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ON THE CAUSE OF TUBERCULOSIS, WITH SUGGESTIONS AS TO ITS PREVENTION.
515 disease. They, for the most part, may be arranged under two ON THE CAUSE OF TUBERCULOSIS, WITH heads, first-general tonics; secondly, those compounds which SUGGESTIONS AS TO ITS PREVENTION. contain large proportions of carbon, such as cod-liver oil, naphtha, It cannot be doubted that the remedial efficacy of the &c., &c. BY J. G. ATKINSON, M.D. Edin. latter class mainly consists in their readily giving up their carbon, TO THE WAKEFIELD DISPENSARY. PHYSICIAN have shown a great want of this element in the tubercular We may also add, that in this disease all the adipose tissues of the are almost become emptied. In one case of phthisis, where the blood had been analyzed in a patient who had taken cod-liver oil, it was found that the fat, when isolated, smelt strongly of the volatile, fatty acid of the cod-liver oil; and, moreover, that the solid constituents of the blood were observed to be of a very large amount.* So far, so good-both theory and practice agree; but it appears to me, that no cure can be expected from such a class of agents. They no douht preserve the body from being so rapidly burnt up, but this is all we can possibly expect them to do. We do not get at the root of the evil, or at what is the primary cause of the
and
THE conflicting statements published, and the indefinite result arrived at, by the many authors who have hitherto written on th subject of Tubercle, urged my especial attention to this subject more
particularly as
I had the
opportunity
of narrowly
watchint
.the progress of this disease, and witnessing the,post-mortem ex aminations of every man who died during the last five years ir the Wakefield Convict Prison, through the kindness of my frien<
we
deposit.
body
Mr. Milner, the resident surgeon of the above establishment. From these observations, I believe I have arrived at conclusions as to the formation of tubercle, very different to those o any other inquirer. And, as a correct diagnosis is the first stel towards cure, so it cannot be doubted that a true knowledge o tubercular deposit. Now, if tubercle be protein, with a deficiency the pathology of tubercle may lead to better and more accuratl of carbon, there appears to be some reason for supposing, that in methods in the treatment of phthisis. this peculiar diathesis the elements of the organism do not adhere From the experiments instituted by Simon, it appears thai together with that degree of tenacity which constitutes normal during respiration the oxygen of the atmosphere combines witt health. Liebig saysthere is nothing to prevent us from con,the blood-corpuscles, and that the consumption of oxygen anc force as a peculiar property, which is possessed ,formation of carbonic acid stand in a direct ratio with the amount sidering the vital certain natural bodies, and that this force is continually being by - of these blood-corpuscles, and with the number of respirations in in the organism by a chemical force ; and by the action opposed a given period; hence it is obvious that the oxygen of th, of this chemical force, a separation of part of the body, in the atmosphere is consumed in the metamorphosis of the corpuscles form of lifeless compounds, begins; and if, from any cause whatAnd it would further appear that the amount of fibrine alwayss the resistance of the vital force diminishes in a living part, ever, varies inversely with the mass of the blood-corpuscles, or, in the of matter increases in an equal degree. In the vegeother words, that the more corpuscles there are, the less in quan tablechange the resistance of the vital force is sometimes shown kingdom tity is the fibrine-and vice versâ. when we perceive leaves charged with turpenvery powerfully, It appears most probable that as the blood-corpuscles principally tine or tannic acid resisting the affinity of oxygen for these consume oxygen during their change, it is by this process that On the other hand, when this force is lessened in the fibrine is produced; and that wherever an extraordinary compounds. the organism, we need not be surprised at great abnormal changes consumption of corpuscles takes place, the quantity of fibrine in occurring. Again, the same author observes that the plasma also increases. If by any means the circulation be necessarily the absorption of oxygen occurs only when the vital force of quickened, or, in other words, the mutual action between the living parts is weaker than the chemical action, and that animal ,blood and oxygen be increased, more blood-corpuscles will be life may be viewed as determined by the mutual action of opposed consumed in a given time. forces; that the increase of the body is effected by the vital force, in Although the temperature of the body is nearly the same all and the waste of the body by the chemical action of oxygen; and parts, in consequence of the metamorphosis of the tissues con- that the condition of the body which is called health, results from of is the the lungs slightly an equilibrium among all causes of waste and of supply. Now, I temperature stantly going on, yet higher than that of the other parts of the system; which may be think we have evidence, that, in this peculiar condition, the carbon accounted for by the more energetic action of the oxygen on the of the body is too easily acted upon by the atmospheric oxygen, * mass of blood in these organs, than in other parts of the body. and therefore that the balancing operation which takes place in Now Andral and Gavarret observe that, in all stages of phthisis, the transformation of protein into carbonic acid, urea, water, &c., analysis of the blood shows that the fibrine is always on the in- which constitutes health, is so far overturned, that a larger quancrease, and the corpuscles on the decrease; but that this increase of carbon is removed in proportion to the amount of nitrogen and decrease vary proportionately with the progress of the tity and hydrogen, which, in the healthy functions, are carried away disease. Liebig states that it must be received as an undeniable by the kidneys, liver, skin, &c.;—hence, these latter elements, truth, that all the organic nitrogenized constituents of the body not being taken away by their proper emunetories, combine in are derived from protein, when we reflect on the development certain definite proportions, and constitute the deposit known of the young animal in the egg of a fowl, where, out of the the term tubercle. albumen, feathers, claws, globules of blood, fibrine, membranes byIn seeking, therefore, to discover a remedy for this disease, our and cellular tissue, arteries and veins, are produced. Now this object ought to be to ascertain whether there are any agents, albumen contains, for the quantity of nitrogen present, exactly or medical, which could prevent this too quick transthe proportion of carbon required for the formation of these dietetic formation. In making this inquiry, we must first observe, there tissues! can be no question that the victims of this disease are chiefly Let us, for one moment, look into the nature of tubercle. taken from amongst that class of individuals whose general tone Chemistry has thrown little light on its mode of formation. Simon of system is lowered, as occurs among the pampered and over-prostates that it might be regarded as protein from which a portion tected children of fortune, or in those living in confined and unof carbon and oxygen have been removed; or, to speak precisely, A remarkable fact exists, strange atmospheres, &c. &e. healthy it may be supposed to be derived from protein, which substance as it may appear, that in consumptive families the most dissihas lost, during the transformation, three atoms of carbon, and one pated and irregular in their habits, and those who have habitually .of oxygen. The formula isexposed themselves to many of the causes liable to engender this diathesis, have yet frequently enjoyed longevity ; whereas, in the same families, the most virtuous, and those who have guarded their lives with the greatest care and prudence, have fallen early From the observations previously made, viz., that the more cor- victims. Hence, it is an interesting matter to ascertain how far puscles there are, the less in quantity is the fibrine; and from the alcoholic drinks, in this disease, preserve those constitutionally experiments of Andral and Gavarret, that the blood in phthisis predisposed from these direful results. I think it is agreed, that contains more fibrine and less corpuscles; and, moreover, recol- alcohol, like all other highly carbonized substances, does supply lecting that the temperature is somewhat greater in the chest a certain amount of pabulum for the blood. Now, does it act in than in other parts of the system, probably because a more any other way? Does it at all prevent that disposition to oxidation energetic action of oxygen takes place in these organs,-it would on the part of the organism, of which we have spoken, and appear fair to conclude from these facts, that in phthisis the com- thus, by making the protein compounds less ready to combine binatiou of oxygen and carbon, in the lungs especially, is more with oxygen, render them less likely to be too easily broken up? active than in the normal state. Now we will say one word con- That it has this property out of the body is very evident, and may cerning the remedies employed and found most beneficial in this it not have an equal power when taken internally?++ There ca * Simon’s Animal Chemistry, vol. i. p. 281. * Simon’s Animal Chemistry, vol. i. p. 153. t Liebig’s Animal Chemistry, edited by Dr. Gregory-On the Phenomena t Liebig’s Ammal Chemistry, by Dr. Gregory. of Motion in the Animal Organism. t Simon’s Animal Chemistry, translated by Dr. Day, vol. ii. p. 479. t Ibid., p. 240.
516 be little doubt that alcohol is taken up and circulated in the first attack, leaves perhaps but a slight cough behind, but, on fresystem, primarily, as alcohol, yet its elements ultimately become quent repetition, gradually and irretrievably lapses into confirmed separated-its carbon and hydrogen are given off as carbonic acid phthisis, or the disease, almost equally often, sets in with hoemoand water ; for Liebig could not detect, either in the expired ptysis." If the author means by this, the commencement of the air, or in the perspiration, or in the urine, any trace of alcohol disease, I cannot agree with him. I regard these symptoms as after indulgence in spirituous liquors. By the use, therefore, of quite of a secondary nature. Although I am well aware that tuber. alcohol, a limit must be put to the change of matter, in certain cular disease of the lungs has been considered the result of parts of the body; for the oxygen of the arterial blood, which, in inflammation, yet I am disposed to believe that this is erroneous, the absence of alcohol, would have combined with the matter of the but that tubercle is deposited in consequence of a peculiar state of tissues, now combines with the elements of the alcohol-the arte- the system, in which the transformation of the tissues has not rial blood becomes venous, without the substance of the muscles, been carried on in perfect equilibrium ; and that when deposited, &c., having taken any share in the transformation. Thus, we the tubercle may, and often does, remain for a longer or shorter perceive, without the manifestation of a corresponding amount of period, without creating much local inconvenience or disturmechanical force, the heat of the body increases after the use of bance. This will, however, greatly depend on the amount wine. We have here some explanation offered to account for the deposited, and on its rapidity, as well as on other collateral cirdark, venous, bloated countenance of the man who lives freely; cumstances ; and the catarrh, inflammation of the lung, pleurisy, and we may contrast it with the florid, arterial hue, so charac- haemoptysis. &c., are entirely dependent on the mechanical irritateristic of the countenance of the phthisical patient. In the former tion caused by the presence of tubercle. I am strongly of opinion case, we have the system surcharged with carbon-in the latter, that the deposition of tubercle may be much more general than is the arterial blood becomes too highly oxidated. Is it not then usually believed, not necessarily shortening life, or perhaps infair to conclude that alcohol acts, in the first place, by preventing ducing ill-health; but I think it both possible, and verv probable, quick oxidation of the tissues, and then, becoming decomposed, that whenever the vital tonicity is sufficiently lowered, this de. it supplies carbon ? And if this be so, would it be attempting to posit might take place in any organ. Dr. Carswell thinks it pos. carry out a principle too far by supposing that the peculiar acute- sible that tubercle may be re-absorbed ; and, if deposited on the ness, if not vigour of intellect, which is so strongly observable in mucous membrane of the air passages, or of the bowels, I cannot the phthisical patient, might depend upon hyper-oxygenation of see why it may not be thrown off and ejected, as any other the blood circulating in the brain? just as we know a temporary foreign matter.-Dr. Addison, having examined, with a lens, exhilaration of the spirits seems to be caused by the inhalation many apparently healthy lungs, absolutely found tubercles depoof oxygen gas. On the other hand, it is equally well-known that sited more or less abundantly in one-third.* From a perusal of a sluggishness, both of mind and body, is a necessary attendant Laennec’s work, it seems evident that, although he had by no on the beer-drinker, which most probably may be accounted for means satisfied himself as to the mechanism of the formation of by the too carbonized state of his blood. It has been found in tubercle, yet there appears little doubt he regarded it as a deposit prisons that men are admitted, apparently in good health, and re- taking place from some unknown cause, and he appeared strongly main so for some months; that they then become dyspeptic, fall averse to the opinion that it was the result of inflammation. M. off in health, and die of tubercular consumption, running through Louis alleges, that, with one single exception, he never found all its stages in a few months, and even, in some cases, in a few tubercles in any other organ without their existing in the lungs weeks. And I believe I am not wrong in stating that four-fifths at the same time, insomuch that he seems positively to consider of the deaths in prisons are the result of tubercular disease.* their presence in the lungs as essential to their development in It may be observed that, as regards diet, cleanliness, regular other parts.-+,I am disposed to believe that tubercle may be habits, and an equalized temperature, the greater part of them deposited in any part where metamorphosis of tissue occurs; yet were infinitely better off than before conviction. The only cause I think it more likely to happen in the lungs, in consequence of a likely to be detrimental to health, would be the effect produced more full and energetic action of oxygen taking place there, than upon the mind by restricted liberty and prison discipline. Now, in any other parts of the organism. Hasse says that, in that I may state, that with scarcely a single exception, these men acute form of tubercular phthisis which often proves fatal in the have been throughout life more or less drinkers. The prison third week, the vital symptoms are very peculiar, bearing so fare, however, does not permit the smallest allowance of alcoholic close a resemblance to those of typhus fever, as to lead to misstimulus, unless specially ordered by the medical officer. Here it takes, and the diagnosis can only be ascertained by the stethowill be interesting to inquire, whether the loss of this agent has scopic sounds?ll In corroboration of these views, I examined a anything to do in producing the tubercular diathesis? I might man at the Convict Prison, who had been ill a few days, and also state as a remarkable circumstance, that at the post-mortem diagnosed the case typhus. He lived about a fortnight, and on a examinations of the convicts during the last five years which I have post-mortem examination, the whole of both lungs were comattended, evtry body examined, no matter how death occurred, pletely studded with tubercles, which had not yet formed comhad tubercular deposits, in one or more organs, with the excep- munications with the bronchi, and tubercular deposits were found tion of one man, who died of epilepsy. Again, no class of men, also in the abdomen and head. The late Dr. John Taylor, of on an average, take more stimulants than innkeepers, or the oldUniversity College Hospital, informed Mr. Milner that he had fashioned but now almost obsolete coachman. To this numbet seen two similar cases, and that in both the disease at its comI might add butchers, who, besides consuming large quantities of 11encement had been considered to be typhus. Now I regard animal food, generally also drink freely; as well as men em- hese cases as the result of a very marked deficiency of the vital ployed at breweries. Whether statistical evidence may prove force. Hence, during a very short period, the protein comor disprove the fact, I am strongly inclined to believe, from a pounds were so rapidly acted upon by the atmospheric oxygen, recollection of cases, as well as from their general appearance, :hat the disease began and finished in the course of a few weeks which is familiar to all people, that they are not liable, but rather - indeed, the rapidity and extent of the tubercular deposit are so the reverse, to tubercular diseases. If the inference be correct sreat, that patients absolutely die before the disease has extended from these and other similar illustrations which might be quoted, further than simple deposition. As some proof of the views I it would appear that alcohol, although most injuribus and de- entertain, I will relate one or two instances which have occurred structive by producing multitudinous diseases, yet may it not in immediately under my own eye; but as many of the individuals this instance act as a kind of preservative, by protecting the spoken of are at present now living, I cannot, of course, furnish organism from the action of oxygen, which we believe we have names. shown to be the immediate cause of the deposition of tubercle ? If 1st.-A family consisting of five sons and one daughter; all this be so, could not some chemical agent be discovered, which appeared to enjoy good health up to about eighteen. Out of this would have a protecting, but not otherwise destructive agency? three sons died between the ages of eighteen and family, For instance-I merely propose it as a theoretical suggestion- twenty-five, of phthisis; the daughter is still living, although in would tann:c acid, combined with some highly carbonized subvery precarious health, evidently phthisical. All these were stance, and a moderate supply of alcoholic beverage. or some such steady, industrious, and peculiarly careful of their health. The compound, have this protecting influence ? I think it likely two remaining sons, now between thirty and forty years of age, that if any such agent be ever discovered, it will be found when last heard of were quite healthy. Early in life. these two amongst that class which have a like preservative property, when latter men were of dissipa’ed habits, and lost many situations in used extrinsically to the body. One of them, at the consequence of their propensity to drink. In Hasse’s work,t edited by Dr. Swaine, it is stated, "for the age of ninetet-n. came over from India with an inflamed early most part this disease is traceable to a catarrh, which, after a Consumption and Scrofula, by William Addison, M.D., p. 51. * Mr. Milner, Surgeon to the Wakefield Convict Prison, authorized the t A Treatise on Di,eases of the Chest, by R. T. H. Laennec, M.D. ; trans’
. ’
-
above observation. t Anatomical Description of Diseases of Circulation and C. E. Haase, M.D.; edited by W. E. Swaine, M.D.; p. 320.
Respiration, by
lated by John Forbes, M.D. ; Second Edition, p. 291. 1 Authority, Dr. Forbes in Laennec’s work. R Dr. Hasse, p. 321.
517 but
night,
dropsy, from spirit drinking ; he was many months ill, ultimately recovered. When last seen, they were in robust‘
liver and
31st.-Half-past
,
and feels
nine
A.M :
The
patient
has
comfortable ; the bowels have
a
passed good been again re-
countenances. lieved ; micturition frequent; slight pain in the back and abdo2nd.-A family consisting of three sons and three daughters. men ; douche repeated, commencing with warm water.-HalfThey all had the characters of the scrofular diathesis strongly past two P.M. : Some slight shivering, nausea, and giddiness have been experienced since last report ; douche repeated, commencing marked-fair hair, clear complexion, blue eyes, thick lips, &c. The three daughters died of phthisis before the age of thirty ; one I with two and a half gallons of cold, followed by five gallons of warm water.-Half-past eight P.M.: The symptoms continue son of tubercles of the brain-the two remaining sons are still alive, of irregular habits, but in apparentlv good health. pretty much as at last report; douche repeated in the usual man3rd.-A young man at the age of eighteen showed every ner and quantity, commencing with warm water. Though no symptom of approaching tuberculosis; he had already lost one perceptible change in the state of the os uteri has occurred, the brother and a sister by phthisis. His medical man advised him to patient whilst in the bath experienced increased shivering, nausea, relinquish a profession of a sedentary nature, in consequence ofgiddiness, and pain in the back. Within an hour after the applithe above facts. He did so, but unfortunately became dissipated. cation of the douche, she had some rather severe rigors, and pains He is now alive, about forty years of age, a confirmed drunkard, continued to increase in regularity and intensity till half-past eleven P.M. On making an examination at this time, the os was and has suffered several times from delirium tremens. We gather, therefore, from the foregoing observations, that: found as large as a crown-piece, the bag of membranes protruding, tubercular deposits are eminently dependent, as the primary ifconical in shape, and very tense, even in the absence of pains. Nov. 1st.-Half-past one A.M. : The os is fully dilated, and the not the sole cause on a diminution of the vital force.-2ndly. That in phthisis the body is rapidly consumed by the combination bag of membranes has almost reached the os externum ; the preof its elements with oxygen.-3rdly. That the consumption ofsentation was found to be either hand or foot, but the membranes the body may be retarded by the ingestion of certain highly car- were too tense to determine which ; consequently, as the pains bonized substances, as cod-liver oil, &c.-4thly. That it is pro- continued regular and severe, it was decided to evacuate the bable the rapid oxidation of the body may be checked, or liquor amnii, so that in the event of its being necessary, turning entirely prevented, by the use of alcohol, or of some agent acting might be immediately performed. On rupturing the membranes, an unusual quantity of water was discharged; one foot was found in the same way.
health, but had bloated
,
’
’
’
’
November,
and being brought down, was secured by a noose. ceased almost entirely, and tte patient obtained some sleep during the remainder of the night. At eleven A.M., she had an enema of warm water, which was repeated at two P.M. :: Some slight pains succeeded. At half-past two P.Di., the vagina No progress being made, a was injected with warm water. scruple of powdered ergot was given at three P.lII., and repeated at half-past three and four. Labour pains of considerable intensity commenced soon after the first dose, and continued to increase till half-past four, at which time a still-born male child was expelled. The head was rather large and firmly ossified, but considerably moulded by its passage through the contracted brim. The plaAt bed-time the patient centa followed almost immediately. took an anodyne draught, followed by a dose of castor-oil in the morning. The bowels were comfortably relieved. The afterpains were slight, and the secretion of lochia and milk was natural. The recovery was rapid and uninterrupted. Labour commenced immediately after the sixth use of the douche,
presenting,
1852.
Pains
A CASE OF PELVIC DISTORTION, IN WHICH PREMATURE LABOUR WAS INDUCED BY THE WATER DOUCHE. BY J. PRIOR SENIOR
SURGEON
LACY, ESQ., M.R.C.S., TO
THE
NEWARK
HOSPITAL.
now
L. C-, aged thirty-seven, a woman of middle stature, fail complexion, phlegmatic temperament, and good general health, i: the wife of an agricultural labourer; she began to menstruate a1 seventeen, and continued to do so regularly till after her marriage, at the age of thirty-two. Has had no miscarriages, and the present is her fourth pregnancy. This woman, on account of congenital deformity of the pelvis, consisting of great projection of the promontory of the sacrum, narrowing of the pubic arch, and and thirty-six hours ccfter the first use of the douche. Duration of consequent lessening of the antero-posterior diameter, was, in her labour, eighteen hours. two first labours, which occurred at the full time, obliged to be The account of the foregoing case has been most correctly delivered by means of craniotomy. The first child was a boy, drawn up by Mr. Rake, the house-surgeon to the hospital. It the second a girl. is evident, that in this instance, though the child was lost, the In her third pregnancy she was admitted into the Newark chances of its being born alive were considerably greater than if hospital, and premature labour induced at seven and a half the membrane had been punctured before the commencement of months, by puncturing the membranes; the presentation was an labour. In the present case, the membranes were ruptured after arm, the labour protracted, considerable difficulty was experienced the os uteri had been completely dilated by the influence of the in turning, and the child, a girl, born dead. douche. Should another case of this description come under my On the occurrence of her fourth pregnancy it was again deter- care, I should allow the liquor amnii to be discharged without any mined to admit her into the Newark hospital, and induce prema- interference. The returned to her home in the country patient ture labour at seven and a half months, with a view of saving the a after her delivery ; and in passing through the village fortnight life of the child. She became an in-patient on October 29th, in which she resides a few days ao, I called and found her quite 1852, and the novel mode of operation described and advocated well, and in the full employment of her domestic duties. I should by Dr. Tyler Smith, in THE LANCET of October 2nd, 1852, was wish to state, that I resorted to the operation entirely from pretty clost’ly followed, except that no syphon was employed, perusing the successful case related by Dr. Tyler Smith in but in its stead the distal end of the india-rubber tube was fastened to a receptacle, placed ten feet above the patient, and the other end of the tube introduced into the vagina without any enema pipe being affixed to it. When the patient was lying in bed the os uteri could with difficulty be felt high up and near the pubes ; but on placing her in the bath, the alteration of position caused it to be felt much more readily. A dose of castor-oil was given on admission, which operated freely, and onOctober 30th-half-past nine A.M.-the patient being placed in an open bath, and the uterine end of the india-rubber tube introduced into the vagina, and held opposite the os uteri, two and a halt gallons of’ water, at 110° Fzihr., were poured into the receptacle; as soon as this had escaped through the tube the same quantity of cold water was poured in, and suffered to flow against the os uteri in like manner. The patient complained of some uneasiness when the cold current first began to run. Three p M.—The douche was repeated in the same manner as last described, but commencing with cold instead of warm water. Since the first douche, micturition has been rather
frequent,
but little pain has been experienced. Nine P.M..—The douche was repeated, commencing with warm water ; the end of the forefinger can be introduced into the os uteri, but no pain of any consequence has occurred.
THE LANCET of October 2nd. November, 1852. "
ON THE TREATMENT OF ERYSIPELAS.
BY VINCENT ’
IT is
n,)w
LITCHFIELD, ESQ., M.R.C.S., Twickenham. some time since, that I began the treatment of
means of the tinct. ferri sesquichlor.; and finding the results so satisfactory, I am induced to record a vote in its favour. I was led to make a trial of it at the recommendation of Dr. Brown, of Edinbugh, who kindly sent me a pamphlt on the subject, written by Mr. Hamilton Bell. He says, 11 I have resorted to this mode of treatment tor a quarter of a century, without having in a single instance failed of’ success." This was boldly penned, and I, for one, did not thoroughly believe it; but I am too glad to state now, that I believe I could cure many cases in a week, which I formerly should have been a month at. Mr. Bell goes on to state the mode of administration, and expresses so much, and that too so aptly, in a few lines, that I cannot do better than transcribe them. He says:-" Of course the first object is to have the bowels freeiy acted on. If the erysipelas be mild, fifteen drops of the iron are administered in water every two
erysipelas by
and
THE conflicting statements published, and the indefinite result arrived at, by the many authors who have hitherto written on th subject of Tubercle, urged my especial attention to this subject more
particularly as
I had the
opportunity
of narrowly
watchint
.the progress of this disease, and witnessing the,post-mortem ex aminations of every man who died during the last five years ir the Wakefield Convict Prison, through the kindness of my frien<
we
deposit.
body
Mr. Milner, the resident surgeon of the above establishment. From these observations, I believe I have arrived at conclusions as to the formation of tubercle, very different to those o any other inquirer. And, as a correct diagnosis is the first stel towards cure, so it cannot be doubted that a true knowledge o tubercular deposit. Now, if tubercle be protein, with a deficiency the pathology of tubercle may lead to better and more accuratl of carbon, there appears to be some reason for supposing, that in methods in the treatment of phthisis. this peculiar diathesis the elements of the organism do not adhere From the experiments instituted by Simon, it appears thai together with that degree of tenacity which constitutes normal during respiration the oxygen of the atmosphere combines witt health. Liebig saysthere is nothing to prevent us from con,the blood-corpuscles, and that the consumption of oxygen anc force as a peculiar property, which is possessed ,formation of carbonic acid stand in a direct ratio with the amount sidering the vital certain natural bodies, and that this force is continually being by - of these blood-corpuscles, and with the number of respirations in in the organism by a chemical force ; and by the action opposed a given period; hence it is obvious that the oxygen of th, of this chemical force, a separation of part of the body, in the atmosphere is consumed in the metamorphosis of the corpuscles form of lifeless compounds, begins; and if, from any cause whatAnd it would further appear that the amount of fibrine alwayss the resistance of the vital force diminishes in a living part, ever, varies inversely with the mass of the blood-corpuscles, or, in the of matter increases in an equal degree. In the vegeother words, that the more corpuscles there are, the less in quan tablechange the resistance of the vital force is sometimes shown kingdom tity is the fibrine-and vice versâ. when we perceive leaves charged with turpenvery powerfully, It appears most probable that as the blood-corpuscles principally tine or tannic acid resisting the affinity of oxygen for these consume oxygen during their change, it is by this process that On the other hand, when this force is lessened in the fibrine is produced; and that wherever an extraordinary compounds. the organism, we need not be surprised at great abnormal changes consumption of corpuscles takes place, the quantity of fibrine in occurring. Again, the same author observes that the plasma also increases. If by any means the circulation be necessarily the absorption of oxygen occurs only when the vital force of quickened, or, in other words, the mutual action between the living parts is weaker than the chemical action, and that animal ,blood and oxygen be increased, more blood-corpuscles will be life may be viewed as determined by the mutual action of opposed consumed in a given time. forces; that the increase of the body is effected by the vital force, in Although the temperature of the body is nearly the same all and the waste of the body by the chemical action of oxygen; and parts, in consequence of the metamorphosis of the tissues con- that the condition of the body which is called health, results from of is the the lungs slightly an equilibrium among all causes of waste and of supply. Now, I temperature stantly going on, yet higher than that of the other parts of the system; which may be think we have evidence, that, in this peculiar condition, the carbon accounted for by the more energetic action of the oxygen on the of the body is too easily acted upon by the atmospheric oxygen, * mass of blood in these organs, than in other parts of the body. and therefore that the balancing operation which takes place in Now Andral and Gavarret observe that, in all stages of phthisis, the transformation of protein into carbonic acid, urea, water, &c., analysis of the blood shows that the fibrine is always on the in- which constitutes health, is so far overturned, that a larger quancrease, and the corpuscles on the decrease; but that this increase of carbon is removed in proportion to the amount of nitrogen and decrease vary proportionately with the progress of the tity and hydrogen, which, in the healthy functions, are carried away disease. Liebig states that it must be received as an undeniable by the kidneys, liver, skin, &c.;—hence, these latter elements, truth, that all the organic nitrogenized constituents of the body not being taken away by their proper emunetories, combine in are derived from protein, when we reflect on the development certain definite proportions, and constitute the deposit known of the young animal in the egg of a fowl, where, out of the the term tubercle. albumen, feathers, claws, globules of blood, fibrine, membranes byIn seeking, therefore, to discover a remedy for this disease, our and cellular tissue, arteries and veins, are produced. Now this object ought to be to ascertain whether there are any agents, albumen contains, for the quantity of nitrogen present, exactly or medical, which could prevent this too quick transthe proportion of carbon required for the formation of these dietetic formation. In making this inquiry, we must first observe, there tissues! can be no question that the victims of this disease are chiefly Let us, for one moment, look into the nature of tubercle. taken from amongst that class of individuals whose general tone Chemistry has thrown little light on its mode of formation. Simon of system is lowered, as occurs among the pampered and over-prostates that it might be regarded as protein from which a portion tected children of fortune, or in those living in confined and unof carbon and oxygen have been removed; or, to speak precisely, A remarkable fact exists, strange atmospheres, &c. &e. healthy it may be supposed to be derived from protein, which substance as it may appear, that in consumptive families the most dissihas lost, during the transformation, three atoms of carbon, and one pated and irregular in their habits, and those who have habitually .of oxygen. The formula isexposed themselves to many of the causes liable to engender this diathesis, have yet frequently enjoyed longevity ; whereas, in the same families, the most virtuous, and those who have guarded their lives with the greatest care and prudence, have fallen early From the observations previously made, viz., that the more cor- victims. Hence, it is an interesting matter to ascertain how far puscles there are, the less in quantity is the fibrine; and from the alcoholic drinks, in this disease, preserve those constitutionally experiments of Andral and Gavarret, that the blood in phthisis predisposed from these direful results. I think it is agreed, that contains more fibrine and less corpuscles; and, moreover, recol- alcohol, like all other highly carbonized substances, does supply lecting that the temperature is somewhat greater in the chest a certain amount of pabulum for the blood. Now, does it act in than in other parts of the system, probably because a more any other way? Does it at all prevent that disposition to oxidation energetic action of oxygen takes place in these organs,-it would on the part of the organism, of which we have spoken, and appear fair to conclude from these facts, that in phthisis the com- thus, by making the protein compounds less ready to combine binatiou of oxygen and carbon, in the lungs especially, is more with oxygen, render them less likely to be too easily broken up? active than in the normal state. Now we will say one word con- That it has this property out of the body is very evident, and may cerning the remedies employed and found most beneficial in this it not have an equal power when taken internally?++ There ca * Simon’s Animal Chemistry, vol. i. p. 281. * Simon’s Animal Chemistry, vol. i. p. 153. t Liebig’s Animal Chemistry, edited by Dr. Gregory-On the Phenomena t Liebig’s Ammal Chemistry, by Dr. Gregory. of Motion in the Animal Organism. t Simon’s Animal Chemistry, translated by Dr. Day, vol. ii. p. 479. t Ibid., p. 240.
516 be little doubt that alcohol is taken up and circulated in the first attack, leaves perhaps but a slight cough behind, but, on fresystem, primarily, as alcohol, yet its elements ultimately become quent repetition, gradually and irretrievably lapses into confirmed separated-its carbon and hydrogen are given off as carbonic acid phthisis, or the disease, almost equally often, sets in with hoemoand water ; for Liebig could not detect, either in the expired ptysis." If the author means by this, the commencement of the air, or in the perspiration, or in the urine, any trace of alcohol disease, I cannot agree with him. I regard these symptoms as after indulgence in spirituous liquors. By the use, therefore, of quite of a secondary nature. Although I am well aware that tuber. alcohol, a limit must be put to the change of matter, in certain cular disease of the lungs has been considered the result of parts of the body; for the oxygen of the arterial blood, which, in inflammation, yet I am disposed to believe that this is erroneous, the absence of alcohol, would have combined with the matter of the but that tubercle is deposited in consequence of a peculiar state of tissues, now combines with the elements of the alcohol-the arte- the system, in which the transformation of the tissues has not rial blood becomes venous, without the substance of the muscles, been carried on in perfect equilibrium ; and that when deposited, &c., having taken any share in the transformation. Thus, we the tubercle may, and often does, remain for a longer or shorter perceive, without the manifestation of a corresponding amount of period, without creating much local inconvenience or disturmechanical force, the heat of the body increases after the use of bance. This will, however, greatly depend on the amount wine. We have here some explanation offered to account for the deposited, and on its rapidity, as well as on other collateral cirdark, venous, bloated countenance of the man who lives freely; cumstances ; and the catarrh, inflammation of the lung, pleurisy, and we may contrast it with the florid, arterial hue, so charac- haemoptysis. &c., are entirely dependent on the mechanical irritateristic of the countenance of the phthisical patient. In the former tion caused by the presence of tubercle. I am strongly of opinion case, we have the system surcharged with carbon-in the latter, that the deposition of tubercle may be much more general than is the arterial blood becomes too highly oxidated. Is it not then usually believed, not necessarily shortening life, or perhaps infair to conclude that alcohol acts, in the first place, by preventing ducing ill-health; but I think it both possible, and verv probable, quick oxidation of the tissues, and then, becoming decomposed, that whenever the vital tonicity is sufficiently lowered, this de. it supplies carbon ? And if this be so, would it be attempting to posit might take place in any organ. Dr. Carswell thinks it pos. carry out a principle too far by supposing that the peculiar acute- sible that tubercle may be re-absorbed ; and, if deposited on the ness, if not vigour of intellect, which is so strongly observable in mucous membrane of the air passages, or of the bowels, I cannot the phthisical patient, might depend upon hyper-oxygenation of see why it may not be thrown off and ejected, as any other the blood circulating in the brain? just as we know a temporary foreign matter.-Dr. Addison, having examined, with a lens, exhilaration of the spirits seems to be caused by the inhalation many apparently healthy lungs, absolutely found tubercles depoof oxygen gas. On the other hand, it is equally well-known that sited more or less abundantly in one-third.* From a perusal of a sluggishness, both of mind and body, is a necessary attendant Laennec’s work, it seems evident that, although he had by no on the beer-drinker, which most probably may be accounted for means satisfied himself as to the mechanism of the formation of by the too carbonized state of his blood. It has been found in tubercle, yet there appears little doubt he regarded it as a deposit prisons that men are admitted, apparently in good health, and re- taking place from some unknown cause, and he appeared strongly main so for some months; that they then become dyspeptic, fall averse to the opinion that it was the result of inflammation. M. off in health, and die of tubercular consumption, running through Louis alleges, that, with one single exception, he never found all its stages in a few months, and even, in some cases, in a few tubercles in any other organ without their existing in the lungs weeks. And I believe I am not wrong in stating that four-fifths at the same time, insomuch that he seems positively to consider of the deaths in prisons are the result of tubercular disease.* their presence in the lungs as essential to their development in It may be observed that, as regards diet, cleanliness, regular other parts.-+,I am disposed to believe that tubercle may be habits, and an equalized temperature, the greater part of them deposited in any part where metamorphosis of tissue occurs; yet were infinitely better off than before conviction. The only cause I think it more likely to happen in the lungs, in consequence of a likely to be detrimental to health, would be the effect produced more full and energetic action of oxygen taking place there, than upon the mind by restricted liberty and prison discipline. Now, in any other parts of the organism. Hasse says that, in that I may state, that with scarcely a single exception, these men acute form of tubercular phthisis which often proves fatal in the have been throughout life more or less drinkers. The prison third week, the vital symptoms are very peculiar, bearing so fare, however, does not permit the smallest allowance of alcoholic close a resemblance to those of typhus fever, as to lead to misstimulus, unless specially ordered by the medical officer. Here it takes, and the diagnosis can only be ascertained by the stethowill be interesting to inquire, whether the loss of this agent has scopic sounds?ll In corroboration of these views, I examined a anything to do in producing the tubercular diathesis? I might man at the Convict Prison, who had been ill a few days, and also state as a remarkable circumstance, that at the post-mortem diagnosed the case typhus. He lived about a fortnight, and on a examinations of the convicts during the last five years which I have post-mortem examination, the whole of both lungs were comattended, evtry body examined, no matter how death occurred, pletely studded with tubercles, which had not yet formed comhad tubercular deposits, in one or more organs, with the excep- munications with the bronchi, and tubercular deposits were found tion of one man, who died of epilepsy. Again, no class of men, also in the abdomen and head. The late Dr. John Taylor, of on an average, take more stimulants than innkeepers, or the oldUniversity College Hospital, informed Mr. Milner that he had fashioned but now almost obsolete coachman. To this numbet seen two similar cases, and that in both the disease at its comI might add butchers, who, besides consuming large quantities of 11encement had been considered to be typhus. Now I regard animal food, generally also drink freely; as well as men em- hese cases as the result of a very marked deficiency of the vital ployed at breweries. Whether statistical evidence may prove force. Hence, during a very short period, the protein comor disprove the fact, I am strongly inclined to believe, from a pounds were so rapidly acted upon by the atmospheric oxygen, recollection of cases, as well as from their general appearance, :hat the disease began and finished in the course of a few weeks which is familiar to all people, that they are not liable, but rather - indeed, the rapidity and extent of the tubercular deposit are so the reverse, to tubercular diseases. If the inference be correct sreat, that patients absolutely die before the disease has extended from these and other similar illustrations which might be quoted, further than simple deposition. As some proof of the views I it would appear that alcohol, although most injuribus and de- entertain, I will relate one or two instances which have occurred structive by producing multitudinous diseases, yet may it not in immediately under my own eye; but as many of the individuals this instance act as a kind of preservative, by protecting the spoken of are at present now living, I cannot, of course, furnish organism from the action of oxygen, which we believe we have names. shown to be the immediate cause of the deposition of tubercle ? If 1st.-A family consisting of five sons and one daughter; all this be so, could not some chemical agent be discovered, which appeared to enjoy good health up to about eighteen. Out of this would have a protecting, but not otherwise destructive agency? three sons died between the ages of eighteen and family, For instance-I merely propose it as a theoretical suggestion- twenty-five, of phthisis; the daughter is still living, although in would tann:c acid, combined with some highly carbonized subvery precarious health, evidently phthisical. All these were stance, and a moderate supply of alcoholic beverage. or some such steady, industrious, and peculiarly careful of their health. The compound, have this protecting influence ? I think it likely two remaining sons, now between thirty and forty years of age, that if any such agent be ever discovered, it will be found when last heard of were quite healthy. Early in life. these two amongst that class which have a like preservative property, when latter men were of dissipa’ed habits, and lost many situations in used extrinsically to the body. One of them, at the consequence of their propensity to drink. In Hasse’s work,t edited by Dr. Swaine, it is stated, "for the age of ninetet-n. came over from India with an inflamed early most part this disease is traceable to a catarrh, which, after a Consumption and Scrofula, by William Addison, M.D., p. 51. * Mr. Milner, Surgeon to the Wakefield Convict Prison, authorized the t A Treatise on Di,eases of the Chest, by R. T. H. Laennec, M.D. ; trans’
. ’
-
above observation. t Anatomical Description of Diseases of Circulation and C. E. Haase, M.D.; edited by W. E. Swaine, M.D.; p. 320.
Respiration, by
lated by John Forbes, M.D. ; Second Edition, p. 291. 1 Authority, Dr. Forbes in Laennec’s work. R Dr. Hasse, p. 321.
517 but
night,
dropsy, from spirit drinking ; he was many months ill, ultimately recovered. When last seen, they were in robust‘
liver and
31st.-Half-past
,
and feels
nine
A.M :
The
patient
has
comfortable ; the bowels have
a
passed good been again re-
countenances. lieved ; micturition frequent; slight pain in the back and abdo2nd.-A family consisting of three sons and three daughters. men ; douche repeated, commencing with warm water.-HalfThey all had the characters of the scrofular diathesis strongly past two P.M. : Some slight shivering, nausea, and giddiness have been experienced since last report ; douche repeated, commencing marked-fair hair, clear complexion, blue eyes, thick lips, &c. The three daughters died of phthisis before the age of thirty ; one I with two and a half gallons of cold, followed by five gallons of warm water.-Half-past eight P.M.: The symptoms continue son of tubercles of the brain-the two remaining sons are still alive, of irregular habits, but in apparentlv good health. pretty much as at last report; douche repeated in the usual man3rd.-A young man at the age of eighteen showed every ner and quantity, commencing with warm water. Though no symptom of approaching tuberculosis; he had already lost one perceptible change in the state of the os uteri has occurred, the brother and a sister by phthisis. His medical man advised him to patient whilst in the bath experienced increased shivering, nausea, relinquish a profession of a sedentary nature, in consequence ofgiddiness, and pain in the back. Within an hour after the applithe above facts. He did so, but unfortunately became dissipated. cation of the douche, she had some rather severe rigors, and pains He is now alive, about forty years of age, a confirmed drunkard, continued to increase in regularity and intensity till half-past eleven P.M. On making an examination at this time, the os was and has suffered several times from delirium tremens. We gather, therefore, from the foregoing observations, that: found as large as a crown-piece, the bag of membranes protruding, tubercular deposits are eminently dependent, as the primary ifconical in shape, and very tense, even in the absence of pains. Nov. 1st.-Half-past one A.M. : The os is fully dilated, and the not the sole cause on a diminution of the vital force.-2ndly. That in phthisis the body is rapidly consumed by the combination bag of membranes has almost reached the os externum ; the preof its elements with oxygen.-3rdly. That the consumption ofsentation was found to be either hand or foot, but the membranes the body may be retarded by the ingestion of certain highly car- were too tense to determine which ; consequently, as the pains bonized substances, as cod-liver oil, &c.-4thly. That it is pro- continued regular and severe, it was decided to evacuate the bable the rapid oxidation of the body may be checked, or liquor amnii, so that in the event of its being necessary, turning entirely prevented, by the use of alcohol, or of some agent acting might be immediately performed. On rupturing the membranes, an unusual quantity of water was discharged; one foot was found in the same way.
health, but had bloated
,
’
’
’
’
November,
and being brought down, was secured by a noose. ceased almost entirely, and tte patient obtained some sleep during the remainder of the night. At eleven A.M., she had an enema of warm water, which was repeated at two P.M. :: Some slight pains succeeded. At half-past two P.Di., the vagina No progress being made, a was injected with warm water. scruple of powdered ergot was given at three P.lII., and repeated at half-past three and four. Labour pains of considerable intensity commenced soon after the first dose, and continued to increase till half-past four, at which time a still-born male child was expelled. The head was rather large and firmly ossified, but considerably moulded by its passage through the contracted brim. The plaAt bed-time the patient centa followed almost immediately. took an anodyne draught, followed by a dose of castor-oil in the morning. The bowels were comfortably relieved. The afterpains were slight, and the secretion of lochia and milk was natural. The recovery was rapid and uninterrupted. Labour commenced immediately after the sixth use of the douche,
presenting,
1852.
Pains
A CASE OF PELVIC DISTORTION, IN WHICH PREMATURE LABOUR WAS INDUCED BY THE WATER DOUCHE. BY J. PRIOR SENIOR
SURGEON
LACY, ESQ., M.R.C.S., TO
THE
NEWARK
HOSPITAL.
now
L. C-, aged thirty-seven, a woman of middle stature, fail complexion, phlegmatic temperament, and good general health, i: the wife of an agricultural labourer; she began to menstruate a1 seventeen, and continued to do so regularly till after her marriage, at the age of thirty-two. Has had no miscarriages, and the present is her fourth pregnancy. This woman, on account of congenital deformity of the pelvis, consisting of great projection of the promontory of the sacrum, narrowing of the pubic arch, and and thirty-six hours ccfter the first use of the douche. Duration of consequent lessening of the antero-posterior diameter, was, in her labour, eighteen hours. two first labours, which occurred at the full time, obliged to be The account of the foregoing case has been most correctly delivered by means of craniotomy. The first child was a boy, drawn up by Mr. Rake, the house-surgeon to the hospital. It the second a girl. is evident, that in this instance, though the child was lost, the In her third pregnancy she was admitted into the Newark chances of its being born alive were considerably greater than if hospital, and premature labour induced at seven and a half the membrane had been punctured before the commencement of months, by puncturing the membranes; the presentation was an labour. In the present case, the membranes were ruptured after arm, the labour protracted, considerable difficulty was experienced the os uteri had been completely dilated by the influence of the in turning, and the child, a girl, born dead. douche. Should another case of this description come under my On the occurrence of her fourth pregnancy it was again deter- care, I should allow the liquor amnii to be discharged without any mined to admit her into the Newark hospital, and induce prema- interference. The returned to her home in the country patient ture labour at seven and a half months, with a view of saving the a after her delivery ; and in passing through the village fortnight life of the child. She became an in-patient on October 29th, in which she resides a few days ao, I called and found her quite 1852, and the novel mode of operation described and advocated well, and in the full employment of her domestic duties. I should by Dr. Tyler Smith, in THE LANCET of October 2nd, 1852, was wish to state, that I resorted to the operation entirely from pretty clost’ly followed, except that no syphon was employed, perusing the successful case related by Dr. Tyler Smith in but in its stead the distal end of the india-rubber tube was fastened to a receptacle, placed ten feet above the patient, and the other end of the tube introduced into the vagina without any enema pipe being affixed to it. When the patient was lying in bed the os uteri could with difficulty be felt high up and near the pubes ; but on placing her in the bath, the alteration of position caused it to be felt much more readily. A dose of castor-oil was given on admission, which operated freely, and onOctober 30th-half-past nine A.M.-the patient being placed in an open bath, and the uterine end of the india-rubber tube introduced into the vagina, and held opposite the os uteri, two and a halt gallons of’ water, at 110° Fzihr., were poured into the receptacle; as soon as this had escaped through the tube the same quantity of cold water was poured in, and suffered to flow against the os uteri in like manner. The patient complained of some uneasiness when the cold current first began to run. Three p M.—The douche was repeated in the same manner as last described, but commencing with cold instead of warm water. Since the first douche, micturition has been rather
frequent,
but little pain has been experienced. Nine P.M..—The douche was repeated, commencing with warm water ; the end of the forefinger can be introduced into the os uteri, but no pain of any consequence has occurred.
THE LANCET of October 2nd. November, 1852. "
ON THE TREATMENT OF ERYSIPELAS.
BY VINCENT ’
IT is
n,)w
LITCHFIELD, ESQ., M.R.C.S., Twickenham. some time since, that I began the treatment of
means of the tinct. ferri sesquichlor.; and finding the results so satisfactory, I am induced to record a vote in its favour. I was led to make a trial of it at the recommendation of Dr. Brown, of Edinbugh, who kindly sent me a pamphlt on the subject, written by Mr. Hamilton Bell. He says, 11 I have resorted to this mode of treatment tor a quarter of a century, without having in a single instance failed of’ success." This was boldly penned, and I, for one, did not thoroughly believe it; but I am too glad to state now, that I believe I could cure many cases in a week, which I formerly should have been a month at. Mr. Bell goes on to state the mode of administration, and expresses so much, and that too so aptly, in a few lines, that I cannot do better than transcribe them. He says:-" Of course the first object is to have the bowels freeiy acted on. If the erysipelas be mild, fifteen drops of the iron are administered in water every two
erysipelas by