LECTURE XII. ON INFLAMMATION AND ASTHENIC DISEASES
The last lecture was taken up chiefly with an account of sthenic diseases, or those depending on too great a degree of excitement, and which have been generally, but improperly, called inflammatory or phlogistic. In that lecture I attempted to show, that when the natural exciting powers, which support life, act with too much power, or particularly if we employ any stimulants not natural to the body, the functions both of body and mind become increased in vigour; but if the exciting causes are continued and increased, the functions become disturbed, and their action becomes painful and distressing. This state, which is called sthenic diathesis, is often accompanied by a redness, swelling, pain, and increased heat of some particular part: these symptoms constitute what is usually termed an inflammation of the part.
The method of cure in sthenic diseases was shown to be, by reducing or moderating the action of the exciting powers; by keeping the body cool; abstaining from high seasoned, and, in general, from animal food; by the use of purgatives, and in many cases by diminishing the quantity of blood in the body. I mentioned likewise, that it would be but of little use to attempt to subdue the excitement of the inflamed part, unless the excitement of the whole system was previously diminished; but that after a general bloodletting, stimulant remedies applied to the inflamed part, might be employed with success. This is strictly agreeable to experience, but at first sight seems so very contrary to the principles that have been advanced, that I shall endeavour to explain the phenomena of inflammation, which do not seem to be in general well understood.
All kinds of inflammation agree, in being attended with redness, increased temperature, pain, and swelling; but they vary according to the situation and texture of the part affected. All parts of the body, excepting the cuticle, nails, hardest part of the teeth, and hair, are subject to inflammation.
Among the causes of these complaints, may be enumerated too full a diet, particularly too free a use of fermented liquors, and whatever increases the impetus of the blood towards the part, as mechanical and chemical irritation, and sudden changes of temperature, particularly from cold to heat.
To explain the nature of inflammation, it may be observed, that such is the wise constitution of the animal body, that whatever injures it, excites motions calculated to correct or expel the offending cause. Thus if an irritating substance is received into the stomach, it excites vomiting; if into the lungs, a violent fit of coughing is excited, and if into the nostrils, sneezing is the consequence. In such cases we can readily trace the motions excited, and the manner in which they act; but cannot trace the manner in which the offending cause excites these motions.
Now if it can be shown that inflammation, like vomiting and coughing, is an effort of the system to remove an offending cause, and if we can trace every step of this operation, with the exception of the changes induced on the nervous system, we shall understand the nature of inflammation as completely as that of any function of the body.
The circumstance the most difficult to explain, is the increased redness of the part affected, which can only depend on an increased quantity of blood in the vessels. This has been supposed to depend upon an increased action of the vessels of the part; but that this is not the case, must be evident from what was said when we were speaking of the circulation of the blood. It was shown, that the circulation could not be carried on by the mere force of elasticity alone; this force, were it perfect, would produce no effect; but as there is no body with which we are acquainted that is perfectly elastic; so the coats of the arteries are very far from being so, hence their effect as elastic tubes will be to diminish the force of the heart, instead of adding to it; for a certain quantity of this force will be spent in distending the vessels, which, were they perfectly elastic, would be restored to them, but as this is not the case, this force is by no means restored. Indeed a variety of considerations, observations, and experiments, tend to prove, that the vessels are endowed with a power very different from elasticity, which differs only in degree from that of the heart; in short, they are possessed of muscular power.
After each contraction of the muscular coat, the elastic will act as its antagonist, and enlarge the diameter, till the vessel arrive at a mean degree of dilatation, but after this there is no further power of distention inherent in the vessel. The action of the elastic coat ceases; and no one will assert that a muscular fibre has power to distend itself.
The only power by which the vessel can be further distended, is the vis a tergo: after the vessel arrives at its mean degree of dilatation, both the elastic and muscular coats act as antagonists to the vis a tergo, or force which propels the blood into, and thus tends further to dilate the vessel. If then the vis a tergo become greater than in health, the powers of resistance inherent in the vessels remaining the same; or if the latter be weakened, the vis a tergo, or propelling force, remaining the same, the vessel must suffer a morbid degree of dilatation. These appear to be the only circumstances under which a vessel can suffer such dilatation.
But if, while the powers of the vessels remain the same, the vis a tergo, or propelling force, be diminished, or the propelling force remaining the same, the power of the vessels become increased; then an opposite condition or state of the vessels, viz. a preternatural diminution of their area, will take place.
In the one case the distending force bears too great a proportion to the resisting force; and preternatural distention is the consequence. In the other the resisting force bears too great a proportion to the distending force, and preternatural contraction is the consequence.
It is not necessary that the vessels should be in a state of greater debility than in health, in order that an inflammation or distention may take place: it is only necessary that the proportion which their action bears to the propelling force be less than in health. If the propelling force remain the same, the vessels must be in a state of debility before an inflammation can take place; but if the propelling force be increased by a fullness of the vessels and sthenic diathesis, inflammation may take place, although the vessels of the part act as powerfully as in health, or more so. But after inflammation has taken place, as the vessels are preternaturally distended, they must also be debilitated.
The degree of inflammation is not however proportioned to the debility of the minute vessels of an inflamed part, but to the diminished proportion of their power to the propelling force.
When, therefore, inflammation arises from an increased action of the arterial system, or an increased propelling force, while the force of the capillaries or minute vessels remains the same, it constitutes what is called an active inflammation, and is to be cured by general bleedings, and then by gentle applications of tonics to the part, to increase its action; but when it arises from a debility of the minute vessels, without any increase of the propelling force, it forms what is known by the name of passive inflammation; in which general bleeding is not required, but the application of stimulants and tonics to the inflamed part to enable the vessels to recover their lost tone, and restore the balance between their action and the vis a tergo. From what has been said, it must be evident, that if inflammation depend on the diminished proportion of the power of the capillaries to the propelling force, it will be more apt to supervene under the three following circumstances.
1. In a state of plethora, because then all the vessels are over distended, and consequently any cause tending further to distend them, whether it be a cause which debilitates them, or increases the propelling force, will be more felt than in health.
2. In a state of general debility, because the vital powers in any part are more readily destroyed than in health.
3. In a state of general excitement, because then the propelling force is every where strong, and consequently apt to occasion distention of the vessels, wherever any degree of debility occurs. These are the states of the system which are found to predispose to inflammation. In the first and last, the inflammation is generally of that kind, which is termed active: the propelling force is considerable, and the larger arteries are readily excited to increased action. In the second state the inflammation is of the passive kind.
This is not merely a useless physiological disquisition; it is of the greatest use in directing our practice; and teaches us that, in passive inflammation, which has all the symptoms of active, and therefore shows in a striking point of view the fallacy of symptoms, we shall not succeed by applying leeches, and other debilitating means, to the inflamed part; on the contrary, we shall aggravate the complaint; and the cure must be effected by stimulants applied to the part.
As an instance of this kind of inflammation, I may mention that kind of ophthalmia or inflammation of the eyes, which is of long standing, and which not only resists the powers of leeches and blisters, but is increased by them. I have frequently been consulted by patients, who had for months been under the debilitating plan, without any benefit; and who have been relieved almost instantly by the application of electricity and a stimulating lotion, which restored the tone of the debilitated vessels of the sclerotic coat, and enabled them to expel their overcharged contents; and the balance between their action and the propelling force being restored, the inflammation disappeared.
Indeed the effects of electricity in these kinds of inflammations are wonderful: it seems to act almost by a charm, so quickly does the inflammation subside; but when we understand the nature of this kind of inflammation, it is nothing but what we might expect from its action.
I have been thus minute on the subject of inflammation, because the theory of it, which I have attempted to defend, differs considerably from the commonly received opinions. I shall now proceed to consider the nature of asthenic diseases.
From what has been already said, it must be evident that the causes of diseases which we have assigned, are very different from those delivered by physicians who preceded Dr. Brown. Some physicians imagined that diseases were caused by a change in the qualities of the fluids, which became sometimes acid, and sometimes alkaline; or on a change of figure of the particles of the blood: some imagined diseases to be owing to a rational principle, which they called the vis medicatrix naturae, which governed the actions of the body, and excited fever or commotion in the system to remove any hurtful cause, or expel any morbid matter, which might have insinuated itself into the body. Others supposed many diseases to arise from a constriction of the extreme vessels by cold; or from a spasm of them, which was a contrivance of the vis medicatrix, to rouse the action of the heart and arteries to remove the debility induced.
We have seen, however, that health and diseases are the same state, and depending upon the same cause; viz. excitement, but differing in degree; and that the powers producing both are the same, sometimes acting with a proper degree of force: at other times either with too much, or too little.
We shall now examine how the diminished actions of the different exciting powers produce asthenic disease; and we shall take them in the same order as when we were speaking of sthenic diseases. It must be recollected however that an asthenic state, or a state of debility, may be produced in two ways. First, by directly diminishing the action of the exciting powers. Secondly, by exhausting the excitability, by a strong or long continued stimulant action. The former state is called direct debility, and the latter indirect debility. This is not merely a distinction without a difference, the body is in very different states, under these two different forms of disease. In the former case, the excitability is abundant, and highly susceptible of the action of stimulants. In the latter, it is exhausted, and the body has very little susceptibility.
Cold, or a diminution of heat, carried beyond a certain degree, is unfriendly to all animals. Dr. Beddoes has shown very clearly in his Hygeia, that it is the cause of a great many diseases which take place at boarding schools, and that it there gives origin to a great number of diseases that afterwards arise, and, indeed, not unfrequently ruins the constitution. It produces relaxation of the vessels, asthenic or passive inflammation, and even gangrene. He has shown that in most schools children are afflicted with chilblains from this cause; this is a case of passive inflammation, but is only a symptom of the general debility induced, which shows itself afterwards by the production of other symptoms. Hence it is necessary for the preservation of health, that the temperature of school rooms should always be kept equable, and regulated by means of a thermometer. It should not exceed 50 degrees, nor should it be allowed to fall much below it. If precautions of this kind are thought to be necessary, and practised with uncommon attention, in places where vegetables are reared, surely they ought not to be neglected in those seminaries where the human species are to be brought to maturity, and a good constitution established.
But though I have no doubt whatever, that this equable temperature would prevent a number of diseases, which originate in too low a temperature, yet I am far from wishing to have it thought that I would not induce a hardy state of the constitution, which would enable it to bear the vicissitudes to which it must be exposed in its journey through life, by every means in my power. Hardiness is the most enviable of all the attributes of animal nature, and can neither be acquired, nor recovered when it is lost, but upon certain terms, to which many people submit with reluctance, because they must give up many indulgences and gratifications with which it is utterly inconsistent.
One of the causes that chiefly contributes to reduce persons living in affluence below the standard of hardiness, is the dependence they place on a considerable degree of external warmth, for preserving a comfortable state of sensation. From what has been said again and again in some of the latest of these lectures, it must be evident that continued warmth renders the living system less capable of being excited to strong, healthy, and pleasant action: heat in excess, whether it may be excess of duration or intensity, constantly debilitates, by exhausting the excitability of the system, and thus producing a state of indirect debility. Every muscle steeped in a heated medium, whether of air or water, loses much of its contractibility. A heart kept in heated air, or put in hot water, will not contract on the application of a stimulus; even the limb of a frog, when heated in this manner, ceases to move on the application of the galvanic exciters. Every nerve grows languid, and when it does become excited, it acquires a disposition to throw the moving fibres, with which it is connected, into starts, twitchings, and other irregular convulsive motions. Though therefore nothing can more contribute to the health of the body than a moderate and well regulated temperature, about 48 or 50 degrees, sometimes for a short interval a little lower, when exercise is taken at the same time, yet when we consider the life led by persons of fashion, we should hope that it proceeded from ignorance of these consequences; so diametrically opposite is it to the dictates of nature and reason.
Instead of rising from table after dinner, and availing themselves of the cooling and refreshing qualities of the air, even in the finest seasons, when every thing which pure and simple nature can offer, invites them abroad, they do every thing they can, as Dr. Beddoes observes, to add to the overstimulating operation of a full and hearty dinner. After taking strong wine with their food, they sit in rooms rendered progressively warmer, all the afternoon, by the presence of company, by the increase of fires, and for more than half the year, by the early closing of the shutters, and letting down of the window curtains. After a short interval, tea and coffee succeed; liquors stimulating both by their inherent qualities, and by virtue of the temperature at which they are often drank. And that nothing may be wanting to their pernicious effect, they are frequently taken in the very stew and squeeze of a fashionable mob. The season of sleep succeeds, and to crown the adventures of the evening, the bed room is fastened close, and made stifling by a fire: and though the robust may not quickly feel the effects of this mode of life, with the feeble it is quite otherwise. These, as they usually manage, rarely pass a few hours of sleep without feverishness and uneasy dreams; both of which contribute to their finding themselves by far more spent and spiritless in the morning, than after their evening fit of forced excitement, instead of having their spirits and strength recruited by the "chief nourisher in life's feast," Perhaps they drink tea before rising, and indulge in a morning nap; this weakens much more than the greatest muscular exertion they would be capable of supporting for an equal time. For the sleep at this time is almost invariably disturbed, and attended by a heat of the skin. The reason of this must be evident to every one who has attended these lectures.
The effect of sleep is to accumulate the excitability, or render it more sensible to the effects of any stimulants applied. This takes place in every constitution, and much more in the more delicate: hence the heat of the bed, and of the tea, acts so powerfully on the surface, as, in general, to produce great perspiration, or, at any rate, great languor and debility.
Let me ask, can any one, who lives in this manner, expect to enjoy good health? With as great probability might we expect, that when we plunged a thermometer into hot water, the mercury would not rise, or when we applied a lighted match to gunpowder, it would not explode. The laws of nature are constant and uniform, and the same, or similar causes, both in the animate and inanimate world, are always productive of the same, or similar effects.
The cure of these complaints is at least obvious, if not easy. It consists in deserting crowded and heated rooms, at least for part of the time they have been usually occupied; in abstaining from strong wines; in keeping the bed rooms moderately cool; and retiring to rest at a proper hour.
With respect to the effects of nutriment, in producing asthenic diseases, we may observe, that all watery vegetable food, too sparing a use of animal food, as also meat which is too salt, and deprived of its nutritious juices by keeping, when more nutritious matter is at the same time withheld, constantly weaken, and thereby tend to produce asthenic diseases. Hence would appear to arise that remarkable imbecility of body and mind which distinguishes the Gentoos. Hence arise the diseases with which the poor are every where afflicted; hence scrofula, epilepsy, and the whole band of asthenic diseases.
But intemperance in eating and drinking, or taking nutritious and highly stimulant substances too freely, will, infallibly, bring on asthenic disease, or a state of indirect debility, by exhausting the excitability; and it must be observed, that this species of debility is much worse to cure than the direct kind; for in the latter we have abundance of excitability, and a variety of stimuli, by which we can exhaust it to the proper degree, and thus bring about the healthy state; whereas, in indirect debility, the vital principle or excitability is deficient; and we have not the means of reproducing it, at pleasure, absolutely under our command. Besides, the subtraction of stimulants, which is one of the most certain means we have of accumulating excitability, if carried to a great extent, in diseases of indirect debility, would produce death, before the system had power to reproduce the lost or exhausted excitability. Hence the cure, in these two kinds of debility, must be very different: in cases of direct debility, as in epilepsy, we must begin with gentle stimulants, and increase them with the greatest caution, till the healthy state is established: we must, however, guard most carefully against over doing it; for, if we should once overstep the bounds of excitement, and convert the direct into indirect debility, we shall have a disease to combat, in which we have both a want of excitement and of exciting power.
In cases of violent indirect debility, as, for instance, in gout, when it affects the stomach: it would be wrong to withdraw the stimulus, for the excitability is in such an exhausted state as to produce no action, or very imperfect and diseased, from the effect of the common exciting powers; we must, therefore, here apply a stimulus greater than natural, to bring on a vigorous and healthy action, and this stimulus we should gradually diminish, in order to allow the excitability to accumulate, by which the healthy state will be gradually restored.
This method was very judiciously recommended, by a very eminent physician, in the case of a Highland chieftain, who had brought on dreadful symptoms of indigestion by the use of whisky, of which he drank a large silver cup full five or six times in the day. The doctor did not merely say, diminish the quantity of spirits gradually, for that simple advice would not have been followed; but he advised him to drink the cup the same number of times full, but each morning to melt into it as much wax as would receive the impression of the family seal. This direction, which had something magical in it in the mind of the chieftain, was punctually obeyed. In a few months the cup was filled with wax, and would hold no more spirits; but it had thus been gradually diminished, and the patient was cured.
This reminds me of a number of cases, which had been brought on by drinking porter, and other stimulant liquors, without knowing the taste of water. In many of these cases if a moderate quantity of water were drank every day they would be cured; but you would find few who would follow such plain and simple directions. How then must a physician proceed? Why, as is generally done by the most judicious: they direct their patients to Bath or Buxton, and there advise them to swallow a certain quantity of water every day, which they do most scrupulously, and, of course, return home cured.
As causes of asthenic disease, we must not omit the undue exercise of the intellectual functions. Thinking is a powerful exciting cause, and produces effects similar to those of intoxication. None of the exciting powers have more influence upon our activity, than the exercise of the intellectual powers, as well as passion and emotion. Homer, the great observer and copyist of nature, observes of the hero, whom he gives for a pattern of eloquence, that, upon his first address, before he had got into his train of thought, he was awkward in every motion, and in his whole attitude; he looked down upon the ground, and his hands hung straight along his sides, as if they had lost the power of motion; and his whole appearance was a picture of torpidity. But when he had once fairly entered upon his subject, his eyes were all on fire, his limbs all motion, grace, and energy.
Hence, as the exercise of the intellectual functions evidently stimulates, an excess of thinking must bring on indirect debility, by exhausting the excitability. But though we do meet with instances of indirect debility arising from this source, it must be confessed that they much oftener arise from the use of very different stimulants.
As excessive exercise of the intellectual powers will bring on indirect debility, so the deficient, weak, or vacant state of mind, which is unable to carry on a train of thinking, will produce direct debility. Indeed this debility often occurs to those whose minds have been all their life actively engaged in business, but who have at last retired to enjoy themselves, without having a cultivated mind fit for retirement. They become languid, inert, and low spirited, for want of the stimulus of mental exertion; and in many cases cannot be completely restored to health, till they are again engaged in their usual occupations.
Violent passions of the mind, such as great anger, keen grief, or immoderate joy, often go to such an extent as to exhaust the excitability, and bring on diseases of indirect debility. Hence both epilepsy and apoplexy have been the consequences of violent passion.
On the contrary, when there is a deficiency of exciting passion, as in melancholy, fear, despair, &c. which are only lower degrees or diminutions of joy, assurance, and hope, in the same way that cold is a diminution of heat, this produces a state of direct debility. The immediate consequences observable are, loss of appetite, loathing of food, sickness of the stomach, vomiting, pain of the stomach, colic, and even low fevers.
The effect of impure air, or air containing too small a proportion of oxygen, is likewise a very powerful cause of debility.
In short, when any or several of these causes, which have been mentioned, act upon the body, asthenic diseases are the consequence.
Asthenic diseases, as has frequently been hinted, may be divided into two classes, those of direct debility, and those of indirect debility.
Among the diseases of direct debility may be enumerated dyspepsia, hypochondriasis, hysteric complaints, epilepsy, bleeding of the nose, spitting and other effusions of blood, cholera morbus, chorea, rickets, scrofula, scurvy, diabetes, dropsy, worms, diarrhoea, asthma, cramp, intermittent fevers.
Among those of indirect debility, or which are produced by over stimulating, which exhausts the excitability, may be enumerated, gout, apoplexy, palsy, jaundice, and chronic inflammation of the liver, violent indigestion, confluent small pox, typhous fever, and probably the plague, dysentery, putrid sore throat, tetanus.
Diseases, therefore, according to this system, may be divided into two classes. First, general diseases, which commence with an affection of the whole system, and which must be accounted general, though some part may be more affected than the rest. Secondly, local diseases, which originate in a part, and which are to be regarded as local, though they may sometimes in their progress affect the whole system, like universal diseases: still however they are to be cured by remedies, applied not to the whole system, but to the part affected only.
A pleurisy or peripneumony, for instance, is a general disease, though the chief seat of the symptoms seems confined to a portion of the thorax: but the affection of this part, though it may be somewhat greater than that of any other equal part, is vastly less than the affection or diathesis diffused over the whole body. The exciting or hurtful causes which produce these diseases, by no means exert their whole power upon a small portion of the superficial vessels of the lungs, and leave the rest untouched; on the contrary, they affect exery part of the system, and the whole body partakes of the morbid change. Indeed the general or universal affection; viz. a sense of heaviness and fullness, uneasy sleep, and other symptoms of increased excitement, are commonly perceived some time before the pain of the thorax becomes sensible. The remedies which remove the disease; viz. venesection, abstaining from animal food, and every mode of debilitating, do not exert their whole efficacy on an inflamed portion of the lungs; for by removing the affection of the lungs we should go but a little way towards removing the disease.
Among local diseases we may enumerate wounds, or solutions of the continuity of the part, bruises, fractures, inflammations from local irritation, &c. Hence it is evident that the treatment of general diseases is the province of the physician; and of local ones of the surgeon. But there are some general diseases which are apt to degenerate into local, and therefore require the attention both of the physician and the surgeon. Among these we may reckon suppuration and gangrene, sphacelus, and some others.
The first class, or general diseases, may be divided into two orders; sthenic, and asthenic. The asthenic order may be subdivided into two genera; viz. diseases of direct debility, and diseases of indirect debility; for debility, according to the system I am explaining, is that relaxed or atonic state of the system which accompanies a deficient action of the stimulant or exciting powers; and this deficient action may arise immediately from the partial or too sparing application of the exciting powers; the excitability or capacity of the system to receive their actions, being unaffected or sufficiently abundant; or it may arise from the excitability being exhausted, by the violent or long continued action of the exciting powers.
This arrangement of diseases, which naturally follows from the fundamental principles of the doctrine, and which is guided by the state and degree of excitement, is widely different from that of former nosologists, who have arranged or classed them according to symptoms, which have already been shown to be fallacious; and which method of arrangement brings together diseases the most opposite in their nature, and separates those most nearly allied. This is evident in every part of the nosology of Sauvages and Cullen. In the genus cynanche of the latter, are placed the common sthenic or inflammatory sore throat, or cynanche tonsillaris, and the putrid or gangrenous sore throat, the cynanche maligna: the former is a sthenic disease; the latter one of the greatest debility; yet they have the same generic name.