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 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.
33 Vide Supplement to Ziemssen's Cyclopædia, 1881, p. 325.
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 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.
Medical opinion is sometimes asked concerning the propriety of marriage with a phthisical man or woman. As an abstract question there need be no hesitation as to the answer. If men went about deliberately selecting wives, or vice versâ—as, for example, horses are selected—there could be no doubt that phthisis should be considered a disqualification. Husbands and wives, however, are not mated in such a way. A marriage engagement has been entered into, and afterward one of the parties becomes phthisical. The friends of the non-phthisical party, not the parties themselves, come for advice, and the adviser is sometimes placed in an awkward situation. With respect to the effect of marriage on the tuberculous party, my analysis of 17 cases, 2 only being women, did not show that it was unfavorable. Were it unfavorable, considerations of sentiment and sense of duty generally outweigh all others. A more important point relates to offspring. A hereditary tendency is entailed in some, but not in all cases. The risk incurred in this point of view having been fairly stated, the responsibility of the medical adviser is ended.
After recovery from phthisis measures for the prevention of a relapse should receive due attention. The hygienic influences which were brought to bear on the disease, and which, as it is fair to conclude, had more or less agency in effecting the recovery, are as far as practicable to remain in operation. This important injunction applies alike to cases in which an arrest of the disease has taken place, so long as it ceases to be progressive. To prevent a renewal of its progress is an object having a similar importance as the prevention of a relapse after recovery.