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 {405} 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 {406} 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 {407} 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.
{408} 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.
[Footnote 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 {409} 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 {410} 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.