FOOTNOTES:

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. Theformer 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 reasonsproper. 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 onlyas 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 byDr.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 affordedby 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 restrainingthose 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 byDr.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 byDr.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 justproposed. 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 primaryand 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.[6]Dr.Lind states, that out of 360 patients whom he attended between July 1, 1758, and July 1, 1760, in consumption, the disease was brought on one fourth of them by falls, bruises and strains, received a year or two before it made its appearance.[7]Dr.Reid.[8]℞Vitriol: alb: Ʒ iijAlum: rup: Ʒ jCoccinnel: pulv: griijAq: ferveut: ℔j. Misce in mortareo marmoreo. Solutio a fæculantia vel residendo expurgetur, vel per chartam bibulam fittretur. Dos. ℥ss.—[9]Dr.Borrowe formerly had a patient labouring under Consumption, a manufacturer of tin ware, who was uniformly relieved of his phthisical symptoms when engaged in soldering tin, a process in which a great deal of resin is used, and constantly inhaled in respiration.

[1]Amer.Med.and Phil. Reg. Vol. I.

[2]Dr.Lettsom observes, that Consumption is decreasing in Great Britain.Med.and Phil. Reg.

[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.

[6]Dr.Lind states, that out of 360 patients whom he attended between July 1, 1758, and July 1, 1760, in consumption, the disease was brought on one fourth of them by falls, bruises and strains, received a year or two before it made its appearance.

[7]Dr.Reid.

[8]℞Vitriol: alb: Ʒ iijAlum: rup: Ʒ jCoccinnel: pulv: griijAq: ferveut: ℔j. Misce in mortareo marmoreo. Solutio a fæculantia vel residendo expurgetur, vel per chartam bibulam fittretur. Dos. ℥ss.—

[8]

[9]Dr.Borrowe formerly had a patient labouring under Consumption, a manufacturer of tin ware, who was uniformly relieved of his phthisical symptoms when engaged in soldering tin, a process in which a great deal of resin is used, and constantly inhaled in respiration.

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