with a phthisical man or woman. As an abstract question there need be
no hesitation as to the answer. If men went about deliberately
selecting wives, or vice versâ--as, for example, horses are
selected--there could be no doubt that phthisis should be considered a
disqualification. Husbands and wives, however, are not mated in such a
way. A marriage engagement has been entered into, and afterward one of
the parties becomes phthisical. The friends of the non-phthisical
party, not the parties themselves, come for advice, and the adviser is
sometimes placed in an awkward situation. With respect to the effect of
marriage on the tuberculous party, my analysis of 17 cases, 2 only
being women, did not show that it was unfavorable. Were it unfavorable,
considerations of sentiment and sense of duty generally outweigh all
others. A more important point relates to offspring. A hereditary
tendency is entailed in some, but not in all cases. The risk incurred
in this point of view having been fairly stated, the responsibility of
the medical adviser is ended.
After recovery from phthisis measures for the prevention of a relapse
should receive due attention. The hygienic influences which were
brought to bear on the disease, and which, as it is fair to conclude,
had more or less agency in effecting the recovery, are as far as
practicable to remain in operation. This important injunction applies
alike to cases in which an arrest of the disease has taken place, so
long as it ceases to be progressive. To prevent a renewal of its
progress is an object having a similar importance as the prevention of
a relapse after recovery.
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 {440} 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]
[Footnote 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 {441} 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 {442} 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.
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 {443} 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 {444} 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]
[Footnote 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]
[Footnote 37: Vide article by William Pepper in _Transactions of the
American Medical Association_, vol. xxxi., 1880.]
Prevention of Phthisis.
The number of deaths throughout the globe which are caused by pulmonary
phthisis vastly exceeds the number caused by any other disease. {445}
The etiology of pulmonary phthisis embraces largely causes which can be
removed. Hence the disease is to a great extent preventable. Are any
comments on these simple statements needed in order that the prevention
of phthisis may be regarded as among the most important of the subjects
belonging to preventive medicine?