The effect of climate on tuberculous disease, being, with additions, the essay for which the Fiske Fund Prize was awarded. With an appendix of corroborative observations and notices of several places of winter resort

Front matter

YALE MEDICAL LIBRARY

HISTORICAL LIBRARY

COLLECTION OF

Appendix

PACE

1. Remarks on the Essay to which was awarded the

Prize of the Academie de M6decine . . . 125

2. Advantages of elevated over low and moist loca-

lities 152

3. Effects of a moist and of a dry air on the economy. 154

4. On the absence of Phthisis in the rarefied air of

elevated regions 156

Upon the influence of marshy localities on Phthisis . 174 Notices of some of the most frequented places of

Winter resort 178

Pau — Hyeres — Nice — Menton — Pisa — Rome —

Naples — Palermo — Malta — Madeira — Malaga —

Algiers— Egypt 179

ON

TUBERCULOUS DISEASE.

Chapter I. Preliminary Remarks

A subject of greater importance than that of the effect of climate on tuberculous disease could scarcely have been chosen from the whole range of medical science, for the consideration of competitors for the prize offered by the trustees of the Fiske Fundboth on account of the generally fatal termination of tuberculous diseases, when seated in a vital organ, and the inefficiency of medical treatment, as well as of the prevailing deficiency of knowledge among the profession respecting the action of climate, and of its capability, when employed with discrimination, and before disease has advanced too far, of frequently arresting its progress, and sometimes of effecting a cure. It is true we possess many valuable monographs of the climates of particular localities and districts, and of their effects upon diseased conditions of the system, but I am not aware that there exists any work, either in the English, French, or German languages, treating of the remedial action of climate in its more general bearing. I propose, therefore, upon the present occasion, to consider the mode in which climate acts most beneficially in preventing the occurrence of tuberculous disease in the lungs, and removing it where already existing ; the observations which I have to offer upon this point being equally applicable to tuberculous affections of other parts. In order, however, to enable us to form a just estimate of the modus operandi of this remedial agent in cases of tubercles of the lungs, it will be necessary to take a brief survey of the opinions which have been expressed by various authors respecting the nature of the disease, and of the causes which most frequently produce it; for it is only by having correct ideas of its pathology, and by endeavouring to neutralize the influence of its predisposing and exciting causes, that we shall be likely to arrive at more satisfactory results than have been hitherto attained under a system of purely pharmaceutical and often empirical treatment — which, however useful in affording relief for a longer or shorter period, has tended but little, if at all, to diminish the amount of mortality occasioned by the prevalence of pulmonary consumption in most parts of the civilized world.

The curability of consumption can no longer be reasonably questioned ; the fact having been verified in numerous instances of persons who, after having presented all the general and local indications of its existence in various stages of structural lesion, have recovered — living in the enjoyment of tolerable health until a more or less advanced age, when on their succumbing under some other disease, the examination, post-mortem, has revealed the traces of the former malady. Laennec remarked this occurrence on several occasions. MM. Ferrus and Cruveilhier state from the result of their observations upon the bodies of old men and women, who died at the large hospitals, Salpetriere and Bicetre, that it is not uncommon to find excavations and other consequences of tuberculous disease which had existed at a former period. More recently, M. Beau stated that 157 out of 160 women who died in his wards in the Salpetriere had cicatrices in the summit of one or other of the lungs, which he considered to be the remains of tubercular disease ; most frequently the summits of both lungs were affected. 1 M. Prus likewise found, on examining the bodies of old people, in a large proportion of them traces of former tuberculization of the lungs ; in some cases the tubercles had disappeared, leaving cavities lined with a membrane of new formation, and communicating with the bronchia ; in other cases there were fibrous or cartilaginous cicatrices ; in others, again, the tubercles sometimes encysted, at other times not, were infiltrated with a large amount of chalky, calcareous, or ossiform substance. 1 Compendium de Medecine Pratique, art. PhtMsie.

B 2

If, therefore, there is reason to believe that pulmonary consumption is not unfrequently cured in persons of the lower classes, who have not the means at command of being suitably treated, it can scarcely be doubted that cures are of more common occurrence among the upper classes than is generally supposed; and that, if practitioners were to seek rather to combat the. tuberculous diathesis than to treat its local manifestation, consumption would come to be looked upon as a curable disease ; for, if recoveries have not been so numerous as they might have been, it is because the right means of effecting cures have rarely been adopted. In Great Britain, more especially, as also in the United States, practitioners, unlike those of most European countries, are accustomed to trust almost exclusively to pharmaceutical agents in the treatment of chronic diseases, but seldom endeavouring to rectify the anormal conditions of the system, upon which depend morbid local manifestations, by the employment of hygienic and medical means, which, by effecting favourable modifications in the constitution of patients, tend to procure permanent cures instead of a temporary alleviation of suffering or a transient amelioration of their state. " To occupy one's self in treating merely the manifestations of a diathesis," says a distinguished French physician, "is, generally, as if one were to run after the shadow, and leave the substance which it is desirable to attain;" 1 and the adoption of this mode of 1 M. Baume's— Traits des Diatheses. Paris, 1853.

treatment in a disease which, like consumption, so directly compromises the lives of the persons affected, is attended with the most pernicious consequences, because the precious time is lost, during.which there would be the greatest probability of succeeding, by the employment of climate and other suitable measures, until the disease has arrived at a stage when the use of all remedial means would fail to arrest its progress.

A serious obstacle, bowever, presents itself to the favourable termination of the disease in many cases where a cure might be effected, viz., the difficulty which often exists in ascertaining the presence of tuberculous matter at its outset. A minute examination of the physical signs supplied by an abnormal state of the respiratory function, would, in many instances, lead to the discovery of tubercles in the lungs before their presence was indicated by clearly marked general symptoms ; but the majority of practitioners are scarcely capable of making such an examination as would frequently suffice to detect pulmonary disease in its earliest stage, especially in England, and probably also in America, where exploration of the state of the organs contained in the thoracic cavity, by means of auscultation and percussion, forms no part of the education of medical students. 1 It consequently follows that the weakness, and various other symptoms experienced by patients in the early stage of pulmonary

1 I understand that in several of the Medical Schools of America, auscultation forms part of the course of study.

tuberculization, are usually regarded as the indications of no very serious malady, or of a temporary indisposition ; which opinion is often confirmed for a period, by the amelioration which takes place from time to time in chronic cases, and by the temporary cessation or alleviation of chest symptoms, produced under the influence of favourable circumstances, as the summer season ; a residence in the country for some weeks or months ; or of the remedies which may have been had recourse to. Hence, patients, their friends, and frequently the medical practitioner, are misled as to the true nature of the disease, until, at the expiration of a longer or shorter period, either spontaneously or from the action of some exciting cause, the symptoms reappear with aggravated intensity, and auscultation, practised by an experienced physician, renders its existence apparent.

Consumptive patients of the United Kingdom of Great Britain and Ireland have sought, more than those of any other nation, the curative influence of climate ; and British medical literature contains a vast accumulation of facts relating to the effects of the climates of our colonies, as well as of other places frequented on this account ; but, owing to the causes above mentioned, and the late period at which recourse is had to this remedial agent, the results have been very unsatisfactory, and we are still far from being able to estimate justly the amount of advantage which climate is calculated to afford in tuberculous disease, if employed under circumstances more favourable to its beneficial action than heretofore.

Aberuethy, following in the steps of John Hunter, is the first pathologist who imparted a definite direction to the ideas of his countrymen, with respect to the constitutional origin and treatment of local diseases, in his celebrated work which bears this title ; and the principles therein promulgated having been put in practice, more especially as respects the treatment of surgical diseases, have powerfully contributed to raise the character of British surgery from a simple art to that of a science, and have rescued innumerable sufferers from local diseases, from painful mutilations, and premature death. But, even at the close of the last century, and several years before the publication of his work, Abernethy, referring particularly to pulmonary consumption, after having shown that the organ may be the seat of the disease, although its causes may be at a distance, insists upon the inutility — the organ being secondarily affected — of treating the disease as an integral thing. 1 His opinions on the origin of pulmonary phthisis are corroborated by the investigations of recent observers, and their exactness appears to be confirmed by the results of experience. The researches instituted of late years, in different parts of Europe, respecting the nature of consumption, and the formation of tubercle, having greatly elucidated its pathology, and induced many practitioners to ascribe more importance to hygienic measures, and seek to cor- 1 Surgical and Physiological Essays, 1799.

rect the morbid disposition by agencies whicb conduce to effect favourable modifications in the constitutions of patients, rather than to persist in following the system of pharmaceutic and palliative treatment generally adopted in these cases.

The investigations of M. Boudet are especially important, inasmuch as they demonstrate, by means of chemical analysis, that tuberculous matter contains several saline and other principles, which enter into the composition of the blood. According to this observer, " tubercle is not distinguishable from the parenchyma of the lungs by any special product, but merely by some difference in the proportions of the principles of which they are both composed, especially of the chloride of sodium, which abounds in tuberculous matter, of the phosphate of lime, which, on the contrary, is present only in a minute quantity^ and of the cholesterine, which is accumulated in it to such an extent that its proportion is ten times as large as in the substance of the lung. Tuberculous matter treated by alcohol yields oleic, margaric, and free lactic acid, lactate of soda, and cholesterine, in the proportion of a 20th part of the whole mass. Chloride of sodium and phosphate of lime are found in the ashes of tubercle, which likewise yield a small quantity of carbonate of lime, sulphate and carbonate of soda, silex, oxide of iron, and lactic acid. 1

The salts which are found in the largest quantity in the blood, are chloride of sodium, carbonate of soda, and phosphate of lime ; and the variation in 1 Compendium de Medecine, art. cit.

the proportions of these salts, as well as that of the iron contained in the blood, occasioned by various causes, must necessarily exercise a considerable influence in the production, and in the course of several chronic diseases. MM. Becquerel and Rodier remark that the diminution of the chloride of sodium is of constant occurrence under the influence of fasting ; its proportion is likewise diminished in acute diseases; the quantity of phosphate in the blood is, on the contrary, increased in most diseases. The proportion of this substance being, in healthy blood, on an average, as 350, increases in cases of pulmonary tuberculization to 403.

The retention in the blood of the water, salts, acids, &c, which should be eliminated by the skin more particularly, by altering the composition of this fluid from its normal condition, gives rise to various chronic diseases, of which the origin is not generally suspected. According to the chemical authorities, whom I have just quoted, in 100 parts of dried sweat, there were found 22 of fixed salts, consisting of carbonate, sulphate, and phosphate of soda and potass, chloride of sodium, phosphate and carbonate of lime, with traces of oxide of iron. 1 M. Favre found ("Archives de Medecine," July 1853) that 14 litres (28 pints) of sweat yielded the following principles : 1. Parts soluble in water : Chloride of sodium, 22.305 grains ; of potass, 2.437 ; alkaline sulphates, 0.9150. 2. Alkaline lactates, 1 Chimie Pathologique. Paris, 1854.

3.171; alkaline sudorates, 14.623; urea, 0.428; fatty matter, 0.13; water, 9,955.

We have seen that some of the products have been found in the analysis of tuberculous matter; that the chloride of sodium, of which the amount in the blood is diminished in diseases of debility, is found to exist in abundance in tubercle, and that, on the other hand, the phosphate of lime, which exists, in a very minute proportion, in tuberculous matter, is found to be greatly increased from its normal proportion in the blood of tuberculous subjects.

It would be out of place to enter, on this occasion, further into details pertaining to the domain of animal chemistry ; the few remarks which have been made sufficing to indicate the relation which exists between the morbid deposit, the blood and the cutaneous secretion, the practical bearings of which will become more apparent after we have entered more fully into the subject of the present enquiry.

CHATTER II.

ON THE NATURE OF PULMONARY TUBERCULIZATION.

Several distinguished pathologists have considered tubercle to be a product of inflammatory action. Foremost among these, in recent times, was Broussais, who said that he had never seen tubercles in the lungs without previously existing inflammation. M. Bouillaud, who, in most instances, adopted the opinion of Broussais, likewise considered that tubercle may arise from inflammation of the organs of respiration. More recently, Dr. Addison, of Guy's Hospital, London, expressed the opinion that scrofula and pulmonary tubercle are frequently occasioned by inflammatory action, and, that a great number of the excavations which have been generally considered as arising from the softening of tubercles, are, in fact, a consequence of pneumonia. 1 Reinhardt, of Berlin, in a late publication, considers tubercle to be a product of chronic inflammation fre- 1 Guy's Hospital Reports.

quently repeated. 1 Van der Kolk, of Utrecht, expresses an analagous opinion ; which, however, is not adopted by the generality of pathologists and practitioners. Laennec remarked that the development of tubercle is owing to a generally disordered state of the system, which takes place independently of preliminary inflammation, and that where inflammation co-exists with tubercles, it is subsequent to them. Besides, the deposition of tubercles simultaneously in several parts of the body, directly disproves the doctrine of their inflammatory origin. Bayle said that tubercles were never an effect of inflammation, even in the chronic form. Louis believes that although inflammatory action may in some instances exercise an influence over the production of tubercles, yet that in others it seems to take no part in their formation.

Dr. Carswell remarks on this point : " An effect and its cause are always inseparable under conditions of an analagous nature. The products of inflammation are coagulable lymph and pus. When, therefore, other products than these present themselves in inflammation, the conclusion to be drawn from this circumstance is, that there exists some other morbid condition than inflammation, and that, to this condition alone should be ascribed the distinctive and essential character of these products.

" Where the tuberculous disposition exists, inflammation or any irritation may attract it to a particular organ j examples of this present themselves in the inflammation of the subcutaneous glands of

i On the Identity of Tuberculous Products with the results of inflammation. (In German.)

the neck ; a testicle, a kidney may become tuberculous from the same cause." 1

In order to corroborate his observations, Dr. Carswell mentions the case of a young woman who was attacked by pneumonia and bronchitis, owing to the position in which she sat at her work in winter, viz : between a good fire and a door, and which, being continually opened, gave ingress to a current of cold air. The inflammation was restricted to the left side, which was always turned towards the door, and it was found, on post-mortem examination, that the lung of this side was in a state of tuberculous infiltration, the bronchial membrane of the same side being more or less inflamed up to the point of bifurcation of the trachea, where all traces of inflammation disappeared. The right lung was healthy, except at the summit of the upper lobe, where there were some tubercles in a crude state, serving to show the existence of tuberculization, preliminary to the occurrence of the inflammation which on the left side had occasioned the disease to assume an acute form, owing to the exciting causes to which the patient was exposed.

Referring to the insufficiency of inflammation to give rise to tubercles in persons not thereto predisposed, M. Andral remarks : " We may readily conceive that a very slight bronchitis may suffice to produce tubercles in one individual, whereas others do not become consumptive notwithstanding the

1 Cyclopedia of Practical Medicine, art. Tubercle.

prolonged existence of pulmonary catarrh." 1 M. Fournet mentions an instance corroborative of the opinion that irritation existing in an organ attracts to it the tubercular deposit in preference to its ordinary seat. "In several patients," he remarks, " unhealthy or insufficient food was the most decided cause of the tuberculous cachexy ; consequently, the intestinal tuberculization was much more advanced in its course than the pulmonary tuberculization; the tubercles were in a crude state, or the softening process had only commenced in the lungs, whereas large and deep tuberculous ulcerations were observed in the small intestine. This fact is explained by the principle, that when from the existence of tuberculous cachexy, tuberculization has become imminent, it will fix itself on the viscera to which it is attracted by any irritation of sufficient degree and duration." 2

Sir James Clark remarks on this subject, "Although I believe tuberculous matter is never a product of inflammation in a healthy person, the inflammation may and often does act as a determining cause in a tuberculous constitution."

In the case of stone-masons, coal-heavers, flaxdressers, metal-grinders, and needle-pointers, who frequently become consumptive, it is not merely on account of the inhalation of metallic particles, stone, dust, &c, that tuberculization is induced, but as Sir James justly remarks : " The sufferers are exposed

> Cours de Pathologie Interne.

3 Recherches Cliniques sur 1 'Auscultation, &c, Paris.

to causes fully adequate to the production of tuberculous cachexia ; they pass most of their time in a confined, deteriorated atmosphere, often in a sedentary position, unfavourable to the action of the lungs; many of them are much exposed to the vicissitudes of the weather, and the majority of them are addicted to the use of ardent spirits." Dr. Alison states that " there is hardly an instance of a mason employed in hewing stones in the vicinity of Edinburgh, living free from phthisical symptoms to the age of 50. Nevertheless, tubercles were not found in the lungs of those who were examined after death. In some there were condensed or indurated portions of lung ; in others, parts of these organs were in a soft pulpy state, with effused serum, pleuritic adhesions, and much effusion into the bronchia. Few of the workmen in the quarries of St. Roch pass the age of 40 ; the disease is commonly called the ' Maladie de Saint Roch.' The symptoms are similar in all these cases to tubercular phthisis, and are often, no doubt, connected with it." 1

We may, then, conclude that inflammation cannot, of itself, give rise to pulmonary phthisis; but that when a predisposition to the disease exists, inflammation, as also irritations of various kinds, when sufficiently powerful and long-continued, may occasion the development of tubercles in any organ which is the seat of them ; and further, that it is with reason that pathologists, with some exceptions, have regarded tuberculization as a disease depending 1 On Consumption.

upon an alteration of the blood from its normal condition.

But, what is the nature of this alteration ? This is a point which has not been determined up to the present time. Several years ago, MM. Andral and Gavarret showed that even at the outset of the disease there was a considerable diminution of the normal amount of globules, with an excess of fibrin in the more advanced stages. "The patients in whose lungs tuberculization is beginning," say these authors, "present the particular modification in the composition of their blood which belongs to weak constitutions j they are truly in a state of incipient ansemia, and their blood resembles that of persons who have been repeatedly bled. Thus, the condition of the blood which coincides with the beginning of consumption, and which most likely precedes it, is the same general condition which we find in all cases where, from whatever cause, the vital powers have lost their energy.

" Is it, however, to be inferred from this, that the impoverishment of the blood in globules is sufficient to produce phthisis ? By no means ; but it is to us a certain sign that this disease originates in a notable weakening of the constitution, and joined to those signs derived from clinical observation, this sign comes to enlighten us in the choice and direction of therapeutical means." 1

That the morbid state of the blood which gives rise to tuberculous cachexy, may exist for a long

1 Hematologic Pathologique.

period before the formation of tubercle in the lungs, has been demonstrated by Sir James Clark, Mr. Ancell, and other pathologists, and there can scarcely be a doubt that the more immediate cause of vitiated states of the blood, is in most instances to be ascribed to a diminution or suppression of the insensible perspiration from inactivity of the capillary circulation of the skin, by which the substances contained, as we have seen, in this secretion, are retained, instead of being eliminated from the system. " We have found," remarks a distinguished medical author, " in the changes which the blood may undergo in its composition, a fruitful source .of alterations in the mode of its vitality. It would seem that it is only through this medium that we can act upon the nervous system to modify its action so as to change the constitution of individuals, on account of the extent to which this fluid may vary, and the apparent immutability of the nervous system in its form and structure/' 1

The authors of a recent work, nevertheless, express the opinion that in the immense majority of cases, tuberculization remains a local lesion, the deterioration of the constitution being owing to the suppuration and to the gradual extension of the disease. " At the beginning of pulmonary phthisis, they observe, if there exist no complication, the composition of the blood preserves its normal characters. As, however, the disease advances, the tubercles become softened, and complications arise,

» Dr. Edwards on the Influence of Physical Agents on Life.

C

(bronchitis pleurisy, &c.) the blood then presents the same alterations as in serious diseases, and especially in inflammations The diminution of its globules is, however, more rapid, and is carried to a greater extent in eases of phthisis." 1

The opinion of these celebrated chemists that the deterioration of the constitution, and the alleviation of the blood are the effects and not the causes of the local affection, is refuted not only by the investigations of pathologists, but likewise by the most ordinary experience, which shews in the very appearance of the patients, frequently before any symptoms have indicated the existence of a local lesion, that their blood is very far from possessing, a healthy character, and I would not have quoted it were I not apprehensive that some practitioners might be misled by the reputation of these authors. 2

We have already noticed the constituent parts of the perspiration, and it may readily be conceived that any notable diminution of this secretion, arising from defective action of the skin, must exert a great influence in the production and maintenance of

1 Becquerel et Rodier — Chimie Pathologique.

2 Dr. RadclyfFe Hall, of Torquay, in an elaborate paper on Tubercle, in the British and Foreign Medical Review, remarks : "The deposition of tubercle is progressive. What causes this progressiveness ? In the first place, and mainly, the persistence and increase of the cachexy. Then inflammation around existing tubercles, provided the cachexy is great. The tubercle already deposited has not, from the mere fact of its presence — at all events, before the period of softening — any direct influence in keeping up the tuberculous diathesis."

cachectic states of the system, and we may reasonably conclude that the most likely means of curing diseases, which result from the consequent deteriorated condition of the blood, would be by restoring the equilibrium of the deranged functions, exciting through constitutional agencies those of the skin, with a view to restore to the blood its normal properties before the diseases thence resulting have become irremediable.

" The regulation of the temperature of the body," says a recent writer, " is only one of the purposes fulfilled by the perspiration. Another and an important one, is the removal from the system of a number of compounds, noxious to animal life. It was estimated by Lavoisier and Seguin, that eight grains of perspiration were exhaled from the skin in the course of a minute, a quantity which is equivalent to 33 ounces in 24 hours ; of this quantity a large proportion is naturally water, but nearly one per cent, according to Anselmino, consists of solid substance. Of the latter, 100 parts contain about 23 parts of salts, the remainder being organic matter. An analysis of 100 parts of the solid matter of perspiration, according to Anselmino, gave the following results : Osmazone combined with common salts, 48 parts; lactic acid salts with osmazone 29 parts; animal matter with vitriolic salts 21 ; calcareous salts 2 ; to which may be added carbonic acid gas, ammonia and iron.

The number of square inches on the surface of a man of average height and bulk is 2500; the

c 2 number of pores 7,000,000 ; 145,833 feet, 48,000 yards, or nearly 28 miles of perspiratory tube. What if this drainage were obstructed ?' n

It is not, however, solely by means of the arrest or defective elimination of excrementitial matters from the blood, that inactivity of the functions of the skin may tend to produce tubercular cachexy. The close relationship which exists between the skin and the organs of respiration, and the part which it takes in the excretion of carbonic acid from the economy — and probably in the absorption of oxygen from the atmosphere — must lead us to consider it as a truly supplementary apparatus for the efficient accomplishment of this function, and that any material derangement of the skin must exercise a most pernicious influence on the organs contained within the thoracic cavity in many cases, even though the effects of this influence may not be immediately apparent.

At the close of the last century, the respiratory action of the skin had already been noted by Messrs. Ingenhouze and Cruikshank ; and the experiments made by Abernethy clearly showed that carbonic acid was excreted, and the oxygen of the atmosphere absorbed in variable proportions by this membrane. After keeping his hand alternately in two inverted vases containing respectively twenty-four ounces of oxygen and of azote, for a period of eight hours, Abernethy found that two thirds of the oxygen had

1 Influence of Tropical Climates on European Constitutions, by Ronald Martin. 1856.

disappeared, whereas oiily a twentieth part of the azote had been absorbed. " After the hand/' he says, "had continued nine hours (in the air of an inverted jar) more than an ounce of carbonic acid gas had been produced, and the remaining air contained one-fourth less of oxygen than before the experiment." Estimating the extent of the surface of the body at 2700 square inches, he remarks that, the increase of the action of the lungs consequent upon the repression of that of the surface of the body, must necessarily often produce diseases of these organs, especially in individuals whose thorax is but imperfectly developed. " If the perspiration of all parts were equal, 77 drachm measures of carbonic acid, and one-third of that quantity of nitrogenous gas, would be emitted from the body in the space of one hour. If we also suppose perspiration to be at all times equal, nearly three gallons of air would be thrown out of the body in the course of one day. About 2£ pounds is the loss of water which the body sustains in one day ; the absorption of air was equal to the perspiration in my experiments, in many it was more, if the air was salubrious to which the skin was exposed."