On the treatment of pulmonary consumption by hygiene, climate, and medicine in its connexion with modern doctrines

Front matter

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Preface

The first edition of this essay was published in 1866, and was purely clinical. Although deeply interested in the discussion then going on respecting the intimate nature and origin of Tubercle and of Pulmonary Consumption, I thought it best to confine myself entirely to the clinical aspect of the disease. I merely described therefore the hygienic or sthenic treatment, which gives such infinitely more favourable results than those obtainable by the antiphlogistic treatment generally adopted in my younger days.

Such reticence, however, is no longer desirable or possible. Two doctrines are in presence, both based on minute histological research, and both exercising all over the world, a profound influence on the treatment of Pulmonary Phthisis. The one — that of Virchow and his followers — all but denies the tubercular origin of chronic Pulmonary Consumption — of the disease clinically recognised as Pulmonary Phthisis ; in their eyes it is either a new growth or a mere form of chronic pneumonia. The other — represented by Professor Bennett of Edinburgh —

VI PREFACE.

defends and supports the tubercular origin of chronic Pulmonary Phthisis, in an exudation of the blood previously impoverished, also on histological grounds, entirely repudiating the data on which Virchow and his school found their opinions.

The singular feature of this controversy is, that the immense body of practising physicians, those who have to act as umpires between the two histological schools, are not competent even to give an opinion on the subject of minute microscopical morbid anatomy discussed. They are followers, not leaders in microscopical research, and have to see with the eyes of faith what they are told to see by the teachers in whom they trust. They are wanting in the knowledge or sharpness of eyesight which would enable them to detect who is right and who is wrong, when such men as Bennett and Virchow, who have spent their lives in microscopical research, thoroughly disagree.

Practical clinical physicians have, however, it appears to me, a locus standi, a basis on which to rest their decision, and that basis is the clinical observation of the disease in question, the one that I took in 1866. It is this basis that I have again taken as my guide, and which leads me to lean rather to the doctrine of my namesake than to that of the celebrated German pathologist. I would draw attention to the fact that not only is Professor Bennett a distinguished Histologist, but he is also equally distinguished as a Pathologist. For more than a quarter of a century he has taught clinical medicine

PREFACE. Vll

at the bedside to a numerous class, and he is universally known as a clear-sighted observer. It is this combination of histological knowledge with that acquired by the lengthened observation of disease that, in my mind, gives peculiar and exceptional value to his opinions.

In leaning to the view respecting the origin of Pulmonary Phthisis advocated by the Edinburgh Professor, I am gratified to find that I agree entirely with Dr. Austin Flint of New York, one of the most eminent and experienced of our American brethren (p. 115).

I believe also that T am warranted in stating that most physicians of matured age and of enlarged experience who have given themselves the trouble to study this controversy, lean to the same side — and are indisposed to substitute the term "chronic pneumonia" for that of " chronic Phthisis," on the ground of long-continued clinical observation. On the other hand, most of the followers of the new " inflammation doctrines" are young, enthusiastic physicians, full of knowledge, but deficient in experience.

As we advance in life our experience naturally increases. Thus the mental horizon expands, and much more is seen, in Medicine as in everything else, than in the earlier part of life. It would be sad indeed if, as we lose power, as our sight fails, we did not reap some little compensation.

As a traveller who has seen many climes, who has ascended many Alpine ranges, it often strikes me

Vlll PREFACE.

that man's mental vision as he advances in life, may be compared to the ocular vision of the traveller who ascends a mountain. He starts, at early dawn, full of life, strength, and enthusiasm, but at first, at the base of the mountain, he sees but little, only what is near and around him. Thus he makes many mistakes, falls into many quagmires. As the day progresses he rises higher and higher, and simultaneously his vision expands. He no longer merely sees the objects just around him ; he grasps those far off — the road he has traversed, that which he has still to encounter, the ravines and dangers passed, and some — and some only — of those that have still to be met. But the higher he gets, the more he sees, the more his strength flags.

So it is in Medicine. As our experience of disease increases, when we have followed its developments in several generations of human beings, we learn to take more comprehensive views, to attach less importance to local morbid manifestations, more importance to general laws, to hereditary, constitutional, social, hygienic conditions. It is, after all, to this comprehensive clinical experience of disease that we must appeal in such discussions as the one which is reviewed in this essay.

Geosvenob Street — May 15th to October 15th. MENTON E — Winter.

Chapter I

Preliminary Remarks — The Nature and Causes of Pulmonary Phthisis pp. !_ 2 o

Chapter II

Bodily Hygiene: Food— Stimulants — Respiration and Ventilation — The Skin — Exercise— Mental Hygiene : The Passions

pp. 21—50 CHAPTER III.

Climate and Medical Doctrines — Warm Climates — Temperate Climates — Cold Climates — Summer Climates — Winter Climates — Madeira — The Riviera and Spain — British Winter Climates pp. 51—86

Chapter IV

The Medicinal Treatment of Phthisis — No Antidote for Phthisis — The Medicinal Treatment of Complications — Cod- Liver Oil — Iodine — Iron — The Preparations of Phosphorus — Opiates — Expectorants pp. 87 — 106

X CONTENTS.

Chapter V

The Results of Modern Treatment — Prognosis : The Types of Phthisis — Histological Theories — Acute Phthisis — General Phthisis — Chronic Phthisis — Phthisis among the Rich — Phthisis with Complications — Scrofulous Phthisis— Localized Phthisis — Phthisis of the Aged — Gouty Phthisis — Phthisis among the Poor pp. 107 — 143

CHAPTER VI. Cases Illustrative of the Cure and Arrest of Phthisis

pp. 144—176 CHAPTER VII.

What are Cured Consumptives to do in Life ? — Can they Marry? pp. 177—184

- ROYAL X

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ON THE

TEEATMENT OF PULMOMKY CONSUMPTION

BY

HYGIENE, CLIMATE, AND MEDICINE, IN ITS CONNEXION WITH MODERN DOCTEINES.

Chapter I. Preliminary Remarks

THE NATURE AND CAUSES OF PULMONARY PHTHISIS.

So much has been written during the last thirty years on Pulmonary Consumption by men of the highest order of intellect, that it requires a certain amount of moral courage to enter the arena. No one, indeed, would be justified in so doing unless he conscientiously thought that he had information to impart calculated to be of use to his fellow practitioners, and to humanity at large. It is because I believe that such is really my case, as regards the treatment of pulmonary phthisis, that I have written the present clinical essay.

I have little that is absolutely new to bring forward — at least that is new to those who keep pace with the progress of Medicine ; but I believe that I have important testimony to give in favour of modern science, as my experience powerfully corroborates

B modern views with reference to the treatment of pulmonary consumption. One who, like myself, has been thirty-seven years in the profession, belongs both to the past and to the present, and is able to speak from personal experience of the views and opinions of former days as well as of those of the present time. This fact may give some weight to the judgment of an author, who certainly does not appear in the character which, according to the Latin poet, characterizes the later periods of life — that of a "laudator temporis acti."

I believe, also, that I have had rather peculiar and exceptional opportunities for forming an opinion respecting the value of the treatment of pulmonary consumption pursued thirty or forty years ago as compared with that now adopted by the leading authorities at home and abroad. My education was carried out partly in England, partly in Paris. During four years (1839-43) I was resident medical officer to several Paris hospitals, and gave clinical lectures on auscultation (not then as generally studied as it is now) and on diseases of the heart and lungs, to several hundred young English and American medical men. Thus I became thoroughly imbued with the knowledge of the day, and have ever since remained much interested in thoracic pathology.

After practising many years in London, as an obstetric physician, I became myself affected with consumption, and in 1859, had to abandon everything i n order to go and die, as I thought, on the shores of the Mediterranean. Relieved from the fatigue, the harass, and the cares of our arduous profession, I managed, hy the application of modern science, to save my own life, and since then I have helped to save the lives of many similarly affected who have followed me in my winter health-exile to the south.

The great fact to which I have to testify is, that pulmonary consumption is a curable disease — indeed, in its early stages, often a very curable disease — under sthenic or restorative treatment.

In making this assertion, I have merely to confirm by matured knowledge, a paper written in 1840, entitled "On the Curability of Consumption," which I recently found among my manuscripts. At that date I had just passed a year as one of the resident medical officers of the Salpetriere, a large asylum hospital in Paris, more especially devoted to aged and infirm women. There 1 had found in the dead room, in the lungs of many women who had died in advanced life from other diseases, large cretaceous deposits and puckered cartilaginous cicatrices, which proved emphatically, undeniably, that they had been consumptive at some antecedent period of their life, but had got well, spontaneously no doubt, dying at last of other disease. Indeed, in those days, the rational treatment of Phthisis was so little understood by the generality of practitioners, that I believe a sufferer had a better chance of recovery if the disease was not discovered than if it was. The low diet, the confinement, the opiates and fever medicines, the

B 2 leeches and blisters, which constituted the usual therapeutics of such cases, were certainly but little calculated to arrest a disease the essence of which is organic debility. The inhabitants of the Salpetriere are mostly aged women belonging to the lower classes, and the pathological conditions observed were undeniable evidence of their having recovered from an advanced stage of consumption, at some period or other of their life. Possibly, feeling ill and weak, they had taken refuge with their relations or friends in the country, and had recovered under the influence of improved hygienic conditions, or of a natural limitation of the disease.

In the year 1840, when, from my own personal observation, I became aware of these pathological facts, that Pulmonary Phthisis is spontaneously curable, it was considered by most of the physicians with whom I had come in contact to be all but inevitably fatal, especially when advanced to its second stage — that of softening. Since then, the same pathological evidences of the spontaneous cure of Phthisis have been found by all who have had special opportunity of making post-mortem observations in the aged. Among these observers I may more especially mention my namesake, Professor Bennett of Edinburgh.*

* Pulmonary Consumption, by John Hughes Bennett, Professor of the Institutes of Medicine, Edinburgh University. First edition, 1853 ; 2nd edition, 1859, p. 26.

Clinical Lectures on the Principles and Practice of Physic. Edinburgh 1868 ; fifth edition, p. 179.

Article, Phthisis Pulmonalis, in Reynolds's System of Medicine Vol. iii. p. 537. 1871.

His luminous work on Pulmonary Consumption, (1853), has much contributed to improve our knowledge of this disease. He was the first to thoroughly establish its treatment on the rational ground of hygiene. Indeed, Professor Bennett has done more than any other British physician to base the treatment of Phthisis on a true appreciation of the nature of the disease, and to prove that it is capable of arrest and even of cure, by a restorative treatment, if recognised before the lungs are so disorganized as to be unable to discharge their physiological functions.

This, I believe, is now the opinion of most practitioners, at home and abroad, whose attention has been specially directed to the subject. Among those who early laboured to demonstrate this fact I may name my friend Dr. Richard Quain, one of the most enlightened pbysicians of the day. In 1852 he published a series of very interesting and valuable cases, illustrating, in the most unimpeachable manner, the arrest and cure of Pulmonary Phthisis under sthenic treatment.* There are many, however, who still look upon Pulmonary Phthisis as incurable, or who are wedded to old and erroneous methods of treatment.

I would remark, incidentally, that the modern change in the treatment of Pulmonary Phthisis is entirely the result of doctrinal progress — of the gradual establishment of pathological views sounder and more rational than those that reigned at the

* See Lancet, 1852, May 22nd, June 12. Report of Cases from the Out-patient Department of the Hospital for Consumption, Brompton.

beginning of this century. I do not believe in the change of the type of disease as a cause of the change of therapeutic doctrines. In my experience disease is exactly what it was when I was a youth, thirty- seven years ago, allowing, of course, for epidemic influences, whilst my own ideas have undoubtedly changed. The contrary opinion has always appeared to me a mere figment, brought forward by men advancing in years, who had rather believe that disease has changed than tbat they themselves can have held false doctrines, and can have treated their patients on erroneous data, in youth and middle age. The probability is that disease is pretty much now what it was a thousand years ago, or in the days of the patriarchs, modified of course by hygienic and social conditions.

Pulmonary Consumption was thought, by most pathologists, in the early part of this century, to be merely a disease of the lungs, having an intimate connexion with inflammation. The doctrines of Broussais were then the order of the day. Nearly every disease of the human economy was considered to be inflammatory, or the sequela of inflammation, and a depleting, lowering, " antiphlogistic" treatment was adopted.

Under the influence of microscopical research, and of more minute and searching investigations into morbid anatomy, these views, doctrinal and therapeutic, have been altogether modified. A lowered vitality, a lowered vital power, are generally considered, and justly so, to be at the root of most morbid changes, and a sthenic or life-supporting instead of a depleting treatment is recommended and adopted in the treatment of disease generally.

The recent histological views of Virchow and his followers have, however, a tendency to revive the Broussaisian explanation of Phthisis, to refer it to the class of inflammatory diseases. As such views must exercise an influence over treatment, I cannot avoid alluding to them, or asking, What is the intimate nature of Phthisis Pulmonalis — what is meant by the term Pulmonary Consumption ?

The answer to this question is both easy and difficult. Easy if we merely consider the clinical features of the disease so called ; difficult if we try to reach its intimate nature. The general consensus of the medical profession embodies under these terms the forms of lung disease in which morbid deposits, localized or general, take place in the intimate structures of the lungs, extend from one region to another, soften gradually, destroy and excavate the lungs, and, if unchecked, end in the death of the patient. So explained and limited, the disease stands out clinically clear and well defined. If, however, we try to ascertain the exact nature of these morbid deposits or formations, obscurity and doubt begin. To some they are, generally, tubercular deposits or exudations, to others they are, generally, inflammatory or scrofulous products, only exceptionally tubercular. To make these views clear, however, I must refer to the text of the authorities. This is the more necessary, as although the intimate and structural nature of tubercle on the one hand, and of the products of inflammation on the other, has been most minutely investigated by hosts of competent observers, there still appears to be room for doubt and discussion.

The views of the more eminent histologists appear to group themselves round two schools — viz., that of Professor Bennett and that of Virchow.

According to Professor Bennett (Lectures, p. 179), " Tubercle may be regarded as an exudation, possessing deficient vitality, sometimes grey, but more frequently of a yellowish colour, varying in size, form, and consistence, essentially composed of molecules and irregularly-formed nuclei .... This exudation " (p. 181) " has little tendency to pass into cell forms. The original albuminous molecular matter melts into nuclei, which constitute the tubercle corpuscles, and are developed no further .... I regard tubercle, therefore, as an exudation which may be poured out into all vascular textures, in the same manner, and by the same mechanism, as occurs in inflammation ; only from deficiency of vital power, it is incapable of undergoing the same transformations, and exhibits low and abortive attempts at organization, and more frequently, as a result, disintegration and ulceration. For the same reason we observe that whenever an undoubted inflammation becomes chronic, with weakness, the symptoms and general phenomena become identical with those of tuberculosis. Hence there is little difference between a chronic pneumonia of the apex of a lung and a phthisis ; the one indeed passing into the other .... "When we endeavour to discover the origin of the weakness producing this effect on the exudation, we must ascribe it to imperfect nutrition."

Dr. Eeginald Southey,* in a series of Lectures exhaustive of the histology of Tubercle, as described by German histologists, gives the following account of Virchow's doctrines : —

" Tubercle" (p. 12), " according to Virchow, is a new growth, and is classed by him among the Lymph tumours — those, namely, which are constructed after the pattern of lymph glands, and which stand most closely in relation to connective tissue formations. The single tuberculum or the tuberculous tumour is not capable of identification from any one element entering into its composition ; but its origin, its development, and its minute structure together confer a particular stamp upon it as a whole, which renders it capable of distinct recognition.

" The Tubercle formation is cell-structured from the moment of its first appearance ; it proceeds always out of connective tissue, or from some tissue closely allied to this, such as false membrane, fat, or the medullary tissue of bone. It exists in two forms — the one the cellular, the other the fibrous form; but they have such features in common as imply un-

* The Nature and Affinities of Tubercle : being the Gulstonian Lectures for the year 1867. London : Longmans. 1867.

mistakable oneness. The fibrous form is only a slight structural modification of the simple cellular — a modification impressed upon it by the external conditions of growth.

" The origin and mode of development of the simple cellular form is best of all to be studied from the tuberculous growth, as this is found upon serous membranes, or upon the mucous membrane of the larynx. .... On a serous membrane the young growth is smaller than the smallest millet seed j it has a granular look, and contains soft, imperfectly-developed cells, which are very easily broken down, and free nuclei. Its elements, although differently grouped, are identical with those that constitute a normal lymph gland.

" The isolated Tubercle forms the tiniest tumour that occurs on the human body, but it is rarely, if ever, single. These growths are almost always multiple ; they are found in nest-like groups close together, and multitudes of nodules thus originally and individually distinct can combine together and form a conglomerate tumour.

" Conglomerate Tubercle increases in size b}' surface accretion : new nodules grow up in the tissue immediately round about the old ones ; and as this accretion can take place from all sides around a centre in the parenchyma of solid organs, the final shape attained by the mass is round or roundish."

According to Virchow the formations, exudations, deposits, infiltrations, which take place in the lung in a chronic form, principally in the apices, are not, generally speaking, tuberculous — that is, formed of tubercles, as above described. They are, generally, either bronchial lymphatic gland tumours of a scrofulous nature assuming the form of caseous or cretaceous masses ; or they are the result of scrofulous (grey) hepatization of the lungs.

" The catarrhal process " (p. 84) " extends into the ultimate air-cells, the appearances finally attained being scarcely distinguishable from those which attend acute pneumonia; catarrhal mucus cells and fibro-plastic ovoid nuclei are mixed together and block up the alveoli ; the inter-vesicular spaces are trebled in thickness, and come to present a dense, and more or less fibrillated connective tissue ; .... in the thoracic tract," (p. 78) " the implication of the lungs, a gland tissue of peculiar aim, and therefore of very special structure in scrofulous chronic inflammation, gave Louis first, then Laennec, and after him the French schools, their primary conception of tubercular disease ; and as Virchow and others maintain, a false idea of the constitution and essential nature of Tubercle.

" If, as in the neck, the scrofulous process had expended itself less upon its primary seat and more upon the bronchial glands (which although large do not become proportionately enlarged) its pathology probably would have been more correctly understood. The peculiar, round, millet- seed-like cast of the ultimate alveoli and finer bronchi, formed of inspissated catarrhal mucus, which shot out like an adventitious product upon gentle pressure, gave colour to the deception by its likeness to actual Tubercle of the pleura and serous surfaces ; and the not infrequent occurrence of the two diseases together in the same person (for they in no way exclude each other), led to this mucus cast of an air-sac, for I can call it nothing else, being thought to be the fons et origo malorum, the typical

and primary form of Tubercle It was an

adventitious product — it was produced by inflammation; true enough it was the result of a local inflammatory process. It was deposited from the blood, and coagulated in the part where it was found ; it softened into a cheesy mass, which hollowed from its centre. As Carswell showed, it was the almost entire plugging of small bronchi which gave rise to this idea. Vomicae were produced by the colliquating influence of the softened tubercles, by the death from pressure and cutting off of nutritive supplies of the interposed parts, and extended by the inflammation of surrounding tissues thus aroused."

Virchow, according to Dr. Southey, appears to reserve the term tuberculosis, all but exclusively, to those cases in which undeniable tubercle is formed simultaneously throughout the economy, or throughout an entire organ, as in the meninges of the brain in tubercular meningitis, or in the lungs in acute Phthisis. Such cases are acute in their manifestation and development, are accompanied by severe constitutional disturbance, and are all but necessarily fatal in their termination.

From the above it will be seen that the schools represented by Professors Bennett and Virchow differ in their account of the histological origin of Tubercle in the following manner. Professor Bennett thinks that tubercle is exuded from the blood, depraved by defective nutrition. Professor Virchow deems that tubercle is formed by a new growth from the connective tissue, the result of irritation or Reiz, as he terms it, originating in this connective tissue. The difference between these two views is most material, and clinically most important, when we come to the consideration of the chronic, sparse or conglomerated deposits, infiltrations, of the lung tissue, which occur in Pulmonary Consumption.

Virchow considers them to be new growths from the fibrous tissues, resulting from irritation or inflammation, whereas Professor Bennett thinks them generally to be coagulated exudations from the blood, which has previously been rendered poor by defective nutrition.

I am certainly incompetent myself to form an opinion on so minute and recondite a question of histological morbid anatomy. " Non nobis tantas componere lites." It is, however, of extreme importance clinically, that the profession should know that both these histological conceptions imply the same disease, Pulmonary Consumption. For the want of such an understanding most palpable and lamentable clinical errors are being daily committed, much to the detriment of the poor sufferers.

Whatever the intimate nature of these chronic deposits in the lungs, whether really tubercular or merely inflammatory, one fact is certain — that they constitute the disease described by Laennec and Louis as Phthisis Pulmonalis. To call them merely caseous pneumonia, or inflammatory consolidations of lung tissue, or lymphoid tumours, as is now very generally done in Gfermany, France, and England, or " lung troubles," a term used by our American brethren, is practically a deception and a snare ; unless the old-fashioned idea of " Phthisis," of a disease distinctly and naturally tending to progress and death, is connected therewith. Unfortunately, when the above terms are used they are often not so connected mentally, either by the young physician, imbued with recent histological lore, or by the patient deluded by terms, the true meaning of which he does not understand. Every winter I have seen, of late, at Men tone a number of decidedly consumptive patients from different parts of the Continent, or of America, who say that they have nothing much amiss — only a slight inflammatory consolidation of the lung, a slight caseous pneumonia of the apex, or some slight "lung trouble." Yet these patients are often far advanced in pulmonary consumption, with all its local ravages and constitutional symptoms. If, therefore, such terms as : localized pneumonia, caseous pneumonia, inflammatory consolidation of a limited area of the lung, scrofulous abscess or deposit, " lung trouble," are to be retained and used by the profession, it is our duty to explain to the patients that they are merely modern phrases for Pulmonary

Consumption — for Phthisis. Otherwise it is utterly impossible to induce them to take that care of themselves, to make those sacrifices, which are indispensable for their recovery.

As the chronic malady of the lungs in which the tubercular exudations or formations, the inflammatory products, the scrofulous caseous tumours above described, constitute the disease universally recognised and described as Pulmonary Consumption or Phthisis, we cannot do better than retain for it the latter name. By so acting we avoid assuming, as decided, points still obscure, or at least still debated. At the same time we imply, as of old, that we are dealing with a very serious and fatal disease, with one which, unchecked, has an undeniable tendency to progress and to destroy life, once it has reached a certain stage of its development ; that we have to treat a dire malady by which a considerable portion of the human race passes into eternity. There can, however, be no objection to applying the term tuberculosis to general acute tuberculization, were it thus applied by general consent.

Whatever opinions be now entertained as to the intimate nature of the morbid conditions of luns which constitute Pulmonary Phthisis, I think that there can be but one opinion as to their secondary character. Indeed, it is generally admitted, as forcibly demonstrated by Professor Bennett in 1853, that the lung disease, however severe, chronic or acute, is merely an epiphenomenon, the secondary result of

16 ON THE NATURE AND CAUSES OP

constitutional disease, of a morbid general diathesis which precedes, occasions, and rules the lung malady. Given the lowered state of vitality, given the diathesis it engenders, these morbid tubercular or other formations or deposits may take place, as a result, in the lungs, and in all but any other organ or region of the body.

Thus, in the investigation of the nature and causes of Pulmonary Consumption, and of tubercular disease in general, we must go a step further than can be reached by the most minute anatomical and histological researches. Clinical observation shows that the manifestation of these forms of lung disease, chronic and acute, must be looked upon as the evidence and result of a serious, perhaps final, diminution of vital or nervous energy. In other words, they may be considered the evidence of incipient decay of the organization from defective vital or nervous power. Indeed, Pulmonary Phthisis and general tuberculization are simply a mode of dying. Unless the vitality of the individual can be roused, the morbid condition will surety progress, and life will be extinguished sooner or later, according to the state of the constitution of the patient, and to the type of the disease.

The very essence of life is the organic vitality, variable in different species, variable in different individuals, with which each organism, vegetable or animal, merges into being and develops itself. It is owing to inherent organic vitality that the medium duration of life in the Oak, the Ash, the Fir, is different, as it is also different in the Whale, the Elephant, the Horse, the Dog, and in Man himself. The medium duration of life in each species is reached in the organisms that are created under favourable conditions, with unimpaired organic vitality, and that pursue their existence under conditions favourable to life. On the other hand, this medium duration is not reached by those individuals that are created under unfavourable conditions, with defective vitality, or in whom originally sound vitality is modified, diminished, destroyed by the unfavourable conditions in which their existence is carried on.