8. HOSPITAL REPORT FROM THE VAL DE GRACE. BY M. BROUSSAIS. [For November, December, January, February, and March. 1826-7.] M. Broussais's doctrine has lately been assailed, through the medium of the practice which it inculcates. It has been said that the success of the Professor in the VAL DE GRACE has not been equal to that of other physicians entertaining different views from the founder of the new doctrine. It is hardly fair to judge of a doctrine or practice by comparative success in different hospitals-or even in the same hospital at different times, or under different physicians. A man may have a run of bad or good luck in the reception of patients, as well as in throwing dice or playing at cards-and this may give a very pleasing or gloomy cast to the numerical results at the end of the quarter or half year. M. Broussais has caused his aide-major (M. Cassimir Broussais) to present a semestral report from the VAL DE GRACE, appealing, for the authenticity and truth of the report, to the records of the institution, and the evidence of those who walked the hospital at the time. Nothing can be more unexceptionable than this plan with the reservations above alluded to—and we shall now proceed to give an analysis of this report.

It is asserted by the reporter, that when M. Broussais takes his turn of duty in the Val de Grace, he desires that the worst cases may be sent to his wards. This is magnanimous-more so than wise, perhaps. In the five months above specified, there were entered 438 patients, of whom 20 died, or about one in twenty-two. This certainly is not a very great mortality, considering that an epidemic raged during part of the time, before which, the mortality was only one in thirty fiveand that 86 cases remained in hospital from the preceding semestre. M. Cassimir asserts, (and there can be no reason to disbelieve him) many were sent to the VAL DE GRACE, in the above period, merely to die. This happens in all hospitals, and must ever prevent a fair estimate of medical treatment. We do not deem it necessary to give the whole table of maladies. Suffice it to say, that there were three aneurisms of the heart-76 cases of acute bronchitis-8 of colitis-7 of duodenitis-3 of encephalitis-60 of acute gastro enteritis-15 of hypertrophy of the heart-35 of intermittent irritation (ague)— 4 of laryngitis-79 of acute pleuritis-29 of other acute inflammations of the thorax.

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1. Pleuritis. Of the 79 cases of acute pleuritis, only one proved fatal, and that from purulent effusion into the cavities of the pleura and pericardium. This inflammation had commenced five days before the patient's entrance into hospital. In all these cases of pleuritis, the disease was combated by the application of leeches to the pained part. In 29 cases venesection preceded leeching. In general. a single application of 15, 20, or 30 leeches was sufficient. In three cases only was it necessary to have recourse a third time to leeching. Emollient cataplasms always succeeded the leeches, and diluent mucilaginous drink was plentifully given. In six cases it was necessary,

to blister after leeching, and, in four of these, the measure was successful. It was remarkable that, in most of these cases, the pulse fell immediately the blisters had risen. In two cases, however, they were applied too soon, and the râle muqueux and fever obliged M. Broussais to have recourse to more leeches. In the great majority of cases, bronchitis preceded the pleurisy, which induced M. Broussais to suppose that the inflammation of the mucous membrane, having arrived at the ultimate ramifications of the bronchia, passed on to the serous membrane, and then produced the corresponding phenomena. When the bronchitis persisted, which was generally the case, leeches were applied under the clavicles, at the top of the sternum, and wherever the râle muqueux could be heard.

These thoracic inflammations were far from being uncomplicated. In 20 cases, at least, there was considerable gastric irritation, which yielded, however, to leeching the epigastrium. In two cases there was evident duodenitis-and, in three instances, the inflammation spread to the other intestines, producing diarrhoea-and to the brain, giving rise to delirium. These cases are detailed at length, but we pass them over.

There were very few instances of relapse in these pleuritic cases. The medium period of residence in hospital was 23 days. It is remarked, however, that M. Broussais never permits a soldier to leave the hospital till he is so completely recovered as to enter immediately on his military duties.

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2. Acute Bronchitis. Of 76 cases of this disease, M. Broussais lost General and local bleeding, especially the latter, was principally trusted to the leeches being applied to the places mentioned above. There were seldom more than 20 leeches applied at first-and afterwards a small number were applied wherever the râle could be distinctly heard. Blisters were employed in only seven cases. In about 20 cases of bronchitis the inflammation spread to the mucous membrane of the stomach, requiring leeches to the epigastrium. It was surprising to see how soon the detraction of blood from this quarter calmed the irritation of the whole system and reduced the fever. In many of these cases the appetite came on quickly after the leeches, and it was difficult to restrain the patients from committing excesses. More relapses, however, were occasioned by exposure to atmospherical vicissitudes than by imprudence in diet. The mean term of resi dence in hospital for this inflammation was 14 days. One case proved fatal. The young man had had cough during the whole of the winter, and was affected with acute bronchitis fifteen days before he was sent to the hospital He was then spitting up large quantities of purulent matter, and was unable to lie down in bed. He died on the fifth day after he was received into hospital. The trachea and bronchia were found filled with muco-purulent matters, and the lining membrane intensely reddened. The parenchyma of the lungs was, in some places, hepatized. The mucous membrane of the stomach, and also of the jejunum, was inflamed. The patient, therefore, evidently died of suffocation from the effusion into the air-passages.

3. Pneumonia Acute. Of sixteen cases of this disease, three died, and a fourth remained doubtful. They were all accompanied by great congestion of blood, not only in the chest, but in the abdomen and other parts, rendering the treatment very difficult. One, two, or three general bleedings were followed by leeches to the chest, or to whatever part appeared to be the seat of congestion. In six cases only were blisters applied. Diminution of the force and frequency of the pulse; of the râle crepitant; of the dull sound; of redness on the cheeks; and, on the other hand, the facility of expectoration were the signs for discontinuing depletion, and trusting to the efforts of nature. If, after these favourable phenomena appeared, there was heard any râle in any part of the chest, then a blister was applied. Mean stay in hospital for pneumonia was 22 days.

The first of the three fatal cases died on the fifth day after he was received into hospital, having been ill for twelve days previously. The depletive system was pursued as far as was consistent with prudence, but it was too late. On dissection, considerable portions of lung were found hepatized, and much muco-purulent matter could be squeezed from the rest. The brain was sound; but the mucous membrane of the stomach was highly inflamed, and there were ulcerations in the ileum.

The second patient, whose case proved fatal, had been ill only four days, according to his own account. When received, the dyspnoea was great, and he was spitting up bloody expectoration, with hard full pulse, great heat of skin, and ardent thirst. One general and one local bleeding somewhat relieved these symptoms; but the inflammation spread to the digestive apparatus, and required many leechings. The patient appeared to be convalescing, when a relapse took place, and then all means failed. On dissection, the posterior half of the left lung was found hepatized, and a considerable portion of the other lung was in the same condition. The mucous membrane of the stomach was softened, and there were marks of inflammation in the mucous membrane of the small intestines.

Before taking up the subject of chronic inflammation of the lungs, M. Broussais thinks it necessary to say a few words respecting those acute thoracic inflammations which were on the point of changing into chronic, and which would have certainly induced phthisis, had it not been for the rigid antiphlogistic means that were used. Of 200 patients that entered the hospital during five months, and who were affected with pulmonary inflammation, only one has died of phthisis. In eleven cases, however, the inflammation proved obstinate, and phthisis was menaced. The following are the signs, M. B. observes, which indicate that chronic inflammation is taking place, to end in pulmonary phthisis. When patients, relieved from the acute symptoms, and especially from those of gastric irritation, begin to recover their appetite-become cheerful-and regain some degree of strength. They think themselves well, in fact, and regard the remaining cough as nothing. But the attentive physician will readily perceive, that, notwithstanding these appearances

of amelioration, a focus of inflammation remains. There will be found some râle muqueux or râle sibilant, or both-the sound will be less clear, on percussion, over these points of the chest-the breathing will not be quite free-the chest will be raised, en masse, on inspiration; or one side will rise more than the other-the cough still continues, though much diminished--there is expectoration of a yellow mucus, or muco-purulent fluid--the pulse is more frequent than natural, and more full, especially towards evening---there is some pain or uneasiness complained of, under the sternum, at the epigastrium, or in the throat---the skin is dry and hot in the day, and often covered with perspiration in the night-the features of the countenance indicate some internal suffering, however the patient may endeavour to conceal it, which he almost always does. When patients are examined by the stethoscope they will breathe remarkably low, lest the wheeze (râle) should be heard. In short, they take every means of misrepresenting their actual condition, lest they should be deprived of food, and put upon rigid regimen. In these cases, the Professor was obliged to have repeated recourse to leeches under the clavicles, over the sternum, and other parts of the chest, wherever the wheeze could be most distinctly heard with the ear. To these means, were added blisters and severe regimen-chiefly milky and farinaceous food. If the appetite became very keen, although the pulmonary affection was not entirely dissipated, some bouillie was allowed, and, in this manner, they were kept under regimen for 10, 15, or 20 days. Nine out of these eleven patients were discharged cured, in the course of March and April, 1827. The other two remained a long time doubtful, and one appears not yet secure; the other has, ultimately, been saved from phthisis, though of a highly strumous habit, and consumptive family.

4. Chronic Bronchitis. In a considerable proportion of these cases, regimen alone succeeded; with the aid of some trifling narcotics. In some cases, it was necessary to employ local, and even general bleeding. By these means, all the cases recovered. The same may be said of the other chronic phlegmasiæ of the chest.

5. Acute Gastro-Enteritis. Of sixty cases of this disease, one proved fatal. In almost all the other cases, the disease gave way to the first, second, or third application of leeches-a few resisting the antiphlogistic treatment for a longer time. The complaint commenced with thirst, loss of appetite, general malaise, sense of heat at the epigastrium, redness of the point of the tongue, occasionally by vomiting, slight delirium, vertigo, &c. Some were taken suddenly and violently ill-others were slowly affected Fourteen or fifteen of these cases are denominated, on the books of the hospital, "gastric irritations," being simple gastro-enterites, following a very rapid course. The symptoms of these were :-Cephalalgia, general sense of fatigue, inappetency, redness of the tip of the tongue, thirst, heat of epigastrium, some elevation and frequency of the pulse. Four of these cases ceded to regimen alone the others to ten, fifteen, or VOL. VIII. No. 15.

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twenty leeches applied to the epigastrium, seconded by rigid abstinence, and emollient mucilaginous drink. In four cases, the disease presented itself in the form of inflammatory fever, and two of them required general bleeding, in addition to the leechings. In one case, the fever was on the point of passing into the adynamic (or what is here called typhoid) state; but two applications of leeches, one of 30 and the other of 10, to the epigastrium, hypochondria, and chest, with friction of vinegar, &c. arrested the progress of the stupor, and saved the patient from a dangerous form of disease into which he was lapsing.

In two cases, there were presented the symptoms of what the ancients denominated ileus, without knowing its cause. This was a sudden development of a circumscribed tumour in the abdomen, accompanied by vomiting and most painful colic, &c. In one case, that of a young man, aged 29 years, the tumour appeared suddenly in the night, and to ease the pain, he had swallowed a quantity of brandy and sweet oil, which were soon thrown up by vomiting. Next day, leeches were plentifully applied to the tumour, followed by fomentations. On the succeeding day, there was neither vomiting, pain, nor tumour. The bowels were opened, and, in a few days, he was discharged cured.

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In the other case, the patient being a man 52 years of age, pain was not very acute, but the vomiting was very frequent. man had also swallowed some hot brandy and oil, which increased the sickness. The tumour was very sensible to the hand, as well as to the eye, being situated in the region of the caput coli. The pain was like that in colica pictonum, but dreadfully severe, and he begged for speedy relief from his sufferings. Twenty leeches were applied to the part. Next day, all the symptoms, and all traces of the tumour had disappeared. M. Broussais does not say much as to the real or supposed nature of these tumours in the abdomen. He thinks there is evidently acute inflammation-and possibly invaginationboth of which speedily cede to the only proper mode of treatment; copious leechings and fomentations. He makes no mention of any accumulations in the colon, as the probable cause of these sudden tumours. We have seen several instances of this complaint-and one lately, in the person of a medical student of the Middlesex Hospital. He was, at one time, in a dangerous predicament, having neglected the complaint for a day or two. He required repeated local and general bleeding, with fomentations, calomel and opium, and smart purgation, when the disease yielded; but not before his face had assumed the Hippocratic cast, and the pulse had remained for more than 24 hours above 160 in the minute. He was judiciously treated in the beginning, by Mr. Weatherfield of Covent Garden, before we saw him.

There were some serious complications of these gastro-enterites. The most formidable was erysipelas supervening on, or succeeding, the fever occasioned by the gastro-enteric affection. Yet, even in these cases, M. Broussais did not hesitate to apply numerous leeches to the cutaneous inflammation-and, it appears, with perfect success. The following are the principal features of the gastro-enteritis which