No. 2792.

MARCH 3, 1877.

Clinical LecturesON

CASES ILLUSTRATIVE OF THE

CURABILITY OF ATTACKS OF TUBERCULARPERITONITIS AND ACUTE PHTHISIS

(GALLOPING CONSUMPTION).BY DR. McCALL ANDERSON,

PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF GLASGOW.

I.-TUBERCULAR PERITONITIS.

GENTLEMEN,-From a therapeutical point of view, WEmay divide diseases into three classes: (1) those whichwill terminate in recovery without any treatment at all ;(2) ihose which, do what we will, are certain to terminatein death, and in the treatment of which we must conteniourselves with palliative measures for the temporary relieiof urgent and distressing symptoms ; and (3) those whichoan be cured by a carefully regulated course of treatment.The old system of treatment, with its bleedings and

purgings and mercurialisations, and which probably is toeuniversally tabooed at the present day, was a dangerousweapon ; for although it saved some patients, it undoubtedlydid harm, if it did not actually prove fatal, to others whcmight have recovered without it; and in any case it was avery unpleasant experience for the poor sufferers themselves,Hence the origin and spread of homoeopathy, with its prettylittle globules, which the merest tyro can dispense, which’has the advantage of doing no harm in those innumerable- cases which come under the first group, and which is littleworse than the old system as regards the second, althoughit is utterly helpless as regards the third.At the present day it is too much the fashion to decry

the virtues of medicine; and it was with much surprisethat I lately read the opening lecture of a distinguishedsurgeon, in which he stated that his students were to cometo him not so much for the purpose of learning treatmentas for the purpose of learning how to make a correctdiagnosis; forgetful of the words of Broussais, who said:"The real physician is the one who cures ; the observationwhich does not teach the art of healing is not that of aphysician, it is that of a naturalist." Now I shall feel thatI did not discharge the duty which I owe to you if I failedto bring prominently before you what I conceive to be themost correct principles of treatment, and if I made mywards mere schools for instruction in the diagnosis of dis-ease. In pursuance of this object, I desire to bring underyour notice illustrations of two diseases which are verygenerally regarded as almost incurable, but which some-times respond to treatment in a most satisfactory manner.The first case that I have to bring before you is that of

the little girl, Helen G-, who is ten years of age, andwho was admitted into bed 2 of ward 5 on Sept. 6th, 1875,tomplaiuing of swelling of the abdomen of three months’duration. Her family history presents no peculiarity, ex-cept that a brother died when young of "decline of thetowels." Her present illness began about three monthsprior to admission, with occasional pains in the epigastrium,to which by and by was added swelling of the abdomen ;her appetite nevertheless continued fair, and her bowelsregular. After the swelling had continued for about amonth, a medical man was consulted, who ordered her re-moval to the country, where she remained about four weeks,her condition improving and the swelling fast disappearingunder the use of "juniper drops." A month before her ad.mission, however, the swelling reappeared; but her motherthinks that, to some extent, it has " been kept under" bythe use of cream of tartar. She has never had much cough,but her urine has frequently thrown down a reddish-yellowprecipitate, and has been lately rather deficient in quantity.On examination, we found that there was only slight fever,

the temperature being usually from 99° to 100°, but therewas decided perversion of the pulse-respiration ratio, thepnise being 104° (of fair strength) and the respiration 36

per minute. She was not much emaciated; her tongue wasslightly furred, her appetite fair, her bowels inclined to beloose, and she complained a great deal of pain and tender-ness of the abdomen. There was distinct evidence of fluidin the peritoneal cavity, and that in considerable quantity,as, when she liy upon her back, the lateral dulness on per-

’ cussion extended as far forwards as a line drawn down fromeach nipple, while below it began at the junction of themiddle with the lower third of the abdomen. The circum-ference at the umbilicus was twenty-six inches.Now what has been the cause of the ascite..? P Manifestly

not disease of the kidneys or heart, for both these organsare healthy; nor disease of the lungs, for although, as weshall see presently, these are not healthy, the condition isnot such as to be likely to produce dropsy, and becausedropsy dependent upon disease of any of these organscommences in the subcutaneous cellular tissue, and onlysecondarily involves the serous cavities. The accumulationof fluid must therefore be due to an abdominal cause, andthen, generally, it arises in consequence of obstruction tothe portal circulation. But in this case there is no evidencewhatever of disease of the liver or of other abdominal sourceof portal obstruction ; and thus, by a process of exclusion,we arrive at the opinion that it probably results from in-flammation of the peritoneum. Further, we are justified insuspecting that the inflammation is of a tubercular nature(although, in the majority of cases, this condition gives riseto adhesive inflammation with matting together of the ab-dominal contents, and not to fluid effusion), and for thesereasons : -lat. The patient’s brother died of "declipe ofthe bowels." 2nd. She is only ten years of age-a time oflife when tubercle of the peritoneum is common. 3rd. Shehad a slight dry cough; there was dulness on percussion atthe left apex, and in the same situation there was "wavy"respiration with an occasional snoring rale—that is to say,she had tubercular disease of the lung (using the term"tubercular" in its widest sense).Our diagnosis, then, was " tubercular peritonitis with

effusion." Our treatment, as you saw, consisted at first ina careful regulation of the diet and of the bowels; to thiswas added, on Sept 15th, Savory and Moore’s pancreaticemulsion, in doses of from half a drachm to two drachms,in milk, an hour after the two principal meals; and onSept. 21st half a drachm of syrup of iodide of iron threetimes a day, before food. On Oct. l9th it was noted thather general state was tolerably satisfactory, but althoughthe local symptoms had not become aggravated, it could notbe said that there was any decided amendment, and theabdomen still measured twenty-six inches. Accordingly, tothe previous treatment was superadded cod-liver oil in dosesof a drachm, gradually increased to half an ounce, threetimes a day. Fifreen days thereafter (on Nov. 4th) theabdomen measured twenty-four inches, and on the 16thtwenty-three inches, by which time all pain had dis-appeared, and not a trace of fluid could be discovered inthe peritoneal cavity, even when the patient rested uponher elbows and knees, an attitude in which a very triflingquantity of fluid can be òetct>-1d. Towards the end of themonth she was dismissed well, although there was stillslight dulness at the apex of the left lung, and she waswarned to persevere steadily with the treatment which hasjust been indicated.

If we were to be guided by the opinion of the professiongenerally, and even by the writings of our best authorities,we should have to take a very gloomy view of such cases.Thus, Sir Thos. Watson says : " These are very unpromisingforms of disease, and it is seldom that we can do more thanmitigate the most distressing of the symptoms, or retard,perhaps, the march of the disorder." And, again: "Dowhat we may, in nine cass out of ten our best-directedefforts will be disappointed 1 I am far from denying thatin a certain propord’m of them the disease will terminate indeath,do what we will; but I would have you enter upon theirtreatment with a hope that your en’orts may be crowned withsuccess, especially where the inflammation is accompaniedby fluid effusion. The case which I have just narrated is byno means a solitary one in my experience. I am at presentseeing a lad, twelve years of age, who is just convalescentfrom a most violent at’ack of tubercular peritonitis, of

1 The Principles and Practice of Physic, by Sir Thomas Watson, Bart..M.D. Fifth edition. Vol. ii., p. 438. London: Longmans, Green, and Co.

1871.

304

which I may perhaps give you full details on some otheroccasion. Suffice it to say, in the mean time, that he is amember of one of the most scrofulous families I have everencountered. His father is dying of scrofulous disease ofthe glands of the neck; his mother had pleurisy last year,and now is phthisical; two of his brothers are at presentabroad on account of phthisis; and a brother died oftubercular disease of the bowels. His illness commencedon the 1st January with fever and pain in the hypogastricregion; was accompanied by high temperature, great ema-ciation, diarrhoea, occasional vomiting, but without serouseffusion into the peritoneal cavity; and during the progressof the attack, which lasted about five weeks in all, a largeabscess formed in the neck, and discharged about a cupfulof pus. He was assiduously nursed, and fed and stimulated;had iced clothes applied to the abdomen for half an hourevery second hour-a method of treatment of which I shallhave more to say in my lecture on the treatment of gallop-ing consumption; and opium was administered in full doses(a quarter to a half grain every four hours), with a grain ofquinine in each dose. His case appeared, as the diseaseadvanced, an almost hopeless one; and yet he is nowsitting up in his arm-chair cheerful and well, althoughof course still weak and thin. And I call to recollectionthe case of a little girl who was treated by me in the RoyalInfirmary a couple of years ago. Her symptoms were verysimilar to thos3 of the first patient, including the presenceof fluid in the peritoneal cavity and consolidation of oneapex. She was treated with cod-liver oil and syrup of theiodide of iron, and she was tapped twice, a large quantityof fluid being removed on each occasion, which a micro-scopical examination showed to be inflammatory exudation.This girl made a perfect, recovery.But some may say, I do not believe that tuberculous

peritonitis can be recovered from, and in these cases theremust have been an error of diagnosis. In answer to this itis sufficient to refer to a case reported by Spencer Wells inhis work on Diseases of the Ovaries.2 This was the case ofa young lady, aged twenty-two, who had an enlargement ofthe abdomen which it was supposed might be due to " athin non-adherent unilocular ovarian cyst." Accordinglya small incision was made below the umbilicus and the

peritoneum opened. "A large quantity of opalescent fluidescaped, and then the whole of the peritoneum was seen tobe studded with myriads of tubercles. Some coils of smallintestine were floating, but the great mass was bound downwith the colon and omentum, all nodulated by tubercle,towards the back and upper part of the abdomen. Theuterus and ovaries were felt to be of the normal size, buttheir peritoneal coat was very rough." This patient madea good recovery, and has since married, and her case notonly illustrates the fact that tubercular peritonitis may berecovered from, but also, as in my last case, that the re-moval of the effused fluid may contribute to that result.

THE BIOLOGIST AND THE PHYSICIAN.Being an Abstract of the Annual Oration before the

Hunterian Society for 1877.

BY W. MOXON, M.D., F.R.C.P.,PHYSICIAN TO, AND LECTURER ON MATERIA MEDICA AND THERAPEUTICS

AT, GUY’S HOSPITAL.

AFTER briefly alluding to the object of the oration-thecommemoration of the life and character of John Hunter,-the orator discussed at some length the opinion of Mill andsome other logicians that it is almost if not quite impossibleto complete the knowledge of living nature and of humannature by the inductive methods which Bacon announcedand urged, which Hunter at length pursued, and whicbthe medical profession is now following; and showed thatHunter had made real what logicians have declared impos.sible.

Dr. Moxon continued : - Mill proves, in cold formality,that by experiment and observation you cannot discern thE

2 J. & A. Churchill, London, 1872, p. 135.

laws of living nature. Hunter, warm with ardour in his

noble pursuit, discovered law after law of living nature, andwas one of the first to make possible that knowledge ofliving nature which is a very worthy pride of our veryproud generation. Hunter showed a most fertile imagina.tion. Did a fact come before him, forthwith arose vividsuggestions, which he pursued ardently. Hunter’s mindwas fruitful of hypotheses and analogies: they came freely,and his great excellence lay in the truthfulness and industrywith which he verified or directed them. He directly repu.diated the looking for principles by studying facts. Withhim facts were to establish principles-principles whoserise constituted the power and life of his mind. He wasnot the biologist who, even if he found it among facts,would accept an apes-universe. A universe without a lead.ing principle like to the power and life of his mind was athing he refused to recognise. Whatever we may say 0/the crudity of his belief in a vital principle, if you studyhis works, you will, I believe, find that belief to have beenno mere accidental ingredient in a mind otherwise com-parable to that of the biologists who construct a universeout of fragmentary facts. If you take away from him his faithin a vital principle, you undo him. That belief animateeand is the soul and faith of him-no mere chance ingre.dient. Without it his genius is reduced to mere inslinct.He would be the first to rise against such a rendering ofthe source of his power. His was the true poet’s imagina.tion-fertile not in freaks of morbid fancy couched inverses full of "fume" and "spume" on some revoltingtheme of lust, or rage, or despair, like some fashionablepoets of a modern school. He was greater even than tbtrue noet whose works mirror nature truthfnllv. TTP, was a

poet whose rich imagination thrilled to accompany thsecret harmonies of nature’s design. Such men makealmost tangible that great poetic power whom, seeing inhis works, we ignorantly worship. Like a true poet, herose from truth to truth by keenly seeing analogies betweenknown and unknown; yet, like a man of sense and science,he held always to an answerable question, and in its solutionshowed grandly that intellect which Carlyle says " sees theessential point and leaves all the rest as surplusage."Hunter did not see Nature in a servile spirit. He went to

her to practise his active intelligence, not to bring factslike a cart-horse brings dust, nor to heap his memory withscientific details until it became the areana of science.Loving nature as he did, hear how he speaks of facts. Ho

says: "In Europe philosophers reason from principles, andthus account for facts before they arise. Too much attention cannot be paid to facts, yet too many facts crowd thememory without advantage, any further than they lead usto establish principles." Really, I wish modern authoritiesin medical education would see that as clearly; but more ofthat presently.Here is no mere matter-of-fact individual on a larger

, scale than usual; no heaper-up of a bigger dust-heap thanother people’s. True, no one ever brought together so manyfacts. Everyone should see the Hunterian collection, andremember Hunter’s busy life, that he may think shame ofsuch a little as we allow our own lives to concentrate them-selves upon. But if he worked patiently at facts, it was notlike us young aspirants of the Pathological Society, whohand up our specimens of happy surprises in a glow ofwonder that such a thing should happen, and of pride tba;it should happen even unto us. Not so did Hunter colleenfacts. He always followed principles in his work; and

herein is the peculiarity of that wonderful Hunterian Col-1 lection, which fully entitles it to the charge of that separate3 commission under the Crown who have care of it.i Hunter’s mind was creative in the highest degree, and hisI energy of inquiry was of lifelong endurance. Ah! how the

1 little experimenters miss his genius who work in a spasm of

t acute inquiry of two hours and a half to twenty-four hours’t duration, to find a secret which Hunter would have given his

- lifetime to reach.Hunter did not sacrifice dogs to foolish inquiries, which

with all the pain and trouble could not thereby be answered.e And if we ask what gave him that most valuable power of- estimating what was worth doing, and what could be done,

the power which Bacon calls the 11 mathematics of th