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.”

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.