An inaugural dissertation on pulmonary consumption

by Edward Delafield

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.