Treatment.
—It is well to emphasize, first of all, that tuberculous disease when circumscribed and accessible is a distinctly curable affection. If this is accepted, it puts a much more hopeful aspect upon the condition than it formerly bore. It moreover justifies operations of a more radical nature than were formerly practised. Treatment should be divided into the hygienic and constitutional and the local and operative.
Of all the natural remedies, oxygen undoubtedly ranks first. This means the best of ventilation, an outdoor life if possible, and preferably in localities and at altitudes free from dust and well supplied with ozone. When this is impossible inhalations of dilute oxygen are capable of doing much good. The two canons of successful treatment of pulmonary tuberculosis are equally of value in surgical tuberculosis, viz., abundance of oxygen and hypernutrition. The diet should be rich and nutritious, at the same time capable of complete digestion. The emunctories should be stimulated and elimination favored in every possible way. Undoubtedly the old standard remedies—cod-liver oil, compound syrup of hypophosphites, etc.—are beneficial, and much good may be accomplished by their proper use.
Certain remedies have been at various times supposed to be endowed with specific properties, and for many years clinicians have endeavored to find that substance with which the system could be safely saturated and prove inimical to the parasite causing this disease. Such agent has not yet been discovered; nevertheless, much has been done in this direction. Of the remedies highly spoken of for this purpose, creosote and guaiacol are considered the best. These are somewhat difficult of administration, but if the latter is given in the form of the carbonate, generally known as benzosol, it comes the nearest to the ideal for which we are striving. Benzosol should be given to the adult in doses of at least a gram a day, perhaps more. It is better tolerated and less offensive than the guaiacol from which it is made. I have never seen anything but benefit result from its use, and yet would not extol it as a positive cure. Nevertheless in conjunction with other local and constitutional measures its administration may be followed by complete recovery.
Of the various local measures, physiological rest should be placed first, and can be achieved in some places better than in others. The various forms of apparatus resorted to by orthopedists are simply mechanical measures in furtherance of this purpose. Some surgeons have faith in iodoform, used locally in solution or suspension in some menstruum like glycerin, oil, etc. The benefit which has been claimed in some cases is not duplicated in the experience of all surgeons; nevertheless, it has undoubtedly been of service. A recent and most promising method of treating tuberculous disease of the extremities has been suggested by Bier, and consists in the establishment of a permanent hyperemia by the application of a rubber tourniquet on the proximal side of the lesion. (See chapter on the [Joints].)
It would appear that the access of more blood which is thus permitted is inimical, presumably by the presence of the oxygen which it brings, to the development of the disease germ. The method depends for its rationale upon the fact that the congested lung does not become tuberculous. Lannelongue has suggested what he calls the sclerogenic treatment of tuberculous lesions, by injection of a very dilute solution of zinc chloride, which serves as an irritant and produces a tissue sclerosis that serves the purpose of a prophylactic membrane, while at the same time the solution is fatal to those germs with which it comes in contact. This treatment is painful and has not proved acceptable.
The astute surgeon, who gains the confidence of his patients and retains it, will not hesitate to remove by a suitable operation the tuberculous focus which he feels confident that he can reach and extirpate. The resulting tissue defects may be in many instances atoned for by plastic operations. At other times this procedure means excision of some joint, which leaves usually a much better functionating member than would the disease if permitted to go on to spontaneous recovery—i. e., ankylosis—and at the same time removes a focus of disease which is a menace if left to the future welfare of the patient. It may mean at other times amputation, but the artificial limbmaker now supplies a member vastly more useful than a natural one crippled by this infectious disease. In a general way, then, time may be saved and recovery ensured by early and judicious operation, while later in the course of this protean malady it may be absolutely necessitated in the endeavor to save life.
After operations where clean extirpation and reunion of the parts with primary healing is impossible a local dressing of balsam of Peru containing 10 per cent. of guaiacol is recommended. Gauze saturated with this dressing and packed into the cavity best accomplishes the purposes of a surgical dressing for such cases.
The superficial and ulcerative (skin) lesions due to tuberculosis often yield very readily to exposure to the Röntgen rays and the ultraviolet rays. Recrudescences appear not infrequently, and the treatment should be administered at intervals long after the apparent subsidence of the lesion.
Deep pain of tuberculous lesions, especially in bone, is often relieved by ignipuncture, meaning thereby a perforation into the depth even of the bone-marrow by the actual cautery (Paquelin’s), which may be thrust directly through the skin or which may be used after exposing the bone by incision. The use of the actual cautery is indicated in eradicating and destroying tuberculous tissue when a neat dissection or extirpation is impossible.