MEDICINE. 
DISEASES OF THE GENERAL SYSTEM. 
HE TREATMENT OF PULMONARY PHTHISIS. 
By Wm. Pepm:r, M. D., Professor of Clinical Medicine in the University of Pennsylvania- 
[After giving a most instructive description of phthisis, too long foi our 
pages, Dr. Pepper describes the following treatment:] 
I will take up the treatment of the fever in chronic catarrhal phthisis. You 
will remember that I spoke of its irregular course, differing in different indi- 
viduals ; being in some very marked, while in others it was very slight. This 
does not appear to depend upon the amount of local disease, since in some 
systems a comparatively small amount of local disease will be attended with 
a high degree of fever, while in others a much more extensive local disease 
will be accompanied by a very slight elevation of temperature and increase 
in the pulse rate. Undoubtedly, an explanation of a part of this great 
difference is found in the fact that different individuals get fever with differ- 
ent degrees of ease, owing to some difference in the nervous organization of 
the individual; but in addition to this, there is reason to fear that in cases 
attended by much fever there is danger of absorption into the system of some 
irritating or septic matter, so that this fever is, to a certain extent, of a septic 
or zymotic character. As a rule, in those who present a considerable degree 
of fever in proportion to the local lung trouble, we are to dread the develop- 
ment of tubercle. Thus, it is an unfavorable prognostic sign. 
I further told you that, in any given individual, the fever, from time to 
time, presented remarkable fluctuations. The true nature of these exacer- 
bations is frequently overlooked. The patient is said to have a bilious attack, 
a little chills and fever; almost every other explanation than the true one, 
which is, that it is due to a fresh attack of pulmonary catarrh ; and exami- 
nation will show that with each attack there has been a distinct extension of 
the area of cataiThal irritation and an increase of the inflammation. There- 
fore, when a patient with catarrhal phthisis gets increased fever, no matter 
what the other symptoms may be, whether associated with disturbance of 
the stomach, loss of appetite, diarrhoea, or not, I advise you to suspect the 
existence of a fresh attack of catarrhal inflammation, and treat it accord- 
ingly. In such patients there is a most intense susceptibility to the action 
of damp, cold, and other disturbing influences, so that a catarrhal attack is 
set on foot by an amount of exposure and with an ease that seems scarcely 
possible. 
The treatment, then, of this febrile action is a matter of the greatest im- 
portance. In the first place, let us recognize that it is distinctly connected 
with the irritation of the local disease, and that when it is very high in pro- 
portion to the local disease there is reason to fear that infection of the blood 
and system is going on. We must also bear in mind that there is nothing in 
the condition of a patient with catarrhal phthisis which wrould prevent him 
from suffering from malaria. Indeed, such a person would be very liable to 
be attacked by malarial fever, if exposed to its cause; and on the other 474 
MEDICINE. 
hand, there are no people who are more likely to get catarrhal phthisis than 
those who have had their blood impoverished and their systems broken down 
by the malarial poison. In such persons an attack of catarrhal pneumonia 
is very apt to pass into a catarrhal phthisis. Therefore, where the fever is 
of a high grade and obstinate, it is well to consider the question of the possi- 
bility of the co-existence of malaria. 
Now, what are the principles that should guide our treatment? I think 
we ought, as a rule, to try to get rid of this fever, even if it is only moder- 
ately severe ; for certainly those patients who have the least fever do much 
better and live longer than those who have more marked fever. 
The first thing we should do is to recognize the cause. Suppose we find a 
malarial element; this should be removed by full doses of quinia, and the 
patient kept upon the continued use of quinia and arsenic. I mention arsenic 
particularly, because you will find, in cases of obstinate hectic fever, arsenic 
a very valuable remedy; but to produce a good effect it must, in the first 
place, be well borne by the stomach, and generally the mucous membranes 
of patients with phthisis are very irritable, so that arsenic must be given with 
the greatest care ; and secondly, if it is well borne, its use must be kept up 
for a long time. Under such conditions it is a very useful remedy. If, 
however, there is no trace of malarial complication to be found, but if the 
hectic fever assumes a distinct intermittent character, presenting, as I have 
said it sometimes does, a rigor, followed by high fever and marked sweating, 
so that it stimulates an ordinary intermittent malaria fever, quinia is always 
to be given in large doses, and will nearly always modify hectic fever, but 
will not stop it, as would be the case if a malarial element was present. To 
accomplish this full doses are required. 
More frequently, however, we have a grade of hectic much less marked 
than this, one in which the morning temperature is not over 100°, and the 
evening 101° or 101.5°. Of course, this fever cannot be broken as long as 
active irritation is going on in the lung. We must, therefore, not expect 
such brilliant results from our remedies as we would in an idiopathic fever, 
and besides treating the febrile action, we must also address our remedies to 
the local catarrhal disease of the lung, by which the fever is kept up. 
In these cases quinia is useful, but should not be given in such large doses 
as we would where a malarial element existed, that is, twelve or fifteen 
grains, but in doses of one or two grains three times a day. As to the mode 
of giving this, I would be guided by the state of the circulation. If, at the 
same time, the pulse was rapid and weak, I should associate digitalis with the 
quinia. If, on the other hand, there was a marked tendency to night sweats 
and relaxation of the system, the fever not ofhigh grade, and the pulse not 
rapid, I should use aromatic sulphuric acid with the quinia, and give them 
in solution. Nearly always, in these cases of fever, you will find a little 
opium an important addition to the quinia; for instance, there is no better 
combination where there is marked irritation, with fever of high grade, with 
rapid, weak pulse, than a pill of quinia, digitalis and opium ; but you are to 
observe that this pill is to be use.d only occasionally, so that the patient; will 
not be led into the habit of taking opium every day. I think there can be 
no doubt but that the habitual use of opium, except in exceedingly trifling 
amount, exerts a depressing effect upon nutrition. Of course, it would not 
injure the patient to take one-eighth or one-sixth of a grain of opium, but to 
take as much as one-grain doses for a long time, I think is injurious; but, 
bad as opium is, there are things that are worse; for instance, a high degree 
of nervous irritation and hectic fever; so that, where we cannot dispense 
with opium, we must use it carefully. In such cases we may give one grain 
of quinia with one-fourth, one-third, or one-half a grain of powdered digitalis, 
and one-eighth, one-sixth, or even one-half a grain of powdered opium three 
times a day, according to the indications of the case. Where there is a 
marked tendency to relaxation of the skin and to night sweats, one grain of 
quinia with ten drops of aromatic sulphuric acid and minute doses of mor- 
phia, may be given in solution three times a day. I have already alluded to 
the use of arsenic where the hectic fever is obstinate, and a pill containing 
quinia, digitalis, opium and arsenious acid, is often followed by an admirable 
result, if its use is kept up for a long time. 
Lastly, you often find that the hectic fever is kept up or increased by irri- 
tation of other mucous membranes, as the gastro-intestinal. Frequently 
after the catarrhal condition of the lung has been much relieved, the hectic MEDICINE. 
475 
Sever will remain obstinate, and on a careful examination of the patient it 
will be found to depend upon a continuance of a catarrhal state of the gastro- 
intestinal mucous membrane, accompanied by a coated tongue, capricious 
appetite, impaired digestion, and other evidences of irritation of the digestive 
tract. Where such a condition exists, we may be sure that any febrile action 
occurring at that time will be aggravated. In these cases, if we suspend all 
remedies directed to the lung, and treat with dietetic and regimenal measures 
and remedies, addressed to the digestive canal, we will obtain more relief for 
the patient than we did while treating the fever as a symptom of the lung 
trouble. All through the ti’eatment of phthisis there is no principle so neces- 
sary as paying scrupulous attention to the digestive apparatus, not only 
because its irritation will increase the fever, but where a cure is effected, it 
is only brought about by a maintenance of the nutrition. 
At the last lecture I spoke of the occurrence of profuse night sweats. 
Let us then consider this symptom of night sweats. Here, again, we find 
an individual element in the matter. Some, with comparatively little lung 
disease, and only a moderate elevation of evening temperature, will have 
•copious night sweats, while others, with a considerable amount of lung 
trouble, and a high degree of fever, will have little or no night sweats. It is 
only when these sweats are extremely profuse that they are to be regarded 
as a bad sign. When they are only about as much as we would expect to 
have in order to carry off the febrile action, they are not unfavorable. It is 
better for a patient to have a fever which terminates in sweating, than to 
have a fever with a temperature of 103° going down to 101°, and the skin 
not becoming entirely relaxed and cool. Of course, the latter patient will 
be consumed much faster than the one in whom the fever is followed by 
sweating. In other words, the one has intermittent, and the other a remit- 
tent fever, and the latter is much the worse. A moderate amount of night 
sweats is not, then, a bad sign. 
Again we are to remember that this is entirely secondary to the local dis- 
ease of the lung and the febrile action; it is to be treated by treating the 
local condition and the condition of the other mucous membranes. It is 
only when it becomes a source of exhaustion that it demands a separate 
treatment. The remedies that do most good are those that increase the tone 
of the skin and act powerfully upon its blood-vessels. 
Frequently you will find that the removal of the patient to a cool and 
bracing climate will greatly lessen night sweats. Sometimes they may be 
checked by a change of diet; a change to one consisting of light and easily 
digested food containing a large amount of liquid, which acts as a diuretic. 
Another useful measure is cool bathing, or cool sponge bathing with water 
containing salt or alcohol. This is a remedy that is too much neglected. It 
may be used much more frequently than is generally supposed, but the 
baths must be taken with care, going over the surface rapidly with the sponge, 
and immediately drying by friction with a towel. The temperature of the 
water must be regulated by the temperature of the body, never being so low 
as to cause chilling of the patient. This bathing is a most important 
element in strengthening the system and fortifying it against the repeated 
attacks of fever. 
The drugs that are used to increase the tone of the skin are astringents, 
tannic and gallic acids, the mineral astringents, acetate of lead, sulphate of 
copper, oxide and sulphate of zinc. Frequently you will find that while 
these remedies do good in one case, in another they will fail. Among the 
drugs that influence the state of the vessels, quinia and atropia may be men- 
tioned as the two most potent. The quinia may be given in combination 
with any of the astringents I have mentioned, and is very useful where there 
is a moderate degree of fever with night sweats. Where the sweating is 
more profuse, you will find that atropia given at bedtime is a powerful 
remedy. It may be given in solution, in doses of one-hundredth to one- 
sixtieth of a grain, according to the susceptibility of the patient. This will 
produce a dryness of the skin, which will often enable the patient to pass 
through the night without his customary sweat; but I do not think that 
atropia is to be regarded as an adequate treatment for night sweats, since 
they depend not only upon the relaxation of skin, but are also due to the 
local trouble. I think it is well to keep up the continuous use of such reme- 
dies as the combination of quinia and tannic acid, or quinia with other 
astringents, while we reserve atropia for use at nights. MEDICINE. 
Sometimes the night sweats are checked by the external use of hot water 
containing alum or alcohol, which has a stimulating effect upon the skin, 
and thus tides the patient over his ordinary time for having the sweat. 
In the patient I had before you at the last lecture I tried probably half 
a dozen of these remedies, without stopping the night sweats. Atropia has 
no effect. I then gave him a remedy whose use lias lately been revived for 
the treatment of this condition, and one which I think is of little value, that 
is, agaric. I gave it to him in large doses, hut it produced no effect. Finally,, 
he began to improve under the use of quinia and tannic acid, but I attribute 
the cessation of night sweats more to the subsidence of the local lung trouble 
than to the quinia and tannic acid, for as the lung became better the nutrition 
improved and the night sweats became less marked. Another symptom to 
which I desire to call attention is hemorrhage from the lung and its significance. 
In the treatment of hfemoptysis something will depend upon the condition 
of the patient and the state of the lung. As regards drugs, I do not know 
anything more difficult than to estimate the value of remedies in haemoptysis. 
The hemorrhage frequently stops spontaneously. There are certain things 
to be done in the treatment of all cases. You must first try to arrest the 
hemorrhage, and then determine the condition of the lung. An essential 
element of the treatment is absolute and perfect rest in bed, avoidance of 
talking, and the suppression of cough, as far as possible. Then, everything 
which renders respiration easier should be encouraged. Nothing should 
obstruct the neck and chest. The room should be cool, the head and 
shoulders elevated, and the patient should swallow little pieces of ice. I 
think that the cold exercises some influence in checking the hemorrhage. 
All the nourishment should be cold and non-stimulating, as, for instance, 
cold milk and meat broths. We will see later that the debility of the system 
is sometimes so great that we have to resort to stimulants in order to main- 
tain the circulation. As to the local application of cold to the outside of the 
chest, I do not think that this is advisable. It is probably true that if we 
could localize the seat of the hemorrhage, and if it was superficial, the cold 
pack might aid in checking it, but I think that the risk of the bad effects 
from the cold would be too great. 1 would prefer to resort to dry cupping 
over the back and front of the chest, over the spot from which the blood 
comes, if this can be located ; but where you cannot locate the exact seat, a 
dozen dry cups may be applied over the back and front of the chest, if it can 
be done without disturbing the patient too much. 
Of drugs, ergot seems to be the most powerful in checking haemoptysis. 
The extraction ergotae fluid may be given in doses of a teaspoonful every 
fifteen minutes, until the hemorrhage is stopped, and then continued in 
smaller doses, or it may be given by hypodermic injection in doses of gtt. xv, 
or ergotine may be used. If the stomach is irritable, gr. v of ergotine may 
be given per rectum. Sometimes ergot will have no appreciable effect. 
Under such circumstances I think that gallic acid is the next best remedy. 
I frequently combine it with aromatic sulphuric acid, which makes a more 
efficient and pleasant mixture. 
R. Acidi gallici g ij 
Acidi sulphurici ai’omat f. £j 
Glycerinaa f. g j 
Aquas, q. s. ut. ft f. g vj. M. 
Sig. A tablespoonful, as required. 
This is to be given every hour, every half hour, or at shorter intervals, 
until the hemorrhage is brought under control. This, I think, ranks next to 
ergot, and where the stomach refuses ergot, or where ergot produces no 
effect, I usually resort to this combination. 
You will observe that so far I have made no mention of the use of opium, 
which should be given to control the cough, quiet nervous irritability, and 
allay vascular excitability. The opium may be given either by suppository, 
by hypodermic injection of morphia, or the deodorized tincture may be 
added to the ergot or gallic acid combination. I prefer the use of opi um to 
that of morphia in the condition I am now describing. For internal use I 
think there is no preparation of opium equal to the deodorized tincture, the 
tinctura opii deodorata. Where the stomach is irritable, suppositories of 
opium or hypodermic injection of morphia may be used. The amount must 
be determined by the effects, but patients with hemorrhage will bear large 
quantities of opium. The proper method is to give small doses, frequently 
repeated, until the desired effect is produced. MEDICINE. 
477 
Sometimes the patient passes into a state of obstinate bleeding, lasting, not 
for an hour or two, but for several days, with evidence of severe congestion 
of some portion of the lung; and you may find that ergot, gallic acid, and 
aromatic sulphuric acid fail to check it; we then come to the mineral astrin- 
gents. Of these, I think the best is acetate of lead, and next sulphate of 
copper. These should be given in pill form with opium ; but I do not think 
that they are so useful for producing an immediate effect as ergot and 
gallic acid. * 
Suppose we are able to tell where the hemorrhage comes from. Take a 
patient who has been healthy, has had no cough, no evidence of lung trouble ; 
he begins to spit blood, but this is checked, in great part, by one of the means 
already mentioned; still it continues in small quantity; an examination of 
the lung reveals no solidification, no rales, no evidence of any disease ; here 
we must conclude that the hemorrhage has, in all probability, come from the 
bronchial mucous membrane. In such a case astringent inhalations are very 
useful. They may consist of solutions of Monsel’s salt, tannic acid, or other 
astringent, which, by being forcibly drawn in, may reach the seat of hem- 
orrhage. In cases where the hmmoptysis is due to an acute congestion of 
the vesicular structure, or to an acute catarrhal pneumonia, you will find 
inhalations of no material service. 
I have spoken of derivation by dry cupping; this I think is an exceedingly 
important mode of treatment, and it becomes more important in proportion 
as you are able to localize the seat of hemorrhage, and to determine that it 
comes from a congestion of some portion of the lung, or from the seat of a 
■catarrhal pneumonia. In such cases, I think that local depletion by dry 
■cupping, or if there is a high degree of vascular excitement with fever, and 
if the patient is strong, by wet cupping, is an exceedingly valuable means of 
arresting the hemorrhage. 
Sometimes a patient with haemoptysis, either from a previous weakening 
•of the system by phthisis, or from the excessive amount of blood lost, or else 
from the severity of the local disease with which he has been attacked, falls 
into a very weak state, with rapid shallow breathing, a rapid feeble pulse, and 
marked muscular prostration. Bleeding, under these circumstances, becomes 
dangerous, and occasionally we find a continual oozing of blood, which may 
even go on to a fatal result. Here we have to treat not only the hemorrhage, 
hut also the constitutional condition of the patient, which verges on to the 
typhoid state. This condition often occurs in severe pulmonary congestion, 
where the system has been run down, or where the congestion involves a 
large part of the lung and is attended with this hemorrhage. In these cases 
the patient’s strength must be supported by quinia, given fi-eely. In order 
to avoid irritating the stomach, it is sometimes better to give the quinia by 
suppository. This drug also acts as an astringent by increasing the tone of 
the vessels. Digitalis, which acts in a similar manner, should also be given. 
It may be given in the form of the tincture or the infusion associated with 
astringents by the mouth. If I found that the appetite had disappeared, that 
the tongue was foul and coated, and that sordes had begun to form on 
the teeth, I would associate turpentine with the quinia and digitalis, in place 
of other astringents. In this low condition turpentine is a valuable remedy, 
both for its haemostatic power and for its influence over the typhoid state. 
I have met with cases where quinia, digitalis, turpentine, good nourishment, 
and a moderate amount of alcoholic stimulus carried the patient through an 
attack of hemorrhage, where I am sure an attempt to keep up the use of 
astringents or to use stronger ones would have resulted in death. 
Finally, in those cases in w'hich hemorrhage takes place from a cavity, 
owing to the ulceration or rupture of a blood vessel, our treatment has, I 
think, little or no power to arrest the bleeding, for if the vessel is large and 
the opening is free, the patient will die ; but if the opening is small or val- 
vular, the bleeding may stop spontaneously; but I do not think that we 
have any means of arresting such hemorrhage. Possibly, astringent inhala- 
tions might reach the part and thus favor coagulation of the blood, but at 
the time of the hemorrhage they can scarcely be used. I have suggested, but 
never tried the operation of introducing the needle of a hypodermic syringe 
directly into the part and injecting some astringent solution. This, I think, 
would be attended with risk, and as I think the general proposition I have 
just made holds good, i. e., if the opening is large the patient will die, and 478 
MEDICIHE. 
if it is small the bleeding may stop spontaneously, the treatment I would 
recommend is to sustain the patient’s strength, keep him perfectly quiet and' 
administer opium. 
The next complication to which I shall ask your attention is diarrhoea. It 
occurs in a great many cases of chronic phthisis. In some it becomes so- 
troublesome that it forms a most serious complication, and may even he a 
cause of death. 
ISTow, as to the treatment. Rest in bed, I should say, was essential in such 
cases, for I assure you, if the patient is allowed to go about and the diarrhoea 
to continue, you will find great difficulty in stopping it. Rest in bed, then,, 
with absolute liquid diet of the most nutritious character, consisting of milk,, 
arrowroot, meat broths, finely-minced meat, and other articles of this kind,, 
must he continued until the has been entirely overcome and the 
stools have been normal for a day or two. A moderate amount of opium 
must be used to control the tendency to diarrhoea. As to astringents, nitrate 
of silver, given in minute doses, guarded by opium, is, I think, a most valu- 
able remedy. Bismuth does well in most cases. Sugar of lead or tannic- 
acid with opium is also very good. Aromatic sulphuric acid with sulphate 
of morphia and camphor solution will do very well in many cases. The 
nitrate of silver may be given in pill form, or in small doses dissolved in 
the syrup of acacia. 
If you find that there is a wide-spread catarrh, with involvment of the 
duodenum, and extension of irritation into the bile ducts with obstruction 
to the flow of bile, I would advise you to preface the treatment by small 
doses of calomel, soda, and opium, given for a few days until the tongue 
begins to clean and the character of the stools shows that the bile passes- 
freely. Then you may substitute nitrate of silver and opium, or one of the 
other astringents. Such patients are very susceptible to the action of mer- 
cury, and we must use the calomel in small doses. It may he given accord- 
ing to the following formula : 
R. Hydrarg. chloridi mite gr. ij 
Sodii bicarb 3j 
Pulv. opii g iij. M. 
Ft. pulv. No. xij. 
Sig. One every four hours. 
These are to be taken until they produce the desired effect, or all are taken.. 
This complication of diarrhoea is an exceedingly important one ; it wastes 
the patient’s strength and flesh, it renders him still more susceptible to 
damp and cold and predisposed to extension of his lung trouble, and conse- 
quently it may be ranked among the most serious complications and deserving 
of the most careful treatment. 
The last of these great complications is the laryngeal complication, or as 
it is called tuberculous laryngitis; but just as we have seen in the case of 
phthisical diarrhoea, many of these cases are not tuberculous at all. Laryn- 
gitis occurring in the course of phthisis may be an expression of tuberculosis, 
and we may find miliary tubercles in the follicles of the mucous membrane, 
but patients with phthisis are very liable to get attacks of ordinary catarrhal 
laryngitis, and such attacks are, for precisely the same reason as in the case 
of the diarrhoea, apt to become troublesome and leave behind lasting lesions, 
thickening of the membrane and enlargement of the follicles, with hyper- 
secretion. These cases of chronic laryngitis may be developed without there 
being any tubercle in the case, or it may be due* to tubercles forming at the 
beginning of the attack or developed later, after the irritation has lasted for 
some time. Here we have an explanation of the fact that in many cases we 
are able to effect a cure, while in others we utterly fail. After true miliary 
tubercles have formed in the larynx, I fancy that an arrest of the disease is 
of the rarest occurrence, for the state of the system and the presence of 
these tubercles and ulcers favor increased congestion, and the course of the 
disease is steadily downward. In cases where the lesion is of a catarrhal 
character, you may, by judicious treatment, greatly relieve if not cure the 
catarrhal trouble. 
We should always warn the patient against the slightest exposure, and 
when the least hoarseness occurs, we should treat it immediately, for by so- 
doing we can often prevent the development of the later stages. In the 
early stages counter-irritation, by means of a blister, or by the repeated' MEDICINE. 
479 
application of iodine, or of iodine and croton oil, and the direct application 
of astringents, as sulphate of zinc, grs. x-xl to the ounce, will often cut. 
short the attack. If the attack is more marked, and we have not been able 
to cut it short, the larynx must be put to rest as much as possible, by induc- 
ing the patient to do without speaking, not even whispering, and to commu- 
nicate everything by writing. The food should be unirritating, and great 
care should be taken that no particles get into the larynx. The patient 
should be careful that he does not take a fresh attack from chilling of the 
surface. Opium must be given, to allay irritability and cough. Counter- 
irritation must be steadily kept up. Topical applications must be used, to 
relieve the swelling and favor cicatrization of the ulcers. 
Now as to topical applications. I think that in treating these cases the 
strength of the solutions used is often too great. We must remember that 
we have to deal with a not very highly vitalized tissue, and one which, when 
in a state of chronic inflammation, will not respond to strong applications. 
You will find that mild applications will do more good than strong ones. 
Solution of sulphate of zinc, or of the salts of iron, or of iodine, will be 
found of service. Lately I have been using a solution of iodoform in ether 
or chloroform, varying in strength from grs. xv to the ounce up to a satu- 
rated solution, which is, I think, about 3 3 to the ounce. This is a very un- 
irritating application, and it certainly possesses very marked absorbifacient 
and alterative powers. Of course, each of these applications is to be made 
only to the diseased spots by the aid of the laryngoscope. 
Inhalations are very valuable in the treatment of the laryngeal complica- 
tion of phthisis. They may be used with the ordinary atomizer, which is a 
good method, hut apt to excite coughing. In this way we may use nitrate 
of silver, tannic acid, sulphate of copper, sulphate of zinc, iodine, etc. We 
may use an inhaler made of a piece of rubber tubing, in which is placed a 
number of small rolls of bibulous paper. The solution to be inhaled is 
dropped in at one end, and then the patient uses it as an ordinary cigar. I 
have made a little alteration in this, by substituting for the rubber tube a 
glass tube with a constriction near one end, and for the paper, pumice stone, 
which makes it more cleanly. With this we may use a number of volatile 
solutions. In other cases we may employ a sort of mask made of two pieces 
of rubber, with sponge between them. By this means the patient may 
breathe medicated vapors for hours at a time. We may use with this tar, 
carbolic acid, iodine, etc. 
We have now finished the discussion of the great complications of phthisis, 
and now I shall ask your attention to the treatment of the pulmonary con- 
dition itself. 
In the first place, if it is true in regard to any disease at all, that we are 
not to treat the disease as a separate entity, but to treat the sick person as 
an individual, it is more true in phthisis than in any other. In its treatment 
we are to begin before the phthisis has commenced, since the treatment of 
phthisis is to prevent its development. This applies not only to cases in 
which there is a local disease of the lung; but still more does it apply to 
persons who are evidently getting ready to have phthisis. Where we have 
an individual showing a weak constitution, who has little power of maintain- 
ing his temperature and circulation, who loses flesh upon slight provocation, 
who, after an acute illness, recovers slowly, such a person is predisposed, 
upon any attack of lung trouble, to have it pass into a chronic state. Where 
we see these indications of weakness of constitution in childhood or infancy, 
we should advise the parents to resort to the proper treatment, in order to 
develop a healthier and stronger constitution ; for, as we have seen, in those 
who have an inherited tendency, or an acquired debility, there is a marked 
susceptibility to have phthisis developed. In such cases an attack of lung 
trouble, which in a healthy individual would disappear in a short time, is 
apt to remain and effect such changes in the epithelial lining as will lay the 
foundation of catarrhal phthisis. 
In order to prevent the development of phthisis, to increase the constitu- 
tional health and eradicate weakness, there is nothing so important as proper 
hygiene. If there are any great and radical differences between the practice 
of to-day and that of fifty years ago, it is in the more accurate diagnosis and 
the broader views of hygiene, as bearing upon treatment, that have been 
introduced. Nowhere do we see this more marked than in this group of 
diseases. 480 
MEDICINE. 
Sunlight, pure air, proper gymnastic exercises, regular out-door exercise, 
maintaining the tone of the skin by bathing and friction, and if necessary, 
a change of residence to a more suitable climate, are the elements that are 
able to convert a feeble system into a vigorous one, and which, when there is 
a commencing predisposition to phthisis, are able to overcome and eradicate 
it. The same thing is true after the patient is taken with catarrhal or 
croupous pneumonia. 
Now, as long as it was the habit to think of phthisis as always tubercular 
and always associated with this special new growth in the lung, the treatment 
was practically regarded as hopeless, and it was thought that all that could 
be done was to render the patient as comfortable as possible and treat the 
special symptoms as they appeared ; but now, since we know that phthisis, 
in the majority of cases, at least in the beginning, is not tubercular, and that 
it may run through its whole course without the development of tubercle, 
its treatment becomes of extreme importance. If a person with a feeble 
constitution gets an attack of catarrhal pneumonia, we must regard him as 
liable to pass into a state of phthisis; and this is true, not only of severe at- 
tacks, in which, perhaps, the whole of one lung or large portions of both 
are involved, but also of those involving small and circumscribed portions 
of the lung tissue, which so frequently occur and are regarded as common 
colds. 
Catarrhal pneumonia of this latter type will be one of the most frequent 
diseases with which you will meet, and it must be treated vigorously. The 
patient should be absolutely confined to bed. Kest should be insisted upon 
until the physical signs of the local disease are removed, or until the disease, 
despite our efforts, has passed into a chronic state. Local counter-irritation 
and depletion should be employed, by dry cupping, or if the fever be high, 
and the patient pretty strong, wet cupping, and by blisters, or counter-irri- 
tant applications. I do not want, to-day, to enter upon the .treatment of 
catarrhal pneumonia, but desire to dwell upon the importance of rooting out 
this disease at its very beginning, the importance of regarding it, as it really 
is, of an inflammatory character, and the danger of the exudation passing 
into a state of cheesy degeneration. If you treat this disease actively, you 
will be able, in many cases, to prevent it from passing into phthisis. 
Suppose, despite your effort, the disease passes into the chronic form, or 
that the patient does not come to you until it has reached this stage ; for in 
five out of six cases you will find a history something like this—the patient 
has had a severe cold, which settled on his lungs, he has been gradually los- 
ing strength and flesh, has, perhaps, a little fever, and on examination you 
will find evidences of local catarrhal disease. Here there has been these 
limited catarrhal attacks, which have attracted little attention, and have 
slowly passed into cheesy degeneration, with perhaps disintegration of the 
lung tissue. Here, again, we find the immense importance of a proper 
hygiene. I think our power of successfully treating these cases depends 
upon our power of getting the patient to understand that we cannot cure 
this condition by drugs. The truth is that the general health is so impaired, 
and the tone of the system is so reduced, that instead of the inflamed epithe- 
lial cells being able to throw off the catarrhal product and return to a healthy 
grade of action, they tend, more and more, to pass into this unhealthy state, 
the matters undergo cheesy degeneration, the lung tissue becomes involved, 
and phthisis is developed. 
Secondly : in consequence of this extreme weakness of system, there is a 
great susceptibility to changes of temperature, damp, and other depressing- 
agents, so that lie is constantly getting, from the most trifling causes, fresh 
attacks of congestion and catarrhal inflammation, which extend the original 
trouble. This weakness of system is what you have to meet by your treat- 
ment. In the great majority of cases, when they first come under notice 
the local trouble is so slight that if the system was in a healthy state it 
would be thrown off in a few weeks. As soon as you have gotten the patient 
to grasp this view of the subject, and to make it his business to endeavor to 
build up his general health, you have accomplished a great deal in the 
treatment. 
In speaking of the hygienic treatment of phthisis, I shall allude to only 
one or two points. All the conditions that predispose to phthisis serve to 
maintain it. The study of the skin and its circulation is most important, for 
a loss of tone of the skin constantly predisposes the patient to take cold, the MEDICINE. 
481 
cutaneous circulation is checked, congestion of internal organs takes place, 
and extension of the local trouble results. I would say, then, that our care 
should first be directed to improving the tone of the skin, and the surface 
circulation. For this purpose you will find a cold sponge bath, or a plunge 
bath taken every day, at suitable times of the year, a very important measure, 
and one which I think is too often neglected. The best way to take this bath, 
is not to take it in the slow desultory manner of an ordinary bath for cleanli- 
ness, but to take one quick plunge, in and out in a second, and then to dry 
the surface rapidly by vigorous friction. Where the patient is too weak to 
do this, sponging with cold salt water may be substituted. The time of day 
when these baths should be taken is important. They are usually taken in 
the morning before breakfast, but this is wrong. They should be taken some 
time after breakfast. Suppose the patient has breakfast at 7:30 a. m., or 
8:30 A. M., then 11 A. M., is the best time for the bath, as at that time the 
power of reaction is at its best. In many cases, where the patient has his 
business to attend to, this time is not suitable. In such cases the bath should 
always be taken in the morning. There is a great amount of good to be 
gained by this mode of treatment, if properly carried out. 
In cases where there is an almost invincible tendency to take cold, with 
feeble circulation, cold extremities, a skin that is delicate, dry and exceed- 
ingly sensitive to changes of temperature and humidity, I have found inunc- 
tion of oil into the skin, over the whole surface of the body, after the bath, 
of the greatest possible value. In many instances it will render the patient 
proof against these changes. 
Diet and exercise require fully as much attention as does bathing. Let 
me here refer to the importance of abundance of fresh air. Note that these 
attacks of congestion depend more upon feebleness of the circulation than 
upon anything else, and that anything that renders the circulation less vigo- 
rous will make the attacks more frequent. If the endeavor is made to pro- 
tect the patient from exposure by keeping him shut up in a warm room, the 
susceptibility will only be increased, so that no matter how warmly clad the 
patient is he will not be able to resist the slightest exposure. The only way 
to protect the patient is to increase his strength, and thus enable him to re- 
sist these changes. If the patient is too weak to carry out the proper mea- 
sures to increase his strength in the climate in which he is living, he must 
change it for a more suitable one. Exercise in the open air is absolutely 
necessary. It should be taken every day, about the middle of the day, 
except when the weather is stormy, blustery, or so intensely cold that the 
patient would be chilled at once, for cold of itself is not so injurious. 
Closely allied to the question of exercise is that of change of climate. 
The greatest fallacies exist as to the reasons for, and the objects gained by 
a change of climate. The climate of one place is essentially the same as 
that of another, leaving out, of course, all consideration of malaria, filth, 
etc. What you induce a patient to change his climate for, is to place him 
under better conditions to practice the same hygiene and therapeusis as he 
would at home. The change of climate is not going to do anything directly 
for that man’s trouble. If he should go to a suitable climate and think that 
then he had done all, leave off all his hygienic measures, fall into irregular 
habits as to eating, sleeping, etc., it would have been far better for him to 
have remained at home. 
Change of climate is exceedingly important under two conditions. In the 
first place, when the climate in which the patient lives is one where there are 
long periods of inclement weather, as, we will say. in this city during the 
next ninety days, to the first of April, when it is doubtful if much out-door 
exercise can be had. A climate like this is not suitable for such patients. 
Again, if the patient is so weak that he is unable to bear much cold, even if 
it be dry cold, he must be sent to a milder climate. Change of climate is, 
then, not to be regarded as possessing any curative effect in itself, but simply 
as an assistance in carrying out the proper hygienic and remedial measures, 
and to be resorted to when the patient does not respond to these measures 
in the climate in which he is. Diet, dress, out-door exercise, gymnastics, 
mostly in-doors, and proper bathing, are then essential elements of our 
treatment, and lie at the bottom of all successful treatment. 
Now, after all these are attended to there comes up the question of thera- 
peutical remedies. There are two principles that would occur to all in the 
thinking what we would do in a case- of phthisis; one is, that we should 482 
MEDICINE. 
aim at improving the general strength, the other, to aim at removing the 
local disease. The patients are always reduced in health, and this would at 
once suggest the use of nutrients and tonics. The best nutrients are food 
and fresh air; besides these we have a number of other valuable remedies, 
as iron, malt, alcohol, glycerine and cod-liver oil. They all are analeptics. 
They supply material from which the system can build up its tissues, and 
when the patient is able to digest these articles, in addition to his ordinary 
diet, they may be given with great advantage. They do not exert any 
specific action upon the local disease. They produce their effects upon the 
general nutrition, and thus tend to restore a more vigorous grade of action 
to the affected cells, so that they will produce more perfect cells. On the 
whole, there are perhaps no remedies of this class so generally applicable as 
the oils, and of these, the best is cod-liver oil. It is to most persons very 
digestible, and can usually be given by some device that will conceal its 
taste. If the patient falls off in the quantity of food that he takes when 
taking oil, he had better give up its use. It is only of advantage when it 
does not interfere with digestion, when the patient is able to take his full 
quantity of food, and when the oil is easily digested. The same is true of 
all other remedies of this class. They furnish the same elements of nutrition, 
in a concentrated form, that we have in milk, beefsteak, etc. 
In many cases, where the digestion will tolerate it, iron is of extreme value 
and perhaps in such cases our choice of the preparation to be used will de- 
pend somewhat upon the condition of the local disease. We may give it 
in a simple form, if we desire only to introduce iron into the system, 
or in the form of the iodide of iron, where we feel that iodine would be of 
service for the local condition. 
The same general principles would govern us in the use of tonics. They 
do not exercise any direct power over the local disease ; but it is only by en- 
abling the system to receive and appropriate nourishment that they do good. 
When the appetite and digestion are good, tonics are not needed; but when 
there is functional disturbance of digestion, the vegetable tonics and mineral 
acids are to be used upon the same principles that would govern their use, in 
the same condition of depraved nutrition, under other circumstances. 
In estimating the progress of the case, and in governing the treatment, 
you have two elements to guide you : first, the quantity and the character of 
food assimilated; secondly, the character of the discharges and the move- 
ments of the body weight, as determined by frequent observations. With- 
out paying attention to these points, I think little can be told as to the con- 
dition of the patient and the success of remedies. 
Now, as to the treatment of the local disease. This is undoubtedly last, 
because it is of the least importance; yet it is very important; and I think 
great good can be done by addressing ourselves to its treatment. Counter- 
irritation is. I think, of great value throughout the whole course of the 
disease until tuberculosis is developed. As long as the disease is a simple 
inflammation, even after destructive disease has shown itself and a cavity has 
formed, I think that mild counter-irritation is of service. 
Secondly, the alterative effect of inhalations is of unquestionable advantage. 
A great variety of inhalers and a great variety of remedies to be inhaled 
might be recommended, but your own judgment will guide you in the se- 
lection of the former, and your preference and the result of your experience 
in the choice of the latter. 
Then, we use certain drugs internally, in the hope that they will modify 
the condition of disease at the affected part. Among these are to be men- 
tioned mercury, iodine, and arsenic, as the most potent. There is great 
difference of opinion as to the use of these powerful alteratives in phthisis, 
and in discussing this subject we are treading on delicate ground. There is 
no doubt that if we had to control only the acute disease, where destructive 
lesions had not shown themselves, we would resort to these drugs, if we did 
not dread their interfering with digestion and destroying the strength and 
vitality ; and just as we find the strength and vitality well preserved, do we 
feel justified in using these remedies. Take, for instance, a case of croupous 
pneumonia, passing into chronic solidification of the lung, and where you 
fear that it will pass into caseous degeneration and phthisis ; here, I think, 
you will find mercury, associated with alkaline expectorants, very useful. 
It may be given in the following combination :— 
R. Hydrarg. bichloridi gr. -fa -g-g. 
Ammonii chloridi gr. v-x. MEDICESTE. 
This may be given dissolved in syrup of acacia, or some other vehicle. 
Instead of the muriate of ammonia you may substitute the iodide of potassium 
in doses of from two to four grains. In cages, then, that have a marked in- 
flammatory beginning, particularly if attended with a considerable amount 
of solidification, which becomes more or less permanent, and where you fear 
that the exudation will pass into cheesy degeneration and terminate in 
phthisis, you will find counter-irritation and the use of mercury and iodide 
of potassium of extreme value, associated, of course, with the most minute 
attention to hygiene ; for we must not forget, while we are trying to remove 
this local effect by drugs, that the ultimate result will depend upon the main- 
tenance of strength and constitutional vitality. 
You will more rarely be led to employ mercury in catarrhal pneumonia 
threatening to pass into phthisis, than in croupous pneumonia ; still, there 
are a number of cases of a catarrhal character where the local signs will 
remain obstinate, and there is a limited patch of solidification, where the 
general strength is not much impaired and other remedies have failed, in 
which minute doses of mercury may be used with great advantage. In such 
cases I usually employ the protoiodide of mercury in minute doses, one-eighth 
to one-sixth of a grain, associated with a vegetable tonic, as the extract of 
gentian, or nux vomica. I do not think that minute doses of mercury given 
in this way exert any very depraving effect upon the constitution and nutri- 
tion, while I am satisfied that they greatly favor the absorption of inflam- 
matory products, whether croupous or catarrhal, which will not yield to 
simply alkaline and resinous expectorants. But I are treading upon 
delicate ground in the use of these powerful remedies, and I do not mention 
them except with the most strenuous caution, that they should only be used 
under the most watchful supervision, and in carefully selected cases. 
We have as other remedies favoring the removal of these products, the 
alkaline expectorants. Of these, muriate of ammonia is at once the most 
accessible, the most used, and as good as any other. It may be given in 
pretty large doses without interfering with the digestion. It enters into the 
composition of a great many cough mixtures ; and just here let me say, in 
regard to cough mixtures in phthisis, that I think, as a rule, they are better 
omitted. I do not know what good is to be done by giving the patient large 
quantities of syrup of tolu, of squills, or of senega. If the patient has a bron- 
chitis with his phthisis, and if there is a large quantity of ropy mucus, 
keeping him constantly coughing and disturbing his sleep at night, you may, 
for a time, employ these stimulating and somewhat nauseant. expectorants ; 
but such remedies as these do not possess any decided alterative effect upon 
the diseased lung tissue, while we know that they lessen appetite and inter- 
fere with digestion, and they should be therefore used only for the temporary 
purpose of relieving the bronchitis. If we are to get any benefit from 
remedies in phthisis, I thing that they must be given in a simple form and 
in pretty solid doses. 
We now come to a question closely connected with this, that is, the use of 
opium in connection with expectorants and alteratives. I think that opium 
should be avoided as long as possible in phthisis. Undoubtedly, the con- 
tinued use of opium, even in small doses, is injurious to digestion and nutri- 
tion ; but there are certain conditions that call for its use. These are a 
tendency to diarrhoea, intense irritability of the air passages, constant irrita- 
tive cough, extreme nervous irritability and wakefulness. These, particularly 
if connected with marked febrile action, are much benefited by minute doses 
of opium. Opium is to be used, not as a remedy for phthisis, but to meet 
certain definite indications, and its use is to be discontinued as soon as the 
indication has been removed. 
Returning to the alterative expectorants, there is a very good preparation 
in the market, known as the compound syrup of the liypophosphites. I refer 
to the preparation without iron. This is a combination of the hypophos- 
phites of soda, magnesia, and lime, with free hypo-phosphoric acid. It is a 
tonic, stimulating the digestion, and at the same time, I think, exerting a 
favorable action on the epithelial cells, softening the secretions and render- 
ing expectoration easier. This preparation will often be well borne by the 
stomach when all others do not agree. 
The other alterative expectorants are drawn from the class of resinous 
substances. The most useful of them being tar, carbolic acid, and yerba- 
santa. Purified tar, taken either in emulsion or in capsules for a long time,. 484 
MEDICINE. 
in cases of chronic catarrhal phthisis, is often well received by the stomach, 
stimulates digestion, and, I think, exercises some alterative action over the local 
disease. It is evidently absorbed, for its odor can he recognized in the vari- 
ous secretions, and if its use is continued for a long time, it may, in its excre- 
tion from the lungs, modify the local disease. This is also true of carbolic 
acid, hut its effect is not as good as that of tar. 
The best of this class is, perhaps, yerba-santa. This is a remedy lately 
introduced. It is the eriodyction glutinosum, a native of and indigenous to 
California, and furnishes a resinous extract. It may be prescribed in the 
form of the fluid extract, and it possesses in a high degree the power of tur- 
pentine and copaiba. It is non-irritating to the stomach, stimulates the 
appetite, may he given in full doses without causing disgust, and probably 
exerts a mild local alterative action. When you think it not advisable to 
employ mercury and iodide of potassium, you may use a combination some- 
thing like this : 
R. Ammonii, chloridi iij 
Ext. eriodyctionis, fld f. 5 j 
Syrupi pruni virg., q. s. ut. ft f. % ij. M. 
Sig. A teaspoonful every three or four hours. 
If necessary one grain of muriate of morphia may be added to this com- 
bination. 
The old expectorants, as squills, senega, etc., I would relegate to a back 
.group, to be used only for occasional attacks of bronchitis. 
I have now alluded to the most important remedies for the treatment of 
phthisis. I will allude to only one thing more in conclusion. Sometimes, 
after you have pursued this treatment as long as possible, you find that the 
general health remains pretty fair, the local disease remains about the same, 
floes not tend to spread through the lung, a cavity has perhaps formed, puru- 
lent expectoration is still kept up, and the patient’s strength is slowly being 
worn out, but yet your remedies do not seem to arrest the disease. Under 
such circumstances, local treatment is very desirable, and after inhalations 
had been tried and abandoned, I should resort to another form of local treat- 
ment, by the introduction of a hypodermic needle through the chest walls, 
and the injection of stimulating substances into the diseased spot. This plan 
of treatment I consider only applicable in rare cases. The group of cases in 
which intei-pulmonary injections are to be used is very circumscribed and 
well defined. 
It includes only those persons who have a local circumscribed spot of dis- 
ease which does not disappear, and particularly if a cavity has formed, whose 
general health is still fair but is slowly breaking down, and where hygienic 
and therapeutic means have been tried without success. These are the cases 
in which inter-pulmonary injections may be used with benefit and without 
risk to the patient.—Medical and Surgical Reporter, July, 1880, p. 89.