Chapter I: Part 1

AN

Inaugural Dissertation

ON

PULMONARY CONSUMPTION.

BY EDWARD DELAFIELD, A. B.

----For want of timely care,
Millions have died of medicable wounds. ARMSTRONG.

_NEW-YORK_:

PRINTED BY JOHN FORBES & CO.
78 WALL-STREET.

1816.

TO

SAMUEL BORROWE, M. D.

ONE OF THE SURGEONS OF THE NEW-YORK HOSPITAL,

THIS DISSERTATION

IS DEDICATED,

AS A TESTIMONY OF GRATITUDE

FOR THE MANY VALUABLE PRACTICAL LESSONS

RECEIVED FROM HIM

BY HIS FRIEND AND PUPIL,

EDWARD DELAFIELD.

INTRODUCTION.

The attention of Physicians has for several years past been excited to the consideration of that inveterate enemy of the human race, the CONSUMPTION. Several works have been published, new remedies proposed, and the practice of former physicians revived with modifications and amendments, in the treatment of this disease. At one period, Consumption had been so long considered without the reach of remedies, that it had almost ceased to excite the enquiries of the learned in medicine. Fortunately, however, the spirit of enquiry has revived; and it is believed that the treatment of this dreadful malady has been so far improved, that many are rescued from its grasp, and the sufferings of those who are still its victims, are materially mitigated. Notwithstanding, it appears that in this city the mortality from Consumption has increased rapidly of late years. Formerly, its climate was considered remarkably salubrious, and diseases of the lungs were rare. Lieutenant Governor Colden, in a series of remarks on the climate and diseases of New-York, made seventy years ago, has the following observations: “The air of the country being almost always clear, and its spring strong, we have few consumptions or diseases of the lungs. People inclined to be consumptive in England, are often perfectly cured by our fine air; but if there be ulcers formed, they die. The climate grows every day better, as the country is cleared of the woods; and more healthy, as all the people that have lived long here testify. This has even been sensible to me, though I have lived but about twelve years in this country; I therefore doubt not but it will in time, become one of the most agreeable and healthy climates on the face of the earth.”[1]

These anticipations have not been realized; but, on the contrary, Consumption has become the prevailing disease of our city. The causes of this increase of the disease are numerous. We are told by Dr. Rush, that it is unknown among the Indians of North America; that it is scarcely known by those citizens of the United States who live in the first stage of civilized life, and are generally called the first settlers; that it is less common in country places than in cities, and increases in both, with intemperance and sedentary modes of life; that ship and house-carpenters, smiths, and all those artificers, whose business requires great exertion of strength in the open air, in all seasons of the year, are less subject to this disease than men who work under cover, and at occupations which do not require the constant action of their lungs. By applying these facts to the situation of this city, the causes which have produced the increased mortality from consumption, become evident.

1. The growth of the city, and consequent state of the atmosphere, most distant from that of the pure air of the country.

2. The increase of all those causes which have enervated the bodies of men, and rendered them more susceptible to the influence of a variable climate. Among these are, augmentation of wealth, and consequently, luxury; increased dissipation, with its accompaniment, imprudence in dress; and extension of manufactures, affording greater opportunity for sedentary employments, and exposure to an insalubrious atmosphere. In general, the causes are, all those circumstances which tend to remove man farthest from that situation, in which the body is possessed of the greatest vigour, and of course, least subject to disease, that of the savage. In proportion as the city has enlarged, these causes have continued to increase, and probably still will do so. But in Great Britain, they appear already to have attained their acme, and as a consequence of the improvements in medicine, the causes not increasing, the disease is on the decline.[2]

The following statement will show the proportion, which the number of those who die from consumption, bears to the whole number of deaths, in this city, during the last twelve years.

In 1804, 499 persons died from Consumption, and were to the whole number of deaths, 2125 as 1 to 4.25.

In 1805 462 2352 1 5.09
1806 354 2225 1 6.28
1807 464 2312 1 4.94
1808 429 2014 1 4.69
1809 413 2108 1 5.1
1810 569 2158 1 3.79
1811 595 2524 1 4.24
1812 669 2553 1 3.81
1813 562 2229 1 3.96
1814 618 2507 1 4.04
1815 572 1974 1 3.8

From this statement it appears, that the number of deaths from Consumption has gradually increased. The average proportion during the period mentioned, is as 1 to 4.36. Nearly one fourth of all those who die in this city are destroyed by this fatal disease.

These facts prove indeed that the power of medicine has little control over so destructive a malady. But it should not therefore paralyse our exertions. From what has been done already, in improving our knowledge of its nature and treatment, a hope may be indulged that consumption may one day, like many other maladies formerly deemed incurable, be placed no longer among that number.

INAUGURAL DISSERTATION

ON

PULMONARY CONSUMPTION.

The term Phthisis, or Consumption, in its broadest sense, is applied to all those diseases, in which the system sinks under a gradual waste of the powers of life. These diseases may be divided into two great classes--1. That form of Consumption in which the lungs are unaffected.--2. Phthisis Pulmonalis, properly so called, where the lungs are the seat of the disease.

Under the first class are included,

1. Atrophia, or Consumption from want of nourishment, or excessive evacuations, but without hectic fever; excluding all those forms of disease produced by immoderate evacuations, in which the lungs become affected.

2. Tabes, accompanied with hectic fever, frequently attended with disease of the mesenteric glands, and produced most commonly by scrophula.

The second class, Phthisis Pulmonalis, to the consideration of which this essay will be more immediately confined, may be also subdivided into,

1. Primary, where the lungs are the original seat of the disease, and as a consequence, the general system becomes affected.

2. Secondary, where the system being first reduced by any debilitating cause, the lungs become secondarily affected, as a symptom of the general disease.

These two forms of Consumption, although somewhat similar in their symptoms, yet proceed from opposite causes, and require opposite treatment. The one is a disease of pure inflammation; the other of unmixed debility. In the one, an active antiphlogistic treatment is necessary; in the other, the system requires all the support, which tonics and good nourishment can afford.

Phthisis Pulmonalis is thus defined by Dr. Cullen, “_Corporis emaciatio et debilitas, cum tussi, febre hectica, et expectoratione purulenta_.” This definition is peculiarly incorrect, because it leads us to neglect, the first stage of the disease; if the symptoms of an Incipient Phthisis were stated to us, and we were asked, what was the disease, from this definition we would be perfectly at a loss for an answer. Except the cough, none of the symptoms there stated are to be found in the first stage of Consumption. And yet that is as truly a part of it, and of as much importance to the practitioner, as the last stage, which alone is included in Cullen’s definition.[3]

Agreeably to this definition, in his view of Phthisis Pulmonalis, Dr. Cullen makes ulceration of the lungs and hectic fever essential to its existence, and seems rather to consider the preceding symptoms a cause of this ulceration and fever, than as constituting an integrant part of the disease.

Nor is the place assigned by him to Phthisis Pulmonalis, in his Nosological Arrangement, more correct than his definition of it. He places it in the order Hæmorrhagiæ, and considers it merely as a consequence of Hæmoptysis. Even if it were always excited by hæmorrhage from the lungs, it would be improperly thus placed; but as that, even by Dr. Cullen, is considered merely as one among many exciting causes, the arrangement is altogether inadmissible. But if it be admitted, according to the view which will be hereafter taken of Hæmoptysis in this treatise, that it is rather a symptom than a cause of Consumption, the propriety of another arrangement will be evident. Accordingly Phthisis Pulmonalis is placed by Dr. Hosack, as one of the Phlegmasiæ. This disposition appears to be the most proper that has hitherto been suggested, and as such I shall adopt it. But before we can ascertain the character and treatment of any diseases, it is necessary minutely to examine their causes and symptoms.

Primary Phthisis Pulmonalis first claims our attention. Its predisposing causes may be mostly arranged into five classes, as they depend on organization, age, sex, occupation and climate.

Organization predisposes to Consumption, by mal-conformation of the chest, which may be either natural or accidental; and an hereditary internal structure not depending on the external form of the thorax. For it is observed, that in some instances, those who have every part of the external configuration, such as is generally attributed to persons predisposed to Consumption, yet shall be free from this disease; while on the other hand, some whose chests are externally perfectly well formed, have been subject to catarrhal and inflammatory complaints of the lungs, terminating in Phthisis. The form of chest peculiar to many Phthisical patients, “is occasioned by the sternal or breast-bone being pressed too much in upon the substance of the lungs: thus the clavicles and shoulder-blades are thrust out of their proper position, and made to assume, in some measure, the form of wings, to which indeed they have been with propriety compared, just raised from the body and about to expand for flight. By this internal direction of the sternum, the full expansion and proper sweep of the ribs is likewise prevented, and an unnatural curvature or prominence is occasioned on either side of the breast, with a corresponding central depression.”[4] This is the peculiar form to which the term narrow chest is generally applied. A flattened or any other unnatural figure of the chest may produce the same injury.

The thorax may become accidentally malformed from any violence done to it, particularly during infancy. A frequent source of it is the mode of fashionable dress adopted by females. The corset, to which I allude, when worn only with moderate firmness, and by those not otherwise predisposed to Phthisis, serves but to add elegance and beauty to the female figure; but when applied with the object of converting into a delicate and slender waist, one naturally otherwise, it cannot but do injury. By immoderate pressure, it converts a well formed chest into the deformed and narrow one, or at least an approximation to it, which has just been described. In our own city and time, too many fatal examples of the deleterious effects of this fashion have occurred, to permit us to retain any doubts on the subject.

The internal constitution of the body predisposing to Phthisis, independent of external form, has been generally attributed to scrophula. English authors are particularly fond of making Consumption another form of that Protæan disease. We are much disinclined to concur in this opinion from the fact, that the mass of those who labour under the disease in question, and cases too, which, after death show that tuberculated state of the lungs, generally ascribed to scrophula, evince no other of the numerous symptoms of that disorder. The supposition that tubercles were scrophulous, probably originated from the opinion that they are diseased glands; an idea now sufficiently exploded. This hereditary predisposition we know to exist, but of its mode of action we are totally ignorant. In this city there are many melancholy examples of whole families successively falling victims to Consumption, and sufficiently proving its hereditary nature. But an hereditary predisposition does not necessarily produce Consumption. It is not uncommon for parents who inherit this taint, to remain free from disease of the lungs, by the pursuit of laborious occupations. Nor is it more uncommon that the children of these very parents, whose active industry had preserved their lives, and amassed them wealth, should by being enabled to indulge in ease and luxury, fall victims to an inherited Consumption.

So the females of a family are sometimes all consumptive, while the males are free from pulmonary disease, in consequence of the more sedentary mode of life of the former.

Although no period of life, from infancy to old age, is exempt from Consumption, but all are liable to its attack, yet at a particular age, it is observed to appear more frequently than at any other. This period commences about, or soon after the age of puberty, and terminates at thirty-six; the period at which inflammatory diseases most generally occur.

Sex also gives a predisposition to Consumption. Females are more frequently affected by it than males. This may be attributed to their greater delicacy of constitution, and nervous temperament. Their comparatively sedentary habits of life add to this peculiar constitution. But improper compliance with the requisitions of fashion and taste constitutes not a small part of the greater susceptibility of females to Phthisis. Independent of the use of corsets, the small quantity of clothing frequently worn by them, under circumstances when it is most necessary, is a fruitful source of mischief to their health. In the coldest of our winter nights, will these fair devotees of fashion issue from rooms, heated to a degree never experienced in our hottest weather, into the chilling air of midnight, with less clothing than they use at noon, when the sun exerts his greatest power. The next day brings with it “a violent cold,” and this cold is too frequently the foundation of the Consumption which destroys them.

Occupation in life is another source of the ravages of this disease. Particular occupations subject those engaged in them to the respiration of air impregnated with foreign materials, irritating the lungs, either by their chemical or mechanical action. Substances acting mechanically upon the lungs, are inhaled by stone-cutters, millers, hair-dressers, bolters, coal-heavers, scythe-grinders, persons engaged in pointing needles, chimney-sweepers, dressers of flax and feathers, spinners in wool, and others employed in similar occupations. Chemical agents are taken into the lungs by manufacturers of acids, and all other volatile corroding substances. These materials constantly acting upon the lungs, produce irritation and slight inflammation, terminating in Phthisis. The operation of any of these causes is favoured when the occupation requires a stooping or other awkward posture of the body to be maintained. This cause may act independently of the former also, and hence, students, and clerks writing at their desks, taylors, shoemakers, &c. are liable to this disease. To the same causes are frequently added, a sedentary life, and confinement in hot rooms; hence “a surgeon of London whose opportunities of observation are very extensive, relates of the gilders of that city, who work in heated rooms, that six out of seven are said to die consumptive in their apprenticeship.” Sedentary habits of life, accompanied with hard study, and too intense application of mind, predispose literary men to Consumption. Loud public speaking, blowing on wind instruments, glass blowing and other circumstances requiring a laborious and continued action of the lungs, produce the same effect. Any one of these causes may frequently exist without injury, but their combined action seldom fails to produce pulmonary disease.

Climate was enumerated under the predisposing causes of Phthisis. That of our own latitude affords an example. Its variableness, increased by contiguity to the ocean, together with the prevalence of the moist and chilling north-east winds, is probably the agent which produces this effect. The climate of Great Britain is not less unfavourable to health, from similar causes, with the addition of its greater moisture; for it is observed that cold combined with moisture is peculiarly dangerous to the consumptive. On the other hand, inland countries, not exposed to the moist winds from the ocean, are free from this disease. Hence, the inhabitants of Russia and other parts of the north of Europe, notwithstanding the severity of their climate, are very little affected by Consumption. The habits of the people, probably assist in producing this immunity from pulmonary disease. Sir John Sinclair, in a communication to Dr. Reid, attributes it in a great measure to the employment of furs, cloaks and other modes of clothing, which preserve an uniformity of warmth throughout the body; to the great care taken by all classes of people to preserve their feet from cold and damp; to the different modes of communicating heat to their apartments; and to the constant use of the vapour bath. Similar observations were made by Dr. Cogan, who in a letter to Dr. Beddoes, remarks that the people of Holland are exempt in a great degree from this disease, so prevalent among the English, and ascribes the difference to the contrast observable between the two countries, in the construction of their habitations, and in the peculiarities of dress.

Debility from the want of accustomed stimuli, is mentioned by Dr. Hosack as another cause of consumption, and he instances those confined in the State Prison. The want of accustomed air and exercise, the deprivation of the use of spirituous liquors and good diet, to which the prisoners had been accustomed before their confinement, was observed by him to have produced this disease.

Depressing passions of the mind, and a consequent too free use of spirituous liquors have also been noticed by authors among the predisposing causes of Consumption.

The last of these causes which I shall notice, is the disposition of the system to form calculous deposits in the lungs, generally in consequence of a plethoric habit. Phthisis from this cause however is rare; of nine hundred patients examined by Bayle, only four were of this description.

These various causes having either separately or conjointly predisposed the body to Phthisis, are most frequently excited into action by a common catarrh; which becomes the more active by frequent repetition. The danger arising from catarrh is not a little increased by the popular mode of treating it: stimulating spirituous drinks, and a vast variety of remedies of the same class are the usual prescriptions. Almost every body has an infallible remedy for a cold; some of them innocent, but many injurious. The common prejudice in favour of “feeding a cold” increases the mischief, and unfortunately, the disease not generally affecting the system sufficiently to destroy the appetite, as in many other maladies, nature does not prevent the practice. Abstinence, cooling acidulous drinks, with perhaps a gentle saline cathartic, are the safest and most effectual remedies in curing a common catarrh, when of its usual slight form. At the same time, inhaling warm air, by means of Mudge’s apparatus, is a valuable and grateful auxiliary to this treatment. Catarrh is so common and generally so easily cured without any consequent ill effects, that it is too apt to be neglected. Many a patient, labouring under incipient Phthisis, has been supposed to be affected by merely a “trifling cold,” and the only opportunity for curing the disease has been lost. “The evil becomes irremediable before it calls either the attention of the parents, the friends, or even the physician, who has not been familiarly conversant with the fatal consequences of this disease.”[5]

Pneumonia is not unfrequently an exciting cause of Phthisis. Like catarrh, its frequent repetition is more dangerous than a single attack. Pneumonia may indeed act merely as a predisposing cause of Consumption, by leaving the lungs in a debilitated and irritable condition, favourable to the production of that disease; but it is an exciting cause, when in consequence of inflammation of the lungs, suppuration follows, and vomica or empyema is the consequence. This shews the close analogy between Phthisis Pulmonalis and ordinary Pneumonia. In the first, the inflammation being seated in the cellular and comparatively insensible portion of the lungs, is slow and gradual, and the consequent suppuration forms in the same manner; while in Pneumonia, the membranous as well as cellular portion of the lungs being involved in the disease, the inflammation is rapid and violent, and must soon terminate in either resolution or suppuration. Hence Phthisis Pulmonalis was appropriately called by Dr. Rush a “_Pneumonicula_.” No word could more accurately describe the nature of the disease. That acute observer has drawn an excellent parallel between the two diseases, and concludes with observing, “In short the pneumony and Consumption are alike in so many particulars, that they appear to resemble shadows of the same substance. They differ only as the protracted shadow of the evening does from that of the noon-day sun.” It is remarked, however, that all cases of Pneumonia terminating in suppuration are not necessarily fatal. If a predisposition to Phthisis do not exist, or the constitution be not too much debilitated, a vomica may burst and be discharged, and the patient recover.

A third exciting cause of Phthisis, is the suppression of accustomed evacuations. These evacuations are the menses, the lochiae, the discharges in Leucorrhæa, and from ulcers, fistulæ and issues. Retention of the menses producing Chlorosis, being a consequence of debility, does not excite primary Phthisis Pulmonalis, but the secondary form of the disease. Suppression of the menses, however, not unfrequently excites a Consumption, bearing all the characters and requiring the treatment of primary Phthisis. The plethora, consequent on the cessation of the menses, has often the same effect.

Asthma, by the constant irritation to which it subjects the lungs, becomes an exciting cause of Consumption.

Several eruptive diseases, as Scarlatina, Small-Pox and measles, often produce the same disease.

Morton also enumerates stone in the kidneys and bladder, gout and rheumatism, as causes of Consumption.

By the same author, contagion is supposed to communicate this disease. Morgagni, Van Swieten, Home and Heberden all hold this opinion. And Morgagni relates that Valsalva, who was predisposed to Consumption, was so satisfied of its contagious nature, that he constantly avoided being present at the dissection of the lungs of persons who had died of that disorder.

Dr. Rush maintains the same doctrine, and relates that the late Dr. Beardsley of Connecticut, informed him that he had known several black slaves affected by a Consumption, which had previously swept away several of the white members of the family to which they belonged. In these slaves no suspicion was entertained of the most distant relationship to the persons from whom they had contracted the disease: nor had grief nor fatigue, been supposed to have had the least share in debilitating their bodies. The force of so much authority with the evidence adduced, constrains us to admit the communicability of Consumption by contagion. But if this agent has any effect, its action must be extremely limited, and extend no farther than to those previously predisposed to the disease. For daily examples without number occur of the constant attendants upon those labouring under Phthisis remaining perfectly free from that malady.

Violence done to the lungs by blows or other injuries of the chest, has in some instances, excited Consumption.[6]

Foreign bodies conveyed accidentally into the lungs has produced the same effect. Morton relates a curious case where three nails had passed into a person’s trachea and destroyed him, by inducing Consumption.

Bayle also enumerates a form of Phthisis, which he calls cancerous, arising in patients in whom the cancerous disposition has become constitutional. It is, however, extremely rare; only three cases having occurred to him among the 900 whom he had examined.

Hæmoptysis and tubercles are mentioned by most authors as exciting causes of Consumption, and remain to be examined. So frequently did Dr. Cullen consider Hæmoptysis the cause of Phthisis, that he placed the latter disease in his Nosology, merely as a consequence of the former. The impropriety of this arrangement has been already touched upon.

On this subject, I would suggest the following facts. Hæmoptysis occurring in persons not predisposed to Consumption, except the quantity of blood lost be so great as to produce it by mere debility, very frequently may be easily cured without danger of any consequent disease. Indeed not only in such cases consumption is not induced by it, but that disease has actually been prevented, by the occurrence of hæmorrhage from the lungs, relieving that inflammation, which the inert physician, by withholding the lancet, would have suffered to destroy his patient. Dr. Rush relates two cases of inflammatory Consumption attended by a hæmorrhage of a quart of blood from the lungs, in which the patient recovered; and ascribes their recovery entirely to the loss of blood. Wounds and other injuries of the lungs frequently heal, when no predisposition to Phthisis exists, as easily as in other parts of the body. Of this fact also Dr. Rush affords an example. A British officer informed him, a few days after the battle of Brandywine, in September 1777, that the surgeon general of the royal army had assured him, that out of twenty four soldiers admitted into the hospitals, during the campaign of 1776, with wounds of their lungs, twenty-three recovered. These facts prove sufficiently that the constant motion of the lungs does not prevent the healing process taking place in them as easily as in other parts of the body.

In most instances, the spitting of blood which is supposed to have produced the Consumption, has occurred a considerable period before the Phthisical symptoms appeared. During this interval perhaps the patient was perfectly well. Can it be supposed, that the inflammation necessary to form an ulcer, and the process of ulceration itself, could so long be going on unperceived, without producing any irritation of the lungs? Is it not more probable, that the Hæmoptysis was recovered from, and that the same cause which produced it, at length produced the Consumption?

Hæmoptysis, then, I would consider, as very seldom, perhaps, never, being the cause of Consumption; but in all those cases in which it is assigned as the cause, merely a symptom of the incipient stage of the disease. The symptoms accompanying hæmorrhage from the lungs, are no other than those of incipient Phthisis. They are thus accurately described by Dr. Reid. “When subsequent to a sense of weight and oppression in the breast, which scarcely amounts to a feeling of pain, together with cough, difficult respiration, and general lassitude, a quantity of blood is suddenly, and in a convulsive manner, discharged from the mouth, there can remain small doubt respecting the part from which it proceeds. If the discharged blood be of a florid colour, and together with the above symptoms, a saltish taste be perceived in the mouth, and the patient become sensible of a degree of irritation in the upper part of the trachea, the nature of the affection is rendered altogether unequivocal.” Every symptom here enumerated, occurs in the early periods of Consumption.

Nor have we any better reason for believing tubercles to be an exciting cause of Phthisis. These appearances are indeed very frequently found in dissections of the lungs of those who have died of Consumption. Of the nine hundred patients examined by Bayle, 624 had tuberculated lungs. Tubercles were formerly considered as indurated glands, and generally attributed to a scrophulous constitution; but we are assured by Baillie, in his morbid Anatomy, “that there is no glandular structure in the cellular connecting membrane of the lungs; and on the inside of the branches of the trachea, where there are follicles, tubercles have never been seen.” These tubercles are roundish bodies, of a firm consistence, and frequently a cartilaginous structure, but often containing decidedly purulent matter. By the union of several of them, vomicæ are formed, which are only larger tubercles. May not the formation of these bodies be sufficiently accounted for by the preceding inflammation, and they be considered therefore a consequence, rather than a cause of Consumption? Dr. Rush insists that tubercles are the effects, and not the cause of pulmonary Consumption; and remarks as a farther evidence of this opinion, that similar tumours are suddenly formed on the intestines by dysentery, and on the omentum by a yellow fever. He refers to cases of the former in the dissections of Sir John Pringle, and one of the latter mentioned by Dr. Mackittrick, in his inaugural dissertation on the yellow fever, published in Edinburgh, in the year 1776. Dr. Hosack, in his Lectures on the Theory and Practice of Physic, advocates the same doctrine, and enforces it, by remarking, that similar tubercles are formed in the parenchyma of the brain, the liver, and the kidneys, in which no small glands have yet been detected, and where, as in the lungs, there is nothing but cellular membrane and vessels. It is his opinion, that it is an union of a number of these cells in a state of congestion that constitutes tubercles or vomicæ--that in some instances they heal, the matter is absorbed, and they remain in a scirrhous state, the patient becoming perfectly restored to health; and hence the remark of Dr. Simmons, that tubercles may exist without Phthisis.

These are all the principal predisposing and exciting causes of Phthisis Pulmonalis. Some few others are mentioned by authors, but they are of either very doubtful agency, or too rare to deserve notice.

The disease having been excited into action, produces a succession of symptoms which are now to be detailed. Its attack is frequently extremely insidious and slow; at other times, well marked and rapid in its progress. It is to this insidious and gradual mode of attack, that Consumption owes much of its fatal character. Before the unfortunate patient suspects himself to be seriously indisposed, it but too frequently happens, that his fate is sealed, and death is inevitable. This arrives in part from the resemblance that Incipient Phthisis bears to a long continued catarrh. It frequently is only marked in its earliest periods by a slight, dry, hacking cough, trivial during the day, increased at evening, and most troublesome at night; a sense of weight about the breast, and some little difficulty of breathing, increased on taking any unusual exercise, or ascending a height; the pulse is slightly accelerated, and sometimes only so after taking food: occasionally, burning hands and feet, and a slight flush in the cheek are the only symptoms of fever. These symptoms may be so slight as hardly to attract the patient’s notice; at other times they are more severe and distressing. Frequently, on any little unusual exercise, the cough is increased, the patient feels a pain in the side, and expectorates a frothy mucus, and blood is discharged from the lungs. This, perhaps, is the first symptom which excites the alarm of the patient. Expectoration of blood is generally preceded by a saltish taste in the mouth, and a sense of irritation at the upper part of the trachea. It is known to come from the lungs and not the stomach, by its frothy appearance and admixture with mucus, while that from the stomach is generally dark coloured and mixed with the food; and by being brought up by coughing and not vomiting. The blood coming from the stomach too, is generally in larger quantity than that from the lungs.

In addition to these symptoms, the patient is often affected by an increased sensibility of the lungs, observable on any exposure to cold, change of dress, or going from a warm to a cool apartment. There is a sense of soreness in the lungs attended with a sensation of stricture about the chest. Pain is felt in the side or breast, and the patient lies with difficulty on the side affected. The pain is frequently lancinating, and shooting through the breast, sometimes in the direction of the mediastinum, at others, confined to one side.

As the disease advances, the symptoms of fever become more marked. The tongue is dry, attended with thirst, loss of appetite, nausea, and occasional vomiting, and a desire for acids. The secretions generally are checked. Perspiration is diminished, and the skin is hot and dry. The urine is at first diminished in quantity, and high coloured. The menses, in females, are either suppressed or very irregular. The bowels are frequently costive. The patient passes restless nights, and is prevented sleeping by a tormenting cough, or if he sleeps, is troubled with dreams. In consequence of indigestion, pain is felt in the situation of the stomach, attended with flatulence. The patient begins to have a pallid countenance, and emaciation gradually takes place.

These symptoms may continue a length of time, gradually debilitating the patient. But the expectoration which at first was frothy, in small quantity, and coughed up with difficulty and pain, increases, and gradually passing through all the stages between mucus and pus, at length becomes decidedly purulent. A new train of symptoms follow. Hectic fever makes its appearance, commencing with irregular cold and shivering fits, returning frequently during the day. It soon, however, assumes a decided character, and has two marked exacerbations, the one at noon, the other at night. These exacerbations begin with a sense of coldness, succeeded by heat, and at night terminating in profuse perspiration. During the chill and hot fit, the cough, pain, and dyspnœa are aggravated, but relieved by the sweating. The pulse before the paroxysm is accelerated and weak, during its continuance quick and strong, but abates as the perspiration flows. The countenance is generally pale, but during the exacerbation is marked by a circumscribed crimson flush, which occurs mostly at noon, but may be produced by taking food or any other cause of excitement. The profuse sweats do not occur after the exacerbation at noon, but in the morning, while the patient is warm in bed, with the system relaxed by sleep. The perspiration is principally confined to the superior parts of the body, as the neck, breast, and about the shoulders. The tongue is often very clean during hectic fever, but sometimes furred. The bowels are generally torpid, alternating with diarrhœa.

The disease continuing to advance, the cough and dyspnæa increase, and the hectic symptoms become more marked and violent. Emaciation rapidly goes on, the face looks sharp and haggard, and the absorption of fat makes the eyes appear remarkably large and prominent. At the same time, the teeth appear unusually white and beautiful. The appetite becomes extremely irregular, the pulse more accelerated and diminished in strength. The mind is extremely vacillating, at one time depressed, at another, elated with hopes of recovery. Profuse diarrhœas, alternated with obstinate torpor of the bowels, exhaust the patient; the eyes assume a ghastly and pearly whiteness; the mouth becomes filled with apthous eruptions; sometimes hiccup ensues; the patient’s mind becoming more and more disturbed, delirium comes on, which soon terminates in death.

An assemblage of some or all these symptoms, constitutes Phthisis Pulmonalis, differing however very materially in number, degree and violence in different patients. They are variously modified by a number of attending circumstances, which require some attention.

Many authors declare, that an expectoration of pus does not always attend this disease. The matter may be confined in a vomica, and the patient die with the symptoms of Phthisis before it bursts. Nor does a purulent expectoration necessarily indicate the existence of an ulcer in the lungs. The matter may be poured out from the secreting surfaces of the lungs without ulceration, precisely as it comes from the adnata of the eye after opthalmia, or the urethra in gonorrhœa, where no ulcer is suspected. In the New-York hospital, dissections of numerous patients who have died of Phthisis, sufficiently prove the fact in question.

Nor does pain in the side or breast, always accompany this disease. Dr. Reid remarks that many cases have occurred in his practice, where no pain in any part of the chest has been observed during the whole course of the disorder. “I have witnessed,” says Dr. Heberden, “many deaths from genuine pulmonary consumption, where dissection has demonstrated an entire destruction of the substance of the lungs, and where through the whole course of the disease, neither expectoration of blood, difficulty of breathing, nor pain in the side had been present.” On the other hand, pain in the side may occur merely as a consequence of the debilitated or irregular action of the muscles, as in walking, and should not be mistaken for a symptom of Consumption.

In the course of the disease, dropsical effusions, constituting Ascites, Hydrothorax and Anasarca, are not unusual, as in other diseases where great debility is produced.

In the advanced periods of Consumption, diarrhœa constitutes a prominent and troublesome symptom. This is sometimes produced by any cause which checks the profuse sweats; while on the other hand, if the diarrhœa be checked, the cough and dyspnœa, which perhaps had been relieved by it, frequently return with redoubled violence. Under these circumstances, the condition of the patient is hopeless indeed.

The approach of summer frequently mitigates the sufferings of the consumptive, and gives them hopes of returning health; but when winter returns, these hopes are blasted; the patient sinks again into his former condition, and most generally is cut off during the cold season.

The symptoms of Phthisis are frequently suspended or mitigated by any cause producing a new determination in the system. The most prominent of these causes is pregnancy. It almost invariably happens that the symptoms of Consumption are relieved by the occurrence of this event; but after parturition the disease returns with all its former violence. The occurrence of mania has produced the same effect, and has even entirely cured the disease; but generally, when the mania is removed, the symptoms of Consumption return. An attack of rheumatism has frequently relieved phthisical complaints. Dr. Rush refers to three clinical patients in the hospital of Pennsylvania to exemplify this observation. In the same manner gout is observed to alternate with Consumption, and during its paroxysms, the complaint of the lungs is relieved. Frequent cases are related, in works on this subject, of eruptions on the skin alternating with Phthisis Pulmonalis.

Long continued ulcers, or fistulæ in ano not unfrequently relieve pulmonic complaints in phthisical patients; while the healing of these ulcers or fistulæ reproduces the disease with tenfold violence.

A farther circumstance worthy of remark in this disease is, the willingness with which the patient suffers himself to be flattered with hopes of recovery. Notwithstanding he sees daily victims of Consumption falling around him; notwithstanding the perfect assurance he has of the small number of those who recover from it; to the last his hopes are not abandoned. Although depressed at night by the evening exacerbation of hectic fever; in the morning, from his comparatively comfortable situation, his hopes revive. Happy is it for these miserable sufferers that they do not despair. In a disease whose progress is frequently so slow, and whose event is but too often so sure, fortunate it is, that a solace remains to cheer the unhappy patient.

The duration of Consumption is extremely various; from a few weeks to fifty years have patients laboured under it. In Bayle’s statement of the duration of the disease in two hundred cases in which the patients were destroyed by it, it was between two months and two years in 168 cases, four were less than two months, and 28 remained more than two years.

From the detail of symptoms which has just been given, it is evident, that there are two distinct stages of Phthisis Pulmonalis, each characterised by peculiar symptoms, and requiring peculiar treatment. The first, incipient, or acute stage as it is variously termed by authors, is the stage of inflammation, and terminates as soon as purulent expectoration and hectic fever commence. The second, confirmed, or chronic stage commences where the first terminates, and ends most generally in death. We would not however assert, that these stages can always be accurately distinguished, and a line drawn between them. On the contrary, hectic fever may occur early in the disease, before any expectoration of pus takes place, and inflammatory symptoms frequently attend its advanced stage. In general, the distinction can be made, and must necessarily guide the prudent physician.

Having taken a view of the causes and symptoms of Phthisis Pulmonalis, we are now prepared to investigate the proximate cause of the disease. From the nature and extent of these symptoms, it appears evidently a disease of the whole system, and not confined merely to the lungs. The proximate cause, as taught by Dr. Hosack, in his lectures, is, an inflammation of the lungs, terminating either in a purulent secretion, or ulceration in their substance. This opinion is much strengthened by the analogy before remarked between Phthisis Pulmonalis and Pneumonia. It is a little singular that Dr. Rush, notwithstanding he had remarked this close analogy, and although he speaks of inflammatory fever as a part of the disease, and prescribes blood-letting in its treatment, should yet have made debility its proximate cause. This is only one instance among many, of physicians arriving at precisely the same modes of treatment by directly opposite routes. If that theory of inflammation be admitted, which makes debility its cause, so far it is also the proximate cause of Phthisis Pulmonalis. In the secondary species of Phthisis, hereafter to be considered, debility may be fairly ranked as the proximate cause, and the indications of cure correctly drawn from it. But in the primary disease under consideration, if we were to found our indications on this basis, and thence deduce the propriety of exhibiting powerful tonics in the first stage of the disease, when brought to the test of practice, its error would soon become sufficiently glaring.

Various other causes have been successively treated of by authors, but to shew their inconsistency and absurdity, it is only necessary to observe that, “the existence of an acid or an alkali, of chemical acrimony, or mechanical changes in the blood, of corroding volatile particles, and even of animalcula in the lungs, have been vaguely conjectured to be the cause of pulmonary ulcer and hectic fever.[7]”

Assuming then, inflammation of the lungs, and consequent ulceration of their substance as the proximate cause of Phthisis Pulmonalis, we naturally deduce the following indications in the treatment of the disease.

1. To endeavour to relieve the inflammation of the lungs, and promote its resolution.

2. If, notwithstanding all our efforts, suppuration takes place, to give sufficient support and tone to the system to enable the ulcers to heal.

In fulfilling these indications, our first object is to remove the remote causes, where it is possible. If the patient’s occupation is one of those which predisposes to Consumption, unless it be abandoned, or at least so modified as to correct the objectionable parts of it, we cannot hope to cure the disease. If the disease arise from the suppression of an accustomed evacuation, our utmost endeavours must be made to restore it. Should suppression of the menses be the cause, means calculated to produce their return must be resorted to. If an ulcer or fistula has healed up, they must be re-opened, or issues established in more convenient situations. In short, the rule is plain and simple. Remove the remote causes, wherever it is practicable.

Among the remedies which are necessary to fulfil the first indication, the most prominent is Blood-letting. This remedy has been strongly advocated by many of the most distinguished authors who have written on Consumption; and its propriety admitted by all under certain circumstances. Probably, most of the injurious effects attributed to it, may be accounted for by a proper distinction not having been made between Primary and Secondary Phthisis Pulmonalis. When bleeding has been practised in the secondary form of the disease, it has been generally injurious, and hence an odium has been cast upon its employment in any circumstances. In the same manner, it has done mischief, when used too late in Primary Phthisis, and thus another groundless argument furnished against the remedy. But the indiscriminate use of blood-letting is not here contended for. Its judicious and cautious use, when inflammatory action is evident, alone is intended to be advocated. On the other hand, too timid practice may induce us to withhold the lancet when it is necessary; and we may thus do as much injury by losing the proper time for action, as we would have done by pushing the remedy too far. It is difficult to fix the period beyond which it is improper to bleed in Consumption. Dr. Hosack insists that as long as there is any pain or soreness on taking a full inspiration, the lancet is necessary. This rule is not applicable to practice; for if we adopt it, we may bleed the patient until he dies. Until that moment will the pain in some instances continue. It is not unfrequent, after the patient has been exhausted by colliquative sweats, and profuse diarrhœa, for pain in the breast to recur at intervals, a few days before death: and what practitioner, under such circumstances, would feel himself justified in using the lancet? But this rule is incorrect in another point of view. In some cases, it will prevent our using this valuable remedy, when it is necessary. On the authority of Dr. Reid, it is asserted, that pain is not always present in Phthisis Pulmonalis; and may not occur during the whole course of the disease. A reference has been already made to Dr. Heberden to prove the same fact. On this subject it is impossible to fix any precise rule. The strength and habit of the patient, the urgency of the symptoms, and state of the pulse, must all be recollected and adverted to in making up our judgment as to the propriety of the remedy. In general, perhaps we may say, that after the formation of matter is perfectly ascertained, it is improper to bleed. This, however, is not without exceptions. Cases sometimes occur, after this period, in which the symptoms of high inflammatory action arise, and where the lancet is indicated. It is now generally admitted that the buffy appearance of the blood is by no means an infallible evidence of the necessity of the repetition of blood-letting. Nor is its cupped form a better proof of the existence of inflammation. Many writers have observed, that the buffy coat appears in the blood drawn in Consumption at the latest periods of the disease. A remarkable and decided case of Enteritis, occurred during the last winter, in the New-York Hospital, in which very large and repeated bleedings were made use of, with the good effect of curing the patient: and yet, neither buff nor the cuplike form appeared in the smallest degree in the blood drawn. This case alone is sufficient to prove, how equivocal are these appearances of the blood, as tests of inflammation. Nevertheless, the judicious practitioner will not fail to observe these circumstances, and as they so frequently accompany inflammation, will consider them, when attended with other evidences, as properly influencing his judgment on the propriety of bleeding.

If the abstraction of blood from the system generally is useful, no less so is it when drawn from the part itself, by the application of cupping-glasses, and the scarificator to the chest. This mode of obtaining blood is peculiarly useful in those frequent cases, where the patient is too much debilitated to bear the loss of much blood, but the existence of inflammatory action makes its abstraction necessary.

Emetics are a powerful remedy in the treatment of Phthisis. They not only promote expectoration, and relieve the distressing cough in the first stage of the disease, but by their general relaxing effects upon the system, are useful in reducing inflammatory action. The use of this remedy, however, should not in general be commenced until blood-letting has been premised; otherwise in plethoric habits, full vomiting might induce hæmoptysis. Practitioners have differed very much in the choice of emetics proper in this disease. The antimonial preparations and ipecacuanha, as acting more generally upon the system in reducing excitement, and from their good effects in other febrile diseases, appear to be the most proper. But in the last stage of Consumption, where our object is to relieve the pulmonary symptoms, without debilitating the patient, the sulphates of zinc and copper are preferable.

Emetics are not only useful when exhibited for the purpose of full vomiting, but medicines of the same class given as diaphorectics are also proper. With this view the various preparations of antimony are in use. Small doses of the Antimonial powder combined with calomel have been found, perhaps, one of the best sudorifics that can be employed, and as such are frequently useful in Phthisis. No medicine is superior to this combination in reducing inflammatory action; and it frequently has a better effect by proving both emetic and purgative.

As a sudorific, warm bathing may be very useful, and is an agreeable remedy in the inflammatory stage of Phthisis. As the warm bath is useful in relaxing the surface of the body generally; in a similar manner inhaling warm air, by means of Mudge’s apparatus, relaxes the inflamed membrane of the bronchiæ, and acts as a fomentation there, with the same good effect as is produced by warmth and moisture upon any other inflamed surface of the body. This remedy gives great relief in the cough and hoarseness so distressing in Phthisis Pulmonalis.

With the same view of counteracting inflammation, cathartics may be prescribed. As in other febrile diseases, so in Phthisis, the bowels are frequently torpid, and require the frequent use of aperient medicines. Saline and mercurial cathartics, possessing the greatest power in diminishing excitement, are perhaps the most proper in this disease. But as it is an object not to induce too much debility, the use of drastic purgatives should be avoided as much as possible, and be confined to the earliest periods of the disease. During its advanced stage, the bowels should be kept open by mild laxatives and enemata, which tend least to debilitate the patient.

Blisters, Setons and Issues relieve the inflammation of the lungs, and produce a new determination to the surface with the happiest effects. Most writers agree in recommending repeated blisters to the chest, as an useful remedy, and with reason. But it is to be regretted that they have been suffered to usurp the place of a more powerful remedy of the same class, viz. Issues. If we may judge from the effect of ulcers and fistulæ, which palliate all the symptoms of confirmed Phthisis, while they continue, but whose healing restores the disease, it would appear that the establishment of similar drains, in the form of issues, ought to have a good effect. In caries of the spine, and disease of the hip joint, where the inflammation in the cellular structure of the bones seems to be very analogous to that in the cells of the lungs, issues are used with the greatest benefit. In these cases, they are uniformly preferred to repeated blistering, and experience has sanctioned the preference. Issues are preferable to blisters by their constant and uniform action, whereas the latter remedy has its effect continually interrupted by healing up and requiring renewal. In general, blisters appear to be more useful in acute diseases, which may soon be subdued: but in Phthisis Pulmonalis, which continues so long, and whose progress is so slow, issues appear to be the better remedy. Dr. Mudge was so well convinced of their efficacy, that he assures us, he cured himself of an Incipient Consumption, by a large issue between the shoulders. Beddoes also recommends them, and relates several cases, in which they were used with the best effect. But if this remedy be tried, it should not be done timidly, and with the fear of giving pain; when used at all, issues should be large and effectual, not only sufficient to contain a single pea, but at least a dozen. This is not the only remedy which has fallen into disrepute by a trifling and inefficient mode of employing it. But as blisters are preferred by many of the most judicious practitioners, their use may easily and with advantage be combined with that of issues. While a large issue is kept open between the shoulders, successive blisters may be applied to the chest. Many patients, perhaps, would not submit to so severe a mode of treatment; but it is only by such active and efficient practice, that we can hope to cure this formidable malady.

It is only in the first stage of Consumption that much benefit is to be expected from this class of remedies, or at all events, before the patient is much debilitated. In its latest periods, they would tend rather to add to the debility already induced by the disease. At any time, however, when the patient is not too much reduced, they may be prescribed with advantage.