decidedly formed, a different mode of treatment becomes necessary.
Little indeed is now to be hoped for from any treatment, as a radical
cure; but our patient is not to be abandoned; if he cannot be cured,
his sufferings may be materially mitigated, and he may be directed to
avoid such things as may increase his malady. Nor should we entirely
despair of performing a radical cure; for solitary cases are related by
many authors of consumptive patients being cured in every stage of the
disease. Many of these cases, perhaps, have been mistaken for Phthisis
Pulmonalis; but of some of them we cannot doubt. The authority from
which they come is too high to permit us to hesitate.
The remedies last mentioned in the treatment of the first stage of
Consumption may yet be proper, and although with not so great a
prospect of success, should still be tried. These are a sea-voyage,
change of climate, and confinement to apartments whose temperature
is regulated. But all the debilitating remedies before recommended,
are now to be avoided. The lancet in general is improper, although
in some few instances, the occurrence of acute inflammation at this
period, still requires its cautious use. Drastic Cathartics should not
be used; the bowels if torpid must be kept open by gentle laxatives
and Enemata. Antimonial and other debilitating Emetics should not
now be exhibited, but the Vitriol Emetics may still be prescribed
with advantage. The Sulphate of Zinc given in such doses as to excite
occasional vomiting, is frequently very useful, and especially where
much irritation is present. It was introduced and strongly recommended
by Dr. Mosely in his Treatise on Tropical Diseases &c. His Vitriolic
solution[8] is certainly an useful remedy in relieving dyspnœa and
promoting expectoration. Instead of debilitating as antimonials do, he
assures us, that its emetic effects are instantaneous, not harassing
the patient, but always leaving the stomach strongly invigorated. Mr.
Warburton, the present House Physician of the New-York Hospital, has
assured me, that he has frequently prescribed it in that Institution
with evident benefit. With similar intentions, Dr. Senter, in the
Medical and Chirurgical Review, published in 1793, recommends the
sulphate of copper.
At this time blisters will be preferable to either setons or issues,
as they relieve the local symptoms without producing a constant
debilitating discharge. Indeed they should be used in such a manner,
as to produce as little discharge as possible. With this view, they
should not be kept open by stimulating dressings, but be healed up, and
occasionally renewed. With the same intention, stimulating plaisters
may be applied to the chest with advantage, and in general are
preferable to blisters.
To support the patient’s strength, as was proposed in the second
indication, tonics are necessary. Of these some of the simple bitters
are preferable, as columbo, gentian, boneset, chamomile, &c. But
we should be careful not to exhibit them during the paroxysms of
hectic fever, but during its intervals. Peruvian bark has not been
found admissible. It produces a sense of stricture and oppression of
breathing, adds to the cough, makes the pulse quick and hard, and
hæmoptysis is not unfrequently the consequence of its exhibition.
Dr. Fothergill dwells particularly on the abuse of this medicine in
Consumption.
As stimulating and bitter medicines, the Polygala Seneka and
Aristolochia Serpentaria have been recommended in this stage of
Phthisis Pulmonalis.
The stimulating balsams and gums are also proper in this stage. They
have been highly recommended by Morton; and myrrh in particular is
prescribed with great confidence by Simmons. They are objected to by
Fothergill, on the ground, that by their stimulating properties, they
increase the inflammation of the lungs. His objection appears well
founded, while symptoms of acute inflammation still exist; but after
they have subsided, the cough and other distressing symptoms of the
last stage of Phthisis, may be much alleviated by these medicines. By
their stimulating effects upon the whole system, also, they may be
useful at a time when the patient is sinking under great debility.
As stimulating applications are frequently found necessary and useful
to indolent ulcers on the surface of the body, it naturally occurred
that similar applications might be made with advantage to ulcers of
the lungs. With this view, the steam of tar water, and the vapour of
sulphuric æther inhaled in respiration, have been used in the treatment
of Consumption.[9] With the same restrictions as are necessary with
the stimulating gums and balsams, these remedies may be beneficial. It
is not probable, however, that any permanent relief can be derived from
them; they can only mitigate symptoms.
To check the profuse sweats, which occur at this period, and add
materially to the debility of the patient, the elixir of vitriol is an
useful medicine. As a general tonic it acts beneficially also upon the
whole system.
With the view of quietting the cough and procuring rest at night,
opiates are necessary; and fortunate are we that we have in our
possession, a remedy, which although it will not permanently cure the
disease, palliates the symptoms, at least for a time; and makes more
smooth the path to death. It is true that opium produces some ill
effects. It debilitates the stomach, and injures the appetite; but when
the symptoms are urgent, it cannot for these reasons be dispensed with.
By lulling pain, and giving rest to the watchful patient, it more than
counterbalances these disadvantages. The humulus lupulus or common
hops, does not possess the objectionable properties of opium, but with
its anodyne combines some tonic powers, and promises to be an excellent
substitute for that medicine.
The large and frequent use of syrups in the form of expectorant
mixtures and linctuses, to alleviate cough, is very injurious. They
cloy the appetite, destroy the tone of the stomach, and prevent the
taking of nutritious aliment, which is now so necessary; and frequently
without producing any material relief of the symptom for which they are
prescribed.
The use of opiates is necessary also, to check the profuse diarrhœas,
which now alternate with costiveness, and reduce the already
debilitated patient. With the same view, the chalk mixture may be used
with advantage, and the astringent medicines, Kino and Catechu, with
others of the same class.
It is not unfrequent for hæmoptysis to occur at this period, as well
as in the earlier stages of Consumption. Sometimes it is the effect of
some temporary excitement, and may be relieved by the loss of a few
ounces of blood. But frequently this evacuation cannot be borne; and
the hæmorrhage proceeds rather from debility in the vessels of the
lungs, than any increased force of the circulation. We must then trust
to astringents--muriate of soda, sulphuric acid, and alum.
We come now to speak of the diet and regimen of patients labouring
under Phthisis Pulmonalis; a subject no less important than the
remedies to be exhibited. In the first stage, the diet should be
perfectly simple, and such as will least tend to increase the
inflammatory action of the system. For this purpose nothing is better
than milk. So sensible have physicians, at all times, been of its
propriety, that in many cases, they have trusted the cure entirely
to a milk diet. It is highly spoken of by almost every author who
has written on this subject, and with reason. It is light, easily
digested, and does not produce any excitement. Many have preferred
Asses’ to Cows’ milk, but it does not appear that there is any material
difference, which should influence our choice. The former is thinner
and less nutritious, and perhaps, to very delicate stomachs, may
be more acceptable; but in general, the latter is as useful. Milk,
however, is very offensive to some stomachs, and not so easily digested
as other food; in such cases it must necessarily be prohibited.
As a general rule, with regard to diet, in this stage, animal food is
improper, and the patient should be confined to the use of vegetables.
Fresh sub-acid fruits are proper; and, indeed, of so much importance
have they been considered, that Hoffman mentions a case of confirmed
phthisis, cured by confining the patient to the use of fruits, and
particularly strawberries. Mucilaginous and diluent drinks, as those
formed from barley, sago and flaxseed are also useful. Among these
may be classed, the Lichen Islandicus, which has gained with some the
reputation of curing Consumption. Weak is the foundation for hope of
those who depend on it. As an article of diet, from its mucilaginous
property, it is useful; and in the last stage, from its possessing
slightly better and tonic virtues, it is also proper; but as a
remedy for phthisis it is altogether inert. Nor are its tonic powers
sufficiently great, to render it injurious in the early stage of the
disease.
The dress of the patient should also be regulated by the Physician. He
should be clothed in flannel, and this frequently changed. A constant
determination is thus kept up to the surface, and to some extent,
diverted from the chest. At the same time, all exposure to cold,
moisture, or sudden alternations of temperature must be studiously
avoided. As in many cases, they lay the foundation for consumption, so
after it has commenced, their repetition aggravates it.
Mental distress and consequent despondence, impedes the cure of
those who otherwise might recover, and should be obviated as much as
possible. Happily, patients labouring under Phthisis, generally with
difficulty, resign hopes of recovery, and despondence from that source
does not often depress them. But mental anxiety, produced by other
causes, is very injurious. It should be relieved, as much as possible,
by pleasant amusements, a journey, a sea-voyage or any other method
most suited to the particular circumstances of the patient.
In the second stage of Consumption, the diet of the patient must be
altered, as well as the medical treatment. The most nutritious articles
of food are then to be chosen, and such as are at the same time the
most easily digested. It is well ascertained that the older meats,
as beef and mutton, possess these properties in a higher degree than
veal or lamb; and generally, the brown more than white meats. With the
same view, wild fowl and game generally, form nutritious articles of
diet, proper for consumptive patients. Eggs combine a large quantity
of nourishment in a small compass, and may be freely used. They should
be taken either quite raw, or boiled a very few minutes. When boiled
hard, they form one of the most indigestible and offensive substances,
to the delicate stomach, that are used in diet. The various culinary
preparations, of which eggs form a principal part, are for the same
reasons proper. Jellies also contain a great quantity of nutritious
matter, and are very acceptable to patients, who, as in Consumption,
have little appetite. Oysters and some other of the testacea, are also
extremely nutritious. Isinglass boiled in milk is frequently in use,
and with advantage, in these cases. Of the vegetable nourishments,
those should be chosen which are most nutritious and abounding in
mucilage, as rice, sago, arrowroot and Tapioca. Chocolate, when
prepared in such a manner as to be free from oily matter, is a very
pleasant article of diet.
The drinks of the patient should also be stimulating and nutritious.
Malt liquors combine both these properties with some tonic virtues,
which they obtain from the bitter of the hops infused in them, and
therefore constitute the best drink for consumptive patients. Wine,
also, may be used moderately with advantage, but requires some caution;
and should be immediately abandoned, if any undue excitement be
produced by it.
In this, as in every other stage of Consumption, while the patient has
sufficient strength, exercise is necessary to the recovery of health.
Of so much importance is exercise, that in many cases, it has alone
cured this disease. Dr. Rush relates many such cases, and particularly,
three instances of persons in confirmed consumptions, perfectly cured
by the hardships of a military life. Of so much consequence was it
in the eyes of Sydenham, that he pronounced riding on horseback, as
certain a cure for consumptions, as bark for an intermittent fever.
Indeed, all writers on this disease join in recommending it, not only
as a part of the regimen, but as a principal remedy in the treatment.
The mode of exercise to be chosen, should depend entirely on the
situation of the patient, at the time. While much pain and soreness
subsist, denoting the presence of active inflammation, the most gentle
exercise only should be used: at that time riding in a carriage or
on horseback, would be as improper as for a patient labouring under
pleurisy. The swing, so highly recommended by Dr. Carmichael Smyth, is
the least fatiguing, and most gentle mode that can be adopted. It may
be serviceable, too, when the patient is too much debilitated to bear
other more fatiguing exercise. But I would, by no means, adopt the
opinion of Carmichael Smyth, that the swing, in itself, and unassisted
by other remedies, will cure Consumption. Experience has proved the
contrary; and has taught us that it is only useful as an article
of regimen, while the patient is under the influence of other more
powerful remedies. When there is sufficient strength to bear it, and
not too much excitement, riding in an easy carriage is the next mode of
gestation which may be used. But when the patient is enabled to ride
on horseback, we have more to expect from it, than any other species
of exercise. To attain the greatest benefit from it, it should be made
use of regularly and constantly; not during the cold air of early
morning, nor the dews of the evening, but rather during the day, after
the sun exerts some influence. A long journey on horseback affords the
most useful method of obtaining all the advantages that can be derived
from exercise. It is then made constant and regular; and the amusement
afforded by travelling serves to divert the patient’s mind from his
own feelings, and adds to its beneficial effects.
Secondary Phthisis Pulmonalis remains yet to be treated of. Under
this order, should be included every form of Consumption, in which
the system has become debilitated by any cause, and the lungs in
consequence become affected. I would exclude from it that form of the
disease occurring after measles, scarlatina, and some other eruptive
diseases, which I would consider as primary Phthisis Pulmonalis;
because, in those cases, the lungs do not become affected merely in
consequence of debility, but these diseases seem rather to act as
exciting causes, in constitutions already predisposed to Consumption;
while in secondary Phthisis, the affection of the lungs is only one
symptom of the general disease, which is wasting the body. Nor would
the treatment, which will be advocated in the latter form, be proper
in the cases alluded to. They require that, which should be used in
the first species of Phthisis, and which has already been detailed.
The reason, why the lungs become affected in consequence of debility
induced by particular causes, I would not attempt to explain. It is
one of those laws of the constitution, not better understood, than why
particular parts are successively affected in consequence of syphilis,
or that the breasts and lower extremities are more liable to disease
than other parts, except the uterus, in females after parturition. Many
laws of this kind exist in the human constitution, of whose effects, we
are every day made sensible, but of the cause of which we are totally
ignorant.
One of the most frequent causes of Secondary Phthisis, is Chlorosis,
that disease which occurs in young females, in consequence of Retention
of the menses. The constitution not having sufficient vigour to produce
this evacuation at the proper period, if any predisposition to Phthisis
exist, a determination takes place to the lungs, producing Phthisical
disease. This case is not analogous to Consumption produced by
Suppression of the menses, after they have been once established; for
in that instance the suppression is not generally induced by debility,
but by cold, or some other cause, not acting merely by weakening the
patient; and it produces active inflammation of the lungs. But in the
case before us, the affection of the lungs is merely a symptom of the
want of vigour in the constitution, which shews itself in retention
of the menses. Accordingly, in the treatment of this disease, our
attention must not be directed primarily to the affection of the lungs,
but to the state of the system, the cause of that affection.
Profuse evacuations, of any kind, may be the cause of Secondary
Phthisis. Hæmorrhages from the Nose, Lungs, Stomach, Kidneys and wounds
are all mentioned by Morton, as having induced Pulmonary disease. Mr.
Hey, in his work on Surgery, observes, that he has seen a great many
cases of pulmonary Consumption, the consequence of debility, induced
by violent hæmorrhages, and in persons who had no apparent tendency to
Consumption. In the same manner, loss of blood from Hæmorrhoids and
in Menorrhagia, may act as causes. Debilitating evacuations, by means
of Diarrhœa, Diabetes, Salivation, and Sweating, have had the same
effect. But the most frequent causes of this class are, immoderate
discharges by fluor albus, and too long suckling by delicate woman
of robust children. They are particularly mentioned by Morton and
Fothergill, and have been adverted to by most authors, who have written
since.
Chronic Catarrh, terminating in Phthisis, may be ranked also in this
class. The profuse and long continued discharge from the membrane
lining the trachea and bronchiæ, is the debilitating agent in that case.
Long continued Fevers, and particularly Intermittent fevers, not
unfrequently leave behind them, a state of debility, sufficient to
induce Consumption.
In the New-York Hospital, frequent instances occur of Consumption
induced by intemperance in the use of ardent spirits. This habit
destroys the tone of the stomach, which becomes primarily affected, and
in consequence the whole system becomes debilitated, terminating in
disease of the Lungs.
Secondary Consumption has also been induced by some other preceeding
diseases, such as Scurvy and Syphilis, and requires the attention of
the Physician, to the primary disease rather than to the affection of
the Lungs.
In the treatment of Pulmonary Consumption, arising from any of these or
analogous causes, our attention is first called to the removal of the
primary source of the disease. If it be Chlorosis, remedies, calculated
to cure that malady, must be prescribed. If profuse evacuations are the
cause, all the means in our power, must be employed in restraining
those evacuations. If the disease has been induced by the long
continued suckling of a vigorous child, by a delicate mother, another
nurse must be provided, or the child must be weaned. If Scurvy or
Syphilis have produced it, the proper remedies for those disorders must
be employed.
Our next object is to remove the debility, the cause of the pulmonary
symptoms. For this purpose, Tonics are indicated, and at their head
stands the Peruvian Bark. In the other species of Phthisis, this
medicine has been much abused, but in the present one, its use is
sanctioned by experience. In the cases proceeding from Leucorrhœa,
and long suckling, it is highly recommended by Dr. Fothergill; but he
cautions us against persevering in its use, longer than while it is
doing good; and remarks, that if the breathing become more oppressed,
the cough dry, the pulse more quick and hard, and especially, if slight
transitory pains or stitches about the thorax, are more frequently
complained of, a perseverance in the use of the bark will increase
the disease. If, in consequence of this increase of symptoms, we
are obliged to desist in the use of the Bark, other Tonics must be
substituted. The combination of bitter and tonic medicines in the
Infus: Amar: of the dispensatories may be then usefully prescribed.
Columbo, which is sometimes an ingredient in that formula, is
particularly recommended by Dr. Thomas Percival, as not possessing any
of the injurious properties of bark.
The Elixir of Vitriol is also an excellent tonic, and may be usefully
given at the same time with the remedies just proposed. But it
requires to be administered with the same cautious hand as the bark,
and to be discontinued, if the symptoms appear to be at all aggravated
by its use. In general, no ill effects arise from it, but if the
determination to the chest be so great, as to produce much inflammatory
action, it may do injury. Independent of its tonic powers, it will be
serviceable in checking any disposition, which may exist, to profuse
sweating.
Iron, in its various officinal preparations, is also a good remedy,
in this form of phthisis. Although, highly dangerous in the primary
disease, there is now little danger of increasing the inflammation,
which in that form, made it improper. Mineral chalybeate waters, will
in this instance, be useful, not only by the journey to them, and the
amusement derived at watering places, but may be drank with advantage
by the patient.
In addition to these remedies, the diet and regimen should be such as
is most invigorating to the constitution. A nutritious diet and the
moderate use of wine will be proper; and country air and exercise with
the same rules as were mentioned in the treatment of primary phthisis,
are very important circumstances in the cure of the secondary form.
A long journey, a sea-voyage and change of climate are also equally
proper.
* * * * *
The prominent feature and primary object of this essay has been, to
establish the distinction between primary and secondary Phthisis
Pulmonalis. Although, perhaps, the minute parts of the arrangement may
not have been distributed, in every instance, with perfect accuracy, I
feel confident that the general plan is correct. Farther observation
and experience will probably suggest a more accurate disposition of the
varieties of Phthisis, under the two orders which I have proposed.
Probably from the want of the distinction between primary and
secondary Phthisis, may be explained the various and contradictory
practice, proposed by physicians of deserved eminence. A more
frequent opportunity of observing one or the other form of the
disease, has determined with each, his mode of treatment: and hence
in diseases bearing the same name, we may see blood-letting and a
rigid antiphlogistic regimen adopted by one party, and bark, iron, and
a nutritious diet by another. Any error which may arise from these
contradictions, may be corrected by the distinction, which has been
proposed.
It has also been my object, to call the attention of the practitioner,
to the earliest symptoms and first dawnings of Consumption. Were they
not so much neglected by the physician, as well as the patient, our
bills of mortality would not continue to present so frightful a picture
of the ravages of this disease; while, on the other hand, a prompt
attention to these incipient symptoms, and the interference of an
active practice, would afford a reasonable prospect of saving many from
Consumption, who are now its victims.
FOOTNOTES:
[1] Amer. Med. and Phil. Reg. Vol. I.
[2] Dr. Lettsom observes, that Consumption is decreasing in Great
Britain.
_Med. and Phil. Reg._
[3] The following judicious remarks on this subject are made by Bayle,
in his “Recherches sur la Phthisie Pulmonaire, D’après la notion que
j’ai donnée de la Phthisie Pulmonaire, on voit que je dois regarder
comme Phthisiques des individus qui n’ont ni fièvre, ni maigreur, ni
expectoration purulente: il suffit que les poumons soient affectés
d’une lésion qui tend à les désorganiser et à les ulcérer. On ne doit
pas regarder cette lésion une simple cause de la Phthisie, mais comme
le premier temps de cette maladie, puisque la Phthisie est cette lésion
même dont la continuation et le developement successif amènent la
mort. Il seroit donc bien peu raisonnable de vouloir attendre, pour
reconnoitre la Phthisie Pulmonaire, qu’elle fut constamment parvenue à
son dernier degré qui est le moment où ses symptômes pathognomoniques
sont bien marqués.”
[4] Dr. Reid.
[5] Dr. Hosack.