THE TREATMENT OF ADVANCED (HOPELESS) CASES OF PHTHISIS BY EDWARD O. OTIS, M. D„ Visiting Physician to the Free Home for Consumptives. Reprinted from the Boston Medical and Surgical Journal of June 20, 1895. BOSTON: DAMRELL & UPHAM, PUBLISHERS, 183 Washington Street. 1895. S. J.. PARKHILL & CO., PRINTERS BOSTON THE TREATMENT OF ADVANCED (HOPE- LESS) CASES OF PHTHISIS.1 BY EDWARD O. OTIS, M.D., Visiting Physician to the " Free Home for Consumptives." It is human nature to evince a more lively interest in any undertaking which offers a reasonable hope of success, than in one in which the result is inevitably failure. This is true in medical work as well as in other departments of labor. The acute or chronic disease which possesses the possibility of a cure natu- rally excites in the physician that eagerness of the chase, that enthusiasm in its treatment which the hopeless case does not. Every true physician, how- ever, with love and sympathy for his kind, recognizes the duty of employing the same conscientious care in the treatment of his hopelessly sick patients as in that of those who offer the possibility of a cure. " Here it is," says Musser,2 " that the exercise of the high and holy qualities typified of old by the Master Physician are essential." Moreover, quite as much skill and judgment are often required in the care of the former class; and the experience one gains is not only of ex- ceeding value but available in any and all varieties of medical work. In this climate and region, advanced cases of phthi- sis are by far the most common of this hopeless class. Every general practitioner has his share of them. They are long drawn out and possess an infinitude of ills, and demand fertility of resources and a large knowledge and skilful use of therapeutic expedients. 1 Read before the Clinical Section of the Suffolk District Medical Society, March 20, 1895. 2 The Treatment of the Final Stage of Phthisis, J. H. Musser, Medical News, Philadelphia, October 15, 1887. 4 with cod-liver oil when no fever existed, and it has seemed to me that this combination not only assisted the appetite but the digestion as well. As to alcohol, I have used it freely in its various forms. Necessary, as a rule, in all stages of this disease, it is especially so in the advanced stage. I have found whiskey, brandy, and the malt liquors the most generally serviceable. III. Fever. - The fever of advanced phthisis is generally the result of septic absorption from suppurat- ing cavities or foci, and unless it produces unpleasant symptoms it is my experience that direct treatment is uncalled for, and is a menace to the already weakened heart. The inunction of guaiacol has been tried for this purpose and it does produce a most marked and rapid reduction in temperature but at the same time a depression which is often alarming, and the same dan- ger exists to a less extent in the use of all the coal-tar antipyretics. The patient with fever should be kept in bed and free from excitement, given easily assimi- lable liquid nourishment, and from one-half to one hour before the expected rise of temperature a glass of Cognac and water or strong wine. This is the plan pursued at the Sanitarium of Gbrbersdorf, and generally by the German specialists in this disease. An ice-bag over the heart is much used also by the Germans, but my limited experience is in accord with that of Wolff, that seldom does any definite result follow its use.3 If the fever has daily exacerbations and is productive of much discomfort, we are obliged to have recourse to some direct anti- pyretic : antipyrine, thallin, antifebrin, salicylate of soda or phenacetine may be used, but cautiously. Daremberg4 with the characteristic French enthusi- 3 Pie Moderne Behandlung der Lungenschwindsucht, von Dr. Felix Wolff, 1894. 4 Traitement de la Phthisic Pulmonaire, Dr. G. .Daremberg, 1893. 5 asm, says the treatment of the fever of tuberculosis was revolutionized when Knorr discovered antipyrine, but few of us, I think, would agree with him. The antithermic, he says, should be used to prevent the rise of temperature rather than to lower it after it has risen, and consequently should be given three or four hours before the expected rise or exacerbation. Of the various antipyretics mentioned perhaps phenacetine is the least harmful and given in small doses as Yeo5 recommends, two or three grains in combination with hydrobromate of quinine two to four grains. When antipyrine is used and there is an inclination to sweat- ing, Szekely 6 advises the use of atropia or agaracin half an hour before the antipyrine is given. It is also advised to give it an hour before, or two hours after eating. A preparation known as pyretine, the compo- sition of which is unknown to me, and which was first called to my attention by my colleague, Dr. Fillebrown, has given me as good results with as few evil effects as any of the antipyretic group. Salicylic acid and salicylate of soda so highly extolled by Jaccoud7 for the fever of phthisis, is especially useful, says Szekely, in the fever of resorption (septic). It should be given, he says, in the late evening, and to avoid the annoying ringing in the ears, combined with ergot. My expe- rience with it, however, has not been very satisfactory. If the fever is continuous no antipyretic is of much avail, but if used, should be given before the fever has reached its height, otherwise sweating and vomiting may be produced. IV. Sweating. - This is not an infrequent occur- rence in advanced phthisis, and is another of the symp- toms of the septic condition which prevails so largely 5 Manual of Treatment, L. Burney Yeo, 1893. 6 JL»ie Behandlung der tuberkulosen Lungenschwindsucht, von Dr. August von Szekely, 1894. ' Curability and Treatment of Pulmonary Phthisis, Jaccoud, 1885. 6 as I have said in the latter days of the disease. Sim- ple means will often serve to modify or avert this troublesome symptom ; a glass of milk with two or three teaspoonfuls of brandy at bedtime, together with gentle friction, either dry or with alcohol or vinegar and water. The drugs for this symptom are numer- ous : atropia, ergot, picrotoxine, oxide of zinc, cam- phoric acid, chloralose, extract of Coto bark (strongly recommended by Szekely), and agaracin. Of all the antisudorifics I have used, agaracin has been the most satisfactory, given in doses of one-twelfth of a grain or larger; as its action is slow it must be given early. Atropia is efficient, but its after-effects are not always agreeable, and after my favorable experience with agaracin, I have abandoned its use. V. Cough. -No one symptom is so distressing to the patient and all about him as his cough; it harasses him by day and renders his nights wretched. From the very nature of the conditions he must cough much, for the material secreted from the various diseased areas is constantly collecting and must be expelled. This constant coughing keeps the mucous membranes of the upper air-passages in a state of continual irrita- tion ; so that the poor sufferer is subjected to a two- fold stimulus to cough, one from below and the other from above. Cough he must, sufficiently to expel the secretion; but cough he does, as a rule, far more than is necessary to accomplish this. Now this unneces- sary and useless coughing can, to a greater or less ex- tent, be restrained by proper training. One must es- tablish a coughing method, and learn how to cough with effect and economy of strength, and to restrain the dry, unproductive cough. Daremberg speaks of taking lunch at Falkenstein with Dettweiler and his one hundred and fifty phthisical patients, and not hear- ing a cough ten times in three-quarters of an hour. 7 In expressing his wonder at so little coughing among so many tuberculous patients, Dettweiler replied that he taught his patients not to cough, by telling them that when they itched in public they did not scratch, and that cough without expectoration was a scratching of the throat which itched, and, therefore, they should not scratch the throat in public. The medicinal treatment of the cough, and in this stage it must be treated medicinally, includes the whole materia medica pretty nearly; but opium in some form is the one drug upon which we must chiefly rely. As some one has said, " Without opium the treatment of phthisis would be impossible." My expe- rience coincides with that of Wolff,8 that codeia is the most useful form of this drug. It does not disturb the stomach as other forms of opium often do, and it quiets the cough. After a trial of a variety of cough prepa- rations, I obtained the most satisfactory results when almost every patient in the hospital was put upon this drug. I used a watery solution in the proportion of 1 to 100. It can be given frequently, and a couple of teaspoonfuls of the solution at night will generally produce a good night's rest. In most cases of advanced phthisis there is an irri- table condition of the mucous membranes of the upper air-passages, the pharynx and larynx which, from the slightest cause, produces a cough of irritation. Local applications will aid us here. If the cough is caused by laryngeal irritation sipping ice-water will sometimes calm it. If the pharynx and larynx are in a chronic irritative catarrhal condition, we can first clean the surfaces by some alkaline solution like Dobell's, or warm borax and water, and then make such applica- tions as cocaine, menthol, insufflations of morphia, iodoform and starch, inhalations of balsamic vapors, or 8 Die Moderne Behandlung der Lungenschwindsucht. 8 a solution of nitrate of silver. Almost every phthisi- cal patient has a paroxysm of coughing in the morning, on arising, if he is well enough to get up, or upon tak- ing food. This is a cough of expectoration, and all we can do is to make the paroxysm as short, easy, and effectual as possible. A glass of some warm alkaline drink, Apollinaris, soda, Vichy, or Seltzer water with a little alcohol in it, brandy or rum; or a glass of warm milk and water with a little bicarbonate of soda and common salt in it, will often accomplish this. VI. Vomiting. - This is an annoying symptom after taking food; and the cause, as given by Yeo, and which seems to be reasonable, is the increased secretion in the air-passages, already in a catarrhal state, caused by the stimulus of the circulation by the food and the rapid absorption of fluid from the sur- face of the stomach. Acting on this theory, he gives about half an hour before a meal, a glass of hot milk with some alkaline water (Ems, Seltzer, or the like), with a tablespoonful of brandy or whiskey, and so favors free expectoration, just as previously mentioned in the morning paroxysm of coughing. The meal should consist of as little fluid as possible; and immedi- ately after it a few grains of pepsin, with a few drops of hydrochloric acid, is given. I have followed this plan partially with more or less success. Peter, quoted by Yeo, ascribes vomiting to the irritation of the gastric portion of the vagus by the contact of food, and just before the meal he gives a rapidly absorbable sedative such as a few drops of laudanum in a teaspoonful of water, and immediately afterwards three drops of hy- drochloric acid in water. If the vomiting seems to be caused by laryngeal irritation, local applications of astringents and anodynes can be used. If digestive disturbances seem to be the cause of it, antifermenta- tives such as carbolic acid, creosote, napthol, charcoal, 9 iced lime-water, Vichy, soda-water and the like, may prevent it. When it is an oft-recurring symptom, per- fect rest in bed and frequent feeding with a small amount of easily digestible nourishment, such as liquid peptonoids or peptonized milk, will aid greatly. VII. Pains. - The phthisical patient in this stage complains of many and various pains and aches - pleuritic, painful affections of the intercostal nerves; pains in the back, joints, abdomen, muscles, etc. The variety of local applications is great, and one after another has often to be tried: Tincture of iodine; dry heat by means of dry cloths and the hot-water bag; belladonna, in liniment or plaster; chloroform; and, what I have found perhaps as efficacious as anything, equal parts of guaiacol and glycerine painted over the painful area. If the pain is pleuritic and aggravated by respiration, and situated at the base of the chest, strapping with adhesive plaster, diagonally applied, as first suggested by Roberts, restrains the respiratory movement, and consequently stops the pain. If the pleuritic pain is at the upper part of the chest, one must have recourse to some counter-irritation. VIII. Diarrhea.-This is either septic, or due to gastric or intestinal irritation, or perhaps most fre- quently in this stage, is the result of tubercular ulcer- ation. If septic, salicylic acid or napthol may be used. When the diarrhea is not dependent upon intestinal ulceration, milk and lime-water, and tannate of bis- muth are serviceable. If tubercular ulceration exists we can only hope to mitigate it, and opium with bis- muth and some astringent have served me the best. Yeo and Szekely recommend highly extract of Coto bark; a solution of nitrate of silver can also be used per rectum. The patient must be kept quiet in bed and given some partially predigested food like liquid peptonoids or peptonized milk. 10 IX. Hemorrhage. - Hemoptysis occurs in this stage as in the earlier ones, and, in the main, requires the same treatment - perfect rest in bed, an ice-bag over the heart region, and opium in the form of mor- phia, or codeia, with the addition of ergot subcutane- ously if indicated. I believe that in the hemoptysis of this stage more or less alcohol is of benefit, con- trary to the common usage in the treatment of this symptom. Cold liquid food is always recommended, and ice. Daremberg mentions "a very useful appli- cation " which is new to me, ice to the testicles or vulva; he applies it twice a day, and keeps it in con- tact with the skin about five minutes. He mentions the case of a consumptive who always carried a box of ice with him when he travelled; he had so much confidence in this practice. In the profuse, sudden, and alarming attacks of hemoptysis in advanced cavity cases, Yeo recommends frozen compresses as " one of our best resources." X. Insomnia. - Sleeplessness is a frequent and trying symptom, not only as a result of the cough, but from the unstable, nervous condition. Some simple nourishment at bedtime, or a glass of wine or whiskey and water may produce the desired result; if not, I use some one of the non-depressing hypnotics - tri- onal, chloralamid or sulfonal. The two former I have found the most satisfactory, in doses of ten to fifteen grains. XI. Edema. - Edema of the lower extremities often ushers in the final event, as if the poor sufferer's cup of woe was not full. I know of nothing better for this painful symptom than a comfortable position in bed, gentle friction with alcohol and water, a light bandage, or wrapping the limb in some soft material like cotton or woollen. XII. The mouth, tongue, and lips need attention 11 at this stage. For the apthous condition of the mouth and tongue frequent cleansing with some alkaline wash, such as Dobell's solution or a boric-acid lotion is comforting; tincture of myrrh or menthol in almond oil can also be used. For the dry, parched lips, cam- phor-water and glycerine, benzoated oxide of zinc ointment, simple glycerine or cold cream. XIII. This stage is accompanied with more or less anaemia, and calls for iron when it can be borne. I have used quite extensively a preparation known as pepto-mangan, first called to my attention last winter by Dr. von Ruck, of Asheville. It is easily assimi- lated, causes no disturbance of the digestion, and can be continued for a long time. XIV. The heart sympathizes with the general con- dition, and cardiac debility and irritability is a constant concomitant of this stage. The pulse is feeble, quick, easily compressed. For this condition I have found strychnia invaluable, and during my service the major- ity of the patients are taking it. It is not only a most efficient heart tonic, but it influences favorably many of the other symptoms. It is an admirable tonic in anorexia, relieves constipation, is a good respiratory stimulant in dyspnoea, will often relieve vomiting, moderates the cough, reduces nervous irritability, and relieves many of the various pains of this stage of the disease. Indeed one is inclined to share the enthu- siasm of Mays,9 who places this drug third in impor- tance in the prominent measures which he employs in the treatment of this disease, putting only physical rest and nutritious food before it. Such in brief seem to be the main features in the treatment of advanced cases of phthisis. It is neces- sarily a symptomatic one, and I have only attempted to deal with the more common and prominent symp- 9 The Strychnine Treatment of Pulmonary Consumption, by Thomas J. Mays, 1894. .Reprint. 12 toms. Their variety indeed is legion, taxing to the utmost the skill and patience of the physician; but he has his reward in the satisfaction of knowing that he has at least smoothed the downward way of the weary traveller, as well as gained for himself added skill and experience in professional work. It is a losing fight at the best, and both the patient and physician know it; but the gratitude of the one, and the satisfaction of the other in duty well and patiently performed, mitigates the bitterness of defeat. " The physician who treats phthisis," says Dett- weiler, " needs the greatest patience and self-sacrifice, and genuine sympathy for the sufferer, and must, therefore, as Nothnagel beautifully expresses it, ' Auch ein guter mensch sein, soil er ein guter Lungenarzt sein.' " THE BOSTON - MedicalandSurgical Journal. A FIRST-CLASS WEEKLY MED~iCAUNEWSPAPER7~ PUBLISHED EVERY THURSDAY. Two Volumes yearly, beginning with the first Nos. in January and July. 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