A Letter to Dr John Wright, F. Col. Phys. Lond. to Mr Wm Cowper, F. R. S. concerning the Cure of an Apostemation of the Lungs

I. A Letter to Dr John Wright, F. Col. Phys. Lond. to Mr Wm Cowper, F. R. S. concerning the Cure of an Apostemation of the Lungs. S I R, According to your desire, I send you the Case of Mrs Jane Terry, Niece to Mr Fowkes in Curitors-Ally, near Lincolns-Inn, and thank you for your assistance in her Cure, to which your extraordinary skill in your Profession very much contributed. I doubt not but an account of her, from the first time I was concerned with her, will be acceptable to you. I knew her some time before she fell ill of the Small Pox, which was in May 1701. She was about 18 years old, of a fresh Complexion, and pretty fleshy. Her Relations apprehending she might have the Small Pox, removed her to a Nurses House, where she had the distinc& sort very kindly, her Case proceeded so very well (as they conceived) that no Physician was called to her, till they began to shell, only for some days before she had a little difficulty in her breathing, which gradually increased till she began to raise Blood, which was about the 7th day from their first appearing. This raising of Blood was accompanied with these circumstances; it had increas'd every day, for 3 days before I saw her, she cough'd and brought up a Viscous Phlegm, such as our Patients Vomit when their Stomachs are very foul; only as meer Phelgm is white, this was all of it as red as Blood, it was not streak'd with Blood, or had a mixture of white Phlegm with it, but was so deeply colour'd, that it seem'd to be all Blood, only it would not flow as Blood. Blood does whilst it is hot; nor did it coagulate as Blood does when it is cold, but hung from the Basins when it was pour'd out, as Vomited Phlegm does; and in this it differ'd from all the Bloody Expectorations I have seen, excepting Mr Jones at Myn Heer Meysters's in Kensington, who Cough'd the same Bloody colour'd Pituita, but in much less quantity, for Mrs Terry rais'd above a Pint in 24 hours, for some days, and tho a less yet a considerable quantity afterwards; Mrs Terry's afforded a very strong smell, but Mr Jones's had no Odour. After some weeks she recover'd, regain'd her Flesh, which was wasted in her illnes; the Menstrus return'd, and she continued very well from July till near Christmas. In January I was carried to see her at Mr Wooleston's, the Queens-head Tavern at Queenhithe, and she gave this account of her self. That about 3 weeks before Christmas she perceiv'd her self a little short breath'd, which increas'd daily, with a fullness and weight in her Left side, that she lay well on the Left side, but when she turn'd to lye on her Right, she felt as if a weight fell from the Left to the Right side, which gave her a shortness of Breath and made her Cough: Thus it continued increasing till Christmas, when she began to raise a considerable quantity of strong stinking Pus; she said she eat her Viuals well enough all this time, and was not Feverish. At first she was under the care of another Physician, who told her Relations when they desired his judgment of the Disease, and its event, That it was an Ulcer in her Lungs, and he believ'd incurable, upon which they again committed her to my care. When I saw her, which was towards the middle of January 1701, she raised a considerable quantity, and often of stinking offensive Pus, which was as fluid as the Pus of other parts; her Flesh was a little abated, but she was at no time Feverish, she eat and slept pretty well, and had the Catamenia duly. I prescribed such Medicines, as abated that Purulent Expectoration several times, and she often gave me hopes of her Recovery, she continuing to have the Menstrues regularly, and being still free from an Hectick, but upon every little Cold she again raised that fetid Pus in a considerable quantity. She generally continued pretty free from Coughing several hours together, till she perceiv'd something of a fullness in her Breast, which would oblige her to Cough, and after she had once began to raise she could not cease, till she had brought up two Spoonfuls or more of that fetid Pus. This she did chiefly in the Morning, Afternoon and at Night; I did apprehend she had an abscess in the Left Lobe of her Lungs, and made her lie upon the Bed, with her head reaching to the Chamber Floor, leaning upon her Left Arm. In this posture she could at any time, after a little Cough, set the Pus a running out of her Mouth, as you have seen several times, till the whole which was therein contain'd was discharg'd. Then she would get up, and seem to be as well as another person, till it was almost fill'd again. In the beginning of May last, those Excellent Physicians, Dr Torleffe and Dr Pitts favour'd me with their kind assistance. They saw her lie in the posture I have describ'd, and saw more than 2 spoonfuls of stinking Pus or Corruption run out of her Mouth, after a little Coughing. This made it so apparent that there was an Ulcer in her Lungs, that they immediately approv'd of what I had before proposed to her and her Relations, of the necessity of making an Apertition in her side, where we could apprechend the Lungs grew to it; for that seem'd unquestionable, from the posture of discharging it; and some little pain she felt in her side. The great opinion her Relations justly entertain'd of these Gentlemen, being not only Men of great Learning, particularly in their own Profession, but also of many years Practice, Dr Torleffe having been almost 30 years since, chosen Physician to St Thomas's Hospital, and Dr Pitts to St Bartholomews several years ago, made them readily consent to what was proposed, and desire your assistance. assistance, being no Strangers to your great Ability both in Anatomy and Surgery: About a week before, the Pus had begun again to encrease, and the day before these Gentlemen saw her she was taken in the afternoon with a chilness, after which her Pulse became a little quicker, and she a little Feverish, as I believe you remember she was, when you applied the Caustick; this Feverish state encreased every day, and after some days a Rash appear'd, which lasted about 14 days before it was quite got off, and left her in a Hectick, with redness in her Cheeks towards evening, Night Sweats, continual Looseness, extreme wasting of her Flesh, and at length a swelling in her Legs, though she kept her Bed. I doubt not but you remember that we felt some little knots betwixt the seventh and eighth Rib, which with other circumstances made us conclude the adhesion was in that part, and would have laid the Caustick there, but that it would certainly have spread to the Glands of her Left Breast, which made us lay it between the sixth and seventh Rib, (sursum numerando); As soon as you could you took it off, and with your Knife gently pass'd through into the Cavity of her Breast, whence issued a Bloodyish Water, but no Pus; by bending your Probe you found the adhesion reach to the lower edge of the 7th Rib, and before the Eschar was separated, the Pus began to flow at every dressing, and so continued, gradually abating, till the Ulcer was cured; during which a part of the inside of that Rib, above an inch long exfoliated, and after that another lesser piece of the outside of the Rib. Towards the latter end of the Cure, she complained very much of a pain at the Cartilago Ensiformis, so great that she sometimes pluck'd out the hollow Tent, which we conceiv'd was occasioned by its pressing upon the Nerve, during the first 7 or 8 days of her Rash, she rais'd very little, if any, of that Pus, nor did it discharge itself then by the Orifice, nor was there a collection of it in her Breast, which made me apprehend, that the Fever did so alter the state of her Blood, as not to per- nit it, to separate its impurities into the Abscess. I must observe to you, that for six days before the Fever began, she had the Catamenia very orderly; by August she was cured, her side heal'd up, and would not endure it to be converted into an Issue; by October she recovered her Flesh, and the Catamenia return'd, which had been wanting ever since May, and now, as you lately saw her, she is plump, fleshy, clear and fresh Complexioned, has little or no Cough, and no foetid or tabid expectoration, and seems, and I believe is perfectly cured, having for many months taken no Medicine. There are several circumstances in this Case, which I cannot forbear making some remarks on. That there was an Ulcer in the Lungs, and that it has admitted of a Cure, contrary to the general opinion of Physicians. That this Ulcer did contain at least 2 spoonfuls, and must have been as large as a Hens Egg. That this Abscess arose from a collection, with an indiscrenible (if any) Fever, and so continued from Christmas to about the 10th of May. The tender Membranous or Vesicular composition of the Lungs seem to justify this opinion, that it is almost impossible for them to heal, when there is a considerable diminution of them, the continual and indispensable necessity of their motion, very much hindring the coalition of the Vesicle. Several parts of the Body afford a proper cement to unite and repair them, when hurt or diminish'd. Carious and broken Bones send forth a Callus; when the Skin is consum'd by Ulcers or Burns the parts afford a Cicatrix, which pretty well supplies the defect of the Skin. The Lungs separate a viscid Pituita, which will be expanded into Flasks like a Membrane; Mr Stringer, Sarah Deeping and some other Patients have brought up great quantities of them, and a little Boy at Mr Tolley's in Kensington, Cough'd up several Pipes, form'd exactly like the Bronchia, and its divarications, and at first view seem'd to be the internal Membrane. Mr Buffier mentions this instance in the Philo- sophical Transactions, April 1700. His haste would not permit him to observe the Case so exactly as it deserv'd: this Child two years before, had an Ulcer in the Right side of his Lungs, and they adhered to his Back, when I separated them I found a Cicatrix near three inches long, but very little (if any) defect in his Lungs. I am of opinion this Pituita or Mucus doth serve to re-unite the parts of the Lungs when there is a solution by an Ulcer. Consumptive Persons generally flatter themselves, that they have no Ulcer in their Lungs, because they do not feel a soreness, as in the Ulcers of other parts. This opinion keeps them from making a timely application to Physicians, whilst they might receive a speedy and easy Cure. When you touch'd the Sound or Ulcerated parts of her Lungs with your Probe or Finger, she discovered no sense of feeling you, which may confirm the opinion of Physicians and Anatomists, that the Lungs have little if any sensation. When you touch'd her Heart with your Finger, tho I believe for not the twentieth part of a minute, she grew very much disordered, pale and ready to faint, which shows Nature cannot suffer the least alteration in its pulsation, without great prejudice and inconvenience. It is the opinion of some Physicians, that the Fever which attends Consumptive Patients, arises from some Particles of the Pus, which being receiv'd into the Blood, and circulating with it, cause that effervescence which we call an Hectick. This Patient had no Fever from Christmas to May, and then unhappily came a continued Fever, with a Rash, which left a Febricitation every afternoon, with those symptoms which attend a Hectick. I have observed for many years, that if I could preserve my Consumptive Patients from that Hectick Fever, or relieved them who already labour'd under it, I could cure them, tho their expectoration was very plentiful and foul. I doubt not, but if some of our faculty applied themselves more particularly to the cure of Consumptions, so many thousands would not dye of it yearly in this City, as appears by the Bills of Mortality. I do not doubt but some part of her Lungs do adhere to her side, and it's probable a little part of them do not receive the Air in inspiration, but I believe that defect is very inconsiderable, because she can run up Stairs, and is no more disordered in her Breath than most other People. The easy discharge of the Pus, by her lying down in that posture, did undoubtedly very much preserve her Lungs, and prevented its breaking through the Abscess, into the Cavity of her Breast, and putrifying her Lungs to a greater degree. Pus, generat Pus is a noted Aphorism, and the Air Bladders of the Lungs are so very tender, that they must have yielded to the pressure of the Pus, had it lain long in the Abscess, and been only discharged by violent Coughing; by lying in a proper posture. Sir Tho. Proby, Sarah Deeping, and other persons have prevented a greater solution in their Lungs, and either prolonged their Lives many years, or recovered their Healths by proper Medicines. This and other instances, make me easily concur with some Physicians in an Opinion, that in some Families the Lungs have originally a more tender Constitution than in others. Mrs Terry's Aunts are subject to great Coughs and Ptyssick. Her Aunt Fowkes little Daughter of about 7 years old, having a little Fever, with some symptoms of the Small Pox, but a great difficulty in Breathing, I advised her Bleeding at the Arm, but she was so fat you could not find a Vein that night; next day the Small Pox appear'd, which a little eas'd her Lungs, upon the sixth night after, she rais'd at several times about 7 or 8 Ounces of clear Blood, by violent Coughing: I was sent for, and drew away about 6 Ounces of Blood by Leeches, which totally reliev'd her Breath, and stopp'd the raising Blood. This instance I mention being so like Mrs Terry's, to confirm what I said before, and to evince that so great loss of Blood will not hinder the regular proceeding of the Small-Pox, which she went through very very orderly, and recovered perfectly. I have observ'd the same effect in other Patients, in whom Bleeding after eruption was indispensable. The continual motion of the Breast in Breathing, made the Caustick spread farther than it was design'd, or could be prevented; I have prevail'd with some Patients to yield to an apertion by Launcet, which I take (in some Cases) to be the better way; that little Blood which may possibly get into the Cavity of the Breast, is easily thrown out again by the Lungs in inspiration, as you may remember she did the injection every time you used it. You cannot forget how after the Pus began to flow at the Orifice, it lessen'd the raising it at her Mouth, and in no long time, the Purulent Expectoration totally ceas'd. SIR, This Letter already exceeds its proper bounds, therefore I will omit some other remarks of less consequence, viz. on the Bloody Colour'd Pituita, the Fetid Odor of the Pus, and the Rash Fever which came without any manifest cause, and only Subscribe my self, Your most Affectionate Friend And Servant, Jo. Wright.