it. The remote causes are pneumony, catarrh, hæmoptysis, rheumatism,
gout, asthma, scrophula, chronic diseases of the stomach, liver, and
kidneys, nervous and intermitting fevers, measles, repelled humours from
the surface of the body, the venereal disease, obstructed menses, sudden
growth about the age of puberty, grief, and all other debilitating
passions of the mind; hypochondriasis, improper lactation, excessive
evacuation of all kinds, more especially by stool[18], cold and damp
air, a cough, external violence acting upon the body[19]; and finally,
every thing that tends, directly or indirectly, to diminish the strength
of the system.
[18] Sir George Baker relates, in the second volume of the Medical
Transactions, that Dr. Blanchard had informed him, that he had
seen the consumption brought on ten persons out of ninety, by
excessive purging used to prepare the body for the small-pox.
I have seen a case of consumption in a youth of 17, from the
spitting produced by the intemperate use of segars.
[19] Dr. Lind says, that out of 360 patients whom he attended between
July 1st, 1758, and July 1st, 1760, in consumptions, the disease
was brought on _one fourth_ of them by falls, bruises, and
strains, received a year or two before the disease made its
appearance.
The most frequent exciting cause of consumption is the alternate
application of heat and cold to the whole external surface of the
body; but all the remote causes which have been enumerated, operate as
exciting causes of consumption, when they act on previous debility.
Original injuries of the lungs seldom excite this disease, except they
first induce a debility of the whole system, by a troublesome and
obstinate cough.
2. From the debilitating occupations and habits of persons who are most
liable to this disease. These are studious men, and mechanics who lead
sedentary lives in confined places; also women, and all persons of
irritable habits, whether of body or mind.
3. From the period in which persons are most liable to be affected by
this disease. This is generally between the 18th and 36th year of life,
a period in which the system is liable, in a peculiar manner, to most
diseases which induce it, and in which there is a greater expenditure of
strength, than in any other stage of life, by the excessive exercises of
the body and mind, in the pursuits of business or pleasure.
I have conformed to authors, in fixing the period of consumptions
between the 18th and 36th year of life; but it is well known that it
sometimes appears in children, and frequently in persons beyond the
40th, or even 60th year of life.
II. The pulmonary consumption is a primary disease of the _whole_
system. This I infer,
1. From the causes which produce it, acting upon the whole system.
2. From the symptoms of general debility which always precede the
affection of the lungs. These symptoms are a quick pulse, especially
towards evening; a heat and burning in the palms of the hands;
faintness, head-ach, sickness at stomach, and an occasional diarrh[oe]a.
I have frequently observed each of these symptoms for several months
before I have heard of a single complaint in the breast.
3. From the pulmonary consumption alternating with other diseases which
obviously belong to the whole system. I shall briefly mention these
diseases.
The RHEUMATISM. I have seen many cases in which this disease and the
consumption have alternately, in different seasons or years, affected
the system. In the winter of 1792, three clinical patients in the
Pennsylvania hospital exemplified by their complaints the truth of this
observation. They were relieved several times of a cough by rheumatic
pains in their limbs, which seemed for a while to promise a cure to
their pulmonic complaints.
The GOUT has often been observed to alternate with the pulmonary
consumption, especially in persons in the decline of life. Dr. Sydenham
describes a short cough continuing through the whole winter, as a
symptom of gouty habits. A gentleman from Virginia died under my care in
the spring of 1788, in the 45th year of his age, with all the symptoms
of pulmonary consumption, which had frequently alternated with pains and
a swelling in his feet.
The pulmonary consumption has been observed to alternate with MADNESS.
Of this I have seen two instances, in both of which the cough and
expectoration were wholly suspended during the continuance of the
derangement of the mind. Dr. Mead mentions a melancholy case of the same
kind in a young lady, and similar cases are to be met with in other
authors. In all of them the disease proved fatal. In one of the cases
which came under my notice, the symptoms of consumption returned before
the death of the patient.
I have likewise witnessed two cases in which the return of reason after
madness, was suddenly succeeded by a fatal pulmonary consumption.
Perhaps the false hopes, and even the cheerfulness which so universally
occur in this disease, may be resolved into a morbid state of the mind,
produced by a general derangement of the whole system. So universal are
the delusion and hopes of patients, with respect to the nature and issue
of this disease, that I have never met with but one man, who, upon being
asked what was the matter with him, answered unequivocally, "that he was
in a consumption."
Again: Dr. Bennet mentions a case of "A phthisical patient, who was
seized with a violent PAIN IN THE TEETH for two days, and in whom,
during that time, every symptom of a consumption, except the leanness of
the body, altogether vanished:" and he adds further, "that a defluction
on the lungs had often been relieved by SALIVARY EVACUATIONS[20]."
[20] Treatise of the Nature and Cure of Consumptions. Exercitation X.
I have seen several instances in which the pulmonary symptoms have
alternated with HEADACH and DYSPEPSIA; also with pain and noise in one
EAR. This affection of the ears sometimes continues throughout the
whole disease, without any remission of the pulmonary symptoms. I have
seen one case of a discharge of matter from the left ear, without being
accompanied by either pain or noise.
In all our books of medicine are to be found cases of consumption
alternating with ERUPTIONS ON THE SKIN.
And who has not seen the pulmonary symptoms alternately relieved and
reproduced by the appearance or cessation of a diarrh[oe]a, or pains in
the BOWELS?
To these facts I shall only add, under this head, as a proof of the
consumption being a disease of the whole system, that it is always
more or less relieved by the change which is induced in the system by
pregnancy.
4. I infer that the pulmonary consumption is a disease of the whole
system from its analogy with several other diseases, which, though
accompanied by local affections, are obviously produced by a morbid
state of the whole system.
The rheumatism, the gout, the measles, small-pox, the different species
of cynanche, all furnish examples of the connection of local affections
with a general disease; but the APOPLEXY, and the PNEUMONY, furnish the
most striking analogies of local affection, succeeding a general disease
of the system in the pulmonary consumption.
The most frequent predisposing cause of apoplexy is a general debility
of the system, produced by intemperance in eating and drinking. The
phenomena of the disease are produced by an effusion of blood or serum,
in consequence of a morbid distension, or of a rupture of the vessels
of the brain. The pulmonary consumption begins and ends in the same
way, allowing only for the difference of situation and structure of the
brain and lungs. After the production of predisposing debility from
the action of the remote causes formerly enumerated, the fluids are
determined to the weakest part of the body. Hence effusions of serum
or blood take place in the lungs. When serum is effused, a pituitous
or purulent expectoration alone takes place; when blood is discharged,
a disease is produced which has been called hæmoptysis. An effusion of
blood in the brain, brought on by the operation of general debility,
has been called by Dr. Hoffman, with equal propriety, a hæmorrhage of
the brain. The effusion of blood in the lungs, in consequence of the
rupture of a blood-vessel, is less fatal than the same accident when it
occurs in the brain, only because the blood in the former case is more
easily discharged from the system. Where no rupture of a blood-vessel
is produced, death is nearly as speedy and certain in the one case as
in the other. Dissections show many cases of suffocation and death,
from the lungs being preternaturally filled with blood or serum. From
this great analogy between the remote and proximate causes of the two
diseases which have been described, I have taken the liberty to call
them both by the name of apoplexy. The only symptom which does not
accord with the derivation of the term, is, that in the apoplexy of the
lungs, the patient does not fall down as if by an external stroke, which
is most frequently the case in the apoplexy of the brain.
The history of the remote and proximate causes of pneumony will furnish
us with a still more remarkable analogy of the connection between a
_local_ affection, and a _general_ disease of the system. The pneumony
is produced by remote exciting causes which act on the whole system. The
whole arterial system is frequently agitated by a fever in this disease
before a pain is perceived in the breast or sides, and this fever
generally constitutes its strength and danger. The expectoration which
terminates the disease in health, is always the effect of effusions
produced by a general disease, and even the vomicas, which sometimes
succeed a deficiency of bleeding, always depend upon the same general
cause. From this view of the analogy between pneumony and pulmonary
consumption, it would seem that the two diseases differed from each
other only by the shorter or longer operation of the causes which
induce them, and by the greater or less violence and duration of their
symptoms. The pneumony appears to be an _acute_ consumption, and the
consumption a _chronic_ pneumony. From the analogy of the pulmonary
consumption with the diminutive term of certain fevers, I have taken the
liberty of calling it a PNEUMONICULA.
5. I infer that the pulmonary consumption is a disease of the whole
system, from its existence without ulcers in the lungs. Of this there
are many cases recorded in books of medicine.
Dr. Leigh informs us, in his Natural History of Lancashire, that the
consumption was a very common disease on the sea coast of that country;
but that it was not accompanied either by previous inflammation or
ulcers in the lungs. It was generally attended, he says, by an unusual
peevishness of temper.
6. I infer that the pulmonary consumption is a disease of the whole
system, from its being relieved, or cured, only by remedies which act
upon the whole system. This will appear, I hope, hereafter, when we come
to treat of the cure of this disease.
Let us now enquire how far the principles I have laid down will apply
to the supposed causes of consumption. These causes have been said to
be, an abscess in the lungs, hæmoptysis, tubercles, without and with
ulcers, catarrh, hereditary diathesis, contagion, and the matter of
cutaneous eruptions, or sores repelled, and thrown upon the lungs. I
shall make a few observations upon each of them.
1. An abscess in the lungs is generally the consequence of a neglected,
or half-cured pneumony. It is seldom fatal, where it is not connected
with a predisposition to consumption from general debility, or where
general debility is not previously induced by the want of appetite,
sleep, and exercise, which sometimes accompany that disease of the
lungs. This explanation of the production of consumption by an abscess
in the lungs, will receive further support from attending to the effects
of wounds in the lungs. How seldom are they followed by pulmonary
consumption; and this only because they are as seldom accompanied by
predisposing general debility. I do not recollect a single instance
of this disease having followed a wound in the lungs, either by the
bayonet, or a bullet, during our revolutionary war. The recoveries
which have succeeded such wounds, and frequently under the most
unfavourable circumstances, show how very improbable it is that a much
slighter affection of the lungs should become the cause of a pulmonary
consumption.
A British officer, whom I met in the British camp, a few days after
the battle of Brandywine, in September, 1777, informed me that the
surgeon-general of the royal army had assured him, that out of
twenty-four soldiers who had been admitted into the hospitals, during
the campaign of 1776, with wounds in their lungs, twenty-three of
them had recovered. Even primary diseases of the lungs often exist
with peculiar violence, or continue for many years without inducing a
consumption. I have never known but one instance of the whooping-cough
ending in consumption, and all our books of medicine contain records of
the asthma continuing for twenty and thirty years without terminating
in that disease. The reason in both cases, must be ascribed to those
two original diseases of the lungs not being accompanied by general
debility. One fact more will serve to throw still further light upon
the subject. Millers are much afflicted with a cough from floating
particles of flour constantly irritating their lungs, and yet they are
not more subject to consumptions than other labouring people. Hence "a
miller's cough" is proverbial in some places, to denote a cough of long
continuance without danger.
2. The hæmoptysis is either a local disease, or it is the effect
of general debility of the whole system. When it is local, or when
it is the effect of causes which induce a _temporary_ or _acute_
debility only in the system, it is seldom followed by consumption. The
accidental discharge of blood from the lungs, from injuries, and from
an obstruction of the menses in women is of this kind. Many persons are
affected by this species of hæmorrhage once or twice in their lives,
without suffering any inconvenience from it afterwards. I have met with
several cases in which it has occurred for many years every time the
body was exposed to any of the causes which induce _sudden_ debility,
and yet no consumption has followed it. The late king of Prussia
informed Dr. Zimmerman that he had been frequently attacked by it during
his seven years war, and yet he lived, notwithstanding, above twenty
years afterwards without any pulmonary complaints. It is only in persons
who labour under _chronic_ debility, that a hæmoptysis is necessarily
followed by consumption.
3. I yield to the popular mode of expression when I speak of a
consumption being produced by tubercles. But I maintain that they are
the _effects_ of general debility communicated to the bronchial vessels
which cause them to secrete a preternatural quantity of mucus. This
mucus is sometimes poured into the trachea from whence it is discharged
by hawking, more especially in the morning; for it is secreted more
copiously during the languid hours of sleep than in the day time. But
this mucus is frequently secreted into the substance of the lungs, where
it produces those tumours we call tubercles. When this occurs, there
is either no cough[21] or a very dry one. That tubercles are formed in
this way, I infer from the dissections and experiments of Dr. Stark[22],
who tells us, that he found them to consist of inorganic matter; that
he was unable to discover any connection between them and the pulmonary
vessels, by means of the microscope or injections; and that they first
opened into the trachea through the bronchial vessels. It is remarkable
that the colour and consistence of the matter of which they are
composed, is nearly the same as the matter which is discharged through
the trachea, in the moist cough which occurs from a relaxation of the
bronchial vessels, and which has been called by Dr. Beddoes a bronchial
gleet.
[21] See Med. Com. Vol. II.
[22] Clinical and Anatomical Observations, p. 26, 27. See also
Morgagni, letter xxii. 21.
I am aware that these tumours in the lungs have been ascribed to
scrophula. But the frequent occurrence of consumptions in persons
in whom no scrophulous taint existed, is sufficient to refute this
opinion. I have frequently directed my inquiries after this disease
in consumptive patients, and have met with very few cases which were
produced by it. It is probable that it may frequently be a predisposing
cause of consumption in Great Britain, but I am sure it is not in
the United States. Baron Humboldt informed me, that the scrophula is
unknown in Mexico, and yet consumptions, he said, are very common in
that part of North-America. That tubercles are the effects, and not the
cause of pulmonary consumption, is further evident from similar tumours
being suddenly formed on the intestines by the dysentery, and on the
omentum by a yellow fever. Cases of the former are to be met with in the
dissections of Sir John Pringle, and one of the latter is mentioned by
Dr. Mackittrick, in his inaugural dissertation upon the yellow fever,
published in Edinburgh in the year 1766[23].
[23] Pages 7, 8.
4. The catarrh is of two kinds, acute and chronic, both of which are
connected with general debility, but this debility is most obvious in
the chronic catarrh: hence we find it increased by every thing which
acts upon the whole system, such as cold and damp weather, fatigue, and,
above all, by old age, and relieved or cured by exercise, and every
thing else which invigorates the whole system. This species of catarrh
often continues for twenty or thirty years without inducing pulmonary
consumption, in persons who pursue active occupations.
5. In the hereditary consumption there is either a hereditary debility
of the whole system, or a hereditary mal-conformation of the breast. In
the latter case, the consumption is the effect of weakness communicated
to the whole system, by the long continuance of difficult respiration,
or of such injuries being done to the lungs as are incompatible with
health and life. It is remarkable, that the consumptive diathesis is
more frequently derived from paternal, than maternal ancestors.
6. Physicians, the most distinguished characters, have agreed, that
the pulmonary consumption may be communicated by contagion. Under the
influence of this belief, Morgagni informs us, that Valsalva, who was
predisposed to the consumption, constantly avoided being present at the
dissection of the lungs of persons who had died of that disease. In
some parts of Spain and Portugal, its contagious nature is so generally
believed, that cases of it are reported to the magistrates of those
countries, and the clothes of persons who die of it are burned by their
orders. The doctrine of nearly all diseases spreading by contagion,
required but a short and simple act of the mind, and favoured the
indolence and timidity which characterized the old school of medicine. I
adopted this opinion, with respect to the consumption, in the early part
of my life; but I have lately been led to call its truth in question,
especially in the unqualified manner in which it has been taught. In
most of the cases in which the disease has been said to be propagated
by contagion, its limits are always confined to the members of a single
family. Upon examination, I have found them to depend upon some one or
more of the following causes:
1. Mal-conformation of the breast, in all the branches of the diseased
family. It is not necessary that this organic predisposition should be
hereditary.
2. Upon the debility which is incurred by nursing, and the grief which
follows the loss of relations who die of it.
3. Upon some local cause undermining the constitutions of a whole
family. This may be exhalations from a foul cellar, a privy, or a
neighbouring mill-pond, but of so feeble a nature as to produce debility
only, with an acute fever, and thus to render the consumption a kind of
family epidemic. I was consulted, in the month of August, 1793, by a Mr.
Gale, of Maryland, in a pulmonary complaint. He informed me, that he had
lost several brothers and sisters with the consumption, and that none of
his ancestors had died of it. The deceased persons, five in number, had
lived in a place that had been subject to the intermitting fever.
4. Upon some peculiar and unwholesome article of diet, which exerts
slowly debilitating effects upon all the branches of a family.
5. Upon a fearful and debilitating apprehension entertained by the
surviving members of a family, in which one or two have died of
consumption, that they shall perish by the same disease. The effects
of all the passions, and especially of fear, acted upon by a lively
imagination, in inducing determinations to particular parts of the body,
and subsequent disease, are so numerous, as to leave no doubt of the
operation of this cause, in producing a number of successive deaths in
the same family, from pulmonary consumption.
In favour of its depending upon one or more of the above causes, I shall
add two remarks.
1. There is often an interval of from two to ten years, between the
sickness and deaths which occur in families from consumptions, and
this we know never takes place in any disease which is admitted to be
contagious.
2. The consumption is not singular in affecting several branches of
a family. I was lately consulted by a young physician from Maryland,
who informed me, that two of his brothers, in common with himself,
were afflicted with epilepsy. Madness, scrophula, and a disposition
to hæmorrhage, often affect, in succession, several branches of the
same family; and who will say that any one of the above diseases is
propagated by contagion?
The practice of the Spaniards and Portuguese, in burning the clothes
of persons who die of consumptions, no more proves the disease to be
contagious, than the same acts sanctioned by the advice or orders of
public bodies in the United States, establish the contagious nature of
the yellow fever. They are, in both countries, marks of the superstition
of medicine.
In suggesting these facts, and the inferences which have been drawn
from them, I do not mean to deny the possibility of the acrid and
f[oe]tid vapour, which is discharged by breathing from an ulcer or
abscess in the lungs, nor of the hectic sweats, when rendered putrid by
stagnating in sheets, or blankets, communicating this disease to persons
who are long exposed to them, by sleeping with consumptive patients;
but that such cases rarely occur I infer, from the persons affected
often living at a distance from each other, or when they live under the
same roof, having no intercourse with the sick. This was the case with
the black slaves, who were supposed to have taken the disease from the
white branches of a family in Connecticut, and which was mentioned, upon
the authority of Dr. Beardsley, in a former edition of this inquiry.
Admitting the above morbid matters now and then to act as a remote
cause of consumption, it does not militate against the theory I have
aimed to establish, for if it follow the analogy of common miasmata and
contagions, it must act by first debilitating the whole system. The
approach of the jail and bilious fevers is often indicated by general
languor. The influenza and the measles are always accompanied by general
debility, but the small-pox furnishes an analogy to the case in question
more directly in point. The contagion of this disease, whether received
by the medium of the air or the skin, never fails of producing weakness
in the whole system, before it discovers itself in affections of those
parts of the body on which the contagion produced its first operation.