Part 4

Having taken a view of the causes and symptoms of Phthisis Pulmonalis, we are now prepared to investigate the proximate cause of the disease. From the nature and extent of these symptoms, it appears evidently a disease of the whole system, and not confined merely to the lungs. The proximate cause, as taught by Dr. Hosack, in his lectures, is, an inflammation of the lungs, terminating either in a purulent secretion, or ulceration in their substance. This opinion is much strengthened by the analogy before remarked between Phthisis Pulmonalis and Pneumonia. It is a little singular that Dr. Rush, notwithstanding he had remarked this close analogy, and although he speaks of inflammatory fever as a part of the disease, and prescribes blood-letting in its treatment, should yet have made debility its proximate cause. This is only one instance among many, of physicians arriving at precisely the same modes of treatment by directly opposite routes. If that theory of inflammation be admitted, which makes debility its cause, so far it is also the proximate cause of Phthisis Pulmonalis. In the secondary species of Phthisis, hereafter to be considered, debility may be fairly ranked as the proximate cause, and the indications of cure correctly drawn from it. But in the primary disease under consideration, if we were to found our indications on this basis, and thence deduce the propriety of exhibiting powerful tonics in the first stage of the disease, when brought to the test of practice, its error would soon become sufficiently glaring.

Various other causes have been successively treated of by authors, but to shew their inconsistency and absurdity, it is only necessary to observe that, “the existence of an acid or an alkali, of chemical acrimony, or mechanical changes in the blood, of corroding volatile particles, and even of animalcula in the lungs, have been vaguely conjectured to be the cause of pulmonary ulcer and hectic fever.”

Assuming then, inflammation of the lungs, and consequent ulceration of their substance as the proximate cause of Phthisis Pulmonalis, we naturally deduce the following indications in the treatment of the disease.

1. To endeavour to relieve the inflammation of the lungs, and promote its resolution.

2. If, notwithstanding all our efforts, suppuration takes place, to give sufficient support and tone to the system to enable the ulcers to heal.

In fulfilling these indications, our first object is to remove the remote causes, where it is possible. If the patient’s occupation is one of those which predisposes to Consumption, unless it be abandoned, or at least so modified as to correct the objectionable parts of it, we cannot hope to cure the disease. If the disease arise from the suppression of an accustomed evacuation, our utmost endeavours must be made to restore it. Should suppression of the menses be the cause, means calculated to produce their return must be resorted to. If an ulcer or fistula has healed up, they must be re-opened, or issues established in more convenient situations. In short, the rule is plain and simple. Remove the remote causes, wherever it is practicable.

Among the remedies which are necessary to fulfil the first indication, 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.