Part 3

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.

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.