of habits as regards out-of-door life and exercise have led to
recovery, such as performing long journeys on horseback or on foot,
accompanying expeditions which involved camping in the open air with
hardships, etc. Several instances of this kind have come within my
knowledge. In one of these the patient, a young physician who consulted
me, on being told that he had incipient phthisis gave up his practice
and joined a tribe of Indians in the Far West. He remained with them
for more than a year, adopting all their customs, and returned in
vigorous health. But in order to rough it a patient need not go to a
distance from home and friends. This fact is lost sight of when
physicians sanction the exposures and hardships of travel without the
limits of civilization, but enjoin upon patients great care in taking
exercise out-of-doors so long as they remain in their places of
residence.
All who have had the opportunity of observing the effect of sea-voyages
in cases of phthisis are agreed as to their utility. A long sea-voyage
or a series of voyages entered prominently into the treatment of 20 of
the cases which I have analyzed. In a large proportion of these cases
the favorable influence was marked. This is an accessory circumstance
which contributes to the benefit in many cases derived from a change of
climate. It is evident that a certain proportion only of phthisical
patients can avail themselves of this measure. It is to be advised
especially for those who can leave home and business without anxiety,
who are fond of ocean-life, and who as a matter of course are good
sailors.
The supposed liability to, and danger of, catching cold often leads
phthisical patients to wear an overplus of clothing. When they strip
for an examination of the chest not infrequently they remove two or
three undershirts, a woollen or fur chest-protector, and sometimes in
addition an oiled-silk jacket. The body is kept in constant
perspiration by these articles. They occasion not only discomfort, but
debility. A single word expresses the governing principle in
clothing--namely, comfort. Articles of dress should be so adapted to
the seasons and to changes of temperature as to secure comfort. This
maxim applies to persons affected with phthisis as well as to those in
health. In some instances, from an erroneous theoretical notion,
patients {434} make themselves uncomfortable in an opposite way. They
dispense with woollen or silk underwear throughout cold seasons with
the idea that the system is thereby hardened. A good non-conductor of
heat next to the surface protects against changes of temperature and
promotes the functions of the skin. Attention to the sense of comfort
will enable the patient to avoid error in this direction as well as an
overplus of clothing.
Other regiminal observances relate to ventilation and the sponge bath.
The apartment in which the patient is expected to pass at least
one-third of the twenty-four hours should be sufficiently large and
well ventilated. Fresh, cool air in abundance is not deleterious, as it
would seem to be regarded when the utmost care is taken to exclude it.
It is essential to healthful sleep and invigoration. Here, again, the
supposed danger of catching cold antagonizes hygienic treatment. Air
should have free access to sleeping apartments in cases of disease as
in health. As a measure for invigoration the sponge bath is often
useful in cases of phthisis. The water used may be cool or tepid
according to the sensations of the patient and the effect. It should be
followed by a glow with a feeling of invigoration. The water may with
advantage be made stimulating by the addition of salt or of alcohol.
Medicinal Treatment.--The medicinal treatment in cases of phthisis
embraces no known remedies having a special influence over the disease;
in other words, no drug has as yet been found to be an antidote to the
tuberculous cachexia. Nevertheless, medicines in many cases form an
important part of the treatment. They have for their objects
improvement of appetite, digestion, assimilation, and nutrition, relief
from complications or associated affections, and the palliation of
symptoms.
Cod-liver oil is considered in this article, as is customary, in
connection with the medicinal treatment. It has, however, little or no
claim to be regarded as a medicine. It is a nutrient. It is a form of
fat which patients often digest readily, and which evidently increases
the weight of the body. That it does more than simply increase the
amount of fat in the body is shown by the fact that frequently under
its use the appetite, the digestion, the condition of the blood, and
the nutrition of the tissues manifest improvement. These effects are
not inconsistent with the statement that it is simply an article of
diet. Although the claims in its behalf as a special remedy which were
made forty years ago have long since been disproved, clinical
experience has continued to furnish proof of its usefulness in the
treatment of cases of phthisis. It should enter into the treatment
wherever it is well tolerated and digested. If it occasion nausea or
diminish the appetite or give rise to eructations, its use should not
be persisted in. In the choice among the different varieties of the oil
experience in each case is to be the guide. Some patients find the
brown varieties more acceptable than the pale, and vice versâ. I have
known in several instances the unrefined, coarse oil obtained at the
fish-markets to be preferred. Patients should not give up this part of
the treatment until the different varieties have been tried. The
popular preparations in which the oil is combined with salts of lime or
with some flavoring extract are sometimes tolerated by those who are,
or who fancy that they are, unable to tolerate the pure oil. They have
probably no advantage for those who are able or who are willing to take
the pure oil. The oil should never be given in doses larger than are
readily digested, and, following this rule, the doses will rarely
exceed half an ounce. They are best given shortly after meals. It is a
popular notion that the oil should not be continued in hot weather. The
weather should have no influence on its continuance, provided it be
well tolerated and digested. The addition of fifteen minims of ether to
a half-ounce dose of the oil has been found to promote its digestion,
and by means of this addition persons with whom the oil disagrees may
be able to take it without difficulty. The ether is to be given {435}
half an hour after the oil has been taken.[32] Salad oil, cream,
butter, and the extracts of malt may be made to supply, in a measure,
the place of the cod-liver oil in the cases in which the latter is not
tolerated.
[Footnote 32: Vide report by Dr. Andrew H. Smith, chairman of Committee
on Restoratives of the New York Therapeutical Society in the _N.Y.
Medical Journal_, April 20, 1879.]
Embracing the varieties of spirits, wine, and malt liquors under the
name alcoholics, these are to be regarded as alimentary, but also as
medicines. That they are useful in certain cases of phthisis is as well
established on the basis of clinical experience as any fact in
practical medicine. Their usefulness in this disease, as well as in
other diseases, is to be considered irrespective of questions relating
to their use and abuse in health. But as bearing on the very important
subject of intemperance it may be stated that, administered purely as
remedies in cases of phthisis, patients do not become so addicted to
them as to make it difficult to relinquish their use whenever this is
advisable. This statement is based on a large experience.
Alcoholics are useful in some and not so in other cases. The question
as to their usefulness is to be decided in each case by trial. If they
produce a sense of comfort without any excitation of the circulation or
of the nervous system, they are likely to be useful. If in lieu of a
cordial effect they occasion flushing, weariness, or indisposition to
exertion or discomfort of any kind, they are not likely to be useful.
The quantity to be given is to be regulated by the immediate effects.
There is sometimes a notably increased tolerance of alcohol. This is to
be ascertained by experimental observation. The quantity of alcohol
given should never occasion the least approach to alcoholic
intoxication. It should be given at or near the times of taking food,
or in combination with food, as in milk-punch or egg-nog.
As to the choice of an alcoholic, this is to be determined by the past
and present experience in each case. Each of the many varieties of
spirits, malt liquors, and wines is best suited to some cases and not
to other cases. There is no rule of choice applicable to all patients.
Changes in the form of alcoholics from time to time are often advisable
in the same case. In the majority of cases some forms of spirits will
be found best to agree. Malt liquors, either the strong or mild
varieties, agree best in some cases. Of wine, some patients take with
most comfort the light and some the stronger varieties. The effect upon
the pulse, respiration, and other symptoms should be observed with
reference to the employment of any of the alcoholics, and of the
particular ones best suited in individual cases, but much reliance must
be placed on the subjective symptoms. It has been proposed to
substitute pure alcohol for any and all the alcoholics used as
beverages, in order to give to the treatment more distinctly a
medicinal character and to avoid risk of the formation of a habit which
may lead to intemperance. Since, however, of the many varieties of
alcoholics, some agree in certain cases and not in other cases, it is
doubtful whether alcohol is able to take the place of all. This is a
point to be decided by clinical observation.
Phosphorus in the form of the hypophosphite of soda and of lime was
recommended about forty years ago on the theoretical ground that it
favored cell-formation and retarded the rapid waste of the tissues.
More recently it has been supposed to have a specific influence over
tuberculous disease. It has been employed pretty largely in different
countries, but without effects sustaining the claim of having a
specific action. It seems to be useful, and many physicians attach
considerable importance to its use.
The preparations of iodine, from their evident utility in certain
scrofulous affections, and in view of the identity of scrofula and
tuberculous affections, have heretofore entered largely into the
treatment of cases of phthisis. From the fact that they are now but
little employed in phthisical cases it may be {436} inferred that in
this instance, as in many other instances, theoretical considerations
have failed to find support from clinical experience.
Of arsenic it can be said that many able observers have borne testimony
to its great usefulness in some cases, as manifested by improvement in
appetite, nutrition, and in the powers of life generally, together with
the cough and expectoration. Here, as in other instances in which it is
desirable to continue the remedy for a considerable period, the doses
should be small and not increased. Noël Guéneau de Mussey testifies to
a remarkable efficiency in some cases of the mineral water of Bourbole,
either exported or taken at the spring.
Sulphur, especially as contained in the Sulphur Springs water, has long
been considered a useful remedy in phthisis as in other chronic
diseases. The Sulphur Springs of our country, however, although much
resorted to for other diseases, have not in phthisical cases with us
the celebrity which those in Europe (of which Des Eaux Bonnes are a
famous type) have with European physicians.
The symptomatic indications for medicinal treatment in cases of
phthisis are many and varied. Among the most important are those
relating to appetite and digestion. For the improvement of these
functions the preparations of cinchona, salicin, gentian, quassia, and
other of the vegetable bitter tonics, including nux vomica, may be
selected, according to the choice of the physician, or given in
succession. They have more or less efficiency in conjunction with the
more potential hygienic measures considered in connection with the
climatic, the dietetic, and the regiminal treatment. Pepsin and dilute
hydrochloric acid, taken after a meal, promote its digestion, their
medicinal action being, however, limited to the meal in connection with
which they are administered. The tincture of the hydrochlorate of iron
and other ferruginous tonics which are much used in cases of dyspepsia
and indigestion are useful in cases of phthisis. The anæmia which
exists so constantly in phthisical cases is an indication for their
use, and there does not seem to be ground for the conjecture which has
been entertained that they promote the occurrence of bronchial
hemorrhage. If they had this effect it would not disprove their
utility.
Pulmonary symptoms which may furnish therapeutic indications are cough
and expectoration, hæmoptysis, pain in the chest, and dyspnoea. Cough
is of course necessary for the removal of the morbid products within
the bronchial tubes and cavities. If the act of coughing be accompanied
by expectoration, palliation is not required. But often there is what
may be called a superfluous cough--that is, not accompanied by
expectoration. This superfluous cough may be frequent, and occur in
violent paroxysms which occasion fatigue and exhaustion. Frequently the
cough prevents sleep. Palliative remedies are then indicated. It is
desirable, if possible, to palliate cough with remedies which do not
contain an opiate, owing to the impairment of appetite and digestion
caused by the latter. Simple remedies, such as the balsam of tolu, the
syrup of wild-cherry bark, Turlington's balsam, etc., may suffice. If
not, other narcotics than opium should be tried--namely, hyoscyamus,
lactucarium, and belladonna. Fothergill recommends hydrobromic acid and
the spirits of chloroform. The addition, however, of some form of
opiate is often required. The paregoric elixir is the simplest form,
and therefore the best if it suffice. Of other forms, perhaps codeia is
in general to be preferred. Patients should be enjoined not to prolong
voluntarily ineffectual coughing efforts. The disposition to cough may
in a considerable degree be controlled by the will until the morbid
products are in a situation to be readily expectorated. The stimulant
expectorants and those which act by causing nausea are not indicated in
cases of phthisis, and are objectionable in so far as they impair
appetite and digestion. Stimulating medicinal {437} inhalations are of
doubtful propriety, but a superfluous cough is sometimes relieved by
breathing some vapor, a little laudanum or paregoric elixir having been
added to the water vaporized. The continuous breathing of an atmosphere
charged with carbolic acid, either by diffusing it in an apartment or
the use of a respirator, is advisable if there be fetor of the
expectoration.
It has been seen that bronchial hemorrhage is not, as a rule, an
unfavorable event in cases of phthisis. It does not follow from this
fact that the loss of blood is desirable, and therefore that the
hemorrhage should not be arrested. Moreover, the loss of blood in some
instances involves immediate danger. A first attack of hæmoptysis
occasions great alarm and anxiety. The prostration which appears is a
moral effect rather than the exhaustion caused by the loss of blood. In
repeated instances after attacks of hæmoptysis have several times
recurred, I have known patients to keep about as usual during an
attack, giving little or no heed to it.
The internal remedies which may be employed for the arrest of
hemorrhage are: Ergot or ergotin, acetate of lead, tannic or gallic
acid, and the astringent preparations of iron. Ergotin has been given
with good effect by subcutaneous injection, from five to ten grains in
water, with or without glycerin, being injected and repeated pro re
nata. Opium in some form should be conjoined in order to allay nervous
excitement. A teaspoonful of table-salt taken into the mouth and
repeated after intervals of a few moments is a well-known remedy during
the hemorrhage. The hemorrhage is sometimes so profuse and rapid that
much blood is swallowed, and may be afterward vomited. Under these
circumstances, and whenever the persistence of the hæmoptysis calls for
more prompt measures, cold may be applied to the part of the chest
which corresponds to the seat of the hemorrhage. This may be found by
means of a localized subcrepitant râle. Another measure is the
inhalation of a vaporized solution of the liquid persulphate of iron.
Still another and more potential measure is the temporary ligation of
one or more of the members of the body, the pressure being sufficient
to interrupt the flow of blood in the veins and not in the arteries.
This measure must be resorted to and continued only when the physician
is present. The effect is sometimes almost magical. The measure is a
substitute for venesection, which was formerly employed for the arrest
of bronchial hemorrhage. Cavernous hemorrhage, occurring usually late
in the disease, if profuse calls for prompt measures, and the topical
employment of cold will be likely to be the most promptly effective.
Pain in the chest denotes either pleurisy or intercostal neuralgia.
Mild counter-irritant applications by sinapisms or stimulating
liniments, with anodynes graduated to the degree of pain, are
indicated. Dyspnoea, if not caused by restrained movements of the chest
from pain, or by pleuritic effusion, or by an intercurrent pneumonia,
may denote either rapidity and extent of the tuberculous deposit or an
accumulation of morbid products within the bronchial tubes: if the
latter be the explanation, acts of expectoration are to be promoted.
This is not easily done if the difficulty of expectoration proceed from
great general debility. The ethereal stimulants, Hoffmann's anodyne,
chloric ether, and the compound spirits of lavender are advisable under
these circumstances as palliatives.
Pyrexia and increased frequency of the heart's action are symptoms
indicative of an active tuberculous cachexia. How far these are purely
symptomatic, and how far they may conduce to the progress of the
disease, cannot be determined with our present knowledge. It may be
assumed that they represent something more than is represented
generally by the fever which is secondary to a local inflammation. That
the febrile temperature is itself causative of changes in the tissues,
as well as in the functions of the body, is probable; and the muscular
power of the heart must be weakened by the {438} persistent frequency
of its action. A rational object in therapeutics is either the removal
or the neutralization of the morbid conditions on which the pyrexia and
the increased frequency of the heart's action depend. The means of
effecting this object are to be determined in the future, when more is
known of the morbid conditions giving rise to pyrexia; meanwhile, there
are certain medicines which, as experience shows, diminish the
temperature, and febrile temperature can be reduced by external means
which abstract heat from the body.
At the present time data are wanting for determining the importance of
antipyretic treatment in cases of phthisis. Hyperpyrexia, however, may
be considered as furnishing an indication for a trial of antipyretic
medication, and the most reliable of the drugs employed for that
purpose is quinia. It should be given for this object in full doses, as
in other instances in which it is given for an antipyretic effect.
These doses should not be continued long enough to disorder the
stomach. Diurnal exacerbations of fever, especially if ushered in by a
chill, may sometimes be arrested, or, if not arrested, materially
modified, by full doses of quinia, although there may be no ground for
the suspicion of malaria.
When the skin is hot and dry, with a high axillary temperature,
sponging the body may be employed and continued until the pyrexia is
diminished. I am not prepared to say whether the cold bath or the wet
sheet is admissible or allowable. As having some antipyretic effect,
and as diminishing the frequency of the heart's action, digitalis might
be expected to prove a valuable remedy to fulfil the symptomatic
indications under consideration. This drug was formerly much employed
in cases of phthisis. The fact that it has in a great measure fallen
into disuse may be taken as evidence that the theoretical
recommendations are not sustained by clinical experience. The liability
to disturbance of the stomach from its use is perhaps a sufficient
reason for considering it inapplicable.
The profuse night-sweating which so often occurs in the course of
phthisis claims treatment. Belladonna or atropia, the oxide or sulphate
of zinc, gallic acid, the acetate of lead, and aromatic sulphuric acid
are internal remedies for the palliation of this symptom. Sponging the
surface before bedtime with diluted alcohol, diluted acetic acid, or
with spirit in which alum is dissolved should be tried. Hot vinegar
largely charged with capsicum has been found to be an efficient
application. The covering at night should be as light as is consistent
with comfort. Brunton has found strychnine and nux vomica, given at
bedtime, useful. Another remedy, recommended by Murrell, is picrotoxin.
This is given in the form of a solution (1 part to 240 parts water),
the doses of from one to four minims daily, the last dose given late at
night.[33] Agaricus, or the common toadstool, is recommended as an
efficient remedy by Wolfenden of London and J. M. Young of Glasgow.
From ten to twenty grains may be given in the form of an electuary with
honey, or it may be given in the form of a tincture. In both these
modes it is apt to cause nausea. This objection does not apply to the
isolated medicinal principle, a crystallized substance which it is
proposed to designate agaracine. Of this one-twelfth of a grain is a
dose, which may be repeated if required. Young is of the opinion that
it is not less effective than atropia as an antihydrotic remedy, and
not open to the same degree of danger from an overdose as the latter.
He has found it to act also as a soporific remedy, to relieve cough,
and to diminish the temperature of the body.[34] A popular remedy is
cold sage tea taken at bedtime.
[Footnote 33: Vide _Supplement to Ziemssen's Cyclopædia_, 1881, p.
325.]
[Footnote 34: _Glasgow Medical Journal_, March, 1882.]
Of complications and associated diseases, one of the most frequent is
disease of the intestine. Of diarrhoea not thus connected the treatment
is that {439} of indigestion. As incident to tuberculous ulcerations
opium and astringents are indicated. Full doses of the carbonate of
bismuth, with a salt of morphia, will often prove an efficient
palliative. Peritonitis, acute and chronic, pleurisy with effusion,
chronic laryngitis, pneumo-hydrothorax, and cerebral meningitis are to
be treated according to indications which are considered in the
articles treating of these affections, making of course proper
allowances for their occurrence as secondary to the phthisical disease.
Intermittent fever associated with phthisis should be arrested as
promptly as possible. There is no foundation for the opinion which some
have held that malaria retards the progress of tuberculous disease.
Clinical facts show directly the reverse. If a perineal fistula occurs
in a phthisical patient, the safest policy is not to interfere with it
except so far as to make it as endurable as practicable. The idea that
a fistula has a salutary effect by way of revulsion has been one of the
reasons for making artificially an issue in the arm or elsewhere. This
was formerly much in vogue, but it has mostly, and probably deservedly,
fallen into disuse.