Observations on M. Laennec's method of forming a diagnosis of the diseases of the chest by means of the stethoscope, and of percussion; and upon some points of the French practice of medicine

by Charles Scudamore

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

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

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

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

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

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

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

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

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

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