|CYO HV2. Columbia ®mbersttp in tiie Citp of JJeto gorfe LIBRARY GIVEN BY General W. B. Parsons T 79 Digitized by the Internet Archive in 2011 with funding from Open Knowledge Commons http://www.archive.org/details/inauguraldissertOOraff AN INAUGURAL DISSERTATION ON PULMONARY CONSUMPTION SUBMITTED TO THE PUBLIC EXAMINATION OF THE FACULTY OF PHYSIC UNDER THE AUTHORITY OF THE TRUSTEES OF COLUMBIA COLLEGE, IN THE STATE OF NEW-YORK, The Right Rev. BENJAMIN MOORE, D. D. President; FOR THE DEGREE OF DOCTOR OF MEDICINE, On the 5th Day of May, 1807. BY ALIRE RAFFENEAU DELILE, Of the City of Versailles, in France; Member of the Institute of Egypt, of the Society of Agriculture of the Department de Seine et Oist; Corresponding Member of the Society of Sciences, Belles Lettres and Arts of Bordeaux ; and Member of the American iEsculaplan Society. NEW-YORK: inted by T. & J. SWORDS, Printers to the Faculty of Physic of Columbia College, No. 160 Pearl-Street. 1807. tK>I/UMBIANA CYo nt idmff ■T)f(f TO DAVID HOSACK, M. D. Professor of Botany and Materia Medica in Columbia College, Fellow of the College of Physicians of Philadelphia, of the Linnsean Society of London, and Member of the Royal Medical and Physical Societies of Edinburgh. Sib, IN addressing this essay to you, I cannot but avail myself of the opportunity of expressing to you the obliga- tions I feel, in common with every person attending the medical school of this city, for the labour you have be- stowed in improving the means of medical instruction, and the liberality you have manifested in devoting the earnings of your profession to the establishment of a Bo- tanic Garden, which being the first that has been instituted in the United States, does you infinite honour, at the same time that it reflects reputation upon the medical school of New- York, to whose benefit you dedicate it. But I should be ungrateful not to acknowledge the kind- ness and attention I have also individually received from you. Accept, Sir, the most sincere expression of my Sentiments of gratitude and esteem. Your most obedient humble servant, A, R. DELILE. TO DOCTORS DESGENETTES, (Late Chief Physician of the Army of Egypt) Professor at the Medical School of Paris, LARREY, (Late Chief Surgeon of the Army of Egypt) Chief Surgeon of the Imperial Military Guard; Members of the Institute of Egypt, Inspectors of the Service of Health of the French Armies, Members of the Legion of Honour, &c. THIS DISSERTATION IS INSCRIBED As a testimony of respect for their talents, and of gratitude for their kindness, BY THE AUTHOR, ON PHTHISIS PULMONALIS, OR PULMONARY CONSUMPTION. 1 HIS disease is thus defined by Dr. Cullen: " Corporis emaciatio et debilitas cum tussi, febre hectica, et expectoratione plerumque purulenta." Morton and Sauvages have distinguished two species, viz. Phthisis sicca, and humida. Sauvages. Phthisis incipiens, and confirmata auctorum, Morton. The first without expectoration of pus; the second with a purulent expectoration. Dr. Cullen has adopted this last distinction, HISTORY OF THE DISEASE, A person predisposed to phthisis is seized commonly at the beginning of winter, or early in the spring. It commences with a slight cough, and some difficulty of breathing. In some in- ( 8 ) stances a pain in the chest is among the first symptoms; but not being confined to a particu- lar part, or felt only during a full inspiration, the patient is induced to consider these premonitory symptoms as nothing more than those of a com- mon cold, and therefore neglects the use of those remedies which are calculated to arrest the pro- gress of the disease. The cough is at first dry, except when the disease begins under the form of a catarrh. It becomes gradually more fre- quent and troublesome, especially at night. The patient expectorates with difficulty a thin phlegm. If the remedies indicated in this stage of the disease be not timely applied, inflammation in- creases. The patient complains of more pain in the chest, and refers it generally to that part of the breast under the sternum, or to one side, upon which he lies with some difficulty. The pulse is quick and hard, as generally occurs in diseases in which membranous parts are the seat of in- flammation. These are unequivocal symptoms of the incipient stage of phthisis. As the disease advances, expectoration increases, and the mat- ter discharged assumes a purulent appearance. Hectic fever gradually approaches; chills are felt at intervals, followed by a dry state of the skin, and a sense of burning in the palms of the hands and soles of the feet. Respiration becomes more frequent, the pulse is quicker than natural, the tongue and fauces are clean, red. and moist. The regular .accession of fever is a concomitant o£ the suppurative stage, and adds to the debility already existing. Two paroxysms assail the pa- tient in the twenty-four hours. The first comes on a little before noon, and ends towards six o'clock in the evening. The second succeeding at night, with more severity than the first, conti- nues until past midnight; is increased by the warmth of the bed, and ends about three or four hr the morning in a profuse sweat, which shows itself more especially upon the head, neck 3 and breast of the patient. A slight chill, a quickened pulse, a burning of the hands and feet, a circumscribed redness of the cheeks, are observed during each paroxysm, but are more strongly marked at night than during the pa- roxysm of the day. The night sweats become very profuse, and are usually attended with a costive state of the. bowels. When they dimi- nish, diarrhoea usually succeeds. No nourishment can repair the constant wasting of the body. Emaciation becomes extreme. The balls of the eyes sink into their sockets; the nails, wanting the. natural support which the fat and hardened cel- lular texture afforded them, curve inwards. The whiteness of the teeth is remarkable, owing pro- bably to a cause similar to that which gives the eyes a pearly hue, viz. a want of carbon in the system, as likewise appears from the general de- ficiency of fat, which requires for its composi- 2 ( io I tion a great proportion of carbonic matter. The smaller circulating and absorbent vessels lose their tone; the legs become oedematous. Small pustules and ecchymoses appear on the skin, the expectoration diminishes, the muscular power necessary to unload the lungs of the great quan- tity of effused matter is exhausted, and the pa- tient, almost speechless through excessive hoarse-* ness and debility, possessed yet of all his senses, sees death approaching, and calmly resigns him- self to his fate* CAUSES OF PHTHISIS PULMONALE The predisposing and exciting causes of phthisis are numerous, and as they vary, the disease progresses moderately, or terminates quickly. Among the predisposing causes, a scrophulous hereditary taint is considered one of the most fatal. The relaxed condition of the glandular system which takes place in scrophula, is also extended to the surface of the bronchia, where tubercles are probably formed at the mouths of the exhaling vessels. A weak and narrow chest, which is probably occasioned by the want of vessels sufficiently large to carry a due proportion of nourishment to that part of the body, predisposes to phthisis, and is oftentimes to be met with in persons of a ( 11 ) scrophulous habit, who have passed their infancy in a state of languor, without that degree of exer- cise necessary for health, and which alone is ca- pable of correcting this hereditary vice of the constitution. The compression made upon the lungs by con^ torsion of the chest in diseases of the bones, de- notes a predisposition to phthisis, marked also by the peculiar affection of the voice which is then produced. It has been observed, that people of a sanguis neous temperament, in whom an active circula- tion takes place in the smaller vessels upon the surface of the body, and which is designated by a peculiar thinness and lustre of the skin, a very fair complexion and fine hair, are more subject to consumption than people of the bilious and me- lancholic temperaments. The rationale of which is found in the delicate structure of the vessels which are spread on the surface of the body, in- ternally as well as externally, and therefore upon the lungs where they come in contact with the air. Sometimes small-pox, measles, and other erup- tive diseases, when suddenly repelled from con- striction occasioned by cold, or the effect of drastic purgatives, have laid the foundation for phthisical complaints, most probably owing to the relative action which subsists between the lungs, the alimentary canal $ and the external surface of the bodv> ( 12 ) Phthisis has been also the consequence of nursing, in delicate mothers, and in those who have suckled their children beyond a period pro- portioned to their bodily strength. In copious discharges of blood from the uterus, or in fhior albus, when it has been of long dura- tion, the debility does not remain locally con- fined; the contents of the chest are considerably weakened, and the lungs become often the seat of the disease. The success of mercury in some consumptive cases, tends to show that phthisis sometimes arises from syphilitic virus, The suppression of accustomed or necessary evacuations, as of haemorrhoids in males, and the catamenia in females; the want of them at that time of life when they should make their appearance, and their cessation at the usual pe- riod, may occasion a disproportionate determi- nation to the lungs, and produce phthisis c The suppression of the menses may be a consequence as well as a cause of this disease, and whenever it occurs is a great source of alarm both to the patient and her friends, who hastily prescribe re- medies oftentimes improper and dangerous. The want of accustomed stimuli, as of exercise in the open air, of fermented or spirituous liquors, manifest often their bad effect by an affection of the chest. Dr. D. Hosack, in his lectures, ob- serves, that during his attendance as physician at the New-York State Prison, many cases of ( 13 ) consumption were occasioned by confinement under such circumstances, and in persons other- wise not predisposed to complaints of the chest. On the contrary, they possessed a good constitu- tion, and were supplied with as many conve- niencies and necessaries as a well-regulated insti tution of this nature can afford. Great and sudden changes of temperature, an atmosphere alternately dry and moist, prove in- jurious to the Jungs, and predispose to phthisis, especially those who are of a delicate habit of body. In proof of this it is to be remarked, that it is not the disease of warm latitudes, nor of countries where an uniform temperature prevails. Hunting, farming, a hardy life, and pursuits which generally require exercise in the open air 5 exempt from phthisis. Frequently also they are the means of preventing that disease when even a predisposition to it exists, and one of the most effectual remedies when it has already taken place. Accordingly it is remarked by Dr. Rush,* that phthisis is unknown among the Indians of this continent. It attacks people of sedentary habits, and rarely those who are exposed to the inclemencies of the weather, or whose occupa- tions require great muscular exertion, as labourers, house-carpenters, blacksmiths, and ship-builders This disease is frequent throughout the whole * See Thoughts on Consumption.- { 14 ) eastern coast of the United States, where it isr induced by the vicinity to the sea, the prevalence of north-east winds, and sudden changes in the temperature of the air. The moist climate of the islands of Great-Britain render it common in that part of the world. All large cities favour its progress. Many trades predispose to it. Ex- traneous matters received into the lungs during inspiration, by millers, hair-dressers, and stone- cutters, render them very susceptible of phthisi- cal complaints. Dr. Withering* has observed, that whilst flints for potteries were pounded in mortars, the people so employed universally died consumptive. Linnaeus, in his valuable collection of the Amsenitates Academicae,f has recorded^ that people who were employed in Sweden in cutting grinding-stones from quarries, died of phthisis before the age of thirty years, from the noxious effects of the stony particles which they inhaled. The dry grinding used in manufactories for polishing steel instruments, or pointing needles, has the same pernicious effect. We learn it from an interesting description given by Dr. Johnstone, of Worcester. The iron dust which flies off, with small particles from the grinding-stones, unite in small balls with the mucus of the bron- chia, and workmen are seized with cough, a * See Letter to Dr. Beeldoes- f See vol. via. p. 159 ( 13 ) bloody and purulent expectoration, waste in fiesh and strength, and die before the age of forty ^ Dr. Kirkland has given a similar account of scythe-grinders, who, among themselves, call this fatal disease the grinder's rot. People em- ployed in spinning wool, and constantly using their saliva while they breathe an atmosphere loaded with fine particles of wool, are also very subject to consumption. Every person who will inquire of gold-smiths employed to gild silver., by a process during which they necessarily inhale fumes of mercury, will learn from them to what danger their trade exposes them. Blowing glass at furnaces is also known to be very pernicious. The violent exercise of the lungs and chest in persons learning the flute, or other wind instru- ments, frequently does injury to the delicate tex- ture of the lungs. Writing at a desk, a bent posture of the trunk, as shoe-makers continue in for the greatest part of the day, have a consider- able tendency to generate phthisical disposition . EXCITING CAUSES. Haemoptysis, or spitting of blood, readily pro- duces phthisis in persons predisposed to this dis- ease. The vessels of the lungs in delicate habits are easily ruptured, and heal with difficulty; they frequently remain in a state of ulceration 1 16 } On account of the frequency of hcemoptoe as the exciting cause of phthisis, Dr. Cullen has placed this disease, with great propriety, in his class hamorrhagia '. It is also to be observed^ that females are more frequently the subject of this disease than males; which is to be ascribed not only to their more delicate frame of body, but also frequently to a suppression or irregula- rity of their periodical evacuations. But haemop- tysis, without some predisposition, is not of itself sufficient to produce phthisis. Persons of good constitution recover with little danger from the rupture of a vessel in the lungs, occasioned by the application of external violence and other causes. Numerous instances have been recorded by practical writers, of females who have en- joyed perfect health after having laboured for many years under habitual discharges of blood from the lungs, which nature seemed to have substituted for menstruation. JP y neumoni 'a , especially /?/z nor is the termination of catarrh in phthisis to be apprehended, except when some predisposing cause is discovered in the general habit of body, or mode of living of the patient. Chronic ca- tarrh, occurring with violence, and often proving fatal in situations and at seasons in which phthisis more generally prevails, is not, however, to be confounded with it. Catarrh renders the lungs less capable of performing their important func- tions, exhausts the system by the abundant se- cretion which it produces, is of itself dangerous, and in some instances terminates in phthisis. Asthma might be mistaken for phthisis, but is generally periodic in its attacks, is characterized by spasmodic affections, and unattended by those febrile symptoms which constitute phthisis, ( 25 ) Phthisis must also be distinguished from a vo- mica of the lungs. This last affection of the chest is preceded by pain s difficult respiration, and other symptoms characterizing active inflamma- tion. The great quantity of pus evacuated at the moment the abscess opens, affords also a suf- ficient distinction between vomica and phthisis. The pain in the side, dry cough, hectic fever, produced by empyema, might be readily mistaken for symptoms of phthisis, but they proceed from vomica, pneumonia, or external injury, which serve to distinguish those diseases. Abscesses of the liver in some instances ex- hibit a train of symptoms, which, at first vieWj resemble those of phthisis. The matter of these abscesses finds its way through the lungs by piercing the diaphragm. The pus, destruction of parts, and ulceration, are not the effect of phthisis, and must be carefully distinguished from it, as the disease requires a particular treat- ment. Dr. William Saunders* has observed, that sometimes hepatic abscesses open sponta- neously through the diaphragm into the air cells of the lungs, giving passage to the matter which is thus evacuated by expectoration. A similar circumstance is noticed as of rare occurrence, in a memoir upon hepatic abscesses, by Bertrandi,f * See Treatise on the Liver, p. 220. t See Memoires d? 1'Acade.mie de Chivurgie de Paris, torn. Hi. p. 5Q4. 4 ( 26 ) who, for the description of the fact, has referred to the observations of Stalpart Vanderwiel.* This winter an instance of the same sort oc- curred at the New- York Hospital, during the attendance of Dr. John R. B. Rodgers, profes- sor of clinical medicine. A patient died of hepatitis after an illness of nearly two months. His body was opened, and the following is the substance of the report which the professor read at his lectures ; Having laid the abdomen open, the liver was found enlarged, and adhered considerably to the diaphragm. In separating the adhesions, the knife passed into a sack in the left lobe of the liver, which was almost entirely hollow and full of pus, mixed with blood perfectly resembling mat- ter which the patient had expectorated before. The diaphragm was corroded, and the left por- tion of the lungs, in other respects not diseased, admitted of a passage for the matter arising from the corresponding lobe of the liver. Another cavity, smaller, and perfectly distinct, existed in the great or right lobe, and communicated with the lungs of the same side. The patient, from the beginning of the disease, had frequently complained of cough. His pulse was quickened, but neither hard nor full. His tongue and teeth were covered with a peculiar * See Obaervatioaes Raniar. vol. ii. p. 202. Leyden, 1727V ( 27 ) fur. The application of blisters and anodyne mercurial liniment to the parts affected; the use of proper remedies to mitigate fever, to sup- port the strength, and to ease the cough, gave the patient little relief. He expectorated a consider- able quantity of matter tinged with ^blood. Di- arrhoea supervened, convulsions seized him, and terminated in death. TKis patient, a seaman, had been admitted into the hospital more than a fortnight after the first attack of the disease, which he attributed to a strain occasioned by hard work. He had not been in a situation to receive timely medical assistance. The previous injury could not be overcome by the remedies which were employed, and he fell a victim to it. A practitioner unac- quainted with the possibility of this source of expectoration in this case, might have pro- nounced the disease phthisis pulmonalis. But the appearance of the tongue and teeth, which were foul, and the absence of fever of a well- characterized type, were sufficient to determine: the nature of the complaint OF THE CURE OF PHTHISIS, The means of cure in this disease are deduced from the consideration of its causes and symp- ( 28 ) toms, which, by early attention, may be often prevented or removed. In those families where a predisposition to this disease is hereditary, great care should be be- stowed upon the first education of the child* and that such regimen be observed as is best calculated to counteract those vices of the habit to which it is naturally inclined. With this view it is important that a child born of a delicate mother predisposed to phthisis, should be provided with a nurse of a vigorous and healthy constitution; for, by continuing at the mother's breast, frequently both the parent and child are sacrificed. For the same purpose, removing children from the city into the country, which, for a part of the year at least, is commonly practicable, seldom fails to improve their constitution,- and generally succeeds in giving vigour to such as are of a weak or delicate habit of body. We are confirmed in the propriety of this re- mark by observing the greater degree of health,, and the more robust form of body, which chil- dren educated in the country acquire s compared with those born and brought up in cities. The hardy mode of life, the active amusements of the country, the freedom from the restraints of dress and fashion common in cities, all concur to im prove the constitution . ( 29 ) In this place the remark also naturally occurs* that the present fashion of dress adopted by young ladies, is not a little calculated to increase this disease. Tight lacing the chest, and the use of corsets, by impeding respiration and confin- ing the motion of the ribs, of themselves be- come, in some instances, exciting causes of phthisis; but where a predisposition to consump- tion exists, they invariably serve to increase it. In the different occupations or trades injurious to health, frequently much is to be done by early attention to the means of counteracting their jnischievous tendency; but in some instances the most cautious management cannot guard against the ill effects of particular employments: the only remedy in such cases, is for the patient not to persist in an occupation found to be un- healthy, but to resort early to another branch of business, before his health is irrecoverably im- paired. The diseases which are most commonly the exciting causes of phthisis, viz. haemoptysis, pneumonia, catarrh, &c. call for the aid of an attentive physician to accomplish the cure, and should teach the patient, when recovered, not to expose himself to the danger of a relapse. Proper dress and diet have generally the most happy effect in preventing a return of the evil. When carefully attended to for a certain space of time, they not only restore the usual strength ( 30 ) to the system, but sometimes invigorate it to a degree which may allow afterward of small irre- gularities; for an injurious cause produces a slight transitory effect upon a person in health, while it generates a disease in others debilitated by long irregular habits. A strict attention to dress and diet is almost impossible in many circumstances; in others the constant watchfulness which it might create, the frequent privations to which it might expose, would be productive of as great inconvenience and injury as the approach of the disease itself. Nevertheless, the good effect of regimen will not be denied in all cases where it is practicable. It is not less important in the treatment of phthisis to attend to the cause, than to the stage and symptoms of the disease; as remedies, to be exhibited with success, must accordingly be ac- commodated to the case. Thus, in young women, when irritation at the chest indicative of approaching phthisis takes place, at the same time that the catamenia should make their appearance, it not unfrequently ori- ginates from a morbid sensibility of the nervous svstem which sometimes attends that period of life. This sensibility first discovers itself in pro- ducing irritation at the stomach, hysteria, flatu- lence, loss of appetite, a dislike for animal food, a fondness for acids, pickles, and such articles as make a strong impression upon the stomach. ( 31 ) From the same source of irritation proceed pain in the chest, a frequency and shortness of breath- ing, a troublesome hacking cough, a general loss of strength, fever, and night sweats. These com- plaints, if neglected or mismanaged, readily ter- minate in a confirmed consumption of the lungs; whereas, tonic remedies, such as steel, bitters, a generous and nutritious diet, exercise in the open air, short journies, especially on horseback, should be prescribed, and will effect a cure, by diminishing the morbid sensibility, and thereby removing the first cause of the disease. In like manner, when incipient phthisis proceeds from an exhausted srate of the system induced by- suckling, if the cause be not attended to by the physician, he will prescribe in vain, and not un- frequently both mother and child perish from his inattention to the great source of the evil. Again, when phthisis is the consequence of the cessation of the menses, a moderare bleed- ing (even when the habit under other circum-. stances might forbid the use of the lancet and other debilitating remedies) will generally re- move the plethora which is induced ; whereas, blisters, emetics, issues, and pectoral remedies usually prescribed, so far from removing the dis- ease, will serve oftentimes to hasten its progress. It will be proper in this place to make some observations upon the use of the lancet in this disease. The experience of practitioners most { 32 } conversant with the treatment of consumption^ teaches us that blood-letting should be in a great degree confined to the first stage of this disease; that in the latter stage, its debilitating effects counteract the advantages otherwise to be ex- pected from this remedy. Moderate bleeding in incipient phthisis relieves the pain in the chest, renders respiration less frequent, and by restor- ing the secretions which had been interrupted, facilitates the transmission of blood through the lungs, and thereby unloads those organs of the disproportionate quantity of fluids which had oppressed them; but this remedy is to be em- ployed with a cautious hand, for if frequently re- peated, or the evacuation be too large, the debi- lity which ensues will soon be succeeded by an irremediable train of symptoms. The buffy or sizy appearance of the blood drawn in this disease, I am induced to con- sider as an equivocal test of inflammation, inas- much as it is frequently observed in diseases unattended with other symptoms of inflamma- tion, and, therefore, must prove a fallacious evi- dence of the necessity of blood-letting in phthisis, especially too as the buffy coat is not uncommon in this disease, even at that period when the pa- tient is sinking under excessive debility. The prudent and judicious physician, in forming his opinion of the propriety of blood-letting, will be guided by the general condition of the pa- ( 35 ) iient, the state of the pulse, the tongue, the digestive organs, and period of the disease, as well as the appearance of the blood drawn. Emetics aid expectoration, promote cutaneous perspiration, produce a revulsion of morbid ac- tion and irritation from the lungs, and allay the frequency and difficulty of breathing. Their good effects have led practitioners to employ a great variety of emetic substances in order to select the quickest and least debilitating. Antimonial pre- parations and ipecacuanha have sometimes been objected to, as acting upon the bowels. They are, however, safe remedies in the first stage of phthisis. The- sulphate of copper, or blue vitriol, acts almost instantaneously when taken into the sto- mach; its action is chiefly confined to that organ, and is less debilitating to the system than those emetics most in use. Dr. Simmons has employed it with good effects prescribed as follows: The patient swallows first about half a pint of water, and a solution of a few grains of blue vitriol immediately after. The whole is instantly rejected; and the same effect is next to be obtained from drinking a second glass of water, which commonly termi- nates its operation. Dr. Thomas Maryat recommends* the blue vitriol, with tartrite of antimony, in the proportion v " See New Practice of Physic, p. 88. .o { 5* ) &{ two grains and a half of each* in a spoonful of water. From the small quantity of water in which this emetic is exhibited, it is called the dry vomit. The sulphate of zinc in solution, according to -the prescription of Dr. Moseley,f affords a con- venient and safe emetic. One or two spoonsful produce vomiting without debilitating effects. Dr. Reid has recommended ipecacuanha both with and without the sulphate of zinc, and has placed much confidence in the daily exhibition of that emetic as successful in the treatment of phthisis, not only in the first stage, but also in some instances even in the second. He considers that the compression made upon the lungs by the action of the diaphragm in vomiting, evacuates the viscid and purulent matter accumulated in the bronchia, and removes the obstructions of the biliary vessels and chylopoetic organs. In this manner the patient is freed from a great source of pain and irritation, at the same time that he is thereby enabled to make use of tonic medicines and nutritious diet. * See New Practice of Physic, p. 23. f §! Vitriol alb 3 hj« Alum. rup. 3j» Coccinellse pulver. gr. iij. Aquae ferventis Ibj. Misce in mortario marmoreo* Solutio a fjeculentia vel residendo expurgetur, vel per char- tarn bibulam filtretur. Treatise on Tropical Diseases-, p. 384 and 542, ( 35 ) A little reflection on the nature of this disease serves to fix the extent to which emetics may be useful. When abused, they weaken the di- gestive organs; and in phthisis all hope of re- cruiting the strength, which gradually vanishes s rests upon the powers of the stomach and intes- tines to receive and to transmit nourishment. Epispastics, viz. blisters, setons and issues, are indicated in phthisis to remove the irritation from the lungs, They stimulate without danger the external parts which are not possessed of the ex- quisite sensibility of the organs affected. Their great efficacy is not owing to the local discharge which they produce, but rather to the artificial irritation which they occasion, and which, ac- cording to the experience of practitioners, ren- ders blisters preferable to issues and setons. Dr a Mudge was cured of consumption by the appli- cation of an issue, and has observed, that the salutary effect of the remedy depends on the great quantity of the discharge produced,* This opinion is not well founded, for if the patient's recovery depends upon the depletion of the sys- tem, we might obtain this end more effectually by means of blood-letting, cathartics, &c. and I am disposed to believe that a local irritation stimu- lates at the same time the whole nervous system, occasions a favourable transfer of excitement, and * See Dr. J. Mudge on Cai;.;-rhc^ Ouo-h, p, 5$ ( 36 7 thus diminishes the violence of the disease* The repeated application of blisters, upon this prin- ciple, is to be preferred, both in the incipient and confirmed stages of phthisis, to issues, setons, or blisters kept open by epispastic dressings. Laxative medicines promote the circulation in the abdomen, stimulate gently the alimentary canal, prevent the torpor which costiveness might Induce upon the secreting organs, and thereby contribute to the cure of phthisis in its first stage. Nitrous medicines, aperients and sudorifics di- minish the heat of the body and febrile excite- ment; linseed tea, barley water, and mucilagi= nous drinks, are also very proper auxiliaries. Anodynes, given at night to procure rest and to allay cough, are attended with good effects, and In many instances are indispensably necessary, especially when an emetic has been previously employed to unload the lungs. Mercury, by producing a general action of all secretory organs, is a valuable remedy in phthisis When it produces salivation the disease is sus- pended, and for the time totally removed; but it frequently recurs when the salivation ceases. We therefore observe, that even those remedies which have been considered as the most valuable, have no specific effect in the removal of phthisis. The moderate use of mercury in the first stage of this disease, may undoubtedly be of service,, Dr. Reid considers that it acts successfully as a . ( 37 } 4eobstruent, and that it is of doubtful efficacy in the second stage; and gives different cautions against its use in some cases.* The practice of the physicians attending at the New- York Hos- pital, has convinced me that its exhibition in many instances, even so far as to produce slight salivation (at the same time that other remedies are applied to allay cough and irritation), may promote the resolution of tubercles, and thus contribute to the cure of the disease, The digitalis purpurea, or fox-glove, a plant of the natural order of solanacece^ which all partake of a narcotic quality, has been celebrated for the cure of phthisis; but physicians have differed widely in their opinion with respect to this re- medy. No less contradiction exists concerning its advantages than its mode of operation. It appears that the use of this medicine was first introduced with an expectation, that as it had been found successful in scrophula, it might also be successfully employed in phthisis, the obstinate and incurable nature of which, in many cases, is ascribed to a scrophulous taint. This reflection arises from a passage in the writings^ of Dr. Beddoes, whose surprise is somewhat em* phatically expressed, that digitalis had not been sooner thought of as a remedy in consumption * See Essay on Phthisis, p. 188. t See Murray's Apparatus Medicaminum, torn. i. p. 72B, | See Essay on Consumption, p. 265, ( 58 } of the lungs, especially as its sensible effects had been long known, and readily suggested the ap«? plication of it to a variety of diseases. The celebrated Haller, more than half a cen- tury ago, in his work upon Helvetic plants, has expressed, in the following terms, the opinion then entertained of digitalis:* " Pro vulneraria babe- tur Lobel. et ad strumas commendatur impo- nenda. Sed acris est et vomitus alvumque ciet Rai. ut inter venenatas censeatur Boerhaavio. Extus contusam herbam et unguentum ex floribus ad podagram, ad strumas et rachitidem Anglif. laudant; nostris officinis ignota est." With the supposition that digitalis might dis« cuss tubercles of the lungs as well as scrophulous tumours, its use had become for a while almost universal and indiscriminate. With a similar theoretical view Dr. Michael Ryan J has recom- mended cicuta and the juice of the leaves of hissilago or colt's -foot. Experience has fully discovered the properties of digitalis. It must be given in small quantities, not exceeding a few grains of the powdered leaves, or a few drops of their tincture, which is preferable. A dose of ten or twenty drops, re- * See Stirp. Helvet. p. 617. f Digitalis is indicated as a remedy for consumption, in a work of the year 1710, by W. Salmon. See London Medical Review and Magazine, vol. v. p. 303. $ See Inquiry into the Nature.. Causes, and Cure of Consumption, p. 158. ( 39 ) peated four or five times a day* may be gradu- ally increased. This medicine has a very sensible effect in di- minishing the frequency of the pulse, and some- times reduces it considerably below its natural standard. It renders respiration slower than na- tural, and if the dose be considerable, it produces nausea, vomiting, fainting, vertigo, stupor; and if taken in very large quantity, or by accident, it operates as a poison, and, like opium, proves fatal. In one respect it differs from the other narcotics; it acts powerfully in increasing the se- cretion of urine: hence it holds a place in the materia medica as a diuretic, and has been a fashionable remedy in the treatment of dropsy ^ but as its sedative operation is very considerable,, we need not be surprised that it should have fallen into disrepute in that disease, which in most instances is the effect of debility. In phthisis a specific power to remove tuber- cles has been ascribed to this plant, and this operation has been accounted for by supposing that it increased the action of the absorbent ves- sels, and enabled them to carry away the matter composing tubercles. A supposition of this sort is not only groundless, but contrary to sound reasoning; since this medicine, by reducing the force of the heart and arteries, and consequently diminishing motion, cannot at the same time in- crease the action of a particular set of vessels, ( 40 } I hare seen this medicine judiciously prescribed in a number of cases at the New- York Hospital and the Alms-House, without that success which might have been expected from the advantageous reports given by some of the most celebrated practitioners of England. In several instances It diminished sensibly the frequency of the pulse, but did not produce any essential change in the disease; the expectoration continued no less abundant, and the gradual decay of the patient's strength increased, notwithstanding the exhibi- tion of bitters, tonic remedies, and nourishing diet. The great difference of results in this country, from those published by Dr. Magennis* in En- gland, renders it necessary for me to adduce the testimony upon which I have formed an opinion of the virtues of this medicine. In doing this I shall avail myself of the observations of Dr. Ho- sack, communicated in his lectures on the Ma- teria Medica, and which he has permitted me to use. " On account of the sedative operation of this plant, it has lately been restored to the Materia Medica as useful in phthisis pulmonaiis. During my attendance as physician at the State Prison, the New-York Hospital, and the Aims-House, as well as in my private practice, I have had op- portunities of prescribing it frequently in all the se London Medical and Physical Journal vol. v. p ( 41 ) different stages of that disease; in some with de- cidedly good effects; in others it manifestly did harm. In the first, or inflammatory stage of that disease, it was useful in removing the pain and soreness of the chest, in lessening the frequency of the cough, in facilitating expectoration, and in diminishing febrile action in general; but in the advanced or latter stage of the disease, it sunk the strength of the patient, destroyed the appetite, and in all respects increased the violence of the complaint. " In one case of incipient phthisis, preceded by haemorrhage from the lungs, it operated like a charm in relievirig the patient from some of the most formidable symptoms of the inflamma- tory stage of that disease. The same medicine will also probably be found a valuable acquisition in the treatment of most inflammatory complaints, and may be no less useful in pleurisy, peripneu- mony, or inflammation of the brain 5 than in the first stage of phthisis. u I fear, however, that from the promiscuous prescription of it in every stage of that disease, it may lose the reputation which it has lately ac- quired. " It was observed by Dr. Young, in his trea- tise on opium, that that medicine is improper where blood-letting is necessary; I remark of digitalis, that it is only useful where blood-letting and other depleting remedies are indicated," { 42 ) The good effect of the remedies which I have already mentioned, depends altogether upon the propriety and time of their application, as no other advantage can be derived from their num- ber than the convenience of choice, according to symptoms and circumstances. Warm bathing is a valuable remedy in addition to those generally used. The bath, at a tempe- rature not exceeding 92° of Farenheit's ther- mometer, abates febrile heat, opens the pores of the skin, equalizes the circulation, and promotes the secretions generally; on these accounts it is an useful remedy in the inflammatory stage of phthisis. Inhaling the steam of warm water is also very proper; it relaxes the inflamed membrane of the bronchia, and assists the secretion and expecto- ration of matter. Factitious airs, viz. carbonated hydrogen, car- bonic acid* gas, or hydrogen, combined with a sufficient portion of atmospheric air to render them respirable with as little danger as possible, have been tried often with apparent success. Owing to a specific quality, and to the absence of a due proportion of oxygen, they diminish the strength and frequency of the pulse, render the respiration less frequent, and produce a dis- position to sleep. They seem calculated rather for the first than for the second stage of phthisis. On the contrary, oxygen gas increases arterial ( 43 ) action, gives a momentary vigour to the system, and might perhaps be useful in the second stage of the disease. Its good effects are unquestion- able in several diseases arising from nervous af- fections ; but in phthisis, the great exhaustion which threatens the system renders the success of oxygen doubtful.* Modern researches in natural philosophy have given rise to the pneumatic branch of medicine, which owes its fame to the writings and experi- ments of Priestley, Black, Lavoisier, Fourcroy, Beddoes, Percival, Thornton, and other practi- cal observers. The methods to procure the dif- ferent gases have been rendered, simple, and con- venient; extensive observations have been re- peated to discover the circumstances to which those gases are applicable; and this science is dailv improving. Having only witnessed the effect of gases in a few experiments, I shall refer to the writings of practical authors for informal tion upon this subject. The diet in the first stage of phthisis should be composed of fruits and vegetables chiefly. Diluent and mucilaginous drinks are likewise extremely proper, and when inflammatory symp- toms subside, milk is a proper nourishment. A certain proportion of lime-water succeeds some- times to accommodate milk to weak stomachs. * See Chaptal's Elements of Chemistry, vol. i. p. 139. ( 44 ) where a disposition to acescency exists; but it should never be given in union with brandy or pther spirituous liquors.* Great benefit is derived from the well-regulated temperature of the apartment of the patient. A partial stream of cool air from a window or door is very injurious to consumptive persons; i\. increases the disposition to cough, and must be carefully avoided. Moderate exercise in the open air, walking, riding, &c. in a mild day, are of service. Flan- nel worn next the skin affords the best defence against the variations of the atmosphere. Its use should be recommended to ail persons affected with symptoms of phthisis, who become particu- larly sensible of the changes of the air. With respect to the salutary effect of wearing flannel, which might be more generally intro- duced in public establishments, a report of the New-York State Prison, published in the year 1800, by one of the inspectors, deserves to be mentioned. In that publication the author states, that since flannel had been used as recommended by the Physician (Dr. Hosack), " the number of the sick had decreased, the diseases became less Violent, and fewer deaths occurred. "f * See Fothevgili. London Medical Observations and Inquires vol. v. p. 376. f See an Account of the State Prison or Penitentiary-House, p. 90. New-York. Isaac Collins and Son. 180J. ( 45 ) The confirmed stage of phthisis requires tonic remedies, and a diet which the first or inflam- matory stage forbids. Blisters, even at an ad- vanced period, may be repeated with success, but as they probably do good by the irritation which they excite, and not by the discharge they produce, it is desirable to have all the advantage of their first effect without the debility produced by the latter. The best method is to dress the blister with some mild ointment, and, when healed, to renew it if the pain in the chest ren- ders it necessary. Aromatic and stimulating bitters give tone to the muscular fibre, prevent the return of febrile paroxysms, lessen the expectoration, and, by di- minishing fever, render the night sweats less fre- quent and profuse. The *nost efficacious medicines for that purpose are the poly gala senega, aristolochia serpent aria, columbo, and gentian roots. Infusions of boneset (eupatorium perfoliatum), horehound (marrubium vulgare), or lichen-islandi- fiis, upon the same principle, are useful tonics, and may be given freely during the remission of fever. Myrrh and ammoniac are also useful stimulants in this disease: they diminish the expectoration, and contribute to support the strength of the patient. These gummi-resinous substances may be exhibited either prepared in the form of a lac. ( *6 ) or made into pills. According to the experi- ments of Macbride,* transparent solutions of them may be obtained by means of lime, and in this manner Dr. Reid has recommended the so- lution of myrrh. The vapours or fumes of different substances have been often prescribed in order to produce upon the lungs, effects similar to those of fo^ mentations upon external parts. The fumes of resins excite coughing, and are injurious, while the vapour of vitriolic ether acts as an antispas-, modic, and is beneficial. Owing to the general property of carbon to arrest the progress of putrefaction, carbonic acid gas diminishes the faetor of the breath and of the matter expectorated; but being among the most noxious gases for respiration, it cannot be used with too much caution. The elixir of vitriol* is useful to check the, tendency to night sweats, and sometimes con- curs, at a late period, to restrain them, and to re- store strength. The most dangerous symptoms of phthisis are often obviated or removed by those remedies. We should be aware of the inefficacy of bark, against the use of which the opinion of Lieutaud J * See Experimental Essays, &c. f The acidum sulphuricum aromaticum of the Edinburgh Dispen gatory by Dr. Duncan. % See Precis de la Medecine Pratique, torn, u p. 391. ( 47 ) and Fothergill* is decisive. The latter author recommends it only in that species of consump- tion which arises from debility occasioned by suckling or immoderate uterine discharges. Opiates, through the whole course of the dis- ease, cannot be dispensed with as moderating cough, alleviating pain, and procuring sleep. In the latter stages they may also serve to arrest diarrhoea; but as the frequent use of opium de- bilitates the system, it should be only had re- course to when absolutely necessary. The sti- mulating medicines mentioned before are found more successful than opiates in preventing the progress of the disorder. Astringents, as preparations of kino, catechu, or the solution of sulphate of zinc, in a dose not sufficient to produce vomiting, succeed some- times to suppress diarrhoea, and thereby to re- establish the functions of the intestinal canal. A nourishing diet is necessary in the advanced stage of phthisis. Eggs, oysters, the different testacea, crawfish, broiled meat, jellies, afford the most substantial food: these articles should be given in small quantities, often repeated. Attention to this circumstance is necessary, that fever may not be excited or increased by the dis- tention of the stomach, and the labour of diges- tion occasioned by a full meal. The farinacea, * S«e London Medical Observations and Inquiries, vol. v. ( 48 ) such as oats, maize, barley, sago, arrow-root; &c. are well adapted to a weak state of the sto- mach in this disease. A milk diet has been highly recommended by authors. While some have given the preference to ass's and goat's milk, others have extolled the efficacy of human milk. The observations of physicians in all ages bear testimony to the good effects of milk in disorders of the lungs; but they are not such as to give us reason to con- sider that aliment as a specific remedy. Milk is not a nourishment suited to all circumstances, nor to all constitutions. The experience of the patient can alone determine the propriety of em- ploying it as an article of diet, otherwise it may impair the digestive functions, and become an additional source of disease. Wine of good quality, and unmixed with brandy* is not to be forbidden ; but the use of ale and porter is infinitely more beneficial, as they are more nutritious and less stimulant, Change of air and a journey, especially from a colder to a warmer situation, are not less useful to persons recovering from phthisis, than they are necessary to those who receive no benefit from the remedies which have been noticed. Much service may be derived likewise from riding on horseback. Both ancient and modern authors have recommended exercise in this dis- ease. In those cases which proceed from, or are { 49 ) attended with haemoptysis, riding on horseback should be cautiously made use of. The cures effected by exercise, added to the high authority of Sydenham in favour of riding, afford abun- dant evidence of its utility. Authors have been greatly divided upon the virtues and qualities of mineral waters, but they all agree upon the benefit of a journey to those places of general resort, and to which probably the patient is more indebted for his recovery than to any quality which the water may possess. Sea voyages, since the time of Pliny* and Cel- sus,j* have been considered as among the most effectual remedies in pulmonary consumption, es- pecially voyages from a cold to a temperate cli- mate. Sea air, sailing, and the exercise occasioned by the motion of the ship, are together benefi- cial; and the sickness and vomiting consequent thereon, especially to those unaccustomed to sea voyages, are often very useful. The exercise of the swing has been recom- mended to consumptive persons (where sea voyages were inconvenient or impracticable) by Dr. Carmichael Smyth, of London, who as- serts, that he prescribed it in a variety of cases with advantage; but the repeated experiments of Dr. DuncanJ on this mode of exercise in * See lib. xxxi. cap. 6. f See lib. iii. cap. 22. % See Medical Commentaries, vol. ii. p. 155. 7 \ { so ) phthisis have not been so successful, and in his opinion do not justify the expectations of Dr. Smyth. Riding, especially in an easy carriage, gives appetite and strength to persons already debili- tated by the disease ; and it must be remarked that the good effects of medicines, diet and re- gimen, are more apparent when prescribed in the early stage; and that when predisposition exists, it is more easy, by timely aid and atten- tion, to prevent the disease, than when advanced to remove it. I cannot conclude this dissertation with lan- guage more applicable to the treatment of this disease, than that adopted by Dr. Reid : Principiis obsta, sero medicina paratur Cum mala per longas invaluere moras. Ovid. THE END.