DYSPEPTIC PHTHISIS.

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in compliance with the wishes of their friends than from any idea of their own, that they are in worse health than usual.

They experience pain in the epigastrium, and often also below the clavicles; the digestion is deranged, they have become a little thinner, and have less energy than is natural to them. These symptoms may shortly disappear, but return from time to time; the patient becomes more feeble, but in many cases so imperceptibly so, that it is only by comparing his amount of strength with what he possessed in the previous year that he can detect its decay. At last some symptom to which he has not been accustomed attracts notice; sometimes hæmoptysis calls attention to the lungs; in others slight, but obstinate diarrhoea gives rise to the suspicion of tubercular deposit on the mucous membrane of the intestines.

Even when the indications of phthisis are so evident that they cannot be mistaken by the medical practitioner, the patient often refers all his sufferings to the stomach. The pain at the epigastrium increases along with his weakness, vomiting occurs after all food, and flatulence and acidity are oftener complained of than cough or night sweats. I have known patients so affected refuse to admit that they are troubled with cough or expectoration, and to the last express their belief that, if the stomach were only relieved, they would be soon in good health.

The treatment of these cases is one of great difficulty in the earlier stages, inasmuch as whilst we have to combat the disorder of the stomach, we must also endeavour to arrest the impending formation of tubercle.

Mercury can seldom be borne, and, if it be necessary to give it, the mildest preparations should be employed.

All active purgatives should be avoided, as the strength of the patient is already lessened by the disease. The gastric irritation should be first allayed by means of bismuth, hydrocyanic acid, morphia, or nitrate of potass; the treatment being regulated by the condition of the digestive organs. These may be followed by alkaline infusion of sarsaparilla, or, if the stomach will bear them, by the mineral acids and cinchona.

Unfortunately, the patients can seldom digest codliver oil; but it should always be tried as soon as the state of the stomach will permit it. In the case of girls steel is invaluable; the mildest forms being those best fitted for exhibition.

From the observations above detailed we may, I think, hazard some conjectures, which, even if not altogether correct, may be useful in directing future inquiries into this important subject.

Observations seem to hint that the materials which at one time would not be absorbed, or, if taken up, would be eliminated, may at another period give rise to tubercle. Thus, a child may for a long time be affected with dyspepsia, and at last be suddenly carried off by tubercle of the brain; or an adult may suffer from indigestion and languor for months or years; and yet, without any change in these symptoms, phthisis may supervene. In either case dyspepsia has been present from the first, but some local action has been required to convert the illformed nutriment into tubercle.

CONCLUSIONS RESPECTING TUBERCLE.

207

It appears to me that the chief cause leading to the actual production of tubercle is an activity of growth in the tissues disproportioned to the amount of healthy nutriment presented to them. In the normal condition the power of the digestive organs is regulated by the requirements of the system; hence the keen appetite and the rapid absorption of the But if the growth of the body progresses young. more quickly than the digestion can supply a sufficient quantity of properly constituted material, then matter of an inferior organization will be taken up and employed in nutrition, and disease must be the result.

Youth is the period of life when growth is most rapid, when tubercle is most common, and when the symptoms of the premonitory dyspepsia are most distinctly marked.

Again, those amongst the young who have shown a sudden increase in growth are especially the victims of phthisis. In common language, they have "outgrown their strength;" according to a more scientific expression, the development of the system has been in excess of the nutriment digested and absorbed. After the cessation of fevers, nature attempts by increased activity to repair the loss of structure, and if the digestion at the same time recover its powers, it shows a corresponding vigour; but if digestion be seriously injured, the supply of normal material is insufficient for the demand, and phthisis is apt to supervene. On the same principle only can only can we explain the frequent occurrence of tubercle during pregnancy; for many of these cases previously exhibited no symptoms indicating any affection of the lungs. Another circumstance often giving rise to tubercle is the occurrence of an accident, or local inflammation,

in a person of a feeble habit of body. In a healthy constitution, properly organized material would supply the amount required for the rapid growth of cells, but in the case we have supposed, a sufficiency of this does not exist in the blood, and a development of tubercle results.

If this theory be correct, we ought not to find indigestion the only symptom preceding phthisis. The organization of new material is the result of a number of processes, of which digestion is only one, and we might therefore anticipate that imperfection in any of these would lead to the formation of tubercle. We have seen that languor and debility often precede the disease of the lung where there is no indigestion, and we may conclude that in such cases the disease has arisen from failure in the functions of some of the other organs that concur with the digestive tract in the elaboration of the materials required for the growth or renovation of the tissues.

I suspect that, under the head of tubercle, we comprise many substances of different chemical constitution. Thus, I found the lung of a camel, which had died of phthisis, hard and calcareous; but the calcification was not the result of the deposit of the inorganic salts of lime, for after being soaked for some months in alcohol, the organ became soft and pliable. Here was a case in which the tubercle was chiefly composed of lime united with some organic acid. On the other hand, the lung of a foreign pigeon was converted into a cheesy mass, which no one would hesitate to declare to be tubercle, but which, under the microscope, seemed to consist almost entirely of cholestrine. In this instance there seemed

IRRITANT NATURE OF TUBERCLE.

209

an absence of lime, and it would be therefore impossible to consider the morbid deposit as alike in both of these cases.

But whatever be the exact nature of tubercle, there is little doubt that it acts as an irritant to the tissues in which it is deposited. This is well shown in the mesentery of many of the lower animals which have died of phthisis. In these a number of minute spots may be often observed, near the edge of the intestine; and if the blood-vessels have been carefully injected, small arteries can be seen by the microscope to converge to each spot from different quarters. The vessels, as soon as they enter the diseased part, become much dilated, and form a close network within it. The elevations themselves are composed of cells intermixed with fat; but after the preparation has been kept for a short time, the cellular structure disappears, and oily and granular matters are alone to be perceived.

Tubercle agrees with the animal poisons we before examined, in its power of reproducing in the system a substance possessing properties similar to its own.1 This appears to be demonstrated by the experiments of M. Villemain, who produced phthisis in rabbits by inoculating them with tubercle taken from the human subject.

The researches of M. Villemain also seem to prove that tubercle follows the law we before observed in regard to the poison of fevers, viz., that it is deposited in certain organs, along with the new growth it excites. The parts chiefly selected are the lungs and lymphatic glands.

1 See page

91.

2 See page 123.

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