the most prominent is Blood-letting. This remedy has been strongly
advocated by many of the most distinguished authors who have written
on Consumption; and its propriety admitted by all under certain
circumstances. Probably, most of the injurious effects attributed
to it, may be accounted for by a proper distinction not having
been made between Primary and Secondary Phthisis Pulmonalis. When
bleeding has been practised in the secondary form of the disease,
it has been generally injurious, and hence an odium has been cast
upon its employment in any circumstances. In the same manner, it
has done mischief, when used too late in Primary Phthisis, and thus
another groundless argument furnished against the remedy. But the
indiscriminate use of blood-letting is not here contended for. Its
judicious and cautious use, when inflammatory action is evident, alone
is intended to be advocated. On the other hand, too timid practice
may induce us to withhold the lancet when it is necessary; and we
may thus do as much injury by losing the proper time for action, as
we would have done by pushing the remedy too far. It is difficult to
fix the period beyond which it is improper to bleed in Consumption.
Dr. Hosack insists that as long as there is any pain or soreness on
taking a full inspiration, the lancet is necessary. This rule is not
applicable to practice; for if we adopt it, we may bleed the patient
until he dies. Until that moment will the pain in some instances
continue. It is not unfrequent, after the patient has been exhausted
by colliquative sweats, and profuse diarrhœa, for pain in the breast
to recur at intervals, a few days before death: and what practitioner,
under such circumstances, would feel himself justified in using the
lancet? But this rule is incorrect in another point of view. In some
cases, it will prevent our using this valuable remedy, when it is
necessary. On the authority of Dr. Reid, it is asserted, that pain
is not always present in Phthisis Pulmonalis; and may not occur
during the whole course of the disease. A reference has been already
made to Dr. Heberden to prove the same fact. On this subject it is
impossible to fix any precise rule. The strength and habit of the
patient, the urgency of the symptoms, and state of the pulse, must all
be recollected and adverted to in making up our judgment as to the
propriety of the remedy. In general, perhaps we may say, that after the
formation of matter is perfectly ascertained, it is improper to bleed.
This, however, is not without exceptions. Cases sometimes occur, after
this period, in which the symptoms of high inflammatory action arise,
and where the lancet is indicated. It is now generally admitted that
the buffy appearance of the blood is by no means an infallible evidence
of the necessity of the repetition of blood-letting. Nor is its cupped
form a better proof of the existence of inflammation. Many writers have
observed, that the buffy coat appears in the blood drawn in Consumption
at the latest periods of the disease. A remarkable and decided case of
Enteritis, occurred during the last winter, in the New-York Hospital,
in which very large and repeated bleedings were made use of, with
the good effect of curing the patient: and yet, neither buff nor the
cuplike form appeared in the smallest degree in the blood drawn. This
case alone is sufficient to prove, how equivocal are these appearances
of the blood, as tests of inflammation. Nevertheless, the judicious
practitioner will not fail to observe these circumstances, and as they
so frequently accompany inflammation, will consider them, when attended
with other evidences, as properly influencing his judgment on the
propriety of bleeding.
If the abstraction of blood from the system generally is useful, no
less so is it when drawn from the part itself, by the application
of cupping-glasses, and the scarificator to the chest. This mode of
obtaining blood is peculiarly useful in those frequent cases, where the
patient is too much debilitated to bear the loss of much blood, but the
existence of inflammatory action makes its abstraction necessary.
Emetics are a powerful remedy in the treatment of Phthisis. They not
only promote expectoration, and relieve the distressing cough in the
first stage of the disease, but by their general relaxing effects
upon the system, are useful in reducing inflammatory action. The use
of this remedy, however, should not in general be commenced until
blood-letting has been premised; otherwise in plethoric habits, full
vomiting might induce hæmoptysis. Practitioners have differed very
much in the choice of emetics proper in this disease. The antimonial
preparations and ipecacuanha, as acting more generally upon the system
in reducing excitement, and from their good effects in other febrile
diseases, appear to be the most proper. But in the last stage of
Consumption, where our object is to relieve the pulmonary symptoms,
without debilitating the patient, the sulphates of zinc and copper are
preferable.
Emetics are not only useful when exhibited for the purpose of full
vomiting, but medicines of the same class given as diaphorectics are
also proper. With this view the various preparations of antimony are in
use. Small doses of the Antimonial powder combined with calomel have
been found, perhaps, one of the best sudorifics that can be employed,
and as such are frequently useful in Phthisis. No medicine is superior
to this combination in reducing inflammatory action; and it frequently
has a better effect by proving both emetic and purgative.
As a sudorific, warm bathing may be very useful, and is an agreeable
remedy in the inflammatory stage of Phthisis. As the warm bath is
useful in relaxing the surface of the body generally; in a similar
manner inhaling warm air, by means of Mudge’s apparatus, relaxes the
inflamed membrane of the bronchiæ, and acts as a fomentation there,
with the same good effect as is produced by warmth and moisture upon
any other inflamed surface of the body. This remedy gives great relief
in the cough and hoarseness so distressing in Phthisis Pulmonalis.
With the same view of counteracting inflammation, cathartics may be
prescribed. As in other febrile diseases, so in Phthisis, the bowels
are frequently torpid, and require the frequent use of aperient
medicines. Saline and mercurial cathartics, possessing the greatest
power in diminishing excitement, are perhaps the most proper in this
disease. But as it is an object not to induce too much debility, the
use of drastic purgatives should be avoided as much as possible, and be
confined to the earliest periods of the disease. During its advanced
stage, the bowels should be kept open by mild laxatives and enemata,
which tend least to debilitate the patient.
Blisters, Setons and Issues relieve the inflammation of the lungs, and
produce a new determination to the surface with the happiest effects.
Most writers agree in recommending repeated blisters to the chest, as
an useful remedy, and with reason. But it is to be regretted that they
have been suffered to usurp the place of a more powerful remedy of the
same class, viz. Issues. If we may judge from the effect of ulcers and
fistulæ, which palliate all the symptoms of confirmed Phthisis, while
they continue, but whose healing restores the disease, it would appear
that the establishment of similar drains, in the form of issues, ought
to have a good effect. In caries of the spine, and disease of the hip
joint, where the inflammation in the cellular structure of the bones
seems to be very analogous to that in the cells of the lungs, issues
are used with the greatest benefit. In these cases, they are uniformly
preferred to repeated blistering, and experience has sanctioned the
preference. Issues are preferable to blisters by their constant and
uniform action, whereas the latter remedy has its effect continually
interrupted by healing up and requiring renewal. In general, blisters
appear to be more useful in acute diseases, which may soon be subdued:
but in Phthisis Pulmonalis, which continues so long, and whose progress
is so slow, issues appear to be the better remedy. Dr. Mudge was so
well convinced of their efficacy, that he assures us, he cured himself
of an Incipient Consumption, by a large issue between the shoulders.
Beddoes also recommends them, and relates several cases, in which
they were used with the best effect. But if this remedy be tried, it
should not be done timidly, and with the fear of giving pain; when
used at all, issues should be large and effectual, not only sufficient
to contain a single pea, but at least a dozen. This is not the only
remedy which has fallen into disrepute by a trifling and inefficient
mode of employing it. But as blisters are preferred by many of the most
judicious practitioners, their use may easily and with advantage be
combined with that of issues. While a large issue is kept open between
the shoulders, successive blisters may be applied to the chest. Many
patients, perhaps, would not submit to so severe a mode of treatment;
but it is only by such active and efficient practice, that we can hope
to cure this formidable malady.
It is only in the first stage of Consumption that much benefit is to
be expected from this class of remedies, or at all events, before the
patient is much debilitated. In its latest periods, they would tend
rather to add to the debility already induced by the disease. At any
time, however, when the patient is not too much reduced, they may be
prescribed with advantage.
Mercury, given until it produce salivation has frequently cured
Phthisis Pulmonalis. It is used with greatest advantage in its first
stage, but after the inflammatory action has been in some measure
reduced, by means of blood-letting, and the other remedies proposed.
Before these evacuations have been premised, it would tend rather to
increase the inflammation; while in the advanced stage it would add too
much to the debility of the patient. It generally succeeds only when
it affects the mouth, and therefore to secure this effect and prevent
its running off by the bowels, it should be combined with opium. But
the best form of exhibiting mercury, is one much in use with my worthy
friend and preceptor, Dr. Borrowe. Calomel, combined with small doses
of antimonial powder, given morning and evening, until it affect the
mouth, is the form proposed. In this way it may be given at an earlier
period of the disease, than would otherwise be proper, by the constant
determination to the skin kept up by the antimonial powder, obviating
the tendency which mercury has to increase inflammatory action. At the
same time it serves to keep the bowels open, and makes almost every
other medicine unnecessary. On the other hand, if it acts too much
on the bowels, it may be usefully combined with opium, which adds to
its diaphoretic effect. The good effects of this mode of exhibiting
mercury, is strikingly illustrated by the result of the following case,
which occurred in the practice of Dr. Borrowe within a few months past.
“Miss ------, aged about 14 years, had been for six months past,
afflicted with some cough, pain in the chest and difficulty of
breathing. She was affected with loss of appetite, emaciation and
profuse sweats at night. Her pulses were frequent; she had the peculiar
pearl-like appearance of the adnata; frequent attacks of diarrhœa, and
an expectoration much resembling pus. She was attacked with chills
about the middle of the day, followed by considerable excitement,
aversion to motion and drowsiness; succeeded by great prostration of
strength; palpitation and hurried breathing on ascending a height or
engaging in any considerable bodily exertion; attended with a livid
appearance of the lips, evidencing a difficulty in the passage of blood
through the lungs.
It was determined to put her upon the use of Calomel and Pulv: Jacob:
which were given in small doses every night and morning; a blistering
plaister was also applied to the chest, and kept in an irritable
state for a considerable length of time. The diet was ordered to be
soft, mild and nutritious. The mercury and antimonial medicine were
occasionally omitted when they acted more on the bowels than the skin,
or occasional anodynes were administered to restrain their action on
the alimentary canal.
Some weeks elapsed before the mercury produced any effect upon the
salivary glands, which was one of the objects aimed at. As soon as the
mouth became sensibly affected, the symptoms were generally mitigated.
A temporary suspension of the use of the remedies became necessary, in
consequence of the considerable effect produced by the mercury. When
the soreness of the mouth abated, small and less frequent doses of the
calomel were given so as to keep up a tenderness of the gums several
weeks longer. The affection of the chest became now entirely relieved,
and it was thought advisable to suspend the use of the mercurial
treatment, the effects of which were suffered to pass off, rather than
be relieved or cured.
From this time no medicines were employed, except a small quantity of
a weak infusion of colombo as a tonic. Long before the patient’s mouth
enabled her to eat, her appetite became craving. She was indulged in
eating moderately of such food as she had a particular desire for;
and she soon was enabled to take exercise without inconvenience. She
did not now complain of any pain in the chest, the cough left her,
the bowels became regular, there was no recurrence of night sweats,
she began to gain flesh, the countenance assumed the healthy aspect,
and the peevishness under which she had long laboured was effectually
cured. She now slept well, and gradually returning to her former
habits, is at the end of five months after discontinuing her remedies,
in perfect health.”
Digitalis is a remedy in Phthisis, which has excited much acrimonious
controversy among practitioners of medicine. As always happens in
these contests, it has been praised too highly by one party, and
condemned too severely by the other. When first introduced, it seemed
to promise the complete eradication of Consumption: and it almost
appeared that digitalis was as specific in the cure of that disease,
as mercury, in syphilis. Dr. Magennis of the Royal Navy Hospital
at Plymouth, England, published a paper, containing an account of
seventy-two cases of incipient or confirmed Consumption, in seamen and
marines, treated with digitalis. Of these, twenty-five with ulcerated
lungs recovered; and fifteen from the stage previous to ulceration.
Thirteen of the seventy-two in an early stage of ulceration were
discharged, greatly relieved; and nine in the previous stage. In ten
cases, the medicine failed; but in some of these it gave considerable
relief. Beddoes assures us, that three cases out of five of tubercular
consumption, in his practice, had recovered under the use of digitalis.
Kinglake insists that one in three cases of the tubercular stage of
Consumption, may be cured by this medicine. Dr. Currie informs us,
that digitalis may be used with safety and success in cases where the
lancet can no longer be employed. These results in the practice of men,
distinguished in their profession, although they may be somewhat warped
by prejudice, are extremely flattering, and prove at least that the
medicine has some power. But like all other new remedies, digitalis has
been rated too highly by those who first used it. Delighted that they
had discovered a medicine, which, in some cases would cure a disease,
which they had been accustomed to look upon as totally incurable, these
physicians have suffered themselves to attend too exclusively to its
successful results, and to neglect cases in which it has failed. Other
practitioners, on reading their exaggerated statements, have tried the
remedy, but finding themselves frequently disappointed, have gone into
the other extreme and condemned it entirely. Their representations
are to be admitted with as much qualification as those of their
opponents, and the judicious physician will not suffer himself to be
exclusively guided by either. That in certain cases, digitalis will
cure Consumption, cannot be doubted; but we have also to regret, that
it very frequently fails. It was prescribed in the New-York Hospital,
under the direction of Dr. Hamersley, during the last winter, in six
cases which I have witnessed, of evident and well marked Phthisis. Of
these, two patients were perfectly cured; one has nearly recovered, and
is only retained in the Hospital for a slight cough, which is yielding;
a fourth was discharged at his own request, but evidently relieved; the
fifth commenced the use of digitalis, at a very advanced period of the
disease, and soon died; in the last it failed entirely, and appeared
rather to have done injury.
Having ascertained that digitalis does sometimes succeed in curing
Phthisis Pulmonalis, it remains to discover what are the cases in
which we may exhibit it with success. For this purpose it would be
desirable to ascertain the _modus operandi_ of the medicine. Here
writers have differed as widely as in their account of its success
in practice. One author determines it to act by diminishing the force
and frequency of the circulation, and reducing inflammatory action; a
second attributes its salutary effect to its operation on the kidneys;
while a third believes it no longer to be of advantage, when it
increases the discharge by urine, excites nausea, vomiting, purging
or any undue excitement, but attributes its beneficial effects to its
stimulant efficiency, in invigorating the arterial and muscular energy
of the system: and a fourth insists that by promoting the action of
the absorbents it cures Consumption. These conflicting and opposite
opinions constrain us to admit, that farther enquiry is necessary,
before we can rest satisfied as to the mode in which digitalis acts.
It must be confessed that this medicine is extremely uncertain in
its operation. Its most evident effect, and that most insisted on,
of reducing the frequency of the pulse, is by no means certain; and
indeed, it is the opinion of Dr. Beddoes, that the force and strength
of the pulse are increased by it. In the N. Y. Hospital I have
witnessed frequent cases in which its continued exhibition produced no
effect in reducing either the force or frequency of the pulse; and in
some instances no effect at all seemed to be produced by it. A case
occurred in that institution in October last, in which a patient, by
his own carelessness took six drachms of Tinct: Digitalis with no
evident injury. In examining the effect of this medicine on the pulse,
it is necessary to recollect the remark of Beddoes, that it is very
different in the recumbent and erect posture; the pulse frequently
being found to be reduced in frequency and irregular in the former,
but recovering its frequency and regularity in the latter situation.
From the same author we learn, that if this remedy do not produce any
good effect within three weeks, we can expect no advantage from it at
all. It is generally admitted that digitalis will succeed only in the
first stage of Phthisis Pulmonalis; in the last or ulcerated stage of
that malady, it will not save our patient, but we are apprehensive,
will rather hasten his dissolution. As it is acknowledged to be an
uncertain medicine, we should not place our whole dependence upon it,
nor suffer it to take the place of blood-letting and the rest of the
antiphlogistic treatment before recommended: it should be used rather
as an auxiliary than a principal remedy. From its uncertainty of
operation it requires a cautious exhibition. The dose for an adult is
from ten to fifteen drops of the saturated tincture, three times a day,
and gradually increased until some effect is produced.
The use of factitious airs in Consumption is now very much abandoned.
No essential benefit has ultimately appeared to be derived from them;
although in the first instance, they produced some apparently good
effect.
Of much more advantage is a sea-voyage and a mild climate. The benefit
evidently derived from sea-voyages has been attributed to various
causes. The nausea and vomiting from sea-sickness, the uniform motion
and gentle regular exercise produced by sailing, and the uniformity
and mildness of the atmosphere of the ocean, so evident at a distance
from the land, probably all combine in producing these happy results.
We can hardly suppose, however, with Dr. Mudge, that the exhalations
from the tar and pitch about the ship, taken into the lungs in
respiration, have any agency in the effect produced. But whatever be
the cause, it is not at all unfrequent for consumptive patients to
experience immediate relief after having been a few days at sea. A
sea-voyage to produce permanent benefit, should be long continued, and
what is of still more importance, terminate in a mild climate. Every
winter, instances occur in this city, of consumptive patients being
restored to health by a voyage to the south of France, or some other
country of similar temperature. The climate most grateful to these
patients is one whose temperature is uniform, not subject to any sudden
variations, and where the atmosphere is dry and pure. The island of
Madeira possesses all these requisites. The part of it best adapted to
the purpose in question is thus described by Dr. Adams, a physician of
that island, in a letter to his friend in London:--
“The valley of Funchall is defended by immense hills from every wind
but the south, where it is open to the sea-breeze; this preserves a
temperature so even, as is unknown in any other part of the world. Our
winters may be compared to your summers in every thing but the length
of days, and those sudden changes from heat to cold, to which you are
subject. The thermometer with us is often steady within doors, or
varies scarcely a degree for weeks together. During winter its whole
range is from 58 to 65; and in summer, from 70 to 75, rarely amounting
to 80; the heat being always tempered by a breeze in proportion to the
force of the sun. The dryness of our atmosphere is not less remarkable.”
If this description be correct, Madeira has a climate possessing every
requisite to make it most favourable to phthisical patients. The
southern parts of the United States are frequently resorted to, also,
by the consumptive with great benefit. I have had the satisfaction
of seeing a young friend return from Charleston, a short time since,
perfectly restored to health, who, during the last autumn, was attacked
with repeated hæmoptysis and other symptoms of Incipient Phthisis.
It is to be regretted, that change of climate, a remedy of so much
advantage in the early stage of Consumption, should so often be
postponed, until no possibility of recovery remains. It is too often
the fate of such patients, to leave their homes in quest of health,
merely to find a foreign grave; resorting to that remedy which should
have been first, as the last effort of despair. To this cause alone,
may we attribute its frequent inefficiency, and unfortunately the same
cause has contributed too much to bring the remedy into disrepute.
Where from any circumstances, change of climate is impracticable, it
may to some extent be imitated, by confining the patient to apartments
whose temperature is kept constant and uniform. This has been tried and
with some success; and is probably, the remedy of the same class, next
in power, but much inferior to a warm climate. Beddoes made use of it
in several cases with relief to his patients, but it has not yet been
sufficiently tested to establish its character as a remedy in Phthisis
Pulmonalis.
Besides the use of the remedies which have been enumerated, with the
view of effecting a radical cure of this disease, there are some
symptoms occurring in its first stage, which require immediate relief.
Hæmoptysis sometimes comes on in such a manner as to be very alarming
to the patient. Blood-letting in large quantities, and repeated in
proportion to the strength and habit of the patient and violence of
the symptoms, is then absolutely necessary. Unless the plethora, which
is oppressing the system, and exciting the hæmorrhage from the lungs,
be relieved by general blood-letting, blood will not cease to pour
out from that viscus. At the same time the free exhibition of saline
cathartics, a blister to the chest, a rigidly abstemious diet and a
strict adherence to the antiphlogistic regimen must accompany this
treatment. Peruvian Bark, Chalybeates and Elixir of Vitriol so often
used, in active hæmorrhage during the inflammatory stage of Consumption
cannot but be injurious. They increase the force of the circulation and
consequently the disposition to hæmorrhage. In the same symptom arising
from an opposite cause, they may be prescribed with advantage. Common
salt, administered dry in the manner directed by Dr. Rush, has been
found by experience to be very useful in abating hæmorrhage from either
cause; but it should not be depended on alone, nor suffered to take the
place of the treatment just detailed.
If possible, we should anticipate the occurrence of hæmoptysis with
our remedies, and thus prevent the formation of a habit of spitting
blood, which when once established, is difficult to destroy. The usual
precursors of this symptom are, a saltish taste in the mouth, a sense
of irritation at the upper part of the trachea, and some oppression
and difficulty of breathing. At this time, before the hæmorrhage has
commenced, blood-letting and the rest of the remedies mentioned above
should be actively exhibited. “_Venienti occurrite morbo._”
A distressing cough at this period also requires the attention of
the physician. From its occurrence more particularly at night, it
disturbs the rest and adds much to the sufferings of the patient. It
should be alleviated by Opiates, accompanied with any of the mild
demulcent remedies, generally denominated Pectorals. Mudge’s Apparatus
for inhaling the steam of warm water, may also be used with relief,
especially on going to bed.