Part 5

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.

When all inflammation is gone and the second stage of Consumption has 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 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. 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.