PULMONARY PHTHISIS (FIBROID PHTHISIS OR CHRONIC INTERSTITIAL PNEUMONIA).
BY AUSTIN FLINT, M.D.
DEFINITION.—Pulmonary phthisis is a chronic disease, characterized in its common form, anatomically, by a morbid product within the air-cells, in a large majority of cases progressively increasing and extending, having a tendency to cheesy degeneration and liquefaction forming collections of puriform liquid which, evacuating by ulceration into the bronchial tubes, are followed by cavities, these pathological conditions accompanied by more or less induration from interstitial morbid growth and by small granules called miliary tubercles. A comparatively rare form of the disease is characterized by the great predominance of interstitial growth, leading to notable diminution of the volume of lung by atrophy and to dilatation of the bronchial tubes. The latter form is now commonly distinguished as fibroid phthisis. This will claim separate consideration after having considered the form generally understood by the name pulmonary or pneumonic phthisis.
SYNONYMS.—Classification.—Much confusion, as regards nomenclature and classification, followed the adoption by many of the theory of Virchow that the sole characteristic of tuberculous disease is the presence of the so-called miliary tubercles. According to this theory, the morbid product which constitutes the most marked anatomical feature of the common form of phthisis is simply an inflammatory exudation. Heretofore, pulmonary phthisis and pulmonary tuberculosis were considered as convertible terms, but, adopting Virchow's theory, in a certain proportion of cases pulmonary phthisis is not a tuberculous disease. Hence arose a variety of names denoting non-tuberculous phthisis, such as chronic broncho-pneumonia, chronic lobular pneumonia, catarrhal pneumonia, cheesy pneumonia, etc. These names have shared the fate of the theory from which they originated, the latter, at the present time, having but few supporters in any country. It is convenient to distinguish the morbid product which is characteristic of pulmonary phthisis as a tuberculous product, and it will be so distinguished in this article.
The name acute pulmonary tuberculosis denotes an affection which may be sharply separated from the chronic forms of pulmonary phthisis. The acute affection is characterized by the presence, exclusively or in great abundance, of miliary tubercles. It runs a rapid course and the symptoms are those of an acute disease. The name phthisis implies a chronic affection. In a small proportion of the cases of pulmonary phthisis miliary tubercles become developed in great abundance. In these cases acute pulmonary tuberculosis supervenes upon chronic phthisis. These cases, by those who regarded phthisis in its ordinary form as a non-tuberculous affection, were designated cases of tuberculous phthisis. The fact that in cases of phthisis there is a liability to the supervention of miliary tubercles as abundantly as in cases of acute tuberculosis, is to be borne in mind, but it does not seem necessary to make a distinct variety of the disease on the basis of this fact. In some cases of pulmonary phthisis the tuberculous product is notably large at the outset, and destructive changes in the lungs go on continuously with unusual rapidity. To these cases the names phthisis florida and galloping consumption have been applied.
In view of what has been stated, the classification in this article will not extend beyond a division into the common form of pulmonary phthisis and the form distinguished as fibroid phthisis. The latter form has been designated chronic interstitial pneumonia, chronic pneumonia, and cirrhosis of lung. It is to be understood that reference is had to the common form of pulmonary phthisis, except in that portion of this article which has for its heading Fibroid Phthisis.
HISTORY.—Pulmonary phthisis, in typical cases, is developed so imperceptibly that it might with propriety be included among the so-called insidious diseases. A slight dry cough is the first local symptom. This increases, and after a variable period is accompanied by the expectoration of a small quantity of mucus. The latter becomes gradually more abundant, and has the characters of the sputa in cases of bronchitis. So slow is the increase of those symptoms before they are regarded as of sufficient importance to require attention that not infrequently the patient is unable to state precisely how long they have existed. They are generally attributed to a slight cold which will take care of itself or call for only popular remedies, and the existence of a grave disease may not have been suspected until a physical examination of the chest discloses the fact that the phthisical affection has already made considerable progress. Coincident with or preceding the commencement of cough is often some obvious impairment of the general health, as indicated by diminished muscular strength and endurance, decrease in weight, pallor of the complexion, and lessened appetite. The impairment, however, may not interfere with customary occupations, and may be evident to others when the patient takes no cognizance of it.
In not a few instances hæmoptysis is the event which first awakens suspicion of an important disease. The hemorrhage generally takes place without any apparent causation, and often in the night. It may be either slight or profuse. It may occur but once, or there may be recurrences after intervals of hours, days, or weeks. The cough in some cases dates from the occurrence of hæmoptysis. In other cases the hemorrhage or hemorrhages antedate the cough for a variable period.
From the time when the symptoms and physical signs render the diagnosis of the disease positive the history in different cases presents notable variations. Comparatively, the course of the disease is continuously progressive and rapid in cases of so-called galloping consumption. The characteristics of the disease in these cases are—an unusual degree of cough with abundant expectoration, rapid breathing, frequency of the pulse, persistent pyrexia, chills or chilly sensations followed by exacerbations of fever, profuse perspirations, anorexia, rapid emaciation with decreasing muscular strength, and a fatal termination after a few months. The physical signs in these cases show a large and progressively increasing amount of solidification from the morbid product, followed quickly by destructive changes.
The disease pursues a rapid course, and ends fatally whenever acute tuberculosis supervenes. This may occur in the early part of the chronic phthisical affection or at any period during its course. The supervention of the acute disease sometimes follows a profuse hæmoptysis. The characteristics are high fever, frequency of the pulse, cyanosis, prostration, and death within a few weeks or even a few days. The physical signs which denote a large extent of solidification of lung and the consequent destructive changes are wanting in these cases.
A small proportion only of cases of pulmonary phthisis fall in the category either of galloping consumption or of the supervention of acute tuberculosis. In by far the larger proportion the disease is chronic from the beginning to the end, and a fatal termination takes place after a period averaging from two to three years, the period sometimes extending to many years.
An important distinction, as regards the history of the disease, is expressed by the terms progressive and non-progressive. The disease is progressive when the local and the general symptoms denote more or less activity in the tuberculous process, the physical signs generally showing progressive extension of the pulmonary affection. It is non-progressive when symptoms and signs having the significance just stated are wanting. The disease may become non-progressive early or late, and at any period during its continuance. A stationary condition may continue indefinitely. The symptoms and signs may show processes of restoration—namely, disappearance of the tuberculous product, diminution in size, and the cicatrization of cavities. The disease is then said to be regressive. A regressive course is not extremely infrequent. It is more or less slow and may or may not end in recovery. A stationary condition, regression having taken place to a greater or less extent, is not infrequently observed. This condition may remain because the pulmonary lesions are too great to admit of restoration. In most cases the disease is not steadily progressive. It ceases from time to time to progress, the periods of non-progression varying much in duration. With each renewal of progress the physical signs generally show an addition to the tuberculous product. As a rule, this product does not increase continuously, but, as it were, by successive eruptions after intervals of time which may be either short or long.
Pulmonary phthisis in some cases ceases to progress, and regression continues, recovery taking place from an intrinsic tendency—that is, irrespective of any measures of treatment. This highly important fact has not hitherto been distinctly recognized by medical writers and practitioners. I have established it by having recorded a series of cases in which recovery took place without medicinal or other treatment and without any material change in habits of life.1 In these cases the disease may be said with propriety to be self-limited.2 The weight of this fact in its bearing on prognosis and treatment is obvious. That non-progression and regression ending in recovery may be brought about by judicious measures of management cannot be doubted; in other words, the disease may be arrested in a certain proportion of cases when non-progression and recovery would not have resulted from an intrinsic tendency or self-limitation.
1 Phthisis, in a Series of Clinical Studies, by Austin Flint, M.D., 1875.
2 Vide "Self-limitation in Cases of Phthisis," by Austin Flint, M.D., N.Y., Archives of Medicine, June, 1879.
Pulmonary phthisis proves fatal by undermining more or less slowly the powers of life. The appetite and digestion fail. There is progressive loss of weight and of muscular strength. A greater or less degree of pyrexia is persistent, with diurnal exacerbations and night perspirations, forming what is known as hectic fever. Muco-purulent matter is expectorated in abundance, with fatiguing cough. The respirations are accelerated, and there is often suffering from dyspnoea. The pulse becomes more and more frequent and weak. Oedema of the lower limbs is of frequent occurrence. The patient dies by slow asthenia, the mental faculties usually remaining intact and the patient hopeful of recovery to the last.
The history of the disease in many cases embraces tuberculous affections elsewhere than in the lungs, and other complications. The duration is often shortened by some of these. The more important are tuberculosis of the intestines, tuberculous peritonitis, perforation of lung giving rise to pneumo-hydrothorax, pneumorrhagia, pulmonary gangrene, tuberculous meningitis, and chronic laryngitis affecting deglutition. The less important affections are pleurisy with effusion, thrombosis of the femoral or the iliac vein, a circumscribed non-tuberculous acute pneumonia, chronic laryngitis not affecting deglutition, intercostal neuralgia, and perineal fistula. Profuse hæmoptysis is sometimes a grave event, and may prove the immediate cause of death.
It is impossible to divide the course of pulmonary phthisis into sharply-defined stages based on anatomical changes. Often after death the lungs present in different situations all the changes which intervene between a fresh tuberculous product and cavities. The division into a stage of crudity of the product and a stage of softening is of no practical utility. There are no symptoms nor signs which are reliable for determining when softening has taken place. The existence of cavities can generally be determined by means of the cavernous physical signs, and the disease may be considered as advanced phthisis when cavities are discovered. The term incipient phthisis is used to designate an early period of the disease. Having passed the incipient or early period, and before reaching the advanced stage or stage of excavation, cases may be conveniently grouped according to the amount of the tuberculous affection. In different cases and at different periods in the same case the affection is either small, moderate, considerable, or large. Exact chronological divisions are impracticable.
ETIOLOGY.—Pulmonary phthisis, as a rule, is developed irrespective of any antecedent affection of the lungs. The researches of Louis established the fact that the phthisical affection is very rarely preceded by bronchitis, either acute or chronic.3 My clinical studies have led to the same result.4 That a neglected cold may eventuate in phthisis is a traditional popular error, unfortunately held also by some medical writers and practitioners. The error is to be regretted because it often interferes with hygienic management in cases of phthisis. The name chronic catarrhal phthisis proposed by Niemeyer was based upon this etiological error. It is a matter of common clinical observation that persistent bronchial inflammation leading to pulmonary emphysema, and often accompanied by asthma, involves no liability to phthisis. The long-continued inhalation of coal- and stone-dust, of the oxide of iron, and particles of other substances gives rise to bronchitis and interstitial pneumonia (pneumonokoniosis, anthracosis, siderosis, etc.), but is rarely followed by the common form of pulmonary phthisis. It is common for phthisical patients to suppose, as a matter of course, that their disease originated in a cold. In giving the previous history they often say that they took cold at a certain time. The analysis of carefully-recorded cases shows that very rarely does the disease follow directly upon an attack of bronchitis, notwithstanding that the frequency of the latter, from the law of chances, would involve an accidental concurrence in a certain proportion of cases. Acute lobar pneumonia or pneumonic fever has little or no tendency to eventuate in phthisis. This statement is sustained by the researches of Louis and by my clinical studies. In the rare instances in which phthisis follows either acute pneumonia or bronchitis, the latter diseases act only as auxiliary causes of the phthisical affection if the sequence be more than an accidental connection. This statement applies also to pleurisy with effusion. In certain of the few instances of phthisis apparently having been preceded by pleurisy it is probable that the former was the antecedent disease, occurring early in the history of the phthisical affection and retarding or arresting the progress of the latter. It may be added that there is no ground for supposing that phthisis is ever produced solely by traumatic causes acting upon the chest.
3 Recherches sur la Phthisie, 1825.
4 Phthisis, in a Series of Clinical Studies.
It is an old doctrine that bronchial hemorrhage may be causative of phthisis. This doctrine has been recently revived by Niemeyer and some others. It is disproved by the following clinical facts: in two-thirds of the cases in which hæmoptysis antedates phthisis the development of the latter is after the lapse of a considerable period—weeks, months, or years. The instances are few in which phthisis immediately follows the hemorrhage. The occurrence of hæmoptysis during the course of phthisis, as a rule, is not followed by any increase of the phthisical affection. On the contrary, the local symptoms are not infrequently relieved by the hemorrhage. It is, however, to be remarked that hæmoptysis as a forerunner of phthisis is of much significance. In the larger proportion of cases phthisis follows its occurrence sooner or later. It is to be added, in view of the recent discovery by Koch, that bronchial hemorrhage may proceed from the same local cause which afterward leads to the development of phthisis—namely, the presence of a special micro-organism.
The etiology of pulmonary phthisis not involving any antecedent affections of the lungs nor any appreciable local causes, it would seem to follow that the disease involves either a predisposing or a causative agency elsewhere within the organism; and as, with our present knowledge, the source of this intrinsic agency cannot be localized, it is customary to say that the disease has a constitutional origin. This use of the term constitutional here, as in other instances, expresses an important fact—namely, that the disease is not purely local; that is, attributable solely to extrinsic or any appreciable causes acting on the affected part. At the same time, the term is a confession of the imperfection of our knowledge, inasmuch as it does not specify the nature of the causative or predisposing agency, nor its origin, beyond the statement that it is not local. That the constitutional agency has a special character is a logical inference from the fact that the disease may be said to have such a character. The term vulnerability does not fully express the special character of the constitutional agency. The condition of the constitution which stands in a causative relation to the disease is something more than an undue susceptibility to morbific influences of any kind—a susceptibility giving rise to diseases the nature and seat of which are accidental. The condition is one which has relation both to the character and the situation of the pulmonary affection. Such a condition is expressed by the term cachexia.
It remains to inquire whence arises this phthisical or tuberculous cachexia.
A congenital predisposition or diathesis exists in a certain proportion of cases. This is to be inferred from the number of instances in which several or many members of a household, brothers and sisters, become affected with phthisis. There may or may not be evidence that this predisposition is inherited. An inherited predisposition is to be inferred from the number of the cases in which parents or grandparents were phthisical. While statistical facts show undoubtedly heredity as involving a causative agency, making due allowance for the law of chances, it is important for the physician to bear in mind that a tuberculous parentage involves only a certain measure of liability to phthisis in the offspring. The progenitors of many healthy men and women have been phthisical. There are instances of large families of children in which many have died with phthisis, leaving, however, some who escape this disease and are in all respects healthy.5 The question arises whether in cases of phthisis where there is lack of evidence of a congenital predisposition the diathesis may not be innate. The affirmative answer seems probable in view of the inability oftentimes to find any rational explanation on the supposition that the diathesis has been acquired. Positive data bearing on this question are of course not available.
5 For data on which these statements are based, vide Phthisis, in a Series of Clinical Studies, by the author.
Age has a decided influence on the development of phthisis. Cases in which the ages of patients are between twenty and thirty years greatly preponderate over the number in any other decade of life. Next in order as to the number of cases are the ages between thirty and forty years. The form of tuberculous disease under present consideration is rare under ten years and also in advanced life. All that can be said with our present knowledge in explanation of the influence of age is, that either an existing diathetic condition tends intrinsically to the development of the disease or that the diathesis is likely to be acquired at certain periods of life more than at other periods. Of these two explanations the former is the more rational.
Statistics show that occupations which involve sedentary habits, confinement within doors, especially in small, illy-ventilated rooms, poor or insufficient food, and prolonged mental depression, increase the liability to phthisis. The disease is developed either during or shortly after gestation in a sufficient number of cases to show that pregnancy has a causative agency. Facts appear to show a less degree of prevalence of the disease in most cold and tropical climates than within the temperate zone. It is, however, true, as stated by Ruehle, that "there are regions in all zones which are free from the disease, and, on the other hand, there is no zone in which it is not very prevalent." The prevalence is less in high than in low altitudes. Humidity of the soil has been shown by Bowditch, Buchanan, and others to enter into the etiology. In order to determine how far purely climatic agencies exert an influence either for or against the prevalence of the disease, it is necessary to take into account other associated agencies, together with an innate predisposition; and the latter especially does not admit an exact estimation.
Certain general diseases seem to involve a liability to phthisis as a sequel. This is true of rubeola and pertussis. In cases of diabetes mellitus, phthisis is considered as occurring sufficiently often to show a causative connection. In my own clinical experience, however, phthisis has not been of frequent occurrence in that disease. Typhoid fever in some cases appears to favor the development of phthisis. Some, however, have contended for the reverse of this statement. Certain affections are apparently antagonistic in their influence. In this category are pulmonary emphysema and obstructive or regurgitant valvular lesions at the mitral orifice of the heart. The disease is rarely developed in chlorotic patients. Facts go to show that alcoholism opposes its development. In opposition to current belief, my clinical studies lead me to conclude that they who have had scrofulous disease of the cervical glands in early life are not likely to become phthisical in after years. Contraction of the chest from deformity diminishes the liability to the disease.
The communicability of phthisis is a doctrine dating as far backward as the history of medicine extends. Distinguished physicians in every age have held that the disease may be communicated under circumstances which involve close proximity, as from husband to wife or vice versâ, and from patients to nurses or attendants. The contagion is supposed to be contained in the expired breath. The clinical evidence in behalf of this doctrine is the number of instances which seem to be striking examples of communicability. It is easy to collect a considerable number of such examples. But in order to constitute clinical proof of the doctrine of communicability the number must be so large as not to be accounted for on the ground of mere coincidence. A collection of isolated instances gathered from medical literature or reports from different physicians does not establish the doctrine. Owing to the great frequency of phthisis, mere coincidence suffices to account for a certain number of instances. Moreover, long-continued proximity to cases of phthisis generally involves causative agencies other than a contagium—namely, confinement within doors and mental anxiety. In my collection of 670 recorded cases of phthisis, the number of instances in which there was room for the suspicion of the disease having been communicated either from the husband to the wife or from the wife to the husband amounted only to 5. In one of these instances, a wife, who became phthisical after her husband, had lost two sisters, one of whom was a twin sister, by the disease. It must be admitted that the analysis of these cases, without disproving the doctrine of communicability, fails to lend to it support, for the reason that in such a large collection of cases the number of examples of apparent communicability are so few.
A new and strong impetus was given to the discussion of the doctrine by the discovery of the inoculability of tuberculous disease. Villemin in 1865 demonstrated the fact that this disease could be communicated to rabbits and guinea-pigs by inserting beneath the skin portions of the tuberculous product. The experiments of Villemin and many others have shown conclusively that the insertion of fresh undecomposed tuberculous matter beneath the skin or within the pleural and the peritoneal cavity, or in the anterior chamber of the eye, is followed by an eruption of tubercles in these animals within two or three weeks. If tuberculous matter taken from an animal in which the disease has been produced by inoculation be inserted in another animal, the disease is transmitted to the latter. These results of inoculation, which have been abundantly confirmed in all countries, prove indisputably the communicability, by that mode, of tuberculous disease in certain animals which have a peculiar susceptibility thereto. The fact that the disease is not readily communicated to dogs, cats, and other animals shows a peculiar susceptibility to be an important factor in the successful results of inoculation. The conclusion drawn by Villemin and others from these experiments is that the disease is communicated by means of a specific virus, a term implying the existence of a contagium.
Opposed to this conclusion are experiments which appear to prove that tubercles may be produced in rabbits by inoculating them with various kinds of non-tuberculous matter. By those who adopt the doctrine of a specific virus it is contended either that true tubercles are not produced in these experiments, or that, if followed by the development of true tubercles, the production of the latter is attributable to the derivation of the virus from the laboratories in which tuberculous animals had been confined or to a contagium received directly from these animals. The introduction of non-tuberculous matter was found by Cohnheim and Fraenkel never to be followed by tuberculous disease when the experiments were repeated in places where tuberculous animals had not been confined and the animals on whom the experiments were made were isolated from those affected with tuberculosis. Cohnheim states that inoculation with portions of indurated lung, or of the nodules resulting from peribronchitis, or of the contents of bronchiectasic cavities, will not give rise to true tubercles, for the reason that, although taken from phthisical lungs, they do not contain the tuberculous virus. This distinguished pathologist, at first an opponent of the doctrine of a specific virus, afterward became a strong advocate therefor. He was led to regard a successful inoculation as affording the only criterion and reliable test of tuberculous disease; that the etiology of tuberculous disease invariably involves the presence in the system of this virus; that it exists in a latent form whenever there is an innate predisposition to phthisis; and that it may enter the system in different directions—namely, with the inspired air into the lungs, and even within the skull through the foramen of the ethmoid bone, into the small intestine by deglutition, and into the uterus with the semen. Becoming developed in any situation, the virus may remain localized, or it may be disseminated more or less extensively by means of the lymph and blood. The behavior of the tuberculous virus, according to Cohnheim, corresponds closely to that of syphilis.
Experiments made by Gerlach, Bollinger, Aufrecht, Chaveau, Leisering, Harms, Gunthern and others, have shown that the disease may be communicated by incorporating tuberculous matter with food. Rabbits, guinea-pigs, dogs, calves, swine, sheep, and goats have been rendered tuberculous by these experiments. Klebs, Tappeiner, Parrot, and Puech claim to have communicated the disease by combining with the food the matter of expectoration from phthisical patients. Gerlach and Klebs have seen the disease in animals fed with milk from cows affected with the so-called pearl disease (perlsucht), which is considered to be identical with phthisis. Finally, the disease appears to have been produced by exposing animals to an atmosphere impregnated with fine particles of tuberculous matter by means of an atomizer, and by blowing into the trachea this matter reduced to a fine powder.6
6 For a summary of the experiments relating to the communicability of tuberculous disease by inoculation, by the ingestion of tuberculous matter, and by its inhalation, and for reference, the reader is referred to an article by Wm. P. Whitney in the Boston Medical and Surgical Journal, July 28, 1881; to the article on "Tuberculosis" by Frederick C. Shattuck in supplement to Ziemssen's Cyclopædia of the Practice of Medicine, 1881; to the "Cartwright Lectures," by William T. Belfield, M.D., published in the New York Medical Record in February and March, 1883; and to an article by Surgeon George M. Stemberg, U. S. Army, in the American Journal of Medical Sciences, January, 1885.
It is noteworthy that tuberculous disease may be produced by inoculating with the infiltrated product, with matter from miliary tubercles, or from scrofulous glands in the neck. The identity of these morbid products is thus made evident, assuming that the fact of communicability involves the existence of a specific virus.
The practical importance of the facts already ascertained respecting the communicability of phthisis is obvious. They constitute the foundation for a reasonable supposition that the disease may be communicated to man by means of the meat of tuberculous animals, by milk, and by breathing an atmosphere charged with particles of tubercle. That the instances in which the disease is communicated, however, are rare seems to be a rational inference from the difficulty of obtaining clinical proof of communicability. That susceptibility is an essential factor is made evident by the well-known predisposition pertaining to certain periods of life. It is to be considered that while the communicability of the disease to certain animals is abundantly shown by the experiments to which reference has been made, the existence of a special virus or a contagium is not as certainly established by these experiments. They leave to be settled, by further investigation, the question whether or not the communicability of the disease involves only the agency of a septic matter devoid of the special character expressed by the terms virus and contagium. Without waiting for data sufficient to settle this important question, prudence would dictate the propriety of all practicable precautionary measures.
Still more recently, and since the foregoing remarks on the communicability of phthisis were written, have appeared the remarkable experimental researches of Koch of Berlin. Koch claims to have demonstrated the constant presence in tuberculous products of a specific organism which he calls the bacillus tuberculosis, and that it is not found in non-tuberculous products. This parasite he has isolated, and by cultivation carried through several successive generations. By its introduction, after, as well as before, cultivation, into the pleural cavity, the peritoneal cavity, the anterior chamber of the eye, and in other situations, he produced tuberculous disease, not only in rabbits and guinea-pigs, but in dogs and rats, the latter animals being less susceptible than the former to tuberculous infection. In his experimental observations, animals not inoculated, placed under the same external conditions as those inoculated, did not become tuberculous. The same parasite, alike capable of infecting healthy animals, he found in miliary tubercles, in the cheesy tuberculous deposit, in scrofulous glands, and in the sputa from tuberculous patients. The parasite was found not to have lost its vitality in dried sputa.7
7 For the details of Koch's researches vide his report in the Berliner klinische Wochenschrift, April 10, 1882; vide, also, Verhandlungen des Congresses für Innere Medicin, Erster Congress gehalten zu Weisbaden, 20–22 April, 1882.
The researches of Koch had been continued for two years before the publication of the results in March, 1882. Moreover, his ability as a skilled experimental observer in the study of micro-organisms, and his sincerity as a truth-seeker, are universally admitted. Naturally, the publication of the results of his researches excited at once great interest in all countries. At the present moment (April, 1885) questions connected with the bacillus tuberculosis are more considered than any others relating to medical pathology and etiology. Thus far, the observations of competent medical mycologists are confirmatory of the results of the researches by Koch. It seems to be established that the so-called bacillus tuberculosis is uniformly present in tuberculous products, and as uniformly absent in other morbid products; that it is generally present in the sputa of phthisical patients, and never present in the sputa of non-phthisical patients; and that tuberculous disease in animals may be produced by inoculation with this organism after cultivation has been sufficiently continued to eliminate all else pertaining to the tuberculous product. On these data are based the conclusions that phthisis is an infectious disease—in other words, that it involves in its causation a specific agent capable of self-multiplication; that it is a communicable disease, and that the agent of the communication is the bacillus tuberculosis—that is, this agent is the contagium. The supposition that the presence of the bacillus is secondary to the tuberculous affection is not tenable in view of the fact that the affection is produced by the introduction of this organism after it has passed through several generations by culture out of the body.
As has been already seen, clinical experience fails to furnish positive proof of the communicability of phthisis. There are many striking instances which, taken by themselves, render it probable that the disease was communicated; but, on the other hand, there are so many cases of its development under circumstances not pointing to contagion, and of the number of persons in close proximity to tuberculous patients the proportion of those who become affected is so small, that it has seemed impossible to establish the doctrine of contagion by clinical evidence.
The insufficiency of clinical proof, however, cannot invalidate the demonstration by inoculation. Assuming it to be demonstrated that the disease involves a specific agent, and that this agent is proven to be a contagium by its capability of producing the disease when introduced into a healthy body, the conclusion as to communicability is not to be shaken by the lack of corroborative clinical evidence or by inability to explain certain facts which seem to be inconsistent with that conclusion. Having accepted a demonstrated truth, the endeavor should be to reconcile therewith facts which do not sustain it and which may appear to be opposed to it. It remains to inquire in what way the communicability of phthisis by means of a contagium vivum is to be reconciled with facts furnished by clinical experience.
If we accept the conclusion that a particular parasitical organism is the primary and efficient causative agent in the production of phthisis, the development and multiplication of this organism must require certain local conditions. Without these the parasite is innocuous. The conditions are to its development and multiplication what the peculiarities of soil are to the production of different vegetables. Of the nature of these conditions we are at present ignorant. When they exist the bacillus develops and multiplies; when they are wanting the parasite is incapable of development and multiplication. This dependence of specific morbific agents upon particular conditions is exemplified in other infectious diseases. For example, the contagium of the eruptive fevers, received into the system ever so abundantly, is inoperative in some persons, and, as a rule with rare exceptions, it is never operative after the disease which it occasions has been once experienced. In these instances it is not the contagium itself which has lost the capability of producing the disease, but the conditions for its activity are wanting. Of the nature of these conditions we know as little as of those which are essential to the development and multiplication of the bacillus tuberculosis. The inoculation of animals with tuberculous matter shows that the disease is produced in some species of animals much more readily than in other species, and some animals of the same species much more than others are susceptible to this contagium. These facts are to be explained by variations in different species of animals, and in different animals of the same species, as regards the conditions required for the efficiency of the morbific agent.
The facts in the clinical history of phthisis which denote a constitutional predisposition thereto or a tuberculous cachexia are explicable by reference to the conditions requisite for the development and multiplication of the parasite. A predisposition which may be innate, inherited, or acquired involves the existence of these conditions. The latter may be greater or less in degree. The causative agencies of confinement within doors, humidity of soil, pregnancy, etc. operate by either giving rise to or increasing these conditions. If this view be correct, it is evident that the curative influence of climatic changes, alteration of the habits of life, and other hygienic agencies must be by means of an effect exerted upon these conditions; and probably it is in this way chiefly that remedies are useful. Of the essential nature of these conditions we know neither more nor less than of what consists the tuberculous cachexia. We are, of course, as ignorant of the one as of the other if it be assumed that they are identical—that, in other words, the different expressions have the same meaning. The only difference is this: If phthisis be an infectious and a communicable disease, a contagium enters into its etiology; whereas if the existence of a contagium be denied, it follows that the cachexia is itself sufficient for the causation of the disease.
In connection with the etiology of phthisis a theory which of late years has found favor with many should be referred to. It is, that this disease may be a result of the absorption of caseated non-tuberculous morbid products in different parts of the body. This theory of autochthonous infection derives but little support from clinical observation. In much the larger proportion of the cases of phthisis it is impossible to discover anywhere caseated morbid products which may be supposed to have a causative connection with the disease. To assume that, when not discovered, foci of infection nevertheless are concealed somewhere within the organism is evidently begging the question. On the other hand, how often do suppurations, necroses, and degenerated morbid products occur in different situations without being followed by phthisis!
SYMPTOMATOLOGY AND COMPLICATIONS.—Giving under this head a fuller account of the symptomatology and complications than has been already given in sketching the history of the disease, it will be a convenient arrangement to consider these topics in their relations to the different anatomical systems of the body—namely, the respiratory, circulatory (including temperature), hæmatopoietic, digestive, nervous, and genito-urinary systems.
Symptoms, etc. referable to the Respiratory System.—The dry cough which is the earliest pulmonary symptom in typical cases is to be regarded as an effect of the local irritation caused by the presence of the tuberculous product. This product, increasing and extending, gives rise to circumscribed bronchitis which causes increase of cough with expectoration. The expectoration represents this secondary bronchitis prior to the occurrence of ulceration, the escape of liquefied tuberculous product, and the existence of cavities. The quantity and the characters of the matter expectorated depend on the degree and the extent of the bronchial inflammation, the latter depending on the extent of the phthisical affection. Different cases present wide variations in these respects. The frequency and severity of the cough depend in a great measure on the quantity of the matter of expectoration and its adhesiveness. The matter expectorated, at first semi-transparent mucus, becomes muco-purulent, the characters pertaining to mucus and pus being combined in varying proportions, as in cases of chronic bronchitis. Nummular sputa—so called from the resemblance in form to a coin when lying on a flat surface, the edges often serrated—are considered as casts of small cavities formed by dilated bronchi. A microscopical examination of the sputa may show elastic yellow fibres. The presence of these is almost pathognomonic of phthisis, and denotes either the process of ulceration or exfoliation of tissue from within cavities.8 Liquefied tuberculous product appears in the matter of expectoration as a puriform fluid. It sometimes contains small semi-solid tuberculous masses. The lining membrane of tuberculous cavities furnishes a veritable purulent matter of expectoration. It is stated by Buhl that the presence of alveolar epithelium in the sputa is distinctive of phthisis; hence the name proposed by him, desquamative pneumonia. It is, however, stated by Frischl that the alveolar epithelium is found in the matter expectorated in cases of oedema and congestion of the lungs.9 There is sometimes notable fetor of the matter of expectoration, due to putrescent decomposition of the purulent contents of cavities or to small sloughing portions of pulmonary tissue. The varieties of sputa which have been mentioned may be accompanied by a serous liquid in more or less abundance. Calcareous masses varying in size from a pin's head to a pea are expectorated in some cases. I have known several hundred to be expectorated in a single case. In the instances which have fallen under my observation these pulmonary calculi have been expectorated when the symptoms have denoted arrest and regression of the disease; and it is consistent with this fact to regard them as obsolete tubercles. They are not to be confounded with the small solid bodies sometimes formed in the follicles of the tonsils, the latter consisting of a sebaceous-like product, which is crushed, without crumbling, by pressure, and emits a fetid odor. Since the discovery of the bacillus tuberculosis by Koch microscopical examinations of sputa in a large number of cases by different observers have shown that this parasite is generally, but not invariably, present. Its abundance in the sputa appears to correspond to the rapidity with which the tuberculous affection is progressing, and examinations with reference to its presence and its abundance are of much practical utility in diagnosis and prognosis.
8 In order to discover the elastic fibres readily, Fenwick advises as follows: "Prepare a solution of caustic soda, about twenty grains to an ounce of distilled water. Collect all the patient has expectorated in twelve or twenty-four hours, from ten at night to ten the next morning being the best period. Pour this, previously mixed and well shaken with an equal quantity of the soda solution, into a glass beaker, and boil it over a gas or spirit-lamp, stirring it occasionally with a glass rod. A test-tube does not warm as well as a beaker. As soon as it boils pour it into a conical glass, and add four or five times the amount of cold distilled water. If the mucus is still gelatinous after boiling, you have either added too little soda or not boiled it sufficiently. The cold water carries down to the bottom of the glass any lung-tissues that may be present, where they form a slight deposit in about a quarter of an hour; if no deposit is visible, put the glass aside for two or three hours. Remove the deposit with a dipping-tube, place it in a glass cell, cover it with a piece of thin glass, and examine with a one-inch object-glass. The lung-structures will be often found clinging to hairs and other foreign bodies present in the sputa" (Guide to Medical Diagnosis).
9 Vide Niemeyer by Seitz, tenth ed.
Hæmoptysis occurs in a large proportion of the cases of pulmonary phthisis. It occurs much oftener in the early than in a later period of the disease. As regards the number of attacks, their duration, the intervals between them, and the amount of hemorrhage, there are wide variations. Prior to the formation of cavities the hemorrhage is from the bronchial tubes (bronchorrhagia). After cavities are formed the blood comes from the interior of these. As a rule, bronchial hemorrhage is not followed by the evidence of any increase of the phthisical affection. Not infrequently a sense of relief follows. The analytical study of a large collection of cases shows that the occurrence of bronchial hemorrhage does not diminish, but apparently increases, the chances of arrest and of tolerance of the disease. This statement holds true with regard to cases in which the hemorrhage is often repeated and profuse, as well as to those in which it is slight and infrequent.10
10 Vide Phthisis, in a Series of Clinical Studies, by the author.
Cavernous hemorrhage may be due to rupture or ulceration of parenchymatous bands which traverse cavities, but often it is caused by the bursting of small aneurisms in their walls. It may be so profuse as to prove fatal. Cavities sometimes become filled with coagulated blood, which, if life continue, becomes decomposed and gives rise to a grumous, fetid matter of expectoration. Bronchial hemorrhage is supposed to be caused by a circumscribed hyperæmia at the situation where the blood escapes. In a case under my observation in which death took place shortly after a profuse hæmoptysis, there was congestion limited to the middle lobe of the right lung, and the bronchial tubes in this situation contained bloody mucus, none being found elsewhere. A circumscribed hyperæmia, however, must depend upon some local cause. Probably in most instances this anterior local cause is the tuberculous product. That the escape of blood involves a change in the coats of the vessels from which it escapes is probable.
A rare event occurring in connection with hæmoptysis is the coagulation within the bronchial tubes of fibrin which may be expectorated in the form of casts of the tubes, analogous to those which characterize fibrinous or plastic bronchitis. I have met with an instance, and also with a case in which after death the bronchial tubes of an entire lobe were found to be filled with solidified fibrin. The death in this instance followed quickly a profuse hæmoptysis. There is not the danger connected with the gradual disintegration and expectoration of the coagulated fibrin which was surmised by Niemeyer.
The presence of the tuberculous product in the lungs and the processes to which it gives rise, inclusive of the secondary bronchitis, occasion no pain. Patients often strike the chest with violence, as affording to them evidence that the organs are sound. But in most cases, from time to time during the course of the disease, sharp stitch-like pains occur. They are sometimes slight or moderately severe, but they may be sufficiently intense to confine to the house or even to the bed. They last, usually, but a few days, and recur at variable intervals. They are referred generally to the upper part of the chest, often beneath the scapula. Patients are apt to imagine that the pains are rheumatic. They are symptomatic of successive, circumscribed, dry pleurisies, which are very rarely wanting in cases of phthisis, leading to the pleuritic adhesions constantly found after death. These pleurisies are secondary to the phthisical affection, and recur at epochs when new developments of the latter take place. There is no reason to suppose that they contribute in any way to the increase of the phthisical affection. On the other hand, they protect against one important event at least—namely, perforation of lung, and, as consequent thereon, pneumo-hydrothorax. In this point of view they are conservative. These pleuritic pains are to be discriminated from those of intercostal neuralgia. The neuralgic pains generally are situated lower, and the diagnostic criterion of intercostal neuralgia is available—namely, the tenderness on pressure in the intercostal spaces near the median line in front, the axillary line, and the spinal column.
The respirations are more or less frequent in different cases and at different periods in the same case according to the impairment of the function of hæmatosis by the pulmonary affection and the increased frequency of the heart's action. A sense of the want of breath as implied in the term dyspnoea is, however, seldom sufficient to occasion much suffering. Even when the respirations are considerably increased in number it is rare for the patient to complain of the want of breath when at rest. A degree of muscular weakness which prevents the patient from freeing the bronchial tubes and cavities of morbid products may give rise to distressing dyspnoea. A sudden increase in the frequency of the respirations, with dyspnoea and cyanosis, when not attributable to filling of the bronchial tubes nor to pneumothorax nor pleuritic effusion, points to the development of miliary tubercles in abundance—in other words, to the supervention of acute tuberculosis.
Important complications referable to the respiratory system are laryngitis, non-tuberculous pneumonia, pleurisy with effusion, perforation of lung with pneumo-hydrothorax, pneumorrhagia, and pulmonary gangrene.
Dysphonia and aphonia, the voice being husky or hoarse and the whisper stridulous, denote laryngitis. These diagnostic symptoms are never wanting, and the laryngeal complication may be excluded if they be absent; but the extent to which the larynx is affected is of course determinable by means of the laryngoscope. The affection in some cases extending to the epiglottis, paroxysms of cough and spasm of the glottis are produced by the act of swallowing food and drinks. The interference with deglutition may be so great as to restrict seriously alimentation, and in this way may hasten a fatal termination of the disease. In the majority of cases, however, deglutition is not interfered with. There is very rarely laryngeal obstruction to respiration. The affection involves little if any liability to the supervention of acute laryngitis or oedema of the glottis.
In most cases the laryngitis occurs at a considerable period after the commencement of the pulmonary affection, this period, in a proportion of more than one-third, being from two to four years. In some instances it seems to occur coincidently with, and in some to precede, the pulmonary affection. In the latter instances it is probable that latent tuberculous disease of the lungs preceded the laryngitis. The diversity as regards the interval of time between the date of the pulmonary affection and of the occurrence of the laryngitis, the apparent coincidence in the occurrence of both in some instances, and the want of any uniformity in different cases as regards the amount of pulmonary disease and the stage of its progress when the laryngitis occurs, render it a rational conclusion that laryngitis is not dependent on the disease of the lungs, but that it proceeds from the same cause which determines the latter.
Excluding the instances in which the laryngitis involves the epiglottis and interferes with alimentation, clinical experience teaches that this complication does not diminish the chances of arrest or recovery from the pulmonary affection, and that it has no untoward influence on the duration of the disease in the cases which sooner or later end fatally.11 As a rule, in cases which recover the voice remains permanently more or less affected.
11 Vide Phthisis, in a Series of Clinical Studies, by the author.
Acute lobar pneumonia or pneumonic fever is sometimes an intercurrent affection in cases of phthisis. The cases are so rare as to show absence of any predisposition to that disease derived from the phthisical affection. The pneumonia ends in recovery in a proportion of cases sufficiently large to show that, as a rule, the prognosis is not unfavorably influenced by phthisis, and, as a rule also, the course of the latter is not influenced unfavorably by the pneumonia. A circumscribed pneumonia is an occasional complication of phthisis. Its non-tuberculous character is shown by the rapidity and completeness of the absorption of the intra-vesicular product. This circumscribed pneumonia gives rise to physical signs which appear to denote a rapid and considerable increase of the phthisical affection. The disappearance within a short period of the added dulness on percussion, bronchial respiration, and bronchophony, is the evidence that these signs represent a circumscribed pneumonia occurring as a complication.
Pleurisy with serous effusion is not an infrequent complication at an early period in the course of the disease. There is very little if any liability to its occurrence at an advanced period, except as associated with pneumothorax from perforation of lung. It is probably secondary in certain of the cases in which the phthisical affection appears to follow the pleurisy. The pleuritic effusion appears to retard the progress of the phthisical affection. Clinical experience shows that this complication, if it be unilateral, is not an untoward event. A double pleurisy with effusion is evidence of the existence of phthisis.
Perforation of lung, giving rise to pleurisy with effusion and pneumothorax, is an event which belongs, with some exceptions, to an advanced period of the disease. The perforation is caused by rupture of the wall of a cavity superficially situated where pleuritic adhesion from circumscribed dry pleurisy had not taken place. In most instances the occurrence of the perforation is quickly followed by acute pain and orthopnoea, with notable disturbance of the circulation, fever, and prostration, these symptoms being due to the sudden entrance of air into the pleural sac, the development of acute inflammation, and rapid serous effusion. The recognition of the pneumo-hydrothorax by means of physical signs is easy. The suffering of the patient becomes less after twenty-four or forty-eight hours. In the great majority of cases death takes place within a short period; that is, within a few days or weeks. The duration of life depends on the amount of phthisical disease, together with the condition of the patient as regards strength, etc. In some instances, the perforation taking place when the phthisical affection is small and accompanied by favorable symptoms, the pneumo-hydrothorax is tolerated for a long period. The accumulation of liquid within the pleural sac sometimes causes the air to disappear, and the pneumo-hydrothorax is converted into simple pleurisy with large effusion.
Pneumorrhagia and pulmonary gangrene are very rare complications of pulmonary phthisis. The analytical study of nearly 700 recorded cases furnished but a single example of each of these complications.
Symptoms and Complications referable to the Circulatory System, including Temperature.—More or less acceleration of the pulse and elevation of the temperature of the body belong to the clinical history of pulmonary phthisis. It may be stated that the pulse and temperature are never normal if the disease be progressive. A persistent normal pulse and no elevation of temperature therefore denote arrest or non-progression of the disease. It may also be stated that the acceleration of the pulse and the increase of temperature form a good criterion of the rapidity or otherwise of the progress of the tuberculous disease, provided inflammatory complications be excluded. The disease is progressing rapidly in proportion to the frequency of the pulse and the increase of temperature.
If the disease be progressive daily exacerbations of fever take place. They occur in the afternoon usually, and continue into the evening or the nighttime, ending in perspiration which is more or less profuse. The exacerbations are often, but not always, preceded by chilly sensations, and sometimes by a well-pronounced chill which may be accompanied by rigors. During the febrile exacerbations the cheeks frequently present a circumscribed flush and the eyes have a glistening appearance. The term hectic fever has long been applied to the febrile exacerbations which characterize progressive phthisis.
The febrile exacerbations sometimes occurring prior to the development of marked pulmonary symptoms may be supposed to be malarial manifestations. Recurring daily at or near the same hour, they may simulate closely the paroxysms of intermittent fever. A differential point is the existence of more or less fever between the exacerbations in cases of phthisis, whereas after a paroxysm of intermittent fever there is apyrexia. Another point is, the occurrence of exacerbations in cases of phthisis is generally after mid-day, whereas in the majority of cases of intermittent fever the paroxysms occur earlier. But of course the existence of phthisis is to be ascertained by means of the diagnostic symptoms and the physical signs. It is, however, to be borne in mind that phthisis and intermittent fever may be associated.
The profuse night-sweating which is a source of great discomfort in cases of phthisis has no fixed relation to the intensity of the fever which precedes it. The fever may be high and very little perspiration follow, and vice versâ.
Acceleration of the pulse and elevation of temperature may arise from an inflammatory complication, such as pleurisy, pneumonia, or peritonitis, and from the supervention of acute miliary tuberculosis.
To endeavor to explain the rationale of the acceleration of the pulse and the rise of temperature would require the consideration of the general pathology of the febrile state. The absorption of septic matter is probably a factor, but is hardly sufficient for a full explanation, and it would not be easy, with our existing knowledge, to explain the modus operandi of this morbific agent. The difficulty here, however, is not greater than in explaining the phenomena of fever when occurring in other pathological conditions. Here, as in other instances, there is no uniformity in the relative degree of acceleration of the pulse and the increase of temperature. The latter may be high without a proportionate disturbance of the circulation, and the reverse. Clinical experience shows a connection between a persistent high temperature and the waste of the body, and in proportion as the vital powers decrease the action of the heart is enfeebled, and a notably small and weak pulse denotes that death by asthenia is not far distant.
Thrombosis of the iliac vein on one side or on both sides is an occasional event in cases of advanced phthisis (marantic thrombosis). The effect is a considerable oedema of the lower limb or limbs. Oedema of both lower limbs, however, occurs as an effect of feebleness of the systemic circulation. If, as is sometimes observed, there be general dropsy, it denotes a renal complication, which is generally the waxy variety of chronic Bright's disease. Under these circumstances the urine is found to be albuminous.
Symptoms and Complications referable to the Hæmatopoietic System.—Pallor of the face is generally more or less marked from an early period in the history of phthisis, and it becomes, as a rule, more and more marked as the disease progresses. There is considerable variation in this respect in different cases. Impoverishment of the blood is in a great measure to be explained by the diminished ability to ingest and assimilate food. It is not, however, in all cases proportionate to defective alimentation, and therefore it is a fair inference that the disease in some other unknown way interferes with the blood-forming processes. Exceptionally, in some cases in which the disease is progressing, pallor is wanting. The complexion sometimes retains for a long time a rosy color. This is probably due to the condition of the vessels, and is not evidence of a normal condition of the blood. It is a noteworthy fact that notwithstanding the appearances denoting anæmia in cases of phthisis the venous hum in the cervical veins is, as a rule, wanting.
That the impoverishment of the blood is an effect of the disease, and that it does not contribute to the progress of the tuberculous affection, may be inferred from the fact that anæmic patients are not likely to become phthisical. This fact, which has already been stated, is established by clinical observation. Nor do the diseases relating to the hæmatopoietic system, anæmia being a prominent feature in all—namely, leucocythæmia, Hodgkin's disease, pernicious anæmia, and Addison's disease—involve any special liability to phthisis. Other intercurrent affections occasion death in these diseases when it is not due exclusively to the latter.
Symptoms and Complications referable to the Digestive System.—The opinion has been held that the development of phthisis is preceded and accompanied by appreciable disorder of the digestive system. This opinion is not sustained by the analysis of carefully-recorded cases. In many, and perhaps the majority of, cases at the time of the commencement of the phthisical affection the appetite is not notably impaired and the digestive functions appear to be well performed. Sooner or later, however, the appetite fails. This symptom may be marked when the food which can be taken does not occasion evidence of indigestion. Different cases differ very much as regards the degree of anorexia. It is marked in the cases in which there is notable increase of temperature and acceleration of the pulse. It is often invincible; that is, not only is the desire for food wanting, but there is a degree of repugnance which renders it impossible for the patient to take it. It is intelligible that in these cases emaciation and exhaustion must be progressive. It is not more easy to give a pathological explanation of anorexia as an effect of phthisis than when the symptom occurs in connection with other diseases not involving either inflammation or any ascertained structural affection of the digestive organs. The symptom is probably connected with morbid changes within the gastro-intestinal or peptic glands.
Vomiting is a rare symptom in cases of phthisis, except it be produced sympathetically in paroxysms of coughing. As thus produced it is not rare. It is of importance from its interference with alimentation.
Diarrhoea is a frequent symptom. It may be due either to intestinal indigestion or to a subacute enteritis or colo-enteritis thereby induced. A waxy or fatty affection of the liver may conduce to diarrhoea by interference with the digestion of certain alimentary principles. If, however, the diarrhoea be persistent, it points to intestinal ulcerations. These are usually seated in the Peyerian and solitary glands within the small intestine, but not infrequently they are found after death in the large intestine, and in the small intestine above the portion in which the Peyerian glands are situated. The number and extent of the intestinal ulcers found after death do not always correspond to the prominence of diarrhoea as a symptom. They cannot be excluded by the fact that this symptom is not prominent. The presence of pus and blood in the dejections is evidence of ulcerations. If the ulcers be situated high up in the intestinal tract, the pus and blood may have undergone changes which render them unrecognizable by the naked eye, and the microscope is necessary to demonstrate their presence. The diarrhoea is often accompanied by griping or colic-like pains. In proportion as diarrhoea is prominent it contributes to emaciation and exhaustion. These effects are expressed by the term colliquative, which has long been applied by medical writers to exhausting diarrhoea and perspirations occurring in cases of phthisis.
Peritonitis occurs in phthisis as an acute and as a chronic affection. When acute, it is caused by intestinal perforation incident to ulcerations; this is a rare accident. It is to be inferred whenever the symptoms denote rapidly-developed acute peritoneal inflammation. The peritoneal sac contains intestinal gas. Perforation is excluded if percussion shows dulness or flatness over the site of the liver. The normal hepatic dulness or flatness on percussion is always abolished if the peritoneal cavity contains gas. A tympanitic resonance over the liver, on the other hand, is not evidence of the presence of gas within the peritoneal cavity, inasmuch as this resonance may be conducted from the transverse colon distended with gas. Peritonitis from perforation is speedily fatal. In a chronic form the peritonitis may be preceded by an eruption of miliary tubercles in this situation, or the inflammation may have proceeded from intestinal ulcerations, perforation not having taken place. The local symptoms of chronic peritonitis are often not marked. The diagnosis is to be based on pain, tenderness, muscular rigidity, and the signs denoting liquid within the peritoneal sac. A chronic peritonitis may be associated with a small pulmonary affection which may not actively progress, and under these circumstances the peritoneal complication may be tolerated for a considerable period.
Peritoneal fistula may be reckoned among the complications referable to the digestive system. It occurs sufficiently often in cases of phthisis to show some pathological connection. Analysis of cases in which it occurs affords no evidence of its having an untoward influence on the course of the phthisical disease. On the other hand, there is ground for the opinion generally held that it either occasions or betokens slowness in the progress of the pulmonary affection. It follows that it is unwise to attempt to effect a cure by surgical interference. The characteristic bacilli have been found in the matter derived from peritoneal fistula, showing that this affection is tuberculous in character.
Symptoms and Complications referable to the Nervous System.—The symptoms referable to the nervous system relate to the mind. The mental faculties in most respects remain intact, except that in proportion to the general feebleness there is diminished ability to continue their exercise. The integrity of the intellect, with one exception, often remains up to the last moment of life. A marked characteristic of the disease, however, is a delusion in respect to improvement and recovery. In spite of the progressive emaciation and debility, which are obvious to every one, patients are apt to believe that their condition is becoming more and more favorable and to feel confident of restoration to health. Even medical men affected with phthisis manifest the same delusive ideas. So strong is the determination in some cases to keep up the delusion that the statements of patients in regard to their symptoms cannot be relied upon. They are sometimes offended if the physician feels it to be his duty to intimate danger. On the other hand, when patients are convinced of the nature of the disease, and that they have not long to live, as a rule they become quickly and completely reconciled thereto. Perhaps there is no other chronic disease in which the near approach of death is generally regarded with greater complacency.
Cephalalgia, delirium, and coma are symptoms which are developed in a few cases. They denote tuberculous meningitis. This is a very rare complication in the adult. When it has given rise to the symptoms just mentioned a speedy fatal termination is to be expected.
Symptoms and Complications referable to the Genito-urinary System.—Tuberculous disease of the kidneys, testicles, ureters and the prostate gland is sometimes secondary to pulmonary phthisis. The local symptoms will depend on the situation and amount of the tuberculous product, together with the destructive changes to which it gives rise. The consideration of the anatomical conditions and the symptomatology falls properly under the head of diseases of the genito-urinary system.
As already stated, the variety of chronic Bright's disease known as the amyloid or waxy is an occasional complication in cases of phthisis. The other varieties may coexist, but the coexistence is rare. There is no tendency in phthisis to these affections, and, on the other hand, they do not involve any predisposition to phthisis.
As regards functional disorders of the genito-urinary system, there is nothing noteworthy which pertains to the urine. From the readiness with which often phthisical patients of either sex enter into the marital relation it may be inferred that the disease does not for a considerable period extinguish the sexual instinct. By interrogating a considerable number of patients Louis was led to conclude that in men the disease has an erotic influence.12 Phthisical women do not readily conceive, but pregnancy is not extremely infrequent. They may give birth to healthy children. During the course of phthisis the menses, as a rule, cease, but they continue in some cases up to a late period in the history of the disease. When suspended early they may return if the disease become non-progressive. That the cessation of the menses has an unfavorable influence on the tuberculous affection is a popular error. Nothing is gained by efforts to bring about their return. Their cessation, however, is not a good omen, and their return has a favorable significance.
12 Recherches sur la Phthisie.
MORBID ANATOMY AND PATHOLOGY.—In the definition of the common form of pulmonary phthisis were embraced the leading anatomical characteristics of the disease. For a full account of these, together with the changes referable to peribronchitis, periarteritis, endoarteritis, secondary pleuritis, and bronchitis, as well as for histological appearances, the reader is referred to treatises on morbid anatomy. The practical objects of this article will be fulfilled by stating the abnormal physical conditions incident to the morbid changes in different cases and at different periods in the same case, and by a statement of the anatomical points involved in the general pathology. Knowledge of the abnormal physical conditions is essential with reference to physical signs and the diagnosis. It has also an important bearing on the prognosis, and is not without importance in its relations to the treatment.
Certain anatomical facts may be premised, as follows: The pulmonary affection begins at or near the apex of one lung in the vast majority of cases; exceptionally it begins at the base of one lung. The affection extends from the apex downward. The extension is not continuous in respect of time, but a series of tuberculous deposits or eruptions takes place at different epochs after variable intervals. Hence it is that different sections of one lung may show all the changes which intervene between a fresh deposit and tuberculous cavities. As a rule, not long after the affection begins in one lung the other lung is affected. This rule is so constant that, although both lungs are not affected simultaneously, the affection may be said with propriety to be bilateral. The constant occurrence of secondary circumscribed pleurisies and bronchitis has been stated under the head of Pulmonary Complications.
At an early period of the disease the marked changes appreciable by physical signs usually consist of a few hardened patches or nodules varying in size from that of a pea to that of a filbert, situated at or near the apex of one lung. The physical signs are those of slight solidification—namely, some dulness on percussion, increase of vocal resonance, and broncho-vesicular respiration. The presence of the morbid deposit causes circumscribed bronchitis affecting the smaller tubes, and this complication may give rise to subcrepitant râles within the area of the tuberculous affection. The disease may end with no further increase or extension of the local affection, this termination resulting either from self-limitation or from the agency of treatment. Of this fact I have proof from cases not only studied during life, but in which appearances were noted after death. The ending of the disease and recovery after a small tuberculous deposit occur oftener than is generally supposed.
An increase and an extension of the phthisical affection occasion larger areas and also a greater degree of solidification. As the amount of increase and extension within a given period varies very much in different cases, it follows that there is nothing like uniformity in these respects. Generally, the solidified portions of the lung form islands between which the tuberculous deposit is wanting. Between these islands the lung not infrequently becomes emphysematous. This vicarious emphysema explains the existence of a vesiculo-tympanitic resonance in some cases notwithstanding the solidification. Exclusive of that sign, as thus accounted for, the solidification causes a dulness on percussion proportional in degree and extent to the solidified portion of lung. The auscultatory signs of solidification are generally present—namely, either bronchial or broncho-vesicular respiration, and bronchophony or increased vocal resonance, according to the degree of solidification. The existence of bronchitis over a larger extent is represented by more abundant and coarser moist bronchial or bubbling râles. These râles do not, as has been supposed, necessarily denote that softening of the tuberculous deposit has taken place. Dry circumscribed pleurisies occurring from time to time, even from the very commencement of the phthisical affection, may give rise to a pleuritic friction murmur. The escape of the liquefied tuberculous deposit into the bronchial tubes by ulceration, added to the products of the bronchial inflammation, occasions an increase of the bubbling râles. Moreover, the liquefied tuberculous deposit is better suited for the production of bubbling sounds than the products of bronchial inflammation. Hence the abundance of the bubbling râles, taken in connection with the characters of the matter of expectoration, is evidence of the escape of liquefied tuberculous deposit.
If phthisis be progressive, the physical conditions already enumerated—namely, solidification, liquid in the bronchial tubes, pleuritic exudation—continue. They are present in both lungs. Associated with these conditions are cavities. The cavities formed in different cases differ greatly in size and number. They differ also as regards the number and the size of the openings by which they communicate with the bronchial tubes. The latter conditions are of importance with reference to the free discharge of the contents of cavities and the production of certain physical signs. Enumerating here the cavernous signs, they are—tympanitic resonance within a circumscribed space, frequently with amphoric or cracked-metal intonation, cavernous and sometimes amphoric respiration, increased vocal resonance, cavernous whisper, pectoriloquy in some instances, and, as a rare sign, metallic tinkling. An accumulation of liquid within a cavity which has free communication with the bronchial tubes gives rise to the cavernous sign called gurgling. I have met with an instance in which a loud splashing sound was produced within a cavity synchronous with the impulse of the heart, and due to the agitation of the cavity by the cardiac movements. Owing to the association of cavities with solidified portions of lung, the latter varying greatly in different cases in the extent and the degree of solidification, with the cavernous signs are combined those which represent varying degrees of solidification—namely, either dulness or flatness on percussion, either bronchial or broncho-vesicular respiration, and either bronchophony or increased vocal resonance.
In the physical conditions incident to pulmonary complications of phthisis—namely, pleurisy with effusion, perforation of lung with pneumo-hydrothorax—the reader is referred to the article on [DISEASES OF THE PLEURÆ].
With reference to the general pathology of phthisis, points relating to the morbid anatomy are to be considered. There are two distinct varieties of morbid product in cases of phthisis—namely, the miliary granulations and the infiltrated deposit formerly distinguished as crude tubercle. Laennec taught that these are only varieties of essentially the same morbid product, the former being preliminary in their occurrence to the latter. Following Virchow, some late writers have restricted the application of the term tubercle to the miliary granulations, regarding the infiltrated deposit as a non-tuberculous inflammatory product. Histological investigations have failed to establish an essential distinction between the two varieties. The fact that they are so constantly associated shows some close pathological connection. Both varieties undergo the same degenerative changes. Each is found by inoculation to produce tuberculous disease in certain animals. Moreover, according to the late researches of Koch and others, each contains the characteristic parasite, the bacillus tuberculosis. In view of these considerations, the doctrine of Virchow, advocated by Niemeyer and others, is not tenable, and, as already stated under the head of the Definition and Classification of pulmonary phthisis, the term tuberculous is properly applied to both varieties. There is no such affection as a non-tuberculous pulmonary phthisis. The terms pulmonary phthisis and pulmonary tuberculosis are now, as heretofore, to be regarded as synonymous.
That the pathology of pulmonary phthisis involves a predisposition or a tuberculous diathesis has been already shown by facts pertaining to the etiology. It does not in the least invalidate this logical conclusion that in the present state of our knowledge pathologists are unable to explain this diathetic condition; that is to say, in what it consists. Its recognition is not merely a matter of speculative or theoretical interest; it has an important bearing upon a rational prophylaxis and on the treatment of phthisis.
Up to a very recent date the opinion has generally been held by pathologists that the local phthisical affection may be determined entirely by a tuberculous cachexia—that the latter, in other words, may produce the affection exclusive of any local extrinsic cause; and the question has been much discussed whether or not at the outset the phthisical affection is an inflammation. But if the parasitic doctrine be accepted, a local causative agent derived from without—namely, the bacillus tuberculosis—is essential, the predisposition or the cachexia consisting of certain unknown conditions which are required for the development and the multiplication of the parasite. According to this doctrine, the extension of the local affection is due to invasions successively of different portions of the lungs, and the development of tuberculous disease in other situations is due to the migrations of this parasite. Without the presence of the bacillus, no matter in how great degree the required conditions may exist, phthisis will not occur.
Inflammatory processes, however, accompany and follow the development of the tuberculous affection. Bronchitis, peribronchitis, periarteritis, endoarteritis, interstitial pneumonia, and pleurisy are terms which denote inflammation. To these are to be added ulceration and suppuration within cavities. The infiltrated tuberculous deposit is to be regarded as an inflammatory exudation. There is an intrinsic propriety, therefore, in calling it a pneumonia. But the behavior of this deposit differs widely from that of the exudation in lobar pneumonia. In the latter affection it is readily absorbed and disappears, leaving the pulmonary structure intact, whereas in phthisis it is absorbed with difficulty, and in most cases leads to more or less destruction of the pulmonary structure. For these reasons, irrespective of histological points of difference, the term tuberculous should be used to distinguish the exudative pneumonia which is characteristic of phthisis. The term desquamative pneumonia was proposed by Buhl. The so-called cheesy degeneration of the tuberculous products—a necrotic, not an inflammatory, process—was considered by Laennec as a distinctive mark of the products. This doctrine has been disproved. Other morbid exudations and growths may undergo similar degenerative changes.
DIAGNOSIS.—It is evidently very desirable to recognize the existence of phthisis at as early a period as possible with reference to the adoption of measures with a view to prevent the further development and progress of the disease. It is also very desirable, if practicable, to determine that phthisis does not exist; that is, by the absence of diagnostic points to exclude it. Difficulty of diagnosis relates almost exclusively to an early period when the phthisical affection is small. The diagnostic points pertaining to the symptoms and the physical signs in the incipiency of the disease therefore especially claim attention.
A cough of more or less duration, which was at first slight and dry, gradually increasing and accompanied by the expectoration of mucus, should always excite a suspicion of phthisis, especially if the patient's age be between twenty and thirty years. This is not the history of a chronic primary bronchitis. A cough as just described should never be considered as nervous or sympathetic without due investigation. It should not be attributed to pharyngitis, although the latter affection is found to exist. Want of breath on exercise is a symptom pointing to something more than a bronchial or pharyngeal affection. The import of these symptoms is still greater if, after the commencement of the cough or from an earlier date, there has been decrease in weight and strength. Their significance is much increased by the occurrence of hæmoptysis. Hæmoptysis followed by a persistent cough, and still more if cough preceded its occurrence, is always presumptive evidence of a phthisical affection. Occurring without having been preceded by cough, and when cough does not immediately follow, it should suggest the probability of phthisis. In the larger proportion of cases under these circumstances it is a forerunner of the diagnostic symptoms and signs of the disease. In connection with the cough a persistent increase of the temperature of the body is an important diagnostic symptom. Chilly sensations and flashes of heat are symptoms of some importance. Especially significant are pleuritic stitch-pains referable to the upper part of the chest or beneath the scapula, these being symptomatic of the circumscribed dry pleurisies which may occur at an early period of the disease. Impaired appetite, pallor of the face, and a tendency to perspire during sleep have much significance taken in connection with the pulmonary and other symptoms.
A positive diagnosis must rest on physical signs, together with more or less of the foregoing symptoms. The physical conditions which furnish the diagnostic signs are solidification of a small portion or of small portions of lung, usually at or near the apex, the presence of mucus in the small-sized bronchial tubes, and perhaps fibrinous exudation on the pleural surface within a circumscribed area corresponding to the solidified portion or portions of lung. The signs furnished by these conditions are slight dulness on percussion, a broncho-vesicular (formerly called rude or harsh) respiration, some increase of vocal resonance and of the whispered voice, subcrepitant râles, and perhaps a grazing friction murmur. It may be important to consider the physical signs of phthisis with some detail. Aside from their importance, a reason for this is that terms by which some signs are designated are not used in precisely the same sense by all medical writers.
A small phthisical affection gives rise to slight or moderate dulness on percussion. In order to appreciate this sign if the dulness be slight, attention should be paid to the pitch of the resonance as well as to the lessened intensity of resonance. The pitch is always raised. By attention to the latter character, in conjunction with the diminution of intensity, a degree of dulness may be sometimes appreciated which, without attention to the pitch, might not be determinable.13 In determining abnormal dulness in the infra-clavicular region on one side, the normal disparity between the two sides of the chest in this region must be taken into account. The resonance at the right summit, as compared with that of the left summit, is, normally, somewhat dull. Hence it is not as easy to make out an abnormal dulness at the right as at the left summit. If the relative abnormal dulness at the right summit be but slight, the question is whether there be more than a normal disparity. This question is rendered difficult by the fact that the degree of normal disparity varies somewhat in different healthy persons. In cases of doubt little reliance is to be placed on this sign alone, but it is to be taken in connection with auscultatory signs.
13 The author was the first to indicate the fact that dulness is always associated with elevation of pitch. Vide "Prize Essay on Variations of Pitch in the Sounds obtained by Percussion and Auscultation," Transactions of the American Medical Association, 1852.
With reference to the auscultatory signs in cases of phthisis, it is to be premised that often, owing to the importance of studying the sounds derived from a limited area and of localizing morbid conditions, the use of the stethoscope is indispensable. It is impossible to meet all the requirements of physical diagnosis by immediate auscultation. After an experience of more than a quarter of a century the writer would advise the binaural stethoscope in preference to any other. For the benefit of those who are not practically familiar with this instrument, it should be added that in order to appreciate its advantages, the instrument, in the first place, must be properly constructed, and, in the second place, some practice is necessary. A sound produced within the instrument is at first an obstacle, but it is speedily overcome by use.14
14 The dissatisfaction with the binaural stethoscope so often comes from defects in its construction that it seems proper to refer to Tiemann & Co., and to Ford & Co., of New York as reliable makers of this instrument.
A small tuberculous solidification is represented by a broncho-vesicular respiration. This sign was named and described by me in 1856. The name takes the place of the terms rudeness, harshness, and hardness—terms which are not only inadequate, but convey an erroneous idea. Quoting from another work, the characters of the broncho-vesicular respiration and its comprehensive signification are as follows: "The sign represents the different degrees of solidification of lung between an amount so slight as to occasion only the smallest appreciable modification of the respiratory sounds, and an amount so great as to approximate closely to the degree giving rise to bronchial or tubular respiration. In other words, all the gradations of respiratory modifications caused by incomplete or an inconsiderable solidification are embraced under the name broncho-vesicular. The gradations correspond to the amount of solidification; that is, they show the solidification to be either very slight, moderate, or nearly sufficient to be regarded as considerable or complete. The sign is therefore important as evidence, first, of the existence of solidification, and, second, of the degree of solidification. Analyzing this sign, the most distinctive feature is the combination of the vesicular and the tubular quality in the inspiratory sound. These two qualities may be combined in variable proportions. The pitch of the sound is raised in proportion as the tubular predominates over the vesicular quality. The expiratory sound is more or less prolonged, tubular in quality, and the pitch raised. The prolongation of this sound, its tubular quality, and the raised pitch are proportionate to the predominance of the tubular over the vesicular quality in the inspiratory sound. If the solidification be slight, the characters of the normal vesicular respiration predominate; that is, the inspiratory sound has but a small proportion of the tubular quality, and is but little raised in pitch, the expiratory sound being not much prolonged, its tubularity not marked, the pitch not high. If, on the other hand, the solidification be almost enough to give a bronchial respiration, the inspiratory sound has only a little vesicular quality, the tubular quality predominating, the pitch proportionately raised, and the expiratory sound is prolonged, high, and tubular, nearly to the same extent as in bronchial respiration. The less the solidification the more the characters of the normal vesicular respiration predominate over those of the bronchial respiration; and, per contra, the greater the solidification the more the characters of the bronchial predominate over those of the normal vesicular respiration."15 By means of the broncho-vesicular respiration a slight morbid solidification may be recognized in one of the infra-clavicular regions or over the scapula. Here, however, as with regard to percussion, an allowance is to made on the right side for a normal disparity. The respiratory sounds on the right side at the summit, as compared with those at the left, have normally the characters more or less marked of a broncho-vesicular respiration. These characters are more marked as the stethoscope is brought toward the sternum. Hence a small solidification of lung is more easily ascertained by auscultation at the left than at the right summit.
15 Vide Manual of Auscultation and Percussion, by the author; also, paper contained in the Transactions of the International Medical Congress, London, 1882. The broncho-vesicular respiration was called by Skoda indeterminate (unbestimmt), and this term is still used by German writers. These sounds are not indeterminate if the characters derived from pitch and quality be analytically studied; they are sounds intermediate between the normal respiratory murmur and bronchial respiration.
Not infrequently in cases of incipient phthisis the respiratory sounds at the summit on the affected side are so weakened that their characters cannot be studied. Weakness of the respiratory murmur in these cases becomes a diagnostic sign taken in connection with other signs.
A small tuberculous deposit may increase the vocal resonance. But, again, a normal disparity between the two sides must be allowed for. The normal vocal resonance is always greater on the right side. If, therefore, it be a question as to the existence of a small tuberculous affection at the right summit, it is to be decided whether the disparity be greater than normal. A small tuberculous deposit at the apex of the left lung, on the other hand, may not increase the resonance to an equality with that at the right summit.
Attention should be paid to the whispered voice, and, still again, the two sides show a normal disparity. The sound heard with the whispered voice, which may be distinguished as the normal bronchial whisper, is louder on the right than on the left side, and somewhat higher in pitch on the left side, at the summit of the chest. If at the right summit it exceed the normal disparity, and the pitch be higher than at the left summit, the sign may be distinguished as increased bronchial whisper, and it denotes solidification. If, on the other hand, the sound at the left summit be louder than that of the right summit, there is increased bronchial whisper, representing the solidification at the apex of the left lung.16
16 The different abnormal modifications of sounds produced by the whispered voice were first named and described by the author. Vide Manual of Auscultation and Percussion.
The normal points of disparity at the summit of the chest render the diagnosis of incipient phthisis by means of alterations in the resonance on percussion, the respiratory sounds, the vocal resonance, and the whispered voice a problem in some cases of not a little difficulty. In these cases an examination of the sputa for the presence of the tuberculous parasite may furnish proof of the existence of the disease. This proof may in some instances be obtained when the physical signs, together with the symptoms, do not render the diagnosis positive, and it may be sought for in order to corroborate the evidence derived from other sources. The author can testify from considerable experience to the value of an examination of sputa for bacilli in cases in which the diagnosis is not rendered positive by other signs and by symptoms. It must, however, be borne in mind that the absence of bacilli in the sputa is not sufficient to exclude phthisis, especially if but a single examination be made. In doubtful cases, if an examination of the sputa be negative, the examination should be repeated. The weight of evidence against the existence of phthisis is, of course, greater in proportion to the number of examinations with negative results.17
17 The following method of staining the bacilli tuberculosis in the sputum is essentially that recommended by Ehrlich in the Deutsche medicinische Wochenschrift, Mai 6, 1882:
It is important that the sputum to be examined should be derived from the lungs, and should not be solely that from the upper air-passages. A small opaque particle from the sputum is to be pressed between two cover-glasses, so that when these are drawn apart a thin film will remain upon each. Each cover-glass, as soon as the film is dry, is to be passed, with the preparation upward, rather rapidly three times through the flame of a Bunsen's burner or of an alcohol lamp. The preparation is now ready for staining.
A small quantity of water in a test-tube or flask is now shaken with an excess of aniline oil (which need be only in small amount), and after a few moments is filtered through moistened filter-paper. To the clear filtrate thus obtained is to be added, drop by drop, a saturated alcoholic solution of fuchsin (gentian-violet, methyl-violet, and several other aniline colors may be substituted) until the fluid begins to be opalescent, showing that it is saturated with the coloring agent. In this manner an alkaline-aniline staining solution is prepared.
Into this staining solution the cover-glasses, having the dried films of sputum prepared as above described, are dropped, preferably so that they will float with the preparation downward. Here they remain from a half hour to twenty-four hours. If taken out in a short time, the fluid, at least for a time during the staining process, should be heated moderately over a water-bath, and in any case the process of staining is accelerated and rendered more certain by heating.
After removal from the staining fluid the cover-glass is washed for a few moments in water, and is then dipped into a mixture of one part of pure nitric acid (it should contain no nitrous acid) to about three or four parts of water. Here it remains only a few moments, when it will be found that the preparation has lost its color, although a part will be restored by the subsequent washing in water, which should be done at once. If the preparation has not been sufficiently decolorized, it may be placed again in nitric acid, but it is not necessary or desirable that it should remain there many minutes. The object of the nitric acid is to extract the color from all but the tubercle bacilli.
The preparation may now be at once examined either in glycerin or (after drying or after treatment with alcohol and oil of cloves) in balsam. Ehrlich recommends, previous to this, a staining of the background with some color other than that of the bacilli; thus, with methyline blue if the organisms are stained red with fuchsin. This staining of the background, however, is not necessary. While the ideal method of studying the stained bacilli is by means of Leis's oil-immersion lenses and Abbé's illuminating apparatus, they can usually be seen readily enough with the high powers in ordinary use, such as the one-fifth or one-sixth inch objectives of our American microscope. After staining with fuchsin the bacilli appear as short rods of a red color, frequently curved or bent.
The adventitious sounds which have been mentioned—namely, the subcrepitant râle and the pleural friction murmur—sometimes afford valuable aid in the diagnosis. Taken in connection with the direct signs obtained by auscultation and percussion, these accessory signs when present make the diagnosis positive: they are by no means uniformly present, and therefore their absence is not proof against the existence of a phthisical affection. To these accessory signs another sign may be added—namely, an abnormal transmission of the heart-sounds within one of the infra-clavicular regions. In the middle of this region there is nearly an equal transmission of these sounds normally. Comparing the two sides as regards the two sounds respectively, the first sound is a little louder on the left, and the second sound a little louder on the right side. Now, with a little solidification the sounds may be better transmitted, so that they are abnormally loud on the affected side.
A decision that there is no physical proof of phthisis must rest on the absence of all the foregoing signs after repeated examinations of the chest.
It is not to be concluded that for a positive diagnosis of incipient phthisis all or most of the foregoing diagnostic signs must be recognized. They are not all present in all cases. Two or three of these signs, and even a single one if well marked and associated with diagnostic points pertaining to the symptoms and history, may suffice for a positive diagnosis.
It is an interesting question how small a portion of solidification may furnish signs sufficient for a diagnosis. I have the records of two cases bearing on this question. A patient came under my observation at Bellevue Hospital in 1867. In the right infra-clavicular region the respiration was abnormally broncho-vesicular, the vocal resonance was increased, and there was increase of the bronchial whisper within a small circumscribed space. On these signs was based the diagnosis of a small tuberculous deposit. The case served to illustrate the signs just named to classes for practical instruction in auscultation and percussion. The patient, who was employed as a helper in the apothecary's shop, died suddenly from taking by mistake an overdose of the fluid extract of aconite. The autopsy showed at the apex of the right lung a nodule of the size of a filbert, no tuberculous deposit being elsewhere found.
A recent medical graduate, twenty-two years of age, had cough and two attacks of hæmoptysis. His father and a sister had died with phthisis. There was slight dulness on percussion on the summit of the chest on the left side, with crepitation at both summits. These were the only signs noted. This case was included among the cases of recovery reported in my work on phthisis published in 1875. He enjoyed excellent health and was notably vigorous for twenty-eight years. Death took place in 1880 from disease of the heart and kidneys. The autopsy showed at the apex of each lung a small indurated portion somewhat larger on the left than on the right side. Elsewhere there was no appearance denoting present or past pulmonary disease.
It is in only a small proportion of cases that, when patients first come under medical observation, the phthisical affection is so small as to render the diagnosis difficult. The tuberculous solidification is generally sufficient to give rise to well-marked signs. The shrinkage of the lung at the apex from interstitial growth and diminished capability of expansion may have caused a small infra-clavicular depression and restricted respiratory movements in this region. The dulness on percussion is readily recognized. The characters of the broncho-vesicular respiration are easily determined. The increase of vocal resonance and increased bronchial whisper admit of no doubt. With these signs, oftener than at an earlier period, are associated accessory signs—namely, subcrepitant râles and bubbling in larger tubes, pleuritic friction murmur, and undue transmission of the heart-sounds.
At a somewhat later period, and sometimes even when cases are first observed, the physical signs denote a still greater degree of solidification. Infra-clavicular depression and restricted movements on one side are marked. The respiration is bronchial and the voice bronchophonic. There may be pectoriloquy with the bronchophonic characters, showing that the speech is transmitted through solidified lung.18
18 Bronchophony is to be understood as a sign distinct from increased vocal resonance. In bronchophony the resonance may or may not be increased. Intensity is not a character of this sign. Its distinctive characters are concentration of the voice sound, nearness to the ear, and elevation of pitch. The terms concentration and nearness to the ear properly express what was intended by Laennec in the words "la transmission évidente de la voix à travers le stethoscope." Pectoriloquy is to be distinguished from bronchophony. These two terms are sometimes confounded. Bronchophony is transmission of the voice, pectoriloquy the transmission of speech—that is, articulate words.
Exceptional cases are to be referred to in which over lung containing solidified portions from tuberculous deposit dulness on percussion is wanting. Not only is dulness wanting, but the resonance is greater than normal. The resonance is altered in character. With an increase of intensity the quality is in part tympanitic and the pitch is raised. This is the sign described by me many years ago under the name vesiculo-tympanitic resonance. The distinctive characters are those just mentioned—namely, increase of intensity, the quality a combination of the vesicular and the tympanitic, and more or less elevation of pitch. The name vesiculo-tympanitic expresses these characters. It is the sign of pulmonary emphysema. It denotes that portions of lung situated between islands of solidification have become emphysematous. The emphysema is vicarious; that is, supplementary to the shrinkage of the portions solidified, and, added thereto, probably collapsed lobules. Were one to be governed by percussion alone in the physical diagnosis, this sign would in some cases mislead. The liability to error is avoided by taking due cognizance of the associated signs furnished by auscultation.
In cases of advanced phthisis cavities are added to tuberculous solidification. It is desirable to recognize the existence of these. In most instances the signs which may be distinguished as cavernous suffice for the recognition of cavities. The cavernous signs are furnished by percussion and by auscultation of the respiration and of the voice.
A purely tympanitic resonance within a circumscribed space points to a cavity, but a tympanitic resonance with either an amphoric or a cracked-metal intonation is more especially a cavernous sign. An amphoric or a cracked-metal resonance over a cavity may often be obtained by observing certain rules in percussion—namely, percussing with a single and rather forcible blow, the mouth of the patient being open and brought close to the ear. These signs may be rendered still more distinct by means of the binaural stethoscope, the pectoral extremity being close to the patient's opened mouth, an assistant making the percussion. These cavernous signs are not present when cavities contain much liquid or when communication with the bronchial tubes is temporarily obstructed; hence the signs are sometimes present and sometimes absent.
There is a distinctive cavernous respiratory sign. This assertion is called for by the fact that the existence of the sign is not as yet recognized by all medical writers. According to Laennec, the respiratory sounds derived from cavities resemble the bronchial respiration. From his description it would be impossible to distinguish the former from the latter. Skoda considered the cavernous and the bronchial respiration as absolutely identical; and this view is held by German writers at the present time. Walshe indicated an essential differential point pertaining to the inspiratory sound in cavernous respiration—namely, its low pitch. The fact that in purely cavernous respiration the pitch of the expiratory is lower than that of the inspiratory sound was stated by me in 1852.19 The distinctive characters of the cavernous respiratory sign as then indicated were as follows: An inspiratory sound low in pitch and non-tubular in quality, followed by an expiratory sound still lower in pitch and non-tubular. The quality of the sound in inspiration and in expiration may be said to be blowing, after the term soufflante used by Laennec, but applied by him to a sound either bronchial or from a cavity, when the air seems to be drawn from the ear of the auscultator.
19 Vide "Prize Essay."
Appreciating clearly the characters which are distinctive of cavernous respiration, it is impossible to confound this sign with bronchial respiration, both the inspiratory and the expiratory sound in the latter sign being high in pitch and tubular in quality. This cavernous sign approaches much nearer to the normal vesicular respiration. The only distinction between these two signs is the presence of the vesicular quality in the latter and its absence in the former. Hence, the only liability to error is in confounding the two. This error can only be committed when the respiratory murmur is so feeble that the vesicular quality is not readily appreciable. In order to avoid the error, the respiration should not be pronounced cavernous when the sounds are quite weak, except there be present other correlative cavernous signs.
Cavities are often situated in close proximity to lung solidified by tuberculous deposit or interstitial pneumonia: cavernous respiration and bronchial respiration are then in juxtaposition, and their differential characters are rendered very distinct by contrast. Under these circumstances, however, the cavernous respiration is sometimes modified by combination with the characters of the bronchial respiration. Not infrequently a cavernous inspiration is joined to a bronchial expiration, the more intense expiratory sound representing adjacent solidification extending over the site of the cavity and drowning the weaker cavernous expiration. In another mode of combination the inspiratory sound is bronchial at the beginning and cavernous at the end. Here the cavernous sound occurs a little later than the bronchial, and the latter is supplanted by the former. This variety of broncho-cavernous respiration has been recently described by Seitz under the name metamorphosing respiratory murmur (metamorphosirendes athmungs geräusch). In like manner, the characters of the cavernous and of the normal vesicular respiration may be combined. This combination may be expressed by the term vesiculo-cavernous respiration.
The effect of a cavity upon vocal resonance is to increase its intensity without giving rise to the characters distinctive of bronchophony—namely, nearness to the ear, concentration, and elevation of pitch. Increased vocal resonance, and not bronchophony, is therefore a cavernous sign. If bronchophony be present over a cavity, it denotes adjacent solidification of lung. With the vocal resonance more or less increased the vocal fremitus appreciable on auscultation is often intensified.
A cavernous whisper has the characters of the expiratory sound in the cavernous respiration; that is, it is low in pitch and blowing or non-tubular in quality, being in contrast, as regards these characters, with a high-pitched tubular sound in whispering bronchophony. The latter sign is often found near a cavity, showing the proximity of solidified lung.
Amphoric respiration, amphoric voice, and amphoric whisper are pathognomonic signs of a cavity, provided pneumothorax be excluded. The same is to be said of metallic tinkling, a very rare cavernous sign. Gurgling within a circumscribed space is a cavernous sign of some value. Pectoriloquy—that is, the transmission of articulated words—is not, per se, a cavernous sign; that is to say, the speech may be transmitted by solidified lung as well as through a cavity. This is true alike of words spoken with the loud and with the whispered voice. It is, however, easy to determine whether pectoriloquy be or be not due to a cavity. If with the loud voice the transmitted speech be unaccompanied by the characters of bronchophony, it denotes a cavity. So, if transmitted whispered words be unaccompanied by the characters of the bronchophonic whisper, they denote a cavity. On the other hand, the transmission is by solidified lung if bronchophony and pectoriloquy be conjoined in either the loud or the whispered voice.
The shrinkage of lung incident to the formation of tuberculous cavities increases the depression apparent on inspection in the infra-clavicular region. The site of a cavity is sometimes indicated by a circumscribed bulging of intercostal spaces, within a localized area, on forced expiration or an act of coughing. A sharply-defined circumscribed depression corresponding to the area of a cavity is visible in some cases. Another effect of shrinkage of lung is to uncover the aorta in the second intercostal space on the right side, or the pulmonary artery in a corresponding situation on the left side. The pulsation of these arteries may then be perceived by the touch, and perhaps, also, by the eye. This effect should not lead to the error of inferring the existence of aneurism. Shrinkage of the upper lobe of the left lung may cause considerable elevation of the heart, also enlarging considerably the space within which is felt the cardiac impulse.
With a practical knowledge of the physical signs of which a concise account has been given, it is practicable to determine, first, the existence of phthisis in its incipiency when the tuberculous affection is small; second, during the progress of the disease to ascertain the degree and the extent of the tuberculous solidification; and, third, to recognize the existence of, and to localize, cavities.
Recapitulating the signs belonging to the foregoing phases of the disease, in incipient phthisis they are slight dulness on percussion, broncho-vesicular respiration approximating to the normal vesicular or a respiratory murmur too weak for its characters to be studied, some increase of vocal resonance, increased bronchial whisper, and, as occasional accompanying signs, subcrepitant râles, pleuritic friction murmur, and abnormal transmission of the heart-sounds, more or less of these signs being limited to the summit of the chest on one side. After further progress of the phthisical affection the signs are, dulness on percussion more or less marked, either a broncho-vesicular respiration approximating to the bronchial or a purely bronchial respiration, either notable increase of vocal resonance or bronchophony, either increase of the bronchial whisper or whispering bronchophony, and moist bronchial or bubbling râles which may be either coarse or fine, or both may be combined. After the affection has advanced to the formation of cavities the cavernous signs are added to those of solidification—namely, circumscribed tympanitic resonance on percussion, cracked-metal and amphoric resonance, cavernous respiration, cavernous whisper, increased vocal resonance and gurgling. Pectoriloquy may be present before and after the formation of cavities; in the former instance the transmission of speech being by solidified lung, and in the latter through a cavity, the two modes of transmission being easily differentiated by means of the characters associated with the pectoriloquy.
An intercurrent pneumonia, not tuberculous, may lead to the error of supposing the tuberculous affection to be much greater than it is. Especially is there liability to this error if the patient have not been under observation prior to the intercurrent pneumonia. The latter may give rise to bronchial respiration and bronchophony, with notable dulness on percussion over a considerable space. If the patient have been under observation, the rapidity with which the solidification denoted by these signs has been developed is a diagnostic point. A notable diminution of the solidification within a few weeks or days is evidence that it was due to an intercurrent pneumonia. The tuberculous deposit is never absorbed with such rapidity. The following case may serve as an illustration of this complication: A man aged thirty had had for some time slight cough and want of breath on active exercise, but he had kept about, actively engaged in business, until within a few days of the date of my visit. He was then up and dressed, his chief complaint being want of breath on any exertion. The physical signs gave evidence of considerable solidification of the upper lobe of the right lung. The question was, whether the solidification was due exclusively to phthisis, or whether with this disease was associated an intercurrent pneumonia. The question was settled definitively by an examination of the chest six weeks afterward. At the time of this examination the solidification had in a great measure disappeared; there was only slight dulness on percussion, with increase of vocal resonance and feeble respiratory murmur. Meanwhile, the symptoms had denoted progressive improvement; the cough was now slight; he no longer suffered from want of breath on exertion, and he had improved as regards appetite, strength, etc. This patient consulted me seven years and four months afterward. In the mean time he had considered himself in fair health, but he had been subject to cough, and for the preceding six months the cough had been persistent. There was now dulness at the summit of the chest on the right side, with feeble broncho-vesicular respiration, increase of vocal resonance, abnormal transmission of the heart-sounds, and subcrepitant râles. He had held his weight and strength, and his appetite and digestion were good.
An occasional event in cases of phthisis is obstruction of a primary bronchus from the pressure of an enlarged bronchial gland. This event may explain a degree of embarrassment of respiration out of proportion to the changes which have taken place in the lungs. The bronchial obstruction is shown by notable feebleness or by suppression of the respiratory murmur on the side of the obstruction, and an increase of the murmur on the other side of the chest. Obstruction of a primary bronchus may prevent the appreciation of morbid respiratory signs on the obstructed side.
During the progress of phthisis the symptoms concur with the physical signs in showing the progressive inroads of the disease upon the pulmonary organs. They show, more than the physical signs, the inroad upon the powers of life. They also afford evidence, in conjunction with the physical signs, of arrest of the disease. More reliance is to be placed on the symptoms than on the signs in judging of the rapidity on the one hand, or on the other hand of the slowness, of the progress of the disease. In these several points of view the consideration of symptoms comes more properly under the head of the prognosis.
The symptoms pertaining to complications of phthisis may be the first to lead patients to consult a physician. Not infrequently advice is sought for harshness or hoarseness of the voice, arising from chronic laryngitis, the cough and other symptoms which preceded this affection not having been regarded as of sufficient consequence to require medical aid. It is to be borne in mind that chronic laryngitis, when not of syphilitic origin, is generally secondary to phthisis. The chest is therefore to be examined carefully with reference to the signs of the latter.
Pleurisy with effusion may be a complication which the physician is called upon to treat. A lung compressed by liquid which fills the affected side of the chest cannot be interrogated by means of physical signs. Under these circumstances subcrepitant râles may denote a phthisical affection on the summit of the chest on the opposite side. The existence of cough and expectoration prior to the pleurisy is strong evidence of an antecedent phthisical affection. The occurrence of hæmoptysis adds greatly to the evidence.
A tuberculous patient who has not been under any treatment may apply to a surgeon to be relieved of the inconvenience of a perineal fistula. Operative interference for this affection should never be resorted to without a careful examination of the chest.
PROGNOSIS.—Whether pulmonary phthisis is ever a curable disease has hitherto been a mooted question. Prior to the time of Laennec instances of apparent cure were open to doubt on the score of diagnosis. Laennec did not admit the probability of a cure before the formation of cavities, but he gave the histories in a number of cases in which the cicatrization of cavities had taken place.20 If by the term curability be meant a complete restoration of the portions of lung affected by tuberculous disease to the normal condition which existed prior to the disease, the doctrine of Laennec is probably true. A moderate or even a small phthisical affection leads to changes which are permanent. There remains more or less impairment of the integrity of the pulmonary organs. But if by the term be meant that all pulmonary symptoms cease, that the patient has good general health, and that the damage to the lungs is not sufficient to prevent an adequate exercise of their functions, a cure may take place before as well as after the formation of cavities. Accepting the latter sense of the term curability, no one at the present time will deny the statement just made—a fact which is due, at least in a measure, to the different views in regard to the treatment of phthisis now as compared with the time of Laennec.
20 "Les observations contenues dans l'ouvrage de M. Bayle, ainsi que ce que nous avons dit nous-mêmes ci-dessus du dévelloppement des tubercles, prouvent suffisamment que l'idée de la possibilité de guérir la phthisie au prémier degré est une illusion. Les tubercles crus tendent essentiellement à grossir et à se ramollir. Il est peut être au pouvoir de l'art de ralentir leur dévelloppement, d'en suspendre la marche rapide, mais non pas de lui faire un pas rétrograde. Mais s'il est impossible de guérir la phthisie au premier degré, un assez grand nombre de faits mont prouvé que dans quelques cas un malade peut guérir après avoir eu dans les poumons des tubercles qui se sont ramollis et ont formé une cavité ulcéreuse" (Traité de l'Auscultation médiate).
The appearances found after death in cases which may be considered as exemplifying, practically, recovery from phthisis vary according to the extent of the tuberculous affection and the stage to which it had advanced. In a case referred to in connection with the diagnosis (vide p. [407]) an examination after death, nearly thirty years having elapsed from the date of recovery, showed within small circumscribed spaces at the apex of both lungs a condensed pulmonary tissue. In the following case there was a similar condition within larger spaces: The patient, a man aged about forty, was attacked with hæmoptysis in April, 1846. Soon afterward the symptoms and signs of tuberculous disease became manifest, and death took place in the following June. On examination after death the lungs were found to contain infiltrated tuberculous deposits, some of which had undergone softening, and miliary tubercles in abundance. In addition to these appearances, at the apex of each lung was a solid mass nearly as large as a hen's egg, that on the right side being somewhat larger than that on the left. The surface over these masses presented a marked depression and a puckered appearance. On dividing the masses they appeared to consist of condensed parenchyma: they were of a reddish color, friable, and contained an abundance of minute calcareous particles. They were surrounded by a thick, firm wall isolating them from the adjacent pulmonary structure. Eighteen years before his death this patient had cough and other symptoms which were regarded at the time as denoting pulmonary phthisis. He recovered, and had good health up to the fatal illness. The only exception to this statement of his previous good health was the occurrence of a perineal fistula, which was nearly cured by division of the gut nine months before the hæmoptysis.
No one can doubt that tuberculous cavities may completely cicatrize. Instances in abundance have been observed since the publication of Laennec's treatise. The gradual contraction and final closure of a cavity may be observed during life, the cavernous signs becoming less marked, and at length disappearing. At the present time I see frequently two persons who have recovered from phthisis, recovery in one taking place nearly twenty, and in the other nearly ten, years ago. In these cases the cavernous respiration was well marked in situations in which now there is a feeble vesicular murmur. In both cases there is a circumscribed depression of the chest in these situations.
Recovery may be said to take place when cavities do not cicatrize, but remain, being lined by a membraniform structure and free from morbid products. Under these circumstances cavities are innocuous. There is an approximation to recovery when cavities furnish more or less matter of expectoration, the lungs elsewhere being free from tubercles or tuberculous products.
Recovery with calcification of tubercles is illustrated by the following case: A farmer from Illinois, aged forty, consulted me in June, 1843. Within the preceding four months he had from time to time expectorated calculi, some of which were of the size of a small pea, in great numbers. A hacking cough had existed for several months before he began to expectorate the calculi. At the time of the expectoration of these the cough was severe and he raised some bloody mucus. In the intervals the cough was slight and without expectoration. The examination of the chest was negative as regards any signs of disease. Thirteen years afterward this patient came to report his condition of health. The expectoration of calculi had continued for some time after his former visit; then his cough ceased, and meanwhile he had been perfectly well.
It is a question whether the tuberculous product is ever absorbed. The fact that in some instances the physical signs in life and the appearances after death give no evidence of either tuberculous deposit or cavities, and the fact that tuberculous solidification is observed to diminish or disappear when apparently the deposit has not been expectorated, render it probable that under some circumstances absorption does take place to a greater or less extent. It is doubtless true that, as a rule, the deposit is not absorbed; the tuberculous affection in this respect affords a striking contrast to non-tuberculous pneumonia.
Cases of recovery from phthisis are cited by medical writers as proving the curability of the disease. The term curability implies that recovery is due to remedial agencies. It does not therefore embrace a truth of great importance in its bearing on the prognosis and the treatment—namely, the disease in certain cases ends in recovery purely from an intrinsic tendency. My clinical studies have furnished facts which conclusively establish this important truth. Out of a large number of cases (640) recorded during a period of thirty-four years, recovery took place in 44. In 23 of these 44 cases there were no measures of treatment to which the recovery could be attributed. The disease ended favorably in these 23 cases from self-limitation. This assertion does not express a conjecture or a theory, but a logical conclusion. Self-limitation, therefore, is a highly important element in prognosis; it is a highly important factor in the treatment. The claim in behalf of phthisis of self-limitation, based on the analysis of cases of recovery, was made by me nearly a quarter of a century ago.21 It has not as yet received that recognition in medical literature which it is desirable that it should receive in view of the importance of its practical bearings. It will enter here into considerations connected with treatment and prognosis.
21 Vide American Journal of the Medical Sciences, January, 1858.
Recovery from phthisis involves, of course, cessation of the progress of the disease. This cessation of progress may be due either to an intrinsic tendency or to arrest by measures of management, or to both combined. Recovery may or may not follow the cessation of progress. Owing to the disposition and the extent of the tuberculous affection, reparation of the lesions does not take place. It is a useful grouping of cases into—first, those which become non-progressive and end in recovery; and, second, those in which the cessation of progress is not followed by complete recovery. It is also useful to consider as forming a third group cases in which the progress of the disease is extremely slow. The cases in the latter group are the opposite to those in which the progress of the disease is continuous and rapid, giving rise to the name galloping consumption.
There is much significance in the fact that in cases of progressive phthisis the disease does not, as a rule, advance by a steady increase, but by a series of invasions. Successive eruptions of the tuberculous affection occur. In these eruptions the affection may be either small or moderate or considerable in amount. The intervals between them may be brief or long. The disease may end with a single eruption. This may be small or even slight, and followed quickly by recovery. There is reason to believe that instances of this kind are not infrequent. The phthisical affection may have been overlooked, or it is inferred from the recovery that there was an error in diagnosis. In the great majority of cases a series of eruptions occurs, and it is in this way that the disease is generally progressive. These clinical facts, regarded from the standpoint of the parasitic origin of phthisis, are to be explained by supposing that bacterial colonies invade at successive epochs different portions of the lungs, but that in a certain number of instances there is neither invasion nor migration of the parasite. The occurrence of successive eruptions is made manifest by the symptoms and the physical signs. After the occurrence of a single eruption or a series, if there be no recurrence the recovery will depend, cæteris paribus, on the amount of the tuberculous affection.
The prognosis in individual cases involves clinical points which pertain to the symptoms and signs of the pulmonary affection, and to the symptomatic phenomena referable to other of the anatomical systems of the body. The latter are of importance as representing the constitutional condition or the cachexia, and as indicating either, on the one hand, self-limitation, or, on the other hand, a progressive tendency of the disease.
Other things being equal, the smaller the pulmonary affection the better the prognosis. But assuming that the first tuberculous eruption is small, it does not follow that other eruptions may not occur more or less speedily, and, assuming a considerable or a large eruption, another may not occur. The prognosis in the latter case is of course much the more favorable. In forming a judgment in respect of the prognosis, the amount of the pulmonary affection is less to be considered than the symptoms which relate to the progressive tendency of the disease and to its tolerance by the system. An unfavorable prognosis, however, is to be based on the existence of an amount of the pulmonary affection sufficient to compromise the respiratory function, as shown by notable increase of the frequency of the respirations and by dyspnoea. Hæmoptysis, as has been seen, if unaccompanied by other symptoms which are untoward, even if the hemorrhage be profuse, is not an unfavorable event. Microscopical examinations of the sputa afford important information bearing on the prognosis. Examinations, thus far, made by different observers, show that in proportion to the abundance of the parasite in the sputa the disease may be considered as actively progressing.
Important prognostics derived elsewhere than from symptoms referable to the pulmonary organs relate especially to the circulatory system, inclusive of the temperature of the body, to the digestive system, to the hæmatopoietic system, and to nutrition. Acceleration of the pulse is an unfavorable symptom. In proportion to the degree of acceleration, either activity of the progress or a want of tolerance of the tuberculous affection, or of both combined, is to be inferred. It is of course important, if practicable, to know the patient's normal pulse as the standard for comparison in individual cases, inasmuch as the frequency in health varies considerably in different persons. A febrile temperature is especially significant as a symptom of progressive phthisis. It is the best criterion of the activity of progress. There is no constant proportionate relation between the amount of the pulmonary affection, as shown by the local symptoms and the signs, and the elevation of temperature. Nor does the degree of fever correspond always with the acceleration of the pulse. Diurnal exacerbations of fever, with more or less profuse sweating, are evidences that the disease is progressive. Both fever and the rapid action of the heart not only have symptomatic significance, but they contribute to progressive exhaustion.
Impaired power of digestion and anorexia are bad prognostics. Especially bad is a degree of anorexia in which not only no desire for food is felt, but it is so loathed as to render adequate alimentation impossible. Diarrhoea, although not dependent on tuberculous disease of the intestine, is a bad prognostic, as denoting impairment of the digestive processes. Notable pallor, whether an effect of deficient alimentation or referable to the hæmatopoietic system, weighs heavily against the expectation of improvement. A considerable emaciation has even greater weight. Whenever in the progress of the disease the patient becomes notably pale and emaciated, there is little ground for hope, especially if there be conjoined muscular debility, a rapid pulse, and a high temperature. It is unnecessary to attempt a clinical picture of the disease as it is presented toward the close of life. The reality is unhappily too familiar to every observer.
The picture just referred to has another side. The disease is not always progressive. There is reason to believe that its progress is sometimes arrested. It ceases to progress in some cases from self-limitation. In a certain proportion of cases recovery takes place. What, then, is the basis for a favorable prognosis? In general terms, it is the absence of the unfavorable prognostics which have been mentioned. The prognosis is favorable in proportion as the action of the heart is but little disturbed, the temperature of the body non-febrile, the appetite and digestion but little affected, the complexion not much changed, and the nutrition of the body fairly maintained. The inference under these circumstances is that the disease does not tend to progress, and that the existing pulmonary affection is well tolerated. The ground for encouragement is greater the less in amount the pulmonary affection; but even if the symptoms and signs show the latter to be considerable or even large, encouragement is warrantable so long as there is evidence of non-progression and tolerance. It is not, however, to be forgotten that there is always more or less danger of a renewed tuberculous eruption.
The suspension of menstruation belongs among the unfavorable events, but alone it has not great significance. Its occurrence as respects the previous duration of the disease varies much in different cases. In some cases menstruation continues nearly to the close of life. The return of menstruation after its suspension for a greater or less period is a favorable prognostic.
The occurrence of certain complications is of marked importance with reference to the prognosis. Perforation of lung followed by pleurisy and pneumothorax is in most instances speedily fatal. On the other hand, simple pleurisy with effusion, in some instances at least, seems to have a favorable effect upon the pulmonary affection. Tuberculous ulcerations of the intestine preclude the expectation of improvement and hasten the fatal termination. Tuberculous peritonitis is a fatal prognostic. Chronic laryngitis, if it interfere with alimentation, is a serious complication, but if that effect be wanting it is not unfavorable as regards its significance in prognosis. Perineal fistula is not unfavorable, to say the least. Renal disease, and any accidental complication sufficient in itself to tell more or less against the powers of life, must be regarded as telling proportionately upon the prognosis.
What influence has the evidence of a congenital tendency and heredity upon the prognosis? It is commonly believed that the chances of arrest and recovery are less in proportion to this evidence. There is doubtless truth in this belief, but it has sometimes too much weight in the minds of both patients and physicians in individual cases. The disease is by no means always progressive even when the antecedents of the patient afford the strongest evidence of an innate predisposition. The following instance is given by way of illustration: In 1861 a young woman, eighteen years of age, affected with phthisis, came under my care. The disease had existed for two years, and she had tried various climates—namely, Cuba, Florida, Minnesota, Kentucky, and Ohio. The case ended fatally in 1863. The mother of this patient and two sisters had died of tuberculous disease. The father was tuberculous at the time of her death, and he died soon afterward with an intestinal complication. There remained two sisters and two brothers. The elder of the brothers, aged seventeen, was attacked in 1861 and died in 1863. The climate of Minnesota was resorted to in this case with no benefit. The younger brother, aged sixteen, in 1861 had a dry cough, which after a short time ceased, and he became apparently well and robust. The physical signs at that time showed a small tuberculous affection at the summit of the left lung. In the winter of 1863 the cough returned, and the signs now showed a tuberculous affection of the summit of the right lung. He was immediately sent to Europe, and he passed the winter and spring at Nice. He returned and went to South America in 1864. He passed the winter of 1865–66 in New Orleans and France, making the voyage in sailing ships. He passed the winter of 1866–67 in St. Paul, and died in the following spring. Of the two remaining sisters, the previous history in the case of the elder, aged thirty, seemed to warrant a retrospective diagnosis of a small phthisical affection which had ceased to progress and from which she had recovered. There were slight dulness of the summit of the chest on the left side and broncho-vesicular respiration. This one of the sisters has been well for the twenty-three years which have elapsed since the date of the supposed phthisical affection. The younger of the two sisters at the age of twenty-two had a cough with small expectoration and a moderate bronchial hemorrhage in the winter of 1862. There was abnormal dulness on percussion at the summit of the chest on the right side, with weakened respiratory murmur, some crepitation, and increase of vocal resonance. After a few weeks the pulmonary symptoms ceased. In this case there was no treatment, medicinal nor hygienic; she had passed the winters in the city and summers at attractive places of resort, entering with zest into social enjoyments, and she has been in all respects well up to the time when I last saw her, in the spring of 1881, twenty years after the phthisical disease.22
22 Since that date a recurrence of the affection has taken place, but without being progressive.
The last two cases are instances of recovery from phthisis irrespective of any medicinal or hygienic agencies; that is, a recovery by self-limitation. Considering the evidence of a family predisposition, a favorable prognosis at the outset would hardly have been justifiable. From my records of cases other instances might be selected illustrative of the caution not to allow too much weight in the prognosis, in individual cases, to the evidence of an innate predisposition.
It might be supposed, from the greater liability to phthisis between the ages of twenty and thirty years, that its occurrence at this period of life affects unfavorably the prognosis. Facts, however, do not appear to sustain this supposition. So far as the ratio of recoveries bears upon the point, the study of a limited number of cases shows it to be not larger after than before the age of thirty.23
23 Vide Phthisis, in a Series of Clinical Studies.
The liability to a recurrence of the disease after recovery is important to be considered in connection with the prognosis. Of 44 cases of recovery among those which I have recorded and analyzed, recurrence had taken place in 6 up to the time of the analysis. In one of these 6 cases the disease had recurred twice. The patient recovered from the second recurrence, and is now well, more than ten years having elapsed. In all the other cases the recurrence proved fatal. The recurrence took place after periods ranging from one and a half to over six years from the date of the recovery. So far as these cases warrant a conclusion, it is that in cases of recurrent phthisis the prognosis is very unfavorable. This conclusion might be materially modified by the study of a large number of cases. The fact that after recovery there is considerable liability to a recurrence of the disease has an obvious bearing upon the prophylactic management.
Facts pertaining to the duration of phthisis come properly under the head of prognosis. Of 44 cases of recovery which I have recorded and studied, the duration varied from six months to ten years. In more than one-half of these cases the pulmonary affection was small; in 4 cases it was moderate in amount; in 10 cases it was considerable; and in 1 case it was large and advanced.24 These facts show that the prospect of recovery is much better when the tuberculous affection is small or moderate, but that a considerable and large affection does not preclude recovery.
24 Vide Phthisis, in a Series of Clinical Studies, for abstracts of the histories of these cases. Absence of all pulmonary symptoms was known to have existed in the different cases for periods between six months and twenty-seven years. Throwing out two cases in which the period was six months, and one case in which it was eight months, the average period was six years.
Next to recovery, the course of the disease is favorable when it ceases to be progressive and life with fair health is continued for a long period. Out of the cases which I have analyzed, there were 28 in which the disease was known to have existed for periods ranging from one year and three months to twenty-five years. The duration was reckoned up to the time of the analysis or of the last information obtained. The number of years noted does not express the duration of life. The average period during which the disease was known to have been non-progressive is a fraction over eight years. The histories in these cases exemplify the fact that phthisis, when it ceases to be progressive, although recovery does not take place, is not incompatible with fair and even good general health and long life. That recovery does not take place is owing to the persistence of pulmonary lesions, such as cavities which do not cicatrize or an interstitial pneumonia with dilatation of bronchial tubes. The tuberculous disease no longer continues, but the local effects of the disease remain. Slowness of progress and prolonged tolerance are to be hoped for when the disease neither ends in recovery nor becomes non-progressive. In some cases the disease ends fatally, having existed for many years where at no time could it be said that its progress had ceased. The prolongation of life under these circumstances depends on the slowness with which the disease progresses and the ability of the system to tolerate it.
The extremes of the duration of the disease in a large collection of fatal cases are so far apart that the average period is of little practical value as bearing on the prognosis in individual cases. In the collection of recorded cases which I have studied analytically, there were 112 the duration of which from the commencement of the disease to its fatal termination was ascertained. The mean duration was about twenty-three months. Laennec found the average duration twenty-four months; Louis and Bayle, twenty-three months; Andral, twenty-four months; Sir James Clark, thirty-six months; and Williams of London, forty-eight months.
TREATMENT.—The author premises the consideration of the treatment by stating that this article was written before sufficient time had elapsed after the publication of the researches by Koch for their confirmation by other competent observers. At the present time (May, 1885) the doctrine that phthisis depends on the presence of a special micro-organism is to be considered as probably established. The grounds for this statement have been presented under the head of the Etiology, and reference to the practical bearings of the doctrine have been introduced in connection with the Diagnosis and Prognosis. It is evident that the doctrine is likely to have important bearings on the treatment. If it be true that the origin, the extension, and the diffusion of the disease within the body require the presence and the multiplication of a particular parasite, it is evidently a rational object of treatment to effect its destruction. For this object an efficient parasiticide is to be sought after, to be administered either by inhalation or by its introduction into the blood-vessels. Already, within the short time which has elapsed since Koch's discovery, extended observations have been made with various substances which are destructive to bacteria outside of the body, but thus far without success. A difficulty as regards inhalation is in the way of a destructive agent in the form of either an impalpable powder or a vapor or a gas reaching the colonies of bacilli in sufficient quantity to effect the object, without doing injury to the tissues or inducing toxæmia. As regards the introduction of parasiticides into the blood, it seems hardly probable that a toxic agent can be safely introduced in sufficient quantity to effect the object. It remains to be determined by clinical observation whether or not these difficulties are insuperable.
Efforts to destroy the parasite in another direction promise to be more effectual—namely, by the removal of the co-operating conditions on which their multiplication depends. It is to be borne in mind that the development and continuance of phthisis involves two factors, one which is the presence of the parasite, and the other the existence of those unknown conditions constituting the tuberculous predisposition or cachexia. The removal of the latter may effect the destruction of the parasite indirectly, but not less certainly than by bringing into direct contact with it a destructive agent. It is in this indirect way that the measures of treatment which experience has shown to be more or less effective may be supposed to operate. And it is to be added that those measures of treatment the usefulness of which rests on clinical observation are in no wise disproved or modified by the parasitic doctrine. At the present time the treatment of the disease is to be governed by principles which, based on reason and experience, are independent of that doctrine.
The intrinsic tendency of phthisis to be either progressive or non-progressive underlies the treatment. In a certain proportion of cases the disease tends to advance steadily and actively, as shown by the symptoms and the physical signs. In these cases treatment cannot be expected to do more than to palliate symptoms, and perhaps prolong the duration of life. These are cases of so-called galloping consumption. In a larger proportion of cases the disease does not steadily or actively advance. Remissions occur. The pulmonary affection increases, and extends by successive tuberculous invasions or eruptions after intervals variable in duration. These cases offer more encouragement for treatment. There is room to hope after each invasion that another will not take place, and that the affection which exists may be tolerated indefinitely if the cases do not end in recovery. In a minority of cases when a certain amount of pulmonary affection has taken place there is no further increase or extension. In this respect the disease ceases to progress. In some of these cases after the lapse of weeks or months all pulmonary symptoms disappear, and the patient may be said to have recovered. The probabilities of the recovery and the time required therefor vary, other things being equal, according to the amount of the pulmonary affection. In other cases recovery does not take place. More or less of pulmonary symptoms remain. The existing lesions which these symptoms represent, however, may be well tolerated, and their existence may not interfere with fair or even good general health and long life.
Whenever the disease ceases to be progressive, with or without recovery, an intrinsic tendency has more or less agency in the cessation of progress. In some instances it is certain that this result is wholly due to self-limitation. Expressing the fact in other language than that of personification, the disease may become non-progressive because the unknown, special, constitutional morbid conditions which it is customary to embrace under the name tuberculous cachexia no longer exist; or, assuming that a particular parasite is essential to the progress of the disease, this organism may cease to multiply in consequence of the non-continuance of conditions which are necessary for its multiplication. Whatever be the explanation of the tendency of the disease—to be, on the one hand, progressive, or, on the other hand, non-progressive—it must be taken into account in estimating the influence of measures of treatment. How largely an intrinsic tendency to be non-progressive is accountable for apparent success in treatment cannot be determined with precision. The evidence of its agency can only be derived from the accumulation of cases of non-progressive phthisis in which no active measures of treatment were pursued. Reference has been made to a few such cases among those which I recorded during a period of thirty-four years. Some cases in addition have come under my observation since the analysis of my cases recorded up to 1875. It is evident that a large collection of such cases cannot be made by a single observer.
From what has been stated, it follows that the treatment in case of phthisis has reference especially to the constitutional conditions which stand in a proximate causative relation to the pulmonary affection. The chief objects are to arrest the disease and to keep the cachexia in abeyance. In the present state of our knowledge measures of treatment addressed directly to the pulmonary affection, albeit important, are of secondary importance when compared with those which either co-operate with or oppose the underlying intrinsic tendency of the disease as manifested in individual cases.
Proceeding to consider the treatment in cases of phthisis, a convenient division of topics is into those relating to the climatic treatment, the dietetic and regiminal treatment, and the medicinal treatment.
Climatic Treatment.—It would be impossible within the limits of this article to enter into a discussion of the various questions connected with climatic influences or to consider the relative advantages of different climates. Nor, were it possible, would this be desirable as regarded from a practical standpoint. I shall confine myself to the general considerations which bear upon the climatic treatment.25
25 For an account of the characteristics of different places of resort in different countries, and a full consideration of the subject of climate in relation to phthisis and other diseases, the reader is referred to the article entitled "Klimatstherapie" by H. Weber of London in Handbuch der Allgemeinen Therapie, von H. v. Ziemssen, Zweiter Band, Leipzig, 1880.
In the analytical study of the cases of phthisis I had recorded up to the year 1875, I endeavored to draw some conclusions respecting climatic treatment from the facts contained in the histories. Temporary changes of climate entered into the treatment in 74 cases. The histories were interrogated with reference to the number of cases in which recovery took place, the number in which the disease ceased to be progressive without recovery, and the number in which the disease progressed slowly, with reference to the apparent influence exerted by climate. The changes of climate in the 74 cases were various. In a considerable number the patients traveled in Europe, visiting different places. The foreign resorts in which they sojourned for greater or less periods were Nice, Algiers, Mentone, Egypt, Nassau, Lima, Rio Janeiro, Cuba, and the West India islands. In this country the different resorts were in Minnesota, California, New Mexico, Florida, Georgia, South Carolina, Louisiana, Virginia, Kentucky, the District of Columbia, Michigan, and the Adirondacks. Colorado as a place of resort had not excited much attention prior to my making abstracts of my histories for analytical study, and for this reason it does not appear in the foregoing list. I have notes of not a few cases in which the latter climate was resorted to. It is at once evident that 74 cases distributed over so many places of resort cannot furnish adequate data for judging of the relative advantages of different climates. Nevertheless, the analysis of these cases led to an important conclusion as respects, in general, the usefulness of a temporary change of climate. Of the 74 cases, 9 ended in recovery, 13 were in the list of cases of arrested or non-progressive phthisis, and 5 were in the list of cases in which the disease was slowly progressive. In 33 cases the disease ended fatally, and in 14 cases neither the duration nor the termination of the disease appears in the histories. Moreover, of the 33 fatal cases, in 23 the histories afforded evidence of more or less benefit from the changes of climate.26 From these facts it seemed warrantable to deduce, as a positive conclusion, that in a considerable proportion of cases a change of climate has a favorable influence on phthisis. It follows also, as a corollary, that a favorable influence is exerted by a variety of climates. Indeed, it would seem, judging from these facts, that the favorable influence pertains to the change rather than to the particular climate selected. If this be true, it follows that the agencies by which a favorable influence is exerted relate to accessory or incidental circumstances more than to purely climatic conditions.
26 For further details vide Phthisis, in a Series of Clinical Studies.
It is an absurd supposition that any climate exerts a specific influence in arresting phthisis. This statement is not in the least inconsistent with the fact that certain climatic conditions are much more favorable than others for an arrest of the disease. Dryness, equability, and purity of the atmosphere are essential elements of a favorable climate. Within late years a high altitude (4000 to 8000 feet above the ocean-level) has been deemed by many of much importance. Aside from the purity of the air incident thereto, the rarefaction is supposed to have a salutary effect by increasing the expansion of the lungs.27 Few at the present time regard a tropical temperature as advantageous. The choice is usually regarded as lying between a cold and a warm climate, each having favorable elements aside from temperature. There is abundant testimony in behalf of each. Circumstances pertaining to cases individually must determine which to choose. A patient who in health has found cold weather more favorable to vigor and well-being than warm weather will be likely to find a cold climate more beneficial than a warm climate, and vice versâ. In order to derive benefit from a cold climate a patient must have preserved sufficient vigor to endure out-of-door life in such a climate. Confinement much of the time within doors must deprive patients of the benefit to be hoped for from a cold climate. For obvious reasons a cold climate is better suited to men than to women. With reference to the superior excellence of particular health-resorts, caution is to be exercised in weighing not only testimony either for or against their superiority, but the value of reported cases. Putting aside the chances of error in diagnosis, it is to be considered that among those who elect a particular place of resort an arrest of the disease or improvement to a greater or less extent would probably have taken place had any one of many places been selected, and perhaps if no change had been made. On the other hand, in a certain proportion of cases the disease will be progressive anywhere. A limited number of cases must not be relied upon to establish the relative advantages of particular places, especially if there be not data enough to judge of the condition of the patient in each case as regards the amount of the pulmonary affection, the temperature, pulse, and other symptoms. A few cases which have been selected to illustrate either the favorable or unfavorable influence of a particular climate are not entitled to any weight in the formation of an opinion. To gather clinical facts sufficient to determine by analytical study the actual advantage severally of different climates is a work attended by so many difficulties that it must be long before it can be accomplished. Meanwhile, in discriminating between different places of resort the physician is to be governed by rational considerations. In reality, custom and fashion have much to do in this matter. Places which were formerly in vogue as health-resorts have now fallen into disrepute. It is almost inevitable that sooner or later this will be the fate of any place which becomes so popular as to attract very largely phthisical patients, owing to the aggregation of the instances in which no benefit could have been expected from climatic treatment.
27 On this topic the reader is referred to an article by C. Theodore Williams, entitled "The Treatment of Phthisis by Residence at High Altitudes," in the Transactions of the International Medical Congress, London, 1881; also to a work entitled Rocky Mountain Health-Resorts, an Analytical Study of High Altitudes in Relation to the Arrest of Chronic Pulmonary Disease, by Charles Denison, M.D., 2d ed., 1880.
There is much reason in the suggestion that the immunity from phthisis in situations which are sparsely settled may be due not so much to climatic influences as to the fact that these situations are free from non-climatic causes contributing to the prevalence of the disease—namely, in-door occupations, overcrowded dwellings, etc.
There is reason to believe that the benefit derived from climatic treatment is often in a great measure due to accessory circumstances. As already intimated, this seems to be a fair inference from the number of instances of arrest of the disease, of cessation of its progress, and of notable improvement in a collection of cases in which many and varied climates had been resorted to. Under the name accessory are embraced a variety of circumstances—in fact, everything not pertaining purely to climatic agencies. The opportunity of living in the open air and freedom from the cares of business, together with relaxation and mental diversion, are in the category of accessory circumstances. These contribute largely in some cases to the benefit derived from change of climate. Patients at a health-resort are apt to carry out hygienic regulations more faithfully than when at home. In contrast to the accessory circumstances which are favorable there are those which have an unfavorable effect, such as home-sickness, ennui from lack of usual occupations, anxiety lest affairs should suffer for want of personal supervision, interruption of fixed habits, and the want of home comforts. These in some cases may go far toward counteracting the benefit from climatic influences.
All these accessory circumstances, as bearing upon individual cases, are to be taken into account in deciding the question as to the importance of climatic treatment. Of course a change of climate is important, other things being equal, in proportion as the climate in which the patient resides is humid, variable, and the atmosphere impure. So far as purely climatic influences are concerned, it may be important only that the patient escape the more trying seasons of the year—namely, the spring and the hot summer months. A malarial climate should certainly be exchanged, if practicable, for another during the season when there is danger of being infected with the malarial miasm. To avoid this cause of disease, as well as the changes of temperature, etc. incident to the spring and summer months, it may not be necessary to go very far from home. It is probably better not to go to a distant climate for a few weeks, in order that the double acclimatation caused by going and returning within such a brief period may be avoided.
It is of essential importance to take fully into account the condition of the patient as regards the pulmonary affection and the general symptoms before advising or sanctioning a change of climate which involves long journeys and separation at a distance from home and friends. There is more reason to expect benefit from a change the stronger the evidence against an intrinsic tendency of the disease to progress actively. Whenever the temperature and circulation denote activity of progress the propriety of a change is doubtful. Whenever there is great emaciation with muscular feebleness there is little ground to expect material benefit from any climate. The experiment is allowable at an advanced period of the disease only with a view to satisfy the wishes of the patient and the friends, having a full understanding with the latter in respect of the danger of dying away from home. It should be added that sometimes in cases which offer no ground for the expectation of any essential benefit journeys or voyages are well borne, and life is apparently prolonged by a change from an inclement to a genial climate.
Distance is a point to be considered in the selection of places of resort. It is often an objection to crossing the ocean that communication with relatives or friends is attended with delay and difficulty. The voyages, as a rule, are not objectionable. Our own country embraces almost every possible variety of climate, and therefore, so far as purely climatic influences are concerned, it is not necessary to resort to foreign countries. The latter, however, have for many the advantage of being made more attractive by novelty and historical associations. Moreover, there are often better arrangements for comfort and enjoyment. The accessory advantages are always to be considered with reference to the particular tastes and needs in individual cases. Good food in abundance and well cooked, large and well-ventilated rooms, facilities for walking, riding, and driving, opportunities for hunting, fishing, and other out-of-door sports, ample provisions for in-door exercise in bowling, etc., agreeable society,—these are among the accessory advantages without which often the best climatic influences will prove inoperative. To these is to be added available judicious medical advice.28
28 For details concerning the health-resorts of the Riviera, Hyères, Cannes, Nice, Mentone, and others which are much esteemed in Europe, the reader is referred to a work entitled The Riviera, by Edward I. Sparks, London, 1879.
A mistake often made by those who find benefit from a change of climate is to continue the change for too short a period. The benefit speedily obtained may be speedily lost when the patient is again placed under the climatic and other circumstances attending the development of the disease. It is to be borne in mind that the benefit from a change of climate does not depend on any special remedial agency, but on a combination of favorable circumstances, and that the salutary influences connected with climate are exerted not so much directly upon the lungs as upon the general system. It follows that the beneficial effect may be manifested more by increase of appetite, better digestion, greater endurance of muscular exercise, and especially gain in weight, than by immediate improvement in the pulmonary symptoms. Many patients cannot afford the loss of time and the expense of lengthened absence, and therefore are unable to make trial of change of climate. These may be consoled by the fact that not a few cases of phthisis do well without any climatic treatment. In some of the most striking of the instances of arrest of the disease which have come under my observation change of climate did not enter into the treatment. Important as is this fact, it does not conflict with the belief that additional chances of arrest and the prospect of more or less improvement are often secured by climatic treatment. It is a wise precaution for patients to reside permanently in a climate in which an arrest of the disease has taken place. Of course this is not always practicable. Its importance is attested by reason and experience, and it is the duty of the physician, according to his discretion, to suggest it. The many obstacles which are often in the way of its adoption are sufficiently obvious.
Sanitaria for phthisical patients at health-resorts are doubtless serviceable in many cases, because hygienic measures are enforced which would not under other circumstances be thoroughly carried out. An offset to this advantage is the depressing effect upon some minds of association with other patients. Owing to this moral effect it is sometimes judicious to advise patients not to go to places which, for the nonce, are especially popular, in order that they may not have before their eyes cases exemplifying all the phases of the disease, and be led to talk over symptoms with other patients affected with phthisis. As regards sanitaria, those in which the chief object is to enforce measures of hygiene are perhaps most likely to be serviceable. If these measures be secondary to some system of medication, there is room for distrust.
It is hardly necessary to say that the treatment of patients in such institutions should be under the charge of competent physicians who have not originated or adopted any peculiar notions respecting the pathology and therapeutics of the disease. As a matter of course, there cannot and should not be any restriction in either originating or adopting ideas and methods of practice, however much they may be at variance with commonly-received opinions; but a physician who appreciates his obligation to his patients will hardly feel willing that they should be made subjects for testing pathological and therapeutical novelties in behalf of which his own belief is not committed.
Dietetic and Regiminal Treatment.—The dietetic treatment resolves itself into a few simple principles. It may be assumed that as much assimilation of aliment as is possible is desirable. No one probably will contend for the propriety of any restriction of diet with a view to limiting the amount of the nutritive constituents of the blood. The difficulty in this part of the treatment lies in the impairment or loss of appetite and in lack of digestive or assimilative ability. It is useless to consider whether such or such articles of food are suitable or not for phthisical patients. All wholesome articles which can be taken with any relish and digested are suitable. Nothing could be more ill advised than to direct kinds of nutriment which a patient does not like, and to enjoin avoidance of those which the patient's appetite would dictate. Pains should be taken to ascertain the articles of diet most acceptable or against which there is the least repugnance, and to excite the appetite by variety and culinary attractions. It is important not to judge too hastily of the ability to digest the food which can be ingested. The evidences of indigestion are nausea, vomiting, flatulence, acidity, and diarrhoea: whenever these symptoms are wanting it is fair to assume digestive ability. Nor should evidence of indigestion deter at once from continuing articles which appear to have occasioned it. The processes of digestion are so apt to be disturbed by extrinsic accidental circumstances that a meal which will occasion indigestion to-day may not do so to-morrow. In short, so far as regulation of the diet is concerned the patient is to be encouraged to take all kinds of wholesome food according to appetite and taste, giving to each and all a fair trial as regards digestibility. Fully aware that these views may not commend themselves to the approval of many who think that the diet should be regulated on scientific principles rather than by the instincts of the patient, I do not any the less adhere to them, believing that they are based on experience and common sense. As regards the liability, where the instincts are followed, to the over-ingestion of food and to the ingestion of food indigestible from its quality or modes of preparation, it is far better to incur whatever inconvenience may therefrom arise than the evils of inadequate nourishment. In short, the dietetic instructions to a phthisical patient may be summed up as follows: Eat of wholesome articles of food whatever the appetite may dictate; endeavor to maintain and develop appetite and relish for food by the excitement of variety in kind and in preparation; eat whenever hungry; satisfy the appetite; eat without any expectation of harm; do not hastily attribute an indigestion to any particular articles of diet; incur the risk of over-feeding rather than of the greater evil of under-feeding.
Anorexia in a degree which I have characterized as invincible—that is, an almost complete inability to take food—is one of the most discouraging of symptoms in cases of phthisis. Of course if the symptom continue the duration of life is simply a question of time and tolerance. Milk is an invaluable form of food when appetite is completely lost. The advantage sometimes of substituting for simple cow's milk buttermilk, koumiss, or milk made sour by fermentation with yeast is due wholly to these being taken more readily and more easily digested. The same is true of the substitution for the milk of the cow that of other animals—the goat, the ass, and the mare. Eggs may be given in a liquid form with milk or other fluids. Very little reliance is to be placed on the various meat-extracts (Liebig's, Valentine's, and others) as representing any considerable amount of nutriment. Meats artificially digested—that is, in the form of peptones, as in Leube's meat solution—form a valuable addition to beef-tea. Rectal alimentation may be resorted to. A. H. Smith has reported marked benefit from defibrinated blood as a form of rectal diet.29 A French writer, Debove, has lately reported notable benefit from forced alimentation, food being injected through a tube introduced into the stomach.30 If in any way food can be introduced, in spite of the anorexia, and assimilated, there may be room to hope that a return of appetite will be among the beneficial effects. Cod-liver oil and alcoholics will be considered in connection with the medicinal treatment.
29 Vide N.Y. Med. Record, 1881, No. xix.
30 Vide Bullétin générale Report, Paris, 1881. Another French writer more recently in the same journal, Desnos, has pointed out a source of danger in forced alimentation—namely, the occurrence of violent acts of vomiting, during which portions of food ejected from the stomach are inhaled. The danger is from asphyxia and pneumonic inflammation excited by the presence of particles of food within the smaller bronchi. In order to avoid this source of danger, food should be introduced slowly and not in too large a quantity at a time. Intolerance of the presence of the tube within the stomach is an obstacle which may be overcome by use, but in some cases it is insuperable (vide article in Philadelphia Med. Times, March, 1882).
The regiminal treatment embraces changes relating to out-of-door life, exercise, occupation, clothing, etc.
Of all the changes in this category, those relating to out-of-door life and exercise are of greatest importance. In-door life and sedentary habits, if not factors in an acquired cachexia, undoubtedly favor it. This is shown by the place which these hold in the etiology and by their agency in the arrest of the disease. With respect to the latter point, the result of my analysis of recorded cases has much significance. In 44 cases change of habits from those more or less sedentary and confining within doors to those involving out-of-door life and activity entered into the treatment. In all but 4 of these cases the hygienic treatment consisted chiefly or exclusively of the change of habits mentioned. Of the 4 excepted cases, in 1 the patient passed several months in Europe; in 1 the patient passed a summer in Minnesota; in 1 the patient made several voyages to Europe; and in 1 the patient travelled in Europe. Of these 44 cases, 15 are in the list of cases of unknown duration and termination. Deducting these, the remaining number is 29. Now, of these 29 cases, 11 are in the list of cases ending in recovery; 7 are in the list of cases in which the disease was arrested or became non-progressive; and 3 are in the list of cases of slowly-progressive phthisis. Thus, only 8 out of the 29 cases were not included among those in which the course of the disease was favorable in the three aspects just named, and in more than one-third of the cases recovery took place. Of the 8 fatal cases, in all save 1 case the change of habits appeared to be beneficial. The benefit was marked in 2 of the cases, there being in 1 of them no evidence of progress of the disease for several months.31 Moreover, the majority of the histories of the 15 cases of uncertain duration and termination show more or less improvement. In 7 of the 11 cases ending in recovery the change in habits constituted all the treatment. Making the fullest allowances for an intrinsic tendency in the disease to end in recovery, and in some instances purely from self-limitation, the foregoing facts afford ample proof that changes of habits from those more or less sedentary and confining within doors to those involving out-of-door life and activity have considerable agency in the arrest of phthisis and exert a favorable influence upon the disease when it is not arrested. There is reason to believe that the favorable influence is greater than any other class of hygienic measures, and it is probable that to this source much of the benefit derived from change of climate is to be referred.
31 For details of the changes of habits in these cases vide Phthisis, in a Series of Clinical Studies.
The particular changes to be made in order to secure as much out-of-door life as practicable with a certain amount of exercise must of course vary in different cases. Clerks, school-teachers, mechanics whose business requires in-door life, etc., should, if possible, adopt some other occupation securing the desired objects. Students, clergymen, and men of leisure should systematically devote a fair proportion of time to exercise in the open air, and as far as practicable the exercise should involve recreation. It is needless to say that the importance of change is as applicable to women as to men. Caution is sometimes necessary not to carry muscular exercise to an injurious extreme. If carried to the extent of producing great fatigue or exhaustion, it is debilitating instead of invigorating. Exercise within doors, although much less useful than when taken in the open air, is nevertheless useful. Gymnastic exercises may be recommended when other measures which are to be preferred are not available. They are inferior to rowing, horseback riding, hunting, etc. An increased expansion of the chest is apparently a desirable effect of exercise. Forced efforts of expiration to overcome a mechanical resistance, the lungs being fully inflated, constituted a method of treatment formerly in vogue, and I have met with instances in which it seemed to have been useful. In taking exercise patients are apt to imagine that in order to avoid catching cold they should go out of doors only when the weather is in all respects favorable. Precautions in this regard are often carried so far as to interfere materially with the amount of life in the open air which is desirable. It should be understood that phthisical patients are no more—and perhaps less—liable to catch cold than persons in health, and that a cold, as a rule, does not affect the progress of the tuberculous disease. These excessive precautions have arisen from the error of considering phthisis as a sequel of bronchitis. There is no ground for the great scrupulousness with which phthisical patients avoid the night air, although out-of-door life in the daytime is to be preferred.
Every practitioner has known of cases in which some remarkable changes of habits as regards out-of-door life and exercise have led to recovery, such as performing long journeys on horseback or on foot, accompanying expeditions which involved camping in the open air with hardships, etc. Several instances of this kind have come within my knowledge. In one of these the patient, a young physician who consulted me, on being told that he had incipient phthisis gave up his practice and joined a tribe of Indians in the Far West. He remained with them for more than a year, adopting all their customs, and returned in vigorous health. But in order to rough it a patient need not go to a distance from home and friends. This fact is lost sight of when physicians sanction the exposures and hardships of travel without the limits of civilization, but enjoin upon patients great care in taking exercise out-of-doors so long as they remain in their places of residence.
All who have had the opportunity of observing the effect of sea-voyages in cases of phthisis are agreed as to their utility. A long sea-voyage or a series of voyages entered prominently into the treatment of 20 of the cases which I have analyzed. In a large proportion of these cases the favorable influence was marked. This is an accessory circumstance which contributes to the benefit in many cases derived from a change of climate. It is evident that a certain proportion only of phthisical patients can avail themselves of this measure. It is to be advised especially for those who can leave home and business without anxiety, who are fond of ocean-life, and who as a matter of course are good sailors.
The supposed liability to, and danger of, catching cold often leads phthisical patients to wear an overplus of clothing. When they strip for an examination of the chest not infrequently they remove two or three undershirts, a woollen or fur chest-protector, and sometimes in addition an oiled-silk jacket. The body is kept in constant perspiration by these articles. They occasion not only discomfort, but debility. A single word expresses the governing principle in clothing—namely, comfort. Articles of dress should be so adapted to the seasons and to changes of temperature as to secure comfort. This maxim applies to persons affected with phthisis as well as to those in health. In some instances, from an erroneous theoretical notion, patients make themselves uncomfortable in an opposite way. They dispense with woollen or silk underwear throughout cold seasons with the idea that the system is thereby hardened. A good non-conductor of heat next to the surface protects against changes of temperature and promotes the functions of the skin. Attention to the sense of comfort will enable the patient to avoid error in this direction as well as an overplus of clothing.
Other regiminal observances relate to ventilation and the sponge bath. The apartment in which the patient is expected to pass at least one-third of the twenty-four hours should be sufficiently large and well ventilated. Fresh, cool air in abundance is not deleterious, as it would seem to be regarded when the utmost care is taken to exclude it. It is essential to healthful sleep and invigoration. Here, again, the supposed danger of catching cold antagonizes hygienic treatment. Air should have free access to sleeping apartments in cases of disease as in health. As a measure for invigoration the sponge bath is often useful in cases of phthisis. The water used may be cool or tepid according to the sensations of the patient and the effect. It should be followed by a glow with a feeling of invigoration. The water may with advantage be made stimulating by the addition of salt or of alcohol.
Medicinal Treatment.—The medicinal treatment in cases of phthisis embraces no known remedies having a special influence over the disease; in other words, no drug has as yet been found to be an antidote to the tuberculous cachexia. Nevertheless, medicines in many cases form an important part of the treatment. They have for their objects improvement of appetite, digestion, assimilation, and nutrition, relief from complications or associated affections, and the palliation of symptoms.
Cod-liver oil is considered in this article, as is customary, in connection with the medicinal treatment. It has, however, little or no claim to be regarded as a medicine. It is a nutrient. It is a form of fat which patients often digest readily, and which evidently increases the weight of the body. That it does more than simply increase the amount of fat in the body is shown by the fact that frequently under its use the appetite, the digestion, the condition of the blood, and the nutrition of the tissues manifest improvement. These effects are not inconsistent with the statement that it is simply an article of diet. Although the claims in its behalf as a special remedy which were made forty years ago have long since been disproved, clinical experience has continued to furnish proof of its usefulness in the treatment of cases of phthisis. It should enter into the treatment wherever it is well tolerated and digested. If it occasion nausea or diminish the appetite or give rise to eructations, its use should not be persisted in. In the choice among the different varieties of the oil experience in each case is to be the guide. Some patients find the brown varieties more acceptable than the pale, and vice versâ. I have known in several instances the unrefined, coarse oil obtained at the fish-markets to be preferred. Patients should not give up this part of the treatment until the different varieties have been tried. The popular preparations in which the oil is combined with salts of lime or with some flavoring extract are sometimes tolerated by those who are, or who fancy that they are, unable to tolerate the pure oil. They have probably no advantage for those who are able or who are willing to take the pure oil. The oil should never be given in doses larger than are readily digested, and, following this rule, the doses will rarely exceed half an ounce. They are best given shortly after meals. It is a popular notion that the oil should not be continued in hot weather. The weather should have no influence on its continuance, provided it be well tolerated and digested. The addition of fifteen minims of ether to a half-ounce dose of the oil has been found to promote its digestion, and by means of this addition persons with whom the oil disagrees may be able to take it without difficulty. The ether is to be given half an hour after the oil has been taken.32 Salad oil, cream, butter, and the extracts of malt may be made to supply, in a measure, the place of the cod-liver oil in the cases in which the latter is not tolerated.
32 Vide report by Dr. Andrew H. Smith, chairman of Committee on Restoratives of the New York Therapeutical Society in the N.Y. Medical Journal, April 20, 1879.
Embracing the varieties of spirits, wine, and malt liquors under the name alcoholics, these are to be regarded as alimentary, but also as medicines. That they are useful in certain cases of phthisis is as well established on the basis of clinical experience as any fact in practical medicine. Their usefulness in this disease, as well as in other diseases, is to be considered irrespective of questions relating to their use and abuse in health. But as bearing on the very important subject of intemperance it may be stated that, administered purely as remedies in cases of phthisis, patients do not become so addicted to them as to make it difficult to relinquish their use whenever this is advisable. This statement is based on a large experience.
Alcoholics are useful in some and not so in other cases. The question as to their usefulness is to be decided in each case by trial. If they produce a sense of comfort without any excitation of the circulation or of the nervous system, they are likely to be useful. If in lieu of a cordial effect they occasion flushing, weariness, or indisposition to exertion or discomfort of any kind, they are not likely to be useful. The quantity to be given is to be regulated by the immediate effects. There is sometimes a notably increased tolerance of alcohol. This is to be ascertained by experimental observation. The quantity of alcohol given should never occasion the least approach to alcoholic intoxication. It should be given at or near the times of taking food, or in combination with food, as in milk-punch or egg-nog.
As to the choice of an alcoholic, this is to be determined by the past and present experience in each case. Each of the many varieties of spirits, malt liquors, and wines is best suited to some cases and not to other cases. There is no rule of choice applicable to all patients. Changes in the form of alcoholics from time to time are often advisable in the same case. In the majority of cases some forms of spirits will be found best to agree. Malt liquors, either the strong or mild varieties, agree best in some cases. Of wine, some patients take with most comfort the light and some the stronger varieties. The effect upon the pulse, respiration, and other symptoms should be observed with reference to the employment of any of the alcoholics, and of the particular ones best suited in individual cases, but much reliance must be placed on the subjective symptoms. It has been proposed to substitute pure alcohol for any and all the alcoholics used as beverages, in order to give to the treatment more distinctly a medicinal character and to avoid risk of the formation of a habit which may lead to intemperance. Since, however, of the many varieties of alcoholics, some agree in certain cases and not in other cases, it is doubtful whether alcohol is able to take the place of all. This is a point to be decided by clinical observation.
Phosphorus in the form of the hypophosphite of soda and of lime was recommended about forty years ago on the theoretical ground that it favored cell-formation and retarded the rapid waste of the tissues. More recently it has been supposed to have a specific influence over tuberculous disease. It has been employed pretty largely in different countries, but without effects sustaining the claim of having a specific action. It seems to be useful, and many physicians attach considerable importance to its use.
The preparations of iodine, from their evident utility in certain scrofulous affections, and in view of the identity of scrofula and tuberculous affections, have heretofore entered largely into the treatment of cases of phthisis. From the fact that they are now but little employed in phthisical cases it may be inferred that in this instance, as in many other instances, theoretical considerations have failed to find support from clinical experience.
Of arsenic it can be said that many able observers have borne testimony to its great usefulness in some cases, as manifested by improvement in appetite, nutrition, and in the powers of life generally, together with the cough and expectoration. Here, as in other instances in which it is desirable to continue the remedy for a considerable period, the doses should be small and not increased. Noël Guéneau de Mussey testifies to a remarkable efficiency in some cases of the mineral water of Bourbole, either exported or taken at the spring.
Sulphur, especially as contained in the Sulphur Springs water, has long been considered a useful remedy in phthisis as in other chronic diseases. The Sulphur Springs of our country, however, although much resorted to for other diseases, have not in phthisical cases with us the celebrity which those in Europe (of which Des Eaux Bonnes are a famous type) have with European physicians.
The symptomatic indications for medicinal treatment in cases of phthisis are many and varied. Among the most important are those relating to appetite and digestion. For the improvement of these functions the preparations of cinchona, salicin, gentian, quassia, and other of the vegetable bitter tonics, including nux vomica, may be selected, according to the choice of the physician, or given in succession. They have more or less efficiency in conjunction with the more potential hygienic measures considered in connection with the climatic, the dietetic, and the regiminal treatment. Pepsin and dilute hydrochloric acid, taken after a meal, promote its digestion, their medicinal action being, however, limited to the meal in connection with which they are administered. The tincture of the hydrochlorate of iron and other ferruginous tonics which are much used in cases of dyspepsia and indigestion are useful in cases of phthisis. The anæmia which exists so constantly in phthisical cases is an indication for their use, and there does not seem to be ground for the conjecture which has been entertained that they promote the occurrence of bronchial hemorrhage. If they had this effect it would not disprove their utility.
Pulmonary symptoms which may furnish therapeutic indications are cough and expectoration, hæmoptysis, pain in the chest, and dyspnoea. Cough is of course necessary for the removal of the morbid products within the bronchial tubes and cavities. If the act of coughing be accompanied by expectoration, palliation is not required. But often there is what may be called a superfluous cough—that is, not accompanied by expectoration. This superfluous cough may be frequent, and occur in violent paroxysms which occasion fatigue and exhaustion. Frequently the cough prevents sleep. Palliative remedies are then indicated. It is desirable, if possible, to palliate cough with remedies which do not contain an opiate, owing to the impairment of appetite and digestion caused by the latter. Simple remedies, such as the balsam of tolu, the syrup of wild-cherry bark, Turlington's balsam, etc., may suffice. If not, other narcotics than opium should be tried—namely, hyoscyamus, lactucarium, and belladonna. Fothergill recommends hydrobromic acid and the spirits of chloroform. The addition, however, of some form of opiate is often required. The paregoric elixir is the simplest form, and therefore the best if it suffice. Of other forms, perhaps codeia is in general to be preferred. Patients should be enjoined not to prolong voluntarily ineffectual coughing efforts. The disposition to cough may in a considerable degree be controlled by the will until the morbid products are in a situation to be readily expectorated. The stimulant expectorants and those which act by causing nausea are not indicated in cases of phthisis, and are objectionable in so far as they impair appetite and digestion. Stimulating medicinal inhalations are of doubtful propriety, but a superfluous cough is sometimes relieved by breathing some vapor, a little laudanum or paregoric elixir having been added to the water vaporized. The continuous breathing of an atmosphere charged with carbolic acid, either by diffusing it in an apartment or the use of a respirator, is advisable if there be fetor of the expectoration.
It has been seen that bronchial hemorrhage is not, as a rule, an unfavorable event in cases of phthisis. It does not follow from this fact that the loss of blood is desirable, and therefore that the hemorrhage should not be arrested. Moreover, the loss of blood in some instances involves immediate danger. A first attack of hæmoptysis occasions great alarm and anxiety. The prostration which appears is a moral effect rather than the exhaustion caused by the loss of blood. In repeated instances after attacks of hæmoptysis have several times recurred, I have known patients to keep about as usual during an attack, giving little or no heed to it.
The internal remedies which may be employed for the arrest of hemorrhage are: Ergot or ergotin, acetate of lead, tannic or gallic acid, and the astringent preparations of iron. Ergotin has been given with good effect by subcutaneous injection, from five to ten grains in water, with or without glycerin, being injected and repeated pro re nata. Opium in some form should be conjoined in order to allay nervous excitement. A teaspoonful of table-salt taken into the mouth and repeated after intervals of a few moments is a well-known remedy during the hemorrhage. The hemorrhage is sometimes so profuse and rapid that much blood is swallowed, and may be afterward vomited. Under these circumstances, and whenever the persistence of the hæmoptysis calls for more prompt measures, cold may be applied to the part of the chest which corresponds to the seat of the hemorrhage. This may be found by means of a localized subcrepitant râle. Another measure is the inhalation of a vaporized solution of the liquid persulphate of iron. Still another and more potential measure is the temporary ligation of one or more of the members of the body, the pressure being sufficient to interrupt the flow of blood in the veins and not in the arteries. This measure must be resorted to and continued only when the physician is present. The effect is sometimes almost magical. The measure is a substitute for venesection, which was formerly employed for the arrest of bronchial hemorrhage. Cavernous hemorrhage, occurring usually late in the disease, if profuse calls for prompt measures, and the topical employment of cold will be likely to be the most promptly effective.
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.
In concluding the consideration of the treatment of pulmonary phthisis reference is to be made to a measure to which one of our countrymen has recently given much attention—namely, the injection of tuberculous cavities. More than thirty years ago the late Brainerd of Chicago related to me a case in which he made an opening through the chest-wall into a tuberculous cavity. He had the idea that cavities might in this way be treated by local applications with advantage. Of the result in that case it is only recollected that no bad consequences followed. Probably Brainerd did not prosecute further experimental observations, as I am not aware of any publication by him on the subject. In 1873, Mosler of Germany advocated making a free opening in tuberculous cavities with a view to drainage and topical treatment. He reported 3 cases in which a drainage-tube was introduced and kept in the cavity. The practicability of the operation and the absence of any evil result were shown by his cases. The operation had been advocated and performed prior to Mosler's publication, but without exciting consideration. To William Pepper belongs the credit of injecting medicated liquids by means of a small syringe and hollow needles. Pepper has reported 12 cases in which cavities were thus injected. In these 12 cases two hundred and ten injections were made. In no instance did any harm result therefrom. The injected liquid in most of the cases was a very weak solution of iodine. In some instances a weak solution of carbolic acid was used. The objects are "the disinfection of the cavities, the relief of cough, the diminution of secretion, and the modification of the morbid action of the lining surface of the cavity, so as to favor cicatrization and contraction and the prevention of infection of the constitution." The results of the treatment in the cases reported by Pepper go to show that it may contribute to these objects. His observations have opened up a new and important department in the therapeutics of pulmonary phthisis.35
35 For reports of Pepper's cases and other details vide article in the Transactions of the American Medical Association, vol. xxxi., 1880; also article in the American Journal of Medical Sciences, October, 1874.
Fibroid Phthisis, Chronic Interstitial Pneumonia, Cirrhosis of Lung.
The characteristic anatomical feature of this variety of phthisis is the predominant growth of the pulmonary connective tissue. If, as is generally held, this hyperplasia be due to a chronic inflammatory process, the name chronic interstitial pneumonia is not inappropriate. From an analogy to the structural affection of the liver characterized by an abnormal development of Glisson's capsule, the affection was called by Corrigan cirrhosis of the lung. The propriety of regarding it as a distinct form of pulmonary phthisis is based on points pertaining to the morbid anatomy and to the clinical history.
An abnormal interstitial growth enters more or less largely as an element into the morbid anatomy in cases of the ordinary form of phthisis. It is the chief element in typical cases of fibroid phthisis. The affected lung-structure is condensed and indurated, owing to obliteration of alveoli and bronchial tubes. The affection leads to notable diminution in volume. Resulting therefrom is a compensatory dilatation of bronchial tubes. Sacculated dilatations may reach the size of an English walnut or even a hen's egg. These are known as bronchiectasic cavities. The pleura is thickened and the opposed surfaces closely adherent to each other. With these distinctive changes are usually found small cheesy tuberculous deposits or true tuberculous cavities and miliary tubercles. The latter anatomical points show relationship to the ordinary form of phthisis. Exceptional cases are those in which the interstitial pneumonia is the result purely of the local action of inhaled irritating particles (vide [PNEUMONOKONIOSIS]). In these cases the tuberculous characteristics may be wanting. In cases of fibroid phthisis both lungs are often affected. But the affection is apt to be confined to, or much more extensive in, one lung, so that during life it either is, or appears to be, unilateral. Exceptionally, both lungs are extensively affected. It may originate in and be limited to a lower lobe. It is stated by Trojanowsky that when the affection is unilateral it oftener begins in the upper lobe, and when bilateral the lower lobes are first affected. A series of bronchiectasic dilatations may be so closely situated as to resemble an anfractuous cavity resulting from the discharge of liquefied tuberculous deposits.
It is customary to consider this affection as occurring consecutively to acute lobar and broncho-pneumonia, to chronic bronchitis, and to pleurisy. Taking into view, however, the slow, insidious development of the affection, the infrequency of its occurrence, and the frequency of the diseases just named, a more rational conclusion perhaps is that when these diseases are associated with the phthisical affection they are secondary to it. The affection occurs oftener after than during the decade in which the ordinary form of phthisis is most apt to occur—that is, after thirty years of age.
The course of the affection as regards activity of progress is strikingly different from that of ordinary phthisis in a large proportion of cases. Commencing imperceptibly, after it has advanced to a certain extent it may remain apparently stationary, or it progresses very slowly during a long period. Its duration may extend over many years. In a case for a long time under my observation it existed probably for forty years. If the lesions be not extensive enough to interfere notably with the respiratory function, it may be tolerated indefinitely. The appetite, digestion, and nutrition may be well maintained. The muscular strength may not be much impaired. The circulation, temperature of the body, and other functions may be but little disturbed. A fatal termination, if not caused by some intercurrent disease, takes place after a very gradually progressive general debility and exhaustion.
As regards the different anatomical systems of the body other than the respiratory system, it is not important to add to the foregoing sketch details of symptomatology. The important symptoms referable to the respiratory system relate to cough, expectoration, and disturbance of respiration. The cough varies according to the quantity and character of the matter to be expectorated, the difficulty of its expulsion, and the susceptibility of the patient to the reflex influences on which cough depends. The matter expectorated is muco-purulent, and in many instances it is at times extremely fetid. This is due to the putrescency of morbid products detained within the bronchiectasic cavities and bronchial tubes, owing to difficulty in effecting their expulsion. The fetor may be suggestive of gangrene. The matter expectorated, however, if examined microscopically, will not be found to contain the débris of pulmonary structure. There may be sloughing of small portions of mucous membrane, but this is probably rare. The expectoration after certain intervals of putrid sputa in considerable or great abundance, the expectorated matter during the intervals having the characters of muco-pus without fetor, is almost pathognomonic of this variety of phthisis. The repeated occurrence of the putrid sputa, the clinical history, and the physical signs render it easy to exclude abscess of the lung. The detention of morbid products within bronchiectasic cavities, and the consequent putrescent decomposition, depend of course on the difficulty with which the contents of the cavity are expelled. This difficulty is greater if the cavities be in the lower than in the upper lobe. In a case which came under my observation the affection had been known by the attending physician to have existed for fifteen years. There was more or less habitual expectoration of ordinary muco-purulent matter, but after intervals of several days a considerable quantity of intolerably fetid matter was expelled. In this case the physical signs showed the affection to be limited to the lower lobe of the left lung. There was notable retraction of the lower and lateral portions of the chest on this side; solidification of lung was denoted by bronchial respiration and bronchophony over the posterior aspect; and the cavernous respiration was perceived over a circumscribed area in the latero-posterior aspect. This patient's general condition of health was fair; he had not a morbid aspect, and he was able to perform the duties of a clerkship in one of the municipal departments.
The respirations are more or less increased in frequency, the increase, other things being equal, being in proportion to the amount of damage of the pulmonary organs, or, in other words, the extent to which the respiratory function is compromised by the lesions. These may be sufficient to give rise to much suffering from dyspnoea. This was true of a case under my observation in which both lungs were extensively affected, while the muscular strength and the functions generally of the body were not greatly impaired. The embarrassment of breathing is increased by an accumulation of muco-pus within the bronchial tubes, and notable relief follows expectoration of the accumulated products. Hæmoptysis occurs in some cases, but much less frequently than in the ordinary form of phthisis. The hemorrhage is sometimes profuse. It proceeds from erosion of the walls of vessels or the bursting of small aneurisms within bronchiectasic cavities.
Cyanosis is marked in some cases. This symptom is not always in proportion to the dyspnoea; that is, the cyanotic appearance of the prolabia and face may be present when the patient does not manifest suffering from a sense of the want of breath. The cyanosis is symptomatic of distension of the cavities of the right side of the heart, this being an effect of the obstruction of the pulmonary circulation. The obstruction may lead at length to dilatation of the right ventricle and auricle. Thence arises the general dropsy which may take place at an advanced period of the history of fibroid phthisis. A tricuspid regurgitant murmur may be perceived with or before the occurrence of dropsy; also visible pulsation of the cervical veins. A frequent physical sign under these circumstances is bulbous enlargement of the ends of the fingers and sometimes of the toes. The clubbed fingers, as they are called, are symptomatic of disturbance of the circulation. They are observed in some cases of disease of the heart, phthisis not existing.
The physical conditions giving rise to physical signs are as follows: Notable shrinkage of lung; solidification, which, if the lung be much diminished in volume, may be considerable or complete in degree and extensive; dilated tubes and bronchiectasic cavities varying in size, number, and relative situations; the presence of muco-pus in more or less abundance, the quantity variable at different times within the bronchial tubes and cavities. Vicarious emphysema is more frequent than in the ordinary form of phthisis.
In typical cases of extensive and advanced unilateral fibroid phthisis the affected side is much contracted. The appearance is like that presented in some cases after recovery from chronic pleurisy. The range of respiratory movements is much diminished, the two sides presenting a marked contrast in this regard. With this one-sided contraction of the chest there may be lateral curvature of the spine, the concavity looking toward the affected side. The supposition that the contraction is in reality a sequel of chronic pleurisy is at once disproved by finding the evidence of a degree of solidification notably greater than would be incident to the mere diminution of the volume of the lung. If the affection be limited to a lobe, either the upper or lower, there may be contraction more or less marked over the portion of the chest corresponding to the affected lobe. If the two lungs be much affected, the evidence of contraction is apparent to the eye on both sides. It is rarely if ever that the two lungs are equally affected.
The signs furnished by percussion and auscultation which represent solidification of lung, the presence of air in dilated tubes or bronchiectasic cavities and emphysematous lobules, are present either separately or in various degrees of combination. Solidification from induration without dilatation, sacculated or otherwise, of tubes, or if these be filled with morbid products and without vicarious emphysema of adjacent lobules, will give dulness on percussion more or less marked and over an area corresponding to the degree and the extent of the solidification. There may be flatness over the greater part or the whole of an entire lobe. Often, however, dulness is found in some situation, and either tympanitic or vesiculo-tympanitic resonance in other situations. Over bronchiectasic dilatations a tympanitic resonance may have the amphoric or the cracked-metal intonation. On auscultation the respiration over a space more or less extensive or within separate spaces of variable extent is either bronchial or broncho-vesicular. With these respiratory signs representing solidification of lung are associated either bronchophony or increased vocal resonance, and the corresponding whispering signs—namely, whispering bronchophony and increased bronchial whisper. Over bronchiectasic cavities, may be heard the cavernous respiration and whisper. These signs of cavity may be combined with those of adjacent solidification of lung, giving rise to the several varieties of broncho-cavernous respiration. Coarse mucous or bubbling râles are of frequent occurrence, and the accumulation of muco-pus within the cavities may be represented by gurgling.
By means of the foregoing signs furnished by percussion and auscultation the character of the lesions, their situation, their extent, and the physical conditions as regards the presence of morbid products within the air-cavities, are determinable. These lesions are sometimes in striking contrast to the symptoms which represent the general conditions of the patient—the pulse, temperature, emaciation, etc. The symptoms and the physical signs may seem to conflict with each other, owing to the remarkable tolerance of the disease in some cases. To the physical changes which have been stated is to be added removal of the heart from its normal situation. If the seat of the affection be the left lung, its shrinkage may be such that the heart rises into the infra-clavicular region, and the space within which it is in contact with the chest-wall is larger than when the organ is in its normal situation. The latter circumstance is to be borne in mind with reference to the error of inferring therefrom enlargement of the heart. Not only is the area of notable dulness on percussion over the heart greater than in health, but the movements of the organ are remarkably apparent to the eye and touch. If the right lung be affected, the heart may be removed to the right of the sternum, the heart-sounds being heard here with their maximum of intensity. In this abnormal situation the presence of the heart may give rise to a notable dulness on percussion, and its impulses may be both seen and felt.
The differentiation of fibroid phthisis from the ordinary forms of the disease cannot be made with positiveness so long as the anatomical changes are small or moderate in degree and extent. The chief differential point is a greater degree of depression at the summit of the chest than would be likely to occur at an early period if the affection were of the ordinary form. If the affection begin at the base of the chest, it is more likely to be the fibroid variety. In typical cases, when the affection is unilateral and has led to notable shrinkage of the entire lung, taking the physical signs in connection with the evidence of tolerance afforded by the symptoms, it may be differentiated with confidence. Age is to be taken into account in the diagnosis; patients are rarely under forty. The expectoration from time to time of fetid mucus has considerable diagnostic significance.
With reference to the diagnosis, it is to be considered that between the ordinary form of phthisis and typical cases of fibroid phthisis there is every degree of gradation as regards the combination of the anatomical characters of both. There is no sharp line of demarcation between the two varieties. In these intermediate cases to determine by means of the symptoms and physical signs the relative proportion of each variety is not practicable, nor is this a matter of much practical importance. It may be added that the coexistence of chronic laryngitis and of tuberculous disease of the intestine is proof against fibroid phthisis. There is no possibility of the restoration of a lung affected with fibroid phthisis to its normal condition; but the prognosis as regards tolerance, arrest of progress or slowness of progress, and consequently duration of life, is much better than in the ordinary form of phthisis. On this account the diagnosis is of importance. The prognosis is better the nearer the approach to the affection in typical cases. Per contra, the prognosis is less favorable in proportion as the changes characteristic of the disease in its ordinary form are associated with those characterizing fibroid phthisis. If the affection be confined to a lower lobe, it may not extend beyond this limit, and the persistence of solidification of the affected lobe may not be incompatible with good general health. Of these facts the following case is an illustration: Phoebe, aged five years, came under my observation in 1864. There was at that time notable dulness on percussion over the lower lobe of the left lung, with bronchial respiration and bronchophony. She had cough and expectoration, but had not been confined to the bed or house, and her general condition of health was then fair. The treatment consisted of tonic remedies and out-of-door life. I saw her repeatedly during the next two or three years, the physical signs remaining the same, and the general health fair. In 1869 she had chorea and was treated with Fowler's solution. I did not see her again until October, 1871; she had then, and had never been free from, some cough and expectoration, but her general health had been maintained. The signs of the solidification of the lower lobe of the left lung were then present, the upper lobe remaining unaffected. In November, 1874, I noted that I had again seen her and examined the chest. The dulness on percussion over the lower lobe of the left lung continued; there was at this time absence of respiratory sound over this lobe, but the vocal resonance was greater than on the opposite side. The left side was considerably contracted. She had still some cough and expectoration, and there was some deficiency of breath on active exercise. Her aspect was healthful, and she was well developed for her age (fifteen years). Menstruation was irregular. She consulted me for this irregularity, not regarding herself as ill in other respects. About six years afterward I met her in the street, and she accosted me. Her appearance was healthful.36
36 This patient remains in fair health at the present time, May, 1883, nearly twenty years after she first came under my observation.
The treatment in cases of fibroid phthisis differs in no essential points from that in cases of the ordinary form of the disease. The slowness of progress and the long duration show less activity of the tuberculous cachexia. Nevertheless, the cachexia either exists or has existed, and the measures relating thereto which have been considered as belonging to the dietetic and regiminal treatment are alike applicable to both varieties of phthisis. The circumstances which render changes of climate admissible, if not advisable, are much oftener present in the fibroid variety, and there is greater probability of the disease being either arrested or retarded. Medicinal treatment is to be employed with reference to therapeutic indications alike in both varieties of the disease.
The treatment by inhalations to prevent putrefactive changes in the contents of bronchial tubes and in cavities is oftener indicated by fetid sputa in cases of fibroid phthisis. The continuous breathing of the atmosphere of a room containing an antiseptic vapor requires the patient to remain within doors. A more effective method is to make use of a respirator inhaler. A portable and convenient instrument, worn over the mouth like an ordinary respirator, has been devised by W. Roberts and improved upon by H. Curschmann. In this instrument the air which is breathed passes through layers of tow moistened with the antiseptic liquid. The disinfecting agents which have been found efficient are carbolic acid, creasote, oil of turpentine, a mixture of the tincture of iodine and the compound tincture of benzoin and thymol.37
37 Vide article by William Pepper in Transactions of the American Medical Association, vol. xxxi., 1880.
Prevention of Phthisis.
The number of deaths throughout the globe which are caused by pulmonary phthisis vastly exceeds the number caused by any other disease. The etiology of pulmonary phthisis embraces largely causes which can be removed. Hence the disease is to a great extent preventable. Are any comments on these simple statements needed in order that the prevention of phthisis may be regarded as among the most important of the subjects belonging to preventive medicine?
It has been assumed that phthisis involves a predisposition which is in most, and perhaps in all, cases innate. Putting aside all questions relating to an acquired tuberculous diathesis, it may be assumed that the development of the phthisical affection depends in many or perhaps in most cases, more or less, and probably often in a great measure, upon causes which promote the diathetic condition. Now, many of these causes are removable, and if removed phthisis is prevented, and the prevention of a disease which may properly be called a scourge of the human family will be diminished.
Of removable causes may be mentioned humidity of the soil in places of residence; living in small unventilated dwellings; confinement within doors; breathing in close workshops or factories, and in overcrowded rooms at night, an atmosphere deficient in oxygen and contaminated with pulmonary and cutaneous emanations; working underground in mines from which light as well as pure air is excluded; a deficiency of food sufficiently wholesome and varied; impairment of the cutaneous functions from uncleanliness; and want of a proper adaptation of clothing to the climate or season. These are obvious violations of the hygienic requirements for health. It is unnecessary to cite facts to show to what extent these violations prevail in different countries. They are causes which admit of removal, however difficult may be the task. Connected with their removal are other considerations than the prevention of phthisis. But confining the attention exclusively to the latter object, how incalculable would be the saving of life and health were these causes to be removed! Much has been done within the last half century toward diminishing the mortality from phthisis by advancement in pathological and therapeutical knowledge; how much more remains to be done by preventive measures!
The prophylaxis against phthisis must date from birth. An infant should not nurse a mother who is consumptive or whose milk is of poor quality. Care is to be observed in the selection of wet-nurses. All the various articles which are sold under the name of infants' food should be discarded. Many of these are fraudulent; that is, they are not what they purport to be. But admitting that, if properly prepared, they are safe substitutes for milk and the simple farinaceous foods, there can be no guarantee for their proper preparation; and the risk is too great to rely upon articles which cannot be readily tested and for the genuineness of which dependence must be placed on irresponsible dealers.38 There is need of much caution respecting the purity of milk, especially in cities. Much harm is not infrequently done by over-care in children's diet—that is, by denying articles which they crave, and restricting them to those which they do not like. In this matter the instincts are not to be set aside, especially in early life, when perversions of appetite and taste have not been acquired. Not infrequently from undue caution the quantity of food is restricted, and children suffer from insufficient alimentation; this is more likely to occur in our country among the wealthy than among the poorer classes. Other prophylactic provisions pertaining to exercise, out-of-door life, clothing, etc. need not here be considered.
38 Vide "Address by A. Jacobi on Infant Diet," Transactions of the New York State Medical Society, 1882.
In order to combat the various causes which have been named, knowledge of hygienic laws must be diffused among all classes. There is a lamentable lack of information and of interest as regards matters of hygiene among the more intelligent classes. But it is not sufficient to enlighten these: the knowledge must be extended, as far as practicable, to those who, in this point of view, are lower in the scale. Many persons of wealth fall in this category. The causes which are purely personal can be reached only by information diffused by means of publications, lectures, and intercourse with medical men and others. Here is a rich field for missionary labors. To overcome certain of the causes, however, the intervention of legislative authority is necessary. With reference thereto health boards, properly constituted and invested with adequate powers, should be organized in States, counties, and cities. In this way it is practicable by the prevention of phthisis to lessen greatly the rate of mortality.
Protection against the communication of the disease requires to be specially noticed. Occupying the same bed with phthisical patients and sleeping in the same room, if the latter be not enjoined by the dictates of humanity, are objectionable. They are to be objected to on the score of unhygienic influences, physical and moral, irrespective of the doctrine of a tuberculous contagium, and of course still more in view of the probabilities in favor of this doctrine. Care should be taken to exclude from the table the meat of tuberculous animals. In addition to the purity of milk in other regards, it should be ascertained that the supply is not from cows affected with tuberculous disease. Obviously, this is especially of importance with reference to infants who are bottle-fed and in childhood, when generally milk forms a much larger proportion of the diet than in after years. The ventilation of apartments occupied by phthisical patients should be attended to with reference to the possibility of the disease being communicated by the inhalation of particles of tubercle; and it may not be a needless precaution to introduce a disinfectant into the vessels which receive the matter expectorated.