Observations on the distinguishing symptoms of three different species of pulmonary consumption, the catarrhal, the apostematous, and the tuberculous ... To which is added, an appendix, on the preparation and use of lactucarium, or lettuce-opium

Front matter

m w

BENJAMIN DRAKE,

OBSERVATIONS

Preface

I here present to the public a very short Treatise, on a very important subject. With little difficulty, I might have extended it to a much greater length. A particular relation or even a selection of those cases from which my observations have been deduced, might have filled a large volume. My object, however, has been to lay before the intelligent reader, not the detail, but the result of experience, and to state merely the conclusions I have drawn from the facts which I have witnessed in watching the progress of pulmonary consumption.

If these conclusions have not been very generally erroneous, they have afforded useful

X PREFACE.

instruction to myself; and if an attentive perusal of them shall afford similar instruction to others, the object which I have in view by this publication will be completely obtained.

Edinburgh, ) Nov. 30, 1813. j

In the second edition of this short Treatise now presented to the public, the attentive reader will not find many alterations. And although, by the observations which have been communicated to me by intelligent medical friends, as well as by cases which have fallen under my own care, I might have sw elled it to a very considerable size ; yet, as my sole aim has been to communicate merely the result of experience, the size of the present edition will be found very little augmented. To the account, indeed, of the preparation and use of the Lettuce Opium, or Lactucarium, as I have named it, some interesting

PREFAGE, XI

additions have been made. A nd let me here observe, that besides the use of that article in phthisis pulmonalis, I have found it highly beneficial in various other affections.

I have particularly employed it with great advantage in many cases of Rheumatism,— a disease, which, I need hardly observe, is, in Britain, both a very common and a very painful complaint. It is not, however, in every condition of rheumatism, that benefit is to be expected from lactucarium. That disease, as well as phthisis, has been divided into a variety of different species. Sauvages, in his elaborate System, has pointed out fifteen different species, all of them, in his opinion, deserving attention, from the difference in practice requisite for combating each particular species. But the greater part of practitioners are not disposed to follow him in such minute distinctions.

Even from the earliest periods of medicine, however, two states of this disease have been

Xil PREFACE.

established, from the circumstance of their requiring very different modes of cure. These are almost universally known in Britain by the appellations of Acute and Chronic Rheumatism. And Dr. Cullen. to whose nosological labours the medical world are very much indebted, has viewed these modifications of the disease as differing so much from one another, that he has defined each as a separate genus. To the acute rheumatism, he has appropriated the name of Rheumatismus: to the chronic that of drthrodynia. The definitions which he has given of each of these genera are accurate and judicious: and while they point out the obvious symptoms in which these genera differ in their appearance, thev also clearly demonstrate to the attentive reader, that the two affections must differ in their nature, and must require a different mode of treatment.

It is not without great diffidence that I venture to dissent from an authority in the practice of medicine, for which I have uniformlv

PREFACE. Xlll

maintained the highest veneration. But in the clinical wards of the Royal Infirmary, and in my Lectures illustrating the cases which I have there an opportunity of treating, I have for many years pointed out a distinction in rheumatism, which, with a view to actual practice, seems to me to be more useful than the distinctions either of Sauvages or of Cullen.

I am of opinion, that, with the view to a successful cure, four different modifications of rheumatism are especially to be had in view. And these I have in my Lectures distinguished by the names of Rheumatismus Inflammatorius, Imtabilis, Jltonicus, and Paralyticus. They cannot with propriety be considered as different stages of the same disease. For although it be true, that the most common progress of the affection is from the inflammatory to the irritable state, and that the irritable often terminates in the atonic, and this again in the paralytic state; yet each modification may occur separately and independently of any b

XIV PREFACE.

other. The rheumatism us irritabilis, in particular, every day takes place without any preceding inflammation, or at least any preceding fever. The rheumatismus inflammatorius, with a high degree of fever, and evident marks of local inflammation at particular joints, not unfrequently supervenes, after the disease has previously existed in its irritable state for a considerable time. And in some though rare instances, the rheumatismus paralyticus is the very first form under which the disease appears, without any preceding marks either of inflammation, irritability, or even atony. Hence, notwithstanding the common progress of rheumatism, there is, I think, good reason for establishing in the genus rheumatismus, the four species which have been mentioned, especially as they require very different modes of cure, and as they can readily be distinguished from each other by obvious symptoms.

On h^ sub e t o" rheumatism, especially with a view to point out the distinction of the

PREFACE. XV

four species irom each other, and the particular modes of cure best adapted for the removal of each, it is now many years since I stated my sentiments very fully, in a course of lectures, delivered at Edinburgh, on the practice of medicine. Since that, 1 have often repeated these observations, in an abridged form, when illustrating, by clinical lectures, the cases of patients who were under my care subjected to rheumatism, in the Royal Infirmary. In that hospital, all the four species of this disease which I have mentioned, are almost every day to be met with.

It was once my intention to have made my observations and opinions on rheumatism, as well as on consumption, the subject of a separate publication. But that intention, from different considerations, I have now relinquished. I shall however, probably soon submit these Observations to the examination of my friends, without having recourse to the press. It is my intention to place my manuscripts on this subject in the Library of the Royal Col-

XVI PREFACE.

lege of Physicans of Edinburgh, where I have already deposited more than fifty volumes, written with my own hand, containing practical remarks on cases which have fallen under my own observation.

By this measure, I am not without hopes, that the experience which has afforded useful lessons to myself, may be of benefit to some of my younger brethren in the college. The presumption, indeed, is, that very few of them will find either leisure or inclination to read much of these manuscripts; but the volumes themselves, even without being read, will at least afford to future members of the College an example of industry, for the advancement of a science which aims at the alleviation of human misery.

On the present occasion, I shall merely take an opportunity of stating, in a very few words, the grounds of distinction between the four species of rheumatism which I have elsewhere attempted to describe at considerable length

PREFACE. XV11

The rheumatismus inflammatorius, then, is chiefly distinguished by the concomitant fever^ by the obvious swelling of the joints, and by the aggravation of the pains from the action of external heat. In the rheumatismus irritabilis there is no concomitant fever, and there is rarely any swelling of the joints, but the pains are greatly aggravated by heat, particularly by the heat of the bed. In the rheumatismus atonicus, on the other hand, the pains are relieved by heat, as is mentioned in Dr Cullen's definition of arthrodynia or chronic rheumatism; fever is very rarely observed, and an obvious local affection of the pained parts is often present, even under the form of distortions and nodosity of the joints. The last species, the rheumatismus paralyticus, which, though less common than either of the others, is, however, not of unfrequent occurrence, is chiefly distinguished by the loss of muscular strength in the limbs most affected, without, however, any diminution of sensibility, but often with a wasting of muscular

XV111 PREFACE.

flesh in those limbs which have been long subjected to the severe pains.

By these marks the four different modifications of rheumatism, which have been mentioned, may, I think, be readily distinguished from each other in actual practice. And it is almost unnecessary to add, that the cure in each must be attempted on very different principles. The intentions of cure, which, in my opinion, are to be aimed at in each, I have long since stated in another publication, Heads of Lectures on the Theory and Practice of Medicine. Here I shall only observe, that while in the rheumatismus inflammatorius, the great object to be aimed at is the diminution of increased action by powerful evacuants, blood-letting and sudorifics, the rheumatismus atonicus is only to be successfully combated by the restoration of due vigour from cold bathing and similar tonics. While, again, in the removal and alleviation of the rheumatismus irritabilis, much may be done, by counteracting the effects of morbid

PREFACE. XIX

sensibility and irritability. For answering this intention, I have found no remedy of equal efficacy with opium, and I doubt very much whether any medicine will ever be discovered, operating with equal power in alleviating pain, allaying action, and inducing sleep. Its sedative powers are fully confirmed by the experience *of ages. Yet it is by no means applicable in every case, or in every constitution where sedatives are required. For some time past, I have also often with great advantage employed lactucatium, or lettuce opium, as it has been called, from its very great resemblance to opium obtained from the papaver somniferum. I have found it, in particular, a very efficacious means of alleviating pains, and procuring sleep in the night, to some rheumatic patients, who, if they had taken opium, would, during the course of next day, have been subjected to great sickness at the stomach, and other distressing symptoms.

Edinburgh, Oct, 20, 18it>.

X.K.

CHAP. VII. — Observations on the general plan of Cure in Phthisis _--.._ 58

CHAP. VIII. — Observations on particular Practices empwyed in Phthisis, recommended by Eminent Writers, - 66

OBSERVATIONS tfN

PULMONARY CONSUMPTION,

INTRODUCTION,

OF all the diseases to which the inhabitants of the British Isles are frequently subjected, Pulmonary Consumption, or Phthisis Pulmonalis, as it is denominated by the best medical writers, may justly be reckoned one of the most fatal. The deaths which it occasions happen chiefly to those who have arrived at the most engaging period of life, the period of youth. Hence they are most deplorable. It is not therefore wonderful, that this disease should have claimed particular attention from the most eminent medical writers. But notwithstanding the study and labour of ingenious and

A

Introduction

discerning men for many ages, plrfliisis pulmcmaKs still continues to be an opprobrium to the healing art; and the prospect of wiping oif this opprobrium, by communicating to the public a successful method of cure, is not great. There is no reason, however, to despair of making some progress in this important object; and if medical practitioners were enabled to distinguish the different modifications under which this disease appears, at its commencement much good might be done. For in the earliest stages, the best chance is at least afforded of combating this dangerous disease.

The following remarks on that interesting subject are the result of observations made with fidelity and attention for more than half a century- And if they shall enable future writers to improve the means of distinguishing the different modifications of Pulmonary Consumption from each other, they may be productive of some benefit to mankind; and I am convinced, that, in some instances of this disease, they will be the means of accomplishing a cure. By proper treatment, adapted to each particular modification from an early period of the disease, there can be no doubt that many valuable lives maybe saved.

hf Phthisis Puhnonalis, or Pulmonary Consumption, is to be understood that affection in which a genera]

INTRODUCTION, 3

wasting or consumption of the body arises from a disease of the lungs. Among eminent writers, it has been a subject of dispute whether phthisis pulmonalis can ever be considered as a proper idiopathic disease. By many it has been regarded merely as symptomatic of other affections, particularly of haemoptysis, catarrh, scrofula, pneumonia, and several other genera. But there can, I think, be no doubt that it may justly be considered as an important genus by itself; and that it not unfrequentiy makes its approaches in such a gradual and imperceptible manner, as to be beyond the power of art, before it be certainly discovered to exist.

In every instance of this affection, that modification of fever, which has been termed Hectic Fever, is observed some time before a fatal conclusion takes place. And this fever principally, perhaps even solely, arises ;.Vom the absorption of purulent matter, or rather from the absorption of a sanious or vitiated purulent matter, which produces in the human system effects much more deleterious than the absorption of mild pus, void of any peculiar fuetor, or other strong 'sensijjj! qualities. Such a sanious matter, however, when generated in the lungs, may be afforded from -different causes. Hence, among those writers who have considered phthisis or tabes pulmonalis as a generic disease, that genus has been divided into many different species. In the Sys-

* INTRODUCTION.

tern of Sauvages, twenty species are enumerated under this genus. But from such minute subdivisions, no benefit and much inconvenience arise. Hectic fever, indeed, produced by purulent matter absorbed from the lungs, may arise from many different accidents, and from many different diseases: And thus it cannot be denied, that there is a foundation for many different species of phthisis. But after, in these cases, consumption is induced, such species can neither be distinguished from each other by the symptoms, nor do they require a different mode of cure. A more simple view, therefore, of the divisions of this genus, may be taken with advantage.

In the division of any genus of disease into species, two great objects are to be had in view. The first and principal object is to point out such species as require a different mode of practice from each other. And the second object is to point out those species which can be distinguished from each other by obvious symptoms during the life of the patient. The distinction from each other, of species which can be discovered only by dissection after death, serves merely to perplex and puzzle, without being of any material benefit. On this general ground, and with these ob^ jects in view, in pulmonary consumption, three different species may be pointed out, which may not only be d

INTRODUCTION. O

anguished by obvious symptoms during the life of the patient, but which also require considerable difference in that mode of treatment best fitted for the removal of each.

These species may, I think, be denominated the - Catarrhal, the Jlpostematous, and the Tuberculous Phthisis. The principal circumstance in which these species differ, and which necessarily requires variety in the mode of treatment, is the difference in the source from whence the purulent matter is derived. In the first modification, it is merely separated from an inflamed surface, in a manner similar to the separation of pus from a blister-issue. In the second modification, it is furnished from an abscess of a considerable size, which may be formed in the cellular substance of the lungs, as well as of any other part of the human body. In the third, it is furnished from a tubercle, or from the parts surrounding a tubercle, terminating in suppuration; and commonly yielding, not proper purulent matter, but rather an ichorous sanies, somewhat resembling that which is often yielded by lymphatic glands, in cases of scrofula, when scrophulous tumours terminate in suppuration. But the distinction of each of these modifications, during the life of the patient, can only be drawn from an accurate account of the symptoms with which they are commonly attended, ^.nd a 2

« 3NTR0DUGTI0N-

with that intention, a short history of each is subjoined.

In every modification of phthisis, the symptoms may be referred to three heads: the pneumonic, or pulmonary symptoms; the symptoms of hectic fever; and the supervening affections, or what may be termed the consequent symptoms. The morbid affections, however, referable to the two last heads, are very much the same in all the species mentioned above. The hectic fever in particular, though most exquisite in tuberculous phthisis, is an essential attendant of all the three; and it is always principally, often entirely, in the pulmonary symptoms, that the three species obviously differ from each other. In describing these affections, then, with a view to the diagnosis, it will be sufficient to give a separate account of the pneumonic symptoms occurring in each different modification of pulmonary consumption which has been mentioned.

Chapter I. Description Of The Pneumonic Symptoms Occurring In Catarrhal Phthisis

This modification of Phthisis generally begins in a manner very similar to ordinary catarrh, arising from accidental exposure to cold. But after the period at which that affection may be expected to decline, some symptoms are observed to increase. The cough becomes very severe through the day; but is generally remarked to be much aggravated on first going to bed. The patient becomes affected with some degree of dyspnoea, even when in an erect posture; but this is commonly increased by a horizontal position. In general it is not particularly increased by lying on one side more than on the other, and the patient sleeps with equal ease on either side. He is not affected with any fixed or constant pain at the breast. But he complains of a general sense of soreness in the thorax, and not unfrequently he is affected with pretty severe^

8 SYMPTOMS OCCURRING

though transitory pains, sometimes in one side,^ome times in the other.

With the continuance of these symptoms, a change takes place in the appearance of the matter expectorated. The expectoration, as is commonly indeed the case in catarrh, when degenerating into its chronic state, becomes of a white or yellow colour. But it does not acq aire that remarkable degree of viscidity which is the characteristic of thickened mucus. It is soon observed to have a peculiar disagreeable taste and smell. The odour which it emits becomes somewhat fetid, particularly upon being burnt in the fire. These changes, however, in the sensible qualities of the matter expectorated, are by no means such as to give certain evidence of its being of a purulent nature.

In most instances, there is no appearance of blood in the matter expectorated. If blood does appear, it is only in streaks, and is merely accidental, adhering to the expectorated matter without any intimate union, and arising from the rupture of some small superficial vessel. The expectorated matter itself has an uniform appearance; yet there is good reason to conclude, that it is a mixture of pus and mucus. This appears from adding it to water. It will often be found, that, in a short time, a considerable portion of it sinks to the bottom of water in a less tenacious form than that

IN CATARRHAL PHTHISIS. V

portion which swims on the surface; and where such a separation does not spontaneously take place, it may frequently be affected by agitation in the water.

In some cases, without any spontaneous separation, the whole of the expectorated matter will be suspended in the middle of the water in a pyramidal shape, and can neither be properly said to sink nor to swim. Where a portion of the expectorated matter sinks to the bottom of the water, there can be little doubt, that it contains pus as well as mucus ; but when it neither sinks nor swims, and cannot be separated by agitation, there is room for hesitating respecting its contents. And if a determination cannot be formed from its specific gravity, we can as little form a certain judgment from its colour, consistence, and smell. For in all these particulars, pure mucus may have a very exact resemblance to a mixture of pus and mucus*

Such, however, is the difference of treatment requisite in every species of phthisis, from that which is proper in catarrh, that it is of great importance to determine, whether the expectorated matter does really contain any pus or not. For this is the chief circumstance, by which, before the occurrence of distinctly marked hectic fever, the presence of catarrhal phthisis can be determined,

10 SYMPTOMS OCCURRING

Besides the tests of purulence, therefore, which are afforded by the appearance of the matter expectorated, by the smell, and by immersing it in water, other and more certain tests have been sought for; and inquiries on this subject, if they have not led to certainty, have at. least done something.

An experimental investigation of a proper chemical test, for distinguishing pus from mucus, when discharged from the lungs by expectoration, was proposed as the subject of a prize question, by the Harveian Society of Edinburgh, in the year 1777. On that occasion the prize was adjudged to a Dissertation written by a very able and ingenious young man, Mr Charles Darwin, son to the celebrated author of the Zoonomia. By the untimely death of that excellent youth he was prevented from prosecuting his discoveries, or from publishing to the world what he had discovered. But Dr Erasmus Darwin, after the death of his son Ch.lree5. published an account of these experiments, as well as some other manuscripts which the young mau had himself intended for publication. Without entering minutely into the subject, it may be sufficient to observe, that Mr. Darwin drew from his experiments the following conclusions.

1. Pus and mucus are boch soluble in sulphuric

IN CATARRHAL PHTHISIS. II

acid, although in very different proportions, pus being by far least soluble.

%. The addition of water to either of these solutions decomposes it. The mucus thus separated either swims on the top of the mixture, or forms large floeeuli suspended in it; whereas the pus- falls to the bottom, and forms, on agitation, an uniform turbid mixture.

3. Pus is diffusible through diluted sulphuric acid, though mucus is not. And the same also occurs with water, or a solution of sea-salt.

4. Nitrous acid dissolves both pus and mucus. Water added to the solution of pus produces a precipitate, and the fluid above becomes clear and green; while water and the solution of mucus form a turbid dirty-coloured fluid.

5. Alkaline lixivium dissolves, though sometimes with difficulty, mucus, and generally pus.

6. Water precipitates pus from such a mixture, but does not precipitate mucus.

7. Where alkaline lixivium does not dissolve pus, it still distinguishes it from mucus, as \\ then prevents its diffusion through water.

12 SYMPTOMS OCCUPYING

8. Coagulated lymph is neither soluble in concentrated nor diluted sulphuric acid.

9. Water produces no change on a solution of serum in alkaline lixivium, until after long standing, and then only a very slight sediment appears.

10. Corrosive sublimate coagulates mucus, but does not coagulate pus.

If these conclusions be well founded, and if they hold at least generally, although not universally, it appears, that strong sulphuric aci-i and water, that diluted sulphuric acid, and that caustic alkaline lixivium and water will serve to distinguish pus from mucus; that the sulphuric acid can distinguish it from coagulable lymph; and the alkaline lixivium from serum. When, therefore, any one entertains doubts about the composition of expectorated matter, let him dissolve it in sulphuric acid, and in caustic alkaline lixivium, or the aqua potassae, as it is now styled in the Edinburgh Pharmacopeia. Let him then add pure water to both solutions. If there be a precipitation in each, he may be assured that some pus is present. But if there be a precipitation in neither, it is a certain test, that the expectorated matter consists entirelv of mucus.

m CATARRHAL PHTHISIS. 13

These are, perhaps, the best criteria yet discovered for ascertaining whether expectorated matter does or does not contain a mixture of pus. Where it is found to be merely mucus, we may safely conclude, that the disease is entirely catarrhal; but where a mixture of purulence, though to a small extent only, is detected, we may conclude that it is an incipient phthisis, even although no symptoms of hectic fever have yet taken place, or have not been obviously observed.

Chapter II

DESCRIPTION OF THE PNEUMONIC SYMPTOMS OCCUR* RING IN THE APOSTEMATOUS PHTHISI6.

That modification d? pulmonary consumption which may be termed the Apostematous, and which immediately arises from a large abscess formed within the thorax, is more distinctly marked than the catarrhal phthisis. It is a less frequent disease than the catarrhal; but when occurring, it is more generally fatal.

The former, as has already been observed, is very commonly ushered in by cough, with copious expectoration, and is almost universally excited by the action of external cold, or rather of sudden transitions from heat to cold. To these transitions the human species are perhaps more exposed in Britain than in any other country. The present species of phthisis, again, which depends upon a large apostema within the chest, may be excited by a variety of different causes. It may be produced by any accident giving rise to an in-

APOSTEMATOUS PHTHISIS. Jc

lammatory affection, either in the lungs, op in those membranes by which they are surrounded; and an inflammation of the thoracic viscera, terminating in a state of suppuration, is perhaps as frequent as a similar termination from the inflammation of any other parte

One of the most frequent causes from which an abscess in the chest derives its origin, is an haemorrhage taking place from the lungs. This, indeed, is so much the case, that Dr Cullen, in his Nosological System, has not considered phthisis as a proper genus of disease, but has merely ranked it under the genus of haemoptysis, and viewed it as a sequela of that affection. But this I am inclined to consider as a very erroneous view of one of the most important genera of disease to which the hitman body is subjected.

That, however, the apostematous phthisis often begins with a profuse spitting of blood, is unquestionable. Haemorrhage, when occurring from the lungs, as well as from other parts of the system, may be either of the active or passive kind. Boih these modifications of 1 haemorrhage, when occurring even to a great degree, have not unfrequently a speedy termination, without any bad consequence; or at least without producing phthisis. As well as the vessels of the nose in epistaxis, those of the lungs, when ruptured, may be healed

16 PNEUMONIC SYMPTOMS

by the first intention. Nay, haemorrhage from the lungs, as well as from the nose, may sometimes be even salutary, by removing a plethoric state. Yet, in many instances, both active and passive haemorrhage from the lungs terminates in that species of inflammation, which has been termed the suppurative; and this more frequently happens as a consequence of haemorrhage from the lungs, than from any other part of the body, probably in consequence of that constant state of motion to which the lungs are subjected in respiration. Haemoptysis, then, may justly be esteemed one of the chief causes from which a large vomica or apostema in the lungs derives its origin.

But it is by no means the only source of the apostematous phthisis. Even larger abscesses than those commonly arising from haemorrhage are not unfrequently observed from other causes. The lungs themselves, and the membranes by which they are surrounded, it is well known, are frequently subjected to a state of active inflammation; and inflammation in this, as well as in other parts of the system, may terminate in a state of suppuration. Thus, apostematous phthisis may be induced from several genera, referred to the order of phlegmasia, which affect the lungs; from pkuritis, peripneumonia, or suppurative inflammation from odier diseases of the lungs.

SN APOSTEMATOUS phthisis. IK

Besides these genera of disease, suppurative inflam« mation, giving rise to a large abscess within the chest, may proceed from accidental injuries to that part of the body. Thus, a large apostema in the lungs may be the consequence of a severe blow received upon the chest, or a wound of the lungs from a sword, a bullet, or the like. Many other causes might also be enumerated, as at times producing an abscess of the lungs. But the particular causes by which such abscesses are commonly produced, may be referred to one of the three general heads already mentioned, haemorrhage, phlegmasia, or injury to the breast.

When, from any particular cause, an apostema is formed in the lungs, those pneumonic symptoms with which it is attended are in several respects very different from the pneumonic symptoms which occur in the catarrhal phthisis; and in the apostematous phthisis, the pneumonic symptoms are very different before the rupture of the abscess, from what they are afterwards.

In most instances of the apostematous phthisis, the first symptom of the affection is a fixed pain of the breast. This pain is not indeed in general excruciating; but it is almost constantly felt to some degree, and is commonly referred to some one particular spot. For fhe most part, it is rather a gravative than an acute

pain; but it is not unfrequently of the pulsating kind Whatever the nature of the pain may be, it is very commonly attended with some degree of dyspnoea. With that dyspnoea the patient is sensibly affected, even when in an erect posture: but it is in general much increased in a horizontal position; and it is often particularly aggravated when the patient lies on one side rather than the other Often it happens that the patient can breathe only "when he lies on that side in which the apostema is situated; the reason of which is abundantly obvious.