of these indications be fulfilled by our remedies, we shall not have been engaged in a vain struggle with disease. A large number of organic affections derive their leading features from local inflammatory actions. In combating these by local depletion and repeated counter-irritation, we are ministering to the arrest of the disease itself; for if the inflammatory element could be deducted from these constitutional disorders, a most important advance would be made towards their cure. CHAP. CHAPTER XXVI. CHAP. Direct treatment. The premonitory stage, THE DIRECT TREATMENT OF PHTHISIS. The Premonitory Stage. THIS has to be considered with regard to the different varieties of the disease, and its various stages. In considering the 'premonitory stage' of phthisis we cannot consent to a definition which includes any manifest changes in the physical condition of the chest. It has been argued that feebleness of respiration, and slight general dulness of the percussion-note, prolonged expiration, with some impairment of the mobility of the chest walls, are characters which accompany the 'pretubercular stage.' But these are some of the actual features by which we recognise an already established deposit. Where, then, shall we draw the line? or, can we, to suit a theory, presume that with these altered physical conditions there does not already exist some amount of structural disease? But when to the above physical signs we add the symptoms which are said to distinguish such premonitory stage,' viz., hæmoptysis, cough, and progressive emaciation, we find ourselves at once in the presence of the history of established tubercular disease. Short of actual demonstration by post-mortem examination, there can be no proof of this group of physical signs and of symptoms being present without any deposit in the lung. This early period of threatened or established tubercular disease has also been designated 'the remediable XXVI. stage of consumption.' If remedy mean cure, it becomes CHAP. a matter of experience whether this stage of established disease (as we believe it to be) is more capable of entire removal than any of those later in the history of the affection. When tubercle is once established as a deposit, its absorption, or cretifaction, or softening and removal, with ultimate cicatrisation of the cavity, are possible events, as we have seen. But these occurrences are rare, and cannot be reckoned on in ordinary practice. In the preceding pages cases have been given illustrative of each of these events; but the whole experience of the writer goes to prove that every stage of phthisis is remediable' in the common and true sense of the word, and that to apply the term to one early and, necessarily, limited period of the affection, is to contradict the daily testimony of experience. Let us boldly say 'curable' when cure is meant, and the expression cannot be confined to any stage of the disease. But, while all that is helpful by restoring the weakened processes of nutrition, by abating the congestion of the lung surrounding the seat of deposit, by lessening and controlling every drain on the system, and by exalting the nervous vitality of organs, is at our command in every stage of phthisis, and is found serviceable in arresting the destructive progress of tubercle, whether as a deposit in the process of softening, or in the achieved mischief of cavity, we cannot consent to limit the term 'remediable' to any stage of the disease. In a former chapter we have dwelt on the features which distinguish the period preceding deposit in the lung, and it has been argued that alterations in the nutrition of the body are in every instance, excepting in acute phthisis, the forerunners of tubercle. We cannot draw the line, nor say with certainty when local disease has taken place; but the earliest appreciable occurrences in the history of the disease are emaciation CHAP. and a subfebrile state. This statement is not offered as a theory, but as the simple result of unprejudiced observation. It has not appeared that appetite is much impaired at this period, or that the loss of flesh can be attributed directly to diminution of the quantity of food taken. Men grow thin and fall into phthisis, who are partaking daily and largely of food of the best quality, containing every element necessary for its conversion into healthy blood. It is not usual to find appetite impaired in this earliest stage, at least to an amount which could at all account for the emaciation. The primary changes of digestion are generally sufficiently complete, but the secondary and higher vitalising actions by which food is made into blood, and blood becomes tissue, are not performed efficiently. It has not appeared that elimination' is, as a rule, so excessive as to account for this early emaciation. There is generally an access of severe sweating, a febrile access, such as occurs in the later stages as the result of irritative action, but this subsides. The skin is not always moist, on the contrary it is often dry, and the pores seem closed, and dry heat is very commonly complained of. Guiding The principles which should guide us in treating this principles. constitutional disorder appear to be the following:— 1. To promote healthy blood-changes. To promote healthy bloodchanges. Exercise. 2. To maintain full respiratory action. 3. To eliminate morbid matters from the system. 4. To supply the largest amount of the most nutritive food which can be digested. 1. The promotion of healthy blood-changes is best accomplished by exercise. The active renewal of tissues is stimulated by their waste in a normal exercise of their functions. The intimate changes between blood and tissue, in which the former is raised into a higher grade of vitality, are constantly going on. But their rapidity and perfection is dependent above all else on a due exercise of the vital functions which are appro priate to the tissue. Should muscle be employed, we are aware that its circulation is increased, its growth accelerated, its bulk enlarged, and its innervation raised by the very fact of its activity. Thus the arm of the blacksmith, the legs of the runner, and the chest muscles of the athlete, increase in size and in power. A more rapid conversion of the nutritive material is effected, and a more rapid waste takes place. If these processes are balanced, the system is no gainer, but an excess of the nutritive over the expending actions is so invariable, that greater volume of tissue is an almost constant result. This increase of bulk is, however, but the end to which a series of vital actions lead. The final step by which the corpuscule deposited is assimilated to the actual form of the tissue to which it is applied, is only the terminal and culminating event in a series of nutritive actions. Backwards in the chain we can recognise increased innervation, stimulated circulation, improvement in the quality of blood formed to meet enlarged requirements, secretions increased from liver and pancreas, respiratory movements and results augmented, till the stimulus reaches the organs devoted to the supply of the primary elements necessary to nutrition. Here the purely gastric and preparatory processes are stirred into activity, and chyle and chyme are prepared of a higher quality, while the demand for food is exalted. These results of bodily exercise are far from theoretical. Let anyone accustomed to the sedentary occupations of town life take an autumn holiday in mountain scenery, and mark the results as he daily increases his muscular activity. At first there is fatigue, because he has drawn on his ordinary powers supplied by his ordinary recruiting forces. But backwards in the chain we have traced, his innervation, sanguification, and appetite increase, till every vital process is quickened, and with enlarged demands, his system is stimulated to produce a greater quantity C C CHAP. XXVI. |