Thorax 1982 ;37 :26-31

Richard Morton (1637-98) and his PhthisiologiaRY KEERS

From Port Erin, Isle of Mall

ABSTRACT Richard Morton was one of the outstanding physicians of the seventeenth century. Aftergraduating BA at Oxford he elected to enter the Church, becoming ultimately Vicar of Kinver inStaffordshire. On the Restoration he found himself unable to comply with the requirements of theAct of Uniformity and was ousted from his Staffordshire living. He disappeared for eight years butreappeared in 1670 when, on the sponsorship of the Prince of Orange, the degree of MD was con-

ferred on him by the University of Oxford. He set up in practice in London and was elected a Fellowof the Royal College of Physicians in 1678. He has left a lasting memorial in the form of his bookPhthisiologia which deals with all aspects of phthisis, the word being interpreted in its widest sense todenote any disease associated with wasting. It is not known where Morton obtained his medicaleducation nor is there anything in his writings to indicate where he spent the eight years between1662 and 1670. It is suggested that he may have been in Holland for part of those years attending theUniversity of Leyden and making the acquaintance of the Prince of Orange whose patronage was toprove so useful at Oxford in 1670.

Pulmonary tuberculosis was rife in seventeenthcentury England, a period when Locke estimated inhis De Phthisi that 20% of the deaths occurring inLondon were caused by that one disease.' Smallwonder therefore that it loomed large in the mindsand practices of the group of outstanding physicianswhich the century was to produce. ChristopherBennet (1617-55) the first of these, was himself avictim of tuberculosis,2 a circumstance which heconsidered made him the authority on the subjectand led him into the making of dogmatic statements,some of which were hardly justified by his sup-porting evidence. Hard on his heels came ThomasWillis (1621-75), appointed Sedlian Professor ofNatural Philosophy at Oxford in June 1660 andremembered in history for the Circle of Willis. In hisPractise of Physick, published some years after hisdeath, he devoted one chapter to tuberculosis"Of a Phthisis properly so called or of a Consump-tion arising from a Fault of the Lungs" which in thetext he defines as "a withering away of the wholebody from an ill formation of the Lungs."3 ThomasSydenham (1624-89) confined his writing on tuber-culosis to a brief communication De Phthisi whichwould probably be of little importance in medicalhistory were it not for its insistence on whatSydenham regarded as a sovereign remedy-horse-riding-of which he wrote with great enthusiasm.As far as tuberculosis is concerned, however, the

outstanding figure of the century was RichardMorton (1637-98) (figure) who has left a memorial in

the form of his book Phthisiologia, the Latin text ofwhich was originally published in London in 1689.Morton had come into medicine fortuitously for it

had not been his first choice when selecting a career.Instead he had elected to follow in the footsteps ofhis father, Robert Morton, who was the Minister ofBewdley Chapel in Worcestershire from 1635 to1646.4 In preparation for entering the church, hematriculated at Oxford as a commoner of MagdalenHall in 1653, subsequently changing to New Collegewhere he graduated BA in January 1656. Shortlyafter graduation he became chaplain to his college,an appointment which he held for some two yearswhen he relinquished it to become chaplain to thefamily of one Philip Foley of Prestwood in Stafford-shire who also assigned to him the living of Kinverin the same county. He proceeded MA in 1659 andsettled down to pursue the peaceful life of a countryvicar, but his peace was soon to be shattered by theevents which followed the Restoration. Under theCommonwealth Morton had embraced non-conformist principles and at the Restoration hebecame one of those Protestant Dissenters whoseconsciences prohibited their subscribing to the Actof Uniformity which, in 1662, had restored thePrayer Book. This restoration of the Prayer Bookhad the effect of turning adrift some 2000 clergy whocould not give their "unfeigned consent and assent"to everything the book contained and Morton wasthus ousted from his living and forbidden to practisehis religious vocation again.

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Richard Mortoni (1637-98) atid his Phthisiologiac

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It is at this point that we come to the great mysteryin his life for literally nothing is known with certaintyof his movements or whereabouts during the eightyears which elapsed between his departure fromKinver in 1662 until his appearance on the medicalscene in 1670 when the degree of MD was conferredupon him by the University of Oxford. He wasnominated for this distinction by the Prince ofOrange who attended a ceremony at Oxford thatyear on the occasion of his first visit to England towhich he had come in the hope of collecting a debtowed him by Charles 11.5 There is no record of whereMorton lived during those eight missing years or ofhow he occupied himself but clearly he must havemade the acquaintance of the Prince of Orangeduring that period and since the Prince did not visitEngland until 1670 Morton must have met him inHolland. What he was doing in that country is a

matter for speculation.From 1670 onwards the cloud of mystery which

had enveloped Morton during those eight yearsseemed no longer to matter for his life thereafter wasan open book. Armed with his Oxford MD he lostno time in settling down to practise in London andestablished himself in a house in Grey Friar's Court,Newgate Street. His troubles, however, were notcompletely resolved. He was admitted a candidate ofthe College of Physicians in March 1675 and becamea Fellow in December 1678. But in 1686 his was oneof four names of Fellows omitted from the list whichaccompanied the renewal of the College Charter byJames II,5 allegedly because the King judged him tobe politically unreliable in view of his acceptance ofthe patronage of the Prince of Orange. A period ofthree years followed during which he was unable totake part in any of the college debates or activitiesbut he was restored to his fellowship in 1689 after theaccession of William and Mary. In 1689 his troubleswere over and Richard Morton progressed to thehighest ranks of his profession. He was a censor of

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Keers

the College in 1690, 1691, and 1697 and was alsoappointed a physician-in-ordinary to the King. Inaddition he left behind him work of an enduringnature, and it is by his Phthisiologia that he isremembered, a book devoted solely to the subject ofphthisis, the Latin text of which was originallypublished in London in 1689. Editions in Englishfollowed in 1719 and 1720 and it is from the second ofthese that the passages quoted here have beenabstracted. There were also continental editionsfrom Frankfurt in 1690, Ulm in 1714, and Helmstadin 1780, dates which indicate how well the bookmaintained its authority over a century.

While the term phthisis came in course of time tobe applied exclusively to pulmonary tuberculosis ithad, in Morton's day, a much wider connotationand was used to describe any disease characterisedby wasting. This wider interpretation led him todivide his Pthisiologia into three sections. The first,in the author's own words, treats "Of consumption ingeneral, and particularly of a Consumption pro-ceeding from the whole Habit of the Body, or anAtrophy, both that which is Nervous, and that whichis caused by Evacuations." Throughout the book heemploys the term "consumption" freely and ob-viously regards it as an acceptable English translationof the more classical "phthisis". In this first sectionhe included, among others, chapters on such items asa "Consumption from Bleeding", a "Consumptionhappening to Nurses, from the giving of Suckbeyond what their strength will allow", a "Con-sumption caused by profuse sweats" a "Consump-tion proceeding from a Dropsy", and a "Consump-tion proceeding from Apostemes and large Ulcers".Clearly this is a somewhat heterogeneous collectionof pathology, only a few of the case histories withwhich the text is illustrated suggesting true pul-monary tuberculosis; nevertheless this section of thebook is of great interest by providing an opportunityto assess Morton's competence as an all-roundphysician. His clinical account of a case "proceedingfrom Apostemes and large Ulcers" deals with theproblem of a woman in poor circumstances whocomplained of long-standing abdominal pain andloss of appetite" even to the degree of a Marasmuswith an intolerable Thirst, a continual weakness,Want of Appetite and Want of Rest."6 She wasultimately seen by Morton who "observing theParts of the Loins to be swell'd and to resist aPressure, and perceiving the Fluctuation of purulentmatter under one finger when we pressed it-Iordered that after the Application of a Caustick, theTumour should be opened in a convenient Place:which was no sooner done, but a great Quantity,first of clear then purulent matter, and a greatnumber of little Bags filled with a very clear Water,

at least five hundred, gushed out with a great force".Even though Morton did not realise that he wasdealing with a hydatid cyst his treatment provedeffective for "the Ulcer within the space of a Yearand a half (which we did designedly keep open solong with a Silver Tent that was hollow) was atlength perfectly healed".Morton illustrated a further chapter on "A

Consumption proceeding from a Dropsy" by thedescription of the problem presented by a 2-year-oldboy, the son of one Thomas Lechmore who "fellinto an Inflammation of his lungs upon taking ofcold and was treated very ill by an Apothecary, whohad omitted Bleeding and other things, that werevery requisite to a true and skilful method of cure.But at length I and my famous colleague Dr. Croon,though we were called in late, recovered him in somemeasure by taking away some Blood-But yet hecontinued sickly with a Cough and difficulty ofbreathing, for the space of a Twelve-month atleast, from which Time the poor child began to beseized with a Hecktick Fever, which intermittedevery day and indeed came upon him by uncertainIntervals for a whole Year, even to his dying Day.But at the very beginning of the Fever his Belly beganto be distended with a dropsical Swelling whichincreased strangely every day; his Cough andshortness of Breath at the same time growing worse-but yet when his body was a perfect skeleton, andthe Dropsy at a high Tide (which was very remark-able) he had a brisk and healthful Look and a lovelycountenance, without the least Tincture of aYellowness-from which I did rightly conjecturethat his Dropsy was truly Chylous, caused by theChyle flowing into the Cavity of the Belly by theLacteal Vessels, which were broke by some Accident,and that the Consumption which accompanied it,was not a true Consumption of the Lungs, but suchas proceeded merely from an Inanition, that is, thedraining of the due Nutritious Juice out of theLacteal Vessels, upon some rupture that had beenmade in them For in Tapping of the Child's Belly,whilst he was yet alive we took out several Pints ofmilky Chyle-But when we opened the body after hewas dead, we found for all the Difficulty of Breathingand long Cough he had, the Lungs themselvessound, without any Distemper, but only that in thehinder part near the wind-pipe there appeared agreat many Glands, and these pretty large and hard,which made a hard and very considerable Pressureupon the Chyle-duct itself, almost at that Part whereit arrives at the Subclavian Vein; and they were of sogreat a Weight and Bulk, that it seemed verydifficult, if not plainly impossible, for the Chyle topass into the Blood, by reason of the Pressure theyhad made upon the Duct, which had streightened it,

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Richard Morton (1637-98) and his Phthisiologia

as if it had tied with a String". From these observa-tions Morton deduced that "the thin LactealVessels which are in the Belly-being distendedbeyond their Tone did at length break, so threw theChyle as it were in a continued Stream, into theCavity of the Belly."6 These findings are a remarkabletribute to his powers of observation and, even if allhis deductions were not entirely justified he had,nevertheless, given prolonged and serious thought towhat he had seen and his thinking led him to a numberof conclusions. First, that these tubercles ortumifyed Glands of the Lungs did at first proceedfrom the ill method of curing the Inflammation ofhis Lungs, that is, for want of timely Bleeding andExpectoration. Secondly, that as the troublesomeand dry cough was caused by the Constriction of theVessels of the Lungs-by these Swellings, so theDifficulty of breathing proceeded from the Pressureof the extravasated Chyle below the Midriff. Thirdly,that the Consumption was not a true Consumptionof the Lungs-but-did really proceed from thatChylous Dropsy from which that Nutritious Juice,which ought to have been employed for the Rep-aration of the Blood-was continually subtractedand carried another way. Fourthly, that this Dropsydid proceed from a rupture of the small LactealVessels that are in the Belly; and, lastly, that thisRupture of the small Lacteal Vessels was causedby that continual Pressure, which the Swellings inthe Lungs had made upon the upper Part of theChyle-duct."The second section of Phthisiologia is entitled

"Of an Original Consumption of the Lungs" whichis defined thus: "Consumption of the Lungs is aConsumption of the whole Body with a Fever,proceeding first from an ill Affection, and at lengthan Exulceration of the Lungs: which, indeed, is themost famous Consumption-and I shall now speakmore largely of it."16

His account opens with a chapter "Of the Causesof an Original Consumption" this being a mdlangeof what he regards as initiating factors which helists under a series of headings: (1) the Stopping ofEvacuations; (2) Troublesome Passions of the Mind(including too much Thinking); (3) Intemperance inEating and Drinking; (4) Want of due Exercise;(5) Night Studies; (6) an Ill Air and, in particular,"that which is filled with the Smoak of Coals";(7) an Hereditary Disposition from the Parents;(8) an Ill formation of the Breast whether it beNatural or Accidental; (9) Infection "for thisDistemper-like a contagious Fever, does infectthose that lie with the sick Person with a certainTaint"; (10) Chalky Stones "that are preternaturallybred in the Lungs"; (11) Also some particularDiseases which "corrupt or overthrow the Nature of

the Blood and Spirits do occasion this Distemper".It is interesting to note that Morton even withVillemin and Koch still 150 years away recognisedthat infection might play some part in the initiationof the disease.

In his second chapter he discusses the degrees ofan original consumption of the lungs and the signswhich give warning of it, together with "what we aredirected to do in order to prevent it". In this lattersection he utters some words of wisdom "Thereforein the preventing of a Consumption (which is mucheasier than the cure of it) the great Business, whilstthe Patients remain in this sickly Condition is to takeall possible Care that no Error be committed in thosesix things, which we call not natural. For in this soslippery a State of Health, they are wont upon everylittle Occasion of this Nature to fall headlong into aFatal Consumption." He then makes his six pointscautioning prudence in the choice and amount offood and drink, the desirability of sleeping in theearly part of the night and avoiding sleeping toolong in the morning, the need each day for somemoderate exercise, the avoidance of strong purgativesthe cultivation of a contented mind, and the enjoy-ment of "an open, fresh, kindly Air and such as is freefrom the Smoak of coals". In concluding thischapter he gives utterance to a heartfelt cry, a crythat has been re-echoing down the ages. "But alas!Physicians have very seldom an Occasion to givetheir Advice about preventing this Distemper-thesick Persons seldom imploring Aesculapius's Help,before the Distemper has run on so far as to be afatal Case and then they in vain expect Miracles fromthe Art of Physick, when it is more convenient forthem to have the good Counsel of a Minister aboutthe future Salvation of their Souls, and the Advice ofa lawyer about making their last Will."6He then passes on to discuss diagnosis which he

does at considerable length by detailing the symptomswhich he has noted and endeavouring to relate thesesymptoms to the findings at his numerous post-mortem examinations. And here he gets carried awayby his study of the tubercles in the lung: "Yea, whenI consider with myself, how often in one Year there isCause enough ministered for producing theseSwellings, even to those that are wont to observe thestrictest Rules of Living, I cannot sufficiently admirethat anyone at least after he comes to the Flower ofhis Youth can die without a Touch of Consump-tion."6

His chapter on prognosis is naturally somewhatgloomy though not universally so for he does admitto the possibility of improvement and even in somecases, of cure. He draws a clear distinction betweenthe acute and the chronic case and speaks of apalliative cure: "So long as those swellings can but

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Keersbe kept from an Inflammation and Exulceration byBalsamick and other such-like Medicines. By whichmeans it comes to pass that the Patient, though he issickly and subject to Fevers, even upon every littleOccasion, yet is able to do his ordinary Business andmany times lives to grow old." He was also wellaware of the propensity of the disease to relapse andwarned that "Every Consumption, though it becured, is apt to return and he that has once been in aConsumption, unless he governs himself veryregularly, falls back into the same condition, evenupon the least Occasion-Yea, moreover even afterthe most perfect Cure of a Consumption, there isReason to suspect that there are some crudeTubercles which at length may, by often meetingwith an Occasion, be inflamed, and ripen intoApostemes and so at last become Ulcers."6

His chapters on treatment are long and contain asound basis of common sense as indicated by hisinstructions on general management. He stresses theneed for an adequate diet, an environment free fromfog and smoke, and the desirability of ensuring amoderate amount of exercise. All Morton's thera-peutic dicta are in their humanity and thoughtfulcare in striking contrast to the regimen of copiousbleeding and semi-starvation inflicted upon the dyingpoet John Keats by a later generation of physicians.He prescribes freely but his prescriptions are theleast important part of his writings consisting as theydo of lists of multiple ingredients of uncertain ornegligible efficacy culled from the apothecary or theherbalist with a few redolent even of the witch'scauldron. As a humane and kindly physician heemployed opium freely to relieve the more distressingsymptoms such as the abdominal pain and diarrhoeaassociated with a terminal intestinal tuberculosis.

In the third section of Phthisiologia Morton passeson to consider what he terms "SymptomaticalConsumption of the Lungs which is caused by anddepends upon some other preceding Disease". Thishe regards as the most common of all consumptionsand he estimates that he sees five such cases for everyone of the "Original Consumptions" which come hisway. As examples of the causative preceding diseaseshe cites "Crapulous and Intermitting Fevers, fromthe Small-Pox, Measles, Scarlet Fever, a Pleuresie,Peripneumony, Melancholy and HysterickAffections; from the King's Evil, Scurvy, GreenSickness, Asthma, Spitting of Blood, Stones in theLungs and sometimes also in the Kidneys andBladder-" and goes on to warn his readers that, indealing with symptomatical consumption, they mustpay due regard to the treatment of the precipitatingdiseases as well as of the consumption itself. As maybe surmised from his comprehensive list of pre-cipitating conditions many, though by no means all,

of the accompanying consumptions were non-tuberculous and some of the case histories with whichhe illustrates his chapters make interesting reading.Thus in the chapter headed "Of a Consumptioncaused by Stones bred in the Lungs and by thingsslipt down into them from without" he describes theproblem of "a young man, living near Cripple-Gate,that was strong and in every way sound in hisEntrails, as he was doing something at his trade ofwhiting, by which he got a convenient livelihood, bychance with laughing heartily let three Nails, whichhe held in his Mouth for his use, go down through hisWind-pipe into his Lungs. Whereupon being seizedwith a most violent cough and continued tickling,he fell into a very great spitting of blood. From whichsymptom I know not by what means, he got himselffree. But this is most certain, that though thoseNails never came up again-yet the young man wasvery well for the space of several months, followinghis Employment as before-but, upon his WeddingDay, whether from his more liberal drinking of Wineor from his dancing too much (with which the nailsthat before lay unmoved, and as it were buried in thesubstance of the lungs, were stirred again) the poorBridegroom in the Evening was taken with dreadfulSpasms and a most acute pain in his Breast andSide, and withal a difficulty of breathing, and a drybut very troublesome cough, so that he could scarcelylie in his Bed or get the least Sleep." Morton saw himon the third day of his illness and considered it "to beplainly Peripneumonick" and ordered bleeding,fomentations and liniments externally with linctusesand "temperate juleps of antispasmodic waters" tobe given internally. He was greatly puzzled, however,both by his own inability to control the fever and thepatient's inability to produce sputum. The victimgradually grew weaker and "he dyed plainly of aconsumption within the space of a Month or fiveweeks. Indeed I wondered very much at the obstin-ateness of the Pain and the difficulty of his Expector-ation; and therefore, being directed by Hippocrates'sAphorism, I did foretell that a consumption from anEmpyema would follow. But I never did so much asdream of the Original cause, to wit the Nails, whichwere slipt down into his lungs, before the Patient'sLife was past all hope-The body being opened afterhe was dead, we found those three fatal Nails as itwere buried together in one bed of Matter, a littlebelow the divarication of the branches of the Wind-pipe, and the Tone of the Lungs universally impairedby the Matter which by degrees had crept all overthem, and the very Membrane which covers theoutside of the Lungs, corroded by the sharpness ofthe Matter; whereupon there came to be a continualdropping or distillation of purulent Phlegm into thecavity of the Breast out of which (to the best of my

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remembrance) I took at least six pints of this purulentliquor which when I saw, I no longer wondered at theobstinateness of the Pain, and the difficulty of hisExpectoration, which accompanyed the Peripneu-mony. Nor did it seem strange that a Peripneumonycaused in this manner should terminate in a fataland such an Acute Consumption".6

Phthisiologia throughout remains a completelyclinical work being based entirely on Morton's ownobservations and experience. Apart from the raremention of one of the aphorisms of Hippocrates hemakes no reference to pre-existing or contemporaryliterature and his account of the various "consump-tions" is clearly derived from what he has personallyseen and studied. In reading the case histories ap-pended to each chapter, compiled 300 years ago, it isimpossible to withold one's admiration for hispowers of clinical observation and deduction. In anera when not even the ancillary aid of a stethoscopewas available to him and before Auenbrugger haddiscovered percussion his examination of the patienthad to be confined to what his eyes could see with theoccasional help of palpation. Thus equipped he madehis diagnosis and, in reading his case histories, who isto say that he committed more diagnostic errorsthan the physicians of later generations.The mystery of where Morton obtained his

medical education remains unsolved. As an oustedNon-Conformist minister he could not have attendedthe flourishing School of Anatomy then located atOxford, for attendance at the University wascontingent on strict adherence to the Anglican formof worship. Trail, in his Gideon Delawne lecture in1969, suggested that "perhaps he was one of themany divines who, according to the poet GeorgeHerbert, then read medicine purely for the good ofthemselves and of their flock and so had commencedhis studies while Vicar of Kinver."5 Some verytentative support for this view may be found inMortons' own writings when he refers to "My dearFather who himself was a very skilful physician"6yet it is known from the Dictionary of NationalBiography that his father was Robert MortonMinister of Bewdley Chapel in Worcestershire,while Munk's Roll confirms that he was the son of aclergyman.7 Is it possible than that as a young manhe had access to medical textbooks in his father'slibrary and did these so excite his interest that whenthe Church was barred to him he turned unhesitat-ingly to a career in medicine? But the author ofPhthisiologia cannot have been entirely self-taughtfor in pursuing his postmortem studies he displays aknowledge of anatomy beyond that which he mighthave culled from a Galenic text, while his observa-tions on the pathological changes which heencountered suggest that at some earlier stage in his

career he had sat at the feet of a master.In seeking an explanation of how this might have

come about his association with the Netherlandsmust be taken into account. Clearly in the eightyears which elapsed between his departure fromKinver and his reappearance at Oxford he must havevisited Holland and remained there for some timesince it is improbable that a transient visitor couldhave secured the patronage of the Prince of Orange.A clear reason for Morton's journey to Hollandcould be found in the existence at that period, withinthe University of Leyden, of what was probably themost famous medical school in Europe, a schoolwhich attracted numerous students from Englandand Scotland. No record of his attendance at Leydenhas been found but it is so improbable that he couldhave lived in Holland and not attended Leyden orthat he could have secured the royal cachet ofapproval without such attendance that the failuresubsequently to trace his name in the records shouldnot be given undue weight. If he attended at Leydenthen the master at whose feet he would sit wouldhave been Sylvius, at that period one of the brighteststars in the Leyden galaxy, remembered in historyfor his work on the morbid anatomy of phthisis andhis elucidation of the importance of the tubercle. Allthis, of course, is entirely supposition but it doesappear to be a reasonable theory to account for theeight blank years in Morton's life.

His path, thereafter, was smooth apart from thecontretemps with James II and the College Charterand he clearly gained the confidence of his colleagues.He has been described as "a man of great gravity,calmness, sound principles, of no faction, an excellentpreacher, of an upright life"2 to which might beadded that he was a truly great clinician, a manhonoured and respected by his peers and contemp-oraries as his memory and achievements have sincebeen honoured by those generations of physicianswho have succeeded him.

References

Brownlee J. An investigation into the epidemiology ofphthisis in Great Britain and Ireland. Med Res CommLondon 1918:43.

2 Cummins SL. Tuberculosis in history. London: Bailliere,Tindall and Cox, 1949:6-7;32.

3 Willis T. Practice of Physick. Phar II Sect I Chap VI.London. 1684:28.

4 Dictionary of National Biography.5 Trail RR. Richard Morton (1637-98). Medical History

1970;14:166-76.6 Morton R. Phthisiologia. London: W and J Innys, 1720:

30-1 ;49-51 ;62;81 ;88;126;247-9;1 18.7 Munk W. The Roll of the Royal College of Physicians of

London. Second edition, London: Royal College ofPhysicians, 1878.

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