Elements of general pathology; a practical treatise on the causes, forms, symptoms, and results of disease

Front matter

r ^

0„ y o

A'

Preface

English Medical Literature has hitherto possessed no work exclusively devoted to General Pathology. In nearly all of the systematic treatises and dictionaries of medicine in our language this subject is either discussed theoretically and imperfectly, or is altogether unnoticed. The well-known and valuable work of Dr. Williams forms scarcely an exception to this statement, for its scope not only embraces General Pathology in the proper sense, but also hygiene, prophylaxis, and therapeutics ; in consequence of which extended plan the author was obliged to restrict himself to " a brief general view of Etiology, Nosology, Semeiology, Diagnosis, and Prognosis," subjects which will be found to occupy •nearly the whole of the following pages.

It is hoped that the attempt now made to supply the deficiency which is thus disclosed in our medical literature will not be thought untimely, and that the difficulties inseparable from such a task, will secure for the writer the candid criticism of his professional brethren. He is convinced that among the most serious defects in the present system of medical education, are an almost total neglect of logical analysis, and a tendency, where generalization is at all encouraged, to speculate on fanciful analogies, rather than to extract truth from facts. How fatal these influences must be to a successful study of disease, and to that confi-

Vlll PREFACE.

dence in medicine which experience imparts to the philosophical physician, is too apparent to require illustration. The author is persuaded that the view of medical science which it is the province of General Pathology to afford, is eminently adapted to correct these evils, by encouraging a more healthful discipline, and infusing a more hopeful spirit, among those who are preparing for medical practice.

Defects like those complained of are nearly if not quite as palpable in the education of English physicians, whose writings but too often afford evidences of their existence. The eminent teacher alluded to above, fully confirms this opinion in the following words, which are respectfully commended to the meditation of American physicians : " I venture to affirm, that a chief reason why the practice of medicine has been commonly so distasteful, and so difficult in its study, and so unsatisfactory when tested at the bedside, is, because its foundation, general pathology , has not been efficiently taught."

An intimation was given in the original announcement of the publishers of this work, that it was to be prepared with reference to the Elemens de Pathologie Generate of M. Chomel. On reflection, this plan was speedily abandoned by the author, who preferred employing as a basis for the work the Lectures delivered by him in a medical institution of this city. He has the less reason to regret this decision, since there has just appeared in Boston, a translation of M. ChomePs treatise, by Dr. F. E. Oliver, and Dr. W. W. Morland. The lectures referred to have merely served as a nucleus, around which have been arranged much more abundant materials, derived from all of the best sources accessible to the author. The works named in the subjoined list, besides those mentioned in the text, have been faithfully consulted and freely employed. The most valuable assistance was rendered by that of

PREFACE. IX

MM. Hardy and Behier, which is the most complete, as well as the* most recent, work on General Pathology.

While acknowledging his obligations to various sources for the materials of his work, the author takes the liberty of mentioning his indebtedness to his brother, Dr. Moreton Stille, for important services rendered in preparing his manuscript for the press.

Philadelphia, March 3d, 1848.

LIST OF THE PRINCIPAL WORKS CONSULTED.

Prosper Alpinus. — The Presages of Life and Death in Diseases ; translated from the Latin by R. James, M. D. ; 2 vols. London, 1746.

Van Swieten, Commentaries upon Boerhaave's Aphorisms. Translated from the Latin ; 18 vols. Edinburgh, 1776.

Zimmerman, Traite de PExperience en general, et en particulier dans Part de guerir. Traduit de PAUemand, par Lefebvrede Villebrune. Paris, 1774.

Gaubius, The Institutions of Medicinal Pathology. Translated by Erskine. Edinburgh, 1778.

Double, Semeiologie Generale, ou Traite des Signes et de leur valeur dans les Maladies ; 3 vol. Paris, 1811-22.

Landre Beauvais, Semeiologie, ou Traite des Signes des Maladies, 3eme ed. Paris, 1818.

Rostan, Traite elementaire de Diagnostic, de Pronostic, dedications Therapeutiques, ou Cours de Medecine Clinique ; 3 vol. Paris, 1826.

Dubois (d' Amiens) Traite de Pathologie Generale, 2eme edition. Bruxelles, 1835.

Piorry, Traite de Diagnostic et de Semeiologie, 3 vol. Paris, 1S37.

Xll LIST OF WORKS CONSULTED.

Schill, Outlines of Pathological Semeiology. Translated from the German, by D. Spillan, M. D. Republished, Philad., 1841.

Chomel, Elemens de Pathologie Generate, 3eme ed. Paris, 1841.

Williams, Principles of Medicine : comprising General Pathology and Therapeutics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, and Prognosis. Republished, Philada., 1844.

Requin, Elemens de Pathologie Medicale; 2 vol. Paris, 1843.

A. Hardy and J. Behier, Traite elementaire, &c. Pathologie Generale et Semeiologie. Paris, 1844.

Copland, A Dictionary of Practical Medicine ; Art. Disease, causes of, &c. American edition, by Dr. Lee. New York, 1846.

Vogel, The Pathological Anatomy of the Human Body. Translated from the German, by George E. Day, M. A., &c. London, 1847*

THE GENERAL PHENOMENA, THEORY, AND CLASSIFICATION OF DISEASES GENERAL DIAGNOSIS AND PROGNOSIS.

Chapter I. The Type, Duration, Stages, Terminations , And Seat Of Disease

Section I. — Of the type or form of disease, - > 114

II. — Of the duration of diseases, - . 116

III. — Of the stages of disease, - - - - - 118

IV. — Of the terminations of disease, - - - - 123

V. — Of the seat of diseases, ..... 142

Chapter II. Pathogenesis, Or The Theory Of Disease. - . 150

CHAPTER 111.

GENERAL NOSOLOGY, - « . 158

Chapter IV

Section I. — The qualifications of a medical observer, - - . 163

II. — The mode of investigating a case of disease, - - 167

III. — The mode of recording and generalizing medical cases, - 175

IV. — Modes of physical examination, - - - 177

CO N TENTS. XV

Chapter I. Signs From The Exterior Of The Body, 217

Section I.- — The position and size of the body — Colour, temperature,

&c, of the surface, - - - - - 218

II. — Signs from the head, face, and neck, - 239

III. — Signs from the exterior of the trunk, » 248

Chapter IV. Signs From The Nervous System

Section I. — Signs from the function of sensibility, - . . 290

II. — Signs from the organs of voluntary motion, - - 301

III. — Signs from the intellectual functions, - . . 308

Chapter V. Morbid Products Not Included In The Preceding Classification, 468

INTRODUCTOKY ESSAY.

MEDICAL TRUTH.

ITS NATURE, SOURCES, AND MEANS OF ATTAINMENT.

General Pathology presents an almost boundless field for study. All branches of medical science and of medical literature, are, to some extent, included within it, because they furnish the materials out of which it is formed. Whoever, therefore, attempts its investigation is obliged to select, from the topics it presents, such as he is capable of grasping ; and must apply to them such principles of reasoning as the peculiarities of his mind and education have rendered natural and familiar.

In common with most authors, the writer of the present treatise proposes to set the truth before his readers, but conscious that this phrase represents no medical doctrine received of all men, but only " that which every man thinketh," he makes bold to claim indulgence while endeavouring to expound his interpretation of medical truth.

Truth, which is an exact accordance with fact or reality, has no absolute existence except in the Creator of the universe, because no finite mind can stand in any conscious relation to all created things. Revealed truth is an expression of the Creator's will, and so far as it extends, is perfect, and, like its author, unchangeable. But medical truth is neither absolute nor revealed. Intuitive truth is that which carries conviction with itself; it has only to be stated to be admitted. Of this sort is the consciousness a man has of his own existence, a conviction which no reasoning can either strengthen or invalidate. It is this which gives sacredness to Genius. No man can seize all the relations of the moral and physical world, but some few possess the power of instinctively perceiving and elucidating moral truths. Such truths, and so discovered, are those which have been sung by the poet and taught by the moralist in all ages, and whose real accordance with the principles of human nature is shown by the fact that they are essentially the same, wherever promulgated. But medical truth is not intuitive. Again, there is demonstrative truth. Mathematical propositions are of this sort. They repose on axioms and postulates, which cannot be gainsaid, and which are, therefore, absolute and immutable. The conclusions at which they furnish the means of arriving are consequently certain. But it is to be observed that the elements of mathematics are mere abstractions. There is really no such thing as a straight line, a plane surface, a regular curve, a perfect sphere, a uniform solid, as defined by the geometrician.

Hence it is that mathematical propositions in the abstract, pure mathematics, are rigorously true; but in practice, applied mathematics, are liable to all the errors created by defective senses, and imperfect instruments, errors which can only be corrected by observation and experience. Medical truth is not demonstrative. These several kinds of truth are intellectual chiefly ; they have their origin in the mind ; they are evolved, weighed, and applied by the mental faculties. But there remains another and a very different one. This is inductive truth. It is that which belongs to the physical sciences, which is the sacred element of all (so called) natural laws ; the search after which is the life-spirit of astronomy, of chemistry, geology, and medicine, whose progress has been rapid while it was active, and slow when it declined. It is that very truth which is " the daughter of time, and not of authority," and which alone can outlive the waste of ages, and man's contempt and neglect. Its origin is not in the mind, but in external nature. Observation is the great instrument for its discovery, and next, experiment, which is observation under circumstances of our own choosing. Facts are its materials, co-ordinated facts contain its laws. The ancients were ignorant of it, or had but a faint perception of its power. They preferred to speculate and dogmatize rather than study the interpretation of nature. Their ambition was to form a sect and captivate public opinion ; to triumph over their opponents rather than to prove themselves possessed of truth ; to sharpen their wits rather than to exercise and improve their senses.

Hence the barrennessofthe ancientphilosophy,its utter unproductiveness of anything really useful to mankind. Well did it deserve the sentence pronounced upon it by its greatest judge. " It is not wonderful," says Lord Bacon, " that the Egyptians (who bestowed divinity and sacred honours on the authors of new inventions) should have consecrated more images of brutes than of men ; for the brutes by their natural instinct made many discoveries, whilst men made few from discussion and the conclusions of reason." If modern times have any advantage over antiquity, it certainly is not either in acuteness or force of reasoning, (which are of all ages and may be made to support a bad as well as a good cause,) but in that knowledge which has flowed from long and repeated observation. The theories which ruled the world successively, have disappeared one after another, like succeeding fashions in equipage and dress, while many of the facts recorded two centuries before the Christian era, recur in the daily walks of our profession, precisely as the Father of medicine inscribed them on his tablets. The Galenical theory, that of Paracelsus, of Borelli, of Van Helmont, of Silvius, all world-renowned in their day and generation, are now less honoured than the scattered dust of their inventors. No other destiny awaits the hypotheses which have more recently arisen and flourished. Brownism and Rushism, Broussaisism and Hahnemannism, with all the other fruits of a luxuriant fancy and a poverty of facts, must descend the inevitable slope to oblivion ; but the vast collection of truths established by the observation of nature, are as immutable as herself.

It is not asserted that the originators of medical systems were wholly ignorant or regardless of observation, or that such physicians as Hippocrates, Celsus, Aretceus, Sydenham, Baglivi, and Morgagni, were entirely free from the shackles of speculation. But while the latter exerted all their industry and talent in collecting and pondering facts, caring little for the establishment of one doctrine rather than another, the former, by dint of medilation and subtle reasoning, elaborated from a few facts such complete and ingenious systems, that they were afterwards ashamed to descend to the

INTRODUCTORY ESSAY.

gross and mechanical process of observing, and by degrees became so charmed with their own work, as to hold for certain what they had at first regarded as only probable. Since the days of Hoffman and Boerhaave, a little more than a century ago, even the most hardy theorists have professed to base their systems upon facts. Technical logic and metaphysical reasoning have been almost discarded from the schools, and no one now claims acceptance for his doctrine, upon the ground of any internal evidence of its truth, but simply on that of its conformity to the results of observation. Such is the spirit of the age. The reigning philosophy has almost always shaped medical theories. While the former occupied itself with unsubstantial shadows, the latter were subtle and flimsy, — mere cobwebs of the brain. But when the old philosophy began to totter under the sturdy blows of Lord Bacon, and was completely overthrown by the Sceptics of the last century, Aristotle and Galen were abandoned to the dust and the worm, and Nature began to be worshipped in their stead. The consequences of this revolution have been stupendous. The physical sciences, one and all, have revived, and in a few years advanced far on the road to perfection. But not content with narrow limits, they have taken under their fostering care the mechanical arts, infusing into them a vigour, and communicating to them an impulse which have reacted upon every human interest, social, political, and religious. Less than half a century has sufficed for this work, for changing the whole of Christendom from speculative to practical, and for rendering this, (what it is so often called,) the mechanical age. If the natural sciences were once crushed under the incubus of metaphysical and theological disquisitions, or etherialized by the refined and poetical tastes of our ancestors, they have already been avenged. They have driven from amongst us nearly all of true faith, of ennobling and generous poetry, of single-hearted devotion. It is the misfortune of humanity ever to run into extremes, to adopt a prescriptive policy, to lose sight of that portion of good which mingles with, and redeems from condemnation, even the most imperfect things. If the. ideal once supplanted the natural, does it follow, that when nature triumphs, the imagination must be chained in the dust? By no means; for each has its appropriate sphere. The poet should hold undisputed sway in his own realm, the scientific investigator reign supreme in his. Thev cannot wield a common and

cor "

united sceptre, for the subjects of the one are airy nothings, — people of the land of dreams, that rise at any moment, or in any shape that their master wills. Those of the other are the works of nature, which exist by no power of his, which change or pass away without his interposition, of which he is merely the spectator, and which he thinks his life well employed, if he can, at last, learn to interpret.

It cannot be kept too constantly in view, that there is no necessary connexion between medical and intuitive truth, between the physical sciences and poetry or religion. To assert such a connexion, is to pervert or degrade them all ; to arrest the progress of human improvement, and to arm the unbeliever with the most fatal weapons. The literary world has, of late years, been deluged with treatises and declamations on the poetical and religious tendencies of science, and especially on the persuasives to religion furnished by medical investigations. All this is essentially erroneous, and indicates a complete misconception of the nature of truth, and an ignorance of the different kinds of evidence required by different truths.

One of the most ingenious and sublime conceptions of astronomical science, — the Nebular Hypothesis, — one which has inspired much ardent and elevated devotion, and been the theme of much impassioned admiration, was invented by the great Laplace, — not because he had exalted notions of the power and wisdom of God, or was impressed with a sense of his own and this world's insignificance, in the midst of that infinite number of systems and worlds with which immensity is filled, but, as he himself avowed, " to do away with the necessity of a Creator" Now, the religious, or rather anti-religious conclusion which he drew from the contemplation of natural phenomena, was precisely the opposite of that which other men, no less acute, inferred from the same premises. Both parties could not possibly be right, and yet neither could convict the other of a logical error. The paradox is explicable by the fact, that Laplace was an infidel before, as well as after his great invention, while those whose conclusions were opposed to his, were Christians. The two parties saw the same object through different media, and therefore saw it differently. If an impartial umpire could have been found, he would, probably, have given judgment against both parties, declaring that the facts in question were scientific facts, — that they had nothing to do with religion, and, of themselves, gave as little countenance to the blasphemy of the one, as to the enthusiasm of the other.

It is common for persons to imagine that the study of astronomy must be delightful; that it must purify and elevate the soul, and inspire it with sublime conceptions of the Creator of all things. With these laudable sentiments, they open an astronomical treatise, and find a sad array of ellipses, parabolse, tangents, parallaxes, equations of curves, and other algebraic formulae, which have no more to do with the visible or metaphysical relations of the heavenly bodies, than have the letters of the alphabet with the objects they are employed to name. The poetico-religious inquirer closes the book in disappointment, and reproaches astronomy for not teaching him what it never professed to teach, — what, indeed, it was incapable of teaching. He should have blamed himself for not having taken the pains to inquire how that science was to be studied, — what were its legitimate objects, and its appropriate sphere. The same remarks are true of the other sciences, and, to their full extent, of medicine. Whoever would cultivate it with pleasure and profit, must first inform himself thoroughly of its nature, capabilities, and aim ; for, if he do not, one of two consequences will inevitably ensue : either he will fail to accomplish anything honourable or useful, let him labour never so assiduously, or he will, sooner or later, abandon the profession in disgust, persuaded that he has been deceived. He will have found that, instead of filling him with veneration of the wonderful contrivances of the human organism, and inspiring him with poetical or devotional feelings, it rather tended to diminish his faith, to materialize his speculations, to blunt his sensibilities ; that instead of his finding in it exhaust less mines of metaphysical research, of gaining from it any light as to the cause of life, the nature of vitality, the connexion of the soul and body, it not only left him as ignorant of these things as ever, but taught him that they were unattainable,

MEDICAL T8U T H. 31

and endeavoured to narrow down his inquiries to mere objects of sense. If this has really happened to any one, the fault was his own. Before entering upon medical studies, he should have fully comprehended their nature, learned how they ought to be prosecuted, and what advantages might fairly be expected from them. From this error the writer would preserve his readers ; he would convince them that the science of medicine is founded alone upon the observation of facts, to the entire exclusion of all hypothetical reasoning, and that, as a science, it has as little to do with the imagination or the conscience, as has the determination of a comet's orbit with the " Music of the Spheres."

It was stated that all the natural sciences are built up and perfected by observation ; but the results of observation are not equally exact in all. This is owing to the character of the elements of which they are composed. In proportion as these are simple and determinate, will the results be accurate. In astronomy, which is concerned with vast masses, bearing but few and constant relations to one another, mathematical calculations are easily applied, and the few general laws of the science readily deduced. Hence it is that astronomers are able to predict the occurrence of an eclipse, or the return of a comet to a given point in space, with as much certainty as the rising of the morrow's sun. If an error is committed in a particular case, the fault is in the observer, or in the imperfection of the instruments employed by him, but not in the irregularity of the phenomena observed, nor in the principle on which the investigation proceeded. In inorganic chemistry, the elements are more numerous, the instruments less perfect, the principles less certain. In its study, therefore, errors are still more inevitable. In organic chemistry, again, the difficulties are multiplied ; besides all of those which belong to its sister department, others, which are the result of life, abound, and substances of identical chemical composition no longer display the same, nor even similar physical properties. Advancing to physiology, we find the uncertainty augmented. Effects are there witnessed which cannot be arranged under any known chemical or mechanical laws, but are sometimes apparently in contravention of such laws. In physiology, we have to deal not only with matter, but with organized matter; not only with organized, but with living matter; not only with living matter, but with a living soul, in its thousand reactions with the body, which are, for the most part, not only unknown, but wholly incomprehensible. If, then, so much doubt and obscurity envelope our knowledge of physiology — of the normal and natural state of the human economy — how much thicker darkness must involve our notions of its abnormal conditions or diseases? If we add to all these difficulties, inherent in the subject itself, and which there is little hope of removing, those which ignorance, fancy, prejudice, and wilful deceit have added, — the false facts of medicine, as they have been called, — medical truth will appear to be shut up in a fortress, impregnable by human wisdom or human industry.

This is a discouraging and disheartening statement; one which would seem to admit, that medicine deserves all the sarcasms and ridicule which have been heaped upon it by the ignorant ; that it is unworthy of the name of science, and scarcely deserves to be called an art. But, after all, what does this avowal amount to? Merely that medical knowledge is neither perfect in itself, nor easy of acquisition. Is it, therefore, to be condemned, and buried in the same tomb with alchemy and astrology ? Or are not its very imperfections the rather to be studied, that they may be removed? For let it be remembered, that disease exists ; and, in one form or another, medical art has existed from the beginning, and must endure just so long as man's physical nature continues to be what it has always been. We are not called upon nor permitted to decide whether medicine shall be abandoned ; we can only choose between cultivating it seriously and ardently, and paying it a lukewarm and enforced respect.

The very uncertainty of medicine, if rightly understood, is one of the most effectual spurs to industry. It keeps benevolence warm; it makes us anxious and observant; it excites our ambition to rank with those who have most largely contributed to the resources and the progress of medicine. It is undeniable, moreover, that this progress is real ; that built upon the foundation already described, our scientific edifice is yearly rising in more stately and elegant proportions, from amidst the rubbish accumulated around it by the lapse of time.

Allusion has been made to the false facts of medicine. Their sources are various, but are principally these : wilful imposture, and self-deception resulting from a too ardent temperament, or from trusting in a preconceived hypothesis. Of the former are the numberless expedients of charlatanism, both within the profession and external to it ; the claims to important discoveries, and to the performance of cures in cases well known to be irremediable, or to a much larger success than is either probable, or proved by subsequent experience, or to the easy removal of diseases which the most honest and skilful practitioners admit to be very obstinate, if not incurable. These things, it is true, deceive none but the ignorant, and the progress of science cannot be long retarded by such small impediments. It meets with far more serious obstacles in some of its most zealous friends, in those who, by the inadequate study and rapid generalization of a few facts, proclaim new and wonderful results which are accepted as so many truths, upon the strength of their author's well-known veracity, and the assurance of their being the legitimate offspring of observation and experience.

Having now endeavoured to show that observation is the only instrument by which the physical sciences, and medicine amongst them, can either be created or perfected, and that false and imperfect observation forms the greatest obstacle to their improvement, it remains to be inquired what are the principles and the method of true observation in medicine.

The primary object of all medical investigation is, to distinguish diseases from one another. It is evident that all discussions about any disease, are utterly futile, so long as it is not agreed in what it differs from all other diseases. That there are various diseases, results from the most trivial and vulgar observation. The records of medicine in their most imperfect state, recognise the same fact, and it is employed as the very foundation of every treatise upon medical art. Consequently, in proportion as observation is minute and accurate, will each disease be exactly defined and separated from others which have a greater or less resemblance to it. Thus, formerly it

was not considered possible to distinguish pleurisy from pneumonia ; but a more rigorous investigation employed in later times, enables us to diagnosticate these affections with almost absolute certainty. Formerly there were united under the common name of inflammation of the brain, what are now known to be distinct affections ; under the name of cardiac palpitations, diseases as widely different as organic and functional alterations: so, too, of continued fevers, and other affections. The power now possessed of discriminating between maladies which were once confounded, to the great injury of the science and all rational therapeutics, has been entirely conferred by a system of close and methodical observation, by series of cases reduced to writing, and analyzed, as nearly as possible, with mathematical rigour. It is affirmed, that the results already obtained are to be regarded, not as absolute and final, but only as provisional ; not as the best possible, but only as the best for the time being. The correctness of the method is alone asserted to be positive, and beyond dispute.

Most of the writers whose names have been mentioned as connected with the real progress of medicine, seem to have adopted this plan to a certain extent, and none more fully than the Father of Medicine himself. But he, as well as all his successors, until very recently, preferred to communicate the general results, rather than the elements of their experience, in the form of aphorisms, or short, pithy maxims, which were easily remembered by their pupils. These aphorisms were what might be called the general impiessions left upon the minds of physicians by the whole course of their experience. There is no evidence of their having been formed by any more rigorous process, and consequently, many of them have long since been shown to be unequivocally false, and many others are expressed so obscurely, as to have little practical value. The cases which have come down to us from the older writers, are, for the most part, such as are least valuable, the rare, namely, the curious, and the anomalous. It became necessary, therefore, that the moderns should apply themselves to the natural history of disease, and build up the science anew, from its very foundations, by slow and gradual labour. Thus it is, that nearly the whole domain of pathology, such as we now possess it, is of very recent acquisition, ind in spite of their declamation against it, is used habitually, and valued by the very persons who insist that we have added nothing o ancient medicine, and who decry and ridicule the mechanical abour of observation. They consider the collection and observaion of facts as among " the slow processes of a vulgar intellect," ind would have truth seized by " the vigorous sallies of speculate genius ;" but they fail entirely to show a single medical ruth which was ever revealed by means of their favourite method.