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.