Page images
PDF
EPUB

Chapters L. and LI. are remarkable only for their brevity; the longest not exceeding 23 lines. The former is entitled, On a Source of Diagnosis in Laryngitis: it runs thus:

"In pure laryngitis, the patient cannot snuff up: see page 342.* The volume of air so admitted into the larynx, though its due velocity be not wanting, is insufficient to produce that effect.

"Laryngitis, in which there is thickening of the lining mucous membrane of the glottis or larynx, and consequent diminution of this orifice, is distinguished in this manner from tuberculous ulceration of the glottis or larynx, in which, so far from there being diminution, there is augmentation of the orifice.

"The effort to snuff up,' in laryngitis, has the most peculiar effect. Instead of the expected noise in the nostril, there is an unexpected sound in the larynx. "But not only is the fact of diminution of the laryngeal orifice ascertained in this manner, but the degree of that diminution is marked by the greater or less degree in which the power of 'snuffing up' exists, and therefore the greater or less degree of urgency of the case! In the same manner, the diminution or augmentation of the disease is accurately marked.

"The same observations have a certain relation to the double danger of this disease—from—1, immediate, and 2, secondary, asphyxia." 349.

The sum and substance of Chapter LI. On the Treatment of the Atrophy of Paralytic Limbs, by William Frederick Barlow, Esq. are contained in these few lines: "I would suggest...... that Galvanism be used at intervals more or less lengthened as circumstances indicate, or tickling, friction, and temperature be employed, if these be found to occasion reflex actions.'

There is surely nothing new in this advice, although the writer seems to think otherwise; for he says: "no one, as far as I know, has proposed that involuntary contractions should be excited in them (the muscles) with a view to their nutrition." Really if we go on at this rate, there will be nothing old under the sun.

With this remark we close our notice of this volume. Our readers will be able to judge for themselves, by the extracts we have given, that it contains much curious and not a little instructive information. We look forward with interest for the succeeding volume or volumes, which are promised, and trust that the talented author will, for the sake of his own reputation, render them more free from the blemishes which we have pointed out.

......

* Reference is here made to the case narrated in the preceding Chapter. "She described the impossibility of snuffing up the nostrils-an effect, I suppose, of the partial closure of the larynx; for, to produce this snuffing, it is necessary that a certain quantity of air should be drawn through the nostrils with a certain velocity; and, in the present instance, the quantity of air admitted appears to have been too small. The patient experienced increased uneasiness on drawing the head backwards."

I. LECTURES ON PULMONARY PHTHISIS. By John T. Evans, M.D. Dublin, 1844. 8vo. pp. 196.

II. RESEARCHES ON PHTHISIS. By P. C. A. Louis, M.D. Second Edition. Translated by W. H. Walshe, M.D. London (Sydenham Society) 1844. 8vo. pp. 566.

III. SYNOPTICAL ACCOUNT OF THE EFFECTS of Certain Medi-
CINES APPLIED TO THE TREATMENT OF ASTHMA AND CON-
SUMPTION, ON THE PRINCIPLE OF ENDOSMOSIS.
Brown, M.D. 1844. 8vo. pp. 24.

By W. H.

DISHEARTENING as is the fact that notwithstanding the immense amount of labour and talent which has been of late years devoted to the investigation of the phenomena of Phthisis, little or no progress has been made in its therapeutical management, it is gratifying to find that the subject is not abandoned in despair, but still occupies the time and thought of intellects of the highest order. They justly deem it an inconcievable anomaly that so vast a proportion of mankind should thus be permitted to perish in the very prime of life; and are willing to believe that diligent research and extended means of investigation, will yet one day be rewarded by the discovery of the manner of limiting the ravages of this devastating plague. M. Louis believes that future inquiry can only be pursued with probable chance of success, by means of the association of a great number of wellqualified inquirers, for the purpose of observing and recording upon an extensive scale all the phenomena of the disease for a considerable space of time, as they may occur in individuals placed under every variety of circumstances. Could a record of this kind be obtained, that it would become a vast aid in improving our knowledge of the etiology and treatment of the disease cannot be doubted: but there are so many obstacles to the forming of one with sufficient accuracy to be depended upon, that we fear it must be placed among the large assemblage of things which are rather desired than hoped for.

In the mean time individual observers are by no means idle, and although the productions they send forth are too often the result of a crude generalization, a misapprehension of fact, or a desire to obtain popularity and its consequences by promising to an ignorant and anxious public that which in the present state of science is impossible; yet enough valuable matter is continually put forth in independent publications, or the British and Foreign periodicals, to shew that a different order of minds has also deeply engaged in the contest with this dread enemy, and thus to stimulate cooperation and prevent despondency.

Dr. Evans, to whose work we shall chiefly confine ourselves in this article, believes that in the amended pathology, which he presents in his Lectures," we may obtain a rational indication of treatment; and he is by no means disposed to regard the disease so necessarily, or so usually, fatal as do the majority of medical men. We have, of course, no intention of presenting an analysis of so well known a work as that of M.

Louis, but it will be desirable to advert to some of the new matter he has introduced into the present edition. The view this author takes of the probabilities of cure is far less sanguine than that of Dr. Evans, and, although we fear it is the more correct of the two, we cannot but subscribe to the justice of the criticism delivered by the latter upon this celebrated work. He says—

"I have found it necessary to differ in many things from the modern Parisian school of stethoscopists. In M. Fournet's book, there appears to me to be many old observations put forward with an imposing air of novelty, and many new assertions destitute of foundation. M. Louis' work on Phthisis is of a higher order admirable on account of its careful pathological descriptions, most useful as a repertory of elaborately-drawn cases; yet, I must consider its etiology illogical, its diagnosis rather meagre, and its treatment inadequate."

PATHOLOGY OF PHTHISIS.

Dr. Evans believes that attention has been unduly directed to the nature, detection, and removal of tubercle, as if it were the cause of the various symptoms, whereas it is but the result of a peculiar form of inflammatory action, occurring in persons possessing the phthisical predisposition. To the examination of this predisposition, as the first stage in the production of phthisis, he attaches great importance; and, after alluding to various circumstances which may give rise to it as hereditariness, exposure to cold and damp, absence of light, the debility caused by various diseases, &c.-he thus speaks of its nature.

"From a careful consideration of the causes which tend to predispose to the development of tubercle, I think you are justified in coming to the conclusion that this predisposition consists in a deficiency of that manifestation of vital force whereby the tissues are enabled to grow at the expense of the circulating fluid. This deficiency may be congenital, or it may be the result of external circumstances: it may be confined to an organ, or it may implicate the whole system. But we are led by strict induction to believe that when this predisposition exists, the slightest local inflammation is liable to terminate in that peculiar variety of fibrinous secretion intermediate between lymph and pus, to which has been given the name of tubercle.

66

Comparative anatomy and embryology prove that the development of muscular tissue is the product of an action of growth, of a higher order than that which gives rise to cellular and nervous tissues, it consequently follows that in a general arrest of development in the organism, the muscular tissue should suffer first, and in the causes which tend to produce atrophy, this tissue should first present a deficiency of nutrition. Therefore it is, that in the predisposition to tubercle, we find a want of proportion between the red and white tissues, the latter are present in excess, and it has been supposed that an excessive development of the white tissues predisposed to tubercle. But from what we have seen you can evidently understand that it is not an hypertrophy of the white tissues, which constitutes the predisposition: but that the same causes that predispose to tubercle, produce likewise atrophy of the red tissues.

"You may perceive how well the locality which tubercle generally occupies, corresponds with the two-fold method of its production; we might be led by pure calculation to conclude that the lungs, of all organs in the body, ought to be most liable to inflammatory affections, subject, as they are to every atmospherical change, and kept in never ceasing activity; and then, on the other hand, the upper lobes are

those in which nutrition is least active, and the left side, again, is in all the higher animals, the least developed." 15.

In the Appendix to his work the author examines, at considerable length, the foundations upon which M. Louis rests his statement, that inflammatory action is not the fore-runner of phthisis. Upon the observation by this eminent pathologist, that pneumonia, pleurisy, and bronchial inflammation, do not cause the deposition of tubercle, Dr. Evans observes

"M. Louis considers, that it is impossible to maintain that inflammation is a powerful or common cause of phthisis. But in his treatment of this subject, he seems to me to have fallen into the sophism which logicians call ignoratio elenchi; that is, he has proved a thing which has no necessary connexion with, and, therefore, does not determine, the question. The question is, are tubercles a result of an inflammation? M. Louis proves, that plastic or suppurative inflammations do not give rise to the deposition of tubercles; and therefore he draws the conclusion, that tubercles do not arise from an inflammation. If inflammation was a thing capable of an exact definition, having always the same anatomical appearances, accompanied by the same vital aberrations, and characterized by the same alterations of functions, this conclusion might be justified. But pathologists know that this word is, on the contrary, very vague in its interpretation; is intended to express extremely varied combinations of lesions; and differs very much in its results under various circumstances. Sometimes inflammation produces softening, at others induration; sometimes it causes secretion of pus, at others coagulable lymph; nay, mere congestions from atony or venous obstruction, have been called asthenic or passive inflammations. If M. Louis succeed, therefore, in proving that ordinary pneumonia, pleurisy, or bronchitis, terminate in the majority of instances, without the development of tubercles, we may admit the truth of his deductions, and yet remain as much as ever in the dark, as to whether tubercles are a result of an inflammation." 167.

The author next enters into a critical examination of the cases of Acute and Latent Phthisis cited by Louis, as proving that tubercle originates independently of inflammation, but from which he draws totally opposite conclusions.

In the same part of his work, Dr. Evans opposes himself to the generally received opinion of the identity of the tuberculous cachexia and serofula. After quoting Sir James Clark's description of the tuberculous diathesis, and complaining of its vagueness, he adds

"The fact is that Sir James was partly influenced by experience, and partly by prejudice, in penning the above description. Experience warned him that he had seen Phthisis attacking every variety of constitution; while prejudice suggested to him, that struma being, according to common opinion, identical with tubercular disease, he should mix its acknowledged phenomena as elements of the picture. But is there any sufficient evidence that scrofula is identical with the phthisical diathesis? I think not, and am inclined to regard these states of the constitution as totally independent of each other, for the following reasons. 1st. I see every day numerous examples of phlyctenular ophthalmia, prurigo, ricketts, &c., diseases confessedly peculiar to scrofulous children. I am frequently called upon to prescribe for lymphatic-looking infants, with tumid upper lips, dilated pupils, swollen bellies, and enlarged cervical glands: but upon inquiring as to the diseases to which their parents and other relations have been liable, I do not find that consumption or decline is mentioned more frequently than among any other class of cases. I have known many large families, the members of which, have, been all more or less subject to scrofula, in one form or another, and none of them had ever got phthisis. 2nd. Upon inquiring into

the early history of numerous phthisical patients, I have remarkably seldom met with persons who at any time presented the characteristics of struma. Nay, in one remarkable instance, when, out of a family of eighteen members, fourteen died of phthisis, not one ever presented a symptom of scrofula, unless acute hydrocephalus in one child could be considered such." 189.

The cause of Emaciation in phthisis is thus stated.

"We have already seen that the predisposition to phthisis consists in a diminution of the force of growth, of that vital attraction whereby the tissues draw from the circulating fluid the materials of their nutrition. It is not difficult to understand, that a diminished power of growing is equivalent to an excess of waste, in producing atrophy of the tissues. If this view be correct, emaciation is one of the essential elements of the disease. It is not the result of tubercle, but is produced by the causes which predispose to tubercle; and if this be true, we should be led to expect that not unfrequently a general atrophy should precede any local evidence of the deposition of tubercle." 21.

In respect to the influence of Haemoptysis in producing phthisis, Dr. Evans is again at issue with M. Louis. The latter author observes:

66

Hæmoptysis was long considered an exciting cause of phthisis; and M. Fournet, in an extensive work recently published, adopts the obsolete notion. But it is impossible to discover the foundation upon which this writer bases it; for no proposition is at the present day more satisfactorily proved, in the opinion of all accurate observers, than the extreme rarity of hæmoptysis of any amount, unless as a dependence upon tubercles; so that, admitting argumenti gratia that attacks of hæmoptysis of this kind, are sometimes the exciting cause of a deposition of tubercles, the fact could not be proved. It is impossible, then, in the existing state of things to regard hæmoptysis, either of considerable or trifling amount, as a cause of tubercles." 505.

Dr. Evans believes, on the contrary, that the profuse hæmoptyses, which are sometimes observed in young people, may give rise to the phthisical predisposition, and thus operate as the cause of tubercle. He says:

"The question is one of vast practical importance. It involves the consideration of whether we are to put into operation every known means of arresting hæmorrhage, cheered with the hope of being able to ward off the tubercular deposition; or whether we are to feel depressed with the conviction, that the seeds of decay have been already sown. M. Louis' argument comes to this, that because in the majority of cases of profuse hæmoptysis, the patients have ultimately become phthisical, we are therefore to consider tubercles to have been the cause of the hæmorrhage; although it may have occurred in a person previously healthy, and who had not as yet presented either rational symptoms or physical signs of pulmonary disease."

"M. Louis himself acknowledges, that this is frequently the case. He says [p. 167,] 'Either in its severe or slight form, hæmoptysis sometimes occurred a variable time before the appearance of the cough or expectoration. Such was the case with 12 of my patients (out of 57), 8 of whom had had severe hæmoptysis. This form set in still more frequently than the other, in course of, or at the commencement of the first period of the disease, in the proportion of 9:7. Spitting of blood occurred but rarely towards the close of life, when the patient's feebleness had reached the maximum.' With these observations I perfectly agree; and I cannot but thank M. Louis for the candour and truthfulness of his observations, at the same time that I am often compelled to differ from his conclusions." 193.

The rarity of hemorrhage at an advanced stage of phthisis depends, as

« PreviousContinue »