repelled, or suddenly healed, have in some cases fallen upon the lungs,
and produced consumption. But I believe, in every case where this has
happened, the consumption was preceded by general debility, or that it
was not induced, until the whole system had been previously debilitated
by a tedious and distressing cough.
If the reasonings founded upon the facts which have been mentioned be
just, then it follows,
III. That the abscess, cough, tubercles, ulcers, and purulent or bloody
discharges which occur in the pulmonary consumption, are the _effects_,
and not the _causes_ of the disease; and, that all attempts to cure
it, by inquiring after tubercles and ulcers, or into the quality of
the discharges from the lungs, are as fruitless as an attempt would be
to discover the causes or cure of dropsies, by an examination of the
qualities of collections of water, or to find out the causes and cure of
fevers, by the quantity or quality of the discharges which take place
in those diseases from the kidneys and skin. It is to be lamented, that
it is not in pulmonary consumption only, that the effects of a disease
have been mistaken for its cause. Water in the brain, a membrane in
the trachea, and a preternatural secretion of bile, have been accused
of producing hydrocephalus internus, cynanche trachealis, and bilious
fever, whereas we now know they are the _effects_ of those diseases
only, in the successive order in which each of them has been mentioned.
It is high time to harness the steeds which drag the car of medicine
before, instead of behind it. The earth, in our science, has stood
still long enough. Let us at last believe, it revolves round its sun.
I admit that the cough, tubercles, and ulcers, after they are formed,
increase the danger of a consumption, by becoming new causes of stimulus
to the system, but in this they are upon a footing with the water,
the membrane, and the bile that have been alluded to, which, though
they constitute no part of the diseases that produce them, frequently
induce symptoms, and a termination of them, wholly unconnected with the
original disease.
The tendency of general debility to produce a disease of the lungs
appears in many cases, as well as in the pulmonary consumption. Dr. Lind
tells us, that the last stage of the jail fever was often marked by a
cough. I have seldom been disappointed in looking for a cough and a
copious excretion of mucus and phlegm after the 14th or 15th days of the
slow nervous fever. Two cases of hypochondriasis under my care, ended
in fatal diseases of the lungs. The debility of old age is generally
accompanied by a troublesome cough, and the debility which precedes
death, generally discovers its last symptoms in the lungs. Hence most
people die with what are called the _rattles_. They are produced by a
sudden and copious effusion of mucus in the bronchial vessels of the
lungs.
Sometimes the whole force of the consumptive fever falls upon the
trachea instead of the lungs, producing in it defluxion, a hawking
of blood, and occasionally a considerable discharge of blood, which
are often followed by ulcers, and a spitting of pus. I have called it
a _tracheal_, instead of a pulmonary consumption. Many people pass
through a long life with a mucous defluxion upon the trachea, and enjoy
in other respects tolerable health. In such persons the disease is of
a local nature. It is only when it is accompanied with debility of
the whole system, that it ends in a consumption. Mr. John Harrison,
of the Northern Liberties, died of this disease under my care, in the
year 1801, in consequence of the discharge of pus from an ulcer which
followed a hæmorrhage from the trachea being suddenly suppressed. I
have seen another case of the same kind in a lady in this city, in the
year 1797. Dr. Spence, of Dumfries, in Virginia, in a letter which I
received from him in June, 1805, describes a case then under his care,
of this form of consumption. He calls it, very properly, "phthisis
trachealis." I have met with two cases of death from this disease, in
which there were tubercles in the trachea. The patients breathed with
great difficulty, and spoke only in a whisper. One of them died from
suffocation. In the other, the tubercle bursted a few days before his
death, and discharged a large quantity of f[oe]tid matter.
Should it be asked, why does general debility terminate by a disease
in the lungs and trachea, rather than in any other part of the body? I
answer, that it seems to be a law of the system, that general debility
should always produce some local disease. This local disease sometimes
manifests itself in dyspepsia, as in the general debility which follows
grief; sometimes it discovers itself in a diarrh[oe]a, as in the general
debility which succeeds to fear. Again it appears in the brain, as in
the general debility which succeeds intemperance, and the constant or
violent exercise of the understanding, or of stimulating passions; but
it more frequently appears in the lungs, as the consequence of general
debility. It would seem as if the debility in the cases of consumption
is seated chiefly in the blood-vessels, while that debility which
terminates in diseases of the stomach and bowels, is confined chiefly
to the nerves, and that the local affections of the brain arise from a
debility, invading alike the nervous and arterial systems. What makes it
more probable that the arterial system is _materially_ affected in the
consumption is, that the disease most frequently occurs in those periods
of life, and in those habits in which a peculiar state of irritability
or excitability is supposed to be present in the arterial system; also
in those climates in which there are the most frequent vicissitudes in
the temperature of the weather. It has been observed, that the debility
in the inhabitants of the West-Indies, whether produced by the heat of
the climate or the excessive pursuits of business or pleasure, generally
terminates in dropsy, or in some disease of the alimentary canal.
I have said, that it seemed to be a law of the system, that general
debility should always produce some local affection. But to this law
there are sometimes exceptions: the atrophy appears to be a consumption
without an affection of the lungs. This disease is frequently mentioned
by the writers of the 16th and 17th centuries by the name of tabes. I
have seen several instances of it in adults, but more in children, and
a greater number in the children of black than of white parents. The
hectic fever, and even the night sweats, were as obvious in several
of these cases, as in those consumptions where general debility had
discovered itself in an affection of the lungs.
I come now to make a few observations upon the CURE of consumption;
and here I hope it will appear, that the theory which I have delivered
admits of an early and very important application to practice.
If the consumption be preceded by general debility, it becomes us to
attempt the cure of it before it produce the active symptoms of cough,
bloody or purulent discharges from the lungs, and inflammatory or
hectic fever. The symptoms which mark its first stage, are too seldom
observed; or if observed, they are too often treated with equal neglect
by patients and physicians. I shall briefly enumerate these symptoms.
They are a slight fever increased by the least exercise; a burning and
dryness in the palms of the hands, more especially towards evening;
rheumy eyes upon waking from sleep; an increase of urine; a dryness of
the skin, more especially of the feet in the morning[24]; an occasional
flushing in one, and sometimes in both cheeks; a hoarseness[25]; a
slight or acute pain in the breast; a fixed pain in one side, or
shooting pains in both sides; head-ache; occasional sick and fainty
fits; a deficiency of appetite, and a general indisposition to exercise
or motion of every kind.
[24] The three last-mentioned symptoms are taken notice of by Dr.
Bennet, in his Treatise upon the Nature and Cure of the
Consumption, as _precursors_ of the disease. Dr. Boerhaave used
to tell his pupils that they had never deceived him.
[25] I have seen the _hoarseness_ in one case the first symptom of
approaching consumption. In this symptom it preserves the
analogy of pneumony, which often comes on with a hoarseness, and
sometimes with paraphonia.
It would be easy for me to mention cases in which every symptom that
has been enumerated has occurred within my own observation. I wish them
to be committed to memory by young practitioners; and if they derive the
same advantages from attending to them, which I have done, I am sure
they will not regret the trouble they have taken for that purpose. It
is probable, while a morbid state of the lungs is supposed to be the
proximate cause of this disease, they will not derive much reputation or
emolument from curing it in its forming stage; but let them remember,
that in all attempts to discover the causes and cures of diseases, which
have been deemed incurable, a physician will do nothing effectual until
he acquire a perfect indifference to his own interest and fame.
The remedies for consumption, in this stage of the disease, are simple
and certain. They consist in a desertion of all the remote and exciting
causes of the disorder, particularly sedentary employments, damp or cold
situations, and whatever tends to weaken the system. When the disease
has not yielded to this desertion of its remote and exciting causes,
I have recommended the _cold bath_, _steel_, and _bark_ with great
advantage. However improper, or even dangerous, these remedies may be
after the disease assumes an inflammatory or hectic type, and produces
an affection of the lungs, they are perfectly safe and extremely useful
in the state of the system which has been described. The use of the bark
will readily be admitted by all those practitioners who believe the
pulmonary consumption to depend upon a scrophulous diathesis. Should
even the lungs be affected by scrophulous tumours, it is no objection
to the use of the bark, for there is no reason why it should not be
as useful in scrophulous tumours of the lungs, as of the glands of
the throat, provided it be given before those tumours have produced
inflammation; and in this case, no prudent practitioner will ever
prescribe it in scrophula, when seated even in the external parts of the
body. To these remedies should be added a diet moderately stimulating,
and gentle exercise. I shall hereafter mention the different species of
exercise, and the manner in which each of them should be used, so as
to derive the utmost advantage from them. I can say nothing of the use
of salt water or sea air in this stage of the consumption, from my own
experience. I have heard them commended by a physician of Rhode-Island;
and if they be used before the disease has discovered itself in
pulmonary affections, I can easily conceive they may do service.
If the simple remedies which have been mentioned have been neglected, in
the first stage of the disease, it generally terminates, in different
periods of time, in pulmonary affections, which show themselves under
one of the three following forms:
1. A fever, accompanied by a cough, a hard pulse, and a discharge of
blood, or mucous matter from the lungs.
2. A fever of the hectic kind, accompanied by chilly fits, and night
sweats, and a pulse full, quick, and occasionally hard. The discharges
from the lungs, in this state of the disease, are frequently purulent.
3. A fever with a weak frequent pulse, a troublesome cough, and copious
purulent discharges from the lungs, a hoarse and weak voice, and chilly
fits and night sweats alternating with a diarrh[oe]a.
From this short history of the symptoms of pulmonary consumption there
are occasional deviations. I have seen four cases, in which the pulse
was natural, or slower than natural, to the last day of life. Mrs.
Rebecca Smith, the lovely and accomplished wife of Mr. Robert Smith,
of this city, passed through the whole course of this disease, in the
year 1802, without a single chilly fit. Two other cases have come under
my notice, in which there was not only an absence of chills, but of
fever and night sweats. A similar case is recorded in the Memoirs of
the Medical Society of London; and lastly, I have seen two cases which
terminated fatally, in which there was neither cough nor fever for
several months. One of them was in Miss Mary Loxley, the daughter of
the late Mr. Benjamin Loxley, in the year 1785. She had complained of
a pain in her right side, and had frequent chills with a fever of the
hectic kind. They all gave way to frequent and gentle bleedings. In the
summer of 1786, she was seized with the same complaints, and as she had
great objections to bleeding, she consulted a physician who gratified
her, by attempting to cure her by recommending exercise and country air.
In the autumn she returned to the city, much worse than when she left
it. I was again sent for, and found her confined to her bed with a pain
in her right side, but without the least cough or fever. Her pulse was
preternaturally slow. She could lie only on her left side. She sometimes
complained of acute flying pains in her head, bowels, and limbs. About
a month before her death, which was on the 3d of May, 1787, her pulse
became quick, and she had a little hecking cough, but without any
discharge from her lungs. Upon my first visit to her in the preceding
autumn, I told her friends that I believed she had an abscess in her
lungs. The want of fever and cough afterwards, however, gave me reason
to suspect that I had been mistaken. The morning after her death, I
received a message from her father, informing me that it had been among
the last requests of his daughter, that the cause of her death should be
ascertained, by my opening her body. I complied with this request, and,
in company with Dr. Hall, examined her thorax. We found the left lobe
of the lungs perfectly sound; the right lobe adhered to the pleura, in
separating of which, Dr. Hall plunged his hand into a large sac, which
contained about half a pint of purulent matter, and which had nearly
destroyed the whole substance of the right lobe of the lungs.
I have never seen a dry tongue in any of the forms or stages of this
disease.
The three different forms of the pulmonary affection that I have
mentioned, have been distinguished by the names of the first, second,
and third stages of the consumption; but as they do not always succeed
each other in the order in which they have been mentioned, I shall
consider them as different states of the system.
The first I shall call the INFLAMMATORY, the second the HECTIC, and the
third the TYPHUS state. I have seen the pulmonary consumption come on
sometimes with all the symptoms of the second, and sometimes with most
of the symptoms of the third state; and I have seen two cases in which
a hard pulse, and other symptoms of inflammatory action, appeared in
the last hours of life. It is agreeable to pursue the analogy of this
disease with a pneumony, or an acute inflammation of the lungs. They
both make their first appearance in the same seasons of the year. It is
true, the pneumony most frequently attacks with inflammatory symptoms;
but it sometimes occurs with symptoms which forbid blood-letting, and
I have more than once seen it attended by symptoms which required the
use of wine and bark. The pneumony is attended at first by a dry cough,
and an expectoration of streaks of blood; the cough in the consumption,
in like manner, is at first dry, and attended by a discharge of blood
from the lungs, which is more copious than in the pneumony, only because
the lungs are more relaxed in the former than in the latter disease.
There are cases of pneumony in which no cough attends. I have just now
mentioned that I had seen the absence of that symptom in pulmonary
consumption.
The pneumony terminates in different periods, according to the degrees
of inflammation, or the nature of the effusions which take place in the
lungs: the same observation applies to the pulmonary consumption. The
symptoms of the different forms of pneumony frequently run into each
other; so do the symptoms of the three forms of consumption which have
been mentioned. In short, the pneumony and consumption are alike in
so many particulars, that they appear to resemble shadows of the same
substance. They differ only as the protracted shadow of the evening does
from that of the noon-day sun.
I know that it will be objected here that the consumption is sometimes
produced by scrophula, and that this creates an essential difference
between it and pneumony. I formerly admitted scrophula to be one of
the _remote_ causes of the consumption; but this does not invalidate
the parallel which has been given of the two diseases. The phenomena
produced in the lungs are the same as to their nature, whether they be
produced by the remote cause of scrophula, or by the sudden action of
cold and heat upon them.
No more happens in the cases of acute and chronic pneumony, than what
happens in dysentery and rheumatism. These two last diseases are for
the most part so acute, as to confine the patient to his bed or his
room, yet we often meet with both of them in patients who go about their
ordinary business, and, in some instances, carry their diseases with
them for two or three years.
The parallel which has been drawn between the pneumony and
consumption, will enable us to understand the reason why the latter
disease terminates in such different periods of time. The less it
partakes of pneumony, the longer it continues, and vice versa. What
is commonly called in this country a _galloping_ consumption, is a
disease compounded of different degrees of consumption and pneumony. It
terminates frequently in two or three months, and without many of the
symptoms which usually attend the last stage of pulmonary consumption.
But there are cases in which patients in a consumption are suddenly
snatched away by an attack of pneumony. I have met with one case only,
in which, contrary to my expectation, the patient mended after an
attack of an acute inflammation of the lungs, so as to live two years
afterwards.
It would seem from these facts, as if nature had preferred a certain
gradation in diseases, as well as in other parts of her works. There is
scarcely a disease in which there is not a certain number of grades,
which mark the distance between health and the lowest specific deviation
from it. Each of these grades has received different names, and has
been considered as a distinct disease, but more accurate surveys of the
animal economy have taught us, that they frequently depend upon the same
original causes, and that they are only greater or less degrees of the
same disease.
I shall now proceed to say a few words upon the cure of the different
states of pulmonary consumption. The remedies for this purpose are
of two kinds, viz. PALLIATIVE and RADICAL. I shall first mention the
palliative remedies which belong to each state, and then mention those
which are alike proper in them all. The palliative remedies for the
I. Or INFLAMMATORY STATE, are
I. BLOOD-LETTING. It may seem strange to recommend this debilitating
remedy in a disease brought on by debility. Were it proper in this
place, I could prove that there is no disease in which bleeding is
prescribed, which is not induced by predisposing debility, in common
with the pulmonary consumption. I shall only remark here, that in
consequence of the exciting cause acting upon the system (rendered
extremely excitable by debility) such a morbid and excessive excitement
is produced in the arteries, as to render a diminution of the stimulus
of the blood absolutely necessary to reduce it. I have used this remedy
with great success, in every case of consumption attended by a hard
pulse, or a pulse rendered weak by a laborious transmission of the blood
through the lungs. In the months of February and March, in the year
1781, I bled a Methodist minister, who was affected by this state of
consumption, fifteen times in the course of six weeks. The quantity of
blood drawn at each bleeding was never less than eight ounces, and it
was at all times covered with an inflammatory crust. By the addition of
country air, and moderate exercise, to this copious evacuation, in the
ensuing spring he recovered his health so perfectly, as to discharge all
the duties of his profession for many years, nor was he ever afflicted
afterwards with a disease in his breast. I have, in another instance,
bled a citizen of Philadelphia eight times in two weeks, in this state
of consumption, and with the happiest effects. The blood drawn at each
bleeding was always sizy, and never less in quantity than ten ounces.
Mr. Tracey of Connecticut informed me, in the spring of 1802, that
he had been bled eighty-five times in six months, by order of his
physician, Dr. Sheldon, in the inflammatory state of this disease. He
ascribed his recovery chiefly to this frequent use of the lancet. To
these cases I might add many others of consumptive persons who have
been perfectly cured by frequent, and of many others whose lives have
been prolonged by occasional bleedings. But I am sorry to add, that I
could relate many more cases of consumptive patients, who have died
martyrs to their prejudices against the use of this invaluable remedy.
A common objection to it is, that it has been used without success in
this disease. When this has been the case, I suspect that it has been
used in one of the other two states of pulmonary consumption which have
been mentioned, for it has unfortunately been too fashionable among
physicians to prescribe the same remedies in every stage and form of the
same disease, and this I take to be the reason why the same medicines,
which, in the hands of some physicians, are either inert or instruments
of mischief, are, in the hands of others, used with more or less
success in every case in which they are prescribed. Another objection
to bleeding in the inflammatory state of consumption, is derived from
the apparent and even sensible weakness of the patient. The men who
urge this objection, do not hesitate to take from sixty to a hundred
ounces of blood from a patient in a pneumony, in the course of five or
six days, without considering that the debility in the latter case is
such as to confine a patient to his bed, while, in the former case, the
patient's strength is such as to enable him to walk about his house,
and even to attend to his ordinary business. The difference between the
debility in the two diseases, consists in its being _acute_ in the one,
and _chronic_ in the other. It is true, the preternatural or convulsive
excitement of the arteries is somewhat greater in the pneumony, than in
the inflammatory consumption; but the plethora, on which the necessity
of bleeding is partly founded, is certainly greater in the inflammatory
consumption than in pneumony. This is evident from women, and even
nurses, discharging from four to six ounces of menstrual blood every
month, while they are labouring with the most inflammatory symptoms
of the disease; nor is it to be wondered at, since the appetite is
frequently unimpaired, and the generation of blood continues to be the
same as in perfect health.
Dr. Cullen recommends the use of bleeding in consumptions, in order
to lessen the inflammation of the ulcers in the lungs, and thereby to
dispose them to heal. From the testimonies of the relief which bleeding
affords in external ulcers and tumours accompanied by inflammation,
I am disposed to expect the same benefit from it in inflamed ulcers
and tumours in the lungs: whether, therefore, we adopt Dr. Cullen's
theory of consumption, and treat it as a local disease, or assent to
the one which I have delivered, repeated bleedings appear to be equally
necessary and useful.