Copyright
Beverley Robinson.

Essays on clinical medicine online

. (page 2 of 20)
Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 2 of 20)
Font size
QR-code for this ebook


3j.


Alcoholis ....


. ad.


gss.— M.



I desire now to direct attention to the tabulated statement of the
results obtained by me from the creasote treatment of pulmonary
phthisis.



1 Antiseptic Inhalations in Pulmonary Affections. By J. St. Clair Coghill, M.D., Brit. Med.
Journal, 1881, vol. i. p. 841.

2 Loc. cit., p. 308.

3 The chloroform in this formula was originally added by me on account of its value as a
preventive of cough. I am glad to And that, according to Salkovvski (Deutsche med. Wochen-
schrift, April 19, 1888), it is also most available, from its volatility, amongst the ethylic chlorine
compounds, as a respiratory antiseptic.



CREASOTE IN PHTHISIS PULMONALIS. 17

The total number of cases which have taken creasote mixture and
used creasote inhalations (simple or compound), to which I have refer-
ence, are: At the New York Hospital, out-patient department, 142;
in private practice, 19. Besides, I have an interesting letter from my
late house physician, at St. Luke's Hospital, Dr. Charles II. Collins,
who, at my request, looked carefully over the records of that institution
and found that during the last two years about 150 cases of phthi-i-
pulmonalis have there been put on the creasote treatment, and a large
percentage of these cases he has been able to watch. The points of
interest observed by Dr. Collins, and the reflections made by him in his
letter to me I will reproduce, after giving an analysis of my own obser-
vations — recorded by myself with some care.

Of the total number of 143 cases seen at the New York Hospital,
there were 51 cases of pulmonary phthisis at the first stage of the dis-
ease; 18 cases at the second stage, 18 cases at the third stage; there
were also 4 cases of laryngeal phthisis, 1 case of fibroid phthisis, and 1
case of acute phthisis. The total number of cases, therefore, in which
the diagnosis is mentioned of the stage and nature of the disease, is
93 — leaving 50 cases of pulmonary phthisis in which the stage of the
disease is not mentioned. Of the whole number of cases seen at the
out- door department of the New York Hospital, 54 were females, 89
were males.

Of the 93 cases mentioned, there are 47 cases in which some notes
were made as to the effect of treatment, of more or less value. Of these
47 cases, I have arranged in tabular form such data as seemed to me to
be of any interest. I have also done a similar work in regard to my 19
private cases. From these tables I shall now proceed to take such facts
as result from their study.

The duration of time during which these cases were treated varied
from one week to two years eleven and a half months. Of these 66
cases, 45 were males and 21 females. Thirty-seven cases were affected
with the first stage in a manifest manner, as shown by the physical signs
and the rational symptoms ; in 3 cases the physical evidences of disease
were doubtful or negative, although the rational symptoms pointed plainly
to beginning phthisis ; in 6 cases there was found an evident second
stage of phthisis ; in 1 it was a question whether the case had advanced
so far as the second stage ; in 11 cases the disease had attained the third
stage ; in the remaining cases the diagnosis of the stage of disease is not
recorded.

In cases of the first stages of the disease, 24 had their cough improved,
sometimes very much, sometimes only a little; in 3 cases the cough did
not improve; in 10 cases the cough was cured. In several cases in which
the cough was improved, the sleep was quieter, and previous insomnia
evidently depended largely upon cough and expectoration ; in a few



18 CREASOTE IN PHTHISIS PULM ON" ALIS.

instances, even though the cough improved, the sleeplessness did not
improve, and evidently was independent of the cough. In those in-
stances in which the cough is stated as being cured, I cannot say in all
of them how long the cure lasted ; in some, I know, the cough returned,
but was again cured by the use of creasote in mixture and as an inhala-
tion. In many cases at different stages (first, second, and third) — 17 in
all — no mention is made of the effect of creasote on the cough. In
some of these instances it is possible that the question was not asked ; in
many of them it is probable that no mention is made, because the cough
remained stationary. What I say here for the cough, I should be
obliged to repeat for other symptoms, and I would, therefore, offer this
as an explanation where my silence shall point to it, without my weary-
ing you by similar repetition.

In 3 cases of phthisis at the second stage, cough improved either
slightly or very much. In the other cases it remained stationary ; in
no case did it increase. In 6 cases of phthisis at the third stage, the
cough improved notably in 4 ; in 1 the improvement was very great ;
in 1, instead of improving, it became worse.

As regards night-sweats at the first stage, 8 cases were cured ; 4 im-
proved ; 3 remained stationary ; in 1 case they increased ; in 6 cases the
patients never suffered from them ; in 15 cases no mention is made of
this symptom. At the second stage, 1 case was cured, 1 remained
stationary. In a doubtful case of second stage, there was great im-
provement in 1 instance. In 4 cases no mention is made. At the third
stage, 1 case was cured, 2 improved (1 greatly), 1 patient never had
night-sweats; in 7 there was no mention of them.

With respect to dyspnoea at the first stage, 15 cases were improved,
4 cured, 1 case remained stationary, 1 case never had dyspnoea; there is
no mention in regard to this symptom in the other cases. At the second
stage, 1 case was cured, 2 cases improved, 1 case remained stationary ;
in 2 cases no mention is made. At the third stage, 5 cases improved ;
in 6 cases no mention is made.

The sputa at the first stage diminished in quantity, and improved
notably in appearance in 18 cases; in 5 cases the sputa disappeared ;
in 3 cases there was no diminution in amount of sputa; in 1 case the
sputa increased in quantity; in 2 cases, in which bacilli had been found
in the sputa, later on they could not be found. In 3 cases the bacilli
were looked for merely to verify the diagnosis, and they were not looked
for later on to see if they had disappeared.

Three times the sputa did not change in appearance or quantity, but
were raised more easily. The changes in appearance of the sputa were
often quite remarkable, and from green and yellow they became white
and frothy ; less tenacious, less thick. When the sputa diminished in
quantity and were less viscid, cough decreased and sleep often improved.



CREASOTE IN PHTHISIS PULMONALIS. 19

At the second stage, the sputa diminished notably in quantity in leases;
in 1 case, although they did not diminish much in quantity, they changed
their appearance for the better and became less thick and tenacious.
At the third stage the sputa diminished much in quantity in 4 cases.

The appetite was improved in 17 cases at the first stage ; it remained
stationary in 3 cases ; in no case did it notably diminish. It improved
in 2 cases at the second stage ; in 1 case it diminished. In 4 cases at
the third stage, appetite increased. In 3 cases at the second stage, and
in 7 at the third stage, there is no mention of the effect on appetite.

In 2 cases dyspepsia was occasioned by creasote ; in one of these cases
the mixture was continued, and the dyspepsia soon improved ; in the
other case capsules of cod- liver oil and creasote were given, and had to
be abandoned altogether.

In 2 cases nausea and gastralgia were evidently caused by the creasote
mixture, which was stopped for a while. In 3 cases the medicine caused
constipation, in 1 case the constipation remained the same ; in 3 cases
the constipation was cured by creasote mixture.

In 2 cases diarrhoea was brought on ; in 1 case there was considerable
pain in the bowels; in 3 cases there .was no effect on the bowels at all;
in 2 cases the bowels became more regular ; previously there had been
alternate attacks of constipation and diarrhoea.

The effect on weight was very notable in many instances. In 18 cases
at the first stage, there was increase of weight, the amount of increase
ranging from one-half pound to twenty-five pounds. Two, three, and
four pounds' increase was quite common. One patient gained three
pounds in six weeks' treatment. In 4 cases weight remained stationary.
In 3 cases weight was lost, in 1 of these in moderate amount (about
two and one-half pounds), due to an acute attack. Previous to this
attack, weight had been stationary. In 2 cases there was a loss of five
pounds ; in 1 of them four pounds were subsequently regained by three
weeks' use of malt and cod-liver oil. At the second stage, in 2 cases
there was some loss of weight; in 1 the weight remained stationary;
in 3 cases there was no mention of it. At the third stage, there was
increase of weight in 2 cases, loss in 1, stationary in 1, no mention in 7.

In a large proportion of cases — 46 in all — no mention is made of
haemoptysis. In 11 cases at the first stage, no haemoptysis occurred
during treatment; in 3 of these cases haemoptysis had occurred pre-
viously, small or large in amount. In 4 cases a slight or very moderate
spitting of blood occurred, but in all these cases one or several hemor-
rhages from the lungs had taken place before the creasote treatment was
begun. In 1 case at the second stage, hemorrhage occurred during
treatment ; but in this case several hemorrhages took place before treat-
ment was instituted. In 5 cases no mention is made of hemorrhage.
In 4 cases at the third stage, no hemorrhage occurred either during, or



20 CREASOTE IN PHTHISIS PULMONALIS.

before treatment with creasote. In 7 cases no mention is made of it.
It seems probable, therefore, from the foregoing statements, that whilst
creasote may not, except to a very limited extent, control pulmonary
hemorrhage, it does not promote or occasion it, and may, therefore, be
given with perfect safety to those patients who are liable to these re-
currences, and, indeed, during the period they actually take place.

As regards elevation of temperature, no record was made in 41 cases.
In the others, as well as could be determined, the following is probably
a correct statement: In 7 cases fever was cured under creasote treat-
ment, viz., it disappeared and did not return during the time the patient
was under observation. In 9 cases fever was notably lessened. In 1
case of these 9, the fever returned for a time when the patient had an
acute exacerbation of the disease, which occurred several times during
many months, and did not always appear to be occasioned by impru-
dence, or cold, but was rather the natural outcome of the disease.
In 8 cases, so far as could be observed, no perceptible effect was pro-
duced on the fever, and it remained about stationary. In only 1 case
did the temperature rise whilst the patient was under treatment, and
then only to a slight degree.

It is fair to assume that in creasote. we have, in the treatment of
phthisis, an antithermic agent of no mean value.

In 35 cases there was no mention of the effect of the treatment on
the strength of the patients. In 26 cases there was manifest improve-
ment in strength. In 6 of these the strength is spoken of as " returned "
or " regained." In 3, as greatly improved ; in 17, as notably improved.
In 1 case strength remained stationary; in 4 cases strength diminished.

Pains in chest were cured 8 times; improved, 13; stationary, 2;
none in one instance. In 42 cases no mention is made.

Pains in throat were cured in 6 cases, improved in 7, made worse in
3, remained stationary in 2. In five cases patient never suffered from pain
in the throat ; in 43 cases no mention is made. In 1 case of cure it
was attributable to the inhalations. In 3 cases in which the pains in
the throat improved, the previous hoarseness diminished, more or less, or
disappeared entirely.

In the 3 cases in which the pains in the throat became worse, they
were thus caused by the local irritating effects of the mixture. In one
instance the voice became weaker and more hoarse.

The pulse is noted as being less frequent and stronger in 6 cases ; in 2
as normal ; in 2 as showing no apparent change and remaining frequent.
In the other instances no mention is made.

Generally speaking, there was no change in the appearance or amount
of urine passed. On only one occasion did it apparently increase con-
siderably in quantity, owing to the use of creasote ; on another it became
clearer, where previously it had contained considerable deposits of



CREASOTE IN PHTHISIS PULMONALIS. 21

urates; in a third instance the urine became more turbid. On many
occasions it was tested for albumin; either none was found, or the amount
previously existing in the urine remained the same. No casts were
observed, in repeated examinations, which could be ascribed to the use
of creasote, nor did any pronounced dark discoloration occur, such as
may follow the internal use of coal-tar creasote. In no instance could I
detect the odor of creasote in the urine, and in only one did ordinary
tests reveal its presence. This was a case of acute phthisis in a young
woman who was taking at the time sixteen minims of creasote daily and
who was, also, making frequent use of creasote inhalations.

As regards physical signs, I have only 2 cases at the first stage, to
report of complete disappearance of every evidence of morbid condi-
tion in the lungs. In two other instances the signs improved so much
that it required the strictest construction not to pronounce them cured.
In 10 cases at first, second, and third stages, there was slight or decided
improvement in the physical signs revealed by careful examinations of
the chest.

This improvement consisted in fewer moist rales heard at the apices,
in diminished area of dulness, in diminution of thoracic vibrations, of
resonance of the voice, in softened, less prolonged expiratory murmur,
which was also of lower pitch. Among the cases which I have observed,
there have been, in my opinion, at least four apparent cures, if due con-
sideration be given to the effects produced on both signs and symptoms
of pulmonary phthisis. 1

Dr. Charles F. Collins's report, dated St. Luke's Hospital, May 30,
1888, reads as follows :

" In regard to the creasote treatment in phthisis pulmonalis in hos-
pital cases, I have gone through all the records since the treatment was
first begun. The notes in the cases, though accurate, are not complete
enough to enable me to make satisfactory tables and to draw positive
conclusions concerning special points. Then, also, the previous condi-
tion of most of the hospital cases is often very bad in respect to hygienic
surroundings, often suffering from want of food and rest, so that after
admission to the hospital when improvement takes place it is sometimes
difficult to isolate the special value of treatment per se. Then, too,
there are many cases admitted in the last stages and the condition often
without hope, so that any results from treatment are not looked for ; to
keep the patient comfortable is the only attempt by way of treatment
that is available. It is also in hospital cases almost impossible to avoid
treating specific symptoms, such as night-sweats, wakefulness, diar-
rhoea, etc.



1 The cases will be found reported in full in the Transactions of the Association of American
Physicians for 1888.



22 CREASOTE IN PHTHISIS PULMONALIS.

" During the last two years about a hundred and fifty cases of
phthisis have been put on the creasote treatment, and a large percentage
of these I have been able to watch, and the following points may prove
of value. It never has been discovered that the drug in any way caused
gastric distress or intestinal symptoms. It is pleasant to take and, in
the formula you introduced, patients often ask for it when leaving and
take it for a length of time, and I have never known a patient to dislike
the mixture.

" As to urinary and kidney symptoms I would add the following:
There has never been any perceptible change in the quantity during
the twenty-four hours, and repeated examinations chemically of the
urine of patients on creasote have failed to reveal any changes ; as far
as I can judge, have not known it to cause albumin even though con-
tinued for months, and many cases suffering from renal complications
when admitted to the hospital show no signs of an increase of their
trouble in regard to urine when put on creasote treatment.

" In general, I would like to add that this mode of treatment, the in-
halations as well as internal administrations, seems to give better results
and be more available than any mode of treatment we have followed
out. Many cases leaving the hospital have asked for the prescription,
and in cases which I have been able to follow and which have con-
scientiously carried out treatment, as far as can be judged, there seemed
to be a lasting benefit and continued improvement.

"It is a matter of considerable regret that I cannot give you records
of a number of special cases, but on account of the conditions above
mentioned, truthful records of hospital patients suffering from diseases
of this character are always subject to many errors."

In this place, and before giving my conclusions to this paper, I will
add a few words which I believe are important to bear in mind. We
all know how readily one may be deceived by tabular statements,
or, indeed, occasionally by reported cases. It is so easy to prove too
much ! Whilst error, however, often arises from the over-valuation o±
a particular drug, it is possible to underestimate the utility of a real
addition to our curative means in this line, when judged after a similar
manner. Therefore it is that final remarks or reflections, more or less
in the form of conclusions, must frequently be added, so that a correct
opinion should be formed of what a writer really believes.

I am convinced, in view of what I have seen, the proofs of which I
have stated, and notwithstanding their imperfect character in many
particulars, that we have in beech wood creasote a remedy of great value
in the treatment of pulmonary phthisis, particularly during the first
stage. Not only does it lessen or cure cough, diminish, favorably change
and occasionally stop sputa, relieve dyspnoea in very many instances ;
it also often increases appetite, promotes nutrition, and arrests night-



CREASOTE IN PHTHISIS PULMONALIS. 23

sweats. It does not occasion haemoptysis, and rarely causes disturbance
of the stomach or bowels, except in cases in which it is given in too
large doses.

There is a fair amount of evidence to show that by its long-continued,
judicious use, it may and will modify favorably the local changes in
pulmonary phthisis, and how it does this I have pointed out previously,
as far as I was able. Whether or not it has any direct anti bacillary
effect when given internally, or by inhalation, or both combined (the
latter method being, in my judgment, the most efficient one;, remains as
yet to be determined in a more accurate manner. It is certainly an un-
objectionable medicament from any point of view. It is easy of adminis-
tration ; it is adapted to the majority of sufferers from pulmonary phthisis
everywhere ; it may be used with some advantage at all stages of this
disease, even the most advanced, and in my experienced has proven itself
superior to any other medicinal treatment with which I am familiar.

That in all cases the nutrition is the cardinal factor to be always kept
in view in the treatment of pulmonary phthisis, no matter what method
or course be followed, is, I believe, as true today as it always has been
from the clinical standpoint, and without regard to the passing theories
which may be adopted in regard to the precise role or influence of mi-
crobes in the pulmonary structures. The words of Dujardin-Beaumetz 1
seem, in this connection, of much value :

"There do not exist several medications of phthisis ; there is but one, that
which addresses itself to the nutrition ; the others are only adjunct methods,
which become dangerous if they succeed in affecting unfavorably a single
day, a single instance, the digestive functions."

Or those other words of E. L. Trudeau : 2

" It should be kept in view that so long as the tissues present a favorable
nidus for the development of the bacilli, the destruction of a portion of them,
if this should be found feasible, would not necessarily eradicate the disease."

To the end of altering those chemical and vital changes in the organism
which allow of the growth of the microbe, " thus far those conditions
which promote bodily vigor have alone been found effectual."

1 Lemons de Clinique Therapeutique, t. 2, p. 647. - Medical News, May 5, 1S88, p. 490.



ON THE COURSE AND TREATMENT OF CERTAIN

URJEMIC SYMPTOMS.



In beginning my paper I wish to say that I ana in doubt as to the
title of it. In some respects I would prefer to use the designation
" symptoms of renal insufficiency, or inadequacy " rather than " ursemic
symptoms." I make this statement because uraemia does not satisfac-
torily express, as we all know, our belief to day in regard to the precise
etiology of many cases in which the kidneys are no doubt at fault pri-
marily or secondarily. If, however, I employ the designation renal
insufficiency, I feel that exception may be taken to the title, as I shall
speak of cases in which the kidney is surely affected with well-defined
structural changes, and the term uraemia, as it is generally received,
implies this belief in the majority of instances.

In my daily routine, especially of private practice, I meet with cases
of the kind I shall at first try to describe, and with which doubtless you
are more or less familiar. The patients to whom I refer are, as a rule,
what are called healthy, i. e., they have no distinctly marked organic
changes which are discoverable in their different organs ; or these
changes are so slight in amount that I cannot fairly attribute major im-
portance to the state of one organ as compared with others, without the
most careful analysis of all the conditions involved. Such patients,
however, have habitually some little bodily annoyances which fret
them more or less, and from which they desire to be relieved, and they
naturally seek, sooner or later, the physician's care. In regarding these
patients at present I am satisfied that many of them suffer primarily
from slight renal disorder. This affection of the kidneys, mainly func-
tional, is at times more pronounced, and occasions symptoms which
hitherto we have considered under the term ursemic.

In the mildest forms of the trouble, I believe renal insufficiency is a
more appropriate term, particularly if we limit its proper significance.
I am aware that the term itself is frequently employed in descriptions of
uraemia, although I have not found an article or chapter in which the
epithet was used as the title of a recognized condition. By adopting
this name with this purpose, we shall be able hereafter to employ it to
cover a definite series of symptoms, which, in my judgment, are not
otherwise properly designated.



TREATMENT OF UREMIC SYMPTOMS. 25

I will now narrate a few cases in my later professional experience
which shall serve as a text to explain my position.

Case I. — A lawyer ; widower ; fifty-five years old ; a man of large
frame, who has enjoyed excellent health. In the winter months he
suffers from nasal obstruction and formation of excess of mucus in the
naso-pharyngeal space, which he relieves by efforts of hawking. Patient
has a somewhat constipated habit, and his urine is often higher colored
than is normal. Frequently, however, the density and color are normal.
It contains at these times no abnormal ingredient. Whenever the den-
sity increases and the color is darker, there is a heavy deposit of pink
urates; but there is no albumin, no sugar, and rarely, if ever, any casts.
The quantity of urine voided, as a rule, approximates the normal. When
the color becomes dark and the density increases, the quantity dimin-
ishes, but not usually to any great extent The patient under the latter
circumstances suffers from general neuralgic manifestations, mild in form,
and which rapidly disappear under judicious medical management.
Appetite is excellent ; no dyspeptic symptoms ordinarily ; lives well,
but commits no excesses. Very moderate in the use of wines or distilled
liquors. No attacks of rheumatism or gout. He finds himself much


2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 2 of 20)