Imatges de pàgina
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authentic histories prove how long the mucous membranes, both of the digestive and respiratory organs, will resist disorganization, when foreign bodies are lodged in contact with them, and keeping up great irritation and disorder of the whole system. Among a number of examples of this kind, related by M. Dumeril, we shall only select the case of a youth of twelve years of age, who, up to that period, had enjoyed perfect health. At this time he began evidently to emaciate, with frequent and dry cough, evening fever, morning sweats, and other symptoms indicative of consumption, which every day increased in severity. The patient seemed at his last goal, when one day he passed by stool the shell of a nut which he had swallowed twelve or fifteen months before. From that instant the symptoms began to abate, and the patient was soon restored to perfect health. This, and other cases of a similar nature, may lead us to hope for a cure, even in long-continued gastritis and enteritis. The above case may give some idea of the endless train of symptoms produced by irritating and morbid secretions passing along the sensible membrane of the bowels from day to day, and keeping up a deranged state of the whole constitution. It elucidates the effects of mild eccoprotic and alterative medicines, steadily persevered in, till the abdominal organs become sound and free in function, and the secretions of a mild and healthy nature.

Our author here supposes that people may object, by observing that patients will often complain of no pain in those parts that are phlogosed-not even when they are a prey to the most terrible anxiety, fever, convulsions, and delirium. But we would answer, that he must be a very bad physiologist as well as pathologist, who would expect that irritation or even breach of substance of an internal organ or tissue shall always exhibit the common feelings or sensations of an organ of sense, as the skin for example. No; these parts have their own organic sensibility, which may produce infinite disorder in the system, before the common sensibility, or feeling of pain be developed. Although pain, therefore, be a strong proof of disorder in an interior part, the absence of it is no proof to the contrary. We must always take various phenomena into consideration.

Those patients who had fallen a little later, after passing from a state of excitement to one of exhaustion, with symptoms of low, putrid fever, especially fotor of the breath, have often presented, on dissection, the mucous membrane black, easily lacerable, and exhaling a gangrenous odour. This was by no means always the case, even when symptoms led to the expectation of it. Erosions only take place

partially, and in the portions most phlogosed. Apparently they are incipient ulcerations.

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Fatal chronic gastrites have presented to our author disease of the mucous membrane differing somewhat from that produced by dysentery. In Italy he found the same morbid appearances after chronic, as after acute, gastritis-namely, discoloration, thickening, and sometimes erosions. never saw unequivocal ulceration. The redness was not so deep in chronic as in acute disease-nor did the violet or black parts exhale the gangrenous odour. The thickening of the membrane was uniform. In almost all the dissections of chronic cases the digestive tube was found contracted, so as to contain scarce any excrementitious matters, its parietes being almost every where in contact. In very protracted cases the whole of the intestines were found wasted and shrunk, so as to occupy but a very small space indeed. Larrey makes the same remark; and Tartra found, in a patient who had been three months ill with gastritis, the intestines so reduced that they could be, as it were, held in his hand. The intestinal calibre did not exceed that of a quill, and in many places was almost completely obliterated. We have seen a few remarkable instances of this kind ourselves; but the peritoneal covering was also implicated in the disease, and the flexures of the intestines all glued together.

M. Broussais remarks that, notwithstanding what has been said, he sometimes found that considerable irritation had continued for two or three months in the mucous membrane, without leaving a single trace of its existence, post mortem; death having, apparently, taken place from that excessive debility resulting from the interruption of the digestive process by pain, together with the sympathetic disorder of various other functions of the system. When, however, chronic phlogosis of the mucous membrane was protracted to a much greater length of time, as for some years, which is not unfrequently the case, then there was a dif ferent result. Disorganization was evident, and generally consisted in a thickening of the stomach, for several inches in extent, involving the three coats in one confused and morbid structure.

Chronic dysentery always leaves, post mortem, a greater or less degree of thickening in the mucous membrane, and generally a number of ulcerations, resembling those of syphilis; the mucous membrane in those places being entirely destroyed, and the muscular coat of the intestine always forming the floor of the ulcer.

A minute examination of such of these ulcers as were in an incipient stage, convinced M. Broussais that they took

their origins in the crypts or glandules that furnish the mucous secretions. Around them the membrane was thicker than elsewhere, and of a blackish colour. These ulcerations were most numerous where the fæces are apt to lodge, as the cœcum and lower half of the colon. In some instances, M. Broussais has observed these ulcerations in the lower portion of the ileum, but never elsewhere. M. Broussais concludes, (and there can be little doubt of the justness of his conclusion,) that when feculent matters become fetid and putrid, whether from protracted remora, or imperfect digestion, they prove a source of irritation, and ultimately of phlogosis in that part of the mucous membrane where they happen most to lodge. It is also evident that, when irritation is present in the mucous membrane of the bowels, a greater quantity than usual of mucus is secreted, and this is a characteristic of the class of complaints under consideration. When ulceration of the mucous membrane has taken place, M. Broussais considers the disease as incurable, or nearly so. They do not exist in the stomach or small intestines. There is no sign by which we can ascertain their existence in the large intestines during life.

V. Before entering on M. Broussais's methodus medendi, we shall here introduce an outline of Dr. Abercombie's opinions on affections of this class of mucous membranes. Viewing the internal coat of the intestinal canal in the double light of a secreting membrane and an absorbing surface, he justly considers that disordered function of secretion must derange the process of absorption, and this latter disorder will have, of course, a great and deleterious effect on the whole constitution, by cutting off the supply of the system.

The morbid conditions of this membrane he refers to acute or chronic inflammation, and their sequelæ, thickening, erosion, and ulceration. As the incipient movements of inflammation here are seldom observed, diarrhoea is generally the first symptom that comes under our cognizance in practice, accompanied by pain in the abdomen, more or less diffused, and usually increased by pressure, but without that acute sensibility attendant on inflammations of the peritoneal covering.

"It differs from peritoneal inflammation also in being less affected by inspiration and by motion, so that the patient can often bear the erect posture with little inconvenience. The pain, in general, varies very much in degree, leaving long intervals of ease, and then occurring in paroxysms of violent tormina; these are generally followed by discharge from the bowels, but may take place without any discharge following them. In some cases, however, the pain is

more permanent, so as more nearly to resemble the pain of enteritis. In general, there is frequency of pulse, with thirst, febrile oppression, and a brownish fur on the tongue; but, in some cases, the pulse is little above the natural standard through the whole course of the disease. There is frequently vomiting, but not urgent, and sometimes a peculiar irritability of the stomach, so that any thing taken into it excites a burning uneasiness, and this is usually followed by an irritation of the bowels, with a feeling as if the article which was swallowed almost immediately passed through them.

"The evacuations from the bowels vary very much both in appearance and frequency. In some cases they are slimy and in small quantity; in others, they are copious; sometimes they are watery and dark coloured; sometimes whitish; frequently yellow and feculent, as in a common diarrhea; and sometimes articles of food or drink pass through nearly unchanged. They are in some cases extremely frequent, the patient being called to stool every ten or fifteen minutes; in others, the disease may be going on rapidly to a fatal termination, while the bowels are not moved above three or four times in the day. No diagnosis of the disease, therefore, can be founded either on the frequency of the evacuations, or on the appearance of the matters evacuated. In some cases there is tension of the abdomen, but in others this is wanting; and it may appear and disappear several times in the course of the same case." Ed. Journ. p.

322.

In this way it may go on for one or two weeks, or extend to five or six-or pass into a chronic state, forming a disease analogous to what is termed lientery, wearing the patient out at the end of several months.

Its fatal terminations, in the acute state, are, according to our author, a peculiar rapid exhaustion-or conversion into peritonitis or enteritis, in which case, the diarrhoea usually ceases a few days before death. Dr. A. lays down little satisfactory as to diagnosis or etiology. We shall here introduce an extract relative to the appearances on dissection, by which it will be seen that Dr. Abercrombie has been anticipated in all essential points, by the French pathologist. The corroboration afforded by Dr. A. however, is satisfactory.

"The appearances, on dissection, vary considerably, according to the period of the disease at which the fatal event takes place. When this happens at an early period, we find the mucous membrane covered with irregular patches of inflammation, which are, in general, sensibly elevated above the level of the sound parts. They vary exceedingly in extent in different cases, in some extending over a great part of the canal; in others, being confined to a very small portion of it, frequently about the lower end of the ileum, or the head of the colon. They vary also in size, consisting, most commonly, of patches one or two inches in diameter, with sound portions interposed betwixt them. above which they are sensibly ele

vated. In other cases, but I think less frequently, a considerable extent of the canal is of a continued uniform redness.

"The inflamed portions are in some cases covered by a brownish tenacious mucus; in others, by coagulable lymph, and frequently the surface of them is studded with minute vesicles, which at a more advanced period, seem to pass into very small ulcers. In other cases small round portions of the membrane are observed of a gray colour and soft pultaceous appearance, are found to be easily separated, and to leave ulcers. In the cases which have gone on to a more advanced period, we find ulcers of various extent and appearance. In some examples, they are of the same colour with the surrounding parts, and merely appear as if a portion of the membrane had been dissected out. In other cases they are more decidedly ulcers, covered at the bottom with yellowish sloughs, often with elevated edges, and surrounded by a ring of inflammation, and sometimes penetrating to such a depth as completely to perforate the intestine. These different appearances seem to be different stages of the same disease; for we may sometimes observe one of these penetrating ulcers, surrounded by a large circle of abrasion, without evident ulceration, and this by another ring of inflammation; this outer inflamed portion being probably covered by the very minute ulcers or small vesicles formerly mentioned. The appearances which I have now described seem to be the most common; but cases occur in which an extensive portion of the mucous membrane is black and gangrenous, and sometimes an extensive portion has been found to be separated, so as to expose the muscular coat, or even the peritoneal. Cases are also described which have recovered, after a portion of the internal coat had been thrown off in this manner, in one continued cylinder of great extent. The external surface of the intestine is sometimes healthy; in other cases there are spots of obscure redness corresponding to the inflamed portions of the mucous membrane. The cases which terminate by peritoneal inflammation or enteritis, have the appearances usual in these affections, and in the cases in which the ulcers penetrate the intestine, effusion of coagulable lymph, lividity, or gangrene, to a small extent, may often be observed on the outer surface, surrounding the perforations." 324.

Dr. A. thinks that acute inflammation of the abdominal mucous membranes is a frequent disease of infants about the age of six or eight months, being with difficulty distinguished from the common bowel complaints of children, resulting from the constitutional irritation of dentition. There is pyrexia, with fretfulness and screaming, bad sleep, frequently vomiting, pressure on the abdomen, in many cases, giving pain. The disease often assumes the character of what is termed "the infantile remittent fever.". The bowels are generally, not always, loose, the evacuations being preceded by much restlessness and apparent uneasiness, and being very various in colour, odour, consistence, &c. Sometimes. they consist of a reddish brown mucus, sometimes of a pale Vol. II. No. 5.

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