum : thirdly, from the first, it gives the nursling good habits. I am opposed to the custom of giving with a spoon sugared water to infants during the first tw'enty-four hours after birth, because it is teaching them to drink without sucking : this is bad ; for sucking is toilsome work which an infant will only be too glad to avoid if shown how otherwise to obtain its needed nourishment. Let, therefore, the infant be put immediately, or at least as soon as possible, to the mother's breast. After the second day, it will there find sufficient nutriment. At first, it ought always to be put to suck on awaking from sleep. But after ten or twelve days, when sucking abundantly at each time of nursing, the feeding ought to be by rule, for the sake both of mother and child. By sucking abundantly, I mean the infant taking each time that he is put to the breast, 6o or 80 grammes [about 14 to 2 fluid ounces] of milk. If a strong vigorous infant takes less than this quantity, the nurse is bad. Here, Gentlemen, is the one and only test by which you can determine whether a woman is or is not a good nurse: it was devised by my honourable colleague Professor Natalis Guillot.1 Before applying the infant to the nurse's breast, it is weighed in its swaddling clothes : when it has sucked, it is again placed in the scales without any change of clothes being allowed. The excess of weight at the last over the first weighing gives the exact weight of milk which has been swallowed. The infant, I repeat, ought to take at least from 60 to 80 grammes, during the first period of lacta- tion : when four or five months old, he ought to take 250 grammes at one nursing, and about 1500 grammes in the 24 hours. Some children, wdiose nurses have a very copious supply of milk, always regurgitate some of it immediately after sucking. With a view 1 Natalis Guillot :—De la Nourrice et du Nourrisson. Union Medicale, 1852 ; p. 61—65. 152 LACTATION: FIRST DENTITION: WEANING. to prevent this occurrence—not, however, one of much consequence ■—the woman ought to place her finger upon the orifices of her nipple which will prevent a too rapid flow of milk. The infant ought to be so trained as to suck five or six times between six in the morning and nine in the evening. It is very important that it should, if pos- sible, not be nursed during the night, so that the mother may have eight or nine hours of undisturbed sleep, which is necessary for her retaining health, and properly nursing her infant. If slie do not get this amount of rest, her strength will become exhausted, and her nursling will suffer. If the infant is a bad sleeper, it must be sent away from its mother to another room, and suckled with the feeding-bottle during the night. Under these rules, the infant attains the age of four, five, or six months. He may then be allowed to take thin farinaceous soups made of arrow-root, tapioca, cassava, vermicelli, rice-flour, bread- crumb (well boiled and passed through a cullender), or better still, hasty-pudding made of wheaten flour: this latter is the best and cheapest farinaceous food. These farinaceous aliments ought to be prepared with milk diluted with sugared water, or with butter. In certain proportions, meat soups may also be given; but they must not constitute the principal part of the supplementary diet. Natural lactation, as I have stated, is unquestionably the best, and on principle it is prescribed. Artificial lactation, or in other words, feeding infants by means of the feeding-bottle or spoon with the milk of animals, is, generally speaking, a deplorable system. In Paris, in particular, but in all large towns, it is the chief cause of infantile mortality: one dies out of every four subjected to this plan of rearing: the three who resist death are generally damaged in health and constitution. As we shall afterwards see, rickets is a very common consequence of this kind of feeding. When circumstances, irrespective of wishes, compel families to have recourse to artificial lactation, the bad consequences to which it naturally leads may be moderated by attention to certain rules. Pirst of all, the infant must be made to suck from the feeding-bottle, and not allowed to drink from the cup. Drinking from the cup is very objectionable: the milk traverses the mouth too rapidly to be duly mingled with the saliva, the alcaline nature of which prevents the milk being too quickly coagulated on its reaching the stomach. Cow’s milk is the best: the infant ought if possible to have an LACTATION : FIRST DENTITION : WEANING. 153 average milk—that is to say, a mixture of the milk of a great number of cows living in the same byre. This milk ought to be mixed with very thin panada, decoction of barley, or decoction of grits, the pro- portions of the fluids being one third of water to two thirds of milk. This mixture when given to the infant is moderately sweetened, and heated to the temperature of the body. When this aliment does not agree with the infant, a small quantity of bicarbonate of soda ought to be added: not more than from 30 to 50 centigrammes of it ought to be given in the twenty-four hours, the quantity administered at each feeding being, therefore, about five centigrammes. Should this admixture with bicarbonate of soda not prevent the milk being rejected, one drop of laudanum—but not more than one drop—may be added to the entire quantity of food taken during the day. Notwithstanding the adoption of all these precautions, some infants will not thrive on artificial feeding. To them, a wet-nurse is a necessity. The lapse of a long period since weaning is no reason why such infants should not be made to resume the habit of suck- ing. To get them again to take the breast, enticement must be mingled with compulsion: the nurse's nipple must be moistened with sugared milk, and the infant must be deprived of every kind of food and drink, so that hunger may force it to recommence sucking the breast. I have now come to the great question:—At what age ought infants to be weaned ? Gentlemen, you every day hear parents announce with the utmost precision the date at which their infants ought to be weaned—fixing it, as the case may be, for the age of nine months, a year, or fifteen months. The proper time for weaning, cannot, however, be thus determined by consulting the almanack. It is not at nine months, a year, nor fifteen months, and far less is it at an earlier age, that we are to place the limit of lactation. Remember this truth, and with it indoctrinate the families who ask you to direct the health of their children. Your true guide in this matter is the more or less advanced state of dentition. The infant ought to be suckled till the time is past during which the formidable complications of teething supervene. The first dentition comprises the evolution of the twenty tem- porary teeth, usually called the milk-teeth, and which about the age of seven begin to be replaced by the permanent teeth. 154 LACTATION : FIRST DENTITION : WEANING. They make their first appearance in groups, at times, and in an order remarkably determinate. The first group includes the two lower middle incisors. The second group includes the upper incisors—the middle coming first, and then the lateral. The infant then has six teeth, four in the upper and two in the lower jaw. In passing, let me observe, that, strange to tell, this fact, though known to every woman who has had children, has been ignored by men of science, even by authors who have specially written on this very subject. The third group includes the two lower lateral incisors and the four first molars. The fourth group is formed by the four canine teeth. The fifth group consists of the four last molars. This is the usual order of appearance; but from it the exceptions are numerous. Though nine times in ten, the lower middle incisors are the first to appear, they are sometimes preceded by the upper middle incisors; but in these rare exceptional cases, the lower middle incisors immediately follow the evolution of the others. The simul- taneous evolution of the upper and lower middle incisors is a still more rare occurrence. Likewise, in very exceptional cases, the small molars show themselves before the appearance of the second group— that is to say, the upper incisors. With reference to the evolution of the third group, it may be stated that, pretty frequently, the two small molars are seen before the lower lateral incisors. There is seldom any irregularity in the evolution of the fourth and fifth groups. Notwithstanding the anomalies now stated, there is much more regularity in the order than the epoch of the appearance of the teeth. The common opinion is that girls are more precocious than boys. This remark, which is perhaps true in respect of intelligence, would seem to be applicable also to the appearance of the first tooth. I find, as the result of my statistical inquiries into this subject, that in girls, the extreme limits at which the first tooth appeared were the second and the fourteenth months, the sixth month representing the average date; whereas, in boys, the extreme limits were the third and fourteenth months, the seventh month representing the average. Before proceeding farther, Gentlemen, let me remark upon the absurdity and inapplicability of averages when applied to matters LACTATION : FIRST DENTITION : WEANING. 155 of this kind. Among the boys who furnished me with the sta- tistical table to which I have been referring, seven months was the average date at which the first tooth appeared, but not even in one of the cases from which this average was deduced did the first tooth appear at the seventh month, so that the average of the facts is not applicable to a single individual fact of those furnishing the average. In respect of the girls, the average of six months applies to three of the facts only, that is, to one fourth of them. Although this application of statistical results is profoundly absurd, we must not on that account reject statistical inquiries altogether as some would wish us to do. A statistical result has this advantage, that it expresses no more than it ought to express; that is to say, a mass of individual facts which group themselves in numbers more or less considerable, and from which we may draw our conclusions, but which conclusions never can be general, inasmuch as they do not admit of application to all the individual cases; and, logically, no conclusion which is not applicable to each individual instance can be a general conclusion. Here, Gentlemen, let me once more raise my voice against the system of averages which has been so extraordinarily abused, and which, though overthrown by every rule of the most common logic, attempts to give as truths an average which are only abstractions, not expressing the fact which is most common, but the fact intermediate between extremes, and which itself may seldom or perhaps never exist. I protest against the mad attempt which has been made to base therapeutics upon averages, and to ask from statistics formulated truths which statistics cannot furnish. Let me now return to the dentition of children. From a collection of cases which I have attentively observed, it would appear that girls are earlier than boys in cutting the first tooth. Experience has shown, that variations are so great as to render it impossible to fix the exact limits of age at which this event may occur. Some infants are even born with teeth : of this phenomenon many examples have been recorded. When teeth exist at birth, they are generally the middle incisors: then we have the other extreme, some children not cutting the first tooth till eighteen months or even an older age than that has been reached. Between the two ex- tremes, all the intermediate ages are met with—two, three, four, five, six, seven, nine, ten, fourteen months. I take these figures from LACTATION : FIRST DENTITION : WEANING. the statistical tables of which I have been speaking.1 It is possible, however, by making an abstract of all the observations made on this subject, to fix a period between six and nine months ; and to be still more precise, let me name six months and a half as tbe period at which the first milk tooth generally makes its appearance. My former pupil, Dr. Duclos,2 one of our most distinguished physicians, now in practice at Tours, has come to the same conclu- sions ; and he has also shown, that the first' group of teeth, the lower middle incisors, appear between the sixth and ninth months. There is no great difficulty in determining the exact epoch at which the first tooth has appeared; for mothers, from whom alone on this point we can derive our information, are seldom mistaken. The cutting of the first tooth is an occasion of great maternal re- joicing, and is watched for with peculiar solicitude. But in respect of statements as to the date at which the second and still more the third tooth has appeared, I have much less confidence in the mother's memory. The cutting of each group of teeth occupies, however, a certain period which, although generally of limited duration, is in excep- tional cases more extended. The evolution of the lower middle incisors generally takes place within a period of from one to ten days. The four upper incisors are usually cut within a period of from a month to six weeks. The lower lateral incisors, and the four molars, are cut within a period of from one to two months. The evolution of the canine teeth occupies from two to three months. The last molar occupy an equally long period in their evolution. The evolution of the canine teeth is attended with the most difficulty, which probably arises from their having the longest roots. The fact to be remembered as that of the greatest practical value in relation to weaning is that between the evolution of each group of teeth, that is to say, between the complete evolution of the last tooth of one group, and the evolution of the first of the succeeding 1 Trousseau :—Journal des Connaissances Medico-Chirurgicales, for Novem- ber, 1841. 2 Ducuos (de Tours):—Bulletin General de Therapeutique for April and May. 157 LACTATION : FIRST DENTITION : WEANING. group, there is a period during which the progress of dentition remains in entire abeyance. The duration of the pause between the completion of the first group, and the appearance of the first tooth of the second group, is from two to three months. The pause between the completion of the evolution of the superior incisors and the appearance of the first lower lateral incisor, or first molar, is two months. Prom four to five months elapse between the complete evolution of the last molar and the appearance of the first canine. There will then be an interval of from three to five months before the appearance of the first molar of the last group. The periods are not, of course, always so precise as I have now stated, and as M. Duclos has described them : but for us, the important point to bear in mind is that, save in some few exceptional cases, there is a well marked interval between the evolution of the different groups : the interval between the complete evolution of the last molar of the third group and the appearance of the first canine tooth is generally very prolonged ; as is also that which separates the appearance of the last canine from the appearance of the first tooth of the last group. When the entire evolution of a particular group takes place rapidly, the interval between the conclusion of that evolution and the appearance of the first tooth of the following group is more prolonged: and on the other hand, when the evolution of the group is exceedingly slow, there will be very little interval between its completion and the appearance of the first tooth of the next series. It is not unusual for the first twelve teeth to be cut’almost simultaneously without any very distinct pause between the different series. These anomalous occurrences have for the most part no appre- ciable cause. Irregularity in the order of dentition does not admit in general of any explanation ; nor does it seem to have any signifi- cance whatever in respect of the general health of the infant. At the same time, there are certain diseases which almost invariably lead to irregularities both in the order and the time of appearance of the teeth. There is no disease which exerts so decided an influence of this description as rickets. It rarely shows itself before the beginning of dentition; but when it does then appear, it retards dentition 158 LACTATION : FIRST DENTITION : WEANING. almost indefinitely. Should it supervene during dentition, about the age, for example, of ten or twelve months, it abruptly interrupts the evolution of the teeth, which then appear at distant intervals. Finally, should rickets supervene at an advanced period of dentition, or even when only a few teeth have appeared, it causes caries of the teeth, all, but particularly the incisors, being apt to become loose and fall out. It is very important to remark, that tuberculisation, which has been for so long a time, and so erroneously, confounded with rickets, has a precisely opposite effect upon dentition. It is not unusual to see in children, whose glands and pulmonary parenchyma are in- filtrated with tuberculous matter, a regular and even a rapid develop- ment of the teeth which, moreover, will probably remain undeteriorated during the whole duration of the malady. Gentlemen, the facts upon which I have now expatiated, would possess only a moderate degree of interest, were it not that we can deduce from them practical conclusions relative to the subject now before us, and which may be expressed in the absolute, I say the absolute rule, never to wean an infant, unless some special circum- stance render it imperative, till after the period during which the serious complications of teething usually occur. There is a popular proverb which says—" bel enfant jusqu’ aux dents ”—signifying that the health of a child is most apt to undergo an unfavorable change at the period of dentition. The possible dangers of dentition are greatest the nearer the period of the evolution of the fourth group ; and the popular belief is well founded, that the time of cutting the canine teeth is a time of anxiety. This probably arises from the canine teeth having very long roots ; and probably is sometimes also caused by the jaws not being suffi- ciently developed, for occasionally the sockets are so narrow, that it is difficult to understand how the teeth can become developed within them. Then again, they are the only milk-teeth which come forth within enclosed spaces—the spaces destined for them are between two teeth already developed, whereas all the other teeth are free, at least on one side, whilst they are piercing the gum. The cutting of the last molars is most exempt from danger, a circumstance explained by the fact that at the period of their'evolu- tion the jaws have attained sufficient development: at this period also, the infant has acquired strength sufficient to contend against complications which it could not have resisted at an earlier age. LACTATION : FIRST DENTITION : WEANING. 159 Let me adcl, as a concluding general remark, that the manner in which a child cuts its first groups of teeth, affords no criterion by which to judge as to the way in which the evolution of the others will take place. Having made these preliminary remarks, I now proceed to review the morbid conditions to which dentition may give rise. The most common complication of teething is high fever, particu- larly at night, characterised by restlessness, insomnia, and cross temper. Along with these symptoms, the flesh becomes soft, there is a loss of natural colour, and a dark areola appears round the eyes. This state of discomfort, which is a manifest effect of inflammatory action, precedes and accompanies the evolution of each tooth. It lasts from one to eight days; and it generally terminates on the very day on wffiich the tooth shows itself, though it sometimes continues for one day or two days more. The symptoms really are those of a slight traumatic fever. They constitute the most common, and the least formidable complication of dentition. Nevertheless, when the teeth are evolved in very rapid succession, the symptoms now de- scribed are quite sufficient deeply to affect the health, and leave on the child’s face the mark of the malady. Sometimes, the disturbed state of the system declares itself by convulsions, which may depend partly on the pain caused by the process going on in the gums, and still more on the fever accom- panying it. When speaking of the eclampsia of children, I gave you my explanation of these nervous attacks. I only name stomatitis to remind you of it; it is very often of sufficient intensity to account for the fever, and is often accom- panied by an ulcerative eruption causing intolerable pain as well as sometimes salivation and thrush \muguet\. I should say nothing about swelling and engorgement of the gums, whicli seldom occurs at the time of the evolution of the first teeth, but is more common at the cutting of the canine and molars, were it not that I wish to warn you against a practice which I con- sider as very objectionable. Mistaking the effect for the cause, many physicians attribute the difficult evolution of the teeth to this swelling, and under the influence of that idea, they scarify or make a crucial incision in the gums for the purpose of facilitating the exit. Tor that purpose, the operation is, to say the least, useless; and I very much doubt whether it even relieves pain by disengorging the turgid gums. 160 LACTATION: FIRST DENTITION: WEANING. There is nothing in respect of the affections of the month which need detain us. The affections of the skin, so common during dentition demand more attention. I do not refer to those transient fugitive erythematous eruptions, those red eruptions unaccompanied by pain, and irregularly cir- cumscribed, which after appearing on different parts of the body (but particularly on the face), go awray spontaneously, as soon as the influence of the process of dental evolution which ex- cited them has moderated; nor do I refer to nettle-rash which may also show itself: I speak at present only of cutaneous affections such as eczema and herpetic and impetiginous erup- tions. These eruptions sometimes occupy a very considerable surface of the body—particularly the impetiginous eruptions which cover the face and hairy scalp, invade the trunk and limbs —causing dismay to families and often to physicians. This is not because they threaten life, but because they occasion great distress to the little patients, and obstinately resist all treat- ment. The general inflammatory state of the system [le mouvement Jluxionnaire general] may show itself by cutaneous affections or by catarrhal affections—by attacks of bronchitis which ought to put us on our guard; but that for which we ought to be specially on the alert is disturbance of the intestines. Some infants are attacked with diarrhoea each time they cut a tooth, so that when in such sub- jects, dentition proceeds too rapidly, or in a confused manner, exhaustion of strength is the result. If the diarrhoea do not continue for more than four or five days, if it be not profuse, if the infant be under no bad influence through an unfavorable medical constitution of the season, the catarrhal phlegmasia, of which the diarrhoea is the expression, ought not to make us uneasy : it will cease spontaneously, leaving no trace behind. But if the diarrhoea be prolonged, the mucous membrane of the large intestine will become inflamed, and ulcerate superficially : the phlegmasia, acute when each new tooth was coming through, will at last become chronic, and may lead the infants to marasmus or the grave. The sympathy which exists between the different parts of the digestive apparatus explains why the disturbance experienced by the stomach and intestines is responded to by their annexed organs. The formidable character of this disturbance is increased by the accompanying fever modifying the character of the gastro-intestinal secretions. It is a prevalent belief of the public, and is likewise an opinion of physicians, founded upon a misconception of a proposition of Sydenham, that diarrhoea exercises a beneficial influence during dentition. This is an error respecting which I beseech you to be on your guard, and against which I implore you to exert all your in- fluence. In sucking infants, diarrhoea is a symptom which must be looked upon in a very serious light. Though it cannot be denied that a very moderate amount of diarrhoea seems to diminish the general state of fever and the inflammation of the gums; yet it is equally true, that if the purging last for more than four or five days, or become too urgent, it must be treated with the greatest possible activity. I anticipate, however, that objections to my views will be urged by some enlightened practitioners, who, in direct opposition to what I have now been telling you, will maintain that the suppres- sion of this diarrhoea is a very frequent cause of serious mischief. It is necessary to establish a distinction. Let us suppose that an infant, during dentition, has pulmonary catarrh or whooping-cough, and at the same time diarrhoea. Should the excessive intestinal secre- tion be abruptly suppressed, the pulmonary inflammation will very often assume a corresponding increase of intensity : and the patients may evidently die from the imprudence of the treatment. But in such a case the question is not as to diarrhoea in relation to dentition : what we have to consider is a pulmonary affection which may be aggravated by suppressing the intestinal flux quite irrespective of the patient's period of life. Do we not see the cough of adult phthisical patients relieved by diarrhoea, and do we not see the severity of their cough and fever return when they become constipated ? It would, however, be pushing the assertion beyond the limits of truth were I to argue that diarrhoea is always a salutary crisis in phthisis : still, you can un- derstand that without maintaining any such proposition, I may hold that the diarrhoea if it do not proceed too far may be a favorable occur- rence. Now, this restriction is similarly applicable to the diarrhoea which, in illustration of the point before us, I supposed in the teething child, as in the case of the phthisical adult. This intestinal flux ought not in such a case to be abruptly suppressed : but it is quite different when diarrhoea is the sole complication of teething. Diar- rhoea, under such circumstances, requires to be combated by the LACTATION : FIRST DENTITION : WEANING. 162 LACTATION : FIRST DENTITION : AVEANING. most active measures; and no untoward consequence will follow the adoption of such a course. The intestinal complications of dentition are always most serious in children prematurely weaned. When the infant is unweaned, to give the breast almost always suffices to stop the purging, the administration of preparations of lime and bismuth being hardly necessary. When, however, the infant has been weaned, the prac- titioner finds himself in this cruel dilemma : he must either put the patient on low diet, which will ere long produce disastrous cachexia, or give such food as will daily excite new attacks of indigestion, which by the frequency of their recurrence will at last produce inflammation. The infant, by being subjected to an unsuitable regimen, becomes the subject of enteritis. The affection is characterised by stools which are very profuse and frequent, consisting of a mixture of green and yellow matter, like chopped vegetables, to which the name of “ haclmres d’herbes” has been given : glairy and lienteric, they con- tain lumps of firmly curdled milk, which indicates that stomachal and intestinal digestion are not being performed, the food traversing the digestive canal without undergoing the normal changes. During the course of this chronic diarrhoea, even when the purging is not of more than ten or twelve days’ duration, the infant is suddenly seized with bilious vomiting. A time soon comes when the food, be it what it may, whether soups made with milk or butter, panada, or even toast and water, are returned in the state in which they were taken, appearing to be no more acted upon in their passage through the intestines than if they had traversed an inert tube. The infant becomes perceptibly thinner: from morning to even- ing, and from evening to morning, it utters plaintive cries, and will not be comforted; and should a wet-nurse not be pro- cured, to supply the sole description of aliment which agrees with it, death from inanition ensues. If it resist, its health is not the less seriously compromised; and when I shall have occasion to address you on the subject of rickets, I shall have to tell you that in most cases it is caused by unsuitable and insufficient food. But when children in this deplorable state are subjected to the influence of the summer season, the diarrhcea assumes a special character, and becomes infantile cholera. You now, Gentlemen, understand my reasons for saying that children ought not to be weaned till they have passed the period LACTATION : FIRST DENTITION : WEANING. 163 during which formidable complications of dentition are of most frequent occurrence. My rule, provided there be no serious obstacles to surmount other than the wishes of the family, is not to wean the child till after the complete evolution of the canine teeth, which is generally a more difficult process than the evolution of the incisors or first molars. My rule, therefore, is to wait, irrespective of age, till the infant has sixteen teeth. When, however, as is unfortunately too often the case, circum- stances render it impossible to continue lactation till sixteen teeth have appeared, I wait till there are at least twelve. Between the evolution of the third and fourth groups, there is generally a suffi- ciently long interval of rest for the digestive organs to recover from the fatigues to which they have been subjected, and to become more disposed to receive the new aliment to which they are unac- customed. Should pressing reasons relating to the health of the nursing mother, or considerations of a pecuniary or personal character necessitate the premature weaning of the child, an endeavour must be made to prolong lactation till the evolution of a group of teeth already commenced has been completed : if the infant has only three or four incisors, we ought to wait till it has six. It is specially important to wait should the time fixed on for the weaning be the hot season, for summer weather (contrary to vulgar belief) is the most unsuitable for weaning, inasmuch as it favours the development of diarrhoea in the terrible form of in- fantile cholera. Under no circumstances ought weaning to be abruptly carried out. From the age of four, five, or six months, the infant will have become accustomed to take, in addition to the nurse's milk, fari- naceous food and soups, the number of feedings and quantity of food being increased as time goes on. By and by, when the teeth have appeared, creams may be added to this aliment, also eggs beat up with milk, and pillars of bread soaked in the yolk of fresh boiled eggs : afterwards, there will be given some chicken bones to be sucked : a little meat will be then allowed; and so by insensible degrees, the stomach and intestines being sufficiently prepared, and dentition sufficiently advanced, the breast-milk may be wholly discontinued and the new diet commenced. By regulating lactation in this manner, by thus accomplishing the weaning, we hold in reserve useful curative means should the infant become ill; for then the mother’s milk will consti- tute, under all circumstances, the best tisane which could be administered. LACTATION : FIRST DENTITION : WEANING. LECTURE LXXIY. DYSENTERY. Most formidable of all Epidemic Diseases.—Its Causes unknown.— Eating Fruit blamed without reason.—Opinion of the ancients on this point.—Different Forms of the Disease.—Character of the Stools : Tenesmus. — Bilious, Inflammatory, Rheumatic, Putrid, and Malignant Forms of Dysentery.—Anatomical Le- sions.—Treatment: Evacuant the most useful: Employment of Saline Purgatives, Calomel, Emetics, Topical Remedies, and Caustic Injections.—Dangers of Opium.—Sequela of Dysentery, viz. Dropsy, Paralysis, and Abscess of the Liver.—Intractable Diarrhoea.—Intestinal Perforation. Gentlemen :—The year 1859 will be looked back to as remark- able for the frightful epidemic of dysentery which wre have just traversed. The disease has prevailed throughout all Trance in a more general manner than on the occasion of previous dysenteric out- breaks ; and it has not spared Paris, where for the last hundred years isolated cases only have occurred. The epidemic, exhibiting its usual features, declared itself about the end of July: it attained its maximum severity in September : by the end of October, it had moderated greatly; and though it continued during November and December, it was much less prevalent. You have had an opportunity of studying the disease in the clinical wards; and during the last few days, you have seen in bed 5 of St. Agnes’s a man, and in bed 11 of St. Bernard’s wTard, a woman, suffering from dysentery. The man is convalescent. The woman died : and I showed you the terrible intestinal lesions which were found on examining her body—lesions which unfortu- nately testified to the uselessness of therapeutic measures in similar cases. The large intestine, throughout its entire extent, presented 166 DYSENTERY. appearances of acute inflammation, there being also at some points ulcerations, and at others, gangrenous patches. The gangrene had in some places extended to the sub-peritoneal membrane. Traces of inflammation were found as high up as the small intestine; but let me call your attention to the remarkable fact that there was no lesion of Peyer’s glands: this is contrary to what occurs in dothin- enteria; in which ulceration of these glands is the anatomical character of the disease. Here, in a few words, is this poor woman’s case. Eight days before her admission to the hospital, she was attacked by diarrhoea, the stools very soon containing blood and glairy matter. They became very frequent; and if the woman’s statement is to be believed, she had had fifteen in an hour. According to the attend- ants, she had gone at least seven or eight times an hour, which would make the number of motions amount to 160 or 180 in the twenty-four hours. The dejections had the appearance of long- boiled flesh mixed with decolorised blood. This was the lotura carnium or flesh-washings described by Stoll, and by him considered as always of the worst possible augury. The general state of the patient was deplorable: the eyes were sunken, the skin was icy cold, and while it became colder and colder, it acquired a bluish tint: the tongue also was cold. Excepting that there was no change in the voice, the condition of this woman was exactly like the algidity of cholera-morbus. Pressure on the abdomen produced only slight pain. Although on the second day after the patient was admitted to our wards, the stools had diminished in frequency, the general symptoms continued quite as formidable as before. The pulse was imperceptible at the wrist, and could with difficulty be felt at the carotids. The woman died on the twelfth or thirteenth day from the beginning of the disease* I stated, Gentlemen, that the epidemic of this year made its ap- pearance towards the end of July, and was characterised by the usual features of epidemic dysentery. It is generally during summer, and principally during its greatest heats, that dysentery breaks out. At first, only a small number of persons are attacked; but up to September, there is a progressive increase in the number of seizures ; and it is during the first fortnight of this month, that the ravages of the epidemic attain their maximum: after this, the number of new cases slowly decreases up to the end of autumn, by which time, generally speaking, the epidemic has disappeared. In some epi- DYSENTERY. 167 demies, however, seizures continue to occur up to January, as in the epidemic of 1765, described by Zimmermann.1 Of all epidemic diseases, dysentery is certainly the most severe and the most deadly. Outbreaks of dothinenteria, scarlatina, small- pox, diphtheria, and even cholera-morbus itself carry off fewer victims. Desgenettes states that dysentery killed a greater number of our soldiers between 1792 and 1815 than fell in the great battles of the Empire.2 This we can understand, for dysentery is not only very deadly, but it breaks out as an epidemic much more frequently than other diseases, and invades particular regions at very short intervals. What are the causes of epidemic dysentery ? The causes of this as of most other epidemics elude our observation : though the in- quiry has been pursued very carefully, nothing positive has yet been established in respect of the conditions in which it originates. In Tours there are two barracks, one in the eastern and the other in the western faubourg: they are similarly situated, and at an equal distance from the river wrhicli flows through the town. The same hygienical system is adopted in both; and in both also, the dietary of the soldiers is exactly similar. Nevertheless, during the twenty years which preceded, and the ten years which followed, the period during which I studied at Tours, it was always in the cavalry barracks that the disease first broke out. The few soldiers belonging to in- fantry regiments who were seized with dysentery at the beginning of the epidemic had contracted it in hospital, whither they had been sent for other diseases: and it was not till a later period that the epidemic showed itself in the infantry barracks. Here then is a case in which no charge can be brought against the local situation, the hygienical conditions, or the food. You are aware that it is very common to impute the causation of dysentery to the use of fruits : so general is this opinion, that one finds it rather difficult not to acquiesce in it. It is, however, a prejudice against which the greatest practitioners of former times have con- tended. Without going back to Alexander of Tralles, who taught that grapes and other fruits not only did not produce dysentery, but 1 Zimmermans :—Yon der Ruhr unter dem Volke, 1765. Zurich, 1767— Traduction Franpaise par Lefebvre de Yillebrune; Paris, 1775. " Desgenettes :—Notes pour servir a Phistoire de la Medecine Militaire de l’Arm6e d’ Italie. [Recueil de la Sociele de Medecine de Paris, annee, 1797, T. II. 168 DYSENTERY. were, on the contrary, really preventive, and very often curative, I shall lay before you the views on this subject of Stoll and Zina- mermann, two of the most illustrious physicians of last century. Zimmermann says :—“ The majority of physicians and women- doctors [commeres] regard fruits of the season as the true and special cause of all dysenteric attacks. It is an opinion which I have re- futed in my treatise on practical experience in medicine; and the great physicians are on my side. Besides, the disease [the epidemic of 1765] appeared among our peasantry in June, when the only procurable fruit were the large cherries of Basle, and their high price placed them beyond the reach of these people: again, during the season in question, there was a great dearth of fruits. It is quite true that the unripe fruit of bad years may occasion colic, purging, as well as intestinal obstruction, and all the symptoms met with in nervous diseases; but still, no one has ever ob- served such a result as an epidemic of dysentery. I say, moreover, that cooling fruits even when not ripe, cannot cause dysentery.” Gentlemen, I attach no value to Zimmerman's reasons, which I join with you in condemning, as merely the echo of the humoral theories of his time; but that does not affect his clinical statement, which is quite applicable to what we are now seeing. Last year, for instance, when fruits were very abundant, there were hardly any cases of dysentery; and this season, when fruits are scarce almost every- where, v7e have this formidable epidemic. It cannot be denied that the spread of the disease is promoted by unfavorable hygienical conditions, such as hot vTeather, bad food, and crowding; but they are only proximate causes to which vre must add another something, and that something we call the epidemic constitution. We cannot otherwise explain why dysentery does not always show itself in those years in which the heat is greatest; why it does not invariably appear wdiere there is overcrowding; and w-hy, for ex- ample, (not to go beyond this line of argument), it so generally spares Paris, so little spared by other epidemic diseases. Therefore, as I have just been saying, wre are in absolute ignorance of its primary cause. We know, however, that when once developed, it is exceedingly contagious; although Stoll denies the contagious character of dysentery as well as of scarlatina. That both diseases, however, are contagious is evident. In small places, it is easier than in great DYSENTERY. 169 centres of population to trace back the disease to its source, and to follow its progress in the regions which it invades. Have not our honorable colleagues of the army of Africa, where dysentery, at in- tervals, commits great ravages, told us, that when it prevails in a regiment, it declares itself at every station where that regiment halts, thus following in the march of our expeditionary columns P1 And when from the Algerian hospitals being overcrowded some of the dysenteric patients have been sent to Marseilles, that town has become the centre of an epidemic of dysentery such as had never occurred before the arrival of these sick soldiers. Gentlemen, before describing the symptoms of dysentery, I must tell you that the disease does not always assume the same forms in all epidemics. On this subject, read the accounts which have been left to us by Pringle,3 Zimmermann, and particularly by Stoll.3 There, you will see that the disease is sometimes purely inflammatory, and at other times rheumatic or catarrhal, for, according to the dis- tinguished physician of Vienna, there is no difference between rheu- matism and catarrh except in the seat of the disease : dysentery, he calls rheumatism or catarrh of the intestines, or abdominal coryza. The form of dysentery which generally predominates is the bilious. At the beginning of the attack, and without appreciable cause, the patients are seized with diarrhoea; in twenty-four or forty-eight hours, the stools change their nature and aspect and become dys- enteric. They contain glairy, yellowish white mucosity resembling a mixture of the white and yelk of an imperfectly cooked egg; or there is an admixture of transparent glairy matter with thin streaks of blood; or there may be an appearance which recalls that of peripneumonic sputa. The evacuations are preceded by frequent desire to go to stool, at times almost incessant, but which result in not more than a spoonful or half a tea-spoonful being passed at any one time. They are accompanied by great pain in the anus, which sometimes extends to the bladder, producing dysuria. Tenesmus of an exceedingly painful nature is an essential characteristic of dysentery. 1 Haspel :—Maladies de l’Algerie: Paris, 1852. See Dysentery in second volume. 2 Pkingle.:—Observations on the Diseases of the Army: London, 1772. [French translation, published at Paris in 1793.] 3 Stoll:—Aphorismes et Medecine Pratique, (par Mahon, Paris, 1809).— Ratio Medendi in Nosocomio Practico Vindobonensi: Yiennse, 1783. 170 DYSENTERY. There is likewise colic, more or less acute, which is felt principally around the navel and in the course of the large intestine. The abdominal pain is increased on pressure, particularly in the left iliac fossa. The tenesmus has been explained by alleging the existence of spasmodic contraction of the sphincter; but this explanation is at once refuted by examining the patients—which I have done many times in your presence—when we find that the anus, in place of being tight and closed, is sufficiently open to allow the five fingers to be introduced. The violent irritation, the acute inflammation of the intestinal mucous membrane, which is intensely red and turgid at the gaping orifice of the anus, quite accounts for the acute burn- ing sensation felt by the patient, and for the painful constriction of the intestine, the lower sphincter of which is evidently inert and paralysed. It is not unusual for this combination of paralysis of the sphincter with turgidity of the mucous membrane, to cause prolapsus of the rectum. Along with the glairy frothy matter of which I have been speak- ing, dysenteric stools likewise contain pure blood, short thin shreds of false membrane greatly resembling burst boiled rice, and which when somewhat longer and thicker, constitute that which the patients call the scrapings of the gut. The quantity of dysenteric matter evacuated at each effort to defecate is small; but as the efforts are repeated at very short in- tervals, a patient may have during the twenty-four hours, as many as twenty, forty, fifty, or even two hundred stools, and thus the total amount passed from the bowels may amount within that time to two, three, four, or six litres. It is a remarkable fact, and one specially characteristic of the malady we are nowr studying, that there are seen in the midst of the stools small masses of faecal matter, which are moulded, and more or less hard: some of these masses are even scybalous, such as are passed by persons suffering from constipation. In point of fact, Gentlemen, in accordance with Stoll’s correct observation, dysentery ought to be considered as one of those disorders in which the bowels are confined. So much does it differ from diarrhoea, that although, in some cases, it is complicated with iliac diarrhoea as an epiphe- nomenon, for the most part the diarrhceal excretions which super- vene in dysentery announce the termination of the attack. About the eighth, tenth, or fourteenth day of the disease, dys- DYSENTERY. 171 enteric stools are horribly fetid and contain almost no mucus: they consist of a reddish serous liquid in which float shreds resem- bling the debris of over-stewed meat. These flesh-washings, to adopt Stoll's expression, almost invariably indicate gangrene of the intestines. Then also, and even sooner, the evacuations contain pus. Having described the nature of dysenteric stools and the local phenomena by which they are accompanied, I now come to speak of the general symptoms, which vary according to the particular form which dysentery assumes in different epidemics, and which may also be met with in the same epidemic. In the bilious form, patients complain of loss of appetite, of a bitter taste in the mouth, of nausea, and of vomiting a greenish matter. The tongue is covered with a saburral coat. The rigors which usher in the attack are of short duration, and there is no much fever. The abdominal pains are of moderate severity. In this form of dysentery, contrary to what generally occurs, there is diarrhoea. The stools, however, though frequent, are scanty : they consist of a greenish or yellowish liquid, in which float mucous, glairy, sanguinolent matters, and sometimes blood nearly pure. Inflammatory dysentery is characterised by burning fever, a notable frequency and hardness of pulse, heat of skin, and sometimes copious sweating. The face has a more or less bright red appear- ance. The tongue, in place of being saburral, is red, dry, and clean. The patients suffer from headache. The abdominal pains, violent and torminous, to use the consecrated term, are aggravated by the least pressure. In some individuals, the abdomen is tym- panitic. The stools are few in number. As they become more frequent, the febrile excitement soon subsides. In rheumatic dysentery, the abdominal pains are most marked. Each time the patient goes to stool, his sufferings are depicted on his countenance, which is expressive of the most painful anxiety; and there is extreme tenesmus. But the chief characteristic of this form of dysentery is the occurrence of metastatic affections of the joints, as was accurately pointed out by Stoll. Sometimes, the metastatic affections are localised in one particular place; and it seems to me, that the knees are most frequently the elected situations. The articular rheumatic inflammation is generally rather transient, or at least is not severe; but sometimes it is of long duration, and of so severe a character that the great quantity of the synovial effusion causes rupture of the 172 DYSENTERY. capsule. The rheumatic attacks are generally erratic, seizing first one place and then another. The chest may be attacked just at the very time when the dysentery is beginning to subside : the patients complain of pleuritic or simply pleurodynic pains : others suffer from oppression, cough, and all the other symptoms of catarrh. Gene- rally, the catarrhal or rheumatic affections yield spontaneously within a very few days. The transformation of dysentery into rheumatism was observed by Dr. Gondouin in an epidemic which prevailed in the department of Sartlie. When dysentery prevails in a district in which palustral fevers are endemic, it is not unusual for the accompanying fever to become intermittent, assuming the tertian or double tertian type. The intermittent is considered the least formidable form of dysentery. Under all its forms, dysentery follows a regular course. Putridity and malignity come athwart that course, complicating it and leading to a fatal issue, as you saw in the case of the unfortunate woman of bed ii St. Bernard’s ward. Algidity is its predominating characteristic. The skin becomes cold, and covered with cold sweat: the complexion becomes clay- coloured : the features are shrunken and the eyes sunken: the extremities, point of the nose, and the tongue are cold. The patient has all the appearances of an individual in the algide stage of Asiatic cholera-morbus. He has, however, merely the appearances of cholera, and we have still oidy to do with dysentery; but it is hardly necessary to say that the disease really changes its nature when cholera is epidemic in a locality already a prey to dysentery. As the slightest diarrhoea gives cholera a pretext for attack, it is not surprising that cholera should strike with fury those prepared by pre-existing dysentery to receive it, and carry them off before the dysentery has had time to pass through its stages. The most marked signs then of malignity in dysentery are algidity coincident with a feeling of great general discomfort; extreme, suddenly supervening feebleness, attended sometimes with fainting fits, and prostration to so great a degree as to render the patients almost indifferent to everything going on around them. The pulse is exceedingly weak, small, and compressible. There are, however, dysenteric patients in whom the temperature rises in place of falling, and in whom the pulse is accelerated and DYSENTERY. 173 less compressible; there is burning thirst: the tongue is dry, and a fuliginous coat covers tongue and gums: aphthous ulcerations appear in the mouth. During these dangerous periods of the disease, the stools become smaller and less frequent, acquire a fetid cadaveric odour, and contain matter resembling flesh washings. There is almost no abdominal pain. The patient complains of a sinking feeling at the prsecordium, of nausea, hiccup, and vomiting. Then also, parotiditis occurs as a complication. The patients complain of pain at the angle of the jaw, where, on examination, there are found swelling, redness of the skin, and a sort of deep- seated fluctuation. By pressing on the parotid region, and on the cheek in the course of Steno's duct, pus is made to issue from the orifice of that canal. The suppuration invades the surrounding cellular tissue, reaching the neck sometimes, and dissecting its mus- cular masses. These symptoms announce that a fatal issue is near. Stupor comes on, complicated with slight convulsive movements, sub- sultus tendinum, and low delirium, death speedily closing the dis- tressing scene. Upon opening the body after death, the depth of the anatomical lesions perfectly account, up to a certain point, for the severity of the disease and its fatal issue. The intestinal lesions, which existed chiefly in the large intestine, were the result of violent inflam- mation : the mucous membrane, of a brownish deep-red, a colour derived from blood mixed with intestinal secretions, is thickened, turgid, and softened : this turgidity and thickening extended to the other tunics, and even to the subperitoneal cellular tissue. Here and there, ulcerations were observed, varying in size and depth according to the period of their commencement. When, at its onset, dysentery strikes down individuals, the ulcerations, about the third or fourth day, are quite superficial, and covered with a muco-sanguinolent fluid: by the fifth day, they assume a very varied aspect: during the course of the second week of the disease, the mucous tunic is more or less destroyed in extent of surface and in depth, so as to expose the muscular tunic. Sometimes, even, the ulceration destroys likewise the muscular fibres and reaches the peritoneum : under such circumstances, there may occur peritoneal perforation leading to peritonitis, but this is a rare occurrence. 174 At other times, there is a multitude of small ulcerations, the orifices of an equal number of small abscesses formed in the sub- mucous cellular tissue. In other cases, or in other situations, there are seen gangrenous sloughs, completely detached at some points, and mixed with a sort of magma, a black, bloody porridgy matter, which covers the surface of the mucous membrane, and is in other places adherent to the parts whence it proceeds. These gangrenous lesions may dissect a great part of the large intestine, so as to present an appearance of a great portion of its mucous coat being entirely destroyed. When, from accidental causes, death does not occur till a remote period—till four or five months after the invasion of the first symptoms—and when recovery from the dysentery has taken place —the ulcerations are found to be cicatrised or nearly cicatrised; but then the cicatrices have given rise to other lesions which may have occasioned death. I refer to strictures of the intestinal tube caused by the contraction of the cicatricial tissue. These strictures explain the pains which often continue long after the disease. They explain the intestinal obstructions and occlusions, in which originate the attacks of subacute peritonitis under which the patients sink. Buboes occur in dysentery, as in all other pestilential diseases. The mesenteric glands are swollen and inflamed, while some are in a state of suppuration. The parenchymatous tissue of the liver, kidneys, and spleen, is softened. The gall-bladder is distended by black, pitchy, grumous bile. In some cases, there are true hepatic abscesses. Gentlemen, I showed you a patient who at the close of an attack of dothinenteria, had had the symptoms characteristic of purulent infection. At the autopsy, as you will recollect, we found a large metastatic abscess in one of the psose muscles, and numerous abscesses of the same kind in lungs and liver. When speaking to you upon that case, I explained to you that my understanding of the way in which dothinenteric ulcerations become the starting point of purulent infection, is the same as in the external wounds wrhich we see in the surgical wards, or the placental wound of the wromb which occurs after delivery. I likewise told you that, in all probability, the hepatic abscesses and the articular suppurations met with at the close of an attack of dysentery, proceed from the same cause. Henceforth at autopsies, it will be necessary to search carefully for metastatic DYSENTERY. DYSENTERY. 175 abscesses of the lungs and kidneys, and to examine minutely the state of the veins leading from the large intestine to the liver. Gentlemen, you will remark that I have said nothing about the lesions of the small intestine. I have not thought this necessary, because when lesions of the small intestine do occur, they are quite secondary. Spots, more or less red, and traces of existing inflammation are met with, and (as in the patient whose autopsy you witnessed), the glands of Brunner and Peyer are exempted from attack in a ratio the opposite of that met with in dothinenteria. The disease has attacked the large intestine principally if not exclusively : let me now add, that the inflammatory lesions which I have pointed out to you are much more extensive when situated nearer the lower extremity of that part of the intestinal tube and become less and less formidable the nearer they get to the caecum. In conclusion, dysentery is nothing more than colitis, but a colitis of a peculiar character, the special characteristics of which do not allow us to confound it with non-epidemic colitis—with that form, for example, of colitis which supervenes after an excessive dose of a drastic purgative, such as jalap or colocynth. Dysentery is also quite a different disease from those attacks of colitis so common in young children and old people, which occur irrespective of any epidemic constitution of the season. To mention some symptoms only, the different kinds of colitis are characterised by sanguinolent, glairy, mucous stools, by tenesmus, which latter, however—and this is a point of differential diagnosis— is never so severe in simple colitis as in dysentery. The lesions though never so profound and extensive in the one as in the other, are of similar nature in both—they are thickening of the large intes- tine accompanied by turgidity, redness, and ulcerations more or less serious. But the feature which essentially distinguishes dysentery from colitis is that the latter is a disease pertaining to the individual, for the most part mild and transient, generally yielding without its being necessary to resort to treatment of any great energy; while epidemic dysentery presents that assemblage of general symptoms of peculiar character and varying severity, which I have described to you; and dysentery, moreover, when left to itself, has a tendency to become aggravated, its gravity in some epidemics being so great, that it often baffles all our therapeutic efforts. What are the measures by which we ought to oppose this for- midable disease? The importance of this question makes it in- DYSENTERY, cumbent on me to give a certain degree of development to the reply. Having seen at Tours, Versailles, and Paris, several epidemics of dysentery, which carried off men in the prime of age and strength, as well as old people and young children, I am able to speak, and I wish to speak, from my own personal experience. Having been entrusted by the committee on epidemics to give an account to the Academy of Medicine of the reports annually received from the departments, I have had to compare observations brought together from all sides, comparing them at the same time with observations collected by myself. Pinally, in reading the accounts left to us by our predecessors, I have been able to complete my own experience by adding to it that of others, and to form, on a sound basis, opinions as to the treatment which presents the greatest pros- pects of success.1 Thirty or forty years ago, we seemed to have quite lost sight of the traditions of past centuries. Broussais had made a tabula rasa of everything said prior to his day, and pretended to have reesta- blished medicine on new foundations. Inflammation according to him was dominant everywhere, and was alwTays of the same nature. In dysentery, he saw colitis only; and starting from that point, the treatment w*as necessarily antiphlogistic. Endowed with a great talent for exposition, influenced by an impetuous mind and a profound conviction of the soundness of his view's, he proclaimed that no treatment except the antiphlogistic wras right: his pupils “ swrore by their masters word,” and spread his opinions everywhere, till they became accepted, without any modification, by so large a number of physicians that for a long time they dominated in medicine. In 1823, however, Bretonneau, a man profoundly clinical, dis- mayed at the non-success of a system of treatment, based upon a preconceived theory rather than upon sound observation, resolved to place himself in opposition to the deplorable practice which resulted from the doctrine of the Val-de-Grace. Having before him, as exemplified in his own practice and that of many others, the sad results of indiscriminate resort to the antiphlo- gistic treatment on all occasions and without reference to the form 1 Tkousseau :—llapports sur les Epidemics qui out regnd en France, pendant I’annee 1856. [Memoires de l’Academie, Paris, 1858: T. xxii.] DYSENTERY. 177 of the disease, he set himself to make trial of the treatment by purgatives in accordance with the plan followed by Stoll, Zimmerman, and Pringle, all of whom stated that they had found it very useful. The trial was attended by success. He then sought for an explanation of the successful results obtained; and he came to the conclusion that in dysentery, as in dothinenteria the quality, the specificity of the local inflammation, plays a much more important part than its quantity : he likewise thought, that most probably the beneficial action of purgatives was due to their substituting for a specific local inflammation of bad type, another inflammation which, although it has also a specific character, has a natural tendency to cease. While in respect of Broussais’ doctrine, theory took the lead, and moulded facts to its service, Bretonneau',s doctrine advanced, under the simultaneous and combined support of observation and theory. Prom that time, and in the different circumstances in which he was placed, the illustrious physician of the hospital of Tours, recognised that the purgative treatment was that most frequently indicated in dysentery. In the account given by Dr. H. Parmentier and me of an epidemic which prevailed in 1826 in the department of Indre-et-Loire, you will find it stated that a really great proportion of recoveries followed the treatment just described.1 I have long employed it; and it has rendered me signal services in the different epidemics against which I have had to contend. Such was the case in the epidemic of 1848 in the garrison of Versailles, whither I went every morning to study the disease in the wards of the military hospital, then in charge of my honourable col- leagues Drs. Perrier, Bollet, and Godard. In the reports communicated to the Academy of Medicine, to which I have just been alluding, there is expressed an almost unanimous opinion in favour of this powerful method of treatment. Nearly all the reporters state that the administration of purgatives was the chief means by which they opposed the disease; and that the purgatives which they principally used were the neutral salts, such 1 Trousseau et Parmentier:—Memoire sur une Epidemie de Dysenterie qui regna dans le departe-d’Indre-et-Loire. [.Archives Generates de Medecine pour Vannee 1827.] 178 DYSENTERY. as sulphate of soda, sulphate of magnesia, and the neutral tartrate of potash and soda, called sel de Seignette. These are the medicines which you have seen me prescribe in the cases which have come under your observation. In my civil practice, I always have recourse to them, particularly in the commune in which my estate is situated, where this year dysentery has committed great ravages. My own household was not spared, several members having been attacked, and one child having died. My farm-bailiff was seized with the malady: I gave him the neutral salts; and though he committed imprudences, he recovered. Generally per- sons recover who are treated in this way, while those who neglect to call in medical aid, or are very late in doing so, and who conse- quently are not actively treated, either die or continue deplorable invalids for six weeks or two months. The evacuant method praised by the physicians of last century, and particularly the administration of the neutral salts in purgative doses once daily, or morning and evening, so as to induce diarrhoea, is, therefore, the best treatment of dysentery. Does it follow that we are to confine ourselves to the use of the sulphates of soda and magnesia, and the salts of Seignette ? Cer- tainly not: there are cases in which other purgatives may be employed with advantage. In 1812, there was dysentery at Gibraltar; numerous deaths from it had occurred, when Dr. Amiel, surgeon-major of the 12th regiment of infantry of the English army, conceived the idea of having recourse to sublimed calomel. This he gave in doses of one gramme, eighty centigrammes [27 grains] morning and evening till the evacuation ceased to be mucous and sanguinolent, and had assumed a deep red colour : the dose was then reduced; and after- wards, the calomel was discontinued, when lavements wrere used in its place. So great was the success of this treatment, that the director- general of the military medical service made obligatory its employ- ment by all the other physicians. In the epidemic of Touraine, which I spoke of a minute or two ago, Bretonneau and I tried this plan of treatment, and obtained similar results. We were, however, obliged to abandon it, on account of the salivation it occasioned in some patients, a complica- tion from which the Gibraltar patients were exempt. This difference arose from the Gibraltar epidemic having occurred during the hot weather, and in a place where the temperature is naturally very high, DYSENTERY. 179 so that the patients ran no risk of chills: at Tours, on the other hand, at the time we gave the calomel, the bad weather was setting in, and the patients being obliged to pass several hours on the stool [sur leur chaise percee], were exposed to chills which favoured the toxic effects of the mercury. How does the calomel act ? Is its action exclusively topical and substitutive, like that of the neutral salts ? Or, is it more general, and does the benefit derived from this medicine depend on its action as an alterative ? These are difficult questions to answer. I should, however, be rather inclined to adopt the former of the two explana- tions, and to accord only a very slight share in the beneficial results to its alterative powers, when I consider that calomel is never so useful as when administered internally, and that I have never heard it said (except by Boag as quoted by Gmelin),1 that mercurial frictions of the skin are of any use. Calomel was also the basis of the treatment of Dr. Leclerc, but our colleague of Tours in place of giving it in large doses, administered it at first in fractional quantities, that is to say in doses of one centigramme [-}th of a grain] morning and evening, after- wards increasing the quantity by an additional centigramme on succeeding days. Simultaneously, and with a view to moderate the tenesmus M. Leclerc prescribes inunction of the abdomen with an ointment of belladonna. I have often had recourse to and have observed the good effects of these inunctions. Adopting at the same time the medication of MM. Amiel and Leclerc in a modified form, I have given calomel fracta dosi according to Law’s method, that is to say, in doses of five centigrammes divided into ten packets, one of which was administered every hour. This method has appeared to me particularly advantageous in the treatment of dysentery in children, as it is very difficult to get them to take saline purgatives. A similar remark applies to the purgatives to which it is necessary to add rhubarb, a combination in favour with some excellent physicians. I have now to speak to you of emetics, which occupy an im- portant place in the evacuant method of treatment, as applied to dysentery. 1 Gmelin :—iu Murray’s Apparatus Medicaminum, [Pars II] : Gottingse, 1793- DYSENTERY. About the middle of the seventeenth century, Piso, the botanist, having, when in the Brazils, heard the praises of a root which was administered in powder, endeavoured to introduce it as a medicine;1 but the medical profession hardly paid any attention to his writings. It was in vain that Legros who had made three voyages to America, brought a supply to Prance, and offered for sale “ ipecacuan ”—for that was the name of the wonderful plant. The new remedy received no credit save from the ranks of quackery. In 1686, nearly, in fact, at the date at which cinchona, the famous remedy of Talbot, had procured for its discoverer the patronage of Louis XIV and a large fortune, a French merchant, named Grenier, imported from the Brazils 75 kilogrammes [between 150 and 160 pounds] of the root of ipecacuan. Not knowing how to turn it to account, nor how to give celebrity to his new medicine, he assumed as a partner Adrian Helvetius, a Dutch physician practising in Paris, whom he made acquainted with the antidysenteric virtues of his arcanum. Helvetius made his first experiments upon obscure persons, then upon persons higher in the social scale, and finally upon the Dauphin himself, whom he cured of a sanguineous ffux: he then obtained permission from the King to make public experiments at the IIotel-Dieu. His experiments having succeeded, he obtained a monopoly of the sale of his remedy, besides a money grant of a thousand pounds. Helvetius, however, acting the part of an unscrupulous partner, kept to himself all the honour and profit: Grenier then tried to be reinstated in his rights, and with that object instituted in the parliament a suit, which he lost. Grenier, indignant at the bad faith of Helvetius, divulged the secret; and from that time ipecacuan became public property. Afterwards, by one of those reactions so common in the history of opinion, a tendency arose to abuse the remedy which had had so much trouble in making itself at all accepted. The utility of ipecacuan in dysentery is, however, incontestible; it is chiefly beneficial in the bilious form, at the beginning of the attack, Avhen the coated tongue indicates a very marked saburral state. It acts, on the same principle as purgatives, as a powerful modifier, and its action is equally beneficial on the entire digestive canal as on the stomach. 1 Piso:—De Medicina Brasiliensi; et Ilistoria llerum Naturalium Brasilia;. Lugduui Batav., 1648. DYSENTERY. 181 To sum up :—here is the plan I generally adopt in the treatment of epidemic dysentery ! At the beginning of the attack, I prescribe ipecacuan in emetic doses, according to the formula which I have given you so often :—three grammes [464 grains] are divided into four powders, one of which is taken every ten minutes till vomiting is induced. Next day, and often even on the evening of the same day in which the ipecacuan has been thus administered, I give one of the neutral salts in a dose of from 15 to 25 grammes [2314 to 386 grains] which ought to be repeated during the following twenty-four hours. I go on giving the saline medicine till there is an obvious modification in the nature of the stools, or in other words, till they cease to contain glairy sanguinolent matter and become diarrhoeal. But concurrently with the use of the means now described, I attack the disease by topical agents, which have a still more direct action on the affected parts. I use styptic and caustic lavements with sulphate of zinc, sulphate of copper and nitrate of silver. For a child, I use nitrate of silver in the proportion of from 5 to 10 centigrammes [-f- of a grain to i4 grain] of the nitrate to 125 grammes [43- fluid ounces of water : for an adult the proportions are from 20 to 75 centigrammes [3 to 114 grains to 200 grammes [7 fluid ounces] of water. The sulphates of copper and zinc are used in the proportions of about 5 centigrammes [4 of a grain] for a child and one gramme for an adult. The lavements are repeated two or three times in the twenty-four hours. They ought to be retained within the bowrel as long as possible: to promote this object a lave- ment of pure w?ater ought in the first instance to be administered, and then the medicated lavement must be slowly injected. Lavements of the acetate of lead have been recommended, and I have employed them : without inducing any toxic effects, I have used a solution of from 30 to 60 grammes [460 to 920 grains] of acetate of lead to a litre [rather more than 35 fluid ounces] of distilled water. Gentlemen, you will be surprised that hitherto I have said nothing of opium, w7hich in the opinion of some physicians seems to be a remedy essential in the treatment of dysentery. I have only to mention it that I may raise my voice against the lamentable manner in which it is too often abused; and I shall recapitulate what I said at length on that point in my lectures on diarrhoea. "When opium is indicated it is not for the purpose of stopping the dysenteric flux, but for moderating the accompanying pains and 182 DYSENTERY. particularly for checking the vomiting which renders the administra- tion of other medicines impossible. In all such cases, the opium must be given in very small doses, beginning with one drop of the laudanum of Sydenham, which may be repeated every hour according to the persistence of the symptoms for which it is administered : the doses of opium must be small, for by giving large doses, the malady will become complicated by formidable typhoid symptoms. There is another point in the treatment of dysentery upon which I must make some remarks. Every day, you hear me prescribe soups for our patients, even for those who are in a very bad state: you observe that I insist upon their taking three or four times a day a small quantity of thick panada. As a tisane, I order barley-water, rice-water, albuminous water,1 or the white decoction of Sydenham, which is simply a form of toast and water. To this practice I attach extreme importance. In dysentery, as in typhoid fever, I look upon alimentation as a matter of absolute necessity; and this opinion has been confirmed by long experience. You thus understand, Gentlemen, that I abstain from antiphlogistic treatment because it would be completely opposed to my alimenting the patients, which I regard as an imperative indication. It is only when the predominating symptoms are of a purely inflammatory nature that the application of leeches is right: such cases are unusual; but when they do occur, they ought without delay to be met as I have stated. The treatment which I have recommended to you, based on my own practice and on the experience of numerous physicians, though that on which we ought to rely, is unfortunately not infallible, and is much less successful in some epidemics than in others. In conclusion, I repeat, that dysentery is the most formidable and dangerous of all epidemic diseases. Even when patients have resisted its first assaults, and seem to be reaching convalescence, danger is not past, and there are evil consequences to be dreaded after the disease. I do not now speak of the dropsical affections of a more or less general nature, or of the paralytic seizures which supervene during the course of the disease, such as supervene in the course of serious fevers, in dothiuenteria, for example, which profoundly implicate the whole economy. However alarming these complications may be, 1 See p. 136. DYSENTERY. 183 they can be got rid of by tonic regimen, restorative diet, and hygienical care. Nor do I speak of purulent infection, or of hepa- titis with abscess of the liver, which, though rare, have nevertheless been noted among the sequelae of dysentery. I speak of intractable diarrhoea caused and kept up by lesions, more or less deep-seated and more or less extensive, of the large in- testine, lesions which are abvays accompanied by an inflammation, an irritation, which makes itself felt throughout the rest of the intes- tinal canal, disturbing its functions, exhausting the strength of the patients, and causing them to sink with every symptom of hectic fever, against which all therapeutic measures are unavailing. Finally, the intestinal adhesions may lead to 'perforations, as I stated when describing the pathological anatomy of dysentery. They may occur at a period more or less remote, giving rise to rapidly mortal peritonitis. Attacks of peritonitis may also originate in intestinal obstruction, caused by the contraction of cicatricial tissue bringing the walls of the tube into mutual proximity, so diminish- ing its calibre, and constituting stricture. LECTURE LXXY. CONSTIPATION. Constipation is not necessarily a state of impaired health.—Causes. Treatment: Influence of Will and Ilabit: Cold lavements: Suppositories of cacao-mit butter, soap, and hardened honey : Mucilaginous Lavements: Belladonna, with or without small doses of Castor-Oil.—In Obstinate Constipation have recourse to Drastic Purgatives.—Hygienical Measures : Regimen: Bran- bread. G entlemen :—I have already, when speaking of dyspepsia, made a few remarks regarding constipation : but the subject is one which merits being treated at greater length; and, moreover, I ought to state to you the reasons which induce me to treat by means so very different, a symptom which, in all patients, seems identical. For the present, I exclude from consideration, mechanical obstacles to the passage of the freces. I exclude tumours, and physical obstacles, using the word constipation in its ordinary meaning. I consider that constipation exists whenever the stools are few in num- ber, irrespective of any mechanical impediment to the passage of the faecal matter. You must bear in mind, Gentlemen, that in certain persons con- stipation is not an infirmity—that it is a state of the system—that unless it go beyond certain limits, it cannot be looked upon as a disease. When you recollect that there exists in the stools, in addition to the residuum of the aliment, a large quantity of juices secreted by the salivary glands, liver, pancreas and glands situated in the intes- tinal mucous membrane, you will understand that these juices may vary infinitely in quantity, not only in respect of the nature of the food and drink, but also in respect of the idiosyncrasies of the indi- vidual. You do not say that a man is in a state of disease because 185 CONSTIPATION. he perspires very little; and you have no more right to say so, because his digestive apparatus is in an analogous condition. Although, as a rule, every adult man ought to have a stool daily, there are some persons, who, from the peculiarity I have just men- tioned, have an alvine evacuation only once in two or three days, and in whom constipation belongs to a state of health. So true is this, that should the individuals of whom I speak have a non- diarrhoeal stool every day, they will experience pains in the bowels, borborygmi, a feeling of debility and general discomfort, precisely similar to the effects produced on other people by diarrhoea. The individual who is physiologically constipated—if I may use so incor- rect an expression—has relatively diarrhoea when he has daily a moulded motion. The contents of the intestines pass onwards in virtue of the peristaltic movement, and in no part of the canal is that movement more energetic than in the small intestine: in the large intestine, it is slower, or at least less efficacious, and the contractions easily ex- haust themselves by acting on the faeces accumulated in the rectum, and on the sphincter. We can any day appreciate these effects, when we resist the sensation by which we are apprised of a need to empty the bowel. We can generally accomplish this without difficulty, provided there be no excessive accumulation in the rectum. Habitual resistance of the peristaltic movement ends by enfeebling the excitability of the intestine, which exhausts itself in superfluous efforts, and becomes expended like all the other muscles; and which becomes so distended by gaseous and other contents, that the mus- cular tunic loses its contractile power just as do all hollow muscles when stretched beyond their normal distensibility. However, the continual contact of fsecal matter with the ex- tremity of the intestine impairs the sensibility of the mucous and muscular coats, and the synergic contraction of the upper portions of the large intestine either does not take place, or takes place in a most inefficacious manner. Gentlemen, I presume that you understand this mechanism. In the normal state, whenever you, in any way, irritate the lower portions of the rectum, you excite, in addition to the immediate contraction of the muscular coat of that portion of intestine, synergic contrac- tion of the portions situated above, and throughout the whole in- testinal canal upwards even tp the stomach, there being produced by CONSTIPATION. the augmented peristaltic motion: the entire contents of the intes- tines are propelled downwards, and there is thus established a state of diarrhoea. You see then that a solidarity exists between all the portions of the alimentary canal, a solidarity both in respect of excess and deficiency of action. Here then, it is sluggishness of the intestine, originating in and maintained by bad habits, which is the cause of the constipation. We shall afterwards see, when we come to speak of treatment, that the will, so powerful in causing the evil, is equally powerful in remedying it. It is not fcecal matter only which is accumulated in the large in- testine : the gaseous contents play a not less active part, and con- tribute not less powerfully to destroy the elasticity of the muscular coat of the intestine. This new anatomical condition, which in youth, and even in adult age, is so frequently the result of carelessness on the part of the patients, becomes in some degree a natural state at a more advanced period of life; for, with increasing years, the intestinal muscular tunic loses its tone, just as do the vesical muscular tunic, and certain muscles of organic life, those of the lungs for example, which allow themselves to be distended so as to cause pulmonary emphysema. In the same way, constipation depending on dilatation of the large intestine is not an accident, but, in a certain sense, a normal state in old people. Thus, Gentlemen, habitual distension of the large intestine leads to its muscular atony, in consequence of which the fecal matter does not easily proceed onward, and to a certain extent may be said only to make way from the pressure of the new accumulations behind: this atony is unquestionably the cause which most certainly produces constipation. But the rectum is certainly the portion of the large in- testine which is most essential to defecation. Provided with powerful fibres, strongly contractile, supplied with numerous nerves, and ter- minated by the anus, which is endowed with exquisite sensibility, this intestine cannot be normally filled with stercoral matter without having its contractility aroused, without trying to get rid of its con- tents. But when, with old age, the sensibility becomes blunted, and the muscular contractility enfeebled; or when the individual by obstinately retaining the fecal matter dulls sensibility, and accustoms the intestinal muscles to a state of constant distension, there is formed that dilatation of the rectum, that pouch, to which the term CONSTIPATION. 187 ampoule rectale, has been applied. There, the faeces accumu- late, and become agglutinated so as to form enormous boluses pressing on the anus, which are inexpulsable except by real parturient travail or by surgical intervention. This kind of consti- pation is more common than young practitioners suppose ; and there is this difficulty in recognising it, that it is sometimes accompanied by a diarrhoeal flux depending upon two causes, viz. the local irrita- tion excited by the presence of the excremental bolus, and the ex- cessive contraction of the colon synergically induced by the irritation of the rectum—a form of diarrhoea belonging to the class of diar- rhoeal affections due to the excitation of the lower part of the intes- tinal canal, and which we have already studied together in detail.1 Although the muscular tunic of the alimentary canal may be re- garded as the chief agent in pushing onwards the faecal matter to the colon—although in the child, and even in the adolescent, it is almost the sole agent in defecation, in the sense that no other agency is required for emptying the intestine—this is not the case in old people, and in persons habitually constipated. I may add indeed, that in general, after getting beyond the age of maturity, it is so no longer. The assistance of the expiratory muscles is then required. Now, Gentlemen, these muscles are under certain circumstances liable to become enfeebled, which renders their assisting efforts in a great measure inefficacious. I am not speaking at present of senile debility which has in the first instance suggested itself to you : I speak of the debility consequent upon repeated pregnancies. When the abdominal walls have been often distended by the product of conception they become extraordinarily flaccid, and unfitted to co- operate efficiently in the expulsatory efforts of defecation. There is a still stronger reason for this being the case when eventration exists. The same remark is applicable to hernia, which makes it to some extent a risk for the patient to strain energetically. In the latter case, the muscular power is intact, but the will restrains it from being called into operation. It is evident that practically a similar state of matters exists when the muscular efforts cannot be made without exciting violent pain : this occurs in rheumatism of the abdominal walls and diaphragm, and in painful affections of the abdomen : it occurs in those who suffer from piles, in those who have fissure of the anus and whose bowels cannot be evacuated except at the 1 See p. 105 of this volume. 188 cost of intolerable pain. These persons restrain the expulsatory action of the abdominal muscles, allowing the peristaltic action of the large intestine to accomplish nearly unaided the process of de- fecation. You perceive, Gentlemen, how all these causes, like the will, act in producing constipation. The diseases of the uterus and its annexes have a complex etio- logical action. If acute pain exist, as in metritis or in utero-pelvic phlegmon, the retention of the faecal matter is caused by a mechanism analogous to that which we have just been studying: the patient abstains from going regularly to stool because he is afraid of going, and ultimately he becomes habitually constipated. It is so likewise when there exists great prolapsus of the womb, which is always aggra- vated by the efforts of defecation, and which induces the woman to re- strain the muscular efforts as much as she can. In extreme anteversion, and still more in retroversion, constipation is produced by a particular mechanism. The pressure exerted upon the rectum, which is flat- tened by being squeezed against the cavity of the sacrum, prevents the contents from escaping through the sphincter of (TJBeirne, and the accumulation takes place in the horizontal portion of the sigmoid flexure of the colon. Now, in defecation, the colon acts with less power than the rectum, the contractile power of which is great: on the other hand, the matter accumulated in the colon does not pro- voke contraction of the rectum in the same -way as matter imme- diately above the sphincter. While great displacement of the uterus is a very effective agent in producing constipation, constipation will itself augment the dis- placement. Beconsider, Gentlemen, what I have now been saying. Suppose that the sigmoid flexure of the colon is filled with hard matter, and you will at once understand how it rests upon the floor formed by the anterior or posterior surface of the uterus, and how the muscular effort itself will augment the displacement and press the womb still more against the sacrum, and so render more formidable the obstacle to be overcome. Thus you see how it is, that constipation is so obstinate and troublesome in women whose condition is such as I have now described. Tor them, there is, in addition to the physical impediment, a sluggishness of the intestine, resulting from voluntary retention of the frnces, retention which is instinctively adopted by women to escape the pain and inconveniences which follow attempts to defecate. CONSTIPATION. CONSTIPATION. 189 The nature of the food and drink, and the sort of life which is led, have a remarkable effect in producing constipation : but in respect of these matters, the physician has no other guide than the idiosyncrasy of each individual. Speaking generally, however, we know that great abstemiousness, and a sedentary mode of life, are great predisposing causes. It is as unusual for great eaters as for persons wrho take a great deal of exercise to be constipated. It can also be shown that an exclusively animal diet predisposes to consti- pation, while the use of green vegetables and fruits produces rather an opposite tendency. Gentlemen, the remarks which I have made upon the conditions which give rise to constipation ought already to have suggested to your minds some therapeutical notions. You must have already seen that, although in many cases the measures employed to coun- teract this infirmity are necessarily inefficacious, or at least only palliative, there are others by which immediate and durable success is obtained. I have pointed out how constipation is produced by the habit of retaining the faeces; and in speaking of dyspepsia associated with constipation, I entered into some of the details of this subject.1 It must be stated—for it is a fact—that when constipation is not con- stitutionally inherent in the individual (which as I have shown you is sometimes the case), the will, patiently and regularly applied, will often triumph over this infirmity. It is necessary that the individual go daily at the same hour to the water-closet. It is also necessary that for a considerable time he make powerful defecatory efforts : should these efforts be unsuccessful, he must wait till the following day, even though he should previously experience a desire to go. If on the second day, after a new attempt, there is no evacuation, a lavement must be taken immediately—not a lavement of tepid water, but, in the first instance, one of w'ater with the chill off, and then one of cold wrater. On the following day, similar measures must be renewed, and repeated next day, should they have been unsuccessful —a second cold lavement must then be administered, should no stool have been obtained. The daily repetition of the attempt at the same hour to defecate, ends by causing a daily need to go to stool at that time: it seldom happens that persons who patiently pursue the manoeuvres I have now described for eight or ten days do not ulti- mately obtain a daily motion. 1 See p. 50 of this volume. 190 CONSTIPATION. There are, however, local adjuvants of some utility. I have spoken to you of the use of clysters of water with the chill off, fol- lowed by clysters of cold water. I have now to mention supposi- tories, which are more easily employed than clysters, particularly by men. In many cases, suppositories of cocao-nut oil suffice: soap suppositories have a more sure and energetic action: and those made of honey hardened by heat are still more efficacious. A sup- pository of hardened honey ought to be in shape and volume nearly like a pigeon’s egg. When it has been slightly moistened, it can be introduced into the rectum with great ease; and there are few cases in which it will not rapidly produce an evacuation. Quite under- stand, that I am decidedly opposed to the use both of clysters and suppositories, till energetic and fruitless efforts at defecation have been made on two successive days. I must not, however, omit to mention, that the time of day at which the patient goes to the wrater-closet is a matter of con- siderable importance. The morning is certainly the most favorable time; one is then less in a bustle—on getting up one can devote more time to the water-closet than is possible during the course of the day. There are also other reasons of convenience in favour of the morning, which I cannot and do not wish here to set forth; but you can understand what they are. It is worthy of remark, however, and the observation has been made by every one for himself, that immediately after a meal there is felt a somewhat urgent call to empty the large intestine. Perhaps the accumulation of food tends in a somewhat mechanical manner to expell the delayed residuum: or perhaps—and this explanation is the most reasonable—the renewal of digestion rouses throughout the whole alimentary canal a preparatory muscular action. It is not only true that the best chosen time for going to stool is immediately after a repast, and particularly after the most ample meal of the day; but then also is the time when the local adjuvant means which I have pointed out are most advantageously em- ployed. It is evident, Gentlemen, that irritant suppositories and even clysters cannot be employed without seriously disturbing digestion. Before leaving the subject of clysters, I have still something to add. We have seen that a deficiency in the intestinal secretions has a great influence in producing constipation; and you can under- stand that by injecting into the rectum strongly mucilaginous fluids, CONSTIPATION. 191 such as infusion of linseed, decoction of marsh-mallows, or wrhite of egg, the excrementitial bolus, and the mucous membrane of the intestine will both be lubricated, so as to allow the former to glide more easily over the latter. When the use of irritant clysters is indicated, it is advisable, in the first instance, to try the emollient enemata of which I have been speaking. Regimen is a matter of great importance. The surest plan to get the better of constipation is to make vegetable predominate over animal diet, to such an extent as the aptitudes of the stomach will permit. Herbaceous vegetables and fruits ought to take the first place in this regimen. But, Gentlemen, it is not easy to avoid going beyond or falling short of our aim. To produce diarrhoea is not to cure constipation, and is only substituting one disease for another. In respect of the vegetable diet, of the efficacy of which I have been speaking so favorably, it will only be useful if it be well borne. Certain kinds of aliment derived from the animal kingdom, such as milk-food, have a slightly laxative effect upon some individuals. Milk-food, may, therefore, be given, whenever it has an aperient effect, without causing indigestion. Many persons find coffee with milk and others find tea powerful correctives of constipation. Of drinks, beer and cider are most suited to persons of consti- pated habit. I may add, that I know many persons who, if they drink a tumbler of cold water in the morning fasting, are certain immediately afterwards to require to go to stool. It would be difficult for me, Gentlemen, to explain the mode of action of what is called bran-bread, a kind of bread made of three parts of flour, and one of coarse bran. I very often prescribe it: the patients eat it in place of ordinary bread, and in general the regular action of the bowels is greatly facilitated by its use. Yfe shall see immediately that belladonna is one of the most gene- rally successful remedies for constipation : and you can thus at once see by recollecting the similarity of the properties of belladonna and tobacco how it is that many men cannot go to stool unless they smoke a pipe or a cigar immediately after a meal. Although, at least in our country, it is not considered very proper for women to smoke, I almost every week advise ladies to try the effect of smoking a tobacco cigarette, to aid in overcoming constipation which had proved inveterate under every hygienical treatment. 192 CONSTIPATION. Following the example of Bretonneau, I constantly prescribe belladonna in constipation. I give it in the form of pills, each pill containing a centigramme of the extract, and as much of the powder of belladonna. One of these pills is taken daily, fasting, by preference in the morning on empty stomach, rather than in the evening. The number of pills may be increased from one daily to two daily within the first five or six days: they ought seldom to exceed four or five in the course of the 24 hours. Whatever number of pills are taken, they ought always to be taken at one time. I cannot tell you the manner in which they act. I can assert, however, that the majority of the patients who have per- severingly though fruitlessly followed the different counsels of which I have spoken to you, have at last obtained a satisfactory stool daily with the aid of belladonna. As soon as the stools become regular, the belladonna must be discontinued, and the organs be allowed to act without assistance. Should the use of the belladonna prove unavailing, a teaspoonful of castor oil may be given with it: and to avoid disgusting the patient, this small dose of the oil may be administered given in a gelatinous capsule. The intestine, prepared by the belladonna, yields to the purgative influence of the castor oil, which may be re- peated twice a wreek if required. By and by, both the laxative medicine and the belladonna may be discontinued. It is important not to go on using them too long, as that might lead to loss of appetite, and under insufficient alimentation, the constipation wrnuld return. But, Gentlemen, it will often happen that the constipation will resist the series of measures which I have pointed out. It then becomes necessary to have recourse to purgatives—extreme reme- dies, useful remedies, and indeed remedies which are indispensable, requiring, however, to be managed with certain precautions and with great prudence. In general, the saline purgatives ought not to be employed. They have a rapid, almost instantaneous action, which, liowrever, is not durable. After they have been used, the intestinal secretions, temporarily augmented, become dried up to some extent, just as the application of certain sapid salts to the mucous membrane of the mouth, after causing a profuse fiowr of saliva leaves a parched state of the mouth and thirst, proportionate to the intensity of the original effect. For some years past, a remedy, which has taken the name of vegetable calomel, has been much used in England. I refer to podophyllin, the active principle of the podophyllum peltatum. It is a very active medicine. I prescribe it in the form of pills, each pill containing one centigramme []- of a grain] of podophyllin, and the same quantity of extract of belladonna. One, two, or three of these pills may be given, morning or evening, fasting. The result is one or two easy stools unattended by colic or heat in the stomach. Generally, it is necessary to have recourse to the purgatives which are called drastic—particularly to aloes, extract of colocynth, gam- boge, and extract of rhubarb. These are the substances which enter into the composition of all the purgative pills so much used by our English neighbours. I use the following formula : CONSTIPATION. 193 Aloes . . G Extract of Colocyuth Extract of Hbubarb . f Gamboge ... , . r , . n ol eao1* 1 8™”™. grams]. Extract of Henbane . 25 centigrammes [nearly 4 grains]. Essential Oil of Anise 2 drops. To be made into a mass, and divided into 20 pills, which are to be silvered. The patient is to take, always in one dose, every second or third day, from one to three of these pills, the number of the pills for a dose being proportionate to the purgative effect produced. They ought to produce an easy and natural, or semi-diarrhoeal evacuation. The time at which these pills ought to be taken is not the same with all patients. Generally, it is best to give them at the beginning of the evening meal. In some persons, however, they produce a sort of indigestion, or act so quickly as to disturb sleep by causing eva- cuations during the night. When the pills act too rapidly, it is better to administer them to the patient in the morning fasting, or at the first meal in the morning. On the other hand, when they are slow in producing an effect, they should be given at the evening repast; or, if their administration at that time cause indigestion, let them be taken at bedtime, when the result will be a stool next morning. You observe that I add henbane and oil of anise to the purgative ingredients of these pills. These additions, recommended by many English practitioners, are very useful: they prevent griping, and the henbane, in addition to its anodyne properties, exerts a beneficial CONSTIPATION. influence, similar to that produced by belladonna and other active plants of the family solanese. Some prefer to give rhubarb in powder, immediately before dinner, in doses of from forty to sixty centigrammes [6 to 9 grains] and upwards. Whatever may be the influence of these purgatives, they ought never to be resorted to till the other means regarding which I have spoken at length have completely failed. The use of these pills is certainly less injurious than is generally sup- posed ; and the abuse of them in England shows that we, on this side of the Channel, are inclined to exaggerate their evil effects. But it is not the less true, that regularity in obtaining relief from the bowels obtained by the observance of hygienical rules, by good and suitable food, and by habit, is always, in the end, preferable to that procured by artificial means. Before leaving the subject of the treatment of constipation, let me refer to the application of cold to the abdomen, a minor method which I have seen recommended, and have myself prescribed, with astonishing success. On rising in the morning, let there be placed on the naked abdomen a compress of several folds soaked in cold water, and let it be separated from the clothes by a sheet of gutta percha or caoutchouc. This compress ought to remain on for three or four hours. LECTURE LXXVI. FISSURE OF THE ANUS. Treatment by Rhatany.—Constriction of the Sphincter of the Anus is the Effect and not the Cause of Fissure.—Fissure is very common in Women Recently Delivered: why it is so.—The Cura- tive Effect of Rhatany depends on its modifying the character of the ulcerated surfaces, and tonifying the parts.—Its action ought to be promoted by Belladonna, which is a remedy for con- stipation.— When Rhatany fails, recourse must be had to a Surgical Operation; that which seems the best is Forcible Di- latation. Gentlemen :—That small portion of St.- Bernard’s ward which we reserve for nurses affords us frequent opportunities of observing an affection which, though apparently insignificant in respect of danger, is a source of great misery to the patient: I refer to fissure of the anus. The history of this affection belongs rather to clinical surgery than to clinical medicine. I cannot, nevertheless, pass unnoticed the numerous cases which daily present themselves to your observation; and I feel the more bound to call your attention to them, that one of my plans of treatment which I have long used successfully, is purely medical, if I may so express myself, and has not been sufficiently appreciated by surgeons. It consists in using clysters containing extract and tincture of rhatany. The fissure or chap in the anus, which has been justly compared to cracked lips resulting from exposure to cold, consists of small, narrow elongated ulcers situated between the stellate folds of the fundament. "Women are much more subject to these fissures than men: and they are of far the most frequent occurrence in women who have been recently delivered. I shall tell you why it is so. From the extreme frequency of this affection, it might be supposed that it has been known from very remote times: but my honourable colleague Professor Yelpeau correctly wrote in 1838, that not more than twenty years had elapsed since fissure of the anus was first described as a distinct malady. Boyer, who was the first to describe this affection in detail, advanced a theory in explanation of the mechanism of its pro- duction, and upon that theory based the plan of treatment which he adopted. He rested his opinion upon the fact, that he had never seen fissures unaccompanied by constriction of the sphincter of the anus, and that he had also several times observed all the symptoms cha- racteristic of fissure without finding anything more than stricture : and also from the fact that section of the sphincter, even without touching the ulcers, immediately afforded relief, Boyer concluded that stric- ture is the sole cause of fissure. He said, that the anal orifice is closed at the time of defamation by energetic spasmodic contraction of the anal orifice, and that the solid contents of the bowel, by forcing a passage against that impediment, cause tearing of the parts. Fissure in his opinion is only a complication, or an accessory, of the disease; and he thought that the only treatment required for the immediate cure of stricture and fissure was relaxation of the spasmodic stricture by section of the muscular fibres. At the present time, a few surgeons hold Boyer’s view, that the fissure is in itself of little importance, and that the preponderance of pathological importance belongs to the stricture; but generally, the only anxiety is to find means wherewith to modify the ulceration either by converting the wound, by an incision, into a simple wound, or by employing detergents, caustics, and the various ointments used in the' treatment of obstinate ulcers in other situations. The treatment which you see me employ is founded upon this principle. The chief efficacy of rhatany depends on the modifying influence which it exerts upon the morbid surfaces : but it pos- sesses, in virtue of principles which it contains, the additional advan- tage of increasing the tonicity of the mucous membrane of the intestine, and subjacent cellular network, which enables the parts to offer a more effectual resistance to the distending power of the excre- mentitial bolus, so that the solution of continuity not being torn afresh every day, is enabled to undergo natural cicatrisation. You perceive, Gentlemen, that so far am I from being in dread of FISSURE OF THE ANUS. FISSURE OF THE ANUS. 197 this constriction of the sphincter, that I am not afraid to employ astringent medicines calculated to increase the stricture. The theory which I have formed from numerous cases to explain the treatment I recommend, is to my mind quite satisfactory. The therapeutic method, however, is not mine : I got it from Bretonneau, to whom the healing art is indebted for so many means of cure. Let us attend to the considerations upon which the illustrious physician of Tours founded the use of rhatany in the treatment of fissure of the anus, and how he was led to adopt it. While on the one hand, constipation, and the expulsive effort which pressing the excrementitial bolus against the sphincter, dis- tending and very often tearing it, are evidently in a number of cases the causes of fissure; on the other hand, constipation is the greatest obstacle in the way of a cure. Constipation is very often accom- panied by a most remarkable structural change in the lower part of the rectum. Immediately above the sphincter, the rectum dilates into a sort of pouch, and again becomes contracted at the sacro- vertebral angle. In the pouch referred to, the faeces accumulate so as to form a very large ball; and every time the patient goes to stool, the expulsive effort is really like the straining of a parturient woman. In Bretonneau's opinion, whether the constipation is or is not associated with fissure, it is good practice to give to the lower portion of the intestine the tone in which it is deficient; and for this purpose rhatany seemed to him exceedingly wrell adapted. Iu cases of simple constipation, coincident with dilatation of the rectum, he was in the habit of giving lavements consisting of water holding in solution extract and alcoholic tincture of rhatany. A lady treated by him had, along with the constipation of which I am speaking, fissure of the anus, 'which occasioned dreadful pain and seriously affected the health. He ordered her to have daily a quarter lavement of rhatany; and the result was a speedy cure both of constipation and fissure. Other patients presented themselves, suffering from constipation and affected likewise with spasmodic stricture of the rectum and fissure. The same treatment which was pursued in the case of the lady cured all these morbid conditions in them. He then thought that notwithstanding the existence of con- stipation, a symptom absent in some cases of fissure, rhatany might be employed, and the trial was crowned with success similar to that obtained in the other cases. By means of very legitimate induction, he accomplished the first step, and then facts to which he did not 198 FISSURE OF THE ANUS. appeal awakened his attention: by simply verifying them, and pur- suing a course of rational experiment, he was led to adopt a treat- ment which perhaps may not be “ rational/'* but which is exceed- ingly good; and that is the principal consideration. In point of fact, Gentlemen, this plan of treatment would be truly rational, if in accordance with Bretonneau’s view, constipation was always the cause or always a complication of fissure. But not unfrequently we meet with diarrhoea or soft stools in patients suffering from fissure of the anus : and we also find fissure in those wdio take clysters morning and evening to prevent pressure against the sphincter in defecation. When the state of constipation is very great, rhatany is by itself inadequate to accomplish a cure; and it then becomes necessary to aid its action by administering a laxative, so as to prevent tearing, by facilitating the passage of the feces through the anal orifice. Bretonneau’s treatment always gave exceedingly good results in his own hands, and in mine, as well as in those of all practitioners who have tried it with perseverance and in accordance with the indications given by its author. Before giving you precise rules in respect of this practice, allow me to state what I believe to be the mechanism of the production of fissure of the anus. There are some cases in which we cannot ascertain the starting point; but we know that it may be occasioned by whatever excoriates or superficially tears the anus, such as the point of a syringe unskil- fully introduced, sodomy, or other causes. We also know that haemorrhoids and constipations are its two most common causes; and that they act with greater certainty when they find the parts in a special state, as in wmmen recently delivered who, as said before, are the persons most liable to suffer from this affection. The pressure which in the latter stage of pregnancy, is made upon the parts within the pelvis, by the greatly enlarged uterus—particu- larly upon the lower portion of the intestine, in which it embarrasses the circulation—keeps up a constant state of congestion, and when in an extreme degree resulting in haemorrhoids. If to this it be added that constipation is also a usual accompaniment of the latter period of pregnancy you will perceive that women in that condition are peculiarly predisposed to fissure of the anus because the different causes now pointed out are liable to coexist in them. During labour, at that stage when the foetus has descended to the floor of the pelvis, and presents at the vulva, the perineum is FISSURE OF THE ANUS. 199 forced forwards by the expulsive efforts of the woman : the skin in the neighbouring parts is chafed, and this chafing, which extends to the anus, may be such as to amount to little tears or abrasions of the mucous membrane, which will ultimately constitute fissures. These minute solutions of continuity wall have all the more chance of being converted into ulcerations by the lochial discharge flowing along the commissure of the vagina to the anus, and by the irri- tation so induced preventing cicatrisation. I need scarcely add that this occurs most frequently in women who neglect scrupulous attention to personal cleanliness. The lochial discharge itself may become a predisposing cause of fissure: the irritation which it induces and keeps up at the anus impresses on the tissues a peculiar modality, in consequence of which they tear and fret more readily when subjected to pressure by the passage of hard feculent masses. The essentially characteristic phenomenon of fissure of the anus is a violent pain, which the sufferer compares to the pain caused by a tear or a burn, or, to use a comparison often employed by patients, to the sensation of a flame of fire passing over the affected parts. This peculiar pain is excited by defecation; and continues after the bowels have been evacuated for a period varying from some hours to a whole day or a whole night. So severe is the pain, that the suffering women, afraid of renewing it, dreading its return more than words can express, shrink so exceedingly from going to stool, that for eight, ten, twelve days or longer, they abstain from any attempt to eva- cuate the bowels. The constipation increases, the feces become harder; and consequently the pains become more and more violent till the feculent matter is expelled. In mauy cases, the pain subsides a few minutes after defecation, to return with augmented severity, and in a few hours to assume a frightful intensity. In some cases, the fissure is smeared with blood, which forms red streaks upon the excrementitial bolus : generally, however, there is very little oozing of blood from the ulcerated surface. It is a remarkable fact, that these pains are not only occasioned by the passage of hard masses : they are sometimes induced by soft, even by liquid motions, as has already been stated. Upon making a digital examination of the anus, the sphincter contracts energetically; and if a forcible attempt be made to over- come the obstacle, the examination causes the patient greater suffering. 200 FISSURE OF THE ANUS. The best method of discovering the seat of the disease is to request the patient to bear down as if at stool: the anus then becomes pro- minent and upon separating its folds, we are able to perceive a small ulceration at the bottom of the separating furrows: the ulcerated surface has a bright red appearance, which may be very well compared to chaps produced in the hands and lips by cold. Many patients conceal from their medical advisers the existence of these fissures, in spite of the dreadful pain to which they give rise : you have often seen, in our wards, that after we have long remained ignorant that certain patients had fissures, the fact was at last disco-, vered merely by chance. Some patients complain of having piles : when this complaint is made by women recently delivered, it is in itself sufficient to lead to the suspicion that there is fissure; and a more minute investigation will often show such to be the case. When matters have advanced to a certain point, the obstinacy and intensity of the symptoms, produce a prejudicial influence on the general health. The habit acquired by patients of restraining their desire to go to stool increases constipation, and so leads to dyspepsia: digestion ceases to be performed with regularity, and dyspepsia becomes all the more urgent that patients abstain from eating that they may not require to go to the closet. However unimportant, therefore, fissure of the anus may be in itself, it may lead to serious consequences: even when the pheno- mena are only local, it is necessary to use measures to save the patients from excruciating pains. To modify the ulcerated surface is the object, and to attain it, we employ a variety of topical means which I need not here enumerate. There is one among them, how- ever, to which I must call attention : I refer to the mode of treat- ment recently recommended by Dr. Chapelle (of Angouleme). Dr. Chapelle’s treatment consists in the introduction into the anus of a pledget soaked in a mixture of chloroform and alcohol in the proportion of ten parts (by weight) of the former to five of the latter. Dr. Chapelle has taken care to give warning that this proceeding at first causes acute pain; but he says that after the third application, sometimes even after the second, a cure is obtained. Having been nominated by the Academy of Medicine as a member of the committee appointed to report on this treatment, I tried it in several cases in our clinical wTards. No untoward results oc- curred. However, the small amount' of success which attended FISSUUE OF THE ANUS. 201 my trials caused me to resume the rhatany plan, which I find the best: The following is my mode of using rhatany. To empty the intestine, I cause to be administered every morning a clyster, in- fusion of bran or marsh mallow. Half an hour after this has been returned, a quarter clyster is given of which the following is the composition :—• Water 150 grammes fluid oz.] Extract of Rhatany . . 4 grammes [61§ grains] Tincture of Rhatany . . 4 grammes [6i| grains]. The patients ought not to retain the lavement more than a few minutes: it should be repeated in the evening. Sometimes, when the fissure is so situated as to protrude entirely when defsecatory efforts are made, the desired object can be very well attained by using lotions of extract of rhatany. Should the fissure be very deep seated and rebellious to treatment, the clyster must be administered with a syringe of continuous jet: the patient resists the injection, which is thrown back into the basin and taken up again by the pump, and may serve for an ablution which might be almost endless, and which ought to last for from two to four minutes or longer. But it very often happens, that constipation which in a great measure was the cause of the malady is an invincible obstacle to its cure. Day by day, the hard and bulky excrementitial bolus tears the wound, and destroys the incipient cicatrisation obtained by the rhatany. It then becomes necessary, during the whole course of the treatment, and even after the cure, to give daily a mild laxative, so as to keep the bowels freely open, and render the faeces less hard. In relation to this point, let me beg you to bear in mind the remarks which I recently made on the treatment of constipation. It often happens, that during the first days of the treatment, the pains are greatly aggravated, to the great discouragement both of physicians and patients. The causes of this aggravation are easily understood. Persons who from the incipient stage of the fissure, had got into the habit of going seldom to stool, to avoid the dreadful pain occasioned by.defsecation, now go several times during the course of one day : the result of this change is pain lasting continuously for perhaps several days. Such cases are fortunately very rare, but they do sometimes occur, rendering it necessary to administer during the 202 FISSURE OF THE ANUS. first days of the treatment only one in place of two rhatany clysters, and to abstain from giving laxatives till the intestine has become less sensitive. As soon as the pains are entirely subdued, one rhatany clyster a day is sufficient; and when there is reason to believe that the cure is complete, it will be necessary to continue giving, every two days for at least two or three weeks. Persevering in the use of the remedy, even after its continuance may seem superfluous, is of great importance; for if it be abruptly discontinued, there will be a risk of a recurrence of the symptoms* Thanks to this plan of treatment, I have been able to heal very painful fissures, and deep fissures with callous edges. The cure, it is true, proceeded slowly; and as an example of this, I may mention the case of a lady who, after refusing to submit to a surgical ope- ration, was cured, contrary to all expectation, by pursuing the rhatany treatment for more than a year. This was certainly paying dearly for the cure; and in similar circumstances, I should certainly recommend an operation, which may either be paring the edges of the fissure—a proceeding which perhaps acts beneficially like the rhatany plan only by modifying the morbid surfaces—or forcible dilatation, to which more than once you have seen me have recourse. It must, however, be admitted, that the rhatany treatment, par- ticularly if prolonged, may be rather too costly. In consideration of this, I have endeavoured to substitute for rhatany, sulphate of copper, a remedy, the price of which is so small as to be within the means of even the poorest. I order a half-lavement, containing ] 5 centigrammes \_2\ grains] of this salt to be given morning and evening. You have seen the effects of this medication. Our night- nurse, a robust young woman, recently confined, had a very painful fissure from which she had been suffering for eleven days : her con- dition had been much ameliorated, and the fissure nearly cured by the use of rhatany lavements for ten days, when, six days later, it was torn anew during defsecation. She lost a great deal of blood, and experienced very acute pain during the whole of the night which followed this occurrence. Next day, March 17 th, she had her first lavement of sulphate of copper, which was returned, a sen- sation being at the same time produced as of a hot iron traversing the anus. Two days later, she no longer had pain when the clyster returned, and she did not suffer for more than half an hour in the night from having had a stool. For three days, from the 21st to 203 FISSURE OF THE ANUS. the 24th, she was absolutely free from pain on going to stool. But on the 24th, the fissure was again torn during defecation, and in consequence the patient suffered for two hours and a half. After using the sulphate of copper for three days, the pains had again en- tirely ceased : the patient only suffered slightly when the motions were hard. The sulphate of copper clysters were continued till the 15th April, that is to say, for a month ; and at the end of that period, the young’woman passed hard stools painlessly. The cure was definitive. You may have observed that since this case occurred, I have been using indiscriminately rhatany or sulphate of copper in the treatment of fissures of the anus; and that I substitute the one for the other when at the end of eight days, the amelioration (always obtained) remains stationary. By proceeding in this way, I always accomplish a cure. Sometimes, the cure takes place under the exclusive use either of rhatany or sulphate of copper, and in other cases, sulphate of copper completes a cure begun by rhatany, or rhatany completes the cure begun by sulphate of copper. I now resume the subject of dilatation. I do not refer to the introduction of gradually increased pledgets of charpie, a practice which some adopt; I speak of sudden forcible dilatation performed by the introduction of the fingers. This operation would be extremely painful, were it not that we can perform it whilst the patient is in a state of anaesthesia from chloroform—a wonderful means of preventing pain. I have still to mention some accessory means, which occasionally are in themselves sufficient to accomplish a cure. I order a sort of porridgy mixture to be prepared, consisting of one part of subnitrate of bismuth and five parts of glycerine; and with this I direct the patient to anoint the anal orifice five or six times a day, and to apply it to the ulcerated surfaces, taking care that whilst the application is being made, the folds of the anus are opened. Pommades of white precipitate and red precipitate aw trentieme, if very carefully employed will produce equally good results. I also order the parts to be bathed morning and evening with very hot water, to which is added a sixth or an eighth of eau phagedenique ;1 or I order five grammes [77 grains] of corrosive sublimate to be dissolved in two hundred grammes [7 fluid oz.] of water : a teaspoonful of this solution is added to a litre or half a litre of very hot water, with which the parts 1 Yide Volume Second of this Translation, p. 629. EISbURE OE THE ANUS. are to be washed for some minutes morning and evening. Cauterisa- tions -with the solid nitrate of silver and sulphate of copper, though very painful, are also sometimes very useful. Gentlemen, I cannot conclude my remarks on this subject without telling you, that careful ablutions three times a day with simple water—that is to say, minute attention to cleanliness—will sometimes supersede the necessity of any medication. LECTURE LXXVI1. INTESTINAL OCCLUSIONS. Their Causes.—Their Mechanism.—Their extreme Gravity.—Treat- ment by medical men.—Gastrotomy may be resorted to in serious cases. Gentlemen :—Last Tuesday you saw my honourable colleague. Prof. Jobert (of Lamballe), operate here, in accordance with my pressing solicitation, upon a man who came into our clinical wards with all the symptoms of intestinal strangulation. The patient died thirty- six hours after the operation. It is iny duty to explain to you the reasons for my urgency with M. Jobert, who was opposed to the performance of gastrotomy: it is my duty to render you an account of this matter, because, notwithstanding the issue of the operation, I have still the complete conviction that it was right to have recourse to it. The patient was a man about fifty years of age. He stated, that for many years he had had bleeding piles, that he often passed blood and pus at stool; and that he was subject to alternations of con- stipation and diarrhoea. With the exception of these symptoms, his health was not bad. He had had no motion for thirteen days ; and for ten or eleven days, he had had vomiting. The matter vomited, which at first was food, had become bilious. We found, in fact, in the spittoon and basin left beside the patient, not only bilious matters, but matters resembling those generally found in the lower part of the small intestine, and which in such cases are improperly called ster- coraceous. The abdomen was very tympanitic, but painful only in a moderate degree. The countenance, however, was expressive of very acute pain, and the most distressing anxiety. In fact, there existed all the characteristic symptoms of strangulated hernia. My inquiries were first of all directed by that view of the case; and I 206 INTESTINAL OCCLUSIONS. searched in the groin and the fold of the thigh for a tumour. None, however, was found. The information derived from the patient's verbal statements evidently referred to an intestinal lesion; and with the greatest care I investigated into the possible seat of the malady. The hemor- rhoids of which he had spoken led me to ask myself whether there did not exist some affection of the large intestine causing an obstacle to the passage of the faeces. Both M. Jobert and I made a digital examination of the rectum, but discovered nothing as far as we could reach with the finger. Hence we concluded, that the obstruction existed higher up, as high up at least as the sigmoid flexure of the colon; that at all events it was beyond the reach of the finger. Ex- ploration through the abdominal parietes was impossible from the enormous tympanitic distension. Whatever was the cause, whatever was the seat of the occlusion, the nature of the phenomena admitted of no doubt: the severity of the symptoms, the extreme anxiety, the smallness of the pulse indicated that danger was imminent, and that death must occur within twenty-four hours. Too much time had already been lost to wait still longer for the doubtful results of the different measures proposed in similar cases; to count on puncturing the intestines distended with gas seemed to me equivalent to abandoning the man's life to chance; while gastro- tomy, twice successful in my private practice, appeared to offer the only hope. Such were the circumstances under which I besought M. Jobert to operate. Along with me, he fully realised the gravity of the situation: he knew that though in itself gastrotomy wras not more dangerous than herniotomy, it was in this particular case a much less hopeful undertaking than the operation for strangulated hernia is in ordinary circumstances. Considering that after a too long delayed operation for strangulated hernia, it is not unusual to see the patient sink, M. Jobert was not unmindful of the serious consequences which we had to dread. Still, he yielded to my entreaties, perceiving very distinctly that it was only by his surgical intervention that a feeble and sole remaining chance of saving the patient was afforded. Gastrotomy, therefore, was decided upon. It was proposed by this operation to form an artificial anus in the right iliac region, whereby to afford an issue to the matter impacted in the intestine; or, in other words, to afford immediate relief from the effects produced by the obstruction. INTESTINAL OCCLUSIONS. 207 When the opening was made, a large quantity of gas and liquid escaped. The edges of the intestinal were united to the edges of the abdominal incision by some sutures, and a sound was introduced into the upper end of the intestine so as to secure a passage for the fceeu- lent matter. Notwithstanding these measures, there was only a partial diminution in the tympanites, and to a certain extent, the other complications also continued. During the night, the patient was attacked by a sort of choleraic diarrhoea; and a large quantity of a yellowish white fluid passed through the gum tube left in the bowel. The patient had vomiting. There was an increase in the severity of the abdominal pains. The pulse became more frequent, the skin grew cold; and death occurred during the following day. At the autopsy, we saw that the bistoury had opened one of the lower folds of the small intestine; and that that had occurred which is usual when the incision is made in the neighbourhood of the ceecum —the lower end of the ileum was the part struck by the knife. This is an exceedingly important fact; for if the opening be made higher up, there will not be so long a portion of intestine between the stomach and the artificial anus for the performance of the digestive functions, and there will be a risk of the patients dying from inanition. The lips of the wound made in the intestine were perfectly adherent to the lips of the wound in the abdominal parietes. Notwithstanding the shortness of the time which had elapsed, the inflammation of the peritoneum, apparently dating back forty-eight or seventy-two hours, had promoted this rapid union, which had the patient lived, would in a few days have been perfect, leaving nothing to fear from the flow of matters from the digestive canal into the peritoneal cavity. The cause of the obstruction was situated in the sigmoid flexure of the colon, which was enormously distended by gas, and seemed to be five times its usual length. It was folded upon itself in such a manner that its left curvature was pushed to the right and its right curvature to the left, while the inverted mesocolon formed a band which still more tightened the obstruction. The small intestine was collapsed, free from fluids which had probably escaped by the artificial orifice made by the surgeon. We also perceived another lesion : the free margin of the omentum was inserted in the ileo-csecal appendix by an elongated false membrane, which, dipping into the pelvis, tense, and fixed at both ends, formed 208 INTESTINAL OCCLUSIONS. a sort of bridge. As we shall see, symptoms similar to those expe-* rienced by our patient, are often occasioned by bands of this descrip- tion entangling and strangling the intestine. In the case now before us, however, this band had no share in producing what we observed, for on opening the abdomen with the utmost possible precaution, we were satisfied that the band did not grasp any loop of intestine. After the death of the patient, when we had the parts before us, it wras easy to perceive how, in this case, the opening made into the intestine might have proved of use. The result, for example, might have been to liberate gases enormously distending the sigmoid flexure of the colon, and to restore the contractility of its muscular tunic paralysed by the distension resulting from the gaseous accumulation. It might likewise have been the means of restoring energetic peristaltic movements, by which the intestine might be brought back to its proper situation. The remarks which I have to make to you to-day on the subject of intestinal occlusion will enable you fully to understand my views. In general, Gentlemen, it is impossible to bestow too much care in ascertaining with the utmost possible precision the seat of intestinal obstructions. You will without difficulty understand—and of this the case which I have just related is a proof—that it is very impor- tant to discover whether the stoppage is in the large or small intes- tine. In the adult, it occurs in the great majority of cases in the small intestine, a fact which explains the success which usually attends the operation for artificial anus when the incision is made in the small intestine. The intestine quickly discharges the matters which had accumulated above the occlusion. But in cases in which the bowel is opened far above the ob- struction, the probability is that the operation will prove useless. This happened in the case which is the subject of this lecture. The obstruction was in the sigmoid flexure of the colon, and—the ope- ration having been performed in the right iliac fossa, and the artificial anus made in the small intestine—the unfavorable state continued, and led to the death of the patient. If Professor Jobert and I could have discovered beforehand the situation of the obstruction, we should not have hesitated to prefer Littre’s method; or in other words, wTe should have made the arti- ficial anus in the sigmoid flexure itself, and then probably we should have saved the patient. INTESTINAL OCCLUSION. 209 Ileus, volvulus, iliac passion, and vomitus stercoris, were the names formerly given to the malady characterised by a complete cessation of alvine evacuations, accompanied by violent, incessant, and intractable vomiting, by tympanitic distension of the abdomen, acute pain— symptoms almost invariably leading to a fatal issue when the patient has been left without treatment, and often even when the most active measures have been resorted to. This disease was formerly considered as an affection essentially spasmodic. Even during last century, how- ever, pathological anatomy had enlightened physicians as to its real nature: it had shown them the great similarity between ileus and strangulated hernia: it had shown them that the supposed spasm was something more material, and that the dreaded symptoms depended upon a structural obstacle in the passage. In our day, internal strangulation is the term substituted for the names I have just mentioned; and it more accurately describes the condition which generally produces the malady. Dr. Oscar Masson, a distinguished interne of our hospitals, has proposed to use in place of intestinal strangulation, the term intestinal occlusion, which has the advantage of being applicable to all cases in which there is accidental oblite- ration of the intestine, and also to all the varieties of hernia, the most common causes of occlusion;1 but regarding which it is not incumbent on me to address you: here, we have to do only with occlu- sions originating within the abdominal cavity. These occlusions, according to their causes, present numerous varieties. The causes are themselves very numerous: some, independent of the intestine and developed external to it, act in such a way as to compress the bowel and diminish its calibre : others originate in the intestine itself, either in its cavity or in the substance of its tunics. Among causes belonging to the first class, I first of all mention abdominal tummrs when they acquire a certain bulk, and occupy a certain relative position to the intestines. The cause, for example, may be tuberculosis or cancer of the mesenteric glands, or a phleg- monous tumour in the iliac fossa; or, it may be the displacement or augmented volume of organs, as of the uterus or spleen in the cases to which Dr. Masson refers in his thesis. 1 Masson (Oscar):—These soutenue devant la Faculte de Medeciue de Paris le 2 Mars, 1857. 210 INTESTINAL OCCLUSION. The most common of the first class of causes, the causes external to the intestine, are those which induce internal strangulation properly so called. Such are adhesions formed between different organs by morbid exudations; and such likewise are the pseudo-membranous bands formed in the abdominal cavity by inflammatory action, gene- rally by inflammation of a latent character. Let us suppose that, consecutive to an attack of peritonitis, the ileo-caecal appendix had contracted adhesions with another portion of the intestine, with the ovary, Fallopian tube, or broad ligament: let us suppose that these adhesions are formed between other parts of the intestine: the result will then be the formation of sorts of bridges under which a loop of intestine might easily become en- tangled. The same will occur in respect of pseudo-membranous bands, of which the number, extent, seat, and disposition, admits of infinite variety. In some cases, these bridges are large enough to allow an intestinal convolution which has got under it to extricate itself. In other cases, a convolution a little too large may be seized : it will at first be only slightly constricted : and were not the tube a living organ, the contained matters would pass onwards, though not so freely, but the tube being possessed of life, vital changes take place in it which in their turn produce obstruction. The embarrassed capillary circulation leads to the engorgement of parts, and consecutively a thickening of the intestinal parietes, the calibre of which diminishes on this account, and diminishes all the more that the muscular contractility is in its turn greatly increased under the influence of irritation. The intestinal fluids and gases, interrupted in their course, accumulate in the canal which contains them; the canal then becomes partially obstructed, and at last com- pletely shut up. In other cases, internal strangulation arises from a very remark- able mechanism: the ileo-caecal appendix twists round a con- volution of intestine in a knot, which is sometimes double. The intestinal diverticula may also become a cause of internal strangu- lation ; but to enable this to take place, they must be some centi- meters in length, and inflammation must have produced adhesion of their free extremity: thus it is, as in the case of the ileo-caecal appen- dix, that the diverticula can embrace and strangle an intestinal convolution. Internal strangulation may also be caused by a sort of hernia in a natural opening, such as the foramen of Winslow, or in an accidental INTESTINAL OCCLUSION. 211 opening, such as a chink in the diaphragm, or a tear in the mesen- tery or epiploon. Occlusions originating in the intestine itself are also equally various in their nature. First in importance are organic lesions, particularly cancerous affections, and most frequently cancerous affections of the large intestine, which, as they advance, cause stric- tures and more or less complete obliteration of the canal. I may also mention syphilitic strictures, strictures resulting from thickening of the intestinal parietes succeeding chronic inflammation, strictures produced by extravasation of blood between the tunics of the intes- tine, such as Bretonneau speaks of having observed, and finally strictures determined by adhesions formed between the cicatrices of ulcers, by vegetations and by polypi. Yery severe symptoms of intestinal occlusion are sometimes induced by the accumulation of stercoral matter. You have cer- tainly, more than once, in the hospitals, met with persons—generally women—having very large tumours of this description in the trans- verse and descending portions of the colon. These tumours, formed by masses of fsecal matter, change their position or entirely disap- pear under the influence of a somewhat energetic purgative; but in other cases they give rise, I repeat, to the symptoms characteristic of intestinal occlusion. That which we so frequently observe in the rectum in cases of habitual and invincible constipation may also occur in the upper portion of the large intestine. Though this kind of obstruction is generally easily got rid of, it sometimes resists all our efforts ; and cases are recorded in which it has caused death. Undigested food may give rise to similar accidents. At an early stage of my medical studies, I saw a soldier who was seized with all the symptoms of intestinal occlusion fifteen or twenty days after gluttonously swallowing some pounds of cherries with their stones. He died : and on opening his body, we found near the termination of the small intestine, at the ileo-csecal valve, a mass of cherry-stones almost half as large as the fist, completely obstructing the intestine. Obliterations of the intestinal canal are likewise produced by foreign bodies accidentally swallowed, such as glass and ivory balls. Cases, too, are recorded in which similar results have fol- lowed biliary calculi passing into, and being arrested in, the digestive canal. Of all the causes of intestinal obstruction, perhaps the most 212 INTESTINAL OCCLUSION. curious is the presence of lumbricoid ascarides. I saw a case of this kind in a woman, who died with all the symptoms of occlusion. At the autopsy, we found an enormous packet of these worms twisted one on the other, so as completely to obstruct the intestine. Gentlemen, to conclude this enumeration of the mechanical causes of intestinal occlusion, I have still to speak of invagination, of vol- vulus, and finally of retroversion of the intestine, an example of which was presented by our patient. You know the meaning of the term invagination. A portion of intestine becomes introduced within the portion below it in such a manner that the serous and mucous tunics are in apposition. The result of this intussusception or inclusion of one part of the canal within the other is necessarily a diminution of the calibre of the canal. You can understand how intestinal occlusion may be the conse- quence of this invagination: it is not however an inevitable conse- quence, for a vigorous contraction of the intestine may suffice to reestablish the normal condition. Unfortunately, however, it is not so always : by the persistence of the invagination, inflammation may arise, and glue together the two peritoneal surfaces which are in apposition. The inflammatory action being necessarily preceded and accompanied by engorgement of the tissues which it attacks, the already narrowed canal becomes still more obstructed, its calibre at last becomes entirely obliterated, and very soon the symptoms of intestinal occlusion show themselves. However, even in such cases, the issue is not so inevitably mortal as when the occlusion is de- pendent upon some other causes which I have mentioned. The occlusion may disappear in a way which I shall now explain. The inflammation of the invaginated portions may proceed to sloughing, and thus they may become detached from the living portions, fall into the intestinal passage, and be evacuated by stool. A reparatory process may at the same time organise a union of the two ends in mutual contact, and although the intestine remain somewhat con- tracted, the contraction is not sufficient to completely prevent the passage of the faeces. After a longer or shorter period, the cure is complete. Of this I have seen two examples. Volvulus consists in the rolling or twisting of the intestines : and the case which has given rise to the present lecture may be consi- dered as of this description. In this case, the intestine was retro- verted upon itself. The sigmoid flexure, retained by a duplicature of peritoneum more than usually lax, and consequently more mobile INTESTINAL OCCLUSION. 213 was retroverted, as you saw, in such a manner that the right curva- ture was placed on the left side, so as to form in the canal a fold by which the passage was obliterated. As to the different kinds of ileus, of miserere mei, or miserere colic, they are generally attributable to the seat of the occlusion, and to the excruciating pains sometimes experienced by the patients. Whatever may be the causes of intestinal occlusion, its symptoms are always those of strangulated hernia. For some days, the patients are without movement of the bowels, while at the same time they experience a dull pain in a limited part of the abdomen. This pain, caused by the retention of the contents of the bowel, increases in intensity and superficial extent: the intestinal convolutions become distended with gas: and then the patient has nausea, with vomiting of matters variable in their character. At this stage, the intestine has so great a tendency to peristaltic action, that the ingestion of fluids by the stomach, or pressure on the abdomen, is sufficient to cause vomiting, first of the fluid contents of the stomach, then of bilious and chylous matters pent up in the lower portion of the small intestine. Fcecal matter, properly so called, that is to say, matter contained in the large intestine, cannot be rejected by the mouth, even when the obstruction is seated in the csecum, the colon, or the sigmoid flexure, because the ileo-csecal valve, if it has retained its normal structural relations, constitutes an insurmountable barrier to the passage of matters from the large to the small intestine. But in these cases in which the sigmoid flexure of the colon is the seat of the occlusion, there is, from the very first, a great degree of meteorismus in the iliac, epigastric, and hypogastric regions; whereas, if the occlusion be situated in the small intestine, the meteorismus, for a certain time, does not extend beyond the umbilical region. M. Laugier has in a special manner insisted upon the importance of ascertaining the locality of the seat of the meteorismus in the diagnosis of strangulated intestinal hernia.1 It is difficult to determine whether the obstruction be seated in the large or small intestine; but it is more than difficult—it is nearly 1 Laugier :—Sur un Signe Nouveau dans l’histoire des Hernies Etranglees, a l’aide du quel on peut reconnaitre si l’intestin est compris dans le sac herniaire et a quelle portion du canal intestinal appartient l’anse dtranglee. [Comptex Rendi(s des Se'ances de VAcademic des Sciences ; 1840. T. X, p. 370.] 214 INTESTINAL OCCLUSION. impossible to determine from the symptoms whether it be in the duodenum, jejunum, or ileum. Whatever may be the seat of the internal strangulation, there is very soon inflammation of the intestine and peritoneum; and from the first,the symptoms sometimes derive a very marked severity of cha- racter from the peritonitis. The vomiting then becomes more frequent, the abdominal pain more general, and the meteorismus extends to the whole abdominal cavity. The pulse becomes very quick and very small: the skin becomes covered with viscid sweat: the very altered expression of the countenance is expressive of suffering: the eyes are sunken : the nose is pinched : the lips are bloodless : and the tongue is cold. The existence of peritonitis renders surgical interference useless. A state of excitement is followed by profound prostration, and death occurs without the intellectual faculties having become impaired. In some cases, so great is the pros- tration at the last, that the patients cease to utter any complaint. When the physician sees the case at its commencement, or when he has had a precise account of the symptoms, there is hardly any risk of his committing a mistake : in point of fact, the total absence of stools, the pain localised in the first instance in the abdomen, then the frequency and persistent vomiting, unaccompanied by yellowness of the skin or conjunctiva, exclude the supposition that the case is either hepatic colic or simple peritonitis. But, on the other hand, if the history of the symptoms is imperfectly given, and if the physician examine the case for the first time, when the intestinal obstruction has become complicated with peritonitis, it is evident that there will be room for doubt as to the nature of the case; or a mistake in diagnosis may remain uncontradicted, till the absence of stools is a certainty. Thus, the symptoms of peritonitis from perforation have been seen to simulate the symptoms of intestinal occlusion. This occurred in a case recently treated in one of the wards of this hospital. The prognosis is generally exceedingly unfavorable. When the occlusion is produced by an accumulation of matter in the intestine, we may hope that energetic purgatives will cause the symptoms to disappear by inducing vigorous contractions of the intestine; but when it depends upon tumours situated in the walls of the intestine, we must admit our inability to cure, because these tumours, like cancerous tumours, are incurable. In strangulation by adventitious bands as well as in cases of INTESTINAL OCCLUSION. 215 invagination, of volvulus, and of inversion of the intestine, our inter- vention, however energetic, is generally of no avail: yet it is sometimes crowned with success. Let us now consider the means of treatment which are available. In strangulated hernia, the treatment which is first indicated is to employ the taxis; but, as can be readily understood, this ope- ration is inapplicable in internal occlusion, even when we know the seat and cause of the obstruction, inasmuch as we cannot reach it by direct means. However malaxation may to a certain extent serve as a substitute : it will induce peristaltic movements of the intestine, the tendency of which will be to restore the parts to their normal position. In performing malaxation very great prudence is required ; and the older the date of the malady, the greater must be the mode- ration employed. The application of a very large cupping-glass, or of several smaller ones, to the abdomen, has also been recommended. A bellows movement ought to be made with the cupping-glasses when they have been fixed on the abdominal parietes. The traction thus ex- erted is said to destroy the bridles of a false membrane and rectify the invaginations, so as to relieve the intestinal obstruction. Leroy (d'Etiolles) proposed to excite the peristaltic movements by electricity, by establishing a galvanic current between the mouth and anus. To accomplish the same object, Dr. Duchene (de Boulogne) has, in three cases, employed faradisation; and in one of them only was the result a cure. Electricity, in fact, does not seem to me to be of any real use, whatever mode of applying it may be adopted. Causing the patients to swrallow mercury and balls of lead are modes of treatment which I merely mention to remark that they were formerly lauded and are now forgotten. The administration of purgatives constitutes the chief means of treating intestinal occlusion. They act on the same principle as malaxation, that is to say, by causing peristaltic motion ; but their action is much more energetic. Senna, and the other purgatives which specially influence the muscular contractility of the intestine have the preference. Eor reasons which I do not require to state, these medicines ought to be administered in clysters. In the work which I have quoteel, Dr. Masson proposes to call the attention of physicians to the treatment of intra-abdominal intestinal occlusion by the external application of ice; but the 216 INTESTINAL OCCLUSION. number of cases which he adduces to show the utility of this mea- sure is too small to justify satisfactory conclusions being drawn from them. Notwithstanding the use of the different means which I have enumerated, the symptoms generally continue, and it becomes neces- sary at last to resort to a surgical operation. The simplest operation is puncture of the abdomen, a proceeding indicated in cases in wdiich there exists tympanites. The great accumulation of gas in the intestine, by producing excessive disten- sion, paralyses the contractility of the muscular tunic ; for the same thing occurs in respect of the intestine, as in the bladder and all hollow organs. The paralysed state is increased by inflammation of the parts. Such of you as have been present at operations for strangulated hernia may have seen, that the portion of intestine which is strangulated does not contract when pricked by the point of the bistoury, though in a normal state, it would have contracted energetically if so treated. The effect of puncturing the abdomen is to liberate confined gas; and to restore contractility by putting an end to the extreme dis- tension. .The punctures are made by inserting small exploratory trocars at the places where the distension seems greatest. Should the first puncture be insufficient, a second or third or even as many as eight or ten may be made. This little operation is neither painful nor dangerous. If you read the inaugural thesis of my colleague in the hospitals, Dr. A. Labric, you will be convinced that the punctures involve no danger, and that they may be productive of benefit—as they probably would have been in the case of our patient in St. Agnes's ward had they been made at an earlier period.1 After the distension has been got rid of, purgatives are useful to renew the contractility of the intestine. The punctures must be performed at an early stage : the longer the delay in resorting to them, the less are the chances of success. When all curative measures, including puncture, have failed, and the symptoms of occlusion continue—when the disease is of eight or ten days' duration, and there is either no diminution or a rapid return of the distension, with frequent profuse stercoraceous vomit- ing, and feeble pulse—when—to sum up in one word the state of 1 Labric :—Theses de Paris, 1852. INTESTINAL OCCLUSION. 217 matters—when there is imminent danger to life—there is only left the grave, the extreme resource of gastrotomy. It is only within the last few years, that this operation has been accepted as admissible in cases of occlusion. As soon as it became an ascertained fact, that, in numerous cases, occlusion is occasioned by bands of false membrane, by a retrover- sion upon itself of a portion of the intestinal tube, by its invagina- tion, it was thought, that by opening the abdomen, there would be a possibility of disentangling the intestines, and of so removing the obstacle to free passage through them. But the questions arose :— Upon what grounds can so perilous an operation be justified ? By what indications is the surgeon to be guided in performing it ? Numerous cases of accidental extensive injuries of the abdominal parietes by cutting instruments, and bull horns, had shown that penetrating wounds of the abdomen were not so dangerous as had been believed, as there were instances of complete recovery, even when the intestines had protruded from the abdominal cavity. It was concluded, that gastrotomy, if performed according to rational surgical rules, need not be fatal, since it was not necessarily fatal in that class of accidents to which I have just referred. Gentlemen, I admit, that when we see surgeons (to search for and detach an ovary) making large openings into the abdomen with mor- bidly thickened walls and the seat of great morbid changes, without taking into account the temporary contact of air with the peri- toneum, and the horrible mutilations necessary for attaining the object desired, there need not be any alarm at the proposal to make a large incision in the linea alba, so as to enable the hand to be in- troduced into the abdomen, there to seek for and destroy the obstacle, or to drag forward the particular intestinal convolution in which it is advisable to form an artificial anus. It appears to me, therefore, that the undeniable success which has attended ovariotomy would justify, for the cure of internal strangulation, recourse being had to an operation which, though perhaps more calculated to excite alarm, is surer, more rational, and less dangerous than ovariotomy. Bor this reason, it is incumbent on me to address you on the modes of performing gastrotomy for the treatment of intestinal occlusion. In 1676, Paul Barbette, a surgeon of Amsterdam, very distinctly suggested opening the abdomen in obstinate volvulus or intestinal intussusception. He said :—“ When the ordinary means have proved unsuccessful, would it not be opportune to make an opening through 218 INTESTINAL OCCLUSION. the muscles and peritoneum, to disentangle the intestine, rather than allow the patient to die without an effort being made to save him ?” Some years later, Nuck, the expert anatomist, caused gastrotomy to be performed with success in the case of a woman affected with volvulus.1 For a very long period nothing was said about this operation; but after the lapse of a century, in 1772, Renault, an illustrious surgeon, performed the double operation of gastrotomy and entero- tomy under the following circumstances. A young man had been operated upon for strangulated hernia under hopeful conditions, when, several days after the operation, without any external appearance of the hernia, symptoms of internal strangulation presented themselves. Renault, without hesitation, cut into the abdomen : having found that the small intestine was strangulated throughout a certain part its course, he made an artificial anus. The operation was successful: on the twenty-eighth day, the fsecal matter passed by its normal outlet; and the wound w'as completely cicatrised. I11 1776, Pillore (of Rouen), and in 1793, Duret (of Brest), successfully practised gastrotomy both when the obstruction was in the large and when in the small intestine. Dupuytren did not meet with similar success in 1818; but that did not prevent Mannoury, in the following year, from proposing as an extreme resource, in internal strangulation, the formation of an artificial anus, and the maintenance of the incised intestinal convo- lution in contact with the abdominal incision by a thread passed through the mesentery. In 1838, Dr. Monod, in conformity with the rules of Dr. Man- noury, performed gastrotomy in a case of internal strangulation. At the autopsy, a serious lesion of the caecum was discovered. In the same year, Professor Laugier called attention to the fact, that after the reduction of hernia, there is often a continuance of the symptoms of strangulation of the intestine: in such cases, he re- commended enterotomy, and added that gastrotomy might also be appropriate in other cases than those resulting from the reduction of hernia. All these facts were nearly forgotten, when, in 1844, M. Maison- neuve read to the Academy of Sciences, the case of a patient upon whom he had operated for strangulated hernia, by dividing the upper 1 Nuck:—Operationes et Experiments Chirurgica. Leyden, 1692. INTESTINAL OCCLUSION. 219 ring of the inguinal canal. Immediately after the reduction of the hernia, the patient experienced relief; but next day, he had symp- toms of internal strangulation. M. Maisonneuve, without hesita- tion, reopened the inguinal wound, and ascertained that the intes- tine was perfectly reduced, but that there was an adhesion of the neck of the sac to the intestine, which he considered was probably the cause of the retention of the faeces. At this point, in fact, the intestine was gorged with feculent matter; and the surgeon after having made himself quite certain that there was adhesion of the intestine to the neck of the sac, and of the latter to the opening of the inguinal canal, made an incision into the gorged portion of in- testine, so as to form an artificial anus. There was perfect and rapid recovery. I11 the following year, M. Maisonneuve made this case the text of a very interesting memoir.1 Subsequently, MM. Denonvilliers and Nelaton declared them- selves favorable to gastrotomy in intestinal strangulation.3 Accord- ing to my colleague, gastrotomy necessarily leads to enterotomy; but in my opinion, on the contrary, enterotomy ought not to be performed, except when it is absolutely necessary to make an artifi- cial anus, that is to say, in the cases in which the intestine is gan- grenous, or contracted in consequence of lesion of its tissues. When there is only volvulus, invagination of recent date, or strangulation caused by cellular bands, by adhesions of the ileo-cmcal appendix, or of an intestinal convolution, I believe that, the causes of the occlusion being known, and there being no serious lesion of the in- testine, it is sufficient to destroy the different causes of the internal strangulation. A case reported by Valse shows that in cases of volvulus or invagination, sometimes all that is required to restore the intestine to its normal relations is to remove the symptoms; and so will it be in the cases of obstruction depending upon the other causes which I have enumerated. But to obtain such a result, it will he necessary to make at some part of the abdominal parietes, an incision sufficiently large to enable the operator to search for the seat and cause of the occlusion both with his hand and eye. Further, if there is to be a probability of success, the operator must proceed slowly, following the same rules which experience has 1 Maisonneuve :—Memoire sur l’Enterotomie de l’intestine grele dans les cas de l’obliteration de cet organe. [Archives Generates de Medecine, 1845. T. vii, p. 448.] 2 Savopoulo Theses de Paris, 1854. 220 INTESTINAL OCCLUSION. sanctioned in ovariotomy. There are two questions which may pre- sent themselves to the mind of the operator when it is necessary to make an incision into the intestine in consequence of its condition from menaced perforation, or incipient gangrene. Ought he to form an artificial anus ? or, would he be rash after having emptied the intestine by the incision, to unite the lips of the intestinal wound by bringing into contact the cut edges of the serous membrane, and completing the operation as in the cases in which gastrotomy is permissible for the purpose of reducing a volvulus and breaking up abnormal adhesions ? It is now an established fact in surgery, that in operating for strangulated hernia, one may successfully return into the abdominal cavity the hernial portion of the bowel, after having brought together by stitches the edges of the opening into the intestine. It is beyond my province to say more on the surgical considera- tions connected with this subject; and I now propose to conclude this lecture by relating two successful cases which may be cited as encouragements to perform enterotomy according to the proceeding adopted by Nelaton in cases of internal strangulation. Sixteen years ago, I was sent for to see in consultation a young painter of Hamburg. I ascertained the existence of all the symp- toms of internal strangulation—vomiting of matters seemingly stercoraceous, which had been going on for six or seven days, great tympanitic distension of the abdomen, sunken eyes, and general coldness. Death seemed imminent. I was told that the patient was the subject of hernia: I constantly made an examination with the view of discovering whether there was any inguinal tumour, and I found that there was none. I then asked myself whether the symptoms did not proceed from strangulation at the neck of the sac. I asked M. Nelaton to see the case with me. My honorable col- league, like me, perceived all the symptoms characteristic of occlu- sion without being able, any more than I had been, to detect the cause. The danger, however, was urgent; and in our opinion it could only be obviated by gastrotomy. The operation for artificial anus was, therefore, performed. There was an immediate cessation of the symptoms. In eight or ten days, the young man was re- stored : eating with appetite, and digesting well what he ate. In three months, his recovery was complete : at that date, the artificial anus was closed : and four years ago, when I last heard of our patient, he was in perfect health. 221 INTESTINAL OCCLUSION. Nine years ago, one of my honorable professional brethren of Paris called me in for the third or fourth time to see his wife, who, on several occasions had presented all the symptoms of intestinal occlusion. These symptoms were coincident with ordinary constipa- tion, over which drastic purgatives are generally triumphant. MM. Requin and Beau were consulted along with me. Upon examining the patient, we all agreed that drastic purgatives ought to be insisted on; and that along with their employment, recourse should be had to belladonna cataplasms, application of ice to the abdomen, long- continued baths, so as to overcome symptoms similar to those which had been previously experienced by the patient. Notwithstanding these different measures, the symptoms continued : there was great tympanitic distension: the matters vomited had assumed that aspect by which they are characterised in strangulated hernia, and it did not seem probable that life could continue for more than twenty-four or thirty-six hours. Under these circumstances, M. Nelaton was invited to meet us in consultation; and it was then decided to per- form gastrotomy. The artificial anus afforded exit to a great quan- tity of gaseous and solid contents : immediate relief followed. The convalescence was rapid; and the lady is at present in perfect health. These, Gentleman, are great facts which you ought to bear in mind; for though such cases are of rare occurrence, they are im- portant, because the affection if left to itself is nearly always fatal. What are the rules in accordance with which the operation of gastrotomy ought to be performed ? Perhaps I ought to leave this question to be answered by your surgical teachers; but as I am addressing medical practitioners, who, one day or another, may be called upon unaided to act by themselves in such cases, under circumstances of urgent necessity, allow me to tell you what I should advise and do if the emergency arose:—let me say also whether I should not prefer to make a large abdominal incision as is practised in ovariotomy. I begin the operation, as M. Nelaton advises, by making, in the right side, an incision two or three centimeters in length, a little above the crest of the ilium, parallel with Poupart's ligament: the length of this incision is subsequently increased to eight or ten centi- meters. In dividing, layer by layer, the skin, the cellular tissue, the muscles and aponeuroses, tying, as may be required, the large vessels involved in the incision, we at last come to the most deeply INTESTINAL OCCLUSION. seated aponeurosis. Proceeding always very slowly, and being very particular in sponging the wound carefully, this deep aponeurosis is cut through, when forthwith the peritoneum is reached. It is taken hold of by a small forceps and incised : afterwards, using the greatest possible precautions, a silver thread, by means of a curved needle, is carried, first through the intestine and then through the abdominal walls : four sutures are then made, two on each side of the incision: two others are made, one at the superior and the other at the inferior angle of the wound ; but this time, the abdominal parietes are first perforated, then the intestine, and afterwards the abdominal parietes on the opposite side of the wound. In this way, the intestine is fixed everywhere, laterally and from above downwards, to the walls of the abdomen : by this proceeding, no exudation can take place into the peritoneum. It is then only necessary to make an exceedingly small incision in the intestine by means of a sharp-pointed bistoury. The opening which M. Nekton makes in the intestine for the passage of its fluid contents is even less than a centimeter in length. Such is the operation. It requires more prudence than skill; although of course it is always better that it should be entrusted to experienced hands. Such is the operation which the able professor at the Clinical Hospital practised in a case which I shall now relate. Dr. Olliffe did me the honour to summon me in consultation with him in the case of a high dignitary of the Eussian empire. This General suffered from great disturbance of the digestive functions. Dor two months his stools had been becoming fewer in number and more painful. His appetite was impaired. Gradually and slowly, the abdomen became distended: gas, at first inodorous and afterwards foetid, was discharged by the mouth. When I saw the patient he had become much reduced in flesh and strength. His face was typical of abdominal disease. There was nothing discoverable, how- ever, indicative of very decided cachexia, nor did the cutaneous tint characteristic of cancer present itself. Through the thin abdominal walls were distinguishable the lumpy masses formed by the distended abdominal convolutions. There was a great degree of tympanites. No pain existed anywhere. For eight days, the patient had had vomiting : at first, the matters vomited consisted of alimentary ingesta: they were afterwards of a yellowish colour, horribly foetid, and very obviously stercoraceous. There was an exceedingly dis- tressing hiccup. The patient was entirely without spontaneous INTESTINAL OCCLUSION. 223 stools. At rare intervals, and as the result of great efforts, he ex- pelled some gas by the anus. In the first instance, I prescribed the ascending douche. There was administered in that form, twice a day, from four to six litres of liquid. The fluid passed in, and was returned; but it only brought back with it an exceedingly small quantity of fsecal matter—small in calibre, and somewhat ribbon- shaped. The existence of an intestinal occlusion was certain; and most probably it was seated in the large intestine, judging from the peculiar form of the matters which were passed. The stricture could not be reached either by the finger or a very long sound in- troduced into the rectum. There was reason to hope that the stricture was fibrous and not cancerous, as that marked cahexia in- dicating hereditary taint was absent. Drastic purgatives, the ascending douche, and other means having all failed, enterotomy was resolved upon, and was admirably performed by M. Nelaton, in the manner in which I have just described. There gushed from the incision in the intestine three large basinfuls of a yellowish, very foetid liquid. The patient immediately experienced very great relief. The operation was performed on the 22nd June, 1863: for the seven following days, gas and matters tinged with bile passed by the artificial anus: the patient was able to eat, and regained his usual strength and spirits. On the evening of June 29th, he had very severe colic; and then, soon after passing gas twice by the anus, he had a formed motion. During the night, he had another stool. On the following day, unfortunately, he had a violent paroxysm of fever, which continued nearly an hour. On the day after the next, he had another attack of fever. The wound, however, was not very painful; and there were no symptoms of peritonitis. Nevertheless, on the 1st July, nine days after the operation, the General died, after having given for seven days the best hopes of recovery. Let me now endeavour to explain the mechanism of the cure of occlusion : I only refer to the cases in which the cure is definite, and not to those in which it is accomplished at the cost of an in- curable artificial anus. In cases of the latter class, the cure obtained is only very partial: it is the snatching of a patient from immediately threatening death, and that certainly is no small matter; but then, on the other hand, it is condemning him to live with a disgusting infirmity. That is, however, the only solution of the case for which there is 224 INTESTINAL OCCLUSION. any ground of hope, when the occlusion depends upon compression by a tumour situated external to the intestine or on stricture result- ing from organic disease of the intestine itself. It is otherwise when there exists intestinal invagination, intestinal strangulation by a band, or retroversion of the intestine: under these conditions, there is a chance, though slight, of enterotomy leading to a complete and radical cure. How then does this cure take place ? It may be brought about in invagination in two ways which I have already explained to you. The state of invagination may spontaneously cease from the peristaltic movements of the intestine restoring the parts to their normal position: or, the invaginated portion of intestine may become detached by sphacelas, and fall into the intestinal canal, passing forth by the natural passage, leaving the two surfaces of divided intestine intimately soldered together by a reparative process originating in the parts themselves. Gastrotomy then, on the one hand, causes a cessation of the symptoms which threaten to put a sudden termination to life, is the means of prolonging existence, and of contributing to recovery in cases in which the unaided efforts of nature might in time accomplish a cure; and, on the other hand, it promotes that cure in the maimer which I have just explained. If the occlusion continue, gas and solid matters go on accumu- lating in the intestines; and the inordinate distension so induced more and more confirms the occlusion. Should the cure proceed by elimination of the invaginated portion of intestine, it may happen that at the time of the elimination taking place, the distension of the bowel, and the stretched condition of its walls may be so great as to hinder the soldering together of the divided intestinal surfaces: this by allowing the contents of the bowel to pass into the peritoneal cavity, may occasion speedily fatal peritonitis. But, on the contrary, should gastrotomy afford an external exit to the contents of the intestine, the intestine collapsing to a certain extent, will allow the reparative process to proceed, and the two ends of the divided canal will become soldered together. I shall now state what occurs in cases in which the strangulation is caused by bands, or by retroversion of the intestine on itself. When, in the dead body, we cautiously distend with air a portion of intestine thus coiled up, the air is perceived to pass onwards, and, as it advances, to gradually uncoil the involution. If, on the other INTESTINAL OCCLUSION. 225 hand, there exist a certain amount of resistance, and the insufflation be performed in a forcible manner, the air will accumulate above the obstacle, distending without unrolling the intestine, and thus augmenting the occlusion. In the living subject, similar phenomena present themselves. A band exerts slight pressure on the intestine, or, in consequence of some mechanical cause which escapes our observation, a part of the intestine becomes temporarily put out of its normal position: the result is a certain amount of impediment to the onward passage of the contents of the bowels : then follow a slightly increased secretion of gas, which goes on augmenting so as to distend the intestine, thereby destroying its contractile power, till, from a disengagement of its gaseous contents, the intestine returns to its normal volume. In these cases, the same thing may occur which sometimes takes place in hernia. A hernia may with facility pass out and in through an opening which is quite adequate, till, at some particular time, the hernia becomes engorged, and so cannot traverse the formerly sufficient passage. In internal strangulation of the intestine, puncture, by affording exit to the gas, is sometimes sufficient to cause the symptoms to cease; but in the vast majority of cases, this measure is inadequate, and the resource which we must then look to is enterotomy. It is explicitly indicated when the symptoms of occlusion have existed for six or eight days—when there is great tympanites—when the matters vomited present that peculiar character of which I have spoken to you—and finally, when the persistence and severity of the symptoms presage imminent death. Though the establishing of an artificial anus is unquestionably a serious operation, it is by no means so dangerous a proceeding as might be supposed. Certainly, the risks which attend it bear no comparison with those to avert which gastrotomy is resorted to. When all other means have failed, therefore, gastrotomy ought to be practised. It was by this means that my able colleague, M. Yelpeau, under desperate circumstances, saved the life of a patient, to whom he was called in by M. Briquet. During my medical career, I have five times recommended its adoption; and I have had the satisfaction to see two patients recover in consequence of the operation, who without it would have been hopelessly lost. I have related to you the history of both their cases. LECTURE LXXVIII. HEPATIC COLIC: BILIARY CALCULUS. More common in JVomen than in Men.—Rarely occurs in Children.— Composition, Form, and Volume of the Calculi.—Biliary Gravel. —Cause of the disease is not known.—Sometimes hereditary.— May be coincident with Urinary Gravel, and be a manifestation of the Gouty Diathesis.— Hepatic Colic.—Diagnosis often very difficult.—May be mistaken for Gastralgia, Colalgia, and Heptalgia.—Fain and Jaundice are not essentially pathogno- monic signs ; and may be absent.—They may be the symptoms of other affections, as of hepatitis, heptalgia, or of the hepatic colic caused by ascarides or hydatids.—Presence of calculi in the stools is the only positive diagnostic sign.—Symptomatic affections caused by the calculi: Acute Hepatitis: Retention of bile in the liver, in the gall-bladder : Dropsy of the Gall-Bladder: Rup- ture of Gall-Bladder and its excretory ducts.—Biliary Fistula. —Paraplegia, reflex and consecutive.—Treatment of Calculous Disease of the Liver. Gentlemen Listen to the language used by Morgagni in relation to biliary calculi:—“ I greatly fear/' he says, “ that what was true in the times of Eernel is true in our day, and will remain the same in the future, that is to say that we shall continue to be without characteristic signs by which they can be easily and certainly recognised, and shall, as hitherto, have only conjectures to guide us in forming a diagnosis." 1 The progress of modern science has not in any way altered the accuracy of Morgagni’s proposition: for us, as for our predecessors, the diagnosis of hepatic colic remains im- perfect up to the time when the patient passes a calculus or a 1 Morgagni :—His 37th Letter on the Seat and Causes of Diseases. HEPATIC COLIC ; BILIARY CALCULUS. 227 fragment of one. Till then, there are no data except probabilities— probabilities in some cases, it is true, exceedingly strong. It is evident, for example, that when persons complain of having experienced on different occasions, and at intervals of longer or shorter duration, violent pains in the right hypochondrium, pit of the stomach, and round the navel—when these pains shoot through the whole abdomen, and up the chest to the right shoulder—when they are so excruciating as not only to cause the patients to cry out and to throw themselves into an almost convulsive state of agitation, but sometimes even to produce syncope—when they are accompanied by nausea and vomiting, and after continuing five hours are followed next day by jaundice—it is evident, I say, that when these conditions exist, we may almost unhesitatingly pronounce that the malady is hepatic colic, a diagnosis which sooner or later will be entirely confirmed. Hepatic colic, however, is very far from being always characterised by so well marked a group of symptoms. Generally, patients only complain of being subject at intervals—twice or thrice a year, per- haps—to what they call cramps in the stomach. They give no ex- planation of the cause of the recurrence of these attacks. The fact which they realise is that the attacks of colic are accompanied by a feeling of anxiety, discomfort, and sometimes a tendency to vomit— that after a crisis of from four to six hours, the symptoms wholly disappear till a new attack sets in. If you ask the patients whether they have remarked that the attacks were followed by jaundice, the majority are unable to reply: but if you are called in soon after an attack, you discover that their skin and mucous membranes have a yellowish colour, which is particularly marked in the oculo-palpebral furrow. The icteric tint is absent in some cases : in others, it is very general, and very decided : I should wish to give you the reasons for the differences which this phenomenon "presents itself. It seldom appears till the day after the attack: then also, the stools, which have been few and more or less hard, become of a greyish hue or of an ash colour, while the urine assumes the mahogany colour peculiar to jaundice. Even during the attack, the urine, which is very copious, is limpid like wrater from the rock, being in fact what is called nervous urine. Attacks of hepatic colic, though generally transient, are sometimes considerably protracted, there being during their continuance alterna- 228 HEPATIC COLIC ; BILIARY CALCULUS. tions of exacerbation and calm, the latter condition, however, being only partial. I saw with my colleague Dr. Bergeron of the Hopital Sainte-Eugenie, a woman who had an attack of six months' duration : and, with my friend Dr. A. Joux of La Eerte-Gaucher, I saw another patient who had hepatic colics accompanied by green jaundice, which lasted almost uninterruptedly for three months. The duration of the colics was still longer in the case of a well-to-do Parisian merchant, whom I attended for more than a year without being able to recognise anything more than the symptoms of hepatitis characterised by turgidity of the liver (which was very painful on pressure), jaundice, an almost ever-recurring fever, loss of appetite, and general debility. Gentlemen, I stated to you that the diagnosis of hepatic colic was of necessity incomplete, so long as the patient had passed neither a calculus nor a fragment of one. Consequently, it is indispensable, when the symptoms lead us to suspect the presence of biliary calculi, to examine each stool attentively, to cause them to be received upon a fine sieve, and to be dissolved and washed by a stream of water in such a way as to cause all except solid matter to pass through : the stools ought to be treated in this way for four or five days after the cessation of the colics, though the proceeding is very disgusting. You saw a woman at the Hotel Dieu, who has been many times under treatment in the wards, but who never passed calculi by stool till the third, fourth, or fifth day after the termination of the attack of colic. Biliary calculi are observed much more frequently in women than in men; and, as you know, it is much more common to find them at autopsies of the old women of the Salpetriere than at autopsies of the old men of the Bicetre. The disease is much more common in old age, and in mature age between thirty and fifty, than during adolescence. Youth, however, does not confer an absolute immu- nity. Two young women between sixteen and seventeen years of age whom we had at the same time in St. Agnes's ward (beds i and 34), were remarkable proofs of this. Two years ago, I ob- served biliary calculi in a girl of nine years of age, whom I saw in consultation at Saint Germain-en-Laye. Lieutaud and Portal have mentioned facts that would show that they may be met with even in newly born children. These exceptional cases do not, how- ever, at all weaken the general rule. It is a mistake to suppose that biliary calculi vary in colour with HEPATIC COLIC; BILIARY CALCULUS. the age of the subject in whom they occur : their colour is solely dependent upon the nature of their constituents. They are gene- rally of a brownish green colour : sometimes, they are of a blackish brown or are even quite black; in the fresh state, some have been seen to present a bluish and others a reddish tint: it is not unusual to meet with them of an ash grey colour: some have been pointed out as white, transparent like crystals, or, to use the better compa- rison of Heister, like gum-Arabic. These whitish calculi are spotted with black and red points, or they may present a yellow golden aspect, or points shining like talc. The different colours are due to the proportions more or less considerable which they contain of cholesterine and the colouring matter of the bile : the colours change as the calculi become dry, from the matters, which in the fresh state produced the coloured coating, losing their properties with desicca- tion, they also lose the lustrous varnished appearance which they sometimes present, and assume that dull hue which some have from the first. They frequently attain the size of a hazel-nut, and may become as large, or even larger, than a hen's egg: their size is in an inverse ratio to their number. "When they are less in volume than a very small lentil, they are no longer considered calculi but “ biliary gravel." The quantity of this gravel may be enormous; for, with- out speaking of the extraordinary cases related by Morgagni, in which the individual grains in the gall-bladder were from seven hun- dred up to one and two thousand, and even to upwards of three thousand, you will meet with patients who pass by stool spoonfuls of these small yellowish green bodies. Dr. P. E. Chauffard lately de- scribed to me a case bearing on this subject: the patient was a magistrate, who had passed a quantity of small uneven gravel, the size of some of which was that of coarse river sand their passage by the anus occasioned acute pain and a sort of laceration: the patient stated that the quantity he had passed was sufficient to fill both hands. Biliary is perhaps more common than urinary gravel; but it is easy to understand why it should more frequently escape observa- tion. I shall not enter upon a long description of the physical cha- racters of biliary concretions, for were I to do so, I should only be repeating what you have learned elsewhere. I shall merely recall one or two facts to your recollection. Their consistence is very variable : 230 HEPATIC COLIC ; BILIARY CALCULUS. when recent, mere pressure is sometimes sufficient to crush them, and usually their resisting power is about equivalent to that of the stearine used in making candles: when placed in the flame of a candle, they melt, and burn like fatty substances. Their specific gravity is very little greater than that of bile; when dry, they float on water. Their form and size have relation to their number. When there is only one, it is pretty nearly round or oval; at some points, its surface may bear the mark of the parts within which it was formed, and which exerted pressure on it. When the calculi are numerous, they affect the most diversified forms, and are usually many-sided, presenting facettes which correspond with other facettes on other calculi; or they may become embedded in one another, as if articulated like the heads of bones in their sockets. Their structure nearly always consists of cortical layers of colour- ing matter: there is the middle portion consisting of thin triangular layers converging from the periphery towards the centre or nucleus. This central nucleus is generally composed of the colouring matter of the bile and mucus; but sometimes it is a foreign body: in a case mentioned by M. Nauche, it was a pin; in a case of which Lobstein gives a drawing, it was a lumbricus teres which had pene- trated the biliary passages.1 It is all the more easy to give an account of the formation of biliary calculi that the colouring matter of the bile not entirely dis- solved in the liquid bile, that the cholesterine, which is present only in a state of suspension, constitute, so to speak, microscopic nuclei: when, under these circumstances, there takes place a modification of the biliary secretion causing an abnormal increase in the suspended materials, a speck of colouring matter a little bigger, and a spangle of cholesterine a little larger than the rest, will become the centre of a calculus, particularly if at the same time the flow of bile is abnor- mally sluggish. That everything which tends to disturb the secretions of the liver, to alter the composition of the bile, and to prolong its progress through the biliary passages, and the duration of its stay in the bladder may be regarded as a proximate cause of biliary calculi is, it must be admitted, a very vague proposition; and again, we have not advanced one step towards the solution of the etiological ques- tion when we have spoken of the influence of the depressing passions, 1 Lobstein :—Atlas d’Anatomie Pathologique. Paris, 1829. 231 HEPATIC COLIC ; BILIARY CALCUI/CS. a sedentary life, office-work, and all the trivial causes which so often come to the help of our ignorance. It is extremely probable that diet has an intimate relation to this affection; but there is diversity of opinion as to the nature of that relation. According to observations made by Glisson and by Peyrilhe, biliary concretions are found more frequently in the gall- bladder of sheep and oxen slaughtered in March, April, and May, after having been kept on dry forage during the winter, than in those killed during summer and autumn, after pasturing in the meadows; and from these statements it has been concluded that the first-mentioned kind of feeding causes the formation of these calculi. This explanation is open to dispute : for it may be asked, whether in the former case, want of exercise and air have not quite as great a disturbing influence, as nature of aliment on the functions of the liver, and consequently upon the formation of calculi. .Finally, Gentlemen, we are baffled in our attempts to discover the real cause of this as of many other diseases. But, be the causes what they may, it is certain that they are dominated by a special predisposition existing in the individual. It is, therefore, the same in this respect with biliary calculi as with renal gravel. Some in- dividuals, who though they lead an active life, and follow a temperate regimen in which vegetables predominate, nevertheless pass gravel almost daily with the urine. It is with difficulty that such persons get rid of the gravelly affection for even a few weeks by taking the iodide of potassium (that specially efficacious lithontriptic), or by drinking the waters of Pougues, Contrexeville, or Yichy. As soon as the treatment is discontinued, and often, even, during it, the malady returns with discouraging obstinacy. A similar statement is applicable to biliary calculi in some women. In virtue of an in- comprehensible predisposition, there is a ceaseless formation of new calculi; and the malady is neither cured nor checked notwithstanding the best hygienical and medical treatment. It would appear from observations made by several physicians that this predisposition is hereditary. It has also been observed—and Morgagni has quoted numerous cases in point—that biliary and renal calculi often co-exist. So great is the importance which Morgagni attaches to this fact, that he admits, that when symptoms of hepatic colic show themselves in a person subject to urinary calculi, there is strong reason to suspect 232 HEPATIC COLIC ; BILIARY CALCULUS. the existence of biliary calculi, particularly if the subject have passed the age of adolescence. When we recollect that urinary gravel is very often the sign of the gouty diathesis, we see why the coincidence which I have just pointed out is to a certain extent the reason of another coincidence referred to by physicians as existing between biliary gravel or calculi and gout, especially when the latter, after having been frankly articular, localises itself in the abdominal viscera. Gout is an unusual disease in women; and yet it is in women that we most frequently meet with biliary calculi. In nine out of ten cases of this affection, the gall-bladder is the seat of the gravel. This arises, as is obvious, from the gall-bladder being a reservoir in which the bile naturally accumulates, and in which the conditions of repose and concentration of the liquid are most favourable to that aggregation of molecules by which the calculi are formed. It is in the gall-bladder that they are occasionally met with in large quantity, and in which, when there is only one calculus, it attains an enormous size. Sometimes, also, biliary concretions may form in the liver itself, that is to say, in the roots, or in the very radicles, of the excretory ducts of that gland. Generally, however, it is biliary gravel and not calculi which we find in that situation : but it occasionally happens that large calculi form and are moulded within the dilated ducts. When the concretions are situated near the periphery of the liver, they con- stitute tumours projecting from the surface of the organ. In such cases, after perforating the walls of the canals within which they have been developed, they become lodged in the parenchyma itself. Save the exceptional cases, to which I shall have immediately to recall your attention, in which the calculi open for themselves an outlet from the place wherein they were formed, they find their exit by the intestine. To reach it, those formed in the branches of the hepatic duct must traverse the trunk of that canal, the gall-bladder, the cystic duct, and at last the choledoch duct. It is when the biliary concretions are passing through the excretory passages of the liver that they give rise to the symptoms which constitute hepatic colic. The pain and the jaundice are symptoms which explain them- selves : the first, by the irritation and spasm produced by the foreign bodies traversing the passages which are narrow and provided HEPATIC COLIC; BILIARY CALCULUS. 233 with valves: the second, by the obstacle which these same foreign bodies present, from their volume or bulk, to the passage of the bile, when once they become impacted in the choledoch duct. The jaundice is also, and perhaps better, accounted for by the sympa- thetic irritation of the liver modifying the secretory functions of that organ. The proximate cause of hepatic colic is not always appreciable when the affection shows itself after some effort, pressure on the hypochondriac region, rather violent exercise, or a powerful mental impression. There is one cause, however, and that, too, the com- monest of all causes, which has been distinctly indicated by authors, particularly by Pujol: I refer to the influence of digestion. It is indeed after the principal meal that the hepatic colic usually super- venes, a fact which may be explained in the following manner. The gall-bladder, the cystic and choledoch ducts are muscular and con- tractile organs, intended to act during duodenal digestion, whilst the liver is going to secrete bile in large quantity to be poured into the intestine. In virtue of a stimulus produced upon the extremity of the choledoch duct, and which is transmitted by reflex action, the secretion of the hepatic gland takes place with a rapidity which is also observed in the secretion of other glands, as, for example in the secretion of the salivary glands, when the appetite is excited by the sight of nice dishes, or in the secretion of milk, when the nipple is sucked. During duodenal digestion, the biliary secretion is similarly excited; and the bladder moreover contracts so as to pour its reserve of bile into the intestine. This ejaculation of bile, if I may use such an expression, will cause the expulsion with it of the concretions whether formed in the ramifications of the hepatic duct or, as is more usual, in the gall-bladder. The pains are first felt at the pit of the stomach, and around the umbilicus; and when they are localised in the right hypochondrium, this is a consecutive occurrence. Patients employ all sorts of comparisons to give an idea of the sufferings which they endure: they speak of pinching, tearing, and burning: but that of which they generally complain is an acute, agonising feeling of constriction, which sometimes extends to the back, epigastrium, and opposite hypochondrium, where it is increased by pressure even by simple palpation. The pain goes down into the abdomen, in some cases simulating nephritic colic : more generally it ascends into the chest and even to the neck, and it 234 HEPATIC COLIC; BILIARY CALCULUS. is a remarkable fact that many persons experience it in the right shoulder. The patients are sometimes exceedingly excited, utter piercing cries, roll on the bed or the floor, endeavouring by ceaseless change of position to moderate their sufferings. In some, the disturbance amounts to more than mere agitation, and consists in convulsive attacks; and in others, there are fainting fits which occasionally though very seldom lead to death. This kind of colic is frequently accompanied by nausea and vomiting. When it sets in soon after a meal, the food is forthwith rejected, after which a glairy substance is ejected : sometimes, at the end of the attack, there is vomiting of yellow bile. As I remarked at the beginning of the lecture, the urine is at the same time clear as water from the rock. It is not till twelve, eighteen, or twenty- four hours later that it assumes the reddish-brown mahogany colour characteristic of jaundice; and if jaundice is to show itself it is not till then that it will appear. In hepatic colic, the pain probably depends on the same mecha- nical cause as in nephritic colic. In the latter, once the renal cal- culus becomes engaged in the urethra, it is constantly propelled onwards by the urine accumulating in the calices and pelvis of the kidney, and with every onward move which it makes in its passage through the narrow canal, it causes excruciating suffering. We may explain in a similar manner the pains produced by biliary cal- culi impacted in the choledoch duct. But how are we to explain the pains produced by calculi engaged in the cystic duct ? I con- fess, Gentlemen, that I have many times fruitlessly asked myself this question; but, nevertheless, calculi of the gall-bladder, and consequently of the cystic duct, are by far the most common, and also the most frequently productive of hepatic colic. I can quite understand that, in some particular movement of the body, a calculus contained in the gall-bladder may present itself at the cystic open- ing, and become engaged in the duct; but when it has got there, how will it make way ? It certainly does make way; and in its progress causes agonizing paroxysms of pain which patients describe with extraordinary exuberance of language. You then require to bear in mind that the gall-bladder, like the urinary-bladder, is provided with a muscle; and that this muscle must contract with increased energy when a calculus is painfully impacted in the neck of the cystic duct just as the urinary bladder contracts with indo- 235 HEPATIC COLIC ; BILIARY CALCULUS. mitable vigour when gravel or a fragment of stone is arrested in the prostate, or even in the canal of the urethra. It is for a similar reason that the uterine muscle contracts energetically at the term of gestation, when we tickle the neck of the uterus, or when the pro- duct of conception becomes more completely engaged in that passage. It is very obvious, that the gall-bladder is full of bile in the intervals between the times during which digestion goes on, and that it empties itself by a somewhat powerful contraction whilst the food is being elaborated in the stomach and duodenum, but particularly during elaboration in the latter. We can understand that in a gall- bladder full of calculi, the muscular tunic will become hypertrophied, just as happens in the case of the urinary-bladder when it contains a stone; and this is not a mere rational hypothesis, for the hyper- trophied muscular tunic can be demonstrated at the autopsy. The conclusion, therefore, is quite natural, that contractions of the bladder, in the first instance, propel the liquid against the calculus engaged in the canal so as to accelerate its progress, and that then contractions, irrespective of the bile, push it onwards. We can also see how it is that the paroxysms of pain may depend, to a certain extent, on these contractions which, like the contractions of all hollow muscles, will be intermittent. I do not require to tell you, that when the cystic canal is free, and the calculus is engaged in the choledoch duct, the action of the vesicular muscle may contribute to produce the paroxysms of pain, and aid in propelling the liquid accumulated behind the obstacle, so as to communicate an onward impulse to the calculus. This rapid sketch which I have now traced embraces the most violent and most characteristic crises of the disease. But, as I was careful to tell you, there are many cases in which the symptoms now described are not so well marked. Generally, your patients will complain of cramps in the stomach; and you may be led to mistake hepatic colic for heptalgia, gastralgia, or coxalgia. It must be admitted that in such cases it is not very easy to form a diagnosis merely from the nature of the pain. There are, however, certain considerations which will assist us in doing so. If a patient, subject to attacks of neuralgia in other parts of the body, the face for example, complains of cramps in the stomach recurring periodically—if he localise with precision the seat of the pain in the epigastric region, and tell you that it comes on at long 236 HEPATIC COLIC; BILIARY CALCULUS. intervals after eating, sufficient grounds will exist to justify your entertaining the idea that there may be gastralgia. Finally, if the pains appear to be more localised in the left liypo- chondriuin, while there exist at the same time constipation and the other symptoms which characterise colalgia (a disease to which I directed your attention in my lectures on dyspepsia), there will be reason to suspect neuralgia of the large intestine. Should the right hypochondrium be more particularly the seat of pain, if it has been positively ascertained that no biliary calculi were ever passed, if the pains recur with tolerably precise periodicity, as in other forms of neuralgia, I conclude that the case must be one of heptalgia, although that be very uncommon as an idiopathic affection. But when the pains, whatever may have been their seat, are followed by jaundice, the diagnosis will be much less doubtful; and examination of the stools will show, sooner or later, that the case is one of hepatic colic. The simultaneous manifestation of these two symptoms generally implies the existence of hepatic calculi, but it is necessary to re- collect that one or other symptom, or even both, may be wanting, and also, that they may both be present, and yet there be no biliary concretion. It is not unusual, perhaps, after an attack of colic induced by the passage of a calculus, for other smaller concretions, or still more probably for biliary gravel, to pass through the prepared passages without occasioning a renewal of the pains. Under other condi- tions, it is much more unusual for small calculi, or even for gravel, to pass through the excretory passages of the liver without leading to severe and characteristic suffering. The pains, it is true, may become more or less dull, and may only amount to a sensation of discomfort, as I have often observed. In these very cases, the jaundice supervenes, though not simul- taneously, at least within twenty-four hours. This symptom may, however, be absent. The most trustworthy authors have given examples of individuals who passed biliary calculi without ever having had jaundice. In these cases, the concretions were either very small, or if not very small had been too quickly expelled to obstruct the flow of bile, or excite that sympathetic influence on the liver which has so great a share in the production of jaundice. Again, colic has been occasioned by calculi contained in the gall-bladder, which, after HEPATIC COLIC; BILIARY CALCULUS. 237 being accidentally put in motion, have regained the place they originally occupied without remaining in the canals wherein they were temporarily engaged. I knew a patient who for more than four years had had attacks of hepatic colic, and yet in whom they had never been followed by jaundice. In the fifth year, the attacks became more severe, jaundice appeared, and the disease ceased upon the expulsion of a single calculus, shaped like an olive, the greatest diameter of which was two centimeters. Absence of pain and of jaundice do not then necessarily imply the non-existence of calculi: more than that, I have said that these symptoms may, in some cases, supervene as manifestations of affections quite different from calculous hepatic colic. True paroxysms of hepatic colic have been caused by hydatids of the liver becoming engaged in the biliary passages. Tor example, there died not long ago in the wards of Dr. Lasegue at the Hbpital Saint-Antoine, an individual affected with jaundice of a very deep shade of colour, in whose body there was found, at the autopsy, hydatids obstructing the excretory biliary conduits. A similar case presented itself in a young woman, who, as you remember, died in our wards on the 20th September, 1863. When I come to speak of hydatid cysts of the liver, I shall have to recur to this case. I would for the present, only remind you, that the hydatic cyst of the liver with which this patient was affected, opened first into the biliary passages, then through the diaphragm into the pleural cavity, and that the first symptoms which showed themselves were violent hepatic colics, which recurred at remote intervals, and were accom- panied by very deep jaundice. These cases, I would remark to you in passing, completely negative an assertion of some physicians to the effect that hydatids in the liver are never accompanied by jaundice. Dr. Bonfils has collected a very considerable number of facts relating to the symptoms which may be produced by the presence of lumbricoid worms in the biliary passages. These symp- toms, which show themselves suddenly, are characterised by violent pains, accompanied by vomiting and jaundice, so similar to, as to be mistaken for, those which characterise hepatic colic depending on biliary calculi.1 Professor Andral has reported cases which appear to prove that 1 Boufils -.—Archives Generates de Medecine, for June, 1858. 238 HEPATIC COLIC ; BILIARY CALCULUS. heptalgia, itself very rare as an idiopathic affection, likewise, in some cases, when complicated with jaundice, simulates hepatic colic.1 If I add, in conclusion, that acute hepatitis, which occasions sharp pain, recurring in paroxysms, and gives rise to jaundice, may also lead to an erroneous diagnosis, you will see how great are the chances of error, and why the only really sure element of diagnosis which we possess is the presence of biliary concretions in the stools. Up to that point, however well-founded our presumptions may be, they still are nothing more than presumptions. You will not be surprised, then, Gentlemen, that I do not attempt to give you any more precise information in regard to diagnosis, a subject upon which some light is pretended to have been shed by certain authors who describe signs by the aid of which they say, we can recognise the situation of the calculi in the different parts of the biliary apparatus. It may happen, however, that the gall-bladder, from containing an accumulation of small calculi projects from under the margin of the false ribs, so as to be recognised through the abdominal walls, in thin subjects. This was the case, as I showed you, in one of our young female patients in Saint Bernard's ward. In exploring the abdominal region in women in whom the parts are very flaccid from repeated pregnancies, we can, by making firm pressure with the fingers whilst the patient takes a deep inspiration, reach a hard pouch within which a well-marked crepitation is perceived. But cases of this description are quite exceptional: the case now before us is only the second of the kind which I have met with. The frequent recurrence of the symptoms, their persistence, their intensity, and the presence or absence of vomiting during the crisis, have by no means the diagnostic significance attributed to them. When the calculi are engaged in the choledoch duct, there is no bilious vomiting, a fact which is explained by the position of the calculus preventing the passage of bile. Bilious vomiting indicates that that duct is free, and that the foreign bodies are impacted either at the neck of the gall-bladder or in the cystic duct. It is conceivable, however, that small concretions may traverse the choledoch duct and produce colic, without preventing the bile from reaching the duodenum and stomach. We can likewise understand that bilious vomiting is not a necessary phenomenon of hepatic colic, 1 Ax dual :—Clinique Medicale. HEPATIC COLIC; BILIARY CALCULUS. 239 even when the colic is occasioned by calculi which have not proceeded beyond the cystic duct. The duration of the symptoms, their intensity, and more or less frequent recurrence, are exceedingly variable phenomena; and depend upon a great many circumstances, of which the most influential is assuredly the volume of the concretions by which they are caused. The larger the concretions, the more slowly will they effect their transit: moreover, at any stage of their passage, they may be stopped, and pushed backwards into the gall-bladder, whence, under the influence of new proximate causes, they may again become engaged in the biliary passages, and again excite paroxysms of colic. Or, on the other hand, they may remain impacted, so to speak, in the cystic or choledoch duct; and if they do not produce colic, they will give rise to symptoms resulting from the distension of the gall- bladder or the accumulation of bile in the hepatic ducts. You, no doubt, recollect an autopsy which we made in 1861. There was no symptom during life which had led us to suspect the existence of hepatic calculi; but on examining the liver, we found two engaged in the cystic duct, one being as large as an olive, and the other a little smaller. The larger was closely adherent to the walls of the duct: prolongations of mucous membrane extending into the interior of the biliary concretion had to be broken before the calculus could be detached. I do not suppose that these prolongations were formed when the calculus had attained its full size: it is more probable that at a somewhat early stage, the presence of the calculus had set up acute irritation of the mucous membrane producing fibrinous exudations which became partially organised: afterwards, new layers of cholesterine and colouring matter augmented the central nucleus, enveloping the bands of accidental cellular tissue. I can scarcely explain in any other way the encasement which I have described. When hepatic colic has been of long duration, or has recurred at very short intervals, two symptoms, which I have already pointed out to you, are added to the feverish condition of the patient arising from inflammation of the liver. This inflammation (which has arisen under the influence of irritation extending to the gland itself, and under the influence, also, of a greater or less obstruction of the excretory ducts, by the bile temporarily impeded in its circulation retained in the passages which it traverses), shows itself by the 240 HEPATIC COLIC ; BILIARY CALCULUS. organ becoming increased in size, and the seat of pain being rendered more severe by pressure. The increase in the volume of the liver is sometimes so great that it extends more than a hand-breadth beyond the false ribs, and descends into the right iliac fossa. This kind of hepatitis, which is that most commonly observed in tem- perate climates, often continues after recovery from the colic in which it originated, and when there are no remaining biliary con- cretions. It becomes chronic: the enlarged state of the liver continues: it is the seat of dull pains, of which, at longer or shorter intervals, there are exacerbations ; the biliary secretion is disturbed; and this functional disturbance causes dyspepsia, and sometimes extreme anaemia. This chronic inflammation, frequently, also, becomes the cause of cirrhosis and other organic changes, which sooner or later terminate in death. The retention of bile in the liver, caused by the obstruction of one of its excretory ducts also induces enlargement of the organ, dilatation of the larger and smaller ramifications of the hepatic duct, the calibre of some of which may become equal to that of the quill of a goose. These dilatations, sometimes partial, like aneurisms, form small fluctuating tumours resembling abscesses in appearance; but it is only on opening the dead body that we can recognise the nature of the lesions, for the retention of bile in the liver does not declare itself by any symptoms different from those of the hepatitis which accompanies it, and was likewise its cause. Disten- sion of the gall-bladder does not lead to these consequences. Distension sometimes proceeds so far, that the augmented volume of the gall-bladder causes it to project into the hypochondriac region. By palpation, we can detect the tumour by which it is constituted —a fluctuating tumour, which, according to its size, occupies different situations. We may detect it under the margin of the false ribs; or, when the distension is greater, we may find that it extends into the epigastric region, and across the median line into the left side : or that it descends to the umbilicus, or sometimes even to the iliac crests. Cases are recorded in which it occupied the entire abdomen. Distension of the gall-bladder is generally accompanied by more or less inflammation; and this inflammation leads to thickening of the different tunics; and particularly to thickening of the muscular tunic, a circumstance which explains the relative variety of rupture. On opening the dead body, no bile is found in the gall-bladder ; but, generally, it contains thin mucus resembling white of egg, and HEPATIC COLIC ; BILIARY CALCULUS. 241 at other times a fluid resembling urine, or, it may be, a fluid which is limpid and colourless. There then exists that condition which has been called dropsy of the bladder. This cystitis "which may terminate in suppuration, and which also produces more or less deep ulcerations of the walls of the gall-bladder, may supervene independently of any obstacle to the passage of the bile through the cystic and choledoch ducts, arising from the mere presence of the calculi causing permanent irritation. This wdiich is, perhaps, the most common cause of the cystitis explains the per- sistence of pains during many consecutive years in persons subject to recurrent hepatic colic. The cystic and choledoch ducts are sometimes the seat of a con- siderable accumulation of bile, producing dilatation of their calibre. The choledoch duct has been found so distended from this cause as to equal the small intestine in volume; and Morgagni (quoting Scheuck) mentions a case of Traffelmann “in which the choledoch duct was as large as a stomach, and completely filled with calculi of different sizes.”1 Though much rarer than distension, atrophy of the gall-bladder, is a structural change which has been mentioned as one of the conse- quences of the presence of biliary calculi. The pouch contracts upon the concretions which it contains : its walls become thickened, and adhere so firmly to the foreign body that they can hardly be separated at the autopsy. At other times, the calculus is imbedded in a part of the gall-bladder in such a way as to cause it to form two pouches, one of which contains the foreign body, and the other is filled with bile and mucus. Inflammation of the gall-bladder is not unfrequently propagated by contiguity of tissue to the peritoneum. In this manner is pro- duced more or less extensive peritonitis. These peritonitic attacks, generally partial, give rise to adhesions between the gall-bladder and neighbouring parts—the omentum, right kidney, stomach, duodenum, colon, and abdominal parietes. The false membranes constituting the adhesions are so thick in certain cases, that when they become lost in the middle of the mass which they form, it is difficult to dissect out separately the gall- bladder. These limited peritonitic attacks sometimes become general in a very sudden manner, assuming a subacute form which soon proves fatal. 1 Morgagni : Letter 37th. HEPATIC COLIC; BILIARY CALCULUS. However, a rapidly fatal attack of peritonitis does not generally supervene in that fashion. It is usually the consequence of rupture or perforation of the gall-bladder or biliary ducts. I have observed, that, when from obstruction of the excretory passages, the retained bile had accumulated in the choledoch duct, cystic duct, or gall-bladder, the walls of the latter were hypertrophied, and consequently more resistant, which explains why rupture of it is so rare an occurrence in such cases. If, however, acute cystitis supervene, the walls of the gall-bladder undergo softening, and then ulcerate. Thus we have a perforation which causes rapidly fatal peritonitis. Eight years ago, I attended a retired notary who had been long subject to attacks of hepatic colic. Upon one occasion, I was sent for to see him on account of the paroxysms having assumed an unusual degree of severity. On my arrival I found that the patient had constant vomiting and a tympanitic state of the abdomen; there was total suppression of urine, an excessively feeble, almost imper- ceptible pulse, and a greatly reduced temperature of the body. To be brief, all the symptoms of subacute peritonitis were present. I pronounced the case to be hopeless, and the next day the patient died. Although unable to obtain an autopsy, I am justified in saying that the case was one of peritonitis caused by effusion into the peritoneum consequent upon rupture of the gall-bladder or one of the biliary ducts; and that what took place was similar to what had occurred in another patient who died in nearly similar circumstances under my observation. The case occurred at Tours. A rich inhabitant of that town, a patient of Bretonneau, was suddenly seized during an attack of hepatic colic (which had continued for five or six days) with intrac- table vomiting and all the signs of severe peritonitis, under which he succumbed in twenty-four hours. On opening the dead body, we found in the peritoneal cavity, a calculus the size of a hazel-nut; and we discovered in the choledoch duct a perforation, through which had passed a considerable quantity of bile along with the calculus. I am indebted to an excellent pupil, Dr. Werner of Dornach, for the history of a similar case, which is particularly interesting from the difficulty experienced in the diagnosis of hepatic colic. “ Yery soon after my arrival in this place,” writes Dr. Werner, “ I was called to a patient who had what he called very violent HEPATIC COLIC ; BILIARY CALCULUS. 243 cramps of the stomach, following great mental emotion. I dia- gnosed the presence of biliary calculi; and instituted my treatment in accordance with that viewr of the case. On the following day, the pains having increased, and peritonitis having declared itself, I suspected that rupture of the gall-bladder had taken place; and re- quested that one of the principal physicians of Mulhouse should be asked to meet me in consultation. Hepatitis was the diagnosis of that gentleman, vdio sneered at my supposing that there were calculi. Dissatisfied with this opinion, I requested that a second physician should be asked to see the patient. He concurred with the former physician's diagnosis. Going home a little shaken in my opinion, I attentively repernsed my notes taken at your clinical lectures; and the result was, that I became more than ever convinced of the soundness of my original view of the case. Your lectures on hepatic colic, it seemed, had not yet reached Mulhouse. In two days, the patient died. With permission of the family, I made an autopsy in presence of one of the colleagues whom I had met in consultation. I found twenty-five calculi, as large as hazel-nuts, in the gall- bladder, which had burst and allowed the bile to pour into the peri- toneum: a calculus larger than any of the others was impacted in the choledoch duct.” Cases of this kind are not uncommon : and a considerable number have been reported by authors. In some cases it wTas pure bile, serosity, or mucus which escaped; in other cases it was pus, the inflamed gall-bladder being transformed into a sort of abscess : while in other cases, again, biliary concretions of greater or less magnitude were found in the cavity of the peritoneum. These perforations and ruptures do not always lead to the formid- able consequences of which I have been speaking. When the gall- bladder or its ducts have contracted adhesions with the neighbouring parts, perforation may take place, without allowing anything to pass into the peritoneum, because the pouch has opened either externally or into the intestinal canal, urinary passages, or liver itself. It is in this way that external and internal biliary fistulce are produced. External biliary fistulse may originate spontaneously : or be formed artificially by the surgeon in opening the tumour which is some- times of very considerable size, projecting beyond the abdominal parietes in such a wray as to be mistaken for an abscess. Cases of this description are reported by authors, particularly by Jean-Louis Petit. 244 HEPATIC COLIC; BILIARY CALCULUS. The following case was communicated to me by Dr. Leon Blondeau who obtained the particulars from a patient whom he saw at Vichy in 1850. A gentleman, aged 68, of vigorous constitution, wdio had had rather frequent attacks of urinary gravel was seized with hepatic colic in 1843, an(l soon afterwards perceived a pretty large tumour in the right hypochondrium. It was painful on pressure; and wras evidently fluctuating. The patient consulted Professors Eostan and Cruveilhier, and insisted that he should be operated on, as he believed that by an operation he could be cured. He was advised to wait; but during the following year, his malady continuing, a surgeon of Versailles consented to apply three cauteries to the tumour. After separation of the eschars, one of the cauterisations closed up, and two others, after giving exit to mucosity tinged with bile, became the orifice of fistulse, w'hence issued about a dozen calculi, several of which were as large as the extremity of the little finger. Prom that time, the patient, wuthout being aware of it, occasionally passed con- cretions : he found them amid the dressings of the wyound in the morning. Sometimes, however, the expulsion of calculi a little larger than usual occasioned pain. He mentioned that on one oc- casion a considerable quantity of bile passed through one of the fistulse, and that coincident wuth this flow of bile, which continued for about a fortnight, there was a certain degree of loss of flesh; the plumpness lost during the flow of bile wras soon regained when the flow ceased. In addition to the wounds affording exit to calculi and harder concretions, they sometimes discharged blood and serosity. In other respects, the health of the patient was good. I attended a similar case along with my honourable friend Dr. Laguerre. Our patient was a gentleman sixty years of age who had been often tormented with hepatic colic. Consequent upon an unusually severe and persistent attack of colic, there supervened acute pain in the right side, in the situation of the gall-bladder. There was soon felt a puffy state of the parts, the skin became red, and a real abscess formed, by opening which an exit was given to a muco-purulent fluid and calculi. Dr. Guyon communicated to the Academy of Sciences a case in which recovery followed the passage of a biliary calculus through the abdominal parietes. The patient w\is a lady who after presenting for some time a not very painful tumour in the region of the liver which only occasionally produced slight febrile action, passed by the HEPATIC COLIC; BILIARY CALCULUS. 245 tumour which had been opened by caustic potash, a triangular cal- culus of about six centimeters in its greatest and of about four and a half in its smallest circumference. Consequent upon the expulsion of the foreign body, the local discomfort diminished day by day, the fever ceased, and the cure was complete. Gentlemen, you are aware that M. Petit held that it ought to be regarded as a rule in surgery, to anticipate by operation the opening of the gall-bladder, with a view to prevent fatal peritonitis from its contents passing by a spontaneous rupture into the peritoneal cavity. Establishing a similarity between retention of bile caused by calculi in the gall-bladder and retention of urine caused by stone in the urinary bladder, he came to the conclusion that lithotomy was applicable in both cases. After quoting Petit’s opinion, Yan Swieten adds :—Forte prima fronte audax apparebit facinus talia moliri ; sed eerie audacior ille full, qui primus ex vesica urinaria sectione calculum educere tentavit. Petit, however, held, that it was only when the gall-bladder had contracted adhesions with the abdominal parietes that the operation ought to be performed; he pointed out that if it was resorted to under other conditions, the very accidents we desire to prevent would be caused, by establishing a communi- cation between the gall-bladder and the abdominal cavity. He indicates the signs by which the existence of adhesions can be recog- nised : but as Boyer justly remarks, these signs, which in reality are only two in number—immobility of the tumour, and puffiness of the integuments, have no certainty of character. According to Boyer, it would, therefore, be better to wait for clearer evidence of the ex- istence of the affection, and till the tumour has shown a decided tendency to open externally. Nevertheless, Gentlemen, there are cases in which the imminence of the patient’s danger obliges the physician to interfere as promptly as possible. That we may proceed with perfect safety in these cases, we must, following the practice of Begin, endeavour to produce adhesions, by cutting through the abdominal parietes, layer by layer, till the peritoneum is reached. When this has been done, we wait twenty-four hours before completing the operation by cutting into the tumour itself. Proceeding in that way, the same results are attained as by Becamier’s method of opening the tumour by the application of potassa fusa. That was the plan pursued in the case I have just related to you. These proceedings are not free from danger. I have often men- 246 HEPATIC COLIC; BILIARY CALCULUS. tioned another plan, which I have devised for accomplishing the same object. I use a multiplicity of acupunctures in the following manner. I insert thirty or forty steel needles having large heads : I cause them to penetrate to the gall-bladder. In treating ovarian cysts, I proceed on a similar plan; and indeed it is principally for such cases that I have employed it. The needles are allowed to remain undisturbed for three or four days : they are then removed, when another set are introduced in the spaces between the punc- tures made by the first set: this system is renewed a third time. It is essential that the needles have heads of sealing-wax : it is like- wise essential that a shield of glove-leather be applied over the part, and traversed by the needles at the time they are pushed into the skin: unless this double precaution be taken, the needles will very quickly penetrate into the tissues, there becoming lost, not without risk of dangerous consequences. The practice which I have just described is certainly simpler, and freer from danger than any other as yet proposed for obtaining adhesions between a cyst and the abdominal serous membrane. I need not say that the small inflammatory areola developed around each puncture causes, from the proximity of the punctures, inflamma- tion of the peritoneum sufficient to comprise all the surfaces which we wish to adhere. You understand, Gentlemen, that internal biliary fistula are quite beyond our means of treatment. As I have just been telling you, communications may be formed between the gall-bladder and the duodenum or colon. An old lady, who lived in the Place Eoyale, was seized after an attack of hepatic colic, with violent pains which were limited to the left side: along with these pains, she had obstinate constipation. These symptoms had led me to think that there might be pelvic abscess, when, in one day, the patient passed forty calculi by stool. Expulsion of biliary concretions with the urine proves that a fistulous passage may form between the gall-bladder and the pelvis of the kidney. Cases reported by reliable authors, such as Prank, show that similar communications may become established between the gall-bladder and the liver itself. “A. woman/' says Prank, “ who had suffered severely from hepatic colic, before her death, presented signs of gangrenous inflammation of the liver. At the autopsy, the concavity of that organ was found to be occupied by a large abscess containing foetid pus. Through HEPATIC COLIC; BILIARY CALCULUS. 247 one of the sides of this gangrenous pouch, there projected the point of a triangular calculus. The walls of the gall-bladder cartilaginous, a finger-breadth in thickness, adherent to the colon and duodenum, only communicated with the liver by several sinuses, whence flowed similar foetid purulent matter. It also contained two calculi as large as chesnuts, and many others of smaller size.” When biliary calculi once get into the digestive canal, whether they enter by the natural route, the choledoch duct, or by a fistulous passage, the peristaltic movements generally carry them on to the anus, whence they are expelled with the stools. There are cases, however, very unusual cases, it is true, in which calculi have ascended into the stomach, and been vomited. You, no doubt, remember the history of a young woman who was admitted to Saint-Bernard's ward with symptoms of formidable peritonitis. At the autopsy, we found a biliary calculus impacted in the appendix vermiformis, in which it had caused a perforation. Similar cases are mentioned by authors. You had an opportunity of observing one of the most curious examples of these internal fistulse in a woman who lay in bed 38 of Saint-Bernard's ward. The following is a succinct account of the case:—A woman fifty-three years of age became a patient in Saint- Bernard's ward, in 1863. She stated, that some years previously she had been under treatment by Dr. Behier at the Hopital Beaujon for paraplegia, with lesion of the vertebrae. The paraplegia was fortunately cured. I was first of all struck with the deeply jaundiced tint of the skin, which at once fixed my attention upon the liver. The patient stated that some weeks previously she had experienced violent cramps in the stomach, which were accompanied by nausea, and sometimes by vomiting: on the following day, the skin became yellow, and the urine assumed a very dark colour. On each recurrence of these symptoms, she had an attack of fever characterised by shivering, followed by a severe and protracted hot fit but which was not succeeded by sweating. Some weeks after she came into the hospital, she had a much more violent attack of colic. The pain in the hepatic region assumed an exceedingly intense form; and for at least a week I thought there was severe hepatitis with inflammation of the gall-bladder. Then she had, at nearly the same hour, daily, for almost a month shivering followed by heat and sweating : at the beginning of the paroxysm, there was no diminution in the jaundice, 248 HEPATIC COLIC; BILIARY CALCULUS. and always an exacerbation of the pain. I remained in tlie belief that the fever wras caused by the hepatitis, and by the inflammation of the gall-bladder induced daily by the presentation of a calculus at the entrance of the neck of the cystic duct. Examining the liver by palpation, I found that throughout its whole extent, it was hard and very sensitive. On the right side, the great lobe extended six or eight centimeters beyond the margin of the ribs; and as the abdominal wTalls wrere thin and flaccid, it wTas easy to follow the sharp edge of the liver to the point where it became lost under the left hypochondrium. After following the cutting edge of the liver for nearly ten centi- meters from right to left, I all at once found an interval occupied by a globular body having the liver for its base and projecting down- wards : it wras about the size of an orange, hard, without inequalities of surface, and very painful: then came another division, limiting on the left the projection of which I have just spoken : and after this, I could again feel the margin of the liver, and continue easily to follow' it. Every one frequenting the w7ards was able to repeat this explora- tion : and, like me, all thought that the tumour they felt on the margin of the liver was the distended gall-bladder. I wras more than ever persuaded that it contained calculi, that a calculus obstructed the cystic duct, that there existed inflammation and extreme dis- tension of the gall-bladder, and that there was also subacute hepatitis. However after residence in hospital for two months our patient wrent out in a good condition. The jaundice had slowdy disappeared : the paroxysms of pain had recurred at greatly prolonged intervals, and then wholly ceased. The fever subsided, the appetite and plumpness returned; and wdien the patient left the hospital, she only complained of a constant acute pain in the hepatic region, while in size the tumour had diminished nearly one half. It was quite evident to me that the calculi remained in the gall-bladder, and that it had become tolerant of their presence. But at the end of December, 1863, this woman, who had enjoyed good health for six months, returned to our wrards with symptoms in all respects identical with those for which she had been previously treated: the same hepatic pains, always coming on towards evening in an irregularly intermittent manner, and alwrays accompanied by a true paroxysm of fever, with shivering, generally slight, and in- IIEPATTC COLIC; BILIARY CALCULUS. 249 variably accompanied by jaundice; the intensity of the febrile paroxysm and jaundice was always proportionate to that of the pains. During the intervals between the attacks, the woman's health was pretty good: her appetite returned: she left her bed, went down into the garden, engaged in the usual occupations of her sex, and gradually lost the icteric tint. The periods of remission were even sometimes so prolonged as to cause her to speak of leaving the hospital. She, however, always retained a bulky tumour in the right hypochondrium, presenting the same form which I described : it was painful during the paroxysm, and very slightly sensitive during the periods of remission. Consequent upon straining in vomiting caused by the attacks of hepatic colic, an inguinal hernia on the right side was produced; and from time to time, this hernia was the cause of suffering. On the 20th May, 1864, the attacks of vomiting suddenly became ex- ceedingly frequent, while at the same time, the hernia was the seat of acute pain; and on the following day, it was evidently strangu- lated. The operation of colotomy was performed; but two days afterwards the woman died. Here is an account of the unexpected lesions of the liver which were found at autopsy :— There was no very remarkable increase in the volume of the organ: it extended about five centimeters beyond the margin of the false ribs, and presented a singular condition on its sharp edge. A deep hollow marked the separation between its right and left portions : a little beyond this, on the anterior margin, there was another hollow : situated between these two clefts, there was a large rounded lobule which looked like the gall-bladder distended with calculi. The general aspect of the liver was very much that presented by cirrhosis. Its external surface was studded with a multitude of yellowish white granulations, among which was perceived the deep brown colour of the organ: the yellow tinge was, however, much less decided than in cirrhosis, and the tissue, when torn, did not present the granular aspect characteristic of that lesion. On its inferior surface, the liver presented the appearance of a double gall-bladder: there were seen, in fact, in the situation of the fundus two pyriform tumours, both of which were evidently distended with calculi. The largest of the two pouches—that is to say, the gall-bladder—was situated internally, immediately below the isolated lobule which I have described. Its globular form, and the resistance 250 HEPATIC COLTC ; BILIARY CALCULUS. which it presented, were sufficient to indicate that it contained solid bodies. From the neck of this tumour proceeded a number of very dilated canals, which were rounded off within the lobules. Con- spicuous among these canals were two describing two concentric curves, the concavity of which was to the front: the one led to the upper and posterior part of the left lobe: the second sent a branch to the quadrilateral lobe, and became lost on the anterior part of the internal extremity of the liver. There existed no trace, therefore, of the usual distribution of the biliary ducts. A fibrous cord, comprised within a peritoneal fold, passed downwards from the middle part of the curved canal I have described; but from its having been cut near its origin, I could not ascertain where it terminated. The accessory pouch situated external to the gall-bladder, to which it was adherent at its summit, was of an oval form, and immo- veably fixed to the inferior surface of the liver by close adhesions. After ascertaining the nature of the external appearances, the biliary reservoir and its afferent ducts were opened. From each incision made in the course of the dilated ducts, there came a gush of yellow bile, containing a great deal of minute gravel. The gall- bladder in its inferior part contained a round calculus the size of a large hazel-nut, yellow externally and internally. Above the place occu- pied by the calculus, was a large cylindrical pouch constituting a common reservoir, in which all the biliary ducts terminated. There was decided thickening of the walls of the gall-bladder. At the base of this dilatation of small tubes, immediately above and externa] to the calculus, there was a series of lines indicating very well the spiral form of the cystic duct. Above this point was seen a rounded cicatrix, the centre of which was perforated by an opening leading to the accessory pouch. Another fistulous passage led to the duodenum. The accessory pouch, filled by three large and three small calculi, pale externally and yellow internally, communicated with the gall- bladder by a small cavity leading into a rounded pouch which exactly resembled a canal contracted at both ends. The bottom of this pouch was large, and was filled by the three calculi of which I have spoken. The walls, which were very thick, presented internally a membrane marbled by vascular arborizations filled by a whitish fluid, in which were seen, by the aid of the microscope, numerous pus- corpuscles, mingled with small globules of fat. Even the wralls of HEPATIC COLIC ; BILIARY CALCULUS. 251 this pouch, when microscopically examined, presented only the elements of adventitious tissue: the internal surface of the cavity was lined by pavement-epithelium. The duodenum, otherwise in a healthy condition, had contracted intimate adhesions with the gall-bladder : by means of an oblique passage through these adhesions, a fistulous communication was established between the gall-bladder and the digestive canal. The intestinal orifice of this passage was quite smooth and rounded; it opened at the beginning of the second portion of the duodenum and easily allowed to pass the canula of a capillary trocar. The opposite opening was smaller, and seemed as if cut by a punch. It was, therefore, by this indirect channel that the bile filtered into the intestine from time to time, in compensation for its inability to pass through the obstructed choledoch duct. We still had to make out the vestiges of that canal. The spiral lines situated near the orifice communicating between the gall-bladder and the neighbouring pouch, seemed to indicate the position of the commencement of the cystic duct: and the enormous sac which surmounted it, and received all the biliary ducts was in reality the enormously dilated hepatic duct. The choledoch duct was no doubt represented by the fibrous cord already mentioned. This cord occupied the anatomical situation of the excretory biliary duct; it presented a distinct cavity, two or three millimeters in length, and had become impermeable. Unfor- tunately, it was impossible to decide the question by following the course of this cord into Yater's ampulla. However, it seems pretty certain that the pouch glued on to the gall-bladder was an accidental cyst formed around calculi which had fallen into the peritoneal cavity. This case, besides other remarkable peculiarities, was characterised by a series of attacks of hepatic colic in each of which there was a real paroxysm of intermittent fever, which always began in the afternoon. How are we to explain this intermittence in the phenomena, seeing that the lesions of the biliary passages were so deep-seated, so inveterate, and so permanent ? Let me add, that it was impossible not to mistake for the gall- bladder distended with calculi, an irregular lobe which was felt extending across the abdominal walls. Here we see what would have been the embarrassment of a surgeon, upon rashly opening this supposed gall-bladder to evacuate its supposed calculi. I only allude to this point because some of you who attend the daily visit 252 HEPATIC COLIC ; BILIARY CALCULUS. discussed the propriety of operating, a proposition which I emphati- cally rejected. The woman of whose case I have been speaking was paraplegic ; and her paraplegia seemed to have resulted from an affection of the vertebrae. I regret that this question wras not elucidated at the autopsy; and I regret it all the more that I wrish now to speak to you regarding a very unusual symptom, a symptom, moreover, which is perhaps even more remarkable for being misunderstood than for being uncommon:—I mean reflex paraplegia. You are aware that much has lately been written upon paraplegia consecutive upon affections of the genito-urinary passages, and in particular on that which follows uterine diseases but so far as I know there has not yet been published any description of the paraplegia which is a sequel of hepatic diseases. In his excellent wrork on diseases of the liver, Frerichs has mentioned this subject.2 Here, however, are the details of a very remarkable case of this kind. In November 1863, I attended along with my friend and pupil Dr. Peter, a lady (Madame d’O.) who was sent to us from the country by an excellent physician, Dr. Levavasseur of Blanc. She was some years beyond thirty, and had married at the age of sixteen: she had had seven children and a miscarriage without suffering from any consecutive ailments. She was remarkably fat in early youth. She had several times been attacked with an eczema- tous eruption on the ears, neck, and cheeks. “Till 1862,” said Dr. Levavasseur, in a letter which he sent to us, “ she never had any serious illness. For some years, however, she had suffered occasionally from epigastric pains which seized her suddenly, lasted some hours, and ceased under the influence of cal- matives. There seemed a coincidence between the first manifestation of these pains and the cessation of the herpetic affection. About four years previously Madame d’O. had lost a sister, who the subject of Addison’s disease. Some members of her mother’s family had had gout. “ A year ago, about the middle of November, Madame d’O., being then between the fourth and fifth month of pregnancy, after two 1 See It. Leroy (d’etiolles) :—Des Paralysies des Membres Inferieurs : Paris, 1857.—Also, Brown-Seqtjard:—Paralysis of the Lower Extremities: London, 1861.—Also, Jaccoud :—Les Paraplegies et l’Ataxie : Paris, 1864. 2 Ererichs :—Traite Pratique des Maladies du Poie. French translation ; Paris, 1866. HEPATIC COLIC ; BILIAHY CALCULUS. 253 days of fatigue from long walks, wras suddenly seized with violent epigastric pain, apparently of the same nature as that which she had before experienced from time to time, and which had generally been of short duration. On this occasion, however, it was otherwise : the pain continued, took possession of the entire hepatic region, and irradiated backwards to the dorsal vertebra}: it was sensibly increased by the slightest pressure. There was intense fever, and the pulse was 120. Universal jaundice showed itself; and the general volume of the liver became notably augmented. There was pain in the right shoulder, and slight epistaxis. After eight days of active antiphlogistic treatment, there was a diminution in the intensity of all the symptoms, which in the opinion of the physicians who had seen the patient—Dr. Mascarel of Chatellerault, Dr. Arnould of Blois, and others—were the characteristic symptoms of acute hepatitis. The fever subsided; the pulse fell to 100, and then to 90; the yellow colour of the skin began to fade; and all seemed to be going on towards speedy and complete recovery. But such really was not the case: from the time that there was an abatement in the original acute symptoms, at first quite localised in the hepatic region, that is to say for a period of eleven months, there occurred a series of symptoms, various in character, and unusual in respect of the original nature of the disease. “ Bor several months, there was complete loss of appetite, disgust at every kind of aliment, frequent vomiting of undigested food, great thirst, the tongue denuded of its epithelium, and obstinate constipation. During this period, the pulse ranged between 90 and 100. “ Subsequently, there supervened a general condition of pain— hyperesthesia of the shin of the wholelody—when the slightest pres- sure was made, and this was most manifest all round the chest and in the superior extremities. After a time, the patient had attacks of acute pain coming on spontaneously: they extorted cries from her, and gave her no respite : their violence, however, varied irregularly in paroxysms : their seat was principally in the extremities and specially in the fingers and toes: by slow degrees, this state— always coincident with the disorders of digestion already mentioned —became modified: the paroxysms of pain became less violent, occurred at longer intervals, and then entirely ceased. They left behind them, however, a peculiar state of muscular impotence, which still exists from the waist to the toes. “ I ought here to mention that, in respect of this want of 254 HEPATIC COLIC ; BILIARY CALCULUS. muscular power, there has been an amelioration in the state of the patient. Her ability to move the superior extremities was not always as great as it now is: for a long time, she had great difficulty in using her hands : for a long time, also, she was unable to change her position in bed, to move herself from one part of it to the other, to turn from one side of the body to the other, or to bend and extend the lower extremities without assistance. Now, however, she can perform all these movements. “ For some months, the great disgust at food has gradually disappeared; and at present, the patient eats with an appetite which it is often necessary to restrain. She has long since ceased to vomit her food; and the constipation has become less obstinate. “ Madame d'O. went to Vichy: on her return home, the pulse had entirely lost its frequency, and before her departure for Paris, it was between 6o and 65. “ Amid all this succession of symptoms, there was great variation in the state of the liver: after the disappearance of the original acute symptoms, it returned to its normal condition; but on several occasions, it again became enlarged, though the increase in size was not great. Likewise also there were several returns of the jaundice with a temporary icteric character of the urine. These returns of jaundice were consequent upon paroxysms of pain experienced at the epigastrium and in the region of the liver, which recurred about two months prior to her leaving Vichy, for the first time since the beginning of the malady. The pain had the same character as at the beginning: that is to say, it was epigastric and hepatic, characterised by acceleration of pulse and by jaundice, and excepting a short continuance of the jaundiced appearance of the skin it was completely at end in fifteen or twenty hours. “ During her sojourn of two months at Vichy, there was a more or less frequent recurrence of the paroxysms of pain: since her return home, they have been more frequent, happening several times a week. They have acquired a character different from that which they originally possessed. At first, they were characterised by pain in the epigastric and hepatic regions, which soon invaded the trunk, loins, shoulders, and spine. Any attempt to speak occasioned struggling and difficulty from constriction of the jaws. There supervened, after a longer or shorter period, natural or provoked vomiting of a thick, stringy, glairy fluid; but there never was any food thrown up, even when the vomiting occurred imme- HEPATIC COLIC; BILIARY CALCULUS. 255 diately after a meal. The pain then suddenly ceased: a general relaxation succeeded: and the patient experienced no subsequent effects of these violent paroxysms, except a feverish state for twelve or fifteen hours, and a sensation of general bruising. “ About a month or three weeks ago, after the patient had not had an attack for more than the usual interval of six or seven days, she was seized, for the first time, with embarrassed movements of the tongue and an extreme difficulty in pronouncing words, a state which continued till next day, and then disappeared, an access of pain occurring at the same time. “ Embarrassment in moving the tongue has returned since then on different occasions, but to a less decided degree. “ The lady’s accouchement took place in January, without leading to any notable change in her state of health. The infant lived eight days. Before delivery, she had albumen in the urine, and puffiness of the extremities. “ Biliary calculi were never discovered in the stools.” To sum up this case :—Violent attacks of hepatic colic occurred in a lady descended from a gouty father, and who herself had had eczema which according to Dr. Bazin’s doctrine must have been arthritic. During the course of these hepatic attacks—and this is the point which I wish to set forth in relief—many nervous symp- toms in succession showed themselves, involving bnth motion and sensation, consisting first in general hypersesthesia, and terminating in paraplegia. Here is the lady’s state when I saw her for the first time with Dr. Peter :—There was an intensely jaundiced appearance with bronzing : the liver, which extended four finger-breadths beyond the false ribs, was hard, slightly painful on pressure, and free from nodulation: the hypochondrium was covered with the cicatrices of wounds pro- duced by cauteries applied on account of supposed chronic hepatitis which some physicians had diagnosed. There existed emaciation in a marked degree, anorexia, difficult digestion, great general debility, but no fever. Along with these symptoms, the lady had great difficulty in moving the inferior extremities, which were not only weakened, but somewhat contracted. I tried to make the patient Avalk. I observed that walking had not merely become very difficult in consequence of the feebleness of her limbs, but was impossible from the vicious position which the feet had taken. They were in a state of forced extension; and as they had been for a long time 256 HEPATIC COLIC; BILIARY CALCULUS. in an anomalous situation, they liad become stiff, and in a condition approaching pseudo-anchylosis. As this vicious position of the feet involved an incapacity to place them at right angles with the legs, standing was impossible. My diagnosis was hypertrophy writh chronic hypersemia of the liver, and without any alteration in the hepatic tissue. I looked upon the hypertrophy as the consequence of the hypersemia which was a consequence of a series of violent attacks of hepatic colic. Bear in mind that I attributed the attacks of hepatic colic to the presence of biliary calculi. The formation of these calculi, I w'as inclined to attribute to the gouty diathesis, (the first manifestations of wThich wrere eczematous eruptions), and which wTas hereditary in Madame d’O. As for the paraplegia, it was in my opinion dependent upon the hepatic affection, the case being analogous to those cases of paralysis which are called reflex, and which supervene in certain persons after affections of the bladder or uterus—the only difference being, that paraplegia consequent upon disease of the liver is a much more uncommon occurrence, and one which has not hitherto been described. Finally, Madame d’O. was, from time to time, affected with a sort of paralysis of the tongue which either prevented her from uttering a single v'ord, or caused her to stammer. These symptoms, wdiich vrere transient, supervened under the influ- ence of even slight mental emotion. We proceeded energetically with the treatment. Madame dJ0. came to us as an infirm person, who wras looked upon by her family as an incurable paralytic. For the paralysis of the motor powers of the inferior extremities, I daily employed electricity: for the vicious position of the feet, I ordered, at Matthieu’s, steel-jointed boots, so constructed that one could daily, by means of a trigger-spring, gradually bring the feet nearer and nearer to a right angle. Electrisation showred that there was diminution of the electrical sensibility of the muscles of the lower extremities, and almost com- plete abolition of the electrical contractility of the same muscles : there was, however, a partial return of the voluntary contractility. After fifteen times employing electrisation and shampooing (which occasioned great pain), there wras a partial return of sensation and electrical contractility: and the voluntary movements became a little more extended. The patient leaves Paris, to place herself again under Dr. Leva- vasseur, whose treatment I recommended in all its details; and HEPATIC COLIC i BILIARY CALCULUS. 257 which was intended to bear simultaneously on the articular rigidity, the paraplegia, and the calculous affection of the liver. Here is an extract from a letter written by Dr. Levavasseur to Dr. Peter some time after her return to Dr. Levavasseur* s care. “ Since the return of Madame d*0. from Paris, her state has been always improving, particularly in respect of the paraplegia. Under the use of electrisation and shampooing, there was a speedy return of sensation and electrical contractility in the muscles of the lower extremities. Por the last two months, the electrisation has been discontinued on account of its having become insupportable by Madame d*0. Since that time, she has, without any other assistance than a short stick, walked distances of some hundred meters, and moved about her house, going from one storey to another without any other aid. Her steel-jointed boots have been long discontinued. “ The large muscles of the thighs and calves of the legs have not yet regained their natural size; but, nevertheless, they feel, when handled, as if they had a much better development: the adipose tissue constitutes a layer very thin compared with the obesity which existed prior to the malady. “There was very little change in the special symptoms of the hepatic affection. The paroxysms, which were perhaps rather less frequent, occurred about once every fifteen days : they were as pro- tracted and as violent as before : no calculi wrere passed. “ The speech, also, was frequently embarrassed : not a day passed during which this symptom was not produced several times by the most trifling emotion. “ There was no fever: sleep was excellent, and the appetite was good. Por about a month, however, digestion has been somewhat difficult: after meals, there was distension of the abdomen, an uneasy feeling at the epigastrium, with flushing of the face and head. I had for some time discontinued the use of ether and turpentine cap- sules. The catamenia had not reappeared.” In June 1864, I saw this lady : she was then walking very much as she did before her illness. To confirm her restored health, Madame d’O. went to Neris, where she remained in a most satis- factory state till August. At the end of that month, Dr. Levavasseur wrote to me to say that there was “ a continuance of her state of general amelioration, a gradual restoration of plumpness and strength, a return of the menstrual function for about three months, with a more and more complete disappearance of the different paralytic 258 HEPATIC COLIC : BILIARY CALCULUS. symptoms, except, perhaps, that from time to time there was some embarrassment of the tongue in speaking. There was, however, a recurrence, pretty much as before, of the hepatic attacks. In con- clusion, let me add, that for a long time past the cessation of the paralytic symptoms has been complete, and that the attacks of hepatic colic have been less frequent. This case, Gentlemen, if I be not mistaken, is a very remarkable example of “ reflex ” paralysis occurring as the sequel of a calculous affection of the liver. The unusual nature of the case has induced me to enter fully into the details : and I feel assured that once attention has been directed to the possibility of paraplegia occurring as a sequel of affections of the liver, additional examples will be detected by observers. The manner of recovery from hepatic colic has not always been by the evacuation of calculi. I have frequently called your attention to the fact that we very often find, at the autopsy, numerous hepatic calculi in the bodies of individuals who for a long period had ceased to suffer from the symptoms which arise from the presence of biliary calculi. When the cystic duct is closed by the impaction of a large cal- culus, inflammation of the gall-bladder is produced, and it becomes distended by the accumulation of mucus secreted in consequence of the inflamed condition of the mucous membrane. But the duration of this inflammation has a term : the secreted mucus is reabsorbed: the gall-bladder shrivels up, contracting upon the calculus : the pain, at first acute in the region of the gall-bladder, becomes more and more blunted : and the bile flowing freely through the choledoch duct, the health is perfectly re-established. There are other cases in which we find the cystic duct obliterated by a pretty large concretion, and numerous calculi floating in the greenish mucus by which the gall-bladder is distended: tolerance is established : the inflammation of the gall-bladder comes to an end, and the calculi, ceasing to be engaged in the neck of the cystic duct, cease to cause pain. In cases of more unusual occurrence, such as that of which I have just been giving you the particulars, the distended and inflamed gall-bladder contracts adhesions with the omentum or the intestines, and becomes ruptured, whereupon the calculi, accom- panied by the pus and bile, fall into, and become encysted in the cellular tissue of, the new formation, where they remain, in the midst of the tissues, without causing any untoward symptoms, forming an HEPATIC COLIC : BILIARY CALCULUS. 259 accidental pouch having a fistulous communication with the ruptured gall-bladder. This was the state of matters in our patient of bed 28. I have now to speak of the treatment of hepatic colic and biliary calculi. But a preliminary question presents itself ! An individual, let us suppose, has biliary calculi. Can we prevent him from having attacks of hepatic colic ? When these attacks have declared themselves, can we hope to prevent them, by acting on the concretions which occasion them, so as to reduce them to fragments sufficiently small to traverse the cystic and choledoch ducts, without occasioning disagreeable consequences ? Were I to base my answers to these questions on my personal ex- perience, I should reply in the negative. I am anxious, however, to add that my honorable colleague Dr. Barth, whose scientific authority is of the greatest weight, has published, in illustration of this subject, interesting cases apparently opposed to my views. Dr. Barth, indeed, believes that he has demonstrated that by the aid of particular medicines capable of imparting certain characters to the bile, the calculi in the gall-bladder may be acted on in such a way as to be disintegrated, and their passage into the intestine facilitated sufficiently to prevent hepatic colic being thereby produced. This proposition has been maintained by other physicians, who, with the object of attaining the same result, have recommended the use of alcalies, which, if they have not, they say, a solvent action on the cholesterine, at least combine with the fatty constituents of the blood, and by saponifying them, carry them away, so as to prevent their being deposited from the bile: the alcalies, and mercury, they say, by dissolving the pus and mucus, prevent the formation of concre- tions, and disintegrate them if already formed, by depriving them of these two elements, so as to isolate the cholesterine and reduce it to small fragments. Dissolving the calculi is the principle on which the famous remedy of Durande is based: it consists in giving the patients a mixture of sulphuric ether and essence of turpentine in the proportion of three parts of ether to two of turpentine. Quite recently, some physicians have seriously proposed the internal administration of chloroform, in consequence of M. Gobley having shown that hepatic calculi were more soluble in this than in any other menstruum. You know, Gentlemen, what I think of the application of chemical theories to the physiological operations of the living body. These theories are entirely fallacious, even in the opinion of chemists them- 260 HEPATIC COLIC : BILIARY CALCULUS. selves, in respect at least of the action of ether and turpentine, which in a test-tube and in direct contact with biliary calculi either do not dissolve them at all, or dissolve them very slowly; and which when introduced into the stomach never reach the gall-bladder. We can easily perceive that although solution may be effected in the test-tube by therein bringing the calculus into direct contact with the men- struum at a maximum strength, it would be absurd to suppose that the same end can be accomplished by bringing into contact with the calculi a diluted solvent essentially modified before reaching the liver. I reject the chemical theories of the solution of hepatic calculi: I reject the chemical theories of the solution of renal calculi by the waters of Contrexeville, Yals, Pougues, or Yichy. Consequently, I deny that medicine can act on either kind of calculi once they are formed: that which medicine can accomplish, is their expulsion by exciting the biliary or urinary secretion, the products of which will tend to entangle the concretions which are formed. And medicine can in a special manner do good by preventing the formation of calculi, by subjecting the patient to a regular plan of treatment in which alcalies, chloroform, ether, and turpentine are the most effica- cious agents. So long as the biliary secretions remain normal, there is no greater tendency in the bile to deposit the solid matter which it holds in suspension, than there is in normal urine to deposit the phosphates, oxalates, or uric acid which it contains. Consequently, in the treat- ment of hepatic colic, our object ought to be to regulate the func- tions of the liver, just as we endeavour to regulate the functions of the kidney with a view to prevent the return of nephritic colic. It is in response to this indication, that the wraters of Pougues, Contrexeville, Yichy, Carlsbad, and Yals are so undoubtedly useful in the treatment of biliary and urinary gravel. Under the influence of this potent medication, if well-directed, patients get rid of the troublesome aptitude which they had contracted. But the benefit, I repeat, does not arise from the alcaline waters dissolving calculi already formed : they act in another way—they modify the constitu- tion of the patient, and perhaps also the organs upon which they seem to have an action quite peculiar and special. It is very necessary, however, to beware of abusing the alcaline system of treatment. When too long continued, it impairs diges- tion, and exhausts the constitution. The alcaline remedies I call “ long-range ” medicines, because they continue to act long after HEPATIC COLIC : BILIARY CALCULUS. 261 their use has been discontinued. Thus, patients after passing a season at Vichy, Vais, Carlsbad, Pougues, or Contrexeville, remain for from six to ten months, or even longer, under the influence of the medication, and without experiencing any symptoms of their malady. It is, therefore, useless, to say the least of it, to keep up the alcaline treatment without intermission, a practice which I have too often seen. Here is the manner in which I proceed. When an individual is subject to hepatic colic, I order him to take for eight consecutive days, once a month, one, or at the most two, glasses of the natural mineral alcaline water of Vichy or Pougues. After a week of the alcaline remedy, I direct him to remain for another wrnek without taking any medicine. During the following week, he has to take immediately before each of the two principal meals of the day, the capsules containing ether, and the capsules containing turpentine of Dr. Clertan; or, he may himself fill the gelatinous capsules of Lehuby with ether or turpentine, in the proportion of two thirds of the former to one third of the latter. Each capsule contains nearly twelve drops of ether and six drops of turpentine. Of these capsules, the patient takes from two to four; and, according to his tolerance of them, the dose may be increased to ten or twelve in the twenty-four hours. Then follow eight days of abstinence from medicines : after which period, comes round the eight days of the alcaline waters. The treatment ought to be continued on this plan for four, five, or six months, even although all the symptoms should have disappeared. My plan is, as you see, a combination of the use of alcalies with the remedy of Durande: the latter is modified only in respect of the mode of administration. The potion of ether and turpentine, in the form prescribed by Durande, has a very disagreeable taste, and turpentine administered according to his formula so greatly irritates the pharynx and oesophagus, as to make its long-continued use impossible. Therefore, gelatinous capsules which are easily swallowed, and do not dissolve till they have reached the stomach, have undoubted advantages. Many physicians, rqjying on the experiments of Gobley, now substitute chloroform for ether: there is no difference in the mode of administration. I need not say that the relative proportions of ether and chloroform on the one hand, and of turpentine on the other, may be varied according to the varying aptitudes of patients. HEPATIC COLIC : BILIARY CALCULUS. Diet occupies an important place in the treatment of calculous affection of the liver. Gentlemen, while I insist on the necessity of vegetable alimentation, I do not think that it ought to be pre- scribed to the exclusion of animal food : my opinion is, that there ought to be a judicious combination of animal and vegetable fare. Patients will prefer to eat herbaceous vegetables, avoiding butter, oil, and fatty substances, which are digested with difficulty by persons in whom the liver is at fault. Kegular exercise must also be insisted on: it promotes organic decompositions and compositions, and favours the combustion of the fatty matters of the economy. When a paroxysm of hepatic colic sets in, I do not know of any really efficacious means of suppressing it. The only remedies which seem to me to procure some relief are ether and chloroform in small doses, belladonna administered internally, frictions over the seat of pain with extract of belladonna, and prolonged general baths. The inhalation of chloroform produces surprising effects upon some patients. You no doubt remember a woman (bed 7), who on inhaling chloroform for half a minute was immediately relieved from very severe paroxysms of pain. The sedative effect of chloro- form will sometimes continue for half an hour: on the return of the colic, the patient must recommence the inhalation, and pursue the same plan till the paroxysm has come to an end. LECTURE LXXIX. HYDATIC CYSTS OE THE LIVER. Case occurring in a child six years of age.—Two cases in which Hydatid Cysts opened into the Thoracic Cavity.—Hydatids: their mode of development.—Hydatids of the Liver.—Symptoms. —At first, nothing characteristic, except sometimes the appear- ance of a Tumour in the region of the Liver.— General symp- toms : Disturbance of the Digestive Functions: tendency to Hemorrhages and Gangrene.—Functional Disturbance of Neigh- bouring Organs.—Hepatitis.—Purulent Infection.—Spontaneous Opening of Cysts into different passages ; through the abdominal walls: into the blood-vessels; into the biliary ducts; into the digestive canal; into the pleural cavity ; and into the bronchial tubes. TREATMENT:—Simple Punchire with the Exploratory Trocar.— Puncture with the Permanent Canula.— Begin’s Method of Successive Lncisions.—Recamier’s Method of opening by Caustics.—Opening the Cyst by the Trocar, after establishing adhesions by Acupuncture.—Iodised Injections. Gentlemen :—Within the last few weeks, three cases of hydatid cysts of the liver have come under your notice. One of them occurred in a little girl, six years of age, who was brought to our out-patients’ consulting room. She had every appearance of a good constitution and perfect health; and according to her mother’s account, never had had an illness. Tor some time, she had complained of pains in the right side, in which situation a certain amount of tumefaction had been perceived. The child, nevertheless, always appeared to be in her usual good health : there was no diminution in her natural cheerfulness: the appetite and digestion continued perfectly normal. The only indication of her being out of sorts was that her sleep, previously sound and calm, was disturbed by nightmare and precordial anxiety. HYDATID CYSTS OE THE LIVER. On examination, I ascertained that there was a tumour, limited on the left by the lower end of the sternum, and projecting under the margin of the costal cartilages. The size might be about that of a hen’s egg. The skin over it was natural in colour. The tumour was not painful, except when strongly pressed, when slight pain was excited in it. On attentively looking at the tumour, it was observed to be the seat of regular pulsations, which were much more sensible when the finger was applied; they were synchronous with the pulsations of the heart and arteries, and were not movements of expansion, but movements of lifting en masse. They ceased, when the child was made to stoop forwards. During a deep inspiration, the tumour rose, to fall down again during expiration, following, thus, the movements of the diaphragm; this circumstance, com- bined with the seat, enabled me to say that the tumour was connected with the liver, which did not otherwise appear to be augmented in volume. The tumour evidently contained liquid ; deep fluctuation could be felt, and in its upper part, there was very distinct crepita- tion. I diagnosed a hydatid cyst of the liver—a diagnosis fully confirmed by the exploratory puncture which I caused to be made. The trocar gave exit to a liquid the first part of which wras limpid, but the subsequent flow of which was sanguinolent, slightly turbid, contain- ing gelatiniform foreign bodies which were the debris of hydatids. The child having been at once taken away by her mother, I lost sight of her, so that the case has no other interest than the early age at which the affection presented itself. You are aware that a hydatid affection—be its seat what it may— and the liver is the most common seat—is hardly ever met with except in individuals who have reached the middle of life or adole- scence. It is equally rare in childhood and old-age: so true is this remark in respect of early life, that Dr. Davaine, in the most com- plete treatise on the subject which has appeared, has not been able to collect more than fourteen cases in subjects under fifteen years of age. Half of the fourteen were cases of hydatid tumours of the liver developed in persons of twelve, ten, nine, and four years. In one case, which he quotes from Professor Cruveilhier, the subject was a child of twelve days old, in which were found only the debris of the cyst, which had opened into the descending colon. The seven other cases recorded in Dr. Davaine’s work are cases of hydatids of the HYDATID CYSTS OF THE LIVER. 265 heart, pericardium, orbit, canine fossa of superior maxilla, kidneys, and lungs. If to these fourteen cases, you add two cases of hydatids of the thoracic cavity which Dr. Henri Roger communicated to the Societe de Medecine des Hojpitaux de Paris, on 9th October, 1861, another example of hydatids of the liver presented to the Societe Anatomique by M. Descroizilles; and, finally, the case of our little patient, you have the sum total of the cases published or known of hydatids in children. They are in number eighteen, and nine of them are cases of hydatid tumours of the liver. A few of you only, I presume, have seen the patient regarding whose case I am now going to speak. He was in another service of this hospital: I knew nothing of him when he was living; but I derived some knowledge of his case from being present at his autopsy. The particulars of his case furnished to me are sufficient to show how numerous are the difficulties surrounding the diagnosis of hydatid cysts of the liver, when there has not been an opportunity of observing their development and evolution for at least a certain time. The man to whom I refer was for two or three months in the ward Sainte-Jeanne: he presented all the signs of extensive effusion into the right side of the chest. The thoracic development of that side, the complete dulness, the blowing sound, the egophony, and the broncho-egophony left no room to doubt the presence of fluid in the pleural cavity. After some weeks, the patient, feeling better, expressed his wish to return home, although there did not seem to be any real modification of the chest symptoms. He left the hospital, but was very soon obliged to return. He was then expec- torating yellow matter, in which bile could be recognised. Hence was inferred the existence of a communication between the lung and the liver. The symptoms assumed an exceedingly serious character, and proceeded to a fatal issue. During the last days of this man's life, his breath and sputa were horribly foetid, suggesting the idea of hydropneumothorax opening into the bronchi, and the contained fluid was altered in character by the presence of air. At the autopsy, there was found in the liver an enormous cyst still containing some acephalocysts; it had opened into the bronchial 1 Davaine :—Traite des Entozoaries et des Maladies Vermineuses de l’Homme et des Animaux Domestiques. Paris : i860. 266 HYDATID CYSTS OF THE LIVER. passage through a gangrenous portion of pulmonary tissue. The pleuritic effusion recognised during life still existed; and, curious to relate, there was no communication between this effusion and the bronchi. You now understand why it was impossible, when the patient was alive, to diagnose what had occurred, to know that the pleurisy, occasioned in all probability by the cyst, was, nevertheless, independent of it. You are now, also able to understand why it was impossible to ascertain the existence of the cyst of the liver, which occupied its convex surface, without causing that organ in the least degree to be abnormally salient. I have now to speak of the young man whose case is the occa- sion of the present lecture. The patient occupied bed 12 of St. Agnes’s ward. You recollect my remark in the presence of my honorable colleague Dr. Legroux, just as I was going to make an exploratory puncture in the right hypochondriac region to complete the diagnosis which I had formed from the nature of the tumour projecting into the abdomen. I said that there spurted from the puncture made by the explora- tory trocar, a transparent limpid fluid, which yielded no precipitate of albumen when treated by heat and nitric acid. This fluid con- tained the debris of hydatids, which by obstructing the canula prevented the flow from being as abundant as it might otherwise have been. This experiment incontestably demonstrated to us that the tumour, apparently belonging to the liver, and which occupied its convex surface, was really a hydatid cyst. This man, who had just made the Crimean campaign, had been discharged from the army. Before his departure for the East, when in garrison at Auxonne in the department of Cote-d’Or, he had complained of pains in the right side : but as these pains were dull, and did not wake up except when he made a forced march or had some kind of violent exercise, and as his health remained good, he was able to continue to perform his duty, and, consequently, went to the Crimea. During the whole of that trying campaign, he re- mained at his post, and underwent the severe fatigues to which our expeditionary force was subjected. Erom time to time, however, the pain in the right side became aggravated; and then it was that the patient perceived a notable swelling in the situation of the pain. This caused him to consult the surgeon of his regiment, who did not attach great importance to what he saw, particularly because the man’s general health was unexceptionable. HYDATID CYSTS OP THE LtVER. 267 When the war was at an end, the young man received his dis- charge. Tormented by the inveteracy of the symptoms, which were complicated by attacks of fever recurring with pretty well marked periodicity, he resolved to seek admission into an hospital; and thus it was that he came into our hands. On the occasion of my first examining him, I was struck with the very decided fulness of the right side of the chest, which presented a globular projection, and occupied the whole of the corresponding hypochondrium, extending to the epigastric region. These appear- ances at once gave characteristic evidence of the existence of the hydatid cyst of the liver. If not to a hydatid cyst, to what could the tumour in the right side be attributed ? No doubt, the amplitude of the chest might be ascribed to thoracic effusion; but then it would be necessary to regard the effusion as completely encysted, as the fulness was ex- actly circumscribed below. Now, encysted is not the most common form of pleurisy. On the other hand, this theory would have made it necessary to assume that the walls of the cyst were so rigid that the pressure of the fluid had more easily overcome the obstacle formed by the thoracic walls than that formed by the lung—an in- admissible hypothesis. In encysted pleurisies, the lung, the medi- astinum, the heart, the diaphragm, are pushed out of the way long before the ribs are interfered with. I repeat, moreover, that the bulge of the ribs is uniform throughout the whole extent of the thoracic cage of the corresponding side, and not merely in a limited space as in this case. The view that thoracic effusion existed was, therefore, inadmissible. The development of the precordial region made it more pro- bable that the affection was intra-abdominal, and its situation being the right side, the liver was clearly pointed to as the seat of disease. What was the nature of the lesion ? Was it cancer ? The patient was of an age at which carcinomatous affections seldom occur. His general health seemed to be but slightly affected by the local dis- ease, which, moreover, was so extensive that we could hardly sup- pose that, were it cancer, it would not have occasioned more severe pains. Finally, with the enormous volume which the tumour pre- sented, we should, in cancer, have felt a nodulated surface of the liver, in place of finding the organ with so even an increase of size. 268 HYDATID CYSTS OF THE LIVER. The fluctuation produced—particularly that produced on exploring the neighbouring epigastric region—was not the false fluctuation sometimes met with in cancer, but was evidently due to the presence of a fluid. The progress of the symptoms, and the very disposition of the affected parts did not allow me to be satisfied with thinking that that fluid was pus, and that we had to do with an abscess of the liver. In fact, the diagnosis finally settled was that which I formed in the first instance, and which the exploratory puncture had amply confirmed. We found that we had to do do with a cyst of the liver: this cyst occupied the convex aspect of the organ. When pressed between the body of the gland (which, supported by the abdominal viscera was prevented from retreating beyond a certain limit) and the right lung, (the elastic force of which also opposed a certain obstacle to its development,) the cyst had exerted all its efforts upon the walls of the chest, causing them to bulge out in the manner we had observed. Having established the diagnosis, the question was :—What are the therapeutic indications ? In such a case, I could not leave the patient to the unaided efforts of nature; for, although, in certain exceptional circumstances, hydatid cysts of the liver have undergone spontaneous cure, this result has assuredly not occurred in cases similar to that which we had under our observation. Sooner or later, cysts of the large size presented in the case now under con- sideration, lead to very serious consequences, and the event which we had above all others to fear in our case was rupture of the cyst into the abdominal or thoracic cavity, which would have led to a speedily fatal peritonitis or pleurisy. Interference was obligatory; and the only chance of useful interference was a surgical operation. I therefore proposed to empty the cyst. Following the established principles of the surgical art, I first endeavoured to establish adhesions between the tumour of the liver and the abdominal walls, so as to prevent the fluid from flowing into the peritoneum when I opened the cyst. I shall explain to you, Gentlemen, the proceedings adopted in such a case. For the present, that I may keep to the case actually before us, I shall be satisfied merely to mention that I had recourse to multiplied acupuncture for the accomplishment of my object. This kind of acupuncture con- sists in burying in the tumour—piercing the skin previously pro- tected by a small piece of linen, leather, or caouchouc—thirty or HYDATID CYSTS OF THE LIVER. 269 forty needles arranged in a circle with about half a centimeter between each of them. These needles must be provided with sealing- wax heads. I was waiting the result of this operation when complications supervened, excited perhaps by the proceedings which I had adopted. The fever, which from the time the man came into the hospital had been showing itself at intervals, all at once assumed a very formidable character, and was accompanied by acute pain in the right side of the chest. I discovered that there was pleurisy with effusion, characterised by dulness in the thoracic region and egophony, phenomena, which, day by day, became more marked. The dulness extended to the infra-spinous fossa of the scapula: the egophony reached as high up as the eighth rib : above there was bronchophony. Still higher up, fine subcrepitant rales were heard. The expectora- tion was catarrhal. On uncovering the chest, a great separation was perceived between the ninth and tenth ribs, with a bulging of the integuments in the same situation. When the patient coughed or made an expiratory effort, there was an increase in the bulging, just as if a liquid were raising the skin. On applying the hand, fluctuation was felt. I asked myself, whether this fluctuation was referable to the cyst, which, after separating the muscular fibres of the diaphragm, had passed into the thorax, and had thus simulated the effusion of which I found the signs. The subcrepitant rales, however, became finer and finer, and were heard on the left, as well as on the right side : the sputa assumed the pneumonic character, so that if the chest symptoms which I had seen become developed on the right side, could up to a certain point, have been set down to the account of the cyst, those on the left side could not be similarly accounted for. I said to myself:—The acupuncture has produced inflammation in the cyst, and also in the parenchyma of the liver itself, as may be inferred from the subicteric tinge of the skin, which had appeared coincidently with increase of the fever. The inflammation (the cyst having perforated the diaphragm) was propagated to the pleura; and perhaps there was some effusion into the chest in addition to that which I attributed to the cyst. But I also said, it was surprising that the inflammation propagated to the pleura had respected the peritoneum, for I found no sign of peritonitis. In vain I sought to explain the bronchitis characterised by the subcrepitant rales : the solution of this question was all the 270 HYDATID CYSTS OF THE LIVER. more embarrassing that the left as well as the right lung was equally implicated. The bronchial affection of the right side might be quite well ac- counted for by supposing that a communication had been established between the cyst and the lung; but no such hypothesis was admis- sible in respect of the left side. Tor every reason, I saw that I could not operate upon the cyst. The case was exceedingly complicated by the thoracic symptoms whatever might be their starting point. The symptoms continuing stationary, I decided upon opening the tumour, which was salient in the intercostal space. This I did by means of a pretty large trocar, giving issue to purulent fluid containing hydatids. Tor two days, nothing occurred which could be regarded as an- nouncing wThat was going to happen; nor was the patient's state worse. When seen at 4 o'clock in the afternoon, it had been as- certained that there was an abundant discharge of pus from the wound: at ten p.m., and again at midnight, the sister of the service found him very calm ; but about one in the morning, he was seized with a fit of coughing which nothing could stop : in the midst of the anxiety and suffocation which accompanied the paroxysms of cough, he exclaimed that he was being suffocated and was dying. A few minutes afterwards he died. I thought that the cyst had burst into the lung, and that the suffocation had been caused by the hydatids getting into the air- passages. The autopsy shows us that no such thing had occurred; and that disorders had existed which we had failed to recognise during life. Here is the dead body. By the opening which I made in the intercostal tumour, I introduce a sound which you see passes into the liver through the costal and diaphragmatic pleurae, which, observe, are firmly united by old adhesions. The liver is enormously enlarged, and I have to traverse its parenchyma to reach the cyst. Above the diaphragm you observe, there is effusion; and the pleural cavity containing it, communicates at one part with the cyst in the liver, and at another with the bronchi, the pulmonary tissue being perforated. Here, therefore, we have hydro-pneumothorax. Gentlemen, in connection with the three cases which I have now related, I propose to-day rapidly to sketch the history of hydatid cysts of the liver. It is not till the beginning of this century that we find in the HYDATID CYSTS OF THE LIVER. 271 writings of physicians the first tolerably accurate notions regarding this singular affection. In 1804, Laennec published his work upon vesicular worms, among which he classed hydatids, and called them acephalocysts.1 In 1843, Dr. Livois2, a pupil of Dr. Bayer, arrived at the following conclusions :—First; that hydatids ought to be excluded from the class of vesicular worms ; and second; that they are simple pouches always containing echinococci in number proportionate to the size of the containing pouch. These conclusions are now generally accepted : but there is not the same concurrence of opinion as to the relations which hydatids bear to echinocoqui. This point in natural history does not come within the limits of my present subject; and in relation to it, I cannot do better than refer you, for complete information, to the remarkable work of Dr. Davaine, of which I spoke at the beginning of this lecture. Let me merely add, that in the opinion of the savant whom I have just named : — “ the hydatid corresponds to a phase in the development of an animal which lives a certain period, and may he produced a certain number of times under the vesicular form: the echinococcus presents a more advanced phase in the development of the same animal.” The most important points upon which we, as physicians, require to be informed, are the phenomena by which hydatids betray their presence in organs, the symptoms to which they give rise, and the treatment which the affection demands. In man, cysts may be developed in all the parenchymatous organs. The liver seems to be the favourite locality : when cysts are found in other organs, it is very unusual for them to be absent from the liver. After the liver, the next most frequent seat of hydatids is the lung: then come the kidneys, spleen, omentum, brain, and pelvis. There are, according to Dr. Davaine, some examples of their being found in the spinal canal, in the eye, and in the bones. I shall borrow pretty exactly from his work the descrip- tion which I am now going to give you. Whatever be the situation which hydatids occupy, they are “ in their state of integrity, round vesicules formed of a substance similar to coagulated albumen, containing a limpid fluid, and free from any adhesion or connection with the organ in which they are 1 Laennec :—Memoires de la de Medecine de Paris. 2 Livois :—Recherches sur les Echinocoques chez l’Homme et chez les Animaux. 272 HYDATID CYSTS OF THE LIVER. enclosed. They almost invariably contain echinococci, which are either adherent to their internal surface, or floating free in the hydatid fluid.” Sometimes, they are scarcely visible to the naked eye: at other times, they are as large as the head of a foetus at the full term. Generally, however, they vary in size between that of a pea, a large hazel-nut, or an orange. Their form, at first spheroidal or oval, is often modified by the pressure exerted upon them by the parts amid which they originate: their walls, the uniform thickness of which is proportionate to the volume of the vesicule, are colourless, transparent, or of an opaline tint at some points, or throughout a greater or less extent of their surface. Accidental circumstances, such as contact with a coloured fluid, the bile for example, may modify the colour. It is not unusual to find along with one large hydatid, several small ones. It is still more common for one large hydatid to contain small hydatids, free in its cavity, or sometimes adherent to its internal or external surface. Originating like granulations, they spring up, increase in size, become hollow, and ere long are detached. When developed within natural serous cavities, or in veins, hydatids do not seem to have any other envelope than that formed by the walls of the cavity in which they are enclosed: when developed in parenchymata, they are surrounded by an adherent membrane, by a cyst formed at the expense of the cellular tissue of the parenchymatous organ, and the structure of which varies with that of the organ. This membrane, exclusively cellular at first, progressively assumes a fibrous, and fibro-cartilaginous consistence ; and in old cysts may be seen disseminated nodules, cretaceous patches, apparently osseous. Their walls vary in thickness according to their age. The cysts are united to the neighbouring parts, some- times by very loose cellular tissue, and sometimes by fibrous adhesions which are solid and difficult to destroy. They may receive blood-vessels which spread over their surface, sometimes penetrate into their interior, and in old cysts reach their inner surface, there assuming a varicose aspect, or an appearance of being surrounded in their course by a real sanguineous injection : the inner surface is then like shagreen, wrinkled, and covered with exudation more or less adherent or thick, while in recent cysts it is white, to a certain extent resembling a serous membrane. HYDATID CYSTS OF LIVER. 273 The hydatid cyst is generally globular, and is seldom composed of distinct compartments : when multilocular, this structure is derived from the fusion of many cysts, or by the hydatid cyst having encountered obstacles to its uniform growth, in which case, if the hydatid be single, it sends prolongations into the different compart- ments. A very variable number of hydatids may be contained within a single cyst; and they have often been found to amount to five hundred, a thousand—even to seven, eight, or nine thousand. The tumour in such cases may attain a size equal to that of a man's head. When the cyst only contains a single hydatid, that hydatid gene- rally fills the cyst entirely, and forms a covering to its walls ; when the cyst contains several hydatids, there is more or less fluid in which they float. This fluid, which is transparent like that of hydatids, contains no traces of albumen, and is neither coagulable by heat nor nitric acid. However, when a hydatid cyst has been punctured several times, an albuminous fluid comes from the last punctures; but this is a new product secreted by the cyst itself, and is not the peculiar fluid of the hydatid. The fluid in the principal pouch may, like that of the therein contained hydatids, accidentally assume different colours, a yellow, greenish, or redish colour, from admixture with bile or blood. Not unfrequently, it becomes opaline, muddy, and thick, so as to resemble pus. Indeed, in many cases, it is a purulent fluid originating in inflammation of the cyst: in other cases, the fluid is only purulent in appearance, and is a serosity, holding in suspense sebaceous matter. This sebaceous matter, which has also been compared to tuber- culous matter, is deposited in layers on the internal surface of the cyst when the enclosed hydatid is single, or when, being multiple, its walls are directly applied, without the interposition of any fluid, to the walls of the cyst. By degrees, it grows thicker, assuming the appearance of concrete mastic, or sometimes of chalk. Under such circumstances, the hydatids become reduced to a few membranous shreds, and finally disappear: the echinococci, which have long before been destroyed, are then represented only by their tenacula. Hydatid tumours thus transformed were, continues Dr. Davaine, formerly called atheromatous. The state resembling pus or tubercle, is, according to his view, merely a less advanced stage of atheroma- 274 HYDATID CYSTS OF LIVER. tous transformation, of which the cretaceous stage is the last; so that in cases of multiple hydatids, we are able to observe the different phases of change in the same individual. Gentlemen, a minute or two ago, I reminded you of a fact ad- mitted by all observers, that the liver is the favourite locality chosen by hydatids. It is, moreover, specially regarding hydatid cysts of the liver, that I wish to address you upon the present occasion. In one of my lectures [Lecture XXXIV, vol. Ill] I spoke to you about hydatids of the lung, in relation to the case of a young man who was in St. Agnes's ward. In the liver itself, hydatids prefer certain localities : they are more commonly met with in the right than in the left lobe, and in the convex, than in the concave part of the organ. There is sometimes only one; pretty often there are two, three, or more hydatids: but their number seldom exceeds five or six. The cysts are developed very slowly; and as they often lead to no functional disturbance till they have attained a certain bulk, it is not unusual for the affection, which had never in any way showed itself during life, to be only accidentally discovered after death in persons who have died from totally different diseases. The cysts may take from two to twenty or even thirty years to be developed; and even then, though very large, they may only occasion feelings rather of discomfort, weight, and distension in the right side, than of real pain. Our patient of St. Agnes's ward told us, that he had been able to go through the Crimean campaign, working at the trenches like his comrades, and taking part in the battles before Sebastopol, without ever having been in hospital. At that time, however, he was feeling a dull pain in the right side, which was sufficiently tumefied to cause the clothes to press unpleasantly in that situation: this pain was increased by fatigue, but it had never attained great severity. The painful sensations, then, were felt in the right hypochondrium, the epigastrium, and often in the right shoulder. The symptoms, you see, are so little characteristic that it is very difficult, if not quite impossible, to diagnose cysts of the liver. But when the cyst has attained a large size, and has caused the side-wall of the abdomen to project, the form of the tumour and its concomi- tant phenomena often furnish the attentive observer with sufficient diagnostic data. The tumour, growing slowly, occasioning no sensations strictly HYDATID CYSTS OF LIVER. 275 entitled to be called pains, accompanied by no state of fever, nor by any disturbance of the general health, is generally globular, and raises up in a uniform manner the thoracic and abdominal parietea beneath which it is situated. On percussion, it yields a dull sound : to pressure with the finger, it offers an elastic resistance, and a feel- ing of fluctuation, which is deep-seated, and sometimes so obscure as to be very difficult to detect. Sometimes also, there is produced a peculiar purring, which has been called hydatid purring \_fremisse- ment hydatique]. It was first described by Dr. Briancon (of Tournon) in his inaugural thesis1 : this is a sign of great value, and when it exists, may be looked upon as pathognomonic. Unfortu- nately, it is, in general, not to be found, however carefully it may be sought for: frequently, also, after having been perceived for some time, it ceases. Dr. Briancon announced his belief that the intensity of the hydatid purring was proportionate to the quantity of acepha- locysts and of fluid contained in the cyst; and that the more numerous the hydatids, and the more abundant the fluid, the more sensible was the purring. Its cause is not quite understood; but this we know, that the purring may exist when there is only a single hydatid, as was ascertained by Professor Jobert in a case of tumour in the region of the deltoid. I have said that hydatid cysts of the liver are slowly developed, and may sometimes exist in an organ without occasioning any disturbance of the economy. Such cases are reported in Dr. Davaine’s work, but they are exceptional; and however slow may be the progress of this as compared with other chronic diseases, it is in reality rather rapid, because, as a general rule, its maximum dura- tion seldom exceeds four or five years. I have also told you, that cysts, even when of large size, may lead to no other symptoms than dull pains, a feeling of weight, uneasi- ness, and distension in the affected side. It is difficult, however, to understand how an organ of so much importance as the liver should be more or less implicated for a long period without the occurrence of serious disorders of the economy. As the tumour, slow in its development, continues limited to a relatively small portion of the organ, the larger unaffected re- mainder is amply sufficient to perform the functions of the gland. 1 Bkianpon :—Essai sur le Diagnostic et le Traitement des Accphalocystes. [These de 1828.] 276 HYDATID CYSTS OF LIVER. But when nearly the entire liver is invaded by a single cyst (of which cases are reported), or by multiple cysts—when the cysts have rapidly attained a great volume—when this pathological change has caused its effects upon the system—when, finally, by their bulk they impede the passage of the bile through the excretory ducts—the result is the production of serious local and general symptoms. The general disorders produced consist in functional disturbance of the digestive organs. The appetite diminishes, and is lost: diges- tion is slow and difficult: at intervals, nausea, vomiting, and diarrhoea supervene. Emaciation and loss of colour proclaim the cachectic state into which the individual has fallen. There has also been mentioned as occurring in these circumstances a tendency to hemorrhages, a very common complication of serious hepatic affec- tions : it occurs in the form of repeated and profuse epistaxis—in women, of attacks of epistaxis and metrorrhagia. According to Dr. Davaine, a tendency to gangrene has also been observed. He says that gangrene of the lungs not unfrequently carries off patients who have large cysts in the liver. Although jaundice is an unusual symptom in hydatid cysts of the liver, it is sometimes met with, though some physicians maintain the contrary. It may be more or less intense, more or less deep in colour, the result sometimes of inflammation of the substance of the liver itself, sometimes of an obstacle to the passage of the bile through the biliary ducts compressed by a cystic tumour, which compression may also lead to partial or total atrophy of the gall-bladder. Jaundice may also be produced by the hydatids getting into and obliterating the biliary ducts, an occurrence of which I mentioned two examples when lecturing upon hepatic colic: one of these cases, I derived from the practice of my friend Dr. Lasegue, and the other, which I observed in our St. Bernard's ward, is one to which I shall have forthwith to call your attention. There may also be jaundice depending upon complete destruction of the biliary ducts and gall- bladder. There are also other symptoms, which may be consequent upon mechanical interference with the play of the organs abnormally affected by the presence of hydatid tumours. The growth of a large cyst in the abdomen may push the stomach out of its place, and press down the intestinal mass to the right iliac crest. Even when the tumour is not very large, it may compress the principal venous trunks, the vena porta and vena cava inferior, HYDATID CYSTS OF LIVER. 2 77 thereby producing ascites and oedema of the inferior extremities. These complications, however, are exceptional occurrences in the disease of which I am speaking. A hydatid cyst forming on the convex surface of the liver, and attaining a great size, will squeeze up the diaphragm into the chest, displacing the lungs and heart: then, again, sometimes, by ascending as high as the second rib and the clavicle, it will simulate a pleuritic effusion, greatly embarrassing the respiration and cardiac circulation. I say nothing at present of those cases in which the tumour, separating or destroying the fibres of the diaphragm, penetrates directly into the pleural cavity : this is a subject to which I shall have to return when I come to discuss the communications which may be formed between hydatid cysts and the respiratory apparatus. I have mentioned hepatitis as one of the complications of the hydatid affection of the liver. This inflammation, more or less acute, more or less extensive, is excited by the presence of a very large cyst, or by the very rapid development of the tumour: it may supervene either accidentally, or as the result of any external violence, such as a muscular effort of the patient, a blow on the seat of the disease, an exploratory puncture, acupuncture, the application of caustic, or any other operation performed with a view to accomplish a cure. This inflammation often ends in suppuration, and in some cases invades the veins. The phlebitis is sometimes caused by the introduc- tion of septic matter into the blood-vessels. In certain cases, indeed, the hydatid cysts have opened into the vena cava, and in others, they have not only opened into branches of that vein, but have likewise opened into vessels of new formation to be seen ramifying on the surface of the tumour. In these cases, the patients die from the effects of purulent infection. Whether originating spontaneously, excited by accidental causes or surgical manipulations, the inflammation may remain confined to the cyst, which will then be transformed into a real abscess. This is one of the terminations, perhaps not unusual, of hydatid cysts of the liver. When suppuration of the cyst takes place, it is either occasioned by a sort of putrid fermentation developed within its cavity by the presence of hydatids killed by an operation, or by the irritation which the instrument has set up in the parts occupied by the tumour, and propagated to its interior. 278 HYDATID CYSTS OF LIVER. This suppurative inflammation is always announced by very violent fever, and by acute pains in the region of the malady, in place of the dull pains which alone were previously experienced by the patient. There is also, at the same time, in the majority of cases, a subicteric tinge, and sometimes a very deep-coloured jaundice indicating that the parenchyma of the liver is involved in the inflammation. Gentlemen, I attach great importance to suppurative inflammation as a termination of hydatid cysts of the liver; and in relation to this subject, I must relate a remarkable case communicated to me by Dr. Laboulbene, one of my colleagues in the hospitals; and afterwards I shall recall to your remembrance the details of another case—one to which I have already alluded, and which was observed by you in our clinical wards. Dr. Laboulbene’s patient was a man of fifty-two years of age, who, on ist September, came into the Hotel-Dieu, where he was placed in bed 23 of the Sainte-Madeleine ward. He said that he had been ill for eighteen days, but that up to that date, he had enjoyed excellent health. When at his usual work as a day- labourer, he was all at once—without having had a fall or a blow — seized with pain in the transverse arch of the colon. Thrice he purged himself, although he experienced neither gastric uneasiness, diarrhoea, constipation, nor vomiting. As the pain increased in severity so much as to oblige him to keep his bed, he came into the hospital. On his admission, Dr. Laboulbene was struck with the typhoid aspect of his countenance. His decubitus was dorsal, and his eyes were injected. However, he neither complained of headache, nor of vertigo, even when he was made to sit up; but his tongue was thickly coated, dry, and blackish. He had burning thirst, and no appetite: he had no tendency to vomit. There was some fulness, but not much tension of the abdomen, nor any gurgling in the right iliac fossa. There was no trace of pink lenticular spots. The right hypochondriac region was slightly painful, and there could be detected enlargement of the liver, which ascended almost to the nip- ple, and descended about four finger-breadths below the false ribs, without presenting any projections or inequalities. The spleen only exceeded by nine or ten centimeters its normal volume. The patient was feverish, his skin was hot, and his pulse 100. Nothing abnor- mal was discovered in the condition of the heart or lungs. The sclerotic had a slightly jaundiced tinge; but the urine HYDATID CYSTS OF LIVER. 279 was natural in colour, and contained neither biliverdin, albumen, nor glucose. Dr. Laboulbene prescribed tonic treatment, of which quinine wine constituted the most important part. Some days later, the patient had a shivering fit towards evening. The typhoid condition was increasing: diarrhoea had supervened, and continued persistent: the abdomen was tympanitic : and the tongue was as dry as a bit of cork. The rigors in the evening, and the whole symptoms considered collectively, were much more charac- teristic of purulent infection than of typhoid fever. On the 8th September, the patient lost a few drops of blood from the nose: his state had been getting worse and worse every day. He died during the night. At the autopsy, Dr. Laboulbene found the liver enlarged, and adherent to the anterior and inferior surface of the diaphragm. The tissue of. the upper part of the right lobe was soft: and in that situ- ation, a cyst which did not protrude beyond the surface of the organ, profusely discharged a whitish yellow fluid having a purulent appear- ance, and containing very numerous bodies resembling transparent capsules of gelatine. Dr. Davaine found that this fluid was composed of white pus-corpuscles and very distinctive mucinous globules. When the gelatinous bodies were cut in thin slices, they presented in the field of the microscope the characteristic appearances of the peculiar membrane of hydatids. Stratified layers were seen present- ing an appearance like the transverse section of superimposed thin strips of oil-silk. Dr. Davaine found no trace of echinococci nor tenacula. The hydatids were destitute of the germinal membrane on which these entozoa germinate before becoming free. In this case, therefore, wre had to do with hydatids arrested in the first stage of their development. The internal surface of the cyst was lined by a slightly adherent false membrane, which was tinged with bile in several places. Some parts of this membrane were thick and fibrous. On removing them Dr. Laboulbene detected on the surface and in the thickness of the walls of the cyst, ramifications of veins and biliary ducts. The veins were large and tortuous. On the anterior surface of the liver, near the falciform ligament, Dr. Laboulbene found several abscesses varying in size and re- sembling metastatic abscesses. Their internal wall was formed by 280 HYDATID CYSTS OF LIVER. the tissue of the liver itself. The purulent fluid which they con- tained was, in some cases, coloured by bile, which exuded from bile- ducts, which M. Davaine ascertained, opened into some of the abscesses. There were similar purulent collections in the left lobe of the liver. One of the branches of the vena cava contained an adherent clot which extended into the most minute ramifications of the vessel; and in one of the afferent veins, there was a tubulated false membrane filled with pus, which exuded when the tube was pressed. Throughout its entire length, the intestine was injected, but not at all ulcerated. There were no metastatic abscesses in the lungs or spleen. Should the hydatid cyst, from becoming an abscess, or from attaining a very large size, have a tendency to burst, the time will come when its contained fluid will open a passage for itself through the neighbouring tissues. This passage will sometimes be outwards, through the abdominal walls, after the manner of hepatic abscesses and biliary tumours: when the adhesions naturally established between the walls of the tumour and the parietal peritoneum prevent effusion of the fluid into the peritoneal cavity, there exist the condi- tions which are most favourable for the ultimate cure of the cyst— the very conditions we endeavour to induce artificially as means of treatment. Hydatid tumours situated on the concave surface of the liver may open spontaneously into the abdomen, either into the peritoneum (occasioning rapidly fatal inflammation), into the blood-vessels, biliary ducts, stomach, or intestinal canal, which latter is the most propitious mode. I must now occupy a minute or two in calling your attention to these peculiarities. I shall not revert to the communication existing between the veins and the hydatid cysts and the liver. Let it suffice to tell you the possibility of such an occurrence, and the nature of the results which may ensue. Hydatid tumours open into the biliary passages by ulceration of their walls, consequent upon compression by the tumour. The vesicules become engaged in the biliary passages. The small hyda- tids first introduce themselves into the passages, and are then con- stantly propelled onwards by the bile secreted behind them, so that they pass on from the branches into the large trunks, and ultimately HYDATID CYSTS OF LIVER. 281 enter the intestinal canal. Should they be very small in size, they are easily expelled; but if larger, they make their way more slowly, and the accumulation of bile which they cause produces dilatation of the passages. This dilatation allows larger hydatids to enter, which in their turn perform the same transit. The same thing occurs which takes place in the case of biliary calculi; the symptoms are nearly the same in respect of pain, jaundice, and pale colour of faeces, with this exception, that the pain is less acute. On examining the stools, we find that they contain the debris of acephalocysts, and even entire hydatids. Communication may be established directly between the tumour and the choledoch duct, or between the tumour and the gall bladder, within which latter hydatids have been found. Like biliary calculi, hydatids engaged in the hepatic or choledoch ducts may cause retention of bile; but in these cases, the nature of the malady usually remains undiscovered till an examination of the evacuations has conclusively established the diagnosis. It sometimes happens, that the bile passes into the cavity of the tumour through the communication formed between the biliary ducts and the hydatid cysts. At the autopsy, in such cases, we find that the hydatids are broken up, empty, and more or less yellow in colour. It is probable, that prolonged contact with the bile causes death of the hydatids; and we shall see that it has been proposed to utilise this fact as a means of cure by injecting ox-bile into the hydatid cysts, a proceeding which (to say the least of it) is strange. Finally, the spontaneous rupture of hydatid tumours of the liver into the biliary passages does not of necessity lead to fatal compli- cations : it is sometimes a favorable termination of the affection. But fortunate issues are in other ways numerous when a com- munication has been established between the cysts and the intestinal canal, although in the one case as in the other, the evacuation of the fluid contained in the tumour proceeds very slowly, so that several months may be required for its completion; although it may also happen, that the very narrow opening being insufficient to allow the contents of the cyst to pass, other openings form, by which the fluid is discharged simultaneously into the intestine, into some other organ, or externally. To enable the communication to become established with the stomach—by far the rarest and least favourable mode of opening—or with the duodenum, ascending, or transverse colon—the most usual and also the most favourable mode of opening—it is essential that 282 HYDATID CYSTS OF LIVER. the tumour should have contracted adhesions with the organs into which it is to discharge itself. If these adhesions have not been formed, there will be danger of the cysts suddenly bursting into the peritoneum, and the production thereby of peritonitis proving fatal within a few hours. These adhesions are the results of an inflam- matory process by which the serous coverings of the cysts and the intestinal tubes become glued to one another. They are formed exactly in the same manner as in cases of abscess of the iliac fossa, or of the broad ligament, when the abscess opens into the intes- tinal canal or bladder. On a future occasion, I shall have to tell you that this is a mode of termination of iliac and pelvic abscesses which is very frequently met with in practice: when left to the unaided efforts of nature, they almost always undergo spontaneous cure. The flattening, or disappearance of the tumour which formerly was prominent in the right hypochondriac region and towards the epi- gastrium, sometimes a peculiar sensation experienced by the patient, the vomiting of purulent matter at first free from fcetor, but soon becoming foetid and containing hydatids or the debris of hydatids are phenomena which indicate that the cyst has opened into the stomach. The presence in the stools of hydatids, or their membranes, announces that the opening has formed into the duodenum or colon. In the latter case, which I repeat, is the most usual, matters proceed without any complication: if profuse diarrhoea supervene, it does not con- tinue long, and on washing the excreta, there are found not only small hydatids, but sometimes also the mother hydatid which resembles a false membrane of greater or less dimensions. The evacuation of hydatid cysts of the liver may take place simultaneously both into the stomach and into some other part of the intestinal canal; but again I repeat, that no mode of termination is more propitious than the entire evacuation taking place into the large intestine. When the hydatid cyst is developed upon the convex surface of the liver, it is, to a greater or less extent, pushed down into the abdominal cavity, where it displaces the mass of intestines: the diaphragm is powerfully squeezed up into the chest. The tumour may in this way be caused to ascend as high as the fourth rib, as the second rib, or even as the clavicle, pushing aside the lung: respiration is greatly embarrassed, because both the diaphragm and the lung are peculiarly impeded in the performance of their functions. Whether the muscle has remained intact, or whether its fibres, as HYDATID CYSTS OF LIVER. 283 a consequence of pressure, have disappeared from a more or less exten- sive surface, a perforation may occur, affording passage to the tumour: the presence of the hydatid cyst in the chest often induces effusion, physical signs of which are furnished by auscultation and per- cussion ; viz., complete dulness, absence of respiratory murmur, and sometimes egophony, if, as very often happens, there exist at the same time, a little effusion into the pleura. By an attentive examination, however, differences can be estab- lished which will assist the diagnosis. Thus, the dulness is usually limited to a certain space: its extent varies so much that on percussing, for example, along the vertebral column, the dulness is found to be complete, whereas beyond it, on the same level, on the lateral wall of the chest, a sonorous sound is heard whatever posi- tion the patient is made to assume: or again, it is beyond that that the dulness is absolute, while along the spine, the sound is clear and the vesicular murmur is audible. No doubt, this circumscribed dulness may be indicative of an encysted pleurisy: but in the first place, that is an unusual form of pleurisy, and secondly, it does not give rise to that peculiar kind of deformity which the chest generally acquires in cases of hydatid tumours—a circumscribed globular deformity extending to the hepatic region. There is no longer any ground for hesitation : besides the fact of the liver being down in the abdomen, deep-seated fluctuation is perceptible on a line with the margin of the false ribs, particularly when there exists an hydatid purring tremor. An exploratory puncture will speedily remove any remaining doubts as to the nature of the affection. We can understand that when a true pleuritic effusion takes place under the influence of the irritation caused by the presence of the tumour in the pleural cavity, the differential diagnosis becomes impossible. In the cases of perforation of the diaphragm to which I have alluded, as being consecutive to disappearance of the muscular fibres under long continued pressure by the hydatid cyst—in these cases, I say, that the tumour of the liver may contract adhesions with the lung, and then, by bursting, form a communication with it. The symptoms of the pulmonary affection, or rather their meaning, is usually not understood until the accidental pulmonary cavity commu- nicates with the bronchial tubes, and so enables the expectoration to furnish diagnostic proof. This proof consists in the presence of hydatids and debris of hydatids; or perhaps, the sputa are mingled 284 HYDATID CYSTS OF LIVER. with bile, which makes it manifest that the seat of the tumour is in the parenchyma of the liver. The establishment of this communication between hydatid cysts of the liver and the bronchial tubes is frequently the happy means employed by nature for accomplishing a complete cure, as is shown by numerous cases which have been reported by physicians. Under other conditions, the propitious termination has taken place in a similar manner,—that is to say by the elimination of the contents of the cyst of the liver through the bronchial tubes— although the tumour after perforating the diaphragm had burst into the pleura. Nevertheless, Gentlemen, rupture of cysts of the liver into the pleural cavity generally gives rise to extremely acute pleurisy, with a great amount of effusion, which declares itself by violent pain in the side, and intense fever soon leading to hydro-pneumothorax and death. When matters advance less rapidly, a communication may be established between the cyst and the pleura on the one hand, and between the pleura and the bronchial tubes on the other; and then we encounter all the signs of hydro-pneumothorax, as in a case which has just come under my observation. In a word, hydatid cysts of the convex surface of the liver may fill the thorax, and simulate pleuritic effusions : they may open directly into the lung, and may then eliminate their contents through the bronchial tubes : in these cases, the patients frequently recover. The cysts may open into the pleura, and give rise to a rapidly fatal pleu- risy ; or finally, they may open simultaneously into the pleura, and through the lung into the bronchial tubes, in which case recovery may take place, though generally the issue is fatal. Already, in one of my lectures on the clinical study of hydatids of the lung, I have had occasion to speak to you of the manner in which hydatid cysts of the liver terminate by opening into the thoracic cavity, and into the lungs.1 I had previously related to you a case which occurred in the hospital practice of my colleague Dr. Empis.2 To that case, and to those other cases reported by different authors to which I have referred3 you, I would to-day add one which occurred 1 Lecture XXXIV: Yolume III, p. 303. 2 Lecture XXXII: Yolume III, p. 2x5. 3 Lecture XXXVI: Volume III, p. 338. HYDATID CYSTS OF LIVER. 285 under your own observation, and which you had an opportunity of attentively studying in our Saint-Bernard’s ward. The case, interesting in every point of view, is peculiar from pre- senting an example of a hydatic cyst of the liver opening successively into the biliary passages below the diaphragm and into the pleura. Believing that the description of the case would lose much of its interest by being curtailed, I ask your permission to read its complete history as drawn up by my chef de clinique, Dr. Michel Peter. “R. (Amelie), aged 27, was admitted to Dr. Trousseau’s wards on the nth September, 1863. She stated that three weeks ago she had experienced for two days acute pains in the epigastrium, and right hypogastrium, and that consequent upon these pains, jaundice appeared. Prom that date, the colour of the skin became deeper and deeper. Prom that date, likewise, the pains recurred periodically in paroxysms, once in two days : the paroxysms came on in the evening, and were of about two hours’ duration. “ Prom the time when these attacks showed themselves, the patient suffered from anorexia, dyspepsia, and pains at the epigastrium soon after eating or drinking. She had not had vomiting till within the last three days. In addition to the intense pains which recurred in paroxysms, there was also a constant but quite bearable pain. “ Three or four years ago, after a violent attack of epigastric pains similar to those by which she was seized three weeks ago, and which continued for twelve hours, jaundice set in, and continued for nearly three weeks. “ On admission to the hospital, the patient presented an exceed- ingly deep yellow colour. She was thin : her face indicated suffering: and her general health appeared to be very bad. There was no heat of skin, and the pulse was but little quicker than natural. “ The diagnosis was:—Hepatic colic with great consecutive con- gestion of the liver. “ During the evening, the patient had severe and prolonged rigors, accompanied by increased pain in the hypochondrium and epigas- trium. The fever continued during the whole night; and on the 12th September, the patient was in a burning fever: the skin was dry, the face flushed, and the pulse 152 in the minute. The hepatic region was the seat of acute pain. On percussion, it was found that the liver was twice its natural size. The patient vomited everything she took. During the evening she had profuse epistaxis. 286 HYDATID CYSTS OT LIVER. " Diagnosis :—Hepatitis. “ Six leeches were applied to the anus, which produced a pretty abundant flow of blood, and afforded marked relief. This relief continued to be felt for three days. There was no diminution, how- ever, in the volume of the liver, which descended almost to the umbilicus, and invaded the entire epigastrium. The fever returned with redoubled severity every evening. " During the evening of the 14th, the patient was seized with exceedingly severe pain at the base of the right lung. This pain, which embarrassed respiration, extended to the right shoulder. Deli- rium soon set in, and continued all the evening. "At the visit on the morning of the 15th, pain in the hypochon- drium, irradiating to the shoulder and to the whole of the cor- responding thoracic parietes, continued with the same intensity. On auscultation of the chest, however, no morbid signs were discovered. A bath afforded some relief. “ On the 16th, the jaundice presented a saffron yellow colour. The state of the patient was most distressing : she groaned continually : there was a continuance of considerable pain, which prevented exa- mination by percussion. Respiration was imperfect and anxious: there was no egophony. The patient was ordered to take five milli- grammes of calomel every hour. " Diagnosis :—Diaphragmatic pleurisy, the inflammation having heen propagated from the convex surface of the liver to the pleura. “ On the 17th, the pain was much less acute. There were heard for the first time a bellows-sound and egophony in the middle third of the dorsal region. There was dulness in the whole of the inferior third, and skodaic resonance anteriorly in the upper third of the chest. "On the 18th, the pulse was 132, and small. The general con- dition of the patient was alarming. Dulness had invaded the whole of the right side of the chest posteriorly, and even occupied the infra-spinous fossa: anteriorly, the dulness ascended as high as the fourth rib. There was no respiration in the lower half of the chest: in the upper half, and in the neighbourhood of the vertebral column, a muffled bellows-sound and egophony were heard, which were most intense in the supra-spinous and infra-spinous fossae. The dulness in the hepatic region continued as formerly; but the pain on per- cussion had almost entirely disappeared. HYDATID CYSTS OE LIVED,. 287 “ Eespiration was excited, without, however, being too frequent. The nose was pinched, the countenance very much changed, and the cheeks cyanosed. “ Next day, the 19th, there was complete dulness posteriorly from the top to the bottom of the chest. It was only in the subclavicular region that there was sufficient resonance, but the resonance was skodaic. A bellows-sound and egophony were heard posteriorly in the infra-spinous fossa and vertebral hollow. Dr. Trousseau demon- strated to those present that there was distinct fluctuation in the intercostal spaces. This fluctuation was produced by percussing the plessimeter with the hammer. “ The excessive profusion of the effusion, quite as much as the patient's difficulty of breathing, caused Dr. Trousseau to resolve to have recourse to paracentesis of the chest. The operation was imme- diately performed by Dr. Peter, the chef de clinique. It presented exciting incidents, and for that reason deserves to be described in detail. “ Having incised the skin over the fifth intercostal space in the axillary line, the operator introduced the trocar with a quick thrust. Upon withdrawing the trocar nothing issued from the canula; but on introducing through the canula a blunt probe, some drops of very foetid pus immediately flowed out. “ Dr. Trousseau seeing that there was an impediment to the free flow of the fluid from the chest, substituted for the ordinary canula, one of a much larger calibre. Some spoonfuls of pus then escaped, when the flow stopped : the re-introduction of the blunt probe allowed the exit of a gelatinous substance recognised as a shrunken hydatid. Dr. Trousseau at once concluded that there was perforation of the diaphragm from rupture of a hydatid cyst of the liver, with consecu- tive purulent pleurisy. Nevertheless, to evacuate the fluid from the chest, and relieve the patient, Dr. Trousseau, having adapted a double syringe to the canula, removed rather more than half a litre of pus. The hydatids were constantly choking the canflla so rendering the operation difficult, and at last making it necessary to discontinue before the chest was completely evacuated. “ Having removed the canula, and applied a piece of diachylon plaster to the wound, the patient was left. During the day, delirium supervened, the difficulty of breathing increased, and, in twenty-four hours after the operation, the patient died. “ Autopsy.—There was an enormous increase in the volume of the 288 HYDATID CYSTS OF LIVER. liver: and its left was at least twice as large as its right lobe. At the posterior and upper edge of the right lobe, and projecting from the thoracic, and not from the abdominal parietes, there was a cyst sufficiently large to contain the fist of an adult. Its diaphragmatic peritoneal surface was circumscribed by numerous false membranes which were thick and evidently of very old standing. The cyst was covered by false membrane, which in some places was fibrous, in others atheromatous, and encrusted nearly everywhere by calcareous deposit. It was filled by pus, in which floated shrivelled hydatids. Three perforations were visible : “One of these perforations opened below the diaphragm, the result of which was the formation of a cavity between the convex surface of the liver and inferior surface of the diaphragm, cir- cumscribed at its periphery by adhesions between the liver and diaphragm. “ The second perforation, the orifice of which might be sufficient to admit the index finger, communicated with the hepatic duct, by which it opened into the choledoch duct, which was very much dilated and contained three small shrivelled hydatids exactly moulded to the shape of the passage they obliterated. “The third perforation opened into the cavity of the pleura, through a perforation of the diaphragm : it had an inferior orifice sufficient to admit the little finger, and a superior orifice in the form of an elongated slit. “ In the left lobe, were four abscesses, the largest of which was the size of a walnut. They contained a semi-concrete purulent looking matter, which was found, on being examined by the microscope, to consist of pus-globules and fibrinous granules. “ The hydatids contained in the choledoch duct were situated at the junction of the hepatic and cystic ducts, which caused great dilatation of the latter. The gall-bladder, more than three times its normal size, contained a biliary fluid, oleaginous in consistence and of a very deep green colour. It did not contain any hydatids. “ In the pleural cavity, were nearly two litres of purulent fluid, containing hydatids in all respects similar to those removed by the paracentesis. The trocar had evidently penetrated into the pleura, and not into the cyst: the distance between the cyst and the wound made in the surgical operation showed that it would have been physically impossible to have reached the hepatic cyst by the trocar. Moreover, the diaphragmatic surface of the pleura and base of the HYDATID CYSTS OF LIVER. 289 lung were covered by thick downy false membranes formed of super- imposed layers, which were easily torn, and were evidently of recent formation. They covered nearly the entire lung, as high up as the infra-spinous fossa, gradually diminishing in thickness. “ The spleen was very large, and did not contain any hydatids. “ Nothing noteworthy was observed in the other organs.” Dr. Peter follows the narrative of this case with some remarks which I wish to bring under your notice; and in which I entirely concur. “ It is evident,” he says, “ that this patient had had three years previously a first attack of hepatic colic, and that even at the com- mencement of that illness which terminated in death, she was suffering from attacks of undoubted hepatic colic : it is not less evident that the attacks of colic had been produced by the successive passage of hydatids through the biliary ducts. The communication between the cyst and the biliary passages produced in the first instance attacks of hepatic colic; which, though not very unusual, are far from being of frequent occurrence. These, however, were not the only consequences. “ 1. Prom the cyst communicating with the hepatic duct, and through it with the choledoch duct, it followed, that the cyst com- municated indirectly with the small intestine: the result was the enabling the hydatids to make a passage for themselves through the intestine, thus allowing the cyst to be evacuated and the patient to be ultimately cured.1 “ 2. Prom the biliary ducts being in permanent communication with the cyst, two results ensued, one relating to the hydatids, and another to the cyst in wThich they were contained. The hydatids were killed, as often happens.2 The other result was inflammation and suppuration of the walls of the cyst, which thus became a large depositary of pus. It was in consequence of this inflammation, a partial peritonitis—slow and obscure, but nevertheless continued, and dating back apparently to the first manifestation of the symptoms —that adhesions were formed between the convex surface of the liver 1 Frerichs thus meutions the fact:—“ Symptoms were observed similar to those which accompany the passage of biliary calculi through the choledoch duct.” [See p. 593 of the second edition of the French translation of his treatise on e Diseases of the Liver:’ Paris, 1866.] 2 Frerichs admits that a cure may take place in this manner:—See his Treatise on ‘ Diseases of the Liverop. cit., p. 581. 290 HYDATID CYSTS OE LIVEll. and the diaphragm : it is also as a consequence of this same inflam- mation that the cyst successively burst:—ist, below the diaphragm, the purulent fluid being prevented from getting into the peritoneum by the adhesions between the diaphragm and the convex surface of the liver: and, through the diaphragm into the pleura, from suc- cessive perforation of the Avails of the cyst, of the diaphragmatic peritoneum, of the diaphragm itself, and ultimately of the diaphrag- matic pleura.1 “ In this way, during the life of the hydatids, the cyst in the first instance opened into the biliary passages from their growth, and the necessity for a larger habitation consequent upon their increased size: afterwards, it opened below the diaphragm, and at a still later period, into the pleura, by ulcerative inflammation caused by the introduction of bile into its interior. “ That was not all. As a consequence of the communication between the hydatid cyst and the intestine, the intestinal gases were enabled to penetrate into the interior of the cyst, which explained the fcetor, almost stercoraceous, of the fluid which issued from the puncture in the chest. By the existence of this fcetor, Dr. Trousseau was at once informed that he had to do with a hepatic cyst which had burst into the pleural cavity. It might have been added, as Dr. Trousseau remarked at a later date, that the cyst was in com- munication with the intestine. This, as was pointed out by Dr. Trousseau, is an almost pathognomonic sign, upon which, for the future, great stress must be laid. “ It has been established by the observations of Velpeau, that the contents of all the purulent collections in the neighbourhood of the digestive canal acquire a stercoraceous odour. There is a still stronger reason for this odour existing, when the cyst communicates with the digestive canal by an abnormal passage permanently established. “ It is worthy of notice, that in spite of the permanent character of the hepatic lesion, the patient had periodically evening attacks, and, at last, epistaxis —symptoms, all of which have been pointed out by Dr. Monneret as occurring in diseases of the liver.” Gentlemen, I have now sketched for your information the great outlines of the history of hydatid cysts of the liver : I have described 1 Dayaine :—‘Traite des Entozoaires/ p. 478: Davaine offers no opinion on the subject. Chuveilhieb, and G. Budd are of opinion that the introduction of bile into the cyst is the cause of its becoming inllamed. HYDATID CYSTS 01)' LIVER. 291 to you the symptoms by which their presence may be recognised; and the consequences they may entail: I have stated to you the difficulties which frequently arise in the diagnosis; in respect of which, in many cases, it is impossible to attain absolute certainty except by making an exploratory puncture, and so giving issue to a fluid having special characteristics, or better still, by containing hydatids or debris of hydatids. I now come to discuss the question of most importance to physicians :—What is the best treatment of hydatids of the liver ? Though admitted that medico-therapeutic means are indicated in the treatment of the complications which may arise; though granted that narcotic applications, cataplasms, ointments containing opium and belladonna, applied to the affected parts may subdue the violence of the pain and the inflammatory symptoms, medicine is absolutely impotent to cure or even to stay the progress of the affection. Surgery alone can afford useful succour. I have described to you the progress of the affection, showing how it increases in gravity from day to day, till the tumour becomes so large as at last to burst. Sometimes, the rupture takes place through the skin, and sometimes into the intestinal canal or bron- chial tubes; and in these cases, there is a spontaneous cure: unfortu- nately, cures of this description are too exceptional to be counted upon. In hydatid cysts of the liver, the physician ought always to give a serious prognosis; and be prepared to employ active surgical intervention, though well aware that his intervention will unfortu- nately cause formidable dangers, and may even lead to a fatal issue at an earlier date than if the case had been left to nature. He, nevertheless, feels compelled to act, because his intervention, how- ever numerous the unfavourable chances may be, affords greater probabilities of radical cure than could be expected from the unaided efforts of nature. The object of the physician, therefore, is to evacuate the cyst; to adopt measures for the prevention of its again forming; to endeavour, consequently, to destroy the hydatids, which, by their increase in bulk and number, produce the tumour. When once the hydatids are destroyed, the pouch which contained them collapses, and finally disappears. Several modes of treatment suggest themselves for the accomplish- ment of this object. In the first place there is simple puncture. This puncture is recommended to be made at the most projecting 292 HYDATID CYSTS OF LIVER. point of the tumonr. As a general rule, however, it is preferable to operate in the hypochondriac region. The operation will be more easily performed in that region, as the abdominal walls which the instrument has to traverse are very thin. There will, moreover, be fewer dangers to dread, as the peritoneum alone will be involved, whereas, if we take as our only guide the precept to operate on the most prominent part of the tumour, we may run the risk of wound- ing several very important organs. Here, let me explain. In our patient of Saint-Agnes’s wrard, the hydatid cyst projected from an intercostal space. Now, in some cases of this description, the trocar would have to traverse the skin, parietal pleura, diaphragm, and peritoneum. There would then be a danger of pleurisy and peritonitis as concurrent consequences of the operation. An exploratory puncture is made with a very small trocar. AVith- out the employment of any other means, it may lead to a definitive cure; but it may likewise be the starting-point of fatal complica- tions. This occurrence is quite exceptional; but still, it has occurred: after an exploratory puncture, peritonitis has supervened, and carried off the patient in a few hours. Dr. Moissenet, my colleague at the Hopital Lariboisiere has related a case of this kind which you will do wrell to remember.1 Let me recommend you to protect yourselves by a statement of possible untoward eventualities, when- ever you have occasion to make an exploratory puncture in this class of cases: while you reassure the relatives of the patient as to the general harmlessness of the operation, also warn them as to the untoward accidents which may sometimes occur. Dr. Boinet2 has formulated certain rules, by following which it would always be possible to avoid introducing any of the fluid into the abdominal cavity, a common cause of rapidly fatal peritonitis. He says that it is necessary to be careful, on withdrawing the canula from the trocar, to press back with the fingers the abdominal parietes towards the cyst, so as not to allow any free space to exist between them. This pressure ought to be continued for a minute or two after the operation, and the relative state of the parts should be 1 Moissenet :—Sur la Ponction avec le Trocar Capillaire, appliquee au traitement des Kystes Hydatiques du Poie. [Archives Generates de Medecine, for February, 1859.] 2 Boinet : Traitement, des Tumeurs Hydatiques du Foie par les Ponctions Capillaires et par les Ponctions swivies d’lnjections Iodees. Paris : 1859. II YD ATT D CYSTS OF LIVER. 293 maintained for some days by means of graduated compresses and a bandage applied round the body. In the memoir by Dr. Moissenet to which I have just been alluding, the author proposes to apply puncture with the exploratory trocar to the radical treatment of hydatid cysts—a means which hitherto had only been used for diagnostic purposes. He quotes some published cases in which exploratory puncture had led to an ultimate cure; but no one prior to my honourable colleague of the Hopital Lariboisiere had thought of turning these facts to account in practice. This method of treatment will be applicable to those cases in which the cysts “have a manifest tendency to advance externally, and when they impede the free exercise of the organs in the midst of, or in the neighbourhood of which they are developed. Under these circumstances, and even in the absence of adhesions to the abdominal parietes, evacuant capillary puncture may be at once resorted to in cases of acephalous cysts, when there is no obstacle to complete evacuation of the cysts. But when from the extreme debility of the patient, and the enormous size of the tumour, it is evident that the contents can only be evacuated little by little, and at intervals, it is necessary to endeavour to produce firm adhesions between the cyst and the abdominal parietes, both for the purpose of performing the capillary puncture without danger to the peritoneum, and of being able afterwards to have recourse, under favourable cir- cumstances, to such other means of treatment as may seem appropriate.” Experience has not given sufficiently decisive testimony in favour of this method of treatment; and I am unable to concur with Dr. Moissenet in believing that evacuant puncture with the trocar is less dangerous than exploratory puncture; for a larger proportion of cases can be adduced in which the exploratory operation was per- formed without any bad result, as a set-off to the other cases in which its issue was unfortunate. No one denies the dangerous consequences which may result from making the evacuant puncture with a trocar the canula of which is sufficiently large to allow the passage of fluid, of small hydatids, and debris of hydatids. The simple incision is an operation which is always applicable when the tumour projects outwardly in such a way as to threaten to open; for then there is reason to hope that adhesions have become established between the tumour and the walls of the abdomen. Should such adhesions not exist, it will neces- 294 HYDATID CYSTS OF LIVER. sarily happen that the fluids contained in the cyst will escape into the peritoneal cavity, if the opening has been made through the abdomen, and into the pleural cavity, if the puncture has been made through the chest: rapidly fatal inflammations are almost inevitably the consequences of the effusions which thus take place. To avert so formidable a complication, Jobert (de Lamballe) has proposed that several punctures should be made in succession, so as gradually to reduce the size of the tumour, giving the cyst time to contract; or better still, after making the puncture, to leave the canula in its place for twenty-four hours. The canula, which tra- verses the abdominal parietes and the cyst, determines, at its points of contact, an inflammatory action, which tends to establish adhesions between the parietal and cystic folds of peritoneum. In reality, Jobert, by this proceeding, obtains results similar to those ob- tained by the plan of Begin, the plan of Becamier, and by my own method. Begin5s proceeding, which I have already explained to you in my lectures on hepatic colic, consists in reaching the tumour by suc- cessive incisions.1 In the commencement of the first stage of the operation, the skin and muscles are alone implicated; then the aponeurosis being reached, is opened with extreme caution: after which, the peritoneum itself is incised. The cyst is then seen at the bottom of the wound. A dressing is applied, which is kept in place by means of a very tight bandage, and the patient is told to move about as little as possible. When inflammation of the parts has produced adhesions between the cyst and the abdominal parietes, the second stage of the operation is proceeded with : this consists in penetrating the tumour with a large trocar, or (which is preferable) with a bistoury. Upon the same occasion, I spoke to you of Becamier's method. It is not so quickly performed as Begin's operation, but what it lacks in rapidity of execution, it gains in safety. In the first stage of the operation, caustic is substituted for a cutting instrument. To the skin of the place where the cyst is to be opened, there is applied potassa fusa, Vienna paste, or the caustic of Filhos, in suffi- cient quantity to produce an eschar of a certain size, involving at least the thickness of the skin. When this eschar is formed, it is 1 Begin -M6moire sur l’Ouverture des Collections Purulentes et autres, d 6veloppees dans 1’Abdomen. Paris: 1830. HYDATID CYSTS OF LIVER. 295 detached, and a new supply of caustic is applied to the bottom of the wound. Proceeding in this way, by successive cauterizations, we at last reach the peritoneum, which we must be careful to respect. Inflammation takes possession of the serous membrane; and by keeping the parts tightly bandaged, we bring the tumour into contact with the abdominal walls in such a way that adhesions are formed between the peritoneal fold covering the cyst, and the peritoneum covering the abdominal walls, in consequence of the former partici- pating in the inflammation of the latter; just as takes place when the plan is followed of leaving the canula in the puncture, or when the other method of successive adhesions is adopted. Thus, there is a possibility of opening and emptying the cyst, without being afraid of causing it to contract upon itself in such a way as to pour its fluid contents into the cavity of the peritoneum. RecamiePs method has been objected to, on the ground that there is often a difficulty in limiting the action of caustics : it has been said that they may give rise to more or less extensive, and even to general peritonitis; while also, an objection of an opposite character has been adduced, to the effect, that the desired result, the production of adhesions, sometimes does not occur. To the latter objection, it may be replied, that in those cases in which adhesions are not pro- duced, the caustic has been badly applied, and has not reached the peritoneum; or that sufficient care has not been taken to maintain the abdominal walls in apposition with the tumour by means of suitably applied pressure. Multiplied acupuncture is another method by which you have seen me endeavour to obtain adhesions between the cyst and the abdominal walls. I have already told you my manner of employing this method : acupuncture when practised in this way seems to me to present the advantage of being always accompanied by an inflam- mation which is circumscribed within the limits of its origin: and another advantage consists in the adhesions being more rapidly obtained, because there exists no necessity, as when RecamiePs method is employed, of successively destroying the different layers of the skin before reaching the peritoneum. When a hydatid cyst has been opened, the suppuration which takes place within it from decomposition of its contents, may become, in some cases, the starting point of a putrid or purulent infection leading to a fatal issue. To prevent such results, it has been proposed to inject water, or some other fluid, such as alcohol, 296 HYDATID CYSTS OP LIVER. or tincture of iodine, into the cavity of the opened pouch, with a view to modify the condition of the suppurating surface. Iodinous injections, used for the first time in the treatment of hydatid cysts of the liver by Dr. Boinet, are those which up to the present date have yielded the best results. Beware, however, of supposing that they constitute an infallible system of treatment. No doubt, a somewhat imposing number of cures has been recorded as resulting from the use of iodinous injections; but still, it must be admitted, that the method is very hazardous even when skilfully employed. The injections ought to be employed daily: the mixture should consist of equal parts—say fifty grammes—of tincture of iodine and distilled water, with an addition of a certain quantity—say four grammes, of the iodide of potassium. Should symptoms of iodism show themselves, the proportion of distilled water must be increased. When the walls of the pouch are thin, they contract on them- selves, and the cavity is at last closed : but it does not so happen when the walls are thick. I shall only say a few words regarding injections of bile, a mode of treatment recently proposed, and used for the first time, in 1857, by Dr. Auguste Yoisin. Before any opinion can be definitively pro- nounced upon this method of treatment, it will be necessary to have reports of a greater number of cases than has hitherto been re- corded. Besides, while it is easy to understand how it is that the infection of iodine is useful, it is not so easy to form a conception of the benefits resulting from the injection of bile, particularly when we bear in mind the terrible consequences of the contact of bile with the peritoneum and subcutaneous cellular tissue. LECTURE LXXX. MALIGNANT JAUNDICE.1 Malignant Jaundice [Ictere Grave] is a general disease—to tins substantive—analogous to Typhoid Fever, and the Bilious Fever of Tropical Climates.—Retention of Bile in the biliary ducts does not constitute Malignant Jaundice.—Typhoid Symptoms at the beginning of the attach.—Yellow colour, and Green colour of Shin and Conjunctiva.—Hemorrhages from the mucous mem- branes : Fpistaxis, Gastrorrhagia, Melcena.—Hemorrhages from the Shin : Fcchymosis, Purpura.—Decrease in size of Liver not constant.—Secondary Nervous Symptoms.—Death the most com- mon termination.—Morbid Anatomy: Change in Structure of Liver not constant.—Primary Alteration of Blood.—Notice of the Fatal Jaundice of Lnfants.—Malignant Jaundice is not Yellow Fever. Gentlemen :—In a recent lecture on hepatic colic, I gave you the complete details of the case of a woman, aged fifty, who died in Saint- Bernard’s ward under complications originating in strangulated hernia. You no doubt recollect, Gentlemen, that this patient (who was in our wards at several different times for hepatic colic), had a very severe attack of jaundice during the latter weeks of her sojourn in hospital. The biliary ducts must have been obstructed during several weeks at each attack of hepatic colic, for the jaundice was long continued, and the urine had a decided mahogany colour, while the faeces presented the characteristic appearances met with under similar circumstances. This patient died, as I have said, from strangulated hernia; but the posthumous examination, made with very great care by Dr. 1 Ictere Grave : Ictere Malia: Ictere Typho'ide. 298 MALIGNANT JAUNDICE. Benjamin Ball, disclosed among other interesting facts, that there was complete obliteration of the excretory bile duct3. The cystic duct and the first portion of the choledoch duct were so blended together, amid the surrounding products of inflammation, that it was impossible to conceive the bile flowing into the intestine by the normal passage. It was evident, that if the bile reached the duodenum, its flow must have been through a fistula, of which we could only find the intestinal opening. I do not propose to enter at greater length into the details of this autopsy, which are still fresh in your recollection: my principal object at present is to call your attention to the fact that when during many weeks, and even during many months, there existed a relative if not an absolute retention of bile, the liver presented no morbid structural alteration, the bile certainly continued to be secreted, but, being retained in the excretory ducts, was to a great extent reabsorbed, as was indicated by the gravity and persistency of the jaundice. It results from the examination of this case, as wrell as from data founded on many other cases of an analogous character, that the retention of bile does not necessarily lead to special poisoning of the economy. Moreover, even the persistent retention of bile does not inevitably produce an organic change in the liver. It is, therefore, impossible to attribute the symptoms of the disease termed “ ictere grave?’ “ ictere malin,” “ ictere typho'ideto retention of bile. For at least the last ten years, in England, Germany, and France, the attention of pathologists has been specially directed to a malig- nant form of jaundice, w'hich almost invariably terminates rapidly in death—a disease evidently general in its nature, existing either with or without structural change of the liver, and having jaundice and numerous hemorrhages as its principal symptoms. Here is a case in point:—A woman, thirty-four years of age, a patient who occupied bed 24 of Saint-Bernard's ward, had been com- plaining for seven weeks of pains throughout the body, but parti- cularly in the joints: she had, nevertheless, continued her employ- ment as a journey-woman, but four days before coming into hospital had experienced general discomfort, and remarked that a little blood was mingled with the sputa and nasal mucus. There was a con- tinuance of pain in the continuity of the lower limbs, and particularly in the right haunch and knee; but there were no other signs of rheumatic arthritis. The patient was feverish, and had a small MALIGNANT JAUNDICE. 299 quick pulse. The tongue was foul, though there was no loss of appetite: there had been neither vomiting nor diarrhoea; and the abdomen was soft and sluggish. The liver extended several finger- breadths beyond the false ribs. There was complete sleeplessness. The skin presented a slightly yellow tinge: the urine had a red mahogany colour, and became decidedly green on the addition of nitric acid or tincture of iodine. Next day, the patient complained of suffocative sensations coming on at intervals : examination of the heart and lungs did not furnish any explanation of this intermittent dyspnoea. The articulations were still painful: the fever was high : the skin was moist: and the pulse was t 20. The mental condition remained quite clear; but on the following night, delirium supervened, and the pulse became more rapid. The jaundice was a little more decided: the sputa again became sanguinolent: though there had been neither epistaxis nor vomiting, the pulse was becoming smaller and smaller: the delirium continued, and the patient sunk on the fourth day after her admission to the hospital, that is to say, on the seventh day from the commence- ment of the hemorrhages, and the more decided feelings of general discomfort which obliged her to seek for hospital succour. The autopsy showed that there was no articular lesion—no pus in the joints—not even a bright injected appearance, nor an abundant secretion of synovia in the articulations which had been painful. In no part of the organism could any evidence be found of either purulent collections or phlebitis. The stomach and intestines pre- sented no morbid changes: Peyer's patches had their normal appearance: there were no ulcerations in the large intestine. The lungs were slightly congested at their base, and there were no traces of pneumonia or of hemorrhage. The heart was small: its valves were normal: and there was neither endocarditis nor pericarditis. The brain itself presented no change. There was no enlargement of the liver ; but it was flabby, and of a brownish yellow tint. When cut, the section presented a deeper colour: every trace of the lobular structure of the liver had dis- appeared. The usual granitic appearance of healthy liver could not be seen. The gall-bladder was contracted and scarcely contained any bile. A microscopic examination was made by Dr. Benjamin Ball at that time chef de clinique. He found that the liver presented the following morbid changes:— 300 1. Capillary vessels few in number, and diminished in calibre. 2. Complete disappearance of the normal cells of the parenchyma of the liver: there was no trace even of their debris. In their place were found brown granules of pigmentary matter, some very small, others pretty large and of a polyhedral form : there was a very great abundance of minute fat globules, which rapidly disappeared on the addition of a small quantity of ether : at some points, extravasated blood-globules were seen. Hyperplasia of the cellular tissue presented itself in bands distinctly visible upon examining a thin slice of the tissue. Clusters of isolated cellules were seen here and there, which were turgid and infiltrated with fat; but nowhere were there any tyrosis or leucocythsemic globules. The leading symptoms in this case were a long-continued state of feverishness, which was soon accompanied by feelings of general discomfort, an icteric tint of skin, and slight hemorrhages from the mucous membrane of the nose and bronchial tubes. The patient complained of dyspnoea, which was not accounted for by any lesion of heart or lungs : cerebral symptoms supervened: there existed delirium and excitement. Seven days after the appearance of the hemorrhages and jaundice, the patient died in a comatose state. The muscular and articular pains could not be attributed to the rheumatic diathesis, because the patient had had no sign, present or past, of that diathesis, so that they might be ascribed, as well as the other morbid symptoms, to a general disease similar in its character to the pyrexise. The appearance of hemorrhage and yellow skin, speedily followed by formidable nervous symptoms gave ground for diagnosing typhoid jaundice, that is to say, a pyrexial malady with a probable organic change in the structure of the liver. The autopsy has verified this diagnosis: but it must be remarked, that in this case there was no atrophy of the liver, although the cellules were entirely destroyed. We could not discover any probable cause of the disease. Here is another case:— A. G., aged forty-six, was of frail health, nervous, hypochon- driacal, and timid. He had had frequently slight disturbance of the digestive functions, but nothing to require active medical interven- tion. In the beginning of July, 1864, without known causes, he had a paroxysm of fever, which subsided about the fifth day, and then, when all was going on well, jaundice, unaccompanied by fever MALIGNANT JAUNDICE. MALIGNANT JAUNDICE. 301 declared itself. Up to that date, nothing had occurred to alarm either the patient or his family; but two days later, there was a new attack of fever, and a phlegmon appeared under the jaw-bone on the left side. The yellowness became very intense : the skin was hot: the pulse ranged between 120 and 130: the tongue became parched, and slight attacks of epistaxis supervened. There was no pain in the region of the liver. The mind was clear. The patient was unable to sleep. The intensity of the fever, and the acuteness of the pain caused by the phlegmon made the diagnosis difficult. Was the fever excited by the phlegmon, or was its chief cause the hepatic affection ? The answer to this twofold question materially influenced the prognosis. In general, wrhen jaundice is accompanied by fever, there is great danger in the case : but this is no longer exactly so when the fever can be ascribed to a concomitant disease, although experience shows that jaundice, even of the simplest kind, is often aggravated by the mere existence of fever, whatever may be the cause of that fever. Therefore although we hoped that matters might assume a more favourable aspect, we could not fail to be exceedingly anxious as to the issue. The hepatic lesion, however, did not give rise to pain: there were no anxious nervous symptoms : the phlegmon advanced satis- factorily ; and although the attacks of epistaxis continued to occur, although the icteric tint of the skin remained as deep as ever, it was justifiable to entertain the pleasing hope that all might still proceed to a favourable termination. As a rule, the fever due to a phlegmon diminishes, when the phlegmon becomes an abscess. Pus accumulated, fluctuation wras felt under the skin, the abscess began to open into the mouth; and yet the fever did not moderate. We were now at the tenth day from the first appearance of the jaundice. One morning, subsultus tendinum was observed, the tongue became more parched, and there was more constitutional excitement: the succeeding night was more agitated : next morning, the subsultus was more violent. In propor- tion as the nervous symptoms increased in severity, our anxiety as to the issue also increased. During the evening, the patient became weak, and expired in the night without having had delirium or convulsive movements. This case, Gentlemen, places before you the difficulties of 302 MALIGNANT JAUNDICE. the diagnosis when jaundice is complicated with an inter current affection. Dr. Jules Worms lately communicated to me the following case:— A soldier of the 14th regiment of the voltigeurs de la garde, twenty- nine years of age, squat, strong, and very healthy, a man said not to have been of intemperate habits, one day when on guard complained of loss of appetite and uncomfortable sensations. Next day, for the benefit of his health, he took a walk with his comrades. On the third day, he felt more unwell, had rigor accompanied by pros- tration of strength, and was unable to leave his bed. He complained of pains in his limbs; and his comrades observed that he was jaundiced. On the fourth day, the prostration was at its height: bilious vomiting having supervened, he was sent to the Hopital du Gros Caillou. The admitting physician observed that there was jaundice of medium intensity, and coldness of the skin. The pulse was slow, and hardly appreciable : the physical prostration and loss of mental power were extreme. During the morning of the fifth day of the attack, the patient died, having been in a state of torpor from the previous evening, without having had any evacuation from the stomach or intestines, or any hemorrhage. The autopsy was made twelve hours after death. The icteric colour of the skin was not very intense; but in both eyes, the sclerotic was as yellow as ochre. The body showed no traces of ecchymosis: the gums, however, were covered with a sanguineous crust. Both lungs were congested at the base. The right side of the heart was filled with clotted blood, part of which was hardly coagulated. The small clots were gelatiniform. The left side of the heart contained some fluid, grumous blood. There were no coagula in the vessels. The spleen was fourteen centimeters in length, and ten in breadth; it was very soft and friable. The stomach contained two hundred and fifty grammes of a fluid as black as ink, from which a black matter was deposited, which, on examination by the aid of the microscope, was found to consist wholly of altered blood-globules. Numerous very small ecchymotic patches were disseminated over the surface of the great curvature of the stomach : the mucous membrane was softened. The kidneys did not present any change of structure apparent or histological. The walls of the bladder were normal. The inferior margin of the liver was found to be three finger- 303 MALIGNANT JAUNDICE. breadths above the costal margin. The liver was of a deep red colour : it was very small, being not larger than the liver of a child. Its transverse diameter was not more than twenty-four centimeters : the perpendicular diameter from the gall-bladder to the point of emergence of the vena cava was fifteen centimeters. The weight of the organ was only nine hundred and forty grammes, the average weight of an adult’s liver being fourteen hundred grammes. The gall-bladder contained sixty grammes of very black, thick bile. The capsule of Glisson was in folds, and thickened at certain points, forming an arborescent appearance. The capsule was evidently too large as a covering for the shrunken liver. The hepatic tissue was very soft and friable. The different sections of the liver presented to the naked eye no striking difference from the usual appearances. Yellow points no doubt were visible; but this appearance fell very far short of that marquetry which is characteristic of cirrhosis. The condition revealed by microscopic examination was as follows. The hepatic cellules were entirely destroyed. It was only here and there that shreds of the cellular envelopes were to be seen. There was a profusion of pigmentary cells. There were also found some nuclei of free cellules, which were beginning to undergo the fatty trans- formation : but there were scarcely any fat-globules. The striking features in this case, Gentlemen, were the abrupt onset and rapid progress of the disease, and subsequently, the nervous symptoms which proclaimed the existence of a serious organic change. This man’s health was remarkably good, when, all at once, he complained of general discomfort and loss of appetite: next day, he had rigors announcing the general affection of the system, and immediately afterwards, he fell into a state of prostration which con- tinued till he died. It was scarcely during more than a few hours before his death that he had a little transient delirium, which soon subsided into a state of torpor. The appearance of the jaundice from the second day of his illness proved that the cause was in the liver; and the typhoid condition of the patient gave certainty to the diagnosis. Although he had had neither nasal, stomachal, nor intestinal hemorrhage, the stomach contained two hundred and fifty grammes of black blood, showing that hemorrhage had preceded death. The blood, moreover, was altered, and the heart contained viscous, diffluent blood: the spleen was soft, and friable: and the liver presented all the anatomical characters of diffuse hepatitis, or the acute yellow atrophy of German authors. These are cases. Gentlemen, which Graves and Budd would have described under the name of malignant jaundice or Irish yellow ; and which Frerichs introduced into his chapter on acute atrophy, or yellow atrophy of the liver.1 Finally, these cases are similar to those described by my learned colleague Professor Monneret under the name of essential hemorrhagic jaundice. What then are the characteristics of this formidable disease, so variously explained, and the subject of so many theories, though regarded as essentially a general disease by the majority of authors ? The icteric colour of the skin, in all its shades of intensity, can only be looked upon as a symptom. Jaundice is not adisease; but is on the contrary the expression of numerous states, some of which are compatible with health, whilst others are invariably mortal. But although jaundice is sometimes symptomatic of organic lesion of the liver, it happens occasionally that no structural change can be demonstrated at the autopsy, and that the most competent histo- logical observers are unable to recognise any important modification in the hepatic cellules. In general, jaundice is only a temporary phenomenon which does not at all disturb the gastro-intestinal functions, nor prevent those in whom it exists from pursuing their ordinary occupations. This is the case even when it arises from a mechanical obstacle to the passage of bile: whatever may be its duration or intensity, there exists no malady (using malady in its vulgar acceptation), though the patients sometimes suffer intense pains, which are generally caused by the difficult passage of biliary calculi through the hepatic ducts. And, Gentlemen, bear in mind the remark I made to you at the beginning of this lecture, to the effect, that jaundice may continue for several months without the economy showing any disturbance resulting from the unwonted circulation of bile in the blood. All the organs and all the fluids are coloured by the bile; and yet none of these organs or fluids cease to fulfil their physiological functions. Finally, there are pathological conditions in which the excretion of the bile is impossible, as, for example, when the choledoch duct is obliterated: there are cases in which there is an almost complete suppression of the biliary secretion, as in atrophy from cirrhosis; and yet the MALIGNANT JAUNDICE. 1 FiiEitiCHS: Traite des Maladies du Foie et des Yois Biliaires: traduit de lAllemand par L. Dumenil et J, Pellagot, 2me edition ; 1866. MALIGNANT JAUNDICE. 305 retention or non-secretion of bile does not, till after long con- tinuance, determine secondary general morbid changes incompatible with life. But although it be true, as a general proposition, that jaundice is only a symptom of inconsiderable gravity, clinical observation demonstrated to Franciscus Rubreus,1 Morgagni,2 Boerhaave, and Graves,3 that though at first mild, and presenting apparently only the usual conditions, it might suddenly manifest general symptoms ter- minating in death. Indeed we all know how necessary it is to give a very reserved prognosis in cases of jaundice. As in cases of pleuritic effusion, so in jaundice, one can never say what is to be the termination. Graves states that he was always uneasy as to the issue when nervous symptoms showed themselves, symptoms more- over, which he remarked, were often coincident with a diminished secretion of urine, the skin and sclerotic retaining their yellow tint: he also states that, fearing the retention of bile in the system, he has often with success administered diuretics, endeavouring by that pro- ceeding to imitate nature, which eliminates bile by the kidneys when there is an impediment to its exit through the intestinal canal. The Dublin Professor, however, has not described a specially malignant jaundice, and even in his lectures on the “ yellow fever of Ireland,” he only accords a secondary importance to the yellow colour of the skin. I must, therefore, refer to observers of the last few years for a description of that special disease which all at once assumes a dan- gerous aspect, and is almost always mortal. It is only this special condition of disease which I wish to bring under your notice in this lecture, intentionally omitting to notice grave conditions and symptoms which complicate attacks of jaundice of variable duration, and indicative of the existence of biliary obstruction. Among the many contemporary authors who have studied sudden typhoid jaundice, may particularly be mentioned Rokitansky, Henoch, Budd, Dusch, Griesinger and Frerichs.4 But side by side with these English and German authors, it is only fair to cite some French 1 KubjEus (Franciscus) :—De Ictero Lethali. 2 Morgagni :—Anatomical Letters, io and 37. 3 Graves :—Clinical Lectures. 4 Frerichs :—Practical Treatise on the Diseases of the Liver and Biliary Passages, 2nd Edition, 1866, p. 164. 306 MALIGNANT JAUNDICE. physicians who have specially based their works on clinical ob- servation and general pathology. Let me particularly refer to the treatise of Dr. Monneret, in which the diagnosis and nature of the malady are studied with great sagacity, and in a manner which shows a profound acquaintance with all diseases in which the liver plays a part. Dr. Genouville, in his inaugural thesis, expressed con- currence in the views of Dr. Monneret. Finally, Dr. Blachez has expounded a theory of Gubler, and published interesting details regarding that species of malignant jaundice called canis.1 If you read the reports of cases of idiopathic malignant jaundice, or if you observe one well-marked case of that malady, it will be impossible for you not to be struck with its similarity to the symp- toms presented in cases of the pyrexise. It may be remarked, in fact, that from the beginning of the attack, the whole organism is affected by the disease, as in dothinenteria, smallpox, bilious fevers of tropical climates, and the pernicious fevers of certain countries. Suddenly, or after some days or weeks of feverish discomfort, the patients complain of general prostration: in vain, they struggle against this state, the malady augments in severity: exhausted in strength, they take to their beds, and soon afterwards, may be detected jaundice, often accompanied by frequent hemorrhages from the skin and mucous membranes. When the progress of the disease is rapid, there occur, after the third or fourth day, various nervous accidents such as excitement, convulsions,5 delirium, and at last profound coma: in which state death takes place. It is important to remember, that in many cases there is a total absence of reaction, scarcely any quickening of the pulse, even a diminution in the temperature of the skin, and no tendency to a critical discharge from the intestines. When the malady continues for several days, repeated hemorrhages take place from the stomach and intestines, after which the vomit and stools consist almost entirely of altered blood. The vomit is black, and identical in composition and aspect with the matter ejected in hematemesis from cancer of the stomach. There is sometimes bile in the matter vomited; but that is only observed at the beginning of the attack. The urinary secretion, which is abundant, deposits altered blood-globules; and (according to Frerichs) leucine and tyrocine could also be detected in the deposit. The same observer 1 Blachez (P.):—Be l’Ictere Grave : these de concours pour l’agregation : Paris, i860. MALIGNANT JAUNDICE. 307 has remarked, that in these cases the urine contains a very small quantity of urea; and pathological anatomy reveals structural changes in the kidneys similar to those which exist in the liver. There may be a recurrence of the epistaxis; and the gums are frequently covered by black sordes, and exude blood from their free margins. Jaundice may either be general, or limited to the upper half of the body, as in a case recently described by Dr. Hecker. The shade of yellow is more or less deep : and the jaundice may either be green or bright yellow, but these variations in colour are of no importance —of no more importance than the greenish brown sometimes ob- served in the conjunctive. Dr. Monneret, and other observers, have remarked, that the appearance of the countenance contrasts with the state of general prostration: the features, so far from presenting a hippocratic appearance, appear on the contrary quite expanded. The two leading symptoms then are the hemorrhages and the yellow colour: when the patients are roused from their apathy to answer questions, they sometimes complain (as did our patient in Saint-Bernard’s ward) of muscular and articular pains, which are probably nothing more than the febricula so common at the com- mencement of pyrexise and toxsemic diseases. They seldom complain of headache: sometimes, they have attacks of suffocation, sighing, and irregular respiration. On examining the different organs, a variety of phenomena are generally observed, all of which are important. The jaundice solicits first of all an examination of the liver. According to Dr. Frerichs, in the majority of cases, there is pain at the pit of the stomach and in the right hypochondrium, as you see in our patient in Saint-Agnes’s ward (whose history I shall forthwith relate to you). Palpation and percussion increase the pain; while at the same time, they generally, but not always, enable us to ascertain that there is considerable diminution in the volume of the organ. This assertion of Frerichs is all the more remarkable, that a great many cases occurred in women at the sixth, seventh, and eighth month of preg- nancy, a stage of gestation at which we know that there is a notable augmentation in the size of the liver, irrespective altogether of any morbid condition. There is, however, nothing doubtful in the state- ment of Prerichs, for the majority of the patients died from the disease, and on posthumous examination of their bodies, the liver was 308 MALIGNANT JAUNDICE. found to be atrophied.1 But many of the cases of Budd,3 Hanlon, and Monneret, as well as the anatomo-pathological history of our patients in Saint-Bernard’s and Saint-Agnes’s wards weaken the generalisation of the assertion of the Berlin professor. In these cases, the liver had retained its normal volume; while on the other hand, in the case related by Dr. J. Worms, it had lost nearly one third both in size and weight. From all these facts, it may be concluded, that diminution in the volume of the liver has only a relative importance, inasmuch as it is a symptom which is wanting in numerous cases. But pain in the epigastric and hypogastric regions has a greater degree of importance, as it is almost always met with, and is the consequence of the morbid action which is progressing in the liver, and sometimes in the mucous coat of the stomach, so frequently the seat of profuse hemorrhage. It is surprising that observers have not more often noted the presence of pain in the spleen, pathological anatomy having demon- strated that that organ has often in this disease been the seat of organic changes, or at least of passive congestion as is observed in septicajmia. Notwithstanding the existence of dyspnoea and irregular respira- tion, nothing morbid was discovered in the lungs or heart; and the autopsy confirmed the conclusions formerly established by clinical experience, viz., the general absence of lesions in these organs. In this way, we become reduced to the necessity of referring these functional disturbances to an affection of the splanchnic nervous system. It is well, however, to bear in mind, that Ilecker, following other observers, has explained the sluggishness of the circulation by the existence of fatty degeneration of the muscular fibres of the heart. As to bronchial or pulmonary hemorrhages, they are not the result of a special pathological change in the lungs, but of passive congestion of all the organs. I have often compared malignant jaundice with the pyrexise : yet every pyrexia has as one of its chief elements acceleration of the pulse; while on the contrary, in many cases of malignant jaundice, there is only a slight elevation of the pulse, or sometimes even a fall 1 Frerichs :—Traite Pratique des Maladies du Foie : traduit de l’Allemand par les docteurs Louis Dumenil et J. Pellagot, 2rne edition. Paris, 1866. 2 BUdd :—On Diseases of the Liver. Third edition : London. MALIGNANT JAUNDICE. 309 below the usual standard. I do not include in this remark the quickening of the pulse which occurs just before death, for that is a phenomenon which belongs to the last agony. The inconsiderable frequency of pulse in typhoid jaundice depends upon the general prostration of functional and organic life : the whole economy being prostrate, there is no febrile movement, because there is no tendency to reaction. The original change in the blood, and the disor- ganisation of the liver (when it exists), are of such a nature, that it is impossible for the reflex and sympathetic actions to be produced, on which depend acceleration of pulse, increase of temperature, and in lieu of them, we have sweating or copious diuresis. It appears that the action of the morbid principle, whatever its origin, whether in or external to, the individual, is such that it does not impart any power of reaction to the organism. But notwithstanding this absence of fever, properly so called, malignant jaundice is not the less appropriately grouped with the pyrexise, with typhoid fever, and with yellow fever, which are only special septicsemics, with or with- out special febrile reaction, according to the intensity of the cause, or the resistance of the individual patient. Likewise, the hemorrhages are passive in typhoid jaundice, and similar in character to those observed in malignant smallpox and malignant scarlatina, the hemorrhage in these pyrexise being fre- quently one of the signs of their malignity. Many authors believe that in malignant jaundice there are two stages : to one of them, belong jaundice, hemorrhages, and the almost total absence of febrile reaction : to the second stage, belong nervous symptoms, convulsions, delirium, and coma. When we study the theories of these authors, we find that they regard the nervous symptoms as consequent upon secondary poisoning, or on biliary poisoning of a simple or complex kind. We shall afterwards discuss this interpretation, which I believe to be too absolute: at present, I only wish to remark that, if there exist a first stage, the epiphenomena constituting the second stage seem to me to be the consequences of the progress of the malady. I shall then briefly analyse the different nervous symptoms which supervene— sometimes, on the third or fourth day of the disease, and at other times, not till one or two weeks from the commencement of the jaun- dice and hemorrhages. The delirium, though generally of a quiet character, may be accompanied by excitement, according to the habits or idiosyncrasy 310 MALIGNANT JAUNDICE. of the patient: generally, it begins during the night, and continues with only slight intermissions: soon, as in all grave diseases, it is succeeded by coma. I have already said that the patients are seldom attacked by convulsions : general convulsions, when they do occur, have a tendency to assume the eclampsic form. Dr. Monneret observed a case in which they occurred only on one side, but in that case, at the autopsy, it was found, that there was hemorrhagic meningitis. Death is the usual termination of malignant jaundice; but cases terminating in recovery have been observed by Hanlon and Griffin. In these cases, the nervous symptoms were mild, and of short duration. It is not stated whether any critical phenomena occurred in these cases. There are also other recorded cases which demon- strate the possibility of a propitious issue in this disease : Professor Monneret relates the case of a medical student whom he attended, who completely recovered from an attack of idiopathic hemorrhagic jaundice. Baudon relates a case of typhoid jaundice : he says that in this exceptional case, “ there was inflammation and enormous enlargement of the parotid gland, which extended from the right temple to below the inferior maxilla. Probably, the parotitis was critical, for from the time of its appearance, there was marked amendment.” Dr.Carville's memoir, just published, on an epidemic of malignant jaundice, observed by him in the summer of 1859, would seem to show that typhoid jaundice is a less formidable disease than has been supposed.1 Of 47 patients who had idiopathic hemorrhagic jaundice, only 9 died. This was a very much less mortality than that hitherto met with in sporadic malignant jaun- dice. The mere announcement of this result is so entirely opposed to existing opinions in general pathology, that one is inclined to believe that some important data relating to the cases escaped observation. Before treating of the nature of the disease, it is necessary to review the principal anatomical lesions of malignant jaundice. So great has been the part assigned in this disease to lesion of the liver, that it has been called “acute yellow atrophy of the liver,” and “ diffuse hepatitis.” The liver, in truth, is often the seat of a more or less generalised alteration of the hepatic cellules: according to Bokitansky and ' Carville : Archives Generates de Medecine for August, 1864. MALIGNANT JAUNDICE. 311 Frerichs, the walls of the cellules are destroyed: they say, that it is hardly possible to recognise even a few isolated nuclei in the affected parts, a fact which may depend on their being lost amid the amorphous and fatty matter. There must be both destruction of the structure of the cellules and an excess of fat. When the lesion is less advanced, some hepatic cellules remain; but they are infiltrated with fatty matter and biliary pigment. The structural alteration of the liver is never uniform throughout the entire parenchyma, there being healthy portions amid those which are diseased. The alteration of structure advances with greatest rapidity in the left lobe; and this lobe also often presents a yellow, ochrous appearance on the surface and where a section is made; whereas, in the right lobe, it is only in isolated portions that the altered appearance is seen. Sometimes, however, the destruction of the cellules is so gene- ralised, that the weight and volume of the organ have decreased to the extent of one third or even two thirds : the liver is then diffluent, and of a yellowish colour, having no longer the usual granitic appearance : moreover, its fibrous envelope, the capsule of Glisson, appears too large, and exhibits numerous wrinkles. The German school of pathologists has erred in applying the term “ atrophy” to this alteration of the cellules; and M. Ch. Robin has done well to point out that there exists destruction, and not atrophy of the hepatic cellules, with or without change in the volume or con- sistence of the liver.1 The actual state of scientific knowledge does not enable us to make any positive statement as to the condition of the hepatic vessels or parenchyma, except that there is softening and fatty infiltration : sometimes, the softening must to a certain extent be attributed to putrefaction. The biliary ducts are not engorged with bile; and it is only in exceptional cases, that the existence in the gall-bladder of a large quantity of bile has been ascertained. The facts which I have now stated in relation to the destruction of the hepatic cellules are quite in accord with the microscopic exa- mination of the liver of our patients in the Saint-Bernard's and Saint-Agnes's wards, and of the patient of Dr. J. Worms, whose case was so kindly communicated to me by that gentleman. But let me add, that Hanlon, Griffin, Budd, Monneret, and Robin, have not only ascertained that the physical characters of the liver may be 1 Robin (Charles) :—Note sur l’etat anatomo-pathologique des Elements du foie dans l’ictere grave. [Memoires de la Socieie de Biologie, 1857, p. 9.] 312 MALIGNANT JAUNDICE. normal, but likewise, that histological examination gives, in many cases, only negative results. It is unnecessary to insist at length upon the importance of such unquestionable scientific facts as those now mentioned: if malignant jaundice can exist without any lesion of the liver, such lesion is not necessary for the production of the disease, and, a fortiori, cannot be the cause of the change in the blood. Lesion of the liver, then, has only an importance which is se- condary, and may be compared to the alteration observed in the kidneys, the spleen, and sometimes in the muscular fibres of the heart. Frerichs, and before him Budd and Spaeth, noted a fatty state of the renal parenchyma: the straight and flexuous tubuli, when examined under the microscope, presented a more or less desquamation, and their epithelium was either destroyed or charged with amorphous and fatty matter. Observe that in malignant jaundice, the urine has been found deficient in urea, and the blood to contain it in excess; while also, there existed albuminuria apart altogether from renal hemorrhage. These clinical and anatomical facts show, that sometimes the renal function is at fault, as so often happens likewise in malignant diseases, fevers, and many toxsemic affections. The spleen is often increased in size, soft, and very friable. Lesions met with in other organs, I regard as of secondary import- ance : the majority of them depend upon stasis of the blood and hemorrhages into the parenchyma or mucous membrane, phenomena most frequently observed at the base of the lungs or in the mucous membrane of the stomach or intestinal canal. No important lesion of the nervous centres has been observed; and the meningeal hemorrhage, to which I have already referred, was merely an occur- rence consequent upon the general hemorrhagic tendency. But the blood which is found in considerable quantity in the venous system, particularly in the venrn cavrn and right side of the heart, has always presented the characters which it exhibits in septsemic affections : it has been of a pitchy, of a dull violet colour, diffluent, and has (accord- ing to Frerichs) contained leucine and urea in appreciable quantities. The heart was often very flaccid; and Dr. Flecker, as well as Dr. Peter (in a recent autopsy), detected granular and fatty degeneration of the primary muscular fasciculi. I have just been saying, that atrophy of the liver is a structural change which is likewise met with in numerous cases of blood- MALIGNANT JAUNDICE. 313 poisoning. There are indeed some cases of toxsemia, accompanied by jaundice and numerous hemorrhages from the mucous membranes and into the parenchymata, which in respect of symptoms, not less than lesions, resemble malignant jaundice, and leave, even at the anatomical table, the mind in a hesitating state. The following case, which has just come under our notice in Saint-Agnes's ward, is one of those calculated to leave the diagnosis in suspense. On July 26th, a man, aged thirty-two, was admitted to our hospital service with slight cyanosis of the face and contraction of the superior extremities. He had been suddenly seized, twenty-four hours previously, with painful cramps in the calves. A little later, very profuse bilious vomiting supervened, which continued all night. Next morning, the cramps had ceased in the legs, and the painful contractions were experienced in the superior extremities. On the morning of the 27th, you saw the man of whom I am speaking: he then had slight cyanosis of the face, an exceedingly feeble, whispering voice, a very remarkable state of contraction in the superior extremities, particularly in the right, which was the seat of great pain. There was no albumen in the urine. On the 28th, forty-eight hours from the first manifestation of the symptoms, jaundice appeared : and there was persistent pain in the right hypochondrium. On the 29th, I remarked to you that there was an increase in the intensity of the jaundice; and that during the morning, slight epistaxis from the right nostril had occurred—the nostril by which, according to Galen, epistaxis takes place in affections of the liver.1 The liver was enlarged, so as to pass three finger-breadths beyond the ribs : it was hard, and pressure upon it caused pain. There was acute persistent pain in the epigastrium. The patient said that he felt worse; and his condition was evidently aggravated. The pros- tration of strength was absolute: the voice was very feeble and languid; and he complained of headache. Throughout the whole spinal column, from the neck to the loins, he experienced very acute pain. There was some contraction of the muscular masses of the neck and spine, which were painful on being pressed : an increase of pain was occasioned by raising the inferior extremities, previously extended, a circumstance which indicated irritation of the spinal cord. The pulse was 112 : respiration was loud and quick. Some 1 “ Oportet autem per directum fluere sanguinem, ex dextra quidem nare hepate affecto ... ex sinistra autem liene.” [De Crisibus, Lib. III.] 314 MALIGNANT JAUNDICE. fine rales were heard at the base of the right lung; but on account of the patient's debility, auscultation was difficult. The remainder of the day was passed in a state of somnolence. The patient had the calm of stupor, but no delirium : he realised the gravity of his con- dition, and said that he was dying. The vomiting and contractions ceased. His slumber was easily broken by making such pressure on the arm as interrupted the venous circulation. Moreover, he gave indications of suffering acute pain when he was touched on the abdomen or chest, and still more, when touched on the neck. He swallowed slowly, and with difficulty. He died at one in the morning, without a struggle, without having lost consciousness, and without having had any recurrence of nasal or intestinal hemorrhage. At the autopsy, made by Dr. Peter, then my chef de clinique, a sanguineous effusion was found at the lower part of the mediastinum: the blood wras black, and encysted in the neighbourhood of the pericardium. Blood was also infiltrated in the whole extent of the mediastinum. The subjacent cellular tissue of the parietal pleura was infiltrated with blood, so as to give to the entire extent of that membrane a blackish red colour : but there was no hemorrhagic transudation into the pleural cavity. At the summit of the left lung, there was hemorrhagic effusion, encysted by a false membrane: this sanguineous collection measured eight by four centimetres. There was no pleuritic effusion in the left side. Into the right pleura, there was slight sero-sanguinolent exudation. Under the diaphragmatic pleura, on both sides, there was an exudation of blood. In respect of size, the heart was normal; but it was flabby and very pale. The valves were healthy. The spleen was twice its natural volume : it was friable, but not diffluent. There was hemorrhage from the hilum. Submucous and interstitial hemorrhage occupied the whole of the great cul de sac of the stomach, without there being any rupture of the mucous membrane or effusion into the interior of the organ, which was in other parts quite healthy. The small intestine was absolutely healthy, except that in its lower third, where psorenteria existed, the solitary glands appeared on the surface like so many millet seeds. Beyer's glands were healthy. The liver, which was of augmented volume (particularly in the right lobe), was yellow, anaemic, and fatty. MALIGNANT JAUNDICE. 315 The kidneys, particularly their cortical portions, were ansemic : in size, they were normal: the suprarenal capsules were healthy. The pancreas was everywhere injected and friable: there was no hemorrhage into its peripheric cellular tissue. The parietal peritoneum was much injected, but was not the seat of hemorrhage. The brain and spinal cord were healthy. Neither the cerebral nor medullary meninges were injected. Microscopic examination disclosed fatty degeneration of the liver: the hepatic cellules were irregular in shape, being swollen out by little drops of fat, which were soluble in ether. Others were granular, but changed though the cellules were in form, they had not disappeared, as in acute atrophy of the liver. Granular alteration of the kidneys, particularly of the cortical substance, was observed : there was fatty infiltration of the cellules. Granular degeneration of the muscles of the heart, the normal striated arrangement of which was much less evident than usual, at certain points had quite disappeared. The great pectoral muscles had undergone a similar change. Frequent hemorrhages occur in cases of poisoning with metallic poisons, such as the salts of antimony and arsenic : fatty degeneration is likewise met with in these cases, and in poisoning with phos- phorus ; but the hemorrhages and fatty degeneration of the liver and kidneys are, as we have seen, the consequences or the charac- teristic lesions of malignant jaundice. Now, we have been told that this man had been working for a long time in a manufactory of arsenious acid, but had discontinued that employment for a year. It could not, therefore, be supposed that the metallic poison had remained all that time in the system without manifesting its effects. On the other hand, this man was addicted to alcoholic excesses : these habits rendered him subject to a profuse diarrhoea, which explained the psorenteria found at the autopsy; and it is likewise possible that the alcoholism was the cause of a consecutive change in the structure of the liver. Finally, this alteration may itself have been the starting-point of all the symptoms which in the aggregate receive the name of “ malignant jaundice.” We now see the category of suppositions to which we can appeal in respect of the symptoms, the etiology, and the lesions of this disease. To elucidate the question of poisoning, I caused the liver and the kidneys to be carefully subjected to a chemical examination, MALIGNANT JAUNDICE. when, as I expected, no trace of arsenic was detected. Nor was there any phosphorus found. It appears that this man succumbed under an affection which commenced with choleraic symptoms and cramps, after which the jaundice supervened. Under these circum- stances, my diagnosis was—malignant jaundice. At the autopsy, we found lesions which explained the jaundice and the death, but threw no light upon the genesis of the symptoms. Malignant jaundice may occur at all ages; but the subjects of most of the published cases are adults. I do not know of any case occurring in infants of what can properly be called malignant jaundice. This is a point regarding which I must make some remarks, so that I may not seem to be opposed to a statement made in a contrary sense to the Societe Medicale des Hopitaux. There is, it is true, a kind of jaundice in infants depending on retention of bile, regarding which Dr. Porchat has written an excellent work; and which had before been the topic of very important clinical remarks by Burns, Gardien, Underwood, and Rosen. According to all of these authors, the jaundice of very young infants terminates in death, when there is a continuance of constipation for more than three or four days : they, consequently, recommend the administration of purgatives with a view to cause the flow of bile into the intestine. But none of the authors whom I have quoted, have described the occurrence of typhoid symptoms in these cases, and most of them are silent on the etiology of the retention of the bile. Dr. Porchat, in his thesis (1859), after remarking that the etiology of jaundice in very young infants has been little studied, proceeds carefully to investigate the causes of this malady. In a first category of cases, anatomical examination demonstrated to him that the biliary ducts were free, but that the bile, thick and abundant in the gall-bladder, had been unable to reach the duodenum, as was proved by the whitish appearance and chemical analysis of its contents. I11 a second group of cases, the biliary ducts were absent, or the ductus choledochus was represented by a fibrous cord. In all the cases, the bile was secreted, but not excreted; and consequently, it must have been absorbed by the veins and lymphatics, as was proved by an examination of the blood, urine, and parenchymata, which were tinged by the colouring matter of the bile. Retention of the bile, not dangerously poisonous to the adult, is sufficient to cause serious consequences to very young infants. Observe, Gentlemen, that this is not a matter of mere hypothesis: MALIGNANT JAUNDICE. 317 comparative pathology, and the experiments of Claude Bernard1 have proved, that retention of bile proves fatal to puppies after some days, while adult dogs do not succumb from complete obstruction of the ductus choledochus. In 1844, Dr. Campbell3 published three cases of jaundice complicated with hemorrhage from the cord, and which terminated in death. I11 these cases, the retention of bile was the consequence either of arrest of development, or of con- traction of the excretory apparatus, or possibly of obstruction of the choledoch duct by a biliary concretion. In all the cases, the jaundice was of a very decided character: in two of them, there was umbilical hemorrhage : and in the third case, although there was no hemorrhage from the umbilicus, the infant died in a state of coma after vomiting a fluid resembling coffee-grounds. It appears then, that very serious symptoms and even a fatal termination may occur in biliary retention in very young infants, or in infants under one year of age. Cases of this nature may be ranged side by side with the very unusual cases in which the reten- tion of bile in an adult has brought on fatal consequences ; but again I say, that malignant jaundice of the adult may exist without lesion of the liver, and is never caused by obstruction of the biliary ducts. Such being the fact in relation to the fatal jaundice of very young infants, let me remind you that malignant typhoid jaundice is chiefly met with in adults. Mental depression seems to have a large share in producing it: wretchedness and excesses hardly act otherwise than as debilitating causes. Cases of this disease, collected by Hanlon and Griffin, which occurred in persons apparently quite healthy, and not seemingly suffering from destitution appeared to demonstrate to me the influence of middle courses. Two patients were pointed out by M. Herard, both of whom inhabited the same furnished lodgings, were attacked at an interval of only a few hours, and both died at the Ilopital Lariboisiere. I propose to make use of these facts to demonstrate the nature of the disease. As for depression of spirits—and to this point I revert intentionally— there can hardly be any doubt as to the reality of its consequences, particularly if we remember the importance which the older authors 1 Bernard (Claude) :—Lejons de Physiologie Experimentale appliquee a la Medecine:—Le?ons sur les proprietes physiologies et les alterations patlio- logiques des liquides de l’organisme. 1859. 2 Campbell :—British and Foreign Medical Review. T. XX, p. 553. 318 MALIGNANT JAUNDICE. attached to low spirits produced by diseases of the stomach and liver, recalling to mind their action on the nervous system. Finally, let me add, that the cases of Frerichs,1 in opposition to those of Spaeth, seem to show that pregnancy may be a cause of malignant jaundice; for in twenty-two women attacked by it, eleven were with child. I now come to consider the nature of malignant jaundice : I shall with brevity examine critically some of the different theories which have been advanced. Bokitansky and many others are satisfied to ascertain the anatomical lesion, but Henoch and Dusch have endea- voured to explain the destruction of the hepatic cellules by enun- ciating the double hypothesis of the existence of paralysis of the biliary radicles and of the hepatic vessels. It is not necessary to discuss fancies of this description : let me merely remark that Dusch believes that the elements of the cellule being dissolved, are absorbed, and so produce secondary toxmmia, giving rise to the nervous symptoms which characterise the second stage of malignant jaundice. Bright was the first to raise the question, whether the hepatic lesion was the primitive phenomenon or only a consequence; but he proceeded no farther, and regarded the alteration in the structure of the liver as an inflammation of the organ. Budd, who had observed many cases of different kinds of malignant jaundice, derived, from his clinical experience, numerous objections to the different theories which had been previously emitted. He stated that malignant jaundice could not be merely an inflammatory affection, because hepatitis was not generally followed by the characteristic symptoms of typhoid jaundice. The general symptoms could not be the con- sequence of mere retention of bile, because protracted jaundice is constantly being met with unaccompanied by the slightest nervous disturbance. Moreover, as I have already remarked, retention of bile is inadequate to lead to disorganization of the hepatic cellules. Therefore we may conclude with Budd, that typhoid malignant jaundice is not the immediate result of biliary retention, and that the alteration of the hepatic cellules, when it exists, is dependent on a different cause. But, admitting that the retention of bile does not lead to serious consequences in respect either of the liver or of the general system, we must look elsewhere than to the liver (which 1 Frerichs Op. cit., pp. 261—262. MALIGNANT JAUNDICE. 319 need not be the seat of any lesion), for the cause of typhoid jaundice. The symptoms of typhoid jaundice, their sudden appearance, particularly the signs of moral and physical prostration resembling the symptoms which usher in fevers and toxmmic affections, lead to the belief that a poison or morbific germ which has either entered the organism from without, or been generated within it, is the cause of all these disturbances, which first appear in the nervous system, then in the liver, spleen, kidneys, and heart. Nearly similar phenomena are met with in dothinenteria : a feeling of general discomfort, and a prostration of strength mark the beginning of the malady, the moment that is to say, when the morbid poison begins to take effect: subsequently, the disease manifests itself with the usual train of symptoms according to the form it assumes; and the special intes- tinal alterations are secondary results. The morbific poison may enter the system from without, that is to say, may have its origin in vicious hygienical conditions. The cases of Hanlon and Griffin (quoted by Graves and Budd), and those observed by Dr. Herard in the Hopital Lariboisiere, justify the con- clusion, that the insalubrity of certain habitations, particularly during very hot weather, may originate a morbific element analogous to that which engenders typhoid fever through overcrowding, and to that which causes yellow fever and bilious fever in tropical climates. Here, let me remind you that Dr. Carville’s memoir seems to prove that malignant jaundice may occur in an epidemic form. The source of the morbific poison may be in the individual himself, when he has been long subjected to physical fatigue and moral depression. The equilibrium of the functions may be so modified, that as a sequel of some determining cause of variable nature, the liver may become the seat of a functional lesion, and typhoid jaundice may declare itself. Recall to mind the case of the patient sent in by Dr. Rirmin, and who occupied bed 30 of Saint-Bernard's ward. This woman, aged fifty-three, had become reduced to great misery, through pecuniary losses and great mental distress. Bor a fortnight preceding her admission to hospital, she had no longer spirit left to work : she felt tired, and had no appetite. Her medical attendant, at his first visit, found that she had both typhoid fever and jaundice. She died in a comatose state some days after admission to hospital. It is probable that unfavourable hygienical conditions and profound sorrow had brought about an alteration in the whole 320 organism ; and that from this change proceeded the jaundice and the typhoid symptoms. There was no organic lesion found in the liver or intestinal canal. In similar cases, the presence of jaundice is sufficient to prove that the hepatic functions are disturbed • and in some patients, the functional disturbance might in itself lead to serious consequences. The passage of the bile into the blood, which does not generally produce much inconvenience, may, in delicate subjects, be the starting point of fatal consequences. This was observed by Graves, who, to prevent the nervous symptoms liable to occur in such cases, lost no time, as I have already told you, in favouring elimination of the bile by administering diuretics and sudorifics. There is more reason to dread nervous complications when per- cussion reveals diminution in the volume of the liver, that is to say, acute yellow atrophy of the organ. Budd, indeed, while he admitted that the poison which engendered the nervous symptoms at the beginning of the icteric attack might suffice to produce secondary nervous symptoms, thought that some share must be attributed to the lesion of the liver, because the disorganised anatomical elements by being absorbed, augment the action of the original poison. To all the other morbific causes, primary or secondary, must be added disturbance of the function of hepatic hematosis, as has been judiciously observed by Professor Monneret. Bile is not the only secretion of the liver. Into the liver opens the entire system of the vena porta : in it, the portal blood demands a special elaboration indicated at its exit from the liver, by increase of its temperature, and its containing hepatic sugar. This process does not arrest the blood-forming function of the liver, as is shown by comparing the blood of the vena porta with that of the subhepatic veins. To form bile, the liver removes from the blood all elements which if not eli- minated must prove injurious to the system. Thus we see that the liver, which Galen regards as an organ of hematosis (for the same reason that the lungs are so regarded), cannot be suddenly and permanently annihilated by the disease, without the suppression of function thereby induced acting injuriously upon the composition of the blood, and producing a corresponding influence upon the nervous system. Now, if the chronic and slowly progressive alterations in the structure of the liver lead to no serious modifications in the composition of the blood and functions of the nervous system, neither can any such modifications arise in the MALIGNANT JAUNDICE. MALIGNANT JAUNDICE. 321 cases in which hepatic hematosis is suddenly and permanently suppressed. It follows, therefore, that malignant or typhoid jaundice (also called fibre jaune nodr as) is a general disease, similar in its nature to the pyrexite, characterised by disturbance of the nervous system, and by structural changes of the liver, spleen, and heart, which changes are special, though not invariably present. It also follows, that this disease is nearly always fatal; and that it appears to be the conse- quence of a poisoning originating sometimes in the surrounding medium, and at other times in the organism itself. Gentlemen, I must enter an emphatic protest against the doctrine that there exists a similarity between malignant jaundice and yellow fever. I had, as you know, an opportunity, in the early part of my career, of seeing a great many cases of yellow fever; and when I afterwards met with cases of malignant jaundice, I had no difficulty whatever in recognising the difference between the two diseases. There is one palpable point on which it is easy to agree; that is, the absence of jaundice in yellow fever: in upwards of a thousand yellow fever patients who came under my observation, not one had jaundice. I recollect two soldiers affected by jaundice being ad- mitted to the military hospitals which I visited daily during the epidemic: the attendants in the wards, though they had never been instructed how to discriminate the one disease from the other, were perfectly satisfied that the two classes of patients were not suffering from the then epidemic yellow fever, and the medical officers without the least hesitation adopted the same view : the tint of the skin was itself sufficient to show the existence of an entirely different disease. When a more minute scrutiny had been made into the distinctive phenomena of the two diseases, there remained no longer room for any one to entertain the slightest doubt on the subject. When we proceed to compare malignant jaundice with yellow fever, looking to the symptoms and anatomical lesions irrespective of the jaundice, it seems surprising that cautious and experienced phy- sicians should regard as similar two affections which present such different characteristics; but the astonishment ceases when it is borne in mind, that those who have instituted this comparison never saw the epidemic, and that those who had studied yellow fever, only knew by books the malignant jaundice with which they com- pared yellow fever. 322 In yellow fever, the extreme violence with which the fever sets in, the great severity of the pains in the loins, the indescribable dis- comfort of which the patients complain, can only be compared to the similar symptoms which usher in an attack of confluent smallpox; while in malignant jaundice, the initial period is rarely invested with such violent characteristics. Hemorrhages from the stomach and intestinal canal are sometimes observed in malignant jaundice, but they are not profuse; whereas, in yellow fever, black vomit, and dejections of a similar kind are seen in nearly all the fatal cases, a circumstance to which the disease owes its names “ vomito negro” and “ vomito prieto.” Black vomit, which in one of the diseases is of rare occurrence and small importance, is a principal characteristic in the other. It is now held that real jaundice [jaunisse reelle\—the affection properly called jaundice—has an almost invariable character in malignant jaundice \ictere maliri\ ; and that in it the urine always contains a large quantity of biliverdin, and acquires a still deeper colour on the addition of tincture of iodine and nitric acid, whilst icterus [ictere\ properly so called, is never seen in yellow fever, in which disease the urine is as red as in acute rheumatism, is often suppressed, and never contains the colouring matter of the bile. It is my conviction then, that the similarity which certain authors have endeavoured to establish between the two diseases is strained ; and can only be maintained by physicians who have not made them a subject of comparative study. Malignant jaundice can hardly be confounded with any other disease, particularly under the climacteric conditions in which I have observed it. Typhoid fever complicated writh jaundice, a com- plication, however, which is very unusual, can hardly lead to a mistake, except during the first days of the attack : but the intensity of the icteric tint, and the various hemorrhages, particularly those from the gastric and intestinal mucous membrane, which take place during the early days of jaundice, do not long allow the nature of the case to remain in doubt. I should be going beyond the limits of my subject, were I to dwell at length upon the differential diagnosis of malignant jaundice and the malignant bilious fever of tropical countries. It is necessary, however, that I should here mention that the two principal conditions which constitute malignant jaundice, the yellowness and the hemor- rhages, are also met with in the bilious fever of the tropics, which is MALIGNANT JAUNDICE. MALIGNANT JAUNDICE. 323 distinctively characterised by its more or less marked remittent type, and repeated rigors. Though in the hepatitis of our climate, as in malignant jaundice, there is a yellow colour of the skin, and frequent hemorrhages, we learn, from clinical observation, that in hepatitis, the yellow colour of the skin is less intense, and shows itself more slowly; and that the hemorrhages are less profuse. On the other hand, the fever is more violent than in typhoid jaundice. The treatment of idiopathic hemorrhagic jaundice has not gene- rally been successful. It appears, that observers have almost always treated the symptoms: hemorrhages have been combated by the mineral and vegetable acids, and the vomiting by iced drinks and gas-charged beverages. Preparations of cinchona have seemed to sustain the strength, and retard the death of the patient. Dr. Ilerard prescribed, with temporary benefit, emetic doses of ipecacuan to one patient, who, however, died on the eighth day of the disease. Perhaps purgatives, and in particular saline purgatives, which have a special action on the liver, may be prescribed with advantage. In pursuing this plan, we should be adopting the treatment of yellow fever successfully followed in America, and should also be responding to the indication supplied by constipation, imitating nature, moreover, which often selects the intestinal mucous membrane as the medium by which to eliminate poisons. LECTURE L XXXI. SYPHILIS IN INFANTS. Sypiiilts in the Fcetus :—Abortion : Pemphigus : Suppuration of the Thymus Gland and Lungs. Syphilis in the Infant :—Pox rarely shows itself before the second week, or after the eighth month.—Slow Form : Subacute Form : Symptoms : Coryza : Fissures : Ulcerations and Mucous Crusts at the mouth, anus, and folds of the skin: Cutaneous Eruptions, Roseola, Sfc.—Peculiar Tint of the Face : Characteristic Phy- siognomy of the Syphilitic Infant. — Caliexia. — Visceral Lesions.—Pathogenic Conditions of Syphilis in the Recently Born Infant. Hereditary Syphilis :—Transmission by the Mother: by the Father. Acquired Syphilis.—Syphilis may be transmitted to Nurse by Syphilitic Nursling.—Has the Nurse been infected in coitu, or by her Nursling ?—Transmission of Syphilis by Vaccination.— Transmission of Syphilis from the Foetus to the Mother.—Treat- ment of Congenital Syphilis. Gentlemen :—To-day, I enter upon the discussion of one of the most delicate and most controverted questions in pathology; and although it is my intention to confine myself within its narrowest limits, I neither wish to conceal from myself nor from you that it is a subject beset on every side with difficulties. Syphilis, in whatever manner it may be engendered in the system, holds the first rank among those affections the study of which belongs exclusively to clinical science, and does not admit of assistance from any other science. We are shut out from experiments on the lower animals; and experiment limited to the human species, is, as SYPHILIS IN INFANTS. 325 you know, liable to a thousand sources of fallacy. It is perhaps by taking syphilis as an example, that one would arrive more certainly at the way to give an account of curative methods and pro- ceedings, and of the scientific value of medicine when left to its own resources. Impressed though I am with the importance of this study, con- vinced though I am of its profitable nature, even when problems are discussed for the solution of which the elements do not exist, I have shrunk from pursuing it, possibly from a sense of the magnitude of the task. I shall not, therefore, discourse to you here regarding syphilis in recently born infants : you have had very frequent oppor- tunities of observing it in a state of full development. Never- theless, while I thus restrict myself, I cannot but look back regret- fully upon the field which I have abandoned. The special hospitals, both those for men and for women, present you with the most ample materials, and your teachers second your inquiring zeal; but in addition to these precious opportunities, there are others, among which are our clinical services, where in place of the rule you will find the exception—a system of instruction not less necessary. Observe how the science of syphilis is constituted, and how the doctrinal revolutions accomplished under your eyes are organised. In the hospitals for syphilitic males, laws are laid down with an authority which facts do not oppose. The dogmatism of observers is sincere, because their conclusions are derived from cases occurring under similar conditions. Science is conducted upon this basis, till the time comes when the physicians placed in another sphere, being brought into contact with doubtful cases, raise objections, and at last—as always happens—pass from hesitation to formal opposition. Were examples required to illustrate a subject so familiar to you, infantile syphilis would itself supply them of the most conclusive kind. In that domain of science, opinions resting upon foundations of the least possible stability have held their ground, because there was an unwillingness to break the unity of a theory; and Hunter himself, despite his great talents, resolutely formulated principles strikingly contradicted by the very facts upon which he sought to establish them. It would be difficult for you to make a complete study of pul- monary tuberculisation in an hospital devoted to phthisis; and in 326 SYPHILIS IN INFANTS. the same way, lock hospitals, in which only confirmed cases of syphilis are received, do not exhaust the category of observable vene- real cases. In these wards, Gentlemen, you are placed in the most favour- able circumstances for studying syphilis as it occurs in early in- fancy. In juxta-position with recently born infants presenting the most characteristic symptoms of the disease, you find others affected with uncertain eruptions, and others, again, in whom there are exanthematous and ulcerous lesions of great gravity, regarding which there cannot exist even a suspicion of syphilitic infection. It is well that you should profit by this instructive aggregation of cases : and the remarks which I am going to make to you will origi- nate from our surroundings—from the cases which we observe together—for I attach great importance to keep you in a field of observation which is real life. Far from confining myself to the exposition of established opinions, I shall enter upon unsettled questions, upon risks of wrong conclusions, and upon unsolved problems, because there are circumstances in which it is worse than a mistake—it is a fault—for a physician to arrive prematurely at a conclusion. To begin, let us consider the recently born syphilitic infant, reserv- ing the more obscure questions of pathogeny. Syphilis may attack the infant during intra-uterine life ; or it may not manifest itself till after birth, in which latter case, there are no signs at birth of the disease, the germ of which exists, and will develope itself sooner or later. In the second case, the entire process of evolution takes place under our eyes: we see the disease in its very beginning, and we follow it through all its phases. In the first case, on the other hand, the commencement escapes our observation, the progress is uncertain, the diagnosis more dubious, and the description less precise. The accoucheurs of former times stated, and modern practi- tioners have confirmed the fact, that syphilis of parents, at least syphilis of the mother, is a frequent cause of abortion. It has been said that this predisposition which causes syphilis has been exag- gerated. I do not know the conclusions which unattainable statis- tics might justify, but I do know, and hesitate not to affirm, that when you are called in by a woman in whom premature labour has become habitual, you would do wrong were you not to regard SYPHILIS IN INFANTS. 327 venereal contamination as among tlie supposable causes of miscar- riage, causes of which you ought to make a list on which to adjudi- cate, before you form your opinion. But it is not enough, unknown to the family, to have inscribed syphilis as one of the probable causes to be successively eliminated one after another: it behoves you to inquire, whether this cause was uncertain and incomplete, or wdiether it authorised such a sup- position. To say positively that repeated abortion is often of syphilitic origin is to say too much and too little. Generally, labour takes place very nearly at the full term, and terminates in the birth of a dead child. When the foetus is born alive, and viable in proportion to its age, w'hen the too early accouchement is entirely attributable to the mother, there is no ground for including syphilis among the conditions, in point of fact so obscure, which have curtailed the duration of pregnancy. Maternal syphilis does not appear, accord- ing to the most complete information which we possess, to extend its influence to the vitality of the placenta; and I am not acquainted with any lesion of the placenta possessed of an undoubted specific character. And yet, we may ask, which we could not have done some years ago, up to what point is this immunity absolute ? Syphilis was formerly regarded as comprised within a circle formed by a small number of symptomatic indications localised in the skin, or in the mucous mem- branes conterminous with the skin, and extending, but slowly, to the osseous tissue : it was supposed not to invade the splanchnic organs. The placenta did not seem to be more susceptible than the liver, spleen, or lungs of a venereal degeneration which had not been directly observed, and wras in contradiction to the ordinary laws of the disease. In the present day, a new direction has been given to scientific inquiry, and the impossible has ceased to exist: to the alterations in the integuments and bones, we have now to add parenchymatous alterations discovered by the aid of the microscope, and the exist- ence of which had been foreseen by clinical observers. In this department, nearly everything yet remains to be done. I call your attention to paths hitherto scarcely explored, being convinced that you will not think, like some persons, that it is necessary to vrait until the truth has verified research. Some problems remain for future elucidation: but it is a well SYPHILIS IN INFANTS. established fact, that the cause of syphilitic abortion is the death of the foetus in utero. Does there exist any known symptom characteristic of the affection whichk has deprived the foetus of life ?—For my part, I admit that I cannot point out to you any really significant lesion ; and I incline to the belief, that those authors who have been most explicit in a contrary sense would have done better had they imitated my reserve. You will be told about the general appearance of the still-born child, the colour of its integuments, the maceration of its epidermis, the ulcers on its body, and the hideous deformities which it presents. The more graphic the picture which is drawn, the more necessary is it to be distrustful of its representations. Once on a time, physi- cians participated with men of the world in regarding all rebellious and obstinate ulcers as venereal: it is from that period that we date descriptions undoubtedly destined to impart disastrous conse- quences to syphilis. An infant is born at or before the full term; it lives, but has con- tracted, during foetal life, a malady which at birth was already in process of evolution, and destined to prove fatal. It is to this syphilis, developed in the infant before its birth, and continuing during the first days of extra-uterine life, that some authors have assigned characters so precise as to enable them to base a diagnosis on them: I refer to pemphigus, to alterations of the thymus gland, and to pulmonary lesions. For two reasons, I shall be brief on this subject; first, because you have very few opportunities in this hospital of seeing infants at birth, and it is my plan to lecture on clinical cases which you have facilities for observing: and in the second place, because the dis- cussions regarding these specific manifestations are of a too recent date for me to require to bring them before you at great length. None of these lesions are met with at a more advanced age, when syphilis shows itself by many varied and indisputable signs: they thus possess the twofold specificity of being of a venereal character, and peculiar to the foetus. Pemphigus makes its appearance within so few hours after birth, that the preparatory stage has evidently been proceeding during intra-uterine life. The bullae, which are chiefly situated on the palms of the hands and soles of the feet, form rapidly, become filled with semi-purulent liquid, burst, and then give place to ill-condi- tioned ulcerations. The surrounding parts have a bluish colour, like SYPHILIS TN INFANTS. 329 most of the cutaneous inflammations of recently born infants. The general health is radically impaired; and there appear the usual signs of infantile cahexia, which, as you know, almost invariably ter- minate in death, whatever may have been their origin. It cannot be disputed, that pemphigus is met with in very young infants: it is an equally well established fact, that in them, as in adults, this affection is the expression of a deep-seated and radical disturbance of the system : the only question open to discussion is, whether this pemphigus is syphilitic. On the one side, it is objected, that the bullae have no specific character, neither in themselves indi- vidually, nor in the manner in which they are grouped—that pem- phigus is one of the rarest complications of confirmed syphilis—and that all the causes of pemphigus find their legitimate, and so to speak, classical place in puny recently born infants. These objections have a value which cannot be ignored: they are met by an argument which, though indirect in its nature, is not the less important. “ In most of the cases in which pemphigus exists,” says Professor Paul Dubois, “ I have been able to verify the signs of former syphilis in the parents, or to obtain from them convincing evidence that they had the disease.”1 Other observers declare that they have been less successful in their search for evidence of this kind, although they have pursued similar inquiries. The settlement of the question, therefore, must depend upon the vigour of the statistical in- vestigation. I have sometimes mentioned to you a fact, which I had the oppor- tunity of observing along with one of my professional colleagues. He called me in to see a child, about fifteen days old, in which the most precise signs of syphilis existed. The father had had a Hun- terian chancre, and secondary symptoms, of which he believed that he was perfectly cured. I told him plainly that his child had con- genital syphilis : I asked him whether he himself had not still some traces of syphilis. He replied in the negative; but nevertheless, I proceeded to investigate the case minutely, and discovered, without difficulty, exostoses of the tibia, which left no doubt as to the disease. He then told me, that fifteen months previously, his wife had been delivered, at the seventh month, of a still-born child, which he had preserved in spirits of wine. He showed me the little dead 1 Dubois (Paul): — Syphilis Congenitale. [Bulletin de VAcadtmie de Medecine, 1851 : T. XVI, p. 980.] 330 SYPHILIS IN INFANTS. body; and on its skin, I distinctly perceived numerous traces of pemphigus. So far as I was concerned, this demonstration did not amount to more than the establishing of a probability; and several physicians who participated in this indecision finally accepted a compromise. They considered that maternal syphilis had determined a sort of cahexia in the foetus, which had led to an eruption of bullae which was not specific. By accepting this too facile hypothesis, you will imprudently open a door which you will with difficulty be able to close. Support is thereby given to those who see in the cahectic diseases of early infancy, certain derivations and metamorphoses of—to use the fashionable phrase—ancestral syphilis [syphilis des ascendants]. This is a dangerous direction for theory to take—one which leads, and has led, to rash generalisations, in which imagination is substituted for observation, and all morbid manifestations are merged in one arbitrary pathogenesis. Suppuration of the thymus, and suppuration of the lungs, have furnished two observers, whose sagacity is known to you, with the materials for interesting monographs. These lesions which sometimes exist separately, and sometimes together, are of rare occurrence, and their relation to the health of the father or mother is still matter of uncertainty. That is the limit of our knowledge of syphilis in the foetus. I pass over, without remark, alterations of the liver, of which I shall afterwards have to speak to you, and syphilitic peritonitis, regarding which Simpson has said a few words.1 The only manifestations attributed to intra-uterine syphilitic taint are first of all abortion, then pemphigus, suppuration of the lungs, and still more, suppuration of the thymus. When the last vestiges of intra-uterine life have disappeared, when the infant in virtue of respiration, and particularly by its changed mode of alimentation, has passed into a new life, syphilis, till then absolutely latent, makes its existence known by signs which easily escape detection. I propose, therefore, to direct your attention to a somewhat more detailed account of symptoms. It is a law which holds good in the whole domain of medicine, that little circumstances have often a leading significance : but this fact is specially true in respect of syphilis, if any difference of degree 1 Simpson (James Y.)On Peritonitis in the Pcetus. SYPHILIS IN INFANTS. 331 as to the truth of the law can be admitted. In infantile syphilis, the diagnosis can be established only by patient inquiry into minute circumstances; and in cases of this kind, descriptions are good only when they are long. In the infant, which in coming into the world bore no certain traces of venereal infection, pox rarely clevelopes itself before the second week; and it is very exceptional for the disease to make its first appearance after the eighth month. Usually, it appears about the fourteenth or fifteenth day after birth. These dates, which I gave so far back as 1847, in a memoir which I published conjointly with my friend Dr. Lasegue,1 have been confirmed by all subsequent observers, and are in harmony with those indicated by our prede- cessors ; if we except cases of doubtful authenticity. The manifestation of the symptoms, therefore, is preceded by a more or less prolonged incubation, during which the physician cannot discover the slightest indication of the impending malady. I am well aware that the physicians of the Hopital des Enfants Malades (to whom the science of infantile syphilis owes so much useful information) believe in a sort of premonitory cahexia. There is no such condition. The doomed infant either has or has not (as the case may be) all the attributes of robust health up to the day on which the first symptoms declare themselves. I go still farther, and maintain that vigorous health does not always exercise the influence attributed to it, upon the progress of syphilis. We see infants, to all appearance in vigorous health, rapidly decline under the stroke of syphilis, while others, more puny, bear up under a similar shock. In the infant, as in the adult, two influences are in operation, viz. the activity of the disease, and the resistance of the patient; but it is difficult to estimate the power of resistance, till we know the extent of the proofs to which it is subjected. But to make this possible, it would be necessary for the infants to be of the same age, identical in apparent health, and affected with syphilis in exactly the same degree of intensity. In some, irre- spective of treatment, evolution is slow, passive, essentially chronic from the first: in others, it is active, subacute, and semi-febrile : the appearance of the patient is greatly changed, complications increase, which ultimately induce a secondary derangement of health more dangerous than the original malady. 1 Trousseau and Lasegue :—Archives Generates de Medecine, 1847. 332 SYPHILIS IN INFANTS. Bear in mind, Gentlemen, that this entirely clinical diversity of evolution is capable of supplying in respect of treatment important counter-indications; that it renders necessary certain therapeutic reservations : and that it explains why the treatment of syphilis in infants is not so common-place as in adults. The signs by which the constitutional affections are manifested are numerous, and do not occur in an order sufficiently precise to autho- rise a chronological classification. Many symptoms are wanting, and their chain of sequence is full of chance occurrences and con- tradictions. Another mode of classification, however, is available. Some of the symptoms have an unambiguous meaning, while the nature of others is open to considerable uncertainty. It is particularly to the first of these classes that I wish to direct your attention. Affections of mucous membranes conterminous with the shin are not uncommon in new-born infants. In most of the eruptions classified together under the name, more convenient than scientific, of glanders \_gourmes\ there are often lesions of the mucous sur- faces which are accessible to sight: but this can only occur when there is a very confluent state of the exanthematous eruption. It begins in the skin, whence it spreads. In syphilitic infants, the mucous membranes may be, and really are, affected, although the eruption be little apparent, not seated in their vicinity, nor even externally manifested. Coryza is one of the signs which appear earliest, and also one of those which have been best studied. The infant breathes with in- creasing difficulty by the nostrils: through the insufficiency of nasal respiration, it is embarrassed in sucking. Up to this point, there is nothing special to distinguish the specific from the other forms of coryza. Soon, there is a running from the nose, and a few drops of blood exude, but there is no true epistaxis. The secretion becomes more and more sanguinolent, without being profuse : it irritates the alse of the nose and the upper lip, causing ulcerations which become covered with crusts where dried by the external air. On making a more attentive examination, there will often be found at the angles of the alse of the nose small ulcerated fissures, already characteristic, inasmuch as they exactly reproduce the special aspect of the fissures seen in the commissures of the lips. At a more advanced stage of the disease, the bones lose their SYPHILIS IN IN PANTS. 333 support, the cartilages become eroded, without being perforated, the nose flattens, and gets a squashed appearance. The upper part, little prominent in infants, spreads out, giving a strange effect to the face. The lesions, however, do not generally proceed to this extreme degree: the progress of the structural change generally stops at its second stage: sometimes, it progresses by fits and starts, just as chronic eruptions alternately augment and diminish. The oppor- tunities after death are only too frequent of ascertaining the true nature, and different degrees of the lesions of the nasal mucous membrane. Coryza is, almost in every case, the earliest sign of infantile syphilis. The mucous membrane of the lips and mouth is, perhaps, less fre- quently attacked than that of the nose; but to compensate for this the symptoms are more obvious. We find at the orifice of the mouth, fissures, in more or less proximity to one another, radiating in the course of the natural folds of the integuments; and also rounded ulcerations, true mucous crusts, having the same seat, though not exactly the same aspect as in the adult. The striee have a cha- racteristic appearance, and are such as I have never seen except in syphilis: in proportion as their situation is distant from the labial mucous membrane, so is their size smaller. At their bottom, they have an appearance which is more or less bright red, bleeding, and gristly : their edges are finely fringed, and blackened by adhering coagulated blood. Tenacious, like all fissures which occupy con- stantly elastic parts, they often leave indelible cicatrices after reco- very. I have seen both young men and young women at the age of puberty who still had these cicatrices, stigmata, the nature of which they did not suspect. The mucous crusts are hardly ever met with except at the com- missure of the lips. They are small, thick, protruding, whitish, and have, at first sight, a diphtheritic appearance. They seldom invade the cheek. Originating within a fissure, and becoming deve- loped consequent upon an irritation irrespective of syphilis, there do not exist the same reasons for their occurring within the mouth as in adults. The mucous membrane of the pharynx ought to be carefully ex* amined, though, very often, it is not affected. By never omitting in any case, to inspect the back part of the pharynx, you will find, more frequently than the statements of authors would lead you to suppose, mucous plates occupying the anterior or posterior pillars, 334 SYPHILIS IN INFANTS. but never the posterior wall of the pharynx. On the pharynx, their appearance is not the same as at the angle of the lips : they pro- trude little, are very superficial, and having no exudation on the surface, are not liable to be mistaken for diphtheritic patches. In every case in which it is possible to suppose that the infection was received from the nipple of the nurse, importance has naturally been attached to the state of the nursling’s mouth and lips. An impression has existed, that the localisation of the symptoms, or at least their predominance at the points of contagion, must furnish valuable information. I cannot too strongly warn you against the danger of being swayed by that notion; for although you may derive advantageous indications, you may also be led into the most regrettable mistakes by giving way to the belief in question. By an exactly similar tendency, it has often been concluded, from the con- centration of lesions around the genital organs, without any other evidence, that young children have received venereal iuoculation in shameful assaults. The infection of the nursling by the nurse may take place by a single erosion; and it is not maintained that the disease has numerous centres of origin because the inoculated lesions belong to the secondary period. It is only too certain that a single chancre is sufficient to admit pox into the system, just as a labial ulceration may suffice to do the same. Many children affected with hereditary syphilis have had one or more mucous patches on the lips; but wdiat conclusion are we to draw from the fact that one or several mucous tubercles are seated at the buccal orifice ? Particularly bear in mind—and the fact is one of which I should not speak were it not often forgotten—bear in mind, that in the case of the infant, no more than in the case of the adult, does the number of secondary lesions in any particular part imply that the infection has entered by that part. The anatomical disposition of the anal orifice is similar to that of the mouth; and, consequently, you will find the same lesions as in the mouth—fissures, rhagades, oozings, and consecutive ulcerations ; but I ought to mention that the affec- tions are generally less extensive and less severe around the anus. There are other parts where the infant’s skin seems to resemble, in its structure, the mucous surfaces, and where, when under a patho- logical influence, it nearly assumes their characters. I refer to those folds in the integument, so deep in fat children, which become ulcerated, or at least irritated by rubbing, and yet more by the infil- tration of excremential fluids, and which so specially demand pre- SYPHILIS IN INFANTS, 335 cautions as to cleanliness : in these situations, fissures and ulcerations are often produced. It is prudent to beware of being misled by the deceitful appearance of simple ulcers; and it is on the hands and feet that these lesions are characteristic. I shall consider them in relation to cutaneous eruptions. I have passed in review the venereal alterations of the mucous membranes : I have assigned them the first place, because they are more expressive, and particularly because they clear up the diagnosis by their frequency, their specialities, and their importance in relation to inoculation. The constitution of women has often been compared to that of children: I cannot venture to say to what extent this comparison is valid, but here it is justifiable to some small extent. In women, as in recently born infants, the mucous membranes are, much more frequently than in men, the chosen seat of syphilitic lesions. Suffice it to remind you of the remarkable frequency of syphilitic sore throat in women. Among the cutaneous eruptions properly so called, roseola is generally the first to show itself : it is also very frequently the first to appear in recently born children. More or less generalised, occupying by preference the inferior extremities, not seen frequently on the face, it manifests itself by spots varied in form, extent, and colour. The exanthem appears and disappears rapidly: so rapid indeed is the disappearance, that before the physician arrives, it often happens that the eruption is gone. Subsequently, different eruptions appear, among which are the many forms, to describe which dermatologists have exhausted the systems of classification. Take a syphilitic infant: examine in it each kind of exanthem, the wrell-defined pustule, papule, vesicle, &c., consider the aggregate of the eruption, and you will be struck with the very special aspect of some of the eruptive lesions which solicit your attention, and will decide the diagnosis. That which makes the description given in books of venereal exanthemata so delicate and sometimes so subtile, is the desire of authors to find in each form a distinctive character. Clinically, we have a right to substitute the real fact for this dogmatism: given, a syphilitic eruption, let us put aside the non-distinctive lesions, and restrict our inquiry to the best marked lesions. The cutaneous affections which may almost be entitled pathogno- monic are those upon which alone it seems to me of any use to insist: of these, the mucous patches occupy the first rank, after which 336 SYPHILIS IN INFANTS. come squamous affections and ulcerations, which represent the second phase of the evolution of different elementary alterations, and the colour of the skin. The mucous patch, as you know, is one of the manifestations of syphilis which is most frequently observed; and yet it is one regarding the value of which fixed views are still far from having been attained. So common is it in women, that in them, there is scarcely a case of constitutional syphilis exempt from it; and in infantile syphilis, it is not less frequent. I have shown you mucous patches upon the cutaneous margins of mucous membranes :—you will like- wise find them on the skin, in the vicinity of the anus, in the in- guinal folds, on the haunches, and even on the trunk. Their form of development varies with their situation. They are quickly curable, when situated where they are free from being chafed; but they accu- mulate and thrive (if I may be allowed the expression) wherever there exists both rubbing and exudation. It is as difficult to describe the mucous patch in the infant as in the adult; and I really cannot depict it without recalling its appe ar- ance to your recollection. Let me simply say that in early infancy mucous patches have a more spongy and less indurated base, that the bottom of the lesion is more generally moist, and the oozing more abundant: and since, from want of an exact definition, I invoke your memory, I cannot do better than compare them to those met with in the labia minora and on the internal surface of the labia majora. The mucous tubercle would of itself be sufficient in the recently born infant to decide the question of syphilis :—but then how numerous are the causes of uncertainty and error! How many non-specific eruptions affect a very similar form under the influence of rubbing, moisture, and contact with irritating substances! The diversity of names given to this lesion tells very clearly the diversity of appear- ances which it presents. I am anxious to try to describe to you the special ulcerations of the skin, buttocks, and thighs, which you have had so good an oppor- tunity of observing during the last few days in a little child in bed 17 of our nursery ward. I pointed out to you these serpiginous ulcerations of the shin, exactly resembling the traces left in wrood by xylophagous insects. These ulcerations, which frequently do not exceed two millimeters in breadth, have so decidedly special an aspect, that I regard their SYPHILIS IN INFANTS. 337 presence as one of the most pathognomonic signs. After they are healed, moreover, they leave linear cicatrices, at first red, then white, which by their form distinctly remind us of their origin. In the infant, false psoriasis occupies the palm of the hand and the sole of the foot. The skin, at first wrinkled, seems to grow thicker; the epidermis, less elastic than natural, cracks at the digital intersections, and wherever movements subject it to extension. Soon, some patches of epidermis are detached, and the surfaces which they leave denuded become covered with new epidermis, which is so thin that it is no stretch of language to compare it to the outer skin of an onion. The feet and hands thus denuded, assume a livid, occasionally copper colour, but present nothing else which is characteristic. The inexperienced physician might easily be led into error, were he to rely on descriptions necessarily insufficient, as be might confound lesions of syphilitic origin with stripping of the epidermis in the recently born infant, an occurrence depending upon wholly different causes. As the mucous patch originates and developes itself upon various cutaneous eruptions, after the manner of a parasitical growth, vesi- cular and pustular eruptions may produce specific ulcerations. Whether the eruption does or does not assist in the transformation, it certainly has to do with it: every venereal ulceration in children has an eruption as the basis of its development. The pustule, in place of cicatrizing, spreads out, and burrows: its diameter in- creases, its edges become elevated, and phenomena are observed similar to those seen in certain cases of smallpox at a stage when the pustules ulcerate, in place of becoming more or l°ss covered with crusts. Engendered in this way, the syphilitic ulcers of children are met with in every situation in which products of the eruption can exist: they have, however, a preference for the buttocks, the lower part of the abdomen, and the cutaneous folds in the vicinity of the genital parts. I have striven, Gentlemen, to indicate salient features to you, without dwelling upon them. I wish you to realise the imperfection of my sketch, and to feel the necessity of your completing it by your own personal observation: this necessity becomes specially apparent to me when I proceed to direct your attention to the peculiar hue of the face. It not unfrequently happens that the physician, taught by long familiarity with this appearance, will almost at once diagnose syphilis 338 ' SYPHILIS IN INPANTS. after having simply seen the child’s face, although the peculiar hue can be described but vaguely in words. The visage presents a special shade of bistre: it looks as if it had been lightly smeared with coffee grounds, or a very dilute aqueous solution of soot. There is neither the pallor, the icteric hue, nor the straw yellow tinge of skin seen in other cahectic affections; the tinge is not nearly so deep, but is almost like that of the countenance of a re- cently delivered woman, and either does not extend at all, or only partially, to the rest of the body. I know no disease except syphilis in which a child’s skin has this peculiar colour: and consequently, when it is well marked, it has more diagnostic value than any other symptom. The child’s little suffering face presents some characteristics besides the bistre colour. The eyebrows have either not been developed, or have fallen out: the eyelashes are often everted : at the external angle of the eye, we sometimes find fissures like those seen on the lips and at the opening of the nares. In place of eyebrows, from which the hair has fallen, there are seen two yellow, bistre-coloured stains, and a considerable amount of desquamation; and these same bistre-coloured stains, which in fact are patches of psoriasis, are most abundant on the chin and round the mouth. I have been obliged in my description to decompose the syphilitic eruption, taking separately its surest manifestations; and it would be useless in me to attempt to re-establish it completely. The forms of infantile syphilis are grouped together so differently, they vary so much individually, in extent, in progress, and in tendency to trans- formation, that it is necessary to be guarded in forming an opinion, necessary to watch events, and to distrust rules applicable only to particular cases. Were syphilis in the adult the subject before us, I might now proceed to speak of treatment, and so complete the history of the disease. But we have at present to do with syphilis in early infancy; and to describe the cutaneous manifestations of syphilis is to indicate a part only of its manifestations, those which are the most important in respect of diagnosis, and which enable us to give a name to the affection; but the least important perhaps for the clinical physi- cian, whose desire is not only to give a name to the disease, but also to be able to foresee its ulterior evolution. SYPHILIS IN IN PANTS. 339 Syphilitic infants are, from the very first, under the influence of a cahexia, which adults do not always escape, but which in them is far from occurring so constantly or presenting so much gravity. In proportion to the greater or less severity of the symptoms, will be the greater or less chances of life or death; and all the signs which intimate the imminence or danger of a disturbance of the general health will acquire the greatest possible value. When called in to an infant said to be affected by syphilis, hesitate to indorse the opinion, and be physicians : watch the most insignificant dis- orders, the slightest functional disturbances, and do not look upon the state of the skin as the sole means of estimating amelioration or aggravation in the state of the patient, as you ought to be able almost authoritatively to do in older subjects. The cahectic physiognomy of the syphilitic infant has been de- scribed in a very exaggerated manner; but the disorder is not the less deep-seated, that it is the less visible. When a robust well- formed infant has brought with it into the world a sufficient reserve stock of vigour to traverse this period of severe trial, it becomes weak and dejected, loses flesh a little, and is rather puffy, and pre- sents a pallor of seemingly cedematous character ; while, at the same time, the integrity of the functions is preserved. The infant is in the same condition as the adult under the influence of the same cahexia: in proportion to the operation of the treatment, the amelio- ration of the general state becomes apparent. The little patient being no longer irritated by its sores, or by the contact of the ex- creta with the ulcerated surfaces, sleeps better, and is forthwith benefited by the tranquility of its slumber. The complexion loses the bistre hue : the physiognomy becomes more lively and cheerful. Should this happy change take place during the early weeks of treatment, an entirely favourable result may be hoped for. Unfortunately, however, the course of events is not always so pro- pitious. The syphilitic infant is seen to grow thin, and to suck with less avidity, symptoms arising from diminished appetite and embar- rassment caused by persistence of the coryza. The sleep is short and disturbed. Digestion is imperfectly performed : vomiting is not a usual symptom: diarrhoea is of frequent occurrence, and is of an inveterate, often sanguinolent character, the large intestine specially participating in the infection. Respiration is inadequate; and the more important functions being thus implicated, no longer assist in accomplishing the urgently required reparation. SYPHILIS IN INFANTS. The cahectic condition sometimes exists to such an extreme degree, that the termination of the case is more disastrous than there seemed reason to anticipate: an excessively weak infant left in a state seemingly serious rather than alarming, has died simply from syncope. Infantile syphilitic cahexia, presents a twofold study : on the one hand, we have to consider the degree of severity in which the syphilis exists, and on the other, the presence in subjects so young of all the causes of exhaustion, which are called inanition, diarrhoea, inter- mittent fever, or pox. The autopsy may often disclose nothing to which death can be directly attributed, but may reveal lesions on which depend slow, profound disturbances of the economy. To this category belong the alterations of the liver studied by Gubler; peritonitis in the foetus described by J. Y. Simpson (an affection from which young infants are not exempt); certain pulmonary lesions, as yet imperfectly known; and organic alterations of different organs presenting no appreciable specific character. Gentlemen, having spoken at some length upon the symptoms of infantile syphilis, and their subordination, I now come to consider the origin of the manifestations of which I have given you a sketch. It is nearly twenty years since I first tried to explain thzpathogenesis of infantile syphilis. I was guided then, as I now am, solely by experience, uninfluenced by any doctrinal bias. Among the facts which I have observed, and specially among the conclusions which these cases seemed to warrant, some were looked upon as rash hypotheses, and others as enormities. These views which excited so much opposition when originally announced in clinical lectures at the Hopital Necker have now become classical, so that in place of having to defend, it is sufficient for me to state them. At the period to which I refer, a generalisation, captivating from its exclusiveness, had reduced the transmission of syphilis to the simplest possible formula. Chancre produced chancre, in virtue of a law so absolute, that from the first moment that syphilis appeared, its presence might be affirmed, although its origin was shrouded in obscurity similar to that which envelopes the beginning of everything. Original inoculation was alleged to be the only means of infection; and you know how many ingenious combinations, how many learned essays on human morality, how many clever anecdotes served to fill up the gaps, and give reasonableness to the theory. SYPHILIS IN INFANTS. 341 The infant might escape the depravity of an inventive libertinism, but neither relations nor nurses enjoyed a like immunity. The infant being in contact with infected individuals, the object of caresses more imprudent than blameworthy, it became the innocent victim of the most unforeseen inoculations. We see the adult elude investigations undertaken in his own interest; but how much more reason is there for even the best conducted inquiries to fail to dis- close the mysteries of the transmission of syphilis in the recently born infant. The intelligent scepticism which reaches incredulity through a course of sagacious observation, which destroys belief by ridiculing credulity, always possesses witty aspects of which experimental truth is deprived. Where is the physician who has not regretted having been too credulous, and who among us has not experienced a feeling of honest self-approval in having detected fraudulent repre- sentations ? To show—what was only too certain—that syphilis was largely used as the means of deceit and lying was a service for which we ought to be grateful. Tacts, at last, became so numerous and so decisive, that criticism was crushed by demonstration. The progress of the truth was gradual; and the movement has not yet attained its full extent. Rules, at first rejected as erroneous, did not afterwards admit of being discussed; and in relation to certain points, it may be said, that in respect of the generation of infantile syphilis, scientific knowledge is complete. Had we only succeeded in establishing on a solid basis the patho- logy of syphilis in early infancy, the gain to science would have been very precious. The study of the venereal disease in children had the advantage of suggesting doubts as to the strict accuracy of prevailing theories, and of inducing physicians to subject them to clinical revision. Then began researches into the transmission of secondary symptoms, which opened up an entirely new path of in- quiry, which made it seem less impossible for their transmission to take place from adult to adult, by proving that it did take place from infants to adults, and from adults to infants. As, however, I have restricted myself for the present to the consideration of syphilis in infants, I must now return within the limits of my subject. A syphilitic mother may give birth to an infant carrying the germ of her disease : that is the first, and the least disputable fact. It is a second, and not less positive lawr, that a syphilitic mother may 342 SYPHILIS IIS INFANTS. produce a child free from syphilis. In respect of both laws, syphilis follows the law applicable to all hereditary affections. Is maternal syphilis transmissible by the mother, only when she had the disease prior to conception ? Or, may pox, contracted by the mother during pregnancy, be transmitted by her to the foetus ? This is an important and difficult question: do not attempt to solve it by the simple rules of common sense, which all agree cannot solve any medical problem. It has been thought most probable, that when syphilis is derived from the mother, it must have existed in her before conception, it being no doubt, more natural to suppose infection of the ovule than of the foetus. Cases, too, in which syphilis contracted by the mother during the latter months of preg- nancy have not contaminated the infant have also seemed to lessen the probability of infection after fecundation. Tinally, there has been an unwillingness, through fear of consequences, to admit that the blood of the foetus can be vitiated by its mother’s blood. Were that admitted, how could it be denied that syphilis may be commu- nicated to the infant by lactation, and in other ways still more hypo- thetical ? I am never afraid of the consequences of a positively ascertained fact. It is quite true that a mother infected before conception may give birth to a syphilitic infant: it is also true, that a mother in- fected during pregnancy may infect the foetus which she carries in her womb; and of this latter truth you had an example in bed 24 of our nursery ward. Between the two classes of cases, however, important distinctions have been rightly established, and ought to be maintained. The more thoroughly we examine the simplest laws of the patho- genesis of syphilis, the more do we find that possibilities multiply, and that casuistry, if I may use the word, becomes increasingly subtle. Bor how long a period is maternal syphilis susceptible of trans- mission ? Does it exist during the primitive, or during the secon- dary symptoms ? Does it exist in the tertiary period? May it still be present after an indefinite period has elapsed since the last mani- festations of the disease? Again, supposing that the infection is possible at any date, which period is the most favourable for its trans- mission ? Unfortunately, I cannot answer all these questions. I do know, however, that the mother may conceive a syphilitic infant, at a time SYPHILIS IN INFANTS. 343 when she herself seemed exempt from the disease wdiich had left no traces. I believe that the period most favourable to transmission is that which succeeds the first phase of the secondary symptoms. I also know that the mercurial treatment, against which they begin to speak, when properly carried out, nullifies syphilis in the woman, even though, as is asserted, it do not cure it; so that she, after having conceived a succession of syphilitic children, is treated by mercury, and then produces uncontaminated offspring. It may perhaps appear strange to you that I thus circumstantially announce a self-evident proposition : but I insist upon it, because syphilographers have not sufficiently taken into account a fact of which they were not ignorant: being engrossed with the treatment, they have almost forgotten the subject of pathogenesis. I leave for your own reflections this very elementary idea, which you will see is not devoid of importance. At what period of pregnancy is syphilis, contracted after concep- tion, transmissible ? This we do not know : but there is rightly a disposition to believe, that the nearer the date of infection is to the commencement of pregnancy, the greater is the probability of the foetus becoming contaminated. Does this depend upon the disease of the mother having a duration relatively longer than when she is infected at an earlier state of gestation ? This question, I cannot answer; and indeed I do not feel myself sufficiently certain as to the fact itself to offer an explanation. We have been supposing a case in which the mother only is syphi- litic ; but let us suppose a parallel case, in which the father alone is infected. This is a less complicated problem, inasmuch as the pa- ternal influence must be contemporaneous with fecundation; but then again, it is obscure in respect of the evidence of paternity. Tor my part, I do not hesitate to declare (and I have long held this opinion), that syphilis is transmitted from father to child when the mother is not infected : I also recognise as fully as any one the difficulties attending a decisive investigation, and would remark that the practice of medicine does not encourage obstinate illusions. But some reservations which a knowledge of the world exacts, certain cases impose, of which I am convinced by having seen enough of such cases: and you, Gentlemen, will meet with them in sufficient number to share with me this conviction. Here, again, the question presents itself in terms similar to those in which we asked it in respect of the mother :—At what stage of its 344 SYPHILTS IN INFANTS. evolution is paternal syphilis transmissible? The answer is the same—with this difference, however, that the opportunities being more numerous, and it being more easy to be well informed as to the syphilitic symptoms of the man, in respect of their progress, date, and phenomena, we may perhaps find more precise elements for arriving at a decision. An infected woman has a thousand reasons for concealing the nature of her malady : besides, she often does not know whether or how she has contracted it; and as she has ignorance for an excuse, she generally escapes continuous observation. In the man, there can hardly be offered any pretext for ignorance. He has no reason for concealment; and, thank God, you will meet with more men who are anxious than men careless as to the future. Observe, I make this remark only in respect of venereal affections. You will find that you are often consulted on this subject by men, but never by women, about to be married. You will be told the exact date of infection, the symptoms which supervened, the treat- ment which was prescribed and followed: every facility will be afforded you for verifying the statements made, and you will be soli- cited to do so : no information will be withheld from you. Yet, how many uncertainties, and legitimate grounds of hesitation in forming your opinion ! It is unnecessary to say that a man who is syphilitic ought to abstain from procreation. But the question is :—To what extent is there absolute security, when a long period has elapsed since the disappearance of the disease? I have often mentioned to you the case of a physician who con- sulted me : he had been cured of syphilis, married, and became the father of a syphilitic child. I have cited the case, because it pre- sented every condition required to constitute such a demonstration as science demands; and because it came under my notice at a time when professional opinion was still undecided. Since I met with that case, how often have I seen similar conditions lead to similar consequences ! How often, also, let me add, have I seen fathers properly cured of syphilis by the classical medication, engender children exempt from any trace of the disease. The hereditary character of syphilis, as of all other diseases, is liable to so many exceptions, that it is necessary to guard ourselves against the undue influence of preconceived opinions; and to bear in mind, that while, in respect of hereditary transmission, there is SYPHILIS IN INFANTS. 345 everything to fear., there may be, occasionally, everything to hope for. It sometimes happens, that under the most unfavourable con- ditions, both father and mother being affected with pox in the most palpable manner, everything consequently conspiring against the health of the fcetus, it nevertheless comes into the world free from the disease. But on the other hand, the symptoms of syphilis in one parent having yielded to rational treatment, we conclude, after mature deliberation, that all is safe; but nevertheless, the child is born infected, and dies of syphilis. Hereditary infection is not the only risk which infants are exposed to from syphilis. The infant, in its constant contact with the nurse, or with other women who bestow on it those little services without which it could not live, often incur the hazard of contracting syphilis in a very easy manner by direct inoculation. I am not now speaking of the risk of inoculation in the genital passages, that being a matter on which it is quite unnecessary to insist, though some ability has been shown in using it as an argument in favour of certain theories. A child directly inoculated by the nurse or otherwise, becomes of course a cause of danger to all those about it, being as able to transmit, as it has been to receive infection. Gentlemen, if, going back in thought some years, I fancy myself explaining to my students, at the Hopital Necker, the laws which preside over the jcostpartum infection of the recently born infant, I am able to estimate without any difficulty the advance which science has accomplished since that time. Then, I had to discuss denials, contend against pressing objections, accumulate proofs, collect cases, and give to my hearers a review of these cases with the fullest details, or submit the patients themselves to the sceptical criticism of my class. Now, facts having spoken, principles are sufficiently firmly established to require merely to be stated. I shall, therefore, be brief, as I ought to be, when dealing with unassailable doctrines. The nurse may transmit to the infant the primary taint by which she was affected. This has never been denied. She may also inocu- late it with secondary symptoms; and although the possibility of transmission in this way was long contested, this mode of transmis- sion is much more frequent, and not less satisfactorily established than the former. Here too, there is reciprocity, as in the former case—the nurse may be the victim of the nursling affected with hereditary syphilis. It is a great matter to affirm this law : but this affirmation is not SYPHILIS IN INFANTS. enough to dispel all the doubts which will present themselves to you in practice. The nursling, like the nurse, is liable to a double in- oculation : it may be infected after birth, or it may bear the insidious germ of a disease destined to break out at the end of some months. The nurse may he inoculated in coitu, or hy the contagium of the recently horn infant. Have we the means of recognising each of these occurrences with certainty, or of estimating their relative proba- bility ? It would be superfluous in me to impress upon you the importance of this inquiry, the momentous gravity of which you can under- stand, even when it does not assume the form of a judicial inquiry. In cases of this kind, the physician exercises a judicial duty which is paramount to every other: his responsibility is enormous in the eyes of the world; but for himself, it will be enough to realise that responsibility in his own conscience. The more I feel the magnitude of the responsibility of giving a decision in cases involving these questions, the more do I desire to be able to fortify your judgments by giving you precise data. Unfortunately, I cannot furnish you with absolute signs; but obedient to the demands of a duty which I believe to be imperative, I shall endeavour to prevent your being misled by perilous asser- tions. Every case will come before you surrounded by complex circumstances, and you will have to disentangle each particular truth, without generalising the results of your examination. Do not be astonished at this seeming impotence of science: accept it as a ne- cessity with which your daily practice will make you familiar. Medical laws are to the physician what the legislative code is to the magis- trate : without them, deviations from the right road would be inces- sant: but guided only by them, individual problems cannot be solved; for being a lawyer never sufficed to make a man an able acute sifter of evidence and examiner of witnesses. The nurse who has transmitted syphilis to, or received it from the nursling, may be in similar if not in identical conditions. It seldom happens that you are consulted at the first occurrence of the un- toward symptoms; more or less time has elapsed since inoculation, so that you have to gather the history of past events from recitals in which ignorance contends with deceit. It has been said that the infection is communicated more frequently by the mouth than by the womb : but how numerous are the exceptions to this pretended rule ! Supposing that the original centre of contagion was in the situation SYPHILIS IN INFANTS. 347 where the infant most frequently came in contact with the nurse, and supposing also that the infant was suckled, how incalculable the opportunities of its disseminating the evil! You see vaccinated in- fants inoculate themselves with vaccine matter from the arm on all parts of the body much better withdrawn from their attempts : you also see the pus of a primary ulceration carried to the genital organs, to the belly, and to every situation to which the nurse herself carries her incessant intervention. If the question be as to primary symptoms, which are almost limitable in duration, limits may be indicated; but we do not know at what period secondary symptoms have ceased to be inoculable. Even a nurse, like all other women, escapes from inquiries which in the case of a man would yield valuable information. In women, the ulcerations consecutive to chancres cicatrize without leaving visible traces, the induration of the edges is not so prominent, and the glands are less affected: the chancre may have its seat on the womb, or may be concealed in some situation unsuspected by the physician, however well acquainted he may be with the divagations of debauchery. Theoretically considered, the solution of the question is beset with doubts: in actual practice, however, it is simplified; for by considering very subordinate circumstances in connection with each other, by analysing statements, and discussing their contradictions, we are enabled to base conclusions upon plain solid reasons. In cases of this description, as in all medico-legal consultations, the possession of knowledge is the important element. Acquire a profound acquaintance with infantile syphilis: study thoroughly the evolution of syphilis in the woman, and having thus made yourselves strong by the possession of knowledge, you will be in a position to grapple with the difficulties of each inquiry. To express the fact in better terms—you will be able to use difficulties themselves as means of discovering truth. There is still another mode of inoculation, which, while it is very much like that of which I have been speaking is in some respects distinct from it: I refer to the transmission of the syphilitic virus by vaccination. This possible means of transmission, at first denied by deservedly esteemed syphilographers, seems to me to be firmly established by conclusive experiments. In 1861, you saw in our service a very sad example of this mode of transmission; and the facts, so testing, of what may be called the epidemic of Rivalta, will 348 SYPHILIS IN INFANTS. satisfy any physician as to the correctness of this view provided his mind be not previously influenced by an opposite bias. It would be out of place, here to refer to the extended discussions which arose out of the law-case of Dr. Hubner of Bambey, which, since 1854, has many contradictory allegations. Since that date, other cases of the same kind have been cited; but it would lead me far beyond the limits of my teaching in this place, to discuss or even describe rare cases, which I know to be exceptional and the subjects of criticism; while at the same time, it would be absurd in me to consign them to the limbo of apocryphal patho- geny. I have already, moreover, sufficiently noticed them in my lectures on vaccination.1 There still remains for consideration another question relative to the transmission of congenital syphilis. Suppose a child engendered by a father who had had the pox, but who no longer showed symp- toms transmissible by inoculation:—Could this syphilitic child when in utero infect its mother? You can estimate, Gentlemen, the number of difficulties which surround such a problem : you can see how many elements will be wanting for its solution, because it may be asked, whether the woman supposed to be infected by her foetus had not been previously the subject of syphilis which had passed without recognition. Be that as it may, the transmission of syphilis from the father to the mother, through the medium of the foetus, is now admitted to occur. The fact admits of an easy physiological explanation. It is indeed certain that the mother by mingling her blood with that of her infected foetus becomes infected with syphilis. Is it at all improbable that a foetus the blood of which is syphilitic should infect the blood of its mother ? It is about the third month that the circulation of the foetus becomes active. By the umbilical vein, it receives the blood of its mother, and it returns to her by the umbilical arteries that which has traversed its organs, and which is a mixture of its own with the maternal blood. You know, without my impressing upon you the fact, that in the foetus the blood and the blood-vessels are formed almost simultaneously. The foetus, therefore, has blood which is peculiarly its own, and if the foetus is syphilitic by its father, its blood is syphilitic in virtue of the same title as the other parts of its organism. Consequently, it can infect 1 Volume II, p. 124. SYPHILIS IN INFANTS. 349 its mother through the medium of its blood, just as the syphilitic mother can infect the foetus in her womb. A reliable observer has communicated to me the following case, which is in accordance with physiological facts :—A young lady of unquestionable morality became pregnant within a few days after her marriage. Her husband, a physician, had had syphilis three years previously, and had no remaining trace of the disease, except slight engorgement of the cervical glands. The lady, at the third month of her pregnancy, felt an itching in the labia majora; after- wards, it was found that there existed pretty extensive ulcerations in process of transformation into mucous crusts. Some days later, they were perfectly formed : there was also sore throat and engorge- ment of the cervical glands. At the eighth month, the lady was delivered of a miserable child, which became affected with syphilitic coryza and ophthalmia on the tenth day after birth; and which died, when six weeks old, with fatty liver, ascites, and cedematous extremi- ties. The day before its death, epistaxis occurred. The most disputable fact in this case is the appearance of ulcer- ations on the external genital organs, ulcerations which may be attributed to direct contagion. But it must be remembered that they were mucous crusts, and not true chancres; and the develop- ment of mucous crusts in these parts, which are during pregnancy the seat of great erethism, appears to me to be a phenomenon in all respects analogous to the formation of vegetations and crista galli on the surface of the vulva in some non-pregnant women. The exuberant vitality of these organs during pregnancy is the starting point of the morbid manifestations. Perhaps I have dilated too much upon the manifestations of syphilis in infants, upon the possible and probable forms of inocu- lation and upon its hereditary genesis. I have omitted all historical notices of the subject, feeling that as I could not do justice to all the observers who have so powerfully contributed to the elu- cidation of the disease, I ought to abstain from quoting any of them. I have still to speak of the treatment of syphilis in infants. Though the subject is most important, it is both possible and useful, I think, to discuss it with brevity. Whatever may be the age of the patient, syphilis must be treated in accordance with the same principles. The remedies to be employed are the same; and the end to be attained, as well as the 350 SYPHILIS IN INPANTS. means of attaining it, are also the same. Keep steadily in view this simple and fundamental truth. Were it allowable to employ in infants the classical preparations so easily administered to adults, the problem would be solved, or rather there would be no problem to solve. The difficulty does not arise from indications, but from counter-indications and obstacles presented by the infantile consti- tution to the tolerance of medicines. I have spoken to you of the influence which syphilis, when left to itself, exercises upon the general health of the infant. I have shown you the increasing cahexia exhibiting itself in functional disturbances, and particularly in an altered state of the digestive function. These are the points to which your attention ought to be unceasingly directed: it is by the state of the stomach and intestines that you are guided as to the increase or diminution of the doses of medicines, and the suspension of a remedy. Mercury ought to be the basis of your treatment. I neither ignore the renewed objections to the mercurial treatment, nor the inconveniences which attach to its employment: I am aware that by a sort of periodical reaction, there have been on different occasions attempts to combat and dethrone it, but I also know that these attempts have only had their day, and that mercury after being strongly denounced, has always been reinstated in favour by the force of circumstances. In the recently born infant, the employment of succedanea is impracticable: depuratives of the best repute are out of court simply because it would be utterly impossible to make use of them. Of the preparations of mercury used internally, after numerous trials by myself and pupils, I continue to prefer the solution of corrosive sublimate so well known as the liqueur de Van Swieten. I give it to the extent of one or at most two grammes a day in milk : so administered, the infant takes it without repugnance. Never- theless, though the administration of the perchloride of mercury be easy, it very often happens that one is obliged to renounce its use on account of the diarrhoea which it keeps up or causes. In such cases, it is best temporarily to desist from all mercurials, because, under the circumstances, not one of them can be used with impunity, all of them favouring the troublesome tendency which it is essential to combat. It was proposed to give calomel in very small doses, particularly at the time when it was hoped that by combining it with chlorate of SYPHILIS IN INFANTS. 351 potash, we should be able to avert salivation in the adult and diarrhoea in the infant. I am not sufficiently well informed in relation to the advantages of this method of treatment to recommend you to adopt it; but I may say, that I am inclined to believe that the addition of the chlorate of potash would, at least for adults, lessen the anti- syphilitic action of the perchloride of mercury. The protoioduret of mercury does not seem to me to possess any advantages; and I do not think that at present it possesses many advocates. With the laudable purpose of averting threatened disturbances of the digestive function, or preventing their imminence, it has been recommended not to give any medicines internally, and trust entirely to mercurial frictions. Although this method reckons among its supporters many respectable physicians, I reject it, as one which (besides other inconveniences) leads to gastro-intestinal symptoms. The skin of the infant receives mercurial applications badly, for they are always irritating, a preventive to their being absorbed. The external use of mercurials, still much in vogue in England, Germany, and in all the north of Europe, is only exceptionally employed in France, even in the treatment of syphilis in adults. As a general rule, we ought not to break the skin of the young infant. Even when the infant’s skin is healthy, it has not a suffi- ciently active vitality to furnish a therapeutical leverage of much value: when diseased, it acquires a very baneful influence, for which reason you ought always to endeavour to cure local lesions of the skin: to eradicate them is to render a signal service to the little patient. Is every ulcerative centre which you allow to become developed, or of which you follow the evolution a source of general infection ? I would not dare to say it, but I know from experience that the general health of the child resents injury of its skin. Whether it be that the little wounds of the skin cause an irritation which agitates the new-born infant, whether it be the greater or less exhaustion caused by every pathological process of ulceration, whether it be that the contact of irritating matters becomes a source of pain, it is a fact, that the syphilitic child always improves, and that the diseased state of the skin is often ameliorated. You will have occasion, according to circumstances, to have recourse to the most varied topical applications to the skin, to caustics more or less diluted, and to emollients, the use of which, however, is very limited; but of all remedies I know none com- 352 SYPHILIS IN INFANTS. parable to baths and lotions of corrosive sublimate. Perchloride of mercury dissolved in water by the aid of alcohol or chlorohydrate of ammonia has the very great advantage of being easily used in what- ever doses circumstances demand, ranging from the slightly caustic lotion to the bath so weak as not to cause any appreciable sensa- tion. For a child’s bath, I never use more than a gramme of sublimate. The infant has almost as much tolerance as the adult for this medicine: it would, therefore, be bad practice to reduce the strength of the solution to that which the formularies almost invariably prescribe. In curing the morbid condition of the skin—which is possible even when we do not cure the syphilis itself—you have the advan- tage of leaving it available as the medium of a medication which may yield you great success. The debilitated cahectic infant may at any given moment be unable to repair its lost strength: tonic baths, sulphurous baths, afford resources which tonics given inter- nally do not confer; but then, unless the skin be sound, you cannot resort to this kind of treatment. In treating infantile syphilis, diet takes the first place as an adjuvant, if not as a medicament. Lay it down as a rule that the infant which is not suckled, or is badly suckled, has a hundred chances against one as compared to the infant fully nourished from the breast: unfortunately, the limits within which you can interfere in this matter are very narrow. Should the mother be unable to supply a sufficiency of milk from her breast, it is a serious responsi- bility to confide so dangerous a nursling to a nurse. You are, in fact, compelled to be satisfied with a nurse who is nearly suitable, with whose insufficiency you are acquainted. In the matter of infantile nourishment, there is nothing more compromising than half- measures. It is even more essential that the infant be suckled by its mother, as internal treatment applied to her will sometimes have so powerful an influence as to cure both. In the infant, the iodide of potassium is almost never applicable, but it is often useful to the nurse and through her to the nursling; but in her also, the liquor of Yan Swieten ought to be specially recommended. I cannot too urgently impress upon you the necessity of adopting the most diligent hygienical precautions. Spare the infant from every cause of discomfort which can be known or pointed out in SYPHILIS IN INFANTS. 353 advance: carefully avoid giving the child a chill, than which nothing could be worse for it. The recently born infant must be kept in a tem- perature which is not only equal, but is also high. You are aware of the importance which physicians of northern countries attach to the elevation of temperature in the treatment of obstinate syphilis, the patients affected with which are kept in veritable stoves. Use their example and experience for the benefit of infants affected with syphilis. However numerous your precautions may be, with whatever solici- tude you may surround the little sufferer, whatever devotion you may have found or awakened in the mother, you must be prepared to meet with many failures. In the recently born infant, syphilis is always formidable, and a disease which is apt to prove mortal. Left with- out treatment, it exhausts the patient by internal lesions, ansemia, and functional disturbances. It often opposes a long resistance to remedial measures: the economy has not the power to sustain the prolonged struggle, and frequently, the remedy injures on the one hand, when on the other, it proves beneficial. It may be said unhesitatingly, that congenital syphilis is nearly always mortal, if it show itself within the first fortnight after birth. The danger dimi- nishes in proportion as it is long in manifesting itself. In conclusion, Gentlemen, allow me to recall your attention to the reservations which I thought it necessary to make at the begin- ning of this lecture. The syphilis which attacks the infant raises the most delicate problems: it is one of those diseases in which expe- rience does not enable us to jump at conclusions. We can seldom proceed with our diagnosis aided by the security of pathognomonic signs, and are obliged to rely upon the attentive discussion and com- parative examination of minute circumstances. The pathogenesis encounters difficulties in practice, which belong at once to the insi- dious nature of the evil, and to urgent interests which bring into the field dissimulation and lying. I endeavoured to give you a sketch of the principal elements of the march, evolution, and symptoms of the disease; but my chief anxiety was to tell you again and again, that you must equally avoid an insufficiency of “ savoir” and that excess of “science” which leads to the premature glorification of theories. LECTURE LXXXII GOUT. Preliminary Considerations.—The word “ Gout” is much to be pre- ferred to any of the other names which have been proposed in place of it.— Gout, acute and regular.—Premonitory phenomena. —Disturbance of Digestion : Disturbance of the Nervous System: Disturbance of the Urinary Organs.—Catarrhal, Urethral, and Ocular Affections.—Arthritis, its progress and appearances.— Acute Gout in the form of short Paroxysms which either succeed to, or run into one another.—The paroxysm may supervene under the influence of an immediate appreciable cause. Gentlemen :—When, in compliance with the request of many of you, it became my intention to devote some clinical lectures to the history of gout, I believed that I was sufficiently acquainted with the disease to treat it in a proper manner. But when, with a view to put you in possession of the subject, I set myself to think over it —when I tried to arrange in proper order the numerous facts which had come before me in the course of my practice, and to complete the results of my own experience by the perusal of the writings of others, I perceived how far I was from being in a position to respond to your expectationSi I will not, however, shrink from the task you have imposed upon me. I shall do my best to state to you my views regarding the nature and different phases of the disease; and I shall likewise point out to you what I think ought to be the] general management of gouty persons. When one has meditated upon Sydenham’s Treatise on Gout, a marvellous monograph, at once concise and complete; when one has gone through the cases described by Musgrave in his work on anomalous gout—a work far too much lauded, I think, and in which gout and rheumatism are very often mistaken for one another: when one has read Scudamore’s treatise on the nature of gout and rheu- GOTJT 355 matism; when, finally (and to refer only to important works of our predecessors), one is acquainted with the Commentaries of Yan Swieten and the Aphorisms of Boerhaave—one is almost able, with the aid of his personal recollections, to form some opinions regarding the disease of which I am now about to speak to you. And at present, if to put our ideas more in harmony with the existing state of knowledge, we read contemporary works—if we cast our eyes over Dr. Garrod’s work, which, by the way, appears to me far inferior to its reputation—if we rummage the innumerable essays published on the subject, and among others, the excellent thesis defended before the Faculty of Paris by Dr. Galtier Boissiere, we feel convinced, notwithstanding the pretensions of modern medicine, that we have made no advances, since the time of Sydenham, in our knowledge of the treatment, phenomena, and special nature of gout. Translate the work of the English Hippocrates into what is called more scientific language, and you will not only admire the description which that great man gave of the disease, but you will be surprised to find how little he left to be said regarding it by those who came after him. Being himself tormented for many years by acute or chronic normal gout, his description is only applicable to normal gout; but that he has described in so masterly a manner as to leave almost nothing unsaid in respect of it. With regard to anomalous gout, you will not find the materials for its history in special treatises. These materials are scattered through books which treat of gout only in a very incidental manner; and generally, you will find them concealed under names widely different from those which unmistakeably pertain to it. Thus, for example, there are many so-called metastases of rheumatism, which are nothing else than metastases of gout. Anomalous gout, more common than is generally believed, assumes such diversified aspects : normal gout itself is so often divested of the type created for it by nosologists, that one would be deceiving himself were he to believe that he was familiar with it. In thus pointing out to you the difficulties of the question, I confess beforehand my incompetence, and perceive the deficiencies for which I may be blamed. To prevent any mistake as to the meaning which I attach to certain words, and to certain theoretical views which will frequently recur in the course of these lectures—to enable you to understand GOUT what I myself understand by normal and anomalous gout—you must have clear ideas of specificity and diathesis. Here then, we are once more brought back to the great question of specificity, upon which I every moment insist, because every moment we see it play its part at the bedside of the patient. This part, which the school of Tours, through Bretonneau, its most illus- trious representative, has placed in a strong light, is no longer disputed by any one. Will any one deny that specificity intervenes in almost all affections to such an extent, that those apparently the most similar differ in reality from each other in a very marked manner—when you see it, in acute or chronic diseases, imposing on the attentive observer by constantly showing itself in the form of anatomical lesions, by invariably manifesting functional disturbance, and by the nature of its concomitant symptoms ? Along with the characters possessed in common by several species of diseases, there always exist others which belong exclusively to each individual disease, and which serve to distinguish it. The subject now before us presents a remarkable example of this. There is certainly a great analogy between gouty arthritis and rheumatismal arthritis, irrespective of the general characteristics of inflammation which they possess in common. But even in this inflammation, we can detect notable differences, if wre consider its preferential seat respectively in the two diseases, its appearing acci- dentally in rheumatism and periodically in gout, the production of tophus as a sequel of an attack of gout and never following an attack of rheumatism; and in particular, if wre consider the manner of evolution. These differences are still more evident, when we study the general symptoms which precede, accompany, or follow the local articular manifestations. In gout, these manifestations are nervous disturbances, which, if I may use the expression, are obli- gatory phenomena of the attack, but which are absent in rheumatism. They are of such a nature, that, with only a single articulation involved, and involved to a less degree than if several joints were invaded by rheumatism, the gouty patient does not bear up so well, and is more weighed down by his disease than the rheumatic. In the complications, or rather in the local non-arthritic mani- festations, these specific differences also exist. Thus, in gout, affections of the urinary organs supervene, which are not seen in rheumatism : and again, the heart is very often implicated in rheuma- tism, and seldom in gout. GOUT. 357 In a word, Gentlemen, whether you have to do with the local or general manifestations of the disease, you will find everywhere engraven the indelible characters of specificity. When, at the first glance, we do not observe the stamp of specificity imprinted upon the more external phenomena, by careful looking, it will be found. I admit, that if I receive no explanation of the case, if all except the affected part be concealed from me—if, for example, I am only shown a joint, or the instep of a person affected with arthritis, it will often, no doubt, be difficult for me, by merely looking at it, to say, whether I have to do with gout or rheumatism. But I ask you, whether any reasons exist why more should be exacted of me than of the naturalist? Among the ablest botanists, is there one, who by merely looking at two leaves, each belonging to different plants of closely allied species, will name the species of plant from which each leaf has been taken ? Before giving his opinion, he must see the fruit. Well then, to continue the comparison, I also require to see the fruit of the gout. If I find that the articular affection has been followed by tophaceous products—if the patient tell me that he has experienced symptoms characteristic of gravel—if I make myself perfectly acquainted with the mode in which the local affection was evolved—my diagnosis is made certain. It is not different in gout from other diseases. The first view is often insufficient to discover the specificity, and it then becomes necessary to examine the phenomena in detail. A patient is suddenly seized with symptoms of a more or less serious character, and implicating the lungs, intestines, or brain. These symptoms have suddenly supervened, and progressed in a peculiar manner, so that at first you do not know to what to attribute them; but you learn that the patient is the child of gouty parents, or of parents subject to attacks of asthma or megrim ; and then you suspect the existence of the diathesis of which the visceral affections are the manifestations. Should the patient tell you that he has had attacks of gout, and that the disease has been abruptly suppressed, your suspicion becomes complete conviction. I shall not now expatiate at greater length upon the subject of specificity, as I have already very fully discussed it with you. I have now to speak of diathesis, a topic not less capital in relation to gout, and one intimately linked with the subject which I have just been recalling to your recollection. The word “ diathesis’-’ has been employed in very different sig- nifications. I have already told you the meaning which I attach to 358 GOUT it. Without now troubling myself by endeavouring to find a new definition, I shall take that given in the Dictionnaire de Medecine of MM. Littre and Ch. Robin, the most complete vocabulary which we possess :l—“ Diathesis [Sta0£ tureron Midwifery and. Diseases of Women and Children at St. Mary's Hospital Medical School; Honorary Secretary to the Obstetrical So- ciety of London, dec. With a new Series of Illustrations. Price, in doth, $5.00; in leather, $6.00. Hiliier’s Clinical Treatise on the Diseases of Children. By Thomas Hillier, M.I)., Physician to the Hospital for Sick Children, and to University College Hospital, &c., Ac. Octavo. Price, $3.00 “Our space is exhausted, but we have said enough to indicate and illustrate the excellence of Dr. Uillier'a rolume. It is eminently the kind of book needed by all medical men who w «h to cultivate clini tal acc vac j »n< sound practice.” — London. Lancet. “It is thoroughly elinical and sound in its observation and practical application of experience. From the therapeutical point of view, which chiefly interests us, we may recommend it with great confidence; and it is certainly a very much needed work.” — The Practitioner. “ Each chapter is carefully written, and every line is thoroughly practical. The busy practitioner will find in its pages, within small compass, much to interest and to instruct him ; and to the student it will form a pleasant gateway to the knowledge of the diseases of early life.” — Edinburgh Medical Journal. LINDSAY AND BLAKISTON’S PUBLICATIONS. Headland on the Action of Medicines in the System, sixth AMERICAN edition. By F. W. Headland, M.D., Fellow of the Iloyal College of Physicians &c., Ac. Sixth American from the Fourth London Edition. Pevised and enlarged. One Volume, octavo $3.00 Dr. Headland's work has been out of print in this country nearly two years, await- ing the revisions of the author, which now appear in this edition. It gives the onlj scientific and satisfactory view of the action of medicine; and this not in the way uf idle speculation, but by demonstration and experiments, and inferences almost as in- disputable as demonstrations. It is truly a great scientific work in a small compass, and deserves to be the handbook of every lover of the Profession. It has received the most unqualified approbation of the Medical Press, both in this country and in Europe, and is pronounced by them to be the most original and practically useful work that has been published for many years. Hide’s Pocket Anatomist. Being a Complete Description of the Anatomy of the Human Body; for the TJse of Students. By M. W. Hilles, formerly Lecturer on Anatomy and Physiology at the Westminster Hospital School of Medicine. Price, in cloth, $1.00 “ in Pocket-book form, 1.25 Heath on the Injuries and Diseases of the Jaws. The Jacksonian Prize Essay of the Royal College of Surgeons of Eng- land, 1867. By Christopher Heath, F.R. C. S., Assistant Surgeon tc University College Hospital, and Teacher of Operative Surgery in Uni- versity College. Containing over 150 Illustrations. Octavo. Price, $0.Of Hodge on Foeticide, or Criminal Abortion. Bv Hugh L. Hodge, M. D., Emeritus Professor in the University of Pennsylvania. A Small Pocket Volume. Price in paper covers, 30 “ flexible cloth, 50 This little book is intended to place in the hands of professional men and others the means of answering latisfactorily and intelligently any inquiries that may be made of them in coiweot.ou vLh this important •object. Holmes’ Surgical Diseases of Infancy and Childhood. By J. Holmes, M.A., Sut gem to the Hospital fov Sick Children, &c. Second Edition. Revised and Enlarged. Octavo. Price, $9.00 Hufeland’s Art of Prolonging Life. EditedbV Erasmus Wilson, M.D., F R.S. Author of '‘A System of Human Anatomy,'1 " Diseases of the Skinf &c., &c. 12mo. Cloth. $] 25 LINDSAY AND BLAKISTON’S PUBLICATIONS. Kirkes’ Hand-Book of Physiology. THE SEVENTH LONDON EDITION. HAND-BOOK OF PHYSIOLOGY, by William Senhouse Kirkes, M.'D. Seventh Edition, edited by W. Morrant Baker, F.ll.C.S., Lec- turer on Physiology, &c., Sc. With 241 Illustrations. In one volume, demy-octavo, containing over 800 pages. Price, bound in cloth, $5.00. This edition of Dr. Kirkes’ Hand-Book of Physiology is fully brought up to the times, and forms one of the most complete and convenient Text-Books on the subject, for the Student of Medicine, now in print. Lawson on the Eye. The Diseases and Injuries of the Eye, their Medical and Surgical Treatment. By George Lawson, F.R.C.S., Surgeon to the Royal London Ophthalmic Hospital, Sc., Sc. With a Formulary, Test Types, and numerous Illustrations. In one volume. Price, . . $2.50 “Dr. Lawson has succeeded In comprising within moderate limits a very complete and succinct account of the Diseases and Injuries of the Eye.” “ The many excellent features of this manual render it at once a safe and thoroughly trustworthy guide to the study of this special class of diseases, aud from its eminently practical character it must be a great acquisition to the library of the busy practitioner. Its value is also much enhanced by an excellent selection of formulas.” — Glasgow Med. Journal. Legg 011 Urine. FROM the second LONDON edition. A Guide to the Examination of the Urine. For the Practitioner and Student. By J. Wickham Legg, M.D., Member of the Royal College of Physicians, Sc., Sc. Second Edition. 16mo. Cloth. Price, 15 cts. “Dr. Legg’s little manual has met with remarkable success, and the speedy exhaustion of the first edition has enabled the author to make certain emendations which have added greatly to its value. We can now confidently commend it to the student as a safe and reliable guide to such examinations of the urine as he may be called upon to make.” — London Medical Times and Gazette. Mackenzie on Laryngeal Growths. Growths in the Larynx, with Reports and an Analysis of 100 Consecu- tive Cases treated by the author, and a Tabular Statement of every published case treated since the invention of the Laryngoscope. By Morell Mackenzie, M.D., author of “ The Laryngoscope,” “Diseases of the Throat,” Sc. Profusely illustrated by wood engravings and chromo-lithographs. Octavo. Price, $3.00 Mackenzie on the Laryngoscope. Its Use in Diseases of the Throat. With additions, and an Essay on Hoarseness, Loss of Voice, and Stridulous Breathing in relation to Nervo-Muscular Affections of the Larynx, by Morell Mackenzie, M.D., Physician to the Hospital for Diseases of the Throat, Sc., Sc. Second Edition, with additions, and a Chapter on the Nasal Passages, by J. Solis Cohen, M.D., author of “ Inhalation, Its Therapeutics and Practice,” Sc. Illustrated by two lithographic plates, and 51 engravings on 'uood. Octavo. Price, .... $3.00 “While was in its infancy, and before it had begun to engage to any extent the attention of the profession, it was studied with the greatest care and enthusiasm by the author of this treatise. Those who are anxious to study the diseases of the larynx and the mode of using the laryngoscope, cannot do better than purchase the treatise before us, as it is by far the best which has been published, aud is thor- oughly to be relied upon.”—Glasgow Medical Journal. Meigs and Pepper on Children. FOURTH EDITION, ENLARGED AND IMPROVED. . The publishers have selected the following notice, from a late number of the London Lancet, of the New Edition of this work, as indicating, ner- haps, more fully than any other of the numerous favorable criticisms that have appeared of it elsewhere, its great value to the Practitioner and Student of Medicine. “It is not necessary to say much, in the way of criticism, of a work so well known as Meigs on Diseases of Children,’ especially when it has reached a fourth edition. Our duty is wellnigh restricted to the point of ascertaining how far, under an old color, it preserves the freshness and the value of a new book — how far it incorpo- rates what, is new with what is old without unseemly marks of mere joining. There is some advantage in starting entirely afresh, in being merely clinical, or in being very short, and limiting one’s self to the expression of one’s own views and experience. But such is not the nature of this book, and the advantages of it are different. It is a work of more than 900 good American pages, and is more encyclopsedial than clinical. But it is clinical, and withal most effectually brought up to the light, pathological and therapeutical, of the present day. “The book is like so many other good American medical books which we have lately bad occasion to notice; it marvellously combines a resumi of all the best European literature and practice with evidence throughout of good personal judgment, knowl- edge, and experience. It is gratifying to see how our English authors are quoted, and especially how the labors of Hillier, who died so prematurely, are recognized. But the book abounds in exposition of American experience and observation in all that relates to the diseases of children. Not the least interesting additions to the volume are several extensive tables, exhibiting the mortality in Philadelphia of some of the most common and fatal diseases in connection with the variations of the temperature, and prepared with great care from the records of the Board of Health. “The thoroughly fresh nature of the book is especially seen in the care with which dertain articles have been written. Such are those on Rickets and Tuberculosis, Infan- tile Atrophic Paralysis, and Progressive Paralysis. No book now on diseases of chil- dren is complete which does not treat specially of constitutional or diathetic diseases, such as rickets and tuberculosis, syphilis, &c. “Among other articles of great interest and value we would mention those on Dis- eases of the Caecum and Appendix Vermiformis, on Indigestion in Children, on Diar- rhoea, on Entero-Colitis, on Intussusception, on Chronic Hydrocephalus, and on Croup and the value of Tracheotomy. “The difficulties of editing a new edition of a medical book of some standing are not more felt in the region of pathology and the classification of disease than in that of therapeutics. In this work this difficulty has been fairly faced by the authors. They have to confess to having changed their practice very materially in the treatment of acute diseases, to having given up mercury in most inflammatory diseases, and almost given up bloodletting. We recommend the views of these authors as to the injurious affects of calomel and antimony to careful consideration. They do not entirely abjure the use of bloodletting in certain cases of pneumonia and meningitis. Indeed, we think they will find reason in future editions to talk a little less freely than they do about bleeding and cupping very young children in certain circumstances of pneumonia, and in certain cases of simple meningitis. With a few exceptions of this kind, the therapeutics are sound and commendable, great importance being given to proper feeding and the general management of infancy and childhood. It is due to authors of so much fairness and experience to publish widely their opinion of the injurious and depressing effects of antimony in the inflammations of children. To infants under two years of age they think it best to give no antimony even in pneumonia. They do lot use tartar emetic at all in the cases of children, but small doses, such as the twelfth of a grain, of the precipitated sulpliuret of antimony, every two, three, or four hours, watching its effects, and withdrawing it quickly if symptoms of prostration appear, perhaps without any vomiting. “We are glad to add this work to our library. There are few diseases of children which it does not treat of fully and wisely in the light of the latest physiological, paihological, and therapeutical science.” —London Lancet, July 23, 1870. Frice, handsomely bound in Cloth . ...... $6 00 “ “ “ Leather ...... 7 00 LINDSAY & BLAKISTON, PUBLISHEKS, PHIL A D EL Pill A. Marshall’s Physiological Diagrams. LIFE-SIZE, AND BEAUTIFULLY COLORED. On account of their large size and the great distinctness of the figures on them, there has been a growing demand in this country for these Maps for the Lecture Room and for lecturing from in Medical as well as other Schools. In order to supply this demand on more favorable terms, we have recently completed an arrangement with the publishers in London, by which we can sell them to the trade and others at a reduced price and on better terms than heretofore. The series, illustrating the whole Human Body, are life-size, each map printed on a single sheet of paper, made specially for the purpose, 7 feet long and 3 feet 9 inches broad, colored in fac-simile of the Original Drawings. There are nine diagrams, as follows' No. 1. The Skeleton and Ligaments. No. 2. The Muscles and Joints, with Ani- mal Mechanics. No. 3. The Viscera in Position. — The Structure of the Lungs. No. 4. The Heart and principal Blood- vessels. No. 5. The Lymphatics or Absorbents. No. 6. The Digestive Organs. No. 7. The Brain and Nerves. No. 8. The Organs of Sense and Voice. No. 9. The Textures. — Microscopic Struc- tures. Prepared under the direction of John Marshall, F.R.S., F.R.C.S., Pro- fessor of Surgery, University College, and Surgeon to University College Hospital. Price of the Set, Nine Maps, in Sheets, .... $50.00 “ “ “ “ handsomely Mounted on Canvas, with Rollers, and Varnished, .... .$80.00 Though designed more especially for purposes of general education, supplying an acknowledged necessity of modern teaching, these diagrams will be found not inappli- cable to the requirements of professed Medical Schools, affording, as they do, a correct preliminary view of the various systems and organs in the human body. For Public School Purposes, for Lectures at Literary, Scientific, and other Institutes, they will be found invaluable; and also to students of Artistic Anatomy, imparting, as they do, when suspended on the walls of the Lecture-hall, School-room, or Studio, a familiar acquaintance with the whole human system. An Explanatory Key to the Physiological Diagrams. By John Marshall, F.R.S., F.R.C.S., &c. Octavo. Paper covers 50 cts. Description of the Human Body. Its Structure and Functions. Illustrated by Physiological Diagrams, Designed for the Use of Teachers in Schools and Young Men destined for the Medical Profession, and for popular Instruction generally. New Edition. By John Marshall, F.R.S., F.R.C.S., Professor of Surgery, University College, and Surgeon to the University College Hospital. The work contains 260 quarto pages of Text, bound in cloth, and 193 Colored Illustrations, arranged in Nine Folio Diagrams, carefully colored and reduced from Prof. Marshall’s large work. 2 vols. Cloth. . $10.00 Murphy’s Review of Chemistry for Students. Adapted to the Courses as Taught in the Principal Medical Schools in the United States. By John Gr. Murphy, M.D. . . . $1.25 LINDSAY AND BLAKISTON’s PUBLICATIONS. Meadows’ Manual of Midwifery, a New Text-Book. Including the Signs and Symptoms of Pregnancy, Obstetric Operations, Diseases of the Puerperal Slate, Sc., &c. By Alfred Meadows, M.D., Member of the Iloyal College of Physicians, Sc., Sc. First American from the Second London Edition. With numerous Illustra- tions. Price, ......... $3.00 “'Those who read the first edition of this work will bear us out in thinking that Dr. Meadows’s Manual forms one of the most convenient, practical, and concise books yet published on the subject. It was espe- cially good as a student’s manual, and the author has, in his second edition, sought to make it of equal value to the practitioner. The part which treats of obstetric operations has been well revised, and has received numerous additions, and the several chapters on Unnatural and Complex Labors likewise comprise much new matter. Upwards of ninety new engravings have been inserted in this edition, and, with a view to facilitate reference, the author has furnished it with a very full and complete table of contents and index. We can cordially recommend this manual as accurate and practical, and as containing in a small compass a large amount of the kind of information suitable alike to the student and practitioner.”—London Lancet, May 6, 1871. “This new edition of a book which was at once recognized as a good manual, is a considerable improve- ment on its predecessor. It is eminently a book which will teach the student. . . . Not merely is the prac- tical treatment of Labor, and also of the Diseases and Accidents of Pregnancy, well and clearly taught, but the anatomical machinery of parturition is more eifectiyely explained than in any other treatise that we remember; and besides this, the book is honorably distinguished among manuals of Midwifery by the ful- ness with which it goes into the subject of the structure and development of the ovum. Dr. Meadows has done good service in giving a clear account of this subject in a very short space, yet with sufficient fulness. On all questions of treatment, whether by medicines, by hygienic regimen, or by mechanical or operative appliances, this treatise is as satisfactory as a work of manual size could be; and altogether, students and practitioners can hardly do better than adopt it as their vade-mecum.” — The Practitioner. Maxson’s Practice of Medicine. By Edwin R. Maxson, M I)., formerly Lecturer on the Practice of Medicine in the Geneva Medical College, Sc. . . $4.00 Morris on Scarlet Fever. Its Pathology and Therapeutics. By Casper Morris, M.D., Fellow of the College of Physicians of Philadelphia, Sc. . . . $1.50 Mendenhall’s Medical Student’s Vade Meeum. A Compendium of Anatomy, Physiology, Chemistry, the Practice of Medicine, Surgery, Obstetrics, Diseases of the Skin, Materia Medica, Pharmacy, Poisons, Sc., Sc. By George Mendenhall, M.D., Pro- fessor of Obstetrics in the Medical College of Ohio, Sc., Sc. Ninth Edition, Revised and Enlarged, with 224 Illustrations. . $2.50 Pennsylvania Hospital Reports. Edited by a Com- mittee of the Hospital Staff, J. M. DaCosta, M.D., and William Hunt, M.D. Vols. 1 and 2, for 1868 and 1869, each volume, contain- ing upwards of Twenty Original Articles, by former and present Members of the Staff, now eminent in the Profession, with Litho- graphic and other Illustrations. Price per volume, . . $4.00 At last, however, the work has been commenced, the Philadelphia Physicians being the first to occupy this field of usefulness. The first Reports were so favorably re- ceived, on both sides of the Atlantic, that it is hardly necessary to speak for them the universal welcome of which they are deserving. The papers are all valuable contri butions to the literature of medicine, reflecting great credit upon their authors. The work is one of which the Pennsylvania Hospital may well be proud. It will do much «ward elevating the profession of this country. — American Journal of Obstetrics. LINDSAY AND BLAKISTON’S PUBLICATIONS. Pereira’s Physician’s Prescription Book. Containing Lists of Terms, Phrases, Contractions, and Abbreviations, used in Prescriptions, with Explanatory Notes, the Grammatical Constructions of Prescriptions, Rules for the Pronunciation of Pharmaceutical Terms, A Prosodiacal Vocabulary of the Names of Drugs, etc., and a series of Abbreviated Prescriptions illustrating the use of the preceding terms, etc.; to which is added a Key, containing the Prescriptions in an unabbreviated Form,, with a Literal Translation, intended for the use of Medical and Pharmaceutical Students. By Jonathan Pereira, M.D., F.R.S., etc. From the Fifteenth London Edition. Price, in cloth, $1.25 “ in leather, with Tucks and Pocket, . . . 1.50 This lit+le work has passed through fifteen editions in London and several in this country. The present edition of which this is a reprint has been carefully revised and many additions made to it. Its great value is proven both by its large sale and the many favorable notices of it in the Medical Press. Paget’s Surgical Pathology. Lectures delivered at the Royal College of Surgeons of England, by James Paget, F.R.S., Surgeon to Bartholomew and Christ's Hospi- tal, dec , &c. The Third American Edition, Edited and Revised by William Turner, M.B., Lond. Senior Demonstrator of Anatomy in the University of Edinburgh, &c., dec. In one volume, Royal Octavo With numerous Illustrations. Price, in cloth, $6.00 “ leather, ........ 7.00 “It would be very superfluous for us to say many words in calling the attention of the profession to this new edition of Mr. Paget’s great work on Surgical Pathology Its author has been singularly fortunate in securing the assistance (for this edition) of so able a collaborator as Mr. Turner, and English surgery may point, with pride to the present volume as one unsurpassed, if it is at all equalled in the surgical literature of the world, in breadth of view and philosophical grasp of its subject.” — Practitioner. Prince’s Plastic and Orthopedic Surgery. Containing, 1. A Report on the Condition of, and Advances made in, Plastic and Orthopedic Surgery up to the Year 1871. 2. A New Classification and Brief Exposition of Plastic Surgery. With numerous Illustrations. 3. Orthopedics : A Systematic Work upon the Prevention and Cure of Deformities. With numerous Illustrations. In one volume, Octavo. Price, ...... $4.50 “This is a good book, upon an important practical subject; carefully written, abundantly illustrated, and well printed. It goes over the whole ground of deformi- ties of all degrees — from cleft-palate and club-foot, to spinal curvatures and ununited fractures. It appears, moreover, to be an original book, so far as one chiefly of com- pilation can be so. Such a book was wanted, and it deserves success.” — Med. and Surg. Reporter. LINDSAY AND BLAKISTON’S PUBLICATIONS. Rindfleisch’s Text-Book of Pathological Histology. An Introduction to the Study of Pathological Anatomy. By Dr. Edward Rindfleiscii, 0. 0. Professor of Pathological Anatomy in Bonn. Translated from the Second German Edition, by Wm. C. Kloman, M. D., assisted by F. T. Miles, M. D., Professor of Anatomy, Uni- versity of Maryland, Sc., Sc. CONTENTS. Introduction, Author’s and Editor’s Prefaces. General Part. 1. Decomposition and Degeneration of Tissues. 2. Pathological New Formations. Special Part. 1. Anomalies of the Blood and the Places of its Formation, especially of the Spleen and Lymphatic Glands. 2. Anomalies of the Circulatory Appa- ratus. 3. Anomalies of Serous Membranes. 4. “ the Skin. 5. “ Mucous Membranes. 6. “ the Lung. 7. “ “ Liver. 8. “ “ Kidney. 9. Anomalies of the Ovaries. 10. “ “ Testicles. 11. “ “ Mammse. 12. “ “ Prostate Gland. 13. “ “ Salivary Glands. 14. “ “ Thyroid Gland. 15. “ “ Suprarenal Cap- sules. 16. “ “ Osseous System. 17. “ “ Nervous System. 18. “ “ Muscular System. Index and Bibliography. Containing 208 Elaborately Executed Microscopical Illustrations. One volume, octavo. Price, Prof. Rindfleisch’s Text-Book of Pathological Histology, so justly celebrated in Germany, where it is considered the most complete and thorough work of its kind, having passed rapidly to a second edition, is also very highly valued and commended by German Medical scholars in this country, many of whom are not only familiar with the book, but with the author’s great reputation as a teacher and professor of this branch of medical study. The translators are both gentlemen who by their past education have been peculiarly fitted for the task of translating the work. Dr. Kloman from early life has been familiar with the German language, while Prof. Miles has made the subject one of special study, both gentlemen being also practical microscopists. The Publishers therefore otfer a translation of this truly valuable work to the Medical Profession in the United States, feeling the utmost confidence that in both manner and style it will prove acceptable to them. In their Preface, the Translators say: “In presenting the English reading portion of the Medical Profession with a translation of the valuable work of Prof. Rindfleiscli, the translators scarcely deem an apology necessary. The merits of the book itself, and the fact that it fills an unoccupied gap in our most recent literature upon the subject of Pathological Histology, was judged to be an ample in- centive for undertaking the labor of the translation. The work of Virchow translated by Chance, is, in many points, antiquated, and the more recent work of Bilbroth, translated by Hackley, occupies the ground but partially, and is professedly a work of Surgical Pathology.” This book is translated and published in this country by special arrangement with the author. LINDSAY AND BLAKISTON’s PUBLICATIONS. Radcliffe’s Lectures on Epilepsy, Pain, Pa- ralysis, And certain other Disorders of the Nervous System. By Charles Bland Radcliffe, M.D., Fellow of the Royal College of Physicians of London, &c., &c. With Illustrations. .... $2.00 “The reputation which Dr. Radcliffe possesses as a very able authority on nervous affections, will commend his work to every medical practitioner. We recommend it as a work that will throw much light upon the Physiology and Pathology of the Nervous System.” — Canada Medical Journal Robertson’s Manual on Extracting* Teeth. Founded on the Anatomy of the Parts involved in the Operation; the Kinds and Proper Construction of the Instruments to be used; the Accidents liable to occur from the Opera Hon, and the Proper Reme- dies. By Abraham Robertson, D.D S., M.D. Second Edition, Revised and Improved. With Illustrations. . . $1.50 Ranking’s Half-yearly Abstract of the Medi- cal Sciences. Price per annum, in advance, . $2.50 Back Volumes or Numbers furnished. Renouard’s History of Medicine. From its Origin to the Nineteenth Century. With an Appendix contain- ing a Philosophical and Historical Revieiv of Medicine to the present time. By P. Y. Renouard, M.D. Translated from the French by Cornelius Gr. Comegys, M.D., Professor of the Institutes of Medicine in the Medical College of Ohio, <&c. Octavo. Price, . $4.00 Reports on the Progress of Medicine and Surgery. Including Physiology, Practical Medicine, Surgery, Ophthalmic Medi- cine, Midwifery, Diseases of Women and Children, Materia Medica, Medical Jurisprudence, and Public Health. Edited by Drs. Power, Holmes, Ainstie, Barnes, Windsor, &c., &c., under the patronage and direction of the Sydenham Society of London. One volume. Octavo. Price, ......... $2.00 Ryan’s Philosophy of Marriage. In its Social, Moral, and Physical Relations, with an Account of the Dis- eases of the Genito-Urinary Organs. The Physiology of Generation in the Animal and Vegetable Kingdoms, &c., &c. By Michael Ryan, M.D., Member of the Royal College of Physicians and Sur- geons in London, &c. 12mo $1.00 Reese’s American Medical Formulary. $1.50 LINDSAY AND BLAKISTOn’s PUBLICATIONS. Reese’s Analysis of Physiology. Being a Condensed View of the most Important Facts and Doctrines, designed especially for the Use of Students. By John J. Reese. M.D., Professor of Medical Jurisprudence, including Toxicology, in the University of Pennsylvania, &c., dec. Second Edition, Enlarged. $1.50 Reese’s Syllabus of Medical Chemistry. $1.00 Stille’s Epidemic Meningitis; Or, Cerebro-Spinal Meningitis. By Alfred Stille, M.D., Professor of the Theory and Practice of Medicine in the University of Pennsylva- nia, dec., dec. In one volume, Octavo, .... $2.00 “This monograph is a timely publication, comprehensive in its scope, and present- ing within a small compass a fair digest of our existing knowledge of the disease, par- ticularly acceptable at the present time. It is just such a one as is needed, and may be taken as a model for similar works.” — Am. Journal Med. Sciences. Stille’s Elements of General Pathology. A Practical Treatise on the Causes, Forms, Symptoms, and Results of Disease. Second Edition preparing. Sweringen’s Pharmaceutical Dictionary. A Pharmaceutical Lexicon or Dictionary of Pharmaceutical Science, containing a Concise Explanation of the various Subjects and Terms of Pharmacy, with Collateral Selections from the Kindred Sciences; also Formulae for Officinal, Empirical, and Dietetic Preparations, Antidotes to Poisons, dec., dec. By Hiram V. Sweringen, 'Member of the American Pharmaceutical Association, dec., dec. In preparation. Sansom on Chloroform. Its Action and Administration. By Arthur Ernest Sansom, M.B., Physician to King's College Hospital, dec , dec. 12mo. . $2.00 “ The work of Dr. Sansom may be characterized as most excellent. Written not alone from a theoretical point of view, but showing very considerable experimental study, and an intimate clinical acquaintance with the administration of these remedies, — passing concisely over the whole ground, giving the latest information upon every point, — it is just the work for the student and practitioner.”—Amer. Medical Journal. Scanzoni on Women. A Practical Treatise on the Diseases of the Sexual Organs of Women. Translated from the French. By A. K. Gardner, A.M., M.D., &c. With Illustrations. Octavo, ...... $5.00 Stokes on the Diseases of the Heart And the Aorta. By William Stokes, Regius Professor of Physic in the University of Dublin; Author of the Diseases of the Chest, dec., dec. Second American Edition. Octavo, .... $3.00 THOMAS HAWKES TANNER’S WORKS. “ The leading feature of Dr. Tanner's books is their essentially practical character.” London Lancet. The Practice of Medicine. JUST READY. FIFTH AMERICAN, FROM THE SIXTH LONDON EDITION. Revised, much Enlarged, and thoroughly brought up to the present time. With a complete Section on the Diseases Peculiar to Women added; also an extensive Appendix of Formulas for Medicines, Baths, Mineral Waters, Climates, &c. By Thomas Hawkes Tanner, M.D., Felloiu of the Royal College of Physicians, &c. One Volume. Royal Octavo, containing over 1100 pages. Price, handsomely bound in Cloth, . . $6.00 “ “ “ Leather, . $7.00 There is a common character about the writings of Dr. Tanner — a character which constitutes one of their chief values: they are all essentially and thoroughly practi- cal. Dr. Tanner never, for one moment, allows this utilitarian end to escape his mental view. He aims at teaching how to recognize and how to cure disease, and in this he is thoroughly successful. ... It is, indeed, a wonderful mine of knowledge.—Medical Times. Dr. Tanner has always shown in his writings that he possesses a peculiar faculty of committing to print just that kind of information which the practitioner most needs in everyday practice, and of rejecting useless theories or hypothetical statements.—Lancet. The author has, in the manner in which he has dealt with the subject, given another evidence of that happy facility which he possesses of giving the essential points of a mass of information in a well connected and instructive form. — Brit. Med. Journ. The student will find the work the best text-book on the practice of medicine, while the practitioner will possess in it a thoroughly safe guide at the bedside. —Dub. Med. Quarterly. Tanner’s Practical Treatise on the Diseases of Infancy and Childhood, price, $3.50. THIRD AMERICAN EDITION, REVISED AND ENLARGED. By Alfred Meadows, M.D., London, M.R.C.P., Physician to the Hospi tal for Women and to the General Lying-in Hospital, &c., dec. “This book of Dr. Tanner’s has been much enlarged and the plan altered by Dr. Meadows. As it now stands it is probably one of the most complete in our language. It no longer deals with children’s diseases only, but includes the peculiar conditions of childhood, both normal and abnormal, as well as the therapeutics specially appli- cable to that class of patients. The articles on Skin Diseases have been revised by Dr. Tilbury Fox, and those on Diseases of the Eye by Dr. Brudenell Carter, both gentlemen distinguished in these specialties.” —Medical Times and Gazette. Tanner’s Index of Diseases and their Treatment. With upwards of 500 Formxdae for Medicines, Bams, Mineral Waters, Climates for Invalids, &c., &c. Octavo. . . $3.00 To the busy practitioner it must be an advantage to see at a glance on a quarter or half a page the principal point in any disease about which he may wish to Lave his memory refreshed or his mind stimulated. It will be found a most valuable companion to the judicious practitioner. — The Lancet. Tanner’s Memoranda of Poisons. From the Second London Edition. ..... 50 eta LINDSAY AND BLAKISTON’S PUBLICATIONS. Tilt’s Change of Life In Health and Disease. A Practical Treatise on the Nervous and other Affections incidental to Women at the Decline of Life. By Edward John Tilt, M.D. From the 'Third London Edition. In one volume. Octavo, ........ $3.00 The work is rich in personal experience and observation, as well as in ready and sensible reflection on the experience and observation of others. The book is one that no practitioner should be without, as the best we have on a class of diseases that makes a constant demand upon our care, and requires very judicious management on the part of the practitioner. — London Lancet. The great abilities of Dr. Tilt, his extensive knowledge, and his literary power are well shown in this book, and we are pleased to say that it has substantial and peculiar merits. It contains many sage, practical recommendations, and will amply repay perusal. — Edinburgh Medical Journal. Dr. Tilt has been a very earnest and a very faithful worker in the physiology and diseases of women, and has made contributions to the literature of the subject which are all of accepted value. — British Medical Journal. Tyler Smith’s Obstetrics. A Course of Lectures. By W. Tyler Smith, M.D., Physician, Ac- coucheur, and Lecturer on Midwifery, &c. Edited by A. K. Gard- ner, M.D. With Illustrations. Octavo, .... $5.00 Toynbee on Diseases of the Ear. Their Nature, Diagnosis, and Treatment. A new London Edition, with a Supplement. By James Hinton, Aural Surgeon to Guy’s Hospi- tal, &c. With Illustrations. Octavo, . . . $5.00 Thompson’s Clinical Lectures on Pulmonary Consumption, octavo, $2.00 Tyson’s Cell Doctrine: Its History and Present State, with a Copious Bibliography of the Sub- ject, for the use of Students of Medicine and Dentistry. By James Tyson, M.D., Lecturer on Microscopy in the University of Pennsyl- vania, dec., &c. With a Colored Plate, and numerous Illustrations on Wood. Price, $2.00 Dr. Tyson furnishes in this work a concise and instructive resume of the origin and advance of the doctrine of Cell Evolution. In it we find the theories of Virchow, Robin, Huxley, Hughes, Bennett, Beale, and other distinguished men. Its pages contain what could otherwise only be learned by the perusal of many works, and they supply the reader with a continuous, complete, and general knowledge of the history, progress, and peculiar phases of the Cell Doctrine, accompanied by careful references and a copious bibliography. Virchow’s Cellular Pathology. Translated from the Second Edition. By Frank Chance, B.A., M. A., &c. With Notes and Emendations, and 144 Engravings. 8vo. $5.00 Trousseau’s Clinical Lectures. VOL. IV. NOW READY. Lectures on Clinical Medicine, delivered at the Hotel-dieu, Paris. A. Trousseau, Professor of Clinical Medicine in the Faculty of Medi- cine, Paris, &c., &c. Trousseau’s Lectures on Clinical Medicine, so favorably received, as well by tbe profession of the United States as abroad, are published in this country in connection with the New Sydenham Society, under whose auspices the translation of Vols. II. and III. have been made. Either of these volumes can be furnished separately, and in order to still further extend the circulation of so valuable a work, the Publishers have now reduced the price to Five Dollars per volume. Contents of Volume I. — Translated and Edited by P. Victor Bazire, 31. D., 3fc.— Lecture 1. On Venesection in Cerebral Haemorrhage and Apoplexy. 2. On Apoplec- tiform Cerebral Congestion, and its Relations to Epilepsy and Eclampsia. 3. On Epilepsy. 4. On Epileptiform Neuralgia. 5. On Glosso-laryngeal Paralysis. 6. Pro- gressive Locomotor Ataxy. 7. On Aphasia. 8. Progressive Muscular Atrophy. 9. Facial Paralysis, or Bell’s Paralysis. 10. Cross-paralysis, or Alternate Hemiplegia. 11. Infantile Convulsions. 12. Eclampsia of Pregnant and Parturient Women. 13. On Tetany. 14. On Chorea. 15. Senile Trembling and Paralysis Agitans. 16. Ce- rebral Fever. 17. On Neuralgia. 18. Cerebral Rheumatism. 19. Exophthalmic Goitre, or Graves’ Disease. 20. Angina Pectoris. 21. Asthma. 22. Hooping Cough. 23. On Hydrophobia. Contents of Volume II.—Translated from the Edition of 1868 (being the last revised and enlarged edition), by John Rose Cormack, 31. D., Edin., F.R.S.E., —Lecture 1. Small-pox. 2. Variolous Inoculation. 3. Cow-pox. 4. Chicken-pox. 5. Scarlatina. 6. Measles, and in particular its unfavorable Symptoms and Complications. 7. Rubeola. 8. Erythema Nodosum. 9. Erythema Papulatum. 10. Erysipelas, and in particular Erysipelas of the Face. 11. Mumps. 12. Urticaria. 13. Zona, or Herpes Zoster. 14. Sudoral Exanthemata. 15. Dothinenteria, or Typhoid Fever. 16. Typhus. 17. Membranous Sore Throat, and in particular Herpes of the Pharynx. 18. Gangrenous Sore Throat. 19. Inflammatory Sore Throat. 20. Diphtheria. 21. Thrush. Contents of Volume III.—Translated from the Edition of 1868, by John Rose Cormack, M.D., Edin., F.R.S.E., 3fc.—Lecture 22. Specific Element in Disease. 23. Contagion. 24. Ozaena. 25. Stridulous Laryngitis, or False Croup. 26. (Edema of the Larynx. 27. 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Wythes’ Physician’s Pocket,Dose,and Symp- tom Book. THE TENTH EDITION. Containing the Doses and Uses of all the Principal Articles of the Materia Medica, and Original Preparations; A Table of Weights and Mear sures, Rules to Proportion the Doses of Medicines, Common Abbre- viations used in Writing Prescriptions, Table of Poisons and Antidotes, Classification of the Materia Medica, Dietetic Preparations, Table of Symptomatology, Outlines of General Pathology and Therapeutics, &c. By Joseph H. W ythes, A.M., M.D., &c. The Tenth Revised Edition. Price, in cloth, ........ $1.00 “ leather, tucks, with pockets, .... 1.25 This little manual has been received with much favor, and a large number of copies sold. It was compiled for the assistance of students, and to furnish a vade mecum for the general practitioner, which would save the trouble of reference to larger and more elaborate works. The present edition has undergone a careful revision. The thera- peutical arrangement of the Materia Medica has been added to it, together with such other improvements as it was thought might prove of value to the worx. Waring’s Practical Therapeutics. NEW EDITION. Considered chiefly with reference to Articles of the Materia Medica. By Edward John Waring, F.R.C.S., F.L.S., &c., &c. Second American, from the Third London Edition. Royal Octavo. Price, in cloth, $5.00. Price, in leather, $6.00. There are many features in Dr. Waring’s Therapeutics which render it especially valuable to the Practitioner and Student of Medicine, much important and reliable in- formation being found in it not contained in similar works; it also differs from them in its completeness, the convenience of its arrangement, and the greater prominence given to the medicinal application of the various articles of the Materia Medica in the treatment of morbid conditions of the Human Body, &c. It is divided into two parts, the alphabetical arrangement being adopted throughout; there is also added an excel- lent Index of Diseases, with a list of the medicines applicable as remedies, and a full Index of the medicines and preparations noticed in the work. “This new edition of Waring’s Practical Therapeutics has been altered and improved with great judgment. A satisfactory account of new agents — chloral, apomorphia, nitrous oxide, carbolic acid, &c., is introduced without adding to its bulk. The additions are made with remarkable skill in condensation. It is one of the best manuals of therapeutics yet in existence.” — British Medical Journal. “ Our admiration, not only for the immense industry of the author, but also of the groat practical value of the volume, increases with every reading or consultation of it. We wish a copy could be put in the hands of every student or practitioner in the country. In our estimation it is the best book of the kind evei written.” — N. Y. Medical Journal. Walker on Intermarriage. Or, the Mode in which, and the Causes why, Beauty, Health, and Intellect result from certain Unions, and Deformity, Disease, and Insanity from others. With Illustrations. By Alexander Walker, Author of “ Womanf “Beauty,” dc., dc. 12mo. .... $1.50 LINDSAY AND BLAKISTON'S PUBLICATIONS. Walton’s Operative Ophthalmic Surgery. By Haynes Walton, F.R.C.S., Surgeon to the Central London Ophthal- mic Hospital, &c. With 169 Illustrations. Edited by S. Littell, M.D., Surgeon to the Wills Hospital for the Diseases of the Eye, &c. Octavo. $4.00 “ It is eminently a practical work, evincing in its author great research, a thorough knowledge of his sub- ject, and an accurate and most observing mind.” — Dublin Quarterly Journal. Watson’s Practice abridged. A Synopsis of the Lectures on the Principles and Practice of Physic. De- livered at King's College, London, by Thomas Watson, M.D., Fellow of the Royal College of Physicians, &c., Ac. 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Cloth. ....... $1.25 “Few affections are more unmanageable and more troublesome than those of which this essay treats; and we doubt not that any suggestions by which we can relieve them will be gladly received by physicians. The author’s plan is simple and practical. He treats of headaches in childhood and youth, in adult life and old age, giving in each their varieties and symptoms, and their causes and treatment. It is a most satis- factory monograph, as the mere fact that this is a reprint of the fourth edition, testifies “The great pains which the author takes to clear up the differential diagnosis of the different varieties, and establish a satisfactory basis for rational treatment, are every - where visible. While such a valuable fund of information is offered to the practitioner at the cost of a single visit, he should not let his patient suffer for want of it.” - • Medical and Surgical Reporter. Wells on Long, Short, and Weak Sight, and their Treatment by the Scientific Use of Spectacles. Third Edition Re- vised, with Additions and Numerous Illustrations. By J. Scelberg Wells. Octavo. ..... Price, $8.06 DENTAL BOOKS PUBLISHED BY LINDSAY & BLAKISTON, No. 25 South Sixth Street, above Chestnut, PHILADELPHIA. Harris’s Principles and Practice of Dentistry. THE TENTH REVISED EDITION. In great part Re-written, Re-arranged, and with many New and Important Illustrations. INCLUDING 1. Dental Anatomy and Physiology. 2. Dental Pathology and Therapeutics. 3. Dental Surgery. 4. Dental Mechanics. By Chapin A. Harris, M.D., D.D.S., &c. The tenth edition, revised and edited by P. H. Austen, M.D., Professor of Dental Science and Mechan- ism in the Baltimore College of Dental Surgery, with nearly 400 Illustra- tions, including many new ones made especially for this edition. One volume, Royal Octavo, bound in Cloth, .... $6.50 “ “ “ Leather, . . . 7.50 The subscribers, in presenting to the Dental Profession The Tenth Re- vised Edition of the late Prof. Harris’s Text-Book of Dentistry, desire to call their attention to the thorough revision, and modification in its arrangement which it has been found necessary to make, in order to bring it fully up to the present advanced state of the science, and to preserve for it that reputation which it has for so many years sustained, as being the first and leading book on the subject in the English language. So great have been the advances in Dental Physiology, Pathology, Sur- gery, and Mechanism, that a revision in all its parts, more complete and thorough than has been made to any previous edition —amounting, in some cases, to a re-writing of the articles or subjects — had become imperative ; and in order to have this done in the most efficient manner, the publishers were, fortunately, able to secure the valuable services of Prof. Austen, of the Baltimore Dental College, who, added to his experience of twenty years as a teacher, was, for a long time, the associate and friend of Dr. Harris. He was thus peculiarly fitted for this task. In order, however, to render the work the more perfect and acceptable to the Profession, Dr. Austen associated with him Prof. Gorgas and Thomas S. Latimer, M.D., of the same school, both gentlemen of acknowledged proficiency in their respective departments, and further obtained valuable original articles from Prof. Kingsley, of the New York Dental College, whose reputation is well known, and other gentlemen of the Profession of equal repute in their respective specialties. The publishers, therefore, offer this edition to the Profession with the utmost confidence that it will be found most complete in every respect as a text-book for the student and a guide and companion for the experienced practitioner. Harris’s Dictionary. the third revised ed.?tion. A Dictionary of Medical Terminology, Dental Surgery, and the Collateral Sciences. By Chapin A. Harris, M.D., D.D.S., Pro- fessor of the Principles of Dental Surgery in the Baltimore College, .Member of the American Medical Association, &c., &c. The Third Edition, carefully revised and enlarged, by Ferdinand J. S. Gorgas, M.D., D.D.S., Professor of Dental Surgery in the Baltimore College, &c., &c. In one volume, Royal Octavo, bound in Cloth, . $6.50 “ “ “ “ Leather, . 7.50 For a long period after the death of Dr. Harris his Dictionary remained out of print, but a constantly increasing demand for it from the Profession and from students urged the publishers to the preparation of a new edition. The many advances in dental science made during this interim rendered the incorporation of many new terms and formulae absolutely necessary to the student of Dentistry, as well as to the dental practitioner. The present edition has been thoroughly revised by Prof. Gorgas, Dr. Harris’s successor in the Baltimore Dental College i and in a very satisfactory manner, nearly three thousand new words have been incorporated into it, besides additions and corrections hemg made to many others. The doses of the more prominent medicinal agents have also been added, and in every way the book has been greatly improved, and its value enhanced as a work of reference. To those studying or practising Dentistry it must prove in- valuable. Heath on the Iniuries and Diseases of the Jaws. The Jacksonian Prize Essay of the Royal College of Surgeons of England, 1867. By Christopher Heath, F.R.C.S., Assistant Surgeon to Uni- versity College Hospital, and Teacher of Operative Surgery in University College. Containing over 150 Illustrations. Octavo,* . . $6.00 This work is of the highest practical value. It treats of dislocations, fractures, deformities, and other disorders of the jaws, with the means for relief, illustrated by drawings of displacements, apparatus, morbid growths, portraits of patients, etc., to the number of 154. It embodies American as well as European experience, and con- tains quite a large appendix of cases in detail. The practical character of its contents, with good paper, print, and engravings, strongly commend this book to the profession. Every surgeon and dentist should have a copy. — Dental Cosmos. It is impossible to over-estimate the value and importance of this comprehensive work. — British Journal of Dental Science. The concise descriptions and excellent arrangement make this monograph valuable for reference. —British Medical Journal. Coles on Deformities of the Mouth, Congenital and Acquired, with their Mechanical Treatment. By James Oakley Coles, D.D.SMember of the Odontological Society, &c., &c. Second Edition, Revised and Enlarged, with 8 Colored Engravings and 51 Illustrations on Wood. ....... $2.50 The second edition of this work shows that the author has continued to devote him self with zeal to the investigation and treatment of a very interesting class of cases. Mr. Coles has especially studied the congenital cleft palate, and has, with the mirror, detected, in several cases, growths in the naso-pharyngeal tonsil. Very beautiful colored drawings are given in illustration of the subject of cleft palate. Mr. Coles gives the preference to mechanical treatment, in both congenital and pathological perforations of the palate, and his experience as to the good results obtained is cer- tainly most encouraging. We recommend the work to the study of both surgeons and dentists. London Lancet. Taft’s Practical Treatise on Operative Den- tistry . a NEW EDITION, THOROUGHLY REVISED. By Jonathan Taft, D.D.S., Professor of Operative Dentistry in the Ohio College of Dental Surgery, &c. The Second Edition, thoroughly Revised, with additions, and fully brought up to the present state of the Science. Containing over 100 Illustrations. Octavo. Leather, . . $4.50 The first edition of Dr. Taft's work imparted a new impulse to the practice cf Oper- ative Dentistry. In the early days of the profession, excellence, as am operator, was attainable only by long years of industrious practice. Now, many of the best opera- tors are found among those comparatively young; and perhaps no single agency has done more to produce this result than this volume of Professor Taft in systematically and clearly setting forth the attained truths of our science in such a way as to be acces sible to all. The second edition contains nearly fifty additional pages of matter, and the whole work is carefully revised, with a labor but little, if ary, short of the preparation of an entirely new volume. — Dental Register The first edition of this “Practical Treatise on Operative Dentistry,” by Prof. Taft, published in 1859, has become very familiar to the dental practitioner and student, and its value universally acknowledged. It is with pleasure, therefore, that we note the issue of a revised edition, which the author’s industry has made still more worthy of professional attention. —American Journal of Dental Science. Professor Taft has done good service to the profession in thus embodying, in a sep- arate volume, a comprehensive view of Operative Dentistry. This gentleman’s position as a teacher must have rendered him familiar with the most recent views which are entertained in America on this matter, while his extensive experience and well-earned reputation in practice must have rendered him a competent judge of their merits. We willingly commend Prof. Taft’s able and useful work to the notice of the profession. — London Dental Review. Richardson’s Practical Treatise on Mechani cal Dentistry. SECOND EDITION, MUCH ENLARGED. By Joseph Richardson, D.D.S., Professor of Mechanical Dentistry in the Ohio College of Dental Surgery, &c. With over 150 beautifully exe- cuted Illustrations. Octavo. Leather ..... $4.50 When the first edition of this work made its appearance, we gave a favorable notice of it. It is only necessary now to add that the second contains all the improvements in this department of Dentistry of the past ten years. Many additions have been made and other parts have been entirely re-written. —Dental Cosmos. Dr. Richardson’s work is justly regarded as indispensable to the dentist. Rejecting all that is useless, and conveying his ideas without the verbiage in which too many encumber their thoughts, he has given to us a concise statement of what is to be done by the mechanical dentist, and how to do it. — Dental Laboratory. Prof. Richai Ison is thoroughly and minutely acquainted with every topic he attempts to discuss, boln in theory and practice. He exhibits a knowledge of the hidden nooks and corners of the dental laboratory quite refreshing, in view of the superficial treat- ment the subject has usually received. He selects one great and important branch of dental science, and exhausts it, placing it in such plain and practical form so that every student sees and understands its merits at a glance. —N. Y. Dental Journal. This work does infinite credit to its authbr. Its comprehensive style has in no way interfered with most elaborate details where this is necessary; and the numerous and beautifully executed wood-cuts with which it is illustrated render this volume as at- tractive as its instructions are easily understood. — Edinburgh Med. Journal. After a careful perusal, we have no hesitation in commending the book to our readers as a good practical work, the illustrations of which greatly surpass, so far as we are aware, any other American work on the subject. — London Lancet. The scope of the whole work is thoroughly carried out, and to any one desiring a theoretical knowledge of Dental Mechanics, Dr. Richardson’s book will be found a most efficient guide. — British and Foreign Medico-Chirurg. Review. Robertson’s Manual on Extracting Teeth. A NEW REVISED EDITION. Founded on the anatomy of the parts involved in the operation, the hinds and proper construction of the instruments to be used, the accidents likely to occur from the operation, and the proper remedies to retrieve such acci- dents. By A. Robertson, M.D„ D.D.S., &c. Second Edition. $1.50. The author is well known as a contributor to the literature of the profession, and as a clear, terse, and practical writer. The subject is one to which he has devoted con- siderable attention, and is treated with his usual care and ability. The work is valu- able, not only to the dental student and practitioner, but also to the medical student and surgeon.—Jiental Cosmos. Bond’s Practical Treatise on Dental Med- icine. FOURTH EDITION IN PREPARATION. Tomes’ System of Dental Surgery. With 208 Illustrations ........ $4.50 Fox on the Human Teeth. Their Natural History, Structure, and Treatment of the Diseases to which they are Subject. With 250 Illustrations. .... $4.00 Sansom on Chloroform. Its Action and Administration, by Arthur Ernest Sansom, M.B., Physician to King’s College Hospital, &c., &c. 12mo . . . $2.00 The work of Dr. Sansom may be characterized as most excellent. Written not alone from a theoretical point of view, but showing very considerable experimental study, and an intimate clinical acquaintance with the administration of these remedies ; pass- ing concisely over the whole ground, giving the latest information upon every point, it is just the work for the student and practitioner. 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The subject is divided into three parts: — Mineralogy, ora Descrip- tion of the Appearance of Minerals, with the localities in which they may or have been found; Assaying, or an Investigation of the value of Minerals, by means which are within the reach of every one; and Practical Mining in its simplest form. Piggott on Copper Mining and Copper Ore. Containing a full Description of some of the Principal Copper Mines of the United States, the Art of Mining, the Mode of Preparing the Ore for Market, Ac., Ac. By A. Snowden Piggott, M.D., Practical Chemist. 12mo 81.50 prices reduced of Lindsay & Blakiston’s PHYSICIAN’S VISITING LIST. NOW READY FOR 1872. “The simplest of all the visiting lists published, it must continue to hold, what it now has, the preference over all other forms of this indispensable companion for the Physician.”—New York Med. Journal. 1. Table of Signs, or Guide for Registering Visits, En- gagements, &c. 2. An Almanac 3. Marshall Hall’s Ready Method in Asphyxia. 4. Poisons and their Antidotes. • 5. Table for Calculating tlie Period of Utero-Gestation. 6. The Visiting List arranged for 25, 50, 75, or 100 Patients. OOITTE1TTS. 7. Memoranda pages for every month in the year. 8. Pages for Addresses of Patients, Ac. 9. “ Hills and Accounts asked for and de- livered. 10. “ Obstetric Engagements. 11. “ Vaccination. 12. “ Recording Obstetric Cases, Deaths, and for General Memoranda. SIZES AND PRICE. For 25 Patients weekly. Tucks, pockets, and pencil, . . . • . $1 00 50 “ “ “ “ “ 1 25 75 “ “ “ “ “ 1 50 100 “ “ “ “ “ 2 00 50 .. “»!*.{££ 5 Sr-} “ 2 50 100 “ “2vols.Haf tt°£une l (July to Dec. / “ 3 00 Also, AN INTERLEAVED EDITION, for the use of Country Physicians and others who compound their own Prescriptions, or furnish Medicines to their patients. The additional pages can also be used for Special Memoranda, recording important cases, &c., &c. For 25 Patients weekly, interleaved, tucks, pockets, etc., . . . . Si 50 50 “ “ “ “ “ “ .... 1 75 50 - « } “ “ . . . . 3 00 This Visiting List has now been published for Twenty Years, and has met with such uniform and hearty approval from the Profession, that the demand for it has steadily increased from year to year. The Publishers, in order to still further extend its circulation and useful- ness, and to keep up the reputation which it has so long retained, of being THE CHEAPEST AND BEST, as well as the Oldest Visiting List published, have now mgde a very considerable reduction in the price. It can be procured from the principal booksellers in any of the large cities of the United States and Canada, or copies will be forwarded by mail, free of postage, by the Publishers, upon receipt by item c i the retail price as annexed. In ordering the work from other booksellers, order Lindsay & Blakiston’s Physician’s Visiting List. And in all cases, whether ordering from the Publishers or otherwise, pecify the size, style, &c., wanted. LINDSAY & BLAKISTON, Publishers, 25 South Sixth St., Philadelphia.