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. {422} 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 {423} 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 {424} 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]
[Footnote 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]
[Footnote 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 {425} when the tuberculous affection is
small or moderate, but that a considerable and large affection does not
preclude recovery.
[Footnote 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 {426} 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 {427} 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]
[Footnote 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.]