Page images
PDF
EPUB

the same appearance in the gastric mucous membrane of hogs, which had been bled to death at the shambles; and the most experienced pathologists say that it is difficult, if not impossible, to discriminate between this merely physical phenomenon, and the redness of inflammation, unless some other marks of this diseased condition be presented. Thus, then, it appears that the gastric mucous membrane is found, in cases of death from fever, without any signs of inflammation, and that often, when these signs apparently exist, they are in fact delusive. But the advocates for the gastric theory maintain that inflammation may have existed without leaving a trace discoverable upon post-mortem examination; and they appeal to the disappearance of the redness after death, in cases of superficial inflammation of the skin. It is, however, utterly impossible, from the very nature of the inflammatory process, that this should exist with sufficient violence, or of sufficient duration to occasion death, without leaving some marks, either of congestion, exudation, softening, or other organic change, discoverable by close inspection. Even in the skin, unless exceedingly slight or transient, it produces some derangement of structure evident after death. Those cases of poisoning by arsenic, in which the stomach retains its healthy colour after death, have been adduced in proof of the assertion, that, even after fatal inflammation, the redness may entirely disappear. But these cases are more reasonably explained upon the supposition, that the deadly influence of the poison upon the nervous system has destroyed life so speedily, that there was no time for the establishment of inflammation; just as the poisonous cause of fever occasionally proves fatal by its first depressing influence, before reaction can take place. The inference, therefore, from the occasional perfectly healthy appearance of the stomach after death, that it was not inflamed during life, remains unaffected; and, if inflammation can be shown to be absent in a single case, the theory is disproved.

But what are the evidences, independent of those offered by dissection, which are relied on to prove the invariable presence of gastritis? The sensation of heat, the intense thirst, the relief afforded by cold drinks, and the distaste for hot and stimulating drinks, and for all kinds of food, have been mentioned. It is true that these symptoms are very generally present; but have we not also a hot skin, and are not cool liquids as agreeable to the surface as to the stomach? and yet it is not maintained that the skin is inflamed. Thirst is not especially a sign of gastric inflammation. It perhaps more frequently indicates a particular condition of the blood, which calls for dilution. The distaste for hot drinks may indicate the existence of gastric heat, but not necessarily inflammation. The distaste for food proves a loss of digestive power, and frequently exists in the state most opposite to inflammation. Other indications of inflammation which have been mentioned are nausea and vomiting, and the red and coated tongue. The first two are often present, but they are also frequently absent, and, even if they were invariable attendants, would not prove the existence of inflammation; as they often indicate mere nervous irritation of the stomach, or of the centres which supply it with nervous influence; and are quite compatible with true debility of the organ. The red and furred tongue has very generally been considered as indicative of gastric disorder; but the investigations of Louis and others have shown conclusively that no certain inference can be drawn from the state of the tongue, in fevers, as to the state of the stomach. The tongue appears to feel, like all other parts of the body, the influence of the morbid cause. That it is so often disordered simultaneously with the stomach proves that they are exposed to the same influence, not that the disorder of one is dependent upon that of the other. Hence, the cleaning of the tongue is one of the best evidences of the decline of the fever. It is said that leeches to the epigastrium,

are speedily followed by improvement in the appearance of the tongue. This is often true, and the fair inference is, that irritation or inflammation of stomach may exist in such particular instances, and aggravate the general fever. But very often, also, no such effect is experienced. Leeching to the temples would have a similar influence if cerebral irritation should exist. It is not, however, intended to deny that there is a sympathetic connexion, to a certain extent, between the tongue and the stomach; the only point maintained is, that this connexion is not sufficiently close to justify the inference, that, because the tongue is red in fever, the stomach is inflamed.

We cer

If gastritis were the cause of fever, it should always precede it. tainly very often have evidences of derangement of stomach before the attack of fever; but there is no proof that this derangement is inflammation. It might as well be maintained that the nervous symptoms, which are much more prominent than the gastric, are proofs of the existence of inflammation of the brain. Besides, the gastric disturbance is by no means an invariable antecedent. I have known a severe febrile paroxysm to commence immediately after a hearty dinner.

The phenomena of intermittent fever afford one of the strongest objections to the gastric hypothesis. This disease is cured by remedies which powerfully irritate the mucous membrane of the stomach. Quinia often produces great gastric irritation, and Peruvian bark still greater. Arsenic, which is a powerful gastric irritant, is perhaps, next to quinia or bark, the most effectual remedy. Intermittents are occasionally cured by black or red pepper, taken between the paroxysms. When an organ is peculiarly disposed to inflammation, the application of an irritant is generally supposed to favour the disposition; and substances of this kind are the last preventives we should be disposed to resort to.

It is, therefore, by no means an established fact, that the fevers commonly considered as essential or idiopathic are gastro-enteritis; much less those denominated symptomatic. Undoubtedly fever may arise from inflammation of the stomach and bowels; but it then takes rank with the other phlegmasiæ. Nevertheless, gastritis is a frequent attendant upon fevers, much more so than was believed before Broussais called attention to the fact; and there is no doubt that the treatment of these diseases has been favourably modified by the new light thrown upon them by this author and his disciples.

Admitting fevers to be in some instances idiopathic, in others symptomatic, the proper febrile movement, from whatever cause it may proceed, and however it may be complicated in different cases, is of the same essential character. The functions are deranged, and in such a manner that all recognize the disorder when they encounter it. There must, therefore, be something in the different febrile diseases common to the whole of them, and to this the name of fever properly belongs.

It is an interesting question what is the nature of the derangements in the functions. The mere statement that they are universally disordered gives no definite notion of the disease. But it is by no means an easy task to explain the nature of the derangement. Some of the functions are in a state of irritation, some probably of depression; but if we attempt to review the whole of them, and point out which are in the one state, and which in the other, we find that in many instances the symptoms do not afford us grounds for a positive decision; and we can derive no aid from organic changes; for these, when they do occur, are not essential. The order in which those states succeed each other, and the chain of mutual dependence which connects them, equally elude our search. It is possible that there may be something peculiar in the irritation and depression. But if such peculiarity

exist, we cannot point out its nature. Together with disorder of the solids, there is very frequently an altered state of the blood; but the question has not yet been settled, whether this is an essential part of the disease, and important in the chain of causation, or a mere incidental effect. We are thus in a condition of uncertainty upon almost all points.

Theorists have failed in endeavouring to trace the complicated disorders of fever to some common source, and to point out a particular succession, a particular and necessary line of march, in the progress of the affection. The universal disturbance of function which constitutes the disease may be brought about in various ways; and the starting point may be entirely different in different cases. Yet among the great majority of cases, there is a close analogy in the mode of onset, which must be ascribed to some common principle. Whether the fever is idiopathic or symptomatic, the first decided step towards its formation seems to be some morbid impression upon the nervous system, and this impression seems to be of a depressing nature. The phenomena immediately preceding, and those attendant on the chill, are for the most part unequivocally those of depression. The whole nervous system appears to have received a shock from the cause, cramping, and occasionally for a time almost deadening its energies. Something analogous to this we have in the effects of a severe surgical operation, of a severe injury in any part of the body, and of sudden alarming or afflictive intelligence. Along with the diminished exercise of the nervous function, is necessarily a diminution of all those functions dependent upon it. We may thus partially explain the condition of the chill; but there is something more which we do not fathom; something in which the chill of fever differs from other instances of nervous depression. Upon principles which have already been explained, the general prostration is succeeded by reaction, and the fever is then esta blished. But there is here also something more than mere reaction. There is the continued action of the cause, a diversified play of sympathies in one case, a widely pervading influence from some unknown agent in another; and fever is not purely, as some have maintained, the resilience of the bowed down system. A proof of this is, that the febrile excitement is by no means proportionate, in all cases, to the initial nervous depression. To unravel this complicated web is in the present state of our knowledge impossible. We are too little acquainted with the precise reciprocal action of the organs, with the nature of the nervous power by which this reciprocal action is maintained, and, in many instances, with the cause of the disease and its mode of operation, to enable us to advance far beyond conjecture. We know that the heart, arteries, and capillaries are in a state of super-excitement, and the blood often disordered; that, under the combined influence of the nerves and blood-vessels, calorification is increased; that all the secreting surfaces, including that of the stomach, and all the secreting glands, and the whole process of nutrition, are deranged; sometimes probably being irritated, sometimes depressed, and sometimes peculiarly affected, under the influence of peculiar causes.

But in many instances of fever, even the imperfect concatenation above described is not evinced. Not unfrequently, the stage of chill is so slight as to preclude any idea of its agency in inducing the succeeding stage, and sometimes it is entirely wanting. In these cases, we must suppose the various derangements constituting the fever to be induced by the exciting cause, without a preliminary action specially upon the nervous system. Either the cause enters the circulation, and reaches all the organs so as to act on all simultaneously, while at the same time it may be acting on the blood, or it affects some one part primarily, from which an influence is conveyed sympa

thetically over the system. The latter was the opinion of the late Professor Chapman, who traced most fevers to an original morbid impression made upon the stomach. His opinion was promulgated in lectures before the annunciation of Broussais' hypothesis. But in ascribing fever to a gastric origin, Dr. Chapman did not consider the affection of the stomach as necessarily inflammation, nor did he consider the original impression upon this organ necessary for the continuance of the fever which it has set in motion.

Article VI.

DISEASE WITH PECULIAR PRODUCTS.

The diseased conditions now to be considered are recognized by peculiar products, not necessarily the result of any exciting or depressing agency, whether ordinary or specific. They may be included under two divisions; the first embracing those in which the new product, if organized at all, has a very feeble organization, the tendency of which is rather to decay than to growth or reproduction; the second, those in which a new body is produced, having a life of its own, and capable of indefinite extension, if not of generation.

1. DISEASE WITH UNORGANIZED OR FEEBLY ORGANIZED Products.

The most important of the affections belonging to this category is beyond all comparison, tuberculous or scrofulous disease; and melanosis may be ranked under the same head. These are constitutional diseases, exhibiting themselves by their peculiar deposits in various parts of the body, where they give rise to phenomena differing according to the locality. Their presence and effects in the several positions in which the deposit occurs may be considered as constituting distinct diseases, and will be treated of as such. In this place, we are concerned with the general affections, independent of locality.

TUBERCULOSIS.

Syn. Tuberculous or Scrofulous Disease.-Strumous Disease.-Scrofulosis.

In certain states of the system, a solid extravasated matter is deposited in various parts of the body, which, from the shape ordinarily assumed by it, is called tubercle. The morbid state of system which leads to this deposition may be denominated the tuberculous diathesis. It is closely analogous, if not absolutely identical with that which usually precedes the development of scrofulous tumours, and which is denominated scrofulous or strumous diathesis. In this work, they are considered as one affection. When this state of system becomes decidedly and obviously morbid, it is sometimes called tubercu lous, scrofulous, or strumous cachexia.

The tuberculous deposition takes place in one of two forms; either that of small, isolated bodies, or that of irregular infiltration into the tissues. In either case, the matter as first deposited may be gray, semi-transparent, and hard, or yellow, opaque, and rather soft. According to Laennee and Louis, the deposit is originally of the former character, and afterwards assumes the latter. But the matter is often found in both conditions at the earliest period at which it can be examined; and it seems to the author that, unless otherwise proved, it must be allowed to have been thus deposited.

The minute, isolated bodies are called miliary tubercles, or tuberculous granulations. When gray, semi-transparent, and hard, they are sometimes. distinguished by the name of gray semi-transparent granulations; when yellow, and of a caseous consistence, they are denominated yellow miliary tubercles. They do not at first exceed a millet seed in size, but gradually increase till they become as large as a cherry stone or larger. When they are at first of the gray semi-transparent variety, a yellow spot soon makes its appearance within them, which enlarges by degrees until the whole tubercle is converted into a yellow, opaque, curdy matter, so soft that it may be crushed between the fingers. Sometimes they are in this state when first observed. The process of change continues, the softness increases, and the tubercle at length breaks down into a pus-like matter, with which are often mingled portions of the tuberculous substance in a cheesy form. This sort of mixed matter may sometimes be found in the centre of the tubercle, while the circumference remains still hard and unaltered. Not unfrequently, numbers of the miliary tubercles are aggregated together, forming a considerable mass; in which case, several points of alteration may be observed in different parts of it.

The infiltrated tubercle may be in the shape of large irregular masses, as in the lungs, of flattened patches, as upon the serous membranes, or of sheaths to the blood-vessels, as about the veins of the pia mater. (Louis.) It undergoes the same changes as the isolated tubercles, from the gray and semi-transparent, through the yellow, opaque, and soft, to the semi-liquid pus-like matter.

When thus mature, the tubercle excites inflammation and consequent ulceration in the surrounding tissue, by which, in many instances, a passage is made for the escape of its contents. The walls of the resulting cavity, which are sometimes lined by a sort of cyst, sometimes consist only of the consolidated surrounding tissue, secrete pus, which continues to be discharged for a long time, often mixed with the curdy matter. In many instances, however, a healing process at length takes place, the cavity is filled, and a cicatrix only remains. This is especially the case in scrofulous affections of the lymphatic glands. Sometimes, there is reason to believe that it takes place also in the lungs, though in the latter, the process of deposition and destruction generally goes on more rapidly than that of reparation, and the result is fatal. Sometimes, instead of the series of changes above described, the tubercle undergoes another process, by which the organic matter is absorbed, and an earthy or chalk-like substance is deposited in its place. This may always be regarded as a favourable termination.

The time occupied in these transformations is very uncertain. Sometimes the tubercle remains long quiescent in its original form; and, when the change begins, it may be completed in a few weeks, or may continue in progress for years. Not unfrequently, the disturbance produced by the tubercles in the tissue in which they are deposited proves fatal before they have passed even their first stage. This is more apt to happen when they are deposited in vast numbers, as sometimes in the lungs and the serous membranes.

Tubercles may be formed in almost any portion of the body, and often exist in many parts at the same time. They are most frequent in the lungs, and, indeed, in adults, are seldom found in other parts, without existing also in greater or less number in that structure. This, however, is not a universal rule. In children, they are often found elsewhere, though wanting in the lungs. After the lungs, the parts most frequently affected are, according to Louis, first, the lymphatic glands; then the pleura, the intestines, the spleen, the liver, the peritoneum, the membranes of the brain, the brain itself, and

« PreviousContinue »