GENERAL OBSERVATIONS.
Hospitals, and hospices, are numerous in Paris. The latter establishments are for the reception of the aged and infirm, or foundlings. Some of the hospitals are general in their principle of administration; while others are appropriated to particular age, or sex, or disease.
A board of general administration is held daily for the purpose of examining the patients who apply for admission. By means of this arrangement, the physician of any hospital whose attention is directed to a particular disease, or class of diseases, may send a patient to the hospital to which he is attached. The attention of the medical officers of the different hospitals is highly laudable, and worthy of imitation. They make their visits of regular attendance in the wards daily, and usually at the earlyhour of seven, and deliver clinical lectures on the most interesting cases at nine. I was present at these lectures, both at the Hotel Dieu and at La Charité, and was much gratified with the ability displayed by M. Dupuytren at the former, and by M. Laennec at the latter hospital.
In most of these abodes of suffering, the sisters of charity exercise the kind office of superintending nurses, in which capacity, however, their humanity leads them to perform various active duties. It is quite delightful to witness the benevolence of their disposition, and the tender manner in which they pay their attentions to those under their pious care. How happily is the influence of religion here displayed, which can thus temper the mind to forego the pleasures of society, and even the common enjoyments of life, for a retirement, in which every hour and almost every moment, eachthought and action, become a homage to the Creator, in the alleviation of human suffering!
There is an establishment in Paris which contributes exceedingly to the comfort and convenience of that class of persons who wish to avoid a hospital, but whose means are too limited to afford all the private aids which sickness requires[4]. I quote the following account of it from Galignani’s Guide to Paris.
“MAISON ROYALE DE SANTÉ.
“This house was opened in 1802 by theAdministration des Hôpitaux et des Hospices, for the reception of invalids in middling circumstances, who pay a daily sum according to the accommodation they receive, as follows, viz. In rooms containing twelve or fourteen beds, two francs fifty cents; in those with two or three beds, three francs fifty cents. A room for a woman, five francs. A room for a man, six francs. In this charge, every thing, even vapour baths, mineral waters, &c. is included.”
“This house was opened in 1802 by theAdministration des Hôpitaux et des Hospices, for the reception of invalids in middling circumstances, who pay a daily sum according to the accommodation they receive, as follows, viz. In rooms containing twelve or fourteen beds, two francs fifty cents; in those with two or three beds, three francs fifty cents. A room for a woman, five francs. A room for a man, six francs. In this charge, every thing, even vapour baths, mineral waters, &c. is included.”
That a material difference exists between the French and English practice of medicine, is universally known; and the compliment of superiority is seldom allowed to the former. Improvement, however, in the art of medicine, which the successful cultivation of chemistry and of morbidanatomy has so largely introduced in the last twenty years, is not confined to ourselves. The professors of chemistry at Paris receive their appointments and their conveniences from the government. That valuable commodity, time, is much at their command, because they confine their pursuits more than most of those who are engaged in teaching chemistry in London. The facility of procuring, at Paris, the examination of dead bodies is such as to favour the study of morbid anatomy most completely.
The general objection amongst the French to the use of calomel prevails almost as strongly as at former periods; and certainly amounts to a prejudice. I learnt, on good authority, at Paris, that this medicine is usually found to act in a peculiar manner on the constitution of the French patient; as it commonly produces irritation in theintestinal canal to a degree that causes extreme discomfort. I need not relate with what freedom and satisfaction the English make use of this active medicine.
I apprehend that the difference of operation is to be ascribed chiefly to the respective nature of the diet in the two countries. The remark applies most particularly to the free use of light wines, amongst the French. The vin ordinaire must produce very different effects from the English malt liquor; or the use of plain or soda water, in conjunction with wines of more sound quality. Indeed the difference of regimen appears to me a sufficient explanation. I may here remark how very materially the action of mercurial medicine on the bowels is controuled by suitable preparation of the patient with mild mucilaginous drinks. If, on the contrary, the stomach and intestinal canal be chargedwith acescent liquor, vinous, or of any other kind, acescent food, and fresh fruits, irritation and disorder, more or less painful, may be expected as almost a certain consequence.
If the French employ calomel or other preparations of mercury too little, we doubtless run into the opposite error, of using them too much. It calls for the gravest censure, that, in almost every nursery, calomel should still be administered by the parent to young children and even infants, with as little consideration as if it were a simple domestic medicine. I am convinced that the infantile constitution is frequently most sensibly injured by so erroneous a practice, and that the scrophulous disposition, which might otherwise be dormant, is thus called into action at an early period of life. I think it ought to be an established rule, that mercurial medicine should not beadministered to young children without the sanction of medical authority.
I wish, however, to be understood, that in speaking of the employment of calomel generally, I censure its abuse only. The proper use of it deserves our confidence and best regard; and I think that the French physician labours under great disadvantage in not having a just practical acquaintance with the virtues of this excellent medicine, which, as a remedy in various kinds of active disease, is without a rival.
Chiefly on the principle of avoiding the frequent use of internal medicine, it is a custom universal among the French to assist the bowels by lavement; which, under circumstances of disease, is variously medicated, but otherwise consists merely of water or gruel.
As an occasional remedy, this practice is most useful and important; and, in certain cases of great delicacy of constitution, it may be a very advisable substitute for aperient medicine, however regularly it may be required: but under ordinary circumstances, as a habit, it appears to me as objectionable in other respects as it is inconvenient. When the bowel becomes much accustomed to this artificial distension, it often fails to act without receiving such solicitation; and hence a mechanical necessity is established for this peculiar stimulus[5].
When the digestive powers of the stomach are unhealthy, and particularly when the functions of the duodenum and of the liver are also in error, as we usually see in established disorder of the chylopoetic viscera, the propagated influence which may take place from the lower bowel being stimulated to discharge its contents by means of the lavement, is insufficientto remedy the functional error existing so much higher up in the canal, and I have witnessed examples in which serious complaint in the liver has made insidious progress, from the circumstance of the patient having placed reliance on this palliative relief, and neglected the employment of an effective course of medicine.
The application of leeches, with a view to derive blood from the vessels which communicate with those of the lower bowels, is a practice quite common in France, and seems a favourite measure, whatever viscus of the body may be affected. I have no doubt of the utility of this mode of obtaining blood, when the lower part of the intestinal canal is in a state of congestion; and, I may add, in many cases of irritation. A gentleman had been troubled with diarrhœa, which was often painful, for two or three months. It had resisted theusual treatment by medicine. By one application of leeches near the rectum he was cured.
Nature often points out the propriety of relieving the overloaded circulation of the intestines, by the discharge of blood from the hemorrhoidal vessels, and when, therefore, the indications for such a mode of evacuation are presented, without any spontaneous relief having taken place, the use of leeches is important. Also in certain states of congestion of the uterine vessels, this method of local depletion will be attended with advantage.
In all cases of inflammation near the surface, in which the detraction of blood is proper, the application of leeches is a very eligible mode of treatment. I apprehend that blood is drawn from a greater number of capillary vessels by this method than byany other; such abstraction being favoured also by the gradual and protracted evacuation of the vessels. It remarkably relieves inflammatory action, either of the acute or chronic kind, in the stomach and bowels. It is by no means so effectual in maladies of the head and chest, in which cupping is a better mode of taking away blood; although occasionally, even in those complaints, the use of leeches may be more convenient, and even more appropriate.
Comparatively speaking, the practice of taking away blood by cupping is very rarely resorted to by the French, and they appear to prefer, in principle, the mode of bleeding by leeches, which they call derivative; thus for the relief of the head, they apply them in the neighbourhood of the rectum. That free cupping at the neck or behind the ears, or opening the jugular vein when the vessels of the head are in a stateof congestion and increased action, is a far more efficacious treatment, appears to me most unquestionable.
I consider it to be an important principle of treatment in regard to the detraction of blood, in local inflammation, that we should make it from the system, when the action of the heart is much increased beyond the natural standard. When we have sufficiently reduced the pulse, or, if in the first instance the general circulation do not appear to be affected, it may be preferable to use cupping or leeches only.
In active inflammation of any of the important organs of the body, thedecidedconduct of the English practitioner in using the lancet as his chief remedy, promptly and boldly, and persisting till the dangerous force of the disease is conquered, demands, in my opinion, an undoubted preferenceover the more tardy, and I must add, the inefficient methods of the French. This leading difference in the method of treating dangerous inflammations, appears to me to constitute the most remarkable distinction in the practice of the English and the French physician.
I believe that severe and dangerous diseases are much less frequent amongst the French than the English. There are physical and moral causes to explain this fact. Their climate is less variable, and less humid, than ours. They use a lighter diet; much more bodily exercise, and they are a more cheerful people, constantly cultivating amusement. Hence, probably, the general plan of French practice is simple; and the use oftisanesandlavemens emolliensis generally preferred to the employment of active medicines.
The pharmacien is not in any case permitted to prescribe; and no one can open a shop for the sale and preparation of medicines, without the permission of the authorities.
La médecine expectanteis still the favourite method of practice with many of the French physicians. I cannot undertake to say how generally. When the principle is directed by a clear judgment, there is much in it to be admired. A constant and too officious interference by means of active medicines, may do serious injury to the powers of the constitution; and, on such terms, the remedy may be worse than the disease: but, on the other hand, to look on passively as a spectator, and witness the formation of disease, forbearing all active treatment until formidable symptoms take place, seems more reprehensible even than excess of zeal in the use of medicine.I approve the maxim,Venienti occurrite morbo.
In inflammations of the most important organs of the body, if we allow delay, or want decision, the moment of being useful soon passes away. It is incumbent upon us always to pay due attention to natural indications, and to consider nature in the light of a good physician; but I maintain that, in all instances of acute disease, and for the most part in chronic, we may interpose our aid with certain benefit, if we form a correct diagnosis, and come armed with just principles of practice.
Within the last few years, new medical doctrines[6]have been introduced in France,by M. Broussais, Professor at the Hôpital du Val-de-Grâce at Paris; of which, the most important part relates to the inflammation of the mucous membrane of the alimentary canal. This inflammation is divided into acute and chronic, and is denominated according to its situation;gastrite, when affecting the stomach;gastro-enterite, when it extends from the stomach to the small intestines; andcolite, when confined to the colon.
The great importance of the functions of the stomach and intestines, and the active sympathies which the stomach especially exchanges with every part of the body, almost as a centre of the nervous system, is one of the medical truths first taught in our schools, and is constantly demonstrated to our observation, both in health and sickness. But M. Broussais has extended to an unauthorized length, his theories foundedon the inflammatory affection of the mucous membrane of the digestive canal; so that, if I mistake not, he assigns to it almost an universality of influence.
Our acquaintance with thegastro-enterite, is a key to the whole pathology of this Professor, who has taken a great lead in Paris, and formed a school of his peculiar doctrines. He considers that all the essential fevers of authors are only various forms of sympathetic phenomena, arising out of a gastro-enterite; that all the pretended nervous affections of the stomach are the result of a chronic gastrite; that the various dangerous disorders of the brain, for the most part, owe their origin to the state of the digestive passages, irritated with chronic disease; that in all the febrile phlegmasiæ, the stomach and small intestines are irritated in the commencement, if not during the whole progress of the malady; that thegout depends commonly on a chronicgastro-enterite, “which prepares and supports the irritation of the joints.”
He considers thatgastriterarely exists alone, and that it is almost constantly joined with an inflammation of the small intestines.
He does not admit that there is any essential difference in the nature of gout and rheumatism.
This is a very concise epitome of the doctrines of M. Broussais, and is offered only as an outline.
The practice which is founded on this view of most of the diseases of the body is remarkably simple, and may be almost included in the free and repeated application of leeches to the most affected part of the abdomen; the use of fomentations andpoultices to the seat of irritation; of emollient lavemens; of tisanes calculated to allay irritation; of the mildest nutriment, as veal broth with rice; also the greatest care is used to avoid every irritating material, whether medicinal or dietetic; and, to favour all these means by entire repose and time. The gravest fevers of the East and of the West; the plague itself; the fevers of our own country, continued or intermittent, typhoid or inflammatory, and the phlegmasiæ, appear to be all arranged under the same general principle of treatment.
From the observations which I had the opportunity of making at the hospitals in Paris, and from the attention I have since devoted to the examination of these doctrines, I am far more inclined to borrow, occasionally, from the opinions of M. Broussais, than implicitly to follow his theory or practice.
I am persuaded that the idea of inflammation of the mucous membrane, founded on the morbid appearance of the tongue, and a dry and heated state of the surface of the body, is often too strongly entertained. When the tongue is wholly red and dry, or red in part, with whitish or yellow fur on its edge, the inference may be fairly drawn, that the digestive organs are in a morbid condition, and which is further shewn by the loss of appetite, and by the state of unnatural thirst. I admit also that in these circumstances, there is a great susceptibility to inflammatory action in the mucous membrane of the stomach and small intestines; and the knowledge of this fact should make us extremely careful in the employment of any heating stimulus, medicinal or dietetic, in the treatment of fevers, or of the phlegmasiæ. I am also aware, that, in many cases of fever, terminating fatally, the morbid appearances ondissection will be found chiefly in the mucous membrane of the alimentary canal, but also in the mucous membrane of the bronchiæ; thus lending great support to the doctrines of M. Broussais. On the other hand, I have had occasion to notice deductions, in my opinion, too hastily drawn to be correct, from the mere appearance of redness here and there in the stomach and intestines, presenting to the zealous admirers of the doctrine in question, the full evidence of gastro-enterite. Respecting the precise interpretation due to such appearances on dissection, the best anatomists and pathologists will sometimes differ. I may here remark, that the inspection is now and then made too hastily and superficially: it is requisite that the state of the whole canal should be accurately traced. In the first view of the parts it may happen that scarcely any morbid appearance is discovered; but on extending the research, eventhe ulcerative process may be met with in patches: at La Charité I saw several examples exactly in point.
That an inflammatory state of the mucous digestive membrane is very influential upon the functions of the other organs, and of the brain especially, is unquestionable; but is it primary or consequential, in the order of occurrence? In reference to the question of continued fever, I apprehend that it is an effect, and not the primary cause of the general disease, which attacks the whole nervous system at once, afterwards producing disorder in parts of the body which are most predisposed to morbid action; and, certainly, it appears that such secondary disease most commonly falls upon the mucous membrane of the alimentary canal, and also on the bronchial membrane.
If in the outset of these observations I may seem to contradict my concluding remarks, I wish it to be understood that I admit the partial, but not the total, fitness of the doctrines in question. I object still more to the rigid practice which is enjoined of avoiding the use of purgative medicine, when the appearances of the tongue are such as I have described, notwithstanding that the patient may be free from nausea, or from tenderness or pain of the stomach or bowels. I consider that the preference is greatly due to our English practice of giving occasional doses of calomel, or some mercurial alterative, in combination with suitable purgatives, by means of which the vitiated secretions, always a source of irritation, are removed. But here again, I admit that we should look watchfully to the symptoms which may indicate the necessity or the propriety of applying, with freedom, leeches to theepigastric region, and subsequentfomentations, for the relief of inflammatory action, and of using purgative medicine, in such circumstances, with proportionate caution.
As a general statement, I would assert, that in the commencement of fever, continued, intermittent, or remittent, the action of an emetic, and of calomel joined with purgative medicine, is most beneficial and important; and the fear of producinggastro-enteriteby such measures, would lead us into the serious error ofomission.
In cases of confirmed indigestion, our improved modern pathology leads us to the employment of those means which remove inflammatory irritation; as, the application of leeches, and other local remedies; the use of mild corrective medicines, abstinence from food, which calls the digestive powers into much action, and general regimen.We avoid using bitters and stimulants to provoke that appetite which nature has so wisely denied during the irritation of disease.
In active inflammation of the intestines, existing in conjunction with their obstruction, it must be our first care to remove the inflammatory action by general and local bleedings, and to refrain from the use of purgative medicines by the mouth, till this first object is accomplished, in case that such medicine causes sickness and vomiting, and evidently aggravates irritation. I do not doubt that much mischief is often produced by the solicitude of the practitioner to remove obstructed action of the bowels, instead of directing his treatment to the removal of inflammation, as the immediate and primary object to be fulfilled.
I will here take occasion to offer a fewremarks on the subject of Gout and Rheumatism. The theoretical opinions advanced by M. Goupil to prove the identity of the two diseases, are to me quite unsatisfactory.
Gout never assails the husbandman who unites temperance with his labours; but he is not exempted from rheumatism in any of its forms. Gout is the disorder of peculiar constitutions, and of the adult age; but rheumatism occurs at every period of life, and to all constitutions.
On the assumption that gout is agastro-enterite, with a developement of irritation in the joints, purgative medicines are prohibited, and the free application of leeches to the affected parts is recommended as the chief curative treatment.
I admit that in some circumstances of the gouty paroxysm, the mucous digestivemembrane is affected with inflammatory irritation, requiring suitable and peculiar treatment; but, as a general principle of practice, I confidently advocate the use of alteratives and purgatives, and, with only occasional exceptions, disapprove of the employment of leeches as a remedy for the local part of the disease.
As in theory, so in practice, I believe that M. Broussais considers that rheumatism is to be viewed in the same light as the gout.
M. Laennec employs general bleeding in acute rheumatism; leeches in the chronic; and tartar emetic in both forms of the disorder.
An analytical examination of the points of doctrine and practice, which I have here briefly discussed, would lead me far beyondthe limits which I have intended to observe in this Essay; but I could not overlook the most interesting novelty which has, for the last five years, engaged the French school of medicine.
It is still a custom amongst the French physicians to employtisanes, which are decoctions or infusions of roots, herbs, flowers, or grains, as medicinal remedies on which they seem to place considerable reliance. The “formulaire pratique des Hôpitaux civils de Paris” contains nearly ninety prescriptions of different kinds of tisane. With us, the Lisbon diet drink, or the simple decoction of sarsaparilla, is the only medicine which we direct to be taken in quantity as a drink. But even sarsaparilla is given with more advantage, in a state of concentration, by using the cortical part of the root, exclusively, in which the whole virtue seems to reside.
I object to the general principle of using medicine in a state of large dilution. It is true that the French do not prescribe active substances in this form; but their fondness for these feeble agents, tends to establish inefficient and almost insignificant practice.
Diluent drinks are useful adjuncts to medicine; but I should think that a very limited number of tisanes would comprise all that can be considered either as useful or agreeable.
The nurse may safely act the part of the pharmacien in this department, but, at the same time, should be directed by the physician as to the preparation of suitable drinks. With this qualification, the attention of the French physician in nicely regulating the regimen of the sick chamber, is worthy of our imitation. The effect of the most useful and appropriate medicineswill often be frustrated, unless a corresponding care in the plan of diet be strictly observed.
To this mode of practical medicine peculiar to the French, which I have here criticised as not worthy of the skilful physician, there are some striking exceptions.
At the excellent Hospital St. Louis, chiefly appropriated to the treatment of the various diseases of the skin, and principally under the direction of Alibert and Biett, arsenical and other active preparations are administered without apprehension. They prefer small doses of arsenical solution, twice a-day for a continuance, to the use of large doses for a short time. Tincture of cantharides, in the dose of twenty drops twice a-day, is one of their favourite remedies, alternately with arsenic, in the treatment of the order Squamæ. Beforeemploying such medicines, however, they are careful to remove all inflammatory action from the system.
Subcarbonate of ammonia, dissolved in water, in the proportion of two drams to a pint and a half, and given in this quantity daily, is found useful in certain states of cutaneous irritation, apparently caused by a free employment of mercury for syphilis.
The inveterate disease calledlupusis very successfully treated by the application of an arsenical caustic. They allow the part to form a crust, before they apply a poultice or any emollient dressing.
Neither expence nor trouble is spared in making the artificial medicated baths. The alkaline bath, prepared by dissolving the subcarbonate of soda in the proportion of two pounds to the necessary quantity ofwater, is extremely useful when the skin is affected with scales.
The douche de vapeur affords great benefit in some obstinate local affections of the skin, when it is necessary to stimulate the vessels so as to bring about an entire change of action. This description of douche often proves useful in chronic rheumatism, and in sciatica, when existing in the chronic form.
I had the opportunity of witnessing the administration of tartar emetic in large doses, as a daily medicine, to patients under the care of M. Laennec. His method is to begin with one, two, or four grains, as the total quantity for the twenty-four hours.
A solution is made in the proportion of half or the whole of a grain, to half an ounce of simple or some lightly aromatic water,sweetened; and it is given every two hours. The patient is desired to drink very sparingly; for without this caution, the medicine would most probably produce too much of emetic effect. In the first instance, this result very commonly happens; but it is remarkable how soon the stomach accommodates itself to large doses of this active medicine. When its continued use produces sickness, syrup of white poppy is added, in the proportion of an ounce to half a pint of the antimonial solution; or, as an equivalent, a grain of extract of opium. The total quantity of the tartar emetic is very commonly increased to twenty grains and upwards in the twenty-four hours. I saw an elderly man, who had, in this space of time, on the preceding day, taken sixty grains without having experienced nausea, or any other inconvenience.
M. Laennec considers that the tartaremetic, when administered with the freedom which I have described, exerts a highly useful power in diminishing inflammatory action in continued fever, and in the phlegmasiæ; and he is most satisfied with its action, when, after the first day or two, it ceases to produce any sensible effect on the stomach.
Reflecting on the extraordinary circumstance of the exhibition of this active medicine in such immense quantity with seeming impunity, I thought it probable that the French preparation might be weaker than our own; but on comparing the crystals which I procured at Paris, with those prepared according to the London Pharmacopœia, I could not discover any difference; nor is there the least essential distinction in the mode of preparation, as directed by the London Pharmacopœia and the French codex. I have lately had many opportunitiesof prescribing tartar emetic on the principle of treatment which I have described; and I have been perfectly satisfied with its useful agency; but I have usually commenced with one grain, and never exceeded two grains, for the first twenty-four hours; nor found it necessary to go beyond eight in the progressive quantity; except in one case of insanity, in which sixteen grains were given daily for a short time, with the greatest advantage. In the quantity of two grains, it has usually produced considerable sickness for the first day or two; but afterwards, even the increased doses have seldom caused any nausea.
With some persons, however, the first dose of a quarter of a grain produces active sickness. It appears to me probable that the maximum of usefulness[7]is to be found ina moderate range of doses; and that it is desirable to avoid trying how much the stomach and the constitution will possibly bear. Have we a security that the accumulation of a very large quantity might not produce violent effects? Indeed, I am informed of an instance in which the amount of sixty grains was taken in divided doses in a short time; the direction being given that the medicine should be repeated till vomiting was produced. At length, such severe sickness did take place, as could not be restrained for many weeks.
In the treatment of active inflammation, I have usually joined nitre in moderate doses, with tartarized antimony, in a saline draught; and when the inflammatory action has so far yielded, that I have had confidence in not requiring the further use of the lancet, and therefore not apprehended the inconvenience to which I have adverted at page 27, of disguising the disease, I have added digitalis to the draught occasionally; thus obtaining a combination of sedative medicines of great efficacy; and, according to my experience, not disagreeing with the stomach during the active state of the disease.
We must always keep in mind that the effect of medicine is in the greatest degree relative to the particular disease for which it is administered, and to the force of such disease. The doses of active medicines are to be diminished as symptoms abate.
In the case of a gentleman suffering from enlargement of the liver, and with whom mercury in any form acted very unfavourably, I obtained the most satisfactory results from the use of tartar emetic as an alterative; this medicine never occasioning that nervous irritation which invariably attended the use either of calomel or the pilula hydrargyri.
The practice which I have here related, of administering large doses of tartar emetic, and that recommended by Dr. Hamilton, of the free use of purgatives, appear very opposite to the doctrines of Broussais, which inculcate such a tender regard to the susceptibility of the stomach and intestinal canal, as almost to discountenance the use of emetics and purgatives, from the apprehension of producinggastrite, orgastro-enterite.
We are greatly indebted to the ingenuityand industry of the French chemists for many important results in vegetable chemistry; and as the most valuable of all the discoveries made, I may mention the separation of the essential principle of the yellow bark (cinchona cordifolia) calledquinine; which, for medical use, is afterwards combined with sulphuric acid, forming the now well-known medicine, sulphate of quinine[8].
I do not consider it to be proved, that the sulphate of quinine embraces all the useful qualities of the entire bark; although, from its power in curing intermittent fever, we may conclude that it possesses the most important. Two of the principles which are removed by the process for obtaining the sulphate, namely, the quinic acid, and resin, must not be disregarded.
I have sometimes found the decoction of bark more acceptable to the stomach, and more useful, than the sulphate of quinine, and particularly grateful when given with the carbonate of potash and lemon juice in effervescence, adding also some tincture and syrup of orange peel.
Bark in substance very often oppresses the stomach, and seems to impair both the appetite and digestion, which in general become improved by the influenceof the sulphate of quinine. Indeed, formerly, when in the habit of directing large and frequent doses of the powder of bark for the cure of ague, I found it expedient almost to forbid food, seeing that the stomach was sufficiently occupied with the presence of the bark. It is scarcely necessary to observe, that, in some cases of ague, where the digestive organs, and the liver especially, are in fault, bark, in any form, is not the appropriate medicine for the cure.
The sulphate of quinine is unquestionably a powerful and excellent tonic, and at the same time does not stimulate unfavourably. I am accustomed to prescribe it with great success to patients convalescent from gout; to whom on all former occasions, bark in its other forms had proved unsuitable, tending to re-excite the gouty action.
The acetate of morphine is another ofthe new medicines derived from the French chemists, which we can administer advantageously to those individuals who are too much stimulated by the ordinary preparations of opium. The process[9]employed for the separation of morphine from opium, removes the resin, the narcotine, and meconic acid.
The black or Lancastrian drop owes its useful quality to the circumstance of its containing a larger proportion of acetateof morphine than the other principles of opium; but it is not so pure a preparation as the acetate ofmorphine, prepared as I have described.
It appears to me that half a grain of the acetate of morphine is about equal to a grain of the extract of opium.
When immediate relief from severe pain is sought to be obtained, and that opium does not materially disagree with the patient, a preference is due to the tincture of opium, as being a more powerful anodyne than any of the other preparations which I have mentioned. I have found, by experiment, that the resin, separated from the other parts of opium, has an anodyne power, not inconsiderable.
The hydrocyanic (prussic) acid is a valuable medicine, but requires, according tomy observation, more care in the administration of full doses, than any other medicine. It may be given in small doses, usually, without any inconvenience. When its qualities were first proclaimed, it was too highly extolled as a remedy in phthisis pulmonalis; and, from consequent disappointment, I conceive that its just merits are not sufficiently appreciated. In some cases of hectic fever, attended with urgent cough, I have procured the happiest effects from the use of this medicine. I have not, with the adult patient, in any instance, prescribed more than twenty-four minims as the total quantity, in twenty-four hours; and usually have confined myself to the extent of fifteen, always commencing with small doses.
In order that this medicine may be given with reliance on its properties, it is necessary that it should be kept in thedark, in a cool situation, and that the vial should be accurately stopped. I proceed to offer a cursory account of several of the other new medicines.
The alcoholic extract of nux vomica exerts a special and powerful influence on the spinal marrow, and has produced very beneficial effects in some urgent cases of paralysis. It may be given either in general or local palsy, provided that inflammatory action be not present; that there be no indications threatening apoplexy; and that due care be taken in its administration.
In order to obtain the beneficial effects of the medicine in very confirmed cases of paralysis, we are informed by M. Magendie, that the paralytic limbs should experience some convulsive action; and this, he says, usually takes place in the courseof a few days. Then the dose of the medicine is to be lessened. It is administered with most advantage in the form of a pill. A quarter of a grain is the least dose which need be used in the beginning for an adult; and it may be given twice or thrice in the day. The dose is to be increased according to its effects: and it is stated by M. Magendie, that some persons have borne the augmented quantity of thirty grains in the day: but from four to six grains per diem, is the maximum amount usually required. This distinguished physiologist mentions that, in Italy, the following tincture is very much employed for the treatment of paralytic limbs, by means of friction:
Alcohol, one ounce,Dry extract of nux vomica, three grains.
Alcohol, one ounce,Dry extract of nux vomica, three grains.
Dr. Edwards, at Paris, was successful with nux vomica in a case of amaurosis, orgutta serena, accompanied with a paralysis of the upper eye-lid. It has afforded great benefit in many cases of local paralysis, affecting different parts of the body in different examples.
A medical friend informs me, that he obtained very great advantage from this medicine in the treatment of a severe case of tic douloureux, after various other medicines had failed to give relief.
In a case of long standing paralysis of one of the lower extremities, I have had great cause to be gratified with the useful agency of the alcoholic extract, in relieving the symptoms of neuralgia. The patient, a gentleman between thirty and forty years of age, had been afflicted with occasional pains of great severity coming on suddenly, causing complete disability, lasting about twelve hours, and during such period, producingexquisite tenderness of the limb. With the abatement of pain, sleep followed; and, on awaking, this tenderness had so completely passed away, that he could bear a free handling of the parts; but the muscular power of the limb was weakened during the day, it was frequently affected with convulsive action, and its usual debility became much increased.
The case is in progress; but up to the present time the medicine has evidently produced good effects, and without causing any tetanic action of the muscles, which I have mentioned as being considered desirable in some cases; although an unusual sense of tightness was produced. Not the least pain has returned, and the limb is stronger. When I had increased the dose to a grain and a quarter during two days, the sense of tightness, joined with much feeling of weight, became troublesome, and Isuspended the use of the extract. In forty-eight hours these symptoms disappeared, and the medicine has been resumed without any kind of disagreement. I may add, with satisfaction, that the retentive power of the bladder, which had been for a long time affected, became materially improved.
It has been discovered by M. M. Pelletier and Caventou, that the nux vomica, the bean of St. Ignatius, and the upas poison, owe their active power over man and animals, to two particular vegetable alkalies, the strychnine and brucine.
Strychnineis procured in the state of crystals, by a complicated chemical process, from the nux vomica. Its action on the animal economy, as proved by experiments on dogs, is so extremely powerful, that one would conceive it to be inadmissible as a medicine; but M. Magendie relates that hehas administered it in paralytic cases with good effects. From an eighth to a quarter of a grain is the usual dose. Brucine has been found combined with strychnine in the nux vomica. In St. Ignatius’s bean, and in the upas, brucine bears a similar relation to that which cinchonine has to quinine in the cinchona barks, the strongest of which (cinchona cordifolia) contains the largest relative proportion of quinine. In the same manner the bean and upas, which are much more active substances than the nux vomica, contain little of the brucine, and much of strychnine. In the upas, strychnine is almost pure[10].
For medicinal purpose, brucine is procured from “la fausse angusture” (angustura ferruginea). The process is in mostrespects similar to that employed for strychnine. It is administered in pills, and has been employed in paralytic cases with reported success by M. Magendie, and by M. Andrals fils, in doses from half a grain to five grains; and it is assuredly a much safer preparation than strychnine.
The active properties of ipecacuanha have been found by M. M. Magendie and Pelletier, to reside in an immediate principle which they have calledemetine. They consider that it may be advantageously substituted for ipecacuanha, as an emetic, it being divested of the offensive odour and taste of that substance, and which M. Caventou found by experiment to be foreign to the emetic qualities of the medicine. As an emetic, from a quarter to a whole grain in solution may be first given, and a quarter or half a grain repeated every twenty minutes till the due effect be produced.
Veratrineis an alkali procured by a long chemical process from the plants of the family of veratrum. It appears to be the chief active principle residing in the colchicum autumnale, and in white hellebore. M. Magendie states that the dose of a quarter of a grain usually affects the intestinal canal rather powerfully. In a case of apoplexy, he prescribed two grains in the twenty-four hours without producing much effect on the bowels. He comments on this result, as proving how much the state of the nervous system influences the action of medicines.
M. Magendie suggests that the use of veratrine might be preferable to the tincture of colchicum and the eau médicinale (which latter medicine he considers to be substantially veratrine), on account of the greater uniformity of the preparation.
In the treatment of gout, I am induced to avoid the active preparations of colchicum entirely; and in employing the acetum colchici, which is very mild, I use it only in combination with other medicines, and desire to procure from its agency rather an auxiliary operation, than that of colchicum distinctly. I have endeavoured to explain my sentiments fully on the subject in my Treatise on Gout and the disordered State of the Digestive Organs.
With these observations, I shall now conclude my summary view of the nature of the principal new medicines, which have been added to our list of remedies by the science and industry of our continental neighbours[11].
It would lead to an interesting field of inquiry, were we to examine the general customs and the habits of living in different countries, in relation to health; and to trace the influence of climate, soil, political and civil institutions, laws, religion, &c. But the subject would demand a volume, rather than a few pages, and be foreign to my present limited purpose.
According to what I have learned from others, and from my own personal observation, I should state that the diseases which arise from repletion, as apoplexy and gout, occur more frequently in this country than in France. I am persuaded also, that the latter disease has increased amongst the middle classes of society in this country, with the progress of luxury and refinement.
The quantity of solid meat consumed at the English table, and the use of heavy malt liquors, together with strong wines not sparingly taken, may be contrasted with the extenuated dishes of the French, and their beverage of lemonade, vin ordinaire, and weak though grateful wines.
I am aware that the French generally eat a greater variety, and take a larger quantity of food than the English; but their meats are stewed, their soups are not heavy, and their vegetables are well dressed. Oil is a plentiful ingredient in many of their dishes, and they scarcely use spices. Altogether their food appears calculated to pass the digestive organs readily; and when the nature of the liquors and some other circumstances are considered, the total regimen is not, I apprehend, so much suited to produce repletion and its evils, as that commonly pursued in this country.
In London, the extreme lateness of the hours both for dining and evening amusement is obviously unfavourable to the constitution. In Paris, fashion in this respect is more rational; and the custom of remaining a short time at the dinner table, after the repast, and the period of conviviality consequently being abridged, much difference of result must follow in regard to the health of the inhabitants of these great cities. The French people are far less inclined to be sedentary than the English, and appear to be active and cheerful both by nature and habit. I conclude, therefore, from these and other causes which might be mentioned, that the medical system of practice must, of necessity, vary considerably in the two countries.
Paris is altogether less humid than London; and the superior clearness of its atmosphere is in great measure to be attributed to the use of wood fires.
A general notion is entertained that the water of Paris is deleterious to strangers, as producing disorder of the stomach and bowels. Not denying the fact of such indisposition occurring to those who visit Paris for a short time, I may still question the nature of the cause.