Physician to Eaux-Bonnes, &c. &c.

MODERN histological researches on the texture and organisation of tubercle, its origin, development, and terminations, have not only done service to science in affording us a better acquaintance with the morbid product which anatomically characterises pulmonary phthisis: they have also had another result, far more valuable for the medical art, that of strengthening in the medical man his belief and trust in the curability of a chronic disease, the most universally prevalent on the surface of the globe.

Without troubling our minds to decide whether all the lesions which we meet with in the lungs of a phthisical subject are of the same nature, or, on the contrary, are of different kindsone sort properly called tubercular, the other simply phlegmatic or inflammatory-it is quite certain that these lesions can no longer form a morbid entity subject to fixed and invariable laws. The microscope, enabling us to assist at the first appearance of tubercle, by permitting us to follow out its evolution from its birth to its death, has returned to irritation and inflammation the office which Laennec and his disciples denied them. Laennec's tubercle, immutable, fatal, specific, can no longer be admitted now-a-days. Far from being original and specific, tubercle is but a common and vulgar production, miserable and degraded. It resembles pus: like pus, it is engendered by numerous and varied causes; like pus, it is attended by inflammation and fever. It may be said of tubercle that it is a profound pus-destructive, organic, and constitu

tional. Even experimentation on animals has concluded against the specificity of tubercular products. Has it not shown that tuberculisation develops under a thousand divers influences, through the fact of a common wound, as well as through the agency of virulent inoculation?

But if tubercle is not specific; if the cause which produces it is not necessarily and always the same; if, on the contrary, it takes rise under the influence of numerous and varied causes, sometimes local and sometimes general; if, on the one hand, irritation and inflammation preside over its birth and attend its evolution, and, on the other hand, it requires for its development a soil which is previously prepared, an organism so changed and degraded that puny and miserable products are the only ones which can thrive in it-then it follows that to seek for a specific medicament which will combat and cure a morbid state of so complex a character, would be an absurdity and a medical heresy; and that, on the contrary, means of treatment must be as numerous and as diverse as are the sources of the disease itself.

To tell all the sources of phthisis pulmonalis would be to relate all its clinical history; and I do not pretend to undertake such a vast subject. I wish only to insist on a few forms and varieties of the disease which are amenable to a particular treatment until now little known in England: I mean thermal sulphurous medication, such as is carried out at the Pyrenean stations, and more especially at that of the Eaux-Bonnes.

The forms and varieties of phthisis do not all consist in the acute or chronic state of the disease, in the gravity or extent of the tubercular lesions of one or the two lungs. The most interesting clinical forms are to be found in the general condition of the phthisical sufferer, in his physiological or morbid temperament, his constitution, his organism more or less altered by the tubercular diathesis itself or other chronic diseases. But before making known the conditions which a phthisical sufferer must combine in order to derive from the Eaux-Bonnes some amendment or recovery from his disease, I will endeavour to describe briefly the immediate and secondary effects which these thermal waters produce on the patient himself.

One word on the chemical characteristics of the Eaux-Bonnes.

Their temperature is thirty-three degrees (centigrade), and their principal mineralising element sulphur, combined with soda and lime in the form of sulphide of sodium and sulphide of calcium. This double mineralisation is peculiar to the Eaux-Bonnes, and belongs to no other source in the Pyrenean range, if we except the Eaux-Chaudes, situated in the immediate neighbourhood of the Eaux-Bonnes, and which equally possesses this double sodic and calcic sulphuration. This chemical particularity would explain, according to M. Filhol, the celebrated professor at Toulouse, the special and quite elective action exerted by the Eaux-Bonnes waters on the respiratory apparatus.

In order to proceed from a simple to a complicated case, I will first take the instance of a man affected simply with catarrhal susceptibility of the bronchi or chronic bronchitis, and I will mention the effects produced upon him by the Eaux-Bonnes. Then I will take the phthisical patient, and will follow out in him the modifications produced in his organism by the same medication.

With the first patient the question is rather to ward off than to cure the disease. The malady is latent and silent, and will be so during all the fine season. But on the first approach of winter the symptoms will come back fatally, as the patient's experience during years but too surely tells him. We then discover the existence of sonorous and dry râles over the whole of the two lungs: cough and expectoration, especially in the morning and evening, are present. Well, let us suppose that such a patient is subjected to a methodical and regular course of EauxBonnes. Towards the tenth or twelfth day of treatment, the patient complains of a slight oppression, of a feeling of heat in the chest; he coughs and expectorates in somewhat greater quantity; he is restless at night, sleeps ill, and feels nervous and anxious. The digestive functions are always good; but there is constipation, and the urine is abundant, clear, and transparent. The sonorous râles are replaced by large mucous râles, having a manifest tumid character. This particular condition does not cause the thermal treatment to be stopped; it lasts two or three days, and dies away of itself. The patient continues his course of waters to the end without ever again experiencing any kind of malaise. He quits the Eaux-Bonnes

after a season of from twenty to twenty-five days; having drunk during that time from one to three glasses of mineral water daily; and he passes the following winter without a cold, without any kind of catarrhal susceptibility; he goes through the dampest and coldest weather without the least return of his bronchitis or catarrh.

Is this cure of chronic bronchitis, of catarrhal susceptibility of the bronchi, only an occasional occurrence at the EauxBonnes? Not in the least. These are cases which belong to the daily clinic of this celebrated thermal station.

But it is of interest to study more searchingly the effects of this ever-generous medication. They are of two kinds: immediate and distant. The first or immediate effects denote local and general excitement together, manifesting itself by a kind of congestive poussée towards the respiratory organs, and by nervous and circulatory stimulation throughout the whole of the system. It seems that the bronchial disease resumes an acute character under the exciting impression of the sulphurous water, and that in order to heal and disappear it requires this ephemeral revivification. The Eaux-Bonnes, as Bordeu used to say, "go to the chest, where they act like a natural mineral balsam," and "ripen the catarrh in order to heal it." And, indeed, after this passing excitement, not only is the disease again silent, but it never appears again, notwithstanding all external circumstances, such as heat, cold, dampness, dryness, which used formerly to bring it on.

Thus, a season of twenty-five days at the Eaux-Bonnes, and the ingestion of the medicinal water in July or August, will prevent the catarrhal subject from taking in November or January the bronchitis that without the thermal cure he would fatally have caught in the cold season. This distant action, these consecutive effects, slow but sure, which manifest themselves several months after the ingestion of the medicament, are one of the most striking features of the thermal medication of the Eaux-Bonnes.

I have made this long digression before coming to the phthisical patient, because I felt it was necessary to prove that the therapeutical action of the Eaux-Bonnes is profound and lasting. Undoubtedly, I do not mean to compare, from a therapeutical

and prognostic point of view, pulmonary phthisis with catarrhal susceptibility of the bronchi, with chronic bronchitis, with the humid forms of asthma, all of which are so happily modified by the Eaux-Bonnes. But, after all, in all those affections, so various in character and gravity, it is always the respiratory apparatus which is involved, and which becomes the seat of the disease; and if phthisis modifies more deeply the different constituting tissues of that apparatus, it is not less true that it is almost invariably attended by bronchitis and catarrh, and that consequently, like bronchitis and simple catarrh, it comes within reach of the same therapeutical means.

The immediate action of the Eaux-Bonnes on the phthisical surface is very variable according to the degree of the pulmonary lesion. In the first degree, when there exist in the lung only granulations without peripheric irritation, without concomitant bronchitis and fever, when auscultation reveals only modifications in the rhythm and quality of sound of the respiratory murmur, the excitement caused by the Eaux-Bonnes is rather weak and little marked. It is only towards the middle or end of the treatment that the patient complains of more frequent, drier, and more painful cough, with a feeling of heat and burning in the throat, and at the same time of pain in the body, and drowsiness. In the second and third degrees of phthisis these pathogenetic effects of the sulphurous agent are more marked. The sub-crepitan trâles rapidly become larger and more humid; the cough is easier, and expectoration more abundant. Sometimes, too, towards the end of treatment the humid râles are superseded by dry souffles as if the secretions of the small caverns were stopped. At the same time respiration in the unimpaired portions of the lung assumes greater energy, and denotes this character by a vesicular murmur, which is stronger, more strident, and much like puerile respiration. One would say that the contractile element of the bronchi is increased, that their tonicity is enhanced, and that there exists, as it were, a spasm of the last bronchial ramifications and pulmonary alveoli. And, indeed, the Eaux-Bonnes modify not only the mucous membrane of the bronchi and all its secretions, normal or morbid; not only do they bring on resolution of the pneumonic points and the peritubercular catarrh; but, also and further, they stimulate the

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