Observations on tuberculous consumption

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Contents

Preface vii

Preliminary Remarks 1

Life cannot be defined 5

CHAPTER I. Phthisis, term defined * . . . » 87

Tubercles how formed ? ; . , , * 92

If by inflammation ? , , , , 93

secretion ? 102

error in nutrition ? , 107

Explanations not satisfactory • • Ill

CHAPTER II. Phthisis, a compound disease * 114

Granulations — ^Tubercles *.. 117

Their identity questioned i * 120

•

IV CONTENTS.

Page

Its compoukid structure . . . • , 139

Formed by minute globules retained in vessels 141

Causes of its retention in them 144

Analogy d^vedirom injecting pulmonary artery 145

Relation between the. blood and vessels 160

Humoral pathology not absurd , . 161

Connexion between phthisis and struma 169

CHAPTER III. Re-action of tubercles, or second stage of phthisis 171

All obstructions in lung important 173

That from tubercle most of all — reason why 177

Result of injections — appearances 185

Contrast presented by hepatized lung 192

Physiological inferences . • 196

Imperfect character of arterial blood in phthisis 199

Physical cause of this 203

Varies in different cases 209

Inflammation necessary to its removal 213

Practical difficulties 215

Conclusions ••• 217

CHAPTER IV. Treatment of phthisis in its formative stage 221

Definition of word " Cure" 222

Points in pathology recapitulated 225

Strumous dyspepsia » 227

Organization determines its action, 231

Treatment of dyspepsia 233

Caution as regards tonics . • . . • 246

Use of alkalis^ and theory of their action 250

CHAPTER V. Treatment of phthisis in its reactive stages 260

Subject considered under three sections 266

Sect. 1 . Diet, exercise, medicine 268

Sect. 2. Vicarious respiration 300

Refrigerants 303

Action of oxygen on skin and living surfaces 306

Experiments 307

CONTENTS. V

Page Sect. 2, continued : —

Solution of nitrous oxide gas • 314

Application of the above principle 320

Riding, sailing, swinging, &c. considered 323

Sect. 3. Inhalation 325

Substances employed, examined under four heads : —

1. Oxygen 329

2. Sedatives 33t

3. Stimulants 333

4. Iodine — Chlorine 336

Sect. 4. Treatment of Symptoms 341

Inflammation 341

Hectic fever 347

Haemoptysis 351

Diarrhoea 358

Colliquitive perspiration 360

Cough 362

CHAPTER VI. Remarks on reporting cases 366

Means of diagnosis in early phthisis 369

' late in the disease 375

Cases arranged under three classes 376

Details of these 379

Plates, with Explanation, 401

Preface

When an author proposes to add another Treatise to numbers already published on the subject he undertakes to discuss, it behoves him to show that he has a rational prospect of either adding to the general stock of ideas on the matter of his discourse— or, of placing old ones \ under a new aspect — or, of improving their arrangement ; i unless one or other of these piu-poses be gained, it would be perhaps better, both for himself and the public, that his pages had never seen the light.

I will not dogmatically assert that this book fulfils any one of these intentions, for a writer is ever a bad judge of his own capacity — ^this must be determined by others : but I may with great confidence declare, that these sheets would never have been printed, had I not believed them to contain some new truths, and to develop views of considerable practical importance.

The whole phenomena of tubercular consumption seem to point out, that it ought to be considered as a compound disease. It is impossible to suppose that the

• •• via PREFACE,

adventitious matter which constitutes its immediate cause^ is merely a growth, or product, springing out of the living textures which form its seat ; and we are thus compelled to consider it as an effect of some aberration from healthy action, deeply rooted in the system. This indeed is an opinion, the truth of which is now very generally admitted, but seldom so strongly urged or well illustrated as in the writings of Sir James Clark and Dr* Tod,

But valuable as the labours of these authors are, they still leave a link wanting in the chain of causes and effects which connects early errors of digestion with final pul-^ monic deposition ; for it can scarce be doubted that the entire symptoms of strumous dyspepsia may exist without being succeeded by pulmonary disease ; and this fact is but vaguely explained when simply referred to the presence of a phthisical or strumous diathesis.

The link thus wanting I have endeavoured to supply, chiefly by examination of the capillary circulation connected with the right side of the heart ; arriving at the conclusion, that while the properties of the blood in phthisis appear to be altered by a primary error of digestion, the immediate determining cause of tubercle is to be traced to certain vices of organization, inherent in the capillaries of the pulmonary artery ; these bodies being, in fact, constituted of minute globules originally existing in the blood, and retained in those vessels during its

PREFACE. IX

transit through the lungs. These vices of vascular organization I presume to be hereditary, and so far as the individual is concerned, unalterable; and theyconsti^ tute, as I believe, the essential element of what has been named a strumous constitution, which it requires only an abnormal condition of blood' to call into full local development : a considerable share of this idea is hence based on the recognition of a humoral pathology — ^a term which not very many years ago it would have required some nerve to employ, except in disparagement ; but which, in the revolutions of medicine, seems at length destined to play its legitimate part in the investigations of general pathology. To this phase of the disease I have ventured to apply the name of *' formative*' stage of phthisis, ftknply because it appeared to indicate, in brief terms, the idea I felt desirous to convey^; and, in discussing it? treatment, I have endeavoured to inculcate, that it is by changing the quality of the blood alone that we can ever hope to effect any useful end. The remedies most effectual in fulfilling this intention I have, after some considerable experience, concluded to be the caustic alkalis.

But the morbid phenomena of phthisis are clearly not all dependant on its formative stage. Organs, whose functions are so important, nay, so immediately necessary to the support of Ufe, as are the lungs, must instantly manifest the presence of any local disease by effects produced on remote parts. This is in truth the case, and

X. PREFACE.

every organic or functional malady of the lung does induce effects^ greater perhaps than the same amount of disease in any other organ produces. Of this general truth there can be no question ; but^ it appeared to me that in phthisis the morbid influence propagated to other organs from the central disease was^ in many cases, greater in proportion to the amount of organic change, than when portions of the lungs were rendered functionarily useless as a result of inflammatory action. The reasons of this difference I have endeavoured to point out; and the conclusions arrived at are reported in the chapters which discuss the pathology and treatment of consumption, in what I have designated its stage of r^- actioni as contradistinguished from that o{ formation* On the management of this stage I have commented at some length, attempting to estimate at their proper value, the various discordant medicines, and methods of treatment which we find so profusely scattered over works directed to the subject, and thus to deduce certain principles which may, in some degree, guide the practitioner.

The intention of this book being to investigate the pathology and cure of phthisis as it actually exists, I have assumed its presence while dealing with the subject, and have consequently neither entered on the statistics of the disease, nor on a consideration of the remote causes which are most influential in calling it

PREFACE. XI

into existence. The vast importance of all such investigations no one will more willingly admit than myself; but they are already ably and amply discussed in other works, and my apology must be, that to encounter all points connected with so wide a subject was beyond my power. As the field is extensive, so ought the reapers to be numerous, and my highest ambition will be gratified, if I have been able to gather even one sheaf into the barn.

I ought, perhaps, to offer a similar apology on the subject of physical diagnosis. It is but slightly noticed in the progress of this work, and that chiefly at its termination, where it became necessary to show that the cases treated had been truly cases of consumption. It would be to me a subject of regret that any inference should from this be drawn, that I undervalue the advantages which have arisen from applying another sense to the investigation of disease; but we are bound to estimate this at its proper value, as a means only to an end. The most perfect diagnosis does not always point out the road to cure.

On the last word thus casually used I may be permitted to offer a few remarks. It is contained in the title page of this book, and some friends, on whose judgment I place considerable reliance, have viewed it as objectionable. Had I employed it as holding out the hope that all cases of phthisis are susceptible of removal, or.

Xll PREFACE.

that lungs once beset with tubercles^ can ever be so restored as to render them again healthyi I should have been guilty of a positive deception; because my own conviction is against the possibility of any such occurrence. But defininff the word « cure," as I have done in the body of the work (p. S23), the case is altogether altered, and I believe that we are often as much gratified in employing the term in reference to phthisis as we are in other organic affections, where appropriate treatment, without absolutely removing the disease, renders it, with care on the patient's part, innocuous.

Of the numerous imperfections of this work I am fully aware. Should it attract any attention at all, it is more than probable that many of its pages afford legitimate subjects of criticism. The subject, however, it must be admitted, is one of high importance ; and while I neither solicit favour or deprecate censure, I cannot help entertainmg an mnate conviction that its pages wiU add in some slight degree to a right comprehension of tuberculous consumption.

Wbtmouth Street,

1th October, 1841.

SOME OBSERVATIONS

ON TQB

NATURE AND CURE

OF

TUBERCULAR CONSUMPTION.

Preliminary Remarks on tfte Connexion between the

Blood and Life*

Every natural science proposes as its object, a reference of the varied phenomena which occur among the material constituents of the earth to certain general laws.

As we have no knowledge a priori of these laws, such acquaintance with them as we do possess has been exclusively obtained : —

First, by carefully investigating effects ; and,

Secondly, by inferring or deducing the law from the unvarying nature of such effects when occurring under similar circumstances.

The first man who observed that a stone or other body when removed from the earth tended to approach it again unless restrained by some coimteracting power, or the first who observed that an acid united with an alkali, and thus formed a new substance which diflfered from either of its constituents, could only have regarded those phe-

B npmena as isolated facts ; but when these and others analogous, observed during a long series of years, and in an immense variety of examples, were found to be always similar under the same circumstances, men doubtless began to reflect on their cause, and the result of the investigation has oeen the reference of one and all of the changes and motions of inanimate matter to two principles alone — those namely of gravitation and chemical attr action:

But it is one thing to infer with correctness the existence of a principle, and ascertain in some degree the law by which it acts ; and another to acquire a knowledge of such principle in its essential nature : and hence, though we perhaps possess a perfect knowledge of the law of gravitation, and a tolerably precise knowledge of the laws of chemical affinity, we are yet profoundly ignorant of the nature of those attributes or qualities of matter on which they depend.

But if this be true as regards physical phenomena, still more obviously true is it that we are profoundly ignorant of the principle on which vital phenomena are dependent*

The causes of this difference in the relative precision of our knowledge of physical and vital laws may, to a certain extent, admit an explanation.

The sequence of cause and effect is in physical phenomena uniform and unvarying under the same conditions ; and these conditions being given, we . can very often predict the results.

For example^ in chemical science a long sei4es of observations has shewn us, that one substance stands towards others in such relations that their particles tend to unite when brought under certain circumstances into close vicinity, but do not unite unless these circumstances exist; thus it often happens that two bodies whose particles strongly attract each other at a high temperature, or when moisture is present, are perfectly inert at a low temperature, or when moisture is absent, while in very many examples the conditions necessary to their union are even more numerous and complex.

The necessity of studying and duly appreciating the influence of these accessary conditions, considerably complicates the science of chemistry, and hence, although great advances have been made towards a precise acquaintance with its laws, they are still much less definitely known than the law of gravitation. This, precisely for the converse reason, is much more perfectly understood ; and perhaps we are warranted in holding that, altogether independent of the fortunate application of a wondrous mind like Newton's to its development, there is inherent in the subject itself a greater probability that it should be fully developed, than that the laws of chemical action should be fully apprehended.

The condition necessary to the exercise of gravitation is one alone, namely, that the mass attracted should contain fewer particles of matter than the mass attracting; and provided this exists, the

B 2 sequence of cause and effect is certain and unvarying.

Thus a mass of matter gravitates towards the earth precisely with the same certainty, and with a velocity regulated by one simple law, whether it be hard or soft, moist or dry, at an elevated or at a low temperature ; all of which variable conditions would more or less have modified the exertion of its chemical affinities, and thus presented us with a problem, whose difficulties are increased by the number and complexity of the elements required for its solution.

It would appear then that the difficulties of attaining a perfect knowledge of any natural law, are to a certain extent dependent on the number and complication of the accessary conditions by which the manifest phenomena resulting fiom such law, and from which its existence is inferred, are modified ; and it is probably very much for this reason that our acquaintance with the laws of vital phenomena is unmeasurably less perfect than that which we possess of those inducing physical phenomena.

A living body, presenting motions which are only explicable by a reference to vital force, exhibits besides, many others which are obviously referable to causes purely physical in their nature : we have thus presented to us a microcosm in whose motions or changes we recognise the operation of three distinct forces, vital, chemical, and inechianical ; a circumstance which renders the study of the science of life considerably more difficult and complex than that of any other natural science whatever.

It is, for the reasons now advanced, impossible to define life, except by contradistinction : all we know with any certainty is this, that organized bodies under particular conditions present in each and every part certain motions or changes which are absolutely inexplicable on the laws of either chemistry or mechanics ; and to the came producing such motions we assign the name of vital principle, or vital force — Life, as the word is usually employed, expressing the assemblage of manifest phenomena which result from its exercise.

But although thus ignorant of the cause of life, it is still desirable, for the better acquaintance with diseases, to endeavour at obtaining some knowledge of the laws by which it acts, for as diseases doubtless depend on certain aberrations from nature in the motions of the bpdy, or on changes in its structure, so it follows that an intimate knowledge of them can never be acquired so long as our acquaintance with natural or healthy action is imperfect ; and it is doubtless from the want of such preliminary information that we are frequently compelled to minister to diseases in an empirical manner, and without any clear conception of the exact nature of that deviation from healthy action in which they consist.

For the attainment of this end no course appears better adapted than that of attempting to discover what motion or change is present under all the modifications of life as manifested by organic bodies ; what one condition appears connected with vitality in the most exten^Jed sense of the term, which being present, life remains, but if taken away, life ceases.

As we cannot define life except, as we have already said, by. contradistinction, the first step in the inquiry proposed consists in conveying some precise idea of what is meant by the term.

This we employ in two distinct acceptations. Employed in one sense, we use it to express the full performance of, or the existing capability of performing, the many motions which we know from observation and experience any special organism ought to be capable of exercising, according to the position it occupies in the extensive scale of living bodies. Here we employ the word to indicate the entire and complex life of an organized structure, a compound as it were of many vital motions which vary in number, in kind, and in degree.

But again we use the term life to express the actual exercise, or the existing capability of exercising any one or more of those motions which in their aggregate constitute a perfect life, others being either for the time dormant, or the capacity of performing them being destroyed.

Thus, when we speak of the life of an animal, we comprehend under this name, the acts of sensation, locomotion, intellectuality, nutrition and reproduction — ^these constituting as it were the sum of its existence ; and when we speak of the life of a v^etable^ we mean to include in the idea all those acts with the exception of the three first ; but in each case the entire life is so constituted^ that so long as any one of those acts is executed^ the organism in the strictest sense of the term — lives. Its life is indeed less perfect than before — but still it lives. These considerations lead us to view the life of an organized body as equally compound with the organs by which it acts — as composed of numerous actions — as they are of numerous tissues, which in their conjunct exercise constitute a perfect life ; but many of which may remain quiescent, or even be annihilated without any absolute destruction of vitality.

Admitting then this strictly compound character of life — but avoiding all hypothetical speculations as to how any act of this compound is performed ' — we may with safety inquire. Is there any one general condition inseparably connected with the execution of each and all — any common sustaining cause which being applied, they continue — being abstracted, they cease ?

Such universal sustaining power of one and all the actions of life, in all its infinitely varied modifications, from the lowest plant to the highest animal, is found in the continued application to the intimate structure of the part performing them of some fluid, similar, or at least analagous to blood, whicU has been subjected to the influence of oxygen. We know this fact beyond all question — but we do not know how this fluid acts in producing the phenomena.

The varpng construction of the organic apparatus, by means of which this oxygen is brought to act on the fluid ; or the different means adapted for ensuring the distribution of this fluid afterwards to the organs, do not invalidate the truth of this general proposition; whether the oxygen acts through leaves, or spiracles, or gills, or lungs — whether the blood it endows with vital properties, be transmitted by a single or double heart, or by vessels only, independently of any central organ, the leading fact remains equally certain.

The functions by which this vitalized fluid is prepared and transmitted, are those of respiration and circulation. They are always intimately associated, and conduce to the common end of supplying each part with its proper excitant to action.

On this account these functions have been named '^ vital functions,'- by which term it is meant to express not that they are the only ones on which life is remotely dependant — ^but those on which it is immediately dependant. To use a mechanical illustration, they produce the steam without whose instant and continued application the whole machinery ceases to act.

In all the higher animals certainly, and pro* bably as a general attribute of animal life, a third vital function, as it is usually termed, is executed by the brain and nerves. The claims of the nervous apparatus to this designation may be considered of two kinds — the one immediate^ but only in some degree apparent — the other remote, less obvious, and yet, in truth, much more real.

The first or apparent claim is founded on the fact, that all the more manifest phenomena of animal life are strictly dependant on the integrity of a nervous system ; and it is hence natural at the first glance to conclude, that in such life itself resides ; yet during sleep, and still more in coma from accident or disease, many of the motions which manifestly depend for their excitation on the nerves are suspended, yet life undoubtedly still continues.

The less manifest but far more real claim to the designation of vital function by the nerves, consists in this — that they excite the respiratory 9iuscles into action, and thus indirectly induce the physical conditions on which the reddening of the blood depends: but it is here to be remarked, that this power of influencing respiration, is itself in turn strictly dependant on the reception by the brain, spinal marrow, and nerves themselves, of red blood, remotely produced by their action, while conversely, artificial delatation of the thorax after all nervous action has ceased, still reddens the blood — still sustains the action of the heart — and still supports for a time very many functions of life — excepting always those which are in their display inseparably connected with nervous energy.

We conclude on these grounds that respiration and circulation are essentially and fundamentally the two vital functions, appertaining to every form and every description of organized bodies, and that in strictness, the claims of a nervous system (superadded to the others in animals alone) to be so considered, consists in its aiding those in effectuating the great purposes of preparing and applying arterial blood to acting organs.

In all the higher orders of animals the influence of oxygen is immediately exerted on their blood during its passage through the lungs ; and tnediately communicated to their organs through the intervention of this fluid, which after traversing the left cavities of the hieart, and large vessels in connexion with it, finally reaches the extreme or capillary branches of the arterial tree.

While in progress through the lungs the blood undergoes a certain change, which may be briefly denominated its pulmonic change — conversely the blood so altered sustains, during its progress through the vessels of the body generally, another change, which may be briefly expressed by that of systemic change.

These respective changes are effected only at particular points of the blood's transit. If examined while yet flowing in the larger trunks of the arteries, or in the smallest subdivisions which admit of one vessel being distinguished from another, the fluid is found to present the same physical characters which it did when first altered in the minute vessels of the lung^

When again this blood is examined in the smallest vein which is appreciable by the senses^ we find that it has lost its arterial character^ and acquired the character of venous; and we thus determine two points between which this change has occurred.

The converse of this is true as regards the circulation in the pulmonic vessels: there the most minute appreciable artery contains black or venous blood, while the most minute appreciable vein contains red or arterial blood ; so that here also we identify two points between which a change has been wrought on this fluid, the counterpart of that induced on it in the systemic vessels.

In considering then the phenomena of circulation without regard to the vital or mechanical causes of propulsion, but simply in relation to its physiological importance, the broad fact is this — that a stream of black blood formed at the ex-- tremities of the systemic arteries flows along the whole line of systemic veins, through the two right cavities of the heart, to the extreme terminal branches of the pulmonary artery; and that a stream of red or arterial blood formed at this point flows along the pulmonary veins through the two left cavities of the heart, to the terminal branches of the aortic system.

As regards the causes which induce these changes in the blood, there remains little if any question, that the one from black to red is produced by the agency of oxygen. With equal certainty may it be affirmed that the converse change, or that from red to black, owns as its cause the execution of those various motions which in their aggregate we term vitality.

For reasons also already stated, it is evident that those changes take place in the most minute vessels of. either circulation respectively; but as the vessels of the living body are, if the expression may be used, infinite in their subdivisions — so the precise point at which venous blood becomes arterial — or arterial blood vetious — are questions to be determined more by inference than demonstration.

But a mere difference in physical characters of the two bloods does not necessarily imply any distinction in their vital influence, and we are hence compelled to observe the effects which result fifom each, either in continuing, impairing, or destroying those intestine changes and motions of parts which constitute life.

When indeed experience teaches us, that a cessation in the function of respiration very soon suspends, and if continued even for a short time destroys, life ; and when we couple this with the admitted fact, that the only immediate and appreciable result of respiration consists in producing in the blood what we designate its arterial change ; we might be led to infer with great certainty that red blood is immediately necessary to life, and arrive, on these grounds alone, at the same Conclusion to which direct experiment conducts.

It is here however not necessary to trust to inferential reasoning alone ; the experiments of Bichat, conducted with every possible precaution, varied in almost every possible manner, conceived by a genius, and prosecuted with an industry nearly unexampled, have conclusively established the one main and leading fact, on which all physiological reasoning must rest, that for the sustenance of every vital act, the fluid which circulates in the vessels requires to be subjected to the action of oxygen, and then transmitted by some mechanism to the most intimate fibre of each acting organ ; and that when its action has taken place, one universal effect follows — the conversion namely of red blood into black.

We conclude on these data, that under the influence of oxygen in the respiratory apparatus, the blood either acquires a something which renders it an appropriate supporter of vitality in parts, or loses a something, which for the time obscures its vital properties, and renders it an inappropriate agent for that purpose — while conversely in the minute vessels of the system, it either gains that which obscures its vital character, or parts with a something which, being taken away, destroys its action as a vital agent ; nor do we arrive at this conclusion with less of certainty, because confessedly ignorant of the inherent property by which each organ, or each tissue of an organ, effects distinct actions under the stimulus of a common cause.

If it be demanded what this " something** is, which by its addition or abstraction exerts such an influence over the phenomena of life, we admit our entire ignorance of its quality or essence. Our senses afford no information beyond what is founded on the varying colours of the blood, to lead us to a knowledge either of its absence or its presence; the most delicate tests which chemistry can apply fail to announce any other decided difference* between the two varieties of the vital fluid ; and all we know with any certainty is, that the absorption of oxygen and the evolution of carbonic acid constitute the most marked physical changes which accompany, at least, if they do not produce f it.