AN

  Inaugural Dissertation

  ON

  PULMONARY CONSUMPTION.

  BY EDWARD DELAFIELD, A. B.

            ----For want of timely care,
  Millions have died of medicable wounds.     ARMSTRONG.

  _NEW-YORK_:

  PRINTED BY JOHN FORBES & CO.
  78 WALL-STREET.

  1816.




  TO

  SAMUEL BORROWE, M. D.

  ONE OF THE SURGEONS OF THE NEW-YORK HOSPITAL,

  THIS DISSERTATION

  IS DEDICATED,

  AS A TESTIMONY OF GRATITUDE

  FOR THE MANY VALUABLE PRACTICAL LESSONS

  RECEIVED FROM HIM

  BY HIS FRIEND AND PUPIL,

  EDWARD DELAFIELD.




INTRODUCTION.


The attention of Physicians has for several years past been excited
to the consideration of that inveterate enemy of the human race, the
CONSUMPTION. Several works have been published, new remedies proposed,
and the practice of former physicians revived with modifications
and amendments, in the treatment of this disease. At one period,
Consumption had been so long considered without the reach of remedies,
that it had almost ceased to excite the enquiries of the learned in
medicine. Fortunately, however, the spirit of enquiry has revived; and
it is believed that the treatment of this dreadful malady has been so
far improved, that many are rescued from its grasp, and the sufferings
of those who are still its victims, are materially mitigated.
Notwithstanding, it appears that in this city the mortality from
Consumption has increased rapidly of late years. Formerly, its climate
was considered remarkably salubrious, and diseases of the lungs were
rare. Lieutenant Governor Colden, in a series of remarks on the climate
and diseases of New-York, made seventy years ago, has the following
observations: “The air of the country being almost always clear, and
its spring strong, we have few consumptions or diseases of the lungs.
People inclined to be consumptive in England, are often perfectly cured
by our fine air; but if there be ulcers formed, they die. The climate
grows every day better, as the country is cleared of the woods; and
more healthy, as all the people that have lived long here testify. This
has even been sensible to me, though I have lived but about twelve
years in this country; I therefore doubt not but it will in time,
become one of the most agreeable and healthy climates on the face of
the earth.”[1]

These anticipations have not been realized; but, on the contrary,
Consumption has become the prevailing disease of our city. The causes
of this increase of the disease are numerous. We are told by Dr.
Rush, that it is unknown among the Indians of North America; that it
is scarcely known by those citizens of the United States who live in
the first stage of civilized life, and are generally called the first
settlers; that it is less common in country places than in cities, and
increases in both, with intemperance and sedentary modes of life; that
ship and house-carpenters, smiths, and all those artificers, whose
business requires great exertion of strength in the open air, in all
seasons of the year, are less subject to this disease than men who
work under cover, and at occupations which do not require the constant
action of their lungs. By applying these facts to the situation of
this city, the causes which have produced the increased mortality from
consumption, become evident.

1. The growth of the city, and consequent state of the atmosphere, most
distant from that of the pure air of the country.

2. The increase of all those causes which have enervated the bodies of
men, and rendered them more susceptible to the influence of a variable
climate. Among these are, augmentation of wealth, and consequently,
luxury; increased dissipation, with its accompaniment, imprudence in
dress; and extension of manufactures, affording greater opportunity for
sedentary employments, and exposure to an insalubrious atmosphere. In
general, the causes are, all those circumstances which tend to remove
man farthest from that situation, in which the body is possessed of
the greatest vigour, and of course, least subject to disease, that of
the savage. In proportion as the city has enlarged, these causes have
continued to increase, and probably still will do so. But in Great
Britain, they appear already to have attained their acme, and as a
consequence of the improvements in medicine, the causes not increasing,
the disease is on the decline.[2]

The following statement will show the proportion, which the number of
those who die from consumption, bears to the whole number of deaths, in
this city, during the last twelve years.

In 1804, 499 persons died from Consumption, and were to the whole
number of deaths, 2125 as 1 to 4.25.

  In 1805      462      2352      1      5.09
     1806      354      2225      1      6.28
     1807      464      2312      1      4.94
     1808      429      2014      1      4.69
     1809      413      2108      1      5.1
     1810      569      2158      1      3.79
     1811      595      2524      1      4.24
     1812      669      2553      1      3.81
     1813      562      2229      1      3.96
     1814      618      2507      1      4.04
     1815      572      1974      1      3.8

From this statement it appears, that the number of deaths from
Consumption has gradually increased. The average proportion during the
period mentioned, is as 1 to 4.36. Nearly one fourth of all those who
die in this city are destroyed by this fatal disease.

These facts prove indeed that the power of medicine has little control
over so destructive a malady. But it should not therefore paralyse our
exertions. From what has been done already, in improving our knowledge
of its nature and treatment, a hope may be indulged that consumption
may one day, like many other maladies formerly deemed incurable, be
placed no longer among that number.




INAUGURAL DISSERTATION

ON

PULMONARY CONSUMPTION.


The term Phthisis, or Consumption, in its broadest sense, is applied
to all those diseases, in which the system sinks under a gradual
waste of the powers of life. These diseases may be divided into two
great classes--1. That form of Consumption in which the lungs are
unaffected.--2. Phthisis Pulmonalis, properly so called, where the
lungs are the seat of the disease.

Under the first class are included,

1. Atrophia, or Consumption from want of nourishment, or excessive
evacuations, but without hectic fever; excluding all those forms of
disease produced by immoderate evacuations, in which the lungs become
affected.

2. Tabes, accompanied with hectic fever, frequently attended with
disease of the mesenteric glands, and produced most commonly by
scrophula.

The second class, Phthisis Pulmonalis, to the consideration of which
this essay will be more immediately confined, may be also subdivided
into,

1. Primary, where the lungs are the original seat of the disease, and
as a consequence, the general system becomes affected.

2. Secondary, where the system being first reduced by any debilitating
cause, the lungs become secondarily affected, as a symptom of the
general disease.

These two forms of Consumption, although somewhat similar in their
symptoms, yet proceed from opposite causes, and require opposite
treatment. The one is a disease of pure inflammation; the other of
unmixed debility. In the one, an active antiphlogistic treatment is
necessary; in the other, the system requires all the support, which
tonics and good nourishment can afford.

Phthisis Pulmonalis is thus defined by Dr. Cullen, “_Corporis
emaciatio et debilitas, cum tussi, febre hectica, et expectoratione
purulenta_.” This definition is peculiarly incorrect, because it leads
us to neglect, the first stage of the disease; if the symptoms of an
Incipient Phthisis were stated to us, and we were asked, what was the
disease, from this definition we would be perfectly at a loss for an
answer. Except the cough, none of the symptoms there stated are to be
found in the first stage of Consumption. And yet that is as truly a
part of it, and of as much importance to the practitioner, as the last
stage, which alone is included in Cullen’s definition.[3]

Agreeably to this definition, in his view of Phthisis Pulmonalis, Dr.
Cullen makes ulceration of the lungs and hectic fever essential to its
existence, and seems rather to consider the preceding symptoms a cause
of this ulceration and fever, than as constituting an integrant part of
the disease.

Nor is the place assigned by him to Phthisis Pulmonalis, in his
Nosological Arrangement, more correct than his definition of it. He
places it in the order Hæmorrhagiæ, and considers it merely as a
consequence of Hæmoptysis. Even if it were always excited by hæmorrhage
from the lungs, it would be improperly thus placed; but as that, even
by Dr. Cullen, is considered merely as one among many exciting causes,
the arrangement is altogether inadmissible. But if it be admitted,
according to the view which will be hereafter taken of Hæmoptysis in
this treatise, that it is rather a symptom than a cause of Consumption,
the propriety of another arrangement will be evident. Accordingly
Phthisis Pulmonalis is placed by Dr. Hosack, as one of the Phlegmasiæ.
This disposition appears to be the most proper that has hitherto been
suggested, and as such I shall adopt it. But before we can ascertain
the character and treatment of any diseases, it is necessary minutely
to examine their causes and symptoms.

Primary Phthisis Pulmonalis first claims our attention. Its
predisposing causes may be mostly arranged into five classes, as they
depend on organization, age, sex, occupation and climate.

Organization predisposes to Consumption, by mal-conformation of the
chest, which may be either natural or accidental; and an hereditary
internal structure not depending on the external form of the thorax.
For it is observed, that in some instances, those who have every
part of the external configuration, such as is generally attributed
to persons predisposed to Consumption, yet shall be free from this
disease; while on the other hand, some whose chests are externally
perfectly well formed, have been subject to catarrhal and inflammatory
complaints of the lungs, terminating in Phthisis. The form of chest
peculiar to many Phthisical patients, “is occasioned by the sternal
or breast-bone being pressed too much in upon the substance of the
lungs: thus the clavicles and shoulder-blades are thrust out of their
proper position, and made to assume, in some measure, the form of
wings, to which indeed they have been with propriety compared, just
raised from the body and about to expand for flight. By this internal
direction of the sternum, the full expansion and proper sweep of the
ribs is likewise prevented, and an unnatural curvature or prominence is
occasioned on either side of the breast, with a corresponding central
depression.”[4] This is the peculiar form to which the term narrow
chest is generally applied. A flattened or any other unnatural figure
of the chest may produce the same injury.

The thorax may become accidentally malformed from any violence done to
it, particularly during infancy. A frequent source of it is the mode of
fashionable dress adopted by females. The corset, to which I allude,
when worn only with moderate firmness, and by those not otherwise
predisposed to Phthisis, serves but to add elegance and beauty to the
female figure; but when applied with the object of converting into a
delicate and slender waist, one naturally otherwise, it cannot but do
injury. By immoderate pressure, it converts a well formed chest into
the deformed and narrow one, or at least an approximation to it, which
has just been described. In our own city and time, too many fatal
examples of the deleterious effects of this fashion have occurred, to
permit us to retain any doubts on the subject.

The internal constitution of the body predisposing to Phthisis,
independent of external form, has been generally attributed to
scrophula. English authors are particularly fond of making Consumption
another form of that Protæan disease. We are much disinclined to concur
in this opinion from the fact, that the mass of those who labour under
the disease in question, and cases too, which, after death show that
tuberculated state of the lungs, generally ascribed to scrophula,
evince no other of the numerous symptoms of that disorder. The
supposition that tubercles were scrophulous, probably originated from
the opinion that they are diseased glands; an idea now sufficiently
exploded. This hereditary predisposition we know to exist, but of its
mode of action we are totally ignorant. In this city there are many
melancholy examples of whole families successively falling victims to
Consumption, and sufficiently proving its hereditary nature. But an
hereditary predisposition does not necessarily produce Consumption. It
is not uncommon for parents who inherit this taint, to remain free from
disease of the lungs, by the pursuit of laborious occupations. Nor is
it more uncommon that the children of these very parents, whose active
industry had preserved their lives, and amassed them wealth, should
by being enabled to indulge in ease and luxury, fall victims to an
inherited Consumption.

So the females of a family are sometimes all consumptive, while the
males are free from pulmonary disease, in consequence of the more
sedentary mode of life of the former.

Although no period of life, from infancy to old age, is exempt from
Consumption, but all are liable to its attack, yet at a particular age,
it is observed to appear more frequently than at any other. This period
commences about, or soon after the age of puberty, and terminates at
thirty-six; the period at which inflammatory diseases most generally
occur.

Sex also gives a predisposition to Consumption. Females are more
frequently affected by it than males. This may be attributed to
their greater delicacy of constitution, and nervous temperament.
Their comparatively sedentary habits of life add to this peculiar
constitution. But improper compliance with the requisitions of fashion
and taste constitutes not a small part of the greater susceptibility
of females to Phthisis. Independent of the use of corsets, the small
quantity of clothing frequently worn by them, under circumstances when
it is most necessary, is a fruitful source of mischief to their health.
In the coldest of our winter nights, will these fair devotees of
fashion issue from rooms, heated to a degree never experienced in our
hottest weather, into the chilling air of midnight, with less clothing
than they use at noon, when the sun exerts his greatest power. The next
day brings with it “a violent cold,” and this cold is too frequently
the foundation of the Consumption which destroys them.

Occupation in life is another source of the ravages of this disease.
Particular occupations subject those engaged in them to the respiration
of air impregnated with foreign materials, irritating the lungs, either
by their chemical or mechanical action. Substances acting mechanically
upon the lungs, are inhaled by stone-cutters, millers, hair-dressers,
bolters, coal-heavers, scythe-grinders, persons engaged in pointing
needles, chimney-sweepers, dressers of flax and feathers, spinners
in wool, and others employed in similar occupations. Chemical agents
are taken into the lungs by manufacturers of acids, and all other
volatile corroding substances. These materials constantly acting upon
the lungs, produce irritation and slight inflammation, terminating
in Phthisis. The operation of any of these causes is favoured when
the occupation requires a stooping or other awkward posture of the
body to be maintained. This cause may act independently of the former
also, and hence, students, and clerks writing at their desks, taylors,
shoemakers, &c. are liable to this disease. To the same causes are
frequently added, a sedentary life, and confinement in hot rooms;
hence “a surgeon of London whose opportunities of observation are very
extensive, relates of the gilders of that city, who work in heated
rooms, that six out of seven are said to die consumptive in their
apprenticeship.” Sedentary habits of life, accompanied with hard
study, and too intense application of mind, predispose literary men to
Consumption. Loud public speaking, blowing on wind instruments, glass
blowing and other circumstances requiring a laborious and continued
action of the lungs, produce the same effect. Any one of these causes
may frequently exist without injury, but their combined action seldom
fails to produce pulmonary disease.

Climate was enumerated under the predisposing causes of Phthisis. That
of our own latitude affords an example. Its variableness, increased
by contiguity to the ocean, together with the prevalence of the moist
and chilling north-east winds, is probably the agent which produces
this effect. The climate of Great Britain is not less unfavourable
to health, from similar causes, with the addition of its greater
moisture; for it is observed that cold combined with moisture is
peculiarly dangerous to the consumptive. On the other hand, inland
countries, not exposed to the moist winds from the ocean, are free
from this disease. Hence, the inhabitants of Russia and other parts of
the north of Europe, notwithstanding the severity of their climate,
are very little affected by Consumption. The habits of the people,
probably assist in producing this immunity from pulmonary disease.
Sir John Sinclair, in a communication to Dr. Reid, attributes it in
a great measure to the employment of furs, cloaks and other modes of
clothing, which preserve an uniformity of warmth throughout the body;
to the great care taken by all classes of people to preserve their feet
from cold and damp; to the different modes of communicating heat to
their apartments; and to the constant use of the vapour bath. Similar
observations were made by Dr. Cogan, who in a letter to Dr. Beddoes,
remarks that the people of Holland are exempt in a great degree
from this disease, so prevalent among the English, and ascribes the
difference to the contrast observable between the two countries, in the
construction of their habitations, and in the peculiarities of dress.

Debility from the want of accustomed stimuli, is mentioned by Dr.
Hosack as another cause of consumption, and he instances those confined
in the State Prison. The want of accustomed air and exercise, the
deprivation of the use of spirituous liquors and good diet, to which
the prisoners had been accustomed before their confinement, was
observed by him to have produced this disease.

Depressing passions of the mind, and a consequent too free use of
spirituous liquors have also been noticed by authors among the
predisposing causes of Consumption.

The last of these causes which I shall notice, is the disposition
of the system to form calculous deposits in the lungs, generally in
consequence of a plethoric habit. Phthisis from this cause however is
rare; of nine hundred patients examined by Bayle, only four were of
this description.

These various causes having either separately or conjointly predisposed
the body to Phthisis, are most frequently excited into action by a
common catarrh; which becomes the more active by frequent repetition.
The danger arising from catarrh is not a little increased by the
popular mode of treating it: stimulating spirituous drinks, and a vast
variety of remedies of the same class are the usual prescriptions.
Almost every body has an infallible remedy for a cold; some of
them innocent, but many injurious. The common prejudice in favour
of “feeding a cold” increases the mischief, and unfortunately, the
disease not generally affecting the system sufficiently to destroy
the appetite, as in many other maladies, nature does not prevent
the practice. Abstinence, cooling acidulous drinks, with perhaps a
gentle saline cathartic, are the safest and most effectual remedies in
curing a common catarrh, when of its usual slight form. At the same
time, inhaling warm air, by means of Mudge’s apparatus, is a valuable
and grateful auxiliary to this treatment. Catarrh is so common and
generally so easily cured without any consequent ill effects, that it
is too apt to be neglected. Many a patient, labouring under incipient
Phthisis, has been supposed to be affected by merely a “trifling
cold,” and the only opportunity for curing the disease has been lost.
“The evil becomes irremediable before it calls either the attention
of the parents, the friends, or even the physician, who has not been
familiarly conversant with the fatal consequences of this disease.”[5]

Pneumonia is not unfrequently an exciting cause of Phthisis. Like
catarrh, its frequent repetition is more dangerous than a single
attack. Pneumonia may indeed act merely as a predisposing cause of
Consumption, by leaving the lungs in a debilitated and irritable
condition, favourable to the production of that disease; but it is
an exciting cause, when in consequence of inflammation of the lungs,
suppuration follows, and vomica or empyema is the consequence. This
shews the close analogy between Phthisis Pulmonalis and ordinary
Pneumonia. In the first, the inflammation being seated in the cellular
and comparatively insensible portion of the lungs, is slow and
gradual, and the consequent suppuration forms in the same manner;
while in Pneumonia, the membranous as well as cellular portion of the
lungs being involved in the disease, the inflammation is rapid and
violent, and must soon terminate in either resolution or suppuration.
Hence Phthisis Pulmonalis was appropriately called by Dr. Rush a
“_Pneumonicula_.” No word could more accurately describe the nature
of the disease. That acute observer has drawn an excellent parallel
between the two diseases, and concludes with observing, “In short the
pneumony and Consumption are alike in so many particulars, that they
appear to resemble shadows of the same substance. They differ only as
the protracted shadow of the evening does from that of the noon-day
sun.” It is remarked, however, that all cases of Pneumonia terminating
in suppuration are not necessarily fatal. If a predisposition to
Phthisis do not exist, or the constitution be not too much debilitated,
a vomica may burst and be discharged, and the patient recover.

A third exciting cause of Phthisis, is the suppression of accustomed
evacuations. These evacuations are the menses, the lochiae, the
discharges in Leucorrhæa, and from ulcers, fistulæ and issues.
Retention of the menses producing Chlorosis, being a consequence
of debility, does not excite primary Phthisis Pulmonalis, but the
secondary form of the disease. Suppression of the menses, however, not
unfrequently excites a Consumption, bearing all the characters and
requiring the treatment of primary Phthisis. The plethora, consequent
on the cessation of the menses, has often the same effect.

Asthma, by the constant irritation to which it subjects the lungs,
becomes an exciting cause of Consumption.

Several eruptive diseases, as Scarlatina, Small-Pox and measles, often
produce the same disease.

Morton also enumerates stone in the kidneys and bladder, gout and
rheumatism, as causes of Consumption.

By the same author, contagion is supposed to communicate this disease.
Morgagni, Van Swieten, Home and Heberden all hold this opinion. And
Morgagni relates that Valsalva, who was predisposed to Consumption, was
so satisfied of its contagious nature, that he constantly avoided being
present at the dissection of the lungs of persons who had died of that
disorder.

Dr. Rush maintains the same doctrine, and relates that the late Dr.
Beardsley of Connecticut, informed him that he had known several black
slaves affected by a Consumption, which had previously swept away
several of the white members of the family to which they belonged.
In these slaves no suspicion was entertained of the most distant
relationship to the persons from whom they had contracted the disease:
nor had grief nor fatigue, been supposed to have had the least share
in debilitating their bodies. The force of so much authority with
the evidence adduced, constrains us to admit the communicability
of Consumption by contagion. But if this agent has any effect, its
action must be extremely limited, and extend no farther than to those
previously predisposed to the disease. For daily examples without
number occur of the constant attendants upon those labouring under
Phthisis remaining perfectly free from that malady.

Violence done to the lungs by blows or other injuries of the chest, has
in some instances, excited Consumption.[6]

Foreign bodies conveyed accidentally into the lungs has produced the
same effect. Morton relates a curious case where three nails had passed
into a person’s trachea and destroyed him, by inducing Consumption.

Bayle also enumerates a form of Phthisis, which he calls cancerous,
arising in patients in whom the cancerous disposition has become
constitutional. It is, however, extremely rare; only three cases having
occurred to him among the 900 whom he had examined.

Hæmoptysis and tubercles are mentioned by most authors as exciting
causes of Consumption, and remain to be examined. So frequently did Dr.
Cullen consider Hæmoptysis the cause of Phthisis, that he placed the
latter disease in his Nosology, merely as a consequence of the former.
The impropriety of this arrangement has been already touched upon.

On this subject, I would suggest the following facts. Hæmoptysis
occurring in persons not predisposed to Consumption, except the
quantity of blood lost be so great as to produce it by mere debility,
very frequently may be easily cured without danger of any consequent
disease. Indeed not only in such cases consumption is not induced by
it, but that disease has actually been prevented, by the occurrence of
hæmorrhage from the lungs, relieving that inflammation, which the inert
physician, by withholding the lancet, would have suffered to destroy
his patient. Dr. Rush relates two cases of inflammatory Consumption
attended by a hæmorrhage of a quart of blood from the lungs, in which
the patient recovered; and ascribes their recovery entirely to the
loss of blood. Wounds and other injuries of the lungs frequently heal,
when no predisposition to Phthisis exists, as easily as in other parts
of the body. Of this fact also Dr. Rush affords an example. A British
officer informed him, a few days after the battle of Brandywine, in
September 1777, that the surgeon general of the royal army had assured
him, that out of twenty four soldiers admitted into the hospitals,
during the campaign of 1776, with wounds of their lungs, twenty-three
recovered. These facts prove sufficiently that the constant motion of
the lungs does not prevent the healing process taking place in them as
easily as in other parts of the body.

In most instances, the spitting of blood which is supposed to have
produced the Consumption, has occurred a considerable period before
the Phthisical symptoms appeared. During this interval perhaps the
patient was perfectly well. Can it be supposed, that the inflammation
necessary to form an ulcer, and the process of ulceration itself, could
so long be going on unperceived, without producing any irritation of
the lungs? Is it not more probable, that the Hæmoptysis was recovered
from, and that the same cause which produced it, at length produced the
Consumption?

Hæmoptysis, then, I would consider, as very seldom, perhaps, never,
being the cause of Consumption; but in all those cases in which it
is assigned as the cause, merely a symptom of the incipient stage of
the disease. The symptoms accompanying hæmorrhage from the lungs, are
no other than those of incipient Phthisis. They are thus accurately
described by Dr. Reid. “When subsequent to a sense of weight and
oppression in the breast, which scarcely amounts to a feeling of pain,
together with cough, difficult respiration, and general lassitude, a
quantity of blood is suddenly, and in a convulsive manner, discharged
from the mouth, there can remain small doubt respecting the part from
which it proceeds. If the discharged blood be of a florid colour, and
together with the above symptoms, a saltish taste be perceived in the
mouth, and the patient become sensible of a degree of irritation in
the upper part of the trachea, the nature of the affection is rendered
altogether unequivocal.” Every symptom here enumerated, occurs in the
early periods of Consumption.

Nor have we any better reason for believing tubercles to be an exciting
cause of Phthisis. These appearances are indeed very frequently found
in dissections of the lungs of those who have died of Consumption.
Of the nine hundred patients examined by Bayle, 624 had tuberculated
lungs. Tubercles were formerly considered as indurated glands, and
generally attributed to a scrophulous constitution; but we are assured
by Baillie, in his morbid Anatomy, “that there is no glandular
structure in the cellular connecting membrane of the lungs; and on
the inside of the branches of the trachea, where there are follicles,
tubercles have never been seen.” These tubercles are roundish bodies,
of a firm consistence, and frequently a cartilaginous structure, but
often containing decidedly purulent matter. By the union of several
of them, vomicæ are formed, which are only larger tubercles. May not
the formation of these bodies be sufficiently accounted for by the
preceding inflammation, and they be considered therefore a consequence,
rather than a cause of Consumption? Dr. Rush insists that tubercles are
the effects, and not the cause of pulmonary Consumption; and remarks as
a farther evidence of this opinion, that similar tumours are suddenly
formed on the intestines by dysentery, and on the omentum by a yellow
fever. He refers to cases of the former in the dissections of Sir John
Pringle, and one of the latter mentioned by Dr. Mackittrick, in his
inaugural dissertation on the yellow fever, published in Edinburgh,
in the year 1776. Dr. Hosack, in his Lectures on the Theory and
Practice of Physic, advocates the same doctrine, and enforces it, by
remarking, that similar tubercles are formed in the parenchyma of
the brain, the liver, and the kidneys, in which no small glands have
yet been detected, and where, as in the lungs, there is nothing but
cellular membrane and vessels. It is his opinion, that it is an union
of a number of these cells in a state of congestion that constitutes
tubercles or vomicæ--that in some instances they heal, the matter is
absorbed, and they remain in a scirrhous state, the patient becoming
perfectly restored to health; and hence the remark of Dr. Simmons,
that tubercles may exist without Phthisis.

These are all the principal predisposing and exciting causes of
Phthisis Pulmonalis. Some few others are mentioned by authors, but they
are of either very doubtful agency, or too rare to deserve notice.

The disease having been excited into action, produces a succession
of symptoms which are now to be detailed. Its attack is frequently
extremely insidious and slow; at other times, well marked and rapid in
its progress. It is to this insidious and gradual mode of attack, that
Consumption owes much of its fatal character. Before the unfortunate
patient suspects himself to be seriously indisposed, it but too
frequently happens, that his fate is sealed, and death is inevitable.
This arrives in part from the resemblance that Incipient Phthisis
bears to a long continued catarrh. It frequently is only marked in
its earliest periods by a slight, dry, hacking cough, trivial during
the day, increased at evening, and most troublesome at night; a sense
of weight about the breast, and some little difficulty of breathing,
increased on taking any unusual exercise, or ascending a height; the
pulse is slightly accelerated, and sometimes only so after taking food:
occasionally, burning hands and feet, and a slight flush in the cheek
are the only symptoms of fever. These symptoms may be so slight as
hardly to attract the patient’s notice; at other times they are more
severe and distressing. Frequently, on any little unusual exercise,
the cough is increased, the patient feels a pain in the side, and
expectorates a frothy mucus, and blood is discharged from the lungs.
This, perhaps, is the first symptom which excites the alarm of the
patient. Expectoration of blood is generally preceded by a saltish
taste in the mouth, and a sense of irritation at the upper part of the
trachea. It is known to come from the lungs and not the stomach, by its
frothy appearance and admixture with mucus, while that from the stomach
is generally dark coloured and mixed with the food; and by being
brought up by coughing and not vomiting. The blood coming from the
stomach too, is generally in larger quantity than that from the lungs.

In addition to these symptoms, the patient is often affected by an
increased sensibility of the lungs, observable on any exposure to
cold, change of dress, or going from a warm to a cool apartment.
There is a sense of soreness in the lungs attended with a sensation
of stricture about the chest. Pain is felt in the side or breast, and
the patient lies with difficulty on the side affected. The pain is
frequently lancinating, and shooting through the breast, sometimes in
the direction of the mediastinum, at others, confined to one side.

As the disease advances, the symptoms of fever become more marked. The
tongue is dry, attended with thirst, loss of appetite, nausea, and
occasional vomiting, and a desire for acids. The secretions generally
are checked. Perspiration is diminished, and the skin is hot and dry.
The urine is at first diminished in quantity, and high coloured. The
menses, in females, are either suppressed or very irregular. The
bowels are frequently costive. The patient passes restless nights,
and is prevented sleeping by a tormenting cough, or if he sleeps, is
troubled with dreams. In consequence of indigestion, pain is felt in
the situation of the stomach, attended with flatulence. The patient
begins to have a pallid countenance, and emaciation gradually takes
place.

These symptoms may continue a length of time, gradually debilitating
the patient. But the expectoration which at first was frothy, in
small quantity, and coughed up with difficulty and pain, increases,
and gradually passing through all the stages between mucus and pus,
at length becomes decidedly purulent. A new train of symptoms follow.
Hectic fever makes its appearance, commencing with irregular cold and
shivering fits, returning frequently during the day. It soon, however,
assumes a decided character, and has two marked exacerbations, the
one at noon, the other at night. These exacerbations begin with a
sense of coldness, succeeded by heat, and at night terminating in
profuse perspiration. During the chill and hot fit, the cough, pain,
and dyspnœa are aggravated, but relieved by the sweating. The pulse
before the paroxysm is accelerated and weak, during its continuance
quick and strong, but abates as the perspiration flows. The countenance
is generally pale, but during the exacerbation is marked by a
circumscribed crimson flush, which occurs mostly at noon, but may be
produced by taking food or any other cause of excitement. The profuse
sweats do not occur after the exacerbation at noon, but in the morning,
while the patient is warm in bed, with the system relaxed by sleep.
The perspiration is principally confined to the superior parts of the
body, as the neck, breast, and about the shoulders. The tongue is often
very clean during hectic fever, but sometimes furred. The bowels are
generally torpid, alternating with diarrhœa.

The disease continuing to advance, the cough and dyspnæa increase, and
the hectic symptoms become more marked and violent. Emaciation rapidly
goes on, the face looks sharp and haggard, and the absorption of fat
makes the eyes appear remarkably large and prominent. At the same time,
the teeth appear unusually white and beautiful. The appetite becomes
extremely irregular, the pulse more accelerated and diminished in
strength. The mind is extremely vacillating, at one time depressed, at
another, elated with hopes of recovery. Profuse diarrhœas, alternated
with obstinate torpor of the bowels, exhaust the patient; the eyes
assume a ghastly and pearly whiteness; the mouth becomes filled with
apthous eruptions; sometimes hiccup ensues; the patient’s mind becoming
more and more disturbed, delirium comes on, which soon terminates in
death.

An assemblage of some or all these symptoms, constitutes Phthisis
Pulmonalis, differing however very materially in number, degree and
violence in different patients. They are variously modified by a number
of attending circumstances, which require some attention.

Many authors declare, that an expectoration of pus does not always
attend this disease. The matter may be confined in a vomica, and the
patient die with the symptoms of Phthisis before it bursts. Nor does a
purulent expectoration necessarily indicate the existence of an ulcer
in the lungs. The matter may be poured out from the secreting surfaces
of the lungs without ulceration, precisely as it comes from the adnata
of the eye after opthalmia, or the urethra in gonorrhœa, where no
ulcer is suspected. In the New-York hospital, dissections of numerous
patients who have died of Phthisis, sufficiently prove the fact in
question.

Nor does pain in the side or breast, always accompany this disease. Dr.
Reid remarks that many cases have occurred in his practice, where no
pain in any part of the chest has been observed during the whole course
of the disorder. “I have witnessed,” says Dr. Heberden, “many deaths
from genuine pulmonary consumption, where dissection has demonstrated
an entire destruction of the substance of the lungs, and where through
the whole course of the disease, neither expectoration of blood,
difficulty of breathing, nor pain in the side had been present.” On
the other hand, pain in the side may occur merely as a consequence of
the debilitated or irregular action of the muscles, as in walking, and
should not be mistaken for a symptom of Consumption.

In the course of the disease, dropsical effusions, constituting
Ascites, Hydrothorax and Anasarca, are not unusual, as in other
diseases where great debility is produced.

In the advanced periods of Consumption, diarrhœa constitutes a
prominent and troublesome symptom. This is sometimes produced by any
cause which checks the profuse sweats; while on the other hand, if the
diarrhœa be checked, the cough and dyspnœa, which perhaps had been
relieved by it, frequently return with redoubled violence. Under these
circumstances, the condition of the patient is hopeless indeed.

The approach of summer frequently mitigates the sufferings of the
consumptive, and gives them hopes of returning health; but when winter
returns, these hopes are blasted; the patient sinks again into his
former condition, and most generally is cut off during the cold season.

The symptoms of Phthisis are frequently suspended or mitigated by any
cause producing a new determination in the system. The most prominent
of these causes is pregnancy. It almost invariably happens that
the symptoms of Consumption are relieved by the occurrence of this
event; but after parturition the disease returns with all its former
violence. The occurrence of mania has produced the same effect, and
has even entirely cured the disease; but generally, when the mania is
removed, the symptoms of Consumption return. An attack of rheumatism
has frequently relieved phthisical complaints. Dr. Rush refers to three
clinical patients in the hospital of Pennsylvania to exemplify this
observation. In the same manner gout is observed to alternate with
Consumption, and during its paroxysms, the complaint of the lungs is
relieved. Frequent cases are related, in works on this subject, of
eruptions on the skin alternating with Phthisis Pulmonalis.

Long continued ulcers, or fistulæ in ano not unfrequently relieve
pulmonic complaints in phthisical patients; while the healing of these
ulcers or fistulæ reproduces the disease with tenfold violence.

A farther circumstance worthy of remark in this disease is, the
willingness with which the patient suffers himself to be flattered with
hopes of recovery. Notwithstanding he sees daily victims of Consumption
falling around him; notwithstanding the perfect assurance he has of the
small number of those who recover from it; to the last his hopes are
not abandoned. Although depressed at night by the evening exacerbation
of hectic fever; in the morning, from his comparatively comfortable
situation, his hopes revive. Happy is it for these miserable sufferers
that they do not despair. In a disease whose progress is frequently so
slow, and whose event is but too often so sure, fortunate it is, that a
solace remains to cheer the unhappy patient.

The duration of Consumption is extremely various; from a few weeks to
fifty years have patients laboured under it. In Bayle’s statement of
the duration of the disease in two hundred cases in which the patients
were destroyed by it, it was between two months and two years in 168
cases, four were less than two months, and 28 remained more than two
years.

From the detail of symptoms which has just been given, it is evident,
that there are two distinct stages of Phthisis Pulmonalis, each
characterised by peculiar symptoms, and requiring peculiar treatment.
The first, incipient, or acute stage as it is variously termed
by authors, is the stage of inflammation, and terminates as soon
as purulent expectoration and hectic fever commence. The second,
confirmed, or chronic stage commences where the first terminates, and
ends most generally in death. We would not however assert, that these
stages can always be accurately distinguished, and a line drawn between
them. On the contrary, hectic fever may occur early in the disease,
before any expectoration of pus takes place, and inflammatory symptoms
frequently attend its advanced stage. In general, the distinction can
be made, and must necessarily guide the prudent physician.

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.[7]”

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.

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[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.

[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 iij
        Alum: rup: Ʒ j
        Coccinnel: pulv: griij
        Aq: 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.




ERRATA.


  Page 10  Note, for _d’après_ read _D’après_.
       22, line 25, for _which like the inert physician_,
        read _which the inert physician_.
       25, line 13, for _dysentary_, read _dysentery_.




Transcriber’s Notes

The errata have been fixed.

Punctuation errors and omissions have been fixed.

Page 10: “peculiary incorrect” changed to “peculiarly incorrect”

Page 40: “very analagous” changed to “very analogous”

Page 54: “frequenty prescribed” changed to “frequently prescribed”

Page 60: “acceptible to patients” changed to “acceptable to patients”