most, and perhaps in all, cases innate. Putting aside all questions
relating to an acquired tuberculous diathesis, it may be assumed that
the development of the phthisical affection depends in many or perhaps
in most cases, more or less, and probably often in a great measure,
upon causes which promote the diathetic condition. Now, many of these
causes are removable, and if removed phthisis is prevented, and the
prevention of a disease which may properly be called a scourge of the
human family will be diminished.
Of removable causes may be mentioned humidity of the soil in places of
residence; living in small unventilated dwellings; confinement within
doors; breathing in close workshops or factories, and in overcrowded
rooms at night, an atmosphere deficient in oxygen and contaminated with
pulmonary and cutaneous emanations; working underground in mines from
which light as well as pure air is excluded; a deficiency of food
sufficiently wholesome and varied; impairment of the cutaneous
functions from uncleanliness; and want of a proper adaptation of
clothing to the climate or season. These are obvious violations of the
hygienic requirements for health. It is unnecessary to cite facts to
show to what extent these violations prevail in different countries.
They are causes which admit of removal, however difficult may be the
task. Connected with their removal are other considerations than the
prevention of phthisis. But confining the attention exclusively to the
latter object, how incalculable would be the saving of life and health
were these causes to be removed! Much has been done within the last
half century toward diminishing the mortality from phthisis by
advancement in pathological and therapeutical knowledge; how much more
remains to be done by preventive measures!
The prophylaxis against phthisis must date from birth. An infant should
not nurse a mother who is consumptive or whose milk is of poor quality.
Care is to be observed in the selection of wet-nurses. All the various
articles which are sold under the name of infants' food should be
discarded. Many of these are fraudulent; that is, they are not what
they purport to be. But admitting that, if properly prepared, they are
safe substitutes for milk and the simple farinaceous foods, there can
be no guarantee for their proper preparation; and the risk is too great
to rely upon articles which cannot be readily tested and for the
genuineness of which dependence must be placed on irresponsible
dealers.[38] There is need of much caution respecting the purity of
milk, especially in cities. Much harm is not infrequently done by
over-care in children's diet--that is, by denying articles which they
crave, and restricting them to those which they do not like. In this
matter the instincts are not to be set aside, especially in early life,
when perversions of appetite and taste have not been acquired. Not
infrequently from undue caution the quantity of food is restricted, and
children suffer from insufficient alimentation; this is more likely to
occur in our country among the wealthy than among the poorer classes.
Other prophylactic provisions pertaining to exercise, out-of-door life,
clothing, etc. need not here be considered.
[Footnote 38: Vide "Address by A. Jacobi on Infant Diet," _Transactions
of the New York State Medical Society_, 1882.]
In order to combat the various causes which have been named, knowledge
of hygienic laws must be diffused among all classes. There is a
lamentable lack of information and of interest as regards matters of
hygiene among the more intelligent classes. But it is not sufficient to
enlighten these: the {446} knowledge must be extended, as far as
practicable, to those who, in this point of view, are lower in the
scale. Many persons of wealth fall in this category. The causes which
are purely personal can be reached only by information diffused by
means of publications, lectures, and intercourse with medical men and
others. Here is a rich field for missionary labors. To overcome certain
of the causes, however, the intervention of legislative authority is
necessary. With reference thereto health boards, properly constituted
and invested with adequate powers, should be organized in States,
counties, and cities. In this way it is practicable by the prevention
of phthisis to lessen greatly the rate of mortality.
Protection against the communication of the disease requires to be
specially noticed. Occupying the same bed with phthisical patients and
sleeping in the same room, if the latter be not enjoined by the
dictates of humanity, are objectionable. They are to be objected to on
the score of unhygienic influences, physical and moral, irrespective of
the doctrine of a tuberculous contagium, and of course still more in
view of the probabilities in favor of this doctrine. Care should be
taken to exclude from the table the meat of tuberculous animals. In
addition to the purity of milk in other regards, it should be
ascertained that the supply is not from cows affected with tuberculous
disease. Obviously, this is especially of importance with reference to
infants who are bottle-fed and in childhood, when generally milk forms
a much larger proportion of the diet than in after years. The
ventilation of apartments occupied by phthisical patients should be
attended to with reference to the possibility of the disease being
communicated by the inhalation of particles of tubercle; and it may not
be a needless precaution to introduce a disinfectant into the vessels
which receive the matter expectorated.
{447}
SYPHILITIC DISEASE OF THE LUNG.
BY EDWARD T. BRUEN, M.D.
DEFINITION.--Lesions of the lungs with a syphilitic impress include
catarrhal inflammation of the bronchial mucous membranes, chronic
inflammatory new formations, which affect especially the connective
tissue, producing sclerosis or else gummatous growths.
HISTORY.--From the early part of the eighteenth century attempts have
been made to create a word-portraiture representing the peculiar
features of syphilitic pulmonary disease as a separate entity. It has
been defined histologically and clinically from simple and from fibroid
phthisis, or from cases of syphilis in which a damaged state of the
general health has fostered the development of phthisis. But the
question, Is there a peculiar microscopic and macroscopic anatomy, or a
special symptomatology by the aid of which the cause, seat, and
dissemination of pulmonary syphilis can be recognized? remains even now
but partially removed from the field of debate and conjecture, although
unquestionably the syphilitic poison bears intimate relation with
various pulmonary processes.
ETIOLOGY.--Predisposing and Exciting Causes.--Syphilis of the lungs is
a rare disease as compared with the forms of specific laryngitis, but
even here Leman asserts that there is an early simple catarrh of the
larynx indistinguishable from the specific catarrhs. Whistler, in
recording his observations upon 88 cases of the lesions found in
syphilis of the larynx, observes that catarrhal congestions in early
laryngeal syphilis simulate the same lesions from ordinary causes.
Schnitzler lays particular stress on the association of pulmonary
syphilis with affections of the larynx and a specific bronchitis which
may occur in the first two months after inoculation. Many other writers
on this subject assert that laryngeal and bronchial catarrh attend the
period of early skin eruptions, disappearing in consequence of an
antisyphilitic treatment.
The rarity of pulmonary syphilis has been further attested by the
observations of Greenfield, who states that out of 22 cases of visceral
syphilis, only 1 occurred in the lung and 4 in the larynx and trachea:
in these cases, while the dura mater and cerebral vessels were
extensively diseased, no trace of skin affection could be found.
Goodhart has collected from the post-mortem records in Guy's Hospital
during twenty-two years 189 cases of visceral syphilis, but in only 38
of these chronic lung disease occurred. Phthisis associated with
syphilis is usually a late secondary or tertiary process, which appears
from two to five years after the infection; in rare cases ten--even
twenty--years have been said to elapse before the supervention of
pulmonary trouble. Cases of phthisis associated with syphilis have,
however, been described as occurring within the first twelve months
after infection. Further investigation may establish these cases of
early pulmonary syphilis as attributable to violent systemic infection,
or their etiology may be involved in the deterioration of the general
health which sometimes occurs. Moreover, one {448} must remember that
simple phthisis may more readily be developed in the scrofulous
syphilitic, owing to the predisposition of such persons to catarrhal
forms of inflammation. In the progress of syphilis there is also a
tendency to catarrhal processes through anæmia and damaged general
health, which may predispose certain cases to an ordinary type of
phthisis. The origin of the new formation in both tubercular and
syphilitic phthisis is similar--viz. the arterial, lymphatic, and the
peribronchial sheaths, spreading thence to the interlobular connective
tissues. It is therefore not surprising that it has been difficult to
differentiate the tubercular from the specific forms of phthisis, and
Goodhart asserts that there is no histological difference between
syphilitic and tubercular phthisis, except that the former is more
vascular.
We may assume that true pulmonary tuberculosis may be associated with
syphilis, but preserves its own pathological characters; that, although
we are ignorant of the exact differential histological changes, there
is sufficient evidence to show that there is a distinct association
between syphilis and pulmonary disease; and that syphilitic phthisis is
commonly interstitial. Whether the relation be one of cause and effect,
or whether the process is simply a modification of ordinary tubercular
phthisis, it is impossible at present to determine. The final
adjustment of the theories concerning the specific etiology of
tubercular phthisis may throw further light upon the etiology of
syphilitic phthisis. That gummata may be found in the lungs is a
well-established fact, and by some authorities is not considered rare.
The discussion of the etiology has already indicated the relation of
the predisposing and exciting causes to pulmonary processes in
connection with syphilis. In certain cases of syphilis the antecedent
of pulmonary changes is a laryngeal or bronchial catarrh. The relation
which an active virus in the blood sustains to the process is still
subject to debate. Hutchinson writes as follows: "If the infected blood
were the cause of the local phenomena, it is almost certain that such
phenomena will be symmetrical, because the blood is equally supplied to
both sides; such is the case during the secondary stage. If, however,
the symptoms result from tissue-conditions, and the blood is at the
time of the outbreak free, then there is a considerable probability
that local influences may take a large share in evoking them, and they
will be asymmetrical--evoked by some local cause."
The existence of gummata, then, does not necessarily show that there is
any active virus in the blood, because their formation is sometimes
symmetrical, sometimes asymmetrical.
PATHOLOGY AND CLASSIFICATION.--The lesions of pulmonary syphilis may be
divided into four classes: _(a)_ early phthisis, associated with
principal interlobular proliferation; _(b)_ advanced syphilis, in which
gummatous or allied formation exists; _(c)_ simple phthisis, developing
in consequence of impaired general health induced by syphilis; _(d)_
inherited or congenital syphilis, occurring in infants.
_(a)_ The pathological process in the majority of cases in the adult is
interstitial new formation, very often evoked by antecedent catarrhal
inflammation. At first small spindle-shaped and round cells appear and
develop into connective tissue, among the fibres of which blood-vessels
are freely produced; the septa of the alveoli are thickened and the
alveoli themselves compressed. In any morbid process in the lungs, such
as tubercle, sarcoma, or cancer, the alveoli act as the
inter-fascicular spaces of the connective tissue. In the same manner in
syphilis the alveoli of the lungs are always in the later stages, and
sometimes primarily, more or less filled with small cells, which,
surrounded by the newly-formed connective-tissue fibrous framework,
gives the appearance of some of the forms of simple phthisis. The
smaller bronchi become narrowed, and perhaps occluded, by the pressure
of the new growth which develops along their lumen. Occlusion of the
bronchi may also be caused {449} by enlargement of the bronchial
glands, which is one of the incidents of the syphilitic pulmonary
process.
If we endeavor to nucleate the peculiar impress attributed to early
syphilitic pulmonary processes, we find much that is vague. The
vascularity and advanced grade of organization of the new growth are
considered by Greenfield and Goodhart to be characteristic when
compared with tubercular consumption, in which the original growth is
bloodless and the tendency is to retrograde metamorphosis. Green and
Virchow suggest that the origin of syphilitic diseases of the lungs is
distinctive in this respect, that while in the ordinary forms of
phthisis the fibroid is secondary or coequal in its development with
changes in the alveoli and alveolar wall, in syphilis there are
primarily interstitial changes. In chronic bronchitis the fibroid
thickening proceeds from the bronchi. Wagner, however, maintains that
implication of the alveolar wall is as common in syphilis as in
ordinary phthisis.
In the general pathology of syphilis the change in the intima of the
blood-vessels is characteristic: this has not yet been demonstrated in
the lung, but merely the general thickening of the external coat of the
vessels. When entire vesicular consolidation and breaking down occurs,
the process is similar to ordinary phthisis, and indistinguishable from
it.
_(b)_ In the gummatous stage the same formation of cellular and
connective tissue is found as in the diffused form, with which gummata
are often associated. Gummata may originate anywhere in the
intervesicular tissue, usually near the visceral pleura. Sometimes they
are formed near the roots of the lungs, intimately connected with the
blood-vessels and bronchial sheaths. They may also be formed in the
deeper layers of the costal pleura or upon the periosteum of the ribs.
Owing to the peculiar anatomical formation of gummata, their subsequent
history is one of combined caseous and fatty degeneration. These
centres of softening may communicate with a bronchus, more or less
rapid evacuation of the mass may occur, and a cavity be formed which
often enlarges as the gummata break down. Contraction may ensue,
leaving a small fibrous scar with cheesy cretaceous deposit, or the
gummata may point externally, with or without the appearance of
inflammation in the adjacent tissues, or they may remain stationary for
an indefinite period. In some cases the pulmonary new formation may be
a combined interstitial, gummatous, and catarrhal process; but, as a
rule, the fibroid process of syphilis in the earlier stages is not
accompanied by the filling of the alveoli with catarrhal cells. Gummata
developed in or near the pleural sac may increase in size, and by
compressing the lung simulate pleural effusions.
_(c)_ The morbid anatomy of cases in which simple phthisis develops in
consequence of the vulnerability of the pulmonary tissues to the
exciting causes of bronchial inflammation requires no special
consideration.
_(d)_ Interstitial inflammation, gummata, and enlargement of the
bronchial glands have been found in the syphilitic foetus and in very
young children. It is also claimed that syphilitic disease of the lung
may be one of the forms of tertiary disease which develop in children
between the second dentition and maturity. Virchow and Lebert have
described pulmonary gummata in children suffering from inherited
syphilis. Depaul gives the cases of two children with pemphigus who had
soft puriform nodules or collections scattered through the lungs. In
the infant lung the highly cellular character and ready reversion to
the embryonic type of structure would naturally lead to exuberant
growth and rapid diffusion of the morbid process, which could not occur
in the more fibrous, less cellular lung of the adult. Hence the slower
growth in the latter establishes the more fibrous and limited extent of
disease: in other respects the origin and distribution of the growth
are identical in both cases. In the infant enlargement of the bronchial
glands {450} and bronchitis leading to broncho-pneumonia, or an unusual
proliferation of epithelium in the alveoli, is more frequent than in
the adult.
MORBID ANATOMY.--In the earlier stages of pulmonary syphilis the
macroscopic appearance of the lung is firmer at the seat of deposit
than elsewhere. It is also heavier and has a smoother surface. The
infiltrated parts are grayish-red or grayish-yellow, smooth, and
homogeneous. Sometimes the appearance resembles pale-whitish patches
invading districts of the lung. The hyperplastic material becomes
converted into a tough, contracting, fibrous tissue, which radiates
through the lung, drawing together the bronchial tubes and flattening
them, possibly even to obliteration. The entire lung may be involved,
but the changes most frequently proceed from the hilus of the organ
into the interior, following the track of the bronchial radicles and
the bronchial and pulmonary arteries. The lesions frequently develop
near the visceral pleura, where there is more connective tissue. This
accounts for the depressed puckered scars which are found on the
pleural surface.
The macroscopic appearances in specific pulmonary disease differ,
according to Goodhart, "both from a chronic pneumonia and from that
solidification ensuing after contraction of the lung from old pleurisy,
in that it is less evenly distributed, and generally less widely spread
over the lobe, than they. It is nodular, rather diffused, and more
symmetrical than unilateral. From miners' phthisis the appearance
differs in the absence of the extreme dilatation of the bronchial tubes
and more solidity from greater growth. The tissues involved are more
tough and less granular than red or gray hepatization." It is possible
to differentiate other forms of fibroid phthisis by noting, in addition
to the above points, the presence of the syphilitic process in other
viscera, and by comparing the clinical records with the post-mortem
examination.
Syphilitic lesions may be found in any part of one or both lungs, but
their localization at definite points in the lungs, leaving the balance
free even when the lesion has proceeded to formation of cavities, may
be characteristic. There is, however, a wide division of professional
opinion upon the subject of the localization of the process in
syphilitic pulmonary disease; some claiming the middle lobe, some a
symmetrical lesion at the apices, others lesions at a definite point
elsewhere than at the apices. If the pulmonary lesions are introduced
by an attack of pleurisy, the process in the lungs is usually located
at one or both bases. Some, however, locate the disease at the base,
without mentioning an antecedent pleurisy.
Gummata are more frequently situated in the middle or lower lobes of
one or both lungs, and are defined by a boundary layer of fibrous
tissue. Fibroid development may ensure their adhesion to the visceral
and costal pleura. They are gray or yellowish-gray, hard, well-defined
nodules, of varying size and number, occurring as single large masses
surrounded by normal or compressed lung. In the centre is found a
diffluent material, not unlike the centre of a scirrhous nodule,
similarly enclosed in a limiting fibrous investment from an inch to
many inches thick. In the condition of the neighboring pulmonary
substance a difference may be observed between gummatous and
tuberculous nodules: the latter occur in more numerous masses, usually
small, and the entire lung is more or less diseased; while in syphilis
extended districts of non-affected lung occur in the neighborhood of
gummata. Whenever gummatous lesions in the lungs exist a history of
pustular eruptions, laryngitis, arterial lesions--in fine, some
indication of general systemic syphilitic poisoning--can always be
found. Fournier thinks there are five anatomical points of distinction
between syphilitic gummata and tubercle: "1. Tubercle involves the
upper part of both lungs; gummata one lung, and may be limited to a
portion. 2. Gummata are few as a rule, solitary; tubercles sooner or
later become confluent. 3. Gummata are larger than tubercles, never
{451} miliary in form. 4. Gummata are always yellow or white, never
transparent like miliary tubercle. 5. Until softening takes place
gummata are of more equal consistence than tubercles, and if they
soften do not break down, wholly owing to the capsule. Histologically,
there is no difference in structure." Gummatous formations may be found
on the pericardium and heart and in the thoracic and abdominal walls.
Clinically, the most important pathological feature is that large
districts of healthy lung are interposed between the affected
districts; this is not so in ordinary phthisis.
Bronchial Lesions.--The syphilitic like the scrofulous are predisposed
to catarrhal inflammation, and this may spread down the bronchial
tubes, giving rise to a general bronchitis; a coexistent laryngitis may
or may not exist. Enlargement of the bronchial glands is frequently
combined with the syphilitic pulmonary process. When the glands are
enlarged they present a firm pigmented character, varying in size from
a hazelnut to an egg, and the connective tissue surrounding them is
usually infiltrated. Subsequently, owing to the pressure of the
mediastinal growths, the bronchi are narrowed and more or less
occluded; the same effects are occasioned in the smaller bronchi by the
pressure of the new growth which develops along their lumen. The
effects of bronchial narrowing or occlusion produce serious mischief in
the lungs proportioned to the degree of obstruction. By the retention
of the bronchial secretions the air-supply to the vesicles is
interfered with; emphysema with or without asthmatic symptoms or
atelectasis may ensue. Further, the results of bronchial narrowing
affect the circulation through the lungs, and in combination with
atelectasis very intractable local bronchitis may be developed; and,
with or without atheroma, hemorrhagic infarctions may occur, with a
form of pneumonia which has been described by Fuchs as apneumatosis.
The narrowing of the bronchial tubes in specific fibroid phthisis
affords a means of differentiating this disease from non-syphilitic
fibroid phthisis, in which the tubes are widened. Cases have been
reported of nodules of syphilitic new formations in the mucous membrane
of the superior and inferior extremities of the trachea and larger
bronchi. The nodules ulcerate, and in healing cicatricial bands of
fibrous tissue are formed which cause contraction of the tracheal tube
transversely or diminish its length. These lesions resemble tuberculous
ulceration, but they differ in the nature of the initial neoplasm by
the formation of cicatricial tissue and by the tendency to stenosis of
the tracheal tube. The cutaneous syphilides, mucous patches, the
exostoses of the bones of the cranium help to demonstrate the
connection of the marked cachexia with syphilis rather than scrofula.