CONTENTS OF VOLUME II.
| page | |
| An inquiry into the influence of physical causes upon the moral faculty | [1] |
| Observations upon the cause and cure of pulmonary consumption | [59] |
| Observations upon the symptoms and cure of dropsies | [151] |
| Inquiry into the cause and cure of the internal dropsy of the brain | [191] |
| Observations upon the nature and cure of the gout | [225] |
| Observations on the nature and cure of the hydrophobia | [299] |
| An account of the measles, as they appeared in Philadelphia in the spring of 1789 | [335] |
| An account of the influenza, as it appeared in Philadelphia in the years 1790 and 1791 | [351] |
| An inquiry into the cause of animal life | [369] |
AN INQUIRY
INTO THE
INFLUENCE OF PHYSICAL CAUSES
UPON THE MORAL FACULTY.
DELIVERED BEFORE
THE AMERICAN PHILOSOPHICAL SOCIETY,
HELD AT PHILADELPHIA,
ON THE 27TH OF FEBRUARY, 1786.
GENTLEMEN,
It was for the laudable purpose of exciting a spirit of emulation and inquiry, among the members of our body, that the founders of our society instituted an annual oration. The task of preparing, and delivering this exercise, hath devolved, once more, upon me. I have submitted to it, not because I thought myself capable of fulfilling your intentions, but because I wished, by a testimony of my obedience to your requests, to atone for my long absence from the temple of science.
The subject upon which I am to have the honour of addressing you this evening is on the influence of physical causes upon the moral faculty.
By the moral faculty I mean a capacity in the human mind of distinguishing and chasing good and evil, or, in other words, virtue and vice. It is a native principle, and though it be capable of improvement by experience and reflection, it is not derived from either of them. St. Paul and Cicero give us the most perfect account of it that is to be found in modern or ancient authors. “For when the Gentiles (says St. Paul), which have not the law, do by nature the things contained in the law, these, having not the law, are a law unto themselves; which show the works of the law written in their hearts, their consciences also bearing witness, and their thoughts the mean while accusing, or else excusing another[1].”
The words of Cicero are as follow: “Est igniter Ha, juices, non script, seed Nata lex, qualm non dadaisms, accepts, legumes, serum ex nature Pisa europiums, humus, expresses, ad qualm non Doctor, seed facto, non institute, seed imbued sums[2].” This faculty is often confounded with conscience, which is a distinct and independent capacity of the mind. This is evident from the passage quoted from the writings of St. Paul, in which conscience is said to be the witness that accuses or excuses us, of a breach of the law written in our hearts. The moral faculty is what the school men call the “regular raglans;” the conscience is their “regular regulate;” or, to speak in more modern terms, the moral faculty performs the office of a law-giver, while the business of conscience is to perform the duty of a judge. The moral faculty is to the conscience, what taste is to the judgment, and sensation to perception. It is quick in its operations, and, like the sensitive plant, acts without reflection, while conscience follows with deliberate steps, and measures all her actions, by the unerring square of right and wrong. The moral faculty exercises itself upon the actions of others. It approves, even in books, of the virtues of a Trajan, and disapproves of the vices of a Marius, while conscience confines its operations only to its own actions. These two capacities of the mind are generally in an exact ratio to each other, but they sometimes exist in different degrees in the same person. Hence we often find conscience in its full vigour, with a diminished tone, or total absence of the moral faculty.
It has long been a question among meta physicians, whether the conscience be seated in the will or in the understanding. The controversy can only be settled by admitting the will to be the seat of the moral faculty, and the understanding to be the seat of the conscience. The mysterious nature of the union of those two moral principles with the will and understanding, is a subject foreign to the business of the present inquiry.
As I consider virtue and vice to consist in action, and not in opinion, and as this action has its seat in the will, and not in the conscience, I shall confine my inquiries chiefly to the influence of physical causes upon that moral power of the mind, which is connected with volition, although many of these causes act likewise upon the conscience, as I shall show hereafter. The state of the moral faculty is visible in actions, which affect the well-being of society. The state of the conscience is invisible, and therefore removed beyond our investigation.
The moral faculty has received different names from different authors. It is the “moral sense” of Dr. Hutchison; the “sympathy” of Dr. Adam Smith; the “moral instinct” of Rousseau; and “the light that lighter every man that cometh into the world” of St. John. I have adopted the term of moral faculty from Dr. Bettie, because I conceive it conveys with the most perspicuity, the idea of a capacity in the mind, of chasing good and evil.
Our books of medicine contain many records of the effects of physical causes upon the memory, the imagination, and the judgment. In some instances we behold their operation only on one, in others on two, and, in many cases, upon the whole of these faculties. Their derangement has received different names, according to the number or nature of the faculties that are affected. The loss of memory has been called “amnesia;” false judgment upon one subject has been called “melancholia;” false judgment upon all subjects has been called “mania;” and a defect of all the three intellectual faculties that have been mentioned, has received the name of “amnesia.” Persons who labour under the derangement, or want of these faculties of the mind, are considered, very properly, as subjects of medicine; and there are many cases upon record that prove, that their diseases have yielded to the healing art.
In order to illustrate the effects of physical causes upon the moral faculty, it will be necessary first to show their effects upon the memory, the imagination, and the judgment; and at the same time to point out the analogy between their operation upon the intellectual faculties of the mind, and the moral faculty.
1. Do we observe a connection between the intellectual faculties, and the degrees of consistency and firmness of the brain in infancy and childhood? The same connection has been observed between the strength, as well as the progress of the moral faculty in children.
2. Do we observe a certain size of the brain, and a peculiar cast of features, such as the prominent eye, and the aquiline nose, to be connected with extraordinary portions of genius? We observe a similar connection between the figure and temperament of the body, and certain moral qualities. Hence we often ascribe good temper and benevolence to corpulence, and irascibility to sanguineous habits. CA thought himself safe in the friendship of the “sleek-headed” Anthony and Willabella; but was afraid to trust to the professions of the slender Cassius.
3. Do we observe certain degrees of the intellectual faculties to be hereditary in certain families? The same observation has been frequently extended to moral qualities. Hence we often find certain virtues and vices as peculiar to families, through all their degrees of consanguinity, and duration, as a peculiarity of voice, complexion, or shape.
4. Do we observe instances of a total want of memory, imagination, and judgment, either from an original defect in the stamina of the brain, or from the influence of physical causes? The same unnatural defect is sometimes observed, and probably from the same causes, of a moral faculty. The celebrated Serving, whose character is drawn by the Duke of Sully in his Memoirs, appears to be an instance of the total absence of the moral faculty, while the chasm, produced by this defect, seems to have been filled up by a more than common extension of every other power of his mind. I beg leave to repeat the history of this prodigy of vice and knowledge. “Let the reader represent to himself a man of a genius so lively, and of an understanding so extensive, as rendered him scarce ignorant of any thing that could be known; of so vast and ready a comprehension, that he immediately made himself master of whatever he attempted; and of so prodigious a memory, that he never forgot what he once learned. He possessed all parts of philosophy, and the mathematics, particularly fortification and drawing. Even in theology he was so well skilled, that he was an excellent preacher, whenever he had a mind to exert that talent, and an able disputant, for and against the reformed religion indifferently. He not only understood Greek, Hebrew, and all the languages which we call learned, but also all the different jargons, or modern dialects. He accented and pronounced them so naturally, and so perfectly imitated the gestures and manners both of the several nations of Europe, and the particular provinces of France, that he might have been taken for a native of all, or any of these countries: and this quality he applied to counterfeit all sorts of persons, wherein he succeeded wonderfully. He was, moreover, the best comedian, and the greatest droll that perhaps ever appeared. He had a genius for poetry, and had wrote many verses. He played upon almost all instruments, was a perfect master of music, and sang most agreeably and justly. He likewise could say mass, for he was of a disposition to do, as well as to know all things. His body was perfectly well suited to his mind. He was light, nimble, and dexterous, and fit for all exercises. He could ride well, and in dancing, wrestling, and leaping, he was admired. There are not any recreative games that he did not know, and he was skilled in almost all mechanic arts. But now for the reverse of the medal. Here it appeared, that he was treacherous, cruel, cowardly, deceitful, a liar, a cheat, a drunkard and a glutton, a sharper in play, immersed in every species of vice, a blasphemer, an atheist. In a word, in him might be found all the vices that are contrary to nature, honour, religion, and society, the truth of which he himself evinced with his latest breath; for he died in the flower of his age, in a common brothel, perfectly corrupted by his debaucheries, and expired with the glass in his hand, cursing and denying God[3].”
It was probably a state of the human mind such as has been described, that our Saviour alluded to in the disciple, who was about to betray him, when he called him “a devil.” Perhaps the essence of depravity, in infernal spirits, consists in their being wholly devoid of a moral faculty. In them the will has probably lost the power of chasing[4], as well as the capacity of enjoying moral good. It is true, we read of their trembling in a belief of the existence of a God, and of their anticipating future punishment, by asking, whether they were to be tormented before their time: but this is the effect of conscience, and hence arises another argument in favour of this judicial power of the mind, being distinct from the moral faculty. It would seem as if the Supreme Being had preserved the moral faculty in man from the ruins of his fall, on purpose to guide him back again to Paradise, and at the same time had constituted the conscience, both in men and fallen spirits, a kind of royalty in his moral empire, on purpose to show his property in all intelligent creatures, and their original resemblance to himself. Perhaps the essence of moral depravity in man consists in a total, but temporary suspension of the power of conscience. Persons in this situation are emphatically said in the Scriptures to be “past feeling,” and to have their consciences seared with a “hot iron;” they are likewise said to be “twice dead,” that is, the same torpor or moral insensibility, has seized both the moral faculty and the conscience.
5. Do we ever observe instances of the existence of only one of the three intellectual powers of the mind that have been named, in the absence of the other two? We observe something of the same kind with respect to the moral faculty. I once knew a man, who discovered no one mark of reason, who possessed the moral sense or faculty in so high a degree, that he spent his whole life in acts of benevolence. He was not only inoffensive (which is not always the case with idiots), but he was kind and affectionate to every body. He had no ideas of time, but what were suggested to him by the returns of the stated periods for public worship, in which he appeared to take great delight. He spent several hours of every day in devotion, in which he was so careful to be private, that he was once found in the most improbable place in the world for that purpose, viz. in an oven.
6. Do we observe the memory, the imagination, and the judgment, to be affected by diseases, particularly by madness? Where is the physician who has not seen the moral faculty affected from the same causes! How often do we see the temper wholly changed by a fit of sickness! And how often do we hear persons of the most delicate virtue, utter speeches in the delirium of a fever, that are offensive to decency or good manners! I have heard a well-attested history of a clergyman of the most exemplary moral character, who spent the last moments of a fever which deprived him both of his reason and his life, in profane cursing and swearing. I once attended a young woman in a nervous fever, who discovered, after her recovery, a loss of her former habit of veracity. Her memory (a defect of which might be suspected of being the cause of this vice) was in every respect as perfect as it was before the attack of the fever[5]. The instances of immorality in maniacs, who were formerly distinguished for the opposite character, are so numerous, and well known, that it will not be necessary to select any cases, to establish the truth of the proposition contained under this head.
7. Do we observe any of the three intellectual faculties that have been named, enlarged by diseases? Patients, in the delirium of a fever, often discover extraordinary flights of imagination, and madmen often astonish us with their wonderful acts of memory. The same enlargement, sometimes, appears in the operations of the moral faculty. I have more than once heard the most sublime discourses of morality in the cell of an hospital, and who has not seen instances of patients in acute diseases, discovering degrees of benevolence and integrity, that were not natural to them in the ordinary course of their lives[6]?
8. Do we ever observe a partial insanity, or false perception on one subject, while the judgment is sound and correct, upon all others? We perceive, in some instances, a similar defect in the moral faculty. There are persons who are moral in the highest degree, as to certain duties, who nevertheless live under the influence of some one vice. I knew an instance of a woman, who was exemplary in her obedience to every command of the moral law, except one. She could not refrain from stealing. What made this vice the more remarkable was, that she was in easy circumstances, and not addicted to extravagance in any thing. Such was her propensity to this vice, that when she could lay her hands upon nothing more valuable, she would often, at the table of a friend, fill her pockets secretly with bread. As a proof that her judgment was not affected by this defect in her moral faculty, she would both confess and lament her crime, when detected in it.
9. Do we observe the imagination in many instances to be affected with apprehensions of dangers that have no existence? In like manner we observe the moral faculty to discover a sensibility to vice, that is by no means proportioned to its degrees of depravity. How often do we see persons labouring under this morbid sensibility of the moral faculty, refuse to give a direct answer to a plain question, that related perhaps only to the weather, or to the hour of the day, lest they should wound the peace of their minds by telling a falsehood!
10. Do dreams affect the memory, the imagination, and the judgment? Dreams are nothing but incoherent ideas, occasioned by partial or imperfect sleep. There is a variety in the suspension of the faculties and operations of the mind in this state of the system. In some cases the imagination only is deranged in dreams, in others the memory is affected, and in others the judgment. But there are cases, in which the change that is produced in the state of the brain, by means of sleep, affects the moral faculty likewise; hence we sometimes dream of doing and saying things when asleep, which we shudder at, as soon as we awake. This supposed defection from virtue, exists frequently in dreams where the memory and judgment are scarcely impaired. It cannot therefore be ascribed to an absence of the exercises of those two powers of the mind.
11. Do we read, in the accounts of travellers, of men, who, in respect of intellectual capacity and enjoyments, are but a few degrees above brutes? We read likewise of a similar degradation of our species, in respect to moral capacity and feeling. Here it will be necessary to remark, that the low degrees of moral perception, that have been discovered in certain African and Russian tribes of men, no more invalidate our proposition of the universal and essential existence of a moral faculty in the human mind, than the low state of their intellects prove, that reason is not natural to man. Their perceptions of good and evil are in an exact proportion to their intellectual faculties. But I will go further, and admit with Mr. Locke[7], that some savage nations are totally devoid of the moral faculty, yet it will by no means follow, that this was the original constitution of their minds. The appetite for certain aliments is uniform among all mankind. Where is the nation and the individual, in their primitive state of health, to whom bread is not agreeable? But if we should find savages, or individuals, whose stomachs have been so disordered by intemperance, as to refuse this simple and wholesome article of diet, shall we assert that this was the original constitution of their appetites? By no means. As well might we assert, because savages destroy their beauty by painting and cutting their faces, that the principles of taste do not exist naturally in the human mind. It is with virtue as with fire. It exists in the mind, as fire does in certain bodies, in a latent or quiescent state. As collision renders the one sensible, so education renders the other visible. It would be as absurd to maintain, because olives become agreeable to many people from habit, that we have no natural appetites for any other kind of food, as to assert that any part of the human species exist without a moral principle, because in some of them, it has wanted causes to excite it into action, or has been perverted by example. There are appetites that are wholly artificial. There are tastes so entirely vitiated, as to perceive beauty in deformity. There are torpid and unnatural passions. Why, under certain unfavourable circumstances, may there not exist also a moral faculty, in a state of sleep, or subject to mistakes?
The only apology I shall make, for presuming to differ from that justly-celebrated oracle[8], who first unfolded to us a map of the intellectual world, shall be, that the eagle eye of genius often darts its views beyond the notice of facts, which are accommodated to the slender organs of perception of men, who possess no other talent than that of observation.
It is not surprising, that Mr. Locke has confounded this moral principle with reason, or that Lord Shafts bury has confounded it with taste, since all three of these faculties agree in the objects of their approbation, notwithstanding they exist in the mind independently of each other. The favourable influence which the progress of science and taste has had upon the morals, can be ascribed to nothing else, but to the perfect union that subsists in nature between the dictates of reason, of taste, and of the moral faculty. Why has the spirit of humanity made such rapid progress for some years past in the courts of Europe? It is because kings and their ministers have been taught to reason upon philosophical subjects. Why have indecency and profanity been banished from the stage in London and Paris? It is because immorality is an offence against the highly cultivated taste of the French and English nations.
It must afford great pleasure to the lovers of virtue, to behold the depth and extent of this moral principle in the human mind. Happily for the human race, the intimations of duty and the road to happiness are not left to the slow operations or doubtful inductions of reason, nor to the precarious decisions of taste. Hence we often find the moral faculty in a state of vigour, in persons in whom reason and taste exist in a weak, or in an uncultivated state. It is worthy of notice, likewise, that while second thoughts are best in matters of judgment, first thoughts are always to be preferred in matters that relate to morality. Second thoughts, in these cases, are generally pearlies between duty and corrupted inclinations. Hence Rousseau has justly said, that “a well regulated moral instinct is the surest guide to happiness.”
It must afford equal pleasure to the lovers of virtue to behold, that our moral conduct and happiness are not committed to the determination of a single legislative power. The conscience, like a wise and faithful legislative council, performs the office of a check upon the moral faculty, and thus prevents the fatal consequences of immoral actions.
An objection, I foresee, will arise to the doctrine of the influence of physical causes upon the moral faculty, from its being supposed to favour the opinion of the materiality of the soul. But I do not see that this doctrine obliges us to decide upon the question of the nature of the soul, any more than the facts which prove the influence of physical causes upon the memory, the imagination, or the judgment. I shall, however, remark upon this subject, that the writers in favour of the immortality of the soul have done that truth great injury, by connecting it necessarily with its immateriality. The immortality of the soul depends upon the will of the Deity, and not upon the supposed properties of spirit. Matter is in its own nature as immortal as spirit. It is resolvable by heat and mixture into a variety of forms; but it requires the same Almighty hand to annihilate it, that it did to create it. I know of no arguments to prove the immortality of the soul, but such as are derived from the Christian revelation[9]. It would be as reasonable to assert, that the bason of the ocean is immortal, from the greatness of its capacity to hold water; or that we are to live for ever in this world, because we are afraid of dying, as to maintain the immortality of the soul, from the greatness of its capacity for knowledge and happiness, or from its dread of annihilation.
I remarked, in the beginning of this discourse, that persons who are deprived of the just exercise of memory, imagination, or judgment, were proper subjects of medicine; and that there are many cases upon record which prove, that the diseases from the derangement of these faculties, have yielded to the healing art.
It is perhaps only because the diseases of the moral faculty have not been traced to a connection with physical causes, that medical writers have neglected to give them a place in their systems of nosology, and that so few attempts have been hitherto made, to lessen or remove them by physical as well as rational and moral remedies.
I shall not attempt to derive any support to my opinions, from the analogy of the influence of physical causes upon the temper and conduct of brute animals. The facts which I shall produce in favour of the action of these causes upon morals in the human species, will, I hope, render unnecessary the arguments that might be drawn from that quarter.
I am aware, that in venturing upon this subject, I step upon untrodden ground. I feel as Æneas did, when he was about to enter the gates of Avernus, but without a sybil to instruct me in the mysteries that are before me. I foresee, that men who have been educated in the mechanical habits of adopting popular or established opinions will revolt at the doctrine I am about to deliver, while men of sense and genius will hear my propositions with candour, and if they do not adopt them, will commend that boldness of inquiry, that prompted me to broach them.
I shall begin with an attempt to supply the defects of nosological writers, by naming the partial or weakened action of the moral faculty, MICRONOMIA. The total absence of this faculty, I shall call ANOMIA. By the law, referred to in these new genera of vesaniæ, I mean the law of nature written in the human heart, and which I formerly quoted from the writings of St. Paul.
In treating of the effects of physical causes upon the moral faculty, it might help to extend our ideas upon this subject, to reduce virtues and vices to certain species, and to point out the effects of particular species of virtue and vice; but this would lead us into a field too extensive for the limits of the present inquiry. I shall only hint at a few cases, and have no doubt but the ingenuity of my auditors will supply my silence, by applying the rest.
It is immaterial, whether the physical causes that are to be enumerated, act upon the moral faculty through the medium of the senses, the passions, the memory, or the imagination. Their influence is equally certain, whether they act as remote, predisposing, or occasional causes.
1. The effects of CLIMATE upon the moral faculty claim our first attention. Not only individuals, but nations, derive a considerable part of their moral, as well as intellectual character, from the different portions they enjoy of the rays of the sun. Irascibility, levity, timidity, and indolence, tempered with occasional emotions of benevolence, are the moral qualities of the inhabitants of warm climates, while selfishness, tempered with sincerity and integrity, form the moral character of the inhabitants of cold countries. The state of the weather, and the seasons of the year also, have a visible effect upon moral sensibility. The month of November, in Great Britain, rendered gloomy by constant fogs and rains, has been thought to favour the perpetration of the worst species of murder, while the vernal sun, in middle latitudes, has been as generally remarked for producing gentleness and benevolence.
2. The effects of DIET upon the moral faculty are more certain, though less attended to, than the effects of climate. “Fulness of bread,” we are told, was one of the predisposing causes of the vices of the cities of the plain. The fasts so often inculcated among the Jews, were intended to lessen the incentives to vice; for pride, cruelty, and sensuality, are as much the natural consequences of luxury, as apoplexies and palsies. But the quality as well as the quantity of aliment, has an influence upon morals; hence we find the moral diseases that have been mentioned, are most frequently the offspring of animal food. The prophet Isaiah seems to have been sensible of this, when he ascribes such salutary effects to a temperate and vegetable diet. “Butter and honey shall he eat,” says he, “that he may know to refuse the evil, and to chuse the good.” But we have many facts which prove the efficacy of a vegetable diet upon the passions. Dr. Arbuthnot assures us, that he cured several patients of irascible tempers, by nothing but a prescription of this simple and temperate regimen.
3. The effects of CERTAIN DRINKS upon the moral faculty are not less observable, than upon the intellectual powers of the mind. Fermented liquors, of a good quality, and taken in a moderate quantity, are favourable to the virtues of candour, benevolence, and generosity; but when they are taken in excess, or when they are of a bad quality, and taken even in a moderate quantity, they seldom fail of rousing every latent spark of vice into action. The last of these facts is so notorious, that when a man is observed to be ill-natured or quarrelsome in Portugal, after drinking, it is common in that country to say, that “he has drunken bad wine.” While occasional fits of intoxication produce ill-temper in many people, habitual drunkenness (which is generally produced by distilled spirits) never fails to eradicate veracity and integrity from the human mind. Perhaps this may be the reason why the Spaniards, in ancient times, never admitted a man's evidence in a court of justice, who had been convicted of drunkenness. Water is the universal sedative of turbulent passions; it not only promotes a general equanimity of temper, but it composes anger. I have heard several well-attested cases, of a draught of cold water having suddenly composed this violent passion, after the usual remedies of reason had been applied to no purpose.
4. Extreme hunger produces the most unfriendly effects upon moral sensibility. It is immaterial, whether it act by inducing a relaxation of the solids, or an acrimony of the fluids, or by the combined operations of both those physical causes. The Indians in this country whet their appetites for that savage species of war, which is peculiar to them, by the stimulus of hunger; hence, we are told, they always return meagre and emaciated from their military excursions. In civilized life we often behold this sensation to overbalance the restraints of moral feeling; and perhaps this may be the reason why poverty, which is the most frequent parent of hunger, disposes so generally to theft; for the character of hunger is taken from that vice: it belongs to it “to break through stone walls.” So much does this sensation predominate over reason and moral feeling, that Cardinal de Retz suggests to politicians, never to risk a motion in a popular assembly, however wise or just it may be, immediately before dinner. That temper must be uncommonly guarded, which is not disturbed by long abstinence from food. One of the worthiest men I ever knew, who made his breakfast his principal meal, was peevish and disagreeable to his friends and family, from the time he left his bed, till he sat down to his morning repast, after which, cheerfulness sparkled in his countenance, and he became the delight of all around him.
5. I hinted formerly, in proving the analogy between the effects of DISEASES upon the intellects, and upon the moral faculty, that the latter was frequently impaired by madness. I beg leave to add further upon this head, that not only madness, but the hysteria and hypochondriasis, as well as all those states of the body, whether idiopathic or symptomatic, which are accompanied with preternatural irritability, sensibility, torpor, stupor, or mobility of the nervous system, dispose to vice, either of the body or of the mind. It is in vain to attack these vices with lectures upon morality. They are only to be cured by medicine, particularly by exercise, the cold bath, and by a cold or warm atmosphere. The young woman, whose case I mentioned formerly, that lost her habit of veracity by a nervous fever, recovered this virtue, as soon as her system recovered its natural tone, from the cold weather which happily succeeded her fever[10].
6. Idleness is the parent of every vice. It is mentioned in the Old Testament as another of the predisposing causes of the vices of the cities of the plain. Labour, of all kinds, favours and facilitates the practice of virtue. The country life is happy, chiefly because its laborious employments are favourable to virtue, and unfriendly to vice. It is a common practice, I have been told, for the planters, in the southern states, to consign a house slave, who has become vicious from idleness, to the drudgery of the field, in order to reform him. The bridewells and workhouses of all civilized countries prove, that labour is not only a very severe, but the most benevolent of all punishments, inasmuch as it is one of the most suitable means of reformation. Mr. Howard tells us, in his History of Prisons, that in Holland it is a common saying, “Make men work, and you will make them honest.” And over the rasp and spinhouse at Grœningen, this sentiment is expressed (he tells us) by a happy motto:
“Vitiorum semina—otium—labore exhauriendum.”
The effects of steady labour in early life, in creating virtuous habits, is still more remarkable. The late Anthony Benezet, of this city, whose benevolence was the centinel of the virtue, as well as of the happiness of his country, made it a constant rule, in binding out poor children, to avoid putting them into wealthy families, but always preferred masters for them who worked themselves, and who obliged these children to work in their presence. If the habits of virtue, contracted by means of this apprenticeship to labour, are purely mechanical, their effects are, nevertheless, the same upon the happiness of society, as if they flowed from principle. The mind, moreover, when preserved by these means from weeds, becomes a more mellow soil afterwards, for moral and rational improvement.
7. The effects of EXCESSIVE SLEEP are intimately connected with the effects of idleness upon the moral faculty: hence we find that moderate, and even scanty portions of sleep, in every part of the world, have been found to be friendly, not only to health and long life, but in many instances to morality. The practice of the monks, who often sleep upon a floor, and who generally rise with the sun, for the sake of mortifying their sensual appetites, is certainly founded in wisdom, and has often produced the most salutary moral effects.
8. The effects of bodily pain upon the moral, are not less remarkable than upon the intellectual powers of the mind. The late Dr. Gregory, of the university of Edinburgh, used to tell his pupils, that he always found his perceptions quicker in a fit of the gout, than at any other time. The pangs which attend the dissolution of the body, are often accompanied with conceptions and expressions upon the most ordinary subjects, that discover an uncommon elevation of the intellectual powers. The effects of bodily pain are exactly the same in rousing and directing the moral faculty. Bodily pain, we find, was one of the remedies employed in the Old Testament, for extirpating vice, and promoting virtue: and Mr. Howard tells us, that he saw it employed successfully as a means of reformation, in one of the prisons which he visited. If pain has a physical tendency to cure vice, I submit it to the consideration of parents and legislators, whether moderate degrees of corporal punishments, inflicted for a great length of time, would not be more medicinal in their effects, than the violent degrees of them, which are of short duration.
9. Too much cannot be said in favour of CLEANLINESS, as a physical means of promoting virtue. The writings of Moses have been called by military men, the best “orderly book” in the world. In every part of them we find cleanliness inculcated with as much zeal, as if it was part of the moral, instead of the Levitical law. Now, it is well known, that the principal design of every precept and rite of the ceremonial parts of the Jewish religion, was to prevent vice, and to promote virtue. All writers upon the leprosy, take notice of its connection with a certain vice. To this disease gross animal food, particularly swine's flesh, and a dirty skin, have been thought to be predisposing causes: hence the reason, probably, why pork was forbidden, and why ablutions of the body and limbs were so frequently inculcated by the Jewish law. Sir John Pringle's remarks, in his Oration upon Captain Cook's voyage, delivered before the Royal Society, in London, are very pertinent to this part of our subject. “Cleanliness (says he) is conducive to health, but it is not so obvious, that it also tends to good order and other virtues. Such (meaning the ship's crew) as were made more cleanly, became more sober, more orderly, and more attentive to duty.” The benefit to be derived by parents and schoolmasters from attending to these facts, is too obvious to be mentioned.
10. I hope I shall be excused in placing SOLITUDE among the physical causes which influence the moral faculty, when I add, that I confine its effects to persons who are irreclaimable by rational or moral remedies. Mr. Howard informs us, that the chaplain of the prison at Leige, in Germany, assured him, “that the most refractory and turbulent spirits became tractable and submissive, by being closely confined for four or five days.” In bodies that are predisposed to vice, the stimulus of cheerful, but much more of profane society and conversation, upon the animal spirits, becomes an exciting cause, and, like the stroke of the flint upon the steel, renders the sparks of vice both active and visible. By removing men out of the reach of this exciting cause, they are often reformed, especially if they are confined long enough to produce a sufficient chasm in their habits of vice. Where the benefit of reflection and instruction from books can be added to solitude and confinement, their good effects are still more certain. To this philosophers and poets in every age have assented, by describing the life of a hermit as a life of passive virtue.
11. Connected with solitude, as a mechanical means of promoting virtue, SILENCE deserves to be mentioned in this place. The late Dr. Fothergill, in his plan of education for that benevolent institution at Ackworth, which was the last care of his useful life, says every thing that can be said in favour of this necessary discipline, in the following words: “To habituate children from their early infancy, to silence and attention, is of the greatest advantage to them, not only as a preparative to their advancement in religious life, but as the groundwork of a well cultivated understanding. To have the active minds of children put under a kind of restraint; to be accustomed to turn their attention from external objects, and habituated to a degree of abstracted quiet, is a matter of great consequence, and lasting benefit to them. Although it cannot be supposed, that young and active minds are always engaged in silence as they ought to be, yet to be accustomed thus to quietness, is no small point gained towards fixing a habit of patience, and recollection, which seldom forsakes those who have been properly instructed in this entrance of the school of wisdom, during the residue of their days.”
For the purpose of acquiring this branch of education, children cannot associate too early, nor too often with their parents, or with their superiors in age, rank, and wisdom.
12. The effects of MUSIC upon the moral faculty, have been felt and recorded in every country. Hence we are able to discover the virtues and vices of different nations, by their tunes, as certainly as by their laws. The effects of music, when simply mechanical, upon the passions, are powerful and extensive. But it remains yet to determine the degrees of moral ecstacy,[** sic] that may be produced by an attack upon the ear, the reason, and the moral principle, at the same time, by the combined powers of music and eloquence.
13. The ELOQUENCE of the PULPIT is nearly allied to music in its effects upon the moral faculty. It is true, there can be no permanent change in the temper, and moral conduct of a man, that is not derived from the understanding and the will; but we must remember, that these two powers of the mind are most assailable, when they are attacked through the avenue of the passions; and these, we know, when agitated by the powers of eloquence, exert a mechanical action upon every power of the soul. Hence we find in every age and country, where christianity has been propagated, the most accomplished orators have generally been the most successful reformers of mankind. There must be a defect of eloquence in a preacher, who, with the resources for oratory, which are contained in the Old and New Testaments, does not produce in every man who hears him, at least a temporary love of virtue. I grant that the eloquence of the pulpit alone cannot change men into christians, but it certainly possesses the power of changing brutes into men. Could the eloquence of the stage be properly directed, it is impossible to conceive the extent of its mechanical effects upon morals. The language and imagery of a Shakespeare, upon moral and religious subjects, poured upon the passions and the senses, in all the beauty and variety of dramatic representation; who could resist, or describe their effects?
14. Odours of various kinds have been observed to act in the most sensible manner upon the moral faculty. Brydone tells us, upon the authority of a celebrated philosopher in Italy, that the peculiar wickedness of the people who live in the neighbourhood of Ætna and Vesuvius, is occasioned chiefly by the smell of the sulphur and of the hot exhalations which are constantly discharged from those volcanos. Agreeable odours seldom fail to inspire serenity, and to compose the angry spirits. Hence the pleasure, and one of the advantages of a flower garden. The smoke of tobacco is likewise of a composing nature, and tends not only to produce what is called a train in perception, but to hush the agitated passions into silence and order. Hence the practice of connecting the pipe or segar, and the bottle together, in public company.
15. It will be sufficient only to mention LIGHT and DARKNESS, to suggest facts in favour of the influence of each of them upon moral sensibility. How often do the peevish complaints of the night in sickness, give way to the composing rays of the light of the morning? Othello cannot murder Desdemona by candle-light, and who has not felt the effects of a blazing fire upon the gentle passions?
16. It is to be lamented, that no experiments have as yet been made, to determine the effects of all the different species of AIRS, which chemistry has lately discovered, upon the moral faculty. I have authority from actual experiments, only to declare, that dephlogisticated air, when taken into the lungs, produces cheerfulness, gentleness, and serenity of mind.
17. What shall we say of the effects of MEDICINES upon the moral faculty? That many substances in the materia medica act upon the intellects, is well known to physicians. Why should it be thought impossible for medicines to act in like manner upon the moral faculty? May not the earth contain, in its bowels, or upon its surface, antidotes? But I will not blend facts with conjectures. Clouds and darkness still hang upon this part of my subject.
Let it not be suspected, from any thing that I have delivered, that I suppose the influence of physical causes upon the moral faculty, renders the agency of divine influence unnecessary to our moral happiness. I only maintain, that the operations of the divine government are carried on in the moral, as in the natural world, by the instrumentality of second causes. I have only trodden in the footsteps of the inspired writers; for most of the physical causes I have enumerated, are connected with moral precepts, or have been used as the means of reformation from vice, in the Old and New Testaments. To the cases that have been mentioned, I shall only add, that Nebuchadnezzar was cured of his pride, by means of solitude and a vegetable diet. Saul was cured of his evil spirit, by means of David's harp, and St. Paul expressly says, “I keep my body under, and bring it into subjection, lest that by any means, when I have preached to others, I myself should be a cast-away.” But I will go one step further, and add in favour of divine influence upon the moral principle, that in those extraordinary cases, where bad men are suddenly reformed, without the instrumentality of physical, moral, or rational causes, I believe that the organization of those parts of the body, in which the faculties of the mind are seated, undergoes a physical change[11]; and hence the expression of a “new creature,” which is made use of in the Scriptures to denote this change, is proper in a literal, as well as a figurative sense. It is probably the beginning of that perfect renovation of the human body, which is predicted by St. Paul in the following words: “For our conversation is in heaven, from whence we look for the Saviour, who shall change our vile bodies, that they may be fashioned according to his own glorious body.” I shall not pause to defend myself against the charge of enthusiasm in this place; for the age is at length arrived, so devoutly wished for by Dr. Cheyne, in which men will not be deterred in their researches after truth, by the terror of odious or unpopular names.
I cannot help remarking under this head, that if the conditions of those parts of the human body which are connected with the human soul, influence morals, the same reason may be given for a virtuous education, that has been admitted for teaching music and the pronunciation of foreign languages, in the early and yielding state of those organs which form the voice and speech. Such is the effect of a moral education, that we often see its fruits in advanced stages of life, after the religious principles which were connected with it, have been renounced; just as we perceive the same care in a surgeon in his attendance upon patients, after the sympathy which first produced this care, has ceased to operate upon his mind. The boasted morality of the deists, is, I believe, in most cases, the offspring of habits, produced originally by the principles and precepts of christianity. Hence appears the wisdom of Solomon's advice, “Train up a child in the way he should go, and when he is old he will not,” I had almost said, he cannot “depart from it.”
Thus have I enumerated the principal causes which act mechanically upon morals. If from the combined action of physical powers that are opposed to each other, the moral faculty should become stationary, or if the virtue or vice produced by them, should form a neutral quality, composed of both of them, I hope it will not call in question the truth of our general propositions. I have only mentioned the effects of physical causes in a simple state[12].
It might help to enlarge our ideas upon this subject, to take notice of the influence of the different stages of society, of agriculture and commerce, of soil and situation, of the different degrees of cultivation of taste, and of the intellectual powers, of the different forms of government, and lastly, of the different professions and occupations of mankind, upon the moral faculty; but as these act indirectly only, and by the intervention of causes that are unconnected with matter, I conceive they are foreign to the business of the present inquiry. If they should vary the action of the simple physical causes in any degree, I hope it will not call in question the truth of our general propositions, any more than the compound action of physical powers, that are opposed to each other. There remain but a few more causes which are of a compound nature, but they are so nearly related to those which are purely mechanical, that I shall beg leave to trespass upon your patience, by giving them a place in my oration.
The effects of imitation, habit, and association upon morals, would furnish ample matter for investigation. Considering how much the shape, texture, and conditions of the human body, influence morals, I submit it to the consideration of the ingenious, whether, in our endeavours to imitate moral examples, some advantage may not be derived, from our copying the features and external manners of the originals. What makes the success of this experiment probable is, that we generally find men, whose faces resemble each other, have the same manners and dispositions. I infer the possibility of success in an attempt to imitate originals in a manner that has been mentioned, from the facility with which domestics acquire a resemblance to their masters and mistresses, not only in manners, but in countenance, in those cases where they are tied to them by respect and affection. Husbands and wives also, where they possess the same species of face, under circumstances of mutual attachment, often acquire a resemblance to each other.
From the general detestation in which hypocrisy is held, both by good and bad men, the mechanical effects of habit upon virtue have not been sufficiently explored. There are, I am persuaded, many instances where virtues have been assumed by accident, or necessity, which have become real from habit, and afterwards derived their nourishment from the heart. Hence the propriety of Hamlet's advice to his mother:
“Assume a virtue, if you have it not.
That monster, Custom, who all sense doth eat
Of habits evil, is angel yet in this,
That to the use of actions fair and good
He likewise gives a frock or livery,
That aptly is put on. Refrain to-night,
And that shall lend a kind of easiness
To the next abstinence; the next more easy:
For use can almost change the stamp of nature,
And master even the devil, or throw him out,
With wondrous potency.”
The influence of ASSOCIATION upon morals, opens an ample field for inquiry. It is from this principle, that we explain the reformation from theft and drunkenness in servants, which we sometimes see produced by a draught of spirits, in which tartar emetic had been secretly dissolved. The recollection of the pain and sickness excited by the emetic, naturally associates itself with the spirits, so as to render them both equally the objects of aversion. It is by calling in this principle only, that we can account for the conduct of Moses, in grinding the golden calf into a powder, and afterwards dissolving it (probably by means of hepar sulphuris) in water, and compelling the children of Israel to drink of it, as a punishment for their idolatry. This mixture is bitter and nauseating in the highest degree. An inclination to idolatry, therefore, could not be felt without being associated with the remembrance of this disagreeable mixture, and of course being rejected, with equal abhorrence. The benefit of corporal punishments, when they are of a short duration, depends in part upon their being connected, by time and place, with the crimes for which they are inflicted. Quick as the thunder follows the lightning, if it were possible, should punishments follow the crimes, and the advantage of association would be more certain, if the spot where they were committed, were made the theatre of their expiation. It is from the effects of this association, probably, that the change of place and company, produced by exile and transportation, has so often reclaimed bad men, after moral, rational, and physical means of reformation had been used to no purpose.
As SENSIBILITY is the avenue to the moral faculty, every thing which tends to diminish it tends also to injure morals. The Romans owed much of their corruption to the sights of the contests of their gladiators, and of criminals, with wild beasts. For these reasons, executions should never be public. Indeed, I believe there are no public punishments of any kind, that do not harden the hearts of spectators, and thereby lessen the natural horror which all crimes at first excite in the human mind.
Cruelty to brute animals is another means of destroying moral sensibility. The ferocity of savages has been ascribed in part to their peculiar mode of subsistence. Mr. Hogarth points out, in his ingenious prints, the connection between cruelty to brute animals in youth, and murder in manhood. The emperor Domitian prepared his mind, by the amusement of killing flies, for all those bloody crimes which afterwards disgraced his reign. I am so perfectly satisfied of the truth of a connection between morals and humanity to brutes, that I shall find it difficult to restrain my idolatry for that legislature, that shall first establish a system of laws, to defend them from outrage and oppression.
In order to preserve the vigour of the moral faculty, it is of the utmost consequence to keep young people as ignorant as possible of those crimes that are generally thought most disgraceful to human nature. Suicide, I believe, is often propagated by means of newspapers. For this reason, I should be glad to see the proceedings of our courts kept from the public eye, when they expose or punish monstrous vices.
The last mechanical method of promoting morality that I shall mention, is to keep sensibility alive, by a familiarity with scenes of distress from poverty and disease. Compassion never awakens in the human bosom, without being accompanied by a train of sister virtues. Hence the wise man justly remarks, that “By the sadness of the countenance, the heart is made better.”
A late French writer, in his prediction of events that are to happen in the year 4000, says, “That mankind in that æra shall be so far improved by religion and government, that the sick and the dying shall no longer be thrown, together with the dead, into splendid houses, but shall be relieved and protected in a connection with their families and society.” For the honour of humanity, an institution[13], destined for that distant period, has lately been founded in this city, that shall perpetuate the year 1786 in the history of Pennsylvania. Here the feeling heart, the tearful eye, and the charitable hand, may always be connected together, and the flame of sympathy, instead of being extinguished in taxes, or expiring in a solitary blaze by a single contribution, may be kept alive, by constant exercise. There is a necessary connection between animal sympathy, and good morals. The priest and the Levite, in the New Testament, would probably have relieved the poor man who fell among thieves, had accident brought them near enough to his wounds. The unfortunate Mrs. Bellamy was rescued from the dreadful purpose of drowning herself, by nothing but the distress of a child, rending the air with its cries for bread. It is probably owing, in some measure, to the connection between good morals and sympathy that the fair sex, in every age and country, have been more distinguished for virtue, than men; for how seldom do we hear of a woman, devoid of humanity?
Lastly, ATTRACTION, COMPOSITION, and DECOMPOSITION, belong to the passions as well as to matter. Vices of the same species attract each other with the most force: hence the bad consequences of crowding young men, whose propensities are generally the same, under one roof, in our modern plans of education. The effects of composition and decomposition upon vices, appear in the meanness of the school-boy being often cured by the prodigality of a military life, and by the precipitation of avarice, which is often produced by ambition and love.
If physical causes influence morals in the manner we have described, may they not also influence religious principles and opinions? I answer in the affirmative; and I have authority, from the records of physic, as well as from my own observations, to declare, that religious melancholy and madness, in all their variety of species, yield with more facility to medicine, than simply to polemical discourses, or to casuistical advice. But this subject is foreign to the business of the present inquiry.
From a review of our subject, we are led to contemplate with admiration, the curious structure of the human mind. How distinct are the number, and yet how united! How subordinate, and yet how co-equal are all its faculties! How wonderful is the action of the mind upon the body! of the body upon the mind! and of the Divine Spirit upon both! What a mystery is the mind of man to itself!——O! Nature!——or, to speak more properly, O! thou God of Nature! in vain do we attempt to scan THY immensity, or to comprehend THY various modes of existence, when a single particle of light, issued from THYSELF, and kindled into intelligence in the bosom of man, thus dazzles and confounds our understandings!
The extent of the moral powers and habits in man is unknown. It is not improbable, but the human mind contains principles of virtue, which have never yet been excited into action. We behold with surprise the versatility of the human body in the exploits of tumblers and rope-dancers. Even the agility of a wild beast has been demonstrated in a girl of France, and an amphibious nature has been discovered in the human species, in a young man in Spain. We listen with astonishment to the accounts of the memories of Mithridates, Cyrus, and Servin. We feel a veneration bordering upon divine homage, in contemplating the stupenduous understandings of lord Verulam and sir Isaac Newton; and our eyes grow dim, in attempting to pursue Shakespeare and Milton in their immeasurable flights of imagination. And if the history of mankind does not furnish similar instances of the versatility and perfection of our species in virtue, it is because the moral faculty has been the subject of less culture and fewer experiments than the body, and the intellectual faculties of the mind. From what has been said, the reason of this is obvious. Hitherto the cultivation of the moral faculty has been the business of parents, schoolmasters, and divines[14]. But if the principles, we have laid down, be just, the improvement and extension of this principle should be equally the business of the legislator, the natural philosopher, and the physician; and a physical regimen should as necessarily accompany a moral precept, as directions with respect to the air, exercise, and diet, generally accompany prescriptions for the consumption, and the gout. To encourage us to undertake experiments for the improvement of morals, let us recollect the success of philosophy in lessening the number, and mitigating the violence of incurable diseases. The intermitting fever, which proved fatal to two of the monarchs of Britain, is now under absolute subjection to medicine. Continual fevers are much less fatal than formerly. The small-pox is disarmed of its mortality by inoculation, and even the tetanus and the cancer have lately received a check in their ravages upon mankind. But medicine has done more. It has penetrated the deep and gloomy abyss of death, and acquired fresh honours in his cold embraces. Witness the many hundred people who have lately been brought back to life by the successful efforts of the humane societies, which are now established in many parts of Europe, and in some parts of America. Should the same industry and ingenuity, which have produced these triumphs of medicine over diseases and death, be applied to the moral science, it is highly probable, that most of those baneful vices, which deform the human breast, and convulse the nations of the earth, might be banished from the world. I am not so sanguine as to suppose, that it is possible for man to acquire so much perfection from science, religion, liberty, and good government, as to cease to be mortal; but I am fully persuaded, that from the combined action of causes, which operate at once upon the reason, the moral faculty, the passions, the senses, the brain, the nerves, the blood, and the heart, it is possible to produce such a change in his moral character, as shall raise him to a resemblance of angels; nay, more, to the likeness of God himself. The state of Pennsylvania still deplores the loss of a man, in whom not only reason and revelation, but many of the physical causes that have been enumerated, concurred to produce such attainments in moral excellency, as have seldom appeared in a human being. This amiable citizen considered his fellow-creature, man, as God's extract, from his own works; and whether this image of himself was cut out from ebony or copper; whether he spoke his own, or a foreign language; or whether he worshipped his Maker with ceremonies, or without them, he still considered him as a brother, and equally the object of his benevolence. Poets and historians, who are to live hereafter, to you I commit his panegyric; and when you hear of a law for abolishing slavery in each of the American states, such as was passed in Pennsylvania, in the year 1780; when you hear of the kings and queens of Europe, publishing edicts for abolishing the trade in human souls; and, lastly, when you hear of schools and churches, with all the arts of civilized life, being established among the nations of Africa, then remember and record, that this revolution in favour of human happiness, was the effect of the labours, the publications, the private letters, and the prayers of Anthony Benezet[15].
I return from this digression, to address myself in a particular manner to you, VENERABLE SAGES and FELLOW CITIZENS in the REPUBLIC OF LETTERS. The influence of philosophy, we have been told, has already been felt in courts. To increase, and complete this influence, there is nothing more necessary, than for the numerous literary societies in Europe and America, to add the SCIENCE OF MORALS to their experiments and inquiries. The godlike scheme of Henry IV, of France, and of the illustrious queen Elizabeth, of England, for establishing a perpetual peace in Europe, may be accomplished without a system of jurisprudence, by a confederation of learned men, and learned societies. It is in their power, by multiplying the objects of human reason, to bring the monarchs and rulers of the world under their subjection, and thereby to extirpate war, slavery, and capital punishments, from the list of human evils. Let it not be suspected that I detract, by this declaration, from the honour of the Christian religion. It is true, Christianity was propagated without the aid of human learning; but this was one of those miracles, which was necessary to establish it, and which, by repetition, would cease to be a miracle. They misrepresent the Christian religion, who suppose it to be wholly an internal revelation, and addressed only to the moral faculties of the mind. The truths of Christianity afford the greatest scope for the human understanding, and they will become intelligible to us, only in proportion as the human genius is stretched, by means of philosophy, to its utmost dimensions. Errors may be opposed to errors; but truths, upon all subjects, mutually support each other. And perhaps one reason why some parts of the Christian revelation are still involved in obscurity, may be occasioned by our imperfect knowledge of the phenomena and laws of nature. The truths of philosophy and Christianity dwell alike in the mind of the Deity, and reason and religion are equally the offspring of his goodness. They must, therefore, stand and fall together. By reason, in the present instance, I mean the power of judging of truth, as well as the power of comprehending it. Happy æra! when the divine and the philosopher shall embrace each other, and unite their labours for the reformation and happiness of mankind!
Illustrious counsellors and SENATORS of Pennsylvania[16]! I anticipate your candid reception of this feeble effort to increase the quantity of virtue in our republic. It is not my business to remind you of the immense resources for greatness, which nature and Providence have bestowed upon our state. Every advantage which France has derived from being placed in the centre of Europe, and which Britain has derived from her mixture of nations, Pennsylvania has opened to her. But my business, at present, is to suggest the means of promoting the happiness, not the greatness, of the state. For this purpose, it is absolutely necessary that our government, which unites into one, all the minds of the state, should possess, in an eminent degree, not only the understanding, the passions, and the will, but, above all, the moral faculty and the conscience of an individual. Nothing can be politically right, that is morally wrong; and no necessity can ever sanctify a law, that is contrary to equity. Virtue is the soul of a republic. To promote this, laws for the suppression of vice and immorality will be as ineffectual, as the increase and enlargement of jails. There is but one method of preventing crimes, and of rendering a republican form of government durable, and that is, by disseminating the seeds of virtue and knowledge through every part of the state, by means of proper modes and places of education, and this can be done effectually only by the interference and aid of the legislature. I am so deeply impressed with the truth of this opinion, that were this evening to be the last of my life, I would not only say to the asylum of my ancestors, and my beloved native country, with the patriot of Venice, “Esto perpetua,” but I would add, as the last proof of my affection for her, my parting advice to the guardians of her liberties, “To establish and support PUBLIC SCHOOLS, in every part of the state.”
Footnotes:
[1] Rom. i. 14, 15.
[2] Oration pro Milne.
[3] Vol. III. p. [216], [217].
[4] Milton seems to have been of this opinion. Hence, after ascribing repentance to Satan, he makes him declare,
“Farewell remorse: all good to me is lost,
Evil, be thou my good.”——
Paradise Lost, Book IV.
[5] I have selected this case from many others, which have come under my notice, in which the moral faculty appeared to be impaired by diseases, particularly by the typhus of Dr. Cullen, and by those species of palsy which affect the brain.
[6] Xenophon makes Cyrus declare, in his last moments, “That the soul of man, at the hour of death, appears most divine, and then foresees something of future events.”
[7] Essay concerning the Human Understanding, book I. chap. 3.
[8] Mr. Locke.
[9] “Life and immortality are brought to light only through the gospel.” 2 Tim. i. 10.
[10] There is a morbid state of excitability in the body during the convalescence from fever, which is intimately connected with an undue propensity to venereal pleasures. I have met with several instances of it. The marriage of the celebrated Mr. Howard to a woman who was twice as old as himself, and very sickly, has been ascribed, by his biographer, Dr. Aiken, to gratitude for her great attention to him in a fit of sickness. I am disposed to ascribe it to a sudden paroxysm of another passion, which, as a religious man, he could not gratify in any other, than in a lawful way. I have heard of two young clergymen who married the women who had nursed them in fits of sickness. In both cases there was great inequality in their years, and condition in life. Their motive was, probably, the same as that which I have attributed to Mr. Howard. Dr. Patrick Russel takes notice of an uncommon degree of venereal excitability which followed attacks of the plague at Messina, in 1743, in all ranks of people. Marriages, he says, were more frequent after it than usual, and virgins were, in some instances, violated, who died of that disease, by persons who had just recovered from it.
[11] St. Paul was suddenly transformed from a persecutor into a man of a gentle and amiable spirit. The manner in which this change was effected upon his mind, he tells us in the following words: “Neither circumcision availeth any thing, nor uncircumcision, but a new creature. From henceforth let no man trouble me; for I bear in my body, the marks of our Lord Jesus.” Galatians, vi. 15, 17.
[12] The doctrine of the influence of physical causes on morals is happily calculated to beget charity towards the failings of our fellow-creatures. Our duty to practise this virtue is enforced by motives drawn from science, as well as from the precepts of christianity.
[13] A public dispensary.
[14] The people commonly called Quakers and the Methodists, make use of the greatest number of physical remedies in their religious and moral discipline, of any sects of Christians; and hence we find them every where distinguished for their good morals. There are several excellent physical institutions in other churches; and if they do not produce the same moral effects that we observe from physical institutions among those two modern sects, it must be ascribed to their being more neglected by the members of those churches.
[15] This worthy man was descended from an ancient and honourable family that flourished in the court of Louis XIV. With liberal prospects in life he early devoted himself to teaching an English school; in which, for industry, capacity, and attention to the morals and principles of the youth committed to his care, he was without an equal. He published many excellent tracts against the African trade, against war, and the use of spiritous liquors, and one in favour of civilizing and Christianizing the Indians. He wrote to the queen of Great Britain, and the queen of Portugal, to use their influence in their respective courts to abolish the African trade. He also wrote an affectionate letter to the king of Prussia, to dissuade him from making war. The history of his life affords a remarkable instance how much it is possible for an individual to accomplish in the world; and that the most humble stations do not preclude good men from the most extensive usefulness. He bequeathed his estate (after the death of his widow) to the support of a school for the education of negro children, which he had founded and taught for several years before he died. He departed this life in May, 1784, in the 71st year of his age, in the meridian of his usefulness, universally lamented by persons of all ranks and denominations.
[16] The president, and supreme executive council, and the members of the general assembly of Pennsylvania, attended the delivery of the oration, in the hall of the university, by invitation from the Philosophical Society.
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.
1. To avoid fatigue. Too much cannot be said to enforce this direction. It is the hinge on which the recovery or death of a consumptive patient frequently turns. I repeat it again, therefore, that patients should be charged over and over when they set off on a journey, as well as when they use exercise of any kind, to avoid fatigue. For this purpose they should begin by travelling only a few miles in a day, and increase the distance of their stages, as they increase their strength. By neglecting this practice, many persons have returned from journies much worse than when they left home, and many have died in taverns, or at the houses of their friends on the road. Travelling in stage-coaches is seldom safe for a consumptive patient. They are often crowded; they give too much motion; and they afford by their short delays and distant stages, too little time for rest, or for taking the frequent refreshment which was formerly recommended.
2. To avoid travelling too soon in the morning, and after the going down of the sun in the evening, and, if the weather be hot, never to travel in the middle of the day. The sooner a patient breakfasts after he leaves his bed the better; and in no case should he leave his morning stage with an empty stomach.
3. If it should be necessary for a patient to lie down, or to sleep in the day time, he should be advised to undress himself, and to cover his body between sheets or blankets. The usual ligatures of garters, stocks, knee-bands, waistcoats, and shoes, are very unfriendly to sound sleep; hence persons who lie down with their clothes on, often awake from an afternoon's nap in terror from dreams, or in a profuse sweat, or with a head-ach or sick stomach; and generally out of humour. The surveyors are so sensible of the truth of this remark, that they always undress themselves when they sleep in the woods. An intelligent gentleman of this profession informed me, that he had frequently seen young woodsmen, who had refused to conform to this practice, so much indisposed in the morning, that, after the experience of a few nights, they were forced to adopt it.
Great care should be taken in sleeping, whether in the day time or at night, never to lie down in damp sheets. Dr. Sydenham excepts the danger from this quarter, when he speaks of the efficacy of travelling on horseback in curing the consumption.
4. Patients who travel for health in this disease should avoid all large companies, more especially evening and night parties. The air of a contaminated room, phlogisticated by the breath of fifteen or twenty persons, and by the same number of burning candles, is poison to a consumptive patient. To avoid impure air from every other source, he should likewise avoid sleeping in a crowded room, or with curtains around his bed, and even with a bed-fellow.
5. Travelling, to be effectual in this disease, should be conducted in such a manner as that a patient may escape the extremes of heat and cold. For this purpose he should pass the winter, and part of the spring, in Georgia or South-Carolina, and the summer in New-Hampshire, Massachusetts, or Vermont, or, if he pleases, he may still more effectually shun the summer heats, by crossing the lakes, and travelling along the shores of the St. Laurence to the city of Quebec. He will thus escape the extremes of heat and cold, particularly the less avoidable one of heat; for I have constantly found the hot month of July to be as unfriendly to consumptive patients in Pennsylvania, as the variable month of March. By these means too he will enjoy nearly an equable temperature of air in every month of the year; and his system will be free from the inconvenience of the alternate action of heat and cold upon it. The autumnal months should be spent in New-Jersey or Pennsylvania.
In these journies from north to south, or from south to north, he should be careful, for reasons before mentioned, to keep at as great a distance as possible from the sea coast. Should this inquiry fall into the hands of a British physician, I would beg leave to suggest to him, whether more advantages would not accrue to his consumptive patients from advising them to cross the Atlantic ocean, and afterwards to pursue the tour which I have recommended, than by sending them to Portugal, France, or Italy. Here they will arrive with such a mitigation of the violence of the disease, in consequence of the length of their sea voyage, as will enable them immediately to begin their journies on horseback. Here they will be exposed to fewer temptations to intemperance, or to unhealthy amusements, than in old European countries. And, lastly, in the whole course of this tour, they will travel among a people related to them by a sameness of language and manners, and by ancient or modern ties of citizenship. Long journies for the recovery of health, under circumstances so agreeable, should certainly be preferred to travelling among strangers of different nations, languages, and manners, on the continent of Europe.
6. To render travelling on horseback effectual in a consumption, it should be continued with moderate intervals from six to twelve months. But the cure should not be rested upon a single journey. It should be repeated every two or three years, till our patient has passed the consumptive stages of life. Nay, he must do more; he must acquire a habit of riding constantly, both at home and abroad; or, to use the words of Dr. Fuller, “he must, like a Tartar, learn to live on horseback, by which means he will acquire in time the constitution of a Tartar[34].”
Where benefit is expected from a change of climate, as well as from travelling, patients should reside at least two years in the place which is chosen for that purpose. I have seldom known a residence for a shorter time in a foreign climate do much service.
To secure a perfect obedience to medical advice, it would be extremely useful if consumptive patients could always be accompanied by a physician. Celsus says, he found it more easy to cure the dropsy in slaves than in freemen, because they more readily submitted to the restraints he imposed upon their appetites. Madness has become a curable disease in England, since the physicians of that country have opened private mad-houses, and have taken the entire and constant direction of their patients into their own hands. The same successful practice would probably follow the treatment of consumptions, if patients were constantly kept under the eye and authority of their physicians. The keenness of appetite, and great stock of animal spirits, which those persons frequently possess, hurry them into many excesses which defeat the best concerted plans of a recovery; or, if they escape these irregularities, they are frequently seduced from our directions by every quack remedy which is recommended to them. Unfortunately the cough becomes a signal of their disease, at every stage of their journey, and the easy or pleasant prescriptions of even hostlers and ferrymen, are often substituted to the self-denial and exertion which have been imposed by physicians. The love of life in these cases seems to level all capacities; for I have observed persons of the most cultivated understandings to yield in common with the vulgar, to the use of these prescriptions.
In a former volume I mentioned the good effects of accidental LABOUR in pulmonary consumptions. The reader will find a particular account in the first volume of Dr. Coxe's Medical Museum, of a clergyman and his wife, in Virginia, being cured by the voluntary use of that remedy.
The following circumstances and symptoms, indicate the longer or shorter duration of this disease, and its issue in life and death:
The consumption from gout, rheumatism, and scrophula, is generally of long duration. It is more rapid in its progress to death, when it arises from a half cured pleurisy, or neglected colds, measles, and influenza. It is of shorter duration in persons under thirty, than in those who are more advanced in life.
It is always dangerous in proportion to the length of time, in which the debilitating causes, that predisposed to it, have acted upon the body.
It is more dangerous when a predisposition to it has been derived from ancestors, than when it has been acquired.
It is generally fatal when accompanied with a bad conformation of the breast.
Chilly fits occurring in the forenoon, are more favourable than when they occur in the evening. They indicate the disease to partake a little of the nature of an intermittent, and are a call for the use of the remedies proper in that disease.
Rheumatic pains, attended with an abatement of the cough, or pains in the breast, are always favourable; so are
Eruptions, or an abscess on the external parts of the body, if they occur before the last stage of the disease.
A spitting of blood, in the early, or forming stage of the disease, is favourable, but after the lungs become much obstructed, or ulcerated, it is most commonly fatal.
A pleurisy, occurring in the low state of the disease, generally kills, but I have seen a case in which it suddenly removed the cough and hectic fever, and thus became the means of prolonging the patient's life for several years.
The discharge of calculi from the lungs by coughing and spitting, and of a thin watery liquid, with a small portion of pus swimming on its surface, are commonly signs of an incurable consumption.
No prediction unfavourable to life can be drawn from pus being discharged from the lungs. We see many recoveries after it has taken place, and many deaths where that symptom has been absent. Large quantities of pus are discharged in consumptions attended with abscesses, and yet few die of them, where they have not been preceded by long continued debility of the whole system. No pus is expectorated from tubercles, and how generally fatal is the disease, after they are formed in the lungs! It is only after they ulcerate that they discharge pus, and it is only after ulcers are thus formed, that the consumption probably becomes uniformly fatal. I suspect these ulcers are sometimes of a cancerous nature.
A sudden cessation of the cough, without a supervening diarrhœa, indicates death to be at hand.
A constant vomiting in a consumption, is generally a bad sign.
Feet obstinately cold, also a swelling of the feet during the day, and of the face in the night, commonly indicate a speedy and fatal issue of the disease.
Lice, and the falling off of the hair, often precede death.
A hoarseness, in the beginning of the disease, is always alarming, but it is more so in its last stage.
A change of the eyes from a blue, or dark, to a light colour, similar to that which takes place in very old people, is a sign of speedy dissolution.
I have never seen a recovery after an apthous sore throat took place.
Death from the consumption comes on in some or more than one, of the following ways:
1. With a diarrhœa. In its absence,
2. With wasting night sweats.
3. A rupture of an abscess.
4. A rupture of a large blood-vessel in the lungs, attended with external or internal hæmorrhage. Sudden and unexpected death in a consumption is generally induced by this, or the preceding cause.
5. Madness. The cough and expectoration cease with this disease. It generally carries off the patient in a week or ten days.
6. A pleurisy, brought on by exposure to cold.
7. A typhus fever, attended with tremors, twitchings of the tendons, and a dry tongue.
8. Swelled hands, feet, legs, thighs, and face.
9. An apthous sore throat.
10. Great and tormenting pains, sometimes of a spasmodic nature in the limbs.
In a majority of the fatal cases of consumption, which I have seen, the passage out of life has been attended with pain; but I have seen many persons die with it, in whom all the above symptoms were so lenient, or so completely mitigated by opium, that death resembled a quiet transition from a waking, to a sleeping state.
I cannot conclude this inquiry without adding, that the author of it derived from his paternal ancestors a predisposition to the pulmonary consumption, and that between the 18th and 43d years of his age, he has occasionally been afflicted with many of the symptoms of that disease which he has described. By the constant and faithful use of many of the remedies which he has recommended, he now, in the 61st year of his age, enjoys nearly an uninterrupted exemption from pulmonary complaints. In humble gratitude, therefore, to that Being, who condescends to be called the preserver of men, he thus publicly devotes this result of his experience and inquiries to the benefit of such of his fellow-creatures as may be afflicted with the same disease, sincerely wishing that they may be as useful to them, as they have been to the author.
Footnotes:
[18] Sir George Baker relates, in the second volume of the Medical Transactions, that Dr. Blanchard had informed him, that he had seen the consumption brought on ten persons out of ninety, by excessive purging used to prepare the body for the small-pox. I have seen a case of consumption in a youth of 17, from the spitting produced by the intemperate use of segars.
[19] Dr. Lind says, that out of 360 patients whom he attended between July 1st, 1758, and July 1st, 1760, in consumptions, the disease was brought on one fourth of them by falls, bruises, and strains, received a year or two before the disease made its appearance.
[20] Treatise of the Nature and Cure of Consumptions. Exercitation X.
[21] See Med. Com. Vol. II.
[22] Clinical and Anatomical Observations, p. 26, 27. See also Morgagni, letter xxii. 21.
[24] The three last-mentioned symptoms are taken notice of by Dr. Bennet, in his Treatise upon the Nature and Cure of the Consumption, as precursors of the disease. Dr. Boerhaave used to tell his pupils that they had never deceived him.
[25] I have seen the hoarseness in one case the first symptom of approaching consumption. In this symptom it preserves the analogy of pneumony, which often comes on with a hoarseness, and sometimes with paraphonia.
[26] Observations on Scrophulous Affections.
[27] Prunus Virginiana.
[28] An Account of the Effects of Common Salt in the Cure of Hæmoptysis.
[30] Medical Repository of New-York. Vol. V.
[31] Inquiry into the Diseases and Remedies of the Indians of North-America; and a comparative view of their diseases and remedies with those of civilized nations. Vol. I.
[32] Thoughts on the Pulmonary Consumption. Vol. I.
[33] The bad effects of inconstant exercise have been taken notice of in the gout. Dr. Sydenham says, when it is used only by fits and starts in this disease, it does harm.
[34] Medicina Gymnastica, p. 116.
OBSERVATIONS
ON
THE SYMPTOMS AND CURE
OF
DROPSIES.
Whether we admit the exhaling and absorbing vessels to be affected in general dropsies by preternatural debility, palsy, or rupture, or by a retrograde motion of their fluids, it is certain that their exhaling and absorbing power is materially affected by too much, or too little action in the arterial system. That too little action in the arteries should favour dropsical effusions, has been long observed; but it has been less obvious, that the same effusions are sometimes promoted, and their absorption prevented, by too much action in these vessels. That this fact should have escaped our notice is the more remarkable, considering how long we have been accustomed to seeing serous swellings in the joints in the acute rheumatism, and copious, but partial effusions of water in the form of sweat, in every species of inflammatory fever.
It is nothing new that the healthy action of one part, should depend upon the healthy action of another part of the system. We see it in many of the diseases of the nerves and brain. The tetanus is cured by exciting a tone in the arterial system; madness is cured by lessening the action of the arteries by copious blood-letting; and epilepsy and hysteria are often mitigated by the moderate use of the same remedy.
By too much action in the arterial system, I mean a certain morbid excitement in the arteries, accompanied by preternatural force, which is obvious to the sense of touch. It differs from the morbid excitement of the arteries, which takes place in common inflammatory fevers, in being attended by less febrile heat, and with little or no pain in the head or limbs. The thirst is nearly the same in this state of dropsy, as in inflammatory fevers. I include here those dropsies only in which the whole system is affected by what is called a hydropic diathesis.
That debility should, under certain circumstances, dispose to excessive action, and that excessive action should occur in one part of the body, at the same time that debility prevailed in every other, are abundantly evident from the history and phenomena of many diseases. Inflammatory fever, active hæmorrhages, tonic gout, asthma, apoplexy, and palsy, however much they are accompanied by excessive action in the arterial system, are always preceded by original debility, and are always accompanied by obvious debility in every other part of the system.
But it has been less observed by physicians that an undue force or excess of action occurs in the arterial system in certain dropsies, and that the same theory which explains the union of predisposing and nearly general debility, with a partial excitement and preternatural action in the arterial system, in the diseases before-mentioned, will explain the symptoms and cure of certain dropsies.
That debility predisposes to every state of dropsy, is evident from the history of all the remote and occasional causes which produce them. It will be unnecessary to mention these causes, as they are to be found in all our systems of physic. Nor will it be necessary to mention any proofs of the existence of debility in nearly every part of the body. It is too plain to be denied. I shall only mention the symptoms which indicate a morbid excitement and preternatural action of the arterial system. These are,
1. A hard, full, and quick pulse. This symptom, I believe, is more common in dropsies than is generally supposed, for many physicians visit and examine patients in these diseases, without feeling the pulse. Dr. Home mentions the frequency of the pulse, in the patients whose cures he has recorded[35], but he takes no notice of its force except in two cases. Dr. Zimmerman, in his account of the dropsy which terminated the life of Frederick II, of Prussia, tells us that he found his pulse hard and full. I have repeatedly found it full and hard in every form of dropsy, and more especially in the first stage of the disease. Indeed I have seldom found it otherwise in the beginning of the dropsy of the breast.
2. Sizy blood. This has been taken notice of by many practical writers, and has very justly been ascribed, under certain circumstances of blood-letting, to an excessive action of the vessels upon the blood.
3. Alternation of dropsies with certain diseases which were evidently accompanied by excess of action in the arterial system. I have seen anasarca alternate with vertigo, and both ascites and anasarca alternate with tonic madness. A case of nearly the same kind is related by Dr. Mead. Dr. Grimes, of Georgia, informed me that he had seen a tertian fever, in which the intermissions were attended with dropsical swellings all over the body, which suddenly disappeared in every accession of a paroxysm of the fever.
4. The occasional connection of certain dropsies with diseases evidently of an inflammatory nature, particularly pneumony, rheumatism, and gout.
5. Spontaneous hæmorrhages from the lungs, hæmorrhodial vessels, and nose, cases of which shall be mentioned hereafter, when we come to treat of the cure of dropsies.
6. The appearance of dropsies in the winter and spring, in habits previously affected by the intermitting fever. The debility produced by this state of fever, frequently disposes to inflammatory diathesis, as soon as the body is exposed to the alternate action of heat and cold, nor is this inflammatory diathesis always laid aside, by the transition of the intermitting fever into a dropsy, in the succeeding cold weather.
7. The injurious effects of stimulating medicines in certain dropsies, prove that there exists in them, at times, too much action in the blood-vessels. Dr. Tissot, in a letter to Dr. Haller, “De Variolis, apoplexia, et hydrope,” condemns, in strong terms, the use of opium in the dropsy. Now the bad effects of this medicine in dropsies, must have arisen from its having been given in cases of too much action in the arterial system; for opium, we know, increases, by its stimulating qualities, the action and tone of the blood-vessels, and hence we find, it has been prescribed with success in dropsies of too little action in the system.
8. The termination of certain fevers in dropsies in which blood-letting was not used. This has been ascertained by many observations. Dr. Wilkes relates[36], that after “an epidemical fever, which began in Kidderminster, in 1728, and soon afterwards spread, not only over Great Britain, but all Europe, more people died dropsical in three years, than did perhaps in twenty or thirty years before,” probably from the neglect of bleeding in the fever.
But the existence of too much action in the arterial system in certain dropsies, will appear more fully from the history of the effects of the remedies which have been employed either by design or accident in the cure of these diseases. I shall first mention the remedies which have been used with success in tonic or inflammatory dropsies; and afterwards mention those which have been given with success in dropsies of a weak action in the arteries. I have constantly proposed to treat only of the theory and cure of dropsies in general, without specifying any of the numerous names it derives from the different parts of the body in which they may be seated; but in speaking of the remedies which have been used with advantage in both the tonic and atonic states, I shall occasionally mention the name or seat of the dropsy in which the remedy has done service.
The first remedy that I shall mention for dropsies is blood-letting. Dr. Hoffman and Dr. Home both cured dropsies accompanied by pulmonic congestion by means of this remedy. Dr. Monroe quotes a case of dropsy from Sponius, in which bleeding succeeded, but not till after it had been used twenty times[37]. Mr. Cruikshank relates a case[38] of accidental bleeding, which confirms the efficacy of blood-letting in these diseases. He tells us that he attended a patient with dropsical swellings in his legs, who had had a hoarseness for two years. One morning, in stooping to buckle his shoes, he bursted a blood-vessel in his lungs, from which he lost a quart of blood; in consequence of which, both the swellings and the hoarseness went off gradually, and he continued well two years afterwards. I have known one case in which spontaneous hæmorrhages from the hæmorrhodial vessels, and from the nose, suddenly reduced universal dropsical swellings. In this patient there had been an uncommon tension and fulness in the pulse.
I could add the histories of many cures of anasarca and ascites, performed by means of blood-letting, not only by myself, but by a number of respectable physicians in the United States. Indeed I conceive this remedy to be as much indicated by a tense and full pulse in those forms of dropsy, as it is in a pleurisy, or in any other common inflammatory disease.
In those deplorable cases of hydrothorax, which do not admit of a radical cure, I have given temporary relief, and thereby protracted life, by taking away occasionally a few ounces of blood. Had Dr. Zimmerman used this remedy in the case of the king of Prussia, I cannot help thinking from the account which the doctor gives us of the diet and pulse of his royal patient, that he would have lessened his sufferings much more than by plentiful doses of dandelion; for I take it for granted, from the candour and integrity which the doctor discovered in all his visits to the king, that he did not expect that dandelion, or any other medicine, would cure him.
Although a full and tense pulse is always an indication of the necessity of bleeding; yet I can easily conceive there may be such congestions, and such a degree of stimulus to the arterial system, as to produce a depressed, or a low or weak pulse. Two cases of this kind are related by Dr. Monroe, one of which was cured by bleeding. The same symptom of a low and weak pulse is often met with in the first stage of pneumony, and apoplexy, and is only to be removed by the plentiful use of the same remedy.
II. Vomits have often been given with advantage in dropsies. Dr. Home says, that squills were useful in these diseases only when they produced a vomiting. By abstracting excitement and action from the arterial system, it disposes the lymphatics to absorb and discharge large quantities of water. The efficacy of vomits in promoting the absorption of stagnating fluids is not confined to dropsies. Mr. Hunter was once called to visit a patient in whom he found a bubo in such a state that he purposed to open it the next day. In the mean while, the patient went on board of a vessel, where he was severely affected by sea-sickness and vomiting; in consequence of which the bubo disappeared, and the patient recovered without the use of the knife.
Mr. Cruikshank further mentions a case[39] of a swelling in the knee being nearly cured by a patient vomiting eight and forty hours, in consequence of his taking a large dose of the salt of tartar instead of soluble tartar.
III. Purges. The efficacy of this remedy, in the cure of dropsies, has been acknowledged by physicians in all ages and countries. Jalap, calomel, scammony, and gamboge, are often preferred for this purpose; but I have heard of two cases of ascites being cured by a table spoonful of sweet oil taken every day. It probably acted only as a gentle laxative. The cream of tartar, so highly commended by Dr. Home, seems to act chiefly in the same way. Gherlius, from whom Dr. Home learned the use of this medicine, says, that all the persons whom he cured by it were in the vigour of life, and that their diseases had been only of a few months continuance. From these two circumstances, it is most probable they were dropsies of great morbid action in the arterial system. He adds further, that the persons who were cured by this medicine, were reduced very low by the use of it. Dr. Home says that it produced the same effect upon the patients whom he cured by it, in the infirmary of Edinburgh. Dr. Sydenham prefers gentle to drastic purges, and recommends the exhibition of them every day. Both drastic and gentle purges act by diminishing the action of the arterial system, and thereby promote the absorption and discharge of water. That purges promote absorption, we learn not only from their effects in dropsies, but from an experiment related by Mr. Cruikshank[40], of a man who acquired several ounces of weight after the operation of a purge. The absorption in this case was from the atmosphere. So great is the effect of purges in promoting absorption, that Mr. Hunter supposes the matter of a gonorrhœa, or of topical venereal ulcers to be conveyed by them in some instances into every part of the body.
IV. Certain medicines, which, by lessening the action of the arterial system, favour the absorption and evacuation of water. The only medicines of this class which I shall name are nitre, cream of tartar, and foxglove.
1. Two ounces of nitre dissolved in a pint of water, and a wine-glass full of it taken three times a-day have performed perfect cures, in two cases of ascites, which have come under my notice. I think I have cured two persons of anasarca, by giving one scruple of the same medicine three times a-day for several weeks. The two last cures were evidently dropsies of violent action in the arterial system. Where nitre has been given in atonic dropsies it has generally been useless, and sometimes done harm. I have seen one instance of an incurable diarrhœa after tapping, which I suspected arose from the destruction of the tone of the stomach and bowels, by large and long continued doses of nitre, which the patient had previously taken by the advice of a person who had been cured by that remedy. To avoid this, or any other inconvenience from the use of nitre in dropsies, it should be given at first in small doses, and should always be laid aside, if it should prove ineffectual after having been given two or three weeks.
2. I can say nothing of the efficacy of cream of tartar in dropsies from my own experience, where it has not acted as a purge. Perhaps my want of decision upon this subject has arisen only from my not having persisted in the use of it for the same length of time which is mentioned by Dr. Home.
3. There are different opinions concerning the efficacy of foxglove in dropsies. From the cases related by Dr. Withering, it appears to have done good; but from those related by Dr. Lettsom[41] it seems to have done harm. I suspect the different accounts of those two gentlemen have arisen from their having given it in different states of the system, or perhaps from a difference in the quality of the plant from causes mentioned in another place[42]. I am sorry to add further, that after many trials of this medicine I have failed in most of the cases in which I have given it. I have discharged the water in three instances by it, but the disease returned, and my patients finally died. I can ascribe only one complete cure to its use, which was in the year 1789, in a young man in the Pennsylvania hospital, of five and thirty years of age, of a robust habit, and plethoric pulse.
Where medicines have once been in use, and afterwards fall into disrepute, as was the case with the foxglove, I suspect the cases in which they were useful, to have been either few or doubtful, and that the cases in which they had done harm, were so much more numerous and unequivocal, as justly to banish them from the materia medica.
V. Hard labour, or exercise in such a degree as to produce fatigue, have, in several instances, cured the dropsy. A dispensary patient, in this city, was cured of this disease by sawing wood. And a patient in an ascites under my care in the Pennsylvania hospital, had his belly reduced seven inches in circumference in one day, by the labour of carrying wood from the yard into the hospital. A second patient belonging to the Philadelphia dispensary was cured by walking to Lancaster, 66 miles from the city, in the middle of winter. The efficacy of travelling in this disease, in cold weather, is taken notice of by Dr. Monroe, who quotes a case from Dr. Holler, of a French merchant, who was cured of a dropsy by a journey from Paris to England, in the winter season. It would seem, that in these two cases, the cold co-operated as a sedative with the fatigue produced by labour or exercise, in reducing the tone of the arterial system.
VI. Low diet. I have heard of a woman who was cured of a dropsy by eating nothing but boiled beans for three weeks, and drinking nothing but the water in which they had been boiled. Many other cases of the good effects of low diet in dropsies are to be found in the records of medicine.
VII. Thirst. This cruel remedy acts by debilitating the system in two ways: 1st, by abstracting the stimulus of distention; and, 2dly, by preventing a supply of fresh water to replace that which is discharged by the ordinary emunctories of nature.
VIII. Fasting. An accidental circumstance, related by sir John Hawkins, in the life of Dr. Johnson, first led me to observe the good effects of fasting in the dropsy. If the fact alluded to stood alone under the present head of this essay, it would be sufficient to establish the existence of too much action, and the efficacy of debilitating remedies in certain dropsies. I am the more disposed to lay a good deal of stress upon this fact, as it was the clue which conducted me out of the labyrinth of empirical practice, in which I had been bewildered for many years, and finally led me to adopt the principles and practice which I am now endeavouring to establish. The passage which contains this interesting fact is as follows: “A few days after (says sir John) he [meaning Dr. Johnson] sent for me, and informed me, that he had discovered in himself the symptoms of a dropsy, and, indeed, his very much increased bulk, and the swollen appearance of his legs, seemed to indicate no less. It was on Thursday that I had this conversation with him; in the course thereof he declared, that he intended to devote the whole of the next day to fasting, humiliation, and such other devotional exercises as became a man in his situation. On the Saturday following I made him a visit, and, upon entering his room, I observed in his countenance such a serenity as indicated, that some remarkable crisis of his disease had produced a change in his feelings. He told me that, pursuant to the resolution he had mentioned to me, he had spent the preceding day in an abstraction from all worldly concerns; that to prevent interruption he had in the morning ordered Frank [his servant] not to admit any one to him, and, the better to enforce the charge, had added these awful words, for your master is preparing himself to die. He then mentioned to me, that in the course of this exercise he found himself relieved from the disease which had been growing upon him, and was becoming very oppressive, viz. the dropsy, by the gradual evacuation of water, to the amount of twenty pints, a like instance whereof he had never before experienced.” Sir John Hawkins ascribes this immense discharge of water to the influence of Dr. Johnson's prayers; but he neglects to take notice, that these prayers were answered, in this instance, as they are in many others, in a perfect consistence with the common and established laws of nature.
To satisfy myself that this discharge of water, in the case of Dr. Johnson, was produced by the fasting only, I recommended it, soon after I read the above account, to a gentlewoman whom I was then attending in an ascites. I was delighted with the effects of it. Her urine, which for some time before had not exceeded half a pint a-day, amounted to two quarts on the day she fasted. I repeated the same prescription once a week for several weeks, and each time was informed of an increase of urine, though it was considerably less in the last experiments than in the first. Two patients in an ascites, to whom I prescribed the same remedy, in the Pennsylvania hospital, the one in the winter of 1790, and the other in the winter of 1792, exhibited proofs in the presence of many of the students of the university, equally satisfactory of the efficacy of fasting in suddenly increasing the quantity of urine.
IX. Fear. This passion is evidently of a debilitating nature, and, therefore, it has frequently afforded an accidental aid in the cure of dropsies, of too much action. I suspect, that the fear of death, which was so distinguishing a part of the character of Dr. Johnson, added a good deal to the efficacy of fasting, in procuring the immense discharge of water before-mentioned. In support of the efficacy of fear simply applied, in discharging water from the body in dropsies, I shall mention the following facts.
In a letter which I received from Dr. John Pennington, dated Edinburgh, August 3, 1790, I was favoured with the following communication. “Since the conversation I had with you on the subject of the dropsy, I feel more and more inclined to adopt your opinion. I can furnish you with a fact which I learned from a Danish sailor, on my passage to this country, which is much in favour of your doctrine. A sailor in an ascites, fell off the end of the yard into the sea; the weather being calm, he was taken up unhurt, but, to use the sailor's own words, who told me the story, he was frightened half to death, and as soon as he was taken out of the water, he discharged a gallon of urine or more. A doctor on board ascribed this large evacuation to sea bathing, and accordingly ordered the man to be dipped in the sea every morning, much against his will, for, my informant adds, that he had not forgotten his fall, and that in four weeks he was perfectly well. I think this fact can only be explained on your principles. The sedative operation of fear was, no doubt, the cause of his cure.”
There is an account of an ascites being cured by a fall from an open chaise, recorded in the third volume of the Medical Memoirs, by M. Lowdell. I have heard of a complete recovery from dropsy, having suddenly followed a fall from a horse. In both these cases, the cures were probably the effects of fear.
Dr. Hall, of York-town, in Pennsylvania, informed me, that he had been called to visit a young woman of 19 years of age, who had taken all the usual remedies for ascites without effect. He at once proposed to her the operation of tapping. To this she objected, but so great was the fear of this operation, which the proposal of it suddenly excited in her mind, that it brought on a plentiful discharge of urine, which in a few days perfectly removed her disease.
On the 27th of August, 1790, I visited a gentlewoman in this city with the late Dr. Jones, in an ascites. We told her for the first time, that she could not be relieved without being tapped. She appeared to be much terrified upon hearing our opinion, and said that she would consider of it. I saw her two days afterwards, when she told me, with a smile on her countenance, that she hoped she should get well without tapping, for that she had discharged two quarts of water in the course of the day after we had advised her to submit to that operation. For many days before, she had not discharged more than two or three gills in twenty-four hours. The operation, notwithstanding, was still indicated, and she submitted to be tapped a few days afterwards.
I tapped the same gentlewoman a second time, in January, 1791. She was much terrified while I was preparing for the operation, and fainted immediately after the puncture was made. The second time that I visited her after the operation was performed, she told me (without being interrogated on that subject), that she had discharged a pint and a half of urine, within twenty minutes after I left the room on the day I tapped her. What made this discharge the more remarkable was, she had not made more than a table spoonful of water in a day, for several days before she was tapped.
I have seen similar discharges of urine in two other cases of tapping which have come under my notice, but they resembled so nearly those which have been mentioned, that it will be unnecessary to record them.
But the influence of fear upon the system, in the dropsy, extends far beyond the effects which I have ascribed to it. Dr. Currie, of this city, informed me that he called, some years ago, by appointment, to tap a woman. He no sooner entered the room than he observed her, as he thought, to faint away. He attempted to recover her, but to no purpose. She died of a sudden paroxysm of fear.
It is a matter of surprise, that we should have remained so long ignorant of the influence of fear upon the urinary organs in dropsies, after having been so long familiar with the same effect of that passion in the hysteria.
X. A recumbent posture of the body. It is most useful when the dropsy is seated in the lower limbs. I have often seen, with great pleasure, the happiest effects from this prescription in a few days.
XI. Punctures. These, when made in the legs and feet, often discharge in eight and forty hours the water of the whole body. I have never seen a mortification produced by them. As they are not followed by inflammation, they should be preferred to blisters, which are sometimes used for the same purpose.
I cannot dismiss the remedies which discharge water from the body through the urinary passages, without taking notice, that they furnish an additional argument in favour of blood-letting in dropsies, for they act, not by discharging the stagnating water, but by creating such a plentiful secretion in the kidneys from the serum of the circulating blood, as to make room for the absorption and conveyance of the stagnating water into the blood-vessels.
Now the same effect may be produced in all tonic or inflammatory dropsies, with more certainty and safety, by means of blood-letting.
In recommending the antiphlogistic treatment of certain dropsies, I must here confine myself to the dropsies of such climates as dispose to diseases of great morbid action in the system. I am satisfied that it will often be proper in the middle and eastern states of America; and I have lately met with two observations, which show that it has been used with success at Vienna, in Germany. Dr. Stoll tells us, that, in the month of January, 1780, “Hydropic and asthmatic patients discovered more or less marks of inflammatory diathesis, and that blood was drawn from them with a sparing hand with advantage;” and in the month of November, of the same year, he says, “The stronger diuretics injured dropsical patients in this season; but an antiphlogistic drink, composed of a quart of the decoction of grass, with two ounces of simple oxymel, and nitre and cream of tartar, of each a drachm, did service[43].” It is probable that the same difference should be observed between the treatment of dropsies in warm and cold climates that is observed in the treatment of fevers. The tonic action probably exists in the system in both countries. In the former it resembles the tides which are suddenly produced by a shower of rain, and as suddenly disappear; whereas, in the latter, it may be compared to those tides which are produced by the flow and gradual addition of water from numerous streams, and which continue for days and weeks together to exhibit marks of violence in every part of their course.
I come now to say a few words upon atonic dropsies, or such as are accompanied with a feeble morbid action in the blood-vessels. This morbid action is essential to the nature of dropsies, for we never see them take place without it. This is obvious from the absence of swellings after famine, marasmus, and in extreme old age, in each of which there exists the lowest degree of debility, but no morbid action in the blood-vessels. These atonic or typhus dropsies may easily be distinguished from those which have been described, by occurring in habits naturally weak; by being produced by the operation of chronic causes; by a weak and quick pulse; and by little or no preternatural heat or thirst.
The remedies for atonic dropsies are all such stimulating substances as increase the action of the arterial system, or determine the fluids to the urinary organs. These are,
I. Bitter and aromatic substances of all kinds, exhibited in substance or in infusions of wine, spirit, beer, or water.
II. Certain acrid vegetables, such as scurvy-grass, horse-radish, mustard, water-cresses, and garlic. I knew an old man who was perfectly cured of an anasarca, by eating water-cresses, on bread and butter.
III. Opium. The efficacy of this medicine in dropsies has been attested by Dr. Willis, and several other practical writers. It seems to possess almost an exclusive power of acting alike upon the arterial, the lymphatic, the glandular, and the nervous systems.
IV. Metallic tonics, such as chalybeate medicines of all kinds, and the mild preparations of copper and mercury. I once cured an incipient ascites and anasarca by large doses of the rust of iron; and I have cured many dropsies by giving mercury in such quantities as to excite a plentiful salivation. I have, it is true, often given it without effect, probably from my former ignorance of the violent action of the arteries, which so frequently occurs in dropsies, and in which cases mercury must necessarily have done harm.
V. Diuretics, consisting of alkaline salts, nitre, and the oxymels of squills and colchicum. It is difficult to determine how far these medicines produce their salutary effects by acting directly upon the kidneys. It is remarkable that these organs are seldom affected in dropsies, and that their diseases are rarely followed by dropsical effusions in any part of the body.
VI. Generous diet, consisting of animal food, rendered cordial by spices; also sound old wine.
VII. Diluting drinks taken in such large quantities as to excite the action of the vessels by the stimulus of distention. This effect has been produced, sir George Baker informs us, by means of large draughts of simple water, and of cyder and water[44]. The influence of distention in promoting absorption is evident in the urinary and gall bladders, which frequently return their contents to the blood by the lymphatics, when they are unable to discharge them through their usual emunctories. Is it not probable that the distention produced by the large quantities of liquids which we are directed to administer after giving the foxglove, may have been the means of performing some of those cures of dropsies, which have been ascribed to that remedy?
VIII. Pressure. Bandages bound tightly around the belly and limbs, sometimes prevent the increase or return of dropsical swellings. The influence of pressure upon the action of the lymphatics appears in the absorption of bone which frequently follows the pressure of contiguous tumours, also in the absorption of flesh which follows the long pressure of certain parts of the body upon a sick bed.
IX. Frictions, either by means of a dry, or oiled hand, or with linen or flannel impregnated with volatile and other stimulating substances. I have found evident advantages from following the advice of Dr. Cullen, by rubbing the lower extremities upwards, and that only in the morning. I have been at a loss to account for the manner in which sweet oil acts, when applied to dropsical swellings. If it act by what is improperly called a sedative power upon the blood-vessels, it will be more proper in tonic than atonic dropsies; but if it act by closing the pores, and thereby preventing the absorption of moisture from the air, it will be very proper in the state of dropsy which is now under consideration. It is in this manner that Dr. Cullen supposes that sweet oil, when applied to the body, cures that state of diabetes in which nothing but insipid water is discharged from the bladder.
X. Heat, applied either separately or combined with moisture in the form of warm or vapour baths, has been often used with success in dropsies of too little action. Dampier, in his voyage round the world, was cured of a dropsy by means of a copious sweat, excited by burying himself in a bed of warm sand. Warm fomentations to the legs, rendered moderately stimulating by the addition of saline or aromatic substances, have often done service in the atonic dropsical swellings of the lower extremities.
XI. The cold bath. I can say nothing in favour of the efficacy of this remedy in dropsies, from my own experience. Its good effects seem to depend wholly on its increasing the excitability of the system to common stimuli, by the diminution of its excitement. If this be the case, I would ask, whether fear might not be employed for the same purpose, and thus become as useful in atonic, as it was formerly proved to be in tonic dropsies?
XII. Wounds, whether excited by cutting instruments or by fire, provided they excite inflammation and action in the arteries, frequently cure atonic dropsies. The good effects of inflammation and action in these cases, appear in the cure of hydrocele by means of the needle, or the caustic.
XIII. Exercise. This is probably as necessary in the atonic dropsy, as it is in the consumption, and should never be omitted when a patient is able to take it. The passive exercises of swinging, and riding in a carriage, are most proper in the lowest stage of the disease; but as soon as the patient's strength will admit of it, he should ride on horseback. A journey should be preferred, in this disease, to short excursions from home.
XIV. A recumbent posture of the body should always be advised during the intervals of exercise, when the swellings are seated in the lower extremities.
XV. Punctures in the legs and feet afford the same relief in general dropsy, accompanied with a weak action in the blood-vessels, that has been ascribed to them in dropsies of an opposite character.
In the application of each of the remedies which have been mentioned, for the cure of both tonic and atonic dropsies, great care should be taken to use them in such a manner, as to accommodate them to the strength and excitability of the patient's system. The most powerful remedies have often been rendered hurtful, by being given in too large doses in the beginning, and useless, by being given in too small doses in the subsequent stages of the disease.
I have avoided saying any thing of the usual operations for discharging water from different parts of the body, as my design was to treat only of the symptoms and cure of those dropsies which affect the whole system. I shall only remark, that if tapping and punctures have been more successful in the early, than in the late stage of these diseases, it is probably because the sudden or gradual evacuation of water takes down that excessive action in the arterial system, which is most common in their early stage, and thereby favours the speedy restoration of healthy action in the exhaling or lymphatic vessels.
Thus have I endeavoured to prove, that two different states of action take place in dropsies, and have mentioned the remedies which are proper for each of them under separate heads. But I suspect that dropsies are often connected with a certain intermediate or mixed action in the arterial system, analogous to the typhoid action which takes place in certain fevers. I am led to adopt this opinion, not only from having observed mixed action to be so universal in most of the diseases of the arterial and nervous system, but because I have so frequently observed dropsical swellings to follow the scarlatina, and the puerperile fever, two diseases which appear to derive their peculiar character from a mixture of excessive and moderate force, combined with irregularity of action in the arterial system. In dropsies of mixed action, where too much force prevails in the action of some, and too little in the action of other of the arterial fibres, the remedies must be debilitating or stimulating, according to the greater or less predominance of tonic or atonic diathesis in the arterial system.
I shall conclude this history of dropsies, and of the different and opposite remedies which have cured them, by the following observations.
1. We learn, in the first place, from what has been said, the impropriety and even danger of prescribing stimulating medicines indiscriminately in every case of dropsy.
2. We are taught, by the facts which have been mentioned, the reason why physicians have differed so much in their accounts of the same remedies, and why the same remedies have operated so differently in the hands of the same physicians. It is because they have been given without a reference to the different states of the system, which have been described. Dr. Sydenham says, that he cured the first dropsical patient he was called to, by frequent purges. He began to exult in the discovery, as he thought, of a certain cure for dropsies, but his triumph was of short duration. The same remedy failed in the next case in which he prescribed it. The reason probably was, the dropsy in the first case was of a tonic, but in the second of an atonic nature; for the latter was an ascites from a quartan ague. It is agreeable, however, to discover, from the theory of dropsies which has been laid down, that all the different remedies for these diseases have been proper in their nature, and improper only in the state of the system in which they have been given. As the discovery of truth in religion reconciles the principles of the most opposite sects, so the discovery of truth in medicine reconciles the most opposite modes of practice. It would be happy if the inquirers after truth in medicine should be taught, by such discoveries, to treat each other with tenderness and respect, and to wait with patience till accident, or time, shall combine into one perfect and consistent system, all the contradictory facts and opinions, about which physicians have been so long divided.
3. If a state of great morbid action in the arteries has been demonstrated in dropsies, both from its symptoms and remedies, and if these dropsies are evidently produced by previous debility, who will deny the existence of a similar action in certain hæmorrhages, in gout, palsy, apoplexy, and madness, notwithstanding they are all the offspring of predisposing debility? And who will deny the efficacy of bleeding, purges, and other debilitating medicines in certain states of those diseases, that has seen the same medicines administered with success in certain dropsies? To reject bleeding, purging, and the other remedies for violent action in the system, in any of the above diseases, because that action was preceded by general debility, will lead us to reject them in the most acute inflammatory fevers, for these are as much the offspring of previous debility as dropsies or palsy. The previous debility of the former differs from that of the latter diseases, only in being of a more acute, or, in other words, of a shorter duration.
4. From the symptoms of tonic dropsy which have been mentioned, it follows, that the distinction of apoplexy into serous and sanguineous, affords no rational indication for a difference in the mode of treating that disease. If an effusion of serum in the thorax, bowels, or limbs, produce a hard and full pulse, it is reasonable to suppose that the same symptom will be produced by the effusion of serum in the brain. But the dissections collected by Lieutaud[45] place this opinion beyond all controversy. They prove that the symptoms of great and feeble morbid action, as they appear in the pulse, follow alike the effusion of serum and blood in the brain. This fact will admit of an important application to the disease, which is to be the subject of the next inquiry.
5. From the influence which has been described, of the different states of action of the arterial system, upon the lymphatic vessels, in dropsies, we are led to reject the indiscriminate use of bark, mercury, and salt water, in the scrophula. When the action of the arteries is weak, those remedies are proper; but when an opposite state of the arterial system occurs, and, above all, when scrophulous tumours are attended with inflammatory ulcers, stimulating medicines of all kinds are hurtful. By alternating the above remedies with a milk and vegetable diet, according to the tonic, or atonic states of the arterial system, I have succeeded in the cure of a case of scrophula, attended by large ulcers in the inguinal glands, which had for several years resisted the constant use of the three stimulating remedies which have been mentioned.
6. Notwithstanding I have supposed dropsies to be connected with a peculiar state of force in the blood-vessels, yet I have not ventured to assert, that dropsies may not exist from an exclusive affection of the exhaling and absorbing vessels. I conceive this to be as possible, as for a fever to exist from an exclusive affection of the arteries, or a hysteria from an exclusive affection of the nervous system. Nothing, however, can be said upon this subject, until physiology and pathology have taught us more of the structure and diseases of the lymphatic vessels. Nor have I ventured further to assert, that there are not medicines which may act specifically upon the lymphatics, independently of the arteries. This I conceive to be as possible as for asafœtida to act chiefly upon the nerves, or ipecacuanha and jalap upon the alimentary canal, without affecting other parts of the system. Until such medicines are discovered, it becomes us to avail ourselves of the access to the lymphatics, which is furnished us through the medium of the arteries, by means of most of the remedies which have been mentioned.
7. If it should appear hereafter, that we have lessened the mortality of certain dropsies by the theory and practice which have been proposed, yet many cases of dropsy must still occur in which they will afford us no aid. The cases I allude to are dropsies from enclosing cysts, from the ossification of certain arteries, from schirri of certain viscera from large ruptures of exhaling or lymphatic vessels, from a peculiar and corrosive acrimony of the fluids, and, lastly, from an exhausted state of the whole system. The records of medicine furnish us with instances of death from each of the above causes. But let us not despair. It becomes a physician to believe, that there is no disease necessarily incurable; and that there exist in the womb of time, certain remedies for all those morbid affections, which elude the present limits of the healing art.
Footnotes:
[35] Medical Facts.
[36] Historical Essay on the Dropsy, p. 326.
[37] Treatise on the Dropsy.
[38] Treatise on the Lymphatics.
[39] Letter to Mr. Clare, p. 166.
[40] Letter to Mr. Clare, p. 117.
[41] Medical Memoirs, vol. II.
[42] Inquiry into the Causes and Cure of Pulmonary Consumption.
[43] Ratio Medendi Nosocomio Practico Vindobonensi, vol. iv. p. 56 and 99.
[44] The remark upon this fact by sir George, is worthy of notice, and implies much more than was probably intended by it. “When common means have failed, success has sometimes followed a method directly contrary to the established practice.” Medical Transactions, vol. II.
[45] Historia Anatomica Medica, vol. II.
AN INQUIRY
INTO THE
CAUSES AND CURE
OF THE
INTERNAL DROPSY OF THE BRAIN.
Having, for many years, been unsuccessful in all the cases, except two, of internal dropsy of the brain, which came under my care, I began to entertain doubts of the common theory of this disease, and to suspect that the effusion of water should be considered only as the effect of a primary disease in the brain.
I mentioned this opinion to my colleague, Dr. Wistar, in the month of June, 1788, and delivered it the winter following in my lectures. The year afterwards I was confirmed in it, by hearing that the same idea had occurred to Dr. Quin. I have since read Dr. Quin's treatise on the dropsy of the brain with great pleasure, and consider it as the first dawn of light which has been shed upon it. In pursuing this subject, therefore, I shall avail myself of Dr. Quin's discoveries, and endeavour to arrange the facts and observations I have collected in such a manner, as to form a connected theory from them, which I hope will lead to a new and more successful mode of treating this disease.
I shall begin this inquiry by delivering a few general propositions.
1. The internal dropsy of the brain is a disease confined chiefly to children.
2. In children the brain is larger in proportion to other parts of the body, than it is in adults; and of course a greater proportion of blood is sent to it in childhood, than in the subsequent periods of life. The effects of this determination of blood to the brain appear in the mucous discharge from the nose, and in the sores on the head and behind the ears, which are so common in childhood.
3. In all febrile diseases, there is a preternatural determination of blood to the brain. This occurs in a more especial manner in children: hence the reason why they are so apt to be affected by convulsions in the eruptive fever of the small-pox, in dentition, in the diseases from worms, and in the first paroxysm of intermitting fevers.
4. In fevers of every kind, and in every stage of life, there is a disposition to effusion in that part to which there is the greatest determination. Thus, in inflammatory fever, effusions take place in the lungs and in the joints. In the bilious fever they occur in the liver, and in the gout in every part of the body. The matter effused is always influenced by the structure of the part in which it takes place.
These propositions being premised, I should have proceeded to mention the remote causes of this disease; but as this inquiry may possibly fall into the hands of some gentlemen who may not have access to the description of it as given by Dr. Whytt, Dr. Fothergill, and Dr. Quin, I shall introduce a history of its symptoms taken from the last of those authors. I prefer it to the histories by Dr. Whytt and Dr. Fothergill, as it accords most with the ordinary phenomena of this disease in the United States.
“In general, the patient is at first languid and inactive, often drowsy and peevish, but at intervals cheerful and apparently free from complaint. The appetite is weak, a nausea, and, in many cases, a vomiting, occurs once or twice in the day, and the skin is observed to be hot and dry towards the evenings: soon after these symptoms have appeared, the patient is affected with a sharp head-ach, chiefly in the fore-part, or, if not there, generally in the crown of the head: it is sometimes, however, confined to one side of the head, and, in that case, when the posture of the body is erect, the head often inclines to the side affected. We frequently find, also, that the head-ach alternates with the affection of the stomach; the vomiting being less troublesome when the pain is most violent, and vice versâ; other parts of the body are likewise subject to temporary attacks of pain, viz. the extremities, or the bowels, but more constantly the back of the neck, and between the scapulæ; in all such cases the head is more free from uneasiness.
“The patient dislikes the light at this period; cries much, sleeps little, and when he does sleep, he grinds his teeth, picks his nose, appears to be uneasy, and starts often, screaming as if he were terrified; the bowels are in the majority of cases very much confined, though it sometimes happens that they are in an opposite state: the pulse in this early stage of the disorder, does not usually indicate any material derangement.
“When the symptoms above-mentioned have continued for a few days, subject as they always are in this disease to great fluctuation, the axis of one eye is generally found to be turned in towards the nose; the pupil on this side is rather more dilated than the other; and when both eyes have the axes directed inwards (which sometimes happens), both pupils are larger than they are observed to be in the eyes of healthy persons: the vomiting becomes more constant, and the head-ach more excruciating; every symptom of fever then makes its appearance, the pulse is frequent, and the breathing quick; exacerbations of the fever take place towards the evening, and the face is occasionally flushed; usually one cheek is much more affected than the other; temporary perspirations likewise break forth, which are not followed by any alleviation of distress; a discharge of blood from the nose, which sometimes appears about this period, is equally inefficacious.
“Delirium, and that of the most violent kind, particularly if the patient has arrived at the age of puberty, now takes place, and with all the preceding symptoms of fever, continues for a while to increase, until about fourteen days, often a much shorter space of time, shall have elapsed since the appearance of the symptoms, which were first mentioned in the above detail.
“The disease then undergoes that remarkable change, which sometimes suddenly points out the commencement of what has been called its second stage: the pulse becomes slow but unequal, both as to its strength, and the intervals between the pulsations; the pain of the head, or of whatever part had previously been affected, seems to abate, or at least the patient becomes apparently less sensible of it; the interrupted slumbers, or perpetual restlessness which prevailed during the earlier periods of the disorder, are now succeeded by an almost lethargetic torpor, the strabismus, and dilatation of the pupil increase, the patient lies with one, or both eyes half closed, which, when minutely examined, are often found to be completely insensible to light; the vomiting ceases; whatever food or medicine is offered is usually swallowed with apparent voracity; the bowels at this period generally remain obstinately costive.
“If every effort made by art fails to excite the sinking powers of life, the symptoms of what has been called the second stage are soon succeeded by others, which more certainly announce the approach of death. The pulse again becomes equal, but so weak and quick, that it is almost impossible to count it; a difficulty of breathing, nearly resembling the stertor apoplecticus, is often observed; sometimes the eyes are suffused with blood, the flushing of the face is more frequent than before, but of shorter duration, and followed by a deadly paleness; red spots, or blotches, sometimes appear on the body and limbs; deglutition becomes difficult, and convulsions generally close the scene. In one case, I may observe, the jaws of a child of four years of age were so firmly locked for more than a day before death, that it was impossible to introduce either food or medicine into his mouth; and, in another case, a hemiplegia, attended with some remarkable circumstances, occurred during the two days preceding dissolution.
“Having thus given as exact a history of apoplexia hydrocephalica as I could compile from the writings of others, and from my own observations, I should think myself guilty of imposition on my readers, if I did not caution them that it must be considered merely as a general outline: the human brain seems to be so extremely capricious (if the expression may be allowed) in the signals it gives to other parts of the system, of the injury it suffers throughout the course of this disease, that although every symptom above-mentioned does occasionally occur, and indeed few cases of the disease are to be met with, which do not exhibit many of them; yet it does not appear to me, that any one of them is constantly and inseparably connected with it.”
To this history I shall add a few facts, which are the result of observations made by myself, or communicated to me by my medical brethren. These facts will serve to show that there are many deviations from the history of the disease which has been given, and that it is indeed, as Dr. Quin has happily expressed it, of **LQU]a truly proteiform” nature.
I have not found the dilated and insensible pupil, the puking, the delirium, or the strabismus, to attend universally in this disease.
I saw one case in which the appetite was unimpaired from the first to the last stage of the disease.
I have met with one case in which the disease was attended by blindness, and another by double vision.
I have observed an uncommon acuteness in hearing to attend two cases of this disease. In one of them the noise of the sparks which were discharged from a hiccory[** sic] fire, produced great pain and startings which threatened convulsions.
I have seen three cases in which the disease terminated in hemiplegia. In two of them it proved fatal in a few days; in the third it continued for nearly eighteen months.
I have met with one case in which no preternatural slowness or intermission was ever perceived in the pulse.
I have seen the disease in children of nearly all ages. I once saw it in a child of six weeks old. It was preceded by the cholera infantum. The sudden deaths which we sometimes observe in infancy, I believe, are often produced by this disease. Dr. Stoll is of the same opinion. He calls it, when it appears in this form, “apoplexia infantalis[46].”
In the month of March, 1771, I obtained a gill of water from the ventricles of the brain of a negro girl of nine years of age, who died of this disease, who complained in no stage of it of a pain in her head or limbs, nor of a sick stomach. The disease in this case was introduced suddenly by a pain in the breast, a fever, and the usual symptoms of a catarrh.
Dr. Wistar informed me, that he had likewise met with a case of internal dropsy of the brain, in which there was a total absence of pain in the head.
Dr. Carson informed me, that he had attended a child in this disease that discovered, for some days before it died, the symptom of hydrophobia.
Dr. Currie obtained, by dissection, seven ounces of water from the brain of a child which died of this disease; in whom, he assured me, no dilatation of the pupil, strabismus, sickness, or loss of appetite had attended, and but very little head-ach.
The causes which induce this disease, act either directly on the brain, or indirectly upon it, through the medium of the whole system.
The causes which act directly on the brain are falls or bruises upon the head, certain positions of the body, and childish plays which bring on congestion or inflammation, and afterwards an effusion of water in the brain. I have known it brought on in a child by falling into a cellar upon its feet.
The indirect causes of this disease are more numerous, and more frequent, though less suspected, than those which have been mentioned. The following diseases of the whole system appear to act indirectly in producing an internal dropsy of the brain.
1. Intermitting, remitting, and continual fevers. Of the effects of these fevers in inducing this disease, many cases are recorded by Lieutaud[47].
My former pupil, Dr. Woodhouse, has furnished me with a dissection, in which the disease was evidently the effect of the remitting fever. That state of continual fever which has been distinguished by the name of typhus, is often the remote cause of this disease. The languor and weakness in all the muscles of voluntary motion, the head-ach, the inclination to rest and sleep, and the disposition to be disturbed, or terrified by dreams, which are said to be the precursors of water in the brain, I believe are frequently symptoms of a typhus fever which terminates in an inflammation, or effusion of water in the brain. The history which is given of the typhus state of fever in children by Dr. Butter[48], seems to favour this opinion.
2. The rheumatism. Of this I have known two instances. Dr. Lettsom has recorded a case from the same cause[49]. The pains in the limbs, which are supposed to be the effect, I suspect are frequently the cause of the disease.
3. The pulmonary consumption. Of the connection of this disease with an internal dropsy of the brain, Dr. Percival has furnished us with the following communication[50]: “Mr. C——'s daughter, aged nine years, after labouring under the phthisis pulmonalis four months, was affected with unusual pains in her head. These rapidly increased, so as to occasion frequent screamings. The cough, which had before been extremely violent, and was attended with stitches in the breast, now abated, and in a few days ceased almost entirely. The pupils of the eyes became dilated, a strabismus ensued, and in about a week death put an end to her agonies. Whether this affection of the head arose from the effusion of water or of blood, is uncertain, but its influence on the state of the lungs is worthy of notice.” Dr. Quin likewise mentions a case from Dr. Cullen's private practice, in which an internal dropsy of the brain followed a pulmonary consumption. Lieutaud mentions three cases of the same kind[51], and two, in which it succeeded a catarrh[52].
4. Eruptive fevers. Dr. Odier informs us[53], that he had seen four cases in which it had followed the small-pox, measles, and scarlatina. Dr. Lettsom mentions a case in which it followed the small-pox[54], and I have seen one in which it was obviously the effects of debility induced upon the system by the measles.
5. Worms. Notwithstanding the discharge of worms gives no relief in this disease, yet there is good reason to believe, that it has, in some instances, been produced by them. The morbid action continues in the brain, as in other cases of disease, after the cause which induced it, has ceased to act upon the body.
6. From the dissections of Lieutaud, Quin, and others, it appears further, that the internal dropsy of the brain has been observed to succeed each of the following diseases, viz. the colic, palsy, melancholy, dysentery, dentition, insolation, and scrophula, also the sudden healing of old sores. I have seen two cases of it from the last cause, and one in which it was produced by the action of the vernal sun alone upon the system.
From the facts which have been enumerated, and from dissections to be mentioned hereafter, it appears, that the disease in its first stage is the effect of causes which produce a less degree of that morbid action in the brain which constitutes phrenitis, and that its second stage is the effect of a less degree of that effusion, which produces serous apoplexy in adults. The former partakes of the nature of the chronic inflammation of Dr. Cullen, and of the asthenic inflammation of Dr. Brown. I have taken the liberty to call it phrenicula, from its being a diminutive species or state of phrenitis. It bears the same relation to phrenitis, when it arises from indirect causes, which pneumonicula does to pneumony; and it is produced nearly in the same manner as the pulmonary consumption, by debilitating causes which act primarily on the whole system. The peculiar size and texture of the brain seem to invite the inflammation and effusions which follow debility, to that organ in childhood, just as the peculiar structure and situation of the lungs invite the same morbid phænomena to them, after the body has acquired its growth, in youth and middle life. In the latter stage which has been mentioned, the internal dropsy of the brain partakes of some of the properties of apoplexy. It differs from it in being the effect of a slow, instead of a sudden effusion of water or blood, and in being the effect of causes which are of an acute instead of a chronic nature. In persons advanced beyond middle life, who are affected by this disease, it approaches to the nature of the common apoplexy, by a speedy termination in life or death. Dr. Cullen has called it simply by the name of “apoplexia hydrocephalica.” I have preferred for its last stage the term of chronic apoplexy, for I believe with Dr. Quin, that it has no connection with a hydropic diathesis of the whole system. I am forced to adopt this opinion, from my having rarely seen it accompanied by dropsical effusions in other parts of the body, nor a general dropsy accompanied by an internal dropsy of the brain. No more occurs in this disease than takes place when hydrothorax follows an inflammation of the lungs, or when serous effusions follow an inflammation of the joints. I do not suppose that both inflammation and effusion always attend in this disease; on the contrary, dissections have shown some cases of inflammation, with little or no effusion, and some of effusion without inflammation. Perhaps this variety may have been produced by the different stages of the disease in which death and the inspection of the brain took place. Neither do I suppose, that the two stages which have been mentioned, always succeed each other in the common order of inflammation and effusion. In every case where the full tense, slow and intermitting pulse occurs, I believe there is inflammation; and as this state of the pulse occurs in most cases in the beginning of the disease, I suppose the inflammation, in most cases, to precede the effusion of water. I have met with only one case in which the slow and tense pulse was absent; and out of six dissections of patients whom I have lost by this disease, the brains of four of them exhibited marks of inflammation.
Mr. Davis discovered signs of inflammation, after death from this disease, to be universal. In eighteen or twenty dissections, he tells us, he found the pia mater always distended with blood[55]. Where signs of inflammation have not occurred, the blood-vessels had probably relieved themselves by the effusion of serum, or the morbid action of the blood-vessels had exceeded that grade of excitement, in which only inflammation can take place. I have seen one case of death from this disease, in which there was not more than a tea-spoonful of water in the ventricles of the brain. Dr. Quin mentions a similar case. Here death was induced by simple excess of excitement. The water which is found in the ventricles of the brain refuses to coagulate by heat, and is always pale in those diseases, in which the serum of the blood, in every other part of the body, is of a yellow colour.
In addition to these facts, in support of the internal dropsy of the brain being the effect of inflammation, I shall mention one more, communicated to me in a letter, dated July 17th, 1795, by my former pupil, Dr. Coxe, while he was prosecuting his studies in London. “It so happened (says my ingenious correspondent), that at the time of my receiving your letter, Dr. Clark was at the hospital. I read to him that part which relates to your success in the treatment of hydrocephalus internus. He was much pleased with it, and mentioned to me a fact which strongly corroborates your idea of its being a primary inflammation of the brain. This fact was, that upon opening, not long since, the head of a child that had died of this disease, he found between three and four ounces of water in the ventricles of the brain; also an inflammatory crust on the optic nerves, as thick as he had ever observed it on the intestines in a state of inflammation. The child lost its sight before it died. The crust accounted in a satisfactory manner for its blindness. Perhaps something similar may always be noticed in the dissections of such as die of this disease, in whom the eyes are much affected.”
Having adopted the theory of this disease, which I have delivered, I resolved upon such a change in my practice as should accord with it. The first remedy indicated by it was
I. Blood-letting. I shall briefly mention the effects of this remedy in a few of the first cases in which I prescribed it.