No. 24.

VOL. I.

SELECTIONS

FROM THE

CLINICAL LECTURES,

DELIVERED AT THE

HOTEL-DIEU IN PARIS,

During the Session of 1831-32;

BY BARON DUPUYTREN, PRINCIPAL SURGEON OF THAT HOSPITAL.

CARIES OF THE SPINE.

Fistulous passages-symptomatic Abscesses. ABOUT two months since a woman was admitted in the Hôtel-Dieu, for an abscess situated at the upper and inner part of the thigh. She was also antcted with spinal disease. You are aware that the spinal marrow is never compressed, when the curvature is not at right angles, and then consequently there is not paralysis of the lower extremities. Such was the case with this patient. The abscess in the thigh burst of itself, and a certain quantity of pus was discharged; a smaller abscess, having evidently the same origin, formed on the other side. It was evident that these two abscesses communicated with the carious bones by fistulous canals. This woman had been treated for three months with preparations of iodine, and she was believed to be cured. The caries however continued to make progress, and she came to require my assistance. Moxas were directed to be applied on each side of the curvature. For a month she appeared to be improving, when she was seized, either from a change of temperature or the absorption of pus, with symptoms of pleuropneumonia. It was in vain that we endeavoured to arrest it by reiterated applications of leeches to the chest, a blister to the sternum, topical emollients, &c. On the 15th of December the patient died, seven or eight

VOL. I.

days after the commencement of the pleuropneumonia.

Autopsy, 36 hours after death. External appearances.-Body emaciated, projection of the spinous processes of the 11th and 12th dorsal vertebræ; traces of cupping glasses on the right side of the chest. Internally. There were no remarkable appearances in the head; in the chest there was a considerable seropurulent effusion with flocculi of lymph, and formation of false membranes, the corresponding lung collapsed; in the abdomen were found marks of an ancient peritonitis. The body of the 11th dorsal vertebra was completely destroyed by caries; the spinal canal was not diminished, and the marrow was of a natural appearance. The bodies of the 10th and 12th dorsal were partially denuded, and superficially carious. A vertical section in the antero-posterior direction shewed evident ramollissement; the scalpel penetrated them with facility. In front of the 11th dorsal, the cellular tissue and periosteum were condensed and hypertrophied; they formed a sae with thick resisting walls, greyish internally, in contact with the pus and pseudo-membranes. It was also adherent to the diseased vertebræ by some strong bands. From this sac descended on each side a fistulous track, contained in the sheath of the psoas muscle, the fleshy portion of which was atrophied and discoloured. These tracks were filled with pus; that on the right side is large enough to contain several fingers; it is lined with thick pseudo-membranes, under which is formed a smooth membrane apparently mucous, of a rose colour; it contains badly-formed pus. This track is dilated above the crural ring, contracted under it, and dilated again below it into a large sac at the upper part of the thigh, in which are the minor trochanter and other osseous parts of new formation. With this sae the fistulous opening in the skin communicates. The track on the left side also descends from the vertebral sac, makes its way through the fleshy fibres of the psoas, and arrives on their internal and anterior edge on a level with

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the superior strait of the pelvis; thence it passes under the crural arch, and terminates on the internal side of the thigh without dilatation. Its internal surface is greyish, and covered with a mucous membrane of new formation; beneath which there is a whitish, dense, fibrous tissue, which forms almost the whole of the canal; it is formed at the expense of the cellular tissue, through which the pus at first infiltrated. This track could hardly receive the point of the little finger; in some places its diameter was almost capillary, shewing that nature was endeavouring to close it up.

Hunter was the first to describe the formation of these apparently mucous canals.

The fistula which establish a communication from a carious bone with any part of the body, those which lead from the urethra to the perinæum, or the neighbourhood of the anus, from Steno's ducts to some part of the face, and those which communicate with the air passages and externally, are all of the same nature, and organization: accidental and anormal, they nevertheless replace the natural passages when destroyed, perforated, or contracted, by giving passage to the matters which previously passed through them.

These accidental passages may be formed at the expense of all the parts with which the pus or deviating liquid may come in contact; thus fibrous, nervous, osseous, and mucous tissues may enter into their composition. This has been sufficiently exemplified by the artificial passages in the case which we have just narrated. In a short time after these canals are formed, and liquids traverse them, they take on the mucous structure. For example, in caries of the spine these canals are organized in the following manner. The caries having commenced, the pus remains for a longer or a shorter period in its neighbourhood, and especially in the cellular tissue; a sac forms in which the purulent matter collects; as this becomes more considerable, the sac enlarges and elongates downwards, on either, or both, sides of the spine; the pus passes downwards, pushing before it the lower end of the sac; if it meets with any obstacle, it dilates; if pressed between any parts, it contracts, and dilates again when the parts are free. Having reached the skin after a course varying in length, it forms a tumour, and terminates in an abscess.

This purulent collection, commonly called abscess by congestion, and which I term sympFomatic abscess, constitutes a very serious disease, and one which is generally considered fatal. Some cases, however well followed up, prove that these abscesses may close and entirely disappear, when the caries is arrested.

Treated actively by issues, moxas, internal remedies, and an hygienic plan of treatment, directed so as to remove the causes producing the caries, it may be arrested, and cured. But will the abscess terminate as happily?

Should it be abandoned to the resources of nature alone, or must surgical treatment be had recourse to? The ordinary process of this disease must be the guide in this respect.

These abscesses remain sometimes in this state for whole years, without causing any bad symptoms; the pus is gradually absorbed, and all traces of it are lost; again, after a longer or a shorter period, the skin covering the abscess may become inflamed, ulcerate, and give issue to the pus, the whole of which may be evacuated, and no more produced. In other cases, the pus has been in the end converted into adipocire; chemical experiments have lately proved that such was the nature of the substance sometimes found in these sort of abscesses.

Many years ago I had a young tradesman, then residing in the Rue aux Ours, and who was affected with a symptomatic abscess, proceeding from caries of the spine, accompanied with curvature; the caries was cured by the reiterated use of moxas, issues, &c. The abscess did not disappear, but it diminished somewhat in size. Four or five years afterwards this young man died from pleuropneumonia. The autopsy shewed the caries completely cured, the curvature remaining; the abscess was changed into a fatty, soft, unctuous mass, presenting all the physical and chemical characters of adipocire, which was also found in parts of the canal; this latter was contracted, and closed in some parts.

I consider it to be dangerous to open a symptomatic abscess resulting from caries of the spine, which has yielded to treatment. If you were to open the abscess, you would risk causing a relapse of the principal disease, and lose the fruit of a long and active treatment; they should be left to the powers of

nature.

I have already described the manner in which the fistulous tracks from caries of the spine are formed; we shall now find that urinary fistulæ take place in the same manner. I suppose that the urine accumulates in a sac, and in large quantities; at the end of a certain time an abscess is formed; this opens, and a fistula is the result; the canal becomes lined with a membrane, apparently mucous. We shall now see what are the consequences of the formation of this membrane. If a catheter be passed in the urethra, while the fistula is yet recent, it can be easily cured; but if it is allowed to remain six months, or a year, without having recourse to that measure, then a eure is almost impossible, because the fistula has become organized.

These fistule have not, when recent, the characters which they afterwards assure. They generally commence by an abscess, from which, when it opens, pus, varying in its nature according to its cause, will be discharged, either pure, or mixed with some animal secretion; there are very few fistul which do not commence in this manner, and they are those which result from wounds in

ficted on an excretory canal; in this case, the liquid which passes through the wounded canal, follows ordinarily the same course as the instrument which inflicted the injury, and the fistula thus formed has but one course. In the first case on the contrary, that is to say, whenever nature presides over the termination of the disease, the accumulated fluid may make its way by one or more passages. If the abscess is external, the opening may take place directly, and only one canal be formed; but deeply situated, one only may be formed, or more than one, uniting together ere they open externally; or they may all open separately externally. Such is the first period of the existence of a fistula.

If the track of the fistula is very short, the phenomena attendant on the second period may be very simple; the inflammation ceases; the edges of the fistulous opening become accustomed to the contact of the fluid; they cicatrize without uniting, and the opening becomes permanent. If the abscess is very deeply seated, very remarkable phenomena occur. The parietes contract, but do not adhere; the external opening contracts, becomes rounded, and soon appears as a small red fungus, pierced in the centre by an opening often very difficult to discover, narrower than the canal, of which it is the orifice, and which may furnish a quantity of pus out of all proportion to its apparent size. At the same time throughout the whole extent of the fistula thus traversed by the liquid, an inflammation at first severe is set up, which is communicated to the neighbouring parts, and which gradually diminishes as the parts become accustomed to the irritation of the fluid. Soon, without entirely disappearing, the inflammation yields place to a process, under the influence of which the whole track becomes organized, is isolated, and changed into a real excretory canal, which presents the same characters, in whatever tissue it may be developed; it is most commonly single, sometimes ramifying towards its extremity, sometimes straight, sometimes flexuous and lined, as has been said above, by a real mucous membrane, which indeed can be isolated only in rare cases, but is always to be recognized by its appearance, the fluid it secretes, the organic elements which compose it, and which differs from natural mucous membranes by the absence of follicles and an epidermic layer.

In some cases where the inflammation is passive, the organization of the canal is so complete, that it is enclosed within cellular tissue analagous to that which surrounds the natural excretory ducts, and to which anatomists have given the name of submucous cellular tissue; but in most cases, the irritation continues in the surrounding tissues, and they form larger or smaller indurated masses, surrounding the fistula.

I have said that these accidental canals resemble the natural mucous canals; the ex

ample we have before us, proves the truth of that which I have advanced. Thus you perceive here a false membrane, analogous to that met with in esophagitis; by scraping it, this can be removed, and the subjacent mem⚫ brane is red, like the natural mucous membranes; it is, like them, soft and villous; examined by a magnifying glass, villi may be discovered, smaller than in the natural membrane, doubtless, but still apparent. If this comparison is pursued further, we find, externally, a fibro-cellular membrane, resembling that which surrounds the mucous mem branes.

Nature sometimes endeavours to cure these fistulæ, and she does it in this manner :-The canal being no longer traversed by any liquid, the tissues which compose it, endowed with contractility, like all the organic tissues, contract, the parietes are brought in apposition, are united, and form a fibro-cellular cord, which, at the end of a shorter or longer period-six months or a year, in part, or entirely disappears. How can these canals disappear? In the same manner as they are formed; they are formed at the expense of all the tissues which they meet with in their course, taking from them the elements of their organization; they disappear, restoring to them that which they had previously abstracted. The truth of these assertions has been demonstrated by pathological anatomy. In persons who have been cured of symptomatic abscesses, and have died of other diseases, at a greater or less distance of time, the fistulous track has been found converted into a cord, as I have said; in others, this cord was not continuous, parts only were found here and there; and in others again, it had entirely disappeared. The case which I shall now cite, is very remarkable in this respect.

A woman was admitted into the HôtelDieu for a strangulated hernia, which terminated in an artificial anus. No one could deny in this instance that the intestine was adherent to the abdominal parietes. At the end of two years, she was again admitted into the hospital for another disease, under which she died; an autopsy took place; for an instant, I thought myself deceived in my diagnosis, for I could not find any adhesions, but on examining the convolutions, a cord was found extending from the intestine to the superior part of the crural arch, thus verify ing my opinion, that in many similar circumstances, these accidental canals restore to the neighbouring parts the elements they had previously abstracted from them.

In the first case, the whole track was much diminished in size, whilst the recent canal was more considerable, The parietes of the first were almost in apposition, containing an albuminous matter, resembling that of false membrane, being the process nature employs to effect the union.

It is true that natural mucous canals are

with difficulty obliterated; nevertheless, positive examples of obliteration are on record. Thus the proposition of Bichat, true in generalities, is capable of exceptions. Accidental canals, on the contrary, are obliterated more readily; the reason is, that the first have a very developed secretory apparatus, while it is little apparent in the latter; thus a square inch of a natural canal will present a hundred villi, while in the same extent of an accidental one, only five or six will be met with.

According to the principles which I have just laid down, the necessity of preventing as speedily as possible the organization of these accidental canals, and of re-establishing the natural course of the secretion by all possible means. But when this effect has not attained, the same measures will become insufficient, and even inapplicable. It then remains only to remove the parts.

Cauterization may then be applied advantageously, but it must be applied over the whole canal. In other cases, weak injections of nitrate of silver-nitric acid may be used, taking care not to pass the fluids in a wrong direction ; about twenty, thirty, or even sixty grains of the nitrate of silver in a pound of distilled water may be used, to be injected by a syphon syringe. I have found this injection successful in many cases dependant on scrofula.

ROYAL COLLEGE OF PHYSICIANS.

Monday, June 25, 1832.

a

THE following Essay was read before large meeting of the Members of the College, and numerous distinguished and literary characters:

Cursory Remarks on the present Condition of Medicine, and requisites for a Physician.

By DAVID UWINS, M.D.

I wish, on the present occasion, to state my opinions openly and candidly in respect to medicine, both as a science and an art, as it is cultivated and practised in our own time; and if, in so doing, I may be found to differ from many who do me the honour to listen to the perusal of this brief paper, the very difference itself inay in some sort be taken as a guarantee against hasty inference; since, when we oppose ourselves to individuals whose talents and character command respect, we ought well to weigh and sift our persuasions ere we commit ourselves by their exposure.

Medicine cannot be ranked among those sciences which the French call exact; neither do its parts hang together in precisely the same connexion as do those which constitute moral and ethical philosophy; ours is, in

fact, at once a science of itself, and a science of other sciences; it is constituted by a mixture of demonstration and inference, and when properly cultivated and legitimately practised, it embraces and brings to its sid many postulates from pure physics, as well as much of moral and ethical truth. But it must be admitted, that upon us precept is less prescriptive-authority less bindingthan upon those who practise law, or professionally inculcate religious doctrine; and why? It is because maladies are not essential entities standing out like moral maxims, independant on time, place, and circumstance; but are so interwoven with the constitution of our frames, and so contingent upon external influences, that amidst much of general, there is almost ever something of peculiar; and something, therefore, which makes its final appeal to the individual discernment and independant discretion of the skilful physi

cian.

If this be received as a correct representation of the distinctive character of medical science and therapeutic art, it must be conceded also that the vagueness of terminology which insensibly creeps in among medical institutes ought as much as possible to be guarded against and avoided. Metonymical modes of expression must be shunned with care, and schemes of nosology and nomenclature rendered accordant with the difference-the essential difference which manifestly obtains between the arrangements of natural history, the principia of natural philosophy, and the embodying into one whole a series of incidental symptoms, or, I might almost say of contingent and accidental signs. Who is there but must allow that the erudite works of one of our latest writers are marred throughout by supposing classes, orders, and genera of diseases, to be like classes, orders, and genera of plants. That classification is absolutely necessary, and that designating terms are equally indispensable cannot be questioned; but the way in which some of our systematics set about the inquiry of what a disease is, and what it is not, often amounts to nothing more than a mere logomacy, while it tends to vitiate our inferences by putting the cause in the place of the effect, and by imagining entity and essence where neither can be properly predicated.

But I am deviating from my first intention; the main object of the present cursory strictures not being nosology and nomenclature, but that of briefly inquiring into the actual condition of medicine in these our times,-a question which may not, perhaps, find so. easy a solution as at first sight might be supposed. With us, it must be generally known, indeed, it results from the very peculiarity of our calling, conséquence cannot always be inferred from sequence. The influenza in Paris of 1802 was much more fatal, for example, than it proved during its presence in London, nearly at the same time; but had

we thence inferred, broadly and largely, that our practical indications were drawn with more distinctness, and our modes of treatment more effective precisely in the ratio of diminished mortality, we might have been subject to the charge of judging too partially or abstractedly, and of not sufficiently recognizing the possible modification of circumstance, an error which has seemed to me to have infused itself into some of our decisions, as to the actual nature, as well as to the mode and measure, of communicable power of the epidemic now present-that contingency and subjection to exterior influence to which I have just alluded, having in my humble judgment, been too much lost sight of by the respective controversialists who have arranged themselves under the banners of contagion on the one side, and of local malaria on the other.

I may, however, remark by the way, that the mysteries and uncertainties which connect themselves with epidemic and contagious distempers, ought to repress our disposition to dogmatic announcement, and induce us to look with complacency upon individual sentiments, how widely soever they may be at variance with our own.

But placing pestilence and its consequences out of the question, surely it will be said by some, the general diminution in the average of mortality during the last half century must most forcibly plead the cause of those speculatists who maintain the rapid march of medical science?

Now, sorry should I be even to insinuate any thing which might bear too hard upon such unqualified assumption, but I am free to confess my feeling, that the assumption demands to be qualified, and that we ought not to overlook medical polity while exulting in the progress of therapeutic skill. To resort, once more to the epidemic of the day; we may ask, whether, had cholera been in London a century ago, a vast difference in malignity and diffusion would not have been witnessed, inasmuch as the physical and moral preventives of pestilence were not then in existence, and act to any thing like the extent that is now happily the case?

To our present polity and habits are we, moreover, mainly indebted for the decline, and, in some districts, disappearance of a sickness which unequivocally originates in local circumstance, and is regulated by local condition. The very name of ague is almost forgotten, even in places where these intermittent forms of fever were not very long since proverbially present. Then, again, what an amazing power has been obtained by man over the depopulating ravages of the specific contagions? Who can calculate or compute the diminution of deaths and deformities, through the whole range of civilized society, by the blessing of vaccination? We must also take into account, the increased intelligence which has made its way into our

nurseries, with all its happy consequences. The comparative sobriety too, and superior tone of moral sentiment which pervade our universities and characterize the habits of our higher and middle classes, may be put down to the score of antidotes against disease; and the whole, I repeat, of these moral advantages of present over former times, ought to be brought into account when we infer the diminution of mortality from an improvement in medical practice.

But the healing art, say some of our youthful enthusiasts, must necessarily have advanced within the very few preceding years, and that too with rapid strides, inasmuch as its modes of cultivation have undergone such a thorough change for the better. I wish I 'could completely accord in sentiment with some of my respected friends and compeers on this particular. Far be it from me to advance a single word by way of disparaging minute and morbid anatomy. Let it not for a moment be inferred, that I deem that course of instruction effective which should leave out of its scheme the paramount importance of an assiduous research into structure, as connected with function; but even on this head it is, I think, possible that extent of detail and minuteness of division may be made to usurp the place of commanding principles, so that too much temerity on the one hand, and indecision or littleness on the other, may come to be the consequence, in practice, of considering disorder merely of membranous origin, or of too sedulously seeking for some locality as the spring and source of every morbid state.

A German physician, who was upon a visit to Britain about half a century since, expressed his surprize that gastricism was treated in this country as rheumatism, and that we set heroically and empirically to work with a vi et armis treatment of disorders which, to him, was frightful; "and yet (he adds) somehow or other, these English practitioners are astonishingly successful."

Were this same individual to come among us now, he would find gastricism, and, if I may so say, membranism, at work to his heart's content. But whether he would witness more happy results in the way of practice, may, in my judgment, be problematical. I am certain, indeed, of this, that the feebleness with which curative indication has been occasionally pursued, has originated in too high an appreciation of topical circumstance.

It is but a little time ago that I was present at a medical society, where a very ingenious paper was read, advocating and illustrating the theories of tender tissue by an especial allusion to mesenteric atrophy-a disease, the author of the essay contended, invariably to be considered a case of inflammation, or sub-inflammation, of those parts of the alimentary tube at which the lacteal absorbents originate; but whether these parts do or do not become so circumstanced in the majority