CHAP. 'XXVII. Sedatives best for cough of phthisis. of tightness across the chest, with dyspnoea, the best remedies are counter-irritation and small doses of tartrate of antimony with alkalies. 4. The purely phthisical cough is best treated by sedatives, and these are better given without any combination with expectorants. Neither from theory nor practice have we any indications for expectorant medicines in ordinary phthisis. The cough is due either to pulmonary or reflex irritation, or to the necessity for getting rid of secretion. For the latter variety no remedy is necessary. Cough from irritation is often due to reflex action; and gastric disorder is a frequent cause in some instances, an ulcer being present in the stomach. In such circumstances food is almost sure to induce a fit, and sometimes the stomach is emptied by the same act. Again, the constant repetition of harassing cough of a nearly dry character, which is so distressing to the patient and his friends, seems caused by an altered innervation of the larynx. In both these instances we have found, after submitting many hundreds of cases to various remedies, that pure sedatives gave most relief. Morphia. Morphia,* from the twelfth to one-sixth of a grain, dissolved in a little syrup, is the very best of these; or morphia with hydrocyanic acid, or laurel water. A small blister, followed by the endermic application of morphia over the larynx, often gives much relief. The inhalation of narcotics (as Ext. Conii gr. xv., Ext. Lupuli gr. xx.) has been found very useful. The tincture of cannabis, the tincture of aconite, and * Many thousands have used the following preparations :B Morphiæ Hydrochloratis gr. iij. Sp. Pulegii 3ss. Syrupi Limonum 3ijss. M. Ft. Syrupus. One teaspoonful for a dose. Acidi Bo Mucilaginis Acacia 3 v. Morphie Hydrochloratis gr. j. Hydrocyanici diluti (P. L.) m xviij. Syrupi Limonum 3j. M. Ft. Mist. One tablespoonful for a dose. the preparation called chlorodyne, whose proportions combine those of cannabis and of morphia, are also useful. The chloric æther seems less valuable than the pure sedatives, but suits many cases. CHAP. XXVII. The cough which causes vomiting is often best re- Brandy. lieved by a small quantity of strong brandy-and-water. It is also occasionally mechanical, caused by distention of the stomach, oppressing the diaphragm. In such instance directions should be given to take a limited quantity of food, and not to drink much fluid at meal-times. Remedies of the demulcent kind often give great Demulrelief. Of these the decoction of cetraria or of the Irish moss (so-called) have proved most useful. The former especially, combined with laurel water, will relieve many patients who cannot take morphia or opium in any form. cents. when not In all cases the tendency of sedatives to disorder the stomach, by stopping the secretions, and to cause secondary nausea and headache, is to be remembered, and a night's rest is not to be purchased at this cost to the general health. When the patient is liable to be thus affected by opium, the best antidote is lemonjuice, or a small cup of strong coffee taken on waking. The combination of camphor or of ipecacuanha with opium is also well known to counteract the disagreeable secondary effects of the latter. Tonics are not so Tonics, suitable in this stage of phthisis, when symptoms of suitable. active irritation are commonly present, as in the other more quiescent periods of the disease. They are more applicable in the limited and local use, for the purpose of rallying a flagging appetite, than when given with the intention of invigorating the general health. Very minute doses of strychnia often answer the purpose admirably. We have found a simple infusion of gentian, made of twice the usual strength, most useful. Iron is not a good appetiser;' but the calumba with which it is often combined will by itself СНАР. XXVII. Cavity. Stimulants. Counter answer the purpose. As a rule, the simple vegetable bitters combined with an aromatic are better than the mineral tonics, when the tone of the stomach has to be reinforced. Treatment of the Third Stage. When cavity has formed in the lung, if it be of the circumscribed and defined form, the other portions of the lung remaining comparatively free from tubercular deposit, there is commonly a cessation of the febrile symptoms and of the constitutional disorder, and the patient has an opportunity of recovering flesh and vigour, which should be taken advantage of for the administration of the more active tonics and of codliver oil. We have already considered this condition. in the chapter on chronic third stage, and have only to repeat that all the indications are for a highly nutritious diet, and a fair allowance of stimulants suited to the age and sex of the patient. During the formation of a cavity of this kind, when the prostration was so great that life was threatened, we have in many instances had to give unusual amounts of stimulants, and have seen the most marked success follow their liberal use. Reference is now made only to the circumscribed cavity; for if tubercular mischief be extending, this mode of treatment can only do mischief. But, under the conditions described, the patient should live on the highest kind of nourishment, and take plenty of wine, egg, milk, turtle, and meat. It is in this case that counter-irritation is of irritation. such marked use; and the best of all modes is the seton. When the cavity has been fully formed and remains stationary in its limits, as evidenced by the physical signs beneath it, and when flattening of the chest-walls is beginning to take place, a seton should be placed over the spot. If this be objected to, an issue or perpetual blister is to be maintained. We XXVII. have very many cases on record which show the utility CHAP. of this mode of treatment, and must offer our testimony in its favour in addition to that of many observers. One of these (Stokes) we may quote :— The patient's best chance I believe to be the use of the seton and travelling.' A small continuous drain, if it does not weaken the patient, may thus be maintained for years; and many of the longest cases which we have witnessed have been so treated. The strong solution of iodine may also be used with great advantage, and should be painted on the affected side about once in ten days. The tendency of such cavities as these is to contract; their walls become lined with a species of membrane when the tuberculous mass has been softened and removed; and in course of time the excavation is greatly reduced in volume-a result which is partly due to new fibrous tissue deposited around it, to the depression of the chest-walls from atmospheric pressure, and possibly to dilatation of the surrounding healthy air-cells of the lung. Active exercise in the open air, and gradually increased efforts to expand the lung by such exercises as riding, reading aloud, and occasional forced expansion, when the case has become quite chronic, are the natural modes by which we may assist the curative process. The irregular cavity, which is in fact only a breaking-down of more or less of the infiltrated pulmonary tissue, generally involves such an extent of the remaining part of the lung, that continuity of the diseased process is almost certain. The third stage of phthisis, when attained in this manner, implies disintegration of large and irregular masses of tubercle, with all their intervening structures. CHAPTER XXVIII. CLIMATE. CHAP. XXVIII. Climate. Change of air cannot cure. The dis ease not local. THE following are submitted as indispensable considerations in selecting cases for removal to a different climate: First, As regards the local disease. It is impossible to cure tubercular disease of the lung by any change of air. It would seem almost unnecessary to enlarge on the subject, were it not that the public, and occasionally an over-credulous practitioner, still cling to the idea. The disorder is not local, has not been caused by irritation of the lung or air-passages, and is not susceptible of cure by merely local remedies. Therefore, warm air, dry air, or any modification of atmospheric influences, can only act by lessening the complication of irritation of the bronchial membrane, which forms a single feature of the disease. If we had to deal with a single ulcer in the pulmonary tissue, we might expect much from constantly keeping the patient in a mild atmosphere; but we have to deal with a tubercular ulcer and a tubercular state of the system, which is a very different thing. The ulcer in the lung is composed of tubercle in the stage of softening, congested pulmonary tissue, the remains of old inflammatory thickening, an altered mucous membrane, and in almost all cases a thickened pleura. To all of these, excepting the last, the entering air is applied. It is true that this necessity of enduring a constantly renewed contact |