ANNUAL ADDRESS BEFORE THE MEDICAL SOCIETY COUNTY OK ONEIDA, DELIVERED JULY 11, ISC.r., BY (\ B. (iOVENTIIY. M. D PRKS1PKNT OF THE SOCIETY. PUBLISHED BY THE SOCIETY. !?£'-'< I'TICA, N. V. ROBERTV, BOOK AM) JOB PRINTER. 60 GENESEE STREET 1865. M '. , % . . ADDRESS. Gentlemen of the Medical Society: T.v the regulations of the Society, it becomes the duty of your presiding officer to address the Society on some medical subject In selecting a subject purely practical, I do not hope t<> instruct or enlighten the older members of the profession who have had the same experience as myself, but I see around me many young men who are just entering upon the trials of professional life. Ii an experience of forty years enables me to relieve them of some of those trials, I shall feel amply rewarded. The subject which I propose for your consideration, is that of Tubercular Phthisis. In the winter ol' 1(>, 1 read before the State Medical Society, a report on Phthisis Pulmonalis, The great length of the report compelled me to abridge my observa- tions on the prevention and treatment, and my present remarks maybe considered a supplement to what was then said; some repetition will, however, be unavoidable. Before proceeding to the consideration of the subject of Pre- vention and Treatment, a few preliminary observations will be U What' is Tuberculosis? It consists in the deposition in the tissues of organs and on the surface of membranes of small bodies, [\vA appearing simplv as a thickening and opacity of the part. then of small bodies termed miliary tubercle, which may remain .fitionarv or unaltered, or may gradually increase in size, be- come yellowish or cheesv, and finally soften and be gradually absorbed, or more frequently inflammation and ulceration occur, when they may be discharged. ORKHN. Pathologists differ in opinion, whether these small bodies con- ^t ^ original nutritive matter which is imperfectly organized, or of effete matter which the system is incompetent to eliminate. 4 or of actual transformation of tissue; it is, however, admitted that in either case it is an evidence of want of vitality or vigor in the system. 1st. Tuberculosis is a constitutional, and not a local affection. Tubercles are found in almost every tissue and organ, as the membranes of the brain, the lungs, liver, peritoneum, intestines, &c. 2d. Tuberculosis is hereditary. Dr. Armstrong in his Lec- tures says he has found tubercles in children at the breast, who had died suddenly of acute disease. No doubt exists that a peculiarity of constitution which predisposes the offspring to the disease, is transmitted from parent to child. 3d. Tuberculosis may be produced, de novo, where there is no hereditary predisposition. 4th. Tubercles may go on increasing and multiplying, or their increase may be arrested, and they remain an indefinite period of time, with no further disturbance of health than what arises from mechanical obstruction ; this obstruction is of itself seldom a cause of death. I have met with one case of the kind; in this instance both lungs seemed masses of miliary tubercles, but there was no appearance of inflammation, or indications of soft- ening. The following changes it is supposed may take place in tuber- cles, when their progress is arrested and inflammation prevented. 1. Liquefaction; 2. Absorption; 3. Fatty degeneracy, granular degeneracy, calcarious degeneracy, shriveling, pigmentum de- generacy, sequestration. We have no positive proof of the ab- sorption of nascent Tubercles. When inflammation supervenes in the lungs of a patient having tuberculosis, and terminates in ulceration, it constitutes Tubercular Phthisis; it should, however, be remembered that Pneumonia occurring in tubercular lungs, is usually more limited in extent, being usually or frequently con- fined to one lung, or a single lobe of the lung. The remote or predisposing cause of tubercular phthisis, is a tubercular condition of the system. The causes of tuberculosis, are: 1. Hereditary predisposition. 2. Insufficient or unwholesome food. 3. Insufficient clothing. 5 1. A variable and damp climate. i>. (Confinement in dark, ill-ventilated, and crowded apartments. <». Irregular habits. 7. Kxhausting drains, exhausting discharges, too long nursing S. Certain occupations, as stone cutting, kc '.). iv iiausting mental application and anxiety of mind. The immediate or exciting causes of tubercular phthisis, are all those: causes which tend to produce pneumonia under other circumstances. PREVENTION. It is an old and trite maxim, that an ounce of prevention is better than a pound of cure. This is particularly true in regard to phthisis; the general impression, however, seems to prevail that the business of the physician is to cure, not to prevent disease, and he is seldom consulted in regard to what is really most important, viz : prevention. Formerly it was customary to a considerable extent, for families to employ a family physician, who was consulted on all occasions connected with the health of the family. Unfortunately for the patients, this practice has in a measure become obsolete, and the practitioner is often called to attend to a particular case without any previous knowledge of the constitution or idiosyncrasies of his patient, and always ready to surrender him to another practitioner whenever the caprice of the patient, or the influence of kind and sympathizing friends should require it, and it not unfrequently happens that two or more physicians are at the same time attending different members oi' the same family. It is nevertheless the duty of every practitioner to labor to prevent disease, though the labor is not rewarded by honor or emolument. It is certainly to the credit ol' our profession, that the most strenuous laborers in the cause of the prevention of disease, and the preservation of the public health, have been physicians. Mothers who are con- sumptive should not nurse their children, but a healthy wet nurse should be substituted for the mother: if this can not be done, the child should be weaned as early as the seventh or eighth month, and nourished on healthy cows" milk. The child should be carefully protected from the inclemency of the weather, but should not be confined to the house; on the contrary, they 6 should be permitted to spend as much time as convenient in the open air, should retire early to bed, and be up in season in the morning. The food should be light and nutritious, but not stim- ulating. In such children more care is necessary to prevent, than to stimulate or excite mental application ; they should not be sent early to school, and the parents should sec that the mind is not over-taxed. Girls who are delicate, if constitutionally in- clined to consumption, should be kept from school from the age of twelve to HI teen, the preservation of health at this period is the most important consideration, and all the energies of the system are required to sustain the rapid growth and development which usually take place at this age. Nutritious food should be used, warm clothing, plenty of exercise in the open air, cheerful com- pany, and freedom from care and anxiety of mind are important. Young persons who are predisposed to phthisis, should be cure- lul in selecting a profession or occupation that would not confine them too much, or be attended with much anxiety of mind. Formerly it was customary, if a boy was feeble or delicate, to give him a profession, or put him in a store, or to some seden- tary mechanical M.-eijpation, on the ground that he was not strong enough for a farmer. Directly the reverse should have been adopted; if a boy is feeble or delicate, an occupation should be selected which would tend to improve his physical health and strength. Many young men have no doubt fell victims to this mistaken idea. When the predisposition is strong, or a person is actually threatened with the disease, a change of customary occupation, and even a change of climate may be useful. Traveling, when the person can indulge in it riding on horseback, systematic exercise of any kind in the open air, carried to the extent of moderate fatigue, is useful. If the appetite is good, the bowels regular, and the other functions of the system properly performed, the patient needs no medicine- The food should be nutritious but not heating or stimulating; ardent spirits of every kind should be avoided. They should be warmly clothed to protect them against the sudden changes of the weather, and should be particularly careful to guard against all those causes which usually produce influenza, or what is usually termed taking cold: if, notwithstanding their care they should contract a cold, they should at once apply for relief, and not permit it to run on without treatment. / It is a mooted question whether consumption is contagious. With the ancients there was no doubt on the subject, and even now in the southern part of Europe, the belief in its conta- gious nature is so strong that they burn the bed and bedding of consumptive patients. Modem writers have mostly denied its contagious nature; but Dr. Armstrong says that he is satisfied. that either from the irritating effects of the effluvia, or its pois- onous character, it tends to produce the disease. Consumption is certainly not contagious in the same sense as small pox, measles, &c, but that it may be communicated or produced by intimate intercourse, I have no doubt. We all know how common it is for whole families to be carried off, one after another, by this disease ; it may be said that they were all probably suffering from the same predisposition and tendency to disease, and that the fatigue of nursing, broken sleep, and anxiety of mind, were sufficient to account for the circumstance, without the aid of contagion. When a pupil, I was cautioned by my preceptor. against making post mortem examinations of consumptive patients, for fear of contracting the disease. The late Professor Willoughby told me that his brother, who was a stout healthy man, caught the disease by nursing a sick daughter. 1 have seen so many cases where husband or wife have evidently con- tracted the disease, the one from the other, where there was no previous predisposition, that I have no doubt of its being com- municated. Where there is a predisposition to the disease, the immediate connections should never nurse a consumptive patient. The anxiety of mind, the disturbed rest, and confinement, would all tend to produce the disease, aside from contagion. In no case should they be permitted to sleep in the same bed, and care should be taken that the apartment is well ventilated. What- ever breaks up the general strength and health, tends to develop tubercles, if they previously existed, or to produce them, F INFLAMMATION. It has been satisfactorily established that tubercles may be generated independent of inflammation ; there is little doubt. however, that they may be increased or developed by inflamma- tion; where a predisposition exists, that inflammation hastens their development and softening, when present, and consequently constitutes the principal danger to' be guarded against. Dr. Hall says : " Pathological observation teaches us that all that is mischievous in the course of tubercles is inflammatory: that if no inflammation arise, or very little, tubercles have a natural tendency to soften so slowly that they soften safely, and undergo curative transformations; that on the contrary, when attended with much inflammation, their softening is rapid, extensive, and dangerous." Again he says: "In no case are we justified in anticipating positive benefit from the supervention of accidental attacks of inflammation; on the contrary, we shall always best promote the benign form of inflammation, by calming down, when present, and avoiding all the causes of the irritative form. If we can master the inflammation around tubercles, we can save our patient When the patient dies it is invariably because in- flammation has mastered art"* Dr. James (Mark says : " Pneumo- nic inflammation is one ol' the worst evils that can befall a patient laboring under tubercular disease ol' the lungs, as it never fails lo increase the mischief; and frequently converts that which was latent, and might have long remained so, into active disease." Dr. Hall says : "When tubercles exist, whatever the stage, nature is adequate to the cure, provided there be time enough allowed, • Ou the Curative Processes in Pulmonary Tubercles, by V. Radcliff Hall, M. D.. Pliysii-ian to the Hospital lor Consumption. Mcliv-Chirurgieai Hiviev for April, IS.'.tV B 10 which implies that fatal allied diseases elsewhere do not arise; that a check is put to the increase of the tubercles ; that inflammation is kept down, and the strength kept up. For the successful treat- ment of every stage of phthisis, the indication is to gain time and tone." TREATMENT OF THE INFLAMMATORY STAGE. The symptoms of consumption are unfortunately too familiar to every practitioner to need description ; but the transition from the first to the second stage is often so slowr, so insidious, and at the same time so important as to require a brief notice. In most cases the patient refers to some particular exposure, when as is usually termed, he took cold, as the commencement of the disease. In other cases there is no marked transition from apparent health, a slight hacking cough without expecto- ration, slight wandering pains about the chest, slight ema- ciation and shortness of breathing on exertion, and often a slight flushing of the face in the after part of the day. On examination, the pulse will usually be found varying from ninety to one hundred, the respiration somewhat hurried; some dullness on percussion, and the respiratory murmur absent or defective in some portion of the lung, most frequently in the upper portion of the left lung. In this stage of the disease, patients seldom have any apprehension of their danger; they say they have taken a slight cold and the cough continues too long, or has become troublesome. In some cases the accession of inflammation is more severe, the cough harassing, the pain acute, the breathing hurried and oppressed, and the pulse varying from one hundred to one hundred and twenty-five in a minute.^ The indications of treatment under all these circumstances arc the same, viz., to arrest the progress of the inflammation, if pos- sible, and with the least expenditure of strength, and thus pre- vent the occurrence of the third stage. The activity and energy of the treatment should depend upon the urgency of the disease. It should be remembered that we have no known means, and consequently no hope of removing tubercles from the lungs ; at the best the patient would remain under their influence, and consequently the inflammation should be relieved with the'least 11 possible expenditure of strength, (ieneral bleeding is seldom if ever necessary or advisable; local bleeding may sometimes be necessary, when the inflammatory action is high or the pain very acute. Our principal reliance must be on rest, counter irritation and anodynes, to allay the NS. There are certain complications liable to occur in the progress of the disease, which require some modification in the treatment, and demand a separate notice. HEMOPTYSIS. The obstruction to the pulmonary circulation caused by the presence of tubercles, often gives rise to congestion, and this congestion to hemoptysis, and although it is not a necessary attendant on tubercular phthisis, and that hemoptysis is not always connected with a tubercular condition of the lungs, yet tins .onnection is so common that the occurrence of hemoptysis 15 is always a cause of alarm, both to the patient and his friends. Hemorrhage from the lungs may occur at any stage of the disease ; not unfrequently it is the first s}rmptom to create alarm. Usually it is moderate in quantity, recurring from time to time, and is caused by the exudation of blood through the mucous membrane of the bronchia. It seldom arises from the rupture of a blood vessel, as was formerly supposed, except in the advanced stage of the disease.', when it may arise from the destruction of a blood vessel, in which case it is often fatal. When it occurs early in the disease, and is attended with febrile excitement, with a full, strong pulse, general or local bleeding may be necessary, with absolute rest, in a horizontal position. cold drink, and sinipisins over the chest, may be necessary. II the discharge is not promptly arrested, dry cupping over the chest, and the internal exhibition of nitrate of potash, in doses of from five to ten grains may be used, either with or without the addition of one-eighth of a grain of tartar emetic, repeated once in two or four hours. I f the patient is feeble, and harassed with cough, instead of the former a powder of morphine and ipecacu- anha may be substituted. If notwithstanding these means, a slight bleeding continues to recur, we may substitute a pill of acetate of lead and opium, or if the discharge seems passive, and is not attended with febrile excitement, the elixir of vitriol, or the muriate tincture of iron may be given. So long as the discharge is moderate in quantity, and does not produce prostra- tion, we need not be particularly anxious about stopping it. as it often operates in the manner of local depletion in relieving the congestion ol' the lungs. When the pulse is very frequent, digitalis" is sometimes used with advantage; turpentine has been highly extolled by some writers. Absolute rest at first should be enforced, but if the difficulty is prolonged, or contin- ues to recair from time to time, and the strength will admit, the patient should ride out, or take moderate exercise, every day. There need be no fear that moderate exercise in the open air would increase or aggravate the hemorrhage II EOT I C FEVE H. Too chills, the fever, and the night sweats, are intimately con- nected, constituting only different stages of the same affection. 16 Sometimes instead of a distinct chill there is only a sense of coldness, this is followed by flashes of heat, burning in the palms of the hands, and increased frequency of the pulse, which terminates at night in a profuse and exhausting perspiration, which instead of relieving, leave the patient in a more languid and feeble condition. A variety of proscriptions have been made for this distressing complication. The most efficient in my hands has been the powder of morphine and sulphate of quinine, either with or without the addition of the elixir of vitriol, and sometimes the addition of a table spoonfull of brandy on going to bed. A powder of morphine or opium and sulphate of qui- nine taken a short time before an expected chill, will often sus- pend or lessen its violence and with it the fever and perspiration. PLEFIllTIO SYMPTOMS. It frequently occurs in the progress of the disease that the patient is harassed from time to time with severe pains in the side, which are supposed to arise from the extension of inflam- mation to the pleura. A mustard plaster to the side will often afford relief. It may be used and an anodyne powder given at the same time. If the suffering of the patient is not relieved by these means, a blister may be applied. NAUSEA AND VOMITING-. Slight nausea and vomiting is sometimes caused by the effort to expel the excessive secretion from the fauces, and without being preceded by or followed by nausea, and this is of little consequence. The stomach sometimes becomes so irritable, that the patient is unable to take or retain food, and unfortunately this difficulty is not easily controlled by medicine. Confining the patient to the simplest kinds of food, with counter irritations over the stomach, I have found most successful. I have some- times found an advantage in giving half a drop of creosote from time to time, and sometimes in confining the patient to milk, or milk wuth a little lime water. AVhen very bad the patient should take a tumbler of milk before rising in the morning, and remain quiet for some time after drinking it. Chloroform, naptha and prussic acid, have all been recommended for this distressing complication. 17 DIARRHEA. When the disease has been of long continuance, the tubercles situated in the mucous membrane of the lower intestines often become ulcerated, and give rise to severe lacerating pains, and diarrhea and tenesmus. This complication seldom occurs except in the advanced stage of the disease, and when it occurs is not only very distressing, but from the profuse discharges, and dis- turbance of the rest, tends to exhaust the patient and hasten his dissolution. All that we can hope to do, is to mitigate his suf- fering, and postpone for a short time the fatal termination. Opium, either alone or combined with acetate of lead, or alum, or sulphate of copper, or tannin, are our principal remedies. At the same time the patient should carefully abstain from all food that would be likely to increase the irritation. The question may be asked, do you believe consumption can be cured ? If by this is meant whether we have any medicine or medicinal agencies by which tubercles can be removed from the lungs, or extensive ulceration of the lungs be made to heal. I answer, no. Many medical men contend that the physician never cures a patient in the ordinary sense of the term. The word (cure) originally and strictly means to care for or nurse, and the old maxim was, " medicus curat natura sanat morbus:' It is a law of the animal economy, that wounded or injured parts should be re- stored The surgeon in treating a wound or fractured limb can- not heal the wound, but only see that the necessary conditions are furnished, in order that the known laws of the economy will restore the part; if he does this I see no impropriety in the term that he cures the patient, i. c, he furnishes whatever is necessary for his restoration. If, then a physician cannot cure a consumptive patient, what can he do? I will answer: 1 When there is a hereditary predisposition, he can, by proper care and hygienic means, frequently prevent the devel- opment of the disease. , •> When tubercles nave been produced by unwholesome occupation, improper nourishment, or a want of PJ* c« can often by a change of occupation, a change of ohma* a nourishing diet, arrest the further deposrtmn and development IS of the tubercles, prevent inflammation, and preserve comlortable health. Dr. Radcliff Hall, before quoted, says: "'flic mere presence of abnormal deposits in the lungs, even to a very large extent, provided irritative inflammation is not set up, interferes surprisingly little with the general signs of health. It is quite compatible with ease and comfort in breathing, unless perhaps. under extraordinary exertion, with a good amount of muscular vigor, and with a fair performance of general nutrition." Again he says: "Conclusions derived from analogy and other consid- erations, support the conclusion that the mere presence of tuber- cles in the lungs, so long as they are unattended by inflammation. is compatible with the appearance of health, and with a fair share of the reality also. Could we manage to keep existing tubercles quiescent, we should fulfill the first condition of safety." 3. When inflammation has supervened, we can often arrest its progress and thus save the patient from the danger from sup- puration. 4. When suppuration has occurred, if it is limited to portions of the lungs, we can often sustain the strength until the recu- perative powers of the system have time to act, and life with tolerable health be preserved. 5. Even in those unfortunate cases that necessarily prove fatal, the physician can do much to relieve some of the most distress- ing symptoms, relieve the suffering, and prolong the life of his patient. It will be seen from the above observations, that we have no specific or panacea for tubercular phthisis, but that by our improved knowledge of the pathology of the disease, we may, by pursuing a rational course, save many lives which would be lost under a different course.