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| Index to Boger's Lesser Writings | Index to Historical Archives | ||||
Tuberculosis - The Medical Side of the Question-- C. M. Boger, 1904 |
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The treatment of the various phases of tuberculosis is dependent upon so many factors direct and contingent, that it embraces a large part of medical science. This paper will not therefore attempt a general resume of the subject but rather review some special considerations. The prognosis in a given case is so closely bound up in the anamnesis, the present state including the surrounding, the reactive power of the organism and the treatment that a just estimate of the outcome presents unusual difficulties. In this connection it may be well to point out the great importance which necessarily attaches to the relative chest capacity, for upon it depends the oxidising power of the whole organism with all its metabolic changes. That cases do get well with the aid or in spite of treatment, or with no attention at all seems well established; but nature carries on her weeding out process most relentlessly when left to herself or when help is clumsily applied. Therefore it seems superfluous to say that all aid should take the most enlightened form; its specific application from a hygienic, climatic or dietetic point of view may well be left to the experts in this line while this paper will look the matter over from a therapeutic standpoint. The curative power of remedies depends upon the very same elements that go to make up the prognosis, the chief one being vital reaction, closely followed by the nature and character of the anamnesis. This being true, the drugs curative in a given case must of necessity include in their pathogeneses as a primary action a similitude to the latest characteristic symptoms of the patient Should it so happen that the secondary drug symptoms of the remedy administered also correspond to the earlier or dyscratic disease manifestations of the case in hand its curative power will extend along the entire line of disease effects and root them out fundamentally, often uncovering the basic dyscrasia upon the soil of which the tubercular .process thrives. Most cases for various reasons do not present a picture clear enough for so sweeping a prescription. Then we are obliged to remove successive groups until the same end is attained, in act for reasons into which we will not enter here this is often the only safe procedure. As will be seen from the above no one remedy can be looked upon as specific for any one disease. The search for specifics is for many reasons fundamentally fallacious; the principal one being that they are supposed to cure diseases, while in reality it is necessary to cure patients and not disease. It is no argument to say that certain medicines have cured such affections. The very fact that percentage is admitted into the discussion, vitiates all figures and puts the matter without the pale of a true scientific demonstration. This fact is very slowly but nevertheless surely finding its way among those that think and are not ruled by preconceived ideas. The factors which play the chief diagnostic role hold a subordinate place in the choice of the curative remedy, although medicines whose pathogeneses point to them, may be used as a broad class from which those lacking the characteristics of the patient, may be dropped by a process of elimination until the symptom picture resembles that of the patient in a greater or less degree. Thus, Kyphosis, often but not necessarily due to tuberculosis, points toward Acon., Asaf., Aur., Bar c., Bell., Bry., Calc., Caust., Cic., Clem., Col., Dul., Hep., Ipec., Lach., Lyc., Mer, Met, Phosac., Plb., Puls., Rhusu., Ruta., Sab., Sep., Sil., Staph., Sul., and Thuja. It is well known that sweats are apt to localize themselves over the affected organ, and in the pulmonary form they often show their presence quite early on the thorax. Of the above remedies the following have chest sweats; Bell., Calc., Hep., Ipe., Lyc., Mer., Phos., Phos ac., Plb“ Rhus., Sep., Sil. This measurably reduces the number from which the choice may be made, always bearing in mind that the final resemblance between the drug effect and the disease picture of the patient, must present certain points of harmony called the "conditions" of the case, in which all kinds of external influences such as heat, cold, light, dampness etc., go to make up the differentiating shades in the final analysis. We also take into consideration the subjective symptoms: resting as they do upon the comprehension and interpretation of the patient as well as of the physician, they require the nicest judgement and most careful discrimination to strip them of all superfluities and exuberances of expression on the one hand, as well as proper amplification' and interpretation on the other. This is after all the crux of the art of prescribing and stamps the physician either as a rank empiric or a painstaking scientist. Whether the subjective phenomena express erethism or depression is an important differentiating point and divides the remedies of the materia into two great classes. Finally the state of the mind gives the last clue for the selection of the most suitable remedy, which if given in a single dose of the appropriate potency will unfailingly bring about the reaction so necessary for our purpose. Following these lines the treatment of tubercular bone disease, periostitis, especially of the ribs or maxillae, Pott's disease, etc., has yielded the most brilliant results and services of the surgeon have rarely been needed; the particular remedies most in use for such conditions have been Silicea and Aurum, especially when fistulous tendencies have become manifest: Calcarea fluorica, where very hard bony exostoses have been present, and Phosphorus in rickety children. The list might be greatly extended to cover special indications but that is unnecessary, the main point being that the indications m each case be carefully elicited after which the choice of the proper curative remedy is not so difficult. The meningeal has perhaps been justly regarded as the most intractable form of tuberculosis, but even here we are not without considerable hope and many cases have been cured with the indicated remedy; the choice will usually lie between Apis., Bell., Calc., Calc phos., Hell., Phos., Sulfur and Tuberculinum, all of which have a number of cures to their credit, some of which I have personally witnessed. In this form it is always well to make the diagnosis as certain as may be under the circumstances; in a suspected case coming under my notice, with somewhat equivocal symptoms a microscopical examination of the spinal fluid cleared matters up by showing the presence of gonococci. The glandular infections have most frequently called for, Bell., Calc fluor., Hep., Staph., Sil., and Sul. In growing children they present little difficulty and very few cases are incurable; in adults they are more intractable but many brilliant successes attest the efficacy of this method. The pulmonary type outnumbers all the others and is for many reasons one of the hardest to control. Its victims are notoriously inconstant, they do not readily submit themselves unreservedly to the care of their physician and are always willing to take all kinds of nostrums and apply the most unheard of measures, which of necessity negatives much if not all that the doctor may do. In a general way I would lay down the rule that unless implicit obedience can be exacted, the case had better be dismissed, not perhaps as incurable but rather as intractable, therefore incurable. This the predominant form calls for all the skill at our command and I am very happy to say that our therapeutic method often yields the most brilliant results when the law is carefully and thoroughly applied. Among the remedies which stand out most prominently in my mind's eye, none exceeds in results the effects which I have seen from the administration of Iodide of Arsenic. But even here, it is to be borne in mind that tuberculosis is a complex dyscrasia and will hardly yield to a single remedy however closely its symptomatology may fit the patient's symptom, complex; although admittedly such may occasionally be the case, for once I saw a complete recovery and at another time what seemed also a restoration of health from the administration of Belladonna only. To review the general treatment would be to repeat much that has already been said. The patient's condition may call for any remedy in the materia medica and when a medicine is thoroughly indicated it is not possible in the present state of our knowledge to fortell just how much good may come of it, as occasionally the most hopeless looking cases have made very wonderful recoveries from the administration of the similimum. lt does not therefore become us to give up hope too soon but rather to cover every phase of a given case with the most careful and searching investigation and from the information thus gleaned prescribe with the full assurance that from a medicinal standpoint the very best has been done. |
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