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.
I have seen two cases of inflammatory consumption, attended by a 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 beingsuddenly 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 caseswhere 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.
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 myselfauthorised 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 morbidexcitement, 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 aMILKandVEGETABLE 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 inwhich 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.Vomitshave been much commended by Dr. Read in this disease. From their indiscriminate use in every state of consumption, I believethey 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.ColdandDRY AIR, when combined with the exercise ofwalking, 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. OrHECTIC STATEof 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 aresuch 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. OrTYPHUS STATEof the pulmonary consumption.
The first of these areSTIMULATING 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. ACORDIALandSTIMULATING DIET. Milk and vegetables, so proper in the inflammatory, areimproper, when taken alone, in this state of consumption. I believe they often accelerate that decay of appetite and diarrhœa, 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 formerhead. 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.
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 useof 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 ideahas 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 aDRY 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 injuredby 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 theabove 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. ACHANGE 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 ofBLISTERSandISSUES. 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 externalparts of the body as had been previously affected by those diseases.
6. CertainFUMIGATIONSandVAPOURS. 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, andDEMULCENT 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 uponits 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 bodyhave 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'sSLEEPING BETWEEN BLANKETSin winter, and on aMATTRASS[** sic] 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.
11. TheMODERATEuse of the lungs, inREADING,PUBLIC SPEAKING,LAUGHING, andSINGING. The lungs, when debilitated, derive equal benefit with the limbs, or other parts of the body, from moderate exercise. I have mentioned, in another place[28], several facts which support this opinion.But too much pains cannot be taken to inculcate upon our patients to avoid allexcessin the use of the lungs, bylong, orloudreading, speaking, or singing, or by sudden and violentburstsof laughter. I shall long lament the death of a female patient, who had discovered many hopeful signs of a recovery from a consumption, who relapsed, and died, in consequence of bursting a blood-vessel in her lungs, by a sudden fit of laughter.
12. Are there any advantages to be derived from the excitement of certainPASSIONSin the treatment of consumptions? Dr. Blane tells us, that many consumptive persons were relieved, and that some recovered, in consequence of the terror which was excited by a hurricane in Barbadoes, in the year 1780. It will be difficult to imitate, by artificial means, the accidental cures which are recorded by Dr. Blane; but we learn enough from them to inspire the invigorating passions of hope and confidence in the minds of our patients, and to recommend to them such exercises as produce exertions of body and mind analogous to those which are produced by terror. Van Sweiten and Smollet relate cures of consumptions, by patients falling into streams of cold water. Perhaps, in both instances, the cures were performed onlyby the fright and consequent exertion produced by the fall. This is only one instance out of many which might be mentioned, of partial and unequal action being suddenly changed into general and equal excitement in every part of the system. The cures of consumptions which have been performed by a camp life[29], have probably been much assisted by the commotions in the passions which were excited by the various and changing events of war.
13. ASALIVATIONhas lately been prescribed in this disease with success. An accident first suggested its advantages, in the Pennsylvania hospital, in the year 1800[30]. Since that time, it has performed many cures in different parts of the United States. It is to be lamented, that in a majority of the cases in which the mercury has been given, it has failed of exciting a salivation. Where it affects the mouth, it generally succeeds in recent cases, which is more than can be said of any, or of all other remedies in this disease. In its hectic state, a salivation frequently cures, and even in its typhus and last stage, I have more than once prescribed it with success. The same regard to the pulse should regulate the use of this new remedyin consumption, that has been recommended in other febrile diseases. It should never be advised until the inflammatory diathesis of the system has been in a great degree reduced, by the depleting remedies formerly mentioned.
During the use of the above remedies, great care should be taken to relieve the patient from the influence of all those debilitating and irritating causes which induced the disease. I shall say elsewhere that decayed teeth are one of them. These should be extracted where there is reason to suspect they have produced, or that they increase the disease.
I have hitherto said nothing of the digitalis as a palliative remedy in pulmonary consumption. I am sorry to acknowledge that, in many cases in which I have prescribed it, it has done no good, and in some it has done harm. From the opposite accounts of physicians of the most respectable characters of the effects of this medicine, I have been inclined to ascribe its different issues, to a difference in the soil in which it has been cultivated, or in the times of gathering, or in the manner of preparing it, all of which we know influence the qualities of many other vegetables. If the theory of consumption which I have endeavoured to establish be admitted, that uncertain and unsafe medicinewill be rendered unnecessary by the remedies that have been enumerated, provided they are administered at the times, and in the manner that has been recommended.
Before I proceed to speak of the radical cure of the consumption, it will be necessary to observe, that by means of the palliative remedies which have been mentioned, many persons have been recovered, and some have had their lives prolonged by them for many years; but in most of these cases I have found, upon inquiry, that the disease recurred as soon as the patient left off the use of his remedies, unless they were followed by necessary or voluntary exercise.
It is truly surprising to observe how long some persons have lived who have been affected by a consumptive diathesis, and by frequent attacks of many of the most troublesome symptoms of this disease. Van Sweiten mentions the case of a man, who had lived thirty years in this state. Morton relates the history of a man, in whom the symptoms of consumption appeared with but little variation or abatement from his early youth till the 70th year of his age. The widow of the celebrated Senac lived to be 84 years of age, thirty of which she passed in a pulmonary consumption. Dr. Nicolswas subject to occasional attacks of this disease during his whole life, and he lived to be above eighty years of age. Bennet says he knew an instance in which it continued above sixty years. I prescribed for my first pupil, Dr. Edwards, in a consumption in the year 1769. He lived until 1802, and seldom passed a year without spitting blood, nor a week without a cough, during that long interval of time. The fatal tendency of his disease was constantly opposed by occasional blood-letting, rural exercises, a cordial, but temperate diet, the Peruvian bark, two sea voyages, and travelling in foreign countries. There are besides these instances of long protracted consumptions, cases of it which appear in childhood, and continue for many years. I have seldom known them prove fatal under puberty.
I am led here to mention another instance of the analogy between pneumony and the pulmonary consumption. We often see the same frequency of recurrence of both diseases in habits which are predisposed to them. I have attended a German citizen of Philadelphia, in several fits of the pneumony, who has been confined to his bed eight-and-twenty times, by the same disease, in the course of the same number of years. He has, for the most part, enjoyed good health in the intervalsof those attacks, and always appeared, till lately, to possess a good constitution. In the cases of the frequent recurrence of pneumony, no one has suspected the disease to have originated exclusively in a morbid state of the lungs; on the contrary, it appears evidently to be produced by thesuddeninfluence of the same causes, which, by acting with less force, and for alongertime, produce the pulmonary consumption. The name of pneumony is taken from the principal symptom of this disease, but it as certainly belongs to the whole arterial system as the consumption; and I add further, that it is as certainly produced by general predisposing debility. The hardness and fulness of the pulse do not militate against this assertion, for they are altogether the effects of a morbid and convulsive excitement of the sanguiferous system. The strength manifested by the pulse is moreover partial, for every other part of the body discovers, at the same time, signs of extreme debility.
It would be easy, by pursuing this subject a little further, to mention a number of facts which, by the aid of principles in physiology and pathology, which are universally admitted, would open to us a new theory of fevers, but this would lead us too far from the subject before us. I shall only remark, that all that has been said of theinfluence ofgeneraldebilitating causes upon the lungs, both in pneumony and consumption, and of the alternation of the consumption with other general diseases, will receive great support from considering the lungs only as a part of the whole external surface of the body, upon which most of the remote and exciting causes of both diseases produce their first effects. This extent of the surface of the body, not only to the lungs, but to the alimentary canal, was first taken notice of by Dr. Boerhaave; but was unhappily neglected by him in his theories of the diseases of the lungs and bowels. Dr. Keil supposes that the lungs, from the peculiar structure of the bronchial vessels, and air vesicles, expose a surface to the action of the air, equal to the extent of the whole external and visible surface of the body.
Thus have I mentioned the usual palliative remedies for the consumption. Many of these remedies, under certain circumstances, I have said have cured the disease, but I suspect that most of these cures have taken place only when the disease has partaken of an intermediate nature between a pneumony and a true pulmonary consumption. Such connecting shades, appear between the extreme points of many other diseases. In a formeressay[31], I endeavoured to account for the transmutation (if I may be allowed the expression) of the pneumony into the consumption, by ascribing it to the increase of the debilitating refinements of civilized life. This opinion has derived constant support from every observation I have made connected with this subject, since its first publication, in the year 1772.
I come now to treat of theRADICAL REMEDIESfor the pulmonary consumption.
In an essay formerly alluded to[32], I mentioned the effects of labour, and the hardships of a camp or naval life, upon this disease. As there must frequently occur such objections to each of those remedies, as to forbid their being recommended or adopted, it will be necessary to seek for substitutes for them in the different species of exercise. These are,active,passive, andmixed. Theactiveincludes walking, and the exercise of the hands and feet in working or dancing. Thepassiveincludes rocking in a cradle, swinging, sailing, and ridingin carriages of different kinds. Themixedis confined chiefly to riding on horseback.
I have mentioned all the different species of exercise, not because I think they all belong to the class of radical remedies for the consumption, but because it is often necessary to use those which are passive, before we recommend those of a mixed or active nature. That physician does not err more who advises a patient to take physic, without specifying its qualities and doses, than the physician does who advises a patient, in a consumption, to use exercise, without specifying its species and degrees. From the neglect of this direction, we often find consumptive patients injured instead of being relieved by exercises, which, if used with judgment, might have been attended with the happiest effects.
I have before suggested that the stimulus of every medicine, which is intended to excite action in the system, should always be in an exact ratio to its excitability. The same rule should be applied to the stimulus of exercise. I have heard a well-attested case of a young lady, upon whose consumption the first salutary impression was made by rocking her in a cradle; and I know another case in which a young lady, in the lowest state of thatdebility which precedes an affection of the lungs, was prepared for the use of the mixed and active exercises, by being first moved gently backwards and forwards in a chariot without horses, for an hour every day. Swinging appears to act in the same gentle manner. In the case of a gardener, who was far advanced in a consumption, in the Pennsylvania hospital, I had the pleasure of observing its good effects, in an eminent degree. It so far restored him, as to enable him to complete his recovery by working at his former occupation.
In cases of extreme debility, the following order should be recommended in the use of the different species of exercise.
1. Rocking in a cradle, or riding on an elastic board, commonly called a chamber-horse.
2. Swinging.
3. Sailing.
4. Riding in a carriage.
5. Riding on horseback.
6. Walking.
7. Running and dancing.
In the use of each of those species of exercise great attention should be paid to thedegreeorforceof action with which they are applied to the body. For example, in riding in a carriage, the exercise will be less in a four-wheel carriage than in a single horse chair, and less when the horses move in a walking, than a trotting gait. In riding on horseback, the exercise will be less or greater according as the horse walks, paces, canters, or trots, in passing over the ground.
I have good reason to believe, that an English sea-captain, who was on the verge of the grave with the consumption, in the spring of the year 1790, owed his perfect recovery to nothing but the above gradual manner, in which, by my advice, he made use of the exercises of riding in a carriage and on horseback. I have seen many other cases of the good effects of thus accommodating exercise to debility; and I am sorry to add, that I have seen many cases in which, from the neglect of this manner of using exercise, most of the species and degrees of it, have either been useless, or done harm. However carelessly this observation may be read by physicians, or attended to by patients, I conceive no direction to be more necessary in thecure of consumptions. I have been thus particular in detailing it, not only because I believe it to be important, but that I might atone to society for that portion of evil which I might have prevented by a more strict attention to it in the first years of my practice.
The more the arms are used in exercise the better. One of the proprietary governors of Pennsylvania, who laboured for many years under consumptive diathesis, derived great benefit from frequently rowing himself in a small boat, a few miles up and down the river Schuylkill. Two young men, who were predisposed to a consumption, were perfectly cured by working steadily at a printing press in this city. A French physician in Martinique cured this disease, by simply rubbing the arms between the shoulders and the elbows, until they inflamed. The remedy is strongly recommended, by the recoveries from pulmonary consumption which have followed abscesses in the arm-pits. Perhaps the superior advantages of riding on horseback, in this disease, may arise in part from the constant and gentle use of the arms in the management of the bridle and the whip.
Much has been said in favour of sea voyages in consumptions. In the mild degrees of the diseasethey certainly have done service, but I suspect the relief given, or the cures performed by them, should be confined chiefly to seafaring people, who add to the benefits of a constant change of pure air, a share of the invigorating exercises of navigating the ship. I have frequently heard of consumptive patients reviving at sea, probably from the transient effects of sea sickness upon the whole system, and growing worse as soon as they came near the end of their voyage. It would seem as if the mixture of land and sea airs was hurtful to the lungs, in every situation and condition in which it could be applied to them. Nor are the peculiar and morbid effects of the first operation of land and sea airs upon the human body, in sea voyages, confined only to consumptive people. I crossed the Atlantic ocean, in the year 1766, with a sea captain, who announced to his passengers the agreeable news that we were near the British coast, before any discovery had been made of our situation by sounding, or by a change in the colour of the water. Upon asking him upon what he founded his opinion, he said, that he had been sneezing, which, he added, was the sign of an approaching cold, and that, in the course of upwards of twenty years, he had never made the land (to use the seaman's phrase) without being affected in a similar manner. I have visited many sick people in Philadelphia,soon after their arrival from sea, who have informed me, that they had enjoyed good health during the greatest part of their voyage, and that they had contracted their indispositions after they came within sight of the land. I mention these facts only to show the necessity of advising consumptive patients, who undertake a sea voyage for the recovery of their health, not to expose themselves upon deck in the morning and at night, after they arrive within the region in which the mixture of the land and sea airs may be supposed to take place.
I subscribe, from what I have observed, to the bold declaration of Dr. Sydenham, in favour of the efficacy of riding on horseback, in the cure of consumption. I do not think the existence of an abscess, when broken, or even tubercles in the lungs, when recent, or of a moderate size, the least objection to the use of this excellent remedy. An abscess in the lungs is not necessarily fatal, and tubercles have no malignity in them which should render their removal impracticable by this species of exercise. The first question, therefore, to be asked by a physician who visits a patient in this disease should be, not what is the state of his lungs, but, is he able to ride on horseback.
There are two methods of riding for health in this disease. The first is by short excursions; the second is by long journies. In slight consumptive affections, and after a recovery from an acute illness, short excursions are sufficient to remove the existing debility; but in the more advanced stages of consumption, they are seldom effectual, and frequently do harm, by exciting an occasional appetite without adding to the digestive powers. They, moreover, keep the system constantly vibrating by their unavoidable inconstancy, between distant points of tone and debility[33], and they are unhappily accompanied at all times, from the want of a succession of fresh objects to divert the mind, by the melancholy reflection that they are the sad, but necessary conditions of life.
In a consumption of long continuance or of great danger, long journies on horseback are the most effectual modes of exercise. They afford a constant succession of fresh objects and company, which divert the mind from dwelling upon the danger of the existing malady; they are moreover attended by a constant change of air, and they are not liable to be interrupted by company, or transientchanges in the weather, by which means appetite and digestion, action and power, all keep pace with each other. It is to be lamented that the use of this excellent remedy is frequently opposed by indolence and narrow circumstances in both sexes, and by the peculiarity of situation and temper in the female sex. Women are attached to their families by stronger ties than men. They cannot travel alone. Their delicacy, which is increased by sickness, is liable to be offended at every stage; and, lastly, they sooner relax in their exertions to prolong their lives than men. Of the truth of the last observation, sir William Hamilton has furnished us with a striking illustration. He tells us, that in digging into the ruins produced by the late earthquake in Calabria, the women who perished in it, were all found with their arms folded, as if they had abandoned themselves immediately to despair and death; whereas, the men were found with their arms extended, as if they had resisted their fate to the last moment of their lives. It would seem, from this fact, and many others of a similar nature which might be related, that a capacity of bearing pain and distress with fortitude and resignation, was the distinguishing characteristic of the female mind; while a disposition to resist and overcome evil, belonged in a more peculiar manner to the mind of man. I havementioned this peculiarity of circumstances and temper in female patients, only for the sake of convincing physicians that it will be necessary for them to add all the force of eloquence to their advice, when they recommend journies to women in preference to all other remedies, for the recovery of their health.
Persons, moreover, who pursue active employments, frequently object to undertaking journies, from an opinion that their daily occupations are sufficient to produce all the salutary effects we expect from artificial exercise. It will be highly necessary to correct this mistake, by assuring such persons that, however useful the habitual exercise of an active, or even a laborious employment may be topreservehealth, it must always be exchanged for one which excites new impressions, both upon the mind and body, in every attempt torestorethe system from that debility which is connected with pulmonary consumption.
As travelling is often rendered useless, and even hurtful in this disease, from being pursued in an improper manner, it will be necessary to furnish our patients with such directions as will enable them to derive the greatest benefit from their journies. I shall, therefore, in this place, mention thesubstance of the directions which I have given in writing for many years to such consumptive patients as undertake journies by my advice.
1. To avoid fatigue. Too much cannot be said to enforce this direction. It is the hinge on which the recovery or death of a consumptive patient frequently turns. I repeat it again, therefore, that patients should be charged over and over when they set off on a journey, as well as when they use exercise of any kind, to avoid fatigue. For this purpose they should begin by travelling only a few miles in a day, and increase the distance of their stages, as they increase their strength. By neglecting this practice, many persons have returned from journies much worse than when they left home, and many have died in taverns, or at the houses of their friends on the road. Travelling in stage-coaches is seldom safe for a consumptive patient. They are often crowded; they give too much motion; and they afford by their short delays and distant stages, too little time for rest, or for taking the frequent refreshment which was formerly recommended.
2. To avoid travelling too soon in the morning, and after the going down of the sun in the evening, and, if the weather be hot, never to travel in themiddle of the day. The sooner a patient breakfasts after he leaves his bed the better; and in no case should he leave his morning stage with an empty stomach.
3. If it should be necessary for a patient to lie down, or to sleep in the day time, he should be advised to undress himself, and to cover his body between sheets or blankets. The usual ligatures of garters, stocks, knee-bands, waistcoats, and shoes, are very unfriendly to sound sleep; hence persons who lie down with their clothes on, often awake from an afternoon's nap in terror from dreams, or in a profuse sweat, or with a head-ach or sick stomach; and generally out of humour. The surveyors are so sensible of the truth of this remark, that they always undress themselves when they sleep in the woods. An intelligent gentleman of this profession informed me, that he had frequently seen young woodsmen, who had refused to conform to this practice, so much indisposed in the morning, that, after the experience of a few nights, they were forced to adopt it.
Great care should be taken in sleeping, whether in the day time or at night, never to lie down in damp sheets. Dr. Sydenham excepts the danger from this quarter, when he speaks of the efficacyof travelling on horseback in curing the consumption.
4. Patients who travel for health in this disease should avoid all large companies, more especially evening and night parties. The air of a contaminated room, phlogisticated by the breath of fifteen or twenty persons, and by the same number of burning candles, is poison to a consumptive patient. To avoid impure air from every other source, he should likewise avoid sleeping in a crowded room, or with curtains around his bed, and even with a bed-fellow.
5. Travelling, to be effectual in this disease, should be conducted in such a manner as that a patient may escape the extremes of heat and cold. For this purpose he should pass the winter, and part of the spring, in Georgia or South-Carolina, and the summer in New-Hampshire, Massachusetts, or Vermont, or, if he pleases, he may still more effectually shun the summer heats, by crossing the lakes, and travelling along the shores of the St. Laurence to the city of Quebec. He will thus escape the extremes of heat and cold, particularly the less avoidable one of heat; for I have constantly found the hot month of July to be as unfriendly to consumptive patients in Pennsylvania,as the variable month of March. By these means too he will enjoy nearly an equable temperature of air in every month of the year; and his system will be free from the inconvenience of the alternate action of heat and cold upon it. The autumnal months should be spent in New-Jersey or Pennsylvania.
In these journies from north to south, or from south to north, he should be careful, for reasons before mentioned, to keep at as great a distance as possible from the sea coast. Should this inquiry fall into the hands of a British physician, I would beg leave to suggest to him, whether more advantages would not accrue to his consumptive patients from advising them to cross the Atlantic ocean, and afterwards to pursue the tour which I have recommended, than by sending them to Portugal, France, or Italy. Here they will arrive with such a mitigation of the violence of the disease, in consequence of the length of their sea voyage, as will enable them immediately to begin their journies on horseback. Here they will be exposed to fewer temptations to intemperance, or to unhealthy amusements, than in old European countries. And, lastly, in the whole course of this tour, they will travel among a people related to them by a sameness of language and manners, and by ancientor modern ties of citizenship. Long journies for the recovery of health, under circumstances so agreeable, should certainly be preferred to travelling among strangers of different nations, languages, and manners, on the continent of Europe.
6. To render travelling on horseback effectual in a consumption, it should be continued with moderate intervals fromsix to twelve months. But the cure should not be rested upon a single journey. It should be repeated everytwoorthree years, till our patient has passed the consumptive stages of life. Nay, he must do more; he must acquire ahabitof riding constantly, both at home and abroad; or, to use the words of Dr. Fuller, “he must, like a Tartar, learn to live on horseback, by which means he will acquire in time the constitution of a Tartar[34].”
Where benefit is expected from a change of climate, as well as from travelling, patients should reside at least two years in the place which is chosen for that purpose. I have seldom known a residence for a shorter time in a foreign climate do much service.
To secure a perfect obedience to medical advice, it would be extremely useful if consumptive patients could always be accompanied by a physician. Celsus says, he found it more easy to cure the dropsy in slaves than in freemen, because they more readily submitted to the restraints he imposed upon their appetites. Madness has become a curable disease in England, since the physicians of that country have opened private mad-houses, and have taken the entire and constant direction of their patients into their own hands. The same successful practice would probably follow the treatment of consumptions, if patients were constantly kept under the eye and authority of their physicians. The keenness of appetite, and great stock of animal spirits, which those persons frequently possess, hurry them into many excesses which defeat the best concerted plans of a recovery; or, if they escape these irregularities, they are frequently seduced from our directions by every quack remedy which is recommended to them. Unfortunately the cough becomes a signal of their disease, at every stage of their journey, and the easy or pleasant prescriptions of even hostlers and ferrymen, are often substituted to the self-denial and exertion which have been imposed by physicians. The love of life in these cases seems to level all capacities; for I have observed persons of the most cultivatedunderstandings to yield in common with the vulgar, to the use of these prescriptions.
In a former volume I mentioned the good effects of accidentalLABOURin pulmonary consumptions. The reader will find a particular account in the first volume of Dr. Coxe's Medical Museum, of a clergyman and his wife, in Virginia, being cured by the voluntary use of that remedy.
The following circumstances and symptoms, indicate the longer or shorter duration of this disease, and its issue in life and death:
The consumption from gout, rheumatism, and scrophula, is generally of long duration. It is more rapid in its progress to death, when it arises from a half cured pleurisy, or neglected colds, measles, and influenza. It is of shorter duration in persons under thirty, than in those who are more advanced in life.
It is always dangerous in proportion to the length of time, in which the debilitating causes, that predisposed to it, have acted upon the body.
It is more dangerous when a predisposition to it has been derived from ancestors, than when it has been acquired.
It is generally fatal when accompanied with a bad conformation of the breast.
Chilly fits occurring in the forenoon, are more favourable than when they occur in the evening. They indicate the disease to partake a little of the nature of an intermittent, and are a call for the use of the remedies proper in that disease.
Rheumatic pains, attended with an abatement of the cough, or pains in the breast, are always favourable; so are
Eruptions, or an abscess on the external parts of the body, if they occur before the last stage of the disease.
A spitting of blood, in the early, or forming stage of the disease, is favourable, but after the lungs become much obstructed, or ulcerated, it is most commonly fatal.
A pleurisy, occurring in the low state of the disease, generally kills, but I have seen a case inwhich it suddenly removed the cough and hectic fever, and thus became the means of prolonging the patient's life for several years.
The discharge of calculi from the lungs by coughing and spitting, and of a thin watery liquid, with a small portion of pus swimming on its surface, are commonly signs of an incurable consumption.
No prediction unfavourable to life can be drawn from pus being discharged from the lungs. We see many recoveries after it has taken place, and many deaths where that symptom has been absent. Large quantities of pus are discharged in consumptions attended with abscesses, and yet few die of them, where they have not been preceded by long continued debility of the whole system. No pus is expectorated from tubercles, and how generally fatal is the disease, after they are formed in the lungs! It is only after they ulcerate that they discharge pus, and it is only after ulcers are thus formed, that the consumption probably becomes uniformly fatal. I suspect these ulcers are sometimes of a cancerous nature.
A sudden cessation of the cough, without a supervening diarrhœa, indicates death to be at hand.
A constant vomiting in a consumption, is generally a bad sign.
Feet obstinately cold, also a swelling of the feet during the day, and of the face in the night, commonly indicate a speedy and fatal issue of the disease.
Lice, and the falling off of the hair, often precede death.
A hoarseness, in the beginning of the disease, is always alarming, but it is more so in its last stage.
A change of the eyes from a blue, or dark, to a light colour, similar to that which takes place in very old people, is a sign of speedy dissolution.
I have never seen a recovery after an apthous sore throat took place.
Death from the consumption comes on in some or more than one, of the following ways:
1. With a diarrhœa. In its absence,
2. With wasting night sweats.
3. A rupture of an abscess.
4. A rupture of a large blood-vessel in the lungs, attended with external or internal hæmorrhage.Suddenandunexpecteddeath in a consumption is generally induced by this, or the preceding cause.
5. Madness. The cough and expectoration cease with this disease. It generally carries off the patient in a week or ten days.
6. A pleurisy, brought on by exposure to cold.
7. A typhus fever, attended with tremors, twitchings of the tendons, and a dry tongue.
8. Swelled hands, feet, legs, thighs, and face.
9. An apthous sore throat.
10. Great and tormenting pains, sometimes of a spasmodic nature in the limbs.
In a majority of the fatal cases of consumption, which I have seen, the passage out of life has been attended with pain; but I have seen many persons die with it, in whom all the above symptoms were so lenient, or so completely mitigated by opium,that death resembled a quiet transition from a waking, to a sleeping state.
I cannot conclude this inquiry without adding, that the author of it derived from his paternal ancestors a predisposition to the pulmonary consumption, and that between the 18th and 43d years of his age, he has occasionally been afflicted with many of the symptoms of that disease which he has described. By the constant and faithful use of many of the remedies which he has recommended, he now, in the 61st year of his age, enjoys nearly an uninterrupted exemption from pulmonary complaints. In humble gratitude, therefore, to thatBeing, who condescends to be called the preserver of men, he thus publicly devotes this result of his experience and inquiries to the benefit of such of his fellow-creatures as may be afflicted with the same disease, sincerely wishing that they may be as useful to them, as they have been to the author.