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.