A system of practical medicine. By American authors. Vol. 3

by Unknown

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.