Volume 2 — AN INQUIRY INTO THE CAUSES AND CURE OF THE PULMONARY CONSUMPTION.

In an essay, entitled “Thoughts on the Pulmonary Consumption[17],” I attempted to show that this disease was the effect of causes which induced general debility, and that the only hope of discovering a cure for it should be directed to such remedies as act upon the whole system. In the following inquiry, I shall endeavour to establish the truth of each of those opinions, by a detail of facts and reasonings, at which I only hinted in my former essay.

The method I have chosen for this purpose, is to deliver, and afterwards to support, a few general propositions.

I shall begin by remarking,

I. That the pulmonary consumption is induced by predisposing debility.

This I infer, 1st, From the remote and exciting causes which produce it. The remote causes are pneumony, catarrh, hæmoptysis, rheumatism, gout, asthma, scrophula, chronic diseases of the stomach, liver, and kidneys, nervous and intermitting fevers, measles, repelled humours from the surface of the body, the venereal disease, obstructed menses, sudden growth about the age of puberty, grief, and all other debilitating passions of the mind; hypochondriasis, improper lactation, excessive evacuation of all kinds, more especially by stool[18], cold and damp air, a cough, external violence acting upon the body[19]; and finally, every thing that tends, directly or indirectly, to diminish the strength of the system.

The most frequent exciting cause of consumption is the alternate application of heat and cold to the whole external surface of the body; but all the remote causes which have been enumerated, operate as exciting causes of consumption, when they act on previous debility. Original injuries of the lungs seldom excite this disease, except they first induce a debility of the whole system, by a troublesome and obstinate cough.

2. From the debilitating occupations and habits of persons who are most liable to this disease. These are studious men, and mechanics who lead sedentary lives in confined places; also women, and all persons of irritable habits, whether of body or mind.

3. From the period in which persons are most liable to be affected by this disease. This is generally between the 18th and 36th year of life, a period in which the system is liable, in a peculiar manner, to most diseases which induce it, and in which there is a greater expenditure of strength, than in any other stage of life, by the excessive exercises of the body and mind, in the pursuits of business or pleasure.

I have conformed to authors, in fixing the period of consumptions between the 18th and 36th year of life; but it is well known that it sometimes appears in children, and frequently in persons beyond the 40th, or even 60th year of life.

II. The pulmonary consumption is a primary disease of the whole system. This I infer,

1. From the causes which produce it, acting upon the whole system.

2. From the symptoms of general debility which always precede the affection of the lungs. These symptoms are a quick pulse, especially towards evening; a heat and burning in the palms of the hands; faintness, head-ach, sickness at stomach, and an occasional diarrhœa. I have frequently observed each of these symptoms for several months before I have heard of a single complaint in the breast.

3. From the pulmonary consumption alternating with other diseases which obviously belong to the whole system. I shall briefly mention these diseases.

The RHEUMATISM. I have seen many cases in which this disease and the consumption have alternately, in different seasons or years, affected the system. In the winter of 1792, three clinical patients in the Pennsylvania hospital exemplified by their complaints the truth of this observation. They were relieved several times of a cough by rheumatic pains in their limbs, which seemed for a while to promise a cure to their pulmonic complaints.

The GOUT has often been observed to alternate with the pulmonary consumption, especially in persons in the decline of life. Dr. Sydenham describes a short cough continuing through the whole winter, as a symptom of gouty habits. A gentleman from Virginia died under my care in the spring of 1788, in the 45th year of his age, with all the symptoms of pulmonary consumption, which had frequently alternated with pains and a swelling in his feet.

The pulmonary consumption has been observed to alternate with MADNESS. Of this I have seen two instances, in both of which the cough and expectoration were wholly suspended during the continuance of the derangement of the mind. Dr. Mead mentions a melancholy case of the same kind in a young lady, and similar cases are to be met with in other authors. In all of them the disease proved fatal. In one of the cases which came under my notice, the symptoms of consumption returned before the death of the patient.

I have likewise witnessed two cases in which the return of reason after madness, was suddenly succeeded by a fatal pulmonary consumption. Perhaps the false hopes, and even the cheerfulness which so universally occur in this disease, may be resolved into a morbid state of the mind, produced by a general derangement of the whole system. So universal are the delusion and hopes of patients, with respect to the nature and issue of this disease, that I have never met with but one man, who, upon being asked what was the matter with him, answered unequivocally, “that he was in a consumption.”

Again: Dr. Bennet mentions a case of “A phthisical patient, who was seized with a violent PAIN IN THE TEETH for two days, and in whom, during that time, every symptom of a consumption, except the leanness of the body, altogether vanished:” and he adds further, “that a defluction on the lungs had often been relieved by SALIVARY EVACUATIONS[20].”

I have seen several instances in which the pulmonary symptoms have alternated with HEADACH and DYSPEPSIA; also with pain and noise in one EAR. This affection of the ears sometimes continues throughout the whole disease, without any remission of the pulmonary symptoms. I have seen one case of a discharge of matter from the left ear, without being accompanied by either pain or noise.

In all our books of medicine are to be found cases of consumption alternating with ERUPTIONS ON THE SKIN.

And who has not seen the pulmonary symptoms alternately relieved and reproduced by the appearance or cessation of a diarrhœa, or pains in the BOWELS?

To these facts I shall only add, under this head, as a proof of the consumption being a disease of the whole system, that it is always more or less relieved by the change which is induced in the system by pregnancy.

4. I infer that the pulmonary consumption is a disease of the whole system from its analogy with several other diseases, which, though accompanied by local affections, are obviously produced by a morbid state of the whole system.

The rheumatism, the gout, the measles, small-pox, the different species of cynanche, all furnish examples of the connection of local affections with a general disease; but the APOPLEXY, and the PNEUMONY, furnish the most striking analogies of local affection, succeeding a general disease of the system in the pulmonary consumption.

The most frequent predisposing cause of apoplexy is a general debility of the system, produced by intemperance in eating and drinking. The phenomena of the disease are produced by an effusion of blood or serum, in consequence of a morbid distension, or of a rupture of the vessels of the brain. The pulmonary consumption begins and ends in the same way, allowing only for the difference of situation and structure of the brain and lungs. After the production of predisposing debility from the action of the remote causes formerly enumerated, the fluids are determined to the weakest part of the body. Hence effusions of serum or blood take place in the lungs. When serum is effused, a pituitous or purulent expectoration alone takes place; when blood is discharged, a disease is produced which has been called hæmoptysis. An effusion of blood in the brain, brought on by the operation of general debility, has been called by Dr. Hoffman, with equal propriety, a hæmorrhage of the brain. The effusion of blood in the lungs, in consequence of the rupture of a blood-vessel, is less fatal than the same accident when it occurs in the brain, only because the blood in the former case is more easily discharged from the system. Where no rupture of a blood-vessel is produced, death is nearly as speedy and certain in the one case as in the other. Dissections show many cases of suffocation and death, from the lungs being preternaturally filled with blood or serum. From this great analogy between the remote and proximate causes of the two diseases which have been described, I have taken the liberty to call them both by the name of apoplexy. The only symptom which does not accord with the derivation of the term, is, that in the apoplexy of the lungs, the patient does not fall down as if by an external stroke, which is most frequently the case in the apoplexy of the brain.

The history of the remote and proximate causes of pneumony will furnish us with a still more remarkable analogy of the connection between a local affection, and a general disease of the system. The pneumony is produced by remote exciting causes which act on the whole system. The whole arterial system is frequently agitated by a fever in this disease before a pain is perceived in the breast or sides, and this fever generally constitutes its strength and danger. The expectoration which terminates the disease in health, is always the effect of effusions produced by a general disease, and even the vomicas, which sometimes succeed a deficiency of bleeding, always depend upon the same general cause. From this view of the analogy between pneumony and pulmonary consumption, it would seem that the two diseases differed from each other only by the shorter or longer operation of the causes which induce them, and by the greater or less violence and duration of their symptoms. The pneumony appears to be an acute consumption, and the consumption a chronic pneumony. From the analogy of the pulmonary consumption with the diminutive term of certain fevers, I have taken the liberty of calling it a PNEUMONICULA.

5. I infer that the pulmonary consumption is a disease of the whole system, from its existence without ulcers in the lungs. Of this there are many cases recorded in books of medicine.

Dr. Leigh informs us, in his Natural History of Lancashire, that the consumption was a very common disease on the sea coast of that country; but that it was not accompanied either by previous inflammation or ulcers in the lungs. It was generally attended, he says, by an unusual peevishness of temper.

6. I infer that the pulmonary consumption is a disease of the whole system, from its being relieved, or cured, only by remedies which act upon the whole system. This will appear, I hope, hereafter, when we come to treat of the cure of this disease.

Let us now enquire how far the principles I have laid down will apply to the supposed causes of consumption. These causes have been said to be, an abscess in the lungs, hæmoptysis, tubercles, without and with ulcers, catarrh, hereditary diathesis, contagion, and the matter of cutaneous eruptions, or sores repelled, and thrown upon the lungs. I shall make a few observations upon each of them.

1. An abscess in the lungs is generally the consequence of a neglected, or half-cured pneumony. It is seldom fatal, where it is not connected with a predisposition to consumption from general debility, or where general debility is not previously induced by the want of appetite, sleep, and exercise, which sometimes accompany that disease of the lungs. This explanation of the production of consumption by an abscess in the lungs, will receive further support from attending to the effects of wounds in the lungs. How seldom are they followed by pulmonary consumption; and this only because they are as seldom accompanied by predisposing general debility. I do not recollect a single instance of this disease having followed a wound in the lungs, either by the bayonet, or a bullet, during our revolutionary war. The recoveries which have succeeded such wounds, and frequently under the most unfavourable circumstances, show how very improbable it is that a much slighter affection of the lungs should become the cause of a pulmonary consumption.

A British officer, whom I met in the British camp, a few days after the battle of Brandywine, in September, 1777, informed me that the surgeon-general of the royal army had assured him, that out of twenty-four soldiers who had been admitted into the hospitals, during the campaign of 1776, with wounds in their lungs, twenty-three of them had recovered. Even primary diseases of the lungs often exist with peculiar violence, or continue for many years without inducing a consumption. I have never known but one instance of the whooping-cough ending in consumption, and all our books of medicine contain records of the asthma continuing for twenty and thirty years without terminating in that disease. The reason in both cases, must be ascribed to those two original diseases of the lungs not being accompanied by general debility. One fact more will serve to throw still further light upon the subject. Millers are much afflicted with a cough from floating particles of flour constantly irritating their lungs, and yet they are not more subject to consumptions than other labouring people. Hence “a miller's cough” is proverbial in some places, to denote a cough of long continuance without danger.

2. The hæmoptysis is either a local disease, or it is the effect of general debility of the whole system. When it is local, or when it is the effect of causes which induce a temporary or acute debility only in the system, it is seldom followed by consumption. The accidental discharge of blood from the lungs, from injuries, and from an obstruction of the menses in women is of this kind. Many persons are affected by this species of hæmorrhage once or twice in their lives, without suffering any inconvenience from it afterwards. I have met with several cases in which it has occurred for many years every time the body was exposed to any of the causes which induce sudden debility, and yet no consumption has followed it. The late king of Prussia informed Dr. Zimmerman that he had been frequently attacked by it during his seven years war, and yet he lived, notwithstanding, above twenty years afterwards without any pulmonary complaints. It is only in persons who labour under chronic debility, that a hæmoptysis is necessarily followed by consumption.

3. I yield to the popular mode of expression when I speak of a consumption being produced by tubercles. But I maintain that they are the effects of general debility communicated to the bronchial vessels which cause them to secrete a preternatural quantity of mucus. This mucus is sometimes poured into the trachea from whence it is discharged by hawking, more especially in the morning; for it is secreted more copiously during the languid hours of sleep than in the day time. But this mucus is frequently secreted into the substance of the lungs, where it produces those tumours we call tubercles. When this occurs, there is either no cough[21] or a very dry one. That tubercles are formed in this way, I infer from the dissections and experiments of Dr. Stark[22], who tells us, that he found them to consist of inorganic matter; that he was unable to discover any connection between them and the pulmonary vessels, by means of the microscope or injections; and that they first opened into the trachea through the bronchial vessels. It is remarkable that the colour and consistence of the matter of which they are composed, is nearly the same as the matter which is discharged through the trachea, in the moist cough which occurs from a relaxation of the bronchial vessels, and which has been called by Dr. Beddoes a bronchial gleet.

I am aware that these tumours in the lungs have been ascribed to scrophula. But the frequent occurrence of consumptions in persons in whom no scrophulous taint existed, is sufficient to refute this opinion. I have frequently directed my inquiries after this disease in consumptive patients, and have met with very few cases which were produced by it. It is probable that it may frequently be a predisposing cause of consumption in Great Britain, but I am sure it is not in the United States. Baron Humboldt informed me, that the scrophula is unknown in Mexico, and yet consumptions, he said, are very common in that part of North-America. That tubercles are the effects, and not the cause of pulmonary consumption, is further evident from similar tumours being suddenly formed on the intestines by the dysentery, and on the omentum by a yellow fever. Cases of the former are to be met with in the dissections of Sir John Pringle, and one of the latter is mentioned by Dr. Mackittrick, in his inaugural dissertation upon the yellow fever, published in Edinburgh in the year 1766[23].

4. The catarrh is of two kinds, acute and chronic, both of which are connected with general debility, but this debility is most obvious in the chronic catarrh: hence we find it increased by every thing which acts upon the whole system, such as cold and damp weather, fatigue, and, above all, by old age, and relieved or cured by exercise, and every thing else which invigorates the whole system. This species of catarrh often continues for twenty or thirty years without inducing pulmonary consumption, in persons who pursue active occupations.

5. In the hereditary consumption there is either a hereditary debility of the whole system, or a hereditary mal-conformation of the breast. In the latter case, the consumption is the effect of weakness communicated to the whole system, by the long continuance of difficult respiration, or of such injuries being done to the lungs as are incompatible with health and life. It is remarkable, that the consumptive diathesis is more frequently derived from paternal, than maternal ancestors.

6. Physicians, the most distinguished characters, have agreed, that the pulmonary consumption may be communicated by contagion. Under the influence of this belief, Morgagni informs us, that Valsalva, who was predisposed to the consumption, constantly avoided being present at the dissection of the lungs of persons who had died of that disease. In some parts of Spain and Portugal, its contagious nature is so generally believed, that cases of it are reported to the magistrates of those countries, and the clothes of persons who die of it are burned by their orders. The doctrine of nearly all diseases spreading by contagion, required but a short and simple act of the mind, and favoured the indolence and timidity which characterized the old school of medicine. I adopted this opinion, with respect to the consumption, in the early part of my life; but I have lately been led to call its truth in question, especially in the unqualified manner in which it has been taught. In most of the cases in which the disease has been said to be propagated by contagion, its limits are always confined to the members of a single family. Upon examination, I have found them to depend upon some one or more of the following causes:

1. Mal-conformation of the breast, in all the branches of the diseased family. It is not necessary that this organic predisposition should be hereditary.

2. Upon the debility which is incurred by nursing, and the grief which follows the loss of relations who die of it.

3. Upon some local cause undermining the constitutions of a whole family. This may be exhalations from a foul cellar, a privy, or a neighbouring mill-pond, but of so feeble a nature as to produce debility only, with an acute fever, and thus to render the consumption a kind of family epidemic. I was consulted, in the month of August, 1793, by a Mr. Gale, of Maryland, in a pulmonary complaint. He informed me, that he had lost several brothers and sisters with the consumption, and that none of his ancestors had died of it. The deceased persons, five in number, had lived in a place that had been subject to the intermitting fever.

4. Upon some peculiar and unwholesome article of diet, which exerts slowly debilitating effects upon all the branches of a family.

5. Upon a fearful and debilitating apprehension entertained by the surviving members of a family, in which one or two have died of consumption, that they shall perish by the same disease. The effects of all the passions, and especially of fear, acted upon by a lively imagination, in inducing determinations to particular parts of the body, and subsequent disease, are so numerous, as to leave no doubt of the operation of this cause, in producing a number of successive deaths in the same family, from pulmonary consumption.

In favour of its depending upon one or more of the above causes, I shall add two remarks.

1. There is often an interval of from two to ten years, between the sickness and deaths which occur in families from consumptions, and this we know never takes place in any disease which is admitted to be contagious.

2. The consumption is not singular in affecting several branches of a family. I was lately consulted by a young physician from Maryland, who informed me, that two of his brothers, in common with himself, were afflicted with epilepsy. Madness, scrophula, and a disposition to hæmorrhage, often affect, in succession, several branches of the same family; and who will say that any one of the above diseases is propagated by contagion?

The practice of the Spaniards and Portuguese, in burning the clothes of persons who die of consumptions, no more proves the disease to be contagious, than the same acts sanctioned by the advice or orders of public bodies in the United States, establish the contagious nature of the yellow fever. They are, in both countries, marks of the superstition of medicine.

In suggesting these facts, and the inferences which have been drawn from them, I do not mean to deny the possibility of the acrid and fœtid vapour, which is discharged by breathing from an ulcer or abscess in the lungs, nor of the hectic sweats, when rendered putrid by stagnating in sheets, or blankets, communicating this disease to persons who are long exposed to them, by sleeping with consumptive patients; but that such cases rarely occur I infer, from the persons affected often living at a distance from each other, or when they live under the same roof, having no intercourse with the sick. This was the case with the black slaves, who were supposed to have taken the disease from the white branches of a family in Connecticut, and which was mentioned, upon the authority of Dr. Beardsley, in a former edition of this inquiry. Admitting the above morbid matters now and then to act as a remote cause of consumption, it does not militate against the theory I have aimed to establish, for if it follow the analogy of common miasmata and contagions, it must act by first debilitating the whole system. The approach of the jail and bilious fevers is often indicated by general languor. The influenza and the measles are always accompanied by general debility, but the small-pox furnishes an analogy to the case in question more directly in point. The contagion of this disease, whether received by the medium of the air or the skin, never fails of producing weakness in the whole system, before it discovers itself in affections of those parts of the body on which the contagion produced its first operation.

7. I grant that cutaneous humours, and the matter of old sores, when 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 fœtid 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 diarrhœa, 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.

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 diarrhœa.

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.

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 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.

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 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 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.

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[** 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. The MODERATE use of the lungs, in READING, PUBLIC SPEAKING, LAUGHING, and SINGING. 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 all excess in the use of the lungs, by long, or loud reading, speaking, or singing, or by sudden and violent bursts of 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 certain PASSIONS in 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 only by 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. A SALIVATION has 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 remedy in 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 medicine will 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. Nicols was 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 intervals of 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 the sudden influence of the same causes, which, by acting with less force, and for a longer time, 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 the influence of general debilitating 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 former essay[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 the RADICAL REMEDIES for 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, and mixed. The active includes walking, and the exercise of the hands and feet in working or dancing. The passive includes rocking in a cradle, swinging, sailing, and riding in carriages of different kinds. The mixed is 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 that debility 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 the degree or force of 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 the cure 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 disease they 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 transient changes 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 have mentioned 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 to preserve health, it must always be exchanged for one which excites new impressions, both upon the mind and body, in every attempt to restore the 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 the substance of the directions which I have given in writing for many years to such consumptive patients as undertake journies by my advice.