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Pulmonary Tuberculosis 
 
 ITS 
 
 PATHOLOGY, NATURE, SYMPTOMS, DIAGNOSIS, 
 
 PROGNOSIS, CAUSES, HYGIENE, AND 
 
 MEDICAL TREATMENT. 
 
 ADDISON P. DUTCHER, M.D., 
 
 LATE PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN THE CLEVELAND 
 CHARITY HOSPITAL MEDICAL COLLEGE, OHIO. 
 
 PHILADELPHIA: 
 
 J. B. LIPPINCOTT & CO. 
 
 1875. 
 

 Entered, according to Act of Congress, in the year 1874, by 
 
 J. B. LIPPINCOTT & CO., 
 In the Office of the Librarian of Congress at Washington. 
 
 
THIS VOLUME IS RESPECTFULLY DEDICATED 
 
 TO 
 
 JAMES DASCOxMB, M.D., 
 
 GUSTAV C. E. WEBER, M.D., 
 
 L. FIRESTONE, M.D., 
 
 A. METZE, M.D., 
 W. P. SCOTT, M.D., 
 
 ORIGINAL MEMBERS OF THE FACULTY OF CHARITY HOSPITAL 
 MEDICAL COLLEGE, CLEVELAND, OHIO. 
 
 A. P. D. 
 
PEEFAOE. 
 
 Op all the maladies to which the human system is subject, none 
 have received more attention than has pulmonary tuberculosis. From 
 the remotest antiquity it has been investigated with ingenuity and 
 perseverance. The success, however, at first attending these labors 
 was not commensurate with the interests involved, and for years phy- 
 sicians despaired of finding the true nature of the disease and the 
 best mode of its medical management. 
 
 But a brighter day has dawned upon the medical world. By a 
 more general study of microscopical pathology, percussion, and aus- 
 cultation, new and unprecedented facilities have been furnished for 
 the investigation of this and other affections of the chest. That 
 these means have been well improved, we have only to turn to the 
 pages of Laennec, Louis, Clark, Carswell, Morton, Bennett, Thomp- 
 son, Ancell, Campbell, Niemeyer, Rokitansky, Williams, Waldenburg, 
 Smith, Flint, Gerhard, Sweet, and Lawson, whose works will stand 
 for ages as monuments of industry and learning. 
 
 With such distinguished authorities before us, it appears almost a 
 work of supererogation to attempt to add anything to their labors. 
 But duty prompts me to the work. And I feel it a great privilege 
 thus to contribute my mite to the advancement of medical science 
 and the art of practical medicine. Although I do not claim any 
 special originality for my work, yet I do not think it will be less 
 valuable to the profession on that account. I have endeavored to 
 cull from our best writers such facts as would lend interest to the 
 subject, and lead to a better understanding of the nature, diagnosis, 
 
 5 
 
tf PREFACE. 
 
 prognosis, causes, and general management of this most complicated 
 and fatal malady. 
 
 A number of the chapters of this work have already been given to 
 the profession through the pages of the medical press in this country 
 and in Europe. The favorable reception they have met with, and the 
 desire of perpetuating their usefulness, have induced me to incorporate 
 them in this volume. I may also add that most of the chapters have 
 been entirely re-written, altered, or corrected, as the nature of the 
 case demanded. In this shape I commit it to the ordeal of a gen- 
 erous profession, with the hope that it may add to our knowledge 
 some important facts in regard to the nature of a disease that has 
 proved so destructive to the human race, and thus lead to its more 
 successful medical treatment. A. P. D. 
 
CONTENTS. 
 
 CHAPTEE I. 
 
 PATHOLOGY OF PULMONARY TUBERCULOSIS. 
 
 PAGE 
 
 I. The Nature of Tubercular Disease in general. II. Pulmonary- 
 Tuberculosis. III. Structural Changes which attend Pulmonary 
 Tuberculosis in Other Parts of the Body 13 
 
 CHAPTER II. 
 
 THE NATURE OP PULMONARY TUBERCULOSIS. 
 
 I. The Inflammatory Theory of the Nature of Tubercle. II. Imper- 
 fect Nutrition. III. Defective Respiration. IV. Specific Mor- 
 bid Condition of the Blood. V. Imperfect Innervation. YI. 
 Retrograde Metamorphosis of the Tissues 26 
 
 CHAPTER III. 
 
 THE BLOOD! ITS CONDITION IN PULMONARY TUBERCULOSIS. 
 
 I. The Nature of the Blood. II. The Red Corpuscles. III. The 
 White Corpuscles. IY. The Fibrin. Y. The Albumen. VI. 
 The Dissolved Animal Matter in the Blood. Conclusions . 47 
 
 CHAPTER IV. 
 
 THE KIDNEYS AND URINE : THEIR CONDITION IN PULMONARY 
 TUBERCULOSIS. 
 
 I. The Importance of the Urinary Excretion. II. Uraemia in 
 Phthisis from Bright's Disease ; A Case. III. Tubercular Dis- 
 ease of the Kidneys, with Extensive Tubercular Deposits in 
 Other Parts of the Body ; An Interesting Case. IV. State of 
 the Urine in Phthisis Pulmonalis 66 
 
 CHAPTER V. 
 
 THE LIVER: ITS CONDITION IN PULMONARY TUBERCULOSIS. 
 
 I. Its Functional Derangement. II. Fatty Degeneration. III. 
 Clinical History of Fatty Liver. IV. Abscess of the Liver in 
 Pulmonary Tuberculosis 69 
 
 CHAPTER VI. 
 
 menstruation: its condition in PULMONARY TUBERCULOSIS. 
 I. The Nature of Menstruation. II. The Condition of the Menses 
 
 in Phthisis .80 
 
 7 
 
s . CONTENTS. 
 
 CHAPTER VII. 
 
 THE GENERAL SYMPTOMS OF PULMONARY TUBERCULOSIS. 
 
 PAGE 
 
 I. Symptoms of Deposit and Induration. II. Symptoms of the Stage 
 
 of Softening. III. Symptoms of the Formation of Vomicae . 91 
 
 CHAPTER VIII. 
 
 THE PHYSICAL SIGNS OF PULMONARY TUBERCULOSIS. 
 
 I. Inspection. II. Percussion. III. Auscultation . . .97 
 
 CHAPTER IX. 
 
 GENERAL SYMPTOMS AND PHYSICAL SIGNS OF CERTAIN CHEST-DIS- 
 EASES WHICH SOMETIMES ATTEND PULMONARY TUBERCULOSIS. 
 
 I. Bronchitis. II. Pneumonia. III. Pleurisy. IV. Emphysema. 
 
 V. Pneumothorax 108 
 
 CHAPTER X. 
 
 THE DIAGNOSIS AND PROGNOSIS OF PULMONARY TUBERCULOSIS. 
 
 I. Diagnosis of Phthisis Pulmonalis. II. A Case of Pulmonary 
 Bronchitis mistaken for Pulmonary Tuberculosis. III. Prog- 
 nosis of Pulmonary Tuberculosis 121 
 
 CHAPTER XI. 
 
 THE PRE-TUBERCULAR STAGE OF PULMONARY TUBERCULOSIS. 
 
 I. General Symptoms of the Pre-tubercular Stage of Pulmonary 
 Tuberculosis. II. Physical Signs of the Pre-tubercular Stage 
 of Pulmonary Tuberculosis 130 
 
 CHAPTER XII. 
 
 THOMPSON'S GINGIVAL MARGIN A SIGN OF PULMONARY TUBERCU- 
 LOSIS. 
 
 I. Description of the Margin. II. Theory of the Margin. III. 
 Cases illustrating the Value of the Margin as a Means of Diag- 
 nosis and Prognosis. Conclusions 140 
 
 CHAPTER XIII. 
 
 THE PCLSE: ITS YALUE AS A DIAGNOSTIC SIGN OF PULMONARY 
 TUBERCULOSIS. 
 
 I. The State of the Pulse in Health. II. The Character of the 
 
 Pulse in Phthisis. Inferences 149 
 
 CHAPTER XIV. 
 
 PAIN AS A SYMPTOM OF PULMONARY TUBERCULOSIS. 
 
 I. Pain a Common Symptom of Disease. II. Pain as it Manifests 
 Itself in Phthisis and other Chest-Diseases . . . .159 
 
CONTENTS. 9 
 
 CHAPTER XV. 
 
 DYSPNCEA AS A SYMPTOM OF PHTHISIS. 
 
 PAGE 
 
 I. Causes of Dyspnoea in Phthisis. II. The Peculiar Character of 
 Phthisical Dyspnoea. III. Medical Treatment of Dyspnoea . 165 
 
 CHAPTER XVI. 
 
 EMACIATION AS IT OCCURS IN PHTHISIS. 
 
 I. A Prominent Symptom of the Malady. II. Emaciation not 
 always a Progressive Symptom of Pulmonary Tuberculosis. 
 
 III. What is an Individual's Normal Standard of Weight? . 174 
 
 CHAPTER XVII. 
 
 VOMITING AS A SYMPTOM OF PHTHISIS. 
 
 I. The Origin of Vomiting in Phthisis. II. The Vomiting of 
 Phthisis confined mostly to the Last Stage. III. Treatment of 
 Vomiting as it occurs in Phthisis 180 
 
 CHAPTER XVIII. 
 
 COUGH AND EXPECTORATION: THEIR DIAGNOSTIC VALUE AS SYMP- 
 TOMS OP PULMONARY TUBERCULOSIS, WITH REMARKS ON THE 
 IMPORTANCE OF A MICROSCOPICAL EXAMINATION OF THE SPUTUM. 
 
 I. Cough and Expectoration. II. Physical and Microscopical Char- 
 acters of Pus and Mucus. III. Microscopical Characteristics 
 of the Sputum in the First Stage of Pulmonary Tuberculosis. 
 
 IV. Dr. Thompson's Cases demonstrating the true Microscopical 
 Indications of Tubercular Sputum. V. Testimony of Drs. Ben- 
 nett and Clark on the Value of the Microscope as a Means of 
 Diagnosis in Phthisis 188 
 
 CHAPTER XIX. 
 
 HEMOPTYSIS AS A SYMPTOM OF PULMONARY TUBERCULOSIS; ITS 
 DIAGNOSIS AND TREATMENT. 
 
 I. The Character of Phthisical Haemoptysis. II. Haemoptysis in 
 the Two Sexes. — Stage of the Disease, and Periods of Life. III. 
 Diagnosis of Phthisical Haemoptysis. — Cases illustrating the 
 Same. IV. Treatment of Phthisical Haemoptysis. V. Purpura 
 Haemorrhagica and Pulmonary Tuberculosis .... 201 
 
 CHAPTER XX. 
 
 HECTIC FEVER AS A SYMPTOM OF PULMONARY TUBERCULOSIS. — ITS 
 CLINICAL HISTORY, DIAGNOSIS, AND TREATMENT. 
 
 I. Clinical History of Hectic Fever. II. Hectic Fever not always 
 a Symptom of Pulmonary Tuberculosis. III. Cases illustrating 
 Phthisical Hectic from Other Diseases. IV. The Treatment of 
 Hectic Fever 218 
 
10 CONTENTS. 
 
 CHAPTER XXL 
 
 DIARRHOEA AS A SYMPTOM OF PULMONARY TUBERCULOSIS. 
 
 PAGE 
 
 I. The Clinical History of Tubercular Diarrhoea. II. The Causes of 
 Phthisical Diarrhoea. III. The Appearance of the Evacuations 
 in Phthisical Diarrhoea. IY. A Case illustrating the Diagnosis 
 of Phthisical Diarrhoea. V. Treatment of Phthisical Diarrhoea 231 
 
 CHAPTER XXII. 
 
 DEATH: CAUSES WHICH PRODUCE ITS SUDDEN OCCURRENCE IN 
 PULMONARY TUBERCULOSIS. 
 
 I. Cere oral Apoplexy. II. Perforation of the Pleura. III. Per- 
 foration of the Intestines. IY. Bursting of a Large Abscess 
 into the Bronchia. Y. Sudden and Profuse Haemoptysis. VI. 
 Acute Pleurisy, Pneumonia, and Catarrh 242 
 
 CHAPTER XXIII. 
 
 ABSORPTION OF TUBERCULAR MATTER. 
 
 The Possibility of its Absorption. History of a Case illustrating 
 
 Diagnosis and Treatment. General Remarks .... 252 
 
 CHAPTER XXIY. 
 
 THE HEALING OF TUBERCULAR CAVITIES. 
 
 I. The Possibility of their Healing. II. The Mode in which a 
 Tubercular Cavity may Heal. III. A Large Cavity more apt 
 to Heal than a Small One. IY. Therapeutics for Healing 
 Tubercular Cavities. Y. A Case illustrating Diagnosis and 
 Treatment : General Symptoms and Physical Signs ; Diagnosis 
 and Prognosis ; Treatment ; Further History of the Case ; 
 Microscopical Examination of the Sputum ; Conclusions . . 259 
 
 CHAPTER XX Y. 
 
 THE CAUSES OF PULMONARY CONSUMPTION. 
 
 I. Hereditary Transmission of Consumption. II. How to Prevent 
 
 its Transmission 267 
 
 CHAPTER XXYI. 
 
 THE TRANSMISSIBILITY OF PULMONARY TUBERCULOSIS BY CON- 
 TAGION. 
 
 I. Is it possible to give rise to Tubercular Matter by Inoculation ? 
 II. Medical Writers differ widely upon the Communicability of 
 Tubercular Disease by Contagion 273 
 
CONTENTS. 11 
 
 CHAPTER XXVII. 
 
 COLD, CLIMATE, AND LOCALITY ; THEIR INFLUENCE IN PRODUCING 
 OR MITIGATING CONSUMPTION. 
 
 PAGE 
 
 I. Cold not a Primary Cause of Consumption. II. The Best Resi- 
 dence for Consumptive Patients ....... 280 
 
 CHAPTER XXVIII. 
 
 THE MIND: ITS INFLUENCE IN PRODUCING PULMONARY TUBERCU- 
 LOSIS. 
 
 I. The Power and Grandeur of the Mind. II. The Union between 
 the Body and the Mind. III. The Propensities ; Their Abuse 
 a Cause of Phthisis. IV. The Sentiments ; Their Abuse a Cause 
 of Phthisis. V. The Intellectual Faculties ; Their Abuse a 
 Cause of Phthisis 289 
 
 CHAPTER XXIX. 
 
 THE INFLUENCE OF DIFFERENT OCCUPATIONS IN PRODUCING PUL- 
 MONARY CONSUMPTION 300 
 
 CHAPTER XXX. 
 
 A PLEA FOR THE BEARD : ITS INFLUENCE IN PROTECTING THE 
 
 THROAT AND LUNGS FROM DISEASE 304 
 
 CHAPTER XXXI. 
 
 TIGHT LACING A CAUSE OF PULMONARY CONSUMPTION . . . 308 
 
 CHAPTER XXXII. 
 
 HOW TO CURE PULMONARY TUBERCULOSIS. 
 
 The Importance and Indispensable Necessity of Pure Air for the 
 
 Preservation of Life and Health 312 
 
 CHAPTER XXXIII. 
 
 FOOD : ANIMAL AND VEGETABLE BOTH NECESSARY TO VIGOROUS 
 
 HEALTH. — CONSUMPTIVES SHOULD HAVE A GENEROUS DIET . 317 
 
 CHAPTER XXXIV. 
 
 ANIMAL HEAT J CLOTHING. THEIR IMPORTANCE IN PREVENTING 
 THE FORMATION OF TUBERCULAR DISEASE. 
 
 I. Man Naturally Destitute of Covering. II. How the Heat of the 
 Body is Maintained. III. The importance of retaining the 
 Heat of the Body. IV. Things to be considered in selecting 
 the Dress of Children. V. Some Diseases produced by Careless- 
 ness in Dressing Infants ; a Case. VI. The Powers of Calorifi- 
 cation progressive in Children. VII. The Dress of Children 
 should be Loose and Easy. VIII. Warm Clothing necessary to 
 the Management of Phthisis 321 
 
CONTENTS. 
 
 CHAPTER XXXV. 
 
 BATHING : A MORAL VIRTUE ; AN IMPORTANT MEANS OF HEALTH ; 
 HOW IT SHOULD BE EMPLOYED IN CONSUMPTION. 
 
 PAGE 
 
 I. Bathing a Virtue and Luxury. II. Bathing necessary to Health. 
 
 III. The different kinds of Baths. IV. "What is meant hy a 
 Warm Bath. V. The Best Time for Bathing. VI. Individ- 
 uals subject to Pulmonary Consumption should never Bathe in 
 Cold Water 330 
 
 CHAPTER XXXVI. 
 
 EXERCISE : ITS PHYSIOLOGY, UTILITY AS A MEANS OF HEALTH, AND 
 INFLUENCE IN PREVENTING PULMONARY CONSUMPTION. 
 
 I. Physiology of Exercise. II. Walking. III. Riding. IV. Swim- 
 ming. V. Gymnastics. VI. Exercise in Consumption . . 336 
 
 CHAPTER XXXVII. 
 
 FEEDING INFANTS: ITS IMPORTANCE AS A MEANS OF PREVENTING 
 THE TUBERCULAR DIATHESIS. 
 
 I. The various Temperaments of the Body may he Altered. II. 
 How to Preserve the Mother's Health. III. The Mother's Milk 
 the Best Food for the Infant. IV. Not Good to feed Children 
 too often. V. How to Select a Good Nurse. VI. Artificial 
 Feeding of Children. VII. Animal Jelly a useful Food for 
 Children ; a Case. VIII. Bread Jelly and other Articles of 
 Food 345 
 
 CHAPTER XXXVIII. 
 
 PREGNANCY : ITS INFLUENCE ON THE DEVELOPMENT AND PROGRESS 
 OF PULMONARY TUBERCULOSIS. 
 
 I. Great Difference of Opinion among Writers. II. Theories some- 
 times adopted for Positive Knowledge 353 
 
 CHAPTER XXXIX. 
 
 ALCOHOLIC STIMULANTS: THEIR INFLUENCE AS THERAPEUTICAL 
 AGENTS IN PULMONARY TUBERCULOSIS. 
 
 I. The Chemical Nature of Alcohol. II. Physiological Action of 
 Alcoholic Stimulants. III. Have Alcoholic Stimulants any 
 Agency in Preventing or Retarding Pulmonary Tuberculosis ? 
 
 IV. Drs. Bell, Condie, Davis, and Chambers ; Their Opinion of 
 Alcohol in Phthisis 360 
 
PULMONARY TUBERCULOSIS: 
 
 CHAPTER I. 
 
 PATHOLOGY OF PULMONARY TUBERCULOSIS. 
 
 Pulmonary Tuberculosis, Phthisis Pulmonalis, and Consumption 
 are terms by which is implied the wasting of the body from the effects 
 of a disorganizing process going on in the lungs. This disorganization 
 owes its origin, not to any inherent disease in the lungs themselves, 
 but to the deposition of tubercular matter, and the changes which that 
 matter undergoes, and the effects that it produces upon the surround- 
 ing tissues. In short, it is a great constitutional malady, which plays 
 its most prominent part in the lungs. In order, therefore, to under- 
 stand the changes that occur during the progress of this disease it will 
 be necessary to describe 
 
 I. The Nature of Tubercular Disease in General. 
 
 Tubercular formations occur at all periods of life, from the most 
 tender infancy to the most decrepit old age, and may be deposited in 
 every organ of the body, but most generally are found in the lungs, 
 mesenteric glands, small intestines, and pleura. They are deposited 
 in three forms, — miliary, aggregated, infiltrated. 
 
 (1) The miliary variety, so called from its resemblance to a millet- 
 seed, is by far the most common of all tubercular deposits. It is 
 usually of a round shape, but may be more or less flattened, according 
 
 * A number of these articles have been published under my signature in the 
 "Medical and Surgical Reporter," Philadelphia; in the " Lancet and Observer, " 
 Cincinnati; and in the "Medical News," Cincinnati. 
 
 2 18 
 
14 PULMONARY TUBERCULOSIS. 
 
 to the degree of compression exerted upon it by the parts in which it 
 is exuded. Iu volume it varies from the size of a pin-head to that of 
 a pea. In number the miliary deposits may vary from one to many 
 thousands. In their early state they are isolated, but as they augment 
 in number they gradually approach one another and ultimately coalesce, 
 forming masses about the size of a walnut. This form is usually found 
 in the lungs, and is the true type of all tubercular matter. 
 
 (2) The aggregated variety has the same general form and relations 
 as the preceding, but the masses in which it is deposited are com- 
 monly larger and less firm, and are often grouped so closely, by fusion, 
 that they make up nearly uniform tubercular deposits, varying in 
 size from half an inch to the bulk of an orange, or even that of the 
 head of an infant. They are of a pale-yellow or yellowish-white color, 
 opaque, friable, and when ripe dry and cheesy. 
 
 (3) The infiltrated variety has been denied by some pathologists, 
 but it can be easily demonstrated by the microscope to be tubercular ; 
 it contains the same tubercle-cells and granules as the other forms. In 
 some instances the whole texture of the parts seems to be completely 
 occupied with the deposit, and for this reason it has received the 
 name of infiltrated tubercle. In the lungs it occupies the spaces out- 
 side of the air-cells, and the air-cells themselves ; thus, by a copious 
 and uniform deposition, rendering a part or a whole lobe of the lung 
 one vast mass of tuberculous matter. 
 
 The minute structure of the various forms of tubercular matter is 
 the same. When examined by the microscope, it is found to be com- 
 posed of 
 
 1. A transparent, amorphous, vitreous stroma, occurring in large 
 masses, which perfectly resemble coagulated fibrin. 
 
 2. Minute granules, varying from the 800th of a line in diameter 
 to imperceptible minuteness, chiefly of a roundish form, and occurring 
 in large masses of a brownish color. 
 
 3. Imperfectly-developed cells and cystoblasts, with or without 
 nucleoli. These cells are generally very imperfectly developed, and a 
 distinct nucleus can seldom be recognized. Their size usually varies 
 between the 200th and 300th of a line, their diameter rarely attaining 
 to the 200th of a line. They are accurately delineated in the follow- 
 ing figures. 
 
 Mingling with these, and varying according to the situation and 
 
PATHOLOGY. 15 
 
 circumstances of the tubercles, various other but accidental substances 
 are often found, such as elastic fibres, degenerated epithelial cells, 
 various degenerated products of inflammation from the adjacent parts, 
 
 Fig. 1. Fig. 2. 
 
 
 
 3 °J C 
 
 o. -^-T7o° 
 
 Fig. 1. — A, tubercular cells magnified 400 diameters. B, the same cells magni- 
 fied 600 diameters. The cells are designated by a, and the granules by b. 
 Fig. 2. — Tubercular cells rendered transparent by acetic acid. 
 
 granule-cells, pus-cells, molecules of calcareous matter, pigment and 
 crystals, especially of cholesterine. These different elements occur in 
 individual cases in very different proportions. Sometimes the epithe- 
 
 Pig. 3. Fig. 4. 
 
 
 
 *$* 
 
 Fig. 3. — Cretaceous tubercles: a a, tubercular cells; fe b, crystals of cho- 
 lesterine ; c c, granules of tubercles. 
 
 Fig. 4. — Tubercular matter mixed with melanosis: a a, melanotic globules; 
 b b, melanotic granules ; c c, tubercular cells. 
 
 Hal cells predominate ; sometimes the common pus-cells ; then, again, 
 the entire mass may be chiefly composed of tubercle-cells and granules. 
 Rarely the calcareous granules will be found in excess, with other 
 degenerated products. 
 
16 PULMONARY TUBERCULOSIS. 
 
 In all ordinary cases of tubercular disease some one or more of 
 those microscopical constituents will be present ; the shriveled nuclei 
 and imperfect cells being usually more numerous and distinct than the 
 other elements. By the universal consent of pathologists they have 
 been called tubercle-cells. 
 
 The chemical composition of tubercular matter has been studied 
 with no very satisfactory results. The greatest diversity of opinion 
 prevails on the subject. From about twenty analytical tables before 
 us, we conclude that there are at least seven constituents entering into 
 the composition of tubercle previous to the stage of softening, — namely, 
 albumen, casein, fibrin, pyin, fatty matter, salts of soda and lime, and 
 a peculiar substance called tuberculin. 
 
 Tubercular matter is commonly deposited in the cellular tissue or 
 on the free surface of mucous membranes. But in whatever organ of 
 the body it is met with, if mucous tissue enter into its composition, 
 that tissue is exclusively affected, or more extensively than any of the 
 other component tissues. At first it is deposited in small portions, 
 which become nuclei for the concentration of more. A new habit or 
 mode of nourishment is established at the spot, and the result is, the 
 tubercle increases in size until it becomes ripe. 
 
 It does not, however, remain in this state long before it exhibits a 
 marked change in its appearance. It loses its semi-transparent char- 
 acter, and becomes of an opaque or dead-yellow color. This change 
 usually begins in the centre of the mass, apparently because, being 
 void of blood-vessels, the centre is farther removed from the vivifying 
 influence of the blood. After the mass has turned yellow it soon 
 becomes soft. This generally occurs in the following manner. The 
 central part first becomes soft, so that when cut across it looks cracked 
 and crumbling, and may be pressed away from the surrounding firm 
 part, leaving a little central cavity. In the second place, it becomes 
 liquid, like thin pus, with flakes or grumous particles in a pale- 
 yellowish turbid fluid, and as the change makes progress, the whole 
 tuberculous mass may be reduced to the same liquid state. The usual 
 sequence of the liquefaction of tubercle is its discharge from the 
 tissues inclosing it. This is accomplished by ulceration, — a con- 
 sequence of inflammation in the tissue over the tuberculous matter, — 
 which resembles that for the discharge of common pus. 
 
 When the liquefied matter is discharged through the intesniments. it 
 
PATHOLOGY. 17 
 
 leaves a cavity or vomica. When a cavity is formed, it will either 
 enlarge, by the formation and discharge of fresh tuberculous deposits 
 adjacent to it, or it may be healed by its boundaries being infiltrated 
 by the products of organizable materials. But, alas for mankind ! the 
 latter result does not often occur. At the borders and base of the 
 cavity we commonly find secondary tubercles, which follow the same 
 course of the primary, liquefy, and are discharged into the cavity, 
 which they thus increase by adding their cavities to it. When these 
 cavities are very numerous, and are situated in vital organs, they 
 produce wasting of the body, with hectic fever, night-sweats, and 
 diarrhoea, which speedily prove fatal to the patient. 
 
 Fig. 5. 
 
 A section of lung magnified 250 diameters, showing the pulmonary air-vessels 
 filled with tubercular corpuscles. 
 
 II. Pulmonary Tuberculosis. 
 
 In the brief outline of tubercular disease just given, we have pre- 
 sented a description of those changes which take place in the lungs in 
 every true case of phthisis pulmonalis. It is in the superior lobes of 
 the lungs that this matter is commonly deposited. It is here that the 
 tubercles are the largest and most numerous. It is in these parts that 
 they first ripen and grow soft, and become ready for expulsion ; hence 
 it is here that we have the most frequent, the most numerous, and 
 the largest cavities in the lungs, the number and magnitude of them 
 diminishing: from the summit downwards. 
 
13 PULMONARY TUBERCULOSIS. 
 
 These pulmonary cavities vary much in size ; sometimes they are 
 not as big as a pea, then, again, they are found large enough to con- 
 tain a pint or more of matter. These cavities are seldom met with in 
 the inferior lobes. They are also confined mostly to one lung, — either 
 side being affected, in different instances, in about an equal ratio. 
 Laennec asserted that they were more frequently found in the left 
 than in the right side. Recent observation has not confirmed his 
 opinion. 
 
 When tubercular cavities are very large, they are found to be 
 formed by the union of several that are smaller, so that they are very 
 irregular in shape, and divided into chambers, as it were, by imperfect 
 bands, which cross them in various directions. These cavities always 
 have one or more openings with the bronchial tubes, which serve as 
 a passage for the discharge of any matter that may form in them. 
 
 When a cavity has recently been formed in the lungs by the soften- 
 ing and discharge of tubercular matter, its walls are soft and rugged, 
 and are lined by a thin layer of lymph, which is easily separated from 
 the surrounding parts. In old cavities the false membrane is dense, 
 and sometimes much thickened. Frequently several layers of this 
 description are deposited, — the last formed being more delicate, more 
 easily torn, and of a more yellow color. In some cases the cavity is 
 entirely destitute of lining membrane, the walls being formed of 
 hardened pulmonary tissue, having a raw, fleshy appearance, not unlike 
 the surface of a granulating ulcer. The bands intersecting these 
 cavities, crossing them in various directions, are composed of dense 
 cellular tissue, the remains of arteries and veins that supplied the 
 parts. The changes which these vessels undergo in such cases are 
 very interesting; indeed, if it were not for them, few individuals would 
 ever survive the softening process: fatal hemorrhage would follow 
 in nearly every case. Some time before the softening process begins 
 in the tubercular mass, the calibre of all the blood-vessels involved in 
 the diseased structure is obliterated, as if nature had anticipated the 
 ulcerative process and the hemorrhage which would evidently follow 
 if the vessels were not obliterated. In the early stage of the disease 
 the vessels are merely forced aside and compressed by the tubercular 
 matter, but as the deposit advances they gradually become impervious, 
 and are at length converted into hard fibrous cofds, as we find them 
 in the cavities. Notwithstanding all the care nature has bestowed on 
 
PATHOLOGY. 
 
 19 
 
 the protection of these vessels, they are sometimes ruptured, and fatal 
 hemorrhage is the consequence. 
 
 When tubercles in the lungs first commence to soften, there is no 
 communication existing between them and the bronchial tubes, but as 
 the softening process goes on the latter soon become involved, and 
 before long a passage is formed between them ; and it is not an uncom- 
 
 FlG. 
 
 A section of the superior lobe of the lung, containing tubercles in different 
 stages, and a vast tubercular cavity : a a a, bronchial tubes opening into the 
 cavity; b b, bands crossing it; c c, coalescing masses of tubercles; d, miliary 
 granules ; e e e, exterior surface of the lung. 
 
 mon thing, on opening a large cavity, to find several tubes terminating 
 in it. Sometimes these openings become obstructed by the accumu- 
 lation of viscid mucus, tubercular matter, or other impediments, which 
 prevent, for a limited period, the elimination of the contents of the 
 cavity. Sometimes these cavities, when situated near the surface of 
 the lung, fail to form a communication with the bronchial tubes ; in 
 this case they occasionally penetrate the pleura, by ulceration, the 
 contents of the cavity escaping into the pleural sac, and producing 
 speedy and fatal inflammation. And it is a remarkable circumstance 
 that these perforations are much more frequently connected with small 
 
20 PULMONARY TUBERCULOSIS. 
 
 deposits than with large ones. It is true that these perforations do not 
 always prove fatal, but they are often the cause of sudden death in 
 those suffering with this fatal malady. 
 
 The contents of a tubercular cavity vary according to the period 
 of its existence. Such as are recent generally contain thick, cream- 
 colored inodorous matter like common pus ; while in those of long 
 standing the fluid is of a thin, bloody, sinuous character, and is often 
 very offensive. Chalky concretions are sometimes found in them, 
 and occasionally a substance resembling fibro-cartilage. Old cavities 
 lined with false membrane contain ordinary pus ; hence we find no 
 tubercular cells in the expectoration of a patient when a cavity is 
 going through the process of healing by the formation of false mem- 
 brane upon its walls. 
 
 The time required for a cavity to empty itself varies from a few 
 weeks to several months, according to the size of the tubercular mass, 
 the extent of the local lesion, and the state of the system. It is not 
 an uncommon thing to find tubercles in nearly every stage of progress 
 in the same lung, — some just forming, some softening, and others Jjost 
 being expelled, — old cavities healing, while new ones are forming ; but 
 in every case destroying the pulmonary tissues, impairing the harmo- 
 nious action of the lungs, and in the great majority of instances causing 
 the dissolution of the patient. 
 
 One of the most interesting things connected with these cavities is 
 their healing. That they do occasionally heal can be attested by every 
 physician who is in the habit of making dissections, or by those who 
 attend many patients suffering with pulmonary tuberculosis. It has 
 been pretty clearly proved that there are three modes in which these 
 cavities may heal : 
 
 1. The cavity may remain open and its surface become lined with 
 a thin layer of plastic lymph. This adheres more or less strongly 
 to the surrounding textures, is gradually organized, and is finally 
 converted into a membrane, which shields the cavity and prevents 
 its further extension. 
 
 2. The healing may be effected by the contraction of the cavity, 
 and the slow but steady agglutination of its sides through the inter- 
 vention of dense cellular substance of new formation. Dr. Carswell, 
 in his work on " Consumption," gives several drawings delineating this 
 mode of healing. 
 
PATHOLOGY. 
 
 21 
 
 3. It may take place by an effusion of coagulative lymph, or by the 
 repeated deposit on the inner surface of the cavity, forming a mass 
 more or less dense in its structure, completely obliterating the cavity, 
 which may be distinctly marked by its fibro-cartilaginous boundary, in 
 which the bronchi abruptly terminate. Fig. 7 is a good diagram of 
 this mode of healing. 
 
 Fig. 7. 
 
 A section of the superior lobe of the lung, illustrating the third mode of 
 healing : a, a fibro-cartilaginous cicatrix, surrounded by pulmonary substance, 
 strongly marked by black pigment; 6, a bronchial tube greatly dilated and 
 terminating in a cul-de-sac at the cicatrix ; c, marks of the obliterated bronchial 
 tube ; d, a band of serous tissue uniting the lungs to the pleura and ribs. 
 
 In either of these modes of healing there is always more or less con- 
 traction of the pulmonary tissues, giving rise to a puckering of the 
 lung, which is distinctly marked when the serous envelopment of the 
 organ is forced to follow the retrocession of the pulmonary substance. 
 These sears are commonly found at the apex of the lungs, and are 
 of various sizes and figures; indeed, they occasionally involve the 
 entire superior lobe of the lung. 
 
 While the ordinary sequence of tubercle in the lungs is softening 
 and expulsion by ulcerative inflammation, yet nature occasionally dis- 
 poses of them in another way, viz., by cretaceous transformation. This 
 is regarded by our best medical authorities as curative. Here is a 
 
22 
 
 PULMOXARV TUBERCULOSIS. 
 
 lung taken from the chest of a man who, several years since, was 
 supposed to have pulmonary tuberculosis, but recovered his health, 
 and was killed a few days ago by an accident on a railway train. It 
 is the right lung. To the eye it looks natural, excepting at its 
 superior portion ; here it appears shrunken and quite black, as if it 
 had been the location of some structural change. On pressing it 
 firmly we find several hard. masses about the size of a cherry-stone, 
 which are firmly imbedded in the pulmonary tissues. Let us cut into 
 one of them : it has the appearance of moist chalk, and when rubbed 
 between the fingers it breaks in small fragments that have an earthy 
 feel. 
 
 The other masses have the same physical appearance, and are 
 unquestionably the result of tubercular transformation, notwithstand- 
 ing some pathologists have recently expressed a contrary opinion. A 
 careful examination of their structure, we think, proves their tuber- 
 
 Fig. S. 
 
 cular origin. They exhibit the same marks of internal change which 
 occur in this matter during the process of softening. Thus, it has 
 been observed that the outside of the mass will present the appearance 
 of the yellow cheesy tubercle ; in the deeper portions the chalky sub- 
 stance will be found, while quite in the centre a small irregular hard- 
 
PATHOLOGY. 23 
 
 ness will be perceived, which bears a striking likeness to ordinary 
 indurated tubercle. In chemical constituents, they are also found 
 composed of nearly the same elements as the matter in tubercular 
 cavities. 
 
 Sometimes these cretaceous masses are of stony hardness, rough, 
 and irregular in shape. They are usually attached to the surrounding 
 pulmonary tissue, which is dark, contracted, and more or less indu- 
 rated in their neighborhood. We have a good illustration of them in 
 Fig. 8, reproduced from Dr. Bennett's " Pulmonary Tuberculosis." It 
 is a diagram of a section of the summit of the right lung, exhibiting 
 the cretaceous masses, more or less loaded with and surrounded by 
 carbonaceous deposits. 
 
 III. Structural Changes which attend Pulmonary Tuberculosis 
 in other Parts of the Body. 
 
 Our description of the pathology of this disease would not be com- 
 plete if we neglected to notice those mutations which occur in other 
 parts of the body, complicating it and rendering it more fatal. Thus, 
 on post-mortem we find effusion of blood, congestions, and hardening 
 of the pulmonary tissues, inflammatory adhesions of the pleura, ulcera- 
 tion, thickening, and dilatation of the bronchial tubes, irregular dilata- 
 tion of the air-cells, and enlargement of the bronchial glands, which 
 are infiltrated with tuberculous matter in various states of induration 
 and softening. 
 
 In the upper portion of the windpipe we often find congestion and 
 ulceration, particularly in those parts over which the expectorated 
 matter passes ; hence the sides of the tubes of the windpipe next to 
 large cavities in the lungs and under the surface of the vocal cords, 
 are more commonly the seat of these ulcers, which vary in size and 
 numbers ; sometimes we find but one, and this of considerable magni- 
 tude. I recently saw one that measured nearly an inch in diameter. 
 When situated in the larynx, they destroy the voice, and greatly add 
 to the severity of the cough and the difficulty of breathing. The 
 mucous membrane of the throat is frequently found congested and 
 ulcerated ; indeed, these ulcers are often so deep and numerous that it 
 is almost impossible for the patient to swallow or speak, and in this 
 condition he may live for weeks suffering untold agony. 
 
 As we pass from the organs of respiration to those of the abdomen, 
 
24 PULMONARY TUBERCULOSIS. 
 
 we frequently find the stomach very much distended and occupying a 
 lower position than natural ; when opened, its mucous membrane 
 appears quite soft and thin, with numerous small ulcers. These are 
 the ordinary gastric ulcers, and are supposed to result from chronic 
 inflammation of the mucous membrane. 'The large perforating gastric 
 ulcer is seldom met with in phthisical patients. The glands which 
 secrete the gastric juice are often found enlarged and indurated, and I 
 have occasionally found them occupied with tubercles. The degenera- 
 tion of the gastric glands is supposed, by some writers on pathology, 
 to be the starting-point of tubercular disease. We shall consider this 
 more at length in another place. 
 
 In this disease the intestines exhibit tubercles in nearly every state, 
 with indurations and ulcers. These ulcers are usually in the small 
 intestine near its termination. They gradually corrode the intestinal 
 mucous membrane in proceeding from within outward, occasionally 
 penetrating all the coats and allowing the contents of the intestines to 
 escape into the abdominal cavity, causing sudden death. Ulcers of great 
 magnitude are sometimes found in the large intestine, producing severe 
 symptoms of dysentery, which are. very annoying to the patient, often 
 masking the pulmonary disorder, and speedily terminating his existence. 
 
 In some cases of pulmonary tuberculosis the liver is found increased 
 in size, much softer than natural, and of a paler color ; on being cut 
 it greases the knife, or more evidently shows its oily qualities by a 
 slice of it being heated on paper. This state of the organ is called 
 fatty degeneration of the liver. This disorder of the liver is also met 
 with in other chronic diseases as well as in phthisis, and is sometimes 
 seen in cases where no organic affection of any severity coexists. One 
 of the most singular things connected with this condition of the liver 
 is, that the bile is not materially altered from its healthy state. Why 
 the liver should become fatty in this disease is a problem yet to be 
 solved by medical science. 
 
 In no other disease is the emaciation so extreme as in pulmonary 
 tuberculosis. It is more strongly marked in the adipose cellular 
 membrane and muscular tissues than in the other structures of the 
 body. The internal organs of the body do not appear to suffer so 
 much in this particular as the parts just named. The brain, spleen, 
 and pancreas present no special marks of emaciation. The blood- 
 vessels commonly appear small, but this is no doubt owing to their 
 
PATHOLOGY. 25 
 
 having been long accustomed to contain only a small quantity of fluid, 
 in consequence of the copious evacuations* and the low regimen to 
 which patients are sometimes compelled to subject themselves. 
 
 The bones of consumptive subjects, although they lose nothing in 
 length, are frequently lessened in diameter and specific gravity by 
 protracted emaciation. The chests of such individuals are usually 
 narrow, and are sometimes evidently contracted. The serous mem- 
 branes and skin are pallid and bloodless. The muscles, on the 
 contrary, are usually of a bright red. The heart is always remarkable 
 on account of its smallness and firmness. 
 
 In this disorder the blood is dark in color, viscid, and exhibits no 
 tendency to form a consistent clot. Its normal constituents are defi- 
 cient, especially the red corpuscles. The fibrin, however, is in excess. 
 Although there is a marked deficiency in the quality and quantity of 
 all the animal fluids, yet they seem to have very little tendency to 
 septical decomposition, since we find that individuals suffering from 
 this disease are much less liable to gangrenous affections than others, 
 and that their bodies after death are generally slower in running into 
 decomposition. 
 
 Such is a brief outline of the changes which occur in the lungs and 
 other parts of the body in consequence of the presence of tubercles. 
 And it may not be out of place to observe that tubercles are frequently 
 found in the lungs of other animals besides man, such as the ape, 
 monkey, ox, dog, lion, and horse. In all these animals the morbid 
 products present nearly the same appearances as those observed in the 
 human system. It is a fact that most of the wild and domesticated 
 animals become affected with tubercles after a certain period of con- 
 finement. Many of the rare and beautiful animals exhibited in our 
 menageries die from this cause. The dairy cows kept in our large 
 cities, deprived of all exercise and constantly confined to close sheds, 
 are very subject to this disease. There is not the least doubt that 
 tubercles may be produced at pleasure in many animals by excluding 
 them from the open air, by making them breathe a damp, unwholesome 
 atmosphere, and by feeding them on unnutritious aliment. 
 
CHAPTER II. 
 
 THE NATURE OE PULMONARY TUBERCULOSIS. 
 
 Numerous theories are entertained by modern pathologists as to the 
 nature of this disease ; but not one of them has passed the ordeal of 
 criticism unharmed. They all have weak points, which, when put to 
 the test of rigid scrutiny, are found wanting. The reason for this is 
 that many of our medical philosophers have fallen into an error be- 
 queathed to the science of medicine by the fathers of antiquity, — that 
 of first framing their theories and then bending facts to suit them. 
 This is reversing the order of reason. It distorts and obscures her 
 teachings by giving place to falsehood, prejudice, and partisan bigotry, 
 which is greatly to be deplored in medical science, as it stands directly 
 in the way of improvement and advancement. 
 
 We hold it a cardinal doctrine in our professional creed, that those 
 who worship at the shrine of science should dismiss from their minds 
 all dishonesty and bigotry. If an individual attempts to explore the 
 field of knowledge with the spirit of a bigot or a partisan, suffering a 
 cloud of desires and aversions to hang around his understanding, he 
 will never discern objects clearly; his mind will be confused by the 
 mists of error, and the light of truth, if seen at all. will only bewilder, 
 and render his way uncertain and difficult. 
 
 Our duty is to inquire what is true, not what is the finest theory. 
 We should not allow ourselves to be bound by the opinions of others ; 
 we should think for ourselves, freely and independently. We need 
 not fear the result of free investigation ; it is the coward who shuns 
 examination and cannot look the truth full in the face. Reason and 
 free inquiry are the effectual antidotes to error. Give them free scope, 
 and they will uphold truth by bringing false opinions, and all the 
 spurious offsprings of ignorance, prejudice, and self-interest before 
 their severe tribunal; subjecting them to the test of close investiga- 
 tion, the murky clouds of error will flee before the brilliant light of 
 science. 
 26 
 
NATURE. 27 
 
 I. The Inflammatory Theory of the Nature of Tubercle. 
 
 The advocates of this theory of the origin of tubercle maintain that 
 the principal feature of this disease is inflammation or arteriality. 
 Dr. Williams, in his " Principles of Medicine," says that tubercular 
 matter may be found within the blood-vessels themselves, as he has 
 repeatedly found something presenting all the external appearance of 
 yellow tubercle in the blood-vessels of parts remote from the lungs ; 
 and he contends " that where fibrin may coagulate, there its degraded 
 form, tubercle, may occur." 
 
 Rokitansky, in his " Manual of Pathology," has labored diligently 
 to prove that tubercle is a modification of fibrin. "Arterial elabo- 
 ration of fibrin," he says, " constitutes, above all, the cardinal feature 
 of the tubercular crasis." He also maintains that in consequence of 
 the alteration of the nature of fibrin, tubercle is continually deposited, 
 even when the blood is very deficient in that constituent. All the 
 fibrin that is formed is soon affected by the peculiar dyscrasia, and is 
 thrown out in the form of tubercle. The rapid coagulation of tubercle- 
 blastema, which must be effused in a fluid form, its tendency, when 
 coagulated, to soften, — its formation being favored by active arteriali- 
 zation, and prevented by a venous condition of the blood, — are circum- 
 stances which he regards as highly indicative of a real afiinity between 
 tubercle and fibrin. 
 
 It is a notorious fact that tubercles are often found in the lungs and 
 other organs without their having manifested any symptoms of their 
 existence during life. It is also true that, if they have not passed to 
 the crude state, the tissues around them are often perfectly healthy, 
 presenting no trace of pneumonitis. Could the pulmonary tissue 
 maintain this integrity if each tubercle was the centre of inflammatory 
 action ? Inflammation appears, therefore, to be rather a consequence 
 than a cause of tubercles ; the latter forming independently of it, and 
 subsequently inducing phlogosis, like other extraneous bodies. 
 
 Laennec, in writing on the origin of tubercles, says, " From all that 
 has gone before, we are authorized to conclude that tubercles are not 
 the product of inflammation of any one of the constituent tissues of 
 the body. On the contrary, a multitude of facts prove that the 
 development of tubercle is the result of a general condition of the 
 system ; that it takes place without previous inflammation ; and that 
 
2S PULMONARY TUBERCULOSIS. 
 
 when inflammation coincides with tuberculous affections, it is most 
 frequently posterior to its origin." 
 
 Dr. Carswell rejects the inflammatory theory. He maintains that 
 tubercles in the lungs are a deposit directly from the blood. He 
 reasons thus : " The products of inflammation are coagulable lymph 
 and pus. When, therefore, other products than these are present in 
 inflammation, the conclusion to be drawn from these circumstances is, 
 that there exists some other morbid condition than inflammation, and 
 that to this condition alone should be ascribed the distinctive and 
 essential character of the product. Where the tuberculous disposition 
 exists, inflammation or any irritation may attract it to a particular 
 oro-an. Examples of this present themselves in inflammation of the 
 subcutaneous glands of the neck and kidneys, which may become 
 tuberculous from the same cause." 
 
 Dr. Campbell, in his excellent work on "Pulmonary Consumption," 
 also discards the inflammatory theory. He gives it as his opinion, 
 that the blood becomes charged with particles derived from the 
 materials of nutrition, which, being carried forward to the lungs, are 
 capable, in some organizations, of passing through their extreme 
 vessels, and hence produce no effect, but which in other cases are 
 retained in the capillaries, and thus, by gradual accumulation, form 
 masses apparently homogeneous, to which we apply the name tubercle. 
 
 Schroder van der Kolk regards the masses here described by Dr. 
 Campbell as filling the air-cells and making up the tubercles, as nothing 
 else than epithelial cells, which swell by imbibition of plastic matter, 
 enlarge, and are detached from the wall of the air-vesicle, and are in 
 no way dependent upon a morbid material for their origin, — tubercles 
 being nothing but blighted epithelial cells. 
 
 Dr. Felix von Niemeyer, in his clinical lectures on " Pulmonary 
 Phthisis," contends for a kind of mixed theory, in which inflammation 
 plays a very important part. He does not regard the disease as con- 
 stitutional, yet in places he speaks of dyscrasiae, and tells us that " the 
 great danger for most phthisical patients is, that they may become 
 tuberculous." He says it is well known that many of the lesions 
 which are attributed to tubercle are really the consequence of pneu- 
 monia, either acute or chronic, or of bronchial hemorrhage ; and no 
 form of pneumonia is so likely to be followed by phthisis as that 
 characterized by the excessive production of cells, known as catarrhal 
 
NATURE. 29 
 
 pneumonia, so called by him to contradistinguish it from Rokitansky's 
 croupal pneumonia. 
 
 Niemeyer further maintains that although phthisis generally takes 
 its origin from catarrhal pneumonia, it occasionally arises from the 
 croupal ; that the product of the inflammation undergoes what is 
 known as the caseous degeneration, and hence gives rise to the case- 
 ous masses in the lungs which are generally mistaken for softened 
 tubercle ; that frequently in the lungs of those who have been pro- 
 nounced phthisical, not a single tubercle has been found. The disease 
 of the lungs characterized by this caseous degeneration is called by 
 him phthisis, to distinguish it from that in which a deposit of miliary 
 tubercles takes place, which is true pulmonary tuberculosis. He there- 
 fore announces the following theory : Tuberculosis, in most cases, is a 
 secondary disease, arising in a manner not known to us, through the 
 influence of caseous morbid products on the organism. 
 
 Billroth, in his " Surgical Pathology," under the head of tubercu- 
 losis, remarks, " The division of tubercles into miliary gray points and 
 into cheesy nodules, the very peculiar acute miliary tuberculosis, the 
 connection of tuberculosis with other and especially with chronic 
 suppurative inflammation, and those tending to caseous degeneration, 
 were gradually developed, and in many places remained obscure, 
 although the idea of tubercle has been rendered more limited and 
 precise by Virchow, so that at present every new formation that has 
 undergone caseous degeneration is not considered tubercle. It was 
 reserved for Buhl, by careful experiment, to arrive at the idea that 
 acute miliary tuberculosis was the proper type of tubercular disease ; 
 he found it always combined with old caseous or purulent inflam- 
 mation foci ; he made the bold assertion that it always resulted from 
 absorption of substances from these foci. According to this, tubercu- 
 losis was a infectious disease, a sort of nodular exanthema on and in 
 internal organs, caused by the absorption of injurious substances, par- 
 ticularly from old caseous points of inflammation in the lymphatic 
 glands, lungs, bone, etc. Investigations of late years have shown that 
 many destructions — in the lungs, for instance — which previously had 
 been considered due to miliary tuberculosis, as a matter of course, are 
 inspissated, caseous, and partly softened spots, that must be regarded 
 as the result of a simple chronic ulcerative inflammation." 
 
 The doctrine of the inflammatory origin of tubercle has of late 
 
 3 
 
30 PULMONARY TUBERCULOSIS. 
 
 been gaining ground among German pathologists. In England and in 
 this country, although at one time very popular, it is now ignored by 
 our best physicians. All the physical signs and general symptoms, 
 with the attending pulmonary lesions, are so different from pneumo- 
 nitis, that very little need be said in review of the subject. 
 
 1. Pneumonitis is a self-limited disease, it tends to recovery; pul- 
 
 monary tuberculosis is not. 
 
 2. Pneumonitis is confined chiefly to the inferior lobes of the lungs; 
 
 tuberculosis to the superior lobes. 
 
 3. Pneumonitis seldom results in suppurating cavities ; softening 
 
 tubercles uniformly leave vomicae. 
 
 4. Pneumonitis has no specific microscopical element : tuberculosis 
 
 has, — the tubercle-cells. 
 
 5. Pneumonitis never results in the formation of caseous masses ; in 
 
 pulmonary tuberculosis they are common, being composed of 
 
 aggregated tubercle and some of the ordinary products of 
 
 inflammation. 
 
 It is maintained by most of the writers who advocate the doctrine 
 
 of the inflammatory origin of tubercle, that these caseous masses are 
 
 often found in the lungs unaccompanied by a single miliary tubercle. 
 
 This no doubt is often the case, but when any one will show me a 
 
 caseous mass, taken from the lungs of an individual who during life 
 
 has manifested marked symptoms of phthisis, that does not contain 
 
 tubercle-cells, then I will embrace the theory of the inflammatory 
 
 origin of pulmonary tuberculosis. 
 
 In our first chapter are described two varieties of tubercle, the 
 miliary and the yellow or aggregated, — the caseous masses of Nie- 
 meyer. Now, it is not uncommon to find both of these varieties in 
 the same lung. I was recently present at the post-mortem of a young 
 man, where the superior lobe of the right lung contained a large mass 
 of aggregated tubercle surrounded by a vast number of miliary tuber- 
 cles. The middle lobe of the same lung contained many miliary 
 tubercles. The inferior lobe gave evidence of recent inflammatory in- 
 duration. In the superior lobe of the left lung there was a large 
 number of miliary tubercles. The inferior lobe was congested, but 
 manifested no marks of recent inflammatory action. In the left 
 kidney there was a large mass of aggregated tubercles going through 
 the process of softening. The peritoneum was studded with a vast 
 
NATURE. 31 
 
 number of miliary tubercles, while many of the mesenteric glands 
 were occupied by large masses of aggregated tubercle. The prostate 
 gland was completely infiltrated with tubercle. A large mass of 
 tubercle was firmly imbedded in the spleen. The liver was somewhat 
 fatty, and contained several large masses of aggregated tubercle. The 
 mucous membrane of the stomach and small intestine was softened 
 in several places ; in the large intestine there were several ulcers of 
 tubercular origin. The heart was very small, but otherwise healthy. 
 Emaciation of the general system was extreme. 
 
 Now, what is the significance of this wide-spreading tubercular 
 devastation ? Is any one so blinded by the inflammatory theory of 
 the origin of tuberculosis as to suppose for one moment that the 
 individual had inflammation at all of the locations where tubercle was 
 found ? This idea would be absurd, — contrary to every pathological 
 principle that presides in the case. The rationale of the whole matter 
 is this : Tubercle first — inflammation its sequence. 
 
 II. Imperfect Hutrition. 
 
 This theory of the origin of pulmonary tuberculosis is based upon 
 the supposition that the disorder commences primarily in the organs of 
 digestion. Certain lesions are said to occur here that interfere with 
 the proper digestion of the food, and lead ultimately to the formation 
 of the morbid matter in question. As to what the precise trouble is, 
 the advocates of this theory are not agreed. Some trace it to a want 
 of gastric juice, others to an excess of acid in the stomach, others to a 
 depraved condition of the bile and pancreatic juice. Dr. Bennett is 
 an ardent advocate of the acid theory. He contends that pulmonary 
 tuberculosis arises directly from excess of acid in the stomach and 
 bowels, which interferes with healthy digestion, so as to give a pre- 
 ponderance to the albumen, and as a result there will be a deficiency 
 of oil, which in connection with albumen is essential to healthy nutri- 
 tion ; as a consequence, elementary molecules and nuclei are not 
 formed, hence abortive cell-growth ; and in this way are constituted 
 tubercular corpuscles, which form the local lesion of phthisis pul- 
 monalis. 
 
 Dr. Bennett, in his work on " Pulmonary Tuberculosis," page 30, 
 says, " One of the great difficulties in the pathology of phthisis, as 
 now brought forward, consists in the fact whilst little fatty food enters 
 
32 PULMONARY TUBERCULOSIS. 
 
 into the economy by the primary digestion, and the adipose tissues of 
 the body disappear, fat is apt to be stowed away in certain organs as 
 the result of secondary deposition, especially in the liver. This fact, 
 however, only proves that the formation of fat by the secondary 
 digestion, and as a secretion of certain organs, like the liver and 
 female mamma, are excretory products, and as such are, per se, in- 
 capable of being reabsorbed or of affording nutrition. In short, such 
 fat must undergo those changes and that elaboration which the 
 digestive functions produce, before it can be available for the forma- 
 tion of good blood, which, in its turn, is only a preliminary step to 
 health}* nutrition." 
 
 There is every reason to believe, however, that the various fatty 
 compounds are convertible into one another, — that fat, for instance, 
 introduced into the alimentary canal, or formed from the starchy and 
 saccharine parts of the food, is through elaboration transformed into 
 the fat of the liver, cholesterine, margarine, butter, etc., in which 
 condition it constitutes products to be excreted ; but that when in- 
 troduced into the alimentary canal, acted upon by the juices of its 
 various glands, and further changed by the blood-glands, it may be 
 resolved into elements capable of nutrition. The true chemistry and 
 effect of vital changes on the fatty compounds, however, have yet in 
 a great measure to be worked out by micro-chemical research. In the 
 mean time we may conclude with certainty — 
 
 1. That an oily emulsion must be formed, to constitute proper chyle 
 
 to be converted into blood. 
 
 2. That in pulmonary and other forms of tuberculosis, the process 
 
 is interfered with ; so that 
 
 3. A depraved state of the constitution is induced, which is favor- 
 
 able to the deposit of tubercular exudation into the various 
 
 tissues, but especially into the pulmonary. 
 Several years since, Dr. Hutchinson published in the London Med- 
 ical Times and Gazette a very elaborate article to prove that indiges- 
 tion was often a precursor of tuberculosis. He presents a table of fifty- 
 six cases of phthisis, in which he ascertained the state of the digestive 
 organs prior to the beginning of tha symptoms of the local disease in 
 the lungs. After stating that in a large majority of cases pulmonary 
 tuberculosis is associated with indigestion, characterized especially by 
 difficulty in the assimilation of fatty aliment, the author proceeds to 
 
NATURE. 33 
 
 describe that form which precedes the development of phthisis. Out 
 of fifty-two patients who manifested marked symptoms of indigestion, 
 the stomach-trouble preceded the pulmonary disease in thirty-three. 
 The special symptoms manifested in these cases were similar to those 
 in the confirmed examples, namely, a distaste for fat, oils, and sugar. 
 It was also further added that, in forty-eight per cent, of the cases, a 
 dislike for fat had existed throughout life. It was also remarked as 
 another characteristic feature, that acidity, manifested in eructations, 
 occurred in a large proportion of cases. 
 
 Dr. Hutchinson does not, however, consider every form of indiges- 
 tion as producing pulmonary tuberculosis. He thinks that it is con- 
 fined mostly to that variety in which there is a dislike and rejection 
 of hydro-carbonaceous food, and the production of an increased amount 
 of acid ; but finally concludes with the statement " that indigestion is 
 a mere link in the chain, and that the tubercular dyscrasia may be 
 produced without any intervening stage of indigestion." But notwith- 
 standing his admission, he immediately adds, " that the tubercular 
 dyscrasia consists, essentially, in a morbid state of the nutritive fluid, 
 which state might be just as efficiently produced by a withholding of 
 the proper articles of food, as by a refusal, on the part of the organs 
 of digestion, to assimilate them." 
 
 Dr. Edward Smith, in his book on " Consumption, its Early and 
 Remedial Stages," says, page 51, " There is commonly some derange- 
 ment of the functions of digestion, but it is frequently small, and in 
 such cases is not important. The evidence which we would adduce 
 in support of this proposition are, that the tongue is more or less dis- 
 colored, or loaded with a buff-colored coat, and presents enlarged and 
 projecting papillae, and is not unfrequently large and flabby; also, 
 that there is a sense of oppression after meals, and tenderness over 
 the epigastrium on pressure, at most periods of the day ; a sour taste 
 in the mouth, and flatulency. These conditions are more commonly 
 found with the lymphatic temperament, whilst in many of the sangui- 
 neo-nervous temperament the tongue retains its usual size and color, 
 and remains clean. It is very frequently in dressmakers, tailors, shoe- 
 makers, and others of a sedentary occupation ; in printers and others 
 living in foul air, and engaged in night-work ; and in the poor, who 
 live chiefly upon bread, potatoes, and tea ; and in all such instances it 
 is a prominent symptom, and demands prime attention. In a majority 
 
34 PULMONARY TUBERCULOSIS. 
 
 of such cases there is an intolerance of fat, and occasionally we have 
 met with instances in which fat caused pain at the stomach." 
 
 That the human system is not well nourished in pulmonary phthisis 
 is a fact which cannot be denied ; the external evidence of this is 
 too palpable. That malassimilation should constitute one of the car- 
 dinal features of the disorder is not to be wondered at ; the degenera- 
 tion and wasting away of all the tissues of the body bear ample testi- 
 mony on this point. But that this malassimilation is the original 
 cause of pulmonary tuberculosis we most seriously doubt. Individuals 
 are often very poorly nourished, and their diet may be very meagre for 
 months or even years, yet they suffer not from tuberculosis. It takes 
 something more than a want of assimilation of fat to produce this 
 wasting disease ; although animal food appears to be necessary, in most 
 cases, for the enjoyment of perfect nutrition, yet we often see persons 
 who are perfectly nourished without it, and are free from tuberculosis. 
 A want of nourishment, however, in an individual who has a proclivity 
 to phthisis pulmonalis, may, like any other debilitating cause, lead to 
 its development, but never can be a primary or originating cause: it 
 does not account for its nature. " Indeed," says Dr. Lawson, ' ; when 
 we witness, as is often the case, the -most inveterate and protracted 
 cases of dyspepsia, running, it may be, through the great part of a 
 lifetime, failing to induce phthisis, it must be acknowledged that this 
 cause, per se, is often inadequate to induce the disease. And further, 
 when we find tubercular deposits a congenital disease, it must be ad- 
 mitted that the digestive organs are not the only source of the morbid 
 condition. In such examples, primary digestion could have had no 
 agency in the production of the disease, and the same is equally true 
 of most cases occurring in early infancy."* 
 
 III. Defective Respiration. 
 
 This theory of pulmonary tuberculosis has a few able advocates, 
 among whom we may mention Dr. Edward Smith, one of the consulting 
 physicians to the Hospital for Consumptives and Diseases of the Chest, 
 Brompton, London. In the January number of the American Journal 
 of the Medical Sciences for 1862, page 84, he advances the following 
 on the origin of tubercles in the lungs : " Thus I have endeavored to 
 
 * Lawson's "Phthisis Pulmonalis/'' page 150. 
 
NATURE. 35 
 
 show that the earliest indication of phthisis is the lessened action of 
 the air-cells, and it is highly probable that this is commonly associated 
 with, or resulting from, depressing agencies. We all know in our own 
 person the temporary effect of depressing causes, as grief or disquietude 
 of any kind, over the action of the lungs, and have observed the slow 
 respiration followed by long sighs or yawns, possibly indicating the ac- 
 cumulation of carbonic acid in the air-cells of the lungs from the pre- 
 vious incomplete respiration. Moreover, as the function of respiration 
 is so important and so unceasing, and as the air-cells are of a delicate 
 organization, it is quite clear that they must be highly endowed with 
 nervous influence from the cerebro-spinal, excito-motory, and sympa- 
 thetic system, and consequently be extremely liable to their special 
 diseases. As they have the power of extension and retraction, that 
 power may be modified both toward decrease as well as increase ; and 
 they are of a delicate organization, and so endowed with nervous in- 
 fluence, it is certain that they will both sympathize greatly with the 
 nervous system and be greatly influenced by it, and also be liable to 
 their special diseases, arising more or less from local causes only. Thus 
 the lessened action which constitutes or leads phthisis may be either 
 general or local ; and whilst admitting that the multiplication of causes 
 point to a general action, we must not ignore the possibility of their 
 being due to local causes only. 
 
 "lam anxious to refer to this, for we have each of us seen cases 
 which appeared to us to have arisen from some local cause, as some 
 prior local disease ; but the prevailing notion of the general and blood 
 origin of phthisis has led us to throw doubts over the correctness of 
 our belief. Without venturing an assertion on a subject about which 
 so little is known, I would take courage to ask if there are not grounds 
 to believe that acute phthisis is the local, as contrasted with chronic 
 phthisis, which is the more general form of the disease? Upon this 
 point I would not dwell, but I feel convinced that a wide field for in- 
 quiry is yet uncultivated in the disease of the air-cells of the lungs, and 
 that whilst we may not give too much attention to the mere condition 
 of the air, we have given too little to the all-important air-vessels. 
 
 " That the lessened action of the air-cells to which I have referred, 
 as an evidence of phthisis, is exclusively restricted to this disease, I 
 dare not venture to affirm. In many cases of chronic bronchitis there 
 is lessened vesicular murmur, and lessened resonance on percussion, 
 
36 PULMONARY TUBERCULOSIS. 
 
 both due, in some degree, to the same cause, as in phthisis. When- 
 ever, however, there is lessened vesicular murmur, with lessened mo- 
 bility, and both flattening and atrophy, and at that early period short 
 and feeble inspiration, with lessened quantity of admitted air, we may 
 safely affirm that to be a case prone to tubercle." 
 
 Dr. Smith maintains further, that all these physical signs may be 
 present prior to the tubercular deposits in the lungs. Lessened res- 
 onance on percussion, lessened vesicular murmur, lessened mobility, 
 flattening and atrophy, all belong to an advance stage of the disease ; 
 they are all characteristic of an extensive tubercular consolidation. 
 If such physical signs exist previous to local deposit of tubercle in 
 the lungs, then we have studied the art of percussion and auscultation 
 in vain. If these are present during the pre-tubercular stage, they 
 are so obscure that no one has ever had the good fortune to discover 
 them but Dr. Smith, and as means of detecting the disorder at this 
 early period, to the general practitioner, they cannot be of the least 
 use in making out a diagnosis. Dr. Smith says, that when these signs 
 are present u we may safely affirm that to be a case prone to tubercle." 
 Surely it is not only prone to tubercle, but tubercles already exist. 
 They are interfering with the expansion movements of the chest ; 
 they lessen if they do not extinguish the vesicular murmur, and render 
 the chest exceeding dull on percussion. What more do we want to 
 make out a case of tubercular consolidation, or some other hardening 
 of the pulmonary structures ? 
 
 If this theory of pulmonary tuberculosis be true, then all those dis- 
 eases of the chest which impair the respiratory movements would be 
 greatly productive of it; thus, valvular obstructions of the heart, pneu- 
 monitis, pleuritis, and bronchitis would be common causes of the dis- 
 order. But this has never been demonstrated. Indeed, our best writers 
 do not consider either of these troubles a cause of phthisis. They no 
 doubt often hasten the development of the disease in individuals pre- 
 disposed to it. The theory of defective respiration, therefore, as the 
 origin of tubercles in the lungs, rests upon a very poor foundation. 
 Indeed, it is imagined by some of our medical philosophers that pul- 
 monary tuberculosis is caused by over-activity of the functions of the 
 lungs, — too rapid oxygenation of the blood ; and to remedy this is to 
 restrain their activity by increasing the venosity of the blood, all of 
 which is ignored by those who advocate the defective-respiration theory. 
 
NATURE. 37 
 
 From the present state of our knowledge on this subject, we feel free 
 to say that there is no demonstrable evidence to prove that either 
 defective respiration or even a vitiated atmosphere can originate 
 pulmonary tuberculosis. 
 
 IV. Specific Morbid Condition of the Blood. 
 
 This theory attributes the foundation of tubercles to certain morbid 
 changes in the natural constituents of the blood. The advocates of 
 this theory contend " that the blood is the seat of the process of depo- 
 sition and absorption : and no matter how tuberculous it may be, so 
 long as the balance between these processes is maintained, although 
 the nutrition may be tuberculous, no tubercles are formed. Physio- 
 logical chemistry appears to indicate of the blastema, as of the blood, 
 that its pathological condition consists of some modification of the ul- 
 timate composition, of the relation of its protean-form or oleaginous con- 
 stituents ; their carbon, nitrogen, oxygen, or some radical and primary 
 compound, being deficient or in excess ; the modification, whatever it 
 may be, rendering it incapable of forming perfectly nucleoli or germ- 
 cells, or those, if formed, being inadequate to the perfect construction 
 of the fibrin-cells. Hence, instead of contributing to the formation 
 and nutrition of the tissues, it becomes granular, and the granular 
 matter is of a more solid structure than natural, less capable of absorp- 
 tion, and more apt to accumulate in masses than the constituents of 
 healthy blastema. It thus becomes a foreign material, subject to 
 chemical and physical changes."* 
 
 That the blood suffers some very remarkable changes in phthisis is 
 a fact which will not be disputed ; and that these changes depend upon 
 some morbid element introduced into it is equally beyond dispute. 
 And it is upon this special morbid element in the blood that the tu- 
 bercular diathesis depends. Without this there could be no such thing 
 as phthisis pulmonalis, no more than there could be syphilis or syph- 
 iloma without a specific virus. And it would be a matter of great 
 practical advantage if we were able to tell the precise condition of 
 the blood upon which this predisposition depends. But it is too occult 
 to be detected either by the microscope or by chemical analysis. 
 
 Dr. Andrew Clark has frequently employed the microscope with 
 
 * Ancell, " On Tuberculosis," page 573. 
 
3S PULMONARY TUBERCULOSIS. 
 
 this view, but has never been able to discover any difference in the 
 appearance of the blood in the phthisical and in those in health. These 
 remarks apply to the first stage of the disease ; in the latter stage 
 there is a visible difference. The red corpuscles are often found de- 
 ficient in quantity and blighted in appearance. In very marked and 
 rapidly-fatal cases they lose their characteristic form, and seem to 
 melt into confused masses. But as the same thing occurs in other 
 diseases, little practical value can be attached to it, especially when we 
 are seeking to discover the nature of a disease so complicated as pul- 
 monary tuberculosis. 
 
 In the September number, 1861, of the St. Louis Medical and 
 Surgical Journal, Dr. S. R. S. Curtis has a very ingenious article on 
 the " Pathology of Tubercle," in which he attempts to prove that the 
 blood has no direct agency in its formation, or that it is in any way at 
 fault in this malady. We cannot quote all he has to say on this sub- 
 ject, but will present a few paragraphs to show his mode of reasoning. 
 
 In the course of his argument he says, " There is one other circum- 
 stance, of the greatest importance, which must not be overlooked, and 
 which is applicable to tuberculosis as to cancer, and that is, the blood 
 has no direct formative power in itself, and consequently cannot directly 
 form even the simplest organ of the body, its purpose in this respect 
 being to distribute through the molecular structure of organs the 
 materials suitable for growth and development, which material is 
 selected from the mass by the molecules ; for the molecules have a 
 discriminating power of selecting from the blood such material as is 
 best suited for their growth and development, and rejecting that which 
 is unsuited, and by them so elaborated as to enter into the formation 
 or subserve the function of the organs which they represent. 
 
 " Bearing upon this point, and in opposition to the doctrine of 
 'free-cell development,' Virchow most ably remarks, 'Even in pa- 
 thology we cannot go so far as to establish, as a general principle, that 
 no development of any kind begins de novo, and consequently to reject 
 the theory of equivocal (spontaneous) generation just as much in the 
 history of the development of individual parts as we do in that of 
 entire organisms. Just as little can we admit that taenia can arise out 
 of saburral mucus, or that out of the residue of the decomposition of 
 animal or vegetable matter an infusorial animalcule, a fungus or alga, 
 can be formed : equally little are we disposed to concede, either physio- 
 
NATURE. 39 
 
 logically or from pathological histology, that a cell can build itself up 
 out of any non-cellular structure. Where a cell arises, there a cell 
 must previously have existed (pmnis cellula a cellula), just as an 
 animal can spring only from an animal, a plant only from a plant. 
 Consequently, we cannot regard cancer or tubercle as the direct result 
 of a depraved condition of the blood, without claiming for the blood a 
 direct formative power, or without denying to the tissues their prop- 
 erty of discriminative selection, either of which positions would be 
 contrary to the known and acknowledged principles of physiology.' 
 
 " That the materials of which these normal products are formed is 
 derived from the blood we would not be understood to deny ; but we 
 claim that such material is derived from normal healthy blood, and 
 not blood in a depraved condition. The same blood, for instance, 
 which supplies to an abnormal malignant growth the material for 
 development, supplies to all organs of the body healthy materials for 
 growth and function. In other words, this morbid condition of 
 vitality, having once become established in a given organ or part, 
 possesses in its ultimate structure the same power of discriminating 
 and selecting from the blood the matter they require, as the molecular 
 structure of healthy tissues. The same condition is observed in the 
 vegetable world. From some cause an excrescence begins to form on 
 a tree or plant. This unnatural action having once been established, 
 for years, or perhaps during the whole life of the tree or plant, this 
 morbid growth derives from the healthy sap the materials for its in- 
 crease, just as the body and branches derive their support from the 
 same source." 
 
 This theory of Dr. Curtis's looks very plausible. But his reasoning 
 is altogether too hypothetical. If cancer is not a blood malady, wiU 
 he, or any of the advocates of this theory, have the goodness to tell us 
 why it is that, after removing the original seat of the malignant de- 
 posit, it will in almost every case reappear in some other locality ? 
 Take as an example a scirrhous breast. Let it be amputated to-day, — 
 every vestige of the local disease removed. In three weeks the wound 
 is perfectly cicatrized, and the patient is dismissed. In six months 
 she returns : the constitution malady has reappeared ; now it is in the 
 axilla, submaxillary glands, or lungs. 'The cicatrix on the breast looks 
 healthy. The parts above named have become the scavengers through 
 which nature seeks to eliminate the depraved products ; but they are 
 
40 PULMONARY TUBERCULOSIS. 
 
 insufficient, and death speedily claims his victim. I have known more 
 than thirty cases of this kiud, and my experience may be quite dif- 
 ferent from other physicians when I record the fact that I never knew 
 a case of scirrhous cancer cured by extirpating the local disease. It 
 has always reappeared with redoubled activity, and terminated the in- 
 dividual's life much sooner than if no operation had been performed. 
 And the same is, to a certain extent, the case with tubercular disease. 
 When it is arrested in one organ it will not unfrequently speedily 
 make its appearance in another, manifesting, beyond all controversy, 
 that the trouble, whatever it may be, is not local, but constitutional, 
 — a specific blood malady, which in the present state of our patho- 
 logical knowledge cannot be defined. 
 
 One of the strongest arguments, however, which can be found to 
 prove that tuberculosis depends upon a specific morbid condition of 
 the blood, is the antagonism which exists between it and cancer, prov- 
 ing very clearly that they are both specific diseases, and that there is 
 no relation between them. And that when they both exist in the 
 same system, the one or the other will be the preponderating disorder, 
 just in proportion as they are supplied by the blood with appropriate 
 material for their development and growth. Sir James Paget, in his 
 lectures on "Surgical Pathology/' page 159, presents a very remarka- 
 ble case illustrating the incompatibility of tuberculosis with cancer. 
 He removed the breast of a young woman, in eluding a large mass of 
 well-marked scirrhous cancer. Six months after the operation, the dis- 
 ease reappeared in the scar and in the axillary glands. For twelve 
 months it made considerable progress, not only in the parts just 
 named, but in other portions of the body. Suddenly the cancerous 
 disease commenced to decline. The patient in the mean time lost 
 strength, became thinner, gradually sinking, and died with marked 
 symptoms of pulmonary tuberculosis. On post-mortem the lungs 
 contained no cancer, but were full of groups of gray succulent tuber- 
 cles, with grayish tuberculous infiltrations in every part except their 
 apices, where were numerous small, irregular tuberculous cavities. 
 " The contrast was so striking," says Paget, "in this case between the 
 appearance of active recent progress in the tuberculous disease, and of 
 the opposite course in the cancerous disease found after death ; and I 
 can hardly doubt that, during life, the progress of the one had been at 
 first coincident, and then commensurate, with the regress of the other." 
 
NATURE. 41 
 
 Sir James also details a case in which active tuberculous disease of 
 the lungs was arrested immediately before the appearance of scirrhus 
 in the breast, which would lead us to conclude with much certainty 
 that there is a marked incompatibility between the two morbid con- 
 ditions. Some writers fancy an identity between syphilis, cancer, 
 and tubercle, — syphilis the parent, cancer and tubercle the offsprings. 
 The idea is a delusion, and, in a practical point of view, has led to the 
 most disastrous results. The conversion of one specific disease into 
 another is contrary to the laws which govern all specific morbid diseases. 
 It is true syphilis may act as an inducing cause of phthisis, but to say 
 that there is any identity between them would be about as rational 
 as to affirm that there is an identity between smallpox and scarlatina. 
 
 V. Imperfect Innervation. 
 
 This theory of pulmonary tuberculosis starts out with the idea that 
 the primary cause of the disease consists in a morbid condition of the 
 nerves of organic life, and that, as a consequence of this, the blood 
 becomes unfit for healthy nutrition, and, in persons predisposed to 
 phthisis, tubercular matter is eliminated in the lungs ; and that, 
 although the morbid product thus deposited in the lungs may be 
 traced directly to the blood, the primary cause of the whole trouble 
 is imperfect innervation. 
 
 " Faulty innervation of the pneumogastric nerve is \h& primary 
 cause of pulmonary consumption," exclaims a grandiloquent medical 
 writer. " Can we prove it to be so? Yes, we can beyond the shadow 
 of a doubt, if the cause of any other disease can be discovered by the 
 process of rational induction. This nerve supplies the stomach, lungs, 
 larynx, and oesophagus with their principal nervous power, and they 
 are the first to show signs of any abnormal condition in the incipient 
 stage of the disease, the symptoms of which occur a long time pre- 
 vious to the localization of tubercles, — even previous to the appearance 
 of haemoptysis, — and are manifested by imperfect digestion, quickened 
 respiration, weakness of voice, and occasionally difficulty of deglutition. 
 Simultaneously, or probably previously, there is an abnormal quantity 
 of phosphoric acid set free from the economy. Now, we cannot say 
 for certain that this acid is the product of diseased nervous structure ; 
 but one thing is certain, it detracts from the nerve-power of the entire 
 organization. We cannot say either whether it is the cause or result 
 
42 PULMOXABr TUBERCULOSIS. 
 
 of nervous disorder, but in all diseases of the nervous system it is dis- 
 charged in unusual quantities.' 1 * 
 
 This theory of pulmonary tuberculosis might perhaps pass the 
 ordeal of criticism without harm, were it not for the fact that tuber- 
 cles are frequently found in parts over which the pneuniogastric nerve 
 has no control. I have now before me a specimen of tubercular 
 matter found in the Sylvian fissure of the brain of a boy fourteen 
 years of age. If the above theory is correct, this deposit should 
 have been in the lungs or stomach. But this theory is not tenable 
 either by the physiology or pathology which obtain in this case. If 
 there is any want of innervation, it must be one of the effects and not 
 the cause of the disease. Just as we have maintained in another 
 article, in relation to the menses : they cease not from any disease in 
 the organs of generation, but from a failure of the vital fluid which 
 nourishes and sustains them, hence we do not consider their su\ 
 sion a cause of tuberculosis. 
 
 In phthisis pulmonalis we are not willing to admit any want of in- 
 nervation. According to our observation, the nervous system generally 
 maintains its integrity until the last. The brain, in particular, appears 
 to be exalted in its functions, and the mind is frequently exceedingly 
 brilliant. There appears to be no depression of the nervous powers, 
 — this indeed is one of the most distinguishing characteristics of this 
 dreaded malady. If it originated primarily in the nervous system. 
 this integrity of functions would not form so marked a feature. — 
 organic lesions and functional derangements in the nervous svstem 
 would always be found as necessary concomitants, which is not the fact. 
 
 VI. Retrograde Metamorphosis of the Tissues. 
 
 This theory of the origin of tubercle ascribes it to a retrograde met- 
 amorphosis of the tissues, in which the lower grade of cell-growth : 
 the place of the higher ; and, as a consequence, tissues are not only 
 imperfectly developed, but there is likewise a retrograde action mani- 
 fest. Thus, cells of a lower grade of action take the place of the higher 
 or coherent cells, and the tissues are constantly degenerated. 
 
 Dr. L. M. Lawson, in his " Practical Treatise on Phthisis Pulmo- 
 
 z Dr. F. A. Anderson, in the Cincinnati " Medical and Surgical Xews" for June. 
 1861. 
 
NATURE. 43 
 
 nalis," favors this theory. On page 165 he says, "Taking all these 
 facts into consideration, I am led to the conclusion that tubercle is 
 almost of necessity the product of the metamorphosis of the tissues. 
 It is here, and here alone, that we find those important changes taking 
 place which result in new combinations, chemical and organic, and 
 which, passing into the blood, lead to local disease. This may be 
 termed a diathesis when it is the result of a peculiar constitutional 
 conformation, which, by its own natural tendency, eventuates in a 
 specific form of disease." 
 
 That the solid tissues have anything to do with the originating of 
 the tubercular element we cannot admit. They have no more to do 
 with it than they have to do with originating the red corpuscles of 
 the blood. It is true there may be a defect in the original cell-growth, 
 which may interfere with the healthy nutrition of the tissues ; but 
 tubercle is a kind of matter which cannot be incorporated into the 
 cell-tissue of any part ; indeed, it may exist in the blood for months 
 before it is deposited in any organ. When thus deposited, it is an 
 exudation from the capillary vessels, and this is confirmed by the fact 
 that tubercle, when thus found, is at first in a semi-fluid, transparent 
 state, " confined exclusively to the interstices of the tissues ; or, in 
 other words, that it is an extravascular deposit, filling up the tissues, 
 and investing them as closely and firmly as the stones of a wall are by 
 the solid mortar which has been applied between them."* 
 
 Whatever retrograde metamorphosis takes place in the tissues is 
 produced by this foreign matter, and it has been proven that whenever 
 tubercle has been deposited in the tissues of an organ, it must sooner 
 or later produce its dissolution : this is its general sequence. 
 
 But physicians may reason as they will in regard to the origin of 
 tubercles in the lungs, they cannot close their eyes to the fact that 
 there are certain morbid changes in the blood which render it unfit 
 for healthy nutrition ; and that when thus affected it leads to the ex- 
 udation of tubercle in the lungs or in some other organ ; and that 
 when thus deposited, it is not capable of being assimilated into the 
 texture of the organs, and, if not absorbed, sooner or later produces 
 their dissolution and all its attendant phenomena. 
 
 This is now the generally received opinion among medical writers 
 
 Vogel's Pathology, p. 225. 
 
44 PULMONARY TUBERCULOSIS. 
 
 as to the origin of pulmonary tuberculosis, and all of our most scien- 
 tific physicians, both in this country and in Europe, base their treat- 
 ment upon it. We cannot enter into a full description of this theory, 
 for our article has already passed far beyond the bounds prescribed in 
 our original plan. We will, however, explain it as briefly as we can, 
 avoiding technicalities as much as possible. 
 
 In order, therefore, to understand the whole process of tubercular 
 disease, it must be considered in connection with the various manifesta- 
 tations displayed in the process which originates organized tissues. It 
 is a conceded doctrine with modern physiologists that the primitive 
 structure of all the tissues of the human body is composed of minute 
 cell- formations and cell-germs ; and these cells are capable of reproduc- 
 tion so long as they are supplied with blood that is appropriate for their 
 formation. When, therefore, all the organic functions are properly per- 
 formed, and the body is in a normal state, there is always a continual 
 disintegration and reproduction of cell-structures. Thus, while on the 
 one hand there is a process continually going on in the body which 
 destroys, there is another which builds up and repairs. 
 
 So long, therefore, as these two processes are thoroughly maintained, 
 there will be health in all the various tissues of the body. Nothing 
 can interrupt it but a material diminution of the original cell-supply, 
 which depends upon a normal performance of the functions of nutri- 
 tion. Hence we trace all the primary forms assumed in the process 
 of developing solid animal tissues to the blood, thereby assuming for 
 the circulating fluid a power of such great importance that without it 
 all the vital changes must cease. 
 
 Now, in pulmonary consumption it has been clearly demonstrated 
 that from a failure in some of the blood-making or blood-purifying 
 organs the blood loses its normal constituents. The beautiful harmony 
 and perfect relation which existed between it and the tissues have 
 departed. The rich materials formerly abounding in it are no longer 
 to be found ; the cell-germ, which, in a healthy state, was conveyed 
 to the remotest tissues and deposited as the nucleus of a plastic struc- 
 ture, has been replaced by one of the lowest and most degenerated 
 materials ever formed in the human body, not capable of the least 
 organization, nor contributing in any way to the nutrition of the parts 
 in which it is deposited ; but, on the contrary, is disorganizing in its 
 nature and tendency. 
 
NATURE. 45 
 
 It is a fact which cannot be denied that, in this instance, the healthy 
 process of nutrition has undergone a perfect change ; the plasticity of 
 the blood has degenerated into a depraved habit, and the plastic forces, 
 instead of compliance with the laws of normal organization, are now 
 subject to a great deviation. If we reflect how injurious to the organs 
 of the body must be the effect exerted through the blood thus degen- 
 erated, — if not positively vitiated, — carrying to all the tissues of the 
 body materials of a very destructive character, we may easily un- 
 derstand why it proves so injurious to the lungs and other vital 
 organs. 
 
 In this way the system not only sustains a negative injury in the 
 arrest of plastic forces, in consequence of the notable deficiency of 
 organizable constituents, but a positive evil resulting from noxious 
 elements present, demanding their speedy exit; and the organs evincing 
 the greatest proclivity to participate in the progressing decay become 
 the receptacle for the depraved product. And observation has certified 
 the fact that the lungs are the organs most frequently selected, particu- 
 larly in the adult, for the purpose of eliminating this offending matter 
 from the organization. 
 
 Now, if we contemplate for a moment how vitally dependent upon 
 the integrity of the pulmonary functions is the adequate preparation 
 of the blood for the use which it is destined to serve in the system, we 
 at once have a direct clue to the series of perverted actions and torpid 
 functions made manifest. The abnormal elements which give rise to 
 the depraved blood finding efficient scavengers in the lungs, the vital- 
 izing functions become impaired in consequence of the impediment 
 offered to the respiration by the accumulation of tubercular deposits, 
 which, still further depraving the quality of the blood, accelerate the 
 formation of morbid matter, thereby increasing the burden of the lungs, 
 and thus becoming cause and effect, until the elaborating process is 
 paralyzed and nutrition permanently arrested. 
 
 If we admit this theory of the formation of tubercular deposits, we 
 may readily explain why it is that the lungs are the most liable of all 
 the organs of the body to tubercular disease. They are the chief or- 
 gans for the purification of the blood ; anything that tends to check 
 this process, and arrest the free circulation of the blood, must have a 
 direct tendency to produce an elimination of the morbid product. 
 Hence the apices of the lungs, from being inclosed in a less yielding 
 
 4 
 
46 PULMONARY TUBERCULOSIS. 
 
 part of the chest, mechanically favor the effusion more than the lower 
 lobes. 
 
 From a careful review of this whole subject we think we are fully 
 warranted in drawing the following conclusions : 
 
 1. That pulmonary tuberculosis is a specific disease depending upon 
 a morbid condition of the blood, which leads to a discharge of some 
 of its depraved constituents on the external surface of the air-cells and 
 under the basement membrane. 
 
 2. That this morbid matter is not capable of being assimilated into 
 their textures, nor in any way contributing to their growth or main- 
 tenance, and ultimately leads to their dissolution and all its attendant 
 phenomena. 
 
 3. That the tubercular diathesis increases, and is attended with 
 cachexia which is often disproportionate to the local disorder, thus 
 clearly proving its specific and constitutional origin. Tubercular disease 
 may, however, sometimes cease in part ; yet if we look to its fearful 
 mortality as an index of its natural course, we may see in it a law of 
 increase like that exemplified in some of the more malignant disorders, 
 such as cancer and the like. And such a law is not exemplified in 
 ordinary local diseases, for they generally tend to subside with the 
 lapse of time. 
 
CHAPTER III. 
 
 THE BLOOD : ITS CONDITION IN PULMONARY TUBERCULOSIS. 
 
 I. The Nature of the Blood. 
 
 The blood has been compared by some writers to a mighty river, 
 endowed with life, impetuously rushing through every part of the body 
 by a vast net-work of canals. In the course of three hundred and 
 sixty-five days, these canals carry not less than three thousand pounds' 
 weight of nutritive material to the various tissues of the body, and the 
 same amount of waste material from them. The blood is also regarded 
 as the great centre of chemical and vital action, as wonderful as they are 
 indispensable, soliciting our attention no less by the many problems 
 afforded to speculative ingenuity, than by the important practical 
 conclusions to which our ideas respecting them lead. 
 
 By some medical philosophers, the blood is regarded as the chief 
 source of all disease ; hence, in tracing out the cause of pulmonary 
 consumption, they find in the blood, as they suppose, specific morbid 
 agents, which produce all the local lesions of this most fatal malady. 
 To what extent the blood is chargeable with these injuries cannot, in 
 the present state of our knowledge, be determined. The subject has 
 not been investigated with that care and attention which its command- 
 ing importance demands. The most of our systematic works contain 
 but little on this subject of any practical value. That there is a dif- 
 ference in the blood of -health and in that of consumption can be 
 demonstrated, especially after the disease has become well established ; 
 but to do this successfully we must first know what healthy blood is. 
 
 Living healthy blood, by which we mean that which is still circu- 
 lating in the living vessels, may be seen to consist of a transparent, 
 nearly colorless liquid, which has been called liquor sanguinis; in 
 which are numerous red and white corpuscles. On the other hand, 
 when the blood has been drawn from the living vessels and allowed 
 to remain at rest, a spontaneous coagulation takes place, separating it 
 
 47 
 
4S PULMONARY TUBERCULOSIS. 
 
 into crassamentum and serum. The crass amentum or clot is com- 
 posed of fibrin and corpuscles ; the serum, of albumen, dissolved animal 
 matter, and various salts. Thus there are five principal constituents 
 in the blood : corpuscles, fibrin, albumen, dissolved animal matter, and 
 salts. We shall treat of them separately. 
 
 II. The Red Corpuscles. 
 
 The red corpuscles are the portion of blood on which its vivifying 
 and calorific properties depend. They are distinct structures, living 
 cells, or celliform nuclei, and may be seen by the microscope when 
 magnified about four hundred diameters. In size they vaiy from the 
 2029th to the 2637th part of an inch. They are somewhat flattened, 
 and have a distinct circular outline. They are said to readily distend 
 themselves by endosmosis, with thin fluid, and, on sudden pressure 
 being applied, and sometimes from other causes, they assume a kind 
 of notched form, conveying the idea that the central mass is broken 
 up into a number of granules pressing irregularly outward the homo- 
 geneous envelope. 
 
 The chief chemical constituent of the red corpuscles is haernatin ; 
 this, when analyzed again, is found to be composed mostly of iron. 
 Liebig looks upon iron as the real agent by means of which oxygen 
 is carried through the circulation and brought to act upon the various 
 tissues of the body. He supposes that if iron, in its original state, be 
 the proto-oxide, it may become the peroxide by uniting with an ad- 
 ditional atom of oxygen, or the protocarbonate by the addition of an 
 atom of carbonic acid. The first change he maintains takes place in 
 the lungs, to which the blood comes charged with carbonic acid ; the 
 carbonic acid is given up by the iron, and replaced by an equivalent 
 of oxygen taken in from the air ; while in the systemic capillaries the 
 second change is accomplished, the oxygen being here imparted to 
 the tissues and replaced by carbonic acid, which is given up by them 
 to be conveyed out of the system. Liebig also maintains that there 
 is far more than sufficient iron in the whole mass of the blood to 
 convey, in this manner, all the oxygen and carbonic acid which are 
 interchanged between the pulmonary and systemic capillaries. 
 
 This is a very ingenious and beautiful theory to account for the use 
 of the red corpuscles, but, like very many others, it cannot be received 
 as a physiological fact. It needs demonstration. But how are we to 
 
CONDITION OF THE BLOOD. 49 
 
 arrive at a definite conclusion as to their use? A brief glance at a few 
 facts in comparative physiology will solve the problem. The existence 
 of the red corpuscles in the blood is confined almost exclusively to the 
 vertebrated class ; the corpuscles which we find in the blood of the 
 invertebrated are mostly white, and are very similar to those we are 
 presently to describe. Among the lower invertebrata, the red cor- 
 puscles are entirely wanting, and the same has been discovered to be 
 the case with the embryos of some of the highest animals at a very 
 early period of their existence. 
 
 From these facts, it may be inferred that the red corpuscles are not 
 necessary to the organizable elements of the blood. This being the 
 case, we must look to some other department of the organization for 
 their use. No intelligent physiologist will deny that they undergo 
 very important changes in the systemic capillaries, their color being- 
 changed from purple to red in the former, and from red to purple in 
 the latter ; the conclusion is obvious that they have, as their principal 
 office, the introduction of oxygen into the blood that circulates through 
 the systemic capillaries, and the removal of the carbonic acid set free 
 there; serving, in fact, as the medium for bringing the tissues in 
 relation with the air, the influence of which is necessary for the main- 
 tenance of their vital activity. 
 
 In pulmonary tuberculosis, the red corpuscles are commonly deficient. 
 In a normal condition of the blood, the red corpuscles constitute about 
 one hundred and twenty-seven parts in one thousand. In consumption 
 they have been known to fall as low as sixty in one thousand parts ; this 
 was in the last stage of the disease. In most instances, they will not 
 fall much lower than seventy in one thousand. The consequence of 
 such a want of one of the most important constituents of the blood 
 cannot fail to be attended with very injurious consequences to the 
 whole system. All of the tissues of the body must suffer more or less 
 from the want of oxygen and the retention of noxious elements in the 
 circulating medium, which are a positive hinderance to their health. 
 
 In pulmonary tuberculosis, we can seldom restore the red corpuscles 
 to their normal standard. We may supply the materials for making 
 them, but in addition to the blood malady we have a local complica- 
 tion : a fearful mutation in the lungs which is not directly amenable 
 to treatment. The reciprocal healthy action between the lungs and 
 blood is gone, and no effort of medical skill can entirely restore them 
 
50 PULMONARY TUBERCULOSIS. 
 
 to their former normal action. Any approximation to such a result 
 may be looked upon as a favorable omen. Iron, quinia, strychnia, 
 and cod-liver oil all have an influence in that direction ; they are 
 invaluable remedies in this disorder, and should be administered ad 
 libitum. 
 
 III. The White Corpuscles. 
 
 t The white corpuscles are much larger than the red. Under the 
 microscope they appear to be round vesicles, containing a number of 
 excessively minute particles imbedded in a gelatinous substance. Their 
 general appearance is, however, by no means uniform ; they vary 
 much in size and form. The cause of this has been traced to their 
 different degrees of development, for it has been definitely settled by 
 the researches of modern physiologists that the white corpuscles 
 originate in the plasma of the blood, and that in the first stage of 
 their existence they are granular, and are ultimately developed in per- 
 fect cell structures. 
 
 In these cell structures, when examined in their early condition, the 
 cell-wall can scarcely be distinguished from the large nucleus to which 
 it is attached, unless the cell be distended with water, which will show 
 the nucleus to be in a soft granular tuberculated state, disposed to 
 break up readily into two or more fragments. In the latter stage, of 
 those at least which do not go on to full development, we find the 
 nucleus apparently dispersed into numerous isolated particles, which 
 give the cell a somewhat granular appearance ; and these particles may 
 be seen in molecular movements within the cell, and in some instances 
 they are so marked as forcibly to remind one of the contractions and 
 expansions of that very minute microscopic animalcule amoeba, prob- 
 ably the smallest of all organic beings. 
 
 The white corpuscles are not very numerous in healthy blood. — 
 about one to three hundred of the red ; and this may be readily 
 accounted for if we admit what is claimed for them by Dr. Draper 
 and some other physiologists, that they are the early stage of the red 
 corpuscles. Others, on the contrary, deny this, and assert that they 
 are the chief agents in the formation of fibrin, which they elaborate 
 out of albumen, imparting to it its peculiar coagulating and so-called 
 plastic properties. Dr. Carpenter is a strenuous advocate of the latter 
 opinion, and has discussed it quite extensively in his "Human Physi- 
 ology," and in several other papers published in the medical journals. 
 
CONDITION OF THE BLOOD. 51 
 
 In his " Human Physiology," page 129, after alluding to some experi- 
 ments of Drs. Addison and Williams, as well as some of his own, to 
 prove the connection between the generation of the white corpuscles in 
 the blood and the production of fibrin, he says,— 
 
 " These facts, therefore, afford strong grounds for the belief that the 
 production of fibrin in the blood is closely connected with the develop- 
 ment of the white corpuscles ; and when we consider them in con- 
 nection with the facts previously urged, there scarcely appears to be a 
 reasonable doubt that the elaboration of fibrin is a consequence of this 
 form of cell-life, and is, in fact, one of its express objects. The fact 
 that in the invertebrated the white corpuscle never undergoes that 
 high state of development which consists in its conversion into the 
 red, and that in inflammation we have the proportion of white corpus- 
 cles to the red augmented (in man) from about 1.50 to 1.10 without 
 any consequent augmentation of the red corpuscles, sufficiently proves 
 that there is some other termination of the existence of the white 
 corpuscles than their development into red ; and it seems probable 
 that a considerable portion of them rupture or deliquesce, so as to 
 yield up their fibrinous contents without undergoing that further 
 change." 
 
 We cannot see very much force in this reasoning of Dr. Carpenter, 
 for the very same arguments have been employed by others to prove 
 that the red corpuscles are the principal agents in elaborating fibrin ; 
 we, therefore, reject the views advanced by Dr. Carpenter, and fully 
 indorse those of Dr. Draper and others, that they are undeveloped red 
 corpuscles. 
 
 In pulmonary tuberculosis, the white corpuscles are usually in- 
 creased in numbers. This is owing to the circumstance that they are 
 not furnished with hsematin as rapidly as in health, hence, while 
 there is a deficiency of red corpuscles, there is an increase of white. 
 When they exist in superabundance they are exceedingly burdensome 
 to the organs of circulation, and add very materially to the patient's 
 suffering. The reason for this is to be found in the adhesive properties 
 of the white corpuscles, as, under certain circumstances, they cling, to 
 other parts with a tenacity which the red corpuscles have not. Thus, 
 in blood in which there is an actual increase in the number of white 
 corpuscles, it is extremely common for agglutinations to take place 
 among them as soon as the red corpuscles are diminished and the 
 
52 PULMONARY TUBERCULOSIS. 
 
 muscular strength of the heart and blood-vessels is lessened ; indeed, 
 in every vessel in which the stream becomes slower and the pressure 
 weaker, an agglutination of the white corpuscles may take place. 
 
 This condition of the blood in consumption renders its circulation 
 very difficult, and demands such remedies as will diminish their num- 
 ber. Iron, quinia, cod-liver oil, chlorate of potash, and strychnia are 
 therapeutical agents of great value in this case. 
 
 IV. The Fibrin. 
 
 The fibrin is one of the most important parts of the blood, the most 
 universally diffused of the animal system, the most necessary for the 
 supply and growth of the tissues. It may be easily seen by submitting 
 a clot to repeated ablutions in water, when the red corpuscles will be 
 entirely separated, leaving nothing but the clear fibrin. In this con- 
 dition it possesses the softness and elasticity which characterizes the 
 flesh of animals, and contains about the fourth of its weight of water. 
 Under the microscope it exhibits fibres, cells, and granules. 
 
 It has been universally believed among - physiologists that the co- 
 agulation of the blood was principally owing to the solidification of 
 the liquid fibrin. But it has been recently demonstrated by M. Ber- 
 nard that blood entirely deprived of its fibrin will coagulate. He 
 whipped out all the fibrin from some blood, and found that when it 
 was even impossible to get any more, the blood subsequently coagu- 
 lated. While it is perfectly evident that the blood will coagulate 
 without fibrin, it is equally well known that it will not often coagulate 
 when fibrin is present even in excess. 
 
 Dr. Bichardson has proved this very clearly in his essay on the 
 causes of coagulation of the blood. On page 34 he says. " Morgagni 
 had described the blood as quite fluid after death in only four cases ; 
 all these were cases in which death ensued from slow arrest of the 
 respiration." Three American physicians, Drs. Peters, Goldsmith, and 
 Moses, have published a report of the appearance of the blood in 
 twelve cases of death resulting from the excessive use of ardent spirits. 
 In every case the blood was fluid and dark, was of a cherry-juice 
 appearance, and showed no tendency to coagulate. In death from 
 narcotic poisoning, from delirium tremens, typhoid fever, and yellow 
 fever, the blood is generally described as thin and uncoagulable. Dr. 
 John Davy found the blood fluid and uncoagulable on exposure in 
 
CONDITION OF THE BLOOD. 53 
 
 cases of drowning, hanging, suffocation from the fumes of charcoal, 
 and effusion of blood into the pulmonary air-cells. 
 
 In pulmonary tuberculosis the fibrin is commonly in excess ; it ex- 
 hibits little or no tendency to form a consistent clot. This can be 
 accounted for only by the supposition that the fibrin in this disease 
 has degenerated, and lost some of its vital properties. In consequence 
 of this degeneration in the quality of the fibrin, it is considered by 
 some physicians as the chief source of tubercular deposits in the va- 
 rious tissues of the body. But this opinion of the origin of tubercle 
 is exceedingly hypothetical, for we find the same degeneration of fibrin 
 in other diseases, particularly in rheumatism, typhoid fever, diabetes, 
 and erysipelas. In all these diseases the fibrin undergoes a great 
 change, and is quite unfit for supplying the tissues of the body with 
 the appropriate materials for their growth and maintenance. 
 
 In pulmonary tuberculosis the fibrin in the blood can be very much 
 reduced by the judicious use of nitre, iodide of potassium, soda, opium, 
 aconite, the bitter tonics, and cod-liver oil, and in some cases attended 
 with intercurrent pneumonia and pleurisy. Calomel will reduce it, as 
 well as all the other constituents of the blood, in a remarkable degree, 
 and should, therefore, be administered with the greatest caution in 
 this malady. The proto-iodide of mercury is a very valuable com- 
 bination of therapeutical agents. As an alterative it has few equals, 
 and as a defibrinate it has no equal. In all cases of phthisis attended 
 with much inflammatory action in the pulmonary tissues, it is very 
 useful, in doses of one-fourth of a grain morning and evening. If 
 there is any medical agent in the world that has the power to promote 
 the absorption of fibrin or crude tubercle, it is the proto-iodide of 
 mercury. 
 
 V. The Albumen. 
 
 This is the chief constituent of the serum. It is generally believed 
 to be useful in affording the materials from which fibrin is elaborated. 
 It is also further useful in giving to the serum a consistency favorable 
 for its circulation ; for suspending and preserving the corpuscles from 
 injury, and blandly sheathing the acrimony of the saline constituents. 
 It was for a long time supposed that there was little or no difference 
 between albumen and fibrin, in their relations to the living organized 
 tissues ; but it has recently been clearly demonstrated that there is a 
 very important difference. It is a well-known fact that albumen has 
 
54 PULMONARY TUBERCULOSIS. 
 
 no tendency to coagulate excepting under the influence of agents 
 purely chemical ; and when thus coagulated it is entirely destitute of 
 structure, being simply a homogeneous aggregation of particles ; while, 
 on the other hand, fibrin manifests a uniform tendency to pass into 
 the form of solid tissue ; and it seems restrained from doing so only by 
 certain influences the nature of which we do not at present understand. 
 The conversion of albumen into fibrin may be said to be the first 
 step in the process of nutrition, by which the materials supplied by 
 the food are made to form part of the living tissue of the body ; and 
 it is one to which some writers have very appropriately applied the 
 term assimilation. This process is very incomplete in pulmonary 
 consumption, and constitutes one of its most distinguishing features. 
 Faulty assimilation may be said to be the first step in all those local 
 lesions which occur in this disease. In consumption this portion of 
 the blood is increased. In healthy blood, albumen constitutes about 
 seventy parts in one thousand ; in this malady it is sometimes found 
 as high as one hundred parts in one thousand, but, like fibrin, it is 
 depraved in quality, and shrinks far below the normal standard of 
 vitality. There are no special therapeutics for this condition of the 
 blood besides such as have already been named. The wine of beef 
 and iron I have found of great value to my tubercular patients as 
 blood-food. Pepsin is also useful in this condition. 
 
 VI. The Dissolved Animal Matter in the Blood. 
 
 From a careful analysis of the blood made by Simon, it appears that 
 one portion of the dissolved animal matter is composed of ordinary fat. 
 while another contains phosphorus, and it seems allied to the fatty 
 acid of nervous matter. They are evidently derived from the food, 
 either directly or by the transformation of its farinaceous ingredients, 
 and are chiefly appropriated to the maintenance of the combustive 
 process. In pulmonary tuberculosis, the dissolved animal matter is 
 commonly found in excess. From some experiments of Simon we 
 learn that the healthy standard of fat in blood is about 2.346, while 
 in phthisis it ranges as high as 4.231. 
 
 The saline matter of the blood amounts to between seven and eight 
 parts in one thousand. More than half its total quantity is com- 
 posed of the chlorides of sodium and potassium, and the remainder is 
 made up of the phosphate of lime, the phosphate of soda, and a fraction 
 
CONDITION OF THE BLOOD. 55 
 
 of the phosphate and oxide of iron. The use of the saline matter is 
 in part to supply the minerals required for the generation of tissues 
 and the production of the various secretions. As to the condition of 
 these elements of the blood in phthisis, we have no positive knowledge, 
 but we may infer that they are decreased, from the fact that its specific 
 gravity is somewhat diminished and its watery particles increased. 
 
 Conclusions. 
 
 1 . There is a decrease of the red corpuscles, and a slight excess of 
 the white. 
 
 2. There is an increase of the fibrin, and a deficiency of its vitality. 
 
 3. The albumen is in excess as to amount, but depraved in quality, 
 and unfit for the elaboration of healthy fibrin. 
 
 4. There is an increase of dissolved animal matter, and a diminution 
 of saline matter. 
 
 5. There is a reduction of its specific gravity, and an increase of its 
 watery particles. 
 
CHAPTER IV. 
 
 THE KIDNEYS AND URINE: THEIR CONDITION IN PULMONARY 
 TUBERCULOSIS. 
 
 I. The Importance of the Urinary Excretion. 
 
 To properly understand the functions of the kidneys, and the im- 
 portant work they perform in the animal economy, we will be greatly 
 aided in our undertaking if we first take a brief survey of the nature 
 of nutrition. This is chiefly effected by absorption and secretion, 
 operations which are continually going on insensibly, and, at least in 
 adult animals, are, in a state of health, so nicely balanced that no 
 alteration in form or structure is observed. That these changes are 
 going on, is proved by many facts. First, if portions of the body were 
 not being constantly cast off, it is reasonable to suppose that the 
 quantity or supply of aliment taken after the body has arrived at its 
 maturity would add to its bulk, and the increase in size would in 
 many cases be enormous. Second, when the aliment is not supplied, 
 as during starvation or diseases which impair the process of nutrition, 
 the body soon becomes wasted away, — a result which can be due only 
 to a removal of a portion of its constituent elements. 
 
 The blood is the great medium by which these vital actions are 
 accomplished. It does, when in a right state, consist of all the 
 chemical elements which enter into the various tissues of the body. 
 It is conveyed to them by the arteries and capillaries, and from it 
 is deposited in them all the elements required for their nutrition. 
 This process is secondary assimilation, and this plastic force, when in 
 health, is perfect. 
 
 As the assimilative process is providing the tissues with new ma- 
 terials, there is another force in operation by which old particles are 
 removed as new ones are added: this is disintegration. Thus we 
 have two wonderful and extraordinary changes going on in our bodies 
 at the same time, — assimilation and disintegration ; one deposits new 
 56 
 
THE KIDNEYS AND URINE. 57 
 
 materials, and the other removes old ones. Now, as a man is provided 
 with a perfect organization, the normal balance between these functions 
 cannot be materially disturbed without producing serious derangement 
 in the system ; hence we have a large class of disorders which are 
 supposed to depend upon a want of proper nutrition, such as fatty 
 degeneration, softening and atrophy of the various tissues of the body, 
 with typhoid, tubercular, and cancerous deposits. 
 
 But what becomes of the worn-out particles after they enter the 
 blood ? They are eliminated from it by the excretory organs, — the 
 liver, lungs, skin, and kidneys. These organs may be said to con- 
 stitute the grand sewerage of the body. The materials which they 
 remove from the system are not only useless, but are in most instances 
 highly noxious. This is especially the case with the kidneys. The 
 office which they perform is to separate certain nitrogenous materials 
 from the blood. Experience has proved that these materials cannot be 
 entirely retained in the system for more than a hundred hours without 
 producing fatal consequences. Even their partial suppression is some- 
 times attended with the most unpleasant symptoms. Take, for ex- 
 ample, a case of simple uraemia. How insidiously it steals upon the 
 individual, destroying his health, and rendering him as helpless as a 
 child ! Permit me to cite a case of this kind, by way of illustration, 
 from my note-book. 
 
 Mr. C, aged fifty-five, had been ill for six weeks, under the care of 
 Dr. S. Not getting any better, I was invited to see him. I found 
 him with a feeble pulse : forty per minute in the recumbent posture. 
 Respirations, twelve per minute ; tongue dry and red ; skin sallow 
 and dry ; bowels alternately relaxed and constipated ; urine scanty 
 and high colored, passes about four ounces during twenty-four hours ; 
 complains of pain in the back of the head and neck ; has constant 
 vertigo when attempting to sit up, and says he has not strength to bear 
 his weight upon his feet and legs. His mind has lost its vivacity, 
 and his memory is much impaired ; digestion is badly performed, and 
 during his illness he has had several attacks of vomiting. There is a 
 strong urinary odor imparted to the hand when passed briskly over 
 his body and limbs. He sleeps most of the time, but is easily 
 aroused ; says his sleep is disturbed by frightful dreams. There is a 
 slight touch of albumen in the urine on the application of heat and 
 nitric acid; it is highly acid, specific gravity 1020, and, on a micro- 
 
58 PULMONARY TUBERCULOSIS. 
 
 scopical examination, shows abundance of epithelium from the pelvis 
 of the kidney, uriniferous casts, and mucous corpuscles. There is 
 considerable tenderness in the region of the kidneys, and, at times, 
 painful micturition. 
 
 These symptoms all made their appearance after a mild attack of 
 influenza. Dr. S. regarded the case as. one of softening of the brain, 
 and had been prescribing accordingly. Tonics and restorative haematics 
 had been used ad libitum, but without any advantage. I could not 
 concur with the doctor in his diagnosis. The symptoms all pointed 
 to uraemie poisoning, caused by subacute desquamative nephritis, a 
 sequel of influenza. The treatment recommended was cupping over 
 the region of the kidneys, a teaspoonful of acetate of potash three 
 times a day in a teacupful of cold water, and one of the following 
 pills every six hours : 
 
 R Ext. eupator. purpur., gr. xxx ; 
 Hyd. chlorid. mit., gr. vi. — M. 
 Ft. in pil. mass., divide in No. x. 
 
 Under the use of these therapeutical agents and an occasional warm 
 bath he improved rapidly, and in two weeks regained his usual health. 
 In conversation with him a short time after his recovery, he informed 
 me that he had always been in the habit of passing a large quantity of 
 urine, — sometimes as high as two quarts a day. It will at once be 
 seen how detrimental it was to his system when it was reduced to 
 only four ounces in the same space of time. There cannot be a doubt 
 but the retention of urea and uric acid in the blood seriously inter- 
 feres with the nutrition of all the tissues of the body. Assimilation 
 and disintegration are speedily arrested; these combined with the 
 poisoned blood explain at once how a train of symptoms may occur, 
 like those in the above case, from a very mild form of suppression of 
 the urinary excretion. 
 
 II. Uraemia in Phthisis from Bright's Disease. A Case. 
 
 Uraemia is occasionally associated with phthisis from Brio-ht's dis- 
 ease of the kidney. I have the notes of an interesting case of this 
 kind that occurred in my practice about six years since. The patient 
 was a young man aged twenty. When I first saw him he had not 
 been well for three months. His pulse was more than a hundred per 
 
THE KIDNEYS AND URINE. 59 
 
 minute, and his respirations over thirty. There was dullness and dry 
 crackling at the apex of the left lung, with prolonged respiratory 
 murmur in the right. Cough and expectoration moderate ; the latter 
 did not amount to more than a tablespoonful during the day. His 
 mouth was dry, and he complained of great thirst, particularly at 
 night. Thompson's gingival margin was clearly defined; his skin was 
 sallow, hot, and dry, his feet and legs oedematous, his mind depressed, 
 and he had the most gloomy apprehensions. He complained of pain 
 in the back of the head and neck ; was stupid all day, and very 
 restless at night; appetite poor, bowels relaxed, and abdomen painful 
 to the touch. 
 
 His urine was scanty, — quantity estimated at six ounces during 
 twenty-four hours, — specific gravity 1008, light straw-colored, acid, 
 and, on the application of heat, yielded a large quantity of albumen. 
 When examined by the microscope, fat-globules, epithelium, urinife- 
 rous tubes, pus, and blood-cells were found in abundance. There was 
 considerable irritability of the bladder, and, on two or three occasions 
 during the month, he had voided blood with his urine. Purpuric 
 spots were visible upon the arms and legs. It was this appearance 
 that led me to a special examination of the condition of the kidneys, 
 for, in young persons, I regard purpura a very significant symptom of 
 granular disease of the kidney. Indeed, I have never met with but 
 one or two cases where it was not present. 
 
 The treatment of this patient consisted of tonics and diuretics, with a 
 liberal quantity of cod-liver oil, and a generous diet. Under it he made 
 some improvement. The dropsical symptoms quite disappeared, his 
 mind became more cheerful, his bowels more regular, the urine more 
 abundant, his skin moist, and, in a word, his strength was so much 
 improved that he was able to ride in a carriage several miles in the 
 course of the day. The weather being warm and pleasant, he now 
 went on a visit to some friends who resided in a distant county, and 
 remained about a month. 
 
 On his return home he appeared much better, but this was only of 
 temporary duration. The renal symptoms became more troublesome; 
 indeed, his pulmonary disease was in a great measure masked by 
 them. His mental faculties were reduced to child-like simplicity, and 
 his memory so failed him that he could scarcely recognize his most 
 intimate friends. At times he was quite comatose, and it was with 
 
60 PULMONARY TUBERCULOSIS. 
 
 great difficulty that he could be aroused to take food or medicine. His 
 skin became more deeply sallow, his pulse and respirations very slow, 
 the urine entirely suppressed, stomach irritable, and bowels very much 
 relaxed. His face was slightly cedematous, but the extremities were 
 free from effusion. He died perfectly comatosed in about three months 
 from my first visit. 
 
 Post-mortem showed the following lesions : On opening the cranium, 
 the membranes were found healthy. On removing the brain, it was 
 found firm and finely injected ; about half an ounce of clear fluid was 
 discovered in each lateral ventricle, but in other particulars it appeared 
 to be in a normal condition. 
 
 The superior lobe of the left lung was adherent to the summit of 
 the chest, very much congested, and contained numerous tubercular 
 deposits in various stages of softening. The inferior lobe was con- 
 gested, but contained no tubercles. The superior lobe of the right 
 lung contained a few scattered semi-transparent tubercular deposits 
 the size of a small pea. Its middle and inferior lobe was slightly con- 
 gested, and somewhat redder than usual, and the pleura contained 
 about eight ounces of serum. The heart was small, and the peri- 
 cardium contained about five ounces of fluid. 
 
 The mucous membrane of the stomach was red and injected ; there 
 were some minute ulcers in the small intestine, and others of larger 
 dimensions in the caecum. The colon and other viscera of the ab- 
 domen were healthy, with the exception of the kidneys. These were 
 both smaller than natural ; their external surface appeared shriveled, 
 shrunken, and fissured. In cutting into them, the cortical substance 
 was found very much wasted, and, in some portions, granulated. On 
 a microscopical examination, the uriniferous tubes were found to be 
 altered in their structure and stripped of their epithelium. Oily 
 matter, in the form of minute molecular granules, was present in 
 considerable abundance. The Malpighian tufts were shrunken and 
 obscured by fibrinous exudation. The arteries and veins also mani- 
 fested marks of degeneration, and the latter contained firm coagula of 
 blood, which, in some of them, were closely adherent to their walls. 
 The lining membrane of the pelvis was soft, and in some spots ex- 
 hibited a few small ulcers ; the ureters were red and congested. The 
 bladder was contracted, but presented no morbid alterations. 
 
 From the history of this case it was difficult to determine which 
 
THE KIDNEYS AND URINE. 6J 
 
 was the primary disease, the tubercular or Bright's. Dr. Roberts, iu 
 his recent work on " Urinary and Renal Diseases," gives it as his 
 opinion that " phthisis is frequently complicated with Bright's dis- 
 ease ;" while Dr. Bees, of the Brompton Consumption Hospital, says 
 that they are rarely associated, and that, according to his observation, 
 it does not occur more than twice in one hundred cases. In over 
 three hundred cases of phthisis that I have seen, Bright's disease was 
 present seven times as a complication. From my own observation I 
 am inclined to indorse the opinion of Dr. Bright, that there is no 
 fundamental connection between pulmonary tuberculosis and granular 
 disease of the kidneys. They are to a certain extent antagonistic. 
 And this is by the supposition that certain cachexia, such as cancer- 
 ous, gouty, and rheumatic, are opposed to the development of the 
 tubercular dyscrasia. 
 
 But we occasionally meet with cases where the tubercular habit is 
 so intense that the lungs are not capable of receiving all the depraved 
 material contained in the blood, and it seeks other organs for its 
 elimination, and the kidneys become implicated in the general disease. 
 Large tubercular masses are often found in them on post-mortem. 
 During life, tubercular and granular disease of the kidney may be con- 
 founded. The following is one of the most interesting cases of tuber- 
 cular disease of nearly all the organs of the body that I have ever 
 met with. 
 
 III. Tubercular Disease of the Kidneys, with, extensive Tuber- 
 cular Deposits in other Parts of the Body. 
 
 January 2, 1866, 1 was called to see W. L. T., aged twenty-eight, of 
 the nervo-bilious temperament, a machinist by occupation. He com- 
 monly enjoyed good health until three months since, when he had what 
 his physician called typhoid fever. His life was despaired of for several 
 days, but he gradually rallied, and has since been laboring under a 
 variety of annoying symptoms, — indigestion, diarrhoea, pain in the 
 back, frequent micturition, painful retraction of the left testicle, cough, 
 slight haemoptysis, chills, fever, and copious night-sweats. He has 
 considerable strength, and could take exercise if it were not for the 
 retracted, painful condition of the testicle and oedema of the feet and 
 legs. 
 
 On general inspection, he presented the appearance of an individual 
 
 5 
 
62 PULMONARY TUBERCULOSIS. 
 
 suffering with severe organic disease. The tubercular cachexia was 
 marked. Thompson's gingival margin was prominently developed 
 upon the gums of the upper and lower jaws. Pulse, one hundred and 
 twelve per minute ; respiration, thirty ; tongue red and pointed ; and 
 the mucous membrane of the throat highly injected. His urine is 
 scanty, and has been so from the commencement of his illness ; daily 
 quantity estimated at six ounces. In appearance it is light straw- 
 colored ; nitric acid and heat show it to contain considerable albu- 
 men ; under the microscope, large pus-cells and oil-globules are found 
 in abundance. His expectoration is muco-purulent, small in quan- 
 tity, and under the microscope exhibits pus-cells, tubercular granules, 
 tubercle-cells, and a few pulmonary fibres. The region of the kidneys 
 and abdomen are quite tender on pressure. 
 
 A careful physical exploration of the chest elicited the following : 
 A capacious chest, well formed; the expansive movements of the two 
 sides are unequal : the right lung appears to be laboring severely, 
 while the motion of the left is almost suspended. Percussion is per- 
 fectly flat for more than three inches under the left clavicle, but not 
 quite so much so on the right side. On the right side, auscultation 
 elicits loud bronchial respiration from the summit to almost the base 
 of the lung, and between the shoulders humid rales were distinctly 
 heard. On the left side, clicking was loud just under the clavicle, 
 and pectoriloquy was distinct over the entire region of the superior lobe. 
 The impulse of the heart was very feeble, and the first sound inaudible. 
 
 From the clinical history of this case the diagnosis appeared per- 
 fectly obvious, — tubercular disorganization of both lungs and granular 
 disease of the kidneys. The prognosis was unfavorable ; and I con- 
 sented to prescribe for the patient with the distinct understanding 
 that his malady would prove fatal. The treatment consisted of tonics, 
 anodynes, diuretics, and such articles of diet as the stomach could 
 easily digest, By these means and good nursing he was made com- 
 fortable, and improved slightly in strength. His mind became quite 
 cheerful, and, notwithstanding my gloomy prognosis, he began to 
 entertain hopes of recovery. A consumptive's delusive hope, — a 
 dream of better days that never come. 
 
 About the first of March a new difficulty presented itself. He had 
 for several days complained of pain in the region of the neck of the 
 bladder, with a return of painful micturition and retraction of the 
 
THE KIDNEYS AND URINE. 63 
 
 testicle. On rising from bed one morning and attempting to pass his 
 urine, he found that nearly all of it came from the rectum. An 
 exploration of the parts led to the discovery of a large fistulous open- 
 ing between the rectum and the bladder, just above the neck of the 
 latter, on the left side, through which the urine passed. 
 
 Various means were employed to obviate this annoying difficulty, 
 but without success. Day by day the patient became weaker ; his 
 appetite failed ; his bowels were obstinately costive ; urine entirely 
 suppressed ; symptoms of uraemia soon presented themselves, and 
 clonic spasms terminated his existence on the morning of the 6th of 
 April. 
 
 Post-mortem, thirty-six hours after death, revealed the following: 
 
 Exterior. — Emaciation not extreme. Inferior extremities slightly 
 oedematous ; abdomen distended ; phlyctaena at the inner and upper 
 part of the thigh, where the skin was of a light red color ; slight 
 oedema of the upper eyelids and lips ; submaxillary glands very much 
 enlarged and indurated. 
 
 Chest. — The left lung was intimately adherent to the costal pleura 
 from its summit to its base. A portion of the upper part of the 
 superior lobe was indurated, containing large masses of tubercular 
 matter in nearly every stage of transformation, surrounding a vast 
 excavation capable of containing a pint or more of fluid. This cavity 
 connected with the bronchial tubes by three large openings. It con- 
 tained a small quantity of purulent matter ; its walls were rugged, 
 and presented pulmonary tissue in almost every stage of disorgani- 
 zation. Immediately beneath this cavity were several small ones, 
 which communicated with one of considerable magnitude, that ex- 
 tended far down into the inferior lobe. This chain of excavations 
 had no connection with the bronchial tubes. It was filled with ill- 
 conditioned tubercular pus, and its walls were lined by a smooth, 
 delicate membrane, common to tubercular cavities of recent formation. 
 In the remaining portion of the inferior lobe there were a large num- 
 ber of tubercular deposits, varying from the size of a pea to that of a 
 walnut ; the pulmonary tissue surrounding them was of a dark red 
 appearance and very much congested, rendering the entire lobe per- 
 fectly useless. 
 
 The right lung was slightly adherent between the third and fourth 
 ribs. About one-fourth of the upper portion of the superior lobe 
 
6-1 PULMONARY TUBERCULOSIS. 
 
 was perfectly consolidated from the infiltration of tubercle, while the 
 remaining portion of the lobe was occupied by a very large cavity 
 filled with tubercular pus ; this excavation was lined by a membrane 
 similar to that in the left lung, and had no external opening. The 
 middle and inferior lobes contained numerous tubercular masses in 
 various stages of softening, and the surrounding pulmonary tissue 
 was very much congested. ■ The bronchial glands were generally in- 
 durated from tubercular deposits, and several of them were in a state 
 of softening. The bronchial mucous membrane was unusually red 
 throughout its whole extent, and congested, but no tubercles were 
 found upon its free surface. The heart was small, its walls thin and 
 soft. The pericardium contained about four ounces of serum. 
 
 Abdomen. — The stomach contained a large quantity of undigested 
 food, but presented no abnormal appearance. The duodenum and 
 small intestines were healthy ; the colon was unusually large and im- 
 pact with fecal matter, from the caecum down to the sigmoid flexure ; 
 the rectum was empty, and its mucous membrane injected and red. 
 The mesenteric glands were increased in volume and almost wholly 
 tuberculous ; this was also the case with the niesocoecal and the right 
 mesocolic glands. The liver was pale and slightly adipose. The 
 spleen contained several tuberculous masses of a large size, and its 
 tissues were redder than natural. The kidneys were much larger 
 than common, of a pale pink color, very soft, and, when opened, ex- 
 hibited the appearance of fatty degeneration coupled with tuberculo- 
 sis. In the inferior portion of the left kidney there was a large mass 
 of tubercular matter undergoing the process of softening. Its state 
 presented a fine illustration of the doctrine that tubercular deposits 
 generally commence to soften at their centre. The central portion of 
 the mass was as thin as ordinary pus, and as we proceeded from 
 within outward its density was found to increase, until it became as 
 hard as tubercle in the last stage of induration. 
 
 The bladder was small, but exhibited no lesion excepting the fistulous 
 opening already mentioned ; this appeared to have been caused by the 
 softening and expulsion of a large mass of tubercular matter between 
 the rectum and bladder. The location of the prostate gland was oc- 
 cupied by a large cavity, which had a small opening into the fistula 
 from the bladder to the rectum ; there was not a vestige of the gland 
 left. The left testicle was retracted by the contraction and induration 
 
THE KIDNEYS AND URINE. 65 
 
 of the spermatic cord. The vesiculse seminales were rather volumi- 
 nous, indurated, and filled with a very firm tuberculous substance, 
 divided into masses by the natural cellular intersections of the parts. 
 
 The head was not examined. 
 
 Conclusions. — This case was unique in several particulars. 
 
 1st. The rapidity with which the disease was developed and with 
 which it proceeded to a fatal termination. 
 
 2d. The extent of the tubercular deposits and the number of or- 
 gans involved. 
 
 3d. The fatty degeneration of the kidneys, the large tuberculous 
 mass in the left, and the patient's succumbing to uraemia. 
 
 4th. The fistulous opening between the bladder and rectum, the 
 total destruction of the prostate gland, and the invasion of the vesi- 
 culse seminales by tubercular infiltration, presenting a mass of dis- 
 organization seldom met with in the history of pulmonary tubercu- 
 losis. 
 
 Lastly. We are of the opinion that most of the cases that are 
 called Bright's disease of the kidneys, met with in phthisis pulmo- 
 nalis, are similar to this, fatty degeneration with tubercular deposits. 
 Primary tuberculosis of the kidneys is a disease seldom met with. I 
 never saw but one case. 
 
 General Remarks. — My patient, for three years previous to his 
 illness, had charge of the machinery of a large iron-works. This re- 
 quired his utmost attention to keep in running order, he frequently 
 being compelled to labor day and night. So long as his digestive 
 organs maintained their integrity he engaged with delight in his 
 occupation, -and felt no lack of physical ability to endure such severe 
 toil. Being very ingenious in mechanical engineering, he was fre- 
 quently consulted by those engaged in the same business, and would 
 often spend those periods which should have been devoted to rest in 
 solving their difficulties. All these things, no doubt, contributed to 
 produce that dyscrasia which led to the extensive tubercular disease 
 which terminated his existence. I could learn nothing in regard to 
 his hereditary proclivities. He was an individual of commanding 
 personal appearance, of excellent intellectual powers, very kind in his 
 disposition, and, withal, a sincere Christian. 
 
QQ PULMONARY TUBERCULOSIS. 
 
 IV. State of the Urine in Phthisis Pulmonalis. 
 
 But some may be ready to ask, Is there any peculiarity of the urine 
 which is characteristic of phthisis ? In answering this question it 
 will be necessary to consider the state of the urine in health, and 
 contrast it with that as we find it during the progress of this malady. 
 
 First, then, as to its specific gravity. According to Dr. Prout, the 
 specific gravity of healthy urine is 1.020 ; Dr. Roberts, from 1.015 
 to 1.025; and Simon, 1.012. But we find a wide difference in its 
 specific gravity in different individuals and at different periods of the 
 day. Thus, on rising in the morning, its specific gravity may in 
 some instances be as high as 1.030, while two hours after breakfast 
 it may be as low as 1.015. In this way we may account for the dif- 
 ference of opinion among medical writers as to its specific gravity. 
 To determine correctly whether the urine has a high or a low specific 
 gravity, we must not be satisfied with taking the weight of a single 
 specimen, but the whole of the urine voided in twenty-four hours 
 should be collected, and the weight of a portion determined. Where 
 this plan is followed, its specific gravity, in health, will approximate 
 much nearer 1.025 than 1.020. 
 
 From numerous observations, I am well satisfied that in pulmonary 
 tuberculosis there is a marked diminution in its specific gravity in 
 every stage of the disease. Indeed, it is sometimes remarkable to 
 notice its diminution as it gradually keeps pace with the increasing 
 mutations in the pulmonary organs. In the pre-tubercular stage, we 
 find its weight almost normal; in the stage of deposit and induration, 
 somewhat reduced ; in the stage of softening and expulsion, particu- 
 larly if attended with much inflammation in the surrounding pul- 
 monary tissues, it may be increased temporarily, only to fall much 
 lower than before ; in the last stage, the gradual failing of the vital 
 powers, it may be very low, particularly where the patient has suffered 
 much from haemoptysis. In uncomplicated cases of pulmonary tuber- 
 culosis not under medical treatment, the mean specific gravity of the 
 urine will not vary much from 1.010 to 1.015 in the stage of expul- 
 sion, after the severity of inflammation has passed. 
 
 Dr. Edward Smith, in his work on " Consumption,'" page 61. has 
 taken some pains to show that there is no diminution of the specific 
 gravity of the urine in this disease. He expresses his astonishment 
 
THE KIDNEYS AND URINE. 67 
 
 at a statement of mine in an article on this subject, published in the 
 Philadelphia Medical and Surgical Reporter, September 21,1861, 
 that " its specific gravity does not exceed 1.010," and to refute it has 
 presented his readers with a table of eight cases of phthisis, showing 
 the day and night urine for one month. After a careful analysis of 
 them, he says, " It is quite clear that the specific gravity was certainly 
 not less than in health." But these cases, as given by Dr. Smith, 
 are of little moment in determining the question under consideration. 
 For he gives neither the stage of the disease, diet of the patient, nor 
 medical treatment, all of which have an important influence upon the 
 specific gravity of the urine. 
 
 It is a well-known fact that tea, coffee, and tobacco perceptibly 
 lessen the specific gravity of the urine. They are said to restrain 
 disintegration, and thereby prevent the too rapid waste of the tissues 
 of the body ; hence there is a marked diminution in the weight of 
 the urine. Cod-liver oil, iron, quinine, and iodine all increase its 
 weight. They do this by increasing the plastic elements of the 
 blood, by promoting a more rapid renewal of the tissues of the body, 
 and a disintegration and diminution of worn-out material, particularly 
 through the urinary excretion, thus augmenting its specific gravity. 
 I have often had demonstrations of the influence of the therapeutical 
 agents just named in increasing the specific gravity of the urine in 
 pulmonary tuberculosis. The following is one which may serve as a 
 type of several : 
 
 A young man applied to me for advice, with the following symptoms : 
 Pulse, one hundred and two per minute; respiration, twenty-eight per 
 minute; skin moist and blanched; Thompson's gingival margin very 
 marked; cough annoying ; expectoration muco-purulent ; hectic fever; 
 urine scanty and pale, specific gravity 1.009 ; cavernous respiration and 
 cracked-pipkin sound at the apex of the right lung, pointing out the ex- 
 istence of a considerable vomica in that part. No abnormal sounds on 
 the left side, excepting a slight exaltation of the respiratory murmur. I 
 gave a guarded prognosis, and prescribed a nutritious diet, with cod-liver 
 oil, iodine, and iron. In nine weeks there was marked improvement: 
 the hectic symptoms had disappeared ; the cough and expectoration 
 were moderate ; the appetite good ; he had improved in flesh and 
 strength; specific gravity of the urine, 1.020. This patient made a 
 good recovery ; and now, after nine years, all that I can discover wrong 
 
68 PULMONARY TUBERCULOSIS. 
 
 from an examination of his chest is a slight flattening under the right 
 clavicle and a little increased frequency of respiration. "When the 
 specific gravity of the urine is very low at the commencement of 
 phthisis, and, under treatment, approximates its normal standard, in 
 connection with a general improvement in flesh and strength, we may 
 regard it a favorable omen, and in making out our prognosis will do 
 well not to neglect its teachings. 
 
 The chemical constituents of the urine in pulmonary tuberculosis 
 are not found to vary much from the normal state. I believe it may 
 be stated as a general rule that where, from any cause, rapid waste of 
 the system is proceeding, an excess of uric acid will be found in the 
 urine. From various tables of the analysis of urine made by Drs. 
 Bird, Budd, Roberts, and Simon, in this disease, I find that it is no 
 exception to the rule. The more rapid the disease the more abundant 
 the uric acid. 
 
 In addition to an excess of uric acid in the urine of phthisical 
 patients, we sometimes find certain constituents which do not belong 
 to normal urine, such as cystine, lucine, tyrosine, albumen, diabetic 
 sugar, phosphate and oxalate of lime, euraerythrin, and vibriones. 
 The latter are common in the last stage of the disease, when the 
 urine is pale, neutral, and of low specific gravity. Euraerythrin is 
 peculiar to the last stage of the disease. It is a beautiful carmine 
 precipitate, combined with the lithate of ammonia, which appears 
 necessary to produce it, and is seldom found in any other disorder. 
 Dr. Bird confounds it with purpurine. Dr. Hassall. on the contrary, 
 regards them as distinct sediments, from the fact that they are found 
 under very different circumstances. Purpurine is frequently found in 
 the urine in several diseases that are not attended with suppuration, 
 such as congestion of the liver, rheumatism, and neuralgia, and is 
 deposited in large quantities without the presence of ammonia. Eu- 
 rserythrin occurs only in suppurative diseases, and then is seldom a 
 free deposit. When this sediment appears in the urine of a phthisical 
 patient, we may consider his dissolution near at hand. 
 
CHAPTER V. 
 
 THE LIVER : ITS CONDITION IN PULMONARY TUBERCULOSIS. 
 
 I. Its Functional Derangement. 
 
 Few organs suffer more from functional derangement during 
 the progress of phthisis pulmonalis than the liver. These derange- 
 ments often occur at the commencement of the disease, and constitute 
 annoying complications until the end. This is mostly the case with 
 individuals of a marked bilious temperament, who reside in a malarial 
 country. In persons predisposed to phthisis, and thus situated, its 
 functions sometimes become deranged before there are any symptoms 
 of the local deposit of tubercle, and they may consist in either a sup- 
 pression or an augmentation of its secretion. When the latter occurs, 
 large quantities of bile are discharged into the stomach and bowels, 
 producing nausea, vomiting, and purging, which, if repeated at short 
 intervals, soon exhaust the patient's strength and end in his dissolution. 
 The most marked case of this kind that I ever met with was that of 
 a young man aged eighteen. His temperament was highly bilious. 
 From the commencement of his illness he had fearful attacks of vom- 
 iting and purging bilious matter. In their severity they presented all 
 the features of an acute paroxysm of cholera morbus. The collapse 
 was extreme, and reaction was produced with great difficulty. He 
 died in one of these attacks before the tubercular disease had pro- 
 gressed to the third stage. 
 
 As to the cause of this morbid activity of the liver in pulmonary 
 tuberculosis, medical writers are not agreed. Some suppose that it is 
 produced by tubercles being first deposited in the liver ; but this is 
 not very evident, for this is a very uncommon occurrence. M. Cru- 
 veilhier states that, among the numerous cases of phthisis which he 
 has had occasion to examine, he never met with tubercles in the 
 liver. M. Louis says that in two cases only had he observed a greater 
 or smaller quantity of tuberculous matter in the liver. Niemeyer 
 
 69 
 
70 PULMONARY TUBERCULOSIS. 
 
 says, " Tuberculosis of the liver is never primary, but always accom- 
 panies an already existing tuberculosis of other organs, or else forms 
 one symptom of miliary tuberculosis. In the latter case, we only find 
 dull, translucent granules, as large as grains of sand, which occur 
 particularly on the surface of the liver, with advanced tuberculosis of 
 the intestines and lungs." I have twice observed tubercular deposits 
 in the liver of pulmonary tuberculosis subjects, and once as a primary 
 affection ; but neither of the patients suffered with excessive biliary 
 flux. 
 
 Others, again, have attempted to account for this abnormal con- 
 dition upon the supposition that the discharge was vicarious. They 
 tell us that, in consequence of the functions of the luDgs being im- 
 peded by tubercular deposits and the various engorgements which 
 attend them, the blood cannot part with its carbon, and therefore it 
 must seek some other channel for its elimination ; and the liver is the 
 medium, hence the flux in question. Perhaps this explanation will 
 do in the absence of a better one. To our view, it seems very prob- 
 able that a morbid activity of the liver may be produced by an altered 
 condition of the blood, and thus cause a superabundance of its secre- 
 tion. Accordingly we find that, as the tubercular cachexia becomes 
 more fully developed and the pulmonary organs more deeply involved, 
 there appears occasionally to be a reciprocal action between them, and 
 as the malady increases the liver becomes morbidly affected ; hence, 
 at the advanced stage of the disease, when the blood has lost its 
 normal constituents, there will be more or less hepatic derangement. 
 
 Often, instead of being morbidly active, the liver is torpid, and its 
 secretion in a measure suppressed. This may occur from the want of 
 innervation, from the absence of biliary principle in the blood, and 
 from structural disease of the minute cells which elaborate the bile. 
 In pulmonary tuberculosis it sometimes becomes suppressed from the 
 want of biliary matter in the blood. This is often the case where 
 haemoptysis has been profuse and has constituted a marked feature of 
 the malady. In this state of the organ, physicians often err in pre- 
 scribing large doses of mercury, with a view of stimulating it to 
 greater activity, that its secretion may be more abundant. It is true 
 that when the liver is congested, and there is evidence of icterus, mer- 
 cury and other liver-stimulants are often demanded. When passive 
 haemoptysis occurs during the progress of phthisis, and the liver is 
 
CONDITION OF THE LIVER. 71 
 
 engorged, few things will relieve the patient quicker than a brisk 
 purge of calomel and podophyllin. 
 
 The chief lesion of the liver under pulmonary tuberculosis is, 
 
 II. Fatty Degeneration. 
 
 This is present in about forty cases in one hundred. When a liver 
 of this kind is carefully examined, it exhibits a pretty uniform and 
 highly characteristic appearance. Its color is a pale yellow, figured 
 irregularly with brownish or deep orange spots. Internally, it is found 
 to present an appearance somewhat corresponding to the exterior, 
 excepting that the pale yellow tissues are more uniformly distributed 
 throughout the entire substance of the organ than they are upon its 
 surface. It is sometimes softer, and more readily crushed between 
 the fingers, than in health. But this is not always the case ; in some 
 instances it has been found much harder than in the normal state. 
 The presence of the fatty matter is manifested by the unctuous feel 
 it communicates to the fingers, by the greasing of the knife with 
 which it is divided, by the stain it imparts to bibulous paper on which 
 it is pressed, and by the manner in which such paper burns, as well as 
 by the exudation of oil when a portion of its substance is exposed to 
 a dry heat. 
 
 When a portion of fatty liver is examined by the microscope, the 
 hepatic cells are found to be engorged with oil. Sometimes, a quantity 
 of yellow matter is also seen in the cell-cavity, together with the oil ; 
 but this is frequently absent. The nucleus disappears as in cells that 
 have fulfilled their work of secretion ; but the envelope persists, and 
 is sometimes thickened and striated. The microscope proves very 
 conclusively that there are progressive changes in the gradual increase 
 of the fatty particles. Thus, some of the cells appear quite healthy ; 
 others deviate from health only in containing two or three shining, 
 black-bordered oil-particles ; in others they are increased, and a large 
 part of the cell- cavity is filled with minute oil-particles, or with one or 
 more large oil-drops ; and in others the cluster of oil-drops has given 
 place to a single drop. In this last case degeneration is complete. 
 
 When the liver has undergone this change, these fatty transforma- 
 tions are commonly confined to the lobules, and are always most ad- 
 vanced there. Sometimes, however, it is found to commence in the 
 centre of the lobules. The pale condition of the liver is supposed to 
 
72 PULMONARY TUBERCULOSIS. 
 
 depend on the enlargement of the cells, which are pressed close to- 
 gether, and thus contract the capillaries and allow less blood to be 
 confined in them. But it should be remembered that there is no 
 obstruction to the flow of blood, such as we find in some other lesions 
 of the liver : the soft state of the oil-laden parenchyma sufficiently 
 accounts for this. 
 
 Various opinions have been entertained by writers on pathology in 
 relation to the cause of this condition of the liver. Some have sup- 
 posed that it is produced by an undue quantity of oily matter in the 
 blood, in proportion to the assimilative powers; others, as the conse- 
 quence of hepatitis; while a third class consider it the result of 
 chronic gastro- enteritis. The majority of writers favor the first 
 theory, and I am inclined to the opinion that it is the true one. 
 
 Niemeyer says, " The frequent occurrence of fatty liver with tu- 
 berculosis of the lungs has long been remarked. Their connection 
 has been ascribed to incomplete oxidation of the hydrocarbons and 
 their transformation into fat, due to impaired respiration. But as fatty 
 liver rarely occurs in other lung-diseases where the respiration is 
 affected, and as it often results from tuberculosis of the bones and 
 intestines, and from carcinomatous and other diseases in which the 
 patients emaciate, the obstructed respiration cannot be the sole cause 
 of its occurrence in the lungs."* 
 
 Yogel remarks, "Very probably, in all cases where fat is produced, 
 not only the cytoblastema, but also the blood from which it is de- 
 rived, is more than usually abundant in fat. We often, indeed, meet 
 with fat occurring in fat-globules and granules in many amorphous 
 blastema : the fat remains, while the rest of the blastema disappears, 
 either by absorption or organization, and in this manner those patho- 
 logical collections of fat are formed which we find in a crystallized 
 state. Whether fat can arise from the protein compounds of an exu- 
 dation or from its other constituents, through a chemical metamor- 
 phosis, must be left at present undecided, as must also the question 
 whether, under certain conditions, a plasma consisting entirely or 
 principally of fat can be separated from the blood ; in other words, 
 whether the vessels can in a direct manner secrete fat. If this were 
 the case, the process of the formation of fat would be much simplified 
 
 * Memeyer's Practical Medicine, page 656. 
 
CONDITION OF THE LIVER. 73 
 
 and more easily explained. There is no doubt that in many cases 
 actual fat is secreted by peculiar, morbidly-formed secreting organs, 
 similar to the sebaceous glands of the skin, the ceruminous glands, 
 etc., which in the normal state secrete fat. This is, for instance, the 
 case in many kinds of encysted tumors."* 
 
 One of the most singular things connected with fatty degeneration 
 of the liver is that the bile is not materially altered from its healthy 
 state. The following table, from Frerich, is a fair exhibit of the bile 
 in health and in fatty liver : 
 
 
 Health. 
 
 Fatty Liver. 
 
 Water .... 
 
 84.77 
 
 91.00 
 
 Solid constituents . 
 
 15.03 
 
 9.00 
 
 Bilate of soda 
 
 8.32 
 
 9.94 
 
 Mucus, protein compounds, and salts 
 
 6.46 
 
 2.97 
 
 Fat . 
 
 0.25 
 
 0.09 
 
 It will be seen that there is not much difference in its chemical 
 constituents ; indeed, not enough to make its analysis a matter of im- 
 portance in a practical point of view. 
 
 III. Clinical History of Fatty Liver. 
 
 The symptoms of fatty degeneration of the liver, as it occurs during 
 the progress of pulmonary tuberculosis, are not very pronounced ; in- 
 deed, I know of none that would render its diagnosis certain. Com- 
 monly there is no pain in the right hypochondriac region, or soreness 
 on pressure ; the evacuations from the bowels look natural, and diges- 
 tion is normal. The only circumstance of any moment that might 
 lead us to suspect this condition of the liver is a sensible enlargement 
 of the organ as distinguished through the walls of the abdomen. This 
 enlargement may generally be determined by percussion, and, in certain 
 cases, by manual exploration between the false ribs. Its blunt margin 
 may sometimes be distinctly made out. The smoothness of its surface 
 is quite appreciable in those subjects of phthisis who are much ema- 
 ciated. Suffer me to cite a case of this kind from my book of " Med- 
 ical Fragments" : 
 
 " October 12, 1858. M. B. came to my office this day and gave 
 the following history of himself: ' Am twenty-six years of age. My 
 
 * Vogel's Pathological Anatomy, page 172. 
 
74 PULMONARY TUBERCULOSIS. 
 
 parents both died of consumption ; I had one brother and two sisters 
 who have perished with the disease. My mother had five sisters ; 
 three died with this malady, and the others are now suffering with it. 
 My health was good until about three years since, when I took a cold ; 
 my physician said that I had pneumonia. It left me with a pain in 
 my left side, bad cough, and expectoration. Have never regained my 
 flesh and strength. Have taken a great variety of medicines without 
 much benefit. Unfortunately, about a year since I commenced to 
 take alcoholic stimulants as a remedy for my disease. I do not know 
 that it has done me any good, but I have become so addicted to its 
 use that I sometimes take it to excess ; then it deranges my stomach, 
 and I cannot retain scarcely any food for several days. I feel that 
 my disease is gaining upon me, and unless I soon find a remedy it 
 will prove fatal.' 
 
 " The speaker had an intelligent countenance ; a bright eye ; tongue 
 slightly coated ; pulse one hundred and two per minute ; respiration 
 twenty-eight per minute ; temperature above the healthy standard ; 
 bowels constipated ; urine high colored and scanty ; sweats at night ; 
 appetite bad ; has jDain in the head and back ; spirits gloomy and de- 
 pressed. Inspection of the chest shows inequality in its expansive 
 movements, the left side being restricted. On percussion, there is 
 dullness on the same side from the summit to the base of the lung ; 
 on the right side the resonance is normal. On auscultation, loud 
 bronchial respiration is heard over nearly the whole left side ; on the 
 right, prolonged expiratory murmur is very distinct over the superior 
 part of the lung. The heart was somewhat smaller than normal, but 
 its sounds were healthy. 
 
 "A physical exploration of the abdomen revealed the following : 
 There was unusual prominence, confined almost entirely to the e] ig 9- 
 triuni, which on percussion presented marked dullness over the whole 
 region ; on flexing his thighs upon his abdomen, the parietes being 
 thin and relaxed, the outlines of a tumor could be easily made out. 
 It was smooth to the touch and rounded at its edges. It extended 
 over the border of the ribs on the left side, and considerably below 
 the free border of the ribs on the right side. No pulsation was pres- 
 ent in it. no thrill nor bruit. Aneurism was thus excluded. Xo 
 nobules were found ; no cancerous cachexia was present : carcinoma of 
 the liver was ignored. There being no ascites, no symptoms of scrof- 
 
CONDITION OF THE LIVER. 75 
 
 ula nor constitutional syphilis, amyloid degeneration of the liver could 
 not be entertained. Thus, by way of exclusion, the case was regarded 
 as pulmonary tuberculosis, complicated with an enormous fatty liver. 
 The prognosis was unfavorable. Hectic fever became more pro- 
 nounced, accompanied by a wasting diarrhoea, and he died on the 
 12th of December. 
 
 " Post-mortem, twenty-four hours after death. — Emaciation was ex- 
 treme ; the whole surface of the body was of a dull golden color. On 
 exposing the cavity of the chest, the right lung was found adherent 
 from the summit to its base. A large cavity occupied its apex, be- 
 neath which the whole superior and middle lobes were occupied with 
 tubercular matter in various stages of induration and softening. The 
 left lung adhered to the apex, and the superior lobe contained a large 
 cavity filled with tubercular pus, having no opening into the bronchial 
 tubes. Its inner surface was rugged, and appeared to have no lining 
 membrane. The inferior lobe was very much congested, but contained 
 no tubercles. The bronchial mucous membrane was injected and red; 
 the bronchial glands were enlarged and indurated, showing extensive 
 tuberculous infiltration. The heart was very small, but in other re- 
 spects normal. The liver was very large, somewhat indurated, and 
 fatty throughout. The mucous membrane of the stomach was quite 
 red, and in patches very much softened. The mucous membrane of 
 the intestines was injected, and in the lower portion of the ileum there 
 were numerous small tubercular ulcers. In the left kidney there 
 were several miliary tubercles. The other abdominal organs appeared 
 normal." 
 
 IV. Abscess of the Liver in Pulmonary Tuberculosis. 
 
 Abscess of the liver is an occasional attendant upon this disease. 
 The following is an interesting case of the kind. It is a good illus- 
 tration of the pathology and diagnosis of this annoying complication. 
 A full report of it is given by Dr. Mitchell in the Proceedings of the 
 Pathological Society of Philadelphia, May 9, 1860, published in the 
 January number of the American Journal of the 31edical Sciences for 
 1861. 
 
 "The patient, M. S. S., proof-reader and agent, aged thirty-seven, 
 was born in Philadelphia, but lived in the West many years. About 
 two years ago he had a cough of several months' duration, and once 
 
76 PULMONARY TUBERCULOSIS. 
 
 spit a little blood. In October, 1859, Mr. S., then residing in Nash- 
 ville, was attacked with general feebleness and depression of spirits, 
 with pain in the bones, and frequent flashes of heat, the feelings of 
 which are usually described as ' a cold.' During the fall and winter 
 he lost flesh and color. A trifling cough now annoyed him, and now 
 and then a return of the general symptoms above described. 
 
 " About the beginning of March, Mr. S. was suddenly seized with 
 fever, and a violent pain under the nape of the neck and under the 
 right shoulder-blade. After some domestic treatment, a physician was 
 called in. He readily diagnosed the case as one of acute hepatitis, 
 and treated it accordingly. Mr. S. was about in three weeks, but had 
 a relapse owing to imprudence. In the second attack he had more 
 pain in the region of the liver, and less in the back. He so far gained 
 as to be able to travel to New York, which he reached June 13. On 
 his way from that place to Connecticut, his hacking cough, which had 
 hitherto been of trifling moment, increased suddenly, so that within 
 twenty-four hours he expectorated at least three-fourths of a pint to 
 a pint of pus daily. 
 
 " Mr. S. was astonished, but continued his journey, presuming that 
 his new symptoms were due to bronchitis from sudden exposure. He 
 went to the North, as I have said, still continuing to cast off from 
 half a pint to a pint of pus daily. Returning southward, he reached 
 Philadelphia on July 13, 1860. On July 23 he sent for me. He 
 told me his history, and especially insisted upon the fact of his con- 
 stant exposure to the exhalations from a large drain and water-closet 
 which was close to his office in Nashville. He was spare, and a little 
 sallow, but not jaundiced. He was able to go up and down stairs 
 without aid. His tongue was clean, his appetite excellent, his digest- 
 ive powers unimpaired. The cough was intermitting, being very 
 violent, and attended with profuse expectoration of bloody pus for 
 some hours, and then ceasing, only to be renewed again within a day, 
 or even a less time. 
 
 " The abdomen was enlarged on the right side by the swollen liver, 
 which extended below the umbilicus and across the epigastric space. 
 There was little or no rigidity of the rectus muscle, but there was a 
 painful spot at the upper line of the right iliac fossa. Above, the 
 liver-dullness was continuous, with a flat-sounding region of the lung. 
 This involved a third of the lung in front, and curved upward on the 
 
CONDITION OF THE LIVER. 77 
 
 side and back so as to reach the scapula spine. At the lower point 
 of the shoulder-blade there were the usual indications of a cavity. 
 Moist rales were heard only in the right chest at first, but at a later 
 period were also audible in the other lung, though to a less amount. 
 We qould detect no evidence of tubercle, but from the history of 
 other cases we conjectured its existence." 
 
 The patient soon became exhausted, and died on the 29th of August, 
 1860. The following is a description of the post-mortem by Dr. Kane, 
 twenty-four hours after death. 
 
 " The body had been kept in ice ; was perfectly rigid, and much 
 emaciated ; the anterior portion of the thorax was perfectly clear and 
 resonant, under percussion, as low down as the superior margin of the 
 sixth rib ; from that point to nearly the level of the umbilicus both 
 sides emitted a dull, flat sound on being percussed. 
 
 " The pericardium was perfectly healthy, and contained no more 
 than the normal amount of fluid. The heart was of the usual size, 
 and showed no evidence of valvular disease ; but its muscular fibres 
 were much softened, and firm white clots were found in the auricles 
 and ventricles of both sides, entangled in and closely adherent to the 
 tendinea3 cordas and columnse carnese. 
 
 " The inferior lobe of the left lung was studded with miliary tuber- 
 cles. It was congested, and of a deep-red color. The upper lobe, 
 though congested, was less so than the lower, and contained no tuber- 
 cles. The upper lobe of the right lung contained several small 
 cretified tubercles, but was otherwise healthy. The lower lobe was 
 completely riddled by an anfractuous vomica ; what remained of its 
 substance was much softened, and of a dirty-brown color. The pleura 
 around this portion was much thickened, and immediately above its 
 two surfaces were closely adherent, thus forming a circumscribed 
 empyema connected with an abscess of the lung. 
 
 " The liver was about double its normal size, its left lobe extending 
 so far into the hypochondriac region as to press strongly against the 
 spleen. A rough measurement, made before removing the organ from 
 the abdomen, gave ten inches as the vertical diameter of the right 
 lobe, nine inches as that of the left, and eleven inches as the trans- 
 verse diameter of the entire viscus at its central portion. The upper 
 left angle of the lobe was the seat of an abscess about as large as an 
 ordinary hen's-egg, which bulged outward so as to press strongly 
 
 6 
 
78 PULMONARY TUBERCULOSIS. 
 
 against the diaphragm, and was filled with a thick, homogeneous 
 pus. 
 
 11 The right lobe was firmly adherent to the right wall of the abdo- 
 men and to the diaphragm, but especially to the right abdominal wall. 
 An abscess as large as a Sicily orange occupied the upper portion of 
 the lobe. It was filled with a thick whitish pus, and did not com- 
 municate either with the abscesses in the liver or lungs. A third 
 abscess, nearly as large as a hen's-egg, existed in the lower portion of 
 the right lobe of the liver. This abscess communicated, by a large 
 opening in its posterior wall, with the gall-bladder, which was firmly 
 agglutinated to the liver, and was distended with thick greenish pus. 
 The walls of the gall-bladder were much thickened. The cystic duct 
 was entirely occluded by the pressure of an enlarged gland. The 
 hepatic duct was unimpeded, as was also the common duct, which was 
 traced to its opening in the duodenum. 
 
 " We had considerable difficulty in detecting the opening of the 
 communication between the liver and the lung, which was not, as 
 might have been expected, above, from one of the large abscesses 
 pressing against the concavity of the diaphragm, but by a small 
 canalicular opening connected with the abscesses in the lower portion 
 of the right lobe, which pierced the liver low down about the junction 
 of its right lateral and posterior surface, and allowed the pus to escape. 
 This, being circumscribed by lymph, had burrowed upward and per- 
 forated the diaphragm at its attachment to the ribs anteriorly, thus 
 opening into the circumscribed empyema in connection with the an- 
 terior surface of the right lung. There was considerable general peri- 
 tonitis, especially in the ileo-csecal region; but the stomach and 
 intestines appeared healthy. The spleen was normal. The kidneys 
 were enlarged and pale. The brain was not examined." 
 
 Dr. Moorehouse, a member of the Society, in remarking upon this 
 case, said "that it was a good example of hepatic disease occurring in 
 association with tubercular deposit in the lungs. He thought such 
 associations were not accidental, but illustrated the relationship be- 
 tween suppurative inflammation of the liver and those systemic con- 
 ditions favoring degeneration of the tissues, and more prominently 
 that denominated tubercular. Eighteen months ago he had exhibited 
 to the Society a large abscess of the liver developed in a tubercular 
 patient; since then he had learned the history of and observed a 
 
CONDITION OF THE LIVER. 79 
 
 number of cases with especial reference to this point, and, from their 
 evidence, was led to believe that those cases of hepatic abscesses 
 coming on insidiously in persons from forty to sixty years of age, are, 
 in the majority of cases, associated with the tubercular diathesis." 
 
 This opinion was not concurred in by Dr. S. D. Gross. He was not 
 inclined to the belief that there is any special connection existing be- 
 tween the tubercular diathesis and suppurative hepatitis. He had come 
 to this conclusion from having seen quite a number of cases of this 
 disease among the boatmen on some of the Western rivers, who had 
 entirely recovered without giving the least evidence of tubercles in 
 the lungs. Suppurative hepatitis may, and frequently does, exist as 
 an independent disorder, and in some countries causes a large mor- 
 tality among the people. This is fearfully true of some portions of 
 India, where hepatic diseases are very common. But this does not 
 militate against the fact that there is a reciprocal action between the 
 lungs and the liver, and that this is of such an intimate nature, espe- 
 cially in pulmonary tuberculosis, that it may lead to hepatic abscesses. 
 
CHAPTER VI. 
 
 menstruation: its condition in pulmonary tuberculosis. 
 
 I. The Nature of Menstruation. 
 
 Menstruation is a term derived from a Latin word winch means 
 " month ;" and in every woman, when healthily performed, it occurs 
 monthly, and is an evidence of her ability to bear children. As a 
 physiological process, it may be said to divide the life of woman into 
 three periods. The first is that of infancy and youth, and exists, in 
 the generality of cases, from birth till the fourteenth or fifteenth year. 
 The second comprises the most important period of her life, — that in 
 which she is capable of becoming a mother. This ceases at the fortieth 
 or fiftieth year ; and the period of its cessation is commonly called the 
 change of life. The third is the remaining period of her life. But cases 
 are constantly presenting themselves in which the menses make their 
 appearance as early as the eleventh or twelfth year, and they are some- 
 times delayed till the seventeenth or even till the twenty-fourth year. 
 
 The following table is from Dr. Lee's work on the " Diseases of 
 Females," and is an exhibit of the time of the appearance of the 
 menses as noticed in fifteen hundred and sixteen women of England 
 and of France : 
 
 In fifteen hundred and sixteen women menstruation occurred — 
 
 A.t 11 years, 
 
 in . . . 
 
 ... 110 
 
 At 16 years 
 
 , in . . . 
 
 . . . 2S4 
 
 " 12 " 
 
 ti 
 
 ... 144 
 
 u 18 .. 
 
 u 
 
 ... 144 
 
 " 13 " 
 
 a 
 
 ... 356 
 
 « 19 u 
 
 u 
 
 72 
 
 " 14 " 
 
 (i 
 
 ... 366 
 
 " 20 " 
 
 u 
 
 ... 40 
 
 The succeeding table is from Dr. Edward Smith's work on " Con- 
 sumption: its Early and Remediable Stages." It is designed to show 
 the age at which the menses made their first appearance in one thou- 
 sand cases in England. The individuals were mostly phthisical patients 
 under the care of Dr. Smith. 
 80 
 
MENSTRUATION. 
 In one thousand women menstruation occurred at — 
 
 Mt. Tears. 
 
 Per Cent. 
 26 
 
 10 ft 
 
 11 .' 
 
 4.4 
 
 12 
 
 6.2 
 
 13 
 
 11.4 
 
 14 
 
 18.2 
 
 15 
 
 18.2 
 
 Mt. Tears. 
 
 16 . . . 
 
 17 . . . 
 
 18 . . . 
 
 19 . . . 
 
 20 . . . 
 
 21 . . . 
 24 . . . 
 
 81 
 
 Per Cent. 
 . 15.1 
 . 8.0 
 . 6.0 
 . 3.9 
 . 1.4 
 .26 
 .26 
 
 From the above tables it appears that from fourteen to fifteen years 
 of age was the most frequent period of the occurrence of the menses, 
 and that there is a progressive increase from eleven years, and a de- 
 crease until twenty years. 
 
 These observations coincide with some tables that have been made 
 in this country on a less extensive scale ; and although cases have 
 been reported of discharges very much resembling menstruation occur- 
 ring in childhood, there is no proof that such discharges are identical 
 with it. They depend mostly upon ordinary congestion of the uterus 
 and kidneys. A mother came to my ofhce with her little daughter, 
 aged eight years, very much alarmed, stating that she believed her 
 child was menstruating ; she had been in the same condition four 
 weeks before. A careful examination of the case proved the existence 
 of haematuria. 
 
 Various causes may contribute to the early or late appearance of 
 the menses, such as climate, constitutional temperament, and habits of 
 life. 
 
 Thus, writers tell us that, in the south of India and other hot 
 countries, girls begin to menstruate at eight, nine, and ten years of 
 age ; but, advancing to the northern climates, there is a gradual pro- 
 traction of the time, till we arrive at the extreme north, where women 
 do not menstruate till they arrive at mature age, and then in small 
 quantities at longer intervals, and sometimes only in summer. And 
 it is also said that when they do not menstruate according to the 
 genius of the country, they suffer equal inconvenience as in warm 
 climates, where the quantity discharged is much greater and the 
 periods shorter. 
 
 I have for several years observed that the menses appear much 
 earlier in females of the nervo-sanguineous temperament than in those 
 
82 PULMONARY TUBERCULOSIS. 
 
 of the other temperaments. Persons thus constituted have an exub- 
 erance of the vital forces ; hence all the physiological changes are 
 accomplished more speedily. Indeed, all here is life and activity ; 
 there is no dullness either of body or mind ; all things are in the 
 springtime to it, and the young miss is sometimes the mother at 
 fifteen. An instance of this kind recently came under my notice. 
 The individual was only a few days over fifteen years. She had an 
 easy labor, the child was of average size, and the patient had a good 
 getting-up. Her mother informed me that she changed regularly at 
 the age of twelve. For her age she was a person of precocious intel- 
 lect, and very beautiful, — a perfect Venus. 
 
 Certain habits of life also accelerate the appearance of the menses, 
 and among them may be enumerated the premature cultivation of the 
 passions by the perusal of obscene romances, the inspection of las- 
 civious pictures, the theatre, the ball-room, the bad example of prema- 
 ture libertinism, of which too many examples are unfortunately fur- 
 nished in great cities. These specimens of premature puberty, the 
 miserable consequences of too great vivacity of the passions, are 
 sometimes met with as early as the tenth year. 
 
 " In this city," says a distinguished physician of New York, "I 
 have known several instances of menstruation at the tenth and eleventh 
 year ; and in all the instances that have passed under my observation 
 the children were born of parents who had exhausted the powers of 
 life by too severely taxing the nervous system in the pursuit of 
 pleasure. One instance, in particular, was that of a scrofulous child 
 with a curvature of the spine. In this case, a tender but unwise 
 mother, contrary to our often-urged entreaties, persisted in feeding 
 the child with highly-spiced food, tea and coffee, bathing in exces- 
 sively warm water, and putting it to rest upon a bed of down. The 
 consequence was the appearance of the menses at the eleventh year, 
 and death at the sixteenth. Tonics, sea-air, and everything that 
 wealth could offer, availed nothing, and the poor girl died from pul- 
 monary tuberculosis."* 
 
 In regard to the amount discharged at each menstrual period, we 
 have no means of positively determining. Some writers have esti- 
 mated it at five ounces, others at eight and ten ; but it is not a matter 
 
 * "Woman and her Diseases," by E. H. Dixon, M.D. 
 
MENSTRUATION. 83 
 
 of any great practical importance to assign any special amount for 
 each monthly period ; because that must depend upon natural causes. 
 For the same reason that they are sometimes established even in those 
 who are perfectly healthy much earlier or later than in others equally 
 so, it is often greater or less in amount. Every physician of extensive 
 experience must have occasionally met with cases in which it is the 
 constant habit of the individual to have but four or six catamenial 
 discharges during the year, and yet enjoy very good health. Careful 
 investigation will no doubt show that these functions will differ as 
 much as some others, such as the required amount of sleep, food, 
 clothing, and exercise. What is demanded by nature is that the 
 woman should menstruate according to the requirements of her own 
 peculiar system ; and this would unquestionably be far more uniform 
 in times of appearance, quantity, and effect upon the constitution 
 were it possible for females to come up to the period of puberty with- 
 out the innumerable obstacles presented by our imperfect and miser- 
 able social system. 
 
 The requirements of fashionable frivolity and the damning vices of 
 our present social system expose the younger female portion to a world 
 of misery. That this opinion is not a mere whim of the writer, I 
 refer the reader to the following remarks of M. Calumbat : " The 
 mode of life to which the social condition condemns women, especially 
 in large cities, delivers them over, so to speak, defenseless against the 
 numerous causes of chronic disorders of the uterus, etc. Thus, in 
 populous cities, idleness, effeminacy, or sedentary life, the constant 
 contact of the two sexes, and the frequenting of places where every- 
 thing inspires pleasure ; prolonged watching, excessive dancing, frivo- 
 lous occupations, and the study of the arts that give too great activity 
 to the imagination ; erotic reading ; the pernicious establishment of 
 an artificial puberty ; the premature shock of the genital system ; the 
 concentration of the sentiments and thoughts on objects which keep 
 the genital system in a state of permanent excitation ; finally, a num- 
 ber of vicious habits and excesses of all kinds, which, by introducing 
 mortifications, more or less profound, into the general constitution, 
 react more particularly upon the sensibility of the womb, which, in 
 the female, is not only the organ most apt to lend itself to fluxion ary 
 movements, but likewise the centre towards which all morbific actions 
 seem principally to tend." 
 
84 PULMONARY TUBERCULOSIS. 
 
 We have not space to prolong our remarks under this head much 
 further. Sufficient has already been said to impress the reader with 
 its importance. We would, therefore, simply add that when men- 
 struation occurs at the proper age, and is well performed, the indi- 
 vidual may be regarded as most fortunate; "for a premature erup- 
 tion of the menses is always to be deprecated, because it is the 
 evidence of a precipitate development of certain parts of structures, 
 while others, not less important in the same category, are delayed and 
 incomplete. The individual who passes at a usual and healthy rate 
 through all stages of growth and development, from infancy up to 
 maturity, is most likely to enjoy a healthy and happy life, free from 
 weakness, pain, and the danger of premature death. Death loves a 
 shining mark, it is said ; and those children whose youth astonishes us 
 by the early perfection of their structures or their intellectual facul- 
 ties are snatched soonest from the world, as the earliest blossoms are 
 ever most exposed to the chilling frosts of spring."* 
 
 II. The Condition of the Menses in Phthisis. 
 
 In pulmonary tuberculosis the menses are almost always suppressed ; 
 and the reason for this is obvious. Phthisis being a constitutional 
 disorder, wherein the life-forces are enfeebled by a failure in some of 
 the blood-making organs, the uterine functions cease for the want of 
 proper nutriment, and not from local disease. Hence, we frequently 
 see young women lose their menses without any visible cause, when 
 all at once symptoms of phthisis will present themselves, and the case 
 proceeds to a hasty and fatal termination. But in some cases they 
 are not suppressed at the commencement of the disease : they may be 
 irregular, scanty, occurring every ten, fourteen, twenty-one, twenty- 
 eight, or forty days, just as the case may be. But, as the disorder 
 advances to the latter stage, they are always suppressed. In several 
 hundred cases I cannot now remember but two where the menses con- 
 tinued until the last. These were exceptional cases, and were patients 
 over forty years of age. And my experience leads me to the conclu- 
 sion that the menses are more generally suppressed at the commence- 
 ment of this disease, in very young women, than in those who are 
 more advanced in life. M. Louis found that where the duration of 
 
 * Mfeigs's "Woman and her Diseases/' page 396. 
 
MENSTRUATION. §5 
 
 phthisis was less than one year, the average period of the menstrual 
 suppression was about the middle of its progress. When the tuber- 
 culous affection was prolonged for more than one or two years, the 
 suppression occurred during the latter period. Thus, in a young- 
 woman, in whom the disease lasted three years, the menses ceased at 
 the end of the thirteenth month ; while another patient of the same 
 age, and in whom the disease was similar, continued to menstruate 
 until within two months of the fatal period. 
 
 The sudden suppression of the menses in an individual who has a 
 hereditary proclivity to pulmonary tuberculosis should be looked upon 
 as a very suspicious circumstance, particularly if she be unmarried. A 
 young woman ceases to have her regular menstrual discharge ; she 
 becomes pale and feeble ; she has pain in her head, loins, and limbs, 
 — after a time she emaciates ; her friends become alarmed, and call in 
 a physician. He gives her case a very superficial examination, and 
 refers all her difficulties to a suppression of the menses. Remedies 
 are prescribed with a view of restoring them, but, alas ! they are 
 without effect, and the medical attendant is suddenly aroused to the 
 sad conviction that he has made a mistake in his diagnosis ; phthisis, 
 with all its formidable features, is staring him in the face. 
 
 It was for a long time the opinion of writers on pulmonary tuber- 
 culosis, — and even Dr. Lawson, in his work on the subject, does not 
 discard the idea, — that the disorders arising from the menstrual sup- 
 pression might lead to the deposit of tubercular matter in the lungs. 
 We do not consider the suppression of the menses in any way a cause 
 of phthisis pulmonalis. In this case they cease from a failure of the 
 vital forces, as already remarked, and it is a marked symptom of the 
 great constitutional malady, which will ultimately end in the dissolu- 
 tion of the whole bodily fabric unless it is speedily remedied. A. 
 limited number of tubercles in a lung may be remedied, and the 
 patient regain her wonted health. But a constant repetition of the 
 morbid process is greatly to be dreaded, and can only be averted by 
 correcting the constitutional diathesis. 
 
 If, therefore, the physician suffers himself to be led away by the 
 local symptoms, and treats them alone, he will not have much success 
 in curing this disease. If, when the menses are suppressed, he em- 
 ploys active emmenagogues alone, it may lead to very injurious results.. 
 I have long since come to the conclusion that, when pulmonary tuber- 
 
86 PULMONARY TUBERCULOSIS. 
 
 culosis exists, all active measures to restore the menses are wrong. 
 Indeed, they stand in the way of other agents that will overcome the 
 constitutional malady, which is the chief difficulty. 
 
 That such cases are sometimes restored to health, I am well satisfied 
 from my own experience. Here is one among a number, which I 
 extract from my book of " Medical Fragments'' : 
 
 ••August 5, 1859. Called this day to see Miss , aged nineteen ; 
 
 she has not been feeling well for three months ; has a slight cough on 
 rising in the morning, with mucous expectoration; pulse, ninety-six; 
 respiration, twenty-five ; has fever in the latter part of the day ; spirits 
 hopeful ; appetite not good ; menses suppressed for four periods ; 
 bowels costive ; very restless at night, with pain in the small of the 
 back and limbs. Thompson's gingival margin presents on the gums 
 of the lower jaw ; urine scanty and high colored ; had slight haemop- 
 tysis four weeks since ; has no hereditary title to phthisis. Menses 
 made their appearance at fifteen, and had been regular up to the time 
 of their suppression, and she knows no cause for their sudden disap- 
 pearance. Her habits are retiring, and for several months she has 
 taken but little exercise. Has never suffered from any severe illness. 
 
 " The physical signs are marked : inequality in the expansion-move- 
 ments of the two sides of the chest ; dullness on percussion at the 
 right inferior clavicular region, and, on auscultation in the same 
 region, prolonged expiratory murmur of a high pitch is elicited. On 
 the left side the sounds are normal, with a little increased resonance 
 and slight sonorous rhonchi. 
 
 " The case was set down as one of limited tubercular deposits in the 
 superior lobe of the right lung ; and the patient was placed upon the 
 use of iron, quinine, cod-liver oil, and the compound syrup of phel- 
 landrium aquaticum, with a nutritious diet. 
 
 " October 1. Patient very much improved ; had a slight menstrual 
 discharge three days since ; treatment continued. 
 
 "November 1. Patient still improving; is able to ride several miles 
 a day on horseback ; has gained in weight fifteen pounds. From this 
 time her menses became regular, and her general health good. When 
 last this patient's chest was examined, nearly three years afterwards, 
 there was dullness on percussion just under the clavicle, and on 
 auscultation there was bronchial breathing over a good portion of the 
 superior lobe of the right lung, showiDg very clearly that the disease 
 
MENSTRUATION. 87 
 
 had been arrested by the correction of the constitutional vice and the 
 transformation of the tubercular deposits into cretaceous matter." 
 
 The regular recurrence of the menses in phthisis, after they have 
 been suppressed for some time, is a good omen. I have notes of 
 several cases where their appearance was almost the first symptom of 
 amendment. I have the history of two cases in particular, where the 
 patients recovered under the most hopeless circumstances, and that, 
 too, by no extraordinary medication. 
 
 The first patient was a young woman, aged eighteen, the only 
 daughter of a widow. I found her in the cottage of loneliness and 
 poverty ; she had toiled hard to support herself and her mother ; had 
 endured numerous privations, and lived on scanty fare. At the time 
 of my visit she had been ill for six months. Her general symptoms 
 all pointed out phthisis pulmonalis in an advanced stage : her eyes 
 had an unearthly brightness, and her cheek the brilliant flush' of 
 hectic. She was emaciated and very weak, — could not sit up more 
 than an hour in the course of the day. Her appetite was good ; 
 bowels regular; menses suppressed from the beginning of illness. 
 The physical signs pointed out the existence of a considerable cavity 
 in the superior lobe of the left lung. The right lung was free from 
 disease. 
 
 From the general symptoms and physical signs I regarded the 
 case as well nigh hopeless. There were three things, however, that 
 inspired me to make an effort to save her from a premature grave : the 
 absence of Thompson's gingival margin, the limited extent of the 
 local lesion, and the integrity of the stomach and bowels. So far as 
 I could discover, there was but a single suppurating cavity, without 
 any signs of tubercular deposits in other portions of the lungs. Cases 
 of this kind stand a better chance of recovering than those where the 
 deposits are smaller, but more universally distributed through the 
 pulmonary tissues. And I have occasionally met with cases where a 
 cavity of considerable magnitude appeared to act as a preventive to 
 the further extension of the local disease, and the life of the patient 
 was greatly prolonged — much longer than where they were more nu- 
 merous, and destroying a much larger amount of pulmonary tissue. 
 
 The patient was treated to iron, quinine, cod-liver oil, and a gener- 
 ous diet, just as circumstances indicated, for three months, with occa- 
 sional inhalations of iodine. Her menses appeared slightly at the 
 
88 PULMONARY TUBERCULOSIS. 
 
 fourth week ; more abundantly at the eighth ; and at three months 
 were nearly normal in quality and quantity. From the eighth week 
 her improvement was very marked. The expression of her countenance 
 became more natural ; her pulse and respiration less frequent ; cough 
 not so troublesome, and expectoration very moderate in amount. The 
 cavity was about nine months in healing. The case occurred about 
 thirteen years since ; the patient has enjoyed a fair amount of health 
 ever since, has been married six years, and is how the mother of two 
 children. The only marks left by the disease are a slightly-increased 
 frequency of breathing, and flattening of the superior part of the left 
 breast, just under the clavicle. 
 
 The second case was that of 3Irs. E. I was called to see her on the 
 10th of October, 1868. Her age was twenty-four; she was of the 
 nervo-sanguineous temperament ; no hereditary title to phthisis — 
 father and mother living and healthy : has been married five years ; 
 has two children, the youngest being thirteen months old. Her ill- 
 ness commenced at the birth of her last child. When it was six days 
 old she took a violent cold ; had chills and fever alternately for a week, 
 with pain in her left breast, cough, and expectoration; she was now 
 quite ill for three weeks ; her physician said she had lung-fever. 
 After this she made some improvement, but never regained her former 
 health. Pain still continued in the breast, and her cough at times 
 was troublesome. About the first of June she commenced to have 
 what her physician called chill fever. He treated her for it, without 
 relief, until the middle of July, when another doctor was called in. a 
 homoeopath, who managed her case until I was invited to take charge 
 of it ; her disease still being called chill fever. 
 
 At the time of my visit her chills and fever were very erratic ; 
 sometimes they occurred every day. then again every other day or 
 third day. Sometimes they came on in the morning, at others in the 
 afternoon. They were not attended by pain in either the head, back, 
 or limbs. At night there was commonly profuse perspiration. Her 
 menses have been suppressed from the beginning ; had milk for her 
 child only six weeks ; appetite good : spirits hopeful ; pulse, in the 
 sitting posture, one hundred and two; respiration, twenty-eight: tem- 
 perature, one hundred and four, in the afternoon ; cough annoving. 
 especially during the chills and fever; expectoration scanty: under 
 the microscope it is found to contain ordinary pus-cells and withered 
 
MENSTRUATION. 89 
 
 tubercular cells; the urine is scanty, high colored, acid, with a specific 
 gravity of 1020, and under the microscope exhibits a large number of 
 octahedral crystals of oxalate of lime. Thompson's gingival margin is 
 slightly defined upon the gums of the lower jaw ; the mucous mem- 
 brane of the throat is injected, and the tongue is clean, but a little 
 redder than natural. Notwithstanding the length of her illness and 
 the severity of her symptoms, she is not much emaciated, neither is 
 her loss of strength very great : for she can sit up most of the time 
 during the day, when not suffering with the chills and fever. 
 
 A physical exploration of the chest revealed the following : In- 
 equality in the expansion-movements of the two sides, the left being 
 somewhat restricted. Percussion over the same side yields marked 
 dullness down to the third intercostal space ; on the right side percus- 
 sion is normal. Over the region of dullness, auscultation elicits humid 
 crackling ; in the bronchial region, on both sides, there is considerable 
 mucous rhonchi ; the respiratory murmurs on the right side are nearly 
 normal, being, if anything, slightly intensified. The heart-sounds are 
 normal. 
 
 The diagnosis appeared to be obvious — tubercular softening in the 
 superior lobe of the left lung. 
 
 Treatment prescribed was — 
 
 R Elix. calisayae, 
 
 Syrup, hypophosph. calcis, aa f Siv ; 
 Syrup, sanguinarise comp., f^ii ; 
 Sol. strychnise, U.S.P., f3ij. — M. 
 SlG. — A tablespoonful three times a day after meals. 
 
 To relieve pain in the side affected, the compound tar plaster was 
 ordered as a counter-irritant. To mitigate night-perspiration, on re- 
 tiring a sponge-bath composed of a drachm of acidum sulphuricum 
 aromaticum in a pint of water was employed, and internally a tea- 
 spoonful of quinise sulph. ; and as her appetite and digestion were 
 good, she was allowed a substantial diet. 
 
 After four weeks' persistent treatment with the above therapeutics, 
 there was a marked mitigation in all of the pressing symptoms. The 
 physical signs and an examination of the sputum by the microscope 
 clearly demonstrated that the softening of the tubercular matter was 
 complete and a cavity formed. From this time she continued to im- 
 
90 PULMONARY TUBERCULOSIS. 
 
 prove daily in weight and strength. Her menses appeared on the first 
 of December, and afterwards continued regular. The cough and ex- 
 pectoration gradually became less, and by the first of May the cavity 
 was perfectly healed. The patient has since had a child, and at the 
 present writing is in the enjoyment of good health. 
 
 She had no chills and fever after the third week. After the fourth 
 week the syrup, sanguinarise comp. was omitted; cod-liver oil and iron 
 were prescribed with the other remedies. The quinia was also con- 
 tinued at night ; given in this manner and quantity it is a splendid 
 sedative : it will often secure the patient a refreshing night's sleep, 
 when opium or morphine fails. 
 
 In concluding our remarks on this subject, we should not neglect 
 to say that there are some practitioners who are in the habit of 
 considering the lungs perfectly safe so long as a woman menstruates 
 regularly. They regard phthisis pulmonalis and menstruation as in- 
 compatible; but this is an error, for some women will menstruate and 
 give birth to robust children until the very last. And it is sometimes 
 astonishing with what perfection the womb will perform its appropri- 
 ate functions, even when the lungs are so impeded in their action by 
 tubercular disease that they can hardly supply the system with oxygen 
 sufficient to support animal life. Yet the foetus will thrive in utero, 
 "issuing into the world redolent of life, and escaping, as it were, from 
 the sepulchral cavity of its dying mother's womb." 
 
CHAPTER VII. 
 
 THE GENERAL SYMPTOMS OF PULMONARY TUBERCULOSIS. 
 
 The course of pulmonary tuberculosis may be divided into five 
 stages, namely : 
 
 1. The pre-tubercular. 
 
 2. The deposit and induration of tubercle. 
 
 3. The softening of tubercle. 
 
 4. The formation and evacuation of vomicae. 
 
 5. The healing of vomicae. 
 
 Each of these stages have their special symptoms and physical 
 signs, but in this chapter we will notice more particularly those which 
 belong to the second, third, and fourth. 
 
 I. Symptoms of Deposit and Induration. 
 
 This stage of phthisis is accompanied by various irritations, both 
 local and general. Of the local irritations, the earliest is cough. At 
 first it is commonly slight and dry. It occurs mostly upon the indi- 
 vidual's getting out of bed in the morning, or his making use of any 
 unusual exertion during the day. It feels to him as if it was caused 
 by some irritation about or in the throat. Sometimes it will cease 
 for a time in warm weather, and return in cold. By degrees it 
 begins to be troublesome, especially at night, and is attended with 
 more or less expectoration. 
 
 Another occasional symptom of local irritation is pain in the chest, 
 referred mostly to the sternum ; sometimes it is a stitch in the side ; 
 sometimes it is a soreness more than an acute pain ; not unfrequently 
 it is absent. These variations of pain are mostly irritations, but 
 sometimes they are the result of real local inflammation excited in 
 the lungs, the bronchi, or the pleura, by tubercular infiltration. 
 
 Of the more general irritations, quickness of the pulse is the most 
 constant, but this is not universal. The quickness is not often uni- 
 
 91 
 
92 PULMONARY TUBERCULOSIS. 
 
 form at first, but depends on any causes of excitement, however 
 trifling, and the pulse may be slow and weak in the interval ; but as 
 the disease advances, it gradually becomes more constant, and is 
 accompanied by an irritable state of other functions, — a general febrile 
 condition. But then there is not power enough in the circulation to 
 maintain a general or constantly increased heat. It is manifest more 
 toward evening, after the excitement of the day, when the fullness, as 
 well as the frequency, of the pulse increases, and there is a flush of 
 the face, and heat in the palms of the hands and soles of the feet. 
 
 Like other weak and intermittent febrile movements, this generally 
 terminates by perspiration more or less profuse, which, occurring in 
 the night, leaves the pulse lowered, but the system weakened and 
 exhausted in the morning. It is only in the severer cases that this 
 general irritation, or hectic fever, as it is termed, becomes marked at 
 this early stage of the disease. Often there is gastric irritation, with 
 a white tongue, red at the edges, thirst, costive bowels, and turbid 
 urine. These symptoms are generally more remarkable in this than 
 in the after-stages, when the irritation is more confined to the organs 
 of circulation and respiration. They are always attended by some 
 diminution of flesh and strength, which, however, varies greatly in 
 degree in different individuals. 
 
 In addition to the symptoms of irritation, we have those of obstruc- 
 tion ; these are confined chiefly to the passage of the air, to that of the 
 blood, and to the motion of the lungs in respiration. Tubercular matter, 
 when it once becomes indurated, by impeding the free passage of the air 
 to the air-cells generally causes more or less shortness of breath, so 
 frequently complained of in this stage of phthisis. The records of 
 pathology abound in cases where, from extensive tubercular exuda- 
 tions in the lungs, together with the oedema which they produced, 
 fatal consequences have ensued even in the first stage of the deposits. 
 In this instance there is great fever, with frequent cough, very quick 
 ,pulse, with symptoms resembling an attack of acute pneumonia or 
 bronchitis, the diagnosis of which will be clearly pointed out in a 
 subsequent chapter. 
 
 The obstruction of the blood-vessels in the lungs by tubercular 
 deposits produces many serious difficulties. They nearly always cause 
 sanguineous congestions, hemorrhages, inflammation, oedema, atrophy 
 of the pulmonary tissues, profuse bronchial secretion, effusion in the 
 
GENERAL SYMPTOMS. 93 
 
 pleura, and various lesions of the heart; and the symptoms which 
 these various pathological changes produce may be variously grouped 
 in the history of different cases of pulmonary tuberculosis. 
 
 The obstruction to the motion of the lungs may be caused by the 
 same circumstances which impede the free admission of air to them ; 
 but in case of extensive solid deposits, it may also result from their 
 mechanical resistance to the motion of the chest. "When, therefore, the 
 integrity of a nicely-adjusted apparatus, like that of respiration, is once 
 extensively injured, disorder begets disorder, and unless the counter- 
 acting respiratory powers come into operation, unless indurations are 
 soon diminished, the whole of that part of the lung may soon become 
 a solid mass, which must inevitably result in its total disorganization. 
 
 II. Symptoms of the Stage of Softening. 
 
 There is no class of symptoms that I am acquainted with, from 
 which we can positively deduce, during life, the softening of tubercu- 
 lar matter in the lungs. There is sometimes an abatement of the 
 more irritating symptoms during the change, with an increased amount 
 of expectoration. In the first stage, the sputum is chiefly mucous, 
 and is freely aerated ; but as the stage of softening advances, it be- 
 comes more yellow, globular, and non-aerated. This is not, however, 
 its uniform character. It may and does frequently differ in appear- 
 ance at particular periods of the same day, and even in the same hour. 
 Thus, the yellow variety is commonly the most profuse in the morn- 
 ing, while as the day advances it will become more mucous and 
 transparent in its character. As it increases in purulency it has a 
 variegated appearance ; sometimes the edges of the masses which are 
 expectorated are irregular and rugged, while at others they are quite 
 smooth, and, as they become more purulent and less aerated, when 
 placed upon the water they immediately sink. In some cases, at this 
 stage of the disorder, the sputum is more or less streaked with blood, 
 or rusty, resembling that which we see in pneumonia. 
 
 As the process of softening goes on, the patient declines in flesh 
 and strength, and there is also a general depression of the functions 
 of the body. The pulse loses strength, and its frequency is slightly 
 increased. Being ninety in the first stage, it now increases to one 
 hundred or one hundred and ten. The chills are more severe ; the 
 fever is of shorter duration ; the night-sweats more profuse ; except 
 
94 PULMONARY TUBERCULOSIS. 
 
 at times of excitement, the color of the cheek fades, or is reduced to 
 a circumscribed hectic patch. There is often less feeling of oppres- 
 sion or pain in the chest than heretofore ; but the shortness of breath 
 on exertion is undiminished, if not increased, and there are frequently 
 transient pains in the shoulder, or under the clavicle of one side, 
 which at times are quite annoying. 
 
 III. Symptoms of the Formation of Vomicae. 
 
 When tubercles become soft or partially liquefied, they are evac- 
 uated by the aid of secretion and ulceration of the adjoining textures. 
 When this takes place, there is an augmentation of all the symptoms 
 before described, with certain other additions and complications. We 
 now have a copious and heterogeneous expectoration of pus, mucus, 
 softened and occasionally solid tubercles, blood, shreds of lymph, and 
 sometimes portions of pulmonary tissue. Then occur the usual con- 
 stitutional concomitants of suppurative ulceration, — confirmed hectic, 
 with its successive chills, heat, sweating, diarrhoea, and increased 
 emaciation. Then are the difficulty of breathing and cough increased 
 by the continual discharge of matter into the air-passages, and the 
 extension of the ulcerative process. 
 
 As the disease advances, the countenance becomes very thin, with 
 the sharpened nostrils habitually moving at every breath, and may 
 have a clearness in it, with color in the lips and a brightness of the 
 eye which are never seen in other serious diseases ; and the mind is 
 often in a hopeful state, indicating a degree of freedom from those 
 painful struggles in which the vital powers commonly contend with 
 other serious disorders. 
 
 It is supposed by some writers that the chief reason for this ex- 
 emption from suffering in this disease lies in a sort of balance that is 
 manifested among the injured functions. The available parts of the 
 lungs are much reduced in extent, but so is the mass of the blood 
 that has to pass through them. The free expectoration and the col- 
 liquative discharges from the skin and the bowels are continually 
 bringing down the bulk of the circulation to the lessened capacity of 
 the remaining lung. The night-sweats, especially, are a periodical 
 discharge of the amount of fluid which is beyond what the reduced 
 system of blood-vessels can conveniently hold ; they often cease when 
 fluids are judiciously reduced. 
 
GENERAL SYMPTOMS. 95 
 
 So also the secondary pulmonary irritations, congestions, and inflam- 
 mations are continually relieved by the purulent expectoration. It is 
 a safety-valve which gives vent to these local lesions before they cause 
 very much distress ; and although the destructive process is perpetually 
 proceeding, the lungs decaying, the body wasting, and the strength 
 failing, yet it is all by even degrees. The thread of life dwindles away 
 fibre by fibre, without a shock, and gentle is the parting of the last 
 filament when the body drops to the earth, and the soul, like a bird 
 set free, plumes its wings for a celestial flight. 
 
 But the progress of pulmonary tuberculosis is not always thus pain- 
 less. The suffering from difficulty of breathing, cough, chills, heat, and 
 a feeling of extreme weakness and faintness, is sometimes very severe. 
 In addition to these, there are incidental lesions contingent upon it, 
 which may render the disease rough and painful. Intercurrent con- 
 gestions, hemorrhages, and inflammations taking place in the lungs or 
 their investing membranes are very common, and may give rise to the 
 symptoms of their several acute lesions superadded to those of phthisis. 
 
 There are several other symptoms, unconnected with the chest, 
 which frequently attend the disease. The throat is frequently in- 
 flamed and ulcerated, which symptom often withdraws the attention 
 from the seat of the more important lesion. There is sometimes great 
 irritability of the digestive organs, attended with severe pain in the 
 stomach and vomiting, which last frequently continues till the fatal 
 termination, greatly adding to the distress and weakness of the patient. 
 
 In the great majority of cases of pulmonary tuberculosis, the bowels 
 sooner or later become deranged ; constipation and diarrhoea alter- 
 nately prevail, dependent not unfrequently on inflammation and ulcer- 
 ation, often complicated with tuberculous deposits in the follicular 
 structure of the mucous membrane of the intestines. The mesenteric 
 glands frequently become involved in the same disease ; sometimes the 
 abdomen is very tender and painful throughout the whole course of 
 the disease. These symptoms generally depend on granular or tuber- 
 cular deposits on the peritoneum, combined occasionally with inflam- 
 mation of the membrane, which may lead to the agglutination of the 
 folds of the intestines. 
 
 Tubercles are occasionally deposited in the brain or spinal marrow, or 
 their membranes, and produce symptoms of mental derangement, con- 
 vulsions, or paralysis. Such cases are, however, not common ; the brain 
 
96 PULMONARY TUBERCULOSIS. 
 
 mostly maintains its integrity until the last, and the mind is usually 
 brilliant and happy. Who has not read the lines of Percival, beginning — 
 
 " There is a sweetness in woman's decay, 
 TVhen the light of beauty is fading away." 
 
 How often in the course of our professional experience have we 
 marked the development of this spiritual beauty as the outward graces 
 disappeared ! As the countenance grows paler and the frame becomes 
 more attenuated, the soul appears to shine through them. The eye 
 grows more spiritually bright, and the wasted cheek puts on a beauty 
 which it had not in its bloom. Disease seems to be gently unclothing 
 the spirit, that it may be robed with the drapery of heaven. The tones 
 of the voice are subdued, and that fond look which regards the loved 
 ones around is such as an angel in heaven might bend on mortals below. 
 It is a look of ineffable tenderness, yet not unmingled with pity. 
 
 This disease, so much dreaded by those in strong and vigorous 
 health, no doubt has many gentle duties to perform for our good. It 
 is mercifully ordered to go before death to prepare the way. It softens 
 the pains of dissolving nature ; with gentle fingers it detaches us from 
 the world. One by one it removes the ties that bind us here, and 
 makes it easier to depart. And then, if the soul is inspired by the 
 Christian's faith and hope, this disorder assists in refining, beautifying, 
 and preparing it for its heavenly home. 
 
 And oh! how often in the still death-room, where the victim of 
 phthisis has met his fate, have we witnessed with what composure a 
 Christian can die ! Even when we have listened to the rude tale, told 
 in uncultivated eloquence, how the fears of dissolution were vanquished 
 by the assurance of a heavenly inheritance, how the weakness of a 
 frail and exhausted nature was supported by succors of celestial grace, 
 and how the anticipation of eternal happiness shed a triumphant glory 
 over the soul, there has been a lofty feeling excited in our bosom, 
 which casts into insignificance all the pride of life and the vain pomp 
 of worldly illusion. 
 
 " The things of earth are like a river, — 
 
 A summer river quickly dry : 
 The things above endure forever, 
 
 Their ocean is immensity : 
 There streams of joy, which ne'er 
 
 Shall be exhausted, roll eternally, 
 
 And there let our spirits flee." 
 
CHAPTER VIII. 
 
 THE PHYSICAL SIGNS OF PULMONARY TUBERCULOSIS. 
 
 There are many physicians who can remember the period in their 
 medical history when the physical signs of chest-diseases were but 
 little understood. The great mass of the profession were groping 
 their way in the dark, with scarcely a ray of light to guide them to a 
 correct diagnosis. And even after the art of auscultation had made 
 considerable progress, and its utility had been clearly demonstrated, 
 there were not found wanting men in the profession who rejected its 
 teachings and ridiculed those who practiced it. 
 
 I well remember, when a student in the city of New York, hear- 
 ing a distinguished physician give his opinion of auscultation in this 
 wise : " It is," said he, " a tube made of wood, with the chest of a 
 fool at one end and the ear of a knave at the other." Such was 
 the contempt with which this valuable art was treated thirty years 
 since by some of the most prominent medical men in this country. 
 But, happily for humanity, the day is past when any respectable 
 member of the profession will stand up and seriously controvert its 
 utility. Its importance in making out a correct diagnosis of all chest- 
 diseases is universally admitted. 
 
 In this chapter we propose to give a brief description of some of 
 the more prominent physical signs of pulmonary tuberculosis. They 
 maybe classed under three heads: 1st, Inspection; 2d, Percussion; 
 3d, Auscultation. 
 
 I. Inspection. 
 
 When we are to inspect an individual's chest, we prefer that he 
 should be in the sitting posture, and placed in such a position that 
 we have an abundance of light. It is proper that all the clothing 
 should be removed from the chest, particularly in males. In females, 
 decency requires that it should be covered, but with some material that 
 will not obscure its motions. A common dressing-gown of thin cotton 
 
 97 
 
98 PULMONARY TUBERCULOSIS. 
 
 will answer a good purpose. When thus placed, we may stand in 
 front of the patient, at such a distance as will enable us to scrutinize 
 the chest carefully. 
 
 The first thing to be observed is the frequency of its movements. 
 These, we know, are very much affected, even in health, by a variety of 
 circumstances, such as periods of life, lying, sitting, standing, walking, 
 and running. In the sitting posture, in the adult, the number of respi- 
 rations per minute varies from fourteen to eighteen. In children it is 
 much more frequent, varying from twenty to twenty-six, according to 
 the age. In phthisis the respiratory movements are nearly always 
 increased in frequency. I have often seen this long before any other 
 sign of the disease has presented itself. I remember one case in par- 
 ticular, which will serve as a marked example of several. 
 
 The patient was a young man, aged twenty-one. It was at church 
 that I first witnessed his hurried breathing, and, as he occupied a seat 
 just in front of me, it annoyed me exceedingly. As I had been his 
 father's family physician for several years, I sent for him to come to 
 my office, as I wished to examine his chest, expressing my fears that 
 he was laboring under some serious disease of the lungs. Nothing 
 positive was elicited by a physical exploration of his chest, and as he 
 did not complain of being unwell, he was dismissed without a pre- 
 scription. This was two years before he had a single physical sign 
 of tubercular deposits in the lungs. I saw him frequently during this 
 time, and he appeared to enjoy his usual health, and was equal to all 
 the duties of a farmer's life. In the sitting posture, his respiration 
 was commonly thirty per minute. Its chief characteristic was its fre- 
 quency; the patient did not complain of any inconvenience from it. 
 
 The second thing to be observed is the expansion-movements of 
 the chest. In health, if there be no deformity of the chest, the ex- 
 pansion of the two sides is equal and its symmetry complete. And it 
 requires considerable tubercular consolidation to produce any irreuu- 
 larity in its shape or motions. But when we do perceive a difference 
 between the two sides, the upper ribs do not move so much on one 
 side as on the other. And it may be laid down as a fundamental prin- 
 ciple, which has been verified by experience, that the movements of the 
 chest become restricted in proportion to the quantity and extent of the 
 tubercular consolidation. 
 
 In the commencement of pulmonary tuberculosis, where there is 
 
PHYSICAL SIGNS. 99 
 
 but very little matter deposited, and this is contained within a small 
 space, or, as is sometimes the case, scattered widely through the luno-s, 
 it is evident that very little or no appreciable difference would occur in 
 the expansion-movements of the chest. But, as the disease advances, 
 the expansion-movements are generally not so strong or free ; and it 
 is not a very uncommon thing to find cases where, from extensive 
 tubercular infiltration, one side of the chest is almost motionless. The 
 irregularity of motion, however, is mostly confined to the superior 
 part of the affected side, and keeps pace with the progress and extent 
 of the internal lesion. 
 
 We also sometimes notice in this disease that, after the expansion- 
 movements have ceased in the affected side, it will look contracted, 
 and the well side will have the appearance of being elevated. The 
 first is real, the latter is not. We should not, therefore, place too 
 much confidence in this appearance as a sign of phthisis, for it is fre- 
 quently present in other diseases of the chest ; but, when associated 
 with some of the other signs about to be described, its significance is 
 greatly enhanced. 
 
 II. Percussion. 
 
 The best position in which a patient can be placed for percussing 
 his chest is standing, if he is able, with his shoulders resting against 
 the wall of the room. If he is too feeble to stand, let him sit in a 
 chair high enough in the back to support the shoulders. Or if, as 
 frequently occurs, the individual is unable to rise from his bed, see 
 that all the pillows are removed, and that he lies upon his back and 
 on a mattress. The chest should be fully exposed, with those excep- 
 tions named under the first head. When the anterior part of the 
 chest is to be percussed, we generally prefer that the patient should 
 put both hands upon the back of his head ; and when the posterior is 
 percussed, with the arms crossed equally upon the breast. In this 
 manner the muscles of the chest are rendered tense, and the different 
 sounds are more easily elicited. 
 
 In the incipient stage of tubercular consolidation, the resonance of 
 the chest is but very little diminished on percussion. But as the lung- 
 becomes more indurated, dullness is one of the most prominent signs. 
 In this disease, the most numerous and largest tubercular deposits 
 occur at the apices of the lungs, and generally more on one side than 
 
100 PULMONARY TUBERCULOSIS. 
 
 on the other. Hence the clavicle on one side, when lightly struck on 
 its centre, may yield a sound duller than the others. If this should 
 be the case, it is quite probable that there are indurations in the 
 lungs. 
 
 G-reat care must be taken to percuss both sides of the chest at the 
 same point, or the comparison will not be correct. To avoid error, 
 various kinds of percussion should be used, particularly in doubtful 
 cases. We have more confidence in immediate percussion than me- 
 diate. The tapping may be conducted at first with a single finger, 
 then with the flat of several fingers, and in different stages of the 
 respiratory act. — on a full breath, and after exhausting the lungs. 
 Sometimes the gentlest patting of the subclavian space is the only 
 mode in which any difference can be discovered. 
 
 When percussion elicits dullness under the clavicle, we find that it 
 commonly diminishes as we pass a little lower down in the chest. 
 Thus, on the first rib, we have a perceptible dullness, while on the 
 second or third we have a natural resonance. This is the case so 
 long as the induration is confined to the upper part of the superior 
 lobe ; but when it includes the whole lung, the dullness is pretty 
 generally distributed over the entire side. This is more particularly 
 the case in consolidation from pneumonitis. It sometimes occurs that 
 both lungs become equally affected with tubercular deposits. When 
 this occurs, we lose, in a great measure, this important means of 
 diagnosis, especially when we institute a comparison between the con- 
 dition of the two sides. 
 
 We, therefore, make the following inferences : 
 
 1st. Dullness on percussion is an important sign of consolidation of 
 the lung. 
 
 2d. Its location commonly points out the nature of the consolida- 
 tion. 
 
 3d. When situated at the apex of the lung, it is usually an evi- 
 dence of tubercular deposits. 
 
 4th. It generally points out the extent of the pulmonary lesion. 
 
 III. Auscultation. 
 
 Before describing the auscultatory signs of pulmonary tuberculosis. 
 I wish to make a few remarks on the normal sounds of respiration ; 
 for it is only by an attentive study of these that we can attain to a 
 
PHYSICAL SIGNS. 101 
 
 correct knowledge of those that are elicited in a morbid condition of 
 the organs. 
 
 All of our best physiologists admit that the air enters the lungs by 
 atmospheric pressure, to fill the increased space made in the chest by 
 the action of the muscles of respiration. On its way to the most 
 expansible parts of the lungs, the pulmonary air-cells, it is propelled 
 against the sides and angles of the trachea and larger bronchi, pro- 
 ducing a sound which is called bronchial breathing. But as the air 
 passes down to the final ramification of the bronchi, this bronchial 
 respiration is lost in the vesicular breathing. This latter sound no 
 doubt depends on the impulse of the air against the angles and sides 
 of the minute tubes of the air-cells, partly also on the opening and 
 stretching of these cells. 
 
 Bronchial respiration is a whining or tubular sound, denoting that 
 it is produced by the passage of air into the bronchial tubes. It is 
 commonly heard over the space of two or three inches on each side 
 of the top of the sternum, between the scapulas, and sometimes in the 
 axillae. Vesicular respiration sounds more like a murmur caused by 
 air passing through minute tubes ; some have compared it to the 
 murmur of a sea-shell, or to the sighing of a gentle breeze among the 
 leaves of the trees. It is heard in those parts of the chest most 
 remote from the larger bronchi. 
 
 In the act of breathing we have two motions of the chest, namely, 
 inspiration and expiration, and between which there is a vast differ- 
 ence. In inspiration, air is the moving body, and in rushing through 
 the air-tubes it distends the passive lung ; in expiration, the lung is 
 the moving body, and by contraction drives before it the passive air, 
 — producing, in either case, pressure between the air and the interior 
 cells. By this it is plain that there must be a difference between the 
 sounds of inspiration and expiration. In inspiring air, it moves with 
 velocity against the angles and sides of the tubes which it has to 
 dilate : here must be sound in the whole passage of the air, down 
 even to the air-cells. In expiration, the motion begins with the 
 lungs ; and the air, passively yielding to it, there is not motion or 
 resistance enough to produce sound until, on the converging together 
 of the small tubes, the impelled air is gathered into a current in the 
 large tubes, where, impinging against their sides with its now ac- 
 quired velocity, it at length produces sound — the expiratory murmur. 
 
102 PULMONARY TUBERCULOSIS. 
 
 Hence the inspiratory murmur is louder and longer than the expira- 
 
 torv. 
 
 When, therefore; we auscultate the chest of a healthy individual, 
 we find, with few exceptions, that the expiratory murmur is very 
 slight, and very little more distinct in any one part of the chest than 
 another. The lungs naturally are very elastic, and this elasticity is 
 necessary to soft and uniform breathing. Now, when any considera- 
 ble portion of their textures becomes consolidated by tubercular 
 deposits, the harmony of their action is destroyed ; bronchial expira- 
 tion is greatly promoted ; but between the state of health and decided 
 consolidation there are various intermediate conditions. Thus, when 
 the air-cells are but slightly thickened by the tubercular exudation, 
 bronchial expiration is^not induced; but, as they become more con- 
 tracted, they render the respiratory murmur more audible. When 
 there is no obstruction in the pulmonary air-cells, the inspiratory 
 murmur occupies the whole time of inspiration ; but the expiratory 
 murmur does not occupy more than one-fourth of the time of the 
 inspiratory. Hence it has been found, with the progress of phthisis, 
 the duration of the inspiratory murmur usually lessens materially, and 
 the expiratory is sensibly prolonged and elevated ; so much so. that 
 instead of only occupying one-fourth part of the period of healthy 
 inspiration, it may come to exceed it in duration. 
 
 Prolonged expiratory murmur of a high pitch is. therefore, a 
 marked physical sign of the first stage of pulmonary tuberculosis — 
 the stage of deposit and induration. I am fully aware that some 
 writers "place but little confidence in it. They tell us that it has to 
 be surrounded with so many qualifications that it is perfectly yalue- 
 less. May not the same be said of nearly every other physical sign 
 of this disease ? for they all have to be taken with exceptions. I am 
 well satisfied, from personal experience, that where the prolonged ex- 
 piratory murmur is absent, the existence of tubercular deposits in the 
 lungs cannot be affirmed with any certainty. I do not, however, 
 pretend to say that we may not occasionally meet with cases of phthisis 
 where it is absent, and that it may occasionally occur in other dis- 
 orders of the chest ; but I do maintain that, in nearly every case, it 
 is an undeviating auscultatory sign of pulmonary tuberculosis in the 
 first stage, and is more to be relied upon than any other. 
 
 But as the tubercular consolidation becomes more extensiye, and 
 
PHYSICAL SIGNS. 103 
 
 approximates the stage of softening, another' sound is gradually 
 developed, of almost equal value as a means of diagnosis, called by 
 some writers dry crackling. It is usually heard just under the 
 clavicle and in the axilla, and consists of several sharp, dry, explo- 
 sive, and distinct crackling rales. It is most commonly heard at the 
 completion of inspiration, and requires a forcible act of respiration for 
 its development. Thus, on making a forced inspiration, it may 
 become distinctly audible. Sometimes this forced inspiration will 
 develop only a single rale, at other times three or four, which will 
 startle us by their clear, dry, and metallic sound. When dry crack- 
 ling is once fully developed, its persistence is constant, although it 
 may be more manifest at one time than at another; and it seldom ever 
 ceases entirely until it passes into humid crepitation, or moist, crack- 
 ling rhoncus, which is its natural tendency. As the disease advances, 
 and the lungs become more occupied with tubercular deposits, dry 
 crackling may be frequently heard during ordinary respiration. When 
 it becomes thus manifest, it is one of the most unfailing proofs of 
 pulmonary tuberculosis that we can have. 
 
 There are several other physical signs of this first stage of tuber- 
 cular disease in the lungs that have been described by writers on 
 auscultation, such as wavy inspiration, pulmonary crumpling, and 
 cog-wheel sound ; but they are of so little value as means of diagnosis 
 that we will not occupy space with their description. Those just 
 noticed are sufficient for all practical purposes ; and he who becomes 
 thoroughly acquainted with them will have better success in detecting 
 the disease than he who has a superficial knowledge of twice the num- 
 ber. Knowledge of any kind, to be useful, must be simple, definite, 
 and positive. We need more of this kind in the practice of medi- 
 cine ; and when it shall become more common our success in miti- 
 gating and curing disease will be much greater. 
 
 When tubercular matter once becomes thoroughly indurated, it is 
 not usually very long before softening supervenes ; this is the second 
 stage of the local disease. The physical signs of this change are not 
 very pronounced ; indeed, I know of no one that is positively in- 
 dicative of it. It is to be supposed, however, that all the signs that 
 pertain to the first stage will in this be either increased or modified, 
 while others will be added. The inequality of the respiratory move- 
 ments, and the dullness on percussion, are now generally more marked, 
 
104 PULMONARY TUBERCULOSIS. 
 
 the respiration more obscure, or bronchial, and accompanied by per- 
 manent humid crackling, which may commonly be regarded as indica- 
 tive of tubercular softening. When this takes place, we may begin 
 to look for those physical signs which belong to the third stage — 
 vomica. 
 
 The chief auscultatory sign of a cavity in the lungs is cavernous 
 respiration. As soon as a portion of tubercular matter is discharged 
 through the neighboring bronchial tube, the cavity has commenced, 
 and the sound produced through these excavations may be of various 
 kinds. It may be, and often is, a mere click, like the opening and 
 shutting of a valve ; or a chirk ; or a crackling ; but all these sounds, 
 under certain circumstances, denote the formation of a cavity, and for 
 convenience' sake have all been included under one name,— cavernous 
 respiration or clicking. 
 
 The various sounds in cavernous breathing are owing to the differ- 
 ence in size, form, and situation of the cavities, and to the different 
 conditions of the surrounding lung. A cavity may be very large or 
 small ; several bronchi may open into it, or only one. It may be a 
 simple cavity, or it may have several chambers. Its sides may be 
 condensed and equal, or rough and rugged. The lung around it may 
 be solid, or pervious and vascular. It may be near the ribs, or far 
 from them ; adherent to, or separate from, the pleura. It is quite 
 obvious that these differences in condition are calculated to modify 
 the sound, which will nevertheless be always such as to indicate the 
 existence of a cavity, particularly when distinctly heard at the apex 
 of the lungs. 
 
 Cavernous respiration is sometimes present in other lesions of the 
 chest, such as bronchial dilatations and pneumonic cavities. But at 
 the period of the disease now under consideration, there are so many 
 other physical signs present with it that we need not be in much doubt 
 as to the true import of its teachings. In tubercular cavities it is 
 almost uniformly heard at the apex of the lungs, while in bronchial 
 dilatations and pneumonic cavities it is heard much lower down. 
 The sound of-clicking is best obtained by quick, forcible respiration, 
 or by slight coughing, which increases the force and velocity of the 
 passing air, and exaggerates the sounds. 
 
 Another very important physical sign of a cavity in the lungs is 
 pectoriloquy or chest^speaking. Laennec regarded it as the most 
 
PHYSICAL SIGNS. 105 
 
 valuable of all the physical signs of pulmonary tuberculosis. Subse- 
 quent writers have not looked upon it with the same degree of favor. 
 Some of them consider it the most fallacious of all the physical signs 
 of the disorder ; but our experience teaches us not to treat it in that 
 light. When distinctly present, no one need hesitate a moment to 
 pronounce the existence of a cavity. Let us briefly examine some of 
 its peculiar features as they are manifested in this malady. 
 
 When a cavity of considerable magnitude exists in the lungs, by 
 placing a stethoscope directly over it and directing the patient to 
 speak we will hear the sound of his voice almost as plainly as if it 
 came from his mouth, and it will be more or less perfect according to 
 circumstances. Thus, it is perfect when the sound transmitted through 
 the stethoscope is complete, and is imperfect when the sound of the 
 voice is wanting in some of its essential tones as heard from the 
 mouth. 
 
 The circumstances which render pectoriloquism perfect are — the 
 complete emptiness of the cavity, the increased density of the portion 
 of lung which forms its walls, its communication with one or more 
 bronchial tubes of a certain diameter, and its approximation to the 
 walls of the chest. It is proper to state, however, that whatever be 
 the distance of the cavity from the surface of the lungs, if it possesses 
 the other qualities indicated it will always yield perfect pectorilo- 
 quism, unless a very considerable thickness of healthy lung be inter- 
 posed, which, owing to its defective density, is necessarily a bad 
 conductor of sound. The extent of the cavity also contributes to the 
 perfection of the phenomenon. It will be imperfect when the cavities 
 are very large and their openings with the bronchi are very small. It 
 will also be incomplete when a cavity opens into the pleura, particu- 
 larly if the opening be large, and when its contents make their way 
 through the walls of the chest into the cellular membrane outside. It 
 may likewise be suspended for several hours, and even days, by the 
 temporary obstruction of the communication of the cavity with the 
 bronchi by the matter contained in it. 
 
 This sign is most characteristic of phthisis when located just under 
 the clavicle, and is very circumscribed. But tuberculosis may exist 
 when it is more diffused ; for, as we have already observed, besides 
 the cavities, there may be extensive consolidations of the lungs, and 
 consequently free transmission of the voice over a considerable extent 
 
10G PULMONARY TUBERCULOSIS. 
 
 of surface. Even in this case a practiced auscultator can distinguish 
 the peculiar phenomena of cavities, in the blowing or tinkling and 
 in the more articulate voice that certain spots present. But I would 
 caution the young practitioner not to be too hasty in concluding upon 
 the existence of cavities from this sign alone. I have known some 
 very good auscultators deceived by it. M. Louis mentions a case of 
 this kind which occurred in his own practice* 
 
 The last physical sign of this disease that we shall notice is the 
 cracked-pipkin sound, the French bruit depot file, from the idea that 
 it resembles the sound produced by striking a cracked pipkin. It is 
 a very sure sign of a cavity in the lungs, and is usually elicited by a 
 smart stroke given just below the clavicle while the patient's mouth 
 is open. The sound may be imitated by doubling the hands together 
 rather loosely, and striking the back of one of them against the knee, 
 in such a manner as to allow the escape of a small quantity of air. 
 The production of this particular sound, by percussing the chest, is 
 owing to the proximity of a considerable cavity, having yielding walls 
 and a free communication with one or more bronchial tubes. If, 
 therefore, when a patient's mouth is open, we strike smartly over a 
 cavity, air escapes freely and suddenly into the bronchus, and thus 
 the peculiar sound in question is produced. 
 
 I have, however, heard this sound where there was no cavity in the 
 luno-. This may occur where the chest is unusually sonorous from 
 emphysema, or bronchial dilatations and mucous engorgements. It 
 should not, therefore, be too much relied on as a sign of vomica. In- 
 deed, it is not wisdom in the physician to judge of a case entirely by 
 the physical signs alone. We should carefully compare them with 
 the general symptoms and previous history of the case. Any prac- 
 titioner who relies too exclusively upon the physical signs, will some- 
 times commit the most flagrant errors in his diagnosis ; whereas, if he 
 had taken a more general and comprehensive view of the case, he 
 would have saved himself frou the mortification which necessarily 
 follows in the wake of such errors. 
 
 As to the manner of auscultation, little need be said. I generally 
 prefer that the patient should lie upon his back, side, or abdomen, 
 according to the region of the chest we want to explore. When the 
 
 * Louis on Phthisis, page 212, Am. ed. 
 
PHYSICAL SIGNS. 107 
 
 sounds are very obscure, the chest should be fully exposed, and every 
 obstacle must be removed that will in any way mask or obscure the 
 resonance of the chest. The best kind of auscultation is mediate, and 
 the instrument which I have been in the habit of using for several 
 years' is Dr. Camman's Double Self- Adjusting Stethoscope. This in- 
 strument is so constructed that it intensifies all the sounds of respi- 
 ration to a great degree. Healthy sounds that cannot be heard by 
 the naked ear become quite manifest by its use. So also morbid 
 sounds that are not recognized by the ear become quite audible while 
 exploring the chest with this excellent instrument. The reason for 
 this intensity of sound appears to be — -first, both ears of the observer 
 are acted upon at once ; second, the ear-pieces of the instrument fitting 
 tightly to the meatus of both ears, all external sounds are cut off, and 
 the mind of the auscultator is thus forcibly drawn to the phenomena 
 taking place within the chest. To the physician, therefore, who is 
 dull of hearing, I consider it an instrument of great value and indis- 
 pensable utility, in detecting all those various abnormal sounds which 
 are manifested in the various lesions of the pulmonary organs and 
 the heart. 
 
CHAPTEK IX. 
 
 GENERAL SYMPTOMS AND PHYSICAL SIGNS OF CERTAIN CHEST-DIS- 
 EASES WHICH SOMETIMES ATTEND PULMONARY TUBERCULOSIS. 
 
 Pulmonary tuberculosis very seldom runs its course without 
 being complicated with some other lesions of the breathing-apparatus, 
 such as bronchitis, pneumonia, pleurisy, emphysema, and pneumo- 
 thorax. When any of these affections occur during the progress of 
 the disease, they produce general symptoms and physical signs quite 
 different from those which constitute the original disorder. 
 
 I. Bronchitis. 
 
 Let us take, as our first example, a case of pulmonary tuberculosis 
 complicated with bronchitis. Mary A., aged fifteen, has been ill six 
 weeks ; her pulse ninety-three, and respiration twenty-eight ; cough 
 and mucous expectoration ; appetite not good, and digestion very im- 
 perfectly performed ; bowels quite loose ; fever every afternoon and 
 evening ; pain in the head and back ; urine scanty and very high 
 colored. Thompson's gingival margin very clearly defined on the 
 gums. Microscopic examination of the sputum shows an abundance 
 of withered pus-corpuscles, and shriveled nuclei, with the common 
 products of mucous expectoration. Her mother died several years ago 
 with phthisis. 
 
 On inspecting the chest, no difference could be detected in the ex- 
 pansion of the two sides. Percussion yielded no dullness on either 
 side. The only sound elicited on auscultation was sonorous rhonclius. 
 This sound was loud and clear over the region of all the larger 
 
 bronchi. 
 
 Although the general symptoms pointed out the existence of phthisis, 
 yet, from the absence of all the more prominent physical signs of any 
 permanent injury from tubercular deposits in the lungs, I regarded the 
 present difficulty as mostly bronchial, and gave a favorable prognosis. 
 
 After attending her for three weeks, there was a material improve- 
 108 
 
GENERAL SYMPTOMS OF CHEST-DISEASES. 109 
 
 ment in all the symptoms, and I fondly hoped that my patient would 
 soon regain her usual health. But in this I was disappointed. She 
 appeared to improve a little for about two months, when she suddenly 
 became much worse. She complained of great weakness ; her pulse 
 and respiration became more rapid ; and, in short, all the symptoms of 
 hectic were very prominent. Sonorous rhonchus was very loud, and 
 masked all the other auscultatory signs. There was little or no dull- 
 ness on either side ; and, on inspection, no inequality could be detected 
 in the expansion-movements of the two sides. Her decline was very 
 gradual, and she fell a victim to the disease in six months from my 
 first visit. 
 
 Post-mortem showed limited tubercular deposits in the superior 
 lobes of both lungs, in various stages of softening, with a few small 
 cavities. The middle and inferior lobes of the right lung were very 
 much congested. The bronchial mucous membrane was thickened, 
 and in several places studded with quite a number of small ulcers, 
 proving very conclusively that it had borne the chief shock of the 
 disease. 
 
 In all cases of phthisis complicated with bronchitis, sonorous rhon- 
 chus is generally very loud, so much so that it will sometimes mask 
 every other sound. But sonorous rhonchus is usually intermitting. 
 Thus, the act of coughing and expectorating all the matter contained 
 in the bronchial tubes will temporarily suspend it, and if we embrace 
 this period we will sometimes hear other sounds which may be present. 
 I have a patient now under my care who has a large suppurating 
 cavity in the superior lobe of the left lung, and who has suffered very 
 much with bronchitis from the very commencement of the tubercular 
 affection. When the bronchia is free from expectoration, cavernous 
 respiration is very audible; but as it becomes engorged with matter, 
 the cavernous respiration will gradually give place to sonorous rhon- 
 chus. I have not the least doubt that, if a careless auscultator should 
 examine this case, he would in all probability pronounce it a bad case 
 of chronic bronchitis. It illustrates very clearly the value of a minute 
 knowledge of auscultation and a careful application of its principles, 
 when employed in diagnosticating the various complicated maladies of 
 the chest. 
 
 But sometimes sonorous rhonchus is indicative of tubercular dis- 
 ease. How are we to distinguish in this case ? When the sound is 
 
HO PULMOXARY TUBERCULOSIS. 
 
 heard at the summit of the lung we may generally conclude that it is 
 tubercular in its origin ; when heard at the base, it is usually bron- 
 chial. I am acquainted with but one exception to this rule, and that 
 is in those cases of chronic bronchitis complicated with dilatation of 
 the bronchi, where distinct pouches are formed. In this instance, the 
 diagnosis from the physical signs is extremely difficult. Where these 
 pouches are very large they may be very readily taken for tubercular 
 cavities, if we rely exclusively upon the physical signs. A micro- 
 scopical examination of the sputum will greatly aid us in solving this 
 problem, and give us a direct clue to the nature of the malady. I 
 have on several occasions met with cases of chronic bronchitis attended 
 with bronchial pouches that have been regarded by other physicians 
 as tubercular. If the microscope had been used to examine.the expec- 
 toration, they would not have fallen into this error in their diagnosis. 
 
 II. Pneumonia. 
 Pneumonia is a very frequent attendant on pulmonary tuberculosis. 
 It may occur at all stages of the disease, and is a very serious com- 
 plication. Some authors have considered pneumonia as the primary 
 cause of tubercles in the lungs. We cannot subscribe to this opinion. 
 Tubercles are unquestionably heterogeneous in their nature, and, to 
 express our idea in common language, have no more business in the 
 lungs than so many gravel-stones. That they should excite irritation, 
 inflammation, and their attendant consequences, is not to be wondered 
 at, The wonder is, that they frequently remain in the lungs so long 
 and produce so little trouble. Pathological observation teaches us that 
 nature is sometimes very accommodating in this particular : she very 
 frequently disposes of these intruders without suffering them to de- 
 stroy the pulmonary tissues to any considerable extent. We allude 
 to the arrest of tubercular disease by cretaceous formations. These 
 are often found in the lungs of individuals who have died with other 
 diseases. 
 
 But when tubercles soften and cavities form, they are evacuated by 
 ulceration, which is one of the results of inflammation. As a general 
 thins, the inflammatory process is confined to the immediate vicinity 
 of the tubercles ; but frequently it will extend its influence fir beyond 
 this, involving the whole lobe of the lung in which they are deposited, 
 and even an adjoining lobe. Hence, in addition to the usual physical 
 
GENERAL SYMPTOMS OF CHEST-DISEASES. HI 
 
 signs of phthisis, we will have some of those which belong to pneu- 
 monia, particularly crepitant rlionchus. At the beginning of the 
 inflammation, this morbid sound will only be heard at the commence- 
 ment of inspiration and at the end of expiration ; but as the affection 
 advances, and the inflammatory process becomes more complete, it 
 accompanies the whole respiratory act, when it masks all the other 
 sounds, and, without a previous history of the case, it might very 
 easily be set down as one of simple pneumonia. Sometimes the 
 crepitation will extend far beyond the point of the tubercular deposit, 
 and compass one lobe or all the lobes of the affected side, and render 
 the diagnosis by the physical signs very uncertain. 
 
 How often is it the case that, after attending an individual through 
 an attack of pneumonia, perhaps very mild in its character, and having 
 prognosticated a happy termination of the disorder, we are suddenly 
 aroused to the sad fact that the chief exciting cause of the inflam- 
 mation has been tubercular deposits in the lungs, and that nothing re- 
 mains for our patient but a series of similar attacks, which will, sooner 
 or later, terminate his existence ! Very frequently have I met with 
 instances of this kind. Here is a brief description of one of them : 
 
 In the spring of 1860, pneumonia was unusually prevalent in this 
 vicinity. I had a large number of cases, and among them was a 
 young woman, aged eighteen. She had generally enjoyed good health 
 up to the evening of her illness. The disorder was ushered in by a 
 severe chill about four o'clock in the afternoon, which was followed 
 by fever, flushed face, headache, and pain in the back and limbs. 
 "When I was called to see her, at nine o'clock the same evening, she 
 complained of a deep-seated feeling of heat and weight in the chest, 
 but no pain or stitch in either side. Her pulse was one hundred and 
 twenty per minute, and respiration forty ; dyspnoea somewhat urgent, 
 compelling her to lie on her back, with her shoulders very much 
 elevated. Cough very frequent, and expectoration scanty, consisting 
 of glairy mucus streaked with blood. The bowels were costive, and 
 the urine scanty and very high colored. 
 
 The physical signs were very marked. On inspection, the respira- 
 tory movements of the two sides of the chest were unequal, the right 
 being partially suspended. On percussion, there was dullness from 
 the base to the summit of the right lung, but apparently more marked 
 at the base. On auscultation, very feeble crepitation was heard over 
 
H2 PULMONARY TUBERCULOSIS. 
 
 the whole side. The physical signs on the left side were nearly 
 normal, with the exception of some mucous rhonchus. 
 
 Her case was regarded as one of simple pneumonia, and she was 
 treated with counter-irritants to the chest, and one of the following 
 powders every three hours : 
 
 R Hyd. chlor. mit., gr. xiij ; 
 
 Pulv. jalapae, 
 
 Potassse nit., aa gr. xx. — M. 
 Divide in powders No. iv. 
 
 On visiting her the next morning, I found her somewhat better. 
 The pulse and respiration not so frequent. No pain in the head or 
 limbs ; skin moist and warm ; bowels freely moved ; urine more abun- 
 dant ; cough not so troublesome, and expectoration more free. Dis- 
 continued the powders, and ordered the following, in teaspoonful 
 doses every six hours : 
 
 R Morph. sulph., 
 
 Ant. et pot. tart., aa gr. ij ; 
 Aq. font., fgij. — M. 
 
 The above, with blistering of the chest, was continued for seven 
 days, when the pneumonia appeared to give way, and she was treated 
 with iodide of potassium, quinia, and occasional doses of Dover's 
 powder when the cough was troublesome. On the twenty-first day 
 from the commencement of the attack, I dismissed the patient as 
 convalescent. 
 
 In about four weeks from my last visit, I was requested to call and 
 see this patient again. She had improved but very little. The pulse 
 in the lying posture was one hundred and five per minute, and on 
 standing it was increased only three beats per minute. This circum- 
 stance alone led me to institute a more careful examination of the 
 chest, Dullness on percussion, and prolonged expiratory murmur on 
 auscultation directly under the right clavicle, pointed to the existence 
 of a large tubercular deposit in that region of the lung. Dullness and 
 crepitation had entirely disappeared from the middle and inferior lobes. 
 The only abnormal sound on the left side was sonorous rhonchus, 
 which was not very loud, and quite intermitting in its character. 
 
 Having informed her friends of the true nature of her malady, and 
 
GENERAL SYMPTOMS OF CHEST-DISEASES. H3 
 
 the probability of its proving fatal, they asked permission to invite 
 Dr. S., a neighboring physician, to meet me in consultation. He came, 
 examined the case, did not agree with me in opinion, considered her 
 case as still one of simple pneumonia, and recommended a rigid 
 antiphlogistic course of treatment, with the most positive assurance 
 that the patient would ultimately recover ; from all which I dissented. 
 I, therefore, relinquished the case to his care, with the full assurance 
 from him that his treatment would restore the patient to her wonted 
 health. 
 
 But Dr. S. was not an auscultator ; he knew nothing about the 
 precise nature of the pulmonary lesion, and he was doomed to be 
 disappointed in his prognosis. After attending her for two months 
 without any material improvement, one day, in the absence of the 
 doctor, she was suddenly attacked with hasmoptysis. Her friends 
 becoming alarmed, I was sent for. I found her very weak ; the 
 discharge of blood had been very profuse. I prescribed what I 
 thought to be necessary, and promised to call again the next day, 
 which I did, early in the morning. The hemorrhage had ceased ; her 
 cough was troublesome; the expectoration abundant and purulent. 
 The physical signs indicated a considerable cavity in the superior lobe 
 of the right lung, with crude tubercular deposits in the left. 
 
 From this time she declined very rapidly, and died in about two 
 months from the occurrence of the hsemoptysis. 
 
 Comment on this case is hardly necessary. It furnishes us with 
 another illustration of the value of the art of auscultation in diagnos- 
 ticating the various diseases of the chest. The general symptoms may 
 point out the chest as the part affected, and may give us some clue as 
 to the nature of the malady; but as to the precise location and extent 
 of the lesion, the physical signs are beyond all value, and he who dis- 
 cards them is as unwise as that man who would attempt to navigate 
 the ocean without chart or compass. 
 
 III. Pleurisy. 
 
 Pleurisy is another very grave complication of pulmonary tubercu- 
 losis. Few patients escape it altogether. Some writers have con- 
 sidered it as one of the principal causes of phthisis. A double 
 pleurisy is regarded by many physicians as a sure precursor of tuber- 
 cles in the lungs. This, to a certain extent, is true. In an individual 
 
114 PULMONARY TUBERCULOSIS. 
 
 predisposed to phthisis, it may precipitate the attack by debilitating 
 the system and preventing the free expansion of the lungs, but -with- 
 out such proclivity I doubt very much its influence as an inducing 
 cause of this disorder. Persons sometimes have pleurisy, and a short 
 time after will have pulmonary tuberculosis. Now, in this instance, 
 it is often a question whether the tubercular deposits produced the 
 pleurisy, or the pleurisy the deposits. 
 
 The question is one which at present cannot be positively deter- 
 mined. Whenever I meet with cases of this kind, I am in the habit 
 of referring them to a tubercular origin and treating them accordingly. 
 Intercurrent pleurisy frequently takes place during the progress of 
 phthisis, and is a source of great distress. If it were not for this and 
 the cough, in the great majority of cases phthisis would be quite a 
 painless disease. 
 
 I have known several instances where an attack of pleurisy was the 
 first thing to announce the approach of the fell disorder. But, as a 
 general thing, it does not make its appearance until the tubercular 
 disease has made some progress, when, all at once, the patient will be 
 attacked with a sharp, cutting pain in the chest, most commonly in 
 the side, which will resist every act of inspiration, making the acts of 
 coughing and deep breathing almost impossible. If we now inspect 
 the chest, we will find the expansive movements of the affected side 
 almost suspended, its dullness more marked on percussion, and if any 
 sound is heard on auscultation it will be crepitant. 
 
 If the disorder is not promptly arrested, and effusion to any con- 
 siderable amount takes place within the pleural membrane, the affected 
 side becomes fuller to the eye ; there is a total absence of resonance 
 on percussion, and no respiratory murmurs are heard on auscultation, 
 the function of the lung appearing to be entirely suspended. Such 
 extensive effusion, however, seldom occurs as the consequence of 
 pleurisy in phthisis. The inflamed pleura throws out a little lymph 
 only, there being no serous effusion, and the only trace of pleurisy 
 we find on post-mortem is the adhesion which exists in the opposite 
 surfaces of the pleura. Some writers maintain that these pleurisies 
 never result in health when they occur in tubercular lungs. But I 
 cannot see that there is any more difficulty in their healing in this case 
 than in the primitive form of the disease. The mode of healing is 
 by adhesions, as just noticed. And I have frequently seen these 
 
GENERAL SYMPTOMS OF CHEST-DISEASES. 115 
 
 adhesions perfectly healthy in lungs that have been well-nigh disor- 
 ganized by tubercular disease. 
 
 From the general history of pleurisy as it occurs during the pro- 
 gress of phthisis, we are warned not to look upon it lightly. It is a 
 serious complication, and has been known to terminate the case very 
 abruptly before the tubercular disease has made very much progress 
 in the lungs. Five years since, I had a woman under my care, about 
 thirty years of age, who had a small suppurating cavity in the supe- 
 rior lobe of the left lung. Her symptoms were all favorable, and I 
 looked for a gradual healing of the cavity. She had three children, 
 and was able to attend to all of her household duties excepting wash- 
 ing. One day, owing to the sickness of the individual who usually 
 performed this for her, she attempted it herself, but gave out before 
 she was half through. That night she was attacked with acute pleuro- 
 pneumonia, which terminated her life in seven days. 
 
 On post-mortem, the right lung was found to be slightly congested, 
 but otherwise healthy. The superior lobe of the left lung was quite 
 contracted, and exhibited, when laid open, a small tubercular cavity 
 undergoing the process of repair by the agglutination of its sides by 
 dense cellular substance of new formation. The inferior lobe was 
 completely hepatized, and the pleural membrane contained about six- 
 teen ounces of bright straw-colored serum. The bronchial mucous 
 membrane was slightly congested, but otherwise healthy. The most 
 careful examination did not reveal a single tubercle in either lung. 
 
 I had this patient under my care for more than a year. Her case 
 was considered hopeless when I commenced to attend her. She was 
 confined to bed, was very much emaciated, and had confirmed hectic. 
 By the persevering use of cod-liver oil, iodide of potassium, quinia, 
 iron, porter, and a very nutritious diet, she was able in three months 
 to attend to her household duties, and was gradually improving in 
 health up to the time of the attack of pleuro-pneumonia. If this 
 had not supervened, we would in all probability have had another 
 case of recovery from pulmonary tuberculosis to add to the list which 
 has already been reported as the result of the present mode of treating 
 this malady. 
 
 IV. Emphysema. 
 
 Emphysema is sometimes associated with pulmonary tuberculosis. 
 It may either precede or succeed it, and render the diagnosis from the 
 
116 PULMONARY TUBERCULOSIS. 
 
 physical signs difficult. When the lungs are emphysematous, they 
 are generally dilated and rarefied ; in tuberculosis they are contracted 
 and condensed. Hence, in emphysema we have increased resonance 
 on percussion, and on auscultation feeble respiratory murmurs ; while 
 in tuberculosis there is dullness on percussion, and very little, if any, 
 diminution of the respiratory murmurs, particularly in the first stage 
 of the disease. 
 
 I have met with some cases of this sort, where, from the physical 
 signs, it was impossible to make out a clear diagnosis. Thus, when 
 tubercles are deposited in the part of a lung that is emphysematous, 
 their tendency is to diminish its capacity for air and render its reso- 
 nance less clear, while they do not materially alter the character of 
 the murmurs. We can, therefore, see how a considerable deposit of 
 tubercle may take place in an emphysematous lung without producing 
 any particular deviation in the normal sounds of the chest. 
 
 These remarks apply to the first stage of tubercular deposits, and 
 when they are quite limited in extent. When they have passed into 
 the stage of softening, the physical signs will be more marked and 
 the diagnosis much easier made out. The chief physical sign of the 
 stage of softening is humid crackling. This is usually heard at the 
 summit of the lung without existing elsewhere. If there has been 
 any obscurity about the case, this will dispel it. Humid crackling 
 at once pronounces the disease tubercular. It does not under any 
 circumstance belong to emphysema ; at least, so say some of our best 
 auscultators. 
 
 Two years since, I met with a case of emphysema that had been 
 pronounced tubercular by three physicians ; one of them had given 
 his written opinion to that effect. The patient was a young woman 
 aged twenty-four; she was of the nervo-sanguineous temperament. 
 When I first saw her she had not been well for four months. Com- 
 plained of weakness, dyspnoea, a troublesome cough, with copious 
 mucous expectoration ; pulse eighty-five per minute, and very suscep- 
 tible to change of posture ; respiration thirty ; digestion good ; rested 
 well at night ; menses regular, but scanty ; no appearance of Thomp- 
 son's gingival margin ; had lost in weight during the past month ; 
 never had any haemoptysis, or pain in the chest ; had no hereditary 
 title to phthisis. 
 
 The physical signs were not marked. On inspection, the expan- 
 
GENERAL SYMPTOMS OF CHEST-DISEASES. 117 
 
 sion of the two sides of the chest was nearly equal ; the right side 
 appeared more arched than the left. On percussion, it yielded a 
 clear resonance, excepting just under the left clavicle, where there 
 was a slight degree of dullness. On auscultation, the respiratory 
 murmurs were very feeble on the right side, and sonorous rhonchus 
 was very loud over the entire bronchi on this side ; on the left the 
 auscultatory sounds were nearly normal. 
 
 From the physical signs, there appeared to be but one circumstance 
 which seemed to indicate tuberculosis, and that was the slight dull- 
 ness on percussion just under the left clavicle. But this was more 
 apparent than real. It existed by comparison only. The emphysema 
 was confined exclusively to the right lung ; hence its resonance was 
 much clearer on percussion than natural, while that of the left was 
 nearly normal. 
 
 The case was set down as one of limited emphysema of the right 
 lung from chronic bronchitis. The treatment instituted consisted of 
 blistering the chest ; iodide of potassium, five grains three times a 
 day two hours after eating, and a teaspoonful of the following mixture 
 when the dyspnoea was troublesome : 
 
 R Tinct. ext. cannabis indica, 
 Syrup. Tolu, aa f^ij ; 
 Sulph. morphiae, gr. ij. — M. 
 
 This treatment was closely followed up for four weeks, with marked 
 improvement in all the chest-symptoms. During this time the blister 
 was reapplied five times, and with very sensible benefit each time. 
 The bronchitis having been subdued by the above treatment, and the 
 emphysema being somewhat troublesome, she was placed upon the use 
 of the following in tablespoonful doses three times a day : 
 R Hyd. chlorid. corrosiv., gr. j ; 
 
 Syrup, sarsaparillae comp., fgxvi. — M. 
 
 By the use of this prescription the emphysema gradually gave way, 
 and up to the present time she has enjoyed her usual health. In 
 cases of emphysema that are curable at all, I have found nothing 
 more useful than minute doses of mercury. I prefer the bichloride 
 to all the other preparations of this mineral. It should be given 
 very cautiously and in very minute doses ; and I have generally found 
 that where the emphysema depends upon the remains of inflammatory 
 
118 PULMONARY TUBERCULOSIS. 
 
 products that may be left in either the air-cells or smaller bronchi, 
 this agent will gradually and surely produce their absorption and 
 restore them to their wonted functions. Those cases of emphysema 
 depending upon organic changes in the air-cells and the capillary cir- 
 culation of the lungs are not only incurable, but incapable of being 
 materially influenced by medical treatment. In such cases mercury 
 will do no good, but may be the means of producing much injury, 
 particularly if tubercles are associated with them. 
 
 V. Pneumothorax. 
 
 This is not a common complication of pulmonary tuberculosis. In 
 all the cases of this disorder that I have attended, I have only met 
 with it four times. In this disease it always occurs as the result of a 
 tubercular abscess opening into the pleural cavity. When you open 
 the chest of an individual who has died from this complication, you 
 will commonly find the pleural sac filled with air, serum, and, if the 
 abscess in the lung was large, blood-clots and tubercular pus. The 
 lung will be found shrunken and adherent to the chest, and the per- 
 foration at some point where the adhesions are not very strong. The 
 opening is usually very small, and sometimes difficult to find. If, 
 however, when found, we introduce a probe into it, it will pass directly 
 to the cavity in the lung ; in this cavity we will find the termination 
 of one or more bronchi, — thus forming a free communication for the 
 admission of air into the pleural sac. 
 
 Sometimes there is more than one perforation, and they seldom, if 
 ever, occur at the very summit of the lung, for the adhesions which 
 exist there are so thick and strong that they prevent this ; but lower 
 down, opposite the angle of the third and fourth ribs, these perfo- 
 rations are usually found. They are seldom found below this, for 
 tubercular cavities in the inferior lobes of the lungs are of very rare 
 occurrence. The quantity of liquid effusion in the chest is commonly 
 not very great, especially if the perforation has proved rapidly fatal ; 
 but this is not always, the case. Patients have been known to live 
 several months after this accident. One of my patients lived five 
 months, but his sufferings were beyond description ; I hope it may 
 never be my lot to witness the like again. In some of these cases of 
 perforation the tubercular deposits are very limited and the cavities 
 very small, and the accident is found to be as frequent as in those 
 
GENERAL SYMPTOMS OF CHEST-DISEASES. 119 
 
 cases where they are more extensive and the cavities much larger. 
 Cavities situated very near the surface of the lungs are more liable to 
 perforate the pleura than those which are more deeply seated. 
 
 At what particular period during the progress of phthisis pneumo- 
 thorax is the most liable to occur, cannot be positively stated ; we 
 have no statistics to guide us in the formation of an opinion. We 
 know, however, as a general thing, that it does not usually take place 
 until the pulmonary lesion has made considerable progress. Thus, an 
 individual may have all the symptoms and physical signs of the" dis- 
 ease for several months, and it may be progressing in the usual way, 
 when all at once the patient is attacked with a sharp pleuritic pain in 
 the side, accompanied with great dyspnoea and a marked increase in 
 all the febrile symptoms. In other cases, the attack may resemble 
 a severe shock to the system rather than an inflammatory invasion. 
 There is no pleuritic pain, but great oppression of the respiration, 
 inability to lie down, a tendency to syncope, a rapid, feeble pulse, with 
 cold, clammy perspiration, pinched countenance, and all the other 
 symptoms of approaching dissolution. 
 
 The physical signs of this complication of phthisis are commonly 
 very marked. The side affected is found unusually resonant on per- 
 cussion ; the respiratory murmurs are indistinct and sometimes 
 entirely absent on auscultation. In some very rare cases, the chest is 
 found very much dilated on inspection. These physical signs, occur- 
 ring under the circumstances described, are quite indicative of the 
 accident in question. But when the patient survives the first shock 
 of the perforation, he will soon have certain other physical signs, 
 which belong to what some writers have been pleased to call hydro- 
 PNEUMOTHORAX, such as metallic tinkling and amphoric respiration. 
 
 Metallic tinkling, when very distinct, is a never-failing sign of effu- 
 sion in the pleural cavity; in this instance it is produced by the 
 bursting of bubbles of air on the surface of the fluid contained in the 
 cavity, when it is but partially filled with air. This sound presents 
 several modifications, which are quite indicative of the condition of 
 the parts and the progressing changes which are likely to occur in 
 them. Thus, when the perforation is small or obstructed by its posi- 
 tion against the walls of the chest or below the level of the liquid, 
 the tinkling is seldom heard excepting on coughing or taking a full 
 breath, which reaches the cavity and may throw the liquid in bubbles. 
 
120 PULMONARY TUBERCULOSIS. 
 
 When the orifice is large and free, the air will pass in and out in 
 ordinary breathing, and will produce in its vicinity a sound like that 
 of blowing into the mouth of a glass bottle ; this is the amphoric 
 respiration just named ; where we hear this sound, there is seldom so 
 much difficulty in breathing as where the air passes less freely and 
 accumulates in the cavity. 
 
 But we have not the space here to give a full description of these 
 sounds. For a minute history of them, and their value as means of 
 diagnosis, we must refer the reader to Skoda on " Auscultation and 
 Percussion," or Dr. Austin Flint's excellent work on " Physical Ex- 
 ploration and Diagnosis of Diseases affecting the Kespiratory Organs." 
 The latter book we would recommend to every physician who may 
 desire to become proficient in the art of percussion and auscultation. 
 It should have a place in the library of every individual engaged in 
 the general practice of medicine. It is based, to a very considerable 
 extent, upon cases numerically examined, and carries the evidence of 
 careful study and discrimination upon every page. It is a work which, 
 in our judgment, reflects great credit upon its already distinguished 
 author. It is also a very readable book, which cannot be said of 
 every one that has been published on percussion and auscultation. 
 
CHAPTER X. 
 
 THE DIAGNOSIS AND PROGNOSIS OF PULMONARY TUBERCULOSIS. 
 
 I. Diagnosis of Phthisis Pulmonalis. 
 
 In the early stage of this disease the diagnosis is sometimes very 
 difficult, but as it advances to the second or third stage, when cavities 
 have formed in the lungs, it is commonly more pronounced. If we 
 regard pulmonary tuberculosis merely as a local disease, its physical 
 signs will frequently be wanting, because the local lesions are formed 
 very slowly, and often so slightly at the commencement as to produce 
 very little obstruction to the functions of the lungs. But if the 
 disease in the lungs be regarded merely as a part, and, as it were, a 
 sign, of a great constitutional disorder, our diagnosis will be greatly 
 facilitated. 
 
 Physicians frequently err in examining cases of this kind, by 
 directing their attention exclusively to detecting those symptoms and 
 physical signs that belong to the last stage of the malady. But we 
 consider these of secondary importance to those numerous and earlier 
 phenomena gathered from an accurate history of the case, all of which 
 should be examined with the greatest care, that their true value may 
 be positively known. The general symptoms of the disorder are easily 
 interpreted, but a correct knowledge of the nice shades of auscultation 
 and percussion, in the first stage of this disease, can only be acquired 
 by long and persevering practice. 
 
 It cannot, therefore, be denied that it is far more useful, in a 
 practical point of view, to be able to detect the first indications of 
 pulmonary tuberculosis, than to describe the various physical signs re- 
 sulting from a cavity in the lungs ; far more important and useful to be 
 able to interpret correctly the value of the frothy expectoration, than 
 to multiply experiments for the purpose of discovering the presence of 
 pus. We should always remember that there is no one symptom 
 which absolutely constitutes a disease, nor any one physical sign which 
 
 121 
 
122 PULMONARY TUBERCULOSIS. 
 
 is invariably present. Our diagnosis, as already remarked in another 
 place, must be deduced from all the symptoms which are presented to 
 our inspection, and their just estimation founded upon an accurate 
 knowledge of the nature of the malady. 
 
 In the first stage of pulmonary tuberculosis, the diagnosis is formed 
 in part by way of exclusion ; that is, many of the symptoms acquire 
 their value from the absence of any apparent lesion which is capable 
 of producing them. If they occur in young persons, especially those 
 who from age or habits of life are exposed to the disease, the proba- 
 bility of its development is of course enhanced, and the diagnosis is 
 more obvious. But when the constitutional malady has made some 
 progress, and the case has become chronic, the general symptoms are 
 emaciation, often accompanied by a good appetite, a changed color of 
 the skin, which seems dusky or earthy in its hue, rounding of the 
 extremities of the fingers, incurvation of the nails, Thompson's gingi- 
 val margin, the bluish tint of the sclerotica, and the occasional flush 
 of the cheek. These are all regarded as marked symptoms of the 
 disease ; but as diagnostic signs they are not of much value, for they 
 are often met with in other disorders of a wasting character. 
 
 In the more acute form of the disease the general symptoms are 
 more active in their character : the fever is higher, and for the most 
 part continuous, with a jerking pulse ; the fever commonly continues 
 throughout the whole twenty-four hours, but is more severe in the 
 after-part of the day than at other times, and at night is apt to ter- 
 minate in profuse perspiration. Chills are rarely present in the first 
 stage of the disease ; in this respect, the formative fever of pulmonary 
 tuberculosis differs from the hectic of the latter stage of it. In this 
 instance it will sometimes continue for several days without intermis- 
 sion, and then be absent for an equal number ; and it is a diagnostic 
 mark of hectic as it occurs in this disorder, that during the most 
 intense and protracted paroxysms of fever the mind is uniformly clear, 
 and the head free from pain. 
 
 The last means of diagnosis by the general symptoms of pulmonary 
 tuberculosis is the existence of certain affections which are closely 
 connected with the disease. These are the inflammations and the 
 tubercular infiltrations of other organs than the lungs, such as the 
 small intestines and the serous membranes of the abdomen. "When 
 these are present they often explain the nature of the disease in the 
 
DIAGNOSIS AND PROGNOSIS. 123 
 
 lungs, and are sufficient to distinguish it from ordinary inflammation. 
 It is not unfrequently the case that we see individuals suffer for 
 months with chronic diarrhoea before the lung-difficulty will manifest 
 itself. Sometimes the lung will become affected first, and appear to 
 be the only part disordered, when all of a sudden the bowels will 
 become deranged and supersede the lung-affection, and the patient die 
 with chronic tubercular diarrhoea. But the connection between these 
 various complications will be easily made out if we pay particular 
 attention to the leading features which characterize this complicated 
 and fatal malady. 
 
 Although we place great reliance on the physical signs as a means 
 of diagnosis in pulmonary tuberculosis, yet they are not always to be 
 taken without exceptions. There are lesions of the lungs which pro- 
 duce physical signs that may be easily mistaken for tubercular deposits 
 and vomicae ; thus, in some forms of chronic bronchitis attended with 
 dilatation of the bronchi, and where large pouches are formed, they 
 may be the seat of clicking or cavernous respiration, pectoriloquy, and 
 even the cracked-pipkin sound. But, as a general thing, their situa- 
 tion, great extent, and more stationary character will serve to distinguish 
 them from tubercular excavations. With few exceptions they usually 
 occupy the scapular and mammary region, and not the subclavian. 
 They sometimes extend over a considerable space, but do not multiply 
 like tubercular cavities. 
 
 Allow me just here to cite a case from my book of " Medical Frag- 
 ments," which to my mind illustrates very clearly the diagnosis be- 
 tween bronchial dilatations or pulmonary pouches and tubercular 
 cavities. 
 
 II. A Case of Pulmonary Bronchitis mistaken for Pulmonary 
 Tuberculosis. 
 
 March 22, 1857. Called this day to see Bev. H. W., a distin- 
 guished Methodist preacher, aged thirty-seven, of a marked nervo- 
 bilious temperament; has always led an active life, and enjoyed good 
 health until about a year since, when he contracted his present ill- 
 ness, which he attributes to a severe cold that he took while engaged 
 in holding a protracted meeting. Instead of suspending his labors 
 and calling in a physician, he continued his work until his disorder 
 became so severe, and his strength so much exhausted, that he was 
 
124 PULMONARY TUBERCULOSIS. 
 
 unable any longer to go to his charge. He now had fever, pain in the 
 region of the sternum, cough, mucous expectoration, loss of appetite, 
 and constipation of the bowels. A physician was called in, who pro- 
 nounced his disease lung-fever, and for two weeks he was quite ill. 
 After the fever left him his appetite returned, his bowels became more 
 regular, and he gained a little in strength ; but his cough and ex- 
 pectoration remained about the same. Various remedies were em- 
 ployed for the relief of these troublesome symptoms, and for six 
 months he made but little improvement. He now called in the aid of 
 homoeopathy, and after trying its empty pretensions for three months 
 without benefit, he was induced by the advice of a ministerial friend 
 to consult the lamented Dr. Lawson, of Cincinnati. The doctor saw 
 him several times, and examined his case carefully ; he pronounced it 
 phthisis pulmonalis, and gave an unfavorable prognosis. Two other 
 medical men were consulted in the same city, and gave the same 
 opinion. 
 
 At the time of my first visit he had just returned from Cincinnati, 
 and felt very feeble and desponding. Hope had well-nigh given him 
 over to despair. After repeated examinations of his case, I was not 
 willing to say that he was suffering from pulmonary tuberculosis. 
 He had, it is true, some symptoms of the disease, but they were not 
 pronounced. The more positive symptoms were wanting. Thus, the 
 tubercular diathesis was not present; Thompson's gingival margin 
 was absent, and there was no clubbing of the fingers nor incurvation 
 of the nails. He had never had haemoptysis, and had no hereditary 
 predisposition to phthisis. He was, however, thin in flesh, had fre- 
 quent pulse, a slight elevation of temperature, and hurried breathing. 
 Auscultation elicited on the right side distinct clicking at the fourth 
 intercostal space from the spine to the sternum ; there was slight 
 dullness on percussion just under the clavicle. On the left side there 
 was no dullness on percussion, but auscultation elicited loud mucous 
 rhonchi. On inspecting the chest, there was a slight inequality in the 
 expansion-movements of the two sides. The right side was restricted 
 in its movements, while the left side appeared to be augmented. 
 
 The history of the case and the physical signs seemed to point out 
 the existence of tubercular consolidation in the superior lobe of the 
 right lung, with a considerable cavity in the middle lobe and chronic 
 bronchitis. But they were by no means conclusive as to the disease 
 
DIAGNOSIS AND PBOGNOSIS. 125 
 
 being tubercular. The dullness was in the right place, but the click- 
 ing was not ; for it is pretty generally conceded by our best writers on 
 pathology that tubercular disorganization commonly commences first 
 at the superior part of the lung, and it is at that part where cavities 
 first form, and clicking is heard just under the clavicle, or at the 
 second intercostal space about two inches from the sternum. The 
 general symptoms and physical symptoms being insufficient to make 
 out a clear diagnosis of the patient's malady, we called to our aid the 
 microscope, which had in several instances like this helped us out of 
 our difficulty. The sputum was, therefore, carefully and repeatedly 
 examined. It was found to contain the usual products of purulent 
 expectoration: mucus and pus-cells in abundance, but no tubercular 
 granules, withered cells, pulmonary fibres or meshes, all of which are 
 necessary to make out a case of tubercular disorganization. 
 
 The case was, therefore, regarded as chiefly bronchial inflammation, 
 attended with certain structural lesions which we will notice as we pro- 
 ceed, and his treatment was based upon this diagnosis. 
 
 He was ordered the following : 
 
 R Potassii iodidi, 5iii ; 
 Hyd. bichloridi, gr. ii ; 
 Tinct. lobeliae, f£i ; 
 Syrup, stillingise comp., 
 Syrup, phell. aquat. comp., aa Sviiss. — M. 
 Sig. — One-half ounce three times a day after each meal. 
 
 As a counter-irritant, his chest was to be painted with the following 
 every night on retiring to rest : 
 
 R Iodine (pure), oi] 
 Potassii iodidi, 5ii; 
 Aquae puras, f^iv. — M. 
 
 He was also ordered to inhale forty drops of the following every 
 night before going to bed : 
 
 R Iodine (pure), gr. xx; 
 Chloroform, fgi.—M. 
 
 To quiet cough and secure rest at night, one of the following pills 
 was ordered : 
 
 9 
 
126 PULMONARY TUBERCULOSIS. 
 
 R Quiniae sulph., 
 
 Ext. hyoscyami, aa gr. xxx ; 
 Morphise sulph., gr. iv. 
 Fiat pil. No. xv. 
 
 These therapeutical agents, with little variation, were continued for 
 two months, at which time he was so much improved that he took a 
 trip to the sea-shore ; was gone two months ; on his return he was so 
 far restored to health that he was once more enabled to enter upon 
 the duties of his vocation. I saw him about two years since. At 
 that time his general health was good, but he was still troubled with 
 shortness of breath and cough, particularly when he overtaxed him- 
 self in preaching or walking. An examination of his chest elicited 
 dullness on percussion, and clicking on auscultation in the right side, 
 the same as years before, and these will probably continue as long as 
 he lives. 
 
 And now some may ask, How do you account for these abnormal 
 sounds if there was no tubercular disorganization in the lung? "We 
 will try and explain. In this patient's case there had evidently been 
 at first an acute inflammation of the bronchial mucous membrane of 
 the larger tubes ; by neglect and mismanagement it extended to the 
 air-cells, which being permanently engorged by effusion of lymph, 
 will produce more or less consolidation of the lung, — hence dullness on 
 percussion. Again, it sometimes occurs that inflammation, instead of 
 obliterating the bronchial tubes and air-cells, causes them to dilate. 
 On post-mortem in cases of this kind, we sometimes find the bronchial 
 tubes supplying the whole lung or a lobe dilated. In this instance 
 the bronchial tubes when slit open may be larger than the trunk from 
 which they originated, and are easily exposed to the very periphery 
 of the lung, where they often terminate in a cul-de-sac. Seiveking 
 and Jones have presented their readers with an excellent diagram of 
 this condition of the bronchial tubes on page 3S9 of their work on 
 " Pathology." In other cases, the tubes are abruptly enlarged at a par- 
 ticular point as a single tube, or several tubes near each other uniting 
 to form an irregular cavity. This we suppose to have been the con- 
 dition of the bronchial tubes in the case just given. The clicking 
 heard was the air passing in and out of a large bronchial pouch, and 
 not by a tubercular cavity. 
 
DIAGNOSIS AND PEOONOSIS. 127 
 
 But some may be ready to ask upon what physical sign we place 
 our chief reliance in determining the existence of a tubercular cavity 
 in the lungs. We answer, clicking, so named by Dr. T. Thompson 
 in "Lectures on Pulmonary Consumption." And, notwithstanding 
 exceptional cases may be cited, like the one just presented, we will 
 seldom err in pronouncing the case tubercular where this sound is 
 constantly heard just under the clavicle and in the upper portion of 
 the scapular space. But the physician should not make up his opinion 
 from any single symptom or physical sign. Let every disordered mani- 
 festation be carefully examined ; let the condition of every organ be 
 faithfully investigated, and its vital condition truly marked, for it is 
 only in this way that we can form a correct opinion of the existence 
 of this or any other disease. 
 
 III. Prognosis of Pulmonary Tuberculosis. 
 
 In a disease which has proved so destructive to the human race as 
 pulmonary tuberculosis, it will, as a matter of course, be supposed 
 that the prognosis is unfavorable. The malady, however, does not 
 always prove fatal ; for it has been clearly shown by pathological re- 
 search that it has been cured by natural process, and every physician 
 of extensive experience has met with individuals who have had all 
 the symptoms and physical signs of the disease, and not unfrequently 
 in an advanced stage, who finally recovered, and afterward enjoyed 
 tolerable health. I could cite several cases of this kind that have 
 fallen under my own notice. But it should be observed that these 
 patients, as a general thing, do not always regain their former health 
 and physical power ; they are apt to have pain in the chest, cough, 
 and dyspnoea on taking brisk exercise. But they are commonly able to 
 attend to the ordinary duties of every-day life without suffering much 
 inconvenience. Six years since, I had under my care a man suffering 
 with tubercular disease of the superior lobe of the left lung. I believe 
 post-mortem would now show total disorganization of that part of the 
 lung ; yet he is considered a good hand, and works daily at the labor- 
 ious business of boiler-making for steam-engines. For more than two 
 years he was apparently a hopeless invalid. 
 
 After the existence of pulmonary tuberculosis has been clearly 
 made out by the physical signs, the prognosis is to be formed prin- 
 cipally through the general symptoms. The extent of the pulmonary 
 
128 PULMONARY TUBERCULOSIS. 
 
 lesion may, indeed, only be determined by the physical signs, such as 
 dullness on percussion, prolonged expiratory murmur, bronchial respi- 
 ration, clicking, the cracked-pipkin sound, and other signs, whether 
 they are confined to a small or extend over a considerable portion of 
 both lungs ; in the latter case, the rapid progress of the disease to a 
 fatal termination may at once be reasonably inferred. But where the 
 physical signs establish the presence of the disease rather than its 
 extent, we must refer to the state of the general health to determine the 
 probable time during which the constitutional strength may struggle 
 against the disease, and the chance, if there be any, that it may get 
 rid of it. 
 
 When there is much cough and great difficulty in breathing, with 
 copious purulent expectoration, and the pulse continually over one 
 hundred beats per minute, temperature over one hundred degrees 
 continually, night-sweats, diarrhoea, the loss of strength and flesh con- 
 siderable and progressing, very little if any hope can be entertained 
 with regard to a favorable termination of the disease, and it will prob- 
 ably end in a short time. In some cases that I have seen, where 
 there was great difficulty in breathing from the commencement, death 
 took place before emaciation was extreme, and this is generally the 
 case in the acute form of the disease, where the fatal termination is 
 caused by pneumonitis or hemorrhage of the lungs. In such in- 
 stances, the feet, face, and other parts sometimes become cedematous 
 before death. But in those cases where the progress of the disorder 
 is not so rapid, the emaciation is very great. In the very last stage 
 of the disease, the expectoration is frequently changed to a dark, 
 dirty green, surrounded by a pinkish halo. This is a most fatal sign. 
 When this kind of expectoration makes its appearance, death will 
 occur in a few days. Shortly before death the expectoration is some- 
 times altogether suppressed. 
 
 In some of the more prolonged cases, the progress of the disease is 
 nearly uniform ; it is at first characterized by a series of attacks of 
 increased symptoms, with temporary amendments between them. 
 This is generally referred to the weather, or increased exertions, and 
 under favorable circumstances may be checked. Thus, individuals 
 frequently pass years, losing ground in winter and spring, and rally- 
 ing during summer, until at length they gradually sink into the grave. 
 In some cases the improvement is more decided and lasting ; the fever 
 
DIAGNOSIS AND PROGNOSIS. 129 
 
 abates ; the pulse loses its frequency ; the cough subsides ; the expec- 
 toration becomes mucous, and after awhile ceases ; the local physical 
 signs are diminished, and if the amendment occurs in the first stage, 
 before induration of the tubercular has taken place, vesicular respira- 
 tion is in a measure restored ; and in some rare instances the disease 
 appears to be entirely removed. If there is a strong hereditary pre- 
 disposition to the disease, the prognosis is always unfavorable. 
 
 I cannot conclude my remarks under this head, without expressing 
 the belief that the idea so generally entertained in respect to the in- 
 curability of pulmonary tuberculosis is principally owing to the fact 
 that the disease is not recognized until it has advanced nearly to 
 the last stage, when there is no remedy. And yet I am free to say 
 that there is scarcely a disease which, by one practiced in the use of 
 the microscope, the stethoscope, and percussion, can be more easily 
 detected in its earliest stage than this, — the withered cells in the 
 expectoration, the dullness on percussion, the prolonged expiratory 
 murmur on auscultation, Thompson's gingival margin, together with 
 the well-known general symptoms, leaving little room for doubt as to 
 the nature of the malady. Now and then there may be cases the 
 symptoms of which are so obscure that they cannot be made out with 
 any degree of certainty. Yet, if physicians would generally accustom 
 themselves to detect the signs just mentioned, and use faithfully those 
 means which recent experience has found so useful, pulmonary tuber- 
 culosis would, in a great measure, be disarmed of its terrors, and many 
 would be restored to health who now sink into premature graves. 
 
CHAPTER XL 
 
 THE PRE-TUBERCULAR STAGE OF PULMONARY TUBERCULOSIS. 
 
 That there is such a stage of this malady as the pre-tubercular 
 will not be denied by any one who regards phthisis a constitutional 
 disorder ; that there are symptoms and physical signs indicative of 
 this peculiar condition of the system, sufficiently marked to be of 
 practical value, will not be so readily admitted. It is common with 
 many practitioners to overlook the lesser symptoms of the constitu- 
 tional disorder and seek those which belong to the local lesion, and, 
 if there be no evidence of these, give a favorable prognosis, and dis- 
 miss the patient with some trifling prescription in no way calculated 
 to meet the wants of his case. His disease is thus suffered to progress 
 until the lungs become involved and little if any benefit can be de- 
 rived from medical treatment. 
 
 I am aware that the great majority of phthisical patients do not 
 apply for advice until they have passed beyond the precursory stage 
 of the affection, and it is not very often that we have the opportunity 
 of carefully studying their symptoms. But I am quite satisfied from 
 my own experience that there are certain symptoms belonging 
 to the pre-tubercular stage of this disorder that are generally very 
 manifest, and may lead to its detection before the deposit of a single 
 tubercle in the lungs. 
 
 But some may ask, " What do you mean by the pre-tubercular 
 stage of phthisis ?" Authors commonly describe three stages of this 
 malady, namely : the stage of deposit, the stage of softening, and the 
 stage of expulsion. That which we now describe is that antecedent 
 morbid condition of the general system which precedes the local de- 
 velopment of tubercles; a state eminently characterized by some 
 special degenerative changes in the blood, which render it unfit for 
 normal nutrition and maintenance of healthy action in the tissues of 
 the body. 
 130 
 
THE PRE-TUBERCULAR STAGE. 131 
 
 In some constitutions this blood-dyscrasia is more marked than in 
 others, so much so that death will sometimes occur before the local 
 lesion has made serious progress. Every physician who has been 
 much in the habit of making post-mortem examinations must have 
 seen cases of this description : the patient succumbs to the constitu- 
 tional disorder. When this dyscrasia is very slight it will frequently 
 produce derangements in the various organs of the body, which cannot 
 fail to attract the attention of every careful student of the laws that 
 govern the human body in health and disease. 
 
 I. General Symptoms of the Pre-Tubercular Stage of Pulmo- 
 nary Tuberculosis. 
 
 The symptoms of this stage of phthisis may be depicted as follows : 
 The countenance is dejected ; the eyes are dull ; the lips have lost their 
 cherry-red, and when the cachexia is very decided they incline to 
 purple ; the complexion is sallow ; and the hair of the head is very 
 dry. The pulse is accelerated, and the respiration is hurried, and 
 very much increased in frequency by even moderate exertion. The 
 appetite is variable ; the bowels are frequently out of order, sometimes 
 costive, but more frequently relaxed ; in the latter instance there are 
 commonly symptoms of indigestion, and the food, although taken in 
 sufficient quantities, is imperfectly assimilated ; consequently the mus- 
 cles become flabby, the body emaciates slightly, its weight is materi- 
 ally lessened, and the individual complains of a want of strength and 
 ability to engage in any of the active pursuits of life. 
 
 The excretory functions are generally very imperfectly performed, 
 with the exception of that of the skin, which is more active than 
 common, yielding an increased quantity of perspiration, which reduces 
 the temperature of the body ; hence the patient complains at times 
 of chills, flashes of heat, cold hands and feet. They always require 
 an extra amount of clothing to maintain a comfortable degree of 
 warmth, and are very sensitive to changes in the weather. The urine 
 is commonly scanty ; and in most of the cases that have fallen under 
 my notice oxalate of lime was present in large quantities, particularly 
 where indigestion was a marked feature of the affection. 
 
 They also at this stage of the disorder frequently complain of thirst, 
 dryness, and sometimes a burning heat in the mouth and throat, 
 with a feeling of soreness about the larynx ; and the slightest external 
 
132 PULMONARY TUBERCULOSIS. 
 
 pressure in this region will excite coughing. On inspecting the throat, 
 the tonsils will sometimes be found slightly enlarged, and the mucous 
 membrane of the pharynx very red and dry. In some instances the 
 individual is troubled with aphthae upon the tongue, cheeks, and lips, 
 a sure sign of approaching phthisis in the adult where it is habitual. 
 In the great majority of cases, even at this early stage, Thompson's 
 gingival margin will sometimes be clearly denned upon the gums. — an 
 outstanding sign of the tubercular cachexia. Although every other 
 symptom of the disorder may be absent, we need not hesitate a moment 
 to pronounce the case tubercular if this streak is upon the gums. 
 
 Patients suffering with the pre-tubercular stage of phthisis sometimes 
 complain of pain in the chest and palpitation of the heart. The pain 
 is usually neuralgic in its character, wandering from one locality to 
 another: sometimes in the side, sometimes just under the sternum, 
 then again between the shoulders or under the scapula, but never very 
 intense. There is not unfrequently considerable tenderness along the 
 dorsal vertebrae. The palpitation of the heart is ephemeral, and is 
 commonly produced by sudden changes in the posture of the body or 
 by strong mental emotions. Several years ago I attended a very intel- 
 ligent lady, who died with phthisis, who informed me that the first 
 symptom of ill health that she felt was a slight palpitation of the heart 
 while she was engaged in the performance of her usual domestic 
 duties, and that it was but a very short time afterward when she com- 
 menced to have more threatening symptoms of the disease. At this 
 stage of the affection the pulsation of the heart is more frequent than 
 in health ; and the reason for this is found in the deteriorated quality 
 of the blood, thus imposing an extra burden upon the circulating 
 organs to carry it to the ultimate tissues of the body. The nervous 
 system is also very impressible, easily excited by the varying conditions 
 of the mind and surrounding circumstances. 
 
 At this stage of the disease there is commonly a slight cough, some- 
 times dry. but more frequently attended with expectoration. When 
 the bronchial tubes are very much irritated or inflamed, there will 
 usually be copious expectoration. The prevailing character of the 
 sputum is mucus ; at first it may be glairy, and when dry will shine 
 like silver ; if the blood-malady has made considerable progress, it will 
 be slightly viscid, frothy, and faintly yellow, particularly in the morn- 
 ing. When examined by the microscope, it will be found to contain 
 
THE PRE-TUBERCULAR STAGE. 133 
 
 withered cells and shriveled nuclei. In one instance I detected these 
 histological elements in the sputum of a phthisical patient two years 
 before there was a single physical sign to indicate the presence of the 
 local lesion. The presence of withered cells and shriveled nuclei in 
 the expectoration is highly indicative of approaching tubercular de- 
 posits in the lungs. They show very clearly that the blood is rapidly 
 degenerating into that peculiar dyscrasia which must, if not corrected, 
 ultimately lead to the development of pulmonary tuberculosis and all 
 its destructive sequences. 
 
 Haemoptysis is also a frequent symptom of this stage of phthisis. 
 Some of our best writers on this subject tell us that haemoptysis does 
 not commonly make its appearance until tubercular deposits have 
 actually formed in the lungs. But I have met with cases where it 
 has occurred long before there was a single physical sign of the local 
 disease. I have had a woman under my care, for more than ten years, 
 who has had the tubercular diathesis very clearly marked ; she has a 
 decided proclivity to phthisis, her father and mother having died with 
 it. During the time mentioned, she has had several attacks of pro- 
 fuse haemoptysis, but at no time has there been a single physical sign 
 of the disease, excepting prolonged expiratory murmur, and that but 
 very recently. Her blood-making organs are very feeble, and her 
 blood is always deficient in its solid constituents ; the bronchial mucous 
 membrane being delicate, the depraved blood is freely exuded into the 
 bronchi, and haemoptysis is the consequence. That she will ultimately 
 fall a victim to pulmonary tuberculosis I have not a doubt. 
 
 During the pre-tubercular stage of the disorder in females the 
 menses are usually scanty or suppressed, but not always so. I have 
 known instances where they were very profuse, occurring at short 
 intervals, exhausting the patient's strength very rapidly, and thus 
 greatly adding to the tubercular cachexia. When the menses are 
 suppressed the patient will be troubled with leucorrhcea and its 
 attendants, pain in the back, limbs, and head, with bearing-down 
 pains in the lower part of the bowels, with a frequent desire to urinate. 
 The walls of the vagina will sometimes be found very much relaxed, 
 and the uterus slightly prolapsed ; and unless the physician is on his 
 guard he will be very apt to take all these symptoms as the mere ex- 
 pression of some local uterine derangement, while the great constitu- 
 tional malady, which is the legitimate cause of all these difficulties, 
 
134 PULMONARY TUBERCULOSIS 
 
 will pass unnoticed until the pulmonary organs have become hope- 
 lessly involved. I do not believe that uterine disorders are ever the 
 primary cause of tuberculosis, but they may, and indeed do frequently, 
 hasten its development. And in females who have a marked proclivity 
 to this malady, they may sometimes be looked upon as symptoms of 
 that disorder which will ultimately absorb every other. 
 
 Such are some of the general symptoms that present themselves to 
 our view in the pre-tubercular stage of phthisis. TVith three or four 
 exceptions they are symptoms that are present in other diseases, and 
 therefore cannot be regarded as altogether pathognomonic of this. 
 But in estimating their value we must study them individually and 
 collectively, placing each one in its proper relation with the other ; 
 they will then present us with the materials out of which we may 
 construct the fabric of a permanent diagnosis, one that will stand the 
 test of rigid scrutiny and practical experience. 
 
 II. Physical Signs of the Pre-Tubercular Stage of Pulmonary 
 Tuberculosis. 
 
 These are not so obvious as the general symptoms. Indeed, I 
 question whether there be any reliable physical signs of this stage of 
 the disease. Dr. Edward Smith, of London, who has done so much 
 to advance our knowledge of phthisis, maintains that there are physi- 
 cal signs which are quite indicative of the existence of the disorder. 
 In his new work, — " Consumption : its Early and Remedial Stages," 
 — he tells us that at this early period, before a single tubercle has been 
 deposited in the lungs, inspection shows a marked diminution in the 
 movements of the chest ; that this diminution is not confined to the 
 summit or sides of the chest, but extends to all the movements of 
 respiration. By this condition of the lungs the amount of air inspired 
 is greatly lessened ; hence the respiratory murmurs are more feeble. 
 He considers that a diagnostic character of the weakened murmur 
 which precedes the tubercular deposit, as compared with the weak- 
 ness caused by general debility, consists in the fact that in the latter 
 case the normal intensity of the murniur is brought out by breathing, 
 while it is otherwise in the former case. 
 
 Dr. Smith says that " the feebleness of respiration is seen both in 
 the ordinary and in forced respiration. In ordinary respiration, not 
 only is the breath-motion small, as it is also in chronic bronchitis, but 
 
THE PEE- TUBERCULAR STAGE. 135 
 
 the effort is feeble, and without that violence which is found in 
 bronchitis. There appears to be not only lessened respiration, but less 
 power to respire, as is evident to the most careless observer. In forced 
 respiration it is, however, better marked, for it is much more difficult 
 to train such an one, than one in health, to perform deep and slow 
 respiration, both because the habit of shallow and feeble respiration 
 prevents him from duly apprehending what is required, and from his 
 inability to inspire deeply. Such a person, when required to breathe 
 deeply, performs quick and short acts of deeper inspiration, analogous 
 to the short action of a pair of hand-bellows when suddenly snatched 
 open or suddenly pressed down. The deep and slow inspiration which 
 alone would fill the bellows (to continue the illustration) he does not 
 easily apprehend, and cannot readily perform. This we believe to be 
 in part due to a forgetfulness of the proper habit of breathing, from 
 the long continuance of an abnormal mode of breathing, and partly 
 to inability to perform what is required. Moreover, it very often 
 occurs that, when such an one is taking a deep inspiration, the in- 
 spiratory muscles too soon cease to act, and the chest suddenly falls to 
 a certain extent, while he believes that he is still inspiring. This is 
 most commonly seen in persons who are much enfeebled, and who, 
 having led a very sedentary life, have not invoked the full power of 
 the inspiratory muscles. . . . Feebleness and shallowness of the re- 
 spiration are commonly associated, and we think that these two quali- 
 ties must be taken together when considering their nature and effect, 
 and that there is such a dependence of the one upon the other that 
 feeble breathing will induce shallow breathing." Both of these 
 conditions Dr. Smith affirms exist in the pre-tubercular stage of 
 phthisis. 
 
 Dr. Lawson takes very nearly the same view of this matter as Dr. 
 Smith. " The condition of the chest," he says, " in this stage appears 
 to be one of debility of the moving powers of the parietes, and con- 
 sequently the movements are restricted, and dilatation becomes com- 
 paratively incomplete ; hence inspiration during tranquil respiration 
 reveals limited expansion, extending equally to both sides. The dis- 
 tinction between this condition and those which occur in tubercular 
 deposits are very marked and characteristic, and can leave no doubt 
 as to the state of the parts. Thus, the diminished movements of the 
 precursory stage are equal on the two sides, and exhibit merely 
 
136 PULMONARY TUBERCULOSIS. 
 
 restricted action, and not change of character, the expansions being 
 sufficiently uniform, although restricted. In ordinary tranquil respira- 
 tion in this stage the expansion is comparatively small, and the motion 
 proportionally less at the apex than at the base, but a full inspiration 
 restores, almost perfectly, the harmony of the movement, the dilata- 
 tion taking place gradually from below upward, the ribs swelling out- 
 ward, as in the physiological state. Forcible inspiration, therefore, 
 restores the diminished expansion ; and herein consists the especial 
 difference between the movements in this state and that which occurs 
 after tubercles have been deposited. In the latter condition, the ex- 
 pansion of the apex cannot be restored even by forcible inspiration, 
 nor is the action of that physiological type which exhibits a gradual 
 swelling from below upwards."* 
 
 Dr. Austin Flint, whom we regard good authority on all questions 
 pertaining to percussion and auscultation, has very little confidence in 
 these signs as means of diagnosticating phthisis at this early stage. 
 In an article published in the January number of the American 
 Journal of the Medical Sciences, 1863, page 93, reviewing Dr. Smith's 
 book, he says, " Diminished respiratory movements, lessened vital 
 capacity, and enfeebled respiratory murmurs, express deviations, not 
 from any fixed normal standard applicable to all healthy persons, but 
 to a standard of health proper to each individual. There is a wide 
 variation in these among; different individuals in health. All who 
 have given attention to examining healthy chests must be aware of 
 this fact. To be able to judge any case with respect to these signs, 
 we must know the healthy standard in the person examined. This 
 knowledge we seldom have, because persons in health do not present 
 themselves for examination. The difficulty would not be nearly so 
 great if the signs which have been mentioned were confined to a por- 
 tion of the chest ; we should then have the advantage of a compari- 
 son of the two sides. We confess we are unable to understand how 
 the author can come to a conclusion respecting a general diminution 
 of the breathing movement, of the amount of inspired air, and of the 
 respiratory murmur, in individual cases, unless it has so happened 
 that he is familiar with the patient's condition in these respects when 
 in health." 
 
 * Lawson's " Phthisis Pulruonalis," page 326. 
 
THE PRE-TUBERCULAR STAGE. 137 
 
 In a case like this, where writers differ so widely in opinion, it is 
 difficult to determine which is the true one. The only way in which 
 we can arrive at the truth is to submit the whole matter to the test of 
 practical observation. I am not aware that any one has yet done 
 this. I do not, perhaps, regard Dr. Smith's opinion on this subject 
 as highly as I ought, from the fact that he seeks to* make use of it with 
 a view to overthrow the present received doctrine of the origin of pul- 
 monary tuberculosis. He considers this lessened respiratory motion 
 something more than a physical sign of approaching tubercular de- 
 posits. He more than intimates that phthisis is a local disease, origi- 
 nating in the feeble or lessened action of the air-cells. The air-cells, 
 he maintains, are of a very delicate organization, and highly endowed 
 with nervous influence from the cerebro-spinal, excito-motory, and 
 sympathetic systems, and are extremely liable to their special diseases, 
 particularly tuberculosis, which may soon follow their lessened action. 
 
 If there is lessened mobility and diminution of the vesicular mur- 
 mur, as maintained by Drs. Smith and Lawson, previous to the actual 
 deposit of tubercle in the lungs, I must say that I have never been 
 able to detect it. Neither can I subscribe to Dr. Smith's theory of 
 the origin of pulmonary tuberculosis. It is a heresy ignored by the 
 entire pathological teachings of the day. But in this connection 
 I should not neglect to observe that I have occasionally met with 
 cases of this disease where there was prolonged expiratory murmur, 
 that under proper treatment has disappeared with the restoration of 
 the patient to health. What the precise condition of the air-cells 
 was that produced this abnormal sound I cannot positively say. But 
 I have sometimes conjectured that it might possibly have been pro- 
 duced by the presence of tubercular matter in the first stage of its 
 deposit, and that by improving the general condition of the system 
 and correcting the constitutional vice it has been absorbed and the 
 lung restored to its normal state. The absorption of tubercular matter 
 before it becomes consolidated, is now admitted by some of our best 
 writers on pathology. 
 
 Dullness on percussion is also mentioned by Drs. Smith and Law- 
 son as a physical sign of the pre-tubercular stage of this disease. 
 But this is not in harmony with the general teachings of percussion. 
 To have dullness on percussion sufficiently marked to be of any prac- 
 tical utility, there must always be more or less consolidation of the 
 
138 PULMONARY TUBERCULOSIS. 
 
 lung, either from pleuritic effusion, pneumonia, or tubercular deposits. 
 The location of dullness on percussion mostly points out the nature 
 and extent of the disorder ; thus, if it is elicited at the summit of the 
 chest on but one side, it is indicative of tubercular consolidation ; 
 ■when confined to the inferior portion, it is generally a prominent sign 
 of pneumonia. Dr. Smith says that this dullness is over the whole 
 chest, and that it is owing to the absence of a fall amount of air in 
 the air-cells. This, he thinks, he has ascertained by a newly-invented 
 spirometer, which shows that the quantity of air admitted into the 
 lungs in this stage of the disease is much less per minute than in 
 healthy persons ; that in no small proportion of such persons the nat- 
 ural capacity of the chest is smaller from a contraction of that cavity 
 in all its diameters. 
 
 " In the early stage of phthisis," observes Dr. Smith, "before there 
 is any evidence of the deposition of tubercle, there is an appreciable 
 degree of dullness on the clavicles, and, indeed, over the chest in gen- 
 eral. This is not found in the earliest condition, but only after the 
 diminution in the expansion of the lung has continued for a long 
 time. It arises no doubt from the absence of the full amount of air 
 in the lung-tissue which was common in health, for in such cases we 
 cannot doubt for a moment that the solid tissues bear a larger propor- 
 tion to the volume of the lung than occurs when the air-vessels are 
 unusually expanded. Some may think this to be over-refinement, and 
 question its truthfulness ; but let such examine the percussion-note of 
 the clavicles in old cases of bronchitis, and the doubt will be removed, 
 for no one believes that in such cases there is the deposition of solid 
 matter in the lungs, or any large accumulation of blood there in the 
 absence of the winter increase of dyspnoea, and yet the percussion- 
 note is duller than is found in conditions of phthisis far more advanced 
 than those now under consideration. There is also in long-continued 
 bronchitis a state of collapse of the apices, as is evident by the de- 
 pression which is found above each clavicle, even when the arms are 
 pulled down ; and without entering into the question as to the pre- 
 cise cause of this, we may remark that the fact is commonly the same 
 in old people." 
 
 Dr. Lawson says, " In consequence of the diminution of the mo- 
 bility of the thorax and its contracted state, the sound elicited by per- 
 cussion is less clear than pertains to a perfectly physiological type. 
 
THE PRE-TUBERCVLAR STAGE. 139 
 
 This diminished resonance extends over the whole surface ; and, al- 
 though its marked condition is in the superior part of the chest, it 
 has a greater extension than can be anticipated if it proceeded from 
 tubercular deposits. In addition to these characteristics, it will be 
 observed that the dullness is equal on the two sides, instead of being 
 developed exclusively at one apex, as usually occurs in the tubercular 
 deposits. In these examples the parieties of the chest seem more rigid 
 and unyielding than in the other conditions ; although the percussion- 
 sound is not positively dull, as when a solid substance is interposed, 
 there is, nevertheless, an appreciable diminution of natural resonance." 
 
 From our own experience we could not say that dullness on per- 
 cussion is a sign of this stage of phthisis. We think it is far from 
 being settled that a narrow, contracted chest is a cause of pulmonary 
 tuberculosis. Neither is the mechanical compression of the lungs 
 by hypertrophy of the heart, effusion from pleuritis, and the like 
 causes, very apt to favor tubercular deposits in the lungs. A simple 
 want of expansion in the air-cells can never originate it. There must 
 first be the constitutional dyscrasia ; then perhaps a contracted chest 
 and a feeble action in the air-cells may be an incidental cause, among 
 numerous other agencies, in inducing this fell disease. 
 
 Auscultation and percussion, therefore, furnish us nothing that 
 is reliable in making out a diagnosis of the pre-tubercular stage of 
 phthisis. We must interrogate exclusively the general symptoms. 
 That these furnish evidence sufficiently conclusive, will be doubted by 
 no one who has studied them with that attention their importance 
 demands. Loss of flesh, hurried breathing, a rapid pulse, indigestion, 
 hemoptysis, expectoration containing withered cells and shriveled 
 nuclei, and Thompson's gingival margin, when grouped together, all 
 point with unerring precision to the nature of the malady. The phy- 
 sician who can close his eyes against the threatening dangers brought 
 to light by these symptoms, and dismiss a patient with an indifferent 
 prescription, is not a careful or wise practitioner of the healing art. 
 This is the stage in which to strike a blow for the permanent eradica- 
 tion of the malady. If the disease now progresses in spite of treat- 
 ment, it will inevitably prove fatal. So take warning, and let not the 
 enemy with which you contend catch you napping. 
 
CHAPTER XII. 
 
 Thompson's gingival margin a sign op pulmonary tuber- 
 culosis. 
 
 The symptoms of pulmonary tuberculosis are sometimes very 
 obscure, particularly in the first stage. After cavities have formed, 
 and hectic has supervened, there is no trouble in making out the 
 diagnosis. Medical treatment is then of little avail. To manage this 
 malady successfully, it must be detected before tubercles have been 
 deposited in the lungs. Any physical sign or symptom, therefore, 
 that will reflect the least light upon the case should be particularly 
 noted, and its teachings faithfully applied. Of all the signs of the 
 tubercular dyscrasia, there is none more valuable than Thompson's 
 gingival margin. Although not infallible, yet in the great majority 
 of cases tubercular disease may be inferred when it is present. 
 
 I. Description of the Margin. 
 
 In most phthisical patients it is found at the edge of the gums, 
 where they are reflected upon the teeth ; it is usually deeper iu color 
 than the adjacent surface, and has a festooned appearance. This line 
 in some instances is a mere streak, and at other times a margin of 
 more than two lines in breadth. As the disease progresses, and be- 
 comes more decided in its character, it will exhibit a vermilion tint, 
 inclining to lake. As a general occurrence, it is more distinct around 
 the incisor teeth, but is frequently apparent around the molars. In 
 very grave cases, when the margin is deep and clearly defined, it is 
 not uncommon to find hypertrophy of the gums also accompanying it. 
 When this occurs, it renders the diagnosis of the streak more pro- 
 nounced. 
 
 But this sign of phthisis should not be taken without some caution. 
 Tartar, mercury, and iodine will produce a redness of the gums, which 
 may be mistaken for it. In these instances the discoloration is more 
 140 
 
THOMPSON'S GINGIVAL MARGIN. U\ 
 
 widely diffused, or, if it in any way assume the appearance of the 
 gingival margin, it does not so naturally merge in the tint of the 
 adjacent membrane. When the discoloration is occasioned by the 
 accumulation of tartar alone, it may be distinguished from that by the 
 rugged and uneven appearance of the border, and from its continu- 
 ance on the gums after the tartar has been scaled off. But if due 
 care be exercised, there is no danger of going astray, for there is no 
 evidence that this red streak ever occurs in any other disease save the 
 tubercular. 
 
 Dr. Cotton, of the Brompton Hospital for Consumptives, an asso- 
 ciate of Dr. Thompson's, says that this margin was first observed by 
 M. Fredrig, who believed that although a similar appearance is com- 
 mon to the latter period of all chronic diseases, the colored line is 
 invariably present as one of the earliest symptoms of phthisis, the red 
 denoting an inflammatory, and the blue a less active kind of tubercular 
 disease ; the deepness of the color, moreover, bearing a direct propor- 
 tion to the rapidity with which the particular case is to proceed. He 
 also observed that when the disease was temporarily arrested the blue 
 streak remained, only paler than before ; and when the disease recom- 
 menced its march, the streak became plainer. The blue margin here 
 described is not especially indicative of tuberculosis ; it is observed in 
 cases where the individual is suffering from the effects of some poison, 
 such as lead, nitrate of silver, copper, and chlorine. Chlorotic females 
 often have a faint blue streak upon the gums, but this is widely differ- 
 ent from Thompson's gingival margin, and will rapidly disappear under 
 the administration of iron, strychnia, and chlorate of potash. 
 
 During the last twenty years I have kept a brief record of two 
 hundred cases of tubercular disease of the different organs of the 
 body ; out of this number the margin was present one hundred and 
 seventy-five times. It was more frequent in males than in females. 
 It also made its appearance in the young much sooner than in the old. 
 In some cases it anticipated the development of the local disease for 
 two or three years ; but commonly the disease succeeds the appearance 
 of the streak in a very short time. The early appearance of the streak 
 is an unfavorable circumstance : cases of this kind run a short course ; 
 but not always. I am acquainted with a medical man who has had 
 phthisis for more than ten years ; Thompson's gingival margin pre- 
 ceded all other signs for more than a year. During the decade just 
 
 10 
 
142 PULMONARY TUBERCULOSIS. 
 
 mentioned lie has had every symptom and sign of the malady, and 
 has several times been so low that his life has been despaired off, bnt, 
 fortunately for him, the disease has been confined to one lung. At 
 the present writing he enjoys reasonable health, and attends to the 
 duties of his profession, which are numerous and laborious. He has 
 taken gallons of cod-liver oil and brandy, — the latter has damaged his 
 reputation for temperance, for he occasionally gets very drunk. How 
 much influence the brandy may have had in prolonging his existence, 
 we shall see in a succeeding chapter. 
 
 In the pre-tubercular stage of phthisis, if the streak disappear 
 under treatment, which it occasionally does, it is a good sign. It is 
 just here that it is of the most value; it points out the commence- 
 ment of the constitutional malady, and gives us warning of the local 
 lesion that will ensue unless proper measures are promptly instituted 
 to correct the depraved condition of the vital fluid upon which the 
 .local lesion depends. 
 
 II. Theory of the Margin. 
 
 'We will let Dr. Thompson give his own views on this subject. They 
 -are not perfectly satisfactory, but, like many other matters pertaining 
 to the philosophy of this disease, we must wait for time to furnish a 
 clearer solution, — one that will stand the test of rigid scrutiny. 
 
 Dr. Thompson says : " I approach this part of my subject with 
 hesitation, and offer a hypothesis more with a view to incite inquiry 
 than as qualifying in any way the mutual relation of the facts. Let 
 me then mention what, indeed, you have had an opportunity of ob- 
 serving : first, that the margin has been found broadest and deepest 
 in tint, and most extended as respect the number of teeth encircled, 
 in cases where the diarrhoea or other symptoms indicate the existence 
 of a state of erethism of the intestinal mucous membrane ; and, 
 secondly, let it be remembered that, in the opinion of some eminent 
 pathologists, blood affected with tuberculosis has a peculiar affinity for 
 oxygen. Any tendency to congestion, which may be supposed to be 
 habitual at the reflected edge of the gums, would probably be increased 
 by the occurrence of intestinal irritation, and the atmosphere, if capa- 
 ble of modifying the condition of the blood partially stagnant in 
 superficial vessels, might be expected to take most effect in situations 
 most decidedly exposed to its influence. 
 
THOMPSON'S GINGIVAL MARGIN. 143 
 
 " Consistently with these views the streaked gingival margin may 
 be considered to depend essentially on tubercular depravation of the 
 blood, and a consequent change in its relation to the atmosphere. 
 When the mucous membrane of the mouth is free from congestion, a 
 greater deterioration of blood may be required in order to induce this 
 appearance under consideration, but when the circulation in this mem- 
 brane is from any cause interrupted, the streak may be expected to 
 occur at an earlier period in the progress of phthisis, and soon to be- 
 come strongly defined. The more constant presence of the sign in 
 men than in women is favorable to this explanation, the habits of men, 
 especially among the lower orders, being in various respects more cal- 
 culated than in women to induce disorder of the mucous membrane. 1 ' * 
 
 Dr. Lawrence McKay, of Rochester, New York, in the Trans- 
 actions of the Medical Society of the State of New York for 1866, 
 on " The Gingival Margin as a Diagnostic Sign," says (p. 35) : " In 
 this spanasmic condition of the system, which gives rise to this pecu- 
 liarity of the gingival margin, I contend that there is a lack of iron, 
 and also of the solid elements of the blood, peroxide of iron being 
 one of its constituent parts along with the different salts. It struck 
 me forcibly, on reasoning on this matter, that some alterative and 
 disinfectant salt, such as the chlorate of potassa, in conjunction with 
 iron, would be the remedy for that condition of the system which 
 gives rise to this condition of the margin. I have been in the habit 
 of combining the muriated tincture of iron and chlorate of potassa, 
 and prescribing them in these cases with perfect success, and as the 
 various preparations of iron attract oxygen with so much avidity, it 
 appears to me that the ferruginous compounds have the power to re- 
 new the blood by adding a pure supply of this element ; and as the 
 red corpuscles of the blood contain iron, it is claimed where they are 
 deficient and the patient anaemic, the chemical elements to supply 
 more are possessed in an eminent degree by iron. 
 
 " When we find the red margin developed, even in a slight degree, 
 the patient complains of a want of appetite, headache, generally 
 frontal, dizziness,, foul breath, bad taste in the mouth, especially morn- 
 ings, and in fact all the symptoms of impaired digestion. For the 
 want of a more appropriate name, I have taken the liberty of denom- 
 
 * Thompson on Pulmonary Consumption, page 181. 
 
144 PULMONARY TUBERCULOSIS. 
 
 inating this condition of the system feransemia, as it is not altogether 
 the want of blood that produces this appearance, but the lack of that 
 important element which the ferruginous compounds furnish. After 
 this state of things, the patient not attending to the difficulty, which 
 now only slightly interferes with his ordinary avocation, he may con- 
 tinue in this way for months, but sooner or later he sickens. ... If 
 we see the patient when the margin is first discoverable, by putting 
 him on the use of iron and chlorate of potassa, and continuing the 
 remedy long enough so as to obliterate this margin entirely, we shall 
 effect a permanent cure." 
 
 Dr. Thompson says, " A large proportion of our hospital patients 
 are the subjects of advanced disease, and afford, therefore, little oppor- 
 tunity of exhibiting to you a common appearance at the early period 
 of the disease ; I mean a delicate, pearly, transparent aspect of the 
 border of the gums, probably the result of fineness of structure. 
 When congestion of the membrane, from whatever cause, occurs in 
 such individuals, the red line may be expected to appear, but I believe 
 the pearly condition to be very significant and peculiarly valuable, as 
 occurring frequently at a very early period of the disease, and not 
 liable to the fallacies with which shades of color may be associated. 
 
 " When consumption exists in any individual, every structure is 
 prone to partake of the disease, and various circumstances may modify 
 the extent to which the lungs are affected. Even if it were practicable 
 to replace disorganized lung with healthy tissue, yet, if the blood 
 remained deteriorated and the process of nutrition defective, the fatal 
 issue, although deferred, would be equally certain ; any particular 
 which seems calculated to assist our judgment regarding the con- 
 stitutional condition is therefore entitled to attention. I readily 
 acknowledge that extended observation is required in order to de- 
 termine the qualifying circumstances to be regarded in fixing the 
 exact value of the sign which I have now commended to your atten- 
 tion ; and this object will be promoted by a due regard to the sug- 
 gestions of minds more apt to detect objections than to perceive 
 evidence ; avail yourselves, therefore, of such assistance, while steadily 
 aiming to attain a habit of seeking truth with an unprejudiced and 
 discriminating mind." * 
 
 * Thompson's Lectures on Pulmonary Consumption, page 1S5. 
 
THOMPSON'S GINGIVAL MARGIN. 145 
 
 III. Cases Illustrating the Value of Thompson's Gingival 
 Margin as a Means of Diagnosis and Prognosis in Phthisis. 
 
 About fifteen years since, a young lady came to my office for the 
 purpose of having a tooth extracted. On examining her teeth, I found 
 the gingival margin very clearly defined upon the gums of the upper 
 and lower jaws. It was more than a line in breadth, and of a bright 
 red color. After extracting the tooth, I made some general inquiries 
 in relation to her health, occupation, and parentage. She said that 
 her health had always been good, that there was no phthisis in her 
 family, and that she was usually employed in light household work. 
 She was of the nervo-sanguineous temperament, and presented the 
 appearance of an individual in perfect health. 
 
 After she left, I observed to a professional friend who was in the 
 office at the time, that if there was any value to be attached to 
 Thompson's gingival margin as a sign of phthisis, that young lady 
 would some day fall a victim to the disease. I did not see her again for 
 more than a year, when I was told that for more than six months she 
 had been gradually declining. Hectic was now confirmed, and the 
 physical signs showed extensive tubercular disease in both lungs. The 
 streak upon the gums was still very marked ; but instead of being 
 brilliantly red, it was a dark red, inclining to purple, a sure index of 
 that condition of the vital fluid which can sustain life but a short 
 time. She died four weeks after my first visit. 
 
 During the month of September, 1856, I was called to attend a 
 young man with a mild attack of dysentery. During my examination 
 of his case, I discovered that the gingival margin was distinctly visible. 
 After his recovery, I informed him that I was fearful he would, at no 
 distant day, have phthisis, and advised a course of treatment. This 
 was declined : there was no consumption in his family ; he thought 
 my fears groundless. I saw him occasionally during the winter ; his 
 health appeared as good as usual. About the first of April he took 
 cold, lost his appetite, had an annoying cough, did not rest well at 
 night, declined in flesh and strength, but was able to attend to his 
 business. He remained in this condition until the first of May, when, 
 becoming much worse, he was compelled to call in the aid of the 
 physician. 
 
 At my first visit his pulse was one hundred and ten per minute, 
 
146 PULMONARY TUBERCULOSIS. 
 
 respiration thirty ; pain in the head ; mouth and throat red and dotted 
 over with prominent follicles ; Thompson's gingival margin streaking 
 the gums of the upper and lower jaws; bowels costive; urine scanty 
 and high colored ; cough dry and suffocating ; complained of pain in 
 the left side, and could not lie upon it. Percussion elicited slight dull- 
 ness under the left clavicle. On auscultation, crepitation was heard 
 from the base to the summit of the lung, indicating pneumonitis of 
 both lobes of the lung. On the right side no abnormal sounds were 
 heard, excepting sonorous rhonchi. 
 
 The medical treatment for the first few days consisted chiefly of 
 blistering, purgatives, and Dover's powder, when the inflammatory 
 action gave way, and no physical signs remained but those of limited 
 tubercular deposits in the superior lobe of the lung. Cod-liver oil, 
 quinia, iron, and a generous diet were prescribed. Under this treat- 
 ment he improved rapidly, and by the first of September he had gained 
 twenty pounds in weight, the red margin was scarcely visible upon the 
 gums, and he appeared to be in the enjoyment of his usual health. 
 
 From this time until the spring of 1853 he appeared to enjoy a 
 measure of health, and we fondly hoped that the tubercular diathesis 
 was eradicated. In this we were disappointed. About the middle of 
 April he walked five miles one evening to a concert, and returned 
 home through a drenching rain, retiring to rest without removing 
 his wet underclothes. The result was a return of his pulmonary 
 difficulties, and he fell a victim to them on the 10th of August. The 
 gingival margin was not so marked in the latter attack as in the first. 
 Between the attacks there was an interval of more than a year during 
 which it was not present, showing that the tubercular habit may be 
 in a measure overcome by those remedies which have for the last few 
 years become so deservedly popular with the profession. 
 
 On the 3d of April, 1854, Mr. R., aged twenty-five, came to my office 
 for advice. He was a book-keeper by profession, — an individual of a 
 highly nervo-bilious temperament ; had been married four years. He 
 was tall, well formed, and his frame appeared to be close-built and 
 sinewy ; his chest was broad and deep ; head large, face bold and 
 commanding, and the whole appearance of the man masculine and 
 staunch. His habits were regular and temperate ; he had a hereditary 
 title to phthisis, his father having died with it. His health had been 
 uniformly good until three months previous to his call upon me, 
 
 
THOMPSON'S GINGIVAL MARGIN 147 
 
 since which time he had suffered from diarrhoea, which at times had 
 been very annoying, causing him to arise several times during the 
 night. Had fever during the after-part of the day, and night-sweats. 
 Mucous membrane of the throat congested; Thompson's gingival 
 margin clearly defined. Pulse frequent and respiration hurried; 
 appetite craving, digestion badly performed, the food passing through 
 the alimentary canal almost unchanged ; was quite gloomy in spirits, 
 and considerably emaciated. His physician had been treating him 
 for chronic muco-enteritis, with no benefit. 
 
 From the very marked appearance of the gingival margin, I was led 
 to examine his chest, when the following physical signs were elicited : 
 On percussion there was dullness on the right side beneath the clavicle, 
 accompanied with prolonged expiratory murmur. On the left side 
 the inspiratory murmur was harsh, and the expiratory prolonged, but 
 little or no increase of vocal resonance could be detected, nor dullness 
 on percussion. These signs clearly indicated a considerable amount 
 of tubercular exudation in the apex of the right lung, which was 
 undoubtedly softening, and a much smaller amount in the left lung, 
 which was still crude. The diarrhoea was the offspring of tubercular 
 disease in the small intestines. 
 
 The prognosis was not pleasing to the patient. He sought advice 
 elsewhere, was assured that his disorder was only diarrhoea, and that 
 with proper medical treatment he would soon be well. I saw no more 
 of him professionally until the middle of September. He had then 
 emaciated very much ; his diarrhoea was very annoying ; cough and 
 expectoration troublesome; hectic confirmed; physical signs showed 
 cavities in both lungs ; gingival margin dark red. From this time he 
 declined rapidly, and died on the 5th of October. 
 
 CONCLUSIONS. 
 
 From our present knowledge on this subject, we may safely draw 
 the following conclusions : 
 
 1st. Thompson's gingival margin is an unfailing sign of the tuber- 
 cular diathesis. 
 
 2d. When the margin is present, no matter how obscure the other 
 symptoms of pulmonary tuberculosis may be, we may with certainty 
 prognosticate its development at no distant day. 
 
 3d, In the medical management of patients suffering with tuber- 
 
148 PULMONARY TUBERCULOSIS. 
 
 culosis, if the red streak is present, and disappears under treatment, it 
 is evidence of amendment, and should be regarded as a favorable 
 omen. 
 
 4th. No matter how favorable the other symptoms may be. medical 
 treatment should not be discontinued until every vestige of the streak 
 has disappeared ; then we may venture to hope that the tubercular 
 diathesis is eradicated. 
 
 5th. When the margin at first appears on the incisors, and grad- 
 ually extends around the molars, where suitable medical treatment has 
 been instituted, it is an unfavorable indication ; and when it changes 
 from a bright vermilion to a dark red or purple, the prognosis is bad. 
 
 6th. In those cases of pulmonary tuberculosis where the streak is 
 absent and the general symptoms mild, we may hope that the consti- 
 tution is not so greatly injured by the morbid condition of the blood 
 that we cannot restore the individual to comparative health by the use 
 of suitable remedial agents, and thus retard or prevent the permanent 
 establishment of the local lesion. 
 
CHAPTER XIII. 
 
 the pulse: its value as a diagnostic sign of pulmonary 
 tuberculosis. 
 
 Perhaps there is no one symptom more frequently relied upon as a 
 diagnostic mark of pulmonary tuberculosis than a tense, jerking, and 
 frequent pulse. In giving this symptom its due weight and impor- 
 tance, we must briefly consider the character and variation of the pulse 
 in health. If this is not correctly known, we will not be able to form 
 a just estimate of what constitutes a morbid condition of the pulse in 
 this or any other disease. 
 
 I. The State of the Pulse in Health. 
 
 The most superficial observer will soon discover that there are vari- 
 ations to be found in the natural state of the pulse, — variations de- 
 pendent on the strength of the heart and on the natural constitution 
 of the arteries. When the heart is large and firm, other things being 
 equal, the pulse will be sharp and strong ; when the contrary exists, it 
 will be dull and feeble. If the arteries have thin and yielding coats, 
 and are at the same time of large diameter, the pulse will generally be 
 large and soft ; if their calibre be small, the pulse will be small and 
 weak ; if their walls, on the contrary, be deficient in elasticity and very 
 firm, the pulse will then be commonly hard and strong, as well in 
 health as in disease. 
 
 The pulse is also influenced by temperature, age, sex, and the tem- 
 peraments. It is also remarkably influenced by the various mental 
 emotions, — anger, grief, fear, and joy. It is likewise very materially 
 affected by various kinds of aliment, by ardent spirits, by opium and 
 other sedatives, by exercise, sleep, and watching, and the periods of the 
 day. Gravitation produces a decided influence on the pulse ; thus, if 
 a limb be raised in a vertical position, the beat of the artery becomes 
 considerably feebler. The influence of exercise in raising the pulse 
 
 149 
 
150 PULMONARY TUBERCULOSIS. 
 
 exceeds that of all other stimuli, and even of the most inflammatory 
 disorder. A full meal will augment the frequency of the pulse by 
 from ten to twenty beats in the minute, according to the excitability 
 of the individual. The frequency of the pulse during sleep is con- 
 siderably reduced, which depends chiefly on the comparative cessation 
 of all voluntary muscular action. 
 
 The effect of posture on the pulse is also very marked. Thus, for 
 the most part, it is more frequent in the erect or standing than in 
 the sitting posture ; and in this latter, again, somewhat quicker than 
 when lying, the averaged difference, in the first instance, being about 
 double that in the second. Thus, we find on experiment, throwing 
 aside nearly every other cause, that the average difference between the 
 standing and sitting postures will be five per minute ; between sitting 
 and lying about ten ; and between standing and lying about fifteen. 
 The difference depends on and is directly proportional to the muscular 
 effort excited in the maintenance of the respective postures. It 
 becomes greatly augmented in cases of debility, and increases in a 
 very rapid ratio whenever the circulation, whether from disease or 
 exercise, is much accelerated. It is, moreover, most conspicuous \n 
 the early part of the day, reaching its maximum about noon and its 
 minimum about midnight. The excitability of the pulse in respect to 
 other causes is, likewise, when in a state of health, at its height in 
 the morning. The strength of the pulse is the greatest in the re- 
 cumbent posture, so that the greatest strength and least frequency are 
 attained simultaneously. 
 
 The temperaments, also, have a great influence on the pulse. Thus 
 persons of the lymphatic temperament, as a general thing, have a 
 slow, soft pulse, those of the sanguine and nervous have a more fre- 
 quent and sharper pulse, while those of the bilious have a full, strong 
 pulse, but not quite so frequent. But as the temperaments are seldom 
 found pure, being united in various combinations, so as to form the 
 nervo-bilious, the nervo-sanguineous, etc., we will always find various 
 gradations in the strength and frequency of the pulse, according to the 
 predominating temperament. Hence we sometimes find individuals of 
 the lymphatic temperament suffering with inflammation having a pulse 
 varying but little from that which would be a normal pulse in a person 
 of the nervous or sanguine. So, also, we frequently see individuals 
 of the nervous temperament with a pulse far above the healthy stand- 
 
THE PULSE. 151 
 
 ard of the lymphatic, Vhen no inflammation is present, its heightened 
 character being the result of the prevailing constitutional tempera- 
 ment. I am acquainted with several persons of the nervous tempera- 
 ment whose pulse, even in health, is seldom less than ninety per minute 
 in the sitting posture. The temperaments, therefore, should be care- 
 fully studied ; and in making out a diagnosis of any disease by the 
 character of the pulse they must not be overlooked. 
 
 The quantity and quality of the blood, also, have a great influence 
 on the state of the pulse. We have a striking example of this in cases 
 of plethora, in which it is distinguished by its fullness as well as its 
 strength, except when, from over-distention or some other cause, the 
 action of the heart is temporarily oppressed. Again, the loss of blood 
 renders the pulse soft and less frequent. But where bleeding, for 
 instance, is carried to excess, it seems to excite or exalt the irritability 
 of the heart, and, consequently, renders the pulse more rapid and 
 sharp ; but even then it will have a quick, jerking, or bounding char- 
 acter, without fullness or permanence under the finger, sufficiently in- 
 dicative of deficiency of blood in the arteries. The quality of the blood 
 has a marked influence on the pulse. "When it abounds in its normal 
 constituents it is circulated with facility. But when it becomes defi- 
 cient in its healthy constituents, and its specific gravity is very much 
 reduced, it is propelled with difficulty through the arteries ; hence the 
 heart labors more actively, and the pulse is augmented in frequency. 
 In anaemia and lucocythaemia, where the red corpuscles are deficient or 
 blighted, the pulse is generally very frequent and small, showing a great 
 want of vital power. 
 
 We have already observed that the pulse is materially influenced by 
 temperature. Cold causes the arteries to contract, and therefore ren- 
 ders the pulse small. This circumstance should never be forgotten 
 when we are estimating the condition and character of the circulation 
 by the pulse, for cold will make the pulse of an artery small and hard 
 when the action of the heart and the condition of the system would give 
 it the reverse qualities. Heat, on the other hand, within certain limits, 
 tends to diminish the tonic contractility of the arteries, so that under 
 its influence they receive more strongly and fully the impulse from 
 the heart. 
 
 Another circumstance which has a powerful influence upon the 
 pulse, and one that is frequently overlooked by the physician, is the 
 
152 PULMONARY TUBERCULOSIS. 
 
 condition of the capillary circulation. When this is free, observa- 
 tion teaches us that the pulse will be softer and fuller than when ob- 
 structed by congestion. This is very clearly seen in fevers ; when the 
 surface is pale and constricted in the cold stage and dry and relaxed 
 in the hot stage, the pulse often preserves through these changes of 
 temperature a hardness and strength which would be much more 
 varied were the capillaries free and exhaling their usual excretion. 
 Thus, in health we almost always find a slow, soft pulse associated with 
 a relaxed condition of the skin, attended by free perspiration. 
 
 The condition of the lungs, situated, as they are, on either side of 
 the heart, no doubt has a material influence upon the pulse. The 
 numerical relation between the pulse and the number of respirations 
 in a given time may be stated in the healthy condition to be about as 
 4£ to 1. This is so generally the case that any great deviation from 
 it may be looked upon as an evidence of disease, providing there be 
 no mechanical impediment within or without the body to the descent 
 of the diaphragm. Where the rate of the respiration to the pulse is 
 notably increased, it generally indicates some impediment to the oxy- 
 genation of the blood, either from disorder in the air-passages or lungs, 
 mechanical impediment, or imperfect function of the organic nerves of 
 the lungs. 
 
 The different periods of life exert a marked influence upon the 
 pulse, particularly upon its frequency. Dr. Carpenter, in his excellent 
 work on "Human Physiology," gives the following as the average 
 frequency of the pulse at the different periods of life : 
 
 Beats per minute. 
 
 In the foetus in utero 140 to 150 
 
 New-born infant 130 to 140 
 
 During the first year 115 to 130 
 
 During the second year 100 to 115 
 
 During the third year 90 to 100 
 
 About the seventh year 85 to 90 
 
 Age of puberty 80 to S5 
 
 Manhood 70 to 80 
 
 Old age 50 to 65 
 
 From these estimates, however, we sometimes find wide deviations. 
 Dr. Dunglison has counted a pulse as low as thirty-six, and Dr. Elliot- 
 son as high as two hundred and eight. Dr. Copeland mentions a pulse 
 as low as twenty-nine in a man eighty-seven years of age in good 
 
THE PULSE. 153 
 
 health. Indeed, we have the record of cases where the pulse has 
 been entirely absent, and the individuals appeared to enjoy the best 
 of health. Several cases of this kind have occurred in which post- 
 mortem did not reveal the cause. In other cases the arteries have 
 been found obliterated by clots, inflammation, degeneration, or the 
 movements of the heart were impeded by disease. 
 
 The difference of the pulse caused by sex is very considerable, 
 particularly in adult age. The pulse of the adult male is much less 
 frequent than that of the adult female at the same age, the latter 
 having a pulse more frequent by ten beats per minute. 
 
 II. The Character of the Pulse in Phthisis. 
 
 The character of the pulse in this disease which has always at- 
 tracted most attention, is frequency. By a reference to the table just 
 quoted from Dr. Carpenter's " Human Physiology," you will see that 
 the average beats of the pulse per minute are seventy to eighty in 
 the adult. Now, when pulmonary tuberculosis exists, the pulse will 
 seldom be less than one hundred per minute. Even at the very com- 
 mencement of the disorder the frequency of the pulse is often its most 
 striking characteristic. If I am called to see an individual who is 
 able to be up and about with a pulse varying in frequency from one 
 hundred to one hundred and ten, or if he is able to come to me with 
 a pulse of this kind, I generally suspect phthisis from this symptom 
 alone, for I am not acquainted with any other disease where the pulse 
 is so frequent that the patient would be capable of such exertion. It 
 is only in phthisis that an individual could do it with a pulse thus 
 augmented in frequency. 
 
 Several years since, I was requested to see a young man said to be 
 suffering with intermittent fever, he having recently come from a mala- 
 rious district. He informed me that his health had not been very 
 good for more than a year. This he attributed to occasional attacks 
 of ague. The present indisposition had commenced about eight weeks 
 since, — during which time he had had regular paroxysms of chills and 
 fever in the morning, attended with slight perspiration in the after- 
 noon. Rested well at night, and had a good appetite. Had but little 
 cough and expectoration. Thompson's gingival margin was not pres- 
 ent. Had no hereditary title to phthisis ; had emaciated but very little. 
 In the after-part of the day was able to ride out in a carriage three or 
 
154 PULMONARY TUBERCULOSIS. 
 
 four miles. "Was cheerful, and disposed to look at the bright side of 
 life's picture. His physician regarded his case as chronic ague, and 
 had been treating him accordingly, without any material improvement. 
 
 It was in the evening when I first saw him, and the only marked 
 peculiarity in the general symptoms which I was able to discover was 
 the frequency of the pulse, which was out of proportion with every- 
 thing else, numbering one hundred and ten per minute in the sitting 
 posture. This circumstance led me to make a more critical examina- 
 tion of his case. Every physician who has been much in the habit 
 of treating cases of intermittent fever will bear testimony to the fact 
 that in the uncomplicated form of the malady, during the interval be- 
 tween the paroxysms, we seldom see the pulse over ninety per minute ; 
 in some instances it will not be more than seventy-five in the sitting 
 posture. And when we do meet with a case where it is over one hun- 
 dred, we are apt to infer the existence of organic disease. In this 
 instance I came to this conclusion, and it was verified by a careful 
 examination of the chest, for, on percussion, dullness was elicited 
 under the left clavicle, with humid clicking, showing very clearly the 
 existence of tubercular softening of the superior lobe of the lung. 
 On the right side percussion was dull just under the clavicle, and on 
 auscultation prolonged expiratory murmur was very distinct, indicating 
 the formation of crude tubercular matter. His case was therefore 
 easily made out. The prognosis was unfavorable. He died some six 
 months afterwards, a very marked example of pulmonary tuberculosis. 
 
 But we must not rely too much on the frequency of the pulse as 
 a symptom of phthisis. We will sometimes meet with individuals 
 suffering with the disease who have a pulse that does not rise above the 
 healthy standard. These persons are somewhat advanced in life, and 
 the progress of the disease is very slow. I recently attended a man, 
 aged seventy, who died with phthisis, and at no time during his ill- 
 ness was the pulse over sixty-five per minute. Dr. Stokes, in his work 
 on " The Heart," relates the case of a man, aged thirty-one, who died 
 with tubercular cavities in both lungs, where, from some obscure dis- 
 ease of the heart, the pulse was almost always below fifty per minute, 
 and would frequently fall to fifteen, and remain so for eight or ten 
 hours. 
 
 The most interesting thing connected with the pulse during the 
 progress of pulmonary tuberculosis, particularly in the second and 
 
THE PULSE. 155 
 
 third stages, is the fact that it is not materially altered by change of 
 posture. We have already said that the pulse in health varies much 
 between the standing and lying posture, about fifteen beats per minute. 
 Now, the difference produced by change of posture in this disease is 
 very trivial. In some cases no change is produced, while in others it 
 will not exceed more than two beats per minute, and very rarely ten. 
 I saw an individual a few days since affected with this disorder, whose 
 pulse in the sitting posture was one hundred and ten, and after ascend- 
 ing a flight of stairs twelve feet high it was only increased ten strokes 
 in a minute. He was in the second stage of the disease. I have fre- 
 quently tried this experiment, with nearly always the same result. The 
 more frequent the pulse, the less influence has the change of posture 
 upon it. Thus, in the case of a young woman aged nineteen, in the 
 third stage of phthisis, her pulse in the lying posture was one hundred 
 and twenty-four, while in the standing posture it was one hundred and 
 twenty-six, being an increase of only two beats ; in health, with a pulse 
 of seventy per minute, the difference would have been at least twenty, 
 for the pulse in women is more easily excited by change of posture 
 than in men. As the pulse is always at the maximum of its frequency 
 in the after-part of the day in this disorder, so, also, at this time is 
 the pulse less susceptible to change of posture. In fifteen cases in 
 the third stage, where the pulse was one hundred and ten, in no 
 instance did it rise above eight beats per minute by changing from the 
 lying to the standing posture. In the morning it was greater, aver- 
 aging about ten beats per minute. 
 
 " There is," says Dr. Thompson, " an additional circumstance con- 
 nected with the effect of posture in phthisis which is entitled to con- 
 sideration. In health, the difference of rapidity of pulse produced by 
 change from sitting to the recumbent position is only about half as 
 much as that produced by the change from standing to sitting; 
 whereas, as far as I have observed in phthisis, the contrary rule ap- 
 pears to obtain. But, not to detain you longer with general state- 
 ments, let me bring the facts under your immediate observation. If 
 any one of my audience in good health will volunteer, we will examine 
 his pulse. The gentleman who has been kind enough to offer him- 
 self, I find, when sitting with his back supported, has a pulse of 
 seventy-four ; but in the standing posture, allowing a little time for 
 the effect of locomotion to pass off, it is ninety-two. 
 
156 PULMONARY TUBERCULOSIS. 
 
 " Let us contrast with this result the pulse of some of our patients. 
 Here is one, — M. A. Gr. Place your hand alternately under the right 
 and left shoulder-blades as she speaks. You observe how much more 
 of vocal vibration is communicated to the hand on the right side 
 than on the left. Listen to the breathing. You find each inspiration 
 on the upper half of the right chest in front accompanied with two or 
 three peculiar clicks. This is a characteristic sign of tubercular affec- 
 tion in the second stage. Try her pulse while sitting : it is one hun- 
 dred and twenty-four; on standing up, it is still one hundred and 
 twenty-four. 
 
 " Here is another patient, — P. S. Her pulse when sitting is ninety- 
 six; on standing it is one hundred, rising only four beats. Try 
 whether the state of chest is such as the rule which I am illustrating 
 would require. There is dull percussion over the summit of each 
 lung. On the left, under the acromial end of the clavicle, you find a 
 bellows-sound synchronous with the heart's contraction ; at the sternal 
 end a rubbing sound, produced probably by intercurrent pleurisy. Over 
 the apex of the right lung you have cavernous voice and respiration. 
 There is some anaemia, and the pressure of tubercular lungs, under 
 such circumstances, does sometimes, as in this patient, induce a bel- 
 lows-murmur, probably by superadding a disturbing cause to that in- 
 duced by impoverishment of blood on the even current of the circula- 
 tion. Supposing a person in health to have a pulse of ninety-six, it 
 should rise about eighteen beats per minute on standing. If anaemia 
 were present the change should be still greater ; but in this case before 
 you the difference, you obseive, is only four beats."* 
 
 It is a question which remains to be settled, whether the pulse ever 
 entirely regains its sensitiveness to change of posture when the lungs 
 have once been the seat of tubercular deposits. The return of such 
 sensitiveness, under treatment, is, without doubt, a favorable circum- 
 stance, as the following case will prove : 
 
 W. B. was an individual of the nervo-bilious temperament, aged 
 twenty-three. Had no hereditary title to phthisis. "When in health, 
 weighed one hundred and thirty. At the time of my first visit he 
 had been ill for nearly two months, and had declined in weight to one 
 hundred and three. In the afternoon, about three o'clock, his pulse 
 
 * Thompson's Lectures on Consumption, page 86. 
 
THE PULSE. 157 
 
 in the lying posture was one hundred and ten per minute ; in the 
 standing, one hundred and twelve. His respiration was thirty per 
 minute in the lying posture ; no change by standing. Mouth and throat 
 very much inflamed. Gingival margin very clearly defined on both 
 the upper and lower jaws. Had had a dry cough fdr three weeks. 
 Bowels costive, and somewhat tender to the touch. Had had fever 
 every afternoon for ten days. Appetite very poor, and he did not rest 
 well at night. Mind hopeful. Complained of pain in the left side, 
 and could not lie upon it. Percussion elicited dullness under the left 
 clavicle. On auscultation, prolonged expiratory murmur was heard over 
 the same region ; in the region of the lower lobe slight crepitation. 
 These physical signs pointed out the existence of recent tubercular 
 infiltration of the superior lobe of the lung, with slight inflammation 
 of the lower in the first stage. The sounds elicited on the right side 
 were nearly normal. 
 
 For the first ten days the treatment was antiphlogistic, after which 
 he was placed upon the use of cod-liver oil, quinia, iron, and a substan- 
 tial diet, which were continued, with slight variations, for two months, 
 at which time he presented the following condition : Pulse, lying, 
 seventy-five per minute ; standing, eighty-five ; respiration, eighteen. 
 There was still slight dullness under the left clavicle ; crepitation and 
 prolonged expiratory murmur had disappeared ; the gingival margin 
 was but faintly defined. He was now able to ride on horseback several 
 miles in the course of the day, and had gained twelve pounds in weight. 
 Two months from this time he was in the enjoyment of his usual health. 
 
 In watching this case attentively, I observed that just in proportion 
 as the pulse was increased in frequency by changing from the lying to 
 the standing posture, was the improvement. And when the differ- 
 ence was ten, the patient was nearly well. His pulse, however, never 
 acquired that sensitiveness to change of posture which belongs to the 
 normal pulse, for at no time since has it ever exceeded a difference of 
 twelve beats per minute between lying and standing. We will, there- 
 fore, do well to keep this peculiar character of the pulse constantly in 
 view, for it will aid us very much in our prognosis and diagnosis of 
 this disease. 
 
 A careful study of the pulse in pulmonary tuberculosis leads to the 
 following inferences : 
 
 1st. That when an individual is able to come to us with a pulse 
 
 11 
 
158 PULMONARY TUBERCULOSIS. 
 
 numbering one hundred or one hundred and ten beats per minute, we 
 may suspect phthisis from that symptom alone. 
 
 2d. That when unnatural frequency of the pulse occurs at the very 
 commencement of the disease, and increases while the patient is under 
 judicious treatment, we may anticipate a speedy and fatal termination 
 of the case. 
 
 3d. That when the pulse is not very frequent, and gradually ap- 
 proaches the natural standard under treatment, and is very sensitive to 
 changes of posture, we may sometimes hope for a favorable termination, 
 — a restoration to comparative health. 
 
 4th. That an improvement in the other symptoms does not always 
 bring with it a uniform improvement in the pulse. Its frequency is 
 sometimes the last thing to disappear in cases which recover. 
 
CHAPTER XIV. 
 
 PAIN AS A SYMPTOM OF PULMONARY TUBERCULOSIS. 
 
 I. Pain a Common Symptom of Disease. 
 
 There are few symptoms more generally present in disease than 
 pain. It is this which renders sickness so trying and hard to bear. 
 And it is this which has led many good people to regard disease as a 
 visitation sent from Grod to punish mankind for their sins. This 
 opinion is based upon the idea that there is a connection between 
 punishment and suffering, as cause and effect ; but however associated 
 these two ideas may be in the mind, we are not willing to admit that 
 there is any logical connection between them. Physiologically con- 
 sidered, pain is designed to give us timely warning of whatever devi- 
 ations from a state of health may occur in any part of the system. 
 
 If there were no such thing as pain, many diseases would take 
 place without the individual having any knowledge of them. With 
 the exception of a certain class of dislocations, the mechanical incon- 
 venience of which gives timely notice of their occurrence, we should 
 be ignorant of almost all other accidents or diseases we are subject to 
 only for the pain that attends them. Hence pain, instead of being a 
 judicial punishment, physiologically considered, is a great blessing, 
 inasmuch as it prompts us to take efficient measures for the recovery 
 of our health as soon as we have been warned of its invasion. 
 
 Pain, therefore, as a symptom of disease, is of great use in assisting 
 the physician in finding out the seat and nature of many internal dis- 
 orders that afflict the body, but which, from their nature, position, 
 and obscurity, could not positively be determined without it. Take 
 as an example some of the obscure inflammatory disorders of the 
 chest, bowels, and brain, the management of which, though having 
 certain points in common, differs in each according to the difference 
 of their structure and functions. To enable us to determine the best 
 
 159 
 
160 PULMONARY TUBERCULOSIS. 
 
 course to be pursued in treating any given case, we must be able to de- 
 termine beforehand what is the precise malady we have to contend with. 
 
 In very many diseases the constitutional symptoms are so nearly 
 alike, that no very positive knowledge can be derived from that source ; 
 and, although there may be other symptoms of a particular kind de- 
 pending upon the form, position, and office of the different organs, 
 which, when discovered, leave no doubt upon the mind as to the nature 
 of the disease, yet they are too obscure in their primary stage, and 
 sometimes too slowly manifested, to answer the purpose of giving 
 timely warning for a correct and satisfactory diagnosis. Pain, there- 
 fore, presents itself as one among the very first symptoms of disease 
 in the suffering organization, and directs our attention at once to the 
 particular part where disease is working its fearful mutations. 
 
 But when we contemplate pain as a symptom of certain local lesions, 
 observation has taught us that it has to be taken with many qualifica- 
 tions. Thus we know that pain may arise in a particular part, either 
 from excessive impression on the nerves of sensation, or from excessive 
 sensibility of these nerves. When pain arises from internal disease, 
 it is mostly from the latter cause ; but it is not uncommon to find 
 them combined, as when a tumor presses upon a part morbidly sen- 
 sitive. The most frequent causes of pain, however, are inflammations, 
 certain vascular excitements, which are nearly allied to it, and primary 
 exaltation in the nervous functions. 
 
 As inflammation is only one of the causes of pain, so the pain 
 present in inflammation is not always a sure index of its extent or 
 situation. Frequent and extensive inflammation of the bowels, liver, 
 and lungs have been known to occur, producing but very little if any 
 pain. It also frequently happens that pain is not confined to the 
 location of the part affected, but is at a distance from it. We have 
 examples of this in some forms of hip-joint disease, where the chief 
 pain complained of is in the knee ; or in nephritis, where the pain is 
 in the neck of the bladder. 
 
 II. Pain as it manifests itself in Phthisis and other Chest- 
 Diseases. 
 
 To fully understand and rightly interpret pain as a symptom of 
 phthisis, it will be useful to contemplate it as it manifests itself in 
 other forms of chest-diseases. Practical observation has confirmed 
 
PAIN. 
 
 161 
 
 the fact that the pain of pneumonia and bronchitis is dull and diffused, 
 while that of pleuritis and pericarditis is sharp and lancinating. The 
 reason for this may be found in the fact that the pneumogastric nerve, 
 which supplies the bronchi and lungs, is not so sensitive as the spinal 
 and intercostal, that supply the pleura and pericardium. And again, 
 for this same reason, there is commonly more acute pain when the 
 costal pleura is inflamed than when the pulmonary pleura is the prin- 
 cipal seat of such serious disorder. 
 
 A further consideration of these different kinds of pain will estab- 
 lish the idea that they do not originate from the same source. The 
 dull, heavy, or aching pain of pneumonia is constant, and although it 
 may be increased by full inspiration, yet then it gives the feeling of 
 soreness under the sternum, rather than a sharp pain. In pleurisy, 
 on the other hand, the pain is sharp, extreme, and sometimes intoler- 
 able. Even in ordinary breathing it causes that sharp stitch of the 
 side, that sudden catching of the breath, which is regarded as so 
 characteristic of pleuritis. 
 
 When the attack of pleuritis is very acute, the patient is often com- 
 pelled to hold his side to lessen its intensity, by restraining the 
 motions of the chest, and, thus placed in opposition to the sensation 
 which prompts the act of respiration, this sharp pain may cause such 
 voluntary restraint of these acts as to bring the patient to the very 
 verge of suffocation. It is under such circumstances that the breath- 
 ing becomes partial, and the sufferer, whom pain compels to breathe 
 only with the diaphragm or with one side, will perform this sup- 
 plementary respiration so well that he is completely free from pain, 
 although the inflammation may be still in progress and matter accu- 
 mulating with great rapidity in the cavity of the chest. 
 
 I recently met with a very interesting example of this kind. It 
 was that of a lad, aged fifteen. From exposure to wet and cold just 
 after a severe attack of measles, he had what his physician called the 
 lung-fever. Not recovering from this malady as fast as his parents 
 thought he should, I was invited to see him. He had now been ill 
 for four weeks. His pulse was one hundred and twenty per minute 
 in the sitting posture, and respiration forty ; tongue moist and clean ; 
 skin warm and very moist ; urine scanty and highly colored ; appetite 
 good, and bowels regular ; countenance pinched, with a bright hectic 
 flush upon the cheeks ; chills and fever every evening ; cough and 
 
162 PULMONARY TUBERCULOSIS. 
 
 mucous expectoration ; complained of no pain in the chest, and, so far 
 as I could learn, never had any during his illness ; mind cheerful, and 
 he rested well at night when under the influence of morphine. 
 
 On examining the chest, the following physical signs were elicited : 
 Inspection showed an inequality in the size of the two sides, the right 
 being larger than the left, and the intercostal spaces in its lateral and 
 inferior portion more distended than natural, giving when pressed a 
 distinct sense of fluctuation ; the respiratory movements were also 
 unequal : in the right side they were suspended, in the left augmented. 
 On the right side percussion yielded a dull sound from its base to the 
 summit, while on the left it was somewhat clearer than in health. 
 Auscultation elicited no respiratory sounds in the right, while in the 
 left they were increased. Loud mucous rhonchi were heard along the 
 track of the larger bronchi. The heart was laboring prodigiously, 
 and its position appeared to be somewhat altered, the apex striking 
 against the fourth intercostal space, and the mitral sound being heard 
 more clearly at the second. 
 
 From the above symptoms and physical signs the diagnosis was 
 pronounced : antecedent pleuritis and its sequence, — empyema. 
 
 He was ordered opiates, tonics, and a nutritious diet. At my 
 second visit, three days afterward, paracentesis was proposed, but this 
 was declined by the patient and his parents. Fortunately for the 
 patient, about ten days from my second visit the abscess pointed in 
 the fifth intercostal space, and was punctured just below the nipple, 
 discharging a large quantity of semi-purulent matter. From this 
 time he gradually improved in health, and ultimately recovered, with 
 his right lung very seriously damaged by the pleuritic disease. 
 
 The attending physician, I learned, had been very careless in his 
 examination of the patient's disorder, never once percussing or auscul- 
 tating the chest to ascertain its true condition. Indeed, he told me, 
 with an air of superior gravity, that he had no faith in the physical 
 signs ; depended altogether on the general symptoms in making out 
 his diagnosis of chest-difficulties, and, as the patient had never com- 
 plained of pain in the side, did not suspect the existence of pleuritis. 
 
 Cases like this are pregnant with instruction and warning. They 
 teach the importance of a careful physical exploration of the chest 
 in all cases where there are the slightest symptoms of lung or cardiac 
 trouble. It is true, the general symptoms may point out the chest as 
 
PAIN. 163 
 
 the seat of the disease, but its precise location and its nature can only 
 be determined by the physical signs. In this case, one of the most 
 marked symptoms of pleuritis was absent,— -pain; yet if the physical 
 signs had been interrogated at the commencement, they would have 
 given a direct clue to the nature of the malady, and proper treatment 
 could have been instituted and much subsequent suffering avoided. 
 
 But let us return from this digression. Pain in the chest, con- 
 sidered as a symptom of phthisis, is not of much value in a diagnostic 
 point of view. Some writers maintain that it is almost always present, 
 while others declare that the great majority of patients are not mate- 
 rially annoyed by it. We can very readily believe the latter, when 
 we reflect that, with the exception of the brain and spleen, the lungs 
 are the most insensible organs in the body. And we have just seen 
 how a large collection of matter may form in the chest, and press upon 
 them in such a manner as to prevent them from performing their 
 proper functions, and yet the individual complain of no pain, or of 
 not sufficient to lead us to suspect such extensive injury. I have 
 occasionally met with extensive tubercular disorganization of the lungs, 
 and yet the patient has complained of little or no pain in the chest. 
 Drs. Bennett and Morton have both recorded cases of this kind. Dr. 
 Morton mentions the case of a woman who died of a hepatic affec- 
 tion, and on post-mortem he found nearly the whole of the superior 
 lobes of both lungs destroyed by tubercular disease, and yet she had 
 never complained of pain or even uneasiness in the chest. Patients 
 thus affected often express themselves as greatly astonished when 
 you explain to them the nature of their disorder. " It cannot be 
 possible," said a young man to me one day, " that my lungs are in 
 the condition which you have described. I know I am a little short 
 of breath when I attempt to walk fast, and cough some in the morn- 
 ing when I rise, but my voice is good. I have no pain in my chest, 
 and if it were not for this sense of weakness I feel when I attempt to 
 exercise, I am as well as I ever was." Poor fellow ! he died in four 
 months after this without scarcely having suffered a pain. 
 
 But such exemption from all pain in pulmonary tuberculosis is not 
 common. Most individuals, sometimes during the progress of the 
 disorder, will complain of more or less pain in the chest. Frequently 
 it comes on at the commencement of the disease, causing annoyance 
 throughout its whole course. In other instances it may be deferred 
 
164 PULMONARY TUBERCULOSIS. 
 
 until the tubercular affection has made considerable progress, when it 
 may suddenly attack the patient, and produce the most intense suffer- 
 ing. When it assumes this character, that is, when it is very acute, 
 comes on suddenly, is located low down in the side, and is increased 
 by full respiration, it is generally indicative of intercurrent pleuritis ; 
 when just under the mammary region, it will commonly be found to 
 depend either upon congestion or pneumonia. But when it depends 
 alone upon tubercles in the superior part of the lungs, it will be located 
 just under the clavicle, extending even to the shoulder or scapula. I 
 have seen instances where it was confined exclusively to the shoulder. 
 The character of the pain, when confined to the parts just named, is 
 analogous to that complained of by individuals suffering under a mild 
 form of rheumatism ; it is never intense, like that of pleuritis. Indeed, 
 the pain of phthisis is sometimes quite migratory in its character, 
 wanderiog even to distant parts of the system, and rendering the 
 patient very miserable by its cruel freaks. 
 
 The practical lesson to be deduced from the character of pain, as 
 it is presented to our view in phthisis, is, that when very mild, amount- 
 ing to nothing but a disagreeable uneasiness, it is a symptom of little 
 importance ; but, on the other hand, when it is fixed and very acute, 
 it is a circumstance of great moment ; it is usually an outstanding 
 sign of intercurrent inflammation, which demands our most serious 
 attention. These intercurrent inflammations are the most serious 
 lesions that complicate this fatal malady. If it were not for these, 
 pulmonary tuberculosis would be an almost painless disorder, and would 
 more frequently result in recovery. x\nd that physician will be the 
 most successful in treating it who promptly meets and overcomes all 
 those intercurrent disorders, which constitute so marked a feature of 
 the disease in our climate. And medical science is not destitute of 
 instrumentalities for the accomplishment of these ends, if they are 
 carefully studied and faithfully applied. 
 
CHAPTER XV. 
 
 DYSPNCEA AS A SYMPTOM OF PHTHISIS. 
 
 There are few things connected with pulmonary tuberculosis more 
 distressing than dyspnoea; even when quite moderate in degree its 
 effects are sometimes very exhausting, if continued any great length of 
 time ; and when it comes on suddenly, and is oppressive, it produces 
 the most inexpressible anguish, with such a feeling of impending dis- 
 solution that the most courageous mind will quail beneath its power. 
 The constrained posture, the anxious expression of the countenance, 
 the desperate exertion of all the muscles that can in any way aid in 
 the respiratory movements, manifest clearly the intensity of the feel- 
 ing, which to some individuals is equal to the most acute pain. 
 
 I. Causes of Dyspnoea in Phthisis. 
 
 During this disorder dyspnoea may be produced by any cause which 
 may derange any one or more of the several parts that are concerned 
 in the function of respiration ; thus, the reduction of the vital capacity 
 of the lungs by tubercular deposits may induce it in such a slow and 
 imperceptible manner that the patient will not feel any inconvenience 
 from it, only on occasions when called upon to make some extra phys- 
 ical exertion. 
 
 Again, it may be caused by intercurrent pneumonia, pleurisy, per- 
 foration of the pleura, emphysema, oedema of the lungs, obstructions of 
 the bronchia, and by all of those lesions of the nervous system which 
 subvert the harmony that exists between the lungs and those great 
 nervous centres that control the respiratory movements ; in fact, all 
 those causes which prevent the proper oxygenation of the blood, even 
 in a moderate degree, will often produce dyspnoea. When any one of 
 the causes just mentioned interferes with the proper action of the air 
 on the blood, the peculiar feeling which induces the respiratory move- 
 ment not being satiated, calls for a full and quick repetition of the 
 
 165 
 
166 PULMONARY TUBERCULOSIS. 
 
 function, and if the interference still remains, the respiration will 
 continue to be more or less hurried and forced, until the sensation is 
 reduced to the standard of unconsciousness. 
 
 I have often met with phthisical patients who did not appear to be 
 sensible of any dyspnoea, while at the same time it was apparent on 
 the most superficial inspection, and I have frequently been at a loss 
 how to account for it. A young man once tottered into my office, 
 nearly out of breath, to ask for advice. When I called his attention 
 to his hurried breathing, and several other symptoms of phthisis, he 
 declared most positively that he had no trouble in breathing, and that 
 he believed his lungs were perfectly sound. 
 
 Perhaps we may account for the want of disagreeable sensation in 
 $4s instance by the supposition that the feeling of dyspnoea depends 
 upon the condition of the mind, for daily observation teaches us that 
 while some patients are exceedingly sensitive to the slightest injury 
 of -tjieir respiratory organs, others are brought to the verge of suffo- 
 cation before any complaint of oppression is made. How often is it 
 the case on post-mortem that a whole lung is found disorganized, yet 
 during life tfye individual has complained of no pain in the chest or 
 difficulty in breathing, while in other cases a very trivial lesion has been 
 attended with severe pain and the most distressing dyspnoea ! Some 
 years since I had a very marked example of this kind in my practice. 
 
 The patient was a young woman, aged nineteen. She had been ill 
 six months when I was called |to see her, during which time she had 
 suffered from cough, expectoration, loss of appetite, pain in the chest, 
 and difficulty in breathing ; the latter appeared to be the paramount 
 symptom. Her physician had been treating her for asthma. Percus- 
 sion and auscultation revealed limited tubercular disease in the supe- 
 rior lobe of the left lung. She succumbed to the malad}- in four 
 months from my first visit, and on post-mortem, with the exception 
 of a small cavity in the lobe of the lung just mentioned, and a slight 
 redness of the bronchial mucous membrane, the organs of respiration 
 were found to be not seriously affected. Throughout the entire course 
 of her disorder she suffered more from dyspnoea than anything else. 
 
 This patient was an individual of a highly nervous temperament ; 
 and it is very probable that these severe paroxysms of dyspnoea may 
 have been greatly promoted by some special pulmonary or spinal 
 neurosis, for we frequently meet with hurried and difficult breathing 
 
DYSPNCEA. 167 
 
 where there is no pectoral lesion to account for it. Here is an inter- 
 esting case in point : 
 
 In the fall of 1852 I was called to see Mrs. A. She had been ill 
 for three months. Her physician had given her up as a hopeless case 
 of pulmonary tuberculosis. She was an individual of a marked ner- 
 vous temperament, was twenty-five years of age, and the mother of 
 two children ; she had a hereditary title to phthisis, her mother havin^ 
 died with the disease. Her pulse was eighty in the sitting posture, 
 and respiration thirty-eight. Complained of great pain just under the 
 sternum, and at times had very severe paroxysms of dyspnoea, which 
 prevented her from lying down at night ; was troubled with a very 
 harassing cough, with mucous expectoration ; appetite not good ; bowels 
 irregular, sometimes relaxed and sometimes costive ; had no chills or 
 fever, but perspired some at night; urine scanty, acid, and high 
 colored ; tongue clean and moist ; Thompson's gingival margin was not 
 present ; had never had haemoptysis ; had emaciated much during the 
 last month ; expression of countenance gave evidence of great suffering ; 
 mind very gloomy, — expressed a desire that death would soon termi- 
 nate her misery. On a physical exploration of the chest, nothing 
 abnormal was elicited but mucous rhonchi. On percussing the spine 
 from the first to the eighth dorsal vertebra, it produced the most 
 intense pain at the location complained of, just under the sternum, 
 and brought on a severe fit of coughing and dyspnoea which lasted for 
 some minutes ; the menses were regular but scanty. 
 
 The diagnosis was spinal irritation, and the prognosis favorable. A 
 succession of small blisters was applied to the tender part of the spine, 
 and one of the following pills was given every six hours : 
 
 B Ext. cannabis indicae, 3ss ; 
 
 Quiniae valerian., 
 
 Ext. Scutellariae, aa 3j- — M, 
 Fiat in pil. No. xxx. 
 
 Under this treatment all her distressing symptoms gave way, and in 
 two months she regained her usual health. She has had four children 
 since, has never had any return of the spinal irritation, and is quite 
 free from any pulmonary trouble. 
 
 During my medical experience I have occasionally met with cases 
 of this kind. With proper care they are easily made out. The pain 
 
168 PULMONARY TUBERCULOSIS. 
 
 and dyspnoea come on mostly in paroxysms, and can be instantly pro- 
 duced by pressure upon the affected part of the spine. The slightest 
 pressure will sometimes cause the patients to scream aloud, and jump 
 from their seats as if they had received a shock of electricity. The 
 pain is also very excruciating and the dyspnoea very extreme, and, while 
 it lasts, out of proportion with every other symptom, and the entire 
 absence of any physical sign of tubercular disease will render the 
 diagnosis obvious. 
 
 II. The Peculiar Character of Phthisical Dyspnoea. 
 
 The feeling to which we apply the term dyspnoea, as it occurs in 
 phthisis, does not consist so much in difficulty or obstruction of 
 breathing, as it does in a peculiar sensation of breathlessness, — an im- 
 perative demand for air. This want of air has been used by some 
 physicians as a means of testing the condition of the lungs. Thus, a 
 person whose lungs are free from tubercles can hold his breath much 
 longer than one whose lungs are occupied by them. The mode of 
 applying this test is as follows : Immediately after the individual has 
 taken a full inspiration, let him hold his breath, and commence to 
 count numbers during the time. A person whose breathing is habit- 
 ually slow, and whose lungs are in a state of health, can continue to 
 count for forty-five seconds without taking breath, while one whose 
 lungs are diseased often cannot keep on for twenty seconds. But 
 this test is by no means sure. It is liable to the same objections as 
 the spirometer. It is not so much a test of the capacity and condition 
 of the lungs, as it is of the strength of the muscles of respiration. 
 So long as these maintain their integrity, an individual of an indom- 
 itable will, although his lungs may be considerably affected with 
 tubercles, may persist in holding his breath as long as many persons 
 whose lungs are in perfect health. 
 
 Dyspnoea, when connected with prolonged respiratory murmur of a 
 high pitch and marked dullness on percussion, is a never-failing symp- 
 tom of pulmonary tuberculosis. As a general thing it commences at 
 a very early stage of the disease. Dr. Edward Smith says that he 
 has marked its presence before the physical signs revealed the exist- 
 ence of any tubercular deposits in the lungs. I have noticed several 
 cases of this kind, but commonly, in the first stage of the disorder, it 
 is so slight that it is seldom noticed or complained of by the patient. 
 
DFSPNCEA. leg 
 
 Its progress is usually in harmony with the pulmonary lesion ; and 
 unless the tubercular disease is complicated with pneumonia, pleurisy, 
 emphysema, bronchitis, or perforations of the pleura, it is seldom ex- 
 treme. Indeed, it seldom reaches that degree of severity that it does 
 in some forms of heart-disease. I was particularly impressed with 
 this fact by seeing an individual die with heart-clot. The dyspnoea 
 was of the most appalling kind, and the exclamations of the patient 
 for air were agonizing beyond all description. I never met with but 
 one case of phthisis that could in any way compare with it, and that 
 was complicated with perforation of the pleura. 
 
 M. Louis says that in all the cases that fell under his observation 
 dyspnoea was seldom very extreme ; and that he never met with more 
 than three instances where the patient was compelled to lie with the 
 head much elevated, or to retain a sitting posture. " In a certain 
 number of cases," he says, " dyspnoea was only sensible several months 
 after the origin of the cough. Most frequently it commenced with 
 it ; it even sometimes existed anteriorly (in one-tenth of the cases), 
 and when this occurred it was coincident with haemoptysis, which had 
 also preceded the other symptoms. Under these circumstances, the 
 dyspnoea *and haemoptysis were probably not symptoms preceding 
 tubercular disease in the lungs, but the first indication of its existence. 
 Perhaps this was equally the case when haemoptysis was present ; but 
 that it was so is far from being demonstrated, for many patients had 
 their breathing more or less affected in infancy, and it was impossible 
 to date the origin of phthisis from a period so remote ; for out of 
 these examples, which formed one-ninth of the whole, as great a num- 
 ber had attained the age of fifty as among those whose dyspnoea had 
 coincided with the first symptom of the disease."* 
 
 III. Medical Treatment of Dyspnoea. 
 
 When a tubercular patient is suddenly attacked with dyspnoea, 
 we should consider it as a very grave symptom, and immediately 
 institute a careful examination of his lungs that we may ascertain 
 its true cause, and prescribe promptly such therapeutics as will meet 
 the wants of the case. When it occurs from perforation of the pleura, 
 the case is indeed a most hopeless one, but still we should not be 
 
 * Louis on Phthisis, page 185. 
 
170 PULMONARY TUBERCULOSIS. 
 
 deterred from the use of means even in this instance, for individuals 
 have been known to live for months in comparative comfort, even 
 after this most fearful accident. Opium in large doses, and counter- 
 irritants, will sometimes accomplish wonders. Several years ago I 
 attended a lady who was suffering from pulmonary tuberculosis. 
 The disease was very mild in its character, and at times she was quite 
 comfortable. One morning, just after rising from a tolerable night's 
 repose, she was suddenly attacked with the most alarming dyspnoea. 
 Her friends thought she would survive but a few moments. I was 
 sent for immediately. I had to ride some three miles to her home, 
 and when I arrived I found her almost pulseless ; skin cold, and 
 bathed with the most profuse perspiration ; countenance blanched, 
 lips purple, eyes widely protruding, nostrils dilated, respiration very 
 difficult, with all the physical signs of a perforation of the pleura in 
 the right side. Counter-irritation was applied to the affected side, 
 and a large teaspoonful of equal parts of the tincture of opium and 
 tincture of capsicum was given every hour, with marked symptoms of 
 improvement. After six hours, reaction was pretty fully established, 
 and the following was prescribed : 
 
 R Pulv. opii, gr. x ; 
 
 Pulv. camphorae, 9i. — M. 
 Fiat in pil. No. x. 
 SlG. — One pill every four or six hours, as occasion may require. 
 
 By the use of these pills, mild counter-irritants, tonics, and a sus- 
 taining diet, she was made comfortable, and survived the perforation 
 nearly six months. The dyspnoea was always the paramount symptom 
 during the remainder of her life. 
 
 Sometimes emphysema is associated with pulmonary tuberculosis, 
 and patients thus affected are frequently subject to the most distress- 
 ing paroxysms of dyspucea. The diagnosis and treatment of such 
 cases are the most difficult and annoying that we are called upon to 
 manage. Indeed, I have met with cases where, from the general 
 symptoms and physical signs, it was impossible to make out even a 
 probable diagnosis. It is true that pathological research teaches us 
 that when the lungs are emphysematous, they are dilated and rarefied ; 
 in tuberculosis, they are contracted and condensed. Hence, in em- 
 
DYSPNOEA. 171 
 
 physema we have increased resonance on percussion, and on auscul- 
 tation feeble respiratory murmurs; while in tuberculosis there is 
 dullness on percussion, and very little, if any, diminution of the 
 respiratory murmurs, particularly in the first stage of the disease. 
 Thus, when tubercles are deposited in the part of a lung that is 
 emphysematous, their tendency is to diminish its capacity for air and 
 render its resonance less clear, while they do not materially alter the 
 character of the murmur. We can, therefore, see how a considerable 
 deposit of tubercle may take place in an emphysematous lung without 
 producing any particular deviation in the normal sounds of the chest. 
 
 These remarks apply to the first stage of tubercular deposits, and 
 when they are limited in extent. When they have passed into the 
 stage of softening, the physical signs will be more pronounced. The 
 chief physical sign of the stage of softening is humid crackling. This 
 is usually heard at the summit of the lung, and very rarely in any 
 other part. If there has been any obscurity about the case, this will 
 dispel it. Humid crackling at once pronounces the disease tubercular. 
 It does not, under any circumstance, belong to emphysema. 
 
 In the summer of 1871 1 was called to see Mrs. C, aged thirty-five. 
 Her physician and friends supposed her to be in the last stage of pul- 
 monary tuberculosis. She had bee.n ill for four months ; referred 
 her illness to a severe cold which she took when her menses were 
 upon her; they were suddenly checked, and have not appeared 
 since. Her disease was ushered in by chills, fever, pain in the back, 
 head, and limbs, loss of appetite, weight in the chest, and a dry, 
 hacking cough. On the fifth day of her attack, during a severe 
 paroxysm of coughing, she expectorated nearly a teacupful of blood. 
 Since then she had had several attacks of haemoptysis, but quite 
 moderate in amount. These attacks had always been preceded by 
 severe paroxysms of dyspnoea, which would last for a day or two, 
 until the bleeding occurred, when they would gradually abate ; but 
 she had more or less dyspnoea at all times. She had a hereditary 
 title to phthisis, her mother having died with the disease. 
 
 At the time of my visit she was having a very severe paroxysm of 
 dyspnoea. Her face was blanched, countenance expressive of great 
 anxiety, lips purple ; the respirations numbered thirty-six per minute, 
 and the pulse one hundred and one ; hands and feet cold, and the skin 
 bedewed with perspiration. I attempted to auscultate the chest, but 
 
172 PULMONARY TUBERCULOSIS. 
 
 it so exasperated the dyspncea that I was compelled to desist. As 
 the dyspnoea appeared to be the paramount suffering, I prescribed for 
 it alone, according to the following formula : 
 
 R Chlorodyne (English), 3iss; 
 Liq. anod. Hoffmani, 3ii; 
 Aquae camphorse, §vi. 
 SiG. — A tablespoonful every hour. 
 
 The next morning when I called I found my patient much im- 
 proved ; three spoonfuls of the medicine had so mitigated her dys- 
 pnoea, that for the first time in three weeks she was enabled to He in 
 bed and take a comfortable sleep. 
 
 At this visit I found her pulse eighty-seven per minute, and respira- 
 tion twenty-five ; tongue slightly coated ; Thompson's gingival margin 
 not present; cough troublesome; expectoration muco-purulent ; com- 
 plained of being very weak ; had emaciated rapidly during the last 
 month ; bowels constipated ; urine scanty and high colored ; digestion 
 not good, and the mind exceedingly gloomy. 
 
 The physical signs were rather obscure. On inspection, the chest 
 appeared to be symmetrical, and the expansion of the two sides full 
 and equal. On percussion it yielded a clear resonance, with the 
 exception of just under the clavicle of the right side, where there was 
 considerable dullness. On auscultation, there was distinct sonorous 
 rhonchus over the bronchial region of the left side, and considerable 
 diminution in the respiratory murmurs. On the right side the respi- 
 ratory sounds were normal. The cardiac sounds were natural, with 
 the exception of a slight blowing sound in the region of the mitral 
 valves, which was the result of an attack of rheumatism from which 
 she suffered ten years ago. A subsequent examination of the sputum 
 with the microscope showed no withered cells, shriveled nuclei, or 
 pulmonary fibres. 
 
 Of the physical signs, there appeared to be but one that indicated 
 the existence of tuberculosis, and that was the dullness on percussion 
 under the clavicle. A careful analysis of this proved it to be more 
 apparent than real. It existed entirely by comparison. The emphy- 
 sema was located exclusively in the left lung, hence its resonance was 
 somewhat clearer on percussion than natural, while that of the right 
 was nearly normal. 
 
DYSPNCEA. !73 
 
 I was therefore rather inclined to the opinion that the disease was 
 not tuberculosis, but chronic bronchitis, with emphysema of the left 
 lung as its consequence ; and a favorable prognosis was given. 
 
 The following treatment was instituted, and a succession of small 
 blisters were to be applied over the bronchial region, and a teaspoon- 
 ful of the following given three times a day, before each meal : 
 
 R Hyd. chloridi corrosiv., gr. i ; 
 Ammoniae hydrochlor., £ii ; 
 Aquae font., %iv. — M. 
 
 As a tonic, the following was ordered : 
 B Quinia sulph., 9ii ; 
 Strychniae, gr. i; 
 Ext. gentianae, 3 1 - — M. 
 Ft. in pil. No. xxx. 
 SlG. — One pill three times a day, after each meal. 
 
 Her diet was to be nutritious, and the sanitary surroundings all 
 particularly attended to. If dyspnoea proved troublesome, she was 
 to take the medicine prescribed on first visit. 
 
 Under this treatment her improvement was very marked, for in 
 'two weeks she was able to walk to my office, more than a mile, and 
 at the present writing is in the enjoyment of good health. I should 
 remark that previous to my attendance her treatment had been con- 
 ducted upon the supposition that her disorder was pulmonary tuber- 
 culosis ; cod-liver oil, elixir of calisaya, iron, and the hypophosphites 
 of lime and soda had been given in abundance, with a gradual 
 increase in the severity of all her symptoms. 
 
 12 
 
CHAPTER. XVI. 
 
 i 
 
 EMACIATION AS IT OCCURS IN PHTHISIS. 
 
 I. A Prominent Symptom of the Malady. 
 
 Of all the constitutional symptoms of pulmonary tuberculosis, there 
 is none so prominently and distinctly marked as emaciation. How 
 often is it the case that we see an individual gradually lose flesh, with- 
 out our being able to account for it until suddenly other symptoms of 
 phthisis will appear, so pronounced that none need doubt the nature 
 of the disease. A careful inquiry into the history of nearly every 
 case of this disorder will show that, from the very commencement, 
 there was a marked diminution of flesh and weight. It is true, 
 phthisical persons often emaciate rapidly from adverse circumstances, 
 especially where the disease is slow in its progress, and yet, by im- 
 proved circumstances, such as leaving an unhealthy occupation, 
 removing to a better climate, abandoning a vicious habit, or im- 
 provement in diet, it may pass away, and the patient once more 
 regain his normal weight. But, as a general thing, emaciation is 
 so constant an attendant upon this disorder that I always expect to 
 find it in every case. And as the malady passes to a final termina- 
 tion, it usually increases until it reaches a very extreme degree. 
 Indeed, there is no disease in which it is so great as in this. 
 
 The wasting process appears to be the most strongly marked in the 
 adipose cellular membrane and muscular tissues ; indeed, every part 
 of the body is more or less emaciated, excepting the liver and heart, 
 and these are found commonly much smaller than natural. The 
 brain, nerves, genital organs, spleen, pancreas, and glands, although 
 they exhibit no very marked signs .of emaciation, yet, if carefully 
 weighed, will generally fail to come up to the normal standard. The 
 blood-vessels usually appear smaller, but this, no doubt, is owing 
 to their having been accustomed to carry only a small quantity of 
 fluid, in consequence of the wasting nature of the disorder ; for it has 
 174 
 
EMACIATION. I75 
 
 been clearly demonstrated that trie blood also participates in the 
 general emaciation, and that its quantity is very much less than in 
 health. 
 
 The emaciation, however, from phthisis is not only a diminution of 
 all the fluids of the body, but an actual loss of structure, by which its 
 weight is reduced ; and it has been found that, when it reaches its 
 extreme degree, death may be looked for at any moment. The 
 minimum weight to which an adult body is capable of being re- 
 duced may be placed at sixty pounds. When it reaches this point 
 the light of life flickers very feebly in its torch ; the slightest breath 
 may extinguish it forever. 
 
 II. Emaciation not always a Progressive Symptom of Pul- 
 monary Tuberculosis. 
 
 In some of the more chronic forms of this malady, individuals will 
 occasionally hold their flesh until almost the last. Then again, as we 
 have already remarked, they will for a time lose it very rapidly, and 
 regain it almost as soon. This was the case with a patient of mine 
 whom I had under my care some years since. She was a Mrs. A., 
 aged thirty-six years. Had been married ten years ; was the mother of 
 three children. At the time she came under my care she had a con- 
 siderable cavity in her left lung ; the right lung appeared free from 
 disease. Her digestion was good ; she commonly rested well at night ; 
 had but little hectic, and was able to attend to her household duties, 
 which were not numerous. In health, her weight was one hundred 
 and thirty-five pounds. After suffering with marked symptoms of 
 phthisis for four months, she lost twenty-five pounds. In the suc- 
 ceeding four months, by the use of cod-liver oil, quinia, iron, and a 
 generous diet, she gained twenty-two pounds. In this way she con- 
 tinued to gain and lose flesh for more than two years before her 
 malady proved fatal. 
 
 Here is a patient of mine, James B., aged twenty-five years, of 
 the nervo-sanguineous temperament; has a hereditary title to phthisis 
 pulmonalis, his father and mother both having died with the disease. 
 He has had cough and expectoration for three years ; in the winter 
 and spring they are always the worst. During the two seasons just 
 mentioned he says his weight becomes very much reduced, while in 
 summer and fall it returns to its ordinary standard, which is one 
 
176 PULMONARY TUBERCULOSIS. 
 
 hundred and forty-two pounds. He informs me that this spring 
 his weight has never been so low (one hundred and twenty), and he 
 has never felt so weak. A careful physical exploration of the chest 
 shows tubercular disorganization of the superior lobe of the right 
 lung, with commencing disease in the left. His general symptoms 
 are anything but promising. The tubercular diathesis is very marked : 
 Thompson's gingival margin is very clearly defined upon the gums of 
 the upper and lower jaws, and hectic fever is quite annoying. Any 
 further reduction in this patient's weight, as the summer comes on, 
 will be a bad omen, as his weight has always increased during that 
 season ; it will mark progress in the local lesion and in the constitutional 
 malady. 
 
 It may, therefore, be set down as a general rule, that all temporary 
 changes in the weight of a phthisical patient are indicative of activity 
 or indolence of the tubercular disease in the lungs. I am free, how- 
 ever, to admit that other causes besides those mentioned may induce 
 emaciation, particularly loss of appetite, diarrhoea, and profuse night- 
 perspirations. On the other hand, I have occasionally seen indi- 
 viduals maintain their weight under favorable circumstances, while 
 the pulmonary malady loses nothing of its activity. This was the 
 case with a patient of mine, George McC. He was a telegraph oper- 
 ator : a class of individuals, by the way, very subject to pulmonary 
 tuberculosis. He suffered with the disease for more than two years. 
 At the time of his death there was very little diminution in his weight, 
 although post-mortem showed both lungs completely disorganized from 
 large tubercular excavations. And, what was remarkable, the day 
 before his death he sat at his operating-table nearly all day, sending 
 and receiving messages ; his endurance was wonderful. 
 
 While phthisical patients sometimes maintain their weight and 
 strength until the very last, it is quite astonishing how rapidly they 
 will occasionally emaciate. I had recently a striking exhibition of 
 this in the case of Mary B., who came to me with a small tubercular 
 cavity in the superior lobe of the left lung. Previous to her visiting 
 me she had lost fifteen pounds in weight. In two months, under the 
 use of cod-liver oil, quinia, and iron, she regained what she had lost, 
 and we began to entertain hopes of her recovery ; but suddenly, 
 without any apparent augmentation of her pulmonary disorder, she 
 commenced to lose strength, and emaciated with such fearful rapidity 
 
EMACIATION. I77 
 
 that in ten days she was the merest shadow of herself, and in a few 
 more she ceased to breathe. 
 
 Intimately connected with the emaciation of phthisis is a certain 
 degree of anaemia, the combined influence of which is rarely met with 
 in any other malady ; in one sense it may be regarded as pathognomonic 
 of this. I refer to a peculiar expression of the countenance, which, 
 when once seen, will never be forgotten. Thus, from the emaciation 
 of the face, the nose becomes sharp and drawn ; the cheeks are prom- 
 inent and red, and appear redder by contrast with the surrounding 
 paleness ; the conjunctiva of the eye is of a shining white, or with a 
 shade of pearly blue ; the cheeks are hollow ; the lips are retracted, and 
 seem moulded into a bitter smile. This peculiar condition of the 
 physiognomy belongs to an advanced stage of the disorder ; it is very 
 rarely seen at the commencement, and then in subjects who are natu- 
 rally very spare in flesh. 
 
 III. What is an Individual's Normal Standard of Weight? 
 
 In the present state of our knowledge this question cannot be 
 positively answered, but we think we have a rule which should govern 
 in the case ; one that is sufficient for all practical purposes : namely, 
 " That the physiological weight is regulated by the height of the 
 individual." Dr. Hutchinson originated this rule, and, according 
 to his observation, a person five feet high should weigh a hundred 
 and twenty pounds ; one five feet four inches, a hundred and forty 
 pounds ; at five feet eight inches, a hundred and sixty pounds ; and 
 at six feet, a hundred and eighty pounds ; thus calculating an addition 
 of about five pounds' weight for every additional inch in height. 
 
 "It is scarcely possible," says Dr. Lawson, "to make a rule so 
 mechanical as the above applicable to the varying state of the human 
 organization, and especially in the early stage of phthisis, when the 
 changes are often so very slight ; but in the absence of more positive 
 data, it will be well to avail ourselves of every means which come 
 within the range of possibility, or which are capable, even with con- 
 siderable variation, of general application. In summing up the sub- 
 ject, Dr. Hutchinson states a more general rule, which is of especial 
 and easy application, and may be made available when the patient's 
 weight has not been previously known. In two thousand nine 
 hundred and seventy-six healthy males he found the average weight 
 
178 PULMONARY TUBERCULOSIS. 
 
 to be one hundred and fifty-five pounds ; while in seven hundred and 
 ten eases of tubercular disease it was reduced to one hundred and 
 eleven pounds in males and one hundred and four in females. These 
 facts are more important in their general than in their special appli- 
 cation, for while they clearly indicate the progressive diminution of 
 weight in tuberculosis, each case, nevertheless, must rest on its own 
 peculiarities."* 
 
 Dr. Thompson, in speaking of Dr. Hutchinson's rule, says, " This 
 calculation you will find sufficiently near the fact for ordinary pur- 
 poses. There are remarkable exceptions, however, to any general 
 law in reference to such standards ; great deviations in this respect 
 are consistent with health. One of the most striking examples is 
 that of Smith, the pedestrian, who at the age of about forty, with a 
 height of five feet five inches, weighs only one hundred and two 
 pounds, instead of the average of a hundred and forty-two as regis- 
 tered by Dr. Hutchinson. Nevertheless, Smith may be adduced as 
 an example of a healthy, energetic man. His stride is four feet two 
 inches to four feet four inches, and he has been known to walk twenty 
 miles in two minutes less than three hours. 
 
 " The circumstance of most importance in applying the question of 
 weight to diagnosis, is not the absolute weight, but the detection of 
 any change which may be in progress. With this view, you should 
 always endeavor to ascertain the greatest known weight of a patient ; 
 for no single fact is more frequently associated with the setting-in of 
 phthisis than a marked reduction in this respect. The common, and 
 in many cases stealthy, approach of consumption among the inmates 
 of prisons is often first detected by a progressive diminution of weight, 
 notwithstanding the influence of improved and regular diet."")" 
 
 In determining emaciation as a symptom of pulmonary tubercu- 
 losis, we must not trust to the patient's statement on the subject. 
 "We should examine the body, especially the arnis, and see if the skin 
 is more loose than it should be ; or trust to a pair of accurate scales. 
 If you wish to be very particular, you should have your patient 
 weighed very early in the morning, before breakfast ; for it has been 
 shown by Dr. Edward Smith that we usually weigh from one pound 
 
 * Lawson's Phthisis Pulmonalis, page 331. 
 
 f Thompson's Lectures on Consumption, page 167. 
 
 
EMACIATION. I79 
 
 and a half to two pounds more at eleven p.m. than at eight a.m. He 
 truly remarks "that the weight of the body depends upon the 
 amount of food and excretions contained within the body, of the 
 fluids in the circulation and in the tissues, of the more solid of the 
 soft tissues, and, lastly, of the heavy and comparatively unchangeable 
 bones. Hence, variation in any of these numerous sources will influ- 
 ence the total weight of the body. The error due to the food and 
 excretions may be almost removed by taking the weight of the body 
 before breakfast, and after faeces and urine have been passed ; but this 
 cannot be effected at any other period of the day." 
 
 Where my tubercular patients are able to be up and go out, I make 
 it a rule to have them weighed every fifteen days. In this way I can 
 determine with considerable certainty whether the disease is progress- 
 ing or receding. When, in spite of judicious treatment, the indi- 
 vidual continues to emaciate, we regard the prognosis unfavorable ; 
 when, on the other hand, the patient regains his strength and flesh, 
 the prognosis is more promising. 
 
 It has often been a question with some whether phthisical patients 
 ever entirely regain their- original weight ; that is, that which they 
 had before they were attacked with the pulmonary disease. I have 
 the history of three cases wherein the individual's weight was some- 
 what increased, while in many others it never attained its normal 
 standard. 
 
CHAPTER XVII. 
 
 VOMITING AS A SYMPTOM OF PHTHISIS. 
 
 I. The Origin of Vomiting in Phthisis. 
 
 This may be traced to a variety of causes, such as irritation of the 
 pneuinogastric nerve, congestion, inflammation, ulceration or softening 
 of the mucous membrane of the stomach, lesions of the kidneys and 
 brain. When it occurs from simple nervous irritation, as in coughing, 
 there is commonly no epigastric pain, the appetite is usually good, 
 and, when food can be retained, the digestion is easy. When it takes 
 place from lesions in the stomach, it is generally attended with more 
 or less anorexia, accompanied with severe gastric pains immediately 
 after eating. When it arises from organic disease of the kidneys, the 
 vomiting may be severe and persistent, but it is not commonly accom- 
 panied with gastric pains, and at times food may be taken with im- : 
 punity and easily digested. The diagnosis in this instance is not 
 difficult ; a chemical and microscopical examination of the urine will 
 make it plain. By neglecting this there is danger of falling into 
 serious errors of diagnosis and of instituting treatment which will be 
 of no benefit to the patient. 
 
 In my book of " Medical Fragments," I have the history of a 
 woman who, in addition to the usual symptoms of pulmonary tuber- 
 culosis, complained of weight in the epigastrium, with nausea and 
 vomiting, immediately after eating. The dejections from the stomach 
 were composed of undigested food, an acid fluid, mucus, and small 
 quantities of bile. The vomiting did not appeal' to be in any way 
 influenced by coughing. Her bowels were relaxed, mouth hot and 
 dry, tongue red and clean. As she complained of no difficulty in 
 urinating, I did not examine the condition of the renal organs as 
 carefully as I should have done, and did not, therefore, discover the 
 disease of those organs which was revealed by post-mortem. 
 
 As she continued to decline, the oppression and distress in the 
 180 
 
VOMITING. 
 
 181 
 
 epigastrium became more constant, and the vomiting more annoying 
 The mildest drinks were often retained but a few moments. For 
 many days previous to death she could retain nothing but a few drops 
 of the tincture of opium and gum-water ; vomiting and nausea con- 
 stituted her chief suffering. So completely did they mask all the 
 pulmonary symptoms, in the last stage of her disorder, that a friend 
 of mine, who had been invited to consult with me in the case, affirmed 
 most positively that her malady was altogether gastritis. The disease 
 was rapid in its course, proving fatal in three months from its com- 
 mencement. 
 
 Post-mortem revealed limited tubercular disorganization of the 
 superior lobe of the right lung, with some isolated deposits in the 
 superior lobe of the left. The bronchial mucous membrane was red, 
 and in some places slightly softened. The heart was smaller than 
 common, and its walls soft and flabby. The stomach was small ; its 
 mucous coat was red and injected, yet there was no softening or ulcer- 
 ation. The muscular coat, however, was much whiter than usual, and 
 in many places was raised in thick bands of four or six lines wide, 
 giving the walls of the stomach the appearance of a barred bladder. 
 With these exceptions it looked healthy. The mucous membrane of 
 the small intestines was healthy, with the exception of a few small 
 ulcers near the ccecum. The mucous membrane of the colon and rec- 
 tum was red, but showed no marks of disorganization. The mesen- 
 teric glands were rather voluminous, but healthy. The right kidney 
 was shrunken, granulated, and fissured ; its cortical substance was very 
 much wasted, and in microscopical examination many of the tubes 
 were found stripped of their epithelium, while some of the cells were 
 filled with fat. The left kidney was somewhat smaller than usual, but 
 exhibited no special marks of disease. 
 
 In the post-mortem of this case we were somewhat disappointed, 
 for we expected to find extensive lesions in the mucous membrane and 
 other structures of the stomach. Where such extensive nausea and 
 vomiting occur, persisting with an unyielding pertinacity in spite of 
 treatment, we commonly look for softening and ulceration of the mucous 
 membrane, induration and thickening of the walls of the stomach, 
 or cancer. But it is very evident that in this case the vomiting did 
 not depend upon the disease of the stomach alone, for this was not 
 great. The disorder of the kidneys obviously contributed much to its 
 
182 PULMONARY TUBERCULOSIS. 
 
 severity. There is a wonderful sympathy between the stomach and 
 kidneys. We have frequent illustrations of this in nephritis. Some 
 of the most obstinate cases of vomiting that I have ever met with 
 have in a great measure originated from this cause. I have on several 
 occasions known physicians to treat individuals for gastritis when it has 
 afterwards been clearly shown that the disorder was altogether renal. 
 
 I met with an interesting case of this kind in the practice of a 
 physician in a neighboring town. The patient was a young woman, 
 aged fifteen. She had been in failing health for three months. She 
 had never menstruated, but, during the time mentioned, had on two 
 occasions profuse hemorrhage from the nose. The first spell occurred 
 about three weeks, and the last about ten days, previous to my visit, 
 after which she had several attacks of vomiting every day. Her 
 physician had been treating her vigorously for gastritis, but it did not 
 yield ; the vomiting still continued. 
 
 At the time of my visit, her pulse was one hundred per minute ; res- 
 piration, thirty ; tongue clean and pale ; skin hot and dry, with large 
 purpuric spots upon the chest and arms. Bowels costive ; the urine 
 scanty and straw-colored. Pain in the back and limbs. The spine 
 tender to the touch, particularly in the region of the kidneys. Slight 
 oedema of the feet and legs. Countenance dull ; complains of pain 
 in the head, and does not rest well at night. Mind gloomy and dis- 
 turbed with the most fearful apprehensions. She also suffers at times 
 with palpitation of the heart, and, when examined with the stethoscope, 
 the bellows-sound is distinctly audible. She cannot lie on either side ; 
 for the moment this is attempted the nausea and vomiting are in- 
 creased in frequency and violence. Deep inspiration increases the 
 pain in the region of the kidneys. From the commencement of her 
 illness she has always experienced more or less trouble in urinating, 
 this being at times attended with considerable pain. 
 
 From the purpuric spots, the oedema of the feet and legs, the trouble 
 in passing urine, and the absence of any grave symptom of gastritis 
 save nausea and vomiting, I was led to suspect the existence of 
 granular disease of the kidney, which suspicion was confirmed by a 
 careful examination of the urine. Its specific gravity was 1012. 
 Heat and nitric acid produced albumen in considerable quantities. 
 Microscopical examination showed an abundance of uriniferous tubes, 
 fat-globules, and blood-cells. 
 
VOMITING. 183 
 
 By mild counter-irritation over the region of the kidneys, and the in- 
 ternal use of opium, quinia, strychnia, iron, and the acetate of potassa, 
 the vomiting was in a great measure relieved and the patient's comfort 
 greatly promoted. But she finally succumbed to the renal disease in 
 four months from my first visit. No post-mortem was allowed ; but 
 I was satisfied there was no organic disease of the stomach, and that 
 the nausea and vomiting were entirely the result of uraemic poisoning 
 and sympathetic action between the kidneys and the stomach. 
 
 II. The Vomiting of Phthisis confined mostly to the Last Stage. 
 
 When persistent vomiting occurs in pulmonary tuberculosis, it is 
 confined mostly to the latter stage of the disorder. Such, at least, is 
 the testimony of M. Louis. In cases of this kind he usually found the 
 stomach small in volume, the mucous membrane softened, with ulcer- 
 ation, and in some chance cases thickening of its walls. When these 
 organic changes were confined to the cardiac region, these symptoms 
 were always very mild, so much so as to excite but little attention ; 
 but, on the contrary, when they were situated mostly at the pyloric 
 region, the nausea and vomiting had always been the most distressing 
 and severe. When these changes take place in the gastric mucous 
 membrane during the progress of phthisis, they will generally be mani- 
 fested by epigastric pains, anorexia, nausea, vomiting, and thirst; and 
 in the great majority of instances no kind of food agrees with the 
 stomach, — even water is frequently rejected, — and so great is the 
 patient's dread of vomiting that he will for a long time resist the 
 cravings of thirst and hunger before he will take either drink or food. 
 
 As a diagnostic symptom of phthisis pulmonalis, vomiting has but 
 little significance. Its occurrence, however, is exceedingly annoying 
 to the patient, and in some instances assists in hurrying him out of 
 the world. I have often observed that those patients who have been 
 the rounds of quackdom and taken many of the vile nostrums that 
 are recommended in the newspapers as specifics for this disease, were 
 more apt to suffer from this source than those who have been treated 
 from the first by a scientific and judicious physician. And it is awful 
 to contemplate the amount of suffering these charlatans inflict upon 
 their deluded victims. The mortality from phthisis, in our judgment, 
 would be greatly lessened if all these unprincipled pretenders were 
 banished from the land, and their nostrums emptied into the sea. 
 
184 PULMONARY TUBERCULOSIS. 
 
 Again: I have observed that those phthisical patients who have 
 been in the habit of using ardent spirits, and have continued to use it 
 during their illness, were more apt to suffer from stomach-troubles 
 than those who abstained from it. And how could it be otherwise ? 
 No one can wonder at this when he contemplates the injurious effects 
 of that narcotic poison upon the stomach. When taken in health, 
 even moderately, it produces effects that are very nearly allied to in- 
 flammation ; this has been abundantly proved by Dr. Beaumont in his 
 experiments upon St. Martin. If in health the stomach is thus seri- 
 ously affected by the use of alcoholic stimulants, how much more in- 
 jurious must they be when taken in a disease like phthisis, when it is 
 incapable of withstanding such injurious impressions ! Some medical 
 writers appear to take especial pleasure in telling us that the lungs of 
 drunkards seldom contain tubercles. But they are very careful not 
 to mention the extensive lesions which are found in the stomach and 
 other vital organs. 
 
 Let me present for your inspection the stomach of a patient of mine, 
 who died a short time since with pulmonary tuberculosis. He had 
 used alcoholic stimulants moderately for some years, and continued to 
 use them during his illness, until his stomach would tolerate them no 
 longer. During the last six weeks of his life, epigastric pains and 
 vomiting constituted the most annoying symptoms of his disease. 
 
 The stomach, you will observe, is much smaller than common, and 
 its tissues are not so firm as we usually find them. Let us open it. 
 You see it contains nothing but a few tablespoonfuls of thin straw- 
 colored liquid, with a few flakes of mucus adhering to its inner coat ; 
 the mucous membrane, which presents a grayish-pink tinge, is quite 
 softened throughout its entire extent, and in several places is slightly 
 detached. 
 
 Near the smaller curvature, between the cardiac and pyloric orifices, 
 you discover a depression about an inch in diameter, around which 
 the mucous membrane is somewhat corrugated ; the corresponding 
 cellular coat is not much affected, but the muscular coat, throughout 
 the whole extent of the depression, has been entirely destroyed, and 
 has been replaced by a white semi-cartilaginous tissue, in which the 
 normal muscular fibres terminate. The submucous layer is softened 
 and very thin, particularly in the pyloric region. 
 
 The larger blood-vessels are more or less indurated, and indeed every 
 
VOMITING. 185 
 
 tissue of the organ presents various degrees of structural degeneration, 
 some of which are of recent origin, while others are of longer standing, 
 — unquestionably the result of drinking alcoholic stimulants as a 
 beverage. If phthisical individuals would keep their stomachs in 
 good working order, and avoid those unpleasant consequences which 
 result from derangement of this organ, they will do well to avoid 
 the use of alcoholic stimulants with scrupulous fidelity ; for I have 
 known even one day's moderate indulgence to produce gastric derange- 
 ment which required weeks to remedy. 
 
 III. Treatment of Vomiting as it Occurs in Phthisis. 
 
 When this is functional, depending upon distant irritation, our reme- 
 dies must be directed as much as possible to the subjugation of such 
 irritation and the soothing of the exasperated organ. Thus, we often 
 find the vomiting associated with cough : the patient vomits nearly 
 every time he coughs. Hence, any remedy that will relieve the cough 
 will mitigate the vomiting. Hydrocyanic acid and opium are our 
 chief therapeutics in this case. Opium in particular is indispensable. 
 It should be administered in grain-doses two or three times a day. 
 
 Dr. Chambers, in his recent work on "Indigestion," page 209, pre- 
 sents this case as a striking illustration of the good effects of opium in 
 the vomiting of phthisis, especially under the circumstances just named : 
 
 " B., aged about five-and-twenty, was placed under my care March, 
 1861. She had a large vomica in the upper lobe of the left lung, and 
 the greater part of the inferior lobe impervious with tubercles ; but she 
 had suffered very little from pulmonary symptoms, would not hear of 
 her being in consumption, and talked about going to dances in a low 
 dress as soon as she could get about again. But she was utterly pros- 
 trated on her bed by the constant vomiting of all she ate, and retching 
 when she ate nothing. The bowels were obstinately costive, and she had 
 taken as much as twelve grains of extract of colocynth without effect. 
 
 " I gave her opium, beginning with a grain, and augmenting it to 
 six grains daily. Then the vomiting ceased, and she recovered her 
 appetite and fondness for luxurious living. She ate twelve shillings' 
 worth of strawberries (in April) daily, and an immeasurable quantity 
 of brown bread and ice. Her bowels recovered their functions, and 
 she passed naturally-colored and formed stools in spite of the opium. 
 She slept naturally and easily, without excess or stupor. 
 
186 PULMONARY TUBERCULOSIS. 
 
 " She died in the summer, but was able to keep off her vomiting to 
 the last, by the help of opium. I think, however, she increased the 
 dose. So that her ending was made much more easy, and probably 
 postponed by it." 
 
 A very common form of vomiting in phthisis is that which occurs 
 during the evacuation of a large cavity ; the expectoration is so fetid, 
 and its odor so offensive, that it sometimes produces the most distress- 
 ing nausea and vomiting. I have at the present time a -young man 
 under my care who has a very large vomica in the right lung. The 
 smell and taste of the sputum are intolerable, and when expectorated 
 cause severe retching and vomiting. Various means have been 
 employed to mitigate these symptoms, without material benefit. The 
 following has been the most useful : 
 
 R Acid, carbolic, (cryst.), gr. iv ; 
 Glycerin., 
 
 Tinct. cinnamom., aa £i. — M. 
 Sig. — A teaspoonful every four hours. 
 Not unfrequently, vomiting in phthisis is the result of indigestion 
 depending upon impaired secretion of gastric juice, and is attended 
 with troublesome acid eructations and costive bowels. In this con- 
 dition of things I have generally found no prescription more beneficial 
 than the following : 
 
 R Bismuth, subnit., gss ; 
 Sodae supercarb., 5 1 ; 
 Sac. albse, §i; 
 Pulv. rhei, 5 1 - — M. 
 Sig. — A teaspoonful three times a day, after meals. 
 Sometimes the vomiting in phthisis depends upon subacute gas- 
 tritis. In this case counter-irritants are demanded : a succession of 
 small blisters over the epigastrium, or a few leeches occasionally applied 
 to the same region. The internal use of the nitrate of silver will 
 frequently prove useful when vomiting arises from this cause. It 
 should be prescribed in connection with opium, thus : 
 R Nit. argenti (cryst.), gr. v ; 
 
 Pulv. opii, gr. xx. — M. 
 Ft. in pil. No. xx. 
 Sig. — One pill three times a day, half an hour before meals. 
 
VOMITING. 187 
 
 When phthisis is associated with disease of the kidneys, there is often 
 great loathing of food, with pain in the epigastrium, and other signs 
 of indigestion. Occasionally the mere suggestion of food or the sound 
 of the dinner-bell are enough to bring on an attack of retching. I 
 know ,of no combination of therapeutical agents that will meet this 
 case so well as the following : 
 
 R Fol. delphin. consol., Sss; 
 
 Potass, acetat., 3ii; 
 
 Acid, hydrocyanic, gtt. xvi; 
 
 Aquae font., fgviii. — M. 
 Ft. infusion. 
 SlG. — Half an ounce three times a day. 
 
 Dr. S. H. Bennett recommends the following in the nausea and 
 vomiting of phthisis : 
 
 R Naphthas medicinalis, f3i ; 
 
 Tinct. cardamom, comp., f §i ; 
 
 Mist, camphorae, fgvii. — M. 
 Ft. mist. 
 SlG. — A tablespoonful every four hours. 
 
 Pepsin, quinia, and strychnia are frequently agents of great value 
 in promoting digestion and in correcting certain derangements which 
 sometimes cause distressing nausea and vomiting during the progress 
 of this disease. I now have a patient under my care suffering with 
 phthisis, who, from the commencement of her illness, was constantly 
 annoyed with vomiting, which readily yielded to the following : 
 
 B Quiniae sulph., gr. xxx ; 
 
 Strychniae, gr. i. — M. 
 Ft. in pil. No. xxx. 
 SlG. — One pill before each meal, three times a day. 
 
 The following has also proved a useful prescription in obstinate 
 cases of phthisical vomiting : 
 
 B Oxalat. cerium, gr. viii ; 
 
 Bismuth, sub nit., 9ii. — M. 
 Ft. in chart. No. xii. 
 SlG. — A powder after each meal, three times a day. 
 
CHAPTER XVIII. 
 
 COUGH AND EXPECTORATION: THEIR DIAGNOSTIC VALUE AS 
 SYMPTOMS OF PULMONARY TUBERCULOSIS, WITH REMARKS ON 
 THE IMPORTANCE OF A MICROSCOPICAL EXAMINATION OF THE 
 SPUTUM. 
 
 I. Cough and Expectoration. 
 
 Cough and expectoration are among the earliest symptoms of 
 pulmonary tuberculosis that attract the attention and awaken the 
 fears of the patient or his friends. At first the cough is generally 
 slight, occasional, and dry. It occurs mostly upon the individual's 
 getting out of bed in the morning, or upon his making any unusual 
 exertion during the course of the day. It feels to him as if it was 
 caused by irritation about the throat. Sometimes it will cease for 
 awhile during the continuance of warm weather, only to recur again 
 when it becomes colder. By degrees it begins to be troublesome at 
 night, and attended with more or less expectoration, and, as the 
 disease advances, it becomes one of the most annoying symptoms 
 connected with the malady ; teasing the victim of phthisis by day, 
 and disturbing his slumbers by night, he sometimes longs for death 
 to terminate his sufferings. 
 
 According to Dr. Thompson, the series of changes that occur in the 
 appearance of the expectoration in the different stages of this disorder 
 may be conveniently classed under four divisions, namely : 
 
 " First, the salivary or frothy ; second, the mucous ; third, the 
 flocculent ; fourth, the purulent. 
 
 " The first is what you would expect from irritation the result of 
 either pulmonary congestion or of tubercular deposits. 
 
 " The second would indicate a more confirmed affection of the 
 bronchial tubes. 
 
 " The third is peculiarly characteristic of secretion from vomicas. 
 modified by the absorption of its thinner constituents. 
 188 
 
COUGH AND EXPECTORATION. 189 
 
 " The fourth is indicative of phthisis far advanced, and, if unmixed 
 with froth, usually involves both lungs."* 
 
 In the earliest stage of the disease, as we have just remarked, the 
 cough is either quite dry or attended by a mere frothy and colorless 
 fluid, This, on the approach of the second stage, gradually changes 
 into the opaque or greenish sputum, intermixed with small lines or 
 fine streaks of a yellowish color. At this period, also, the expectoration 
 is sometimes intermixed with small specks of a dead-white or slightly 
 yellow color, varying from the size of a pin's head to that of a grain 
 of rice, and which have been compared by some writers to that grain 
 when boiled. 
 
 After the complete evacuation of a tubercular cavity, the expecto- 
 ration assumes various forms of purulence ; but it frequently presents 
 .a particular character which is almost pathognomonic of phthisis. 
 The expectoration to which I allude consists of a series of globular 
 masses, flocculenti, of a white color, with rugged edges, having very 
 much the appearance of little balls of cotton or wool. These com- 
 monly, but not always, sink in water. At other times, where these 
 globular masses are observed, and also where they have not appeared, 
 the expectoration presents the common characters of the pus of an 
 abscess, constituting a uniform, smooth, coherent or diffused mass, of 
 a greenish or rather grayish color, with an occasional streak of red ; 
 shortly before the final termination of the disease it is often surrounded 
 by a pinkish halo ; death always follows in a very few days after they 
 assume this color. 
 
 As to the quantity of expectoration, very much will depend upon 
 the stage of the disease and the progress it has made. In the first 
 stage it is absent or quite scanty ; but as the disorder advances it 
 becomes more copious. If the cavities are small and the bronchial 
 membrane and glands not much affected, it will be scanty ; but if the 
 cavities are large and the bronchial mucous membrane much affected, 
 it will be more abundant. When it is very copious it becomes a 
 very serious drain upon the system, and soon exhausts the vital forces, 
 and no doubt tends greatly to keep up that state of the system upon 
 which the disease depends. 
 
 The following table, compiled from Dr. Thompson's Lecture on 
 
 * Thompson's Lectures on Consumption, page 64. 
 13 
 
190 
 
 PULMONARY TUBERCULOSIS. 
 
 the Expectoration, shows the age of the patient, the daily quantity 
 and character of the sputum, and the stage of the disorder, in nineteen 
 cases of confirmed phthisis : 
 
 No. 
 
 Age. 
 
 Quantity daily. 
 
 Chaeacteb. 
 
 Stage. 
 
 1 
 
 29 
 
 4 ounces. 
 
 Purulent,, frothy. 
 
 2 
 
 2 
 
 46 
 
 4 « 
 
 Mucous, frothy. 
 
 1 
 
 3 
 
 46 
 
 4 « 
 
 Mucous, frothy. 
 
 1 
 
 4 
 
 32 
 
 10 drachms. 
 
 Purulent. 
 
 3 
 
 5 
 
 17 
 
 2 
 
 Purulent. 
 
 2 
 
 6 
 
 33 
 
 1£ ounces. 
 
 Muco-purulent. 
 
 2 
 
 7 
 
 16 
 
 None. 
 
 None. 
 
 3 
 
 8 
 
 18 
 
 None. 
 
 None. 
 
 1 
 
 9 
 
 21 
 
 3 drachms. 
 
 Purulent. 
 
 3 
 
 10 
 
 21 
 
 i ounce. 
 
 Mucous, frothy. 
 
 1 
 
 11 
 
 29 
 
 1 " 
 
 Frothy. 
 
 1 
 
 12 
 
 25 
 
 4 ounces. 
 
 Muco-purulent. 
 
 2 
 
 13 
 
 27 
 
 4 « 
 
 Muco-purulent. 
 
 3 
 
 14 
 
 13 
 
 4 " 
 
 Flocculent. 
 
 3 
 
 15 
 
 18 
 
 li drachms. 
 
 Mucous. 
 
 1 
 
 16 
 
 29 
 
 1-J- ounces. 
 
 Frothy. 
 
 1 
 
 17 
 
 29 
 
 2 " 
 
 Purulent. 
 
 3 
 
 18 
 
 20 
 
 None. 
 
 None. 
 
 3 
 
 19 
 
 34 
 
 3 ounces. 
 
 Purulent. 
 
 3 
 
 1 
 
 By the above table it will be seen that it is chiefly in the third 
 stage of phthisis that purulent matter is expectorated ; and this kind 
 of sputum is regarded by most physicians as highly indicative of 
 vomica. Hence it has always been made a very nice point in medical 
 diagnosis to distinguish between mucous and purulent expectoration. 
 The records of medicine abound in pus-tests, which at the present 
 time are of little value, except as showing the slender foundation upon 
 which they were based. They were formed for the most part on the 
 chemical relation of pus-corpuscles towards various reagents. But 
 the microscope has rendered all these chemical tests superfluous. It 
 enables us not only to distinguish pus from mucus, broken epithelium, 
 blood, etc., but likewise to determine the amount of these different 
 constituents, which chemical analysis has never succeeded in doing. 
 
 II. Physical and Microscopical Characters of Pns and Mucus. 
 
 Pus, when pure, appears to the naked eye as a creamy, thick, and 
 homogeneous fluid, communicating an unctuous feeling when rubbed 
 between the fingers ; it is of a yellowish tint, sweetish or insipid to 
 
COUGH AND EXPECTORATION. 191 
 
 the taste ; and, while warm, gives off a peculiar mawkish smell. Its 
 specific gravity is 1.030 to 1.033. If allowed to stand some time in a 
 tall, narrow glass vessel, the fluid separates into a thick sediment, more 
 or less abundant, and a supernatant serum. This latter, according to 
 Vogel, is identical with the serum of the blood, containing much albu- 
 men, extractive saline matter, and fat. The reaction is alkaline, but it 
 readily becomes acid, from the generation of an acid which is com- 
 monly supposed to be lactic. In some cases it is said to have an acid 
 reaction even at the time of its formation. 
 
 The sediment consists almost entirely of small organized corpuscles, 
 the well-known pus-globules. These are of a spherical form, and 
 have a well-defined contour formed by a distinct homogeneous en- 
 velope, including a mass of soft, granulous substance, and a varying 
 number of nuclear corpuscles. These latter are, in well-formed pus- 
 globules, for the most part concealed by the surrounding substance ; 
 but in the younger cells of healthy pus, and in all those of pus of an 
 inferior kind, they are very perceptible. Occasionally a single nucleus 
 exists, but more commonly it is made up of two, three, or more 
 granules. 
 
 The single nuclei are always the largest, and indicate the most per- 
 fect kind of development. The more numerous the nuclear corpuscles, 
 the less perfect the development. The nucleus is generally seated on 
 the envelope. Its diameter is about one six-thousandth of an inch, 
 that of the entire globule about one three-thousandth. Single as well 
 as compound nuclei are seen floating in the serum of pus, but they 
 are not numerous. There is generally a small quantity of diffused 
 granular matter mingled with pus-globules. This is more abundant 
 in pus of a low temperament. It must not, however, be confounded 
 with the elementary granules, which are originally discrete, and con- 
 sequently, grouping together, constitute the nuclei. 
 
 The formation of the pus-globules does not appear to take place in 
 one uniform manner. The nucleus is generally stated to be formed by 
 the grouping together of the granules, which appear in a fluid blastema. 
 Around this there may be formed, first, the envelope, closely em- 
 bracing the composite mass, so as only to be brought in view by the 
 endosmotic action of water ; or a granulous deposit is formed around 
 the nucleus, which afterward becomes limited and inclosed by a cell- 
 wall. 
 
192 PULMONARY TUBERCULOSIS. 
 
 Mucus may be looked upon as consisting, like pus, of a fluid — 
 liquor muci — and corpuscles. The liquor muci, as we find it in the 
 secretions of a membrane which has been subject to moderate irrita- 
 tion, is a transparent, tenacious fluid, of alkaline reaction, and more 
 or less saline in taste. The addition of acetic acid or any other weak 
 acid produces a kind of coagulation and the formation of a granular 
 precipitate, which is the mucine, the principal constituent of the fluid. 
 This is held in solution by an alkali, and consequently falls when the 
 latter is taken up by an acid. Not much is known of this substance, 
 except that it is a protein compound. 
 
 The proper corpuscles of mucus are said, by some writers, to be 
 identical with those of pus ; but they are not, except in specimens of 
 a very morbid character. Healthy mucus, as it is seen under the 
 microscope, is composed of epithelial cells, — flat, irregular, five-sided, 
 and with central nuclei ; with numerous granular masses, and a few 
 spherical bodies very much like pus-corpuscles, excepting that they 
 contain much fewer oil-globules, and these are suspended in a viscid, 
 ductile fluid. Under inflammation, there is an increased exudation of 
 albuminous liquids ; the epithelium-cells are, perhaps, shed more 
 quickly before they have been flattened out ; the quantity of globules 
 is increased, and they acquire a character which resembles very much 
 the pus-cells, from which they are easily distinguished, however, by 
 their irregular form. 
 
 As to the origin of pus and mucus, pathologists all agree in the 
 opinion that they are both exudations, but the one is poured out 
 directly from the blood-vessels as an albumino-fibrous blastema, in 
 which special corpuscles (the pus-cells) are formed ; the other trans- 
 udes not only through the capillary walls, but through the basement 
 membrane of mucous surfaces, with more or less of the attached 
 epithelium, and in so doing experiences a peculiar modification, which 
 remains impressed upon it, while the corpuscles mingled with it are 
 the natural cell-growth of the surface, or such as form naturally in 
 blastemata that are destined to become effete.* 
 
 * See Vogel's Pathological Anatomy, American edition, page 135. 
 
COUGH AND EXPECTORATION. ] <,;> 
 
 III. Microscopical Characteristics of the Sputum in the First 
 Stage of Pulmonary Tuberculosis. 
 
 The chief microscopical characteristic of tubercular sputum, in the 
 first stage of the disease, is the withered pus-cell.* When these 
 are present in the expectoration, we may conclude with the greatest 
 certainty the commencement of tubercular formations in the lungs. 
 As a general thing they are much .smaller than the common pus-cell 
 described under the last head. Under a magnifying power of four 
 hundred and fifty diameters their nuclei look shriveled, and the cell- 
 walls shrunken and not very clearly defined in outline. 
 
 In simple bronchitis or pneumonia I have never yet found these 
 withered pus-cells in the sputum. In pneumonia they always assume 
 the appearance of the healthy pus-cell, and it is only when a portion 
 of the lung loses its vitality or becomes gangrenous that we see 
 them. The grade of inflammation must be very destructive, and the 
 patient's vital powers very feeble, if they are found at all in the ex- 
 pectoration. In bronchitis I never saw them but once, and this was 
 in an old lady of very feeble health ; she had suffered long with the 
 disease, and I have not the least doubt that, if an examination of the 
 chest had been instituted after death, tubercular disorganization would 
 have been found associated with the bronchial, although there was no 
 evidence of the kind during life from either percussion or auscultation. 
 
 Permit me just here to relate a case wherein I was very much as- 
 sisted in my diagnosis by a knowledge of this characteristic of the 
 sputum as revealed by the use of the microscope ; and it is only a type 
 of several that have since fallen under my observation : 
 
 " May 2, 1857. — Mrs. A., aged twenty-seven, called for advice this 
 morning at my office. Has been married five years, and has had two 
 
 * It may be erroneous to call these cells withered pus-cells ; for, according to 
 some of our recent writers on pathology, a pus-cell is merely a changed or 
 blighted white corpuscle. Dr. Hall, in his excellent work on Thoracic Consump- 
 tion, calls them gagged cells. Some have suggested that they may be undeveloped 
 tubercular cells ; which, in my opinion, is perhaps true. And what is a tuber- 
 cular cell ? In the present state of our knowledge on the nature of tubercle, this 
 question cannot be positively answered. The most recent opinion advanced on 
 the subject is that they are changed white corpuscles, and that a tubercle is 
 merely an extravasation of the white corpuscles of the blood. See " New York 
 Medical Journal" for January, 1872. 
 
294 PULMONARY TUBERCULOSIS. 
 
 children. Her temperament is nervo-sanguineous. Height five feet 
 six inches, and weight one hundred and twenty-five pounds. Has 
 always had good health until four weeks since, when she took cold 
 and was confined to the house for five days: since then she has 
 been suffering from an annoying cough, accompanied by considerable 
 expectoration. Pulse eighty-five per minute in the sitting posture ; 
 respiration eighteen. Mouth and throat healthy. Thompson's gingival 
 margin not present upon the gums. No fever ; appetite good ; bowels 
 regular ; menses regular and abundant. Rests well at night, with the 
 exception of occasional spells of coughing. Complains of weakness on 
 rising in the morning, but is able to attend to her usual household 
 duties. 
 
 " Her general symptoms do not indicate any serious organic disease ; 
 there is no apparent emaciation, and her mind is hopeful. Her chest 
 is full and capacious, and the expansion of the two sides is equal. On 
 percussion, no dullness is elicited, and auscultation reveals nothing 
 abnormal in the lungs ; the respiratory murmurs are distinct and 
 clear, and there is no increase of the vocal resonance. Along the 
 track of the upper bronchi there is slight vibration, accompanied 
 with mucous rhonchi. From these physical signs the disease was 
 set down as simple bronchitis, and she was ordered to use croton oil 
 as a counter-irritant to the chest, and take a teaspoonful of the fol- 
 lowing three times a day, about an hour before each meal : 
 
 " R Syrup, senegae, 
 
 Sp. nit. dulc, aa fgss ; 
 Morphiae sulph., gr. i ; 
 Syrup, simplicis, fgij. — M. 
 
 " May 12. — Patient called again this morning. Cough no better. 
 Complains of being weaker, and does not rest so well at night. Per- 
 cussion and auscultation elicited nothing new. She was directed to 
 continue treatment, and forward all matter expectorated during the 
 next twenty-four hours. 
 
 "May 14. — Received matter as directed above. Quantity, by 
 measurement in graduating glass, three and one-half ounces. In ap- 
 pearance it was muco-purulent, slightly viscid and frothy ; in color 
 a faint yellow. When examined with the microscope it exhibited 
 the ordinary products of muco-purulent matter, interspersed with a 
 
COUGH AND EXPECTORATION. 195 
 
 number of withered pus-corpuscles and shriveled nuclei, with scarcely 
 a vestige of a cell-wall. 
 
 " From this appearance of the sputum I was led to change my 
 views of her case. The bronchial disorder was evidently complicated 
 with tuberculosis. She was therefore placed upon the use of iodide 
 of potassium and cod-liver oil, with a generous diet. Under this 
 treatment she gradually improved, and by the first of July had re- 
 gained her usual health. I examined the expectoration frequently 
 during the time she was under my care, and found that just in pro- 
 portion as she gained strength and the cough became better these 
 withered pus-corpuscles were less numerous, until not one was to be 
 seen. When they were no longer to be discovered with the micro- 
 scope, the cough and sputum soon disappeared. 
 
 " April 1, 1858. — Called this day to see Mrs. A. She informed me 
 that she had enjoyed good health during the winter. About the first 
 of March she took cold, and has been coughing and expectorating 
 very freely ever since. The symptoms differ but little from those 
 described on the second of May, 1857. The sputum exhibited the 
 same microscopical appearance, only the withered pus-cells were more 
 numerous. Iodide of potassium and cod-liver oil were prescribed, as 
 on the former attack, and were attended with the same beneficial effects. 
 
 " Her health continued good until the first of March, 1860, when it 
 commenced gradually to decline. Her disorder now assumed a more 
 decided tubercular character. No therapeutical measures appeared to 
 have any control over it, and in six months it terminated her life. Her 
 malady was unquestionably tubercular from the beginning, although 
 the general symptoms and physical signs were not pronounced." 
 
 This case may be regarded as an exception to those commonly met 
 with in practice where, from the absence of the general symptoms 
 and signs, the existence of tubercular disease could not have been 
 made out ; but, by the aid of the microscope, we had at least a prob- 
 able clue to her difficulty. 
 
 But some critical reader may say that these withered pus-cells can- 
 not be characteristic of tubercular disease, because they are frequently 
 exuded from suppurating cavities in other parts of the body. Admit- 
 ting this, which is a fact, yet it does not invalidate the importance of 
 our position, that their appearance in the sputum is strong presump- 
 tive evidence of tubercular disease in the lungs. 
 
196 PULMONARY TUBERCULOSIS. 
 
 Perhaps it would not always be safe to say that the lungs are free 
 from tubercular disease so long as there are no withered pus-cells in 
 the sputum. But I will venture the assertion, without the fear of 
 contradiction, that they will very seldom be found in the expectoration 
 of any other disorder of the lungs or bronchia ; and we may almost 
 always infer the existence of tubercular deposits when they are found 
 in the sputum. Their disappearance under treatment is a good omen. 
 I could cite several cases from my note-book corroborative of these 
 assertions, but as I wish to present a synopsis of Dr. T. Thompson's 
 interesting cases illustrating the value of the microscope as a means 
 of diagnosis in phthisis in the other stages of the disorder, it would 
 extend this chapter far beyond the prescribed limits. 
 
 IV. Dr. Thompson's Cases demonstrating the true Microscop- 
 ical Indications of Tubercular Sputum. 
 
 At the time of the delivery of his lectures on pulmonary consump- 
 tion, in 1851, Dr. Thompson had paid but little attention to the use 
 of the microscope as a means of diagnosis ; and from a very super- 
 ficial examination of the subject, he expressed the opinion that very 
 little could be expected from it as an instrumentality in determining 
 the existence of phthisis by an examination of the sputum. But 
 fortunately, when he was about to abandon the subject, he had an in- 
 terview with Dr. Andrew Clark, the distinguished microscopist, who 
 readily demonstrated to him its true character under this wonderful 
 instrument. And a short time before his death, Dr. Thompson read 
 a very interesting paper before the Harveian Society, renouncing his 
 former views, explaining the true nature of the tubercular corpuscles, 
 and illustrating them by several accurate and beautiful diagrams. 
 
 In this paper the doctor has shown very conclusively that the spu- 
 tum of phthisical patients contains materials corresponding in appear- 
 ance with the elements present in the air-passages, and that before 
 any amount of disease can be detected, either by the general symptoms 
 or physical signs, there will not be found wanting the withered cells 
 and shriveled nuclei. He also maintains that when the sputum con- 
 tains, in addition to the withered cells, isolated masses of moleculo- 
 granular matter, fat, blood-corpuscles, with numerous areolar meshes, 
 we may conclude that there is pulmonary disorganization. 
 
 In confirmation of these views, Dr. T. presents the history of sev- 
 
COUGH AND EXPECTORATION. 197 
 
 eral cases, a brief description of which cannot fail to be interesting to 
 every reader who is desirous of adding to his knowledge of the natural 
 history of this dreaded malady. 
 
 The first case which he presents is that of a man, aged sixty-three, 
 who, after an attack of pleurisy in the left side, did not regain his 
 usual health. Dull percussion and prolonged expiratory murmur over 
 a small portion of the right apex were the only important ausculta- 
 tory signs ; but the expectoration, under the microscope, was found to 
 contain withered cells, blood-corpuscles, moleculo-granular matter, and 
 numerous areolar meshes, which are conclusive signs of phthisis. 
 More decided symptoms appeared, and he fell a victim to the disease 
 in a few months. 
 
 The second case was that of a lady aged thirty-nine. The first 
 sickness of any severity that she suffered was during the winter of 
 1855, and was supposed to depend on some gastric difficulty, the pre- 
 cise nature of which could not be accurately determined. The per- 
 sistency of the disorder and the progressive emaciation led to an 
 exploration of the chest. Some dullness was elicited on percussion, 
 and an increased vocal thrill was observed near the sternal end of the 
 second intercostal space on the right side. 
 
 The expectoration was carefully examined under the microscope, and 
 was found to contain shriveled cells, lung-tissue, and isolated masses 
 of granules. She was put under the use of cod-liver oil, and hygienic 
 treatment of a soothing kind was instituted, which was followed by a 
 marked improvement in her health. But early in the year 1856 the 
 expectoration became more copious ; dullness on percussion was more 
 extensively obvious ; near the inferior angle of the scapula clicking 
 was audible, shortly followed by cavernous breathing and other grave 
 symptoms of pulmonary tuberculosis. She died in March. 
 
 In this case, almost from the very first, we find the principal signs 
 of the disease in the sputum. Although dullness and increased vocal 
 thrill were observed, with cough and emaciation, yet they did not 
 point out the nature of the malady, for these signs are sometimes 
 present in bronchitis and pneumonia, particularly when these dis- 
 orders assume a chronic form. The microscopical examination of the 
 sputum at once gave a direct clue to a correct diagnosis of the case. 
 This is fully sustained by a third case, which Dr. T. presents in con- 
 trast to this. 
 
19S PULMONARY TUBERCULOSIS. 
 
 A woman, aged thirty-eight, had precisely the same physical signs ; 
 but the occasional slight cloudy expectoration, from time to time ex- 
 amined by the microscope, exhibited ciliary cells, some with long tails, 
 probably tracheal ; some in masses, as though from follicles ; but there 
 were no tubercular elements. In harmony with the encouraging testi- 
 mony thus afforded by the microscope, the general symptoms continued 
 favorable, and have during a period of five years, notwithstanding an 
 accomplished auscultator had previously pronounced the most unfavor- 
 able prognosis. 
 
 The following case is given by Dr. Thompson to show that a micro- 
 scopical examination of the sputum is useful in confirming doubtful 
 
 signs: Mr. , aged fifty, in the winter of 1854 had a cough, 
 
 copious expectoration, hurried breathing, and some symptoms of 
 hectic. The left lung had extensive consolidations in consequence of 
 pneumonia ten years previously. Over a small space, near the lower 
 angle of the left scapula, a sound could be heard, of which it was diffi- 
 cult to determine whether the correct designation was sub-crepitation 
 or clicking. 
 
 A portion of the expectoration was sent to Dr. Clark for micro- 
 scopical examination. The doctor reported that it contained shriveled 
 cells, large cells with shriveled nuclei, and some earthy matter ; and, 
 without having had a previous history of the case, he gave the diag- 
 nosis of "slight tubercular deposits tending to restoration,*' a diagnosis 
 which was confirmed by the subsequent history of the case. The 
 conversion of tubercles into cretaceous masses is generally regarded 
 as a curative process, and when found in the expectoration it is looked 
 upon as a favorable sign. The case, at least, is still considered hopeful. 
 
 In the summer of 1854, Dr. Thompson was called to see Mr. , 
 
 aged twenty-two. On examination, there was dullness on percussion, 
 and a murmur over the left pulmonary artery, but no crackle or 
 clicking ; the expectoration, however, exhibited lung-tissue, tubercular 
 corpuscles, and blood-disks. He took cod-liver oil freely, at one 
 period to the extent of a pint and a half in a week, and had ioduretted 
 neat's-foot oil (a grain to the ounce) rubbed into the chest. After a 
 time the expectoration became chiefly bronchial, and free from lung- 
 tissue. After spending the winter in Madeira, he returned in the 
 latter part of spring quite improved in health. 
 
 The doctor introduces this case to prove that the microscope affords 
 
COUGH AND EXPECTORATION. 199 
 
 us evidence of amelioration of the pulmonary disorder, and furnishes 
 the medical attendant such indications as will lead him to persevere in 
 the use of such means as will have a tendency to counteract the dia- 
 thesis and repair the local lesion. Nothing, in our judgment, is more 
 conclusive of amendment than the disappearance of the withered cells, 
 the shriveled nuclei, and lung-tissue from the sputum of a phthisical 
 patient. 
 
 The microscope also furnishes very important evidence of the 
 rapidity of the pulmonary disorganization, and its fatal termination. 
 Dr. Thompson illustrates this by a case where the individual had 
 been in a decline for two years, but whose friends did not fully realize 
 the danger. Some expectorated matter sent to him for examination 
 contained blood, copious corpuscles, and numerous large meshes of 
 pulmonary tissue, perfectly retaining their form and elasticity. A 
 very unfavorable prognosis was given, which was verified by the death 
 of the patient in a few days. 
 
 In this paper, Dr. Thompson gives it as his decided opinion that 
 the microscopical inspection of the sputum at a very early period of 
 pulmonary tuberculosis furnishes knowledge in relation to the malady 
 that is not otherwise attainable ; that the microscopical examination 
 and study of the sputum opens up a very important chapter in the 
 progress of medical science ; and that it should not be discarded by 
 those who wish to become proficient in diagnosticating the various 
 disorders of the chest. 
 
 V. Testimony of Drs. Bennett and Clark on the value of the 
 Microscope as a means of Diagnosis in Phthisis. 
 
 Dr. Hughes Bennett, of Edinburgh, although at first exceedingly 
 skeptical as to the value of a microscopical examination of the sputum 
 as a means of diagnosis in chest-diseases, has recently added his testi- 
 mony as to its importance, and concurs with Dr. Thompson in recom- 
 mending it as a very useful means of diagnosis in all doubtful cases of 
 phthisis. 
 
 Dr. Andrew Clark, of London, has studied the microscopical charac- 
 ter of the sputum carefully, and has published, in the British Medical 
 Journal, the most scientific article on this subject that I am acquainted 
 with. He gives it as his firm conviction " that the examination of 
 the sputum is useful at all periods of the disease, as being the only 
 
200 PULMONARY TUBERCULOSIS. 
 
 certain means of detecting the disintegration of the lungs and the in- 
 crease of the disease." 
 
 With such testimony in favor of the value of a microscopical ex- 
 amination of the sputum as a means of diagnosis in phthisis, it makes 
 us feel a little combative when we hear individuals affirm "that there 
 is nothing found in the sputum of phthisical patients which is con- 
 clusive of the existence of the affection, and that those who claim that 
 there is are laboring under a delusion." Persons entertaining such 
 views have never made this subject one of special observation and 
 study. Hence their opinions are not entitled to much confidence, — 
 time will triumphantly explode them. 
 
 The introduction of the microscope is a new power in the empire 
 of medical diagnosis, and, like all intruders, it will encounter hos- 
 tility and bitter opposition ; and no strange thing has happened to it 
 when it is condemned before its merits have been fairly examined and 
 fully tested, for the very same thing has occurred to nearly every dis- 
 covery that adorns the temple of science. Take, for example, the art 
 of auscultation. For how many years did its advocates encounter the 
 stormy waves of opposition ! How were they denounced as pretenders 
 by those who stood high in the profession ! But now its utility is 
 universally admitted ; and there is not a man in the profession who, 
 having any regard for his reputation, will stand up and seriously 
 controvert its value. 
 
 But opposition is not without its use either in science or morals. 
 Its influence is frequently beneficial in causing more thorough and 
 accurate investigation to be made, in order to furnish stronger evi- 
 dence in proof of any alleged discovery or improvement. The nature 
 of the principles involved becomes better understood, and their limits 
 more clearly defined and definitely settled. Another beneficial result 
 is that it tends to prevent too hasty improvements or changes in 
 practice, which would otherwise occur, as growing out of new dis- 
 coveries. As a general thing, such transitions as have a tendency to 
 produce a radical change, either in society or science, to be useful must 
 be gradual. The understanding must be thoroughly enlightened, 
 all the intricate principles connected with the subject must be unfolded, 
 and, when submitted to the analysis of reason and judgment, they 
 illumine the mind, and the murky clouds of error flee before the bril- 
 liant light of science. 
 
CHAPTER XIX. 
 
 HAEMOPTYSIS AS A SYMPTOM OF PULMONARY TUBERCULOSIS ; ITS 
 'DIAGNOSIS AND TREATMENT. 
 
 I. The Character of Phthisical Haemoptysis. 
 
 This is one of the most significant symptoms of pulmonary tuber- 
 culosis. It is usually present in about three-fourths of all the cases 
 that come under our care, and is often the first to announce the ap- 
 proach of the fell disease. In many instances I have seen it precede 
 all other symptoms for more than a year, and sometimes longer. At 
 one time I had a patient under my care for several years, who had 
 occasional attacks of profuse haemoptysis before I could detect any 
 positive physical signs of tubercular deposits in the lungs. Many 
 patients, however, experience but one attack, and that only near the 
 close of the disease. In some cases it is trifling in amount, mixed 
 with mucus and pus, and repeated at intervals of a few days. In others 
 — and this frequently at the commencement of the tubercular disorder 
 — the discharge of blood is copious ; so much so, that many individuals 
 look upon it with great alarm, and the danger of sudden death is 
 regarded as very imminent. But it is astonishing what an amount of 
 blood a patient may lose in this. way and recover. Laennec* records 
 the case of a young man who lost thirteen 'pounds in fifteen days. 
 Death is very rare from this cause, and many physicians, in the 
 course of extensive practice, have never seen such an instance. 
 
 Nature has guarded against this event with wonderful care. An 
 examination of the circulation of a lung when occupied with tuber- 
 cular deposits reveals several things that are unfavorable to the occur- 
 rence of profuse or fatal hemorrhage. In a state of health, the blood- 
 vessels transmit the blood with the most perfect freedom ; but when 
 the lungs are tubercular, the blood coagulates in the extremities of 
 
 * Laennec on the Chest, page 192. 
 
 201 
 
202 PULMONARY TUBERCULOSIS. 
 
 the vessels, and obstructs them in such a manner that scarcely a drop 
 of the vital fluid can escape. Again, when we look into a large tuber- 
 cular cavity, we discover bands crossing in various directions. These 
 bands consist mainly of blood-vessels and cellular substance. Now, it 
 has been observed by pathologists that blood-vessels are not very apt 
 to ulcerate. Muscles, bones, and cellular tissue disappear under the 
 influence of ulceration, while the blood-vessels remain almost perfect. 
 Thus, the walls of the pulmonary arteries, when surrounded by tuber- 
 cular ulceration, instead of sharing the disorganization, usually thicken 
 by the development of fresh materials ; their calibre gradually dimin- 
 ishes ; after a time they cease to be pervious, and are transformed into 
 solid cords. And it is only in those cases in which such vessels are 
 suddenly torn before they are perfectly closed that there can be pro- 
 fuse hemorrhage from a pulmonary cavity. There may be. however, 
 haemoptysis from the granulations of a tubercular cavity, but it is 
 never very profuse — not sufficient to terminate the patient's existence 
 very suddenly. 
 
 But haemoptysis more frequently occurs in this disease without the 
 rupture of a blood-vessel or granulations in a pulmonary cavity. Per- 
 haps in the great majority of cases tubercular deposits cause a com- 
 pression and obliteration of the pulmonary veins, in consequence of 
 which the blood, interrupted in its natural channel, overflows or exudes 
 into the neighboring bronchi. And this is often greatly facilitated by 
 the peculiar condition of the constituents of the blood, which, being 
 in a deteriorated condition, allow it readily to escape by exhalation 
 from the overloaded pulmonary capillary vessels. If we admit this 
 explanation as true, it will be readily seen in what manner haemoptysis, 
 moderate in amount, may be useful in preventing the extension of the 
 tubercular disease and relieving intercurrent inflammation. Indeed. 
 statistics prove that those phthisical patients who experience haemop- 
 tysis moderate in amount usually live much longer than those who do 
 not. But when the disease is attended with frequent and profuse 
 haemoptysis, it often proves rapidly fatal. In the winter of 1871 I 
 attended a young man suffering with pulmonary tuberculosis, who 
 succumbed to the malady in less than three months, from frequent 
 and profuse haemoptysis. It is a well established fact that, where 
 haemoptysis is very free from the commencement, and continues so. 
 without any very extensive lesion of the pulmonary tissue, it soon 
 
HEMOPTYSIS. 203 
 
 exhausts the vital forces and greatly adds to the tubercular dyscrasia. 
 Tuberculosis is pre-eminently a disease of debility, and whatever tends 
 in any way to produce this condition of the system will hasten the 
 disease to a more speedy and fatal termination. 
 
 But what is a profuse haemoptysis ? I find that practitioners differ 
 very widely in opinion on this subject. When I read the case of W. 
 A. (which will be described in a succeeding part of this chapter) to a 
 medical friend of mine, he called it a very alarming instance of haemop- 
 tysis, — " very profuse indeed." But when I related another, where 
 six ounces were expectorated in three hours, this was very moderate. 
 We have been in the habit of considering four or five ounces of blood 
 expectorated in as many hours a very free hemorrhage ; one or two 
 ounces during twelve hours as moderate ; when but a teaspoonful, or 
 half the quantity, trifling. And when it is expectorated in this trifling 
 quantity from time to time, it should be looked upon as a suspicious 
 circumstance, and the patient's symptoms should be examined with the 
 greatest care, that the true source of the hemorrhage may be ascertained. 
 
 When haemoptysis is very copious, the blood will flow into the 
 throat with great rapidity, and will excite symptoms of vomiting, so 
 that for a moment we may be at a loss to say whether it was dis- 
 charged from the lungs or stomach. But if the operation is carefully 
 watched, there will be no trouble in making out a clear diagnosis. It 
 will be seen whether it is expectorated by coughing or vomiting. On 
 the other hand, when haemoptysis is moderate in quantity, the blood 
 will frequently pass up through the air-passages into the throat with- 
 out exciting much cough. Individuals sometimes try to deceive them- 
 selves and their friends as to the source of the hemorrhage, and the 
 physician may be deceived unless he is constantly on his guard. I 
 have known patients to be exceedingly careful to conceal the fact of 
 their having had haemoptysis at all from their physician. A young 
 man once came to me suffering with pulmonary tuberculosis, who, 
 when asked if he had ever had bleeding from the lungs, said no, — but 
 subsequently confessed that he had bled frequently. 
 
 II. Hemoptysis in the Two Sexes. — Stage of the Disease, and 
 Periods of Life. 
 
 As to the frequency of haemoptysis in the two sexes, our record of 
 cases is not sufficiently accurate to deduce any very positive conclu- 
 
204 PULMONARY TUBERCULOSIS. 
 
 sions from them. The statements, therefore, which follow are drawn 
 from the report of cases that have occurred at the Hospital for Con- 
 sumptives at Brompton, London, and from Dr. John "Ware's excellent 
 paper on " Haemoptysis as a Symptom." 
 
 From Dr. Ware's table, exhibiting the age and sex of three hun- 
 dred and seventeen cases, we learn that previous to the age of twenty 
 years females are more liable to haemoptysis than males, in the pro- 
 portion of one hundred and thirty to thirteen ; that during the next 
 ten years the number preponderates in favor of the males, forty-nine 
 to twenty-eight females ; during the next, the numbers are nearly 
 equal, twenty to twenty-eight ; while from the fiftieth to the sixtieth 
 year it is once more greatly on the side of the females, thirteen to five 
 males. 
 
 " Whether," says Dr. Ware, " this has any connection with a dis- 
 turbance in the balance of the circulation at the two periods during 
 which there is an excess in the number of females connected with the 
 establishment, and cessation of the functions of the uterus, is an in- 
 teresting question." 
 
 In regard to the relation of haemoptysis to the different stages of 
 phthisis, we glean the following from the Brompton reports : In the 
 first stage, haemoptysis was present twenty-eight times in thirty-nine 
 cases; in the second, eighteen times in twenty cases; and in the third, 
 fifty-seven times in sixty-nine cases: making 71.70 per cent, in the 
 first, 90 in the second, and 82.61 in the third. 
 
 When, however, the analysis is made from the table of the sex. the 
 proportion is somewhat different, We then find that the increase in 
 frequency during the third stage preponderates in favor of the males. 
 Thus, in the following table we have — 
 
 Males. No. of Cases. Frequency. Per Cent. 
 
 First stage ... 18 ... 12 .. . 66.66 
 
 Second and third stages 56 . . . 49 ST. 50 
 
 First stage ... 21 ... 16 .. . 79.19 
 
 Second and third stages . 33 . . .26 . . . 7 . .> 
 
 Hence it will be seen that the frequency during the first and second 
 stages is considerably greater in men than in women, which may be 
 fairly explained by the great bodily labor and increased tax upon the 
 
HEMOPTYSIS. 205 
 
 pulmonary circulation in the former than in the latter. It also has a 
 tendency to lead to the inference that the existing influence of the 
 tubercular cachexia itself, in producing haemoptysis, is greater than 
 that of its secondary results. 
 
 From Dr. Ware's report, we may also infer that the seasons of the 
 year have an influence in producing haemoptysis. Thus, from a table 
 showing the months in three hundred and fifty-five cases, we find that 
 the first attack of hemorrhage occurred in much the larger number of 
 cases during cold weather. The greater number of cases, thirty-eight 
 and thirty -nine, occurred in March and November respectively ; the 
 smaller number, eighteen, in June. The season of the year in which 
 the largest number of cases are recorded may be denominated the 
 transition seasons, spring and autumn, which gave, respectively, one 
 hundred and one and one hundred and two. Those in which the 
 smallest number are recorded were the equable seasons, winter and 
 summer, — which gave respectively eighty-three and sixty-nine. 
 
 As to the more exciting causes which produce haemoptysis in pul- 
 monary tuberculosis, we know but little. Patients, when interrogated 
 on the subject, can seldom state anything which seems likely to have 
 acted as an exciting cause. In a large proportion of cases it occurs 
 unexpectedly, without any premonition. Sometimes it will occur after 
 an unusual effort of the chest, either in lifting or running; but I have 
 frequently known it to occur at night, when the patient was in bed ; 
 he would be aroused from his slumbers, and find the blood flowing 
 from his mouth in alarming quantities. 
 
 III. Diagnosis of Phthisical Haemoptysis. — Cases Illustrating* 
 
 the Same. 
 
 Haemoptysis may arise from other conditions of the system than 
 pulmonary tuberculosis ; such as plethora, or congestion, with pneu- 
 monitis ; from external violence, as blows, and accidents of any kind ; 
 from violent muscular action ; from disease of the heart, and from the 
 suppression of some accustomed evacuation. All of these causes may 
 produce it in certain conditions of the system, and I do not regard it 
 a difficult thing to distinguish phthisical haemoptysis from that which 
 proceeds from other sources. 
 
 Let me cite two or three cases to illustrate the mode of diagnosis. 
 Here we have a case of pulmonary tuberculosis, which has advanced 
 
 14 
 
206 PULMONARY TUBERCULOSIS. 
 
 to the third stage, and the first intimation we have of it is a profuse 
 haemoptysis. 
 
 W. Y.j aged twenty-four, a farmer by occupation, of the nervo- 
 bilious temperament; an individual of unusual physical energy. After 
 having been engaged for two days in handling heavy sacks of grain, 
 he was suddenly seized, on the evening of the second day, with a very 
 copious expectoration of blood. When I saw him the same evening 
 he had a very feeble pulse, hurried breathing, cold and clammy skin, 
 with occasional syncope. The amount of blood lost was estimated at 
 four pounds. 
 
 And to add to the danger of his case, a few moments after I arrived 
 profuse vomiting and purging ensued, from the effects of a large quan- 
 tity of chloride of sodium which he had taken by the advice of some 
 friend to stop the hemorrhage. From these two causes he appeared 
 to be on the eve of dissolution for several days. But by the persever- 
 ing use of stimulants, tonics, and a generous diet, he gradually im- 
 proved, and in four weeks was able to leave his bed. 
 
 His health had always been good up to the occurrence of the 
 haemoptysis. He had no hereditary title to phthisis. As his Btrength 
 improved, he complained of a constant pain in the right breast just 
 above the nipple. His pulse continued frequent and his breathing 
 hurried. He had cough, and expectorated muco-purulent matter 
 streaked with blood. Symptoms of hectic were pronounced. Thomp- 
 son's gingival margin was clearly defined upon the gums ; his mind 
 was hopeful, and his conversation very animated ; thought he would 
 be well in a week or two. 
 
 A physical exploration of his chest showed the expansion-move- 
 ments of the two sides unequal. During inspiration there was scarcely 
 any motion in the upper part of the right side. Percussion yielded a 
 dull sound over the right side of the chest, with the exception of just 
 below the clavicle. Here a smart stroke, when the patient's mouth 
 was opened, elicited a cracked-pipkin sound, bruit de pot f£U. On 
 auscultation in the same region, cavernous respiration was marked, 
 pointing out the existence of a cavity in the superior lobe of the lung. 
 On the left side the physical signs were normal, with the exception of 
 the prolonged expiratory murmur, an unfailing sign of commeneing 
 tubercular infiltration and all its destructive consequences. 
 
 The haemoptysis never occurred again but once, and then only to 
 
HAEMOPTYSIS. 207 
 
 the amount of two or three ounces. The disease, however, pursued 
 its undeviating way to a speedy and fatal termination. He emaciated 
 rapidly ; and with occasional attacks of pleuritis, night-sweats, diarrhoea, 
 a troublesome cough, and distressing paroxysms of dyspnoea, his tem- 
 pest-tossed spirit was wafted into the haven of eternal rest. He died 
 in four months from the first hemorrhage. 
 
 Post-mortem verified the diagnosis. The superior lobe of the right 
 lung was entirely disorganized. It was a vast cavity, containing pus 
 and a few small clots of blood. The middle and inferior lobes were 
 infiltrated with tubercular matter in various stages of softening. The 
 pleura was adherent in several places. In the superior lobe of the 
 left lung there was gray tubercular matter in various stages of soften- 
 ing, but no cavities. The inferior lobe was congested, but presented 
 no appearance of tubercular deposits. The bronchi were red, but free 
 from ulceration. Heart rather small in volume ; parietes of the left 
 ventricle thinner than usual ; aorta healthy. The other organs of the 
 body, so far as examined, were healthy, except the small intestines, 
 which in places exhibited tubercles in nearly every stage, with numerous 
 indurations and ulcers. 
 
 This case was unique in three particulars. First, In the sudden- 
 ness of its development. The tubercular disease had proceeded to the 
 third stage before the patient manifested any symptoms of failing health. 
 I made particular inquiry on this point, and, so far as I could learn, 
 he made no complaints of trouble in the chest or of failing strength. 
 Second, The hemorrhage was very profuse, from the nature and extent 
 of the pulmonary lesion ; for it has been well established by patho- 
 logical research that haemoptysis is not a common sequence of large 
 tubercular cavities. Third, The rapidity with which the malady 
 proved fatal, eighteen months being the average duration of the dis- 
 ease in males. In this case it no doubt proved fatal in six months 
 from the first stage. 
 
 The next case is one of haemoptysis caused by suppression of the 
 catamenia. 
 
 June 22, 1855. — Called to see Miss S., aged twenty-three, of the 
 nervo-sanguineous temperament. This morning, on rising, she com- 
 plained of dyspnoea, accompanied with pain in the chest, which was 
 soon followed by a profuse flow of blood from the mouth, amounting in 
 quantity to about sixteen ounces. After the hemorrhage ceased, the 
 
208 PULMONARY TUBERCULOSIS. 
 
 dyspnoea and pain were in a measure relieved. Pulse seventy-five per 
 minute, and respiration eighteen ; skin sallow, moist, and cool ; bowels 
 costive and tender; spine tender to the touch; nervous system ex- 
 citable ; has had several paroxysms of hysteria during the last two 
 months ; appetite not good for a long time : pain in the head and 
 back ; a dry cough, and suppression of the catamenia for the last six 
 months. 
 
 Physical Signs. — No dullness on percussion. Auscultation elicits 
 nothing abnormal except mucous rhonchi with unequal bubbles, not 
 unlike those in bronchial catarrh, only much louder, from which we 
 conclude that the liquid material in the bronchial tubes is more fluid 
 than mucus ; hence it is blood, and the diagnosis is bronchial hemor- 
 rhage. 
 
 Treatment. — Enjoined rest, and prescribed mass. pil. hyd., gr. x. : 
 to be followed in six hours by castor oil, one ounce, and oil of turpen- 
 tine, one drachm. Dry cupping to the sacrum. 
 
 June 23. — Was called this morning at three o'clock. Patient awoke 
 at two o'clock, and found the blood flowing from her mouth and the 
 bed-clothes quite wet with it. The quantity could not be estimated. 
 A short time after this she took a hysterical paroxysm, and had not 
 recovered from it when I arrived. Inhalations of chloroform soon 
 relieved her from this, and, as her bowels had not been moved, the 
 castor oil and turpentine were repeated. During the afternoon her 
 bowels were freely moved, and at night an anodyne was prescribed. 
 
 2ith. — Patient rested well during the night. No return of hemor- 
 rhage. As there was still tenderness of the bowels on pressure, 
 ordered twelve drops of turpentine every six hours. 
 
 26th. — Much better every way; prescribed iron, quinine, and 
 strychnine. 
 
 28th. — Symptoms all better. In addition to iron, etc., ordered ten 
 drops of the oil of savin, with the warm hip-bath every evening. 
 
 July 10. — Patient still improving. Had a free catameuial discharge 
 yesterday, which still continues to-day, moderate in amount. 
 
 From this time she gradually regained her health ; subsequently 
 married, and is now the mother of six children. The ha?inopty<is in 
 this case was vicarious, and exuded from the bronchial mucous mem- 
 brane, and was permanently relieved by a restoration of the catamenia. 
 
 The following case of pregnancy complicated with hemoptysis I 
 
HEMOPTYSIS. 209 
 
 shall ever remember for the sorrow it caused in a once happy family, 
 where I delighted to spend a pleasant day, retired from the toils and 
 cares of professional life. 
 
 Miss was a young woman of rare beauty and accomplish- 
 ments. Her social and moral position in society, and the sweetness of 
 her disposition, joined with the most perfect amiability of character, 
 caused her to be admired and loved by all who enjoyed her society. 
 But the seducer came in the garb of an angel of light, and she fell a 
 victim to his machinations. After spending the winter in a neighbor- 
 ing city, enjoying the gayeties and frivolities of fashionable life, she 
 returned home about the first of March, pale and somewhat emaciated, 
 with a distressing cough, attended at times with profuse haemoptysis. 
 Dr. C, the family physician, was called in, and attended her until the 
 first of May, during which time there was little alteration in her con- 
 dition. Dr. C. regarded her case as phthisis, and he having exhausted 
 his stock of therapeutics, I was invited to meet him in consultation. 
 
 I found her feeble; countenance pale and dejected; pulse, eighty 
 per minute ; respiration, twenty ; tongue moist and clean ; bowels 
 regular ; appetite good, excepting in the morning ; no fever ; slight 
 dyspnoea on lying down ; no pain in the chest ; Thompson's gingival 
 margin not present upon the gums. Haemoptysis recurs about once in 
 seven days ; quantity estimated at four ounces. In the mean time the 
 cough is troublesome and attended with mucous expectoration. Per- 
 cussion of the chest yields no dullness ; and auscultation nothing but 
 mucous rhonchi. The respiratory murmurs were distinct, clear, and 
 free. While engaged in exploring the chest, my attention was attracted 
 by the unusual size of the breasts and the deep blue of the areola 
 around the nipple. This circumstance led to a careful examination of 
 the abdomen, and her pregnancy was readily made out by the motions 
 of the foetus and the pulsations of the heart. She was in the fifth 
 month of her gestation, and up to this time it had not been discovered 
 by Dr. C. or her family. 
 
 The cough and haemoptysis were entirely relieved in two weeks by 
 the following : 
 
 R= Tinct. ext. cannabis indicse, 
 Syrup. Tolu, aa fgij ; 
 Sulph. morphiae, gr. i. — M. 
 SiG. — A teaspoonful three times a day, after meals. 
 
210 PULMONARY TUBERCULOSIS. 
 
 From this time no untoward symptoms occurred. Her labor was 
 natural ; she made a good recovery, and has never manifested any 
 lung-trouble since, after a period of nearly twenty years. 
 
 During a medical experience of more than thirty-three years, I 
 have met with several cases of pregnancy attended with haemoptysis, 
 where there was no tubercular affection of the lungs. This is more 
 frequently the case in first pregnancies, and it behooves the physician 
 to be on his guard, — to exercise great care in his diagnosis and prog- 
 nosis. Let him examine his patient rigidly, explore faithfully the 
 condition of every organ, never trusting to a simple examination, or 
 taking for granted every statement the patient may make in regard 
 to her case. 
 
 I am acquainted with some practitioners who are too negligent in 
 this particular. They will visit a patient, feel his pulse, look at his 
 tongue, ask a few general questions as to his pains, and in a hurried 
 manner make out a prescription, and depart without having the re- 
 motest conception of the true nature of the patient's malady. Nothing 
 but such haste and carelessness could have betrayed Dr. C. into so 
 flagrant an error in his diagnosis of the case just cited, thus injuring 
 his own reputation, and bringing a reproach upon the profession to 
 which he belongs. 
 
 And it is just here that unprincipled quacks sometimes achieve 
 their greatest triumphs. They take advantage of the errors of scien- 
 tific physicians, and by an indefinable assumption of superior gravity 
 and wisdom impose upon the ignorant, and supplant the regular at- 
 tendant ; and will not readily yield the downy couch of charlatanry 
 for that of truth and justice. Accustomed to the ignoble fruit of de- 
 ception, they summon to their aid every device that is a stranger to 
 the manly breast ; they reap a rich harvest from the ills of suffering 
 humanity. To remove these loathsome pests from society the scientific 
 physician must be constantly on his guard ; and if every member of 
 the profession will do his duty, the day is not flu- distant when society 
 will cease to be cursed with such hordes of medical impostors and 
 mountebanks. 
 
 General Inferences. — 1st. Haemoptysis is the most significant of 
 any of the single symptoms of pulmonary tuberculosis. 
 
 2d. That it is rarely fatal, — nature having taken great care to pre- 
 vent such a result. 
 
H2EM0PTYSIS. 211 
 
 3d. That, commonly, those patients who experience haemoptysis 
 moderate in amount live longer than those who do not ; hence it is 
 rather beneficial than otherwise, by removing congestion and inter- 
 current inflammations. 
 
 4th. On the other hand, when frequent and profuse, it will have a 
 tendency to weaken the system and add very much to the tubercular 
 habit, and thus cause a more speedy termination of the disorder. A 
 profuse hemorrhage in the third stage has been known to prove in- 
 stantly fatal. 
 
 5th. That phthisical patients, previous to the age of puberty, sel- 
 dom have haemoptysis. After this period, up to the age of twenty- 
 five, females are more liable to it than males, particularly in the first 
 stage of the disease, but in the second and third stages it frequently 
 preponderates in favor of males. 
 
 6th. That no individual who has once had haemoptysis, however 
 slight, can afterward be regarded as entirely safe from the dangers of 
 pulmonary tuberculosis. It may, however, as already remarked, occur 
 from other causes, but it is so rare, excepting in heart-disease, that 
 it points most commonly to the true nature of the case. Indeed, 
 haemoptysis is so frequent from tubercular disease that its occurrence 
 will naturally bring with it the presumption that where it is present 
 tubercular deposits also exist in the lungs. 
 
 IV. Treatment of Phthisical Haemoptysis. 
 
 This should be conducted with great care. When the hemorrhage 
 is moderate in amount, and does not occur often, I am not very 
 anxious to check it, and therefore refrain from all active measures. 
 When it is considerable, and of an active character, prompt treatment 
 is demanded. If the tubercular disease is in the first stage, and the 
 patient is plethoric, with a hard, full pulse, high bodily temperature, 
 hurried breathing, and pain just under the sternum, nothing will arrest 
 the bleeding quicker than cupping just under each axilla, and the in- 
 ternal use of large doses of sulphate of magnesia and sulphuric acid. 
 The following is a convenient formula : 
 
 R Infus. rosae compos., f^vi; 
 Acid, sulph. aromat., f5ij ; 
 Magnesiae sulph., §i. — M. 
 SiG. — A teaspoonful every hour. 
 
212 PULMONARY TUBERCULOSIS. 
 
 When this form of haemoptysis proves obstinate. I have in some 
 cases prescribed, with advantage. Dr. Dobell's formula, so highly 
 recommended by Niemeyer in his " Lectures on Pulmonary Tuber- 
 culosis:" 
 
 B Ext. ergot, fluid., f5ij ; 
 Tinct. digital., f5iij ; 
 Acid, gallic, 5 1 ; 
 Magnesiae sulph., 5iv *> 
 Acid, sulph. dilut., f3i ; 
 Infus. rosae, fgviii. — M. 
 Sig. — One ounce every hour until the hemorrhage ceases. 
 
 A popular remedy for haemoptysis, not only with the profession but 
 the laity, is a strong solution of the chloride of sodium. You cannot 
 turn to the treatment of haemoptysis, in any work on the practice of 
 medicine, without reading the following stereotyped language : " One 
 of the most efficacious remedies for haemoptysis, and at the same time 
 always convenient, is the chloride of sodium. It may be eaten by the 
 teaspoonful, or drank in a strong solution ; and there is no reason to 
 dread an overdose, for if the quantity taken should offend the stomach 
 and occasion vomiting, this will be of no injury to the patient." I 
 have no faith in this article as a remedy for haemoptysis. The bene- 
 ficial effects attributed to it are purely imaginary. Frequent draughts 
 of cold water will staunch a hemorrhage from the lungs just as soon. 
 And instead of its being a harmless agent, it is sometimes atteuded 
 with the most injurious consequences, producing derangements of the 
 stomach and bowels that annoy the patient throughout the future 
 progress of his malady. The case of W. Y. was a marked example 
 of this kind. I have long since ceased to prescribe the chloride of 
 sodium for phthisical haemoptysis. 
 
 The best therapeutical agent for active haemoptysis is the acetate of 
 lead ; it is not only a powerful astringent, but a useful sedative. In 
 profuse hemorrhage of a threatening character, two, three, or four 
 grains may be given every hour. When combined with opium, it has 
 no superior as a remedy in this case ; the latter is especially called for 
 when there is considerable irritation in the air-passages, exciting cough ; 
 it should be given in full doses sufficient to quell the cough, for 
 nothing is so liable to keep up the hemorrhage, or cause its return, as 
 
HEMOPTYSIS. 213 
 
 this. Next to the acetate of lead as a remedy for active haemoptysis, 
 is turpentine ; it is probably more suitable in a majority of instances 
 than any that have been named. The following is a good formula for 
 its administration : 
 
 R 01. terebinthinae, foij ; 
 Misturas gum acacias, fgij ; 
 Aquae cinnamom., f^iv ; 
 Tinct. capsicum, gtt. xxx. — M. 
 SiG. — One ounce every hour or two, according to the necessities of 
 the case. 
 
 Some writers speak very highly of inhalations of turpentine in 
 haemoptysis. In the few cases in which I have administered it in 
 this way, no obvious beneficial result has followed. In passive haemop- 
 tysis, turpentine is a therapeutical agent of great value ; for in con- 
 nection with its astringent properties it contains a valuable stimulant, 
 which is highly useful in all cases where the patient is feeble, with 
 a frequent pulse, cold skin, and breathing rendered difficult, not only 
 by the effusion within the air-passages, but by the want of muscular 
 power to sustain the fatiguing efforts of respiration. 
 
 Another excellent therapeutical agent for phthisical haemoptysis is 
 bugle-weed (Lycopus Virginicus). In protracted cases it has few 
 equals as a remedy. Administered in the form of a strong infusion 
 three or four times a day, it will speedily check the hemorrhage by 
 diminishing bronchial irritation, lessening the frequency of the pulse, 
 mitigating the severity of the cough, and materially relieving hectic 
 symptoms. It is also a very good tonic. I could name several cases 
 of passive, continued phthisical haemoptysis, that have been effectually 
 relieved by the bugle-weed, after resisting all the common medical 
 agents used for that purpose. It has merits as an astringent, sedative, 
 and tonic in phthisis, that recommend it to a more extensive employ- 
 ment by the profession. 
 
 When there is much congestion of the lungs and bronchial tubes, 
 and haemoptysis is profuse, counter-irritants are in demand, — mustard, 
 ammoniated liniment, and cantharides may be employed as indicated. 
 In passive hemorrhage, blistering will sometimes relieve when every- 
 thing else fails. Years ago it was considered good practice to establish 
 a drain on each infra-clavicular region by a succession of blisters on 
 
214 PULMONARY TUBERCULOSIS. 
 
 an issue, especially where attacks of hemorrhage were frequent. 
 Modern refinement in therapeutics pronounces such treatment bar- 
 barous. We cannot see it just in that light. These means often 
 accomplish much good, and should not be entirely ignored. 
 
 After haemoptysis has been checked, we should make use of every 
 instrumentality in our power to prevent its return. Hence the patient 
 should be placed in bed, having his shoulders somewhat elevated ; per- 
 fect rest being enjoined and conversation prohibited. His diet must be 
 very simple, — confined to such articles as are inviting to the stomach, 
 easy of digestion, and at the same time nutritious. His drinks should 
 all be cold. The temperature in which he is placed must not be high ; 
 everything calculated to excite the patient's mind should be carefully 
 avoided ; comfort his mind with the assurance that the bleeding will 
 not prove fatal, and your work is more than half done. 
 
 V. Purpura Hemorrhagica and Pulmonary Tuberculosis. 
 
 The co-existence of these two disorders has been noticed by several 
 pathologists. And there cannot be a doubt that their occurrence is 
 not merely incidental, but that the purpura is the symptom of an 
 especial alteration of the blood which is itself but the result of the 
 tubercular dyscrasia. At least such is the opinion of Rokitanskv and 
 M. Leudet. The latter in particular has brought forth a large number 
 of cases to substantiate this opinion. In two hundred and fortj--four 
 cases of pulmonary tuberculosis, he found nineteen cases in which 
 hemorrhages manifested themselves in some other way than in the 
 lungs ; five times the hemorrhage took place through the intestines, 
 twice in the muscular walls of the abdomen, twice in the skin, three 
 times in the brain, five times through the nose, and twice through the 
 urine. Most frequently the hemorrhage took place simultaneously 
 from various organs ; it was sometimes sufficiently abundant to com- 
 promise the life of the patient ; and in all cases the primary affection 
 caused a fatal termination soon after the occurrence of the hemorrhage. 
 
 These hemorrhages, however, occur commonly at an advanced stage 
 of the disease, particularly in acute tuberculosis of the miliary form, 
 or in the acute paroxysms of chronic cases. This rule must not be 
 considered as absolute^ for they are observed much more rarely in the 
 chronic form. They cannot be regarded as a consequence of severe 
 or often-recurring haemoptysis. Nor can they be looked upon as the 
 
HEMOPTYSIS. 215 
 
 result of tubercular ulceration. A true hemorrhagic diathesis must 
 therefore be conceded. 
 
 While we admit the latter proposition, it should be remembered 
 that purpura hemorrhagica is intimately associated with and frequently 
 the result of other disorders, such as hepatitis, gastritis, induration 
 of the spleen, tubular nephritis, granular disease of the kidney, and 
 certain structural changes in the mesenteric glands. These parts, 
 with the lungs, constitute the chief blood-making and blood-purifying 
 organs. When one or more of them cease to perform their functions 
 properly, the blood is often found deficient in its solid constituents. 
 In this case it loses its adhesive properties, and in this condition 
 escapes with ease from certain mucous surfaces of the body. This 
 deteriorated condition of the blood also induces a relaxed state of the 
 solids of the body, which still further adds to the hemorrhagic tendency. 
 
 According to my observation, wherever purpura hemorrhagica has 
 been associated with pulmonary tuberculosis, it has been mostly in 
 individuals of the nervo-sanguineous or sanguino-lymphatic tempera- 
 ments, and is a symptom of special gravity. And when it assumes an 
 active form, it speedily exhausts the vital powers, and the individual 
 falls a sure prey to the fell disease. I also regard it as a marked 
 symptom of co-existing disease in other vital organs. Suffer me to 
 relate a case by way of illustration : 
 
 Not long since I had under my care a phthisical woman whose case 
 I shall never forget. She was an individual of considerable personal 
 beauty and mental accomplishments. She was twenty-five years of 
 age, of the nervo-sanguineous temperament, had been married seven 
 years, was the mother of three interesting children, and the idol of a 
 loving husband and a large circle of admiring friends. She had a 
 hereditary title to pulmonary tuberculosis, her mother having died 
 with the disease after an illness of nearly two years, during which 
 time she had frequent and alarming attacks of haemoptysis. 
 
 As my patient's disease appeared to be recent, and the tubercular 
 exudation limited to a small portion of the superior lobe of the right 
 lung, her appetite and digestion good, and her hygienic surroundings 
 all that could be desired, I gave a rather favorable prognosis, and 
 prescribed my therapeutics with confidence. After two months' treat- 
 ment, consisting chiefly in the use of the syrup phellandrium aquaticum 
 compound, cod-liver oil, iron, quinia, and iodine, there appeared to be 
 
21G PULMONARY TUBERCULOSIS. 
 
 progressive symptoms of amendment. Her cough, which at first was 
 exceedingly troublesome, had in a measure ceased ; her pulse and 
 respiration were not so frequent, and she had gained in weight and 
 strength. Her mind was much more cheerful, and we fondly antici- 
 pated a favorable termination of her malady. 
 
 Unfortunately for my patient, about this time influenza was rife in 
 the neighborhood, and she had a very severe attack of it, which 
 aggravated her tubercular disorder and left her in a very feeble con- 
 dition. Her appetite was gone, her stomach irritable, and the bowels 
 relaxed. Her cough was annoying, and she complained of painful 
 micturition ; the urine was scanty, light colored, acid, and contained 
 considerable albumen. She also had severe pain just under the clav- 
 icle of the right side. Auscultation and percussion showed com- 
 mencing tubercular exudation on the left side. Hectic fever now 
 became fully established, and her troubles appeared to be thickening 
 and expanding in every direction. 
 
 About three weeks after her attack of influenza, purpuric patches 
 made their appearance on the lower extremities, and soon spread to 
 other parts of the body and assumed a very dark color. It was not 
 long until the gums became swollen and tender, and there was slight 
 hemorrhage from the mouth and nose. 
 
 Her malady now bid defiance to all our best therapeutics. The 
 purpura assumed a most formidable character, and quite masked the 
 pulmonary disorder. The gums became dark and more swollen, and 
 bled profusely when irritated. Hemorrhagic patches were more fully 
 developed beneath the epidermis, particularly on the lower extremities, 
 and, when accidentally injured, bled freely. Hemorrhages soon fol- 
 lowed from the lungs, bowels, and vagina, and were so frequent and 
 copious that they terminated her existence in about six weeks from 
 the appearance of the purpura. 
 
 The post-mortem showed limited tubercular deposits in the superior 
 lobes of both lungs. They were of the aggregated variety, and a few 
 of the deposits in the right lung were undergoing the process of soften- 
 ing ; in the left lung they were not so far advanced. In addition to 
 the tubercular deposits, there were numerous hemorrhagic effusions 
 scattered through both lungs, and the pulmonary tissue appeared to 
 be somewhat softened. The pleural cavity contained a small quantity 
 of bloody serum, and in various places the pleura was eeehymosed. 
 
HAEMOPTYSIS. 217 
 
 The heart was larger than usual, and its walls were quite soft. The 
 pericardium contained bloody serum, and was much redder than usual. 
 The liver was slightly fatty, and the spleen somewhat indurated. 
 The kidneys were large, and their surfaces smooth and white. On 
 section, the cortex and cones were found increased in size, and on 
 microscopical examination the Malpighian bodies exhibited no marks 
 of disease. The tubuli uriniferi were opaque and dilated, filled with 
 fatty epithelium and loose oil-globules, evidently the products of 
 tubular nephritis, — a sequel of influenza. The stomach and bowels 
 exhibited no special anatomical lesions. The peritoneum was ecchy- 
 mosed in several places. The brain was not examined. 
 
 In reflecting over this case, I have inferred three things which con- 
 tributed to the fatal purpura hemorrhagica : 
 
 1. The hemorrhagic diathesis. 
 
 2. The co-existence of tuberculosis. 
 
 3. The supervention of tubular nephritis. 
 
CHAPTER XX. 
 
 HECTIC FEVER AS A SYMPTOM OF PULMONARY TUBERCr/LOSIS. 
 ITS CLINICAL HISTORY, DIAGNOSIS. AND TREATMENT. 
 
 I. Clinical History of Hectic Fever. 
 
 Hectic fever is a never-failing symptom of pulmonary tubercu- 
 losis ; few patients escape it altogether. It commonly steals upon the 
 individual insidiously. He may at first in the morning feel chilly : in 
 the afternoon too warm ; in the evening, on till midnight, his hands and 
 feet are dry and burning ; after this he perspires until morning. As 
 the pulmonary lesion progresses, the paroxysms of fever become more 
 severe and its different stages more pronounced. The most peculiar 
 features of the fever, as it presents itself in this disease, are to be 
 found in the state of the pulse and perspiration. The pulse is small, 
 hard, tense, jerking, and very frequent, from one hundred and twenty 
 to one hundred and forty, and in the last stage of the disorder even 
 more. The perspiration is usually out of all proportion to the other 
 stages of the fever. It seems to have some important connection 
 with the patient's sleep ; it very seldom comes on while he is awake, 
 but after sleeping, he awakes and finds that he is sweating. The 
 perspiration is commonly most copious upon the chest and head ; 
 sometimes it is moderate, amounting to a slight and pleasant moisture 
 of the skin ; at others it is profuse, and he is completely drenched. 
 
 Such profuse perspiration usually belongs to the latter stage of the 
 malady, and is very distressing to the patient, making him even dread 
 to sleep. It also tends to a rapid exhaustion of the vital powers, and 
 indicates, when very copious, that the course of the disease will be of 
 short duration ; for it has been observed that the perspiration gener- 
 ally keeps pace with the febrile excitement, and this with the rapidity 
 of the pulmonary lesion. It has also been observed that any tempo- 
 rary cause which will increase the fever will likewise iucrease the night- 
 sweats. Chills are not always present in hectic fever. Frequently 
 218 
 
HECTIC FEVER. 219 
 
 they are wanting, and the patient may be ignorant of any exciting 
 cause for his profuse perspiration at night. 
 
 When pulmonary tuberculosis has advanced to the stage of soften- 
 ing, suppuration extensive in the pulmonary tissues, and the blood 
 loaded with putrid matter, the perspiration becomes very acid, and 
 not unfrequently has a peculiar sour odor that often attracts the at- 
 tention of the patient. Sometimes it is so pungent that it fills the 
 room, rendering it alike unpleasant for the patient and his attendants. 
 Dr. E. Smith says, " We have taken pains to prove that acid per- 
 spiration occurs in cleanly persons, and after daily washing of the 
 whole body, and when using clean linen, and is therefore not the re- 
 sult of circumstances too commonly found in the working classes. Of 
 one hundred and seventy-seven cases of phthisis, 56.4 per cent, had 
 a constitutional tendency to acid perspiration ; whilst of those who 
 perspired much, 70.7 per cent, had sour perspiration ; and of those 
 who perspired less than usual, 5-±.2 per cent, had remarked the acidity 
 of the excretion. Hence phthisical persons appear to be constitu- 
 tionally predisposed to an acid state of the perspiration."* 
 
 During the febrile excitement the countenance of the patient almost 
 always becomes animated, the eye brightens, and, in an individual of 
 delicate complexion, the fine flush upon the cheek gives a new beauty 
 to the features. After the night is past, and the sweating stage is 
 over, the pale cheek and the languid expression point again more 
 clearly to the internal ravages of the fatal malady. Sometimes there 
 is in the last stage of the disease a circumscribed redness on one or 
 both cheeks, which, when it becomes permanent, is regarded as the 
 speedy harbinger of dissolution. The poet has truly said, — 
 
 " But ah ! the flush upon my cheek, 
 
 That showed like health's first bloom, 
 "Was death's own color, — he had decked 
 His victim for the tomb." 
 
 II. Hectic Fever not always a Symptom of Pulmonary Tuber- 
 culosis. 
 
 Hectic fever, as a diagnosed symptom of pulmonary tuberculosis, 
 must be taken with caution, for it is a frequent attendant upon other 
 
 * Smith on Consumption, page 63. 
 
220 PULMONARY TUBERCULOSIS. 
 
 diseases, such as chronic bronchitis, pulmonary abscesses that result 
 from pneumonia, empyema, and, indeed, upon all inflammations of the 
 abdomen and pelvis that are attended with suppuration. Hectic fever 
 is sometimes present in other disorders that do not terminate in sup- 
 puration. I have frequently met with it in cholestersemia. uraemia, 
 and anaemia . Some authors maintain that it is occasionally idio- 
 pathic. I have never met with a case of this kind, but have always 
 been able to find an adequate cause for its existence in some special 
 pathological condition of the system. 
 
 Several years since, I was invited to examine a case that had been 
 pronounced idiopathic hectic by two respectable physicians. A care- 
 ful investigation proved the case to be one of diabetes mellitus. 
 Although the Urine was but little augmented in quantity, yet the 
 saccharine matter was abundant ; indeed, the urine was loaded with it, 
 and the patient's constitution was suffering to that degree that he had 
 two paroxysms of hectic during the day. His sufferings were greatly 
 mitigated by a diet composed almost exclusively of animal food, in 
 connection with such therapeutical agents as the bromide of potassium, 
 strychnia, navel-wort, quinia, iron, and opium. After some months, 
 pulmonary tuberculosis supervened and terminated his existence. This, 
 by the way, is a common sequel of diabetes mellitus. Nearly one-half 
 of the cases of this disease that have fallen under my notice have 
 terminated by acute miliary tuberculosis. 
 
 The most remarkable feature of phthisical hectic is the state of the 
 patient's mind. This is seldom depressed: he is cheerful, and is fond 
 of dwelling upon bright pictures of days to come, which hope pre- 
 sents to his imagination. Such, indeed, is the fact while the digestive 
 system preserves unimpaired its comfortable sensations and elastic 
 tone, a state of things most frequently the case where the pulmonary 
 organs have borne the weight of attack ; and some writers have gone 
 so far as to regard it an important point in diagnosis. If the patient's 
 mind is anxious, depressed, and melancholy, they tell us it is a sure 
 indication that the malady is more in the digestive than in the pul- 
 monary organs. 
 
 I have no reason to question this, for it is in perfect accordance with 
 my own observation. Indeed, I am not acquainted with any chronic- 
 disorder in which the hopefulness and buoyancy of spirits are so re- 
 markable as in pulmonary tuberculosis. In some cases there appeal's 
 
HECTIC FEVER. 221 
 
 to be an unusual brilliancy of the mind and cheerfulness of the dispo- 
 sition. Thus we frequently see that the least improvement in the 
 symptoms is at once hailed as a harbinger of returning health, while 
 their aggravation is attempted to be reasoned away by many trivial 
 circumstances, which are as baseless as the fabric of a dream. 
 
 It is often quite difficult to determine whether the trifling manner 
 in which phthisical patients speak of their symptoms and condition is 
 to be regarded as an effort to conceal a fatal truth or the result of real 
 indifference to their state. I once attended a young physician who fell 
 a victim to this disease. A brother of his had recently died with the 
 complaint ; and when I intimated to the family the nature of his 
 malady, they were greatly alarmed for his safety, but the patient did 
 not appear to be the least excited by his condition, and throughout 
 the whole course of his decline appeared cheerful and happy ; and 
 frequently when I interrogated him in relation to his health, he was 
 always better and would soon be well. A few days before he expired, I 
 told him that he was laboring under a delusion, that his disorder would 
 soon terminate his life. " Oh, no," said he, " dear doctor, I know I 
 cannot recover, I knew it from the beginning ; but for the sake of 
 saving my friends an unnecessary alarm and anxiety, I have braved 
 the storm of dissolving nature, and am prepared to die." And when 
 his last hour came, he closed his eyes upon the scenes of earth, 
 
 " Like one who wraps the drapery of his couch about him, 
 And lies down to pleasant dreams." 
 
 III. Cases Illustrating Phthisical Hectic from other Diseases. 
 
 The hectic of pulmonary tuberculosis is not unfrequently mistaken 
 for intermittent fever. This is common in sections of the country 
 where the latter disorder prevails. This is owing to the circumstance 
 that when intermittent fever becomes chronic it is so modified in its 
 features as to resemble hectic fever. I have on several occasions met 
 with cases of this kind, and at first their diagnosis is not always 
 readily made out. I will present a case or two by way of illustration. 
 
 April 7, 1859. — Called this morning to see Mr. A., aged twenty- 
 nine ; just returned from Fort Wayne, Indiana, where he has resided 
 for the past year. He has always enjoyed good health until four 
 months since, when he had a severe attack of chills and fever. He 
 had but two paroxysms, when it was checked with quinia. In twenty- 
 
 15 
 
222 PULMONARY TUBERCULOSIS. 
 
 one days from the last paroxysm, he had a relapse. This time it was 
 not so severe ; the chills, fever, and sweating were much lighter. 
 Quinia was again prescribed, but did not, as on the former occasion, 
 entirely relieve the disorder. The chills and fever were very erratic ; 
 some days he would have fever and sweating without chills ; then 
 again he would have severe rigors, with little fever and no sweating. 
 Sometimes he would have a paroxysm for several days in succession, 
 then they would cease for a day or two and return as before. 
 
 From the commencement of his illness his appetite has been uni- 
 formly good ; he has rested well at night ; and has attended to his 
 business when not suffering with the chills and fever. He now has a 
 slight cough, and mucous expectoration. Pulse, in the sitting posture, 
 ninety-five per minute ; respiration, twenty-five ; tongue clean, but 
 very red, particularly at the edges ; Thompson's gingival margin very 
 clearly defined upon the gums of the lower jaw; bowels regular; urine 
 highly colored and scanty ; mind cheerful. For three days the chills 
 have come on quite early in the morning, and by one o'clock the 
 entire paroxysm is completed, and the afternoon and night have been 
 comfortably passed. During the cold stage he complains of weight 
 and heaviness in the chest, with a slight increase of the cough and 
 expectoration. 
 
 On examination of his chest, the following physical signs were 
 elicited. The expansion of the two sides was equal ; on percussion, 
 little or no dullness was discovered on either side; on auscultation, 
 the prolonged expiratory murmur was distinctly elicited, immediately 
 under the right clavicle ; the respiratory sounds on the left side were 
 normal ; the heart-sounds were louder than common ; the bellows- 
 sound was very pronounced ; and the impulse of the heart extended 
 far beyond its normal bounds. 
 
 From the absence of enlargement of the liver and any serious pul- 
 monary lesions, we were almost ready to conclude that our patient 
 was suffering from valvular disease of the heart, complicated with in- 
 termittent fever. But the presence of Thompson's gingival margin, 
 the prolongation of the expiratory murmur just under the clavicle of 
 the right side, the erratic character of the fever, and the rapidity of 
 the pulse between the paroxysms, led to a different conclusion. The 
 case was set down as one of commencing tuberculosis, and treated 
 accordingly. During the summer there was temporary improvement 
 
HECTIC FEVER. 223 
 
 in his symptoms, and we fondly hoped that he would be relieved of 
 his disease. 
 
 About the first of October, however, he commenced to decline, and 
 more grave symptoms supervened. Hsemoptysis, purulent expecto- 
 ration, copious night-sweats, diarrhoea, and occasional attacks of pleu- 
 ritis terminated his life on the 19th of January, 1860. 
 
 Post-mortem, twenty-four hours after death, revealed the condition 
 of the lungs and their surroundings. Several broad, long, and 
 thickened adhesions existed at the apex of the right lung, with con- 
 siderable serum in the pleura. The superior lobe of the lung was 
 quite indurated, having several small vomicae at the summit, all com- 
 municating with the bronchia. The most of them were not larger than 
 a pea, the three largest being not quite so large as a common-sized 
 marble. None of their parietes were lined by false membrane, but 
 were formed of a semi-opaque substance, of a yellowish aspect, quite 
 firm and tenacious. In the middle lobe quite a number of tubercular 
 deposits were found in various stages of softening, but no excavations. 
 The inferior lobe was congested, but presented no tubercular deposits. 
 The left lung was but little affected. The bronchial mucous mem- 
 brane was very much congested, and ulceration was found in several 
 places on the right side. The heart was«omewhat larger than natural, 
 but in appearance normal. The semilunar valves of the aorta were 
 slightly thickened, but in other respects healthy. The liver was fatty ; 
 the spleen slightly enlarged ; the mucous membrane of the intestines 
 congested, and in patches very much softened. The kidneys were 
 small but healthy. 
 
 In reflecting over this case, it is evident that the patient in the 
 first instance had ague. This we conclude from his residing in a 
 place where the disease was common, and from the paroxysms being 
 promptly checked by quinia. The attack that supervened three 
 weeks afterward was more than ague. The erratic character of the 
 paroxysms, and their not being relieved by the free use of quinia, was 
 sufficient proof of this. The malarial poisoning probably had some 
 influence in developing the hectic fever thus early in the disease, and 
 giving it such prominence that it constituted the chief feature of the 
 subsequent pulmonary mutations. It was present at the commence- 
 ment, and continued with unabated severity until the last. It is true 
 that during his temporary improvement there was a brief respite from 
 
224 PULMONARY TUBERCULOSIS. 
 
 its annoyance, but when lie relapsed it became more distressing than 
 ever, especially the night-sweats, which at times were so copious that 
 his garments had to be changed two or three times during the night. 
 
 At first the sweating was mostly in the afternoon, directly after the 
 fever. At this early period the disease might have been mistaken for 
 intermittent fever alone, for there was but one physical sign that 
 pointed out the existence of pulmonary tuberculosis. The presence of 
 Thompson's gingival margin furnished grounds for a reasonable infer- 
 ence that the patient was suffering under the pre-tubercular stage of 
 the disease. — a special dyscrasia. — that would eventually work out its 
 fearful mutations in the lungs, sap the fountain of life, and consign 
 the patient to a premature grave. 
 
 The next case I would introduce is that of Ann B. I was called 
 to see her in the fall of 1858. Her parents had died with pulmonary 
 tuberculosis, and at an early age she was left to the care of a maiden 
 aunt, who had watched over her with more than a mother's solicitude. 
 She was a delicate child, and everything that a scientific physician 
 could suggest to strengthen the vital force and overcome the proclivity 
 to phthisis was scrupulously enforced, and, at the age of sixteen, she 
 had the appearance of a healthy girl. 
 
 About this time she was sent to one of our fashionable female semi- 
 naries. Being anxious to improve her mental powers and keep up with 
 her class, she applied herself diligently to her studies. Overtaxing 
 her brain, taking little exercise, living on scanty diet, and imitating 
 some of her school-mates in the barbarous habit of tight lacing, she 
 soon laid the foundation of ill health and for the subsequent develop- 
 ment of pulmonary tuberculosis. 
 
 Some eight weeks previous to my first visit, she commenced to have 
 chills in the morning, fever and sweating in the afternoon ; pain in 
 the back and limbs ; loss of appetite ; cough and expectoration, particu- 
 larly in the morning. By degrees the chills and fever became so severe 
 that she was obliged to relinquish her studies and call in a physician. 
 After a hasty examination, he pronounced her disease intermittent fever, 
 said she would be well in a few days, and prescribed the following : 
 
 B Sulph. quinine, gr. xxx ; 
 Ext. cinchomae. ji. — M. 
 Ft. in pil. Xo. xx. 
 Sig. — One pill every four hours. 
 
HECTIC FEVER. 225 
 
 These pills were continued for six days without any improvement, 
 when the following was substituted : 
 
 R Sulph. quiniae, gr. xxx ; 
 
 Acid, sulph. dilut., gtt. xxxv ; 
 Sp. vin. gallic, f^iii. — M. 
 SiG. — A teaspoonful every four hours. 
 
 While using this prescription, the paroxysms of fever were in a 
 measure relieved, and she was enabled to resume her studies in part ; 
 but still they never entirely left her, although she was under the in- 
 fluence of antiperiodic medicine all the time, the doctor maintaining 
 that her disease was nothing but ague. After struggling along in 
 this way for several weeks, she was compelled to relinquish her studies 
 and return to the residence of her aunt. 
 
 My first visit was early in the morning. She had passed a very 
 restless night. In the lying posture her pulse was one hundred and 
 five per minute ; respiration twenty-five ; tongue clean ; Thompson's 
 gingival margin clearly defined upon the gums ; appetite poor and 
 bowels relaxed. Complained of dyspnoea when the chills and fever were 
 on, and for the last two weeks had had copious night-sweats. Cough 
 and expectoration not troublesome. 
 
 The physical signs were pronounced. The two sides were quite 
 unequal in their expansion-movements, the left being deficient in 
 motion. Percussion yielded dullness over one -third of the left side 
 from the summit of the lung downward. Humid crackling was dis- 
 tinctly heard just under the clavicle. On the right side the resonance 
 was normal; the only abnormal sounds heard on auscultation were 
 prolonged expiratory murmur and slight mucous rhonchus. 
 
 The diagnosis was clear : tubercular induration and softening in 
 the superior lobe of the left lung, and semi-fluid tubercular matter in 
 the right. The prognosis was unfavorable. I consented to attend 
 her with the understanding that her disease would prove fatal. This 
 is a sad office, but one from which the physician should never shrink. 
 There is a chastened and holy pleasure in administering to the wants 
 of one who is standing as it were upon the verge of the better land. 
 The silent chamber where the messenger of dissolution waits for his 
 expiring prey, is often the gateway to eternal life. And oh, how 
 often, as I have felt the last throb of the pulse, heard the last breath, 
 
226 PULMONARY TUBERCULOSIS. 
 
 and seen the last flash of the eye, as the soul escaped from its earthly 
 tenement, have I been reminded of those beautiful lines of Mrs. Bar- 
 bauld, — 
 
 " How blest the righteous when he dies ! 
 When sinks a weary soul to rest ; 
 How mildly beam the closing eyes! 
 
 How gently heaves th' expiring breast ! 
 
 " So fades a summer cloud away ; 
 
 So sinks the gale when storms are o'erj 
 So gently shuts the eye of day ; 
 So dies a wave along the shore. 
 
 " A holy quiet reigns around, 
 
 A calm which life nor death destroys ; 
 And naught disturbs that peace profound 
 Which his unfettered soul enjoys." 
 
 The reader must pardon this seeming rhapsody ; such thoughts are 
 so intimately connected with this disease, it is difficult to escape them, 
 and the physician who has not been inspired by them must have a 
 heart that does not beat in sympathy with his kind, a mind that can- 
 not appreciate the sublimity and glory of the Christian's faith and 
 hope. 
 
 This patient lived some three months from the commencement of 
 my attendance; her chief suffering, until the last, was from hectic 
 fever. 
 
 IV. The Treatment of Hectic Fever. 
 
 In the treatment of this fever, as it occurs during the progress of 
 pulmonary tuberculosis, there are four indications to be filled. — 1st. To 
 relive the morbid sensibility of the nervous system. 2d. To subdue 
 local irritations and congestions. 3d. To eliminate morbid products 
 from the blood. 4th. To sustain the vital powers. To fill the first 
 indication we have four invaluable medical agents: viz., opium, hydro- 
 cyanic acid, quinia, and digitalis. 
 
 1st. Opium. This has long been used in the treatment of pul- 
 monary tuberculosis ; it is indispensable. Of late it is seldom pre- 
 scribed in its crude form, especially in hectic fever, experience having 
 taught physicians that in many patients it is apt to disorder the 
 stomach, impair the appetite, and increase the general debility. Hence 
 morphia and its salts are commonly prescribed in its place. The 
 acetate of morphia will sometimes arrest the febrile paroxysms speedily. 
 
HECTIC FEVER. 227 
 
 I 
 
 I have frequently seen it alone relieve patients who were having two 
 paroxysms of fever in twenty hours. I remember one case where the 
 patient was scarcely through with one paroxysm before he was attacked 
 by another, where the eighth of a grain of this article, given every 
 four hours for three days, mitigated their severity so that he would 
 not have a paroxysm for several days. When it was discontinued, they 
 would return as usual. When the acetate or sulphate of morphia 
 disagrees with the patient, try Squibb's liquor opii compound. From 
 what I have seen of its effects in my practice, it appears to possess 
 rare powers in relieving the morbid sensibility of the nervous system, 
 preventing the frequency of the paroxysms, and producing quiet and 
 refreshing sleep. It should not be administered in large doses at long 
 intervals, but frequently, every three or four hours, in small doses, — 
 eight, twelve, or fifteen drops, — so as to continue its steady anodyne 
 action. Given in this manner it has no superior as a remedy for 
 phthisical hectic. 
 
 2d. Hydrocyanic Acid. This is a most valuable medicinal agent 
 to overcome and control morbid nervous sensibility. Indeed, it is 
 almost equal to opium in mitigating fever, reducing the frequency of 
 the pulse, relieving troublesome dyspnoea, quieting harrassing cough, 
 and producing refreshing sleep. When the tubercular disease is com- 
 plicated with bronchial catarrh, I know of no medical agent that acts 
 with more promptness and efficacy than this, particularly when the 
 cough is troublesome and the expectoration profuse. Here is a pre- 
 scription that I have found useful in cases of this kind : 
 
 R Acid, hydrocyanic, gtt. xx ; 
 Morph. acetat., gr. ii ; 
 Tinct. sanguinariae, 
 Tinct. digital., 
 Ext. cubebae fl., aa f3ii ; 
 Hoffman's anodyne, f^ss; 
 Simple syrup, fgii. — M. 
 SlG. — A teaspoonful three or four times a day. 
 
 In administering hydrocyanic acid in hectic fever, great care should 
 be taken that it does not produce vertigo, nausea, vomiting, and diar- 
 rhoea. If it produces these effects it should be discontinued at once. 
 When hectic occurs early in phthisis, hydrocyanic acid will sometimes 
 
228 PULMONARY TUBERCULOSIS. 
 
 • 
 
 check the night-sweats, substituting for them an intense heat and dry- 
 ness of the skin which is about as annoying to the patient as the 
 sweating. When it produces this effect it should be given in connec- 
 tion with some diaphoretic, such as solution of acetate of ammonium, 
 or solution of citrate of potassium. The following will be found a 
 useful formula : 
 
 B Acid, hydrocyanic, gtt. iv ; 
 
 Liq. opii comp. (Squibb's), f5i; 
 
 Sol. potass, cit., fgiii; 
 
 Syrup, limon., fgi. — 31. 
 SlG. — A teaspoonful every four hours. 
 
 3d. Quinia has long occupied a place in our list of therapeutics 
 for hectic fever, but it has not the same power over this disorder that 
 it has over intermittent fever. In the latter it is a specific ; in the 
 former it is not. When given in the same way as in regular inter- 
 mittent fever, it will sometimes check the paroxysms, but it cannot be 
 depended upon for this purpose. It is true that when given in large 
 doses, although it does not often entirely check the fever, it greatly 
 modifies it. I recently had a phthisical patient under my care, who 
 suffered severely from hectic. During the hot stage his temperature 
 was 105° Fahr. He was in the second stage of the disease, and had 
 from the beginning of his illness been under homoeopathic treatment. 
 Fifteen grains of quinia, administered morning and evening for two 
 days, lessened the severity of the cold stage, reduced the temperature 
 to 101° Fahr., and rendered the perspiration quite endurable. I have 
 no faith in small doses of quinia for hectic fever. A grain given 
 every three or four hours only aggravates the disease. It must be 
 given in quantities sufficient to render insensible those nervous centres 
 through which the source of irritation operates in producing the par- 
 oxysms. Ten or fifteen grains taken at night will usually be sufficient. 
 Some physicians object to the use of quinia in such large doses in pul- 
 monary tuberculosis ; they say it is apt to produce haemoptysis and 
 intensify congestion in the pulmonary tissues. I have never wit- 
 nessed such effects attending its exhibition, and, so far as haemoptysis 
 is concerned, I believe it would have the contrary effect. Indeed, 
 there are numerous cases recorded of obstinate hemorrhages from the 
 lungs, bowels, and uterus being speedily cured by quinia. In some 
 patients quinia produces disagreeable brain-troubles when given in 
 
HECTIC FEVER. 229 
 
 much smaller doses than those just named. When it produces such 
 effects it should be immediately suspended. 
 
 4th. Digitalis. There are few articles in the materia medica that 
 have been more extensively prescribed in the treatment of pulmonary 
 tuberculosis than this. At one time it was considered almost a specific 
 for the disease. But, like all our boasted therapeutics, it was soon 
 discovered that it would not cure the disorder ; it is one of our most 
 useful remedies, but no specific. Physicians are not entirely agreed as to 
 its physiological action upon the system, but experience will soon teach 
 any one that it is a powerful neurotic, exerting some special sedative 
 action upon the vagus nerve. When administered in small doses in 
 this disease, it lessens the frequency of the pulse, allays nervous irri- 
 tation, and diminishes night-sweats. When the fever is very high, 
 out of proportion with the other symptoms, and destructive metamor- 
 phosis is going on rapidly, digitalis and quinia should be prescribed 
 together. German physicians are in the habit of giving for this pur- 
 pose Heim's pills, the formula for which is — 
 
 R Pulv. digitalis, gr. xx ; 
 
 Pulv. rad. ipecac, 
 
 Pulv. opii, aa gr. v. — M. 
 
 Ext. helenii, q. s. ut fiat pil. No. xx. 
 SlG. — One pill three times a day. 
 
 Niemeyer says, " The addition of a scruple of quinia to the above 
 prescription becomes all the more important ; the more periodical the 
 type assumed by the fever, the more severe its evening exacerbations 
 become and the more pronounced the chills by which they are ushered 
 in. I am so much in the habit of using Heim's pills, with or without 
 quinia, in consumption, when the fever proves refractory to other 
 remedies heretofore mentioned, that it has become a very common 
 practice at my clinic."* 
 
 In prescribing digitalis as a sedative in hectic fever I generally 
 prefer the powder, seldom giving it in larger doses than one grain 
 three times a day, abstaining from its use as soon as the action of the 
 heart becomes intermittent. In some patients it destroys the appetite ; 
 in others, it produces vertigo, nausea, and vomiting, when it should be 
 discontinued at once. 
 
 * Nienieyer's Practice of Medicine, vol. i. p. 274. 
 
230 PULMONARY TUBERCULOSIS. 
 
 Hectic fever is often greatly intensified by intercurrent congestions 
 and inflammations that require special treatment. And I know of no 
 class of remedies that will subdue them better than counter-irritants. 
 At the head of the list is emplastrum cantharides. In some cases it 
 is indispensable. In acute miliary tuberculosis I have sometimes been 
 astonished at the marked mitigation of the fever on the application of 
 a considerable blister over the affected lung. Even in the last stage 
 of the chronic form, when pain in the chest, fever, and sweating are 
 very annoying to the patient, it is a remedy of great value. Many 
 patients prefer it to the milder counter-irritants, — mustard, croton 
 oil, and ammoniated liniment. 
 
 Another great source of hectic fever is the presence of pyoid and 
 other effete matter in the blood. To eliminate these is a matter of 
 prime- importance. No healthy innervation or assimilation can take 
 place while they remain in the circulating medium ; they greatly add 
 to the morbid irritability of the nervous system, and exhaust the 
 patient's vital powers. The best blood eliminatives to fill the indica- 
 tions to be met in the disease are iodide of potassium, chlorate of 
 potassium, hyposulphite of soda, nitric, muriatic, and sulphuric acids. 
 Nitric acid in particular is a most valuable remedy for hectic fever ; 
 its chief virtue consists in its catalyptic and eliminative action. 
 Indeed, under some circumstances, it is a valuable restorative haematic. 
 Muriatic acid is also a good remedy in this disease, and may be pre- 
 scribed freely. When the chief object appears to be the arrest of the 
 night-sweats, the sulphuric acid is probably the best remedy ; it may 
 be used externally and internally. Ten or fifteen drops of the diluted 
 acid in a wineglassful of a strong infusion of sage, taken two or three 
 times a day, with a sponge-bath of the acid diluted (a teaspoonful to 
 a pint of water) at night, will sometimes promptly arrest them. 
 
 But while we are dealing with the prominent symptoms of hectic 
 fever, and managing them with our best therapeutics, we should not 
 neglect the patient's vital powers ; these are to be maintained at all 
 hazards. The vegetable tonics, iron, cod-liver oil, and stimulants, 
 should be employed just as the necessities of each case demand them. 
 In this way, by a careful and judicious use of the instrumentalities 
 named above, we can control, mitigate, and sometimes cure phthisical 
 hectic fever. 
 
CHAPTER XXL 
 
 DIARRHCEA AS A SYMPTOM OF PULMONARY TUBERCULOSIS. 
 
 I. The Clinical History of Tubercular Diarrhoea. 
 
 Diarrhcea is a common attendant upon pulmonary tuberculosis. 
 Statistical tables, made out from cases that have occurred at the Hos- 
 pital for Consumptives at Brompton, London, show that diarrhoea 
 began early in the disease, and continued throughout its whole course 
 in one out of every eight patients ; and only one in twenty-five 
 escaped it altogether. In some instances, it preceded every other 
 symptom of the disease ; in about one in eight cases it began at the 
 same time as the disease in the lungs, and attended its whole course, 
 — from five to twelve months, and in some cases much longer ; but 
 in the great majority of the cases it began at the latter half of the 
 disease, and continued with more or less severity until the end. 
 
 When it occurs early in the disease, it is a symptom of more than 
 ordinary gravity. In some phthisical patients it is the first symptom 
 that announces the approach of the wasting malady ; hence it has been 
 called colliquative, from its blighting and withering influence upon 
 the system. When it occurs thus early, and is unyielding to appro- 
 priate treatment, we may look for a speedy termination of the case ; 
 for there are few things which exhaust the vital forces more rapidly 
 than a constant and profuse diarrhoea. It will bleach a patient out 
 directly, so that you will hardly know him. In acute miliary tubercu- 
 losis it sometimes constitutes the most annoying symptom, and the 
 physician has often not detected the lung-trouble until the very last, 
 having had his attention directed exclusively to the diarrhcea. 
 
 II. The Causes of Phthisical Diarrhoea. 
 
 This is commonly the effect of ulceration in the small intestines and 
 colon. These ulcers usually commence in the mucous follicles of the 
 
 231 
 
232 PULMONARY TUBERCULOSIS. 
 
 small intestines, and, when once begun, the ulcerating process extends 
 itself indefinitely to the surrounding mucous membrane. These ulcers 
 are mostly produced by the deposit (softening and deposit) of tuber- 
 cular matter ; and in most cases the entire process is accomplished 
 without any very marked symptoms of inflammation. These tubercles 
 are mostly of the miliary form, and are very small, not more than one- 
 sixteenth or one-eighth of an inch in diameter. They have an opaque, 
 cheesy appearance, and when we examine them minutely we find that 
 they are composed of immense numbers of granules of fat and of 
 withered nuclei ; in others we find that the centre is semi-fluid, soften- 
 ing down ; while in others still more advanced, we find that the slight 
 covering of the mucous membrane has given way, and a small ulcer is 
 formed, with a depression in its centre and an irregular excavated margin. 
 
 At the base of these ulcers, immediately beneath the peritoneum, 
 are sometimes found numerous minute tubercles, arranged in nearly 
 the same form as we find them in the lungs, and by softening and 
 expulsion they increase the magnitude of the ulcer. "We do not, how- 
 ever, find these ulcers always presenting the appearance just described. 
 Not unfrequently we find the mucous membrane raised, presenting a 
 swelling about the fourth of an inch in diameter ; and on making an 
 incision into it, it is found to contain pus, and presents the appearance 
 of a common abscess in the mucous membrane. 
 
 A fortunate thing connected with these ulcers is that they seldom 
 perforate the intestines. I never met with but one case of this kind. 
 It was that of a young woman ; she had been afflicted with pulmonary 
 tuberculosis for more than a year, — diarrhoea was the chief trouble. 
 One morning, just after rising, she was suddenly seized with an ago- 
 nizing pain in the caecum. She speedily collapsed, and died in thirty- 
 six hours. Post-mortem revealed a small perforation in the colon 
 about an inch above the caecum. 
 
 In some cases of diarrhoea attending this disease, we find it alter- 
 nating with constipation. I recently attended a case where this state 
 of things occurred. For several days the bowels would be very much 
 relaxed, and could scarcely be restrained by the most active measures. 
 Then again they became constipated, swollen, and painful, and would 
 not move for days without physic. In this instance the disease was 
 confined more to the peritoneum than to the mucous membrane of the 
 intestines. This was demonstrated by post-mortem ; for that membrane 
 
DIARRHCEA. 233 
 
 was extensively studded with miliary tubercles, and there was con- 
 siderable serous effusion in its cavity. 
 
 This is an important fact in the diagnosis of phthisical diarrhoea 
 worthy of being remembered. Where we have such alterations in the 
 condition of the bowels attended with soreness on pressure, tympanitis, 
 and pain on deep inspiration, we may, as a general thing, suspect more 
 or less tubercular and inflammatory disease of the peritoneum, which 
 is a grave complication of pulmonary tuberculosis, and adds greatly to 
 the sufferings of the patient. 
 
 III. The Appearance of the Evacuations in Phthisical Diarrhoea. 
 
 These have no uniform appearance. In some cases they are mixed 
 with blood, in others with bile, mucus, and serum, or they may pre- 
 sent a yeasty character. Sometimes they are profuse, and attended 
 with little or no pain ; in other instances the stools may be scanty, 
 and composed of little else than blood and mucus, attended with pain 
 and tenesmus, and the case may easily be mistaken for one of acute 
 dysentery. In others, the evacuations are composed chiefly of blood 
 and amount to what might be called hemorrhage from the bowels. This 
 is apt to be the case when the ulcers are near the sigmoid flexure or 
 the rectum. I have the notes of one case in particular, where the 
 patient succumbed to copious hemorrhage from the bowels, in con- 
 sequence of several large ulcers near the sigmoid flexure, where there 
 was but a very limited amount of tubercular disease in the pulmonary 
 organs, not enough to cause the death of the patient. 
 
 But hemorrhage from the bowels frequently occurs, during the 
 progress of pulmonary tuberculosis, where there is no ulceration of the 
 intestines. Obstructions either from pulmonary lesions or from the 
 hepatic congestions which are so common in this disorder, may lead to 
 engorgements of the portal circulation, which may be the means of pro- 
 ducing congestion of the intestinal mucous membrane, and may cause 
 hemorrhage from it, in the same manner as we have extensive exuda- 
 tions of blood from the bronchial mucous membrane, without any 
 special breach of structure. I have frequently known profuse hemor- 
 rhage to occur from the rectum in this disease/ from simple engorge- 
 ment of the hemorrhoidal veins. And in many cases the patient 
 experiences much relief from such discharges, when moderate in 
 amount. 
 
234 PULMONARY TUBERCULOSIS. 
 
 The appearance of the discharges most generally points out the 
 source from which they come ; if they arise from the hemorrhoidal 
 vessels, the blood will be abundant and its color very florid, and it 
 will either precede or follow the dejections; if higher in the intestines, 
 it will be incorporated with fseces ; and when it travels a considerable 
 portion of the alimentary canal, it becomes discolored by the secretions 
 from the membranes. This is particularly the case when the blood 
 comes from the caecum or the stomach. In the latter organ, the acid 
 of the gastric juice acts upon the blood, and it becomes black, and is 
 evacuated from the bowels in the form of a fluid which very much 
 resembles tar. 
 
 The distinguishing feature, however, of phthisical diarrhoea is its 
 unmanageable character. It commonly resists all medical treatment ; 
 it may be checked for a short time, but it again returns, frequently 
 with renewed severity ; and as a general thing physicians have ceased 
 to employ any very active measures to arrest it, being persuaded that 
 it is a concomitant of the constitutional malady, and that in this way 
 the lungs are partially relieved by the bowels acting as a secondary 
 scavenger for the elimination of tubercular matter from the system ; 
 for it is a fact, which has been demonstrated by frequent observation 
 in cases of pulmonary tuberculosis attended with profuse diarrhoea, 
 that the chest-symptoms are in a great measure kept in abeyance ; 
 cough, pain, and dyspnoea are mitigated ; and in some instances the 
 pulmonary lesion has been completely masked by the bowel-symptoms, 
 so much so that it was only revealed by post-mortem. 
 
 Another feature of this diarrhoea as it manifests itself in phthisis is 
 the period of the day at which it occurs. In most patients this is at 
 night, particularly the after-part. I have known patients to have six 
 or ten evacuations from midnight till morning, while during the re- 
 mainder of the twenty-four hours they would not be annoyed by it. 
 
 When diarrhoea is very profuse, and accompanied with copious 
 night-sweats, we may generally prognosticate a speedy and fatal 
 termination of the case ; few constitutions can long withstand such 
 excessive drains upon the vital fluid, for they are not only effete in their 
 nature, but are the expressive symptoms of a profound tubercular 
 dyscrasia. 
 
DIARRHOEA. 235 
 
 IV. A Case Illustrating the Diagnosis of Phthisical Diarrhoea. 
 
 The diagnosis of phthisical diarrhoea is not always easy. It is 
 sometimes confounded with muco-enteritis ; I have occasionally made 
 this mistake, and have known others to do the same. Here is a brief 
 description of one of my cases ; it will serve for nearly all : * 
 
 May 14. — Called this day to see Miss E., aged twenty-two. Has 
 been annoyed with diarrhoea for four weeks ; nervo-sanguineous tem- 
 perament : pulse ninety per minute ; respiration twenty-eight ; tongue 
 furred, mouth dry ; fever in the after-part of the day, but no night- 
 sweats ; complains of thirst; appetite very poor, and digestion badly 
 performed: food passing through the alimentary canal almost un- 
 changed ; bowels tender to the touch, the evacuations abundant, thin, 
 watery, and attended with pain ; urine scanty and highly colored ; cata- 
 menia regular but scanty ; skin sallow, countenance dejected ; mind 
 hopeless ; no cough, expectoration, dyspnoea, or pain in the chest. Has 
 emaciated somewhat, and complains of weakness on attempting to ex- 
 ercise. She has no hereditary title to phthisis, and her health has been 
 good until the present illness. 
 
 The diagnosis was muco-enteritis, and a favorable prognosis was 
 given. A large blister was applied to the abdomen, and the following 
 was ordered : 
 
 R Mass. pil. hyd., gr. x ; 
 Pulv. opii, gr. xii ; 
 Pulv. ipecac, gr. x ; 
 Pulv. camphorae, gr. xx. — M. 
 Ft. in pil. No. xx. 
 
 Sig. — A pill every six hours. 
 
 This treatment was continued for six days, with marked improvement. 
 The tongue commenced to clean, the afternoon fever abated, the evacu- 
 ations from the bowels became more natural and not so frequent, the 
 expression of the countenance not so desponding, and the mind more 
 cheerful. As the abdomen still remained tender to the touch, the 
 blister was reapplied, and the pills were continued every eight hours. 
 Her diet was chiefly boiled rice, animal jelly, and gum-water. Perfect 
 rest was enjoined, with due attention to ventilation, bathing, and 
 mental occupation. 
 
 On the first of June her symptoms were all improved, and a mild 
 
236 PULMONARY TUBERCULOSIS. 
 
 tonic course of treatment was instituted. For three weeks she appeared 
 to he regaining her usual health. But after this there was little or no 
 improvement. The diarrhoea was troublesome, although her tongue 
 was clean, appetite good, and digestion much improved. Various 
 remedies were now prescribed without any special advantage. At this 
 juHcture Dr. F. was called in consultation ; he agreed with me as to 
 the nature of the malady, and suggested the following prescription : 
 
 B Argent, nitrat., gr. viii ; 
 
 Morphiae acetat., gr. ii; 
 
 Bismuth, nitrat., 9iiss; 
 
 Ext. conii, gr. xxx. — M. 
 Ft. in pil. No. xx. 
 SiG. — One pill three times a day, after meals. 
 
 From this time until the first of August she was more comfortable ; 
 but on that day, just after breakfast, she had haemoptysis. This was 
 the first symptom of pulmonary trouble that appeared. The hemor- 
 rhage was quite free, but did not weaken her much. A careful phys- 
 ical exploration of the chest was now instituted, when the following 
 signs were elicited : 
 
 Inspection showed the expansion-movements of the two sides of 
 the chest to be nearly equal. On percussion there was dullness on the 
 right side, accompanied with prolonged expiratory murmur, with humid 
 crepitation. On the left side the inspiratory murmur was harsh, the 
 expiratory prolonged ; but no marked dullness on percussion. These 
 signs clearly indicated a considerable amount of tubercular exudation 
 in the right lung, which was softening, and a much smaller amount in 
 the left, which was crude. 
 
 Her decline was now rapid ; cavities soon formed in both lungs, and 
 she fell a victim to the disease on the 17th of October. The most 
 annoying symptom throughout the whole course of her decline was 
 diarrhoea ; and so effectually was the disorder in the pulmonary organs 
 masked by it that, if it had not been for the haemoptysis, the true 
 nature of her malady would not have been known until almost the 
 last. The physical signs of the pulmonary lesion were, no doubt, as 
 marked on the first of June as at the time I examined the chest, 
 and it was a want of attention on my part that led me into such an 
 error of diagnosis. 
 
DIARRHCEA. 237 
 
 The case just described occurred before I bad any knowledge of 
 Dr. Thompson's gingival margin. Since then there need be no diffi- 
 culty in distinguishing between phthisical and other forms of diarrhoea. 
 Although it is'not always present in pulmonary tuberculosis, yet it is 
 seldom found wanting where the intestinal mucous membrane has 
 borne the principal shock of the disease, and diarrhosa has been pro- 
 fuse and annoying. And where it is clearly defined upon the gums, I 
 never hesitate a moment to pronounce the case tubercular. 
 
 And I am happy to say that since the publication of my article in 
 the Philadelphia Medical and Surgical Reporter, August 4, 1860, 
 on Thompson's gingival margin, I have received several letters from 
 distinguished members of the profession in this country and in Europe, 
 confirming the views expressed in that article as to its value as a means 
 of diagnosis in pulmonary tuberculosis. Dr. Telephe P. Desmartis, a 
 distinguished physician of Bordeaux, France, says, " I consider the 
 gingival margin an infallible sign of phthisis pulmonalis. I have 
 found it useful in detecting the disease in the incipient stage, and 
 have thus been able to employ prophylactic treatment with advantage ; 
 . . . its value is generally admitted." 
 
 And I would rejoice could I say as much for my own country. Its 
 value is not appreciated here as elsewhere ; I know this for the follow- 
 ing reasons : 
 
 1. I never hear it mentioned in my consultations with members of 
 the profession, as a symptom of any value in making out a diagnosis 
 of tuberculosis. 
 
 2. It is never mentioned as a symptom in cases of phthisis reported 
 in our medical journals. 
 
 3. It is never once mentioned by our systematic writers on the 
 practice of medicine. Not an American work on pulmonary tubercu- 
 losis published during the last ten years has a word on the subject. 
 
 The ignoring of a symptom so valuable as the gingival margin is 
 not a mark of wisdom in any physician or writer. By so doing they 
 reject one of the most important signs of the tubercular diathesis that 
 nature has given us. 
 
 V. Treatment of Phthisical Diarrhoea. 
 
 This should be conducted with great caution. When it depends 
 upon imperfect chymification, pepsin, subnitrate of bismuth, and 
 
 16 
 
238 PULMONARY TUBERCULOSIS. 
 
 strychnia are useful remedies. Pepsin, in particular, may be prescribed 
 with great advantage. I often hear physicians complain that their 
 phthisical patients derive no benefit from its use. The reason of this 
 is that it is improperly prescribed. When the pepsin-glands of the 
 stomach are healthy, and secrete a normal amount of gastric juice, 
 there is no call for this article ; chymification is complete without it, 
 and when furnished in superabundance, it must, to a certain extent, 
 interfere with other chemical agents that are useful in the normal pro- 
 cess. We know that a certain portion of hydrochloric acid is de- 
 manded for the formation of healthy chyme ; if more be taken than 
 is necessary, it interferes with the healthy functions of the stomach, 
 and in some instances produces painful digestion and diarrhoea. The 
 injurious effect of a superabundance of pepsin is not quite so obvious, 
 although I have often heard patients complain of feeling much worse 
 after taking it. 
 
 The indications for its administration may be briefly stated thus : 
 There is loss of appetite, or a fastidious one ; pain in the head ; the 
 tongue is slightly injected in its papillae, and there is whitish fur upon it, 
 though in many cases the tongue is clean, large, and indented: there is 
 sometimes nausea or actual vomiting ; the bowels are commonly very 
 loose, the evacuations being composed mostly of undigested food. bile. 
 and mucus. The patient also complains of a sensation of weight in 
 the stomach after eating, followed by throbbing in the abdomen, with 
 languor and drowsiness. In some cases, especially where the food re- 
 mains in the stomach longer than usual, there is flatulence, heart-burn, 
 and sometimes agonizing gastralgia. 
 
 I now have a young lady under my care suffering with pulmonary 
 tuberculosis, who had all the symptoms just described, that gave way 
 in a few days by the use of pepsin. The practitioner should see that 
 he employs a good article, for much of it sold in the shops is perfectly 
 worthless — of no more use than so much starch or soda. M. Bou- 
 dault's pepsin is a very inferior article when compared to E. Scheffer's. 
 If any one doubts this, let him prescribe Scheffer's a few times, and 
 he will find that it will seldom disappoint his expectations. I now 
 employ no other. 
 
 A combination of pepsin and bismuth sometimes acts kindly in 
 phthisical diarrhoea, especially where it depends upon indigestion. 
 Here is a favorite prescription of mine : 
 
DIARRHOEA. 239 
 
 R Pepsin (Scheffer's), 
 Bismuth, subnit., aa 3i ] 
 Strychniae, gr. \ ; 
 Pulv. gum. acaciae, gr. xxiv ; 
 Sac. albae, Sii- — M. 
 Ft. in chart. No. xii. 
 Sig. — A powder every six hours. 
 
 When phthisical diarrhoea depends upon tubercular disorganization 
 and its consequent inflammatory action in the intestines, pepsin and 
 bismuth are of little use. It is true they may exert a soothing effect 
 upon the ulcers and a tonic influence upon the surrounding blood- 
 vessels, but aside from this they have little influence. When ulceration 
 exists in the small intestines, I have found the following a better pre- 
 scription : 
 
 R Potass, chlor., 
 
 Tinct. ferri hydrochlor., aa gss ; 
 Aquae font., fgvii. — M. 
 SiG. — A teaspoonful every four hours. 
 
 In those cases where inflammation is active, where the abdomen is 
 tender to the touch, swollen, and the dejections profuse, I have found 
 no remedy so efficacious as a large blister over the abdomen. This, in 
 connection with opium, constitutes our chief reliance for the mitigation 
 of the patient's suffering and the prolongation of his life. 
 
 When the dejections are scanty and partake of a dysenteric char- 
 acter, opium and astringents should be cautiously used at first. This 
 condition often follows a constipated condition of the upper bowel ; 
 opium and astringents will not relieve this. In this case a brisk purge 
 will often accomplish wonders. I have frequently seen individuals 
 who have suffered for days under the use of opium and astringents, 
 speedily and permanently relieved by a brisk purge of turpentine and 
 castor oil. 
 
 When the evacuations are copious and watery, and the patient appears 
 to be rapidly wasting away under their influence, a permanent astrin- 
 gent is needed ; and I know of no combination of therapeutical agents 
 more efficacious than the following : 
 
240 PULMONARY TUBERCULOSIS. 
 
 R Pulv. opii, gr. x ; 
 
 Plumb, acetat., gr. xx ; 
 Piperis, gr. vi ; 
 Strychnise, gr. \. — M. 
 Ft. in mass. : et div. in pil. No. 10. 
 SlG. — One pill every four or six hours, as occasion may require. 
 
 Suppositories of opium are of service when there is distressing 
 tenesmus, which disturbs the patient's rest, or where from irritability 
 of the stomach an opiate cannot be administered by the mouth. 
 
 In those cases of pulmonary tuberculosis attended with hemorrhage 
 from the bowels, particularly if it be profuse and has resisted ordinary 
 remedies, I should recommend the tincture of larch bark. It is an 
 excellent astringent ; I have prescribed it for years in every form of 
 hemorrhage from mucous membranes. In profuse bronchial hemor- 
 rhage it has few rivals. When opium and acetate of lead disagree 
 with the stomach, the tincture of larch bark may be prescribed with 
 great advantage in nearly every form of diarrhoea where an astringent 
 is indicated. I recently treated a very grave case of chronic diarrhoea, 
 that had resisted all the usual remedies for the disorder, successfully 
 with the following prescription : 
 
 R Tinct. larch bark, 
 
 Liq. opii comp. (Squibb's), aaf^ss; 
 
 Tinct. cinnamom., 
 
 Syrup, simplicis, aa fgi. — M. 
 Sig. — A teaspoonful every six hours. 
 
 In this case the stools were very copious, being composed of serum, 
 mucus, blood, and feculent matter. The patient was very much 
 emaciated, and little hope was entertained of her recovery. Indepen- 
 dent of its astringent properties, I think it has a special alterative 
 action upon all the mucous membranes of the body, — restraining pro- 
 fuse secretion, removing congestion, and exerting a tonic influence 
 upon the blood-vessels that supply the parts. In catarrhal diarrhoea 
 it is an invaluable remedy. 
 
 In the treatment of phthisical diarrhoea little will be accomplished 
 if the patient's diet is neglected. It is becoming quite common with 
 some practitioners to prescribe raw beef in this disorder to the exclu- 
 
DIARRHCEA. 241 
 
 sion of vegetable food. From what I have seen of this mode of 
 alimentation, I cannot say that it is preferable to a mixed diet. 
 Amylaceous aliment, such as arrow-root, sago, and tapioca, made with 
 milk, may be used with benefit. Independent of their nutritious qual- 
 ities, they have a soothing effect upon the irritable intestinal mucous 
 membrane. Milk, rice, bread-toast, and eggs may be used as the 
 patient desires. Rich and greasy food, highly-seasoned dishes, un- 
 cooked vegetables, and unripe fruit should be avoided. Beef, mutton, 
 and fish should not be altogether ignored. Bread and animal jelly 
 agree with most phthisical patients, and may be given ad arbitrum. 
 But in prescribing food for individuals suffering with phthisical diar- 
 rhoea, it must be with caution. A little too much of the best article 
 will sometimes cause mischief. 
 
 While directing special therapeutical measures to mitigate phthisical 
 diarrhoea, we must not neglect to sustain the patient's vital powers by 
 the administration of restorative haematics. Most patients will bear 
 the following combination of medical agents very well : 
 
 R Ferri citratis, q[ ; 
 
 Sol. strychnise, U.S. P., f'oii; 
 Syrup, aurantii, 
 Tinct. cardamomi, aa f^ii; 
 Inf. calombas, f^iv. — M. 
 Sig. — A tablespoonful three times a day, after meals. 
 
 In most cases of phthisical diarrhoea, it is well to delay the employ- 
 ment of opiates and astringents as long as the safety and comfort of 
 the patient will permit. Opium in particular depresses the nervous 
 powers and interferes with the nutrition of the patient, — things to be 
 avoided in the successful treatment of pulmonary tuberculosis. Tonics 
 and proper alimentation are our chief reliance. Under the bracing 
 mode of treatment this troublesome symptom of phthisis is often soon 
 checked, and the digestive functions restored to their wonted action. 
 
CHAPTEB XXIT. 
 
 death: causes which produce its sudden occurrence in 
 pulmonary tuberculosis. 
 
 The average duration of pulmonary tuberculosis is about eighteen 
 months, but in some instances it is not prolonged to half that period, 
 death supervening from accidental complication, such as — 
 
 1. Cerebral apoplexy. 
 
 2. Perforation of the pleura. 
 
 3. Perforation of the intestines. 
 
 4. Bursting of large abscesses into the bronchia. 
 
 5. Sudden and profuse haemoptysis. 
 
 6. Acute pleurisy, pneumonia, and catarrh. 
 
 I. Cerebral Apoplexy. 
 
 Every physician who has been much in the habit of treating in- 
 dividuals suffering with pulmonary tuberculosis must have occasionally 
 met witJi instances of the sudden termination of this disorder by the 
 supervention of this fatal complication. The symptoms which precede 
 the accident are commonly very obscure. The patient may sometimes 
 complain of slight pain in the head, inability to sleep, and a loss of 
 intellectual power ; but aside from these complaints there is nothing 
 to call particular attention to any special brain-trouble. 
 
 Three years since, I had under my care a man, aged thirty-five, 
 of the nervo-bilious temperament. He had a hereditary title to 
 phthisis, his father and mother having died with the malady. He 
 had suffered with marked symptoms of pulmonary tuberculosis for 
 about four months. He was still, however, able to attend to his busi- 
 ness most of the time ; complained chiefly of weakness and cough, 
 which troubled him at night, preventing sleep. He had emaciated 
 considerably, and his friends had discovered a marked change in his 
 disposition ; naturally he was violent in temper, but now he was mild 
 242 
 
CAUSES WHICH PRODUCE SUDDEN DEATH 243 
 
 as a lamb, and his countenance wore an expression of ineffable 
 tenderness. 
 
 One morning, just after rising, lie bad an apoplectic paroxysm. I 
 did uot see bim until tbree hours afterward. He had partly regained 
 bis mental faculties, but could not speak. He appeared to hear as 
 well as usual, and answered all our questions by physical signs. 
 There was also paralysis of the right arm and leg. He could 
 protrude his tongue but a short distance beyond the lips, and its 
 point was directed toward the right side of the mouth. During the 
 remainder of the day and succeeding night he rested well, and took 
 food and medicine without difficulty. 
 
 The next morning, while I was seated by his bedside, about the 
 same hour, he was suddenly seized with the most violent convulsions. 
 His face and eyes twitched with the greatest rapidity in almost every 
 possible direction ; his countenance at first was quite flushed, but in a 
 few seconds became livid ; the respiration at first was rapid, but soon 
 was almost suspended ; whenever air was expired the cheeks flapped 
 outward ; the pulse could scarcely be felt at the wrist, while the ca- 
 rotids were pulsating most furiously and the jugular veins were very 
 much engorged ; the pupils were dilated, and the limbs flexed. In 
 less than five minutes from the commencement of the seizure, the 
 respiration ceased and the patient was dead. 
 
 Post-mortem showed extensive tubercular softening in the superior 
 lobe of the left lung, with limited crude tubercular matter in the right. 
 The left hemisphere of the brain near its central connection was found 
 very much softened, its structure was lacerated, and a large apoplectic 
 clot, weighing two ounces, was removed. The pathological character 
 of the softening was tubercular ; granulated nuclear corpuscles of an 
 ovoid or somewhat irregular shape, interspersed with granular blastema 
 and particles of oily matter, were found until the softening was imper- 
 ceptibly lost in the healthy brain-tissue. 
 
 It may not be out of place just here to observe that tubercular dis- 
 ease of the substance of the brain is a very rare disorder. It is com- 
 monly confined to membranes of the brain, particularly the pia mater, 
 where it assumes the miliary variety. When the tubercular deposits 
 assume this form they are about the size of a large pin's-head, and 
 appear in the form of gray granulations imbedded among a vascular 
 net-work. This constitutes the prevailing pathological feature in the 
 
244 PULMONARY TUBERCULOSIS. 
 
 tubercular meningitis of children. In the adult subject, however r 
 tubercular deposits occur most frequently beneath the pia mater, on 
 the surface of the brain, forming irregular nebulae within the cerebral 
 tissues, of various shapes and sizes. These nebulas are confined 
 principally to the inferior part of the cerebrum and cerebellum, and 
 when they soften form abscesses that may be readily taken for those 
 which occur in common inflammation of the brain. In this respect 
 our case was unique, the tubercular disorganization being exclusively 
 confined to the minute structure of the brain, as was clearly de- 
 monstrated by the use of the microscope. 
 
 Our patient was an individual of more than ordinary intelligence. 
 He was a hard student. For some time after his health began to fail 
 he continued to tax his mental powers beyond what he was able to 
 bear, and as his memory failed him, it appeared only to stimulate him 
 to redouble his mental energy. This, no doubt, augmented his lung- 
 trouble, and perhaps was an incidental cause of the tubercular deposits 
 in the brain and of their fatal sequence. There cannot be any doubt 
 but the over-tasking the mental powers, particularly in children of the 
 tubercular diathesis, will sometimes produce tubercular meningitis. I 
 can now call to my remembrance several children who have died with 
 this disease in my practice, wherein I had every reason to believe that 
 the disorder was mainly induced by overworking the brain in the ac- 
 quisition of knowledge. Children of the tubercular habit are usually 
 gifted with very active mental organs ; and under a false and erroneous 
 system of education the physical powers are not properly attended to, 
 the brain is overworked, tubercular meningitis is induced, and the 
 little sufferer soon fills a premature grave. The most watchful care 
 should, therefore, be exercised on the part of those who have the 
 charge of the physical and mental training of children, to avoid such 
 debilitating measures as will be likely to increase the tubercular dys- 
 crasia, and studiously avoid such causes as will produce too much 
 mental excitement and disturb the healthy functions of the brain. 
 
 II. Perforation of the Pleura. 
 
 This is a frequent cause of sudden death in phthisis. It may occur 
 at any period of the disease after softening of the tubercular deposit 
 has taken place; and the symptoms which mark the accident are, 
 with few exceptions, very pronounced. A patient may have mild. 
 
CAUSES WHICH PRODUCE SUDDEN DEATH. 245 
 
 progressing symptoms of the malady, and there may be no threatening 
 signs of speedy dissolution, when suddenly you may be summoned to 
 see him die with perforation of the pleura. This was the case with 
 Gr. D., a young and interesting patient of mine, who died with pul- 
 monary tuberculosis several years since. He had been suffering with 
 very mild symptoms of the disease for about four months. The tuber- 
 cular deposit was confined to a limited portion of the superior lobe of 
 the right lung, and as he had no hereditary title to the affection, no 
 very marked tubercular diathesis, good digestion, and excellent sani- 
 tary surroundings, I gave a favorable prognosis. 
 
 Imagine my disappointment when, a short time afterward, I was 
 called in haste to see my patient die with a perforation of the pleura. 
 When I entered his room he appeared to be on the verge of suffoca- 
 tion. I was informed that about an hour before my visit he had been 
 suddenly seized with a sharp, cutting pain in the right side, which 
 produced continual coughing and dyspnoea. His pulse was extremely 
 small and weak, numbering one hundred and thirty per minute ; skin, 
 cold and clammy ; countenance, pinched and expressive of great suf- 
 fering ; percussion on the right side of the chest was much clearer 
 than on the left ; auscultation detected but the faintest respiratory 
 murmurs of the right side, on the left , they were much louder than 
 natural ; his dyspnoea gradually increased, his pulse became impercep- 
 tible, and after three hours of the most intense suffering he expired. 
 
 He had emaciated but little. On making an incision into the right 
 side of the chest, fourteen hours after death, a large quantity of air 
 escaped with considerable noise. The lung, at its superior part, was 
 adherent to the pleura costalis by several small white cords. Near 
 the apex of the superior lobe of the lung was situated a small cavity, 
 capable of containing about two ounces of fluid; this had discharged 
 its contents into the cavity of the pleura, by a considerable perforation, 
 not far from the superior part of the sac. The walls of this cavity 
 were rugged, a few bands of pulmonary tissue crossed it in various 
 directions, and near its inferior part was an opening which communi- 
 cated with a bronchial tube of considerable magnitude. The surround- 
 ing lung-structure appeared healthy, not a single tubercle being found 
 outside of the cavity. The middle and inferior lobes were congested, 
 and somewhat denser than common, but otherwise presented no marks 
 of disease. The pleura was slightly inflamed, and its cavity contained 
 
246 PULMONARY TUBERCULOSIS. 
 
 about four ounces of turbid sero-purulent fluid. The left lung was a 
 little congested, but in other particulars healthy. The bronchial 
 mucous membrane was somewhat redder than usual, but in other 
 respects exhibited no signs of disease. The heart was normal. The 
 other organs were not examined. 
 
 This patient would, in all probability, have recovered if perforation 
 had not occurred. The tubercular lesion was limited, every vestige 
 of the local deposit had been eliminated, and the cavity by judicious 
 management would have healed in the course of time. His vital 
 powers were suffering but little, and his strength had been improving 
 up to the time of the fatal accident. 
 
 It is not common for patients to succumb so rapidly as this one did 
 from a simple perforation of the pleura. The immediate entrance of 
 the external air into the pleural cavity, by means of the bronchia that 
 terminated in the vomica, caused the lung to collapse more rapidly 
 than it would have done if there had been no passage for the external 
 air. The sudden ingress of air into the pleural cavity was too great a 
 shock for the system to endure. When a lung collapses from a 
 gradual process of effusion, the shock to the system is not so great, 
 and the danger is not so imminent. 
 
 III. Perforation of the Intestines. 
 
 Some writers on pulmonary tuberculosis have doubted whether this 
 lesion ever occurs during the progress of this disease. It is undoubt- 
 edly rare, for I have frequently conversed with physicians of extensive 
 experience who have never met with an instance of the kind. In my 
 own practice I never saw but one case, and that I have already 
 described in another place. In typhoid fever, perforation of the in- 
 testines is a common accident, being the cause of a large mortality in 
 this disorder. Its occurrence is so sudden, and the suffering that it 
 produce's so great, that it speedily terminates the existence of the in- 
 dividual. The pain in the abdomen may at first be confined to a 
 small space, but it soon extends over the entire belly, and is of the 
 most agonizing character. The pain is generally accompanied by great 
 tenderness on motion or on pressure upon the abdomen ;. tympanitic 
 distention ; rapid, feeble, and thready pulse ; extreme nausea and 
 vomiting ; pinched and cadaveric features ; cold and clammy skin ; 
 which are speedily followed by death. 
 
CAUSES WHICH PRODUCE SUDDEN DEATH 247 
 
 M. Louis has recorded a case of perforation of the intestines that 
 occurred during the progress of phthisis, the pathological anatomy of 
 which is worthy of a particular study. "We will give our readers a 
 brief description of it. The patient had suffered from pulmonary 
 tuberculosis for about four months, when he was suddenly seized with 
 acute pain in the abdomen, and after a few hours of suffering expired. 
 
 Limited tubercular lesions were found in both lungs, but the prin- 
 cipal injury was in the intestines. On examining the small intestines, 
 they were found rather larger than natural, offering externally many 
 gray, bluish-colored spots, and containing a large quantity of turbid, 
 reddish, and moderately thick fluid. Dividing them into five equal 
 parts, the mucous membrane was healthy in the first and last. In the 
 remainder were numerous ulcerations, almost all situated parallel to 
 the direction of the valvulse conniventes. The largest were in the 
 centre of the intestines, intersecting the whole of its circumference, 
 and leaving the muscular coat exposed. Two among them presented 
 a superficies of from four to six inches ; they were grayish-colored 
 and rugged. The muscular coat in the same point was three-quarters 
 of a line thick ; its fibres were more brittle and less flexible than 
 natural. 
 
 Above and below this portion of the intestine, ulceration existed, 
 the edges of which were thick, but the centres were very thin, so that 
 the muscular coat seemed cut obliquely. The bottom of several con- 
 sisted of peritoneum, which was itself sometimes destroyed, and per- 
 forations had taken place in two spots. Round one of these perfora- 
 tions the serous membrane was of a livid red color, and for the space 
 of four or five lines exceedingly thin, in all respects resembling those 
 that take place in acute disease. Around the others it was of a 
 natural color, and less attenuated, as if rather the result of tearing than 
 of any other cause. 
 
 The appearance of the large intestines was similar to that of the 
 small. The muscular coat was denuded in the whole circumference of 
 the caecum, and for about seven inches of the ascending colon. It 
 was of a grayish color, with partial loss of substance, and one line 
 thick. Below this, even to the middle of the transverse colon, there 
 were other very extensive ulcerations, exactly similar to the one de- 
 scribed, leaving the intervening mucous membrane healthy. This last 
 was pale, and slightly softened in the descending colon and rectum. 
 
248 PULMONARY TUBERCULOSIS. 
 
 The greater part of the mesenteric glands were increased in volume, 
 and transformed into tubercular matter. The other abdominal viscera 
 were healthy. The cavity of the peritoneum contained a little limpid, 
 reddish-colored fluid, with a small quantity of pus. 
 
 This patient suffered with diarrhoea from the beginning, and at the 
 time of his death he was very much emaciated and broken down with 
 the profuse discharge from his bowels. What influence the perfora- 
 tions of the intestines may have had in producing the sudden termi- 
 nation of the case is a question. There was evidently considerable 
 peritonitis, although the appearance of that membrane is not noticed. 
 This may have existed previous to the first symptoms of perforation. 
 M. Louis is of the opinion that these perforations did not exist during 
 life, and that the death of the patient was caused by the number and 
 extent of the ulcerations in both the small and large intestines. But 
 we have yet to learn how small a perforation of the intestines will cause 
 the fatal termination of a case of chronic disease. In the case that I 
 have recorded, the tubercular disease had made but little progress, the 
 intestinal lesion was very small, and the effusion in the peritoneum 
 very trifling, yet the patient survived the event but a few hours. 
 
 IV. Bursting of a Large Abscess into the Bronchia. 
 
 Tubercular cavities of various sizes are found in the lungs ; some- 
 times they are not larger than a pea ; then again they may be large 
 enough to contain a pint or more of matter. Indeed, it is not un- 
 common in phthisis to find almost the whole superior lobe of a lung 
 converted into a vast abscess. When an abscess of considerable mag- 
 nitude suddenly bursts into the bronchia, there is always danger of 
 immediate suffocation. I have met with several cases where the acci- 
 dent proved almost instantly fatal. The case of S., an intimate friend 
 of mine, I shall never forget. He had been ill for several months 
 with symptoms of phthisis. The disease appeared to be of the mildest 
 form, and he was able to attend to his business until the day of his 
 death. In the morning of that day he went to his place of business 
 as usual. Returning home about the middle of the day, he com- 
 plained of being very weak, and lay down for a few moments to 
 rest. On being summoned to dinner by some member of the family, 
 it was discovered that a very sudden change had come over him : he 
 could not rise ; his countenance was blanched ; in a few moments 
 
CAUSES WHICH PRODUCE SUDDEN DEATH 
 
 249 
 
 he became speechless, and before the family could be gathered in he 
 was dead. 
 
 In consequence of his sudden and unexpected dissolution, his family 
 requested a post-mortem. This revealed the existence of a very large 
 tubercular abscess in the superior lobe of the right lung, which had 
 ruptured into the bronchia, filling it up in such a manner as to pro- 
 duce suffocation, which was the more immediate cause of the patient's 
 death. If the contents of this cavity had been gradually evacuated, 
 his life might have been prolonged for months. But he could not have 
 recovered from the disorder, for there were other tubercular deposits 
 in other parts of the lung, which would have softened and caused 
 further disorganization of lung-tissue, that would have terminated his 
 existence. 
 
 Fig. 9. 
 
 Abscesses that rupture in this way are generally encysted. Mor- 
 ton, in his " Illustrated Consumption," presents the above diagram, 
 
250 PULMONARY TUBERCULOSIS. 
 
 which we regard a very correct representation of this form of tuber- 
 cular disorganization. 
 
 This abscess was found in the middle lobe of the right lung. The 
 cyst was less than a line in thickness, and was composed of a sub- 
 cartilaginous texture. Toward the bottom of the cavity was a cruci- 
 form cord of condensed pulmonary tissue, in which the remains of the 
 blood-vessels were still visible. The internal parietes of the cavity 
 were straw-colored and much corrugated. The surrounding pulmonary 
 tissue contained irregular, blackish tubercles, with solitary spheroidal 
 crude tubercles. The bronchia opened into the cavity by four large 
 orifices. 
 
 V. Sudden and Profuse Haemoptysis. 
 
 Although haemoptysis is one of the first and most prominent symp- 
 toms that announce the approach of this fell disease, yet. strange to 
 say, it is very seldom the cause of sudden death. I have had phthisical 
 patients under my care who have bled most profusely, but in no instance 
 has it proved immediately fatal. As has been observed in another 
 place, nature has taken the greatest care to prevent such an event. 
 Tubercle being an extra-vascular deposit, when it is exuded into the 
 interstices of the air-cells of the lungs it compresses their blood-vessels 
 in such a manner that scarcely a drop of the vital fluid can escape. 
 Bones, muscles, and cellular tissue rapidly disappear under the influ- 
 ence of ulceration, while blood-vessels remain almost perfect. Thus, 
 the walls of the pulmonary arteries, when surrounded by tubercular 
 softening and ulceration of the pulmonary tissues, instead of sharing 
 in the disorganization, usually thicken by the development of materials ; 
 their calibre gradually diminishes ; after a time they cease to be per- 
 vious, and are transformed into solid cords. And it is only in those 
 cases in which such vessels are suddenly torn before they are perfectly 
 closed that profuse hemorrhage can take place from a tubercular cav- 
 ity in the lungs. Haemoptysis in phthisis, however, may and does 
 frequently occur from other sources ; it may proceed from the parietes 
 of a granulating abscess, or as an exhalation from the bronchial mucous 
 membrane, or even from a rupture of the pulmonary tissues. But it 
 matters not from what source it comes, if it is very profuse, and the 
 patient's strength is very much exhausted by the tubercular disease, it 
 may produce sudden death by the quantity lost, or by its accumulating 
 in the air-passages and suffocating the patient. 
 
CAUSES WHICH PRODUCE SUDDEN DEATH. 251 
 
 VI. Acute Pleurisy, Pneumonia, and Catarrh. 
 
 Pleurisy and pneumonia are very common complications of pulmo- 
 nary tuberculosis : at one time they were considered the chief cause of 
 the disease. This opinion was based upon the theory of the inflam- 
 matory and local origin of the malady, which is now generally discarded 
 by all enlightened pathologists. Pleurisy and pneumonia never origi- 
 nate pulmonary tuberculosis. They may, however, by the local injury 
 they inflict upon the pulmonary organs and the system generally, in 
 individuals predisposed to the disorder, lead to a more rapid develop- 
 ment of it. 
 
 An acute attack of either pleurisy or pneumonia, at any time during 
 the progress of phthisis, is a circumstance of very grave importance. 
 I have known many cases to be very abruptly terminated in this way. 
 This is more apt to occur in the miliary form of the disease, when the 
 deposits are scattered extensively through the pulmonary tissues ; they 
 act as foreign bodies, exciting inflammation long before $iey arrive at 
 the stage of softening, causing such extensive obstruction to the func- 
 tions of respiration that the breath of life is speedily extinguished. 
 
 An attack of acute bronchial catarrh is also frequently suddenly 
 fatal to patients suffering with pulmonary tuberculosis, particularly in 
 the last stage of the disease, when the patient's strength is much ex- 
 hausted and his vital powers are at a low ebb. The bronchial excre- 
 tion is sometimes thrown out so rapidly that the patient has not the 
 strength to expectorate it, and suffocation is the result. Patients in a 
 promising condition are sometimes very suddenly carried off in this 
 way. Dr. T. Thompson, in one of his lectures on Pulmonary Con- 
 sumption, speaks of an epidemic catarrh, which at one time prevailed 
 in London, that was very fatal to his ' phthisical patients, removing 
 some of them from the world very suddenly. And I have observed 
 for several years that when pneumonia and broncho-pneumonia were 
 very rife, the mortality from phthisis would be greatly increased. 
 Patients that were in comparatively comfortable circumstances would 
 become suddenly worse, and die in a few days. 
 
CHAPTER XXIII. 
 
 ABSORPTION OF TUBERCULAR MATTER. 
 
 The Possibility of its Absorption. 
 
 Dr. Carswell and a few other writers advocate the doctrine that 
 tubercular matter may be absorbed without undergoing any change, — 
 that is, without softening and its common sequence, the formation of 
 vomica. Vogel and other pathologists deny this in the most positive 
 manner, and consider the tubercular process, from first to last, disor- 
 ganizing and destructive in its nature and tendency. Perhaps in the 
 present state of our knowledge it cannot be positively determined, yet 
 there are some reasons, derived from analogy and practical experience, 
 which would lead to the conclusion that such absorption is possible. 
 
 There cannot be the least doubt that at first tubercular matter is 
 always deposited in a semi-fluid state, and there is no evidence to show 
 that it immediately becomes indurated or concrete ; and if it should 
 remain fluid for even a limited time, it would but obey the ordinary 
 laws of the animal economy to re-enter the circulation by absorption. 
 And it is a legitimate inference that such actions may be carried on 
 for a considerable time, and thus retard or prevent the accumulation 
 of the morbid matter, especially in those cases where the tubercular 
 predisposition is not very great ; or, if favorable influences are brought 
 to act on the patient, there is every reason to believe that the tuber- 
 cular exudation, like the inflammatory, may be absorbed, and the parts 
 regain their usual health. 
 
 The evidence of the absorption of tubercle, as derived from clinical 
 observation, is to our judgment quite conclusive, and admits of little 
 doubt. It cannot have escaped the notice of those much engaged in 
 the treatment of phthisical patients, that the incipient stages of the 
 disease may be well marked by general symptoms and physical signs, 
 yet the disorder, instead of advancing, will recede, and the patient 
 252 
 
ABSORPTION OF TUBERCULAR MATTER. 253 
 
 regain his usual health. I have occasionally met with instances of 
 this kind, where, from the presence of Thompson's gingival margin, 
 prolonged expiratory murmur, dullness on percussion, with numerous 
 withered cells and shriveled nuclei in the expectoration, I have had 
 every reason to suspect the existence of tubercular exudations in lungs. 
 By prompt and efficient medical treatment the individual has been re- 
 stored to health, and these signs have disappeared, — the respiration in 
 every particular becoming normal. 
 
 Admitting the proposition that tubercular blastema may be absorbed, 
 it becomes a question of great practical importance how this may be 
 effected. Have we any therapeutical agents that will aid nature in 
 this work ? I believe we have. Many years' experience in treating 
 phthisical patients leads me to this conclusion. I will not enumerate 
 just here the various remedies which I have found useful in filling these 
 indications, but will cite a case from my book of " Medical Frag- 
 ments," that will present a better idea of my mode of diagnosis and 
 treatment of this stage of pulmonary tuberculosis than any general 
 description that T can give. 
 
 " History of the Case. — June 26, 1858. Mr. T. M. came to my 
 office this morning for advice. Says he has usually enjoyed good 
 health until about six months since. He is a merchant by occupation, 
 and attributes his loss of health to constant application to business, 
 irregularity in sleeping and eating ; has also been intemperate in the 
 use of tobacco and venereal indulgences. Has been married twelve 
 years, and his wife has no children. He is of the nervo-sanguineous 
 temperament ; aged thirty-five. His brain is large ; the region of the 
 sentiments and propensities preponderating. The base of his brain is 
 well developed, indicating an abundance of nerve-power to drive the 
 respiratory and circulating apparatus. Height, five feet and six inches ; 
 weight, one hundred and fifteen pounds ; weight in health, one hundred 
 and thirty-five pounds. Has a hereditary title to phthisis, his mother 
 having died with the disease. And is in good circumstances to enjoy 
 life if he only had health. 
 
 " Present Condition. — Pulse ninety-six in the sitting posture, and 
 respiration thirty. Tongue red and dry. Thompson's gingival margin 
 clearly defined upon the gums of the lower jaw. His appetite is bad; 
 stomach irritable, with occasional vomiting. Bowels constipated ; 
 urine scanty and high colored, and under the microscope exhibits 
 
 17 
 
254 PULMONARY TUBERCULOSIS. 
 
 numerous epithelial cells from the bladder and large numbers of the 
 crystals of the oxalate of lime. For the last month he has been 
 troubled with cough and expectoration ; a microscopical examination of 
 the sputum shows the ordinary constituents of mucous expectoration, 
 with a small number of withered cells and shriveled nuclei. He has 
 constant pain in the left breast, just under the clavicle. On pressure, 
 there is tenderness over the epigastric region ; there is also tenderness 
 and fullness in the region of the liver, pointing to considerable en- 
 gorgement of that organ. Is troubled at times with vertigo and 
 palpitation of the heart ; hands and feet almost always cold ; has to 
 wear an extra amount of clothing to maintain his animal heat. Has 
 never had chills or fever. His muscles are soft and flabby ; skin 
 blanched, and countenance expressive of debility and anxiety. 
 
 " On inspection, the chest was found to be large and symmetrical ; no 
 inequality in its motion could be detected. On percussion, the reso- 
 nance of the chest was clear, excepting over the superior lobe of the 
 left lung ; here marked dullness was elicited from the summit to the 
 third intercostal space, corresponding with the location of the pain 
 complained of by the patient. On auscultation, the respiratory 
 murmur of the right lung seemed to be somewhat louder than 
 natural, with slight mucous rhonchi ; on the left side, prolonged 
 expiratory murmur was pronounced ; it was heard over the region 
 bounded by the whole superior lobe. The heart-sounds were normal, 
 but its impulse was more forcible than usual. 
 
 " Diagnosis. — This is quite obvious. Kecent tubercular exudation 
 in the superior lobe of the left lung, congestion of the mucous mem- 
 brane of the stomach, and engorgement of the liver. 
 
 "Prognosis. — This is far from flattering. Patient has no idea of 
 the gravity of his case. Although an intelligent and prosperous business 
 man, yet, as is frequently the case, he is exceedingly ignorant of the 
 laws of health. Also very self-willed ; thinks he ought to be cured in 
 a few days, and is unwilling to leave his business, reform his habits, and 
 employ such hygienic measures as will improve his general health. 
 
 " Treatment. — This I declined for the want of assurance that the 
 patient would be obedient to prescription. He left, and I saw no 
 more of him until the 26th of July. His symptoms had changed but 
 little since his first visit. He had made up his mind to submit to 
 the treatment proposed. 
 
ABSORPTION OF TUBERCULAR MATTER. 255 
 
 " The indications for treatment seemed to be three : 
 
 " (1) To improve his hygienic condition ; 
 
 " (2) To relieve the engorgement of the liver, and improve his 
 digestion ; and 
 
 " (3) To produce absorption of the tubercular exudation in the lung. 
 
 " In the first instance, he is to abandon all his irregular habits, put 
 away his tobacco, relinquish his confining employment ; take such out- 
 door exercise as his strength will allow, use the tepid bath every third 
 day just before tea, retire to rest at nine o'clock p.m., and rise at six 
 a.m. ; his mind is to be occupied with cheerful conversation and 
 pleasant reading ; his animal heat is to be maintained by such clothing 
 as the temperature may indicate. To improve the condition of the 
 digestive organs, he is to take twenty grains of the chlorate of potas- 
 sium three times a day. His diet is to consist chiefly of bread, butter, 
 boiled rice, and animal jelly. To relieve congestion of the liver and 
 costiveness, he is to take one of the following pills at night on retiring 
 to rest : 
 
 " R Mass. pil. hyd., gr. xii ; 
 Podophyllin, gr. vi ; 
 Ext. hyoscyami, gr. xxiv. — M. 
 Ft. in pil. No. xii. 
 
 "Asa counter-irritant to the affected lung, a small blister is to be 
 applied just under the clavicle, and is to be renewed as often as it heals. 
 
 "August 10. — Patient returned this morning; treatment appears 
 beneficial. The tongue looks better, and the digestion is improving ; 
 bowels regular ; rests well at night ; has a desire for greater latitude 
 in his diet, but this is not allowed. Omitted the pills, and continued 
 the chlorate of potassium. 
 
 "September 1. — The stomach has regained its healthy functions; 
 liver entirely relieved ; patient's strength is very much improved ; can 
 walk a couple of miles in the course of the day ; has tried riding on 
 horseback, but finds that it increases the pain in the chest. The 
 patient was now allowed a slight increase in the range of his diet, 
 and a tablespoonful of cod-liver oil and a dessert-spoonful of the 
 following three times a day, one hour after eating : 
 
 " B Syrup, phelland. aquat. comp., gviii; 
 Potass, iodid., 3ii. — M. 
 
256 PULMONARY TUBERCULOSIS. 
 
 c: This is a favorite prescription of mine in all cases of tubercular 
 exudation, particularly in the first stage. The following is the formula 
 which I use for making the syrup, phellandrium aquaticuni compound : 
 
 " R Sem. phelland. aquat., 
 Had. stillingise sylvaticse, 
 Cort. cinchonige rub., aa 5ii; 
 Sacc. albse, Ibii ; 
 Aquag bullientis, Oii. 
 
 " The seeds, bark, and roots, are to be well bruised, placing them in 
 a proper vessel ; add the boiling water, and simmer over a slow fire 
 for twenty minutes ; when cold, strain ; then evaporate the liquid to 
 one pint ; add the sugar ; dissolve with a gentle heat, removing any 
 scum which may form ; strain the mixture while hot. 
 
 " To secure a more permanent counter-irritant, the emp. cantharides 
 was omitted, and the comp. tar plaster of the •' Eclectic Dispensatory' 
 was substituted. This, by the way, is a most powerful revulsant, and 
 when we wish to keep up counter-irritation for a considerable time, it 
 is far superior to cantharides, tartar emetic, or croton oil. 
 
 " October 1. — Patient has been slowly gaining weight and strength. 
 He now rides five or six miles a day on horseback ; eats with a relish 
 the most substantial food ; he has still some cough and expectoration, 
 but no pain in the chest ; his pulse is seventy-five in the sitting pos- 
 ture, and respiration twenty-one ; percussion still elicits slight dullness 
 under the clavicle. On auscultation, the inspiratory and expiratory 
 murmurs are nearly equal, showing a decided improvement in the func- 
 tions of the affected lung. Thompson's gingival margin has nearly dis- 
 appeared, and the color of the patient's skin and lips shows a marked 
 increase of the red corpuscles of the blood, and the prognosis is more 
 favorable. The treatment was continued, with the addition of one of 
 the following pills three times a day : 
 
 " R Quiniae sulph., gr. xxx ; 
 Ferri sulph., 5i; 
 Strychnia? , gr. i ; 
 Ext. gentians, 5i ss - — ML 
 Ft. in pil. No. xxx. 
 
 " November 25. — Patient appears to have regained his wonted health. 
 
ABSORPTION OF TUBERCULAR MATTER. 257 
 
 The resonance of the chest on percussion is normal, there being no 
 difference between the right and left sides. The respiratory murmurs 
 are natural ; his cough and expectoration have ceased ; the pulse still 
 remains at seventy-five in the sitting posture ; has gained fifteen pounds 
 in weight, and feels able to resume his business." 
 
 General Remarks. — Twelve years have now elapsed since this 
 patient was under my care, and, so far as I can learn, he has enjoyed 
 good health ever since. There were several circumstances in his case 
 that clearly pointed out the existence of tuberculosis. In the first 
 place, Thompson's gingival margin was well defined upon the gums of 
 the lower jaw ; second, there were numerous withered cells and shriv- 
 eled nuclei in the expectoration ; and third, there was dullness under 
 the clavicle on percussion, and prolonged expiratory murmur; all of 
 which we regard as characteristic of pulmonary tuberculosis. The 
 treatment was based upon this diagnosis. That special virtues are to 
 be attached to the medical agents which were employed, I do not 
 maintain, for I admit, or rather claim, no specific for this malady. 
 But in my hands, at this stage of the disorder, these agents have 
 proved more generally useful than any others that I have ever used. 
 If the reader will take the trouble to investigate their nature and 
 physiological action, he will see the philosophy of their employment to 
 fill the indications presented in this case. 
 
 We should, however, always remember in treating phthisical cases, 
 that medicine can avail but little so long as the patient is permitted to 
 live in violation of the laws of health. Although my patient had a 
 hereditary proclivity to phthisis, his health would not have suffered if 
 he had been regular in his habits, and attended with proper care to 
 the wants of his physical system. Even when he first became ill he 
 possibly would have regained his health without medication if he had 
 relinquished for a season his business, abandoned his vices, and pur- 
 sued a course of life more in accordance with the laws of man's phys- 
 ical being. Nothing but the most careful hygienic regulations can 
 save individuals suffering with pulmonary tuberculosis, and these must 
 be insisted on from the very first. In some diseases a person may 
 continue to engage in an unhealthy occupation, chew or smoke tobacco, 
 drink ardent spirits, and indulge in other vices, and yet, after a time, 
 regain comparative health ; but not so in phthisis ; here there must be 
 total abstinence from every injurious habit. 
 
258 PULMONARY TUBERCULOSIS. 
 
 In phthisis we can sometimes accomplish much with medicine when 
 it is well sustained by proper hygienic measures. Our patient, T. M. 3 
 like many others, was willing to take any bitter drug that we might 
 prescribe. He desired to be cured, but at first was unwilling to re- 
 nounce those things which lay at the foundation of all his troubles 
 and were the chief obstacles in the way of his recovery : his seden- 
 tary pursuits, his attachment to tobacco, and his abuse of the sexual 
 propensities. To abandon vicious habits is no easy task. The disor- 
 der of man's moral nature is such that he finds gratification in vicious 
 indulgences. This proclivity in man's mental constitution is fre- 
 quently a great obstacle in the way of our benefiting the afflicted of 
 the race. They are not always willing to relinquish their vicious 
 habits. We prescribe for their physical maladies, but all in vain. 
 They eke out a wretched existence, and often fill a premature grave. 
 
CHAPTER XXIV. 
 
 THE HEALING OF TUBERCULAR CAVITIES. 
 
 I. The Possibility of their Healing. 
 
 Previous to the days of Boyle, Laennec, and Louis, the healing 
 of a tubercular cavity in the lungs was regarded as a circumstance 
 well nigh impossible. When the disorganizing process reached this 
 stage, the disorder was considered incurable, and all efforts for the re- 
 covery of the patient were regarded as useless. But recent patholog- 
 ical investigations have demonstrated the fact that the healing of a 
 tubercular cavity in the lungs is not only possible, but a circumstance 
 of frequent occurrence. Indeed, it is not an uncommon thing to find 
 in the same lung tubercular cavities in every stage of formation ; some 
 being just constructed by the deposit of fresh matter, others being 
 evacuated ; old cavities healing, and new ones forming. This process 
 may continue until the lung is rendered quite useless. At least such 
 will be the case in the great majority of instances, yet it is equally 
 true that we will sometimes meet with favorable cases, that with 
 proper medical treatment may be restored to comparative health. 
 
 II. The Mode in which a Tubercular Cavity may Heal. 
 
 The healing of a tubercular cavity is one of the most interesting 
 things connected with the pathology of phthisis pulmonalis. It is now 
 generally admitted that after tubercular deposits in the lungs have 
 become indurated, the whole subsequent process connected with their 
 history is one of disorganization. When tubercular matter is first 
 exuded, it may possibly be absorbed, and leave the tissues of the parts 
 in a normal state. But when it becomes indurated, we have no evi- 
 dence to believe that it is ever absorbed, and under such circumstances 
 we know of but two modes in which it can be disposed of: first, by 
 softening and expulsion by ulceration ; and second, by cretaceous 
 
 259 
 
260 PULMONARY TUBERCULOSIS. 
 
 transformation ; and in either instance more or less pulmonary tissue 
 is destroyed. 
 
 Now, it has been ascertained that there are three modes in which 
 the healing of a tubercular cavity may be effected. In the first place 
 the cavity may remain open, and its surface become lined with a thin 
 layer of plastic lymph. This adheres more or less firmly to the sur- 
 rounding textures, is gradually organized, and is finally converted into 
 a membrane which shields the cavity and prevents its further extension. 
 In the second place, its healing may be effected by the construction of 
 the cavity, and the slow but steady agglutination of its sides through 
 the intervention of dense cellular substance of new formation. In the 
 last place, it may take place by an effusion of coagulative lymph, or 
 by repeated deposition on the inner surface of the cavity, forming a 
 mass more or less dense in its structure, complete!}' obliterating the 
 cavity, which may be distinctly marked by its fibrocartilaginous 
 boundary. 
 
 A diagram found in " Bennett on Pulmonary Tuberculosis" presents 
 a very good delineation of the last mode of healing. The cicatrix 
 measured about three inches in length and nearly three-fourths of an 
 inch in breadth. The cavity must have been very large, and shows 
 the wonderful power of nature in repairing such extensive pulmonary 
 lesions. The patient from whom the specimen was taken died with de- 
 lirium tremens. In early life he had marked symptoms of phthisis, 
 but changing his place of residence from the city to the country, his 
 health was re-established, and for many years he had no signs of disease. 
 A writer, not long since, in one of our medical journals, quoted this case 
 to prove the beneficial effects of ardent spirits in treating this disorder. 
 But there is no evidence from the history of the case that, during 
 the time that he was suffering from the cavity, he was in the habit 
 of drinking ardent spirits. He probably did not become dissipated 
 until several years afterwards, when he fell a victim to this degrading 
 vice, and died the most miserable of all deaths — The Death of the 
 Drunkard. 
 
 III. A Large Cavity more apt to Heal than a Small One. 
 
 We have often asserted this proposition in the numerous articles 
 which we have written for the press on pulmonary tuberculosis ; and 
 as it has been called in question by some, we will briefly give our 
 
THE HEALING OF TUBERCULAR CAVITIES. 261 
 
 reasons for it. They are to be found chiefly in the nature of tuber- 
 cular disorganization, and the form in which it occurs in the lungs. 
 Pathological investigation shows that tubercular deposits may exist in 
 three forms, the miliary, infiltrated, and aggregated. The miliary is 
 the most common form. Where the tubercular diathesis is very de- 
 cided, this is the form in which it is commonly deposited, one lung or 
 both being very apt to become extensively affected. Being thus gen- 
 erally diffused through the lung-tissue, their presence being highly 
 offensive, they excite pneumonia, which in some cases is so extensive 
 that the existence of the patient is terminated before the tubercles 
 have had time to soften. 
 
 The infiltrated form of tubercle, unlike the miliary variety, is not 
 deposited in isolated spots, but is frequently exuded in such copious 
 and unbroken deposition as to render the parts a perfect mass of tuber- 
 cular matter, which some of our standard writers on pathology have 
 called tuberculous hepatization. In individuals who die with acute 
 pulmonary tuberculosis, infiltrated tubercle will almost always be found 
 in the lungs. In this case the function of the lung is speedily de- 
 stroyed, and death almost always occurs before the stage of softening. 
 
 In the aggregated form, the deposit is generally single and more 
 circumscribed ; and, although they may be large, soften rapidly, and 
 leave a large cavity, yet as a general thing they do not destroy as much 
 pulmonary tissue, nor produce as much constitutional disturbance, as 
 either of the other forms. The wall of a large separating cavity also 
 acts as a kind of scavenger for the elimination of tubercular matter 
 that might be exuded in other part's of the lungs, and thus lead to a 
 further extension of the local disorganization. In this manner we 
 believe the system may sometimes become freed from the offending 
 matter, the blood restored to its normal vitality, the local lesion ar- 
 rested, and the parts placed in a good condition for healing. Hence 
 we would not despair of a patient's life so long as his vital forces re- 
 main good, and there is sufficient healthy pulmonary structure to 
 maintain the proper oxygenation of the blood. 
 
 IV. Therapeutics for the Healing of Tubercular Cavities." 
 
 While some practitioners admit the possibility of the healing of 
 tubercular cavities, they reject the idea that medicine has any influence 
 in that direction. We do not hesitate to differ with those who hold 
 
262 PULMONARY TUBERCULOSIS. 
 
 such opinions. There is medicine for tubercular disease just as much 
 as, and even more than, there is for inflammation of the brain, puerperal 
 fever, or purpura hemorrhagica, and it may be rendered just as success- 
 ful in overcoming the malady as in either of the disorders just named. 
 It cannot be denied that since the employment of cod-liver oil, iodine, 
 iron, quinia, bromine, stillingia sylvatica, and the different phosphates, 
 and proper hygienic regulations, the mortality from pulmonary tuber- 
 culosis has been very materially reduced. That tubercular cavities 
 may sometimes be made to heal by the use of the medicinal agents 
 just named, I have had abundant evidence from my own experience ; 
 I have reported several cases in the medical journals which have been 
 cured in the third stage. Some may object to the term cured. I use 
 it in its literal sense, and those who do not like it may, if they can, 
 find one more to the purpose. I now have another case to record, the 
 history of which may be interesting to some of my readers. 
 
 V. A Case Illustrating Diagnosis and Treatment. 
 
 March 14, 1862, I was called in haste to see L. McGL, a young 
 man aged nineteen, of the nervo-bilious temperament. He was said to 
 be bleeding to death from his lungs. When I arrived the hemorrhage 
 had ceased, but he was vomiting and purging from the effects of a 
 large quantity of common salt which had been given him to stop the 
 bleeding. This was soon relieved by a pill composed of two grains of 
 opium and three of camphor. On inquiry, I learned that he had 
 been failing in health for more than six months ; that he had had a 
 cough, expectoration, and occasional paroxysms of chills and fever, 
 which were regarded as simple attacks of cold. In this way he 
 lingered along for three months before a physician was called in to 
 see him. 
 
 His first physician regarded his case as pneumonia, and treated him 
 accordingly ; but having exhausted his stock of therapeutics without 
 materially benefiting the patient, he was discharged, and an eclectic 
 was called in. He considered the patient's disorder congestion of the 
 liver, complicated with bronchitis ; the bronchitis being produced by 
 the morbid condition of the liver. But the famed liver-medicines of 
 this modern school of empiricism did not mitigate his troubles. After 
 this, a third physician was consulted, who pronounced his disorder 
 consumption, and declined treating him. This was only three days 
 
THE HEALING OF TUBERCULAR CAVITIES. 263 
 
 before the occurrence of the haemoptysis. As there were no symp- 
 toms of a return of the hemorrhage, the recumbent posture was 
 strictly enjoined, and the eighth of a grain of morphia was ordered 
 every six hours, with suitable diet, and I left with the promise that I 
 would call again in two days and investigate the case more fully. 
 
 General Symptoms and Physical Signs. — March 16. Saw 
 the patient this afternoon, according to promise. Looks very much 
 improved ; has had no haemoptysis since the last visit. His pulse in 
 recumbent posture is one hundred and ten, and not changed more 
 than two beats by the sitting. Respiration thirty-five. Has hectic, 
 which is evinced by the brilliant eye, flushed cheek, morning chill, 
 afternoon fever, and night-perspiration ; complains of pain in the right 
 breast just under the clavicle. His appetite and digestion are good, 
 bowels regular, urine scanty and loaded with euraerythrin. Thomp- 
 son's gingival margin is clearly defined upon the gums. His expec- 
 toration is profuse ; its physical character is muco-purulent, and under 
 the microscope it presents the following elements : mucous corpuscles, 
 pus-globules, tubercular granules, and isolated pulmonary fibres. 
 
 The physical signs were pronounced. Inspection showed consider- 
 able difference in the expansion-movements of the two sides. Per- 
 cussion yielded no particular dullness on either side. The chief 
 sound elicited on auscultation was sonorous rhonchus. During the 
 physical exploration, the patient had a very severe paroxysm of 
 coughing, and considerable muco-purulent matter was expectorated. 
 On resuming the examination after he became quiet, the sonorous 
 rhonchus was scarcely audible, but at the second intercostal space, 
 about two inches from the sternum, the clicking of a considerable 
 cavity was distinctly heard. At the summit of the left lung the 
 vesicular murmur was distinctly heard ; at the middle and inferior 
 region it was very much exalted, showing very clearly that this lung 
 was bearing the chief burden of respiration. 
 
 Diagnosis and Prognosis. — From the general symptoms, phy- 
 sical signs, and the microscopical constituents of the sputum, I inferred 
 the existence of a tubercular cavity in the right lung, together with 
 bronchitis. The cavity was situated near the summit of the lung, 
 and was consequently near its surface. From the absence of dull- 
 ness on percussion and feeble vesicular murmurs, I also inferred 
 slight emphysema in other portions of the lung, which was evidently 
 
264 PULMONARY TUBERCULOSIS. 
 
 caused by the obstruction of the bronchial tubes. The cavity was 
 undoubtedly the result of the softening and expulsion of a large 
 deposit of aggregated tubercle. The prognosis was not as unfavorable 
 as it appeared from a superficial view of the case. I anticipated the 
 healing of the cavity by sustaining the patient's vital powers, relieving 
 the bronchitis, and correcting the tubercular dyscrasia. 
 
 Treatment. — As the patient's digestion was good, he was allowed 
 nutritious and substantial diet: boiled and roasted beef, potatoes, 
 bread, butter, and rice pudding. For drinks, coffee, tea, and milk. 
 He was not to be annoyed with company, and was to be up as much 
 as his strength would allow. His room was to be well ventilated, 
 and, to relieve cough and procure rest at night, he was ordered one- 
 fourth of a grain of morphia. This was not to be taken until four 
 hours after the evening meal, as all opiates have a tendency to arrest 
 the perfect digestion of food if administered during the process of 
 chymifi cation. 
 
 To further promote nutrition and to sustain the vital powers, he 
 was directed to take, one hour after each meal, a tablespoonful of cod- 
 liver oil, and one of the following pills : 
 
 B Quinise sulph., gr. xxx; 
 Ferri citras, 5* ; 
 Strychnine, gr. i ; 
 Ext. gentianae, £i. — M. 
 Ft. mass. div. in pil. No. xxx. 
 
 To mitigate the bronchitis, the comp. tar plaster was applied to the 
 breast, over the bronchial region, and thirty drops of the following 
 were placed in a small vial with a wide mouth, and freely inhaled three 
 or four times a day, — 
 
 R Iodinii resubl., gr. xx ; 
 Chloroform., fgi. — M. 
 
 To counteract pyoid matter in the blood, thirty grains of bromide 
 of potassium were dissolved in a tumblerful of cold water, and taken 
 in broken doses during the day. 
 
 Further History of the Case. — In four weeks from the com- 
 mencement of the above treatment, our patient had made decided im- 
 provement. He was able to be up the most of the day ; slept well at 
 night ; cough and expectoration very much diminished. Hectic syuip- 
 
THE HEALING OF TUBERCULAR CAVITIES. 265 
 
 toms had all disappeared with the exception of night-perspiration, but 
 this was not annoying. The clicking of the cavity was very marked, 
 while the mucous rhonchus had diminished. The patient was hopeful 
 and anxious to get well, and attended to the prescription with the 
 utmost fidelity. 
 
 The treatment was continued the same, with the exceptions of the 
 inhalations of the iodine and chloroform ; these were discontinued, 
 and the vapor of an infusion of hops used in their place. These 
 inhalations were to be so performed that the air passing out of the 
 lungs should carry before it all matters contained in the air-passages. 
 In this way the cavity will be evacuated of any portion of putrefactive 
 secretion that may remain, and the process of its healing greatly 
 promoted. 
 
 Microscopical Examination of the Sputum. — At this time I 
 procured three specimens of his sputum and submitted them to a 
 careful microscopical examination ; and they all presented such posi- 
 tive evidence of disorganizing disease in the lungs, that I kept a record 
 of their appearance. I will here transcribe it for the benefit of those 
 who may be interested in the study of microscopical diagnosis. 
 
 Three specimens were obtained, each being expectorated at different 
 periods of the day ; the first specimen in the morning, the second in 
 the afternoon, and the third at night. Two preparations were made 
 from each, and, under magnifying powers of four hundred and six 
 hundred diameters, they presented the following constituents : 
 
 Preparations of Specimen First. — No. 1. Blighted starch-cells, 
 withered tubercular cells, mucous and blood-cells. 
 
 No. 2. Mucous and blood-cells, pus-cells, tubercular granules and 
 cells. 
 
 Preparations of Specimen Second. — No. 1. Epithelium from the 
 mouth, mucous corpuscles, pus-globules, tubercular granules and cells. 
 
 No. 2. Mucous corpuscles, pus-globules, tubercular granules, and 
 isolated pulmonary fibres. 
 
 Preparations of Specimen Third.— No. 1. Mucous corpuscles, pus- 
 cells, crystals of cholesterin, tubercular granules and cells. 
 
 No. 2. Mucous and pus-globules, blood-corpuscles, and pulmonary 
 meshes. 
 
 Concluding Remarks. — With the medical treatment described, 
 varied to suit the changing condition of the patient's malady, in about 
 
266 PULMONARY TUBERCULOSIS. 
 
 nine months from the commencement of my attendance I had the 
 satisfaction of seeing him restored to a state of good health ; and from 
 a physical exploration of the chest, the only signs remaining to tell 
 of the mutations of the disease were a marked flattening and dullness 
 just under the clavicle of the right side of the chest, and a slight in- 
 crease in the frequency of his respiration. And I would here add 
 that during the last seven years he has been engaged in teaching 
 school, and has been quite free from all pulmonary difficulties. 
 
 The recovery of this patient I believe may be attributed, in a great 
 measure, to the pertinacity with which he clung to the treatment. 
 Xothing could prevent him from fulfilling its minutest detail. He 
 ate. drank, exercised, and slept to get well ; and so must every indi- 
 vidual who is a subject of pulmonary tuberculosis. 
 
 In the treatment of this disease the medical attendant must pursue 
 no vacillating course. In dictating the measures to be employed, his 
 word should be law. If he is undecided, and manifests a want of 
 confidence in his therapeutics, he will soon find that his success in 
 treating patients of this class will not be very flattering. 
 
 In medical practice, faith and confidence are reciprocal. If the 
 physician has no faith in his treatment, the patient will soon have no 
 confidence in his physician. If he express doubt as to an ultimate 
 cure, he need not be disappointed if his patient seeks it from some 
 other quarter. T^e frequently wonder that so many consumptives 
 resort to empirics for relief, and often denounce them for it ; but some 
 physicians are more to blame for this than are their patients. As soon 
 as they discover a patient has phthisis, they abandon him at once ; per- 
 haps never make an effort to cure him. Such conduct is not in har- 
 mony with the teaching of modern medical science. TTe should never 
 abandon a patient until we have exhausted all of our therapeutics 
 and the lungs have become so disorganized that they can no longer 
 fan the flame of life. 
 
CHAPTER XXV. 
 
 THE CAUSES OF PULMONARY CONSUMPTION. 
 
 The causes of this disease may be classed under two heads — the 
 hereditary and the accidental. The hereditary is the most frequent 
 cause, descending from parent to child through successive generations 
 until the family relation becomes extinct. The accidental causes are 
 such as relate to variations of temperature, imperfect nutrition, — 
 whether from deficient or improper food, — breathing a vitiated atmos- 
 phere, depressing and exciting passions, insufficient clothing, tight 
 lacing, weakening discharges, intemperance in the use of alcoholic 
 stimulants, and sexual excesses ; these are some of the most common 
 causes ; but a deranged state of health, it matters not how produced, 
 predisposes to tubercular disease in the lungs or in some minor organ 
 of the body. 
 
 In this chapter we propose to treat more particularly of — 
 I. Hereditary Transmission of Pulmonary Consumption ; 
 
 II. How to Prevent its Transmission. 
 
 I. Hereditary Transmission of Consumption. 
 
 There is no principle in medical science better established than that 
 of the hereditary transmission of disease. Indeed, it is an inexorable 
 law of our being, and dates back to the fall of man, when the Almighty 
 revealed to the race that he would " visit the sins of the fathers upon 
 the children to the third and fourth generation." Awful and im- 
 pressive as the enunciation is, the warning is sometimes unheeded by 
 the medical skeptic, and set at naught by those who are suffering its 
 infliction. Human nature is so debased, the influence of self-love so 
 overwhelming and blinding t® reason and judgment, that even while 
 possessing numerous facts to guide them to the truth, thousands still 
 resist the conviction, and suffer the penalty due to violated law. 
 
 I know of no disease in which we have so marked an exhibition of 
 
 267 
 
268 PULMONARY TUBERCULOSIS. 
 
 the doctrine of hereditary transmission as consumption. It is the out- 
 standing type of all others. Whatever is characteristic of hereditary 
 transmission in other maladies, finds its counterpart in the history 
 of this. Peculiarities of mind, special configurations of hody or of 
 features, are not more decidedly transmitted from parent to off- 
 spring, than is the constitutional taint of pulmonary tuberculosis. It 
 is not, in my judgment, simply the influence of a temperament, but a 
 settled inherent predisposition to the deposit of tubercle in the lungs, 
 and is propagated from one generation to another with more frequency 
 than any other disease. And I am well satisfied that when the mode 
 of keeping medical statistics in this country shall become more uniform 
 and perfect, they will show hereditary predisposition in at least one- 
 half of all who perish with this disease. 
 
 As a general thing, pulmonary consumption is more frequently trans- 
 mitted to the younger than to the older children of the family, and more 
 commonly to the females than to the males. In a table compiled from 
 the Brompton Consumption-Hospital Reports, London, I find that in 
 one hundred cases of consumption the disease is transmitted by the 
 father four times, and by the mother thirteen times. The reason for 
 this may be found in the fact that females are more exposed to the 
 same inducing causes as their maternal parent. I have known several 
 families where the disease was confined exclusively to the females ; the 
 mother and daughters dying with it, while the father and sons were 
 exempt. We sometimes witness the same thing in cancer. I am 
 acquainted with the history of a family where for three generations 
 nearly every female died with this malady, while there was not an ex- 
 ample among the males. 
 
 But we sometimes see children of a family die with consumption, 
 of which the parents exhibit no signs, when subsequently the father 
 or mother or both are attacked, and thus the departure of the disease 
 which exerts a kind of anticipatory action in the offspring is disclosed. 
 Several years since, I attended two young men in a family that was 
 supposed to be entirely free from this disease ; they died with very 
 pronounced symptoms of the malady. Their mother at the time of 
 their death appeared to be in vigorous health. Six months subse- 
 quently, she fell a victim to the same disease, thus exhibiting the ex- 
 istence of an hereditary influence, the effect of which had preceded 
 the manifestation. Again, on the other hand, we frequently see whole 
 
CAUSES OF PULMONARY CONSUMPTION. 269 
 
 families of children cut off with consumption whose parents, having 
 shown no signs of the disease, live to old age, and perish with 
 other maladies. I have the history of a family of twelve children, al* 
 but one of whom died with pulmonary tuberculosis ; the mother died 
 with dysentery a few years since, and the father lived to be over ninety 
 years of age, dying from paralysis. 
 
 It must not, however, be inferred from anything that I have written, 
 that this disorder when produced by hereditary transmission com- 
 mences at birth. In most instances it is developed by growth, or some 
 other circumstances in life. A parent, for example, has it in middle 
 life ; his son does not get it until about the same period, — sooner or 
 later. In this way the disease may remain latent for years before it 
 is manifest. It has, however, been observed that under the influence 
 of hereditary predisposition the disease manifests itself at an earlier 
 age than that at which it is ordinarily developed independent of other 
 causes. 
 
 Again, we sometimes see individuals marry when actually suffering 
 under the first stage of consumption ; and we have known a single 
 year to circumscribe the existence of one of the parties, and occasion- 
 ally both. Not unfrequently an offspring is the result of the union, 
 who is almost sure to fall a victim to some form of tubercular disease. 
 Infants, as has been already remarked in another place, seldom die with 
 pulmonary tuberculosis. In the earlier part of my practice I had 
 under my care a youog man who gave every evidence of incipient 
 consumption. He inherited a predisposition to the disease from his 
 mother. At a period of temporary improvement in health he married 
 a young woman of good constitution, having no proclivities to the dis- 
 order. He fell a victim to consumption five years afterwards. The 
 result of this union was three children, all of whom perished when 
 they were about a year old, from tubercular disease of the brain. His 
 wife subsequently married a man free from all tubercular taint ; they 
 had four children, and so far as I know, — and I was the family phy- 
 sician for more than fifteen years, — not one of them ever manifested 
 any symptoms of tubercular disease. 
 
 But children whose parents have never exhibited any traces of the 
 malady so frequently die with tubercular disease, that some medical 
 skeptics, like Dr. Walshe, of London, ignore any hereditary influence 
 in the case. I have no sympathy with such teachers. I have not the 
 
 18 
 
270 PULMONARY TUBERCULOSIS. 
 
 least hesitation in saying that there are few cases of tubercular disease 
 in children which cannot be traced directly to the parent as the source 
 of their origin. It is true that in every instance the parent may not 
 labor under tubercular disease, but he may suffer from other constitu- 
 tional maladies which are known to produce tubercular disease in off- 
 spring. How often do we see the children of those who have had 
 syphilis die with the most aggravated forms of tuberculosis ! "What 
 vast numbers of children perish with tubercular disease of the brain 
 whose parents are inebriates ! All going to prove that the sins of the 
 fathers are visited upon the children. 
 
 II. How to Prevent its Transmission. 
 
 It is the settled conviction of some of our best medical writers who 
 have expressed an opinion on this subject, that the hereditary predis- 
 position to tubercular disease can be in a great degree prevented by 
 attention to the laws of health and matrimonial alliances of successive 
 generations. Sir Janies Clark, in his elaborate work on consumption, 
 says, " If a more healthy and natural mode of living were adopted by 
 persons in that rank of life which gives them the power of choice, and 
 if more consideration were bestowed on matrimonial alliances, the dis- 
 ease which is so often entailed on their offspring might not only be 
 prevented, but even the predisposition to it extinguished in those fam- 
 ilies in the course of a few generations." 
 
 The propriety of avoiding intermarriages with those families who 
 give evidence of being tainted with the disorder, will not be questioned 
 by any one who has made the subject of consumption a particular 
 study. I think every physician should protest against every union 
 which will have the slightest tendency to entail on posterity this fatal 
 malady. God and humanity require it. The physician is the guardian 
 of the public health. His mission is to prevent as well as to cure 
 disease. It is with the living, moving, present race, he has to do ; 
 with a being who contains within himself the germ of the highest 
 mental and corporeal excellence. Alas that the web of depravity and 
 ignorance that has so assiduously been wound around him, even from 
 his earliest existence, should have so long opposed his physical and 
 moral regeneration ! 
 
 In my intercourse with mankind, I have felt it almost a fruitless 
 task to advise the practice of reason and common sense to those who 
 
CAUSES OF PULMONARY CONSUMPTION. 271 
 
 were about to enter into the matrimonial state, especially to those who 
 believe that love is invincible and -uncontrollable : yet I have occasion- 
 ally seen it attended with good. We know that all our passions are 
 apt to take on morbid action by over-excitement. This is especially 
 the case with love as it relates to the sexes. When an individual is 
 thus affected, there is a peculiar overpowering influence that takes 
 possession of the mind, which is fruitful in sighs, tears, and sleepless 
 nights, caused by a pretty foot, a keen eye, a winning smile, or a 
 tender expression ; and one thus affected deems himself most desper- 
 ately and irrecoverably in love. But, unless the being for whom he 
 sighs happens to possess some of the standard excellences of character, 
 he will perhaps find, when too late, that he has entered upon a course 
 from whence there is no retraction. How often it is the case, that 
 those who have been once as blind as the little god himself, are at 
 length aroused from their sweet dreams of fancied bliss to the sad 
 realities of wedded unhappiness ! 
 
 But he is often not the only sufferer ; others reap the fruits of his 
 errors ; posterity has a greater interest at stake than is often supposed, 
 and which is still less oftener consulted. Suppose a couple, both the 
 branches of a stock affected with tubercular disease, fall desperately in 
 love, and there can be no objection to their union so far as respects the 
 moral worth of either party ; is marriage, with their predispositions to 
 the disease, justifiable or expedient ? Or, in other words, will they 
 be excusable for knowingly entailing such a fatal disease upon pos- 
 terity ? Are they excusable for perpetuating a malady that blights 
 the fairest prospects of the race, and consigns so many to a premature 
 grave ? It would be better for them to suffer in their feelings, than 
 that a numerous progeny should endure the ills of this wasting dis- 
 ease. Such reflections and sentiments enunciated by the scientific 
 and upright physician, enforced by the spirit of truth, must touch the 
 heart ; they cannot fail to reach the conscience. Reason would follow 
 the dictates of conscience, but feeling, passion, self-love, prompt to a 
 violation of moral and organic law. 
 
 I am well satisfied, from personal observation, that there is no rela- 
 tion in life which contributes more to the happiness or health of man- 
 kind, when judiciously formed, than matrimony ; and yet, strange to 
 say, we frequently see individuals enter into it with as little reflection 
 as if they were devoid of reasoning powers. Passion too often rules 
 
272 PULMONARY TUBERCULOSIS. 
 
 the hour, and when blinded and maddened by its influence, they hur- 
 riedly enter into this important relation ; and it is a truth which cannot 
 be denied, that very many of these marriages formed in haste, when the 
 parties are intoxicated with passion and insensible to everything but 
 its influence, frequently end in mutual coldness, disgust, and faithless- 
 ness to the marriage vows. 
 
 It is true, a couple may for a time live on little else than love ; but 
 if there is a great inequality in temper, disposition, or education, or if 
 the habits of living of one or both have been much more expensive 
 than their means will warrant in the new relation they are about to 
 form, they may well ponder the step they are about to take. Mar- 
 riage alone does not confer happiness, but when formed with due 
 reflection and proper principles, it will result in prosperity, and be 
 followed by the most enduring affection. 
 
 The chief object that every individual has in getting married, is to 
 render himself more comfortable and happy ; and, therefore, with such 
 objects in view, it is not stoicism, nor speculative philosophy, to 
 consider the means by which it may be best promoted, or to have an 
 eye to the obstacles that may interfere to prevent the anticipated end. 
 If a couple are about to take this step which is to render them 
 happy or miserable for life, we deem it the part of true wisdom for 
 each party to examine well whether there be not some circumstance 
 which, in the end, will produce unlooked-for results. Wealth, posi- 
 tion, and beauty are all good ; but what are they worth without 
 health ? Hence, when an individual is about to enter into this im- 
 portant relation, he will do well not to leave out of his estimate the 
 physical health of his intended companion. If the party has a decided 
 proclivity to pulmonary consumption or scrofula, it should be forever 
 considered a bar to such union. While I write, my memory is 
 crowded with instances where this advice has been unheeded, and 
 the individuals have suffered the penalty of that law which visits the 
 sins of the fathers upon the children, even unto the third and fourth 
 generation. 
 
CHAPTER XXVI. 
 
 THE TRANSMISSIBILITY OF PULMONARY TUBERCULOSIS BY CON- 
 TAGION. 
 
 In consulting modern authorities on the practice of medicine, we 
 find a great contrariety of opinion on the subject of the transmissibility 
 of pulmonary tuberculosis by contagion. Some scout at the idea, 
 pronouncing it a delusion, while others maintain it with confidence 
 and contend for it with great pertinacity. So far as my observations 
 and experience extend, I am inclined to the opinion that under some 
 circumstances the disease is capable of being transmitted from one 
 individual to another, and, in this way, propagated from family to 
 family and from one nation to another. What the special morbid 
 agent is that constitutes the medium of communication, in the present 
 state of our knowledge we are unable to say. Some of our best 
 writers on tuberculosis uphold the opinion that the germs of the 
 disease are contained in the phthisical person's breath, perspiration, 
 etc., which, being constantly inhaled, prove a source of contagion. 
 
 I. Is it possible to give rise to Tubercular Matter by In- 
 oculation? 
 
 This question was asked by Laennec, more than fifty years since. 
 He did not attempt to answer it positively, but referred to an injury 
 that he had received by the stroke of a saw upon his fore-finger while 
 examining some vertebrae containing tubercle, the result of which was 
 a small tumor, that had the appearance of crude tubercle. It was left 
 for M. Villemin to show that tuberculosis could be produced by in- 
 oculation, — can be communicated from man to lower animals, and from 
 one animal to another ; and the legitimate inference is that it may be 
 transmitted from man to man, but as yet there has been no one found 
 bold enough to make the experiment. 
 
 Let us briefly recount some of the experiments of Villemin. They 
 
274 PULMONARY TUBERCULOSIS. 
 
 were first made known to the medical world in the year 1865. They 
 consisted in the introduction of portions of miliary and aggregated 
 tubercle beneath the skin of rabbits and guinea-pigs, by means of 
 which he obtained, with scarcely a single failure, the following results : 
 For two or three days after the operation, nothing appeared ; but, at 
 the expiration of that time, the parts operated upon became red ; on 
 the fifth or sixth day a little nodule was felt under the skin, resem- 
 bling the primary induration of syphilis. This nodule slowly increased 
 in size, and at last, softening centrally, discharged, through a hole in 
 the skin, a cheesy substance. 
 
 In some of Villemin's experiments, — those, namely, where the inocu- 
 lation was from man to rabbits, — the animal did not suffer much in 
 health, but kept its flesh, and was at last killed ; but in others, — those 
 more particularly where inoculation was from the cow to the rabbit, 
 or from rabbit to rabbit, — the animal began somewhere between the 
 tenth and fifteenth day to suffer in health, refusing food, and slowly 
 wasting till it died, — generally before the completion of the third 
 month. 
 
 There was in this instance discovered at the location of the inocu- 
 lation, a sore, sometimes covered with a crust, and having a bare base, 
 in and for some distance around which were distributed numerous 
 small, miliary, yellowish granules, single and aggregated, in a thick- 
 ened, sometimes lardaceous connective tissue. The lymphatic glands 
 were infiltrated with tubercle, and the lungs and other viscera were 
 strewn with tubercles, for the most part miliary, but often aggregated, 
 and occasionally cheesy. 
 
 His experiments also show that the cheesy matter which forms at 
 the seat of inoculation is itself virulent, and produces tuberculosis 
 when inoculated. In like manner, the sputa of phthisical patients 
 and the blood of tubercular rabbits produced, without failure, tuber- 
 culosis in rabbits. Yillemin concludes, from all his investigations, 
 that the cheesy matter of pneumonia which accompanies tubercle is 
 just as inoculable as the gray miliary tubercle, perhaps more so, and 
 points to this as a strong evidence in favor of all these substances 
 being alike tubercular in their nature. 
 
 These experiments of Yillemin and the conclusions to which he 
 arrived excited at once the attention of numerous distinguished 
 pathologists, and immediately led to a repetition of them, not only in 
 
ITS TRANSMISSIBILITY BY CONTAGION. 275 
 
 France, but in Germany and England. And it is no wonder that his 
 statements were distrusted, and his conclusions ignored, when he 
 affirmed that tuberculosis is a specific disease ; that it has its origin in 
 an inoculable virus ; that it belongs to the zymotic diseases, and is 
 allied to smallpox, glanders, syphilis, and scarlatina. But the obser- 
 vations of Villemin have been more than verified by Bizzero, Lebert, 
 Simon, and Waldenburg, in the numerous experiments which they 
 have made. 
 
 Simon, in particular, corroborates fully the views set forth by Vil- 
 lemin, that both the yellow and the gray tubercle are inoculable from 
 man to the rabbit, and from rabbit to rabbit, with more intense and 
 general results in the latter than in the former case. The results of 
 his experiments were even more conclusive than Yillemin's, in that 
 he inoculated the smallest possible quantity of tubercular matter, "not 
 more than is employed in vaccination." He concludes that, "whether 
 called tubercular or not, the action must be allowed to be specific."* 
 
 Dr. L. Waldenburg, of the Boyal University, Berlin, made one 
 hundred and four experiments after the manner of Yillemin's, using 
 seventy-one rabbits, twenty-eight guinea-pigs, and three horses. Of one 
 hundred experiments, thirty-four gave positive, nine doubtful, and fifty- 
 seven negative results ; they include eleven series of experiments, — 
 
 (1) Inoculation with fresh, softened, gray miliary tubercle. 
 
 (2) Inoculation with the products of cheesy pneumonia and pus 
 from the cavities of consumptives. 
 
 (3) Inoculation with the non-tuberculous cheesy matter of lym- 
 phatic glands extirpated from living persons. 
 
 (4) Inoculation with thickened pus from the inoculated point of 
 an animal already inoculated, either with tubercle or cheesy matter. 
 
 (5) Inoculation with pathological products non-tubercular, such as 
 cancerous matter, catarrhal sputum, and hepatized lung-substance of 
 an individual who died with croupous pneumonia, and subcutaneous 
 injection of pus. 
 
 (6) Inoculation with tubercle and cheesy matter taken from pre- 
 parations which had laid several months in alcohol. 
 
 (7) Inoculation or subcutaneous injection of tubercle or cheesy 
 matter submitted to intense chemical action. 
 
 * London "Lancet," 1867, page 367. 
 
276 PULMONARY TUBERCULOSIS. 
 
 (8) Inoculation or subcutaneous injection of chemically changed 
 non-tuberculous matter. 
 
 (9) Introduction of colored substances. 
 
 (10) Inoculation or injection of blood. 
 
 (11) Traumatic injuries. 
 
 It would be interesting to give the result of each of these series of 
 experiments by Waldenburg, as recorded in his great work, " Tuber- 
 culosis. Pulmonary Consumption, and Scrofula. Historically and Exper- 
 imentally Studied," but I have not the space in this chapter. Suffice 
 it, however, to say that they all very clearly demonstrate the chief 
 assumption of Yillemin, that tubercle is a virus which cannot be 
 entirely destroyed by the most intense chemical action. 
 
 In the Archives Generales de Medecine for July, 1867, M. Herard 
 publishes a series of experiments that fully verify those of Yillemin and 
 others. He took seven rabbits, and inoculated five only of the seven. 
 Three of these five were inoculated with tubercular granulations, either 
 gray and semi-transparent or yellowish, taken from the pleura and peri- 
 toneum of a phthisical patient. The two others were inoculated with 
 cheesy matter from what is called catarrhal pneumonia, as contradis- 
 tinguished from tubercle. At the end of two months all the seven 
 rabbits were killed. The two which had not been inoculated were in 
 every respect healthy ; the two which had been inoculated with cheesy 
 substance were likewise healthy ; two of the three which had been 
 inoculated with tubercle were manifestly tubercular. M. Herard 
 concludes — first, that tubercle is inoculable from man to the rabbit ; 
 secondly, that the cheesy inflammatory products are not inoculable, 
 and that they are, therefore, not tubercular ; thirdly, that the miliary 
 tubercle is alone inoculable, and is the specific lesion of tuberculosis. 
 
 Now, I would ask, what is the significance of all these experiments ? 
 Do they furnish an argument in favor of the transmissibility of tubercle 
 from man to man? I am of the opinion that they do; but I have 
 already remarked that 
 
 II. Medical Writers differ widely upon the Communic ability 
 of Tubercular Disease by Contagion. 
 
 Dr. Morton, in his "Illustrations of Pulmonary Consumption" 
 (the first systematic treatise on this malady of any special value by an 
 American author), says that some authors have insisted upon the con- 
 
ITS TRANSMISSIBILITY BY CONTAGION. 277 
 
 tagious nature of phthisis ; but in no case that had corne under his 
 notice could he attribute it to such a source. Yet he presents in the 
 same paragraph a case that fairly proves that he had. " I attended," 
 he remarks, " the wife of an inn-keeper in chronic consumption ; she 
 died after having been ill for nearly two years. Her husband was a 
 short, athletic, florid-complexioned man, the very reverse of what we 
 usually see in phthisis, and yet he, also, died of that disease six months 
 after his wife."* 
 
 Dr. Thomas Watson, who has probably done more to shape the 
 medical practice of this age than any other man, in answer to the 
 question, "Is phthisis contagious?" replies, "No, I believe it is not." 
 But a few lines farther on he says, " Nevertheless, if consulted on the 
 subject, I should, for obvious reasons, dissuade the occupation of the 
 same bed, or even the same sleeping-apartment, by two persons, one of 
 whom was to labor under pulmonary consumption." f 
 
 From an article on the nature and mode of propagation of phthisis, 
 by Dr. William Budd, we glean the following : 
 
 " (1) Tubercle is a zymotic disease of a specific nature, in the 
 same sense as typhoigl fever, scarlet fever, typhus, and syphilis. 
 
 " (2) That, like these diseases, tubercle never originates sponta- 
 neously, but is perpetuated by laws of continuous succession. 
 
 " (3) That tuberculous matter itself is (or includes) the specific 
 morbific matter of the disease, and constitutes the material by which 
 phthisis is propagated from one person to another, and disseminated 
 through society. 
 
 " (4) That the deposits of this matter are, therefore, of the nature 
 of an eruption, and bear the same relation to the disease, phthisis, as 
 the yellow matter of typhoid does to typhoid fever. 
 
 " (5) That by the destruction of this matter on its issue from the 
 body, by means of proper chemicals or otherwise, seconded by good 
 sanitary conditions, there is reason to hope that we may eventually, 
 and possibly at no very distant day, rid ourselves of this fatal scourge." 
 
 Waldenburg maintains that tuberculosis is a contagious disease, and 
 is propagated by a corpuscular element received into the blood, and is 
 more nearly allied to pyaemia than any other disease. He regards both 
 
 * Morton's "Illustrations of Pulmonary Consumption," first edition, page 47. 
 f Watson's Practice, page 648. 
 
278 PULMONARY TUBERCULOSIS. 
 
 tuberculosis and pyaemia absorption-diseases of a non-specific character. 
 "Pyaemia," he says, "forms scattered centres of disease through vari- 
 ous organs, but they are larger than those of tuberculosis, and are of 
 inflammato-purulent nature. In tuberculosis the elements are small 
 and finely divided, and do not appear extremely irritating in character ; 
 wherefore, instead of producing considerable inflammation, they give 
 rise only to the formation of small miliary centres of foci." 
 
 In opposition to the views just presented by Drs. Budd and Wal- 
 denburg, I would place those of Dr. R. P. Cotton, Sr., Physician of 
 the Hospital for Consumptives, Brompton, London ; a gentleman of 
 vast experience in this special branch of medical practice, and whose 
 opinion is entitled to more than ordinary consideration. He says, — 
 
 " (1) I believe phthisis to be purely a constitutional disease, which 
 may be either inherited or acquired, but which is incapable of being 
 communicated from one person to another, in the ordinary sense of 
 contagious diseases. 
 
 " (2) I regard tubercle as the product of such constitutional dis- 
 ease, just as lithate of soda is of gout, and sugar of diabetes. 
 
 " (3) I consider that a person may be really consumptive, or, in 
 other words, may have this constitutional disease, while the tubercular 
 element is still in the blood, — that is to say, before they are deposited 
 as tubercle in the lungs or other tissues. 
 
 " (4) Although I think it very possible that tuberculous matter, 
 like many other diseased products, may be introduced into the system 
 by artificial inoculation, producing its like, or something more or less 
 similar to it, I do not believe tubercle can exist naturally in such a 
 state as to be, as Dr. Budd expresses it, ' disseminated through society 
 by the ordinary principles of contagion.' 
 
 " (5) I think it probable, although not perhaps quite demonstrable, 
 that there are variations of consumption, both in degree and kind ; 
 but I am unacquainted with any such variety forming an exception to 
 the general principles which I have stated above." 
 
 M. Villemin recently read a paper before the Societe Medicale des 
 Hopitaux, on the " Prophylaxis of Pulmonary Phthisis," in which he 
 contends for the transmissibility of the disease by contagion, and pre- 
 sents several cases in support of his views, as well as cases from the 
 observation of others. The cases presented by him are mere proto- 
 types of similar instances that can be gathered from the experience of 
 
ITS TRANSMISSIBILITY BY CONTAGION. 279 
 
 every physician who has had much to do with the treatment of pul- 
 monary tuberculosis. 
 
 In speaking of the prevalence of the disorder in the French army, 
 he says, " Many things happen in the army which ought to direct 
 attention to the subject of the transmissibility of phthisis. A phthis- 
 ical soldier enters a hospital and dies there ; his garments are returned 
 to the store-house of the regiment, and given to a fresh arrival ; his 
 bed is immediately occupied by another. May not this transmission 
 of clothing and bed-linen from one soldier to another be a source of 
 tuberculization in the army ? Is not the caserne to the soldier in the 
 production of phthisis what the regimental stable is to the horse in 
 the development of farcy ? 
 
 " But, though the mode of transmission can be readily traced in the 
 disease of animals, in which every act passes under our notice, it is not 
 so with man, who, from his complicated social relation, is subject to 
 numerous contacts difficult to determine. Is the phthisical patient 
 always sure that the furnished apartments he occupies were not pre- 
 viously held by a phthisical patient ? The proof of this and many 
 other points is generally absent in large towns, but in the country the 
 mode and course of the transmission can be readily made out." 
 
 In view of all the facts and opinions of distinguished physicians, 
 for and against the communicability of pulmonary tuberculosis by 
 contagion, I do not think we are justified in rejecting it altogether. 
 It is true, we do not see it communicated from one individual to 
 another, like smallpox ; we never see it prevail in communities, like 
 typhoid fever; neither have we ever seen any person who has received 
 it by inoculation ; yet we are compelled to infer its occasional trans- 
 mission from one individual to another by an accumulation of facts 
 derived from personal experience too numerous to be rejected entirely. 
 And I have faith to believe that the day is not far distant when we 
 shall have a better knowledge of the nature and causes of tubercular 
 disease. I also believe that medical science will yet devise means by 
 which we shall be enabled to prevent or mitigate its ravages, and 
 when, instead of producing one-fourth of the mortality of mankind, 
 it will rank with the lowest on our mortuary tables. 
 
CHAPTER XXVII 
 
 COLD, CLIMATE, AND LOCALITY | THEIR INFLUENCE IN PRODUCING 
 OR MITIGATING CONSUMPTION. 
 
 I. Cold not a Primary Cause of Consumption. 
 
 From the remotest antiquity, physicians have considered cold a 
 primary cause of this disease. But I am inclined to differ from them, 
 for various reasons. It is true, cold is the chief cause of inflamma- 
 tion of the lungs ; and as inflammation was regarded as the parent 
 of tubercle in the lungs, tubercle as a matter of course must be the 
 offspring of inflammation. But modern pathological research has 
 very clearly demonstrated that tubercle is not the product of inflam- 
 mation ; it is a degenerated material eliminated from the blood, having 
 physical and microscopical elements specifically its own. I am will- 
 ing, however, to admit that when tubercles have been exuded into the 
 pulmonary tissues, they may be developed more speedily by undue 
 exposure to cold and by the inflammation which often supervenes. 
 Indeed, it is still an open question whether persons who have suffered 
 from inflammation of the lungs are more subject to pulmonary con- 
 sumption than are others. From my own observation. I would say 
 that they were not. 
 
 That cold is not a primary cause of this disease may also be inferred 
 from the fact that it is not so common in cold countries as in warm. 
 Thus, at Stockholm, the capital of Sweden, sixty persons out of a 
 thousand die with consumption. At St. Petersburg, sixty-six in the 
 same number. These cities are in a northern clime, where the winters 
 are extremely cold. At London and Paris, about two hundred and 
 thirty-six die in a thousand. The climate of these two cities is tem- 
 perate. In the cities of New York and Philadelphia, the mortality 
 from the disease is a fraction less than two hundred in a thousand. 
 The climate of these cities is changeable, but for the most part cold. 
 280 
 
COLD, CLIMATE, AND LOCALITY. 281 
 
 In nearly all the southern cities of this country, — particularly those 
 situated on the Atlantic coast, — consumption causes about one-fifth of 
 the mortality. In the West Indies, where the climate is very warm, 
 the disease is very common, constituting a large mortality, especially 
 among the negroes, one-half of whom, it is said, die with the disorder. 
 In the East Indies considerable numbers fall victims to this malady. 
 At the extreme north, according to Dr. Kane, consumption is almost 
 unknown. 
 
 If, then, this disease originated from cold, we would naturally ex- 
 pect to find it more frequently in northern than in southern climes ; 
 more frequent at Stockholm and St. Petersburg than in Paris, 
 London, or New York ; more common in the latter place than in 
 many of our southern cities : but such is not the case. Locality has 
 more to do with its production than has temperature. This has been 
 clearly shown by the researches of Dr. Henry I. Bowditch, of Boston. 
 In his address delivered before the Massachusetts Medical Society, 
 May 28, 1862, on " Consumption in New England, or Locality one 
 of its Chief Causes," he maintains the following propositions : 
 
 "1st. A residence on or near a damp soil, whether that dampness 
 be inherent in the soil itself or caused by percolation from adjacent 
 ponds, rivers, meadows, or springs, is one of the principal causes of con- 
 sumption in Massachusetts, and possibly in other portions of the globe. 
 
 "2d. Consumption can be checked in its career, and possibly, nay 
 probably, prevented in some instances by attending to this law." 
 
 Dr. Bowditch has produced a large mass of evidence to prove these 
 propositions. It is testimony gathered from his own experience and that 
 of a large number of physicians, in the State of Massachusetts, engaged 
 in the active duties of their vocation. With few exceptions, they all 
 bear testimony to the fact that in certain localities the inhabitants are 
 more obnoxious to consumption than in others, and that those places 
 are commonly very damp. Indeed, in some instances the evidence 
 presented would lead us to conclude that some houses may become 
 the foci of consumption, in consequence of being built on moist soil 
 and surrounded by other circumstances favorable to dampness. 
 
 Dr. Bowditch says, " I know a homestead in which resides a family 
 of wealth and refinement. It is a sweet rural cottage, overhung with 
 clustering vines, delightfully situated amid shade-trees, thickly hemmed 
 in by a shrubbery that Shenstone might have envied. It rests on the 
 
282 PULMONARY TUBERCULOSIS. 
 
 borders of a sylvan lake, on a rich, loamy, fertile, moist soil, a few 
 feet only from the water, and scarcely more than a few inches above 
 its level. In the heat of our midsummer every passer-by would point 
 out the spot as one to be selected for its perfect coolness of situation 
 and quiet loveliness. But I fear it is most unhealthy, and for the fol- 
 lowing reasons : The parents occupying it are themselves healthy, and 
 have had ten children. None have been perfectly robust. Three 
 have already died of consumption. A fourth has it now in its last 
 stages. The young daughters who remain are, during the day-time, 
 some miles away at school, in a high and dry location. They sleep at 
 home. They do not seem so strong as others, and in the eyes of 
 neighbors seem threatened with the disease of which the others died. 
 One son, who is constantly at sea, is healthy. 
 
 " A previous occupant of this house died of consumption. His 
 family was liable to frequent coughs while resident there, from which 
 they have escaped since their removal. 
 
 " All this has happened, and yet I cannot persuade the parents that 
 the pleasant house, in its present location, is the charnel-house of their 
 race, as I verily believe it to be." 
 
 It is no new idea that dampness is a fruitful source of pulmonary 
 consumption. It has been proven years ago, by the mortuary statis- 
 tics of the United States army, that the deaths from this malady at 
 maritime stations are more than double what they are farther inland ; 
 and all places surrounded by water, or valleys made verdant by flowing 
 streams, are more productive of this scourge of humanity than are dry 
 mountainous regions. Thus, all along the shores of our great northern 
 lakes and the Mississippi Valley, the disease is very common. In 
 damp, malarial regions, recent investigation has shown a large mortal- 
 ity, contrary to the opinion formerly held by physicians that there was 
 a positive antagonism between consumption and malaria. t Cold, damp- 
 ness, and a variable atmosphere may all be ranked as active causes in 
 producing this disease in those who are predisposed to it. Hence the 
 selection of a residence for such individuals becomes a matter of par- 
 amount importance. 
 
 II. The Best Residence for Consumptive Patients. 
 
 From the days of Hippocrates down to the present time, volumes 
 have been written on this subject, and the greatest diversity of opinion 
 
COLD, CLIMATE, AND LOCALITY. 283 
 
 exists among physicians in relation to the place where a consumptive 
 individual should be sent, and the time when he should go. In this 
 country it has been customary with most of our physicians, when a 
 man has injured his health by too high living and sedentary life, to 
 order him forthwith to Europe. And if he has threatening symptoms 
 of consumption, he is ordered to the south of Europe. This is re- 
 garded as the happy clime which, once reached by the invalid, is sure 
 to make his disease disappear and restore him to perfect health. But, 
 if we compare the number who visit there actually diseased, and who 
 deposit their remains there, with those who return with improved 
 health, we will find small encouragement to recommend patients to 
 leave their own country. 
 
 We have in the United States all the various climates that are to be 
 found in the world ; and if there be one spot on the globe more ben- 
 eficial to a consumptive patient than another, it is here. Two sections 
 of our country have recently become quite celebrated as a residence 
 for individuals suffering from this disease, — Minnesota and the south- 
 ern shore of Lake Superior. For twelve summers we have seen large 
 numbers of patients from all our eastern cities thronging our steam- 
 boats and railway cars, bound for St. Paul or Marquette in pursuit of 
 health ; and in many instances they return in the fall very much 
 improved, and perhaps a few have regained their original health and 
 vigor. 
 
 But while I am willing to admit the excellency of these places as 
 a temporary residence for consumptive persons, I am well satisfied 
 that there is another portion of our country which, in point of salu- 
 brity and adaptation of climate for the class of individuals just named, 
 far surpasses these, if not any other on the face of the globe. I refer 
 to the southwestern part of the State of Texas. And if the reports 
 of those who have gone there in pursuit of health, and those who re- 
 side there, speak the truth, this region will yet be the paradise of the 
 world. 
 
 No section of our vast country can rank with the southwestern part 
 of Texas either in mildness of climate or equability of atmosphere. It 
 has a mean winter temperature of about fifty-three degrees. But its 
 chief characteristic is its exemption from swamps and stagnant pools. 
 The land commonly ascends from the water-courses, and, rising to 
 moderate eminences, precludes the formation of swamps or putrid pools 
 
28-4 PULMONARY TUBERCULOSIS. 
 
 to any extent. This is probably one efficient cause of the singular 
 purity and equability of the atmosphere, which is so frequently noticed 
 in the reports of our army surgeons who have been stationed in that 
 section of the country. While the summer air of Louisiana is com- 
 bined with moisture surcharged with noxious miasma, the pure air of 
 southwestern Texas is refreshed and renovated by the lively breezes 
 from " old ocean," rolling over a dry, verdant, varying surface, im- 
 parting elasticity, health, and vigor to all who inhale it. 
 
 Now, here is a country where perpetual summer smiles, where 
 flowers are constantly blooming, and the fields arrayed in their richest 
 green. Here, too, is an equable atmosphere, sufficiently warm and dry 
 in the winter months, and not loaded with moisture and poisonous 
 effluvia in summer. Are not all the climatic wants of the consump- 
 tive here fully met ? Indeed, there is nothing on this continent or in 
 Europe that can compare with it. Even far-famed Italy must yield 
 the palm to the " Lone Star.' : 
 
 No one will deny that the best climate for a consumptive patient is 
 one which is dry, equable, and of rather low temperature. Indeed, a 
 low temperature is much to be preferred to a uniformly high one, 
 because it generally exerts a tonic and stimulating effect upon the 
 system, while a high one produces general debility and exhaustion. It 
 is no doubt owing to this low temperature of the atmosphere that even 
 in summer the climate of St. Paul and Marquette has proved so 
 beneficial to individuals suffering with pulmonary consumption. It 
 appears to tone up the nervous forces, sharpen the appetite, promote 
 digestion, and prompt to exercise, all of which are very desirable, if 
 not absolutely needed, in mitigating this wasting malady. 
 
 For a summer residence for consumptive individuals, the places just 
 named are as good as any that can be found. But when winter comes 
 on they are too cold and damp ; and I have yet to see the first con- 
 sumptive who has remained in either place all winter who has not been 
 positively injured. Not so, however, with Georgetown or Clarksville, 
 Texas. Clarksville, in particular, is my favorite location for consump- 
 tive patients the year round. Its site is healthy, and it has a dry, 
 equable climate. Pulmonary disorders are said to be exceedingly rare. 
 Dr. B. Norris, of the United States army, who spent some time in its 
 vicinity, regards the climate of this place as very beneficial to persons 
 suffering with consumption. 
 
COLD, CLIMATE, AND LOCALITY. 285 
 
 Previous to our great war, I sent several consumptives to Texas, all 
 of whom were more or less benefited, and in one instance a perma- 
 nent cure was effected. This was the case of a merchant who had 
 been under my care for nearly a year. At this time he had a cavity 
 of considerable magnitude in the left lung, with limited tubercular 
 deposits in the right. He had lost flesh and strength, but was still 
 able to attend to his business. One day, when conversing with him, I 
 carelessly remarked that I thought the best way for him to get relief 
 for his malady would be to go to Texas. Imagine my surprise a few 
 days afterwards, when a friend told me he had made up his mind to 
 go. This was about the middle of October. He went, spent a pleas- 
 ant winter, and came home about the first of June, very much improved 
 in general health, with a marked mitigation of the local disorder in 
 the lungs. He was so much pleased with the country, that he con- 
 cluded to make it his permanent home. He returned early in the fall, 
 bought a farm near Clarksville, kept a large number of sheep, and 
 engaged in all the active duties of a farmer's life. His health was 
 permanently restored. I shall ever believe that his life was saved by 
 going to Texas. 
 
 In thus commending Texas as a residence for consumptive invalids, 
 I do not wish any one to go there simply upon my recommendation. 
 Others have eulogized its climate far beyond anything that I have 
 said. Allow me to quote the opinion of one who has given more at- 
 tention to the study of climate, and its influence in mitigating this 
 disease, than any American writer I am acquainted with, — one who 
 had himself tried the influence of various climates without any very 
 material benefit. I refer to the lamented Dr. L. M. Lawson, of 
 Cincinnati, who fell a victim to this wasting disease. 
 
 In his " Practical Treatise on Pulmonary Consumption," page 530, 
 we find the following language : " It is a conceded fact that the 
 climate of Texas is favorable to consumptives, not only during the 
 winter, but also in the summer. Indeed, it is probable that a resi- 
 dence the year round would be preferable to a temporary sojourn 
 during the winter. But if this course be adopted, it is necessary 
 that the summer be spent in the more northern portions, where the 
 temperature is seldom oppressive. Indeed, throughout the entire 
 country, the gulf breeze renders the summer nights cool and invigor- 
 ating. Examples are by no means rare of persons predisposed to the 
 
 19 
 
286 PULMONARY TUBERCULOSIS. 
 
 disease, or with it actually developed, entirely recovered by a pro- 
 tracted sojourn in Texas." 
 
 While Texas is my first choice for consumptive patients, there is 
 another section of our country that is perhaps quite as good. I refer 
 to Colorado. A recent writer, who has spent some time at Denver, 
 
 " This climate is proverbial for its mildness, the average tempera- 
 ture of the region about Denver being from 50° to 55°, while the 
 mercury rarely indicates below zero, even in the coldest weather, and 
 seldom exceeds 80° in the warmest. Damp, chilly days, or hot, sultry 
 nights are unknown. Snow seldom remains on the ground longer 
 than twenty-four hours, the winters being usually very mild. There 
 is no ' rainy season' in any portion of Colorado, and the absence of 
 clouds the year round is remarkable ; the clear sky and warm, genial 
 sunshine are seldom hidden. The purity of the atmosphere is unsur- 
 passed, and it possesses a great deal of electricity, consequent upon 
 altitude. It is entirely free from humidity, and is wonderfully clear 
 and exhilarating. Malarious or poisonous exhalations never burden 
 this air. Decomposition of animal matter takes place so slowly, that 
 the noxious gases engendered pass away imperceptibly. We have 
 warm days and cool nights. There are not half a dozen nights in a 
 season when a pair of blankets are in any degree uncomfortable. 
 There is no such thing known as ' damp night-air ;' although the air 
 is cool, it is dry, and one may sleep with doors and windows wide 
 open, summer or winter, without once taking cold. There is not a 
 score of days in any year in which invalids may not sit out of doors, 
 ride or walk, forenoon or afternoon, with comfort and pleasure. Add 
 to this the fact already cited, that the nights are always cool, insuring 
 plenty of restful and refreshing sleep, and two of the most essential 
 conditions for the restoration of shattered nervous systems and broken 
 constitutions have been secured. For most forms of disease, the 
 increased activity imposed on the respiratory organs by residence in 
 high altitudes is a direct and constant benefit. Nothing is better for 
 a dyspeptic or a sufferer from hepatic disorder or general torpor, than 
 to make him breathe. Increase his respirations from sixteen to 
 twenty-four per minute, and you give him a new experience. His 
 blood circulates with increased rapidity, and is much more perfectly 
 aerated ; his appetite is increased, digestion and assimilation promptly 
 
COLD, CLIMATE, AND LOCALITY. 287 
 
 responding to the increased demand and increased action. The bed 
 of the Platte River at Denver is a lineal mile higher above the sea- 
 level than New York or Philadelphia ; here, one must breathe both 
 more fully and more rapidly. The result is a permanent increase of 
 the breathing capacity, the formation of tubercle never taking place 
 in lungs expanded with this rarefied air. 
 
 " Our climate is, on the whole, the mosfc equable and desirable of 
 the Western Hemisphere. Probably one-half of the present population 
 of Colorado are reconstructed invalids. Some came with intractable 
 dyspepsia ; some with asthma and bronchitis ; others had commenced 
 bleeding at the lungs, or were confirmed victims of consumption. 
 Many came too late to be benefited. On the other hand, thousands 
 whose cases were considered hopeless have here found permanent 
 relief. This is especially true of asthmatics. For this class of patients 
 the atmosphere of Colorado is an almost certain panacea. Consump- 
 tives, in the first stage, may come to Colorado with the assurance that 
 whatever climate, natural hygienic surroundings, pure air and water, 
 good food, grand scenery, and perpetual sunshine, can do for an invalid, 
 here awaits them. Whatever will aid the consumptive will aid the 
 dyspeptic, for the consumptive is first a dyspeptic, and in fatal cases 
 always starves to death. In patients afflicted with bronchitis, the 
 results are very flattering ; scarcely a case but is rapidly relieved. For 
 all of scrofulous habits, there is no better climate than that of Colo- 
 rado. Chronic invalids are almost always benefited by a mere change 
 of regimen. If the change be made from the humdrum of the eastern 
 home to the fresh and novel life of a mountain country, with its more 
 substantial bread, more virile, blood-invigorating beef, its tempting 
 mountain trout, and juicy wild meat, the benefits will be multiplied. 
 Patients in the second and third stages of consumption, and those 
 suffering from certain forms of heart-disease, are more injured than 
 benefited by a removal to locations much more elevated than the one 
 to which they have been accustomed." 
 
 But, notwithstanding all that has been written in favor of a change 
 of locality and climate in this disorder, I am free to confess, from my 
 own observation, that, when the disease is fully established, they have 
 but very little influence either in mitigating or retarding it ; and that 
 those who are seeking a remedy from these sources alone, are pursuing 
 a phantom. I am well satisfied that physicians frequently make a 
 
288 PULMONARY TUBERCULOSIS. 
 
 great mistake in ordering their consumptive patients from all the 
 comforts of home and kind friends to a new and untried locality and 
 climate. I have met with many instances where it had an unfavorable 
 influence upon the successful treatment of the malady. In most cases 
 the invalid expects to derive some specific virtues from the locality or 
 climate. He therefore quietly seats himself down, discards or neglects 
 other efficient remedial measures, and waits for the coveted blessing. 
 But it never comes, and cannot, without the diligent employment of 
 such medical agencies as are known to have an influence in correcting 
 the tubercular habit and arresting the local disease. No matter how 
 favorable the local and climatic advantages may be, medical treat- 
 ment must not be neglected, if the disorder is to be in any way miti- 
 gated or cured. 
 
CHAPTER XXYIII. 
 
 THE MIND : ITS INFLUENCE IN PRODUCING PULMONARY TUBER- 
 CULOSIS. 
 
 I. The Power and Grandeur of the Mind. 
 
 How wonderful, how complicated, is the human mind ! Who can 
 portray the magnificence of its powers, or the vastness of its compre- 
 hension ? Think for a moment of its capabilities and of the grandeur 
 of its achievements ! Man has but to will, and in an instant his mind 
 is soaring with a velocity which leaves the flashing light of heaven far 
 behind its speed. At will it mounts to the starry heavens, and, wrapt 
 in wonder and admiration, gazes on the sparkling gems of night. At 
 will it pierces beyond the azure vault which limits its earthly vision to 
 those regions where every star we see lights up other systems of 
 worlds, which roll in other circuits ; or to those still more distant orbs 
 whose rays, though traveling since the birth-time of creation, have 
 never fallen upon mortal eye, and there descries new planets and the 
 " seed-bed of future worlds." Wonderful to contemplate ! By his 
 reflective and mathematical faculties time has been computed, space 
 measured, the celestial motions recognized and represented, the heavens 
 and the earth compared ; and man has not merely executed, but ex- 
 ecuted with the utmost accuracy, the apparently impracticable task 
 assigned him by the poet : 
 
 " Go, wondrous creature, mount where science guides ; 
 Weigh air, measure earth, and calculate the tides." 
 
 By the stupendous powers of the human intellect, mountains have 
 been overcome and seas have been traversed ; the pilot pursuing his 
 course on the ocean with as much certainty as if it had been traced 
 for him by engineers, and finding at each moment, by means of astro- 
 nomical tables, the exact point of the globe on which he is. Thus 
 nations have been united, and new worlds opened up for the unfet- 
 tered energies of the race, so that the senses are confused, the mind 
 
 289 
 
290 PULMONARY TUBERCULOSIS. 
 
 dazzled, and judgment and calculation almost suspended, by the grand- 
 eur and brightness of the glorious and interminable prospect. 
 
 Nearly the whole face of nature exhibits the works of human power, 
 which, though subordinate to that of nature, at least so wonderfully 
 seconds her operations that by the aid of man her amazing resources 
 have been unfolded, and she has gradually arrived at that point of 
 perfection and magnificence in which we now behold her. In all 
 these points of view man stands alone. In his mental powers and 
 what he has accomplished, he is without a rival. Lord of the lower 
 creation, nearly allied to his divine original, inherently weak, — 
 
 "Midway from nothing to the Deity ! 
 A beam etherial sull'd and absorpt ! 
 Though sull'd and dishonored, still divine. 
 Dim miniature of greatness absolute ! 
 A •worm ! a god." .... 
 
 — Youxg. 
 
 II. The Union between the Body and the Mind. 
 
 Between the body and the mind there is a most intimate union. As 
 to the manner in which they are connected, we know nothing. This 
 much, however, we do know : that the mind, in this world, depends 
 upon the brain for its existence and manifestation, and it is only through 
 the brain that it can act. Although we know nothing in regard to the 
 mysterious connection between the mind and the body, — the link that 
 joins us to another world, — we can yet perceive and appreciate their 
 effects upon each other, and the manner in which their influence is 
 wrought. They are the subjects of constant observation. TTe behold 
 them daily in the strong play of the passions. Observe the stormy cir- 
 culation, the convulsive muscular motion, the foaming mouth, and the 
 glancing eye, so instantaneously produced by a fit of anger. Grief makes 
 its insidious entrance to the very citadel of life, weakens its forces one 
 after another, until by slow degrees they lie prostrated before its para- 
 lyzing energies. Extreme joy may destroy life. The passion of fear 
 diminishes the action of the heart, empties the blood-vessels of the 
 skin, and robs the muscular system of all its powers. The most trifling 
 derangement of the liver or stomach has been known to generate a 
 moping melancholy or delirium that has continued through life. 
 
 On the other hand, the mental operations are constantly modified by 
 the varying conditions of the body, — by hunger and thirst, by im- 
 
THE MIND. 291 
 
 moderate nourishment, even by the slightest change of air. The 
 energies of the stomach are suspended by intense application of the 
 mind. How is the memory impaired, the judgment weakened, and 
 the imagination disordered, by the slightest disease of the digestive 
 organs ! The experience of every individual will teach him that the 
 judgment is less clear after a full meal than before. What remarkable 
 differences in the character of mind, temper, and disposition are in- 
 variably connected with the different temperaments of the body ! 
 Who does not know, for example, the influence of the liver upon the 
 temperaments ? Its preponderance over the other organs throws over 
 the external habits, the passions, the character itself, a peculiar cast, 
 remarked by the ancients, and fully confirmed by modern observation. 
 Differences equally remarkable are uniformly true of the sanguineous 
 and other temperaments. 
 
 We might cite other examples to show the wonderful union which 
 exists between the body and the mind. But those just presented are 
 amply sufficient to introduce us to the influence which may be exerted 
 by the mind in producing pulmonary tuberculosis. That it sometimes 
 is a means of causing this malady, I have not a single doubt. My 
 experience leads me to believe that the abuse of the propensities, the 
 depression of the moral sentiments, the overworking of the intellectual 
 faculties, and the incidental infractions of the physiological laws which 
 attend their abuse will, in individuals who inherit the tubercular 
 diathesis, soon develop the fell disease. 
 
 III. The Propensities : Their Abuse a Cause of Phthisis. 
 
 According to the mental philosophy which we take as our text-book, 
 the various elements that constitute the human mind are classed under 
 three heads, viz. : propensities, sentiments, and intellectual faculties. 
 The propensities relate more particularly to man's physical being. 
 They never form ideas ; their sole function is to produce feelings of a 
 specific kind, such as sexual love, the love of offspring, love of home, 
 and physical courage. They are the attributes of mentality which 
 constitute man a social being, and are the bases of the married relation, 
 the propagation of the race, and its defense. When properly directed 
 by the moral and intellectual faculties, they give a healthy and vigor- 
 ous tone to the mind, impelling it to the performance of high and 
 noble duties. But when diverted from their legitimate use, they some- 
 
292 PULMONARY TUBERCULOSIS. 
 
 times produce the most fearful wreck of mind and body which falls to 
 our lot to contemplate. The propensities are blind ; they seek their 
 own gratification : hence all those hideous vices that pollute the heart 
 and corrupt the morals of mankind. Take, for example, those pro- 
 pensities the abuse of which leads to sexual excess and self-pollution. 
 What a dreadful amount of misery they inflict upon their deluded 
 votaries ! Oh, how many beautiful forms and brilliant intellects have 
 been shrouded in the gloom of eternal night by these hateful vices ! 
 
 Every physician who has been in the habit of observing the human 
 countenance as an index to health and disease of the body, must have 
 been often impressed with the conviction that some great and exten- 
 sively-operating cause is at work depressing the physical and mental 
 energies of an immense number of young men and women who, by 
 continuing their daily avocation, give little or no indication of disease. 
 Yet there is a want of physical energy and mental vivacity which 
 points to some debilitating cause which is sapping the fountain of life, 
 and consigning to a premature grave vast numbers of our race. This 
 secret enemy is very often found to be sexual excess and self-abuse. 
 
 The reason for this will be readily seen, when we reflect that it is 
 between the sixteenth and twenty-fifth year that nature has occasion 
 for the highest activity of all her forces, in order to form a frame fit 
 not only to endure the trials of life and vicissitudes of climate, but to 
 transmit health and vital power to offspring ; that any very extensive 
 failure to attain this result at once arrests the attention, and leads us 
 to ask, Why is this ? Has nature willed it to be so ? We think not. 
 It is man's folly. It is man's wicked violation of Heaven's constituted 
 law. That law he cannot break without subjecting himself to the 
 direst penalty. 
 
 Where nature's laws are strictly followed, as is the case with the 
 inferior animals, we see no violations of this kind. We find that they 
 produce their species at the time of life and season of the year best 
 suited to the intentions of nature ; there is no such thing as early 
 sexual desire, provoked by many errors of early life and actual in- 
 struction of impure associates in the human family. It is true that 
 animals reach maturity at different periods in the same species ; but 
 this will always be found to depend upon circumstances, either favor- 
 able or otherwise to early development. The mind and nervous sys- 
 tem furnishes the powerful means of too early development of the 
 
THE MIND. 293 
 
 sexual desire in man, which frequently results in that great bane of 
 the human family, — onanism. 
 
 This is a most consuming vice ; it throws into shade nearly every 
 other means of cutting short human life ; it rivals war, intemperance, 
 pestilence and famine. I am well satisfied, from my own observation, 
 that more nervous irritation and debility, more epileptic convulsions, 
 more idiocy, and insanity, and scrofula, especially among the young, 
 arise from the one source, self-abuse, than from all others combined. 
 And if you will take the trouble to examine the reports from the phy- 
 sicians and superintendents of our almshouses, asylums for the insane, 
 and idiotic schools, you will find that I am sustained in this opinion 
 by evidence of the most positive kind. 
 
 That this ignoble abuse of the sexual propensities should be a fruit- 
 ful source of pulmonary tuberculosis, is not to be wondered at, for its 
 very tendency is to impair the vital forces, and cause a low degree of 
 nutrition, which leads almost directly to the deposit of tubercular 
 matter in the lungs. And from some inquiries that I have made on 
 this subject, I am perfectly satisfied that in nearly two cases out of five, 
 where pulmonary tuberculosis occurs under thirty years, it may be 
 ranked among the chief predisposing causes. 
 
 The most hopeless cases of pulmonary tuberculosis that fall under 
 our care, are those addicted to the vice of self-pollution. Indeed, it 
 has always appeared to me that the victims of this habit were bound 
 in fetters stronger than steel, and that nothing short of omnipotent 
 power could break them, and emancipate the victim from its de- 
 grading servitude. Hence, medical treatment is of little avail. The 
 moral pharmacopoeia furnishes us with the most reliable agents to 
 overcome this vice. And although it is a secret one, yet I have 
 never found much difficulty in detecting it. False delicacy is a great 
 barrier in the way of some physicians from eliciting all the facts in 
 the case. This should never be allowed to stand in the way of our 
 duty, especially when life is the prize for which we contend. I have 
 never thought it derogatory to the dignity of my profession to employ 
 every moral consideration which Christianity presents, to relieve the 
 sufferings and maladies of mankind. And I envy not that physician 
 who would ignore the principles of Christianity in their practical 
 application to his own personal actions or to the correction of wicked 
 and profane habits in others. 
 
294 PULMONARY TUBERCULOSIS. 
 
 IV. The Sentiments: Their Abuse a Cause of Phthisis. 
 
 The sentiments constitute man a religious and moral being. They 
 remind him of his duty to his Maker and to his fellow-man. They also 
 cheer him in adversity with the genial rays of hope, and present to 
 his view a brighter and more glorious existence in a better land 
 beyond the shores of time. The abuse of the sentiments gives rise to 
 several passions, such as blind religious zeal, disappointed hope, and 
 grief. When these passions are in excess, they prostrate nervous 
 energy, upon which the normal activity and strength of the system 
 depend. This depression of the vital forces, if long continued, may, 
 in individuals predisposed to tubercular disease, lead to its develop- 
 ment. This has been frequently noticed by writers on phthisis. 
 
 Laennec was of the opinion that the depressing passions were, in 
 many instances that fell under his notice, the principal cause of this 
 malady. In his work on the chest, he tells us that he had under his 
 observation, during a period of ten years, a marked exemplification 
 of the effect of the depressing passions in producing phthisis, in the 
 case of a religious association of women, which never obtained ec- 
 clesiastical authority other than a provisional toleration, on account 
 of the extreme severity of its rules. 
 
 The diet of these individuals, he says, was very abstemious, yet it 
 was by no means beyond what nature could bear. But the ascetic 
 spirit which regulated their minds was such as to give rise to con- 
 sequences no less serious than surprising. Not only was the attention 
 of the deluded victims of this society habitually fixed on the most 
 terrible truths of religion, but it was the constant practice to try 
 them by every kind of contrariety and opposition, in order to bring 
 them as soon as possible to an entire renunciation of their own will. 
 
 The consequences of this discipline were the same in all : after 
 being one or two months in the establishment, the catamenia became 
 suppressed ; and in the course of two or three months after, phthisis 
 declared itself. As no vows were taken in this society, Laennec 
 advised his patients to leave the house as soon as symptoms of phthisis 
 began to appear, and nearly all those who followed his advice recovered 
 their wonted health. During the period that he was physician to this 
 association, he witnessed its entire evacuation and renovation three 
 times, owing to the successive loss of all its members, with the ex- 
 
THE MIND. 295 
 
 ception of a small number, consisting chiefly of those who had the 
 business management of the establishment. 
 
 This is a very extraordinary history, and its distinguished author 
 would have conferred a great favor upon mankind if he had been 
 more particular in his details. But a moment's reflection on the 
 physiological laws that preside in the case cannot fail to satisfy the 
 most skeptical in regard to its truth. It is a great fact that the 
 passions, through the medium of the nervous system and circulation, 
 operate most powerfully upon the functions of organic life ; and when 
 they are greatly depressed, they are very likely to produce that pecu- 
 liar diathesis which leads directly to tubercular disorganization in the 
 lungs. The observation of every physician must teach him that it is 
 impossible to maintain the physical forces of the system in a natural 
 and vigorous condition, if the mind be in a state of suffering. Every 
 one must have observed the altered appearance of persons who have 
 sustained calamity. A misfortune that struck to the heart happened 
 to a person a year ago. Observe him some time after : he is wasted, 
 worn, — the miserable shadow of himself; inquire about him at the 
 distance of a few months : he is no more ! 
 
 Examples of this kind lie scattered all through my medical experi- 
 ence. Take a case of disappointed love. See that delicate and 
 emaciated female ; she is on the brink of the grave. I knew her 
 when the rose of health bloomed upon her cheek, and hope danced 
 before her captivated vision in the sunshine of coming prosperity, and 
 joyous anticipation painted in glowing colors the veil of futurity. Of 
 excellent parentage, she was the pride of her friends, the boast of her 
 relatives, and the centre around which revolved the affection of all 
 who had the honor of her acquaintance. If this earth ever gave 
 birth to an angelic spirit, it was she. But in an unlucky moment 
 she received a blow, from which she has never recovered. Disap- 
 pointed love has crushed her heart. At the very moment expectation 
 stood on tiptoe, the idol of her soul eluded her grasp. The blow was 
 too severe ; her physical powers gave way under the crushing weight of 
 her mental anguish, and phthisis is now consuming her vital powers? 
 and death is waiting for his victim. 
 
 This is no fancy sketch. It is a brief description of a living reality. 
 Every city and town has its prototype. This world of ours is full of 
 broken hearts and crushed affections ; and who witnesses more of it 
 
296 PULMONARY TUBERCULOSIS. 
 
 than the physician ? From the very nature of his calling, he is 
 brought into immediate contact with it. The chamber of disease and 
 death is the legitimate sphere of his action. While other men cull 
 the sweets of creation in their perfect state of action and repose, and 
 while they enjoy the delights of general society, his attention is occu- 
 pied with her melancholy condition of disease and decay ; instead of 
 the music of the festive hall, he listens to the sighs of suffering 
 anguish with a heart yearning for its relief. And thrice happy is 
 that individual who, when smitten with affliction, is so fortunate as 
 to fall into the hands of a scientific, conscientious, and sympathizing 
 physician ! He is a friend, indeed, who can relieve our physical 
 suffering, bind up the broken heart, and restore peace to a soul tossed 
 on a sea of trouble. 
 
 Take another example of the depressing passions in producing 
 pulmonary tuberculosis. Morton a long time ago treated of grief as 
 a prominent cause of this malady ; and nearly every physician of 
 extensive experience must have met with instances of it. I had a 
 very striking case of it in my practice a short time since. It was 
 that of Mrs. A., aged thirty-five, whose husband had been dead some 
 eight months. Mr. A. was a man of wealth. His mind had been 
 well cultivated in his youth, and he delighted in literary pursuits. 
 His temper was amiable, his manners retiring, and he spent the most 
 of his time in the duties and enjoyments of his happy home. He 
 unfortunately inherited the tubercular diathesis, his father and mother 
 having died with phthisis. Mrs. A. was a woman of fine mental 
 powers, very orderly in her habits, affectionate in her disposition, 
 and greatly attached to her family and home. Here was an earthly 
 paradise, where congenial and pure spirits delighted to meet and hold 
 sweet converse. But it was of short duration. The health of Mr. 
 A. commenced to decline, and before he was aware of his true con- 
 dition, he was beyond the skill of the physician ; and gradually 
 
 " He faded, and so calm and meek, 
 So softly worn, so sweetly weak, 
 So tearless, yet so tender — kind, 
 And grieved for those lie left behind : 
 "With all the while a cheek whose bloom 
 Was as a mockery of the tomb, 
 Whose tints as gently sunk away 
 As a departing rainbow"s ray." — Byko>\ 
 
THE MIND. 297 
 
 He left many friends to mourn his untimely departure. But none 
 grieved so bitterly as did his bosom companion. His death overwhelmed 
 her in the deepest sorrow. Her grief was tearless. She felt that the 
 last link which bound her to earth was broken, and she coveted death 
 as a boon for all her woes. Her anguish was so great that her nights 
 became sleepless, and her days wretched and miserable. Her appetite 
 and strength failed, and day by day she withered under the blighting 
 influence of her mental depression. The consoling powers of friend- 
 ship and religion furnished but a temporary mitigation for her deep 
 despondency. Threatening symptoms of pulmonary tuberculosis soon 
 manifested themselves, and by degrees ripened into certainty. Haemop- 
 tysis and hectic speedily supervened, and she fell a victim to the dis- 
 ease in one year and three months after the death of her husband. So 
 far as I could learn, she had no hereditary proclivity to tubercular 
 disease, her family being free from its taint. Grrief was evidently 
 the moving cause of the malady in this case, for it induced all those 
 circumstances which are favorable for its development. 
 
 V. The Intellectual Faculties : Their Abuse a Cause of 
 Phthisis. 
 
 These faculties constitute man a thinking, reasoning being. They 
 enable him to ascertain those abstract relations and bearings of things 
 which neither observation nor any other mental faculty can reach. 
 They create a thirst for information, and furnish the ability to acquire 
 knowledge in general. When confined to their legitimate use, guided 
 by the moral sentiments, they ennoble man, and elevate him far above 
 all the creatures that surround him. Indeed, they ally him very nearly 
 to his divine original. That their abuse should be a source of ill 
 health and unhappiness, cannot be doubted by the most superficial 
 observer. "When fired by an unholy ambition, they overwork the 
 brain, and light up a train of causes which frequently prove most dis- 
 astrous to health and life. 
 
 The history of literature in all ages presents melancholy instances 
 of superior minds over which the grave has prematurely closed ; of 
 genius formed for long and adventurous flights, and talent whose 
 beginning gave promise of enduring fame, suddenly extinguished. 
 Nor do our times fail to swell the melancholy list. The path of science 
 is beset with dangers. It is presented to our eyes nearly every day in 
 
298 PULMONARY TUBERCULOSIS. 
 
 the pallid look, the dull eye, the weary gait, and the emaciated form of 
 many of our most promising youth, who throng our various institu- 
 tions of learning. 
 
 The age in which we live is one of progress and improvement. The 
 march of mind is onward and upward, and intellectual excellency and 
 superiority is the golden crown for which many of our youth are 
 striving. This desire for intellectual improvement has aroused a spirit 
 of ambition, which to a certain class of minds is full of danger. We 
 do not, however, wish it to be understood that we consider intellectual 
 pursuits detrimental to health. Far from it. The frequent failures 
 that come under our observation, especially among the young, are to 
 be attributed to many causes. It is the unfavorable circumstances 
 under which this kind of labor is performed. It is crowded rooms, 
 improper hours, transgressing upon the period of sleep, positions unfav- 
 orable to the freedom of the corporeal organs, with unnatural repose of 
 others, and protracting the labors of the mind long after the changing 
 countenance has uttered the warning voice that nature demands repose. 
 
 There is very much in our present improved system of education, 
 as we sometimes call it, which is destined to be very injurious to the 
 young and rising race, unless it be speedily corrected. In every depart- 
 ment of learning there is an urgent necessity for a more rigid applica- 
 tion of those laws which lay at the very foundation of man's physical 
 being. Where these laws are habitually transgressed, health can 
 never be enjoyed. I most firmly believe that, if more attention was 
 bestowed upon the physical and intellectual training of children, the 
 mortality from pulmonary tuberculosis would be greatly reduced. 
 
 It is a generally prevalent notion among those who are ignorant of 
 the principles of physiology, that a superior intellect is incompatible 
 with a vigorous and healthy body ; that strong powers of mind are 
 necessarily lodged in a weak and delicate frame ; or, in other words, it 
 requires but little strength of constitution to be a student, acquire 
 massive learning, and be an intellectual giant. The origin of this 
 opinion is probably to be traced to the fact that there are and have been 
 men of great mental powers who had very feeble constitutions, — were 
 always in delicate health ; but there is every reason to believe that, 
 if their constitutions had been vigorous and their health robust, their 
 mental powers would have been stronger, and their intellectual achieve- 
 ments more °Tand and glorious. 
 
THE MIND. 299 
 
 In accordance with this popular error, children of the most feeble 
 constitutions are selected to be made scholars ; and although many 
 victims have been annually sacrificed, the mistake is likely to be per- 
 petuated. There is, however, not the least doubt that a boy in delicate 
 health might, with proper care, obtain a thorough education and attain 
 to eminence ; but, on account of his feebleness, it is evident that he 
 cannot perform so great an amount of labor as he could were he more 
 robust. A man of good constitution and in high health can endure 
 labor and privations without fatigue or inconvenience, and resist the 
 causes of disease longer than one of an opposite condition. Mental 
 labor, of all others, produces the greatest degree of wear and tear of 
 life, and causes the most sad inroads upon health. Who, then, can 
 best endure it, the robust or the weak ? 
 
 When a parent estimates the talent of his child, he does it with a 
 parent's fondness and a parent's prejudice ; ill health in childhood ex- 
 cites his compassion, and the most delicate boy is selected for one of 
 the learned professions. Great mistakes are thus made, — the boy is 
 compelled to study a profession because he is sickly, and not because 
 he has talent or relish for the occupation into which he is forced. He 
 is thus sacrificed, and the cause of science and the welfare of the 
 community are entirely overlooked by an erring, misguided father. 
 Exercise and active employment in the open air give health and 
 strength; a sedentary, studious life, and confinement within doors, 
 tend directly to undermine the strength and destroy health. There- 
 fore, let the feeble pursue the former, and the more robust the latter 
 course, and we will hear far less about the ravages of pulmonary 
 tuberculosis among the youth of our land. 
 
 But, in conclusion, we should always remember that the abuse of 
 the intellectual faculties may not only produce a great variety of 
 physical derangements, but many mental affections which embitter 
 life and end in premature death. Where these faculties are kept on 
 the constant stretch, and the mind perpetually occupied without 
 relaxation, the healthy functions of the brain are destroyed, and in- 
 sanity in some of its fearful forms is frequently the result. To guard 
 against this, all the faculties of the mind should be kept strictly within 
 the sphere of their legitimate action. Propensities, sentiments, intellec- 
 tual faculties, all should be controlled by that wisdom which animated 
 the mind of Him who said, — " If ye love me, keep my commandments." 
 
CHAPTER XXIX. 
 
 THE INFLUENCE OF DIFFERENT OCCUPATIONS IN PRODUCING PUL- 
 MONARY CONSUMPTION. 
 
 This earth of ours is full of labor-saving machines, of the most 
 curious construction and power, that daily perform the work of millions 
 of hands ; and they are multiplying to an almost indefinite extent. 
 Railroads radiate to every point of the compass. Steamboats, with 
 their untiring wheels, plow deep in all our navigable streams ; and 
 ere long the whole globe will be traversed by steamboats and locomo- 
 tives, connecting land and sea to their remotest bounds. Science, 
 eagle-like, has soared above the clouds, and seized the lightning by 
 its flaming tongue, compelling it to become a machine of thought 
 between man and man. Wonderful ! to compel that fierce power 
 that is born of the ravening elements, that goes with a leap and a 
 shout on its mission of destruction and death, to utter friendly words ! 
 Sunlight is made to paint ; the microscope has revealed a new world, 
 the telescope discovered new planets that revolve in the immensity of 
 space, which add to our knowledge of the skill, wisdom, and grandeur 
 of the Great Architect of the universe. 
 
 But while science has done so much, — has forced the clouds, winds, 
 waves, and all the elements of nature to do her bidding, — why has there 
 been so little done to remedy those evils which inflict so much misery 
 on a very large proportion of those engaged in our manufacturing 
 establishments? Who is to blame for the scrofula and pulmonary 
 consumption which are so common among the artisans and tradesmen 
 of our country ? Who that has a head to think and a heart to feel, 
 will stand up and plead, Not Guilty ? Let every statesman, philan- 
 thropist, and physician ponder these questions well, and see if he has 
 done all in his power to lessen these evils and to promote the health 
 and happiness of this large class of our population. 
 
 Many ordinary readers, and even some professional readers, are 
 300 
 
INFLUENCE OF DIFFERENT OCCUPATIONS. 301 
 
 not aware of the extent to whicli pulmonary consumption prevails 
 among the working classes, or the influence that certain occupations 
 have in producing it. The subject is not a new one. It has been 
 patiently and perseveringly investigated, in this country and in Europe, 
 by some of the greatest minds of the age. In Great Britain and in 
 France statistics show that among mechanics like bakers, coal-men, 
 cotton-spinners, etc., who breathe an atmosphere loaded with fine 
 vegetable dust, the average mortality from this disease is 2.22 per 
 cent., or a little more than twenty -two individuals in a thousand, of 
 this class. The mortality from consumption is least among cotton- 
 spinners, being about eighteen to a thousand ; and the greatest among 
 coal-men, about forty-one to a thousand. Among those who breathe 
 an atmosphere charged with mineral dust, such as stone-cutters, etc., 
 the average number of deaths from disease of the lungs is 2.99 per 
 cent., or nearly thirty persons in a thousand. Among the laborers 
 engaged in hewing stone the mortality from this cause is least, being 
 about eighteen in a thousand, while it is the greatest among the 
 plasterers, exceeding thirty in a thousand. Among those who breathe 
 an atmosphere loaded with fine particles of animal matter, such as 
 wool, hair, and feathers, the average number of deaths from disease 
 of the lungs is 5.44 per cent., or upwards of fifty-four persons in a 
 thousand. The smallest mortality is among the carders, the greatest 
 among those who work among feathers. 
 
 These statistical tables also show that the danger of attack from 
 consumption, among persons whose occupation obliges them to breathe 
 an atmosphere charged with dust, is about 2.40 per cent. ; in other 
 words, twenty-four persons in a thousand of such individuals die with 
 this wasting disease. These tables harmonize with the most accurate 
 statistics that have been kept in this country. And how could it be 
 otherwise? Mineral, animal, and vegetable substances of all kinds, 
 when inhaled into the lungs for a length of time, cannot fail to be 
 very injurious to the health, and must, to a very great extent, produce 
 consumption in those who have the tubercular habit. And, further, 
 when we reflect that individuals thus exposed are often compelled, 
 from the nature of their occupation, to lead a sedentary life, the cause 
 is fearfully aggravated. Thus, it has been found, by a comparison of 
 all the trades carried on in the open air with those carried on in work- 
 shops, that the proportion of deaths from consumption was doubled 
 
 20 
 
302 PULMONARY TUBERCULOSIS. 
 
 among those who were confined to the house, and that the proportion 
 increased as the apartments were close, warm, and imperfectly venti- 
 lated. Hence, tailors, shoe-binders, shoemakers, milliners, lace-makers, 
 engravers, printers, watch-makers, etc., from the nature of their em- 
 ployments, may be more particularly regarded as the victims of this 
 disorder, and in many occupations there is no doubt that consumption 
 is more commonly produced by a want of exercise, and a confined 
 posture of the body, than by any other causes to which the disease 
 is generally referred. 
 
 From the statements just made, it will at once be seen to what an 
 extensive portion of our population, both in our large towns and cities, 
 they are applicable ; and consequently the immense importance of 
 being aware of the fatal tendency of influences which have been 
 overlooked, or regarded as secondary to other causes which may now 
 be considered as comparatively inert. Muscular exercise and fresh 
 air may be regarded as two of the most important means of health ; 
 and when they are not enjoyed, as in some occupations of civilized 
 life, pulmonary tuberculosis, or some of its kindred disorders, must be 
 the inevitable result. And who that has examined this subject with 
 the attention which its importance demands, but must be convinced, 
 when reflecting on the condition of those individuals, such as sewing 
 girls, whose monotonous employment deprives them of fresh air, keeps 
 the body in a bent position, and checks the free circulation of the 
 blood, or of those delicate children employed in our factories, of the 
 injurious influence of such occupations on the health of those thus 
 employed ? "Who can estimate the injury they produce upon the lon- 
 gevity of the race, and the untold suffering inflicted upon their victims ? 
 
 But is there no remedy for these evils ? I am aware that it is 
 much easier to point out the cause of a physical or social wrong than 
 to apply the remedy, even when the remedy is obvious. Conscience 
 prompts to the right, while avarice and self-interest cling to the wrong. 
 It may be desirable to destroy human life in the cotton-factory, as the 
 political economists tell us, for reasons very convincing to themselves ; 
 but it is very opposite to the development, growth, and health of those 
 thus employed. If the philanthropist could but reach the conscience 
 and the heart of every employer in the land, there would be some 
 hope for the toiling millions, some remedy for the physical evils under 
 which they suffer. 
 
INFLUENCE OF DIFFERENT OCCUPATIONS. 303 
 
 "We cannot enter into a full detail of the means that would be 
 necessary to correct the evils under consideration, for many of them 
 are in no way connected with the province of the physician. But it 
 is a clear case that, before we can lessen very much the mortality from 
 pulmonary consumption, some of them must be corrected. In a few 
 cases, however, this may be easily accomplished. "When a person is 
 subjected to any of the influences just noticed, particularly if he is 
 threatened with the disease, we should by all means recommend him 
 to take regular exercise in the open air, restrict the number of hours he 
 is employed, and not follow exclusively any one occupation, which 
 experience has shown will invariably terminate in consumption. He 
 should pursue alternately other departments of his trade, requiring 
 very opposite conditions of the muscular system ; and where this is 
 not practicable, he would do well to change his occupation altogether. 
 
CHAPTER XXX. 
 
 A PLEA FOR THE BEARD ; ITS INFLUENCE IN PROTECTING THE 
 THROAT AND LUNGS FROM DISEASE. 
 
 In the last chapter we observed that many individuals while pur- 
 suing their vocation are exposed to the injurious effects of an atmos- 
 phere loaded with particles of fine dust. On examination after death 
 of the lungs of persons who have been thus exposed, there have been 
 found numerous particles, sometimes of wood, stone, or iron, according 
 to the occupation of the individual, incased in a membrane, going to 
 prove that nature had for a time resisted the efforts of these insidious 
 invaders of her rights, and endeavored by every means within her 
 power to protect the person from disease and death. 
 
 It has long been a desideratum to offer something to workmen thus 
 exposed to protect their lungs from the fatal effects of their necessary 
 occupation. Various temporary expedients have been resorted to, 
 which it is unnecessary to enumerate, for they have all been found 
 ineffectual. And is it not extraordinary that the very thing which 
 nature designed as a preventive, in a great part, for this evil, should 
 have until very recently escaped our notice ? I refer to the heard. 
 There cannot be the least doubt that the beard, and the hairs that 
 grow in the nostrils, were designed by nature to guard the lungs from 
 the invasion of these deleterious particles. Such being the use of the 
 beard, individuals engaged in employments where the air is constantly 
 filled with particles of fine dust should never shave. 
 
 I have come to this conclusion from a careful observation of the 
 effect of wearing the beard and of shaving upon the air-passages and 
 lungs. And I could, if space allowed, record many cases of throat 
 and lung-diseases that have been permanently cured by wearing the 
 beard. And I have not the least hesitation in saying that hundreds 
 have been cheated of their lives by the conventional habit of shaving. 
 Many an individual has fallen a victim to consumption whose life and 
 304 
 
INFLUENCE OF THE BEARD. 305 
 
 usefulness might have been greatly prolonged, if this unnatural habit 
 had never had an existence. 
 
 We sometimes blame woman for her wicked practice of tight lacing 
 as the cause of pulmonary consumption ; but look at the shorn faces, 
 who through successive generations have, by leaving the organs of 
 respiration unprotected by the beard, entailed upon posterity an undue 
 proclivity to disease of the throat and lungs. " Preternatural ! ab- 
 surd !" I think I hear some smooth-face exclaim. Not so absurd as 
 you may suppose. Examine the matter carefully, and you will see its 
 beauty and consistency. Prejudice and custom are most powerful 
 enemies of reform, and aside from these I cannot think of a single 
 reason for shaving or mutilating the beard. 
 
 Physiologically, the beard seems as truly designed by nature to aid 
 in the preservation of the health as the hair covering the head. The 
 moustache is emphatically nature's simple respirator, while the hair 
 covering the jaws and throat is intended to afford warmth and protec- 
 tion to the delicate structures in the vicinity, especially the fauces and 
 the larynx. In shaving, then, do we not destroy the provisions which 
 have been made for the maintenance of the health of these important 
 organs ? 
 
 Several years ago, Dr. Skoda, a celebrated German physician, gave 
 a detailed account of some observations he had made on fifty-three 
 strong, healthy men, whose ages ranged from twenty-five to fifty-five, 
 who shaved their faces after having previously worn the whole beard. 
 All of them at first experienced very unpleasant sensations of cold, 
 but only fourteen of them became speedily accustomed to the change, 
 and experienced no further inconvenience. The others suffered more 
 or less in various ways. Twenty-seven had painful affections of the 
 teeth and jaws, eleven had toothache and neuralgia in the face, and 
 sixteen had rheumatism of the gums with and without abscess. In 
 six cases there was obstinate enlargement of the glands of the neck ; 
 and in thirteen there was rapid increase of decay in previously affected 
 teeth, requiring the extraction of the aching grinders. He compared 
 the statistics of toothache in thirty men of the age of thirty years, 
 one-half of whom wore the beard, and the others shaved. Among those 
 of the first class, there had been only eight teeth extracted, while 
 among the others there had been no less than twenty-six extractions. 
 All the cases of dental neuralgia which came under his notice as the 
 
306 PULMONARY TUBERCULOSIS. 
 
 result of shaving, were obstinate and tedious in their character ; in a 
 few cases the disease assumed an intermittent type ; and in two cases 
 all remedies proved unavailing until the beard had been allowed to 
 grow once more. Dr. Skoda, therefore, gave it as his deliberate opin- 
 ion, that the growth of the beard is conducive to health, and that 
 shaving renders individuals more susceptible to violent alternations of 
 temperature, and consequently more liable to disease. 
 
 The beard, as already remarked, is an excellent respirator, for it not 
 only mechanically prevents the entrance of foreign particles into the 
 air-passages, but it also lessens the coldness of the air we breathe, by 
 imparting to it, as it passes through the thick moustache, some of the 
 heat which has been left there by the warm breath just expired. In 
 these respects it has been found an indispensable hygienic agent by 
 all persons who are engaged in running railway trains, such as conduc- 
 tors, engineers, and brakesmen. These men are exposed to many 
 vicissitudes of temperature, and are also constantly obliged to inspire 
 air loaded with minute particles of dust and carbonaceous matter. 
 The beard is of great service to them, by rendering them insusceptible 
 to violent alternations of temperature, and by preventing the inhalation 
 of deleterious particles in the air. Careful investigation, both in this 
 country and in England, clearly shows that railway men who wear their 
 beards enjoy a greater immunity from disease of the air-passages and 
 lungs than those who shave. 
 
 Indeed, I have for years regarded it physiologically wrong to shave 
 the beard, and have generally recommended my patients who have a 
 predisposition to throat- and lung-diseases to desist from the use of 
 the razor. I can now call to mind a number of my patients who were 
 troubled with pain in the chest, and during the cold season with a 
 slight hacking cough and sore throat, who since they have ceased to 
 shave their beard have become entirely relieved of these troublesome 
 disorders. Indeed, I am acquainted with a number of individuals 
 who, during the cold winter months, were constantly annoyed with 
 chapped and fissured lips, which were very sensitive, bleeding from 
 the slightest injury, and who, since they have ceased shaving, have 
 not been annoyed with a return of the disease. 
 
 Let every man, then, who has a proclivity to consumption, abandon 
 the habit of shaving the beard. Let folly give place to manly pride, 
 and save the race from the ravages of pulmonary tuberculosis, which 
 
INFLUENCE OF THE BEARD. 307 
 
 is year by year increasing upon us. We have it upon the very best 
 authority, that diseases of the throat and chest were not so common 
 previous to the commencement of shaving. Let the beard, therefore, 
 be cultivated with care, and it will be of great use in shielding the 
 throat and lungs from many fatal diseases, besides adding to the 
 beauty and grandeur of the " human face divine." 
 
CHAPTER XXXI. 
 
 TIGHT LACING A CAUSE OF PULMONARY CONSUMPTION. 
 
 Before me is one of the best works ever written on " Pulmonary 
 Consumption." Its author was the distinguished French physician, M. 
 Louis. In his day his opinions were almost considered medical law, 
 and his teachings are still highly respected in all our medical schools. 
 On page 445 of his book he says, " The influence of dress, and 
 especially the stays, on the production of consumption, is also, perhaps, 
 a mere assertion." How any one so learned on all subjects connected 
 with this disease, one also acquainted with every department of medical 
 science, could take such a position as this, I am at a loss to conceive. 
 Mechanical compression no cause of consumption ! Let us briefly ex- 
 amine this subject. Perhaps nature has made a grand mistake, and 
 given women more lungs than they need for the purpose of respiration, 
 and hence they do well to use the barbarous corset ! 
 
 It is computed that a person in health generally respires about 
 twenty times in a minute, and takes in at every breath about forty 
 cubic inches of air (rather more than a pint), the oxygen of which is 
 not only nearly all used up, but forms part of a substance as positively 
 injurious to health as are the fumes of burning charcoal. When, there- 
 fore, a number of persons for a long time breathe the same atmosphere, 
 without any ventilation or renewal of it, they rapidly exhaust the air 
 of its healthy properties, and subject themselves to great danger. The 
 reason is this : No pure, fresh oxygen being admitted to the lungs, the 
 venous blood cannot part with its carbon, because this is the only 
 means by which it can be taken away. The blood does not, therefore, 
 become revitalized : it goes back to the heart from the lungs in its im- 
 pure state, and is sent through the body totally unfit to give proper 
 nourishment, thus injuring and debilitating the whole system, and 
 exposing it to the attack of many dangerous and fatal disorders, 
 and especially to tubercular disease of the lungs. 
 308 
 
TIGHT LACING, 309 
 
 Such being the effect of breathing the contaminated atmosphere of 
 an ill-ventilated room, who can fail to see the folly of incapacitating 
 the lungs from fulfilling their function by mechanical compression ? 
 It is clear to my mind that those individuals who encase their chest in 
 the corset do virtually shut out the very breath of life, that gives de- 
 velopment, symmetry, elasticity, beauty, and strength to the whole 
 body. There can be no vigorous action either of body or mind without 
 it. How soon would the whole animal world gasp in death, if the 
 atmosphere were for one moment withdrawn from the earth ! 
 
 The lungs, from the nature of their construction, are so arranged 
 that they can receive no more air into them than is sufficient to supply 
 the increased capacity produced by the enlargement of the chest. The 
 respiratory muscles enlarge the chest to a certain extent, and a quantity 
 of air just sufficient to fill the lungs is taken in, and no more. All 
 that can be taken in is necessary to purify the blood thoroughly ; and 
 if by any cause the requisite quantity of oxygen is prevented from 
 reaching the lungs, the whole system feels the effect. 
 
 Again, by referring to the anatomy of the chest, we discover that a 
 large portion of its walls are made of elastic cartilage, which will readily 
 yield to pressure. The object of these cartilages is principally to assist 
 in expiration and inspiration. Their flexibility may be proved by 
 placing a hand on each side of the chest and pressing them together ; 
 they can be thus made to yield several inches. Now, it will be readily 
 seen that if a bandage is tightly drawn around the chest, and continued 
 there for a short time, not only will the chest be prevented from fully 
 expanding, and shut out a great quantity of air, but the right side of 
 the heart must labor harder to propel the blood through the constricted 
 lungs ; and the lungs, being thus impeded in their wonted freedom, are 
 placed in a condition which greatly favors the exudation of tubercular 
 matter in their tissues. 
 
 That mechanical constriction of the chest sometimes produces this 
 result, we have the most abundant evidence, especially in those who 
 have a proclivity to pulmonary tuberculosis. Here is a case, which 
 may serve as an illustration of the pernicious effects of tight lacing, 
 
 and is a fair sample of many that could be recited. Miss , aged 
 
 about fifteen, when at a fashionable school, away from home, and re- 
 moved from the care of a sensible and judicious mother, contracted 
 the habit of tight lacing. Her naturally healthy complexion was soon 
 
310 PULMONARY TUBERCULOSIS. 
 
 lost, the glow of health faded, and the rose gave place to the lily ; her 
 appetite forsook her, digestion became bad, and. in addition to these 
 symptoms, she had the hectic flush and hacking cough, with other in- 
 dications of consumption. Her friends became very much alarmed, 
 medical advice was sought, and the cause of her indisposition readily 
 discovered. The remedy was, of course, obvious : her lacing-apparatus 
 was taken from her, and placed where it could not on aoy occasion be 
 used. In a few months her lost health was regained ; but, not con- 
 vinced of the injurious effect of tight lacing, and not satisfied with 
 having once placed her life in jeopardy, she must repeat the experi- 
 ment ; but this time the recuperative powers were unable to repair the 
 damages, consumption supervened, and soon terminated her existence. 
 Such cases frequently fall under the notice of the observing physi- 
 cian. I could name several, just now, who are suffering from this 
 cause in my limited practice. Human nature, or rather the infirmity 
 of it, is such that individuals will sometimes seek to gratify their 
 passions at the risk, or even the certain sacrifice, of life. The soldier 
 indulges his ambition by seeking a " bubble reputation even in the 
 cannon's mouth," and females indulge their love of admiration by 
 displaying what is in fact a deformed person. The soldier is nothing 
 daunted by seeing his companions fall around him ; his aspirations 
 for glory impel him on to death or to renown ; so she whose passion 
 is display, and whose glory is to be admired, still persists in her in- 
 jurious practice, though she, too, sees her companions silently falling 
 by a species of involuntary suicide. 
 
 „ I am aware that there are many females who maintain that the 
 narrowing of the waist by art adds to the symmetry and beauty of the 
 human form. Nothing is more absurd than this. And every moral 
 teacher should rise up in his strength and denounce such pretensions 
 as a libel upon nature and classic art. Improve the human form ! 
 Who has the presumption to attempt it ? Folly and ignorance may 
 try it, but it must invariably result in defeat and ruin. The human 
 form is perfect, and in this respect is in harmony with all the works 
 of our great Creator. 
 
 Mechanical compression by the corset not only destroys the sym- 
 metry of the chest, but it impairs the beauty of the complexion and 
 countenance. Let us try the experiment. Here is a young woman 
 in perfect health ; her complexion is fair, her countenance wears an 
 
TIGHT LACING. 311 
 
 expression of peace and happiness, and her movements are classic and 
 graceful. Let a band be drawn around her chest in such a manner as 
 to prevent its full expansion. Now look at her complexion : it has 
 lost its healthy color ; the blood is impeded in the superficial vessels 
 under the skin, and gives a dark, unnatural red. The features are 
 also distorted ; the nostrils are thrown into more frequent and hurried 
 action ; the lips are contracted unpleasantly ; the eyes have a staring 
 expression and an unnatural fullness and projection, all foreign to the 
 beauty of the countenance. 
 
 If these are some of the effects of a single band around the waist, 
 how much greater must those be from including the entire chest in a 
 tight corset. A woman tightly laced will have, despite all exertion 
 to the contrary, an afflicted, if not a suffering countenance ; and she 
 cannot possibly in that state exhibit that lively play of features and 
 ingenuous expression of face which she could do without effort at an- 
 other time. Every change of motion, however transient, is promptly 
 followed by a change of respiration, marked either by more frequent 
 movements or by greater expansion of the chest; but how can an 
 emotion be indulged, or how receive its appropriate expression, if 
 the sides of the chest be pressed in as if with iron ? 
 
 Such being the injurious effects upon the system of mechanical 
 compression of the chest, who will undertake to say that it has no 
 influence in producing pulmonary consumption ? Every view that we 
 can take of its injurious effects, both local and general, leads us to the 
 conclusion that, if this habit was banished from the world, the mor- 
 tality from this disease would be greatly reduced among the female 
 portion of the race. And it is a melancholy reflection that this per- 
 nicious habit is so general, and so obstinately persisted in, at so great 
 an expense of health and life. 
 
CHAPTER XXXII. 
 
 HOW TO CURE PULMONARY TUBERCULOSIS. 
 
 We have already remarked in another place that this disease could 
 not be cured by medicine alone. It must be sustained by proper 
 hygienic measures. Indeed, in our judgment the latter is of more 
 importance than the former, for it is necessarily the basis of all medi- 
 cation in this and all other diseases which afflict mankind. Experi- 
 ence has demonstrated the fact that the first and most important 
 thing in the treatment of disease in general, and consumprion in par- 
 ticular, is to surround those afflicted with the best possible hygienic 
 influences. These, of themselves, without the aid of medication, are 
 often sufficient to remove disease and restore the body to its wonted 
 health. The influence of hygiene, therefore, becomes a grand and 
 paramount necessity in the management of disease, and cannot be 
 overlooked or disregarded without violating the first principles of 
 medical practice. Our success, therefore, in curing this malady, will, 
 in a great measure, depend upon the degree in which the influence of 
 hygiene can be brought to our aid. 
 
 Hygiene, in its most extensive signification, includes everything of 
 a salutary nature that relates to the preservation and restoration of 
 health. It embraces quite a number and variety of objects, presenting 
 distinct and characteristic peculiarities. Some of the principal and 
 most important of these are air, food, drinks, exercise, bathiDg. cloth- 
 ing, and sleep. 
 
 In this chapter we shall consider more particularly, — 
 
 The Importance and Indispensable Necessity of Pure Air for 
 the Preservation of Life and Health. 
 
 To form a just estimate of its value for the purpose just named, we 
 must first understand something of the nature and chemical qualities 
 of air. Atmospheric air is composed of two distinct elementary gases, 
 312 
 
HOW TO CURE. 313 
 
 the proportions of which are very different. They are called nitrogen 
 and oxygen* The former constitutes about four-fifths of the air, and 
 the latter one-fifth. Nitrogen gas, when pure, possesses no active 
 properties ; it will not support either combustion or animal life, nor 
 will it destroy either by any peculiar power of its own. On the con- 
 trary, pure oxygen has many active and powerful properties. Bodies 
 not commonly inflammable will burn in it with great brilliancy, and 
 animals live in it with an increased activity ; but they cannot live in 
 it so long as in the open air. They die sooner, as they seem to live 
 faster. 
 
 But the Creator of all things designed not this element as an agent 
 of destruction. He has, therefore, so tempered it, by uniting it with 
 nitrogen, as to sustain the lives and conduce to the comfort of his 
 creatures. He gives to the air that proportion of oxygen which pro- 
 motes the oxygenation of the blood, the combustion of wood, oil, and 
 coal, sufficient for all the purposes of human life. Less oxygen would 
 be insufficient to afford us the necessary fire and light ; more oxygen 
 would render combustion dangerous and destructive. 
 
 The oxygen of the atmosphere being thus the principle which sup- 
 ports life and flame, it is obvious that large quantities of this gas 
 must be consumed every hour, and that therefore its quantity must 
 be diminished unless there exists some means by which it is replaced. 
 The quantity consumed must be exceedingly small, in a definite 
 period of time, when compared with the whole, for the whole atmos- 
 phere not only surrounds the earth, but extends above it about forty- 
 five miles. Now, when we consider how small a proportion of this 
 immense mass comes in contact with animals and fires at one time, 
 and that it is only a small proportion that becomes vitiated, we must 
 suppose that ages would elapse before any difference could be detected 
 in the quantity of the oxygen, were there no means of replenishment 
 provided. 
 
 But the wisdom and design of the Deity which the study of nature 
 everywhere detects, and which is so constantly vouchsafed for the 
 benefit and comfort of man, has not left so important a principle as 
 
 * Oxygen was discovered in 1774, by Dr. Priestley, an English chemist. Since 
 that period the whole science of chemistry has changed its character, and all has 
 seemed to become subservient to this wonderful agent. 
 
314 PULMONARY TUBERCULOSIS. 
 
 that of vital air to be consumed without a source of regeneration. It 
 has been fully established by experiment that vegetation is the source 
 from which the atmosphere is replenished with oxygen, and so far as 
 is known this is the only source. Growing plants, during the day, 
 absorb carbonic acid from the atmosphere, decompose the gas, emit 
 oxygen, of which it is in part composed, and retain the carbon to in- 
 crease their growth. 
 
 Any one who may doubt the fact that oxygen is given off by vege- 
 tables, can prove it to his satisfaction by a very simple experiment. 
 Take an eight-ounce vial ; fill it one-fourth full of sprigs of green mint ; 
 then fill the vial with water ; after this invert it in a basin of water, 
 and leaving it for a short time exposed to the action of the rays of 
 the sun, small bubbles will begin to appear on the surface of the 
 leaves. These bubbles are oxygen, which, rising into the upper part 
 of the vial, will in a few days afford a sufficient quantity of pure gas 
 for the purpose of performing several interesting experiments. 
 
 But our atmosphere contains other things besides oxygen and 
 nitrogen. They are not, however, proper normal constituents of the 
 air, but are foreign exhalations from numerous sources on the land and 
 sea. Wherever man moves, his fire, his food, the materials of his 
 dwelling, the soil he disturbs, all add their volatile parts to the atmos- 
 phere. Vegetable death and decay pour into it copiously substances 
 foreign to the composition of pure air. It 'is said that the combus- 
 tion of one ton of coal adds sixteen tons of impurity to the atmos- 
 phere ; and when we estimate the daily consumption of coal, the 
 addition from this source alone, the amount becomes enormous. 
 
 Experiments have frequently been made for the purpose of esti- 
 mating these additions, and the result of those most carefully con- 
 ducted shows in how slight a degree all these combined causes affect 
 the general composition of the atmosphere ; and although the present 
 refined methods of chemical science enable us to detect the presence 
 of an abnormal amount of some of these substances, no research has 
 yet been successful in determining how this varies the natural quan- 
 tity at all times necessarily present in the atmosphere. In this 
 instance, nature has also instituted means of purification, and we 
 need not fear that the atmosphere will ever become deteriorated in 
 purity by any of these noxious emanations. The agent which accom- 
 plishes this is called ozone or ozonized oxygen. It is said that when 
 
HOW TO CURE. 315 
 
 this substance is brought in contact with nitrogenized bodies, it forms 
 with them nitrous acid, completely destining their former condition 
 and composition ; hence in the atmosphere ozone becomes a purifier 
 of the whole mass, from which it removes putrescent exhalations, 
 miasmatic vapors, and the effluvia from every source of land and sea. 
 
 Having thus presented a general outline of the chemical qualities 
 of the atmosphere, let us briefly notice some of the changes which 
 it suffers during respiration. Before it is inspired, as already 
 stated, it consists of nitrogen four-fifths, and oxygen one-fifth ; but 
 after its passage through the lungs, it is expired in a very different 
 state ; for on reaching the lungs, about two-fifths of the oxygen enters 
 into combination with the venous blood, and is mixed with the circu- 
 lating fluid, the remaining three-fifths being exhaled along with the 
 nitrogen, nearly in the same state as it was originally received. In 
 place of the oxygen consumed, there is expired an equal volume of 
 carbonic acid gas, which has been generated in the system ; and when 
 this gas exists in a large proportion in a confined apartment, the 
 atmosphere becomes of a noxious character, and is rendered unfit to 
 be again breathed. 
 
 From the above considerations, it is evident that during respiration 
 the venous blood loses carbon, acquires oxygen, and is thus better 
 adapted for carrying on the nutrition of the body. It is not only 
 better fitted for maintaining the health of the various organs of the 
 body, but is absolutely necessary for the preservation of life. Indeed, 
 if oxygen were to be withdrawn from the blood for one moment, we 
 would sink into the slumber of death, and speedily vanish from the 
 living world. 
 
 Such being the nature and use of atmospheric air in the process of 
 respiration, it will not take much mental penetration to see how 
 injurious it must be to health when it becomes vitiated, and how 
 readily it will produce tubercular disease in those who have a pro- 
 clivity to it. Indeed, there are few causes more productive of this 
 disorder, either in man or the inferior animals, than an atmosphere 
 loaded with carbonic acid. This has been very conclusively demon- 
 strated by some experiments made by Dr. McCormick, and reported 
 to the Academy of Medicine, Paris. He relates experiments made 
 upon dogs and rabbits. Half were confined in an atmosphere loaded 
 with carbon, while the other half were left in pure air. In the short 
 
316 PULMONARY TUBERCULOSIS. 
 
 space of six weeks the half that were confined to the impure air were 
 found affected with tubercles, while the half that were not confined 
 remained free from the disease. 
 
 These experiments of Dr. McCormick are fully confirmed by what 
 we frequently witness in ill-ventilated prisons and hospitals, and by 
 observation of those who are confined in workshops where the atmos- 
 phere is loaded with carbon ; among this class of operatives the mor- 
 tality from tubercular disease is very large. Thus, it has been found 
 that in the close workshops of a printing establishment, the composi- 
 tors, whose employment requires but little exertion, fall victims to 
 consumption in the proportion of forty- four to thirty-one and a half 
 per cent, of the pressmen, who have more exercise and generally get 
 more fresh air. Similar exercise in the open air would have a much 
 more salutary effect, the deaths from the same cause in out-door 
 laborers not exceeding twenty-five per cent. If, therefore, more atten- 
 tion were paid to the ventilation of our stores, workshops, dwellings, 
 school-houses, churches, and other places where great numbers are 
 collected together, the public health would be greatly promoted, and 
 the mortality from all chest-diseases very much diminished. 
 
 The practical conclusion from the preceding remarks is, that a full 
 and free supply of atmospheric air is of indispensable necessity to 
 prevent or remove pulmonary tuberculosis. It is my firm conviction 
 that fresh air in abundance is of more importance to consumptive 
 patients than are drugs. Hence, all persons who have a predisposition 
 to the disease, or are suffering from its wasting effects, should, if 
 possible, be so placed as to obtain with the least trouble a full quantity 
 of this necessity of life. Indeed, there is nothing better for sore lungs 
 than fresh air, and I am therefore in the habit of recommending 
 my consumptive patients, where they are able, to be out in the air as 
 much as possible. Physicians have sometimes been astonished at the 
 recovery of tubercular patients when they have abandoned all drugs, 
 relinquished their in-door confinement, and gone out. as it were, to 
 seek health in the roughest kind of life. But if they would examine 
 this mode of life, they would, perhaps, find not half so many violations 
 of the hygienic laws as in the former. 
 
CHAPTER XXXIII. 
 
 FOOD : ANIMAL AND VEGETABLE BOTH NECESSARY TO VIGOROUS 
 HEALTH. — CONSUMPTIVES SHOULD HAVE A GENEROUS DIET. 
 
 One of the peculiar characteristics of living bodies is the changes 
 which take place in their dimensions, form, and structure, from the 
 moment of their formation until their existence ceases. Take, as an 
 example, the human body. We know that we are continually losing 
 in different ways, as from perspiration, respiration, etc., a part of the 
 elements which enter into the composition of our bodies. These losses, 
 which in a day amount to many pounds, weaken us, and we would 
 soon die did we not repair them by food and drink. Thus, it appears 
 that there is going on a continuous intrinsic movement, by means of 
 which our organs appear on the one hand to use up and destroy them- 
 selves, and on the other to repair themselves and acquire new power ; 
 and this renewal of our constituent elements is one of the fundamental 
 actions of life. 
 
 The organs which effect these wonderful changes are those of diges- 
 tion, circulation, respiration, etc., called in brief the organs of nutrition. 
 But they would be of no use without aliment. Whatever is taken 
 into the stomach, and is there changed by digestion so as to furnish 
 materials for the support and growth of the body, is aliment. Man, 
 by the structure of his digestive organs, is capable of deriving nour- 
 ishment from both the animal and vegetable kingdoms. 
 
 Animal food, without doubt, contributes more directly to the nour- 
 ishment of the body than does vegetable. But, owing to its putrescence 
 and stimulating nature, it is not suited to form the whole of his ali- 
 ment ; and, in fact, if long and exclusively used, it overheats and 
 stimulates the system in such a manner that exhaustion and debility 
 are sure to ensue. 
 
 Those, therefore, who have lived for any great length of time on a 
 diet composed entirely of animal food, become oppressed and indolent ; 
 the tone and excitability of their bodies are impaired ; they are afflicted 
 
 21 317 
 
318 PULMONARY TUBERCULOSIS. 
 
 with indigestion ; the breathing is hurried on the smallest exercise ; 
 the gums swell and bleed ; the breath is fetid, and the limbs are in- 
 active, stiff, and swollen. 
 
 On the other hand, vegetables are acescent, less stimulating, and 
 generally of more difficult assimilation than is animal food. Hence, 
 in certain constitutions, where the system is severely taxed by labor, 
 vegetable food seems insufficient to support the health and strength of 
 the body ; consequently, flatulency and acidity of the stomach, muscu- 
 lar and nervous debility, and a long train of mental disorders, are fre- 
 quently caused by this too sparing diet. 
 
 In view of these facts, we are led to infer that a mixed diet of 
 animal and vegetable food is that which is best suited to the nature of 
 man. The proportion in which they should be used depends upon a 
 variety of circumstances, such as age, constitutional peculiarities, cli- 
 mate, and occupation. Generally speaking, the quantity of vegetable 
 should exceed that of animal food. 
 
 On examining the writings of physiologists, you will frequently find 
 opinions and assertions respecting the influence of animal and vege- 
 table diet on the human system quite at variance with truth and ob- 
 servation ; and, indeed, some have even sought for a support to their 
 systems in the fictions of poetry. 
 
 " The use of a purely vegetable diet," says Buffon. in his " Natural 
 History of Man," " though extolled by ancient and modern philos- 
 ophers, and even recommended by certain physicians, was never indi- 
 cated by nature. If man were obliged to abstain totally from flesh, 
 he would not, at least in our climate, either exist or multiply. An 
 entire abstinence from flesh can have no effect but to enfeeble nature. 
 To preserve himself in proper plight, man requires not only the use of 
 solid nourishment, but to vary it. To obtain complete vigor he must 
 choose that species of food which is most agreeable to his constitution ; 
 and as he cannot preserve himself in a state of activity but by pro- 
 curing new sensations, he must give his sensations their full stretch, 
 and eat a variety of meats, to prevent disgust arising from a uniform- 
 ity of nourishment." 
 
 We are told, on the other hand, that in the Golden Age man was as 
 innocent as the dove ; his food was vegetables, and his beverage pure 
 water from the fountain. Finding everywhere abundant subsistence, 
 he felt no anxiety, but — 
 
FOOD. 319 
 
 .... "did good pursue, 
 Unforced by punishment, unawed by fear, 
 His words were simple, and bis soul sincere. 
 ******* 
 No walls were yet, no fence, no moat, no mound; 
 No drum was beard, no trumpet's angry sound ; 
 No swords were forged ; but, void of care and crime, 
 The soft creation slept away its time." 
 
 In this condition lie lived in peace, both with his own species and 
 with the other animals. But he no sooner forgot his native dignity, 
 and sacrificed his liberty to the bonds of society, than war and the Iron 
 Age succeeded that of gold and peace. Cruelty and an insatiable ap- 
 petite for flesh and blood were the first fruits of a depraved nature, the 
 corruption of which was completed by the invention of manners, arts, 
 and sciences. Either immediately or remotely, all the physical and 
 moral evils by which individuals are afflicted and society laid waste 
 arose from these carnivorous practices. 
 
 But these representations are neither of them correct. They are 
 contradicted by the only criterion in such questions, an appeal to ex- 
 perience. That animal food renders man more cruel and courageous 
 is fully disproved by the inhabitants of Northern Europe and of Asia, as 
 well as by the Esquimaux, the smallest, weakest, and least brave people 
 on the globe, although living almost entirely on flesh, and that often raw. 
 
 Yegetable diet is as little connected with weakness and cowardice as 
 that of animal matter is with physical force and courage. That men 
 have been and can be perfectly nourished, and their bodily and mental 
 capabilities fully developed, in certain climates by a purely vegetable 
 diet, admits of abundant proof from experience. We might refer to 
 the Greeks and Bomans, who, in the period of their greatest sim- 
 plicity, manliness, and bravery, lived exclusively on a plain vegetable 
 diet. And also the modern Italians and Scotch, who certainly are not 
 rendered weaker than the English by the free use of vegetable food. 
 
 Again, the representations of the vegetarians respecting the noxious 
 and debilitating effect of animal food are, on the other hand, the mere 
 offsprings of imagination. We have not the shadow of proof, unless 
 we admit Ovid's " Metamorphosis," and other poetical compositions, 
 that this state of society, of exalted temperance, of entire abstinence 
 from flesh, ever existed, or that it is more than a fable designed to 
 convey moral instruction. If the experience of every individual were 
 
320 PULMONARY TUBERCULOSIS. 
 
 not sufficient to convince him that the use of animal food is quite 
 consistent with the greatest strength of body and exalted energy of 
 mind, this truth is proclaimed by the voice of all history. 
 
 From our reading and experience, we are fully convinced that in 
 our climate a substantial diet of animal and vegetable food is necessary 
 at all times to vigorous health. Good blood cannot. be made of slim 
 and slender fare. Hence, in a disease like pulmonary consumption, 
 where the blood is so deficient in its nutritious qualities, and where 
 there is such a vast wasting of all the tissues of the body, too much 
 attention cannot be paid to the diet of all who have a predisposition 
 to or are suffering with the disease. It is true the individual's diet 
 should be simple, but it should be at the same time solid: roasted, 
 boiled, and broiled meats, especially beef, and such farinaceous articles 
 as are easily digested. The raw-beef diet for consumptives, so highly 
 extolled by some physicians, is simply barbarous, condemned alike by 
 the sacred scriptures and by the refined taste of mankind. 
 
 Nearly allied to food is the subject of drinks. And at the head of 
 the list is water. This is indispensable in the animal economy, but 
 individuals affected with consumption, from the peculiar nature of the 
 disorder, are often apt to use it to excess. This is no doubt owing to 
 the many local irritations, and the consequent hectic fever, which com- 
 monly produce inordinate thirst. The patient should control as much 
 as possible this desire for water, for when taken in large quantities it 
 debilitates the digestive organs, and thus greatly interferes with healthy 
 nutrition. The excessive use of this and of other liquids should there- 
 fore be carefully guarded against, and, when required, they should be 
 taken in small quantities at a time, just sufficient to alleviate the thirst. 
 Sometimes this morbid desire for water may be very much mitigated 
 by the use of saccharine, acid, or mucilaginous drinks, either alone or 
 in conjunction with other liquids. 
 
 Other articles in the liquid form, such as coffee and tea, are much 
 employed for invigorating and nutritive purposes, and, when not used 
 so freely as to disturb the regular processes of the economy, may be 
 of service to consumptives by retarding the rapid wasting that is con- 
 stantly going on, and in giving support to the system generally. Some 
 physicians recommend alcoholic stimulants as useful drinks in this 
 disease. We will try in the concluding chapter of this work to ven- 
 tilate this whole subject. 
 
CHAPTER XXXIV. 
 
 ANIMAL HEAT; CLOTHING. THEIR IMPORTANCE IN PREVENTING 
 THE FORMATION OF TUBERCULAR DISEASE. 
 
 I. Man Naturally Destitute of Covering. 
 
 There is no being that comes into the world so naked of all cover- 
 ing, so destitute of natural protection, so exposed to injuries and 
 suffering of temperature, as man. Some short-sighted, splenetic men 
 have found fault with our Creator for this. But we can discover no 
 reason for fault-finding or grumbling. Where is the man that appre- 
 ciates his exalted position in the scale of being, who would exchange 
 his beautiful skin for the hide of a beast or the feathers of a bird ? 
 Could any man that sees, feels, or reasons, desire to have the physi- 
 ognomy of a horse or a lion, instead of the human face divine, — instead 
 of its lovely complexion, its eloquent features, its attractive delicacy, 
 and its impressive dignity ? But, independent of all beauty and all 
 that delights the eye, the taste, and the touch in the human skin, who 
 would relinquish the mental advantages which we derive from its 
 exquisite nervous sensibility ? We would be devoid of a large portion 
 of our sensations and ideas without it. The delicate sensibility of the 
 ends and inside of our fingers and of our palm provides us with an 
 important part of our most useful knowledge. The connection is 
 unceasing between the mind and the skin. A fine, nervous expansion, 
 proceeding from the brain, is purposely spread over the outside of the 
 body immediately under the last cuticle. That our intellects may 
 have the benefit of the universal sensibility, it is materially associated 
 with our moral feelings and with our best sympathies. 
 
 Although man comes into the world so naked, so destitute of 
 natural covering, yet nature has placed means within his reach where- 
 by he may hide his nakedness and shield his body from external 
 injuries and the extremes of heat and cold. As man was designed 
 to inhabit every clime, from the ice-bound regions of the extreme 
 
 321 
 
322 PULMONARY TUBERCULOSIS. 
 
 North to the burning sands of the South, his body is so constituted 
 that, by incasing it in furs, and living exclusively upon an animal diet, 
 he can endure the most extreme reduction in the temperature of the 
 atmosphere, and live in the enjoyment of perfect health, while by 
 throwing aside his furs and animal food, and clothing himself with 
 the flimsiest garments, and living upon a vegetable diet, he can enjoy 
 equal health under the scorching sun of the torrid zone. In our lati- 
 tude we have annually extremes of heat and cold, requiring frequent 
 changes in our garments to suit the varying changes in the tempera- 
 ture of the atmosphere. By very many accurate experiments it has 
 been conclusively demonstrated that the temperature of the adult 
 human body is 98°, while that of the infant is 93° or 95°. It has 
 also been shown that it is much more difficult to sustain the normal 
 standard of heat in infants than in adults, and that they perish much 
 sooner from the effects of cold than from those of heat ; and it is an 
 appalling fact that more children die from diseases produced by cold 
 than from any other cause. The mortality among children would be 
 greatly lessened if more attention was paid to their dress. Its phi- 
 losophy is little understood by parents, and much less attended to by 
 the physician. 
 
 II. How the Heat of the Body is maintained. 
 
 But how can we maintain the normal standard of heat in the sys- 
 tem ? The principles of natural philosophy involved in the solution 
 of this question are exceedingly simple. Let us take a brief glance 
 at them. One of the most common properties of heat is its tendency 
 to diffuse itself through space, or through every body with which it 
 conies in contact. When any body is heated. — that is, when a large 
 quantity of caloric has been introduced into it. — the caloric has a ten- 
 denc} T to pass off into other bodies that may be near it ; and this dif- 
 fusion of the heat goes on until all the bodies that are in the range of 
 its influence come to the same temperature. There are two ways in 
 which caloric may pass from heated matter. It may fly off as light 
 does, in rays passing through the air, until it meets with some sub- 
 stance which absorbs it, or it may pass away from the heated body 
 along any substance placed directly in contact with it. 
 
 The first of these is called radiation, the second is conduction, of 
 caloric. Thus, when we light a fire in a room, the apartment becomes 
 
ANIMAL HEAT— CLOTHING. 323 
 
 warm, because rays of heat pass into it by radiation ; and if we put 
 the point of the poker into the fire and keep it there, by and by the 
 handle of the poker becomes hot, because heat has passed along the 
 handle by conduction. But heat is not passed or conducted along all 
 substances with equal rapidity. Some substances conduct it very 
 rapidly, others very slowly ; and in proportion as they do so, they are 
 termed good or bad conductors of caloric. Thus it is quite obvious 
 that if a heated body be surrounded by a bad conductor of heat, it 
 will part with its caloric much slower than it would do if surrounded 
 by a good conductor. 
 
 Now, it is precisely on this principle that we proceed in the selection 
 of materials for clothing. The heat of the human body, as just stated, 
 is 98°, but as the temperature of the air in temperate, and still more 
 in cold, climates is much lower than this, it is evident that, in accord- 
 ance with the laws of the diffusion of caloric, the heat of our bodies 
 must have a constant tendency to pass off into the surrounding atmos- 
 phere. In order, therefore, to prevent the cooling of the surface 
 which would thus ensue, we surround our bodies with substances 
 which are bad conductors, and which consequently prevent our animal 
 heat from passing away from us. 
 
 The materials of which clothing is made are chiefly wool, silk, 
 hair, down, cotton, and linen. Of these, wool, from its being a very 
 imperfect conductor of heat, and being at the same time an abundant 
 commodity, is mostly employed to retain the natural heat of our 
 bodies — that is, for warm clothing. Raw silk, raw cotton, and hair are 
 as bad conductors as is wool, and would therefore be equally warm ; but 
 silk and cotton are only used in clothing when woven, and they do not 
 then retain the heat so readily, for the manner of manufacture has an 
 important effect in modifying the conducting power of the substance. 
 Generally, the looser the texture the better it will maintain the heat of 
 the body, because it only acts in virtue of its non-conducting power ; 
 but, being in this loose state, it retains among its particles a quantity 
 of warm air in contact with the surface of our bodies. 
 
 III. The Importance of Retaining the Heat of the Body. 
 
 The importance of maintaining the natural heat of the human body 
 will be readily seen if we consider for a moment the effect of cold upon 
 it. Whenever a portion of the body parts with its caloric, — when, in 
 
324 PULMONARY TUBERCULOSIS. 
 
 short, it becomes cooled in any way, — the blood-vessels of the part be- 
 come constricted ; the blood, of course, is prevented from circulating 
 freely through them. Now, a very large portion of blood in the nor- 
 mal condition of the body circulates through the skin, and it is clear 
 that if the vessels of the parts become constricted, the blood must 
 pass into it in small quantities, and will therefore be obliged to find 
 its way in undue proportions into other parts. Hence, when the sur- 
 face becomes chilled, we have morbid effects produced in internal 
 organs, just because the blood is, as it were, forced into them in im- 
 proper quantities, from not being allowed to circulate freely in the 
 superficial part of the body. Hence arise inflammations, catarrhs, sore 
 throat, and bowel-complaints, which, in the changeable weather of 
 spring and autumn, so frequently require the aid of the physician. 
 The proper preventive of all this is to surround the body with a good 
 non-conductor, which will retain the animal heat and prevent it from 
 passing off into the surrounding atmosphere. 
 
 IV. Things to be Considered in Selecting the Dress of 
 Children. 
 
 In selecting clothing for children, there are three things worthy of 
 special attention, namely, warmth, simplicity, and ease. In our 
 climate there is no material more appropriate for the clothing of 
 children than flannel. This has been our conviction for many years, 
 and we are in the habit of recommending our patients to provide 
 such clothing for their infants. As soon as a child enters the world, 
 and its body has been thoroughly cleansed by frequent ablutions, and 
 the surface carefully dried with a soft napkin, and the umbilic cord 
 properly dressed, we would secure it by a band of thin flannel, five or 
 six inches broad, and long enough to go twice round the body. Great 
 care should be taken not to bind it too tightly, for if this be done it 
 will be a source of much trouble both to the child and the mother. 
 Not very long since, I was called to see an infant some ten days old, 
 who was very troublesome, crying almost incessantly night and day, — 
 disturbing the whole household. On examination, a rupture was 
 found in each groin, and a little further examination discovered the 
 cause, which was the band, applied as tightly, almost, as the strength of 
 the nurse would allow. The case was remedied by loosening the band. 
 Many nurses will persist in applying it very tightly, although ordered 
 
 
ANIMAL HEAT— CLOTHING. 325 
 
 to the contrary. They imagine that the band serves to keep the child 
 from falling to pieces, and, therefore, the tighter it is applied the 
 better. We should give special directions in this particular, and see 
 that they are not disregarded. We may thus prevent a great deal of 
 mischief and future suffering. 
 
 Next comes the shirt ; and this we think should, in the cold season 
 of the year, also be flannel. Some, we know, have objected to it, 
 because they say it is more apt to irritate the delicate skin of an 
 infant, and unless it be changed every day, as the inner garment of an 
 infant ought always to be, it is much less cleanly. But we see no 
 force in these objections. If the flannel is fine, and the shirt nicely 
 adjusted, what little irritation it may produce on the skin will be 
 rather advantageous, in exciting the cutaneous circulation and causing 
 the skin to perform its functions more vigorously. After the shirt 
 comes the petticoat : this should also be made of flannel, and should 
 be made very long and wide. Next comes the frock or robe, which 
 should be easy, long, and warm. Its sleeves should be long, and its 
 neck very high. There are few things more injurious to the tender 
 infant than the fashion which many mothers follow, in exposing the 
 thorax, and almost the whole of the arms, at all seasons. If any 
 portion of the child's body really demands protection from the cold, 
 physiology would teach us it must be those parts that are not very 
 profusely supplied with blood. This is the case with the arms ; being 
 as it were remote from the common source of the circulation and heat, 
 they are more exposed to cold, and therefore require almost double 
 protection. 
 
 V. Some Diseases Produced by Carelessness in Dressing In- 
 fants ; a Case. 
 
 I am well satisfied, from my own personal observation, that many 
 diseases of infancy and childhood are caused by this undue exposure 
 of the arms, especially in cold weather, even if the room in which the 
 child is kept feels comfortably warm to the nurse or mother ; and any 
 one may be convinced that the child suffers, by feeling his arms, which 
 are almost always colder than the rest of his body. The mute little 
 creatures not only suffer within doors, but they are frequently allowed 
 to be carried out, without any additional covering, when the weather 
 is by no means warm ; and so long as they are unable to make known 
 
326 PULMONARY TUBERCULOSIS. 
 
 their sufferings by speech, their protectors are too ignorant to know 
 that they are laying the foundation for future disease or a long life 
 of wretchedness. After such exposure to cold as just described, there 
 is always a powerful effort of reaction to overcome the injurious im- 
 pression. Now, a moment's reflection will lead any enlightened mind 
 to the conclusion that such efforts, frequently occurring in children of 
 irritable constitutions, and especially those that are very feeble, will 
 in the end produce serious disorders in the lungs or bowels. I could 
 cite many cases from my note-book to substantiate this opinion. Here 
 is one : 
 
 " September 8, 1858. — Called this day to see Jane, aged eighteen 
 months. Has been under treatment for the last four weeks. Dr. M. 
 considers her disease cholera infantum; has exhausted his stock of 
 therapeutics, and pronounced an unfavorable prognosis. The little 
 patient is indeed very low : pulse very feeble ; respiration quite hurried ; 
 a slight, hacking cough; tongue clean and moist; skin cold and clammy; 
 countenance pinched ; bowels very loose, swollen, and flatulent ; stomach 
 retains food well, which she takes with avidity ; urine scanty, and 
 after standing a few minutes in the night-vessel, looks like milk, but 
 being subjected to heat, yields no albumen ; head is somewhat warmer 
 than natural ; extremities cold ; emaciation is very extreme. She has 
 been quite restless for several days, and for the last eight hours there 
 have been threatening symptoms of convulsions ; several teeth have 
 just pierced the gums, which are but little inflamed, and cannot be 
 the source of very much trouble. 
 
 " From a careful examination of her early history, I find that she 
 has been subject to frequent attacks of bowel-complaint ever since she 
 was three months old, and that they always appear to be induced by 
 some extra exposure to cold. The present attack I traced directly to 
 an evening ride, when the atmosphere was quite cool, without any 
 extra garments to preserve the animal heat. Her ordinary clothing 
 was a flannel petticoat, a cotton shirt, and frock made very low on 
 the neck, with short sleeves. I attempted to explain the nature of the 
 case to the parents ; recommended that all her clothing should be of 
 flannel, high in the neck, and long sleeves. The little patient was to 
 be bathed regularly every day in warm water, and the surface of her 
 body carefully dried with a soft napkin, and her diet was to be con- 
 fined to beef-tea and bread-jelly. Under this management she was 
 
ANIMAL HEAT— CLOTHING. 327 
 
 gradually restored to health, and T have never know* her to be sick a 
 day since ; her clothing, summer and winter, has been flannel." 
 
 In this instance medicine was of no avail, nor could it have been so 
 long as a fundamental law of the child's hygiene was neglected. And 
 I might just add that I have, on several occasions, cured the most 
 alarming cases of spasmodic croup, by simply clothing the child in 
 flannel. I remember one case in particular, — a little boy who was very 
 subject to this malady. He never had an attack of it after his 
 mother made him a flannel under-garment, which incased his whole 
 body. 
 
 VI. The Powers of Calorification Progressive in Children. 
 
 Experience teaches us that from infancy to manhood calorification 
 is progressively performed with greater facility ; so that, as a child 
 advances in age, till he arrives at maturity, he needs proportionally 
 less protection by artificial means. But the general practice is quite 
 the reverse, most children being thinly clad, and only having the 
 quantity of their clothing increased as they increase in years. I have 
 observed that, among certain classes of the community, it is common 
 to make clothes for the younger children of garments already half- 
 worn by the parents or some other member of the family. This may 
 be well enough so far as economy is concerned, but when that is made 
 an offset to health and comfort, the balance is found greatly in favor 
 of the latter. It is a fact that a new garment is much warmer than 
 an old one ; and we may well suppose that the light heart and buoy- 
 ancy of youthful spirits do not compensate in a cold season for thin 
 or inadequate clothing. A shirt, and that often of not great longi- 
 tude, with a jacket and trousers of half- worn stuff, is the ordinary 
 dress in the winter season of boys of the common class ; and many are 
 not able to afford their children clothing as comfortable as this. The 
 children of very poor parents, who go half-naked, and without shoes 
 or stockings, in the most inclement seasons, are often cited as instances 
 of the benefit of a toughening system ; and so, also, are the rare, self- 
 taught geniuses brought forward as a proof that education is not 
 necessary to attain to great eminence. The one case only proves that 
 some children can live through undue exposure, while we entirely lose 
 sight of those who die in this attempt at hardening ; and the other is 
 an evidence that a man may become great by the force of native talent 
 
328 PULMONARY TUBERCULOSIS. 
 
 alone, while we may fairly conclude that he would be still greater 
 with the aid of a regular education. Parents should, therefore, be 
 instructed to provide at least as warm clothing for their children as 
 they do for themselves, — ever bearing in mind that a child is but a 
 tender plant, little calculated to endure the rude and chilling blasts of 
 our northern clime ; and that if we would counteract any predisposition 
 to tuberculosis that may be lurking in its system, we must not neglect 
 to maintain its animal heat. 
 
 VII. The Dress of Children should be Loose and Easy. 
 
 The child's garments should not only be warm, but they should be 
 arranged upon its person in such a manner as to place no constraint 
 upon the motions of any part. We have already referred to the in- 
 jurious effect of making the band too tight, in early infancy, around 
 the child's bowels; but how much more injurious must it be, when it 
 is but a few years older, to incase its entire chest in the " barbarous 
 corset.' ' The injuries inflicted upon the young girl's chest and abdomen 
 by this article are well known to be of the most formidable character ; 
 the chest may be completely altered in shape, and the lungs dimin- 
 ished in their capacity, by a continued pressure so applied; while, at 
 the same time, the stomach and liver are driven from their natural 
 positions, and made to press upon the other organs of the abdomen. 
 Derangements of the functions of respiration, circulation, and diges- 
 tion follow as a legitimate consequence, and but too frequently lead to 
 a premature grave, or, what perhaps is equally as bad, to a life of de- 
 bility and untold wretchedness. But why this sacrifice of health and 
 life? What are the ends to be attained by it? Some tell us that it 
 improves the human form, — that it adds to its beauty. Nothing can 
 be more absurd than this. Nature has made the figure of the human 
 chest just right, and the only way that we can be of any use or assist 
 in the production of a finely-formed or symmetrical chest is to remove 
 all restrictions, and secure, as far as possible, such free action of all its 
 parts as will lead to their perfect development. Anything more than 
 this is injurious, and should be strictly ignored. I am well aware 
 that many women are so led away by the frivolities of fashion that 
 they will frequently sacrifice the health and life of their children to 
 attend to its minutest details. But this should not deter us from the 
 faithful discharge of our duty. We should protest earnestly against 
 
ANIMAL HEAT— CLOTHING. 329 
 
 every custom which is detrimental to the health and longevity of man- 
 kind. Our success in curing disease demands it, humanity demands 
 it, and G-od requires it. Let us not, then, be recreant to our trust. 
 
 VIII. Warm Clothing Necessary to the Management of 
 Phthisis. 
 
 " What is true of prevention in childhood," says Dr. Morton, in 
 his "Illustrations of Pulmonary Consumption," page 253, " is of equal 
 application to the therapeutic treatment of adults. In vain is the use 
 of medicine or the regulation of the diet, in vain are all the other 
 precautions that ingenuity can devise, if the skin is not kept warm 
 and its healthy secretion maintained by proper attention to the quan- 
 tity and quality of the clothing. As winter approaches, the chest of 
 the invalid should be coated in flannel up to the neck, and the same 
 dress should be extended down the arms to the wrist; and where this 
 material is insufficient to prevent the sensible access of cold, a buck- 
 skin vest ought to be worn over it. The body and lower limbs are to 
 be protected in like manner, and particular attention given to the feet ; 
 for if the latter are habitually cold, the whole system will participate 
 in the inconvenience. 
 
 " I could mention several examples, both in children and adults, in 
 whom the constitution has been suddenly and effectually restored 
 from a languid and almost hectic condition to comparatively robust 
 health, by a timely change of dress in the manner above mentioned ; 
 and I must, once for all, repeat that without this precaution all other 
 measures, whether prophylactic or remedial, will end in disappoint- 
 ment." 
 
 In Russia, where the climate is intensely cold, pulmonary tubercu- 
 losis is far less common than in England or the United States, where 
 the climate is not so cold ; and Dr. Morton regards the difference as 
 chiefly attributable to the Russian custom of keeping their houses 
 warm, clothing themselves in furs, and taking particular care to pre- 
 serve their feet from cold and damp. It is said that in that country 
 the lower class of people suffer more from phthisis than the wealthy, 
 owing to the absence of the comforts of life. 
 
CHAPTER XXXV. 
 
 bathing: a moral virtue; an important means of health. 
 HOW it should be employed in consumption. 
 
 I. Bathing a Virtue and Luxury. 
 
 Bathing is one of the first moral virtues. It is intimately asso- 
 ciated with everything that is pure and lovely. It has been enforced 
 in both the Jewish and Mohammedan laws as part of their religious 
 observances. The Greeks and Eomans were so much impressed with 
 its importance that they made bathing one of the principal duties of 
 the day. Under the Christian dispensation it has been enforced with 
 peculiar emphasis. Physical and moral purity always go hand in 
 hand ; hence water, or baptism by water, is used as a type of spiritual 
 cleansing. 
 
 Bathing is also a great luxury. Nearly all the various avocations 
 of life are attended with more or less active exercise, which increases 
 the cutaneous secretions, and demands frequent ablutions in warm water 
 to keep the skin clean. It is true, however, that all trades are not 
 alike in this particular. There are some occupations in which the 
 operative cannot pretend to be clean while he is actually employed ; to 
 attempt it would be affectation ; but there is no reason why be should 
 not enjoy the feeling of perfect cleanliness when work is over. Others, 
 again, may be very neat while engaged at their work, but there are 
 none who are entirely exempt from the need of water. 
 
 Only he who has made the experiment can know how delicious is 
 the feeling produced by a thorough warm ablution after a day of heat 
 and exertion. " To wash one's self,"' says Dr. John Bell, in his excel- 
 lent work on ' ; Baths and Mineral Waters/' " ought to have a more 
 extended meaning than people generally attach to the word. It should 
 not consist merely in washing the hands and rubbing the face over 
 with a wet towel, and sometimes the neck ; the ablution should extend 
 over the whole surface, and it is particularly necessary where often 
 330 
 
BATHING. 331 
 
 least thought of, as at the bends of the limbs, etc. In a tepid bath, 
 with the aid of a little soap and sponge or brush, the process may be 
 completely performed with a feeling of comfort at the moment and of 
 much pleasure afterward." 
 
 II. Bathing Necessary to Health. 
 
 If bathing affords so much comfort, it conduces not less to health. 
 No person can be in health whose skin is out of order. This is ad- 
 mitted by all who think and write upon the physiology of the human 
 system. It is the skin which is the seat of perspiration, of which 
 a*bout thirty-three ounces pass through every twenty-four hours, even 
 when there is no visible moisture on the surface. The skin is the 
 regulator of animal heat ; it is a great absorbent, and takes in again 
 much of the effete matter left in contact with it by a want of cleanli- 
 ness. It is in close connection with almost every important function 
 of the system. 
 
 A glance at the above facts will show that the skin requires daily 
 attention. But this wonderful covering of the human body has other 
 important offices to perform. It not only lets out liquid, but it takes 
 in air, as well as watery vapor, so that it may almost be said to play 
 the part of the lungs, by secreting and absorbing the same gases. In 
 some animals, indeed, as in the leech, all the breathing is done by the 
 skin, and you may kill a frog as effectually by varnishing him all over 
 as by tearing out his lungs. The filthy covering of an unwashed per- 
 son is not unlike such a varnish, and he who never bathes labors under 
 a sort of half-suffocation. The outer scurf which we may scrape 
 away is a deposit from the true or inner skin. A good washing and 
 rubbing softens this outer skin, and makes it easy to rub off the dead 
 parts with a brush or hard towel. In this respect all baths, of what- 
 ever temperature, are useful. The surface is cleansed and freed from 
 obstructions, and a way is cleared for the passage of the proper fluids 
 and gases. On a subject so important, I trust these little details will 
 not be considered out of place. 
 
 Dr. Erasmus Wilson, in his work on the " Management of the 
 Skin," says, " To arrive at something like an estimate of the value of 
 the perspiratory system, in relation to the rest of the organism, I 
 counted the perspiratory pores on the palm of the hand, and found 
 3,528 in a square inch. Now, each of these pores being the aperture 
 
332 PULMONARY TUBERCULOSIS. 
 
 of a little tube of about a quarter of an inch long, it follows that in a 
 square inch of skin on the palm of the hand there exists a length of 
 tube equal to 882 inches, or 73 \ feet. Surely, such an amount of 
 drainage as 73 feet in every square inch of skin — assuming this to be 
 the average of the whole body — is something wonderful, and the 
 thought naturally intrudes itself, What if this drainage were ob- 
 structed? Would it be possible to furnish a stronger proof of the 
 necessity of maintaining a healthy state of the skin?" 
 
 III. The Different Kinds of Baths. 
 
 The cold bath is the most natural and the most easily taken, but it 
 is not always proper or safe. There are some, I know, who recom- 
 mend it indiscriminately to all persons at all seasons ; but such is not 
 the advice of wise physicians. " In proportion as cold bathing is in- 
 fluential in the restoration of health when judiciously used, it is hurt- 
 ful when resorted to without discrimination." — Dr. Andrew Combe. 
 " Many persons in health cannot tolerate the cold bath for the shortest 
 period ; still less can they habitually use it with benefit. Even they 
 who have accustomed themselves to it are in danger from the practice, 
 if it be continued after any sudden diminution of vital energy, by 
 whatever cause produced." — Dr. John Bell. 
 
 Nothing is more erroneous than the opinion entertained by some 
 physicians that the warm bath is enfeebling. They speak of the cold 
 bath as bracing, and the warm as relaxing. But these terms are too 
 mechanical, and are not very applicable to vital action, and are simply 
 metaphors when applied to the physiology of bathing. Travelers in 
 hot countries tell us that when overcome by inward heat, and so ex- 
 hausted as to be ready to faint, they have been made as fresh and 
 strong by a warm bath as on rising in the morning. It is recorded of 
 the distinguished Count Kumford that he once repaired to Harrow- 
 gate in very feeble health. Such was his fear of taking cold from the 
 warm bath, that he used it only once in three days, for less than 
 fifteen minutes, and always went to a warm bed. But finding this 
 unattended with benefit, he reversed his method, and bathed every 
 day at two o'clock, for half an hour, at ninety-six and ninety-seven 
 degrees Fahrenheit, far thirty-five days together. " The salutary 
 effects of this experiment," he says, -were perfectly evident to all 
 who were present and saw the progress of it, and the advantages I 
 
BATHING. 333 
 
 received from it have been permanent. The good state of health 
 which I have since enjoyed I attribute to it entirely." He also ex- 
 poses the mistake of those who avoid the warm bath for fear of 
 taking cold; as, indeed, one has no more occasion to dread taking 
 cold after being in a warm bath, than from going out of doors in the 
 air of a frosty morning. There are few individuals who do not derive 
 great benefit from the regular use of the warm bath, and still fewer 
 who are in any way injured by it. 
 
 IV. What is Meant by a Warm Bath. 
 
 By a tepid or warm bath we are to understand that in which the 
 temperature ranges from seventy-five to ninety-eight degrees, Fahren- 
 heit thermometer. Now this, so far from heating or irritating the 
 body, as some have supposed, has a most soothing and tranquillizing 
 effect. The pulse, on immersion in a bath of about ninety degrees, is 
 rendered slower, and the respiration more equable. If the heat be 
 ninety-eight degrees, we may then look for accelerated pulse, flushed 
 cheek, and after a while a copious perspiration bedewing the head 
 and face. As to the length of time an individual should remain in 
 the bath, it depends upon a variety of circumstances. For the ordi- 
 nary purposes of cleansing the skin and invigorating the nervous 
 system, fifteen or twenty minutes is sufficient. 
 
 At the time of immersion, individuals in delicate health should be 
 careful to maintain the proper temperature of the bath, by withdraw- 
 ing from time to time portions of water from it and replacing it by 
 warmer water. On coming out of the bath the surface of the body 
 should be wiped thoroughly dry, and if the person is sensitive to cold 
 it would be well that the operation be performed with warm towels, 
 that no sense of chilliness be produced. It is also a good precaution in 
 some cases to have the bathing-room somewhat warmer than is required 
 under ordinary circumstances. As a general rule, it should not be less 
 than eighty degrees. 
 
 V. The Best Time for Bathing. 
 
 No person should take a bath just after a full meal ; hence it will 
 be found to agree with most persons about four hours after dinner ; 
 in summer, just before retiring. Many individuals are deterred from 
 taking it at either of the times mentioned by the fear of catching cold 
 
 22 
 
33-4 PULlIOXAXr TUBERCULOSIS. 
 
 afterward, in consequence of exposure to the open air. The error 
 here proceeds from confounding the effects of overheating and fatigue 
 after violent exercise, with those produced by the warm bath, whereas 
 they are totally dissimilar. In the former case the skin is cold and 
 weakened by excessive perspiration, and doubly liable to suffer from 
 reduction of atmospheric temperature. In the second, on immersion 
 in warm water the heat of the system is prevented from escaping, and 
 has rather a tendency to accumulate, so that in fact the living body 
 is. after coming out from this kind of bath, better prepared to resist 
 cold than before. 
 
 This is fully demonstrated by the practice of the Russians, who 
 rush out of a vapor-bath and jump into the nearest stream of water, 
 or roll themselves in the snow. Xow, in this case the impunity with 
 which they expose themselves to the extreme cold is precisely in the 
 ratio of their prior excitation by a hot bath. Were they, immediately 
 after stripping themselves, to plunge at once into a cold stream, severe 
 colds or inflammation of some of the internal organs would be the 
 consequence. 
 
 The more vigorous the frame and active the circulation of an in- 
 dividual, the lower may be the temperature of the bath. The aged 
 and the feeble, and those whose hands and feet are habitually cold, 
 require it to be near the degree of blood-heat. It is said by physiolo- 
 gists that the immediate cause of old age seems to reside in the irri- 
 tability of the minute tissues of the body or blood-vessels ; hence they 
 cease to act, and collapse, and become impervious to the blood. The 
 warm bath is particularly adapted to prevent these circumstances, by 
 its increasing our irritability, and by moistening and softening the 
 skin and the extremities of the fine vessels which terminate in it. To 
 those who are past the meridian of life, and have dry skins and begin 
 to emaciate, the warm bath, for half an hour two or three times a 
 week, is eminently serviceable in retarding the advance of age. 
 
 VI. Individuals Subject to Pulmonary Consumption should 
 Never Bathe in Cold Water. 
 
 I know of nothing more hurtful to consumptive patients than the 
 cold bath. The early advocates of hydropathy will have much to 
 answer for on this score. Their cold bath, wet jacket, cold wet-sheet 
 packs, and total abstinence from all animal food, have been the means 
 
BATHING. 335 
 
 of cutting short the lives of many who, under an opposite and more 
 generous mode of practice, might have had their lives prolonged for 
 several years, and been a comfort and blessing to those who were 
 depending upon them for support and the endearments of domestic 
 life. 
 
 Perhaps there has never been a book published which has been the 
 means of doing more injury to persons suffering with consumption 
 than Dr. Joel Shew's " Consumption : its Prevention and Cure by 
 the Water-Treatment." It made its appearance at the time hydro- 
 pathy was at the summit of its popularity, and thousands embraced its 
 delusive teachings only to find premature graves. Dr. Shew more 
 than intimated that he had verified the truth of his theory of con- 
 sumption; that he knew cold-water treatment would cure it. He 
 ignored the use of flannel underclothing, prohibited the use of animal 
 food, and recommended cold bathing and the wet jacket, with mode- 
 rate exercise. 
 
 But a few years' experience has dissipated the dreams of the en- 
 thusiast. Candid hydropathists admit that, so far as consumption is 
 concerned, their treatment has resulted in a perfect failure. And I am 
 satisfied, from my own observation, that it is the worst possible treat- 
 ment for this disease. 
 
CHAPTER XXXVI. 
 
 exercise: its physiology, utility as a means of health, 
 and influence in preventing pulmonary consumption. 
 
 I. Physiology of Exercise. 
 
 To rightly understand and appreciate the importance of exercise as 
 a means of health, it will be necessary to take a brief glance at its 
 physiology. All the motions of the human body are accomplished by 
 muscles. They are very numerous, embracing several hundred pairs, 
 and constituting more than one-half of the bulk of the body ; and con- 
 sequently a very large portion of the whole quantity of the blood is 
 devoted to supplying them with nourishment. By continued exertions 
 their energy and materials become rapidly impaired and reduced, and 
 can only be restored by an increased activity in the circulation. The 
 manner in which this is accomplished will be readily understood by 
 examining the movements of the blood-vessels of any of the limbs. 
 Take as an example the arm. By inspecting the arm, you will see 
 that its blood-vessels are covered and protected throughout their whole 
 course by the adjacent muscles, which they furnish with blood by their 
 numerous branches. In consequence of this position, the muscles 
 cannot contract without at the same time compressing the blood-vessels 
 and propelling their contents forward. The assistance afforded to the 
 blood by this arrangement is very great, and may be familiarly exem- 
 plified in the simple operation of bleeding. Thus, when the blood 
 stops or flows slowly, it is customary to put a hard body in the hand 
 of the patient, and desire him to squeeze it by opening and shutting 
 his hand rapidly. The success of this action depends on the muscles 
 of the arm compressing the blood-vessels and forcing onward the cur- 
 rent of the blood by their successive contractions. 
 
 The increased activity of the circulation thus induced by general 
 muscular action is not confined to the circulation of the blood-vessels 
 of the muscular system, but the whole frame partakes, and every organ 
 336 
 
 
EXERCISE. 337 
 
 and texture feels its good influence. Not only, is the circulation in- 
 vigorated, but a greater quantity of blood is required to supply the 
 demand. It passes through the lungs more rapidly and in larger 
 quantities, urging the respiratory organs to more active operations in 
 order to purify the blood with sufficient rapidity ; while to supply the 
 demand for the quantity of blood the appetite is excited, more food is 
 eaten, and the digestive organs partake of the excitement. Thus, 
 directly or indirectly, almost every function is impelled to increased 
 activity, and the whole system receives a healthy impulse. 
 
 Illustrations of these facts, as well as the reverse, may be daily met 
 with, especially in our large towns and cities. We find that those 
 who lead active, and even laborious lives, are generally in possession 
 of good, vigorous constitutions, healthy looks, and frames that will 
 endure an almost incredible amount of labor ; while we see others 
 equally well prepared in early life for a state of body so very desirable, 
 but who, by a course of sedentary and inactive pursuits, are thin, pale, 
 without muscular strength, and subject to a variety of diseases. The 
 difference between these two opposite conditions is justly attributable 
 mainly to the non-employment, in the one case, of the muscular system, 
 and to its regular and continued exercise in the other. 
 
 It is a well-established fact that moderate and uniform exercise of 
 individual muscles will increase their size and strength. This is ex- 
 emplified in the case of various artisans who have occasion to employ 
 different sets of muscles. With the blacksmith, who is daily in the 
 habit of striking with a heavy hammer or in lifting massive bars of 
 iron, we shall find the muscles of the arms so large as to appear almost 
 deformed from their size, and possessing proportionate strength and 
 hardness, while the muscles of the lower limbs, used for but little else 
 than to keep him in an erect posture, present nothing remarkable. 
 On the contrary, we find the muscles of the legs of the dancing-mas- 
 ter, which are used to throw his body into a thousand different atti- 
 tudes, and with great force and rapidity, large and firm, while the 
 muscles of his arm, having but little to do, are small and weak. 
 
 To increase the size and strength of a muscle, therefore, to its 
 greatest degree, its exercise must be uniform, and not excessive. The 
 intervals of relaxation from labor should be frequent, in order to give 
 the muscles an opportunity to recruit their powers. It is very easy 
 to propel the action of a set of muscles beyond their strength, — a cir- 
 
338 PULMONARY TUBERCULOSIS. 
 
 cumstance which every individual has had made known to him when 
 it occurs by the production of painful sensations in the organs, called 
 fatigue ; and if this occurrence is not regarded, and the muscles are 
 still continued in action without rest, their energies may at last become 
 so far exhausted as to cause unpleasant results, requiring at least a 
 long period of inaction to recover them, and their contractible power 
 may become permanently impaired. For nearly the same reason, a 
 muscle should never be exerted to excess. A strenuous effort, espe- 
 cially of a muscle unaccustomed to work, will oftentimes exhaust it 
 completely. 
 
 Exercise of the muscular system, to be beneficial, ought, in the, first 
 place, always to be proportionate to the strength of the constitution, 
 and not carried beyond the point, easily discernible by experience, at 
 which waste begins to succeed nutrition, and exhaustion to take the 
 place of strength ; and, secondly, it ought to be regularly resumed 
 after sufficient intervals of rest, in order to insure the permanence of 
 healthy impulse given to the vital powers of the muscular system ; 
 and in the last place, it is of the utmost consequence to join with 
 it a mental or nervous stimulant. 
 
 Exercise is the natural food of the muscles. Upon it they will in- 
 crease and strengthen ; they will be more able to do their required 
 work ; the spinal column will then be kept straight ; an upright figure 
 and a graceful carriage, but above all, a full and easily dilated chest, 
 and an exemption from many pulmonary disorders and other com- 
 plaints, will insure to the individual a happier and longer life. 
 
 " Exercise is life ! 'tis the still water faileth ; 
 Idleness ever despaireth, bewaileth; 
 Keep the watch wound, for the dark rust assaileth : 
 Flowers droop and die in the stillness of noon. 
 
 "Exercise is glorious ! the flying cloud lightens : 
 Only the waving wing changes and brightens; 
 Idle hearts only the dark future frightens ; 
 
 Play the sweet keys, would you keep them in tune." 
 
 II. Walking. 
 
 There are two modes of exercise which contribute very materially 
 to the health and strength of the body — namely, walking and riding ; 
 but they will not produce these happy effects unless they are properly 
 
EXERCISE. 339 
 
 regulated. Walking is an exercise in which all must, to a certain ex- 
 tent, engage ; it is therefore a matter of considerable importance that 
 the circumstances connected with it are such as not to render it a bur- 
 den or an inconvenience. The wants of the system compel us to 
 exercise all our limbs, and the laws of health imperiously demand that 
 we perform locomotion. To take pleasure in this mode of exercise, it 
 is necessary that the body should be free and unrestrained in all its 
 motions ; that the respiration be not impeded by a tight dress ; that 
 the arms be at liberty ; and that the feet are not confined by tight 
 shoes. 
 
 We know from experience that just in proportion to the activity of 
 exercise the circulation of the blood and the respiration are increased 
 in man and all the inferior animals, and in proportion as the motions 
 of the chest are restrained will be the difficulty of breathing. We 
 see these facts exemplified in the horse daily. Who has not noticed 
 his perspiration and panting after a fast drive ? And who that has 
 been much in the habit of riding on horseback, has not more than 
 once seen the saddle-girth broken by the violent expansion of the chest 
 in a deep inspiration ? Nature thus makes known her wants by her 
 great efforts to supply them. Besides the great obstacle that a tight 
 dress opposes to respiration, it hinders the action of the muscles in 
 walking. The muscles which keep the body erect and move the limbs 
 forward are confined and compressed by the corset, so that their func- 
 tion is not half performed, and hence the unsteady, vacillating move- 
 ments of those who little deem that they display any other than a 
 graceful form and equally graceful gifts. 
 
 In walking, nothing is so uncomfortable as a tight boot or shoe. 
 The best article, in our judgment, for this purpose, is a light gaiter- 
 boot, made of elastic materials, and laced so that it shall exactly fit 
 the foot and ankle, without being tight ; the sole should be just so 
 thick as to prevent injury to the foot from irregularities in the ground 
 on which we walk. The best material used in the manufacture of the 
 gaiter is buckskin, which in all cases, notwithstanding a desire to show 
 a small foot, should be so large as not to confine the natural and 
 necessary action of the foot and toes. In all ancient paintings and 
 statues we look in vain for a modern foot ; the toes in them are spread 
 so that each one presses the ball upon the ground ; but in three feet 
 out of four of those of the present generation, we shall find one or 
 
340 PULMONARY TUBERCULOSIS. 
 
 two toes squeezed in such a manner as to be riding upon the others. 
 But this malposition is not the only evil, for who is there who is not 
 suffering from corns, or growing of the nails into the flesh, or both ? 
 And when an inquiry is made as to the cause of these painful affec- 
 tions, you never have any other answer than tight boots or shoes. 
 
 III. Riding. 
 
 But of all the various modes of exercise, riding is the most con- 
 ducive to vigor of constitution and health ; but as a good thing may 
 be improperly used, so riding sometimes produces an effect contrary to 
 what is intended. Those who are not accustomed to riding are most 
 apt to suffer, the pleasure and exhilaration being so great that fatigue 
 or exhaustion are induced when they are least expected. In cold 
 weather people unused to carriage-exercise are apt to think that the 
 same quantity of clothing necessary in walking will be an adequate 
 protection when riding. Often a person will not experience a sensa- 
 tion of cold ; he will not be aware that his body is becoming chilled 
 till he alights from his carriage, or till he approaches the fire, when 
 he becomes fully sensible that his ride has been too protracted. Those 
 who are in good health do not often experience anything more than a 
 temporary inconvenience from this cause, but in the delicate it is suf- 
 ficient to be followed by serious illness. TVhen this form of exercise, 
 therefore, is selected as a means of health, the individual should be 
 very careful to put on clothing sufficient to defend himself from the 
 cold. If this be neglected, injury instead of benefit will be the legit- 
 imate consequence. I have often known individuals to suffer from 
 pneumonia and bronchitis produced by riding in a carriage in a damp 
 and chilly air, with a thin dress that afforded but little protection from 
 the cold. 
 
 Riding on horseback is quite a different exercise from the pre- 
 ceding ; and fast riding is not only active exercise, but severe labor. 
 This is one of the most noble, manly, and healthful exercises that can 
 be imagined ; and as it formed a part of the education of the Spartan 
 youth, so ought it to be made a part of the education of the youth, of 
 both sexes, in our country. Riding on horseback exercises every 
 muscle and every organ of the body ; and it causes the blood to cir- 
 culate so freely that in cold weather this is one of the most comfort- 
 able ways in which a person can travel, providing he can bear the 
 
EXERCISE. 341 
 
 exercise without fatigue. This may seem strange to those who have 
 not made the experiment ; but the evidence of those who have tested 
 it for several successive years, in all weathers and at all seasons, have 
 established the fact to their satisfaction, that, at a speed of seven or 
 eight miles an hour, no person would feel the cold in unusually severe 
 winter weather. During my practice in the country, I have fre- 
 quently risen from my bed at midnight, when the thermometer was 
 some degrees below zero, mounted my horse, and rode five or six 
 miles in forty minutes, and at the end of the ride I have been much 
 warmer than at the commencement. The stimulating influence of 
 the keen, sharp air, the rapid motion of the horse, and the active 
 labor of riding, will send the blood bounding through all parts of the 
 body, and produce an extra amount of animal heat for the emergency, 
 which will preserve the normal temperature of the body. When I 
 commenced the practice of medicine, more than thirty years since, I 
 was in very feeble health, having threatening symptoms of consump- 
 tion. I have for several years enjoyed most excellent health, which 
 I attribute mainly to horseback exercise. 
 
 When we recommend horseback exercise to an individual in ill 
 health, who is not accustomed to it, he frequently desists before 
 making a fair trial to ascertain whether or not he will receive benefit 
 from the exercise; the reason for not persevering is, that he be- 
 comes fatigued and discouraged. In riding on horseback, a new set 
 of muscles is called into action, or they are required to perform a 
 service to which they are unused ; too much is demanded of them at 
 first, and hence the consequent soreness and lameness of the limbs and 
 back. Besides, the exercise is pushed too far at the commencement, 
 and induces a free perspiration, which is generally suddenly checked 
 when the exercise is discontinued. If an organ has been suffering an 
 affection, its derangement is most certainly aggravated, and the person 
 believes that the remedy is not suited to his case. One who is un- 
 accustomed to exercise should ride at first but a short distance, and 
 make himself at the outset acquainted with the gait and disposition 
 of his horse, and habituate himself to his seat in the saddle ; the next 
 day the ride may be extended, and thus gradually the distance may 
 be prolonged, until an individual may be able to ride many miles in a 
 day without suffering much fatigue. 
 
342 PULMONARY TUBERCULOSIS. 
 
 IV. Swimming. 
 
 But there are other modes of exercise, besides walking and riding, 
 that are useful means of health, such as rowing, swimming, and gym- 
 nastics. Swimming is a very healthy exercise. What is more 
 delightful on a beautiful summer evening than a plunge and a swim 
 in the pure and running stream ! Few know its pleasures or compre- 
 hend its physiology. In swimming, we have the combined advantages 
 of bathing and exercise. There is no exercise, excepting riding on 
 horseback, that calls into action a greater number of muscles than 
 this, and there is none that fatigues and exhausts the vital powers 
 more rapidly. There are few men, although they may be expert 
 swimmers, who have the physical endurance to swim a mile without 
 resting. It is, therefore, an exercise ill adapted to those in feeble 
 health and those whose constitutional powers are weakened by disease. 
 Even those in robust health, and with strong physical powers, may carry 
 it too far and greatly injure themselves thereby. In our climate, swim- 
 ming can only be practiced in the summer season. Although uncivil- 
 ized men in the extreme North may, without injury, at every season 
 of the year plunge into the coldest stream, yet the health, if not the 
 life, of an individual reared in civilized society would be endangered 
 were he to attempt a similar course. Some caution is. therefore, 
 necessary in selecting the best time adapted for this exercise. The 
 best time for swimming is about an hour before sunset. We select 
 this period because the water is then much warmer than at any other 
 time during the day, and the individual's stomach will not be apt to 
 be burdened with digesting food. It is an important law of health 
 that no person should engage in very active exercise immediately after 
 eating, and in this case it should be imperative. 
 
 V. Gymnastics. 
 
 The gymnasium was the war school of the ancient Greeks and 
 Romans. It was in them that their youth were trained to feats of 
 activity and strength ; hence they were considered schools of health. 
 In these establishments there were five principal exercises practiced : 
 running, wrestling, boxing, leaping, and throwing the quoit. By 
 these means not only were the muscular powers increased in flexibility 
 and strength, but the senses were also rendered more acute, and the 
 
EXERCISE. 343 
 
 facility for acquiring through them greatly increased. The connec- 
 tion between the efforts of the mind and feats of bodily strength and 
 agility was formally acknowledged, not only in the practices of many 
 of the distinguished statesmen and philosophers of antiquity, but also 
 in the fact of prizes being disputed, as well for the exercises already 
 mentioned. Consequently, some author has denned gymnastics to be 
 " the art of regulating the movements of the body in order to develop 
 its strength, to improve its agility, its pliancy, and its powers ; to pre- 
 serve or re-establish health ; it is intended, in fact, to enlarge the 
 moral and physical faculties." That gymnastic exercises will improve 
 all the physical powers, when judiciously used, cannot be doubted by 
 any one who has been in the habit of engaging in them. I have in 
 several instances seen the most beneficial effects from the dumb-bell 
 exercise in some chest-disorders. Indeed, it is a very healthy exercise, 
 particularly when varied according to the plan recommended by Dr. 
 Lewis, in his " New Gymnastics," — a book that should be carefully 
 studied by every individual who wants health and strength. The 
 author is a practical physiologist, who has faithfully studied the 
 adaptation of exercise to the human frame, and has in his book ex- 
 posed many of the errors of the old system. In my judgment, he has 
 devised a series of gymnastic exercises which, if properly attended to, 
 cannot fail to strengthen and invigorate every organ of the human 
 body. 
 
 VI. Exercise in Consumption. 
 
 Individuals predisposed to pulmonary consumption cannot pay too 
 much attention to the subject of exercise. In addition to general ex- 
 ercise, they should adopt such local exercise of the chest and subsid- 
 iary organs as is calculated to expand the lungs and increase the 
 strength and power of the muscles of respiration. The following I 
 consider a good plan to accomplish this end : While the individual 
 is standing, let him throw his arms and shoulders back ; while in this 
 position, let him inhale slowly as much air as he can, and repeat this 
 exercise at shorter intervals several times in succession. This exercise 
 should be adopted daily by all young persons whose chests are narrow 
 or deformed, and should be slowly and gradually increased. Persons 
 whose lungs are naturally weak will derive great benefit from this 
 exercise after a short trial. Marked changes soon take place in the 
 external appearance of the chest, for not only are the lungs themselves 
 
344 PULMONARY TUBERCULOSIS. 
 
 expanded by means of the dilation of their cells, formerly compressed, 
 but the ribs become elevated, and the muscles concerned in respiration 
 acquire a greater degree of power and volume by this increased action 
 of their parts. If pulmonary tuberculosis be the result of defective 
 respiration, as maintained by some writers, the local exercise of the 
 muscles of the chest cannot be too highly recommended to those who 
 have a proclivity to this disease. 
 
 When consumption becomes established in an individual who has 
 been leading a sedentary life, he should by all means change his 
 habits, — he must exercise. If he does not, all medication will be 
 in vain. Those who sit down and nurse their disease will fall a sure 
 prey to it. I always despair of a listless, inactive patient. It is 
 emphatically true in this case that action is life, and repose is death. 
 The records of medicine abound with instances of recovery from this 
 malady under the influence of active vigorous exertion. And hundreds 
 more would be added to the list, if physicians would be more positive 
 in their directions on this subject. There should be no timidity here. 
 If the individual is able to walk or ride at all, he should take daily 
 exercise. " Neither should the weather be scrupulously studied, 
 though I would not advise the consumptive patient to expose himself 
 recklessly to the severest inclemencies of weather. I would, never- 
 theless, warn him against allowing the dread of taking cold to confine 
 him on every occasion when the temperature may be low or the skies 
 overcast. I may be told that the patient is often too feeble to be able 
 to bear exertion ; but except in the last stage, when every remedy 
 must prove unavailing, I believe there are few who cannot use exercise 
 out of doors ; and it sometimes happens that those who are exceed- 
 ingly debilitated find, upon making the trial, that their strength is in. 
 creased by the effort, and that the more they exert themselves the 
 better able they are to support the exertion." — Richardson s "Hy- 
 gienic Treatment of Pulmonary Consumption," p. 52. 
 
CHAPTER XXXVII. 
 
 FEEDING INFANTS: ITS IMPORTANCE AS A MEANS OF PREVENT- 
 ING THE TUBERCULAR DIATHESIS. 
 
 I. The Various Temperaments of the Body may be Altered. 
 
 Some children are born with a hereditary proclivity to pulmonary 
 tuberculosis. That this predisposition may be counteracted and erad- 
 icated by proper management, I most firmly believe. And this is 
 no new doctrine. As far back as the days of G-alen, it was distinctly 
 taught that by particular management the various temperaments of 
 the human body might be altered or changed. Indeed, some of the 
 ancient teachers of medicine affirmed that individuals of the most 
 elevated and sanguine temperament may be broken down into a 
 nervous habit by confinement, anxiety, and affliction ; while, on the 
 other hand, the most restless and audacious of the bilious tempera- 
 ment may be altered to the quiet of the phlegmatic by an uninter- 
 rupted succession of peaceful luxury and indulgence. These are 
 important truths, and should not be lost sight of in our efforts to 
 lessen the mortality from phthisis. The earlier such efforts are 
 commenced, the better. We cannot be too particular in this case. 
 If the child is at the breast, I would look after the mother's health 
 very anxiously, particularly if she be a subject of pulmonary tuber- 
 culosis, or have marked and threatening symptoms of the malady. I 
 would not allow her to suckle her babe. The physician who gives his 
 consent to it is inflicting a great wrong both upon the mother and her 
 child. The popular opinion that a woman suffering under phthisis 
 should nurse her child so long as she has a particle of milk, cannot 
 be too severely denounced. Suckling, under such an exhausting and 
 mortal disease as pulmonary consumption, can never be attended with 
 any good, and no infant should ever be suffered to draw its sustenance 
 from such a corrupt source. We Cannot expect the stream to be pure 
 when the fountain is impure. Nothing but a miracle can alter this 
 
 345 
 
346 PULMONARY TUBERCULOSIS. 
 
 fundamental law of nature. If, therefore, we would keep the child 
 healthy, we must keep the mother healthy. 
 
 II. How to Preserve the Mother's Health. 
 
 And how, it may be asked, is this to be accomplished ? Is it by 
 confining her exclusively to the house ; not permitting her to breathe 
 the pure air of heaven ; gorging her stomach with indigestible food 
 and stimulating drinks ? By no means. She should be encouraged 
 to take plenty of out-door exercise, and eat such food as will preserve 
 her in good health. No nursing woman should be kept upon any one 
 kind of food exclusively. Her diet should be mixed, animal and 
 vegetable. The proportion of animal should rather exceed the vege- 
 table. Women of tubercular proclivities commonly have a repug- 
 nance to animal food, and I have seen some who would never touch 
 it. Nurses of this description are always sure to have cross and 
 unhealthy children. The milk being deficient in its animal con- 
 stituents, is digested with difficulty, and does not contain all those 
 elements which are requisite for the proper nutrition of the child ; 
 hence its physical development and growth are greatly retarded, and 
 certain derangements are induced, such as colic, vomiting, diarrhoea, 
 tabes mesenterica, tubercular meningitis, and other serious disorders, 
 which very frequently terminate its existence before it is a year and a 
 half old. 
 
 III. The Mother's Milk the best Food for the Infant. 
 
 To a child under a year old, its mother's milk should constitute its 
 chief aliment. Indeed, for the first few months it requires nothing 
 else; and if the mother be a good nurse, she should be able to support 
 her infant independent of artificial nutriment, during at least two- 
 thirds of infancy ; that is, until the seventh or eighth month. About 
 that time the teeth usually begin to appear, indicating that the diges- 
 tive organs are capable of doing more work than they were at first, 
 and accordingly we should then improve this indication of nature, and 
 gradually commence to train and exercise those important powers. 
 We may commence at first by adding to its usual diet, once or twice 
 a day, a small portion of soft bread, steeped in hot water, with a little 
 sugar and fresh cow's-milk ; subsequently some light broth, free from 
 fat. Great care ought to be taken that it receive no more than it can 
 
FEEDING INFANTS. 347 
 
 easily digest. Everything that disagrees with its stomach should be 
 strictly prohibited. 
 
 IV. Not Good to Feed Children too often. 
 
 A very grave error is frequently made in the management of chil- 
 dren by suckling or feeding them too often. It is true that, during 
 the first five or six months, an infant requires to be nursed frequently 
 through the night as well as the day, but this should be done at 
 regular intervals, so that the stomach be not constantly gorged. 
 Sufficient time should be allowed to digest its entire contents before 
 more is taken. An interval of three or four hours will do at first, 
 but as the child approaches the period of weaning, the time may be 
 gradually extended to five or six hours, as the nature of each partic- 
 ular case may demand. And it is highly important that the hours 
 for feeding should be arranged in such a manner as not to encroach 
 upon the hours proper for sleep. After a child has attained the age 
 of one year, and is weaned, it is a very bad practice to feed it in the 
 night. Children thrive best where this habit is not followed. The 
 stomach of the infant requires a regular and systematic period of 
 repose. Where this is denied, the harmony of its functions will soon 
 be destroyed, and indigestion, with its numerous ills, will follow in its 
 wake. This practice is also injurious to the mother. 
 
 V. How to Select a Good Nurse. 
 
 Sometimes from the loss of the mother, or a failure of her milk 
 from disease, it becomes necessary to procure a strange nurse ; and 
 the opinion of the physician will often be asked as to the best mode 
 of selecting one. In a matter of such vast importance to his little 
 patient, he should always be guided by some fixed rules. We have 
 generally been governed by the following ; it is our beau-ideal of a 
 good nurse. She should be about twenty-five years of age, of the 
 nervo-sanguineous temperament, in height about five feet six inches, 
 and a fair amount of embonpoint, with an average-sized brain, and a 
 good intellectual and moral education. She should also bear the 
 marks of a good state of health, such as a skin free from eruptions, 
 tongue clean, gums full and not streaked with the tubercular margin ; 
 her teeth should be sound and perfect; her functions of digestion 
 should be active and vigorous ; her breast should be firm and well 
 
348 PULMONARY TUBERCULOSIS. 
 
 formed, and with perfect, well-developed nipples, from which the milk 
 should flow freely upon the slightest pressure ; her milk should be 
 thin, of a bluish-white color, sweet to the taste, and rich in cream ; 
 she should not have been confined less than one month nor more than 
 three ; if she has had more than one child, all the better, for this will 
 have given her some experience in the management of infants, which 
 will add very materially to her other qualifications ; she should be 
 cleanly in her personal habits, and not addicted to the use of alcoholic 
 stimulants, tobacco, or opium ; she should have the most perfect com- 
 mand of her temper, and be in no way given to the abuse of the animal 
 propensities ; living at peace with God and all mankind. And happy, 
 indeed, is that child who, when deprived of its own mother, is so 
 fortunate as to fall into the arms of such a nurse ! 
 
 VI. Artificial Feeding of Children. 
 
 But in the vast majority of instances it is impossible to procure a 
 strange nurse, and we will be compelled to resort to artificial feeding. 
 The article usually selected for this purpose is cows' milk ; but it 
 differs so much in the relative proportion of its constituents from 
 human milk, that when given in a state of purity to very young 
 children it is apt to disagree with them, and, unless it be so changed 
 as to approximate the mother's milk, it will produce the most injurious 
 effects, such as vomiting, diarrhoea, emaciation, and convulsions, 
 which, if not relieved, will speedily terminate the existence of the 
 little sufferer. 
 
 Chemistry teaches us that the new-born babe requires for its nourish- 
 ment proper quantities of oil, casein, albumen, sugar, fixed salts and 
 water. In the mother's milk these constituents are provided just in 
 proportion to fill every demand of the child for aliment. In the cow's 
 milk this is not the case, as the following analysis of the two kinds of 
 milk will show : 
 
 In cows' milk Simon found — 
 
 TVater S57.0 
 
 Butter 40.0 
 
 Casein 72.0 
 
 Sugar and extractive matter 28.0 
 
 Fixed salts 6.2 
 
 In human milk he found — 
 
FEEDING INFANTS. 349 
 
 Water „ 898.0 
 
 Butter 28.0 
 
 Casein 32.0 
 
 Sugar and extractive matter 36.0 
 
 Now. if these two tables be compared, it will be seen that cows' 
 milk contains less water and less sugar than the milk of the human 
 female. It also contains more casein and butter than the latter. This 
 will serve to explain why it is that cows' milk, when substituted for 
 the mother's, is so disagreeable to the digestive organs of the young 
 child. When, therefore, we are compelled to resort to cows' milk as 
 a diet for infants, we should endeavor to bring the relation of the 
 constituent elements as nearly as possible into accordance with the 
 quality of the milk of the human female. For very young children 
 we have generally found that, by diluting it with one part water and 
 adding sufficient white sugar to make the necessary sweetness, it will 
 agree with most children very well. 
 
 VII. Animal Jelly a Useful Food for Children ; A Case. 
 
 But we will occasionally meet with cases that will not tolerate the 
 use of cows' milk in any form. I have met with instances in which 
 it appeared to act like poison upon the young infant. What shall we 
 do under such circumstances? I will answer this question by reciting 
 a case that occurred in my practice some years since. 
 
 One beautiful evening in the month of August, 1853, a man and 
 woman called at one of our hotels, and desired to remain all night. 
 The woman was quite young and very beautiful. She had a babe, 
 which she said was five weeks old. In the morning the man told the 
 landlord that he had business in a neighboring town, and as it would 
 not be convenient for his wife to accompany him, he would leave her 
 in his care. The woman was very fashionably dressed, very attractive 
 in her manners, and appeared very much attached to her child. On 
 the third morning after her arrival, just about the time the mail train 
 was due at our station, she made some excuse to go there, and, leaving 
 her babe in the care of one of the female servants, she never came 
 back to look after its wants. 
 
 Being thus abandoned by its mother, it fell into the hands of a very 
 excellent woman, who had had considerable experience in raising chil- 
 dren by artificial feeding. The little stranger was a boy, and the day 
 
 23 
 
350 PULMONARY TUBERCULOSIS. 
 
 that lie came under the care of his good curse he was in perfect 
 health. His food for two or three days consisted of equal parts of 
 water and cows' milk. This appearing too strong for his digestive 
 organs, it was still further reduced with water, and a small portion of 
 white sugar was added. But this did not appear to mend the matter. 
 His bowels became very loose, and his food was passed almost un- 
 changed. His diet was now changed to a mixture composed of half a 
 teacupful of water, a tablespoonful of cream, and a teaspoonful of white 
 sugar. This appeared to agree with him very well for a few days. But 
 by degrees his bowels again became very much relaxed, and the stomach 
 very irritable, so much so that it retained but very little of the food 
 that was given. He now commenced to emaciate, was very restless, 
 and at times appeared to suffer from severe pain in the bowels. 
 
 This state of affairs continued about ten days, when early one 
 morning he was suddenly attacked with convulsions, and I was called 
 in to see him. His general appearance was that of a child in the 
 collapsed stage of cholera infantum. I ordered stimulating appli- 
 cations to the extremities, and a teaspoonful of the following every 
 
 hour: 
 
 R Mucil. acacias, gj ; 
 
 01. valerian., gtt. iv. — M. 
 
 Under the use of this prescription the convulsions were promptly 
 arrested, the extremities became warm, the pulse full and regular, and 
 the stomach and bowels more quiet. 
 
 From the history of the case, I was satisfied that any further attempt 
 to nourish him by any mixture that contained cows' milk was. in his 
 present condition, out of the question. I therefore recommended the 
 following : 
 
 R Calves-foot jelly, 5ij ; 
 Cinnamon-water, 5j I 
 Warm water, 5iv. — M. 
 
 This, with the oil of valerian, was freely given for several days with 
 the most happy effects. The little stranger's nervous powers were well 
 sustained by the valerian, while the jelly was easily digested and 
 nourished the tissues of the body most perfectly. This, with the 
 addition of beef-tea and barley-water, constituted his diet for nearly 
 four months, when a weak gruel, prepared from rice and light bread, 
 
FEEDING INFANTS. 351 
 
 softened in warm water, was gradually substituted. Frequent attempts 
 were made to use cows' milk, but it always disagreed with the stomach, 
 and had to be speedily discontinued. 
 
 I haVe also found animal jelly very useful in some cases where the 
 mother's milk has disagreed with the child, especially where it pro- 
 duced colic, vomiting, and diarrhoea. In cholera infantum I consider 
 it almost a specific, if given in the form just described. I know of 
 no article of food or medicine that agrees better with the stomach and 
 bowels of young children than this. Milk and other substances that 
 are used in artificial feeding are not commonly very easily digested, 
 and leave a very large quantity of excrement. Hence, when the 
 mucous membrane of the bowels is very irritable, or inflamed, these 
 excrementitous matters have a tendency to keep up the irritation, and 
 render the case more difficult to manage. But animal jelly is easily 
 digested, leaves but little excrement, and furnishes a large amount of 
 nutriment, which is a matter of vast importance in all serious diseases 
 of the stomach and bowels. 
 
 VIII. Bread Jelly and other Articles of Food. 
 
 Another article of food which I have found very useful for very 
 young children, when cows' milk does not agree with them, is bread 
 jelly, and it may for common use be prepared in the following man- 
 ner : A portion of soft bread is broken up, and boiling water being 
 poured upon it, it is covered and allowed to steep for some time ; the 
 water is then completely strained off, and fresh water is added, and 
 the whole placed on the fire and allowed to boil slowly for some time 
 until it becomes smooth ; the water is then pressed out, and the bread 
 on cooling forms a thick jelly, a portion of which is then mixed with 
 water and sugar for use as it is wanted. 
 
 As the child grows older and the digestive organs increase in power, 
 the range of its diet may be greatly extended ; beef-tea, rice, and 
 barley-water, — all of which form a combination of vegetable and ani- 
 mal matter that constitutes a very salutary diet for many children. 
 When a child has teeth to masticate solid food, bread and butter, 
 boiled beef and mutton, potatoes, and boiled rice, and the like, may be 
 given according to the wants of each case. The only drink allowable 
 is water, or milk and water. The practice of giving children stimu- 
 lating drinks is one that cannot be too severely reprobated. Every 
 
352 PULMONARY TUBERCULOSIS. 
 
 physician should raise his warning voice against it. If the strength 
 and vigor of manhood cannot resist the deleterious influence of stim- 
 ulating drinks, as has been fully demonstrated, what must be their 
 effect when given to children ? Besides proving ruinous to health by 
 undermining the constitution and laying the foundation for future 
 disease, thousands who have filled the drunkard's grave may thank the 
 ill-directed kindness of their parents for a taste for strong drink 
 acquired in infancy, which, in after-life, has irresistibly hurried them 
 on their downward course to wretchedness and death. 
 
 I am aware that there are some physicians who profess to believe 
 that the moderate use of alcoholic stimulants will prevent the develop- 
 ment of tubercular disease in children and adults. But nothing can 
 be more delusive than this. The most superficial investigation will 
 dissipate the idea at once. Alcoholic stimulants, when given to chil- 
 dren in the form of punch, sling, essences, and the like, derange the di- 
 gestive organs, preventing those changes in the food which are necessary 
 to the formation of healthy chyle, and thus remotely interfering with 
 the healthy nutrition of all the tissues of the body, and, in those 
 children predisposed to tubercular disease, leading almost directly to 
 its development, either in the brain or some minor organ of the body. 
 
 I have been thus particular on the diet of young children because 
 I believe that a proper attention to it will greatly aid in overcom- 
 ing that constitutional diathesis upon which the development of pul- 
 monary tuberculosis depends in after-life. Poverty of diet, either in 
 the young or the old, must ever be regarded as a fruitful source of 
 this disease. Good blood, the very life of the system, cannot be elab- 
 orated out of scanty and slender fare. No person should be a glutton, 
 but I would recommend all who have a predisposition to phthisis to 
 live well. Indeed, a good substantial diet of animal food and vegetable 
 aliment is necessary at all times to vigorous health. Deny this to the 
 growing child, and you expose him to the danger of an early grave. 
 Look then to his diet. See that his body is well nourished, and you 
 will accomplish more in overcoming tuberculosis than in prescribing 
 any of the famed articles of the materia medica that are supposed to 
 have any agency in that direction. 
 
CHAPTER XXXVIII. 
 
 PREGNANCY : ITS INFLUENCE ON THE DEVELOPMENT AND PROG- 
 RESS OF PULMONARY TUBERCULOSIS. 
 
 I. Great Difference of Opinion among "Writers. 
 
 This is a subject of commanding interest. From my reading and 
 acquaintance with physicians, I am satisfied that it has never received 
 that attention which its importance demands. Medical writers are 
 quite at variance in their opinions on the subject. The greatest con- 
 fusion prevails on every point connected with it ; and from my studies 
 I have found it impossible to harmonize the different and conflicting 
 opinions expressed with the facts which preside in the case. This 
 will appear quite evident if I call your attention for a few moments to 
 some of these opinions as they stand recorded on the pages of our 
 most prominent medical authors. For brevity, we will not go farther 
 back than the last edition of Morton's " Illustrated Pulmonary Con- 
 sumption," published in 1839. 
 
 On page 206, he says, " The duration of phthisis is greatly modi- 
 fied by the peculiar functions of the female constitution. During the 
 period of pregnancy the morbid action is suspended in the lungs, while 
 all the resources of the system are devoted to the uterine functions. 
 Lactation produces in some degree the same effect, and it is thus that 
 child-bearing women, although decidedly consumptive, enjoy a state of 
 comparative health for many years. But the disease is only latent, 
 and prone to recur with fatal violence when this check is removed. A 
 young lady who was attacked with the worst symptoms of phthisis 
 was soon after married, and at the usual period became a mother. She 
 bore eight children in eleven years, and throughout all that time had 
 no other evidence of her pulmonary affection than an occasional catarrh, 
 or slight haemoptysis, and in the opinion of her friends enjoyed good 
 health. After her eighth parturition, however, her system became 
 enfeebled, and pregnancy did not recur ; her consumptive symptoms 
 
 353 
 
354 PULMONARY TUBERCULOSIS. 
 
 then reappeared with redoubled violence, and carried her to the grave 
 in a few months." 
 
 Dr. Montgomery, in his work, " Signs of Pregnancy," when speak- 
 ing of the sanitary influence of pregnancy upon co-existing disease, 
 says, " I think we have sufficient evidence to justify the belief that 
 pregnancy acts in a good degree as a protection against the reception 
 of disease, and apparently on the common principle that during the 
 continuance of any one active operation in the system, it is less apt to 
 be invaded or acted upon by another. Thus, it has been observed that, 
 during epidemics of different kinds, a smaller proportion of pregnant 
 women have been attacked than others ; and when women who have 
 been laboring under certain forms of disease happen to conceive, the 
 morbid affection previously existing is greatly mitigated or suspended 
 for the time, as has been frequently observed in phthisis." 
 
 Dr. Edward Warren, in his Fisk Fund Prize Essay on the " Influ- 
 ence of Pregnancy in Developing Pulmonary Tuberculosis," published 
 in the American Journal of the Medical Sciences for July, 1857, con- 
 tends, with much ingenuity and no little learning, that pregnancy is an- 
 tagonistic to the development of pulmonary tuberculosis, and that when 
 it occurs during the progress of the disease, it is opposed to the continu- 
 ation of the tubercular diathesis, and may in this way contribute to the 
 arrest of the local lesion. On page 113 he has the following interest- 
 ing remarks : 
 
 " Dr. Holland, in his ' Medical Notes,' affirms that nothing exercises 
 a more potent influence upon the development or prevention of disease 
 than the concentration of the attention upon any particular organ. 
 This must be admitted by every careful observer of morbid actions, 
 and is received as a truism by the profession. What can give more 
 fixedness and concentration of attention than the expectation of being 
 impregnated, the assurance that pregnancy has been established, and 
 the certainty of becoming a mother ? With what constant watchful- 
 ness must the woman regard her womb, who perceives that her menses 
 have been arrested, that her abdomen is enlarging, and that a child is 
 developing itself within her bosom ! And if it be possible for disease 
 to be removed from an organ, and for the nervous iufluence and san- 
 guineous current to be directed upon another by any mental effort, 
 under what circumstances could it be so well accomplished as when the 
 uterus is engaged in the act of reproduction, and employed with all 
 
PREGNANCY. 355 
 
 the changes, alterations, and labors incident to that important process ? 
 Here, then, is another reason for attributing to pregnancy the power 
 of arresting the progress of tubercular deposition. 
 
 " The object of pregnancy is to reproduce the species and perpetuate 
 the race. Like all other physiological acts, it requires certain condi- 
 tions for its perfection, which nature labors to supply with a generous 
 and intelligent hand. Health is essential to the proper performance of 
 all vital actions, and the amount of health demanded is always in direct 
 proportion to the importance of the physiological process. Pregnancy 
 implies the existence and progress of the most important process known 
 to the economy. Its successful accomplishment requires, consequently, 
 the maximum development of vital power and the nearest approach to 
 the normal standard of which the organism is capable ; and hence, its 
 proper performance is an evidence of the abatement of all serious 
 morbid action, and the establishment of a condition essentially antago- 
 nistic to the invasion and progress of disease. This statement is veri- 
 fied by the following facts : 
 
 " (1) Most women increase both in size and strength during the 
 period of gestation. 
 
 " (2) Women who bear children habitually enjoy better health than 
 those who do not. 
 
 " (3) Pregnant women are less susceptible to the influence of con- 
 tagious diseases, epidemics, etc., than others who are in a normal con- 
 dition, as has been affirmed by Boyle, Andral, Montgomery, Ash well, 
 Sydenham and many others. 
 
 " Thus it is evident that nature attempts to throw safeguards around 
 this important process by inducing that condition most essential to its 
 success, and by arresting every action calculated either to interfere 
 with its progress or to prevent its consummation. From these consider- 
 ations, it is plain that pregnancy must tend to prevent the progress of 
 consumption with those in whom the tubercular diathesis has been 
 established." 
 
 Dr. L. M. Lawson, in his work on " Phthisis Pulmonalis," says 
 (p. 306), " My own convictions on this subject have been deduced from 
 personal observations, and, although not in the form of statistics, are, 
 at least to myself, not the less conclusive on that account. It is my 
 conviction, then, that in the tubercular predisposition, or even the pre- 
 cursory stage of phthisis, the occurrence of pregnancy under favorable 
 
356 PULMONARY TUBERCULOSIS. 
 
 circumstances, and frequently repeated, so changes the vital actions as to 
 delay or entirely arrest the impending local deposit. And what I mean 
 by favorable circumstances is, that the person should be in the enjoy- 
 ment of a fair degree of general health and strength, the pregnancy 
 progress regularly to its natural termination, and that the subject 
 during the time be placed under proper hygienial conditions in regard 
 to exercise, clothing, diet, and habitation." "When the disease has be- 
 come fully established, Dr. Lawson is of the opinion that, if the tuber- 
 cular deposit be limited, and the patient's strength and digestion good, 
 pregnancy may still retard the progress of the local disease. But if 
 the deposit be extensive, and softening has occurred, gestation will not 
 retard the malady, but, on the contrary, will have a tendency to accel- 
 erate it. 
 
 Dr. Sweet, in his " Lectures on Diseases of the Chest," expresses 
 an opinion quite different from those just cited. He says (p. 263), 
 •' : There is a common impression that pregnancy retards the progress of 
 phthisis. Probably it only renders it latent, and thus an apparent rather 
 than a real advantage is gained. That it produces neither of these results 
 in some cases I am well convinced ; and the practitioner who recom- 
 mends it to his patient may be disappointed, even in a temporary ad- 
 vantage. Even supposing that the progress of tuberculosis is retarded 
 during the existence of pregnancy, what is the final result ? As soon 
 as delivery has taken place, the pulmonary disease usually advances 
 with a greater rapidity, and, in addition, a child with a strong tuber- 
 culous tendency is born. Certainly there is no great advantage in 
 these results, and you will, I hope, be disposed to adopt the opinion 
 that I have formed : never to advise pregnancy to a tuberculous female. 
 Cases of this kind will occur often enough, and the evil consequences 
 be experienced, without or in opposition to our advice." 
 
 M. Louis, in his great work, i: Pathological Researches on Phthisis." 
 p. 305, Boston edition, 1S36, occupies nearly the same ground as Dr. 
 Sweet, although his ideas are not so clearly expressed. He remarks, 
 " TTe have not been able to decide whether pregnancy is capable of re- 
 tarding the progress of phthisis ; it is evident that numerous facts are 
 required, and several years in a lying-in hospital, before we can have 
 any positive information on the subject. TVe must observe, however, 
 that perhaps there have been some error and confusion among those 
 who have hitherto admitted such an influence. It is indeed possible 
 
PREGNANCY. 357 
 
 that many symptoms of phthisis may be less prominent during preg- 
 nancy, while the progress of the disease is really unaffected. On the 
 other hand, it is not impossible that after labor the progress may be 
 more rapid than at any previous period ; and the difference before and 
 after confinement may, to a certain extent, have given rise to the im- 
 pression." 
 
 MM. Dubreuilh and Grisolle have both presented reports to the 
 French Academy of Medicine in which they ignore the opinion of 
 the antagonism between pregnancy and phthisis, and have attempted 
 to establish the idea that the progress of phthisis is hastened by that 
 state. These gentlemen are the only individuals, so far as my knowl- 
 edge extends, who have made any attempt to furnish us with any sta- 
 tistics on this subject. They have produced forty-eight cases for the 
 solution of this question ; but they are limited in number, and are too 
 imperfectly described to be of any material use. It appears, however, 
 from the cases reported by these gentlemen, that, while occasionally 
 phthisis may suddenly declare itself, or else rapidly grow worse after 
 delivery, as it does during the convalescence from various acute dis- 
 eases, yet in by far the greater number the disease pursues its regular 
 course, and in half of those who were delivered during the first or at 
 the beginning of the second stage of the disease, the symptoms under- 
 went a decided improvement. 
 
 II. Theories Sometimes Adopted for Positive Knowledge. 
 
 It cannot be denied that the weight of authority, as it stands recorded 
 on the pages of medical practice, is in favor of the opinion that preg- 
 nancy is antagonistic to the tubercular diathesis. But when we reflect 
 that this opinion is based in a great measure upon theoretical deduc- 
 tions, we 'do not consider it entitled to very much confidence. In so 
 important a question as this we should have something more than 
 theory ; nothing but facts and their legitimate deductions can fill the 
 bill of our wants in this case. Fine-spun theories may do to amuse 
 the man of fanciful intellect, but they are of little value when applied 
 to the healing art. Perhaps some will regard it an unjust criticism 
 when I say that in some of our most popular works on the practice of 
 medicine theories are taught almost to the exclusion of facts. 
 
 In our profession it is a humiliating reflection that the opinions and 
 theories of great writers and teachers are too often taken for positive 
 
358 PULMONARY TUBERCULOSIS. 
 
 knowledge. Antiquated dogmas take the place of the great practical 
 truths discovered by the research of modern medical science. Facts 
 derived from experience and observation must give place to some mis- 
 erable hypothesis that should never have found a lodgment in the 
 human mind. The young physician thus learns to depend upon others ; 
 he adopts their opinions without proper investigation, and he frequently 
 finds, to his great mortification, that they are erroneous and of no 
 practical value. 
 
 If a man would become a successful practitioner of medicine, he 
 must not depend too much on the opinion of others ; and, indeed, this 
 is true in every department of life. If a man would have success in 
 any branch of business, he must stand up for himself. Every man has 
 his own sphere, his own duties, and his own powers to discharge them. 
 This place no other man is to take, — his labor no other is to perform. 
 This is the natural order, the divine arrangement. If a man would 
 acquire might of intellect, be a power in the world, and gain an im- 
 mortal name, he must, to a great extent, travel through the fields of 
 science alone, never adopting a theory or an opinion because it is sanc- 
 tified by a great name. And by this we do not mean to intimate that 
 the aid and teachings of others are to be abjured. No ; far from it. 
 Let us go to all the great masters of our noble profession, and to all 
 the wisdom which past ages have treasured ; of the works of the pres- 
 ent time, let us study all those which stand as the indices and proto- 
 types of modern medical science. Let us apply to all the great foun- 
 tains of knowledge for ourselves, — not to fill a reservoir, but to water 
 plants which grow in our fields. To the young physician I would say, 
 plant your own crops, reap your own fields, and you will enjoy the 
 sweet fruition of your own labors. 
 
 In investigating every subject that relates to the practice of medi- 
 cine, we should exercise our own judgment, and conscientiously follow 
 its teachings. Especially is this necessary in the case before us, where 
 there is such a contrariety of opinion. If pregnancy is antagonistic 
 to phthisis, its occurrence in a consumptive patient is a fortunate cir- 
 cumstance ; if not, it is unfortunate, and he who recommends it is 
 inflicting a great wrong upon his confiding patient. For my own part, 
 I am convinced that pulmonary tuberculosis is not in any way amelio- 
 rated by pregnancy. 
 
 If pregnancy has such a powerful influence in correcting the tuber- 
 
PREGNANCY. 359 
 
 cular diathesis and arresting the local lesion as some authors maintain, 
 we ought at least sometimes to meet with cases of recovery from the 
 disease where it has occurred ; but such has never been my good for- 
 tune, and I have never yet heard of a well-authenticated instance in 
 the observation of others. Dr. Warren, in that elaborate essay of his, 
 has not produced a single instance. It is true he has labored very 
 diligently to show that pregnancy is a state of plethora, and that this 
 condition is unfavorable to the tubercular diathesis. I do not know 
 that this has ever been seriously controverted. But that this state 
 will be generally produced in phthisical females by the occurrence of 
 pregnancy has never been demonstrated. Indeed, experience teaches 
 us to believe the contrary. According to Dr. W.'s own statement, 
 pregnancy, for its proper accomplishment, always requires an extra 
 expenditure of vital power ; and as phthisis is essentially a disease of 
 weakness and debility, this must inevitably tend to its development in 
 those who have a decided proclivity to the malady. And how often 
 is it the case that we see a young woman afflicted with this disorder 
 marry, become pregnant, struggle through it, and fall a prey to the 
 disease within a year? While I write, my memory is crowded 
 with instances of this kind. From these considerations, and others 
 that might be named, I am compelled to dissent from the commonly 
 received doctrine that pregnancy is antagonistic to the development 
 and progress of pulmonary tuberculosis. 
 
CHAPTER XXXIX. 
 
 ALCOHOLIC STIMULANTS : THEIR INFLUENCE AS THERAPEUTICAL 
 AGENTS IN PULMONARY TUBERCULOSIS. 
 
 Many physicians imagine that there is an antagonism between pul- 
 monary tuberculosis and alcoholic stimulants, and are therefore in the 
 constant habit of recommending their free use to those "who are sup- 
 posed to have any proclivity to this malady. I am acquainted with 
 no writer who has been more explicit and outspoken on this subject 
 than Dr. Austin Flint. He sings its praise in season and out of season : 
 and from reading some of his elaborate articles on phthisis, especially 
 his book-reviews in the American Journal of the Medical Sciences, one 
 would conclude that alcohol was the only medicine for the disease. 
 Here is one of his emphatic utterances : " If there be any article in 
 the materia medica which may be considered as in any measure specially 
 efficacious, that is exerting a remedial effect on the morbid condition 
 or cachexia on which the deposit of tubercle depends, we believe it to 
 be alcohol" 
 
 From a faithful examination of this subject for many years. I can- 
 didly confess that I have never been able to see that alcoholic stimu- 
 lants have the least influence as a remedy in arresting or retarding 
 tubercular disease. And my experience may be different from that of 
 others, but it has led me to the opinion that alcoholic stimulants cannot 
 be used in any form as a beverage without inflicting great injury upon 
 the delicate tissues of the human body, causing many disorders which 
 have a direct tendency to produce tubercular disease, particularly in 
 those who have a predisposition to it. And there are few things that 
 astonish me more than to hear scientific physicians attempt to vindi- 
 cate the use of alcoholic stimulants as a preventive of phthisis, when 
 they must know from their daily observation that they are agents of 
 evil in every sense of that term. Xo man can tamper with them with 
 safety. The history of the world has written it in letters of fire that 
 360 
 
ALCOHOLIC STIMULANTS. 361 
 
 the moderate dram-drinker is in continual danger of becoming a 
 drunkard. 
 
 With these facts staring us in the face, are we not warned, most 
 earnestly, as guardians of the health and happiness of mankind, to be 
 exceedingly cautious how we give our recommendation to an article 
 fraught with such injurious consequences to the race? It would be 
 better to let them die with pulmonary tuberculosis, than subject them 
 to the fearful danger of becoming drunkards and suffering all its mul- 
 tiplied physical and moral evils. 
 
 But in opposition to these views, I am told that when we estimate 
 the value of therapeutical agents, moral questions are not to be taken 
 into the account. This class of objectors tell us that we have no busi- 
 ness to meddle with any question of morality connected with the case. 
 If alcoholic stimulants will cure phthisis, we should not hesitate to 
 prescribe them, if some do abuse them ana ruin themselves for time 
 and eternity. 
 
 I repudiate such moral philosophy ; it is unworthy of so exalted a 
 profession as ours. Twenty years ago, when the temperance reform 
 was at the zenith of its glory, the medical profession of this country — 
 and I speak it to their honor — bore a most faithful testimony against 
 the use of ardent spirits as a beverage. They united heart and hands 
 with the friends of reform, and thus presented an unbroken phalanx 
 against one of the mightiest evils in our land. They condemned 
 liquor-drinking and liquor-trafficking most emphatically. And it is only 
 within a short time that any man of standing in the profession has 
 attempted to reverse the decision, and 'advise the daily use of alcoholic 
 stimulants. 
 
 Some great German chemist pretended to have made the discovery 
 that alcohol was food ; that it could be burnt up in the lungs like oil 
 in a lamp ; that it produced a large amount of animal heat, supplied 
 materials to replenish the wasting tissues of the body, and had some 
 wonderful and peculiar property to sustain the vital powers. Physi- 
 cians who looked upon phthisis as a disease of debility and wasting, 
 at once exclaimed, " We have found the great remedy for the fell dis- 
 order." Big doctors and little ones vied with each other in shouting 
 amen ! So alcohol has been regularly initiated on our list of thera- 
 peutics for pulmonary tuberculosis. 
 
 In this chapter I propose to discuss its merits for such a distin- 
 
362 PULMONARY TUBERCULOSIS. 
 
 guished position. To investigate the question fairly, it will be neces- 
 sary to examine three things : 
 
 1st. The chemical nature of alcohol. 
 
 2d. Its physiological action upon the human system. 
 
 3d. Its adaptation to fill the indications to be met in the treatment 
 of pulmonary tuberculosis. 
 
 If on examination it is found to be innoxious in its nature, possessing 
 qualities which are life-sustaining and health-producing, it will be en- 
 titled to some consideration as a remedial agent in the disease which 
 constitutes the more immediate subject of our study. 
 
 I. The Chemical Nature of Alcohol. 
 
 The principal chemical ingredient of all the various articles that are 
 known as alcoholic stimulants or ardent spirits is alcohol. The mode 
 of extracting alcohol from fermented liquor was discovered about nine 
 hundred years since, by an Arabian alchemist. Some individuals, who 
 have a very superficial view of chemistry, imagine that alcohol is a 
 natural production, and that there is a portion of it in all vegetable 
 substances, at least in all whose fermentation after death will produce 
 it. But this is an entire mistake. Not a living vegetable under the 
 shining sun, so far as has yet been ascertained, contains a particle of 
 it. It does not exist in any living substance. Those substances, 
 however, which contain sugar after they are dead, and have become 
 subject to those laws which then operate on inanimate matter in the 
 incipient stage of decomposition, undergo a process called vinous fer- 
 mentation. 
 
 By this process a new substance is formed, called alcohol. The ele- 
 ments by the combination of which this is formed existed before, but 
 the substance which this combination forms did not before exist. It 
 is an entirely new substance, and is altogether different in its nature 
 and effects from what existed before. It was formed not by the pro- 
 cess which operates in the formation of living matter, but by that 
 which operates on a certain kind of matter only after it is dead. 
 This is alcohol, the intoxicating agent of all fermented liquors. 
 After it has been thus formed, it can be extracted in a number of 
 ways. The most common method is by the application of he 
 in ordinary distillation. It is composed of the following chemical 
 constituents : 
 
ALCOHOLIC STIMULANTS. 363 
 
 Hydrogen 13.04 
 
 Oxygen 52.17 
 
 Carbon 34.79 
 
 100.00 
 
 Alcohol, when pure, is a transparent, colorless liquid, having a 
 rather pleasant odor and a strong, burning taste. It is very inflam- 
 mable, burning with a clear, blue flame, without any smoke. It com- 
 bines with water in every proportion, and their combination is attended 
 with a sensible evolution of heat. Its affinity for water is so great 
 that it speedily removes that fluid from the atmosphere. It is decom- 
 posed by nearly all the acids. It dissolves the caustic alkalies, and 
 has but little or no effect on their carbonates. It dissolves most of 
 the muriates that are easily soluble in water, some of the nitrates, but 
 none of the metallic sulphates. It also dissolves iodine, phosphorus, 
 and sulphur — the last two in very small proportions. It is a power- 
 ful solvent of many vegetable principles, especially those that exert an 
 action on the animal system, such as the vegetable alkaloids, most 
 neutral crystalline principles, extractive matter, sugar, tannin, very 
 many resins, all essential and fixed oils, fluid as well as concrete. 
 Alcohol is therefore an indispensable agent in pharmacy as well as in 
 pharmaceutic chemistry. As yet, in the particulars just named, there 
 is no known substance which will supply its place. 
 
 Medical writers, with but few exceptions, class alcoholic stimulants 
 among the narcotic poisons. Dr. Christison says, — 
 
 " The sedative action of alcohol on the brain constitutes it a power- 
 ful narcotic poison." 
 
 Dr. Kirk, in speaking of the nature of alcoholic stimulants, says, — 
 
 " All of them contain, as a basis, alcohol, — a narcotic stimulant pos- 
 sessing properties of the kind that opium does, which you know to be 
 poison, with this addition — that it is more immediately irritating to 
 the tissues of the body to which it is applied than opium." 
 
 Dr. Johnson says, — 
 
 " Alcohol is a narcotic poison of the very same nature as prussic 
 acid, producing the same effects, killing by precisely the same means : 
 paralyzing the muscles of respiration, and so preventing the necessary 
 changes of the venous into arterial blood." 
 
 Mr. Brande, in his excellent work on chemistry, says, — 
 
 " Ardent spirit is composed of alcohol and water in nearly equal 
 
364 PULMONARY TUBERCULOSIS. 
 
 proportions, and is as destructive to life as henbane, deadly night- 
 shade, hemlock, and various other narcotic poisons." 
 
 Dr. Headland, in his prize essay on the " Action of Medicines in 
 the System," has the following remarks upon the action of narcotics, 
 and alcohol in particular : 
 
 " We have already considered in order the peculiarities in the action 
 that distinguishes narcotics alike from stimulants and sedative medi- 
 cines ; how they tend, first to exalt the nervous forces, and then de- 
 press them, and have, further, a particular action on the intellectual 
 part of the brain. We have observed that these remedies may be 
 divided into three minor groups, which differ considerably, if only 
 regarded in their action on the nervous forces generally. For that 
 inebriants approach very nearly to stimulants, and deliriants to seda- 
 tives, while soporifics occupy an intermediate place. 
 
 " We have seen also that though, during the stage of stimulation, 
 these three orders tend all more or less to excite the powers of the mind, 
 they differ characteristically in their secondary or depressing effect upon 
 the same. That, with respect to our present purpose, the intellectual 
 functions may be divided into three parts : the mind itself; volition and 
 sensation, by which it is united to the body ; and the special senses, by 
 which it is connected with external things. And that the secondary 
 or depressing action of inebriants is such as to impair these three 
 in a tolerably equal degree ; that soporifics extinguish, for a time, sensa- 
 tion, volition, and the five senses, while they may leave the mind un- 
 affected ; but that of deliriants excites and deranges all the intellectual 
 functions. 
 
 " If these things are borne in mind, the nature of alcohol will be 
 tolerably understood when it is said to be an inebriant narcotic. But 
 it must be observed that, when given in small quantities, its stimulant 
 effect may be the first action manifested ; its secondary sedative effect 
 may hardly take place, and the production of inebriation, or drunken- 
 ness, may be altogether avoided. So much is this the case, that alcohol 
 is by some regarded as a stimulant. But the same thing is remarked 
 of opium, though in a less degree. And the effects of a large dose of 
 alcohol are sufficiently obvious to indicate its place among narcotics ; 
 for the state of inebriation may even pass on into coma and death." * 
 
 * Headland on the Action of Medicines, p. 3S0. 
 
ALCOHOLIC STIMULANTS. 365 
 
 II. Physiological Action of Alcoholic Stimulants. 
 
 Several years since, Liebig advanced the doctrine that alcohol is 
 burned in the body like sugar and fat, and thus contributes to animal 
 heat, and might claim to be ranked among articles of food. This theory 
 of its physiological action was extensively adopted by those who sought 
 to justify its employment as a remedy for phthisis, and those who 
 hated teetotalism. But this doctrine has never been demonstrated. 
 It is based altogether upon certain deductions from its extreme com- 
 bustibility. It has not one direct or positive fact to sustain it. In 
 medical science we should take nothing for granted. She is constantly 
 challenging the validity of antiquated and popular opinions, and de- 
 manding their most vigorous investigation and proof. 
 
 But is it a fact that alcohol is used up in the body like common 
 aliment ? I think not, for the following considerations : It is a well- 
 established truth, that, when alcohol is oxidized out of the body, it 
 passes through successive steps or stages of decomposition, giving rise 
 to peculiar productions, which have been called aldehyd and acetic 
 acid. These productions, the evidence of the oxidating process, 
 cannot be detected in the blood after the ingestion of alcoholic stim- 
 ulants. Traces of acetic acid have been found in the stomach, but 
 as a sequence of gastric fermentation of sugar and starch, and wholly 
 independent of the introduction of alcohol. 
 
 The ultimate productions of the oxidation of alcohol are carbonic 
 acid and water ; but they are also derived from the oxidation of food, 
 and are incessantly thrown from the lungs, day and night, whether 
 alcohol be taken or not. There is not a particle of evidence, there- 
 fore, that can be adduced from chemical science to prove that alcohol 
 is used up in the system like common alimentary matter. 
 
 If alcohol is not used up in the system like common aliment, what 
 becomes of it ? It has been well ascertained that when alcohol is 
 taken into the system, it seeks the brain by preference and local affinity, 
 more of it being found there than in any other part of the body ; it is, 
 therefore, attracted out of the blood into the cerebral substance. This 
 may be proved by distilling the brains and blood of men and animals 
 that have died from intoxication, and separating the alcohol, when it 
 may be identified, and its quantity estimated with the greatest certainty. 
 It has also been proved that alcohol is not changed in any essential 
 
 24 
 
366 PULMONARY TUBERCULOSIS. 
 
 particular by passing the rounds of the circulation ; that it goes into 
 the blood alcohol, and comes Out the same. It is eliminated from the 
 system by the skin, lungs, and kidneys. 
 
 Until quite recently, it was a matter of doubt among medical phi- 
 losophers whether alcohol was eliminated from the lungs at all. But 
 this subject has been entirely put to rest by MM. Lallemand, Perrin, 
 and Duray. In the course of their experiments, they discovered a 
 most delicate test to prove the existence of alcohol in the breath. It 
 consists of a solution of bichromate of potassium in sulphuric acid. If 
 the expired air contains the alcoholic vapor, when it comes in contact 
 with this solution it is turned to an enameled green. They found that 
 persons who had taken no alcohol for some hours previous might expire 
 for any length of time through the solution without producing any 
 discoloration of it ; and furthermore, so exact was the reaction, that 
 by employing a test-liquid of a certain known strength they could 
 estimate the quantity of the alcoholic vapor given off in different ex- 
 periments and at different times. In this way they have proved very 
 clearly that alcohol, unchanged, is thrown from the system by means 
 of the breath. 
 
 These experimenters affirm most positively that alcohol undergoes no 
 combustive action in the living body, but that the whole of what is 
 taken in is thrown off unchanged. They admit that they have not 
 been able to recover from the excretions the whole amount taken, and 
 nistly state that, in the nature of the case, this is not to be expected. 
 Their experiments show the important fact that it is not the mere 
 excess of alcohol which the system cannot profitably use up that is 
 excreted, for the ingestion of only one ordinary bottle of wine, very 
 weak at that, gave rise to a coutinual elimination of alcohol by the 
 lungs during eight hours, and by the kidneys during fourteen hours. 
 
 These experimenters have also shown that the physiological action 
 of alcohol upon the system is almost identical with that of chloroform 
 and some other anaesthetics, the difference in their effects being only of 
 a secondary character, and beiug obviously referable to their chemical 
 and physical properties. From a careful study of their experiments. 
 I am of the opinion that they have completely and triumphantly ex- 
 ploded the Liebigian doctrine, that alcohol is food. I do not see how 
 it ever entered into a sane man's brain, unless the devil put it there. 
 that alcohol was food, capable of nourishing the tissues of the body. 
 
ALCOHOLIC STIMULANTS. 367 
 
 The idea is a delusion, a phantom of an intoxicated brain ; and I have 
 most generally found that those writers who recommend it as a bev- 
 erage are more or less addicted to its intemperate use. One of our 
 most gifted American medical writers, who was a great advocate for 
 its use, fell a victim to its seductive agency. 
 
 I, therefore, look upon alcohol as an enemy to the human system. 
 On every tissue of the body with which it comes in contact, it must be 
 rejected as an intruder, and as such is chased from organ to organ, 
 marking its course with irregularity of action and disturbance of 
 function, till the last remnant of the intruder is expelled. Till the vital 
 forces of the system are prostrated before its paralyzing energy, this 
 deleterious agent can never find a lodgment. Nature, true to herself 
 and to God, is incapable of such treason. 
 
 III. Have Alcoholic Stimulants any Agency in Preventing or 
 Retarding Pulmonary Tuberculosis ? 
 
 If I have not misrepresented the nature of alcohol in the preceding 
 remarks, it does not present a very favorable passport to our confidence 
 as an antagonist of phthisis. It is not just the therapeutical agent to 
 fill the bill of our wants in this case. In this complicated disorder we 
 want medicines that will fill at least three indications : 
 
 1st. The integrity of the vital forces is to be restored and main- 
 tained. 
 
 2d. A specific morbid condition of the blood is to be overcome, and 
 its normal vitality sustained. 
 
 3d. Certain local obstructions are to be removed, and the parts re- 
 stored to their wonted functions. 
 
 It cannot be denied that alcohol when taken in moderate quantities 
 is an active stimulant ; and when properly regulated may be given for 
 a long time without being followed by any sedative effect. Its stimu- 
 lating properties constitute its chief attraction as a beverage. It 
 quickens, excites, and animates the vital forces. This, by a funda- 
 mental law of the human system, is attended with a feeling of comfort 
 and pleasure. This is universally taken for good by the victims of 
 this habit. It also arouses for a moment the reserved and dormant 
 energies of the system which are not needed and were not designed for 
 ordinary occasions, but were intended for special emergencies, and 
 which cannot be drawn out and used without inflicting injury upon 
 
368 PULMONARY TUBERCULOSIS. 
 
 the physical organs. This awakening of dormant energy is never 
 attended with permanent benefit, and those who mistake it for an 
 increase of vital force, a permanent good, are entirely deceived. It 
 imparts no real strength to the vital organs. As well might we con- 
 clude because the delirium of a fever sometimes arouses dormant 
 energy, and the man who before had hardly life enough to raise a 
 hand for a moment puts on the strength of a giant, that, therefore, 
 disease and delirium are a source of permanent strength, as to draw 
 any such conclusions concerning alcohol. 
 
 In the pretubercular stage of phthisis there is a partial failure of 
 the vital forces. The system is not properly nourished, the individual 
 complains of languor and of an inability to perform the usual duties of 
 his avocation. His muscles have become flabby ; his countenance has 
 not the glow of health ; his eyes are dim ; his step is unsteady ; his 
 pulse and respiration are hurried ; his tongue is coated, and his diges- 
 tion impaired ; his urine scanty and high colored ; his bowels irregular ; 
 he has a slight hacking cough, particularly in the morning ; Thomp- 
 son's gingival margin is slightly defined on the gums ; he has occasional 
 headache, and pain in the back and limbs; is restless at night, 
 disturbed by unpleasant dreams, and the mind not very hopeful. Per- 
 cussion reveals no dullness, and auscultation only a slight incn 
 the expiratory murmur. Here we have a case of incipient tubercu- 
 losis. The vital forces must be sustained ; and alcoholic ,-tinmlants 
 would be the very last therapeutical agents that I would seleet for 
 this purpose. They may, for a time, arouse the flagging energies of 
 the system, but unless something more permanent is supplied, the 
 jaded organs will give out. and the banner of universal ruin will speed- 
 ily triumph over all. My experience leads me to the opinion that in 
 cases of phthisis like those just described, alcoholic stimulants are 
 highly injurious ; that, instead of sustaining the vital forces, they ex- 
 haust them with the most fearful rapidity, the patients sueeumbing 
 much sooner than if they had not been used. 
 
 I had a very marked example of this kind in my practice about five 
 years since. A young man aged twenty-one. and a young woman aged 
 twenty-four, became affected with pulmonary tabereulosifl. In the 
 spring of the year they had the measles. Their recovery from this 
 was attended with slight symptoms of pneumonia, whieh soon yielded 
 to mild antiphlogistics. During the summer they enjoyed their usual 
 
ALCOHOLIC STIMULANTS. 369 
 
 health. Some time in the fall they commenced gradually to decline. 
 I was not called in at this period, as the father of the family had 
 become a very ardent advocate of hydropathy, and had determined to 
 try the merits of its pretensions. For three months they were most 
 rigidly subjected to the various manipulations recommended by Dr. 
 Shew for the cure of phthisis, but without the least benefit. After 
 this, I was invited to see them. In both cases tubercular disease was 
 developed in their lungs. They were placed upon the use of anodynes, 
 tonics, and a very nourishing diet. By these means they were made 
 comfortable, and life was prolonged, in the case of the young lady, for 
 eighteen months, and in that of the young man for two years. 
 
 In this family there was a young man aged nineteen. After the 
 death of his brother, he began to have threatening symptoms of phthisis. 
 One day his father called on me, and commenced very abruptly to 
 remark that we doctors did not know anything about the nature or 
 treatment of consumption. He had found a remedy for the disease, 
 and he thought it mighty strange that doctors had not discovered it a 
 long time ago. I asked him if he would be so good as to inform me 
 what that specific was. With great earnestness of manner he replied,. 
 " Surely ; it should be published to the ends of the earth — good rye 
 whisky? His son had taken it, and was recovering very fast. I con- 
 gratulated him, and he left, after making some very unkind remarks in 
 regard to the stupidity and ignorance of physicians. Ten days after 
 this conversation, I was summoned in great haste to see his son. He 
 had an attack of haemoptysis. It was very profuse. His decline was 
 now very rapid, and he died in less than six months from the com- 
 mencement of his illness. 
 
 Alcoholic stimulants are not the therapeutical agents indicated in 
 the pretubercular stage of this malady. Restorative haematics and. 
 tonics are the medicines. Alcoholic stimulants, as we have already 
 shown, contain nothing of this sort. They restore nothing to the 
 blood. They contain nothing out of which a single constituent of the 
 blood can be elaborated. Some writer has had the audacity to affirm 
 that " alcohol acts in the same manner as cod-liver oil, by supplying; 
 respiratory materials and increasing the fat of the blood ;" all of which, 
 is a mere presumption, completely and triumphantly exploded by the; 
 experiments of MM. Lallemand, Perrin, and Duray. Cod-liver oil, 
 iron, quinia, these are the best known therapeutical agents to meet the 
 
370 PULMONARY TUBERCULOSIS. 
 
 indications in the incipient state of tubercular disease. They impart 
 permanent strength to the vital forces by supplying to the blood certain 
 elements which are indispensable for healthy nutrition. In a pre- 
 ceding chapter I have already alluded to the fact that in individuals 
 who indulge in the use of alcoholic stimulants the blood manifests a 
 deficiency in its coagulating quality. This is undoubtedly owing to a 
 want of vitality in the fibrin of the blood. I think there is abundant 
 reason to believe that even the moderate use of alcohol depraves this 
 constituent of the blood, and renders it unfit for its appropriate use in 
 the formation of healthy tissues ; and, in persons who are predisposed 
 to phthisis, may lead directly to the formation of tubercular deposits 
 in the lungs. 
 
 In the pretubercular stage of phthisis, the vital forces are not only 
 to be sustained, but certain morbid materials in the blood are to be 
 eliminated. That alcoholic stimulants have any influence in that 
 direction, I am very loth to admit. Alcohol when taken into the 
 system passes directly into the blood ; and it has been ascertained by 
 experiment that it prevents the normal exhalation of carbonic acid 
 from the lungs, thereby increasing the venosity of the blood, which 
 has a direct tendency to produce torpidity in all the excretory organs 
 of the body, and to render them incapable of performing their proper 
 functions. By this means the blood is overloaded with effete matter, 
 which is very deleterious to the health of the system. Some writers 
 have based their chief argument for the use of alcoholic stimulants in 
 phthisis upon this effect. They regard the restraining of the excre- 
 tions, and the too rapid oxygenation of the blood, very important 
 means of curing the disease. But there is no philosophy in this. 
 Nature has made the organs of respiration just right, and under no 
 circumstance do they oxidize the blood any faster than the wants of 
 the system demand it. In pulmonary tuberculosis the great evil is, 
 that the blood is not aerated as rapidly as it should be ; and in conse- 
 quence of this and the inactivity of the excretions the blood becomes 
 unfit for the performance of its wonted functions. Alcoholic stimu- 
 lants are, therefore, not only useless in this particular, but may be the 
 means of much injury. I am satisfied that in phthisis they add to the 
 morbid condition of the blood. Indeed, they have no catalytic prop- 
 erties ; they counteract no morbid process in the tissues of any organ, 
 neither have they any agency in eliminating any morbid material from 
 
ALCOHOLIC STIMULANTS. 371 
 
 the blood. Iodide of potassium, chlorate of potassium, and stillingia 
 sylvatica are the most reliable articles that we have to meet this 
 second indication. 
 
 Although the moderate use of alcoholic stimulants may temporarily 
 excite the dormant energies of the great nervous centres which sustain 
 the functions of organic life, and may sometimes be of great benefit in 
 cases of extreme emergency, when they are given indefinitely they 
 will always be attended with injurious consequences. This they do 
 by inflicting an extra burden upon the excretory organs, particularly 
 the liver and kidneys. These organs, in the normal state of the sys- 
 tem, have just as much labor to perform as is compatible with their 
 health. When compelled to eliminate alcohol, they are grappling 
 with a substance which deranges their functions, and sometimes in- 
 flicts injuries which ultimately lead to their dissolution. There are 
 very few cases of phthisis which are unattended with some lesion in- 
 one or more of the blood-making or blood-purifying organs. The 
 liver, for instance, very seldom escapes. I have already, in another 
 chapter, shown that this organ is very liable to a variety of engorge- 
 ments and congestions, which commence at a very early period of the 
 disease, and sometimes constitute most formidable complications. 
 Alcohol, instead of relieving these engorgements, will only increase 
 them. It cannot, therefore, suit this, our third indication. Blue 
 mass is the most efficient livei stimuiator that we are acquainted 
 with ; but in every stage of phthisis it should be used with the utmost 
 care. 
 
 IV. Drs. Bell, Condie, Davis, and Chambers : their Opinion 
 of Alcohol in Phthisis. 
 
 At the commencement of this chapter we quoted the opinion of Dr. 
 Flint, in favor of the use of alcohol in phthisis. From the high po- 
 sition of the doctor as a writer and teacher of medical science, we 
 would hesitate to differ with him on so grave a subject. He has had 
 a very extensive experience in treating chest-diseases, and his opinion 
 is entitled to great respect. But when we find so many others who 
 stand equally high in the ranks of the profession expressing a contrary 
 view, we feel bold to differ with him. 
 
 Dr. Bell, in his Fisk Fund Prize Essay, entitled, " Effects of the 
 Use of Alcoholic Liquors in Tubercular Disease," after reviewing all 
 
372 PULMONARY TUBERCULOSIS. 
 
 the materials that could be found, says. ;: It seems to me almost con- 
 clusive that the use of alcohol not only has no power to defend those 
 predisposed to phthisis from its attacks, but with little doubt changes 
 the predisposition into actual disease."* 
 
 Dr. Condie says, ;: I do not believe in either the preventive or 
 curative powers of alcohol in tubercular affections. Evidence the 
 most unexceptionable can be presented to show that a life of drunken- 
 ness is by no means a safeguard against the occurrence of pulmonary 
 tuberculosis, or of the deposit of tubercle in any organ or tissue of the 
 body. That those who partake daily of alcoholic drinks are as prone, 
 if not more so, to the occurrence of tubercular disease as those who 
 abstain entirely from their use, is in fact susceptible of the clearest 
 demonstration. That, on the other hand, these drinks have no special 
 therapeutical powers in tuberculosis has. we believe, been very fully 
 shown by, among other facts, their very extensive employment in cases 
 of phthisis at a former period, when the disease was inscribed upon 
 the list of diseases resulting from debility."")" 
 
 Dr. X. S. Davis, in his able report on the " Influence of Alcoholic 
 Drinks on the Development and Progress of Pulmonary Tubercu 
 after discussing the question at considerable length, and producing a 
 large amount of evidence against its use as a therapeutical agent in 
 phthisis, draws the followiug conclusions : 
 
 " ; 1st. The development of tubercular disease is facilitated by all 
 those agents and influences, whether climatic or hygienic, which 
 directly or indirectly impair or retard the metamorphosis of the organ- 
 ized structures and the efficacy of those structur 
 
 ' ; 2d. That observation and carefully devised experiments both show 
 that the presence of alcohol in the human system, notwithstanding its 
 temporary exhilaration of the cerebral functions, positively retards 
 both metamorphosis and elimination. 
 
 " 3d. That neither the action of alcoholic stimulants on the human 
 body, nor the actual result of experience, furnishes any evidence that 
 these stimulants are capable of either preventing or retarding the 
 development of tubercular phthisis." T 
 
 * American Journal of the Medical Sciences. Oct. 1So9. p. 429. 
 
 f Medical and Surgical Reporter, vol. iii. p. 1S3. 
 
 I Transactions of the American Medical Association for I860. 
 
ALCOHOLIC STIMULANTS. 373 
 
 Dr. Chambers, in his "Lectures on the Renewal of Life," page 308, 
 says, " In my opinion, alcohol is not only useless but injurious to the 
 consumptive, excepting for its beneficial action upon the mucous mem- 
 branes. It arrests and obstructs the vigor of vital action ; by it growth 
 is checked, as we see practiced in animals kept small for artificial pur- 
 poses, and in men who have from youth habitually indulged in ardent 
 spirits. Under its use renewal goes on slowly, as we know by the 
 diminished excretion of urea, water, bile, etc. ; and we can hardly, 
 therefore, reckon it advantageous where the chronic renewal of vital 
 power is our primary object. 
 
 " But you may ask, how are we to explain cases like the following, 
 in which alcohol seems the preservative of life : 
 
 " S. P., a butcher, remarkably strong and stout, was first attended 
 by me for delirium tremens, which he had suffered from several times 
 before, and was always well in the interval ; an attempt to become a 
 teetotaler was immediately followed by galloping consumption. 
 
 " S. A., a brewer, came to me last year about indigestion and pim- 
 ples (acne rosacea) on his nose and face; I urged him to give up 
 brandy-drinking before breakfast and between meals, and I find now a 
 developed vomica in his lungs, of which previously there was no evi- 
 dence. 
 
 " You may cite instances such as these, and attribute the vomica to 
 the omission of alcohol, which therefore you may represent as a direct 
 preservative. I think you would be wrong. 
 
 " I confess I do not take such cases as mere coincidences, but I ex- 
 plain them in a way by no means corroborative of the idea that spirit- 
 drinking keeps off consumption. I think that alcohol acts as an 
 anaesthetic, and prevents the system from resenting the presence of 
 the tubercles ; then ¥ when it is left off they act with double deleterious 
 effects on the body, .unprepared by their gradual increase to bear them, 
 as it were, by habit. The quondam tippler is then in the same relative 
 position as one in whom there is a large sudden development of the 
 morbid matter ; for the existence of the morbid matter unexpectedly 
 becomes known to the system, and its ravages suddenly taken notice 
 of. Thus, instead of really checking tubercular disease, the alcohol 
 has acted merely as a mask, behind which the evil has gone on un- 
 awares. 
 
 " What should you do in such cases as those above related ? Should 
 
374 PULMONARY TUBERCULOSIS. 
 
 you advise a return to drinking habits ? I think not ; for though the 
 symptoms are somewhat lightened thereby, this is merely a misty 
 cloud of anaesthesia which stands between the patient and his pain, 
 and I doubt if life is prolonged." 
 
 That alcohol in its physiological effects is almost identical with 
 chloroform, will hardly be doubted by any one who has witnessed its 
 excessive action upon the human system. Chloroform prevents the 
 proper oxygenation of the blood ; so does alcohol ; they both destroy 
 life in the same manner. It is mainly upon this peculiar effect of 
 alcohol that the advocates of its use in pulmonary tuberculosis place 
 their main reliance. They maintain that the chief feature of the 
 tubercular crasis consists in the too rapid oxygenation of the blood, 
 and that by preventing this we counteract the blood-malady and pre- 
 vent the local deposit of tubercle. Keep your patient continually 
 stupefied with alcohol, and he may bid defiance to pulmonary tubercu- 
 losis. 
 
 This is indeed a beautiful theory ! Unfortunately, it is not true. 
 It is not sustained by a single fact derived from practical experience. 
 I believe it can be safely asserted that there is no cause more produc- 
 tive of tubercular disease, either in man or in the inferior animals, than 
 an atmosphere loaded with carbonaceous matter. This has been con- 
 clusively demonstrated by the experiments of Dr. McCormic, alluded 
 to in another place, and by what we frequently witness in ill-ventilated 
 prisons and hospitals, and among those who are confined in work-shops 
 where the atmosphere is loaded with carbon; among this class 
 operatives the mortality from tubercular disease is very large. If car- 
 bonaceous matter, when introduced into the system through the air we 
 breathe, is so productive of tuberculosis, why may it not be equally 
 injurious when introduced into the system through the digestive organs 
 in the form of alcohol? I do not feel the least hesitation in saying 
 that it is. The appearance of those who indulge in the use of alco- 
 holic stimulants proves it. Look at the bloated face, the widely 
 expanded nostrils, the purple lips, and the bloodshot eyes. — they 
 all point to a want of proper oxygenation of the circulating fluid. To 
 say that such a condition of the blood is congenial to a healthy per- 
 formance of the various functions of the body, is contrary to every 
 principle of physiology, and the physician who insists upon it only 
 betrays his ignorance of the laws of life. If we would have health 
 
ALCOHOLIC STIMULANTS. 375 
 
 in all the tissues of the body, we must have pure blood; and this can 
 never be when it is poisoned by alcohol. 
 
 Alcohol, however, aside from its injurious effects upon the physical 
 constitution of man, its ruinous effects upon his moral and intellectual 
 faculties, should make us exceedingly careful how we prescribe it as 
 a remedy for disease ; for it has been demonstrated beyond all contra- 
 diction that its habitual use tends directly to harden the affections, 
 sear the conscience, blind the reason, and corrupt the morals of man- 
 kind. It has been proved time and again that it causes three-fourths 
 of all the crimes that are committed ; that it changes gigantic strength 
 to pigmy weakness, celestial order to infernal discord, and heavenly 
 purity, light, and love to infernal pollution, darkness, and hate. De- 
 pravity it depraves, and makes vileness still more vile. It increases 
 all the mischief which the wicked one has occasioned in the soul, 
 while with a mighty force it counteracts all the beneficent designs of 
 our heavenly father for its deliverance from sin, and its restoration to 
 the dignity and beauty of his image. 
 
 In the name of Grod and humanity, then, I call upon every physician 
 who cares for the happiness of the race, who regards his obligation to 
 his Maker, who appreciates his children's welfare or the rights of suc- 
 ceeding generations, to use his utmost endeavors to discountenance the 
 use of alcoholic stimulants as a beverage under any circumstances, in 
 any quantity, and under whatever form they may be disguised. 
 
INDEX. 
 
 A. 
 
 Abscess of the liver : a case, 75. 
 
 Absorption of tubercular matter, 252. 
 
 Abuse of the propensities a cause of 
 phthisis, 291. 
 
 Acetate of lead useful in haemoptysis, 
 212. 
 
 Acid, hydrocyanic, in hectic fever, 227. 
 
 Age, influence of on the frequency of 
 the pulse, 152. 
 
 Aggregated tubercle, 14. 
 
 Albumen, condition of, in phthisis, 53. 
 
 Alcohol, chemical nature of, 362. 
 
 Alcoholic stimulants injurious in phthi- 
 sis, 360, 367. 
 
 Aliment, vegetable and animal, 317. 
 
 Apoplexy, cerebral, a cause of sudden 
 death in phthisis, 247. 
 
 Animal heat and clothing, 321. 
 
 Animal matter in the blood, 54. 
 
 Auscultation, 100. 
 
 B. 
 
 Bathing : a moral virtue and luxury, 
 330. 
 
 Beard : a plea for, 304. 
 
 Best residence for consumptives, 282. 
 
 Biliary derangement, 69. 
 
 Bilious temperament, influence of on the 
 pulse, 150. 
 
 Bismuth, Scheffer's, 186, 239. 
 
 Blood, condition of, in phthisis, 47. 
 
 Bowditch, Dr. H. I., on consumption in 
 New England, 281. 
 
 Brain, tubercles in, 42, 243. 
 
 Breathing, bronchial and vesicular, 101. 
 
 Bright's disease of the kidneys in 
 phthisis, 58. 
 
 Bronchial tubes opening into cavities, 
 19. 
 
 Bronchial pouches mistaken for tuber- 
 cular cavities, 126. 
 
 Bronchitis mistaken for phthisis, 123. 
 
 Bruit de pot fele, 106. 
 Bugle-weed useful in haemoptysis, 213. 
 Bursting of large abscesses into the 
 bronchia, 248. 
 
 C. 
 
 Cancer and tubercle not identical, 41. 
 
 Causes of pulmonary tuberculosis, 267. 
 
 Cavities, formation of, in the lungs, 16. 
 
 Cerebral apoplexy a cause of sudden 
 death, 242. 
 
 Chemical changes of the air in respira- 
 tion, 315. 
 
 Chloroform and alcohol nearly identical 
 in their effects, 374. 
 
 Cholesterine, crystals of, 15. 
 
 Clothing, 321. 
 
 Cold not a primary cause of phthisis, 
 280. 
 
 Compositors and pressmen, their liabil- 
 ity to phthisis, 316. 
 
 Contagion of phthisis, 273. 
 
 Cough and expectoration, 188. 
 
 Counter-irritants in phthisis, 256. 
 
 Crackling, dry, 103. 
 
 Crackling, humid, 104. 
 
 Crassamentum and serum in the blood, 
 48. 
 
 Cretaceous transformation of tubercle, 
 21. 
 
 Death, causes of sudden, 242. 
 
 Defective respiration a cause of phthisis, 
 34. 
 
 Denver, Colorado, climate of, 284. 
 
 Depressing passions a cause of phthisis, 
 294. 
 
 Desmartis, Dr. T., opinion of the gingi- 
 val margin, 237. 
 
 Diabetes, relation to tuberculosis, 220. 
 
 Diagnosis of pulmonary tuberculosis, 
 121. 
 
 Diagram of tubercle-cells, 15. 
 
 377 
 
INDEX. 
 
 Diarrhoea in phthisis, 231. 
 
 Diet in phthisis, 240. 
 
 Digitalis in hectic fever, 2. 
 
 Drinks for children ; alcoholic injurious, 
 
 351, 361. 
 Dry crackling, 103. 
 Duration of phthisis, 242. 
 Dyspnoea, 165. 
 
 E. 
 
 Elimination of tubercle after softening, 
 
 16. 
 Emaciation in phthisis, 174. 
 Emphysema associated with phthisis, 
 
 115. 
 Euraerythrin and purpurin in the urine, 
 
 68. 
 Exercise, physiology of, 336. 
 Expectoration, microscopical character 
 
 of, 188. 
 
 F. 
 
 Fatty degeneration of the liver, 71. 
 Feeding of children, artificial, 348. 
 Fever, hectic, 218. 
 
 Fibrin, condition of, in phthisis, 52. 
 Flint's, Dr. Austin, work on physical 
 
 exploration, etc., 120. 
 Food, animal and vegetable, 317. 
 
 G. 
 
 Gagged or tubercular cells, 193. 
 General symptoms of pulmonary tuber- j 
 
 culosis, 91. 
 General symptoms of other chest-dis- 
 
 eases, 10S. 
 Gingival margin, a sign of tuberculosis, 
 
 140. 
 Grandeur of the mind, 289. 
 Grief a cause of phthisis, 296. 
 Gymnastics, 312. 
 
 H. 
 
 ILvmoptysis, character of, in phthisis, 
 201. 
 
 Hemorrhagica purpura and tuberculo- 
 sis, 214. 
 
 Healing of tubercular cavities, 20, 259. 
 
 Heat, animal, how it is maintained, 317 
 
 Hectic fever. 226. 
 
 Hepatic derangement, 69. 
 
 Hereditary transmission of phthisis, 207. 
 
 How to cure pulmonary tuberculosis. 
 312. 
 
 Humidity of the atmosphere a cause of 
 phthisis, 2S1. 
 
 I. 
 
 Imperfect nutrition a cause of phthisis, 
 31. 
 
 India, West, phthisis in, 281. 
 
 Indigestion a cause of phthisis, 32. 
 
 Infiltrated tubercle, 14. 
 
 Inflammatory origin of tubercle, 27. 
 
 Influence of the different occupations, 
 300. 
 
 Inoculation by tubercular matter, 273. 
 
 Intestines, disease of, in phthisis, 231. 
 perforation of, 246. 
 
 Iodide of potassium, and soda, 53. 
 
 Iodine, inhalations of, in tubercular cav- 
 ities, 269. 
 
 Iron, a useful remedy in phthisis, 241. 
 
 Italy, climate of, in phthisis, 284. 
 
 J. 
 
 Jelly, animal and bread, good food for 
 children, 359. 
 how to make bread jelly, 351. 
 Jerking pulse a symptom of phthisis, 
 149. 
 
 K. 
 
 Kidneys, their condition in pulmonary 
 tuberculosis, 56. 
 functions of, 56. 
 tubercles in, 61. 
 
 Labor, intellectual, a cause of phthisis, 
 
 Larch bark, a useful remedv in diarrhoea, 
 
 240. 
 Larynx, condition of, in phthisis. 23. 
 Liver, abscess of, in pulmonary tubercu- 
 losis, 
 fatty degeneration of, 71. 
 tubercles in, 69. 
 Locality in relation to consumption. 281. 
 Love, disappointed, a cause of phthisis, 
 
 295. 
 Lung most frequently affected. IS. 
 Lung-tissue in the sputum, 197. 
 Lymphatic temperament, influence on 
 the pulse, 150. 
 
 31. 
 
 Marquette, Lake Superior, a place of 
 
 residence for consumptives. 1 8 
 Membrane lining tubercular cavities. 20. 
 Menstruation in pulmonarv tuberculosis, 
 80. 
 age at which it occurs. B0, Bl. 
 condition of, in phthisis, S4. 
 nature of. 80. 
 recurrence after suppression good, 
 
 87. 
 sudden suppression a bad sign, 85. 
 
INDEX. 
 
 379 
 
 Menstruation, recurrence after suppres- 
 sion ; cases illustrating the same, 86, 
 87, 88. 
 Mental depression a cause of phthisis, 
 
 294. 
 Mercury in pulmonary tuberculosis, 53. 
 
 proto-iodide of, 53. 
 Microscope as a means of diagnosis in 
 phthisis; testimony of Drs. Bennett 
 and Clark, 199. 
 Microscopical examination of the spu- 
 tum, 193, 265. 
 character of tubercle, 14. 
 
 of the red corpuscles, 48. 
 Miliary tubercle, 13. 
 Milk, mother's, best food for infant, 346. 
 
 chemical composition of, 348. 
 Mind: its influence in producing pul- 
 monary tuberculosis, 289. 
 Mucus, nature of, 192. 
 Murmur, prolonged expiratory, an early 
 sign of phthisis, 102. 
 
 N. 
 
 Nature's respirator, 305. 
 
 Nervous system, condition of, in phthi- 
 sis, 41. 
 
 New York, consumption in, 280. 
 
 No vacillating course to be pursued in 
 treatment, 266. 
 
 Not good to feed children too often, 347. 
 
 0. 
 
 Opium in hectic fever, 226. 
 Origin of pulmonary tuberculosis, gen- 
 eral received opinion of, 43. 
 Oxalate of lime in the urine, 68. 
 Oxygen in the air, how it is renewed, 313. 
 Ozone, or ozonized oxygen, its use, 314. 
 
 Pain a common symptom of disease, 159. 
 a symptom of pulmonary tuberculo- 
 sis, 159. 
 as manifested in other chest-dis- 
 eases, 160. 
 not always present in pleuritis, 161. 
 not of much value as a symptom of 
 phthisis, 163. 
 Pathology of pulmonary tuberculosis, 
 
 13, 17. 
 Pectoriloquism, 104. 
 Percussion, 99. 
 Perspiration, nocturnal, 218. 
 Physical signs of pulmonary tuberculo- 
 sis, 97. 
 auscultation, 100. 
 inspection, 97. 
 percussion, 99. 
 
 Pleura, perforation of, in phthisis, 240. 
 Pleurisy connected with tubercles in the 
 
 lungs, 113. 
 Pneumonia a frequent attendant on 
 
 phthisis, 110. 
 Pneumonitis and pulmonary tubercu- 
 losis, lesions not the same, 30. 
 Pneumothorax, 118. 
 Pre-tubercular stage of phthisis, 130. 
 general symptoms of, 131. 
 physical signs of, 134. 
 Pregnancy : its influence on the devel- 
 opment of phthisis, 353. 
 great difference of opinion among 
 
 writers, 353. 
 theories sometimes adopted for pos- 
 itive knowledge, 357. 
 Prognosis of pulmonary tuberculosis, 
 
 127. 
 Prolonged expiratory murmur, 102. 
 
 a sign of the first stage of phthisis, 
 102. 
 Pulmonary tuberculosis ; its transmissi- 
 
 bility by contagion, 273. 
 Pulse : its value as a diagnostic sign of 
 phthisis, 149. 
 character of, in phthisis, 153. 
 influence of posture on, 150. 
 
 of temperaments on, 150. 
 influenced by quantity of the blood, 
 151. 
 by heat and cold, 151. 
 by condition of the lungs, 
 152. 
 state of, in health, 149. 
 Pus, microscopical character of, 190. 
 Pus-cells, withered, 193. 
 
 Quinine, use of, in hectic fever, 228. 
 
 E. 
 
 Red corpuscles in the blood, 48. 
 
 changed in the latter stage of phthi- 
 sis, 38. 
 
 Respiration, defective, a cause of phthi- 
 sis, 34. 
 
 Respiratory murmurs, altered in phthi- 
 sis, 101. 
 
 Retrograde metamorphosis of the tissues 
 a cause of phthisis, 42. 
 
 Riding, 338. 
 
 Rule for estimating the weight of the 
 body, 177. 
 
 S. 
 
 Saline matter in the blood, 54. 
 Salt, common, its use in haemoptysis, 
 212. 
 
 
380 
 
 INDEX. 
 
 Scheffer's pepsine, 238. 
 
 Sem. phelland. aquat., syrup of, 256. 
 
 Sexual excess and self-abuse a cause of 
 
 phthisis, 292. 
 Signs, physical, inadequate without other 
 
 symptoms, 127. 
 Skoda on auscultation, 120. 
 
 on the influence of the beard, 305. 
 Specific morbid condition of the blood, 
 
 37. 
 State of Texas the best place for con- 
 sumptives, 283. 
 Stethoscope, double self-adjusting, 107. 
 St. Paul a residence for consumptives, 
 
 283. 
 Structural changes in other organs from 
 
 phthisis, 23. 
 Sulphuric acid in night-sweats, 230. 
 Sweden, phthisis in, 280. 
 Swimming, 342. 
 Symptoms of phthisis, 91. 
 
 of pretubercular stage, 131. 
 of stage of cavity, 94. 
 of stage of deposit, 91. 
 of stage of softening, 93. 
 Syphilis and tuberculosis not identical, 
 41. 
 
 T. 
 
 Temperaments of the body may be 
 
 altered, 345. 
 Temperaments in relation to the pulse, 
 
 150. 
 Temperature, influence of, on the pulse, 
 
 151. 
 Texas, climate of, 283. 
 Thompson's gingival margin, 140. 
 Tight lacing a cause of pulmonary con- 
 sumption, 308. 
 Treatment of haemoptysis, 211. 
 of diarrhoea, 237. 
 of dyspnoea, 169. 
 of hectic fever, 226. 
 of vomiting, 185. 
 Tubercle-cells, diagram of, 15, 16. 
 
 Tubercle, absorption of, 252. 
 
 aggregated, 14. 
 
 chemistry of, 16. 
 
 cretaceous transformation, 21. 
 
 forms of, 13. 
 
 histology of, 14. 
 
 intestinal deposits, 232. 
 
 microscopical appearance, 15. 
 
 miliary variety, 13. 
 
 softening and elimination, 16. 
 
 where deposited in the tissues, 16. 
 Tubercular disease, nature of, 13. 
 
 certain morbid changes in the blood, 
 43. 
 
 defective respiration, 34. 
 
 imperfect innervation. 41. 
 
 imperfect nutrition, theory of, 31. 
 
 inflammatory theory of, 27. 
 
 retrograde metamorphosis of the 
 tissues, 42. 
 
 specific morbid condition of the 
 blood, 37. 
 Turpentine useful in haemoptysis, 213. 
 
 U. 
 
 Ulceration of the intestines in phthisis, 
 
 231. 
 Union of the body and mind, 290. 
 Uraemia in phthisis, 58. 
 Urine, importance of the excretion of, 
 
 56. 
 
 V. 
 
 Yillemin's experiments, inoculating with 
 
 tubercle, 273. 
 Vomiting, a symptom of phthisis, 180. 
 
 W. 
 
 Waldenburg's, Dr. L., experiments in 
 
 tubercular inoculation, 275. 
 Walking. 338. 
 Withered tubercle-cells, 193. 
 
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