hæmorrhage of a quart of blood from the lungs. I agreed at first with
the friends of these patients in expecting a rapid termination of
their disease in death, but to the joy and surprise of all connected
with them, they both recovered. I ascribed their recovery wholly to
the inflammatory action of their systems being suddenly reduced by a
spontaneous discharge of blood. These facts, I hope, will serve to
establish the usefulness of blood-letting in the inflammatory state of
consumption, with those physicians who are yet disposed to trust more to
the fortuitous operations of nature, than to the decisions of reason and
experience.
I have always found this remedy to be more necessary in the winter and
first spring months, than at any other season. We obtain by means of
repeated bleedings, such a mitigation of all the symptoms as enables the
patient to use exercise with advantage as soon as the weather becomes so
dry and settled, as to admit of his going abroad every day.
The relief obtained by bleeding, is so certain in this state of
consumption, that I often use it as a palliative remedy, where I do not
expect it will perform a cure. I was lately made happy in finding, that
I am not singular in this practice. Dr. Hamilton, of Lynn Regis, used it
with success in a consumption, which was the effect of a most deplorable
scrophula, without entertaining the least hope of its performing a
cure[26]. In those cases where inflammatory action attends the last
scene of the disease, there is often more relief obtained by a little
bleeding than by the use of opiates, and it is always a more humane
prescription, in desperate cases, than the usual remedies of vomits and
blisters.
[26] Observations on Scrophulous Affections.
I once bled a sea captain, whom I had declared to be within a few
hours of his dissolution, in order to relieve him of uncommon pain,
and difficulty in breathing. His pulse was at the same time hard. The
evacuation, though it consisted of but four ounces of blood, had the
wished for effect, and his death, I have reason to believe, was rendered
more easy by it. The blood, in this case, was covered with a buffy coat.
The quantity of blood drawn in every case of inflammatory consumption,
should be determined by the force of the pulse, and the habits of the
patient. I have seldom taken more than eight, but more frequently but
six ounces at a time. It is much better to repeat the bleeding once or
twice a week, than to use it less frequently, but in larger quantities.
From many years experience of the efficacy of bleeding in this state
of consumption, I feel myself authorised to assert, that where a
greater proportion of persons die of consumption when it makes its
first appearance in the lungs, with symptoms of inflammatory diathesis,
than die of ordinary pneumonies (provided exercise be used afterwards),
it must, in nine cases out of ten, be ascribed to the ignorance, or
erroneous theories of physicians, or to the obstinacy or timidity of
patients.
In speaking thus confidently of the necessity and benefits of bleeding
in the inflammatory state of consumption, I confine myself to
observations made chiefly in the state of Pennsylvania. It is possible
the inhabitants of European countries and cities, may so far have passed
the simple ages of inflammatory diseases, as never to exhibit those
symptoms on which I have founded the indication of blood-letting. I
suspect moreover that in most of the southern states of America, the
inflammatory action of the arterial system is of too transient a nature
to admit of the repeated bleedings in the consumption which are used
with so much advantage in the middle and northern states.
In reviewing the prejudices against this excellent remedy in
consumptions, I have frequently wished to discover such a substitute
for it as would with equal safety and certainty take down the morbid
excitement, and action of the arterial system. At present we know of no
such remedy; and until it be discovered, it becomes us to combat the
prejudices against bleeding; and to derive all the advantages from it
which have been mentioned.
2. A second remedy for the inflammatory state of consumption should
be sought for in a MILK and VEGETABLE DIET. In those cases where the
milk does not lie easy on the stomach, it should be mixed with water,
or it should be taken without its cheesy or oily parts, as in whey,
or butter-milk, or it should be taken without skimming; for there are
cases in which milk will agree with the stomach in this state, and in
no other. The oil of the milk probably helps to promote the solution of
its curds in the stomach. It is seldom in the power of physicians to
prescribe ass' or goat's milk in this disease; but a good substitute
may be prepared for them by adding to cow's milk a little sugar, and a
third or fourth part of water, or of a weak infusion of green tea. The
quantity of milk taken in a day should not exceed a pint, and even less
than that quantity when we wish to lessen the force of the pulse by the
abstraction of nourishment. The vegetables which are eaten in this state
of the disease, should contain as little stimulus as possible. Rice,
in all the ways in which it is usually prepared for aliment, should
be preferred to other grains, and the less saccharine fruits to those
which abound with sugar. In those cases where the stomach is disposed
to dyspepsia, a little salted meat, fish, or oysters, also soft boiled
eggs, may be taken with safety, mixed with vegetable aliment. Where
there is no morbid affection of the stomach, I have seen the white meats
eaten without increasing the inflammatory symptoms of the disease. The
transition from a full diet to milk and vegetables should be gradual,
and the addition of animal to vegetable aliment, should be made with the
same caution. From the neglect of this direction, much error, both in
theory and practice, has arisen in the treatment of consumptions.
In every case it will be better for the patient to eat four or five,
rather than but two or three meals in a day. A less stimulus is by this
means communicated to the system, and less chyle is mixed with the blood
in a given time. Of so much importance do I conceive this direction to
be, that I seldom prescribe for a chronic disease of any kind without
enforcing it.
3. VOMITS have been much commended by Dr. Read in this disease. From
their indiscriminate use in every state of consumption, I believe they
have oftener done harm than good. In cases where a patient objects to
bleeding, or where a physician doubts of its propriety, vomits may
always be substituted in its room with great advantage. They are said to
do most service when the disease is the effect of a catarrh.
4. NITRE, in moderate doses of ten or fifteen grains, taken three or
four times a day, has sometimes been useful in this disease; but it has
been only when the disease has appeared with inflammatory symptoms. Care
should be taken not to persevere too long in the use of this remedy,
as it is apt to impair the appetite. I have known one case in which it
produced an obstinate dyspepsia, and a disposition to the colic; but it
removed, at the same time, the symptoms of pulmonary consumption.
5. COLD and DRY AIR, when combined with the exercise of _walking_,
deserves to be mentioned as an antiphlogistic remedy. I have repeatedly
prescribed it in this species of the consumption with advantage, and
have often had the pleasure of finding a single walk of two or three
miles in a clear cold day, produce nearly the same diminution of the
force and frequency of the pulse, as the loss of six or eight ounces of
blood.
I come now to treat of the palliative remedies which are proper in the
II. Or HECTIC STATE of consumption. Here we begin to behold the disease
in a new and more distressing form than in the state which has been
described. There is in this state of consumption the same complication
of inflammatory and typhus diathesis which occurs in the typhoid and
puerperile fevers, and of course the same difficulty in treating it
successfully; for the same remedies do good and harm, according as the
former or latter diathesis prevails in the system.
All that I shall say upon this state is, that the treatment of it
should be accommodated to the predominance of inflammatory or typhus
symptoms, for the hectic state presents each of them alternately every
week, and sometimes every day to the hand, or eye of a physician. When a
hard pulse with acute pains in the side and breast occur, bleeding and
other remedies for the inflammatory state must be used; but when the
disease exhibits a predominance of typhus symptoms, the remedies for
that state to be mentioned immediately, should be prescribed in moderate
doses. There are several palliative medicines which have been found
useful in the hectic state, but they are such as belong alike to the
other two states; and therefore will be mentioned hereafter in a place
assigned to them.
I am sorry, however, to add, that where bleeding has not been indicated,
I have seldom been able to afford much relief by medicine in this
state of consumption. I have used alternately the most gentle, and
the most powerful vegetable and metallic tonics to no purpose. Even
arsenic has failed in my hands of affording the least alleviation of
the hectic fever. I conceive the removal of this fever to be the great
desideratum in the cure of consumption; and should it be found, after
all our researches, to exist only in exercise, it will be no departure
from a law of nature, for I believe there are no diseases produced by
equal degrees of chronic debility, in which medicines are of any more
efficacy, than they are in the hectic fever of the pulmonary consumption.
I proceed now to speak of the palliative remedies which are proper in the
III. Or TYPHUS STATE of the pulmonary consumption.
The first of these are STIMULATING MEDICINES. However just the
complaints of Dr. Fothergill may be against the use of balsams in the
inflammatory and mixed states of consumption, they appear to be not only
safe, but useful likewise, in mitigating the symptoms of weak morbid
action in the arterial system. I have therefore frequently prescribed
opium, the balsam of copaivæ, of Peru, the oil of amber, and different
preparations of turpentine and tar, in moderate doses, with obvious
advantage. Garlic, elixir of vitriol, the juice of dandelion, a strong
tea made of horehound, and a decoction of the inner bark of the wild
cherry tree[27], also bitters of all kinds, have all been found safe
and useful tonics in this state of consumption. Even the Peruvian bark
and the cold bath, so often and so generally condemned in consumptions,
are always innocent, and frequently active remedies, where there is
a total absence of inflammatory diathesis in this disease. The bark
is said to be most useful when the consumption is the consequence of
an intermitting fever, and when it occurs in old people. With these
remedies should be combined
2. A CORDIAL and STIMULATING DIET. Milk and vegetables, so proper
in the inflammatory, are improper, when taken alone, in this state of
consumption. I believe they often accelerate that decay of appetite
and diarrh[oe]a, which form the closing scene of the disease. I have
lately seen three persons recovered from the lowest stage of this
state of consumption, by the use of animal food and cordial drinks,
aided by frequent doses of opium, taken during the day as well as in
the night. I should hesitate in mentioning these cures, had they not
been witnessed by more than a hundred students of medicine in the
Pennsylvania hospital. The history of one of them is recorded in the 5th
volume of the New-York Medical Repository, and of the two others in Dr.
Coxe's Medical Museum. Oysters, it has been said, have performed cures
of consumption. If they have, it must have been only when they were
eaten in that state of it which is now under consideration. They are
a most savoury and wholesome article of diet, in all diseases of weak
morbid action. To the cordial articles of diet belong sweet vegetable
matters. Grapes, sweet apples, and the juice of the sugar maple tree,
when taken in large quantities, have all cured this disease. They all
appear to act by filling the blood-vessels, and thereby imparting tone
to the whole system. I have found the same advantage from dividing the
meals in this state of consumption, that I mentioned under a former
head. The exhibition of food in this case, should not be left to the
calls of appetite, any more than the exhibition of a medicine. Indeed
food may be made to supply the place of cordial medicines, by keeping
up a constant and gentle action in the whole system. For this reason,
I have frequently advised my patients never to suffer their stomachs
to be empty, even for a single hour. I have sometimes aimed to keep up
the influence of a gentle action in the stomach upon the whole system,
by advising them to eat in the night, in order to obviate the increase
of secretion into the lungs and of the cough in the morning, which are
brought on in part by the increase of debility from the long abstraction
of the stimulus of aliment during the night.
[27] Prunus Virginiana.
However safe, and even useful, the cordial medicines and diet that have
been mentioned may appear, yet I am sorry to add, that we seldom see any
other advantages from them than a mitigation of distressing symptoms,
except when they have been followed by suitable and long continued
exercise. Even under this favourable circumstance, they are often
ineffectual; for there frequently occurs, in this state of consumption,
such a destruction of the substance and functions of the lungs, as to
preclude the possibility of a recovery by the use of any of the remedies
which have been discovered. Perhaps, where this is not the case, their
want of efficacy may be occasioned by their being given before the
pulse is completely reduced to a typhus state. The weaker the pulse,
the greater is the probability of benefit being derived from the use of
cordial diet and medicines.
I have said formerly, that the three states of consumption do not
observe any regular course in succeeding each other. They are not only
complicated in some instances, but they often appear and disappear half
a dozen times in the course of the disease, according to the influence
of the weather, dress, diet, and the passions upon the system. The great
secret, therefore, of treating this disease consists in accommodating
all the remedies that have been mentioned to the predominance of any
of the three different states of the system, as manifested chiefly by
the pulse. It is in consequence of having observed the evils which
have resulted from the ignorance or neglect of this practice, that I
have sometimes wished that it were possible to abolish the seducing
nomenclature of diseases altogether, in order thereby to oblige
physicians to conform exactly to the fluctuating state of the system
in all their prescriptions; for it is not more certain, that, in all
cultivated languages, every idea has its appropriate word, than that
every state of a disease has its appropriate dose of medicine, the
knowledge and application of which can alone constitute rational, or
secure uniformly successful practice.
I come now to say a few words upon those palliative remedies which are
alike proper in every state of the pulmonary consumption.
The first remedy under this head is a DRY SITUATION. A damp air, whether
breathed in a room, or out of doors, is generally hurtful in every
form of this disease. A kitchen, or a bed-room, below the level of the
ground, has often produced, and never fails to increase, a pulmonary
consumption. I have often observed a peculiar paleness (the first
symptom of general debility) to show itself very early in the faces of
persons who work or sleep in cellar kitchens or shops.
2. COUNTRY AIR. The higher and drier the situation which is chosen
for the purpose of enjoying the benefit of this remedy, the better.
Situations exposed to the sea, should be carefully avoided; for it is
a singular fact, that while consumptive persons are benefited by the
sea-air, when they breathe it on the ocean, they are always injured by
that portion of it which they breathe on the sea-shore. To show its
influence, not only in aggravating consumptions, but in disposing to
them, and in adding to the mortality of another disease of the lungs, I
shall subjoin the following facts. From one fourth to one half of all
the adults who die in Great Britain, Dr. Willan says, perish with this
disease. In Salem, in the state of Massachusetts, which is situated
near the sea, and exposed, during many months in the year, to a moist
east wind, there died, in the year 1799, one hundred and sixty persons;
fifty-three died of the consumption, making in all nearly one third of
all the inhabitants of the town. Eight more died of what is called a
lung fever, probably of what is called in Pennsylvania the galloping
grade of that disease. Consumptions are more frequent in Boston,
Rhode-Island, and New-York, from their damp winds, and vicinity to
the sea-shore, than they are in Philadelphia. In the neighbourhood of
Cape May, which lies near the sea-shore of New-Jersey, there are three
religious societies, among whom the influenza prevailed in the year
1790. Its mortality, under equal circumstances, was in the exact ratio
to their vicinity to the sea. The deaths were most numerous in that
society which was nearest to it, and least so in that which was most
remote from it. These unfriendly effects of the sea air, in the above
pulmonary diseases, do not appear to be produced simply by its moisture.
Consumptions are scarcely known in the moist atmosphere which so
generally prevails in Lincolnshire, in England, and in the inland parts
of Holland and Ireland.
I shall not pause to inquire, why a mixture of land and sea air is so
hurtful in the consumption, and at the same time so agreeable to persons
in health, and so medicinal in many other diseases, but shall dismiss
this head by adding a fact which was communicated to me by Dr. Matthew
Irvine, of South-Carolina, and that is, That those situations which
are in the neighbourhood of bays or rivers, where the salt and fresh
waters mix their streams together, are more unfavourable to consumptive
patients than the sea-shore, and therefore should be more carefully
avoided by them in exchanging city for country air.
3. A CHANGE OF CLIMATE. It is remarkable that climates uniformly cold
or warm, which seldom produce consumptions, are generally fatal to
persons who visit them in that disease. Countries between the 30th and
40th degrees of latitude are most friendly to consumptive people.
4. LOOSE DRESSES, AND A CAREFUL ACCOMMODATION OF THEM TO THE CHANGES
IN THE WEATHER. Many facts might be mentioned to show the influence of
compression and of tight ligatures of every kind, upon the different
parts of the body; also of too much, or too little clothing, in
producing, or increasing diseases of every kind, more especially those
which affect the lungs. Tight stays, garters, waistbands, and collars,
should all be laid aside in the consumption, and the quality of the
clothing should be suited to the weather. A citizen of Maryland informed
me, that he twice had a return of a cough and spitting of blood, by
wearing his summer clothes a week after the weather became cool in the
month of September. But it is not sufficient to vary the weight or
quality of dress with the seasons. It should be varied with the changes
which take place in the temperature of the air every day, even in the
summer months, in middle latitudes. I know a citizen of Philadelphia,
who has laboured under a consumptive diathesis near thirty years, who
believes that he has lessened the frequency and violence of pulmonic
complaints during that time, by a careful accommodation of his dress to
the weather. He has been observed frequently to change his waistcoat and
small clothes twice or three times in a day, in a summer month.
A repetition of colds, and thereby an increase of the disease, will be
prevented by wearing flannel next to the skin in winter, and muslin in
the summer, either in the form of a shirt or a waistcoat: where these
are objected to, a piece of flannel, or of soft sheepskin, should be
worn next to the breast. They not only prevent colds, but frequently
remove chronic pains from that part of the body.
5. ARTIFICIAL EVACUATIONS, by means of BLISTERS and ISSUES. I suspect
the usefulness of these remedies to be chiefly confined to the
inflammatory and hectic states of consumption. In the typhus state, the
system is too weak to sustain the discharges of either of them. Fresh
blisters should be preferred to such as are perpetual, and the issues,
to be useful, should be large. They are supposed to afford relief by
diverting a preternatural secretion and excretion of mucus or pus from
the lungs, to an artificial emunctory in a less vital part of the
body. Blisters do most service when the disease arises from repelled
eruptions, and when they are applied between the shoulders, and the
upper and internal parts of the arms. When it arises from rheumatism
and gout, the blisters should be applied to the joints, and such other
external parts of the body as had been previously affected by those
diseases.
6. Certain FUMIGATIONS and VAPOURS. An accidental cure of a pulmonary
affection by the smoke of rosin, in a man who bottled liquors, raised
for a while the credit of fumigations. I have tried them, but without
much permanent effect. I think I have seen the pain in the breast
relieved by receiving the vapour from a mixture of equal parts of tar,
bran, and boiling water into the lungs. The sulphureous and saline air
of Stabiæ, between Mount Vesuvius and the Mediterranean Sea, and the
effluvia of the pine forests of Lybia, were supposed, in ancient times,
to be powerful remedies in consumptive complaints; but it is probable,
the exercise used in travelling to those countries, contributed chiefly
to the cures which were ascribed to foreign matters acting upon the
lungs.
7. LOZENGES, SYRUPS, and DEMULCENT TEAS. These are too common and too
numerous to be mentioned.
8. OPIATES. It is a mistake in practice, founded upon a partial
knowledge of the qualities of opium, to administer it only at night,
or to suppose that its effects in composing a cough depend upon its
inducing sleep. It should be given in small doses during the day, as
well as in larger ones at night. The dose should be proportioned to the
degrees of action in the arterial system. The less this action, the more
opium may be taken with safety and advantage.
9. DIFFERENT POSITIONS OF THE BODY have been found to be more or less
favourable to the abatement of the cough. These positions should be
carefully sought for, and the body kept in that which procures the
most freedom from coughing. I have heard of an instance in which a
cough, which threatened a return of the hæmorrhage from the lungs, was
perfectly composed for two weeks, by keeping the patient nearly in
one posture in bed; but I have known more cases in which relief from
coughing was to be obtained only by an erect posture of the body.
10. Considerable relief will often be obtained from the patient's
SLEEPING BETWEEN BLANKETS in winter, and on a MATTRASS in summer. The
former prevent fresh cold from night sweats; the latter frequently checks
them altogether. In cases where a sufficient weight of blankets to keep
up an agreeable warmth cannot be borne, without restraining easy and full
acts of inspiration, the patient should sleep under a light feather bed,
or an eider down coverlet. They both afford more warmth than double or
treble their weight of blankets.
However comfortable this mode of producing warmth in bed may be, it does
not protect the lungs from the morbid effects of the distant points of
temperature of a warm parlour in the day time, and a cold bed-chamber
at night. To produce an equable temperature of air at all hours, I have
frequently advised my patients, when going to a warm climate was not
practicable, to pass their nights as well as days in an open stove room,
in which nearly the same degrees of heat were kept up at all hours. I
have found this practice, in several cases, a tolerable substitute for a
warm climate.