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.