in the relation to them of predisposing and exciting causes. This we
believe to be some anatomical and histological peculiarity, congenital
or acquired, which gives to the individual that defective organization
which is denominated the {477} tubercular diathesis. It seems probable
that this diathesis comprises two factors--viz.: 1st, an unusual
thinness, and consequently weakness, of the walls of the capillary
blood-vessels, which permits and favors a too facile emigration of the
leucocytes; and 2d, a diminished or lowered vitality of the leucocytes
themselves.
Both of these factors may exist at the birth of the individual as an
inheritance from his progenitors, or both may be produced by causes
which impair the general nutrition during either intra-uterine life or
during the earlier infancy of the subject. Or one of them may exist
without the other, and the animal thus escape for a long time, though
exposed to the exciting causes of the disease. Sternburg's guinea-pigs
(animals peculiarly susceptible to tuberculosis) remained healthy while
enjoying the freedom of grassy fields, although inoculated with Koch's
bacilli, which were found in their blood and tissues when killed, while
those that were confined in cages under bad hygienic conditions
speedily succumbed after a similar inoculation.[9] If the first of
these factors exist, any exhausting disease producing a dyscrasia,
habits or hygienic conditions which tend to impair the nutritive
functions, even psychological and emotional influences which take away
the appetite for food or impair the functions of digestion--anything,
in fact, which tends to degrade the quality of the blood and diminish
the functional activity of the white blood-cell--may furnish the second
factor constituting the tubercular diathesis. Both factors being
present, it only requires an uncertain increase of the blood-pressure,
causing a dilatation of the capillaries, to ensure that increased
leucopedesis which constitutes the first step in the tubercular
process.[10] A protracted fever, therefore, of any kind, may furnish
both the second factor in the tubercular diathesis and the exciting
cause of the tubercular process itself; while any fever or any irritant
capable of exciting fever or reaction against its presence occurring in
man or other animal that happens to have the complete tubercular
diathesis may excite tuberculosis. Koch's bacillus will undoubtedly
excite tuberculosis in animals (and probably also in man) that have the
tubercular diathesis complete; but it does so only by exciting that
inflammatory and febrile reaction against its presence in the blood
which other and perhaps indifferent irritants may also excite. In
rabbits and guinea-pigs confined in cages, and therefore under
unnatural and unhygienic conditions, it suffices to excite the disease
only to introduce the bacillus into any part of their tissues: that it
will not do so in guinea-pigs that are healthy and kept under natural
conditions and surroundings Sternburg's experiments, alluded to above,
clearly prove. It is true that other animals that are regarded as
ordinarily non-tuberculous can also be inoculated with the bacillus
with affirmative results, provided the bacillus is introduced into the
eye or other serous membranes; but we must not forget that the pain and
injury of such an operation will almost inevitably produce that
deterioration of the health and impairment of cell-vitality which we
maintain constitutes so essential a part of the tubercular diathesis.
That the bacillus tuberculosis is always found in tubercle is
undoubtedly true; but it is there because tubercle furnishes the most
favorable and congenial breeding-place for it. Some special microbe is
found in almost every special inflammatory product--vibriones in the
pus of abscess, gonococcus in urethral inflammation, micrococcus in
diphtheria, etc.--but no one, we believe, now holds that these various
microbes are the causes of these diseases, since inoculation with pure
cultures have given entirely negative results. While we believe,
therefore, that the bacillus of Koch can excite tuberculosis in man or
animal having the tubercular diathesis, we {478} also believe that it
does so because of its property of exciting that amount of irritation
and reaction necessary to initiate the tubercular process--a property,
however, possessed by many other irritants; and while it is probable
that a few cases may be thus produced in man, a vast majority of the
cases arise independently of its presence. And hence we maintain that
tuberculosis is not a specific contagious disease in the sense that it
is only produced by a special contagion, as small-pox and other similar
diseases are.
[Footnote 9: _Journal of the American Medical Association_, vol. iv.
No. 12, p. 314.]
[Footnote 10: We hold that leucopedesis is a normal physiological
process that is always going on during the period of active growth of
the individual, as well as during the process of repair.]
Primary acute miliary tuberculosis occurs only in the young or early
adult period of life, for the reason, perhaps, that persons of the
tubercular diathesis can hardly long escape the exciting causes of the
disease, and so are attacked early. Persons possessing what may be
called the incomplete or partial diathesis may be attacked by a
secondary miliary tuberculosis at any, even the most advanced, age; but
it will be found that in all such cases of late tubercularization there
has occurred a direct infection of the blood by absorption of caseous
detritus from a softening cheesy pneumonia or cavity. "In 28 out of 52
cases collected by Litten, it was associated with pulmonary phthisis,
and this accords with general experience" (Roberts[11]).
[Footnote 11: _Practice of Medicine_, 5th ed., p. 301.]
Acute primary general miliary tuberculosis--that is, in which all or
nearly all the vascular tissues are attacked at once--must be one of
the rarest diseases. Such cases can only occur when the tubercular
diathesis is strongly marked and exciting causes of the most active
character have been applied. As a rule, tubercular eruptions occur in
successive crops, attacking the more vascular organs, as the lungs,
cerebral meninges, spleen, liver, serous and mucous membranes, and
bones, first and usually in the order given. Laennec's law, that if
tubercle is found in any other organ it will also be found in the lung,
is undoubtedly true, with the single exception perhaps of tubercular
meningitis. If our explanation of the causes and mode of formation of
tubercle is correct, we must a priori expect to find that a tissue so
soft and spongy as the lung, and which is so vascular and subject to
such great and sudden alterations of pressure and relaxation, would
naturally be the site of the first formation of tubercle.
SYMPTOMS AND COURSE.--It is impossible to give a clear or lucid
description of acute miliary tuberculosis, since there cannot be said
to be any constant or pathognomonic symptoms produced by the disease
per se. The symptoms present in any given case depend upon the organs
involved, and may be said to consist merely of those furnished by such
organs when invaded by inflammation. Fever is present in all cases. The
grade or height of this fever will depend upon the number and extent of
tubercular formations, and to some extent upon the organs involved. It
will generally be highest in tubercle of the serous membranes, and of
the lungs next. In general miliary tuberculosis the fever is highest,
and can be distinguished with difficulty from enteric fever. If the
intestinal mucous membranes are involved, and diarrhoea consequently
exist, the differential diagnosis will be almost impossible. The fever,
following the law of nearly all inflammatory and symptomatic fevers, is
usually remittent, and the remissions and exacerbations correspond to
the normal diurnal variations of temperature--lowest in the morning,
highest in the evening. The remissions are also usually attended with
perspiration, sometimes profuse, at others moderate. The patient early
falls into that condition of prostration and general exhaustion which
speedily comes on in all fevers of high temperature and protracted
duration expressed by the term typhoidal state. Even the pains
ordinarily complained of in inflammation of various organs are not
felt, or if felt at all are seldom mentioned; which perhaps helps to
render the diagnosis more difficult. Almost the only exception to this
is when the cerebral meninges are early affected, in which case
unusually severe headache may be complained of. Cough may be present,
{479} but is not more troublesome than in many cases of enteric fever,
and is quite out of proportion to the lesions found in the lungs and
pulmonary mucous and serous membranes. The expectoration varies, and is
sometimes entirely absent. Generally, it is moderate and consists of
frothy serum, occasionally streaked with blood. Hæmoptysis is said to
be occasionally present, but must be extremely rare. Respiration is
notably frequent early in the disease, and in the absence of pronounced
physical signs of pulmonary lesions is perhaps one of the most reliable
and pathognomonic signs present. Respirations are often as frequent as
60, seldom less than 30, per minute. The pulse is usually rapid,
generally hard at first, but soon becoming soft and weak. The rate
varies between 110 to 120 to 160 or more late in the disease.
The disease runs a rapid and invariably fatal course, often ending
within the first fortnight, seldom lasting as long as two months.
Tubercles, miliary and submiliary, are found after death in almost all
the vascular organs, varying much, however, in number in various
organs, and often presenting different stages of development. In some,
and especially in the lungs, tubercles will be found already in a state
of incipient softening, others still firm and yellow (caseous), and
others still grayish and semi-translucent, showing, we think, a
different period of eruption, and demonstrating the correctness of our
observation that miliary tubercles are always formed in successive
crops.
If the tuberculosis is associated with inflammatory phthisis, and, as
is the case in a majority of instances, has been caused by absorption
of caseous detritus, large masses of caseous matter may be found in the
lung, either in a softening condition, or cavities will be met with
empty or partially filled with pus, and surrounded by indurated walls
the result of interstitial pneumonia. These caseous masses and cavities
are, in our view, the result of precedent catarrhs or croupous
pneumonias, and not a result of the tubercular process.
Partial or local miliary tuberculosis is a much more frequent
occurrence than the general disease above described. It occurs most
frequently in persons under twenty-five years of age, and in a very
large majority of cases between the ages of two and twenty. It occurs
also most generally in the lungs first in point of frequency, in the
mesentery next, and last in the cerebral meninges. Of course a
secondary general tuberculosis may result in any of these cases from
resorption, except in the meningeal variety, which generally destroys
life before there is time for secondary infection.
Acute miliary tuberculosis may occur in the young as a consequence of
measles and other exanthematous fevers, whooping cough, typhoid fever,
and various other affections which seriously impair nutrition.
According to our own observation, it is most likely to attack boys and
girls soon after puberty who are pursuing too severe a course of study
in school with insufficient exercise in the open air, and perhaps also
those evil practices unfortunately too common in both sexes. Tubercular
meningitis as an idiopathic affection (that is, without the previous or
concurrent deposit of tubercles elsewhere) is almost exclusively met
with in children between two and seven years, but secondary
tuberculosis of the meninges may occur at any age. We have seen two
cases of pulmonary phthisis, one of three and one of three and a half
years' duration, and who bid fair to live for a long time, suddenly
carried off by tubercular meningitis. Both of these persons were past
thirty years of age.
Tuberculosis of the mesentery, peritoneum, and liver (for they are
sometimes found in all three of these organs) is invariably either
coincident with a general tuberculosis or the secondary consequence of
scrofulous inflammation of the intestinal glands. Quite often here the
tubercular process is associated with the scrofulous process, and large
masses of caseous material will be found in the mesenteric system of
glands.
{480} As in general miliary tuberculosis there are no symptoms by which
the disease can be positively recognized, so too in the partial or
local disease there are absolutely no pathognomonic signs. We may say
in general terms that if a person who is known to have had a pneumonia
which has ended in a permanent consolidation of any considerable
portion of one or both lungs, and who has for some time presented the
symptoms, however slight, of chronic pulmonary phthisis, is suddenly
attacked with fever and night-sweats; or, if fever has already existed,
the temperature rises considerably above the previous average, with
increase of cough; or if an uncontrollable diarrhoea sets in; or if
headache and delirium should suddenly occur--delirium out of proportion
to the fever,--then we are justified in believing that tuberculosis of
the lungs, mucous membrane of the bowels, or arachnoid has occurred. Or
if a young person of either sex, such as above described, should, after
becoming pale and anæmic, begin to have slight fever with a dry,
hacking cough, at first without expectoration or with a frothy
muco-serous expectoration, which for an unusual length of time
continues to retain this characteristic, and this fever and cough
cannot be otherwise accounted for, then the existence of pulmonary
tuberculosis is rendered extremely probable, although there is neither
history nor evidence of preceding pneumonia or scrofulous glandular
degeneration. If a few scattered and slight crepitant râles can be
heard over one or both lungs without alteration of pulmonary resonance,
and the respiratory rate is much too frequent for the temperature and
pulse, then the diagnosis becomes almost absolutely certain.
Unfortunately, this scattered or diffuse crepitant râle is often
absent, and there are absolutely no physical signs whatever of the
deadly mischief going on in the lungs.
Prolonged expiratory movement is spoken of by some as one of the
reliable signs of tuberculosis, but as this sign is usually present in
almost all forms of chronic pulmonary disease, its significance cannot
be relied upon. Or if a child over two and under ten years of age,
after showing evidences of malnutrition, should suddenly be attacked
with fever of moderate temperature, become restless and fretful, should
frequently vomit and retch even when the stomach is empty, and begin to
have convulsions, with squinting and trismus, and if old enough
complain of severe pain in the head, have a rapid, frequent, but
irregular or slow and intermitting pulse,--if these symptoms become
exaggerated at night and somewhat mitigated in the daytime, the
diagnosis of tubercular meningitis may be made with tolerable
certainty.
It would take more space than is allotted to this article to describe
all the phases of tuberculosis: we shall therefore summarize the
symptoms of this disease by saying again that the signs and symptoms of
tuberculosis are simply those of inflammation with fever and such
derangements of function and other local disorders as would be
furnished by inflammation of any given organ under other circumstances,
except that the pain produced by tubercular inflammation is not usually
so severe as in other inflammations, and hence diagnosis is not always
so easy as in the latter. For it is a remarkable fact that in tubercle
of the peritoneum--an organ which in a state of inflammation usually
gives such excruciating pain--this symptom is often not complained of,
and the existence of tuberculosis not suspected until after a
post-mortem. The same may be said of tubercle of the meninges. Pain is
often not complained of, and is never so severe as in ordinary
meningitis.
TREATMENT.--In acute general tuberculosis no treatment will be of any
avail. All that can be done is to moderate the fever and support
nutrition by appropriate food. For the first, quinia in large doses is
undoubtedly the best remedy. It should be given in one or at most two
doses daily. Twenty grains should be given early in the morning, and
this dose repeated at 1 o'clock P.M., or thirty to forty grains may be
given in a single dose about 8 or 9 o'clock A.M. Antipyrine should
prove a valuable antipyretic in these {481} cases, and, being probably
equally effective, produces less disorder of the nervous system and
digestive functions than the salt of cinchona. Judging from what we
have seen of its effects in other fevers and inflammations, fifteen to
twenty grains repeated about four times in the twenty-four hours should
keep the temperature very near normal.
For the second indication milk and raw eggs constitute the best diet.
Brandy or whiskey in the form of eggnog or milk-punch is useful, and in
the latter stages indispensable. It should not be forgotten that
according to the latest observations muriatic acid disappears from the
gastric juice of fever patients, and that its power to digest animal
food is therefore very much impaired. This should be supplied,
therefore, by giving after every ingestion of milk, eggs, or other
animal food ten to fifteen drops of dilute hydrochloric acid in a
sufficient quantity of water. Peptone will also aid in the proper
digestion of protein substances, and should therefore be added to the
acid. Some of the liquid peptone sold by manufacturing chemists
contains hydrochloric acid, and would therefore meet both these
indications.
By these means we may doubtless prolong the life of the patient and
promote his comfort or at least diminish his suffering, and if a cure
is possible secure it. Tuberculosis of the mesentery and peritoneum, as
well as tuberculosis of the cerebral meninges, will generally prove
fatal, the one by impairing the chylo- and hæmatopoietic functions, the
other by injury to the central nervous system, though Hartshorne of
Philadelphia reports one case of the latter in which temporary recovery
lasting one month took place, and quotes two cases by Guersant in the
_Dictionnaire de Médecine_ (1839) in which also partial recovery,
lasting five weeks and two months respectively, occurred. "May we not
imagine, however," says Hartshorne, "that if such convalescence could
last two months, it might in a case affected with nearly similar
lesions be prolonged indefinitely?"[12] I am informed that a case of
permanent recovery has been reported in England, but I have not been
able to obtain the reference. To these I have to add a case of my own
in which recovery has been maintained for a little more than nine
months. In this case, a boy of twenty-six months, the convulsions were
controlled for many days by hypodermic injections of morphia, while
quinia was given by the mouth when possible, and otherwise by the
rectum; and, though he had left hemiplegia and was for a time both
blind and deaf, he recovered entirely in about six weeks, and has
remained well.
[Footnote 12: _Reynolds's System of Medicine_, Am. ed., Philadelphia,
1880, vol. i. pp. 826, 827.]
In pulmonary miliary tuberculosis the treatment is by no means so
hopeless if the disease is promptly recognized and actively treated.
The thing to be accomplished in this case is to prevent secondary
eruptions and the softening of the tubercles already formed. We know
that this last can be done in caseous deposits resulting from
catarrho-pneumonia, and we also know that tubercle can be maintained in
a quiet state or be made to dry up by calcareous impregnation or
degeneration for an indefinite time, since post-mortems often show old
tubercles in one or the other of these conditions. We know of one man
who carried a caseous lung for nineteen years, coughing more or less
during all that time, but in a sufficiently good state of health and
strength to follow his occupation of ship-carpenter, but who died at
last from phthisis; while another, a farmer living in one of the
Southern States, has lived in fair health, with his left lung indurated
from top to bottom, for twenty-four years. There cannot be a doubt,
therefore, that if secondary crops of tubercles are prevented, and a
perfect state of health and general nutrition maintained, the tubercles
may remain quiescent in their cheesy condition or may undergo
calcareous degeneration and dry up into inert and innocuous masses
incapable of further harm.
The first and most important indication, therefore, in the treatment of
{482} tuberculosis is to suppress the fever; for as long as this
continues new tubercles will continue to form, since the fever is both
a predisposing and exciting cause. Quinia, therefore, or antipyrine,
should be given as directed in general tuberculosis. The patient should
be put to bed and not permitted to go about until the arrest of fever
seems permanent. Nutrition should be supported and promoted also by the
same means already indicated. As soon as the fever is permanently
arrested (but not before) the patient should be permitted to take
gentle exercise in the open air, and should be encouraged to spend as
much time as possible out of doors, and if able to do so should be sent
during the winter to that climate or place where, on account of its
warmth and dryness, the most time can be spent in the open air.
Hypophosphites of lime and soda should be given constantly, and
cod-liver oil also if the stomach can tolerate it. Large doses of the
oil are useless, and often hurtful, a dessert-spoonful being quite as
much as most stomachs can bear without exciting unpleasant eructations
and nausea. The appetite and digestion are best excited by tincture or
extract of cinchona and nux vomica. Iron we have found to be of little
use, and often hurtful. We much prefer small doses of arsenic (two to
five drops of Fowler's solution), and if there is much bronchitis this
will be found especially useful. Some persons, however, cannot tolerate
arsenic in any dose. The patient should carry a clinical thermometer,
and as soon as the slightest fever is detected he should go to bed and
active antipyretic treatment should be instituted, the tonics and
alteratives being meanwhile suspended. If cough is troublesome (but not
otherwise), one to two grains of codeia should be given two or three
times a day or as often as may be found necessary. This is much
preferable to morphia or other preparations of opium, which constipate
the bowels, dry the mouth, impair the appetite, and so stupefy the
patient that all inclination or even ability to take exercise in the
open air is destroyed. Codeia is amenable to none of these objections.
Guided by these principles, we think we have successfully treated many
cases of primary pulmonary tuberculosis--many in which the hereditary
predisposition was strongly marked and the diagnosis unquestionable. It
is true that many of these cases have relapsed and died after a
variable period, but others have remained well for several years, and
still others permanently.
{483}
DISEASES OF THE PLEURA.
BY FRANK DONALDSON, M.D.
Pleurisy.
DEFINITION.--Inflammation, partial or general, of one or both pleuræ.
SYNONYMS. Pleuritis ([Greek: pleuritis]) morbus lateralis; Morbus
pleuriticus (Celsus); Pneumona pleuritis (Cullen). _Fr._ Pleurésie;
_Ger._ Seitenstich.